ANATOMY

BSE Notes 2006 [Link] ANATOMY 1

TISSUES & STRUCTURES
KEY PRINCIPLES
Four basic tissue types make up the body – epithelium, connective tissue, muscle and nerve.
• Epithelium makes up skin, glands, blood vessels, lymphs, etc…
• Connective tissues make up fascia, ligaments, tendon, bones, etc…
• Muscles can be smooth, skeletal or cardiac
• Nerve is just nerve

EPITHELIUM
The Skin
• epidermis and dermis + other structures skin
• The epidermis ectodermal, made of keratinised stratified squamous epithelium.
• The dermis mesodermal, mainly collagen fibres bundles, elastic tissue, vessels and nerves.
• b/n epidermis & dermis is where Melanocytes are found in basal layer of epidermis activity determines pigmentation

Other structures in the skin

• Sweat glands
1. Extend into the dermis and subcutaneous tissue.
2. Supplied by cholinergic fibres in sympathetic nerves
3. Are all over skin except tympanic membranes, lip margins, nipples, inner surface of prepuce, glans penis & labia
minora
• Apocrine glands
1. Large modified sweat glands
2. Confined to axillae, areolae, periumbilical, genital and perianal regions
3. Enlarge at puberty and undergo cyclical changes in relation to menstrual cycle
• Sebaceous glands
1. Open into the side of hair follicles (keeps hair moist)
2. Any areas that don’t have sweat glands, have sebaceous gland so found on lips, nipples, areolae, inner surface of
prepuce, glans penis and labia minora.
• Hair
1. Hard keratin formed from the hair matrix, a region of epidermal cells at the base of the hair follicle.
2. Melanocytes in the hair matrix impart pigment
3. Arrector pili muscles receive sympathetic stimulation and make hair stand on end.
• Nails - consists of nail plates lying on nail beds on the dorsum of the terminal segment of fingers and toes.
• Arteries of the skin are derived from a tangential plexus at the boundary between the subcutaneous and connective tissue.
• Veins have a similar arrangement.
• Cutaneous nerves carry afferent somatic fibres and efferent autonomic(sympathetic) fibres.
• Rule of nines for skin surface area: head 9%, UL 9%, LL 18%, front of thorax and abdomen 18%, back of thorax and
abdomen 18%.

Mucous Membrane
• A mucous membrane is the lining of an internal body surface that communicates with the exterior.
• Consist of epithelium, underlying lamina propria (containing muscularis mucosae in the alimentary tract), which lies on top of
the submucosa.

Serous Membrane
• The lining of a closed body – pericardial, pleural and peritoneal – and consists of connective tissue covered on the surface by a
single layer of flattened mesothelial cells.
• Parietal and visceral layers separated by a film of tissue fluid.
• Parietal layer supplied by spinal nerves, visceral layer possesses no sensory supply.

BSE Notes 2006 [Link] ANATOMY 2

CONNECTIVE TISSUE
Fascia
• Superficial loose areolar connective tissue, most distinct on lower abdominal wall where it differentiates into 2 layers
• Deep fascia wrap around muscles for movements, attaches to bones, or between bones (intermuscular septae) supplied
by nerve of overlying skin

Ligaments
• condensed connective tissue, mainly collagen, usually attached to bone at their 2 ends.
• Generally unstretchable unless subjected to prolonged strain.

Tendon
• Similar to ligaments attaches muscle to bone.
• May be cylindrical or flattened into aponeuroses.

Synovial sheaths
• Provide lubrication where tendons bear heavily on adjacent structures
• Parietal layer firmly fixed to surrounding structures, visceral layer firmly fixed to the tendon, with a thin film of synovial fluid
in b/n.

Cartilage
• dense connective tissue, cells embedded in a firm matrix, contains fibres & ground substance mainly proteoglycan, water &
dissolved salts.
• 3 Types of cartilages hyaline, fibrocartilage, & elastic
o Hyaline cartilage bluish white appearance found on costal, nasal, some laryngeal, tracheobronchial, articular
cartilage of typical synovial joints and epiphyseal growth plates of bones.
o Fibrocartilage contains small islands of cartilage cells + ground substance think of IV discs, labrum of shoulder
& hip joints, menisci of knee joints and articular surface of bones which ossify in membranes.
o Elastic cartilage contains a large number of elastic fibres and occurs in the external ear, Eustachian tube and epiglottis.
• Fibrocartilage has a sparse blood supply, hyaline and elastic cartilages rely on diffusion of substrates through the ground
substance.

BONE
Vascularised dense connective tissue, contains cells embedded in a matrix of collagen fibres, inorganic salts rich in calcium and
phosphate.
2 main types of bone compact & cancellous

Compact bone
• Hard, dense, like ivory, on surface cortex of bones, thicker in shafts of long bones & surface plates of flat bones
• Contains osteocytes embedded in a matrix of collagen fibres arranged in layers contains Haversian systems or osteons
• Transversely running Volkmann’s canals link Haversian canals with each other and the medulla.

Cancellous bone
• Spongework of trabeculae, inside bones & inside articular ends of long bones
• No haversian system so osteocytes depend on diffusion from adjacent medullary vessels
• This is where BM is made in adults, found in ribs, sternum, vertebrae & skull
• Periosteum
o is a thick layer of fibrous tissue covers bones osteogenic deeper cells differentiate into osteoblasts when
required.
o does not cover the articulating surfaces of synovial joints.
o Subcutaneous periosteum supplied by nerve of overlying skin
o Deeper periosteum supplied by nerve from nearby muscles
BSE Notes 2006 [Link] ANATOMY 3
• The single layered endosteum that lines the inner bone surfaces is also osteogenic.
• One or two nutrient arteries enter the shaft of a long bone obliquely and divide into ascending and descending branches within
the medullary cavity. Near the ends of bones they join branches from neighbouring systemic vessels and periarticular vascular
arcades.
• Two main processes of bone development via membranes or via cartilage (see ossification notes)

Sesamoid bones
• May be fibrous, cartilaginous or bony nodules and are usually associated with certain tendons where they glide over the bone.
• Their presence is variable, the only constant examples being the patella and the ones in the tendons of adductor policis, flexor
policis brevis and flexor hallucis brevis.

MUSCLE
• 3 types of muscle – skeletal, cardiac and smooth
• Both skeletal and cardiac muscles are striated whereas smooth muscle is non-striated.
• Smooth and cardiac muscle fibers have a single nucleus whereas skeletal muscle is multinucleate.

