---

🔴 SURFACE ANATOMY (Red Cards) — Mark on Cadaver

---

THORAX

Right Lung Borders

• Superior border: Passes 2.5 cm above the medial 1/3 of clavicle (apex)
• Anterior border: From apex down to the sternal angle, then along the left edge of sternum to the 6th costal cartilage (right side stays close to midline)
• Inferior border: 6th rib at mid-clavicular line → 8th rib at mid-axillary line → 10th rib at scapular line → T12 posteriorly
• Posterior border: Lateral to vertebral column from T1 to T12

Left Lung Borders

• Same as right lung except the anterior border deviates leftward at the 4th costal cartilage forming the cardiac notch, then returns at the 6th costal cartilage
• Inferior border same levels as right

Right Costo-mediastinal Reflection (Pleura)

• The right parietal pleura reflects from chest wall to mediastinum. Line runs from behind sternoclavicular joint → down behind sternum → meets left side at sternal angle → right side stays close to sternal edge and continues to 6th CC

Left Costo-mediastinal Reflection

• Diverges from right at 4th CC level → sweeps left to mid-clavicular line forming the cardiac notch of pleura → descends to 6th CC

Costo-vertebral Reflection

• Posterior parietal pleura reflects from ribs onto vertebral column. Mark along the necks of ribs from T1-T12 vertebrae on each side (lateral to the vertebral column)

Costo-diaphragmatic Reflection

• The lowest line of pleura. Mark from:
  • 8th rib at mid-clavicular line
  • 10th rib at mid-axillary line
  • 12th rib at scapular line
  • T12 level posteriorly
• This reflection is ~2 rib spaces BELOW the lower border of the lung

---

CARDIAC VALVES (mark on anterior chest wall)

---

HEART BORDERS

Right Border of Heart

• From 3rd costal cartilage, right sternal edge → curving 1-2 cm to the right → down to 6th costal cartilage, right sternal edge
• Formed by the right atrium

Left Border of Heart

• From 2nd intercostal space, just left of sternum (pulmonary trunk/auricle) → curving down and left → to the apex at the 5th intercostal space, mid-clavicular line
• Formed mainly by left ventricle

---

ABDOMINAL ORGANS

Stomach

• Mark in the left hypochondrium and epigastrium
• Cardiac end: Left of xiphoid, 7th costal cartilage level
• Fundus: Under left dome of diaphragm (5th rib, left MCL)
• Pylorus: Transpyloric plane (L1), slightly right of midline
• Greater curvature curves downward to approximately the umbilicus level

Spleen

• Located in the left hypochondrium
• Lies along the 9th, 10th, 11th ribs (long axis)
• Medial border at mid-axillary line
• Not normally palpable below the costal margin
• Mark from 9th-11th ribs, posterior to mid-axillary line, left side

Duodenum

• Mostly retroperitoneal, in the epigastrium and right side
• 1st part (cap): Right of pylorus at L1, transpyloric plane
• 2nd part: Descends from L1-L3, right of spine
• 3rd part: Crosses L3 horizontally
• 4th part: Ascends to L2, left of spine
• "C-loop" framing the head of pancreas

Kidneys

• Right kidney: T12 to L3; upper pole at 12th rib, 2.5 cm lateral to spinous processes
• Left kidney: T11 to L2; slightly higher than right (liver pushes right one down)
• Anterior surface: Right kidney upper half behind liver, lower half behind hepatic flexure; Left kidney behind stomach, pancreas, splenic flexure
• Mark on posterior abdominal wall: Right 12th rib bisects right kidney; left kidney extends slightly above 12th rib

Ileocaecal Junction

• In the right iliac fossa, about 2 cm below and medial to the McBurney's point
• Surface marking: Junction of right lateral 1/3 and medial 2/3 of a line from ASIS to umbilicus (McBurney's area), at approximately the right iliac fossa
• Or: 3.5 cm below and medial to the ASIS on the right

---

UPPER LIMB VEINS & NERVES

Cephalic Vein

• Starts at the anatomical snuffbox (lateral wrist)
• Runs along the lateral forearm → lateral to biceps → enters deltopectoral groove
• Drains into the axillary vein just below the clavicle
• Mark: Lateral border of wrist → up radial side of forearm → lateral arm → deltopectoral groove → clavipectoral fascia

Basilic Vein

• Starts on the medial wrist/forearm (medial to dorsal venous arch)
• Runs up the medial forearm → joins the brachial vein just above the mid-arm to form the axillary vein
• Mark: Medial wrist → up medial forearm → pierces deep fascia at mid-arm → continues as axillary vein

