FIRST EDITION

Exam Oriented

Anatomy
 Anatomy

TABLE OF CONTENTS

SCALP ........................................................................................................................... 6
posterior triangle ......................................................................................................... 9
STERNOCLEIDOMASTOID MUSCLE ............................................................................. 11
Carotid Sheath ........................................................................................................... 14
Carotid triangle .......................................................................................................... 14
Cavernous Sinuses ..................................................................................................... 15
PAROTID GLAND ........................................................................................................ 17
Surfaces: .................................................................................................................... 18
TEMPOROMANDIBULAR JOINT .................................................................................. 20
Relations of Temporomandibular Joint ...................................................................... 20
OTIC GANGLION ......................................................................................................... 22
Nasal Septum ............................................................................................................. 24
Lateral Wall of Nose .................................................................................................. 26
Maxillary Sinus ........................................................................................................... 28
Facial nerve ............................................................................................................... 30
LACRIMAL APPARATUS .............................................................................................. 32
THYROID GLAND ........................................................................................................ 33
MIDDLE EAR ............................................................................................................... 36
Nerve supply and lymphatic drainage of tongue ....................................................... 37
Palatine tonsil ............................................................................................................ 39
Soft palate ................................................................................................................. 40
Mandibular Nerve ...................................................................................................... 42
Interpeduncular fossa ................................................................................................ 44
Inferior cerebellar peduncle ...................................................................................... 44
internal capsule ......................................................................................................... 45
Third ventricle ........................................................................................................... 47

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4th ventricle ................................................................................................................ 48

floor of 4th ventricle ................................................................................................... 48
lateral medullary syndrome ....................................................................................... 50
Medial medullary syndrome ...................................................................................... 50
Hemisection of the spinal cord or brown sequard syndrome .................................... 51
Corpus callosum ........................................................................................................ 51
Blood supply to brain ................................................................................................. 53
Breast ........................................................................................................................ 54
Lymphatic drainage of breast .................................................................................... 55
Clavipectoral fascia .................................................................................................... 57
axilla boundary and content ...................................................................................... 58
axillary artery ............................................................................................................. 59
Relation of axillary artery with brachial plexus .......................................................... 60
Erb’s palsy .................................................................................................................. 60
Klumpke’s paralysis- .................................................................................................. 61
Deltoid muscle ........................................................................................................... 62
Musculo tendinous cuff(rotatory cuff) ....................................................................... 63
Biceps brachi muscle ................................................................................................. 63
Anastomosis around the elbow joint ......................................................................... 64
Cubital fossa .............................................................................................................. 65
Brachioradialis muscle ............................................................................................... 65
Carpal tunnel syndrome ............................................................................................ 66
Ulnar nerve in hand ................................................................................................... 67

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First carpo metacarpal joint ....................................................................................... 69

Supination and pronation .......................................................................................... 70
Superficial Palmer arch .............................................................................................. 71
Deep Palmer arch ...................................................................................................... 72
Flexor Retinaculum .................................................................................................... 72
Extensor retinaculum................................................................................................. 73
THE INFERIOR APERTURE/OUTLET OF THE THORAX/ Diaphram ................................ 76
RESPIRATORY MOVEMENTS ...................................................................................... 78
Inter Costal Space ...................................................................................................... 79
IN the anterior part of the intercostal space .............................................................. 79
THE AZYGOS VEIN ...................................................................................................... 81
Pleura and its applied ................................................................................................ 82
Recesses of pleura ..................................................................................................... 83
CLINICAL ANATOMY OF PLEURA ................................................................................ 84
Root of the Lung ........................................................................................................ 85
Bronchopulmonary Segments.................................................................................... 87
Sinuses of Pericardium .............................................................................................. 88
THE RIGHT ATRIUM ................................................................................................... 89
Blood supply of heart ................................................................................................ 92
Arch of aorta .............................................................................................................. 94
Thoracic duct ............................................................................................................. 96
Anterior Abdominal wall ............................................................................................ 98
Umbilicus ................................................................................................................. 100
Linea alba ................................................................................................................ 100
Rectus Abdominis Muscle ........................................................................................ 101
Rectus sheath .......................................................................................................... 102
INGUINAL CANAL ..................................................................................................... 104
Structures Passing through the inguinal Canal ......................................................... 105
CLINICAL ANATOMY of Inguinal canal ...................................................................... 107
Inguinal Hernia ........................................................................................................ 107

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Direct Inguinal Hernia .............................................................................................. 107

Indirect Inguinal Hernias .......................................................................................... 108
Epiploic Foramen/Foramen of Winslow ................................................................... 109
Rectouterine pouch ................................................................................................. 110
THE STOMACH ......................................................................................................... 110
Stomach Bed ............................................................................................................ 112
Blood Supply of Stomach ......................................................................................... 112
Lymphatic Drainage of the stomach ........................................................................ 113
THE DUODENUM ..................................................................................................... 115
Second Part of the Duodenum ................................................................................. 116
Meckel's Diverticulum (Diverticulum ilei) ................................................................ 118
VERMIFORM APPENDIX ........................................................................................... 119
PORTOSYSTEMIC COMMUNICATIONS (PORTOCAVAL ANASTOMOSIS ..................... 121
ISCHIORECTAL FOSSA ............................................................................................... 123
SUPPORTS OF THE UTERUS ...................................................................................... 125
ANAL CANAL ............................................................................................................ 128
Piles or hemorrhoids................................................................................................ 131
Relations of the Kidneys .......................................................................................... 132
Write a short note on Femoral triangle ................................................................... 134
write a Short note on Femoral sheath ..................................................................... 136
Femoral Canal .......................................................................................................... 137
Femoral hernia ........................................................................................................ 138
Adductor canal/ hunter’s canal/ subsartorial canal ................................................. 139

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Obturator Nerve ...................................................................................................... 140

Poplitial fossa .......................................................................................................... 142
DORSALIS PEDIS ARTERY .......................................................................................... 143
What is Guy ropes ................................................................................................... 145
COMMON PERONEAL NERVE ................................................................................... 146
Plantar Arch ............................................................................................................. 147
Great /Long Saphenous Vein ................................................................................... 148
Hip joint ................................................................................................................... 150
Locking and Unlocking of the Knee Joint .................................................................. 153
Inversion and Eversion of the Foot .......................................................................... 154
Contraception .......................................................................................................... 156
ORAL CONTRACEPTIVES (PILL METHOD) .................................................................. 158
SURGICAL METHOD (STERILIZATION) ....................................................................... 159
Surrogacy or Surrogate Mother ............................................................................... 160
Karyotyping ............................................................................................................. 161
Trisomy 21 or Down’s syndrome ............................................................................. 163
Turner syndrome [45, XO] Or Monosomy ................................................................ 164
Klinefelter syndrome [47,XXY] ................................................................................. 165
Somites .................................................................................................................... 166
Primitive streak ........................................................................................................ 168
Notochord ............................................................................................................... 169
Pharyngeal arches ................................................................................................... 169
Development of face ............................................................................................... 173
Hyaline cartilage ...................................................................................................... 174
Elastic cartilage ........................................................................................................ 176
Fibrocartilage ........................................................................................................... 178
Skeletal muscle ........................................................................................................ 179
Cardiac muscle ......................................................................................................... 180
Compact Bone ......................................................................................................... 181
Artery ...................................................................................................................... 182

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Thyroid gland ........................................................................................................... 183

Spleen ...................................................................................................................... 184
Appendix ................................................................................................................. 185
Supra renal gland ..................................................................................................... 186
Testis ....................................................................................................................... 187
Ovary ....................................................................................................................... 188
Ureter ...................................................................................................................... 189

SCALP
The soft tissues covering the cranial vault form the scalp.

Extent of scalp
Anteriorly- Supraorbital margins;
Posteriorly- External occipital protuberance and superior nuchal lines; Each side-
The superior temporal lines.

Structure
The scalp is made up of five layers:
(1) Skin- first layer of the scalp It is thick and hairy.
It is joined to the epicranial aponeurosis through the dense superficial
fascia.

(2) Superficial fascia [connective tissue] second layer of the scalp It binds skin to
aponeurosis.

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vessels and nerves to the skin pass from this layer.

(3) Deep fascia – [epicranial aponeurosis] Third layer of scalp. It is freely movable on
the pericranium.
• Anteriorly, it receives the insertion of the frontalis,
• posteriorly, it receives the insertion of the occipitalis

The occipitofrontalis muscle has two bellies, occipital and frontal.

Both are inserted into the epicranial aponeurosis.

(4) Loose areolar tissues - Fourth layer of the scalp

• It extends anteriorly into the eyelids because the frontalis muscle has no bony
attachment;
• posteriorly to the highest and superior nuchal lines;

(5) pericranium. The fifth layer of the scalp

• It is loosely attached to the surface of the bones. It is firmly attached to
their sutures.

Arterial Supply of Scalp

In front of the auricle, the scalp is supplied from- (1)

Supratrochlear;
(2)supraorbital; and
(3) superficial temporal arteries

Behind the auricle, the scalp is supplied from

(4) posterior auricular, and
(5) occipital arteries

The scalp has a rich blood supply derived from both the internal Anatomyand the
external carotid arteries.

Venous Drainage

The veins of the scalp accompany the arteries and have similar names

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Nerve supply
In front of the auricle Behind the auricle
Sensory nerves Sensory Nerves
• Supratrochlear Nerve • Great auricular nerve
• Suprorbital Nerve • Lesser occipital Nerve
• Zygomatico-temporal nerve • Greater occipital Nerve
• Auriculo temporal nerve • Third occipital Nerve

Motor nerve Motor Nerve

• Temporal nerve • Posterior auricular Nerve

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Clinical anatomy of scalp

Bleeding is more from scalp because scalp is having rich Blood supply.
Bleeding can be arrested by applying pressure against the bone.

• inflammations in scalp cause little swelling but much pain.

• The layer of loose areolar tissue is known as the dangerous area of the scalp
because the emissary veins, which open here, may transmit infection from the
scalp to the cranial venous sinuses.

• Collection of blood in the layer of loose connective tissue causes generalised

swelling of the scalp. The blood may extend anteriorly into the root of the nose
and into the eyelids, causing black eye.

• Surgical layers of scalp - first three layers are firmly attached with each other
and cannot be separated from each other. Wounds of the scalp do not gape
unless the third layer is divided.

• In Infants the veins of scalp are easily seen deep to the skin, so it is used for
intravenous infusion.

• Pericranium is adherent to sutures so, collections of fluid deep to the

pericranium take the shape of the bone, known as cephalhaematoma

• sebaceous glands are more in scalp. So, scalp is a common site for sebaceous
cysts.- In this condition fluid is accumulated in sebaceous gland and converted
into cyst.

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STERNOCLEIDOMASTOID MUSCLE

The sternocleidomastoid are large superficial muscles of the neck.

Origin
1.The sternal head arises from the superolateral part of the front of the manubrium
sterni
2.The clavicular head arises from the medial one-third of the superior surface of the
clavicle.

Insertion
• It is inserted on the mastoid process and lateral half of the superior nuchal
line of the occipital bone.

Nerve Supply
• The spinal accessory nerve provides the motor supply.
• Branches from the ventral rami of C2 are proprioceptive.

Actions
• When one muscle contracts:
 It turns the chin to the opposite side, 
It can tilt the head towards the shoulder.

• When both muscles contract together  They bring the head forwards  The
helps in forced inspiration.

Relations

Superficial
1.Skin
2.Superficial fascia; 3.Platysma.

Deep
1.Bones and joints:

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(a)Mastoid process above (b) sternoclavicular joint below.

2.Carotid sheath

3.Muscles
(a) Sternohyoid, (b) sternothyroid;

4.Arteries:
(a) Common carotid, (b) internal carotid, (c) external carotid

5.Veins: Internal jugular

6.Nerves: (a) Vagus; (b) accessory (c) cervical plexus, (d) upper part of brachial plexus

7.Lymph nodes- deep cervical

Clinical Anatomy
Torticollis or wryneck
• It is the condition in which the head is bent to one side and the chin points to
the other side.
• This occurs due to spasm or contracture of the muscles supplied by the spinal
accessory nerve.

Although there are many varieties of torticollis. depending

on the causes the common types are :
• Rheumatic torticollis due to exposure to cold.
• Reflex torticollis due to inflamed or suppurating cervical lymph nodes which
irritate the spinal accessory nerve.
• Congenital torticollis due to birth Injury.
• Spasmodic torticollis due to central irritation

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CAROTID TRIANGLE

It is the part of anterior triangle

It is called carotid triangle because it contains all the three carotid arteries
Boundries
Antero Superiorly – posterior belly of digestric, stylohyoid muscle
Antero inferiorly – superior belly of omohyoid
Posteriorly – anterior border of sternocleidomastoid muscle Roof-
• Skin,
• Superficial faascia,
• Investing layer of deep cervical fascia Floor-
• Middle and inferior constrictor of pharynx
Contents
1. Carotid arteries
• Common carotid artery
• Internal carotid artery
• External carotid artery
2. Carotid sinus and carotid body
3. Carotid sheath
4. Internal juglar vein
5. Last three cranial nerves Vegus
• Spinal accessory nerve
• Hypoglossal nerve
6. Ansa cervicalis
7. Cervical part of sympathetic chain
8. Deep cervical group of lymph nodes

Clinical anatomy
Carotid sinus syndrome

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• Pressure on carotid sinus result in slowing of heart rate, falling of blood

pressure and syncope.
• It commonly occurs in person with carotid sinus hypertrophy

CAVERNOUS SINUSES
Each cavernous sinus is a large venous space situated in the middle cranial fossa.
They are situated on either side of the body of the sphenoid bone.

• The floor is formed by the endosteal dura mater.

• The lateral wall, roof and medial wall are formed by the meningeal dura
mater.
• Anteriorlythe sinus extends up to the the superior orbital fissure and
posteriorly, up to the apex of the petrous temporal bone.
It is about2 cm long, and 1 cm wide.

Relations
Structures outside the sinus:
Superiorly: Optic tract, optic chiasma
Inferiorly- foramen lacerum
Medially- pituitary gland and sphenoidal air sinus
Laterally: temporal lobe anteriorly: superior orbital
fissure posteriorly: petrous temporal bone

Structures in the Lateral Wall of the Sinus, from above Downwards

• Oculomotor nerve Trochlear nerve
• Ophthalmic nerve.
• Maxillary nerve.

Structures Passing through the Centre of the Sinus

• Internal carotid artery
• abducent nerve,

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Tributaries or Incoming Channels

From the orbit:
• The superior ophthalmic vein;
• inferior ophthalmic vein
• the central vein of the retina From the brain:
• Superficial middle cerebral vein From the meninges:
• Sphenoparietal sinus
• middle meningeal vein

Draining Channels or Communications

The cavernous sinus drains into-
• transverse sinus, internal jugular vein , pterygoid plexus of veins, facial vein.
• The right and left cavernous sinuses communicate with each other through the
anterior and posterior inter cavernous sinuses
All these communications are valveless, and blood can flow through them in either
direction.

CLINICAL ANATOMY
Thrombosis of the cavernous sinus
It may be caused by spreading of infection from face, nasal cavities and paranasal
air sinuses.
This gives rise to the following symptoms.

• Severe pain in the eye and forehead

• involvement of the third, fourth and sixth cranial nerves resulting in paralysis
of the muscles supplied. Marked oedema of the eyelids Exophthalmos.

Pulsating exophthalmos.
• A communication between the cavernous sinus and the internal carotid
artery may occurs due to head injury.
• When this happens arterial blood rush into the cavernous sinus and creates
force into connecting veins so o the eyeball comes out and pulsates with each
heart beat. It is called the pulsating exophthalmos.

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o Orbital and congunctival edema occurs

PAROTID GLAND
• The parotid is the largest of the salivary glands.
• It weighs about 15 g.
• It is situated below the external acoustic meatus, between the ramus of
the mandibleand the sternocleidomastoid.

Parotid Capsule
The investing layer of the deep cervical fascia forms
a capsule for the gland.

External Features
• The gland resembles a three sided
pyramid.
• The apex is directed downwards.
• The gland has four surfaces
(1) Superior (base)
(2) Superficial; (3) anteromedial; and
(4)posteromedial.

The surfaces are separated by three borders: (1) Anterior; (2) posterior;(3) medial.

SURFACES:

The superficial surfaceis the largest of the four surfaces. It is covered with
Skin;
• superficial fascia
• parotid fascia

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The anteromedial surface is related to:

• masseter;
• posteriorborder of the ramus of the mandible;
• medial pterygoid posteromedial surface is related to:

• mastoid process, with the sternocleidomastoid Borders:

The anterior border separates the superficial surface from the anteromedial surface.
The posterior border separates the superficial surface from the posteromedial
surface.
Medial border seperates anteromedial surface with posteromedial surface

Parotid Duct

• It is thick walled and is about 5 cm long.

• It emerges from the anterior border of the gland.
• It opens into the mouth opposite the upper second molar tooth.

Blood Supply

• The parotid gland is supplied by the external carotid artery and its
branches. The veins drain into the external jugular vein.

Nerve Supply

Parasympathetic and sensory supply by

auriculotemporal nerve.
Sympathetic nerve
• Derived from the plexus around the external carotid artery.

Lymphatic Drainage

 parotid nodes

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Clinical anatomy of parotid gland

Parotid swellings are very painful due to the unyielding nature of the parotid fascia.

Mumps is an infectious disease of the salivary glands (usually the parotid) caused by
a specific virus.

Parotid abscess may be caused by spread of infection from the mouth cavity.

Parotidectomy - surgical removal of the parotid gland

Stones or calculi may form in the parotid duct and parotid gland. They block the
secretion by gland.
Frey’s syndrome or auriculotemporal nerve syndrome
– when person eats, same side cheek becomes red, hot and painful due
to communication of parasympathetic with sensory fibers. Mixed parotid
tumour is a slowly growing painless tumour. Malignant change of such
a tumour also occurs
It is indicated by pain, rapid growth, involvement of the facial nerve, and
enlargement of cervical lymph nodes.

TEMPOROMANDIBULAR JOINT
This is a synovial joint of the condylar variety

Articular Surfaces
• mandibular fossa of the temporal bone:
• the head of the mandible.

Ligaments related to the joint

Fibrous capsule- It enclose the joint cavity
The lateral or temporomandibular ligament –
• attached above articular tubercle on temporal bone and below with neck of
mandible
• strenghthens the lateral aspect of capsule

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The sphenomandibular ligament

• attached above with sphenoid bone and below with lingula of mandible.
The stylomandibular ligament
• attached above with styloid process and below with angle of mandible

Articular Disc
The articular disc is an oval fibrous plate that divides the joint into an upper and a
lower compartments.

RELATIONS OF TEMPOROMANDIBULAR JOINT

Lateral
• Skin and fasciae Medial:
• The tympanic plate Anterior:
• Lateral pterygoid muscle
Posterior
• the external auditory meatus;
Superior
• Middle cranial fossa, Inferior:
• Maxillary artery and vein

Blood Supply

• Branches from superficial temporal and maxillary arteries. Veins follow the
arteries.
Nerve Supply
• Auriculotemporal nerve and masseteric nerve

Muscles Producing Movements at TM Joint

Depression
• Depression is brought about mainly by the lateral pterygoid.
• The digastric, geniohyoid and mylohyoid muscles also help.
• It is also done passively by gravity.

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Elevation
• Elevationis brought about by the masseter, the temporalis, and the medial
pterygoid muscles of both sides.
• These are antigravity muscles.

Protrusionis done by the lateral and medial pterygoids.

Retractionis produced by the posterior fibres of the temporalis.

Lateral or side to side movements,

• By lateral pterygoid and medial pterygoid muscles.

CLINICAL ANATOMY

1.Dislocation of mandible
• During excessive opening of the mouth the head of the mandible of one or
both sides may slips anteriorly.

2.Derangement of the articular disc

May result from any injury.
• This gives rise to pain during movements of the jaw.

3.In operations on the joint, the seventh nerve should be preserved with care.

OTIC GANGLION
Introduction
• it is a peripheral parasympathetic ganglion
• It is related to the mandibular nerve, but functionally it is a part of the
glossopharyngeal nerve

Size and Situation

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It is 2 to 3 mm in size, and is situated in the infratemporal fossa just below foramen

ovale.

Connections and Branches

• The motor or parasympathetic root is formed by the lesser petrosal nerve.

o The preganglionic fibres are derived from the inferior salivary nucleus -
the ninth nerve, its tympanic branch, the tympanic plexus -the lesser
petrosal nerve to reach the ganglion
o Postganglionic - pass through the auriculotemporal nerve to the parotid
gland.

• The sympathetic root is derived from the plexus on the middle meningeal
artery.
o It contains postganglionic fibres arising in the superior cervical ganglion.
o The fibres pass through the ganglion without relay and reach the parotid
gland via the auriculotemporal nerve.

• The sensory root comes from the auriculotemporal nerve and is sensory to the
parotid gland.

Other fibres passing through the ganglion are as follows.

• nerve to medial pterygoid
• chorda tympani

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NASAL SEPTUM
The nasal septum is median osseocartilaginous partition between the two halves
of the nasal cavity.
• On each side, it is covered by mucous membrane.
• It forms the medial wall of both nasal cavities.

The bony part is formed almost entirely by

• vomer, and
• perpendicular plate of the ethmoid.

The cartilaginous part is formed by

• septal cartilage, and

The lower margin of the septum is called the

columella.

The septum has

• Four borders-superior, inferior,
anterior and posterior

• Two surfaces- Right and left.

Arterial Supply

• Anterosuperior partis supplied by the anterierethmoidal artery

Anteroinferiorpart:by the superior labial artery branch of facial artery.
• Posterosuperior part: by the posterior ethmoidal artery.
• Posteroinferior part: is supplied by the spheno palatine artery.

What is Kiesselbach's plexus?

The anteroinferior part of the septum contains anastomoses between superior

labial branch of the facial artery, branch of sphenopalatine artery, and of anterior
ethmoidal artery.

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• These form a large capillary network called the Kiesselbach's plexus. This is a
common site of bleeding from the nose also known as epistaxis It is known as
Little's area .
Venous Drainage

• The veins form a plexus.

• The plexus drains into facial vein, sphenopalatine vein, pterygoid venous
plexus. Nerve Supply

General sensory nerves, arising from trigeminal nerve, are distributed to whole of
the septum
• anterior ethmoidal nerve.
• anterior superior alveolar nerve
• nasopalatine nerve
They carry sensations of pain, touch and
temperature.

Olfactory nerves carry smell sensation.

Lymphatic Drainage
Anterior half to the submandibular nodes.
Posterior half to the retropharyngeal and deep cervical nodes.

CLINICAL ANATOMY

• Little's area on the septum is a common site of bleeding from the nose or
epistaxis .

• Pathological deviation of the nasal septum [DNS] o It is responsible for

repeated attacks of common cold, allergic rhinitis.
o It requires surgical correction
• Rhinoscopy- o Examination of nasal cavity is known as rhinoscopy.

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LATERAL WALL OF NOSE

The lateral wall of the nose is irregular.
The skeleton of the lateral wall is partly bony and partly cartilaginous.

The bony part is formed by following bones:

(1)Nasal;
(2) frontal process of maxilla;
(3) lacrimal;
(4) ethmoid with superior and middle conchae;
(5) inferior nasal concha;

The cartilaginous partis formed by:

Superior nasal cartilage; Inferior nasal
cartilage; and 3 or 4 small cartilages
of the ala.

Chonchae and Meatuses.

• The inferior concha is an independent bone.
• The middle concha and The superior concha is a projection from the medial
surface of the ethmoidal labyrinth.

The inferior meatus lies below the inferior concha

• nasolacrimal duct opens into it

The middle meatuslies below the middle concha.

It is having ethmoidal bulla, hiatus semilunaris.
It is having opening of
• Frontal air sinus

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• Maxillary air sinus

• Anterior ethmoidal air sinus
• Middle ethmoidal air sinus

The superior meatus lies below the superior concha.

It receives the openings of the posterior ethmoidal air sinuses.

Arterial Supply of Lateral Wall

Anterosuperior quadrant is supplied by the anterior

ethmoidal artery

Anteroinferior quadrant, is supplied by branches

from the facial and greater palatine arteries

The posterosuperior quadrant, is supplied by the

sphenopalatine artery.

The posteroinferior quadrantis supplied by

branches from the greater palatine artery

Venous Drainage

The veins form a plexus which drain into facial vein; pharyngeal plexus of veins;
pterygoid plexus of veins.
Nerve Supply

General sensory nerves from the branches of trigeminal nerve are distributed to
whole of the lateral wall:

• anterior ethmoidal nerve

• anterior superior alveolar nerve
• greater palatine nerve

olfactory nerve for smell sensation

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Lymphatic Drainage

• submandibular nodes,
• Retropharyngeal and upper deep cervical nodes.

CLINICAL ANATOMY

• Common cold or rhinitis is the commonest infection of the nose.

• The paranasal air sinuses may get infected from the nose. Maxillary sinusitis is
the commonest of such infections.

• Hypertrophy of the mucosa over the inferior nasal concha is a common

feature of allergic rhinitis, which is characterized by sneezing, nasal blockage
and excessive watery discharge from the nose.

MAXILLARY SINUS
The maxillary sinus lies in the body of the maxilla and is the largest of all the
paranasal sinuses.
It is pyramidal in shape.
• Base directed medially towards the lateral wall of the nose.
• Apex directed laterally in the zygomatic process of the maxilla.
• Roof is formed by the floor of orbit.
• Floor is formed by the alveolar process of the maxilla, o The floor is marked by
elevations produced by the roots of the upper molar and premolar teeth It
opens into the middle meatus of the nose in the lower part of the hiatus
semilunaris

The size of the sinus is variable. Average measurements are: height, 3.5 cm; width,
2.5 cm and anteroposterior depth- 3.5 cm

CLINICAL ANATOMY

Infection of a sinus is known as sinusitis.

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• It causes headache and discharge from the nose. The maxillary sinus is most
commonly involved.

Carcinoma of the maxillary sinus arises from the mucosal lining. Symptoms
depend on the direction of growth.

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FACIAL NERVE
This is the seventh cranial nerve.
The fiber of nerve arise from four nuclei situated in the lower pons.

• Motor nucleus
• Superior salivatory nucleus • Lacrimatory nucleus
• Nucleus of tractus soliterius
Cource and relation
The facial nerve attached to the brainstem by two
roots motor and sensory

Reach the internal acaustic meatus

The first part is directed laterally

Second part runs backward in relation to the midial

wall of middle ear
Third part is directed vertical downward
Facial nerve leaves skull by passing through
stylomastoid foramen

• It enters the posteromedial surface of the parotid gland, Behind the neck of
the mandible it divides into its five terminal branches

Branches and Distribution Within

the facial canal:
• Greater petrosal nerve
• Nerve to the stapedius;
• Chorda tympani

At the exit from the srylomastoid foramen:

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• Posterior auricular; • digastric; and

• stylohyoid.

Terminal branches within the parotid gland:

• Temporal;
Zygomatic; Buccal
Marginal mandibular; Cervical.

Bell's palsy. [Facial palsy]

In infranuclear lesions of the facial nerve, known as Bell's palsy.

• The whole of the face of the same side gets paralyzed.
• The face becomes asymmetrical and is deviated to the normal side. The
affected side is motionless.
• Wrinkles disappear from the forehead.
• The eye cannot be closed.
• Any attempt to smile deviates the mouth to the normalside.
• During mastication, food accumulates between the teeth and the cheek.
• Articulation of labials is impaired.

In suprannclear lesions of the facial nerve;

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• only the lower part of the opposite side of face is paralysed.

• The upper part with the frontalis and orbicularis oculi have bilateral
representation in the cerebral cortex so do not affected

LACRIMAL APPARATUS
The structures related with secretion and drainage of the lacrimal fluid combinely
known as the lacrimal apparatus.

It is made up of the following parts:

 Lacrimal gland and its ducts.
 Conjunctival sac.
 Lacrimal puncta and lacrimal canaliculi.
 Lacrimal sac.
 Nasolacrimal duct.

Lacrimal Gland
 It is a serous gland situated in the lacrimal fossa on the anterolateral part of
the roof of the bony orbit.
 The gland is 'J' shaped,
 10-12 lacrimal ducts open into the conjunctival sac
 The gland is supplied by the lacrimal branch of the ophthalmic artery and by
the lacrimal nerve.
 The lacrimal fluid secreted by the lacrimal gland flows into the conjunctival sac
 it lubricates the front of the eye and the deep surface of the lids.

Conjunctival Sac
 The potential space between the palpebral and bulbar part of conjunctiva is the
conjunctival sac.

Lacrimal Puncta and Canaliculi

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 Each lacrimal canaliculus begins at the lacrimal punctum, and is 10 mm long.

 It has a vertical part and a horizontal part.
 Both canaliculi open into the lacrimal sac

Lacrimal Sac
 It is membranous sac situated in the lacrimal groove
 Its upper end is blind. The lower end is continuous with the nasolacrimal duct.

Nasolacrimal Duct
 It is a membranous passage
 It begins at the lower end of the lacrimal sac, runs downwards, backwards and
laterally, and opens into the inferior meatus of the nose

Clinical anatomy

 In Bell’s palsy , lacrimal gland fail to secrete lacrimal fluid

 Inflammation of lacrimal sac is known as dacrocystitis
 Epiphora – overflow of tears from conjunctival sac to cheeks. It occurs due to
hyperlacrimation or blockage of lacrimal passage

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THYROID GLAND
The thyroid is an endocrine gland, situated in the lower part of the front and sides of
the neck.
• The gland consists of right and left lobes that are joined to each other by the
isthmus
Each lobe measures
• about 5 cm x 2.5 cm x 2.5 cm,
• and the isthmus 1.2 cm x 1.2 cm.
On an average the gland weighs about 25 g.
Capsules of Thyroid
1. The true capsuleis the peripheral condensation of the connective tissue of the
gland.
2. The false capsuleis derived from the pretracheal layer of the deep cervical
fascia

Relations
The lobes are conical in shape having:
• Apex,
• Base
• Three surfaces, lateral, medial and posterior Two borders, anterior and
posterior.

The apex is directed upwards

The base is on level with the 4th or 5th tracheal ring.
The lateral or superficial surface is convex, and is covered by:
• sternohyoid;
• superior belly of the omohyoid;
• sternothyroid; and
• sternocleidomastoid

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Medial surface is related to- trachea and oesophagus;

Posterior surface is related to the carotid sheath; Isthmus
connects the lower parts of the two lobes.

Blood Supply
The thyroid gland is supplied by the superior and inferior thyroid arteries.

The superior thyroid artery is the branch of the external carotid artery

• It runs downwards and forwards

• It reach the upper pole of the lobe.
• Here it divides into anterior and posterior branches.
• The anterior branch o continues along the upper border of the isthmus o It
anastomose with anterior baranch of the opposite side.
• The posterior branch descends on the posterior border of the lobe o It
anastomoses with the ascending branch of the inferior thyroid artery

The inferior thyroid artery is a branch of the thyrocervical trunk It

reach the lower pole of the gland.
• The artery divides into 4 to 5 glandular branches.
• One ascending branch anastomoses with the posterior branch of the superior
thyroid artery.

• Sometimes (in 3% of individuals), the thyroid is also supplied by the lowest

thyroid artery.

Venous Drainage
The thyroid is drained by the superior, middle and inferior thyroid veins.

Lymphatic Drainage
deep cervical nodes

CLINICAL ANATOMY
Any swelling of the thyroid gland known as goitre

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Removal of the thyroid is known as thyroidectomy

• It may be necessary in hyperthyroidism or thyrotoxicosis

In partial thyroidectomy , the posterior parts of both lobes are left behind.
• This avoids the risk o Simultaneous removal of the parathyroid.
Hypothyroidism causes cretinism in infants and myxoedema in adults.

Benign tumours of the gland may compress neighbouring structures, like the
carotid sheath, the trachea

Malignant growths invade and damage neighbouring structures.

MIDDLE EAR
The middle ear is also called the tympanic cavity.
• The middle ear is a narrow air filled space situated in the petrous part of the
temporal bone
• between the external ear and the internal ear

Shape and Size

The middle ear is shaped like a cube
Boundaries
The Roof or Tegmental Wall
• The roof separates the middle ear from the middle cranial fossa.
• It is formed by a thin plate of bone called the tegmen tympani

The Floor or Jugular Wall

• The floor is formed by a thin plate of bone
• Which separates the middle ear from the superior bulb of the internal jugular
vein.

The Anterior Wall

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The anterior wall is narrow due to the approximation of the medial and lateral walls It
has the opening of the auditory tube

Posterior or Mastoid Wall

There is an opening or aditus
• through which communication with the mastoid antrum

The Lateral or Membranous Wall

• The lateral wall separates the middle ear from the external ear.
• It is formed Mainly by the tympanic membrane

The Medial or Labyrinthine Wall

The medial wall separates the middle ear from the internal ear.
Clinical anatomy
Otitis Media- Inflamation of middle ear is known as otitis media
Throat infections commonly spread to the middle ear through the auditory tube and
cause otitis media.
Otitis media is more common in children than in adults

NERVE SUPPLY AND LYMPHATIC DRAINAGE OF TONGUE

Nerve supply of tongue

It is two types
Motor supply

 All the muscles of tongue except palatoglossus are supplied by

hypoglossal nerve.
 Palatoglossus is supplied by cranial root of accessory nerve via
pharyngeal plexus.
Sensory supply
Anterior 2/3rd of the tongue

 General sensation – by lingual nerve

 Taste sensation – by chorda tympani nerve

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Posterior 1/3rd of the tongue

 General sensation and taste sensation by glosopharyngeal nerve

Posterior most part of the tongue

 General sensation and taste sensation by vegus nerve Lymphatic

drainage of tongue
Apical portion of tongue
 It drains into submental group of lymphnodes Marginal portions of
anterior 2/3rd of the tongue
 On each side drains into the submandibular group of lymph nodes
Cenral portion of anterior 2/3rd of the tongue
 Drains into deep cervical group of lymph nodes Posterior 1/3rd and root
of tongue
 Bilaterally drains into the deep cervical group of lymph nodes

Applied anatomy
Cancer on posterior part of tongue

 Spreads through lymphatics to both the sides of lymphnodes.

 It occurs due to huge communication with two sides.

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 so poor prognosis

Cancer on anterior side of tongue

 Does not spread to opposide side of lymphnodes till the late stage.
 Better prognosis than posterior side carcinoma.

PALATINE TONSIL

Palatine Tonsils are lymphoid mass of tissue situated in tonsillar fossa between
palatoglossal and palaatopharyngeal arch.
External features

 Anterior border- related to palatoglossal arch

 Posterior border- related to palatopharyngeal arch
 Upper pole- related to soft palate
 Lower pole – related to tongue
 Medial surface-
• It is free and towards oropharynx.
• It is having 12 to 15 tonsillar crypts.
• The largest crypt is known as crypta magna or intertonsillar cleft.
 Lateral surface- It is covered by capsule.
The structures related to lateral surface forms tonsillar bed. It is formed by…
• Pharyngobasilar fascia
• Buccopharyngeal fascia
• Superior constrictor muscle
• Styloglossus muscle
• Glossopharyngeal nerve
• Facial artery

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Loose areolar tissue between tonsillar capsule and tonsillar bed is called as
peritonsillar space.
Blood supply of tonsil

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 Tonsilar branch of facial artery [ main artery]

 Branches from dorsal lingual artery, ascending pharyngeal artery and
greater palatine artery. Nerve supply
 Glosopharyngeal nerve
 Lesser palatine nerves Venous drainage
 By paratonsillar vein into pharyngeal plexus of vein. Lymphatic drainage
 Into deep cervical group of lymphnodes

Applied anatomy

 Tonsillitis – Inflammation of tonsil is known as tonsillitis.

• It is mainly due to viral or bacterial infection. It is more common in children. 
Quensy- [peritonsillar abscess] – collection of pus in the peritonsillar space.
 Tonsillectomy – Removal of tonsil is known as tonsillectomy.
• bleeding after tonsillectomy is common. It occurs mainly due to damage to
paratonsillar vein.

SOFT PALATE

The soft palate is movable muscular fold which is attached to posterior border of
hard palate separating nasopharynx from orpharynx.

External features

Anterior surface- is concave and towards oral cavity

Posterior surface – is convex and towards nasal cavity
Superior border is attached to the posterior border of hard palate Inferior border
is free.
• small tongue like projection is hanging down from middle is called uvula.
Structure

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It is made up of fold of mucous membrane enclosing five pairs of muscles.

Muscles of soft palate
Tensor veli palatine – tightens the soft palate
Levator veli palatine- elevates the soft palate
Palatoglossus- pulls up the root of tounge
Palatopharyngeus- raise the walls of pharynx during swallowing.
Musculus uvulae- pulls the uvula

Nerve supply
• All the muscles of soft palate are supplied by cranial root of accessory nerve via
pharyngeal plexus [ comes through vegus nerve] except tensor veli paltini
which is supplied by mandibular nerve.
• Sensory supply by branches of maxillary nerve and glosopharyngeal nerve

Arterial supply
• Ascending palatine A. branch of facial artery Lesser palatine A. branch from
maxillary A.
• Palatine branches of ascending pharyngeal A. Venous drainage
• Pharyngeal venous plexus and pterygoid venous plexus Lymphatic drainage
• Retropharyngeal and upper deep cervical group of lymphnodes.

