Essentials of Human Anatomy

Essentials of
Human Anatomy
h
a
9
ri 9
n
U
V
d
ti e
G
R
tahir99 - UnitedVRG
Essentials of
Human Anatomy
BK Tandon
MBBS MS (ANATOMY)
V
d
ti e
G
R
Former
Professor and Head, Department of Anatomy,
Maulana Azad Medical College, New Delhi, India
Professor of Anatomy, AI Fateh University, Tripoli, Libya
Professor and Head of Anatomy, AI Ameen Medical College, Bijapur, India
Professor and Head of Anatomy, BLDEAs Medical College, Bijapur, India
Professor and Head of Anatomy, Nepal Medical College, Kathmandu, Nepal
h
a
9
ri 9
n
U
JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

St Louis (USA) Panama City (Panama) New Delhi Ahmedabad Bengaluru Chennai
Hyderabad Kochi Kolkata Lucknow Mumbai Nagpur
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
Corporate Office
4838/24, Ansari Road, Daryaganj, New Delhi 110 002, India, Phone: +91-11-43574357
Fax: +91-11-43574314
Registered Office
B-3, EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi 110 002, India
Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021, +91-11-23245672
Rel: +91-11-32558559, Fax: +91-11-23276490, +91-11-23245683
e-mail: jaypee@jaypeebrothers.com, Website: www.jaypeebrothers.com
Branches
2/B, Akruti Society, Jodhpur Gam Road Satellite
Ahmedabad 380 015, Phones: +91-079-26926233, Rel: +91-079-32988717
Fax: +91-079-26927094, e-mail: ahmedabad@jaypeebrother.com
202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East
Bengaluru 560 001, Phones: +91-80-22285971, +91-80-22382956, Rel: +91-80-32714073
Fax: +91-80-22281761, e-mail: bangalore@jaypeebrothers.com
282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon Road
Chennai 600 008, Phones: +91-44-28193265, +91-44-28194897, Rel: +91-44-32972089
Fax: +91-44-28193231, e-mail: chennai@jaypeebrothers.com
4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote Cross Road
Hyderabad 500 095, Phones: +91-40-66610020, +91-40-24758498, Rel:+91-40-32940929
Fax:+91-40-24758499, e-mail: hyderabad@jaypeebrother.com
No. 41/3098, B & B1, Kuruvi Building, St. Vincent Road
Kochi 682 018, Kerala, Phones: 0484-4036109, +91-0484-2395739, +91-0484-2395740
e-mail: kochi@jaypeebrothers.com
1-A Indian Mirror Street, Wellington Square
Kolkata 700 013, Phones: +91-33-22651926, +91-33-22276404, +91-33-22276415
Fax: +91-33-22656075, e-mail: kolkata@jaypeebrothers.com
Lekhraj Market III, B-2, Sector-4, Faizabad Road, Indira Nagar
Lucknow 226 016, Phones: +91-522-3040553, +91-522-3040554
e-mail: lucknow@jaypeebrothers.com
106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital, Parel
Mumbai 400 012, Phones: +91-22-24124863, +91-22-24104532, Rel: +91-22-32926896
Fax: +91-22-24160828, e-mail: mumbai@jaypeebrothers.com
KAMALPUSHPA 38, Reshimbag, Opp. Mohota Science College, Umred Road
Nagpur 440 009 (MS), Phones: Rel: 3245220, Fax: 0712-2704275
e-mail: nagpur@jaypeebrothers.com
North America Office
1745, Pheasant Run Drive, Maryland Heights (Missouri), MO 63043, USA Ph: 001-636-6279734
e-mail: jaypee@jaypeebrothers.com, anjulav@jaypeebrothers.com
Central America Office
Jaypee-Highlights Medical Publishers Inc., City of Knowledge, Bld. 237, Clayton, Panama City, Panama Ph: 507-317-0160
Essentials of Human Anatomy
2009, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means:
electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of
material, but the publisher, printer and author will not be held responsible for any inadvertent error (s). In case of any dispute, all legal
matters are to be settled under Delhi jurisdiction only.
First Edition: 1995
Second Edition: 2009
ISBN 978-81-8448-720-6
Typeset at JPBMP typesetting unit
Printed at
tahir99 - UnitedVRG
To
my dear wife
and darling daughters
h
a
9
ri 9
n
U
V
d
ti e
G
R
tahir99 - UnitedVRG
Preface to the Second Edition
G
R
The second edition of Essentials of Human Anatomy is being released after a long waiting period.
The book is thoroughly revised in its contents and is being presented in a new format. However, the
main theme of the book i.e. presenting the basic facts of different structures and organs of human body
in a simple correlated manner in easily understandable language, is left untouched.
The unnecessary details and complicated descriptions are avoided so that studying facts of anatomy
becomes a pleasing experience.
Care has been taken to emphasize applied anatomy of structures wherever applicable.
Multiple choice questions (MCQs) with explanatory answers at the end of each section of the book
help in quick revision of the text.
Simple figures in each chapter further help in understanding the facts.
The study of anatomy of human body forms a basic prerequisite for not only medical students but
also for the students of dentistry, nursing, physiotherapy, and other paramedical subjects. The book will
prove a useful guide for them.
Hope the book in its revised edition will be helpful in learning the difficult subject of anatomy in an
interesting way.
h
a
9
ri 9
n
U
V
d
ti e
BK Tandon
tahir99 - UnitedVRG
Preface to the First Edition
G
R
Anatomy is a vast and difficult subject comprising many facts with complicated description of different
parts and systems of the human body. At the same time, study of this subject is very important for
undergraduate and postgraduate medical students because anatomy forms the backbone of all clinical
and applied medical sciences.
It is necessary for a teacher of the subject to cut out the unnecessary details and make the subject
more palatable and easy. The present book is an attempt to present the essential facts of human anatomy
in a correlated and simplified manner.
Following are the objectives of this book:
V
d
ti e
To give a working knowledge of basic human anatomy with the help of illustrations, figures and
tables.
To cut down the detailed description and present the main facts in a point-wise manner.
To minimise the time taken for study of different regions of the body.
To serve as a framework of human anatomy upon which the students or medical practitioners can
build up details.
To include the clinical importance and applied anatomy of different parts of the body.
To include multiple choice questions with answers at the end of each chapter for revision of the text.
9
ri 9
n
U
The book presents the different parts of the body in a region-wise manner. However, the bones and
joints of the part have been discussed in the beginning of each chapter. This treatment of the subject is
different from other textbooks of anatomy. This has been done with a view that when a student learns
about one region of a part of human body (e.g. shoulder region of upper limb) he should revise all the
structures of the region, viz. muscles, blood vessels, lymphatics and nerves. In this attempt, some
repetitions of the structures are unavoidable. But then, anatomy is best learnt by repetition.
h
a
I hope that the book will be helpful in learning anatomy in an interesting way.
BK Tandon
tahir99 - UnitedVRG
Acknowledgements
I am thankful to Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Duneja (DirectorPublishing), Mr SK Choudhary, Mr Ram Murti and Mrs Neeti Dobriyal of M/s Jaypee Brothers Medical
Publishers (P) Ltd. towards publishing this book.
tahir99 - UnitedVRG
Contents
Section One: Introduction to Anatomy
1.
2.
3.
4.
5.
6.
7.
The
The
The
The
The
The
The
Basics ................................................................................................................................... 1
Skin and Its Appendages .................................................................................................. 4
Bones, Cartilages and Joints ............................................................................................ 9
Muscles and the Fasciae .................................................................................................. 16
Blood Vascular System .................................................................................................... 21
Lymphatic System ........................................................................................................... 26
Nervous System ............................................................................................................... 29
Section Two: The Upper Extremity

8.
9.
10.
11.
12.
13.
The Bones of the Upper Extremity ........................................................................................ 43

The Joints of the Upper Extremity ........................................................................................ 55
The Shoulder Region and Superficial Back Region ............................................................ 65
The Upper Arm and the Elbow Region .................................................................................. 78
The Region of Forearm ........................................................................................................... 85
The Region of Wrist and Hand .............................................................................................. 95
Section Three: The Lower Extremity

14.
15.
16.
17.
18.
19.
The Bones of the Lower Extremity ..................................................................................... 113

The Joints of the Lower Extremity ..................................................................................... 129
The Hip Region ...................................................................................................................... 141
The Region of the Thigh ....................................................................................................... 146
The Region of the Leg .......................................................................................................... 161
The Region of the Foot ......................................................................................................... 168
Section Four: The Thorax

20.
21.
22.
23.
24.
The Bones and Joints of Thorax .......................................................................................... 183

The Musculature of the Thoracic Wall ............................................................................... 194
The Pleura and Lungs ........................................................................................................... 206
The Pericardium and the Heart ........................................................................................... 215
The Mediastinum ................................................................................................................... 228
xiv
Section Five: The Abdomen

25.
26.
27.
28.
29.
The Anterior Abdominal Wall and the Inguinal Region ................................................... 243
The Peritoneum ..................................................................................................................... 259
The Gastrointestinal System-1 ............................................................................................ 271
The Gastrointestinal System-2 ............................................................................................ 289
The Kidneys, Suprarenals and the Posterior Abdominal Wall ......................................... 303
Section Six: The Pelvis

30.
31.
32.
33.
34.
The
The
The
The
The
Bones and Joints of the Pelvis ..................................................................................... 322

Fasciae, Muscles, Blood Vessels and Nerves of the Pelvis ........................................ 327
Perineum ........................................................................................................................ 335
Pelvic Viscera-1 .............................................................................................................. 346
Pelvic Viscera-2 .............................................................................................................. 359
Section Seven: The Head and Neck

35.
36.
37.
38.
39.
40.
41.
42.
The Bones of the Head and Neck ........................................................................................ 371

The Joints, Fasciae and Deep Muscles of the Back of Head and Neck ........................... 391
The Scalp, Face and the Cranial Cavity ............................................................................. 400
The Parotid Region, Temporal and Infratemporal Fossae ............................................... 417
The Triangles of the Neck .................................................................................................... 427
The Muscles, Glands, Blood Vessels and Nerves of the Front of Neck ........................... 435
The Viscera of the Head and Neck-1 ................................................................................... 452
The Viscera of the Head and Neck-2 ................................................................................... 460
Section Eight: The Spinal Cord, Brain, Eyes and the Ears
43.
44.
45.
46.
47.
48.
49.
The Spinal Cord ..................................................................................................................... 481

The Meninges and Blood Supply of Brain ........................................................................... 486
The Hind-Brain and Mid-Brain ............................................................................................ 492
The Forebrain ........................................................................................................................ 502
The Cranial Nerves ............................................................................................................... 517
The Eyes ................................................................................................................................. 525
The Ears .................................................................................................................................. 536
Index ........................................................................................................................................ 551
tahir99 - UnitedVRG
Introduction to
Anatomy
ONE
1
CHAPTER
The Basics
The term Anatomy is derived from Greek word
anatome (= cutting up). Anatomy, therefore, is the
study of structure of human body after dissection.
Human anatomy is the oldest medical science. The
first person to describe the structure of human body
was the Greek philosopher, Aristotle, nearly 2,300
years ago.
2.
3.
THE SUBDIVISIONS OF ANATOMY

1. Gross-anatomy: Macroscopic study of human
body after dissection. It can be studied as:
A. Systemic (Systematic) anatomy: Study of
different systems of the body:
Osteology: Study of the bones
Arthrology: Study of the joints
Myology: Study of the muscles
Angiology: Study of the cardiovascular
system
Splanchnology: Study of the internal
organs
Neurology: Study of the nervous system
Endocrinology: Study of the endocrines
or the ductless glnds
Integumentary system: Study of the skin
and its derivatives.
B. Regional anatomy: Study of the different
regions of human body:
Head and neck
Brain
Thorax
4.
5.
6.
7.
Abdomen and pelvis

Upper extremity
Lower extremity.
Microscopic anatomy (Histology): Study of the
minute structure of the body with the help of a
microscope.
Developmental anatomy (Embryology): Study
of the embryo and fetus within the uterus or
the womb.
Applied anatomy (Clinical anatomy): Study of
those aspects of anatomy which are applicable
to the clinical disciplines and help to explain
and provide a background for the clinical signs
and symptoms.
Functional anatomy: Study of structure of
different parts of the body related to their
functions.
Surface anatomy: Study of the landmarks, e.g.
bony prominences and muscular elevations, and
projections of outlines of viscera and other
structures on the surface of the body.
Radiological anatomy: Study of different parts
of body, specially bones and joints, with the
help of X-rays.
THE POSITIONS OF THE BODY

1. The anatomical position: The body is standing
erect with arms by the sides and palms facing
forwards. The legs and feet are together and
eyes look directly to the front.
All the structures of human body are

described with reference to the anatomical
position.
2. The supine position: The body is in lying down
position with the back touching the surface and
the front of the body facing upwards.
3. The lithotomy position: The upper part of the
body is lying in supine position with the back
touching the surface. Both lower limbs are
flexed and abducted at hip joints and flexed at
the knee joints.
This position of the body is used for
Child birth
Operations in the pelvic and perineal regions
Dissection of the perineal and pelvic regions
in the cadavers.
THE PLANES OF THE BODY
1. The median sagittal (median) plane: It is the
vertical plane passing through the center of the
body and dividing the body into two equal
halvesright and left.
2. The sagittal (para-sagittal) plane: It is the
vertical plane that lies parallel to the median
sagittal plane.
3. The coronal plane: It is the vertical plane that
is placed perpendicular to the sagittal planes.
4. The transverse (horizontal) plane: It is the
horizontal plane that lies perpendicular to the
sagittal and coronal planes.
THE DESCRIPTIVE ANATOMICAL TERMS
1. Anterior-posterior
Anterior (ventral) is towards the front of
the body.
Posterior (dorsal) is towards the back of
the body.
2. Superior-inferior
Superior (upper) is towards the head end
of the body.
Inferior (lower) is towards the foot end of
the body.
3. Medial-intermediate-lateral
Medial is nearer the median plane of the
body.
Intermediate is in between medial and lateral.
Lateral is away from the median plane of
the body.
4. Cranial-caudal
Cranial is towards the head end of the body.
Caudal is towards the lower end of the trunk
or cauda (tail)
These terms are used in cases of embryo
and fetus usually.
5. Proximal-distal
Proximal is closer to the median plane of
the body or the origin of the structure.
Distal is farther from the median plane of
the body or the origin of the structure.
6. Superficial-deep
Superficial (external) is closer to the surface
of the body.
Deep (internal) is farther from the surface
of the body.
7. Palmer-plantar
Palmer refers to the ventral aspect of the
hand.
Plantar refers to the sole of the foot.
8. Peripheral-central
Peripheral is away from the median plane
of the body.
Central is closer to the median plane of the
body.
THE TERMS RELATED TO THE
MOVEMENTS
The movements take place mostly at various joints
of the body and are responsible for changing
position of diferent parts of the body.
1. Flexion-extension takes place at the transverse
axis of the joint.
Flexion is the angular movement which
consists of bending at the joint.
Extension is the straightening movement,
whereby a joint is made straight.
tahir99 - UnitedVRG
The Basics
2. Abduction-adduction takes place at an anteroposterior axis of the joint.
Abduction is the movement of the joint away
from the median plane of the body or a fixed
axis.
Adduction is the opposite movement
towards the median plane of the body or a
fixed axis.
3. Circumduction is combined movement of
flexionextension and abductionadduction
at a joint. This movement is possible only in
very mobile joints, e.g. shoulder joint and hip
joint.
4. Medial rotation-lateral rotation takes place at
the vertical axis of the joint.
Medial rotation consists of rotating the
ventral surface of the part towards the
median plane.
Lateral rotation consists of rotating the
ventral surface of the part away from the
median plane.
5. Elevation-depression
Elevation is the movement whereby the part
is raised towards the head end of the body.
Depression is the movement of lowering the
part towards the foot end of the body.
6. Protraction-retraction
Protraction is moving a joint or a structure
towards the front of the body.
Retraction is moving a joint or a structure
backwards.
7. Inversion-eversion
Inversion is the movement of rotating the
foot so that sole faces inwards.
Eversion is the movement of rotating the
foot so that the sole faces outwards.
These movements occur in relation to
the foot only.
8. Pronation-supination
Pronation is the movement of rotating the
forearm and hand so that the front of the
forearm and palm faces backwards.
Supination is the opposite movement of
rotating the forearm and hand so that the
front of the forearm and palm face
forwards.
These movements occur in relation to
the forearm and hand only.
Most of the anatomical names are derived
from the Latin and Greek languages. There are
nearly 5,000 terms in anatomy, which are used for
naming the structures. These terms were adopted
at a meeting of the German Anatomical Society,
held at Basle in the year 1895. Therefore, these
terms are called BNA (Basle Nomina Anatomica).
These terms are universally accepted all over the
world.
Subsequently, some revisions were made at the
Fifth International Congress of Anatomists held at
Oxford in the year 1950. In the meeting a new
body called International Anatomical Nomenclature
Committee has been formed for subsequent
revisions of terms.
CHAPTER
The Skin and Its

Appendages
THE SKIN
The skin covers the entire external surface of the
body. It is also considered to be largest organ of
the body. The total surface area of the skin, if
unfolded, comes to nearly two square metres.
Main Functions of the Skin
1. Protection against
Injury or trauma
Infections
Fluid loss of the body.
2. Sensations with the help of receptor nerve
endings for all exteroceptive sensations, viz.
pain, touch, temperature and pressure.
3. Secretion
Sweat glands produce sweat and help in
temperature regulation and to some extent
in excretion
Sebaceous glands secrete sebum or natural
oil for the hair follicles
Mammary glands in females secrete milk
(These are modified sweat glands).
Parts of the Skin
The skin consists of two partsouter epidermis
and inner dermis.
Layers of epidermis: It is made up of stratified
squamous epithelium (keratinized type). It has five
strata of layers of flattened cells.
a. Stratum basale (germinativum): Consists of
single layer of low columnar (cuboidal) cells
resting on basement membrane
Mitosis access mainly in this layer
b. Stratum spinosum: Consists of several layers

(prickle cell layer) of polyhedral cells.
Cell membranes possess spines or prickles
that interdigitate with those of adjacent cells.
c. Stratum granulosum: Consists of several layers
of flattered cells
Cells certain conspicuous basophilic granules
d. Stratum lucidum: Consists of several layers
flattened anucleate cells
The layer has a hyaline appearance and
shows weak cytoplasmic eosinophilia
e. Stratum corneum: Consists of many layers of
large, cornified, anucleate cells that appear as
scales
The last two layers consist of dead or cornified
scales (Fig. 2.1).
Thickness of epidermis varies from 20 to 1400
micrones, depending upon the location.
The dermis: It is made up of connective tissue
containing the following structures:
a. Derivatives of the epidermis
Hair follicles
Sebaceous glands
Sweat glands
Nails
b. Arrector pili musclessmooth muscle fibers
attached to the hair follicles.
c. Cutaneous blood vessels.
d. Cutaneous nerves and receptor nerve endings
e. Superficial lymphatics.
f. Mammary glands in the females.
g. Variable amount of that fat lies in deeper part of
the dermis and merges with the subcutaneous
fat of superficial fascia.
tahir99 - UnitedVRG
The Skin and Its Appendages
Fig. 2.1: Structure of skin
The Cleavage Lines [Lines of Langer]

The collagen fiber bundles in the dermis follow a
general directional pattern in different parts of the
body forming these cleavage lines.
An incision across the prevailing direction of
these collagen fiber bundles cuts many collagen
fibers resulting in gaping of the skin wound, that
heals by a prominent scar.
If, however, an incision is made in the skin
parallel to the direction of these cleavage lines, it
does not cut across many collagen fibers. So, there
is not much gaping of the skin wound and it heals
with minimum of scar tissue.
In the neck, thorax and abdomen, the cleavage
lines run circumferentially, while in the limbs they
follow a longitudinal pattern.
The cleavage lines are important from point of
view of surgical incisions on the skin (Fig. 2.2).
The Skin Creases
The skin over the joints always folds at some places
causing skin creases. The skin creases are also
present in the palm and to a lesser extent in the
skin of the sole.
Fig. 2.2: The cleavage lines of skin
At the sites of the skin creases, the skin is

thinner and firmly attached to the underlying
structures.
The Appendages of the Skin
The appendages of the skin are the nails, hair
follicles, sebaceous glands and the sweat glands.
1. The nails: These are keratinised plates on dorsal
surface of tips of fingers and toes.
The proximal edge of the plate is the root of

the nail, while the distsal edge projects beyond
the nail bed and become dead; so it can be cut
or trimmed.
The surface of the skin covered by the nail
plate is called the nail bed.
The nail is surrounded by the nail folds
except at the free edge.
2. The hair follicies: These are invaginations of
the epidermis that grow obliquely in the deeper
part of the dermis.
The hair grow out of the hair follicles. Their
roots form the hair bulbs with concave bases
occupied by vascular connective tissue forming
hair papillae.
The arrector pili are smooth muscle fibers
that connect the lower part of hair follicles to
the deeper layer of the epidermis.
The arrector pili are supplied by sympathetic
fibers
Their contraction causes hair follicles to
become more erect causing socalled goose
flesh
Their contraction also causes compression
of the sebaceous glands and helps in extruding their secretion, sebum, in the hair
follicles.
The hair are distributed all over the surface
of the body except in
Palms and soles
Lips
Sides of fingers and toes
Labia majora and labia minora (external
genitals) in the females.
3. The sebaceous glands: These are branched
alveolar glands that secrete sebum (natural oil)
in the hair follicles.
These glands are present between the
arrector pili muscles and the sloping surface of
the hair follicles. The sebum keeps the hair
flexible and also oils the skin surface.
4. The sweat glands: These are coiled tubular
glands that secrete sweat.
These glands lie in the deeper part of the dermis

and have long ducts, that pass through dermis and
the layers of the epidermis to open at minute pores
on the surface of the skin.
The sweat glands are distributed on all surfaces
of the body except:
Red margin of the lips
Nail beds
Glans penis in males and clitoris in females.
The Nerve Supply of the Skin
The skin receives sensory nerve supply from the
spinal and the cranial nerves.
The sensory nerve fibers begin from the
receptor end organs and free nerve endings located
in the dermis of the skin.
Basically, the sensory nerve supply of the skin
follows a segmental pattern. The skin area supplied
by one pair of spinal nerves (i.e. one spinal segment)
is called a dermatome.
There is overlapping in the nerve supply of a
dermatome from the adjoining dermatomes.
The spinal nerves also carry post-ganglionic
sympathetic fibers that supply:
The blood vessels of the skin
The sweat glands
The arrector pili muscles.
Clinical Importance of Skin
1. Systemic diseases often produce manifestations
on the skin in the form of:
Vasoconstriction
Vasodilatation
Eruptions
Edema
2. The skin is very important for plastic surgery,
viz:
Skin grafting
Cosmetic surgery.
3. Loss of skin in cases of burn injuries causes
extensive fluid loss.
tahir99 - UnitedVRG
The Skin and Its Appendages

THE MAMMARY GLAND
The mammary gland is a secondary sex gland in
females for production of milk.
It consists of highly enlarged and modified
sweat glands placed on the front of upper part of
thorax.
Areola is a circular patch of colored skin that
surrounds the nipple.
It has large sweat glands, that become enlarged
during pregnancy and form raised tubercles of
Montgomery
It is lighter in color, but during second month
of first pregnancy, its color becomes permanently darker.
forms a membranous capsule on its deep

surface, that is separated from deep fascia of
pectoralis major by retro-mammary space.
3. The suspensory ligaments (Ligaments of
Cooper) are fibro-elastic bands, which act as
connective tissue septa inter-connecting the
lobes.
They also connect the lobes of the gland to
the skin and underlying deep faseta.
In old age, these ligaments lose their
elasticity causing sagging of the breast.
In cases of tumor of the breast, these
ligaments are shortened, thereby causing
retraction of the overlying skin (Fig. 2.3).
Nipple (Mammary papilla) is a conical elevation

present in the center of areola.
It is situated a little below and lateral to the center
of the breast
In males the nipple is located in the 4th
intercostal space about 10 cm, from the median
plane
The nipple has openings of about 15 to 20
lactiferous ducts on its summit
It has a subareolar muscle at its base with both
circular and radiating muscle fibers.
Architecture of the Mammary Gland
1. The glandular part has 15 to 20 pyramidal
shaped lobes.
Each lobe has clusters of secreting units or
acini forming many lobules
From each lobe one lactiferous duct collects
the secretion and converges towards the
base of nipple
There is a slight dilation lactiferous sinus in
the duct at the base of the nipple
Each lactiferous duct opens separately at
the summit of the nipple.
2. The connective tissue stroma surrounds the
lobes. It contains variable amount of fat, which
gives the breast a round contour. The stroma
Fig. 2.3: Sagittal section through breast
The Nerve Supply of the

Mammary Gland
The secretory activity of the gland is under control
of prolactin hormone of anterior pituitary gland.
The proliferation of the glandular tissue during
pregnancy and lactation is due to increase in
the level of estrogen and progesterone.
The blood vessels supplying the gland are
supplied by the sympathetic nerves.
The Blood Supply
Development
The mammary gland develops from a thick ridge

of ectoderm called the milk ridge (or line), that
extends from the region of axilla to the groin or the
inguinal region.
The gland develops from the upper part of this
ridge in the pectoral region. The rest of the ridge
disappears.
The nipple area, in the developing breast,
remains inverted in the fetal period and gets everted
only in the later part of fetal period before birth.
The mammary gland is supplied mainly by the

branches of the axillary artery thoracoacromial and lateral thoracic.
It is also supplied by the perforating branches
of the internal mammary artery (specially those
in the 2nd, 3rd, and 4th intercostal spaces).
The Lymphatic Drainage
The lymphatics generally follow the blood

vessels.
Nearly 80% of the lymph from the mammary
gland drains into the axillary lymph nodes.
The remaining 20% lymph drains into the
parasternal lymph nodes present along the
internal thoracic artery, and the supra-clavicular
lymph nodes.
For purpose of lymphatic drainage of the
mammary gland the breast has been divided into
four quadrants superior medial, superior
lateral, inferior medial and inferior lateral.
All four quadrants drain their lymph into
axillary lymph nodes, mainly in the anterior
and posterior groups
The medial quadrants drain part of their
lymph in parasternal lymph nodes
Some lymphatics from the lower medial
quadrant pass into the rectus sheath and
reach peritoneal cavity (thus making most
dangerous route for the spread of cancer
of breast)
Some lymphatics from upper quadrants
cross clavicle and may reach supraclavicular lymph nodes
Some superficial lymphatics may communicate
across midline with the lymphatics of the
opposite breast.
The Anomalies of Development

1. Amastia absence of mammary gland (on one
side mostly).
2. Polymastia presence of accessory or
supernumerary breasts.
3. Polythelia presence of accessory nipple or
nipples.
4. Gynecomastia development of mammary
gland in the males (due to hormonal disorder).
5. Congenital retraction of nipple due to noneversion of nipple at the time of birth.
Clinical Importance of the
Mammary Gland
1. The female breast is often a site of cancer.
It manifests as a hard lump that gets fixed
to the skin or the deep fascia.
The breast cancer spreads to the lymph
nodes of drainage.
The overlying skin (or the nipple if it is under
the nipple) shows retraction.
2. The mammary gland may develop retention
cysts due to blockage of lactiferous ducts.
3. The breast may also be the site of acute
inflammatory conditions like breast abscess.
tahir99 - UnitedVRG
CHAPTER
The Bones,
Cartilages and Joints
THE BONES
The bones of the body form the skeleton
(endoskeleton, as it lies deep to the muscles)
The skeleton can be divided into:
1. The axial skeleton consisting of the skull,
mandible, hyoid bone, vertebral column
(including sacrum and the coccyx), sternum
and the ribs.
2. The appendicular skeleton consisting of bones
of the upper and lower extremities.
The skeleton is bilaterally symmetrical and has
approximately 206 bones.
The axial skeleton has 80 bones as under:
The skull
Cranial bones
8
Facial skeleton (including mandable)
14
The ear ossicles
6
The hyoid bone
1
The vertebrae
26
7 Cervical
12 Thoracic
5 Lumbar
1 Sacrum
(Formed by fusion of 5 sacral vertebrae)
1 Coccyx
(formed by fusion of 4 coccygeal vertebrae)
The sternum
1
The ribs
24
Total
80
The appendicular skeleton has 126 bones as under:
1. The upper extremity
Scapula
1
Clavicle
Humerus
Radius
Ulna
Carpal bones
Metacarpals
Phalanges
Total bones for two upper extremities

32 2 = 64
2. The lower extremity
Innominate bone
(Hip bone)
Femur
Patella
Tibia
Fibula
Tarsals
Metatarsals
Phalanges
1
1
1
1
8
5
14
32
1
1
1
1
1
7
5
14
31
Total bones for two lower extremities

31 2 = 62
Thus the bones in the appendicular skeleton are
126(64+62); and total number of bones in the body
are (80+64+62)=206.
The Main Functions of the Bones
1. Shape: The bones give shape to the body by
providing a rigid framework.
2. Protection: The bones provide protection to the
vital internal organs, e.g. brain, heart, lungs,
and liver.
10
3. Joints: The bones form the joints, which act as

levers and provide movements.
4. Storehouse: The bones act as store houses of
Ca, PO4 and CO3 ions.
5. Hemopoiesis: The bone marrow is the source
of red blood cells, white blood cells, and the
platelets.
The Structure of the Bone
The bone is calcified connective tissue. It consists
of:
1. An organic matrix (nearly 33%) made up of
collagenous tissue. This forms the basic
framework of the bone.
2. An inorganic content (nearly 66%) that
impregnates the organic matrix. It is made up
of crystalline hydroxyapatite of calcium. The
inorganic content gives the sheer strength to
the bone.
3. The osteocytes (bone forming cells) that lie in
the spaces within the bone tissue called lacunae.
By keeping the bone in weak, mineral acid for
some time, the inorganic content of the bone is
removed and the bone becomes decalcified. Such
a bone becomes soft and malleable.
By incinerating, the bone loses the organic
matter. The remaining inorganic matter maintains
the shape of the bone, but becomes very brittle.
A transverse section through the long bone
shows:
I. The periosteum: That lines the external surface
of all parts of the bone except those that are
covered by hyaline articular cartilage at the joints.
The periosteum consists of:
An outer fibrous layer
An inner vascular layer with plexus of fine
blood vessels (periosteal plexus). It has also
a layer of osteocytes, that are modified
fibroblasts.
The functions of the periosteum are:
1. It protects the bone.
2. It nourishes the bone through its vascular
plexus.
3. It helps in growth and repair of the bone by
its osteocytes.
II. The compact bone lies deep to the periosteum

and looks like ivory with naked eye.
The compact bone is made up of haversian
systems and canals.
III.The cancellous bone consists of of bony lamellae
enclosing narrow spaces containing the bone
marrow tissue.
The cancellous bone fills up the interior of
the bone.
IV. The medullary cavity is present in most of the
long bones.
It is located mainly in the shaft of the bone and
contains bone marrow tissue (Fig. 3.1).
Fig. 3.1: LS through a long bone
Types of Bones
1. Long bones are present in the extremities.
They have a main part or shaft called
diaphysis.
The two ends form the epiphysis.
There is medullary cavity containing bone
marrow tissue in the shaft.
Examples: Femur, humerus.
2. Short bones are small size bones usually cuboidal
in shape.
Examples: Tarsals, Carpals.
3. Flat bones consist of two layers of compact
bone with spongy or cancellous bone in between
called diploe. They are expanded like a plate.
tahir99 - UnitedVRG
The Bones, Cartilages and Joints

Examples: Skull bones, e.g. frontal, parietal.
4. Irregular bones have irregular shapes
They have compact bone surrounding
spongy bone in between.
Examples: Vertebrae, hip bones
5. Sesamoid bones (= seedlike) are small nodules
of bone, developed in tendons of certain muscles
at sites of friction or pressure.
Examples: Patella, pisiform.
6. Pneumatic bones are skull bones having airfilled cavities called air sinuses.
Examples: Frontal, maxilla.
Ossification of the Bones
The ossification is the process of bone formation
by the bone forming cells- osteoblasts.
The osteoblasts form centers of occification in
the developing bone.
For growth and remodelling another type of
bone cellsthe osteoclastsare also required.
There are two types of ossification:
1. Intra-cartilaginous type (enchondral ossification): In this type, first a cartilaginous model of
bone is formed. The centers of ossification
appear within the cartilaginous model and
replace it with bone.
Examples: Most of the limb bones.
2. Intra-membranous type: In this type the centers
of ossification appear in the mesenchymatous
model itself without forming the cartilaginous
model.
Examples: Clavicle, Skull bones, e.g. frontal
parietal.
The primary center of ossification of the bone
usually appears before birth and forms the main
part of the bone. In long bone it forms the diaphysis.
The secondary centers of ossification usually
appear after birth and form small parts of the bone
called epiphyses.
In case of long bones, there is usually one (or
more than one) epiphysis at either end of the
bone.
11
There is an epiphyseal plate or cartilage

separating the epiphysis from the diaphysis. This
epiphyseal plate disappears, when the growth in
length of the bone stops.
The epiphyseal end of diaphysis is called
metaphysis.
This is the most vascular and active area of
growth of the long bone.
The growing end of the long bone is that end
of the bone whose epiphysis fuses with the
diaphysis (shaft) later than the other end (i.e. it
continues to grow in length a little longer).
The growing end of the long bone lies opposite
to the direction of the nutrient canal of the bone
(Fig. 3.2).
Fig. 3.2: Parts of a developing long bone
Functional Considerations
The bone is a living tissue capable of growth and
repair.
The growth in length of the long bone takes
place at the epiphyseal cartilage, while the growth
in thickness (appositional growth) takes place deep
to the periosteum. The remodeling of the bone
takes place along with the growth of the bone. It is
done by the osteoclaststhe bone absorbing cells.
12
The lamellae of the spongy bone, specially

towards the ends of the long bone, develop along
the lines of force transmission.
The ridges, crests and tubercles, etc. on the
bone develop at the sites of attachment of the
muscles and tendons, due to the traction exercised
by them on the bone.
The Blood Supply of the Bones
The bones receive their blood supply from three
sources:
1. The nutrient vessels enter through the nutrient
foramen, in long bones, they pass through the
nutrient canal directed away from the growing
end of the bone.
The nutrient vessels provide main blood
supply of the bone.
In long bone, they also supply the bone
marrow in the medullary cavity.
2. The periosteal vessels are derived from the
periosteal plexus, which is nourished by the
muscular vessels supplying muscles attached
to the bone.
The periosteal vessels supply the superficial
part of the compact bone only.
3. The epiphyseal and juxta-epiphyseal vessels are
derived from the vessels supplying the articular
capsule of the joint.
These are mostly present at the ends of the
long bone and pass through the vascular
foramina located there.
Clinical Considerations
The fractures of the bones are caused due to
abnormal pressure or traction applied to the bones.
Fractures are classified according to:
a. Degree of displacement of broken bone pieces.
b. Compression of the bone.
c. Whether the skin over the fracture is also torn
leading to compound fracture.
The fractures can be seen and diagnosed
with the help of X-ray photographs.
The fracture of epiphyseal plate in developing bone is difficult to detect and it may
interfere with the subsequent growth of the
bone.
The fractures of bone may injure the nerves
and the blood vessels close to the bone.
The fracture of skull bones may result in
compression of the brain and injury to nerves
and blood vessels passing through the
foramina of the bone.
The repair of the fractures

The fracture results in loss of function of the
bone in that region.
As a first step towards repair, a collar of collagen
called callus is formed by the fibroblasts lying
in the deeper part of periosteum.
The callus calcifies later and forms a temporary
union between the fractured pieces of the bone.
Both osteoblasts (bone forming cells) and
osteoclasts (bone absorbing cells) become active
at the site of callus formation and result in the
formation and remodelling of the bone, so that
the original size and shape of the bone is
restored.
THE CARTILAGES
The cartilage is a firm and resilient structure that
forms a small part of skeleton.
The cartilage is a form of connective tissue
in which the living cellschondrocytesare
embedded in the intercellular matrix composed
of muco-polysaccharides.
Except for the cartilage present on the articular
surfaces of the joints, the cartilages located
elsewhere are covered by a fibrous membrane
called perichondrium.
There are three types of cartilageshyaline,
white fibrocartilage and yellow elastic cartilage.
1. The hyaline cartilage has no demonstrable
fibers, by ordinary H and E stain, in the
intercellular matrix, which is very large in
amount.
tahir99 - UnitedVRG
The hyaline cartilage has great resistance

to wear and tear.
The hyaline cartilage is found at
Costal cartilages
Articular surfaces of the joints
Epiphyseal plate of growing bones.
The hyaline cartilage is incapable of
repair; the defect is filled up by fibrous
tissue.
2. The white fibro-cartilage has large number
of collagen fiber bundles embedded in the
matrix, which is small in amount.
The white fibro-cartilage is a resistant
and durable form of cartilage.
The white fibro-cartilage is found at
Intra-articular disc of the joints
Inter-vertebral discs of the vertebral
column.
3. The yellow elastic cartillage has a large
number of elastic fibers embedded in the
matrix.
The yellow elastic cartilage is stretchable
and more resilient than other two forms
of cartillage.
The yellow elastic cartilage is found at
Cartilage of external acoustic meatus
Cartilage of pinna or auricle
Cartilage of auditory tube
Epiglottis
THE JOINTS
The joints are formed, where two or more than
two bones meet and get united.
The joints can be classified broadly into three
groupssynarthroses, amphiarthroses and
diarthroses.
1. The synarthroses (fibrous joints) are immovable
or hardly movable.
These joints can be further divided into three
types:
13
a. The suture is the joint between two flat skull

bones.
The outer and inner fibrous layers of
the two bones become continuous and
there is a fibrous sutural ligament in
between the bones.
Examples: Coronal suture, sagittal
suture.
b. The syndesmosis is the fibrous joint where
the two bones are connected by ligaments
only (Fig. 3.3).
Examples: Inferior tibio-fibular joint.
c. The gomphosis (peg and socket joint) is the
fibrous joint between the root of the tooth
and the bony socket provided by the upper
jaw or lower jaw bone.
2. The amphiarthroses (cartilaginous joints) may
allow a limited movement.
These joints can be further devided into two
types:
a. The primary cartilaginous joint (synchondrosis) is a joint, where two bones are joined
together by hyaline cartilage.
No movement is possible in these joints:
Examples: First chondro-sternal joint.
Epiphyseal cartilage between diaphysis and
epiphysis.
b. The secondary cartilaginous joint (symphysis) is a joint, where the two bones are
covered by hyaline articular cartilage and
united by a plate of fibro-cartilage.
Fig. 3.3: Fibrous joints
14
The joint is surrounded by ligaments.

A limited movement is possible in these
joints.
Examples:
Pubic symphysis
Intervertebral disc between the two
vertebral bodies (Fig. 3.4).
3. The diarthroses (synovial joints) permit
relatively free movements.
The articular surfaces are covered by hyaline
articular cartilage, that can withstand pressure and change in shape to some extent.
The joint is surrounded by a fibrous articular
capsule, that keeps the bones together, and
prevents their separation during movements
of the joint.
The fibrous capsule is reinforced by straplike fibrous bands called ligaments.
The joint cavity has synovial membrane,
which lines the inner surface of fibrous
capsule, and also covers all intra-articular
structures. The synovial membrane, however, does not cover the articular surface
of the bones.
A fibro-cartilaginous, intra-articular disc is
also found in some synovial joints. The disc
makes the joint more stable (Fig. 3.5).
Classification of synovial joints (according to the
movements):
1. Uniaxial where movements take place in one
axis only.
Examples: Elbow joint, ankle joint.
2. Biaxial where movements take place at two

axes.
Examples: Metacarpo-phalangeal joints, radiocarpal (wrist) joint
3. Multiaxial where movements take place at more
than two axes.
Examples: Shoulder joint, hip joint.
Classification of synovial joints (according to the
shape of the articular surfaces):
a. Plane type where the two joint surfaces are
plane.
Examples: Acromio-clavicular joint
b. Hinge type where the two joint surfaces are
reciprocally curved to allow movement in one
axis only.
Examples: Elbow joint, ankle joint.
c. Pivot type where one joint surface forms the
central pivot, while the other is shaped like a
ring.
Examples: Superior radio-ulnar joint median
atlanto-axial joint.
d. Condyloid type Where one joint, surface is
convex and other is concave.
Examples: Metacarpo-phalangeal joints.
e. Ellipsoid type where the two joint surfaces,
are convex and concave and shaped like an
ellipsoid.
Examples: Radio-carpal (wrist) joint.
f. Ball and socket type where one joint surface is
shaped like a sphere, while the other presents a
socket-like joint surface.
Examples: Shoulder joint, hip joint.
Fig. 3.4: Cartilaginous joints
tahir99 - UnitedVRG
15
Fig. 3.5: Typical synovial joints
g. Saddle type where the two joint surfaces are

reciprocally concavo-convex.
Examples: Calcaneo-cuboid joint
First carpo-metacarpal joint
The Blood Supply of the Joints

The blood supply of the joints is provided by small
vessels from the attachment of the muscles near
the joint.
The large joints have arterial anastomoses
around the joints to supply adequate amount of
blood.
Examples: Elbow joint, knee joint.
The Nerve Supply of the Joints
The nerve supply to the joints is usually derived
from the main nerve of the region.
Hiltons law states that a nerve supplying a joint
also supplies the muscle moving the joint, and the
skin over the insertion of the muscle.
The articular capsule and the ligaments receive
a rich sensory nerve supply.
The articular cartilage covering the joint surfaces
has only a few nerve endings near its edges.
The stretch receptors in the articular capsule

and the ligaments send proprioceptive impulses
to the central nervous system, about the position
of the joint.
Overstretching of the capsule and ligaments
produces reflex contraction of muscles around
the joint, causing pain.
The ligaments are cord-like or strap-like structures

made up of dense connective tissue.
The ligaments firmly connect the bones forming
the joints.
Most of the ligaments are composed of thick
bundles of collagen fibers, and are unstretchable. Such ligaments contribute to the stability
of the joint.
A few ligaments are composed of elastic fibers
and therefore, can be stretched normally.
Example:Ligamenta flava of vertebral column.
Injury to the ligament causes sprain of the
joint with pain and limitation of movements.
Healing of such injury to the ligament is slow,
as ligaments are comparatively less vascular.
Example: Ilio-femoral ligament of the hip
joint.
CHAPTER
The Muscles
and the Fasciae
THE MUSCLES
1. The origin of the muscle is usually the proximal

and more fixed attachment of the muscle.
2. The insertion of the muscle is usually the distal
and relatively mobile attachment of the muscle.
3. The muscle belly is the main part of the muscle
between the two attachments.
Tendon is cylindrical cord-like structure, that
replaces the muscle fibers towards the insertion
of the muscle usually.
The tendon is made up of dense, regularly
arranged collagen fiber bundles.
The tendon has a smaller cross-sectional
area and occupies smaller space on the bone
of attachment.
Example: Tendo-calcaneus
There are three types of muscles in the body:

1. Skeletal (striated)
2. Visceral (non-striated, smooth or plain)
3. Cardiac
The main features of three types of muscles
are given in Table 4.1.
Skeletal Muscles
The skeletal muscles form nearly 50% of body
weight. These muscles are made up of bundles of
muscle fibers, which are specialized muscle cells
with special property of contraction.
Parts of the Skeletal Muscle
Aponeurosis is that fibrous sheet which replaces a

flat muscle towards insertion.
Example: Aponeurosis of external oblique muscle.
Each skeletal muscle has at least two attachmentsorigin and insertionand a muscle belly.
Table 4.1: Main features of muscles
1. Location
2. Histological
structure
Skeletal muscle
Visceral muscle
Cardiac muscle
Attached to the skeleton

Cylindrical muscle fibers
Related to the viscera

Spindle shaped muscle
fibers
No transverse striations
Single oval nucleus
present in the middle of
muscle fiber
In myocardium of heart
Muscle fibers branch and
anastomose
Faint transverse
striations
Intercalated discs present
Centrally placed nuclei
Autonomic nerves
Involuntary
Autonomic nerves
Involuntary
Muscle fibers show both

transverse and longitudinal
striations
3. Nerve supply
4. Actions
Have multiple peripheral

nuclei
Somatic nerves
Mostly voluntary
with few exceptions
Muscle action quick
Muscle action slow

and sustained
tahir99 - UnitedVRG
Property of rhythmic
contraction
The Muscles and the Fasciae

Raphe is a fibrous structure, formed by the inter digitation of muscle fibers of the two sides.
Example: Fibrous median raphe of the two mylohyoid muscles.
Shapes of the Muscle Belly
1. Fusiform where the muscle fibers lie along the
long axis of the muscle.
2. Pennate where the muscle fibers lie at an angle
to the long axis of the muscle.
The pennate muscles have many more
muscle fibers as compared to the fusiform
muscles.
The pennate muscles have, therefore, more
powerful contraction than fusiform muscles.
Their contraction,may be slow and the range
of contraction may be less.
The pennate muscles are classified as
follows:
a. Unipennate muscle where bundles of
muscle fibres are attached to one side
of the tendon.
Example: Flexor pollicies longus.
9
ri 9
3.
4.
5.
b. Bipennate: muscle where bundles of

muscle fibers are attached to both sides
of the tendon.
Example: Flexor hallucis longus.
c. Multipennate: muscle where a series of
bipennate muscles lie alongside one
another in the muscle belly.
Example: Deltod (middle part).
d. Circumpennate muscle where muscle
fibers converge from all sides to reach
a centrally placed tendon.
Example: Tibialis anterior.
Quadrilateral (Quadrangular) where the muscle
belly is short and quadrangular.
Example: Quadratus femoris.
Strap like where the muscle belly is long and
strap or ribbon like with parallel muscle fibers.
Example: Sartorius
Triangular where muscle belly is shaped like a
triangle.
Example: Obturator externus.
Digastric where two muscle bellies are joined
by a common tendon.
Example: Digastric
V
d
ti e
n
U
6.
h
a
17
Fig. 4.1: Shapes of skeletal muscles
G
R
18
7. Bicipital where the muscle belly has two headsjoined by a common tendon.
Example: Biceps brachii.
8. Tricipital where the muscle belly is divided into
three heads, that are joined at the common
tendon of insertion (Fig. 4.1)
Example: Triceps brachii.
Types of the Skeletal Muscles
The skeletal muscles are also classified according
to their actions
1. The prime movers are the main muscles
responsible for a particular movement at a joint.
Example: Brachialis a prime flexor of
the elbow joint.
2. The antagonists are the muscles that are just
opposite in action to the prime movers.
Examples: Tricepsa prime extensor of the
elbow joint, is antagonist to the brachialis.
3. The synergists are the muscles which help in
the action of the prime movers by stabilizing
the intermediate joints or preventing unwanted
movements.
Examples: Long flexors of carpals that help
in action of long flexors of the fingers.
4. The fixators are those muscles which contract
isometrically to stabilize the attachment of the
prime movers, so that they may contract more
effectively.
Example:Scapular muscles fix the scapula,
so that deltoid can abduct the shoulder joint.
The Contraction of the Muscle
The contraction of the skeletal muscle may be.
a. Isometric contraction when muscle contracts
and exercises force without producing any
movement.
Example:Flexor muscles of the elbow joint
trying to lift a weight that is too heavy.
b. Isotonic contraction when a muscle shortens
to produce a movement.
Example: Flexor muscles of the elbow joint

lifting a weight, that is manageable.
The Nerve Supply of the Muscle

The nerve supply of the skeletal muscle is by a
motor nerve. The nerve contains about 60% motor
nerve fibers and 40% afferent or pro-prioceptive
nerve fibers.
The neuro-vascular hilum is present in most of
the skeletal muscles. It is the site where the
motor nerve and the main blood vessels enter
the muscle belly.
The motor nerve fibers supplying the muscle
are of two types:
a. Large alfa motor efferents are derived from
large motor neurons of anterior grey column
of the spinal cord.
b. Small gamma efferents are derived from the
small neurons in the anterior grey column
of the spinal cord.
Both types of motor nerve fibers are myelinated
and end by dividing into many branches, which
terminate in individual muscle fibers at the motor
end plate.
The sensory or afferent nerve fibers are also
myelinated, and arise from specialized sensory nerve
endings within the muscle called neuro-muscular
and neuro-tendinous spindles.
These receptor endings are stimulated by the
tension in the muscle, during active contraction
or passive stretching.
These afferent fibers carry proprioceptive
impulses from the receptor nerve endings to
the spinal cord and brain.
The afferent fibers help in maintenance of the
posture and carrying on complex, coordinated
movements.
The motor point is the point on the skin covering
the muscle, that marks the site of entry of motor
nerve in the muscle.
The point is located, often, about the middle of
the muscle, or nearer to its origin.
tahir99 - UnitedVRG
The Muscles and the Fasciae

The motor unit consists of a single motor nerve
fiber (alpha efferent) and the number of muscle
fibers innervated by it.
The motor unit varies in different muscles
according to the precision in the muscular
movements.
Examples: Extraocular muscles have motor
units with 6-12 muscle fibers.
In major limb muscles, the motor units have
about 200 muscle fibers.
The muscle tone: Each skeletal muscle in resting
condition remains in a state of partial contraction.
This is referred to as muscle tone.
In muscle tone some groups of muscle fibers
are fully contracted,while other groups are
relaxed.
To avoid fatigue different groups of muscle
fibers contract alternately.
The muscle tone depends on a simple reflex
are composed of two neurons.
a. Receptor neuron in dorsal root ganglion,
which receives proprioceptive impulse from
the neuro-muscular and neuro-tendinous
spindles.
It sends its axon to motor neuron in the
anterior grey column of the spinal cord.
b. The axon of the motor neuron reaches the
muscle fibers.
In case of injury to the motor nerve of the
muscle, this reflex arc is interrupted, and the
muscle loses its muscle tone and becomes
flaccid.
h
a
9
ri 9
Electrodes are applied to the muscle of a living

person and the movement is performed. The
difference in the electric action potential of the
muscle is amplified and recorded.
THE FASCIAE
The fascia is composed of connective tissue
fibroblasts, collagen fiber bundles and elastic fibers.
Electromyography is the study of actions of muscle

with the help of electrical changes in the muscle
during contraction.
Electric excitation of a muscle passes along the
nerve fibers to the muscle. This is the basis of
nerve conduction studies.
There is a direct relation between tension
developed in a muscle and its electrical activity.
G
R
The superficial fascia is the loose connective tissue

layer that lies deep to the dermis of the skin.
The superfacial fascia consists of
a. Superficial blood vessels
b. Cutaneous nerves
c. Superficial lymphatics
d. Variable amount of fat (more in females)
e. Superficial muscle fibers, that are derivatives
of panniculus carnosus a superficial muscle
sheetpresent in superficial fascia of of cattle
and horses. The remnants of panniculus carnosus in human beings are:
Platysma
Muscles of scalp, face and auricle
Sub-areolar muscle
Palmaris brevis.
f. Mammary gland in females lies in superficial
fascia of front of thorax.
The superficial fascia in anterior abdominal wall
below umbilicus and in perineum is divided into
two layers:
a. Outer fatty layer(Campers fascia) contains
superficial vessels and nerves.
b. Inner membranous layer(Scarpas fascia) is
thin and consists of an elastic membranous
sheet.
In palm and sole, the superficial fascia is
quite thick and contains dense connective
tissue.
The superficial fascia serves as a loose
packing material. It also serves for insulation and padding of the body.
This layer is sensitive to oestrogenic
hormones.
V
d
ti e
n
U
Electromyography
19
20
The deep fascia forms a distinct fibrous layer deep

to the superficial fascia.
The deep fascia is an inelastic membrane made
up of collagen tissue. It separates the superficial
fascia from the deeper structures.
The deep fascia may be present as
1. Outer investing layer that covers the
muscles and lies deep to the superficial
fascia.
Example: Investing layer of deep
cervical fascia of neck.
2. Inner investing layer that lies on the deep
aspect of muscles of the body wall.
Example: Fascia transversalis of anterior
abdominal wall.
3. Intermediate investing layer: That forms
fascial septa separating muscle groups and
inside the muscle belly. It also forms fascial
sheaths around neuro-vascular bundles.
The retinacula are thick bands of deep fascia in
relation with the large joints of the body. The
retinacula keeps the tendons that cross the joint
in position during the movements of the joint.
Example: Flexor retinaculum of wrist.
1. The infections spread along the fascial planes
and are also limited by them.
Example:Tubercular infection of lumbar
vertebrae spreads inside psoas sheath (ilio
psoas fascia) and may reach femoral triangle
in front of upper part of thigh.
2. The fascial planes can also limit collections of
body fluids blood, urine, and pus.
3. The fascial planes can be easily opened by blunt
dissection or surgical incision.
THE BURSAE AND SYNOVIAL SHEATHS
The bursa is a closed serous sac lined by a serous
membrane
Function: The bursa prevents friction and
allows free movement between the two
structures.
Types of bursa
a. Sub-cutaneous bursa between the skin and
the bone.
Example: Prepatelar bursa of knee.
b. Sub-tendinosus bursa between the tendon
and the bone.
Example: Deep infra-patellar bursa of
knee
c. Sub-ligamentous bursa deep to the ligament
Example: Sub-acromial bursa of the
shoulder.
4. Inter-tendinous bursa between two or more
tendons.
Example: Inter-tendinous bursa between the
insertions of gracilis, sartorius and
semitendinosus on upper part of shaft of
tibia.
5. Articular bursa in relation to a joint.
Example: Sub-scapular bursa.
The synovial sheath is a synovial bursa that
surrounds a long tendon of a muscle.
It is a tubular sheath with double layers
enclosing a long tendon in relation to a joint.
a. The visceral layer adheres to the tendon
b. The parietal layer lies outside.
The two layers are separated by a small amount
of serous fluid, which lubricates the opposing
surfaces and thus prevents friction between the
tendon and the neighboring structures.
The two layers are continuous at certain places
to form mesotendons, which carry blood
vessels to the tendon for its nourishment. The
mesotendons are called vinculae in certain
situations, e.g. in long flexor tendons of fingers.
1. Infection of bursa is called bursitis. This results
in swelling and pain in the bursa. Later it may
burst on the skin and form a sinus.
2. The synovial sheaths can also be involved in
infections. This leads to tenosynovitis with
collection of inflammatory fluid inside the
sheath. This condition also causes swelling and
pain.
tahir99 - UnitedVRG
CHAPTER
The Blood
Vascular System
The blood vascular system includes
The heart
The blood vessels arteries, veins and
capillaries. There are two separate circulatory
cycles in the blood vascular system.
1. The pulmonary circulation in which venous
blood is pumped from the right ventricle of
heart to both the lungs for oxygenation, and
pure blood is returned to the left atrium of
the heart.
2. The systemic circulation in which pure blood
is pumped from the left ventricle of heart to
all parts of the body and venous blood is
returned to right atrium of heart (Fig. 5.1).
THE HEART
9
ri 9
The heart is a muscular pump that pumps blood to

all parts of body and lungs through blood vessels.
h
a
Fig. 5.1: Two circulatory cycles
V
d
ti e
n
U
G
R
Position: The heart lies obliquely in the middle

mediastinum of thorax, 2/3rd to the left and
1/3rd to the right of median plane.
The pericardium: The heart is surrounded by a
fibro-serous sac called pericardium.
The pericardium consists of
a. Outer fibrous pericardium which forms a
thick conical fibrous sac, that encloses heart
and roots of all great vessels.
b. Inner serous pericardium which forms a
closed serous sac with a potential pericardial
cavity containing a small quantity of serous
fluid.
Functions
a. The pericardium protects the heart and
prevents overdistention.
b. The pericardium also facilitates the movements of heart by preventing friction from
the neighboring structures.
The chambers of the heart: There are four
chambers in the heart two atria and two
ventricles.
a. The right side of the heart has right atrium
and right ventricle. It has venous blood
circulating through it.
The right atrium receives venous blood
from all parts of the body including heart
and passes it on to the right ventricle.
The right ventricle passes the venous
blood to the lungs for oxygenation.
b. The left side of the heart consists of left
atrium and the left ventricle. It has pure or
oxygenated blood circulating through it.
22
The left atrium receives oxygenated

blood from the lungs and passes it on to
the left ventricle.
The left ventricle pumps the oxygenated
blood to all parts of the body.
The valves of the heart
The muscular wall (myocardium) of the heart
contracts and propels the blood through the
chambers of heart and blood vessels.
There are four important valves in the heart
1. The tricuspid valve lies between the right
atrium and the right ventricle.
2. Mitral valve lies between the left atrium and
the left ventricle.
3. The aortic valve is at the beginning of aorta
from the left ventricle.
4. The pulmonary valve is at the beginning of
the pulmonary trunk from the right ventricle.
The valves ensure the passage of blood through
the chambers of heart in a fixed direction and
prevent backflow of blood.
The valves of the heart are subject to stenosis
(narrowing) or dilatation, leading to
insufficiency in the function of the heart. These
conditions may be congenital or due to some
disease.
The Rate of Contraction of Heart
The rate of contraction of heart is determined
by the pacemaker(sinu-atrial node-SA node),
a modified part of neuromyocardium.
The pacemaker functions under the control of
autonomic nervous system.
The cardiac impulse starting from the pacemaker passes through other parts of neuromyocardium AV node (atrio-ventricular
node) and AV bundle.
Then, the cardiac impulse passes via the right
and left ventricular branches of AV bundle, and
reaches the Purkinje fibers modified cardiac
muscle fibers lying deep to the myocardium.
Through the neuro myocardium (conducting
system of the heart), the contraction of atrial
and ventricular chambers is coordinated.
An interruption of the conduction of cardiac

impulse due to vascular lesion, leads to a
condition called heart block or incoordinated
contraction of the chambers of heart.
The Coronary Circulation

The myocardium is supplied by two coronary
arteries right and left.
The coronary arteries are highly enlarged and
modified vasa vasorum (small vessels supplying
a large vessel), heart being an enlarged blood
vessel.
The coronary arteries arise from the root of
ascending aorta, and are filled during diastole
of the heart.
Although some anastomosis exists between the
larger branches of coronary arteries, it is not
capable of much blood flow.
As the coronary arteries branch, there is hardly
any anastomosis between the smaller branches
of the two coronary arteries in the myocardium.
Thus the two coronary arteries are functional
end arteries.
1. If there is sudden blockage of a large branch of
coronary artery, by a thrombus, it results in the
ischemia of the part of myocardium supplied
by that branch. This is the basis of coronary
thrombosis or heart attack.
The affected part of the myocardium undergoes a vascular necrosis (infarct).
2. If there is gradual narrowing of the coronary
arteries due to atherosclerosis, it leads to cardiac
ischemia, which manifests as angina pectoris
pain in the left pericardial region.
3. Some anastomosis may develop between the
branches of the coronary arteries in old age.
The Fetal Circulation
The fetal circulation is different from the adult
circulation because:
tahir99 - UnitedVRG
The Blood Vascular System
Oxygenation of blood in fetus takes place in

the placenta, as lungs are not functioning.
Very little amount of blood passes to the liver
and lungs, and shunts operate to bypass these
structures.
The left ventricle of fetal heart pumps blood to
the placenta and systemic circulation.
The following fetal structures are functioning
in the fetal circulation:
1. The foramen ovale allows the blood from the
right atrium to reach left atrium, bypassing the
pulmonary circulation.
2. The ductus arteriosus connects the pulmonary
trunk to the aorta, bypassing the lungs.
3. The ductus venosus conducts the oxygenated
blood from the umbilical vein to inferior vena
cava bypassing liver.
These short-circuiting channels or shunts close
after birth, and adult circulation is established with
blood passing through lungs and liver.
THE ARTERIES
h
a
The arteries are thick-walled vessels, that carry

blood from the heart to the capillary plexuses in
organs and tissues of the body.
The arteries carry oxygenated blood, except the
pulmonary arteries that carry deoxygenated
blood from the right ventricle to the lungs.
The arteries are divided into two types:
1. The conducting arteries (elastic arteries)
these are large size arteries.
Example: Aorta, pulmonary trunk.
2. The distributing arteries (muscular arteries)
these consist of rest of medium and small
size arteries.
These arteries divide into smaller

branches to supply organs and tissues.
These arteries take the most direct and
shortest route usually. In limbs they lie
on flexor surface in between muscles,
to avoid compression when the muscles
contract.
Structure of the arteries
The elastic arteries have plenty of elastic tissue
in the tunica media to withstand higher blood
pressure. The amount of elastic tissue is
proportional to the pressure inside the arteries,
i.e. greater the pressure, larger the amount of
elastic tissue.
The muscular arteries have mostly smooth
muscle fibers in their tunica media.
The arterial anastomosis: The arterial
anastomosis provides alternate channels of
supply to the organs.
In some parts, only potential arterial anastomosis exists, which may not be functional, and
may take time to enlarge.
In arterial anastomosis, collateral channels
develop to keep up the arterial supply, when
one of the arteries supplyin the organ is
occluded.
In large joints, e.g. knee joint, elbow joint an
arterial anastomosis exists all around the joint
to supply sufficient amount of blood.
The end arteries: The end arteries are those
arteries, that do not anastomose with their
neighboring arteries. The end arteries have a
separate well-developed area of supply. The end
arteries are present in following organs:
Heart
Kidneys
Liver
Brain
Parts of gastro-intestinal tract
In case of blockage of an end artery, due to
a thrombus, the part supplied by it undergoes ischemia and later avascular necrosis.
V
d
ti e
n
U
Failure of closure of these shunts after birth leads

to congenital heart disease.
Examples: Patent foramen ovale, patent ductus
arteriosus, patent ductus venosus.
9
ri 9
23
G
R
24
The functional end arteries are those arteries, whose

terminal branches do anastomose, but the
anastomosis, being with much smaller arteries, is
not sufficient to maintain blood supply of the part.
Example: Coronary arteries.
The arterioles are the terminal branches of the
arteries that join with the capillary plexus.
They are nearly as small as the capillaries in
size.
They have smooth muscle fibers in their walls,
which run in spiral direction.
The size of their lumen can be controlled by
the sympathetic nerves which supply them.
THE VEINS
The veins are thin-walled vessels, that collect
venous blood from the capillary plexuses in organs
and tissues and bring it back to the heart.
The veins carry deoxygenated blood except the
pulmonary veins, that carry oxygenated blood
from the lungs to the heart.
The veins have larger lumen than the arteries.
The veins have thin tunica media with smooth
muscle fibers.
The large veins have elastic fibers also in their
tunica media to resist right atrial systole.
The veins have valves in their lumen, which
permit flow of blood in one direction only, i.e.
towards the heart.
The valves are absent in case of:
Cerebral veins
Portal veins and its tributaries.
The venous pattern: The venules start from the
venous end of capillary plexuses. They come
together to form the veins
The veins usually run along the arteries,
except very large veins, that run singly.
The medium-size veins run in pairs venae
comitanteswhich accompany the
arteries.
The venous pattern of a part is far more
variable than the arterial pattern.
In following organs, the venous pattern is

quite separate and distinct than the arterial
pattern
Brain
Liver
Lungs
Penis
The venous flow is dependent upon the pressure
gradient between the periphery and the right
atrium of the heart.
The venous flow is assisted by the following
factors
1. The arterial pressure of nearly 10 mm of Hg
transmitted through the capillary bed to the
venous side.
2. The suction force during the right ventricular
diastole.
3. The negative pressure relative to the atmospheric
pressure produced by the thoracic cage during
inspiration.
4. The contraction of the muscles of extremities
that milks the venous system blood towards
the heart.
This action is helped by the two sets of veins
in the limbs deep and superficial.
When the muscles contract, the venous
blood from the deep veins is pushed towards
the heart guided by the valves present inside
the veins.
The movement of parts of limbs helps to
push the blood in the superficial veins.
THE ARTERIO-VENOUS ANASTOMOSIS
These are sites, where blood is transferred from
the arteries to the veins without passing through
capillary plexus.
The AV anastomoses are widely distributed in
the body.
These channels may also arise as side branch
of one arteriole, and may directly join a venule.
The AV anastomoses have thick muscular walls,
that are supplies by vasomotor nerve fibers of
tahir99 - UnitedVRG
The Blood Vascular System
the sympathetic system. Such AV anastomosis

is called a Glomus.
Such type of AV anstomoses act as sphincters
controlling the blood flow.
The AV anastomoses lie in organs, whose
functions are intermittent. These also help in
temperature regulation.
Examples: Skin of apical part of fingers
Nose
Lips
Ears.
THE CAPILLARIES
The capillaries are smallest blood vessels, that form
capillary plexuses in organs and tissues.
Their diameter is about 5 microns, i.e. just
sufficient for a single red blood cell to pass
through.
Their walls are lined by a single layer of
endothelium supported by a thin layer of
connective tissue. These two together form the
diffusion barrier of the capillaries.
Gaseous exchange occurs in the walls of the
alveoli of lungs through the diffusion barrier of
capillaries, due to pressure gradient.
The oxygen from the oxygenated blood diffuses
in the tissue spaces, while the carbon dioxide
from the tissue spaces diffuses into the blood,
to be carried to the lungs for oxygenation.
The nutrient fluid is also exchanged through
the diffusion barrier of the capillaries in the
tissues.
At the arterial end of the capillary plexuses the
blood pressure is higher than the tissue osmotic
pressure.
At the venous end of the capillary plexuses, the
blood pressure is less so that the tissue fluid
rich in metabolic waste products passes back
to the venous blood.
h
a
9
ri 9
25
The capillary plexuses are very rich in organs

and tissues, whose metabolic needs are higher,
while other tissues like cartilages with poor
metabolic needs are relatively avascular.
The sinusoids are dilated capillaries found in certain
organs.
Examples: Liver, spleen, endocrines.
The sinusoids have similar structure as the
capillaries.
Their walls may, sometimes, be incomplete, in
some situations, to allow blood cells to pass
out of their lumen.
Their walls may, sometimes, contain phagocytic
cells.
The blood circulation in sinusoids is much
slower.
V
d
ti e
G
R
The vasa vasorum are small vessels, that supply

the coats of large blood vessels.
Examples: Aorta, inferior vena cava, pulmonary
trunk.
n
U
1. The hematoma results from injury to the

capillary plexus.
The condition is usually seen in superficial
fascia of certain regions, e.g. scalp.
The hematoma causes edema, with blue and
black discoloration.
2. The edema is collection of excess fluid in the
tissue spaces.
It can be caused by
Higher hydrostatic pressure in veins, that
causes transudate passing back into the
tissue spaces from the capillary plexuses.
Trauma or infection, when inflammatory
fluid passes into tissue space due to
increased capillary permeability. This
edema fluid is rich in proteins.
CHAPTER
The Lymphatic
System
The lymphatic system consists of:
1. The lymph vessels: lymph capillaries, lymphatics
and large lymph ducts.
2. The lymph nodes: that act as filters and produce
lymphocytes and plasma cells.
3. The lymphatic organs: Thymus gland, spleen,
tonsils and lymphoid collections in walls of
gastro-intestinal tract (e.g. Peyers patches
appendix). These are described in the respective
regions of body.
The lymph is a clear, colorless fluid from tissue
spaces at capillary plexuses.
The lymph is formed by the excess tissue fluid
in the tissue spaces, that is not taken up by the
venous end of the capillary plexus.
The lymph absorbs fat from the walls of the
intestines and is called chyle (milk) in that
situation.
Composition: The lymph resembles blood
plasma in composition. It contains lymphocytes
only.
The Lymph Vessels
The lymph capillaries begin blindly at tissue spaces
at capillary plexuses.
I. The lymph capillaries have wider lumen than
the blood capillaries.
They are irregular in their diameters.
Their walls are made up of a single layer of
endothelium.
The lymph capillaries are numerous in
The dermis of the skin
Serous surfaces
Mucous membrances
The lymph capillaries are absent in

Brain and spinal cord
Eyeball
Bone marrow
Nails, hairs and epidermis.
II. The lymphatics are the lymph vessels formed
by the union of the lymph capillaries.
As the lymphatics increase in size, their
walls acquire small number of smooth
muscle fibers
The lymphatics have many paired valves in
their lumen, which given them a beaded
appearance, when they are full.
The lymphatics are more in number in tissues
than the veins.
The superficial lymphatics accompany the
veins.
The lymphatics are interrupted by the lymph
nodes.
III.The lymph ducts are the largest lymph vessels.
The lymph ducts are formed by the union of
many lymphatics.
The large lymph ducts are:
1. The lumbar lymph duct begins from
lymphatics of pelvis and lymph nodes
that drain lymph from the lower extermity.
The lumbar lymph duct terminates
in cisterna chyli.
2. The cisterna chyli is a dilated lymph sac
present in front of 1st and 2nd lumbar
vertebrae, behind the abdominal aorta.
tahir99 - UnitedVRG
The Lymphatic System

The cisterna chyli contains smooth
muscle fibers in its walls and can
pulsate.
It receives thetwo lumbar lymph
ducts.
3. The intestinal lymph duct brings the
chyle (lymph with dissolved fat) from
the intestines. It terminates in the cisterna
chyli.
4. The thoracic duct is the great lymph duct
of the body, which drains lymph from
all parts of the body except:
Right side of head and neck
Right upper extremity
Right side of thorax including right
lung
The thoracic duct begins at the
upper end of cisterna chyli, at the
lower border of 12th thoracic vertebra (aortic opening of diaphragm).
The thoracic duct ascends vertically
in front of thoracic vertebrae, lying
to the right side of median plane, in
the posterior mediastinum of thorax.
On front of 5th thoracic vertebra,
thoracic duct crosses over to the left
side of median plane and ascends
along the left border of esophagus,
in the superior mediastinum of
thorax.
It ascends through the inlet of thorax
and lies at the root of neck.
It curves laterally behind the carotid
sheath and terminates in the beginning of left brachiocephalic vein.
Near its termination, thoracic duct
often contains venous blood, due to
higher pressure in the left brachiocephalic vein.
The thoracic duct has many valves,
that give it a beaded appearance,
when it is full.
27
The thoracic duct receives lymph

from:
a. The cisterna chylibringing
lymph from
Both lower extremities
Pelvis
Abdominal cavity including
gastrointestinal tract
Abdominal wall
Near its termination, thoracic
duct receives the following
lymph ducts:
b. Left brancho-mediastinal lymph
duct bringing lymph from left side
of thorax including lung.
c. Left subclavian lymph duct
bringing lymph from left upper
extremity.
d. Left jugular lymph duct bringing
lymph from left side of head and
neck.
5. The right lymphatic duct recieves the
following lymph ducts:
a. Right broncho-mediastinal lymph
duct bringing lymph from right side
of thorax including lung.
b. Right subclavian lymph duct bringing
lymph from right upper extremity.
c. Right jugular lymph duct bringing
lymph from right side of head and
neck.
The lymphatic-venous communications exist
between the lymph ducts and the neighboring veins
of the region.
Normally no or very little lymph passes through
these channels.
But when the lymph ducts are blocked, these
channels open up and convey lymph to the
venous blood.
Example: Communications between thoracic
duct and herniazygos veins.
Communications between abdominal lymph
ducts and inferior vena cava.
28
The flow of the lymph towards the large veins at

the root of the neck is helped by the following
factors:
1. Hydrostatic pressure of tissue fluid taken up by
the lymph capillaries.
2. Mechanical factors:
Contraction of the voluntary muscles
Repiratory movements
Pulsations of the neighboring blood vessels
Contractions of smooth muscles in the walls
of lymph ducts, to some extent.
3. Valves inside the lymph ducts prevent backflow
of lymph. These valves also give a beaded
appearance to the lymph ducts, when they are
full.
The lymph nodes vary in size from a pins head to
a pea.
They are present in groups mostly.
Example: Axillary lymph nodes, inguinal lymph
nodes.
The nodes are pink in color in the young.
The shape of the nodes is bean-shaped, with a
hilum on the inner side from where a few
efferent lymphatics come out. The afferent
lymphatics enter at the periphery.
Functions:
1. The lymph nodes act as filters for the lymph,
and collect all the foreign particles in the
lymph flow.
2. The lymph nodes also produce lymphocytes
and plasma cells and thus help in fighting
the infections.
Clinical considerations
The secondary deposits (metastases) of
cancer spread mainly by lymphatics.
The cancer cells may be held up at the lymph
nodes and develop secondary growth.
The cancer cells may reach venous blood
stream via lymphatics, and thus reach
distant organs.
Surgical removal of cancer also includes
removal of major lymph nodes of the area.
Blockage of thoracic duct (or its injury) may
cause chylothorax accumulation of chyle
in one of the pleural cavities.
Chyluria: Passing of chyle via urine. It may

be caused due to backup in the lymph vessels
in kidney or the urinary tract. This condition
is seen in cases of filariasis, where main
lymph ducts are blocked.
In abdominal cavity, the lymph gets absorbed mainly from the peritoneal surface of
diaphragm. Very little lymph is absorbed by
the omenta.
The rate of absorption of lymph from
the peritoneal cavity is very rapid, i.e.
about 1 litre per day. This forms the
basis of peritoneal dialysis.
The lymph from the liver passes from the
hepatic nodes directly into cisterna chyli.
This lymph from liver forms a large part
of lymph in thoracic duct. The ascitic
fluid is partly transudated from the
dilated hepatic lymphatics.
In lungs the lymph is drained by bronchopulmonary lymph nodes. The pulmonary
edema is caused mainly by increased
capillary permeability in pulmonary vascular
bed with fluid accumulation in tissue spaces
around alveoli.
Hydrothorax is caused through the transudate accumulating is the pleural cavity.
From limbs the lymph follows two sets of
lymph channels:
1. The superficial lymphatics accompany
the superficial veins. The infections may
spread along superficial lymphatics
causing fine red streaks in the skin.
2. The deep lymphatics accompany the deep
veins.
The lymph edema in case of filariasis is
caused by accumulation of tissue fluid as a
result of lymphatic obstruction, and the
hypertrophy of the connective tissue.
The bacterial and other antigens (foreign
particles) passing through lymph nodes
cause painful enlargement of lymph nodes
(lymphadenitis).
Wound healing results in regeneration of
lymph capillaries along with the blood
capillaries.
tahir99 - UnitedVRG
CHAPTER
The Nervous
System
The nervous system is highly specialized system
of the human body.
FUNCTIONS
1. The nervous system helps in reacting to the
external environment through somatic part of
nervous system.
It receives impulses through sensory
receptors.
It functions consciously and subconsciously
through reflex arcs.
The motor component of somatic nervous
system regulates the motor activity of the
body, controlling the muscle action and the
secretion of glands.
2. The nervous system also controls and regulates
the activities of organs and systems of the body
through visceral nervous system.
It receives the afferent impulses from the
organs.
It controls the functions of internal organs
through its efferents.
3. The central nervous system is responsible for
all higher mental activities, which differentiate
man from other higher animals.
PARTS OF THE NERVOUS SYSTEM
The nervous system is bilaterally symmetrical and
is divided into:
1. The central nervous system (CNS) consists of
brain and spinal cord.
The CNS is center of reception and integration of all sensory impulses general
and special.
The CNS initiates all motor activity of the

body.
The brain is the center of all higher mental
activities.
2. The peripheral nervous system (PNS) includes:
Twelve pairs of cranial nerves attached to
the brain.
Thirty one pairs of spinal nerves attached
to the spinal cord.
The PNS conveys sensory and motor
impulses to and from brain and spinal cord
to muscles and glands.
Functional Classification of Nervous
System
1. The somatic nervous system: Includes the most
parts of the central nervous system and
peripheral nervous system.
2. The autonomic nervous system (Visceral nervous
system) controls the activities of internal organs
and tissues.
The autonomic nervous system consists of
two parts:
A. The parasympathetic system (craniosacral outflow) has
I. A central component consisting of
nuclei of III, VII, IX, and X nerves.
Lateral grey column in S2, S3,
and S4 spinal segments.
II. A peripheral component consisting
of
Parasympathetic fibers in III,
VII, IX, and X cranial nerves.
30

Pelvic splanchnic nerves from
S2, S3, and S4 segments of spinal
cord.
B. The sympathetic system (Thoracolumbar outflow) has
I. A central component in lateral grey
column of T 1 to L 2 segments of
spinal cord.
II. A peripheral component consisting
of two ganglionated sympathetic
trunks.
The sympathetic plexuses
THE CENTRAL NERVOUS SYSTEM
Fig. 7.1: Parts of brain
The Brain
The brain is the largest part of the central nervous
system. It is divided into:
1. The forebrain has
I. A median part diencephalon made up
mainly by the thalamus and hypothalamus.
II. Two lateral cerebral hemispheresleft and
rightwhich together constitute the
cerebrum.
The forebrain is the largest and most
dominant part of the brain.
2. The midbrain (mesencephalon)
It is a short portion connecting the forebrain of
the hindbrain.
3. The hindbrain consists of
The cerebellum
Pons
Medulla oblongata (Fig. 7.1)
The brainstem is the straight portion that supports
the cerebrum above and gives attachment to
cerebellum behind. The brainstem is formed by:
The midbrain
Pons
Medulla oblongata
Average weight of the brain is about 1400 gm i.e.
nearly 2% of the total body weight. The brain is
heavier in the males.
The white matter and the grey matter

The fresh-cut surface of the brain and the spinal
cord shows grey and white matter.
The white matter is made up of:
The nerve fibers (processes of the neurones)
with their myelin sheaths
The neuroglia (connective tissue of the central
nervous system)
The blood vessels.
The grey matter is made up of:
The cell bodies of the nerve cells
The nerve fibers (processes of the neurons)
The neuroglia
The blood vessels.
It is mostly due to the myelin sheaths of the
nerve fibers that white matter appears white.
The Membranes (Coverings)
of the Brain
The brain (as well as the spinal cord) has three
coverings or the meninges:
Outerthe dura mater
Middlethe arachnoid mater
Innerthe pia mater
1. The dura mater is thick, fibrous and protective
covering.
The cerebral dura mater has two layers
outer endosteal layer and inner meningeal.
tahir99 - UnitedVRG
The Nervous System

The venous sinuses are enclosed between
the two layers.
The cerebral dura mater forms four folds
to separate the cranial cavity into compartments and to support the weight of brain.
The spinal dura mater has only one layer,
that is continuous with the inner layer of
cerebral dura mater. The spinal dura mater
ends at the level of 2nd sacral vertebra.
2. The arachnoid mater is thin, transparent and
delicate covering.
The arachnoid mater is relatively avascular.
It closely follows the dura mater and is
separated from dura mater by subdural
space.
The arachnoid mater is connected to the
pia mater by delicate trabeculae and is
separated from pia mater by a wider subarachnoid space.
Enlarged sub-arachnoid spaces are called
sub-arachnoid cisterns, located mostly at
the base of brain.
3. The pia mater is the intimate vascular covering
that lines the surface of brain and spinal cord.
The pia mater is continued from the lower
end of spinal cord as filum terminale.
The pia mater also sends vascular folds inside
the ventricles of brain that from choroid
plexuses.
The epidural space is a potential space
between dura of spinal cord and the
periosteum of the vertebral canal.
It containsinternal vertebral venous
plexus
Small arteries
Fat (small quantity)
The epidural hematoma is a high
pressure arterial hemorrhage.
The subdural space is a potential space
between meningeal dura mater and
arachnoid mater.
It contains a very small amount of serous
fluid to lubricate the opposing surfaces
31
The sub-dural hematoma is due to injury

of venous sinuses, and it takes a long
time for absorption.
The sub-arachnoid space is a wide space
that surrounds the brain and spinal cord.
This space is filled up by the CSF
(cerebro-spinal fluid). It also contains
large blood vessels lying on the surface
of brain and the spinal cord.
An injury to these vessels leads to
collection of blood in this spacesubarachnoid hemorrhage.
The CSF acts as a shock absorber for
the delicate tissue of brain and spinal
cord.
Due to buoyancy of CSF, 1400 gm
weight of the brain weighs only 50 gm
on being immersed in CSF.
The Spinal Cord

The spinal cord is the continuation of medulla
oblongata of brain.
The spinal cord occupies upper 2/3rd of the
vertebral canal.
Extent and lengthThe spinal cord is about
45 cm long in young adult male.
It extends
Superiorlyfrom upper border of atlas
vertebra.
Inferiorlyup to lower border of 1st lumbar
vertebra
In child it extends up to 3rd lumbar vertebra;
it ascends upwards due to greater growth
in length of vertebral canal. At puberty it
reaches the adult level.
Conus medullaris is the lower tapering end of
the spinal cord. It is surrounded by long nerve
roots on either side, giving it an appearance of
a horse-tail (cauda equina).
The filum terminale is the non-nervous filament
made up of pia mater. It is about 20 cm long
and connects conus medullaris to the first piece
of coccyx.
32

Enlargements: There are two enlargements in
the spinal cord.
1. The cervical enlargement from 5th cervical
to 1st thoracic segments of the spinal cord.
It innervates the upper extremity.
2. The lumbar enlargement from 2nd lumbar
to 2nd sacral segments of the spinal cord.
It innervates the lower extremity.
The Neuron
The neuron is the excitable cell of the nervous
system, that is concerned with reception,
transformation, integration and conduction of the
nerve impulse.
Parts of the neuron
1. The cell body (perikaryon) is the main part
of the cell.
2. The processes of the neuron:
a. The dendrites are the afferent processes,
which are usually multiple in a typical
neurone.
b. The axon is the efferent process, which
is usually single in a typical neurone.
Types of neurons
A. According to the shape:
1. Unipolar neuron (or pseudo-unipolar
neuron)
Example: Dorsal root ganglion cells of
the spinal cord.
2. Bipolar neuron
Example: Retina, olfactory cells.
3. Multipolar neuron
Example: Majority of cells in brain and
spinal cord (Fig. 7.2).
B. According to the functions:
1. The receptor neuron that receives the
afferent impulse from the receptor end
organs.
Example: Dorsal root ganglion cells of
the spinal cord.
2. The connector (inter-nuncial) neuron that
conducts impulse from the receptor
neuron to the effector neuron.
Fig. 7.2: Types of neurons
Example: Posterior grey column cells

of the spinal cord.
3. The effector neuron from where the
efferent impulse begins for the effector
end organsthe muscles and the glands.
Examples: Pyramidal cells of motor
cortex, anterior grey column cells of the
spinal cord.
The Neuroglia
The neuroglia is the connective tissue of the central
nervous system.
The neuroglia has the following types of cells:
Astrocytes are of the two types
Fibrous astrocyte
Protoplasmic astrocyte
Oligodendrocytes
Microglial cells are of mesodermal origin
Ependymal cells
Functions of the neuroglia
1. The neuroglia provides mechanical support
to the neurons.
2. The neuroglial cells separate the neurons and
act as insulators.
tahir99 - UnitedVRG
The Nervous System

3. The microglial cells act as phagocytic cells
of the central nervous system.
4. The oligodendrocytes form and maintain the
myelin sheaths of the nerve fibers in brain
and spinal cord.
5. The ependymal cells are columnar cells, that
line ventricles of brain and central canal of
the spinal cord. These cells are also
concerned with the secretion and transport
of cerebrospinal fluid.
6. The neuroglial cells also perform an essential
metabolic function of regulating the
biochemical environment of the neurons.
The Nerves Fibers
The nerve fibers are the axons and long dendrites
of the neurons.
The nerve fibers form the nerve tracts of the
brain and the spinal cord.
The nerve fibers form the bulk of the peripheral
nerves and nerve plexuses.
Types of the nerve fibers:
i. The sensory (afferent) fibers carry afferent
impulses from the peripheral end organs
towards the higher centers in brain and
spinal cord.
ii. The motor (efferent) fibers carry efferent
or motor impulses from the higher centers
in the brain and spinal cord to the muscles
and the glands.
The sheaths of the nerve fibers:
a. The neurilemma sheath is thin nucleated
sheath, that lies outside the myelin sheath.
It is also known as nucleated sheath of
Schwann.
The neurilemma sheath is responsible for
the regeneration of nerve fibers.
This sheath is absent in nerve fibers
inside the brain and spinal cord.
Therefore, the nerve fibers inside the
brain and spinal cord do not regenerate.
b. The myelin sheath (medullary sheath) is
laminated lipoprotein sheath, that is
interrupted at the nodes of Ranvier.
33
Outside central nervous system, the

myelin sheath is formed by the activity
of Schwann cells.
Inside the central nervous system, the
myelin sheath is formed by the activity
of oligodendrocytes (Fig. 7.3).
Functions of the myelin sheath:
1. The myelin sheath protects and insulates the
nerve fibers.
2. The myelin sheath also increases the rate of
conduction of nerve impulse and reduces their
energy requirements.
The nerve fibers are also classified according
to presence of the myelin sheath as
A. The medullated (myelinated) nerve fibers.
B. The non-medullated (non-myelinated) nerve
fibers.
The Lumbar Puncture
The lumbar puncture is a diagnostic procedure, that
is done to take out a sample of cerebro-spinal fluid
from the lumbar cistern surrounding the nerve roots
below the conus medullaris of the spinal cord.
The puncture is done usually between 3rd
lumbar and 4th lumbar vertebra at the back
between the spinous processes of the lumbar
vertebrae.
Fig. 7.3: Sheaths of nerve fibers
34

Uses of the lumbar puncture
1. It may show blood in cerebro-spinal fluid
in case of hemorrhage in subarachnoid
space around brain and spinal cord.
2. The lumbar puncture may show altered
pressure and composition of cerebro-spinal
fluid in cases of the infections of the
meninges.
3. The lumbar puncture may be used to give
spinal anesthesia.
ix.
x.
xi.
xii.
The Spinal Nerves
THE PERIPHERAL NERVOUS SYSTEM

The peripheral nervous system consists of cranial
and spinal nerves.
The nerves are made up of bundles of nerve
fibers enclosed in connective tissue sheaths. The
nerve fibers may be functionally axons (motor
fibers) or long dendrites (sensory fibers) carrying
nerve impulses from and to the neurons.
The nerve plexus is a network of nerve fibers outside
the central nervous system.
The ganglion is a swelling on a nerve or nerve
plexus due to collection of nerve cell bodies.
Pseudoganglionis a swelling of peripheral
nerve with no nerve cells bodies.
According to the types of nerve fibers they
contain, the nerves are classified as:
1. The sensory nerves
2. The motor nerves
3. The mixed nerveswhich contain both the
sensory and motor nerve fibers.
The Cranial Nerves

The cranial nerves are twelve pairs attached to the
brain. They are as follows:
i. Olfactory nerve
ii. Optic nerve
iii. Oculomotor nerve
iv. Trochlear nerve
v. Trigeminal nerve
vi. Abducent nerve
vii. Facial nerve
viii. Vestibulo-cochlear
Glosso-pharyngeal
Vagus
Accessory
Hypoglossal
There are 31 (thirty-one) pairs of spinal nerves.

They are:
8 Cervical
12 Thoracic
5 Lumbar
5 Sacral
1 Coccygeal
Each spinal nerve is attached to the side of the
spinal cord by two nerve rootsa dorsal and a
ventral.
1. The dorsal nerve root carries sensory fibers
arising from receptor end organs. The
dorsal nerve root has a dorsal root ganglion
containing pseudo-unipolar nerve cells.
These cells give rise to the sensory fibers,
of the dorsal nerve root.
2. The ventral nerve root carries motor fibers,
which innervate the muscles and the glands.
These fibers arise from the nerve cells
located in the anterior grey column of the
spinal cord.
The spinal nerve trunk is formed by the union
of dorsal and ventral nerve roots and lies at the
intervertebral foramen. It is a very short stem,
that divides into dorsal and ventral primary rami,
as it comes out of the intervertebral foramen.
a. The dorsal primary ramus passes backwards
and supplies the skin and deep muscles of
the back.
b. The ventral primary ramus passes ventrolaterally to supply the skin and muscles of
ventro-lateral aspect of body, including both
the upper and lower extremities.
The meningeal branch of the spinal nerve is the
first branch. It enters the vertebral canal and
supplies sensory fibers to the dura mater.
tahir99 - UnitedVRG
The Nervous System
It also contains sympathetic fibers for the blood

vessels of the vertebral canal.
The rami communicans are twowhite and
greyand connect the ventral ramus to the
corresponding sympathetic ganglion.
1. The white ramus communicans (WRC)
carries preganglionic sympathetic fibers
from the spinal nerve to the sympathetic
ganglion. They also carry visceral afferent
fibers.
The WRC are present from T1 to L1
spinal nerves.
2. The grey ramus communicans (GRC) carries
postganglionic sympathetic fibers from the
sympathetic ganglion to the spinal nerve to
supply sweat glands, arractor pili muscles
and the blood vessels. They are present in
relation to all spinal nerves.
The spinal segment is the part of the spinal cord
that gives attachment to one pair of spinal nerves.
There are 31 (thirty-one) spinal segments
corresponding to the number of spinal
nerves.
The dermatome is the skin area supplied by the
sensory fibers of one pair of spinal nerves (one
spinal segment).
The adjacent dermatomes overlap; so the loss
of one dermatome (i.e. spinal nerve) only results
in the dimunition of sensations and not complete
loss of sensations in the affected dermatome.
The C1 and coccygeal nerves have only ventral
nerve roots, so there are no dermatomes for
these nerves.
The myotome is the group of muscles supplied
by the efferent fibers of one spinal nerve.
FUNCTIONAL PARTS OF THE

NERVOUS SYSTEM
The Somatic Nervous System
The somatic nervous system (both in CNS and
PNS) is concerned withreceiving and modifying
conscious and unconscioussensory impulses and
35
giving out motor impulses for control of skeletal

muscles.
I. The somatic afferent part (sensory part) receives
sensory impulses from receptor end organs and
free nerve endings.
Types
a. The general somatic afferent (GSA)
conveys
i. Exteroceptive sensations: i.e. pain,
touch, temperature and pressure
sensations.
ii. Proprioceptive sensations: i.e.
muscle, tendon, bone, and joint
sensations.
b. The special somatic afferent (sp. SA)
conveys special sensations of vision,
hearing, balance and taste to the brain
and spinal cord.
The somatic afferent part has more than two
neurons concerned with conduction of sensory
impulse.
1. The peripheral (receptor) neuron is pseudounipolar neuron located, in dorsal root ganglion
of the spinal nerves.
The peripheral process of the neuron
(dendrite) begins from receptor end organ
or free nerve ending.
The central process of the neuron (axon)
enters the spinal cord to synapse with the
connector neuron.
2. The connector (internuncial) neuron is situated
in the posterior grey column of the spinal cord.
3. The efferent neuron is usually located in thalamus, where all sensory impulses are received
before passing on the cerebral cortex.
II. The somatic efferent part (motor part) is
concerned with voluntary muscular movements
and maintenance of balance and posture.
Types
a. The general somatic efferent (GSE)
supplies the muscles of head and neck,
body wall and both the extremities,
which develop from the somites.
36

b. The branchial (Special somatic) efferent:
(Sp.SE) supplies the muscles of head
and neck, that develop from the
branchial arches.
Two neurons are involved in conduction of motor

impulse in somatic efferent part.
1. The upper motor neuron (UMN) whose cell
bodies are located in motor cortex of cerebral
hemisphere and various motor nuclei of the brain
stem.
The axons of UMN pass through cerebrum,
brain stem and white matter of the spinal
cord to reach lower motor neuron.
The lower motor neuron whose cell bodies
are located in the motor nuclei of cranialnerves in the brain stem, and anterior grey
column of the spinal cord.
The axons of LMN pass through the cranial
and spinal nerves to reach the skeletal
muscles.
Simple reflex arc is composed of:
One receptor neuron
One connector neuron
One effector neuron
The complex reflex arcs have more connector
neurons in between the receptor and effector
neuron.
The Visceral Nervous System
The visceral nervous system consists of
The visceral afferent part
The visceral efferent part (the autonomic
nervous system)
I. The visceral afferent part is concerned with
receiving afferent impulses from the viscera.
It is usually not considered to be a part of
autonomic nervous system.
Types
a. The general visceral afferent (GVA)
receives afferent sensations from the
viscera and carry them to the brain and
the spinal cord.
The visceral afferents in cervical region

reach the sympathetic chain travel down
via WRC to upper thoracic spinal nerves
and corresponding spinal segments.
From thoracic and lumbar regions, the
visceral afferents pass along splanchnic
nerves to the sympathetic chain.
From upper pelvic organs, the visceral
afferents pass via lumbar splanchnic
nerves and then via WRC to spinal
nerves. They finally reach upper lumbar
segments of the spinal cord.
From lower pelvic organs the visceral
afferents travel along pelvic splanchnic
nerves to reach S2, S3 and S4 segments
of the spinal cord.
b. The special visceral afferent (Sp. VA) conveys the taste sensation from the branchial
arch region (pharynx) to the brain.
The referred pain: The visceral afferents provide
anatomical basis of the referred pain, whereby a
somatic dermatome supplied by same spinal segment has pain sensation, which receives visceral
afferents from the affected organ.
II. The visceral efferent system is concerned with
the innervation of :
Involuntary muscles
Cardiac muscle
Glands
Viscera
Sweat glands and arrector pili muscles
Muscles developed from the branchial
(visceral) arches.
In visceral efferent system three neurons are
involved.
1. Upper motor neuron is located in the autonomic
nuclei of cerebral cortex.
2. Connector (preganglionic) neuron
In sympathetic system it is located in lateral
grey column of T1 to L1 segments of spinal
cord.
In parasympathetic system it is located in
cranial nuclei of 3rd. 5th, 7th, and 10th
tahir99 - UnitedVRG
The Nervous System

cranial nerves and lateral grey column of
S2, S3 and S4 segments of spinal cord.
3. Postganglionic neuron is located outside CNS
In sympathetic system, it is located in sympathetic chain, Great sympathetic plexuses.
In parasympathetic system, it is located
close to the organ that it innervates.
Types
A. General visceral efferent (GVE) controls the
internal organs, blood vessels, glands and sweat
glands and arrector pili muscles of the skin.
This type is actually the autonomic nervous
systemcomposed of two components
sympathetic and parasympathetic.
The activities of this system do not come
under the level of conciousness.
I. The sympathetic system (Thoracolumbar outflow) has its connector
(preganglionic) neurons located in lateral
grey column of T1 to L1 segments of
spinal cord.
The sympathetic system stimulates
the activities of organs and systems
during condition of stress or emergency
(so-called flight and fright reactions).
A. The preganglionic sympathetic fibers
arise from the connector neurons
and pass via ventral nerve roots to
anterior primary rami of spinal
nerves.
a. Then, these fibers pass via WRC
to corresponding sympathetic
ganglia in the sympathetic chain.
b. The preganglionic fibers end by
making synapses with postganglionic neurons in sympathetic ganglia.
c. Or the preganglionic fibers pass
through the sympathetic chain
without relay and come out as
splanchnic nerves, and form
synapses with postganglionic
neurons in ganglia of sympathetic
plexuses.
37
d. The neuro-transmitter for the

preganglionic synapses of the
sympathetic system, is acetylcholine.
B. The postganglionic sympathetic fibers arise
from:
i. Postganglionic neurons in sympathetic
chain.
ii. Postganglionic neurons in ganglia of the
sympathetic plexuses.
The postganglionic sympathetic fibers
reach back into spinal nerves through
GRC from the corresponding sympathetic ganglia. These fibers supply
Smooth muscles of blood vessels
Sweat glands
Arrector pili muscles of skin
The postganglionic sympathetic
fibers from the ganglia in sympathetic
plexuses reach the thoracic, abdominal and pelvic organs along the
blood vessels.
The neuro-transmitter for the postganglionic synapses of sympathetic
system is norepinephrine.
The cells of suprarenal medulla are
specialized postganglionic sympathetic
neurons and secrete norepinephrine.
In the sympathetic system the preganglionic
fibers are shorter and postganglionic fibers are
longer.
II. The parasympathetic system (Cranio-sacral
outflow) controls the activities of organs and
systems during conditions of rest i.e. ordinary
vegetative state.
The connector neurons are located in:
Nuclei of 3rd, 7th, 9th, and 10th cranial
nerves
S2, S3, and S4 segments of spinal cord in
the laterals grey column.
A. The preganglionic parasympathetic
fibers that arise from these connector
neurons pass through the cranial nerves
and make synapses with postganglionic
38

nerves located outside CNS. The postganglionic fibers supply:
Glands in the head and neck
Thoracic and upper abdominal
organs
The preganglionic parasympathetic
fibers arising from S2, S3 and S4
segments of spinal cord (Nervi erigentes or pelvic splanchnic nerves)
and synapse with postganglionic
neurons located in pelvic plexuses
or organs themselves.
B. The postganglionic parasympathetic
fibers supply:
Lower abdominal viscera
Pelvic viscera
These fibers are connected with
defecation, micturation and sexual

functions.
The neuro-transmitters for both
pre-ganglionic and postganglionic
parasympathetic synapses is acetylcholine.
In parasympathetic system the
preganglionic fibers are longer
and postganglionic fibers are
shorter.
Special visceral efferent (Sp.VE) supplies the
muscles developed from the branchial or visceral
arches.
tahir99 - UnitedVRG
Introduction to Anatomy
Multiple Choice Questions
Q.1. Select the one best response to each question from the four suggested answers:
1. In the sympathetic system:
A. The connector neuron lies inside the
central nervous system
B. The postganglionic neuron is situated
close to the organ of supply
C. The white ramus communicans contains
the postganglionic sympathetic fibers
D. The grey ramus communicans contains
the preganglionic sympathetic fibers.
2. In the lymphatic system:
A. The lymph capillaries freely communicate
with the tissue spaces
B. The large lymph vessels contain many
valves
C. The right lymphatic duct is the largest
lymph duct in the body
D. The lymph must pass through one lymph
node before entering blood stream.
3. The superficial fascia:
A. Is a well-defined and definite layer of
connective tissue
B. Contains only elastic fibers
C. Gives shape to the muscles
D. Contains variable amount of fat.
4. The skeletal muscles:
A. Have at least two attachmentsone
relatively fixed and the other mobile
B. Contract very slowly
C. Have no sensory (proprioceptive) fibers
in their motor nerve
D. Possess great power of regeneration
5. The following vessels contain many valves:
A. Veins of the viscera
B. Lymphatics
C. Capillaries
D. Cerebral veins
Q.2. Each question below contains four suggested answers, of which one or more is
correct. Choose the answers:
A. If 1, 2, and 3 are correct
B. If 1 and 3 are correct
C. If 2 and 4 are correct
D. If only 4 is correct
E. If 1, 2, 3, and 4 are correct
6. The anatomical position of the body is the
position in which:
1. The body is standing erect
2. The arms are by the sides of the body
3. The eyes are looking straight forward
4. The feet are placed wide apart
7. The flexion movement at the shoulder joint
involves:
1. Taking the arm forwards and medially
2. Taking the arm straight forward
3. Taking the arm medially at right angles
to the glenoid fossa
4. Taking the arm away from the midline
8. The eversion of the foot:
1. Takes place at the ankle joint
2. Consists of raising the lateral border of
foot
3. Turns the sole of foot medially
4. Takes place at subtalar and midtarsal
joints
9. The lines of cleavage:
1. Are skin creases over the joints
2. Indicate the direction of elastic fibers in
the dermis of skin
40

3. Are finger prints
4. Indicate the direction of collagen fiber
bundles in the dermis of skin
10. The lymphatic drainage of breast:

1. Is mainly in the axillary lymph nodes
2. Some lymphatics from superior quadrants reach supra-clavicular lymph nodes
3. From medial quadrants lymphatics reach
parasternal lymph nodes
4. Superficial lymphatics cross midline and
communicate with those of opposite side.
11. The stability of the joint:
1. Depends upon the shape of the articular
surfaces
2. Is helped by the powerful ligaments
surrounding the joint
3. Is also helped by the articular disc inside
the joint
4. Is mainly maintained by the articular
capsule.
12. In the circulatory system:
1. The arterioles are the smallest branch of
the arteries
2. The capillaries have only a single layer
of endothelium in their walls
3. The end arteries are those arteries, that
have no anastomosis with neighboring
arteries
4. The venules are the smallest veins and
contain valves.
13. The synapses in the nervous system:
1. Are sites of physical continuity between
processes of two neurons
2. Are sites where a chemical mediator
substance is liberated
3. Allow both ways passage of the nerve
impulse
4. Are sites where the processes of two
neurons come in close proximity
14. A spinal nerve:
1. Is a mixed nerve having both sensory
and motor fibers
2. Is connected to the spinal cord by two

nerve rootsventral and dorsal
3. Has a dorsal ramus that supplies the skin
and muscles of back only
4. Supplies an area of skin called dermatome.
15. A developing long bone:
1. Has two epiphyses at the two ends, that
are developed from secondary centers
of ossification
2. Has at least one nutrient foramen through
which main nutrient vessels enter the
bone
3. Has metaphysissite for maximum
growthtowards epiphyseal plate
4. Has epiphyseal plates at the two ends that
persist in the adult bone.
Q.3. Cross match the following with appropriate answers on the left:
16. For each joint below give the most appropriate
answer from the list given on right side:
I. Syndesmosis
A. Elbow joint
II. Saddle joint
B. Interior tibiofibular
joint
III. Hinge joint
C. Calcaneo-cuboid
joint
IV. Ball and socket D. Hip joint
joint
V. Plane joint
E. Acromio-clavicular
joint
17. For each joint below give the movement
associated with it from the list given on right
side:
I. Ankle joint
A. Medial rotation
II. Shoulder joint B. Gliding
III. Sterno-claviC. Dorsiflexion
cular joint
IV. MetacarpoD. Adduction
phalangeal joint
V. Radio-ulnar
E. Pronation
joints
tahir99 - UnitedVRG
41
Answers
A1. The answer is A.
The sympathetic connector neuron lies inside
spinal cord. The postganglionic neuron lies
in sympathetic trunk or plexus. The WRC
has preganglionic and GRC has postganglionic
fibers.
A2. The answer is B.
The large lymph ducts have many valves to
help in conduction of lymph fluid. The lymph
capillaries begin blindly. Thoracic duct is the
largest lymph duct; and the lymph may not
pass through a lymph node before entering
blood stream.
A3. The answer is D.
The superficial fascia contains variable
amount of fat. It is not a well-defined layer
and contains both collagen and elastic fibers.
It does not give shape to the muscles.
The skeletal muscles have at least two
attachments. Their contraction is not very
slow. They have proprioceptive fibers in their
motor nerves. The skeletal muscles do not
have great power of regeneration.
Only the lymphatics have many valves to help
in conduction of lymph fluids. The veins of
viscera and cerebral veins and capillaries have
no valves.
A6. The answer is A, (1, 2, 3).
The anatomical position of the body is the
position when the body is standing erect with
arms by sides and eyes looking straight front.
The feet, however, are not wide apart.
A7. The answer is B, (1, 3).
The flexion at the shoulder joint involves
taking the arm forward and medially at right
angles to the glenoid fossa. It does not involve
taking arm straight forwards or away from
the midline.
A8. The answer is C, (2, 4).

The eversion of foot consists of raising lateral
border of foot and takes place at subtalar and
mid-tarsal joints. The movement does not
occur at ankle joint and the sole of foot is
turned laterally and not medially.
A9. The answer is D, (4).
The lines of cleavage indicate the direction
of collagen fibers in the dermis of skin. They
are neither skin creases over joints, nor finger
prints. They do not indicate the direction of
elastic fibers in the dermis.
A10. The answer is E, (1, 2, 3, 4).
The lymphatics of breast end mainly in axillary
lymph nodes. From the superior quadrants,
some lymphatics reach the supra-clavicular
nodes. From medial quadrants they end in
parasternal lymph nodes. The superficial
lymphatics of the two sides communicate
with each other across midline.
The stability of a joint depends on the shape
of articular surfaces, presence of intraarticular disc and the powerful ligaments
surrounding the joint. It is not maintained
mainly by the articular capsule.
A12. The answer is E, (1, 2, 3, 4).
The arterioles are the smallest branch of
arteries and the venules are the smallest veins.
The capillaries have only a single layer of
endothelial lining. The end arteries have no
anastomosis with neighboring arteries.
At the synapses inside nervous system, the
processes of two neurons come in close
proximity, and a chemical mediator substance
is liberated. There is no physical continuity
between the processes of neurons at synapses. The synapses allow unidirectional flow
of impulse.
42
A14. The answer is E, (1, 2, 3, 4).

The spinal nerve is a mixed nervewith both
motor and sensory fibers. It is attached by
two nerve rootsventral and dorsalto the
spinal cord. The dorsal ramus supplies the
skin and muscles of the back only. The skin
area supplied by a spinal nerve is called a
dermatome.
The developing long bone has two epiphyses
at the two ends. It has at least one nutrient
foramen for the nutrient vessels. The metaphysis is the site of maximum growth of the
long bone. The epiphyseal plates disappear,
when the bone growth in length ends.
A16. The answers are B, C, A and D, E (1-III).