Median Cubital Vein

• Connects cephalic to basilic vein across the cubital fossa
• The most common site for venepuncture
• Mark: Oblique line in front of elbow, crossing from cephalic (lateral) to basilic (medial)
• Lies superficial to the bicipital aponeurosis (which protects the brachial artery below)

Ulnar Nerve in Forearm

• Enters forearm between the two heads of flexor carpi ulnaris (FCU)
• Runs down the medial forearm between FCU and flexor digitorum profundus (FDP)
• At the wrist, passes lateral to pisiform (through Guyon's canal)
• Mark: From the medial epicondyle → down the medial aspect of forearm → lateral to pisiform to wrist

Femoral Nerve

• Enters the thigh lateral to the femoral artery (just below the inguinal ligament)
• Lies in the femoral triangle, outside the femoral sheath
• Mark: Mid-inguinal point (midpoint between ASIS and pubic symphysis) → lateral to femoral artery pulse → branches immediately in the femoral triangle

---

LOWER LIMB VEINS & ARTERIES

Great Saphenous Vein

• Longest vein in the body
• Starts at the medial side of dorsum of foot (medial to great toe base)
• Passes anterior to medial malleolus → up medial calf and thigh → drains into femoral vein at the saphenofemoral junction (4 cm below and lateral to the pubic tubercle / femoral triangle)
• Key landmark: Always anterior to medial malleolus at the ankle
• Mark: Medial dorsum foot → anterior medial malleolus → medial leg → behind medial condyle of knee → medial thigh → saphenofemoral junction

Anterior Tibial Artery

• Enters anterior compartment by passing through the interosseous membrane below the proximal tibiofibular joint
• Runs between tibialis anterior and extensor hallucis longus
• At the ankle = dorsalis pedis artery (palpable on dorsum of foot between EHL and EDL tendons)
• Mark: From 2 cm below the head of fibula → down the anterior compartment → dorsum of foot

---

HEAD & NECK

Pterion

• The H-shaped suture where frontal, parietal, temporal, and greater wing of sphenoid meet
• Thinnest part of the skull
• Surface marking: 4 cm above the midpoint of the zygomatic arch (or 3 cm posterior and 4 cm superior to the frontozygomatic suture = level of middle meningeal artery anterior branch)
• Clinically important: Blow here can rupture the middle meningeal artery → extradural haematoma

External Carotid Artery

• Branches from common carotid at the level of the upper border of thyroid cartilage (C4)
• Runs from the carotid triangle → enters the parotid gland → terminates as the maxillary and superficial temporal arteries behind the neck of mandible
• Mark: From the carotid bifurcation (C4, anterior to SCM) → upward through carotid triangle → behind mandible → into parotid

Facial Artery in Face

• Winds around the lower border of mandible just anterior to the masseter muscle (pulsation felt here)
• Runs obliquely across the face → lateral to the mouth → alongside the nose → terminates as angular artery at the medial angle of the eye
• Mark: Notch at lower border of mandible (anterior to masseter) → oblique line to nasolabial fold → up to medial canthus

---

---

⬛ LIVING ANATOMY (Black Cards) — Palpate on Living Subject

---

HEAD & NECK

Palpate Carotid Artery

• With the subject's head slightly turned AWAY from you
• Place fingers between the trachea and SCM at the level of the thyroid cartilage (C4)
• Feel the pulsation of the common carotid artery
• ⚠ Do NOT press both sides simultaneously (can cause reflex bradycardia/syncope)
• The carotid bifurcation is at the upper border of the thyroid cartilage
• The carotid sinus (baroreceptor) is at the bifurcation - avoid firm pressure

Palpate Facial Artery

• Place finger at the anterior border of masseter on the lower border of the mandible
• Feel the facial artery pulsation here as it winds around the mandible
• It can also be felt at the nasolabial fold area

Superficial Temporal Artery

• A branch of the external carotid artery
• Palpate just anterior to the tragus of the ear (preauricular area)
• Feel the pulse of the superficial temporal artery here as it crosses the zygomatic arch
• It then ascends onto the temple, dividing into frontal and parietal branches

Parotid Duct (Stensen's Duct)

• Mark a line from the tragus of the ear to the midpoint of the upper lip
• The parotid duct runs along the middle third of this line
• Or: Draw a line from the tragus to the midpoint between the ala of nose and upper lip - the duct runs along this
• It pierces the buccinator muscle and opens into the oral vestibule opposite the upper 2nd molar tooth
• Feel: Roll a finger over the line over the masseter - the duct may be felt as a cord-like structure

