Bony landmarks used to organize the physical exam (if you use "Anatomy Clinic" refer to "Body Painting" in the graphics resource)

(At any time you can rotate the image or add or subtract structures. Clicking the link will always bring you back to a starting point. Remember to use rollovers to see the labels for the various structures. Also, by moving the axial plane to any point in the image on the right, you can see the cross-section on the lower left. Using <ctrl-P> will toggle the axial plane marker on and off. Any coloration in the right image will be shown in the cross-sections.)

Beginners can ignore the axial images; advanced students should note that the axial image corresponds to the feature that is being discussed in the text.

Midline structures:

Suprasternal notch and Sternal Angle of Louis

Insert your finger gently into the suprasternal notch at the upper end of the sternum. Feel the manubrium and the heads of the clavicles. (You can change the opacity of the skin at any time using the slider at the lower right.) Let's add in another part of the sternum in a different color, the body of the sternum. The junction between the manubrium and the sternum is the sternal angle of Louis.

To relate the superior end of the manubrium (suprasternal notch) and the inferior end of the manubrium (sternal angle of Louis) to the vertebral column, use the wheel to rotate the body to 90 degrees. (Add back and remove the skin to see why you can easily palpate the sternal angle and suprasternal notch.) Now add in the cervical vertebrae, and the thoracic vertebrae. The difference between the vertebrae is the thoracic vertebrae articulate with the ribs. Add in rib 1 to identify thoracic vertebra 1 (T1). Which vertebrae is in the same axial (transverse) plane as the suprasternal notch? (It may help to rotate the image back and forth between 60-90 degrees.) Let's give T3 a different color. Which vertebrae is in the same axial plane as the sternal angle of Louis? Let's give T5 a different color.


Xiphoid process and Costal margin

Let's rotate back to 15 degrees and add in the xiphoid process. Let's add the costal cartilages on one side to indicate which ribs articulate (via their costal cartilage) directly to the sternum and which costal cartilages form the costal margin. Let's add in ribs 7and 12 as a reference. Which vertebra is in the same axial plane as the xiphoid process? Rotate the image to 275 degrees to find out. Let's give T10 a different color. Take a moment to add back and remove the skin.

Pelvis

Look for a gap along the anterior midline between the left and right the pelvic bones.This space is occupied by a cartilage known as the pubic symphysis. Rotate the body back and forth from 0 degrees to be sure you are looking at the narrow, anterior gap. The inguinal ligament (of Poupart) connects the pubic tubercle (just lateral to the pubic symphysis to the anterior iliac spine. Rotate the image to 45 degrees to appreciate the position of the ligament. Locate these attachments and palpate them on yourself.

To complete the axial skeleton let's add in the sacrum and the lumbar vertebrae

 

Important transverse (axial) planes:

For the individual standing upright, these planes cut through the body parallel to the floor. Use bony landmarks to locate them and draw them with black marker as dashed lines.

Transpyloric plane

This transverse plane lies half-way between the suprasternal notch and the pubic symphysis. On a fit and trim individual this plane also lies half-way between the Xiphoid process and the umbilicus. Which vertebra is in this plane? On average the pylorus (the exit of the stomach) and L1 (or the L1/L2 junction) lie in this plane. Let's give L1 a different color.

Planes related to the iliac crests

Draw an imaginary line between the superior edge of the iliac bones (iliac crest). Which vertebra does it cross. Let's give the disc between L4 and L5 a different color. Add back some skin to see where the umbilicus (belly button) lies relative to this plane. Typically, in the thin individual it lies superior to this plane. Observe how this landmark is not as reliable as the bony landmarks.

Subcostal plane

This transverse plane lies at the inferior edge of the costal cartilages. The belly button (umbilicus, more typically marks this location on the slender individual). Let's mark it by giving L3 a different color.

Important sagittal planes:

A midsagittal plane divides the body into left and right halves. Clinically, the midsagittal plane is the most important sagittal plane.

The terms right and left always refers to the patient's (or your donor's) right or left. (This is easy to forget when you are looking at an imaging study or pointing something out on your donor.) A parasagittal plane parallels the midsagittal plane. An important parasagittal plane is indicated by the mid-clavicular line.Draw an imaginary line inferiorly from the mid point of each clavicle. The line should cross the nipples. The nipples overlie which rib or intercostal space? Hint: use your previous observation that the second costal cartilage articulates with the angle of Louis. Count down from there. Alternatively, add and remove the skin from the image. The location of the nipples will vary for women with pendulous breasts. Note how the mid-clavicular line crosses the costal margin close to where the transpyloric plane (L1 or L1/L2disce crosses the costal margin.

Important coronal (frontal) planes:

A midaxillary (middle of the armpit) plane divides the body into anterior and posterior halves. Clinicians commonly refer to the anterior and posterior axillary lines, which cross the anterior or posterior border of the armpits.

Diaphragm
The phrenic diaphragm divides the cavity of the thorax from the cavity of the abdomen. Note that it is labeled in both the main window and the cross-section window. In the main window, ctrl-click on different parts of the diaphragm, and see how the position of the diaphragm changes in the cross-section (axial plane). Do this until you get the sense that the diaphragm is a dome with two peaks. Why is the dome higher on the right side? What lies inferior to the diaphragm on the right side. Use a roll-over with your mouse on the cross-section window to find out.