Function of soft palate

• Separate oropharynx from nasopharynx during swallowing so that food does

not enter the nose
• To modify the quality of voice
• Protect during sneezing and coughing
Applied anatomy

Paralysis of the soft palate [due to lesion of vagus nerve]results in…

• Nasal regurgitation of food and liquid
• Nasal twang in voice

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• Deviation of uvula to normal side

MANDIBULAR NERVE

It is the largest Division of trigeminal nerve

It is mix variety of nerve. Sensory and motor both.
Course

It starts in middle cranial fossa

It comes out from cranial cavity through foramen ovale
After coming out Main trunk devides into anterior and posterior trunk
Branches
From Main trunk
1. Meningeal branch - supplies dura mater
2. Nerve to medial pterygoid- supplies medial pterygoid muscle.
 its fibers pass from otic ganglion and supplies tensor veli palatini

From anterior trunk

1. Massetric nerve- supply messeter muscle and temporomandibular joint
2. Nerve to lateral pterygoid- supply lateral pterygoid muscle
3. Deep temporal nerve- supply temporalis muscle
4. Buccal nerve it is the sensory branch

From posterior trunk [ ALI ]

1 Auriculotemporal nerve-
 Supply auricle and temporal part of skin
 Also supply parotid gland and temporomandibular joint
2. Lingual nerve
 sensory for anterior 2/3rd of tounge [taking general sensations]
3.Inferior alveolar nerve
 it enters the mandibular foramen runs in mandibular canal
 It supplying mylohyoid muscle, lower teeth and gums

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 Comes out as mental nerve from mental foramen Clinical

Reffered pain
• In case of cancer of tounge pain radiates to the ear and temporal fossa along
the distribution of auriculotemporal nerve
Mandibular neuralgia
• Pain along the distribution of mandibular nerve

INTERPEDUNCULAR FOSSA

• It is situated at base of brain

• It is rhomboid shaped fossa Boundry

 Anteriorly by optic chiasma and optic tracts

 Posteriorly by pons
 On each side by crus cerebri

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Content of fossa
1. Tuber cinerium which is raised area of grey matter
2. Two small spherical boddies known as mammillary bodies
3. A narrow stalk which connects pituitary gland with tuber cinerium is called as
infundibulum
4. Posterior perforated substance
5. Oculomotor nerve

INFERIOR CEREBELLAR PEDUNCLE

The afferent and efferent fiber of cerebellum are grouped together on each side into
three types of bundle called cerebellar peduncles
• Superior cerebellar peduncles
• Middle cerebellar peduncles
• Inferior cerebellar peduncles Inferior cerebellar peduncles
 It is formed on the posteriolateral aspect of the upper half of medulla
oblongata.
It contains
Afferent fibers [ORSVC]
• Olivocerebeller fibers from olivery nucleus
• Reticulocerebeller fibers from reticular nucleus
• Spinocerebellar fibers from spinal cord to cerebellum
• Vestibule cerebellar fibers from vestibular nerve
• Cuneocerebeller fibers from cuneate nucleus

Efferent fibers [ORV]

• Cerebello olivary fibers
• Cerebello reticular fibers

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• Cerebello vestibular fibers

INTERNAL CAPSULE

Internal capsule is compact bondle of projection fiber

In horizontal section of cerebral hemisphere it appear as v shaped. Situation
• Medially—thalamus and caudate nucleus
• Laterally—lentiform nucleus

Parts of internal capsule

It is devided in to five parts
• Anterior limb—lies between thalamus and lentiform nucleus
• Posterior limb—lies between thalamus and lentiform nucleus
• Genu-it is between anterior limb and posterior limb
• Retrolentiform part—lies behind the lentiform nucleus
• Sublentiform part—lies below lentiform nucleus

Fibers of the internal capsule

Motor fibers

Pyramidal fibers
Which are two types
• Corticonuclear fibers for head and neck—passing from genu
• Corticospinal fibers for upper limb,trunk,lowerlimb passing from posterior limb
and situated from anterior to posterior

Extrapyramidal fibers occupying position near the corticospinal fibers.

Sensory fibers
They are thelamo-cortical fibers
• Anterior thalamic radiation from anterior limb. Connecting thalamus to frontal
lobe

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• Superior thalamic radiation from genu and posterior limb connecting thalamus
to frontal and parital lobe
• Posterior thalamic radiation from retrolentiform part. connect the LGB to
occipital lobe[optic radiation]
• Inferior thalamic radiation from sublentiform part. Connect the MGB to
temporal lobe[auditory radiation]
Arterial supply
Branches from middle cerebral ,anterior cerebral, internal carotid, posterior
communicating and posterior cerebral arterys.

Clinical anatomy
Damage to internal capsule- It occurs
due to haemorrhage.
• Haemorrhage occurs due to damage of charcot’s artery which supply posterior
limb of internal capsule.
• It leads to loss of sensation and paralysis of the opposite half of the body.

THIRD VENTRICLE

It is a slit like cavity situated between two thalami

Boundries
Anterior wall –
• Anterior commissure

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• Lamina terminalis
Floor
 Optic chiasma
 Tuber cinerium and infundibulum
 Mammillary bodies
 Posterior perforated substance
 Tegmentum of midbrain

Posterior wall
 Pineal gland
 Posterior commissure
Roof
 By ependyma [telachoroidia of 3rd ventricle] Lateral wall
 Larger upper part of lateral surface by medial surface of thalamus
 Smaller lower part of the lateral wall is by hypothalamus
Communication
 With lateralventricle by intraventricular foramen[of montro] 
With 4th ventricle by cerebral aqueduct[of sylvius]

It receives CSF from lateral ventricle transport it into to fourth vent.

Recesses of the ventricle- Cavity of 3rd ventricle extend into surrounding structure
as pocket like prostration is called as recess. They are as follow
 Anterior recess
 optic recess
 infundibular recess
 suprapineal recess
 pineal recess

Clinical anatomy

hydrocephalus or increased intra-cranial pressure

• 3rd ventricle is easily obstructed by local brain tumor or congenital defect

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• Obstruction result in accumulation of CSF

• Intracranial pressure raised in adults and hypocephalus in children

4TH VENTRICLE

It is tent like cavity situated in posterior cranial fossa

It is situated in front of cerebellum and behind the pons and upper part of medulla
oblongata

Boundaries
Lateral wall on each side
• Inferolateraly by inferior cerebellar peduncle
• Suprolaterlly by superior cerebellar peduncle

Roof [posterior wall]

 Upper part by convergence of two superior cerebellar peduncles and thin shit
of white matter known as superior medullary velum

 Lower part by inferior medullary velum

FLOOR OF 4TH VENTRICLE

Floor
It is formed by posterior surface of pons and upper part of medulla.
It is rhomboid in shape
• Entire floor is devided into two halves by median sulcus
• On side of median sulcus there is elevation called median eminence
• Median eminence having oval swelling known as facial colliculus

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• Lateral to median eminence there is sulcus limitance

• Stria medullaris devide the floor into upper and lower part
• In the lower part in the lower medullary part o Hypoglossal triangle above o
Vegal triangle below
• Area between vegal triangle and gracile tubercle is known as area postreama.

Angle of 4th ventricle

 Four angle –superior,inferior,and two lateral angle

Recesses of fourth ventricle

• Two lateral recess
• Two lateral dorsal recess
• One median dorsal rrecess

Openings in the fourth ventricle

There are five openings
• Central openings in the roof-foramen magendie
• Two lateral opening in the roof-foramen lushka
• Central canal of medulla oblongata
• Central aqueduct of midbrain

Clinical anatomy

Medulloblastoma-
• Most common tumor in the region of 4th ventricle It is highly malignant.
• It do compression on vital centres located in the floor and cardiac arrhythmia,
irregular respiration and vasomotor disturbance occure

Internal hydrocephalus
• It occur due to blockage of opening of 4th ventricle.
• CSF accumulate and produce internal hydrocephalus

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LATERAL MEDULLARY SYNDROME

 Dorsolateral part of the medulla and inferior surface of cerebellum is supplied

by posterior inferior cerebellar artery [pica]
 Thrombosis of posterior inferior cerebellar artery affects dorso lateral aspect
of medulla and inferior surface of cerebellum
 Result in following signs and symptoms Opposite side
• Loss of pain and temperature sensation of opposite side of trunk and limbs due
to involvement of spinothelemic tract
Same side

• Loss of pain and temperature sensation same side of face due to involvement
of the spinal nucleus of trigeminal nerve
• Paralysis of muscle of platelet, pharynx and larynx due to involvement of
nucleus ambiguous
• Ataxia due to involvement of inferior cerebellar peduncle and cerebellum •
Horner’s syndrome due to involvement of reticular formation

MEDIAL MEDULLARY SYNDROME

 Paramedian part of the medulla is supplied by branches of vertebral artery

• Thrombosis of that branch affect paramidean aspect of medulla result in
following sing and symptoms Opposite side

 Loss of position and vibration sensation opposite side of body due to

involvement of medial meniscus
 hemiplegia-paralysis of opposite side arm and leg due to damage to
pyramid.
Same side

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• Same side atrophy of the half of the tongue due to damage of hypoglossal
nerve.

HEMISECTION OF THE SPINAL CORD OR BROWN SEQUARD

SYNDROME

Effects of hemisection of spinal cord are as below

Below the level of hemisection
Same side
• Spastic paralysis due to involvement of pyramidal tract
• Loss of proprioception, vibration ,fine touch due to involvement of dorsal
columns Opposite side
• Loss of pain and temperature sensation due to involvement of spinothalamic
tract.

At the level of hemisection

Same side
 Spastic paralysis due to involvement of pyramidal tract.
 Loss of proprioception ,vibration ,fine touch due to involvement of dorsal
columns.
 Loss of pain and temperature sensation due to involvement of spinothelemic
tract.
Opposite side-
 no effect on opposite side at the level of hemisection

CORPUS CALLOSUM

It is the largest commissure of the brain.

 It is connecting two cerebral hemispheres.
 Length: 10 cm

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 It is having 300 million fibers

External features
 In sagittal section of cerebrum, it is seen as c shped
 It lies 4 cm behind the frontal pole and 6 cm anterior to posterior
pole
 Superior aspect is convex and inferior aspect is concave Parts of
corpus callosum
• It is devided in 4 part
• From before to backward- rostrum, genu, body, splenium

Rostrum
• It is directed downward and backward from genu
• Fiber passing from this part connect orbital surface of two frontal lobes.

Genu
• It is thick and curved part.
• Fiber of genu connecting anterior parts of frontal lobes It forms fork like
structure known as forceps minor.

Body/trunk
• It is main part of corpus calloosum
• It lies between genu and splenium
• Fibers of the body connect most of the frontal lobe and anterior part of partial
lobe of two hemisphers.

Splenium
 It is most posterior part of corpus callosum.
 Fibers of splenium connect posterior part of parietal lobes, temporal and
occipital lobes of two hemisphere
 Fibers connecting two occipital lobes forming a fork like structure called as
forceps major
Function of corpus callosum

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 It is responsible for transmission of information between two cerebral

hemispheres Applied
Split-brain syndrome
• If the corpus callosume is congenitally absent or surgically sectioned
• Then the person has two separate hemispheres this condition is known as split
brain syndrome.
• In this case person learns to perfume task with one hand he is unable to repeat
it with other hand

BLOOD SUPPLY TO BRAIN

Brain is supply by two systems of artery

1. Vertebral system having two vertebral artery
2. Carotid system having two internal carotid artery
 These arteries of brain get interconnected and form circle of willis  It is the
base of brain around interpeduncular fossa.

Circle of willis is formed:

 Anteriorly -by anterior communicating artery and anterior cerebral arteries
 Posteriorly -by basilar artery dividing into two posterior cerebral artery
 Latterly on each side- by posterior communicating artery which is connecting
internal carotid artery with posterior cerebral artery.

Functional significance of circle of willis

Normally there is little or no mixing of blood stream of
1. Two vertebral artery in basilar arteries
2. Two anterior cerebral artery in anterior communicating arteries
3. Internal carotid and posterior cerebral arteries.
 Therefore, right half of brain is supplied by right vertebral and right internal
carotid artery.

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 And left half of brain is supplied by left vertebral and left internal carotid
arteries
 If one of the major arteries of circle of willis is blocked, connection provide
collateral circulation.

Applied

Aneurysms
 Abnormal dilation of arteries is known as aneurysms
 It occur mostly as sites where arteries join with each other
 In brain arteries it’s common. It’s berry shaped so named as berry aneurysms

Subarachnoid haemorrhage
 If the artery rupture, it produces haemorrhage in Subarachnoid space  it
produce severe pain in head and mental confusion

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BREAST
Breast or mammary gland
 The breast lies in the superficial fascia of the pectoral region Extent
 Vertically extends from the second to sixth rib
 Horizontally it extends from lateral border of sternum to the mid axillary line

Skin covers the gland

Conical projection on skin called Nipple

Skin surrounding base of nipple is pigmented forms a circular area called the areola
 This region is rich in modified sebaceous glands

Breast parenchyma
 having tubule-alveolar arrangement. It secretes milk.
 It consist of 15 to 20 lobes
 Each lobe having alveoli which are drained by lactiferous duct  Lactiferous
ducts open into nipple

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Stroma
 It is partly fibrous and partly fatty
 Fibrous part is formed by septa known as suspensory ligaments which connects
skin with pectoral fascia
 Fatty part forms bulk of the gland

Blood supply
 By internal thoracic artery
 Lateral thoracic, superior thoracic artery and branch from posterior intercostal
arteries.

LYMPHATIC DRAINAGE OF BREAST

 By lymph nodes and the lymphatics

Lymph nodes
There are mainly three groups of lymph nodes
The axillary group of lymph nodes
 anterior
 posterior,
 lateral,
 central,
 and apical groups
Internal mammary group of lymph nodes
Supra clavicular group, Posterior intercostal group of lymph nodes

Lymphatic vessels
 The superficial lymphatics
Which drain the skin over the breast except nipple and areola

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Deep lymphatics
 Drain the parenchyma of the breast. also nipple and areola

 About 75% of lymph goes to axillary nodes

 20% to internal mammary group of lymph nodes
 5% into postrior intercostal nodes

Lymph from
 Anterior and posterior group goes into central and lateral groups
 From here it goes to apical group
 And finally to supra clavicular nodes

Clinical Of Breast
 The upper and outer quadrant of breast is a frequent site for carcinoma
 Incisions of breast are usually made radially to avoid injury to lactiferous ducts
Folding of skin
• when cancer cells infiltrate suspensory ligaments folding of skin occurs
• It leads to retraction of nipple peau d'orange appearance
• Obstruction of lymphatics produce oedema of skin and orange color changing
known as peau d'orange appearance

Spreading of cancer cells occur through lymphatics

• Cancer spread to liver

It can spread through veins also

• It spread to vertebrae and to other parts also

Self examination of breasts

• Inspect symmetry of breast and nipples

• Change in color of skin

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• Retraction of nipple is a sign of cancer

• Any discharge from nipple
• Palpate four quadrents and see for any abnormal swelling
• See for lymph node swelling

 X-Ray of breast is known as mammogram

 FNAC is safe and quick method for diagnosis of lesion of breast
 Self examination is the way for early diagnosis and treatment

CLAVIPECTORAL FASCIA

Clavipectoral fascia is a fibrous sheet situated deep to pectoralis major muscle.

Extent- Above -clavicle
Below- axillary fascia

Attachments
Medially- attached with 1st rib Laterally-
coracoids process
Above- attached with lips of subclavian groove of clavicle. Here it splits to enclose
subclavius muscle.
Below- It splits to enclose pectoralis minor muscle
It continues downward as suspensory ligament of axilla which is attached to
dome of axillary fascia. It helps to keep it pulled up.

Functional significance
 Act as a suspensory ligament of axilla to maintain its concavity.

Structures piercing clavipectoral fascia

 Lateral pectoral Nerve
 Thoracoacromial artery

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 Cephalic vein
 Deep lymphatics of breast going towards apical group of axillary lymphnodes.

AXILLA BOUNDARY AND CONTENT

It is a pyramidal space situated between the upper part of arm and the chest wall It
has
 Apex, a base, four walls - anterior, posterior, medial and lateral
Apex
It is directed upwards towards the root of neck
It's not pointed.It's a triangular interval Bounded
by
 Anteriorly by clavicle
 Posteriorly by scapula
 Medially by a rib

Base
It's directed downwards
 Formed by skin, superficial and axillary fascia

Anterior wall
 Pectoralis major
 Clavipectoral fascia
 Pectoralis minor

Posterior wall
 Subscapularis
 Teres major
 Latissmus dorsi

Medial wall
 Upper four ribs with their intercostal muscles

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 Serratus anterior muscle

Lateral wall
It is very narrow. Anterior and posterior walls converge on it
It is formed by
 Bicipital groove, upper part of shaft of humerus

Contents of axilla
 Axillary artery and its branches
• Axillary vein and its tributaries
• Part of brachial plexus
• Axillary lymph nodes
• Fat and areolar tissue

AXILLARY ARTERY

It is the continuation of subclavian artery

Extends
• From outer border of the first rib To lower border of teres major

Pectoralis minor muscle cross the artery and divides it into three parts
• First part superior to the muscle
• Second part posterior to muscle
• Third part inferior to muscle

RELATION OF AXILLARY ARTERY WITH BRACHIAL PLEXUS

First part
Anterior-lateral pectoral nerve and loop of communication between lateral and
medial pectoral nerve

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Posterior- Medial cord with medial pectoral nerve

Lateral- lateral and posterior cord
Second part

• Posterior- Posterior cord

• Lateral- Lateral cord
• Medial- Medial cord

Third part
Posterior – Radial nerve and axilary nerve
Lateral- lateral root of median nerve and musculocutenious nerve
Medialy-medial cutaneous nerve of arm and medial cutaneous nerve of fore arm

ERB’S PALSY

Site of injury- Erb’s point

6 nerves meet here it is situated in upper trunk of the brachial plexus

Cause of injury damage at shoulder due to

• Birth injury
• Fall on the shoulder
• Anesthesia
Nerve root involved - mainly c5 and partly c6
Muscle paralysed-
Mainly
• biceps brachi

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•
deltoid,
• brachialis,
• brachioradialis
Partly - supra spinatus and supinator

Deformity-
• Arm is adducted and medially rotated
• Forearm is extended and pronated

Disability
 Abduction and lateral rotation of the arm is lost
 Flaxion and supination of forearm is lost
 Biceps and supinator jerks lost

KLUMPKE’S PARALYSIS-

Site of injury- lower trunk of brachial plexus

Nerve root involved - mainly T1 and partly C8
Muscles paralysed
 Intrinsic muscles of hand
 Ulner flaxors of wrist and finger Deformity
 Claw hand
 In claw hand there is hyperextansion at metacarpo phalangeal joints and
flexion at inter phalangeal jonts

Disability
• Complete claw hand
• Cutenious sensation loss over ulner border of fore arm and hand
• Horner’s syndrome o Ptosis, miosis, anhydrosis, enopthalmos

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•
Vasomotor changes
• Skin becomes warm due to arterio dilatation
Skin becomes dry due to loss of sweating which occurs due to loss of
sympathetic activity

Trophic changes
• Long duration paralysis Lead to dry and scaly skin
• Nails crack easily

DELTOID MUSCLE

Origin

• Anterior border of lateral one third of clavicle

• Lateral border of acromian process
• Lower lip of spine of scpula Insertion
• Deltoid tuberosity of humerus Nerve supply
• Axillary nerve Action
• Multipinnate acromial fibers are powerful abductor of the arm at sholder joint
up to ninty degree
• Anterior fibers are flaxor and medial rotator of arm
• Posterior fiber are extensor and lateral rotators of arm

Structure under cover of deltoid

• Upper end of humerus
• Coracoids process
• Musculo tendinous cuff

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•
• Origin of bisceps choraco brachialis and triceps
• Anterior and posterior circumflex humeral artery

Clinical anatomy
• Intramuscular injection often given in deltoid
Axilary nerve may get demaged due to dislocation of sholder joint or fracture
at surgical neck of humerus then deltoid is paralysed and actions of deltoid
lost

MUSCULO TENDINOUS CUFF(ROTATORY CUFF)

It is a fibrous sheeth formed by the tendons crossing shoulder joint

This tendons while crossing shoulder joint flattend and join with each other and also
with joint capsule
Muscles which form rotator cuff are
• Subscapularis
• Supraspinatus
• Infraspinatus
• Teres minor
This muscle are originated from scapula
Inserted on humerus

Cuff gives strength to the capsule of the shoulder all around except inferiorly That’s
why dislocation of humerus most commonly occurs in downward direction.

BICEPS BRACHI MUSCLE

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•
It is the muscle of anterior compartment of arm
Origin
• Short head from coracoids process along with coraco brachialis
• Long head from supra glinoid tubercle
Incertion
• Redial tuberosity-posterior rough part
• And bicipital aponeurosis whitch is extenson of tendon extend to ulna and
separates median cubital vain from brachial artery

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Nerve supply
• Musculo cutaneous nerve Action
 It is stong supinator of fore arm
 Flexion of elbow
 Short head- is a flexor of arm
 Long head-prevents upward displacements of humerus
Applied
In erb’s palsy damage occurs at erb’s point and biceps muscle is affected So
flaxion and supination of fore arm is affected.

ANASTOMOSIS AROUND THE ELBOW JOINT

Anastomosis around elbow joint links brachial artery with upper end of radial
and ulnar artery

In front of the lateral epicondyle of the humerus

 Anterior descending artery (branch of profunda brachii artery) With
radial recurrent artery(branch of radial artery)

behind lateral epicondyle of the humerus

 posterior descending artery (branch of profunda brachii artery) with
interosseous recurrent artery (branch of posterior interosseous artery )

infront of medial epicondyle of humerus

 inferior ulnar collateral artery (branch of brachial artery) with
anterior ulnar recurrent artery (branch of ulnar artery)

behind medial epicondyle of humerus

 superior ulnar collateral artery (branch of brachial artery) with
posterior ulnar recurrent artery (branch of ulnar artery)

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CUBITAL FOSSA
it is triangular fossa situated on the front of elbow boundaries
 laterally- brachioradialis  medially- pronator teres
 base- by an imaginary line joining epicondyles of humerus  apex-
formed by meeting point of lateral and medial boundries.
 Roof- skin, superficial fascia, deep fascia and bicipital aponeurosis
 Floor by brachialis and supinator
Contents
From medial to lateral side
MBBS
• Median nerve
• Brachial artery
• Biceps brachii tendon
• Superficial branch of radial nerve
Clinical anatomy
Median cubital vein is used for intravenous injection
Blood pressure is recorded by auscultating brachial artery

BRACHIORADIALIS MUSCLE

It is the muscle of forearm

Origin-
 from lateral supracondylar ridge of humerus Insertion-
 styloid process of radius Nerve supply
 Radial nerve
Action
 Flexion of forearm at elbow joint
 Rotate forearm to midprone position from supine or prone position

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CARPAL TUNNEL SYNDROME

It is caused by compression of median nerve in the carpel tunnel In
this syndrome
Motor, sensory, vasomotor and trophic changes occur

Motor changes
• Wasting of thener eminence
• Ape like thumb deformity
• Loss of opposition of thumb
• Partial clawing due to paralysis of 1st and 2nd lumbricles Sensory
changes
• Loss of sensations from lateral 3 and half digits
Vasomotor changes
• Skin becomes warm due to arteriodilatation
• Skin becomes dry due to loss of sweating which occurs due to loss of
sympathetic activity

Trophic changes
• Long duration paralysis Lead to dry and scaly skin
• Nails crack easily

It occurs both in males and females between age of 25 and 70

• Main complain is pain
• It occurs intermittently over the distribution of median nerve
• Frequently occurs at night
• It is more common due to excessive working on computer

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ULNAR NERVE IN HAND

Ulnar Nerve is the Main Nerve In the hand

Course
• It passes from superficial to the flexor retinaculum
• It ends by dividing into superficial and deep branch
Relations
At wrist- superficial to flexor retinaculum
It is in relation to ulnar vessels Here
it decides into two branch

Branches and supply

Superficial branch Supply
 Muscle- Palmaris brevis
 Cutaneous supply to medial one and half fingers

Deep branch supply

Muscles
 Hypothener muscles
 Flexor digiti minimi
 Abductor digiti minimi
 Opponens digiti minimi

 4 Palmer interrossei
 4 dorsal interrossei
 3 and 4th lumbricals  Adductor pollicis Applied anatomy
Ulnar nerve lesion at the wrist joint
 It produce ulnar nerve claw hand

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 Hyperextention at the metacarpophalangeal joints and flexion at interphalangeal

joint
 Involving little and ring finger

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 Intermetacarpel space increased due to wasting of introsserous muscles

At wrist joint injury profundus muscle is not paralyzed so flexion at terminal

phalanges occur more
Sensory changes
 Sensory loss of medial one third of Palm
 medial one and half finger
 Medial half of dorsum of hand Vasomotor changes
• Skin becomes warm due to arteriodilatation
• Skin becomes dry due to loss of sweating which occurs due to loss of
sympathetic activity

Trophic changes
• Long duration paralysis Lead to dry and scaly skin
• Nails crack easily

Disability
 Person is unable to spread out fingers due to paralysis of dorsal interrossei
 Addction of thumb is lost
 Movement of ring and little fingers affected

FIRST CARPO METACARPAL JOINT

It is the carpometacarpal joint having separate joint cavity Type

 Its saddle variety of synovial joint Articular surface
 The distal surface of trapezium
 Proximal surface of the first metacarpal bone
Ligaments

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Capsular ligament – It surrounds the joint

Lateral ligament - strengthens the capsule from lateral side
Anterior ligament
Posterior ligament

Relations Blood supply

Anteriorly - muscles of thener eminence • Radial vessels Nerve
Posteriorly – extensors of thumb supply
Medially – first dorsal interossie muscle • Median nerve supplies
Laterally- tendon of abductor pollicis longus the capsule of the joint

Movements
Flexion- flexor pollicis bravis
Opponens polices
Extension – Extensor pollicis brevis
Extensor pollicis longus
Opposition – Opponens polices
Flexor pollicis bravis
Abduction – Abductor pollicis brevis
Abductor pollicis longus
Adduction – Adductor pollicis

Applied

First carpo metacarpal joint can undergo degenerative changes with age
 It produces pain at the base of the thumb

SUPINATION AND PRONATION

Supination and pronation are rotators movements of the forearm/hand

 In semiflexed elbow, the palm is turned upwards is supination And
downwards is pronation

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In anatomical position palm is facing forward is supination and facing backward

is pronation

Joints involved in this movement is

 Superior and inferior radio-ulnar joint
Supination
 It is more powerful than pronation because it is antigravity movement
 It is responsible for screwing movement of hand
 It is done by supinator muscle and biceps brachi muscle
 During supination radius and ulna are parallel to each other
Pronation
 In semiflexed elbow palm facing downwards is pronation.  It is towards
gravity
 It is mainly done by pronator quadratus
 Also by pronator teres
 During pronation radius cross over the ulna

Clinical anatomy
Synostosis
 When upper end of radius and ulna fused known as synostosis 
In this condition pronation is not possible

SUPERFICIAL PALMER ARCH

Superficial and deep Palmer arch represents the anastomosis between the ulnar
and radial artery Formation
 Superficial Palmer arch is formed as the direct continuation of the ulnar artery

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 The arch is completed by superficial Palmer branch of radial artery

Relations
• It lies deep to palmaris Bravis and Palmer aponeurosis
• It lies superficial to flexor tendons of the fingers and lumbricals Branches
• Three common digital and one proper digital branch Supplying medial 3 and
half fingers o Digital arteries are joined with deep Palmer arch by Palmer
metacarpal arteries

DEEP PALMER ARCH

It is connecting the radial artery and ulnar artery

Formation
 It is formed by the terminal part of radial artery
 And completed medially by deep branch of ulnar artery Relations
 It lies deep to flexor tendons of fingers and lumbricals.  It lies on the
metacarpals and interrossei. Branches
 Three Palmer metacarpal arteries which join with common digital branches of
superficial Palmer arch
 Three perforating digital arteries
 Recurrent branches for supplying carpal bones and joints

FLEXOR RETINACULUM

It is the strong fibrous bend which is present at flexor aspect of wrist and carpal
bones
 It converts anterior concavity of carpal bones into a tunnel

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Attachments
Medially - Pisiform bone and Hook of hamate
Laterally- Scaphoid and Trapezium

Retinaculum having slip

Lateral deep slip - Form a tunnel from which tendon of flexor Carpi radialis pass
Medial superficial slip - Ulnar vessels and nerve pass deep to the slip

Relations
Structure passing superficial to flexor retinaculum
 Palmaris longus tendon
 Palmer cutaneous branch of the median nerve
 Palmer cutaneous branch of ulnar nerve
 Ulnar vessels and nerve

Structure passing deep to the flexor retinaculum

 Median nerve
 Four tendons of flexor digitorum superficialis
 Four tendons of flexor digitorum profundus
 Tendon of flexor pollicis longus
 Ulnar bursa
 Radial bursa
 Tendon of flexor Carpi radialis

EXTENSOR RETINACULUM

Deep fascia on the back of wrist is thickened to form Extensor retinaculum 

It is oblique band. It is directed downwards and medially

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Attachments
Laterally - lower part of radius
Medially- styloid process of ulna, Triquetral and pisiform bone

The retinaculum sends septa which are attached on the posterior surface of radius So
six compartments are formed
Content
1st Abductor pollicis longus
Extensor pollicis brevis

2nd Extensor Carpi radialis longus

Extensor Carpi radialis brevis

3rd Extensor pollicis longus

4th Extensor digitorum

Extensor indicis
Posterior interosseous nerve
Anterior interosseous artery

5th Extensor digiti minimi

6th Extensor Carpi ulnaris

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THE INFERIOR APERTURE/OUTLET OF THE THORAX/

DIAPHRAM

It separate thorax from abdominal cavity. That is diaphragm.

Boundaries
Anteriorly: Infrasternal angle Posteriorly:
Twelfth thorasic vertebra.
On each side: Seventh to twelfth ribs.
Structures passing through the diaphragm

There are three large, and several small, openings part of the diaphragm.

Large opening in the diaphragm.

 T8 level Vena caval opening o

Inferior vena cava o Branch of
right phrenic Nerve

 T10 level Oesophageal opening o

Oesophagous o Vagus nerve
o Oesophageal branch of left gastric artery with some oesophageal veins

 T12 level Aortic opening o Aorta o

Thorasic duct o
Azygous vein

Small Openings in the Diaphragm

medial lumbocostal arch.

• The sympathetic chain passes from the thorax to the abdomen behind the medial
arcuate ligament also called the medial lumbocostal arch.

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lateral lumbocostal arch

• The subcostal nerve and vessels pass behind the lateral arcuate ligament or
lateral lumbocostal arch.

foramen of Morgagni
 The gap between the xiphoid, 7thcostal cartilage and origins of the diaphragm is
foramen of morgagni.
The superior epigastric vessels and lymphatics passes through it.

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RESPIRATORY MOVEMENTS

The lungs expand passively during inspiration and

retract during expiration. Principles of Movements

pump-handle movements.
 The anterior end of the rib is lower than the
posterior end.
 Therefore, during elevation of the rib, the
anterior end also moves forwards.
 In this way, the anteroposterior diameter of
the thorax is increased.
 Along with the up and down movements of the
ribs, the body of the sternum also moves up and Pump handle movement
down called pump-handle movement.
 It is brought about by elevation of the second to sixth ribs. Partly by elevation
of the seventh to tenth ribs

'bucket-handle' movements
 The middle of the shaft of the rib lies at a lower level than the plane passing
through the anterior and posterior end of the ribs.
 Therefore, during elevation of the rib, the shaft moves outwards.
 This causes increase in the transverse diameter of the thorax called
'bucket-handle' movements .
 Mainly by the seventh to tenth ribs Partly by elevation of the second to sixth
The vertical diameter is increased
It is done by downward movement of the diaphragm.

Clinical Anatomy
Dyspnoea means Difficulty in breathing
 the patients are most comfortable on sitting position.
The diaphragm is lowest while sitting.

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The patient is quite comfortable as the effort required for inspiration is the least
INTER COSTAL SPACE

The gap between the ribs is called intercostals space.

 They are filled by the intercostal muscles and contain the intercostal
nerves, vessels and lymphatics.

Intercostal Muscles-

• External intercostal muscle,

• Internal intercostal muscle, and
• Transversus thoracis muscle
• Transversus thoracis is divisible into three parts o Subcostalis o Intercostalis
intimi o Sternocostalis.

Direction of Fibres

IN THE ANTERIOR PART OF THE INTERCOSTAL SPACE:

1.The fibres of the external intercostal
muscle Run downwards, forwards and
medially

2.The fibres of the internal intercostal run

downwards, backwards and laterally, at right
angle to the external intercostal.

3.The fibres of the transversus thoracis run

in same direction as those of the internal
intercostal

Nerve Supply
intercostal muscles are supplied by the intercostals nerves of the spaces in which
they lie.

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Actions of the Intercostal Muscles

 The main action of the intercostal muscles is to prevent retraction or
bulging of the intercostal spaces
Intercostal Nerves

• The intercostal nerves are the anterior primary rami of thoracic 1 to 11

spinal nerves.

• The anterior primary ramus of the 12th thoracic nerve forms the subcostal
nerve.

The relationship of structures in the costal groove from above downwards is

veinartery-nerve (VAN)

Intrercostal Arteries

 Each intercostal space contains one posterior inter-costal artery with its
collateral branch and two anterior intercostals arteries.
 Greater part of the space is supplied by posterior intercostal artery.
 They are 11 posterior intercostal artery in number on each side. One in each
space.
Intercostal Veins

 There are two anterior intercostal veins in each of the upper nine spaces.
 There is one posterior intercostal vein and one collateral vein in each
intercostal space.
Each vein accompanies the corresponding artery and lies superior to the artery.

Lymphatics of an Intercostal Space

 Lymphatics from the anterior part of the spaces pass to the anterior intercostal
or internal mammary lodes.
 Lymphatics from the posterior part of the space pass to the posterior
intercostal nodes.

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THE AZYGOS VEIN

It forms an important channel connecting the superior and inferior venae cavae. The
term 'azygos' means unpaired.
Formation
The azygos vein is formed by union of
The lumbar azygos, Right subcostal and Right ascending lumbar veins.

 Occasionally the lumbar azygos vein is absent. Course

ℎℎ
𝑇ℎ ℎ ℎℎ
.
ℎ ℎ
𝑇ℎ ℎ ℎℎ
𝑉

𝐼 ℎ ℎ ℎ
ℎ .

𝐼 ℎ ℎ .

Relations.
Posteriorly: Lower eight thoracic vertebrae To
the right: Right lung and pleura To the left:
 Thoracic duct and aorta in lower part.
 Oesophagus and trachea in the upper
part.

Tributaries
 Right superior intercostal vein

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 Fifth to eleventh right posterior intercostal veins

 Hemiazygos vein
 Accessory hemiazygos vein

CLINICAL ANATOMY
 In superior vena caval obstruction, azygos vein is main channel which transmits
the blood from the upper half of the body to to the inferior vena cava.

PLEURA AND ITS APPLIED

Pleura is a serous membrane.

It has two layers.
 Outer layer is the parietal pleura.
 Inner layer is visceral pleura
The two layers are continuous with each other around the hilum of the lung.

There is a potential space between two layers known as the pleural cavity

visceral pleura
 visceral pleura covers the surface of the lung, except at the hilum.
 Along the attachment of the pulmonary ligament where it is continuous with
the parietal pleura.
 It is firmly adherent to the lung and cannot be separated from it.

The Parietal Pleura

The parietal pleura is thicker than the visceral pleura, It
is subdivided into four parts:
 costal,
 diaphragmatic,
 mediastinal, and
 cervical

The costal pleura lines the thoracic wall related to ribs and intercostal spaces.

The mediastinal pleura lines the mediastinal surface of lung

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 It is reflected over the Hilum and becomes continuous with the visceral pleura
around the hilum.

The cervical pleura extends into the neck, above the first costal cartilage and clavicle.
 It covers the apex of the lung.

Diaphragmatic pleura lines the superior aspect of diaphragm.

 It covers the base of the lung. It is continuous with mediastinal pleura medially
and costal pleura laterally.
The Pulmonary Ligament
The parietal pleura surrounding the root of the lung extends downwards beyond the
root as a fold called the pulmonary ligament.

It provides a dead space into which the ulmonary veins can expand during increased
venous return as in exercise.

RECESSES OF PLEURA

There are two folds of recesses of parietal plura.

Costomediastinal recess-
 It is between the costal and mediastinal plura.
 It lies behind the sternum and costal cartilages.
This recess is filled up by the anterior margin of lungs. It
is filled up during quite breathing also.

Costodiaphragmatic recess-
 It lies between the costal and diaphragmatic Plura.
Vertically it measures about 5 cm.
 It extends from eighth to tenth ribs along mid axillary line.

 These recesses act as a reserve spaces for the lung to Expand during deep
inspiration.
So they are well defined in expiration and not in deep inspiration.

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Nerve Supply of the Pleura

Parital plura.
 Intercostal and phrenic nerves supply parital plura.
 The parietal pleura is pain sensitive.

