39251123 Translated Russian to English Topography Anatomy

SECTION I

REGION OF EXTREMITIES

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1.1 TOPOGRAPHY OF UPPER EXTREMITIES REGION

BORDERS Superior – clavicle, upper part of acromial processus, line to upper part of VII cervical vertebra processus. Inferior – horizontal line across arch of scapula, III rib. Medial anterior – border of sternum. Medial posterior – medial border of scapula.

ASSOCIATED REGION

Subclavicular, axillary, deltoid, scapular, shoulder (anterior and posterior), elbow (anterior and posterior), forearm (anterior and posterior), hand (dorsum, palm).

EXTERNAL ORIENTATION

Bone formation (clavicle, scapula, epicondyles of arm); cylindrical muscles (biceps, deltoid, brachial, choracobrachialis), contours of tendon (m. palmaris longus); sulcus (sulci bicipitales medialis et lateralis, cubitales, ulnaris), ulnar flexure.

PROJECTION Neuro-vascular bundles, commisural opening, synovial sheath, joint slit (SEE <ASSOCIATED REGION>).

SUPERFICIAL FORMATION

Thin thick in region of scapula, deltoid, palm. Superficial tissue classical form, except in region of scapula, deltoid, palm (cellular) and dorsum of hand (loose). Superficial fascia not developed sectional sheath in region of axillary, palm. V. cephalica – region of hand (dorsum), forearm, arm (anterior), sulcus deltoideopectoralis. V. basilicia – region of hand (dorsum), forearm, arm (anterior). Nn. supraclaviculares – subclavicular region. Nn. cutaneus brachii medialis, posterior – region of arm. Nn. cutaneus antebrachii medialis, lateralis, posterior – region of arm, elbow, forearm. Nn. aa. vv. digitales palmares et dorsales – region of hand (fingers). Bursa synovialis subcutanea – region of elbow (posterior).

PROPER FASCIA Expressed on all region. Formed crura (in thickness of mm. pectoralis major, deltoideus), sheath (for mm. pectorales major et minor, deltoideus), deep sheath (f. clavipectoralis, f. profundabrachii, scapular region), septum (region of arm, forearm, dorsum of hand, palm), aponeurotic strip (aponeurosis bicipitalis et palmaris, retinaculi extensorum et flexorum). Has opening in region of axillary, palm.

MUSCLES (SEE <ASSOCIATED REGION>)

NEURO-VASCULAR BUNDLES

(SEE <ASSOCIATED REGION>)

LYMPH FLOW From hand and forearm, lymph flows usually in elbow lymph nodes (superficial and deep), later (or at once) into axillary (deep lateral). From arm, scapular, subclavicular, deltoid region – into axillary. Delivered by vessels of the upper part of the axillary nodes forming truncus subclavius, flow right into venous arch, left – in neck part of ductus thoracicus.

TISSUE SPACE Bone-fibrous muscle floor – region of scapula, arm, forearm, hand (palm). Tissue space – subpectoral, subdeltoid, axillary, Pirogov. Canal – canali spiralis, supinatorius, carpalis, lumbricales.

COLLATERAL BLOOD SUPPLY

Arterial network: - Main type – scapular arterial circle, network of elbow joint; - Multiple type – arterial palm arch (deep, superficial, dorsum). Venous network of multiple type – anastomosis between superficial vein (vv. cephalica, basilica), between deep and superficial veins.

JOINTS Arm, elbow, wrist, metacarpal, interphalangeal.

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1.1.1 SUBCLAVICULAR REGION

BORDERS Superior – clavicle. Inferior – horizontal line to III rib. Medial – external border of sternum. Lateral – anterior border of m. deltoideus.


(SEE <BORDERS>), also coracoid processus of scapula, m. pectoralis major, sulcus deltoideopectoralis, trigonum deltoideopectorale.

PROJECTION V. cephalica – sulcus deltoideopectoralis. A. v. axillaris, plexus brachialis – middle of clavicle.


Skin thin. Subcutaneous tissue developed. Superficial fascia formed by sheath of m. platysma, nn. supraclaviculares (from plexus cervicalis)

PROPER FASCIA F. pectoralis covers m. pectoralis major externally and internally, goes in depth and its crura; attached to clavicle, sternum, enters to neighbouring region; in its depression (in sulcus deltoideopectoralis) lies v. cephalica, which pierced it in trigonum deltoideopectorale and exits in subpectoral spaces. F. clavipectoralis – deep sheath fascia, starts from clavicle, coracoid processus, I rib, grow together with lower border of m. pectoralis major with f. pectoralis; formed sheath for mm. pectoralis minor et subclavius.

MUSCLES Mm. pectorales major et minor, subclavius.


A. axillaris lies between plexus brachialis (superiorly) and v. axillaris (inferiorly), deep f. clavipectoralis, goes a. thoracoacromialis, divide on branches of ramus pectoralis, ramus deltoideus, ramus acromialis, nn. thoracales anteriores (from plexus brachialis). V. cephalica goes across subpectoral spaces and flow into v. axillaris. PEARL. Vein attached to adventitious with fascia and bone (I rib, clavicle).

LYMPH FLOW Inconstant nodi lymphatici interpectorales. Across mm. pectorales major et minor goes lymphatic vessels, gather lymph from mammary gland in nodi lymphatici infraclaviculares.

TISSUE SPACE Subpectoral tissue space lies between fascia f. pectoralis et f. clavipectoralis, from axillary section of crura fascia – ligamentum suspensorium axillae, joint with tissue of axillary region, lateral triangle of neck.


No significant arterial network.

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1.1.2 AXILLARY REGION

BORDERS Anterior – lower border of m. pectoralis major. Posterior – lower border of m. lastissimus dorsi. Medially – line on chest tissue, join only to end of its muscles.


(SEE <BORDERS>), also cylindrical m. coracobrachialis, zone of hair growth, short head of m. biceps, depression (axillary fossa).

PROJECTION A. axillaris – medial border of m. coracobarchialis or anterior border zone of hair or borders of laternal and middle third of wide axillary sheath.


Skin thin, covered with hair, contain apocrine and sebaceous gland. Subcutaneous tissues attached to proper fascia, has nodi lymphatici superficiales. Superficial fascia sheath not developed.

SUPERFICIAL FASCIA

F. axillaris – thick, thin in center, where perforated vessels and nerves; has dome form, which bear lig. suspensorium axillae (sheath, goes from f. clavipectoralis).

MUSCLES Formed wall of axillary region: - Anterior – mm. pectorales major et minor, f. clavipectoralis; - Posterior – mm. subscapularis, teres major, latissimus dorsi; - Medial – m. serratus anterior; - Lateral – mm. coracobrachialis, biceps brachii (short head). In posterior wall has two openings: 1. Foramen trilaterum (caput longum m. tricipitis, mm. subscapularis et teres minor, m.

latissimus dorsi et teres major); 2. Foramen quadrilaterum (also similar muscles and surgical neck of humerus).

NEURO-VESSELS BUNDLES

V. axillaris – lies superficial and medially from artery on all length. A. axillaris – branches on level of trigonum clavipectorale (between clavicle and m. pectoralis minor): - A. thoracica suprema, a. thoracoacromialis; - Trigonum pectorale (behind m. pectoralis minor); - Trigonum subpectorale) between lower border of mm. pectorales major et minor): a.

subscapularis (branches on a. circumflexa scapular, which enters across for. trilaterum and a. thoracodorsalis); a. circumflexa humeri anterior; a. circumflexa humeri posterior (enters across for. quadrilaterum).

Plexus brachialis – in trigounum clavipectorale lies above and laterally to the artery; in trigonum pectorale branches on bundles, lies around arteries and give nerves: - Fasciculus lateralis – n. musculocutaneus goes in thickness of m. coracobrachialis;

part of n. medianus; - Fasciculus medialis – part of n. medianus, lies in front of a. axillaries; - n. cutaneus

brachii medialis; n. cutaneus antebrachii medialis, n. ulnaris. - Fasciculus posterior – n. axillaris enters in for. quadrilaterum; n. radialis goes on

posterior region of arm below tendons of m. latissimus dorsi.

LYMPH FLOW Nodi lymphatici laterals (brachiales) – on external wall, gather lymph from free upper extremities. Nodi lymphatici mediales (pectorales) – on m. serratus anterior gather lymph from chest wall (mammary gland). Nodi lymphatic posteriores (subscapulares) – on posterior wall, gather lymph from scapula and spine. Nodi lymphatici centrales – in center under proper fascia, receive lymph from all previous nodes. Nodi lymphatici apecales (infraclaviculares) – under clavicle, receive lymph from central nodes.

TISSUE SPACE Enclosed between sheath of proper fascia and wall cavity; communicate with infraspinatous bed of scapula, subdeltoid space, anterior and posterior bed of arm, lateral triangle of neck, subcuteaneous tissue.


A. axillary gives branches, anastomosis with neighbouring region (deltoid, scapula).

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1.1.1 DELTOID REGION. SHOULDER JOINT.

BORDERS Contour of m. deltoideus: - Superior – clavicle, spine of scapula, acromion; - Inferior – point of attachment of muscles to humerus.


(SEE <BORDERS>), also sulcus deltoideopectoralis.

PROJECTION Enters n. axillaris on posterior surface of humerus – intersect vertically, pass from acromion, with posterior border of m. deltoideus (or middle posterior border of m. deltoideus on 6 cm below acromion).


Skin thick, non-mobile. Subcutaneous tissue developed, cellular. Superficial fascia thick.

PROPER FASCIA F. deltoidea superficial and deep sheath covering m. deltoideus. Between sheat in thickness of muscles enters crura. Above attached with clavicle, acromion, spine of scapula, below goes to other region. In its depression in sul. deltoideopectoralis lies v. cephalica.

MUSCLES M. deltoideus. Muscles, attached to proximal section of humerus and joint with arm joint (SEE <JOINT>)


A. vv. circumflexae humeri anteriores. A. vv. circumflexae humeri posterior, n. axillaris enters from axillary region across for. quadrilaterum, lies to surgical neck of humeri.

LYMPH FLOW Lymph node absent, lymph flows in axillary and neck lymphatic nodes.

TISSUE SPACE Subdeltoid tissue space joint with axillary across for. quadrilaterum, on entrance of tendon of mm. supraspinalis et infraspinatus – with associated bed in scapular region.


A. circumflexa humeri posterior anastomosis with a. circumflexa humeri anterior.

JOINT Shoulder joint formed by head of humerus and joint with depression on scapula with labrum glenoidale. Joint groove projection: - Anterior on upper part of coracoids processus; - Lateral – under upper part of acromion. - Posterior – base of acromion (between acromion and spine part of m. deltoideus). Capsule of joint attached to borders of labrum glenoidale and to anatomical neck of humerus. Synovial bursa has protrusion (weak spot of capsule): recessus axillaris, bursa synovialis subscapularis, vagina synovailis intertubercularis – infection can leave from joint into subdeltoid, axillary and subscapular tissue space. Syntopia: - Anterior – mm. subscapularis, coracobrachialis, caput breve m. bicipitis brachii; - Posterior – mm. supraspinatus, infraspinatus, teres minor. - Lateral – m. deltoideous, tendo capitis longi m. bicipitis; - Medial – no muscles (weak spot of joint), n. axillaris.

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1.1.4 SCAPULAR REGION

BORDERS Superior – line between acromion and upper part of spinous processus of VII cervical vertebra. Inferior – horizontal line across arch of scapula. Medial – medial border of scapula. Lateral – vertical line from base of acromion.


(SEE <BORDERS>), also spina scapulae.

PROJECTION -


Skin thick, non-mobile. Subcutaneous tissue pierce fibrous strand, cellular. Superficial fascia thick, in all layer, fixed to proper fascia of fibrous strand.

MUSCLES Superficial layer – mm. latissimus dorsi, trapezius, deltoideus. Deep layer – mm. supraspinatus, infraspinatus, teres minor, teres major.


A. suprascapularis – branches of tr. Thyreocervicalis (system of a. subvlavia), goes from region of neck in supraspinatous bed above lig. transversum scapulae, goes into infraspinatous bed in base of acromion; n. suprascapularis lies from brachial plexus in invisura scapular under lig. transversum scapulae. A. circumflexa scapulae – branches of a. subscapularis, goes from axillary region across foramen trilaterum in infraspinatous floor. Ramus profundus a. transversae colli (system of a. subvlacius) goes along medial border of scapula.

LYMPH FLOW Absent. Lymph flow from region of neck and axillary nodes.

TISSUE SPACE Supraspinatous and infraspinatous bone-fibrous bed (SEE <PROPER FASCIA>) joint between them (in base of acromion), with supraclavicular and axillary region (across for. trilaterum).

COLLATERAL BLOOD VESSELS

A. circumflexa scapulae anastomosis with a. suprasacularis et. r. profundus a. transversae colli – anastomosis between system of a. subvlavia and a. axillaris.

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1.1.5 ANTERIOR REGION OF ARM

BORDERS Superior – line, joint at attachment of mm. pectoralis major et latissimus dorsi to shoulder. Inferior – line on 4 cm above medial and lateral epicondyles of shoulder. Medial – vertical from medial epicondyles (sulcus bicipitalis medialis) Lateral 0 vertical from lateral epicondyles (sulcus bicipitalis lateralis)


(SEE <BORDERS>), also mm. deltoideus, pectoralis major, biceps brachii, triceps brachii, humerus.

PROJECTION A. brachialis, n. medianus – on sulcus bicipitalis medialis. N. ulnaris – in upper third on sulcus bicipitalis medialis, lower – on line from middle to medial epicondyles of humerus.


Skin thin in medial section, mobile. Subcutaneous tissue developed, loose. Superficial fascia has appearance of thick sheath. V. basilica et n. cutaneus antebrachii medialis goes in sulcus bicipitalis medialis on level of lower third of arm; v. cephalica goes in subcutaneous tissue on sulcus bicipitalis lateralis (has anastomosis with deep vein).

PROPER FASCIA F. branchialis thick, formed by sheath for v. basilica et n. cutaneus antebrachii medialis (canal Piragov), from it goes to humerus on two septum: septum intermusculare mediale (formed sheath for main neuro-vascular bundles) and septum intermusculare laterale, divided into anterior and posterior muscles bed of arm. F. produnfa brachii divides superficial and deep muscles of anterior region of arm.

MUSCLES M. biceps brachii – superficial layer. Mm. coracobrachialis, brachialis, brachioradialis – deep layer.


N. musculocutaneus enters from m. coracobrachialis, goes below and lateral between m. biceps brachii, et m. brachialis under f. produnda brachii. A. brachii goes in upper third of a . profunda brachii (goes together with n. radialis); in middle third a. collateralis ulnaris uperior (goes together with n. ulnaris); in lower third a. collateralis ulnaris inferior. N. medianus – located in front from artery, intersect it from above to below, externally to internally. N. ulnaris, a. collateralis ulnaris superior pierced septum intermusculare mediale on borders of superior and middle third of arm and exits in posterior bed. N. radialis, a. produnda brachii exits in posterior bed in lower border of m. latissimus dorsi.

LYMPH FLOW Lymphatic node absent, lymph flows into axillary lymph nodes.

TISSUE SPACE Anterior fascial bed communicate on entry of neuro-vascular bundles with posterior bed, tissue space of axillary region and anterior region of elbow.


No significant arterial network. A. brachialis goes to collateral branches for network of elbow joint (SEE <NEURO-VASCULAR BUNDLES>)

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1.1.6 POSTERIOR REGION OF ARM

BORDERS Anterior region of arm (SEE <TABLE 1.1.5>)


Anterior region of arm, and also sulcus between head of m. triceps brachii.

PROJECTION N. radialis – spiral line from lower border of m. latissimus dorsi to point between lower and middle third of sulcus bicipitalis lateralis. For access, take advantage sulcus between long and lateral head of m. triceps brachii.


Skin thick. Subcutaneous tissue classical, developed good. Superficial fascia – thin sheath.

PROPER FASCIA F. brachialis formed posterior fascial bed, anterior region of arm (SEE <TABLE 1.1.5>)

MUSCLES M. triceps brachii.


A. profunda brachii – in middle third of arm branches on a. collateralis radialis et collateralis medialis. N. radialis goes together with a. produnfa brachii in canal between m. triceps brachii and humerus (canalis spiralis), give nn. cutanei brachii et antebrachii posteriores, on borders with region of elbow pierced septum intermusculare laterale and exits in lateral bed of anterior region of elbow.

LYMPH FLOW Lymphatic nodes absent, lymph flows into axillary lymph nodes.

TISSUE SPACE Posterior fascial floor joint with anterior bed of arm, axillary region, region of elbow.


No significant arterial network. A. produnda brachii gives collateral branches for network of elbow joint.

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1.1.7 ANTERIOR REGION OF ELBOW

BORDERS Superior – line on 4 cm above epicondyles of arm. Inferior – line on 4 cm below epicondyle. Medial – vertical across medial epicondyle. Lateral – vertical across lateral epicondyle.


Tendons of m. biceps brachii, m. brachiradialis, sulci cubitales anteriores lateralis et medialis, epicondyles of humerus, subcutaneous vein, ulnar flexure.

PROJECTION A. brachialis – on medial border of m. biceps brachii, point of division is on 2 cm below ulnar flexure. N. medianus – middle distance between tendon of m. biceps brachii and medial epicondyles. N. radialis – medial border of m. brachioradialis. N. musculocutaneus – sulcus cubitalis anterior lateralis.


Skin thin. Subcutaneus tissue has lamellar texture. Superficial fascia formed by sheath for superficial vein and nerves: 1. V. cephalica, n. cutaneus antebrachii lateralis – in sulcus cubitalis anterior lateralis; 2. V. basilica, n. cutaneus antebrachii mediales – in sulcus cubitalis anterior medialis; 3. V. intermedia cubiti – anastomosis between 1) and 2) in appearance of <И>, <H>.

Also in appearance of <M>, vein called v. intermedia cephalica et v. intermedia basilica; anastomosis with deep vein.

Nodi lymphatici cubitales superficiales – on 1-2 cm above medial epicondyles.

PROPER FASCIA From f. cubitii goes two septum, which is prolongation from arm, thickened in center which accounts for aponeurosis m. bicipitis brachii.

MUSCLES Three groups, every group has two layers: 1. M. brachioradialis, deep m. supinator – lateral; 2. M. biceps brachii, deep m. brachialis – in center, abover ulnar flexure. 3. Mm. pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, deep

and medial – m. flexor digitorum superficialis.


A. collateralis radialis, n. radialis lies on capsule of joint in groove between mm. brachioradialis et supinator on level of lateral epicondyle, nerve divides on two branches: deep (goes on posterior region of forearm in canalis supinatorus) and superficial (goes to anterior region of forearm). A. vv. brachiales lies in medial border of tendon of m. biceps brachii, divides on aa. radialis et ulnarid under aponeurosis m. bicipitis brachii (later SEE <COLLATERAL BLOOD SUPPLY>) N. medianus goes on 0.5-1.0 medially from a. brachialis, enters from region between head of m. pronator teres.

LYMPH FLOW Nodi lymphatici cubitales lies in bifurcation of a. brachialis, gather lymph from forearm.

TISSUE SPACE Internal and external fascial bed. Joint with tissue space of anterior and posterior region of arm and forearm.


Rete articulare cubiti: - A. recurrens radialis (from a. radialis) anastomosis with a. collateralis radialis (end

branch of a. profunda brachii); - A. recurrens ulnaris (from a. ulnaris) divides on two branches (anterior and

posterior), which anastomosis accordingly with a. collateralis ulnaris inferior et a. collateralis ulnaris superior.

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1.1.8 POSTERIOR REGION OF ELBOW. ELBOW JOINT.

BORDERS Anterior region of elbow (SEE <TABLE 1.1.7>)


Epicondyle of humerus, olecranon, sulcus cubitalis posterior lateralis, sulcus cubitalis posterior medialis.

PROJECTION N. ulnaris – on sulcus cubitalis posterior medialis between olecranon and medial epicondyle. Caput radii – middle of sulcus posterior lateralis, on 1 cm below lateral epicondyle.


Skin thick, mobile. Subcutaneous tissue has synovial bursa on olecranon. Superficial fascia not developed.

PROPER FASCIA Has appearance of aponeurosis, attached with epicondyle and posterior border of ulnar.

MUSCLES Tendo m. tricipitis brachii attached to olecranon, where lies bursa subtendinea tricipitis brachii. Mm. anconeus, extensores carpi radials longus et brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris, supinator.


A. collateralis ulnaris superior, n. ulnaris enters in sulcus cubitalis posterior medialis under proper fascia, on capsule of elbow joint; enters on anterior region of forearm between head of m. flexor carpi ulnaris.

LYMPH FLOW Lymphatic nodes absent. Lymph flow into axillary nodes.

TISSUE SPACES Not significant.


Anterior region of elbow (SEE <TABLE 1.1.7>)

JOINT Elbow joint fromed by three bones (humerus, radial, ulnar), consist from three joint in one cavity in general capsule. Joint fissure projected in front on transverse line 1 cm below lateral and on 2 cm below medial epicondyle of arm, behind palpable sulcus cubitalis lateralis posterior. Capsule of joint fixed in front to humerus in radial and cubital fossa, posterior – on ulnar fossa, to bone of forearm – on border of joint cartilage. Good strengthening ligaments, on sides from tendon of m. triceps brachii not covered by muscles. Synovial bursa has one weak spot – recessus sacciformis, which directed to deep layer of forearm. Syntopia: Anterior m. brachialis; posterior mm. triceps brachii, supinator, anconeus. N. radialis lies on capsule on lateral border of m. brachialis, n. ulnaris – behind.

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1.1.9 ANTERIOR REGION OF FOREARM

BORDERS Superior – line on 4 cm distal to epicondyle of arm. Inferior – line on 2 cm proximal to styloid processes of ulnar and radial bone. Lateral and medial – vertical, connecting styloid processes and epicondyles.


M. brachioradialis, sulci radialis et ulnaris, tendines mm. flexoris carpi radialis, palmaris longus, styloid proceessus of ulnar and radial bone.

PROJECTION A. radialis – on sulcus radialis. A. ulnaris, n. ulnaris – in upper half laterally from line, goes from medial epicondyles to pisiform bone, in lower correspond to that line. N. medianus – on lines, goes from middle distance between medial epicondyle and tendons of m. biceps to middle distance between styloid processes.


Skin thin. Superficial tissue developed poorly. Superficial fascia loosely attached to proper fascia. V. cephalica, branches of n. cutaneus antebrachii lateralis – in medial border of m. brachioradialis. V. basilica, branches of n. cutaneus antebrachii medialis – medial section in region. V. intermedia antebrachii.

PEARL. All veins anastomosis with deep vein and between them. PROPER FASCIA F. antebrachii in proximal section thick, in distal thin. Anterior and posterior ulnar

intermuscular septum goes to ulnar bone. Together with interosseus membrane and bone limit anterior, lateral and posterior fascial bed. Septum formed sheath for neuro-vascular bundles.

MUSCLES Anterior bed – four layers: 1. Mm. pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris; 2. M. flexor digitorum superficialis; 3. Mm. flexor digitorum profundus, flexor pollicis longus; 4. M. pronator quadrates (in lower third). Lateral bed – two layers: 1. M. brachioradialis; 2. M. supinator (in upper third).


A. vv. radials – between m. brachioradialis et m. pronator teres (in lower 2/3 between m. brachioradialis et m. flexor carpi radialis). Ramus superficialis n. radialis – lies laterally from artery to borders of m. brachioradialis, in lower third of forearm goes backwards under them and exits in subcutaneous tissue posterior region of forearm. A. vv. ulnares – between mm. flexor digitorum superficialis et flexor carpi ulnaris, goes branches – a. interossea communis (branches on aa. interosseae posterior et anterior), in middle third of forearm bed on m. flexor digitorum profundus, where joint to n. ulnaris, from which exit r. dorsalis, goes under tendon of m. flexor carpi ulnaris in subcutaneous tissue of dorsum of hand. N. medianus, a. mediana – between mm. flexores digitorum superficialis et profundus, in lower third – directly under proper fascia in middle sulcus. A. vv. interosseae anteriores, n. interosseus lies on interosseus membrane, which artery pierce upper border of m. pronator quadrates.

LYMPH FLOW Lymphatic nodes absent. Lymph flow in cubital and axillary lymph nodes.

TISSUE SPACE In anterior fascial bed, distinguished deep section between superficial and deep flexor of fingers. In lower third of forearm – space of Piragov between mm. flexor digitorum profundus et pronator quadrates, which communicate with middle bed of hand, posterior bed of forearm, anterior region of elbow.


Significant arterial network absent.

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1.1.10 POSTERIOR REGION OF FOREARM

BORDERS Superior – line on 4 cm distal to epicondyles of arm. Inferior – line on 2 cm proximal to styloid processes of ulnar and radial bone. Lateral and medial – vertical between styloid processes and epicondyles.


(SEE <BORDERS>), also border of ulnar bone on all length and radial bone in lower third.

PROJECTION -


Skin thick. Subcutaneous tissue and superficial fascia developed poorly. Nn. cutanei antebrachii posterior (branches of n. radialis) lateralis et medialis. Tributaries of vv. cephalica et basilica, has anastomosis with deep veins.

PROPER FASCIA F. antebrachii thick, attached to muscles and bone, on borders with hand participate in formation of bony-fibrous canal for tendons of extensors (SEE region of hand <TABLE 1.1.11>).

MUSCLES Arranged in two layers: 1. Mm. extensors carpi radials longus et brevis, extensor digitorum, extensor digiti

minimi, extensor carpi ulnaris; 2. Mm. supinator, abductor pollicis longus, extensors policis longus et brevis, extensor

indicis.


Ramus profindis n. radialis, exit from canalis supinatorius, bed between layers of muscles; a. vv. interosseae posteriores arrives from anterior bed across interossus membrane in upper third. A. interossea anterior arrives from anterior bed across interosseus membrane in lower third.

LYMPH FLOW Lymphatic node absent, lymph flow in cubital and axillary nodes.

TISSUE SPACE In posterior fascial bed – deep sulcus between layers of muscles. Associated with anterior bed and lower third with space of Piragov.

COLLATERAL BLOOD FLOW

Significant arterial network absent. A. interossea anterior anastomosis with a. interossea posterior.

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1.1.11 REGION OF DORSUM OF HAND. WRIST JOINT

BORDERS Superior – line on 2 cm above styloid processes of radial bone. Lateral and medial – On radial and ulnar border of hand.


Styloid processus, metacarpal bone and its head, phalangeal and its head, <anatomical snuffbox> tendon (m. abductor pollicis longus and mm. extensors pollicis longus et brevis)

PROJECTION A. radialis – in <anatomical snuffbox>. Ramus dorsalis n. ulnaris – upper part of styloid processes of ulnar bone. Ramus superficialis n. radialis – upper part of styloid processes of radial bone. Sulcus of wrist joint – arch woth upper part on 1 cm above line between styloid processus. Sulcus of interphalangeal joint – on 2-3 mm below head of metacarpal bone.