Smooth muscle
• Parallel, narrow, spindle-shaped cells.
• Arranged in a longitudinal and circular fashion in tubes that undergo peristalsis.
• Arranged in whorls and spirals in viscera that undergo mass contraction without peristalsis, eg. Bladder and uterus
• Impulses are transmitted across “nexuses” or “gap junctions” and thus there are fewer autonomic nerves

Cardiac muscle
• Broader, shorter cells that branch.
• Less powerful than skeletal but more resistant to fatigue
• Intercalated discs increase the surface area for impulse conduction
• Cells arranged in whorls and spirals, innervation by autonomic nerves

Skeletal muscle
• Long cylindrical non-branching fibres
• Surrounded by endomysium (individual fibers), perimysium (bundles) and epimysium (whole muscle).
• Orientation of fibres is either parallel (longer range of contraction) or oblique (greater force).
• Muscles with an oblique disposition may be unipennate, bipennate or multipennate.
• Muscles may be prime movers, antagonists (relaxing in a controlled manner to assist the prime mover), fixators (stabilizing
one attachment of a muscle so that the other may move), or synergists (preventing unwanted movement).
• Arteries and veins usually pierce the muscle with the motor nerve.
• Lymphatics run back with the arteries to regional lymph nodes.
• Muscle spindles act as a type of sensory receptor, transmitting back to the CNS information of the state of contraction of the
muscles in which they lie.
• Skeletal muscle is supplied by somatic nerves through one or more motor branches which also contain afferent and autonomic
fibres.
• CN III, IV, VI and VII contain no sensory fibres, rather local branches of CN V convey proprioceptive impulses.

JOINTS
3 types of joints fibrous, cartilaginous & synovial
1. any joints requiring lots of movement synovial
2. any joints needs more stability than movement fibrous or cartilaginous

BSE Notes 2006 [Link] ANATOMY 4

Fibrous joints
• Bone connected to bone by fibrous tissue therefore limited movement
• 4 places skull sutures, interossesous membranes, interior tibiofibular joint, costotransverse 11 & 12

Cartilaginous joints
Essential bone connected to bone by a cartilage primary or secondary
• primary (synchondrosis) when B-C-B think of costochrondal, 1st sternochondral, spheno-occipital
• secondary (symphysis) B-C-FC-C-B think of midline structures, e.g. pubic symphysis, IV joints

Synovial joints
• Characterized by the following 6 things
o Synovial joints must have synovial membrane
o It’s purpose is movement so variable degree of movements
o Like all joint there are ligaments
o 3 more Cs that characterize it cartilage, capsule, cavity
• When the cartilage component is hyaline typical joint
• When it’s fibrocartilage atypical joint
• synovial membrane
o lines the capsule and invests all non-articulating surfaces within the joint
o secrete a hyaluronic acid lubrication for joint
• Interarticular fibrocartilages, discs or menisci are found in joints where the congruity between articular surfaces is low, eg.
Knee, sternoclavicular and temporomandibular joints.
• Fatty pads are found in some synovial joints, eg. Haversian fat pad of the hip joint.

BSE Notes 2006 [Link] ANATOMY 5

BLOOD VESSELS
• Capillary walls consist of flattened endothelial cells forming an anastomotic network within most tissues.
• Arteries consist of three layers:
1. Tunica intima – endothelial lining, collagenous connective tissue and internal elastic lamina
2. Tunica media – elastic connective tissue and smooth muscle in varying amounts.
3. Tunica adventitia – external elastic lamina surrounded by connective tissue
• Veins have the same three layers but have
1. a less distinct internal elastic lamina
2. much less muscle in the media.
3. generally, there are no valve in the veins of the thorax and abdomen.
• Anastomoses between arteries are either actual or potential. Potential anastomoses reflect the ability of end arterioles to dilate
over time to convey adequate blood.
• End arteries are found in spleen, kidney, lung, liver, medullary branches of the CNS, the retina and the straight branches of the
mesenteric arteries; penis and fingers.
• Sinusoids are wide capillaries that have a fenestrated or discontinuous epithelium and are numerous in the liver, spleen,
adrenal medulla and bone marrow.
• Blood vessels are innervated by efferent autonomic fibres, with constriction mediated by adrenergic sympathetic fibres.
• Large vessels have their own vasa vasorum.

LYMPHATICS
• Lymphatic vessels are simple endothelial tubes.
• They are different from veins in that they have more valves
• In general, superficial lymphatics follow veins whereas deep lymphatics follow arteries.
• Lymph nodes may be bypassed by disease processes so don’ t necessarily flow in order
• The thoracic duct may be ligated with no consequence because lymphatics communicate with veins freely in many parts of
body.

LYMPHOID TISSUE
• 2 ways we fight infection
1. via non-specific immune system mainly phagocytosis
2. specific immune response require antigen + T & B cells
• T cells kill specifically by cell-mediated immune response
• B cells kill by turning into plasma cells and producing antibodies IgG, A, M, D, E
BSE Notes 2006 [Link] ANATOMY 6
• Both B & T cells come from the same village(s) BM (or liver & spleen)
• Once released
1. T cells get educated in the thymus
• it graduates with 4 degrees Thelper, T killer, T suppressor, & Tmemory
• it then go and settle in spleen, LNs, & other lymphoid follicles
2. B cells don’ t go to school they head straight to lymphoid follicles and live there
• It can form 2 types of cells plasma cells or B memory cells
• The lymphoid organs are like ‘store house’ for these cells they consist of the thymus, lymph nodes and spleen all
encapsulated
• LNs & spleen contain lymphoid nodule or follicle round collection of lymphocytes with a pale central area germinal
centre
• Unencapsulated lymphoid organs mucosa-associated lymphoid tissues (MALT) these include GIT, respiratory,
genitourinary tracts, Waldeyer’ s peripharyngeal lymphoid ring of tonsils, Peyer’ s patches so the overlying epithelium
samples antigens and bring them to the underlying lymphoid tissues
• In the thymus no lymphoid aggregations like LNs & spleen instead, spread evenly around cortex medulla has fewer
lymphoid tissues, but contain characteristic thymic ‘Hassall’ s corpuscles’ these are remnants of the 3rd pharyngeal pouches
from which the thymus developed
• The LNs are the only organs with afferent & efferent channels the rest, e.g. thymus, spleen, MALT do not have these
features
• Lymphoid follicles of the spleen are found in its white pulp which is scattered in the red pulp that constitutes most of the
substance of the spleen
• In the white pulp T lymphocytes form periarteriolar sheaths some of which are lymphoid follicles with B lymphocytes in
the germinal centres
• Apart from lymphocytes all lymphoid organs & organized lymphoid tissue contain macrophages

BSE Notes 2006 [Link] ANATOMY 7

NERVOUS SYSTEM

KEY PRINCIPLES
1. Structurally divided into CNS & PNS
• CNS = brain + spinal cord
• PNS = cranial nerves + spinal nerves
2. CNS & PNS each has 2 functional components of somatic nervous system (SNS) & autonomic nervous system (ANS)
• Somatic = we have control over, e.g. skeletal muscles (efferent), sensation (afferent)
• Autonomic = it’ s automatic; e.g. cardiac muscles, smooth muscles & glands
3. group of cell bodies with similar function
• if in CNS called ‘nuclei’
• if in PNS called ‘ganglia’
4. nerve fibres of similar function tend to run together
• if in CNS called ‘tract’
• if in PNS called ‘nerves’
5. nerves fibres may be myelinated or non-myelinated
• in CNS myelin is formed by oligodendrocytes
a. some nerve fibres are myelinated therefore appear white we call ‘white matter’
b. some are not myelinated because cell bodies, not tracts therefore darker we call ‘grey matter’
• in PNS myelin is formed by schwann cells (neurolemmocytes)
6. Node of Ranvier exist only b/n myelinated nerve fibres purpose is to greatly enhance conduction velocity
7. 2 main types of cells that make up the entire nervous system
• Neurons – structural & functional unit of the nervous system transmits signals the main actors
• Neuroglia – the support cells of which there are 4 types (see below)