Viceral Pleura
 It is upplied by autonomic nerves.
 The sympathetic nerves from 2nd to 5th spinal Segments.
 Parasympathetic nerves from the vagus nerve.
 This part of the pleura is not sensitive to pain.

Blood Supply and Lymphatic Drainage of the Pleura

The parietal pleura supplied by intercostal arteries.

The veins drain mostly into the azygos and internal thoracic veins.
The lymphatics drain into the intercostals nodes.

The Viceral Pleura is supplied by the bronchial arteries

the veins drain into bronchial veins.
The lymphatics drain into bronchopulmonary lymphnodes.

CLINICAL ANATOMY OF PLEURA

Pleurisy-
This is inflammation of the pleura.

Pleurisy accompaneid by collection of fluid in the pleural cavity.

The condition is called the pleural effusion.
 It cause obliteration of costodiaphragmetic recess.

Pneumothorax. Presence of air in the pleural cavity.

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Haemothorax. Presence of blood in the pleural cavity.

Hydropneumothorax Presence of both fluid and air in the pleural cavity.

Empyema Presence of pus in the pleural cavity.

Paracentesis thoracis.
 Aspiration of fluid from the pleural cavity is called paracentesis thoracis.
 It is usually done in the eighth intercostal space in the midaxillary line.
 The needle is passed through the lower part of the space to avoid injury to
neurovascular bundle.

Reffered pain

Costal plurae Irritation cause reffered pain along thorax and Abdominal wall.

Mediastinal and diaphragmetic plura Irritation cause referred pain on the tip of
Shoulders.

ROOT OF THE LUNG

Root of the lung is a short, broad pedicle which connects the

medial surface of the lung to the mediastinum.
 It is formed by structures which either enter or come out of the lung.

Contents
The root is made up of the following structures:
 Principal bronchus on the left side, and eparterial and hyparterial
bronchi on right side.
• One pulmonary artery.

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• Two pulmonary veins, superior and

inferior.
• Bronchial arteries, one on the right
side and two on the left side.
Bronchial veins.
• Anterior and posterior pulmonary
plexuses of nerves.
• Lymphatics of the lung.
• Bronchopulmonary lymph nodes.
• Areolar tissue.

Arrangement of Structures in the Root

From before backwards. It is similar on the two sides [
VAB ]
• Superior pulmonary vein
• Pulmonary artery
• Bronchus

From above downwards. It is different on the two sides.

Right side Left side

• Pulmonary artery
• Eparterial bronchus
• Bronchus
• Pulmonary artery
• Inferior pulmonary vein
• Hyparterial bronchus

• Inferior pulmonary vein

Relations of the Root

Common on the two sides

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Anterior Superior Relation

 Phrenic nerves On Right side – Terminal part of
Posterior azygous vein
On Left side – Arch of Aorta
Vagus nerve Inferior
 Pulmonary ligament

BRONCHOPULMONARY SEGMENTS

These are well defined anatomic, functional and surgical Sectors of the lung.
 Each one of which is provided by a tertiary bronchus.

 Each segment is pyramidal in shape with its apex directed towards the root of
the lung.

 Each segment has a tertiary bronchus, Segmental artery, autonomic nerves and
lymphvessels.

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 There are 10 segments on the right side and 10 on the left side.
 Bronchopulmonary segments are independent respiratory units.

Clinical anatomy
1.Usually the infection of a segment remains restricted to bronchopulmonary
segment
But infections like tuberculosis may spread from one segment to another. Knowledge
of the bronchopulmonary segment helps in:
• Surgical removal of a segment postural drainage.
• Bronchoscopy

SINUSES OF PERICARDIUM

Transverse sinus of pericardium

The epicardium at the roots of the great vessels is arranged in form of two tubes.
• The arterial tube encloses the ascending aorta and the pulmonary trunk at the
arterial end of the heart tube

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• venous tube encloses the venae cavae and pulmonary veins at the venous end
of the heart tube.

The passage between the two tubes is known as the transverse sinus. The
transverse sinus is a horizontal gap between arterial and venous ends of the
heart tube. It is bounded
Anteriorly- ascending aorta and pulmonary trunk
Posteriorly- superior vena cava
Each side - it opens into pericardial cavity

oblique pericardial sinus

• During development As the heart increases in size and these veins separate out
• Pericardial reflection surrounds all of them and forms the oblique pericardial
sinus.
This is situated posterior to the left atrium.

The oblique sinus is a narrow gap behind the heart. It is bounded

Anteriorly - Left atrium
Posteriorly - Parietal pericardium.
On the right and left sides it is bounded by reflections of pericardium it
opens into pericardial cavity.

THE RIGHT ATRIUM

 The right atrium is the right upper chamber of the heart.

 It receives venous blood from the whole body, pumps it to the right ventricle
External Features

 The chamber receiving the superior vena cava at the upper end and the inferior
vena cava at the lower end.  right auricle.

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The upper end is prolonged to the left to form the right auricle.

sulcus terminalis

 Along the right border of the atrium there is a shallow vertical groove which
passes from the superior vena cava to the inferior vena cava.
 This groove is called the sulcus terminalis.
 It is produced by an internal muscular ridge called the crista terminalis

The upper part of the sulcus contains the sinuatrial or SA node which acts as
the pacemaker of the heart.

The right atrioventricular groove

 The right atrioventricular groove separates the right atrium from the right
ventricle
Tributaries or Inlets of the Right Atrium

 Superior vena cava,

 inferior vena cava,
 coronary sinus,
 anterior cardiac veins,
 venae cordis minimi (Thebesian veins),  sometimes the right marginal vein.

Right Atrioventricular Orifice

 Blood passes out of the right atrium through the right atrioventricular or
tricuspid orifice and goes to the right ventricle.
 The tricuspid orifice is guarded by the tricuspid valve which maintains
unidirectional flow of blood

Internal Features

• The interior of the right atrium can be broadly divided into the following three
parts.
The Smooth Posterior Part

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• Most of tributeries opens into it

• Superior vena cava, inferior venacava, coronary sinus open into it
• Intervenous tubercle of lower is small projection. During embryonic life it
directs blood from superior venacava to right ventricle.

Rough anterior part

• It is rough due to transverse muscular ridges called musculi pectinati

Interatrial Septum

• Developmentally it is derived from the septum primum and septum secundum.

• It presents the fossa ovalis and limbus fossa ovalis.

Clinical anatomy

Foramen ovale may remain open after birth leads to mixing of blood of right atrium
and left atrium.

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BLOOD SUPPLY OF HEART

Heart is supplied by two coronary arteries
They origin from aorta.

Right coronary artery

Origin- anterior aortic sulcus

Course-
• it runs forward
• Then downwards in the right coronary sulcus
• It wind rounds inferior border and reach diaphragmetic surface
• Reach up to posterior inter ventricular groove

Termination -
By anastomosing with circumflex branch of left coronary artery

Branches -
• Marginal
• Posterior interventricular branch
• nodal branch

Area of distribution
• Right atrium
• Ventricles - right ventricle except anterior inter ventricular groove
Small part of left ventricle at posterior interventricular groove
• Conducting system of heart

Left coronary artery

Origin - left posterior aortic sinus

Course -
• Runs forward

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• Gives anterior interventricular branch

• Then runs into left anterior coronary sulcus
• Winds round left border of the heart And now known As circumflex artery
Reach posterior inter ventricular groove.
Terminaton - Anstomose with right coronary artery

Branches-
• anterior inter ventricular branch
• Diagonal branch
• Left atrial branch

Area of distribution
 Left atrium
 Ventricles-
 Greatrt part of left ventricle except posterior interventricular groove
 Small part of right ventricle at anterior interventricular groove
 Anterior part of interventricular septum

Clinical anatomy

Thrombosis of coronary artery

 Formation of thrombus in coronary artery leads to shortening of lumen of artery
 And blood supply to heart is decreased and results in myocardial infaction
 Sever pain over chest occurs

Incomplete obstruction leads to spasm of artery

 And reaults in angina pectoris
 That pain radiates towards medial side of the left arm forearm.

Coronary angiography
 Is done to diagnose occlusion of coronary arteries

Angioplasty

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 Is done to remove small obstruction in coronary arteries

 In this procedure small stent is used
 Or balloon is inflated at obstructed site

Bypass surgery
 Is done if blockage is at multiple sites
 In this procedure great saphenous vein or internal thorasic artery is used as graft

ARCH OF AORTA
Aorta is the great arterial trunk receives oxygenated blood from the left ventricle
and distributes it to all parts of the body

It is studied in the following three parts

 Ascending aorta
 Arch of aorta
 Descending aorta Arch of aorta
 Arch of aorta is the continuation of the ascending aorta
 It is situated in the superior mediastinum Course
• It begins at the level of sternal angle behind second right sternochondral
joint
• It runs upward, backward and to the left side
• It arches over the left root of lung
• It ends at the lower border of the fourth thoracic vertebrae by becoming
continuous as the descending aorta
• Thus it starts anteriorly and ends posteriorly at same level.

Relations

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Superiority Posteriorly
Three branches of the aorta
• Trachea
• Brachiocephalic artery
• Oesophagus
• Left common carotid artery
• Vertebral column
• Left subclavian artery Anteriorly
• Left phrenic and left
Inferiority
Vegas nerve
• Bifurcation of pulmonary trunk
• Left pleura and left lung
• Left Recurrent Laryngeal Nerve

Branches

1. Brachiocephalic artery which decides into the right common carotid artery and right
subclavian artery
2. Left common carotid artery
3. left subclavian artery

Clinical anatomy

Aortic knuckle - it is the shadow of aorta in the PA view of x-Ray of chest.

Coarctation of aorta - Narrowing of aorta
• It occurs mainly just beyond the attachment of ductus arteriosus. Aortic
aneurism- It is the abnormal dilatation of aorta
• It compress surrounding structures

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THORACIC DUCT
It is the largest lymphatic of the body
It is about 45 cm long. It had beaded appearance Course
• It is a continuation of the cisterns Chyli
• It starts at the level of twelfth thoracic vertebra and enters the thorax from aortic
opening of the diaphragm
• Ascends from posterior mediastinum
• Crossing from right to left side at the level of fifth thoracic vertebrae Further
ascends
• Reaches neck up to level of 7 th cervical vertebrae
• Descends and finally
• Ends by opening into the angle between the left subclavian and left internal
jugular veins

Relations

At the aortic opening of the diaphragm

Anteriorly - diaphragm
Posteriorly- vertebral column
To the right- azygous vein
To the left- aorta

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Tributaries

• It receives the lymph from Both the half of body below diaphragm and left half
above the diaphragm
At the ending part it receives lymph from
• Left jugular lymph trunk
• Left subclavian lymph trunk
• Left bronchi mediastinal lymph trunk

Abdomen
What is abdomen?

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It is the lower part of trunk and lies below the diaphram

It is devided by a plane of the pelvic inlet
 larger upper part abdomen proper
 smaller lower part true or lesser pelvis
Abdomen and pelvis form the biggest cavity in the body

Boundaries of abdomen

Roof-
 Undersurface of diaphram
Floor-
 Pelvic diaphram mainly Anterior wall-
 It is musculo-fibrous and formed by muscles and their apponeurosis
Posterior wall-
 Osseo-musculofascial and rigid

ANTERIOR ABDOMINAL WALL

it is covering the abdominal cavity anteriorly
it is made up of six layers
1. skin
2. superficial fascia
3. muscles
4.continuous layer of fascia
5.extraperitoneal connective tissue
6. the peritoneum it includes both the front as well as side walls of the abdomen
so called anterolateral abdominal wall

Abdominal Skin
skin the outermost layer

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 it is capable of undergoing enormous stretching

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UMBILICUS
Normal scar formed by remanants of the root of the umbilical cord
 position- variable
 in healthy adult it lies in the antriormedin plane at the level b/w 3 & 4 th lumbar
vertebrae Water Shed Line
 venous blood and lymph which are above the plane goes upwards down the
plane go downwards
they do not cross normally. That line passing from umbilicus is water
shed line

 But in some abnormalities its open up and dilated veins seen radiating from the
umbilicus known as caput medusae
 Dilated veins normally do not break water shed line

 Embryological importance of umbilicus-

Meeting point of three system digestive, excretory and vascular system

LINEA ALBA

 It is a Tendinous Raphe

 Extending from xiphoid process to the pubic symphysis

 Formed by crossing the apponeurosis of two sides muscle

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 Apponeurosis of each muscle made up of two laminae

 Superficial and deep laminae- this lamina interdigitate in a manner that superficial
lamina of one side continuouse with deep lamina of other side.

RECTUS ABDOMINIS MUSCLE

Origin- Two tendinous head

 Lateral head from the pubic crest lateral part

 Medial head from anterior pubic ligament

Direction- fibres run vertically upwards
Insertion-

 Lateral to xiphoid process on 7,6 and

5 th costal cartilage
Nerve supply –

 Lower six or seven thorasic nerves

Points to remember about RAM

 Muscle is enclosed in a sheath which is known as rectus sheath
Tendinous insertion-

 There are three transeverse bands

 1st opposite to umbilicus
 2nd free end of xiphoid process
 3rd between 1st and 2nd

Action of muscle of anterior abdominal wall

 Support of abdominal viscera-  Expulsive act-
 like micturation, defecation parturation, vomiting
 Forcefull expiratory act-

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 mainly external oblique which is useful for coughing, sneezing, shouting.

 Movement of the trunk-
 Flexion of the trunk- mainly by RA
 Lateral flexion- same side of IO and EO
 Rotation of the trunksame side EO and opp IO

RECTUS SHEATH
 This the aponeurotic sheath covering the rectus abdominis
 Having two walls-
 Anterior
 It’s a complete.covering muscle from end to end
 Posterior
 Its incomplete. Deficient above the costal margin and below the
arcuate line Above the costal margin
 Anterior – external oblique
aponeurosis

 Posterior- deficient

 It directly rest on 5th, 6th and 7th costal cartilage

Between costal margin and arcuate line

Anteriorly-

 External oblique aponeurosis

 Anterior lamina of the aponeurosis

of the internal oblique
Posterior wall

 Posterior lamina of the aponeurosis of the internal oblique

 Aponeurosis of the transverse muscle

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Below the arcuate line

 Anterior wall

 Aponeurosis of all the three

muscles of abdomen 

Posterior wall

 Deficient

 Directly rest on fascia transversalis

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Content of rectus sheath

Muscle- rectus abdominis main

 Pyramidalis lies infront of lower part of rectus
abdominis
Arteries
 Superior epigestric artery
 Inferior epigestric artery
Veins
 Superior epigestric vena comitantes
 Inferior epigestric vena comitantes Nerve
 Lower six thorasic nerves Function of rectus
sheath
 It checks the bowing of the rectus Abdominis muscle during contraction 

It maintains the strength of anterior abdominal wall

INGUINAL CANAL

Definition

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 Inguinal canal is an oblique passage in the lower part of the anterior

abdominal wall. It is situated just above the medial half of the inguinal
ligament.

Length and direction:

 It is about 4 cm (1.5 inches) long.
 It is directed downwards, forwards and medially.
Extention
 It extends from the deep inguinal ring to the superficial inguinal ring.

The deep inguinal ringis an oval opening in the fascia transversalis.

The superficial inguinal ring is a triangular gap in the external oblique

aponeurosis.
Boundaries anterior
wall
In its whole extent:  Skin
 superficial fascia
 external oblique aponeurosis.
posterior wall
In its whole extent:
 fascia transversalis
 extraperitoneal tissue  parietal
peritoneum.

In its medial two-thirds

 conjoint tendon

Roof - internal oblique and transversus abdominis muscles

Floor - inguinal ligament

Sex Difference

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 The inguinal canal is larger in males than in females.

STRUCTURES PASSING THROUGH THE INGUINAL CANAL

 Spermatic cord in males,

 Round ligament of the uterus in females,
They Enters the inguinal canal through the
deep inguinal ring and passes out through
the superficial inguinal ring.

 The ilioinguinal nerve

Contents of the Spermatic Cord

These are as follows.
(1) The ductus deferens

(2) Arteries
 The testicular arteries
 cremasteric arteries
 the artery of the ductus deferens.

(3) veins.
 The pampiniform plexus of veins.

(4) Lymph
 lymph vessels from the testis.

(5) Nerve
 Genital branch of the genitofemoral nerve
 Plexus of sympathetic nerves around the artery to the ductus deferens.

(6) Remains of the processus vaginalis.

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Coverings of Spermatic Cord
From inside to outwards, these are as follows.
1. Internal spermatic fascia
2. Cremasteric fascia
3. External spermatic fascia

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CLINICAL ANATOMY OF INGUINAL CANAL

Hernia
Hernia is abnormal protrusion of any of body contents through any of its wall Hernia
Consists of sac, contents, and coverings

 Sac is the protrusion of the peritoneum. It has neck which is narrowed part and
Body which is bigger part.
 Contents are mobile part they can be intestine or omentum or other viscera 
Covering are the layers of abdominal wall covering hernia sac.

INGUINAL HERNIA
Abnormal protrusion of abdominal contents (greater omentum and intestines) into the
inguinal canal is known as inguinal hernia.

Cause
This is more likely to occur in persons in whom intra-abdominal pressure is frequently
increased, e.g.
• chronic cough,
• by work involving frequent lifting of heavy weights

Types of Inguinal Hernia

DIRECT INGUINAL HERNIA

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When the contents of the hernia enter the inguinal canal through the posterior wall the
hernia is said to be direct Inguinal Hernia
Hesselbach's triangle which is
• A direct hernia passes through Hesselbach's
triangle bounded
The triangle is divided into medial and lateral parts medially by the lateral border
by the obliterated umbilical artery. of rectus abdominis, laterally
by the inferior epigastric artery,
• Direct hernia through the medial part known and below by the inguinal
As direct medial hernia ligament.
• Direct hernia through lateral parts of the
Triangle are referred as direct-lateral hernias

• Direct inguinal hernia occurs in old age, when the abdominal muscles become
weak.
• It is frequently bilateral and incomplete

INDIRECT INGUINAL HERNIAS

When the contents of the hernia enter the inguinal canal by passing through the deep
inguinal ring the hernia is said to be indirect inguinal hernia.

• Indirect inguinal hernias may be congenital.

• It may occur in the young through areas of congenital weakness produced by
descent of the testis.

Processusvaginalis
During the descent of the testis, a pouch of peritoneum descends
through the inguinal canal into the scrotum is the
processusvaginalis.

Abnormal persistence of the processus is causative factor in the production of inguinal

hernias and hydrocele.

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Congenital hernia : The entire processusvaginalis remains patent and the contents of
the hernia pass through it into the scrotum.

Complications of Hernia
Irreducibility- When Hernia content do not go back and produce persistent swelling
considered as irreducible hernia

Obstruction- Loop Get narrowed so content of the loop cannot move leading to
obstruction. But blood supply is intact.

Strangulation-
When arterial supply of hernia content also gets blocked the loop get necrosed called
as strangulation.

EPIPLOIC FORAMEN/FORAMEN OF WINSLOW

This is a vertical slit-like opening through which the lesser sac communicates with
the greater sac.

The foramen is situated behind the right free margin of the lesser omentum at the
level of the 12th thoracic vertebra.
Boundaries
Anteriorly: Right free margin of the lesser
Omentum containing the portal vein, the
hepatic artery, and the bile duct

Posteriorly: The inferior vena cava, the

right suprarenal gland and T12 vertebra.

Superiorly :Caudate process of the liver.

Inferiorly :First part of the duodenum and
thehorizontal part of the hepatic artery

Clinical Anatomy-Internal hernia into the lesser sac can result through this foramen

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RECTOUTERINE POUCH

CLINICAL ANATOMY

 The floor of the pouch is 5.5 cm from the anus.

 It can be easily felt with a finger passed through the rectum or the vagina.
 It is the most dependent part of theperitoneal cavity, pus tends to collect here.
 The pouch can be drained either through the rectum or through the posterior
fornix of the vagina.

THE STOMACH

Definition

• The stomach is a muscular bag forming the widest and most distensible part
of the digestive tube.
Extent-
It is connected above to the lower end of the oesophagus,
andbelow to the duodenum. Location

• The stomach lies obliquely in the upper and left part of the abdomen It is
occupying the epigastric, umbilical and left hypochondriac regions. • Most
of it lies under cover of the left costal margin and the ribs

Shape and Position

• When empty, the stomach is somewhat J-shaped (vertical);

whenpartially distended, it becomes pyriform in shape.

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• In obese persons, it is more horizontal.

The shape of the stomach can be studied in the living by radiographic examination after
giving a barium meal.

Size

• It is about 25 cm. Long.

• the mean capacity is 30 ml at birth, 1 litre at puberty, and 1.5 to 2 litres or
more in adults.

External Features
The stomach has
• 2 orifices or openings,
• 2 curvatures or borders,
• 2 surfaces

Two Orifices
The cardiac orifice
It is joined by the lower end of the oesophagus.
The pyloric orifice
It opens into the duodenum.
Two Curvatures
• The lesser curvature is concave and forms the right border of the stomach.
• It provides attachment to the lesser omentum.

• The greater curvature is convex and forms the left border of the stomach.

• It provides attachment to the greater omentum, Two Surfaces

The anterior The posterior
Two Parts Subdivided into Four
The stomach is divided into two parts.
1. Cardiac and
2. pyloric

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.
• Cardiac part is further subdivided into the fundus and body,
• Pyloric part is subdivided into the pyloric antrum and the pyloric canal.

STOMACH BED

• The posterior surface of the stomach is related to structures forming

the stomach bed.

• The structure forming stomach bed are

separated from the stomach by the
cavity of the lesser sac.

These structures are :

(1) The diaphragm;

(2) the left kidney;
(3) the left suprarenal gland;
(4) the pancreas;
(5) the transverse mesocolon;
(6) the splenic flexure of the colon; and
(7) the splenic artery

Sometimes the spleen is also included in the stomach bed.

BLOOD SUPPLY OF STOMACH

The stomach is supplied by:

(1) Left gastric artery, a branch of coeliac trunk

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(2) Right gastric artery, a branch of common hepatic

artery

(3) Right gastroepiploic artery, a branch of

Gastroduodenal artery

(4) Left gastroepiploic artery, a branch of Splenic artery

(5) 5 to 7 short gastric arteries, which are branches of

splenic artery

The veins of the stomach drain into the portal, superior mesenteric and splenic
veins.

LYMPHATIC DRAINAGE OF THE STOMACH

The stomach can be divided into four lymphatic territories The drainage
of these areas is as follows:

Area a, or pancreatico splenic area,

Upper part of left 1/3rd drains into the pancreaticosplenic nodes

 Lymph vessels from these nodes travel

Along splenic artery to reach coeliac nodes.

Area B right upper 2/3rd

• drains into the left gastric nodes.

• Lymph from these nodes drains into the coeliac nodes.

Area c lower part of left 1/3rd

• Drains into the right gastroepiploic nodes.

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• Lymph vessels arising in these nodes drain into the subpyloric nodes
• From here the lymph is drained further into the hepatic nodes And finally into
the coeliac nodes.
area d pyloric part

• drains into different directions into the pyloric, hepatic and left gastric nodes,
Lymph passes from all these nodes to the coeliac nodes.

Note that lymph from all areas of the stomach ultimately reaches the coeliac nodes.
From here it passes through the intestinal lymph trunk to reach the cisterna chyli.

Nerve Supply
The stomach is supplied by sympathetic and parasympathetic nerves.

• The sympathetic nerves are derived from thoracic six to ten segments of the
spinal cord
• The parasympathetic nerves are derived from the vagus

Clinical Anatomy Of stomach

Gastric pain
• Gastric pain is felt in the epigastrium.
• Because the stomach is supplied from segments T6 to T10 of the spinal cord.
• These segments also supply the upper part of the abdominal wall.
Peptic ulcer

• Peptic ulcer can occur in the sites which exposed to pepsin and hydrochloric acid.
• In the stomach peptic ulcer is named as Gastric ulcer

Gastric ulcer
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• Gastric ulcer occurs typically along the lesser curvature.

Gastric Carcinoma
• Gastric carcinomais common and occurs along the greater curvature.
• The lymphatic drainage of stomach assumes importance.
• Metastasis can occur through the thoracic duct to the left supraclavicular lymph
node.
• Its common in blood group A

Investigations
Chemical.
• Gastric analysis (fractional test meal) is done chiefly to estimate the gastric
acidity.
Radiological examination
by the barium meal.
Endoscopic
• It’s called gastroscopy for stomach.
• The interior of stomach can be scanned under direct vision by endoscope.

THE DUODENUM

Definition and Location

• The duodenum is the widest and

most fixed part of the small intestine.
• It extends from the pylorus to the
duodenojejunal flexure. length and
Parts Duodenum is 25 cm long.
It is divided into the following four parts.
 First or superior part, 5 cm long.

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 Second or descending part, 7.5 cm long.

 Third or horizontal part, 10 cm long.
 Fourth or ascending part, 2.5 cm long.

SECOND PART OF THE DUODENUM

Part of duodenum which begins at the superior duodenal flexure and end at the
inferior duodenal flexure.
Course
• This part is about 7.5 cm long.

Its relations are as follows.

Peritoneal Relations

• It is retroperitoneal and fixed.

• Its anterior surface is covered with
Peritoneum. Visceral Relations nd
Anterior relations of 2 part
Anteriorly :

• Right lobe of the liver;

• Transverse colon,

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• Root of the transverse

mesocolon Small intestine

Posteriorly:

• Anterior surface of the right

kidney near the medial border,
• Right renal vessels,
• Right edge of the inferior vena
cava, Right psoas major.
Medially :
nd
Posterior relations of 2 part
• Head of the pancreas
• the bile duct

Laterally:
• Right colic flexure

The interior of the second part of the duodenum shows the following special
features.

The major duodenal papilla is an elevation

The hepatopancreatic ampulla opens in it.

The minor duodenal papilla

• presents the opening of the accessory pancreatic duct.

Arterial Supply

• Upto the level of the hepatopancreatic ampulla opening, the duodenum is

supplied by the superior pancreaticoduodenal artery,
• Below opening duodenum supplied by the inferior pancreaticoduodenal artery.

Venous Drainage
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• The veins of the duodenum drain into the splenic, superior mesenteric and portal
veins.

Lymphatic Drainage

• lymph vessels from the duodenum end in the pancreaticoduodenal nodes

Nerve Supply

• Sympathetic nerves from thoracic ninth and tenth spinal segments •

parasympathetic nerves from the vagus,

Clinical anatomy
Duodenal diverticula
• They are seen along its concave border, generally at points where arteries
enter the duodenal wall.

Congenital stenosis and obstruction of the second part of the duodenum

• may occur at the site of the opening of the bile duct.
• Other causes of obstruction is an annular pancreas.
X-ray • The x-ray taken after giving a barium meal.

MECKEL'S DIVERTICULUM (DIVERTICULUM ILEI)

• Meckel's diverticulum occurs from the persistent proximal part of the

vitellointestinal duct.
• vitellointestinal duct which normally disappears during the 6th week of
intrauterine life.

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• Some points of interest about it are as follows.

1. It occurs in 2% subjects.

2. Usually it is 2 inches or 5 cm long.

3. It is situated about 2 feet or 60 cm proximal

to the ileocaecal valve.

4. Its calibre is equal to that of the ileum.

5. Its apex may be free or may be attached to

the umbilicus, to the mesentery, or to any other abdominal structure by a
fibrous hand.

CLINICAL ANATOMY
Meckel's diverticulum may cause intestinal obstruction.

VERMIFORM APPENDIX

Definition

• This is a worm-like diverticulum arising from the the caecum Dimensions

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• The length varies from 2 to 20 cm with an average

of 9 cm.
• It is longer in children than in adults.
• The diameter is about 5 mm. Positions

• The appendix lies in the right iliac fossa. Although

the base of the appendix is fixed, The tip can point
in any direction.
• The positions are compared to clock

• paracolic or 11 O'clock position.

• It may lie behind the caecum or colon, known As retrocaecal or 12 O'clock

position. This is the commonest position of the appendix, about 65%.

• The appendix may points towards the spleen. This is the splenic or 2 O'clock
position.
The appendix may lie in front of the ileum
(preileal) or behind the ileum (postileal).

• It may pointing to the sacral promontory

called promontoric or 3 O'clock position.

• It may descend into the pelvis called pelvic or

4 O'clock position.
This is the second most common position about
30%.
 It may point towards the inguinal ligament called as midinguinal or 6 O'clock
position.
Appendicular Orifice
 The appendicular situated on the posteromedial aspect of the caecum 2 cm
below the ileocaecal orifice.

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Lumen of Appendix

It is quite small and may be partially or completely obliterated after mid-adult life.

Peritoneal Relations
The appendix is suspended by peritoneum, called the mesoappendix.

Blood Supply - The appendicular artery supplies appendix.

Nerve Supply
• Sympathetic nerves are derived from thoracic nine and ten segments of spinal cord.

• Parasympathetic nerves are derived from the vagus.

Lymphatic Drainage

• lymphatics drains into the ileocolic nodes, appendicular nodes.

CLINICAL ANATOMY

Appendicitis
Inflammation of the appendix is known as appendicitis.

Appendicectomy.
The operation for removal of the appendix is called appendicectomy.

McBurney's pointis the site of maximum tenderness in appendicitis.

The point lies at the junction of the lateral one-third and the medial two-thirds of
the line joining the umbilicus to the right anterior superior iliac spine.

PORTOSYSTEMIC COMMUNICATIONS (PORTOCAVAL

ANASTOMOSIS

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These communications form important routes of collateral circulation in portal

obstruction.
The following are the important sites of portosystemic communications.

1.Umbilicus:
• The paraumbilical veins from left branch of the portal vein
Anastomoses with veins of the anterior abdominal wall.
• In portal obstruction the veins around the umbilicus enlarge forming the
caput medusae.

2.Lower end of oesophagus:

Oesophageal tributaries of the left gastric vein (portal) anastomose with
Oesophageal tributaries of the accessory hemiazygos vein (systemic).

3.Anal canal:
The superior rectal vein (portal) anastomoses
with
the middle and inferior rectal veins (systemic)

4.Bare area of the liver

Hepatic venules (portal)
anastomose with
the phrenic and intercostal veins (systemic).

5.Posterior abdominal wall:

Veins of retro-peritoneal organs, like the duodenum, the ascending colon and
the descending colon (portal) anastomose with the retroperitoneal veins of the
abdominal wall and of the renal capsule (systemic).

6. Liver:
Rarely, the ductus venosus remains patent and connects the left branch of the portal
vein directly to the inferior vena cava.

CLINICAL ANATOMY

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Portal pressure:
Normal pressure in the portal vein is about 5-15 mm Hg.

Portal hypertension (pressure above 40 mm Hg): It

can be caused by the following:
• Cirrhosis of liver, in which the vascular bed of liver is markedly obliterated

It cause
• Congestive splenomegaly,
• Ascites, and
• Collateral circulation through the porto-systemic communications.
• It forms o (i) Caput medusae around the umbilicus o (ii) oesophageal varices at
the lower end of oesophagus which may rupture and cause dangerous or even
fatal haematemesis; and
o (iii) haemorrhoids in the anal canal may be responsible for repeated
bleeding per rectum.

ISCHIORECTAL FOSSA

The ischiorectal fossa is a wedge-shaped space situated one on each side of the anal
canal below the pelvic diaphragm.

Dimentions
Length- 5cm ,
Width- 2.5 cm,
Depth- 5 cm
Boundaries
Base is formed by the skin.
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Apex is formed by the line where the obturator fascia meets the inferior fascia of the
pelvic diaphragm.

Anteriorly - perineal membrane

Posteriorly - gluteus maximus

lateral wall - formed by:

(a) obturator internus with the obturator fascia
(b) medial surface of the ischial tuberosity

Medial wall is formed by :

(a) External anal sphincter, with the fascia covering it in the lower part;
(b) Levator ani with the anal fascia in the upper part

Contents of Ischiorectal Fossa

1. Ischiorectal pad of fat.

2. Inferior rectal nerve and vessels.
3. Posterior scrotal or posterior labial (in females) nerves and vessels 4. Perineal branch
of the fourth sacral (S4) nerve.
5. Perforating cutaneous branches of nerves S2, S3.
6. Pudendal canal with its contents.

CLINICAL ANATOMY

1. The two ischiorectal fossae allow distention of the rectum and anal canal during
passage of faeces.

2. Abscesses

Both the perianal and ischiorectal spaces are common sites of abscesses.

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• Sometimes an abscess may burst into the anal canal or rectum internally, and on
to the surface of the perineum externally.
• In this way an ischiorectal type of anorectal fistula or fistula in ano may be
produced

3. The ischiorectal fat acts as a cushion-like support to the rectum and anal canal.
Loss of this fat in some diseases like diarrhoea in children may result in
prolapse of the rectum.

SUPPORTS OF THE UTERUS

• The uterus is a mobile organ.

• It undergoes extensive changes in size and shape during the reproductive
period of life.
• It is supported and prevented from going down by a number of factors which
are chiefly muscular and fibromuscular.

Primary Supports
A. Muscular or active supports

1. Pelvic diaphragm
2. Distal urethral sphincter mechanism
3. Perineal body

B. Fibromuscular or mechanical supports

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1. Pubocervical ligaments
2. Uterosacral ligaments
3. Transverse cervical ligaments of Mackenrodt
4. Uterine Axis
5. Round ligaments of uterus.

Secondary Supports

These are formed by peritoneal ligaments- 1.

Rectovaginal fold of peritoneum
2. Uterovesical fold of peritoneum
3. Broad ligaments

Role of Individual Supports

Pelvic Diaphragm
• The pelvic diaphragm supports the pelvic viscera and resists any rise in the
intraabdominal pressure.
• The pubococcygeus part of the levator ani is partly inserted into the perineal
body between the vagina and the rectum.
• Some of these fibres also form a supporting sling and a sphincter for the vagina,
and so indirectly for the uterus and the urinary bladder.

Perineal Body

• It is a fibromuscular node to which ten muscles are attached.

• It acts as an anchor for the pelvic diaphragm, and thus maintains the integrity of
the pelvic floor.
Distal urethral sphincter

• The sphincter urethrae muscle chiefly forms the external sphincter of the urethra.
• Many inferior fibres of the muscle support the vagina by getting attached to its
walls

Uterine Axis

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• The anteverted position of the uterus itself prevents the organ from sagging
down through the vagina.
• Any rise in intra-abdominal pressure tends to push the uterus against the
bladder and pubic symphysis.
• The angle of anteversion is maintained by the uterosacral and round ligaments
Pubocervicol Ligaments

• These ligaments connect the pubis to cervix and support the uterus.
Transverse Cervical Ligaments of Mackenrodt

• They connect the cervix to the pelvic wall that supports the uterus

Uterosacral Ligaments

• They connect the cervix to the sacrum(S2, S3)

• The uterosacral ligaments keep the cervix pulled backwards against the forward
pull of the round ligaments.
• Uterosacral and round ligaments form a couple that maintains the uterine axis

Round Ligaments of Uterus

• The round ligaments are two fibromuscular flat bands, 10 to 12 cm long.

• The round ligament keeps the fundus pulled forwards and maintains the angle of
anteversion against the backward pull of the uterosacral ligaments

CLINICAL ANATOMY

1. Retroverted uterus
• In some cases the uterus comes to lie in straight line with the vagina. This is
called a retroverted uterus

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2. Prolapse of the uterus

• Sometimes the uterus passes downwards into the vagina.
• The condition is called prolapse of the uterus. • It is caused by weakening of
the various supports of the uterus.

ANAL CANAL

The anal canal is the terminal part of the large intestine.

Situation
• Anal canal is situated below the level of the pelvic diaphragm.
• It lies between the right and left ischiorectal fossae

Length, Extent and Direction

• The anal canal is 3.8 cm long.
• It extends from the anorectal junction to the anus.
• It is directed downwards and backwards.
• The anal canal is surrounded by inner involuntary and outer voluntary sphincters
which keep the lumen closed
Relations of the Anal Canal

Anteriorly
• In both sexes : perineal body,
• In males : membranous urethra and bulb of penis,

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• In females : lower end of the vagina

Posteriorly
• Anococcygeal ligament; and
• Tip of the coccyx

Laterally
• Ischiorectal fossae

All round
• Anal canal is surrounded by the sphincter muscles, the tone of which keeps the
canal closed.

Interior of the Anal Canal

It can be divided into three parts:
• Upper part, about 15 mm long; Middle part, about 15 mm long; Lower part
about 8 mm long.

Upper Mucous Part

• This part is about 15 mm long. It is lined by mucous membrane The mucous
membrane shows
• 6 to 10 vertical folds; these folds are called the anal columns of Morgagni.
• The lower ends of the anal columns are united to each other by short transverse
folds of mucous membrane; these folds are called the anal valves
• Above each valve there is a depression in the mucosa which is called the anal
sinus.
• The anal valves together form a transverse line that runs all round the anal canal.
This is the pectinate line.
Middle Part or Transitional Zone or Pecten

• The next 15 mm or so of the anal canal is also lined by mucous membrane.

• The mucosa has a bluish appearance because of a dense venous plexus that lies
betweem it and the muscle coat.
• This region is referred to as the pecten or transitional zone.
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• The lower limit of the pecten often has a whitish appearance because of which it
is referred to as the white line of Hilton.
Lower Cutaneous Part

• It is about 8 mm long and is lined by true skin containing sweat and sebaceous
glands.
• The epithelium of the lower part resembles that of true skin.