Syndesmosisis inferior tibio fibular
joint.
Saddle jointis calcaneo-cuboid joint.
Hinge jointis elbow joint.
Ball and socket jointis hip joint.
Plane jointis an acromio-clavicular
joint.
A17. The answers are C, A, B and D, E (I-III).
Ankle jointhas dorsiflexion movement.
Shoulder jointhas medial rotation.
Sterno-clavicular jointhas gliding
movements.
Metacarpo-phalangeal jointhas adduction movement.
Radio-ulnar jointshave pronation
movement.
tahir99 - UnitedVRG
The Upper Extremity
TWO
8
CHAPTER
The Bones of the Upper Extremity

Both the upper and lower extremities are
homologous in their development and are built on
same plan.
FEATURES OF THE UPPER EXTREMITY
1. The upper extremity has developed greater
mobility so that hands can be used for
prehension or grasping.
2. The upper extremity has undergone lateral
rotation by 90 from its premitive position. So
that flexor surface faces anteriorly and extensor
surface faces posteriorly.
3. The thumb and radius bones are situated on
cranial side in prenatal life and they form the
preaxial border of the limb.
4. The little finger and ulna bone are similarly,
situated along caudal side in prenatal life and
they form postaxial border of the limb.
5. The muscles of hand permit complex and
delicate movements for all skilled activities.
6. The rich sensory supply of tips of fingers make
the hand and a sensitive tactile apparatus.
The bones of the upper limb are
The scapula and claviclethat form shoulder
girdle
The humerusthe bone of arm
The radius and ulnathe bones of forearm
The bones of wrist and handcarpals, metacarpals and phalanges
THE SCAPULA
General Features
The scapula is a flat bone that lies on posterolateral aspect of upper part of thorax.
The scapula is a part of shoulder girdle.
It is triangular in shape. It has three angles
superior, inferior and lateral.
The scapula has three surfacesupper dorsal,
lower dorsal and costal.
It has three borderssuperior, medial and
lateral (Figs 8.1 and 8.2).
Fig. 8.1: The scapulaanterior aspect
44
Fig. 8.2: The scapulaposterior aspect
The Angles
I. The superior angle lies at the level of second
thoracic spine.
II. The inferior angle lies at the level of seventh
thoracic spine.
III. The lateral angle is truncated to form the
shallow, pear-shaped glenoid fossa for
articulating with head of humerus.
The Surfaces
I. The upper dorsal surface lies above the spine
of scapula. It forms the supraspinous fossa
with superior surface of spine of scapula.
II. The lower dorsal surface lies below the spine
of scapula and forms the infraspinous fossa
with inferior surface of spine of scapula.
III. The costal surface is hollow and forms the
subscapular fossa.
It has ridges for attachment of intermuscular septa of subscapularis muscle.
II. The medial (vertebral) border lies close to

the spines of thoracic vertebrae.
III. The lateral border extends from the glenoid
fossa to the inferior angle
It has a thickeningventral baron its
costal surface, that supports the bone
acting like a prop during movements at
the shoulder joint
The scapula has three processes alsothe
coracoid process, acromion and the spine.
1. The coracoid process points directly forwards
when arm is by side of body.
It has a tip that can be palpated through
anterior fibers of deltoid in the infraclavicular fossa.
The body of coracoid process has a superior
and an inferior surface. It has a medial
border and a lateral border.
The root of coracoid process is attached
above the glenoid fossa.
2. The acromion process is the lateral extension of
spine of scapula. It has a medial border that is
continuous with upper edge of crest of spine
of scapula. It has also an oval facet for the
acromio-clavicular joint.
The acromion has a lateral border that
extends from tip to the angle and has four
tubercles for attachment of inter-muscular
septa of deltoid muscle.
The tip of acromion forms a bony landmark
and lies on top of shoulder.
3. The spine of scapula is a horizontal shelf-like
projection that separates the dorsal surface into
upper and lower dorsal.
The spine is trriangular in shape. Its attached
margin is fixed to dorsal surface.
The posterior border points posteriorly and is
known as crest of spine of scapula.
The crest of spine has an upper and a lower
edge and is subcutaneous throughtout.
Special Features
The Borders
I. The superior border is very short. It has a
supra-scapular notch at the root of coracoid
process.
Muscles attached to scapula

Subscapular fossaSubscapularis
Supraspinous fossaSupraspinatus
tahir99 - UnitedVRG
Infra-spinous fossaInfra-spinatus
Medial border
Costal aspectSerratus anterior
Dorsal aspectLevator scapulae
Rhomboid major
Rhomboid minor
Infraspinatus tubercleLong head of
Triceps
Supraspinatus tubercleLong head of
Biceps brachii
Coracoid processMedial border-Pectoralis
minor
Tip
- Conjoint origin of
- Short head of Biceps brachii and
- Coracobrachialis
Spine and acromion
- Upper edge crest of, crest of spine
Trapezius
- Lateral border acromion and lower edge
of crest of spineMiddle part of Deltoid
Inferior angleA slip of latissimus dorsi
(dorsum)
Suprascapular notchInferior belly of
omohyoid
Ligaments attached to scapula
Lateral border of acromionCoraco-acromial ligament
Superior surface coracoid processTrapezoid part of coraco-clavicular ligament
Root of coracoid processConoid part of
Coraco-clavicular ligament
Inferior surface of coracoid process
Coraco-humeral ligament.
acromion, one for medial border, one for inferior

angle and one horse-shoe shaped for rim of
glenoid fossa.
The secondary centers appear at puberty and
fuse with the bone by the twentieth year.
THE CLAVICLE (COLLAR BONE)

General Features
The clavicle is a long bone that lies horizontally at
the root of neck (Figs 8.3 and 8.4).
The clavicle differs from the other long bones
in following respects:
It has no medullary cavity
It is subcutaneous throughout
It ossifies in membrane
It has only one epiphysis at its medial end.
The clavicle articulates at its medial end with
manubrium sterni to form sterno-clavicular
joint.
It articulates at its lateral end with acromion to
form acromio-clavicular joint.
The clavicle is divided intoa lateral one-third
and a medial two-third part.
1. The lateral one-third part is flat with
concavity facing forwards
It has a superior surface and an inferior
surfacethat shows a trapezoid ridge
and a conoid tubercle.
It has an anterior border and posterior
border.
Ossification
The scapula ossifies from eight centers
One primary center appears in the body in eight
weeks of intrauterine life.
Seven secondary centers appeartwo for
coracoid (precoracoid center appears in first
year, subcoracoid center at puberty), two for
45
Fig. 8.3: The claviclesuperior aspect
46

Ligaments attached to clavicle:
Trapezoid ridge and conoid tubercle (On inferior
surfce lateral 1/3rd)Coraco-clavicular
ligament
Inferior surface medial end (Rough area)
Costo-clavicular ligament
Upper part medial end of clavicleInter
clavicular ligament
Ossification
Fig. 8.4: The clavicleinferior aspect
2. The medial two-third part is nearly

cylindrical and has convexity facing
forwards
It has four surfaces
Anterior surface is rough for muscular attachment
Posterior surface is smooth
Superior surface is also smooth
Inferior surface has a subclavian
groove in its medial one-third and a
rough area near the medial end for
attachment of costo-clavicular
ligament.
The lateral end bears an oval facet for the
acromio-clavicular joint.
The medial end is expanded and articulates with
clavicular notch of manubrium sterni at sternoclavicular joint.
Special Features
Muscles attached to clavicle:
Anterior border lateral 1/3rdDeltoid
Posterior border lateral 1/3rdTrapezius
Superior surface-medial 1/2Sterno-mastoid
(clavicular head)
Anterior surface medial 1/2Pectoralis
major
Posterior surface medial endSternohyoid
Subclavian grooveSubclavius
(on inferior surface)
The clavicle is first bone to ossify. It ossifies in

membrane by two primary centers that appear
in 6th week of intrauterine life and fuse soon.
A secondary center for sternal end appears at
puberty and fuses by twentieth year.
Applied Anatomy
I. The clavicle helps in transmission of force
from the upper limb to the axial skeleton.
II. The clavicle is easily fractured at the junction
of lateral one-third and medial two-third, that
is, surgically the weak point of the bone.
THE HUMERUS
General Features
The humerus is the long bone of the arm.
It has an upper end, a shaft and a lower end.
1. The upper end of humerus has
a. The headwhich is less than half a sphere,
is covered with hyaline articular cartilage
and articulates with glenoid fossa at the
shoulder joint.
b. The lesser tubercle (tuberosity) is an elevation
on the front of upper end and shows an
impression for muscular attachment.
c. The greater tubercle (tuberosity) forms a
prominence on the lateral aspect of upper
end.
It shows three impressions for muscular
attachments.
tahir99 - UnitedVRG

d. The inter-tubercular sulcus (bicipital
groove) separates the two tubercles and
has a medial lip and a lateral lip for muscular
attachments.
The anatomical neck is a slight
constriction that separates head from
the rest of the bone.
The surgical neck is the junction of upper
end with rest of the shaft. It is a common
site for the fracture of the bone.
2. The shaft of humerus is cylindrical in upper
half and triangular in section in lower half.
The shaft has three surfacesposterior,
anteromedial and anterolateral.
a. The posterior surface has a spiral groove
behind deltoid tuberosity.
47
b. The antero-medial surface has muscular

attachment in lower part.
c. The antero-lateral surface has a V-shaped
rough deltoid tuberosity about its middle.
The lower half of the shaft has a medial and a
lateral supra-condylar ridge, that give attachment
to the intermuscular septa (Figs 8.5 and 8.6).
3. The lower end of humerus has two epicondylesa medial and a lateralon either end.
a. The medial epicondyle is more prominent
and is related to ulnar nerve behind. It shows
rough surface for attachment of flexor
muscles of forearm.
b. The lateral epicondyle is much less prominent, and also shows rough surface for
attachment to extensor muscles of forearm.
Fig. 8.5: The humerus
48

Special Features
Fig. 8.6: The angle of humeral torsion
The lower end has two articular partsthe

trochlea and capitulum.
I. The trochlea articulates with the trochlear
notch of ulna
The medial edge of trochlea is 6 mm
lower than its lateral edge. This is
responsible for the carrying angle.
The carrying angle is the angle between
long axis of arm and long axis of extended
and supinated foreman. It is nearly 170.
II. The capitulum is a round elevation on anterior
and inferior surface of lower end. It articulates
with concave superior surface of head of
radius.
There are three depressions or fossae at the
lower end.
I. The radial fossa is present anteriorly above
capitulum for accommodating the head of
radius in full flexion at elbow joint.
II. The coronoid fossa lies above trochlea on the
anterior surface of lower end. It
accommodates the coronoid process of ulna
during full flexion at elbow joint.
III. The olecranon fossa is a deep fossa above
trochlea on the posterior surface of lower
end. It accommodates the olecranon process
of ulna in full extension at elbow joint.
The angle of humeral torsion is the angle formed
between the long axis of articular surface of head
of humerus and long axis of articular surface of
lower end of humerus.
This angle is nearly 164. In quadrupeds it is
nearly 90. In humans, the head of humerus is
rotated laterally by another 74 so that the angle
eventually comes to be 164.
Muscles attached to humerus:

Upper end
Lesser tuberositySubscapularis
Greater tuberositySupraspinatus Infraspinatus and Teres minor
Bicipital groove
Lateral lipPectoralis major
Medial lipTeres major
FloorLatissimus dorsi
Shaft
Deltoid tuberosityDeltoid
Anteromedial and Posteromedial surfaces
(lower half)Brachialis
Oblique ridge above spiral groove on
posterior surfaceLateral head of triceps
Posterior surface upper 3/4th below spiral
grooveMedial head of triceps
Impression on middle of medial border
Coraco-brachialis
Lower end
Medial epicondyleCommon flexor origin
Lateral epicondyleCommon extensor origin
Medial supracondylar ridgePronator teres
Lateral supracondylar ridgeBrachioradialis and Extensor carpi radialis longus
Back of capitulumAnconeus
Ligaments attached to humerus
Anatomical neckCoracohumeral ligament
Medial epicondyleMedial collateral
ligament of elbow joint.
Lateral epicondyleLateral collateral
ligament of elbow joint.
Medial supra-condylar ridgeMedial intermuscular septum
Lateral supra-condylar ridgeLateral intermuscular septum.
Ossification
The shaft of humerus ossifies from a primary center
that appears in eighth week of intra-uterine life.
For upper end: Three secondary centers
appearhead (first year), greater tubercle
tahir99 - UnitedVRG
(second year), lesser tubercle (fifth year). By

sixth year the three epiphyses fuse and join with
shaft by twentieth year. The upper end is the
growing end of the bone.
For lower end: Four secondary centers
appearmedial epicondyle (fourth year), medial
edge of trochlea (ninth year), lateral edge of
trochlea and capitulum, (first year), and lateral
epicondyle (twelfth year). The epiphysis for
medial epicondyle remains separate and fuses
by twentieth year.
The other three epiphyses fuse together and
join the shaft by fourteen to sixteen years.
THE RADIUS
General Features
The radius is the lateral bone of the forearm. The
bone has a proximal end, a shaft and a distal end.
1. The proximal (upper) end of radius has a head,
neck, and a tuberosity.
The head of radius is cylindrical in shape
with a concavity on its superior aspect. The
head articulates with capitulum of lower end
of humerus.
The neck is slightly constricted part below
the head.
The tuberosity is rough posteriorly for
muscular attachment. Its anterior part is
smooth and is related to a bursa.
2. The shaft of radius is narrow above but it
broadens below. It is triangular in section.
The shaft has three surfacesanterior,
posterior and lateral.
i. The anterior surface reaches up to the
tuberosity from in front.
ii. The posterior surface also reaches up
to the tuberosity from behind.
iii. The lateral surface encroaches on the
anterior and posterior aspects of upper
part of shaft.
It has a rough impression for
muscular attachment about its middle.
49
The shaft has three bordersanterior,

posterior and medial.
i. The anterior border (anterior oblique
line) is sharp and converges towards
the tuberosity.
ii. The posterior border also converges
towards the tuberosity.
iii. The medial (interosseous) border is
sharp and gives attachment to the
interosseous membrane of forearm
(Fig. 8.7A).
3. The distal (lower) end of radius has a styloid
process and an ulnar notch.
The styloid process is a pointed process on
lateral aspect of lower end. Its tip is about
1.2 cm lower than the styloid process of
ulna.
The ulnar notch on the medial aspect of the
distal end articulates with head of ulna at
the inferior radioulnar joint.
The dorsal aspect of lower end has a prominent
dorsal (Listers) tubercle with a narrow groove
medial to it for tendon of extensor pollicis longus.
The dorsal aspect of lower end has other grooves
also for tendons of extensor muscles.
The inferior surface of lower end articulates
with scaphoid and lunate bones at the
radiocarpal joint.
Special Features
Muscles attached to radius
Radial tuberosity (Posterior part)Biceps
brachii
Lateral surface (Upper half)Supinator
Impression on middle of lateral surface
Pronator teres
Anterior oblique lineFlexor digitorum superficialis
Anterior surface (Upper 2/3rd) below anterior
borderFlexor pollicis longus
Anterior surface (distal 1/4th) - Pronator quadratus
Base of styloid processBrachio-radialis
Posterior surface (upper part)Abductor
pollicis longus, Extensor pollicis brevis
50
Ligaments attached to radius

Below radial tuberosityOblique cord
Tip of styloid processRadial collateral ligament of wrist joint
Ridge on inferior surface of lower endArticular disc of inferior radio-ulnar joint.
THE ULNA
General Features
The ulna is the medial bone of forearm. It has a
proximal end, a shaft and a distal end.
1. The proximal (upper) end has an olecranon
process, a trochlear notch, a coronoid process
and a radial notch.
a. The olecranon process is a thick and prominent hook-like process that extends upwards from the posterior aspect of upper
end.
It has a triangular subcutaneous part

below it that forms the point of elbow.
b. The trochlear notch is a deep notch for
articulating with trochlea of lower end of
humerus at the humero-ulnar part of elbow
joint.
c. The coronoid process is a triangular shelflike projection, anteriorly below the trochlear
notch.
It presents a rough surface for muscular
attachment.
d. The radial notch is situated on the lateral
aspect of coronoid process for articulating
with head of radius at the superior radioulnar joint.
2. The shaft of ulna is broad above, but it is narrow
below. It has three surfacesanterior, medial
and posterior (Fig. 8.7B).
Figs 8.7A and B: The radius and ulna
tahir99 - UnitedVRG

i. The anterior surface is smooth and presents
an oblique ridge for muscular attachment in
its distal part. It has a nutrient foramen in
upper part.
ii. The posterior surface extends above up to
lateral border of olecranon process.
iii. The medial surface between anterior and
posterior borders is smooth.
The shaft of ulna has three borders
anterior, posterior and lateral (interosseous)
border.
i. The anterior border begins from medial
border of coronoid process and extends up
to styloid process below.
ii. The posterior border descends from back
of olecranon process, and curving laterally
reaches up to styloid process.
iii. The lateral (interosseous) border is sharp
and extends from a depression below radial
notch (supinator crest) up to lower end.
It gives attachment to the interosseous
membrane of forearm.
3. The distal end has a head and a styloid process.
i. The head of ulna is round and articulates
with the ulnar notch of lower end of radius
to form inferior radio-ulnar joint.
ii. The styloid process is a pointed process on
the postero-medial aspect of the lower end.
The styloid process is grooved on its
posterior aspect by extensor carpi ulnaris
tendon.The lower end of ulna does not
take part in the formation of radio-carpal
(wrist) joint. It is separated from the
triquetral bone by the articular disc of
inferior radio-ulnar joint.
Special Features
Muscles attached to ulna
Superior surface olecranon processTriceps
Coronoid processBrachialis
Medial border of coronoid process - Pronator
teres
51
Supinator crest and depression in front of it

Supinator
Anterior and medial surface (upper 3/4th)
Flexer digitorum profundus
Oblique ridge on front of lower part of shaft
Pronator quadratus
Posterior surfaceAbductor pollicis longus,
Extensor pollicis longus and Extensor indices
Lateral border of olecranonAnconeus
Ligaments attached to ulna
Margins of radial notchAnnular ligament
Lower border of radial notchQuadrate ligament
Tip of styloid processUlnar collateral
ligament of wrist joint
Ossification of Radius and Ulna
The radius ossifies by the three centersone
primary center for shaft appears at eighth week of
intra-uterine life, one for upper end (appears fourth
year) and one for lower end (first year). The lower
epiphysis fuses by nineteenth year. The proximal
epiphysis fuses by fourteenth year.
The ulna also ossifies by three centersone
primary center of shaft (eighth week), one for
upper end (eleventh year) and distal end (sixth year).
The distal epiphysis fuses by eighteenth year the
proximal epiphysis fuses by fourteenth year.
The lower ends of radius and ulna are the
growing ends.
Applied Anatomy of Radius and Ulna
1. Fracture of head or neck of radius may occur
due to fall on out-stretched hand.
2. Pulled elbowresults in very young children,
when head of radius slips out of annular
ligament. It is caused when arm is pulled
forcibly
3. Colles fractureis fracture of distal end of
radius due to fall on outstretched hand.
4. Tennis elbowis caused by sprain of lateral
collateral ligament of elbow or by injury to
common extensor origin.
52
THE CARPAL BONES

There are eight carpal bones at the wrist: They are
arranged in two rowsproximal and distal
The proximal row has four bonespisiform,
triquetral, lunate, and scaphoid.
The distal row also has four boneshamate,
capitate, trapezoid, and trapezium.
1. The pisiform is not a true carpal bone. It is
a sesamoid bone, developed in the tendon
of flexor carpi ulnaris.
It is pea shaped bone that articulates with
triquetral.
It gives attachment to flexor retinaculum
and hypothenar muscles.
2. The triquetral is somewhat pyramidal in
shape (Fig. 8.8). It articulates
Proximally with articular disc of inferior
radio-ulnar joint
Distally with hamate
Anteromedially with pisiform
Laterally with lunate
3. The lunate is nearly semilunar in shape. The
bone articulates
Laterallywith scaphoid
Mediallywith triquetral
Distallywith capitate
Proximallywith inferior surface of

lower end of radius at radio-carpal joint.
The lunate bone is concerned with transmission of force to the radius.
The lunate bone may be displaced anteriorly
into carpal tunnel causing compression of
median nerve.
4. The scaphoid is the largest carpal bone of
the proximal row. It is boat-shaped.
It articulates
Proximally with inferior surface lower
end of radius at the radiocarpal joint.
Distally with trapezoid and trapezium
Medially with lunate
The scaphoid also helps in transmission of
force to the radius.
The scaphoid bone is more prone to
fracture during fall on outstretched hands,
because its compact bone is quite thin.
The blood supply enters distally, so the
proximal segment (after fracture) may
undergo avascular necrosis.
5. The hamate is the most medial carpal bone
in the distal row.
The hamate is wedge shaped and has a
prominent hook-like process on its anterior
surface.
Fig. 8.8: The carpals and metacarpalsanterior aspect
tahir99 - UnitedVRG

The hamate articulates
Proximally with triquetral
Medially with capitate
Distally with bases of fourth and fifth
metacarpals.
6. The capitate is the central and largest of all
carpal bones.
The head of capitate projects proximally
in the cancavity formed by the lunate
and scaphoid bones
The capitate articulates
Proximally with lunate and scaphoid
Distally with base of third metacarpal
Medially with hamate
Laterally with trapezoid
The capitate transmites force from second,
third and fourth fingers to proximal row of
carpal bones.
7. The trapezoid is small and irregular in shape.
The bone of articulates
Proximally with scaphoid
Distally with base of second metacarpal
Laterally with trapezium
Medially with capitate.
8. The trapezium is the most lateral carpal bone
of the distal row.
The trpezium has a prominent groove on its
anterior aspect for flexor carpi radialis tendon.
The groove is limited by a crest laterally that
gives attachment to flexor retinaculum.
The bone articulates
Proximally with scaphoid
Distally with base of first metacarpal
Medially with trapezoid.
THE METACARPAL BONES
There are five metacarpals in the skeleton of hand.
They are classified as long short bones as they
have no medullary cavity.
Each metacarpal has:
A proximal end or base which articulates
with the corresponding carpal bone of distal
row to form carpo-metacarpal joint.
53
The shaft is triangular in section having

three surfaces:
a. Antero-lateral
separated by an
b. Antero-medial
anterior border
c. A posterior border that is flat and
subcutaneous
The distal end or head is more prominent than
the base. It makes the metacarpo-phalangeal
joint with base of proximal phalanx.
The first metacarpal (of thumb) is short and
thick and is rotated by 90 in relation to other
metacarpals. This arrangement gives it a wider
range of movements.
THE PHALANGES
There are two phalanges in the thumb and three in
other four fingers.
The phalanges are known as proximal, middle
and distal for the fingers. For thumb there are only
proximal and distal phalanges.
The phalanges are classified as short bones.
They have two ends and a short shaft, but have no
medullary cavity.
The phalanges form proximal and distal interphalangeal joints in fingers by their articulations.
In thumb there is only one inter-phalangeal joint.
Ossification of Bones of Hand
The carpal bones are cartilaginous at birth. Each
carpal is ossified by one center. The centers of
ossification appear as followes.
First yearcapitate, hamate
Third yeartriquetral
Fourth yearlunate
Fifth yearscaphoid, trapezium, trapezoid
Pisiformninth or tenth year
The metacarpals ossify by
One primary center for shaftappears eighth
week
One secondary center
For base in first metacarpals (appears third
year)
For heads in second to fifth metacarpals
(appears by third year)
54
The epiphyses join the shaft by fifteen to

seventeen years.
The phalanges ossify by
One primary center for shaft
One secondry center for lower end
The center for distal phalanx appears in eighth
week
The center for middle phalanx appears in twelfth
week
The center for proximal phalanx appears in tenth
week
The epiphysis for bases for phalanges fuse with
shaft by eighteen years.
Applied Anatomy of Bones of Hand

i. Fracture of scaphoiddue to fall on outstretched hand is common in young adults.
The fragments usually do not unite. The blood
supply enters distally, so the proximal segment
may undergo avascular necrosis.
ii. Dislocation of lunateoccurs sometimes
due to fall on outstreched hand causing hyperextension of wrist. Involvement of median
nerve commonly takes place.
iii. Bennetts fractureis fracture of base of
metacarpal of thumb caused when injury is
along long axis of thumb.
tahir99 - UnitedVRG
CHAPTER
The Joints of the

Upper Extremity
THE STERNO-CLAVICULAR JOINT
It is the joint between the medial end of clavicle
and manubrium sterni.
TypeSaddle type of synovial joint
Articular surfaces
Articular surface of medial end of clavicle
Clavicular notch of manubrium sterni. These
surfaces are covered by hyaline articular
cartilage.
Articular capsule surrounds the joint on all
sides. It is reinforced by anterior and posterior
sterno-clavicular ligaments.
Ligaments
Costo-clavicular ligament is a strong
ligament that firmly connects medial end of
clavicle to the first costal cartilage.
Inter-clavicular ligament is T-shaped
ligament connecting upper parts of medial
ends of two clavicles with vertical limb
attached to supra-sternal notch.
Articular discA complete intra-articular disc
separates the joint into two joint cavities.
It is attached above to the medial end of
clavicle and below to the first costal cartilage
The articular disc gives stability to the joint.
The nerve supply of the joint is by
i. Nerve to subclavius
ii. Anterior supra-clavicular nerve
The arterial supply of the joint is by
i. Internal thoracic artery
ii. Supra-scapular artery (Fig. 9.1)
Fig. 9.1: The sterno-clavicular jointsanterior aspect
Movements
The movements occur at the joint, along with
movements of shoulder joint and of scapula.
The movements occur at two axes:
Elevation and depression
Protraction (forward movement) and
retraction (backward movement)
Circumduction occurs as combination of above
movements.
Applied anatomy:The dislocation of the joint,
is very rare as it is strengthened by strong
ligaments. Instead, fracture of clavicle occurs
more commonly.
THE ACROMIO-CLAVICULAR JOINT

It is the joint between the lateral end of clavicle and
acromion process of scapula.
56
Type: Plane type of synovial joint.

Articular surfaces
Oval facet on lateral end of clavicle
Oval facet on medial border of acromion.
Both articular surfaces are covered by hyaline
articular cartilage.
Articular capsule surrounds the joint on all sides.
It is thin and loose and is reinforced by the
ligaments around the joint.
Ligaments
1. Acromio-clavicular ligament strengthens the
articular capsule from above.
2. Coraco-clavicular ligament extends
between the coracoid process and inferior
surface of lateral one-third of clavicle.
It consists of two parts conoid and
trapezoid.
It is a strong ligament and gives stability
to the joint.
Articular disc: An incomplete intra-articular disc
is present in the upper part of the joint.
The nerve supply is by
1. The supra-scapular nerve
2. The lateral pectoral nerve
The arterial supply is by
Suprascapular artery
Thoraco-acromial artery
Movements: Some gliding movements take place
in the joint along with movements of scapula
and of sternoclavicular joint.
It is covered by hyaline articular

cartilage and is further deepened by a
fibro-cartilaginous rim the labrum
glenoidale.
Articular capsule surrounds the joint. It is loose
below
On humerus It is attached to the anatomical
neck except inferiorly, where it is attached
to the shaft of humerus about 1.2 cm below
the head.
On scapula It is attached to the margins of
glenoid fossa just beyond the labrum
glenoidale.
It includes the supraglenoid tubercle
superiorly.
The capsule is strengthened by three thickeningssuperior, middle and inferior glenohumeral
bandsthat are present on inner surface of
capsule.
The capsule has two openings:
1. Opening for subscapular bursa anteriorly.
2. Opening between two tuberosities for giving
passage to long tendon of biceps brachii.
THE SHOULDER JOINT

(SCAPULO-HUMERAL JOINT)
The shoulder is a large joint between the head of
humerus and glenoid fossa of scapula.
Type: Ball and socket type of synovial joint.
Articular surfaces are formed by
1. The head of humerus which is less than half
sphere and is covered by hyaline articular
cartilages.
2. The glenoid fossa of scapula is pear-shaped
and shallow and much smaller than head of
humerus.
Ligaments
1. The coraco-acromial ligament is triangular
in shape and extends between the tip of
acromion and lateral border of coracoid
process.
This completes along with olecranon and
the coracoid process a secondary socket
for head of humerus.
2. The transverse humeral ligament bridges the
gap between the two tuberosities of
humerus, through which the long tendon
of biceps brachii passes.
3. The coraco-humeral ligament extends
between the inferior surface of coracoid
process and the two tuberosities of
humerus.
The rotator cuff (musculo-tendinous cuff) is
formed by the fusion of tendons of insertions
of the following muscles with articular capsule:
Subscapularis-anteriorly
tahir99 - UnitedVRG
The Joints of the Upper Extremity

Supraspinatus, infra-spinatus and teres
minor-posteriorly.
The rotator cuff muscles act as elastic ligaments
and keep the head of humerus firmly in position
during movements at the joint (Fig. 9.2).
Bursae around the joint: There are a number

of bursae around the joint:
9
ri 9
1. The sub-acromial bursa separates acromion

process from insertion of supraspinatus.
Inflammation of this bursa leads to
painful abduction at shoulder joint.
2. The sub-scapular bursa lies deep to the
tendon of subscapularis. It communicates
with the joint cavity.
3. The sub-deltoid bursa separates the deltoid
muscle with rotator cuff. Frequently, it
communicates with sub-acromial bursa.
4. The infra-spinatus bursa lies deep to the
tendon of infraspinatus. It sometimes
communicates with joint cavity.
5. The synovial sheath of long tendon of
biceps brachii is an extension of synovial
membrane of shoulder joint (Fig. 9.3).
The axillary nerve
The suprascapular nerve
The lateral pectoral nerve
The arterial supply of the joint is by
The anterior and posterior circumflex
humeral arteries
The suprascapular artery
V
d
ti e
n
U
Fig. 9.2: Section through shoulder joint
h
a
57
Fig. 9.3: The shoulder joint
G
R
58

Movements: The shoulder joint is the most
mobile joint of the body
The factors responsible for mobility are
laxity of the capsule and large articular
surface of head as compared with glenoid
cavity.
The shoulder joint is multiaxial joint with
movements ocurring around three axes
i. Around an antero-posterior axis
abduction and adduction take place.
ii. Around transverse axis flexion and
extension take place.
iii. Around a vertical axis medial and
lateral rotation take place.
Muscles responsible for movements
Flexion
Clavicular head of pectoralis major
Anterior part of deltoid
Coracobrachialis
Biceps brachii
Extension
Posterior fibers of deltoid
Teres major
Latissimus dorsi
Sterno-costal head of pectoralis major
Abduction
Supraspinatus (initiates the movement)
Deltoid (up to 90)
Lower part of trapezius and lower part of
serratus anterior cause overhead abduction
of arm by rotation of scapula
Adduction
Pectoralis major
Latissimus dorsi
Teres major
Coraco-brachialis
Biceps brachii
Long head of triceps
Medial rotation
Pectoralis major
Anterior part deltoid
Subscapularis
Teres major
Latissimus dorsi
Lateral rotation
Posterior part of deltoid
Infraspinatus
Teres minor
Applied anatomy
1. The dislocation of shoulder joint may take
place due to high mobility of the joint.
a. Anterior dislocation: The head of
humerus comes to lie below coracoid
process. It occurs due to weakness of
opening of subscapular bursa.
The labrum glenoidale may be injured
and axillary vein may also be
involved.
b. Inferior dislocation: The head of humerus comes to lie below glenoid fossa. It
occurs due to laxity of lower part of
capsule.
The axillary nerve and circumflex
humeral vessels may be injured.
2. Ankylosis of shoulder joint may take place
in old age with limitation of movements
accompanied by pain.
THE MOVEMENTS OF SHOULDER

GIRDLE (SCAPULA)
The movements of scapula are caused by the
muscles that connect it to the axial skeleton.
1. Elevation and depression of scapula take place
through an axis passing through both sternoclavicular joints.
Elevation is done by
Upper part of trapezius
Levator scapulae
Depression is done by
Subclavius
assisted by the
Pectoralis minor weight of the limb
Lower part of trapezius
2. Protraction and retraction take place through a
vertical axis passing through sterno-clavicular
joint
tahir99 - UnitedVRG
Protractors are
Serratus anterior
Pectoralis minor
assisted by upper
part of latissimus
dorsi
Rectractors are
Rhomboid minor and major
Trapezius
3. Rotation of scapula takes place through an
antero-posterior axis between sterno-clavicular
and acromio-clavicular joints
Upward rotation is done by
Lower part of trapezius
Lower part of serratus anterior
Downward rotation is done by
Pectoralis minor
assisted by
Rhomboid minor
gravity
and major
THE ELBOW JOINT
h
a
9
ri 9
Ligaments
i. The medial collateral ligament is a strong
fan-shaped ligament having three bands
anterior, oblique and posterior.
The ligament is attached to
Medial epicondyle of humerus above
Medial margin of olecranon process
below
ii. The lateral collateral ligament reinforces
the joint on the lateral side
The ligament is attached to
Lateral epicondyle of humerus above
Annular ligament of radius below
(Fig. 9.4)
i. The musculo-cutaneous nerve
ii. The radial nerve
iii. The median, ulnar and anterior interosseous
nerves also supply the joint.
The arterial supply is by an arterial anastomosis
around the elbow joint formed by the branches
of brachial, radial and ulnar arteries.
Movements are flexion and extension around a
transverse axis.
The flexors are
Brachialis
assisted by brachio Biceps brachii radialis and flexors of
forearm
The extensors are
Triceps
assisted by gravity and
Anconeus
extensors of forearm
Applied anatomy
i. The dislocation of elbow joint is rare, except
due to some external force.
ii. The tennis elbow is caused by the sprain of
lateral collateral ligament or by injury to
common extensor origin.
The condition may also be caused by
inflammation of bursa deep to triceps.
iii. The pulled elbow of little children is caused
due to traction of elbow leading to the head
of radius escaping from the annular
ligament.
V
d
ti e
G
R
n
U
The elbow joint consists of two articulations:

A humero-ulnar joint
A humero-radial joint
1. The humero-ulnar joint is formed by the
trochlea of humerus articulating with
trochlear notch of upper end of ulna.
2. The humero-radial joint is formed by the
capitulum of humerus articulating with
superior concave surface of head of radius.
Type: Both joints together form a hinge type of
synovial joint.
Articulator surfaces
On humerustrochlea and capitulum.
On ulnatrochlear notch of ulna
On radiussuperior surface of head of radius
Articular capsule surrounds the joint and is
attached beyond the articular surfaces including
coronoid and radial fossa anterioly and part of
olecranon fossa posteriorly on humerus.
The capsule is thin anteriorly and posteriorly.
It is reinforced by the two collateral
ligamentsmedial and lateral.
59
60
Fig. 9.4: The elbow joint
THE RADIO-ULNAR JOINTS

There are three radio-ulnar joints proximal,
middle and distal.
i. The proximal (superior) radio-ulnar joint is
formed by head of radius and the radial notch
of upper end of ulna.
Type: A pivot type of synovial joint.
Ligaments
1. The annular ligament is attached to
the anterior and posterior margins of
radial notch of ulna
It completes the ring inside which
the head of radius rotates.
It also gives attachment to lateral
collateral ligament of elbow joint.
2. The quadrate ligament is a short
quadrangular band, that passes from
lower border of radial notch to the
neck of radius.
It is lined by synovial membrane
superiorly.
Nerve supply is by the median nerve.
ii. The middle radio-ulnar joint is formed by
the interosseous membrane and the oblique
cord.
a. The interosseous membrane is a thick

sheet of connective tissue that connects
the interosseous borders of radius and
ulna.
The direction of fibers of the membrane is downwards and medially
from radius to ulna.
The interosseous membrane performs the following functions:
i. It binds the two bonesradius
and ulna firmly together and
prevents their separation.
ii. It provides additional surface for
the attachment of muscles.
iii. It helps to transmit the force
from hand and radius to ulna and
elbow and on to the humerus.
b. The oblique cord is a round cord-like
structure that passes downwards and
laterally from lateral border of coronoid
process of ulna to shaft of radius below
radial tuberosity (Fig. 9.5).
iii. The distal radio-ulnar joint is formed by
The head of ulna and
The ulnar notch at lower end of radius
tahir99 - UnitedVRG
Fig. 9.5: The radio-ulnar joints
9
ri 9
The anterior interosseous branch of median

nerve
Movements at the radioulnar joints
The movements of pronation and supination take
place at the radioulnar joints.
The axis of movement passes from the head of
radius proximally to the ulnar attachment of
articular disc distally
The pronation is the movement, where the
radius carrying the hand turns anteromedially across ulna.
a. The proximal end of radius remains
lateral, but the distal end becomes medial.
b. In this movement the interosseous
membrane is spiralized
The supination is the movement, where
radius carrying the hand regains its normal
position lateral to the ulna.
a. The interosseous membrane is despiralized and regains its original position.
V
d
ti e
G
R
n
U
Type: A pivot type of synovial joint.

Articular capsule surrounds the joint.
Articular disc is a triangular fibro-cartilaginous
disc that separates the joint from radio-carpal
joint.
The apex of the disc is attached to the
depression at base of styloid process of ulna
The base of the disc is attached to the
prominence between ulnar notch and inferior
surface of lower end of radius
The proximal surface of disc articulates with
head of ulna
The distal surface of articular disc articulates
with lunate bone. In fully adducted hand it
articulates with triquetral also.
The synovial membrane of the joint projects
upwards in front of interosseous membrane
between the two bones as recessus sacciformis.
The nerve supply is
h
a
61
The pronators are

Pronator quadratus
Pronator teres
The supinators are

Supinator
Biceps brachii (in flexed elbow)
THE RADIOCARPAL (WRIST) JOINT
The radiocarpal joint is formed by the lower end of
radius and carpal bones of proximal row.
Type: Ellipsoid type of synovial joint
Articular surfaces:
Proximal:
Inferior surface lower end of radius
Inferior surface of articular disc of distal
radio-ulnar joint
Distal: Scaphoid and lunate bones mainly
Articular capsule surrounds the joint.
Ligaments
62

1. The anterior radio-carpal ligament is a
broad membrane on anterior aspect of the
joint.
It passes from anterior margin of lower
end of radius to front of scaphoid, lunate
and triquetral.
2. The posterior radio-carpal ligament
strengthens the posterior aspect of the joint.
3. The radial collateral ligament connects the
tip of styloid process of radius to scaphoid.
4. The ulnar collateral ligament connects the
tip of styloid process of ulna to triquetral
(Fig. 9.6).
Anterior interosseous nerve
Posterior interosseous nerve
The anterior interosseous artery
The anterior and posterior carpal branches
of radial and ulnar arteries.
Movements in the joint are permitted around
two axes:
There is transverse axis for flexion and
extension
There is anteroposterior axis for movements

of adduction and abduction.
Muscles producing movements
Flexors
Flexor carpi radialis assisted by other
Flexor carpi ulnaris long flexors
Extensors
Extensor carpi
radialis longus
assisted by other
Extensor carpi
long extensors
radialis brevis
Extensor carpi
ulnaris
Adductors
Flexor carpi ulnaris
Extensor carpi ulnaris
Abductors
Extensor carpi radialis longus
Extensor carpi radialis brevis
Extensor carpi radialis
THE MID-CARPAL JOINT

The mid-carpal joint is formed between the proximal
and distal row of carpal bones.
The medial compartment of the joint is between
the convexity of head of capitate and the
concavity formed by scaphoid, lunate and
triquetral.
The lateral compartment of the joint is between
The scaphoid proximally
The trapezium and trapezoid distally
Type: Saddle type of synovial joint
Movements: Small gliding movements take place
at the joint during movements at radio-carpal
joints or when the hand is flattened or hollowed.
THE INTER-CARPAL JOINTS
Fig. 9.6: Section through carpal joints
These joints lie between the adjacent carpal bones

Type: Plane type of synovial joints
Ligaments of the joint are
The dorsal carpal ligament
The palmar carpal ligament
tahir99 - UnitedVRG
There may also be interosseous ligaments

between adjacent carpal bones.
Movements: Very small gliding movements
occur at these joints.
THE SMALL JOINTS OF THE HAND

The small joints of the hand are
The carpo-metacarpal joints
The metacarpo-phalangeal joints
The inter-phalangeal joints
1. THe carpo-metacarpal joints:
a. The first carpo-metacarpal joint is between
the base of first metacarpal and trapezium
Type: Saddle type of synovial joint
The joint lies at 90 to the palm due to
rotation of metacarpal of thumb.
Articular capsule surrounds the joint
Movements occur at two axes
The flexion brings thumb ventral to
the palm. The extension brings it back
to the plane of palm.
The abduction takes place at a plane
perpendicular to the palm. The
adduction brings it to the front of
palm.
The opposition is a type of circumduction that opposes thumb to the
palm and other fingers.
The rotation is combination of
flexion, extension, abduction and
adduction.
b. The second, third, fourth, and fifth carpometacarpal joints.
These joints are between the bases of
metacarpals and corresponding carpal bones
of distal row
The second metacarpal articulates with
trapezoid.
The third metacarpal articulates with
capitate.
The fourth and fifth metacarpals articulate with hamate.
h
a
9
ri 9
63
Ligaments
The Dorsal ligaments are stronger,
connecting the dorsal surfaces of
carpals and metacarpals.
The palmar ligaments are smaller and
cover the ventral aspects of the joints.
Movements: Slight movements take
place at these joints during movements
at metacarpo-phalangeal joints.
During hollowing of the palm
movements occur at these joints.
Muscles producing movements at the
first carpo-metacarpal joint
Flexion
Flexor pollicis longus
Flexor pollicis brevis
Extension
Extensor pollicis assisted by
longus
abductor
Extensor pollicis pollicis longus
brevis
Abduction
Abductor pollicis longus
Abductor pollicis brevis
Adduction: Adductor pollicis
Opposition: Opponens pollicis
2. The metacarpo-phalangeal joints
These joints are formed between
The heads of metacarpals
The bases of proximal phalanges
Type: Condyloid type of synovial joints
Articular capsule: Surrounds the joint on
all sides.
Ligaments
1. The collateral ligaments of the joints are
attached to sides of articulating bones.
These ligaments become tense in
flexed position and are relaxed in
extended position of fingers.
2. The deep transverse metacarpal
ligaments: They inter-connect the heads
of medial four metacarpals and prevent
their separation.
n
U
V
d
ti e
G
R
}
64
Movements at these joints occur at two axes:

At transverse axisflexion and
extension take place
At antero-posterior axisabduction and
adduction take place with reference to
the neutral axis passing through middle
finger.
Muscles producing movements:
Flexion
Flexor digitorum
in four fingers
superficialis
assisted by
Flexor digitorum
lumbricals and
profundus
interossei
Flexor pollicis brevis in thumb
Extension
Extensor digitorumassisted in second
and fifth fingers by extensor indicis and
extensor digiti minimi
Extensor pollicis
longus
in thumb
Extensor pollicis
brevis
Abduction (in fingers)
Dorsal interossei for second and fourth
fingers
In middle finger there are two dorsal

interossei and cause medial and lateral
abduction.
In little finger abductor digiti minimi
Adduction (in fingers)
Palmar interossei.
3. The inter-phalangeal joints are formed between
the phalanges
The proximal inter-phalangeal joint is
between the head of first phalanx and base
of second phalanx.
The distal inter-phalangeal joint is between
the head of second phalanx and base of
terminal phalanx. The thumb has only one
inter-phalangeal joint.
Type: Hinge type of synovial joint.
Ligaments: The collateral ligaments reinforce the sides of the joints.
The ligaments are lax when finger is
extended.
Movements are possible in one transverse
axis only
Flexion is done by long flexors.
Extension is done by long extensors.
Nerve supply of small joints of hand is by
the digital branches of ulnar and median
nerves.
tahir99 - UnitedVRG
CHAPTER
10
The Shoulder Region and

Superficial Back Region
The shoulder region includes:
1. The pectoral region and the axilla.
2. The shoulder region proper
3. The scapular region
THE PECTORAL REGION
1. The pectoral region lies on front of upper part
of thorax.
In the superficial fascia of the region, in
females, lies the mammary gland (described
in Chapter 2).
The muscles of the pectoral region are:
a. The pectoralis major
b. The pectoralis minor
c. The subclavius
a. The pectoralis major is a large and powerful
muscle.
Origin is by two heads
i. The clavicular head arises from
anterior surface medial half of clavicle.
ii. The sternocostal head arises from
Anterior surface of sternum
Upper six costal cartilages
Aponeurosis of external oblique
muscle.
Muscle belly is thick and triangular
The clavicular fibers pass downwards and
laterally for insertion on anterior lamina of the
tendon.
The upper sternocostal fibers are attached
to deeper part of anterior lamina.
The lower sternocostal fibers are twisted in
such a manner, that each lower fiber passes
deep to the upper fiber and is inserted on
h
a
9
ri 9
G
R
posterior lamina of the tendon at higher level.

This arrangement forms the anterior fold of
axilla.
Insertion is by a bilaminar tendon on the
lateral lip of inter-tubercular sulcus (bicipital
groove) of humerus. The posterior lamina
extends to a higher level.
Nerve supply is by
Medial pectoral nerve (C5,C6)
Lateral pectoral nerve (C 7, C 8, T 1 )
(Fig. 10.1)
Actions
1. The entire muscle acts as a powerful
adductor and medial rotator of upper
arm.
2. The clavicular part helps in flexion of
arm along with anterior fibers of deltoid
and coracobrachialis.
3. The sternocostal part helps in extension
of arm along with posterior fibers or
deltiod, latissimus dorsi and teres major.
4. The muscles helps in climbing by pulling
up the trunk.
5. The muscles also helps in deep inspiration.
Relations
Anteriorly
Skin, superficial fascia, platysma, supraclavicular nerves and mammary gland.
Deep fascia (pectoral fascia)
PosteriorlySternum, ribs, costal cartilages,
intercostal muscles
Clavipectoral fascia, pectoralis minor
and serratus anterior.
n
U
V
d
ti e
66
Fig. 10.1: The pectoralis major
Upper borderDelto-pectoral groove (infraclavicular fossa) with cephalic vein, deltoid

branch of thoraco-acromial artery, separates
it from deltoid
Lower borderforms anterior axillary
fold.
b. The pectoralis minor
Originupper margin and outer surface of
third to fifth costal cartilages.
Muscle belly is thin and triangular
The fibers pass upwards and laterally to
form tendon of insertion .
InsertionMedial border and upper surface
of coracoid process.
Nerve supply
Medial pectoral nerve (C8, T1)
Lateral pectoral nerve (C6,C7, C8)
Actions
i. It assists serratus anterior to draw the
scapula forwards.
ii. It helps to depress the shoulder along with
subclavius.
It lies deep to clavicular head of pectoralis major

Below it splits to enclose pectoralis minor and
descends to fuse with axillary fascia
Above it splits to enclose subclavius and is
attached to the margins of subclavian groove
of clavicle.
The clavipectoral fascia is pierced by
i. Cephalic vein
ii. Thoraco-acromial vessels
iii. Lateral pectoral nerve
The Clavipectoral Fascia

It is a thick fibrous membrane that fills up the gap
between pectoralis minor and subclavius (Fig.
10.2).
tahir99 - UnitedVRG
Fig. 10.2: The clavipectoral fascia
The Shoulder Region and Superficial Back Region

The Subclavius
OriginFirst costal cartilage at its junction with

first rib.
Muscle bellyIt is small and triangular. The
fibers ascend laterally on inferior surface of
clavicle.
InsertionA groove on inferior surface of
middle one-third of clavicle.
Nerve supplyNerve to subclavius (C5, C6)
Actions
i. It depresses the shoulder along with pectoralis minor
ii. It steadies the clavicle.
THE AXILLA
The axilla is the space between upper part medial

side of arm and thorax.
Shape is pyramidal
BoundariesThe walls are anterior, posterior
medial and lateral. It has an apex and a base.
a. The anterior wall is formed by
Pectoralis major
Clavipectoral fascia
Pectoralis minor
b. The posterior wall is formed by
Subscapularis
67
Latissimus dorsi
Teres major
c. The medial wall is formed by
Serratus anterior covering upper part of
lateral thoracic wall.
d. The lateral wall is narrow and formed by
Shaft of humerus
Coraco-brachialis
Short head of biceps brachii
The apex is triangular and directed upwards and
medially towards root of neck. It is bounded by
Clavicle anteriorly
First rib medially
Upper border scapula posteriorly
The base of axilla is formed by axillary fascia
(Fig. 10.3).
Contents of the axilla are:
i. The axillary artery and its branches
ii. The axillary vein and its tributaries
iii. The three cords of brachial plexus and their
branches.
iv. The axillary lymph nodes
v. Fibrofatty tissue
vi. The axillary tail of mammary gland in
females.
Fig. 10.3: TS through axilla
68
The Axillary Artery

The axillary artery is the main arterial trunk of the
upper extremity.
BeginningThe axillary artery begins at the
outer border of first rib as continuation of
subclavian artery.
CourseThe artery passes laterally and
downwards with a concavity below, when arm
is by side of the body.
For purpose of description, it is divided into
three parts:
a. First part extends from outer border of
first rib to medial border of pectoralis
minor
b. Second part is the short segment of
artery that lies behind pectoralis minor
c. Third part is the longest part that extends
from lateral border of pectoralis minor
to lower border of teres major.
The lower half of third part is quite
superficial covered by skin, superficial
fascia and deep fascia (Fig. 10.4).
BranchesThe artery gives six branches. From
first part one branch.
1. The superior thoracic artery is a small branch

supplying first intercostal space.
From second parttwo branches.
2. The thoraco-acromial artery pierces
clavipectoral fascia and divides into four
branches.
a. The deltoid branch lies in deltopectoral
groove.
b. The clavicular branch supplies sternoclavicular joint.
c. The acromial branch reaches the
superior surface of acromion.
d. The pectoral branch supplies pectoral
muscles.
3. The lateral thoracic artery runs along the
lateral border of pectoralis minor.
In females, it is large and supplies the
mammary gland.
From third partthree branches.
4. The anterior circumflex humeralpasses
deep to the muscles and curves around the
surgical neck of humerus from in front.
5. The posterior circumflex humeralis a larger
branch that accompanies axillary nerve
through quadrangular space and curves
around surgical neck of humerus.
Fig. 10.4: The axillary artery
tahir99 - UnitedVRG

6. The subscapular artery is a large artery that
follows lateral border of scapula.
It gives a large circumflex scapular
branch. Both subscapular artery and its
branch take part in the scapular
anastomosis.
The Axillary Vein
The axillary vein is formed at the lower border of
teres major by union of
The basilic vein
The venae comitantes of brachial artery
The axillary vein lies on the medial side of the
axillary artery.
It receives tributaries corresponding to the
branches of axillary artery.
It also receives cephalic vein, that joins it after
piercing clavipectoral fascia.
The axillary vein continues as the subclavian
vein in the neck at the outer border of first rib.
The Axillary Lymph Nodes
1. There are five sets of lymph nodes in axilla
a. The anterior group (pectoral group) lies
along the anterior wall of axilla.
b. The posterior group (subscapular group) lies
along the lateral border of scapula.
c. The central group lies in the center of axilla.
d. The apical group lies at the apex of axilla
and receives lymphatics from all other
groups.
e. The lateral group lies along the lateral wall
of axilla.
The axillary lymph nodes receive lymph
from
The entire upper extremity
The anterior and posterior thoracic wall
The anterior abdominal wall above
umbilicus
Most lymphatics from breast in females.
2. The delto-pectoral lymph nodes are a few lymph
nodes in the infra-clavicular fossa (deltopectoral
groove).
69
The Brachial Plexus

The brachial plexus supplies the skin and muscles
of the upper extremity.
FormationThe plexus is formed by the ventral
rami of C5, C6, C7, C8 and T1 spinal nerves.
There are four stages of its formation.
First stageThe roots are formed by the above
ventral rami.
Second stageThree trunks are formed
Upper trunk is formed by union of ventral
rami of C5 and C6 nerves.
Middle trunk is formed by continuation of
ventral ramus of C7 nerve.
Lower trunk is formed by union of ventral
rami of C8 and T1 spinal nerves.
Third stageEach trunk divides into two
divisionsanterior and posterior.
The anterior divisions carry motor fibers
to supply flexor muscles.
The posterior divisions carry motor fibres
to supply extensor muscles.
Fourth stageThree cords are formed
The lateral cord is formed by anterior
divisions of upper and middle trunks.
The medial cord is formed by anterior
division of lower trunk (Fig. 10.5).
The posterior cord is formed by posterior
divisions of all three trunks.
RelationsThe roots and trunks (first and
second stages) of brachial plexus lie in posterior
triangle of neck above clavicle (supra-clavicular
part).
The divisions (third stage) lie behind clavicle.
The three cords (fourth stage) lie in the axilla
around the axillary artery (infra-clavicular
part)
Branches
From the supra-clavicular part
i. Grey rami communicans are received from
the corresponding sympathetic ganglia by
the ventral rami.
70
Fig. 10.5: The brachial plexus
ii. Muscular branchesto prevertebral muscles

from ventral rami of C5, C6, C7 and C8.
iii. Contribution to phrenic nerve from ventral
ramus of C5.
iv. Four motor branches to muscles of upper
limb.
a. Dorsal scapular (C5)
b. Supra scapular (C5,C6)
c. Nerve to subclavius (C5,C6)
d. Long thoracic nerve (C5, C6, C7)
From the infra-clavicular part
I. Lateral cordgives three branches.
Lateral pectoral (C5, C6, C7)
Musculo-cutaneous (C5,C6,C7)
Lateral root of median (C5, C6,C7)

II. Medial cord gives five branches.
Medial pectoral (C8, T1)
Medial cutaneous of arm (C8,T1)
Medial cutaneous of forearm (C8,T1)
Medial root median (C8,T1)
Ulnar (C7,C8,T1)the contribution of C7 to
ulnar comes from lateral root of median
nerve.
III.Posterior cordgives five branches

Upper subscapular (C5,C6)
Thoraco-dorsal (C6,C7,C8)
Lower subscapular (C5,C6)
Axillary (C5,C6)
Radial (C5,C6,C7,C8,T1)
Applied anatomy
1. Compression of roots of branchial plexus may
be caused by cervical spondylitis.
The condition causes pain in the dermatomes
supplied by the affected spinal nerve.
2. Upper trunk injury(Erb-Duchenne paralysis)
Causes
Violent downward displacement of arm.
Birth injury due to pulling of arm at
childbirth.
Effects of injuryParalysis of all the muscles
supplied by anterior and posterior divisions of
upper trunk (C5 and C6 spinal nerves). This
leads to
Loss of abduction (deltoid)
tahir99 - UnitedVRG

Loss of lateral rotation (infraspinatus and
teres minor).
Loss of flexion of elbow joint (brachialis)
Loss of supination of forearm (biceps
brachii).
Position of limbThe upper extremity adopts
a Waiters tip (Porters tip) position (with
shoulder adducted and medially rotated, elbow
extended and forearm pronated).
3. The lower trunk injury (Klumpkes paralysis)
is less common.
Causes:
Violent upward displacement of arm.
Dislocation of shoulder joint.
Cervical rib.
Effects of injuryParalysis of all muscles
supplied by anterior and posterior divisions of
lower trunk (C 8 ,T 1 spinal nerves).This
condition leads to
Loss of adduction at wrist (ulnar nerve)
Paralysis of all short muscles of hand except
three thenar muscles and lateral two
lumbricals.
Loss of skin sensations along the medial
border of hand and forearm (medial
cutaneous nerve of forearm).
Position of limbThe hand assumes claw
hand position.
4. Scalene syndrome (cervical rib syndrome)
Presence of cervical rib causes compression
of lower trunk of brachial plexus.
Effects of injury
Pain along medial border of forearm.
Atrophy of small muscles of hand in later
stages.
Compression of subclavian artery causes
ischemic symptoms of upper extremity.
5. Injury to long thoracic nervein the medial wall
of axilla leads to:
Paralysis is serratus anterior muscle
causing Winging of Scapula (prominence of medial border of scapula)
71
THE SHOULDER REGION PROPER

The shoulder region proper consists of deltoid
muscle covering upper part of hemerus and the
shoulder joint.
The Deltoid Muscle
Origin
Anterior border and superior surface of
lateral third of clavicle (anterior part)
Lateral border of acromion (middle part)
Lower edge of crest of spine of scapula
(posterior part).
Muscle belly is thick, curved and triangular.
The anterior and posterior fibers converge
towards its tendon of insertion.
The middle part is multipennate. Four intermuscular septa descened from four tubercles
on acromion and interdigitate with three
septa ascending from deltoid tuberosity.
Insertionis on V-shaped, rough deltoid
tuberosity on middle of anterolateral surface of
shaft humerus.
Nerve supplyis by axillary nerve (C5, C6) (Fig.
10.6)
Actions
i. Anterior fibers help pectoralis major in
flexion and medial rotation of arm.
ii. Posterior fibers help latissimus dorsi and
teres major in extension and lateral rotation
of arm.
iii. The multipennate middle part is powerful
abductor of arm up to 90, assisted by
supraspinatus. During abduction, the
anterior and posterior fibers help to steady
the humerus.
Relations
Superficial
Skin, superficial fascia containing
platysma and lateral supraclavicular
nerve.
Deep fascia
72
Fig. 10.6: TS through deltoid muscle
Deep
Coracoid, process, coraco-acromial ligament. Subacromial bursa
Tendons of biceps brachii, coracobrachialis.
Supraspinatus, infraspinatus, teres
minor.
Tendon of pectoralis major and long head
of triceps.
Axillary nerve and circumflex humeral
vessels.
Surgical neck, tuberositiesgreater and
lesserand upper part shaft of
humerus.
Anterior border is separated from pectoralis
major by infra-clavicular fossa containing
cephalic vein and deltoid branch of thoracoacromial artery.
Posterior borderoverlies infraspinatus and
triceps muscles.
Appllied anatomy
The deltoid muscle is paralyzed due to
an injury to axillary nerve.
In later stages, the muscle atrophies
leading to flattening of the shoulder.
The axillary nerve - (circumflex nerve)
The axillary nerve is a branch of posterior cord

of brachial plexus. Its root value is C5,C6 (ventral
rami ).
CourseThe axillary nerve behind third part
of axillary artery.
It passes backwards through quadrangular space accompanied by posterior
circumflex humeral vessels.
The quadrangular space is bounded
Above
a. Subscapularis
b. Capsule of shoulder joint
c. Teres minor
Below
a. Teres major
MediallyLong head of triceps
LaterallySurgical neck of humerus)
As the nerve passes through quadrangular
space, it divides into two divisionsanterior
and posterior.
The anterior division curves around the
surgical neck of humerus accompanied by
posterior circumflex humeral vessels, deep
to deltoid muscle. It gives motor branches
to deltoid and sensory branches to skin
covering deltoid.
tahir99 - UnitedVRG
73
The posterior division supplies posterior part

of deltoid
It gives a branch to teres minor, that has
a pseudoganglion.
It continuous as upper lateral cutaneous
nerve of arm.
Branches
1. Muscular
Deltoid
Teres minor
2. Cutaneous
Skin over deltoid
Upper lateral cutaneous nerve of arm.
3. Articular
Shoulder joint
Applied anatomy
The axillary nerve may be injured in cases of

Fracture of surgical neck of humerus
Inferior dislocation of shoulder joint.
Effects of injury
1. Paralysis of deltoid, leading to inability to
abduct the arm up to 90.
2. Loss of skin sensation over deltoid and
upper lateral part of arm.
3. Late effectFlattening of shoulder due to
atrophy of the muscle.
Fig. 10.7: The scapular muscles
THE SCAPULAR REGION

The scapular region consists of muscles attached
to scapula, their blood supply and nerve supply
(Fig. 10.7 and Table 10.1).
Serratus Anterior Muscle

Serratus anterior muscle connects the medial border
of scapula to lateral thoracic wall.
OriginBy eight fleshy digitations from outer
surfaces and superior borders of upper eight
ribs.
Muscle belly
A large muscular sheet that covers lateral
thoracic wall.
The first digitation reaches superior angle

of scapula.
Next two or three digitations spread out for
their insertion on medial border of scapula.
The lower four or five digitations converge
towards the lower angle of scapula.
InsertionOn a strip along costal surface of
medial border of scapula from superior angle
to inferior angle.
The lower four or five digitations are inserted
on a broad area on costal surface of inferior
angle.
Nerve Supply
Long thoracic nerve (C5, C6, C7)
Actions
i. It is a powerful protractor of scapula and is
used in all pushing and punching movements.
ii. The lower part of muscle, along with lower
part of trapezius help in rotation of scapula
during overhead abduction of arm.
Applied Anatomy
i. In case of paralysis of the muscle, due to
injury to long thoracic nerve the protraction
of scapula is weakened.
74

Table 10.1: The Scapular muscles
Name
Origin
1. Supraspinatus Medial twothird of

supaspinous
fossa
2. Infraspinatus
3. Teres minor
4. Teres major
5. Subscapularis
Medial twothird of infra

spinous fossa
Muscle belly
Insertion
Nerve supply
Muscle belly
coverages
towards the
greater tuberosity
of humerus
Muscle belly
converges to form
a tendon that
passes behind
shoulder joint
A narrow elongated muscle
belly
Highest impression of greater

tuberosity of
humerus
Supra scapular
(C5, C6)
Main actions
It initiates abduction
It helps to steady
head of humerus
(part of rotator cuff)
It acts as lateral rotator of arm

It helps to steady
head of humerus
Upper two-third
Lower facet of
Axillary nerve It helps in lateral
rotation of arm
of flat strip on
greater tuberosity (C5, C6) (The
dorsal aspect
of humerus
nerve has a
It helps to steady
of lateral border
pseudo-ganglion) head of humerus
of scapula
A broad oval area Thick muscle belly Medial lip of
Lower sub It helps in extension
on dorsum of
gives rise to a
inter-tubercular
scapular nerve
and medial rotation
of arm
inferior angle of
flat tendon that
sulcus (bicipital
(C5, C6)
scapula
passes laterally
groove) of shaft
of humerus
Medial two-third Large and trianLesser tubercle
Upper and
It helps to steady the
of subscapular
gular muscle
of upper end of
lower subhead of humerus
fossa of scapula
belly
humerus
scapular nerves
It also helps in
Tendinous septa
(C5, C6)
of muscle attached
adduction and medial
to the ridges in
rotation of arm.
fossa
ii. The medial border of scapula falls away

from thoracic wall and becomes quite
prominent (Winging of scapula).
The Blood Supply of Scapular Muscles
The Scapular anastomosis is an arterial anastomosis around scapula bone between the branches
of subclavian and axillary arteries (Fig.10.8).
The arteries taking part in this anastomosis
are
i. The suprascapular artery from thyrocervical trunk of first part of subclavian
artery.
The artery reaches upper border of
scapula and passes above suprascapular
ligament to reach supraspinous fossa
Middle facet of
Supra scapular
greater tuberosity (C5, C6)
of humerus
then it curves around great scapular

notch and reaches infraspinous fossa.
ii. The deep branch of transverse cervical
arteryalso from thyro-cervical trunk.
The artery descends along medial border
of scapula deep to levator scapulae and
rhomboids (Some times the artery arises
from third part of subclavian artery and
is known as dorsal scapular artery).
iii. The subscapular artery from third part of
axillary artery descends along the lateral
border of scapula.
Its circumflex scapular branch pierce the
origin of teres minor, and grooving the bone
enters infraspinous fossa.
tahir99 - UnitedVRG
75
Fig. 10.8: The scapular anastomosis
The scapular arterial anastomosis lies in the

substance of scapular muscles and deep to the
muscles in relation to the bone.
Functional importance
1. The anastomosis provides sufficient amount
of blood to scapular muscles and upper
extremity during movements of shoulder
joint.
2. In case of blockage of main arterial trunk
distal to the origin of thyro-cervical trunk
and proximal to the origin of subscapular
artery, this anastomosis provides an alternative route for the supply of blood to upper
extremity.
The Nerves of Scapular Region
1. The suprascapular nerve (C5,C6)
Origin is from upper trunk of brachial

plexus in posterior triangle of neck.
CourseThe nerves passes laterally to reach
upper border of scapula, deep to trapezius.
It enters supraspinous fossa through the
suprascapular notch below the ligament.
It curves around lateral border of spine
of scapula to reach infraspinous fossa.
Branches
Motor branches to supply
Supraspinatus
Intraspinatus
Articular branches are given to
Shoulder joint
Acromio-clavicular joint
2. The dorsal scapular nerve (C5)
OriginIt arises from the C5 ventral ramus
in posterior triangle of neck.
Course
The nerve pierces scalenus medius and
then passes deep to levator scapulae.
It runs along medial border of scapula
deep to rhomboids, along with deep
branch of transverse cervical artery.
BranchesMotor branches supply
Rhomboid minor
Rhomboid major
Levator scapulae
THE SUPERFICIAL BACK REGION
The superficial back region has the muscles
connecting the upper limb to the axial skeleton.
These muscles are arranged in two layers:
1. The superficial layer has two muscles
Trapezius
Latissimus dorsi
2. The deeper layer has three muscles
Levator scapulae
Rhomboid minor
Rhomboid major (Fig.10.9 and Table 10.2)
76
Fig. 10.9: The superficial muscles of the back
Table 10.2: The superficial muscles of the back

Name
Origin
Muscle belly
Insertion
Nerve supply
Trapezius
External occipital
protuberance
Medial one-third
of superior nuchal
line
Ligamentum nuchae
Spine of 7th cervical
vertebra
Spines of all twelve
thoracic vertebrae
and supra-spinous
ligaments
Flat and triangular

It covers back
of neck and
upper part of
trunk
Posterior border Motor supply

lateral one-third
from spinal
of clavicle
accessory nerve
(superior fibers)
Proprioceptive
Medial margin
fibers from C3,
acromion and
C4 ventral rami
superior edge of
crest of spine of
scapula (middle
fibers)
Apex of triangular
area at the root
of spine of scapula
(inferior fibers)
Latissimus
dorsi
Lower six thoracic

spines and supraspinous ligaments
Thoraco-lumbar
fascia
Posterior part of
iliac crest
Large flat and

Floor of intertriangular
tubercular sulcus
It covers lower
of humerus in
part of back of
front of teres
trunk
major
The muscles curves around lower
Thoraco-dorsal
(C6, C7, C8)
Main actions
1. The muscle retracts the scapula
2. Upper fibers help
to elevate scapula
with levator
scapulae
3. Lower fibers
along with lower
part of serratus
anterior help in
rotation of scapula in overhead
abduction of arm.
4. Trapezius also
helps to steady
scapula during
movements of
shoulder joint
1. It helps in adduction extension
and medial rotation of arm
2. It also helps in
elevating trunk
during climbing
Contd...
tahir99 - UnitedVRG
77
Contd...
Name
Origin
Lower three or
four ribs
Levator
scapulae
Rhomboid
minor
Rhomboid
major
Muscle belly
border of teres
major and forms
a tendon
Insertion
Nerve supply
Main actions
3. It also helps in
deep inspiration
and voluntary
expulsive efforts
1. It helps to elevate
Transverse proces The muscle belly Dorsal surface
C3, C4 VR
scapula with
ses of atlas and axis
descends to
medial border of Dorsal scapular (C5)
Posterior tubercles
superior angle
scapula between
trapezius
of transverse procesof scapula
superior angle and
2. It also helps to
ses of third and
root of spine
retract scapula
fourth cervical
with rhomboids
vertebrae
Lower part of
Slender muscle Base of the tria- Dorsal scapular
1. It helps to retract
the scapula
ligamentum nuchae
belly
ngular area at
(C5)
Spines of 7th
root of spine of
2. It also helps to
cervical and 1st
scapula
steady scapula
thoracic vertebrae
along with other
scapular muscles
Spines of 2nd to
Flat and thin
Dorsal surface
Dorsal scapular
1. It helps to retract
scapula
6th thoracic
belly, descends to medial border of (C5)
vertebrae and
medial border of
scapula from root
2. It also helps to
supraspinous
scapula
of spine to the
steady the scapula
ligaments
inferior angle
during movements at shoulder
joint.
CHAPTER
11
The Upper Arm and

the Elbow Region
The region of upper arm is divided into two
osseofascial compartments
Anterior (flexor) compartment
Posterior (extensor) compartment.
THE ANTERIOR COMPARTMENT OF
ARM
See Table 11.1 (Fig. 11.1).
The Cubital Fossa
The cubital fossa is a hollow triangular
intermuscular space on front of proximal part of
forearm (Fig.11.2).
Boundaries:
Lateralmedial border of brachio-radialis
Mediallateral border of pronator teres
BaseImaginary plane joining the two
epicondyles of humerus.
Apexis below where brachio-radialis
overlaps the pronator teres
Roof(superficial boundary) is formed by
skin, superficial fascia, and deep fascia
supplemented by bicipital aponeurosis
Flooris formed by
Brachialis medially
Supinator laterally
Contents
1. Tendon of biceps brachii
2. Brachial arterybifurcating into radial and
ulnar arteries opposite neck of radius.
3. Median nerve
Fig. 11.1: The front of arm and brachial artery
4. Radial nervedoes not form a direct content

as it lies deep to brachioradialis, and divides
into a superficial and a deep branch.
tahir99 - UnitedVRG
The Upper Arm and the Elbow Region
79
Table 11.1: Muscles of anterior compartment of upper arm

Name
Origin
Muscle belly
Insertion
Nerve supply
Main actions
Coracobrachialis
Tip of coracoid
process of scapula
(in conjunction with
short head of biceps
brachii)
Two heads of
origin
Short head from
tip of coracoid
along with
coracobrachialis
Long head from
supraglenoid
tubercle inside the
capsule of shoulder
joint
Lower half of
anterolateral and
anteromedial
surfaces of
humerus
Front of lateral
and medial
intermuscular
septa
Short, rounded
muscle belly
Impression on
middle of medial
border of humerus
Musculo-cutaneous
(C5, C6, C7)
It flexes and adducts

the arm
Large, fusiform
muscle body
Flat tendon
attached to rough,
posterior part of
radial tuberosity
The tendon gives
a broad expansion
medially that
blends with deep
fascia of forearmbicipital aponeurosis
Coronoid process,
of ulna and ulnar
tuberosity
Musculo-cutaneous
(C5, C6)
separate branches
for two heads
1. The muscle is
powerful supinator of flexed
elbow
2. It also helps to
flex the elbow
3. The long head
helps to check
upward displacement of head of
humerus
Powerful flexor
of the elbow joint
Biceps
brachii
Brachialis
Muscle belly is
closely applied
to front of
humerus
Fibers converge to
form a thick
tendon
Musculo-cutaneous
(C5, C6)
Radial nerve (C7)
supplies a small
lateral part
The Blood Vessels of the Upper Arm
Fig. 11.2: The cubital fossa
The arteries
The brachial artery is the main arterial trunk of
upper extremity.
BeginningThe artery begins at the distal
border of teres major as continuation of axillary
artery.
CourseThe brachial artery proceeds distally
and lies medial to the shaft of humerus in upper
part of arm.
The artery gradually passes in front of
humerus in lower part of arm.
It is overlapped by biceps brachii muscle
and is separated from the elbow joint by
brachialis muscle.
TerminationThe brachial artery bifurcates into
radial and ulnar arteries, in the cubital fossa,
1.0 cm below elbow joint at level of neck of
radius.
80

Branches
From lateral side of artery
i. A number of small muscular branches are
given to the muscles of anterior compartment
From medial side of artery
ii. The profunda brachii artery accompanies
the radial nerve to the posterior compartment
of arm.
iii. The superior ulnar collateral artery pierces
medial intermuscular septum, along with
ulnar nerve and descends in the posterior
compartment of arm.
iv. The nutrient artery is given to humerus at
level of insertion of coraco-brachialis.
v. The inferior ulnar collateral artery (supratrochlear artery) descends to front of medial
epicondyle.
The Arterial Anastomosis

Around the Elbow Joint
There is a rich arterial anastomosis around the elbow
joint, the arteries participating are branches of
brachial, radial and ulnar arteries (Fig. 11.3).
In front of medial epicondyle
Anterior ulnar recurrent branch of ulnar artery
anastomoses with inferior ulnar collateral
branch of brachial artery.
Behind medial epicondyle
Posterior ulnar recurrent branch of ulnar artery
anastomoses with superior ulnar collateral
branch of brachial artery.
In front of lateral epicondyle
Radial recurrent branch of radial artery
anastomoses with anterior descending branch
of profunda brachii branch (of brachial artery)
Behind lateral epicondyle
Interosseous recurrent artery from posterior
interosseous branch of ulnar artery anastomoses with posterior descending branch of
profunda brachii artery.
Fig. 11.3: The anastomosis around the elbow joint
Applied Anatomy
1. The supra-condylar fracture of humerus may
injure the brachial artery as well as the median
nerve.
The traction of brachialis pulls the lower
segment of humerus forwards, thus injuring
the artery and the nerve.
2. The Volkmanns ischemic contracture results
from ischemia of forearm and hand due to
compression of main vessels.
The Veins
1. The superficial veins of the arm are
a. The cephalic vein lies in front of lateral
epicondyle of humerus and ascends upwards
along the lateral border of the arm.
It lies in delto-pectoral groove and
pierces the clavipectoral fascia to end in
the axillary vein.
tahir99 - UnitedVRG

b. The basilic veinascends in front of medial
epicondyle of humerus and then passes
upwards along the medial border of biceps
brachii muscle.
The basilic vein pierces deep fascia about
the middle of arm at level of insertion of
coraco-brachialis.
The basilic vein joins with venae comitantes of brachial artery at distal border
of teres major to form axillary vein.
c. The median cubital vein connects the cephalic and basilic veins in front of the cubital
fossa.
The vein lies in front of bicipital aponeurosis.
The medial cubital vein is commonly used
for giving intravenous injection.
2. The deep veins
There are two venae comitantes accompanying
the brachial artery.
The venae comitantes receive venous blood
from the veins accompanying the branches
of brachial artery.
The Lymphatics of the Arm
The superficial lymphatics accompany the superficial veins and drain into axillary lymph nodes.
The deep lymphatics accompany the brachial
vessels and also end in axillary lymph nodes. There
are one or two supra-trochlear lymph nodes in distal
part of arm just proximal to medial epicondyle. They
can be easily palpated, if enlarged.
The Nerves of the Anterior
Compartment of Arm
The nerves of anterior compartment aremusculocutaneous, median ulnar nerve and small part of
radial nerve.
1. The musculo-cutaneous nerve (C5, C6, C7) is a
branch of lateral cord of brachial plexus.
CourseThe nerve pierces the coracobrachialis muscle and descends between
coraco-branchialis and biceps brachii.
81
Lower down, in front of arm the nerve

descends between biceps brachii and
brachialis.
TerminationJust above the bend of elbow,
the musculo-cutaneous nerve pierces deep
fascia of arm at lateral border of biceps
brachii.
The nerve continues as lateral cutaneous
nerve of arm.
Branches
a. Muscular branches are given to
Coracobrachialis
Both headsshort and long of
biceps brachii (separate branches)
Brachialis (medial part)
b. Articular to elbow joint
c. Cutaneous lateral cutaneous nerve of
forearm supplying skin of lateral aspect
of forearm up to ball of thumb.
Applied Anatomy
Injury to musculo-cutaneous nerve results
in
Inability to strongly flex the elbow
Loss of sensations along the lateral
border of forearm.
2. The median nerve (C5, C6, C7, C8, T1) is formed
by
The lateral root from lateral cord of brachial
plexus.
The medial root from medial cord of brachial
plexus.
Course
The median nerve descends lateral to the
brachial artery up to the insertion of
coracobrachialis.
In lower half of front of arm, the median
nerve descends medial to brachial artery
after crossing the brachial artery.
The median nerve enters cubital fossa
medial to the brachial artery, deep to
bicipital apponeurosis.
BranchesThe median nerve gives no
branches in the arm.
82
Applied anatomyThe median nerve may

be injured in supracondylar fracture of
humerus along with brachial artery.
3. The ulnar nerve (C7, C8, T1) is a branch of
medial cord of brachial plexus.
CourseThe ulnar nerve lies medial to the
brachial artery up to the insertion of
coracobrachialis muscle.
At middle of arm, the ulnar nerve pierces
the medial intermuscular septum of arm,
accompanied by the superior ulnar collateral
artery.
BranchesThe ulnar nerve does not give
any branch in the arm.
4. The radial nerve (C5, C6, C7, C8, T1) lies in
lower part of anterior compartment between
brachialis medially and brachioradialis laterally.
Radial nerve crosses front of elbow and
enters forearm deep to brachioradialis.
BranchesThe radial nerve gives three
muscular branches here to:
Brachioradialis
Lateral part of brachialis
Extensor corpi radialis longus
THE POSTERIOR COMPARTMENT

OF ARM
The Blood Vessels of

Posterior Compartment
The posterior compartment of arm has only one

muscletriceps brachii.
The Arteries
The Triceps Brachii
Origin of the muscle is by three heads

i. The long headarises from the infraglenoid tubercle of scapula.
ii. The lateral headis attached to a narrow
oblique ridge on posterior surface of upper
part of shaft of humerus.
iii. The medial head is attached to whole of
posterior surface of humerus distal to the
spiral groove.
It is also attached to back of lateral
intermuscular septum.
Muscle belly
The long head descends between teres minor
and teres major and then medial to the lateral
head and superficial to medial head.
The lateral head overlaps the medial head.
The medial head lies on a deeper plane.
All three heads join to form a common
tendon.
Subanconeus is formed by deep fibers of
medial head.
Insertion of tendon of triceps is on superior
surface of olecranon.
It is separated from articular capsule by a
bursa.
Subanconeus fibers are attached to fibrous
capsule.
Nerve Supply
Radial nerve gives separate branches to the three
heads.
Actions
1. Triceps is the main extensor of the elbow.
2. The long head supports the shoulder joint
from below, when the arm is raised.
3. The subanconeus (articularis cubiti) retracts
the fibrous capsule during extension.
1. The profunda brachii is a large branch of

brachial artery, given in upper part of arm.
Course
It accompanies radial nerve and passes
between long and medial head of triceps
to reach posterior compartment.
It descends in the radial (spiral) groove
on back of shaft of humerus along with
radial nerve deep to the lateral head of
triceps.
Branches
Muscular branches to triceps muscle.
The nutrient branch is given to humerus,
that enters the bone behind deltoid
tuberosity.
tahir99 - UnitedVRG

The deltoid (ascending) branch ascends
upwards to anastomose with descending
branch of posterior circumflex humeral
artery.
The posterior descending branch (middle
collateral) descends behind lateral
malleolus to anastomose with interosseous recurrent artery.
The anterior descending branch (radial
collateral) is the arterys continuation.
It accompanies the radial nerve and
pierces lateral intermuscular septum.
It runs between brachialis and
brachioradialis and anastomoses with
radial recurrent artery.
2. The superior ulnar collateral branch of brachial
artery accompanies ulnar nerve in posterior
compartment piercing medial intermuscular
septum.
83
It descends behind medial epicondyle and

anastomoses with posterior ulnar recurrent
artery.
The Nerves of the Posterior

Compartment (Fig. 11.4)
I. The radial nerve (C5, C6, C7, C8, T1) is a branch
of posterior cord of brachial plexus.
CourseThe radial nerve lies behind the
third part of axillary artery and uppermost
part of brachial artery.
The nerve, accompanied by profunda
brachii artery passes between lateral and
medial heads of triceps and enters
posterior compartment.
The nerve descends laterally, lying in
spiral groove on back of shaft of
humerus, covered by lateral head of
triceps.
Fig. 11.4: The posterior compartment of arm and radial nerve
84
The radial nerve along with anterior

descending branch (radial collateral) of
profunda brachii pierces lateral
intermuscular septum.
The radial nerve lies between brachialis
and brachio-radialis in lower part of
anterior compartment.
The radial nerve descends in front of
lateral epicondyle and lies in cubital fossa
deep to brachio-radialis.
TerminationThe nerve terminates by
dividing into a superficial branch and a deep
branch below elbow joint.
Branches in posterior compartment
i. The muscular branches are given to
Long head
Lateral head
of triceps brachii
Medial head
Anconeusa long slender branch
that descends through medial
head of triceps.
The muscular branches are also given
in anterior compartment to:
Brachioradialis
Lateral part of brachialis
Extensor carpi radialis longus.
ii. The cutaneous branches are
Posterior cutaneous of arm is a
small branch, that arises in axilla.
The lower lateral cutaneous of
arm pierces lateral head to supply
lateral side of arm.
The posterior cutaneous of
forearm arises in common with
lower lateral cutaneous nerve.
a. It supplies skin on posterior

aspect of forearm.
iii. The articular branches are given to
the elbow joint.
iv. The superficial branch accompanies
the radial artery in the forearm.
It is a cutaneous branch that
supplies sensory fibers to back
of hand and lateral digits.
v. The deep branchpierces supinator
to enter the posterior compartment of
forearm.
Applied anatomy
i. Fracture of middle of shaft of humerus
may involve the radial nerve.
Effects of injury
a. Paralysis of extensors of
forearm, leading to Wrist
drop.
b. Loss of skin sensations in
lower lateral part of arm and
posterior part of forearm and
hand.
II. The ulnar nervedescends in the
posterior compartment, along with
superior ulnar collateral artery, after
piercing medial intermuscular septum.
It descends behind the medial
epicondyle, and then passes
between two heads of flexor
carpi ulnaris to enter front of
forearm.
Branches
The ulnar nerve does not give any branch
in posterior compartment.
tahir99 - UnitedVRG
CHAPTER
12
The Region
of Forearm
The region of forearm is divided into two
compartments:
An anterior or flexor compartment
A posterior or extensor compartment
THE ANTERIOR COMPARTMENT

1. The muscles of the anterior compartment (Table
12.1)
The muscles are divided into two groups:
A. The superficial group of muscles: These are
Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
B. The deep group of muscles: These are
Flexor digitorum profundus
Pronator quadratus
2. The blood vessels of anterior compartment
The arteries
A. The radial artery is the smaller terminal
branch of brachial artery, but appears
as continuation of it.
Origin: The radial artery arises from brachial
artery in cubital fossa, at level of neck of
radius about 1.0 cm from elbow joint.
Course: The artery descends along lateral
border of forearm with convexity towards
lateral side.
The artery is overlapped by brachioradialis in the upper part. At wrist the
artery lies quite superficially on the lower
end of radius.
The artery along its course on front of

forearm lies superficial to following
structures:
Insertion of biceps brachii
Supinator
Insertion of pronator teres
Radial head of flexor digitorum
superficialis
Pronator quadratus
Lower end radius
The radial artery leaves the anterior
compartment by turning laterally deep to
tendon of abductor pollicis longus and
extensor pollicis brevis and reaches back
of carpal bones.
Branches in anterior compartment
i. The radial recurrent branch takes part
in anastomosis around elbow joint.
ii. The anterior carpal branch given near
the wrist joins the corresponding
branch of ulnar artery to form anterior
carpal arch.
iii. The superficial palmar branch passes
through thenar muscles of palm to
complete superficial palmar arch.
iv. Many small muscular branches supply
the muscles of anterior compartment.
B. The ulnar artery is the larger terminal
branch of brachial artery
Origin: The ulnar artery arises in cubital
fossa from brachial artey, at level of neck
of radius, about 1.0 cm from elbow joint.
Course: The artery passes downwards and
medially deep to superficial flexor muscles
to reach the medial border of forearm.
86

Table 12.1: Muscles of anterior compartment of forearm
Name
Origin
The superficial flexors

Pronator
1. Humeral head
tetres
Medial epicondyle
2. Ulnar head
(smaller)
Medial border of
coronoid process of
ulna
Flexor carpi Medial epicondyle
radialis
by common
origin
Palmaris
longus
Medial epicondyle
by common flexor
origin
Flexor carpi 1. Humeral head

ulnaris
(smaller)
Medial epicondyle
by common flexor
origin
2. Ulnar head
Medial margin of
olecranon and proximal two-third of
posterior border
ulna by common
aponeurosis (with
flexor digitorum
profundus and
extensor carpi
ulnaris)
Flexor digi- 1. Humero-ulnar head
torum super- Medial epicondyle
ficialis
by common flexor
origin and medial
side of coronoid
process of ulna
Radial head
Anterior border
of radius from tuberosity to insertion of
pronator
teres
The Deep Flexors (Fig. 12.2)
Flexor
Anterior surface of
pollicis
radius from tuberlongus
osity to the attach-
Muscle belly
Insertion
Nerve supply
Main actions
Muscle belly
Rough area on
crosses upper
middle of lateral
part forearm
surface of radius
and forms a flat
tendon
Median
(C5, C6)
1. It helps in pronation of forearm

2. It is a weak flexor
of elbow joint
Fusiform muscle
belly ends in
tendon in middle
of forearm
Tendon passes in
a groove of trapezium deep of
flexor retinaculum
Slender fusiform
muscle belly
Long tendon
passes superficial
to flexor rentinaculum
Two heads joined
by a fibrous arch
The muscle belly
is most medial
on front of forearm
Gives rise to a
tendon in lower
half of forearm
Palmar aspect
base of second
metacarpal
A slip to base of
third metacarpal
Median
(C6, C7)
1. It is a flexor of
wrist joint
2. It abducts the
hand
of elbow joint
Palmar
aponeurosis
Median
(C7, C8)
1. It helps in flexion
of wrist joint
2. It is a tensor of
palmar aponeurosis
Pisiform bone
Insertion prolonged by pisohamate ligament
to hook of
hamate and pisometacarpal ligament to base
of fifth metacarpal
Ulnar
(C7, C8)
1. It is a flexor of
wrist joint
2. It helps in adduction of hand
of elbow joint
Large muscle
belly lies deep to
other flexors
Divides into four
tendons
Two superficial
for middle and
ring fingers
Two deep for
index and little
fingers
The four tendons

pass to four fingers
and are inserted on
sides of middle
phalanx
Median
(C7, C8, T1)
1. If flexes middle
and proximal
phalanges of four
fingers
2. It also helps in
flexion at wrist
and elbow joints
Muscle belly is
unipennate
Tendon passes
Palmar aspect
base of first
metacarpal
Anterior interosseous branch of

median (C8, T1)
1. It flexes phalanges of thumb

2. It also helps
Contd...
tahir99 - UnitedVRG
The Region of Forearm
87
Contd...
Name
Flexor
digitorum
profundus
Origin
Muscle belly
ment of pronator
quadratus
Upper three-fourths
of anterior and
medial surfaces of
ulna
Front of interosseous membrane
of forearm
deep to flexor
retinaculum
Large muscle
belly lies deep

to superficial
flexors
Gives rise to
four tendons
that pass deep to
flexor retinaculum
at wrist
Insertion
Nerve supply
Main actions
Four tendons
Medial part ulnar 1.
reach four fingers Lateral partInserted on
anterior interosPalmar aspect base seous branch of
of distal phalanges
median (C8, T1)
2.
3.
Pronator
quadratus
Oblique ridge on
front of distal
part of ulna
Muscles belly flat

and quadrangular
Anterior surface Anterior interdistal one-fourth ossous branch

of radius
of median (C8, T1)
Deep fibers on
triangular area
above ulnar notch
of radius
Fig. 12.1: The superficial flexor muscles and radial artery
1.
2.
in flexion of
wrist joint
It flexes distal
phalanges of
fingers after
flexion of middle
phalanges by
superficialis
It also helps in
flexion of metacarpo-phalangeal
joints of fingers
It also helps in
flexion of wrist
joint
It is the principal
pronator of forearm
It prevents separation of lower
ends of two bones
88
Fig. 12.2: The deep flexor muscles and ulnar artery
The oblique part of the artery is separated

from the median nerve by deep (ulnar)
head of pronator teres.
The artery passes distally along the
medial border of forearm lying between
flexor carpi ulnaris and flexor digitorum
profundus.
The artery leaves anterior compartment
by passing superficial to flexor
retinaculum along with ulnar nerve and
enters palm.
i. The anterior ulnar recurrent passes in
front of medial epicondyle to anastomose with inferior ulnar collateral
artery.
ii. The posterior ulnar recurrent passes
behind medial epicondyle to joint with
superior ulnar collateral artery.
iii. The common interosseous branch is a
large branch that divides immediately
tahir99 - UnitedVRG
into an anterior and a posterior

branch.
a. The anterior interosseous branch
descends in front of interosseous
membrane along with anterior
interosseous nerve
It terminates by piercing interosseous membrane deep to pronator quadratus and reaches
posterior compartment of forearm.
It gives
Nutrient arteries to both
radius and ulna
Median artery to accompany
median nerve
b. The posterior interosseous branch
passes backwards through a gap at
upper border of interosseous membrane and enters posterior compartment of forearm.

Near its origin, it gives intero-
sseous recurrent that takes part

in anastomosis around elbow
joint.
iv. The anterior carpal branch completes
anterior carpal arch on front of carpal
bones with corresponding branch of
radial artery.
v. The posterior carpal branch joints the
corresponding branch of radial artery to
complete posterior carpal arch on back
of wrist.
vi. Many small muscular branches are given
to supply the muscles of anterior
compartment.
Applied Anatomy
1. The radial pulse can easily be felt at the
wrist as the radial artery lies quite
superficially there. It can be compressed
against the distal end of radius.
2. The ulnar pulse is not easily palpable, as
the ulnar artery cannot be pressed against
the narrow lower end of ulna.
The veins
The superficial veins
i. The cephalic vein begins from the lateral
side of dorsal venous arch on back of hand
It courses upwards behind styloid
process of radius, along lateral border
of forearm, up to the bend of elbow.
The cephalic vein receives superficial
veins from the forearm.
ii. The basilic vein begins from medial side of
dorsal venous arch on back of hand.
The basilic vein ascends more anteriorly
along medial border of forearm, up to
the bend of elbow.
The cephalic and basilic veins are joined
together at the bend of elbow by medial
cubital vein.
89
iii. The median antebrachial vein is only

sometimes present in the midline of front
of forearm
It drains venous blood from palm and
front of forearm and ends in the basilic
vein near the elbow.
The deep veins
The radial and ulnar arteries are accompanied
by venae comitantes.
These veins join in cubital fossa to form
the venae comitantes of brachial artery.
3. The lymphatics of anterior compartment
The superficial lymphatics accompany the
superficial veins, and the deep lymphatics
accompany the deep veins of the forearm.
4. The nerves of the anterior compartment
A. The median nerve arises in axilla from
two roots medial and lateral-carrying
fibers from ventral divisions of ventral
rami of C5,C6,C7,C8, and T1spinal nerves
to supply the flexor muscles of forearm.
Course in forearm
The median nerve lies medial to the
brachial artery in the cubital fossa.
The nerve enters the anterior
compartment by passing between
two heads of pronator teres, the ulnar
head separating it from ulnar artery.
The median nerve descends deep to
flexor digitorum suerficialis up to
wrist.
At wrist, the median nerve lies quite
superficially between tendons of
palmaris longus and flexor carpi
radialis.
The nerve passes deep to flexor
retinaculum through carpal tunnel to
enter palm.
Branches in forearm
i. The Muscular branches are given to supply:
Pronator teres
90

Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
ii. The anterior interosseous branch given in
upper part of front of forearm, descends in
front of interosseous membrane along with
anterior interosseous vessels. It supplies:
Muscular branches to
Lateral part flexor digitorum
profundus
Pronator quadratus
Articular branches supply
Distal radio-ulnar joint
Radio-carpal joint
Inter-carpal joints
iii. The cutaneous branch is the palmar
cutaneous branch that passes superficial to
flexor retinaculum and supplies skin of
lateral part of palm.
iv. The articular branch supplies
The proximal radio-ulnar joint
Applied anatomy
The lesions of median nerve can occur in cases
of:
1. The supracondylar fracture of humerus
Effects of injury
Paralysis of flexor muscles of
forearm supplied by median nerve
Paralysis of three thenar muscles,
which may atrophy later giving rise
to Ape hand
Loss of skin sensations in lateral part
of palm, and lateral three and half
digits
Weakness of abduction of hand.
2. The carpal tunnel syndrome results from
compression of median nerve in carpal
tunnel due to:
Inflammatory lesion of synovial sheaths
of flexor tendons
Dislocation of lunate after Colles fracture of lower end of radius
Effects of injury
which may give rise later to atrophy
of these muscles giving rise to Ape
hand.
Loss of skin sensation in lateral part
of palm and lateral three and half
digits.
B. The ulnar nerve arises from the ventral
division of ventral rami of C7, C8 and T1
spinal nerves and supplies flexor muscles
of forearm.
Course in anterior compartment
The ulnar nerve enters the anterior
compartment of forearm by passing
between two heads of flexor carpi
ulnaris, from back of medial epicondyle.
The nerve courses distally along the
medial border of forearm lying
between flexor carpi ulnaris and
flexor digitorum profundus.
The ulnar vessels lie lateral to the
nerve in lower two-third of front of
forearm.
The ulnar nerve, along with ulnar
vessels passes superficial to flexor
retinaculum and enters the palm.
a. The muscular branches supply
Flexor digitorum profundus
(medial part)
b. The cutaneous branches
The dorsal cutaneous branch
passes backwards to supply skin
of back of hand and medial one
and half fingers.
The palmar cutaneous branch
passes superficial to flexor retinaculum and supplies skin of medial
side of palm.
c. The articular branches supply
Radio-carpal joints
tahir99 - UnitedVRG

Applied anatomy
The ulnar nerve may be involved in
Supra-condylar fracture of lower
end of humerus
Fracture of medial epicondyle of
humerus
Effects of injury
Paralysis of hypothenar muscles, all
interossei, adductor pollicis and
medial three lumbricals.
Loss of skin sensations on medial
part of palm and medial one and half
fingers.
Later effect will be wasting of all
short muscles of hand supplied by
ulnar nerve. This leads to Ulnar
claw hand.
C. The superficial branch of radial nerve
Courses in anterior compartment
From lateral epicondyle the nerve
descends along lateral border of forearm
deep to brachio-radialis.
The nerve lies lateral to the radial artery
in middle third of forearm.
91
About 7.0 cm from the wrist, the nerve

curves backwards around lateral side of
radius and pierces deep fascia.
It descends to back of hand to supply
skin of back of hand and lateral three
and half digits.
THE POSTERIOR COMPARTMENT OF
FOREARM (FIG. 12.3)
1. The muscles of posterior compartment are
divided into two groups (Table 12.2):
A. The superficial extensors
Brachio-radialis
Extensor carpi radialis longus
Extensor digitorum
Extensor digiti minimi
Anconeus
B. The deep extensors
Supinator
Extensor pollicis brevis
Extensor pollicis longus
Extensor indicis
Table 12.2: The muscles of posterior compartment of forearm

Name
Origin
Muscle belly
Insertion
The Superficial Extensors

Brachio Proximal two-third
Muscle belly ends Distal end of
radialis
lateral supracondylar
in a flat tendon
radius above its
ridge of humerus
about middle of
styloid process
Lateral intermuscular
forearm
septum
Extensor
carpi radialis
longus
Extensor
carpi
radialis
brevis
Distal one-third
Muscle belly ends
lateral suprain a tendon at
condylar ridge
junction of upper
of humerus
third and middle
Lateral interthird of forearm
muscular septum
Lateral epicondyle
Muscle belly ends
by common extensor
in a tendon about
origin
middle of forearm
Nerve supply
Main actions
Radial (C5, C6, C7)
1. It helps in flexion
of elbow in mid
prone position
2. Acts as a shunt
muscle during
rapid flexion and
extension at
elbow
1. It acts as extensor of wrist
2. It helps to abduct
the hand
Radial side dorsal Radial (C6, C7)

aspect of base
of second metacarpal
Radial side dorsal Posterior interaspect of base of osseous (C7, C8)
third metacarapal
1. It acts as extensor
of wrist
2. It helps to abduct
the hand
Contd...
92
Contd...
Name
Origin
Extensor
digitorum
Lateral epicondyle by Muscle belly divi-

common extensor
des into four
origin
tendons that pass
deep to extensor
retinaculum on
dorsum of hand
Extensor
digiti
minimi
Lateral epicondyle
Slender muscle belly Dorsal digital exby common extensor gives rise to a long
pansion of little
origin
tendon
finger
Posterior interosseous (C7, C8)
Extensor
carpi
ulnaris
Lateral epicondyle
by common extensor origin
Common aponeurosis attached to
posterior border
to ulna
Posterior surface
of lateral epicondyles of humerus
Anconeus
Muscle belly
Insertion
Muscle belly is most

medial on back of
forearm
The tendon lies
in a groove on
styloid process
of ulna
Muscle belly
small and triangular lies behind

the elbow joint
The Deep Extensors (Fig. 12.4)

Supinator
Lateral epicondyle
of humerus
Radial collateral
ligament
Annular ligament
Supinator crest of
ulna and the depression in front of it
Abductor
Posterior surface
pollicis
upper part ulna
longus
Interosseous membrane
Middle third posterior
surface of radius
Extensor
Posterior surface radius
pollicis
distal to abductor
brevis
pollicis longus
Nerve supply
The four tendons Posterior interdiverge to reach

osseous (C7, C8)
four fingers
Inserted on dorsal
digital expansion
on dorsum of first
phalanx
Tubercle on
medial side base
of fifth metatarsal
Lateral surface
Radial
alecranon
(C7, C8, T1)
Upper one-fourth
posterior surface
of ulna
Main actions
1. It extends interphalangeal and
metacarpo-phalangeal joints of
four fingers
2. It also helps in
extension of
wrist joint
1. It helps in extension of joints of
little finger
2. It also helps in
extension of
wrist joint
1. It acts as extensor
of wrist joint
2. It also helps in
adduction of hand
It helps in extension
of elbow joint
Muscle belly has Lateral surface

Posterior intera superficial and
proximal third
osseous (C5, C6)
a deep part
radius, encroaches
It is wrapped
on anterior and
around upper
posterior aspects
third of radius
It supinates the
forearm assisted by
biceps brachii
Muscle belly ends Radial side base

in a tendon above of first metathe wrist
carpal
It abducts the thumb
Muscle belly ends Dorsi-lateral sur- Posterior interin a tendon above face base of proxi- osseous (C7, C8)
wrist
mal phalanx thumb
1. It extends proximal phalanx of

thumb
2. It helps in extension of thumb also
1. It extends distal
phalanx of thumb
2. It helps in extension of thumb and
radio-carpal joint
(wrist joint)
It helps in extension
of index and radiocarpal joint
Extensor
pollicis
longus
Middle third posterior Muscle belly ends Base of distal

Posterior intersurface of ulna
in a tendon above phalanx of thumb osseous (C7, C8)
wrist
Extensor
indicis
Posterior surface of
ulna distal to extensor pollicis longus
Narrow elongated Joins dorsal distal

muscle belly
expansion of
Ends in a tendon
index finger
above wrist
tahir99 - UnitedVRG
93
Fig. 12.3: The superficial extensor muscles of forearm
The Blood Vessels of Posterior

Compartment
The Arteries
1. The posterior interosseous artery is branch of
common interosseous branch of ulnar artery.
Course: The artery enters posterior
compartment by passing through gap at
upper border of interosseous membrane
The artery descends between the
superficial and deep extensor muscles
It ends by anastomosing with terminal
part of anterior interosseous artery.
Branches:
The interosseous recurrent branch
ascends upwards to take part in
anastomosis around the elbow joint.
Small muscular branches supply the

extensor muscles.
2. The terminal part of anterior interosseous artery
enters posterior compartment by piercing distal
part of interosseous membrane.
The artery anastomoses with posterior
interosseous artery and descends to the back
of carpal bone, to join dorsal carpal arch
The Veins
The deep veins of posterior compartment of
forearm accompany the arteries as venae
comitantes.
The Nerves of Posterior Compartment
1. The deep branch of radial (posterior interosseous) nervearises from radial deep to
94
But, below extensor pollicis brevis, it passes

deep to extensor pollicis longus, and descends
in front of interosseous membrane, to the dorsal
surface of carpal bones.
It ends in an expanded terminal pseudo-ganglion
from where branches supply carpal joints.
Branches
1. Muscular branches supply
Extensor digitorum
Extensor digiti minimi
Extensor pollicis longus
Extensor indicis
Extensor pollicis brevis
Supinator
2. Articular branches supply
Radiocarpal joint
Carpal joints
Fig. 12.4: The deep extensor muscles of forearm
brachioradialis in front of lateral epicondyle of

humerus.
Course
The nerve pierces supinator and passes between

the superficial and deep parts of the muscle.
The nerve, as it descends lies between superficial
and deep extensors.
Applied Anatomy
Injury to radial nerve at elbow joint produces
Paralysis of all extensor muscles of forearm
leading to inability to extend radio-carpal joint
and the joints of the digits. This condition is
known as Wrist drop.
Loss of skin sensation along the lateral border
of dorsum of hand and lateral two and half (or
three and half) digits.
tahir99 - UnitedVRG
CHAPTER
13
The Region of
Wrist and Hand
The region of wrist and hand includes:
The dorsum of wrist and hand
The palm
THE DORSUM OF WRIST AND HAND
There are two fascial spaces on back of hand.
a. The dorsal subcutaneous space is limited by the
deep fascia extending on dorsum of hand along
with extensor tendons.
The skin on the dorsum of hand is freely
movable on underlying structures.
There is a rich lymphatic plexus in this space
that produces swelling on back of hand in
cases of infections of palm.
b. The dorsal sub-aponeurotic space lies between
the deep fascia on the dorsum of hand and the
extensor tendons.
The space covers the interossei and the

metacarpals
The extensor retinaculum of the wrist is formed by

thickening of deep fascia on the dorsum of wrist.
Attachment
Medially: Tip of styloid process of ulna and
triquetral bone
Laterally: Anterior border of styloid process
of radius
The retinaculum forms a strong, fibrous band
that lies obliquely on dorsal aspect of carpal
bones.
From the deep surface of retinaculum, connective tissue septa are given to ridges on dorsal
aspect of lower end of radius to divide the space
deep to it into six compartments (Fig. 13.1).
Fig. 13.1: The extensor retinaculum
96

The first compartment contains
Tendon of abductor pollicis longus
Tendon of extensor pollicis brevis
The second compartment contains
Tendon of external carpi radialis longus
Tendon of external carpi radialis brevis
The third compartment contains
Tendon of extensor pollicis longus
The fourth compartment contains
Four tendons of extensor digitorum
Tendon of extensor indicis
Terminal part of anterior interosseous artery
Posterior interosseous nerve
The fifth compartment has
Tendon of extensor digiti minimi
The sixth compartment has
Tendon of extensor carpi ulnaris
Synovial Sheaths of Extensor Tendons
The extensor tendons, as they pass deep to the

extensor retinaculum, have synovial sheaths
around them to prevent friction and facilitate
their contractions.
The synovial sheaths begin proximal to the
retinaculum and are prolonged for some distance
on back of hand.
The Blood Vessels on Dorsum of Hand

The Arteries
1. The radial artery enters the dorsum of hand by
passing deep to tendons of abductor pollicis
longus and extensor pollicis brevis.
The radial artery on dorsum of carpal bones
lies in a depression calledAnatomical
snuff-box
The depression is bounded
Laterally by tendons of abductor pollicis
longus and extensor pollicis brevis
Medially by tendon of extensor pollicis
longus
The radial artery lies on trapezium covered
only by skin, superficial and deep fascia.
The radial artery leaves the space by passing

between the two heads of first dorsal
interosseous muscle and enters palm.
Branches
The posterior carpal branch joins with
corresponding branch of ulnar artery to
form posterior carpal arch
The first dorsal metacarpal artery divides
into two branches to supply adjacent
sides of thumb and index finger
2. The posterior carpal arch lies on dorsal aspect
of carpal bones.
The arch is formed by dorsal carpal branches
of radial and ulnar arteries.
Branches
Three dorsal metacarpal branches
descends on dorsum of hand and supply
adjacent sides of fingers by dividing into
two dorsal digital branches.
These arteries anastomose with
superficial and deep palmar arches
by perforating branches
A dorsal digital branch to medial side
of little finger is also given.
3. The terminal part of anterior interosseous artery
descends on dorsal aspect of carpal bones.
It joins the posterior carpal arch.
The Veins
The dorsal venous arch lies on dorsal aspect of
hand.
The arch receives three dorsal metacarpal veins
that receive dorsal digital veins from sides of
fingers
The dorsal venous arch is drained
Medially by basilic vein
Laterally by cephalic vein
The Deep Veins
The venae comitantes accompany the arteries on
dorsum of hand.
tahir99 - UnitedVRG
The Region of Wrist and Hand

The Nerves on the Dorsum of Hand
1. The superficial terminal branch of radial nerve

enters dorsum of hand, after piercing deep
fascia lateral to brachio-radialis.
The nerve divides into five dorsal digital
nerves that descend on dorsum of hand.
These nerves supply the skin of lateral part
of dorsum of hand.
They also supply skin on dorsum of lateral
three and half (sometimes two-and-half)
digits, up to middle of middle phalanx.
2. The dorsal branch of ulnar nerve pierces deep
fascia, about 5.0 cm proximal to the wrist
and passes backwards deep to flexor carpi
ulnaris.
The nerve descends on back of hand and
divides into three dorsal digital nerves.
The dorsal digital nerves supply the skin on
medial part of dorsum of hand
They also supply skin on dorsal aspect of
medial one-and-half (sometimes, two-andhalf) fingers.
9
ri 9
THE PALM OF THE HAND
The flexor retinaculum keeps the long flexor

tendons in position during flexion at the wrist
joint.
The retinaculum also provides additional surface
for attachment of thenar and hypothenar
muscles (Fig. 13.2).
Structures passing superficial to flexor
retinaculum are
1. Ulnar nerve
2. Ulnar vessels
3. Palmar cutaneous branch of ulnar nerve
4. Tendon of palmaris longus
5. Palmar cutaneous branch of median nerve
The carpal tunnel is an osseo-aponeurotic
tunnel formed between the flexor retinaculum
and the concave anterior surface of carpal
bones.
The carpal tunnel transmits
i. Four tendons of flexor digitorum superficialis
ii. Four tendons of flexor digitorum profundus
These eight tendons are enclosed in a
common synovial sheaththe ulnar
bursa
iii. Tendon of flexor pollicis longus is
enclosed in a synovial sheaththe radial
bursa
iv. The median nerve lies between the ulnar
bursa and the radial bursa.
The tendon of flexor carpi radialis with its
synovial sheath lies in a separate compartment
V
d
ti e
G
R
n
U
The superficial fascia of the palm is thick, and

consists of fibrous bands connecting skin to
the deep fascia.
The superficial fascia has
The palmaris brevis muscle covering
proximal part of hypothenar eminence.
The palmar cutaneous branches of median
and ulnar nerves.
The deep fascia on the front of carpal bones
forms a thick bandthe flexor retinaculum.
Attachments of flexor retinaculum
Medially
Pisiform
Hook of hamate
Laterally
Tubercle of scaphoid
Crest of trapezium
h
a
97
Fig. 13.2: The carpal tunnel
98

deep to flexor retinaculum, occupying the
groove of trapezium.
The deep fascia of palm is divided into three
parts:
i. A lateral part covering the thenar muscles
ii. A medial part covering the hypothenar
muscles
iii. A central part, that is thickened to form the
palmar aponeurosis.
The palmar aponeurosis is triangular in shape
Proximally it receives the insertion of
palmaris longus
Distally it splits into four slips for four
fingers
Each slip becomes continuous with
fibrous flexor sheath on proximal
phalanx of finger
The fibrous flexor sheath is a curved
and condensed plate of deep fascia
on palmar aspect of proximal and
middle phalanges of fingers, to keep
the long flexor tendons in position
(Fig. 13.3).
Fig. 13.3: The palmar aponeurosis
Applied Anatomy
Fibrosis and shortening of palmar aponeurosis may
result from infections of the palm. The condition
is known as Dupuytrens contracture.
The shortening is more severe on the ulnar side
of palm.
The fascial compartments of the palm.
The palm is divided into four fascial
compartments (Fig. 13.4).
A thenar compartment containing thenar
muscles
A hypothenar compartment containing
hypothenar muscles
An adductor compartment contains adductor
pollicis
A central compartment lies deep to palmar
aponeurosis and contains
a. The superficial palmar arch
b. The digital branches of median and ulnar
nerves
c. The long flexor tendons and their synovial
sheaths
The palmar spaces lie in deep portion of central
part of palm behind the synovial sheaths of long
flexor tendons.
There are two palmar spaces
i. The mid-palmar spaces
ii. The thenar space
The two spaces are separated by an intermediate septum attached to
The front of third metacarpal
The deep surface of synovial sheath of long
flexor tendons
The shape of both the spaces is triangular.
The two palmar spaces communicate with the
webs of fingers through the lumbrical canals,
formed by connective tissue around lumbrical
muscles.
Applied anatomy
The palmar spaces may be involved in the
infections of palm.
The spaces can be surgically approached at the
webs of fingers through the lumbrical canals.
tahir99 - UnitedVRG
Fig. 13.4: The fascial compartments of the palm
The Long Flexor Tendons in the Palm

(Fig. 13.5)
1. The tendon of palmaris longus passes superficial
to flexor retinaculum and is attached to the apex
of palmar aponeurosis.
2. The tendon of flexor pollicis longus has a
separate synovial sheath (radial bursa) as it
passes through the carpal tunnel deep to flexor
retinaculum.
The tendon passes deep to the thenar
muscles to reach the palmar surface of base
of distal phalanx of thumb for insertion.
3. The four tendons of flexor digitorum
superficialis diverge on reaching palm from
carpal tunnel, to reach the four fingers.
Each tendon on the proximal phalanx splits
into two parts to enclose a fibrous tunnel
for flexor digitorum profundus tendon.
9
ri 9
h
a
Fig. 13.5: The long flexor tendons in finger
V
d
ti e
99
G
R
The two parts of each tendon, again separate

out and are inserted on sides of middle
phalanx.
4. The four tendons of flexor digitorum profundus
also diverge on reaching palm from carpal
tunnel, to reach the four fingers.
In each finger, the tendon of flexor
digitorum profundus lies deep to the tendon
of flexor digitorum superficialis on proximal
phalanx.
The tendon of flexor digitorum profundus
passes through fibrous tunnel formed by
flexor digitorum superficialis tendon on
middle phalanx.
The tendon of flexor digitorum profundus
is finally inserted on palmar surface base of
distal phalanx of finger.
The long flexor tendons, as they pass through
carpal tunnel, deep to flexor retinaculum, are
enclosed in a common synovial sheath, the ulnar
bursa, that extends up to middle of palm.
The long flexor tendons in each finger are also
enclosed in digital synovial sheaths.
The digital synovial sheath of little finger is
continuous with the common synovial sheath-ulnar
bursa.
Applied anatomy
The inflammation of the synovial sheath tenosynovitis may compress the vinculaeslender
n
U
100
fibrous bandsthat convey blood vessels to

long flexor tendons.
This may lead to necrosis of the tendons in
the palm.
The muscles of the palm can be divided into
four groups:
1. The thenar muscles and adductor pollicis (Fig.
13.6 and Table 13.1)
Opponens pollicis
Adductor pollicis
2. The hypothenar muscles (Table 13.2).
Palmaris brevis
Adductor digiti minimi
Flexor digiti minimi
Opponens digiti minimi
3. The lumbricals are four slender muscle bellies
attached to the tendon of flexor digitorum
profundus in palm (Table 13.3).
These are numbered from lateral to medial
side.
4. The interossei fill up the gap between the
metacarpals (Fig. 13.7).
They are further classified into:

The palmar interosseifour (Table 13.4).
The dorsal interosseifour (Table 13.5).
The interossei are also numbered from lateral
to medical side.
The Blood Vessels of the Palm
The Arteries
1. The ulnar artery enters the palm by crossing
superficial to flexor retinaculum, lateral to
pisiform and medial to hook of hamate, along
with ulnar nerve.
The ulnar artery just distal to flexor
retinaculum gives a deep branch and
continues as superficial palmar arch.
The deep branch joins with terminal part
of radial artery to form the deep palmar
arch.
2. The superficial palmar arch is formed by (Fig.
13.8)
Medially by continuation of ulnar artery.
Laterally by superficial palmar branch of
radial artery
Fig. 13.6: The thenar and hypothenar muscles
tahir99 - UnitedVRG
101
Table 13.1: The thenar muscles and adductor pollicis

Name
Origin
Muscle belly
Insertion
Abductor
pollicis
brevis
Flexor retinaculum
Tubercle of scaphoid
A thin, superficial Radial side base of Lateral terminal

muscle belly
proximal phalanx branch median
of thumb
(C8, T1)
It abducts the thumb

to right angles to the
palm
Flexor
pollicis
brevis
Distal border of
flexor retinaculum
Tubercule of
scaphoid
Thin muscle belly Radial side base

Lateral terminal
lies medial to
of proximal
branch median
abductor muscle
phalanx of thumb (C8, T1)
It flexes the proximal phalanx of

thumb
Opponens
pollicis
Crest of trapezium
Flexor retinaculum
Muscle belly lies

deep to abductor
muscle and flexor
pollicis brevis
Adductor
Pollicis
1. Obligue head
Capitate
Bases of second and
third metacarpal
2. Transverse head
Distal two-third
palmar aspect
third metacarpal
The transverse Ulnar side base

Deep branch
head is triangular
of proximal
ulnar (C8, T1)
The two heads
phalanx of thumb
converge towards
base of first
phalanx
Nerve supply
Lateral border
and lateral half
palmar surface
first metacarpal
n
U
G
R
Lateral terminal
branch median
(C8, T1)
V
d
ti e
Main actions
It flexes metacarpal
and rotates it medially so thumb can be
opposed to fingers
and palm
It adducts thumb to
the side of palm
Table 13.2: The hypothenar muscles
Name
9
ri 9
Origin
Muscle belly
Palmaris
brevis
Insertion
Flexor retinaculum
Thin, quadran- Skin on medial
Medial border of palgular muscle
border of hand
mar aponeurosis
belly
Covers proximal
part of hypothenar eminence
Abductor
Pisiform
Thin, lies along Ulnar side base
digiti
Tendon of flexor
medial side of
of proximal
minimi
carpi ulnaris and
hypothenar emiphalanx of little
piso-hamate
nence
finger
ligament
Flexor
Hook of hamate
Thin, lies lateral Ulnar side
digiti
Flexor retinaculum
to the abductor
base of proximal
minimi
digiti minimi
phalanx of little
finger
Opponens Hook of hamate
Triangular muscle Medial border
digiti minimi Flexor retinaculum
belly, lies deep to palmar surface of
abductor and
fifth metacarpal
flexor digiti
minimi
h
a
Nerve supply
Main actions
Superficial branch
ulnar (C8, T1)
It wrinkles skin on
medial side of palm
thus helping in
palmar grip
Deep branch ulnar

(C8, T1)
It abducts little finger

from neutral axis of
middle finger
Deep branch ulnar

(C8, T1)
It flexes the little

finger
Deep branch ulnar

(C8, T1)
It flexes little finger

and rotates it medially so that it can be
opposed to other
fingers and palm
102

Table 13.3: The lumbricals
Name
Origin
Muscle belly
Insertion
Nerve supply
Main actions
First
lumbrical
Radial side and palmar surface tendon

of flexor digitorum
profundus to index
Slender and
unipennate
muscle belly
Lateral side of
dorsal digital
expansion of
index
Median
(C8, T1)
Second
lumbrical
Radial side and palmar surface tendon

of flexor digitorum
profundus to middle
finger
Adjoining sides of
tendons of flexor
digitorum profundus
to middle and ring
fingers
Adjoining sides of
tendons of flexor
digitorum profundus
to ring and little
fingers
Slender and
unipennate
muscle belly
Lateral side of
dorsal digital
expansion of
middle finger
Median
(C8, T1)
Flexion at metacarpophalangeal
and extension of
inter-phalangeal
joint of index finger
Same action on
middle finger
Slender bipennate Lateral side of

muscle belly
dorsal digital
expansion of
ring finger
Deep branch ulnar

(C8, T1)
Same action on ring

finger
Slender bipennate Lateral side of

muscle belly
dorsal digital
expansion of
little finger
Deep branch
ulnar (C8, T1)
Same action on
little finger
Third
lumbrical
Fourth
lumbrical
Figs 13.7 A and B: (A) The palmar interossei (B) The dorsal interossei
tahir99 - UnitedVRG
103
Table 13.4: Palmar interossei

Name
Origin
Muscle belly
Insertion
Nerve supply
Main actions
First palmar Ulnar side palmar

interosseous
surface base of first
metacarpal
Second
Whole length palpalmar
mar surface second
interosseous
metacarpal
Small, slender
muscle belly
Ulnar side base

proximal phalanx
of thumb
Ulnar side base
proximal phalanx index finger
Dorsal digital expansion of index
Deep branch
ulnar (C8, T1)
Third
Whole length palpalmar
mar surface fourth
interosseous
metacarpal
Small, slender
muscle belly
Adducts thumb towards neutral axis of

middle finger
1. Adducts index
towards neutral
axis of middle
finger
2. Flexes metacarpophalangeal
and extension of
interphalangeal
joints
Same actions in
relations to ring
finger
Fourth
Whole length
palmar
palmar surface
interosseous
fifth metacarpal
Small, slender
muscle belly
Small slender
muscle belly
Radial side base

proximal phalanx
of ring finger
Dorsal digital
expansion
Radial side base
proximal phalanx
of little finger
Dorsal digital
expansion
Deep branch ulnar

(C8, T1)
V
d
ti e
n
U
G
R
Deep branch ulnar

(C8, T1)
Deep branch ulnar

(C8, T1)
Same actions in
relation to little
finger
Table 13.5: The dorsal interossei
Name
Origin
Muscle belly
First dorsal interosseous
Adjacent sides
of first and second
metacarpals
Bipennate muscle Lateral side base Deep branch

belly, fills up gap
of proximal phal- ulnar (C8, T1)
between the first
anx of index
and second meta- Dorsal digital
carpal
expansion
h
a
Second
Adjacent sides of
dorsal
second and third
interosseous
metacarpal
Third dorsal interosseous
9
ri 9
Adjacent sides of
third and fourth
metacarpal
Fourth dor- Adjacent sides of

sal interfourth and fifth
osseous
metacarpal
Insertion
Bipennate muscle Lateral side base

belly, fills up gap
of proximal of
between second
phalanx of middle
and third metafinger
carpal
Dorsal digital expansion
Bipennate muscle Medial side base of
belly, fills up gap
proximal phalanx
between third and
of middle finger
fourth metacarpal Dorsal digital
expansion
Bipennate muscle Medial side base
belly fills up gap
of proximal phabetween fourth
anx of ring finger
and fifth meta Dorsal digital
carpal
expansion
Nerve supply
Deep branch ulnar

(C8, T1)
Main actions
1. Abducts index
finger from neutral axis of middle
finger
2. Flexion at metacarpophalangeal
joints and extension at inter
phalangeal joints
of index
1. Lateral abduction
of middle finger
2. Same action on
middle finger
Deep branch
ulnar (C8, T1)
1. Medial abduction
middle finger
2. Same action on
middle finger
Deep branch
ulnar (C8, T1)
1. Abduction of
little finger
2. Same action on
ring finger
104

If this, branch is absent, then the arch is
completed by either of the following
branches of radial artery:
Princeps pollicis artery
Radialis indicis artery
Position: The superficial palmar arch lies
at the level of fully extended thumb
Relation
Superficial:The palmar aponeurosis
Deep
The digital branches of median and
ulnar nerves
The long flexor tendons with synovial
sheaths
Branches
A Palmar branch to medial side of little
finger
Three Common palmar digital branches
that divide at the web of fingers into two
palmar digital branches to supply the
sides of medial three and half digits.
The three palmar metacarpal
branches of the deep palmar arch
join the three common palmar digital
arteries before they divide, at the

web of fingers.
Thus the blood supply to the finger
is maintained even when the
superficial palmar arch is compressed during gripping of an
object.
3. The radial artery enters the deep part of palm
by passing between the two heads of first dorsal
interosseous muscle, from anatomical snuff
box.
The radial artery appears in palm between
the two headsoblique and transverse
of adductor pollicis.
Before joining the deep branch of ulnar artery
the radial artery gives two branches:
a. The princeps pollicis artery divides into
two branches to supply the sides of
thumb.
b. The radialis indicis artery supplies the
lateral side of index finger.
4. The deep palmar arch is the smaller and deeply
placed arterial arch in the palm. It is formed
(Fig. 13.9):
Fig. 13.8: The superficial palmar arch
tahir99 - UnitedVRG
V
d
ti e
Fig. 13.9: The deep palmar arch
Laterally by continuation of radial artery

Medially by deep branch of ulnar artery
Position: The deep palmar arch lies just distal
to the flexor retinaculum.
Relations
Superficial: Synovial sheaths of flexor
tendons
Deep: Bases of metacarpals
Fascia covering the interossei muscles.
Branches
i. Three Palmar metacarpal branches, that
joint the three common palmar metacarpal branches of superficial palmar
arch, before they bifurcate at the web
of fingers.
ii. Three perforating branches, which pass
through the gaps between two heads of
second, third, and fourth dorsal interosseous muscles.
These perforating branches joint
dorsal metacarpal branches of posterior carpal arch.
h
a
9
ri 9
n
U
105
G
R
iii. Recurrent branches are given from the

deep arch that ascend up to supply the
carpals and their articulations.
The Veins of the Palm
The radial and ulnar arteries and the two palmar

arterial arches are accompanied by paired venae
comitantes.
The Nerves of the Palm (Fig. 13.10)
1. The medial nerve enters the palm through the
carpal tunnel
On entering the palm the median nerve gives
a recurrent muscular branch to three thenar
muscles and then divides into two terminal
brancheslateral and medial.
a. The lateral terminal branch divides into
three palmar digital nerves, to supply the
two sides of thumb, and lateral side of
index finger.
b. The medial terminal branch bifurcates
into two common palmar digital nerves.
106
Fig. 13.10: The nerves of the palm
The two common palmar digital nerves

divide into two palmar digital nerves to
supply the sides of index, middle and ring
fingers.
Branches
I. The muscular branches are:
a. Recurrent muscular branch, that
supplies the three thenar muscles
Opponens pollicis
b. Muscular branch to first lumbrical
is given from palmar digital nerve to
lateral side of index finger
c. Muscular branch to second lumbrical
is given from common palmar digital
nerve that supplies sides of index and
middle fingers
II. The cutaneous branches are the palmar
digital nerves.
a. These nerves supply the skin of
lateral three and half digits on palmar
aspect.
b. They also supply the skin on dorsum
of digits up to middle of middle
phalanx
III.A cummunicating branch to ulnar

nerve from most medial palmar digital
branch.
Applied Anatomy
The lesion of median nerve can be
Near elbow joint
In the carpal tunnel
Over the thenar eminence due to a
piercing wound.
Effects of Injury
Paralysis of flexor muscles of forearm,
if the injury is at the elbow joint
leading to weakness of movements of
thumb
Sensory loss overlateral part of palm
and lateral three and half digits.
Late effects of lesionwasting of thenar
muscles, leading to Ape hand
2. The ulnar nerve enters the palm by passing
superficial to flexor retinaculum, medial to the
ulnar vessels.
The ulnar nerve and ulnar vessels lie lateral to
pisiform and medial to the hook of hamate
On reaching the hypothenar eminence, the
ulnar nerve divides into a superficial branch
and a deep branch.
tahir99 - UnitedVRG
I. The superficial branch passes distally

and gives a muscular branch to palmaris
brevis.
It gives a palmar digital nerve to
medial side of little finger
It also gives a common palmar digital
nerve, that divides at the web into
two palmar digital nerves that supply
sides of little and ring fingers (oneand half-digits)
Branches
a. A muscular branch to palmarisbrevis
b. The cutaneous branchesthree
palmar digital nervesthat
supply medial one-and half-digits.
c. A communicating branch to most
medial palmar digital branch of
median
II. The deep branch pierces hypothenar
muscles and then runs in deep part of
palm from lateral to medial side, lying in
the concavity of deep palmar arch.
The deep branch ends deep to adductor
pollicis, that it supplies also:
Branches:
I. The muscular branches supply:
a. Three hypothenar muscles
h
a
9
ri 9
Abductor digiti minimi

Flexor digiti minimi
Opponens digiti minimi
b. Medial two lumbricals (third and
fourth lumbrical)
c. Four palmar interossei
d. Four dorsal interossei
e. Adductor pollicis
II. The articular branches supply:
The carpal joints
Applied anatomy
The ulnar nerve lesions can take place
At elbow by fracture of medial epicondyle
At wrist as the nerve lies superficial to
flexor retinaculum
Effects of injury
Paralysis of flexor carpi ulnaris and
medial part of flexor digitorum profundus, if injury is at the elbow. This
results in weakening of adduction of
hand.
Paralysis of short muscles of hand,
except three thenar muscles and lateral
two lumbricals.
Loss of sensation on medial side of hand
and medial one-and half-fingers.
Late effect: Wasting of affected short
muscles ofhand leading to Ulnar claw
hand.
V
d
ti e
n
U
107
G
R
The Upper Extremity

Q.1. Select the best response to each question
from the four suggested answers:
1. The strong ligament that connects the clavicle
with upper limb is:
A. Coraco-clavicular ligament
B. Costo-clavicular ligament
C. Inter-clavicular ligament
D. Acromio-clavicular ligament
2. The nerve that lies behind medial epicondyle
of humerus is:
A. Ulnar nerve
B. Median nerve
C. Radial nerve
D. Musculo-cutaneous nerve
3. The carpal bone that has no muscular
attachment is:
A. Scaphoid
B. Hamate
C. Capitate
D. Lunate
4. The overhead abduction of arm is caused by
contraction of:
A. Supraspinatus
B. Deltoid
C. Trapezius
D. Lower part of trapezius and lower
digitations of serratus anterior
5. The ulnar nerve has the following root value:
A. C8,T1
B. C5,C6
C. C7,C8,T1
D. C 5,C6 ,C7
6. The pectoralis minor muscle is inserted on:
A. Greater tuberosity of humerus
B. Acromion process of scapula
C. Coracoid process of scapula
D. Lesser tuberosity of humerus
7. The structures passing through quadrangular

space are:
A. Radial nerve
B. Ulnar nerve
C. Axillary nerve and posterior circumflex
humeral artery
D. Anterior circumflex humeral artery
8. The nerve passing through carpal tunnel at
the wrist is:
A. Ulnar nerve
B. Median nerve
C. Anterior interosseous nerve
D. Radial nerve
9. The movements of supination and pronation
of forearm take place at:
A. Superior and inferior radio-ulnar joints
B. Elbow joint
C. Superior radio-ulnar joint only
D. Inferior radio-ulnar joint only
10. The carpal bones taking part in radio-carpal
joint are:
A. Scaphoid only
B. Lunate only
C. Lunate nad triquetral
D. Scaphoid and lunate
correct. Choose the answer:
A. If 1, 2 and 3 are correct
E. If 1, 2, 3 and 4 are correct
tahir99 - UnitedVRG
109
11. The muscles inserted on greater tuberosity

of humerus are:
1. Supra spinatus
2. Infra spinatus
3. Teres minor
4. Subscapularis
2. Runs along lateral border of arm and

forearm
3. Is connected with basilic vein on front
of elbow by medial cubital vein
4. Terminates in axillary vein after piercing
clavi-pectoral fascia
12. The structures passing deep to the flexor

retinaculum are:
1. Median nerve
2. Ulnar artery
3. Flexor pollicis longus tendon
4. Radial nerve
18. The mammary gland:

1. Lies in superficial fascia except the
axillary tail part
2. Remains active and secretory in adult
females only during lactation phase
3. Has its secretion controlled by the
prolactin hormone of pituitary gland
4. Has its lymphatics drain mainly in the
para-sternal lymph nodes
13. The median nerve in hand supplies:

1. Adductor pollicis
2. Three thenar muscles
3. Dorsal interossei
4. First and second lumbricals
14. The following muscles take origin from the
medial epicondyle of humerus:
1. Pronator teres
2. Flexor carpi radialis
3. Palmaris longus
4. Flexor carpi ulnaris
15. The abductors of hand at the wrist joint are:
1. Flexor carpi radialis
2. Flexor carpi ulnaris
3. Extensor carpi radialis longus
4. Brachio radialis
16. The brachial artery:
1. Begins at lower border of teres major
muscle
2. In cubital fossa lies superficial to bicipital
aponeurosis
3. Bifurcates at level of neck of radius
4. Lies lateral to the shaft of humerus in
upper part of arm
17. The cephalic vein:
1. Begins on dorsum of hand from lateral
end of dorsal venous arch
19. The first carpo-metacarpal joint

1. Is a condyloid type of synovial joint
2. Is a saddle type of synovial joint
3. Is joint between base of first metacarpal
and trapezoid
4. Is joint between base of first metacarpal
and trapezium
20. The radial nerve gives the following branches
in posterior compartment of arm:
1. Nerve its anconeus
2. Posterior interosseous nerve
3. Nerve to medial head of triceps
4. Nerve to brachioradials
Q.3. Match the following on the left side with
their appropriate answers on the right side
21. The nerves and their origins:
i. Axillary
A. Upper trunk
ii. Lateral pectoral
B. VRC5
iii. Dorsal scapular
C. Lateral cord
iv. Suprascapular
D. Posterior cord
22. The clinical signs after nerve injury:
i. Ape hand
A. Radial nerve
ii. Winging of
B. Ulnar nerve
scapula
110

iii. Claw hand
iv. Wrist drop
C. Long thoracic
nerve
D. Median nerve
23. The muscles and their nerve supply:

i. Trapezius
A. Radial nerve
ii. Supinator
B. Thoraco-dorsal
nerve
iii. Latissimus dorsi
C. Ulnar nerve
iv. Palmaris brevis
D. Spinal accessory
nerve
24. The movements of the

i. Abduction of
shoulder joint
ii. Adduction at
radiocarpal joint
iii. Supination at
radio-ulnar joint
iv. Flexion at dorsal
inter-phalangeal
joint of index
muscles:
A. Supra
supinatus
B. Biceps brachii
C. Flexor carpi
ulnaris
D. Flexor digitorum
profundus
Answers
The strong ligament that binds clavicle to the
upper limb is coraco-clavicular ligament. The
other ligaments are not so strong.
The ulnar nerve lies behind medial epicondyle
of humerus. The median and ulnar nerves
cross in front of elbow joint, the musculocutaneous nerve pierces deep fascia above
elbow joint and continues as lateral cutaneous
nerve of forearm.
The lunate bone has no muscular attachments.
Scaphoid gives attachment to thenar and hook
of hamate to hypothenar muscles, capitate
and trapezoid give attachment to oblique head
of adductor pollicis.
of brachial plexus. The contribution of C7 is

recieved by ulnar nerve from the lateral root
of median nerve.
A6. The answer is C.
The pectoralis minor muscle is inserted on
middle of medial border and superior surface
of coracoid process of scapula.
The axillary nerve and posterior circumflex
humeral vessels pass through the quadrangular space. The radial nerve passes to
posterior compartment of arm between long
and medial heads of triceps. The ulnar nerve
pierces medial intermuscular septum lower
down. The anterior circumflex humeral artery
curves around the surgical neck from in front
of humerus.

The overhead abduction of arm is caused by
lower part of trapezius assisted by lower
digitations of serratus anterior. The supinator
initiates abduction and deltoid takes it up to
90 only.

The nerve that passes through carpal tunnel
is median. The ulnar nerve passes superficial
to flexor retinaculum. The superficial branch
of radial nerve pieces deep fascia above radiocarpal joint. The anterior interosseous nerve
ends deep to pronator quadratus.

The root value of ulnar nerve is C7,C8,T1.
The ulnar nerve is a branch of medial cord

The supination and pronation movements of
forearm take place at both superior and
tahir99 - UnitedVRG

inferior radioulnar joints. The elbow joint is
pure hinge joint where only flexion and
extension of forearm take place.
The carpal bones taking part in radiocarpal
joint are scaphoid and lunate. The triquetral
is separated by the articular disc of inferior
radioulnar joint.
The three muscles attached to greater
tuberosity of humerus aresupraspinatus,
infraspinatus and teres minor. The subscapularis is inserted on lesser tuberosity of
humerus.
The median nerve and flexor pollicis longus
tendon pass deep to flexor retinaculum. The
ulnar artery passes superficial to flexor
retinaculum, and radial nerve has no relation
with flexor retinaculum.
The median nerve in palm supplies the three
thenar muscles and first and second lumbricals. The adductor pollicis is supplied by deep
branch of ulnar nerve and palmaris brevis is
supplied by superficial branch of ulnar nerve.
A14. The answer is E, (1, 2, 3, 4).
All the four muscles pronator teres, flexor
carpi radialis, palmaris longus and flexor carpi
ulnaris take origin from medial epicondyle of
humerus.
The abductors of hand at wrist joint are flexor
carpi radialis and extensor carpi radialis
longus. The flexor carpi ulnaris is adductor
of hand and the brachioradialis does not take
part in adduction and abduction at wrist joint.
The brachial artery begins at lower border of
teres major as continuation of axillary artery.
111
It bifurcates into radial and ulnar arteries at

level of neck of radius. The artery at cubital
fossa lies deep to bicipital aponeurosis. The
brachial artery lies medial to the shaft of
humerus, in upper part of arm.
A17. The answer is E, (1, 2, 3, 4).
The cephalic vein begins on dorsum of hand
from lateral end of dorsal venous arch. It runs
along lateral broder of forearm and arm. It is
connected with basilic vein on front of elbow
by median cubital vein. The cephalic vein
ends in axillary vein.
The mammary gland lies in superficial fascia
on front of thorax. It is active only during
lactation phase in females. Its secretion is
controlled by prolactin hormones of pituitary
gland. The lymphatics of mammary gland end
mainly in axillary lymph nodes.
The first carpo-metacarpal joint is between
trapezium and base of first metacarpal. It is a
saddle type of synovial joint. The trapezoid
does not take part in this joint.
The radial nerve in posterior compartment of
arm gives nerve to anconeus and nerve to
medial head of triceps. The posterior interosseous nerve arises on front of lateral
epicondyle. The nerve to brachio-radialis is
given in lower part front of arm.
A21. The answers are D, C, B and A.
The axillary nerve is a branch of posterior
cord of branchial plexus.
The lateral pectoral is a branch of lateral
cord.
The dorsal scapular arises from VR of
C5 spinal nerve.
The suprascapular nerve is a branch of
upper trunk of branchial plexus.
112
A22. The answers are D, C, B, A.

The Ape hand results from injury to
medial nerve.
The Winging of scapula is the results of
injury to long thoracic nerve.
The Claw hand deformity results from
injury to ulnar nerve.
The Wrist drop results from injury to the
radial nerve.
A23.
The answers are D, A, B, C.

The trapezius is supplied by spinal
accessory nerve.
The supinator is supplied by radial nerve.
The latissimus dorsi receives its nerve

supply from thoraco-dorsal nerve.
The palmaris brevis is supplied by the
superficial branch of ulnar nerve.
A24. The answers are A, C, B, D.
The abduction at shoulder joint is initiated
by supraspinatus.
The adduction at radiocarpal joint is done
by flexor carpi ulnaris.
The supination at radio-ulnar joint is done
by biceps brachii.
The flexion at distal interphalangeal joint
of index finger is done by flexor digitorum
profundus.
tahir99 - UnitedVRG
The Lower
Extremity
Three
CHAPTER
14
The Bones of the

Lower Extremity
As mentioned before, both the upper and lower
extremities are homologous in development.
However, due to different functions performed by
the two extremities, there are structural differences.
FEATURES OF THE LOWER EXTREMITY
1. The lower extremities are adapted for giving
support to the body and for forward progression.
2. The lower extremity has undergone a medial
rotation by 90 from the embryonic position,
so that the primitive extensor surface faces
anteriorly, and primitive posterior surface faces
posteriorly.
3. The bones forming the pelvic girdle are fused
and firmly connected with axial skeleton as a
result of assumption of erect posture.
4. The joints of the lower extremity develop greater
stability and are adapted for weight bearing.
5. The bones of the foot develop arches to help in
the dual function of weight bearing and forward
progression.
6. Since the big toe and tibia lie on the cranial side
of embryo, they are said to be on pre-axial
border. The little toe and fibula lie towards the
caudal side of embryo, hence they are said to
be on the postnatal side.
The bones of the lower extremity are:

The hip bone (innominate bone) that forms
pelvic girdle
The femurbone of thigh
The patellaknee cap
The tibia and fibulathe bones of the leg
The bones of the foot:
Tarsals
Metatarsals
Phalanges
THE HIP BONE (INNOMINATE BONE)
General Features
The hip bone is a large, irregular bone that forms a
part of bony pelvis.
The hip bone articulates with opposite bone to
complete the pelvic girdle.
The bone consists of three bonesIlium,
ischium and pubisthat are fused in a cup shaped
depression on lateral surface called acetabulum.
A. The ilium is the expanded upper part of the hip
bone.
It has an upper end that forms an elongated
iliac crest and a lower end.
1. The iliac crest has a ventral segment,
that forms anterior two-third part of
crest, and a dorsal segment that forms
the posterior one-third part.
114

The ventral segment of iliac crest has
an outer lip, an intermediate area and
an inner lip, that give attachment to
the three oblique muscles of anterior
abdominal wall.
The dorsal segment of iliac crest has
an outer sloping area and an inner
sloping surface.
The iliac crest extends from anterior
superior iliac spine to posterior
superior iliac spine.
The highest point of ilaic crest lies
at the level of 4th lumbar spine.
The iliac crest has a tuberosity on
the outer lip about 5.0 cm from
anterior superior iliac spine.
2. The lower end of ilium forms nearly
upper two-fifth part of acetabulum.
The lower end is fused with pubis
and ischium both inside and outside
acetabulum.
The ilium has two bordersanterior
and posterior.
The anterior border of ilium extends from
the anterior superior iliac spine to anterior
inferior iliac spine, located just above the
acetabulum.
The posterior border of ilium begins at the
posterior superior iliac spine (vertebral level
2nd sacral spine) and continues through
posterior inferior iliac spine and upper part
of greater sciatic notch.
The ilium has three surfaces:
a. The gluteal surface (or dorsal surface)
is divided into four areas by the three
gluteal linesposterior, middle and
inferior.
b. The iliac fossa is the internal surface,
that is gently hollowed for muscular
attachment.
c. The sacro-pelvic surface is the posteriorinferior surface on medial aspect of the
bone.
The upper part of this surface forms

the articular surface for sacro-iliac
joint (Fig. 14.1).
The lower part of this surface forms
the lateral wall of bony pelvis.
B. The ischium forms the lower and posterior part
of the hip bone.
The ischium has a bodythe main part
and a ramus.
The body of ischium has
A femoral surfacepointing forwards.
A dorsal surfacecontinuous with the
gluteal surface of ilium.
A smooth pelvic surfacefacing
medially.
The lower end of the body of ischium
forms the ischial tuberosity, that is
divided by a transverse ridge into:
An upper quadrangular area
A lower triangular area
The upper quadrangular area is further
divided into an upper lateral and an upper
medial part.
The ischial spine projects downwards
and medially from the ischial tuberosity.
It is a pointed process that gives
attachment to sacro-spinous ligament.
The ramus of ischium fuses with the inferior
ramus of pubis to complete the conjoint
ramus. The conjoint ramus has an anterior
and a posterior surface and two borders
superior and inferior.
C. The pubis forms the anterior part of the hip
bone and joins with the bone of the opposite
side to form the pubic symphysis.
The pubis bone consists of a body or main
part and two ramisuperior and inferior.
1. The body of pubis has three surfaces:
An anterior-femoral surface
A medial-symphyseal surface
A posterior-pelvic surface
The body of pubis has a thick upper
borderthe pubic crest that ends laterally
in a pubic tubercle.
tahir99 - UnitedVRG
The Bones of the Lower Extremity
115
Fig. 14.1: The hip bonelateral surface
The superior ramus is triangular in section

and also has three surfaces.
An anteriorpectineal surface
A posteriorpelvic surface
An inferiorobturator surface
The three surfaces are separated by three
borders
A sharp pectineal borderpecten pubis
A rounded obturator crest
A sharp inferior border
The inferior ramus fuses with the ramus of
ischium to complete the conjoint ramus. The
conjoint ramus has two surfacesan
anterior or external surface and a posterior
or pelvic surface. The two borders of the
conjoint tendon are superior and inferior
(Fig. 14.2).
Special Features
[Important muscles and ligaments attached to the
box]
I. The ilium
Ventral segment of iliac crest
External oblique - (outer lip)
Internal oblique - (Intermediate area)
Transversus abdominis (inner lip)
Dorsal segment of iliac crest - Erector spinae
Dorsal surface between gluteal linesThe
three gluteal muscles - maximus, medius and
minimus.
Anterior superior iliac spine and upper half
of notch below itSartorius.
Anterior superior iliac spineLateral end
of inguinal ligament.
116
Fig. 14.2: The hip bonemedial surface
Anterior inferior iliac spine Upper part - straight head of Rectus

fenoris
Lower part - Iliofemoral ligament
Outer lip of iliac crest - (Anterior 5.0 cm)Tensor fascia lata
Iliac fossa (upper 2/3rd part) Iliacus
Posterior part inner lip of iliac crest Quadratus lumborum
II. The Ischium
Ischial tuberosity
Upper lateral part - Semi - membranous
Upper medial part - Long head of Biceps
femoris and tendinosus
Lateral border of ischial tuberosity Quadratus lumborum
Lower lateral part of ischial tuberosity Hamstring part of adductor magnus
Ischial spine - Gemellus superior and Gemellus inferior
Tip of ischial spine - Sacro-spinous ligament
and coccygeus
III.The Pubis
Anterior surface of body - Adductor longus
Inferior ramus - lateral surface - Adductor
brevis
Ischio pubic ramus - Adductor part of
adductor magnus
Margins of obturator foramen
Lateral aspct - Obturator externus
Medial aspect - Obturator internus
Pectineal surface of body - Pectineus
Pubic tubercle - Medial end of Inguinal
ligament and cremaster muscle (in males
only)
Pubic crest and pectineal line - Conjoint
tendon.
Ossification
The hip bone ossifies from three primary centers:
One for ilium appears at eight week.
One for ischium appears at fourth month
One for pubis appears at fifth month
tahir99 - UnitedVRG
Six secondary centers appeartwo for iliac

crest, one for acetabulum, one for ischial
tuberosity. One for anterior inferior iliac spine
and one for symphyseal surface of pubis.
Secondary centers of ossification appear by
puberty and fuse with rest of the bone by
twentieth year.
THE FEMUR
General Features
The femur is the long bone of the thigh. It hasa
proximal end, a shaft and a distal end.
1. The Proximal end consists of head, neck greater
trochanter and lesser trochanter.
a. The head is approximately two-thirds of a
sphere
It is covered by hyaline articular cartilage
except at a depressionfovea
centralisthat gives attachment to
ligamentum teres of femur.
b. The neck joints the head to the shaft.
It makes an angle of nearly 125
(slightly less in females) with the shaft.
It is also turned forwards by about 15.
c. The greater trochanter is a quadrangular
projection on the lateral aspect of upper end.
It projects upwards and has three
surfaces.
An anterior surface
A lateral surface, that has a prominent oblique ridge on it.
A medial surface that has a
depression called trochanteric fossa.
The greater trochanter has a thick upper
border. It gives attachment to the gluteal
muscles.
d. The lesser trochanter is a small elevation on
the medial aspect, just distal to the junction
of neck with the shaft.
The trochanteric line is a slight ridge on
the anterior aspect of proximal end that
separates neck from the shaft.
117
The trochanteric crest lies on the posterior aspect of proximal end, between the
two trochanters. It has a quadrate
tubercle in the upper part for muscular
attachment (Fig. 14.3).
2. The shaft of femur is covered anteriorly by the
extensor muscles.
a. The shaft has three surfacesanterior,
medial and lateral.
The anterior surfaceis smooth and
gently curved.
The medial surfaceis also smooth and
directed postero-medially.
The lateral surfaceis directed posterolaterally.
b. On posterior aspect of middle one-third of
shaft, there is a double ridge called linea
asperaa for muscular attachments.
The linea aspera has a medial lip that is
continuous above with spiral line. The
spiral line is joined proximally by intertrochanteric line.
The lateral lip of linea aspera is continuous above with a thick ridgegluteal
tuberosity.
Both medial and lateral lips of linea aspera
are continued below as medial and lateral
supra-condylar ridges.
Between the two supra-condylar ridges
below lies a triangular area on posterior
aspect of shaft known as popliteal
surface.
3. The distal end of femur consists of two condylesmedial and lateraland an articular
surface (Fig. 14.3).
i. The medial condyle projects distally and
medially. The exaggerated medial angulation
(more in females) causes knock-knee (genu
valgum).
The most salient point on medial condyle
is called medial epicondyle. This gives
attachment to the medial collateral
ligament of the knee point.
118
Fig. 14.3 The femur
Just above medial condyle is a prominent

adductor tubercle that gives attachment
to the ischial part of adductor magnus.
The lateral surface of medial condyle is
rough and gives attachment to anterior
cruciate ligament.
ii. The lateral condylelies in line with the
shaft and helps more in force transmission.
The most prominent point of lateral
condyle is called the lateral epicondyle.
It gives attachment to the lateral
collateral ligament of the knee joint.
On its lateral surface, there is popliteal
groove. The anterior part of the groove
gives attachment to popliteus muscle,
while the posterior part of groove lodges
the tendon of popliteus in full flexion of

knee joint.
The medial surface of lateral condyle is
rough, and gives attachment to posterior
cruciate ligament.
The intercondylar fossa between the two
condyles is non-articular. It is intracapsular and extra-synovial.
The inter-condylar line posteriorly gives
attachment to the capsular ligament and oblique
posterior ligament of knee joint.
The articular surface of medial condyle is
longer and more curved than the articular
surface of lateral condyle (Fig. 14.4).
The femur transmits the body weight from
the bony pelvis to the tibia. Due to this fact, the
tahir99 - UnitedVRG
119
Fig. 14.4: The distal end of femur
bony trabeculae inside head, neck and the

trochanters of femur are arranged according
to lines of force transmission up to compact
bone of the shaft.
iii. The articular surfaceof the lower end of
femur is divided into:
A patellar articular surface.
A tibial articular surface.
a. The patellar articular surface is
placed anteriorly and is more on
lateral condyle than medial condyle.
It is separated from tibial articular surfaces of the two condyles by faint ridges.
b. The tibial articular surfaceis on
the inferior aspect of medial and
lateral condyles.
Special Features
bone]
i. Upper end:
Superior border of greater trochanter
piriformis
Oblique ridge on lateral aspect of greater
trochanterGluteus medius
Anterior surface of greater trochanter
Gluteus minimus
Medial surface of greater trochanter
Obturator internus and gemelli
Trochanteric fossaobturator externus

Quadrate tubercle on trochanteric crest
Quadratus femoris
Lesser trochanter and line below ofpsoas
major and iliacus
ii. The shaft
Upper part trochanteric line, anterior and
lateral border of greater trochanter and
lateral lip of linea asperaVastus lateralis
Lower part trochanteric line, spiral line,
medial lip of linea aspera and medial supra
condylar ridgeVastus medialis
Anterior and medial surfaces (upper 3/4 th)
Vastus intermedius
Line descending from lesser trochanter to
linea asperaPectineus
Linea asperaAdductor longus and Adductor brevis
Line descending medial to gluteal tuberosity,
medial lip of linea aspera, and medial
Supracondylar ridgeAdductor part of
Adductor magnus
Gluteal tuberositylower and deeper 1/4th
part of Gluteus maximus
Lateral lip of linea asperaShort head of
biceps femoris
iii. The lower end:
Popliteal surface and lower part of lateral
supra-condylar ridgePlantaris
Popliteal surface and depression above
lateral femoral condyleLateral head of
Gastrocnemius
120
Popliteal surface above medial femoral

condyleMedial head of Gastrocnemius
Posterior part of popliteal groove on lateral
surface of lateral femoral condylePopliteus
Medial epicondyleMedial collateral ligament of knee joint
Lateral epicondyleLateral collateral ligament of knee joint.
Nutrient foramen
The nutrient foramen for femur are usually two
One situated near proximal end of linea
aspera.
The second located near the distal end of
linea aspera.
The nutrient arteries are provided by second
and third perforating branches of profunda
femoris artery.
Applied anatomy
i. The head of femur can be palpated just below
inguinal ligament lateral to femoral artery
ii. The neck of femur joins the shaft at an angle
of 125 in adults (160 in children)
Coxa valga is the condition where this angle
is increased as is seen in
Congenital dislocation of lip joint
Coxa vara is decrease in neck-shaft angle.
It occurs in fracture of neck of femur.
iii. The fracture of neck of femur interferes
with the blood supply of head of femur and
ischemic necrosis may set in. It occurs
mostly in elderly people.
For distal end one center appears just before

birth in ninth month of intra-uterine life and
fuses by twentieth year.
The distal end is the growing end of femur.
THE TIBIA
General Features
The tibia is medial, stout and weight bearing bone
of the leg.
The tibia has a proximal end, a shaft and a distal
end.
I. The proximal endis expanded to form two
condylesmedial and lateralwhich articulate
with the two femoral condyles to form the
femoro-tibial part of the knee joint (Fig. 14.5).
a. The medial tibial condyleis concave both
in coronal plane and sagittal plane.
It is larger and semi-circular in outline.
b. The lateral tibial condyle is concave in
coronal plane but convex in sagittal plane.
It is smaller in diameter and nearly
circular in shape.
c. The inter condylar eminence lies between
the two tibial condyles.
It gives attachment to the medial and
lateral semilunar cartilages (menisci) of
the knee joint and the two cruciate
ligamentsanterior and posterior.
d. The tibial tuberositylies on the anterior
surface of upper end. It gives attachment
to the patellar ligament (ligamentum patellae)
Ossification
One primary centre of ossification appears in

the shaft in eighth week of intra-uterine life.
For proximal endthree secondary centers of
ossification appear.
One for head in first year.
One for greater trochanter in fourth year.
One for lesser trochanter in twelfth year.
All these epiphyses fuse separately with the
shaft by sixteenth year.
Fig. 14.5: Upper end of tibiasuperior aspect
tahir99 - UnitedVRG

II. The shaft of the tibia is triangular in section
and becomes narrow towards medial malleolus.
The shaft has three surfacesmedial, lateral
and posterior.
a. The medial surface is subcutaneous
throughout. Its upper part gives attachment to the three muscles of thigh
sartorius, gracilis and semitendinosis
and medial collateral ligament of the knee
joint.
b. The lateral surface is broad and smooth
and lies between the anterior and
interosseous borders.
c. The posterior surfacein its upper part
has a triangular area for attachment of
popliteus.
The triangular area is limited below
by a thick ridgethe soleal line that
gives attachment to soleus muscle.
Below the soleal line, the posterior
surface is divided by a faint vertical
line into a medial and a lateral area.
The shaft has three borders also
anterior, medial and lateral or interosseous border.
The anterior borderbegins as
continuation of tibial tuberosity
and is subcutaneous throughtout.
It is slightly curved in its lower
part towards medial malleolus.
The medial border is well-defined
in middle one-third part of the
shaft only. It separates medial and
posterior surfaces.
The lateral (interosseous) border
is sharp and gives attachment to
the interosseous membrane of the
leg.
III.The distal end of the tibia is expanded and
articulates with talus at the talo-crural (ankle)
joint.
The distal end has a medial malleolus, a
fibular notch and an articular surface.
a. The medial malleolus is a stout projection on the medial aspect of the distal
end.
121
It has a groove on its posterior aspect

for the tendon of tibialis posterior.
To the apex and a depression near it,
is attached the deltoid ligament of the
ankle joint.
The lateral surface of medial malleolus has a comma shaped articular
facet for articulating with medial
surface of talus at the ankle joint.
b. The fibular notch lies on the lateral
aspect of the distal end of tibia.
To the edges of fibular notch are
attached the anterior and posterior
tibio-fibular ligaments of inferior
tibio-fibular joint.
c. The articular surface of the distal end
of tibia is wider anteriorly and concave
in shape (Fig 14.6).
It articulates with the superior
trochlear surface of talus at the ankle
joint.
Fig. 14.6: The tibia and fibulaanterior aspect
122
Special Features
Ossification

bone]
i. The upper end
Tuberosity of TibiaLigamentum patellae
Groove on back of medial condyleSemimembranosus
Lateral condyleIlio-tibial tract
Intercondylar area on superior surface of
upper endAnterior and posterior cruciate
ligaments
Superior surface of medial and lateral condylesMedial and lateral semilunr cartilages (menisci)
ii. The shaft
Upper part of medial surfaceSartorius
Gracitis and semi-tendinosus
Upper part of medial surface (behind the
three musclesMedial collateral ligament
of knee joint
Lateral surface (proximal 2/3rd)Tibialis
anterior
Popliteal surface (medial 2/3rd)Popliteus
muscle
Soleal line and middle 1/3rd of medial border
of shaftSoleus
Upper part posterior surface below soleal
line (medial to vertical line) Flexor digitorum
longus
Upper Part posterior surface below soleal
line (lateral to vertical line) Tibialis posterior
iii. The lower end
Tip of medial malleolusmedial collateral
ligament (Deltoid ligament) of ankle joint
The tibia ossifies by three centers.

One primary center of ossification appears by
seventh week of intrauterine life.
The secondary center for proximal end appears
just before birth. It forms the tibial tuberosity
also.
The secondary center for distal end appears in
first year.
The proximal epiphysis fuses by eighteenth year,
while distal epiphysis fuses by fifteenth year.
The proximal end is the growing end of bone.
Nutrient foramen
The nutrient foramen of tibia is present in
upper part of posterior surface below soleal
line.
The nutrient artery is a large branch of
posterior tibial artery.
THE FIBULA
General Feature
The fibula is lateral and non weight-bearing bone

of the leg.
The bone does not take part in the formation of
knee joint.
The fibula has a proximal end, a shaft and a
distal end.
a. The proximal end of fibula has a head and
a short neck.
The head is slightly expanded and
projects anteriorly, laterally and posteriorly.
The head has a small round facet on
its medial aspect for superior tibiofibular joint.
The lateral surface of head gives
attachment to fibular collateral ligament of knee joint and biceps
femoris muscle.
A blunt apexthe styloid process
projects proximally from the posterolateral aspect.
b. The neck is a slight constriction that joins
the head with the shaft.
The common peroneal nerve crosses
postero-lateral to the neck and can be
compressed against the bone.
tahir99 - UnitedVRG

c. The shaft of the fibula is narrow and has
three surfacesmedial, lateral and posterio.
The medial surface is very narrow and
lies between anterior and interosseous
borders.
This surface gives attachment to the
extensor muscles of the leg.
The lateral surfacegives attachment
to the peroneal muscles.
The lower one-fourth of this surface
twists behind the lateral malleolus.
The posterior surface is the largest
surface. It lies between the interosseous
and posterior borders.
The proximal two-thirds of this
surface has a grooved medial part,
limited by a medial crest. This part
of posterior surface gives attachment to tibialis posterior.
The rest lateral part of posterior
surface gives attachment to flexor
muscles of the leg (Fig. 14.7).
123
The shaft of fibula has three bordersanterior,

posterior and medial or interosseous border.
a. The anterior border extends from the inferior
aspect of head up to the apex of triangular area
above lateral malleous.
b. The posterior border is rounded in its proximal
part but is distinct distally.
c. The medial (interosseous) border extends up to
a triangular area on medial aspect of lower end
of fibula, for the inferior tibio-fibular joint.
It gives attachment to interosseous
membrane.
d. The distal end of fibula projects distally and
posteriorly to form lateral malleous.
The lateral malleolus projects to a lower level
than the medial malleolus.
The posterior aspect of lateral malleolus has
a broad groove for the tendons of peroneal
muscles.
The lateral aspect of lateral malleolus is
subcutaneous and is continuous above with
a triangular area.
The medial aspect has a triangular articular
facet for articulating with lateral surface of
talus.
The triangular area above the facet gives
attachment to the ligaments of inferior tibiofibular joint.
Near the tip of lateral malleolus, on medial
aspect lies malleolar fossa for giving attachment to posterior talo-fibular ligament.
Special Features
Fig. 14.7: The tibia and fibulaposterior aspect

bone]
i. The head
Lateral surface of headbiceps femoris and
lateral collateral ligament of knee joint.
Posterior surface of headSoleus
ii. The shaft
Lateral surface (proximal 2/3rd) Peroneus
longus
Lateral surface (distal 2/3rd ) Peroneus
brevis
124
Posterior surface (upper 3/4th) Soleus

Medial surface - (proximal 3/4th) Extensor
digitorum longus
Medial surface - middle 2/4th) Extensor
hallucis longus
Medial surface (distal 1/4th) Peroneus tertius
Posterior surface (distal 2/3rd) Flexor
hallucis longus
Posterior surface (medial part - proximal
2/3rd) -Tibialis posterior
iii. The lower end
Tip of lateral malleolusLateral collateral
ligament of ankle joint.
Nutrient foramen
The nutrient foramen is located on middle
of posterior surface distal to attachment of
soleus.
The nutrient artery is a branch of peroneal
artery.
Ossification
The fibula ossifies by three centers.
The primary center of ossification for shaft
appears in eighth week of intra-uterine life.
The secondary center for proximal end appears
in fourth year and the epiphysis fuses by
ninteenth year.
The secondary center for distal end appears in
first year and fuses by fifteenth year.
The proximal end is the growing end of the
bone.
THE PATELLA (KNEE CAP)
General Features
The patella is the largest sesamoid bone that is
developed in the tendon of quadriceps femoris.
The patella is a triangular bone with an apex
and a base.
The apex of patella is directed downwards and
gives attachment to ligamentum pattelae.
The base of patella lies above and gives
attachment to tendon of quadriceps muscle.
The patella has an anterior surface and an
articular posterior surface (Fig. 14.8).
Fig. 14.8: The patella
a. The anterior surface is convex and sub

cutaneous. It presents foramina for nutrient
vessels.
b. The posterior surface has smooth and oval
articular area for patellar surface of femur.
It has a smooth vertical ridge dividing the
articular surface into a larger lateral part and
a smaller medial part.
The medial and lateral borders of patella
converge towards apex. They give attachment to medial and lateral patellar retinaculaexpansions from vastus medialis and vastus
lateralis.
Ossification
Several ossification centers appear during third

to sixth year in patella and join together to form
the bone.
The patella is a sesamoid bone that has no
periosteum. There is no regeneration of repair
of bone in case of its fracture.
Applied anatomy of patella and bones of leg:
I. Fracture of patelladoes not cause any
displacement of fragments, as they lie within
quadriceps femosis. Repair of fracture is not
possible as patella is a sesamoid bone.
II. Fracture of Tibia and Fibulamay occur
commonly due to external trauma. If one bone
is fractured, there is hardly any displacement
of fragments as the other bone acts as a splint.
Fracture of distal 1/3rd of tibia results in delayed
union as nutrient artery is torn.
tahir99 - UnitedVRG

THE BONES OF THE FOOT
The bones of the foot are the tarsals, metatarsals
and the phalanges.
I. The tarsals are seven bones arranged in three rows.
The proximal row has talus and calcaneum
The middle row has navicular
The distal row has cuboid and three cuneiform
bonesmedial, intermediate and lateral.
A. The talus has a round head, a neck and a body
(Fig. 14.9).
The head of talus is directed distally and
articulates with the navicular bone.
The plantar surface of head has three faces
for articulating with calcaneum.
The neck is the narrow region between the
head and the body.
Its plantar surface has a deep groove.
The body of talus is cuboidal in shape.
The dorsal surface (trochlear surface)
articulates with inferior surface of distal
end of tibia at the ankle joint.
The medial surface has a comma shaped
articular facet for medial malleolus.
The lateral surface has a triangular
articular facet for lateral malleolus
The posterior surface has a projecting
process and an oblique groove for tendon of flexor hallucis longus.
The inferior (plantar surface) articulates
with calcaneum.
The talus has no muscular attachment.
Only ligaments are attached to the bone.
Fig. 14.9: The talussuperior aspect
125
B. The calcaneum is the largest tarsal bone and

projects posteriorly.
The calcaneum is irregularly cuboidal in
shape, having superior, inferior (plantar),
anterior, posterior, medial, and lateral
surfaces.
a. The superior surface has three articular
facets for talus, forming sub-talar joint.
Its proximal part is rough, while its
distal part has a depressionsulcus
calcaneithat completes sinus tarsi
with talus.
b. The inferior (plantar) surfaceis rough
and has a prominent medial tubercle and
a smaller lateral tubercle for attachment
of muscles and ligaments of the sole.
c. The anterior surface is small and has a
concavo-convex articular facet for
cuboid bone.
d. The posterior surface is divided into
(Figs 14.10 A and B)
A smooth proximal area for a bursa.
A middle larger rough area for
attachment of tendo-calcaneus
A distal (inferior) area related to a
fibro-fatty cushion, that forms the
heel.
e. The medial surfacehas a prominent
shelf like projectionthe sustentaculum
talithat supports talus and gives attachment to spring ligament.
The sustentaculum tali is grooved on
its inferior surface by tendon of
flexor hallucis longus.
f. The lateral surface is almost flat.
It presents a small and variable
elevation
The peroneal tubercle (trochlealies)
about 2.0 cm distal to the tip of lateral
malleolus.
The peroneal tubercle has a
shallower groove above for peroneus
brevis tendon and an obligue groove
below for peroneus longus tendon.
126
Figs 14.10 A and B: The calcaneum
Fig. 14.11: The naviculardistal surface
C. The navicular bone articulates with all tarsal

bones except calcaneum, with which it is
connected by spring ligament (plantar calcaneonavicular ligament) (Fig. 14.11).
The navicular bone has a concavity proximally for articulating with head of talus.
Fig. 14.12: The cuboidproximal and lateral aspect
Distally the navicular presents a convex

articular surface divided into three facets
for articulating with three cuneiform bones.
The lateral surface is rough and bears a
facet for articulating with cuboid bone.
Medially the navicular has a prominent
tuberosity, for insertion of main part of tibialis
posterior muscle.
The dosal surface of navicular bone is more
extensive than its plantar surface.
D. The cuboid bone is the most lateral tarsal bone
of the distal row (Fig. 14.12).
a. The dorsal surface of cuboid is rough for
attachment of ligaments.
b. The plantar surface has a prominent oblique
groove for the peroneus longus tendon. The
groove is limited proximally by a prominent
ridge.
c. The lateral surface is rough and has a deep
notch for tendon of peroneus longus.
d. The medial surface bears a facet for navicular.
Proximallythe cuboid has a concavoconvex facet for articulating with calcaneum.
Distallythe articular area is divided into
two parts.
Medial quadrangular part for the base
of fourth metatarsal.
tahir99 - UnitedVRG
Lateral triangular part for the base of

fifth metatarsal.
E. The cuneiform bones are three wedge shaped
tarsal bones that form the distal row.
a. The medial cuneiform is the largest cuneiform. It is quadrangular in shape.
It articulates distally with the base of
first metatarsal.
Proximally it has a smaller facet for
articulating with navicular.
The medial surface of medial cuneiform
is thick, rough and subcutaneous.
The lateral surface presents a facet for
the intermediate cuneiform.
b. The intermediate cuneiform is nearly square
in shape.
It articulates distally with base of second
metatarsal.
Proximally it has a facet for articulating
with navicular bone.
Medially it has a facet for intermediate
cuneiform.
Laterally it has a facet for articulating
with cuboid.
Ossification of Tarsal Bones
The calcaneum ossifies by a center appearing

in third month of intrauterine life. It has a
secondary center for posterior surface that
appears by eighth year and units by sixteenth
year.
The talus ossifies by a center that appears in
sixth month of intrauterine life.
The cuboid develops by a center that appears
in ninth month of intrauterine life.
The navicular ossifies by a center appearing in
third year after birth.
The medial cuneiform ossifies in second year,
the intermediate cuneiform in third year and
lateral cuneiform in first year.
II. The metatarsals

There are five metatarsals in the skeleton of
foot.
127
They connect the tarsal bones to the phalanges.

The metatarsals are short bones with a prominent base, a shaft and a smaller head of distal
end.
The bases of metatarsals are thicker and
articulate with the distal row of tarsal bones.
The heads articulate with the bases of proximal
phalanges.
The first metatarsal is shortest and thickest.
The fifth metarsal has a tuberosity on the lateral
side of the base.
III. The phalanges of the foot resemble those in
the hand.
There are two phalanges in the big toe.
The rest of the toes have three phalanges.
The phalanges of the foot are much shorter,
specially their shafts,
The base of proximal phalanx articulates with
the head of the metatarsal.
The head of proximal phalanx articulates with
concave base of middle phalanx.
The middle phalanx is short but broader than
proximal phalanx .
The head of middle phalanx articulates with base
of distal phalanx.
In big toe, the proximal phalanx articulates with
base of terminal phalanx.
The distal phalanges have a rough projection or
tuberosity on plantar surfaces for attachment
of the pulp of the toe.
Ossification of the Metatarsals and
Phalanges
The metatarsals ossifies by two centers
For the shaft
In first metatarsal center of ossification
appears in tenth week.
For other four metatarsals the center appears
in ninth week.
For the heads of lateral four metatarsals the
secondary center appears in third to fourth year
and unites with the shaft by twentieth year.
128
For base of first metatarsal the secondary center

appears by third year and unites with the shaft
by twentieth year.
The phalanges ossify by two centersone for
the shaft and one for the base.
For shaft
For proximal phalanx the center for shaft
appears in eleventh week.
For middle phalanx the center for shaft
appear after fifteenth week.
For distal phalanx the center for shaft
appears by ninth week.
For base
For the bases of phalanges the center
appears by fifth to sixth year and unites with
the shaft by eighteenth year.
Applied Anatomy of Bones of Foot

i. Fracture of talusOccurs due to violent
dorsi-flexion of ankle joint.
ii. Compression fracture of calcaneum results
from a fall from a height.
Sustentaculum tali can be fractured due to
voilent inversion of foot.
iii. Fracture of metatarsalsBase of 5th metatarsal may be fractured due to forced inversion.
Stress fracture of metatarsals (distal 1/3rd
of second, third, and fourth metatarsals)
occurs commonly in soldiers after long
marches.
tahir99 - UnitedVRG
CHAPTER
15
The Joints of the

Lower Extremity
THE HIP JOINT
The hip joint is a large joint between the lower limb
and the pelvic girdle.
Type: A ball and socket type of synovial joint.
Articular surface:
i. The head of femuris more than half a
sphere. Except for a small depression
fovea centralisit is covered by hyaline
ii. The acetabulum is a cup shaped depression
on lateral surface of hip bone.
It has a horse-shoe shaped articular
surface covered by hyaline articular
cartilage, that encloses a non-articular
acetabular fossa.
It is deepened by a fibro-cartilaginous
rim called the labrum acetabulare.
Stability of the joint: The hip joint is a very
stable joint for transmission of force to and from
the pelvis to the limb.
The factors responsible for the stability of the
joint are:
i. The shape of articular surfaces
ii. The strong ligaments surrounding it.
iii. The strong muscles around the joint.
Articular capsulesurrounds the joint on all
sides (Fig. 15.1).
Attachments:
On the hip bone all around the margins
of acetabulum and transverse acetabular
ligament.
On femur - on the neck of femur.
Anteriorly to trochanteric line.
Fig. 15.1: The hip jointanterior aspect
Posteriorly to back of neck of femur
proximal to trochanteric crest.

Medially to the spiral line.
There are two types of fibers in the articular

capsule.
i. The longitudinal fibers are in form of three
thickenings that can be seen externally as
iliofemoral, pubofemoral and ischiofemoral
ligaments.
ii. The circular fibers run circumferentially deep
to the longitudinal fibers. These fibers are
known as zona orbicularis.
The retinacular fibers of the capsule are
those fibers that are reflected along the neck
of femur towards the head of femur. They
carry small blood vessels for the head of
femur. In case of intra-capsular fracture of
neck of femur, they help to keep the pieces
of neck together.
130
The ligaments of the hip joint

i. The iliofemoral ligament is thick, strong
and V-shaped ligament on anterior aspect
of the joint.
It is one of the strongest ligaments of
the body.
It is attached above to anterior-inferior
iliac spine and below the trochanteric
line.
ii. The pubofemoral ligament lies on medial
aspect of the joint.
It is attached above the iliopectineal
eminence and below lower part of
trochanteric line and upper end of spiral
line.
iii. The ischiofemoral ligament lies on the
posterior aspect of the capsule.
It is attached above the posterior aspect
of acetabulum and below the back of
neck of femur.
The fibers of this ligament are arranged
spirally.
iv. The transverse acetabular ligament bridges
the gap on the inferior aspect of acetabulum.
The ligament is continuous with labrum
acetabulare.
It leaves a gap below it through which
articular nerves and vessels enter the
joint.
v. The ligament of head of femur (ligamentum
teres) is attached to the pitfovea
centralison the head of femur.
The other end of the ligament is attached
to the margins of acetabulum and
transverse acetabular ligament.
The ligament is triangular in shape (not
round) and carries a small artery to
supply the head of femur.
The ligament has hardly any role in the
stability of the joint.
The synovial membrane lines the deep surface
of the capsule.
It lines the acetabular pad of fat and covers
both surfaces of labrum acetabulare.
The synovial membrane lines the nonarticular part of the neck of femur and
surrounds the ligamentum teres of head of
femur (Fig. 15.2).
The nerve supply is by:
i. Femoral: via nerve to rectus femoris.
ii. Obturator.
iii. Accessory obturator (if present).
iv. Nerve to quadratus femoris.
v. Superior gluteal.
The arterial supply is by:
i. The superior gluteal artery.
ii. The inferior gluteal artery.
iii. The obturator artery.
iv. The medial circumflex femoral artery.
Movements of the joint
The hip joint is a multiaxial joint, so the
movements are possible in more than two
axes.
Flexion and extension occur along a
transverse axis.
Abduction and adduction take place along
an antero-posterior axis.
Circumduction is combination of all
above movements.
Medial and lateral rotation occur along a
vertical axis.
Fig. 15.2: The hip joint (section through joint)
tahir99 - UnitedVRG
The Joints of the Lower Extremity
The muscles producing movements:

Flexion : Iliopsoas
Assisted by pectineus, sartorius, rectus
femoris, adductor longus and tensor fascia
lata.
Extension:
Gluteus maximus.
Assisted by hamstring muscles.
Adduction: Three adductors - longus, brevis
and magnus.
Assisted by gracilis and pectineus.
Abduction: Gluteus medius
Gluteus minimus
Assisted by tensor fascia lata
Medial rotation Gluteus medius
Gluteus minimus
Tensor fascia lata
Lateral rotation: Small lateral rotators:
Piriformis, obturator internus, gemelli, obturator
externus, quadratus femoris.
Gluteus maximus
Sartorius
Applied anatomy
i. Dislocation of hip joint is very rare, as the
joint is very stable. Posterior dislocation due
to trauma might occur when flexed thigh is
jerked backwards forcefully.
ii. The congenital dislocation of hip joint is
seen sometimes when head of femur lies
below acetabulum. Surgical reconstruction
is possible.
iii. Osteo-arthritis of hip joint results from
progressive degenerative changes of
articular cartilage, resulting in pain and
limitation of movements of the joint.
iv. Fracture (intracapsular) of neck of femur
occurs commonly in old people. The retinacular fibers of capsule hold the pieces
together.
THE KNEE JOINT

The knee joint is a large joint between the lower
end of femur, patella and upper end of tibia.
131
Type: A modified hinge type of synovial joint,

as some rotation movement takes place during
locking and unlocking of the joint.
The knee joint consists of two joints.
i. Femoro-patellar: Between femur and patella.
ii. Femoro-tibial: Between the two femoral and
the two tibial condyles.
The knee joint is a very stable joint and bears
body weight.
Articular surfaces:
Articular surface of lower end of femur.
Posterior articular surface of patella.
Articular surfaces of the two tibial condyles.
Articular capsule is quite extensive, but weak.
Attachments: Anteriorly the capsule is deficient
due to patells and ligamentum patellae.
On tibia
Medially it is attached to the periphery
of medial meniscus (semilunar cartilage)
Laterally it includes the tendon of
popliteus and is attached to head of fibula.
Posteriorly it is attached to the intercondylar area of tibia.
On femur
The articular capsule is attached to the
margins of articular surfaces of the two
femoral condyles except laterally where
it includes the origin of popliteus from
the popliteal groove.
The ligaments of the joint
i. The ligamentum patellae is attached to the
apex of patella above and the tuberosity of
tibia below.
It represents the continuation of insertion
of quadriceps femoris muscle.
ii. The medial (tibial) collateral ligament is a
broad band attached above to medial
epicondyle of femur and below to upper part
medial surface of tibia.
It is fused with the periphery of medial
meniscus and articular capsule.
It is supposed to be phylogenetically
fibrosed part of tendon of adductor
magnus.
132
iii. The lateral (fibular) collateral ligament is

a strong cord-like structure attached above
the lateral epicondyle of femur and below
the lateral surface of head of fibula.
It is related laterally to the tendon of
insertion of biceps femoris.
It is not fused with the fibrous capsule,
and is separated from lateral meniscus
by popliteus muscle.
It is supposed to be phylogenetically
fibrosed part of peroneus longus muscle.
iv. The oblique popliteal ligament is a straplike expansion from the insertion of semimembranosus. It strengthens the posterior
part of capsule and is attached to
intercondylar line of femur.
v. The coenary ligaments are thickenings of
the capsule, that are loosely attached to the
margins of the two menisci.
A transverse ligament sometimes
connects the anterior margins of two
menisci.
vi. The cruciate ligaments are twoanterior
and posteriorand are present inside the
joint.
a. The anterior cruciate ligament is a strong
cord-like band connecting the medial
surface of lateral femoral condyle to
intercondylar area of tibia.
b. The posterior cruciate ligament is also
a strong cord-like band connecting lateral
surface of medial femoral condyle to
Fig. 15.3: Superior aspect of tibia
posterior part of inter-condylar area of

tibia (Fig. 15.3).
The ligament prevents anterior
bending of femur on tibia. It is a big
stabilizer of the knee joint.
The menisci (semilunar cartilages) of the knee
joint.
There are two menisci, medial and lateral
present above the tibial condyles.
The menisci are made up of fibrocartilage
and serve to deepen somewhat the articular
surfaces of tibial condyles.
1. The lateral meniscus is smaller and
nearly circular.
It is attached by two horns to the
intercondylar area of tibia inside the
medial meniscus.
It is separated from the lateral collateral ligament of the joint by popliteus
muscle.
2. The medial meniscus is larger and semicircular in outline.
It is attached by two horns on the
inter-condylar area of upper end of
tibia.
It is fused with articular capsule and
medial collateral ligament. It is more
prone to injury.
The important bursae in relation to the joint (Fig.
15.4).
i. The suprapatellar bursa lies deep to the
tendon of quadriceps femoris in relation to
Fig. 15.4: Sagittal section through the knee joint
tahir99 - UnitedVRG
anterior surface of lower part of shaft of

femur.
The bursa is continuous with synovial
membrane of the joint.
ii. The deep infra-patellar bursa lies between
upper part of tibial tuberosity and ligamentum patellae.
iii. The subcutaneous infra-patellar bursa lies
between lower part of tibial tuberosity and
the skin.
iv. The prepatellar bursa lies between patella
and the skin.
The nerve supply is by:
i. Femoral via muscular branches to the three
vasti muscles.
ii. Posterior division of obturator.
iii. Tibial
iv. Common peroneal.
The arterial supply is by an arterial anastomosis
around the joint in which following arteries take
part (Fig. 15.5).
Descending genicular branch of femoral
artery.
Superior, middle and inferior genicular
branches of popliteal artery.
Anterior and posterior recurrent branches
of anterior tibial artery.
Circumflex fibular branch of posterior tibial
artery.
Descending branch of lateral circumflex
femoral artery.
Fig. 15.5: The arterial anastomosis around the knee joint
133
The movements of the joint.

The knee joint, being a modified hinge joint, the
movements take place along two axes.
i. The movements of flexion and extension
take place along a transverse axis.
ii. The rotational movementsduring locking
and unlockingoccur along a vertical axis
passing through intercondylar area.
The locking movement involves about
20 rotation of lower end of femur
medially (or upper part of tibia laterally
when foot is off the ground), and takes
place towards the end of extension.
The rotation is caused mainly due to
length and shape of articular surfaces
of femoral condyles. (The articular
surface of medial femoral condyle is
longer and curved).
The unlocking movement in the beginning of flexion is a reverse rotation of
lower end of femur laterally (or upper
end of tibia medially, when foot is off
the ground). The unlocking movement
is done by the contraction of popliteus
muscle.
Flexion: Hamstring muscles Semimembranosus, semitendinosus and biceps femoris.
Assisted by sartorius, gracilis and popliteus.
Extension: Quadriceps femoris.
Medial rotation: (of fixed leg)
Popliteus, semimembranosus
Assisted by gracilis and sartorius.
Lateral rotation: Biceps femoris.
Applied anatomy
i. Injury to the menisci can take place due to
twisting strains and violent trauma.
The medial meniscus usually gets torn
with a bucket handle type of injury.
Sometimes a detached part of menisci
may be wedged between the articular
surfaces.
134
ii. Injury to the ligaments especially cruciate

ligaments can take place due to violent hyperextension.
The collateral ligaments may also be
involved in traumatic lesions.
iii. Acute synovitis with accumulation of fluid
inside the joint is also a common condition.
iv. Osteoarthritis in old age results from damage
to the articular cartilage. It results in pain
and limitation of movements.
v. The bursae around knee joint may be
involved in inflammatory process.
Inflammation of prepatellar bursa causes
painful swelling in front of patella
Housemaids knee.
Inflammation of subcutaneous infrapatellar bursa causes painful swelling in
front of tibial tuberosityClergymans
knee.
THE ANKLE (TALO-CRURAL) JOINT
The ankle joint is a big joint between lower ends of
tibia, fibula and the talus (Fig. 15.6).
Type: A hinge type of joint.
Articular surfaces
Upper articular surface is formed by:
Lower end of tibia
Medial malleolus of tibia
Lateral malleolus of fibula
Lower articular surface is formed by:
Superior articular (trochlear) surface of
talus.
Facets on lateral and medial aspects of
talus.
It is attached to the margins of articular
surfaces of bones.
Ligaments
i. The medial collateral (Deltoid) ligament is
a strong triangular ligament on medial aspect
of the joint (Fig. 15.7).
Apex is attached to the tip of medial
malleolus.
Base or lower attachment.
The superficial fibers are attached
to
Sustentaculum tali of calcaneum.
Spring (calcaneo-navicular)
ligament.
Navicular.
Medial tubercle of talus.
The deep fibers are attached to
Medial surface of talus.
ii. The lateral collateral ligament consists of
three separate bands:
a. The anterior talo-fibular extends from
the tip of lateral malleolus to talus
anteriorly.
b. The posterior talo fibular extends from
the malleolar fossa of fibula to talus
posteriorly.
c. The calcaneo-fibular extends from the
tip of lateral malleolus to lateral surface
of calcaneum (Fig. 15.8).
Fig. 15.6: The ankle jointtransverse section
tahir99 - UnitedVRG
135
Fig. 15.7: The ankle jointmedial aspect

i. Deep peroneal nerve.
ii. Tibial nerve.
i. The malleolar branchesmedial and
lateralof anterior tibial artery.
ii. The malleolar branchesmedial and
lateralof peroneal artery.
The movements
The ankle joint is a very stable joint, and helps
to transmit body weight from tibia to talus and
then to the foot.
The center of gravity of the body in erect
posture passes in front of ankle joint.
The movements of dorsiflexion and plantarflexion occur along a transverse axis passes
through lateral malleolus and trochlear

surface of talus.
Dorsiflexion is done by:
Tibialis anterior
Extensor muscles of legextensor
hallucis longus, extensor digitorum
longus and peroneus tertius.
Plantar flexion is done by:
Gastrocnemius
Soleus, plantaris
Assisted by flexors of legtibialis
anterior, flexor digitorum longus flexor
hallucis longusand two peroneus
muscleslongus and brevis.
Applied anatomy:
i. Dislocation of joint is rare without the
fracture of malleoli.
ii. Sprain of the joint may occur due to forcible
plantar flexion.
Most of the abduction-sprains are at the
sub-talar joint.
The ligaments may be torn, e.g. the
anterior fibers of deltoid ligament, and
anterior talo-fibular ligament.
THE TIBIO-FIBULAR JOINTS

Fig. 15.8: Coronal section through ankle
joint and sub-talar joint
There are three tibio-fibular jointsproximal,

middle and the distal (Fig. 15.9).
136
Fig. 15.9: The tibio-fibular joints
a. The proximal tibio-fibular joint is the joint

between lateral tibial condyle and the head of
fibula.
Type: A plane type of synovial joint.
Articular surfaces are formed by round
facets on lateral condyle of tibia and medial
surface head of fibula.
Articular capsule surrounds the joint on all
sides and is attached to the margins of
articular facets.
The capsule is reinforced by two thickeningsanterior ligament and posterior
ligament.
Common peroneal nerve
Nerve to popliteus
The lateral supply is by
Anterior and posterior recurrent branches of anterior tibial artery.
The movements are extremely limited.

Only some gliding movements take place.
b. The middle tibio-fibular joint connects the
inter-osseous borders of tibia and fibula by the
interosseous membrane of the leg.
The direction of fibers of the membrane is
downwards and laterally from tibia to fibula.
The interosseous membrane firmly binds the
two bonestibia and fibulaand also
provides an additional surface for muscular
attachment.
The upper border of membrane leaves a gap
through which anterior tibial vessels pass
to the anterior compartment of leg.
The lower part of membrane is pierced by
the perforating branch of peroneal artery.
c. The distal tibio-fibular joint is a joint between
triangular rough area on medial aspect of lower
end of fibula and fibular notch of tibia.
Type: A syndesmosis type of fibrous joint.
The ligaments
i. The anterior tibio-fibular ligament lies
on anterior aspect.
ii. The posterior tibio-fibular ligament
is stronger ligament and lies on
posterior aspect.
iii. The interosseous tibio-fibular ligament firmly connects the lower ends
of the two bones.
It is continuous above with the
interosseous membrane of the
leg.
i. Deep peroneal
ii. Tibial
iii. Saphenous
The arteial supply is by
i. Medial malleolar branches of anterior
and posterior tibial arteries.
ii. Perforating branch of peroneal artery.
The movements is by
Very slight movement of separation of
two bones is possible in this joint.
tahir99 - UnitedVRG

THE SUBTALAR JOINT
The subtalar joint is between inferior surface of
talus and calcaneum.
Type: A plane type of synovial joint. The joint
surfaces are somewhat curved reciprocally.
Articular surfaces
A concave facet on posterior part of inferior
surface of talus.
A posterior facet on superior surface of
calcaneum.
Ligaments
i. The lateral talo-calcaneal ligament is a
short flat band between lateral surfaces of
the two bones.
ii. The medial talo-calcaneum ligament connects the talus to sustentaculum tali of
calcaneum.
Its fibers blend with deltoid ligament.
iii. The interosseous ligament is a flat band in
the sinus tarsi.
This ligament provides axis for the
rotational movement at this joint.
Movements Inversion (adduction) and eversion
(abduction) of foot takes place at this joint.
These movements involve gliding and rotation
at this joint.
THE MID-TARSAL JOINT
(TRANSVERSE TARSAL JOINT)
This joint consists of two joints.
A. Talo-calcaneo-navicular joint.
B. Calcaneo-cuboid joint.
A. Talo-Calcaneo-Navicular Joint
Type: A ball and socket type of joint.
i. Ovoid head of talus
ii. Navicular, spring ligament and anterior
articular facet of calcaneumthat form the
socket.
Ligaments
i. The talo-navicular ligament is a broad thin
band connecting the dorsal surface of neck
of talus to the navicular bone.
137
ii. The plantar calcaneo-navicular ligament

(spring ligament) is present on plantar aspect
of the joint.
It is a broad thick band, conecting the
sustentaculum tali of calcaneum to the
navicular bone.
The spring ligament supports the head
of talus and plays an important role in
maintaining medial longitudinal arch of
the foot.
Movements: Gliding and rotational movements
at this joint result in inversion and eversion of
foot.
A small amount of dorsiflexion and plantar
flexion also occur at this joint.
Inversion:
Tibialis anterior
Tibialis posterior
Assisted by long flexors of toesflexor
digitorum longus and flexor hallucis
longus.
Eversion:
Peroneus longus
Peroneus brevis
Peroneus tertius.
B. The Calcaneo-Cuboid Joint
Type: A saddle type of synovial joint

Distal facet of calcaneum
Proximal facet of cuboid.
Articular capsulesurrounds the joint
Ligaments
i. The dorsal calcaneo-cuboid ligament is
thickening of dorsal aspect of articular capsule.
ii. The bifurcate ligament is a Y-shaped strong
band.
Stem is attached to dorsal surface of
calcaneum.
The two limbs of the Y are attached to
Dorsal surface of cuboid
Navicular
138
iii. The long plantar ligament is the longest

ligament of the foot,
Attachment
ProximallyPlantar surface of
calcaneum
Distallysuperficial fibers pass to
the bases of second, third, and fourth
metatarsals. The deep fibers are
attached to the ridge of cuboid converting the groove of peroneus longus into a tunnel.
The long plantar ligament also plays a
role in maintaining longitudinal arch of
the foot.
iv. The plantar calcaneo-cuboid (short plantar)
ligament is a short, wide band that lies deep
to the long plantar ligament.
It extends from anterior tubercle of
calcaneum to plantar surface of cuboid.
Movements
Some gliding and rotational movements
occur at this joint along with sub-talar and
talo-calcaneo-navicular joints during
inversion and eversion of foot.
THE SMALL JOINTS OF THE FOOT

The small joints of the foot are:
i. The intertarsal joints
ii. The tarso-metatarsal joints
iii. The metatarso-phalangeal joints
iv. The inter-phalangeal joints.
I. THe inter-tarsal joints are the joints between
adjacent tarsal bones.
Type Plane type of synovial joints.
Ligaments
a. The dorsal ligaments cover the dorsal
b. The plantar ligaments cover the plantar
MovementsSome gliding movements
occur at these joints, which help to change
transverse arches of foot.
II. The tarso-metatarsal joints are the joints

between bases of metatarsals and distal row of
tarsal bones.
Type - Plane type of synovial joints.
Ligaments
The dorsal ligaments are strong and flat
and cover the dorsal aspects of the joint.
The plantar ligaments cover the plantar
aspects of the joints.
Movements some gliding movements occur
at these joints.
III.The metatarso-phalangeal joints are joints between the heads of metatarsals and bases of
proximal phalanges.
Type condyloid type of synovial joints.
Articular capsules surround the joints.
Ligaments:
The plantar ligament reinforces the
plantar aspect of joint.
The deep transverse metatarsal ligaments
are short wide bands that firmly connect
the heads of metatarsals.
The collateral ligaments are two strong
bands that firmly connect the sides of
bones.
Movements at these joints are possible on
two axes.
Flexion and extension occur at transverse
axis.
Abduction and adduction take place at an
antero-posterior axis in relation to the neutral
axis of the second toe.
Muscles producing movements.
Flexion
Flexor digitorum longus
Flexor digitorum brevis
Flexor digitorum accessorius
Flexor hallucis longus (for big toe).
Extension
Extensor digitorum longus
Extensor digitorum brevis
Extensor hallucis longus (for big toe).
tahir99 - UnitedVRG

Abduction
Dorsal interossei
Abductor digit minimi
Abductor hallucis (for big toe)
Adduction
Plantar interossei
Adductor hallucis (for big toe).
IV. The inter-phalangeal joints are joints between
the phalanges.
There is one inter-phalangeal joint in big toe.
There are two inter-phalangeal joints
proximal and distalfor rest of the four toes.
Type:Hinge type of synovial joints.
Articular capsules : Surrounds the joints
Ligaments 1. There are two collateral
ligaments that firmly connect the sides of
phalanges.
Movements are flexion and extension, that
take place at a transverse axis.
Flexion
Flexor hallucis longus (for big toe)
Extension
Extensor hallucis longus (for big toe)
THE ARCHES OF THE FOOT
The foot has two major functions to perform:

a. To support the body during standing and
moving.
b. To help in forward progression during
walking, running, and jumping.
To perform these two functions effectively the
human foot has arches: both longitudinal and
transverse.
There are two longitudinal arches: medial and
lateral.
However, the one transverse arch involving the
tarsals and bases of metatarsals is half arch
completed by both feet put together.
139
I. The medial longitudinal arch: Consists of

calcaneum, talus, the navicular, three cuneiform
bones and medial three metatarsals. The talus
form, the keystone of the arch. It is a larger
and more pronounced longitudinal arch (Fig.
15.10).
The maintenance of medial longitudinal arch
done by the following factors:
a. The shape of the bones: The sustentaculum
tali supports talus, the head of talus is
received by the concavity of navicular bone.
b. The ligaments of the small joints firmly join
the tarsal bones and help to maintain the
arch.
c. The spring ligament (plantar calcaneonavicular ligament) by supporting the head
of talus is the single most important factor
in maintaining medial longitudinal arch.
d. The plantar aponeurosis acts as a tie beam
maintaining the two pillars of arch closer.
e. The short muscles of foot by their tone play
an important role.
f. The tibialis posterior, tibialis anterior and
the long flexors of the leg: suspend the arch
from above,
II. The lateral longitudinal arch: Consists of calcaneum, cuboid and fourth and fifth metatarsals.The cuboid forms the key-stone of this
arch also.
It is smaller and less prominent longitudinal
arch.
Fig. 15.10: The medial longitudinal arch of foot
140
The maintenance of lateral longitudinal

arch is done by the following factors (Fig.
15.10):
a. The shape of bones: the dorsal surface of
the bones is more extensive than the plantar
surface.
b. The long and short plantar ligaments firmly
connect the bones forming the longitudinal
arch and thus help in maintaining it.
c. The short muscles of foot by their tone help
in maintaining the arch.
d. The plantar aponeurosis acts as a tie beam
of this longitudinal arch as well.
e. The tendon of peroneus longus suspends
the lateral longitudinal arch from above.
III.The transverse arches are formed by the bases
of the metatarsal bones, cuboid and three cuneiform bones. The arch is incomplete, shaped
like a halfdome.
The maintenance of transverse arch is done
by:
a. The shape of bones whose dorsal surface
is more extensive than plantar surface.
b. The deep transverse ligaments of the sole
by tying the metatarsal heads together help
maintain transverse area.
Fig. 15.11: The lateral longitudinal arch of foot
c. The peroneus longus tendon crossing the

sole obliquely ties the ends of the arches
together.
d. The peroneus longus and brevis tendons also
suspend the arch from above.
Applied anatomy
The flat foot is a condition, where the
arches are flattened due to weakness of its
supports.
The condition causes pain and discomfort
in walking and running.
Low arches of foot can be corrected to some
extent by specially designed shoes with builtin arch supports.
tahir99 - UnitedVRG
CHAPTER
16
The Hip Region

The hip region of the lower extremity consists of
gluteal region at the back of lower end of trunk.
THE MUSCLES OF THE
GLUTEAL REGION
The muscles of the gluteal region are divided into
two groups:
A. The gluteal muscles (Table 16.1)
Gluteus maximus
Gluteus medius
Gluteus minimus
B. The small lateral rotators of the hip joint.

Piriformis
Obturator internus
Gemelli: superior and inferior
Obturator externus
Quadratus femoris
Relations of Gluteus Maximus (Fig. 16.1)
Superficial
Skin
Superficial fascia containing plenty of fat
Table 16.1: The gluteal muscles

Name
Origin
1. Gluteus Posterior gluteal line

maximus
and posterior surface
of ilium above it
Aponeurosis of
erector spinae
Muscle belly
Insertion
Largest muscle in
body
Thick quadrilateral
muscle belly
Dorsal surface of
sacrum and side of
coccyx
Sacro-tuberous ligament
Deep fascial covering
gluteus medius
2. Gluteus Posterior surface of
medius
ilium between posterior and middle
gluteal lines
Deep fascia covering
it
3. Gluteus Posterior surface of
minimus
ilium between middle
and inferior gluteal lines
4. Tensor Anterior 5 cm
fascialata of outer lip of
liac crest
Thick muscle belly

Fibers converge to
form a flat tendon
Fan shaped
muscle belly
Fibers converge to
form a flat tendon
Short flat musde
belly
Nerve supply
Main actions
Upper, larger Inferior gluteal I. Powerful extensor

and superficial (L5, S1, S2)
of hip joint
three fourth
II. Straightens trunk
attached to
on limb and limb
iliotibial tract
on trunk in all
Lower and
walking, running
deeper fourth
and jumping
attached to
movements
gluteal tuberIII. Upper fibers help
osity
in abduction of hip
joint
IV. Supports hip and
helps to maintain
erect posture
Oblique ridge Superior
on lateral as- gluteal
pect of greater (L5, S1)
trochanter of
femur
Antero-lateral
surface of greater
trochanter of
femur
Ilio-tibial
tract
Superior
gluteal
L5, S1
Superior
gluteal
I. They abduct the

thigh and rotate it
medially
II. They supports the
pelvis, when foot
is raised off the
ground thus help
in walking and
running
I. It assists in
abduction and
medial rotation
of thigh
II. It helps to steady
the pelvis
142
Fig. 16.1: The structures under cover of gluteus maximus
Deep fascia
Deep
Bones - Ilium, sacrum and coccyx, ischial
tuberosity, greater trochanter.
Ligament
Sacro-tuberous ligament.
Muscles
Gluteus medius
Piriformis
Tendon of obturator internus
Gemelli-superior and inferior
Quadratus femoris
Attachments of semi-membranosus,
semi-tendinosus and biceps femoris.
Vessels and nerves
Superficial branch of superior gluteal
artery
Inferior gluteal artery and nerve
Sciatic nerve
Internal pudendal vessels
Pudendal nerve
Posterior cutaneous nerve of thigh
First perforating branch of profunda
femoris artery
Branches of medial circumflex femoral

artery.
Bursatrochanteric bursa.
Proximal bordercrosses gluteus medius
Distal bordersloping downwards and laterally
crosses the posterior gluteal fold.
Relations of Gluteus Medius
Superficial
Skin, superficial fascia
Deep fascia
Overlapped by gluteus maximus
Deep
Gluteus minimus
Superior gluteal vessels
Superior gluteal nerve
Trochanteric bursa
Relations of Gluteus Minimus
Superficial
Gluteus medius
Deep
tahir99 - UnitedVRG
The Hip Region

Reflected head of rectus femoris
Articular capsule of hip joint
Trochanteric bursa
The Blood Vessels of the Gluteal Region

The Arteries
1. The superior gluteal artery is a branch of
posterior division of internal iliac artery.
CourseThe artery leaves pelvis by passing
through greater sciatic foramen above
piriformis along with superior gluteal nerve.
The artery divides into a superficial
branch and a deep branch.
The superficial branchpasses deep to
gluteus maximus and anastomoses with
inferior gluteal artery.
The deep branch passes deep to gluteus
medius along with superior gluteal
nerve, and divides into a superior and
143
inferior ramus to supply the gluteal

muscles.
The deep branch anastomoses with
lateral and medial circumflex femoral
and inferior gluteal arteries.
It also gives an articular branch to the
hip joint.
2. The inferior gluteal artery is a branch of anterior
division of internal iliac artery.
CourseThe artery leaves pelvis by passing
through greater sciatic foramen, below
piriformis along with inferior gluteal nerve.
The artery enters the deep surface of
gluteus maximus muscle and supplies it.
Branches
I. The descending branch anastomoses
with the ascending branch of first perforating artery and transverse branches
of lateral and medial circumflex femoral
artery to form cruciate anastomosis
Table 16.2: Small lateral rotators of hip joint

Name
1. Piriformis
2. Obturator
internus
3. Gemellus
superior
Gemellus
inferior
4. Obturator
externus
5. Quadratratus femoris
Origin
By three digitations
from front of middle
three pieces of sacrum
Upper margin of
greater sciatic notch
Pelvic surface of ilium
and margins of obturator foramen-Internal
surface of obturator
membrane
Dorsal aspect of
ischial spine
Ischial tuberosity
along lesser sciatic
notch
Outer surface of
pubic bone and margins of obturator
foramen
Outer surface of
obturator membrane
Upper part external
surface of ischial
tuberosity
Muscle belly
Tapering muscle belly
gives rise to a round
tendon
Insertion
Nerve supply
Upper border of
L5, S1, S2 VR
greater trochanter
of femur
Main actions
I. It rotates extended
thigh laterally
II. It abducts the
flexed thigh
Muscle belly flat forms Medial surface of

a tendon that enters
greater trochater
gluteal region through of femur
lesser sciatic foramen
Nerve to
obturator
internus
(L5, S1)
I. It rotates extended
thigh laterally
II. It abducts the
flexed thigh
Muscle fibers blend

with upper border
of tendon of obturator internus
Muscle fibers blend,
with lower border
of tendon of obturator internus
Flat and triangular
muscle belly
Tendon crosses
behind and then
below hip joint

Medial surface of
greater trochanter
Medial surface of
greater trochanter
Trochanteric fossa
on medial surface
of greater trochanter
Nerve to
obturator
internus
L5, S1
Nerve to quadratus femoris
L5, S1
It helps in action
of obturator internus
Posterior branch
of obturator
L5, L4
It laterally rotates
the hip joint
Flat and quadrangular Fibers pass

behind hip joint
Quadrate tubercle
on trochanteric
crest of femur
It helps in action
of obturator
internus
Nerve to quadralus It laterally rotates

the hip joint
femoris L51, 51
144

on postero-lateral aspect of greater
trochanter of femur.
II. The inferior gluteal artery anastomoses
with superior gluteal artery and gives an
articular branch to the hip joint.
The Veins
The venae comitantes accompany the superior

and inferior gluteal arteries.
These veins end in internal iliac vein.
These deep veins are connected by gluteal
perforating veins with the superficial veins of
gluteal region, which drain in the femoral vein.
The Lymphatic Drainage of the

Gluteal Region
The superficial lymphatics of the gluteal region

end in the superficial inguinal lymph nodes.
The Nerves of the Gluteal Region

1. The superior gluteal nerveis a branch of
sacral plexus and derives its root value from
posterior division of ventral rami of L4,L5,S1.
CourseThe nerve leaves the pelvis by
passing through greater sciatic foramen,
along with superior gluteal vessels, above
piriformis.
The nerve passes deep to gluteus medius
and divides intoa superior branch and
an inferior branch.
The superior branchaccompanies the
superior branch of superior gluteal artery
and supplies gluteus medius.
The inferior branch runs along the
inferior branch of superior gluteal artery
and supplies gluteus medius, gluteus
minimus and tensor fascia lata.
Branches
I. The muscular branches supply:
Gluteus medius
Gluteus minimus
Tensor fascia lata
II. The articular branch supplies the hip

joint.
2. The inferior gluteal nerve is a branch of sacral
plexus and derives its root value from posterior
division of ventral rami of L5,S1,S2.
CourseThe nerves leaves the pelvis
through greater sciatic foramen below
piriformis along with inferior gluteal vessels.
On entering gluteal region, the nerve
passes to the deep surface of gluteus
maximus, to supply it.
Branches
I. The muscular branch supply gluteus
maximus.
II. The articular branch supplies the hip
joint.
3. The sciatic nerve is the thickest nerve in the
body. It is branch of sacral plexus.
The sciatic nerve consists of two nerves
enclosed in a common sheath.
a. The tibial nerve is a branch of ventral
divisions of ventral rami of L4 L5, S1,
S2, S3.
b. The common peroneal nerve is a branch
of posterior divisions of ventral rami of
L4, L51,S1,S2.
CourseThe sciatic nerve leaves the pelvic
wall by passing through greater sciatic
foramen below piriformis. The sciatic neve
does not give a branch in gluteal region.
The nerve lies deep to gluteus maximus.
The nerve descends with convexity
between ischial tuberosity and greater
trochanter, to enter posterior compartment of thigh.
It crosses obturator internus tendon with
two gemelli and quadratus femoris in its
course.
4. The nerve to quadratus femoris is a branch of
sacral flexus, and arises from ventral divisions
of ventral rami of L4,L5, and S1 nerves.
Course
The nerve leaves pelvis by passing
through the greater sciatic foramen
below piriformis.
tahir99 - UnitedVRG
The Hip Region

It enters gluteal region and lies deep to
the sciatic nerve.
Then it passes deep to obturator internus
tendon and gemelli and reaches the deep
surface of quadratus femoris.
Branches
I. Muscular branches supply
Quadratus femoris
Inferior gemellus
II. Articular branch supplies
Hip joint
5. The nerve to obturator internus is a branch of
sacral plexus and arises from ventral divisions
of ventral rami of L5,S1 and S2 nerves.
CourseThe nerve leaves pelvis, by passing
through greater sciatic foramen below
piriformis.
It enters gluteal region and lies deep to
the gluteus maximus.
The nerve crosses the base of ischial
spine along with internal pudendal
vessels and enters lesser sciatic notch.
It enters the obturator internus muscle
to supply it.
Branches
Obturator internus
Superior gemellus
145
6. The pudendal nerveis a branch of sacral

plexus from ventral divisions of ventral rami of
S2,S3 and S4 nerves.
CourseThe nerve enters gluteal region by
passing through greater sciatic foramen,
below piriformis.
It lies deep to gluteus maximus muscle.
It crosses the tip of ischial spine and
enters lesser sciatic foramen, accompanied by internal pudendal vessels and
nerve to obturator internus.
From gluteal region, the pudendal nerve
enters pudendal canal in ischio-rectal
fossa of perineum.
It does not give any branch, in gluteal
region.
7. The posterior femoral cutaneous nerve is a
branch of sacral plexus and arises from dorsal
divisions of S1 and S2 and ventral divisions of
S2 and S3 ventral rami.
CourseThe nerve enters gluteal region by
passing, through greater sciatic foramen
below piriformis.
The nerve lies superficial to sciatic nerve
and deep to gluteus maximus as it
descends down.
The nerve enters posterior compartment
of thigh at lower border of gluteus
maximus.
It does not give any branch in gluteal
region.
CHAPTER
17
The Region of
the Thigh
The region of the thigh includes:
A. The anterior compartment of thigh including
femoral triangle and adductor canal.
B. The medial compartment of the thigh.
C. The posterior compartment of the thigh.
D. The popliteal fossa at the back of knee.
THE ANTERIOR COMPARTMENT OF THE
THIGH (Table 17.1)
The muscles of the anterior compartment are:
I. Iliacus
II. Psoas major
III. Psoas minor

IV. Quadratus femoris having four heads
Vastus medialis
Vastus lateralis
Vastus intermedius
Rectus femoris
V. Sartorius
The Femoral Triangle (Fig. 17.1)
The femoral triangle is a triangular intermuscular
space on front of upper one-third of thigh.
Table 17.1: Muscles of the anterior compartment

Origin
Muscle belly
Insertion
Nerve supply
1. Iliacus
Name
Upper two-third of iliac

fossa, Ala of sacrum
Anterior sacro-iliac
ligament
Anterior surface and
lateral borders of transverse processes of five
lumbar vertebrae
Five digitations from
sides of two lumbar
vertebrae and the inter
vertebral discs
From four tendonous
arches joining the two
digitations from side of
lumbar vertebrae
Four heads
a. Vastus medialis
Distal part of inter trochanter line
Spiral line
Medial lip of linea
aspera Proximal part
medial supracondylar
Lesser trochanter
of femur For 2.5
cm below lesser
trochanter on
the shaft of femur
Summit of lesser
trochanter along
with iliacus
Femoral
(L2, L3)
2. Psoas
major
Flat, triangular muscle

belly Fibers converge
towards lateral side to
form a strong tendon
with psoas major
Long fusiform muscle
belly lies lateral to
lumbar part of vertebral column
Descends along pelvic
inlet and its tendon is
joined by iliacus from
lateral side
Large muscle belly,

covers front and
sides of shaft of
femur
Tendons of four
heads unite to form
a strong tendon
above patella
Base of patella
Insertion is carried
by ligamentum
patellae to the tuberosity of tibia
(patella being sesamoid bone) Medial
and lateral patellar
Femoral
L2, L3, L4
(Separate
branches are
given to the
four heads of
quadriceps
femoris)
3. Quadriceps
temoris
Ventral rami
L1, L2 from
lumbar plexus
Main actions
I. Powerful flexor of
hip joint with
psoas major
II. Helps to maintain
posture at hip joint
I. Same as iliacus
II. Helps to bend
trunk on lower
limb while getting
up.
III. Does not act as
medial rotator of
hip joint; rather
helps in lateral
rotation
I. Powerful extensor
of knee joint
II. Rectus femoris
helps in flexing of
of hip joint
III. Helps to maintain
posture at knee
joint
Contd...
tahir99 - UnitedVRG
The Region of the Thigh
147
Contd...
Name
Origin
line
b. Vastus lateralis
Intertrochanteric line
Anterior and inferior
borders of greater trochanter Lateral lip of linea
aspera
Proximal half
lateral supracondylar
line
c. Vastus intermedius
Proximal two-third
anterior and lateral
surfaces of femur
d. Rectus femoris
I. Straight head-anterior inferior iliac spine
II. Reflected headgroove above acetabulum
4. Sartortus Anterior superior iliac
spine
Upper half of the
notch below it.
5. Psoas
From sides of
minor
12th thoracic and 1st
(absent Lumbar vertebra
in 40%
subjects)
Muscle belly
Insertion
Nerve supply
retinacula are expansions attached
to sides of patella
Some lower fibers
of vastus medialis
are directly attached
to medial border of
patella
Main actions
IV. Lowest fibers of
vastus medialis
stabilize patella
by preventing its
lateral displacement during
contraction of
quadriceps femoris
Articularis genu are

deepest and lowest
fibers of vastus intermedius attached to
synovial membrane
of knee joint.
Long, strap like

muscle belly
Crosses the front
of thigh obliquely
to reach medial side
of tibia
Upper part medial Femoral

surface of tibia in
front of gracitis
(L2, L3)
and semi-tendinosus
Small muscle belly

with long tendom
Pecten
pubes
Fig. 17.1: The femoral triangle
VRL 1
I. Flexion and
abduction of hip
joint
II. It also helps in
lateral rotation of
hip joint.
III. It also helps in
flexion of knee
joint (The combination of these
movements helps
the tailor to work
his foot-operatedsewing machine.
1. Weak flexor of
trunk
148
Boundaries
Lateral Medial border of sartorius
Medial Medial border of abductor longus
Apex lies below, where sartorius overlaps
adductor longus
Base Inguinal ligament
Floor (deep boundary) is formed by
Iliacus
Psoas major
Pectineus
Adductor longus
Roof (superficial boundary) is formed by
Skin, superficial fascia with superficial
inguinal lymph nodes.
Deep fascia (fascia lata) of thigh.
Contents
I. Arteries Femoral artery and its branches
Three superficial branches
Superficial external pudendal
Superficial epigastric
Superficial circumflex iliac
Deep external pudendal
Profunda femoris and its two branches
Lateral circumflex femoral
Medial circumflex femoral
II. Veins Femoral vein and its tributaries
III.Nerves
Femoral nerve and its branches
Part of lateral femoral cutaneous
Femoral branch of genito femoral nerve
IV. Deep inguinal lymph nodes
V. Fibro-fatty tissue
The Adductor Canal (Sub-Sartorius or

Hunters Canal) (Fig. 17.2)
The adductor canal is a narrow intermuscular canal
on front of middle one-third of thigh, medial to the
shaft of femur.
Boundaries
Antero-lateral: Vastus medials
Antero-medial (Roof) : A thick fascia deep
to sartorius
Posterior:
Adductor longus (in upper part)
Adductor magnus (in lower part)
Communications
Superiorly: Adductor canal communicates
with apex of femoral triangle
Posteriorly: Adductor canal communicates
through hiatus magnus (an osseo-aponeurotic opening in adductor magnus) with
popliteal fossa.
Contents
I. Femoral artery and its descending genicular
branch.
II. Femoral vein
III. Saphenous nerve.
IV. Nerve to vastus medials
Applied anatomy Ligation of femoral artery is
done in adductor canal for treating the aneurysm
of popliteal artery (Hunters operation)
Fig. 17.2: The adductor canal
tahir99 - UnitedVRG

The Blood Vessels of the Anterior
Compartment
The Arteries
The femoral artery is the main arterial trunk of the
lower extremity.
BeginningThe artery begins deep to midinguinal point as continuation of external iliac
artery.
CourseThe femoral artery descends almost
vertically in the femoral triangle up to its apex.
The lower part of the artery descends in
the adductor canal, medial to the shaft of
femur.
In femoral triangle, the femoral artery lies
quite superficially on the muscles of the
floorpsoas major, pectineus and adductor
longus
In adductor canal it is separated from shaft
of femur by vastus medialis.
TerminationThe femoral artery passes through
the hiatus magnus and enters popliteal fossa as
popliteal artery.
Branches
In the femoral triangle.
I. The three superficial branches
a. Superficial external pudendal passes
medially to supply external genitals
b. Superficial epigastric is directed upwards and medially in anterior abdominal
wall towards umbilicus
c. Superficial circumflex iliac: passes laterally towards iliac crest.
II. The deep external pudendalpasses medially deep to femoral vein to supply external
genitals.
III. The profunda femoris arteryis a large
branch that arises from lateral side of highest
part of the femoral artery.
The profunda artery gives two brancheslateral and medial circumflex
femoraland leaves the triangle by
passing deep to adductor longus.
149
The lateral circumflex femoral passes

laterally deep to sartorius and rectus
femoris and divides into three branchesascending, transverse and
descending.
The medial circumflex femoral artery has
a very short course in femoral triangle.
It leaves the triangle between psoas
major and pectineus.
In the adductor canal
IV. The descending genicular branch descends
from adductor canal and joins the anastomosis around the knee joint.
The Veins
The venous return from the front of thigh is by
two sets of veinssuperficial and deep.
A. The superficial veins
The long saphenous veinis the longest
superficial vein in the body.
CourseIt ascends on the medial side of
the knee and then gradually ascends a little
laterally to reach the saphenous opening in
upper part of front of thigh.
There are many valves in long saphenous
vein that direct the venous blood, against
gravity upwards.
TerminationThe long saphenous vein
pierces the cribriform fascia by hooking
around lower sharp margin of saphenous
opening and ends in femoral vein.
Tributaries
I. Three superficial veins that accompany
the three superficial branches of femoral
artery.
Superficial external pudendal
Superficial epigastric
Superficial circumflex iliac
II. Other superficial veins from the front
of thigh
III. Perforating veins that connect the long
saphenous vein to the deep veins of front
of thigh.
150
B. The deep veins

I. The femoral veinaccompanies the femoral
artery in the adductor canal and femoral
triangle.
BeginningThe femoral vein begins at
the hiatus magnus as continuation of the
popliteal vein.
CourseThe femoral vein ascends up
in the adductor canal lying posterolateral and then posterior to the femoral
artery.
In the femoral triangle, the artery at
first, lies behind the femoral artery
at the apex of triangle. Then the
femoral vein ascends lying medial to
the artery.
TerminationThe femoral vein passes
deep to the inguinal ligament and continues as external iliac vein.
Tributaries:
I. Small muscular veins
II. Descending genicular veins
III. Profunda vein
IV. Medial circumflex femoral vein
V. Lateral circumflex femoral vein
VI. Long saphenous vein
The Lymph Nodes of the
Anterior Compartment
These lymph nodes are divided into two groups superficial and deep.
A. The superficial inguinal nodes are present in
the superficial fascia below inguinal ligament.
These are further divided into
I. The proximal horizontal group of four to
five nodes
The lateral nodes of this group receive lymph
from
The gluteal region
Anterior abdominal wall below umbilicus
The medial nodes of this group receive
lymph from:
The external genitals (including lower

part of vagina in females)
Lower part of anal canal
The perineum
Some lymphatics from fundus of uterus
in females reach along with round
ligament of uterus.
II. The distal vertical groupof four to five
nodes accompanies upper part of long
saphenous vein. This group receives lymph
from lower limb. The superficial lymph
nodes drain into external iliac lymph nodes.
B. The deep inguinal lymph nodes are one to three
in number and lie in relation to femoral vein.
One small node lies inside femoral canal
They receive lymph from
The lower limb
The glans of penis in males and clitoris
in females.
Few efferents from superficial lymph
nodes.
These lymph nodes drain in the external iliac
lymph nodes.
Compartment
I. The femoral nerve is a branch of lumbar plexus,
arising from posterior divisions of ventral rami
of L2, L3 and L4 nerves.
CourseThe femoral nerve enters front of
thigh deep to the inguinal ligament, lateral
to the femoral artery.
The nerve has a very short course in
femoral triangle and divides into a
superficial and a deep division.
Branches
From the superficial division
i. Muscular branches to
Pectineus
Sartorius
ii. Cutaneous branches
Intermediate femoral cutaneous
Medial femoral cutaneous
tahir99 - UnitedVRG

From the deep division
iii. Four muscular branches to four heads
of quadriceps femoris
Vastus medialis
Vastus lateralis
Vastus intermedius
Rectus femoris
iv. Articular branches
To hip joint via nerve to rectus
femoris
To knee joint via the three branches
to vasti
v. Cutaneous branch
Saphenous nerve
vi. Vascular branches
Supply the femoral vessels
II. The lateral femoral cutaneous nerve
It is a branch of lumbar plexus arising from
posterior divisions of ventral rami of L2 and L3
nerves
CourseThe lateral femoral cutaneous
enters the lateral angle of femoral triangle
by passing deep to the inguinal ligament.
The nerve divides into an anterior and a
posterior branch. Both pierce deep fascia of thigh and supply skin on the lateral
aspect of thigh.
III.The femoral branch of genitofemoralThe
genito-femoral nerve arises from ventral
divisions of ventral rami of L1 and L2 nerves of
lumbar plexus.
151
CourseThe femoral branch of genitofemoral enters femoral triangle by descending inside femoral sheath lateral to the
femoral artery.
The nerve pierces anterior wall of rectus
sheath and deep fascia of front of thigh
It supplies skin of upper part of femoral
triangle.
The Femoral Sheath (Fig. 17.3)

The femoral sheath is a funnel shaped fascial sheath
that surrounds the uppermost part of femoral vessels
in the femoral triangle.
Formation
Anteriorly by fascia transversalis
Posteriorly by fascia iliaca
Size
Lateral wall is 3.0 cm long
Medial wall is very oblique and is only
1.2 cm long.
Relations
Anterior: Saphenous opening covered by
cribriform fascia
Posterior: Fascia covering pectineus
CompartmentsThe femoral sheath is divided
by two septa into three compartments:
Lateral compartment has femoral artery and
femoral branch of genitofemoral nerve
Intermediate compartment has femoral vein
Fig. 17.3: The femoral sheath
152
Medial compartment is empty and is known

as femoral canal.
The Femoral Canal

The femoral canal is the medial compartment of
femoral sheath.
ShapeFunnel shaped
Size1.2 cm long
Sex differenceThe femoral canal is wider in
females as:
I. The distance between pubic tubercle and
anterior superior iliac spine is more in
females, bony pelvis being wider.
II. The femoral vessels are smaller in size in
females.
The femoral ring is the upper end of femoral
canal that opens towards abdominal cavity.
The femoral ring is closed by a plug of fat
known as femoral septum.
Boundaries of femoral ring
LateralFemoral vein
MedialSharp edge of lacunar ligament
AnterialInguinal ligament
PosteriorPectineal line of pubic bone
Content of femoral canalBeside some areolar
tissue, it contains a small lymph node of deep
inguinal group.
The Femoral Hernia
The femoral hernia is abnormal protrusion of some
abdominal content through femoral canal. The
femoral hernia is more common in females.
CourseThe femoral hernia passes through
femoral ring in the femoral canal.
It forms a small swelling below the inguinal
ligament.
Later, it bulges through the saphenous
opening and bends upwards above the
inguinal ligament.
Strangulation of femoral hernia is common
as hernia has to pass through a very narrow
femoral ring.
Reduction of femoral herniamay be possible

manually if the hernia is small.
However, surgical reduction may be
required if strangulation is set in.
The lacunar ligament has to be divided to
relieve strangulation. Care has to be taken
to ligate the abnormal obturator artery
before-hand.
This artery may be present on deep surface
of lacunar ligament. The artery is formed
by enlargement of anastomosis of pubic
branches of obturator and inferior epigastric
arteries.
Differences from the inguinal hernia
i. The femoral hernia lies below the inguinal
ligament.
ii. The femoral hernia begins below and lateral
to the pubic tubercle.
THE MEDIAL COMPARTMENT

OF THE THIGH
A. The muscles of the medial compartment are (Fig.
17.4 and Table 17.2):
i. Adductor longus
ii. Adductor brevis
iii. Adductor magnus
iv. Pectineus
v. Gracilis
The Blood Vessels of Medial
Compartment
The Arteries
1. The profunda femoris artery is a large artery
that mainly supplies the muscles of thigh.
OriginThe profunda femoris artery arises
from lateral side of upper part of femoral
artery in femoral triangle.
CourseThe artery passes downwards and
medially deep to adductor longus.
At the apex of femoral triangle, the
profunda artery lies deep to the femoral
artery separated by profunda vein,
adductor longus and femoral vein.
tahir99 - UnitedVRG
153
Table 17.2: The muscles of the medial compartment

Name
Origin
Muscle belly
1. Adductor By a narrow tendon from Flat and triangular

longus
front of pubic bone
muscle belly
Insertion
Nerve supply
Linea aspera
between vastus
medialis and
adductor magnus
Main actions
Anterior division I. Adduction of hip

of obturator
joint
L2, L3 and L4
II. Help in flexion
medial rotation of
thigh.
2. Adductor Narrow origin from
Flat and triangular
Posterior surface Anterior division I. Adduction of hip
brevis
front of body of
muscle belly
of femur on a line of obturator
joint.
pubis and inferior
descending from L2, L3 and L4
II. Help in flexion of
ramus of pubis
lesser trochanter
of thigh
to linea aspera
3. Adductor Outer surface inferior
Large, triangular
Medial margin
Composite muscle I. Powerful adductor
magnus ramus of pubis and
muscle belly
gluteal tuberosity -Adductor part
of hip joint
conjoint ramus
Forms the main
Linea aspera and Posterior diviII. Helps in lateral
Infero-lateral surface of
muscular mass on
medial supra
sion of obturrotation of thigh
ischial tuberosity
medial side of thigh
condylar line
ator L2, L3, L4
(Ischial part)
-Ischial part des- -Ischial part
cends to form a Tibial division
tendon attached of sciatic
to adductor tubercle
4. Pectineus Pectineal line and pecti- Flat and quadrangular Line descending Femoral L2, L3
I. Adduction of hip
neal surface of pubic bone muscle belly
from lesser tro- Accessory obtujoint
chanter to linear rator L5 (if pre- II. Helps in flexion
aspera
sent) Branch
of thigh
from obturator
(sometimes)
5. Gracilis Medial margin body of
Thin and flat muscle Upper part of
Anterior division I. Helps in adduction
pubis
belly
medial surface of obturator L3, L4
of hip joint
Medial margin
Broad above
tibia between
II. Helps in flexion
of conjoint ramus
but narrows below
sartorius and
and medial rotasemi-tendinosis
tion of leg
Fig. 17.4: A section through medial compartment of thigh
154

The artery descends along the medial
side of shaft of femur.
TerminationThe profunda femoris artery
terminates as the fourth perforating artery,
that anastomoses with superior muscular
branches of popliteal artery.
Branches
I. The lateral circumflex femoral artery
arises in femoral triangle and passes
laterally deep to rectus femoris and
divides into three branches:
a. An ascending branchthat anstomoses with inferior gluteal artery.
b. A transverse branchthat forms
cruciate anastomosis at back of
greater trochanter with:
Transverse branch of medial circumflex femoral.
Descending branch of inferior
gluteal
Ascending branch of first perforating artery.
c. A descending branchthat takes
part in anastomosis around knee
joint.
II. The medial circumflex femoral artery
arises from the profunda artery in
femoral triangle.
CourseIt passes backwards between psoas major and pectineus,
then between obturator externus and
adductor brevis.
BranchesIt reaches upper border
of adductor magnus, deep to
quadratus femoris and divides into
two branches:
a. An ascending branch: that
ascends towards neck of femur.
b. A transverse branch that takes
part in cruciate anastomosis.
III.Four perforating branches: (the fourth
being the terminal branch of profunda
femoris artery).
CourseThe perforating branches

curve laterally behind the shaft of
femur piercing the muscles attached
to linea aspera.
They end by supplying vastus
lateralis.
BranchesThese arteries give three
sets of branches.
a. Muscular branches supply
muscles of thigh
b. An ascending these anastomose
branch
with each other and
c. A descending form a chain of arbranch
terial anastomoses
at back of thigh.
2. The obturator artery is a branch of anterior

In about 30 percent cases this artery may
arise from the inferior epigastric artery, and
is known as abnormal obturator artery.
CourseThe artery enters the medial
compartment of thigh through upper part
of obturator foramen.
The artery does not descend in thigh and
ends by dividing into an anterior and a
posterior branch.
Branches
I. The anterior branch supplies adductor
muscles and anastomoses with medial
circumflex femoral artery.
II. The posterior branch supplies the hamstring muscles and gives an acetabular
branch to the acetabular fossa.
The Veins
The profunda femoris vein accompanies the

profunda femoris artery.
It recieves tributaries corresponding to the
branches of profunda femoris artery except the
medial and lateral circumflex femoral veins that
open directly in femoral vein.
The profunda vein drains into femoral vein.
tahir99 - UnitedVRG

The Nerves of the Medial Compartment
1. The obturator nerve is a branch of lumbar plexus
and arises from ventral divisions of ventral rami
of L2, L3 and L4 nerves.
CourseIt enters medial compartment of
thigh through upper part of obturator foramen along with obturator vessels.
As it passes through the obturator foramen, it divides into an anterior and a
posterior branch.
a. The anterior branchdescends in
the medial compartment of thigh
between adductor longus and pectineus superficially and adductor
brevis deep to it.
b. The posterior branchdescends in
the medial compartment between
adductor brevis and adductor magnus.
Branches
From the anterior division
Adductor longus
Adductor brevis
Gracilis
Pectineus (sometimes)
II. Cutaneous branches supply
Skin of medial side of thigh
Subsartorial plexus: a plexus of
cutaneous nerves deep to sartorius
formed by three nerves:
Saphenous
Medial femoral cutaneous
Anterior division of obturator
III.Articular to hip joint
IV. Vascular to femoral artery
From the posterior division
Obturator externus
Adductor magnus (adductor part)
II. Articular to knee joint
2. The accessory obturator nerve is a small nerve
that is sometimes present.
155
The nerve arises from the lumbar plexus taking

its origin from ventral divisions of ventral rami
of L3 and L4 nerves.
CourseThe accessory obturator nerve
descends superficial to the superior ramis
of pubis, medial to psoas major muscle.
Branches
I. Muscular branch to
Pectineus
II. Articular branch to hip joint
[Sometimes the nerve may take up the
supply of anterior division of obturator
nerve].
THE POSTERIOR COMPARTMENT
OF THE THIGH
The posterior compartment of the thigh is also
known as the flexor compartment of the thigh.
1. The muscles of the posterior compartment are
(Fig. 17.5 and Table 17.3):
i. Biceps femoris
ii. Semi-tendinosus
iii. Semi-membranosus
iv. Ischial part of adductor magnus (described
earlier)
These muscles are known as hamstring muscles.
Their common features are:
a. These muscles take origin from the ischial
tuberosity.
b. These muscles are inserted in one of the
bones of leg.
c. The nerve supply of hamstring muscles is
by the tibial nerve [part of sciatic nerve]
d. The hamstring muscles are flexors of the
knee joint and extensors of the hip joint.
The Blood Vessels of the
Posterior Compartment
The blood supply of the posterior compartments

is done by a chain of arterial anastomosis at the
back of thigh.
This anastomosis supplies the muscles and skin
of the back of thigh.
156
Fig. 17.5: The muscles of gluteal region and posterior compartment of leg
The following arteries take part in this anastomosis:

i. The descending branch of inferior gluteal
artery
ii. The ascending and descending branches of
the four perforating branches of profunda
femoris artery.
iii. The superior muscular branches of popliteal
artery.