Neurons
• Specialized for rapid communication has a cell body, dendrites and axons
• Dendrites receives electrical signals and carry them towards the body
• Axons carry ‘efferent’ signals away from body
• Myelin = layers of lipid and protein substance, designed for fast conduction
• Many myelin joined together = myelin sheath, wraps around an axon, like a gladwrap, and greatly enhance conduction
velocity
• Neurons communicate with each other via synapses (= point of contact between neurons) by neurotransmitters
• Neurotransmitter can do many things – it can excite, inhibit, continuing or terminating the relay of impulses
• ‘classic’ transmitters Ach & NA now include, monoamines, amino acids, nitric oxide, neuropetides

Neuroglia
• non-neuronal, non-excitable cells that exist purely to support, insulate and nourish the neurons
• ~5x more abundant than neurons
• In the CNS (i.e. brain and spinal cord), there are 4 types of neuroglia
1. Oligodendroglia cells (or oligodendrocytes the ‘schwann cells’ of CNS)
2. Astrocytes
3. Ependymal cells
4. Microglia (i.e. small neuroglial cells the ‘macrophages’ of CNS)
• In the PNS (i.e. peripheral nerves and cranial nerves), there are 2 types of neuroglia
1. Satellite cells – hangs around neurons in the spinal ganglia (dorsal root ganglia)
2. Neurolemma (i.e. Schwann) cells these form the myelin & neurolemmal sheaths around peripheral nerve fibres

Peripheral nerves
1. classified according to conduction velocity which is proportional to their size & function
2. are held together by 3 connective issue coverings
• Endoneurium – sticks individual fibres together
• Perineurium – hold them in a bunch
• Epineurium – wrap these bunches in a single nerve

BSE Notes 2006 [Link] ANATOMY 8

3. note that in the sciatic nerve only 20% is nerve, the other 80% is connective tissue
4. but in smaller nerves, the proportions are different, obviously more nerve to connective tissues
5. need blood supply to survive
• sciatic nerve & median nerve have their own blood supply inferior gluteal & anterior interosseous arteries respectively
• elsewhere supplied by branches from local arteries
6. widest fibres tend to conduct most rapidly
7. as a general rule
• largest unmyelinated fibres may be motor or proprioceptive
• smallest, whether myelinated or not, are autonomic or sensory
8. Group A up to 20um, subdivided into
• A 12-20um, motor & proprioception (Ia & Ib)
• B 5-12um, touch, pressure & proprioception (II)
• G 5-12, fusimotor to muscle spindles (II)
• D 1-15um, touch, pain & temperature (III)
9. Group B up to 3um, myelinated preganglionic autonomic
10. Group C up to 2um, unmyelinated postganglionic autonomic, touch & pain (IV)

SPINAL NERVES
1. 31 pairs of spinal nerves 8 cervical, 12 thoracic, 5 lumbar, 5 sacral & 1 coccygeal
2. each spinal nerve formed by union of anterior & posterior root attached to the side of spinal cord by little rootlets in IV
foramen
• anterior root contains
• motor (efferent) fibres for skeletal muscles
• autonomic fibres from T1 L2 and S2 S4
• small amount of unmyelinated afferent pain fibres, relayed from posterior root ganglion
• posterior root contains sensory (afferent) fibres cell bodies in the posterior root ganglion (simply a site of cell bodies ,
no synapses here)
3. immediately the spinal nerve divides into anterior & posterior ramus
• anterior rami form plexuses cervical, brachial, lumbar, & sacral
• posterior rami do not

GENERAL PRINCIPLES OF NERVE SUPPLY

Nerves are faithful; arteries are promiscuous
Nerves always stay with their origin, e.g. migration of phrenic nerve from C4
Arteries changes with embryology
Motor neuron pools group of nerve cells in brainstem or spinal cord supplying one muscle & overlaps the other
For example C5,6 supplies deltoid, but also subscapularis

BSE Notes 2006 [Link] ANATOMY 9

The only exceptions are trochlear & abducen nerve sole motor SO4, LR6

NERVE SUPPLY OF BODY WALL

1. body wall is supplied segmentally by spinal nerves
2. posterior rami pass backwards supply extensor muscles of vertebral column & skull +/- varying extent of overlying skin
3. anterior rami supply all other muscles of trunk & limb + skin at the sides and front

Posterior rami
1. each posterior ramus divides into a medial & lateral branch
2. both supply muscle, but only one branch, either medial or lateral, reaches the skin
• in the upper half of body it’ s the medial branch
• in the lower half it’ s the lateral
3. C1 has NO cutaneous branch
4. posterior rami of C7, 8, L4 & 5 DOES NOT reach the skin
5. all 12 thoracics & 5 sacrals reach the skin
6. no posterior ramus ever supplies skin or muscle of a limb

Anterior rami
1. supply prevertebral flexor muscles segmentally by separate branches from each nerve
2. form plexuses
• C5,6,7,8 & T1 form brachial plexus supply upper limb
• T1-12 + L1 supply muscles of body wall segmentally
• each intercostal nerve supplies muscles of its intercostals space
• the lower 6 pass beyond costal margin to supply muscles of anterior abdominal wall
• muscles supplied by anterior rami below L1 are no longer in the body wall they have migrated into the lower limb
• L1, 2,3,4 form lumbar plexuses
• L4,5 S1,2,3 form sacral plexuses

NEUROVASCULAR PLANE
1. VAN run together, spiral around thoracic & abdominal wall, in the plane b/n middle & deepest of the 3 layers
2. in this neurovascular plane nerve lies below and superficial to artery as they run around the wall
3. nerve crosses the artery twice in this path posterioly along the vertebral column and anteriorly near ventral line
4. as a general rule
• aorta is deeper to skin than spinal cord
• so artery is always deeper to skin than nerves in this neurovascular plane
• larger outer nerve circle
• smaller inner arterial circle

SEGMENTAL INNERVATION OF THE SKIN

Dermatomes
1. area of skin supplied by a single spinal nerve
2. overlaps considerably hence division of a single ICN does not give rise to anaesthesia on the trunk except at axial lines

Axial lines
1. is the junction of 2 dermatomes supplied from discontinuous spinal levels, e.g. C6 & C8 in forearm or C5 & T1 in arm
2. in the upperlimb approximately sternal angle to front of limb, almost to wrist
3. in lower limb is distorted for 2 reasons
• the way the limb of the fetus untwist
• skin borrowed from trunk
BSE Notes 2006 [Link] ANATOMY 10
A practical reason for axial line obvious in spinal analgesia
1. a low spinal anaesthesia anaesthetizes skin of posterior 2/3 of scrotum (which is S3)
2. but to anaesthetize an entire scrotum, i.e the anterior 1/3 as well L1 must be involved
3. this is 7 levels higher up

Regarding dermatomes
1. C1 has NO cutaneous branch
2. C2,3,4 supply skin of neck by branches of cervical plexus
3. C5,6,7,8,T1 skin of upperlimb via brachial plexuses
4. In the trunk skin is supplied in strips from T2 L1 (intercostals nerves each has a lateral & anterior cutaneous branch)
5. The lower 6 ICNs (i.e. T7-12) supply skin of abdominal wall