Musculature of the Anal Canal Anal Sphincters

The internal anal sphincter It is

involuntary in nature.
• It is smooth muscle.
• It surrounds the upper three-fourths, i.e. 30 mm of the anal canal.

The external anal sphincter

• It is under voluntary control.
• It is made up of a striated muscle.
• It surrounds the whole length of the anal canal.
Arterial Supply
• The part of the anal canal above the pectinate line is supplied by the superior
rectal artery.
• The part below the pectinate line is supplied by the inferior rectal artery.

Venous Drainage
1. The internal rectal venous plexus
• It lies in the submucosa of the anal canal
• Veins present in the three anal columns situated at 3, 7 and 11 O'clock positions
as seen in the lithotomy position.
• They are large and constitute potential sites for the formation of primary
internal piles.

2. The external rectal venous plexus

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• It lies outside the muscular coat of the rectum and anal canal. It communicates
freely with the internal plexus.

Nerve Supply
• Above the pectinate line o anal canal is supplied by autonomic nerves, both
sympathetic and parasympathetic
• Below the pectinate line o It is supplied by somatic [inferior rectal]nerves.

Sphincters
• The internal sphincter is contracted by sympathetic nerves and relaxed by
parasympathetic nerves. • The external sphincter is supplied by the inferior
rectal nerve.

CLINICAL ANATOMY

Anal Fissure/Fissure in Ano

• Anal fissure is caused by the rupture of one of the anal valves,
• usually by the passage of dry hard stool in a constipated person Because of the
involvement of skin the condition is extremely painful.

Fistula in Ano
A fistula is an abnormal epithelialised track connecting two cavities, or one cavity
with the exterior.

PILES OR HEMORRHOIDS

Internal piles or true piles

• Internal piles are dilatations of the internal rectal venous plexus.
• They occur above the pectinate line.
• They are painless.
• They bleed more during straining at stool.
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• The primary piles occur in 3, 7 and 11 O'clock positions of the anal wall when
viewed in the lithotomy position.
• They are formed by enlargement of the radicles of the superior rectal vein
which lie in the anal columns

• Varicosities in other positions of the lumen are called secondary piles.

The various factors responsible for causing internal piles are:

• Poor support to veins from the surrounding loose connective tissue,

• absence of valves in the superior rectal and portal veins;
• Direct transmission of the increased portal pressure at the portosystemic
communications.

• For these reasons the development of piles is favoured by constipation,

prolonged standing, excessive straining at stool, and portal hypertension.
External piles or false piles

• It occur below the pectinate line and are, therefore, very painful.
• They do not bleed on straining at stool.

RELATIONS OF THE KIDNEYS

• The kidneys are retroperitoneal organs.

• partly covered by peritoneum anteriorly. Relations Common to the Two Kidneys

• The upper pole of each kidney is related to the corresponding suprarenal gland.
• The lower poles lie about 2.5 cm above the iliac crests. The medial border of
each kidney is related to

(1) the suprarenal gland, above the hilus (2)

the ureter below the hilus.

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The posterior surfaces of both kidneys are related to

(1) The diaphragm;

(2) the medial and lateral arcuate ligaments;
(3) the psoas major;
(4) the quadratus lumborum;
(5) the transversus abdominis;
(6) the subcostal vessels
In addition, the right kidney is related to twelfth rib, and the left kidney to eleventh
and twelfth rib.

The structures related to the hilum

The following structures are seen in the hilum from anterior to posterior side: (1) The
renal vein
(2) the renal artery, and
(3) the renal pelvis, which is the expanded upper end of the ureter.

Other Relations of the Right Kidney

Anterior Relations
(1) Right suprarenal gland,
(2) liver,
(3) second part of duodenum, (4) hepatic flexure of colon, and
(5) small intestine.
The lateral border of the right kidney is related to the right lobe of the liver and
to the hepatic flexure of the colon
Other Relations of the Left Kidney
Anterior Relations
(1) Left suprarenal gland,
(2) spleen,
(3) stomach,
(4) pancreas,
(5) splenic vessels,
(6) splenic flexure and descending colon, and
(7) jejunum.
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The lateral border of the left kidney is related to the spleen and to the descending
colon.

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WRITE A SHORT NOTE ON FEMORAL TRIANGLE.

It’s a triangular shape. It’s situated in upper 1/3 rd of thigh.

Boundaries-
Laterally- By medial border of Sartorius
Medially- By medial border of adductor longus
Base- is formed by inguinal ligament
Apex- is formed by the point where medial and
lateral boundaries meet
Apex is continuous below with th adducutor canal.

Roof-  skin
 Superficial fascia -containing superficial inguinal
lympnodes, branches of femoral artery with veins,
and upper part of great saphenous vein.  Deep
fascia- with saphenous opening and
cribriform fascia

Floor- a-p-p-i
Medial to lateral by adductor longus---pectineus---
psoas major---iliacus.

Contents-
1. Femoral artery and its branches
2. Femoral vein and its tributaries
3. Femoral sheath covering upper 4 cm of femoral
vessels
4. Nerves a] femoral nerve- lateral to femoral artery
b] nerve to pectineus c]femoral branch of genitofemoral nerve d] lateral cutaneous
nerve of thigh
5. Deep inguinal lymph nodes.

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WRITE A SHORT NOTE ON FEMORAL SHEATH.

Shape of sheath is funnel type

It is prolongation of fascia around proximal part of femoral vessels. Enclosing Upper 3 to
4 cm of femoral vessels.
Site- situated in the femoral triangle below inguinal ligament
Formed by downward extension of two layers of facia of
abdomen. Anterior wall by – fascia transversalis Posterior wall by
– fascia iliaca.
Inferiorly- sheath merge with connective tissue around vessels.
Lateral wall is vertical
Medial wall is oblique and directed downward and laterally
The sheath is divided into the three compartments by septa

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Lateral compartment- it contains femoral artery and femoral branch of genitofemoral

nerve
Intermediate compartment- it contains femoral vein Medial
compartment- it is the smallest of all.
It is known as femoral canal.

FEMORAL CANAL

[ Draw the diagram of above short note]

This is the medial compartment of femoral sheath
Shape – conical
Dimensions- it is wide at base and narrow below. About 1.5 cm long and 1.5 cm wide
at base.
Base- also known as femoral ring
It is the upper end of femoral canal. It is wider.
This is a weak point in lower abdomen and it is the site for femoral hernia.
content- femoral canal contains lymph node of cloquet, lymphatics and small amount of
areolar tissue.
Thus femoral canal is the space in the femoral sheath and femoral ring is the upper
end of the femoral canal SQ-Femoral Ring
The base or upper end of femoral canal is called femoral ring
Boundaries-
Anteriorly- by inguinal ligament
Posteriorly – by pectineus and its covering fascia
Medially by the concave margin of lacunar ligament
Laterally by the septum separating it from femoral vein

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Femoral septum- the femoral ring is closed by a condensation of extraperitoneal

connective tissue called as femoral septum
Femoral fossa parietal peritoneum covering femoral septum from above shows a
depression called as femoral fossa.

FEMORAL HERNIA

Hernia- is abnormal swelling due to the normal content of body which protrude out
with their coverings
Femoral canal is an area of potential weakness in the lower abdominal wall so
abdominal content pass from it and they reach there and produce swelling.
Mostly the content is bowel loop.

Course-First it passes downwards through femoral canal forwards through saphenous

opening finally upwards along with superficial epigestric and superficial circumflex
iliac vessels.
For reduction of hernia
The reverse course has to be followed.
SQ-Femoral hernia is more common in Females than males.

• Because femoral canal is wider in females.

• Femoral canal is wider in females because females have wider pelvis than males.
And smaller size of femoral vessels
• femoral ring is the entry site for femoral hernia

Complication of hernia
Obstructed hernia-
When the content of hernia sac can’t go back to their original position known as
obstructed hernia

Strangulated hernia-

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when blood supply of content of hernia is also impaired, it’s known as strangulated
hernia
• For hernia repair surgery is done
• In surgical process contents are pushed back following the reverse root.

ADDUCTOR CANAL/ HUNTER’S CANAL/ SUBSARTORIAL CANAL

Adductor canal is an intramuscular space situated on the medial side and middle one
third of thigh.
Extent- Above from apex of the femoral triangle to Below tendinous opening in the
adductor magnus muscle.
Shape- the canal is triangular on cross-section.
Boundries
Anterior wall – is formed by vastus medialis
Posterior wall [floor]- is formed by above- adductor longus and below by- adductor
magnus
Medial wall [roof] – is formed by strong fibrous membrane joining the anterior and
posterior walls.
It is overlapped by Sartorius
Sabsartorial plexus of nerves lies on the fibrous roof of the canal and under
Sartorius This plexus is formed by- branches from [1] medial cutaneous nerve of
thigh [2] saphenous nerve [3] anterior division of obturator nerve Content artery

• Femoral artery which gives muscular branches and descending genicular artry
• Femoral artry leaves canal through hitus magnus and continue as poplitial artry
Vein
• Femoral vein
• Femoral vein is a continuation of poplitial vein
Nerve
• Saphenous Nerve
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Saphenous nerve is the longest cutaneous nerve.It’s a branch of femoral N

• Nerve to Vastus medialis and obturator nerve’s branches Clinical anatomy
• operation for the treatment of poplitial aneurism is done by ligating the femoral
artery in the adductor canal OBTURATOR NERVE

It’s the main nerve of Medial Compartment of Thigh.

Origin and Root value-
Ventral devisions of the ventral primary rami of spinal nerve L2, L3, L4
Course and division

• It emerges at the medial border of psoas major muscle then decends down lying
on the lateral wall of true pelvis
• Enters thigh by passing from obturator foramen
• Within the obturator canal nerve devides into anterior and posterior devision
Supply
Anterior Division supplies

• Pectineus
• Adductor longus
• Gracilis
• Adductor brevis if not supplied by the posterior division
• Gives branch to subsartorial plexus
• Hip joint
• Ends by supplying the femoral artery
Posterior Division supplies

• Obturator externus
• Adductor magnus
• Adductor brevis if not supplied by the anterior division
• Genicular branch which enters the poplitial fossa then supplies capsule and
cruciate ligaments of knee joint

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• Some fibers supply poplitial artery

Clinical anatomy
Referred pain – a disease in the hip joint may cause referred pain in the knee and on
the medial side of the thigh.
Because of common nerve supply by the obturator nerve
Spastic paraplegia may involve adductor muscles and it creates spasm of the adductor
muscles.

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POPLITIAL FOSSA
Poplitial fossa is a diamond shaped depression lying behind the knee joint.
In relation to lower part of femur and upper part
of tibia.
Boundries
Superolaterally- Biceps femoris Superomedially-
Semitendinousus, semimembranosus mainly
Gracilis, Sartorius and adductor magnus also
Inferolaterally- Lateral head of gastrocnemius
mainly and plantaris
Inferomedially – Medial Head of gastrocnemius
Roof –

• deep fascia or popliteal fascia

• Superficial fascia which contains small saphenous Vein
• cutaneous nerves
Floor-

• Poplitela surface of the femur,

• Capsule of the knee joint,
• Oblique popliteal ligament,
• Strong popliteal fascia covering popliteus muscle Contents of the fossa
• Popliteal artery and its branches
• Popliteal vein and its tributaries
• The tibial nerve and its branches
• Common peroneal nerve and its branches
• Posterior cutaneous nerve of the thigh
• Genicular branch of the obturator nerve
• Popliteal lymph nodes
• Fat

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CLINICAL ANATOMY

1. Blood pressure in the lower limb is recorded from the popliteal artery.

2. Constant palpation of the popliteal artery may cause changes in the vessel wall,
leading to narrowing and occulsion of the artery.

3.The Popliteal artery is more prone to aneurysm than many other arteries of the
body.

DORSALIS PEDIS ARTERY

Introduction and Origin
• This is the chief artery of the dorsum of the foot.
• It is a continuation of the anterior tibial artery on to the dorsum of the
foot. Course
• The artery begins in front of the ankle between the two malleoli.
• It passes forwards along the medial side of the dorsum of the foot to
reach the proximal end of the first intermetatarsal space

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• Here it dips downwards, ends in the sole by completing plantar arterial

arch. Relations Superficial:
• Skin, fasciae, and extensior retinaculum.

Deep:
• Capsular ligament of the ankle joint.
• The talus, navicular and intermediate cuneiform bones. Medial:
• Extensor hallucis longus. Lateral
• First tendon of the extensor digitorum longus.

Branches
1. The lateral tarsal artery
2. The medial tarsal branches
3. The arcuate artery
• It gives off the second, third and fourth dorsal metatarsal arteries
4. The first dorsal metatarsal artery
• It gives a branch to the medial side of the big toe.

CLINICAL ANATOMY
Pulsations of the dorsalis pedis artery are easily felt between the tendons of the
extensor hallucis longus and the first tendon of the extensor digitorum longus.

• dorsalis pedis artery is congenitally absent in about 14% of subjects.

• It is commonly palpated in patients with vaso-occlusive diseases of the lower
limb.

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WHAT IS GUY ROPES

• The three muscles inserted into the upper part of the medial surface of tibia
• represent one muscle from each of the three compartments of thigh

• Sartorius belongs to anterior compartment of thigh,

• gracilis belongs to medial compartment of thigh,
• Semitendinosus belongs to posterior compartment of thigh
• These three muscles are reaching below at one point, and spread out above
towards pelvis, like three strings of a tent.

From this arrangement it appears that they act as "guy ropes", to stabilize the
bony pelvis on the femur

Anserine bursa.
• This is a large bursa, with several diverticula.
• It separates the tendons of sartorius, gracilis and semitendinosus al their
insertion from one another, from the bony surface of tibia, and from the tibial
collateral ligament

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COMMON PERONEAL NERVE

This is the smaller terminal branch of the sciatic nerve Root
Value: (L4, L5, SI, S2) Course
• It extends from the superior angle of the poplitial fossa to the lateral angle,
along the medial border of the biceps femoris.
• Continuing downwards and forwards.
• it winds around the posterolateral aspect of the neck of the fibula, pierces the
peroneus longus, and divides into the superficial and deep peroneal nerves.
Branches
Cutaneous branches are two:
• Lateral cutaneous nerve of the calf
• Peroneal communicating nerve

Articular Branches
• Superior lateral genicular nerve.
• Inferior lateral genicular nerve
• Recurrent genicular nerve

 common peroneal nerve divides into superficial and deep peroneal nerves.
o superficial peroneal supplies evertors of the foot and o
deep peroneal supplies dorsiflexors

Muscular branches do not arise from this nerve.

However, it may give branch to the short head of biceps femoris.

Clinical Anatomy
• The common peroneal nerve can be palpated against the posterolateral side of
the neck of the fibula.
• It may be injured in this area.

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• It can get injured easily by a stick blow on the posterolateral aspect of neck of
the fibula.
• Dorsiflexion and evertion are lost. This condition is called "Foot drop".

• It is the most frequently injured nerve in the lower limb.

PLANTAR ARCH
Plantar arch is formed by the direct continuation of the lateral plantar artery, and
is completed medially by the dorsalis pedis artery. The arch is slightly curved with
its convexity directed forwards.

Course
It extends from the base of the fifth metatarsal bone to the
proximal part of the first inter metatarsal space, It lies between
third and fourth layers of the sole.

Branches of the Plantar Arch

1. Four plantar metatarsal arteries run distal one in each intermetatarsal space.
• Each artery enter by dividing into two plantar digital branches for adjacent sides
of two digits.
• The first artery also gives off a branch to the medial side of the great toe.
• The lateral side of the little toe gets a direct branch from the lateral plantar
artery.

2. The plantar arch gives off three proximal perforating arteries that pass through
the second, third and fourth intermetatarsal spaces and communicates with the
dorsal metatarsal arteries which are the branches of the arcuate artery.
3. The distal end of each plantar metatarsal artery gives off a distal perforating artery
which joins the distal part of the corresponding dorsal metatarsal artery.

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GREAT /LONG SAPHENOUS VEIN

This is the largest and longest superficial vein of the lower limb
Formation,course and Termination

• It begins on the dorsum of the foot from the medial end of the dorsal venous
arch,
• Runs upwards in front of the medial malleolus, along the medial side of the leg,
• and behind the knee.
• In the thigh, it goes upward, forwards to reach the saphenous opening
where it pierces the cribriform fascia and opens into the femoral vein.
• Before piercing the cribriform fascia, it receives three named tributaries
corresponding to the three cutaneous arteries, and also many unnamed
tributaries

Characteristic
• It contains about 10 to 15 valves which prevent back flow of the venous blood,
which tends to occur due to gravity.
• Incompetence of these valves makes the vein dilated and tortuous leading to
varicose veins.

Connection
• The vein is also connected to the deep veins of the limb by perforating veins.
• The perforating veins are also provided with valves which permit flow of blood
only from the superficial to the deep veins.
• failure of these valves also gives rise to varicose veins

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Clinical Anatomy
Varicose veins and ulcers.

• If the valves in the perforating veins or at the termination of the superficial veins
become incompetent, the defective veins become "high pressure leaks"

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•
Through which the high pressure of the deep veins produced by muscular
contraction and it is transmitted to the superficial veins.
• This results in dilatation of the superficial veins Known as varicose Vein
Gradual degeneration of their walls producing varicose ulcers.
"Calf pump" and "Peripheral heart".
• In the upright position of the body, the venous return from the lower limb
depends largely on the contraction of calf muscles.
• These muscles are, therefore, known as the "calf pump".
• For the same reason the soleus is sometimes called the peripheral heart.

• Sinuses are present in soleus

• When the muscle relaxes, blood flows into the sinuses from the superficial
veins.
• When this muscle contracts, blood from sinuses pumped into the deep veins.
• Unidirectional blood flow is maintained by the valves in the perforating veins.

Trendelenburg test.
• This is done to find out the site of leak or defect in a patient with varicose
veins.
• Only the superficial veins and the perforating veins can be tested, not the deep
veins. Procedure
• The patient is made to lie down, and the veins are emptied by raising the limb
and stroking the varicose veins in a proximal direction.
• Now pressure is applied with the thumb at the saphenofemoral junction, and
the patient is asked to stand up quickly.

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To test the superficial veins, the pressure is released.

• Quick filling of the varicose veins from above

indicates incompetency of the superficial veins.
To test the perforating veins ,
• The pressure at the saphenofemoral junction is
not released, but maintained for about a minute.
• Gradual filling of the varices indicates
incompetency of the perforating veins, allowing
blood to pass from deep to superficial veins.

HIP JOINT
Ball and socket variety of synovial joint
• The head of the femur articulates with the acetabulum of the hip bone to form
the hip joint.
• The hip joint is unique in having a high degree of stability as well as mobility.
Ligaments
• Fibrous capsule,
• Iliofemoral ligament
• Pubofemoral ligament,
• Ischiofemoral ligament,
• Ligament of the head of the femur,
• Acetabular labrum, and

• Transverse acetabular ligament. Relations

Anterior relations
• Tendon of the iliopsoas

Posterior Relations
• obturator internus and gemelli,
• piriformis,

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•
• gluteus maximus muscle.

Superior Relations
Reflected head of the rectus femoris covered by the gluteus minimus, gluteus
medius

Inferior Relations
• Lateral fibres of the pectineus and obturator externus.
• In addition there are gracilis, adductors longus, brevis, magnus and hamstring
muscles.

Blood Supply
The hip joint is supplied by the obturator artery, two circumflex femoral and
two gluteal arteries.

CLINICAL ANATOMY
The region of the hip joint is commonly affected by disease or injury. Congenital
dislocation
• Congenital dislocation is more common in the hip

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• The head of the femur slips upwards on to the gluteal surface This causes
lurching gait, and Trendelenburg's test is positive.

Coxa vera
• Coxa vera is a condition in which the neck-shaft angle is reduced from the
normal angle

Osteoarthritis
• Osteoarthritis is a disease of old age, characterized by growth of osteophytes at
the articular ends,
• which make movements limited and painful.

Injuries:
Dislocation of the hip
• Dislocation of the hip may be posterior, anterior or central.
• The sciatic nerve may be injured in posterior dislocations.

Fracture of the neck of the femur

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•
Fracture of the neck of the femur may be subcapital, near the head, cervical in
the middle, or basal near the trochanters.
• These fractures are common in old age, between the age of 40 and 60 years.
Femur-neck-fracture is usually produced by trivial injuries.
.
Referred pain
Disease of the hip may cause referred pain in the knee because of the common
nerve supply of the two joints.

LOCKING AND UNLOCKING OF THE KNEE JOINT

Locking
Locking is a mechanism that allows the knee to remain in the position of full
extension as in standing without much muscular effort.
• Locking occurs as a result of medial rotation of the femur during the last stage
of extension.

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• The anteroposterior diameter of the lateral femoral condyle is less than that of
the medial condyle.

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•
As a result, when the lateral condylar articular surface is fully 'used up' by
extension, part of the medial condylar surface remains unused.
• At this stage the lateral condyle serves as an axis around which the medial
condyle rotates backwards, i.e.
• medial rotation of the femur occurs, so that the remaining part of the medial
condylar surface is also 'taken up'.
• This movement locks the knee joint.

• Locking is aided by the oblique pull of ligaments during the last stages of
extension.
• When the knee is locked, it is completely ' rigid and all ligaments of the joint
are taut.
• Locking is produced by continued action of the same muscles that produce
extension, i.e. the quadriceps femoris mainly vastus medialis

• The locked knee joint can be flexed only after it is unlocked by a reversal of the
medial rotation, i.e. by lateral rotation of the femur.

Unlocking
Its lateral rotation of femur on fixed tibia at the starting of flexion of knee joint.
It is done by popliteus muscle.

INVERSION AND EVERSION OF THE FOOT

Inversion
Inversion is a movement in which the medial border of the foot is elevated, so that
the sole faces medially.

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• Inversion is accompanied by plantar flexion of the foot and adduction of the

forefoot
Muscles producing movements of inversion
Main muscles- tibialis anterior, tibialis posterior
• Accessory muscles- flexor hellucis longus, flexor digitorum longus

Eversion
Eversion is a movement in which the lateral border of the foot is elevated, so that
the sole faces laterally.
• Eversion is accompanied by dorsiflexion of the foot and abduction of the
forefoot
Muscles producing movements of Eversion
• Main muscle- peroneus longus, peroneus brevis
• Accessory muscles- peroneus tertius
These movements can be performed voluntarily only when the foot is off the ground.
• When the foot is on the ground these movements help to adjust the foot to
uneven ground.

Joints Taking Part

Main:
1. Subtalar
2. Talocalcaneonavicular

Accessory:
• Transverse tarsal which includes calcaneocuboid and talonavicular joints.

Axis of Movements
• Inversion and eversion take place around an oblique axis.

Range of Movements 1. Inversion is much

more free than eversion.

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CONTRACEPTION

Contraception means to prevent pregnancy

 It is also called birth control, family planning.

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 Fertility control techniques may be temporary or permanent.

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Several methods are a aila le for fertility ontrol des ri ed elo …

RHYTHM METHOD (SAFE PERIOD)

It is based on the time of ovulation.

 After ovulation, i.e. on the 14th day of menstrual cycle, the ovum is fertilized.
Its viability is only for 2 days after ovulation
 Sperms survive only for about 24 to 48 hours after ejaculation.
 If sexual intercourse occurs during this period there is chance of pregnancy.
This period is called the dangerous period.
 Pregnancy can be avoided if there is no sexual intercourse during this period.

 The prevention of pregnancy by avoiding sexual mating during this period is

called rhythm method or safe period.

MECHANICAL BARRIERS – PREVENTION OF ENTRY OF SPERM INTO UTERUS

Mechanical barriers are used to prevent the entry of sperm into uterine cavity. These
barriers are called condoms.

Male condom
 It is a leak proof sheath, made of latex.
 It covers the penis and does not allow entrance of semen into the female
genital tract during coitus.

Female condom
 In females, the commonly used condom is cervical cap or diaphragm.
 It covers the cervix and prevents entry of sperm into uterus.
„
CHEMICAL METHODS
Chemical substances, which destroy the sperms, are applied in female genital tract
before coitus.
 Destruction of sperms is called spermicidal action.

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 The spermicidal substances are available in the form of foam,tablet, jelly,

cream and paste.
ORAL CONTRACEPTIVES (PILL METHOD)

Oral contraceptives are the drugs taken by mouth (pills) to prevent pregnancy.
These pills prevent pregnancy by
 inhibiting maturation of follicles and ovulation
 Progesterone increases the thickness of mucosa in cervix, which is not
favorable for transport of sperm.
These pills contain synthetic estrogen and progesterone. Contraceptive
pills are of three types:

1. COMBINED PILLS
 Combined pills contain synthetic estrogen like ethinyl estradiol and synthetic
progesterone like norgestrol.
 Pills are taken daily from 5th to 25th day of menstrual cycle.
 The withdrawal of the pills after 25th day causes menstrual bleeding.
 The intake of pills is started again after 5th day of the next cycle.

2. SEQUENTIAL PILLS
Sequential pills contain estrogen along with progesterone.
 These pills also prevent ovulation.
 Sequential pills are taken in two courses

3. MINIPILLS OR MICROPILLS
Minipills contain a low dose of only progesterone
 Taken throughout the menstrual cycle.
„
DISADVANTAGES AND ADVERSE EFFECTS OF ORAL CONTRACEPTIVES
Following are the disadvantages and adverse
 May not be suitable for women having disorders such as diabetes,
cardiovascular diseases or liver diseases
 Hypertension and heart attack

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
QUE. INTRAUTERINE CONTRACEPTIVE DEVICE (IUCD)

Fertilization and the implantation of ovum are prevented by inserting some object
made from metal or plastic into uterine cavity.
Such object is called intrauterine contraceptive device (IUCD).
„ MECHANISM OF ACTION OF IUCD
 Prevents fertilization and implantation of the ovum.
 The IUCD with copper content has spermicidal action also.
 The IUCD which is loaded with synthetic progesterone slowly releases
progesterone.
 Progesterone causes thickening of cervical mucus and prevents entry of sperm
into uterus.
It is inserted into the uterine cavityby using some special applicator.
„
DISADVANTAGES OF IUCD
 Cause heavy bleeding in some women
 Promote infection
 Come out of uterus accidentally.

SURGICAL METHOD (STERILIZATION)

PERMANENT METHOD
 Permanent sterility is obtained by surgical methods. It is also called
sterilization.

TUBECTOMY
In tubectomy, the fallopian tubes are cut and both the cut ends are ligated
[closed]
 It prevents entry of ovum into uterus.
 The operation is done through vaginal orifice in the postpartum period.
 During other periods, it is done by abdominal incision.

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 Tubectomy is done quickly (in few minutes) by using a laparoscope.

 Though tubectomy causes permanent sterility
 Its reversible- If necessary recanalization of fallopian tube can be done using
plastic tube by another surgical procedure.

VASECTOMY
In vasectomy, the vas deferens is cut and the cut ends are ligated.

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
So the sperms cannot enter the ejaculatory duct and the semen is devoid of
sperms.
 It is done by surgical procedure with local anesthesia.
 If necessary, the recanalization of vas deferens can be done with plastic tube.

SURROGACY OR SURROGATE MOTHER

Defination- The practice by which a woman (called a surrogate mother) becomes

pregnant and gives birth to a baby in order to give it to someone who cannot have
children
There are two kinds of surrogate mothers.
Traditional surrogates.
 Artificial insemination first made surrogacy possible.
 A traditional surrogate is a woman who is artificially inseminated with the
father's sperm.
 She then carries the baby and delivers it for the parents to raise.
 A traditional surrogate is the baby's biological mother. That's because it was
her ovum that was fertilized by the father's sperm.
 Donor sperm can also be used for a traditional surrogacy.

Gestational surrogates.
 In vitro fertilization (IVF) now makes it possible to take ovum from the mother,
fertilize them with sperm from the father,
 And place the embryo into the uterus of a gestational surrogate.
 The surrogate then carries the baby until birth.
 A gestational surrogate has no genetic ties to the child.  That's because it
wasn't her ovum that was used.
Gestational surrogacy has become more common than a traditional surrogate
because of less legal complications.

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
A woman decides to use a surrogate for several reasons:

She may have medical problems with her uterus.

 She may have had a hysterectomy [removal of uterus.]
 There may be conditions that make pregnancy impossible or medically risky,
such as severe heart disease.
Few criteria for selecting a surrogate mother

 She Is at least 21 years old,

 She Has already given birth to at least one healthy baby
 Has passed a psychological screening by a mental health professional
 Willingly signs a contract agreeing to her role and responsibilities in the
pregnancy.

KARYOTYPING

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
Karyotyping is the procedure to obtain karyotype of an individual.
 In this procedure, Metaphase chromosomes of a cell are obtained and
photographed.
From this photograph individual chromosomes are cut and arranged according
to slandered classification.
For preparation rapidly dividing cells are used.
They can be obtained from following sources:
 Lymphocytes from blood
 Fibroblast of skin
 Bone marrow cells
Most commonly used cells are lymphocytes from peripheral blood. Following
steps are involved
 5 ml of venous blood is collected and mixed with heparin for avoiding clotting
 Lymphocytes are separated from other cells
 They are put into culture media
 Phytohaemogglutinin which stimulates the cell division is added into the
culture
 The culture is kept in incubator for three days at 37` temperature
 At the end of three day colchicin is added to culture
 Colchicin has the property to arrest cell division during metaphase by
preventing formation of spindles.

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
These cells are put into hypotonic saline. Cells will be enlarged and chromosomes are
separated
 Cells are then fixed by glacial acetic acid and
methanol.
 When cells ruptures, chromosomes spread
in large area known as metaphase spread.
 Those slides are stained and photographed
 From the photograph individual
chromosome is cut and arranged.
Thus, a karyotype of an individual is obtained.

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TRISOMY 21 OR DOWN’S SYNDROME

Incidence- 1 in 700 live births
Genetic abnormality
It occurs due to chromosomal abnormalities – Trisomy of 21 chromosome

Clinical features  Mentally

retarded.
 IQ is low.
 Poor growth.  Short stature 
Poor muscle tone.
 Small head , protruding tongue,
 Small ears and nose
 Hands are short and broad.
 Single palmer crease
 Many children suffer from major
heart defect.
 Abnormal pelvis

Cause
 21 chromosome trisomy occur due to non disjunction during maternal meiosis
 Incidence increases with advancing maternal age [After 35 years of age]
 Recurrence risk is high when one child is already affected by down’s syndrome
Life span
 The mean age is 16 years. It may varies from few weeks to decades also  Most
affected adults develop Alzheimer’s disease

Counselling
Prenatal diagnosis of Down’s syndrome can be carried by following methods
 Amniocentesis
 Triple test- Alpha feto protein and estriol level is decressed and chorionic
gonadotropin level is increased in Down’s syndrome

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TURNER SYNDROME [45, XO] OR MONOSOMY

Incidence- 1 in 5000 to 10000 live births

Genetic abnormality
It occurs due to chromosomal abnormalities – monosomy of X chromosome

Clinical features
 Affected individual is female
 Normal intelligence Or slightly
retarded.
 Webbed Neck
 Low posterior hair line
 Short stature
 Cubitus valgus
 Broad chest
 Widely spaced nipples
 Poor breast development
 Ovary –non functional
 Menstrual abnormality
 Female is sterile. She is not Able to have child.
 Secondary sexual characteristic is Underdeveloped
 Coarctation of aorta

Cause
 Monosomy of X chromosome is the most common cause for turner’s
syndrome [ 45, XO]

Counselling and Treatment

 Oestrogen replacement therapy should be given at adolescent age for
development of secondary sexual characteristics

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 Females are sterile so they can have child with the help of in vitro Fertilisation

KLINEFELTER SYNDROME [47,XXY]

Incidence- 1 in 1000 live births
Genetic abnormality
It occurs due to chromosomal abnormalities – 47,XXY

Clinical features
 Affected individual is male
 Normal intelligence Or slightly
retarded.
 Tall stature

Secondary sexual characteristic is

Underdeveloped
 Pubic hair pattern is like female
 Poor facial hair groath
 Gynecomastia [ breast
Development]

 Testis are small.

 Normal penis and scrotum 
male is infertile. he is not Able
to produce sperm

Karyotype-
 47 XXY
 It’s trisomy of sexual
Chromosome

Counselling and Treatment

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 At the Age of puberty treatment with testosterone will help to develop the
secondary sexual characteristics.

SOMITES
Paraxial mesoderm becomes segmented to form somites
 They develop on the sides of developing neural tube
 It’s a triangular structure
 It is divisible into three parts
Ventromedial part – it is called sclerotome.
• The cells of this part migrate medially. They surround the neural tube.
• They give rise to vertebral column and ribs. Lateral part- It is called
dermatome
• The cells of this part migrate and reach ectoderm.

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• These cells form dermis of the skin and subcutaneous tissue.

Intermediate part – It is called as myotome.
• This part forms skeletal muscles.
• Cervical,thorasic, lumbar, and sacral nerve innervate corresponding
myotome
• Somites exceed the number of spinal nerves but many of them
subsequently degenerate

PRIMITIVE STREAK
 In blastocyst inner cell mass is arranged into two plates
 The upper layer towards amniotic cavity is the epiblast. Cells of this layer are
coloumner.
 The lower layer towards the yolk sac is the hypoblast. Cells of this layer are
cubical.

 At one circular area near margin of the disc, cubical cells of the hypoblast
become columnar.This area is called the prochordal plate.  It determines the
central axis of the embryo  And also determines the head and tail ends.
 Soon after formation of the prochordal plate,

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 epiblast cells lying along cenral axis near the tail end of the disc begin to
proliferate.
 Those cells form an elevation that bulges into amniotic cavity.
 This elevation is called the primitive streak
 Primitive streak is at first rounded or oval swelling.
 With elongation of the embryonic disc, it becomes a linear structure.
 Linear structure lying in the central axis of the disc.

The cells that proliferate in the region of the primitive streak pass side ways.
They pushing themselves between the epiblast and hypoblast.
 These cells form the intra embryonic mesoderm.
 Some cells displace hypoblast and form layer which is now known as endoderm 
Thus both endoderm and mesoderm are derived from the epiblast.
 The remaining cells of epiblast now form ectoderm.

The process of formation of the primitive streak , endoderm, intra-embryonic

mesoderm is referred as gastrulation.

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NOTOCHORD
Notochord is a midline structure that develops in the region lying between the
cranial end of the primitive streak and caudal end of the prochordal plate.

 During development, notochord passes through several stages,

 The cranial end of the primitive streak becomes thickened to from primitive
knot
 A depression appears in to the primitive knot known as blastopore
 Cells in the primitive knot multiply and pass cranially in the midline
 They pass in between ectoderm and endoderm
 They reach upto caudal end of the prochordal plate
 These cells form a solid chord known as notochordal process
 This process undergoes several stages of rearrangements and form definitive
notochord.
• Blastopore cavity extends into the notochordal process and convert it
into a tube called notochordal canal
• Floor cells of notochordal canal becomes mixed up with the endoderm
• Gradually the canal become flattened and becomes a plate like structure
called as notochordal plate
• This process is reversed and notochordal plate again becomes curved and
forms a tube.
• Then tube is converted into a solid rod which is known as the definitive
notochord.

Notochord enlarge in the midline

 Then that position is taken up by vertebral coloumn.
 Notochord persists in the region of intervertebral disc as nucleus pulposus.

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PHARYNGEAL ARCHES
 They are thickening of mesoderm present in the wall of foregut.
 At first there are six arches. The fifth arch disappears and only five remain.
 Between two arches, the endoderm is pushed outwards to form a series of
pouch
 Opposite the each pouch the surface ectoderm dips inwards as an ectodermal
cleft
 From each arch different muscles, bones and cartilages are formed
 It is described below

First pharyngeal arch

Mandibular arch
Skeletal
• Malleus & Incus of the middle ear
• maxilla & mandible
• spine of sphenoid bone
• Sphenomandibular ligament
• palatine bone
Muscles
Muscles of mastication
• Masseter
• medial & lateral pterygoid muscles
• Temporalis muscles
• Mylohyoid muscle
• anterior belly of Digastric muscle,
• Tensor palati muscle
• Tensor tympani muscle
Nerve supply

 Mandibular Nerve

Derivatives of 2nd pharyngeal arch

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Skeletal and

• Stapes,
• Temporal styloid process,

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• Stylohyoid ligament, and

• Lesser cornu of the hyoid bone.
Muscles
 Muscles of face
 Occipitofrontalis muscle
 Platysma
 Stylohyoid muscle
 Posterior belly of Digastric
 Stapedius muscle
 Auricular muscles
Nerve supply

 Facial nerve

Derivatives of 3rd pharyngeal arch

Skeletal
 Greater cornu of hyoid bone
 Lower part of the body of hyoid bone Muscles

 Stylopharyngeous

Nerve supply

 Glosopharyngeal nerve

Cartilages of the larynx are derived from the fourth and sixth pharyngeal arches

4th pharyngeal arch

Muscles- cricothyroid muscle, all intrinsic muscles of soft palate except tensor veli
palatini
Nerve- superior laryngeal nerve

6th pharyngeal arch

Muscles- All intrinsic muscles of larynx except the cricothyroid muscle Nerve-
Recurrent laryngeal nerve

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DEVELOPMENT OF FACE
Face develops from frontonasal process and right and left mandibular arches
( First pharyngeal arch)
 The mandibular arch devides into maxillary process and a mandibular
process Lower lip and lower jow
 The right and left mandibular processes meet in the midline and fuse
They form lower lip and lower jow Upper lip
 It is formed by the fusion of the frontonasal process with the right and
left maxillary process Cheeks
 Cheeks are formed by fusion of the maxillary and mandibular processes
Nose
 It is derived from the frontonasal process Nasal cavity
 The nasal placode gets depressed and form nasal pit
 That nasal pit enlarge to form the nasal cavity Paranasal air sinuses
 They appears due to outgrowth from the nasal cavity Palate
 It is formed by fusion of three components
 Right and left palatal process arising from maxillary process and
primitive plate which is derived from the frontonasal process

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Cartilage

• It is a specialized connective
tissue

• It consist of three components o Ground

substance o Fibers and o Cells. Three types of

cartilage are found in the body

1. Hyaline cartilage
2. Elastic cartilage
3. Fibro cartilage
They differ from each other because of the type and amount of fibers present in
them.
 Cartilage is not supplied with blood vessels
 It is avascular
 It is usually surrounded by membrane called as perichondrium.
 Perichondrium having reach blood supply.