Compartment
1. The sciatic nerveDescends in the posterior
compartment from the gluteal region.
OriginThe sciatic nerve is a composite
nerve made up of two separate nerves
enclosed in a common sheath.
a. The tibial nerveL4,L5,S1,S2,S3 (ventral

divisions of ventral rami).
b. The common peroneal nerveL 4,
L5,S1,S2 (dorsal divisions of ventral
rami).
Course in posterior compartment
The sciatic nerve as it descends lies deep to
biceps femoris and superficial to adductor
magnus.
It bifurcates about the middle of back of
thigh into its two terminal branches the
tibial and common peroneal nerves.
The two branches enter the popliteal
fossat the back of knee.
Branches
I. The muscular branches from the tibial
nerve part are
tahir99 - UnitedVRG
157
Table 17.3: The muscles of the posterior compartment

Name
1. Biceps
femoris
Origin
Muscle belly
Insertion
Nerve supply
Two heads
a. Long head arises from
lower medial area of
ischial tuberosity in
conjunction with semitendinosis
b. Short head from
lateral lip of aspera
The long head forms

a funiform muscle
belly, joined by short
head
Forms a narrow tendon, that passes
laterally
Lateral surface
head of fibula
The tendon is
grooved by
fibular collateral ligament
Long head-tibial
Short headcommon peroneal L5, S1, S2
2. SemiLower medial part of

tendino- ischial tuberosity in
sus
conjunction with long
head of biceps femosis
Fusiform muscle badly Upper part

Tibial
Gives rise to a long
medial surface L5, S1, S2
tendon in middle of
of tibia, behind
thigh
gracilis and
sartorius
3. Semimembranosus
Upper half of muscle

is aponeurotic
Lower half is muscular
Lower end forms a
tendon
Upper lateral part of

ischial tuberosity
Long head of biceps femoris

Semi-tendinosus
Semi-membranosus
Ischial part of adductor magnus
From common peroneal nerve:
Short head of biceps femoris
II. Articular branch
To hip joint
Applied anatomy
I. The sleeping foot: consist of tingling and
numbness in the back of lower limb,
caused by compression of sesory fibers
of sciatic nerve against the back of
femur.
II. The sciatica: is the name given to the
low back pain, that radiates to the back
of lower limb. There may be several
causes of sciatica; it may be also due to
involvement of sensory nerve fiber, of
the sciatic nerve.
Groove on
Tibial
posterior
L5, S1,2
aspect medial
condyle of tibia
Two expansions
given from
insertion
a. Fascia convering popliteus
b. Oblique popliteal ligament
of knee joint
Main actions
I. It flexes the knee
joint
II. It helps in extension of hip joint
III. It helps in lateral
rotation of leg
joint
III. It helps in medial
rotation of leg
joint
III. It helps in medial
rotation of leg
THE POPLITEAL FOSSA

The popliteal fossa is a diamond-shaped intermuscular hollow space at the back of knee
(Fig.17.6).
Boundaries
I. The side boundaries
Upper lateral: Biceps femoris
Upper medial: semi-membranosus
Adductor magnus
Assisted by semi-tendinosus gracilis
and sartorius.
Lower lateral: Lateral head of gastrocnemius
Assisted by plantaris
Lower medial: Medial head of gastrocnemius
II. The superficial boundary (roof)
Skin, superficial fascia
Deep fascia of back of knee (popliteal
fascia)
158
Fig. 17.6: The popliteal fossaboundaries
III. The deep boundary (Floor)

Popliteal surface of lower end of femur
The back of knee joint reinforced by
oblique popliteal ligament.
Fascia covering popliteus.
Contents (Fig. 17.7)

I. The popliteal artery and its branches
II. The popliteal vein and its tributaries
III. The tibial nerve and its branches
Fig. 17.7: The popliteal fossadeep contents
tahir99 - UnitedVRG

IV. The common peroneal nerve and its branches
V. Popliteal lymph nodes
VI. Fibro-fatty tissue
Applied Anatomy
a. The aneurysm of popliteal artery forms a
pulsatile tumor behind the knee. It can be
surgically treated by ligating femoral artery in
the adductor canal.
b. The popliteal artery can be compressed against
the popliteus muscle, when the knee is flexed.
I. The popliteal artery is the main arterial trunk
of the lower limb in the popliteal fossa.
BeginningThe popliteal artery begins at
the hiatus magnus (in adductor magnus
muscle) as continuation of femoral artery.
CourseThe artery descends in the deep
part of the fossa with a lateral inclination.
The artery passes between the two condyles of femur at the back of knee joint.
The artery descends on fascia covering
popliteus, overlapped by gastrocnemius
The artery is crossed from behind by
the popliteal vein and the tibial nerve.
Termination At the lower border of
popliteus, the popliteal artery bifurcates into
its two terminal branches: the anterior tibial
and posterior tibial arteries.
Branches
a. The muscular branches
The superior muscular branches
supply the hamstring muscles at back
of thigh.
The inferior muscular branches
supply the muscles of calf.
b. The cutaneous branches supply the skin
of the back of leg.
c. The genicular branches (five) pass deep
to the muscles of side boundaries and
take part in anastomosis around the knee
joint.
Superior medial genicular
Superior lateral genicular
159
Inferior medial genicular

Inferior lateral genicular
Middle genicular
II. The popliteal vein is formed at the lower
border of popliteus by the union of venae
comitantes of anterior tibial and posterior tibial
arteries.
The popliteal vein ascends in the popliteal
fossa first medial, then posterior and findly
postero-lateral to the popliteal artery.
The popliteal vein passes through hiatus
magnus and continues as femoral vein in
adductor canal.
Tributaries
a. The veins accompanying the branches
of popliteal artery.
b. The short saphenous vein.
III.The tibial nerve is the larger terminal branch of
sciatic nerve arising from ventral divisions of
ventral rami of L4,L5,S1,S2, and S3 nerves.
The tibial nerve begins, about the middle of
back of thigh, by bifurcation of sciatic
nerve.
Course: The tibial nerve descends vertically
in the popliteal fossa, from its upper angle,
lying superficial to popliteal vesels in
between two femoral condyles.
At the lower border of popliteus, the
tibial nerve enters the back of leg.
Branches in popliteal fossa
I. The muscular branches are five and they
are given in the lower part of popliteal
fossa to:
Medial head of gastrocnemius
Lateral head of gastrocnemius
Plantaris
Soleus
Popliteus
II. The cutaneous branch is:
Sural nerve
III.The genicular (articular) branches are
Superior medial
Middle
Inferior medial
They supply the knee joint.
160

IV. The common peroneal nerve is the
smaller terminal branch of sciatic nerve,
arising from dorsal division of ventral
rami of L4, L5, S1, and S2 nerves.
The common peroneal nerve begins
about the middle of back of thigh,
by bifurcation of sciatic nerve.
Course: The nerve enters popliteal fossa
lateral to the tibial nerve.
The common peroneal nerve inclines
laterally, and follows the medial border
of biceps femoris muscle.
The nerve curves around the lateral
surface of neck of fibula.
The common peroneal nerve terminates
in the substance of peroneus longus
muscle by dividing into two terminal
branches: the superficial and deep
peroneal nerves. It gives a recurrent
genicular branch near termination.
tahir99 - UnitedVRG
Branches in the popliteal fossa

I. The genicular (articular) branches are:
Superior lateral
Inferior lateral
They supply the knee joint.
II. The cutaneous branches are:
The lateral cutaneous nerve of calf
Sural communicating
III.The terminal branches
The superficial peroneal nerve
The deep peroneal nerve
Applied anatomy
In case of fracture of neck of fibula,
the common peroneal nerve may be
injured.
Effects of injury
I. Paralysis of extensors and evertors of
foot. This condition leads to Foot
drop.
II. Loss of skin sensations on lateral side
and back of leg and dorsum of foot.
CHAPTER
18
The Region of
the Leg
The region of the leg is divided into three osseofascial compartment by the deep fascia of the leg
and two inter-muscular septa, anterior and
posterior:
1. The anterior (extensor) compartment
2. The lateral (peroneal) compartment
3. The posterior (flexor) compartment
THE ANTERIOR (EXTENSOR)
COMPARTMENT OF THE LEG
The Muscles of the Anterior
Compartment (Fig. 18.1 and Table 18.1)
I.
II.
III.
IV.
Tibialis anterior
Extensor hallucis longus
Peroneus tertius

Compartment
The arteries
A. The anterior tibial artery is the smaller
terminal branch of popliteal artery.
Beginning: The artery begins at the
lower border of popliteus, where the
popliteal artery bifurcates at back of the
knee.
Course: The anterior tibial artery enters
the anterior compartment by passing
through a gap at the upper border of
interosseous membrane.
It descends on the front of interosseous membrane of the leg along
with the deep peroneal nerve.
Fig. 18.1: The anterior compartment of leg
The artery is placed deeply and is
overlapped by the extensor muscles

of anterior compartment.
Termination: The artery passes deep to
superior extensor retinaculum, crosses
the front of ankle joint and enters dorsum
of foot as dorsalis pedis artery.
Branches
i. The anterior tibial recurrent takes
part in the arterial anastomosis
around knee joint
162

Table 18.1: The muscles of the anterior compartment
Name
1. Tibialis
anterior
Origin
Proximal half or twothird of lateral surface
of tibia
Anterior surface of
interosseous membrane
Muscle belly
Muscle belly gives
rise to a tendon in
distal third of leg
2. Extensor
hallucis
longus
Middle half of medial

Muscle belly lies betsurface of fibula medial
ween tibials anterior
to extensor digitorum
and extensor digitolongus
rum longus
Anterior surface of
It gives rise to a
interosseous memtendon in distal
brane
part of leg
3. Extensor Proximal three-fourth
Muscle belly gives
digitorum
of medial surface of
rise to a tendon in
longus
of fibula
distal part of leg
Anterior surface of
interosseous membrane
4. Peroneus
tertius
Distal third medial

surface of fibula
Insertion
Nerve supply
Medial surface
Deep peroneal
medial cuneiform (L4, L5)
and adjoining part
base of first metatarsal
Dorsal surface
base of distal
phalanx of big
toe
Deep peroneal
(L4, L5)
The tendon divi- Deep peroneal

des into four
(L5, S1)
slips on dorsum of
foot
Slips are attached
to dorsal digital
expansion of the
lateral four toes
Short muscle belly
Base of fifth
Deep peroneal
gives rise to a tendon metatarsal bone (L5, S1)
ii. The posterior tibial recurrent also

takes part in the anastomosis around
knee joint
iii. Many small muscular branches
supply the extensor muscles.
iv. The anterior medial malleolar
branch passes medially deep to the
extensor tendons and anastomoses
with branches of posterior tibial
artery.
v. The anterior lateral malleolar
branch passes laterally, deep to the
extensor tendons and anastomoses
with branches of peroneal artery.
B. The perforating branch of peroneal artery:
pierces the interosseous membrane about
5.0 cm proximal to the lateral malleolus and
enters the anterior compartment.
Course:The artery descends in front of
inferior tibio-fibular joint and anasto-
Main actions
I. It dorsiflexes and
inverts the foot
II. It helps in maintaining medial
longitudinal arch of
foot
I. It helps in dorsiflexion
II. It extends the
big toe
I. It dorsiflexes the
foot
II. It extends the
lateral four toes
I. It helps in dorsiflexion
II. It is evertor of
foot
moses with anterior lateral malleolar

branch of anterior tibial artery.
The perforating branch of peroneal
artery may be enlarged sometimes, and
may continue as dorsalis pedis artery.
The Veins
The long saphenous vein ascends
along the medial border of tibia and
receives the superficial veins from
the front of leg:
The deep veins
The anterior tibial artery is accompanied by a pair of venae comitantes,
that are continuation of the paired
venae comitantes accompanying
dorsalis pedis artery.
The perforating branch of peroneal
artery is also accompanied by a pair
of venae comitantes.
tahir99 - UnitedVRG
The Region of the Leg

Compartment
The deep peroneal (anterior tibial) nerve is the

larger terminal branch of the common peroneal
nerve.
Beginning: The deep peroneal nerve arises in
the substance of peroneus longus muscle, lateral
to the neck of fibula, where the common
peroneal nerve bifurcates.
Course: The deep peroneal nerve pierces the
lateral intermuscular septum and extensor
digitorum muscle to enter the anterior compartment of leg.
The nerve descends on the front of
interosseous membrane along with anterior
tibial vessels.
The nerve and the vessels are overlapped
by the extensor muscles in the anterior
compartment.
The nerve passes deep to the superior
extensor retinaculus, crosses the front of
ankle joint and enters the dorsum of foot
where it divides into its two terminal
branchesmedial and lateral.
163
Branches
I. The muscular branches supply
Tibialis anterior
Extensor hallucis longus
Peroneus tertius
II. The articular branch: supplies
The ankle joint.
THE LATERAL (PERONEAL)

COMPARTMENT OF THE LEG
The muscles of the lateral compartment are (Table
18.2):
Peroneus longus
Peroneus brevis
The Blood Vessels of the Lateral
Compartment
There are no separate blood vessels for the lateral
compartment of leg.
The branches of peroneal artery enter the lateral
compartment by curving laterally and piercing the
lateral intermuscular septum.
These muscular branches supply the peroneal
muscles.
Table 18.2: The muscles of the lateral compartment

Origin
Muscle belly
Insertion
1. Peroneus
longus
Name
Lateral surface head

and proximal twothird of lateral surface
of fibula
Few fibers from lateral
tibial condyle
Lateral side of
Superficial pero- I.
base of first meta- neal L5, S1, S2
tarsal and adjacent
II.
medial cuneiform
bone
III.
2. Peroneus
brevis
Distal two-third lateral

surface of fibula
Muscle belly lies

superficial to
peroneus brevis
Muscle belly ends
in a long tendon
that passes behind
lateral malleolus
and reaches dorsum
of foot
The tendon curves
around lateral
border of foot and
enters sole
The muscle belly is
overlapped by peroneus longus
Muscle belly gives
rise to a tendon that
passes behind lateral
malleolus and above
the peroneal tubercle
of calcaneum
Lateral surface
base of fifth
metatarsal
Nerve supply
Superficial
peroneal
L5, S1, S2
Main actions
It is an evertor of
foot
It helps in plantar
flexion of foot
It supports and
helps to maintain
lateral longitudinal
arch and transverse arches of
foot
I. It is an evertor
of foot
II. It helps in plantar
flexion of foot
164
The Nerves of the Lateral Compartment

The superficial peroneal (musculo-cutaneous)
nerve: is the smaller terminal branch of common
peroneal nerve.
Origin: The superficial peroneal nerve arises in
the substance of peroneus longus muscle, lateral
to the neck of fibula, where common peroneal
nerve divides.
Course: The nerve descends in the lateral
compartment deep to peroneus longus.
Then, it descends between peroneus longus
and peroneus brevis muscles.
Finally, it lies between the peronei and
extensor digitorum longus.
The superficial peroneal nerve pierces, deep
fascia in distal one-third of leg. It descends
to the dorsum of foot.
Branches in lateral compartment
Muscular branches supply
Peroneus longus
Peroneus brevis
THE POSTERIOR COMPARTMENT OF
THE LEG
The muscles of the posterior compartment are
divided in two groups (Fig. 18.2 and Table 18.3):
A. The superficial muscles of calf
i. Gastrocnemius
ii. Plantaris
iii. Soleus
B. The deep muscles of calf
i. Popliteus
ii. Flexor digitorum longus
iii. Flexor hallucis longus
iv. Tibialis posterior
Fig. 18.2: The posterior compartment of leg

superficial muscles of calf
The Blood Vessels of the Posterior

Compartment
The Arteries
The posterior tibial artery: is the larger terminal
branch of popliteal artery.
Beginning: The artery begins at the lower border

of popliteus where the popliteal artery
bifurcates.
Course: The posterior tibial artery descends in
the posterior compartment along with tibial
nerve.
It lies between tibialis posterior and flexor
digitorum longus and deep transverse fascia
of the leg
The artery reaches deep to the flexor
retinaculum of the ankle.
Termination: The posterior tibial artery divides
into its two terminal branches: medial and lateral
plantar arteriesmidway between medial
malleolus and medial tubercle of calcaneum,
deep to the flexor retinaculum.
Branches
a. The circumflex fibular artery passes laterally
and takes part in anastomosis around knee
joint.
tahir99 - UnitedVRG
165
Table 18.3: The muscles of posterior compartment of leg

Name
Origin
The superficial muscles of the calf

Two heads
1. Gastroa. Medial head
cnemius
(larger)
Depression on upper
and posterior part of
medial condyle
Popliteal surface
of femur
b. Lateral head (smaller)
Small area on lateral
surface of lateral
condyle of femur
2. Plantaris Distal part of lateral supracondylar
line
Oblique popliteal
ligament of knee
joint (Muscle may
be absent)
3. Soleus
Posterior surface
head of fibula
Proximal one-fourth
posterior surface of
fibula
Soleal line of tibia
Middle third medial
border of tibia
The deep muscles of the calf (Fig. 18.3)
4. Popliteus Anterior part of popliteal groove on
lateral surface of
lateral condyle of
femur (origin is
intra-capsular)
5. Flexor
Upper part posterior
digitorum
surface tibia below
longus
soleal line, medial to
tibialis posterior
6. Flexor
hallucis
longus
Distal two-third of
posterior surface of
fibula
Interosseous membrane of leg
7. Tibialis
posterior
Two heads Tibial head

Lateral part posterior
surface tibia below
soleal line
Interosseous membrane
Fibular-head
Proximal two third
medial part posterior
surface of fibula
Muscle belly
Two muscular bellies

form main muscular
mass of calf
The two heads join
to form a broad
aponeurosis
Insertion
Nerve supply
Main actions
Joins with soleus

to form the
tendo-calcaneus
Tibial S1, S2 I. Major plantar

flexors of foot
II. Provides propelling force in
walking, running
and jumping
III. Helps in flexion
of knee
Small fusiform muscle Medial border of

belly
tendo-calcaneus
Gives rise to a long,
thin tendon
Tibial
S1, S2
Rudimentary
muscle
I. Acts with gastrocnemius
Broad, flat, muscle

belly lies deep to
gastrocnemius
A central tendon
starts from muscle
belly
Tibial
S1, S2
I. Powerful plantar
flexor of foot
II. Action slow and
sustained
III. Helps to steady
leg on foot
Joins with gastrocnemius to

form tendocalcaneus
Inserted on
middle part
of posterior
surface of
calcaneum
Medial two-third
Tibial L4-L5 I. Unlocks knee joint
II. Rotates tibia mediof popliteal surand S1
face of tibia above
ally and femur
soleal line
laterally
III. Helps in flexion of
knee joint
The bipennate muscle Divides into four Tibial
I. Flexor of lateral
four toes
belly gives rise to a
tendons in sole for S2, S3
tendon that crosses
lateral four toes.
II. Helps in plantar
tibialis posterior and
Each is attached to
flexion of foot
passes behind medial
base of distal phamalleolus
lanx
Thicker bipennate
Receives a slip
Tibial
I. Flexor of big toe
muscle belly
from flexor digi- S2, S3
Gives rise to a tendon
torum longus in
flexion of foot
that grooves posterior sole
Helps to maintain
surface lower end, of
Inserted on base
medial longitudinal
tibia and enters sole
of distal phalanx
arch
of big toe
Bipennate muscle belly Superficial part Tibial L4-L5 I. Main invertor
Tendon grooves back
on tuberosity
of foot
of medial malleolus
of navicular
Deeper part
flexion of foot
sends slips to all
III. Helps in maintain
short bones of
medial longitudinal
tool except talus
arch of foot
and base of first
metatarsal
Muscle is attached
to fibrous capsule
A flat, triangular
muscle belly
166

v. Lateral calcaneal branches, are
terminal branches that supply the
heel.
c. The nutrient artery to tibia is one of the
largest nutrient artery given to a long
bone.
d. The medial malleolar branches: anastomose
with anterior medial malleolar branches of
anterior tibial artery.
e. The medial calcaneal branches: supply the
medial side of the heel.
The Veins
Fig. 18.3: The posterior compartment of leg

the deep muscles of calf
b. The peroneal artery is a large branch given

from uppermost part of the artery.
Course: The peroneal artery descends
along the medial crest of fibula between
tibialis posterior and flexor hallucis
longus.
It terminates as lateral calcaneal
branches.
Branches
i. Muscular branches supply the
muscles of calf and curve laterally
to supply the peroneal muscles.
ii. Perforating branch is given in distal
part of leg. It pierces interosseous
membrane and enters anterior
compartment of leg.
iii. Nutrient artery is given to fibula.
iv. Communicating branch is given to
A. The superficial veins

a. The long saphenous vein is formed on the
dorsum of foot, from the medial end of
dorsal venous arch of foot.
Course: The long saphenous vein
ascends on front of medial malleolus,
and then along medial border of tibia,
accompanied by saphenous nerve.
The vein lies on the medial side of
knee and ascends a little laterally to
the front of thigh.
The long saphenous vein has about
twelve valves in the leg part.
Tributaries
i. The superficial veins from the leg.
ii. The perforating veins which piece
the calf muscles and joint with deep
veins of the posterior compartment.
b. The short saphenous veins begin behind
lateral malleolus as continuation of lateral
side of dorsal venous arch joining with
lateral marginal vein from little toe.
Course: The vein ascends behind lateral
malleolus and then on posterolateral
aspect of the leg.
It pierces the deep fascia of roof of
popliteal fossa and terminates in
popliteal vein.
tahir99 - UnitedVRG
Tributaries
i. The superficial veins from the back
of the leg.
ii. The perforating veins that connect
the short saphenous vein with deep
veins of the leg.
iii. The communicating veins with the
long saphenous vein.
Applied anatomy
a. The varicose veins are dilated and
enlarged veins of the back of the leg.
These are caused by
The incompetence of valves in
the perforating veins which
allows venous blood from the
deep veins to enter the superficial
veins.
The venous stasis associated with
long periods of standing, that
reduces the efficiency of valves
and thus acts as a causative factor
for the varicose veins.
The varicose veins may give rise
to varicose ulcers.
The treatment consists of ligating
the perforating veins with
incompetent valves.
b. In bypass surgery, pieces of long
saphenous vein are utilized to replace
the arteriosclerosed and blocked
segments of coronary arteries.
B. The deep veins
A pair of venae comitants accompany the
These veins join with venae comitants of
anterior tibial artery at the lower border of popliteus
to form the popliteal vein.
167

Compartment
The tibial nervethe larger terminal branch of
sciatic nerve continues in posterior compartment
of leg from the popliteal fossa.
Course
The tibial nerve enters the posterior compartment at the distal border of popliteus.
The nerve descends along with posterior
tibial vessels superficial to tibialis posterior
and deep to flexor digitorum longus.
The tibial nerve passes deep to flexor
retinaculum of ankle.
Termination
The nerve divides into its two terminal
branches.
Medial and lateral plantar nerves: midway
between medial malleolus and medial
tubercle of calcaneum, deep to flexor
retinaculum.
Branches in posterior compartment
i. The muscular branches supply
Soleus (deep part)
Flexor hallucis longus
Tibialis posterior
ii. The cutaneous branches are
Medial calcaneal branches that
supply skin on medial side of heel
iii. The vascular branches supply
Posterior tibial artery
iv. The terminal branches are
Medial plantar nerve
Lateral plantar nerve
CHAPTER
19
The Region of
the Foot
The region of foot consists of
A. The dorsum of the foot
B. The plantar region or the sole
THE DORSUM OF THE FOOT
The Muscles and Tendons on
Dorsum of Foot
There is only one muscle on the dorsum of foot
extensor digitorum brevis.
The tendons of extensor muscles of the leg
diverge on the dorsum of foot to reach their insertions.
a. The extensor digitorum brevis
Origin: Anterior part of lateral surface of
calcaneum
Muscle belly: Thin, short muscle belly, lies
deep to the extensor tendons and divides
into four slips for medial four toes.
Insertion
First slip (extensor hallucis brevis) is
attached to the base of proximal phalanx
of big toe
Second, third, and fourth slips join the
lateral sides of tendons of extensor
digitorum longus to second, third, and
fourth toes.
Nerve supply lateral terminal branch of deep
peroneal nerve (S1,S2)
Actions Extension of phalanges of medial
four toes.
b. The extensor tendons
i. The tendon of tibialis anterior passes deep
to both superior and inferior extensor
retinacula and turns medially.
It is inserted on medial cuneiform and

adjoining side of base of first metatarsal
bone.
ii. The tendon of extensor hallucis longus also
passes deep to both superior and inferior
extensor retinacula.
It passes almost straight forwards on
the dorsum of foot to reach the base of
distal phalanx of big toe for insertion.
iii. The tendon of extensor digitorum longus
passes deep to superior and inferior extensor
retinacula. It divides on dorsum of foot in
four tendons that diverge to reach lateral
four toes.
Each tendon is inserted on base of middle
phalanx and terminal phalanx of the toe
via dorsal digital expansion.
iv. The tendon of peroneus tertius turns laterally
as it passes deep to superior and stem of
inferior extensor retinacula.
It is inserted on the tubercle at the base
of fifth metatarsal.
All the extensor tendons are enclosed in synovial
sheaths as they pass deep to the two extensor
retinacula on dorsum of foot.
The superior extensor retinaculum is a thick band
of deep fascia, just proximal to the ankle joint (Fig.
19.1)
Attachments: Medially anterior border of tibia
Laterally anterior border of fibula
Its function is to bind down the extensor tendons
close to the bone during movements of the ankle
joint.
tahir99 - UnitedVRG
The Region of the Foot
169
Fig. 19.1: The dorsum of foot
Structures passing deep to retinaculum (from

medial side)
i. Tendon of tibialis anterior
ii. Tendon of extensor hallucis longus
iii. Anterior tibial artery.
iv. Deep peroneal nerve
v. Tendon of flexor digitorum longus
vi. Tendon of peroneus tertius.
The inferior extensor retinaculum is a thick Y-shaped

band of deep fascia, just below ankle joint on the
dorsum of foot.
Attachments
Lateral end (stem) is attached to superior
surface of calcaneum.
Proximal band is attached to the medial
malleolus.
Distal band is attached to the deep fascia
of sole.
The extensor tendons pass through the loops
in the retinaculum, while the anterior tibial vessels
and peroneal nerve lie behind the retinaculum.
The Blood on the Dorsum of Foot

The Arteries
The dorsals pedis artery is the continuation of

anterior tibial artery on the dorsum of foot.
Beginning The dorsalis pedis artery begins on
the front of ankle joint below the superior
extensor retinaculum.
Course The artery passes distally on the dorsum
of foot lying between the tendons of extensor
hallucis longus, medially and extensor digitorum
longus laterally.
The dorsalis pedis artery is accompanied
by deep peroneal nerve and its medial
terminal branch on its lateral side.
The artery can be compressed against the
tarsal bone for feeling the pulse.
Termination The artery passes between the two
heads of first dorsal interosseous muscle and
enters the sole.
In the sole the dorsalis pedis artery joins the
lateral plantar artery to complete the plantar
arterial arch.
170
Branches
i. The tarsal branchesmedial and lateral
that supply small joints of foot and extensor
digitorum brevis.
They anastomoses with anterior lateral
malleolar artery and perforating branch
of peroneal artery.
ii. The arcuate artery courses laterally across
the bases of metatarsals deep to the extensor
tendons.
It gives second, third, and fourth dorsal
metatarsal arteries, that passes distally
and divide at the web of the toes into
two dorsal digital arteries that supply the
sides of lateral four toes.
The dorsal metatarsal arteries are
connected:
a. To the plantar arch by proximal
perforating branches.
b. To the plantar metatarsal arteries by
the distal perforating branches.
iii. The first dorsal metatarsal artery arises from
the dorsalis pedis, just before it passes between the two heads of first dorsal interosseous muscle.
It divides into two dorsal digital branches
to supply the sides of first and second
toes.
The deep veins

The paired venae comitants accompany the dorsalis
pedis artery and its branches.
The Nerves of the Dorsum of Foot
(Fig. 19.2)
1. The superficial peroneal nerve supplies the skin
of dorsum of foot and the toes.
On reaching dorsum of foot it divides into a
medial branch and a lateral branch
a. The medial branch divides into two
dorsal digital nerves.
One supplies the medial side of big
toe.
The other divides into two branches
to supply the sides of second and
third toes
b. The lateral branch passes a little laterally
and divides into two dorsal digital nerves.
One divides to supply the sides of
third and fourth toes.
The other divides to supply the sides
of fourth and fifth toes.
The Veins
The dorsal venous arch on dorsum of foot
recieves the dorsal metatarsal veins that are
formed by the dorsal digital veins, draining the
sides of the toes.
On either side there are medial and lateral
marginal veins from the big toe and little
toe.
The long saphenous vein begins from the medial
end of dorsal venous arch
The short saphenous vein begins from the lateral
end of dorsal venous arch.
Fig. 19.2: The cutaneous supply of the dorsum of foot
tahir99 - UnitedVRG

2. The sural nerveThe terminal part of sural
nerve after supplying the skin of back of leg
continues behind lateral malleolus to supply the
skin of lateral border of foot and lateral side of
little toe.
3. The saphenous nerveThe terminal part of
saphenous nerve, after crossing in front of
medial malleolus of tibia, descends on dorsum
of foot, to supply the skin along the medial
border of foot.
4. The deep peroneal nerve enters the dorsum of
foot by crossing front of ankle joint lateral to
anterior extensor retinaculum.
On dorsum of foot, the nerve divides into
two terminal brancheslateral and medial.
a. The lateral terminal branch passes
laterally deep to extensor digitorum
brevis and ends in a swelling (pseudo
ganglion). It supplies
Extensor digitorum brevis
Inter-tarsal and tarso-metatarsal
joints
Second dorsal interosseases muscle
b. The medial terminal branch passes
distally on the dorsum of foot, lying
lateral to the dorsalis pedis artery.
It pierces deep fascia at the web, and
divides into two branches to supply
the sides of first and second toes
It also supplies the first dorsal
interosseous muscle and also the
metatarso-phalangeal joint of big toe.
THE SOLE OF THE FOOT
The deep fascia of the sole is divided into three

parts
i. A medial part covering abductor hallucis
ii. A lateral part covering abductor digiti minimi
iii. A middle part known as Plantar aponeurosis
The plantar aponeurosis (Fig 19.3)
This is the thickest and strongest middle part
of deep fascia of sole.
171
Fig. 19.3: The plantar aponeurosis
Attachments
Proximally to medial tubercle of
calcaneum
Distally divides into five slips for five
toes. These slips become continuous
with fibrous flexor sheaths of the toes.
Functions
i. It covers and protects the deeper structures of the sole.
ii. It acts as a Tie Beam, and helps to
maintain the longitudinal arches of foot.
The Muscles of the Sole (Table 19.1)
The muscles of sole are arranged in four layers:
A. The first layer has three muscles
Abductor hallucis (Fig. 19.4)
Abductor digit minimi
B. The second layer has two muscles and two
tendons (Fig. 19.5)
The muscles are four lumbricals and flexor
digitorum accessorius
172
Fig. 19.4: The muscles of first layer of sole
Fig. 19.5: The muscles of second layer of sole
tahir99 - UnitedVRG
173
Table 19.1: The muscles of the sole

Name
Origin
A. First layer
1. Abductor Flexor retinaculum
hallucis
Medial tubercle
of calcaneum
2. Flexor
Medial tubercle of
digitorum calcaneum
brevis
3. Abductor
digiti
minimi
B. Second
layer
1. Flexor
digitorum
accessorius
2. The lumbrical
muscles
(Four
bellies)
Both medial and lateral

tubercles of calcaneum
Two heads separated by

lateral plantar ligament
a. Medial larger head
from medial surface of
calcaneum
b. Lateral smaller and
tendinous from lateral
surface of calcaneum
First from medial
side of flexor digitorum longus tendon
to second toe
The other three
from adjacent sides
of flexor digitorum
longus tendons
C. Third layer
1. Flexor
Cuboid proximal to
hallucis
groove for peroneus
brevis
longus
-Lateral cuneiform
2. Adductor
hallucis
Muscle belly
Insertion
Muscle belly lies along

medial border of foot,
and ends in a tendon
Muscle belly lies
deep to plantar
aponeurosis
Divides into four
slips for lateral four
toes
Medial side base of

proximal phalanx
of big toe
Each slip divides
into two parts to
enclose a fibrous
tunnel for the
longus tendon
Inserted on
sides of middle
phalanx of the
toe
Muscle belly lies along Base of proximal
lateral border of foot phalanx of little
and gives rise to a
toe
tendon
Nerve supply
Medial plantar
(S2, S3)
Medial plantar
(S2, S3)
Main actions
I. Abductor of big toe
from neutral axis
of second toe
I. Helps in flexion
of lateral four toes
Lateral plantar
S2, S3
I. Abductor of little
toe from neural
axis of second toe
The muscle belly joins Plantar surface

the flexor digitorum
flexor digitorum
longus tendon, before longus tandon
it divides into four
slips
Lateral plantar
(S2, S3)
I. It is a direct flexor
of lateral four toes
(by bringing flexor
digitorum longus
tendons in line
with toes.
First lumbrical has

slender unipennate
muscle belly
The other three
have slender bipennate muscle bellies
The muscle end in
tendons that pass
distally on medial
sides of lateral four
toes.
Medial side dorsal

digital expansions
of lateral four
toes
Firstby medial I. The lumbricals

plantar
help in flexion of
The other three
metatarso-phalanlateral plantar
geal and extension
(deep branch)
of inter-phalangeal
joints of lateral
(S2, S3)
four toes
Muscle belly divides

into two parts
medial and lateral
that reach on two
sides of big toe
Sesamoid bones
develop in the two
parts near insertion
On two sides of
Medial plantar
base of proximal (S2, S3)
phalanx of big toe
Two heads
a. Oblique head from
Two heads give rise to Lateral side of
Lateral plantar
bases of second to
two bellies, that join
base of proximal (deep branch)
fourth metatarsals
and are inserted tophalanx of big toe (S2, S3)
and sheath of pergether
oneus longus tendon
b. Transverse head from
plantar metatarso-phalangeal ligaments of
third to fifth toes.
I. Flexor of the big

toe
I. It adducts big toe

towards neutral
axis of second toe
Contd...
174
Contd...
Name
Muscle belly
Insertion
3. Flexor
Base of fifth metatarsal
digiti
minimi
brevis
D. Fourth layer
1. Dorsal
Adjacent sides of metainterossei tarsal bones
(Four
bellies)
Slender muscle belly
Lateral side of base Lateral plantar

of proximal pha- (superficial
lanx of little toe branch) (S2, S3)
2. Plantar
Bases and medial sides
interossei of third, fourth and
(three
fifth metatarsals
bellies)
Unipennate, slender
muscle bellies
Tendons pass on
medial sides of third,
fourth, and fifth toes
Origin
Bipennate muscle
Bases of proximal
bellies, fills up gaps
phalanges and dorbetween metasal digital expantarsals
sion of toes
A fibrous arch between First on medial
two heads at proximal Second and third
end of inter-metatarsals on lateral sides of
spaces
third toe
Fourth on lateral
side of fifth toe
The tendons are those of flexor digitorum

longus and flexor hallucis longus
C. The third layer has three muscles (Fig.
19.6)
Flexor hallucis brevis
Adductor hallucis
Flexor digiti minimi brevis
D. The fourth layer has two sets of muscles and
two tendons (Fig. 19.7)
The muscles are four dorsal interossei and
three planter interossei
The tendons are peroneus longus tendon,
and tibialis posterior tendon.
Nerve supply
Main actions
I. Helps in flexion of
little toe
First, Second,
Third
Lateral plantar I.
(deep branch)
(S2, S3)
Fourth dorsal
II.
interosseous (by
superficial branch
lateral plantar)
III.
Abductors of toes
from neutral axis
of second toe
First and second
cause medial and
lateral abduction
of second toe
Flexion of metatarso-phalangeal
and extension of
inter-phalalangeal
joints
Medial sides bases First and
I. Adductors of third
and dorsal digital Second by
fourth and fifth
expansions of
lateral plantar
toes towards the
third, fourth, fifth (deep branch)
neutral axis of
toes
second toe
Third by lateral II. Flexor of metaplantar (supertarso-phalangeal
ficial branch)
and extensor of
(S2, S3)
inter-phalangeal
joint of third,
fourth, and fifth
toes.
The Blood Vessels of the Sole

The Arteries
a. The medial plantar artery is the smaller terminal
branch of posterior tibial artery.
Origin: The artery arises deep to flexor
retinaculum of ankle where the posterior
tibial artery divides.
Course: The medial plantar enters the sole,
by passing distally deep to abductor hallucis
and plantar aponeurosis, with medial plantar
nerve lateral to it
The artery appears in the gap between
abductor hallucis and flexor digitorum
brevis and divides into branches.
tahir99 - UnitedVRG
175
Fig. 19.6: The muscles of third layer of sole
Figs. 19.7A and B: The interossei of sole
Branches
The digital branch to medial side of big
toe
The superficial digital branches, which
join the three plantar metatarsal branches
of the lateral plantar artery.
The superficial branches emerge along
medial border of plantar aponeurosis to
supply the skin of sole
Small muscular branches.
b. The lateral plantar artery is the larger terminal
branch of the posterior tibial artery.
Origin: The artery arises deep to flexor
retinaculum of ankle where the posterior
tibial artery divides.
Course: The artery enters sole by passing

deep to abductor hallucis.
The lateral plantar nerve lies medial
to it
The lateral plantar artery crosses the sole
obliquely from medial to lateral side
between the muscles of first and second
layers, to reach the base of fifth
metatarsal bone.
From the base of fifth tarsal, the lateral
plantar artery curves medially, along
with deep branch of lateral plantar artery.
It continues as the plantar arterial arch
between third and fourth layer of
muscles.
176
Branches
Small muscular branches to the muscles
of the sole.
The superficial branches emerge along
lateral border of plantar aponeurosis to
supply the skin of sole.
Anastomotic branches join with
branches of lateral tarsal artery.
c. The plantar arterial arch is the arterial arch
placed deeply in the sole.
Formation: The plantar arch is formed by
The continuation of lateral plantar artery
The dorsalis pedis artery in first inter
metatarsal space.
Course: The arch lies across the bases of
metatarsal bones, superficial to the
interossei and deep to the adductor hallucis.
Branches
A plantar digital branch that supplies the
lateral side of little toe
Four plantar metatarsal arteries, that
divide to supply the sides of toes
(The first plantar metatarsal artery is
considered to be the branch of terminal part
of dorsalis pedis artery.)
The lateral three plantar metatarsal
arteries receive the three distal
perforating branches that join them with
dorsal metacarpal arteries
The three proximal perforating branches
pass through fibrous arches to second,
third and fourth dorsal interossous
muscles.
They join the plantar arch with dorsal metacarpal
arteries.
The Veins
The superficial veins of the sole form a plantar
cutaneous arch across the roots of toes.
The venous arch joins with medial and lateral
marginal veins.
The deep veins The lateral and medial plantar

arteries are accompanied by paired venae comitantes.
The Nerves of the Sole
1. The medial plantar nerve is the larger terminal
branch of tibial nerve.
Origin: The nerves arise deep to flexor
retinaculum where the tibial nerve divides.
Course: It passes deep to abductor hallucis
and lies in the interval between abductor
hallucis and flexor digitorum brevis.
The medial plantar nerve lies lateral to
the medial plantar vessels
Termination: The nerve divides into three
common plantar digital nerves.
The first plantar digital nerve supplies
medial side of big toe.
The three common plantar digital nerves
divide into two plantar digital nerves to
supply the sides of medial three and half
toes.
Branches
The muscular branches supply
Abductor hallucis
Flexor hallucis brevis (from first
plantar digital nerve)
First lumbrical (from first common
on plantar digital nerve)
The cutaneous branches
Medial side of skin of sole
First plantar digital nerve
Three common plantar digital nerves
supply skin of medial three and half
toes
2. The lateral plantar nerve is the smaller terminal
branch of tibial nerve
Origin: The nerve arises deep to the flexor
retinaculum where the tibial nerve divides.
tahir99 - UnitedVRG
Course: The lateral plantar nerve lies medial

to the lateral plantar vessels, as it passes
distally deep to abductor hallucis.
The nerve crosses the sole obliquely
from medial to lateral side lying between
flexor digitorum brevis and flexor
digitorum accessorius.
Termination: The nerve reaches the base
of fifth metatarsal bone where it divides
into a superficial branch and a deep
branch.
a. The superficial branch divides into two
plantar digital nerves. One supplying
lateral side of little toe, the other dividing
at the web to supply the sides of fourth
and fifth toes.
b. The deep branch accompanies the
continuation of lateral plantar artery
(plantar arch), and lying in the concavity
of the arch, crosses the bases of metatarsals.
It passes deep to adductor hallucis
where it terminates.
177
Branches
a. From the stem of the nerve
Muscular
Abductor digiti minimi
Cutaneous
Skin of lateral side of sole
b. From the superficial branch
Muscular
Flexor digiti minimi brevis
Third plantar and fourth dorsal
interossei
Cutaneous two digital nerves that
supply
Skin of lateral one and half toes
c. From the deep branch
Muscular
Adductor hallucis
Medial two plantar interossei
Medial three dorsal interossei
Lateral three lumbricals
Articular to
Tarso metatarsal joints of the
foot.
The Lower Extremity

Q.1. Select the best response to reach question
from the four suggested answers
C. Compression
D. Hyperflexion
1. The neck of femoral hernia lies:

A. At the femoral ring
B. At deep inguinal ring
C. At the obturator canal
D. At saphenous opening
7. The following muscle is attached to the

posterior surface of calcaneum:
A. Flexor hallucis brevis
B. Abductor hallucis
C. Gastrocnemius and soleus
D. Flexor digitorum accessorius
2. Which of the following muscles is the main

flexor of thigh:
A. Pectineus
B. Adductor longus
C. Rectus femoris
D. Ilio-psoas
8. The peroneal artery is a branch of:

A. Anterior tibial artery
B. Femoral artery
C. Posterior tibial artery
D. Lateral plantar artery
3. The iliotibial tract receives the insertion:

A. Gluteus maximus
B. Tensor fascia lata
C. Both
D. None
4. For giving deep intramuscular injection, which
quadrant of gluteus maximus is preferred:
A. Upper medial quadrant
B. Upper lateral quadrant
C. Lower medial quadrant
D. Lower lateral quadrant
5. The following structure passes through greater
sciatic foramen:
A. Superior gluteal nerve
B. Obturator internus tendon
C. Obturator externus
D. Gluteus minimus muscle
6. The tear of the menisci usually results from
the following conditions of the knee joint:
A. Rotation in partial flexion
B. Rotation in full extension
9. The most anterior structure deep to flexor

retinaculum of ankle is:
A. Tibial nerve
B. Tibialis posterior tendon
C. Long saphenous vein
D. Flexor hallucis longus tendon
10. The movements of inversion and eversion of
foot that take place at:
A. Inferior tibiofibular joint
B. Ankle joint
C. Subtalar joint
D. Subtalar and mid-tarsal joints
correct, choose the answers
D. If only 4 is correct.
E. If 1,2,3 and 4 are correct
11. The muscles inserted on greater trochanter
of femur are:
1. Gluteus medius
tahir99 - UnitedVRG

2. Piriformis
3. Gluteus minimus
4. Gluteus maximus
179
2. Tibialis posterior
3. Tendo-calcaneus
4. Calcaneo-navicular (spring) ligament
12. The structures contributing to the boundaries

of popliteal fossa are:
1. Biceps femoris
2. Quadratus femoris
3. Semi-membranosus
4. Peroneus longus
19. The muscles that act on both hip joint and

knee joint are:
1. Biceps femoris
2. Sartorius
3. Rectus femoris
4. Adductor magnus
13. The muscles of the anterior compartment of

leg are:
1. Tibialis anterior
2. Extensor hallucis longus
3. Extensor digitorum longus
4. Peroneus tertius
20. The dorsalis pedis artery enters sole by:

1. Passing between two heads of first dorsal
interosseous muscle
2. Passing between two heads of second
dorsal interosseous muscle
3. Passing between the bases of first and
second metatarsals
4. Passing between two heads of flexor
digitorum accessorius
14. The tibial portion of sciatic nerve in back of

thigh supplies:
1. Short head of biceps femoris
2. Long head of biceps femoris
3. Vastus lateralis
4. Semi-tendinosus
Q.3. Match the following on the left side with

their appropriate answers on the right side
15. The factors responsible for the stability of

the ankle joint are:
1. Trochlear surface of talus
2. Spring ligament
3. Deltoid ligament
4. Calcaneo-fibular ligament
21. Clinical signs of injury/inflammation:

1. Foot drop
A. Sciatic nerve
2. Lurching giant
B. Prepatellar bursa
3. Housemaids knee C. Common peroneal
nerve
4. Sleeping foot
D. Gluteus medius
16. The adductor (subsartorial) canal contains:

1. Obturator nerve
2. Femoral vessels
3. Long saphenous vein
4. Saphenous nerve
22. Muscles and their attachments:

1. Popliteus
A. Anterior 5.0 cm
of outer lip of iliac
crest
2. Psoas major
B. Calcaneum
3. Extensor
C. Lateral condyle of
digitorum brevis
femur
4. Tensor fascia lata D. Lesser trochanter
of femur
17. The muscle that help in abduction at the hip

joint are:
1. Gluteus medius
2. Piriformis
3. Gluteus minimus
4. Obturator externus
18. The medial longitudinal arch of foot is
maintained by:
1. Peroneus longus
23. Types of joints:

1. Syndesmosis
2. Saddle joint
A. Superior tibiofibular
B. Inferior tibiofibular
180

3. Ball and socket
joint
4. Plane joint
24. Origin of nerves:

1. Saphenous
2. Sural
3. Superficial
peroneal
4. Superior gluteal
C. Hip joint
25. Actions of muscles:
D. Calcaneo-cuboid
joint
A. Sacral plexus
B. Femoral
C. Common peroneal
D. Tibial
1. Adductor longus A. Abduction of hip

joint
2. Piriformis
B. Lateral rotation of
hip joint
3. Popliteus
C. Unlocks the knee
joint
4. Sartorius
D. Adducts the hip
joint
Answers
The neck of femoral hernia lies at the femoral
ring. The deep inguinal ring is concerned with
oblique inguinal hernis. The obturator canal
gives passage to the obturator nerve and
vessels. The saphenous opening is defect in
deep fascia below inguinal, and femoral hernia
may bulge through it.
The main flexor of hip joint is iliopsoas. The
other three muscles pectineus adductor longus
and rectus femoris help in flexion of hip joint.
The two muscles inserted on iliotibial tract
are gluteus maximus and tensor fascia lata.
The upper lateral quadrant of gluteus
maximus is preferred for giving deep intramuscular injection, because no nerve or large
blood vessel lies deep here. Other quadrants
are related to nerves and blood vessels deep
to the muscle.
The superior gluteal nerve passes through
greater sciatic foramen. The obturator internus tendon comes out of lesser sciatic
foramen. The obturator externus and gluteus
minimus are attached on outer surface of hip

bone and they do not pass through greater
sciatic foramen.
A tear of the menisci (mainly medial meniscus)
results from abnormal rotation of the knee
joint in partial flexion. In other three abnormal
positions, sprain of ligaments of the joint takes
place.
The gastrocnemius and soleus are attached
to the middle part of posterior surface of
calcaneum as tendo calcaneus. The flexor
hallucis brevis attached to cuboid bone. The
abductor hallucis is attached to medial
tubercle of calcaneum. The flexor digitorum
accessories is attached to medial and lateral
surfaces of calcaneum.
The peroneal artery is a branch of posterior
tibial artery. The anterior tibial artery lies in
the anterior compartment of leg. The femoral
artery lies on the front of upper part of thigh.
The lateral plantar artery lies in the sole.
The tibialis posterior tendon lies most
anteriorly deep to flexor retinaculum of the
ankle. The tibial artery lies just behind the
tahir99 - UnitedVRG
181
tibialis posterior. The long saphenous vein

ascends in front of medial malleolus. The
flexor hallucis longus tendon lies most
posteriorly deep to flexor retinaculum.
stability of ankle joint. The spring ligament

plays a role in maintaining medial longitudinal
arch of foot. The calcaneo-fibular ligament
is a weak ligament.

The movements of inversion and eversion take
place at subtalar and mid-tarsal joints. The
inferior tibio-fibular joint is a syndesmosis,
where hardly any movements take place. The
ankle joint is a pure hinge type of joint where
only dorsiflexion and plantar flexion occur.

The femoral vessels and the saphenous nerve
are the contents of the adductor canal. The
obturator nerve lies in the medial compartment
of thigh. The long saphenous vein is a
superficial vein lying on medial aspect of knee
and thigh.

The three muscles inserted on greater
trochanter are gluteus medius, piriformis and
gluteus minimus. The gluteus maximus is
inserted on gluteal tuberosity of femur and
iliotibial tract.
The biceps femoris forms the upper lateral
boundary and the semi-membranosus forms
the upper medial boundary. The quadratus
femoris is a deep muscle of gluteal region.
The peroneus longus lies in the lateral
compartment of leg.
A13. The answer is E, (1, 2, 3, 4).
All the four musclestibialis anterior, extensor hallucis longus, extensor digitorum longus
and peroneus tertius belong to the extensor
compartment of leg.
The two muscles supplied by tibial portion
of sciatic nerve in back of thigh are long head
of biceps femoris and semitendinosus. The
short head of biceps femoris is supplied by
the common peroneal part of sciatic nerve.
The vastus lateral is a muscle of extensor
compartment of thigh, supplied by femoral
nerve.
The shape of trochlear surface of talus and
deltoid ligament are responsible for the

The muscles helping in abduction at the hip
joint are gluteus medius and gluteus minimus.
Piriformis is a short lateral rotator of hip joint.
Obturator externus also helps in lateral rotation
of hip joint.
The medial longitudinal arch of foot is
maintained by tibialis posterior and the spring
ligament. The peroneus longus helps in
maintaining lateral longitudinal arch of foot.
The tendo-calcaneus is a strong plantar-flexor
of the foot.
The three muscles that act both on hip joint
and knee joint are biceps femoris, sartorius
and rectus femoris. The adductor magnus
acts only on hip joint.
The dorsalis pedis artery enters sole by
passing between the two heads of first dorsal
intrerosseous muscle and between the bases
of first and second metatarsals.
A21. The answers are C,D,B,A.
The foot drop, is a caused by injury to
common peroneal nerve.
The lurching joint is symptom of paralysis of gluteus medius.
182
The housemaids knee is caused by

inflammation of prepatellar bursa.
The sleeping foot is caused by compression of sensory fibers of sciatic
nerve.
A22. The answers are C,D,B,A.

The popliteus is attached to lateral condyle
of femur
The psoas major is inserted on lesser
trochanter of femur.
The extensor digitorum brevis is attached
to lateral surface of calcaneum.
The tensor fascia lata is attached to
anterior 5.0 cm of outer lip of iliac crest.
A23. The answers are B,D,C,A.
Syndesmosis is inferior tibio-fibular joint.
The saddle joint is calcano cuboid joint.
The ball and socket type of joint is hip
joint.
The plane type of joint is superior tibiofibular joint.
A24. The answers are B,D,C,A.

The saphenous nerve is branch of
femoral nerve.
The sural nerve is a cutaneous branch of
tibial nerve.
The superficial peroneal nerve is one of
the terminal branches of common
peroneal nerve.
The superior gluteal nerve is a branch of
sacral plexus.
A25. The answers are D,B,C,A.
The adductor longus adducts the hip
joint.
The piriformis is a small lateral rotator
of the hip joint.
The popliteus muscle helps in unlocking
the knee joint at beginning of flexion.
The sartorius helps in abduction of hip
joint.
tahir99 - UnitedVRG
The Thorax
Four
CHAPTER
20
The Bones and Joints of Thorax

The thorax is upper part of trunk, that contains
vital organs like lungs and heart.
Superiorly: It communicates with root of neck
by thoracic inlet (superior aperture of thorax).
Inferiorly: There is a wide thoracic outlet
(inferior aperture of thorax), that is closed by
thoracic diaphragm, separating thorax from
abdominal cavity.
THE BONES OF THE THORAX
a prominent bony ridge called sternal

angle.
Laterally, the manubrium articulates
Above with sternal end of clavicle at
sterno-clavicular joint.
Below with Ist costal cartilage, and
also with 2nd costal cartilage at sternal
angle.
ii. The body of sternum (middle part) is made
up by fusion of four pieces called sternebrae
The bones of thorax form a bony thoracic cage.

These bones are:
1. The sternum
2. Twelve pairs of ribs with costal cartilages
3. Twelve thoracic vertebrae and intervertebral
discs.
THE STERNUM
General Features
The sternum forms the front of thoracic cage and
consists of three parts manubrium, body and
xiphisternum (Figs 20.1 and 20.2)
i. The manubrium sterni - (upper part) has a
thick upper border called supra - sternal notch
Its posterior surface is related to arch of
aorta its three large branches and two
brachiocephalic veins.
The manubrium articulates with body of
sternum below forming manubriosternal joint, that is marked in front by
Fig. 20.1: The sternumanterior aspect
184
Anterior surface of manubrium sterni and body

of sternum - Pectoralis major
Posterior surface of lower 1/3rd of body sterno-costalis
Xiphisternum - in midline - linea alba of oblique
muscles of anterior abdominal wall
Xiphisternum - posterior surface - Two slips
of thoracic diaphragm.
Ossification
Fig. 20.2: The sternumposterior aspect
It has an anterior surface and a posterior

surface.
Laterally, the body of sternum has facets
for articulation with 2nd to 7th costal
cartilages.
The lower end of body of sternum articulates with xiphisternum at the xiphisternal joint.
The body of sternum is a favourite site
for bone-marrows aspiration, as the bone
is quite superficial and there is not much
fat covering it.
iii. The xiphisternum (lower part) is variable in
size and shape and may be perforated.
It has an anterior and a posterior surface
and fuses with body of sternum after the
age of forty years.
Special Features
[Muscles attached to the sternum]
Anterior surface of manubrium sterni - sternomastoid
Posterior surface of manubrium sterni Upper part - Sternohyoid
Lower part - Sternothyroid
Sternum is formed by fusion of two cartilaginous sternal plates. Incomplete fusion leads
to a sternal foramen.
Manubrium sterni ossifies from one to three
centers appearing in third to fifth month of
intrauterine life.
First and second pieces (sternebrae) ossify at
the same time by one center each.
Third and fourth pieces of sternum usually
ossify by two centers each that appear in fifth
and sixth months.
Xiphoid process ossifies by one center appearing
in third year.
The fusion of pieces of sternum begins at
puberty and is completed by twentyfifth year.
THE RIBS
General Features
There are twelve pairs of ribs in the thoracic cage.
The ribs are classified as:
a. The true ribs (vertebro-sternal) are first to
seventh. They articulate with sides of sternum
in front, through costal cartilages and sides of
thoracic vertebrae behind.
b. The false ribs are those which do not reach the
sides of sternum in front. The false ribs are
further subdivided as:
i. The vertebro-costal ribs ribs are eighth, ninth
and tenth. These articulate with next higher
cartilage in front and sides of thoracic
vertebrae behind.
tahir99 - UnitedVRG

ii. The vertebral ribs are eleventh and twelfth.
They only articulate with sides of thoracic
vertebrae. Their anterior ends are free, hence
they are known as floating ribs also.
The ribs are further classified as:
a. The typical ribs that show all typical common
features. The third to ninth are typical ribs.
b. The atypical ribs are those that show some
atypical features, the first, second, tenth,
eleventh, and twelfth are atypical ribs.
a. A typical rib has a head, a neck, a tubercle and
a shaft (Fig. 20.3)
i. The head is expanded posterior end of the
rib, that articulates with sides of corresponding vertebra and next higher vertebra
to form costo-vertebral joint.
It presents two facets separated by a
ridge.
ii. The neck is the narrow portion between head
and the tubercle.
iii. The tubercle has an articular facet for
articulating with facet on tip of transverse
process of corresponding vertebra.
It has a non-articular facet for attachment of lateral costo-transverse-ligament.
iv. The shaft has an upper thick border and a
sharp lower border. The shaft is curved
The outer surface is rough for attachment of muscle.
185
The inner surface is smooth and related

to pleura. There is a costal groove lying
along the lower border on the inner
surface. It lodges the intercostal vein,
artery and nerve.
The angle is present posteriorly, where
the shaft changes its direction.
b. The atypical ribs (Fig. 20.4)
i. The first rib is short and wide.
It has a superior surface, that shows
grooves for the subclavian artery and
vein separated by a ridge.
The inferior surface is smooth and
related to pleura.
On the inner border of first rib there is
scalene tubercle for insertion of scalenus
anterior.
There is no angle in the shaft of first rib.
There is no costal groove in first rib.
It articulates with side of first thoracic
vertebra only posteriorly.
ii. The second rib has an upper surface that
faces partly outwards, and a lower surface
that faces inwards (Fig. 20.5).
It has a shallow costal groove
The head of second rib articulates
posteriorly with sides of first and second
thoracic vertebra.
Fig. 20.3: The typical rib
186
Fig. 20.6: The twelfth ribanterior aspect
Fig. 20.4: The first rib-superior aspect
iii. The tenth rib has all the other features of a

typical rib, but it articulates with side of
tenth thoracic vertebra only.
iv. The eleventh and twelfth ribs have no
tubercles and angles (Figs 20.6 and 20.7):
Their outer surface gives attachment to
muscles
The inner surface is smooth
They articulates posteriorly with side of
eleventh and twelfth thoracic vertebrae
respectively.
Special Features
[Important muscles and ligaments attached to ribs]
1. The First rib
Scalene tubercle on inner border scalenus
anterior
Superior surface Scalenus medius

Superior surface near anterior end
subclavius
Outer border 1st digitation of serratus
anterior
Superior surface near anterior end Costoclavicular ligament.
2. The Second rib
External surface, behind middle Serratus
anterior
External surface in front of angle
Scalenus posterior
External surface posterior part Serratus
posterior superior
3. The Twelfth rib
Anterior surface - medial 2/3rd Quadratus
lumborum
Upper border - Thoracic diaphragm
External surface - Serratus posterior inferior
erector-spinae, latissimus dorsi and levator
costae
Ossification
Fig. 20.5: The second rib-superior aspect
Each rib ossifies by one primary center for the

shaft appearing in eighth week of intrauterine
life.
Fig. 20.7: The twelfth ribposterior aspect
tahir99 - UnitedVRG
There are three secondary centersone for

head, one each for articular and nonarticular
part of tubercle. These centers appear at
puberty.
First rib has only two secondary centersone
for head and one for tubercle.
Eleventh and twelfth ribs have only one
secondary center for the head.
The secondary centers appear at puberty and
fuse by twentieth year.
Applied Anatomy of Ribs

1. A cervical rib may sometimes be present. It
arises as an enlargement of costal element of
transverse process of 7th cervical vertebra.
The cervical rib (if present) may cause
pressure on lower trunk of brachial plexus
producing pain on medial side of forearm
and hand [later if the condition persists it
may lead to wasting of small muscles of
hand]
The cervical rib may also exert pressure on
subclavian artery and interfere with circulation of blood in upper limb.
These symptoms of compression are called
cervical rib syndrome.
2. A lumbar rib may arise by enlargement of costal
element of 5th lumbar vertebra. This is much
rarer condition than cervical rib.
187
The third to seventh costal cartilages articulate

with side of body of sternum forming synovial
joints.
The eighth, ninth, and tenth costal cartilages
articulate with next higher costal cartilage
forming synovial joints.
The eleventh and twelfth costal cartilages are
present on anterior ends of their ribs.
The Thoracic Vertebrae

The thoracic vertebrae are twelve in number. They
form a part of vertebral column
Each vertebra has two main parts
i. A body placed anteriorly
ii. A vertebral arch placed posteriorly.
The thoracic vertebrae are classified as:
a. Typical thoracic vertebrae that show
common typical features. Second to eighth
thoracic vertebrae are typical.
b. Atypical thoracic vertebrae that show some
uncommon features. First, ninth, tenth,
eleventh, and twelfth thoracic vertebrae are
atypical.
a. A typical thoracic vertebra has following
features (Figs. 20.8 and 20.9):
I. The body is kidney shaped and bulky.
The Costa Cartilages

The costal cartilages are present at anterior ends
of the ribs. These may calcify in old age.
The costal catilages are hyaline type of
cartilages.
The first costal cartilage articulates with side
of manubrium sterni forming a primary
cartilaginous type of joint.
The second costal cartilage articulates at the
sternal angle with side of manubrium sterni
and body of sternum forming two synovial
joints.
Fig. 20.8: A typical thoracic vertebralateral aspect
188
Fig. 20.9: A typical thoracic vertebraSuperior aspect
It makes joints with adjacent vertebrae

at the intervertebral discs.
The sides of the body have two costal
demifacets for articulating with heads
of the ribs.
The upper costal demifacet is larger
and articulates with the head of same
or corresponding rib.
The lower costal demifacet is smaller
and articulates with the head of next
lower rib.
II. The vertebral arch encloses a vertebral canal
in which spinal cord lies along with its
meninges. The vertebral arch is made up
of:
Two pedicles anteriorly
Two laminae posteriorly
The spinous process (vertebral spine) arises in
midline where the two laminae, meet posteriorly.
The spines of thoracic vertebrae are long and
slope downwards
Two transverse processes arise on either side
from the junction of pedicles and laminae. They
have facets on their tips for articulating with
tubercles of the ribs.
The vertebral arch has also two paired articular

processes to articulate with adjacent vertebrae.
The superior articular facet faces posteriorly
and articulates with inferior articular facet
of next higher vertebra.
The inferior articular facet faces anteriorly
and articulates with superior articular facet
of next lower vertebra.
There is an intervertebral notch at the inferior
border of pedicle.
This together with similar small notch on
the superior border of pedicle of next lower
vertebra completes the intervertebral
foramen, through which the spinal nerve
leaves the vertebral canal.
b. The atypical thoracic vertebrae (Fig. 20.10)

I. The first thoracic vertebra has a complete,
round upper costal facet for head of first
rib. The lower costal demifacet, however,
is incomplete for the head of second rib.
The spinous process of first thoracic
vertebra is horizontal and not sloping.
II. The ninth thoracic vertebra has only upper
costal demifacet for ninth rib.
There is no lower costal facet for tenth rib.
tahir99 - UnitedVRG
189
III.The tenth thoracic vertebra has only one

complete oval costal facet on the side of
body for articulating with head of tenth rib.
IV. The eleventh thoracic vertebra has only one
round costal facet on the side of the body
for articulating with head of eleventh rib.
The transverse process is small and has
no articular facet, as the eleventh rib has
no tubercle.
V. The twelfth thoracic vertebrae has also only
one round costal facet on the side of the
body for articulating with head of twelfth
rib.
The transverse process is small and has
no articular facet, as the twelfth rib also
has no tubercle.
The lower thoracic vertebrae gradually increase
in size and the twelfth vertebrae has some features
of lumbar vertebrae.
Ossification
The thoracic vertebrae are ossified by three

primary centersone for body (centrum) and
two for each half of vertebral arch. The center
for body appears early and for the arch appear
a little later in ninth to tenth week.
There are five secondary centers
Two for superior and inferior surface of
body of vertebra
Two for apex of transverse processes
One for the spinous process.
These centers appear at puberty and fuse by
twentyfifth year.
THE JOINTS OF THE THORAX

I. The Costo-Vertebral Joints
Fig. 20.10: The atypical thoracic vertebrae-Lateral
aspect
The costo-vertebral joints are between the heads

of the ribs and the costal facets on the sides of
bodies of thoracic vertebrae (Fig. 20.11).
Type: The first, tenth, eleventh, and twelfth ribs
articulate with their corresponding vertebral
190
Fig. 20.11: The costo-vertebral joints
bodies only. They have plane type of synovial

joints.
The second to ninth rib articulate with sides
of bodies of two vertebraecorresponding
vertebrae and next higher vertebrae. These
ribs have plane type of double synovial joints
with an intra-articular ligament.
The articular capsule surrounds the joint, and
is reinforced by ligaments.
The ligaments of the joint are
a. Radiate ligament strengthens the anterioraspect of the articular capsule.
It is attached just beyond the head and
has three sets of fibers.
Upper fibers reach the side of vertebra
above
Middle fibers are short and attached to
the intervertebral disc
Lower fibers reach the side of the
vertebra below
b. The intra-articular ligament is present in
costovertebral joints of second to ninth-ribs
that have double joint cavities.
It is attached to the crest between the
two demifacets on the heads of ribs
laterally, and to the intervertebral disc

medially.
II. The Costo-Transverse Joints
The costo-transverse joints are joints between the
facets on tips of transverse processes of thoracic
vertebrae and tubercles of the ribs (Fig. 20.12)
The elventh and twelfth ribs have no tubercles,
hence they have no costo-transverse joints.
Type
Plane type of synovial joints
In relation to upper six thoracic ribs the
joint surfaces are slightly curved reciprocally.
tahir99 - UnitedVRG
Fig. 20.12: The costo-transverse joints
Articular capsule is thin and surrounds the joint

on all sides. It is reinforced by the ligaments.
Ligaments
i. The superior costo-transverse ligament is
attached to the neck of the rib and inferior
surface of transverse process above.
ii. The costo-transverse ligament is attached
to the dorsal surface of neck of rib and front
of the corresponding transverse process.
iii. The lateral costo-transverse ligament
connects the tip of the transverse process
to the non-articular part of tubercle of the
rib.
Movements
The articular facets of upper six ribs are
oval and vertically convex, fitting with
corresponding concavities on transverse
process. At these joints rotation movement
on their long axes takes place during up and
down movements of the ribs.
The articular facets on tubercles of seventh
to tenth ribs are almost flat facing downwards and medially. At these joints only
gliding movements occur.
III. The Sterno-Costal Joints

(Chondro-Sternal Joints)
These are joints between the costal cartilages

and facets on the side of sternum.
The sterno-costal joints are present in relation
to upper seven ribs only.
The first costal cartilage joins with side of
manubrium sterni by a primary cartilaginous
joint
The second to seventh costal cartilages articulate
with facets on the side of sternum by synovial
joints. The end of costal cartilage presents a
small convexity, while the sternal facets are
slightly concave
Articular capsule surrounds the joints on all
sides.
191
Ligaments
i. Radiate sterno-costal ligaments are attached
from front of costal cartilages to the
corresponding sternal surface.
ii. The intra-articular is present only between
second costal cartilages and the sternum,
where the joint cavity is divided by the
ligaments into two joints cavities.
iii. The costoxiphoid ligament connects the
front of seventh costal cartilage with
xiphisternum.
Movements
Slight gliding movements take place at the
sterno-costal joints during movements of ribs
in respiration.
IV. The Interchondral Joints

These are synovial joints between the cartilage of
sixth to ninth rubs at their contiguous borders.
There are small oblong facets on costal cartilages.
Articular capsule surrounds the joints.
Inter-chondral ligamentsmedial and lateral
connect the costal cartilages.
Movementsvery little movements are possible
at these joints.
V. The Costochondral Joints
These are junctions between anterior ends of ribs
and costal cartilages
The anterior end of the rib has a depression,
and the costal cartilage presents a rounded end
to fit in that depression.
The periosteum of rib becomes continuous with
the perichondrium of the cartilage.
VI. The Manubrio-Sternal Joint
The manubrio-sternal joint is between the lower
border of manubrium sterni and body of sternum.
Type: A symphysis or or secondary cartilaginous
type of joint
192

There is a plate of fibro-cartilage between the
two joint surfaces. This fibro-cartilage may
ossify in old age.
A fibrous membrane covers the joint.
Movements: A small range of movements take
place at this joint, in the longitudinal axis of
sternum with a limited antero-posterior displacement.
The movements take place during the
respiratory movements of the thoracic cage.
Each disc consist of

An outer laminated annulus
fibrous
An inner nucleus pulposus
VII. The Xiphisternal Joint

The joint lies between lower end of body of sternum
and xiphoid cartilage.
Type: A symphysis or secondary cartilaginous
joint; but may be converted into synostosis by
fortieth year.
VIII. The Joints between
Thoracic Vertebrae
Joints of vertebral bodies

The vertebral bodies are connected by
anterior and posterior longitudinal ligaments
and by the intervertebral discs.
A. The anterior longitudinal ligament - is
a thick, strong band that extends along
the anterior surface of bodies. It is
strongly adherent to the intervertebral
discs.
B. The posterior longitudinal ligament lies
inside vertebral canal on the posterior
surface of vertebral bodies. It is narrower than anterior ligament and is also
attached to the intervertebral discs.
C. The intervertebral discs - are adherent
to the thin layer of hyaline cartilages on
superior and inferior surfaces of vertebral bodies thus forming the intervertebral symphysis.
The nucleus pulposus is soft,

gelatinous, mucoid material. It is
derrivative of notochord of
embryonic stage.
The joints of vertebral arches:
a. The zygophyseal joints - are simple synovial
joints between the superior and inferior
articular processes of adjacent vertebrae
The articular capsules are thin and loose
and are attached to the margins of
articular facets.
b. The ligamentum flava - connect the laminae
of adjacent vertebrae. These consist of
elastic tissue mainly.
c. The supra-spinous ligaments are strong
fibrous cords, connecting the apices of the
spinous processes of adjacent vertebrae.
Between the 7th cervical spine and
external occipital protuberance of
occipital bone the supraspinous ligament
is expanded to form the ligamentum
nuchae.
d. The inter-spinous ligaments - are thin and
membranous. These connect the adjacent
spinous processes
e. The inter-transverse ligaments lie between
the adjacent transverse processes. These are
largely replaced by inter-transvere muscles.
Applied Anatomy
Herniation of intervertebral discIn young

adults the intervertebral discs are quite strong
and are seldom damaged.
As age advances, degenerative changes take
place in the disc leading to softening of
annulus fibrosus.
Minor strains or trauma can lead to derangement of nucleus pulposus. It may bulge
through the annulus - in posterolateral
direction usually.
tahir99 - UnitedVRG

The herniated nucleus pulposus may press
upon adjacent nerve roots causing back pain
called sciatica
This condition is quite common in lower
lumbar region.
THE INLET OF THORAX
The inlet of thorax is the opening through which

the thorax communicates with root of the neck.
Shapekidney shaped
Plane of inlet is sloping downwards and
forwards from upper border of first thoracic
vertebra to supra-sternal notch.
Boundaries
Posteriorly Upper border of first thoracic
vertebra
Anteriorly Upper border of manubrium
sterni (supra-sternal notch)
On two sides Inner border of first rib and
costal cartilage.
Structures passing through inlet of thorax
A. Midline structures
Lower parts sternohyoid, sternothyroid
and longus colli muscles
193
Remains of thymus, inferior thyroid

veins
Trachea and oesophagus
Left recurrent laryngeal nerve
Thoracic duct
B. On right side
In front of neck of first rib
Sympathetic chain
First posterior intercostal vein
Superior intercostal artery
Ventral ramus of first thoracic nerve
Internal thoracic artery and vein anteriorly
Brachiocephalic artery
Right brachiocephalic vein
Right vagus and right phrenic nerves
C. On left side
Four structures crossing front of neck
of first rib (same as on right side)
Internal thoracic artery and vein
Left common carotid artery
Left subclavian artery
Left brachiocephalic vein
Left vagus and left phrenic nerves.
CHAPTER
21
The Musculature of
the Thoracic Wall
THE EXTRINSIC MUSCLES
These muscles are attached to the external surface
of thoracic cage. They help in the movements of
shoulder girdle, upper extremity and the neck.
Some of these muscles also help to a great
extent in the respiratory movements of thoracic
cage.
I. The pectoralis major connects medial half of
clavicle, upper six costal cartilages and front
of sternum to the lateral lip of bicipital groove
of humerus.
The muscle elevates upper six ribs during
forced inspiration.
II. The pectoralis minor connects third, fourth, and
fifth ribs to coracoid process of scapula.
It helps to elevate third, fourth, and fifth
ribs during deep inspiration.
III.The sterno-cleidomastoid muscle passes from
manubrium sterni and medial one-third of
clavicle to mastoid process and superior nuchal
line of skull.
It elevates manubrium sterni
IV. The scalene muscles
a. The scalenus anterior connects anterior
tubercles of transverse processes of third
to sixth cervical vertebrae to scalene
tubercle of first rib
b. The scalenus medius connects posterior
tubercles of transverse processes of second
to sixth cervical vertebrae to first rib
c. The scalenus posterior (when present)
connects posterior tubercles of transverse
processes of fifth and sixth cervical vertebrae to second rib.
The scalene muscles elevate first and second

ribs during deep inspiration.
THE INTRINSIC MUSCLES
The intrinsic muscles consist of three layers of
intercostal muscles, that fill up the intercostal
spaces.
a. The outer layer has external intercostal muscles
(Fig. 21.1).
b. The intermediate layer has internal intercostal
muscles
c. The inner layer is incomplete and consists of
i. Sternocostals (transversus thoracic)
anteriorly
ii. Innermost intercostal (intercostalis intimus)
located in middle two-fourth part of intercostal space
iii. Subcostalisposteriorly.
The External Intercostal Muscles
There are eleven pairs of external intercostals filling
up all eleven intercostal spaces.
tahir99 - UnitedVRG
Fig. 21.1: Part of thoracic wall showing

three layers of muscles
The Musculature of the Thoracic Wall
Attachments
UpperSharp inferior border of the rib
above
LowerOuter edge of thick superior border
of the rib below
Extent
AnteriorlyThe external intercostal extends
up to costo-chondral junction. It is replaced
in between the costal cartilages by anterior
(external) intercostal membrane
PosteriorlyThe muscle extends up to the
posterior end of the intercostal space.
Direction of fibersis downwards forwards
and medially in front of chest wall.
Nerve supplyis by the corresponding intercostal nerve (i.e. ventral ramus of thoracic
nerve)
ActionsElevation of the rib during inspiration.
The Internal Intercostal Muscles

There are eleven pairs of internal intercostal
muscles, that fill up all eleven intercostal spaces.
195
Attachments
Upperthe floor of the costal groove of
the rib above
Lowermiddle part of thick superior border
of rib below
Extent
AnteriorlyThe muscle extends up to the
side of sternum
PosteriorlyIt extents up to the angle of
the rib, beyond that it is replaced by internal
(posterior) intercostal membrane
Direction of fibers is upwards, forwards and
medially in anterior part of chest wall, nearly at
right angles to the fibers of external intercostal
muscle.
Nerve supplyis by the corresponding intercostal nerve (ventral ramus of thoracic nerve).
Actions
i. The intra-cartilaginous part helps to elevate
the anterior ends of the rib.
ii. The rest of the muscle helps in depression
of the rib (Fig. 21.2).
Fig. 21.2: TS thoracic wall showing intercostal muscles and intercostal arteries
196
The Innermost Intercostal

(Intercostalis Intimus)
This muscle of the inner layer of thoracic wall
covers only middle two-fourth part of the intercostal
space.
Attachments
UpperInner surface of the upper rib
above costal groove
LowerInner edge of the thick upper border
of the rib below
ExtentThe muscle covers only middle twofourth part of the intercostal space
Direction of fiberssame as internal intercostal
Nerve supplyis by the corresponding intercostal nerve (ventral ramus of thoracic nerve)
Actions
i. Functionally the muscle is part of internal
intercostal. The innermost intercostal is
separated from the internal intercostal by
intercostal vessels and nerve (neuro-vascular
plane)
ii. The three intercostal muscles also help to
prevent bulging in and bulging out of
intercostal spaces during inspiration. Thus
they maintain the integrity of intercostal
spaces.
The Sternocostalis
(Transversus Thoracis)
The sternocostalis is a part of inner layer of
intercostal muscles, that is attached to sternum (Fig.
21.3).
OriginPosterior surface of lower third of
body sternum
Muscle bellyconsists of digitations that pass
upwards and a little laterally towards costal
cartilages
InsertionInner surface second to sixth costal
cartilages
Nerve supplyThird to sixth intercostal nerves
(ventral rami of thoracic nerves)
ActionsIt depresses anterior ends of second
to sixth ribs.
Fig. 21.3: The sternocostalis muscle
The Subcostalis
The subcostalis is a part of inner layer of intercostal
muscles, that is attached to posterior part of ribs
as digitations. The subcostalis is better developed
in lower part of thoracic cage.
Attachments
UpperInternal surface of one rib near its
angle
LowerInternal surface of second or third
rib below
Direction of fibersSame as internal intercostal
Nerve supplyis by corresponding intercostal
nerves
ActionsThe subcostalis depresses posterior
parts of ribs during expiration.
MUSCLES CONNECTING THORACIC
CAGE TO VERTEBRAL COLUMN
I. The Serratus Posterior Superior
It is a thin quadrilateral muscle covering upper
posterior part of thoracic cage.
Origin
Lower part of ligamentum nuchae
Spine of seventh cervical vertebrae
tahir99 - UnitedVRG
Spines of upper two or three thoracic

vertebrae
InsertionUpper border and external surfaces
of second to fifth ribs
Nerve supplySecond and third intercostal
nerves (Ventral rami of second and third thoracic
nerves)
ActionsThe muscles elevates second to fifth
ribs during inspiration.
II. The Serratus Posterior Inferior

It is also a thin quadrilateral muscle covering lower
posterior part of thoracic cage.
Origin
Spines of lower two or three thoracic
vertebrae
Spines of upper two or three lumbar
vertebrae through lumbar fascia
InsertionInferior border and outer surfaces
of lower four ribs
Nerve supplyVentral rami of ninth to twelfth
thoracic spinal nerves
ActionsIt depresses lower four ribs.
197
III. The Levatores Costarum

These are twelve pairs of strong bundles of muscles
fibers connecting vertebrae with the posterior parts
of the ribs.
Origin: Seventh cervical to eleventh thoracic
transverse processes at their tips.
Insertion: Upper edge and external surface of
neck of the rib below.
Nerve supply: Lateral branches of dorsal rami
of corresponding thoracic spinal nerves.
Actions: The levatores costarum elevate
posterior parts of the ribs.
THE THORACIC DIAPHRAGM
The thoracic diaphragm is a musculo-tendinous

bidomed structure, that separates thoracic cavity
from the abdominal cavity.
The diaphragm completely fills up the thoracic
outlet.
Origin (Fig. 21.4)
a. Sternal is by two slips from inner surface
of xiphisternum.
b. Costal is by slips from inner surface of
lower six costal cartilages of both sides.
Fig. 21.4: The thoracic diaphragm
198
c. Lumbar is by means of two cruramusculo-tendinous structuresand two paired

ligaments.
i. The right crus is larger and is attached
to front of bodies of upper three lumbar
vertebrae and intervertebral discs.
ii. The left crus is smaller and is attached
to front of bodies of upper two lumbar
vertebrae and intervertebral disc.
The two ligaments are:
i. Lateral arcuate ligament (lateral lumbocostal arch) is attached from tip of first
lumbar transverse process to lower border
of twelfth rib.
ii. Medial arcuate ligament (Medial lumbocostal arch) is attached from the side of
crus to transverse process of first lumbar
vertebra.
Muscle belly
The muscular fibers from the three origins
ascend upwards and converge medially
towards the central tendon.
The diaphragm forms two domes or
cupolae. The right dome is a little higher
due to liver below it.
The fibers of right crus cross towards left
of the median plane and form a sling-like
elliptical opening for giving passage to the
esophagus.
Insertion
The muscular fibers from all sidesi.e. from
sternum, costal cartilages and the two crura,
ascend upwards and medially and are inserted
on Central tendona fibrous aponeurosis in
the center, from all sides.
Nerve supply
Motor fibers are supplied by two phrenic
nerves (C3, C4, C5)
Sensory (proprioceptive fibers)
For central portion by the phrenic nerves
For peripheral part of the lower five
intercostals and subcostals (T7 to T12
ventral rami)
Actions
i. The thoracic diaphragm is the main muscle
of inspiration. When it contracts, it descends
and increases the vertical diameter of
thoracic cavity.
ii. The diaphragm helps in all voluntary expulsive efforts, e.g. micturition, defecation,
coughing, sneezing, vomiting and parturition
(in females).
iii. The diaphragm helps to maintain and control
the intra-abdominal pressure.
iv. The fibers of right crus of diaphragm exercise a sphincteric control over esophageal
opening (Table 21.1).
Table 21.1: Major openings of diaphragm

Inferior vena caval opening Esophageal opening
1. Position
2. Vertebral level
3. Shape
4. Structures
passing
through
In central tendon, between

right and central leaflet
8th thoracic vertebra
Quadrangular
Inferior vena cava
Branches of right phrenic
nerve
Some lymphatics
5. Effect of conThe inferior vena caval
traction of
opening is dilated (venous
diaphragm
return takes place)
Muscular part of diaphragm

surrounded by fibre of right crus
10th thoracic vertebra
Elliptical
Esophagus
Anterior and posterior gastric nerves
Branches of left gastric artery
Esophageal opening is closed
tahir99 - UnitedVRG
Aortic opening
{
{
Behind median arcuate ligament

of diaphragm
12th thoracic vertebra (lower
border)
Oval
Descending aorta
Thoracic duct
Azygos vein
No effect on aortic opening

Other Structures Passing
Through Diaphragm
I. The superior epigastric artery passes between
sternal and costal slips.
II. The musculo phrenic artery passes between
slips of seventh and eighth costal cartilages.
III. The lower five intercostal nerves (T7 to T11)
pass between costal slips.
IV. The subcostal vessels and nerve pass out deep
to lateral arcuate ligament.
V. The sympathetic trunk passes out deep to
medial arcuate ligament.
VI. The three splanchnic nervesgreater, lesser
and lowerpierce the crus of diaphragm.
VII. The hemiazygos vein pierces left crus of
diaphragm.
Development
The thoracic diaphragm develops from the
following embryonic structures
1. Septum transversum-(median part of
secondary mesoderm) that forms the central
tendon of diaphragm.
2. Two pleuro-peritoneal membranes.
3. Muscular components from lateral and
dorsal body walls.
4. Mesentery of esophagus in which the
crura of diaphragm develop.
Anomalies
Incomplete fusion of developmental parts may
result in congenital defects or anomalies in
diaphragm.
a. Incomplete closure of pleuro-peritoneal canal
results in diaphragmatic hernia. It is more
common on left side.
b. Foramen of Morgagni is result of incomplete
closure of sterno-costal triangle, between
sternal and costal origins. This is also a site for
rare type of diaphragmatic hernia.
Applied Anatomy
I. The phrenic nerve lesion paralyses half the
diaphragm. It may lead to paradoxical
199
movements of paralyzed hemidiaphragm,

resulting in poor oxygenation of blood.
II. Hiccups are recurrent spasms of diaphragm,
phrenicotomy is done sometimes to relieve
chronic case of hiccups.
III. Diaphragmatic hernia is a rare type of hernia
that occurs due to a defect in development
of diaphragm.
THE MOVEMENTS OF RESPIRATION
The respiratory movements can be divided into:
The costsal movements
The diaphragmatic movements
The Costal Movements
a. Normal Costal Inspiration
The external intercostals and intra-chondral

parts of internal intercostals contract and move
the ribs upwards and outwards (bucket-handle
movements).
The concave inner surface of ribs is also turned
outwards. By these movements the transverse
diameter of thoracic cavity is increased.
Simultaneously with movements of ribs, the
sternum moves forwards and upwards, thereby
increasing the anteroposterior diameter of thoracic cavity (pump-handle type of movements).
By increasing transverse and anteroposterior
diameter of thorax, the intrathoracic pressure
becomes lower and lungs expand, thus bringing
more air by inspiration.
b. Forced Costal Inspiration

Apart from the intercostal, pectoral muscles assist
in maximal elevation of ribs. The sterno-mastoid
and the scalene muscles further elevate the first rib
and manubrium sterni. These muscles, therefore,
help in further increasing the transverse and
anteroposterior diameters of thoracic cavity.
Forced inspiration is required for ventilating a
larger part of lung for greater oxygenation of
blood.
200
c. Normal Costal Expiration
No muscular effort is needed to expel the air from

the lungs.
Quiet (normal) expiration is done mainly by the
elastic recoil of the costal cartilages and the
lungs.
External elastic recoilis provided by the costal
cartilages, that are deformed during normal quiet
inspiration. They, now, turn back to their normal
shape. Gravity also helps in this process. This
elastic recoil of costal cartilages decreases as
age advances.
Internal elastic recoilis provided by the lungs.
The elastic fibers of interstitial tissue between
the alveoli of lungs, tend to cause shrinkage of
lung tissue.
The tension between two surfacesvisceral and
parietal pleuraseparated by a thin film of fluid
produces a very high degree of adhesive effect
(surface tension). This force called intrathoracic pressure tends to pull the chest wall
inwards.
Diseases like emphysema, that reduce the
elasticity of lung tissue, affects this type of
movements.
b. The Diaphragmatic Expiration
d. Forced Costal Expiration

Forced costal expiration is caused by additional
muscular effort.
The internal intercostal muscles contract and
decrease the transverse and anteroposterior
diameters of thoracic cavity.
Quadratus lumborum muscle lowers and fixes
the twlfth rib so that thoracic cage can be
depressed effectively.
The Diaphragmatic Movements
Active diaphragmatic movements lower the

dome of diaphragm as much as 10.0 cm.
During diaphragmatic contraction, the
abdominal contents are displaced.
This movement is helped by slight relaxation of
abdominal wall muscles.
The abdominal wall muscles act as antagonists

to diaphragm. When they contract, they push
the abdominal viscera upwards, thus they stretch
the diaphragm in thoracic cavity and reduce
the vertical diameter and volume of thoracic
cavity.
The abdominal musculature comes into effect
when respiratory requirements are more than
normal.
In erect posture, gravity tends to lower the
diaphragm.
But when one is in supine position, the gravity
tends to push up the abdominal viscera and
stretch the diaphragm. So when a person has
respiratory difficulty, he has to be propped up
for proper ventilation of lungs.
The normal balance between the costal and
diaphragmatic movements depends upon many
factors like sex, body type, profession, state of
health and clothing.
The children and elderly people breathe more
by the abdominal type of respiration.
Fat persons and women in advanced pregnancy
cannot have abdominal type of respiration, so
they respire mainly due to the movements of
ribs (costal respiration).
Applied Anatomy
a. The Diaphragmatic Inspiration

The contraction of diaphragm lowers the level of
its two domes, thereby increasing the vertical
diameter of thoracic cavity. This decreases the intrathoracic pressure.
1. Pneumothorax: A penetrating wound or rupture

of pulmonary tissue or tear of pleura allows the
entry of air into pleural cavity, thereby abolishing
the negative intra-thoracic pressure and results
in collapse of lung.
tahir99 - UnitedVRG

[A negative intrathoracic pressure (as compared
to the atmospheric pressure) and surface tension
normally holds the lungs against thoracic wall.]
a. A sucking pneumothorax is accompanied by
hyper-expansion of chest wall on normal
side. This causes mediastinal flutter, a slight
shift of mediastinal contents towards normal
side during inspiration and injured side
during expiration.
b. A tension penumothorax is created when
due to nature of wound air is sucked in
during each thoracic expansion, without
expelling out the air. The resultant
pneumothorax pushes mediastinal contents
significantly towards the normal side,
thereby interfering with vital capacity of
normal lungs.
2. Pleural effusion: Fluid may collect in the pleural
cavity due to
a. Inflammation of pleura (pleurisy with
effusion)
b. Secondary to congestive heart failure, as a
part of generalized edema of body.
Such collections reduce the vital capacity
of lung and thus reducing the
oxygenation taking place in the lung.
As little as 500 ml of fluid may be seen
in X-ray of the chest as it obscures the
costo-diaphragmatic angle.
The fluid in the pleural cavity can be
aspirated out if it causes embarrassment
to function of the lung.
3. Fracture of rib may penetrate thoracic wall,
tear visceral pleura and cause pneumothorax
Tearing of associated blood vessels (intercostal vessels) may cause hemothorax
(collection of blood in the pleural cavity).
Fracture of several ribs in two locations
(anterior and posterior) diminishes the
structural integrity of thoracic cage. It leads
to flat chest. The thoracic wall cannot
201
withstand the decrease in intra-thoracic

pressure and during expiration the flat
portion moves outwards (paradoxical respiratory movements). This results in reduced
ventilation of lungs.
4. The respirators
Negative pressure devices of iron lung or
respiratory lower the extra thoracic and
intra-pulmonary pressure below the
atmospheric pressure thereby simulating
natural negative pressure breathing.
Positive pressure devices elevate the
atmospheric pressure above normal, so that
air is forced inside the lung.
The Blood Vessels of the Thoracic Wall
The Arteries
a. The internal thoracic artery supplies anterior
part of the thoracic wall (Fig. 21.5)
OriginThe internal thoracic artery arises
from inferior surface of first part of subclavian artery.
Fig. 21.5: The internal thoracic artery
202
Course
The artery descends behind internal
jugular and right brachio-cephalic vein
to enter thoracic inlet behind first costal
cartilage.
As it enters thorax, the phrenic crosses
in front of the artery from lateral to
medial side.
The internal thoracic artery descends
deep to the upper six costal cartilages
and intercostal spaces, lying about
1.2 cm from side of sternum.
TerminationThe artery divides into its two
terminal branchessuperior epigastric and
musculophrenicin the sixth intercostal
space.
Branches
i. The pericardio-phrenic branch: A slender
artery that accompanies phrenic nerve
and after supplying pericardium supplies
the diaphgram.
ii. The mediastinal branches supply lymph
nodes and other structures in mediastinum
iii. The pericardial branches supply the
fibrous pericardium.
iv. The sternal branches supply the sternum
v. The paired anterior intercostal branchessuperior and inferiorfor upper
six intercostal spaces supply anterior part
of thoracic wall
vi. The perforating branches accompany
second to sixth intercostal nerves
In second, third and fourth spaces in
females the perforating branches are large
and supply the mammary gland.
vii. The superior epigastric artery enters the
rectus sheath in anterior abdominal wall,
between sternal and costal slips of orign
of diaphragm.
viii. The musculo-phrenic artery passes
between seventh and eighth costal slips
of diaphrarm and runs along costal
margin, supplying inter-costal muscles

and diaphragm.
b. The intercostal arteries: The intercostal arteries
supply the thoracic wall
The upper nine intercostal spaces have two
anterior and one posterior intercostal arteries.
The lower two intercostal spaces are small
and have only one posterior intercostal
artery.
I. The anterior intercostal arteries are two
superior and inferior-in each space
Origin
The anterior intercostal arteries in upper
six spaces are branches of internal
thoracic artery
In seventh, eighth and ninth space they
are branches from musculophrenic
artery.
Course
The anterior, superior intercostal artery
runs in the costal groove between intercostal vein above the intercostal nerve
below. The anterior inferior intercostal
artey runs along the upper border of the
rib below. The intercostal vessels and
nerve lie in the neuro-vascular plane of
thoracic wall between internal intercostal
and innermost intercostal.
The anterior intercostal arteries are
smaller and supply only anteior one third
part of intercostal space.
The anterior superior intercostal artery
anastomoses with the posterior intercostal artery.
The anterior inferior intercostal artery
anastomoses with the collateral branch
of posterior intercostal artery.
II. The posterior intercostal arteries are larger and
supply nearly two-third part of the intercostal
space.
Origin (Fig. 21.6)
In upper two spaces, the posterior intercostal arteries are branches of superior
tahir99 - UnitedVRG
ii.
iii.
iv.
v.
203
meninges and also give radicular branch

of spinal cord.
The collateral branch supplies the intercostal muscles
The small muscular branches are also
given
The lateral cutaneous branch accompanies the lateral cutaneous nerve. In
females, the lateral cutaneous branch in
second, third and fourth spaces supply
mammary gland.
The right bronchial artery arises from
the first right aortic intercostal artery.
The Veins
Fig. 21.6: The intercostal arteries
intercostal branch of costo-cervical

trunk for first part of subclavian artery.
In lower nine intercostal spaces, the
posterior intercostal arteries are branches
of descending thoracic aorta.
Course
The posterior intercostal artery runs in
the costal groove with intercostal vein
above and intercostal nerve below, in the
neuro-vascular plane of thoracic wall.
It gives a collateral branch, near the
angle of rib, that runs along the upper
border of rib below and anastomoses
with anterior inferior intercostal artery.
The posterior intercostal artery anastomoses with anterior superior intercostal
artery
Branches
i. The dorsal branch supplies the muscles
of the back and gives a spinal branch
that enters vertebral canal to supply
a. The internal thoracic artery is accompanied by

a pair of venae comitantes up to the lower
border of third costal cartilage
Above that, there is only one internal
thoracic vein, that ascends, medial to internal
thoracic artery.
The internal thoracic vein ends in brachiocephalic vein.
The internal thoracic veins receive tributaries corresponding to the branches of
internal thoracic artery.
b. The intercostal veins
I. The anterior intercostal veins are two in each
upper nine intercostal spaces.
These veins accompany the corresponding arteries, lying in the neurovascular plane of thoracic wall.
They drain venous blood from anterior
part of thoracic wall.
In upper six intercostal spaces, the
anterior intercostal veins end in internal
thoracic veins.
In lower three intercostal spaces, the
anterior intercostal veins end in venae
comitantes of musculophrenic artery.
II. The posterior intercostal veins are one in
each eleven intercostal spaces, accompanying posterior intercostal artery (Fig.
21.7).
204
anterior to arch of aorta and ends in left

brachiocephalic vein.
The fifth, sixth, seventh, and eighth
posterior intercostal veins join to form
accessory hemiazygos vein that ends
in azygos vein.
The ninth, tenth, and eleventh posterior
intercostal veins join the hemiazygos
vein that also ends in the azygos vein.
The Nerve Supply of the Thoracic Wall
Fig. 21.7: The posterior intercostal veins
The posterior intercostal veins, run in

the costal grooves of the ribs above the
intercostal artery, lying in the neurovascular plane of the thoracic wall.
They drain venous blood from most part
of intercostal space and receives
tributaries corresponding to the branches
of posterior intercostal arteries.
On right side
The first posterior intercostal vein ends
in the right brachiocephalic vein.
The second, third, and fourth posterior
intercostal veins join to form right
superior intercostal vein that ends in
azygos veins.
The fifth to eleventh posterior intercostal
veins join the azygos vein.
On left side
The first posterior intercostal vein ends
in left brachiocephalic vein.
The second, third, and fourth posterior
intercostal veins join to form left
superior intercostal vein that crosses
The muscles and the skin of the thoracic wall

are supplied by the intercostal nerves (ventral
rami of first to eleventh thoracic spinal nerves).
A typical intercostal nerve is one that supplies
the skin and muscles of the thoracic wall only.
Third to sixth intercostal nerves are typical.
The first intercostal nerve mainly joins the
branchial plexus.
The second intercostal nerve gives an intercosto-brachial nerve that supplies the skin of
upper part medial side of arm.
The seventh to eleventh intercostal nerves after
supplying thoracic wall, enter anterior abdominal
wall to supply muscles and skin.
The Typical intercostal Nerve (Fig. 21.8)
BeginningThe typical intercostal nerve begins

near the inter-vertebral foramen, where the spinal
nerve divides into a ventral ramus and a dorsal
ramus.
CourseThe typical intercostal nerve enters
posterior part of intercostal space by passing
behind the intercostal vessels
The nerve runs forwards in the costal groove
below the intercostal artery and vein lying
in the neuro-vascular plane of the thoracic
wall between internal intercostal and
innermost intercostal.
In anterior part of intercostal space, the
intercostal nerve passes in front of internal
thoracic vessels, pierces internal intercostal
muscle, anterior intercostal membrane,
tahir99 - UnitedVRG
205
Fig. 21.8: TS thoracic wall showing a typical intercostal nerve
pectoralis major and its fascia and comes

out as the anterior cutaneous nerve.
Branches
I. The communicating branches are two and
connect the intercostal nerve to the corresponding sympathetic ganglion.
a. The white ramus communicans (WRC)
lies laterally and contains preganglionic
sympathetic fibers from the nerve to the
ganglion.
b. The grey ramus communicans (GRC)
lies medially and contains postganglionic
sympathetic fibers from the ganglion to
the intercostal nerve.
II. The muscular branches are twocollateral
and smaller muscular branches
a. The collateral branch is given near the
angle of the rib, and runs along the upper
border of rib below. It may rejoin the

parent stem.
b. Small muscular branches supply the
three layers of intercostal muscles, subcostalis and sterno-costalis.
III.The cutaneous branches are twolateral
cutaneous and anterior cutaneous.
a. The lateral cutaneous branches pierces
the muscles along mid-axillary line and
divides into anterior and posterior
branches to supply skin of lateral part
of thoracic wall.
b. The anterior cutaneous branch pierces
the muscles, about 1.2 cm lateral to the
sternum. It divides into a medial and a
lateral branch to supply skin of anterior
part of thoracic wall.
CHAPTER
22
The Pleura and

Lungs
THE PLEURA
The pleura is a closed serous sac, that surrounds

lung on all sides, except the hilum.
The pleura consists of two layers: parietal and
visceral.
1. The parietal pleura is the layer that lines the
inner surface of thoracic cavity, beneath
endothoracic fascia.
The parietal pleura is named according to
its position in thoracic wall:
a. Cervical pleurabulges in the root of
neck through inlet of thorax (dome of
pleura)
b. Costal pleuralines the inner surface
of ribs and intercostal spaces separated
by endothoracic fascia.
c. Diaphragmatic pleura lines the superior
surface of diaphragm.
d. Mediastinal pleuralines the lateral

surface of mediastinum.
2. The visceral pleura (pulmonary pleura) lines
the outer surface of lung intimately. It lines the
fissures of the lung, but does not cover the
hilum:the site on the medial surfacewhere
the lung root is attached.
The Lines of Pleural Reflection
(Fig. 22.1)
The lines of leural reflection indicate on the surface
of thorax, the extent of pleural sacs.
I. The Anterior Lines of Pleural Reflection
It begins from the dome of pleura at the

neck about 2.5 cm above the junction
between the middle and medial third of
clavicle.
Fig. 22.1: Anterior and inferior lines of pleural reflections
tahir99 - UnitedVRG
The Pleura and Lungs
From this point, at lower border of neck of

first rib the line passes downwards and
medially through sterno-clavicular joint, to
reach the sternal angle by side of median
plane.
On right sidethe anterior line of pleural
reflection passes vertically up to level of
xiphisternal joint from here. It may reach
below costal margin of right costo-sternal
angle. An incision beginning at this angle
may injure right pleura.
On left sidethe anterior line passes
vertically from sternal angle up to the level
of fourth costal cartilage. Then it describes
a cardiac notch and descends along left
sternal margin up to the sternal end of left
sixth (or seventh) costal cartilage. It does
not descends below costal margin.
II. The Inferior Lines of Pleural Reflection

The inferior lines of pleural reflection lie superior
to the costal margin, except on right side at the
right costo-sternal angle.
It begins on right side at xiphisternal joint and
on left side at sternal end of sixth (or seventh)
costal cartilage.
It crosses eighth rib at mid-clavicular line
approximately at costo-chondral junction.
It crosses tenth rib at mid-axillary line and
middle of shaft of eleventh rib.
Finally it crosses twelfth rib and reaches the
side of twelfth thoracic vertebra.
On both sides, inferior lines of pleural reflection
descend below costal margins by the side of
twelfth thoracic vertebra forming right and left
costo-vertebral angles.
207
The Pleural Recesses (Fig. 22.2)

The Pleural sacs are larger in size than the lungs.
The pleural recesses are the spaces between
two layers of parietal pleura, in the pleural
cavities, that are not filled up by the lungs during
quiet inspiration.
In deep inspiration, the lungs tend to occupy
the pleural recesses, but they never fill up these
recesses completely.
There are three pleural recesses:
i. Right costo-diaphragmatic recess
ii. Left costo-diaphragmatic recess
iii. Left costo-mediastinal recess
The costo-diaphragmatic recesses are lower parts
of the pleural cavities.
These recesses lie between lower margin of
lungs (two ribs higher) and lower margin of
pleural sacs.
Here the costal pleura lies in contact with
diaphragmatic pleura. These are most dependent
parts of pleural cavities, when a person is
standing erect.
Fluid may collect in the recess and obliterate
the recess.
In X-ray of chest, these recesses appear as
costo-diaphragmatic angles.
The left costo-mediastinal recess is a part of
left pleural cavity.
III. The Posterior Lines of Pleural Reflection

The posterior lines of pleural reflection run vertically
upwards from the level of lower border of twelfth
thoracic vertebra up to the neck of first rib.
Fig. 22.2: The costo-diaphragmatic recess of pleura
208
It is formed because cardiac notch of left lung

is deeper than cardiac notch of left pleural sac.
Here the costal pleura lies in contact with the
mediastinal pleura lining the pericardium.
The depth of this recess is variable.
A needle inserted medial to the recess (just by
side of sternal margin) will avoid pleura and
reach pericardial cavity, for tapping pericardial
fluid.
The Nerve Supply of Pleura

The parietal pleura is supplied by the somatic
nerves.
The costal pleura is supplied by the intercostal
and subcostal nerves (T1 to T12 ventral rami).
The diaphragmatic pleura is supplied by the
phrenic nerves. The peripheral parts are supplied
by the intercostal nerves.
The mediastinal pleura is supplied by the
phrenic nerves
The cervical pleura is supplied by the phrenic
nerves
The visceral pleura is supplied by the autonomic
nerves.
The Blood Supply of the Pleura
The parietal pleura is supplied by:
The internal thoracic vessels
The posterior intercostal vessels
The visceral pleura is supplied by:
The bronchial vessels that supply the lungs.
The pleural cavity is the potential cavity that
contains a small amount of serous fluid that lubricates the opposing surfaces.
The pleural fluid provides great surface tension
between parietal and visceral layers of pleura
and keeps the lungs inflated.
III. The pleural recesses are potential spaces of

the pleural cavities, that provide additional
space for lungs to expand in deep inspiration.
Applied Anatomy
1. Pleurisyis inflammation of parietal pleura:
It can be dry pleurisy: causing pain in the
affected area, accentuated by respiratory
movements.
A pleural rub: (a friction sound) can be
heard on the affected area on auscultation.
Pleurisy with effusion: is collection of fluid
in the pleural cavity.
The fluid collects in the costo-diaphragmatic
recess and causes collapse of basal part of
lung (atelectasis of lung).
2. Pneumothorax: is collection of air in the pleural
cavity. The air from outside may enter via:
External perforating injury of thoracic wall.
Rupture of lung alveoli.
3. Hemothoraxmay results from collection of
blood in the pleural cavity, due to rupture of the
blood vessels (intercostal vessels) of thoracic
wall in case of injury to the chest wall.
4. Chylothoraxis a rare condition, in which due
to blockage of main lymphatic ducts (e.g.,
thoracic duct), chyle or lymph mixed with fat,
from intestines may leak in the pleural cavity.
5. Thoracocentesisis removal of fluid from the
pleural cavity.
The fluid level is determined by the percussion in intercostal spaces and also by
X-ray of the chest.
It is usually done in ninth intercostal space
in mid-axillary line with patient in sitting
position.
A needle is inserted immediately above the
superior margin of the rib to avoid injury to
intercostal nerves and vessels, that run along
the lower border of the rib.
The Functions of Pleura

I. The pleura gives protection to the lung.
II. It facilitates the movements of the lung and
prevents friction with neighboring structures.
THE LUNGS (PULMONES)

The lungs are essential organs of respiration. The
lungs are covered by the visceral layer of pleura
except at the hilum, where the lung root is attached.
tahir99 - UnitedVRG
During development, the lung buds invaginates

pleural sac from medial side, forming the parietal
and visceral layers connected around the hilum.
External features:
Shapeconical
Differences between the two lungs:
i. Right lung is shorter and wider, as liver
pushes it higher on the right side.
ii. Left lung is longer and narrower, as the heart
and pericardium lie more on left side.
iii. There is a cardiac notch in the anterior:
border of the left lung with a tongue-shaped
lingula below it.
iv. The right lung has a larger capacity than
the left lung.
v. The right lung has two fissures and three
lobes. The left lung has one fissure and two
lobes.
vi. The right lung is also heavier (weight625
gm) than the left lung (weight565 gm).
Surfaces: The lung has
An apex (cupola)
A base
Two surfacescostal and medial
9
ri 9
a. The apexbulges in the root of neck

up to the neck of first rib.
b. The base(diaphragmatic surface) is
related to the dome of diaphragm and is
hollow.
c. The costal surfaceis convex and is
related to the ribs and intercostal spaces.
d. The medial surfaceis divided into:
i. A vertebral surfacerelated to the
bodies of vertebral bodies.
ii. A mediastinal surfacerelated to the
lateral aspect of mediastinum.
iii. This surface has a hilum, which has
lung root attached to it.
The lung root consists of structures passing to
and from the hilum of lung to the mediastinum.
The structures of lung root are embedded
in connective tissue and surrounded by
extension of mediastinal pleura around them
(Fig. 22.3).
The right lung root has the following
structures:
1. Hyparterial bronchus
2. Eparterial bronchus
V
d
ti e
n
U
h
a
209
Fig. 22.3: Mediastinal surface of right lung
G
R
210

3.
4.
5.
6.
Pulmonary artery
Superior pulmonary vein
Inferior pulmonary vein
Other smaller structures
One bronchial artery
Two bronchial veins
Sympathetic plexuses: (anterior and
posterior pulmonary plexuses)
Lymphatics and lymph nodes.
The left lung root has the following structures
(Fig. 22.4):
1. Left principal bronchus
2. Left pulmonary artery
3. Superior pulmonary vein
4. Inferior pulmonary vein
5. Other smaller structures
Two bronchial arteries
Two bronchial veins
Sympathetic plexus (anterior and posterior pulmonary plexuses)
Lymphatics and lymph nodes
The pulmonary ligament is the lower part of
the lung root, that extends from the lower part
of hilum to the mediastinum.
The pulmonary ligament
i. Supports the lung and firmly connects it to
the mediastinum.
ii. Provides dead space for the inferior pulmonary vein to expand.
The fissures of the lung
The right lung has two fissuresoblique and
transversethe left lung has only one fissure:
oblique fissure.
The oblique fissure begins at second
thoracic spine at the back, curves forwards
across the chest wall and reaches sternal
end of sixth costal cartilage.
On left side it is more vertical.
The transverse fissureis on front only. It
passes from sternal end of right fourth costal
cartilage to join the oblique fissure in midaxillary
line.
The Lobes of the Lung

The right lung has three lobes: Upper, middle, and
lower.
The left lung has only two lobes: Upper and
lower.
Each lobe of the lung is supplied by:
A lobar (secondary) bronchus
A lobar branch of pulmonary artery
The lobar tributaries of pulmonary veins.
Fig. 22.4: Mediastinal surface of left lung
tahir99 - UnitedVRG
The lingula of left lung lies below cardiac notch

and corresponds to the middle lobe of right lung.
The Broncho-Pulmonary Segments
The bronchopulmonary segments are functional or

respiratory units of the lung (Fig. 22.5).
They are conical in shape with their bases on
the surface of lung and their apices at the hilum.
They are separated by connective tissue septa.
Each broncho-pulmonary segment has:
A segmental (tertiary) bronchus.
A segmental branch of pulmonary artery.
Intersegmental veins, that lie in the
connective tissue septa. These act as guides
for separating the segments during surgical
resection.
There are ten broncho-pulmonary segments in
each lung.
The broncho-pulmonary segments of the right
lung are (Fig. 22.6):
Upper lobe has three segments:
1. Apical
2. Posterior
3. Anterior
Middle lobe has two segments
4. Lateral
5. Medial
Lower lobe has five segments
6. Superior basal
7. Medial basal
9
ri 9
h
a
Fig. 22.5: A single broncho-pulmonary

segment (diagrammatic)
211
8. Anterior basal
9. Lateral basal
10. Posterior basal
The broncho-pulmonary segments of the left
lung are (Fig. 22.7):
Upper lobe has five segments.
1. Apical
2. Posterior
3. Anterior
4. Superior lingular
5. Inferior lungular
Lower lobe has five segments
6. Superior basal
7. Medial basal
8. Anterior basal
9. Lateral basal
10. Posterior basal
In left lung, the apical and posterior segments
may be common forming apico-posterior
segment.
Similarly, the medial basal segment and anterior
basal segment of the left lung may form a
common medial-anterior segment.
Thus the left lung may have eight or nine
bronchopulmonary segments instead of ten
segments.
V
d
ti e
G
R
n
U
The Blood Vessels of the Lungs

A. The pulmonary vessels
a. The pulmonary artery, carries deoxygenated
blood from the heart to the lung for oxygenation.
On entering the hilum of the lung, the
pulmonary artery divides into lobar and
later segmental branches that follow the
branches of lobar and tertiary bronchi.
b. The pulmonary veins are twosuperior and
inferiorfor each lung. They carry oxygenated blood from the lung to the left
atrium of heart. Inside the lung the pulmonary veins, lie in between the bronchopulmonary segments (intersegmental) along
the connective tissue septa.
212
Fig. 22.6: Broncho-pulmonary segments of right lung
Fig. 22.7: Broncho-pulmonary segments of left lung
B. The bronchial vessels supply the substance of

the lung with oxygenated blood and carry back
the deoxygenated blood from the lungs to the
systemic veins.
a. The bronchial arteries follow the branching
of bronchi and supply the non-respiratory
part of bronchial tree:
The right lung has one bronchial artery
that arises from first aortic intercostal
artery of right side.
The left lung has two bronchial arteries
that arise from descending thoracic
aorta.
b. The bronchial veins are two for each lungs:
The right bronchial veins end in azygos
vein.
The left bronchial veins end in accessory

hemiazygos vein.
The Lymphatic Drainge of Lungs

The lymph vessels from the alveoli of lung, proceed
to the pulmonary lymph nodes, associated with
lobar bronchi.
From there, the lymphatics terminate in broncho-pulmonary lymph nodes, located in the
lung roots.
The lymph from broncho-pulmonary nodes,
then passes to tracheo-bronchial and tracheal
lymph nodes.
The lymphatics from the tracheal lymph nodes
unite with those from para-sternal nodes to form
broncho-mediastinal lymph trunk, that ends in
tahir99 - UnitedVRG
right lymph duct on right side and thoracic duct

on the left side.
The lymphatics provide pathways for secondary
deposits (metastases) of lung carcinoma.
In case of secondary deposits of cancer of
lung, there may be a back flow of lymph
towards the contralateral lung, or towards the
coeliac lymph nodes in upper part of abdomen.
Nerve Supply of Lungs

The nerve supply of the lungs is provided by the
autonomic nerves.
I. The sympathetic supply is provided by the
branches from T 2 to T 5 ganglia of the
sympathetic chain.
The sympathetic fibers join the two pulmonary plexuses.
Anterior and posterior flexuses are located
in the anterior and posterior parts of the lung
roots.
The sympathetic supply vasoconstrictor
fibers to pulmonary vasculature and secretomotor fiber to the bronchial glands.
II. The parasympathetic supply is by branches from
the vagus nervesright and left.
These parasympathetic fibers also join the
two pulmonary plexuses.
The parasympathetic fibers supply the
bronchial smooth musculature. Excessive
stimulation produces asthmatic syndrome
by broncho-constriction.
The parasympathetic fibers also carry the
afferent sensation from the lungs.
h
a
9
ri 9
213
II. Bronchoscopy is a special endoscopic procedure

to visualize the interior of bronchial tree.
An accurate knowledge of anatomy of
broncho-pulmonary segments is required
for conducting this investigation.
III.Bronchography is a special X-ray procedure,
where the bronchial tree is visualized after
introducing a radiopaque dye in the lobar
bronchi.
For interpretation of bronchogram, a knowledge of bronho-pulmonary segments is
required.
IV. Pulmonary embolism is usually caused by
venous stasis in right side of heart due to some
valvular disease of heart or myocardial
infarction.
The pulmonary embolism is one of the
greatest causes of death in elderly people
after injury or in post-operative cases.
V. Carcinoma of lung is also a common type of
tumor seen in a large percentage of persons
who smoke.
The lung carcinoma may have metastases
in lymph nodes draining lung parenchyma.
V
d
ti e
G
R
n
U
Applied Anatomy
I. Surgical resection of broncho-pulmonary segments may be done, in case of lesions of few

segments.
Examples of such lesions are lung abscesses
and bronchiectasis.
However, some diseases of lung involve
many segments like pulmonary tuberculosis
and lung cancer. In such conditions lobectomy is preferred.
THE BRONCHIAL TREE
The bronchial treea part of respiratory passage

consists of:
An extrapulmonary part and
An intrapulmonary part
The extrapulmonary part of bronchial tree
consists of :
The trachea
The two primary bronchiright and left
The intrapulmonary part of bronchial tree
consists of:
The lobar bronchi: three for the right lung and
two for the left lung.
The segmental (tertiary) bronchi that supply the
broncho-pulmonary segments.
The branches of tertiary bronchi, which divide
and subdivide and finally their terminal branches
the bronchioles end in the alveoli or the air sacs.
214
The trachea: [Wind pipe]

The trachea begins in lower part of front of
neck at lower border of cricoid cartilage
(vertebral level: 6th cervical vertebra).
Length: 12.0 cm, width: 2.0 cm.
Location: The trachea lies nearly in median plane
on front of neck and superior mediastinum. The
trachea is kept patent by C-shaped hyaline
cartilaginous rings.
Bifurcation: The trachea divides into two
primary bronchiright and leftat the level
of sternal angle (lower border of 4th thoracic
vertebra)
The bifurcation is not a fixed point, and at end
of inspiration. It descends to lower border of
5th thoracic vertebra.
Relations
In the neck
Anteriorly the trachea is related to
Isthmus of thyroid gland
Inferior thyroid veins
Thyroidea ima artery (if present)
Posteriorly: Esophagus
Recurrent laryngeal nerve lies in tracheoEsophageal groove
In superior mediastinum:
Anteriorly
Arch of aorta
Three branches of arch of aorta
a. Brachiocephalic
b. Left common carotid
c. Left subclavian
Left branchiocephalic vein
Deep cardiac plexus
Manubrium sterni
Posteriorly:
Esophagus separating it from bodies of upper
four thoracic vertebrae.
The right primary bronchus is wider, shorter
(2.5 cm) and is more vertical than the left
primary bronchus.
The right bronchus divides into:
An eparterial (upper lobar) bronchus.
A hyparterial (middle and lower lobar
bronchus) before it enters the hilum of
right lung.
The foreign bodies are more likely to enter the
right bronchus because of its wider diameter
and it being more in line with trachea.
The left primary bronchus is narrower and
longer (5.0 cm). It arises at an angle with the
trachea at bifurcation.
The left primary bronchus enters the hilum of
left lung before dividing into lobar branches.
tahir99 - UnitedVRG
CHAPTER
23
The Pericardium and

the Heart
THE PERICARDIUM
The pericardium is a fibro-serous sac that surrounds
the heart and roots of great vessels (Fig. 23.1).
Location: The Pericardium lies in middle
mediastinum behind the body of sternum and
in front of bodies of fifth to eighth thoracic
vertebrae.
The pericardium lies obliquely, one-third to
the right and two-third to the left of median
plane.
Parts: The pericardium consists of two parts
fibrous pericardium and serous pericardius.
a. The fibrous pericardium is outer fibrous and
thick layer of pericardium.
It is conical in shape. Its apex lies above
and is pierced by:
Superior vena cava.
Pulmonary trunk.
Ascending aorta.
The base lies below and is fused with
the central tendon of diaphragm (Both
structures are developed from same
embryonic structure: Septum transversum
Relations
Antriorly
Anterior margins of both pleurae
(with cardiac notch on left side)
Anterior margin of both lungs (with
cardiac notch in anterior margin of
left lung).
Two sterno-pericardiac ligaments:
superior and inferiorthat connect
h
a
9
ri 9
V
d
ti e
n
U
G
R
Fig. 23.1: The fibrous pericardium
the pericardium to the body of sternum.