SUMMARY OF DERMATOMES
C1 no skin supply
C2 occipital region, posterior neck & skin over parotid
C3 neck
C4 infraclavicular region (to manubriosternal junction), shoulder & above scapular spine
C5 lateral arm
C6 lateral forearm & thumb
C7 middle fingers
C8 little finger & distal medial forearm
T1 medial arm above & below elbow
T2 medial arm, axilla & thorax
T4/5 nipple
T7 subcostal angle
T8 rib margin
T10 umbilicus
T12 lower abdomen, upper buttock
L1 suprapubic & inguinal regions, penis, anterior scrotum, upper buttock
L2 anterior thigh, upper buttock
L3 anterior & medial thigh & knee
L4 medial leg, dorsum of foot, medial sole
S1 lateral ankle, lateral side of dorsum & sole
S2 posterior leg, posterior thigh, buttock, penis
S3 sitting area of buttock, posterior scrotum
S4 perianal
S5 & C0 behind anus & over coccyx

SUMMARY OF MYOTOMES
Shoulder
• abduct & laterally rotate C5
o abduct deltoid, supraspinatus (assist in abduction)
o laterally rotate infraspinatus, teres minor
• adduct & medially rotate C6,7,8
o adduction pec major, lat dorsi, teres major, weak adductors teres minor, coracobrachialis
o medial rotation subscapularis, teres major

Elbow
• Flexion C5,6
o Biceps, brachialis
o Brachioradialis

BSE Notes 2006 [Link] ANATOMY 11

• Extension C7,8
o triceps

Forearm
• Supinate C6
• Pronate C7,8
o Pronator teres, pronator quadratus

Wrist
• Extension C6,7
o ECRB, ECU
• Flex C6,7
o FCR, FCU, (PL)

Fingers & thumb

• Extension C7,8
o ED, EDM
• Flexion C7,8
o FDS, FDP

Hand intrinsic muscles T1

o Lumbricals

Hip
• flexion (iliacus) = adduction (adductors) L2,3
• extension (gluteus maximus) = abduction (glut medius & minimus) L4,5

Knee
• extension (quads) L3,4
• flexion (biceps femoris) L5,1

Ankle
• dorsiflex (tibialis anterior) L4,5
• plantar flex (soleus) S1,2
• invert (tibialis posterior) L4
• evert (peroneus longus & brevis) L5,1

Key summary
• C4 diaphragm respiration
• C5 deltoid abduction of shoulder
• C6 biceps flexion of elbow & bicep jerk
• C7 triceps extension of elbow & triceps jerk
• C8 flexor digitorum profundus & extensor digitorum finger flexion & extension
• T1 abductor pollicis brevis abduction of thumb
• T7-12 anterior abdominal wall muscles & abdominal reflexes
• L1 lowest fibres of IO muscles & transversus abdominis
• L2 Psoas major, flexion of hip
• L3 quadriceps femoris extension of knee & knee jerk
• L4 Tibialis anterior & posterior inversion of foot
• L5 EHL extension of great toe
• S1 gastrocnemius plantar flesion of foot & ankle jerk
• S2 small muscles of foot
• S3 perineal muscles; bladder (parasympathetic) and anal reflex

BSE Notes 2006 [Link] ANATOMY 12

AUTONOMIC NERVOUS SYSTEM
We control skeletal muscles via somatic nervous system
When it comes to cardiac & smooth muscle + gland secretions we rely on autonomic nervous system
Key difference here information is interrupted by a ganglion thus there is a presynaptic & postsynaptic neurons
1. presynaptic cells are always in the CNS in lateral horn cells of all thoracic & upper 2 lumbar
2. these synapse at ganglia sympathetic trunk information is then relayed via postganglionic fibres to effector organs
3. the ganglia for parasympathetic however are different
• in the sacral segments ganglia are found in the walls of the effector viscera
• in the head 4 ganglia exist, so no need for ganglia in visceral wall ?why limited space perhaps

functionally, ANS is divided into sympathetic & parasympathetic

structurally
1. Sympathetic is from T1-L2
2. Parasympathetic from craniosacral outflow

SYMPATHETIC FIBRES
1. every spinal nerve without exception, from C1 to coccygeal carries postganglionic (unmyelinated, grey) sympathetic fibres
2. these hitch hike along the nerves & accompany all their branches
3. their main function VASOCONSTRICTION purely for temperature regulation
4. however, some go to sweat glands in the skin (sudomotor) and to the arrectore pilorum muscle in the hair roots (pilomotor)
5. thus, sympathetic system innervates the whole body wall & all 4 limbs
6. the visceral branches of the sympathetic system have a different manner of distribution

Having reached a sympathetic trunk ganglion, the incoming preganglionic fibres have 3 options
1. synapse right away, or move up or down and synapse in a different ganglion
2. leave the trunk ganglion without synapsing, and pass to a ganglion in an autonomic plexus for synapse
3. leave the trunk without synapsing pass to suprarenal gland (+) medulla very few fibres do this
thus cell bodies of postganglionic neurons can be found in 2 places sympathetic trunk or in plexus (e.g. celiac plexus)

General structure of sympathetic trunk

1. 3 in the cervical region
• C1,2,3,4 fuse together to form superior cervical ganglion
• C5,6 fuse to form middle cervical ganglion
• C7,8 form inferior cervical ganglion often this again fuses with T1 ganglion forming stellate ganglion (or
cervicothoracic)
2. 11 in thoracic
3. 4 lumbar
4. 4 sacral

fibres from lateral horn cells of each segment of spinal cord leave in the anterior nerve root reaches spinal nerve & its
anterior ramus
the link to sympathetic trunk here is the rami communicantes
there are 2 types
1. white ramus communicans white because myelinated myelinated because it contains preganglionic fibres
2. grey ramus communicans grey because not myelinated contains efferent postganglionic fibres

thus fibres in grey ramus communicans hitch hike on spinal nerves get off at their stop on blood vessels, sweat glands, etc…
Every spinal nerve receives a grey ramus
All the thoracic & upper 2 lumbar nerves have both white & grey rami

Note that because there is no inflow from the cervical region there are no white rami communicantes

BSE Notes 2006 [Link] ANATOMY 13

Each sympathetic trunk ganglion has a collateral or visceral branch splachnic nerve in the thoracic, lumbar & sacral regions
But in the cervical region a cardiac branch this goes to cardiac plexus
Visceral branches generally arise high up & descend steeply to form plexuses for the viscera
1. so the 3 cervical ganglia give off cardiac plexus (supplemented by upper thoracic ganglia)
2. lower thoracic ganglia 3 splanchnic (greater, lesser & least) nerves pierce the diaphragm reach the celiac plexus
3. upper lumbar ganglia lumbar splanchnic nerves descend to the superior hypogastric plexus & then to the left & right
hypogastric (pelvic) plexuses
4. the inferior hypogastric plexuses are joined by visceral branches from all the sacral ganglia (sacral splanchnic nerves)

sympathetic visceral plexuses thus formed are joined by parasympathetic nerves

1. vagus to the celiac plexus
2. pelvic splanchnics (S2,3,4) to inferior hypogastric plexuses

the mixed visceral plexuses reach the viscera by branches that hitch-hike along the relevant arteries

