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Surface & radiological
1. Surface Markings & Vertebral
Levels
C2- Angle of Mandible
C3- Hyoid Bone
C4- Thyroid Notch
C6- Cricoid Cartilage; Trachea, Esophagus begin
C7- Vertebra Prominens
T2/3- Upper border of Manubrium /Suprasternal
notch
T3 & 4- Manubrium- overlies the aortic arch
T5 to 8- Sternum- overlies the heart
2. • Sternal Angle- T4/5- Approx level of 2 nd
pair of costal cartilages; approx beginning
and end of aortic arch; bifurcation of
trachea in to Rt. & Lt. main bronchi.
• Xiphisternal joint- T9
• Lowest part of costal margin-10 th rib (the
subcostal line)- passes through L3
3. • Scapula
superior angle- T2
spine of scapula- T3
Inferior Angle- T7
Esophagus: Approx length-25 cm
Cervical:
superiorly- just below the level of cricoid
(cricopharyngeus muscle (C7))- 15 cm from
incisors
Inferiorly- Thoracic inlet approx 18 cm, T3 level
at the level of suprasternal notch
4. • Thoracic Esophagus
Superiorly- level of T3 (18 cm from
incisors)
Inferiorly- T10 or 11
Carina- 24-25 cm from incisors
GE jn.- Approx 40 cm from incisors
AJCC Classification: Cervical (15-18 cm),
upper Thoracic (18-24 cm), mid Thoracic
(24-32), Lower Thoracic (32-40)
5. • Thorax- Lines of Orientation
Midsternal Line- Lies in the Median Plane
over the sternum
Midclavicular Line- Runs vertically
downward from the midpoint of the clavicle
Anterior Axillary Line- Runs vertically
downwards from the anterior axillary fold
Posterior Axillary Line- Runs Vertically
downwards from the posterior axillary fold
6. • Midaxillary Line- Runs vertically downward
from a point situated midway between the
anterior and posterior folds
• Scapular Line- Runs vertically downward
on the posterior wall of the thorax, passing
through the inferior angle of the scapula
(arms at sides)
7. • Nipple (in males)-lies in the 4th intercostal
space about 10 cm from midline.
• Apex Beat- in 5th intercostal space 9cm
from midline (just below and medial to the
nipple). Marks the lowest and outermost
point at which the cardiac impulse can be
palpated.
8. • Transpyloric Plane (of Addison)- Lies halfway
between the suprasternal notch and pubis, or
approx one hands breadth below the xiphoid (L1
Level)
passes through the Pylorus, the pancreatic neck,
the duodenojejunal flexure, the fundus of the gall
bladder, the tip of the 9th costal cartilage, and hila
of the kidneys.
Also corresponds to the level of termination of
the Spinal Cord.
9. • Subcostal Plane- L3
Line joining the lowest point of the thoracic
cage on each side (inferior margin of the
10th rib).- passes through the origin of the
inferior mesenteric artery.
• Plane of the Iliac Crests- L4
Corresponds to the level of the Aortic
bifurcation. Useful landmark in performing
LP.
13. The Anterior Region of the Neck
• Has several palpable landmarks, including the larynx, trachea, and
sternal notch.
• The larynx.
– found in the middle of the neck
– composed of multiple cartilages
– thyroid cartilage
• “Adam’s apple”
• Inferior to the larynx are the cricoid cartilage and trachea.
• Terminates at the sternal (jugular) notch of the manubrium and the
left and right clavicles.
14. The Nuchal Region
• The posterior neck region.
• Houses the spinal cord, cervical vertebrae, and associated
structures.
• The bump at the lower boundary of this region is the vertebra
prominens.
• Superiorly along the midline of the neck, is the ligamentum nuchae,
a thick ligament that runs from C7 to the nuchal lines of the skull.
15. Left and Right Lateral Portions of
the Neck
• Contain the sternocleidomastoid muscles which partitions the neck
into two clinically important triangles, an anterior triangle and a
posterior triangle.
• Each triangle houses important structures that run through the neck.
• Triangles are further subdivided into smaller triangles.
• Anterior triangle lies anterior to the sternocleidomastoid muscle and
inferior to the mandible.
– subdivided into four smaller triangles
• the submental, submandibular, carotid, and muscular
triangles
16. The Posterior Triangle
• Lateral region of the neck.
• Posterior to the sternocleidomastoid muscle.
• Superior to the clavicle inferiorly.
• Anterior to the trapezius muscle.
• Subdivided into two smaller triangles.
– the occipital triangle
– supraclavicular triangle
17. Position of Nodes
1. Submental
2. Submandibular
3. Parotid / tonsilar
4. Preauricular
5. Postauricular
6. Occipital
7. Anterior cervical superficial
and deep
8. Supraclavicular
9. Posterior cervical
22. Gluteal Region
• The inferior border of the gluteus maximus
muscle forms the gluteal fold.
• The gluteal (natal) cleft extends vertically to
separate the buttocks into two prominences.
• In the inferior portion of each buttock, an ischial
tuberosity can be palpated; these tuberosities
support body weight while seated.
• The gluteus maximus muscle forms most of the
inferolateral “fleshy” part of the buttock.
• The gluteus medius muscle may be palpated
only in the superolateral portion of each buttock.