Skin thin, covered with hair. Superficial tissue loose (maybe edematous). Superficial fascia – thin sheath. V. cephalica (source), r. superficialis n. radialis (branches) – in lateral part region. V. basilica (source), r. dorsalis n. ulnaris (branches) – in medial part region. Nn. aa. digitales dorsales – on lateral surface of fingers (near to dorsum) on level of middle phalanx.

PROPER FASCIA Superficial sheath well developed, on level of wrist developed retinaculum extensorum, under which six fibrous-osseus canal of tendons of extensors (SEE <MUSCLES>), on level of metacarpal attach to II and V metacarpal bone. Deep sheath fascia covers dorsum interossus muscles and metacarpal bone.

MUSCLES Tendon of extensors of hand and fingers hoes into osseus-fibrous canal, where enclosed in synovial sheath: I canal – mm. abductor pollicis longus et extensor pollicis brevis; II canal – mm. extensores carpi radials longus et brevis (communicate with capsule of joint); III canal – m. extensor pollicis longus; IV canal – mm. extensor digitorum et extensor indicis; V canal – m. extensor digiti minimi; VI canal – m. extensor carpi ulnaris; Mm. interossei dorsales


A. radialis from <anatomical snuffbox> goes through I dorsal interosseus muscles on level of palm for formation of deep arterial arch of palm; goes branches to I finger and participate in formation of rete carpi dorsal, which goes aa. metacarpeae dorsales (2-4 units), and also – aa. digitales dorsale.

LYMPH FLOW Lymphatic node absent. Lymph flow into elbow and axillary nodes.

TISSUE SPACE Subaponeurotic tissue space between proper fascia and its deep sheath covering. COLLATERAL BLOOD VESSELS

Rete carpi dorsale formed anastomosis between aa. interossease anterior et posterior, branches of a. radalis et a. ulnaris.

JOINT Wrist joint formed by bones: radial, scaphoid, lunate, triquetrum and discus articularis. Projection of joint sulcus – (SEE <PROJECTION>). Capsule of joint fixed to border of articular surface, has defects, across which communicate with synovial sheath of tendon (part often with ulnar synovial bursa of palm). Distal wrist joint section from radial-metacarpal by means of fibrocartilago triangularis, in 40% if people communicate with them. Synovial bursa of capsule formed recessus sacciformis, situated between bone in anterior region of forearm. Metacarpal-phalangeal joint. Interphalangeal joint.

14

1.1.12 REGION OF PALM

BORDERS Region of dorsum of hand (SEE <TABLE 1.1.11)>


Styloid processes of radial and ulnar bone, pisiform bone, skin fold of wrist, skin groove and fold of palm, palm-phalangeal and interphalangeal fold, elevation of thenar and hypothenar, between them palm depression; interphalangeal pad (monticuli).

PROJECTION A. ulnaris, n. ulnaris – lateral pisiform bone. Sulcus of wrist joint – middle transverse fold of wrist. Palm aponeurosis (aponeurosis palmaris) – palm sheath. Ramus motoricus n. median – borders of upper and middle third of fold, separate thenar (restrict zone of Канавелла. Upper part of arcus palmaris superficialis – proximal transverse sulcus of palm. Commisural opening of palm aponeurosis – three pad. Synovial sheath of tendon of flexors: - II-IV fingers – from base of distal phalangeals to distal transverse sulcus of palm; - V finger – from base of ungula of fingers to merge mutually; - I (big) finger – from base of ungula of fingers to lower third of forearm. - General – from proximal transverse sulcus of palm to lower third of forearm. Cruciate ligament sheath – interphalangeal fold.


Thin thick, non-mobile; fixed to connective-tissue on palm to proper fascia, on level of phalangeal – to bone (ungeal of phalanyx) or to fibrous canal sheath of tendon of flexors. Subcutaneous tissue cellular. Superficial fascia sheath not developed. M. palmaris brevis starts from medial border of palm aponeurosis, attached to skin. Ramus superficialis a. radialis – in lateral border of palm on thenar. Nn. aa. digitales palmares proprii – on level phangeal to end of phalnyx on lateral surface (dorsum to palm) along phalnyx.

PROPER FASCIA

Has several section. Ligamentum carpi volare – thickening of distal section of fascia of forearm. Retinaculum flexorum stretch between os scaphoideum et trapezium, formed canal for tendon of flexors. Aponeurosis palmaris – plane of fibrous sheath on strip of palm sheath, goes in distal section into deep septum, forming three canal for vermiform muscles with entrance into commissural opening. Thick sheath fascia correspond to thenar et hypothenar. From medial and lateral border of aponeurosis palmaris exits two intermuscular septum – laterally to III metacarpal bone and medially to V metacarpal bone, forming three fascial floor – middle, thenar et hypothenar. Deep sheath fascia, covers mm. interossei palmares. Palm fascia of phalanyx covers on borders of palmar surface of phalanx, has thickened strip (annular and cruciate ligament) and formed together with periosteum of phalanx fibrous canal for tendon of flexors, covering internally synovial parietal bursa.

MUSCLES Thenar (lateral bed) – mm. abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, adductor pollicis, tnedo m. flexoris pollicis longi. Hypothenar (medial bed) – mm. abdcuctor digiti minimi, opponens figit minimi, flexor digit minimi brevis. Middle bed – mm. lumbricales, tendon of flexor of phalanx, enclosed in synovial sheath (general and phalanx II-V phalanx). On level of phalynx: to ungeal of phalanx – tendon of mm. flexores digitorum profundus, pollicis longus; to base of middle phalanx – m. flexor digitorum superficialis. PEARL. All tendon of flexor on level of phalanx enclosed in synovial sheath.


A. n. ulnares – in splitting of retinaculum flexorum; give deep branches. Arcus palmaris superficialis formed anastomosis with a. ulnaris et ramus superficialis a. radialis; from its exits aa. digitales palmares communes, which, exits from commissural opening, branches on aa. digitales palmares proprii; n. medianus goes r. motoricus and divides on nn. digitales palmares proprii to I, II, III and lateral surface of IV phalanx; n.

15

ulnaris divides on nn. digitales palmares proprii to IV and V phalanx. Arcus palmaris profundus formed connection with a. radialis et ramus profundus a. ulnaris; goes aa. metacaepeae palmares, flow into aa. digitales communes on level of commissural opening. Nn. aa. digitales palmares proprii – (SEE <SUPERFICIAL FORMATION>).

LYMPH FLOW Lymph flow basent, lymph flow into cubital and axillary nodes.

TISSUE SPACE Fascia bed for thenar, hypothenar – (SEE <MUSCLES, PROPER FASCIA>). Middle bed of tendon of flexor of phalanx divides in two sulcus: - Subaponeurotic contains arcus palmaris superficialis et n. medianus; - Subtendinous contains arcus palmaris produndus. Sulcus communicate between eat other on entrance of aa. metacarpear palmares, with subcutaneous tissue of palm across commissural opening, with dorsum of hand through entrance of mm. lumbricales.


(SEE <NEURO-VASCULAR BUNDLES>)

JOINT Region of dorsum of hand (SEE <TABLE 1.1.11>)

16

1.2 TOPOGRAPHY OF LOWER EXTREMITIES REGION

BORDERS Inguinal (Poupart) ligament (from tuberculum pubicum to spina iliaca anterior superior), crista ilii, intergluteal fold, femoral-perineal fold.

ASSOCIATED REGION

Thigh (anterior and posterior), gluteal, knee joint (anterior and posterior), shin (anterior and posterior), ankle joint, foot (dorsum and sole).


Bone formation (tuberculum pubicum, spina iliaca anterior superior, crista ilii, tuberculum pubicum, patella), contour of muscles and tendon (femoral triangle, mm. sartorius, biceps femoris, semimembranosus, gastrocnemius), folds (inguinal, intergluteal, subgluteal), sulcus (sulci planters medialis et lateralis)

PROJECTION Vessels and nerves, fissure of joints (pelvic, knee, ankle), canals (femoral, obturator, adductor, popliteal, calcaneal, plantar) – (SEE <ASSOCIATED REGION>).


Skin thick in region of gluteal, knee joint (anterior), foot (sole). Subcutaneous tissue developed thick layer: cellular in region of gluteal, foot (sole), loose – region of knee joint, foot (dorsum). Superficial fascia not developed in sectional sheath in region of gluteal, foot (sold). Aa. pudendae externae, epigastrica superficialis, circumflexa ilium superficialis – region of thigh (anterior). V. saphena magna – region of foot (dorsum), ankle joint, shin, knee joint, thigh (anterior). V. saphena parva – region of foot (dorsum), ankle joint, shin (posterior). N. saphenus – region of shin (anterior), foot (dorsum). Nn. clunii – gluteal region. Nn. cutaneus fromis anteriores, lateralis, posterior – region of thigh. Nn. cutaneus surae medialis, lateralis, n. suralis – region of shin (posterior), ankle joint. N. peroneus superficialis – region of shin (anterior), ankle, foot (dorsum). N. peronus profundus – region of foot (dorsum). Aa. vv. digitales plantares et dorsales – region of foot. Bursa synovialis subcutanea – region of knee joint (anterior).

PROPER FASCIA Formed crura (in thickness of m. gluteus maximus), sheath (for mm. sartorius, gracilis, tensor fascia lata, gluteus maximus), aponeurotic thickening (tractus iliotibialis, pes anserinus majus, retinaculi mm. peroneorum et extensorum, aponeurosis plantaris), septum in region of thigh, shin, sole, deep sheath in region of gluteal, thigh, shin, foot. Has opening – fascia cribrosa (region of thigh anterior), commissural (region of foot – sole).

MUSCLES (SEE <ASSOCIATED REGION>)


(SEE <ASSOCIATED REGION>)

LYMPH FLOW From region of foot (sole), shin (posterior) lymph partly flow in popliteal lymph nodes. From all associated region lymph flows into inguinal superficial and deep lymphatic nodes, later into external iliac lymph nodes in pelvis. From region of posterior thigh and gluteal – into parietal nodes in pelvis.

TISSUE SPACE Bone-fibrous bed of region of thigh, shin, foot. Tissue spaces – subgluteal, femoral triangle, popliteal fossa. Canal – femoral, obturator, adductor, popliteal, malleolus, calcaneal, sole.


Arterial network of main type – network in pelvic-thigh (anterior region of thigh), knee joint (region of knee joint). Arterial network of multiple type – region of foot. Venous network of multiple type – anastomosis between system of vv. saphena magna et saphena parva, anastomosis between system of superficial and deep vein by means of perforating vein, located primarily in region of shin.

JOINT Pelvic, knee, ankle, metatarsal-phalangeal, interphalangeal.

17

1.2.1 ANTERIOR REGION OF THIGH. PELVIC JOINT

BORDERS Superior – inguinal (Paupart) ligament (from tuberculum pubicum to spina iliaca anterior superior). Inferior – 4 cm above base of patella. Lateral – line from lateral epicondyle of thigh to spina iliaca anterior superior. Medial – line from medial epicondyle to lower border of symphysis pubis.


(SEE <BORDERS>), also femoral (Scarpa) triangle – trigonum femorale (limited by m. sartorius, lig. inguinale, m. adductor longus, peak at 15-17 cm below inguinal ligament), inguinal fold.

PROJECTION A. v. femorales (exits on thigh) – middle third of inguinal ligament. Anulus internus canalis femoralis – internal third of inguinal ligament. Anulus externus (saphenus) canalis femoralis – on 1-2 cm below internal third of inguinal ligament. A. femoralis (entry to thigh) – line Кена (from middle part of intuinal ligament to medial epicondyle of femur – thigh flexed in pelvis and knee joint, rotated externally). N. cutaneus femoralis lateralis – exits on 1-2 cm below and laterally from spina iliaca anterior superior. Nn. cutanei femoris anteriores – exits on entry of m. sartorius. Canalis obturatorius – on 1.2-1.5 cm below inguinal ligament externally from pubic tubercle.


Skin thin. Subcutaneous tissue on two layers divided by sheath of superficial fascia. Superficial fascia formed by sheath fro superficial vessels and nerve. A. epigastrica superficialis, a. circumflexa ilium superficialis, aa. pudendae externae – branches of a. femoralis, exits fan-shaped across facia cribrosa (SEE <PROPER FASCIA>). V. saphena magna enters under proper fascia across f. cribrosa, span across cornu inferior (SEE <PROPER FASCIA>) and flow into v. femoralis. N. genitofemoralis branches under medial part of inguinal ligament. N. cutaneus femoris lateralis exits from-under proper fascia on 2 cm under and medially to spina iliaca anterior superior. Nn. cutenei femoris anteriores exits from-under proper fascia along medial border of m. sartorius. R. cutaneus n. obturatorii branches in medial part region of patella. Nodi lymphatici inguinales superficialies – on entrance of inguinal ligament (gather lymph from anterior abdominal wall under umbilical, from external sex organs, skin in anal region and gluteal region). Nodi lymphatici subinguinales superficiales – along projection of femoral artery (gather lymph from skin of extremities).

PROPER FASCIA F. lata thick laterally (tractus iliotibialis), and goes three intermuscular septum (attached to linea aspera): lateral and medial developed well, posterior poorly developed. Formed sheath for mm. tensor fascia lata, sartorius, gracilis and above femoral triangle divided into two sheath – deep covers m. iliopsoas et m. pectineus; and superficial – thick, has cresent-shaped appearance margin (margo falciformis) with two crura (cornua superior et inferior), tightened cribate fascia (fascia cribosa), across which exits vessels and nerve (SEE <SUPERFICIAL FORMATION>). Canalis femoralis (femoral canal) formed only when occur femoral hernia: - Internal ring (annulus internus canalis femoralis) limited by lig. inguinale, v. femoralis,

lig. pectinale, lig. lacunare; - External (subcutaneous ring – annulus saphenus) – medial strip of fascia cribosa; - Wall: cornu superior marginis falciformis, v. femoralis, deep sheath of f. lata, covering

of m. pectineus. Lacuna musculorum et lacuna vasorum – space between inguinal ligament and pelvic bone, divided by arcus iliopectieus, in which goes m. iliopsoas et n. femoralis (lacuna musculorum) and a. v. femorales (lacuna vasorum).

MUSCLES Anterior bed – m. iliopsoas, m. pectineus formed floor for trigonum femorale in upper third of thigh; m. tensor fascia lata, m. sartorius, m. quadriceps femoris (mm. rectus,

18

vastus medialis, vastuc lateralis, vastus intermedius). Medial bed – mm. adductors longus et brevis, magnus, gracilis. Canalis adductorius (adductor muscle canal, Hunter) length 5-6 cm in lower third of thigh; walls: mm. adductor magnus, vastus medialis, lamina vastoadductoria (m. sartorius covers it); opening: superior (enters a. v. femorales, n. saphernus); anterior – in lamina vastoadductoria (exits n. saphenus, a. v. genus descendens); inferior – sulcus between tendons of m. adductor magnus (exits a. v. femorales). Canalis obturatorius (obturator canal) formed sulcus in pubic bone, mambran obturatoria, mm. obturatorii.


A. femoralis on level of femoral triangle gives superficial branches (SEE <SUPERFICIAL FORMATION>), a. profunda femoris goes in canalis adductoris; v. femoralis lies in upper third medially from artery, in peak of femoral triangle – posterior, on exit from adductor canal – laterally from artery; n. femoralis lies laterally from vessels, separated from them at arcus iliopectineus; its branches (n. sapheneus) travel with a. v. femorales in upper third of thigh. A. profunda femoris goes from posterior semicircumference a. femoralis on 3-5 cm below inguinal ligament, give branches: a. circumflexa femoris lateralis, a. circumflexa femoris medialis, aa. perforantes (2-3 units) (later SEE <COLLATERAL BLOOD SUPPLY>). A. obturatoria (branches of a. iliaca interna and a. epigastrica inferior) exits from canalis obturatorius into medial bed together with n. obturatorius.

LYMPH FLOW Nodi lymphatici inguinales profundi enters along v. femoralis along proper fascia. One of the nodes, Piragov-Rosenmuller, lies in medial ring of femoral canal. Gather lymph from deep layer of lower extremities and superficial inguinal lymph nodes.

TISSUE SPACE Anterior and medial fascial bed, interfascial sulcus of femoral triangle (its part – femoral canal), adductor canal, obturator canal.


R. profundus a. circumflexae femoris medialis anastomosis with aa. gluteae, obturatoria, perforantes. R. descendes a. circumflexae femoris lateralis – with a. glutea superior. R. descendens a. circumflexae femoris lateralis et a. genus descendens – with branches of poplteal artery (arterial netweok of knee joint).

JOINT Pelvic joint formed by head of femur and acetabulum of pelvic bone. Head of femur projected in front under middle part of inguinal ligament, posterior together with neck –along lateral half line from spina iliaca posterior superior to base of greater trochanter. Capsule attached to the front to intertrochanter line, posterior to neck of femur between its lateral and middle third. Secured by strong ligament. Weak point is at posterior and below, anterior – bursa iliopectinea (in 10% of people communicate with capsule). Syntopia: anterior – mm. iliopsoas, rectus femoris, pectineus, lateral – m. gluteus maximus; posterior – mm. piriformis, obturatorius internus, gemelli, obturatorius externus, quadrates femoris, inferior – m. obturatorius externa.

19

1.2.2 GLUTEAL REGION

BORDERS Superior – crista iliaca. Inferior – plica glutea. Lateral – vertical from spina iliaca anterior superior. Medial – intergluteal fold.


(SEE <BORDERS>), also sciatic tuberculum, greater trochanter, spina iliaca posterior superior.

PROJECTION A. glutea superior – borders upper and middle third line from spina iliaca posterior superior to upper part of trochanter major. A. glutea inferior – below and lateral from middle line from spina iliaca posterior superior to medial border tuber ishii. N. ischiadicus – vertical across middle portion between greater trochanter and sciatic tuberculum.


Skin thick, has numerous sebaceous gland, joins with superficial and proper fascia partition. Subcutaneous tissue cellular owing to partitions. Superficial fascia sheath not developed. Nn. clunium superiores, medii, inferiores.

PROPER FASCIA F. glutea above attached to crista iliaca, below changes to f. lata; formed sheath for m. gluteus maximus, give deep muscles crura and its deep sheath.

MUSCLES Separated into three layers: - M. gluteus maximus (has bursa synovialis above greater trochanter); - Mm. gluteus medius, piriformis, obturatorius internus, gemelli superior et inferior,

quadrates femoris. - Mm. gluteus minimus, obturatorius externus.


From foramen suprapiriformis (region of lesser pelvis) enters: - A. glutea superior (attached to periosteum, behind divides to branches); - N. gluteus superior. From foramen infrapiriformis (region of lesser pelvis) enters: - N. cuteneus femoris posterior; - A. glutea inferior, n. gluteus inferior; - A. pudenda interna, n. pudendus (most medially) enveloping iliac bone and

ligaments, gors across foramen ischiadicum minus in fossa ischiorectalis, later in perineum (SEE <TABLE 8.1.1>).

LYMPH FLOW Lymphatic nodes absent. Lymph flow in inguinal lymph nodes and parietal lymph nodes of pelvis.

TISSUE SPACE Subgluteal tissue space – under m. glutea maximus, separated from lumbar region, proper fascia attached to crista ilii. Communicate with tissue space of pelvis, posterior bed of thigh, anterior bed of thigh (under tendon of m. gluteus maximus).


A. glutea superior et a. glutea inferior anastomosis with r. profundus a. circumflexae femoris medialis et r. ascendens a. circumflexae femoris lateralis, aa. perforantes.

20

1.2.3 POSTERIOR REGION OF THIGH

BORDERS Superior – intergluteal fold. Inferior – line on 4 cm above base of patella. Medial – line from medial epicondyle to symphysis. Lateral – line from external epicondyle of femur to spina iliaca anterior superior.


(SEE <BORDERS>), also trochanter major et tuber ischiadicus.

PROJECTION N. ischiadicus – from middle distance between greater trochanter and sciatic tuberculum to upper angle of popliteal fossa.


Skin thin, has hair covering. Subcutaneous tissue lies in thickness layer. Superficial fascia developed sheath. Branches of n. cutaneus femoris posterior et n. cutaneus femoris lateralis. V. femoropoplitea – anastomosis between v. saphena magna et v. saphena parva.

PROPER FASCIA F. lata secure transverse connective bundles. From it, it goes powerful septum intermusculare laterale and less developed septum intermuscilare mediale, which separate posterior bone-fibrous bed from anterior and medial.

MUSCLES M. biceps femoris – lateral. Mm. semitendinosus et semimembranosus – medial.


N. ischiadicus, a. commitans n. ischiadici (exits from border of m. gluteus maximus) in upper third of thigh lies behind under f. lata, lateal from sciatic tuberculum; in middle third – in front of long head of m. biceps femoris, behind m. adductor magnus; in lower – in tissue between m. biceps femoris et m. semimembranosus. In upper angle of poplitel fossa (frequently almost all) nerve divides on n. tibialis et n. peroneus communis (maybe and more higher divide – even at exit from for. infrapiriformis). Aa. perforantes (2-4 units) goes near to femur, attached to tendon of adductor muscles. A. v. femorales in lower third of thigh exits from lower opening of adductor canal.

LYMPH FLOW Lymphatic nodes absent. Lymph flow into inguinal lymph nodes and parietal lymphatic nodes of pelvis.

TISSUE SPACE Posterior fascial bed of thigh (SEE <PROPER FASCIA>).


Significant arterial network absent. Perforating artery anastomosis between each other.

21

1.2.4 ANTERIOR REGION OF KNEE JOINT

BORDERS Superior – horizontal line on 4 cm above base of patella. Inferior – horizontal line on level of tuberositas tibiae. Lateral – vertical line across posterior border of condyle of femur bone.


Patella, tuberositas, tibiae, caput fibulae, condyli tibiae lateralis et medialis, condyli et epicondyli femoris laterals et mediales, tuberculum adductorium, ligamentum patellae, tendo m. bicipitis femoris, tractus iliotibialis, tendines mm. semitendinosi et semimembranosi.

PROJECTION <SAME>


Skin thick. Subcutaneous tissue present in thin layer, loose. Superficial fascia has in cleavage of bursae synovialis infrapatellaris et prepatellaris subcutaneae. Ram inn. cutanei femoris anetriores, n. saphenus (give r. infrapatellaris).

PROPER FASCIA F. poplitea – continuation of f. lata. Fixed to epicondyles of thigh, condlyes and tuberosity of tibia bone, head of fibula bone; strengthened by tr. Iliotibialis, cylindrical tendon of mm. sartorius, gracilis, semitendinosus, semimembranosus.

MUSCLES M. quadriceps femoris – in front, continue in lig. patellae. Mm. sartorius, gracilis, semitendinosus, semimembranosus – medial (<goose foot>). Tendo m. bicipitis femoris – lateral. Synovial bursa: 1. Bursa infrapatellaris profunda – between lig. patellae et tuberositae tibiae; 2. Bura prepatellaris subtendinea – between tendo m. quadricipitis and periosteum; 3. Bursa suprapatellaris – above patella under tendo m. quadricipitis (in 85%

communicate with cavity of joint).


Rete patellae formed artery for knee joint, (SEE posterior part of knee joint <TABLE 1.2.5>)

LYMPH FLOW Lymphatic nodes absent. Lymph flow into popliteal and inguinal lymph nodes.

TISSUE SPACE Absent.

JOINT Knee joint formed by condyles of femur and tibia (encloses meniscus) bone, patella, strengthen by internal cruciate ligaments and powerful externally. Joint sulcus in the front can be palpated as curve located between condyles of femur et tibia. Capsule to the front to tibia bone on 1-2.5 cm from cartilagous covering, on tibia bone on border of articular surface. Its synovial bursa formed inversions: - Superior anterior (recessus superior) communicate with bursa suprapatellaris; - Anterior: superior lateral and medial, inferior lateral and medial. - Inferior: superior lateral and medial, inferior lateral and medial. Syntopia: - Anterior – tendon of m. quadriceps, patella. - Posterior – muscles of posterior region of knee joint.

22

1.2.5 POSTERIOR REGION OF KNEE JOINT. POPLITEAL FOSSA.

BORDERS Anterior region of knee joint (SEE <TABLE 1.2.4>).


<SAME>

PROJECTION N. tibialis, a. v. popliteae – middle line of popliteal fossa. N. peroneus communis – medial border of tendo m. bicipitis femoris, later lateral surface of neck of fibula.


Skin thin. Subcutaneous tissue expressed. Superficial fascia expressed. Nn. cutaneus femoris posterior, saphenus, cutaneus surae lateralis, lymphatic nodes, v. femoropoplitea.

PROPER FASCIA F. poplitea has aponeurotic texture, formed sheath for neuro-vascular bundles, separated on two septum to tibia bone, formed also sheath for m. biceps femoris and mm. semitendinosus et semi membranosus, popliteal fossa. V. saphena parve goes in splitting of proper fascia in lower section region.


N. tibialis lies behind and under f. poplitea and on middle line directed under arcus tendineus m. solei in canalis cruropopliteus; v. popliteal – deep and medial from nerve; a. poplitea – deeper and more medially to vein, near to bone, goes muscles and collateral brances (SEE <COLLATERAL BLOOD SUPPLY>), divides on aa. tibiales anterior et posterior. N. peroneus communis from upper angle of fossa directed externally on lateral direction of neck of fibula along border of m. biceps femoris. N. cutaneus surae medialis – branches n. tibialis, goes between head of m. gastrocnemius in subcutaneous tissue. N. cutaneus surae lateralis – branches of n. peroneus communis.

LYMPH FLOW Subfascial lymph nodes, on entrance of neuro-vascular bundles, closely behind the capsule of joint. Gather lymph from shin, foot, knee joint.

TISSUE SPACE (SEE <PROPER FASCIA>).


Rete articulare genus, in formation which participate: 1. Branch of a. femoralis – a. genus descendens, ramus descendens a. circumflexae

femoris lateralis, a. perforans III, IV; 2. Branch of a. poplitea – aa. genus superior lateralis, superior medialis, inferior

medialis et inferior lateralis; 3. Branch of a. tibialis anterior – a. recurrens tibialis anterior.

23

1.2.6 ANTERIOR REGION OF SHIN

BORDERS Superior – circular line on level of tuberositas tibiae. Inferior – circular line across base of ankle. Medial – medial border of tibia bone. Lateral – sulcus between mm. peronei et soleus.


(SEE <BORDERS>), also shape of mm. tibialis anterior, extensor digitorum longus, extensor hallucis longus, peronei longus et brevis, groove between peroneal muscles and muscles-extensor, head of fibula bone, anterior-medial surface of tibia.

PROJECTION A. tibialis anterior, n. peroneus profundus – on line from middle distance between tuberositas tibiae et caput fibulae to middle distance between ankles.


Skin thin, non-mobile. Subcutaneous tissue expressed. Superficial fascia expressed. Tributaries of v. saphena parva, branches of n. cutaneus surae lateralis – in lateral section of region. V. saphen magna, n. saphenus – in antero-medial section region. N. peroneus superficialis exit from-under proper fascia on border of middle and lower third of shin from groove between peroneal muscles and extensors. PEARL. Has anastomosis with superficial and deep vein (perforating veins).