Body of sternum and second to sixth
costal cartilages with intercostal
spaces of both sides.
Posteriorly
Descending thoracic aorta.
Other contents of posterior mediastinum separating it from bodies of
fifth to eighth thoracic vertebrae.
b. The serous pericardium is a closed serous
sac into which heart invaginates from above
and behind during development.
It consists of two layersparietal and
visceralenclosing a potential pericardial cavity.
216

I. The parietal layer: lines the deep
surface of fibrous pericardium.
II. The visceral layer: covers the heart
externally (epicardium).
It also covers the roots of great
vessels enclosed within pericardium.
The sinuses of pericardium are spaces
inside serous pericardium (Fig.23.2):
The reflection of visceral layer over
the roots of greater vessels in form
of two sheaths:
a. A tubular sheath that includes the
roots of ascending aorta and pulmonary trunk.
b. An inverted J-shaped sheath that
encloses six veinssuperior
vena cava, inferior vena cava,
two right pulmonary veins and
two left pulmonary veins.
These two sheaths of visceral pleura
are responsible for formation of the
two sinuses inside serous pericardium.
I. The transverse sinus: is a transverse
passage behind the tubular sheath
enclosing the ascending aorta and
pulmonary trunk.
It is related behind to the two

atria: right and left of the heart.
During cardiac surgery, a temporary ligature or clamp is passed
through it to occlude the two
great vessels.
II. The oblique sinus is in form of a culde-sac of pericardial cavity behind
the base of the heart.
It lies between the right and
left limbs of common J-shaped
sheath.
On the right side are: superior
vena cava, two right pulmonary
veins and inferior vena cava.
On the left side are two left pulmonary veins
The oblique sinus opens downwards
and towards the left.
In pericardial effusion, fluid collects
in the oblique sinus, when person lies
in the supine position. The fluid in
the oblique sinus may compress the
descending aorta and esophagus
causing compression symptoms.
The blood supply of pericardium
I. The fibrous pericardium and the parietal
Fig. 23.2: The sinuses of pericardium
tahir99 - UnitedVRG
The Pericardium and the Heart

layer of sinus pericardium are supplied by
the blood vessels of the thoracic wall:
Internal thoracic vessels
Branches from descending thoracic aorta
The venous blood is drained by the
azygos and hemiazygos veins.
II. The visceral layer of pericardium (epicardium) is supplied by the coronary arteries
of the heart.
The venous blood is drained by the
tributaries of coronary sinus.
The nerve supply of pericardium
I. The fibrous pericardium and the parietal
layer of serous pericardium are supplied by
the phrenic nerves.
II. The visceral layer of serous pericardium is
supplied by the autonomic nerves that
supply the heart.
The functions of pericardium
I. The pericardium protects the heart.
II. It facilitates the contractions of heart by
preventing friction with other structures.
III. The fibrous pericardium being inelastic,
prevents overdistention of heart.
Applied anatomy
I. Pericardial tamponade: In pericarditis with
effusion, or collection of blood in pericardium compresses heart and decreases
the cardiac output with increase in heart rate.
The condition is accompanied by a weak
and rapid pulse. Increased venous
pressure causes jugular vein distention
and pulsating liver with dyspnea are
significant symptoms of the pericardial
effusion.
II. Pericardio-centesis is removal of pericardial
fluid. It may be done from the following
two routes:
a. The left subcostal angle adjacent to the
xiphoid process; angling upwards and
to the left at an angle of 45C. The risk
of injuring pleura is less in this procedure.
h
a
9
ri 9
217
b. The para-sternal route: The needle is

introduced in pericardial cavity, through
left 4th or 5th intercostal space just
adjacent to the sternum.
This procedure also involves very
little risk of injuring pleura as anterior
margin of left pleura has a cardiac
notch here.
III. Dry pericarditis is caused due to inflammation of the parietal layer of serous pericardium.
The pain of pericarditis is referred to
the epigastrium usually.
A pericardial friction sound is heard on
auscultation.
V
d
ti e
G
R
THE HEART
The heart is a muscular organ, that pumps blood

to all parts of body.
Locations: The heart lies in middle mediastinum
of thorax, surrounded by the pericardium.
The heart lies obliquely one-third to the right
and two third to the left of the median plane.
Shape is conical with apex pointing downwards,
and to the left and base pointing posteriorly.
Weight: About 300 gm in adult male; 250 gm in
adult female.
Size: Transverse diameter: 8.0-9.0 cm
Antero posterior diameter: 6.0 cm
(From base to apex)
n
U
External Features
The heart has an apex and a base (Fig. 23.3)
Three surfaces
Sterno costal
Diaphragmatic
Left surface
Four borders
Superior, inferior, right and left.
I. The apex of heart is formed by the left
ventricle. It lies in left fifth intercostal space,
about 9.0 cm from the median plane.
218

V. The anterior (sternocostal) surface is formed
by right atrium, left auricle and both the
ventricles (right ventricle two third, and left
ventricle one-third part of ventricular area).
Sulci and Fissures
Fig. 23.3: The heartsternocostal surface
The apex is responsible for apex beat,

that is a visible, palpable and auscultable
impulse in a living person.
II. The base is directed posteriorly (Fig. 23.4).
It is formed mainly by the left atrium, and
partly by the right atrium of heart.
III. The diaphragmatic (inferior) surface is
formed one-third by right ventricle and twothird by left ventricle.
IV. The left (pulmonary) surface is formed mainly
by the left ventricle.
I. The coronary sulcus (atrio-ventricular sulcus)

completely encircles the heart between the two atria
and two ventricles.
The anterior part of coronary sulcus is partly
obscured by the attachment of ascending aorta
and pulmonary trunk.
The right coronary artery, and circumflex
branch of left coronary artery occupy the
sulcus.
The coronary sinus lies in posterior part of
coronary sulcus.
II. The anterior interventricular groove
separates the right and left ventricles on the
sternocostal surface.
It runs parallel to the left border of heart and
contains:
Anterior interventricular branch of left
coronary artery.
Great cardiac vein.
III. The posterior interventricular groove
separates the right and left ventricles on the
diaphragmatic surface.
It is continuous with anterior interventricular
groove at the apical notch, near the apex of
heart.
It contains:
Posterior inter-ventricular branch of right
coronary artery
Middle cardiac vein.
The Borders of the Heart
Fig. 23.4: The heartposterior inferior surface
a. The right border extends between the roots of

superior vena cava and inferior vena cava.
It is formed by the right atrium of heart.
Sometimes it is referred to as right pulmonary surface.
tahir99 - UnitedVRG

b. The inferior border extends from the root of
inferior vena cava to the apex of heart.
c. The left border is formed mainly by the left
ventricle. Its uppermost part is formed by the
left auricle.
d. The superior border is formed by the upper
borders of the two atria.
It is obscured by the attachment of
ascending aorta and pulmonary trunk.
The Blood Supply of the Heart

The Arteries
The heart is supplied by two arteries: right and left
coronary arteries (Fig. 23.5).
Features
i. The coronary arteries are highly enlarged
vasa vasorum.
ii. These arteries get filled up during diastole
of the heart.
iii. These are the first branches of the aorta
arising near its root.
iv. The coronary arteries are functional end
arteries, i.e. there is hardly any anastomosis
between their smaller branches.
Origin: The coronary arteries arise from the
aortic sinuses (dilatations opposite the cusps
of the aortic valve) at the root of ascending
aorta.
Fig. 23.5: The arterial supply of the heart-sternocostal surface
219
The right coronary artery arises from the

anterior aortic sinus.
The left coronary artery arises from the left
posterior aortic sinus.
Course
The right coronary artery lies deep to the
right auricle at its origin.
It courses downwards in the anterior
part of coronary sulcus, and curves
backwards at the junction of right and
inferior borders of the heart.
It runs towards left in the posterior part
of coronary sulcus.
It terminates usually by anastomosing
with the terminal branches of left coronary artery.
The left coronary artery turns towards left
between pulmonary trunk and ascending aorta
to reach the coronary sulcus.
It bifurcates into anterior inter-ventricular
branch and circumflex branch.
The anterior inter-ventricular branch
descends in the anterior interventricular
groove. It terminates by anastomosing with
posterior interventricular branch of right
coronary artery on diaphragmatic surface
near apex.
The circumflex branch represents the
continuation of the left coronary artery. It
runs in the coronary sulcus, curves around
the left border and reaches posterior part of
coronary sulcus.
The circumflex branch terminates by
anastomosing with terminal branches of left
coronary artery.
Distribution and branches
The right coronary artery gives
i. Small branches to roots of ascending aorta
and pulmonary trunk.
ii. Branches to right atrium, including a nodal
branch to supply sino-atrial node.
iii. Branches to superior part of right ventricle.
iv. Right marginal artery passes along the
inferior border of the heart towards the apex,
supplying portion of right ventricle.
220
v. Posterior inter-ventricular branch gives a

branch to atrio-ventricular node and
anastomoses with anterior inter-ventricular
branch of left coronary artery, near the apex
of heart. It also supplied posterior third of
interventricular septum.
The left coronary artery gives
i. Small branches to the roots of ascending
aorta and pulmonary trunk.
ii. A large anterior inter-ventricular branch,
that supplies both ventricles and larger part
of inter-ventricular septum.
iii. A left marginal branch that runs along the
left border of heart and supplies left ventricle.
iv. Posterior ventricular branches supply the
left ventricle.
v. Small branches to supply the left atrium.
The Venous Drainage of the Heart

(Fig. 23.6)
The venous blood from the myocardium and
epicardium is drained by three systems of veins
coronary sinus and its tributaries, anterior cardiac
veins and the minute cardiac veins.
I. The coronary sinus drains most of the venous
blood from the heart.
It is a short, wide venous channel, about
2-5 cm long.
Variations of the Coronary Arteries

A. Balanced coronary circulation: is when the
coronary circulation is shared by the two
coronary arteries. It is seen in 60-65 percent of
the population.
B. Left dominant coronary circulation: when the
posterior interventricular branch arises from the
left coronary artery.
In this type, the left coronary artery supplies
the entire inter-ventricular septum including
the atrio-ventricular node.
This type is seen in 10-15 percent of the
population.
C. Right dominant coronary circulation: In this
type the right coronary artery, in addition to
giving the posterior inter-ventricualr branch,
reaches the coronary sulcus up to the left
marginal artery.
A large part of posterior surface of left
ventricle is supplied by right coronary artery.
This type is seen in 20-25 percent of the
population.
D. Variations may occur in the origin of the
coronary arteries.
Course: The coronary sinus lies in posterior

part of coronary sulcus from left to the right
side, superficial to the terminal parts of left and
right coronary arteries.
Its left end is continuous with the great
cardiac vein. Its right end opens in the right
atrium of heart between the openings of
inferior vena cava and right atrio-ventricular
opening.
Tributaries
a. The great cardiac vein lies in the anterior
inter-ventricular groove with anterior interventricular artery.
It drains venous blood from anterior
aspects of both ventricles and anterior
part of interventricular septum.
Fig. 23.6: The coronary sinus and its tributaries

Posterior-inferior surface
tahir99 - UnitedVRG

b. The middle cardiac vein lies in posterior
inter-ventricular groove along with posterior
inter-ventricular artery.
It drains venous blood from posterior
parts of both ventricles and posterior part
of inter-ventricular septum.
It ends in the middle of coronary sinus.
c. The small cardiac vein: lies along the interior
border of heart.
It drains venous blood from the right
ventricle.
d. The oblique vein of left atrium: [Marshalls
Vein] is a small vein on posterior aspect of
left atrium.
It joins the left end of coronary sinus.
It is embryonic remnant of left common
cardinal vein (that may develop into left
superior vena cava sometimes).
II. The anterior cardiac veins are several small
veins, that drain venous blood from anterior
aspect of right ventricle.
They course across the coronary sulcus,
lying anterior to the right coronary artery.
They open independently in the right atrium.
III.The minute cardiac veins [venae cordis minimae,
Thebesian veins) drain venous blood from
endocardium and deeper part of myocardium.
They open directly into the chambers of
heart. They are more in atria than ventricles.
The Myocardial Circulation
Normally, there is very little anastomosis between
the branches of right and left coronary arteries in
the substance of myocardium, in a normal healthy
person.
Thus, most of the branches of coronary arteries
are functional end arteries.
Any anastomosis present, is not sufficient to
maintain effective circulation in the event of
sudden occlusion of a large branch of coronary
artery.
However, with slow onset of atherosclerosis,
in elderly persons, some collateral circulation
develops.
221
Obstruction to flow of blood in coronary arteries

produces ischemia of myocardium causing pain:
angina pectoris.
The cardiac pain originates from the precordial
region and is referred to:
Epigastrium
Left shoulder
Inner side of left arm frequently
The myocardial ischemia may lead to coronary
thrombosis or heart attack.
If a large branch of coronary artery is involved,
the infarct following heart attack, may prove
fatal.
The Nerve Supply of the Heart
The heart rate and the cardiac output are

controlled by the autonomic nerves.
The parasympathetic fibers are provided by the
cardiac branches of two vagus nerves.
The preganglionic fibers synapse with postganglionic neurones located in myocardium.
The vagal activity slows heart rate and
reduces the stroke volume.
The sympathetic fibers are provided by the
cardiac branches of superior, middle and inferior
cervical ganglia and T 2 to T 5 ganglia of
sympathetic chains.
The sympathetic are cardiac accelerator
nerves.
The afferent fibers from heart run along sympathetic and parasympathetic via thoracic and
cervical cardiac nerves to reach T2 to T5 spinal
segments, and dorsal vagal nucleus in medulla
oblongata.
The cardiac plexuses are twosuperficial and
deep:
I. The superficial cardiac plexusis located
below the arch of aorta, in front of right
pulmonary artery.
It is formed by:
Cardiac branch of superior cervical
ganglion of left sympathetic chain.
Inferior cervical cardiac branch of
left vagus.
222
II. The deep cardiac plexus is located behind

the arch of aorta, in front of tracheal bifurcation.
It is formed by:
Cardiac branches of superior, middle
and inferior cervical ganglia of both
sympathetic chains (except the
branch of superior cervical ganglion
of left side).
Cardiac branches of T2 to T5 ganglia
of both sympathetic trunks.
Superior, inferior and recurrent
cardiac branches of both vagi (except the inferior cardiac branch of
left vagus).
The two cardiac plexuses contain contributions
of both sympathetic and parasympathetic. The
plexuses give branches to:
Both coronary plexuses that accompany the right
and left coronary arteries.
Pulmonary plexuses.
The conducting system of the heart (neuromyocardium). The neuro-myocardium consists of
specialized cardiac muscle fiberscalled Purkinje
fibers, enclosed in a sheath of connective tissue.
This system has developed a high degree of
sensitivity and autorhythmicity.
The neuro-myocardium ensures proper
spread of cardiac impulse to all chambers of
heart and regulates their contraction in a proper
sequence.
The conducting system consists of:
I. The sinu-atrial node (SA Node or Pacemaker), that initiates the cardiac impulse
(about 72 per minute) that spreads to both
atria and atrio-ventricular node.
It is about 7 mm 2 mm 1 mm in
size.
It is situated in myocardium between the
opening of superior vena cava and crista
terminalis.
II. The atrio-ventricular node (AV node) is
situated in right atrium, near interatrial
septum medial to the opening of coronary

sinus and above the septal cusp of tricuspid
valve.
It gives rise to atrioventricular bundle
(bundle of His).
III. The atrio-ventricular bundle crosses the
annulus fibrosus and descends along
posterior margin of membranous part of
inter-ventricular septum to enter muscular
part of septum.
It divides into two branches: right
ventricular branch and left ventricular
branch.
The two branches descend along the
interventricular septum and spread out
in the walls of ventricles along cardiac
muscle fibers, carrying the cardiac
impulse.
Applied Anatomy
If an infarct or any other vascular lesion interferes
with the impulse propagation in atrio-ventricular
bundle, it causes heart block, resulting in
asymmetrical beating of atria and ventricles.
An artificial pacemaker is implanted for
correcting the cardiac rhythm in cases of heart
block.
The Interior of the Chambers
of the Heart
1. The right atrium: is the venous receiving
chamber of the heart (Fig. 23.7).
It has the thinnest walls of all the four chambers.
The crista terminalis: A thick muscular ridge
separates the cavity of right atrium into two
parts.
An anterior part: atrium proper
A posterior part: sinus venarum.
I. The atrium proper: has the crista terminalis,
that extends from the opening of superior vena
cava to the opening of inferior vena cava.
This ridge runs along the right border of
the heart.
tahir99 - UnitedVRG
223
Fig. 23.7: The interior of right atrium
It gives origin to parallel muscular ridges:

the musculi pectinati, that run across the
deep surface of anterior wall of right
atrium.
The right auricle, is an ear shaped appendage
that arises from the left anterior wall of right
atrium. It has a network of musculi pectinati
in its interior.
The right auricle is a potential site for
formation of thrombus, which if dislodged
can give rise to pulmonary embolism.
II. The sinus venarum is the smooth walled
posterior part of the cavity.
It represents the right horn of sinus venosus
of developing heart.
The sinus venarum receives the openings
of following veins:
a. Superior vena caval opening in upper
posterior part, without any valve.
b. Coronary sinus opening between opening
of inferior vena cava and right atrio-ventricular opening. It has a small semilunar
valve.
c. Inferior vena caval opening in lower
posterior part with a semilunar valve.
d. Anterior cardiac veins: small veins
opening separately in the anterior wall.
e. Venae cordis minimi opening by minute

openings.
The septal wall of right atrium is formed by the
interatrial septum.
I. It has fossa ovalis, an oval depressed area
that represents septum primum of fetal
heart. It also marks the site of foramen ovale
of fetal circulation. A probe patency exists
in its upper part in about 10 percent
individuals.
The fossa ovalis is the most common
site for atrial septal defect (ASD).
II. The annulus (limbus) fossa ovalis is a thick
crescentic margin that surrounds fossa
ovalis. It represents the lower edge of
septum secundum of fetal heart.
III. The intravenous tubercle is a low elevation
below the opening of superior vena cava. It
directs venous blood of superior vena cava
towards tricuspid opening in fetal life.
2. The right ventricle: It is the venous chamber
of heart that receives venous blood from the right
atrium and sends it via pulmonary trunk to the lungs
for oxygenation (Fig. 23.8).
The right ventricle has moderately thick walls
to overcome the resistance to flow in pulmonary circulation.
224
Fig. 23.8: The interior of right ventricle
The right ventricle is divided into two parts

by supra-ventricular crest, lying between
septal cusp of tricuspid valve and pulmonary
orifice.
The right ventricle proper
The infundibulum
a. The right ventricle proper is the inflow
part of the cavity of right ventricle.
It has rough muscular walls with
three types of muscular ridges called
trabeculae carnae.
Ridges
Bridges
Papillary muscles
The papillary muscles are largest type
of trabeculae carnae. They are conical in shape, with base attached to
the muscular wall.
From the apices of papillary muscles,
fibrous cord-like structureschordae tendinaepass to the free margin and ventricular surfaces of the
cusps of the tricuspid valves.
There are three papillary muscles in
right ventricle:
The anterior papillary muscle:
largest, attached to the anterior
wall.
The posterior papillary muscle:
smaller in size, attached to the
posterior (diaphragmatic) wall.
tahir99 - UnitedVRG
The septal papillary muscle:

smallest in size, attached to the
septal wall.
The right atrioventricular opening
is elliptical in shape and about 3.0
cm long.
It leads from right atrium to the
right ventricle and is guarded by
tricuspid valve.
The tricuspid valve has a fibrous
ring surrounding the opening and
three cuspsanterior, posterior
and septal.
The cusps are formed by folding
of the endocardium with some
connective tissue in between.
The chordae tendinae from the
three papillary muscles are attached alternately to the three
cusps.
The papillary muscles contract
during ventricular systole and
firmly oppose the cusps of tricuspid valve, thus preventing
backflow of the blood.
The moderator band is a bridge type
of trabeculae cornae, that carries
right ventricular branch of bundle of
His from septal wall to the root of
anterior papillary muscle.

b. The infundibulum is the outflow part of
the right ventricle.
It is funnel shaped smooth lined
upper part of the cavity of right
ventricle.
It has pulmonary opening in its upper
end guarded by pulmonary valve.
The pulmonary opening is 2.0 cm
wide oval opening.
The pulmonary valve has a fibrous
ring surrounding the opening with
three semilunar cusps:
Right anterior
Left anterior
Posterior
The cusps are formed by folding of
the endothelium with some connective tissue in between.
The free edges of the cusps are
directed upwards towards pulmonary trunk.
The free margins of the cusps are
strengthened by thickening in center
called nodule for proper opposition,
when the valve is closed.
The pulmonary valve prevents
regurgitation of blood from pulmonary trunk to the right ventricle.
3. The left atrium is the arterial chamber of
heart that receives oxygenated blood from the two
lungs via the pulmonary veins, and sends it to the
left ventricle.
The left atrium is cuboidal in shape and due to
rotation of heart lies on left side and behind the
right atrium separated by inter-atrial septum.
The left atrium has slightly thicker walls than
right atrium to overcome elasticity of extremely
thick left ventricular walls.
It receives usually two right pulmonary veins,
and two left pulmonary veins, but there may be
variations (commonest being one left and two
or three right pulmonary veins).
225
It gives the left auricular appendage from left

anterior part. The appendage has a network of
muscular ridges in its interior.
The left atrium opens, in left ventricle via the
left atrioventricular opening guarded by mitral
valve.
4. The left ventricle is the main arterial chamber
of the heart, that receives oxygenated blood from
left atrium and sends it via aorta to all parts of
body.
The walls of left ventricle are three times as
thick as walls of right ventricle, to overcome
the resistance of systemic vascular bed.
The left ventricle is divided into two parts:
The left ventricle proper
The aortic vestibule
a. The left ventricle proper is the inflow part of
the left ventricle.
The cavity is conical, and appears round
in a transverse section, as the interventricular septum bulges towards the right
ventricle.
The walls have thicker trabeculae carnae of
three types: ridges, bridges and papillary
muscles.
There are two papillary muscles anterior and
posteriorin the cavity of left ventricle. The
papillary muscles are thick and large.
Their chordae tendinae are attached
alternately to margins and ventricular
surface of two cusps of mitral valve.
The left atrioventricular openings is elliptical
in shape and about 2.0 cm wide.
The mitral valve: guards the left atrioventricular opening.
The valve has a fibrous ring around the
opening and two cuspsanterior and
posteriorformed by folding of
endothelium with connective tissue in
between.
Incompetence of mitral valve leads to
transmitting the left ventricular systolic
226
pressure to left atrium and pulmonary

vasculature leading to right sided heart
failure or cor pulmonale.
Mitral stenosis (narrowing of valve) is
one of the commonest valvular condition
of heart.
b. The aortic vestibule: is situated anterior and to
the right of mitral valve.
It is the smooth lined part of cavity of left
ventricle and has aortic opening at its upper
end.
The aortic opening is 2.0 cm wide, oval
opening guarded by aortic valve.
The aortic valve has a fibrous ring surrounding it and three semilunar cusps formed
by folding of endothelium with connective
tissue in between.
The positions of cusps of aortic valve is
just opposite to those of the pulmonary
valve. They are:
Right posterior
Left posterior
Anterior
The structure and disposition of cusps is
similar to the cusps of pulmonary valve.
The aortic valve prevents regurgitation of
blood from aorta to left ventricle during left
ventricular disastole.
Aortic stenosis in aged results from anomalous aortic valve and manifests a high
pitched systolic murmur.
The membranous part is the common

site of ventricular septal defect (VSD),
that is the principal defect in Fallots
tetralogy.
The Structure of the Heart
The heart consists of (Fig. 23.9):
i. Epicardium is made up of visceral layer of
serous pericardium, lining outer surface of
heart.
ii. Myocardium is the main muscular part made
up of cardiac muscle.
iii. Endocardium is the inner lining of the
chambers of the heart, and consists of a single
layer of endothelium.
The cardiac muscle fibers form thicker layer in

ventricles than in atria. They are arranged in
spiral form to produce a wringing movement
during systole of heart.
Some specialized parts of myocardium form

the conducting system of the heart.
The annulus fibrosus: (Fibrous ring) is a layer

of dense connective tissue arranged in atrioventricular plane.
The annulus fibrosus forms is the skeleton
of the heart and provides attachment to the
cardiac muscle fibers.
The Inter-ventricular Septum

The interventricular septum, is thick and curved
septum that separates the cavities of left and right
ventricles.
It is crescentic in shape and bulges, in the cavity
of right ventricle.
The septum has:
I. A large muscular part
II. A small membranous upper posterior part,
that is continuous with the annulus fibrosus
of the heart.
Fig. 23.9: The skeleton of heart and myocardium
tahir99 - UnitedVRG

It surrounds and supports each valvular
opening, and only right atrioventricular
bundle passes through the ring.
Applied Anatomy
The Valvular Defects
A. Insufficiency of a valve is incompetence or
insufficiency of valve leading to back flow of blood.
Causes:
Congenital defects
Infarct in the vicinity of papillary muscles
Endocardial inflammation resulting in
rupture of chordae tendinae
a. Tricuspid insufficiency leads to right
sided heart failure, in which right
ventricular pressure is transmitted back
to venous system.
b. Mitral insufficiency leads to left sided
heart failure in which left ventricular
pressure is transmitted back to lungs to
produce pulmonary edema.
B. The stenosis is constriction of the valve
resulting in restriction to flow of blood.
Causes
Congenital defect
Secondary to endocardial inflammation.
Stenosis can be corrected by simple surgical
methods but insufficiency requires correction
by means of an artificial valve.
227
The Septal Defects

I. Patent foramen ovale is a type of atrial septal
defect (ASD) that is compatible with normal active
life.
II. Ventricular septal defect (VSD) is usually
associated with tetralogy of Fallot that includes
Ventricular septal defect (VSD)
Hypertrophy of right ventricle
Pulmonary stenosis
Dextroposition of aorta with right ventricle
The septal defects with right to left shunts of blood,
admit deoxygenated blood into aorta resulting in
increased cardiac work and possibility of
decompensation and heart failure.
Patent Ductus Arteriosus (PDA)
Patent ductus arteriosus (PDA) may remain without
any major problem, but it can be ligated surgically.
The Dextrocardia
The dextrocardia is seen in 0.02 percent of
population in which the heart is normal, but located
on the right side of thorax, as a mirror image of
left sided heart.
It may be associated with right sided or left
sided aorta.
It may be a part of situs inversus (i.e. associated with reverse rotation of gut in abdomen
with all organs lying in reverse position.
CHAPTER
24
The Mediastinum
The mediastinum is the median septum or partition
that separates the two halves of thoracic cavity.
The mediastinum is a complete partition
extending from:
Sternum in front to
Bodies of thoracic vertebrae behind.
The mediastinum is divided by an imaginary
plane passing from sternal angle anteriorly to
the lower border of fourth thoracic vertebra
posteriorly into (Fig. 24.1).
i. Superior mediastinum
ii. Inferior mediastinum, which is further.
Subdivided into
a. Anterior mediastinum
b. Middle mediastinum
c. Posterior mediastinum.
THE SUPERIOR MEDIASTINUM

The superior mediastinum is the part of mediastinum that lies between the plane of inlet of thorax
and the imaginary plane (Figs 24.2 and 24.3).
Boundaries
Anterior: Posterior surface of manubrium
sterni
Posterior: Bodies of upper four thoracic
vertebrae and intervrtebral discs
Two sides: Right and left mediastinal pleura
Contents
Oesophagus
Trachea
Superior vena cava and two brachiocephalic
veinsright and left.
Fig. 24.1: The subdivisions of mediastinum
tahir99 - UnitedVRG
The Mediastinum
229
Fig. 24.2: TS through superior mediastinum (level-third thoracic vertebra)
Arch of aorta and its three branches

brachio-cephalic, left common carotid and
left subclavian.
Nerves Two vagus nervesleft and right
Two phrenic nervesleft and right
Cardiac branches of vagus and sympathetic chain.
Thoracic duct
Cardiac plexuses Superficial and deep
Lymph nodes
Thymus gland in children
The Superior Vena Cava

The superior vena cava is great venous trunk
draining venous blood from all parts of body above
diaphragm except heart.
Formation: The superior vena cava is formed
by the union of right, and left brachio-cephalic
veins at the lower border of first right costal
cartilage.
Course: The upper half of superior vena cava
lies in superior mediastinum, to the right side
of arch of aorta.
Fig. 24.3: TS through superior mediastinum (level-fourth thoracic vertebra)
230
The lower half of superior vena cava lies in

the middle mediastinum to the right of
ascending aorta.
Termination: The vena cava opens in the upper
posterior part of cavity of right atrium.
Tributaries: The superior vena cava receives
the azygos vein on its posterior aspect at level
of second costal cartilage.
Development: The superior vena cava develops
from.
Right common cardinal vein.
Proximal part of right anterior cardinal vein.
Anomalies
i. Left superior vena cava may be present, due
to persistence of left common cardinal vein.
ii. Both right and left superior vena cavae may
be present sometimes.
The Brachiocephalic Veins
The right brachio-cephalic vein is short and

vertical in course. The left brachio-cephalic vein
is longer and passes obliquely from left to the
right behind upper half of manubrium sterni.
Formation both brachio-cephalic veins are
formed by the union of internal jugular and
subclavian veins behind medial end of clavicle.
Termination The two brachio-cephalic veins join
to form the superior vena cava, at the lower
border of first right costal cartilage.
Tributaries
i. Vertebral vein
ii. Inferior thyroid vein
iii. Internal thoracic vein
iv. First posterior intercostal vein
v. Thoracic duct (joins left brachiocephalic
vein)
vi. Right lymphatic duct (joins the right brachiocephalic vein)
The Arch of Aorta

The arch of aorta is the convex part of aorta
between ascending and descending parts of aorta.
Location: The arch of aorta lies behind lower

half of manubrium sterni.
Extent: Anteriorly from the right half of sternal
angle to posteriorly up to lower border of fourth
right thoracic vertebra.
Curvatures: The arch of aorta has two curvatures.
a. Convex above and concave below.
b. Convex towards left side and in front and
concave towards right side and behind.
The arch of aorta has four surfaces:
Left anterior surface
Right posterior surface
Superior surface
Inferior surface
Relations:
The left anterior surface is related to:
i. Left mediastinal pleura and left lung
ii. Left phrenic and left vagus nerve
iii. Left superior intercostal vein
iv. Cardiac branches of sympathetic and vagus
nerves.
The right posterior surface is related to:
i. Esophagus
ii. Trachea, including bifurcation of trachea
Deep cardiac plexus
Thoracic duct
The superior surface is related to:
Origin of three branchesbrachio-cephalic,
left common carotid and left subclavian.
Remains of thymus gland
Left brachio-cephalic vein
The inferior surface is related to
Bifurcation of pulmonary trunk
Ligamentum arteriosum
Superficial cardiac plexus
Branches: The arch of aorta gives three large
branches
i. Brachio-cephalic artery
ii. Left common carotid artery
iii. Left subclavian artery.
The branching pattern may be anomalous.
tahir99 - UnitedVRG
The Mediastinum
iv. Thyroidea ima arteryis occasionally

present. It supplies isthmus of thyroid gland.
v. One of the vertebral artery may arise directly
from arch of aorta.
Development: The arch of aorta develops from:
Aortic sac and left horn of aortic sac
Left fourth aortic arch
Part of left dorsal aorta
The Vagus Nerves

The vagus nerves are the tenth cranial nerves.
The vagus nerves pass through neck and thorax
into abdomen and supply parasympathetic fibers
to cervical, thoracic viscera and foregut and
midgut.
a. The right vagus nerve passes behind the
internal jugular vein and crosses in front of
first part of subclavian artery to enter thorax.
It descends behind right brachiocephalic vein in superior mediastinum,
on right side of trachea.
The nerve passes behind right lung root
and divides into branches for posterior
pulmonary plexus.
From lower part of the plexus, vagal
branches descend to form esophageal
plexus.
Branches in thorax
i. The right recurrent laryngeal nerve
that curves around right pulmonary
artery at root neck and lies in tracheooesophageal groove
ii. Branches to posterior pulmonary
plexus.
iii. Branches to esophageal plexus. From
this plexus posterior gastric nerve
carrying fibers of right vagus nerve
to the abdomen.
b. The left vagus nerve descends between left
common carotid and left subclavian arteries
behind the left brachiocephalic vein.
It descends through superior mediastinum lying a left side of arch of aorta
231
and passes behind left long root to divide

into branches for posterior pulmonary
plexus.
From posterior pulmonary plexus vagal
branches descend to form esophageal
plexus.
Branches
i. The left recurrent laryngeal nerve
arises in superior mediastinum. It
curves below the arch of aorta and
ascends up in the tracheo-oesophageal goove.
ii. Branches to the pulmonary plexus.
iii. Branches to the esophageal plexus.
From the plexus anterior gastric
nerve arises and enters abdominal
cavity.
The Phrenic Nerves (Right and Left)
The phrenic nerves arise from ventral rami of C3,
C4 and C5 spinal nerves in the neck.
Course
i. The right phrenic nerve enters thorax by
passing behind right subclavian vein.
It crosses the internal thoracic artery and
lies lateral to right brachio-cephalic vein,
and superior vena cava.
It runs lateral to fibrous pericardium
covering right atrium of heart and inferior
vena cava to reach diaphragm which it
supplies.
ii. The left phrenic nerve passes anterior to left
subclavian artery behind thoracic duct and
enters thorax.
It crosses the internal thoracic artery and
runs down between left subclavian and
left common carotid arteries.
It crosses on left side of arch of aorta
and descends along fibrous pericardium
covering left ventricle of heart to reach
diaphragm which it supplies.
232
The Thymus Gland
The thymus gland is an important lymphoid organ

concerned with immunological response of the
body.
It is present from birth up to puberty as a bilobed
structure in lower part of neck and superior
and anterior mediastinum.
It weighs about 10.0 to 15.0 gm at birth, but
by puberty its weight increases 30.0 to
40.0 gm
After puberty, it undergoes fatty atrophy and
becomes much smaller, weighing only 10.0 gm
in adults.
The thymus lies in front of trachea, brachiocephalic veins, arch of aorta and fibrous
pericardium.
i. Thymus is the mother colony for T-lymphocytes, that settle in developing lymphoid
organs and help in their development.
ii. In myasthenia gravis an autoimmune disorder
associated with neuromuscular junctions,
thymectomy is done as a palliative measure.
iii. Thymus is also concerned with tissue or
organ rejection during transplant operations.
THE ANTERIOR MEDIASTINUM
The anterior mediastinum is the anterior part of
interior mediastinum.
Boundaries
Anteriorly: Body of sternum
Posteriorly: Fibrous pericardium
On two sides: Right and left mediastinal
pleurae
Contents
Two sterno-pericardiac ligamentssuperior
and inferior
Remains of thymus gland
Sternal branches of internal thoracic arteries
Some connective tissue.
THE MIDDLE MEDIASTINUM
The middle mediastinum is the middle part of
inferior mediastinum.
Boundaries
Anteriorly: anterior mediastinum separating
it from body of sternum.
Posteriorly: posterior mediastinum separating it from bodies of fifth to eighth
thoracic vertebrae.
Inferiorly: thoracic diaphragm
Two sides: right and left mediastinal pleurae
Contents
The heart
Lower half of superior vena cava
Ascending aorta
Pulmonary trunk
Pulmonary veinstwo for each lung
Arch of azygos vein
Fibrous pericardium containing
Right and left phrenic nerves with accompanying pericardio-phrenic vessels
Lymph nodes
Right and left bronchi.
THE POSTERIOR MEDIASTINUM

The posterior mediastinum is the posterior part of
inferior mediastinum:
It is a narrow space, behind pericardium and
diaphragm.
Boundaries
Anteriorly: Fibrous pericardium and thoracic
diaphragm
Posteriorly: Bodies of fifth to twelfth
thoracic vertebrae and inter-vertebral discs
On two sides: Right and left mediastinal
pleurae
Inferiorly: Lower border of twelfth thoracic
vertebra.
Contents
a. Longitudinal tubular structures
Descending thoracic aorta
Esophagus
Thoracic duct
Azygos and two hemiazygos veins.
b. Transverse tubular structures
Transverse part of thoracic duct on
front of fifth thoracic vertebra
Transverse parts of two hemiazygos
veins
tahir99 - UnitedVRG
The Mediastinum
Upper right aortic intercostal arteries for
third, fourth, fifth, and sixth spaces.
c. Other structures
Three splanchnic nervesgreater, lesser
and loweston both sides
The mediastinal lymph nodes.
The Descending Thoracic Aorta

The descending thoracic aorta is continuation of
arch of aorta in posterior mediastinum (Fig. 24.4):
Beginning: The descending aorta begins at the
lower border of fourth thoracic vertebra.
233
Course: The upper part of descending aorta (i.e.

from lower border of fourth thoracic vertebra
to eighth thoracic vertebra lies on left side of
vertebral bodies.
The lower part of descending aorta (i.e.
from eighth thoracic vertebra to the lower
border of twelfth thoracic vertebra lies in
the median plane.
The descending thoracic aorta lies behind
fibrous pericardium and is crossed by
esophagus from in front.
Termination: at the lower border of twelfth
thoracic vertebra the descending thoracic aorta
passes through aortic opening of diaphragm and
continues as abdominal aorta.
Branches
i. The posterior intercostal arteries (paired) for
lower nine intercostal spaces.
ii. The bronchial arteries
Two for left lung
One for right lung (from first right aortic
intercostal artery)
iii. The esophageal branches
iv. The mediastinal branches for mediastinal
lymph nodes
v. The superior phrenic arteries for superior
surface of diaphragm
vi. The pericardial arteries for fibrous pericardium.
The Esophagus
Fig. 24.4: The descending thoracic

aorta and thoracic duct
The esophagus (gullet) is a muscular tube that

conveys food from lower end of pharynx to the
stomach.
Beginning: The esophagus begins in the neck
at the lower border of cricoid cartilage (vertebral level sixth cervical vertebra) as continuation
of pharynx.
Course: The esophagus descends in front of
bodies of vertebrae and behind trachea in its
cervical part.
It descends in superior mediastinum and
deviates towards the left side still lying
behind the trachea
234
As it passes down in posterior mediastinum

it comes to median plane at fifth thoracic
vertebra, but again deviates towards left side.
The esophagus presents two lateral
curvatures (Fig. 24.5).
i. Upper convex towards the left
ii. Lower convex towards the right
It has also two antero-posterior curvatures
i. Cervical curvatureconvex forwards
ii. Thoracic curvatureconcave forwards.
The esophagus passes through esophageal
opening of diaphragm, located 2.5 cm
towards the left, surrounded by fibers of
right crus of diaphragm (vertebral level-tenth
thoracic vertebra)
After a very short abdominal course (about
2.0 cm) the esophagus opens in the cardiac
end of stomach.
Constrictions: The esophagus has four constriction in its course:
i. First constrictionAt the beginning
of esophagus (about 15 cm from incisor
teeth)
ii. Second constrictionWhere the arch of
aorta crosses at (about 22.5 cm from incisor
teeth)
iii. Third constrictionWhere the left bronchus
crosses it (about 27.5 cm from incisor
teeth)
iv. Fourth constrictionAt the oesophageal

opening of stomach (about 40.0 cm from
the incisor teeth.
These constrictions are important for passage
of Ryles tube, inserted in stomach for gastric
analysis or gastric feeding (Fig. 24.6)
The Blood Supply of esophagus
The arteries are

i. Esophageal branches of inferior thyroid
artery supply cervical part
ii. Esophageal branches of descending thoracic
aorta supply thoracic part
iii. Esophageal branches of left gastric artery
supply the abdominal part.
The veins
From upper portion, the veins end in inferior
thyroid veins
From middle portion, the veins drain in
azygos and hemiazygos veins
From lower portion, the veins drain in left
gastric vein.
Fig. 24.5: The curvatures of esophagus
Fig. 24.6: The esophagusrelations
tahir99 - UnitedVRG
The Mediastinum
The nerve supply of esophagus

The parasympathetic supply comes from the
vagus nerves that form esophageal plexus
in thoracic part of esophagus
The sympathetic fibers from ganglia of
sympathetic chains join the esophageal
plexus.
The sphincters of esophagus
i. For upper end, there is crico-pharyngeal
sphincter at its beginning. This sphincter
remains closed except when food passes
through it.
ii. For lower end, there is a functional sphincter
formed by the circular muscle fibers, that
are continuous with those of stomach.
The sphincter remains relaxed most of
the time except during abnormal physiological stimulation.
Applied anatomy
a. The esophageal varices consist of enlargement of veins in submucous coat, at junction
of systemic esophageal tributaries of
hemiazygos and azygos veins and esophageal tributaries of left gastric vein, in
cases of portal hypertension. The esophageal varices may rupture and cause
bleeding in stomach (hematemesis).
b. The esophagitis occurs mostly due to reflux
of gastric contents in lower end of esophagus
This is the most common cause of
heart-burn
c. Achalasia results from spasm of cardiac
sphincter at the lower end of esophagus
The achalasia causes dysphagia and
inability to swallow
d. The cancer of esophagus is also a common
type of cancer in the elderly persons.
The Thoracic Duct

The thoracic duct is the largest lymph duct in the
body that drains lymph from all parts of body
except
235
Right half of head and neck

Right half of thoracic cavity and right lung
Right upper limb
Beginning: The thoracic duct begins at the
upper end of cisterna chyli at lower border
of twelfth thoracic vertebra.
Course: The thoracic duct enters posterior
mediastinum through aortic opening of
diaphragm lying between azygos vein on
right side and descending aorta on the left
side.
It ascends up in posterior mediastinum lying
to the right side of median plane overlapped
by descending thoracic aorta, with the
azygos vein lateral to it.
In front of fifth thoracic vertebra, the
thoracic duct crosses from right to the left
side (transverse part) behind the esophagus.
Thoracic duct ascends in superior mediastinum lying along left border of esophagus.
It passes up through inlet of thorax and
enters root of the neck.
In the neck thoracic duct curves laterally in
front of vertebral vessels and behind the
carotid sheath. The thoracic duct gives a
beaded appearance when full due to many
valves inside it.
Termination: The thoracic ducts enters the
beginning of left brachio-cephalic vein. The
terminal part is often full of venous blood.
Tributaries
i. The cisterna chyli (a dilated lymph sac
located on front of first and second lumbar
vertebrae).
It receives
Intestinal lymph trunk bringing chyle
(lymph mixed with fat) from walls
of the intestines.
Two lumbar lymph trunks from lower
limbs, pelvic cavity and posterior
abdominal wall.
ii. Lymphatics from lower posterior intercostal
lymph nodes.
236
iii. Left bronchomediastinal lymph trunk

received near its termination, bringing lymph
from left half of thoracic cavity and lung.
iv. Left jugular lymph trunk from left side of
head and neck.
v. Left subclavian lymph trunk from left upper
limbs
Development of thoracic duct is from
a. Caudal part of right primitive lymph trunk
b. Transverse communication between two
primary lymph trunks on front of fifth
thoracic vertebra
c. Cranial part of left primitive lymph trunk.
Anomalies
i. Double thoracic ducti.e. present on both
sides
ii. Right thoracic duct (mirror image of the
original)
Applied anatomy
a. The chylo thorax is seen, when chyle leaks
into a pleural cavity from ruptured or
obstructed thoracic duct
b. The chyluria results from blocked lymphatics or thoracic duct communicates with
urinary passage.
The Azygos Vein

The azygos vein is a large vein in posterior
mediastinum that drains venous blood from:
Most of the thoracic wall
Esophagus
Pericardium
Lungs
Diaphragm
Other contents of posterior mediastinum.
The azygos vein also forms an important
link or connection between inferior vena
cava and superior vena cava.
Beginning: The azygos vein begins in
posterior abdominal wall by union of:
Lumbar azygos vein connecting it to the
interior vena cava and ascending lumbar vein
formed by first and second right lumbar
veins.
Course: The azygos vein enters posterior

mediastinum through aortic opening of diaphragm lying to the right side of thoracic
duct.
The azygos vein ascends up in front of
thoracic vertebrae in posterior mediastinum.
Termination: At the level of fourth thoracic
vertebra, the azygos vein arches forwards
above the right lung root and ends in the
back of superior vena cava.
Tributaries
i. Right subcostal vein
ii. Posterior intercostal veins from fifth to
eleventh intercostal spaces of right side
iii. Two right bronchial veins
iv. Two hemiazygos veins at level of eighth
thoracic vertebra
v. esophageal veins
vi. Mediastinal veins
vii. Pericardial veins
viii. Superior phrenic veins
ix. Right superior intercostal veins.
The Hemiazygos Veins
a. The superior hemiazygos (accessory hemiazygos)
vein is formed by the posterior intercostal veins of
fifth, sixth, seventh, and eighth spaces.
It descends on front of thoracic vertebrae on
left side of median plane.
It terminates by turning towards right side in
front of eighth thoracic vertebra and ends in
azygos vein.
Tributaries
i. Posterior intercostal veins from third to
eighth spaces on right side.
ii. Two left bronchial vein.
iii. Esophageal veins
iv. Pericardial veins
v. Mediastinal veins.
b. The inferior hemiazygos (hemiazygos) vein
begins in posterior abdominal wall by union of:
Left subcostal vein
Left ascending lumbar vein formed by union of
first and second right lumbar veins.
tahir99 - UnitedVRG
The Mediastinum
It enters posterior mediastinum by piercing left

crus of diaphragm
It ascends up in front of thoracic vertebrae to
the left of median plane
It terminates by turning towards right on front
of eighth thoracic vertebra and ends in the
azygos vein.
Tributaries
i. Posterior intercostal veins from ninth to
eleventh intercostal spaces of left side
ii. Esophageal vein
iii. Pericardial vein
iv. Mediastinal veins
v. Superior phrenic veins.
THE SYMPATHETIC TRUNKS

(THORACIC PART)
The thoracic parts of sympathetic trunks descend
on front of neck of ribs (therefore, they are not
included in the contents of posterior mediastinum.
There are eleven ganglia (paravertebral in
position) in thoracic part of sympathetic trunks.
Branches
i. Grey rami communicans (GRC) to the
ventral rami of thoracic nerves, carrying
post ganglionic sympathetic fibers from
corresponding ganglia.
237
ii. White rami communicans (WRC) from the

ventral rami of thoracic nerves carrying
preganglion sympathetic fibers to the
corresponding sympathetic ganglia.
iii. Greater splanchnic nerve arises from fifth
to tenth ganglia. It has preganglionic
sympathetic fibers that synapse in the coeliac
ganglia and supply abdominal organs.
iv. Lesser splanchnic nerve arises from tenth
and eleventh ganglia. It also carries
preganglionic sympathetic fibers that
synapse in the coeliac ganglia.
v. Lowest splanchnic nerve arises from
eleventh ganglion and accompanies the other
two splanchnic nerves. It also carries
preganglionic sympathetic fibers that
synapse in coeliac ganglia. The three
splanchnic nerves pierce the left crus of
diaphragm to enter abdomen.
vi. Branches from second to fifth ganglia to
posterior pulmonary plexus.
vii. Branches from second to fifth ganglia to
the deep cardiac plexus.
viii. Medial branches from upper five ganglia
from aortic plexus on thoracic aorta and its
branches.
ix. Branches from second to fifth ganglia and
greater splanchnic nerves to esophageal
plexus.
The Thorax
Q.1. Select the one best response to each
question from the four suggested answers:
1. The first chondro-sternal joint is:
A. Primary cartilaginous joint
B. Secondary cartilaginous joint
C. Fibrous joint
D. Synovial joint.
2. The sternal angle lies at the level of:
A. Upper border fourth thoracic vertebra
B. Lower border second thoracic vertebra
C. Lower border fourth thoracic vertebra
D. Lower border fifth thoracic vertebra.
3. The cervical rib arises as enlargement of:
A. Costal element of sixth cervical vertebra
B. Costal element of seventh cervical
vertebra
C. Transverse process of seventh cervical
vertebra
D. Transverse process of sixth cervical
vertebra
6. The costo-diaphragmatic recess:

A. Space between the lung and diaphragm
B. Space between parietal and visceral
pleura
C. Space between diaphragm and costal
cartilages
D. Space between costal and diaphragmatic
pleura at the lower border of lung.
7. The blood clot entering circulation from a
larger vein is likely to be lodged and produce
local infarct in:
A. The lung
B. The brain
C. The heart
D. The liver
8. The anterior inter-ventricular branch of left
coronary artery is accompanied by:
A. Middle cardiac vein
B. Coronary sinus
C. Great cardiac vein
D. Oblique vein of left atrium
4. The sternocostalis muscle:

A. Is attached to posterior surface of manubrium sterni
B. Is attached to posterior surface of xiphoid cartilage only
C. Is attached to lower ribs
D. Is attached to lower third of posterior
surface of body sternum.
9. The myocardial infarction limited to the

interverticular septum is likely to produce:
A. Disturbance in cardiac impulse conduction
B. Mitral valve incompetence
C. Tricuspid valve incompetence
D. Aortic valve insufficiency
5. The neuro-vascular bundle of the intercostal

space lies:
A. Above superior border of the rib
B. Midway in intercostal space
C. In the costal groove of rib along lower
border
D. Below the inferior border of rib.
10. The sinuatrial node:

A. Is the pacemaker for initiating cardiac
impulse
B. Located in myocardium at opening of
inferior vena cava
C. Is continued as atrio-ventricular bundle
D. Is supplied by left coronary artery.
tahir99 - UnitedVRG

Q.2. The questions below contain four suggested answers of which one or more or
correct. Choose the answers
11. The following structures pass through inlet
of thorax:
1. Esophagus
2. Trachea
3. Brachio-cephalic veins
4. Azygos vein
12. The right lung:
1. Has usually three lobes and two fissures
2. Is longer and narrower than the left lung
3. Inhaled foreign bodies are more likely to
enter right bronchus
4. Is related directly to the arch of aorta
and descending aorta
13. The broncho-pulmonary segments:
1. Are separated by connective tissue septa
2. Are supplied by a tertiary [segmental]
bronchus
3. Are pyramidal in shape with apex lying
at the hilum of lung
4. Have intersegmentally arranged pulmonary arteries
14. The right border of heart is formed by:
1. The right ventricle
2. The right auricle
3. The right atrium and right ventricle
4. The right atrium only
15. The venous blood of heart is drained by:
1. Thebesian vein
2. Anterior cardiac veins
3. Coronary sinus
4. All of the above
16. The anterior mediastinum of thorax contains:
1. Phrenic nerves
239
2. Remains of thymus gland

3. Superior vena cava
4. Two sterno-pericardiac ligaments
17. The coronary arteries:
1. Are branches of the ascending aorta
2. Are filled up during diastole of the heart
3. Can be classified as functional end
arteries
4. Have sufficient extracardial anastomoses
with pericardial arteries
18. The arch of aorta:
1. Begins and ends at the same vertebral
level, i.e. lower border of fourth thoracic
vertebra
2. Extends in the root of neck in adults
3. Has usually three main branches
4. Is closely related to the right lung
19. The esophagus in superior mediastinum:
1. Lies behind trachea in front of thoracic
vertebrae
2. Is deviated towards left side
3. Has thoracic duct related to its left
border
4. Has esophageal plexus of nerves related
to it
20. The azygos vein
1. Begins in posterior mediastinum by union
of posterior intercostal veins
2. Begins in posterior abdominal wall by
union of lumbar azygos and right
ascending lumbar veins
3. Enters thorax by piercing right crus of
diaphragm
4. Terminates by joining superior vena cava
Q.3. Match the structures on the left with
suitable answers given on the right
21. Structures in the chambers of heart:
1. Fossa ovalis
A. Left ventricle
2. Moderator band B. Right ventricle
240

3. Right pulmonary C. Left atrium
veins
4. Aortic vestibule D. Right atrium
22. Embryonic structures:

1. Left horn of
A.
sinus venoses
2. Left common
B.
cardinal vein
3. Ligamentum
C.
arteriosum
4. Bulbus cordis
D.
23. Termination of veins:
1. Right internal
thoracic vein
2. Hemiazygos vein
3. Left bronchial
vein
4. Great cardiac
vein
Oblique vein of
left atrium
Ducts arteriosus
Infundibulum of
right ventricle
Coronary sinus
A. Right brachiocephalic vein

B. Azygos vein
C. Coronary sinus
D. Accessory
hemiazygos
vein
24. Levels of structures:

1. Bifurcation of
A. Opposite fourth
trachea
left costal cartilage
2. Suprasternal
B. Lower border of
notch
fourth thoracic
vertebra
3. Mitral opening
C. Lower border
of heart
second thoracic
vertebra
4. Apex beat of heat D. Left fifth intercostal space. 9.0
cm from median
plane
25. Location of structures
1. Crista terminalis A. Aortic opening of
diaphragm
2. Thoracic duct
B. Lest crus of diaphragm
3. Sphanchnic
C. Right atrium
nerves
4. Oblique sinus
D. Serous pericardium
Answers
The first chondro-sternal joint is a primary
cartilaginous joint. The manubrio-sternal joint
is secondary cartilaginous joint. The second
to seventh chondro-sternal joints are synovial
joints.
The sternal angle lies at level of lower border
of fourth thoracic vertebra. The upper border
of manubrium sterni (suprasternal notch) lies
at level of lower border of second thoracic
vertebra.
The cervical rib is an anomalous rib, sometimes present, as an enlargement of costal
element of seventh cervical vertebra. It is
important clinically, as it may compress lower

trunk of brachial plexus producing pain.
The sterno-costalis muscle, a part of the inner
layer of intercostal muscles, arises from the
posterior surface of lower one-third of body
of sternum. It is inserted by digitations on
posterior surface of second to sixth costal
cartilages.
The neuro-muscular bundle consisting of
intercostal vein, artery and nerve, lies in the
costal groove along the lower border of the
rib. The collateral branch of the intercostal
nerve and vessels run along the upper border
of the rib below.
tahir99 - UnitedVRG

The costo-diaphragmatic recess of pleura is
the space between two layers of parietal
pleuracostal and diaphragmaticat the
lower border of the lung. During deep inspiration, the lung partly descends in the costodiaphragmatic recess.
241
A11. The answer is A, (1, 2, 3)

The following three structures pass through
inlet of thoraxesophagus, trachea and
brachiocephalic veins. The azygos vein does
not pass through the inlet; it ends in superior
vena cava.

The blood clot from a big vein lodges mostly
in the lung, causing pulmonary embolism.
The blood from big vein reaches right atrium
of heart and from there reaches right ventricle. The pulmonary trunk and pulmonary
artery carry the blood clot from the right
ventricle to one of the lungs.
A12. The answer is B, (1, 3)

The right lung has usually three lobes and
two fissures. The inhaled foreign bodies are
more likely to enter right bronchus, as it is
wider and more vertical i.e. in line with
trachea. The left lung is narrower and longer,
being related more to pericardium and heart.
The arch of aorta and descending aorta lie in
relation to mediastinal surface of left lung.

The anterior inter-ventricular branch of left
coronary artery is a large artery that descends
in the anterior inter-ventricular groove,
accompanied by the great cardiac vein. The
coronary sinus lies in the posterior coronary
sulcus. The middle cardiac vein lies in
posterior inter-ventricular groove and is
accompanied by posterior inter-ventricular
branch of right coronary artery.

The bronchopulmonary segments are
separated by connective tissue septa and are
supplied by tertiary (segmental) bronchus.
They are pyramidal in shape with apex lying
at the hilum of lung. They have, however,
inter-segmentally arranged pulmonary veins.
The pulmonary artery gives a segmental
branch of each segment that accompanies
tertiary bronchus.

The myocardial infarction limited to interventricular septum produces disturbances in
cardiac impulse conduction, because the right
and left ventricular branches of atrioventricular bundle (bundle of His) lie on two
sides of interventricular septum. The valvular
incompetence results from the disease of the
valves.
A14. The answer is D, (4)

The right border of heart is formed by right
atrium only between the roots of superior
vena cava and inferior vena cava. The inferior
border is formed mostly by right ventricle;
only a small part near apex of heart is formed
by left ventricle.

The sinuatrial node is the pacemaker of the
heart and initiates cardiac, impulse. It is
located below the opening of superior vena
cava in right atrium. It is not continued as
atrio-ventricular node. It is supplied mostly
by nodal branch of right coronary artery.
A15. The answer is E, (1, 2, 3, 4)

The venous blood of heart is drained by all
three sets of veins i.e. thebesian veins, anterior
cardiac veins and the coronary sinus.
A16. The answer is C, (2, 4)
The anterior mediastinum of thorax contains
remains of thymus gland and the two sternopericardiac ligamentssuperior and inferior.
242

The phrenic nerves lie on the lateral aspect
of mediastinum. The superior vena cava lies
partly in middle mediastinum and partly in
superior mediastinum.

The coronary arteries are branches of
ascending aorta. They are filled up during
diastole of the heart. They can be classified
as functional end arteries, as they have very
little anastomoses between their smaller
branches. They, however, do not have,
sufficient extracardiac anastomoses.
The arch of aorta begins and ends at the same
vertebral level, i.e. lower border of fourth
thoracic vertebra. The arch does not extend
in the root of neck in adults. It has three main
branchesbranchiocephalic, left common
carotid and left subclavian. The arch of aorta
is related to the mediastinal surface of left
lung and not right lung.
The esophagus in the superior mediastinum
lies behind trachea in front of thoracic
vertebrae. It is deviated towards left side and
has thoracic duct related to its left border.
But the esophageal plexus of nerves is related
to esophagus in posterior mediastinum.
The azygos vein begins in posterior abdominal
wall by union of lumbar azygos and right
ascending lumbar vein. It does not pierce right
crus of diaphragm, but enters thorax through
the aortic opening. It terminates by joining
superior vena cava.
A21. The answers are D, B, C, A.
The fossa ovalis is located on the septal
wall of right atrium
The moderator band passes from the
septal wall to root of anterior papillary
muscle in the right ventricle
The right pulmonary veins open in the

left atrium
Aortic vestibule is the upper outflow part
of the left ventricle
A22. The answers are D, A, B, C

The coronary sinus develops from left
horn of sinus venosus
The left common cardinal vein persists
as the oblique vein of left atrium
Ligamentum arteriosum is remnant of
ductus arteriosus of fetal heart
Bulbus cordis of fetal heart gives rise to
the infundibulum of right ventricle from
its right half portion
A23. The answers are A, B, D, C
The right internal thoracic vein ends in
right brachiocephalic vein
The hemiazygos veins end in azygos vein
The left bronchial veins drain in the
accessory hemiazygos vein
The great cardiac vein is a tributary of
the coronary sinus.
A24. The answers are B, C, A, D
The bifurcation of trachea is at level of
lower border of fourth thoracic vertebra
The suprasternal notch (upper border of
manubrium sterni) is at level of lower
border of second thoracic vertebra
The mitral opening of heart is opposite
fourth left costal cartilage
The apex of heart is located in left fifth
intercostal space, 9.0 cm from median
plane
A25. The answers are C, A, B, D
The crista terminalis is present in the
interior of anterior wall of right atrium
along right border
Thoracic duct enters posterior mediastinum of thorax through aortic opening
of diaphragms
The three splanchnic nerves pierce the
left crus of diaphragm
The oblique sinus is located in the serous
pericardium, behind left atrium of heart.
tahir99 - UnitedVRG
The Abdomen
Five
CHAPTER
25
The Anterior Abdominal

Wall and the Inguinal Region
THE BONES AND JOINTS OF
ABDOMINAL WALL
The bones at the back of abdominal wall are

the five lumbar vertebrae and the inter-vertebral
discs between them.
The upper parts of two hip bones with their
iliac crests lie in lower part of abdominal wall.
The iliac fossa of hip bones also lie below.
[Detail description of hip bones is given in
Chapter 16].
THE LUMBAR VERTEBRAE

There are five lumbar vertebrae. These vertebrae
are quite large and become progressively larger
towards sacrum.
The characteristics of typical lumbar vertebrae
[upper four] are:
i. The body of vertebra is wider transversely
and the vertebral canal is triangular
ii. The pedicles are very short
iii. The transverse processes are thin and have
no costal facets or foramen transversarium.
These are homologous with ribs of thoracic
region
iv. A small acessory process lies at the root of
transverse process. This represents true
transverse process
v. The laminae are short, thick, and broad

vi. The spinous process forms a quadrilateral plate
and is directed almost directly backwards
vii. The superior articular process bears a
concave facet facing medially and backwards.
viii. The inferior articular process bears convex
facet that faces laterally and forwards
ix. The posterior border of superior articular
process is marked by a rough elevation
mamillary process.
Fifth lumbar vertebra - has some atypical features
The transverse process is thick, short and
pyramidal in shape. The process appears turned
upwards. Their base is attached to whole thickness of pedicle.
The spine is small and rounded at the tip.
The body is largest of all lumbar vertebrae. Its
anterior surface is much wider than posterior
surface.
The superior articular facet looks more
backwards and inferior articular facet looks
more forwards.
Variations of Lumbar Vertebrae
The fifth lumbar vertebra may be fused with
sacrum. The condition is known as sacralization
244
of lumbar vertebra. The fusion, usually is

incomplete and is limited to one side only.
Ossification of Lumbar Vertebrae

The lumbar vertebrae ossify from
Three primary centers (one for body and two
for two halves of vertebral arch)
The two halves of vertebral arch fuse during
1st year and the arch fuses with the body by
6th year.
Seven secondary centers are:
One for epiphysis of upper surface of body
One for epiphysis of lower surface of body
Two centers for the two transverse processes
Two centers for the two mammillary processes
One center for tip of spinous process
THE JOINTS OF LUMBAR VERTEBRAE
[Same as described for thoracic vertebrae in
Chapter 20].
THE LUMBO-SACRAL JOINT
The joint between 5th lumbar vertebra and 1st sacral
vertebra resembles those between other lumbar
vertebrae.
There are some additional features of this joint:
The lumbo-sacral inter-vertebral disc is very
large and wider ventrally to fill up the gap
between body of 5th lumbar vertebra and base
of sacrum. It is covered by the anterior and
posterior longitudinal ligaments.
The Iliolumbar ligament is attached to the tip
of transverse process of 5th lumbar vertebra.
It is connected to iliac crest passing laterally in
front of sacro-iliac joint and partly fusing with
it.
It also gives attachment to the quadratus
lumborum muscle.
THE ANTERIOR ABDOMINAL WALL
The anterior abdominal wall covers the anterolateral aspect of the abdomen.
Boundaries on other side are:

Superiorly
Xiphisternal joint
Costal margin formed by seventh to tenth
costal cartilages.
Inferiorly
Upper border of pubic symphysis
Pubic crest
Inguinal ligament
Anterior 5 cm of iliac crest, i.e. from
anterior superior iliac spine to the tubercle of iliac crest.
Laterally
Lateral border of quadratus lumborum
muscle
Layers of the anterior abdominal wall
1. The skin has cleavage lines (lines of Langer)
in the dermis that run in horizontal direction.
The abdominal incisions along the
direction of cleavage lines do not gape
much and heal with minimum scarring.
2. The superficial fascia is divided into two
layers.
Outer fatty layer and inner membranous
layer. The distinction between the two
layers is more obvious in the infraumbilical part of the anterior abdominal
wall.
a. The outer fatty layer (Campers
fascia) contains variable amount of
fat with cutaneous nerves and blood
vessels.
The fatty layer is continuous
superiorly with superficial fascia
of thorax, and inferiorly crosses
the inguinal ligament to become
continuous with the superficial
fascia of front of thigh.
b. The inner membranous layer
(Scarpas fascia) is more distinct
below umbilicus.
It contains elastic fibers.
Superiorly: It is continuous with
superficial fascia of thorax.
tahir99 - UnitedVRG
The Anterior Abdominal Wall and the Inguinal Region

Inferiorly: The Scarpas layer
crosses the inguinal ligament and
is attached to fascia lata of thigh
about 1 cm below and parallel to
the inguinal ligament.
MediallyIt is adherent to the
linea alba and symphysis pubis,
and is thickened to form fundiform ligament of penis (in males
more developed).
The Scarpas fascia is continuous with membranous
layer of perineum (Colles
fascia).
There is no deep fascia in the anterior
abdominal wall. The epimysium
(outer fibrous layer) covers the
muscles and aponeuroses of the
anterior abdominal wall.
3. The muscles of the anterior abdominal wall
are divided into two groups:
A. The antero-lateral muscles are also called
oblique muscles. They are arranged in
three layers (Table 25.1):
i. Outer layer: external oblique
ii. Intermediate layer: Internal oblique
iii. Inner layer: Transversus abdominis
B. The anterior group has two muscles:
i. Rectus abdominis
ii. Pyramidalis.
4. The fascia transversalis is a thin membranous layer that forms the anterior fascial
lining of the abdominal cavity deep to the
transversus abdominis muscle.
Superiorly: It fuses with diaphragmatic
fascia.
Inferiorly: It is attached to:
Inner lip of iliac crest
Deep surface of inguinal ligament
Pectineal line of pubic bone
Forms anterior wall of femoral
sheath.
It also gives Internal spermatic fascia
around spermatic cord in males.
245
The fascia transversalis is continuous
below with fascia iliaca and parietal

layer of pelvic fascia.
Medially It is continuous with the
opposite half of the abdominal wall, by
passing deep to linea alba.
5. The extra peritoneal connective tissue
separates the fascia transversalis from the
parietal layer of peritoneum.
This layer contains variable amount of
fat, specially above the iliac crest and
around pubic bones.
6. The parietal layer of peritoneum forms the
deeper layer of the anterior abdominal wall.
Actions of the anterior abdominal wall muscles
i. The anterior abdominal wall muscles
provide a firm and elastic wall of abdominal
cavity. By their normal tone, they maintain
the intra-abdominal pressure and keep the
organs in position.
ii. These muscles help in expiration by forcing
the abdominal viscera against diaphragm and
pushing it up.
iii. These muscles help in all voluntary expulsive
efforts, e.g. coughing, sneezing, vomiting,
defecation, micturition and parturition (in
females).
iv. When pelvis is fixed, the rectus abdominis
muscles helped by the oblique muscles flex
the lumbar part of vertebral column.
v. The oblique muscles of one side contracting,
help in lateral flexion of lumbar part of
vertebral column.
vi. The oblique muscles are also active during
rotation movements of vertebral column.
vii. The pyramidalis acts as a tensor of linea
alba.
The linea alba is a tendinous raphe formed by
the aponeuroses of three oblique muscles of
the two halves of anterior abdominal wall.
The linea alba extends from xiphoid process
to upper end of pubic symphysis.
The linea alba has a complex structure with
the aponeuroses of oblique muscles dividing
into two laminae and joining in linear
decussations.
246

Table 25.1: The muscles of the anterior abdominal wall
Name
Origin
The antero-lateral muscles

1. External
By eight digitations
obliqe
attached to outer sur(Fig. 25.1)
faces and lower borders
of lower eight ribs
Muscle belly
2. Internal
oblique
(Fig. 25.2)
3. Transversus
abdominis
(Fig. 25.3)
Lateral two-third of
upper surface of
inguinal ligament
Anterior two-third intermediate ridge of ventral
segment of iliac crest
Thoraco-lumbar fascia
Costal origin inner

surface lower six
costal cartilages
Lumbar origin
Fused anterior and
middle laminae of
lumbar fascia
Pelvic origin
Anterior two third inner
lip of the iliac crest
Lateral third of inguinal
ligament
Insertion
Nerve supply
Largest oblique muscle a. By muscle fibers on

Ventral rami of lower
The fibers of flat
outer lip anterior half six thoracic nerves
muscle belly pass
ventral segment of
(T7 -T12)
downwards and
iliac crest
medially
b. By aponeurosis attaPosterior fibers desched to linea alba from
cend more or less
xiphisternum to the
vertically
upper end pubic symMuscle fibers give
physis A triangular gaplies
rise to aponeurosis
above pubic crest
lateral to linea
(superficial inguinal
semilunaris
ring) Lower margin
thickened and folded
to form inguinal ligament between the pubic
tubercle and anterior
superior ilic spine
Flat muscle belly
Posterior fleshy fibers as- Ventral rami lower
Fibers ascend
cend to get attached to
six thoracic nerves
upwards and medilower borders of lower
(T7 -T12)
ally except lowest
three or four ribs
Iliohypogastric iliofibers that pass
Aponeurosis is attached to inguinal (L1)
downwards forward
linea alba from xiphistermedially
num to upper end of pubic
Muscle fibers give
symphysis
rise to aponeurosis
From costal margin to
along a line lateral
midway between umbilicus
to linea semilunaris
and pubic symphysis, the
aponeurosis splits into two
laminaeanterior and
posterior Below midpoint
aponeurosis does not split
Lowest fibers join the conjoint tendon
Flat muscle belly
By aponeurosis on linea Ventral rami lower
Fibers pass almost
alba between Xiphisternum six thoracic nerves
horizontally toand Upper end of pubic
(T7 -T12)
wards linea alba
symphysis
Iliohypogastric
Lowest fibers pass
By conjoint tendon
Iliongunal nerves
downwards forward
The lowest fibers of inter- (L1)
and medially
nal oblique fuse with lowMuscle fibers give
est fibers of transversus
rise to aponeurosis
abdominis to form the
along a line lateral
conjoint tendon attached
to linea semilunaris
to pecten pubis and pubic
(except highest part) crest.
The conjoint tendon reinforces the defect caused
by superficial inguinal ring
on lower part of anterior
abdominal wall
Contd...
tahir99 - UnitedVRG
247
Contd...
Name
Origin
Muscle belly
The anterior group

1. Rectus
Two heads
abdominis
Lateral head larger
attached to pubic crest
and pubic tubercle
Medial head smaller
attached to front of
pubic symphysis
2. Pyramidalis
(inconstant
muscle)
Front of body of pubis

and anterior ligament
of pubic symphysis
Muscle belly long strap

like. It is thick and
narrow below, flat and
wider above
Three tendinous intersections divide the
belly and shorten the
muscle fibers
one at costal margin
one at umbilicus
one in between
Small triangular muscle,
lies in front of lower
part of rectus abdominis
The linea alba has the umbilical scar just

below its midpoint.
It is wider above umbilicus and narrow
below umbilicus.
It is surgically important for giving the
midline incision for emergency surgery of
abdomen.
The Rectus Sheath
The rectus sheath is an aponeurotic envelope
Insertion
Nerve supply
By three inequal slips

attached to fifth, sixth,
and seventh costal cartilages
Ventral rami lower

six thoracic spinal
nerves (T7 -T12)
Linea alba midway between umbilicus and pubic

symphysis
Ventral ramus of
twelfth thoracic
nerve
formed by the aponeuroses of three oblique muscles

of the anterior abdominal wall, to lodge the rectus
abdominis muscle.
Location: The rectus sheath is located on the
front of anterior abdominal wall between linea
alba medially and linea semilunaris laterally.
Formation
The posterior wall of the rectus sheath is
incomplete above the costal margin, and
Fig. 25.1: The external oblique muscle
248
Fig. 25.2: The internal oblique muscle
below the arcuate line (linea semicircularis)

that marks the lower limit of posterior wall.
The anterior wall is complete all over. The
formation of rectus sheath can be studied
at following three levels:
a. Above the costal margin (Fig. 25.4)

Anterior: wall is formed by
External oblique aponeurosis
Posterior: wall is absent and the
rectus abdominis rests on costal
cartilages
Fig. 25.3: The transversus abdominis muscle
tahir99 - UnitedVRG
249
Fig. 25.4: The rectus sheath (TS above costal margin)
b. Between the costal margin and mid-way

between umbilicus and upper border of
pubic symphysis (approximately the level
of arcuate line) (Fig. 25.5)
Anterior wall is formed by
External oblique aponeurosis.
Anterior lamina of internal oblique
aponeurosis.
Posterior wall is formed by
Posterior lamina of internal
oblique aponeurosis.
Transversus abdominis aponeurosis.

c. Below the midpoint (or arcuate line) (Fig.
25.6)
Anterior wall is formed by
Internal oblique aponeurosis
Transversus abdominis aponeurosis
Posterior wall is absent. A thickened
fascia transversalis lies behind the
rectus abdominis.
Fig. 25.5: The rectus sheath (TS from costal margin to mid-point)
Fig. 25.6: The rectus sheath (TS below mid-point)
250
Contents
i. The muscles
Rectus abdominis
Pyramidalis
ii. The vessels
Superior epigastric
Inferior epigastric
iii. The nerves parts of lower five intercostals
(T7-T11) and subcostal (T12) nerves.

Abdominal Wall
The Arteries
a. The superior epigastric artery is one of the
terminal branch of internal thoracic artery.
CourseThe artery enters upper part of rectus
sheath by passing deep to seventh costal
cartilage.
It descends inside rectus sheath lying deep
to the rectus abdominis muscle.
It terminates by anastomosing with the
inferior epigastric artery.
Branches
i. The muscular branches supply the rectus
abdominis muscle.
ii. The cutaneous branches accompany the
anterior cutaneous nerves.
iii. The anastomotic branches join with
branches of inferior epigastric artery.
b. The inferior epigastric artery is a branch of
the external iliac artery given just above the inguinal
ligament.
CourseThe artery ascends upwards and
medially lying medial to deep inguinal ring, in
the extra peritoneal tissue.
It pierces thick part of fascia transversalis
deep to rectus abdominis.
The artery enters rectus sheath by crossing
in front of arcuate line.
Branches
Before entering rectus sheath
i. The pubic branch that descends deep to
pubic bone (or lacunar ligament) to
anastomose with pubic branch of obturator artery.
ii. The cremasteric branch in males accompanies spermatic cord. In females it is

known as artery to the round ligament
and descends to the labium majus.
Inside rectus sheath
iii. The muscular branches supply rectus
abdominis muscle.
iv. The cutaneous branches accompany the
v. The anastomotic branches anastomose
with branches of superior epigastric
artery.
c. The deep circumflex iliac artery arises from
the external iliac artery above the inguinal ligament.
Coursethe artery runs along the inner lip of
the iliac crest.
It gives a large ascending branch that lie in
the neuro-vascular plane of the anterior
abdominal wall between the internal oblique
and transversus abdominis muscles.
d. The musculo-phrenic artery is one of the
terminal branch of internal thoracic artery.
CourseThe artery runs along the costal margin
and supplies the anterior abdominal wall muscles
and the diaphragm.
e. The three superficial branches of femoral
artery supply the skin of lowest part of anterior
abdominal wall.
i. The superficial circumflex iliac passes
laterally along the inguinal ligament.
ii. The superficial epigastric ascends upwards
and medially towards umbilicus.
iii. The superficial external pudendal chiefly
supplies the external genitals.
The Veins
Above umbilicus drain upwards in the axillary vein
via thoraco-epigastric veins.
Below umbilicus drain in the femoral vein via the
tributaries of the long saphenous vein.
The superficial veins of the anterior abdominal
wall are connected with left branch of portal
vein via paraumbilical veins travelling along the
ligamentum teres.
tahir99 - UnitedVRG
In case of portal obstruction this venous anastomosis between superficial veins of anterior
abdominal wall and paraumbilical veins enlarges
giving rise to caput medusae (enlarged tortuous
veins radiating from umbilicus).
The deep veins

The deep veins of the anterior abdominal wall
accompany the arteries.
Anterior Abdominal Wall
Above umbilicus the lymphatics pass upwards

and end in the axillary lymph nodes.
Below umbilicus the lymphatics descend and
end in the superficial inguinal lymph nodes.
The Nerve Supply

The nerve supply of the anterior abdominal wall:
The skin and muscles of the anterior abdominal
wall are supplied by lower five intercostals (ventral
rami of T7 to T11 spinal nerves), subcostal (ventral
ramus of T12) iliohypogastric and ilioinguinal nerves
(both from ventral ramus of L1 spinal nerve).
a. The lower five intercostals and subcostals
enter the anterior abdominal wall from the costal
margin.
CourseThese nerves course forwards and
medially lying in the neuro-vascular plane of
anteior abdominal wall between internal oblique
and transversus abdominis muscles.
These nerves enter the rectus sheath by piercing
the posterior lamina of internal oblique aponeurosis.
They pass forwards through lateral half of
rectus abdominis and anterior wall of rectus
sheath, and come out in superficial fascia as
Branches
i. The muscular branches are given to supply
anterolateral and anterior abdominal muscles.
251
ii. The lateral cutaneous branches pierce the

interocostal muscles and external oblique at
the mid-axillary line.
The lateral cutaneous branches divide
into anterior and posterior branches to
supply the lateral aspect of abdominal
wall.
The lateral cutaneous branch of subcostal crosses iliac crest and supplies
the skin of anterior part of gluteal region.
iii. The anterior cutaneous branches divide into
a medial and a lateral branch to supply skin
of front of abdominal wall.
The dermatomes (skin area supplied by
one spinal segment) are arranged horizontally
parallel to each other in the abdominal wall.
b. The iliohypogastric nerve (ventral ramus of
L1 nerve) appears at lateral border of psoas major
muscle, and pierces transversus abdominis muscle.
It passes forwards in the neuro-vascular plane
of abdominal wall.
It pierces internal oblique and external oblique
aponeuroses close to median plane and comes
out as anterior cutaneous nerve.
The iliohypogastric nerve supplies the skin of
hypogastric region above public symphisis.
It also supplies the lower parts of oblique
muscles of the abdominal wall.
The lateral cutaneous branch of iliohypogastric
nerve also supplies skin of anterior part of
gluteal region.
c. The ilio-inguinal nerve (ventral ramus of L1
nerve) also appears at the lateral border of psoas
major muscle.
It pierces transversus abdominis near anterior
end of iliac crest.
It pierces internal oblique and passes forwards
in inguinal canal, and comes out from superficial
inguinal ring.
The ilio-inguinal nerve supplies skin of external
genitals and upper part medial side of thigh.
The nerve also supplies lower part of oblique
muscles of the abdominal wall.
252
Applied Anatomy
A. The incisions of the anterior abdominal wall:
i. The midline incision through linea alba is done
sometimes, in emergency surgery of the
abdomen.
The healing of such incision is poor and
may produce mid-line ventral hernia.
ii. The paramedian incision (via rectus sheath).
After skin, the incision is made in anterior
wall of rectus sheath.
If rectus abdominis is well developed a
vertical incision is made in medial half
of the muscle (Rectus splitting procedure).
If rectus abdominis is poorly developed
the muscle is reflected laterally (Rectus
reflecting procedure).
Incision is made in posterior wall of
rectus sheath and parietal peritoneum to
open up the abdominal cavity.
This incision is preferred in abdominal
surgery.
iii. The lateral abdominal incisions are made,
sometimes taking into account the direction
of cleavage lines. McBurneys incision for
appendicectomy is made in right lower
quadrant of anterior abdominal wall. The three
oblique muscles are split in the direction of
their fibers to prevent weakness of abdominal
wall.
B. The hernias through anterior abdominal wall.
i. The epigastric hernia is midline hernia
through upper part of linea alba where fat
or some abdominal content comes out.
It is usually a postoperative complication.
ii. The umbilical hernias
a. The congenital umbilical hernia (exomphalos) is caused due to failure of
reduction of physiological umbilical
hernia of fetal life.
A child is born with a loop of intestine in the umbilical cord.
The condition may show spontaneous regression.

b. The infantile umbilical hernia is seen
in infants up to three years of age.
It is caused by stretching of umbilical scar tissue.
This type causes a small swelling of
the umbilicus, and is associated with
increased intra-abdominal pressure.
c. The acquired umbilical hernia usually
occurs in adult life in fat persons.
Actually, the herniation is through
linea alba near umbilicus (paraumbilical hernia).
The umbilicus is the scar just below midpoint
of linea alba, where the umbilical cord in the fetal
life was attached.
In fetal life two umbilical arteries, one
umbilical vein and urachus pass through
umbilicus.
After birth these structures are represented by
vestigeal structures. The umbilical arteries
remain as medial umbilical ligaments up to urinary bladder. The umbilical vein is represented
by the ligamentum teres of liver, while urachus
gives rise to median umbilical ligament connecting umbilicus to apex of urinary bladder.
Applied Anatomy
i. The umbilical hernias (described above).
ii. Patent urachus results in urinary fistula at
the umbilicus.
iii. Urachal cysts may persist in part of urachus.
iv. Meckels diverticulum (remnant of vitello
intestinal duct of fetal life) may be connected
by a fibrous cord to the umbilicus.
Rarely the Meckels diverticulum may
open at umbilicus causing a faecal
fistula.
THE INGUINAL REGION
The inguinal region (groin) is the lowest part of the
anterior abdominal wall, just above the inguinal
ligament, at junction with front of thigh.
tahir99 - UnitedVRG
The inguinal region is surgically a weak part of

the anterior abdominal wall, and inguinal hernias
take place in this region.
In males, this region is concerned with the
descent of testes.
The inguinal canal is an oblique intermuscular
space formed in the inguinal region due to descent
of testes in males (round ligament of uterus in
females) (Fig. 25.7).
LocationThe inguinal canal lies a little above
and parallel to medial half of the inguinal
ligament.
ExtentLaterally deep inguinal ring medially
superficial inguinal ring (Table 25.2).
Direction is downwards, forwards and medially.
Length is about 4.0 cm.
The Walls of the Inguinal Canal (Fig. 25.8)
The walls of the inguinal canal are formed by

the layers of the anterior abdominal wall.
The inguinal canal has anterior wall, posterior
wall, roof and floor.
a. The anterior wall is formed by:
External oblique aponeurosis.
Fleshy part of internal oblique in lateral
half.
Fig. 25.7: The inguinal canal
253
b. The posterior wall is formed by:

Fascia transversalis throughout.
Conjoint tendon in medial one-third.
Reflected part of inguinal ligament in
medial one-fourth.
The roof (superior wall) is formed by the lower
arching fibers of internal oblique muscle.
The floor (inferior wall) is formed by:
Superior grooved surface of inguinal ligament.
Superior surface of lacunar ligament.
The structures transmitted by the inguinal canal.
In males
Spermatic cord.
Cremasteric artery
Genital branch genito-femoral nerve
Ilioinguinal nerve
In females
Round ligament of uterus
Artery of the round ligament
Nerve of the round ligament
Ilioinguinal nerve
Sex Difference
The inguinal canal is wider in males, as it is caused
by the descent of testis
For this reason, the inguinal hernias are
commoner in males than females.
The normal mechanism of the inguinal canal.
The inguinal canal is potentially a weak part of
the anterior abdominal wall. The hernia through
the canal is normally prevented by the following
factors:
i. The obliquity of the canal is an important
factor preventing hernia.
ii. The increase in intra-abdominal pressure and
contraction of internal oblique muscle pushes
the posterior wall of canal firmly against the
anterior wall, thus preventing hernia.
iii. The contractions of internal oblique and the
transversus abdominis muscles, flatten their
lower borders, and thus exercise a safety
valve mechanism on the deep inguinal ring.
254

Table 25.2: The deep and superficial inguinal rings
i. Location
ii. Layer
iii. Shape and size
Superficial inguinal ring
Deep inguinal ring
Above the pubic crest

Aponeurosis of external oblique muscle
1.2 cm above mid-inguinal point

Fascia transversalis
Triangular with apex pointing laterally
Oval with long axis vertical
In
Two sides formed by two thickenings

(the crurae)
Some intercrural fibers in aponeurosis
prevent separation of crura
males
Spermatic cord
Cremasteric artery
Genital branch of genitofemoral nerve
Ilio-inguinal nerve
In
females
Round ligamentum of uterus
Artery to the round ligament
Nerve to the round ligament
Ilioinguinal nerve
External spermatic fascia
iv. Structures transmitted
v. Covering given to spermatic cord from margins
In
males
Spermatic cord
Cremasteric artery
Genital branch of genito-femoral nerve
In
females
Round ligament of uterus
Artery to the round ligament
Nerve to the round ligament
Internal spermatic fascia
Fig. 25.8: A section through inguinal region showing walls of inguinal canal
tahir99 - UnitedVRG

Applied Anatomy
The inguinal hernias consist of abnormal protrusion
of some abdominal content in the inguinal region.
The inguinal hernias constitute the majority of
hernias in the males.
There are two types of inguinal herniasoblique
(indirect) type and direct type.
a. The oblique (indirect inguinal hernia)
passes through the deep inguinal ring lateral
to the inferior epigastric artery.
CourseThe oblique hernia passes
through the inguinal canal, comes out
of the superficial inguinal ring and
descends in the scrotum up to a variable
level along the spermatic cord.
Coverings(structures separating
hernia from the surface).
Extraperitoneal tissue
Internal spermatic fascia
Cremaster muscle and fascia
External spermatic fascia
Superficial fasciatwo layers
Skin
Strangulation (or constrictions of the
vessels of the herniated structure) in
common is oblique inguinal hernia as the
hernia passes through very narrow deep
inguinal ring.
CausesThe most common cause of
oblique hernia is imperfect obliteration
of processus vaginalis that becomes
more obvious at puberty.
The oblique inguinal hernia is
commoner in young adult males.
Types
The congenital oblique hernia
present since birth can be:
1. Complete if the hernial sac reaches up to upper end of testes.
255
2. Incomplete (funicular) when

hernia descends in processus
vaginalis, but it is shut off from
the testis.
The oblique inguinal hernia of adult.
b. The direct inguinal herniaconsists of
some abnormal protrusion of an abdominal
content through posterior wall of inguinal
canal.
CourseThe direct hernia passes
through the inguinal (Hesselbachs)
triangle on deep aspect of lower part of
anterior abdominal wall. It is bounded
Inferiorly by medial half of inguinal
ligament.
Medially by lateral border of rectus
abdominis.
Laterally by inferior epigastric
artery.
The direct hernia can take place
either lateral to the medial umbilical
ligament (obliterated umbilical artery)
or medial to this ligament.
Coverings
Extraperitoneal tissue
Fascia transversalis
Conjoint tendon
Superficial fasciatwo layers
Skin
The direct hernia bulges through posterior wall of inguinal canal. It may pass
through superficial inguinal ring medial
to the spermatic cord.
The direct inguinal hernia is much less
common, and occurs in older age group.
It is always acquired.
The risk of strangulation in this type of
hernia is low, as it bulges through the
fascia.
256
Differences Between Oblique and

Direct Inguinal Hernia
i. The direct hernia is situated mostly above the
pubic bone, while oblique hernia descends to
scrotum.
ii. The inferior epigastric artery is lateral to the
neck of direct hernia, while the artery is
medial to the neck of indirect hernia.
iii. The spermatic cord lies directly behind in
oblique hernia. In direct hernia the spermatic
cord lies postero-laterally.
The Descent of the Testes (Fig. 25.9)
The gonad or sex gland (testes/ovary), develops
behind peritoneum from the genital ridge in upper
lumbar region. The testes in males descend towards
the perineum (future scrotum).
The factors causing descent of testes are:

i. Hormonal factors gonadotropins and androgens.
ii. Relative growth of different parts of posterior
abdominal wall.
iii. Mechanical factorgubernaculum testes a
fibro-muscular band, that is attached to the
lower end of developing testes and to the skin
of future scrotum.
The gubernaculum shortens progressively and pulls down the testes, along
with a tube of peritoneumthe processus vaginalis.
Sequence of Descent of Testes
a. By third month of intra-uterine life, the testis
comes to lie in the iliac fossa.
Fig. 25.9: The descent of testis
tahir99 - UnitedVRG

The processus vaginalis bulges towards the
perineal skin at future scrotum (genital swelling).
b. By seventh month of intra-uterine life the testis
reaches the deep inguinal ring.
c. During seventh and eight months the testis
passes through the iguinal canal behind the
processus vaginalis.
d. By end of ninth month, just before birth, the
testis is totally descended and touches the floor
of scrotum.
The processus vaginalis mostly obliterates
before birth, only its lower end surrounding tests
persists as tunica vagnalis.
Sometimes, the processus vaginalis may not
be obliterated after birth, and gives rise to congnital
oblique inguinal hernia.
Applied Anatomy of Descent of Tests
a. Congenital oblique inguinal hernia.
b. Congenital hydrocele is collection of serous fluid
in the tunica vaginalis since birth, and it
communicates with the peritoneal cavity
through non-obliterated processus vaginalis.
c. Infantile hydrocele is collection of serous fluid
in tunica vaginalis up to deep inguinal ring. This
condition is seen in little children.
d. Encysted hydrocele is collection of serous fluid
in middle part of processus vaginalis, whose
upper and lower parts are obliterated.
e. The undescened testis is testis that is held up
anywhere in its normal course of descent. It
can be.
In the posterior abdominal wall.
In iliac fossa
At deep inguinal ring
At the superficial inguinal ring
The undescended testes may not be fully developed.
f. The maldescended testis is testis that has
descended elsewhere, not along its normal
course. It is known as ectopic testis. It can be
(Fig. 25.10):
257
Fig. 25.10: The ectopic testisaccessory

tails of gubenaculum testis
In the perineum.
At the root of penis.
Above the superficial inguinal ring in anterior
abdominal wall.
In front of upper part of thigh.
The ectopic testis is explained on the basis of
additional extensions of gubernaculum testis.
The Nerves of the Inguinal Region
a. The ilio-inguinal nerve is a branch of lumbar
plexus (ventral ramus of L1 nerve).
It passes through inguinal canal and comes
out of superficial inguinal ring lateral to the
spermatic cord (or round ligament of uterus).
It supplies
Skin of external genitals,
Skin of upper part medial side of
thigh.
b. The ilio-hypogastric nerve is also a branch of
lumbar plexus (ventral ramus of L1nerve).
It pierces external oblique aponeurosis
about 2.0 cm above superficial inguinal
ring.
258
It supplies the skin of hypogastric region

above pubic crest and symphysis.
Both ilio-inguinal and ilio-hypogastric
nerves also supply the lower parts of the three
oblique muscles. An injury to first lumbar nerve
weakens the lower parts oblique muscles (i.e.
in inguinal region) and makes the person more
prone to inguinal hernias.
c. The genitofemoral nerve is also a branch of
lumbar plexus (ventral ramus of L1- L2). The
nerve divides into a genital branch and a femoral
branch.
i. The genital branch is known as cremasteric

nerve in males. It lies lateral to the spermatic
cord and supplies cremaster muscle.
In females it is known as nerve of the
round ligament of uterus and supplies the
fibromuscular tissue of the round ligament.
ii. The femoral branch passes deep to inguinal
ligament lying lateral to femoral artery in
femoral sheath.
It pierces femoral sheath and deep fascia
of front of thigh and supplies skin of
front of thigh below inguinal ligament.
tahir99 - UnitedVRG
CHAPTER
26
The Peritoneum
The abdominal cavity, more correctly called the
abdomino-pelvic cavity, is the largest cavity in the
body:
It is divided intoabdominal cavity proper and
the pelvic cavity.
The Abdominal Cavity
The abdominal cavity proper is bounded by its

fascial linings.
Superiorly is diaphragmatic fascia
Inferiorly it communicates with the pelvic
cavity at the inlet of pelvis.
Antero-laterally is fascia transversalis
Posteriorly is fascia iliac.
Contents
i. Most parts of gastro-intestinal tract.
ii. The accessory glandsthe liver, its excretory apparatus and the pancreas.
iii. The spleen
iv. The kidneys, ureters and supra-renal glands.
v. The blood vessels
Abdominal aorta and its branches
Inferior vena cava and its tributaries
Portal vein and its tributaries
vi. Peritoneal folds or mesenteries
vii Fat
viii Mesenteric lymph nodes
The regions of the abdominal cavity proper: The
abdominal cavity proper is divided into regions to
help in the topographical study of the organs. The
division is done with the help of two horizontal
planes and two vertical planes.
The horizontal planes
a. The transpyloric plane encircles the
trunk at level of lower border of first
lumbar vertebra
The plane passes through
i.
ii.
iii.
iv.
The tips of ninth costal cartilages

Pylorus of stomach
The hila of both kidneys
Origin of superior mesenteric
artery from front of abdominal
aorta
[The subcostal plane was previously
used in place of transpyloric plane.
This plane passes through third
lumbar vertebra.]
b. The trans-tubercular plane encircles the
trunk at level of fifth lumbar vertebra.
The plane passes through tubercles
of the iliac crest.
The vertical planes
There are two vertical planesright and left
extend vertically from the mid-inguinal
points up to mid-clavicular points above
(Fig. 26.1).
The abdominal cavity proper is divided into nine
regions with the help of two horizontal and two
vertical planes.
Above transpyloric plane
1. The right hypochondrium
2. The epigastrium
3. The left hypochondrium
Between transpyloric and trans-tubercular
planes
4. The right lumbar region
5. The umbilical region
6. The left lumbar region
Below the trans-tubercular plane
7. The right iliac fossa
8. The hypogastrium
9. The left iliac fossa
260
Fig. 26.1: The subdivisions of the abdominal cavity
THE PERITONEUM
The peritoneum is the largest and most complex
serous sac in the body.
The peritoneum consists of two layersparietal
and visceralenclosing a potential cavity.
A. The parietal layer forms the inner lining of the
abdominal walls and diaphragm.
The layer develops from the somatopleure
part of secondary mesoderm.
B. The visceral layers covers the outer surface of
abdominal viscera partially or completely
It also forms peritoneal foldsmesenteriesto connect the viscera to the body
wall.
The visceral layer develops from the
splanchnopleure part of secondary mesoderm.
The Mesenteries
The mesenteries or folds of peritoneum suspend
parts of digestive tube from the body wall.
In the fetal life the developing digestive tube
has two mesenteriesventral mesentery up to
umbilicus and a dorsal mesenteryconnecting
the digestive tube to ventral and dorsal body wall,

respectively.
The ventral mesentery gives rise to the following
peritoneal folds in the adults
i. The ligaments of the liver
a. The coronary ligament has two layers
anterior and posteriorand connects
liver to the diaphragm.
b. The triangular ligamentsright and
leftalso connect the liver to the diaphragm
c. The falciform ligament is a large, sickleshaped fold that connects the liver to
anterior abdominal wall and diaphragm.
It contains ligamentum teres of liver
in its lower bordera remnant of
left umbilical vein of fetal life.
ii. The lesser omentum is a fold of peritoneum
connecting the liver with lesser curvature
of stomach and duodenum.
It is divided into two parts:
a. The hepato-gastric part is the larger
part between the liver and the stomach.
tahir99 - UnitedVRG
The Peritoneum
b. The hepato-duodenal part is smaller

part between the liver and superior
surface first part of duodenum.
This portion contains three
important structures in its right
free border.
The hepatic arteryanteriorly to the left
The bile ductanteriorly to
the right
The portal veinposteriorly
The free border of lesser omentum forms the anterior boundary
of epiploic foramen.
The dorsal mesentery provides the main
attachment of digestive tube to the body wall.
It also provides a pathway for the blood
vessels, nerves and lymphatics to reach the
parts of the digestive tube.
The dorsal mesentery gives rise to the
following peritoneal folds in the adult:
a. The dorsal mesogastrium part of dorsal
mesentery is attached to the stomach.
It is represented by:
i. The gastro-phrenic ligament connecting the highest part of greater
curvature to the diaphragm.
ii. The gastro-splenic ligament connecting the next part of greater curvature
to the hilum of spleen.
iii. The lieno-renal ligament connecting
the hilum of spleen to front of left
kidney on posterior abdominal wall.
iv. The greater omentum, a large double
fold of peritoneum, that hangs from
the lower part of greater curvature
like a loose apron.
It fuses with transverse colon and
transverse mesocolon and is
connected to the posterior wall
of abdomen.
b. The meso-duodenum is present in fetal
life only.
261
In adult, the meso-duodenum fuses
c.
d.
e.
f.
g.
with the parietal peritoneum, except

a small portion connected to first part
of duodenum.
The meso-duodenum contains developing pancreas, that also becomes
retroperitoneal in adults.
The mesentery of small intestine (jejunum
and ileum) is a large fold of peritoneum
that suspends jejunum and ileum from
the posterior abdominal wall.
The attachment of mesentery (root
of mesentery) is only about 15.0 cm
long, while its free border is thrown
into pleats and is about six meters
long.
The ascending mesocolon is also present
in fetal life only.
The ascending mesocolon becomes
fused with parietal peritoneum,
making ascending colon a retroperitoneal organ.
The transverse mesocolon connects the
transverse colon to the posterior
abdominal wall, almost transversely
across the abdominal cavity.
The descending mesocolon is also a fetal
structure only, and disappears before
birth.
It fuses with parietal peritoneum and
the descending colon becomes a
retro-peritoneal organ.
The pelvic mesocolon suspends the
pelvic colon (sigmoid colon) from the
inlet of pelvis and posterior wall to pelvis.
It has inverted V-shaped attachment, with apex of attachment at
bifurcation of left common iliac
artery.
The Peritoneal Cavity

The peritoneal cavity is the potential space between
the parietal and visceral layers of peritoneum.
262
Normal content is a small amount of serous

fluid that lubricates the opposing surfaces and
this facilitates the movements of intestines.
Abnormal contents can be:
a. Collection of inflammatory fluid in pathological conditions called ascitis.
b. Air or gas (pneumo-peritoneum) from
external injury or perforation of hollow
viscus.
c. Blood (hemo-peritoneum) may collect in the
peritoneal cavity due to external injury or
perforation of a viscus leading to rupture of
blood vessels. The organs commonly
involved are liver, spleen, gastric ulcer and
tubal pregnancy in females.
Subdivisions of Peritoneal Cavity

The peritoneal cavity is divided into
A. The lesser sac or omental bursa.
B. The greater sac
A. The lesser sac of peritoneum (omental bursa) is
the smaller part of peritoneal cavity that lies
behind stomach and lesser omentum (Fig. 26.2).
The lesser sac is a closed space and

communicates with greater sac through an
opening the epiploic foramen.
Boundaries of the lesser sac
a. The anterior wall is formed by
The lesser omentum
Peritoneum covering postero-inferior
surface of stomach and 2.0 cm of
duodenum.
Anterior two layers of greater omentum.
b. The posterior wall is formed by:
Posterior two layers of greater
omentum
Transverse colon and transverse
mesocolon fused with posterior
layers of greater omentum.
Peritoneum covering upper part of
posterior abdominal wall.
The borders of the lesser sac (omental bursa)
are fourinferior, superior, right and left.
a. The inferior border developmentally is
the lower border of greater omentum.
Fig. 26.2: A vertical section of abdomen showing lesser sac (omental bursa)
tahir99 - UnitedVRG
The Peritoneum
In adult, however, the lower border

extends up to transverse colon only,
due to fusion of anterior and posterior
layers of greater omentum.
b. The superior border is very short
It extends between the right border
of esophagus and upper end of
fissure for ligamentum venosum.
c. The right border is formed by:
The right border of greater omentum
Reflection of peritoneum from neck
of pancreas to first part of duodenum
Interrupted by the epiploic foramen
Right margin of caudate lobe of liver
along left side of inferior vena cava
d. The left border is formed by:
The left border of greater omentum
The lieno-renal and gastro-splenic
ligaments
The gastro-phrenic ligament
There are two prominent semilunar folds
the gastro-pancreatic folds that bulge inside
omental bursa
The right gastropancreatic fold is formed
by the hepatic artery
The left gastropancreatic fold is formed
by the left gastric artery
The recesses of the lesser sac are
a. The superior recess lies behind the lesser
omentum and liver.
The caudate lobe of liver bulges in
the superior recess from right side.
b. The inferior recess lies below the two
folds and lies behind the stomach and
between the layers of greater omentum.
The epiploic foramen (Foramen of Winslow) is a slit-like vertical opening in the
right border of omental bursa, that connects
it with the greater sac (Fig. 26.3).
SizeAbout 3.0 cm long
LevelTwelfth thoracic vertebra
263
Fig. 26.3: The epiploic foramen
Boundaries
Superiorly: Caudate process of liver.
Posteriorly: Parietal peritoneum covering
a short segment of inferior vena cava.
Anteriorly: Free right border of lesser
omentum containing bile duct, hepatic
artery and portal vein.
Inferiorly: Reflection of peritoneum
above head of pancreas from front of
inferior vena cava to posterior layer of
lesser omentum.
The epiploic foramen opens in the hepatorenal pouch (Morrisons pouch) of greater
sac of peritoneum.
The epiploic foramen may be a site of
internal hernia.
B. The greater sac of peritoneum is divided into
two compartments (Fig. 26.4):
A supracolic compartment
An infracolic compartment
A. The supracolic compartment is further divided
into the right and left subphrenic (subdiaphragmatic) spaces by the attachment of
falciform ligament of liver.
1. The right subphrenic spaces are three in
number:
i. The right anterior subphrenic space lies
between the diaphragm and right lobe
of liver.
264
Fig. 26.4: TS through abdominal cavity
ii. The right posterior subphrenic space

(Hepato-renal or Morrisons pouch) is
situated between the inferior surface of
right-lobe of liver and upper pole of right
kidney.
The hepato-renal pouch is the most
dependent part of the peritoneal
cavity when person is in supine
position.
The pouch communicates with
The lesser sac or omental bursa
The right paracolic gutter
The right anterior subphrenic
space.
An infection in any part of peritoneal
cavity may give rise to collection of
infected material in hepato-renal
pouch, when patient is put in supine
position.
iii. The right extra-peritoneal subphrenic
space corresponds to the bare area of
liver, where the posterior surface of right
lobe of liver lies in direct contact with
the diaphragm.
2. The left subphrenic space are two in number
i. The left anterior subphrenic space lies
between the diaphragm and anterior and
superior surfaces of left lobe of liver.
ii. The left posterior subphrenic space

corresponds to the superior recess of
the lesser sac.
B. The infracolic compartment of greater sac of
peritoneum is divided into following regions:
i. The right infracolic space lies below the
transverse mesocolon and to the right side
of mesentery of small intestine.
The space becomes narrow below,
where the vermiform appendix lies.
The space does not communicate with
the pelvic cavity.
ii. The left infra-colic space is a wide space
limited above by the transverse mesocolon:
It lies to the left side of mesentery of
small intestine and communicates freely
with the pelvic cavity via the inlet of
pelvis.
iii. The right and left paracolic gutters lie lateral
to the ascending colon and descending
colon respectively.
The right paracolic gutter communicates
superiorly with the hepatorenal pouch.
The left paracolic gutter is closed above
by the phrenico-colic ligament connecting the left colic flexure to the diaphragm.
tahir99 - UnitedVRG
The Peritoneum
The left paracolic gutter communicates
below with the pelvic cavity.
The Peritoneal Recesses
The peritoneal recesses are small spaces of the
peritoneal cavity guarded by peritoneal folds, some
of which may contain blood vessels.
The peritoneal recesses may be site of internal
hernia when a small part of intestine may be
held up in one of them.
The omental bursa is the largest peritoneal
recess.
A. The duodenal recesses (Fig. 26.5)
i. The superior duodenal recess present in
about 50% cases. It is guarded by a small
fold attached to the left side of terminal
part of duodenum.
ii. The inferior duodenal recess present in
about 75% cases.
It is usually present along with the
superior recess.
It is also guarded by a small fold
attached to left side of terminal part
of duodenum.
Fig. 26.5: The duodenal recesses
265
iii. The paraduodenal recess is seen in only

about 2% of adults.
It is a large recess guarded by a
paraduodenal vascular fold, that
contains inferior mesenteric vein, and
ascending branch of left colic artery.
This recess may be a site of internal
hernia as a developmental anomaly
seen in children.
iv. The retroduodenal recess is rarely present
It is a large recess present behind
the third and fourth parts of duodenum.
v. The mesocolic recess present in about
20% cases.
It lies between the transverse mesocolon and duodeno-jejunal junction.
vi. The mesenterico-parietal fossa of
Waldeyer is present more frequently in
the newborn.
In adults, it is present in about 2%
cases. In this recess, the duodenum
invaginates the root of mesentery.
B. The Cecal recess (Fig. 26.6)
i. The superior ileocecal recess is guarded
by a vascular fold containing anterior
cecal artery.
It lies at the ileocecal junction, and
is limited behind by the mesentery.
Fig. 26.6: The cecal recesses
266
ii. The inferior ileocecal recess is guarded

by a bloodless fold (of Treeves)
It is also limited behind by the mesentery.
iii. The retrocecal recess lies behind the
cecum
It is variable in size and may ascend
behind ascending colon.
The recess is bounded on either sides
by the two cecal folds.
It frequently contains the vermiform
appendix.
C. The intersigmoid recess is usually present in
fetal life and in infants.
It lies behind the apex of inverted Vshaped attachment of pelvic mesocolon.
It varies in size and left ureter lies in its
posterior wall.
It is potential site for internal hernia,
involving pelvic colon or terminal coil
of ileum.
D. The fossae in the anterior abdominal wall
i. The lateral inguinal fossa is a shallow
depression that lies lateral to the lateral
umbilical fold (formed by the inferior
epigastric artery)
The fossa is site for oblique (indirect
inguinal hernia)
ii. The medial inguinal fossa lies medial to
the lateral umbilical fold and lateral to
medial umbilical fold (raised by medial
umbilical ligament, a remnant of
umbilical artery)
The fossa is site for direct inguinal
hernia.
iii. The supra-vesical fossa lies above the
apex of urinary bladder, between medial
umbilical fold and median umbilical fold
(raised by median umbilical ligament, a
remnant of urachus).
The Blood Supply of the Peritoneum

i. The parietal peritoneum is developed from
the somatopleure part of secondary mesoderm.
It is supplied by the somatic blood
vessels of the abdominal and pelvic
walls.
ii. The visceral peritoneum is developed from
the splanchnopleure part of secondary
mesoderm.
It is supplied by the blood vessels
supplying the viscera that it covers.
Peritoneum
The parietal peritoneum is drained by the lymphatics
joining those of the body wall, and draining into
regional parietal lymph nodes.
The visceral peritoneum has its lymphatics join
lymphatics of the viscera and end in the visceral
lymph nodes.
The Nerve Supply of the Peritoneum
The parietal peritoneum is supplied by the somatic
nerves, that also innervate the body wall.
The parietal peritoneum is very sensitive to all
exteroceptive sensations.
The visceral peritoneum is supplied by the
autonomic nerves, hence it is insensitive to ordinary
exteroceptive sensations.
However, tension causes pain when applied to
viscera or visceral peritoneum. Also spasms of
visceral muscles cause colic type of pain.
Applied Anatomy
The peritonitis is an acute inflammatory condition
of the peritoneal cavity.
The inflammation of parietal peritoneum causes
tension and guarding of the anterior abdominal
wall muscles, thereby causing a rigid abdomen.
tahir99 - UnitedVRG
The Peritoneum
The nerve supply of parietal peritoneum by the

somatic nerves makes the abdomen extremely
tender and painful.
The inflammation of visceral peritoneum is
secondary to the inflammation of the organ.
The condition causes colic type of abdominal
pain due to stretching of the automatic nerves.
The paracentesis consists of removal of fluid of

ascitis that is collected in the peritoneal cavity.
The fluid that is inflammatory in nature (rich in
proteins) may collect in
Hepatorenal pouch
Pelvic cavity
The fluid level can be percussed through the
anterior abdominal wall or seen in X-ray of the
abdomen.
The fluid is removed by a cannula introduced
through the sides of the abdomen.
The Rotation of Gut
Stage before of gut

The gut or digestive tube developes from
the part of yolk sac included within the
embryo after formation of head, tail and
lateral folds.
By fifth week of intrauterine life the gut is
divided into three parts:
a. The foregut extends from the stomodeum or primitive mouth cavity up to
beginning of hepatic diverticulum
(opening of bile duct). The foregut is
divided into:
1. A cranial part that lies above diaphragm
2. A caudal part that lies below diaphragm
b. The midgut extends from the opening
of bile duct up to junction of right twothird and left one-third of transverse
colon.
c. The hindgut portion extends from the
left one-third of transverse colon up to
the anal canal.
267
The three parts of gut have their main arterial

supply by the three branches of abdominal aorta
For foregutcoeliac axis artery
For midgutsuperior mesenteric artery
For hind gutinferior mesenteric artery.
The abdominal part of gut (i.e. caudal part of
foregut, midgut and hind gut) is suspended by
mesenteries from the body wall.
1. The dorsal mesentery connects the gut to
the dorsal body wall.
2. The ventral mesentery is only present up to
foregut portion and connects it to the ventral
body wall above umbilicus.
Development and Rotation of Stomach

The stomach develops as a fusiform dilatation from
the caudal part of foregut in fifth week of intrauterine life.
Due to development of liver on right side of the
abdominal cavity, the developing stomach
undergoes a 90 rotation to the right.
As a result of rotation, the left surface becomes
anterior surface and the right surface becomes
posterior surface.
Along with rotation, the dorsal surface (left after
rotation) grows more rapidly and forms the
greater curvature of stomach.
The greater omentum is formed by enlargement
and folding of dorsal mesentery of stomach
(mesogastrium). The omental bursa also
develops along with it.
Rotation of Duodenum
Due to rotation of stomach, the duodenum moves
posteriorly and forwards to the right and assumes
a C-shaped position.
The meso-duodenum also becomes fused with
the peritoneum of dorsal body wall, thus making
the duodenum, a retro-peritoneal structure.
The pancrease, that develops in the mesoduodenum also becomes retroperitoneal.
The duodenum in second month of intrauterine
life passes through a solid state and later
268
Fig. 26.7: The first stage of rotation of midgut
canalises. This condition may result in narrowing of lumen of duodenum.