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 Chondrocytes receive nutritive substance by diffusion through the

ground substance.

HYALINE CARTILAGE

It is the most abundant type of cartilage in human Body.

Location:

 In fetal skeleton,
 Ends of adult Bones,
 Nose,
 Costal cartilage,
 Trachea,bronchi and larynx.

Description:
 It consist of homogeneous,transparent and amorphous intracellular matrix. 
Matrix consist of collagen fibers and ground substance
 Cartilage cell known as chondrocytes
 Chondrocyte is present in small spaces called as lacunae.
 It is surrounded by perichondrium

Fibers

 Its type 2 collagen fibers

 It is provide stability and strength to the cartilage
 They are not seen in the histological section because they have same refractive
index as that a ground substance.

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Ground substance
 Homogenous, gel like
structure.

Chondrocytes
 They occupy lacunae in the matrix.
 They are responsible for the synthesis of collagen fibers and ground substance.

Perichondrium

 Hyaline cartilage on its free surface covered with a fibro vascular membrane
called as perichondrium.
 It is absent at the free surface of bone at joint cavity. Known as[articular
cartilage]
 It is consist of two layers 1. Outer fibrous layer.
2. inner cellular layer
Functions

 Articular cartilage provides smooth surface for movement of joints.

 It is provides support[as in costal cartilage]
 Firmness keeps the lumen of trachea and bronchi patent.

ELASTIC CARTILAGE
Location

 It is present in pinna of the ear.

 Epiglottis
 Corniculate
 Cuneiform cartilage of larynx.
 External auditory meatus and auditory tube.

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Description

 Also known as yellow elastic cartilage

Fibers

 Elastic cartilage contains branching elastic fibers.  Contains type 2 collagen

fibers.
Ground substance

 Contains proteoglycans.
Cells
 Chondrocytes are present in lacunae.
 These cells are bigger than cells present in hyaline cartilage.
 They are closely placed.
Perichondrium

Having two layer

(1) Outer fibrous layer
(2) Inner cellular layer.
Function.
 It provides shape
and support to
the organ.

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FIBROCARTILAGE
 It is also known as white fibrocartilage
Location

 Intervertebral discs
 Public symphysis
 Manubriosternal joint
 Menisci of knee joint
 Articular disc of temporomandibular and sternoclavicular joints
Description Fibers

 Type-1 variety
Ground substance

 Very less variety. Cells

 Very few chondrocytes are seen

 They are placed between large fiber bundles
Perichondrium

 It’s abscent in fibrocartilage.

Function

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 It is capable of resisting compressive and shear forces.

SKELETAL MUSCLE
They are also known as striated or voluntary muscle.

 They are supplied by somatic nerves

 Under light microscope it shows alternating dark and light bands
 Skeletal muscle consists numerous muscle fibers Covering
 Each individual muscle fiber is surrounded by a covering known as
endomysium
 Many muscle fibers aggregate to form bundle which is surrounded by a layer
called as perimysium
 Many bundles unite to form a muscle which is covered by epimysium.

The point of contact between terminal end of axon and muscle fiber is called motor
end plate.

Basic unit of skeletal muscle is long cylindrical fiber. Fiber is formed by fusion of
many myoblast

Nuclei of cells are present towards peripheral part of cytoplasm

Striations

 The dark band is called as A band and Light band is called as I band

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 A thin line is seen in the middle of the light area is called as Z line
 The mid region of the dark band is called as H band
 In the middle of the H band the line is known as M line

The area between two adjacent Z

lines called as Sarcomere.
 A sarcomere is the
contractile unit of muscle
 It’s containing thick myosin
and thin actin filaments

CARDIAC MUSCLE
Cardiac muscle is also striated
similar to skeletal muscle but its contraction is involuntary.

 They are supplied by autonomic nerves  They are present only in heart.

Cardiac muscle is consisting of long and thick muscle fibers

 These fibers show branching
 So, individual fiber appears as Y shaped.
 Each fiber is made up of cardiac myocytes.
 Each myocyte has a centrally placed single oval nucleus.
 They are joined and form a junction known as intercalated disc.
 Gap junctions are present in the longitudinal or lateral portion of intercalated
disc. It helps in spreading of action potential
Myofibrils of cardiac muscle have actin and myosin filaments.

Applied
• Hypertrophy of cardiac muscle – when cardiac muscle works excessively
their size is enlarged.
• No capacity for regeneration
• Damaged part is replaced by fibrous tissue.

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COMPACT BONE
It forms the bulk of the diaphysis of long bone
• It forms a thin layer on the external surface of all other bones.
• This part of bone is called compact because no space is visible on naked
eye examination
Bone core is made up of spongy bone
Copmact bone covering
Periosteum- the bone on its external surface is covered by a membrane called
periosteum
• It consists two layer – outer fibrous layer and inner cellular layer.
Endosteum – It is the thin lining of the bone towards marrow cavity and
spongy bone
Compact bone is made up of Lamella.
Lamellae are present in three different patterns

Haversian system of lamellae

Also known as osteon
Lamellae Arranged around a canal known as Haversian canal. This canal is
containing vessels and lymphatics.

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Blood vessels and nerves go inside the compact bone through volkmann’s canal

Intersitial lamellae
Lamellae seen in areas between osteon is known as interstitial lamellae

Circumferential lamellae
It is two types
Outer circumferential lamellae- present on the outer surface of bone just below
periosteum.
Inner circumferential lamellae- It encircle the marrow cavity

Clinical application
 Rickets- poor mineralization of bone due to vitamin d deficiency in child
results in bowing of legs known as rickets.

ARTERY
Arteries are vessels which conduct blood from heart to tissue. The
wall of the artery is having three layers.
Tunica intima
 Innermost layer of artery.
 It is having four components o Endothelium- made up of simple squamous
epithelium. o Basal lamina o Subendothelial connective tissue o Internal
elastic lamina- made up of a layer of elastic lamina
Tunica media
 Intermediate layer
 It is the thickest layer and consisting of elastic fibers and smooth muscle cells
 The amount of elastic fibers and smooth muscle is depending upon the size of
artery
 They arranged circularly
 It is separated from tunica adventitia by external elastic lamina Tunica
advantitia
 Outermost layer of artery

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 Made up of connective tissue cells and collagen fibers

Classification of arteries Into

three types

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Elastic arteries- larger arteries ex. Common carotid, subclavian artery 

Muscular arteries- medium sized arteries.
 Arterioles- Smaller arteries. Terminating into capillaries.

Clinical
Atherosclerosis- deposition of lipid,
fibrous tissue in tunica intima

THYROID GLAND
It is surrounded by thin connective
tissue capsule.
 From the capsule septa
extend into gland carrying blood vessels along with
them

Parenchyma
 The parenchyma of the gland is arranged in the form of thyroid follicles.
Thyroid follicles
 Follicles are having central cavity that contains gel like material called colloid.
o Colloid is containing thyroglobulin.
o Thyroglobulin is the storage form of thyroid hormones
 Follicles are lined by a single layer of epithelium
 Epithelial cells of follicle vary in size from cuboidal to columner
 It depends on the activity of cells o Cuboidal cells reffered as resting stage o
Coloumnar cells reffered as active or secratory stage

Each follicle is surrounded by a network of reticular fibers, vessels and lymphatics

Parafollicular cells
 Few cells present surronding follicular cells called as parafollicular cells 
They secrete hormone calcitonin.

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SPLEEN
The structure of the spleen is similar to the lymphnode.
capsule
 It is covered with a capsule. That capsule is made of dense connective tissue
and elastic fibers.
A cut section through the spleen shows the substances of spleen arranged in the
form of white pulp and red pulp
The white pulp
The white pulp appears basophilic (bluish) in the haematoxylin stained
section because it contains lymphocytes.
The red pulp
 The red pulp appears red because it contains many sinuses filled with RBC.

Circulation of blood through spleen

 Splenic artery enters at hilum . It is branched and enters the pulp where it is
covered by lymphocytes
 That periarteriolar lymphatic sheath is called as white pulp.
 At the center of this pulp is the central artery
 There are two theories of circulation open and closed circulation

Functions of spleen
 Filteration of blood

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 Site of production of B and T lymphocytes

 Destruction site for RBC Applied
Splenomegaly- enlargement of the spleen is called as spleanomegaly.

APPENDIX
 It occurs in malaria and leukaemias.

Appendix is a worm like diverticulum attached at the caecum

 It’s wall contains all four layers typical of intestinal tract.
1. Mucosa-Innermost layer.
Epithelium of mucosa

 It is made up of columnar epithelium. Also contain goblet cells.

Lamina propria of mucosa- this is a layer of loose connective tissue, which support
the epithelium

 It contains the blood and lymphatic vessels.

 It is occupied with many large and small lymphatic nodules. These may
extend upto submucosa.
 Lymphatic nodules can be enlarged and can block the lumen of appendix.
The muscularis mucosa

 It consists of thin layer of smooth muscle. These are arranged as inner circular
and outer longitudinal layer.

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
 It helps in changing the shape of mucosa
 It is disrupted where lymphatic nodule extend to submucosa

2. Submucosa

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
It consist of moderately dense connective tissue rich in collagen and elastic
fiber
 It contains blood vessels, lymphatics vessels and Nerves and meissener’s
plexus
 It may show extension of lymphatic nodules.

3. muscle layer
 muscle layer containing inner circular and outer longitudinal smooth muscle
coats
 also contains myentric plexus
4. Serosa- the outer most covering

SUPRA RENAL GLAND

The supra renal gland consists of two structurally and functionally different parts.

 Centrally located – Medulla

 And outer - Cortex
Cortex is divided in to three zones.
Zona Glomerulosa-
 It is thin outer most layer
 The cells of this region are arranged in arches
 When it is sectioned it looks like cluster of balls, so known as glomerulosa 
Mineralocorticoid is produced from this layer.

Zona Fasciculata
 Thick zone situated in the middle of the cortex.
 It is continuous superficially with zona glomerulosa and deeply by zona
reticularis. No demarcation line is present between zones.  Cells are
arranged into parallel columns  Glucocorticoids are produced from this
layer.

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
Zona Reticularis
 It is situated adjacent to medulla
Cells are arranged in three dimensional Network of branching and
anastomosing cords.
 Androgens are produced from this
Layer.

Medulla
 The cells of medulla are of two
types
 Norepinephrine and epinephrine
secreting cells.
 It is innervated by preganglionic
sympathetic fibers

TESTIS
It has a thick white capsule called as tunica albuginea.
Tunica vasculosa underlies the tunica albuginea

The connective tissue septa devides testis into about 250 compartments called as
lobules.
 Each lobule contain one to three seminiferous tubules.
 These tubules are the sites where sperms are produced.

In between the seminiferous tubules there is presence of loose connective tissue.

It is known as interstitial tissue
 It is having blood vessels
 It contains leyding cells which produce testosterone

Seminiferous tubules open into rete testis

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 Rete testis having efferent ducts which is connected with epididymis.

OVARY
Ovaries are almond shaped paired structure
Each ovary measures about 3cm length, 1.5 cm width, 1 cm in thickness.
Each ovary contains following parts -
Germinal epithelium-
• It is covering surface of ovary
• It is single layered cuboidal or squamous epithelium Name is
misnomer beacuce it does not give rise to germ cells. Tunica albuginea
• It is connective tissue layer lying below germinal epithelium. Cross
section of ovary shows outer cortex and inner medulla. Cortex
• Lies below tunica albugenia
• It contains germ cells. Ovarian follicles formed here.
• Ovarian follicles are in various stages of development

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
Medulla
• It is present deep to cortex.

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• It consists of loose connective tissue. And containing lymphocytes, blood vessels,

and nerves
The demarcation between cortex and medulla is not clear.

URETER
Ureter is a tube with star
shaped lumen inside

It

conducts urine from renal pelvis to the urinary bladder It’s structure
containing three walls

Mucosa
• Epithelium- transistional type of Epithelium which is 4 to 5 layers thick
• Lamina propria- made up of loose connective tissue containing blood vessels and
lymphatics

Muscle layer
• Inner longitudinal and outer circular layer of smooth muscle

Adventitia
• Outer most layer of ureter made up of loose connective tissue.

Clinical
• Ureter stone – Stone in the ureter.
o Kidney may dislodge the stone and pass into ureter.
o It causes severe pain radiating from back to front side at lower abdomen.

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MEDIASTINAL
SURFACE OF
LUNG

• The mediastinal
part is related to the
mediastinal septum,
and shows a cardiac
impression, the hilum
and a number of other
impressions which differ on the two sides.

BOUNDARIES OF SUPERIOR MEDIASTINUM

• Anteriorly: Manubrium sterni
• Posteriorly: Upper four thoracic vertebrae
• Superiorly: Plane of the thoracic inlet
• Inferiorly: An imaginary plane passing through the sternal angle in front, and the lower
border of the body of the fourth thoracic vertebra behind.
• On each side: Mediastinal pleura.

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STRUCTURE OF HEART IN DETAIL

The heart has five surfaces: base (posterior), diaphragmatic (inferior), sternocostal (anterior),
and left and right pulmonary surfaces. It also has several margins: right, left, superior, and
inferior:

• The right margin is the small section of the right atrium that extends between the
superior and inferior vena cava.
• The left margin is formed by the left ventricle and left auricle.
• The superior margin in the anterior view is formed by both atria and their auricles.
• The Inferior margin is marked by the right ventricle.
Inside, the heart is divided into four heart chambers: two atria (right and left) and two
ventricles (right and left).The right atrium and ventricle receive deoxygenated blood from
systemic veins and pump it to the lungs, while the left atrium and ventricle receive
oxygenated blood from the lungs and pump it to the systemic vessels which distribute it
throughout the body. The left and right sides of the heart are separated by the interatrial
and interventricular septa which are continuous with each other. Furthermore, the atria are
separated from the ventricles by the atrioventricular septa. Blood flows from the atria into
the ventricles through the atrioventricular orifices (right and left)–openings in the
atrioventricular septa. These openings are periodically shut and open by the heart valves.

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Heart valves: There are two sets of valves: atrioventricular and semilunar. The
atrioventricular valves prevent backflow from the ventricles to the atria:

• The right atrioventricular/tricuspid valve is between the right atrium and right
ventricle. It has three cusps/leaflets: anterior/anterosuperior, septal, and
posterior/inferior.
• The left atrioventricular/bicuspid valve is also called the mitral valve since it only has
two cusps and resembles a miter in shape. It is between the left atrium and left ventricle
and has two cusps/leaflets: anterior/aortic and posterior/mural.
Semilunar valves prevent backflow from the great vessels to the ventricles.

• The pulmonary semilunar valve is between the right ventricle and the opening of the
pulmonary trunk. It has three semilunar cusps/leaflets: anterior/non-adjacent, left/left
adjacent, and right/right adjacent.
• The aortic semilunar valve is between the left ventricle and the opening of the aorta. It
has three semilunar cusps/leaflets: left/left coronary, right/right coronary, and
posterior/non-coronary.

INTERNAL FEATURES OF HEART

INTERNAL FEATURES OF RIGHT ATRIUM: broadly divided into the following three
parts a. Smooth Posterior Part or Sinus Venarum: The superior vena cava opens at the
upper end. The inferior vena cava opens at the lower end.
1. The opening of inferior vena cava is guarded by a rudimentary valve of the inferior vena
cava or Eustachian valve.
2. During embryonic life, the valve guides the inferior vena caval blood to the left atrium
through the foramen ovale.
3. The coronary sinus opens between the opening of the inferior vena cava and the right
atrioven tricular orifice.
4. The opening is guarded by the valve of the coronary sinus or thebesian valve.

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b. Rough Anterior Part or Pectinate Part, including the Auricle:

1. It presents a series of transverse muscular ridges called musculi pectinati

2. They arise from the crista terminalis and run for wards and downwards towards the
atrioventricorifice, giving the appearance of the teeth of a comb. In the auricle, the muscles are
interconnected to form a reticular network

c. interatrial septum:

1. It presents the fossa ovalis, a shallow saucer-shaped depression, in the lower part.
2. The fossa represents the site of the embryonic septum primum.
3. The annulus ovalis or limbus (Latin a border) fossa ovalis is the prominent margin of the fossa
ovalis.
4. It represents the lower free edge of the septum secundum.

INTERNAL FEATURES OF RIGHT VENTRICLE:

The interior shows two orifices: a The right atrioventricular or tricuspid orifice, guarded by the tricuspid
valve. b. The pulmonary orifice guarded by the pulmonary valve.
The interior of the inflowing part shows trabeculae carneae or muscular ridges of three types:
a. Ridges or fixed elevations
b. Bridges
c. Pillars or papillary muscles with one end attached to the ventricular wall, and the other end connected
to the cusps of the tricuspid valve by chordae tendineae
The cavity of the right ventricle is crescentic in section because of the forward bulge of the
interventricular septum

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OESOPHAGUS

ANATOMY: The esophagus is divided into three parts:

• Cervical which travels through the neck

• Thoracic which is located in the thorax, more specifically in the mediastinum
• Abdominal which travels past the diaphragm into the abdomen, reaching the stomach

MEDIASTINUM

The mediastinum is an area found in the midline of the thoracic cavity, that is surrounded by
the left and right pleural sacs.

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FLOATING RIBS

Eleventh and twelfth ribs are short and are called floating ribs. They have pointed ends. The necks
and tubercles are absent. The angle and costal groove are poorly marked in the eleventh rib and are
absent in the twelfth rib.

Attachments and Relations of the Twelfth Rib: 1. The capsular and radiate ligaments are attached to
the head of the rib.

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2.quadratus lumborum, internal intercostal muscle, costodiaphragmatic recess of the

pleura,diaphragm are attached on the inner surface 3. a. Attachments on the medial
half
i. Costotransverse ligament ii. Lumbocostal
ligament iii. Lowest levator costae iv. Iliocostalis
and longissimus parts of sacrospinalis. b.
Attachments on the lateral half
i. Insertion of serratus posterior inferior ii.
Origin of latissimus dorsi iii. Origin of external
oblique muscle of abdomen.

RIGHT LUNG
The right lung consists of three lobes: the right upper lobe RUL , the right middle lobe RML , and the
right lower lobe RLL. The right lobe is divided by an oblique and horizontal fissure, where the
horizontal fissure divides the upper and middle lobe, and the oblique fissure divides the middle and
lower lobes.
The lobes further divide into segments that are associated with specific segmental bronchi.
Segmental bronchi are the third-order branches off the second-order branches (lobar bronchi) that
come off the main bronchus.
The right lung consists of ten segments. There are three segments in the RUL (apical, anterior, and
posterior), two in the RML (medial and lateral), and five in the RLL (superior, medial, anterior,
lateral, and posterior). The oblique fissure separates the RUL from the RML, and the horizontal
fissure separates the RLL from the RML and RUL.
The hilum (root) is a depressed surface at the center of the medial surface of the lung and lies
anteriorly to fifth through seventh thoracic vertebrae. It is the point at which various structures enter
and exit the lung. The hilum is surrounded by pleura, which extends inferiorly and forms a
pulmonary ligament. The hilum contains mostly bronchi and pulmonary vasculature, along with the
phrenic nerve, lymphatics, nodes, and bronchial vessels. Both left and right hilum contain a
pulmonary artery, pulmonary veins (superior and inferior), and bronchial arteries.

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Blood supply: This blood supply contains deoxygenated blood and travels to the lungs
where erythrocytes, also known as red blood cells, pick up oxygen to be transported to
tissues throughout the body. The pulmonary artery is an artery that arises from the
pulmonary trunk and carries deoxygenated, arterial blood to the alveoli. The pulmonary
capillary network consists of tiny vessels with very thin walls that lack smooth muscle
fibers. The capillaries branch and follow the bronchioles and structure of the alveoli. It is at
this point that the capillary wall meets the alveolar wall, creating the respiratory membrane.
Once the blood is oxygenated, it drains from the alveoli by way of multiple pulmonary veins,
which exit the lungs through the hilum.

Nervous Innervation

Dilation and constriction of the airway are achieved through nervous control by the
parasympathetic and sympathetic nervous systems. The parasympathetic system
causes bronchoconstriction, whereas the sympathetic nervous system stimulates
bronchodilation.

GROSS ANATOMY OF LEFT LUNG

The lungs are pyramid-shaped, paired organs that are connected to the trachea by the right
and left bronchi; on the inferior surface, the lungs are bordered by the diaphragm. The
diaphragm is the flat, dome-shaped muscle located at the base of the lungs and thoracic
cavity. The lungs are enclosed by the pleurae, which are attached to the mediastinum. The
right lung is shorter and wider than the left lung, and the left lung occupies a smaller
volume than the right. The cardiac notch is an indentation on the surface of the left lung,
and it allows space for the heart .The apex of the lung is the superior region, whereas the
base is the opposite region near the diaphragm. The costal surface of the lung borders the
ribs. The mediastinal surface faces the midline. Each lung is composed of smaller units
called lobes. Fissures separate these lobes from each other. The left lung consists of two
lobes: the superior and inferior lobes. A bronchopulmonary segment is a division of a lobe,

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and each lobe houses multiple bronchopulmonary segments. Each segment receives air
from its own tertiary bronchus and is supplied with blood by its own artery. Some diseases
of the lungs typically affect one or more bronchopulmonary segments, and in some cases,
the diseased segments can be surgically removed with little influence on neighboring
segments. A pulmonary lobule is a subdivision formed as the bronchi branch into
bronchioles. Each lobule receives its own large bronchiole that has multiple branches. An
interlobular septum is a wall, composed of connective tissue, which separates lobules from
one another.

VENOUS DRAINAGE OF HEART

Coronary veins

The arrangements of the drainage pathway of the coronary veins are less predictable than that of the
arterial supply.

Anterior cardiac veins

The anterior cardiac veins may also receive blood from the right marginal vein as it travels along
the acute cardiac border. However, this vein has also been found to drain independently into the
right atrium as well as to the coronary sinus. The anterior cardiac veins are responsible for
draining the sternocostal aspect of the right ventricle.
Thebesian veins

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The smallest cardiac veins (venae cordis minimae) are a collection of small veins of the heart.
Otherwise known as Thebesian veins or small cardiac veins, these vessels range from 0.5 – 2
mm in diameter
Coronary sinus

The coronary sinus is roughly a 3 cm saccular dilatation between the left cardiac chambers. The sinus
commences at the junction of the great cardiac vein and the oblique vein of the left atrium. It is
oriented obliquely in the posterior atrioventricular groove; partly overlying the cardiac crux. Its
opening into the right atrium is protected by the semilunar valve of the coronary sinus (also called
the Thebesian valve), in order to prevent reflux into the cardiac venous system.

Great cardiac vein

The great cardiac vein originates at the cardiac apex, travels through the anterior
interventricular and then to the atrioventricular groove. It receives blood from the left
marginal vein and other tributaries that drain both ventricles and the left atrium, and
empties into the coronary sinus at its origin. Middle cardiac vein

Also arising at the cardiac apex, the middle cardiac vein travels in the posterior
interventricular groove to empty into the atrial end of the coronary sinus. Small
cardiac vein

the small cardiac vein is a singular vessel found in the posterior atrioventricular groove. It is
sometimes joined by the right marginal vein as they drain the posterior aspect of the right
chambers.
Oblique vein of the left atrium

the oblique vein of left atrium takes an inferior oblique course along the back of the left atrium to insert
in the distal end of the coronary sinus.

Posterior vein of the left ventricle

The posterior vein of left ventricle opens centrally in the coronary sinus. However, it may also
open into the great cardiac vein. It travels along the diaphragmatic aspect of the left ventricle,
alongside the middle cardiac vein

UTERUS
The uterus is a thick-walled muscular organ capable of expansion to
accommodate a growing fetus. It is connected distally to the vagina, and laterally
to the uterine tubes.The uterus has three parts;

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• Fundus – top of the uterus, above the entry point of the uterine tubes.

• Body – usual site for implantation of the blastocyst.

• Cervix – lower part of uterus linking it with the vagina. This part is structurally
and functionally different to the rest of the uterus
The fundus and body of the uterus are composed of three tissue layers;
• Pe ritoneum – a double layered membrane, continuous with the
pe abdominal
ritoneum. Also known as the perimetrium.
•M yometrium – thick smooth muscle layer. Cells of this layer undergo
hy pertrophy and hyperplasia during pregnancy in preparation to expel
fet the us at birth.
ndometrium – inner mucous membrane lining the uterus. It can be
• E further
su bdivided into 2 parts:
o Deep stratum basalis: Changes little throughout the menstrual
cycle and is not shed at menstruation.
o Superficial stratum functionalis: Proliferates in response to
oestrogens, and becomes secretory in response to progesterone.
It is shed during menstruation and regenerates from cells in the
stratum basalis layer.
Vascular Supply and Lymphatics
The blood supply to the uterus is via the uterine artery. Venous drainage is
via a plexus in the broad ligament that drains into the uterine veins.

Lymphatic drainage of the uterus is via the iliac, sacral, aortic and inguinal
lymph nodes

FALLOPIAN TUBE
The uterine tubes (or fallopian tubes, oviducts, salpinx) are muscular ‘J-shaped’
tubes, found in the female reproductive tract.They lie in the upper border of the
broad ligament, extending laterally from the uterus, opening into the abdominal
cavity, near the ovaries.

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Functions
The main function of the uterine tubes is to assist in the transfer and transport of
the ovum from the ovary, to the uterus.

The ultra-structure of the uterine tubes facilitates the movement of the female
gamete:
• The inner mucosa is lined with ciliated columnar epithelial cells and peg
cells (non-ciliated secretory cells). They waft the ovum towards the uterus
and supply it with nutrients.
•
Smooth muscle layer contracts to assist with transportation of the ova and
sperm. Muscle is sensitive to sex steroids, and thus peristalsis is greatest
when oestrogen levels are high.
PARTS
The fallopian tube is described as having four parts (lateral to medial);

• Fimbriae – finger-like, ciliated projections which capture the ovum from the surface of the ovary.
• Infundibulum – funnel-shaped opening near the ovary to which fimbriae are attached.
• Ampulla – widest section of the uterine tubes. Fertilization usually occurs here.
• Isthmus – narrow section of the uterine tubes connecting the ampulla to the uterine cavity.

Blood Supply and Lymphatics

The arterial supply to the uterine tubes is via the uterine and ovarian arteries. Venous
drainage is via the uterine and ovarian veins.

Lymphatic drainage is via the iliac, sacral and aortic lymph nodes.
Innervation
The uterine tubes receive both sympathetic and parasympathetic innervation via
nerve fibres from the ovarian and uterine (pelvic) plexuses. Sensory afferent
fibres run from T11- L1.

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PORTAL VEIN

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LUMBOSACRAL PLEXUS

The lumbosacral plexus is formed by the anterior rami of the nerves (spinal
segments T12–S4) to supply the lower limbs. The lumbosacral plexus can be
divided into the lumbar plexus, which innervates the ventral upper half, and the
sacral plexus, which mainly innervates the dorsal side.

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lumbar plexus: is composed of segments Th12–L4 and is located next to the

lumbar spine behind the psoas major muscle. In addition to the short nerves
leading to the hip muscles, the lumbar plexus includes the following major
nerves:

• Iliohypogastric nerve: Th12–L1

• Ilioinguinal nerve: Th12–L1
• Genitofemoral nerve: L1–L2
• Lateral cutaneous nerve of the thigh: L2–L4
• Femoral nerve: L1–L4
• Obturator nerve: L2–L4

(mnemonic: Indians In Georgia Love Fresh Oranges.)

Iliohypogastric nerve:The
iliohypogastric nerve proceeds obliquely laterally on
the quadratus lumborum muscle and runs ventrally. It supplies motor
innervation to the caudal portions of the transverse abdominis and the
internal oblique muscles of the abdomen. It is further divided into the
anterior cutaneous branch and the lateral cutaneous branch for sensory
innervation of the skin above and to the side of the inguinal ligament.

Ilioinguinal nerve :This nerve runs below the iliohypogastric nerve; it leans against
the abdominal wall and pierces through it at a spot that varies to finally run
medially at the level of the inguinal ligament and to pass through the external
inguinal ring to the pubic symphysis and the scrotum or the labia majora.

Genitofemoral nerve:After it pierces the psoas major muscle, the genitofemoral

nerve is divided into the genital branch and the femoral branch. It provides
motor innervation to the cremaster muscle.

Lateral cutaneous nerve of the thigh:The purely sensory lateral femoral cutaneous
nerve supplies the lateral skin of the thigh. It passes the psoas major muscle
and then the muscular lacuna to finally break through the fascia lata.
Femoral nerve:The femoral nerve is the longest nerve of the lumbar plexus. It
runs between the psoas major muscle and iliacus muscle and reaches the
muscular lacuna on the lateral side of the femoral artery and vein.

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Obturator nerve:The obturator nerve moves behind the psoas major muscle
distally and leans against the wall of the pelvis; together with the obturator
artery, it enters through the obturator canal to move to the inner thigh.Before
the obturator nerve divides into anterior and posterior branches

DESCENT OF TESTIS

Between the 3rd month of pregnancy and its end the testes become transferred from the lumbar
area (ventro-medial to the mesonephros) into the future scrotum. This transfer is due to a
combination of growth processes and hormonal influences.The gubernaculum testis also
plays a decisive role in this phenomenon.
The gubernaculum testis arises in the course of the 7th week from the lower gubernaculum, after
the mesonephros has atrophied. Cranially it has its origin at the testis and inserts in the region of
the genital swelling (future scrotum).In that the vaginal process lengthens downwardly, it takes the
muscle fibers of the oblique internal muscle and the transverse muscle with it.The muscle fascia of
the transverse muscle is the innermost layer and in the scrotal region, it forms the internal
spermatic fascia of the spermatic cord and the scrotum.
The muscle layer of the musculus cremaster is formed from fibers of the oblique internal and
transverse muscles.Externally, the external spermatic fascia is formed from the superficial
aponeurosis of the oblique external abdominal muscle.At the same time, at the inguinal

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canal along the lower gubernaculum, an evagination of the peritoneum arises, the vaginal
process, on which the testes will slide through the inguinal canal. The region, where the testes
pass through the abdominal wall, is called the inguinal canal.
Between the 7th and the 12th week the gubernaculum shortens and pulls the testes, the deferent
duct and its vessels downwards.Between the 3rd and 7th month the testes stay in the area of the
inguinal canal so they can enter into it. They reach the scrotum at roughly the time of birth under the
influence of the androgen hormone.

INTERVERTEBRAL DISC

The intervertebral discs (or discs) are fibrocartilages lying between adjacent surfaces of the
vertebrae. They form a fibrocartilaginous joint between the vertebral bodies, linking them
together. the discs make up one third to one quarter of the total spinal column’s length,
forming an interpose between adjacent vertebrae from the axis (C2) to the sacrum.

There are about 23 discs in the spine; 6 cervical, 12 thoracic, and 5 in the lumbar region. The
intervertebral discs are approximately 7-10 mm thick and 4 cm in diameter (anterior –
posterior plane) in the lumbar region of the spine.

Structure

Anulus fibrosus

The anulus is made up of a series of 15-25 concentric rings, or lamellae, with the collagen fibres lying
parallel within each lamella. Cells of the anulus are elongated, thin, and aligned parallel to the collagen
fibres. Towards the inner anulus the cells are oval. The anulus is relatively stiff, providing greater
strength to the disc and withstands compressive force.
Nucleus pulposus

The central nucleus pulposus contains collagen fibres which are organized randomly, and
elastin fibres which are arranged radially. These fibres are embedded in a highly hydrated
aggrecan containing gel. Endplate

The endplate is the third morphologically distinct part of the intervertebral disc. It is a thin
horizontal layer, usually less than 1 mm thick. This structure interfaces the disc and the
vertebral body.

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Functions

• The intervertebral disc forms the fibrocartilaginous joint which allows slight movement of the
vertebral column, and acts as a ligament to hold the vertebrae together.
• The discs act as fibrocartilaginous cushions, serving as the spine’s shock absorbing system. This
cushions the effect of shock and stress produced when an individual walks, runs, bends, or twists.
• The intervertebral discs prevent friction between two moving vertebrae by preventing vertebral
bodies from grinding against each other.

Innervation

The intervertebral disc is innervated through the sinovertebral nerves.

SUPERIOR MESENTERIC ARTERY

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PANCREAS

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CAECUM

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SPERMATOZOA/SPERM
Sperm develop in the testes and consist of a head, a midpiece, and a tail. The head contains
the nucleus with densely coiled chromatin fibers, surrounded anteriorly by an acrosome that
contains enzymes for penetrating the female egg. The midpiece has a central filamentous
core with many mitochondria spiraled around it. Motile sperm cells typically move via flagella
and require a water medium in order to swim toward the egg for fertilization.These cells
cannot swim backwards due to the nature of their propulsion. The uniflagellated sperm cells
(with one flagellum) of animals are referred to as spermatozoa.

In the head of most animal sperm, closely apposed to the anterior end of the nuclear envelope, is a
specialized secretory vesicle called the acrosomal vesicle (see Figure 20-25). This vesicle contains
hydrolytic enzymes that may help the sperm to penetrate the egg's outer coat. When a sperm contacts
an egg, the contents of the vesicle are released by exocytosis in the so-called acrosome reaction; in
some sperm, this reaction also exposes or releases specific proteins that help bind the sperm tightly to
the egg coat.
The motile tail of a sperm is a long flagellum, whose central axoneme emanates from a basal body
situated just posterior to the nucleus. The ATP is generated by highly specialized mitochondria in the
anterior part of the sperm tail (called the midpiece), where the ATP is needed

Fertility Factors

Sperm quantity and quality are the main parameters in semen quality, a measure of the
ability of semen to accomplish fertilization. The genetic quality of sperm, as well as its
volume and motility, all typically decrease with age.

Spermatogenesis
Male gametes (sperm cells) are haploid cells produced via spermatogenesis.

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PANCREATIC ISLETS
• The pancreatic islets are small islands of cells that produce hormones that
regulate blood glucose levels. Hormones produced in the pancreatic islets
are secreted directly into the bloodstream by five different types of cells.
• The alpha cells produce glucagon, and make up 15–20% of total islet cells.
The beta cells produce insulin and amylin, and make up 65–80% of the total
islet cells. The delta cells produce somatostatin, and make up 3–10% of the
total islet cells.
• The gamma cells produce pancreatic polypeptide, and make up 3–5% of
the total islet cells. The epsilon cells produce ghrelin, and make up less
than 1% of the total islet cells.
• The feedback system of the pancreatic islets is paracrine, and is based on
the activation and inhibition of the islet cells by the endocrine hormones
produced in the islets.

LUMBAR PUNCTURE
A lumbar puncture (spinal tap) is performed in your lower back, in the lumbar region. During
a lumbar puncture, a needle is inserted between two lumbar bones (vertebrae) to remove a
sample of cerebrospinal fluid. This is the fluid that surrounds your brain and spinal cord to
protect them from injury.

A lumbar puncture can help diagnose serious infections, such as meningitis; other
disorders of the central nervous system, such as Guillain-Barre syndrome and multiple
sclerosis; or cancers of the brain or spinal cord. Sometimes a lumbar puncture is used to
inject anesthetic medications or chemotherapy drugs into the cerebrospinal fluid.

FEMALE REPRODUCTIVE SYSTEM

The human female reproductive system contains two main parts: the uterus and the
ovaries, which produce a woman’s egg cells.

• An female’s internal reproductive organs are the vagina, uterus, fallopian

tubes, cervix, and ovary.
• External structures include the mons pubis, pudendal cleft, labia majora and
minora, vulva, Bartholin’s gland, and the clitoris.

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Ovaries
The ovaries are the ovum-producing organs of the internal female reproductive system

• In addition to producing ova, the ovaries are endocrine organs and produce
hormones that act during the female menstrual cycle and pregnancy.
• Ovaries secrete estrogen and progesterone.
• Each ovary is located in the lateral wall of the pelvis in a region called the
ovarian fossa.
• The ovaries are attached to the uterus via the ovarian ligament (which runs
in the broad ligament).
• Usually, the ovaries take turns releasing eggs every month; however, if one
ovary is absent or dysfunctional then the other ovary releases eggs every
month.
• There are two extremities to the ovary, the tubal extremity and the uterine
extremity.