Muscle of Mastication

• Masseter: Ask subject to clench teeth - feel the bulge anterior to the ear over the ramus of mandible
• Temporalis: Ask to clench - feel the contraction in the temporal fossa (fan-shaped muscle above zygomatic arch)
• Medial pterygoid: Palpated intraorally on medial surface of mandible ramus
• Lateral pterygoid: Palpated intraorally at the roof of mouth - tested by asking to protrude jaw and move side to side

Testing Muscles of Facial Expression

• Temporal branch: Raise eyebrows, wrinkle forehead
• Zygomatic branch: Close eyes tightly (orbicularis oculi)
• Buccal branch: Puff out cheeks, show teeth
• Marginal mandibular branch: Depress lower lip / show lower teeth
• Cervical branch: Tense the platysma (pull corners of mouth down)
• To distinguish UMN vs LMN: UMN lesion spares forehead (bilateral cortical supply); LMN lesion affects ALL branches including forehead

Extraocular Muscles

• Lateral rectus (CN VI): Lateral gaze
• Medial rectus (CN III): Medial gaze
• Superior rectus (CN III): Up and lateral
• Inferior rectus (CN III): Down and lateral
• Superior oblique (CN IV): Down and medial (intort)
• Inferior oblique (CN III): Up and medial
• Look for: Diplopia, abnormal eye position, nystagmus, lid ptosis (CN III)

Movement of Atlanto-occipital and Atlanto-axial Joints

• Atlanto-occipital joint (C0-C1): Nodding "YES" motion - flexion and extension; 15° each direction
• Atlanto-axial joint (C1-C2): Shaking "NO" motion - rotation; ~45° each side (50% of total cervical rotation)
• To test atlanto-occipital: Stabilize C2 and ask to nod
• To test atlanto-axial: Ask to rotate head while you stabilize C2 spinous process
• ⚠ In rheumatoid arthritis and Down syndrome, atlanto-axial subluxation risk - always check before airway manipulation

McBurney's Point

• Located at the junction of the medial 2/3 and lateral 1/3 of a line drawn from the umbilicus to the right ASIS
• This overlies the base of the appendix (where the taenia coli converge)
• Clinical significance: Maximum tenderness in acute appendicitis
• Related signs to test:
  • Rebound tenderness (Blumberg's sign)
  • Rovsing's sign: Pressure on left iliac fossa causes pain at McBurney's point on the right

---

UPPER LIMB

Thenar Eminence

• The fleshy mound at the base of the thumb (lateral palm)
• Contains:
  • Abductor pollicis brevis (ABP)
  • Flexor pollicis brevis (FPB)
  • Opponens pollicis (OP)
  • All supplied by recurrent branch of median nerve
• Palpate: Ask subject to abduct the thumb (lift it perpendicular to the palm) - feel APB contract
• Wasting of thenar eminence = carpal tunnel syndrome / median nerve lesion

Hypothenar Eminence

• The fleshy mound at the base of the little finger (medial palm)
• Contains:
  • Abductor digiti minimi (ADM)
  • Flexor digiti minimi (FDM)
  • Opponens digiti minimi (ODM)
  • All supplied by the deep branch of ulnar nerve
• Palpate: Ask to abduct the little finger - feel ADM contract
• Wasting = ulnar nerve lesion (claw hand deformity of ring and little finger)

Movements of the Thumb

• Flexion: Moving thumb across palm (flexor pollicis longus + brevis)
• Extension: Moving thumb away from palm in plane of palm (extensor pollicis longus + brevis)
• Abduction: Moving thumb perpendicular to palm (abductor pollicis longus + brevis)
• Adduction: Bringing thumb back to side of index finger (adductor pollicis - ulnar nerve)
• Opposition: Tip of thumb to tip of little finger - combined movement (median nerve via recurrent branch)
• Clinical test: "Opposition" tests the median nerve; "Froment's sign" (paper grip test) tests adductor pollicis (ulnar nerve)

Adduction & Abduction of Fingers

• Abduction: Spreading fingers apart - dorsal interossei (4 muscles, ulnar nerve)
  • "DAB" - Dorsal interossei ABduct
• Adduction: Bringing fingers together - palmar interossei (3 muscles, ulnar nerve)
  • "PAD" - Palmar interossei ADduct
• To test: Ask to spread fingers apart (abduction) - resist this movement to test dorsal interossei
• Ask to squeeze a card between adjacent fingers (adduction) - tests palmar interossei
• Both are supplied by the ulnar nerve (deep branch)
• Wasting of interossei = ulnar nerve lesion → clawing of ring and little finger

---

BACK & CHEST

Inferior Angle of Scapula

• Palpated easily by feeling the lowest point of the scapula
• Normally at the level of T7 spinous process (or 7th rib posteriorly) when arms are at the side
• When arm is raised to 90°, inferior angle moves to T8
• Important landmark for counting ribs posteriorly
• To confirm: Ask subject to place their arm behind their back - the inferior angle becomes more prominent ("wings out")