PROPER FASCIA F. cruris – has aponeurotic texture (point of partial attachment of muscles), join with periosteum of anterior surface of tibiae, give septum intermusculare anterior et septum intermusculare posterior, which attached to fibula. Together with bone of shin and membrane interossea septum restrict anterior and lateral fascial bed. On ankle fascia thickend into retinaculum mm. extensorum.

MUSCLES Anterior bed – mm. tibialis anterior, extensor digitorum longus, extensor hallucis longus (emerge between first second on level middle third of shin). Lateral bed – mm. peroneus longue et brevis. Canalis musculoperoneus superior – canal between bundles of m. peroneus longus et fibula, lies n. peroneus communis, which divides here on two branches (profundes et superficialis).


A. v. tibiales aneriores entes from behind region of shin across opening in membrane interossea. In upper third lies between mm. extensor digitorum et tibialis anterior, lower between mm. extensor policis longus et tibialis anterior; artery gives branches (aa. malleolares anteriores medialis et lateralis, recurrens tibialis); n. peroneus profundus lies across septum intermusculare anterior from canalis musculoperonus superior; lie laterally from artery, with level of middle third – medially. N. peroneus superficialis descends in lateral bed along septum intermusculare anterior and on borders with lower third of shin exits on subcutaneous tissue.

LYMPH FLOW Lymphatic nodes absent. Lymph flow in popliteal and inguinal nodes.

TISSUE SPACE Anterior and lateral fascial bed (SEE <PROPER FASCIA>).



24

1.2.7 POSTERIOR REGION OF SHIN

BORDERS Anterior region of shin (SEE <TABLE 1.2.6>)


Shape of m. gastrocnemius, Achilles tendon, malleoli medialis et lateralis.

PROJECTION V. saphena parva – from malleolus lateralis, between head of m. gastrocnemius to middle popliteal fossa. N. cutaneus surae lateralis – on lateral head of m. gastrocnemius. N. cutaneus surae medialis lies together with v. saphena parva to borders with lower third of shin. N. suralis accompany v. saphena parva in lower third of shin. A. tibialis posterior, n. tibialis – on line from middle popliteal fossa to middle distance between malleolus medialis and Achilles tendon. V. saphena magna – in front from medial ankle, later to medial border of tibia.


Skin thin, mobile. Subcutaneous tissue developed well. Superficial fascia developed well. V. saphena parva pierces proper fascia in middle shin and enters in canal of Piragov (splitting in proper fascia), has anastomosis with deep vein (perforating veins). N. cutaneus surae medialis goes with v. saphena parva till malleoulus lateralis. N. cutaneus surae lateralis exits from-under proper fascia into distal third of shin, where join with n. cutaneus surae medialis, forming n. suralis. N. suralis accompany v. saphena parva on level of distal third of shin.

PROPER FASCIA F. cruris formed two sheath: 1. Superficial formed sheath for m. triceps surae; 2. Deep covers layers of flexors of foot and toes

MUSCLES M. triceps surae (mm. gastrocnemius and soleus), m. plantaris. Mm. flexor digitorum longus, tibialis posterior, flexor hallucis longus. Canalis cruropopliteus – sulcus between m. tibialis posterior and deep sheath fascia, encloses m. soleus: - Entrance opening – between m. popliteus et arcus tendineus m. solei; - Upper exit – in interosseus membrane, leave a. tibialis anterior. - Lower exit – between m. tibialis posterior and Achillis tendon, leaves a. tibialis

posterior et n. tibialis. - Canalis musculoperoneus inferior – sulcus between m. flexor hallus longus et fibulae,

contains a. v. peroneae.


A. v. tibiales posteriors, n. tibialis goes through canalis cruropoliteus and exit in canalis malleolaris; in upper third of shin from artery goes branches a. peronea, travel across canalis musculoperoneus inferior to malleolus lateralis and from which in greatly turn to enter branches r. perforans et r. communicans.

TISSUE SPACE Canalis cruropopliteus et canalis musculoperoneus inferior.



25

1.2.8 REGION OF ANKLE JOINT

BORDERS Superior – circular line across base of ankle. Inferior – oblique line across upper part of ankle, sole, dorsum of foot.


Ankle (lateral below medial on 1.5-2 cm), tendon of extensors, peroneal muscles, Achilles tendon.

PROJECTION A. v. dorsales pedia, n. peroneus profundus – line from middle between ankle to I interphalangeal space. A. tibialis posterior, n. tibialis – behind medial ankle on 2 cm. V. saphena parva, n. suralis – line from middle distance between lateral ankle to Achilles tendon to tuberosity of V metatarsal bone. V. saphena magna, n. saphenus – anterior surface of medial ankle.


Skin thin (except in region of Achilles tendon, heel). Subcutaneous tissue developed on side from Achilles tendon, almost absent above ankle. Superficial fascia in appearance of thick sheath. V. saphena magna (tributaries and main trunk), n. saphenus – in front from medial ankle on 1 cm. V. saphena parva (tributaries and main trunk), n. suralis – behind from lateral ankle.

PROPER FASCIA Thickened in front in retinaculum mm. extensorum (superius et inferius), from which enters septum deep down, formed osteo-fibrous canal for tendons of extensor muscles; behind – two sheath formed sheath for Achilles tendon, lateral – retinaculi mm. peroneorum (fibularium) superior et inferior, from which enters septm to bone, formed osteo-fibrous canal for tendon of peroneal muscles; medial – retinaculum mm. flexorum, which together with medial ankle and calcaneal formed canalis malleolaris (ankle canal).

MUSCLES Anterior – tendons in synovial sheath of mm. tibialis anterior, extensor digitorum longus, extensor hallucis longus. Posterior – Achilles tendon (between them and calcaneal tuberosity – bursa synovialis). Lateral – tendon in synovial sheath of mm. peronei longus et brevis. Medial – tendon in synovial sheath of mm. tibialis posterior, flexor digitorum longus, flexor hallucis longus (enters together with neuro-vascular bundle into ankle canal). Canalis calcanesus (calcaneus canal) – continuation of canalis malleolaris, formed by os calcaneum et m. abductor hallucis.


A. v. tibiales anteriores (in region of ankle joint – a. v. dorsales pedis); n. peroneus profundus goes in osteo-fibrous canal together with m. extensor hallucis longus. A. tibialis posterior, n. tibialis goes into vanalis malleolaris, posterior from tendon of flexor, where divides correspond on aa. et nn. plantares mediales et laterals; above ankle artery goes branches – a. calcanea.

LYMPH FLOW Lymphatic nodes absent, lymph flows to popliteal and inguinal lymphatic nodes.

TISSUE SPACE (SEE <PROPER FASCIA>).


Rete calcaneum formed anastomosis with aa. peronea et tibiales posterior et anterior.

JOINTS Ankle joint formed from ankle part of fibula and tibia bone, joint surface of tibia bone, talus bone. Projection of joint sulcus – horizontal line on 2.5 cm above upper part of lateral ankle. Capsule attached to border of joint surface and anteriorly along neck of talus. Securely strengthened by ligaments on lateral and medial side (weak point – anterior and posterior). Syntopia: anterior – tendon of extensor muscles of toes and foot, a. dorsalis pedis, n. peroneus profundus, posterior – Achilles tendon, tendon of flexors and peroneal muscles.

26

1.2.9 REGION OF DORSUM OF FOOT

BORDERS Proximal – line connecting upper part of ankle. Lateral – line from middle peak of calcaneal to middle head of V metatarsal bone. Medial – line from middle peak of calcaneal to middle part of I metatarsal bone.


Tendons of extensor muscles, tuberosity of V metatarsal bone, belly of m. abductor digit minimi.

PROJECTION A. dorsales pedis, n. peroneus profundus – line from middle distance between ankle to first interphalangeal space on level of tarsus.


Skin thin. Subcutaneous tissue loose, poor fat tissue. Superficial fascia developed poorly. Rete venosum dorsale pedis – tributaries vv. saphenae parve et magna formed arcus venosus dorsalis. Branches (deep vein) n. peroneus superficialis, n. saphenus, n. suralis. N. peroneus profundus (cutaneous branches) – I interphalangeal space.

PROPER FASCIA Superficial sheath formed canal for tendon of muscles and neuro-vascular bundles. Deep sheath (fascia interossea) covers interosseus muscles.

MUSCLES In splitting of superficial sheath of proper fascia – tendon in synovial sheath mm. tibialis anterior, extensor hallucis longus, extensor digitorum longus. Under superficial sheath of proper fascia – mm. extensor hallucis brevis, extensor digitorum brevis. Under deep sheath of proper fascia – mm. interossei dorsales.


A. vv. dorsales pedis, n. peroneus produndus lies between tendon of mm. extensor hallucis et extensor digitorum longus; artery gives a .arcuata, from which goes aa. metatarseae dorsales, from them its curve – aa. digitales dorsales. Later a. dorsalis pedis divides on a. metatarsea dorsalis I et a. plantaris profundus, goes to sole across I intermetatarsal space.

LYMPH FLOW Lymphatic nodes absent, lymph flow in popliteal and inguinal lymphatic nodes.

TISSUE SPACE Sulcus between superficial sheath of proper fascia and fascia interossea.


From a. dorsalis pedis goes a. tarsea lateralis, anastomosis with a. arcuata (branch also with a. dorsalis pedia). Ramus plantaris profundus pierce I intermetatarsal space and anastomosis with a. plantaris lateralis.

27

1.2.10 REGION OF SOLE

BORDERS Region of dorsum of foot (SEE <TABLE 1.2.9>)


A. v. n. plantares laterals – lateral sulcus of sole (from middle width of heel to IV interphalangeal space). A. v. n. plantares mediales – medial sulcus of sole (from middle medial half width of heel to I interphalangeal space).

PROJECTION Mm. lumbricoles (4 units).


Skin thick, non-mobile. Subcutaneous tissue well developed, cellular, pierce fibrous tissue, bind together skin with sole aponeurosis. Superficial fascia section of sheath not developed.

PROPER FASCIA Sole aponeurosis (aponeurosis plantaris) – in middle section, formed by longitudinal and transverse tendon cylinders, stretch from calcaneal tuberosity to head of metatarsal bone, where separated into 4-5 crura, surrounding commissural opening. Medial and lateral fascial septum goes from borders of aponeurosis to I and V metatarsal bone. In deep and interosseus muscles – sold interosseus fascia.

MUSCLES Middle fascial bed (four layers): - M. flexor digitorum brevis; - Mm. quadrates plantar, lumbricales (4 units), tendo m. flexoris digitorum longi; - M. adductor hallucis (oblique and transverse head); - Tendo m. peronei longi. Medial fascial bed (continuation of canalis calcaneus): mm. abductor hallucis, flexor hallucis brevis, tendo m. flexoris hallucis longi. Lateral fascial bed: mm. abductor digiti minimi, flexor digiti minimi brevis, opponens digiti minimi.


A. v. n. plantares mediales – in middle bed along medial fascial septum, gives branches to muscles of medial and middle bed. A. v. n. plantares laterals goes at first between tendons of mm. flexor digitorum brevis et quadrates, on lateral fascial septum enters into deeply to interossus sole fascia, where artery formed arcus plantae (from it exits aa. metatarseae plantares, branches on aa. digitales plantares). Artery of end branch anastomosis with a. dorsalis pedis in I intermetatarsal space.

LYMPH FLOW Lymphatic nodes absent, lymph flow into inguinal and popliteal lymphatic node.

TISSUE SPACE Middle fascial bed has two sulcus: between mm. flexores digitorum longus et brevis and between m. flexor digitorum longus et m. adductor hallucis; appear to be continuation of calcaneal and sole canal. Canalis plantaris (sole canal) formed by side of fascial septum, above by long ligament of sole, below – fascial sheath between m. flexor digitorum brevis and m. quadrates plantae. Medial and lateral fascial bed.


A. plantaris medialis anastomosis with a. metatarsea I (branch of a. plantaris lateralis). A. plantaris lateralis anastomosis with r. plantaris profundus a. dorsalis pedis in I intermetatarsal space.

28

SECTION II

REGION OF HEAD

2.1 REGION OF HEAD BORDERS Lower border of mandible, arch of mandible, superior border of mastoid processus,

superior nuchal line, protuberantia occipitalis externa. Brain part of head separated from face by line, starting from supraorbitalis bordes, zygomatic arch to external auditory meatus.

ASSOCIATED REGION

Brain part: region of frontal-parietal-occipital, temporal, mastoid processus. Face part: region of buccal, parotid-masticatory, deep.


(SEE <BORDERS>), also glabella, incisura supraorbitalis, superciliary arch, parietal tuberculum, parietal sutures, fossa canina, temporal-mandibular joint, coronal and processus articularis of mandible.

PROJECTION A. v. supraorbitales – borders of middle and medial third of supraorbital borders. A. v. n. supratrochleares – intersection between supraorbital border with vertically from medial arch of orbital fissure. A. v. temporales superficiales, n. auriculotemporalis – vertically in front of tragus. A. v. n. auricularis posteriores – posterior to attachement of pinna. A. v. occipitals, n. occipitalis major – middle distance between posterior wall of mastoid process and protuberantia occipitalis externa. N. occipitalis minor – 3-3.5 cm posterior from attachment of pinna. A. meningea media and its branches – Krenleyn schema. Emissarium parietale – on level of sagittal suture , towards the front and rear from longitudinal cerebral fissure. Sinus sagittalis superior – from glabella to protuberantia occipitalis exterior; confluens sinuum – protuberantia occipitalis exterior; sinus transverses – linea nucha superior; sinus sigmoideus – posterior lower quadrant of mastoid processes. Antrum mastoideum – anterior lower quadrant of mastoid processes. Canalis facialis – anterior lower quadrant of mastoid processes. A. v. n. infraorbitalis – fossa canina, on 0.5-0.8 cm below infraorbital border. A. v. n. mentales – on middle distance between alveolar and lower border of mandible on 2.5 cm towards the inside from middle line of face. A. v. n. facials – from intersection between anterior border of m. masseter with lower border of mandible to medial part of angle of eye. N. facialis – from point at tragus to anterior and inferiorly separated into its branches: - R. temporalis – in temporal region; - R. zygomaticus – to lateral angle of eye. - Rr. buccales – to middle distance between wing of nose and corner of mouth; - R. marginalis mandibulae – on lower border of mandible (or 1-2 cm lower) - R. colli – vertically descends to the region of neck. Ductus parotideus – on 2-2.5 cm below and parallel to the zygomatic arch.


Skin thin, has hair covering (size and area depends on sex and age). Subcutaneous fatty tissue contains various structures and thickness (SEE <CORRESPONDING REGION>). Contains large quantity of blood vessels (aa. vv. facialis, temporalis superficialis, occipitalis, supraorbitalis, supratrochleares), sensation (V part – n. trigeminus, cervical plexus) and motor (VII part – n. facialis) nerve, ductus parotideus, mimicry muscles. Superficial fascia formed independently only in temporal region.

PROPER FASCIA Not expressed in all regions. In brain part – temporal aponeurosis. In facial part – fascia parotideomasseterica, interpterygoidal fascia.

DEEP FORMATION

Muscles – mm. frontalis, occipitalis, galea aponeurotica; masseteric (mm. masseter, pterigoidei lateralis et medialis, temporalis), mimicry. Blood vessels: 1. A. maxillaries and its branches in deep region of face; 2. Venous plexus (plexus pterygoideus) anastomosis with superficial vein of skull vault

and face, with sinus cavernosus, blood from plexus flows into v. retromandbularis; 3. Artery of dura mater, sinus of dura mater. 4. Artery and vein of brain.

31

Parotid salivary gland: Bone plate (brain section), short (facial section), mixed and aeriferous. Bone cavity: 1. Limited by bone (skull cavity, covering of dura mater, contains brain; cavity of eye,

mouth, nose; 2. Inside bone: accessory nasal sinuses (frontal, base, ethmoidal, maxillary); tympanic

region; cavern and cell of mastoid processus.


Arterial and venous system arranged on multiple symmetrical type (more detail, SEE <CORRESPONDING REGION>).

TISSUE SPACE Brain part – subaponeurotic, subperiosteum, interaponeurotic space. Facial part – parotid-massteric, bed of parotid salivary gland, fat lump of buccal, spatium temporopterygoideum, spatium interpterygoideum (see CORRESPONDING REGION).

LYMPH OUTFLOW

From superficial layer and organ of head, lymph flows into lymphatic nodes, lies on borders of head and neck: nodi lymphatici occipitals, mastoidei, parotidei, (superficiales et profundi), retropharyngeales, mandibulares, submandibulares, submentales. Later lymph flows into superficial and/or deep lymph nodes of neck.

32

2.1.1 FRONTAL-PARIETAL-OCCIPITAL REGION BORDERS Superior – supraorbital border.

Posterior – on superior nuchal line to protuberantia occipitalis externa. Lateral – upper border of mastoid processus.


See <BORDERS>, also glabella, incisura supraorbitalis, supratrochlear arch, parietal tuberculum, parietal sutures.

PROJECTION A. v. n. supraorbitales – borders of middle and medial third of supraorbital borders. A. v. n. supratrochlearis – intersection between supraorbital borders with vertically from medial corner of eye orbit. A. v. temporales superficiales, n. auriculotemporalis – vertically in front of tragus. A. v. n. auriculares posteriores – behind attachment of pinna. A. v. occipitals, n. occipitalis major – middle distance between posterior border of mastoid processus and protuberantia occipitalis externa. N. occipitalis minor – 3-3.5 cm posteriorly from attachment of pinna. Vv. emissariae parietalis – on direction of sagittal suture, anterior and posterior from longitudinal cerebral fissure. Sinus sagittalis superior – from glabella to protuberantia occipitalis externus. Confluens sinuum – protuberantia occipitalis externus. Sinus transverses – linea nucha superior.

SUPERFICIAL FORMATION, PROPER FASCIA, MUSCLES

SCA

LP

Skin covered with hair (except in frontal region), less mobile, attached with galea aponeurotica. Subcutaneous tissue divides tissue on cellular, contains neuro-vascular formation (see <PROJECTION>), artery attached to surface of galea aponeurotica, vein anastomosis with diploe vein and sinus of dura mater. Galea apneurotica consist of superficial fascia and tendon of m. occipitofontalis, towards the front to the superior nucheal line, superiorly to infraorbital border, lateral enter into superficial fascia of temporal region.

BONE Ossa frontale, occipitale, two parietalia. Periosteum loosely joint with external lamina of bone, in region of suture strongly attached to bone. External and internal (lamina vitrea) of compact lamina encloses the diploe layer of numerous diploe veins. Lamina vitrea has multiple sulcus and canal for vessels membrane arteries.

DURA MATER Loosely joined to bone of skull cavity, dense connection with base. Consist of two loose connecting sheath. Formed by three branches: falx cerebri, falx cerebella, tentorium cerebella. Epidural space – between bone of skull and dura mater; subdural space – between dura mater et arachnoidea. Sinus of dura mater – Splitting in point of attachment to its branches, flow of venous blood from brain: - Sinus sagittalis superior, sinus sagittalis inferior (in upper and lower border of falx

cerebri); - Sinus rectalis, sinus transverses, sinus occipitalis, sinus cavernosus, confluens sinuum; - Sinus sigmoideus – blood from previously mentioned sinuses into v. jugularis interna. Artery of dura mater (joined with external lamina dura mater and lamina vitrae): a. meningeal media (main) – branches of a. maxillaries; aa. meningeae anterior et posterior.

TISSUE SPACE Subaponeurotic – between galea aponeurotica and periosteum, isolated from border of region of attachment of scalp to periosteum. Subperiosteum – limiting single bone.


All superficial artery (see <PROJECTION>) anastomosis between each other, formed dense network of multiple type. Vein also formed network, anastomosis with diploe vein, sinus of dura mater through vv. emissariae. Artery of dura mater also anastomosis between themselves.

LYMPH OUTFLOW

Lymph from superficial layer region flows into nodi lymphatici parotidei superficiales et profundi, retroauriculares, occipitals, later – into lymph nodes of neck.

33

2.1.2 TEMPORAL REGION BORDERS Anterior – zygomatic processes of frontal bone, frontal processes of zygomatic bone.

Superior – contour of superior border of temporal muscles (superior temporal line). Inferior – zygomatic arch.


(SEE <BORDERS>).

PROJECTION A. v. temporales superficiales, n. auriculotemporalis – towards the front from tragus. A. meningea media and its branches – scheme of Krenleyn.


Skin thin, mobile. Superficial tissue, thin, loose. Superficial fascia developed layers. A. v. temporales superficiales, n. auriculotemporalis divides on frontal and parietal branches.

PROPER FASCIA F. temporalis has appearance like aponeurosis, starts from bone of skull to anterior border of the region, on level 3-3.5 cm above zygomatic arch splitting on superficial and deep sheath, which in isolated grow together with upper border of zygomatic arch.

MUSCLES M. temporalis

VESSLES Aa. temporalis profundi anterior et posterior – branches of a. maxillaries, goes to periosteum. Vv. temporalis profundi anterior et posterior – flow into venous deep plexus of the region of the face.

NERVE Nn. temporales profundi anterior et posterior – branches of V part of trigemini nerve (r. mandibularis n. trigemini)

TISSUE SPACE Interaponeurotic space groove – enclosed between sheath of proper fascia. Subaponeurotic tissue spaces – between fascia and muscles, at which penetrate into temporal processes of buccal fat lump.


Superficial temporal vessels anastomosis with vessels of frontal-parietal-occipital region.

LYMPH OUTFLOW

Lymphatic nodes absent, lymph flow into nodi lymphatici profundi of deep region of face.

BONE Squamous of temporal and large pterygoisal wing bone usually thin, medial surface branches to a. meningea media in proper bone sulcus.

DURA MATER Loosely attached to bone. Surface of plate is tightly attached to branches of a. meningea media.

34

2.1.3 MASTOID PROCESS REGION BORDERS Corresponds to contour of mastoid process.

PROJECTION Antrum mastoideum - anterior upper quadrant. Canalis facialis – anterior lower quadrant. Fossa craniocerebralis posterior – posterior upper quadrant. Sinus sigmoideus – posterior lower quadrant. Emissarium mastoideum – posterior point of base of mastoid process.


Skin thin, less mobile. Subcutaneus tissue – thin, loose. Superficial fascia not developed. A. v. auriculares posteriores, n. auricularis magnus; branches of n. auricularis posterior, n. occipitalis minor, nodi lymphatici retroauricularis.

PROPER FASCIA Fascia – very thin continuation of galea aponeurotica, covers mm. longissimus capitis, sternocleidomastoideus, digastricus, which here attached to processus.

VESSELS (See <SUPERFICIAL FORMATION>)

NERVE (See <SUPERFICIAL FORMATION>)

TISSUE SPACE (See <SUPERFICIAL FORMATION>)


A. auricularis posterior anastomosis with a. occipitalis et a. temporalis superficialis. V. emissaria mastoidea join with superficial vein with sigmoid sinus.

LYMPH NODES Absent.

BONE Periosteum joint with processes, in region of trepanation of triangle of Shipo (crista mastoidea – posterior border of external auditory meatus – horizontal prolongation of zygomatic arch) easily exfoliated. On that level in thickness of bone, depth is 1.5-2 cm to reach antrum mastoideum.

35

2.1.4 BUCCAL REGION OF FACE BORDERS Superior – lower border of orbit.

Inferior – lower border of mandible Anterior – naso-labial and naso-buccal fold. Posterior – anterior border of m. masseter


(See <BORDERS>), fossa canina

PROJECTION A. v. n. infraorbitalis – fossa canina, on 0.5-0.8 cm below infraorbital border. A. v. n. mentales – on middle distance between alveolar and lower border of mandible, on 2.5 cm laterally form medial line of face. A. v. facialis – from intersection between anterior border of m. masseter with lower border of mandible to medial orbital arch.


Skin thin, contains multiple sweet and sebaceous glands, covered with hair (male – coarse). Subcutaneous fat tissue developed good, it is thick, in sheath from superficial fascia located mimetic muscles (starts from bone and attached to skin), partly – buccal fat lump (corpus adiposum buccae) – limited by thin fascial sheath, goes to deep region of face layer branches: temporal, orbital, pterygoidal. A. facialis – turn, anastomosis with a. buccalis, a. transversa faciei, a. infraorbitalis, a. ophthalmica. V. facialis goes posteriorly from artery and straight, source located at v. angularis, anastomosis with region of medial ophthalmic arch with v. nasofrontalis, on level of wing of nose – with plexus venosus profundus and across them with sinus cavernosus. Branches of n. trigeminus (sensory) – n. infraorbitalis, nn. buccalis et mentalis. Branches of n. facialis (motor) – in deep layer tissue. Ductus parotideus – perforate m. buccinators on level of parotid-masseter region (anterior border of m. masseter).

PROPER FASCIA F. buccopharyngea covers m. buccinator.

MUSCLES F. buccopharnygea covers m. buccinator.

TISSUE SPACE Buccal fat lump.


Branches of a. facialis anastomosis with analogical branches of opposite side of face (symmetrical network of multiple type), (See <SUPERFICIAL FORMATION>).

LYMPH OUTFLOW

Lymph nodes absent. Lymph flows into neck lymph nodes, (See <ANTERIOR NECK REGION, TABLE 5.1>)

36

2.1.5 PAROTID-MASSATER REGION OF FACE BORDERS Superior – zygomatic arch.

Posterior – external acoustic meatus and mastoid processus. Inferior – lower border of mandible. Anterior – anterior border of m. masseter.


See <BORDERS>, temporal-mandibular joint, coronal and articular processes of mandible.

PROJECTION N. facialis – from point to anteriorly and inferiorly from tragus fan-out branches: - R. temporalis – in temporalis region. - R. zygomaticus – to lateral orbital corner. - Rr. buccales – to middle distance between wing of nose and corner of mouth; - R. marginalis mandibulae – on lower border of mandible (or 1-2 cm lower); - R. colli – vertically descends into region of neck. Ductus parotideus – on 2-2.5 cm below and parallel to zygomatic arch.


Skin thin, contain numerous sweat and sebaceous gland, covered with hair (coarse in male). Subcutaneous fat tissue developed, contains branches of facial nerve. Ductus parotideus parallel with a. v. transversae faciei (branches of a. temporalis superficialis) goes to external surface of m. masseter; nodi lymphatici parotidei superficiales receives lymph from superficial layers of skull cavity and face.

PROPER FASCIA F. parotideomasseterica formed capsule for parotid gland, give out thickness branches, also formed sheath for m. masseter.

DEEP FORMATION

M. masseter. Glandula parotis located in fossa retromandibularis, its bed formed by anatomical formation: - Superiorly – cartilaginous part of external auditory meatus (weak spot of capsule); - Posterior – m. sternocleidomastoid; - Inferior – branches of fascia, isolated from gl. submandibularis; - Anterior – lower corner of mandible. - Medial – peripharyngeal tissue spaces (weak spot of capsule). In bed of gland, located: N. facialis pierces glands vertically, formed plexus parotideus and goes branches, exit from below capsule into buccal region (see <PROJECTION>); - N. auriculotemporalis goes in thickness of glands and exit on superficial layer of

temporal region; - V. retromandibularis receives blood from deep region of face and temporal region; - A. carotis externa – on level of neck of articular processes divides into final branches:

a. temporalis superficialis et a. maxillaris; - Nodi lymphatici parotidei profundi.