BSE Notes 2006 [Link] ANATOMY 14

SYMPATHETIC SUMMARY
1. sympathetic has 2 components
• ‘peripheral’ concerned with vasoconstriction and (+) sweating via peripheral nerves hence thermoregulation
• ‘central’ concerned with visceral, gland secretions, peripheral blood vessels etc… via splanchic nerves
• ‘vascular’ component side branches to adjacent large blood vessels, e.g. ICA, vertebral, aorta, etc…
2. white rami communicantes from T1 to L2 nothing above T1 so every sympathetic fibres from C1-8 has to channel via
T1 then up to the cervical ganglia
3. T1 is ‘information overloaded’ so usually does not control upper limb ANS mainly to do with head & neck
4. in sympathectomy to control excessive sweating NEVER remove T1 ganglion can lead to horner’ s syndrome
5. likewise for lumbar sympathectomy L1 ganglion MUST NOT be removed otherwise ejaculation may be compromised

PARASYMPATHETICS
Parasympathetic fibres is entirely visceral no distribution trunk or limbs
Most viscera has both sympathetic & parasympathetic innvervation
The only exceptions suprarenal glands & gonads only sympathetic here

Parasympathetic has cranio-sacral distribution

Cranial part preganglionic fibres arise from nuclei in brainstem
1. Accessory (Edinger-Westphal) oculomotor nucleus parasympathetic for CN III
2. superior salivary nucleus CN VII
3. inferior salivary nucleus – CN IX
4. dorsal motor nucleus CN X
fibres from CN3, 7, 9 are connected to 4 parasympathetic ganglia in the head
vagus nerve runs solely postganglionic cell bodies in the walls of the viscera supplied, e.g. heart & lungs

Sacral part
1. preganglionic fibres arise from lateral grey horn of S2,3,4 of spinal cord constitute pelvic splanchnic nerves
2. they leave the sacral segment go straight to form the inferior hypogastric plexuses
3. from here, they run to pelvic viscera & to hindgut, as far up as splenic flexure
4. they do this in 2 ways
• hitch hiking on blood vessels, or
• make their own way retroperitoneally then synapse around postganglionic cell bodies in the walls of these viscera

CRANIAL PARASYMPATHETIC GANGLIA

4 ganglia ciliary, pterygopalatine, submandibular & otic
Each has 3 inputs & 1 output
The 3 inputs are
1. parasympathetic root carries preganglionic fibres from brainstem nucleus fibres synapse here
2. sympathetic root carries postganglionic fibres from superior cervical ganglion, whose preganglionic cell bodies are in
lateral grey horn of cord segment T1-3
3. sensory root contains peripheral processes of cell bodies in the trigeminal ganglion

the 1 output branches of distribution carry postganglionic parasympathetic fibres to the effector cells
1. ciliary ganglion ciliary muscle & sphincter pupillae
2. pterygopalatine ganglion lacrimal, nasal & palatal glands
3. submandibular & otic ganglia to salivary glands

BSE Notes 2006 [Link] ANATOMY 15

Ciliary ganglion
1. parasympathetic input from Edinger-Westphal part of CN III, via a branch from the nerve to inferior oblique muscle, from
the inferior division of CNIII
2. sympathetic input from SCG by branches of the ICA nerve
3. sensory input from a branch of the nasociliary nerve with cell bodies in the trigeminal ganglion
4. branches short ciliary nerves to the eye thus controlling accommodation & pupil reaction

Pterygopalatine ganglion
1. parasympathetic from superior salivary nucleus by nerve of pterygoid canal & greater petrosal nerve from nervus
intermedius part of facial nerve
2. sympathetic SCG by ICA nerve, the deep petrosal nerve & nerve of the pterygoid canal
3. sensory from a branch of maxillary nerve, with cell bodies in trigeminal ganglion
4. branches
• to lacrimal gland via zygomatic & lacrimal nerves
• to mucous glands in the nose, nasopharynx & palate via maxillary nerve branches
• a few are taste fibres from the palate, running in the greater petrosal nerve with cell bodies in the geniculate ganglion of
the facial nerve

Submandibular ganglion
1. parasympathetic from superior salivary ganglion nucleus, via nervus intermedius part of facial nerve & chorda tympani,
joining the lingual nerve
2. sympathetic from SCG by fibres running with the facial artery
3. sensory from a branch of lingual nerve, with cell bodies in trigeminal ganglion
4. branches to submandibular & sublingual glands via branches of the lingual nerve

Otic ganglion
1. parasympathetic from inferior salivary nucleus by CNIX & its tympanic branch to the tympanic plexus & then to the lesser
petrosal nerve
2. sympathetic from SCG by fibres running with middle meningeal artery
3. sensory from auriculotemporal nerve with cell bodies in the trigeminal ganglion
4. branches to parotid gland via filaments of the auriculotemporal nerve
5. unlike other 3 ganglia the otic ganglion has an additional somatic motor root from the nerve to the medial pterygoid
the fibres pass through without synapse, to supply the tensor tympani & tensor palate muscles

BSE Notes 2006 [Link] ANATOMY 16

EMBRYOLOGY
PHARYNGEAL ARCHES & POUCHES
Mesoderm condensations, side walls form pharyngeal arches
5 of them 1, 2, 3, 4, 6 5th arch is rudimentary
4 clefts in between these arches
all curve around to the front and meet at midline
opposites the clefts and in between the arches the lining of the pharynx outpouches pharyngeal (branchial) pouches
In each arch there is
1. skeletal derivatives
2. an allocated nerve and muscles it supplies
3. an allocated artery
4. pouch derivatives
remember nerves are always faithful, vascular is promiscuous!

FIRST ARCH MANDIBULAR

Right & left halves of arch fuse ventrally in midline
When the mesoderm becomes ‘chrondrified’ forms Meckel’ s cartilage a template for mandible to form
Skeletal derivative
1. incus
2. malleus
3. anterior ligament of the malleus
4. sphenomandibular ligament fibrous perichondrium of Meckel’ s cartilage
5. the lingula at the mandibular foramen

Nerve mandibular nerve

1. mastication muscles – masseter, temporal, pterygoids
2. mylohyoid & anterior bell of digastric
3. 2 tensor muscles tensor palate & tensor tympani

Artery maxillary artery

First pharyngeal pouch gives rise to

1. auditory (pharyngo-tympanic) tube
2. part of the tympanic membrane
3. the middle ear
4. mastoid antrum
5. mucous membrane & glands of anterior 2/3 of tongue

SECOND ARCH HYOID

Skeletal derivatives
1. styloid process
2. stylohyoid ligament
3. lesser horn & superior part of body of hyoid bone
4. stapes

Nerve facial nerve, supplying

1. muscles of facial expression (including buccinator & platysma)
2. stylohyoid
3. stapedius

BSE Notes 2006 [Link] ANATOMY 17

4. posterior belly of digastric

Artery Stapedial artery which DOES NOT persist after birth

The 2nd pouch forms all supplied by glossopharyngeal nerve

1. part of tympanic membrane
2. palatine tonsil
3. tonsillar crypts
4. supratonsillar fossa

THIRD ARCH
Skeletal
1. greater horn of hyoid bone
2. inferior part of body of hyoid