The Rotation of the Midgut
The midgut portion undergoes rotation in three
stages.
i. The first stage (stage of physiological
umbilical hernia): This stage takes place between
fifth and tenth weeks of intrauterine life (Fig. 26.7).
The midgut grows rapidly and forms a U-loop
that herniates through umbilicus into the extraembryonic coelom of the umbilical cord.
The midgut loop is connected to the yolk sac
by vitello-intestinal duct, that may persist later
as Meckels diverticulum.
The midgut loop, inside umbilical cord undergoes
a 90 rotation anticlockwise around the axis of
superior mesenteric artery.
The right (cranial) limb develop into:
The caudal part of duodenum
The jejunum and ileum up to Meckels
diverticulum (vitello-intestinal duct)
The left (caudal) limb develops into:
The terminal part ileum
The ascending colon
The right two-third of transverse colon
ii. The second stage of rotation (Stage of
reduction of physiological hernia): This stage takes
place between tenth and eleventh weeks of intrauterine life (Fig. 26.8).
The abdominal cavity grows larger in size, so
the physiological hernia is reduced.
The cranial (right) limb reduces first and passes
behind the superior mesenteric artery to come
to lie in the left upper quadrant. This explains
the position of jejunum in left upper part of
abdomen, and the superior mesenteric artery
passing in front of duodenum.
Fig. 26.8: The second stage of rotation of midgut
tahir99 - UnitedVRG
The Peritoneum
The caudal (left) limb reduces last and the

cecum comes to lie below liver on the right
side.
The withdrawal of hernia also results in anticlockwise rotation of midgut by 180, so that
the total rotation of 270 around axis of superior
mesenteric artery takes place.
iii. The third stage of rotation (Stage of retroperitonization or fixation of gut): This stage takes place
from eleventh week till end of intra-uterine life (Fig.
26.9).
The cecal diverticulum of the caudal (left) limb
of midgut loop descends from the subhepatic
position to its adult position in right iliac fossa.
The cecal diverticulum differentiates into
vermiform appendix (from terminal part) and
cecum (from basal part).
The ascending mesocolon and descending
mesocolon fuse with the parietal peritoneum of
dorsal body wall and thus the ascending and
descending colon become retroperitoneal.
The posterior two layers of greater omentum
fuse with the two layers of transverse mesocolon.
Fig. 26.9: The third stage of rotation of midgut
269
The transverse attachment of transverse mesocolon on dorsal body wall divides the peritoneal
cavity into:
A supracolic compartment
An infracolic compartment
Anomalies of Rotation of Mid-Gut

1. Non rotation of gut: The midgut loop does not
undergo any rotation as it returns to the abdominal cavity.
In such cases the jejunum and ileum lie on
right side of abdominal cavity.
The colon lies on the left side of abdominal
cavity.
The small intestine may undergo twisting
around the superior mesenteric artery, resulting in volvulus, causing obstruction in the
intestine that may lead to necrosis.
2. The reverse rotation of gut is a rare condition
and may involve other organs also
In this condition, the position of different
parts of gut is exactly opposite (mirror image
of the normal) while external appearance
remains normal.
3. The malrotation of gut consists of various stages
of incomplete rotation of midgut loop.
More frequently, it involves cecum, which
may remain in sub-hepatic or lumbar
position.
Malrotation may also cause paraduodenal
hernia.
4. The congenital umbilical hernia results from
incomplete reduction of physiological umbilical
hernia of the embryo.
The child is born with a loop of small intestine in the umbilical cord covered by a layer
of peritoneum and amnion.
It is a rare condition, but it should be recognized before ligating the umbilical cord after
birth.
5. The Meckels diverticulum is the persistent
remnant of proximal part of vitello-intestinal
duct.
270
Fig. 26.10: The anomalies of Meckels diverticulum
The Meckels diverticulum is seen in about

2% of births and is located about two feet
from the ileo-cecal junction.
The Meckels divericulum lies on the
antemesenteric border of terminal part of
ileum.
Anomalies of Meckels of
Diverticulum (Fig. 26.10)
a. The diverticulum may be connected by a fibrous
cord to the umbilicus. Volvulus of small intestine
may occur with possible obstruction and strangulation.
b. There may be a patent Meckels diverticulum

forming a fecal fistula at umbilicus.
c. The vitelline vessels may persist at their attachment with umbilicus, and they may anastomose
with blood vessels of the anterior abdominal
wall.
d. There may be a cyst formation from the
remnant of Meckels diverticulum, deep to the
umbilicus.
e. Ectopic gastric mucosa or pancreatic tissue may
be present in the epithelium lining Meckels
diverticulum. The gastric mucosa may show
ulceration.
tahir99 - UnitedVRG
CHAPTER
27
The Gastrointestinal
System1
The major part of gastrointestinal tract lies in the
abdominal cavity, along with associated glands. The
caudal part of foregut, midgut, and nearly entire
part of hind gut (except rectum and anal canal) lie
in the abdominal cavity.
ESOPHAGUS
The abdominal part of esophagus is very small,
only about 2 cm long.
The esophagus enters abdomen through
esophageal opening of diaphragm and ends in
the cardiac opening of stomach.
Relations
Anteriorly left lobe of liver.
Posteriorly the diaphragm.
Right border continues as the lesser curvature of stomach.
Left border is separated from the fundus of
stomach by a cardiac notch.
MusculatureThe lower third of esophagus
(including the abdominal part) has smooth or
plain muscle fibers in its walls.
SphincterThere is a functional sphincter
formed by the circular muscle fibers of abdominal part of esophagus.
The blood supply
The arteries supplying this part of esophagus
are derived from the left gastric artery
The veins end in the left gastric vein. There
is anastomosis between esophageal tributaries of left gastric vein and hemiazygos
vein in the submucous coat of abdominal
part of esophagus.
Thus abdominal part of esophagus is one
of the sites for porto-systemic anastomosis.
The nerve supply

i. The para-sympathetic supply is from left
and right vagus nerves via anterior and
posterior gastric nerves.
The dysfunction of parasympathetic
nerves causes spasm of abdominal part
of esophagus (achalasia cardia) leading
to difficulty in swallowing.
ii. The sympathetic supply is from T2 to T5
sympathetic ganglia of the sympathetic
trunks, and reaches via esophageal plexus.
Applied anatomy
a. Esophagitis is caused by the regurgitation
of gastric contents in abdominal part of
esophagus. The so-called Heartburn is a
result of esophagitis causing dysphagia
(difficulty in swallowing).
b. Esophageal varices are caused in cases of
portal obstruction due to engorgement of
venous plexus in the submucous coat of
abdominal part of esophagus (site of portosystemic anastomosis).
The enlarged and dilated veins may be
injured during swallowing, causing
bleeding in stomach that is vomited out
(hematemesis).
c. Hiatus hernia results due to herniation of a
part of greater curvature of stomach through
enlarged esophageal opening of diaphragm.
The hiatus hernia results in reflux
esophagitis due to incompetence of
functional cardiac sphincter.
The condition may lead to ulceration of
the abdominal part of esophagus.
272
THE STOMACH (GASTER)

The stomach is the most dilatable part of the
gastrointestinal tract.
LocationThe stomach lies in the left hypochondrium and epigastric region of the
abdominal cavity.
When full the stomach descends in upper
part of umbilical region.
Size and shape: The empty stomach is more or
less tubular with bulges present in upper part
of greater curvature (fundus) and in lower part
of greater curvature.
When full, stomach becomes typically
J-shaped stomach.
The capacity of stomach is variable, as the
stomach is highly distensible.
At birth the capacity is only 30 ml.
By puberty it increases to 1000 ml.
In adults, the capacity is 1500 to 2000 ml.
Openings, surfaces, borders
The stomach has two openings:
a. The cardiac opening is situated at level with
eleventh thoracic vertebra, behind left
seventh costal cartilage 2.5 cm from
sternum.
The esophagus opens at the cardiac
opening.
b. The pyloric opening is situated at level of
lower border of first lumbar vertebra (transpyloric plane), about 1.2 cm to the right of
median plane.
The duodenum is attached at the pyloric
opening.
There is a pyloric sphincter at the opening
formed by thickening of circular muscle
fibers.
The stomach has two borders or curvatures:
i. The lesser curvature represents the primitive
ventral border of stomach.
This border is concave and much
shorter than the other border.
It gives attachment to the two layers of

lesser omentum (derivative of ventral
mesogastrium).
ii. The greater curvature represents the primitive dorsal border of stomach.
The highest part of greater curvature
forms the fundus stomach.
The greater curvature is convex and at
least five times longer than lesser
curvature.
The following peritoneal folds
(derivatives of dorsal mesogastrium) are
attached to it.
a. The gastro-phrenic ligament
connects the fundus to the diaphragm.
b. The gastrosplenic ligament connects
the next part of greater curvature to
the hilum of spleen.
c. The anterior two layers of greater
omentun are attached to the rest part
of greater curvature.
The stomach has two surfacesantero-superior
and postero-inferior.
i. The antero-superior surface is related to the
greater sac of peritoneum which separates
this surface from:
The left dome of diaphragm.
The left lobe of liver.
The left costal margin and anterior
abdominal wall.
ii. The postero-inferior surface is related to the
lesser sac of peritoneum, that separates this
surface from structures in upper part of
posterior abdominal wall (Fig. 27.1).
These structures constitute the stomach
bed , They are:
a. The left part of diaphragm.
b. Part of left suprarenal.
c. Upper part front of left kidney.
d. The splenic artery.
e. The anterior surface of pancreas.
f. The transverse mesocolon and the
left colic flexure.
tahir99 - UnitedVRG
The Gastrointestinal System1
273
Fig. 27.1: The stomach shape and parts
(The gastric surface of spleen is

separated from the postero superior
surface of stomach by the greater
sac of peritoneum.
The stomach is divided into two partsthe
cardiac part and pyloric part (Fig. 27.2).
An imaginary plane passing from the angular
notch of lesser curvature is joined to the left
end of the bulge on greater curvature to divide
the stomach.
Fig. 27.2: The stomachbed
i. The cardiac part is further divided into:

a. The fundus is convex bulging part that
lies above the level of cardiac opening.
b. The body is the remaining portion of the
cardiac part.
ii. The pyloric part is the narrow tubular
portion and is further divided into:
a. The pyloric antruma slightly dilated
part below the angular notch.
b. The pyloric canalabout 3.0 cm long,
narrow part that lies proximal to the
pyloric sphincter.
The pyloric sphincter, that guards the pyloric
opening is sometimes abnormally thick in
infants(Congenital pyloric stenosis) requiring
surgical correction.
The interior of stomachPresents
i. The gastric rugae or folds of mucous membrane in empty state of stomach.
These folds are temporary and disappear
when stomach becomes full.
ii. The gastric canal consists of permanent
longitudinal folds along the lesser curvature
enclosing a canal.
274
The gastric canal helps to direct the fluids

to flow towards pylorus, without
spreading in the body of stomach.
The blood supply of stomach
The arteriesThe stomach has a very rich
blood supply from the various arteries (Fig.
27.3).
a. The left gastric artery from coeliac axis
artery runs along the lesser curvature.
b. The right gastric artery from common
hepatic artery runs along the lower part
of lesser curvature.
c. The short gastric arteries (5-7) from
splenic artery, supply the region of
fundus.
d. The left gastro-epiploic artery from
splenic artery and right gastro-epiploic
artery from gastro-duodenal artery
anastomose along the greater curvature.
The arteries have a rich anastomosis in
the coasts of stomach. In operations on
stomach, one or more of these arteries
can be ligated.
The veins
The veins of the stomach, accompany the
arteries and end in portal vein or its main
tributariesthe splenic vein and superior
mesenteric vein.
The lymphatic drainage of stomach (Fig. 27.4)
The lymphatics generally follow the blood
vessels of the stomach.
The lymphatic areas are divided by an
imaginary plane, passing parallel to the
greater curvature, separating right two-third
area from left one-third area.
i. The left one-third area is further divided
into upper third and lower two third.
The left third of the left lymphatic
area drains into pancreatico-splenic
lymph nodes.
The lower two third of the left
lymphatic area drains into inferior
gastric group and subpyloric nodes.
ii. The right two third lymphatic area drains
into superior gastric nodes, present in
the lesser omentum.
Fig. 27.3: The arterial supply of stomach
tahir99 - UnitedVRG
275
Fig. 27.4: The lymphatic drainage of the stomach
The nerve supply of stomach.

The sympathetic nerves are derived from the
coeliac plexus and accompany branches of the
coliac axis artery supplying stomach.
The parasympathetic nerves are derived from
both vagus nerves, via the anterior and posterior
gastric nerves.
a. The anterior gastric nerve carries the fibers
of left vagus nerve mainly.
b. The posterior gastric nerve carries the fibers
of right vagus nerve mainly.
The sympathetic supply is vasomotor to the blood
vessels of the stomach. It also carries afferent
pain fibers from the stomach.
The parasympathetic supply is secretory to the
glands and motor to the musculature of stomach.
Applied anatomy
1. Gastritis results from overactivity of the
parasympathetic leading to excess secretion
of juices and hydrochloric acid that irritate
the gastric mucosa.
Chronic gastritis may lead to the formation of peptic ulcer.
2. The peptic ulcer usually occurs at the nonacid secreting parts of the stomach and
duodenum.
The peptic ulcer produces pain, referred

to the epigastric region.
Other complications may be severe
bleeding and perforationan acute
surgical emergency.
The peptic ulcer is treated by
a. Vagotomy or section of the gastric
nerves to reduce acid secretion.
b. Gastrectomy surgical resection of
about one-third of distal part of stomach.
3. Gastroscopy is done by a special endoscopic
instrument, for direct visualization of the
gastric mucosa.
THE DUODENUM
The duodenum is the first, shortest and most fixed
part of small intestine.
Length25.0 cm (10.0 inches)
LocationThe duodenum forms a constant
C-shaped curvature behind peritoneum in upper
part of umbilical region (Fig. 27.5).
Extent
The duodenum begins at pyloric opening
1.2 cm to the right on transpyloric plane.
276
Fig. 27.5: The duodenum (position and parts)
The duodenum ends at duodeno-jejunal

junction (D-J junction) located on left side
of second lumbar vertebra.
PartsThe duodenum is divided into four parts:
a. The first part (Superior part) is only 5.0
cm long (Fig. 27.6).
i. The proximal 2.5 cm acts as a mooring
rope for the pyloric part of stomach.
It has lesser omentum attached to
its upper border and anterior two
layers of greater omentum attached
to its lower border.
ii. The distal 2.5 cm is retro-peritoneal.
It is related anteriorly to neck of gall
bladder and quaderate lobe of liver.
It is related posteriorly to
Bileduct
Gastro-duodenal artery
Portal vein
b. The second part (Descending part) is
7.5 cm long and is retro-peritoneal.
It is related
Anteriorly to
Right lobe of liver
Beginning of tranverse colon (no
peritoneum)
Coils of jejunum
Posteriorly to
Medial border of right kidney
Fig. 27.6: The duodenum (first part)
tahir99 - UnitedVRG

Right renal vessels
Right edge of inferior vena cava
The second part receives the opening
of hepato-pancreatic ampulla on summit
of major duodenal papilla, about middle
of its postero-medial wall.
c. The third part (Horizontal part) is about 10.0
cm long and is also retro-peritoneal (Fig.
27.7).
The third part crosses the front of third
lumbar vertebra from right to the left of
median plane.
It is related
Anteriorly to coils of jejunum, except
near its left end where the root of
mesentery and the superior mesenteric vessels cross it.
Posteriorly to
Right psoas major
Right ureter
Inferior vena cava
Right testicular (ovarian) vessels
Abdominal aorta
Origin of inferior mesenteric artery
d. The fourth part (Ascending part) is the
shortest part and is only about 2.5 cm long.
277
The fourth part ascends to the left side

of abdominal aorta and second lumbar
vertebra upto duodeno-jeunal flexure.
It is related
Anteriorly to
The left layer of mesentery
Transverse mesocolon and transverse colon.
Posteriorly to
Left psoas major
Left testicular (ovarian) vessels
Inferior mesenteric vein
Left sympathetic chain
A fibro-muscular bandsuspensory ligament
of Treitzis present sometimes, connecting the
fourth part of duodenum to the right crus of
diaphragm. Its upper part has striated muscle
fibers and lower part has smooth muscle fibers.
The blood supply of duodenum
The arteries supplying duodenum are branches
of coeliac axis artery and superior mesenteric
arteries (Fig. 27.8).
i. The superior pencreatico-duodenal is a
branch of gastroduodenal artery (from
common hepatic artery).
Fig. 27.7: The duodenumrelations
278
Fig. 27.8: The arterial supply of duodenum and pancreas
ii. The inferior pancreatico-duodenal artery is

a branch of superior mesenteric artery.
iii. The supra-duodenal artery (of Wilkie) is a
branch of common hepatic artery.
This artery supplies first part of
duodenum. It is present in about 30%
cases and is supposed to be an end
artery. A thrombosis or blockage of this
artery is said to be one of the causative
factors of duodenal ulcer.
The veins
The veins of the duodenum accompany the
artery, except supra-duodenal artery.
The veins end in portal vein and superior

mesenteric vein (Fig.27.9)
The lymphatic drainage
The lymphatics of duodenum end in subpyloric nodes, situated between the head of
pancreas and duodenum.
Some lymphatics end in superior mesenteric
lymph nodes.
The nerve supply of duodenum
The sympathetic supply of duodenum is
provided by the coeliac plexus.
The parasympathetic supply is by the vagus
nerves and reaches via coeliac plexus.
Fig. 27.9: The venous drainage of duodenum and pancreas
tahir99 - UnitedVRG

THE LIVER (HEPAR)
The liver is the largest gland in the body.
Location
The liver occupies
Right hypochondrium
Upper part of epigastrium
Extends up to left hypochondrium
Shape Wedge shaped somewhat
Weight
1400-1800 gm in males
1200-1400 gm in females
Color reddish brown in fresh state
Consistency pliable and easily lacerated
Surfaces and borders The liver has five surfacesanterior, posterior, right lateral, superior
and inferior (visceral).
i. The anterior surface is convex and is related
to the diaphragm and anterior abdominal
wall.
It has attachment of two layers of
falciform ligament (Fig. 27.10).
ii. The posterior surface is short and has the
following features (Fig. 27.11).
Bare area of liver enclosed by two layers
of coronary ligament and right triangular
ligament.
Groove for inferior vena cava with two
or three large openings for hepatic veins.
279
Caudate lobe
Fissure for ligamentum venosuma
deep fissurethat gives attachment to
two layers of lesser omentum.
Groove for esophagus is located just to
the left of upper end of fissure for
ligamentum venosum.
Left triangular ligament that connects the
left lobe of liver to the diaphragm.
iii. The right lateral surface is covered by
peritoneum and is gently convex.
It is related to right dome of diaphragm
that separates it from right lung, right
costo-diaphragmatic recess of pleura
and seventh to eleventh ribs.
iv. The superior surface is closely related to
the inferior surface of diaphragm.
It is convex on both sides, but shows in
the middle a depressioncardiac impression.
It is covered by peritoneum except
a small triangular area where the
two layers of falciform ligament
diverge.
v. The inferior (visceral) surface faces downwards and backwards. It is covered by
peritoneum except at porta hepatis, gall
Fig. 27.10: The liveranterior surface
280
Fig. 27.11: The liverposterior surface
bladder fossa and fissure for ligamentum

teres.
The inferior surface presents following
impressions (better seen in the hardened
specimen) for the organs (Fig. 27.12)
a. The gastric impression is present on
left lobe; the pyloric portion in the
quadrate lobe.
b. The duodenal impression is located
on the right lobe just to the right of
gall bladder fossa.
c. The colic impression for right colic

flexure and beginning of transverse
colon is present on right lobe and
anterior part of quadrate lobe.
d. The renal impression is prominently
present on the right lobe behind colic
impression. It is related to upper part
of right kidney.
e. The suprarenal impression is located
above renal impression. It lies partly
in the bare area.
Fig. 27.12: The liverinferior surface
tahir99 - UnitedVRG
The gall bladder fossa lies on right side

of quadrate lobe. The body and neck of
the gall bladder lie here in direct relation
to the liver.
The porta hepatis is a wide gap in posterior part of inferior surface. It transmits.
Two hepatic ducts right and left
anteriorly
Two branches of hepatic artery in
the middle
Two branches of portal vein posteriorly
Sympathetic nerves and lymphatics
The caudate process is a narrow bridge
of liver tissue that connects the caudate
lobe with remaining part of right lobe.
The fissure for ligamentum teres is a deep
fissure on left boundary of quadrate
lobe.
The quadrate lobe is a quadrangular part
of liver between inferior border and
porta hepatis. It has fissure for ligamentum teres on left side and gall bladder
fossa in right side.
The liver has only one sharp inferior
border, that separates the anterior and
right lateral surface from the inferior
surface.
The lobes of the liver
The liver is divided into two lobesright and
left by:
Attachment of falciform ligament
Fissure for ligamentum venosum
Fissure for ligamentum teres
The right lobe has two smaller lobes
i. The caudate lobe on posterior surface
ii. The quadrate lobe on inferior surface
Functionally the caudate and quadrate
lobes belong to the left lobe; as their
blood supply (portal vein and hepatic
artery) is from the left branches of these
281
vessels. Their bile drainage is also in the

left hepatic duct.
Thus the dividing line between the
functional (physiological) right and
left lobes passes from gall bladder
fossa and groove for inferior vena
cava on inferior and posterior surfaces.
The segmentation of liver (Fig. 27.13)
The liver is divided into segments, depending
upon the principal branches of hepatic artery
and accompanying hepatic ducts.
Although, the segments are regarded as
functionally independent with least intrahepatic
arterial anastomoses, there are exceptions to
this. However, before segmental resection of
liver, portal venography and cholangiography
is needed to find out individual variations.
The peritoneal attachments
a. The falciform ligament extends from the
anterior abdominal and diaphragm to the
liver.
It is a sickle-shaped fold, and contains
the ligamentum teres (remnant of left
umbilical vein) in its free border.
b. The coronary ligament has two layers
superior and inferior. It connects posterior
surface of liver to the diaphragm and
encloses the bare area of liver.
c. The right triangular ligament is formed by
the meeting of two layers of coronary
Fig. 27.13: The segmentation of liver
282
ligament. It forms the apex of the bare area

and connects the right lobe to diaphragm.
d. The left triangular ligament is a small fold
that connects the left lobe of liver to the
diaphragm.
e. The lesser omentum connects the liver to
the lesser curvature of stomach and first
2.5 cm of duodenum.
The bare areas of the liver
The bare areas are parts of liver surface
that are not covered by visceral layer of
peritoneum.
The main bare areas are:
a. The bare area proper is a large triangular
area on posterior surface between two
layers of the coronary ligament.
b. The groove for inferior vena cava is a
wide shallow groove on posterior
surface that lodges the highest part of
inferior vena cava.
c. The gall bladder fossa is a shallow
depression on inferior surface that lies
in direct contact with body and neck of
gall bladder.
In bare area proper, the liver lies
directly in relation to diaphragm, so
any hepatic abscess or cyst can
burst through diaphragm into the
pleural cavity or any pulmonary
abscess can burst through diaphragm into liver.
The blood supply of liver
The afferent supply
The liver has two sources of blood supply.
a. The arterial blood is brought by the
hepatic artery. It supplies nearly 20% of
the total blood to the liver.
b. The portal blood carrying absorbed
nutrients from the intestines is brought
by the portal vein.
The portal vein supplies nearly 80%
of the total blood to the liver.
The right and left branches of hepatic

artery and portal vein supply the right
and left physiological lobes of the
liver.
The veins
The hepatic veins (2-3) collect venous blood
from the central veins of the hepatic lobules.
The hepatic veins pierce the inferior vena caval
groove and open directly in inferior vena cava.
The lymphatic drainage of liver
The superficial lymphatics end in the lymph
nodes around terminal part of inferior vena
cava. Some open directly into thoracic duct.
The deep lymphatics are divided into two
groups.
Ascending trunks end in the lymph nodes
around inferior vena cava.
Descending trunks end in hepatic lymph
nodes.
The nerve supply of the liver
The nerve supply of liver is via the hepatic
plexus of nerves accompanying hepatic
artery, from the coeliac plexus.
The hepatic plexus carries both sympathetic
and parasympathetic fibers.
Applied anatomy
i. Hepatitis or inflammation of liver can occur
due to viral infection.
This condition can lead to jaundice due
to liver damage.
ii. Cancer of liverThe liver is a common site
for metastasis (or secondary deposit) of
cancer of some parts of digestive tract.
Primary carcinoma of liver is a rare
condition.
iii. Abscess of liver may occur due to amoebic
infection. The abscess can burst through
bare area of liver into lung.
iv. Regenerationthe liver has great power of
regeneration. After injury or operation a
portion of liver can be removed without
much damage to its functions.
tahir99 - UnitedVRG

THE EXTRA-HEPATIC BILIARY
APPARATUS (Fig. 27.14)
The extrahepatic biliary apparatus consists of
The right and left hepatic ducts
The common hepatic duct
The gall bladder and cystic duct
The common bile duct
i. The hepatic ducts The bile ductules of the
two functional lobes join to form the right and left
hepatic ducts.
The two hepatic ducts come out of porta hepatis
and join at the right end of porta to form
common hepatic ducts.
ii. The common hepatic duct formed by the two
hepatic ducts is about 3.0 cm long.
It lies in the free border of lesser omentum in
front of portal vein and to the right of hepatic
artery.
iii. The gall bladder is the fibro-muscular sac
that stores the bile.
LocationThe gall bladder lies in the gall
bladder fossa on interior surface or right lobe
of liver.
The fundus part projects below the inferior
border of liver and lies against tip of ninth
right costal cartilage.
Fig. 27.14: The extra-hepatic biliary apparatus
283
PartsThe gall bladder has three parts.

a. The fundus is the convex bulging part
covered by peritoneum all around.
b. The body and neck are covered with
peritoneum only on sides and inferior surface.
Superiorly the body and neck lie in direct
relation to liver surface in gall bladder
fossa.
From the right border of neck, a pendulous pouchHartmanns pouchis
seen (mostly present in diseased gall
bladder).
In the interior of neck and cystic duct,
a spiral folding of mucous membrane is
present. It is called Spiral valve of Heister. It is not a valve, rather an ingenious
device that keeps the cystic duct and
neck patent all the time.
Functions of gall bladder
i. The gall bladder stores bile for a short
period.
ii. It also absorbs water and electrolytes and
concentrates the bile.
Capacity 30-50 ml. (1 oz).
The blood supply
The artery supplying gall bladder is
cystic artery, from right hepatic
artery.
The origin and length of cystic artery,
is variable.
The vein draining gall bladder
cystic veinends in right branch of
portal vein.
iii. The cystic duct is about 3.0 cm long and
connects the neck of gall bladder to the
common hepatic duct to form the common
bile duct.
The length and course of cystic duct
may vary
284
iv. The common bile duct is formed by the union

of cystic duct with common hepatic duct.
Length is about 8.0 to 10.0 cm.
CourseThe bile duct descends in the
free border of lesser omentum in front
of portal vein and to the right of hepatic
artery (supra-duodenal part)
It then passes deep to the first part
of duodenum (retro-duodenal part).
The bile duct descends in a groove
on posterior surface of head of
pancreas and (infra-duodenal part).
It turns laterally for termination.
Termination of bile duct The common
bile duct joins with the main pancreatic
duct to form the common hepatopancreatic ampulla (Ampulla of Vater).
The ampulla pierces the duodenal wall
very obliquely and opens on the summit
of major duodenal papilla located about
middle of postero-medial wall of duodenum.
Sometimes the two ducts may not join
to form a common ampulla, and open
separately in the duodenum.
A thickening of circular muscle coat of
duodenum surrounds the common
ampulla and form the Sphincter of Oddi.
A similar sphincter also encircles the
terminal parts of the bile duct and main
pancreatic duct.
The variations in the biliary passages are quite
common. Some important ones are as follows:
i. Anomalies of gall bladder
Congenital absence
Double gall bladder
Septate gall bladder
Sessile gall bladder
Solid gall bladder
ii. Anomalies of cystic duct
Congenital absence
Very short
Very long
iii. Anomalies of hepatic ducts

Accessory hepatic duct.
Applied anatomy
i. Cholecystitis is inflammation of gall bladder.
The condition may give rise to biliary
colic, that is referred to T5 to T8 dermatome.
The condition is common in fat females
above the age of forty and may become
chronic.
Gallstones (cholesterol stones), usually
multiple, may develop in cases of chronic
cholecystitis.
Small stones may pass through bile duct,
but the bigger stones may get impacted
in the bile duct or hepato-pancreatic
ampulla giving rise to the obstructive
type of jaundice.
ii. Cholecystogram is special X-ray procedure
to visualize the healthy gall bladder.
A radiopaque dye is given, which is
excreted by the liver in the bile.
The bile is concentrated in gall bladder
and a shadow of dye in gall bladder is
seen.
Since a diseased gall bladder cannot
concentrate bile, it is not visualized.
THE PANCREAS
The pancreas is lobulated greyish pink gland that
lies in the curvature of duodenum.
Type
The pancreas is mixed gland. It has
a. An exocrine part that secretes pancreatic
juice.
b. An endocrine part that secretes insulin
and other hormones.
LocationThe pancreas lies behind peritoneum
in upper part of posterior abdominal wall, at
back of epigastrium and left hypochondriac
region.
PartsThe pancreas hasa head, neck, body
and tail (Fig. 27.15).
tahir99 - UnitedVRG
Fig. 27.15: The parts of the pancreas
i. The head is located within the curvature of

duodenum.
From its lower left portion, a hook-like
uncinate process projects behind superior
mesenteric vessels.
a. Anterior surface in upper part is
related to transverse colon, the lower
part is covered with peritoneum and
related to coils of jejunum.
The uncinate process is related
anteriorly to superior mesenteric
vessels.
b. Posterior surface is related to
Inferior vena cava
Right renal vessels
Right crus of diaphragm
Bile duct (lies in a groove on
posterior surface)
Abdominal aorta (behind uncinate
process)
ii. The neck is about 2.0 cm long
On right side is groove for gastroduodenal artery.
On left side and behind is beginning of
portal vein by union of superior mesenteric and splenic veins.
Its anterior surface is related to omental
bursa separating it from first part of
duodenum.
285
iii. The body is the elongated tapering portion

that lies obliquely across the posterior
abdominal wall behind peritoneum.
The body is triangular in section having
three surfacesanterior, inferior, and
posterior.
a. The anterior surface is related to the
lesser sac of peritoneum and forms
a part of stomach bed (i.e. related
to posterior-inferior surface of stomach).
b. The inferior surface covered by
peritoneum of lower layer of transverse mesocolon and is related to
Duodeno-jejunal flexure
Coils of jejunum
Left colic flexure
c. The posterior surface is devoid of
peritoneum and is related to the
structures in upper part of posterior
abdominal wall:
Aorta and origin of superior
mesenteric artery
Left crus of diaphragm
Part of left kidney and left suprarenal
Left renal vessels
Splenic vein (lies closely attached
to the posterior surface)
The anterior border of the body of pancreas
gives attachment ot transverse mesocolon.
iv. The tall is the narrow end of the body that
lies between the two layers of lieno-renal
ligament along with splenic vessels.
The tail of pancreas reaches the lateral
end of hilum of spleen.
The tail contains maximum concentration of islets of Langerhans.
In operation of splenectomy care is
taken to preserve the tail of pancreas
while ligating the splenic vessels.
286
The Pancreatic Ducts

a. The main pancreatic duct (Wirsungs duct)
courses through the pancreas from left to
the right.
It lies nearer posterior surface and
receives small ducts at right angles
(Herring bone pattern).
The main duct joins with the common
bile duct to form the hepato-pancreatic
ampulla.
b. The accessory pancreatic duct (Santorinis
duct) remains in the head of pancreas only.
The duct may end blindly, or may open,
in the duodenum separately at minor
duodenal papilla, situated proximal to the
major duodenal papilla.
The blood supply
The arteries
i. The superior pancreatico-duodenal
arterya branch of gastroduodenal
artery.
ii. The inferior pancreatico-duodenal
arterya branch of superior mesenteric
artery.
These two arteries divided into two
branchesanterior and posteriorthat
run between concavity of duodenum and
head of pancreas, anastomosing with
each other.
iii. The pancreatic branches of splenic artery
supply the body of pancreas. One large
arteria pancreatica magna is given near
the tail.
The veins The veins of pancreas drain into
portal vein, superior mesenteric vein and the
splenic vein.
The lymphatic drainage of pancreas.
The lymphatics from the pancreas drain
mainly in the pancreatico-splenic nodes.
Some lymphatics from head of pancreas
end in superior mesenteric and pyloric
nodes.
The nerve supply of pancreas

The sympathetic and parasympathetic
nerves come from the coeliac plexus. They
reach the pancreas along the blood vessels.
The sympathetic supply is mainly vasomotor.
Applied anatomy
i. Acute pancreatitis The blockage of
hepato-pancreatic ampulla by a small
biliary stone or contraction of sphincter
of Oddi, leads to reflux flow of bile into
the main duct.
This leads to chemical autolysis of
pancreatic acini causing this condition.
Acute pancreatitis is a very serious
and painful condition.
ii. Cancer of head of pancreas is also a
common type of abdominal cancer.
The cancer may cause jaundice due
to involvement of bile duct.
It may also cause portal hypertension and the resultant complication like esophageal varices.
iii. Annular pancreas is a congenital defect,
where the second part of duodenum is
surrounded by the head of pancreas.
The condition causes narrowing and
obstruction of the lumen of duodenum.
iv. Ectopic pancreatic tissue may be found
in gall bladder and Meckels diverticulum.
THE SPLEEN (LIEN)
The spleen is the largest lymphoid organ in the body.
Location The spleen is located in the left
hypochondrium along the long axis of tenth rib
(Fig. 27.16).
Size and weight of the spleen varies according
to age and different conditions of nutrition.
In adult male it weighs about 150 gm
tahir99 - UnitedVRG
Fig. 27.16: The location of spleen
The size is nearly 12.0 cm long 7.0 cm

wide 4.0 cm thick.
Ends, surfaces and borders
The spleen has two endsanterior and posterior.
i. The anterior (Lateral) end is expanded and
related to left colic flexure and phrenicocolic ligament.
ii. The posterior (Medial) end is pointed and
lies about 3-4 cm from the mid-dorsal line.
The spleen has two surfacesdiaphragmatic
surface and visceral
i. The diaphragmatic surface is gently convex
and is separated from diaphragm by a part
of greater sac (Fig. 27.17).
Fig. 27.17: The spleenrelations
287
The diaphragm separates it from the left

pleura and lower margin left lung.
ii. The visceral surface is related to upper
abdominal viscera and has four impressions
(seen better in hardened specimen) (Fig.
27.18).
a. The gastric impression is the broadest
and related to upper part of greater
curvature of stomach.
The lower part of this impression has
hilum through which splenic vessels,
sympathetic nerves and lymphatics
enter the spleen.
b. The renal impression is located in the
lower part of visceral surface.
It is related to upper and lateral part
of anterior surface of left kidney.
c. The colic impression lies near the lateral
end and is related to the left colic flexure
and phrenico-colic ligament.
d. The pancreatic impression is located near
the lateral end hilum of spleen.
The spleen has two borderssuperior and
inferior.
i. The superior border separates the diaphragmatic surface from the gastric impression.
Fig. 27.18: The Spleenvisceral surface
288
It has two or three notches near the lateral

end indicating the lobulated origin of spleen.
ii. The inferior border separates the renal
impression from the diaphragmatic
surface.
The peritoneal relations: The spleen is completely covered by peritoneum except at the
hilum.
The spleen is supported by two peritoneal
folds.
a. The gastro-phrenic ligament connects the
spleen to the greater curvature of stomach.
It contains the short gastric arteries
(5-7) and left gastro-epiploic artery.
b. The lieno-renal ligament connects the
hilum of spleen to the front of left kidney.
It contains the splenic vessels and
the tail of pancreas between the two
layers.
The phrenico-colic ligament (sustentaculum
lienis) connects the left colic flexure to the
diaphragm.
It supports the lateral end of spleen.
The blood supply of the spleen.
The arteries
The spleen is supplied by the splenic
arterya large and tortuous branch of
coeliac axis artery.
The splenic artery divides into five to six
branches before entering the hilum.
The veins
The splenic vein is formed by five or six
large tributaries emerging from the hilum.
The splenic vein joins with superior mesenteric vein to form the portal vein.
The lymphatic drainage
The lymphatics from the capsule end in the

pancreatico-splenic lymph nodes.
There are no lymphatics in the splenic pulp.
The nerve supply
The nerves of the spleen are derived from
the coeliac plexus and reach along the
splenic artery.
The sympathetic nerves are vasomotor in
nature.
The functional significance of spleen
The spleen performs a number of functions.
i. Destruction of red blood cells in adults.
ii. Formation of lymphocytes.
iii. Part of reticulo-endothelial system. It
helps to catch the toxins and other
harmful substances, e.g. enlargement of
spleen in cases of malaria.
iv. Immunological functionsby producing
antibodies.
In fetal life, the spleen, also has hemopoietic
function.
In humans, the spleen does not act as reservoir of blood.
Applied anatomy
i. Enlargement of spleen (splenomegaly)
may occur in number of conditions, e.g.
Parasitic infections like malaria and
kala azar.
Hemopoietic deseases due to increased red blood cell breakdown.
Portal obstruction.
Enlarged spleen becomes very friable
and can be easily lacerated.
ii. Splenectomy is done to remove enlarged
spleen. Spleen is not a vital organ, as its
functions can be taken up by other lymphoid organs.
tahir99 - UnitedVRG
CHAPTER
28
The Gastrointestinal
System2
THE JEJUNUM AND THE ILEUM
The jejunum and ileum constitute the large part of
small intestine extending from duodeno-jejunal
flexure up to junction of cecum and ascending
colon (Fig. 28.1 and Table 28.1)
Length about 6 metres (20 feet)
The jejunum constitutes proximal two-fifth
part (nearly 8 feet)
The ileum constitutes distal three-fifth part
(nearly 12 feet)
The mesentery The jejunum and ileum are
completely covered by peritoneum, and are
suspended by a large peritoneal foldthe
mesenteryfrom the posterior abdominal wall.
The root (attachment) of mesentery is
oblique and extends from duodeno-jejunal
flexure on the left to the ileocecal junction

on the right. The root contains superior
mesenteric vessels between the two layers.
The root of mesentery crosses the following
structures on posterior abdominal wall
Abdominal aorta
Inferior vena cava
Right psoas major
Right ureter
Table 28.1: Differences between jejunum and ileum
1. Position in
abdominal
cavity
2. Diameter
3. Walls
Jejunum
Ileum
Mostly in upper
left portion
Mostly in hypogastroic region above

pubic symphysis
About 3.0 cm
Thinner
About 4.0 cm
Thick
Contd...
Fig. 28.1: The jejunum and ileumblood supply
290
Contd...
4. Color
5. Arterial
arcades
6. Vasa recta
7. Fat in
mesentery
8. Circular folds
9. Peyers
patches
(Aggregated
lymphoid
follicles)
10.Barium meal
X-ray
About 12-15 jejunal and ileal veins end in

the superior mesenteric vein.
Jejunum
Ileum
Deep red due to

more vascularity
Less, about 1-2
Pale pink
Longer, about
2.5 cm long
Less-(windows)
Shorter, about
1.2 cm long
More
Well developed
Few
Incomplete
Many
Shows feathery
appearance and
narrow lumen
Shows dense
appearance
More, about 2-5
The Blood Supply of the

Jejunum and Ileum
The arteries The jejunal and ileal arteries (1215) are branches of superior mesenteric artery.
These arteries reach the small intestine
between the two layers of mesentery
On approaching small intestine, the jejunal
and ileal arteries branch to form arterial
arcades
The arterial arcades are one to two in case
of jejunum and three to five in cases of
ileum. These arcades provide a route of
collateral circulation.
From the terminal arcades, vasa recta
(straight arteries) are given, that supply
alternately the right and left surfaces of the
intestine
The vasa recta are longer (2.5 cm) in
jejunum and shorter (1.2 cm) in case of
ileum
The vasa recta in the walls of intestine are
end arteries, and they have very few
anastomoses with adjacent arteries.
The veinsThe veins follow the pattern of
arterial supply

Jejunum and Ileum
There are nearly 100-150 lymph nodes in the
mesentery of small intestine.
The lymph from the jejunum and ileum is drained
by three sets of lymph nodes.
i. The distal set is present in relation to the
terminal branches of jejunal and ileal arteries
ii. The intermediate set is located among the
jejunal and ileal arteries
iii. The proximal set is present in relation to
superior mesenteric vessels.
The mesenteric lymph nodes are enlarged in
several conditions like tuberculosis, typhoid
fever and malignant tumors.
The lymphatics of jejunum and ileum mainly
transport the absorbed fat (as chyle) to the
thoracic duct)
The Nerve Supply of Jejunum and Ileum
The sympathetic and parasympathetic nerves are
derived from the coeliac plexus and the vagus
nerves respectively.
There are two nerve plexuses in the coats of
small intestine
a. The mysenteric plexus is located between
the circular and longitudinal muscle coats
b. The submucous plexus is located in the
submucous coat
Both plexuses have the nerve fibers and ganglia
where the parasympathetic fibers are relayed.
Applied Anatomy
I. The Meckels diverticulum is a blind diverticulum
from antemesenteric border of ileum about two
feet from ileocecal junction.
It is a remnant of vitello intestinal duct (detailed
description given in Chapter 26)
tahir99 - UnitedVRG

II. The small intestine can be resected up to
one third of its total length without seriously
impairing its junction.
III. Gastro-jejunostomy is one of the operations
done in cases of peptic ulcer.
The stomach is anastomosed with jejunum
bypassing duodenum.
THE LARGE INTESTINE
The large intestine begins in right iliac fossa at
cecum, where terminal ileum ends.
The parts of the large intestine are
The cecum
The vermiform appendix
The colonascending, transverse, descending and sigmoid (pelvic)
The rectum
The anal canal
The main function of the large intestine (chiefly
colon) is absorption of fluids and solutes
The features of the large intestine are
a. It has greater caliber in most parts than small
intestine and it has greater distensibility.
b. Most parts of large intestine are fixed or
retro-peritoneal.
c. The longitudinal muscle coat (except rectum
and anal canal) is incomplete. It is concentrated in form of three taenia coli.
d. The large intestine shows sacculations.
e. It has small pouches of peritoneum filled
with fat (appendices epiploiceae) attached
to the surface (exception rectum and anal
canal).
The length of the large intestine is nearly 1.5
metres (6 feet).
Size: The cecum is about 6.0 cm long and

7.5 cm broad.
Shape: Four types of cecum are described by
Treeves, so far as the shape is concerned (Fig.
28.2).
i. The first type (Infantile type) is seen in about
2 percent cases.
In this type cecum is represented as a
conical sac with appendix attached to
its tip
ii. The second type (Quadrate type) is seen in
about 3 percent cases.
In this type, there are two equal sacculationsright and leftand appendix is
attached to the depression between the
two saccules
iii. The third type (Normal type) is seen in about
90 percent cases.
In this type, the right saccule is larger
and left saccule is smaller. The appendix
is pushed toward the ileocecal junction
medially.
iv. The fourth type (Exaggerated type) is seen
in nearly 4 percent cases.
Cecum
The cecum is the enlarged sac, that forms the first
part of large intestine.
Location: The cecum lies in the right iliac fossa
below the trans-tubercular plane.
291
Fig. 28.2: The four types of caecum
292
In this type the right saccule is much

larger, and left saccule is nearly atrophic.
The appendix is attached just close to
the ileocecal junction.
Relations
The cecum is a retroperitoneal organ,
covered by peritoneum on front and sides.
Anteriorly it is related to coils of terminal
ileum separating it from anterior abdominal
wall.
Posteriorly it is related to
Iliacus and lateral border of psoas major
muscle.
Femoral nerve and lateral femoral
cutaneous nerve of thigh.
A retro-cecal recess is present frequently and it contains vermiform
appendix.
Interior of cecum: The interior of cecum shows
two openings
i. The ileocecal opening is situated on the
postero-medial wall at junction of cecum
and ascending colon (Fig. 28.3).
The opening is elliptical in shape and
guarded by an ileo-cecal valve
The ileo-cecal valve is formed by
thickening of the circular muscle coat
of terminal ileum.
It prevents regurgitation of contents of
cecum into terminal ileum.
Fig. 28.3: The interior of cecum
ii. The appendicular opening is small, oval

opening situated about 2.0 cm below the
ileocecal opening.
There is, sometimes, a semilunar fold
of mucous membrane forming an
incomplete valve at the opening.
The Blood supply of cecum
The arteries The cecum is supplied by the
anterior and posterior cecal branches of
ileocolic artery.
The veins of the cecum end in the ileocolic
vein, that joins the superior mesenteric vein.
The lymphatic drainage of cecum: The
lymphatics of the cecum end in the ileocolic
lymph nodes (15-20) situated along the ileocolic
vessels.
The ileocolic nodes include anterior cecal
nodes and posterior cecal nodes
An appendicular node is present in mesoappendix
The nerve supply of cecum: The nerve supply
is both by sympathetic and para sympathetic.
The sympathetic nerves are branches of the
coeliac plexus
The parasympathetic nerves are derived
from the vagus nerves.
THE VERMIFORM APPENDIX

The vermiform appendix is a narrow tubular
structure attached to the postero-medial wall of
cecum, about 2.0 cm below the terminal ileum.
Location: The appendix lies in the right iliac
fossa along with cecum
Length varies from 2.0 to 20.0 cm (average is
9.0 cm)
PositionsSince the appendix has a mesentery,
it can change its position (Fig. 28.4)
The various positions are
a. The retrocecal (Retrocolic) position
where the appendix is present in retrocecal recess behind cecum (or ascending colon if it is long enough)
tahir99 - UnitedVRG
Fig. 28.4: The positions of appendix
b. The pelvic position where the appendix

points towards the pelvic brim.
c. The subcecal position where the
appendix lies below cecum.
d. The splenic position where the appendix
lies in relation to terminal ileum
This position may be present either
in front of ileum (pre-ileal) or behind
ileum (post-ileal)
The position is important as in case
of inflammation of appendix, the
terminal ileum is also involved easily,
leading to intestinal obstruction.
e. The mid-inguinal position where
appendix points below towards the midinguinal point
The mesoappendix The appendix has a small
triangular mesentery, that is attached to back
of mesentery proper of small intestine.
The appendix lies in the lower border of the
mesentery, that usually does not reach up
to the tip of appendix
The meso-appendix makes the appendix
mobile.
The Blood Supply of the Appendix
The arteryThe appendix is supplied by the

appendicular artery, a branch of ileocolic artery.
The appendicular artery passes behind
terminal ileum and lies in the free border of
the mesentery
293
The terminal part of the artery lies directly

on the wall of the appendix
The appendicular artery anastomoses with
the posterior cecal artery, and this anastomosis, at times, may be very large.
The veinThe appendicular vein joins the
ileocolic vein
The lymphatic drainage of appendix: A number
of lymphatics (10-15) ascend in the mesoappendix and end ina few appendicular lymph
nodesand superior and inferior ileocolic
nodes.
Lymphatics from the root of appendix, run
along the lymphatics of cecum and end in
ileocolic nodes.
The nerve supply is both by sympathetic and
parasympathetic
The sympathetic nerves are branches of the
coeliac pelvis
The parasympathetic nerves are derived
from the vagus nerves
The nerve supply reaches along with the
blood vessels
The canal of appendix is narrow and opens
into the cecum by a small appendicular opening
The canal of appendix may be partially or
totally blocked.
Functional significanceThe vermiform
appendix is a highly specialized vestigeal organ
in humans.
This is proved by large amount of lymphoid
tissue in its walls and a separate blood supply
by appendicular artery.
Applied Anatomy
Appendicitis is the inflammation of appendix.

The inflammation spreads rapidly and
affects the blood supply
The appendicitis is an acute surgical emergency and requires immediate surgery
The appendicular pain is felt in the right iliac
fossa due to involvement of peritoneum
294
McBurneys point is the junction of medial

two-third and lateral one-third of a line
connecting umbilicus to the anterior superior
iliac spine
The point marks the base of appendix and
also the site for incision for the operation of
appendicectomy.
Colon
The colon is divided into four parts: ascending,
transverse, descending and sigmoid (pelvic).
A. The ascending colon is the first part of colon.
LocationThe ascending colon ascends in the
right lumbar region from the trans-tubercular
plane to midway between subcostal and
transpyloric planes.
Length is about 15-20 cm
The ascending mesocolon is lost during
development, so the ascending colon is a
retroperitoneal structure, covered on front
and sides by peritoneum
Relations
Anteriorcoils of ileum and greater
omentum separate it from anterior abdominal
wall.
Posteriorly the acending colon is connected
by areolar tissue to:
The iliac fascia covering iliacus muscle
Iliolumbar ligament
Quadratus lumborum
Aponeurotic origin of transversus abdominis
Renal fat and fascia in front of right
kidney
Laterally it is related to right paracolic gutter
The right colic flexure is the terminal part of
ascending colon bending at nearly right angles
to continue as the beginning to transverse colon
RelationsAnteriorly Right lobe of liver
Fundus of gall bladder
Posteriorly Front of right kidney surrounded
by renal fat and fascia.
B. The transverse colon is the second part of

colon.
The transverse colon begins at the right colic
flexure in front of right kidney
It ends at the left colic flexure near lateral end
of spleen
Length is about 45-50 cm
LocationThe transverse colon extends from
the right lumbar region, and crosses upper part
of umbilical region and ends in left hypochondriac region, making a U-shaped curve.
The position also depends upon the degree
of distention of transverse colon and stomach
The transverse colon is suspended by a
peritoneal foldtransverse mesocolon from
the posterior abdominal wall
The transverse mesocolon is fused in adults
with posterior layers of greater omentum.
Relations
SuperiorlyLiver and gall bladder
Greater curvature of stomach
Lateral end of spleen
InferiorlyCoils of small intestine
AnteriorlyGreater omentum
The left colic flexure is the terminal part of
transverse colon, joining at an acute angle with
the beginning of descending colon.
Relation
SuperiorlyLateral end of spleen
Tail of pancreas
MediallyLeft kidney
The left colic flexure is higher and lies on a
more posterior plane than the right colic
flexure.
C. The descending colon is the third part of the
colon.
The descending colon begins at the left colic
flexure and ends at the pelvic inlet where it is
continuous with the sigmoid (pelvic) colon
LocationLeft hypo-chondrium and left
lumbar region.
tahir99 - UnitedVRG
Length 25.0 cm.

The descending colon has lost its mesentery
the descending mesocolonin course of
development, so this part of colon becomes
retroperitoneal, covered with peritoneum on
front and sides only
Relations
AnteriorlyCoils of small intestine and
greater omentum, separating it term the
anterior abdominal wall
Posteriorly descending colon is separated
by connective tissue from
Antero-lateral part of left kidney
Quadratus lumborum
Iliac fascia covering iliacus and psoas
major
Laterally it is related to the left paracolic
gutter
D. The sigmoid (pelvic) colon is the fourth and
last part of the colon
The sigmoid colon begins at the pelvic inlet
where the descending colon ends. It ends on
front of third piece of sacrum, where rectum
begins.
LocationLeft iliac fossa and upper part of
pelvic cavity.
The position depends upon its state of
distension, and length and mobility of
sigmoid mesocolon.
LengthAbout 40 cm
The sigmoid mesocolon is a peritoneal fold that
suspends the sigmoid colon from the pelvic inlet
and front of upper part of sacrum
The sigmoid colon depicts an S-shaped curvature
The loop first reaches the left pelvic wall then
crosses the pelvic cavity between rectum and
urinary bladder in males and between rectum
and uterus in females
Finally, the loop of sigmoid colon turns backward, to reach front of sacrum in midline to
terminate in rectum.
295
The Blood Supply of the Colon
The arteries The colon is supplied by the colic

branches of superior mesenteric and inferior
mesenteric arteries.
From the superior mesenteric artery:
Iliocolic artery
Right colic artery
Middle colic artery
From the inferior mesenteric artery:
Superior left colic artery
Sigmoid (lower left colic) arteries (2-5).
These colic arteries on reaching the colon divide
into two branches which anastomose with each
other and form a continuous anastomotic channel
The marginal artery of Drummond
The marginal artery gives long and short colic
branches to supply the coats of parts of colon
The marginal artery may be deficient at junction
of right two-third and left one third of transverse colon (junction between midgut and
hindgut)
At pelvi-rectal junction, the anastomosis
between the last sigmoid artery and superior
rectal artery may be very poor. This region is
called critical point of Sudeck.
The Veins
The colic veins accompany the colic arteries

The colic veins accompanying colic branches
of superior mesenteric artery end in superior
mesenteric vein
The colic veins accompanying colic branches
of inferior mesenteric artery end in inferior
mesenteric vein.
The Lymphatic Drainage of the Colon
The lymphatics from ascending and transverse

colon end in superior mesenteric lymph nodes.
The lymphatics from descending and sigmoid
colon end in small nodes along left colic arteries
and finally drain in preaortic nodes around the
origin of inferior mesenteric artery.
296
The Nerve Supply of the Colon
The ascending colon and right two-third of

transverse colon (midgut) have
The sympathetic supply from coeliac plexus
The parasympathetic supply from the vagus
nerves
The left one-third of transverse colon, descending colon and sigmoid colon (hindgut)
have:
The sympathetic supply from lumbar part
of sympathetic trunks and superior hypogastric plexus
The parasympathetic supply from the pelvic
splanchnic nerves (derived from S2, S3 and
S4 segments of spinal cord)
The sympathetic supply of the colon also
carries the pain afferents. The referred pain
from the colon is felt in the associated skin
dermatomes.
The diverticula usually lie close to the taenia

coli adjacent to the penetrating blood vessels
The diverticulitis is associated with chronic
constipation, leading to increased intra-abdominal pressure.
This condition may lead to perforation, bleeding
inside colon and peritonitis.
II. The Hirschsprungs disease (congenital megacolon) is a condition, where the colon becomes
enormously enlarged.
The condition is caused by the congenital
absence of the myenteric plexus in the terminal
part of sigmoid colon
This leads to interruption of peristaltic movements and junctional blockage of colon
The condition is seen in young children and
leads to chronic constipation
The treatment consists of surgical resection of
the affected part of colon.
Applied Anatomy
THE ARTERIES OF THE GASTROINTESTINAL TRACT
I. The diverticulitis occurs more commonly in the

sigmoid colon and descending colon
The diverticula are small protrusions of the
mucosa of colon through its walls
A. The coeliac axis artery supplies the abdominal

part of foregut and the structures derived from
itthe liver, excretory apparatus of liver, pancreas
and the spleen (Fig. 28.5).
Fig. 28.5: The coeliac axis artery
tahir99 - UnitedVRG
OriginThe coeliac axis artery arises from the

front of abdominal aorta, just below the aortic
opening of diaphragm.
CourseThe artery passes almost horizontally
forwards for 1.2 cm, behind peritoneum and
divides into its three branches that diverge from
it
Relations Anteriorly is omental bursa
Right side is Right coeliac ganglion
Caudate lobe of liver
Left side is Left coeliac ganglion
Cardiac end of stomach
The coeliac artery is surrounded by the coeliac
plexus of nerves
The suspensory muscle of duodenum may
encircle the artery (when present)
Branches
i. The left gastric artery is the smallest branch
It ascends to the left to reach cardiac
end of stomach; then it runs between
the two layers of lesser omentum along
lesser curvature of stomach
It anastomoses with the right gastric
artery
Branches
a. Gastric branches supply both
surface of stomach
b. Esophageal branches (2-3)
supply the abdominal part of
esophagus
ii. The splenic artery is the largest branch of
coeliac artery.
The artery runs tortuously upwards and
to the left behind peritoneum, along
upper border of body of pancreas to
reach the hilum of spleen.
The terminal part of artery along with
splenic vein and tail of pancreas lies
inside lieno-renal ligament
297
The artery divides into five or more

segmental branches, which enter the
hilum of spleen
Branches
a. The pancreatic branches are small
branches that supply the neck, body
and tail of pancreas
One large branch arteria pancreatica magna is given near the
tail and follows a recurrent course
b. The short gastric arteries (5-7) reach
the fundus of stomach, by passing
between two layers of gastro-splenic
ligament
c. The left gastro-epiploic artery
reaches the greater curvature
through the gastro-splenic ligament.
d. The terminal spenic branches (5-6)
enter the hilum of spleen.
iii. The common hepatic artery is intermediate
in size to the other two branches
The artery passes forwards and to the
right behind peritoneum to reach upper
border of first part of duodenum.
It gives a large gastro-duodenal branch
and ascends upwards and to the right
within right border of lesser omentum
in front of portal vein to reach porta
hepatis.
It terminates by dividing into right and
left hepatic branches that enter porta
hepatis.
Branches
a. The right gastric artery runs
upwards along the lesser curvature
of stomach between two layers of
lesser omentum.
It anastomoses with the left
gastric artery.
b. The gastro-duodenal artery is a large
branch given from the common
hepatic artery, just above first part
of duodenum.
298

The artery descends deep to first
part of duodenum in front of

portal vein.
The artery divides into
The right gastro-epiploic
artery that supplies the lower
part of greater curvature and
anstomoses with left gastroepiploic artery.
The superior pancreaticoduodenal that runs between
the head of pancreas and
curvature of duodenum.
It anastomoses with inferior
pancreatico-duodenal branch
of superior mesenteric
artery
c. The supra-duodenal artery (of
Wilkie) is an inconstant branch.
It supplies first part of duodenum.
d. The two terminal hepatic branches
right and leftenter porta hepatis
and supply the two functional lobes

of liver.
e. The cystic artery usually arises from
the right hepatic artery and supplies
the gall bladder.
B. The superior mesenteric artery supplies
structures developed from the mid-gut (i.e. lower
part duodenum, jejunum, ileum, caecum, appendix,
ascending colon and right two-third of transverse
colon) (Fig. 28.6).
OriginThe superior mesenteric artery arises
from the front of abdominal aorta, about
1.0 cm below the coeliac axis (vertebral levellower border of first lumbar vertebra)
At origin the artery is related
AnteriorlyBody of pancreas
Splenic vein
PosteriorlyLeft rectal vein
Front of abdominal aorta
Course
The artery passes downwards and forwards
in front of uncinate process of pancreas and
third part of duodenum
Fig. 28.6: The superior mesenteric artery
tahir99 - UnitedVRG
The artery along with superior mesenteric

vein enters the root of mesentery and passes
downwards and forwards towards the right
iliac fossa, crossing the structures on
posterior abdominal wall
The artery describes a gentle curvature
convex towards the right side
The artery terminates by anastomosing with
ileal branches of iliocolic artery in terminal
coil of ileum.
Branches
i. The inferior pancreatico-duodenal branch
divides into an anterior and a posterior
branch, that anastomose with similar
branches of superior pancreatico-duodenal
artery lying in the curvature of duodenum.
ii. The jejunal and ileal branches (12-15 arise
from the convexity of the artery and pass
downwards between the two layers of
mesentery.
These branches form arterial arcades and
from terminal arcades vasa recta are
given to supply jejunum and ileum.
iii. The iliocolic artery arises from the concavity of the artery
It passes downwards and to the right to
reach ileo-caecal junction
It divides into an ascending branch and
a descending branch, that gives four sets
of branches.
a. Anterior cecal
b. Posterior cecal
c. Appendicular
d. Ileal
iv. The right colic artery may arise in common
with iliocolic artery
The artery passes towards the right colic
flexure and divides into an ascending
branch and a descending branch.
These branches join to form a part of
the marginal artery supplying the
ascending colon, right colic flexure and
transverse colon.
299
v. The middle colic artery arises from the

superior mesentery artery just below the
pancreas
The artery descends between the two
layers of transverse mesocolon and
divides into right and left branches to
supply the right two-third of transverse
colon.
The two branches of the artery contribute to the formation of marginal artery.
The left branch of the artery anastomoses with ascending branch of
superior left colic artery (junction of
midgut and hindgut). This anastomosis
may be absent sometimes.
C. The inferior mesenteric artery supplies the
portions of gastro-intestinal tract derived from the
hindgut (i.e. left third of transverse colon, descending colon, sigmoid colon, rectum and upper
part of anal canal.
OriginThe inferior mesenteric artery arises
from front of abdominal aorta behind the third
part of duodenum (vertebral level 3rd lumbar
vertebra).
The origin is about 4.0 cm above the
bifurcation of abdominal aorta
CourseThe artery descends in front of
abdominal aorta, and then the left psoas major
muscle behind peritoneum (Fig. 28.7).
The artery forms a curvature convex
towards the left side.
The artery crosses the left common iliac
artery medial to left ureter and then crosses
the pelvic inlet.
In the pelvis, the inferior mesenteric artery
descends between the two layers of pelvic
mesocolon as superior rectal artery, that
supplies rectum and upper part of anal canal.
Branches
i. The superior left colic artery ascends
towards the left colic flexure behind peritoneum.
300
Fig. 28.7: The inferior mesenteric artery
It divides into two branches. The ascending branch anastomoses with left
branch of middle colic artery to supply
left one-third of transverse colon.
The descending branch forms a part of
marginal artery
ii. The signoid (inferior left colic) branches
(2-3) divide into ascending and descending
branches and complete the marginal artery.
These arteries supply descending colon
and the lower ones enter between the
two layers of pelvic mesocolon to supply
the sigmoid colon.
iii. The superior rectal artery is the continuation
of inferior mesenteric artery in the pelvis.
This artery has poor anastomosis with
the lowest sigmoid artery.
THE PORTAL VEIN
The portal vein belongs to the hepatic-portal venous
system that drains venous blood from
Abdominal part of gastro-intestinal tract (except
terminal part of anal canal)
The Spleen
The pancreas
The liver
The excretory apparatus of liver (gall bladder
and bile duct).
Features of the Hepatic-Portal System

I. The portal system is a closed venous system,
that collects venous blood via tributaries of portal
vein.
The portal vein divides like an artery inside liver
supplying liver sinusoids.
II. In the portal system, the blood passes
through two system of capillaries.
a. The blood capillaries in the walls of gastrointestinal tract
b. The hepatic sinusoids
III. There are no valves in the veins of the portal
system.
IV. The portal system joins with the systemic
venous system at some well defined sitesthe sites
of porto-systemic anastomosis.
tahir99 - UnitedVRG
BeginningThe portal vein begins behind the

neck of pancreas (vertebral level 2nd lumbar
vertebra) by union of two large veinssplenic
vein and superior mesenteric vein (Fig. 28.8).
Length is 8.0 cm nearly
CourseThe portal vein ascends towards right
side behind the first (superior) part of duodenum in front of inferior vena cava.
The vein enters the right border of lesser
omentum and ascends in front of the
epiploic foramen with bile duct and hepatic
artery in front of it.
Reaching the porta hepatis the portal vein
divides into a right branch and a left branch
that enter porta hepatis to supply the
functional right and left lobes of liver.
Tributaries
A. The direct tributaries
i. The right and left gastric veins
ii. The pancreatico-duodenal veins
iii. The cystic vein ends in the right branch
301
iv. The paraumbilical veins connect the left

branch to the veins of anterior abdominal
wall.
These veins accompany the round
ligament of liver up to the umbilicus.
B. The tributaries of superior mesenteric vein.
i. The jejunal and ileal veins (12-15)
ii. The middle colic vein
iii. The inferior pancreatico-duodenal vein
iv. The right colic vein
v. The iliocolic vein
vi. The right gastro-epiploic vein.
C. The tributaries of the splenic vein
i. The short gastric veins (5-7)
ii. The left gastro epiploic veins
iii. The terminal splenic vein (5-6)
iv. The inferior mesenteric vein, that receive
Superior rectal vein
Superior left colic vein
Sigmoid veins (2-3)
v. The pancreatic veins (including vena
pancreatica magna)
Fig. 28.8: The portal vein
302
Applied Anatomy
The portal obstruction (hypertension)In this

condition the blood of the hepatic-portal system
is not able to flow freely into the systemic
circulation via the hepatic veins
Causes of portal obstruction
i. The common cause is cirrhosis of liver
ii. Compression of portal vein by
A tumor in the nearby organs, e.g. liver
Enlarged lymph nodes along the right
border of lesser omentum
Carcinoma of head of pancreas.
iii. Partial thrombosis of portal vein
In portal obstruction the sites of porto-systemic
anastomosis become enlarged in an attempt to
send the portal blood into the systemic circulation.
These sites are
i. Abdominal part of esophagusWherein the
submucous coat, the tributaries of left
gastric vein join with tributaries of azygos
and hemiazygos veins.
The esophageal varices caused by the
enlargement of this anastomosis may
rupture causing excessive bleeding in
stomach leading to hematemesis.
ii. The umbilicus where paraumbilical veins
from left branch of portal vein join with
veins of anterior abdominal wall
Enlargement of this anastomosis causes
a conditionCaput medusae where
enlarged tortuous veins radiate from
umbilicus like spokes of a wheel
iii. In the submucous coat of the anal canal the

tributaries of superior rectal vein join with
the tributaries of the inferior rectal vein.
Enlargement of the anastomosis causes
the piles (hemorrhoids)
The piles can be internal piles if lined by
mucous membrane only
External piles if lined by the skin
onlyor internor-external piles if
lined both by mucous membrane and
skin
The piles cause lot of bleeding during
defecation.
iv. The retro-peritoneal veins (veins of Retzius).
These veins communicate with the veins of
the retro-peritoneal organs, viz. colon,
duodenum and pancreas.
These veins are very small and are not
important as far as the drainage of portal
blood is concerned.
v. The patent ductus venosus is rarely present.
This anastomatic channel directly connects
the left branch of portal vein with the inferior
vena cava.
The surgical treatment of portal obstruction
consists of making alternate channels or shunts
to push the portal blood into systemic circulation.
a. The porto-caval shunt is made by the sideto-side anastomosis between the portal vein
and inferior vena cava.
b. The splenic-renal shuntAfter splenectomy
the splenic vein is joined with the left renal
vein.
tahir99 - UnitedVRG
CHAPTER
29
The Kidneys, Suprarenals and

the Posterior Abdominal Wall
THE KIDNEYS
The kidneys are a pair of essential organs of
excretion
They remove excess of water and waste
products of metabolism from the body.
The kidneys also perform endocrine function,
producing a number of hormones, e.g. renin,
that influences blood pressure and erythropoietin, that affects blood formation.
LocationThe kidney is located in lumbar
region on the posterior abdominal wall behind
peritoneum.
The upper pole lies at the level of 12th
thoracic vertebra. The lower pole lies at the
level of 3rd lumbar vertebra.
The hilum of kidney lies at the transpyloric
plane (lower border of 1st lumbar vertebra).
The right kidney lies a little lower due to
presence of liver on the right side.
The kidney is embedded in large amount of
prerenal and pararenal fat.
Size and Shape

The kidney is nearly 11.0 cm long, 6.0 cm
broad, and 3.0 cm thick.
The average weight in males is 150 gm
and in females 135 gm.
The upper pole is broader and lies nearer
the median plane.
The lower pole is smaller and tapering and
lies farther from the median plane.
The shape of kidney is like a bean with
concavity on its medial aspect.
Surfaces, Borders and Ends

The kidneys has two surfacesanterior and
posterior.
I. The anterior surface is gently convex and is
related to other abdominal organs.
The anterior surface of right kidney is related
to (Fig. 29.1).
The right suprarenal glandnear its upper pole
The right colic flexureat its middle
Fig. 29.1: The anterior surface of left kidney
304
Second part of duodenumnear medial

borderall the three structures are related
directly to the kidney without peritoneum.
Visceral surface of right lobe of liver
Coils of jejunum.
The anterior surface of left kidney is related to
The left suprarenal glandnear its upper fold
Body of pancreas and splenic vesselsat its
middle.
The descending colonalong lower part of
lateral border.
All the three structures are related directly to
the kidney without peritoneum.
Lesser sac of peritoneum and posterior surface
of stomach.
Visceral surface of spleen
Coils of jejunum
II. The posterior surface of kidney is flat and is
related to the muscles of posterior abdominal wall.
This surface is devoid of peritoneum (Fig. 29.2).
The structures related to the posterior surface
are
Thoracic diaphragm in upper part separating
the kidney from
Twelfth rib in both sides
Eleventh rib (on left side only)
Psoas majoralong medial border

Quadratus lumborum-about middle
laterally
The vessels and nerves are
Subcostal vessels and nerve
Iliohypogastric nerve
Ilioinguinal nerve (on right side only)
The kidney has two borderslateral and medial
i. The lateral border is convex
ii. The medial border has three parts
Upper convex partrelated to the supra
renal gland
Middle concave part has hilum
Lower convex part
The hilum of the kidney is the gap in middle of
medial border through which structures enter and
leave the kidney.
The structures at the hilum are
The renal vein anteriorly
The renal artery in the middle
The renal pelvis posteriorly
The sympathetic nerves
The lymphatics
The perirenal fat
The renal fascia is a thick layer of fascia that
surrounds the kidney loosely and forms its fascial
capsule (Fig. 29.3).
Fig. 29.2: The posterior surface of kidney
tahir99 - UnitedVRG
The Kidneys, Suprarenals and the Posterior Abdominal Wall
305
MediallyThe two layers fuse and pass in

front of renal vessels, inferior vena cava
and abdominal aorta.
LaterallyThe renal fascia is continuous
with fascia transversalis
The renal fascia divides the renal fat into
a. The perirenal fat (perinephric fat). That is
finely granular and lies within the renal
fascia.
b. The pararenal fat (paranephric body) that
is coarsely granular and lies outside renal
fascia.
General Structure of Kidney
Fig. 29.3: The renal fascia
AttachmentsSuperiorly it splits to enclose the

suprarenal gland and is attached to the
diaphragm.
InferiorlyThe two layers of renal fascia
do not fuse and reach iliac fossa.
I. The kidney is surrounded by a thin capsule made

up of collagen fibers, some elastic fibers and
smooth muscle fibers. The renal capsule is loosely
attached to the kidney substance (Fig. 29.4).
II. The kidney substance is made up of cortex
and medulla.
a. The renal cortex forms a uniform pale layer
deep to the capsule.
The cortex contains the renal corpuscles (the
Bowmanns capsule and glomerulus) the
Fig. 29.4: The structure of kidney
306
proximal and the distal convoluted tubules

(parts of nephrons or kidney tubules).
The cortex has also light colored medullary
rays consisting of collecting ducts.
The cortex, close to medulla, is designated
as juxta-medullary cortex.
b. The renal medulla consists of 9-14 conical
striated renal pyramids.
The bases of pyramids lie towards the
cortex
The apices of pyramids point medially and
are called renal papillae
The renal papillae are received in the minor
calyces and are pierced by the openings of
large collecting ductsthe ducts of Bellini.
III. The renal sinus is the cavity inside kidney
that is not occupied by the renal subtance.
The structures in the renal sinus are:
a. The renal pelvis, dividing into 2-3 major
calyces each further dividing with 2-5 minor
calyces.
The minor calyces receive the apices of
renal pyramidsthe renal papillae.
b. The lobar (segmental) branches of renal
artery.
c. The lobar (segmental) veins.
d. The renal plexus of sympathetic nerves.
e. The lymphatics
f. The peri-renal fatthat enters through the
hilum and fills up the renal sinus.
The Blood Supply of the Kidney

The Arteries
The blood supply of kidney is very profuse.
The renal artery is a large branch of abdominal
aorta and arises at level of inter-vertebral disc
between 1st and 2nd lumbar vertebrae.
The renal artery before it enters the hilum of
kidney gives:
a. The inferior suprarenal artery
b. Small branches to the ureter
On entering the hilum of kidney the renal artery
gives five lobar (segmental) branches that
supply the five vascular segments of the kidney.
The vascular segments of the kidney are (Fig.
29.5.):
a. Apical
b. Superior (anterior)
c. Middle (anterior)
d. Inferior
e. Posterior
There are very little anastomoses between the
four anterior segments and posterior segment.
An avascular plane (Brdels plane) lies along
this junction on posterior aspect of lateral border.
An incision along this plane produces very little
bleeding.
Obstruction or ligation of a segmental artery
leads to avascular necrosis of the vascular
segment.
Fig. 29.5: The vascular segments of the kidney
tahir99 - UnitedVRG
The segmental (lobar) artery gives rise to inter

lobar arteries that pass between the pyramids
to reach the boundary zone. Where they divide
dichotomously to form the arcuate arteries.
The arcuate arteries give rise to interlobular
arteries that course towards renal surface and
give afferent arteriole to the glomerulus.
Accessory (super numerary) renal arteries exist
in about 30% cases. These arise from the renal
artery before it enters hilum and mostly reach
the lower pole.
The Veins
The venous pattern inside the kidney follows

that of the renal artery.
The renal vein comes out of the hilum in front
of renal artery.
The right renal vein is short and opens directly
with superior vena cava.
The left renal vein is larger and crosses in front
of abdominal aorta just below the origin of
superior mesenteric artery.
The left renal vein also receives
a. The left supra renal vein
b. The left testicular (ovarian) vein.
The Lymphatic Drainage of the Kidney
There are three lymphatic plexuses in relation

to kidney
i. One around renal tubules
ii. One deep to the renal capsule
iii. One in the peri-renal fat
The efferent lymphatics from these plexuses
follow the renal vein and end in lateral aortic lymph
nodes.
The Nerve Supply of the Kidney

Lowest splanchnic nerve (T11 ganglion)
Lumbar part of sympathetic chain (L1, L2
ganglia)
There is an aortico-renal ganglion, where these
fibers relay and postganglionic fibers begin.
307
The sympathetic supply is mainly vasomotor

and sympathectomy produces vasodilation
The efferent pain fibers from kidney reach T12
to L2 segments of spinal cord, and the referred
pain is felt in the lumbar and inguinal regions
Applied Anatomy
I. The renal calculus (stone) is formed in the renal
pelvis and may pass down the ureter to reach urinary
bladder.
The renal calculus may cause renal colic and
hematuria (bleeding along with urine)
The renal calculus, if not removed, may increase
in size and cause blockage to the passage of
urine leading to hydronephrosis and damage to
the kidney substance.
II. Mobile (floating) kidney may result due to
depletion of renal fat, which fixes the kidney to the
posterior abdominal wall
The renal fat is absorbed slowly in wasting
disease and prolonged starvation.
III. The intra-venous pyelography is a special
X-rays procedure done to visualize the urinary
passage and also assess kidney function.
A radiopaque medium is injected very slowly
intravenously
The dye is excreted by the kidney and concentrated in the urinary tract, thus visualizing it.
A series of X-ray are taken at intervals.
THE URETER
The ureters are two muscular tubes that conduct
urine by peristaltic movements from the renal pelvis
to the urinary bladder.
BeginningThe ureters begins from the lower
end of renal pelvis at the level of lower pole of
kidney (pelvi-ureteric junction).
Length25.0 cm
CourseThe ureter descends in front of psoas
major muscle along the tips of transverse
processes of lumbar vertebrae
308
The ureter lies behind peritoneum. It crosses

the pelvic inlet at bifurcation of common
iliac artery and enters pelvic cavity
[The pelvic part of ureter is described in
Chapter 33].
Constrictions of ureter: There are three
constrictions in the course of ureter, where a
small renal calculus may lodge and cause
obstruction to the flow of urine:
i. The pelvi-ureteric junction
ii. At the pelvic inlet
iii. At its opening in the urinary bladder.
Relations (abdominal part of motor)
i. The right ureter is crossed anteriorly by:
The third part of duodenum
The root of mesentery with superior
mesenteric vessels
Iliocolic and right colic vessels
The right testicular (ovarian) vessels
ii. The left ureter is crossed anteriorly by:
The superior left colic vessels
The inferior left colic vessels
The left testicular (ovarian) vessels
Apex of pelvic mesocolon.
The blood supply of the ureter
The arteriesThe ureter receives its blood
supply from a number of arteries in form
of small branches:
The renal arterysupplies the upper part
Abdominal aortasupplies the middle
part
Testicular (ovarian
supply the
artery)
lower part.
Common iliac artery
Too much mobilization of ureter during
removal of ureteric calculus (stone) should
be avoided, so that the blood supply by small
branches may not be interrupted.
The veins follow the arteries and end in
corresponding veins.
The lymphatic drainage of the ureter
The lymphatics from upper abdominal part
of ureter end in lateral aortic lymph nodes.
The lymphatics from lower abdominal part

of ureter end in common iliac lymph nodes
The lymphatics from the pelvic part of ureter
end in common, external and internal iliac
lymph nodes.
The Nerve Supply of the Ureter
The sympathetic fibers of the ureter are derived

from lumbar part of sympathetic clain (T10, T12
and L1 segments of spinal cord), and superior
hypogastric plexus.
The parasympathetic supply is derived from the
pelvic splanchnic nerves (S2, S3 and S4 spinal
segments)
The afferent fibers reach spinal cord via the
lowest splanchnic nerve.
Applied Anatomy
The ureteric calculus: A small renal stone may be
lodged at one of the three constrictions in the course
of ureter.
This may lead to ureteric colic, referred to the
abdominal wall according to the part of ureter
where the stone is impacted:
a. From upper part obstruction, the pain is
referred to the region (T10-T12)
b. From middle part obstruction the pain is
referred to the inguinal and pubic regions
(L1)
c. From lower part obstruction the pain is
referred to the perineum or to the back of
thigh (S2, S3 and S4 segments)
The ureteric stone may lead to hydronephrosis
and consequent damage to the kidney.
THE SUPRARENAL (ADRENAL) GLANDS
The suprarenal glands are a pair of important
endocrine glands.
LocationThe suprarenal glands lie on the
upper pole of the kidneys in front of diaphragm
and behind peritoneum (Fig. 29.6).
tahir99 - UnitedVRG
309
Fig. 29.6: The suprarenal glands
SizeEach suprarenal gland is about 50.0 mm

vertically, 30.0 mm transversely and 10.0 mm
antero-posteriorly
The left supra renal is usually a little larger
The weight is about 5 gm.
At birth the suprarenal gland is one-third
the size of kidney, but in adult it is nearly
one-thirtieth the size of kidney.
ShapeThe right suprarenal gland is shaped
like a tetrahedron.
The left suprarenal gland is semilunar in
shape.
Relations (Fig. 29.7)

a. The right suprarenal gland is related:
Anteriorly to the right lobe of liver
Inferior vena cava
Posteriorly to the diaphragm above
Upper pole right kidney below
b. The left suprarenal gland is related (Fig.
29.8)
Anteriorly to the omental bursa
Posterior surface of stomach
Renal impression of spleen
Body of pancreas and splenic vessels
Fig. 29.7: The right suprarenal glandrelations
310
Fig. 29.8: The left suprarenal gland
Posteriorly to the diaphragm medially

Upper pole of left kidney laterally.
Accessory suprarenal gland (cortical tissue)
may be found nearby.
The blood supply of the suprarenal gland
The arteries The gland is supplied by three
arteries.
a. The superior suprarenal artery is a
branch of the inferior phrenic artery
b. The middle suprarenal artery is a direct
branch from abdominal aorta
c. The inferior suprarenal artery is a branch
of the renal artery.
The Veins
A single supra-renal vein comes out of hilum.
The right suprarenal vein ends in the inferior
vena cava.
The left suprarenal vein ends in the left renal
veins.
The Lymphatic Drainage of the Gland
The lymphatics of the suprarenal gland end in the
lateral aortic lymph nodes.
The Nerve Supply of the Gland
The supra renal cortex is controlled by the ACTH
(adreno-corticotropic hormone) secreted by the
anterior pituitary gland.
The suprarenal medulla is supplied by many

myelinated preganglionic sympathetic fibers. From
the coelic plexus these preganglionic fibers end
around the cells of the suprarenal medulla.
The secretion of cells of suprarenal medulla
epinephrinereplaces the post ganglionic fibers.
The Parts of the Suprarenal Gland
The suprarenal gland consists of two parts
a. An outer suprarenal cortex
b. An inner suprarenal medulla.
The two parts are developmentally phylogenetically and functionally distinct.
The suprarenal cortex consists of three zones.
Zona glomerulosa
Zona fasciculata
Zona reticularis
The suprarenal medulla consists of chromaffine
cells belonging to the sympathetic system. The
cells of suprarenal medulla secrete epinephrine.
Applied Anatomy
I. The pheochromocytoma a tumor of suprarenal
medulla secretes excess of epinephrine, that gives
rise to hypertension.
II. Atrophy of suprarenal cortex leads to insufficiency of cortical secretion.
tahir99 - UnitedVRG
The condition is known as Addisons disease

with muscular weakness, low blood pressure
and cutaneous pigmentation.
III. Bilateral adrenelectomy is done for some
inoperable mammary or prostatic carcinoma in
which malignant changes are supposed to occur
due to excess of androgens and estrogens.
THE POSTERIOR ABDOMINAL WALL
The posterior abdominal wall has the following
muscles (Fig. 29.9):
Quadratus lumborum
Psoas major
Iliacus
The quadratum lumborum muscle is covered
by the thoraco-lumbar fascia. At the lateral
border of the muscle the fused anterior and
middle lamina of thoraco-lumbar fascia form
311
the aponeurotic origin of transversus abdominis

muscle.
The psoas major and iliacus muscles are
covered by the iliopsoas fascia (fascia iliaca).
i. The quadratus lumborum lies lateral to the
psoas major muscle on the posterior abdominal wall.
Origin fromIliolumbar ligament
Adjacent part of inner lip of iliac crest
for about 5.0 cm.
Muscle belly is quadrangular in shape
and is broad inferiorly
The upper part of the muscle lies deep
to the lateral arcuate ligament of
diaphragm.
Insertion is on medial half lower border
of twelfth rib
Fig. 29.9: The posterior abdominal wall
312
Apices of transverse processes of

upper four lumbar vertabrae by four
small tendons
Nerve supply ventral rami of T12 and L1,
L2 and L3 spinal nerves
Actions
It is a lateral flexor of lumbar part of
vertebral column
It fixes twelfth rib during inspiration
ii. The psoas major muscle lies just lateral to
the lumbar vertebral bodies.
The fusiform muscle belly descends
along the pelvic inlet medial to iliacus
muscle, and gives rise to a tendon that
descends deep to the inguinal ligament
to reach front of thigh
[Description given in Chapter 17].
iii. The iliacus muscle arises from the iliac
fossa and lies lateral to the psoas major
muscle.
The muscle also descends deep to the
inguinal ligament to reach front of thigh
[Description given in Chapter 17]
The Blood Vessels of the Posterior
Abdominal Wall
The Arteries
The abdominal aorta is the continuation of the

descending thoracic aorta in the abdomen.
BeginningThe abdominal aorta begins at the
aortic opening of diaphragm at level of lower
border of twelfth thoracic vertebra.
CourseThe abdominal aorta descends in the
median plan in front of the bodies of lumbar
vertebrae.
At the lower border of fourth lumbar
vertebra, slightly to the left of median plane,
the aorta bifurcates into two common iliac
arteries.
Relation
Anteriorly
Coeliac axis artery and its branches

surrounded by coeliac plexus of nerves
Peritoneum of posterior wall of lesser
sac
Body and uncinate process of head of
pancreas
Origin of superior mesenteric artery
Left renal vein
Third part of duodenum and origin of
inferior mesenteric artery
Root of mesentery and superior mesenteric vessels
Parietal peritoneum
Aortic plexus of nerves and the preaortic lymph nodes.
Posteriorly
Bodies of upper four lumbar vertebrae
Intervertebral discs
Origin of four pairs of lumbar arteries
Right side
Cisterna chyli and beginning of thoracic
duct
Azygos vein
Inferior vena cava
Left side
Fourth part of duodenum
Branches of the abdominal aorta are divided into
three groups.
The ventral splanchnic branches are unpaired and supply the three partsforegut,
midgut and hindgutof the gastrointestinal
tract.
The coeliac axis artery for the foregut.
The superior mesenteric artery for the
midgut
The inferior mesenteric artery for the
hindgut.
The lateral splanchnic branches are paired
The inferior phrenic artery supplies the
diaphragm
The middle suprarenal artery supplies
suprarenal gland
tahir99 - UnitedVRG
The renal artery supply the kidney

The testicular (ovarian) artery supply the
gonad.
The dorsal somatic branches are
Four pairs of lumbar arteries that supply
the muscles of the back
The median sacral artery is a slender
branch that continues in the posterior
pelvic wall
The terminal branches
The two common iliac arteries
Applied anatomy
The aneurysm of the abdominal aorta is
usually located near the origin of its branches
A large aneurysm may erode the related
vertebral body
Partial occlusion of aorta below the origin
of renal arteries results in development of
collateral circulation between the internal
thoracic artery and the abdominal aorta.
The Veins
The inferior vena cava is the great venous trunk
that collects venous blood from all parts of body
below diaphragm and takes it to right atrium of
heart.
BeginningThe inferior vena cava begins on
front of body of fifth lumbar vertebra by union
of the two common iliac veins-right and left.
The beginning is located to the right side of
the median plane.
CourseThe inferior vena cava ascends in front
of the lumbar vertebral bodies lying to the right
side of the abdominal aorta
The upper part of inferior vena cava bends
anteriorly and lies in a deep groove on the
posterior surface of right lobe of liver.
The inferior vena cava passes through the
opening in the central tendon of diaphragm
and ends in posterior part of right atrium of
heart.
Relation
Anteriorly
Right common iliac artery
Root of mesentery with superior mesenteric vessels
313
Parietal peritoneum
Third part of duodenum
Head of pancreas, bile duct, portal vein
First part of duodenum
Peritoneum of posterior wall of epiploic
foramen
Right lobe of liver
Posteriorly
Bodies of lower three lumbar vertebrae
Inter-vertebral discs
Right psoas major
Right sympathetic chain
Right suprarenal gland
Right renal, suprarenal and inferior
phrenic arteries
Right side
Right ureter
Second part of duodenum
Medial border of right kidney
Right lobe of liver
Left side
Abdominal aorta
Tributaries
The two common iliac veinsright and left
Third and fourth lumbar veins of both sides
Right testicular (ovarian) vein
Right supra-renal vein
Inferior phrenic veins
Renal veins
Two-three hepatic veins.
Applied anatomy
Thrombosis of the inferior vena cava is
usually partial and collateral circulation
develops by enlargement of both superficial
and deep veins.
The following superficial veins connect
the inferior vena cava to the superior
vena cava:
The epigastric veins
The lateral thoracic vein
The thoraco-epigastric vein
The posterior intercostal veins.
314

The deep veins that connect the inferior
vena cava to the superior vena cava and

are enlarged are:
The azygos and hemiazygos veins
The lumbar veins
The vertebral venous plexus also
affords an important site for collateral circulation.
The lymphatics and lymph nodes of posterior
abdominal wall
The common iliac lymph nodes are grouped
along the common iliac vessels
These nodes drain lymph from the
external and internal iliac nodes and in
turn drain into aortic lymph nodes
They receive lymph from
Lower limb including gluteal region
Perineum
Pelvic cavity
The aortic (lateral aortic) lymph nodes lie
by the side by abdominal aorta along the
medial margin of psoas major muscle.
They drain lymph from the structures
on the posterior abdominal wall, kidney,
suprarenal gland, abdominal part of
ureter and testis (ovary) uterine tube and
upper part of uterus in females.
Efferent lymphatics from there lymph
nodes end in the cisterna chyli and
lumbar lymph trunk.
The cisterna chyli is a dilated lymph sac that
is present on front of first and second
lumbar vertebral body
LocationThe cisterna chyli lies behind
the right crus of diaphragm and to the
right of abdominal aorta
The cisterna chyli continues as the
thoracic duct through the aortic opening
of diaphragm
TributariesThe cisterna chyli receives
The two intestinal lymph trunks
bringing chyle from the walls of small
intestine
The two lumbar lymph trunk bringing
lymph from the lower extremities,
pelvis and perineum
Lymphatics from lateral aortic,

superior mesenteric and coeliac
lymph nodes.
The nerves of the posterior abdominal wall
The lumbar parts of the sympathetic trunks
The sympathetic trunk enters posterior
abdominal wall deep to the medial
arcuate ligament of diaphragm
The sympathetic trunk descends between the medial margin of psoas major
and the bodies of lumbar vertebrae.
The lumbar part of sympathetic trunk
has five ganglia corresponding to the
five lumbar spinal nerves. The fifth
ganglion is variable.
Branches
Grey rami communicans (GRC)
connect the sympathetic ganglia to
the corresponding lumbar spinal
nerves
White rami communicans (WRC) are
usually given from the first lumbar
spinal nerve to the first sympathetic
ganglion [sometimes the second
lumbar spinal nerve also gives a white
ramus communicans to the corresponding sympathetic ganglion]
The lumbar splanchnic nerves are
usually four from upper four ganglia
a. The lumbar splanchnic nerves
give branches to the coeliac,
aortic, mesenteric and superior
hypogastric plexuses.
b. The lumbar splanchnic nerves
also carry afferent pain fibers
from the descending colon,
sigmoid colon and from upper
and middle parts of ureter
The aortic plexus of sympathetic nerves
lies in front of abdominal aorta
Superiorly it communicates with
superior mesenteric plexus and
coeliac plexus
Inferiorly it communicates with the
superior hypogastric plexus
tahir99 - UnitedVRG
The aortic plexus also contains small

sympathetic ganglia, that relay
sympathetic fibers and post-ganglionic sympathetic fibers arise from the
ganglia
The lumbar plexus supplies the skin and
muscles of the anterior abdominal wall. It
also gives branches to supply the skin and
muscles of the lower extremity
LocationThe lumbar plexus lies by the
side of the lumbar part of vertebral
column in the substance of psoas major
muscle
FormationThe lumbar plexus is
formed by the ventral rami of upper four
lumbar spinal nerves
The ventral rami divide into anterior
divisions and posterior division
The anterior division supplies the
skin and muscle of medial compartment of thigh
The posterior division supplies the
skin and muscle of anterior (extensor) compartment of thigh.
Branches: The main branches of the
lumbar plexus are
The ilio-hypogastric nerve (L 1 )
emerges from the lateral border of
psoas major
a. It gives a lateral cutaneous
branch to supply the skin of
anterior part of gluteral region
b. It gives muscular branches to the
three oblique muscles of the
anterior abdominal wall
c. Its terminal branches supply the
sensory fiber to the skin of
hypogastric region above the
pubic symphysis
The ilio-inguinal nerve (L1) emerges
from the lateral border of psoas major
below ilio-hypogastric nerve.
315
a. The ilio-inguinal nerve lies below

and parallel to the ilio-hypogastric
nerve
b. The ilio-inguinal nerve runs in the
inguinal canal and comes out of
the superficial inguinal ring
c. Its muscular branches supply the
lower parts of the three oblique
muscles of the anterior abdominal
wall
d. Its sensory fiber supply the skin
of external genitals and upper
part medial side of thigh
The genito-femoral nerve (anterior
division of ventral rami of L1 and L2)
The genito-femoral nerve emerges
from the anterolateral surface of
psoas major and descends on the
muscle
The nerve divides into a genital
branch and a femoral branch.
a. The geintal branch passes
through inguinal canal and
suppliesthe cremaster muscle in
males and round ligament of
uterus in females.
b. The femoral branch descends on
front of thigh lateral to the femoral artery lying inside femoral
sheath
It pierces femoral sheath and
supplies skin of upper part
of front of thigh.
The lateral femoral
described in
cutaneous nerve
Chapter 17
The femoral nerve
The obturator nerve
The lumbo sacral trunk (L4, L5) is a large
nerve that descends into the pelvic cavity
by crossing the ala of sacrum
It joins the sacral plexus
The Abdomen
Q1. Select the one best response to each
question from the four suggested answers:
1. The cremaster muscle in males is continuous
with the muscle fibers of:
A. External oblique
B. Internal oblique
C. Transversus abdominis
D. Rectus abdominis
2. The deep inguinal ring is the gap in the:
A. External oblique aponeurosis
B. Internal oblique aponeurosis
C. Transversus abdominis aponeurosis
D. Fascia transversalis
3. The dermatome at the level of umbilicus is:
A. T10
B. T11
C. T12
D. L1
4. The spleen lies inside abdominal cavity in the:
A. Left hypochondrium
B. Left lumbar region
C. Epigastrium
D. Partly in left hypochondrium and partly
in epigastrium
5. The portal vein is formed by the union of:
A. Superior mesenteric vein and inferior
mesenteric vein
B. Superior mesenteric and splenic vein
C. Splenic and inferior mesenteric veins
D. Splenic and short gastric veins
6. The normal capacity of gall bladder is:
A. 250 ml
B. 500 ml
C. 100 ml
D. 30-50 ml
7. The arteries supplying the fundus part of
greater curvature are:
A.
B.
C.
D.
Left gastric artery

Left gastroepiploic artery
Short gastric arteries
None of the above
8. The medial umbilical fold overlies the:

A. Urachus or median umbilical ligament
B. Obliterated umbilical artery
C. Inferior epigastric artery
D. Lateral border of rectus abdominis
9. The length of ureter in normal adult male is:
A. 10.0 cm
B. 25.0 cm
C. 30.0 cm
D. 50.0 cm
10. The left supra renal vein ends in:
A. Left renal vein
B. Inferior vena cava
C. Splenic vein
D. Left testicular (ovarian) vein
Q2. Each question below contains four suggested answers of which one or more is
correct. Choose the answers:
11. The stomach:
1. has lesser curvature along which left and
right gastric arteries lie
2. has parasympathetic innervation from
two gastric nerves, that carry vagal fibers
3. has fundusthe highest part of greater
curvature, that contains gas
4. has a thick sphincter at the cardiac
opening
tahir99 - UnitedVRG

12. The pancreas:
1. has splenic artery running along its upper
border
2. has a tailthe tapering end of the bodythat reaches up to hilum of spleen
3. has an uncinate process from lower part
of head that lies behind superior mesenteric vessels.
4. has a main pancreatic duct that mostly
joins with the bile duct to from a
common ampulla.
13. The superior mesenteric artery:
1. is the artery of hindgut
2. terminates about two feet from ileocecal
junction at Meckels diverticulum (if
present)
3. supplies the entire transverse colon
4. gives an appendicular branch to supply
vermiform appendix
14. The lesser sac of peritoneum (omental bursa):
1. is a part of peritoneal cavity
2. has lesser omentum in its anterior wall
3. communicates with rest of the peritoneal
cavity by one openingepiploic foramen
4. extends up to lower border of greater
omentum in adults
15. The oblique (indirect) inguinal hernia:
1. passes through the deep inguinal ring
2. is commoner in older age group
3. is usually associated with incomplete
fusion of processus vaginalis
4. seldom enters the scrotum
16. The right suprarenal gland:
1. is larger than left suprarenal gland
2. is related anteriorly to the inferior vena
cava
3. has its suprarenal vein draining into right
renal vein
4. lies in a separate compartment of renal
fascia
317
17. The liver:

1. is developed from endodermal hepatic
diverticulum
2. receives 80 percent supply from the
portal vein
3. is related directly with diaphragm at the
bare area
4. has two-three hepatic veins draining into
inferior vena cava
18. The three constrictions in the course of ureter
are:
1. Where ureter crosses the pelvic inlet
2. At its opening in the urinary bladder
3. At pelvi-ureteric junction
4. Where testicular (ovarian) vessels cross
it anteriorly
19. The referred pain of cholecystitis is felt at:
1. Umbilical region
2. Right lumbar region
3. Right inguinal region
4. Right shoulder tip
20. Upon exploration of abdominal cavity, blood
and some fluid is observed in Morrisons
pouch. The collection may be from:
1. Left paracolic gutter
2. Lesser sac of peritoneum
3. Right infracolic compartment
4. Right paracolic gutter
Q3. Match the structures on the left with their
related structures on the right:
21. Embryonic remnants:
i. Ligamentum
A. Median umbilical
teres of liver
ligament
ii. Meckels
B. Left umblical vein
diverticulum
iii. Urachus
C. Medial umbilical
ligament
iv. Umbilical artery D. Vitello-intestinal
duct
318
22. Arterial supply:
i. Coeliac axis
artery
ii. Superior
mesenteric artery
iii. Inferior mesenteric artery
iv. Inferior phrenic
artery

iii. Presacral nerve
A. Suprarenal gland
B. Head of pancreas
C. Vermiform
appendix
D. Rectum
23. Related structures:

i. Sphincter of Oddi A.
ii. Falciform
B.
ligament
iii. Hartmanns
C.
pouch
iv. Ducts of Bellini D.
24. Drainage of veins:
i. Left testicular
vein
ii. Middle colic
vein
iii. Para-umbilical
veins
iv. Inferior mesenteric vein
Gall bladder
Kidney
Ampulla of Vater
Liver
A. Splenic vein
B. Superior mesenteric vein
C. Left renal vein
D. Left branch of
portal vein
25. Fascial layers of the abdomen:

i. Fascia
A. Kidney
transversalis
ii. Campers fascia B. Fatty layer of
superficial fascia
iii. Renal fascia
C. Membranous
layer of superficial fascia
iv. Scarpas fascia D. Inner fascia of the
anterior abdominal
wall
26. Origin of nerves:
i. Ilio-inguinal nerve A. Lumbar plexus
(VRL1)
ii. Genito-femoral B. Lumbar plexus
nerve
(VRL1, L2)
iv. Greater splanchnic nerve
C. Thoracic part
of sympathetic
trunk
D. Superior hypogastric plexus
Q4. Find the wrong answer (except) in the

following questions:
27. The following structures are present in the
free border of lesser omentumexcept:
A. Portal vein
B. Main pancreatic duct
C. Bile duct
D. Hepatic artery
28. The following veins form important portosystemic anastomosisexcept:
A. Veins of bare area of liver and phrenic
veins
B. Superior rectal vein and inferior rectal
vein
C. Paraumbilical veins and superficial veins
of anterior abdominal wall
D. Esophageal tributaries of left gastric vein
and tributaries of azygos vein.
29. The following structures form part of stomach
bedexcept:
A. Splenic artery
B. Body of pancreas
C. Coeliac trunk
D. Upper part front of left kidney
30. The following statements about inferior mesenteric artery are correctexcept:
A. Its colic branches supply descending
colon
B. It gives inferior pancreatico-duodenal
branch
C. It continues as superior rectal artery
D. Its branches contribute to the formation
of marginal artery.
tahir99 - UnitedVRG
319
Answers
The cremaster muscle is continuous with the
muscle fibers of internal oblique muscle. The
external oblique has a triangular gap above
pubic crestthe superficial inguinal ring. The
transversus abdominis forms the main part
of conjoint tendon. The rectus abdominis is
placed more medially.
The deep inguinal ring, is an oval gap 1.2 cm
above the mid-inguinal point in the fascia
transversalis. The lower margins of internal
oblique and the transversus abdominis leave
wider gaps above the inguinal ligament.
9
ri 9

The spleen lies in the left hypochondrium.
The left kidney lies in the left lumbar region.
The stomach lies partly in left hypochondrium
and partly in epigastrium.
h
a

The portal vein is formed by the union of
superior mesenteric vein and the splenic veins.
The inferior mesenteric vein is a tributary of
the splenic vein. The short gastric veins are
also the tributaries of splenic vein.
The normal capacity of gall bladder is between
30 and 50 ml.
G
R

The medial umbilical fold in lower part of
deep surface of the anterior abdominal wall
overlies the obliterated umbilical arteries. The
urachus (median umbilical ligament) raises
the median umbilical fold and the inferior
epigastric artery raises the lateral umbilical
fold.
V
d
ti e
n
U

The dermatome at the level of umbilicus
belongs to T10 spinal nerve. The dermatomes
of T11 and T12 spinal nerves are above and
below the umbilicus respectively. The dermatome of L1 spinal nerve lies in the hypogastric
region just above pubic symphysis.
The fundus part of greater curvature of stomach is supplied by the short gastric
arteriesbranches of splenic artery. The left
gastric artery lies along the lesser curvature
of stomach. The left gastro-epiploic artery
supplies lower part of greater curvature.