TISSUE SPACES Masseter-masticatory space – between masseter muscles and mandible. Bed of parotid salivary gland.


A. v. transversae facici anastomosis with a. v. facialis; v. retromandibularis anastomosis with plexus facialis profundus and across them with sinus cavernosus.

LYMPH FLOW See <SUPERFICIAL FORMATION>, later lymph flows into deep lymphatic nodes of neck.

37

2.1.6 DEEP REGION OF FACE BORDERS Spaces (infratemporal fossa), limited:

- Lateral – ascending branches of mandible. - Anterior – tuberculum maxillaries. - Medially – pterygoidal processes of cuneiform bone. - Superior – base of skull. - Posterior –parotid salivary gland and its capsule. - Inferior – isolated attachment to corner of mandible mm. masseter et pterygoideus

medialis.

PROPER FASCIA Fascia covers muscles (mm. pterygoidei medialis et lateralis, temporalis) and formed interpterygoidal aponeurosis, covers external surface of medial pterygoidal muscles.

MUSCLES Mm. pterygoidai medialis et lateralis, temporalis.

TISSUE SPACE Spatium temporopterygoideum contains: 1. venous plexus (plexus pterygoideus), which anastomosis with superficial vein of skull

cavity with face, also with sinus cavernosus; blood from plexus flows to v. retromandibularis;

2. a. maxillaries surrounds neck of articular processus of mandible, later goes into transverse direction into pterygoidal fossa and gives branches: - A. meningea media across foramen spinosum exit into middle skull-brain fossa; - A. alveolaris inferior goes into canal of mandible. - Aa. masseterica, temporales profundi anterior et posterior buccales – to muscles. - A. infraorbitalis, aa. alveolares superiores posteriores; - A. palatine descendens, a. sphenopalatina.

Spaces communicate with pterygoidal fossa, cavity of skull (round opening), orbital, buccal fat lump (Bisha) penetrate through its processes. Spatium interpterygoideum contains branches of n. mandibularis (branches of n. trigeminus): - N. massetericus, nn. temporales profundi anterior et posterior, - N. buccinatorius – to muscles. - N. auriculotemporalis – enveloped two branches of a. meningea media and exit across

parotid salivary gland with superficial layers of temporal region. - N. alveolaris inferior goes n. mylohyoideus and enters into canal of mandible. - N. lingualis joint with chorda tymphani and goes inferiorly and laterally, turn to

mucous membrane of tongue. Spaces communicate with peripharnyngeal space, cavity of skill, floor region of mouth, pterygoidal fossa. Both spaces of deep region of face communicate also with each other, anteriorly one with another.


(See <TISSUE SPACES>)

LYMPH OUTFLOW

Lymphatic nodes absent. Lymph flows into nodi lymphatici parotidei profundi and deep lateral lymph nodes of neck.

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SECTION III

REGION OF NECK

5.1 TOPOGRAPHY OF ANTERIOR REGION OF NECK

BORDERS Superior – lower border of body of mandible, peak of mastoid process, superior nuchal line, external occipital tuberosity. Inferior – jugular notch, clavicle, acromion, upper part of spinal processus of VII cervical vertebra. Lateral – anterior border of m. trapezius.

ASSOCIATED REGION

Suprahyoid and infrahyoid region (separate upper and lower based on os hyoideum) and triangles of neck: medial – anterior neck line, lower border of mandibular, anterior border of m. sternocleidomastoideus; lateral – anterior border of m. trapezius, clavicle, posterior border of m. sternocledomastoideus. Triangle divided by muscles to more smaller: Submental, submandibular, carotid, scapular-tracheal, scapular-trapezius, scapular-clavicular and stenocleidomastoid region.


(SEE <BORDERS>), also os hyoideum, m. sternocleidomastoideus: between its crura – fossa supraclavicularis minor, fossa supraclavicularis major; v. jugularis externa, cartilage of larynx (thyroid, cricoids), first ring of trachea, tuberculum caroticum transverse processus of VI cervical spine.

PROJECTION A. carotis communis, v. jugularis interna, n. vagus – in upper third of neck lies anterior from m. sternocledomastoideus, in lower third – behind it (on line from middle distance between arch of mandible and mastoid process to fossa supraclavicularis minor). N. accessories intersect m. sternocleidomastoideus; towards behind from arch of mandible to borders between upper and middle third behind its border, later to borders of lower and middle third of m. trapezius. N. phrenicus – on middle of m. sternocleidomastoideus at level of middle thyroid cartilage vertically downwards. Dome of pleura – fossa supraclavicularis minor on 4 cm above clavicle. A. v. facialis – intersect anterior border of m. masseter with lower border of mandible Ramus marginalis mandibulae (branch of n. facialis) – along lower border of mandible; ramus colli – from angle of mandible downwards. Arch of aorta, v. brachiocephalica sinistra – fossa jugularis. A. subclavia – fossa supraclavicularis major. Plexus brachialis – line from orders of lower and middle part of posterior border of m. sternocleidomastoideus to middle clavicle. Exit cutaneous branch of plexus cervicalis – middle width of posterior border of m. sternocleidomastoideus.


Skin thin, extensible, joint tissue with sheath of m. platysma. Subcutaneous tissue developed. Superficial fascia (I based on Шевкуненко) formed sheath for m. platysma. V. jugularis externa goes under superficial fascia, joint with proper fascia, from angle of mandible to medial angle of scapular-clavicular triangle, where it pierces proper fascia. Vv. jugulars anteriores goes from chin to jugular notch, where it pierces proper fascia. Branches of plexus cervicalis: - N. transverses colli intersect m. sternocleidomastoideus horizontally, gives branches

to ramus colli; n. facialis – on formation of arcus colli superficialis. - N. auricularis magnus goes upwards and behind v. jugularis externa; - Nn. supraclaviculares medius, intermedius et lateralis – to sternum, clavicle and

acromial processus. Ramus marginalis mandibulae et ramus colli n. facialis – (SEE <PROJECTION>).

PROPER FASCIA В. Н. Шевкуненко mentioned about five sheath of neck fascia. I fascia (fascia superficialis) – superficial fascia, goes to neighbouring region; II fascia (lamina superficialis f. colli propriae) – united sheath, surround the neck, secured to borders neck to bones, formed sheath for m. sternocleidomastoideus, m. trapezius, glandula submandibulares. III fascia (lamina profunda f. colli propriae, sails of Рише) above attached to os hyoideum, below – to sternum and clavicle; lateral ends on level of m. omohyoideus;

41

formed sheath for mm. omohyoideus, sternohyoideus, sternothyreoideus, thyreohyoideus. IV (fascia endocervicalis) – has parietal sheath (formed sheath for main neuro-vascular bundles of neck), and visceral (formed sheath for every organ of neck), behind its organ lies in anterior and posterior mediastinum. V fascia (fascia prevertebralis) formed sheath for long muscles of the head and neck (SEE <MUSCLES>), fixed to base of skull above, to III and IV thoracic vertebra below, to transverse processus of vertebra laterally. On middle line of neck below os hyoideum attached II and III fascia formed white line of neck with width of 3 mm, which under it end on 3.5 cm above jugular notch.

MUSCLES M. sternocleidomastoideus – in sheath, formed II fascia. Mm. omohyoideus, sternothyreoideus, sternohyoideus, thyreohyoideus – pretracheal muscles in sheath, formed III fascia; in infrahyoid region. Mm. digastricus, mylohyoideus, hyoglossus, genioglossus, geniohyoideus – in suprahyoid region. Mm. scalene anterior, medius, posterior, mm. levator scapular, longus colli, longus capitis – deep muscles of sheath of V fascia.

VESSELS Submental, submandibular, carotid and other triangles of neck (SEE <TABLE 5.1.1-5.1.4, 5.1.11, 5.1.12), larynx, trachea, pharynx, esophagus, thyroid and parathyroid gland (SEE <TABLE 5.1.5-5.1.9>).

NERVE -SAME-

INTERNAL ORGANS

-SAME-

TISSUE SPACE Sheath for m. sternocleidomastoideus. Sheath for glandula submandibularis. Spatium interaponeuroticum suprasternale – between II and III fascia on 2-3 cm above jugular notch, contains arcus venosus juguli between anteriorjugular vein, multiple lymph nodes, communicate with recessus retrosternocleidomastoideus. Recessus retrosternocleidomastoideus (Грубера) – on lower third of m. sternocleidomastoideus, between II and III fascia, contains tissue. Spatium previscerale – between parietal and visceral sheath of IV fascia, well developed anterior trachea (spatium pretracheale), communicate with anterior mediastinum, contains venous thyroid plexus, lymph nodes, in 8% of people – a. thyreoide ima. Spatium retroviscerale – between IV and V fascia, communicate with posterior mediastinum. Spatium vaso-nervorum surround sheath for main neuro-vascular bundles of neck (parietal sheath of IV fascia), contains a. carotis communis, v. jugularis interna, n. vagus, deep lymphatic nodes. Spatium antescalenum – between m. scalenus anterior (V fascia) and m. sternocleidomastoideus (posterior surface, covers II and II fascia). Trigonum scalenovertebrale – sternocleidomastoid region (SEE <TABLE 5.1.10>). Spatium interscalenum – between mm. scalene anterior et medius (scapular-clavicular triangle, SEE <TABLE 5.1.12>). Spatium prevertebrale – behind from V fascia, sheath for long muscles of neck and head.


Venous and arterial system, arranged in multiple type, symmetrical, (SEE also triangles of neck <TABLE 5. 1.1-5.1.4, 5.1.12).

LYMPH FLOW Nodi lymphatici: - Occipitales gathers lymph from hair part of head. - Submandibulares gathers lymph from face. - Submentales gathers lymph from root of tongue, middle lower part of mouth. - Cervicales superficiales (inconstant) – along v. jugularis exterior; - Cervicales profundi arteriores (prelaryngeales, thyreoidei, pretracheales,

paratracheales); - Cervicales profundi laterals – along v. jugularis interna, gather lymph from all

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mentioned previously; - Supraclaviculares – along a. supraclavicularis, gather lymph from head, neck,

mammary gland, eosophagus, stomach. Later lymph flows to truncus lymphaticus jugularis, later to left in ductu thoracicus, right – ductus lymphaticus dexter.

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5.1.1 SUBMENTAL TRIANGLE

BORDERS Superior (peak) – submental spine of mandible. Inferior – os hyoideum Lateral – anterior belly of mm. digastrici.


(SEE <BORDERS>).

PROJECTION -


Skin thin, mobile. Subcutaneous tissue developed. Superficial fascia formed sheath for m. platysma. Usually has 1-2 superficial lymph nodes.

PROPER FASCIA II fascia based on Шевкуненко (lamina superficialis f. colli propriae) formed sheath for anterior belly of mm. digastrici.

DEEP FORMATION

Muscles: mm. digastrici, mylohyoidei – fromed sulcus for middle line of neck; deeper lies mm. geniohyoidei (cylindrical): deepest – mm. genioglossi (fan-shaped); mm. hyoglossi (sheath). Glandulae sublianguales et n. lingualis on lateral surface of mm. hyoglossi. A. v. submentales et n. mylohyoideus goes between m. mylohyoideus and anterior belly of m. digastricus.

TISSUE SPACE Between mucous envelope floor cavity of mouth and mm. genioglossi lies loose layer of tissue.

LYMPH FLOW Nodi lymphatici submentales (1-2 units). Gather lymph from root of tongue, middle section floor of cavity of mouth, middle section of lower lips.

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5.1.2 SUBMANDIBULAR TRIANGLE

BORDERS Superior – borders of mandible. Inferior – m. digastricus (both belly)


(SEE <BORDERS>).

PROJECTION Ramus marginalis mandibulae (n. facialis) – parallel to border of mandible. Enter on region of face a. facles – intersect lower border of mandible with m. masseter.


Skin thin, mobile. Subcutaneous tissue developed. Superficial fascia formed sheath for m. platysma. Deeply located: - Ramus marginalis mandibulae n. facialis; - Ramus colli n. facialis; - N. transversus colli; formed arcus cervicalis superficialis - Nodi lymphatici submandibulares (superficiales) – accept lymph from superficial layer

of lateral region of face.

PROPER FASCIA II fascia (lamina superficialis f. colli propriae) formed sheath for glandula submandubularis. Its surface sheath attached to lateral side of mandible, its deep more loose – medially to linea mylohyoidea, cover muscles of floor of triangle.

DEEP FORMATION

Mm. mylohyoideus et hyoglossus make up floor for submandibulae triangle. Glandula submandibularis section from surrounding capsule loose layer of tissue; its duct goes into tissue floor of cavity of mouth. V. facialis lies under superficial sheath fascia (or in its thickness), merge with v. retromandibularis. A. facialis goes from carotid triangle, lies behind glandula submandibularis, exits in subcutaneous tissue of face where intersects border of mandible with m. masseter. N. lingualis – above from salivary gland in spaces between mm. mylohyoideus et hyoglossus. N. hypoglossus lies above spaces of tendon of m. digastricus, together with them and border of m. mylohyoideus limits triangle of Piragov, floor which formed m. hyoglossus. A. lingualis enters in triangle of Piragov under m. hyoglossus on posterior wall of pharynx; v. lingualis exit through surface of m. hyoglossus.

TISSUE SPACE Anterior region of neck (SEE <TABLE 5.1>).

LYMPH FLOW Nodi lymphatici submandibulares gather lymph from medial part of eyelid, external nose, envelope of cheek , gums, mouth, floor cavity of mouth and middle section of tongue.

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5.1.3 CAROTID TRIANGLE

BORDERS Superior – posterior belly of m. digastricus Posterior – anterior border of m. sternocleidomastoideus. Inferior – superior belly of m. omohyoideus.


Anterior region of neck (SEE <TABLE 5.1>)

PROJECTION Anterior region of neck (SEE <TABLE 5.1>)


Skin thin. Subcutaneous tissue expressed. Superficial fascia formed sheath for m. platysma. R. colli n. facialis, n. transversus colli (from plexus cervialis). V. jugularis anterior – along anterior border of m. sternocleidomastoideus.

PROPER FASCIA II fascia (lamina superficialis f. colli propriae). IV fascia (parietal sheath) formed by sheath for main neuro-vascular bundles of neck (a. carotis communis, v. jugularis, n. vagus). V fascia (fascia prevertebralis) covers deep long muscles of neck.

DEEP FORMATION

Muscles – (SEE <BORDERS>), also m. scalenus anterior, show floor of triangle. Vessels: - V. facialis lies immediately under II fascia, pierce sheath of neuro-vascular bundeles

and flow in v. jugularis interna; - A. carotis communis lies on bifurcation arch between mm. omohyoidus et

sternocleidomastoideus; divide on level of upper border of thyroid cartilage (or os hyoideum) to a. carotis interna (lies often laterally); a. carotis externa (gives branches a. thyreoidea superior (usually exits from a. carotis communis), a. lingualis; a. facialis; a. occipitalis, a. auricularis posterior, a. pharyngea ascendens);

- V. jugularis interna lies lateral to artery, here in them flow v. facialis, in which in this level flow vv. lingualis et thyreoidea superior.

Nerve formation: - N. hypoglossus intersect region in upper part of arch and goes radix superior ansae

cervicalis, which descend on sheath of neuro-vascular bundles along a. carotis interna on anastomosis with radix inferior from plexus cervicalis; formed ansa cervicalis for innervations of pretracheal muscles;

- N. vagus – between a. carotis et v. jugularis interna, behing them. - N. laryngeus superior – branched of n. vagus goes from below nodes in oblique-

transverse direction behind branches of a. carotis externa, its internal branch together with a. laryngea superior pierce membrane thyreohyoidea and innervate mucous membrane of larynx above vocal ligaments;

- Truncus sympathicus – behind and lateral from n. vagus under V fascia (or its thickness).

- Sinus caroticus – widening at first a. carotis interna, contains baroreceptor. - Glomus caroticum – corpuscle on bifurcation of a. carotis communis, contain

chemoreceptor.

TISSUE SPACE Anterior region of neck (SEE <TABLE 5.1>)

LYMPH FLOW Nodi lymphatici jugulars (profundi) lies along v. jugularis interna, gather lymph from all nodes of head and neck, from derivation of vessels formed truncus lymphaticus jugularis.

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5.1.4. SCAPULAR-TRACHEAL TRIANGLE

BORDERS Superior – superior belly of m. omohyoideus. Posterior – anterior belly of m. sternocleidomastoideus. Medial – middle line of neck. Right and left scapular-tracheal triangle formed infrahyoid region of neck, in which lies main internal organs of neck.

INTERNAL ORIENTATION

(SEE <BORDERS>), also cartilage of larynx and trachea, jugular fossa.

PROJECTION -


Skin thin, mobile. Subcutaneous tissue expressed. Superficial fascia contains m. platysma, which absent in middle section above jugular fossa. Vv. jugulars anteriores goes on 0.5-1.0 cm lateral medial line vertically down, penetrate in spatium interaponeuroticum suprasternale, where anastomosis between them (arcus venosis juguli).

PROPER FASCIA II fascia (lamina superficialis f. colli propriae). III fascia (lamin profunda f. colli propriae) IV fascia (f. endocervicalis) – anterior region of neck (SEE <TABLE 5.1>).

DEEP FORMATION

Muscles – anterior region of neck (SEE <TABLE 5.1>) Internal organs – larynx, thyroid and parathyroid gland, trachea, larynx, esophagus (SEE <TABLE 5.1.5-5.1.9>).

TISSUE SPACE Anterior region of neck (SEE <TABLE 5.1>).

LYMPH FLOW Anterior region of neck (SEE <TABLE 5.1>).

47

5.1.5 LARYNX

HOLOTOPIA Infrahyoid region, cartilage of larynx clearly detected by palpation.

BORDERS Lies from level of upper border of V cervical vertebra (upper border of thyroid cartilage) to lower border of VI cervical vertebra (lower border of cricoid cartilage), epiglottis reach III cervical vertebra.

SHEATH Enclosed by visceral layer of IV fascia of neck.

SYNTOPIA In front of larynx enclosed muscles – mm. sternohyoideus, sternothyreoideus, thyreohyoideus; laterally lies lateral lobe of thyroid gland (on middle part of thyroid cartilage); behind of larynx – pharynx; above epiglottis reach to root of tongue; below larynx goes into trachea.

BLOOD SUPPLY, INNERVATION

A. v. laryngeae superior goes from carotid triangle, together with ramus internus n. laryngei superior pierce lateral section of membrane thyreohyoidea, supply blood and innervations of mucous membrane epiglottis and cavity on level of vocal ligament. Ramus externus n. laryngei superior goes parallel to a. thyreoidea superior and innervate m. constrictor laryngeus inferior et m. cricothyreoideus. a. laryngea inferior – bracnhes of a. thyreoidea inferior; anastomosis with branches of opposite side and with a. laryngea superior. V. laryngea inferior flow into v. thyreoidea inferior. N. laryngeus inferior – end part of n. laringeus recurrens, which exit from n. vagus right in spot of dividing of brachiocephalic trunk, enclosing a. subclavia behing, later goes between trachea and oesophagus. Left, it goes on level of lower border of arch of aorta, enveloping from behind, goes later behind trachea and anterior wall of esophagus; enter into cavity of larynx together with similar vessels behind cricoids articulation, innervate muscles of vocal cord and mucous membrane of larynx below.

LYMPH FLOW Lymphatic nodes of first degree – nodi lymphatici profundi anteriores, later lymph flows into nodi lymphatici profundi laterales.

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5.1.6. THYROID AND PARATHYROID GLAND

HOLOTOPIA Infrahyoid region of neck

BORDERS Upper pole of lateral lobe of thyroid gland – middle plate of thyroid cartilage; below pole – under border on 1.5-2 cm; isthmus lies on first ring of trachea; additional (pyramidal) lobe has in one per third chance, raise above from isthmus or from one of the lobes of gland. Parathyroid gland lies on two or posterior-medial surface of every lobe of thyroid gland near point of entrance of their a. thyreoidea inferior: superior – on level below border of cricoids cartilage, inferior – on 1.5-2 cm above its lower pole border of lobe.

SHEATH Fibrous covering (internal) gives in thickness of thyroid gland interlobular septum. Fascial covering (external) formed by visceral sheath of IV fascial of neck, gives from fibrous loose tissue of cells, formed connection from isthmus to cricoids cartilage, from upper pole of lateral lobe to thyroid cartilage.

SYNTOPIA Thyroid gland on front covered by mm. sternothyroidei, sternohyoidei, omohyoidei; posterior-medial surface of lateral lobe lies to larynx, trachea, esophagus, nn. laryngei recurrentes; posterior-lateral surface aa. carotis communes on length of its middle third; isthmus lies anterior from trachea. Parathyroid gland (on two with each level) lies between fibrous and fascial covering of thyroid gland (SEE <BORDERS>).

BLOOD SUPPLY Aa. thyreoidea superiores dextra et sinistra – branches of a. carotis externa (usually – a. carotis communis) in carotid triangle, later goes parallel ramus externus n. laryngei superior, supply blood to upper border of isthmus laterally, anterior and posterior surface of upper pole of lateral lobe; vv. thyreoideae superiores – goes together with artery, flow into general face veins. Aa. thyreoideae inferiores dextra et sinistra – branches of trunci thyreocervicales, rise on level of VI cervical vertebra parallel n. phrenicus, formed loop and directed to lower third posterior surface of lateral lobe; here intersect n. laryngeus recurrens; supply blood also to parathyroid gland, give branches to all organ of neck. A. thyreoidea ima (has in 6-8% event) goes from arch of aorta or a. subclavia sinistra, goes in pretracheal tissue in lower border isthmus. PEARL. All artery anastomosis between them in thickness thyroid glands. Vv. thyreoideae inferiors, v. thyreoidea impar starts from plexus venosus thyreoideus inpar, flow into vv. brachocephalicae.

INNERVATION Nerve plexus of thyroid and parthyroid glands accompany branches and formed from truncus sympathicus, nn. laryngei superior et inferior.

LYMPH FLOW In near organ lymph nodes (first degree), later in deep lateral lymphatic nodes of neck

49

5.1.7. TRACHEA (NECK SECTION)

HOLOTOPIA Infrahyoid region of neck.

BORDERS Upper larynx lies in trachea on level of intervertebra disc between VI-VII cervical vertebra, below enter into region of thorax on level of jugular notch of thorax (upper border of III thoracic vertebra). All 6-8 cartilages ring of cervical section of tracheal can be assessed by palpation. Trachea directed upwards to below and anterior to posterior (below ring lies on depth of 4 cm).

SHEATH IV fascia neck (lamina visceralis f. endocervicalis) formed sheath for trachea. Between parietal and visceral sheath of IV fascia – pretracheal tissue space, continuation below into superior mediastinum.

SYNTOPIA First ring of trachea covers anteriorly by isthmus of thyroid gland, lobe of gland covered by lateral and posterior wall of trachea. Below isthmus in pretracheal tissue – plexus venosus thyreoideus and a. thyreoidea ima (in 6-8% of people), nodi lymphaticis pretracheales. Membranous part of tracheal wall join posterior to anterior wall of oesophagus, in esophagus-tracheal sulcus right and left exit nn. laryngei recurrentes. On level of trachea in thoracic section in front – upper border arch of aorta and its braches; left and right from trachea tr. brachiocephalicus divides on a. carotis communis et a. subclavia dextra; on anterior wall of trachea to the left and above noted a. carotis communis sinistra.

BLOOD SUPPLY Branches of aa. thyreoideae inferior, flow of blood – in plexus thyreoideus impar.

INNERVATION Nn. laryngei inferior (reccurentes)

LYMPH FLOW Nodi lymphatici pretracheales, later in nodi lymphatici jugulares

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5.1.8. PHARYNX

HOLOTOPIA, BORDERS

From base of skull to VI cervical vertebra, where goes into oesophagus, epipharynx (noso-pharynx) and mesopharynx (rota-pharynx) lies on level of face (head), hypopharynx (larynx-pharynx) – in infrahyoid region of neck.

SHEATH Covered by visceral sheath of IV fascia of neck (lamina visceralis f. endocervicalis).

TISSUE SPACE Spatium retropharyngeum – behind pharynx, between IV and V fascial, separate septum on left and right half, contains nodi lymphatici retropharyngeales (gather lymph from wall of nose, palatine tonsils, auditory tube). Spatium parapharyngeum (left and right) – between wall of pharynx and m. pterygoideus medialis and bed of parotid salivary gland, separate on anterior and posterior stitch diaphragm (fascial sheath mm. stylopharyngeus, styloglossus, stylohyoideus); in anterior section – a. pharyngea ascendens, pharyngeal processes of parotid salivary gland (SEE parotid-masseter region, TABLE 4.1.5); in posterior – a. carotis interna, v. jugularis interna, nn. glossopharyngeus (IX), vagus (X), accessories (XI), hypoglossus (XII).

SYNTOPIA Anteriorly from pharynx lies cavity of nose, mouth, larynx; posterior section of tissue space covers V fascia long muscles of neck; lateral to larynx-pharynx lies upper pole of lateral lobe of thyroid gland and aa. carotes communes.

BLOOD SUPPLY Aa. pharyngea ascendens, palatine ascendens, palatine descendens, thyreoideae superior et inferior.

INNERVATION Nn. vagus, glossopharyngeus, tr. sympathicus

LYMPH FLOW Nodi lymphatic profundi (along v. jugularis interna).

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5.1.9 OESOPHAGUS (CERVICAL SECTION)

HOLOTOPIA Infrahyoid region, from middle line descends to the left.

BORDERS Superior border (first narrowing in oesophagus) – lower border of IV cervical vertebra. Inferior – III thoracic vertebra (entrance into region of thorax).

SHEATH Visceral sheath of IV fascia (lamina visceralis f. endocervicalis) formed sheath for cervical part of oesophagus and together with them descendin mediastinum.

TISSUE SPACE Spatium retroviscerale – behind oesophagus, between IV and V fascia; above continuation into postpharyngeal space, below – in tissue behind mediastinum.

SYNTOPIA Anterior – cricoids cartilage, trachea; n. laryngeus reccurens sinister lies on anterior wall of oesophaus, n. laryngeus recurrens dexter – in sulcus tracheoesophageus. Posterior – prevertebral muscles (section of spatium retroviscerale). Laterally above – below pole of lateral lobe of thyroid gland, inferior – a. thyreoidea inferior, below lateral wall of oesophagus lies close from a. carotis communis (left – in few millimeter, right 1-2 cm)

BLOOD SUPPLY Aa. thyreoideae inferiores

INNERVATION Nn. laryngei inferiores (recurrentes) LYMPH FLOW Nodi lymphatici paratracheales, later into deep lymphatic nodes of neck along vv.

jugulares internae.