Nerve glossopharyngeal nerve (nerve of third arch) supplies Stylopharyngeus

Artery remains as part of ICA

the 3rd pouch forms

1. the inferior parathyroid gland
2. thymus

FOURTH & SIXTHE ARCHES

Skeletal derivatives are
1. thyroid
2. cricoid
3. epiglottic
4. arytenoids cartilages

Nerve laryngeal & pharyngeal branches of vagus nerve which supply

1. intrinsic muscles of larynx
2. muscles of pharynx
3. levator palate

Dedicated artery
1. 4th arch
• on the right SCA
• on the left arch of aorta
2. 6th arch
• ventrally connected to the pulmonary trunk
• dorsally on the left ductus arteriosus
• dorsally on the right disappear completely
• this is why the RLN hooks around differently on both sides

Coming from the pouch

1. 4th pouch superior parathyroid glands
2. 5th pouch ultimobranchial body parafollicular (C) cells of the thyroid gland

Derivatives of the L) 6th pharyngeal arch include

1. ductus arteriosus
2. L) RLN

BSE Notes 2006 [Link] ANATOMY 18

3. L) pulmonary artery
Note that the L) superior laryngeal nerve is derived form the 4th arch

BRANCHIAL ARCH ARTERIES

1st arch maxillary artery
2nd arch stapedial artery DOES NOT persist after birth
3rd arch remains part of the ICA
4th arch
• on the right SCA
• on the left arch of aorta
5th disappear entirely
6th arch
• ventrally connected to the pulmonary trunk
• dorsally on the left ductus arteriosus
• dorsally on the right disappear completely
• this is why the RLN hooks around differently on both sides

The right RLN ‘loops’ under the SCA

BECAUSE
On the right side, the 5th & dorsal part of the 6th branchial arch arteries degenerate

Derivatives of the left 6th pharyngeal arch include

1. ductus arteriosus
2. L) RLN
3. L) pulmonary artery

HEART EMBRYOLOGY
Pain sensation in the heart is subserved by the sympathetic system
BECAUSE
The heart is a modified blood vessel

Ductus arteriosus
1. arises from L) 6th branchial arch
2. thick muscular wall
3. closed off after birth by contraction of its muscular walls
4. stimulated to contract into closure due to raised oxygen tension, acting locally
5. persists as a fibrous band ligamentum arteriosus

Ductus arteriosus closes at birth by muscular contraction

BECAUSE
Oxygen tension in the blood perfusing the ductus arteriosus rises when the pulmonary circulation opens up

SEPTUM TRANSVERSUM
A mass of mesoderm lying on the cranial aspect of the coelomic cavity
Its cranial part
1. gives rise to pericardium & part of diaphragm
2. invaded by cervical myotomes, mainly the 4th producing muscle of the diaphragm

Caudal part is invaded by developing liver forms the ventral mesogastrium around the developing liver
BSE Notes 2006 [Link] ANATOMY 19
DIAPHRAGM
Origins of muscles fibres & connective tissue of diaphragm are different

Connective tissue comes from 4 sources

• Central tendon from Transverse septum
• Oesophageal & vena caval openings from the oesophageal mesentery
• Connective tissue around periphery of diaphragm – from pleuroperitoneal membranes & mesoderms of the dorsal body wall
• inability of pleuroperitoneal membrane development is the most common cause of congenital diaphragmatic hernia

Muscles derived from muscle cells of 3rd, 4th & 5th cervical myotomes bring its own nerve supply hence phrenic nerve
rootlets
These invade the transverse septum by muscle cells
Muscle cells carry their own nerve supply with them, hence the motor supply from the phrenic nerves

Thus the diaphragm is derived from

1. the transverse septum
2. the pleuroperitoneal membrane
3. 3rd, 4th & 5th cervical myotomes
4. body wall tissues

In its development, the diaphragm receives contributions form

1. the transverse septum
2. 4th cervical myotomes
3. pleuro-peritoneal membranes
4. transversus layer of body wall musculature

GIT
The ventral mesogastrium
1. has a free border containing the left umbilical vein
2. forms the lesser omentum in it thus containing CBD + many other structures that lies b/n the 2 layers of lesser omentum

The ductus venosus

1. connects the left branch of portal vein to the IVC
2. carries blood from the L) umbilical vein to the IVC
3. short circuits the developing hepatic vasculature
4. clots off after birth, when no blood flows through it
5. becomes fibrosed called the ligamentum venosum bound the caudate lobe
6. it is connected to the ligamentum teres

Features of the development of the pancreas include

1. fusion of dorsal & ventral outgrowths from the gut
2. assymetrical growth of the duodenal wall, bringing the openings of its 2 ducts in line with each other
3. drainage of part of the head of pancreas by an accessory pancreatic duct
4. an interchange of drainage areas between the 2 ducts through anastomotic channels

BSE Notes 2006 [Link] ANATOMY 20

ANATOMY OF THE CHILD
Newborns have different proportions to us
• Some structures are fully developed at birth, e.g. the internal ear
• While others are not, e.g. corticospinal tracts to become myelinated, teeth to erupt

Know that
• Neonates are more fully developed in the head than in the tail end
• Newborns have no visible neck – this gradually changes as the neck elongates and the head become more mobile in terms of
flexion/extension and rotation
• The abdomen is large & out of proportion reason
o cos the liver is massive and pelvis small
o so most of the pelvic organs lie in the abdominal cavity, e.g. ovaries & rectum
• but this changes, as
o infant grows, pelvic cavity expands, and pelvic organs sink into place
o abdominal wall grows, and eventually the abdomen flattens.

THE SKULL
Key differences
• larger cranial vaults compared to the face
• vertical diameter of the orbit = vertical height of maxilla + mandible
o In adult, the vertical diameter of the orbit is only 1/3 that of the height of the maxilla and mandible.
o This is because the growth of maxillary sinuses and alveolar bone around the permanent teeth, that basically
elongates the face.
• Most of the separate skull and face bones are ossified by the time of birth, but they are fairly mobile and easily disarticulate
• The skull vaults
o Only compact bone is developed at birth
o The cancellous part is yet to develop
• Posterior fontanelle closed at 6 months
• Anterior fontanelle closed at 18 months
• Frontal bone 2 halves separated by a median metopic suture closed ~7yrs metopic suture may persist (rare)
• Fully developed at birth are
o Internal ear
o Middle ear
o Mastoid antrum
• Mastoid process is absent at birth facial nerve is unprotected at birth, covered only by in fibres of SCM
• tympanic membrane almost as big as adult’ s, but faces more downwards and less outwards than the adult ear drum
• mandibular fossa shallow at birth & faces slightly laterally with development, fossa deepens & faces directly forward

The maxilla
• Very limited in height and full of developing teeth
• Maxillary sinus is a narrow slit excavated into its medial wall
• Eruption of teeth allows room for excavation of sinus beneath the orbital surface but the maxilla grows slowly until the
permanent teeth begin to erupt at 6yrs
• At this time, it grows rapidly. The rapid increase in size of the sinus and the growth of the alveolar bone occur simultaneously
with increased depth of the mandible
• These factors combine to produce a rapid elongation of the face

The mandible
• This is in 2 halves at birth and their cartilaginous anterior ends are separated by fibrous tissue at the symphysis menti
• Ossification unites the 2 halves in the first year
• At first the mental foramen lies near its lower border
• After eruption of the permanent teeth, the foramen lies higher, and is halfway between the upper and lower borders of the bone
in adults

BSE Notes 2006 [Link] ANATOMY 21

• In the edentulous jaw of the elderly, absorption of the alveolar margin leaves the mental foramen nearer the upper border of
the mandible.