The length of ureter in normal adult male is
nearly 25.0 cm.

The left suprarenal vein ends in the left renal
vein, due to developmental reason. The right
supra renal vein ends in the inferior vena cava.
The stomach has a lesser curvature with left
and right gastric arteries running along it. It
has parasympathetic innervation from the two
vagus nerves. The fundus is the highest part
of greater curvature and contains gas. There
is, however, no thick sphincter at the cardiac
opening. The thick pyloric sphincter is present
at the pyloric opening of stomach.
A12. The answer is E, (1, 2, 3, 4).
The splenic artery runs along the upper border
of body of pancreas. The tapering tail reaches
up to the hilum of spleen. It has an uncinate
process from the lower part of head that lies
behind superior mesenteric vessels. Also, the
320

main pancreatic duct usually joins with the
bile duct to form the common hepatopancreatic ampulla.

The superior mesenteric artery terminates
about two feet from ileocecal junction, at
Meckels diverticulum (if present). It gives
an appendicular branch. It is, however, artery
of midgut and not hindgut and it supplies only
right two-third of transverse colon.
The lesser sac of peritoneum is a part of
peritoneal cavity, and has lesser omentum in
its anterior wall. It communicates with rest
of the peritoneal cavity by one openingthe
epiploic foramen. However, in adults it does
not extend up to lower border of greater
omentum, it extend only up to transverse
colon.
The oblique (indirect) inguinal hernia passes
through the deep inguinal ring. It is usually
associated with incomplete fusion of processus vaginalis. The oblique hernia is commoner in young adults and enters the scrotum.
The right suprarenal gland is usually smaller
than left suprarenal gland. It is related
anteriorly to the inferior vena cava. The right
suprarenal gland lies in a separate
compartment of renal fascia, but the right
suprarenal vein opens directly in the inferior
vena cava.
A17. The answer is E, (1, 2, 3, 4).
The liver is endodermal in origin from hepatic
diverticulum of foregut. It receives 80 per
cent of its blood supply from the portal vein.
At bare area, the posterior surface lies directly
in relation with diaphragm. The two or three
hepatic veins draining venous blood from the
liver open directly in inferior vena cava.

The three constrictions of the ureter are one
where ureter crosses the pelvic brim second
at its opening in the urinary bladder and third
at pelvi-ureteric junction. There is no constriction where the testicular (ovarian) vessels
cross the ureter.
A19. The answer is D, (4).
The referred pain of cholecystitis is felt at
the right shoulder tip, as this condition irritates
the inferior surface of diaphragm supplied by
the phrenic nerve (C3, C 4, C5, V, R), the
ventral rami of C3 and C4 spinal nerves
supra-clavicular nerves also supply the skin
covering the right shoulder tip.
The blood and fluid collected in the Morrisons
(Hepatorenal) pouch comes from the lesser
sac of peritoneum through epiploic foramen.
The right paracolic gutter superiorly also
communicates with the Morrisons pouch.
The right intra-colic compartment is separated
from Morrisons pouch by the right colic
flexure. The left paracolic gutter is on the
other side of the peritoneal cavity.
A21. The answer are B, D, A and C.
The ligamentum teres of liver is a remnant
of the left umbilical vein of fetal life.
The Meckels diverticulum is remnant of
vitello intestinal duct.
The urachus persists as median umbilical
ligament.
The umbilical artery, after birth, gets
fibrosed to form the medial umbilical
ligament.
A22. The answers are B, C, D and A.
The coeliac axis artery supplies a part of
head of pancreas via superior pancreatico-duodenal artery.
The superior mesenteric artery supplies
vermiform appendix by a separate
appendicular artery.
tahir99 - UnitedVRG
The inferior msenteric artery continues

in pelvis as superior rectal artery to supply
rectum.
The inferior phrenic artery supplies
suprarenal gland.
A23. The answers are C, D, A, and B.

The sphincter of Oddi surrounds the
ampulla of Vater
The falciform ligament is attached to the
liver.
The Hartmanns pouch is located at the
right border of neck of gall bladder.
The ducts of Bellini are the largest
collecting ducts of the kidney.
A24. The answers are C,B,D and A.
The left testicular vein joins the left renal
vein.
The middle colic vein ends in superior
mesenteric vein.
The paraumbilical veins end in left branch
of portal vein.
The interior mesenteric vein ends in the
splenic vein.
9
ri 9
The genitofemoral nerve is also a branch

of lumbar plexus (VR L1, L2).
The presacral nerve is a sympathetic
plexus located on front of fifth lumbar
vertebra.
The greater splanchnic nerve arises from
T5 to T 9 ganglia of thoracic part of
sympathetic trunk.
G
R

The three structures present in free border
of lesser omentum are the portal vein,
bile duct and hepatic artery.
The main pancreatic duct does not lie in
the free border of lesser omentum.
V
d
ti e

The veins of the bare area of liver and
the phrenic veins are quite small and do
not form an important site of portosystemic anastomosis.
The important sites are the other three.
n
U
A25. The answers are D,B,A and C.

The fascia transversalis, is the inner fascia
of the anterior abdominal wall.
The Campers fascia is the fatty layer of
superficial fascia of the anterior abdominal wall.
The renal fascia forms the fascial capsule
of the kidney.
The Scarpas fascia is the membranous
layer of superficial fascia of the anterior
abdominal wall.
h
a
321
A26. The answers are A, B, D and C.

The ilio-inguinal nerve, is a branch of
lumbar plexus (VR L1).

The coeliac trunk does not form a part
of stomach bed, as it lies at a higher level.
The other three structuressplenic
artery, body of pancreas and upper part
of left kidney form part of stomach bed.
The inferior mesenteric artery does not
give inferior pancreatico-duodenal artery,
that is a branch of superior mesenteric
artery.
It gives colic branches to supply descending colon and helps to form a part
of marginal artery.
It continues as superior rectal artery in
the pelvic cavity.
The Pelvis
Six
CHAPTER
30
The Bones and

Joints of the Pelvis
The bones of the pelvis are:
1. The two hip bones
2. The sacrum
3. The coccyx
1. The hip bone(Innominate bone) forms the side

of the bony pelvis.
It is formed by the fusion of three bones
ilium, ischium, and pubis in the cup-shaped acetabulum.
a. The ilium expands above to form the iliac crest.
It forms the sacro-iliac joint with sides of the
sacrum.
The ilio-pectineal line forms a part of the
pelvic inlet.
b. The ischium forms the lower part of the hip
bone.
It has ischial tuberosity below that gives
attachment to muscles of posterior compartment of thigh.
c. The pubis forms the anterior part of the hip
bone.
The body of pubis joins with the bone of
the opposite side to form pubic symphysis.
2. The sacrum forms the posterior part of the
bony pelvis.
The sacrum is formed by the fusion of five
sacral vertebrae.
of
It has four anterior sacral foramina, that

transmit the ventral rami of sacral spinal nerves
and branches of lateral sacral artery.
It has four posterior sacral foramina, that
transmit the dorsal rami of sacral spinal nerves.
The sacral hiatus at lower end of sacral canal,
transmits filum terminale and fifth sacral and
coccygeal nerves.
3. The coccyx (Tail bone) is formed by the fusion
four rudimentary coccygeal vertebrae.
The coccyx articulates with lower end of
sacrum to form the sacro-coccygeal joint.
THE BONY PELVIS

The bony pelvis is divided into:
A. The greater (false) pelvis is the upper part of
the bony pelvis, that lies between the iliac crests
and the pelvic inlet.
The contents of greater pelvis are the pelvic
colon and terminal coils of ileum.
B. The lesser (true) pelvis is the lower part of the
bony pelvis, that is enclosed by the lower parts of
the hip bones below the pelvic inlet.
The lesser pelvis is limited above by the pelvic
inlet and below by the pelvic outlet.
1. The pelvic inlet (pelvic brim) is bounded:
Anteriorlyby the pubic crest
tahir99 - UnitedVRG
The Bones and Joints of the Pelvis

Posteriorlyby the sacral promontory
Laterallyby ala of sacrum, and Iliopectineal line
The diameters of the pelvic inlet are:
i. The antero-posterior diameter is
measured from sacral promontory in
midline up to the upper end of pubic
symphysis.
It is about 10.0 cm in normal adult
females.
ii. The oblique diameter is measured from
the sacro-iliac joint to the opposite iliopectineal eminence.
females.
iii. The transverse diameter is the widest
distance across the pelvic inlet.
female (Fig. 30.1).
2. The pelvic outlet is bounded:
Anteriorly by the lower end of pubic
symphysis
Posteriorly by the tip of coccyx
Antero-laterally by the conjoint ramus of
ischium and pubis
Laterally by the ischial tuberosity
Postero-laterally by sacro-tuberous
ligament.
9
ri 9
h
a
Fig. 30.1: The diameters of pelvic inlet
323
The pelvic outlet is closed by the pelvic diaphragm formed mainly by two levator ani
muscles.
The pelvic diaphragm separates the cavity of
lesser pelvis from the ischio-rectal fossae.
The diameters of the pelvic outlet are:
i. The transverse diameter is the distance
between two ischial tuberosities.
This diameter is approximately as wide
as the clenched fist.
ii. The transverse mid-plane diameter is the
distance between two ischial spines.
The distance normally is 9.5 cm or
more; if it is less than 9.5 cm, the delivery
of the child may be difficult.
iii. The antero-posterior diameter is measured
from the lower margin of pubic symphysis
to the sacro-coccygeal joint.
The diameter is nearly 13.5 cm in adult
females.
The contents of the lesser pelvis are
Pelvic colon, rectum and upper part of anal
canal.
Urinary bladder, pelvic parts of two ureters.
In males, seminal vesicles, the two vas deferens
and the prostate gland.
In females uterus, the ovaries, the two uterine
tubes and upper part of vagina.
The diameters of bony pelvis are measured for
the inlet and the outlet. They helps to establish the
diagnosis of pelvic disproportions in females.
V
d
ti e
G
R
n
U
The Shapes of the Bony Pelvis

The bony pelvis is classified according to the shape
of the pelvic inlet.
1. The android type is the normal male pelvis. The
inlet is heart shaped, as the sacral promontory
is very prominent.
2. The gynaecoid type is the normal female pelvis.
The inlet is oval with more transverse diameter.
3. The anthropoid type is the abnormal type. The
inlet is oval in shape with antero-posterior
diameter more than the transverse diameter.
324
4. The platypaloid type (flat pelvis) is another

abnormal type with a rather long transverse
diameter and a short antero-posterior diameter.
The Sex Differences of the Bony Pelvis
The differences in the bony pelvis are the most
characteristic sex differences in male and female
skeletons. These differences are even obvious to a
lesser degree in fetal and early post-natal life (Table
30.1).
In adults the differences are limited to the
functions of the bony pelvis.
The primary function of the bony pelvis in both
sexes is to bear body weight and help in
locomotion.
In females, the bony pelvis is adapted for
parturition (delivery of the newborn).
THE SACRUM
General Features
The sacrum is formed by fusion of five sacral
vertebrae
The sacrum is a large triangular bone located
between two hip bones forming posterior wall of
pelvic cavity.
i. The base of sacrum - or upper surface of Ist

sacral vertebra articulates with fifth lumbar
vertebra The anterior projecting edge of body
of sacrum is called sacral promontory.
On either side, the superior surface or base
of sacrum is formed by alae that are formed
by fusion of transverse processes and costal
elements.
ii. The apex or caudal end of sacrum articulates
with the coccyx.
iii. The pelvic surface - of sacrum is concave. It
has four pairs of anterior sacral foramina that
transmit ventral rami of upper four sacral
nerves.
There are faint ridges separating the sacral
vertebrae on pelvic surface.
iv. The dorsal surface of sacrum is convex and
and raised dorsally by median sacral crest. It
has four pairs of dorsal sacral formina, that
transmit the dorsal rami of upper four sacral
nerves.
v. The lateral surface is formed by fusion of
transverse processes. If broad upper part
bears the articular surface for sacro-iliac joint.
vi. The sacral canal is triangular in section. It
contains sacral and coccygeal nerve roots,
Table 30.1: Main differences in bony pelvis in both sexes

S No Features
Male pelvis
Female pelvis
1.
2.
3.
4.
5.
6.
7.
8.
9.
Thickness of bones and muscle markings

Weight of the bones
Shape of the bones
Bony inlet
Cavity
Acetabulum
Iliac fossa
Subpubic angle
Ischio-pubic rami
Less pronounced
Lighter
Gynaecoid type
Oval with transverse diameter more
Smaller part of a larger cone
Smaller
Shallower
80-85 (Nearly right angle)
Thinner and lightly built
10.
11.
12.
13.
14.
15.
16.
Ischial spines
Sacrum
Sacral promontory
Auricular surface
Sacral index (Ratio of Breadth: Length)
Diameters of pelvic inlet
Diameters of pelvic outlet
Farther from each other

Less curved
Less prominent
Smaller
11.5%
More in females
More in females
More pronounced
Heavier
Android type
Heart shaped
Larger part of a smaller cone
Larger
Deeper
50-60 (acute angle)
Thicker, bear an everted area
for attachment of crus of penis
Closer to each other
More evenly curved
More prominent
Larger
105%
Less in males
Less in males
tahir99 - UnitedVRG
The Bones and Joints of the Pelvis

the filum terminale and dural tube (up to
second sacral vertebra)
vii. The sacral hiatus is the caudal opening of
sacral canal. It transmits fifth sacral and
coccygeal nerves and filum terminale.
Variations
Sometimes sacrum may contain six vertebrae due
to an additional sacral element or by incorporation
of fifth lumbar vertebra, the condition is called the
sacralization of lumbar vertebrae.
Two primary centers for each 1/2 of

vertebral arch
These centers appear between 10th and 20th
weak of intra-uterine life.
Primary centers for costal elements appear us
upper 3 sacral vertebrae between 6th to 8th
fetal month. Costal elements fuse with the
vertebral arch between 2nd and 5th year.
Vertebral arches and body fuse by 8th year
Upper and lower surfaces of each sacral body
are covered by epiphyseal plate of hyaline
cartilage
Special Features
THE COCCYX
[Muscles and ligaments attached to sacrum]

Pelvic surface - 2nd to 4th segment - piriformis
Pelvic surface - supro-lateral part - Iliacus
Pelvic surface - infro-lateral part - Coccygeus
Dorsal surface - U-shaped aponeurosis of
erector spinae
Dorsal surface - [Within erector spinae]
Multifidus
Lateral border - [below auricular surface]
Gluteus maximus
Lateral border (ventral aspect) Coccygeus
Lateral border (dorsal aspect) Sacro-tuberous
and sacro-spinous ligaments
9
ri 9
Sex-difference
V
d
ti e
G
R
The coccyx is a small triangular bone that is

formed by fusion of four rudimentary coccygeal
vertebrae
The base or upper surface articulates with apex
of sacrum
Two coccygeal cornua project upwards to
articulate with sacral cornua
Second to fourth diminish in size and are like
fused no dules.
The pelvic surface gives attachment to levator
ani and coccygeus muscles.
The dorsal surface gives attachment to gluteus
maximus and sphincter ani externus. The filum
terminale blends with dorsal surface
n
U
The female sacrum is shorter and wider forming

a wider pelvic cavity.
The ventral concavity is deeper and it faces
more downwards
The articular surface of female sacrum is shorter
The male sacrum: Sacral promontory is more
prominent.
The first sacral vertebra forms a larger part of
base of sacrum. Its transverse diameter is
longer than ala
The male sacrum is less curved also.
h
a
325
Ossification
Each coccygeal segment is ossified by one primary
center.
The center for 1st segment appears at birth and
its cornua may ossify by separate centers
The other three segments of coccyx ossify by
centers which appear much later up to 20th
year.
The coccyx fuses with sacrum in old age
specially in females.
The Joints of the Bony Pelvis
Ossification
Ossification of sacrum resembles typical vertebra
Each sacral vertebra has
One primary center for body
The joints of the bony pelvis are

The sacro-iliac joints
The public symphysis
The sacro-coccygeal joint
326
The sacro-iliac joint is formed by the lateral

surface of ala of sacrum and the auricular surface
of ilium.
Type: Plane type of synovial joint.
Stability: One of the most stable joints in the
body due to strong ligaments that surround it.
Reciprocal irregularities in the joint surfaces of
the two bones also contributes to the strength
of the joint.
Articular capsule: surrounds the joint.
Ligaments:
1. The anterior sacro-iliac ligament reinforces
the articular capsule on the anterior aspect.
2. The posterior sacro-iliac ligament passes
between posterior superior iliac spine and
the posterior surface of sacrum.
3. The interosseous sacro-iliac ligament connects the rough part of non-articular surface
between the two bones.
It is one of the strongest ligaments of
the body.
Movements: Slight antero-posterior rotatory
movements are possible in the joint. During
pregnancy, in females, weeks before parturition
more movements are possible.
Applied Anatomy
Sprain or dislocation of the sacro-iliac joint
is extremely rare.
Low back pain (sciatica) is usually either of
muscular origin or due to herniated disc at
4th and 5th lumbar vertebrae.
The public symphysis is a secondary cartilaginous joint, between the symphyseal surfaces of
the two public bones.
Type: Secondary cartilaginous joint.
Articular surfaces are coated with hyaline
Ligaments surround the joint.

1. The anterior pubic ligament covers the
anterior surface of the joint.
2. The posterior pubic ligament covers the
posterior surface of the joint.
3. The inferior pubic ligament lies on the
inferior aspect of the joint. It is also called
arcuate ligament.
4. The superior pubic ligament lies on the
superior aspect.
Articular disc is a fibro-cartilaginous disc that
separates the two articular surfaces.
Movements: slight displacement and rotation
movements are possible at this joint.
The sacro-coccygeal joint is the joint between
the lower end of sacrum and the coccyx.
Type: Secondary cartilaginous joint
Ligaments: Surround the joint
1. The anterior sacro-coccygeal ligament lies
on the anterior aspect of the articulating
bones
2. The posterior sacro-coccygeal ligament has
a. A superficial part extends between sacral hiatus to posterior aspect of coccyx.
b. A deep part passes between back of 5th
sacral vertebra and the coccyx.
3. The lateral sacro-coccygeal ligaments on
either side connect the sacrum to coccygeal
transverse processes.
4. The inter-cornual ligament connects the
sacral and coccygeal cornua on either side.
Articular disc is a fibro-cartilaginous intervertebral disc between the body of sacrum and
coccyx.
Movements: Very slight movements are possible
in females, during later months of pregnancy,
more separation is possible prior to the parturition.
tahir99 - UnitedVRG
CHAPTER
31
The Fasciae, Muscles,

Blood Vessels and
Nerves of the Pelvis
THE PELVIC FASCIA
The pelvic fascia is present in the cavity of pelvis

as:
i. The parietal pelvic fascia
ii. The visceral pelvic fascia
The parietal pelvic fascia is continuation of the

fascia transversalis of the anterior abdominal wall.
The various parts of parietal pelvic fascia are:
a. The obturator fascia covers the obturator
internus muscle at the lateral pelvic wall.
It is attached above the ilio-pectineal line.
Over the obturator internus, it forms a
tendinous arch of origin of levator ani
muscle.
b. The pelvic fascia at the tendinous arch splits
into two layers to cover both superior and
inferior surfaces of levator ani.
These two layers form the superior and
inferior fasciae of the pelvic diaphragm.
c. The piriform fascia is a very thin layer of
parietal pelvic fascia that covers the piriformis
muscle.
The visceral pelvic fascia is the condensation of
connective tissue that covers the pelvic organs.
This layer also forms condensation around the
blood vessels of the pelvic organs.
The fascial capsule of prostate gland in males
is formed by the visceral pelvic fascia.
h
a
9
ri 9
G
R
The ligaments of the pelvic organs are condensations of pelvic fascia around the neurovascular bundles of pelvic organs.
These ligaments play an important role in support
of pelvic organs; specially important for the
uterus and urinary bladder.
V
d
ti e
n
U
THE PELVIC MUSCLES

The pelvic musculature consists of:
The levator ani muscles together with coccygeus
muscles form pelvic diaphragm, that lies in the floor
of pelvic cavity (Fig. 31.1).
Origin: The levator ani arises from
Pelvic surface of body of pubis
Obturator fascia at the tendinous arch.
Medial surface of ischial spine.
Fig. 31.1: The pelvic diaphragm
328
Muscle belly is a broad, thin, muscular sheet.

The muscle fibers pass downwards and
medially with varying obliquity.
Insertion:
a. Most anterior fibers are attached to perineal
body
In males: They sweep around prostate gland
to form levator prostatae.
In females: They cross lateral to vagina
forming an additional sphincter for vagina.
b. The intermediate fibers form a muscular
sling at the ano-rectal junction forming
pubo-rectalis, an important factor
preventing fecal incontinence.
Some intermediate fibers blend with longitudinal coat of anal canal to form conjoint
longitudinal coat.
c. The posterior fibers mingle with those of
external anal sphincter. Most posterior fibers
are attached to ano-coccygeal body and last
two pieces of coccyx.
Nerve supply:
Inferior rectal nerve
Perineal branch of 4th sacral nerve.
Actions
1. Levator ani supports pelvic viscera and by
its tone keeps them in position.
2. It helps in maintaining the intra-abdominal
pressure and thus is used in all voluntary
expulsive efforts.
3. The pubo-rectalis sling is an important factor
in preventing fecal incontinence.
4. In females the pelvic diaphragm supports
and maintains uterus and also helps in
parturition.
The coccygeus muscle is a musculo-tendinous sheet
that lies on deep surface of sacro-spinous ligament
Origin:
Is from pelvic surface and tip of ischial spine.
Insertion:
Is on lateral margin of coccyx and fifth sacral
vertebra.
The muscle may be absent; it is, in fact, a

degenerate part of sacro-spinous ligament.
Nerve supply:
Is from fourth and fifth sacral nerves.
Actions:
a. Together with levator ani, it forms the pelvic
diaphragm.
b. The coccyx muscle pulls forwards the
coccyx during defecation and parturition.
The piriformis muscle is attached on front of middle

three pieces of sacrum.
It has a piriform muscle belly that passes out
of pelvis through greater sciatic foramen and
lies behind the hip joint.
The obturator internus muscle is attached to the
pelvic surface of lower half of hip bone and the
obturator membrane.
It gives rise to a tendon that passes out of lesser
sciatic foramen to the gluteal region.
The above two muscles belong to the inferior
extremity. [Detail description in Chapter 15]
THE PELVIC PERITONEUM
The peritoneum in the pelvic cavity lines the walls
and covers the pelvic viscera.
The peritoneum lines on front and sides of upper
one-third of rectum and front of middle onethird of rectum.
On either side of upper one-third of rectum,
the peritoneum is reflected on front of sacrum
forming the para-rectal fossae, which allow for
distension of rectum.
From front of middle one-third of rectum:
a. In males: The peritoneum is reflected on
base of urinary bladder, forming rectovesical pouch, that is 7.5 cm deep from the
perineal skin.
b. In females: The peritoneum is reflected on
back of uppermost part of vagina forming
recto-uterine pouch (pouch of Douglas), that
is 5.5 cm deep from the perineal skin.
tahir99 - UnitedVRG
The Fasciae, Muscles, Blood Vessels and Nerves of the Pelvis

The peritoneum covers both anterior and
posterior surfaces of uterus and is
reflected on superior surface of urinary
bladder as utero-vesical pouch.
On either side of the uterus, the pelvic
peritoneum forms two large foldsthe
broad ligamentsthat connect the
uterus to the lateral pelvic walls.
The recto-uterine pouch in females is accessible
surgically through the uppermost part of posterior
wall (posterior fornix) of vagina.
Any collectionblood, pus or fluidcan be
easily felt and aspirated out from the rectouterine pouch.
The Blood Vessels of the Pelvis
The Arteries
h
a
9
ri 9
}
The external iliac vein accompanies it on

the medial side.
The artery passes deep to the inguinal
ligament at mid-inguinal point and continues
as femoral artery on front of the thigh.
Branches
i. The inferior epigastric artery passes
upwards and medially and pierces fascia
transversalis behind rectus abdominis
muscle to enter rectus sheath.
It gives two small but important branches:
a. The cremasteric branch accompanies
the spermatic cord in males. In
females, the artery is known as
artery of the round ligament.
b. The pubic branch anastomoses with
the pubic branch of obturator artery
on deep surface of pubic bone and
lacunar ligament. In 30% of adults,
this anastomosis continues as the
abnormal obturator artery.
ii. The deep circumflex iliac artery runs along
the inner lip of the iliac crest and supplies
the muscles attached to it.
It gives an ascending branch that runs
upwards between the internal oblique
and transversus abdominis muscles of
the anterior abdominal wall.
C. The internal iliac artery is the smaller terminal
branch of the common iliac artery (Fig. 31.2).
Course: From its origin at the level of lumbosacral disc in front of sacro-iliac joint, the artery
passes backwards up to the upper margin of
greater sciatic notch, where it divides into two
trunksanterior and posterior.
1. The anterior trunk gives the following
branches:
a. The superior vesical that gives branches
to the urinary bladder.
The artery forms the proximal part
of umbilical artery of fetal life.
V
d
ti e
n
U
A. The common iliac arteryright and leftare

the terminal branches of abdominal aorta.
Beginning: The common iliac artery begins at
the lower border of fourth lumbar vertebra,
where the abdominal aorta bifurcates.
Course: The common iliac arteries diverge as
they descend.
The common iliac artery bifurcates into its two
terminal branchesinternal iliac and external
iliacat level of lumbo-sacral inter-vertebral
disc.
Branches
i. Small muscular branches to psoas major and
iliacus
ii. Small branches to ureter
iii. Ilio-lumbar artery (sometimes)
iv. External iliac artery
v. Internal iliac arter
terminal branches.
B. The external iliac artery is the larger terminal
branch of common iliac artery.
Course
The artery descends laterally along the
medial border of psoas major muscle following the inlet of pelvis.
329
G
R
330
Fig. 31.2: The internal iliac artery (in male pelvis)
The distal part of umbilical artery, in

adults, becomes fibrosed to form
medial umbilical ligament up to
umbilicus.
b. The obturator artery passes forwards
along the lateral pelvic wall to reach
obturator canal.
The artery enters medial compartment of thigh along with obturator
nerve.
It gives muscular branches to iliacus
and a pubic branch in pelvis.
c. The inferior vesical artery (in males)
reaches the neck of urinary bladder.
It supplies
The urinary bladder
The prostate gland
The seminal vesicles
The vas deferens (via artery to
the vas deferens)
d. The uterine artery (in females) is
homologous with inferior vesical artery
of the males.
It is a large, tortuous artery that runs
along the lateral border of uterus.
The artery supplies uterus, medial

two-third of uterine tube and upper
part of vagina.
During pregnancy, the artery hypertrophies greatly.
e. The vaginal artery (in females) may be
two or three and may arise from the
uterine artery.
The artery is also homologous with
inferior vesical artery of the males.
It also gives small branches to the
rectum.
f. The middle rectal artery is a small branch
that supplies the muscular coat of
rectum.
The artery anastomoses with superior rectal and inferior rectal arteries.
g. The internal pudendal artery is the
smaller terminal branch of the anterior
trunk.
It passes out of the pelvic cavity
through greater sciatic foremen
below piriformis, crosses the ischial
spine and enters ischiorectal fossa
Branches in the pelvis:
tahir99 - UnitedVRG

Muscular branches to muscles of
pelvic wall.
Vesical branches to neck of the
urinary bladder, and seminal
vesicles and prostate gland in the
males.
h. The inferior gluteal artery is larger
terminal branch that comes out of greater
sciatic foremen and supplies gluteus
maximus muscle.
ii. The posterior trunk gives the following
branches:
a. The ilio-lumbar artery passes upwards
behind the external iliac vessels to reach
iliac fossa and divides into:
Iliac branches to supply iliacus
muscle.
Lumbar branches ascend to supply
psoas major, and quadratus lumborum. They anastomose with fourth
lumbar artery.
b. The lateral sacral branchessuperior
and inferiordivide into two branches
each. Thus superior one supplies
branches to first and second sacral
foramina; and inferior lateral sacral
artery gives branches to enter third and
fourth sacral foramina.
c. The superior gluteal artery is the largest
branch of internal iliac artery.
The artery leaves pelvis through
greater sciatic foramen above piriformis and enters gluteal region to
supply gluteal muscles.
d. Median sacral arteryrepresents
continuation of dorsal aorta in pelvis.
Origin: The artery arises from back of
abdominal aorta just above its bifurcation.
Course: The artery runs downwards in
median plane in front of sacrum accompanied by median sacral vein.
It ends on front of coccyx by joining
the glomus coccygeum
331
Branches: Small branches to back of

rectum
Communicating branches to lateral
sacral and ilio-lumbar arteries.
The Veins
The veins of the pelvis generally follow the arteries.
1. The common iliac veins are formed by the union
of external iliac and internal iliac veins.
The left common iliac vein is longer and crosses
the front of fifth lumbar vertebra.
The two common iliac veins join on front of
fifth lumbar vertebra to the right of midline to
form the inferior vena cava.
2. The external iliac vein is the continuation of
femoral vein, and begins deep to the inguinal
ligament.
It ascends medial to the external iliac artery and
on front of sacro-iliac joint and joins with the
internal iliac vein to form the common iliac vein.
Tributaries
The inferior epigastric vein.
The deep circumflex iliac vein.
The pubic vein ascends on pelvic surface
of pubis and connects the external iliac vein
with obturator vein.
3. The internal iliac vein is formed at the upper
margin of greater sciatic foramen by the union of
veins accompanying branches of internal iliac artery.
Tributaries
From outside pelvis
i. The gluteal veinssuperior and inferior
ii. The internal pudendal vein
iii. The obturator vein
From inside pelvis
iv. The lateral sacral veins
v. The rectal venous plexus
vi. The vesical venous plexus
vii. The uterine venous plexus
viii. The vaginal venous plexus in females.
4. Median sacral vein: accompanies median
sacral artery.
332
It begins from glomus coccygeum on front of

coccyx
It receives small tributaries from back of
rectum
It terminates in left common iliac vein.
The Venous Plexuses of the Pelvic Viscera

The pelvic organs are drained by the venous
plexuses along their walls.
i. The rectal venous plexus is formed by the
superior rectal vein joining with middle rectal
veins and the inferior rectal veins.
ii. The vesical venous plexus lies around the base
of the urinary bladder.
In males, it also lies around the prostate
gland and drains venous blood from the
prostate gland, vas deferens and the
seminal vesicles.
iii. The uterine venous plexus accompanies the
uterine artery and lies along the lateral border
of the uterus between two layers of broad
ligament.
iv. The vaginal venous plexus lies along the walls
of vagina. It is connected with uterine and
rectal venous plexuses.
Pelvic Organs
The lymphatic drainage of the pelvic organs is quite
variable, but it is of great clinical importance in
relation with spread of cancer of pelvic organs.
The different groups of lymph nodes in the pelvis
are:
1. The common iliac lymph nodes are few in
number
These nodes are present below the bifurcation of abdominal aorta on front of fifth
lumbar vertebra.
They drain lymphatics from the external and
internal iliac nodes and send their efferents
to the aortic lymph nodes.
2. The external iliac lymph nodes are arranged

along the external iliac vessels:
They drain lymph from:
Inguinal lymph nodes
Anterior abdominal wall
Genital organs
Superior surface of urinary bladder.
Their efferents reach common iliac
nodes.
3. The internal iliac lymph nodes lie around the
internal iliac vessels.
They receive lymphatics from
The pelvic viscera
The deeper parts of perineum
The gluteal region and back of thigh.
Their efferents reach the common iliac
lymph nodes.
4. The sacral lymph nodes lie along the median
sacral and lateral sacral vessels.
These are members of the internal iliac
lymph nodes and receive some lymphatics
from the rectum.
The Nerves of the Pelvis
The lumbo-sacral plexus supplies the structures of
the pelvis, perineum and the inferior extremity.
Formation: The lumbosacral plexus is formed
by the ventral rami of L4, L5, S1, S2,S3, and S4
spinal nerves (Fig. 31.3).
Position: The lymbo-sacral plexus lies in the
posterior wall of the pelvis behind the parietal
pelvic fascia.
Branches
1. The tibial nerve (L4, L5, S1, S2, S3 anterior
devisions of ventral rami).
2. The common peroneal nerve (L4,L5,S1 and
S2 posterior divisions of ventral rami).
These two nerves are enclosed in a
common sheath forming the sciatic
nerve.
Sometimes there is High division of
sciatic nerve, when these two nerves
do not join and remain separate from
the beginning.
tahir99 - UnitedVRG
333
Fig. 31.3: The lumbo-sacral plexus
3. The superior gluteal nerve (L4,L5,S1 posterior divisions of ventral rami).

It leaves pelvis above piriformis through
greater sciatic foramen to enter gluteal
region.
4. The inferior gluteal nerve (L5, S1, S2 posterior divisions of ventral rami).
It leaves pelvis below piriformis through
the greater sciatic foramen to enter
gluteal region.
5. The pudendal nerve (S 2, S3, S 4 anterior
It leaves pelvis below piriformis through
greater sciatic foramen.
The nerve enters ischiorectal fossa
through lesser sciatic foramen and
supplies the structures in the perineum.
6. The pelvic splanchnic nerves (Nervi erigentesS2, S3, and S4 segments of spinal cord).
They belong to the cranio-sacral outflow
of autonomic nervous system and con-
tain the pre-ganglionic parasympathetic

fibers.
They supply the pelvic organs and the
hind gut by parasympathetic fibers.
They also carry some visceral afferent
fibers.
7. The nerve to the obturator internus (L5, S1,
S2 anterior divisions of ventral rami).
It emerges through the greater sciatic
foramen below piriformis to reach
gluteal region.
It supplies obturator internus and superior gemellus.
8. The nerve to the quadratus femoris (L4, L5,
S1 anterior divisions of ventral rami)
It comes out of the pelvis through
greater sciatic foramen below piriformis.
It supplies quadratus femoris and inferior
gemellus.
9. The posterior cutaneous nerve of thigh
(S1,S2 posterior divisions and S2,S3 anterior
334
It leaves pelvis through greater sciatic

foramen below piriformis.
It lies superficial to the sciatic nerve in
gluteal region.
It supplies skin on back of thigh and
popliteal fossa.
10. The perforating cutaneous (S2,S3 posterior
The nerve pierces sacro-tuberous ligament and supplies skin over lower part
of gluteus maximus.
The Autonomic Nerves in the Pelvis
A. The sympathetic: There are two sympathetic
trunks in the pelvisright and leftand they
descend medial to the anterior sacral foramina.
I. The two sympathetic trunks end in a median
ganglion impar on front of first piece of coccyx.
Branches:
a. Grey rami communicans (GRC): Connect
the sympathetic ganglia to ventral rami of
sacral nerves. They carry vascular branches
for the arteries.
b. Medial branches
Form a plexus around medial sacral
artery.
From upper two ganglia join inferior

hypogastric (pelvic) plexus
II. The sympathetic plexuses
The inferior hypogastric (pelvic) plexus divides
into two partsright and left.
Each part lies lateral to the rectum and
contain many small ganglia.
Superiorly, the plexus is connected with
superior hypogastric plexus (Presacral
nerve).
The preganglionic sympathetic fibers arise from
T11,T12,L1 and L2 segments of spinal cord. The
postganglionic sympathetic fibers arise from the
sympathetic ganglia of sympathetic plexus and
accompany the visceral branches of internal iliac
artery.
B. The parasympathetic is in form of pelvic splanchnic nerves (Nervi erigentes) from S2,S3, S4 spinal
segments.
They carry preganglionic parasympathetic
fibers that join the pelvic plexuses and are
distributed along them.
The pelvic splanchnic nerves constitute the
sacral outflow of parasympathetic.
tahir99 - UnitedVRG
CHAPTER
32
The Perineum
The perineum is the lower end of the trunk, that
lies between the two ischial tuberosities.
The perineum covers the pelvic outlet and
extends from the pubic symphysis in front to
coccyx behind.
Parts: The perineum is divided by an imaginary
plane passing between two ischial tuberosities into:
i. Anal triangleposteriorly
ii. Urogenital triangleanteriorly
THE ANAL TRIANGLE
The anal triangle contains
The anal canal surrounded by external and
internal sphincters in median plane.
Two ischio-rectal fossae on either side of anal
canal containing pads of fat.
The Anal Canal
The anal canal is the last subdivision of the digestive
tube that opens at anus.
Location: It lies in median part of anal triangle
of perineum.
Direction : The anal canal is directed downwards
and backwards from lower end of rectum at
tip of coccyx up to anus.
Length 3.8 cm.
Relations
Anteriorly: Perineal body separating it from
bulb of penis in males and posterior vaginal
wall in females.
Posteriorly: Ano-coccygeal body and tip of
coccyx.
Laterally: ischio-rectal fossa
Parts: The anal canal is divided into three parts:
1. Upper endodermal part (about 15 mm) has
8-10 vertical folds of mucous membrane
anal columns joined together by crescentic

foldsanal valvesenclosing anal sinuses.
This part is limited below by pectinate
line that forms the junction between
endodermal and ectodermal parts.
2. The middle transitional zone-pecten-(about
15 mm) is lined by stratified squamous nonkeratinizing epithelium.
This part is limited below by white line
of Hilton.
3. The lower part (about 7 mm) is lined by
true skin, having hair follicles, sebaceous
and sweat glands.
The Musculature of the Anal
Canal (Fig. 32.1)
The anal canal remains closed except during
defecation due to tonic contraction of sphincters
surrounding it.
A. The internal anal sphincter is formed by
thickening of circular muscle coat, surrounding
upper 30 mm of anal canal.
It is made up of smooth muscle fibers and
is supplied by autonomic nerves.
B. The external anal sphincter is voluntary
sphincter made up of striated muscle fibers.
It has three parts:
i. The deep part is thick annular band that
encircles upper part of anal canal.
ii. The superficial part is attached
Anteriorly to the perineal body
posteriorly to the ano-coccygeal raphe
and tip of coccyx.
iii. The subcutaneous part surrounds the
lowest part of anal canal, below white
line.
336
Fig. 32.1: Coronal section through anal canal
Nerve supply of external sphincter is by

Inferior rectal nerve
Perineal branch of 4th sacral nerve
Actions: The external sphincter remains in
state of tonic contraction to prevent passage
of feces except at defecation.
However, it can be used voluntarily also.
The ano-rectal ring surrounds upper part of
the anal canal. It consists of:
The puborectalis part of levator ani.
The deep part of external anal sphincter
The internal anal sphincter
This ring is palpable during rectal examination as a constricting band. The surgical
division of this ring results in incontinence of
feces.
C. The conjoint longitudinal coat is formed by
the pubo-rectalis part of levator ani fusing with
the longitudinal muscle coat of the anal canal.
It is fibro-elastic in nature, and is divided into
a number of strands below, that are attached
to perianal skin, causing furrows on the skin.
The Blood Supply of the Anal Canal
The endodermal part is supplied by autonomic

nerves.
Sympathetic fibers from pelvic plexuses.
Parasympathetic fibers from the pelvic splanchnic nerves.
The Arteries
The upper endodermal part is supplied by

superior rectal artery.
The lower part (ectodermal) is supplied by

inferior rectal artery.
The Veins
The superior rectal vein continues as the

inferior mesenteric vein that joins splenic
vein.
The inferior rectal vein drains into internal
pudendal vein.
There is a venous plexus in submucous coat of
anal canal connected with superior rectal vein above
and inferior rectal vein below.
Anal Canal
The upper part (endodermal) drains into the internal
iliac lymph nodes.
The lower part (ectodermal) drains into the
superficial inguinal lymph nodes
The Nerve Supply of the Anal Canal
tahir99 - UnitedVRG
The Perineum
The ectodermal part is supplied by inferior rectal

nerve.
1. The piles (Hemorrhoids)develop in cases of
portal obstruction, due to enlargement of the
venous plexus in the submucous coat, between
the tributaries of superior rectal and inferior
rectal veins.
The piles can be
a. Internal piles that develop in relation to
endodermal part only
b. External piles that develop below pectinate
line in relation to ectodermal part
c. Interno-external piles that are covered partly
by mucous epithelium of endodermal part
and partly by stratified squamous epithelium
of ectodermal part.
2. The anal fistula is an abnormal passage in anal
triangle, by side of anus, through which fecal
matter comes out.
The anal fistula may be formed by the
infection of anal glands, which open in anal
sinuses.
Sometimes, a neglected ischio-rectal
abscess may burst in wall of anal canal and
on the perineal skin forming anal fistula.
3. The anal fissure is caused by rupture of one of
the anal columns by hard fecal matter.
The fissure usually extends below the anal
column in the pecten or transitional zone,
and becomes very painful.
The Ischio-Rectal Fossa
The ischio-rectal fossa forms the lateral part of the
anal triangle.
It lies by the side of the anal canal.
Shapewedge shaped
Boundaries
Superior: Origin of levator ani from the
obturator fascia.
Inferior: Perianal skin
Medial:
External anal sphincter
337
Inferior surface of levator ani, covered
by pelvic fascia.
Lateral:
Ischial tuberosity
Obturator fascia covering obturator
internus muscle.
Pudendal canal (Alcocks canal) lies
in the lateral wall.
Anterior: Posterior border of urogenital
diaphragm.
Posterior:
Posterior border of gluteus maximus
Sacro-tuberous ligament.
The two ischio-rectal fossae communicate with each other behind the anal
canal.
Contents
1. Ischio-rectal pad of fat that supports the
anal canal.
2. Inferior rectal nervea branch of
pudendal nerve. Its motor fibers supply
external anal sphincter. Its sensory fibers
supply ectodermal part of anal canal and
perianal skin.
3. Inferior rectal vessels that are branches
from the internal pudendal vessels.
4. Perineal branch of fourth sacral nerve
that enters ischiorectal fossa between
coccyges and levator ani.
It supplies external anal sphincter,
levator ani and coccyges. It also
supplies the skin between anus and
coccyx.
The ischio-rectal abscess is a very painful condition.
A large abscess may extend to the opposite side
behind the anus, thus making a horseshoeshaped abscess.
A neglected ischio-rectal abscess may burst
through its medial wall into the anal canal. It
may later burst through skin, causing anal
fistula.
338
The Pudendal Canal (Alcocks Canal)

It is a fascial canal, that lies in the lateral wall of the
ischiorectal fossa.
Extent: It extends from the lesser sciatic notch
to the posterior border of urogenital diaphragm.
Formation: The pudendal canal is formed
between the obturator fascia and the fascia
lunata, which is described as the deep fascia of
the ischiorectal fossa.
Contents:
i. The internal pudendal vessels.
ii. The pudendal nerve, that divides into
A perineal branch
A dorsal nerve of penis (or clitoris).
The Blood Vessels of the Perineum
The Arteries
A. The internal pudendal artery is one of the
terminal branches of anterior division of internal
iliac artery.
Origin: The internal pudendal artery arises
in the posterior pelvic wall, from the anterior
Course: The artery enters the perineum by
passing through the lesser sciatic foramen
from the gluteal region.
The artery lies within the pudendal canal
in the lateral wall of ischiorectal fossa,
as it passes forwards.
The internal pudendal artery runs along the
conjoint ramus in urogenital triangle above
perineal membrane.
It bifurcates below inferior pubic ligament
into
Deep artery of penis (clitoris)
Dorsal artery of penis (clitoris)
Branches
1. Inferior rectal artery arises in pudendal
canal and supplies the anal canal and
lower part of rectum.
2. Perineal branch also arises in the
pudendal canal. It gives:
A transverse perineal branch

Two posterior serotal (labial)
branches
An artery to the bulb of penis
(clitoris)
3. The deep artery is one of the terminal
branches, that enters crus of the penis
(clitoris) and supplies corpus cavernosum.
4. The dorsal artery of the penis (clitoris)
is the other terminal branch. It runs on
the dorsal aspect of penis (clitoris)
reaching up to glans.
B. The external pudendal arteries are two
superficial and deep that arise from the femoral
artery in the femoral triangle.
These arteries supply the superficial parts
of the perineum including the external
genitals.
The Veins
The veins of the perineum generally follow the
arteries. The internal pudendal vein is a tributary
of the internal iliac vein.
The external pudendal veins end in the femoral
vein. The deep dorsal vein of penis (clitoris) passes
into the pelvic cavity through the gap below inferior
pubic ligament and ends in
Prostatic venous plexus in males.
Vesical venous plexus in females.
The Nerves of the Perineum
The pudendal nerve (S2,S3,S4 ventral division of
the ventral rami) is a branch of sacral plexus.
Course: The pudendal nerve enters perineum
by passing through the lesser sciatic foramen
from the gluteal region.
The nerve lies in pudendal canal along with
the internal pudendal vessels.
The nerve divides into its branches in the
pudendal canal.
Branches
1. The inferior rectal nerve arises in the
posterior part of pudendal canal. It supplies
tahir99 - UnitedVRG
The Perineum
motor fibers to external anal sphincter; and
sensory fibers to lower end of anal canal,
ischio-rectal fossa and perianal skin.
2. The perineal branch is the larger terminal
branch.
It lies in pudendal canal below the
internal pudendal vessels.
It gives two posterior scrotal (labial)
branches to supply the skin of posterior
two-third of scrotum (labium majus).
It supplies motor fibers to all the perineal
muscles.
3. The dorsal nerve of penis (clitoris) lies on
the dorsum of penis (clitoris) deep to the
fascia.
It supplies sensory fibers to the penis
(clitoris) including its glans.
Clinical Consideration
The pudendal nerve can be blocked by infiltrating
a local anesthetic in the nerve. The needle is
introduced just medial to ischial tuberosity, and
directed towards the ischial spine.
THE UROGENITAL TRIANGLE
IN THE MALES
The urogenital triangle in the males has:
i. The male external genital organs
The scrotum with spermatic cord
The penis.
ii. Two perineal pouchessuperficial and
deepcontaining muscles, vessels, nerves
and structures of root of penis.
The Scrotum
It is a pendulous sac made up of skin and fasciae
that lodges both testes and lower parts of the two
spermatic cords.
Layers of the scrotum
1. The skin is thin, dark colored and has no
fat.
339
2. The dartos muscle is the involuntary muscle

that replaces the fat in subcutaneous tissue.
It is supplied by sympathetic nerves and
it wrinkles the skin of scrotum.
3. The membranous layer of superficial fascia
(Colles fascia) forms a thin layer deep to
dartos.
The Blood Vessels
The arteries are:
Two external pudendal branchessuperficial and deepfrom femoral artery.
Two posterior scrotal branches of internal
pudendal artery.
The cremasteric branch of the inferior
epigastric artery.
The veins follow the corresponding arteries.
The lymphatics of the scrotum drain into the
superficial inguinal lymph nodes.
The nerves
Anterior one-third of scrotum is supplied
by ilio-inguinal nerve (L1 spinal segment).
Posterior two-third of scrotum is supplied
by posterior scrotal branches of perineal
nerve (S3 spinal segment).
The Penis (Male Copulatory Organ)

The penis consists of a body and an attached
portionthe root.
1. The body of penis has three structures made up
of cavernous erectile tissue.
i. One corpus spongiosum situated ventrally and
contains penile (spongy) part of urethra. It
terminates anteriorly as the glans penis.
ii. Two corpora cavernosa that lie dorsally and
have a thick tunica albuginea made up of
fibrous tissue.
The two corpora cavernosa are incompletely separated by a pectiniform
septum.
The layers of the body of penis (Fig. 32.2)
i. The skin is thin and dark in color. It is loosely
connected to the deeper structures.
340

The crura are continuous with corpora
cavernosa of the body of penis. The structures of the root of penis lie in the superficial
perineal pouch of urogenital triangle.
The Blood Vessels of the Penis
Fig. 32.2: TS of penis
ii. The superficial fascia contains no fat. The

membranous layer of superficial fascia
Colles fascia lies in its deeper part.
iii. The fascia penis is a condensed layer of
fibrous tissue, that surrounds the body of
penis. The deep dorsal vein, along with
dorsal artery and dorsal nerve of penis lies
deep to the fascia penis on dorsal aspect.
The ligaments of body of penis.
i. The fundiform ligament is made up mostly
of elastic fibers from the lower part of linea
alba. It divides into two parts that unite
below the body of penis.
ii. The suspensory ligament is triangular in
shape and lies deep to the fundiform
ligament. It is attached above the front of
pubic symphysis and below it fuses with
fascia penis.
2. The root of the penis consists of three erectile
structures, that are continuous with the corresponding structures of the body of penis.
The bulb of the penis is firmly attached to the
perineal membrane. It is a slightly dilated portion,
that is continuous with the corpus spongiosum
of the body and contains penile (spongy) part
of urethra.
The crura of the penis are elongated erectile
structures attached firmly to the everted edges
of the ischio-pubic rami.
The arteries of the penis are

1. The deep arteries that supply the erectile
tissue of corpora cavernosa.
2. The dorsal arteries that lie on the dorsal
aspect of penis deep to the fascia penis.
3. The artery to the bulb supplies the erectile
tissue of the bulb and the corpus
spongiosum.
All the arteries are branches of internal
pudendal arteries.
The veins of the penis drain the venous blood
from the erectile tissue.
The superficial dorsal vein divides into two
branches that end in external pudendal veins.
The deep dorsal vein receives venous blood
from corpora cavernosa and corpus spongiosum, and enters pelvic cavity through a
gap below the inferior pubic ligament.
It ends in prostatic venous plexus.
The Lymphatics of the Penis
The lymphatics from the glans penis pass on to

the deep inguinal lymph nodes.
The lymphatics from the erectile tissue and
penile urethra end in internal iliac lymph nodes.
The Nerves of the Penis

i. The pudendal nerve (S 3,S 4,S 5) gives the
dorsal nerves of the penis.
ii. The pelvic plexuses carry autonomic fibers.
The Spermatic Cord
The spermatic cord is a round bundle consisting
of structures passing to and from the testis up to
the deep inguinal ring (Fig. 32.3).
tahir99 - UnitedVRG
The Perineum
iv. The vestige of the processus vaginalis is

remnant of a tube of peritoneum that
extended from the deep inguinal ring up to
the tests: where its lower portion persists
as the tunica vaginalis.
v. The sympathetic plexus accompanies the
testicular artery and supplies the testes
(testicular plexus). The sympathetic plexus
also accompanies the vas deferens.
vi. The lymphatics from the testes ascend along
the testicular vessels.
They end in para-aortic lymph nodes.
vii. Two small arteries
a. Artery to the vas deferens is a branch of
inferior vesical artery and reaches up to
the posterior border of testes.
It has very little anastomosis with
the testicular artery.
b. Cremasteric branch of the inferior
epigastric artery.
Fig. 32.3: The spermatic cord
Location: The spermatic cord ascends in the

scrotum and passes through the inguinal canal.
Coverings: The spermatic cord has three
coverings derived from the layers of anterior
abdominal wall.
1. Outer coveringexternal spermatic fasciais derived from aponeurosis of external
oblique muscle.
2. Middle coveringcremaster muscle and
fasciais derived from internal oblique
muscle.
3. Inner coveringinternal spermatic fascia
is derived from fascia transversalis.
Contents: The main structures are:
i. The vas deferens is a thick-walled muscular
tube that conveys sperms from epididymis
to the ejaculatory duct.
It feels like a whip cord and lies in the
posterior part of the spermatic cord.
ii. The testicular artery a long slender branch
of abdominal aorta.
It is the only artery supplying tests.
iii. The pampiniform plexus (pampini = tendrils
of vine) of veins surrounds the testicular
artery.
At the deep inguinal ring, the veins of
the plexus join to form a single testiculat
vein.
The smaller structures are:
341
Clinical Importance
Varicocele is congestion and enlargement of the
pampiniform plexus due to venous stasis.
The condition is quite common, and mostly
occurs on the left side as the left testicular vein
is likely to be compressed by loaded pelvic
colon.
The Superficial Perineal Pouch in
Males (Fig. 32.4)
It is defined as the space between the perineal

membrane (inferior fascia of urogenital
diaphragm) and the membranous layer of
superficial fascia of perineum (Colles fascia).
Boundaries
On two sides the pouch is closed by the
conjoint rami, where both layers of fascia
(mentioned above) are attached.
Posteriorly the pouch is closed due to
attachment of Colles fascia to posterior free
border of perineal membrane.
342

Two ischio-cavernosus
Two superficial transverse perinei
c. Other contents
Perineal branch of posterior cutaneous
nerve of thigh.
Posterior scrotal nerves and vessels
(paired)
Nerve Supply
All the superficial perineal muscles are supplied by
the branches of perineal nerve (a branch of pudendal
nerve).
Fig. 32.4: The superficial perineal pouch in males
Anteriorly the pouch is open and communicates with space in anterior abdominal wall
between membranous layer (Scarpas
fascia) and external oblique muscle.
Contents
a. Structures of root of penis
Bulb of penis
Two crura of penis
b. Superficial perineal muscles (Table 32.1)
Bulbo-spongiosus
The Deep Perineal Pouch in Males
It is the space between parietal layer of pelvic

fascia (superior fascia of urogenital diaphragm)
and the perineal membrane (inferior fascia of
urogenital diaphragm).
Boundaries
On two sides: The pouch is closed as the
two layers of fascia are attached to the
conjoint rami.
The pouch is closed due
Posteriorly:
to fusion of the two fascial
Anteriorly:
layers
Table 32.1: Superficial perineal muscles in the male

Name
1. Bulbo spongiosus
Origin
Muscle belly
Insertion
Actions
Perineal body
Muscle belly lies in

mid-line
Covers bulb of penis
1. Help to empty
urethra
Inferior surface of
perineal membrane
2. Ischiocavernosus
3. Superficial
transverse
perinei
Medial aspect of
ischial tuberosity
and ramus of
ischium
Medical aspects
of ischial
tuberosity
Muscle belly covers

medial and inferior
aspects of crus of
penis
posterior border of
superficial perineal
pouch
Dorsum of corpus
spongiosum
Extension on dorsum
of penis
Aponeurosis attached
to sides and inferior
aspect of crus of penis
Perineal body
tahir99 - UnitedVRG
2. Helps in erection of
penis
Help to maintain the

erection of penis
The two muscles help

to steady the perineal
body
The Perineum
Contents
a. Membranous part of male urethra
b. Deep perineal muscles (Table 32.2)
Two deep transverse perinei
Sphincter urethrae
c. Other contents
Bulbourethral glands(Cowpers glands)
paired
Artery and nerve of the bulb of penis
Internal pudendal vessels
Pudendal nerve.
Nerve Supply
Deep perineal muscles are supplied by perineal
nerve.
The urogenital diaphragm forms a partition
between the pelvic cavity, and the superficial part
of perineum.
The diaphragm fills up the space between the
two conjoint rami, leaving a small gap anteriorly
below inferior pubic ligament.
The urogenital diaphragm consists of
1. The parietal layer of pelvic fascia (superior
fascia or urogenital diaphragm)
2. The deep perineal muscles
Sphincter urethrae
343
3. The perineal membrane (inferior fascia of

urogenital diaphragm).
The perineal membrane (Inferior fascia of
urogenital diaphragm)
It is a thick fibrous membrane that stretches
between two conjoint rami.
It is nearly quadrangular in shape, and its
anterior part is thickened to form transverse
ligament of perineum.
It leaves a small gap anteriorly below inferior
pubic ligament, through which deep dorsal vein
of penis enters the pelvic cavity and ends in
prostatic venous plexus.
Structures piercing the perineal membrane:
1. Membranous part of urethra.
2. Arteries of the bulb of penis (paired).
3. Posterior scrotal nerves and vessels (paired).
4. Dorsal nerve of the penis.
5. Ducts of the bulbo-urethral glands (on either
side).
THE UROGENITAL TRIANGLE IN
FEMALES
The external genitals of females consists of
i. The labia majoratwo large folds with hairy
skin separated by pudendal cleft, into which urethra
and vagina open.
ii. The mons pubis is a rounded eminence in
front of pubic symphysis formed by subcutaneous
fat.
Table 32.2: Deep perineal muscles in the male

Name
Origin
Muscle belly
Insertion
Actions
1. Deep transverse
perinei
Medial aspect of
ramus of ischium

posterior border of
perineal membrane
Perineal body
2. Sphincter
Urethrae
(a) External
part
Medial aspect of
conjoint ramus
Two partsanterior
and posteriorthat
pass in front and
behind the urethra
Attached to the opposite

conjoint ramus
1. The two muscles help

to steady perineal
body
1. It helps to compress
the membranous urethra (external sphincter)
2. It helps to express
last drops of urine or
semen.
(b) Internal part
Surrounds membranous urethra

circumferentially
344
iii. The labia minora are two small cutaneous folds

located inside labia majora. They do not contain
fat.
The two labia minora are seprated by vestibule
of vagina.
Anteriorly the labia minora are divided into two
parts
Above they from the prepuce of clitoris.
Below they form the frenulum of clitoris.
iv. The clitoris is an elongated erectile structure
that is homologous with penis of males.
The body od clitoris is composed of:
Two corpora cavernosa made of erectile
cavernous tissue.
The glans is continuation of a commissure
formed by the two vestibular bulbs.
The root of clitoris is the attached part and is
made up of:
Two crura of clitoris attached to the conjoint
rami and continuous with the corpora
cavernosa.
Two bulbs of the vestibule made up of
erectile tissue and lie on either side of vaginal
orifice.
v. The vaginal orifice (introitus) is a sagittal
orifice covered by a membranehymen.
The hymen is ruptured during first coitus and
small remnantscarunculae hymenales
remain.
vi. The external urethral meatus is located about

2 cm anterior to the vaginal orifice.
The Superficial Perineal Pouch in
Females (Fig. 32.5)
The superficial pouch has the same boundaries

as in the males.
Contents
a. Structures of the root of clitoris
1. Two crura of clitoris
2. Two bulbs of the vestibulethat join on
the ventral aspect of clitoris to form a
commissure that is continuous anteriorly
as glans of clitoris.
b. Superficial perineal muscles (Table 32.3)
Two superficial transverse perinei
Two ischio-cavernosus
Bulbo-spongiosuspaired
c. Other contents
Greater vestibular (Bartholins) glands
paired.
Posterior labial vessels and nerves
paired.
Perineal branch of posterior cutaneous
nerve of thigh.
Nerve Supply
Superficial perineal muscles are supplied by perineal
nerve, a branch of pudendal nerve.
Fig. 32.5: The superficial perineal pouch in females
tahir99 - UnitedVRG
The Perineum
345
Table 32.3: Superficial perineal muscles in the female

Name
1. Superficial
transverse
perinei
Origin
Muscle belly
Insertion
Actions
Corpora cavernosa of
clitorisfasciculus on
dorsum of clitoris
1. It contracts vaginal
orifice
2. It helps in erection
of clitoris
Same attachments and actions, except that

they are much smaller
2. Ischio-cavernosus
3. Bulbo-spongiosus
Anterior part of
perineal body
Muscle belly surrounds

vaginal orifice and
covers the vestibular
bulbs
Table 32.4: Deep perineal muscles in the female

Name
1. Deep transverse
perinei
Origin
Muscle belly
Insertion
has same attachments and actions as in males
2. Sphincter urethrae
Superior fibers
Surround the female urethra circumferentially
Inferior fibers
Transverse
Muscle belly sweeps
Some fibers interlace
perineal ligament backwards on each side
with opposite side
of urethra
Some fibers are attached
to vaginal wall
The Deep Perineal Pouch in Females

The deep perineal pouch has the same boundaries
as in the males (Table 32.4).
Actions
Contents:
1. A part of female urethra.
2. A part of vagina.
3. Deep perineal muscles
It compresses the
urethra

Sphincter urethrae.
4. Internal pudendal vessels.
5. Dorsal nerve of clitoris.
Nerve Supply
The deep perineal muscles are supplied by the
perineal nerve, a branch of pudendal nerve.
CHAPTER
33
The Pelvic Viscera1

The pelvic cavity has:
A part of gastrointestinal tract consisting of
Part of sigmoid (pelvic) colon
Rectum.
A part of urinary system consisting of
Pelvic part of ureter
Urinary bladder
Urethra
Genital organs
In males
In females
Testes
Ovaries
Epididymis
Uterine tubes
Vas deferens
Uterus
Seminal vesicles
Vagina
Prostate gland
THE RECTUM
The rectum is part of gastro-intestinal tract that
lies between pelvic colon and the anal canal.
Location: The rectum lies in front of lower half
of sacrum, in posterior part of pelvic cavity.
Extent: It begins on front of 3rd sacral vertebra,
where pelvic colon ends.
It is continuous with anal canal, about 1 cm
below and in front of tip of coccyx.
Length: About 12 cm.
Flexures: The rectum is not a straight tube (Fig.
33.1).
It shows two anteroposterior flexures.
a. Upper: sacral flexure, is concave anteriorly.
b. Lower: perineal flexure, is convex anteriorly.
The rectum also shows three lateral flexures.
i. Upper: convex towards right.
ii. Middle: quite prominent and convex towards
left.
iii. Lower: convex towards right.
Fig. 33.1: The flexures of rectum
The rectal ampulla is the lower dilated portion of

rectum just above the pelvic floor.
The rectum differs from the pelvic colon in
following respects:
The rectum has no sacculations and taenia coli,
because its longitudinal muscle coat is complete.
It has no appendices epiploiceae (pouches of
peritoneum full of fat).
The rectum has no mesentery.
Peritoneal Relations
The peritoneum covers front and sides of upper
one-third of rectum.
It covers only front of middle one-third of
rectum. The lower one-third has no peritoneal
covering.
In males: The peritoneum from front of middle
one-third of rectum passes to the base of urinary
bladder forming recto-vesical pouch.
In females: The peritoneum from front of
middle one-third of rectum passes to the back
of upper part of vagina forming recto-uterine
pouch (pouch of Douglas).
tahir99 - UnitedVRG
The Pelvic Viscera1
347
Interior of Rectum
The Lymphatic Drainage of Rectum
These are three horizontal folds (Valves of

Houston) inside the cavity of rectum.
These horizontal folds are permanent, and have
a crescentic shape with muscous membrane
covering a part of muscle coat of rectum.
1. The upper fold is near the beginning of
rectum and projects usually from left wall.
2. The middle fold is the largest and most
constant. It lies just above rectal ampulla,
projecting from right and anterior wall.
3. The lower fold is inconstant and projects
from left wall.
According to Paterson, the rectum is divided
into two functional parts by the middle fold.
The upper part develops from the hind
gut and is free to distend, when it is full of
feces.
The lower part develops from the endodermal cloaca, along with endodermal part
of anal canal.
The lymphatics from the upper half of rectum

accompany the superior rectal vessels and pass
via para rectal nodes to the inferior mesenteric lymph
nodes.
The lymphatics from lower half of rectum
accompany the middle rectal vessels and end
in internal iliac lymph nodes.
The Supports of the Rectum
The rectum is kept in position by the following
factors:
1. The normal tone of muscles forming the pelvic
diaphragm (mainly levator ani)
2. The fascia of Waldeyer is condensation of
connective tissue in front of lower half of
sacrum, that binds rectum firmly to the sacrum.
3. The two lateral true ligaments are formed by
thickening of connective tissue around the
middle restal vessels.
The Nerve Supply of the Rectum
The Blood Supply of the Rectum

The Arteries
1. The superior rectal artery is continuation of the
inferior mesenteric artery.
2. The middle rectal artery (paired) from the
anterior division of internal iliac artery is a small
artery that mainly supplies the muscle coat.
3. Small branches from median sacral artery.
The Veins
Form a rectal venous plexus that lies mainly in the
submucous coat.
The venous plexus is drained mainly by the
superior rectal vein, that continues as the inferior
mesenteric vein.
The middle rectal veins drains venous blood
mainly from the muscle coat.
The rectum is supplied by the autonomic nerves.

The sympathetic is contributed by pelvic plexuses.
The parasympathetic is supplied by the pelvic
splanchnic nerves (nervi erigentes) derived from
S2, S3 and S4 segments of spinal cord.
1. Prolapse of rectum takes place due to weakness
of its supports, mainly by loss of tone of levator
ani muscles.
2. Cancer of rectum is also common in elderly
persons.
THE PELVIC PART OF URETER
The ureter is a muscular tube, that conveys urine
from the renal pelvis to the urinary bladder.
348
Course: The ureter enters the pelvic cavity by

crossing the common iliac artery, near its
bifurcation at the pelvic inlet.
The ureter runs downwards and backwards
along the lateral pelvic wall lying just deep to
the peritoneum in extraperitoneal tissue.
It crosses the obturator nerve, branches of
anterior division of internal iliac artery and
obturator internus muscle, covered by obturator
fascia up to the level of ischial spine.
Then, ureter bends forwards above levator ani.
In males: It is crossed from lateral to medial
side by the vas deferens, and reaches posterior
superior angle at the base of urinary bladder.
In females: The ureter passes forwards by side
of upper part of vagina, lying just below the
uterine artery and broad ligament of uterus to
reach the base of urinary bladder.
The ureter pierces the bladder wall very
obliquely through its muscle coat, and opens in the
cavity of urinary bladder at upper angle of the
trigone of the bladder.
The Blood Supply of Ureter
The arteries supplying pelvic part of ureter are
Small branches of common iliac artery
Inferior vesical artery (in males)
Uterine artery (in females).
These vessels have longitudinal anastomosis in
the walls of the ureter.
The veins accompany the arteries.
The Lymphatic Drainage of Ureter
The lymphatics of ureter end in common iliac,
external iliac and internal iliac lymph nodes.
The Nerves Supply of the Ureter
At the pelvic inlet, the ureter is supplied by the

hypogastric plexus (L1, L2 segments of spinal
cord). The referred pain from this part is felt in
inguinal and pubic regions.
The terminal part of ureter is supplied by the

pelvic plexus (S2, S3, and S4 segments of spinal
cord). The referred pain from this part of ureter
is felt in perineum and back of thigh.
1. Ureteric stone: Causes abnormal uretrine
contractions and spasm leading to ureteric colic.
The ureteric stone is liable to be impacted at
one of the following three constrictions:
a. At the pelvi-ureteric junction
b. At pelvic inlet
c. At site of piercing the bladder wall.
2. The left ureter, in females, is more closely related
to the lateral vaginal wall. Thus, it is more likely
to be lacerated in cases of difficult childbirth.
THE URINARY BLADDER
The urinary bladder is a hollow muscular organ
that stores urine for a short period, till the next act
of micturation (Fig. 33.2).
Location
In adults: It lies in the anterior part of pelvic
cavity behind pubic symphysis. When full,
the bladder rises above the pubic symphysis
in hypogastric region of abdominal cavity.
In infants at birth, the urinary bladder, is an
abdominal organ since there is no pelvic
cavity.
It progressively descends with age and
reaches its adult position in pelvis by
puberty.
Shape
When emptyTetrahedron
When fullOvoid
Capacity
In adult male: It is about 120-320 ml (average about 220 ml)
In adult female: It is less
The bladder can hold up to 500 ml, but it
becomes painful.
tahir99 - UnitedVRG
The Pelvic Viscera1
349
Fig. 33.2: Sagittal section through male pelvis
Surfaces: The urinary bladder has:

1. An apex: That lies at upper border of pubic
symphysis. The median umbilical ligament
(remnant of urachus) connects it to the
umbilicus.
2. The base: Fundus of posterior surface) is
triangular in shape.
In males: It has peritoneal covering in
median plane. On either side it is related
to the ampulla of vas deferens and
seminal vesicle.
In females: It is related to the anterior
vaginal wall.
3. The superior surface is triangular in shape
and covered by peritoneum. It is related to
coils of pelvic colon and terminal ileum.
4. The two infero-lateral surfaces are related
to pubic bone, retropubic fat and origin of
levator ani from obturator fascia.
5. The neck of urinary bladder is the lowest
and most fixed part that lies behind lower
part of pubic symphysis.
The neck is pierced by internal urethral
meatus.
In males: The neck is related to the base

of prostate gland.
The Ligaments of the Urinary Bladder
i. The median umbilical ligament ( remnant of
urachus) connects the apex of bladder to the
umbilicus.
ii. Two medial umbilical ligaments lie on either
side of apex, reaching up to umbilicus. These
are remnants of umbilical arteries.
iii. Two pairsmedial and lateral pubo-prostatic
(pubo-vesical in females) ligamentsconnect
the neck of bladder to the pelvic surface of
pubic bones.
The Inferior Urinary Bladder
Shows mucosal folds in the empty state except at
a triangular area in the interior of base of bladder
called trigone of bladder.
The trigone has the following features
1. The openings of two ureters are located at the
lateral angles of trigone.
2. The internal urethral meatus lies at the anterior
inferior angle.
350
3. The two ureteric openings are 2.5 cm apart in

an empty bladder. However, when the bladder
is full, they become 5.0 cm apart.
4. The trigone has a separate trigonal muscle,
derived from the muscle coat of ureters.
5. In males: There is a slight swelling uvula
vesicae behind the internal urethral meatus,
caused by the median lobe of prostate gland.
The Blood Supply of the Urinary Bladder
The arteries are:
Paired superior vesical artery.
Paired inferior vesical artery (uterine in females)
Small branches from obturator artery.
All these arteries are branches of anterior division
of internal iliac artery.
The veins from vesical venous plexus that lies
in relation with infero-lateral surfaces.
In males: The venous plexus joins with the prostatic
venous plexus.
The venous plexus drains into the internal iliac
veins.
The afferent pain fibers stimulated

by overdistention, stone or muscle spasm
travel both via sympathetic and parasympathetic. Therefore, simple division
of sympathetic pathways (presacral
neurectomy) does not relieve the bladder
pain.
1. Cystoscopy is performed by passing an endoscopic instrumentthe cystoscopevia urethra.
This procedure visualizes the interior of bladder.
2. Vesical calculus(stone in bladder)causes
pain and hematuria.
3. Patent urachus is a rare condition, that causes
a urinary fistula from the apex of bladder to umbilicus.
THE URETHRA
The urethra is the fibrous canal that carries urine
from urinary bladder to the exterior (Fig. 33.3).

Urinary Bladder
The lymphatics begin from the lymph plexuses deep
to the mucous membrane and among the muscle
fibers. The lymphatics end mainly in external iliac
lymph nodes.
The Nerve Supply of the Urinary
Bladder
The urinary bladder is supplied by autonomic
nerves.
The sympathetic fibers reach via pelvic plexus.
(T11, T12, L1 and L2 segments of spinal cord).
The parasympathetic fibers are derived from
pelvic splanchnic nerves (Nervi erigentes). They
are derived from S2, S3, and S4 segments of
the spinal cord.
Afferent fibers: The afferent fibers concerned
with emptying of bladder reach via parasympathetic nerves.
tahir99 - UnitedVRG
Fig. 33.3: The male urethra
The Pelvic Viscera1

A. The male urethra is about 20.0 cm long and is
divided into three partsprostatic, membranous
and spongy (penile).
a. The prostatic urethra begins at the neck of
bladder at internal urethral meatus and ends at
the superior fascia of urogenital diaphragm.
Length: 3.0 cm
The prostatic urethra is the widest and most
dilatable part of male urethra.
Features: In its posterior wall there is
urethral crest with a round swellingcolliculus seminalisin the middle.
There are three openings on the colliculus
seminalis:
1. One median for prostatic utricle.
2. Two lateral for the ejaculatory ducts.
3. On either side of urethral crest, there is
a shallow depressionprostatic sinus
in which the ducts of the prostatic glands
open.
b. The membranous urethra lies in the deep
perineal pouch between two fascial layers
enclosing the urogenital diaphragm.
This is the narrowest segment of male
urethra.
It is surrounded by sphincter urethraethat
acts as a voluntary external sphincter.
The segment of urethra is more susceptible
to injury, during passage of instrument
through urethra due to
i. Its narrowness
ii. Its delicate walls
iii. Its angulation with the spongy urethra.
Length: 2.0 cm
c. The spongy (penile) urethra is the longest part
of male urethra.
Length15 cm.
It begins at the inferior fascia of urogenital
diaphragm and ends at external urethral
meatus.
This part lies within the bulb of penis, corpus
spongiosum and glans of penis.
There are two dilatations in this part:
351
i. One intrabulbar fossa in the bulb of penis.

ii. One navicular fossa in the glans of penis.
The ducts of bulbo-urethral (Cowpers)
gland open in this part just below urogenital
diaphragm.
The dorsal wall of spongy urethra has
Openings of many mucus glands.
Lacunae or pit-like recesses directed
forwards. The lacuna magna lies in the
navicular fossa.
While passing an instrumentmetal catheter
or bougiethrough urethra, its point may
be held up in these openings if it is directed
towards dorsal wall.
The spongy urethra ends at external urethral
meatus, that is a sagittal slit, about 6 mm
long at the tip of the glans.
The external meatus is guarded by two
lateral labia. It is the narrowest point of male
urethra. If an instrument can pass through
it, it can easily pass through rest of urethra.
The urethral sphincters: There are two sphincters
in relation to male urethra.
1. The internal-sphincter vesicaeis
present at the neck of the bladder. It is
an involuntary sphincter formed by nonstraited muscle, and controlled by
autonomic nerves.
2. The external-sphincter urethrae
surrounds the membranous part of
urethra. This is a voluntary sphincter
formed by skeletal muscle and controlled
by somatic nerves.
B. The female urethra is about 4.0 cm long.
It extends from the neck of bladder to the
external urethral meatus.
It is homologous with upper part of prostatic
urethra of males.
Location: The female urethra is embedded in
anterior wall of vagina. Thus in cases of difficult
child-birth, it is more likely to be lacerated.
352
The female urethra is more dilatable and opens

in anterior part of vestibule of vagina between
two labia minora, about 2.5 cm behind the glans
clitoris.
Many small urethral glands open in female
urethra.
The paraurethral glands (Skenes glands) open
by paraurethral duct in vestibule of vagina close
to the urethral orifice.
MALE REPRODUCTIVE ORGANS

Testis
The testis: The testes are the male gonads (sex

glands), that produce the sperms and the male
hormone (testosterone).
Size: 4-5 cm(l) 2.5 cm (w) 3.0 cm (th).
Shape: Oval, laterally compressed.
Location: The testes lie in scrotum outside
pelvic cavity; because high intra-abdominal
temperature is not suitable for production of
normal, motile sperms.
The coats of the testis: The testis has three coats:
i. Tunica vaginalis: The visceral layer of tunica
vaginalis covers the testis on all sides except
the posterior border.
ii. Tunica albuginea is thick fibrous coat that
covers the testis externally.
The coat sends delicate connective tissue
septulae in the interior of testis to divide
it into 200-300 compartments (lobules).
The tunica albuginea is thickened along
the posterior border of testis to form
the mediastinum testes, that contains:
Branches of testicular artery
Venous plexus, that will continue as
pampiniform plexus
Rete testis: A plexus of efferent
tubules that conducts sperms
Lymphatics
Sympathetic plexus
iii. Tunica vasculosa is formed by delicate

connective tissue containing plexus of fine
blood vessels.
It lines the interior of the lobules (compartments) of testis.
The Coverings of the Testis
a. Parietal layer of tunical vaginalis.
b. The internal spermatic fascia derived from
fascia transversalis.
c. The cremasteric muscle and fascia derived from
fleshy party of internal oblique muscle.
d. The external spermatic fascia derived from
external oblique aponeurosis.
The tunica vaginalis is a closed serous sac
with a parietal and visceral layer that surrounds
testis and epididymis except at its posterior
border.
The tunica vaginalis is the persistent lower
end of processus vaginalisa tube of
peritoneum that descends along with testis
up to scrotum.
The part of processus vaginalis from upper end
of testis up to deep inguinal ring, is obliterated
usually persisting as a fibrous cordvestige of
processus vaginalis (Fig. 33.4).
Structure of the Testis
The testis has about 200-300 compartments

(lobules) separated by connective tissue
septulae.
Each lobule contains 1-3 seminiferous tubules
just visible to the naked eye as delicate threads
(length 70-80 cm)diameter 0.010.13 mm
(Fig. 33.5).
Each seminiferous tubule has
a. A coiled part where spermatogenesis takes
place.
b. A short straight part that opens in the network of efferent tubules in mediastinum
tahir99 - UnitedVRG
The Pelvic Viscera1
353
Fig. 33.4: TS of testis
rete testis. No spermatogenesis takes place

here.
Rete testis lies in the mediastinum and is
connected with the seminiferous tubules.
From the upper part of mediastinum about 1520 efferent tubules (vasa afferentia) pierce
tunica albuginea and enter the head of epididymis.
The Blood Supply of the Testis

The Arteries
1. The testicular artery is a long, slender branch
from abdominal aorta arising a little below the renal
artery.
It descends deep to peritoneum in posterior wall
of abdomen, then runs along the spermatic cord
to reach posterior border of testis.
It is the main artery supplying testis.
2. The artery to the vas deferens, a branch of
inferior vesical artery, also reaches posterior border
of testis along with vas deferens.
The artery has some anastomosis with the
testicular artery but that is not adequate.
However, in case of injury or ligature of testicular artery, the testis undergoes avascular
necrosis.
The Veins
Fig. 33.5: Structure of testis
The veins issuing from the posterior border of testis

form a pampiniform plexus of veins, that ascends
in the spermatic cord.
354
The venous plexus has 8-10 longitudinal

channels joined by cross channels.
At deep inguinal ring, the venous plexus gives
rise to a single testicular vein, that ascends by
side of testicular artery.
Right testicular vein joins inferior vena cava.
Left testicular vein ends in left renal vein.
The Lymphatic Drainage of the Testes

The lymphatics of the testis follow the testicular
vein and drain in para-aortic lymph nodes.
The Nerve Supply of the Testes
The nerves supplying testis accompany testicular
vessels.
The sympathetic nerves come from renal and
aortic plexuses, and carry fibers from T10 and T11
segments of spinal cord.
The afferent fibers (pain) also travel via sympathetic nerves. The referred pain of testis is felt in
lower and middle part of anterior abdominal wall.
1. Hydrocele is collection of watery fluid in the
cavity of tunica vaginalis.
a. Vaginal hydrocele is collection of fluid in the
sac only.
b. Congenital hydrocele is collection of fluid in
the processus vaginalis, that is not obliterated
and remains patent. The collection of fluid
extends up to the peritoneal cavity.
c. Infantile hydrocele collection of fluid extends
up to the deep inguinal ring, as processus
vaginalis obliterates only near the ring.
d. Encysted hydrocele of the cord is formed when
processus vaginalis is obliterated above and
below the localized collection of fluid.
2. Testicular torsion or rotation many occur
usually externally. The condition leads to
compression of testicular vessels and may lead to
ischemic necrosis of testis. The torsion may be
relieved by medial rotation of testes by external
pressure gently.
THE EPIDIDYMIS
The epididymis is a helmet-like structure that lies
along the postero-lateral aspect of testis. The
epididymis consists of:
1. Head: Enlarged upper end connected to the
upper pole of testis by the efferent ductules.
2. Body is slender part that is separated from the
lateral surface of testis by sinus of epididymis
formed by reflection of visceral layer of tunica
vaginalis.
3. Tail is the narrow lower end of epididymis
connected to lower pole of testis by some connective tissue.
The tail of epididymis is continued as the vas
deferens.
Structure
The head of epididymis consists of 15-20 conical
lobules (about 15-20 cm long) that are convoluted
ducts continuous with the efferent ductules.
The body and tail have a highly-coiled duct of
epididymis, formed by union of lobules of the head.
The duct is nearly six metre long. It acquires
thick walls and continues as vas deferens.
Functions
The epididymis helps in maturation and storage of
sperms.
The blood supply of epididymis is by the artery of
vas deferens, that is usually a branch of inferior
vesical artery.
The nerve supply is by the pelvic splanchnic nerves
(nervi erigentes) from S2, S3, and S4 segments of
spinal cord.
The nerves reach via the pelvic plexus.
The Vas Deferens
The vas deferens is a thick-walled male genital duct
that conveys sperms from the epididymis to the
ejaculatory duct.
tahir99 - UnitedVRG
The Pelvic Viscera1
Beginning: The vas deferens begins as

continuation of duct of epididymis at its tail.
The vas deferens has thick muscular walls and
feels like a whip cord.
Length45.0 cm
Course:
The vas deferens ascends a little tortuously
from the lower pole of testis, lying medial
to the epididymis along posterior border of
testis.
From testis, it ascends up in the scrotum
and inguinal canal lying in the posterior part
of spermatic cord, surrounded by veins of
pampiniform plexus.
It enters abdominal cavity at the deep
inguinal ring lying lateral to inferior epigastric
vessels.
The vas deferens crosses external iliac
vessels, as it descends along the lateral pelvic
wall. It crosses superior vesical artery and
obturator nerve and vessels.
The vas deferens crosses medial to the ureter
at the base of urinary bladder.
Reaching the base of bladder, the vas
deferens becomes dilated and tortunous
forming the ampulla of vas deferens. The
ampulla lies medial to the seminal vesicle.
Termination: The ampulla of vas deferens joins
with the duct of seminal vesicle to form the
ejaculatory duct.
The Blood Supply
The arteries: The vas deferens is supplied by a

separate artery of the vas deferens, a branch of
inferior vesical artery (sometimes the artery of
vas deferens may arise from superior vesical
artery).
The nerve supply is from the pelvic plexus, and
the nerves accompany the artery of the vas
deferens.
355
Applied Anatomy
1. Tubectomy (Male family planning operation): By
a midline incision at the root of scrotum below
penis, both vas deferens are secured by identifying
them by their cord-like feel. Then 1.0 cm parts of
both vas deferens are cut off and the cut ends are
ligated.
After this operation, the person becomes sterile
(incapable of fertilizing) but is not impotent.
2. Recanalization operation: This operation is done
in selected cases, when the ligated ends of the vas
deferens are joined again, to establish the continuity
of lumen of vas deferens.
The Seminal Vesicles
These are two sacculated glandular structures
located at the base of urinary bladder.
Length: About 5.0 cm, but where uncoiled it is
nearly 15.0 cm.
Shape: Pyramidal. The seminal vesicle consists
of a single coiled tube with diverticula.
Relations
Anteriorly: Base of urinary bladder.
Posteriorly: Recto-vesical fascia separating
it from rectum.
Medially: Ampulla of vas deferens.
Functions: The seminal vesicles act as secreting
glands in humans.
Their secretion adds to the seminal fluid and
contains fructose, choline and a coagulating
enzymevesiculase.
They do not store sperms in humans.
The Blood Supply
The arteries are derived from the inferior
vesical and middle rectal arteries.
The Nerve Supply
The seminal vesicles are supplied by the pelvic
plexuses carrying autonomic nerves.
1. The seminal vesicles can be palpated through
the anterior wall of rectum by the rectal examination.
356
2. Vesiculitis is inflammation of seminal vesicle may

lead to abscess formation which may rupture in
the peritoneal cavity.
The Ejaculatory Ducts
The ejaculatory ducts are two narrow ducts formed
by the union ofduct of seminal vesicle and
ampulla of vas deferens
Length: About 2.0 cm long
Course: The ejaculatory duct passes anteroinferiorly through the prostate gland, separating
median lobe from the posterior lobe.
Termination: The ejaculatory duct opens on the
colliculus seminalis by the side of opening of
prostatic utricle, in the prostatic urethra.
The Prostate Gland

The prostate gland is a glandular structure with
fibro-muscular stroma, that surrounds the beginning of male urethra.
Location:The prostate gland lies in the lower
part of pelvic cavity behind the lower part of
pubic symphysis, in front of ampulla of rectum.
Surfaces and relations
1. The base of the prostate gland surrounds
the neck of urinary bladder.
2. The apex lies below. It rests on the urogenital

diaphragm.
3. The posterior surface is separated from the
rectal ampulla by retro-prostatic fascia. The
posterior surface is vertically convex and
presents a groove in the median plane.
4. The anterior surface is narrow and is separated from lower part of pubic symphysis
by some adipose tissue.
5. The two infero-lateral surfaces are separated
from anterior parts of levator ani muscles
by plexus of veins embedded in the sheath
of prostate gland.
Capsules: The prostate gland has two capsules.
i. A true capsule formed by condensation of
connective tissue all around it.
ii. A fascial capsule is formed by the visceral
layer of pelvic fascia.
The prostatic venous plexus lies between
the two capsules (Fig. 33.6).
Size and shape
Anteroposterior diameter
2.0 cm
Transverse diameter
4.0 cm
Vertical diameter
3.0 cm
Weight is approximately 8 gm in young adult
male.
Shape is like a chestnut.
Fig. 33.6: Coronal section through prostate gland
tahir99 - UnitedVRG
The Pelvic Viscera1
The lobes of prostate gland

The Prostate gland is divided into five surgical
lobes by prostatic urethra and ejaculatory ducts.
1. Anterior lobe (isthmus) lies in front of urethra. It contains very little glandular tissue.
2. Right and left lateral lobes lie on either side
of prostatic urethra. These lobes contain
large amount of glandular tissue.
3. The posterior lobe lies behind the urethra
and below the ejaculatory ducts.
4. The median lobe lies behind the urethra and
above the ejaculatory ducts.
This lobe bulges normally, inside urinary
bladder, behind the internal urethral
meatus forming a slight elevation uvula
vesicae.
This lobe also contains more glandular
tissue and is involved in benign enlargement of prostate gland.
Structure inside the prostate glands (Fig. 33.7):
i. The prostatic urethra
ii. The two ejaculatory ducts
iii. The prostatic utriclea small sac-like
structure that is homologous with vagina
of females.
357
The blood supply

The arteries supplying the gland are derived
from:
The internal pudendal artery
The middle rectal artery
The inferior vesical artery
The veins form prostatic venous plexus that
is located around the gland between the true
and fascial capsules.
The prostatic venous plexus, receives the
deep dorsal vein of penis, communicates
with vesicular venous plexus and drains into
internal iliac vein.

The lymphatics of prostate gland end mainly in the
internal iliac lymph nodes.
Some lymphatics from posterior surface end
in sacral lymph nodes and external iliac nodes.
The Nerve Supply
The nerves supplying the prostate are derived from
the pelvic plexuses.
Fig. 33.7: The lobes of prostate gland
358
Benign enlargement: After the age of sixty years,
sometimes the prostate gland enlarges due to
poliferation of the glandular tissue.
The enlargement involves median lobe mostly
causing obstruction to the internal urethral
meatus.
The condition results in difficulty in passing
urine.
The hypertrophied prostate gland is removed

by an operationprostatectomy.
Cancer of prostate gland begins from the
posterior lobe.
The secondary deposit of cancer of prostate
gland in the vertebral bodies is probably due to
absence of valves in the veins connecting the prostatic venous plexus and the vertebral venous plexus.
tahir99 - UnitedVRG
CHAPTER
34
The Pelvic Viscera2

THE FEMALE REPRODUCTIVE ORGANS
The female reproductive organs are:
1. The ovaries
2. The uterus
3. The uterine tubes
4. The vagina
The Ovaries
The ovaries are the female gonads or sex glands.
They reproduce the ova and the female
hormonesestrogens and progesterone
Location: The ovaries lie on either side of uterus
near the lateral pelvic wall.
The ovaries are attached to the posterior
layer of broad ligament of uterus by a fold
of peritoneummesovarium.
The position of ovary varies in parous
women (women who have borne children).
Size and shape 3.0 cm (l) 1.5 cm (w) 1.0
cm (th) (nearly half the size of testis of male)
the ovaries are shaped like an almond.
The color of ovary is greyish pink, and its
surface smooth before ovulation begins.
After that, surface becomes puckered by
ovulation and corpus luteum formation.
Surfaces and ends
The ovary has two surfaces
i. The medial surface is mostly covered
by the uterine tube. A peritoneal recess
ovarian bursa lies between the ovary
and mesosalpinx part of broad ligament.
ii. The lateral surface is related to parietal
peritoneum on lateral pelvic wall.
The part of lateral pelvic wall related
to the ovary is called Ovarian

fossa, that is bounded:
Anteriorly by superior vesical
artery.
Posteriorly by ureter and internal
iliac artery.
The ovary has two ends
i. The tubal end lies laterally and is
connected to the ovarian fimbria of the
uterine tube, and suspensory ligament
of ovary.
ii. The uterine end faces downwards and
is connnected to the lateral border of
uterus by ligament of ovary.
The ovary has two borders:
i. The free border is convex.
ii. The attached border gives attachment
to the mesovarium.
The Blood Supply
The arteries: The ovary is supplied by the ovarian
artery, a long slender branch of abdominal aorta
arising just below renal artery.
The artery descends on posterior abdominal
wall behind peritoneum and enters the pelvic
cavity. It passes through suspensory ligament
of ovary and between two layers of broad
ligament of uterus.
It reaches ovary through mesovarium.
The ovarian artery also supplies lateral part of
uterine tube and has some anastomosis with
the uterine artery.
The veins: The ovarian veins form a pampiniform
plexus, that is drained by a single ovarian vein. The
right ovarian vein drains into inferior vena cava:
the left ovarian vein drains into the left renal vein.
360
The lymphatics from the ovary accompany the

ovarian vessels and end in pre-aortic and para-aortic
lymph nodes.
Rarely, the ovaries may descend lower, and

come to the near the deep inguinal ring,
inguinal canal or even in labium majus.
An ectopic ovary is usually an undeveloped
ovary.
The Nerve Supply
The Uterus [The Womb] (Fig. 34.1)
The role of autonomic nerve supply of ovary is not

clear. The sympathetic fibers travel as ovarian
plexus with the ovarian vessels from the aortic
plexus.
These are derived from T11 ,T12,L 1, and L 2
segments of spinal cord.
the pelvic splanchnic nerves (nervi erigentes).
They carry fibers from S2,S3, and S4 segments
of spinal cord.
The uterus, is a thick-walled, hollow muscular

organ in females, in which fertilized ovum is
implanted and development of embryo and fetus
takes place.
Location: The uterus lies in the pelvic cavity
between the urinary bladder and rectum.
Normal position of the uterus is anteverted and
ante-flexed.
Anteversion: The long axis of uterus makes an
angle of nearly 90 with long axis of vagina.
Anteflexion: The uterus is bent upon itself. The
long axis of body of uterus makes an angle of
nearly 125 with long axis of cervix portion of
uterus (Fig. 34.2).
Size and shape
The nulliparous uterus (where embryo and
fetus have not developed) is 7.5 cm (l) 5.0
cm (w) 2.5 cm (th).
1. The ovarian tumors are quite common in
elderly females.
2. The ectopic ovary: Sometimes the ovary fails
to descend from posterior abdominal wall to its
normal position.
Fig. 34.1: Sagittal section through female pelvis
tahir99 - UnitedVRG
The Pelvic Viscera2
Fig. 34.2: Anteversion and anteflexion of uterus
Weight is nearly 30-40 gm

Shape is pear shaped or piriform.
Parts: The uterus has two partsbody and
cervix.
The body is the upper part and is nearly
5.0 cm long. It has two surfacesanterior
and posteriortwo lateral borders, and a
convex upper end called fundus.
The anterior (vesical) surface is separated
from superior surface of urinary bladder by
the utero-vesical pouch.
The posterior (intestinal) surface is related
to pelvic colon and lies in the anterior wall
of recto-uterine pouch (pouch of
Douglas).
The two lateral borders are convex and
sometimes called as lateral surfaces. They are
related to the following structures.
a. Attachment of uterine tube
b. Two layers of broad ligament
c. The ligament of ovary
d. The round ligament (ligamentum teres) of
uterus
e. The uterine vessels with accompanying
lymphatics and nerve plexuses.
The fundus is the convex upper end of the body
of uterus that bulges through pelvic inlet.
The Cervix of Uterus is the lower, narrow and
cylindrical part of uterus.
It is nearly 2.5 cm long, and is divided into two
parts:
361
a. The supravaginal part lies above vagina and

is related:
Anteriorly to base of urinary bladder
separated by some connective tissue.
Posteriorly is covered by peritoneum and
is related to anterior wall of recto-uterine
pouch.
b. The vaginal part of cervix is surrounded
by four vaginal fornicesanterior, two
lateral and posterior.
The posterior fornix is deeper and related
to recto-uterine pouch.
The Cavity of the Uterus is narrow as the anterior
and posterior walls are close together.
The shape of cavity of body is triangular, with
openings of uterine tubes at upper angles, and
internal os at the low angle.
The cervical canal begins at the internal os and
ends at the external os in the vagina.
The cervical canal is dilated in the middle and
has parallel mucus foldspalmate folds.
Many mucus-secreting glands open in the
cervical canal.
The isthmus of the cervix is its upper one-third part.
It has the following features:
It undergoes some changes during menstrual
cycle.
During pregnancy, it is taken up by the body of
uterus, as lower uterine segment by second
month of pregnancy.
The fetal membranes, that are fused with other
parts of uterus, are not blended here.
The Blood Supply
The arteries: The main arterial supply of the uterus
is by paired uterine artery.
The uterine artery is a large tortuous vessel that
arises from anterior division of internal iliac
artery.
The artery ascends along the lateral border of
uterus, between two layers of broad ligament.
The uterine artery also supplies upper part of
vagina and medial two-third part of uterine tube.
362
The veins: The veins accompany the uterine artery

and from uterine venous plexus, that ends in the
internal iliac vein.
The lymphatics from the fundus pass along the

ovarian vessels and end in pre-aortic and paraaortic lymph nodes.
The lymphatics from lower part of body and
cervix pass to external iliac lymph nodes.
Some lymphatics from posterior part of cervix
reach the internal iliac and sacral lymph node.
The Nerve Supply

The nerve supply is by autonomic nerves.
The sympathetic fibers reach via pelvic plexuses.
They are derived from T12 and L1 segments of
spinal cord.
the pelvic splanchnic nerves. They carry fibers
from S2, S3 and S4 segments of spinal cord.
The autonomic afferents from the body of
uterus travel via the sympathetic fibers; from
the cervix they travel via pelvic splanchnic
nerves.
The Supports of the Uterus
1. The pelvic diaphragm (levatores ani) and the
urogenital diaphragm, support the pelvic organs,
by their normal tone. Thus, they help to keep
the uterus in position.
2. The two round ligaments of uterus (ligamentum
teres) act like a sling, pulling up the uterus from
two sides, thus maintaining the anteverted
position of uterus (Fig. 34.3).
3. The two transverse ligaments of cervix
(Mackenrodts ligament) connect the
supravaginal part of cervix to the lateral pelvic
wall. They form important supports of uterus.
4. The two utero-sacral ligaments and the two
pubo-cervical ligaments also help to keep the
supravaginal part of cervix in position.
Fig. 34.3: TS through body of uterus
5. The two broad ligaments on either side of

uterus are large peritoneal folds that connect
the lateral borders of uterus to the lateral pelvic
wall.
These ligaments serve to stabilize the uterus.
The broad ligament contains the following
structures between the two layers:
i. The uterine tube (Fig. 34.4)
ii. The round ligament of uterus
iii. The ligament of ovary
iv. The uterine vessels
v. The sympathetic nerves and lymphatics.
vi. Embryonic remnants(derivatives of
mesohephric duct)
Epophoron
Parophoron
Gartners duct
6. The anterior ligament and posterior ligament
of uterus are reflections of peritoneum to
the urinary bladder and front of rectum
respectively.
1. Prolapse of uterus takes place due to weakness
of its supports.
There are three degrees of prolapse.
The first degree prolapse is retroversion with
cervix bulging more prominently in vagina.
The second degree prolapse is protrusion of
cervix through vagina.
The third degree prolapse is complete
extroversion of uterus.
tahir99 - UnitedVRG
The Pelvic Viscera2
363
Fig. 34.4: Coronal section through uterus
2. Compression and avulsion of ureter may take

place in cases of different child-birth. The ureter
may also be accidentally ligated or clamped during
hysterectomy operation along with uterine vessels.
3. Hystero-salpingography is a special X-ray
procedure in which a radiopaque dye is injected
under pressure through the cervix of uterus.
The dye passes from the uterus into the uterine
tubes and may leak in peritoneal cavity.
The procedure is adopted to visualize the female
genital passage.
The Uterine Tubes (Fallopian Tubes)
The uterine tubes are two muscular tubes, that
convey ova from the ovaries to the cavity of uterus.
Length: About 10.0 cm.
Location: The uterine tubes lie in medial 4/5th
part of free upper border of broad ligament on
either side of the uterus.
Parts: The uterine tube has the following parts:
i. The infundibulum or the lateral end is open
like a funnel with an abdominal ostium
opening in the abdominal cavity.
The ostium is surrounded by 6-8 fingerlike projectionsfimbriaone fimbria

is longer and adherent to the lateral end
of ovary. It is called ovarian fimbria and
it helps in transver of ovum from the
ovary to the tube.
ii. The ampulla is thin-walled, dilated part of
uterine tube. It forms nearly half part of
tube.
Fertilization of ovum takes place in this
part of tube.
iii. The isthmus is the narrow part of tube that
is attached to the uterus. It forms nearly
1/3rd part of tube.
iv. The Intra-mural (uterine) part is nearly
1.0 cm long and passes through thickness
of muscular wall of the uterus.
It is narrowest part of uterine tube.
The uterine tube opens in the superior angle of
cavity of body of uterus.
The ova are propelled through the uterine tube
by gentle peristaltic contractions.
364
The Blood Supply
The arteries
The uterine artery supplies medial two-third part
of uterine tube.
The ovarian artery supplies lateral one-third part
of uterine tube.
The Veins follow the arteries.
From the medial part, the veins end in the uterine
venous plexus.
From the lateral part, the veins join the ovarian
venous plexus.
The lymphatics from the lateral part of tube

accompany the ovarian lymphatics and end in
pre-aortic and para-aortic lymph nodes.
The lymphatics from the medial part of tube
accompany the uterine lymphatics and end in
The Nerve Supply
The sympathetic fibers from T10 to L2 segments

of spinal cord reach via pelvic plexus.
The parasympathetic fibers from the pelvic
splanchnic nerves reach the lateral half of uterine
tube.
Afferent autonomic fibers accompany sympathetic nerves.
1. In females, pelvic peritonitis may occur more
frequently, as infection from vagina and uterus can
travel via the uterine tubes into the peritoneal cavity.
Salpingitis or inflammation of the tube leads to
blockage of lumen of tube. This is the most common
cause of female infertility.
2. Tubal ligation (TubectomyFemale Family
Planning Operation).
The operation is done preferably 4-5 days after
childbirth, when the uterus lies midway
between umbilicus and pubic symphysis.
By one incision, both uterine tubes are secured

and 1.0 cm parts of tubes are cut off and cut
ends ligated.
The operation blocks the passage of ovum
through the tube, and person becomes sterile.
3. Tubal pregnancy may occur rarely, due to
implantation of fertilized ovum in the ampullary part
of tube.
The tubal pregnancy ruptures by tenth week
leading to excessive hemorrhage.
The Vagina
The vagina is the copulatory organ of the females.
It is a fibro-muscular canal that extends from the
uterus to the vestibulecleft between two labia
minora.
Location: The vagina is located between the
urinary bladder and urethra anteriorly, rectum
and anal canal posteriorly.
Length: The anterior wall is nearly 7.5 cm long,
the posterior wall is nearly 9.0 cm long.
Cavity of vagina remains collapsed normally
and is H-shaped in a TS.
The upper part of cavity is wider and surrounds
the vaginal part of cervix.
Relations: The upper two-third of vagina lies
in the pelvic cavity.
The lower one-third lies below the pelvic
diaphragm in the perineum.
Anteriorly:
Base of urinary bladder
Female urethra
Posteriorly:
Upper one-thirdRecto-uterine pouch
Middle one-thirdRectal ampulla separated
by a septum
Lower one-thirdPerineal body separating
it from the anal canal.
Laterally
Levator ani muscle
Ureter
Uterine artery
Endopelvic fascia
tahir99 - UnitedVRG
The Pelvic Viscera2

The Blood Supply
The arteries: supplying the vagina are

Vaginal branches of uterine artery
Vaginal artery
Small branches from internal pudendal and
middle rectal arteries.
The veins form the vaginal venous plexus and
drain into the internal iliac vein.