Uterus
The uterus is the largest and major organ of the female reproductive tract that is the site of fetal
growth and is hormonally responsive.

• The body of the uterus is connected to the ovaries via the fallopian tubes,
and opens into the vagina via the cervix.
• Two Müllerian ducts usually form initially in a female fetus, but in humans
they completely fuse into a single uterus during gestation.
• The uterus is essential in sexual response by directing blood flow to the
pelvis and to the external genitalia, including the ovaries, vagina, labia, and
clitoris.
• The reproductive function of the uterus is to accept a fertilized ovum which
passes through the utero-tubal junction from the fallopian tube.
• The lining of the uterine cavity is called the endometrium.

Female Duct System

The Fallopian tubes, or oviducts, connect the ovaries to the uterus.

• The Fallopian tube allows passage of the egg from the ovary to the uterus.
• The lining of the Fallopian tubes are ciliated and have several segments,
including the infundibulum, ampullary, isthmus, and interstitial regions.

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• Interspersed between the ciliated cells are peg cells, which contain apical
granules and produce the tubular fluid that contains nutrients for
spermatozoa, oocytes, and zygotes. • Occasionally, the embryo
implants into the Fallopian tube instead of the uterus, creating an ectopic
pregnancy

Vagina
The vagina is the female reproductive tract and has two primary functions: sexual
intercourse and childbirth.

• The vagina is situated between the cervix of the uterus and the external
genitalia, primarily the vulva.
• Although there is wide anatomical variation, the length of the unaroused
vagina of a woman of child-bearing age is approximately 6 to 7.5 cm (2.5 to
3 in) across the anterior wall (front), and 9 cm (3.5 in) long across the
posterior wall (rear).
• During sexual arousal the vagina expands in both length and width.
• A series of ridges produced by the folding of the wall of the outer third of the
vagina is called the vaginal rugae.
• Vaginal lubrication is provided by the Bartholin’s glands near the vaginal
opening and the cervix.
• The hymen is a membrane of tissue that surrounds or partially covers the
external vaginal opening.

Vulva
The vulva is the external genitalia of the female reproductive tract, situated immediately
external to the genital orifice.

• Major structures of the vulva include the labia major and minora, mons
pubis, clitoris, bulb of vestibule, vulva vestibule, vestibular glands, and the
genital orifice (or opening of the vagina ).
• The vulva is rich in nerves that are stimulated during sexual activity and
arousal.
• The vulva also contains the opening of the female urethra and thus serves
the vital function of passing urine.

Perineum
The perineum is the region between the genitals and the anus, including the perineal body
and surrounding structures.

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• The perineum refers to both external and deep structures.

• Perineal tears and episiotomy often occur in childbirth with first-time
deliveries, but the risk of these injuries can be reduced by preparing the
perineum through massage.
• The perineum is an erogenous zone for both males and females.

Mammary Glands
A mammary gland is an organ in female mammals that produces milk to feed young
offspring.

• Mammary glands are not associated with the female reproductive tract, but
develop as secondary sex characteristics in reproductive-age females. •
The basic components of a mature mammary gland are the alveoli, hollow
cavities, a few millimeters large lined with milk-secreting cuboidal cells and
surrounded by myoepithelial cells.
• Alveoli join up to form groups known as lobules, and each of which has a
lactiferous duct that drains into openings in the nipple.
• Secretory alveoli develop mainly in pregnancy, when rising levels of
prolactin, estrogen, and progesterone cause further branching, together
with an increase in adipose tissue and a richer blood flow

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RECTUM

BILE DUCT
The union of the cystic and common hepatic ducts give rise to the 6 – 8 cm long common bile
duct. On average, the adult common bile duct is about 6 mm wide; however, there have been
reports of it increasing with age. This structure can be anatomically divided into four portions:

• The supraduodenal portion accounts for 2.5 cm of the total length of the structure. It
travels inferiorly in the right part of the free edge of the lesser omentum, anterior to the
gastroepiploic foramen of Winslow. Of note, the hepatic artery is medially related to
this part of the common bile duct, and the portal vein is posteromedial to it as well.

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• The retroduodenal portion travels behind the pars superioris (first part) of the
duodenum along with the gastroduodenal artery also medially related to the duct at this
level.
• The infraduodenal portion travels in a groove on the superolateral aspect of the
posterior surface of the head of the pancreas. The inferior vena cava is posterior to the
duct here. The duct usually lies within 2 cm of the pars descendens of the duodenum.
• The intraduodenal portion pierces the medial wall of the pars descendens (second part)
of the duodenum along with the pancreatic duct.

VAS DEFERENS

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INGUINAL RINGS

BURSAE AROUND KNEE

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ILIOTIBIAL TRACT

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TRENDELENBURG SIGN
The Trendelenburg sign is a quick physical examination that can assist the therapist
to assess for any hip dysfunction.[1]This is often referred to as the Trendelenburg test
but should not be confused with the Brodie–Trendelenburg test which is used to
determine the competency of the valves in the superficial and deep veins of patients
with varicose veins.

A positive Trendelenburg sign usually indicates weakness in the hip abductor

muscles: gluteus medius and gluteus minimus.[1] These findings can be associated
with various hip abnormalities such as congenital hip dislocation, rheumatic
arthritis, osteoarthritis.

SCIATIC NERVE

Branches:

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SURAL NERVE

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TENDOCALCANEUS
is a common tendon shared between the gastrocnemius and soleus muscles of the
posterior leg. It connects the two muscle groups (collectively, triceps surae) to the
calcaneus.

Attachments

The tendon provides a distal attachment site for the gastrocnemius (lateral and
medial heads) as well as the soleus muscles. It inserts onto the posterior surface of
the calcaneus (heel bone). The plantaris tendon also fuses with the medial side of
the Achilles tendon proximal to its attachment site.

Function

Through the action of the triceps surae, which raises the heel and lowers the
forefoot, the Achilles tendon is involved in plantar flexion of the foot (approximately
93% of the plantar flexion force).[1] The contraction of the gastrocnemius and soleus
muscles result in a translational force through the Achilles tendon that results in
plantar flexion of the foot. This action is very significant in human locomotion and
propulsion responsible for actions such as walking, running and even jumping.[2][4]
Also, these motions exert the greatest load on the Achilles tendon, with tensile loads
up to about ten times the body's weight. The anatomy of the tendon provides for
both elasticity (recoil) and shock-absorbance in the foot.[1] It is the largest and
strongest tendon in the human body and is capable of supporting tensional forces
produced by movement of the lower limb.[5]
Blood Supply

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The Achilles tendon has its blood supply from longitudinal arteries which course the
length of the tendon from two main blood vessels[6]:

1. Posterior tibial artery: Which supplies the proximal and distal sections.
2. Peroneal artery: Which supply the middle section.
The tendon has a generally poor blood supply throughout its length, as measured by
the number of vessels per cross-sectional area.

Innervation

The Achilles tendon is innervated by nerves of the muscles from which it is formed
and cutaneous nerves. the sural nerve particularly plays a major role in its
innervation with a smaller supply from the tibial nerve.[7] The nerve endings form a
longitudinal plexus which supplies afferent fibres in the great majority of the
tendon. [8] The afferent receptors are largely located close to the osteotendinous
junction and have all four types of receptors which are the type I, II, III, IV receptors
(Ruffini corpuscle pressure receptors, Vater-Paccinian corpuscle sensitive to
movement, Golgi tendons mechanoreceptors and free nerve endings that serve as
pain receptors).

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POPLITEUS

PLANTAR APONEUROSIS
The Plantar aponeurosis is the modification of Deep fascia, which covers the sole. It
is a thick connective tissue, that functions to support and protect the underlying
vital structures of the foot. The fascia is thick centrally, known as aponeurosis and is
thin along the sides. The fascia consists of three parts, medial, lateral and the central
part, respectively

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Attachment s

The aponeurosis is triangular in shape. T he central

portion, is attached to the medial tubercle of the
calcaneal , proximal to the attachment of the Flexor
Digitorum Brevi s and it divides into five processes,
near the head of the metatarsal bones, one for each of
the toes. Each of these processes further divides opposite to the MTP articulation
into two strata, superficial and deep. The superficial strata is attached to the skin,
which separates the toes from the sole. The deep strata, divides into two slips which
embrace the side of the Flexor tendons of the toes, blend with the sheaths of the
tendons, and with the deep transverse metatarsal ligament. The intervals left
between the five processes gives passage to the digital vessels and nerves.

The lateral and medial portions of the aponeurosis are thin compared to the central
portion, and cover the sides of the sole of the foot. The lateral portion covers the
Abductor digiti minimi, and medial portion covers the under surface of Abductor
hallucis.

Function

The aponeurosis is important for

• Protecting deeper structures of the foot, such as nerves and vessels.

• To maintain the longitudinal arches of the foot.
• For muscular attachment.
• Prevent excessive dorsiflexion.[1]
• Distribute plantar pressure during static and dynamic loading.[1]

Clinical relevance

The plantar aponeurosis supports the arch of the foot and distribute the plantar
loading. Overstretching of this fascia, may lead to Plantar Fascitis.

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MEDIAL PLANTAR NERVE

The medial plantar nerve is the larger one of the two terminal branches of the tibial
nerve, it covers most of the sole of the foot and supplies multiple intrinsic muscles of
foot. It arises under the flexor retinaculum and runs forward deep to the abductor
hallucis with the medial plantar artery on its medial side. It comes to lie in the
interval between the abductor hallucis and the flexor digitorum brevis.

Branches:

Cutaneous branches: plantar digital nerves run to the sides of the medial three and
the medial half of the fourth toe. The nerves extend onto the dorsum and supply the
nail beds and the tips of the toes.

Muscular branches: it gives a branches to these four muscles, abductor hallucis,

flexor digitorum brevis, the flexor hallucis brevis and the first lumbrical muscle.

Function

Innervates (sensory and motor):

Terminal Branches:

• Medial Plantar Cutaneous Nerve of Hallux and 3 Medial Common digital

nerves
• Proper Digital Nerves carries sensation from the medial two-thirds of the
plantar surface of the foot.

Movements produced:

Flexion and abduction of the big toe (flexor hallucis brevis and abductor hallucis)

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Flexion of the toes (flexor digitorum brevis and the first lumbrical muscle)
Pathology/Injury

Medial plantar nerve entrapment:

It is a compression of the nerve branches, where the nerve branches are compressed
between bones, ligaments and other connective tissues causing a pain at the inner
heel area. Entrapment in the medial longitudinal arch of the foot may result in
altered sensation on the medial aspect of the sole of the foot.

Symptoms include almost constant pain whenever adding a pressure to the foot
either by walking or sitting, just standing is often difficult.[2] The condition maybe
referred to as Jogger's Foot or Medial Plantar Neuropraxia.

PERFORATORS OF LOWER LIMB

The perforating veins of the lower limb (PV or “perforators”) are so called because they perforate the deep
fascia of muscles, to connect the superficial venous systems of the lower extremity with the deep veins where
they drain.

Perforators of the foot (venae perforantes pedis)

• dorsal foot perforators
• intercapitular veins

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• plantar foot perforators

• lateral foot perforators
• medial foot perforators

Perforators of the ankle (venae perforantis tarsalis)

• medial ankle perforators
• anterior ankle perforators
• lateral ankle perforators

Perforators of the leg (venae perforantes cruris)

See main article here: perforators of the leg

• medial leg perforators

o paratibial PV o posterior tibial PV

• anterior leg perforators

• lateral leg perforators
• posterior leg perforators
o medial gastrocnemius perforators o lateral

gastrocnemius perforators o intergemellar

perforators o para-Achillean perforators

Perforators of the knee (venae perforantes genus)

• medial knee perforators
• suprapatellar perforators
• lateral knee perforators
• infrapatellar perforators
• popliteal fossa perforators

Perforators of the thigh (venae perforantes femoris)

• medial thigh perforators
o perforators of the femoral canal (Dodd) o

inguinal perforators

• anterior thigh perforators

• lateral thigh perforators
• posterior thigh perforators
o posteromedial thigh perforators

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o sciatic perforators

o posterolateral thigh perforators “perforator of Hach”

o pudendal perforators

Perforators of the gluteal muscles (venae perforantes glutealis)

• superior perforators
• mid perforators
• lower perforators

GASTROCNEMIUS

Origin

• The two heads are located from the medial and lateral condyles of the
femur.
• The medial head from behind the medial supercondylar ridge and the
adductor tubercle on the popliteal surface of the femur.
• The lateral head from the outer aspect of the lateral condyle of the femur,
just superior and posterior the lateral epicondyle.The fabella is an
accessory ossicle most always found in the lateral head of the
gastrocnemius.[3]
• Both heads have attachments from the knee joint capsule and from the
oblique popliteal ligament.[1]

Insertion

• The bulk of the gastrocnemius muscle from each of the heads come
together and insert into the posterior surface of a broad membranous
tendon.
• It then fuses with the soleus tendon to form the upper part of
tendocalcaneus.

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• This broad tendon then narrows until it reaches the the calcaneous where
it expands again for its insertion on the middle part of the posterior
surface of the calcaneus.[1]
Nerve supply

• Both heads of the gastrocnemius is supplied by the tibial nerve (S1 and 2).
• Cutaneous supply is mainly provided by L4, 5 and S2.[1]

Function

The gastrocnemius with the soleus, is the main plantarflexor of the ankle joint. The
muscle is also a powerful knee flexor. It is not able to exert full power at both joints
simultaneously, for example when the knee is flexed, gastrocnemius is unable to
generate as much force at the ankle. The opposite is true when the ankle is flexed.

When running, walking or jumping the gastrocnemius provides a significant amount

of propulsive force. Consider the amount of force required to propel the body into
the air, triceps surae can generate a lot of force

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SOLEUS

Origin

• Posterior surface of the head and upper 1/3 of the shaft of the fibula;
• Middle 1/3 of the medial border of the tibia, tendinous arch between tibia
and fibula.

Insertion

• Posterior surface of the calcaneus via the Achilles tendon

Action

• Plantar flexion of the foot at the ankle;

• Reversed origin insertion action: when standing, the calcaneus becomes
the fixed origin of the muscle;
• Soleus muscle stabilizes the tibia on the calcaneus limiting forward sway.

Nerve supply

Tibial nerve, L4, L5, S1 , S2

No sensory supply to the intramuscular aponeurosis.

Blood supply

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• Blood supply of the soleus muscle is from peroneal artery proximally and
the posterior tibial artery distally;
• Muscle has a mixed blood supply;
• Vascular supply of the soleus is from popliteal, posterior tibial, & peroneal
vascular pedicles to the proximal muscle, peroneal pedicles to distal lateral
belly, and segmental posterior tibial pedicles to distal medial belly;
• With distal pedicles from the posterior tibial artery ligated & based on
proximal pedicles from the posterior tibial and peroneal arteries, muscle
can be transposed medially or laterally to cover defects in middle third of
the leg;
• Proximal vasculature arises directly from the popliteal vessels and can
reliably carry all but the distal 4 to 5 cm of the muscle;
• Intramuscularly, vasculature of the soleus divides into a bipenniform
segmental pattern;
• With this vascular pattern, either half of the soleus muscle can be used,
leaving a functional hemisoleus muscle intact

Function

Soleus has two major functions:

• To act as skeletal muscle:

• Along with other calf muscles it is powerful plantarflexor and has
a major contribution in running, walking and dancing.
• It is also a major postural muscle designed to stop the body from
falling forwards at the ankle during stance.
• In the seated calf raise (knees flexed approximately 90º), the
gastrocnemius is virtually inactive while the load is borne almost
entirely by the soleus.
• In moderate force, the soleus is preferentially activated in the
concentric phase, whereas the gastrocnemius is preferentially
activated in the eccentric phase [2].
• Human soleus muscle tissue consists predominantly of slow
twitch fibers, though the composition can range between 60 and
100% slow fibers.[3][4][5].

• To act as muscle pump:

• The soleal pump assists with venous return from the periphery to
the heart when upright as the venous circulatory system passes
through the muscle tissue.

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CUTANEOUS NERVE SUPPLY OF DORSUM OF FOOT

The foot is supplied by four nerves; the medial border of the dorsum up to the ball of the
great toe is supplied by the saphenous nerve. The area of the first interdigital cleft is
innervated by the deep peroneal nerve (DPN). The lateral border is supplied by the sural
nerve (SN) and the rest of the portion is supplied by the superficial peroneal nerve (SPN)
by its 2 branches the intermediate dorsal cutaneous nerve (IDCN) and medial dorsal
cutaneous nerve (MDCN)

ADDUCTOR MAGNUS

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CRUCIATE LIGAMENTS OF KNEE JOINT

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PATELLA

FLAT FOOT
Pes planus also known as flat foot is the loss of the medial longitudinal arch of the foot,
heel valgus deformity, and medial talar prominence. [1] In lay terms, it is a fallen arch of the
foot that caused the whole foot to make contact with the surface the individual is standing
on.
It is of two forms; flexible flat foot and rigid flat foot. When the arch of the foot is intact on
heel elevation and non-bearing but disappears on full standing on the foot, it is termed
flexible flat foot while rigid flat foot is when the arch is not present in both heel elevation
and weight bearing

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GLUTEUS MEDIUS

SARTORIUS

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BLOOD SUPPLY OF LOWERLIMB

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PERFORATING VEINS:

FACTORS THAT HELP IN VENOUS RETURN:

SOLEUS IS KNOWN AS PERIPHERAL HEART:

APPLIED ASPECT:

ANKLE JOINT
The ankle joint (or talocrural joint) is a synovial joint located in the lower limb. It is formed
by the bones of the leg (tibia and fibula) and the foot (talus).Functionally, it is a hinge
type joint, permitting dorsiflexion and plantarflexion of the foot

Articulating Surfaces
The ankle joint is formed by three bones; the tibia and fibula of the leg, and the talus of the
foot:

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The
tibia and fibula are bound together by strong tibiofibular ligaments. Together, they form a
bracket shaped socket, covered in hyaline cartilage. This socket is known as a mortise.

The body of the talus fits snugly into the mortise formed by the bones of the leg. The
articulating part of the talus is wedge shaped – it is broad anteriorly, and narrow posteriorly:

• Dorsiflexion – the anterior part of the talus is held in the mortise, and the joint is more
stable.
• Plantarflexion – the posterior part of the talus is held in the mortise, and the joint is
less stable

Ligaments
There are two main sets of ligaments, which originate
from each malleolus.

Medial Ligament
The medial ligament (or deltoid ligament) is attached
to the medial malleolus (a bony prominence projecting
from the medial aspect of the distal tibia).

It consists of four ligaments, which fan out from the

malleolus, attaching to the talus, calcaneus and
navicular bones. The primary action of the medial
ligament is to resist over-eversion of the foot.

Lateral Ligament
The lateral ligament originates from the lateral malleolus (a bony prominence projecting
from the lateral aspect of the distal fibula).

It resists over-inversion of the foot, and is comprised of three distinct and

separate ligaments:

• Anterior talofibular – spans between the lateral malleolus and lateral aspect of the
talus.
• Posterior talofibular – spans between the lateral malleolus and the posterior aspect
of the talus.
• Calcaneofibular – spans between the lateral malleolus and the calcaneus.

Movements and Muscles Involved

The ankle joint is a hinge type joint, with movement permitted in one plane.

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Thus,
plantarflexion and dorsiflexion are the main movements that occur at the ankle joint.
Eversion and inversion are produced at the other joints of the foot, such as the subtalar
joint.

• Plantarflexion – produced by the muscles in the posterior compartment of the

leg (gastrocnemius, soleus, plantaris and posterior tibialis).

• Dorsiflexion – produced by the muscles in the anterior compartment of the

leg (tibialis anterior, extensor hallucis longus and extensor digitorum longus).

Neurovascular Supply
The arterial supply to the ankle joint is derived from the malleolar branches of the anterior
tibial, posterior tibial and fibular arteries.

Innervation is provided by tibial, superficial fibular and deep fibular nerves

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QUADRICEP FEMORIS
The quadriceps femoris consists of four individual muscles; three vastus muscles and the
rectus femoris. They form the main bulk of the thigh, and collectively are one of the most
powerful muscles in the body.

The muscles that form the quadriceps femoris unite proximal to the knee and attach to the
patella via the quadriceps tendon. In turn, the patella is attached to the tibia by the patella
ligament. The quadriceps femoris is the main extensor of the knee.

Vastus Lateralis
• Proximal attachment: Originates from the greater trochanter and the lateral lip of
linea aspera.
• Actions: Extends the knee joint and stabilises the patella.
• Innervation: Femoral nerve.

Vastus Intermedius
• Proximal attachment: Anterior and lateral surfaces of the femoral shaft.
• Actions: Extends the knee joint and stabilises the patella.
• Innervation: Femoral nerve.

Vastus Medialis
• Proximal attachment: The intertrochanteric line and medial lip of the linea aspera.
• Actions: Extends the knee joint and stabilises the patella, particularly due to its
horizontal fibres at the distal end.
• Innervation: Femoral nerve.

Rectus Femoris
• Attachments: Originates from the anterior inferior iliac spine and the area of the ilium
immediately superior to the acetabulum. It runs straight down the leg and attaches to
the patella via the quadriceps femoris tendon.
• Actions: The only muscle of the quadriceps to cross both the hip and knee joints. It
flexes the thigh at the hip joint, and extends at the knee joint.
• Innervation: Femoral nerve.

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HAMSTRING MUSCLES
The muscles in the posterior compartment of the thigh are collectively known as
the hamstrings. They consist of the biceps femoris, semitendinosus and
semimembranosus, which form prominent tendons medially and laterally at the back of the
knee.

As group, these muscles act to extend at the hip, and flex at the knee. They are innervated
by the sciatic nerve (L4-S3).

Biceps Femoris
Like the biceps brachii in the arm, the biceps femoris muscle has two heads – a long head
and a short head.

It is the most lateral of the muscles in the posterior thigh – the common tendon of the two
heads can be felt laterally at the posterior knee.

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• Attachments: The long head originates from the ischial tuberosity of the pelvis. The
short head originates from the linea aspera on posterior surface of the femur.
Together, the heads form a tendon, which inserts into the head of the fibula.

• Actions: Main action is flexion at the knee. It also extends the thigh at the hip, and
laterally rotates at the hip and knee.

• Innervation: Long head innervated by the tibial part of the sciatic nerve, whereas the
short head is innervated by the common fibular part of the sciatic nerve.

Semitendinosus
The semitendinosus is a largely tendinous muscle. It lies medially to the biceps femoris, and
covers the majority of the semimembranosus.

• Attachments: It originates from the ischial tuberosity of the pelvis, and attaches to
the medial surface of the tibia.
• Actions: Flexion of the leg at the knee joint. Extension of thigh at the hip. Medially
rotates the thigh at the hip joint and the leg at the knee joint.
• Innervation: Tibial part of the sciatic nerve.

Semimembranosus
The semimembranosus muscle is flattened and broad. It is located underneath the
semitendinosus.

• Attachments: It originates from the ischial tuberosity, but does so

more superiorly than the semitendinosus and biceps femoris. It attaches to the medial
tibial condyle.
• Actions: Flexion of the leg at the knee joint. Extension of thigh at the hip. Medially
rotates the thigh at the hip joint and the leg at the knee joint.
• Innervation: Tibial part of the sciatic nerve

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SUBTALAR JOINT
The subtalar joint is an articulation between two of the tarsal bones in the foot – the talus
and calcaneus. The joint is classed structurally as a synovial joint, and functionally as
a plane synovial joint.
Articulating Surfaces
The subtalar joint is formed between two of the tarsal bones:

• Inferior surface of the body of the talus – the posterior talar articular surface.
• Superior surface of the calcaneus – the posterior calcaneal articular facet.

As is typical for a synovial joint, these surfaces are covered by articular cartilage.

Stability
The subtalar joint is enclosed by a joint capsule, which is
lined internally by synovial membrane and strengthened
externally by a fibrous layer. The capsule is
also supported by three ligaments:

• Posterior talocalcaneal ligament

• Medial talocalcaneal ligament
• Lateral talocalcaneal ligament

An additional ligament – the interosseous talocalcaneal ligament – acts to bind the talus
and calcaneus together. It lies within the sinus tarsi (a small cavity between the talus and
calcaneus), and is particularly strong; providing the majority of the ligamentous stability to
the joint.
Movements
The subtalar joint is formed on an oblique axis and is therefore the chief site within the foot
for generation of eversion and inversion movements. This movement is produced by
the muscles of the lateral compartment of the leg. and tibialis anterior muscle respectively.

The nature of the articulating surface means that the subtalar joint has no role in plantar or
dorsiflexion of the foot.
Neurovascular Supply
The subtalar joint receives supply from two arteries and two nerves. Arterial supply comes
from the posterior tibial and fibular arteries.

Innervation to the plantar aspect of the joint is supplied by the medial or lateral plantar
nerve, whereas the dorsal aspect of the joint is supplied by the deep fibular nerve

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ARCHES OF FOOT
The foot has three arches: two longitudinal (medial and lateral) arches and one anterior
transverse arch. They are formed by the tarsal and metatarsal bones, and supported by
ligaments and tendons in the foot.
Longitudinal Arches
There are two longitudinal arches in the foot – the medial and lateral arches. They are
formed between the tarsal bones and the proximal end of the metatarsals.

Medial Arch
The medial arch is the higher of the two longitudinal arches. It is formed by the calcaneus,
talus, navicular, three cuneiforms and first three metatarsal bones. It is supported by:

• Muscular support: Tibialis anterior and posterior, fibularis longus, flexor digitorum
longus, flexor hallucis, and the intrinsic foot muscles
• Ligamentous support: Plantar ligaments (in particular the long plantar, short plantar
and plantar calcaneonavicular ligaments), medial ligament of the ankle joint.
• Bony support: Shape of the bones of the arch.
• Other: Plantar aponeurosis.

Lateral Arch
The lateral arch is the flatter of the two longitudinal arches, and lies on the ground in the
standing position. It is formed by the calcaneus, cuboid and 4th and 5th metatarsal bones.
It is supported by:

• Muscular support: Fibularis longus, flexor digitorum longus, and the intrinsic foot
muscles.

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• Ligamentous support: Plantar ligaments (in particular the long plantar, short plantar
and plantar calcaneonavicular ligaments).
• Bony support: Shape of the bones of the arch.
• Other: Plantar aponeurosis.

Transverse Arch
The transverse arch is located in the coronal plane of the foot. It is formed by the metatarsal
bases, the cuboid and the three cuneiform bones. It has:

• Muscular support: Fibularis longus and tibialis posterior.

• Ligamentous support: Plantar ligaments (in particular the long plantar, short plantar
and plantar calcaneonavicular ligaments) and deep transverse metatarsal ligaments.

• Other support: Plantar aponeurosis.

• Bony support: The wedged shape of the bones of the arch

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DORSIFLEXION AND PLANTAR FLEXION

Dorsiflexion and plantarflexion are terms used to describe movements at the ankle. They
refer to the two surfaces of the foot; the dorsum (superior surface) and the plantar surface
(the sole).

Dorsiflexion refers to flexion at the ankle, so that the foot points more superiorly.
Dorsiflexion of the hand is a confusing term, and so is rarely used. The dorsum of the hand
is the posterior surface, and so movement in that direction is extension. Therefore we can
say that dorsiflexion of the wrist is the same as extension.

Plantarflexion refers extension at the ankle, so that the foot points inferiorly. Similarly there
is a term for the hand, which is palmarflexion

FONTANELLA
Fontanelles, often referred to as "soft spots," are one of the most prominent anatomical features of the newborn's skull.
Six fontanelles are present during infancy, with the most notable being the anterior and posterior fontanelles. Fontanelle
morphology may vary between infants, but characteristically they are flat and firm.

Anterior Fontanelle
The anterior fontanelle is the largest of the six fontanelles, and it resembles a diamond-shape ranging in size
from 0.6 cm to 3.6 cm with a mean of 2.1 cm.[2] It forms through the juxtaposition of the frontal bones and
parietal bones with the superior sagittal sinus coursing beneath it. Two frontal bones join to form one-half the
anterior fontanelle with the metopic suture serving as the parallel divider between the paired bones. Next, the
parietal bones are positioned against each other to complete the fontanelle. The positioning of the two parietal
bones against each other gives rise to the sagittal suture.

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Posterior Fontanelle
Unlike the anterior fontanelle, the posterior fontanelle is triangular and completely closes within about six to
eight weeks after birth.[7] This structure arises from the juncture of the parietal lobes and occipital lobe.
Through this placement, the lambdoid suture forms. On average, the posterior fontanelle is 0.5 cm in Caucasian
infants and 0.7 cm infants of African descent.[4] Often, the delayed closure of the posterior fontanelle is
associated with hydrocephalus or congenital hypothyroidism.[9]
Mastoid Fontanelle
The mastoid fontanelle, a paired structure, can be found at the intersection of temporal, parietal, and occipital
bones. Additionally, the mastoid fontanelle also has the name of the posterolateral fontanelle. These fontanelles
may close anywhere from six to eighteen months of age.
Sphenoid Fontanelle
Similarly, the sphenoid fontanelle is also paired. Its location can be on either side of the skull at the convergence
of the sphenoid, parietal, temporal, and frontal bone. It is also known as the anterolateral fontanelle; their
closure occurs at approximately the sixth-month mark after birth.
Third Fontanel
Uniquely, a third fontanelle between the anterior and posterior fontanelles correlates with certain conditions like
Down syndrome and congenital infections such as rubella.

Clinical Significance
•

o Most Common
o Achondroplasia
▪ Congenital hypothyroidism
▪ Down syndrome
▪ Increased intracranial pressure
▪ Rickets
o Less Common
▪ Osteogenesis imperfecta
▪ Hypophosphatasia
▪ Trisomy 13
▪ Trisomy 18

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FORAMEN OVALE
The foramen ovale is another opening located at the base of the greater wing of the
sphenoid.

It is positioned posterolateral to the foramen rotundum within the middle cranial fossa. It
conducts the mandibular nerve (branch of the trigeminal nerve, CN V) and the accessory
meningeal artery

This oval shaped hole lies posterior and lateral to the foramen rotundum. The foramen ovale allows passage
of the final division of the trigeminal nerve, the mandibular nerve (CNV3). Not surprisingly perhaps, the
mandibular nerve enters the skull through the foramen ovale bringing sensory information from the face and
skin that overlies the mandible, or lower jaw bone. The foramen ovale occasionally also allows passage of
the lesser petrosal nerve (a branch of the ninth cranial nerve (CNIX), the glossopharyngeal) which will
innervate the parotid gland, as well as the emissary vein and accessory meningeal branch of the maxillary
artery. A useful mnemonic to remember these structures is "MALE" (Mandibular branch of trigeminal
nerve, Accessory meningeal branch of maxillary artery, Lateral petrosal nerve, Emissary vein).

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ANSA CERVICALIS
The ansa cervicalis (C1-C3) is a nerve loop which stems from the cervical plexus and innervates the three
out of four infrahyoid neck muscles. It is located in the carotid sheath, deep to the sternocleidomastoid
muscle

The ansa cervicalis is formed by two roots which stem from the cervical plexus; superior and inferior.

The superior root is composed of the fibers from the anterior rami of spinal nerves C1 and C2. These fibers
travel together with the hypoglossal nerve behind the posterior belly of the digastric muscle, after which
they branch off of the hypoglossal nerve and continue as the superior root of the ansa cervicalis. Note that
the root does not contain any fibers from the hypoglossal nerve. The superior root then curves downwards
and travels along the anterior wall of the carotid sheath. During its path, it gives rise to the muscular
branches to the superior belly of the omohyoid muscle, as well as to the upper halves of
the sternothyroid and sternohyoid muscles. Then, it joins the inferior root to complete the ansa cervicalis.

The inferior root arises from the fibers of the anterior rami of spinal nerves C2 and C3. It crosses the
anterolateral side of the internal jugular vein, giving rise to branches that supply the inferior belly of the
omohyoid muscle, as well as the lower halves of the sternothyroid and sternohyoid muscles.

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MOVEMENTS OF MANDIBULAR JOINT

A variety of movements occur at the TMJ. These movements are mandibular depression,
elevation, lateral deviation (which occurs to both the right and left sides), retrusion and
protrusion.

Each of these movements are performed by a number of muscles working together to

perform the movement while controlling the position of the condyle within the mandibular
fossa.

Chewing and talking require a combination of jaw movements in a number of directions

WALDEYER’S RING
Waldeyer’s ring consists of four tonsillar structures (namely, the pharyngeal, tubal, palatine and lingual
tonsils) as well as small collections of lymphatic tissue disbursed throughout the mucosal lining of
the pharynx (mucosa-associated lymphoid tissue, MALT).

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EXTERNAL CAROTID ARTERY BRANCHES

The external carotid artery has eight branches: the Superior thyroid, Ascending
pharyngeal, Lingual, Facial, Occipital, Posterior auricular, Maxillary and Superficial temporal arteries. You
can easily remember them with the mnemonic Some Anatomists Like Freaking Out Poor Medical Students'.

Superior thyroid artery

The superior thyroid artery (S) is the origin of the superior laryngeal artery that supplies the larynx. The
main artery also supplies the thyroid gland, infrahyoid muscles and the sternocleidomastoid muscle.

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(mnemonic "I Shall Squeeze Charlie's Glutes", which stands for the branches of the superior thyroid
artery; Infrahyoid, Superior laryngeal, Sternocleidomastoid, Cricothyroid and Glandular.)

Ascending pharyngeal artery

The ascending pharyngeal artery (A) ascends superiorly along the pharynx, while branching off to
the pharynx, prevertebral muscles, the middle ear and the cranial meninges.
Lingual artery

The lingual artery (L) is covered by the hypoglossal nerve (CN XII), the stylohyoid muscle and the
posterior belly of the digastric muscle. It runs beneath the hyoglossus muscles and branches into the deep
lingual and sublingual arteries which supply the intrinsic muscles of the tongue and the floor of
the mouth.

Facial artery

The facial artery (F) runs around the middle of the mandible before it enters the face, where it gives
branches to the tonsils, palate and the submandibular glands.
Occipital artery

The occipital artery (O) supplies the posterior region of the scalp and grooves the base of the skull as it
travels. Initially it passes deep to the posterior belly of the digastric muscle.
Posterior auricular artery

The posterior auricular artery (P) runs behind the external acoustic meatus and the mastoid process,
separating the two structures. It supplies the adjacent musculature, the parotid gland, the facial nerve (CN
VII), the ear and the scalp.

Maxillary artery

The maxillary artery (M) is the larger of the two terminal branches Its branches supply:

• the external acoustic meatus

• the tympanic membrane
• the dura mater
• the calvaria
• the mandible
• the gingivae

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• the teeth
• the temporal muscle
• the pterygoid muscle
• the masseter muscle
• the buccinator muscle
Superficial temporal artery

The superficial temporal artery (S) supplies only the temporal region of the scalp, as it is the smaller
terminal branch and does not have additional named branches or divisions.

CARVENOUS SINUS
Anatomical Location and Borders
The cavernous sinuses are located within the middle cranial fossa, on either side of the sella
turcica of the sphenoid bone (which contains the pituitary gland). They are enclosed by the
endosteal and meningeal layers of the dura mater.

The borders of the cavernous sinus are as follows:

• Anterior – superior orbital fissure.

• Posterior – petrous part of the temporal bone.
• Medial – body of the sphenoid bone.

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• Lateral – meningeal layer of the dura mater running from the roof to the floor of the
middle cranial fossa.
• Roof – meningeal layer of the dura mater that attaches to the anterior and middle
clinoid processes of the sphenoid bone.
• Floor – endosteal layer of dura mater that overlies the base of the greater wing of the
sphenoid bone.

Contents
Several important structures pass through the cavernous sinus to enter the orbit. They can
be sub-classified by whether they travel through the sinus itself, or through its lateral wall:

Dural Venous Sinus System

Each cavernous sinus receives venous drainage from:

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• Ophthalmic veins (superior and inferior) – these enter the cavernous sinus via the
superior orbital fissure.
• Central vein of the retina – drains into the superior ophthalmic vein, or directly into
the cavernous sinus.
• Sphenoparietal sinus – empties into the anterior aspect of the cavernous sinus.
• Superficial middle cerebral vein – contributes to the venous drainage of the
cerebrum
• Pterygoid plexus – located within the infratemporal fossa.

It is important to note that the superior ophthalmic vein forms an anastomosis with the facial
vein.

TONGUE
the tongue is embryologically divided into an anterior and a posterior part. The anterior part of the tongue
is also called the oral or presulcal part of the tongue. Conversely, the posterior part of the tongue is referred
to as the pharyngeal or postsulcal part of the tongue.

Anatomy

the length of the tongue among individuals, on average, the organ is roughly 10 cm long. It has three main
parts:

• The tip or apex of the tongue is the most anterior, and most mobile aspect of the organ.

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• The tip
is followed by the body of the tongue. It has a rough dorsal (superior) surface that abuts the palate
and is populated with taste buds and lingual papillae, and a smooth ventral (inferior) surface that is
attached to the floor of the oral cavity by the lingual frenulum.
• The base of the tongue is the most posterior part of the organ. It is populated by numerous lymphoid
aggregates known as the lingual tonsils along with foliate papillae along the posterolateral surface.