THE THORAX
Key differences
• Thorax more barrel shaped in infants
1. Cross section in infant = circular
2. Cross section in adults = oval (transverse = 2x AP diameter)
• There is a large thymus
1. Extends from lower part of neck through the superior into the anterior mediastinum
2. Thymus regresses at puberty
• The ribs lie more horizontal; thus the cage is set at a higher level than in adult, therefore higher diaphragm level; therefore
more abdominal volume.
• the left brachiocephalic vein crosses the trachea above the jugular notch

THE ABDOMEN
Key differences
• Large liver
1. At birth, this is relatively 2x as big as that in the adult
2. Inferior border palpable below costal margin
• Kidneys are highly lobulated at birth with very little perinephric fat
• Suprarenal is enormous at birth, almost as big as the kidneys
• Caecum is cone shaped and appendix arises from its apex in the fetus
• pelvic cavity is very small so Fundus of bladder lies above the pubis symphysis even when empty

UPPER & LOWER LIMB

Upper limb
• Upper limb more fully developed than lower limb at birth
• Grasping reflex of the hand is very pronounced
• Growth in length occurs more at the shoulder and wrist than at the elbow

Lower limb
• Poorly developed at birth; occupies the fetal position of flexion
• This position is maintained for >6months
• The lower limb then undergoes extension and medial rotation to prepare for standing and walking
• This rotation carry the flexor compartment around to the posterior aspect
• Foot is inverted in the new born, but gradually becomes everted harmoniously with the changes in position of the knee and hip
joints
• Growth of the limb proceeds more rapidly at the knee than at the hip or ankle

VERTEBRAL COLUMN
Key differences
• Before birth, the column is C-shaped, and concave ventrally (this is due to constriction in utero)
• After birth, the column is flexible, and therefore can take on any curvature imposed by gravity
• The cervical curve opens up into a ventral convexity when the infant holds up its head

BSE Notes 2006 [Link] ANATOMY 22

• The lumbar curve opens up into a ventral convexity when the infant walks (lordosis)
• The spinal cord ends at L3 at birth; this gradually reduces relatively to L1-2, as the vertebral column extends.

IN SUMMARY
In the new born,
1. the spinal cord ends at L3
2. the internal ear is fully developed
3. Suprarenal is enormous at birth, almost as big as the kidneys
4. the appendix arises from the apex of a conical caecum
5. the fundus of the bladder lies above the symphysis pubis
6. skull vault, cancellous bone is not developed
7. the thymus lies in the superior & anterior mediastina
8. the left brachiocephalic (innominate) vein may cross the trachea in the neck
9. the thorax is nearly circular in cross section
10. the normal liver is palpable below the costal margin
11. Foot is inverted in the new born, but gradually becomes everted harmoniously with the changes in position of the knee and hip
joints

BSE Notes 2006 [Link] ANATOMY 23

OSSIFICATION CENTRES
KEY NOTES
2 ways bones can be formed
1. from membranes intramembraneous ossification here osteoblasts lay down bone in fibrous tissue 3 places to think of
skull vault, face and clavicle
2. from cartilage enchrondral ossification a pre-existing hyaline cartilage model gradually destroyed and replaced by
bone most bones, other than the 3 above, are formed in this way

Primary center of ossification is where bone first appears

Secondary center where bone appears elsewhere after primary center often much later
For long bones
1. The primary center of ossification, i.e. most bone first appear in the shaft (diaphysis) ~ 8th intrauterine week.
2. secondary ossification, mainly in the epiphyses (ends) centers after birth thus responsible for growth
3. The metaphysis overtakes the epiphysis as the cartilaginous gap is bridged and bony fusion occurs.

HUMERUS
1. cartilaginous ossification thus the entire humerus is cartilage until the 8th week
2. a primary centre appears in the centre of the shaft at 8th week
3. Like most long bones secondary centres appear at both ends
4. the upper end has 3 secondary centres
• the head during 1st year
• greater tuberosity at 3 year
• lesser tuberosity at 5 year
• these 3 fuse into a single bony epiphysis this is the growing end of the bone
• fusion occurs with the shaft at 20yrs
5. The lower end has 4 secondary centres
• capitulum and lateral ridge of the trochlea 2 year
• medial epicondyle 5 year
• trochlea 12 year
• lateral epicondyle 13 year
6. the medial epicondyle remains a separate centre fuses with the shaft at 20yrs
7. the other three fuse together into a single epiphysis which fuses with the shaft at 15 yrs

RADIUS
1. cartilage before 8 weeks
2. at 8 weeks primary centre appears in middle of shaft
3. secondary centres for head & lower end the lower is the growing end (note growing end always distal)
• lower end appears at 1 year, and fuses at 20 years
• the head appears at 4 years, fuses at 15

ULNA
1. cartilage before 8 weeks
2. starts ossifying in cartilage at 8th week
3. there is a secondary centre for the head, the growing end, which fuses with the shaft at ~18yrs (growing end always distal)
4. 2 secondary centres contribute to the development of the olecranon they join the shaft at ~16yrs

BSE Notes 2006 [Link] ANATOMY 24

CARPUS
1. all cartilaginous at birth unlike the tarsus
2. each carpal bone ossifies from one centre
3. capitate the largest bone, ossifies first (first year)
4. pisiform the smallest bone, ossifies last (tenth year)
5. the others ossify in sequence, according to their size, at approximately yearly intervals
6. so roughly one centre appears per year from age 1 to 7, anticlockwise in the R) hand (see below)
7. the sequence therefore is
• capitate hamate triquetral lunate scaphoid trapezium trapezoid pisiform 1,2,3,4,5,6,7, & 10
• the whole carpus, except the sesamoid pisiform bone, is ossified by the seventh year

METACARPALS & PHALANGES

1. primary centres appear by 9th intrauterine week i.e. shafts of all metacarpals & phalanges ossify in utero
2. secondary centres appear at 2yrs
• all at the bases
• exception 2, 3, 4, & 5 metacarpals where the epiphysis is at the head
3. all fuse at 20 years
4. the tuberosity of each terminal phalanx ossifies in membrane

CLAVICLE
1. first bone to ossify in fetus membranous ossification
2. 2 centres, which ossify at the 5th week rapidly fuse

BSE Notes 2006 [Link] ANATOMY 25

3. a secondary centre appears at the sternal end during late teens fuses rapidly

SCAPULA
1. ossify in cartilage from several centres
2. before 8 weeks cartilaginous
3. ossification starts at 8 weeks at the thick part of lateral angle gradually enlarges
4. at birth
• ossified are the blade and the spine
• still composed of hyaline cartilage are acromion, coracoid process, medial border and inferior angle
5. secondary centre at the base of the coracoid process ossifies at 10 years fuses, across the glenoid cavity, soon after puberty
6. secondary centres appear at about puberty at acromion, coracoid process, medial border, inferior angle, and the lower
margin of the glenoid cavity all fuse by 20yrs