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5.1.10 STERNOCLEIDOMASTOID REGION

BORDERS Contour m. sternocleidomastoideus: - Superior – mastoid processus. - Inferior – clavicle and manubrium sterni. - Anterior and posterior – corresponding with anterior and posterior borders of m.

sternocleidomastoideus.


(SEE <BORDERS>), also v. jugularis externa, fossa supraclavicularis minor.

PROJECTION A. carotis communis, v. jugalaris interna, n. vagus – in upper section, anterior from m. sternocleidomastoideus, in below, behind thoracic crura. A. subclavia – middle upper border of clavicle. Truncus brachiocephalicus (right) – arch between upper border of clavicle and thoracic crura of m. sternocleidomastoideus.


Skin in upper third region of thick, below – skin, mobile. Subcutaneous tissue loose, weakly expressed. Superficial fascia (I based on Шевкуненко) on top of middle third muscle formed sheath for m. platysma. Deep surface fascia lies: - V. jugularis externa – from angle of mandible to angle between posterior border of

m. sternocleidomastoideus and clavicle. - N. auricularis magnus – goes parallel and behind v. jugularis externa; - N. transversus colli – intersect m. sternocleidomastoideus horizontal in the middle.

PROPER FASCIA II fascia based on Шевкуненко (lamina superficialis f. colli propriae) formed sheath for m. sternocleidomastoideus, in which along posterior border m. sternocleidomastoideus ascends n. occipitalis minor. III fascia – only in lower half region. IV fascia in lower hald region formed sheath for main neuro-vascular bundles. V fascia formed sheath for long muscles of neck and head (SEE <DEEP FORMATION>).

DEEP FORMATION

Muscles – in upper half region mm. longi capitis et colli (medial) and m. scalenus medialis (lateral); in lower half – mm. omohyoideus, scalenus anterior, longus colli. N. accessories (XI cranial nerve) – in upper third under sheath of m. sternocleidomastoideus. Plexus cervicalis – formed from ventral branches spinal cervical nerve, it’s trunks lies between the muscles. N. phrenicus. A. carotis communis, v. jugularis interna, n. vagus, v. subclavia, venous angle (SEE <TISSUE SPACE>) Pirogov Ductus thoracicus A. subclavia and its branches. Truncus sympathicus

TISSUE SPACE Recessus retrosternocleidomastoideus – anterior region of neck (SEE <TABLE 5.1>). Spatium antescalenum – between deep surface of m. sternocleidomastoideus and m. scalenus anterior. In them lies: - N. phrenicus – branches of plexus cervicalis, descend under V fascia on anterior

surface of m. scalenus anterior; - A. carotis communis (lateral), v. jugularis interna (medial), n. vagus (between them

behind) covered with sheath (vagina caroticum – pierce IV fascia); - V. subclavia merge with v. jugularis interna above clavicle, formed Piragov’s venous

angle; - Ductus thoracicus (left) exits from trigonum scalenovertebrale and flow into arch

(usually multiple tributaries) in Piragov’s venous angle behind. Trigonum scalenovertebrale surrounds behind dome of pleura; laterally m. scalenus anterior, medial vertebra with m. longus colli; peak – tuberculum caroticum of transverse processes of VI cervical vertebra. In them lies:

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- A. subclavia (its first section, lies on dome of pleura), which gives branches a. vertebralis – goes to opening in transverse processes of IV cervical vertebra in groove between mm. scalenus anterior et longus colli, later in canal in transverse processes to base of skulls; a. thoracica interna from lower semi-circle, goes below in anterior thoracic wall; truncus thyreocervicalis with four branches: a. thyreoidea inferna goes arch in above and descend to posterior surface lobe of thyroid glands; a. cervicalis superficialis intersect in front m. scalenus anterior; a. suprascapularis parallel m. omohyoideus goes in scapular region; a. cervicalis ascendens goes upwards parallel n. phrenicus;

- Ductus thoracicus (left), exits from sulcus behind oesophagus, arch intersect spaces in front of a. subclavia, accept in them truncus lymphaticus jugularis et truncus lymphaticus subclavius;

- Truncus sympathicus descends from region of carotid triangle, formed ganglion stellatum, which lies to first section of a. vertebralis behind;

- N. phrenicus lies in front a. subclavia lateral n. vagus, which right give here n. recurrens, enveloping a. subclavia.

BLOOD SUPPLY Absent

LYMPH FLOW Anterior region of neck (SEE <TABLE 5.1>)

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5.1.11. SCAPULAR-TRAPEZIUS TRIANGLE

BORDERS Posterior – anterior border of m. trapezius. Anterior – posterior border of m. sternocleidomastoideus. Inferior – inferior belly of m. omohyoideus


(SEE <BORDERS>, anterior region of neck (SEE <TABLE 5.1>).

PROJECTION (SEE <BORDERS>, anterior region of neck (SEE <TABLE 5.1>).


Skin thin, mobile. Subcutaneous tissue loose. Superficial (I) fascia developed. N. occipitalis minor – along posterior border of m. sternocleidomastoideus (often in its sheath).

PROPER FASCIA II fascia (lamina superficialis f. colli propriae) – formed by sheath for mm. trapeziue et sternocleidomastoideus. V fascia (fascia prevertebralis) covers deep long muscles of head and neck, lies on trunk of plexus cervicalis et brachialis.

DEEP FORMATION

N. accessories goes in tissue between II and V fascia, innervate mm. trapezius et sternocleidomastoideus. A. v. cervicales superficiales goes in transverse direction from-under belly of m. omohyoideus, exit under m. trapezius. Muscles – mm. splenii cervicis et capitis, levator scapulae, scalene posterior et intermedius.

LYMPH FLOW Two group of lymphatic nodes: on entrance to n. accessories and a. cervicalis superficialis. Gather lymph from region of neck.

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5.1.12 SCAPULAR-CLAVICULAR TRIANGLE

BORDERS Anterior – posterior border of m. sternocleidomastoideus. Posterior – lower belly of m. omohyoideus. Inferior – clavicle


Triangle laterally defined by fossa supraclaviculais major, in thin individuals contour under skin is trunk of plexus brachialis.

PROJECTION -


Skin thin, mobile. In subcutaneous tissue descend from above to middle of m. sternocleidomastoideus, sensory nerve plexus cervicalis: nn. supraclaviculares medialis, intermedius et lateralis. Superficial fascia (I fascia) formed sheath for m. platysma.

PROPER FASCIA II fascia (lamina superficialis f. colli propriae). III fascia (lamina pretrachealis f. colli propriae). V fascia (fascia prevertebralis) – formed sheath for mm. scalene and attached together with them to I and II rib, and also to sheath for a. subclavia et plexus brachialis.

DEEP FORMATION

Muscles – mm. scalene anterior, medius, posterior. A. subclavia – lies on I rib laterally attached to m. scalenus anerior (tuberculum scalenum), goes in spatium interscalenum (where gives truncus costocervicalis), later descend sharply to clavicle (from there exit a. transversa colli, goes between trunk of plexus brachialis). V. subclavia goes close to clavicle, in front of m. scalenus anterior and directed into spatium antescalenum; vein fixed to adventitious to fascial formation of neck and to clavicle. Plexus brachialis – its trunk lies above and behind from a. subclavia.

TISSUE SPACE Spatium interscalenum – between mm. scalene anterior et medius.

LYMPH FLOW Nodi lymphatici supraclaviculares gather lymph from region of head, neck, mammary gland and stomach.

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SECTION IV

REGION OF CHEST

4.1 TOPOGRAPHY OF REGION OF THE CHEST

BORDERS Lateral – Chest wall (SEE <TABLE 4.1.1>). Medial - Superior – dome of paretial pleura (left and right), associated with fossa clavicularis minor; inferior – diaphragm, rise up to level of IV intercostal, left – to V intercostal.


Chest wall, anterior region of neck (SEE <TABLE 4.1.1, 4.1).

PROJECTION -SAME-


-SAME-

PROPER FASCIA OF MUSCLE

-SAME-

SEROUS COVERING

Lies in three serous sack, one pericardium and two pleural. Pericardium – (SEE heart <TABLE 4.1.7>). Pleural (left and right) formed by parietal pleural, in which seperated in numerous sheath: 1. Costal pleural cover ribs and intercostal, covered by f. endothoracica: 2. Diaphragmatic pleura, covered by diaphragm. 3. Mediastinal pleura stretched in sagittal direction between chest and vertebra, limited

by lateral mediastinum. Borders of pleura goes togeyher with pleural sheath into chest: - Anterior border (entrance of costal pleural in mediastinal in front) right pleural goes

behind chest on level of middle line to VI intercostal, where goes below; anterior border of left pleural reach cartilage of IV rib, deflect left, intersect IV intercostal space, cartilage of V rib, V intercostal space on level of middle VI costal cartilage goes in below;

- Lower border of pleural (goes from costal pleural in diaphragm) from cartilage of VI rib turn downwards, on mid-clavicular line intersect VII rib, on middle axillary – X rib, on scapular – XI rib, on paravertebral – XII rib.

- Posterior border (entrance of costal pleura in mediastinal behind) left pleural associate with joint between rib and vertebra, right pleural – exit on anterior surface of vertebra.

Dome of pleural on 2-3 cm above clavicle in anterior region of neck, behind lies to head and neck of I rib, long muscles of neck, inferior cervical nodes of truncus symphaticus, laterally and in front – to mm. scalene, plexus brachialis, medially – tr. brachiocephalicus, a. carotis communis sinistra, in front – av. vertebrales. Visceral pleura covers lungs, between them and parietal pleura formed visceral capillary space – region of pleura. Part of the cavity, located in point of entrance of similar section of parietal pleura into others, called pleural sinuses: - Costal-diaphragmatic sinus (sinus costodiaphragmaticus) – very deep (to 8 cm), not

filled up by lungs, even in deep entrance; - Mediastinal-diaphragmatic; - Anterior and posterior costal-mediastinal.

INTERNAL ORGANS

Lungs, heart, aorta, trachea, oesophagus (SEE <TABLE 4.1.4, 4.1.6, 4.1.7, 4.1.9, 4.1.10>)

TISSUE SPACE Tissue space in chest wall. Tissue space of mediastinum limited in front by chest wall and posterior chest fascia; behind by thoracic vertebra, neck of rib and prevertebral fascia; lateral – mediastinal pleural; inferior – diaphragm, superior – enters to anterior region of neck. Frontal plane, build on level of posterior border of root of lung, mediastinal branches to anterior and posterior (SEE <TABLE 4.1.5, 4.1.8>). - Anterior of mediastinium lies glandula thymus, vv. brachiocephalicae, v. cava

superior, arcus aortae, tr. brachiocephalicus, a. carotis communis sinistra, a. subclavia sinistra, trachea, pericardium with heart and medialpericardial section of large vessels, bifurcation of trachea, main bronchi, pulmonary artery and vein, nn. phrenici et vasa pericardiacophrenicae, plexus nervorum, a. v. thoracicae internae,

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nodi lymphatici retrosternales (SEE chest wall <TABLE 4.1.1>), lymphatic nodes at bifurcation and paratracheal.

- Posterior mediastinal contains aorta descendens, vv. azygos et hemiazygos, trunci sympathici, nn. splanchnici, nn. vagi esophagus, ductus thoracicus, lymphatic nodes.

Give also tissue space: - Prepericardial – behind from posterior thoracic fascia, in front from thymus gland,

great vessels and pericardium; - Pretracheal. - Perioesophageal.


Between system of arterial network of main type – in chest wall, multiple type (functional insufficiency) – in heart. Venous network of multiple type between system – in chest wall, eosophagus.

LYMPH FLOW Chest wall, diaphragm, lungs, heart, ascending aorta, trachea (SEE <TABLE 4.1.1, 4.1.3, 4.1.4, 4.1.6, 4.1.7, 4.1.10)

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4.1.1. CHEST WALL

BORDERS Lateral part: - Superior – Jugular notch of sternum, upper border of clavicle, clavico-acromial joint,

later conditional line from upper part of spinous processus of VII cervical vertebra. - Inferior – base of xiphoid processes, border of costal arch to X rib, later conditional

line across free ends of XI-XII rib to spinous processus of XII thoracic vertebra.


(SEE <BORDERS>), also mm. pectoralis major, serratus anterior, obliquus externus abdominis, rectus abdominis, mammary gland (in females), fossa infraclavicularis and on its floor – processus coracoideus, rib II-XII, vertical conditional line: - Anterior middle – linea mediana anterior – on middle width of chest. - Sternal – linea sternalis dextra (sinistra) – on border of sternum. - Midclavicular – linea medioclavicularis dextra (sinistra) – across middle part of

clavicle. - Parasternal – linea parasternalis dextra (sinistra) – across middle distance between

sternum and midclavicular; - Anterior axillary – linea axillaris anterior dextra (sinistra) – across anterior border of

axillary fossa; - Middle axillary line – linea axillaris dextra (sinistra) – across middle distance between

anterior and posterior; - Posterior axillary line – linea axillaris posterior dextra (sinistra) – across posterior

border of axillary fossa; - Vertebral line – linea vertebralis dextra (sinistra) – across end of transverse processus

of thoracic vertebra; - Scapular line – linea scapularis dextra (sinistra) – across lower angle of scapula. - Paravertebralis – linea paravertebralis dextra (sinistra) – across middle distance

between vertebral and scapular line.

PROJECTION Diaphragm, lungs, heart, oesophagus, aorta and other organs (SEE <TABLE 4.1.3, 4.1.4, 4.1.7, 4.1.9, 4.1.10)


Skin on anterior and lateral surface is thick, which in region of spine; hair covering in male expressed usually in front and in region of scapula, numerous sebaceous gland. Subcutaneous tissue in region of sternum and spinous processus weakly developed, absent in region of nipples and areola (skin here not expressed), in the rest of the region, moderately developed. Artery gives branches aa. intercostales, axillaris, thoracica lateralis, thoracica interna; veins formed by subcutaneous network, anastomosis with veins of anterior wall of abdomen. Nn. supraclaviculares (from cervical plexus), superficial branches of I-IX nn. thoracici. Superficial fascia under clavicle contains bundles of m. platysma, forming capsule of mammary gland.

PROPER FASCIA In region of chest, on line where spinous processus of spine join with periosteum, on rest of length, in appearance of more thin sheath covering muscles of shoulder zone and abdominal wall (SEE <SUPERFICIAL MUSCLES>)

SUPERFICIAL MUSCLES

Mm. pectorales major et minor – covers chest tissue in front. M. serratus anterior – lateral. M. latissimus dorsi – part of lateral and behind. M. trapezius – behind medial. Mm. supraspinatus, infraspinatus, teres minor et teres major, rhomboideus major et rhomboideus minor attached to scapula. M. obliquus externus abdominis take at first in lower-lateral section of chest tissue. Long and short muscles of spine – along vertebra.

DEEP LAYERS Bone – sternum, rib, thoracic vertebra. Intercostal space – strips of chest tissue between ribs, which fill with: 1. Mm. intercostales externi starts in every intercostal from lower border of rib, goes

from above to downwards and from behind to front, attached to upper border of lower rib; on level of rib cartilage, muscles substitute for flat ligament (membranae intercostalia externae);

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2. Mm. intercostales interni starts from the internal surface of rib, above sulcus costalis, goes from below to upwards, from behind to front to upper borders of lower rib; posterior from rib angle, substitute membranae intercostales internae;

3. V. intercostalis a. intercostalis – in tissue sulcus between muscles of 1) and 2), goes into rib sulcus in posterior section to level of middle axillary line, rib not protected in front; fascial sheath for vessels of ligaments with periosteum of rib and sheath of muscles; n. intercostalis – lies below vessels, not protected in costal sulcus.

4. Lymphatic vessels and nodes. Vasa thoracicae internae goes along borders of sternum between posterior surface of costal cartilage, mm. intercostales interni and f. endothoracica (above III rib) or m. transversus thoracis (below III rib); on level of I rib from artery exits a. pericardiacophrenica (goes with n. phrenicus to diaphragm and pericardium), on level of costal arch, artery divides on terminal branches – aa. musculophrenica et epigastrica inferior. Artery participate in formation of important collateral network (SEE <COLLATERAL BLOOD SUPPLY>). M. transversus thoracis. Fascia endothoracica covers internally intercostal muscles, rib, costal cartilage, anterior surface of thoracic vertebra and diaphragm. Pleural parietalis – region of chest (SEE <TABLE 4.1>)

TISSUE SPACE Retromammary tissue – between capsule of mammary gland and f. pectoralis. Subpectoral tissue space – (SEE subclavicular space <TABLE 3.1.1>). Intercostal sulcus between costal sulcus and intercostal muscles. Subpleural tissue – loose tissue between parietal pleural and f. endothoracica.


Aa. intercostales anteriores (on six with every level) – branches of a. thoracica interna – anastomosis in every intercostal with aa. intercostales posteriores – branches of thoracic aorta. A. pericardiacophrenica (branches of a. thoracica interna) anastomosis with branches of coronary artery, blood supply to pericardium and heart. A. epigastric superior (terminal branch of a. thoracica interna) anastomosis with a. epigastrica inferior (branch of a. iliaca externa) in sheath of anterior muscles of abdomen, formed connection with aa. subclavia et iliaca externa.

LYMPH FLOW Lymph flow from superficial layer – mammary gland (SEE <TABLE 4.1.2>). From deep layer of chest tissue – in parietal lymphatic nodes: posterior intercostal and paravertebral nodes, anterior lymphatic nodes, lies on entrance of a. thoracica interna (nodi lymphatici sternales). Later lymph flows into ductus lymphaticus dexter.

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4.1.2 MAMMARY GLAND

HOLOTOPIA Chest wall (anterior)

BORDERS Superior – III rib. Inferior – VI or VII rib. Lateral – Anterior axillary line. Medial – Border of sternum.

CONNECTIVE-TISSUE SHEATH

Enclosed in capsule, formed by superficial fascia, which attached to clavicle (suspensory ligament of mammary). From capsule deep down goes crura, separating it into 15-20 lobes. Every lobe has its own exit duct, goes radially to nipple and on level of areola dilation (sinus lactiferi).

SYNTOPIA Behind from gland lies mm. pectoralis major et serratus anterior, covered by proper fascia of chest. Between sheath of mammary and fascia lies loose retrommamary tissue.

BLOOD SUPPLY Aa. thoracica interna, thoracica lateralis, intercostales posteriores. Superficial vein formed subcutaneous network, joined with axillary vein.

INNERVATION Branches of nn. intercostales, supraclaviculares (plexus cervicalis), thoracales anteriores (plexus brachialis). Sympathetic nerves goes with blood vessels.

LYMPH FLOW Lymphatic vessels formed superficial (subcutaneous) and deep (parenchymatous) network and anastomosis between them. Tracts of lymph flow: 1. Axillary lymph nodes (4/5 of lymph), on tract of lymph flow maybe located nodes of Зоргиуса (later numerous) in border of m. pectoralis major on level of III rib;

2. Subclavical lymph nodes with lymph vessels, goes across thickness of mm. pectorales major et minor, sometimes on tracts of lymph flow to occasionally nodi lymphatici interpectorales;

3. Supraclavicular lymph nodes. 4. Parasternal lymph nodes along a. thoracica interna (mainly on medial section of

gland); 5. Lymphatic nodes of opposite side; 6. On anastomosis with lymphatic vessels of anterior abdominal wall in lymphatic

system of upper floor of abdominal cavity.

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4.1.3 DIAPHRAGM

HOLOTOPIA, BORDERS

Thickness (0.3-0.5 cm) muscle-tendinous sheath which separate abdominal cavity from chest. Attachment of diaphragm to chest wall projected on line, goes from lower surface of xiphoid processes, on 1-2 cm above and parallel to lower border of costal arch, on XII rib and body of III-IV lumbar vertebra. Left dome of diaphragm – in front on upper border of V rib, behind on level of IX intercostal, right dome – in front, on upper border of IV rib, behind on VIII intercostal.

SHEATH On side of chest region closed by parietal pleural and pericardium, under which goes f. endothoracica; On side of abdominal cavity – parietal peritoneum and under it f. endoabdominalis.

MUSCLES Diaphragm consist from muscular part and centrum tendineum. Muscles part include: - Pars sternalis starts from the posterior surface of lower border of xiphoid processus

and part of aponenurosis of anterior abdominal wall; - Pars costalis – from VII – XII rib; - Pars lumbalis – from four upper lumbar vertebra, three crura with every side: medial,

intermediate, lateral crura. <Weak point> - sulcus strip in diaphragm, in which absent muscle bundles and touches sheath of interabdominal and interthoracic fascia: 1. Between thoracic and rib part of diaphragm on the left – sulcus of Ларрея, right –

sulcus of Морганьи (goes vasa thoracica interna); 2. Between rib part and lumbar (lateral crura) – sulcus of Бохдалека.

SYNTOPIA Superior – lungs, heart; Inferior – liver, stomach, spleen. Across opening in diaphragm goes: 1. Aorta and closely to it, behind - right ductus thoracicus – across hiatus aorticus

between medial crura of diaphragm on level of I lumbar vertebra left of medial line. 2. Esophagus and vagus nerve – across hiatus oesophagus, formed that same crura. One

attached in appearance of figure 8, on upper and anterior from previously mentioned; crura formed sphincter of oesophagus, which exits hernia;

3. Vv. azygos (right) et hemiazygos (left) together with nn. splanchini major et minor – across sulcus between medial and intermediate crura;

4. Truncus sympathicus – between intermediate and lateral crura.

BLOOD SUPPLY Aa. phrenicae inferiores (from abdominal aorta) superiors (from thoracic aorta), aa. musculophrenicae (from aa. thoracicae interior), branches aa. pericardiacophrenicae intercostales.

INNERVATION Nn. phrenici, intercostales, vagi, trunci sympathici.

LYMPH FLOW In upper diaphragmatic lymphatic nodes, later in retrosternal, posterior mediastinal, trachea-bronchial.

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4.1.4 LUNGS

HOLOTOPIA Lies in pleural cavity, separated by mediastinum.

BORDERS Anterior borders coincide with borders of pleura – (SEE serous covering, region of chest <TABLE 4.1>). Lower starts from level of cartilage of VI rib on left thoracic line and on right parasternal, later goes together: - Mid-clavicular line – upper border of VII rib; - Anterior axillary line – lower border of VII rib; - Middle axillary line – VIII rib; - Scapular line – X rib; - Parasternal line – XI rib. Upper border lies on 3-5 cm above clavicle (supraclavicular fossa minor). Oblique interlobular fissure projected right and left similar: Vertebral line – spinous processus of III thoracic vertebral; later oblique to front and downwards to entrance of VI rib in cartilagous part; right horizontal interlobular sulcus correspond with line from IV rib from middle axillary line to attachment of costal cartilage of that rib to sternum. Root of lungs correspond to V, VI, VII thoracic vertebra. Segments of lungs (in left – 9, in right -10) upper directed to hilum, base – to its surface.

SHEATH (SEE serous covering, region of chest, SEE <TABLE 4.1>).

SYNTOPIA External surface of every lungs lies on the rib and intercostal spaces (section from sheath of pleura to pleural cavity). Inferior surface – to diaphragm, covers pleural, which separate lungs from abdominal cavity and its organs (liver, stomach, spleen). Mediastinal surface of right lung lies in front of hilum to right mediastinum, superior vena cava, apical and subclavicular artery, behind – to oesophagous, azygos vein, body of vertebra; left lobe in front of hilum lies to left stomach, arch of aorta, apical to subclavical and left common carotid artery, behind hilum – to thoracic aorta. Root of right lungs contains upper main bronchi, below and in front of it – pulmonary artery, below – upper pulmonary vein; right main brochi is wider and shorter compared to left, goes more steeply (revealed as transverse trachea). V. azygos surrounded the root above, behind to front. Root of left lung, above lies pulmonary artery, below and behind – main brochi, upper and lower pulmonary vein lies behind to artery and brochi. Arch of aorta surround root above, front to back.

BLOOD SUPPLY Aa. brochiales – branches of thoracic aorta, supply nutrition to pulmonary tissue. Aa. pulmonalis – exit from pulmonary trunk (truncus pulmonalis), perform function of breathing. Between them, arterial system has anastomosis. Vv. brochiales flow into vv. azygos et hemiazygos. Vv. pulmonalis flow into left mediastinal (smaller angle of blood supply).

INNERVATION Plexus pulmonales anterior et posterior correspond to anterior and posterior section of root of lungs. Formed branches for sympathetic trunk (II-IV cervical and I-V thoracic nodes), vagus nerve and n. phrenicus.

LYMPH FLOW Para-organ lymph nodes, lies in point of length of bronchi, later (or at once) lymph flow in lymphatic nodes of root of lungs, later in trachea-bronchial nodes and in ductus thoracicus.

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4.1.5 ANTERIOR MEDIASTINAL

BORDERS Superior – apertura thoracica superior. Inferior – diaphragm Posterior – frontal sheath, pass across posterior border of hilum of lungs. Lateral – right and left mediastinal pleura.

INTERNAL ORGANS (PROJECTION, SYNTOPIA)

Thymus gland lies in upper interpleural space behind sternum. Behind it lies brachio-cephalic vein and arch of aorta, below and behind – pericardium. In adult, gland replaced by tissue and surrounded in thin fascial sheath. Brachio-cephalic vein (vv. brachiocephalica) formed behind, corresponding with sterno-clavicular joint by means of merging of internal jugular and subclavicular vein. Right is twice as short compared to left, goes vertical on right border of manubrium sterni on level of attachment to cartilage of I rib to sternum, where flow with oblique left vein. Both vein attached in front to thymus gland, more in right and mediastinal pleural. Right touch behind with brachiocephalic trunk and left common carotid artery. Superior vena cava (v. cava superior) projected on the right border of sternum on length of I-III rib. In front enclosed by thymus gland and right mediastinal pleura; behind and left to it lies trachea, in posterior wall on level of middle third goes v. azygos. In tissue behind vein, goes n. vagus, along right of its wall – n. phrenicus. Left – ascending aorta. Junction of vein (below 2/3 of length) lies in cavity of pericardium. Arch of aorta (arcus aortae) lies on ascending aorta on level of attachment of cartilage of II rib to left border of sternum and lies on descending aorta on left on level of IV thoracic vertebra, superior point of arch – center of manubrium of sternum, at first and end of arch attached in front to pleural costal-mediastinal sinus and mediastinal pleura. In middle section, anteriorly enclosed by thymus gland, posterior – trachea, on level of entrance into descending aorta behind it lies oesophagus. Under arch – right pulmonary artery, - left – n. vagus sinister, divides to n. laryngeus recurrens, surrounding arch below and behind. Laterally from n. vagus on arch of aorta lies n. phrenicus sinistra et vasa pericardiacophrenicae. From superior wall arch gives: - Truncus brachiocephalicus – from left, on semi-circumference left middle line to right

sternum-clavicular joint, where branches on right subclavicular and common carotid artery;

- A. carotis communis sinistra; - A. subclavia sinista in front partly covers mediastinal pleura. Pulmonary trunk (truncus pulmonalis) starts on level of attachment of III left rib cartilage to sternum, divides on right and left pulmonary artery on level of superior border of II left rib cartilage. Under arch of aorta to wall of pulmonary trunk on point of its length attached to arterial ligaments. (SEE also trachea (thoracic section), heart <TABLE 4.1.6, 4.1.7>)

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4.1.6 TRACHEA (THORACIC SECTION), PRIMARY BRONCHI

HOLOTOPIA Anterior mediastinum (SEE <TABLE 4.1.5>).