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PARANASAL AIR SINUSES

The paranasal sinuses are air-filled extensions of the nasal cavity. There are four paired
sinuses – named according to the bone in which they are located – maxillary, frontal,
sphenoid and ethmoid. Each sinus is lined by a ciliated pseudostratified epithelium,
interspersed with mucus-secreting goblet cells.

The function of the paranasal sinuses is a topic of much debate. Various roles have been
suggested:

• Lightening the weight of the head

• Supporting immune defence of the nasal cavity
• Humidifying inspired air
• Increasing resonance of the voice

The paranasal sinuses are formed during development by the nasal cavity eroding into the
surrounding bones. All the sinuses therefore drain back into the nasal cavity – openings to
the paranasal sinuses can be found on the roof and lateral nasal walls

Frontal Sinuses
There are two frontal sinuses located within the frontal bone of the skull. They are the most
superior of the paranasal sinuses, and are triangular in shape.

Drainage is via the frontonasal duct. It opens out at the hiatus semilunaris, within the
middle meatus of the nasal cavity.

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Sensation is supplied by the supraorbital nerve (a branch of the ophthalmic nerve), and
arterial supply is via the anterior ethmoidal artery (a branch of the internal carotid).
Sphenoid Sinuses
The sphenoid sinuses are situated within the body of the sphenoid bone. They open out
into the nasal cavity in an area supero-posterior to the superior cocha – known as the
spheno-ethmoidal recess.

They are innervated by the posterior ethmoidal nerve (a branch of the ophthalmic nerve),
and branches of the maxillary nerve. They recieve blood supply from pharyngeal branches
of the maxillary arteries.

Ethmoidal Sinuses
There are three ethmoidal sinuses located within the ethmoid bone:

• Anterior – Opens onto the hiatus semilunaris (middle meatus)

• Middle – Opens onto the lateral wall of the middle meatus
• Posterior – Opens onto the lateral wall of the superior meatus

They are innervated by the anterior and posterior ethmoidal branches of the nasociliary
nerve and the maxillary nerve. The anterior and posterior ethmoidal arteries are responsible
for arterial supply.
Maxillary Sinuses
The maxillary sinuses are the largest of the sinuses. They are located laterally and
slightly inferiorly to the nasal cavities.

They drain into the nasal cavity at the hiatus semilunaris, underneath the frontal sinus
opening. This is a potential pathway for spread of infection – fluid draining from the frontal
sinus can enter the maxillary sinus.

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EPISTAXIS
Epistaxis refers to bleeding from the nose. In the vast majority, cases will terminate with
simple manoeuvres and minimal intervention. However, in a small proportion of patients,
epistaxis can lead to significant haemorrhage warranting urgent intervention.

Epistaxis can be caused from:

• Anterior bleeds – originate from ruptured blood vessels in Little’s area, a highly-
vascularised region formed by the anastomosis of 5 arteries, and cause around 90%
of cases
• Posterior bleeds – originate from the posterior nasal cavity, typically from branches
of the sphenopalatine arteries of the nose, and cause around 10% of cases (more
common in older patients)
• There are numerous causes for epistaxis to consider, including trauma (i.e. nose
picking), hypertension, iatrogenic (e.g. anti-coagulants), or foreign bodies.
• Less common causes include coagulopathies, platelet disorders, vascular
malformations, vasculitis, rhinosinusitis (including allergies), malignancy, or cocaine
use

CAVITY OF LARYNX

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EAR OSSICLES

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TYMPANIC MEMBRANE
The tympanic membrane, commonly known as the eardrum, is a thin layer of skin
stretched tight, like a drum, in the ear. The eardrum separates the outer ear from the
middle ear and vibrates in response to soundwaves.

The eardrum is part of a complex system involved in the hearing process. It also protects
the middle ear from debris and bacteria.

Anatomy
The eardrum has three layers: the outer layer, inner layer, and middle layer. The middle
layer is made of fibers that give the eardrum elasticity and stiffness. Cartilage holds the
eardrum in place.

The eardrum covers the end of the external ear canal and looks like a flattened cone with its
tip pointed inward toward the middle ear. It is transparent and is about the size of a dime.1

The eardrum divides the outer ear from the middle ear. The eardrum sits between the end of
the external ear canal and the auditory ossicles, which are three tiny bones in the middle
ear, called the malleus, incus, and stapes.

Function
The two primary functions of the eardrum are auditory and protective.

Auditory
As soundwaves enter the ear canal, they hit the eardrum, causing it to vibrate. These
vibrations then move the three tiny bones in the middle ear.

Those bones then increase the sound and send them to the cochlea in the inner ear, where
hair cells ripple and an electrical signal is created. From there, an auditory nerve carries the
signal to the brain, where it is received as sound.2

Protective
In addition to helping you hear, the eardrum also acts as a protective barrier, keeping the
middle ear free from dirt, debris, and bacteria. If an eardrum becomes perforated or
ruptures, the middle ear is vulnerable to infection.

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CLINICAL SIGNIFICANCE:the eardrum is delicate and can rupture or tear. Most often this
happens as a result of a middle ear infection (called otitis media). Damage to the eardrum
can also occur as a result of trauma from things like:

• Injury from hitting the eardrum with an object, such as a cotton swab
• Loud noises
• Head injury
• Changes in air pressure

INFRAHYOID MUSCLE
The infrahyoid muscles are a group of four muscles that are located inferiorly to the hyoid
bone in the neck. They can be divided into two groups:

• Superficial plane – omohyoid and sternohyoid muscles.

• Deep plane – sternothyroid and thyrohyoid muscles.

The arterial supply to the infrahyoid muscles is via the superior and inferior thyroid arteries,
with venous drainage via the corresponding veins

Omohyoid
The omohyoid is comprised of two muscle bellies, which are connected by a muscular
tendon.

• Attachments:

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o The inferior belly of the omohyoid arises from the scapula. It runs
superomedially underneath the sternocleidomastoid muscle.
o It is attached to the superior belly by an intermediate tendon, which is anchored
to the clavicle by the deep cervical fascia.
o From here, the superior belly ascends to attach to the hyoid bone.
• Actions: Depresses the hyoid bone.
• Innervation: Anterior rami of C1-C3, carried by a branch of the ansa cervicalis

Sternohyoid
The sternohyoid muscle is located within the superficial plane.

• Attachments: Originates from the sternum and sternoclavicular joint. It ascends to

insert onto the hyoid bone.
• Actions: Depresses the hyoid bone.
• Innervation: Anterior rami of C1-C3, carried by a branch of the ansa cervicalis.

Sternothyroid
The sternothyroid muscle is wider and deeper than the sternohyoid. It is located within the
deep plane.

• Attachments: Arises from the manubrium of the sternum, and attaches to the thyroid
cartilage.
• Actions: Depresses the thyroid cartilage.
• Innervation: Anterior rami of C1-C3, carried by a branch of the ansa cervicalis.

Thyrohyoid
The thyrohyoid is a short band of muscle, thought to be a continuation of the sternothyroid
muscle.

• Attachments: Arises from the thyroid cartilage of the larynx, and ascends to attach to
the hyoid bone.
• Actions: Depresses the hyoid. If the hyoid bone is fixed, it can elevate the larynx.
• Innervation: Anterior ramus of C1, carried within the hypoglossal nerve.

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RAMUS OF MANDIBLE
Rami
There are two mandibular rami, which project perpendicularly upwards from the angle of
the mandible. Each ramus contains the following bony landmarks:

• Head – situated posteriorly, and articulates with the temporal bone to form
the temporomandibular joint.
• Neck – supports the head of the ramus, and site of attachment of the lateral pterygoid
muscle.
• Coronoid process – site of attachment of the temporalis muscle

The internal surface of the ramus is also marked by the mandibular foramen, which acts
as a passageway for neurovascular structures

INTERIOR OF LARYNX
The internal space of the larynx is wide in the superior and inferior parts but narrows in the middle, forming a
section named glottis, and dividing all the spaces into three sections: supraglottic, glottis, and infraglottic.
The vocal cords, the glottis, and the larynx ventricles comprise the glottic space.

STYLOID PROCESS OF TEMPORAL BONE

The styloid process located immediately underneath the opening to the auditory meatus. It
acts as an attachment point for muscles and ligaments, such as the stylomandibular
ligament of the TMJ.

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PARATHYROID GLAND

Anatomical Location
The parathyroid glands are usually located on the posterior aspect of the thyroid gland.
They are flattened and oval in shape – situated external to the thyroid gland itself but within
the pretracheal fascia.

Most individuals have four parathyroid glands, although variation in number (from two to
six) is common:

• Superior parathyroid glands (x2) – derived from the fourth pharyngeal pouch. They
are located at the middle of the posterior border of each thyroid lobe,
approximately 1cm superior to the entry of the inferior thyroid artery into the thyroid
gland.

• Inferior parathyroid glands (x2) – derived from the third pharyngeal pouch. Although
inconsistent in location between individuals, the inferior parathyroid glands are usually
found near the inferior poles of the thyroid gland.

Vasculature
The vascular supply is similar to that of the thyroid gland.

Arterial supply is chiefly via the inferior thyroid artery (as this artery supplies the posterior
aspect of the thyroid gland – where the parathyroids are located). Collateral arterial supply
is from the superior thyroid artery and thyroid ima artery.

Venous drainage is into the superior, middle, and inferior thyroid veins.
Lymphatics
The lymphatic drainage from the parathyroid glands is to the paratracheal and deep
cervical nodes.
Nerves
The parathyroid glands have an extensive supply of sympathetic nerves derived
from thyroid branches of the cervical ganglia

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BASAL GANGLIA

EXTRA OCULAR MUSCLES

• Superior rectus

• Inferior rectus
• Lateral rectus
• Medial rectus

• Superior oblique
• Inferior oblique
• Levator palpebrae superioris

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MANDIBLE

MAXILLARY AIR SINUS

The maxillary sinus is one of the four paranasal sinuses, which are sinuses located near
the nose. The maxillary sinus is the largest of the paranasal sinuses. The two maxillary
sinuses are located below the cheeks, above the teeth and on the sides of the nose. The
maxillary sinuses are shaped like a pyramid and each contain three cavities, which point
sideways, inwards, and downwards. The sinuses are small air-filled holes found in the
bones of the face. They reduce skull weight, produce mucus, and affect the tone quality of
a person’s voice.

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The
maxillary sinus drains into the nose through a hole called the ostia. When the ostia
becomes clogged, sinusitis can occur. The ostia of the maxillary sinus often clog because
the ostia are located near the top of the maxillary sinus, thus making proper drainage
difficult.

Maxillary sinusitis or an infection of the maxillary sinus can have the following symptoms:
fever, pain or pressure in face near the cheekbones, toothache, and runny nose. Sinusitis
is the most common of maxillary sinus illnesses and is usually treated with prescription
antibiotics.

ORBICULARIS OCULI MUSCLE

AUDITARY PATHWAY

Components of the Auditory Pathway

The auditory pathway is complex in that divergence and convergence of information
happens at different stages.

There are two main components of the auditory pathway:

• Primary (lemniscal) pathway – this is the main pathway through which auditory
information reaches the primary auditory cortex (A1).

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• Non-
lemniscal pathway – mediating unconscious perception such as attention, emotional
response, and auditory reflexes.

Primary Pathway
Spiral Ganglion
The spiral ganglion houses the cell bodies of the first order neurons (ganglion refers to a
collection of cell bodies outside the central nervous system). These neurones receive
information from hair cells in the Organ of Corti and travel within the osseous spiral lamina.
Their central axons form the main component of the cochlear nerve.

Cochlear Nuclei
Fibres from the cochlear nerve bifurcate and information is sent to the cochlear nuclei on
each side of the brainstem:

• Ventral (anterior) cochlear nucleus – located in the area where the nerve enters the
brainstem.
• Dorsal (posterior) cochlear nucleus – located posterior to the inferior cerebellar
peduncle.
o It forms a small bulge on the surface of the brainstem – known as the auditory
tubercle.

Inferior Colliculus and Medial Geniculate Body

fibres ascending through the lateral lemniscus from both cochlear nuclei and from the
superior olivary nuclei arrive at the inferior colliculus, where all these fibres carrying
auditory information converge.

These fibres project to the ipsilateral medial geniculate body (MGB) in the thalamus

Primary Auditory Cortex

The primary auditory cortex (A1) is located in the superior temporal gyrus, right under
the lateral fissure. The primary auditory cortex is organized tonotopically, although its
organisation is complex

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PITUITARY GLAND

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NASAL CAVITY LATERAL WALL

THORACOLUMBAR FASCIA

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MENINGES OF SPINAL CORD

Spinal dura mater

The dura mater of the spinal cord differs from that of the brain by having only one layer; the meningeal
layer. The spinal dura mater attaches to the tectorial membrane and posterior longitudinal ligament
superiorly. Inferiorly, it extends up to S2 vertebral level, thus extending below the spinal cord termination
(L1/L2).

The space between the spinal dura mater and the periosteum of the vertebral column is called the epidural
space. It is filled with loose connective and adipose tissues, and traversed by the anterior and posterior
internal vertebral venous plexuses.
Spinal arachnoid mater

It lies close and beneath the spinal dura, with a narrow subdural space existing between them. Deep to the
arachnoid is the spinal pia mater. Between arachnoid and pia, there is the spinal subarachnoid space.
The lumbar cistern extends from L1-S2 and it contains the dorsal and ventral rootlets of L2-Co spinal
nerves (cauda equina). It is clinically significant as it is the site of lumbar puncture (extraction of CSF for
biochemical, microbiological and cytological analyses or application of certain medicine).
Spinal pia mater

The spinal pia mater continues onto the cranial pia at the level of the foramen magnum. It closely envelops
the spinal cord, containing a vascular plexus for the spinal cord tissue

ENLARGEMENT OF SPINALCORD
spinal cord expansion that corresponds to the arms is called the cervical enlargement and includes spinal
segments C5—T1; the expansion that corresponds to the legs is called the lumbar enlargement and includes
spinal segments L2—S3.

The lumbar enlargement (or lumbosacral enlargement) is a widened area of the spinal cord that gives attachment
to the nerves which supply the lower limbs.
It commences about the level of T11 and ends at L2, and reaches its maximum circumference, of about 33 mm.
Inferior to the lumbar enlargement is the conus medullaris.[1]
An analogous region for the upper limbs exists at the cervical enlargement
The cervical enlargement corresponds with the attachments of the large nerves which supply the upper limbs.
Located just above the brachial plexus, it extends from about the fifth cervical to the first thoracic vertebra, its
maximum circumference (about 38 mm.) being on a level with the attachment of the sixth pair of cervical nerves.
The reason behind the enlargement of the cervical region is because of the increased neural input and output to the
upper limbs.

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An
analogous region in the lower limbs occurs at the lumbar enlargement.

FILUM TERMINALE
The filum terminale ("terminal thread") is a delicate strand of fibrous tissue, about 20 cm in length, proceeding
downward from the apex of the conus medullaris. It is one of the modifications of pia mater. It gives longitudinal
support to the spinal cord and consists of two parts:

• The upper part, or filum terminale internum, is about 15 cm long and reaches as far as the lower border
of the second sacral vertebra. It is continuous above with the pia mater and contained within a tubular
sheath of the dura mater. In addition, it is surrounded by the nerves forming the cauda equina, from
which it can be easily recognized by its bluish-white color.
• The lower part, or filum terminale externum, closely adheres to the dura mater. It extends downward
from the apex of the tubular sheath and is attached to the back of the first segment of the coccyx in a
structure sometimes referred to as the coccygeal ligament.
The most inferior of the spinal nerves, the coccygeal nerve leaves the spinal cord at the level of the conus medullaris
via respective vertebrae through their intervertebral foramina, superior to the filum terminale. However, adhering to
the outer surface of the filum terminale are a few strands of nerve fibres which probably represent rudimentary
second and third coccygeal nerves.[1] Furthermore, the central canal of the spinal cord extends 5 to 6 cm beyond the
conus medullaris, downward into the filum terminale.

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CAUDA EQUINA SYNDROME

Cauda equina syndrome (CES) is a rare but serious neurological condition affecting the
bundle of nerve roots at the lower end of the spinal cord. The CE provides innervation to
the lower limbs, and sphincter,controls the function of the bladder and distal bowel and
sensation to the skin around the bottom and back passage [1].CES occurs when the nerves
below the spinal cord are compressed causing compromise to the bladder and bowel. The
most common cause of CES is a prolapse of a lumbar disc but other conditions such as
metastatic spinal cord compression can also cause CES

Symptoms and Diagnosis

• Urinary retention: the most common symptom. The patient’s bladder fills with urine, but the
patient does not experience the normal sensation or urge to urinate.
• Urinary and/or fecal incontinence. The overfull bladder can result in incontinence of urine.
Incontinence of stool can occur due to dysfunction of the anal sphincter.
• “Saddle anethesia” sensory disturbance, which can involve the anus, genitals and buttock
region.
• Weakness or paralysis of usually more than one nerve root. The weakness can affect lower
extremities.
• Pain in the back and/or legs (also known as sciatica).
• Sexual dysfunction.

Potential Causes of CES

• Spinal lesions and tumors

• Spinal infections or inflammation
• Lumbar spinal stenosis
• Violent injuries to the lower back (gunshots, falls, auto accidents)
• Birth abnormalities
• Spinal arteriovenous malformations (AVMs)
• Spinal hemorrhages (subarachnoid, subdural, epidural)
• Postoperative lumbar spine surgery complications
• Spinal anesthesia

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EXTERNAL FEATURES OF SPINALCORD

The following are external features of the spinal cord (see Figure 1):

• Spinal nerves emerge in pairs, one from each side of the spinal cord along its length.
• The cervical nerves form a plexus (a complex interwoven network of nerves—nerves converge
and branch).
• The cervical enlargement is a widening in the upper part of the spinal cord (C 4–T 1). Nerves
that extend into the upper limbs originate or terminate here.
• The lumbar enlargement is a widening in the lower part of the spinal cord (T 9–T 12). Nerves
that extend into the lower limbs originate or terminate here.
• The anterior median fissure and the posterior median sulcus are two grooves that run the
length of the spinal cord on its anterior and posterior surfaces, respectively.
• The cauda equina are nerves that attach to the end of the spinal cord and continue to run
downward before turning laterally to other parts of the body.
• There are four plexus groups: cervical, brachial, lumbar, and sacral.The thoracic nerves do not
form a plexus.

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INTERNAL FEATURES OF SPINALCORD

The spinal cord is composed of an inner core of gray matter, which is surrounded by an outer covering of
white matter.
GRAY MATTER
• On cross section; the gray matter is seen as an H-shaped pillar with anterior and posterior gray
columns, or horns, united by a thin gray commissure containing the small central canal.
• A small lateral gray column or horn is present in the thoracic and upper lumbar segments of the
cord.
• The amount of gray matter present at any given level of the spinal cord is related to the amount of
muscle innervated at that level.
• Thus, its size is greatest within the cervical and lumbosacral enlargements of the cord.
WHITE MATTER
q The white matter, may be divided into anterior, lateral, and posterior white columns or funiculi.
q The anterior column on each side lies between the midline and the anterior nerve roots;
q The lateral column lies between the anterior and the posterior nerve roots;
q The posterior column lies between the posterior nerve roots and the midline.
Neuronal groups
Ø Nerve cell groups in anterior gray column
Ø Nerve cell groups in posterior gray column
Ø Nerve cell groups in lateral gray column

CAUDA EQUINA
The cauda equina consists of the spinal nerve roots L2-S5 and the coccygeal nerve. It lies within the distal
third of the vertebral canal and extends into the sacral canal. It occupies the lumbar cistern, which is an
enlargement of the subarachnoid space containing cerebrospinal fluid (CSF).

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Function

the cauda equina provides parasympathetic innervation to the viscera of the pelvic cavity and perineum,
including the urinary bladder, descending and sigmoid colon, rectum and both the internal and external
reproductive organs. This parasympathetic innervation is also involved in the stimulation of erectile tissues
of the external genitalia, enabling erection of the penis/clitoris.

The cauda equina, through its somatic and parasympathetic innervation, plays a crucial role in bladder
control, control of the urethral and anal sphincters and the overall maintenance of continence.

SPINAL SEGMENT
the spinal cord is divided into segments: cervical, thoracic, lumbar, sacral, and coccygeal. Each segment of the
spinal cord provides several pairs of spinal nerves, which exit from vertebral canal through the intervertebral
foramina. There are 8 pairs of cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal pair of spinal nerves
(a total of 31 pairs).

CRANIAL NERVES

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WEBER’S SYNDROME
Weber syndrome, classically described as a midbrain stroke syndrome and superior alternating hemiplegia,
involves oculomotor fascicles in the interpeduncular cisterns and cerebral peduncle, thereby causing ipsilateral
third nerve palsy with contralateral hemiparesis. It most commonly results from the occlusion of a branch of the
posterior cerebral artery.

Weber's syndrome can cause sudden weakness and vision changes, usually blurred or double vision
and eyelid droopiness. Weakness in the muscles of the face, arms, and legs is also possible.

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BLOOD SUPPLY OF SPINALCORD

LATERAL VENTRICLE
Body

The central part of the lateral ventricle is elongated anteroposteriorly. Anteriorly, it becomes continuous
with the anterior horn at the level of the interventricular foramen. Posteriorly, the body reaches
the splenium of the corpus callosum.

It is triangular in cross section and has a roof, floor, and a medial wall; the roof and floor meeting on the
lateral aspects.

• The roof is formed by the trunk of the corpus callosum

• The medial wall is formed by the septum pellucidum and by the body of the fornix, which is common to two
lateral ventricles.
• The floor is formed mainly by the superior surface of the thalamus, medially, and by the caudate nucleus
laterally. Between these two structures are the stria terminalis and the thalamostriate veins.
Inferior (temporal) horn

The inferior (temporal) horn is the largest component of the lateral ventricle. It begins at the posterior end
of the central region, and runs anteroinferiorly into the temporal lobe. It has an anterior end that reaches

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close to
the uncus of the cerebrum, a floor, and a roof. The roof of the inferior horn is formed mainly by
the tapetum of the corpus callosum and the cauda of the caudate nucleus. The lateral part of the roof (lateral
wall) is formed by fibres of the tapetum, while the medial part of the roof is formed by the tail of the caudate
nucleus and the stria terminalis. The floor of the inferior horn is formed mainly by the hippocampus, along
with the alveus and fimbriae.

Anterior (frontal) horn

he anterior (frontal) horn of the lateral ventricle lies anterior to the central part, from which it is separated
by an imaginary vertical line that runs at the level of the interventricular foramen. This extension is
triangular in cross section and has a roof, floor and medial wall. Its roof is formed by the most anterior part
of the trunk of the corpus callosum, while the floor is formed by the head of the caudate nucleus. The medial
wall is formed by the septum pellucidum.
Posterior (occipital) horn

The posterior (occipital) horn of the lateral ventricle extends posteromedially into the occipital lobe, and
like other parts of the lateral ventricle it has a roof, lateral wall and a medial wall.

The roof and lateral wall are formed by the tapetum, while the medial wall shows two elevations, one
superior and the other inferior and referred to as the calcar avis.

This bulb is formed by fibres of the forceps major as they run backwards from the splenium of the corpus callosum.

SUPEROLATERAL SURFACE OF BRAIN

The superolateral surface of the cerebral cortex is marked with striking features which divide the cortex
into the frontal lobe, temporal lobe, parietal lobe, occipital lobe and the insula, and define these lobes as
follows:

Frontal lobe
The inferior boundary of the frontal lobe, which is defined by the lateral fissure, has a stem – stem of the
lateral sulcus from which an anterior ramus (anterior branch) and an ascending ramus extend into the
inferior frontal gyrus to divide it into three parts:

• Pars orbitalis
• Pars triangularis

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• Pars
opercularis
The frontal lobe is defined on this surface by a fissure called central sulcus (fissure of Rolando) which runs
downwards and forwards towards a second fissure called the lateral sulcus
. It is further subdivided as follows: a sulcus called the precentral sulcus

Temporal lobe
This lobe is defined on the superolateral surface by the lateral sulcus and the inferior temporal sulcus

These two sulci are termed the superior and inferior temporal sulci, and they divide the superolateral surface of the
temporal lobe into the superior, middle and an inferior temporal gyri.

Parietal lobe
This lobe is defined on the superolateral surface by the central fissure anteriorly, and the parieto-occipital
sulcus, posteriorly.

three parts are the:

• Supramarginal gyrus – which is the part that arches over the upturned posterior end of the posterior
ramus of the lateral sulcus
• Angular gyrus – this part arches over the superior temporal sulcus
• Arcus temporooccipitalis – which arches over the posterior end of the inferior temporal sulcus.
Occipital lobe
This lobe is defined anteriorly by the parieto-occipital sulcus, the first imaginary line and the upturned
posterior end of the inferior temporal sulcus. It shows three short sulci. One of these, the lateral occipital
sulcus lies horizontally and divides the lobe into superior and inferior occipital gyri. The third is
the transverse occipital sulcus located in the uppermost part of the occipital lobe.

Insula
The surface of the insula is divided into a number of gyri. During development of the cerebral cortex, the
insula grows less than surrounding areas which, therefore, come to overlap it and occlude it from surface
view. These surrounding areas are called opercula (meaning lids; singular of opercula is operculum), and
are three in number:

• The frontal operculum: lying between the anterior and ascending rami of lateral sulcus
• The frontoparietal operculum: which lies above the posterior ramus of lateral sulcus
• The temporal operculum: which lies below the posterior ramus of lateral sulcus. This operculum has
a superior surface which is hidden in the depth of the lateral sulcus.

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FUNCTIONAL SURFACE OS THE BRAIN

Motor area (primary motor cortex)
This is the area corresponding to area 4 of Brodmann and possibly to the part of area 6 which lies in the
precentral gyrus. The motor area is located in the precentral gyrus on the superolateral surface, and in the
anterior part of the paracentral lobule on the medial surface. This area of the cortex is responsible for
initiation of voluntary movement.

Pre-motor area (motor association cortex)

This is the area corresponding to areas 6,8,44 and 45 of Brodmann. It is located just anterior to the motor
area, occupying the posterior parts of the superior, middle and inferior frontal gyri. The part of the
premotor area located in the superior and middle frontal gyri corresponds to area 6 and 8 of Brodmann.
The part in the inferior frontal gyrus corresponds to areas 44 and 45, and constitutes the motor speech area
(of Broca) or what is also called the anterior speech area (of Broca).

Sensory area (primary somatosensory cortex)

This functional area is located in the postcentral gyrus. It corresponds to area 1, 3 and 2 of Brodmann. It
extends into the medial surface, from the lateral surface, where it lies in the posterior part of the paracentral
lobule.

Auditory (acoustic) area

This is the cortex for hearing, situated in the temporal lobe. It is mostly hidden in the lateral sulcus, in the
anterior transverse temporal gyrus. It corresponds to areas 41 and 42 of Brodmann. It extends into the
superior temporal gyrus below the sulcus, and is here surrounded by the auditory association area (area
22)

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Visual areas
The areas concerned with vision are located in the occipital lobe, mainly on the medial surface, both above
and below the calcarine sulcus (area 17). Area 17 extends into the cuneus, and into the lingual gyrus.

the visual areas can be categorized as follows:

• visual area – area 17 – sensory

• occipital eye field – area 17 & 18 – motor
• psychovisual area – area 18 & 19 – sensory
Prefrontal areas (prefrontal cortex)
The part of the frontal lobe excluding the motor, premotor and motor association cortex is referred to as
the prefrontal area. It includes the parts of the frontal gyri anterior to the motor association area, most of
the anterior parts of the orbital gyri, most of the medial frontal gyrus, and the anterior part of the gyrus
cinguli.

CEREBELLUM
The cerebellum (or small brain) weighs about 10% of the cerebral hemispheres and it is about 150 g in the
adult. It has a superficial layer of grey matter, the cerebellar cortex, and like other parts of the brain, it is
marked by numerous fissures. The cerebellum lies behind the brainstem, and it is separated from the
cerebrum by a fold of dura mater called the tentorium cerebelli. The cerebellum consists of a part lying near
the midline called the vermis, and of two lateral hemispheres. It has two surfaces, superior and inferior. The
surface of the cerebellum is marked by a series of fissures that run more or less parallel to one another. The
fissures sub-divide the surface of the cerebellum into narrow leaf-like bands or folia. The long axis of the
majority of folia is more or less transverse. Sections of the cerebellum cut at right angles to the axis have a
characteristic tree-like appearance to which the term arbor-vitae Some of the features of the surface of the
cerebellum are deeper than others, and they divide the cerebellum into lobes within which
smaller lobule may be recognised. The deepest fissures in the cerebellum are the primary fissure (fissure
prima) which runs transversely across the superior surface, and the posterolateral fissure seen on the
inferior aspect.

These features divide the cerebellum into three lobes; a part anterior to the primary fissure, the anterior
lobe, a part between the two fissures, the posterior lobe (sometimes called the middle lobe). The remaining
part is flocculonodular lobe. The anterior and posterior lobes together form the corpus cerebelli.

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EXTRA PYRAMIDAL SYSTEM

CEREBRAL NUCLEI & CONNECTIONS

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CORTICOSPINAL TRACT

Anterior corticospinal tract (ACST)

The anterior corticospinal tract (also called the "Bundle of Turck”) emerges from the un-decussated fibers
of the corticospinal tract, at the level of the bulbomedullary junction. The anterior corticospinal tract is
usually small, varying inversely in size with the lateral corticospinal tract. Lying close to the anterior
median fissure, it is present only in the upper part of the spinal cord, gradually diminishing in size as it
descends. The tract ends around the level of the mid-thoracic region.
Function

The anterior corticospinal tract is primarily responsible for gross and postural movement of the trunk
and proximal musculature (axial muscles).

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Lateral
corticospinal tract

he lateral corticospinal tract (LCST) is the largest descending motor

pathway in the human body, it spans the entire length of the spinal cord,
eventually supplying motor signals to all the skeletal muscles of
our upper and lower limbs.
Function

The lateral corticospinal tract is responsible for the voluntary movement of the contralateral upper and
lower limbs.

WHITE MATTER OF CEREBRUM

White matter is composed of myelinated axons and glia and connects distinct areas of the cortex.
White matter is one of the two components of the central nervous system (CNS). It consists mostly of
glial cells and myelinated axons and forms the bulk of the deep parts of the cerebrum and the
superficial parts of the spinal cord. In a freshly cut brain, the tissue of white matter appears pinkish
white to the naked eye because myelin is composed largely of lipid tissue containing capillaries. The
axons of white matter transmit signals from various grey matter areas (the locations of nerve cell
bodies) of the cerebrum to each other and carry nerve impulses between neurons. While grey matter
is primarily associated with processing and cognition, white matter modulates the distribution of action
potentials, acting as a relay and coordinating communication between different brain regions.

Tracts

There are three different kinds of tracts (bundles of axons) that connect one part of the brain to
another within the white matter:

• Projection tracts extend vertically between higher and lower brain areas and spinal cord centers,
and carry information between the cerebrum and the rest of the body. Other projection tracts
carry signals upward to the cerebral cortex. Superior to the brainstem, such tracts form a broad,
dense sheet called the internal capsule between the thalamus and basal nuclei, then radiate in a
diverging, fanlike array to specific areas of the cortex.
• Commissural tracts cross from one cerebral hemisphere to the other through bridges called
commissures. The great majority of commissural tracts pass through the large corpus callosum. A
few tracts pass through the much smaller anterior and posterior commissures. Commissural
tracts enable the left and right sides of the cerebrum to communicate with each other.
• Association tracts connect different regions within the same hemisphere of the brain. Long
association fibers connect different lobes of a hemisphere to each other, whereas short
association fibers connect different gyri within a single lobe. Among their roles, association tracts
link perceptual and memory centers of the brain.

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Corpus
Callosum

The corpus callosum (Latin: “tough body”), also known as the colossal commissure, is a wide, flat
bundle of neural fibers beneath the cortex in the eutherian brain at the longitudinal fissure. It connects
the left and right cerebral hemispheres and facilitates interhemispheric communication. It is the largest
white matter structure in the brain, consisting of 200 to 250 million contralateral axonal projections.

The posterior portion of the corpus callosum is called the splenium, the anterior is called the genu (or
“knee”), and the area between the two is the truncus or body of the corpus callosum. The part
between the body and the splenium is often markedly thin and thus called the isthmus. The rostrum is
the part of the corpus callosum that projects posteriorly and inferiorly from the anteriormost genu. The
rostrum is so named for its resemblance to a bird’s beak.

Agenesis of the corpus callosum (ACC) is a rare congenital disorder in which the corpus callosum is
partially or completely absent. It is usually diagnosed within the first two years of life and may manifest
as a severe syndrome in infancy or childhood, as a milder condition in young adults, or as an
asymptomatic incidental finding. Initial symptoms of ACC usually include seizures that may be
followed by feeding problems and delays in holding the head erect, sitting, standing, and walking.
Hydrocephaly may also occur.

Other possible symptoms include impairments in mental and physical development, hand-eye
coordination, and visual and auditory memory. In mild cases, symptoms such as seizures, repetitive
speech, or headaches may not appear for years.

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CSF CIRCULATION
Cerebrospinal fluid is constantly produced at a secretion rate of 0.2-0.7 ml/min, meaning that there is 600–
700 ml of newly produced CSF per day. Since the total volume of CSF averages around 150-270 mL, this
means that the entire volume of CSF is replaced around 4 times per day.

The pathway of the cerebrospinal fluid is as follows:

1. The CSF passes from the lateral ventricles to the third ventricle through the interventricular foramen
(of Monro).
2. From the third ventricle, the CSF flows through the cerebral aqueduct (of Sylvius) to the fourth
ventricle.
3. From the fourth ventricle, some CSF flows through a narrow passage called the obex and enters the
central canal of the spinal cord. However, the majority of CSF passes through the apertures of the
fourth ventricle; the median aperture (of Magendie) and two lateral apertures (of Luschka). Via
these openings, the CSF enters the cisterna magna and cerebellopontine cisterns, respectively.
4. From there, the CSF flows through the subarachnoid space of the brain and spinal cord.
5. It is finally reabsorbed into the dural venous sinuses through arachnoid granulations.
DURA MATTER
The dura mater is the outermost layer of the meninges and is located directly underneath
the bones of the skull and vertebral column. It is thick, tough, and inextensible.

The dura mater consists of two layered sheets of connective tissue:

• Periosteal layer – lines the inner surface of the bones of the cranium.

• Meningeal layer – located deep to the periosteal layer. It is continuous with the dura
mater of the spinal cord.

The dural venous sinuses are located between the two layers of dura mater. They are
responsible for the venous drainage of the cranium and empty into the internal
jugular veins.

The dura mater receives its own vascular supply – primarily from the middle
meningeal artery and vein. It is innervated by the trigeminal nerve (V1, V2 and V3)

Dural Reflections
The meningeal layer of dura mater folds inwards upon itself to form four dural reflections.

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These
reflections project into the cranial cavity, dividing it into several compartments – each of
which houses a subdivision of the brain.

The four dural reflections are:

• Falx cerebri – projects downwards to separate the right and left cerebral
hemispheres.
• Tentorium cerebelli – separates the occipital lobes from the cerebellum. It contains
a space anteromedially for passage of the midbrain – the tentorial notch.
• Falx cerebelli – separates the right and left cerebellar hemispheres.
• Diaphagma sellae – covers the hypophysial fossa of the sphenoid bone. It contains
a small opening for passage of the stalk of the pituitary gland.

FUNCTIONAL AREAS OF THE BRAIN

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UPPER END OF HUMERUS

Proximal end

The proximal end of the humerus consists of a head, an anatomical neck and the greater and lesser tubercles.

Head

The head is a hemispheroidal shape, with hyaline cartilage covering its smooth articular surface. In the
anatomical position, the head faces in a medial, superior and posterior direction where it articulates with
the glenoid fossa of the scapula.
Anatomical neck

The anatomical neck is a slight narrowing below the articular surface of the head. Here, the joint capsule
of the shoulder joint is attached.
Greater tubercle

The greater tubercle is the most lateral portion of the proximal end of the humerus. It consists of three
smooth and flat impressions at the posterosuperior aspect for the attachment of muscles. From superior
to inferior, the muscles that attach at these impressions are the:

• supraspinatus
• infraspinatus
• teres minor

• The deltoid muscle covers the lateral aspect of the greater tubercle, resulting in the normal
rounded shape of the shoulder. The lateral aspect also contains multiple vascular foramina.
• Lesser tubercle

• The lesser tubercle is located anterior to the anatomical neck and has a smooth, palpable muscular
impression. The lateral part forms the medial margin of the intertubercular sulcus.
The subscapularis muscle attaches at this tubercle and the transverse ligament of the shoulder also
attaches on its lateral part.
• Intertubercular sulcus

The intertubercular sulcus is an indentation located between the two tubercles. It is sometimes referred to as
the bicipital groove.

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Surgical neck

There is also a narrowing below the tubercles referred to as the surgical neck, which is a common fracture
site.

LOWER END OF HUMERUS

The lateral and medial borders of the distal humerus form medial and
lateral supraepicondylar ridges. The lateral supraepicondylar ridge is more roughened,
providing the site of common origin of the forearm extensor muscles.

Immediately distal to the supraepicondylar ridges are extracapsular projections of bone,

the lateral and medial epicondyles. Both can be palpated at the elbow. The medial is the
larger of the two and extends more distally. The ulnar nerve passes in a groove on the
posterior aspect of the medial epicondyle where it is palpable.