HIP BONES
1. the bone develops in cartilage
2. 3 primary centres in the fetus one for each bone, near the acetabulum
• ilium weight-bearing, appears first, at 2 month fetal life
• ischium at 3 month
• pubis at 4 month
3. At birth
• acetabulum is entirely cartilage
• the ilium is a broad blade of bone
• the ischium and pubis are just tiny bars of bone buried in the cartilage
4. when these 3 bones grow they approximate in a y-shaped cartilage forming the acetabulum
5. ischial and pubic rami fuse with each other at about 7 years
6. secondary centres begin in the acetabular cartilage at 8 yrs ossification across acetabulum complete by 18yrs
7. other centres occur in cartilage around peripheral of the bone these fuse with the main bone by 25yrs

FEMUR

1. except for the clavicle, femur is the first long bone to ossify it does so in cartilage
2. a centre in the shaft appears at 7th week of foetal life
3. a centre for the lower end appears at birth, its presence is acceptable medicolegal evidence of maturity
4. lower epiphysis this is the growing end of the bone, bisects the adductor tubercle unites with the shaft after 20 years
5. 3 secondary centres in upper epiphyses

BSE Notes 2006 [Link] ANATOMY 26

 • the head at 1 year of age
• greater trochanter at 4 years
• lesser trochanter at12 years
• these 3 centres fuse with the shaft at ~ 18 years of age
6. note that the NOF is the upper end of the shaft and ossifies as part of it, not from an epiphysis

PATELLA
1. forms in hyaline cartilage
2. several centers that appears b/n 3 & 6 yrs they appear as the child start running
3. fuse at puberty
4. occasionally one centre may not fuse with the main bone, resulting in a bipartite patella, which must not be mistaken for a
fractured patella on an x-ray

TIBIA
1. shaft ossifies in cartilage; primary centre appears in the 8th week of foetal life
2. upper epiphysis the growing end, shows a centre immediately after birth; joins the shaft at 20 years, along the epiphyseal
line already noted a secondary centre for the tuberosity may appear about puberty
3. lower epiphysis ossifies at the second year, joins the shaft at 18 years, epiphyseal line passes, a centimetre above the distal
end of the shaft includes the medial malleolus it is extracapsular

FIBULA
1. ossifies in cartilage centre in the shaft appears in the eighth week
2. epiphysis at each extremity
3. head the growing end, ossifies in the fourth year, later than the lower end (in this it is exceptional) fuses with shaft at 20
years
4. lower epiphysis ossifies 1st year joins the shaft at 18yrs

OSSIFICATION OF FOOT BONES

1. all the foot bones ossify in cartilage
2. 3 bones of the tarsus ossify at birth calcaneus, talus, cuboid
• calcaneus at 3 month
• talus at 6 month
• cuboid at 9 month, the presence of this centre is acceptable medicolegal evidence of maturity
3. navicular & cuneiforms ossifies during the first 4 year
4. metatarsals and phalanges ossify by shaft centres in utero; their epiphyses are as in the hand
• epiphysis of first metatarsal at the base
• epiphyses of the other 4 metatarsals in the head
• epiphyses ossify 2 or 3 years later than those in the hand; centres appearing about the fifth year
• they join earlier than in the hand, ~ 18 years
5. secondary centre on the posterior surface of the calcaneus at ~ 10 year joins at 18 years

BSE Notes 2006 [Link] ANATOMY 27

BRAINSTEM & CRANIAL NERVES
BRAINSTEM
1. connects cerebrum & diencephalons above to spinal cord below
2. consists of midbrain, pons and medulla oblongata with cerebellum sitting behind, wrapping the back of pons & medulla
3. from the torium to C1 vertebra below foramen magnum
4. essentially a highway for up and down nerve fibres
5. has a bunch of nuclei mainly in 3 broad groups
• cranial nerve nuclei 3 to 12
• the ‘named’ nuclei, e.g. colliculi, red nucleus, substantia nigra, pontine nuclei & olivary nucleus
• reticular formation diffuse system of cells & fibres, intermingled with the ‘named’ nuclei very important

Level of cranial nerve nuclei

1. 3 & 4 in midbrain
2. motor of 5, the 6 & 7 in the pons
3. 3 sensory nuclei of 5 distributed b/n midbrain, pons, medulla & upper spinal cord
4. 8 overlap the junction of pons & medulla, and lie partly in each
5. 9 12, in medulla, with 11 having a spinal part derived from cervical region

BSE Notes 2006 [Link] ANATOMY 28

MIDBRAIN
1. CN 3 comes out from the front, medial surface, at junction b/n cerebral penducle & pons
2. CN4 comes out from the back, curls around the lateral side of the peduncle and passes forward, b/n the 2 arteries, like CN 3
3. blood supply by PCA & superior cerebellar arteries as they curl around the cerebellar peduncle

PONS
1. the only ‘complete’ cranial nerve to come out here CN 5 by large sensory and small motor root
2. come out laterally from middle of anterior aspect of pons, motor root slightly cranial and medial to sensory root
3. the 2 pass forward, together, in the posterior cranial fossa, below tentorium
4. basilar artery, may or may not lie in the midline groove
5. 6 enter on ventral surface, on the clivus
6. 7 & 8 enter more laterally at junction of pons & medulla

MEDULLA OBLONGATA
1. b/n pons above & spinal cord below

BSE Notes 2006 [Link] ANATOMY 29

2. extends through foramen magnum to level of atlas
3. ventral surface 2 pyramids in front, olives to the side, & inferior cerebellar peduncles, even further
4. what comes out of here
• 6, 7, 8 emerge b/n pons & medulla
a. 6 b/n pons & pyramid
b. main part of 7 b/n pons & olive
c. nervus intermediate part of 7 & 8 b/n pons & inferior cerebellar peduncle
• 9,10, & cranial part of 11 emerge lateral to the olive
• 12 b/n pyramid & olive

Blood supply to the medulla

1. anteriorly by branches of vertebral & basilar arteries
2. laterally and dorsally by posterior inferior cerebellar artery
3. anterior spinal branch of vertebral gives penetrating branches which supply the region next to the midline, i.e. the part
containing the pyramid, medial lemniscus & hypoglossal nucleus damage to these vessels produces ‘medial medullary
syndrome’ , characterized by
• paralysis of tongue on same side
• hemiplegia with loss of touch & kinaesthetic sense on the opposite side
4. Damage to vessels of the lateral & dorsal part gives rise to the ‘lateral medullary syndrome’ , characterized by
• Loss of function of nucleus ambiguous leading to paralysis of vocal cord, palatal & pharyngeal muscles on that side
giving dysphonia & dysphagia
• Loss of uncrossed spinal tract of trigeminal & of the crossed spinal lemniscus results in loss of pain & temperature
sensation on the same side of face & opposite side of body

BSE Notes 2006 [Link] ANATOMY 30

 • Horner’ s syndrome on the same side due to interruption of descending hypothalamo-spinal fibres of sympathetic
pathway
• Involvement of the vestibular nuclei causes vertigo & nystagmus with nausea & vomiting
5. Venous drainage
• Dorsal aspect to occipital sinus
• Ventral aspect to basilar plexus of veins and inferior petrosal sinus
• Medullary vein communicates with the spinal vein

BSE Notes 2006 [Link] ANATOMY 31