BORDERS Projection in front from insicura of sternum till angle of sternum (second intercostal), posterior – from II thoracic vertebra till upper border of V thoracic vertebra. Bifurcation of trachea – V-VI thoracic vertebra.

SHEATH Has general fascia covering with oesophagus. Between them and wall of trachea and bronchi – loose tissue.

SYNTOPIA Depth of posItion of trachea increase in caudal direction (in jugular fossa – 3-4 cm, in region of bifurcation – 6-12 cm): - Behind trachea lies oesophagus; - Anterior – arch of aorta with ascending and its brachiocephalic trunk and left

common carotid artery; - Right – right pleura bursa, right vagal nerve, brachiocephalic trunk. - Left – arch of aorta, left common carotid and subclavicular artery, left recurrence

nerve. Right main bronchi is short and wider than left, partly has vertical orientation. In front from right bronchi lies superior vena cava, in which here flows from v. azygos, surrounding brochi above and from back to front; behind them – right vagus nerve and v. azygos. In front from left bronchi – arch of aorta, surrounding it later anteriorly before above; behind – enters arch of aorta into descending and left vagus nerve.

BLOOD SUPPLY Rr. tracheales from aa. thyreoidea inferior, thoracica interna, aorta; rr. bronchiales (2-3 units) from aorta.

INNERVATION Nn. laryngei recurrentes, trunci sympathici

LYMPH FLOW In paratracheal, tracheobronchial and bifurcation lymphatic nodes, later lymph flow or at once into lymphatic system of neck.

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4.1.7 HEART, PERICARDIUM AND LARGE VESSELS IN REGION OF PERICARDIUM.

HOLOTOPIA Anterior mediastinum (SEE <TABLE 4.1.5>).

BORDERS, PROJECTION

Right sterum (superior vena cava and right atrium) goes in angle formed from upper border of III costal cartilage to lower border of V costal cartilage, on distance of 2-2.5 cm laterally from right sternal line. Lower border (right and parts of left ventricle) – from lower border of V costal cartilage oblique left and below on base of processus xiphoidus to V left intercostal spaces. Left border (pulmonary artery, left atrium, left ventricle) – from lower border of I rib in point of attachment to sternum to upper border of II rib on 2 cm left border of sternum, on level of III rib 2-2.5 cm lateral from border of sternum, below on 1.5-2 cm laterally from midclavicular line to V intercostal. Tricuspid valve – on right half sternum on line from end of V right rib to end of I left rib. Mitral valve – left half of sternum on level of III intercostal. Semilunar valve of aorta – right in border of sternum on level of III intercostal. Semilunar valve of pulmonary trunk – left on level of attachement of sternum to cartilage of III rib.

SEROUS COVERING

Pericardium formed covering for serous cavity for heart and section of main vessels. Its internal (serous) part enters in epicarardium near orifice of large vessels, flow into atrium and enters from ventricles. External (fibrous) part goes on wall of outside pericardium section and its vessels. Not covered by pericardium in posterior surface of region of left atrium, flow in it pulmonary vein, part of posterior surface of right atrium between orifice of cava vein, superior and posterior vena cave behind. Anterior section of pericardium lies to sternum and costal cartilages, partly not covered by pleura (attachment of VI-VII left costal cartilage to sternum, left half of xiphoid processus). Lower section attached to tendon of cental diaphragm. Posterior section closely to posterior mediastinum (oesophagus, usually to thoracic aorta). Lateral section lines to mediastinal pleura (in loose tissue between pleura and pericardium lies n. phrenicus). Sinuses of pericardium: - Sinus anterior inferior pericardii – on level of entrance of anterior section of

pericardium inferiorly; - Sinus transversus pericardii limit anterior and above posterior surface of ascending

aorta and pulmonary trunk, behind ring of pulmonay artery and posterior wall of pericardium, below groove depression between left ventricle and left and right atrium;

- Sinus obliquus pericardii limits in front posterior surface of left atrium, behind – posterior wall of pericardium, left – end section of left pulmonay vein, right, - inferior vena cava and end section of right pulmonary vein.

SYNTOPIA Anterior surface of heart (right part of atrium, terminal section of superior vena cava, right atrium and pulmonary artery, longitudinal sulcus of heart, left ventricle with apex, left atrium) part lies to sternum on costal cartilage, section from them pericardium, with lateral section from chest tissue costal-mediastinal sinuses and anterior border of lungs. Posterior surface of heart (right atrium, part of left atrium and left ventricle) section of pericardium from organ of posterior mediastinum (left main brochi, oesophagus, aorta, vagus nerve, right main bronchi). Lower surface (left ventricle, part of right ventricle and right atrium) section of pericardium and diaphargm from left pole of liver and stomach.

BLOOD SUPPLY Artery goes from ascending aorta: 1. A. coronaria dextra goes on coronary sulcus between right atrium and ventricle, goes

r. interventricularis posterior, which goes on similar suclus to apex of heart; 2. A. coronaria sinistra at once divides on r. interventricularis anterior, goes on anterior

longitudinal sulcus between left and right ventricle and r. circumflexus, envelope heart left on coronary sulcus.

Branches of left and right coronary artery anastomosis, forming two arterial circle: transverse in coronary sulcus and longitudinal in anterior and posterior interventricular sulcus.

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Vein gather blood in coronary sinus (sinus coronarius), lies in coronary sulcus on posterior surface of heart and opens in right atrium below and in front from opening of inferior vena cava.

INNERVATION Nn. vagi, phrenici, trunci sympathici give branhes for formation of aortal-cardiac plexus: - Superficial – on anterior surface of arch of aorta and its branches; - Deep – on anterior surface of trachea and its terminal section.

LYMPH FLOW Lymph flow in tracheo-bronchial (bifurcation) and superior anterior mediastinal lymph nodes.

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4.1.8 POSTERIOR MEDIASTINUM.

BORDERS Superior – apertura thoracis superior. Inferior – diaphragm. Anterior – frontal plane, goes across posterior border of root of lungs. Lateral – right and left mediastinal pleura, bifurcation of trachea and pericardium. Posterior – vertebra.

INTERNAL ORGANS (PROJECTION, SYNTOPIA)

Azygos and hemiazygos vein (vv. azygos et hemiazygos) gather blood from intercostal veins, lies along vertebra in sheath of prevertebral fascia. Azygos vein goes to right surface of body of vertebra in the right from thoracic lymphatic duct, behind oesophagus and on level of IV thoracic vertebra, attached across right main bronchi and flow into superior vena cava. Hemiazygos vein goes on left surface of vertebra between descending aorta and truncus sympathicus, on level of VII-VIII thoracic vertebra and flow into azygos vein. Vein joint anastomosis with inferior vena cava and portal vein (caval-caval and porto-caval anastomosis). Vagus nerve (nn. vagi) right and left. Right enters into thoracic cavity lies in front from subclavian artery and here it gives n. laryngeus recurrens, enveloping that artery behind. Later goes behind right brachiocephalic and superior vena cava, goes to posterior surface of root of right lung, turn to posterior suface of oesophagus, where divides and goes together with oesophagus into abdominal cavity. Left goes in front from the first section of left sbclavian artery, behind from left brachiocephalic vein, on left level of arch of aorta, where goes n. laryngeus recurrens. Later goes in sulcus between arch of aorta and left pulmonay artery on posterior surface of root of lungs and enters on anterior wall of oesophagus. Sympathetic trunk (trunci sympatici) formed 11-12 nodes, lies in sheath of prevertebral fascia on superficial head of ribs. With each level, trunk goes in front from intercostal vessels, laterally from azygos (right) and hemiazygos (left) vein, gives branches to intercostal nerves, nerve plexus of thoracic cavity, formed nn. splanchnici major et minor, which enters across diaphragm together with vv. azygos et hemiazygos and participate in formation of celiac plexus. (SEE also eosphagus (thoracic section), ascending aorta (thoracic section), thoracic lymphatic duct <TABLE 4.1.9-5.1.11>).

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4.1.9 OESOPHAGUS (THORACIC SECTION).

HOLOTOPIA In posterior mediastinum on level from II to XI thoracic vertebra.

BORDERS -SAME-

SHEATH Surrounded by perioespohageal fascia. Mediastinal pleura on left lies to that fascia on strip between descending aorta and pulmonary joint, right covers lateral wall and part of posterior wall of oesophagus below root of lungs.

SYNTOPIA Posterior wall lies closely to the body of vertebra, from which section of loose tissue: on level of IV thoracic vertebra, oesophagus lies to left side of vertebra, later turn to right, on level of VII thoracic vertebra once again exit in left, on level of VIII-IX goes in front, located in front of aorta. Anterior wall on level of IV thoracic vertebra lies to trachea, below – to arch of aorta, left main bronchi, pericardium (section of oesophagus from left mediastinum) Left on level of VIII (or IX) thoracic vertebra goes descending aorta. Right from level of IV thoracic vertebra downwards of oesophagus touch with mediastinal pleura. On level of root of lung to oesophagus approach vagus nerve: left to front surface, right – to back. Thoracic section of oesophagus narrow on level of adjacent to aorta.

BLOOD SUPPLY Branches of aa. bronchiales, intercostales, also rr. oesophagei from thoracic aorta. Rr. oesophagei from a. gastrica sinistra also blood supply from lower part of thoracic section of oesophagus. Vein flows in vv. azygos et hemiazygos (later into v. cava superior), from lower part of thoracic section of oesophagus – in v. gastrica sinistra (later in v. porta) – porta-caval anastomosis.

INNERVATION Nn. vagi, trunci sympatici formed plexus oesophageus.

LYMPH FLOW From upper section – in peritracheal lymphatic nodes, in middle section – in tracheobronchial and prevertebral nodes, from lower section – in superior gastric and nodes around celiac trunk. Part of lymphatic vessels of oesophagus flow directly into thoracic lymphatic duct.

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4.1.10 DESCENDING AORTA (THORACIC SECTION).

HOLOTOPIA Posterior mediastinum, level of IV-XII thoracic vertebra.

BORDERS -SAME-

SHEATH From IV to VI thoracic vertebra, left lateral circumference of aorta covers left mediastinal pleura; from VII to IX-X vertebra covers right mediastinal pleura on the right. On all length surrounded by planar fascial bursa.

SYNTOPIA From VI thoracic vertebra, in front – root of left lungs and left vagus nerve; behind – v. hemiazygos, vv. intercostales sinistrae, left – truncus sympaticus, nerve plexuses. Below VI thoracic vertebra, right to front – oesophagus, nn. vagi; right to back – ductus thoracicus. In periaortal tissue lies lymphatic nodes. Thoracic section of aorta goes into abdominal, exit across aortal opening of diaphragm (SEE lumbar region, <TABLE 7.1.10>).

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4.1.11 THORACIC LYMPHATIC DUCT.

HOLOTOPIA, BORDERS

At first – retroperitoneum space, II lumbar vertebra (merging left and right lumbar trunk, in 35% of people formed cisterna chyli). Thoracic section – posterior mediastinum. End – left prescalene space in region of sternocleidomastoid (flow into Piragov venous angle – merging with vv. jugular interna et subclavia).

SHEATH Thoracic section on right at level of diaphragm to III thoracic vertebra enclosed by right mediastinal pleura.

SYNTOPIA In region of thoracic duct goes from retroperitoneum space across aortal opening of diaphragm, right and behind from aorta. To V-VI thoracic vertebra goes right medial line along vertebra above between descending aorta and v. azygos; behind lies aa. intercostales, anastomosis between vv. azygos et hemiazigos; in front – perioesophageal fascia. Below V-VI vertebra bend left, obliquely goes behind arch of aorta and oesophagus behind left mediastinal pleura, goes on dome of pleura (trigonum scalenovertebrale) later flow into Piragov venous angle – merging with v. subclavia sinistra et. v. jugularis interna. PEARL. Described additional lymphatic duct, goes parallel to ductus thoracicus and flow into them on various levels.

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SECTION V

REGION OF ABDOMEN

7.1 TOPOGRAPHY OF THE REGION OF ABDOMEN.

BORDERS Superior external – xiphoid process and borders of arcus costalis, XII rib, spinous processes of XII thoracic vertebra. Inferior external – upper border of symphysis, inguinal ligament, wing of iliac bone. Superior internal – diaphragm. Inferior internal – linea terminalis.

ASSOCIATED REGION

Anterior wall, lumbar region, posterior wall, abdominal cavity (with internal organs), retroperitoneum spaces.


Anterior wall of abdomen, lumbar region (posterior wall) (SEE <TABLE 7.1.1, 7.1.10>).

PROJECTION -SAME-


-SAME-

CONNECTING FASCIA

-SAME-

MUSCLES -SAME- ABDOMINAL CAVITY

Parietal sheath of abdomen (peritoneum parietale) covers wall of abdominal cavity internally; also anterior wall of abdomen, lumbar area (posterior wall), retroperitoneum spaces (SEE <TABLE 7.1.1, 7.1.10, 7.1.11>). Visceral sheath (peritoneum visceral) covers organs of abdominal cavity (while all surface of organs covered by peritoneum – organ intraperitoneum; one surface not covered – organ mesoperitoneum; one surface covering – retroperitoneum), also formed ligaments, folds, bursa and mesentery (see liver, stomach and other organs (SEE <TABLE 7.1.2 – 7.1.14>). Separate upper and lower floor by transverse colon and its mesentery (mesocolon transversum), in which located internal organs, covered by peritoneum. Between organs, also between organs and parietal peritoneum has fissure – peritoneum cavity, subdivide on more or less bounded spaces. Upper floor: 1. Right subphrenic space (bursa hepatica dextra) bounded: - superior and anterior by diaphragm; - inferior by superior surface of right lobe of liver. - posterior by ligg. coronarium et triangulare dextrum; - left by lig. falciformis hepatis, continue inferiorly into right paracolic sinus of lower floor; 2. Left subphrenic space (bursa hepatica sinistra and bursa pregastrica); - bursa hepatica sinistra: superior and anterior by diaphragm; inferior by left lobe of liver; right by lig. falciformis hepatis, posterior by ligg. coronarium et triangulare sinistrum; - bursa pregastrica; anterior and superior by diaphragm; left lobe of liver, anterior abdominal wall, posterior by lesser omentum and stomach, lig. phenicolienale, right by ligg. falciforme et teres hepatic, left and inferior – lig. phrenicocolicum. 3. Omentum bursa (bursa omentalis): - anterior wall – omentum minor (ligg. hepatoduodenale, hepatogastricum, gastrophrenicum), posterior wall of stomach, lig. gastrocolicum; - posterior wall – parietal wall of peritoneum, covers pancreas, aorta, v. cava inferior, plexus nervorum; - upper wall – caudate lobe of liver, diaphragm; - lower – mesocolon. - left – spleen, ligg. gastrolienale et phrenicolienale; - right has openings (for. epiploicum), bounded by ligg. hepatoduodenale, hepatorenale, duodenorenale, opens into right paracolic sinus. Lower floor: 1. Right paracolic sinus (canalis lateralis dexter): - anterior and right – anterior wall of abdomen; - left – colon ascendens;

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- anterior exits into right subphrenic space; - interior - into right iliac fossa, later into region of pelvis; 2. Left paracolic sinus (canalis lateralis sinister): - anterior and left – anterior abdominal wall; - right – colon descendans; - superior – lig. phrenicocolicum; - inferior – enters into left iliac fossa, later into lesser pelvis. 3. Right mesentery sinus (sinus mesentericus dexter): - superior – mesocolon; - right – colon caecum et ascendens; - left and inferior – mesentery of colon, terminal section of ilium; - anterior – greater omentum; - joint with left sinus on flexura duodenojejunalis. 4. Left mesenteric sinus (sinus mesentericus sinister) - superior and right – root of mesentery of colon, mesocolon. - left – colon descendens and mesentery of sigmoid colon. 5. Recessus duodenojejunalis: - superior – mesocolon; - anterior – plica duodenojejunalis (ligament Treitz); - posterior – parietal sheath of peritoneum of posterior wall; - inferior – upper border of flexura duodenojejunalis. 6. Recessus angulus ileocaecalis: - recessus ileocaecalis superior – between upper border of ilium and internal surface of colon ascendens; - recessus retrocaecalis – behind cecum. 7. Recessus intersigmoideus – between folds of parietal peritoneum on ureter and mesentery of sigmoid colon on level of borders with small pelvis.

INTERNAL ORGANS

Stomach, liver, gall bladder, bile duct, spleen, pancreas, duodenum, small intestine, colon and others (SEE <TABLE 7.1.2-7.1.14>).

INNERVATION -SAME-

LYMPH FLOW -SAME-

COLLATERAL BLOOD FLOW

Anterior wall of abdomen (SEE <TABLE 7.1.1>). Also located collateral internal arterial network with multiple type formation, forming anastomosis between branches of unpaired arterial trunk (tr. coeliacus, aa. mesentericae superior et inferior) in abdominal cavity. Venous network is of multiple type – porto-caval anastomosis in cardiac section of stomach, anterior of intestine and anterior wall of abdomen.

TISSUE SPACES Located in anterior abdominal wall (SEE <TABLE 7.1.1>), retroperitoneum space (SEE <TABLE 7.1.11>).

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7.1.1 ANTERIOR WALL

BORDERS Superior – xiphoid process and borders of arcus costalis. Inferior – crista iliaca, spina iliaca anterior superior, inguinal ligament, tuberculum pubicum, upper border of symphysis pubica. External – vertical line from edge of XI rib to crista iliaca.


SEE BORDERS, and also relative line: 1. two horizontal (between lower point of X rib – linea bicostarum; between spinae iliacae anteriores superiores – linea bispinarum); 2. two vertical (from tuberculum pubicum on external border of mm. recti abdominis) between wall on three regions (nine section): - regio epigastrium (regiones epigastrica propria, hypochondricae dextra et sinistra); - regio mesogastrium (regiones umbilicalis, abdominals laterales dextra et sinistra); - regio hypogastrium (regiones suprapubica, inguinales dextra et sinistra). Except – depression on middle line, umbilical, inguinal fold, inguinal ligament.

PROJECTION Regio epigastrica propria – stomach, pancreas, left pole of liver, duodenum. Regio hypochondrica dextra – right lobe of liver, gall bladder, right flexure of colon, upper pole of right kidney. Regio hypochondrica sinistra – cardiac section of stomach, spleen, tail of pancreas, left flexure of colon, upper pole of left kidney. Regio umbilicalis – loop of small intestine, transverse colon, lower horizontal part of duodenum, greater curvature of stomach, kidney, ureter. Regio lateralis dextra – ascending colon, part of loop of small intestine, lower pole of right kidney. Regio lateralis sinistra – descending colon, part of loop of small intestine, lower pole of left kidney. Regio suprapubica – bladder, lower section of ureter, uterus, loop of small intestine. Regio inguinalis dextra – cecum, end section of ilium, appendix, right ureter. Regio inguinalis sinistra – sigmoid colon, loop of small intestine, left ureter. Depression on middle line – linea alba abdominis.


Skin thin, mobile, elastic, hair covering expressed in lower part. Subcutaneous tissue more developed under umbilical, divided into three layers sheath of superficial fascia. Its superficial fascia has two sheath: superficial soft tissue enters from neighboring region: deep (lamina Tomson) compactly attached to lig. inguinale. Branches of a. femoralis: - av. epigastrica superficialis; - av. circumflexa ilium superficialis; - aa. vv. pudendae externae. VV. thoracoepigastricae anastomosis with mentioned branches and with vv. paraumbilicales (later v. porta), forming porto-caval anastomosis – collateral system of multiple type texture.

PROPER FASCIA Sheath covering both superficial oblique muscles, separates from each other by loose tissue, merge with tendons of oblique muscle. Between internal oblique and transverse muscles located layers of loose tissue, in which enters nerve and vessels. Fascia, covering the wall of abdomen internally, called f. endoabdominalis, its part, attached to m. transverses, called f. transversalis.

MUSCLES Lateral symmetrical arranged three layers (left and right) flat muscles: 1. m. obliquus externus abdominis enters into flat tendons (aponeurosis), which at inferior formed lig. inguinale and branches to two horns, attached to tuberculum pubicum et symphysis pubica; 2. m. obliquus internus abdominis also enters into aponeurosis. 3. m. transverses abdominis enters into aponeurosis in C-formed vertical line. Medial symmetrical formation mm. recti abdominis dextra et sinistra, under umbilical has 3-4 intersectiones tendineae, joints with anterior wall sheath of every muscles. Sheath formation: - on level of rib anteriorly – aponeurosis of m. oblique externus, posterior – cartilages of V-VI rib;

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- on level of 2-5 cm below umbilical, anterior – aponeurosis m. oblique externus, superficial sheath of aponeurosis m. oblique internus; posterior – deep sheath of aponeurosis of m. oblique internus, apnoeurosis m. transverse, f. endoabdominalis (transversalis). <Weak> spot of anterior wall of abdomen (strip, lacking muscles covering): 1. canalis inguinalis: - anterior wall – aponeurosis of m. obliquus externus; - inferior wall – lig. inguinale; - superior wall – borders of mm. obliquus internus et transversus; - posterior wall – f. endoabdominalis (transversalis); - deep ring (annulus inguinalis profundus) – protrusion of f. endoabdominalis, correspond to fossa inguinalis lateralis; - superficial ring (annulus inguinalis superficialis) – splits crura of aponeurosis of m. obliquus externus on 1-2 cm; - contains – spermatic cord (in male) or round ligament of uterus (in females), n. ilioinguinalis; 2. linea alba abdominis – interweaving tendons of wide muscles under umbilical with wideness of 2-3 cm, thickness of 1-2 mm; below umbilical wideness of 1-2 mm, thickness of 3-4 mm; 3. umbilicus – umbilical ring (round fissure in linea alba), tight crura, scar tissue, f. transverslis, peritoneum. 4. canalis femoralis – anterior section of thigh (SEE <TABLE 3.2.1>)

SEROUS BURSA Peritoneum: 1. parietal sheath separated from f. endoabdominalis preperitoneum tissue and formed folds: - lig. teres hepatis (developed from umbilical, v. umbilicalis et vv. paraumbilicales) goes from the umbilical to liver; - plica umbicalis mediana (developed from urachus) goes to umbilical from upper part of bladder. - plica umbicalis medialis dextra (sinistra) – developed from aa. umbilicales, goes from bladder to umbilical. - plica umbilicalis lateralis dextra (sinistra) – folds of peritoneum on vasa epigastricae inferiors; together with lig. inguinale (inferior) folds restricted by fossa: - fossa supravesicalis (bladder and its filling) - fossa inguinalis medialis (correspond to external ring of inguinal canal); - fossa inguinalis lateralis (correspond to internal ring of inguinal canal). 2. visceral sheath – region of abdomen (SEE <TABLE 7.1>)

COLLATERAL BLOOD FORMATION

A. epigastrica superior – branches of a. thoracica interna, enters into posterior fissure sheath of m. rectus, where anastomosis with branches of a. iliaca externa: a. epigastrica inferior, a. circumflexa ilium profunda and its branches of aorta: five aa. intercostale, four aa. lumbales. Formation of arterial collateral network of primary type, between systems, functioning during narrowing of aorta. Similar vein accompany artery – caval-caval anastomosis.

VESSELS AND NERVES

Rr. arteriores of last six nn. intercostales innervate wall on level of linea bispinarum. N. iliohypogastricus – below linea bispinarum; n. ilioinguinalis – external ring of inguinal canal, goes between mm. obluqiu externus et internus. Vessel-nerve bundles goes in layers of tissue between m. obliquus internus et m. transverses, later goes into posterior fissure sheath of anterior muscles of abdomen.

LYMPH FLOW Nodi lymphatic inguinales superficiales receives lymph from superficial layer of abdominal wall below umbilical. From the rest of the area, lymph flows into axillary, epigastric, thoracic, anterior medistinal, lumbar, iliac and deep inguinal lymphatic nodes.

TISSUE SPACES Sheath of anterior muscles of the abdomen (anterior and posterior fissure). Fissure between m. obliquus internus et m. transverses. Prevesical and vesical tissue spaces (region of small pelvis, SEE <TABLE 8.1>) Layers of spaces between parietal peritoneum and f. endoabdominalis.

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7.1.2 STOMACH, ESOPHAGUS (ABDOMINAL SECTION)

HOLOTOPIA Upper floor of abdominal cavity.

PROJECTION, SKELETOPIA, BORDERS.

Left subcostal and proper epigastric region of the anterior wall. Cardiac section of stomach and abdominal section of esophagus – attached to thoracic left VI. VII costal cartilages. Pyloric section of stomach – 2-2.5 cm right from middle line on level of VIII costal cartilage. Small curvature (fixation) – arch formation line around sternum of left and bottom. Greater curvature (borders vary from behind to the extent of filling of stomach) – arch from lower border of V rib on left midclavicular line to VIII rib and later to middle right rectus muscle of the abdomen (here hide under liver).

SEROUS SHEATH

Stomach – intraperitoneal organ; esophagus – retroperitoneum. Superficial ligaments: - lig. gastrocolicum – from greater curvature of stomach to transverse colon, contains anastomosis between its aa. gastroepiploicae dextra et sinistra; - lig. gastrolienale – between upper part of greater curvature of stomach and hilum of spleen, contains aa. vv. gastricae breves; - lig. gastrophrenicum – enters peritoneum with diaphragm on anterior superficial floor and cardial part of stomach; - lig. hepatogastricum – between lower superficial liver and lesser curvature, contains aa. vv. gastricae dextrae et sinistrae, lymphatic lymph nodes. Deep ligaments: - lig. gastropancreaticum – enters peritoneum with upper border of pancreas on posterior superficial floor and cardiac part of stomach, contains a. v. gastricae sinistrae; - lig. pyloropancreaticum – between pyloric section and right part of pancreas, contain lymph nodes.

SYNTOPIA Anterior wall of stomach cover liver, left – rib part diaphragm, body part and pylocric section lies to anterior abdominal wall; posterior wall section omentum bursa from organ of retroperitoneum space (under stomach, crura diagphragm, left suprarenal, upper pole of left kidney) and touch with hilum of spleen; lesser curvature attached to left lobe of liver greater curvature touch with transverse colon and its mesentery, Abdominal section of esophagus to the front attached to left lobe of liver.