Serratus Anterior

• Originates from the outer surfaces of ribs 1-9, inserts into the medial border of the scapula (costal surface)
• Nerve: Long thoracic nerve (C5, C6, C7 - "C5,6,7 keeps the wing from heaven")
• To palpate: Ask subject to push their hands against a wall - see the serrations on the lateral chest wall (ribs 5-9 visible/palpable)
• "Winging of scapula": If long thoracic nerve is cut, serratus is paralyzed → medial border of scapula wings away from chest wall when pushing forward

Latissimus Dorsi

• Largest muscle in the back
• Origin: Spinous processes T7-L5, thoracolumbar fascia, iliac crest, lower 3-4 ribs
• Insertion: Intertubercular groove (bicipital groove) of humerus
• Action: Extension, adduction, medial rotation of humerus; also used in climbing, coughing
• To palpate: Ask to cough or ask subject to adduct the arm against resistance - feel the posterior axillary fold contracting
• Or: Place your hand in the posterior axillary fold - the main bulk of the fold is latissimus dorsi

Pectoralis Major

• The anterior axillary fold
• Origin: Clavicle (clavicular head), sternum and costal cartilages 1-6 (sternocostal head), aponeurosis of external oblique
• Insertion: Lateral lip of bicipital groove
• Action: Adduction and medial rotation of arm; clavicular head helps flexion
• To palpate: Ask to push hands together in front of chest (adduction against resistance) - feel the anterior axillary fold
• Or: Ask to adduct the arm against your resistance - the pectoralis major contracts visibly and palpably

---

LOWER LIMB

Ligamentum Patellae

• The continuation of the quadriceps tendon below the patella to the tibial tuberosity
• Lies in the anterior knee, between the patella and the tibial tuberosity
• To palpate: Feel the firm cord between the lower edge of the patella and the bony bump of the tibial tuberosity
• Tested with the knee jerk reflex (L3, L4): Tap the ligamentum patellae with a reflex hammer → knee extends
• Osgood-Schlatter disease: Pain and swelling at the tibial tuberosity in adolescents due to traction on this ligament

Anterior Tibial Artery (Palpate)

• Felt on the dorsum of the foot as the dorsalis pedis artery (continuation of anterior tibial)
• Palpate between the tendons of extensor hallucis longus and extensor digitorum longus on the dorsum of the foot (proximal to 1st web space)
• Press gently between the tendons - feel the dorsalis pedis pulse
• Also palpable along the anterior compartment of the leg (deep - harder to feel)
• Absent in peripheral vascular disease

Posterior Tibial Artery (Palpate)

• Palpate posterior to the medial malleolus (in the groove between the medial malleolus and the heel)
• Place fingers in this groove and feel the pulse
• Can also be felt more proximally between flexor digitorum longus and soleus in the leg
• Key landmark for checking circulation to the foot
• Clinical: Absent in peripheral arterial disease of the lower limb

Gastrocnemius

• The superficial muscle of the calf (posterior compartment of leg)
• Two heads: Medial head (larger, palpable in the midline) and lateral head
• Both arise from the respective femoral condyles
• Join the Achilles tendon distally
• To palpate: Ask to stand on tiptoes - feel the two heads of gastrocnemius contracting in the calf
• Or: Ask to plantarflex foot against resistance while you palpate the calf
• Nerve: Tibial nerve (S1, S2)
• Simmonds'/Thompson's test: Squeeze the calf while patient lies prone - absence of plantarflexion = Achilles tendon rupture

Superficial Temporal Artery (also listed above)

---

CLINICAL NOTES ON ALL LIVING ANATOMY PALPATIONS

1. Position of patient (supine, sitting, standing)
2. Anatomical landmark used to locate structure
3. Whether pulsation/contraction/edge is felt
4. Any abnormality (tenderness, absence of pulse, wasting)

---

QUICK REFERENCE CHEAT SHEET

Surface Anatomy (Red) - Key Numbers to Remember

Living Anatomy (Black) - Key Nerves

---

• For surface anatomy viva, practice drawing each structure on a diagram using bony landmarks as reference points
• For living anatomy, practice on a partner and narrate your steps out loud: state the landmark → technique → what you're feeling
• The valves are often tested together - remember they're in the "APTM" order (clockwise from 2nd right ICS): Aortic, Pulmonary, Tricuspid, Mitral
• Pterion is a favourite question because of its clinical significance (extradural haematoma)
• The great saphenous vein is always anterior to the medial malleolus - this is the single most tested fact about it