Locating internal structures in the abdomen

Palpating an enlarged gall bladder

Now, we'll remove the diaphragm and add the gall bladder. Note how it is related to the intersection of the costal margin and the transpyloric plane, and also the intersection of the costal margin and the mid-clavicular line. Rotate the image to 310, and 270 degrees to get a better idea of its location. It is palpable by digging your fingers into the abdomen and up under the rib cage. (Not fun, I don't advise it!)

Palpating an enlarged Liver

Now add in the liver (we've also added in more ribs for reference, and change the color of the gall bladder). Rotate this image through 360 degrees.

Palpating an enlarged Spleen

The spleen is not palpable unless it is very enlarged. In this donor, the spleen is normal size; rotate this image through 360 degrees to see how posterior it is. In the case of an enlarged spleen, the tip of the spleen can be palpated anteriorly in the intercostal spaces near where the transpyloric plane or left mid-clavicular line cross the costal margin.

Palpating the abdominal aorta and listening for bruits in the renal arteries

Let's add in the abdominal aorta. This vessel starts out exiting the heart but it is called the abdominal aorta after it crosses the diaphragm. We'll add in the rest later. Rotate the image between 0 and 270 degrees. The descending aorta crosses the diaphragm at T12 (L1 in this donor). Note how the abdominal aorta ends at the L4/5 disc (just below the umbilicus -- add back some skin -- in the plane connecting the iliac crests. In a thin individual who is completely relaxed, the pulsating abdominal aorta may be palpated. Now add the common iliac arteries: At L4 the aorta bifurcates, to form the left and right common iliacs. After giving off the internal iliac, they continue as the external iliac and common femoral arteries (use mouse role overs to identify these). Note how the external iliac changes names to the femoral artery as it crosses the inguinal ligament (of Poupart). The renal arteries branch off the aorta near the subcostal plane (L2). A bruit is the sound of turbulence when an artery becomes partially occluded by disease. Add back some skin -- most beginning residents misplace their stethoscopes when trying to listen for a renal bruit!

McBurney's point and appendicitis

McBurney's point is where a surgeon would make an incision to remove an inflamed appendix. This point lies 1/3rd the distance from the right anterior iliac spine to the navel (umbilicus). Note that this is near the junction of the large and small intestine. In this image the terminal ileum (of the small intestine) and ascending colon are purple. The cecum is brownish. If an appendix were present it would be near the ileocecal junction. Add and then remove the skin entirely. Rotate the image through 360 degrees. In another image taken from the Visible Female, we can see the appendix. (Mac users may need to switch to the visible female manually for the link to work.) The appendix, ascending colon, and terminal ileum are purple. The cecum is brown. McBurney’s point marked by the “X” overlies the cecum. Rotate the female image through 360 degrees.

Locating internal structures in the neck:

Hyoid Bone

Palpate the hyoid bone at the junction between the neck and the floor of the mouth. Slide it from side to side. Palpate your hyoid bone and swallow.

Listening for breath sounds in the trachea

Just below the hyoid bone palpate the thyroid cartilage (Adam's apple), and below that the first cartilaginous ring of the trachea, the cricoid cartilage. To better appreciate the relationship of the hyoid, thyroid and cricoid, rotate the image from 130 degrees - thru 0- to 230 degrees. Now lets add the rest of the trachea (just the tracheal cartilages are show, which you can palpate).

Listening for carotid bruits

The common carotid artery bifurcates in the neck as it travels superiorly. This is an area of turbulence where an atherosclerotic plaque can develop and create audible turbulence. On yourself, palpate the lateral horn of the hyoid bone and the superiolateral aspect of the thyroid cartilage. From here push the sternocleidomastoid muscle laterally (we'll add this muscle only on the right side), and feel for a pulse. Rotate the image to 0 degrees and then 320 degrees.

Palpating an enlarged thyroid gland

The thyroid gland lies on either side of the trachea. The two sides are joined by an isthmus that crosses superficial to the trachea just below the cricoid process. The isthmus is not normally palpable, because it is small. The main portions of the gland are not normally palpable, because they lie behind several muscle layers. Rotate the image to appreciate the relationships of the thyroid.

Locating internal structures in the thorax:

Position of the heart

For clarity, lets get rid of the body of the sternum and the manubrium. For reference, we'll keep the xiphoid process and the costal cartilages and we'll add soft tissue to the trachea. Remember, the second costal cartilage articulates with the sternum at the angle of Louis and the first costal cartilage and clavicle articulate with the manubrium near its superior end. We'll leave in the liver and spleen to remind us of the phrenic diaphragm that is draped over these structures. Rotate the image to appreciate the 3D relationships, and return to 0 degrees. On yourself, feel the apex heart beat in the 5th or 6th intercostal space just medial to the mid-clavicular line. Add the left ventricle, which forms the left border of the heart, and note the location of its inferior end -- this is the apex. If you do not see it, press <ctrl-p> to see the marker for the plane o