BLOOD SUPPLY Stomach blood supply is from truncus coeliacus. On lesser curvature (in small omentum) anastomosis: - a. gastrica sinistra (branches of truncus coeliacus), enters into lig. gastropancreaticum, where goes branches to esophagus and later into lig. hepatogastricum; - a. gastric dextra- branches a. hepatica communis, enters in ligg. hepatoduodenale et hepatogastricum. On greater curvature (in lig. gastrocolicum) anastomosis: - a. gastroepiploica dextra – branches of a. gastroduodenalis, enters in its alternative from truncus coeliacus; - a. gastroepiploica sinistra – branches of a. lienalis, exits from truncus coeliacus and located in log. Gastrolienale. To the floor of stomach in lig. gastrolienale goes aa. gastricae breves (1-6 units), branches of a. lieanlis, anastomosis with aa. gastric sinistra et gastroepiploica sinistra. Formed collateral arterial in organ net of multiple type level. Has functional insufficienct internal organ vessels anastomosis. Esophagus (abdominal section) of blood supp;y is from a. gastric sinistra. Venous flow goes to similar veins in sistem v. porta. Porto-caval anastomosis located in region of cardia (vv. gastricae anastomosis with vv. oesophageae, accompanied with vv. azygos et hemiazygos).

INNERVATION Parasympathetic innervation – n. vagus sinistrer on anterior wall of esophagus and stomach, n. vagus dexter – on posterior wall. Sympathetic innervations – plexus coeliacus.

LYMPH FLOW Flow of lymph from lesser curvature goes to nodes of lesser omentum (lymph nodes of right order) and later to celiac nodes (second order)l from greater curvature – in nodes

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in hilum of the spleen, pancreas and superior mesentery (right order), later in celiac, aorta and caval.

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7.1.3 LIVER


PROJECTION, SKELETOPIA, BORDERS

Right subcostal, proper epigastric region, part of left subcostal. Upper borders: - On left midclavicular line – V intercostal; - On right parasternal – V rib cartilage; - On right midclavicular line – IV intercostal; - On right midaxillary – VIII rib; - On veterbral – XI rib. Lower borders: - On right midaxillary line – X intercostal. On middle line – middle section between umbilical and base of sternum, leave under left rib arch on level of VI costal cartilage.

SEROUS AND NEIGHBOURING SHEATH

Mesoperitoneum organ (not covered hilum and dorsal surface). Under peritoneum, liver covered by capsula fibrosa hepatis (Glissoni). Ligaments of peritoneum: - lig. teres hepatis – from umbilical to left longitudinal sulcus, containing v. umbilicalis, vv. paraumbilicales, enters into lig. falciformis hepatis, - lig. falciformis hepatis – in sagittal plane between diaphragm and upper superficial liver, left and right enters into lig. coronarium; - lig. coronarium – in frontal plane between lower superficial diaphragm to posterior section of diaphragmatic surface of liver, left and right enters into ligg. triangular dexter et sinter; - lig. hepatoduodenale contains left a. hepatis communis and its branches, right ductus choledochus and form its ductus hepaticus and ductus cysticus, between them and posterior – v. porta, also lymphatic nodes, nerve plexus (plexus hepatici anterior et posterior); - lig. hepatogastricum – (SEE stomach <TABLE 7.1.2>) PEARL. Ligg. hepatoduodenale, hepatogastricum et gastrophrenicum formed omentum minus (lesser omentum).

SYNTOPIA Upper superficial (diaphragmatic) lies to diaphragm. Anterior – to diaphragm and anterior abdominal wall. Posterior – to X, XI thoracic vertebra, crura diaphragm, abdominal portion of esophagus, aorta, right suprarenal, v. cava inferior (in special bursa). Lower covers stomach (cardia, lesser curvature, antral and pyloric part), upper horizontal part of duodenum, flexura coli dextra, gall bladder.

BLOOD SUPPLY Tributaries of blood from liver enters from system truncus coeliacus and from v. porta. A. hepatica propria (branches of a. hepatica communis) goes in lig. hepatoduodenale, goes a. gastric dextra, in hilum of liver branches on aa. hepaticae sinistra et dextra. From subsequently enters a. cystic (part variance of manner). PEARL. Internal organ and outside organ collateral arterial net for liver absent. V. porta formed from confluence of v. mesenteric superior and v. lienalis behind head of pancreas, goes behind of duodenum, and later into lig. hepatoduodenale and branches on right and left trunk. V. umbilicalis (located in lig. teres hepatis) flow into left trunk of v. porta, obliterate closeby umbilical ring. Vv. paraumbilicales located in lig. teres hepatis, flows into v. porta, carry blood from anterior abdominal wall (porto-caval anastomosis). Flow of blood from liver goes to vv. hepaticae (part three), which flows into v. cava inferior lower diaphragm.

INNERVATION Nn. vagi, nn. splanchnici major et minor formed plexus coeliacus, liver plexus (anterior and posterior), n. phrenicus dexter.

LYMPH FLOW Flow of lymph from visceral surface – in lymph nodes of lesser omentum (right sequence), from diaphragmatic surface and from its parenchyma – in nodes prediaphragmatic and posterior mediastinum. Lymph nodes of second floor – celiac nodes.

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PEARL. Lobe, sector, segment of liver – its area, has until some stages detached blood supply, bile duct, innervations and lymph flow. Based on Kyuneo liver brances into two lobes (left and right), four sectors and eight segments.

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7.1.4 GALL BLADDER AND BILE DUCT


PROJECTION Right subcostal.

SKELETOPIA Floor of bile duct – angle, formed by costal arch (IX-X cartilage) and external border of right straight muscles of abdomen.

SEROUS SHEATH

Gall bladder lies partly in mesoperitoneum; outmost variant location – intraperitoneum (with mesentery) and extreperitoneum (in liver). Superior surface body join with liver (not covered by peritoneum), floor covered by peritoneum on all levels. Between peritoneum and fascia of bladder – loose tissue. Duct of gall bladder – intraperitoneum organ. General gall and liver duct lies in thickness of lig. hepatoduodenale.

SYNTOPIA Gall bladder superior surface body lies to liver and separated from it by loose tissue; base lies on anterior abdominal wall, lower surface body contact with transverse colon, pyloric part of stomach, duodenum. General liver duct formed from junction of two lobes liver ducts from hilus of liver; on 2.5-3 cm lower from it flow duct of gall bladder and formed general gall duct (ductus choledochus), in which branches into four parts: - supraduodenale – from site of junction with bladder to level of duodenum (lies in right border of lig. hepatoduodenale); - retroduodenale – posterior of upper horizontal part of duodenum; - pancreatic – in thickness of head of pancreas; - interstitial – in wall of intestine to opening on crest of Vater’s papilla. PEARL. Varient on formation and location of gall duct and bladder meet very often.

BLOOD SUPPLY A. cystic – branches of a. hepatica dextra (part always) located in lig. hepatoduodenale and formed one from direction of Kalo triangle (two others direction – ductus cysticus et ductus hepaticus communis), part meet variant location. Flow of blood from gall tracts – in v. porta.

INNVERVATION Plexus coeliacus, nn. splanchnici, phrenicus dexter.

LYMPH FLOW In lymphatic nodes in hilus of liver (right order), later – in paraaortal (second order).

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7.1.5 SPLEEN


PROJECTION Left subcostal.

SKELETOPIA (BORDERS)

Between IX and XI rib from parevertebral to middle axillary line. Ligaments peritoneum: - lig. phrenicolienale fixed spleen to lumbar part of diagphragm; - lig. gastrolienale fixed spleen to greater curvature of stomach. Lower floor of spleen lies on lig. phrenicocolicum.

SYNTOPIA External surface lies to rib part of diaphragm. Internal surface join in front to floor of stomach, posterior – to lumbar part of diaphragm, left kidney, left suprarenal, below contact with tail of pancreas and splenic flexture of colon.

BLOOD SUPPLY A. lienales exits from truncus coeliacus, goes behind and above border of pancreas, branches in thickness of lig. phrenicolienale on aa. gastricae breves, gastroepiploica sinistra (STOMACH, SEE <TABLE 7.1.2>), 4-6 splemic branches. V. lienalis goes parallel and lower to artery, flow posteriorly to head of pancreas with v. mesenterica superior and formed v. porta.

INNERVATION Left nodes of celiac plexus, left epigastic and diaphragmatic plexus.

LYMPH NODES In lymphatic nodes region hilus of spleen and tail of pancreas (first order), later to celiac nodes.

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7.1.6 DUODENUM

HOLOTOPIA Retroperitoneum space on level of upper and lower flow of abdominal cavity.

PROJECTION Epigastric and umbilical region of anterior wall of abdomen.

BORDERS Zone, restricted superiorly to horizontal line across umbilical; left vertical line on 4 cm left from middle line right vertical line on 6-8 cm right from middle line.

SKELETOPIA At first (bulbus duodeni) – upper border I lumbar vertebra. Lower (horizontal) part – on level III lumbar vertebra. End (flexura duodenojejunalis) – left from II lumbar vertebra.

SEROUS SHEATH

Retroperitoneum organ, only bulbus duodeni with three covering or peritoneum (lies on mesoperitoenum) Ligament of peritoneum and its bursa: - lig. hepatoduodenale – liver (SEE <TABLE 7.1.3>); - lig. duodenorenale – from upper ascending part of colon to right kidney. - lig. suspensorium duodeni (ligament of Treintz) support flexura duodenojejunalis, contain m. suspensorius duodeni (from colon goes to crura of diaphragm); - recessus duodenojejunalis – region of stomach (SEE <TABLE 7.1>)

SYNTOPIA Pars superior (bulbus) duodeni: - anterior of liver and neck of gall bladder; - superior – lig. hepatoduodenale; - inferior – pancreas. Pars descendens go lower along internal border of right kidney posterior located hilum of kidney, v. cava inferior and ductus choledochus (opening in gap in intestine, flow from ductus pancreaticus on middle posterior wall, - papilla duodeni major); on the inside – head of pancreas, externally – liver flexure of colon. Pars inferior – behind lies v. cava inferior and aorta, in front – a. v. mesentericus superior, enters into root of mesentery of colon. In lower floor to anterior surface of duodenum fit closely section of peritoneum of loops of small intestine.

BLOOD SUPPLY A. pancreaticoduodenalis superior (from a. gastroduodenalis) branches in front and back. A. pancreaticoduodenalis inferior (from a. mesenterica superior) branches in front and back. Artery enters to accordingly in front and posterior sulcus between pancreas and pars descendens duodeni, anastomosis between them (anastomosis between truncus coeliacus and a. mesenterica superior, functional insufficiency). Vein follow the entering artery, flow into system v. porta.

INNERVATION Nn. vagi, plexus coeliacus, plexus mesentericus superior, plexus hepatici anterior et posterior.

LYMPH FLOW Lymph flow in lymphatic nodes in hilum of liver, root of mesentery of colon, head of pancreas, later into paraaortic nodes.

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7.1.7 PANCREAS

HOLOTOPIA Retroperitoneum spaces on the level borders of upper and lower floor of abdominal cavity. Proper epigastric region and left subcostal.

PROJECTION Projected on horizontal line, connected with end of VII and VIII rib right and left or on horizontal line across middle distance between sternum and umbilical.

SEROUS SHEATH

Retroperitoneum organ, separated from posterior wall of stomach cavity by omental bursa. Ligament peritoneum: - lig. gastropancreaticum; - lig. pancreaticolienale; Root of mesentery of transverse colon goes in front from pancreas, close part from head show on level of lower floor, and body and tail – upper.

SYNTOPIA Anteriorly located: posterior wall of stomach, lower surface of liver (omentum prominence of pancreas), root of mesentery of transverse colon, loops of small intestine. Posteriorly (right to left) – at first section of v. porta, v. cava inferior, aorta (with move away from it’s a. mesenterica superior), v. mesenterica superior, plexus coeliacus, left kidney, v. lienalis (along body and tail). Superiorly – on borders of head and body from aorta goes truncus coeliacus, along upper border of body and tail gives av. lienalis. Inferiorly goes a. v. mesentericae superiores (on borders of head and body). Left tail reach hilum of spleen. Right head envelopes duodenum. Ductus pancreaticus goes along its gland, flow in ductus choledochis, formed ampula major papilla, later open to space in duodenum (sometimes flow independently).

BLOOD SUPPLY Head of gland blood supply: - a. pancreaticoduodenalis superior (from system of truncus coeliacus); - a. pancreaticoduodenalis inferior (from system of a. mesenterica superior), which branches on anterior and posterior branches, anastomosis between them (outside organ net collateral blood supply, between systems, functional insufficiency). Tail and body supplied by branches of a. lienalis segment lobules.

INNERVATION Celiac plexus, spleen, superior mesentery and left kidney.

LYMPH NODES Lymph flows into lymphatic nodes right order: pancreatic (along upper and lower boreder of gland), pyloric, pancreatoduodenale, second order – celiac; third – preaorta.

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7.1.8 SMALL INTESTINE

HOLOTOPIA Lower floor of abdominal cavity, peritoneum floor of smaller pelvis.

PROJECTION Celiac and subcostal region anterior wall of abdomen.

SKELETOPIA Starts (flexura duodenojejunalis) – body II lumbar vertebra. End angulus ileocaecalis – right iliac fossa (often most of the time)

SEROUS SHEATH

Intraperitoneal organ. Root of mesentery – from II lumbar vertebra to right sacral-iliac articulation.

SYNTOPIA From anterior abdominal wall divided into greater omentum. Posteriorly lies organ of retroperitoneum spaces (kidney, pars inferior duodeni, aorta and v. cava inferior, and branches of ducts, ureter), divided from intestinal parietal perioneum. Superiorly – transvers colon and its mesentery. Inferior (in region of smaller pelvis) in male loop of intestine lies between sigmoid and straight intestine posteriorly and bladder anteriorly, and in female to the front also the same and uterus. Lateral right – secum, appendix and ascending colon, left – descending colon and sigmoid colon.

BLOOD SUPPLY A. mesenterica superior (branches of aorta), which exits on level I lumbar vertebra, goes anterior of aorta (section from its left kidney vein) posterior spleen vein and pancreas, goes from under lower border of pancreas and settle anteriorly from lower part of duodenum, exits into mesentery of intestine and goes branches sequentially: - a. pancreaticoduodenalis inferior (or at once two trunk – aa. pancreaticoduodenales anterior et posterior). - a. colica media goes to liver flexure of colon. - a. colica dextra – to ascending colon. - a. ileocolica – to ileocecal flexure (end branches of a. mesenteric superior); To colon (from convex of superficial arteries): - aa. jejunales et aa. ilei (12-20 units). Each branches has two branches (ascending and descending, anastomosis with each other: formed arch first, second and third (to fifth) order. From arch afterwards order – parallel (or marginal) vessels – goes aa. rectar, blood supply organ area of intestine. Formed collateral arterial system multiple type outside (inside organ anastomosis absent). Branches from 7 to 27 goes parallel to arteries, in front from behind horizontal part of duodenum, goes from head of pancreas, where, flow into v. lienalis, forming v. porta.

INNERVATION Plexus mesentericus superior (from n. vagus and nn. splanchnici major et minor).

LYMPH FLOW Lymphatc vessels of mesentery, carry lymph from colon, multiple numerous and width in diameter (lacteal vessels up to 3 mm), with them lymph at once can get into chest lymphatic duct. Located three order of lymph nodes: - lymphatic of first order: along mesentery border of intestine: on level of intermediate arcade; entrance for main branches of a. mesenterica superior; - lymphatic of second order: in root of mesentery in head of pancreas. - lymphatic of third order – paraaorta.

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7.1.9 COLON

HOLOTOPIA Lower floor of abdominal cavity.

PROJECTION Colon, appendix – right iliac (inguinal) region of anterior wall of abdomen. Ascending colon – right lateral region. Liver flexure of colon – right subcostal. Transverse colon – umbilical region. Spleen flexure of colon – left subcostal. Descending colon – left lateral region. Sigmoid colon – left iliac (inguinal) and suprapubic region. Base of appendix processus (multiple variance of location) part often: accurate Mac-Burney (borders between external and middle third linea spinoumbilicalis) or accurate Lantsa (borders between right external and middle third of linea bispinarum).

SEROUS SHEATH

Caecum, appendix, colon transversum, colon sigmoideum – intraperitoneum organ; colon ascendens et descendens – mesoperitoneum. Maybe extreme varients (from intra- to extra-). Foundation peritoneum: - plicae ileocarcales superior et inferior; - mesoappendix – mesentery of appendix; - lig. gastrocolicum – stomach (SEE <TABLE 7.1.2>); - lig. phrenicocolicum – region abdomen (SEE <TABLE 7.1>); - mesocolon transverses – line attached from III lumbar vertebra right to I vertebra left, root cross descending part of duodenum, head of pancreas and left kidney. Contains a. colica media, its branches and anastomosis with ascending branches of a. colica sinistra – arch of Riolan. - mesocolon sigmoideum – root attached from left iliac wing to broders of II and III sacral vertebra in pelvis, line formed right arch on level of left ureter (here has recessus intersigmoideus). Contains aa. vv. sigmoideae.

SYNTOPIA Caecum et appendix vermiformis lies in right iliac burse, seperates from m. iliopsoas of peritoneum and retroperitoneum tissues. Most changeable location of peripheral part of processus, maybe has the following variance location: 1. pelvis descending – processus on right inferior in lesser pelvic; 2. medial – parallel to ilium; 3. lateral – on right sided canal; 4. anterior – on anterior surface of secum; 5. transverse (ascending) – superior to level of transverse surface. 6. retrocecal – posterior to caecum (sometimes – retroperitoneum, without mesentery, in tissue). Colon ascendens located in the borders of canalis lateralis dexter et sinus mesentericus dexter. Colon descendens located in the borders of canalis lateralis sinister. To the front separated from anterior abdominal wall, loops of small intestine and major omentum. Posterior surface (pars nuda) – without peritoneum, lies to retroperitoneum and near renal tissue and muscles of posterior abdominal wall (mm. iliopsoas, quadrates lumborum, transverses abdominis) left and right. Flexura coli dextra contact with lower surface of liver, floor of gall blader, descending part of duodenum, lower pole of right kidney. Colon transversum superiorly at border of liver, gall bladder, greater curvature of stomach and spleen; inferior – with loops of small intestinel anterior – with anterior abdominal wall; post – with duodenum, pancreas, left kidney. Flexura coli sinistra superiorly under lower lower pole of spleen, posterior attached to left kidney. Located 4 cm below and deep flexura coli dextra. Colon sigmoideum – relationship with organs changeable mobility and variance in structure (length). In most people cases, its attached to loops of small intestine and greater omentum. Later it stretch, and lies directly to abdominal wall, posterior section to peritoneum from m. iliopsoas and vasa iliacae externar. In region of pelvis, lies to sacrum.`

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BLOOD SUPPLY A. mesenterica superior – small intestine (SEE <TABLE 7.1.8>). A. mesenterica inferior give branches: - a. colica sinstra goes retroperitoneum and level of sinus mesenterica sinistra to the front of left ureter and flexura coli sinistra, across ascending branch anastomosis with a. sigmoidea, across ascending – with a. colica media (arch of Riolan). Collateral artery blood supply is of multiple type, between system, functional insufficiency only with blok a. mesenterica inferior. - aa. sigmoideae (2-4 units) goes at first retroperitoneum, later between sheath of mesocolon sigmoideum, anastomosis between them, with aa. colica sinistra et rectalis superior; - a. rectalis superior – final branches a. mesenterica inferior (small intestine, see 7.1.8). Veins goes parallel to arteries, tributaries of v, mesenterica inferior, which flow into v. lienalis, v. rectalis superior across plexus haemorrhoidales anastomosis with v. cava inferior (porto-caval anastomosis).

INNERVATION Plexus mesenterici superior et inferior.

LYMPH FLOW Lymph nodes of first order – along mesentery border and on wall of intestine. Lymph nodes of second order – along branches of descending (retroperitoneum) and upper mesentery (in mesocolon) artery, later lymph flow to lymph nodes near abdominal part of aorta and lower vena vein (lumbar lymph nodes).

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7.1.10 LUMBAR REGION

BORDERS Upper – XII rib. Lower – wing of iliac bone. External – posterior axillary line (posterior middle line – line of spinous processus – divide region into two symmetrical part). Anterior – fascia endoabdominalis.


See <BORDERS>, also cylinder of m. erector spinae, transverse processus of lumbar vertebra.

PROJECTION Kidney, suprarenal, ureter (SEE <TABLE 7.1.12-7.1.14>).

SUPERFICAL FORMATION

Skin thick, non mobile. Subcutaneous fat developed poor, have additional later between well expressed superficial fascia and proper fascia.

PROPER FASCIA F. thoracolumbalis thin sheath formed sheath for all muscles in the region, and for m. erector spinae – flat thich sheath. F. endoabdominalis cover internally m. transverses abdominis, formed sheath for mm. psoas minor et major, quadrates lumborum.

MUSCLES Arranged in three layers (symmetrical right and left): 1. m. latissumus dorsi begin flat tendon from processus spinosus of the sixth thoracic and lumbar vertebra bone; m. obliquus externus abdominis – goes from eight rib from upper to lower; 2. m. erector spinae – medial; m. serratus posterior inferior – later upwards; m. obliquus internus abdominis – lateral downwards; 3. m. transverses abdominis – lateral; m. quadrates lumborum, mm. psoas major et minor – medial. <Weak spots>: 1. trigonum lumbale (triangle Pti): - superior – border of mm. latissimus dorsi et obliquus externus abdominis; - inferior – wing of iliac bone; tighten fibers of m. obliquus externus abdominis; 2. rhombus lumbalis (rhombus Lesgaft-Gryunfilda) located deeply to m. latissumus dorsi, bounded: - superior – lower border of m. serratus posterior inferior; - inferior – upper border of m. obliquus internus abdominis; - medial – borders of m. erector spinae; - lateral – XII rib, tighten tendons of m. transverses abdominis.

NERVE FORMATION

Branches of lumbar plexus: - n. subcostalis. Dispose on first surface of m. quadraus lumborum; - n. iliohypogastricus. - n. ilioinguinalis – under f. quadrata (strip of f. endoabdominalis); - n. genitofemoralis – on anterior surface of m. psoas under f. psoatis (endoabdominalis). Truncus sympaticus penetrate from behind mediastinum between lateral and interweaving crura diaphragm, arranged (207 nodes) in splitting f. endoabdominalis in later border body of vertebra along medial border m. psoas major, go down into region of smaller pelvis. Vegetatci nerve plexus: plexus coeliacus, plecus mesentericus superior et inferior, plexus renalis, plexus suprarenalis.

BLOOD VESSELS Aorta abdominalis goes into region across hiatus aorticus diaphragnm lies left on anterior surface of lumbar vertebra, on level of V lumbar vertebra branches to general iliac vessels (aa. iliacae communes): to the front of aorta arranged pancreas, horizontal part of deudenum, root of mesentery of small intestine, left – truncus sympathicus sinister, right – v. cava inferior. Goes: 1. parietal veins: - aa. phrenicae inferiors dextra et sinista; - aa. lumbales (four); - a. sacralis mediana. 2. viscereal branches (also liver, stomach, spleen and other organs, (SEE <TABLE 7.1.2-

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7.1.14>): - truncus coeliacus – level of XII thoracic or I lumbar vertebra, branches on three branches (aa. gastric sinistra, hepatica communis, lienalis); - a. mesenterica superior – level of I lumbar veterbra, to the front from lower horizontal part of duodenum. - aa. suprarenales mediae; - aa. renales – I lumbar vertebra, goes aa. suprarenales inferiors, uretericae; - aa. testiculares (ovaricae) – on level of origin of kidney artery. Aa. iliacae communes branches on level of sacra-iliac joint on a. iliaca externa (goes to borders with lesser pelvis, goes branches of aa. epigastrica inferior, circumflexa ilium profunda) and a. iliaca interna (goes in smaller pelvis, see 8.1). V. cava inferior starts on level of IV-V lumbar vertebra, left wall lies to aorta; posterior – to fascia m. psoas, crura diaphragm, right supra renal; left – to lumbar section of truncus sympathicus; anterior – to pancreas, duodenum, root of mesentery of transverse colon or colon, left a. testicularis (ovarica), right a. iliac communis. On level of liver vein surround with parts of parenchyma of liver; tributaries of v. cava inferior located: vv. lumbales, phrenicae inferior, vv. testiculares (ovaricae), vv. renales, suprarenales, hepaticae.

LYMPH FLOW Nodi lymphatic lumbales located along aorta and v. cava inferior, receives lymph from region of the abdomen, pelvis and lower extremities. On level of I lumbar or XII thoracic vertebra merging of trunci lumbales et truncus intestinalis formed cistern chili (in 85%), from them formed ductus thoracicus, which les right from aorta and together rhe exit across diagphragm into posterior mediastinum.

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7.1.11 RETROPERITONEUM SPACE

BORDERS Internal: - anterior – parietal perioteneum of posterior abdominal wall; - posterior – f. endoabdominalis; - superior – line that enters parietal peritoneum on organs; - inferior – promontorium, linea terminalis; - lateral – line enters parietal peritoneum with lateral wall of abdomen on posterior.

PROJECTION Kidney, suprarenal, ureter (SEE <TABLE 7.1.12-7.1.14>)

PROPER FASCIA F. retroperitonealis starts from parietal peritoneum on level posterior to axillary line (lateral border of colon ascendens et descendens), branches on two sheath in its external border of kidney: 1. f. retrorenalis continue course f. retroperitonealis posterior of kidney to lumbar vertebra, where interweave in sheath of aorta and lower cava vein and m. psoas major; on top joined with f. prerenalis and fixed to crura of diaphragm; under continue in f. retrouretica; 2. f. preranalis enters to the from from tissue, surround kidney, on above formed sheath for suprarenal, attached with f. retrorenalis; medial enters on opposite level into similar fascia, send to connecting tissue to aorte and v. cava inferior; below continue to f. preureterica: between ff. pre- et retrorenalis its lower pole of kidney located connecting tissue, fixed to kidney. F. retrocolica (fascia Toldta) located from parietal peritoneum into point of entrance of tis wall of abdominal cavity on colon ascendens et descendens, medial fascia ligament with fascia of root of mesentery (right), left lose its internal border of descending colon.

INTERNAL ORGAN

Kidney, ureter, superrenal, pancreas, duodenum (SEE <TABLE 7.1.6, 7.1.7, 7.1.12-7.1.14>).

TISSUE SPACES Textus celilosus retroperitonealis – between ff. endoabdominalis et retrorenalis; upper locked union with diaphragm, lower to free continuation to tissue of pelvis; medial locked union with f. retrorenalis with sheath of abdominal aorta, v. cava inferior and m. psoas. Capsula adipose renis (paranephron) – between fascia of prerenalis, retrorenalis and kidney, upper locked union with their fascia, lower continuation to paraureterium and later into region of pelvis. Paracolon – between f. prerenalis and posterior wall of colon descendens (ascendens), which covers f. retrocolica; continuation to above till root of mesentery of colon transversum, below till coecum right and till root of mesentery of sigmoid colon left; internally to root of mesentery of colon; lateral – till point of connection of periotenum to f. retroperitonealis.

BLOOD SUPPLY Lumbar region, kidney, ureter, suprarenal, pancreas, duodenum (SEE <TABLE 7.1.6, 7.1.7, 7.1.10, 7.1.12-7.1.14>).

INNERVATION -SAME-

LYMPH FLOW -SAME-

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7.1.12 KIDNEY

HOLOTOPIA Retroperitoneum space.