23. The Thigh
• Many muscular and bony features are readily identified
in the thigh, which extends between the hip and the knee
on each lower limb.
• An extremely important element of thigh surface
anatomy is a region called the femoral triangle.
• The femoral triangle is a depression inferior to the
groove that overlies the inguinal ligament on the
anteromedial surface in the superior portion of the thigh.
• The femoral artery, vein, and nerve travel through this
region, making it an important arterial pressure point for
controlling lower limb hemorrhage.
24. Thigh and Knee
• On the distal part of the anterior thigh, are the
three parts of the quadriceps femoris as they
approach the knee.
• Still on the anterior side of the thigh, three
obvious skeletal features can be observed and
palpated:
– (1) The greater trochanter is palpated on the superior
lateral surface of the thigh;
– (2) the patella is located easily within the patellar
tendon; and
– (3) the lateral and medial condyles of both the femur
and tibia are identified and palpated at each knee.
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73. Level Ia
Level Ia
CRANIAL Geniohyoid m., plane tangent to
basilar edge of mandible
CAUDAL Plane tangent to body of hyoid bone
ANTERIOR Symphysis menti, platysma m.
POSTERIOR Body of hyoid bone
LATERAL Medial edge of ant. belly of digastric
MEDIAL n.a. (midline)
74. Level Ib
Level Ib
CRANIAL Mylohyoid m., cranial edge of
submandibular gland
CAUDAL Plane through central part of hyoid
bone
ANTERIOR Symphysis menti, platysma m.
POSTERIOR Posterior edge of submandibular gland
LATERAL Basilar edge / innerside of mandible,
platysma m., skin
MEDIAL Lateral edge of ant. belly of digastric
75. Level IIa
Level IIa
CRANIAL Caudal edge of lateral process of C1
CAUDAL Caudal edge of the body of hyoid
bone
ANTERIOR Post. edge of submandibular gland;
ant. edge of int. carotid artery;
IIA post. edge of post. belly of
digastric m.
POSTERIOR Post. Border of int. jugular vein
LATERAL Medial edge of sternocleidomastoid
MEDIAL Medial edge of int. carotid artery,
paraspinal (levator scapulae) m.
76. Level IIb
Level IIb
CRANIAL Caudal edge of lateral process of C1
CAUDAL Caudal edge of the body of hyoid
bone
ANTERIOR Post. Border of int. jugular vein
POSTERIOR Post. border of the
IIB
sternocleidomastoid m.
LATERAL Medial edge of sternocleidomastoid
MEDIAL Medial edge of int. carotid artery,
paraspinal (levator scapulae) m.
77. Level III
III
CRANIAL Caudal edge of the body of hyoid bone
CAUDAL Caudal edge of cricoid cartilage
ANTERIOR Postero-lateral edge of the
sternohyoid; ant. edge of
sternocleidomastoid m.
POSTERIOR Post. edge of the sternocleidomastoid
LATERAL Medial edge of sternocleidomastoid
MEDIAL Int. edge of carotid artery, paraspinal
(scalenius) m.
78. Level IV
Level IV
CRANIAL Caudal edge of cricoid cartilage
CAUDAL 2 cm cranial to sternoclavicular joint
ANTERIOR Anteromedial edge of sternocleido-
mastoid m
POSTERIOR Post. edge of the
sternocleidomastoid m.
LATERAL Medial edge of sternocleidomastoid
MEDIAL Medial edge of internal carotid
artery, paraspinal (scalenius) m.
79. Level V
Level V
CRANIAL Cranial edge of body of hyoid bone
CAUDAL CT slice encompassing the
transverse cervical vesselsb
ANTERIOR Post. edge of the
sternocleidomastoid m.
POSTERIOR Ant. border of the trapezius m.
LATERAL Platysma m., skin
MEDIAL Paraspinal (levator scapulae,
splenius capitis) m.
80. Level VI
Level VI
CRANIAL Caudal edge of body of thyroid
cartilage
CAUDAL Sternal manubrium
ANTERIOR Skin; platysma m.
POSTERIOR Separation between trachea and
esophagus
LATERAL Medial edges of thyroid gland, skin
and ant.-medial edge of
sternocleidomastoid m.
MEDIAL n.a.
81. Retropharyngeal nodes
Retropharyngeal
CRANIAL Base of skull
CAUDAL Cranial edge of the body of hyoid
bone
ANTERIOR Fascia under the pharyngeal
mucosa
POSTERIOR Prevertebral m. (longus colli,
longus capitis)
LATERAL Medial edge of the internal carotid
artery
MEDIAL Midline
Editor's Notes
— Neck as seen from left anterior view. Drawing shows specific margins of anatomy seen in A that relate to definitions of classification levels. Note that line of separation between levels I and II is posterior margin of submandibular gland. Separation between levels II and III and IV is posterior edge of sternocleidomastoid muscle. Line of separation between levels IV and V is oblique line extending from posterior edge of sternocleidomastoid muscle to posterior edge of anterior scalene muscle. Posterior edge of internal jugular vein separates level IIA and IIB nodes. Carotid arteries separate levels III and IV from level VI. Top of manubrium separates levels VI and VII. (Reprinted with permission from [16])