Distally, the trochlea is located medially, and extends onto the posterior aspect of the bone.
Lateral to the trochlea is the capitulum, which articulates with the radius.

Also located on the distal portion of the humerus are three depressions, known as
the coronoid, radial and olecranon fossae. They accommodate the forearm bones during
flexion or extension at the elbow.

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CLAVICLE

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CARPAL BONES

SUPINATOR

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WRIST JOINT MOVEMENTS

The wrist is an ellipsoidal (condyloid) type synovial joint, allowing for movement along two
axes. This means that flexion, extension, adduction and abduction can all occur at the wrist
joint.

All the movements of the wrist are performed by the muscles of the forearm.

Flexion – Produced mainly by the flexor carpi ulnaris, flexor carpi radialis, with assistance
from the flexor digitorum superficialis.

Extension – Produced mainly by the extensor carpi radialis longus and brevis, and extensor
carpi ulnaris, with assistance from the extensor digitorum.

Adduction – Produced by the extensor carpi ulnaris and flexor carpi ulnaris

Abduction – Produced by the abductor pollicis longus, flexor carpi radialis, extensor carpi
radialis longus and brevis.

SCAPHOID BONE
The scaphoid bone is the largest carpal bones of the proximal row and it lies beneath the anatomical snuff
box. From a palmar view, it is surrounded on the proximal side by the radius, on the distolateral side by the
trapezium bone and on the distomedial side by the trapezoid bone. Superomedially, it articulates with the
lunate bone and inferomedially with the capitate bone. On the palm of the hand, its tubercle is easily
palpable as it sits subcutaneously.

The blood vessels that supply the carpal bones enter the wrist along the lateral roughened surface of the

scaphoid bone .

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SESAMOID BONE
a sesamoid bone (/ˈsɛsəmɔɪd/[1][2]) is a bone embedded within a tendon or a muscle

• n the knee—the patella (within the quadriceps tendon). This is the largest sesamoid bone.[4]
• In the hand—two sesamoid bones are commonly found in the distal portions of the first metacarpal
bone (within the tendons of adductor pollicis and flexor pollicis brevis). There is also commonly a
sesamoid bone in distal portions of the second metacarpal bone.
• In the wrist—The pisiform of the wrist is a sesamoid bone (within the tendon of flexor carpi ulnaris).[7] It
begins to ossify in children ages 9–12.[8]
• In the foot—the first metatarsal bone usually has two sesamoid bones at its connection to the big
toe (both within the tendon of flexor hallucis brevis).[9] One is found on the lateral side of the first
metatarsal while the other is found on the medial side. In some people, only a single sesamoid is found
on the first metatarsal bone.
• In the neck—Although the hyoid bone is free-floating, it is not technically a sesamoid bone. All sesamoid
bones form directly from the connective tissue found in tendons and ligaments. By contrast, the hyoid
bone forms from a cartilaginous precursor like most other bones in the body.

Clinical significance[edit]
• A common foot ailment in dancers is sesamoiditis (an inflammation of the sesamoid bones under the first
metatarsophalangeal joint of the big toe). This is a form of tendinitis which results from the tendons
surrounding the sesamoid becoming inflamed or irritated.[3]
• Sesamoid bones generally have a very limited blood supply, rendering them prone to avascular
necrosis (bone death from lack of blood supply), which is very difficult to treat
SCAPULA

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SPINE OF SCAPULA
the most prominent feature of the posterior scapula. It runs transversely across the
scapula, dividing the surface into two.

INTERPHALYNGEAL JOINT

BRACHIALIS MUSCLE ACTION

The brachialis is known as the workhorse of the elbow. It is a major flexor of the forearm at the elbow joint, flexing the
elbow while it is in all positions. The brachialis is the only pure flexor of the elbow joint–producing the majority of
force during elbow flexion. It is not affected by pronation or supination of the forearm, and does not participate in
pronation and supination due to its lack of attachment to the radius.

UPPER END OF FEMUR

The proximal aspect of the femur articulates with the acetabulum of the pelvis to form
the hip joint.

It consists of a head and neck, and two bony processes – the greater and lesser
trochanters. There are also two bony ridges connecting the two trochanters; the
intertrochanteric line anteriorly and the trochanteric crest posteriorly.

• Head – articulates with the acetabulum of the pelvis to form the hip joint. It has a
smooth surface, covered with articular cartilage (except for a small depression – the
fovea – where ligamentum teres attaches).
• Neck – connects the head of the femur with the shaft. It is cylindrical, projecting in a
superior and medial direction. It is set at an angle of approximately 135 degrees to the
shaft. This angle of projection allows for an increased range of movement at the hip
joint.

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• Greater trochanter – the most lateral palpable projection of bone that originates from
the anterior aspect, just lateral to the neck.
o It is the site of attachment for many of the muscles in the gluteal region, such
as gluteus medius, gluteus minimus and piriformis. The vastus lateralis
originates from this site.
o An avulsion fracture of the greater trochanter can occur as a result of forceful
contraction of the gluteus medius.
• Lesser trochanter – smaller than the greater trochanter. It projects from the
posteromedial side of the femur, just inferior to the neck-shaft junction.
o It is the site of attachment for iliopsoas (forceful contraction of which can cause
an avulsion fracture of the lesser trochanter).
• Intertrochanteric line – a ridge of bone that runs in an inferomedial direction on the
anterior surface of the femur, spanning between the two trochanters. After it passes
the lesser trochanter on the posterior surface, it is known as the pectineal line.
o It is the site of attachment for the iliofemoral ligament (the strongest ligament of
the hip joint).
o It also serves as the anterior attachment of the hip joint capsule.
• Intertrochanteric crest – like the intertrochanteric line, this is a ridge of bone that
connects the two trochanters. It is located on the posterior surface of the femur. There
is a rounded tubercle on its superior half called the quadrate tubercle; where
quadratus femoris attaches.

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RADIOULNAR JOINT
The radioulnar joints are two locations in which the radius and ulna articulate in the
forearm:

• Proximal radioulnar joint – located near the elbow. It is articulation between the
head of the radius and the radial notch of the ulna.

• Distal radioulnar joint – located near the wrist. It is an articulation between the ulnar
notch of the radius and the ulnar head.

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MEDIAN NERVE
The median nerve gives off two major branches in the forearm:

• Anterior interosseous nerve – supplies the deep muscles in the anterior forearm.

• Palmar cutaneous nerve – innervates the skin of the lateral palm.

After giving off the anterior interosseous and palmar cutaneous branches, the median nerve
enters the hand via the carpal tunnel – where it terminates by dividing into two branches:

• Recurrent branch – innervates the thenar muscles.

• Palmar digital branch – innervates the palmar surface and fingertips of the lateral
three and half digits. Also innervates the lateral two lumbrical muscles.

Motor Functions
The median nerve innervates the majority of the muscles in the anterior forearm, and
some intrinsic hand muscles.

Anterior Forearm
In the forearm, the median nerve directly innervates muscles in the superficial and
intermediate layers:

• Superficial layer: Pronator teres, flexor carpi radialis and palmaris longus.
• Intermediate layer: Flexor digitorum superficialis.

The median nerve also gives rise to the anterior interosseous nerve, which supplies the
deep flexors:

• Deep layer: Flexor pollicis longus, pronator quadratus, and the lateral half of the flexor
digitorum profundus (the medial half of the muscle is innervated by the ulnar nerve).

In general, these muscles perform pronation of the forearm, flexion of the wrist and flexion
of the digits of the hand.

Hand
The median nerve innervates some of the muscles in the hand via two branches.

The recurrent branch of the median nerve innervates the thenar muscles – muscles
associated with movements of the thumb. The palmar digital branch innervates the lateral

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two
lumbricals – these muscles perform flexion at the metacarpophalangeal joints and extension
at the interphalangeal joints of the index and middle fingers

Sensory Functions
The median nerve is responsible for the cutaneous innervation of part of the hand. This is
achieved via two branches:

• Palmar cutaneous branch – arises in the forearm and travels into the hand. It
innervates the lateral aspect of the palm. This nerve does not pass through the carpal
tunnel, and is spared in carpal tunnel syndrome.

• Palmar digital cutaneous branch – arises in the hand. Innervates the palmar
surface and fingertips of the lateral three and half digits.

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EPIPHYSIS
The pineal gland, or epiphysis is a small cone-like structure that comprises a part of the diencephalon. It is a
neuroendocrine gland that secretes the hormone melatonin and several other polypeptide hormones that
have a regulatory function on other endocrine glands.

The pineal gland projects posteriorly from the wall of the third ventricle above the quadrigeminal plate,
resting in the groove between the two superior colliculi. The gland has several functions, the most
important of which is maintaining the body’s circadian rhythm and regulating the sleep-wake cycle. In
addition, the pineal gland plays a role in modulating the onset of puberty and the development of the
reproductive system.

MUSCLES OF FRONT ARM

Anterior Compartment
There are three muscles located in the anterior compartment of the upper arm – biceps
brachii, coracobrachialis and brachialis. They are all innervated by
the musculocutaneous nerve. A good memory aid for this
is BBC – biceps, brachialis, coracobrachialis.

Arterial supply to the anterior compartment of the upper arm is via muscular branches of
the brachial artery.

Biceps Brachii
The biceps brachii is a two-headed muscle. Although the majority of the muscle mass is
located anteriorly to the humerus, it has no attachment to the bone itself.

As the tendon of biceps brachii enters the forearm, a connective tissue sheet is given off
– the bicipital aponeurosis. This forms the roof of the cubital fossa and blends with the
deep fascia of the anterior forearm.

• Attachments: Long head originates from the supraglenoid tubercle of the scapula,
and the short head originates from the coracoid process of the scapula. Both heads
insert distally into the radial tuberosity and the fascia of the forearm via the bicipital
aponeurosis.

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• Function: Supination of the forearm. It also flexes the arm at the elbow and at the
shoulder.
• Innervation: Musculocutaneous nerve. The bicep tendon reflex tests spinal cord
segment C6.

Coracobrachialis
The coracobrachialis muscle lies deep to the biceps brachii in the arm.

• Attachments: Originates from the coracoid process of the scapula. The muscle
passes through the axilla, and attaches the medial side of the humeral shaft, at the
level of the deltoid tubercle.
• Function: Flexion of the arm at the shoulder, and weak adduction.
• Innervation: Musculocutaneous nerve.

Brachialis
The brachialis muscle lies deep to the biceps brachii, and is found more distally than the
other muscles of the arm. It forms the floor of the cubital fossa.

• Attachments: Originates from the medial and lateral surfaces of the humeral shaft
and inserts into the ulnar tuberosity, just distal to the elbow joint.
• Function: Flexion at the elbow.
• Innervation: Musculocutaneous nerve, with contributions from the radial nerve

Posterior Compartment
The posterior compartment of the upper arm contains the triceps brachii muscle, which
has three heads. The medial head lies deeper than the other two, which cover it.

Arterial supply to the posterior compartment of the upper arm is via the profunda brachii
artery.

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Triceps Brachii
• Attachments: Long head – originates from the infraglenoid tubercle. Lateral head –
originates from the humerus, superior to the radial groove. Medial head – originates
from the humerus, inferior to the radial groove. Distally, the heads converge onto one
tendon and insert into the olecranon of the ulna.
• Function: Extension of the arm at the elbow.
• Innervation: Radial nerve. A tap on the triceps tendon tests spinal segment C7.

ABDUCTOR POLLICIS

MEDIAN CLAW HAND

Claw Hand deformity is a condition where the fingers are bent into a position that looks
like a claw. It may affect all of the fingers or only some of them depending on its cause.

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The
fingers are usually bent or curved and the deformity can affect one hand or both
hands. [1] Claw Hand is a hand deformity with hyperextension of the metacarpophalengeal
(MCP) joints and flexion of the interphalengeal (IP) joints due to weakness of the intrinsic
muscles of the hand. Claw finger deformity occurs during attempted finger extension in
patients whose intrinsic finger muscles are weakened or paralyzed by neural impairments.
The deformity is generally not acutely present after intrinsic muscle palsy. [2]

Causes
The causes of Claw Hand might include: [3][4]

• Nerve damage in the arm e.g ulnar palsy, median palsy, ulnar tunnel
syndrome, cubital tunnel syndrome.
• Congenital birth defect.
• Some genetic diseases such as Charcot-Marie-Tooth Disease.
• Bacterial infections such as Leprosy.
• Scarring after a severe hand or forearm burn.
• Compartment syndrome of the hand.
Types
Claw Hand deformity can be:

Complete when it involves all the digits and therefore results from both Ulnar and
Median Nerve Palsy.

Incomplete or Partial where it involves only ulnar 2 digits and is referred to as

an isolated Ulnar Nerve Palsy.

MUSCULOCUTANEOUS NERVE
Anatomical Course
The musculocutaneous nerve is the terminal branch of the lateral cord of the brachial
plexus (C5, C6 and C7) and emerges at the inferior border of pectoralis minor muscle.

It leaves the axilla and pierces the coracobrachialis muscle near its point of insertion on
the humerus. It gives a branch to this muscle. The musculocutaneous nerve then passes
down the flexor compartment of the upper arm, superficial to brachialis but deep to the
biceps brachii muscle. It innervates both these muscles and gives articular branches to the
humerus and the elbow.

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The
nerve then pierces the deep fascia lateral to biceps brachii to emerge lateral to the biceps
tendon and brachioradialis. It continues into the forearm as the lateral cutaneous
nerve and provides sensory innervation to the lateral aspect of the forearm.

Motor Functions
The musculocutaneous nerve innervates the muscles in the anterior compartment of the
arm:

• Biceps brachii
• Brachialis
• Coracobrachialis

These muscles flex the upper arm at the shoulder and the elbow. In addition, the biceps
brachii also supinates the forearm.

Sensory Functions
The musculocutaneous nerve gives rise to the lateral cutaneous nerve of forearm.

This nerve initially enters the deep forearm, but then pierces the deep fascia to become
subcutaneous. In this region, it can be found close to the cephalic vein.

The lateral cutaneous nerve of forearm innervates the skin of the anterolateral aspect of
the forearm.

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RADIUS BONE

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BRACHIAL PLEXUS
The brachial plexus is divided into five parts; roots, trunks, divisions, cords and
branches
Roots
The ‘roots’ refer the anterior rami of the spinal nerves that comprise the brachial plexus.
These are the anterior rami of spinal nerves C5, C6, C7, C8, and T1.

At each vertebral level, paired spinal nerves arise. They leave the spinal cord via
the intervertebral foramina of the vertebral column.

Each spinal nerve then divides into an anterior and a posterior ramus. The roots of the
brachial plexus are formed by the anterior rami of spinal nerves C5-T1

Trunks
At the base of the neck, the roots of the brachial plexus converge to form three trunks.
These structures are named by their relative anatomical location:

• Superior trunk – a combination of C5 and C6 roots.

• Middle trunk – continuation of C7.
• Inferior trunk – combination of C8 and T1 roots.

The trunks traverse laterally, crossing the posterior triangle of the neck.

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Divisions
Each trunk divides into two branches within the posterior triangle of the neck. One division
moves anteriorly (toward the front of the body) and the other posteriorly (towards the back
of the body). Thus, they are known as the anterior and posterior divisions.

We now have three anterior and three posterior nerve fibres. These divisions leave the
posterior triangle and pass into the axilla. They recombine into the cords of the brachial
plexus.
Cords
Once the anterior and posterior divisions have entered the axilla, they combine together to form three cords,
named by their position relative to the axillary artery.

The lateral cord is formed by:

• The anterior division of the superior trunk

• The anterior division of the middle trunk

The posterior cord is formed by:

• The posterior division of the superior trunk

• The posterior division of the middle trunk
• The posterior division of the inferior trunk

The medial cord is formed by:

• The anterior division of the inferior trunk.

The cords give rise to the major branches of the brachial plexus.

Major Branches
Musculocutaneous Nerve
• Roots: C5, C6, C7.
• Motor Functions: Innervates the brachialis, biceps brachii and coracobrachialis
muscles.
• Sensory Functions: Gives off the lateral cutaneous branch of the forearm, which
innervates the lateral half of the anterior forearm, and a small lateral portion of the
posterior forearm.

Axillary Nerve
• Roots: C5 and C6.

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• Motor
Functions: Innervates the teres minor and deltoid muscles.
• Sensory Functions: Gives off the superior lateral cutaneous nerve of arm, which
innervates the inferior region of the deltoid

Median Nerve
• Roots: C6 – T1. (Also contains fibres from C5 in some individuals).
• Motor Functions: Innervates most of the flexor muscles in the forearm, the thenar
muscles, and the two lateral lumbricals associated with the index and middle fingers.
• Sensory Functions: Gives off the palmar cutaneous branch, which innervates the
lateral part of the palm, and the digital cutaneous branch, which innervates the lateral
three and a half fingers on the anterior (palmar) surface of the hand.

Radial Nerve
• Roots: C5 – T1.
• Motor Functions: Innervates the triceps brachii, and the muscles in the posterior
compartment of the forearm (which are primarily, but not exclusively, extensors of the
wrist and fingers).
• Sensory Functions: Innervates the posterior aspect of the arm and forearm, and the
posterolateral aspect of the hand.

Ulnar Nerve
• Roots: C8 and T1.
• Motor Functions: Innervates the muscles of the hand (apart from the thenar muscles
and two lateral lumbricals), flexor carpi ulnaris and medial half of flexor digitorum
profundus.
• Sensory Functions: Innervates the anterior and posterior surfaces of the medial one
and half fingers, and associated palm area.

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Minor Branches

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WRIST DROP
Wrist drop is a medical condition in which the wrist and the fingers cannot extend at the metacarpophalangeal
joints. The wrist remains partially flexed due to an opposing action of flexor muscles of the forearm. As a result, the
extensor muscles in the posterior compartment remain paralyzed. It occurs due to the paralysis of the posterior
forearm muscles and their inability to extend the wrist.

The sensory loss will depend on the anatomical location of the injury. For example, if the nerve is injured in
the axillary region, the sensory loss will be located at the lateral arm and the posterior aspect of the forearm
radiating to the radial aspect of the hand and digits. This is seen commonly with "Saturday night palsy"

ANATOMICAL SNUFF BOX

The anatomical snuffbox (also known as the radial fossa), is a triangular depression found
on the lateral aspect of the dorsum of the hand. It is located at the level of the carpal bones,
and best seen when the thumb is extended.

Borders
As the snuffbox is triangularly shaped, it has three borders, a floor, and a roof:

• Ulnar (medial) border: Tendon of the extensor pollicis longus.

• Radial (lateral) border: Tendons of the extensor pollicis brevis and abductor pollicis
longus.
• Proximal border: Styloid process of the radius.
• Floor: Carpal bones; scaphoid and trapezium.
• Roof: Skin.

Contents
The main contents of the anatomical snuffbox are the radial artery, a branch of the radial
nerve, and the cephalic vein:

• Radial artery – crosses the floor of the anatomical snuffbox, then turns medially and
travels between the heads of the adductor pollicis muscle.
o The radial pulse can be palpated in some individuals by placing two fingers on
the proximal portion of the anatomical snuffbox.
• Superficial branch of the radial nerve – found in the skin and subcutaneous tissue
of the anatomical snuffbox. It innervates the dorsal surface of the lateral three and half
digits, and the associated area on the back of the hand.

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• Cephalic vein – arises from the dorsal venous network of the hand and crosses the
anatomical snuffbox to travel up the anterolateral aspect of the forearm

CORONOID PROCESS
The coronoid process, as previously mentioned, is the foremost structure at the head of the ramus, attaches
to the temporalis muscle, which is utilized during mastication. Although it is not directly part of the
temporomandibular joint, it still aids the various functions of the jaws, such as opening and closing, due to its
proximity to the TMJ and it involvement with its adjacent structures.

PECTORALIS MAJOR

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BLOOD SUPPLY OF BREAST

Breast blood supply comes from three sources:

• Branches of the axillary artery supply the lateral part of the breast. These are the superior
thoracic, thoracoacromial, lateral thoracic and subscapular arteries.
• Branches of the internal thoracic artery, supply the medial part of the breast as the medial mammary
arteries.
• Perforating branches of second, third and fourth intercostal arteries contribute to the supply of the
entire breast.
Breast veins follow the mentioned arteries. They drain into the axillary, internal thoracic and second to
fourth intercostal veins.

The anterior and lateral cutaneous branches of the second to sixth intercostal nerves are responsible for breast
innervation. Note that the nipple is supplied by the fourth intercostal nerve.

WINGING SCAPULA

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CARPAL TUNNEL
The carpal tunnel is a narrow passageway found on the anterior portion of the wrist. It
serves as the entrance to the palm for several tendons and the median nerve.

Borders
The carpal tunnel is formed by two layers: a deep carpal arch and a superficial flexor
retinaculum. The deep carpal arch forms a concave surface, which is converted into a
tunnel by the overlying flexor retinaculum (transverse carpal ligament).

Carpal Arch
• Concave on the palmar side, forming the base and sides of the carpal tunnel.
• Formed laterally by the scaphoid and trapezium tubercles
• Formed medially by the hook of the hamate and the pisiform

Flexor Retinaculum
• Thick connective tissue which forms the roof of the carpal tunnel.
• Turns the carpal arch into the carpal tunnel by bridging the space between the medial
and lateral parts of the arch.
• Spans between the hook of hamate and pisiform (medially) to the scaphoid and
trapezium (laterally).

Contents
The carpal tunnel contains a total of 9 tendons, surrounded by synovial sheaths, and
the median nerve. The palmar cutaneous branch of the median nerve is given off prior to
the carpal tunnel, travelling superficially to the flexor retinaculum.

Tendons
• The tendon of flexor pollicis longus
• Four tendons of flexor digitorum profundus
• Four tendons of flexor digitorum superficialis

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Median Nerve
Once it passes through the carpal tunnel, the median nerve divides into 2 branches:
the recurrent branch and palmar digital nerves.

The palmar digital nerves give sensory innervation to the palmar skin and dorsal nail
beds of the lateral three and a half digits. They also provide motor innervation to
the lateral two lumbricals. The recurrent branch supplies the thenar muscle group.

INTEROSSEI MUSCLES OF HAND

The interosseous muscles of the hand are muscles found near the metacarpal bones that help to control the
fingers. They are considered voluntary muscles.
They are generally divided into two sets:

• 4 Dorsal interossei - Abduct the digits away from the 3rd digit (away from axial line) and are bipennate.
• 3 Palmar interossei - Adduct the digits towards the 3rd digit (towards the axial line) and are unipennate.

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BLOOD SUPPLY OF UPPER LIMB

The arterial supply to the upper limb is delivered via five main vessels (proximal to distal):

• Subclavian artery
• Axillary artery
• Brachial artery
• Radial artery
• Ulnar artery

Subclavian Artery
he subclavian artery travels laterally towards the axilla. It can be divided into three parts
based on its position relative to the anterior scalene muscle:

• First part – origin of the subclavian artery to the medial border of the anterior scalene.
• Second part – posterior to the anterior scalene.
• Third part – lateral border of anterior scalene to the lateral border of the first rib.

Axilla: Axillary Artery

The axillary artery lies deep to the pectoralis minor and is enclosed in the axillary sheath

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the artery can be divided into three parts based on its position relative to the pectoralis
minor muscle:

• First part – proximal to pectoralis minor

• Second part – posterior to pectoralis minor
• Third part – distal to pectoralis minor

Upper Arm: Brachial Artery

The brachial artery is a continuation of the axillary artery past the lower border of the teres
major. It is the main supply of blood for the arm.

Immediately distal to the teres major, the brachial artery gives rise to the profunda brachii

Forearm: Radial and Ulnar Arteries

The radial and ulnar arteries are formed by the bifurcation of the brachial artery within the
cubital fossa:

• Radial artery – supplies the posterolateral aspect of the forearm. It contributes to

anastomotic networks surrounding the elbow joint and carpal bones.

Ulnar artery – supplies the anteromedial aspect of the forearm. It contributes to an

anastomotic network surrounding the elbow joint.

Hand: Superficial and Deep Palmar Arches

• Superficial palmar arch – located anteriorly to the flexor tendons in the hand and
deep to the palmar aponeurosis. It gives rise to the digital arteries, which supply the
four fingers.
• Deep palmar arch – located deep to the flexor tendons of the hand. It contributes to
the blood supply to the digits and to the wrist joint.

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BICEPS
The biceps is a muscle on the front part of the upper arm. The biceps includes a “short head” and a “long head”
that work as a single muscle.

The biceps is attached to the arm bones by tough connective tissues called tendons. The tendons that connect the
biceps muscle to the shoulder joint in two places are called the proximal biceps tendons. The tendon that
attaches the biceps muscle to the forearm bones (radius and ulna) is called the distal biceps tendon. When the
biceps contracts, it pulls the forearm up and rotates it outward.

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WRIST JOINT
Structures of the Wrist Joint
Articulating Surfaces
The wrist joint is formed by:

• Distally – The proximal row of the carpal bones (except the pisiform).

• Proximally – The distal end of the radius, and the articular disk (see below).

Joint Capsule
Like any synovial joint, the capsule is dual layered. The fibrous outer layer attaches to the
radius, ulna and the proximal row of the carpal bones. The internal layer is comprised of a
synovial membrane, secreting synovial fluid which lubricates the joint.

Ligaments
There are four ligaments of note in the wrist joint, one for each side of the joint

• Palmar radiocarpal – Found on the palmar (anterior) side of the hand. It passes from
the radius to both rows of carpal bones. Its function, apart from increasing stability, is
to ensure that the hand follows the forearm during supination.

• Dorsal radiocarpal – Found on the dorsum (posterior) side of the hand. It passes
from the radius to both rows of carpal bones. It contributes to the stability of the wrist,
but also ensures that the hand follows the forearm during pronation.

• Ulnar collateral – Runs from the ulnar styloid process to the triquetrum and pisiform.
It acts to prevent excessive radial (lateral) deviation of the hand.

• Radial collateral – Runs from the radial styloid process to the scaphoid and
trapezium. It acts to prevent excessive ulnar (medial) deviation of the hand.

Neurovascular Supply
The wrist joint receives blood from branches of the dorsal and palmar carpal arches, which
are derived from the ulnar and radial arteries

Innervation to the wrist is delivered by branches of three nerves:

• Median nerve – Anterior interosseous branch.

• Radial nerve – Posterior interosseous branch.
• Ulnar nerve – deep and dorsal branches.

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Movements of the Wrist Joint

All the movements of the wrist are performed by the muscles of the forearm.

Flexion – Produced mainly by the flexor carpi ulnaris, flexor carpi radialis, with assistance
from the flexor digitorum superficialis.

Extension – Produced mainly by the extensor carpi radialis longus and brevis, and extensor
carpi ulnaris, with assistance from the extensor digitorum.

Adduction – Produced by the extensor carpi ulnaris and flexor carpi ulnaris

Abduction – Produced by the abductor pollicis longus, flexor carpi radialis, extensor carpi
radialis longus and brevis.

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SHOULDER JOINT
Structures of the Shoulder Joint
Articulating Surfaces
The shoulder joint is formed by the articulation of the head of the humerus with the glenoid
cavity (or fossa) of the scapula

the articulating surfaces are covered with hyaline cartilage.

Joint Capsule and Bursae

The joint capsule is a fibrous sheath which encloses the structures of the joint.

It extends from the anatomical neck of the humerus to the border or ‘rim’ of the glenoid
fossa. The joint capsule is lax, permitting greater mobility (particularly abduction).

The synovial membrane lines the inner surface of the joint capsule, and produces synovial
fluid to reduce friction between the articular surfaces.

To reduce friction in the shoulder joint, several synovial bursae are present.

The bursae that are important clinically are:

• Subacromial – located deep to the deltoid and acromion, and superficial to the
supraspinatus tendon and joint capsule.

Subscapular – located between the subscapularis tendon and the scapula.

Ligaments
In the shoulder joint, the ligaments play a key role in stabilising the bony structures.

• Glenohumeral ligaments (superior, middle and inferior) – the joint capsule is formed
by this group of ligaments connecting the humerus to the glenoid fossa. They are the
main source of stability for the shoulder, holding it in place and preventing it from
dislocating anteriorly. They act to stabilise the anterior aspect of the joint.
• Coracohumeral ligament – attaches the base of the coracoid process to the greater
tubercle of the humerus. It supports the superior part of the joint capsule.
• Transverse humeral ligament – spans the distance between the two tubercles of the
humerus. It holds the tendon of the long head of the biceps in the intertubercular
groove.]
• Coraco–clavicular ligament – composed of the trapezoid and conoid ligaments and
runs from the clavicle to the coracoid process of the scapula. They work alongside the

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acromioclavicular ligament to maintain the alignment of the clavicle in relation to the

scapula.

Movements
As a ball and socket synovial joint, there is a wide range of movement permitted:

• Extension (upper limb backwards in sagittal plane) – posterior deltoid, latissimus

dorsi and teres major.
• Flexion (upper limb forwards in sagittal plane) – pectoralis major, anterior deltoid
and coracobrachialis. Biceps brachii weakly assists in forward flexion.
• Abduction (upper limb away from midline in coronal plane):
o The first 0-15 degrees of abduction is produced by the supraspinatus.
o The middle fibres of the deltoid are responsible for the next 15-90 degrees.
o Past 90 degrees, the scapula needs to be rotated to achieve abduction – that is
carried out by the trapezius and serratus anterior.
• Adduction (upper limb towards midline in coronal plane) – pectoralis major,
latissimus dorsi and teres major.
• Internal rotation (rotation towards the midline, so that the thumb is pointing
medially) – subscapularis, pectoralis major, latissimus dorsi, teres major and anterior
deltoid.
• External rotation (rotation away from the midline, so that the thumb is pointing
laterally) – infraspinatus and teres minor.
• Circumduction (moving the upper limb in a circle) – produced by a combination of
the movements described above.

Mobility and Stability

The shoulder joint is one of the most mobile in the body, at the expense of stability. Here,
we shall consider the factors the permit movement, and those that contribute towards joint
structure.

Factors that contribute to mobility:

• Type of joint – ball and socket joint.

• Bony surfaces – shallow glenoid cavity and large humeral head – there is a 1:4
disproportion in surfaces. A commonly used analogy is the golf ball and tee.
• Inherent laxity of the joint capsule.

Factors that contribute to stability:

• Rotator cuff muscles – surround the shoulder joint, attaching to the tuberosities of
the humerus, whilst also fusing with the joint capsule. The resting tone of these
muscles act to compress the humeral head into the glenoid cavity.

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• Glenoid labrum – a fibrocartilaginous ridge surrounding the glenoid cavity. It

deepens the cavity and creates a seal with the head of humerus, reducing the risk of
dislocation.
• Ligaments – act to reinforce the joint capsule, and form the coraco-acromial arch.
• Biceps tendon – it acts as a minor humeral head depressor, thereby contributing to
stability.

Neurovasculature
The shoulder joint is supplied by the anterior and posterior circumflex humeral arteries,
which are both branches of the axillary artery. Branches of the suprascapular artery, a
branch of the thyrocervical trunk, also contribute.

Innervation is provided by the axillary, suprascapular and lateral pectoral nerves.

RADIAL NERVE

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BRACHIAL ARTERY

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HYALINE CARTILAGE – MICROSCOPIC STRUCTURE

SYNOVIAL JOINT TYPES WITH EXAMPLES

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THYROID GLAND – DIAGRAM

SACRAL PLEXUS- DIAGRAM

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CONNECTIVE TISSUE WITH EXAMPLES

Connective tissue can further be broken down into three categories: loose connective tissue, dense connective tissue,
and specialized connective tissue. Loose connective tissue works to hold organs in place and is made up of extracellular
matrix and collagenous, elastic and reticular fibers. Dense connective tissue is what makes up tendons and ligaments and
consist of a higher density of collagen fibers. Examples of specialized connective tissues are adipose tissue, cartilage,
bone, blood, and lymph.

SKELETAL MUSCLE- DIAGRAM

MICROSCOPIC ANATOMY OF LYMPH NODE

• At low power, lymph node structures are capsule, cortex and medulla, follicles, paracortex, sinuses
• Germinal center: round / oval zone containing pale staining cells, surrounded by darker cells
• Mantle zone: small unchallenged B cells surrounding pale staining germinal centers
• Marginal zone: light zone surrounding follicles; contains postfollicular memory B cells derived after
stimulation of recirculating cells from T cell dependent antigen; named "marginal cells" due to location at
interface of lymphoid white pulp and nonlymphoid red pulp in the spleen; however, marginal zone is rarely
seen except in mesenteric nodes (APMIS 2002;110:325)
• Sinuses: direct the flow of lymph from the afferent lymphatics, to the subcapsular sinus, to the trabecular
sinus, to the medullary sinus, to the efferent lymphatics (see diagrams) (Toxicol Pathol 2006;34:409)

• Centroblasts:
o Large noncleaved follicular center cells (B cells) with moderate amounts of basophilic
cytoplasm, large round nuclei, open chromatin, multiple peripheral nucleoli
o Frequent mitotic figures
• Centrocytes:
o Large and small cleaved follicular center cells (B cells) with scant cytoplasm and inconspicuous
nucleoli
• Immunoblasts:

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o Large B cells scattered throughout the paracortex

o Intermediate between small B cell and a plasma cell
o Prominent single nucleoli
o Express B cell markers (CD20, CD79a, PAX5) and CD30
• Macrophages:
o Process antigens via phagocytosis
o Related to circulatory monocytes
o Are present throughout the lymph node
o May contain thyroglobulin in lymph nodes draining thyroid tumors (J Clin Pathol 2001;54:314)
o Abundant cytoplasm with medium to large nuclei with vesicular chromatin
o Tingible body macrophages have clear cytoplasm and contain apoptotic bodies, which gives
node a starry sky pattern
• Mast cells:
o Present in T cell areas (World J Surg Oncol 2003;1:25)
o Difficult to detect
o Distinct cytoplasmic boundaries, faintly granular cytoplasm, large pale nuclei
o Some cells are elongated and resemble fibroblasts
• NK cells:
o Distinct group of non T, non B lymphocytes (5 - 10% of peripheral blood lymphocytes) with large
granular lymphocyte morphology on Wright-Giemsa stains
o NK cells derive from a common lymphoid progenitor with T cells

CURVATURES OF VERTEBRAL COLUMN

The spine consists of the four regions that shape the four curvatures.

Primary curvatures

The vertebral curvatures provide a flexible support (shock-absorbing resilience) for the body.
The thoracic and sacral (pelvic) curvatures are concave anteriorly and are referred to
as kyphoses (singular: kyphosis). They appear during the fetal period of embryonic development, hence
they are also termed primary or developmental curvatures.

The primary curvatures are retained throughout life as a consequence of differences in height between
the anterior and posterior parts of the vertebrae.
Secondary curvatures

The cervical and lumbar curvatures are concave posteriorly and convex anteriorly, being referred to
as lordoses (singular: lordosis). They appear later (although before birth) and are accentuated in infancy
by support of the head and by the adoption of an upright or erect human posture. As a result, they are
termed secondary or acquired curvatures.

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Secondary curvatures are maintained by differences in thickness between the anterior and the posterior
parts of the intervertebral discs (IV discs). The cervical curvature becomes fully evident when an infant
begins to raise (extend) its head while prone and to hold its head erect while sitting.

The lumbar curvature becomes apparent when an infant begins to assume the upright posture, while standing and
walking. The lumbar curvature is more pronounced in females and ends at the lumbosacral angle formed at the
junction of L5 vertebra with the sacrum. The sacral curvature also differs in males and females. That of the female is
reduced so that the coccyx protrudes less into the pelvic outlet.

DIFFERENCE B/W MALE & FEMALE BONY PELVIS

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LAWS OF OSSIFICATION

SPERMATOGENESIS
Spermatogenesis is the process of the gradual transformation of germ cells into spermatozoa. It occurs mainly within
the seminiferous tubules of the testes and can be divided into three phases, each of which is associated with
different germ cell types:

• Proliferative phase: spermatogonia → spermatocytes

• Meiotic phase: spermatocytes → spermatids
• Differentiation phase (also known as spermiogenesis): spermatids → spermatozoa
The seminiferous tubules are the site of spermatogenesis. The two main cell types within the tubules involved in
spermatogenesis are the germ cells, which will develop into sperm, and somatic cells known as Sertoli cells, which
nuture the germ cells throughout the development process.

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Stages of spermatogenesis
Proliferation phase
Meiotic phase
Differentiation phase

STYLOID PROCESS OF RADIUS

The distal end of the radius consists of:
• Radial styloid process
• Two facets for articulation with the scaphoid and lunate bone
• Ulnar notch
The radial styloid process projects obliquely downward from the distal end of the radius. It
serves as the point of attachment for the brachioradialis muscle and the radial collateral
ligament. Laterally, the tendons of extensor pollicis brevis and abductor pollicis longus run
in a flat groove.

ILIAC CREST
The crest of the ilium (or iliac crest) is the superior border of the wing of ilium and the superiolateral margin of
the greater pelvis.

Structure[edit]
The iliac crest stretches posteriorly from the anterior superior iliac spine (ASIS) to the posterior superior iliac
spine (PSIS). Behind the ASIS, it divides into an outer and inner lip separated by the intermediate zone. The outer lip
bulges laterally into the iliac tubercle.
The iliac crest is derived from endochondral bone.

CLAVICLE- DIAGRAM

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