PROJECTION Lumbar region on level of II (III) lumbar vertebra: - right kidney – upper pole on level of XI intercostals, hilum – lower XII rib; - left kidney – upper pole on level upper border of XI rib, hilum – XII rib.

SKELETOPIA -SAME-

SEROUS SHEATH

Retroperitoneal organ, peritoneum covers only anterior surface. Ligaments peritoneum: ligg. hepatorenale, duodenorenale, pancreatolienale, lienorenale.

FASCIAL SHEATH

Fascia retroperitonealis (retoperitoneum spaces, (SEE <TABLE 7.1.11>).

SYNTOPIA Posterior of kidney, behind f. retrosternalis – crura diaphragm, m. quadrates lumborum, aponeurosis m. transverses abdominis, m. psoas; behind upper pole – pleural sinus (sinus costodiaphragmaticus). Superior and anterior – suprarenal in capsule. Anterior (to the front from f. prerenalis) to right kidney attached liver, liver flexure of colon, descending part of duodenum; to left liver – spleen, floor of stomach, tail of pancreas, splenic flexure of colon. Medial, on level of hilum, - body XII thoracic, I and II lumbar vertebra, abdominal aorta (right), kidney crura (between them and kidney).

BLOOD SUPPLY Aa. renales – branches from aorta abdominalis on level I and II of lumbar vertebra. Posterior and below vv. renales in 30% of people has extra aa. renales, goes partly always from aorta to pole of kidney. VV. renales (dextra et sinistra) – left long right, enters to the front of aorta; in its flow to v. testicularis sinista. Between them located porto-caval anastomosis and v. lienalis.

INNERVATION Plexus renalis formed branches nn. splanchnici, truncus sympathicus, plexus coeliacus.

LYMPH FLOW Lymph flows in lumbar and aorta lymphatic nodes.

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7.1.13 SUPRARENAL

HOLOTOPIA Retroperitoneum spaces.

PROJECTION Lumbar region, level of XI-XII thoracic vertebra.

SEROUS AND CONNECTING SHEATH

Retroperitoneum organ, has capsule, formed fascia prerenalis (retroperitoneum spaces, (SEE <TABLE 7.1.11>).

SYNTOPIA Lies to anterior pole of kidney. Posterior surface – to lumbar section of diaphragm. Anterio to right suprarenal lies extraperitoneal surface of liver, left suprarenal covers parietal peritoneum posterior wall of omentum bursa. Medial – celiac plexus, also to right suprarenal lies lower cava vein, left – aorta. Lower border of left suprarenal reach pancreas.

BLOOD SUPPLY Aa. suprarenales superior (branches of a. phrenica inferior), media (branches of aorta), inferior (branches of a. renalis). Vv. suprarenales flow in renal vein (or right vein – in v. cava inferior).

INNERVATION Plexus coeliacus, renalis, n. phrenicus.

LYMPH FLOW In lymphatic paraaortal nodes.

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7.1.14 URETER

HOLOTOPIA Retroperitoneum space, subperitoenum floor of lesser pelvis.

PROJECTION On anterior abdominal wall – external border of straight muscle of abdomen. On lumbar region – vertical line, joining ends of transverse spinous processes of lumbar vertebra.


Retroperitoneum organ, small ligament with peritoneum connecting intersection. Continuation ff. retrorenalis et prerenalis formed for ureter sheath, in which located tissue – paraureterium.

SYNTOPIA Lumbar region (pars abdominalis) lies in retroperitoneum space on fascia m. psoas, intersect vasa testiculares (ovaricae) to posterior, n. genitofemoralis to anterior, on level of linea terminalis intersect iliac vessel to the front. Internally from right ureter located v. cava inferior, externally – internal bordor of colon ascendens et cecum, to anterior and to posterior – root of mesentery of small intestine. Internally from left ureter located aorta abdominalis, externally – internal border of colon descendens, to front – root of mesentery of sigmoid colon. Pelvic section (pars pelvine) – in subperitoneum floor of pelvis, in side of tissue spaces. In male goes between right muscles and vessels of pelvis, later intersect a. v. n. obturatoria et a. vesicalis superior, lie between posterior wall of bladder and straight intestine, intersect seminal duct externally and seminal vesicle anteriorly, under sharp arch flow into bladder. In female intersect a. iliaca interior in front, later a. uterine to the front, enters into base of wide ligament of uterus, and again intersect a. uterine posteriorly on 1.5-2 cm from internal mouth of cervis, later lies on wall sheath and under acute angle flow into bladder. In ureter three service: 1. on level of entrance pelvis in ureter. 2. on level of intersection with iliac vessels. 3. its narrow – nearby wall of bladder.

BLOOD SUPPLY Aa. renalis, testicularis (ovarica) – pars abdominalis; aa. rectalis media, vesicularis inferior – pars pelvina. Blood flows in vv. testiculres (ovaricae), iliaca interna.

INNERVATION Pars abdominalis – plexus renalis; pars pelvina – plexus hypogastricus

LYMPH FLOW From pars abdominalis – in nodi lymphatici aortales abdominals; from pars pelvina – in nodi lymphatic iliaci.

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SECTION VI

REGION OF LESSER PELVIS

8.1 TOPOGRAPHY OF LESSER PELVIS

BORDERS Internal: superior – linea terminalis (promontorim, pars sacralis lineae terminalis, linea arcuata ossis ilium, pectin osis pubis, upper border of symphysis pubica); lateral, anterior and posterior – bone pelvis (ossa coccygis, sacrum, ilii, pubis, ischii). External: inferior – perineum (SEE <TABLE> 8.1.1)

CORRESPONDING REGION

Floor: peritoneum, subperitoneum, subcutaneous (perineum).


Perineum (SEE <TABLE 8.1.1>)

PROJECTION Perineum (SEE <TABLE 8.1.1>)


Perineum (SEE <TABLE 8.1.1>)

BONE, LIGAMENTS

Bone base – SEE <BORDERS>. Connecting bone to ligaments: - symphysis pubica strengthened by lig. pubicum superius, below – lig. arcuatum pubis; - articulation sacroiliaca – flat joint, strengthened by multiple ligaments; - symphysis sacrococcygea – flat joint, maybe mobile (during delivery); - lig. sacrospinale – close foramen inschiadicum majus; - lig. sacrotuberale – close foramen ischiadicum minus; - membrane obturatoria – tighten for. obturatorium leave superior opening (canalis obturatorius).

MUSCLES Parietal muscles: - m. piriformis – from anterior surface of sacrum goes into buttock region across for. ischiadicum majus leaving fossa (for. suprapiriformis et. for. piriformis); - m. obturatorius internus begin from internal surface of bone pelvis and membrane obturatoria, goes into buttock region across for. ischiadicus minus; - m. coccygeus – between coccyx and sciatic spine (not usually developed). Deep muscle floor of pelvis: - m. levator ani (diaphragm of pelvis) in see foramen starts fron internal surface of lower branches of os pubis, from thickening fascia of m. obturatorius internus (arcus tendineus), attached to ligg. anococcygeum, sacrococcygeum anterior, os coccyhis, interweave in m. sphincter ani externus. - m. transverses perinei profundus tighten arch between lower branches of pubic and sciatic bone. Superfical muscles of floor of pelvis – perineum (SEE <TABLE 8.1.1>).

PROPER FASCIA Fascia pelvis – continuation below f. endoabdominalis: - f. pelvis parietalis covers parietal muscles of deep muscles of floor, thicken on borders of upper and lower pubic m. obturatorius internus, forming arcus tendieus (not very flat); - f. pelvis visceralis covers organs of lesser pelvis (or its strip), forming floor of its closed sheath, seperates loose tissue from wall of organs. See also subperitoneum floor of pelvis.

PERITONEUM FLOOR OF PELVIS

Cavum pelvis peritoneale: peritoneum goes with anterior abdominal wall on urinary bladder (plica vesicalis transversue), later in male with urinary ballder goes on ampula of seminal duct, roof of seminal vesicle, and later on rectum, formed excavatio retrovesicalis – Douglas pouch. In female peritoneum with urinary bladder goes on body of uterus, formed excavatio vesicouterina, later covers uterus behind (floor, body and neck), behind dome of vagina and goes on rectum – excavatio rectouterina (Douglas pouch) – lowest point of peritoneum of floor of pelvis and cavity of peritoneum: Douglas pouch limited:

- Anterior – peritoneum on wall of urinary bladder (in male) or on uterus and behind dome of vagina (in female).

- Lateral – (on both level) – plicae rectrouterinae (in female) or retrovesicales (in male);

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- Posterior – peritoneum of anterior wall of rectum. Ligaments and folds of peritoneum – also uterus, urinary bladder, rectum and others (SEE <TABLE 8.1.1-8.1.7.)

SUBPERITONEUM FLOOR OF PELVIS

Cavum pelvis subperitoneale lies between peritoneum and sheah of parietal fascia of pelvis. In sagital orientation lies two crura of pelvic fascia: from medial border of internal opening of obturator canal to anterior opening of sacrum (sacral-iliac joint). At them goes crura grow together with visceral fascia of urinary bladder, uterus in female, rectum. In frontal plane lies fascial sheath – aponeurosis peitoneo-perinealis (Денонвилле-Салищева), tighten between floor of excavatio retrovesicalis (in male) or rectrouterina (in female) and central tendon of perineum. Laterally, it merge together with sagital fascia sheath. That sheath divides subperitoneum floor on parietal tissue space of pelvis: 1. Prevesicalis – spatium prevesicale s. retropubicum – has triangular form, raised to

anterior wall of abdomen to level of umbilical above and plicae umbilicales mediales laterally. It is bounded by:

- Anterior – f. endoabdominalis (on strip between plicae umbilicales mediales) and f. pelvis on posterior surface of symphysis.

- Posterior – f. prevesicalis (on anterior wall of urinary bladder and on anterior abdominal wall between plicae vesicales medialis;

- Inferior – fascia of urinary diaphargm of pelvis, covers m. Transversus perinei profundus et ligg. Pubovesicales;

- Lateral – fascial side flap and f. pelvis, covered by m. obturatorius internus (also urinary bladder (SEE <TABLE 8.1.2).

Contains loose tissue, urinary and prostate venous plexus, artery of urinary bladder;

2. Retrovesicalis – spatium retovesicale – bounded by:

- Anterior – f. vesicalis, covered by posterior wall of urinary bladder.

- Posterior – periotenum-perineum aponeurosis (in male).

- Lateral – sagital sheath of pelvic fascia.

- Inferior – fascia of urogenital section of diaphragm of pelvis. Contains loose tissue, and in male also prostate gland in fascial capsule Piragov-Retsing, terminal section of ureter, seminal duct with ampulla, seminal vesicles, prostate venous plexus;

3. Parameterium – (only in female) – lies around cervix and goes in sulcus between sheath of wide ligament of uterus. It is bounded:

- Anterior – wall of urinary bladder, covered by viseral of bladder fascia;

- Posterior – wall of rectum, also covered by fascia;

- Lateral – ligg. Pubouterina, sacrouterina.

- Inferior – fascia of pelvis diaphragm. 4. Rectrorectales – spatium rectorectale seu presacrale. It is bounded:

- Anterior – posterior wall of rectum, covered by fascial Амюсса capsule;

- Posterior – anterior surface of sacrum, covered by f. pelvis;

- Lateral – sagital sheath of pelvic fasica.

- Above goes into retroperitoneum space; Contain fatty tissue, a. reactalis superior, aa. sacrales mediana et laterales, truncus sympathicus, plexus sacralis.

5. Lateral – spatium laterale (dextrum et sinistrum) – lies in lateral wall of pelvis. Every limited by:

- Anterior – fused with vesical fascia with lateral fascial crura;

- Posterior – sagital sheath fascia, attached to sacral-vertebra joint;

- Lateral – f. pelvis, covered upper surface of mm. levatoris ani;

- Superior goes into retroperitoneum spce. Contains:

- a. iliaca interna in medial border of m. iliopsoas divides on level of sacral-

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vertebral joint on anterior trunk (gives aa. umbilicalis, vesicales superior, uterina, vesicalis inferior, rectalis media, obturatoria, glutea inferior, pudenda interna) and posterior trunk (aa. sacralis lateralis, iliolumbalis, glutea superior);

- v. iliaca interna lies deep and medial to the artery; its tributaries – vein with such name, as in artery.

- plexus sacralis exits from pelvis opening of sacral, lies on anterior surface of m. piriformis formed nerve: nn. gluteus superior, gluteus inferior, ischiadicus, cutaneus femoris posterior, obturatorius, pudendus;

- plexus hypogastricus inferior – around a. iliaca interna;

- nodi lymphatici – along a. iliaca interna;

- ureter (in male – seminal duct) SUBCUTANEOUS FLOOR OF PELVIS

Cavum pelvis subcutaneum – between inferior surface of m. levator ani and skin (SEE perineum <TABLE 8.1.1>).

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8.1 PERINUEM

BORDERS Medial – SEE subcutaneous floor of pelvis. Superficial: rhomboid shape, peak which appear: anterior – lower border of symphysis; posterior – upper part of coccyx; lateral – ischial tuberculum. Level of rhomboid: anterior – lower bracnh of pubic and ischium bone; posterior – lower border of mm. glutei maximi.


SEE borders, also linea biischiadia (arch, curved forward), which divides region on two section: 1. regio (trigonum) urogenitalis; 2. regio (trigonum) analis.


Skin more thin in center, thicker in lateral section, covered with hair, has a lot of sebaceous and sweet gland. Subcutaneous tissue and superficial fascia more developed in regio analis. Part of its tissue filled in fossa ischiorectalis (SEE muscles), across which goes vessels and nerve to m. sphincter ani externus. Also in tissue goes branches of nn. ilioinguinalis, pudendus, cutaneus femoris psoterior. External sexual organs: in male penis, progress in its deep body in urethra, scrotrum with its contains (testes, appendage of testes, seminal canal); in female large and small labium, vestibule of vagina, large gland vestibule (Bartolium), clitoris and bulb of vestibule of vagina.

PROPER FASCIA Has numerous sheath. On level of regio urogenitalis divided: 1. superficial loose sheath formed sheath for superficial muscle region; 2. fascia diaphragmatis urogenitalis inferior covers lower surface of m. transversus

perinei profundus; 3. fascia diaphragmatis urogenitalis superior covers upper surface of m. transversus

perinei profundus; 4. fascia diaphragmatis pelvis inferior, coveres lower surface of m. levator ani, lies on

triangle regio analis. Fascia and muscles (SEE muscles), interworn with ceneter, formed centrum tendineum perinei.

MUSCLES In regio urogenitalis lies two layers of muscles: 1. superficial (symetriccal left and right) – mm. bulbospongiosus, ischiocavernosus,

transversus perinei superficialis; 2. deep – m. transversus perinri profundus tighten space between branches of pubic

bone, encloses in fascia (SEE proper fascia), across them goes ureter and vagina (in female).

In regio analis also two layers of muscles: 1. superficial – m. sphincter ani externus; 2. deep – mm. levator ani, obturatorius internus (symetrical left and right). In center region lies fascial nodes – centrum tendineum perinei. In its interweave bundles of mm. sphincter ani externi, transversi perinei superficiales, bulbocavernosis and its facia. Fossa ischiorectalis – pair triangle tissue space in side from peritoneum part of rectum. Both similarly bounded by:

- medially – m. sphincter ani externus, lower surface of m. levator ani;

- laterally – tuber ischiadicum, m. obturatorius internus (lower 2/3 surface below arcus tendineus), covered by fascia, in opening which goes gential neuro-vascular bundles:

- anterior – m. transversus perinei superficialis;

- posterior – lower border of m. gluteus maximus. VESSELS AND NERVE

Vasa pudendae internus, n. pudendus exits from gluteal region across for. Ischiadicum minus and lies in splitting in pelvic fascia on surface of m. obturatorius internus (Alcock canal) on 4-5 cm above upper part of tuber ischiadicum, turn externally to sexual organs and gives branches to rectum. A. v. n. rectales inferiores enters through tissue fossa ischiorectalis and goes to m. sphincter ani externus.

TISSUE SPACES Fossa ischiorectalis – SEE muscles. Fascial sheat of m. transversus perinei produndus – SEE proper fascia.

LYMPH FLOW Lymph flow in nodi lymphatici inguinales superficialis et nodi lymphatici iliaci.

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8.2 URINARY BLADDER, URETER

HOLOTOPIA, PROJECTION

Urinary bladder lies in peritoneum and subperitoneum floor on symphisis pubica. Filled bladder can raise to anterior abdominal wall only to level or umbilical (point of fixation of fascia of vesicle). Ureter enters in subperitoneum and subcutaneuous floor.


Peritoenum covers upper wall of urinary bladder, parly posterior and side (mesoperitoneum organ). Under it lies fascia prevesicalis, which covers bladder on all levels; lateral from vesicle it formed lateral flap, above bladder raised to level of umbilical and have appearance of two triangle sheath (anterior and posterior), which on level of plicae umbilcales mediales grow together between them and with fascia endoabdominalis. Formed prevesicle, retrovesicle (SEE region of lesser pelvis <TABLE 8.1>) and visceral (between wall of vesicle and fascia, its covering) tissue space of urinary bladder. Fixation ligaments: ligg. Pubovesicale, puboprostaticum, plicae umbilicales mediana et mediales. Ureter has no relation to peritoneum .

SYNTOPIA Anterior wall of urinary bladder lies to symphysis pubica. Posterior wall in male join with ampula of rectum, amupula of vescal duct, seminal vesicle, ureter; in female also join with uterus and vagina. Above and with side – with loops of small, sigmoid, someties – with transver colon and secum, which section of urinary bladder peritoneum. Below in male lies prostate, in female – fascia of urinary diaphragm. Uretra in female lies on level of lower border of symphysis, on 1.5-2 cm behindm goes downwards and to front, perforate urinary diaphragm, fixed to symphysis and open in vestibule of vagina, posterior surface of attachement with anterior wall of vagina. In uretra in male has three parts:

- pars prostatica (deeper than prostate) - on its posterior wall opens to orifice of seminal duct and appear duct of prostate gland.

- Pars membranaces (on level of urinary diaphragm of pelvis) joint behind with with glandulae bulbourethrales;

- Pars spongiosa (in which divides also pars bulbosa) lies in cavernous body of penis. Divides three narrowing: in internal opening (involuntary sphincter), on lever of pars membranacea (voluntary sphincter), in external opening of urethra.

BLOOD SUPPLY Urinay bladder – branches of a. iliaca interna: aa. vesicales superiores (branches of aa. umbilicales), vesicales inferiores. Urethra blood supply in principally a. pudenda interna. Vein formed plexus in wall and on anterior surface of bladder, flow into vv. iliacae internae.

INNERVATION Plexus aorticus abdominalis, hypogastricus, n. pudendus.

LYMPH FLOW In nodes that goes together with aa. iliacae interna et externa, on anterior surface of sacrum. In female, lymphatic vessels of urinary bladder anastomosis with vessels of uterus and vagina in base of wide ligament of uterus.

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8.3 PROSTATE GLAND

HOLOTOPIA In subperitoenum floor of pelvis ring-liked formation surrounding early section of urethra.

SHEATH No relationship to peritoneum. Viseral fascia of pelvis formed Piragov-Retsing capsule, from which to pubic bone goes ligg. Puboprostatica.

SYNTOPIA Superior – floor of urinary bladder, seminal vesicle, ampula of seminal duct. Inferior – urinary diaphragm. Anterior – posterior surface of symphysis. Posterior – ampula of rectum, detached from aponeurosis peritoneo-perinealis. Lateral – m. levator ani.

BLOOD SUPPLY Aa. vesicalis inferioris et rectales mediae. Veins formed pl. Prostaticus, which flow with pl. vesicalis and flow into v. iliaca interna.

INNERVATION Plexus hypogastricus.

LYMPH FLOW In lymphatic nodes which goes with a. iliaca interna, a. iliaca externa, on anterior surface of sacrum.

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8.4 SEMINAL DUCT

HOLOTOPIA In subperitoenum floor of pelvis directed from internal ring of inguinal canal below and behind.

SYNTOPIA Intersect a. epigastrica inferior, a. v. iliacae exteriores, a. v. obturatoriae, a. umbilicalis, a. vesicalis superior, pass on lateral wall of urinary bladder, later between ureter and posterior surface vesicle and formed ampula of seminal duct, behind from which lies seminal vesicle. Duct of ampulla flow with duct of seminal vesicle and to opening in pars postatica in urethra.

BLOOD SUPPLY A. ductus deferentis (branches of a. umbilicalis), venous blood flow into pl. vesicalis.

INNERVATION Plexus hypogastricus.

LYMPH FLOW In nodi lymphatici iliaci.

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8.5 SEMINAL VESICLE

HOLOTOPIA In peritoneum and subperitoneum floor of pelvis, between ampula of rectum and urinary bladder.

SHEATH Retroperitoneum organ (superior-medial section covers peritoneum). Visceral fascia formed posterior sheath of visceral fascia of urinary bladder. From rectum section aponeurosis peritoneoperinealis.

SYNTOPIA Medial – seminal duct with ampulla; Lateral – ureter. Anterior – urinary bladder. Posterior – rectum.

BLOOD SUPPLY Aa. vesicalis inferior, rectalis media. Veins flows into pl. vesicalis.

INNVERVATION Plexus hypogastricus inferior.

LYMPH FLOW In nodi lymphatici iliaci interni.

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8.6 RECTUM

HOLOTOPIA Lies on level of all three floor of lesser pelvis. Lies to anterior surface of crest – from III sacral to coccyx. Has dlexure: in sagital plane – flexura sacralis (front to back), flexura perinealis (back to front); in frontal plane formed opening for right angle.


Pelvic section: epiampular part lies intraperiteneum – ampulla – mesoperiteoneum to IV-V sacral verterbral, later – retroperitoneum, and lower section lies in subperitoneum floor of pelvis (enclosed capsule Амюсса – visceral fascial of pelvis). Perineum section (canalis analis) lies extraperitoneum in subcutaneous floor of pelvis. Excavatio rectovesicalis (in male), rectouterina (in female), plicae rectovesicales (in male), rectouterinae (in female), fossae pelviorectales – (SEE region of lesser pelves <TABLE 8.1>)

SYNTOPIA In peritoneum floor:

- Anterior in male – urinary bladder, seminal duct; in female – uterus and its appendages;

- Posterior – sacral (between them retrorectal tissue space);

- Superior – loops of small intenstine, sigmoid colon, sometimes – transverse colon. In subperitoneum floor:

- Anterior in male – posterior surface of prostate gland, posterior wall of urinary bladder, seminal vesicle, ampula of seminal duct, ureter; in female – posterior wall of vagina, ureter.

- Posterior – sacrum, coccyx. In subcutaneous floor:

- Anterior in male – urethra; in female – vagina;

- Posterior – coccyx;

- Lateral – fossae ischiorectales.

BLOOD SUPPLY A. rectalis supeior – terminal branches of a. mesenterica inferior, goes behind rectum in retrorectal space. Aa. rectalis mediae – from anterior trunk of a. iliaca interna to subperitoneum section of rectum. Aa. rectales inferiores – from a. pudenda interna (branches of a. iliaca interna) in subcutaneous floor of pelvis across tissue in fossa ischiorectalis in readial arrangement to m. sphincter ani externus. Venous flow goes from venous plexus (plexus venous rectales):

- Subcutaneous – around anal opening;

- Submucous – in submucous layer and between bundles of muscles;

- Sunfascial – between capsule of Амюсса and muscles layers. Plexus anastomosis between them and formed five veins: v. rectalis superior (later v. porta); vv. rectales mediae vv. rectale inferior (later – v. cava infeior). Formed porto-caval anastomosis – venous collateral system of multiple type level.

INNERVATION Plexus mesentericus inferior, hypogastricus, n. pudendus.

LYMPH FLOW From epiampular and ampular part – in nodi lymphatici rectales (first order), later into nodi lymphatici mesenterici inferiores; from middle part – in nodi lymphatici iliaci interni, sacrales; from canalis analis - in nodi lymphatici inguinales superficiales. In female lymphatic vessels anterior wall of rectum formed anastomosis with vessels of vagina and uterus.

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8.7 UTERUS WITH APPENDAGES, VAGINA

HOLOTOPIA Uterus lies in center of lesser pelvis, in peritoneum and subperitoneum floor. Slenting to mainly longitudinal axis to front (anteversio), body of uterus attached to cervix also slenting to front (anteflexio). Appendages (Fallopian tube and ovary) lies in wall of pelvis in peritoneum floor. Vagina – in peritoenum and subperitoneum floor.


Uterus – mesoperitoneum organ (not opened to peritoneum at edge of body, part of cervix and body in front). Fallopian tube – intraperitoneaul organ, overy covered by embryonic epithelium. In vagina, peritoneum encloses only posterior dome on length of 2 cm. Formed by peritoneum (suspensory apparatus of uterus right and left):

- Lig. latum uteri – duplicate of peritoneum in frontal plane at side of uterus.

- Lig. teres uteri – under front sheat of lig. latum, from angle of uterus to internal ring of inguinal canal;

- Mesovarium dixed ocary to posterior sheah of wide ligament of uterus.

- Lig. suspensorium ovarii constains a. et v. ovaricae;

- Lig. ovarii proprium fixed ovary to angle of uterus, contains branches of a. uterina to overy.

Fixation apparatus to uterus – ligament (right and left) from connecting and smooth muscles tissue: lig. cardinale (in base of lig. latum), lig. sacrouterinum, lig. pubovesicale, proceed into lig. vesicouterinum. Supporting appartus of uterus (right and left) – m. transversus perinei profundus, m. levator ani. Parametrium – (SEE region of lesser pelvis <TABLE 8.1>).

SYNTOPIA Anterior from uterus – urinary bladder, posterior – rectum, lateral – lig. latum and appendages, superior – loops of small intestine, sometimes sigmoid, transver colon, inferior - attached to vagina. Vagina in upper end surrounded by cervix, lower end opens into vestibule of vagina. To anterior of wall of vagina lies urinary bladder and urethra, section of septum vesicovaginale, to posterior – rectum, section of septum rectovaginale (aponeurosis peritoneo-perinealis).

BLOOD SUPPLY Uterus and appendages blood supply: 1. From a. iliaca interna – a. uterina (hoes in base of lig. latum, intersect uretra above); 2. Aorta – a. ovarica (gives ramus uterinus to uterus). 3. Artery of round ligament of uterus. Artery of wide anastomosis between them on level of wide ligament of uterus. Vagina blood supply by vagina branches of a. uterina et a. pudenda interna. Venous flow from all organs – to vv. uterinae in v. iliaca interna.

INNERVATION Plexus hypogastricus, uterinus, uterovaginalis.

LYMPH FLOW From cervis – to nodes on entery of iliac artery and to sacral nodes. From body of uterus – in nodes surrounding aorta and lower pudendal vein. Part of vessels on floor of uterus and from lower section of uterus on round ligament directed to pundendal nodes. Lymphatic vessels of uterus anastomosis with vessels of rectum.

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39251123 Translated Russian to English Topography Anatomy

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