From the upper part of vagina, the lymphatics
accompany the uterine vessels and end in internal
and external iliac lymph nodes.
From the middle part, the lymphatics end in
365
From the part of vagina below hymen, the

lymphatics end in superficial inguinal lymph
nodes.
The Nerve Supply

The upper two-third of vagina is supplied by the
utero-vaginal plexus of nerves carrying.
Sympathetic fibers from pelvic plexuses.
Parasympathetic fibers from pelvic splanchnic
nerves.
The afferents from this part travel via the pelvic
splanchnic nerves.
The lower one-third of vagina is supplied by the
pudendal nerve.
The Pelvis
Q1. Give the one best response to each question
from the given four answers:
1. The fertilization of the ovum takes place in:
A. Body of the uterus
B. Ampulla of the uterine tube
C. Peritoneal cavity
D. Ovarian follicle
2. The remnant of peritoneal cavity present in
the scrotum is:
A. Gubernaculum
B. Ductus deferens
C. Tunica vaginalis
D. None of the above
3. The length of the anal canal is:
A. 1 1/2 inches
B. 6.0 inches
C. 10.0 inches
D. 12.0 inches
4. The prostatic hypertrophy involves mainly.
A. Anterior lobe
B. Two lateral lobes
C. Median lobe
D. B and C
5. The urogenital diaphragm is formed by:
A. Sphincter urethrae
B. Levator ani
C. Deep transverse perineal
D. A and C
6. Which of the following structures cannot be
palpated by rectal examination in males:
A. Bulb of the penis
B. Seminal vesicles
C. Ureter
D. Anorectal ring
7. Which of the following structures cannot be

palpated by vaginal examinationin females.
A. Sigmoid colon
B. Urethra
C. Perineal body
D. Ischial spines
8. The ano-rectal ring that prevents fecal
incontinence is formed by:
A. Deep part of external anal sphincter
B. Internal anal sphincter
C. Pubo-rectalis part of levator ani
D. All of the above
9. In infants, the internal urethral meatus of the
urinary bladder lies at the level of:
A. Upper border of pubic symphysis
B. Midway between umbilicus and pubic
symphysis
C. Middle of pubic symphysis
D. Lower border of pubic symphysis
10. The narrowest part of male urethra is:
A. Prostatic part
B. Membranous part
C. Internal urethral meatus
D. External urethral meatus
Q2. Each question below contains four suggested answers, of which one or more are
correct. Choose the answer:
11. The ischiorectal fossa:
1. Contains a pad of fat that supports anal
canal
tahir99 - UnitedVRG

2. Has pudendal canal in its lateral wall
3. Has floor formed by perineal skin
4. Has levator ani muscle in its lateral wall
12. The female urethra:
1. Is about 4.0 inches long
2. Lies embedded in anterior wall of vagina
3. Does not pierce the deep perineal pouch
4. Has external urethral meatus situated in
vestibule of vagina about 2.5 cm from
the pubic symphysis
13. The rectum:
1. Begins on middle of sacrum as
continuation of sigmoid colon.
2. Is about 10.0 inches (25 cm) long
3. Has a dilatationrectal ampullain its
lower one-third part
4. Is related to peritoneum in upper onethird only
14. The seminal vesicles:
1. Are lobulated sac-like structures that store
sperms in humans
2. Can be palpated through anterior rectal
wall in the rectal examination.
3. Are separated from the base of urinary
bladder by peritoneum
4. Join the ampulla of vas deferens to form
the ejaculatory duct
15. The ovary has the following features:
1. The ovarian lymphatics end in para-aortic
lymph nodes
2. The ovary is suspended from posterior
layer of broad ligament by mesovarium
3. The lateral surface of ovary is related to
a depressionovarian fossa in lateral
pelvic wall
4. The ovary has no peritoneal covering. It
has cuboidal germinal epithelium lining
its surface
16. The nerve supply of urinary bladder:
1. The parasympathetic pre-ganglionic
fibers originate from S 2, S 3, and S 4
segments of spinal cord
367
2. The pre-ganglionic parasympathetic

fibers synapse with post-ganglionic
neurones in the bladder wall
3. The afferent sensations from the bladder
reach spinal cord via pelvic splanchnic
nerves as well as via sympathetic
4. The sympathetic post-ganglionic fibers
originate from inferior hypogastric plexus
17. The sacrum in females:
1. Is shorter and wider than males
2. Is more curved than in males
3. Has a shorter articular surface for sacroiliac joint
4. Has only four sacral vertebrae
18. The levator ani muscle:
1. Forms the main part of pelvic diaphragm
2. By its normal tone keeps the pelvic organs
in position
3. If torn or weakened can cause prolapse
of rectum.
4. Is supplied by inferior rectal nerve and
perineal branch of 4th sacral nerve
19. The distinguishing feature of bony female
pelvis is:
1. A narrow subpubic angle
2. Is smaller part of a larger cone
3. Has heart shaped pelvic inlet
4. Has a wider pelvic outlet
20. The piles (hemorrhoids) develop:
1. As enlargement of venous plexus in
submucus coat of anal canal
2. In the endodermal part of anal canal only
3. As primary piles and are located in 3, 7
and 11 oclock positions
4. Into anal fistula if not treated properly
Q3. Match the structures on the left with their
related structures/functions of the right:
21. Male reproductive organs:
i. Seminal vesicles A. Produces seminal
fluid
368

ii. Prostate gland
B. Conveys sperms
from epididymis
to ejaculatory duct
iii. Cowpers gland C. Situated in deep
perineal pouch
iv. Vas deferens
D. Secretes fructose
for nutrition of
sperms
22. Embryonic remnants:
i. Prostatic utricle A. Cranial end of
paramesonephric
duct
ii. Appendix of test B. Caudal end of
paramesonephric
duct
iii. Appendix of epi- C. Mesonephric duct
didymis
in females
iv. Gartners duct
D. Mesonephric
tubule
23. Lymphatic drainage:
i Cervix of uterus A. Para-aortic lymph
nodes
ii. Prostate gland
B. Internal iliac
lymph nodes
iii. Lower one-third C. Superficial inguiof vagina

nal lymph nodes
iv. Ovary
D. Internal and external iliac lymph
nodes
24. Origin of arteries:
i. Superior rectal A. Abdominal aorta
artery
ii. Testicular artery B. Anterior division
of internal iliac
artery
iii. Ilio-lumbar artery C. Posterior division
of internal iliac
artery
iv. Uterine artery
D. Inferior mesenteric artery
25. Root value of nerves:
i. Pudendal nerve A. L2,L3,L4 (ventral
divisions of ventral rami)
ii. Lumbo-sacral
B. S2, S3, S4 ventral
trunk
rami
iii. Obturator nerve C. L4,L5 ventral rami
iv. Genitofemoral
D. L1,L2 (ventral
nerve
division of ventral
rami)
Answers
The fertilization of ovum takes place in the
ampullary part of uterine tube. The
implantation of fertilized ovum takes place in
the body of uterus. Abnormal implantation
may be in uterine tube, ovarian follicle or even
in peritoneal cavity.
The remnant of peritoneal cavity in the
scrotum is tunica vaginalis. Actually, during
descent of testis, a tube of peritoneum
processus vaginalisdescends along with
testis, and later its lower end persists as tunica
vaginalis.

The length of anal canal is 1 1/2 inches or
3.6 cm.
The prostatic hypertrophy involves mainly the
lateral lobes and the median lobe. The anterior
lobe or isthmus has very little glandular tissue,
therefore, it is not involved in hypertrophy.
The urogenital diaphragm is formed by
sphincter vesicae and two deep transverse
perinei. The two levatores ani muscles form
the main part of pelvic diaphragm.
tahir99 - UnitedVRG

The ureter cannot be palpated by rectal
examination. The bulb of penis, seminal
vesicles and anorectal ring can be palpated
by rectal examination in the males.
The ischial spines are not palpated by the
vaginal examination in females. The sigmoid
colon, rectum and perineal body can be
palpated through posterior wall of vagina. The
ureters can be palpated through lateral
fornices of vagina.
The fecal incontinence is prevented by all
three structuresdeep part of external anal
sphincter, internal anal sphincter and puborectalis part of levator ani that form the anorectal ring
In infants, at birth, the internal urethral meatus
lies at the level of upper border of pubic
symphysis, because there is no pelvic cavity.
By puberty, it descends to its adult level at
lower border of pubic symphysis.
The narrowest part of male urethra is its
membranous part. The narrowest point of
male urethra is external urethral meatus. If a
catheter or an instrument can pass through
external meatus. It can easily pass through
rest of male urethra.
The ischio rectal fossa contains pad of fat
and has pudendal canal in its lateral wall. its
floor is formed by perineal skin; but levator
ani muscles form its medial wall and not lateral
wall.
The female urethra is embedded in anterior
wall of vagina, and its external office is
located in vestibule of vagina, about 2.5 cm
369
from the pubic symphysis. Its length is only

1 1/2 inches (4.0 cm) and its pierces deep
perineal pouch.
The rectum begins on front of middle sacrum
as continuation of sigmoid colon. It has rectal
ampulla in lower one-third part. The length
of rectum is only 5.0 inches (12 cm), and it
has peritoneal covering on front of middle
one-third part also.
The seminal vesicles are two lobulated
structures, but in humans they act like glands
and do not store sperms. They can be palpated
by anterior rectal wall. Their duct joins with
ampulla of vas deferens to form ejaculatory
ducts. However, they are connected with the
base of urinary bladder by connective tissue
and not peritoneum.
A15. The answer is E, (1, 2, 3, 4)
The ovary is suspended from posterior layer
of broad ligament by mesovarium, and is
related to ovarian fossa in lateral pelvic wall.
The peritoneal covering of ovary is modified
to form germinal epithelium. The lymphatics
from ovary end in para-aortic lymph nodes.
A16. The answer is E, (1, 2, 3, 4)
The nerve supply of urinary bladder is from
both sympathetic and parasympathetic. The
parasympathetic pre-ganglionic fibers
originate from S2,S3 and S4 segments of spinal
cord and synapse with postganglionic
neurones in bladder wall. The sympathetic
postganglionic fibers come from inferior
hypogastric (pelvic) plexus. The afferent
sensations reach spinal cord both via pelvic
splanchnic nerves (parasympathetic) and
sympathetic.
The sacrum in females is shorter and wider
than in males and has shorter articular surface
370

for sacro-iliac joints. It is less curved than
males and has five sacral vertebrae.
A18. The answer is E, (1, 2, 3, 4)
The levator ani muscle forms the main part

of pelvic diaphragm and by its normal tone
keeps the pelvic organs in position. If its tone
is weekend, it may cause prolapse of rectum.
It is supplied by inferior rectal nerve and
perineal branch of 4th sacral nerve.
The female bony pelvis is smaller part of a
larger cone and has a wider pelvic outlet. It
has a wider subpubic angle and an oval pelvic
inlet. The narrow subpubic angle and heart
shaped pelvic inlet are chracteristics of male
bony pelvis.
A20. The answer is B. (1, 3).
The piles (hemorrhoids) develop from
enlargement of venous plexus in submucus
coat of anal canal. The piles develop in both
endodermal and ectodermal parts of anal
canal. The primary piles are formed at 3, 7
and 11 oclock positions. The piles never
develop into anal fistula.
A21. The answes are D, A, C, B.
The seminal vesicles secrete fructose for
nutrition of sperms.
The prostate gland produces seminal fluid
mainly.
Cowpers glands are located in deep
perineal pouch.
Vas deferens conveys sperms from
epididymis to the ejaculatory duct.
A22. The answers are B, A, D, C.
The prostatic utricle is remnant of caudal
part of paramesonephric ducts in males.
The appendix of testis is remnant of

cranial end of paramesonephric ducts in
males.
Appendix of epididymis is remnant of
mesonephric tubules in males.
The Gartner s duct is remnant of
mesonephric duct in females.
A23. The answers are D, B, C, A.

The lymphatics of cervix of uterus drain
in both internal and external iliac lymph
nodes.
The lymphatics of prostate gland drain
into internal iliac lymph nodes
The lymphatics from lower one-third of
vagina drain in superficial inguinal lymph
nodes
The lymphatics of ovary drain in paraaortic lymph nodes.
A24. The answers are D, A, C, B.
The superior rectal artery is continuation
of inferior mesenteric artery.
The testicular artery is a branch of
abdominal aorta.
The iliolumbar artery is a branch of
posterior division of internal iliac artery.
The uterine artery is a branch of anterior
A25. The answers are B, C, A, D.
The root value of pudendal nerve is S2,S3
and S4 ventral rami
The lumbo-sacral trunk comes from
ventral rami of L4 and L5 spinal nerves
The obturator nerve has L2, L3 and L4
ventral divisions of ventral rami as its root
value.
The root value of genito-femoral nerve
is L1, L2 ventral divisions of ventral rami.
tahir99 - UnitedVRG
The Head and Neck
Seven
CHAPTER
35
The Bones of the

Head and Neck
The skeleton of head is formed by the skull and the
mandible or lower jaw bone forming lower part of
facial skeleton. The skull (cranium) is divided into
an anterior part that forms the upper part of facial
skeleton and a posterior part that forms the calvaria
or the brain box.
The skeleton of the neck is formed by the seven
cervical vertebrae and the inter-vertebral discs.
There is a small hyoid bone in the front of upper
part of neck.
THE CRANIUM
i. The facial skeleton has fourteen bones
Vomer
1
Maxillae
2
Nasal
2
Lacrimal
2
Palatine
2
Zygomatic
2
Inferior nasal concha 2
ii. The Calvaria (brain box) is made up of eight
bone.
Ethmoid
1
Sphenoid
1
Occipital
1
Frontal
1
Parietal
2
Temporal
2
Anatomical position of skullcan be visualized

by the following planes.
Reids base lineAn imaginary horizontal
plane connecting infraorbital margins to the center
of external acoustic meatus
Frankfurts planeAn imaginary horizontal
plane connecting infra-orbital margins to the upper
margin of external acoustic meatus
EXTERIOR OF THE SKULL
A. Norina verticalis (Superior view)
When viewed from above the skull appears
wider posteriorly. The bones seen in this view
are:
Frontal bone anteriorly
Occipital bone posteriorly
Two parietal bones on either sides
The sutures seen in this view are:
Coronal suture between frontal and two
parietal bones.
Sagittal suture between the two parietal
bones
Lambdoid suture between the two parietal
bones and occipital bone.
The Other features of skull in this view are:
Bregma - point where coronal and sagittal
suture meet
Lambda - point where sagittal and lambdoid
sutures meet
372
Parietal tubers (eminences) are the points

of maximum convexity of parietal bones
Parietal emissary foraminaare two small
foramina or either side of sagittal suture
about from lambda. Sometimes a point on
sagittal suture between two parietal foramina
is known as obelion.
Temporal lines - superior and inferior - lie
on either side. They arch upwards and
backwards across sides of frontal bone and
parietal bones
B. Norma Occipitalis (posterior view)
When viewed from behind the skull appears
arched above and flattened below. The bones
seen in this view are:
Posterior parts of two parietal bones
Squamous part of occipital bone below
Mastoid parts of two temporal bones on
either side.
The sutures seen in thus view are:
Lambdoid suture between the two parietal
bones and occipital bone
Posterior part of sagittal suture
Occipito-mastoid suture
Parieto-mastoid suture
The other features of skull in this view are:
Lambda and parietal foramina
External occipital protuberance in midline
on occipital bone. Most salient point is called
inion
Two superior nuchal linespass on either
side from external occipital protuberence
as curved bony ridges.
Two highest nuchal linesare faint bony
ridges sometimes present above superior
nuchal lines
External occipital crestpasses downwards
in midline from the external occipital
protuberance
Two mastoid emissary foraminaare
present on the mastoid bone
Interparietal bonesometimes present is
the separated upper triangular part of the
occipital bone.
C. Norma Frontalis (Anterior view)

When viewed from front the skull appears
wider above. The bones seen in this view are
Frontal bone - forms upper broader part
Two maxillae - form the upper jaw
Two nasal bones - form the upper part of
skeleton of nose
Two zygomatic bones - form the bony
prominences on either side
The features of skull in this view are
Two frontal tubers (eminences) form low
rounded elevations in upper part.
Two superciliary arches -form curved
elevations above the supra-orbital margins.
Glabella - median elevation joining the two
superciliary arches
Nasion - point that lies in median plane where
internasal and fronto-nasal sutures meet
Two orbital openings on the skull represent
the openings of orbital cavities. The supra
orbital margin is formed by frontal bone.
The infra-orbital margin by zygomatic and
maxilla. The lateral orbital margin by frontal
and zygomatic and medial orbital margin by
frontal and frontal process of maxilla.
The piriform aparture lies in midline formed
by two nasal bones and two maxillae
The two zygomaticofacial foramina lie on
the zygomatic bones.
The anterior nasal spine is present in midline
at lower end of piriform aperture
Two infra-orbital foramina are present below
the infra-orbital margins in maxillae
The alveolar processes of two maxillae bear
the sockets of upper jaw teeth
D. Norma lateralis (Lateral view)
When viewed from side the skull presents an
arched appearance above. The bones seen in
this view are
Frontal bone - anteriorly
Parietal bone - in middle
Occipital bone - behind
Nasal bone - anteriorly
tahir99 - UnitedVRG
The Bones of the Head and Neck
Maxilla - anteriorly
Zygomatic bone forming zygomatic arch on
side
Sphenoid bone - on side anteriorly
Temporal bone - with external acoustic
meatus
The features of skull in this view are
The two temporal lines - curving on side of
skull from zygomatic process of frontal to
supra-mastoid crest of temporal bone
The zygomatic arch - is formed on side of
skull by temporal process of zygomatic and
zygomatic process of temporal bone
(zygoma)
External acoustic meatusan oval bony
aperture on side in the temporal bone
Suprameatal triangle (Macowens triangle)
is a small depression on postero-superior
aspect of external acoustic meatus. This
triangle forms the lateral wall of mastoid
antrum and is used for surgical approach to
middle ear.
Mastoid process forms a triangular bony
mass behind external acoustic meatus.
Styloid processis a pointed bony projection
from in front of mastoid process
Pterion is an area on side of skull where
four bonesfrontal parietal, greater wing
of sphenoid and temporal - meet deep to
pterion lie middle meningeal vessels
Temporal fossais the name given to the
area on side of skull that is bounded by
temporal lines above and upper border of
zygomatic arch below.
Two zygomatico-temporal foramina pierce
the temporal surface of zygomatic bone
E. Norma basalis (Inferior view)
The inferior view of skull is studied in three
partsanterior, middle, and posterior.
The anterior part is formed by the hard plate
and the alveolar arches. The features in anterior
two third are:
373
The hard plate is formed by the palatal

processes of two maxillae and in posterior
one third by horizontal plates of two palatine
bones. These bones are joined by sutures
Incisive fossa is a deep fossa situated
anteriorly in midline. Two incisive foramina
pierce the floor of incisive fossa. Occasionally two anterior and posterior incisive
foramina also exist.
Greater palatine foramina are located in
posterior part of hard palate. A groove leadsfrom the foramen to the incisive fossa.
Lesser palatine foramina (may be 1-3) lie
on each side behind greater palatine
foramina
Posterior border of hard palate is free and
presents posterior nasal spine in median
plane.
Palatine crests are curved ridges near
posterior border
The middle part of norma basalis extends
from posterior border of hard palate to an
imaginary plane passing through anterior
margin of foramen magnum. The features
in this part are:
A. The median area:
The posterior border of Vomerthat forms
medial wall of posterior nasal aperture. It
splits into two alae to articulate with rostrum
of sphenoid
A broad bar of bone formed by the body of
sphenoid and basilar part of occipital bone.
Two minute canals vomero-vaginal and
platino-vaginal are present on each side
A pointed pharyngeal tubercle lies in front
of foramen magnum in midline
B. The lateral parts show two parts of sphenoid
bonepterygoid process and greater wing of
sphenoid and three parts of temporal bone
petrous, tympanic, and squamous.
The pterygoid process consists of two bony
platesmedial and lateral pterygoid - and
encloses pterygoid fossa.
374
The infra temporal surface of greater wing

of sphenoid presents three foramina
foramen ovale, emissary sphenoidal foramen
and foramen spinosum
Sulcus tubaeis the groove between greater
wing of sphenoid and petrous temporal. It
lodges the cartilaginous part of auditory
tube.
The spine of sphenoid is a pointed spine
located lateral to foramen spinosum.
The inferior surface of petrous temporal
bone is triangular and is wedged between
the greater wing of sphenoid and basiocciput. Its apex is pierced by carotid canal
and is separated from sphenoid by foramen
lacerum.
The tympanic part of temporal boneis a
curved bony plate that lies between petrous
and squamous temporal bones. It forms
walls of external acoustic meatus.
The squamous part of temporal bone
forms part of mandibular fossa (for head
of man-dible) articular tubercle at root of
zygoma and a small part of roof of
infratemporal fossa.
Squamo-tympanic and petro - tympanic
fissures are present.
The posterior part of norma basalis is divided
into a median area and two lateral parts
A. The median area presents
Foramen magnumthe largest foramen of
skull that opens above in posterior cranial
fossa and transmits lower part of medulla
oblongata bondes other structures.
External occipital protubrancea median
protuberance on occipital bone
External occipital cresta bony ridge that
extends from external occipital protuberance to posterior margin of foramen
magnum
B. The lateral area has the following features
The condylar part of occipital bone
It presents the occipital condyles situated along

anterior margin of foramen magnum. They
articulate with superior facets of atlas vertebra
Hypoglossal canal (anterior condylar canal)
Pierces antero superior part of occipital
condyle
Posterior condylar canalan emissary
foramen located in floor of condylar fossa
Jugular process of occipital bone lies lateral
to occipital condyle and forms posterior
boundary of jugular foramen
Jugular foramen is a large elongated
foramen situated between jugular process
of occipital bone and petrous temporal bone
Tympanic canaliculus is a minute opening
between carotid canal and jugular fossa
Styloid processa thin long process from
medial to mastoid process directed downwards forwards and medially
Mastoid processa large conical bony profection behind external acoustic meatus
Stylomastoid foramen - situated between
mastoid process and base of styloid process
INDIVIDUAL BONES OF SKULL
1. Vomeris a thin plate of bone in midline
forming posterior and inferior part of nasal
septum
It divides into two alae superiorly that
articulate with rostrum of sphenoid
2. Maxillaforms the skeleton of upper jaw with
bone of opposite side
It has a pyramidal body occupied by
maxillary air sinus. Its anterior surface has
an infra-orbital foramen and canine
eminence, while its posterior surface has
minute vascular canals and forms anterior
wall of infra-temporal fossa
The superior triangular surface forms floor
of orbital cavity. The medial surface with a
large maxillary hiatus forms part of lateral
wall of nasal cavity
tahir99 - UnitedVRG
3.
4.
5.
6.
Maxilla has four processes:

i. Zygomatic processarticulates with
zygomatic bone
ii. Frontal processforms lateral orbital
margin and joins with frontal bone
iii. Alveolar processhas eight sockets for
teeth and has maxillary tuberosity behind
iv. Palatal processlies horizontally and
forms four-fifth part of hard palate with
opposite bony process
Age changes in Maxilla:
At birthbone has no maxillary sinus, Frontal
process is prominent. Its transverse diameter
is more than vertical diameter
In adultlateral diameter is greatest owing to
development of teeth. The maxillary sinus is
fully developed
In old ageThe alveolar magin is absorbed due
to loss of teeth. The height of bone becomes
less
Nasalis a small bone that forms the bridge of
nose with bone of opposite side
It articulates with nasal part of frontal bone
above and frontal process of maxilla laterally
Lacrimalis smallest and thinnest of all cranial
bones
It lies in medial wall of orbit between frontal
process of maxilla and orbital plate of ethmoid
It has a lacrimal groove on lateral surfacethat lodges lacrimal sac
Palatinelies in lateral wall of nasal cavity and
palate
It has two partsa horizontal plate and a
perpendicular plate
The horizontal platejoins the bone of
opposite side to form posterior one-fifth part
of hard palate. It has a nasal spine in midline
The perpendicular part forms posterior part
lateral wall of nasal cavity
Zygomatic forms the prominence of cheek
Its lateral surface has a foramen, The
temporal surface forms anterior wall of
375
temporal fossa and its medial surface

forms part of lateral wall and floor of
orbital cavity
Zygomatic has three processes
i. Frontal processlies along lateral
margin of orbit to join with frontal bone
ii. Maxillary processjoins medially with
maxilla
iii. Temporal
processforms
the
zygomatic arch with zygomatic process
of temporal
7. Inferior nasal conchais a curved bony plate
that lies in the lateral wall of nasal cavity above
the inferior meatus
8. Mandible or the lower jaws bone forms the
lower half of fascial skeleton
Each half of mandible has a horizontal body
and a vertical part - ramus
The two halves of mandible are connected
by a fibrous joint at birth. Bony fusion (synostosis) takes by end of first year to from
symphysis menti
The body of mandible has two surfaces
i. Lateral surface (Fig. 35.1) - has an
oblique line an incisive fossa and a
mental foramen
Fig. 35.1: The mandiblelateral aspect
376

surface of angle for muscular attachment
ii. The lateral surface - of the ramus is
rough for muscular attachment
Special Features of Mandible
[Muscles and ligaments attached to the bone]
Body of Mandible
Fig. 35.2: The mandiblemedial aspect
ii. Medial surface (Fig. 35.2) - has a

mycolyoid line separating sublingual
and submandibular fossa, and by side
of midline two genial tubercles
There are two borders of the body
a. Superior borderis alveolar border that
bears eight sockets for teeth
b. Inferior borderis thickened to form
the base of mandible. A shallow digastric
fossa lies near symphysis menti
The ramus of mandiblejoins the
body at an angle that is nearly 90 in
adults
a. Superiorlythe ramus is divided into
two processes separated by mandibular notch.
b. The coronoid processis thin and
triangular and the condyloid process
is divided into a neck and a convex
head. The neck presents anteriorly
a triangular pterygoid fossa
The ramus has two surfacesmedial and
lateral
i. The medial surfacehas mandibular
foramen in center with a triangular bony
process lingula anterior to it. A mylohyoid groove passes dowwards from the
foramen. There is a rough area on medial
Alveolar margin opposite molar teeth - Buccinator

Anterior oblique line - Depressor anguli oris,
depressor labii inferioris
Incisive fossa - Mentalis
Lower border (base) - Platysma, deep cervical
fascia
Mylohyoid lineMylohyoid and superior constrictor of pharynx
Behind last molar tooth - Pterygo-mandibular
ligament
Genial tubercles - Geniohyoid and genioglossus
Digastric fossa - Anterior belly of digastric
Ramus of Mandible
Lateral surface (except neck) Masseter

Rough area on medial aspect of angle - Medial
pterygoid
Lingula-spheno-Mandibular ligament
Coronoid process - Temporalis (medial surface)
Masseter (lateral surface)
Pterygoid fossa of neck- Lateral pterygoid
Age Changes of Mandible

In children
Angle of mandible is obtuse (140).
Coronoid process is large and projects above
condyloid process
Alveolar margin presents sockets for deciduous
teeth (five in each half)
Mental foramen is near lower border
In adults
Angle of mandible reduced is 110 (i.e. nearly
right angle)
tahir99 - UnitedVRG
Alveolar margin presents sockets for permanent

teeth (eight in each half) (Fig. 35.3)
Mental foramen is located midway between
upper and lower borders
Fig. 35.3: The structure of a toothlongitudinal section
In old age (after 60 years)

Angle become obtuse again (140)
Alveolar margin is absorbed as teeth fall out
and height of bone is reduced
Mental foramen comes to lie near the upper
border
9. Ethmoidforms roof, lateral wall of nasal
cavity and part of nasal septum
Ethmoid has a cribriform plate superiorly
two ethmoidal labyrinths and a perpendicular
plate
The cribriform plate lies in roof of nasal
cavity. It is divided into two halves by crista
galli and supports the olfactory bulbs. The
olfactory nerves pass through its foramina
The ethmoidal labyrinths form a part of
lateral wall nasal cavities. Its orbital plate
forms part of medial wall of orbit. The
labyrinths have a dozen small air sinuses
divided into three groupsanterior, middle
and posterior
The perpendicular plate forms posterior and
superior part of nasal septum
377
10. Sphenoidlies in the base of skull between

frontal and temporal bones. It has a central part
- body and three paired processesgreater
wings, lesser wings and pterygoid processes
The body of sphenoid is cuboidal and
contains two large sphenoidal air sinuses.
It has six surfaces.
i. Superior surfacebears a sulcus chiasmaticus for optic chiasma, tuberculum
sellae and hypophyseal fossa (sella
turcica). Dorsum sellae with two posterior clinoid processes lie posteriorly
ii. Inferior surfacehas a median ridge the rostrum. A triangular vaginal plate
extends on either side from medial
pterygoid plate.
iii. Two lateral surfacesEach has a carotid
sulcus for internal corotid artery. The
rest of lateral surface is occupied by
attachment of greater wing.
iv. Anterior surfacepresents sphenoidal
crest in midline. On either side are
openings of sphenoidal air sinuses and
sphenoidal concha.
v. Posterior surface of body of sphenoid
fuses with basilar part of occipital bone
by 25th year.
Greater wingsare two strong and curved
processes that project laterally from body.
It has three surfacessuperior (cerebral)
lateral and orbital.
a. Superior (cerebral) surface is deeply
concave and lodges temporal lobe of
cerebral hemisphere. It has important
foramina, e.g. foramen ovale, foramen
spinosum and foramen rotundum.
b. Lateral surface is convex and divided
by infra-temporal crest into temporal and
infra-temporal surfaces. A spine of
sphenoid projects downwards and gives
attachment to spheno-mandibular ligament.
378

c. Orbital surfaceis nearly quadrangular
and forms part of lateral wall of orbit.
Lesser wingsare triangular processes that
project laterally from body above greater
wings. Its posterior border is sharp and at
its medial end is pointed anterior clinoid
process. Inferioly it forms upper margin of
superior orbital fissure. Optic foramen lies
between its two roots.
Pterygoid processes descend vertically from
the junction of body and greater wings.
Each consists of a lateral and a medial
pterygoid plate separated by a pterygoid
fossa.
A small scaphoid fossa is formed by
splitting of posterior border of medial
pterygoid plate. A pterygoid hamulus
projects from lower end of medial pterygoid plate. The vaginal process prolonged on inferior surface of body of
sphenoid forms palatino-vaginal canal.
11. Occipitalforms the posterior and inferior

parts of the cranium. (Fig. 35.4) It consists of
four partssquamous, basilar and two condylar
separated by foramen magnum.
Squamous parthas a convex external
surface and a hollow internal surface.
The external surface has in center
external occipital protuberance and a
crest passing from here to foramen
magnum. There are three bony ridges
nuchal linesradiating from the protuberance and crest. The superior nuchal lines are quite well defined highest
nucheal lines may be seen in old skull.
Inferior nucheal line arise from middle
of crest.
The internal surface is divided into four deep
fossae by an internal occipital protuberance
and one sagittal and two transverse sulci.
The superior fossae are occupied by
occipital poles of cerebral hemispheres and
inferior fossae by cerebellar hemispheres.
Fig. 35.4: The occipitalexternal aspect
tahir99 - UnitedVRG
Basilar partis a rectangular plate of bone

that lies in front of foramen magnum. It
fuses anteriorly with body of sphenoid by
25th year.
Its superior surface is hollow and
supports medulla oblongata.
Its inferior surface presents a pharyngeal tubercle in midline for pharyngeal
raphe of constrictor muscles of pharynx.
Lateral (condylar) partslie in either side
of foramen magnum. Each part has
An occipital condyle that articulates with
superior facet of atlas vertebra.
Jugular process that froms posterior
boundary of jugular foramen
Hypoglossal (anterior condylar) canal
above occipital condyle.
12. Frontal forms the anterior part of cranium and
roof of orbital cavities
The frontal bone has a convex external
surface and a hollowed internal surface.
The external surface shows the following
features (Fig. 35.5)
Two prominent frontal eminences on
either side.
379
Two superciliary arches radiate laterally

above orbital margins. A median swelling
glabella lies above roof of nose
The zygomatic processes lie laterally and
join with zygomatic bones. The temporal
linessuperior and inferiorradiate from
this process.
The internal surfaceis concave. It
presents frontal crest in midline that
continues backwards as sagittal sulcus.
The internal surface shows impressions
for cerebral gyri and small furrows for
meningeal vessels.
The nasal part of frontal bone lies between
two supraorbital margins. It articulates with
nasal bones and has a small nasal spine in
midline that contributes to nasal septum.
13. Parietal bonesform the lateral aspects of
skull.
Each parietal bone has an external surface and
a hollowed internal surface.
The external surface is smooth and convex.
It has a central parietal eminence. Two
curved temporal linessuperior and inferior
lie laterally.
Fig. 35.5: The frontalexternal aspect
380
Posteriorly close to superior border is

parietal foramen.
The internal surface is marked by
impressions of cerebral gyri and grooves
for middle meningeal vessels.
Along the superior border is sulcus for
superior sagittal sinus that is completed
by the opposite bone.
Near the anterior inferior angle is a
groove for junction of transverse and
sigmoid sinuses.
14. Temporal boneslie on lateral aspects of
cranium below parietal bones.
Each temporal bone consists of four parts
squamous, tympanic, petro-mastoid and styloid
(Fig. 35.6).
Squamous partis the upper expanded part:
Its temporal surface is grooved by middle
temporal artery. It forms part of temporal
fossa.
Its infra-temporal surface is separated
by a crest.
The zygomatic process completes the
zygomo-tympanic arch with zygomatic
bone. Articular tubercle and mandibular
fossa lie below this arch.
Fig. 35.6: The temporalexternal aspect
External acoustic meatus is a large

opening below the arch.
A supra-mastoid crest separates the
squamous part from mastoid part.
Tympanic partforms a curved bony plate
that forms the anterior and inferior boundary
of external acoustic meatus.
A small supra meatal triangle and spine
lie postero-superior to external acoustic
meatus. The mastoid antrum lies
1.5 cm. deep to this triangle in adults
Petro-mastoid part is divided into a mastoid
part and a petrous part.
The mastoid part lies behind the external
acoustic meatus. The outer surface is
rough and prolonged as mastoid process
that has mastoid air cells inside.
The internal surface has a deep
sulcus for sigmoid sinus.
Petrous part lies internally in base of
skull between sphenoid and occipital
bones.
It is triangular in shape. Its apex
points medially and contains anterior
end of carotid canal. Its base corresponds to junction between petrous
and squamous parts.
Its anterior surface bears trigeminal
impression near apex for trigeminal
ganglion. An arcuate eminence lies
laterally caused by anterior semi
circular canal.
Its posterior surface lies in posterior
cranial fossa. Near its center is internal acoustic meatus.
Its inferior surface has a quadrangular area for muscular attachment.
There is lower opening of carotid
canal. A jugular fossa lies behind it
for lodging superior bulb of internal
jugular vein.
tahir99 - UnitedVRG
381
Table 35.1: The ossification of the cranial bones

S No Name of the bone
Ossification in membrane
1.
Vomer
2.
Maxilla
3.
Nasal
4.
5.
Lacrimal
Palatine
6.
7.
Zygomatic
Inferior nasal concha
8.
Mandible
9.
Ethmoid
10.
Sphenoid
11.
Occipital
Ossification in cartilage
Two centres appear in eight weeks on

either side of midline; fuse by twelfth week
Three centres
One for main body appears above canine
fossa at sixth week
Two centres appear for premaxilla (os
incisivum) by seventh week and fuse soon
One centre appears in third month of
intrauterine life
One center appears in twelfth week
One center appears in eighth week in
perpendicular plate
One center appears in eighth week
One center appears in fifth month in the
lower border of cartilaginous nasal capsule
Each half is ossified by one center, that
Ossification spreads in condylar cartiappears in sixth week, near mental
lage, extending from mandibular head
foramen
down to the ramus
Three centers appear in cartilaginous
nasal capsule
One in perpendicular plate plate during
first year after birth
Two center one for each labyrinth
appear between fourth and fifth months
of intrauterine life
a. Presphenoidal part (in front of tuberculum sellae and lesser wings) has six
ossification centers
Two for body of sphenoid in ninth
week
Two for the two lesser wings in ninth
week
Two for the two sphenoidal conchae in
fifth month
b. Post sphenoidal part (posterior part
body, greater wings and pterygoid processes) has eight centres
[The rest portions of greater wings and lateral Two for the two greater wings in eighth
pterygoid plates ossify in membrane from
week forming the root only
same centers]
Two for post sphenoidal part of body
of fourth month
Two centres for medial pterygoid plates
Two centres appear for the two pteryappearing in ninth week
goid hamulus during third fetal month
Above highest nuchal line by two centers
Two centers for squamous part below
that appear in second month of fetal life
highest nuchal line appear in seventh
[may remain separate as interparietal bone]
week
One Kerckring center appears for posterior margin of foramen magnum in
sixteenth week
Contd...
382
Contd...
S No Name of the bone
Ossification in membrane
Ossification in cartilage
12.
Frontal
13.
Parietal
14.
Temporal
Two primary centers appear in eighth

week near frontal eminences. At birth bone
is in two halves separated by a suture.
Fusion starts soon. But remains of metopic
suture may persist in adult skull
Two centers appear in seventh week near
the parietal eminence and fuse soon
Squamous part by one centre appearing in
seventh week
Tympanic part from one centre appearing
in third month
Two centres one for each lateral parts

appear in eighth week.
One center appears for the basilar part
in sixth week.
Petromastoid part is ossified by several

centres appearing in cartilaginous ear
capsule during fifth month
Styloid process develops from cranial
end of second branchial arch cartilage.
Two centers appear in itone before
birth (tymponohyal) and one another
after birth (stytohyal)
Table 35.2: Important foramina outside the skull

S No Name
Bone
Structures passing through
1.
2.
3.
4.
Frontal
Maxilla
Zygomatic
Zygomatic
Supra-orbital nerve and vessels

Intra-orbital nerve and vessels
Zygomatico-facial nerve and vessels
Zygomatico-temporal nerve
5.
6.
Supra-orbital foramen
Intra-orbital foramen
Zygomatico-facial foramen
Zygomatico-temporal
foramen
External acoustic meatus
Petro-tympanic fissure
Temporal
Temporal
7.
Pterygo-maxillary fissure
8.
Inferior orbital fissure
Between pterygoid
process and maxilla
Between greater wing
sphenoid and maxilla
9.
Posterior superior dental canals
Maxilla
10.
Stylomastoid foramen
Temporal
11.
Posterior condylar canal
Occipital
12.
13.
Anterior condylar canal

Mastoid foramen
Occipital
Mastoid temporal
Sound waves
Chorda tympani
Anterior tympanic artery
Third part of maxillary artery
Maxillary nerve
Maxillary nerve
Zygomatic branch of maxillary nerve
Intraorbital vessels
Emissary vein connecting the interior
ophthalmic vein with pterygoid venous
plexus
Posterior superior alveolar nerve and
vessels
Facial nerve
Stylomastoid artery
Emissary vein connecting the sigmoid
sinus with suboccipital venous plexus
Hypoglossal nerve
Emissary vein joining the veins of scalp
with transverse sinus
Contd...
tahir99 - UnitedVRG
383
Contd...
S No Name
Bone
14.
Parietal foramen
Parietal
15.
Jugular foramen
16.
Carotid canal
Between condylar part of

occipital and petrous
temporal bone
Petrous temporal
17.
Foramen lacerum
Between apex of petrous

temporal and sphenoid
18.
Foramen ovale
Greater wing of sphenoid
19.
Foramen spinosum
Greater wing of sphenoid
20.
Greater palatine foramen
Horizontal plate of palatine
21.
22.
Lesser palatine foramina

Incisive fossa
(It has four foramina anterior,
posterior and two lateral)
Palatine
Between palatal processes
of two maxillae
23.
Foramen magnum
Occipital bone
Emissary vein joining veins of the scalp

with superior sagittal sinus
Inferior petrosal sinus
Ninth, tenth and eleventh cranial nerves
Sigmoid sinus
Internal carotid artery with its sympathetic plexus
Emissary vein joining the pharyngeal
veins with cavernous sinus
Meningeal branch of ascending pharyngeal artery
Internal carotid artery with its sympathetic plexus, passes through upper
part
Mandibular division of trigeminal nerve
Motor root of trigeminal
Emissary vein joining pterygoid venous
plexus with cavernous sinus
Accessory meningeal artery (sometimes)
Middle meningeal artery
Meningeal branch of mandibular nerve
Greater palatine nerve
Greater palatine vessels
Lesser palatine nerves
Anterior foramenLeft nasopalatine
nerve
Posterior foramenRight nasopalative
nerve
Two lateral foraminaTerminal parts
of greater palatine arteries
Medulla oblongata with its meninges
Two vertebral arteries with their
sympathetic plexuses
Spinal roots of accessory nerves
Membrana tectoria
Apical ligament
Two posterior spinal and one anterior
spinal arteries
Tonsils of cerebellum (bulge through
foramen magnum)
384

Table 35.3: Important foramina inside the skull
S No Name
Anterior cranial fossa
1.
Foramen cecum
(1% skulls)
2.
3.
Foramina in cribriform plate

Anterior ethmoidal canal
4.
Posterior ethmoidal canal
Bone
Between crista galli of

ethmoid and frontal crest
of frontal bone with beginning
of superior sagittal sinus
Ethmoid
Between cribriform plate and
orbital plate of frontal
Between cribriform plate and
orbital plate of frontal
Emissary vein connecting the veins of

roof of nose
Olfactory nerves
Anterior ethmoidal nerve and vessels
Posterior ethmoidal vessels
Middle cranial fossa

5.
Optic canal
Sphenoid
6.
Sphenoid
Optic nerve with its three sheaths

Ophthalmic artery
Lacrimal, frontal and nasociliary
nerves
Trochlear nerve
Two divisions of oculomotor nerve
Abducent nerve
Superior and inferior ophthalmic veins
Maxillary division of trigeminal nerve
Superior orbital fissure
7.
Foramen rotundum
Sphenoid
8.
9.
10.
Foramen ovale
Foramen spinosum
Foramen lacerum
(described in Table 35.2)
11.
12.
Hiatus for greater petrosal nerve

Hiatus for lesser petrosal nerve
Petrous temporal
Petrous temporal
Greater petrosal nerve

Lesser petrosal nerve
Petrous temporal
Facial nerve
Vestibulo-cochlear nerve
Labyrinthine vessels
Posterior cranial fossa

13.
Internal acoustic meatus
14.
15.
16.
17.
Jugular foramen
Anterior condylar canal
Foramen magnum
(described in the Table 35.2)
A minute tympanic canaliculus lies
in the ridge between carotid canal

and jugular fossa.
The petrous part contains parts of
middle ear and internal ear.
Styloid partforms a slender, pointed
styloid process that projects downwards
and forwards from inferior surface of
temporal bone.
The process is about 2.5 cm long and
its tip gives attachment to stylohyoid
ligament.
INTERIOR OF THE SKULL

A. Internal surface of cranial vault presents the
following features.
The coronal suture, sagittal suture and the
lambdoid sutures are seen
Frontal crest lies anteriorly in median plane.
It is grooved by beginning of sagittal sulcus
Sagittal sulcus - runs in median plane along
the adjoining margins of parietal bones
Parietal foramina are located near sagittal
sulcus posteriorly
tahir99 - UnitedVRG
Deep irregular
pits for archnoid
grannulations are seen on either side of
sagittal sulcus
Vascular markings for branches of middle
meningeal vessels are seen on either side
Impressions for cerebral gyri are also seen
on either side
B. Internal surface of base of skullis divided into
three cranial fossaeanterior, middle, and
posterior (Fig. 35.7)
The anterior cranial fossa lodges the frontal
lobes of two cerebral hemispheres. It is bounded
anteriorly by the frontal bone and posteriorly
by sharp free margins of two lesser wings of
sphenoid, anterior clinoid processes and anterior
margin of optic groove (sulcus chiasmaticus)
The features of this fossa are:
The cribriform plates of ethmoid and the
crista galli
385
Orbital plates of two frontal bones

Orbital surface of two lesser wings of
sphenoid
Jugum sphenoidale at anterior part of body
of sphenoid in median plane
The middle cranial fossalodges the temporal
lobes of two hemispheres on either side and
base of brain with bypophysis cerebre in midline
The fossa is bounded anteriorly by the
posterior boundary of anterior cranial fossa.
It is bounded posteriorly by dorsum sellae
posterior clinoid processes, apex and
superior border of petrous temporal bone
The bones forming the floor of middle
cranial fossa are
In median plane - optic groove, tuberculum sellae and hyphyseal fossa - all
parts of body of sphenoid
Fig. 35.7: The cranial cavityshowing the cranial fossae
386
On either side - greater wing of sphenoid

with foramen rotundum foramen ovale and foramen spinosum.
The squamous part of temporal bone
and anterior surface of petrous temporal
bone lie lateral to greater wing of
sphenoid.
Superior orbital fissure is an oblique
fissure between lesser wing and greater
wing of sphenoid
Trigeminal impression for the trigeminal
ganglion lies near the apex of petrous
temporal bone.
The posterior cranial fossa lodges the cerebellum and is roofed over by tentorium cerebelli.
The fossa is bounded anteriorly by posterior
boundary of middle cranial fossa and posteriorly
by the two transverse sulci and internal occipital
protuberance.
The bones forming posterior cranial fossa are
In the median plane grooved plate of bone
formed by fusion of body of sphenoid and
basilar part of occipital bone. Also the
squamous part of occipital bone with internal
occipital crest leading to internal occipital
protuberance
On either sidelie the posterior surface of
petrous temporal bone, the mastoid temporal, condylar part occipital bone and the
remaining part of squamous temporal bone
The internal acoustic meatus lies on posterior
surface of petrous temporal
The jugular foramina lie on either side
between petrous temporal and jugular part
of occipital
Anterior condylar canal and posterior
condylar canals lie in relation to anterior and
posterior margins of foramen magnum.
The Fontanelles of the Skull
The fontanelles of the skull are gaps filled up by
fibrous membrane at corners of the parietal bones
in skull of infants at birth.
The flat bones of skull forming the calvaria
develop by intra-membranous ossification. At
birth, however, their corners remain unossified
forming fontanelles
There are six fontanelles
1. The anterior fontanelle is largest and
diamond shaped. It closes by eighteen
months.
This fontanelle is clinically important, as
it is used for assessing intra-cranial
pressure in dehydration of infants, and
also for giving intra-venous injections
in infants.
2. The posterior fontanelle is small and
triangular and closes by end of first year
3. Two antero-lateral fontanelles are small and
irregular and close by first year
4. Two postero-lateral fontanelles are also small
and irregular and close by first year.
Wormian (Sutural) Bones

These are small irregular bones seen sometimes at
the site of fontanelles. These are formed by additional ossification centers. The common ones are
found at lambda and asterion.
The inter-parietal bone (upper part of
squamous occipital bone) may be included in this
group.
Important foramina outside and inside the skull
are enumerated in Tables 35.2 and 35.3 respectively.
THE CERVICAL VERTEBRAE
There are seven cervical vertebrae in the skeleton
of neck joined by the inter-vertebral discs
1. Typical cervical vertebrae are from third to
sixth vertebra
A typical cervical vertebra has the following
It has a small but broad body
The vertebral canal is large and nearly
triangular in shape
The spinous process is short and bifid
The superior and inferior vertebral
notches are equal in size
The transverse process has a large
foramen transversarium and is divided
tahir99 - UnitedVRG
into anterior tubercle and posterior

tubercle
The anterior tubercle and inter-tubercular
lamella (costo-transverse bar) represent
the costal element in cervical vertebra.
387
superiorly and a flat facet on inferior aspects

for superior articular facets of axis vertebra.
The prominent transverse processes have
foramen transversarium
3. Axis vertebra [Second cervical vertebra] forms
the pivot for rotation of head with atlas vertebra
around the dens.
Axis vertebra has the following features (Fig.
35.10):
The dens or odontoid process forms a projection above the body. It articulates with
facet on back of anterior arch of atlas
vertebra.
Fig. 35.8: A typical cervical vertebraesuperior aspect
2. Atlas vertebra - [First cervical vertebra]

supports the globe of head (hence the name)
Atlas vertebra has the following features
(Fig. 35.9)
It has no body. The body of atlas is fused
with body of axis (second) vertebra to form
the dens or odontoid process.
The anterior arch is short and is slightly
convex. It has an anterior tubercle in front
and an articular facet behind for the dens of
axis vertebra
The posterior arch - forms two-fifth of the
ring surrounding vertebrae canal. It has a
groove on superior aspect for vertebral
artery
The lateral masses on either side have a large
concave facet for occipital condyle
Fig. 35.9: The atlas vertebra (superior aspect)
Fig. 35.10: The axis vertebrae (postero-superior aspect)
The dens is about 1.5 cm long and gives

attachment to apical ligament at the tip and
two strong alar ligaments on either side of
tip.
The superior articular facet is large oval
and flat. It articulates with inferior facet of
lateral mass of atlas vertebra.
The transverse processes are small and have
only one tubercle (homologous with posterior tubercles of typical cervical vertebra.
It has a foramen transversarium.
The rest of features resembly a typical
cervical vertebra.
4. Seventh cervical vertebra (Vertebra prominens)
The seventh cervical vertebra has the following
It has a long spinous process that is visible
at lower end of ligamentum nuchae at back
388

of neck. This vertebra forms the first
prominent spinous process at back of neck,
hence the name
The rest of the features resemble those
of a typical cervical vertebra.
One secondary center for apex of dens appears

in second year and one for lower surface of
body at puberty.
IV. The seventh cervical vertebra
It has the usual centers for ossification like the
typical vertebra. It has usually two separate
centers for the costal elements that may fuse
with the body or remain separate and form the
cervical rib.
The Hyoid Bone
The hyoid bone is a small U-shaped bone that lies
in uppermost part of front of neck (Figs 35.12 and
35.13).
Fig. 35.11: The seventh cervical vertebra
Ossification of Cervical Vertebrae

I. The typical cervical vertebra ossifies by three
primary centers
One for the centrum or body.
One for each half of vertebral arch.
The center for body appears in cervical region
by twelfth week of intra-uterine life. For
vertebral arch the two centers appear in ninth
to tenth week.
There are five secondary centers one in apex of
each transverse process, one in spinous process
and two for the body (superior and inferior
surfaces). These centers appear at puberty.
II. The atlas vertebra ossifies by three centers one
in each lateral mass appearing in seventh weak.
One center appears in anterior arch by end of first
year.
III. The axis vertebra ossifies by five primary
centers and two secondary centers.
The vertebral arch by two centers, (seventh to
eight week) the centrum by one center, (fourth
month), the dens by two centers (sixth month).
Fig. 35.12: The hyoid bonesuperior aspect
Fig. 35.13: The hyoid bonelateral aspect
General Features
Hyoid bone consists ofa median body, paired
greater cornu and paired lesser cornu.
The body is roughly quadrangular. Its anterior
surface faces antero-superiorly. The posterior
surface is smooth and concave and related to a
bursa.
tahir99 - UnitedVRG
The greater cornu are attached to the body by a

cartilage, but they fuse with body in old age.
The greater cornu curve backwards and are
horizontally flattened. They end in a tubercle.
The lesser cornu are two small conical projections at the function of body and greater cornu.
They are connected to the body by some fibrous
tissue. They also may get fused with the body
in old age.
389
Upper part of body and lesser cornu - from

second arch cartilage.
Lower part of body and greater cornu from
third arch cartilage.
There are six centers of ossification two for
body, two for greater cornu and two for lesser
cornu.
The centers for greater cornu appear at end of
fetal life, for body after birth and lesser cornu at
puberty.
Special Features
The Vertebral Column
Muscles and ligaments attached to hyoid bone
At the back of the body, there is vertebral column

(or the spine), that is made up of thirty-three
vertebrae (7 cervical, 12 thoracic, 5 lumbar, 5
sacral and 4 coccygeal)
The five sacral vertebral are fused to form the
sacrum and four coccygeal vertebrae (that are
rudimentary) are fused to form the coccyx.
The inter-vertebral disc Between the bodies of
the vertebrae there are about twenty-four
intervertebral discs (5 in cervical region, 11 in
thoracic region, 4 in lumbar region, 1 or 2 in
sacral region and 1 between sacrum and coccyx
and 1 rudimentary between first and second
piece of coccyx.
The intervertebral discs constitute about onefourth of the total length of vertebral column.
Their shape and size conform to the bodies of
vertebrae in different regions.
Structure: The intervertebral disc consists of
two parts
i. The nucleus pulposus is the inner part. It
consists of muco-polysaccharide complexes
with high osmotic pressure
The nucleus pulposus is remnant of
notochordthe primitive axis of the
body.
ii. The annulus fibrosus is the outer part that
surrounds the nucleus pulposus
It consists of dense connective tissue
bands, and it binds firmly the adjacent
vertebral bodies.
The Body
Anterior surface of bodyGeniohyoid and

mylohyoid on either side of midline.
Junction of body and greater cornu
Hyoglossus
Upper border of body - Lower fibers of genioglossus and thyrohyoid membrane
Lower border of body-Sternohyoid and omohyoid and pretracheal fascia below omohyoid
thyrohyoid muscles.
The Greater Cornu
Upper surfaceMiddle constrictor medially and

hyoglossus laterally, fibrous pulley of digastric
and stylohyoid at function with body.
Lower surfaceis separated from thyrohyoid
membrane by fiber - fally tissue.
Medial borderThyrohyoid membrane.
Lateral borderInsertion of thyrohyoid muscle
and deep fascia of neck.
The Lesser Cornu
Tip - Stylohyoid ligament.

Posterolateral aspect - Middle constrictor
muscle.
Ossification of Hyoidbone
Hyoid bone is developed from the cartilages of
second and third pharyngeal arches.
390
The Spinal Curvatures

The vertebral column presents curvatures. Some
of these curvatures are primary curvatures, i.e. they
are present since birth
While some other curvatures develop later due
to functional reasons. These are called
secondary curvatures
The primary curvatures are present in fetus
also and continue in the adults. The primary
curvatures are
i. The thoracic curvatureconcave forwards
ii. The sacral curvatureconcave forwards
The secondary curvatures develop later in life.
These are
i. The cervical curvature convex forwards and
develops as the child starts to raise the neck
to support the head.
ii. The lumbar curvature also convex forwards
and develops mainly due to adoption of erect
posture by humans.
Applied Anatomy
1. Abnormal curvatures of spine may develop due
to:
Congenital abnormality
Trauma leading to compression of spine
Pathological lesion of the vertebrae
Functional reasons
The abnormal curvatures are
a. Kyphosis (hunchback)caused by exaggerated thoracic curvature
b. Lordosiscaused by exaggerated lumbar
curvature. It is usually present in late
pregnancy and in obese persons
c. Scoliosisabnormal lateral curvature of the

spine. It may also show a corresponding
curve in opposite side.
2. Compression fracture of bodies of vertebrae is
caused either by trauma or by pathological lesion.
It may lead to a deformity of the spine, e.g.
kyphosis or scoleosis or it may cause compression of the spinal nerves.
3. Spondylolisthesis is anterior displacement of
vertebral body.
It commonly occurs at lumbosacral joint and
involves compression of S1 and S2 spinal nerves
producing low back pain or sciatica.
The condition may be a congenital defect or
may be caused by fracture of fifth lumbar
vetebra.
4. Sacralization of fifth lumbar vertebra may occur
rarely due to fusion of fifth lumbar vertebra with
sacrum.
5. Slipped disc (Herniation of intervertebral disc)
is caused by an injury to the annulus fibrosus and
resultant prolapse of nucleus pulposus.
The prolapse of disc occurs commonly between
the fourth lumbar and fifth lumbar vertebra or
between fifth lumbar and first sacral vertebra
The herniation results in low back pain due to
compression of spinal nerves
There may be painful spasm of back muscles
also.
6. Degeneration of intervertebral discs results from
damage to the nucleus pulposus. This leads to
narrowing of the intervertebral space.
It occurs commonly in the cervical region and
may cause compression of spinal nerves leading
to pain in the arm.
tahir99 - UnitedVRG
CHAPTER
36
The Joints, Fasciae and

Deep Muscles of the
Back of Head and Neck
THE JOINTS OF THE HEAD AND NECK
The various joints of the head and neck are:
1. The temporo-mandibular joint
2. The atlanto-occipital joint
3. The atlanto-axial joints
4. The ligaments connecting axis with the occipital
bone
5. The sutures of the skull
6. The joints between cervical vertebrae.
1. The Temporo-Mandibular Joint (Fig.
36.1)
This joint is formed by the head of mandible

and articular fossa and eminence of temporal
bone
TypeBicondylar type of synovial joint
Fig. 36.1: The temporo-mandibular jointlateral aspect
Articular capsulesurrounds the joint on all

sides.
It is attached on mandible all around the
articular surface of the head.
On temporal, it is attached on squamotympanic fissure and margins of articular
fossa and eminence.
Ligaments
a. The lateral (temporo-mandibular) ligament
reinforces the lateral aspect of the capsule.
It is attached above to tubercle of root
of zygoma and below to posterior border
of neck of mandible.
b. The spheno-mandibular ligamentlies on
medial aspect of the joint.
It is attached above to the spine of
sphenoid and below to the lingula of
mandibular foramen It is separated from the joint and neck
of mandible by
Lateral pterygoid muscle
Auriculo-temporal nerve
Maxillary vessels
Inferior alveolar vessels
A part of parotid gland
It is pierced by the mylohyoid nerve. It
develops from the dorsal end of Meckels
cartilage.
c. The stylo-mandibular ligamentis a
thickened band of deep cervical fascia that
is attached from apex and anterior aspect
392
of styloid process to posterior border of

angle of mandible (Fig. 36.2).
It is an accessory ligament and its role
in the joint is not much.
d. The articular discis oval disc of fibrocartilage that completely separates the joint
into two joint cavities.
It is attached all along its periphery to
the inner surface of the capsule (Fig.
36.3).
The superior surface of the disc is
concavo-convex for articular fossa and
eminence and inferior surface is concave
for the head of mandible.
The disc is developmentally fibrosed
part of tendon of lateral pterygoid
muscle.
The disc gives stability to the joint and
permits two different types of movements in the two joint cavities.
The arterial supply
The arteries supplying the joint are derived
from the superficial temporal and maxillary
arteries, both terminal branches of the
external carotid artery.
The nerve supply: The nerves supplying the joint
are
The auriculo-temporal nerve
The mesenteric branch of anterior division
of mandibular nerve
Fig. 36.2: The temporo-mandibular jointsagittal section
Fig. 36.3: The temporo-mandibular jointmedial aspect
The movements
The movements of the joint take place in
relation to the occlusal position (position of
rest) of mandible, when jaws are together
and molar teeth of both jaws are in apposition.
The mandible can be depressed (opening of
mouth) or elevated. It can be protruded or
retracted.
Both joints always act together, although
they may be having different types of
movement.
The axis of movement passes through
mandibular foramina of the two sides, as
the neuro-vascular bundles pass through
them.
Depression
Lateral pterygoids helped by
Digastric, geniohyoid and mylohyoid
muscles.
ElevationTemporalis, masseter, medial
pterygoid of both sides. During depression,
the head of mandible is pushed downwards
and forwards so that it comes to lie below
articular eminence. During elevation it is
pushed backwards in articular fossa.
ProtractionLateral and medial pterygoid
muscles
tahir99 - UnitedVRG
The Joints, Fasciae and Deep Muscles of the Back of Head and Neck
RetractionPosterior fibers of temporalis,

assisted by deep fibers of masseter, digastric
and geniohyoid.
Lateral (side to side) movementsmedial
and lateral pterygoids of each side acting
alternately.
Applied anatomy
The anterior dislocation of head of mandible
may occur anteriorly in front of articular
eminence due to spasm of temporalis
muscle.
For reduction of dislocation, the mandible
has to be pulled downwards and then pushed
backwards.
2. The Atlanto-Occipital Joint

This joint is between the two occipital condyles
and the superior articular facets of atlas vertebra
Typecondyloid type of synovial joints
The articular capsulesurrounds the joints on
all sides. It is reinforced by ligaments and
membranes.
The anterior atlanto-occipital membrane
connects the anterior margin of foramen
magnum to the anterior arch of atlas.
393
The posterior atlanto-occipital membraneis

broad and thin.
It connects the posterior margin of foramen
magnum to the posterior arch of atlas.
It arches over the grooves for the vertebral
arteries.
MovementsBoth the joints act as one ellipsoid
joint with long axis transverse.
The movements taking place at these joints
are flexion, extension and lateral flexion.
Flexionlongus capitis and rectus capitis
anterior
Extensionrectus capitis posterior major
and minor, obliquus capitis superior,
semispinalis capitis, splenius capitis and
upper part of trapezius (of both sides).
Lateral flexionrectus capitis, lateralis,
semispinalis capitis, splenius capitis,
sternomastoid and upper part of trapezius
(of one side)
3. The Atlanto-Axial Joints (Fig. 36.4)

There are three joints between the atlas and the
axis vertebraone median atlanto-axial joint and
two lateral atlanto-axial joints.
Fig. 36.4: The atlanto-axial jointmedian sagittal section
394
a. The median atlanto-axial jointis a pivot

type of synovial joint with dens of the axis acting
as a pivot and anterior arch of atlas and transverse
ligament providing the ring.
There is a loose fibrous capsule lined by synovial
membrane.
The tranverse ligament of atlasis a thick
fibrous band attached to medial tubercles on
medial aspects of lateral masses of atlas
vertebra.
b. The lateral atlanto-axial joints are plane type
of synovial joints between the inferior articular
facets of atlas and superior articular facets of axis
vertebra.
Both articular surfaces are ovoid and sloping.
The fibrous capsule is loose and thin. It is
attached to the margins of articular surfaces.
The anterior longitudinal ligamenta strong
wide band attached above to anterior arch of
atlas and below to the body of axis.
Movements occurring at atlanto-axial joints

The movements at all the three atlanto axial
joints occur together.
The movement consists of rotation of atlas
and skull on the axis vertebra with its dens
acting as a pivot.
Muscles producing the movements
Obliquus capitis inferior, rectus capitis
posterior major and splenius capitis of one
side and sterno-mastoid of the opposite side.
4. The Ligaments Connecting Axis with

the Occipital Bone
The ligaments aremembrana tectoria, two alar
ligaments and median apical ligament.
a. The membrana tectoria is a broad strong band,
that is upward prolongation of posterior longitudinal
ligament of the vertebral column.
It is attached below to posterior surface of body
of axis and above it passes through foramen
magnum and is attached to the basilar part of
occipital bone.
b. The alar ligaments are two round fibrous

cords attached below to either side of tip of dens
of the axis vertebra. Above they are attached to the
rough surface on medial aspect of occipital condyles.
They become taut in flexion and are relaxed
during extension of the skull. The excess
rotation movement is checked by the alar
ligaments.
c. The median apical ligament of the dens is
attached below to the tip of the dens and above to
the anterior margin of foramen magnum.
The apical ligament is the remnant of notochord
or the primitive axis of the embryo.
5. The Sutures of the Skull
The sutures of the skull - are fibrous joints between
serrated edges of flat bones of skull. The sutures
are immovable joints.
However, during childhood, due to the increased
intra-cranial pressure, the sutures open up. In
old age the sutures are gradually obliterated by
fusion of adjoining bones beginning from inner
surface of bones.
The important sutures of skull are
Coronal suture between frontal and parietal
bones
Sagittal suture - between two parietal bones.
It is placed in median plane
Lambdoid suture is placed posteriorly
between the occipital bone and two parietal
bones
Metopic suture is present only sometimes
(6-8% individuals) in median plane between
two halves of frontal bone. The remains of
suture are seen at glabella.
6. The Joints between the Cervical
Vertebrae
The cervical vertebrae are connected by:
The cartilaginous joint between the vertebral
bodies.
The synovial joints between the articular
processes.
tahir99 - UnitedVRG
The fibrous joints between their laminae,

transverse processes and spinous processes.
a. The Joints between Vertebral Bodies

These are secondary cartilaginous joints
(symphyses) with inter-vertebral disc
between vertebral bodies.
The inter-vertebral discs have a central
nucleus pulposus surrounded by annulus
fibrosus.
The bodies are connected by
1. The anterior longitudinal ligament in
front.
2. The posterior longitudinal ligamentbehind.
b. The Joints between Articular Processes
(Zygophyseal Joints)
There are two paired articular processes in
relation to one vertebrae. They form joints
with similar processes of adjacent vertebrae.
These are plane type of synovial joints.
The joints are surrounded by the fibrous
capsules.
c. The Fibrous Joints between the Vertebrae
The ligamenta flava connect the laminae of
the adjacent vertebrae. These ligaments
consist of elastic tissue mainly.
The supraspinous ligaments are strong
fibrous bands that connect the apices of
spinous processes of vertebrae.
The ligamentum nuchae is a bilaminar,
fibroelastic membrane that forms an
intermuscular septum between two halves
of back of neck.
It is attached above to the external
occipital crest and to tips of spinous
processes of cervical vertebrae.
Its free border also gives attachment to
muscles of the back.
In quadriped animals, this ligament is
much thicker and supports the head of
the animals.
395
The inter-spinous ligaments are thin and

connect the adjoining spinous processes
from their roots up to the apex.
The inter-transverse ligaments connect the
adjoining transverse processes. These
ligaments are poorly developed in cervical
region.
The nerve supply of the intervertebral joints is
by the corresponding spinal nerves by their dorsal
rami. They also have sympathetic supply.
THE FASCIAE OF THE HEAD AND NECK
A. The superficial fasciae of the head and neck
region contains.
Loose areolar tissue with variable amount of
fat
Cutaneous nerves, blood vessels and lymphatics
The platysma is a superficial muscular sheet
that lies on the side of neck. It consists of
striated muscle fibers and is supplied by facial
nerve.
Superficial muscles of face and scalp lie in the
respective regions.
B. The deep cervical fascia consists of several of
well-defined layers that can be demonstrated.
The deep fascia surrounds the neck and gives
off septa, which separate the neck into fascial
compartments.
The deep cervical fascia consists of following
layers.
a. The investing layer surrounds the neck on all
sides deep to the superficial fascia.
Attachments
Superiorly
Lower border of mandible
Mastoid process and superior nuchal line
of occipital bone.
Inferiorly
Suprasternal notch
Superior surface of clavicle
Crest of spine of scapula
396
PosteriorlyPosterior free border of ligamentum nuchae

AnteriorlyBody of hyoid bone.
The investing layer splits repeatedly
i. To enclose two muscles sternomastoid
and trapezius
ii. To form fascial capsules of two salivary
glands parotid and submandibular.
iii. To enclose two fascial spaces.
a. Suprasternal space (of Burns) above
manubrium sterni. This space contains
Jugular venous arch and parts of two
anterior jugular veins.
Sternal heads of sternomastoid
muscles.
Interclavicular ligament.
An occassional lymph node.
b. A fascial space in lower part of roof of
posterior triangle. This space contains
(Fig. 36.5)
Suprascapular vessels
Part of external jugular vein
Parts of three supra-clavicular
nerves.
Fig. 36.5: Fascial space above claviclesagittal section
b. The pretracheal fascia lies deep to the

infrahyoid muscles on the front of trachea.
This layer forms the fascial capsule of thyroid
gland and holds it in position.
Attachments
Superiorly
Arch of cricoid cartilage.
Oblique lines of thyroid cartilage.
Inferiorly
It continues in the mediastinum of
thorax and fuses with the fibrous pericardium.
Medially
Sides of pharynx and trachea.
c. The carotid sheath is the fascial condensation
around the carotid arteries, internal jugular vein and
the vagus nerve.
The carotid sheath is attached anteriorly to the
investing layer and posteriorly to the prevertebral
layer of deep fascia.
The carotid sheath extends from the base of
skull to the root of neck.
It is thick around the carotid arteries and thin
around the internal jugular vein to allow it to
expand.
The sympathetic chain lies behind the carotid
sheath in the neck.
d. The pre-vertebral fascia lies in front of the
prevertebral muscles that cover the front of bodies
of cervical vertebrae.
The prevertebral fascia extends laterally to cover
the scalene muscles.
It also forms the axillary sheath by its lateral
extension that surrounds the axillary artery and
the brachial plexus in axilla.
Attachments
Anteriorly
Bodies and transverse processes of
cervical vertebrae.
Inferiorly
Extends into superior mediasterum up
to third thoracic vertebra to cover the
longus colli muscle.
tahir99 - UnitedVRG
e. The retro-vertebral fascia covers the retrovertebral muscles and sends fascial septa between
them.
Attachments
Superiorlyextends up to skull.
Inferiorlycontinues with deep fascia on
back of thorax.
f. The buccopharyngeal fascia is thickened
epimysium that covers buccinator and constrictor
muscles of pharynx.
g. The pharyngo-basilar fascia lies deep to the
constrictor muscles of pharynx. It is thickened at
the gaps in the pharyngeal wall.
THE DEEP MUSCLES OF THE BACK
Common features
The deep muscles of the back extend from
the occipital bone to the back of sacrum.
These muscles consist of muscle slips
forming short segmental muscles.
The deep muscles of the back are bound by
thoraco-lumbar fascia to the back of
vertebral column.
These muscles are supplied by the dorsal
rami of the spinal nerves.
Functionally these muscles are extensors,
rotators and lateral flexors of vertebral
column.
397
The thoraco-lumbar fascia covers the deep

muscles of the back.
A. The thoracic part is continuous above with
posterior layer of deep cervical fascia.
Below, it is continuous with posterior
lamina of the lumbar part.
Attachments
Medially the tips of spinous processes of thoracic vertebrae and
supraspinous ligaments.
Laterally the angles of the ribs.
B. The lumbar part is divided into three
laminaeposterior, middle and anterior (Fig.
36.6).
i. The posterior lamina is attached
Medially to the tips of spinous
processes of lumbar vertebrae and
supraspinous ligaments.
Laterally it fuses with the back of
middle lamina at lateral margin of
erector spinae muscle.
ii. The middle lamina is attached
Medially to the tips of lumbar transverse processes.
Laterally it fuses with anterior lamina
at the lateral border of quadratus
lumborum.
Fig. 36.6: The thoraco-lumbar fascia
398
iii. The anterior lamina covers the quadratus

lumborum muscle. It is attached
Medially to the anterior aspect of
lumbar transverse processes.
Laterally it fuses with the middle
layer at the lateral border of quadratus lumborum to form the aponeurotic origin of transversus
abdominis.
The deep muscles of back are arranged in three
layers.
a. The splenius
b. The erector spinae or sacrospinatis
c. The transverso-spinalis
A. The splenius muscle has two parts
i. The splenius cervicis is attached from
spinous processes of third and fourth
thoracic vertebrae to transverse processes
of second to fourth cervical vertebrae.
ii. The splenius capitis arises from
Lower part of ligamentum nuchae and
spinous processes of seventh cervical
and upper four thoracic vertebrae.
It is inserted on lateral part superior
nuchal line of occipital bone and mastoid
process.
Actions:
The splenius muscle of both sides
extends the head.
One side muscle acting rotate the
head and neck to the same side.
B. The erector spinae (sacro-spinalis) arises by a
thick aponeurosis from
Back of sacrum and sacrotuberous ligament.
Dorsal segment of iliac crest
Spinous processes of lumbar and lower
thoracic vertebrae.
Dorsal sacroiliac ligament.
The muscle divides into three partslateral,
intermediate and medial.
i. The lateral part is iliocosto cervicalis,
it is again subdivided into three portions.
a. The iliocostalis lumborum from

common aponeurosis to lower
borders of lower six ribs.
b. The iliocostalis thoracisfrom
upper borders of lower six ribs to
lower borders of upper six ribs.
c. The iliocostalis cervicis from upper
borders of upper six ribs to posterior
tubercles of transverse processes of
fourth, fifth, and sixth cervical vertebrae.
ii. The middle part is longissimus. It is
further subdivided into three portions:
a. The longissimus thoracis from
common origin to thoracic transverse processes and lower nine or
ten ribs.
This is the largest segment of erector
spinae.
b. The longissimus cervicis from transverse processes of upper four or five
thoracic vertebrae to the transverse
processes of second to sixth cervical
vertebrae.
c. The longissimus capitis also extends
from transverse processes of upper
four or five thoracic vertebrae to the
mastoid process of temporal bone
deep to splenius capitis.
iii. The medial part is the spinalis. It is poorly
developed.
a. The spinalis thoracis runs between
transverse processes of thoracic
vertebrae.
b. The spinalis cervicis is an inconstant
muscle and is often absent.
c. The spinalis capitis is fused with
medial part of semispinalis capitis.
C. The transverso-spinalis group of muscles:
These muscle slips fill up the gap on the back
of vertebral column between the spinous processes
and the transverse processes. The muscle group
consists of three subdivisions lying deep to one
another.
tahir99 - UnitedVRG
i. The semispinalis is the superficial part.
ii. The multifidus is the intermediate part.
iii. The rotators is the deep part.
I. The semispinalis is further subdivided into
a. The semispinalis thoracic extends from
transverse processes of lower six thoracic
vertebrae to the spinous processes of lower
two cervical and upper four thoracic
vertebrae.
b. The semispinalis cervicis extends upper six
thoracic transverse processes to spinous
processes of second to fifth cervical vertebrae.
c. The semispinalis capitis lies superficial to
semispinalis cervicis.
It arises from transverse processes of
upper six thoracic and lower four
cervical vertebrae.
399
It is inserted on thumb shaped medial

area between superior and inferior
nuchal lines of occipital bone.
The medial portion is also attached to spinous
process of lower cervical vertebrae.
II. The multifidus consists of muscle fasciculi that
lie deep to the semispinalis muscle.
These fasciculi pass from back of transverse
processes to whole length of the spinous
processes of vertebrae.
III.The rotators lie deep to multifides.
This muscle group consists of fasciculi that
connect the roots of transverse processes
to the laminae of the vertebrae.
There are also intertransverse muscles that
connect the transverse processes. These are best
developed in cervical region and consist of an
anterior and a posterior slip.
CHAPTER
37
The Scalp, Face and the

Cranial Cavity
THE SCALP
The scalp is the region on top of the skull and
includes forehead also
Boundaries
AnteriorlyThe supra-orbital margins
On two sidesSuperior temporal lines
PosteriorlyExternal occipital protuberance and superior nuchal lines
LayersThere are five layers in the scalp (Fig.
37.1)
1- S Skin
2- C Connective tissue
3- A Aponeurosis
4- L Loose areolar tissue
5- P Pericranium
Fig. 37.1: The layers of the scalpcoronal section
1. The skin is mostly having hairs and has many

sebaceous glands.
The skin of scalp is a frequent site for
sebaceous cysts
2. The connective tissue is quite dense and firmly
binds the skin to the underlying aponeurosis
It is richly supplied with blood vessels and
cutaneous nerves.
The incised wounds of this layer bleed
profusely, but heal well if properly stitched
A blunt injury here causes a localized but
very painful hematoma
3. The aponeurosis belongs to the occipito-frontalis
(epicranius) mucle
Attachments: The two large frontal bellies
have no bony attachment. They are attached
to the skin of eyebrows.
The two small occipital bellies are
attached to the lateral half of highest
nuchal line (if present) or superior nuchal
line
The epicranial aponeurosis receives the
insertion of frontal and occipital bellies
and is attached to the two superior
temporal lines on the sides
As the aponeurosis is firmly adherent to
the skin, and is under tension, so the
wounds of the aponeurosis gape widely
Nerve supply the frontal bellies are
supplied by the temporal branches and
the occipital bellies by the posterior
auricular branch of facial nerve
Actions the frontal bellies produce
transverse creases on the skin of the
forehead.
tahir99 - UnitedVRG
The Scalp, Face and the Cranial Cavity

4. The loose areolar tissue forms the potential
space between the aponeurosis and the
pericarnium
It forms a wide sub-aponeurotic space that
extends
Anteriorly into the subcutaneous
tissue of eyelids, as frontal bellies have
no bony attachment
Posteriorly up to superior (highest)
nuchal lines
On two sides up to superior temporal
lines.
Injury to blood vessels in this layer leads to
black eye, i.e. collection of blood in the
subcutaneous tissue of the eyelids.
This layer is also called the dangerous layer
of scalp due to presence of emissary veins,
that can carry infection inside the skull.
5. The pericranium is attached firmly to the bone
in the adults. It is firmly attached to the sutural
ligament at the sutures
In children, the pericranium is loosely
attached to the bones. This gives rise to
safety valve hematoma (i.e. in cases of
401
fracture of skull bone, the blood collects in

the loose areolar tissue layer, before collecting inside skull and causing compression
of brain.
The Blood Supply of the Scalp
A. The arteries
There are three arteries supplying the scalp
in front of auricle (Fig. 37.2)
a. The supra trochlear and
b. The supra arbitalboth branches of
ophthalmic arteryand emerge from the
orbit at supra-orbital margins
c. The superficial temporal a large branch
of the external carotid artery that supplies
scalp in front of auricle and the temporal
region.
There are two arteries supplying the scalp
behind the auricle
d. The posterior auriculara branch of
external carotid artery
e. The occipital artery also a branch of
external carotid artery that supplies the
posterior part of scalp
Fig. 37.2: The blood supply of the scalp
402
The scalp is the site of anastomosis between

the branches of internal carotid and external
carotid arteries.
B. The veins of the scalp join the veins of the face.
The veins from deeper layers of the scalp join
with the diploic veins and the emissary veins.
The emissary veins have no valves, so blood
can flow in either direction in these veins,
and also they can carry infection inside the
skull from outside.
i. The supra
The Lymphatic Drainage of the Scalp
The lymph from anterior part of the scalp, in

front of the auricle drains in the superficial
parotid lymph nodes
The lymph from the scalp behind the auricle
drains into the posterior auricular lymph nodes.
The lymph from the posterior part of scalp drains
into occipital lymph nodes.
The Nerve Supply of the Scalp

A. The sensory nerves The scalp is richly supplied
by sensory nerves (Fig. 37.3)
The anterior part of scalp (in front of auricle)

is supplied by four branches of trigeminal nerve.
arise from the ophthalmic
trochlear
division of trigeminal in the
ii. The supra
orbit and come out at the
orbital
supra-orbital margin
iii. The zygomatico-temporal is a branch of
maxillary division to trigeminal and emerges
after piercing temporal fascia.
iv. The auriculo-temporal is a branch of
mandibular division of trigeminal nerve and
emerges just in front of auricle.
The posterior part of scalp (behind the auricle)
is supplied by four spinal nerves.
i. The greater auricular nerve is a branch of
cervical plexus (VR, C2, C3)
ii. The lesser occipital nerve is also a branch
of cervical plexus (VR, C2)
iii. The greater occipital nerve is a branch from
the dorsal ramus of second cervical nerve.
It is a thick nerve that supplies posterior
part of scalp
Fig. 37.3: The nerve supply of the scalp
tahir99 - UnitedVRG

iv. The third occipital nerve is a branch from
the dorsal ramus of third cervical nerve. It
supplies a small area of scalp around external
occipital protuberance
B. The motor nerves of the scalp are branches
of facial nerve (seventh cranial nerve)
The temporal branches of facial nerve supply
the frontal belly of occipito-frontalis and auricularis anterior and superior
The posterior auricular branch of facial nerve
supplies the occipital belly and auricularis
posterior.
THE FACE
The face is the region on front of skull and mandible

below the supra-orbital margins. It is limited below
by the lower border of mandible. The region of
forehead, although appears as upper part of face is
anatomically a part of scalp.
A. The muscles of the face (Table 37.1) have
the following common features (Fig. 37.4):
These are superficial musclesOne end of the
muscles is attached to the bone, the other end
to the skin
403
They are developed from the mesoderm of second

branchial arch
When these muscles contract, they produce
some grooves or ridges on the face denoting
some expression, hence they are called muscles
of facial expression
They are arranged around the openings of the
faceorbital openings, nasal openings and
mouth opening, and they act as their dilators
and sphincters.
The Blood Vessels of the Face

The arteries of the face are mostly the branches
of the external carotid artery. The largest branch
is the facial artery. Others mostly accompany
the sensory nerves (Fig. 37.5)
a. The facial artery arises in the neck from
external carotid artery at level of greater
cornu of hyoid bone
Course in the face: The facial artery
enters the face at anterior-inferior angle
of masseter muscle after piercing deep
cervical fascia and platysma.
Fig. 37.4: The muscles of the face, scalp and auricleLateral view
404

Table 37.1: The muscles of the face
S.No. Name
I.
Origin
Insertion
The muscles of the orbit

a. Orbicularis ocult
Orbital part
Medial orbital margin
Medial palpebral ligament
Palpebral part
Medial palpebral ligament
Lacrimal part
It surrounds the
orbital openings
Lateral palpebral raphe
Posterior lacrimal crest

Lacrimal fascia
Lateral palpebral raphe
b. Corrugator
supercilli
Medial part of superciliary

arch
Skin of eyebrow
c. Levator palpebrae
superioris
(described with extra-ocular muscles in Chapter 48)
II. The muscles of the nose

a. Procerus
Fascia covering bone
b. Nasalis
Compressor
naris
Dilator naris
c. Depressor septi
nasi
Maxilla along margin of

piriform aperture
Maxilla along margin of piriform aperture below compressor naris
Incisive fossa of maxilla
III. The muscles of the mouth

a. Orbicularis oris
Surrounds the oral fissure
forming a series of elliptical
loops
b. The labial retractors
Upper lip
1. Levator labii
superioris
alaque nosi
2. Levator labii
superioris
3. Zygomaticus
minor
4. Zygomaticus
major
Lower lip
5. Depressor
labii inferioris
Frontal process of maxilla
Maxilla
Zygomatic
Zygomatic
Oblique line of mandible
Main actions
It tightly closes the eye

against external injury
It depresses the eyelid
during blinking
It dilates lacrimal sac
and helps in drainage of
tears
It produces vertical
furrows in forehead to
express annoyance
Skin at the root of the

nose (continuous with
medial parts of frontal
bellies)
It produces transverse
furrows at root of the
nose
Aponeurosis across the

bridge of nose with
opposite muscle
Alar cartilage in ala of
nose
It compresses the anterior nasal opening acting

as sphincter
It dilates the anterior
nasal opening
Septal cartilage
It depresses anterior
part of septal cartilage
Compound sphincter
muscle of oral fissure
It purses and puckers

the lips
It helps in all movements of lips
Medial partalar carti- It elevates upper lip and

lage of nose
dilates the nostril
Lateral partupperlip
Fibers blend in substance It elevates and everts
of upper lip
the upper lip
Upper lip
It elevates the angle of
mouth in laughing
Upper lip
mouth in laughing
Fibers blend in substance of the lower lip
It depresses lower lip

Contd...
tahir99 - UnitedVRG
405
Contd...
S.No. Name
Origin
Insertion
6. Facial part
Continuation of some fibers of
of platysma
platysma in face
c. The modiolar muscles (cruciate modiolar muscles)
a. Levator anguli
Maxillacanine fossa
oris
Depresser
anguli oris
Mandible
Main actions
Lower lip
It depresses the lower

lip
Fibers decussate at
modiolus-a knot of
muscles 1.0 cm from
angle of mouth
Fibers decussate at
modiolous and enter
upper lip

mouth
It depresses the angle of

mouth
(Transverse modiolar muscles)

Buccinator
Alveolar margins of maxilla Upper and lower fibers It helps to blow out air
(Buccinaand mandible opposite molar
pass in substance of
from mouth
trumpet)
teeth
upper and lower lips
It helps in mastication
Pterygo-mandibular ligament The middle fibers decusby keeping vestibule of
sate at modiolus and pass
mouth free of food
in opposite lip
Risorius
Fascia covering parotid gland Reaches modiolus at the It pulls the angle of
angle of mouth
mouth laterally and
helps in grinning
d. Incisivus superior
Two slips attached to incisive Upper lip
It binds upper lip to
fossa of maxilla
maxilla
Incisivus
Two slips attached to incisive Lower lip
It binds the lower lip
inferior
fossa of mandible
of mandible
e. Mentalis
Incisive fossa of mandible
Skin of chin
It puckers the skin of
chin to express doubt
Fig. 37.5: The arteries of the face
406

It passes tortuously (to allow for
movements of lower jaw) upwards

and medially to reach about 1.0 cm
from angle of mouth
It then ascends up almost vertically
to reach the medial angle of the eye
(angular artery)
It terminates by anastomosing with
dorsal nasal branch of ophthalmic
artery.
Branches in the Face
i. The inferior labial artery passes
medially in lower lip
ii. The superior labial artery passes
medially in upper lip
iii. The lateral nasal branch supplies the
external nose
iv. The angular artery is the terminal
part of facial artery
v. Small muscular and cutaneous
branches.
b. Small arteries in the face
1. The transverse facial artery is a branch
of superficial temporal artery and runs
medially below zygomatic arch
2. The infraorbital artery is a branch of

maxillary artery and comes out of
infraorbital foramen
3. The buccal artery is also a branch of
maxillary artery and accompanies buccal
nerve in the face
4. The mental artery arises from inferior
alveolar branch of maxillary artery and
emerges from mental foramen
Some small branches of internal carotid artery
also supply the face
a. The dorsal nasal branch of ophthalmic
artery supplies the root of nose and
anastomoses with facial artery
b. The zygomatico-facial artery from
ophthalmic artery accompanies zygomaticofacial nerve on the face
c. The supratrochlear and supraorbital
branches of ophthalmic artery supply
forehead
The veins of the faceThe venous blood from
anterior part of the face and scalp is drained by
the facial vein and posterior part of face and
scalp is drained by the retro-mandibular vein
(Fig. 37.6)
Fig. 37.6: The venous drainage of the face
tahir99 - UnitedVRG

I. The facial vein begins at the medial angle
of the eye by union of supra-trochlear and
supra-orbital veins.
It courses backwards and laterally lying
behind the facial artery
It crosses lower border of mandible,
pierces platysma and deep cervical
fascia and reaches upper part of neck
It terminates by joining with anterior
division of retro-mandibular vein to form
common facial vein that ends in internal
jugular vein.
Tributaries and communication in the
face
i. The lateral nasal vein
ii. The superior labial vein
iii. The inferior labial vein
iv. Two important communications
a. At medial angle of eye with
superior ophthalmic vein
b. Deep facial vein that connects it
with the pterygoid venous plexus
II. The superficial temporal vein drains venous
blood from the anterior part of scalp
including forehead
It joins with the maxillary vein behind
the neck of mandible to form the retromandibular vein
III.The retro-mandibular vein lies in the
substance of parotid gland superficial to
external carotid artery and deep to the facial
nerve
It terminates inside parotid gland by
dividing into an anterior division and a
posterior division, that emerge at the
lower pole of the gland
The anterior division joins with facial
vein to form the common facial vein
The posterior division joins with the
posterior auricular vein to form the
external jugular vein
407
The Lymphatic Drainage of the Face

The lymphatics of the face follow the veins of the
face
From anterior part of face the lymphatics end
in the submandibular lymph nodes
From posterior part of face the lymphatics end
in the superficial parotid lymph nodes
The Nerve Supply of the Face
The sensory nerves of the face are branches from
the three divisions of trigeminal nerveophthalmic,
maxillary and mandibular.
I. The ophthalmic division supplies medial part
of the skin of forehead and face. The branches are
(Fig. 37.7):
a. From frontal branch supra-trochlear and supraorbital nerves supply medial part of forehead
b. From lacrimal branch palpebral branch supplies
the skin of upper eyelid
c. From the nasociliary branch infratrochlear and
external nasal nerves supply the skin of nose
including its tip
II. From the maxillary division branches supply
the skin of eyelid, ala of nose, upper lip and upper
part of cheek. The nerves are
a. The zygomatico-facial nerve comes out from
a foramen in zygomatic bone and supplies skin
of cheek
b. The infra-orbital nerve is a large branch that
comes out of infraorbital foramen and gives
three sets of branches
Nasal to supply ala of nose
Labial to supply upper lip
Palpebral to supply lower eyelid
III. From the mandibular division the branches
supply the skin of lower part of face, and lower
jaw except a small area overlying the angle of
mandible.The branches are:
a. The auriculo temporal nerve supplies the skin
of auricle, external acoustic meatus and also of
temporal region and lateral part of scalp
408
Fig. 37.7: The sensory nerve supply of face
b. The buccal nerve emerges from under cover

of masseter and supplies skin of lower part of
face
c. The mental nerve comes out of mental foramen
and supplies skin covering lower jaw, including
chin
IV. The skin overlying the angle of mandible is
supplied by the greater auricular nerve (VR. C2,
C3) a branch of cervical plexus. Actually, it is a
part of skin of neck that has been pulled upwards
to cover the angle of mandible, due to greater
growth of brain and skull.
Applied Anatomy
The motor nerves of the face are branches of facial

nerve (seventh cranial nerve)
The facial nerve comes out of stylomastoid
foramen at the base of skull.
It gives a posterior auricular branch that passes
behind the auricle and supplies occipital belly
and auricularis posterior. It also gives two
muscular branches to supply two muscles of
the neckstylohyoid and posterior belly of
digastric.
The trigeminal neuralgia (Tic douloureaux) is

caused by inflammation of one of the divisions of
trigeminal nerve
It produces a very severe and excruciating pain
in the skin area supplied by the affected division.
The pain may be initiated by touching a trigger
area. The severity of the pain may drive the
person to suicide
The condition is treated by:

i. Injection of alcohol in the stem of the affected division that, temporarily degenerates the
nerve fibers, thus interrupting the painpathway
ii. Partial trigeminal ganglionectomy is done
to cut off the pain fibers of the affected
division.
iii. Partial rhizotomy cutting off the pain fibers
of the affected division in the sensory root
of trigeminal nerve
The Motor Nerves
tahir99 - UnitedVRG
The facial nerve enters parotid gland and divides

into five sets of branches that emerge near the
anterior border of the gland
The facial nerve also divides the parotid gland
into a superficial lobe and a deep lobe.
a. The temporal branches cross zygomatic
arch and supply the muscles of anterior part
of scalp and forehead
b. The zygomatic branches reach the zygomatic
bone and supply the muscles of orbit and
nose
c. The buccal branches reach the mouth and
supply the muscles of the oral fissure
d. The mandibular branch runs along the lower
jaw and supplies the muscles of the lower
lip
e. The cervical branch of facial nerve emerges
at the lower pole of parotid gland and
descends in upper part of the neck
Supplies platysma and communicates
with the transverse cutaneous nerve of
the neck.
It may cross the lower border of mandible, enter face and supply the muscles
of lower lip.
Applied Anatomy
Lesion of facial nerve in the bony facial canal or
near the stylo-mastoid foramen leads to Bells
paralysis
The symptoms are :
Drooping of angle of mouth or affected side
Inability to close the eye, and resulting loss
of conjunctival reflexes
Difficulty in mastication, as the food collects
in the vestibule of the mouth
There is no effective treatment of Bells paralysis. Most cases recover spontaneously often
with no permanent damage
THE CRANIAL CAVITY
The cranial cavity is divided into three cranial fossae
Anterior, middle, and posterior.
409
[Details of the boundaries and the foramina

present in three cranial fossae are described in
Chapter 35]
The dural folds are seen after removal of the
brain from the cranial cavitythere are four dural
folds.
a. The falex cerebri is a large sickle shaped dural
fold
Attachments
Apex is attached to the crista galli in
anterior cranial fossa
Base is attached to superior surface of
tentorium cerebelli
Attached border (superior border) is
attached to frontal crest and margins of
sagittal sulcus in calvaria of skull.
The free border (inferior border) lies in
the longitudinal fissure between two
cerebral hemispheres
Venous sinuses enclosed
At upper attached bordersuperior
sagittal sinus
At lower free borderinferior sagittal
sinus
At its basestraight sinus
b. The falx cerebelli is a small sickle shaped dural
fold that lies in the posterior cerebellar notch
between the two cerebellar hemispheres.
Attachments
The posterior border is fixed on internal
occipital crest
The apex is divided into two small folds
that reach in either side of foramen
magnum
The base is attached to the inferior surface of tentorium cerebelli.
The venous sinuses enclosedThe occipital
venous sinus lies along its posterior attached
margin.
c. The tentorium cerebelli is a large tent shaped
fold that roofs over the posterior cranial fossa,
supporting the occipital lobes of cerebral
hemisphere.
It has a concave free border anteriorly that
encloses the tentorial notch, through which
410
the brain stem passes. The anterior border

is attached anteriorly to the anterior clinoid
processes.
The posterior margin is attached to (on both
sides)
Posterior clinoid process
Apex and superior border of petrous
temporal bone
Margins of transverse sulcus up to
internal occipital protuberance
The venous sinuses enclosed are
The superior petrosal sinuses along the
superior border of petrous temporal
bones.
The transverse sinuses along the transverse sulci
The straight sinus along the attachment
of base of falx cerebri
d. The diaphragma sellae is a small circular dural
fold that roofs over the hypophyseal fossa.
Attachments
Anteriorlyon tuberculum sellae
Posteriorlyon dorsum sellae
On two sidescontinuous with dura
mater of roof of cavernous sinus
It has a central perforation for the infundibulum of hypophysis cerebri
The nerve supply and blood supply of dura mater
is described in Chapter 44.
The Venous Sinuses of the Dura Mater
These venous sinuses lie between two layers

of dura mater.
They are lined by endothelium only, that is
continuous with the lining of the veins.
They drain blood from
Brain
Dura mater
Cranial bones
They have no valves, so blood in smaller sinuses
can flow in either direction
The dural venous sinuses are divided into two

groups according to their positionthe posterosuperior group and antero-inferior group.
i. The postero superior group has:
The superior sagittal sinus
The inferior sagittal sinus
The straight sinus
Two transverse sinuses
Two sigmoid sinuses
The occipital venous sinus
ii. The antero-inferior group has:
Two cavernous sinuses
Two intercavernous sinusesanterior
and posterior
Two superior petrosal sinuses
Two inferior petrosal sinuses
Two spheno-parietal sinuses
The basilar venous plexus
Out of these venous sinuses, the large and
important venous sinuses are the superior sagittal,
transverse, sigmoid and the cavernous venous
sinus.
A. The superior sagittal sinus lies along the attached
margin of falx cerebri, occupying the frontal crest
and the sagittal sulcus.
It begins at crista galli by union of small dural
veins. It increases in size as it flows backwards
It usually ends on the right side of internal
occipital protuberance, by becoming continuous
with right transverse sinus
It is triangular in coronal section and has
groups of arachnoid granulation bulging into
it after piercing the inner layer of dura mater.
Tributaries
i. The superior cerebral veins
ii. The meningeal veins from dura mater
iii. Small diploic veins from cranial bones
iv. Two emissary veins
a. One passing through foramen cecum
(1% only) connecting it with veins of
roof of nose
b. Parietal emissary veins passing through
parietal foramina and connecting it to
the veins of scalp
tahir99 - UnitedVRG
Applied anatomy In infants, the superior sagittal

sinus through anterior fontanelle is used for
giving intravenous fluids.
B. The transverse sinuses are tworight and
left
The right transverse sinus begins at internal
occipital protuberance and is usually the
continuation of the superior sagittal sinus and
is, therefore, larger in size
The left transverse sinus is continuation of
straight venous sinus and is smaller in size.
The transverse sinus occupies transverse sulcus
of squamous occipital and parietal bone, lying
along the attached margin of tentorium cerebelli
It becomes continuous with sigmoid sinus at
the base of petrous temporal bone
Tributaries
i. Inferior cerebral veins
ii. Inferior cerebellar veins
iii. Small diploic veins
iv. Inferior anastomotic vein
It is connected by superior petrosal sinus with
the cavernous venous sinus.
C. The sigmoid sinuses are also tworight and
left.
Each sigmoid sinus is continuation of transverse
sinus at base of petrous temporal bone
The sigmoid sinus occupies the S-shaped
sigmoid sulcus on deep surface of:
411
Mastoid temporal bone and

Jugular process of occipital bone
The sigmoid sinus passes through posterior part
of jugular foramen and is continuous with the
superior bulb of internal jugular vein
It is related anteriorly to the mastoid antrum
separated by a thin plate of bone (which may
be absent sometimes, so that middle ear infection
can reach the sinus)
Tributaries
Inferior cerebellar veins
Veins from medulla oblongata
Two emissary veins
Mastoid emissary vein connecting it
with veins of scalp
Posterior condylar emissary vein connecting it to the suboccipital venous
plexus
D. The cavernous venous sinuses are also two
right and left. These are a pair of large and important
venous sinuses that lie on either side of body of
sphenoid (Fig. 37.8).
The interior shows fine trabeculae at the
margins, therefore, it is called cavernous venous
sinus
It has three wallsroofs, lateral wall and medial
wall
The roof is formed by meningeal dura mater,
that is continuous with diaphragma sellae
medially.
Fig. 37.8: Coronal section through cavernous venous sinuses
412
The roof is pierced by

The internal carotid artery
The oculomotor and trochlear nerves
The lateral wall is nearly vertical and is
formed by the meningeal dura mater of
middle cranial fossa
The medial wall is sloping and is formed
by the endosteal dura mater lining the lateral
surface of body of sphenoid.
Relations
Superiorly
The internal carotid artery
The base of the brain
Medially
The hypophysis cerebri
The sphenoidal air sinuses
Laterally is uncus part of parahippocampal gyrus
Trigeminal ganglion in its dural cave
(Meckels cave) posteriorly
Structures inside dural walls
i. Oculomotor, trochlear, ophthalmic and
maxillary nerves lie along lateral wall
ii. Internal carotid artery, its sympathetic
plexus and abducent nerve lie along
medial wall.
All there structures are separated from
the venous blood by the endothelium.
Tributaries
i. The central vein of retina
ii. Two ophthalmic veinssuperior and
inferior
iii. The hypophyseal veins
iv. The spheno-parietal sinus
v. The anterior middle meningeal vein
vi. Some inferior cerebral veins
vii. The superficial middle cerebral vein.
The cavernous sinus drains its blood in the
transverse sinus via superior petrosal sinus
and the internal jugular vein via the inferior
petrosal sinus
It also receives emissary veins passing
through foramen ovale, foramen lacerum
and emissary sphenoidal foramen (if present)

connecting it to the pterygoid venous plexus
The cavernous sinus is also connected with
facial vein via superior ophthalmic vein
The two cavernous sinuses are connected
by the anterior and posterior intercavenous
sinuses. These four sinuses constitute the
circular venous sinus.
Applied anatomy
Infection in the face, nasal cavities or
paranasal sinuses may reach the
cavernous venous sinus causing a septic
thrombosis that may prove a serious
condition
An arterio-venous fistula may occur
between internal carotid artery and
cavernous venous sinus causing a
pulsatile swelling behind orbit.
The confluence of venous sinuses is located on right
side of internal occipital protuberance.
It is formed by dilated posterior end of superior
sagittal sinus, where five venous sinuses join
The superior sagittal sinus
The straight sinus
The two transverse sinuses
The occipital venous sinus
The Emissary Veins
The emissary veins connect the dural venous

sinuses with veins outside the skull
They have no valves, so blood can flow in either
direction
They pass through some foramen of skull and
are named accordingly (Table 37.2)
Applied anatomythese veins can carry the
infections from outside skull into the dural
venous sinuses.
The Diploic Veins
These vein lie in spongy substance (diploe) of

the cranial bones. They have no valves are large
in size and cross the sutures.
tahir99 - UnitedVRG
413
Table 37.2: The emissary veins of skull

S.No. Name
Foramen of skull
Venous sinus
Veins outside skull
1.
2.
3.
4.
5.
Emissary vein (1%)

Parietal emissary vein
Mastoid emissary vein
Emissary vein
Condylar emissary vein
Foramen cecum
Parietal foramen
Mastoid foramen
Hypoglossal canal
Superior sagittal sinus

Superior sagittal sinus
Transverse sinus
Sigmoid sinus
Sigmoid sinus
6.
7.
Emissary vein
Emissary vein
Cavernous sinus
Cavernous sinus
8.
Two or three emissary

veins
Internal carotid venous
plexus
The ophthalmic vein
Foramen ovale
Emissary sphenoidal
foramen
Foramen lacerum
Veins of roof of nose

Veins of scalp
Veins of scalp
Internal jugular vein
Suboccipital venous
plexus
Pterygoid venous plexus
Carotid canal
Cavernous sinus
Superior orbital tissue
Cavernous sinus
9.
10.
They start developing after birth. There are

many small diploic veins that open in the neighboring venous sinuses.
The large diploic veins are
i. The frontal diploic vein that opens in supraorbital vein by a minute foramen in supraorbital notch.
ii. The anterior temporal (parietal) diploic vein
draining venous blood from frontal and
parietal bone ends in the spheno-parietal
sinus.
iii. The posterior temporal (parietal) diploic
vein ends in the lateral part of transverse
sinus.
iv. The occipital diploic vein ends in transverse
sinus near confluence of sinuses.
The Intra-cranial Part of Internal

Carotid Artery
The internal carotid artery enters the skull

through the lower opening of carotid canal in
petrous temporal bone
The artery is divided into three partsthe
petrous part, the cavernous part and the
cerebral part
i. The petrous partThe artery passes
forwards and medially in the carotid canal
Cavernous sinus
Pharyngeal veins
Facial veinpterygoid
venous plexus
Then it bends upwards above the

cartilage of foramen lacerum to enter
the middle cranial fossa.
This part of artery is surrounded by a
venous plexus and sympathetic plexus
Branches are two:
Carotico-tympanic branch-supplies
the middle ear
Pterygoid branchenters the pterygoid canal
ii. The cavernous partThe artery on entering
the cranial cavity turns anteriorly and then
passes forward, inside cavernous sinus along
the side of body of sphenoid. It is separated
from the venous blood by endothelium.
The abducent nerve lies infero-lateral and
then lateral to the artery
It curves upwards and pierces the roof
of cavernous sinus medial to anterior
clinoid process
Branches
The cavernous branches are small and
supply trigeminal ganglion, and the
dura mater of cavernous sinus
Hypophyseal branchessuperior
and inferiorsupply the hypophysis
cerebri
Meningeal branches supply the dura
mater of anterior cranial fossa
414
iii. The cerebral partThe artery after

piercing the roof of cavernous sinus, runs
backwards on the roof and then ascends
up to anterior perforated substance, lateral
to optic chiasma, where it divides into its
branches.
Branches (Described in Chapter 44).
Trigeminal Ganglion
Trigeminal ganglion is the sensory ganglion of

trigeminal nerve. It contains pseudounipolar
neurons that relay all sensory fibers carried by
the three branches of trigeminal neve
ophthalmic maxillary and mandibular.
LocationThe ganglion lies in a shallow
depression trigeminal impressionon anterior
surface of petrous temporal bone (bear its apex)
Cavum trigeminaleis the pocket of dura mater
of posterior cranial fossa between two rayersendosteal and meningeal of middle cranial fossa.
It contains trigeminal ganglion.
Relations:
Superiorly Temporal lobe
Inferiorly Motor root of trigeminal
Greater petrosal nerve
Petrous temporal bone
MediallyPosterior end of cavernous sinus
Curvatures and Shape
Trigeminal ganglion is crescentic
(semilunar) in shape
Convex distal border gives attachment to
three branches of nerveophthalmic
maxillary and mandibular
Concave preximal border is attached to the
sensory root of nerve
Arterial Supplyis from small branches of
internal carotid artery
The Nerves in the Cranial Cavity
The intracranial parts of the cranial nerves are

described in Chapter 47.
The petrosal nerves are three
i. The greater petrosal nerve is a branch of
facial nerve. It enters the middle cranial fossa
through a hiatus on anterior surface of

petrous temporal bone
It passes forwards and medially in a
groove and then reaches foramen
lacerum
The greater petrosal nerve joins with
deep petrosal nerve to form nerve of the
pterygoid canal
The greater petrosal nerve carries
fibers of lacrimal gland
fibers for the nasal and palatine
mucosal glands.
ii. The deep petrosal nerve is formed by the
sympathetic plexus around the internal
carotid artery in foramen lacerum.
The deep petrosal nerve joins with
greater petrosal nerve in foramen
lacerum to form nerve of pterygoid canal
iii. The lesser petrosal nerve arises from the
tympanic plexus and receives a communication from the facial nerve.
It appears in middle cranial fossa through
a hiatus on anterior surface of petrous
temporal bone below the greater petrosal
nerve
The nerve lies in a groove on bone and
reaches the foramen ovale. It passes out
through foramen ovale and just below
skull joins with the otic ganglion
The nerve carries preganglionic parasympathetic fibers of parotid salivary
gland.
The Hypophysis Cerebri (Pituitary Gland)
The hypophysis cerebri is an important endocrine
gland. It is sometimes called master endocrine as it
controls the secretion of other endocrines (Fig.
37.9).
Shape and Size: The gland has an ovoid body
The transverse diameter is 12.0 mm
tahir99 - UnitedVRG
The vertical diameter is 8.0 mm

The weight is nearly 500 mgm
Location the hypophysis cerebri lies in
hypophyseal fossa roofed over by diaphragma
sellae. It is connected by the infundibulum with
floor of third ventricle
Parts: The hypophysis cerebri has two parts
the neuro-hypophysis and the adeno-hypophysis
The Neuro-hypophysis consists of
The infundibulum
Pars posterior (posterior lobe)
Medial eminence
Fig. 37.9: The hypophysis cerebriparts
The adeno-hypophysis consists of

Pars anterior or distalis
Pars intermedia
Pars tuberalis
The two parts of the hypophysis cerebri are
different developmentally and functionally.
Relations
i. Meningeal relationsThe arachnoid and pia
mater are not distinguishable in hypophyseal
fossa
ii. Vascular relations
The circular venous sinustwo cavernous and two intercavernoussurround
the hypophyseal fossa
The circular arteriosus (circle of Willis)
also surrounds the hypophysis cerebri,
but it is located at a higher level.
415
iii. Relations with optic chiasmaThe optic

chiasma lies antero-superior to the hypophysis cerebri.
The chiasma lies closely applied to the
anterior surface of infundibulum
iv. Relations with other structures
Superiorlylies base of brain and interpeduncular fossa
InferiorlyThe two sphenoidal air
sinuses separated by a thin plate of bone
LaterallyThe cavernous sinuses and
the structures inside cavernous sinuses
More laterally lies the uncus part of
parahippocampal gyrus
The blood supply
The arteries are superior and inferior
hypophyseal arteries from the internal
carotid artery
The inferior hypophyseal arteries supply the
neuro-hypophysis
The superior hypophyseal arteries break up
into capillariess in medial eminence. From
there a number of efferent vessels descend
in front of infundibulum to reach the pars
distalis where they end in the sinusoids.
Thus the adenohypophysis receives an
indirect blood supply through this hypothalmo-hypophyseal portal system. By this
portal system the hormone releasing factors
(HRF) and hormone inhibiting factors (HIF)
reach from hypothalmic nuclei to the adenohypophysis
The veins The veins of the hypophysis cerebri
end in the cavernous venous sinus.
The hormones produced by the pituitary gland
The neuro hypophysis produces
Oxytocin
Vasopressin (Antidiuretic hormone)
These hormones are produced by hypothalmic nuclei and reach neurohypophysis
The adenohypophysis produces
i. Somatotropin (growth hormone)
416

ii. Corticotropes (Adrenocorticotropic hormone (ACTH)
Thyrotropic hormone (TSH) from basophil cells
Gonadotropic hormone (FSH and
LH)
ii.
iii.
Applied Anatomy
Enlargement of pituitary gland (tumors) produce
two types of symptoms
i. Constitutional symptoms due to over production of certain hormones
ii. Neighborhood symptoms due to compression on neighboring structures.
Theses are
i. The visual signs produced due to compression of optic chiasma.
iv.
v.
vi.
Bitemporal hemianopialoss of
temporal nasal fields of both sides
Paralysis of third, fourth, and sixth
nerves by laterally growing tumor
Deepening of sella turcica is seen is lateral
X-ray of skull
Pressure on uncus leads to aura of different
types of smell
Pressure on crus cerebri leads to paresis or
paralysis of voluntary muscle groups of
opposite half of body
Pressure on inter-ventricular foramen may
lead to internal hydrocephalus of lateral
ventricle
The pituitary tumor by raising the intracranial
pressures leads to papilledema or swelling
of optic disc that can be visualized by ophthalmoscope.
tahir99 - UnitedVRG
CHAPTER
38
The Parotid Region, Temporal and

Infratemporal Fossae
THE PAROTID GLAND
The parotid gland is the largest of the three paired

salivary glands in the body.
Location: The gland occupies the parotid
space behind the ramus of mandible bounded:
Mediallyby styloid process and lateral
pharyngeal wall
Anteriorlyby ramus of mandible
Posteriorlyby sternomastoid and mastoid
process
The space is open inferiorly, and the gland
overlaps the masseter muscle anteriorly and
sternomastoid posteriorly.
Shape, Size, and Color: The gland is an irregular, lobulated, yellowish mass. It weighs about
25 gm.
The capsules: The parotid gland has two

capsules
a. A true capsule formed by condensation of
connective tissue around it.
b. A facial capsule formed by splitting of
investing layer of deep cervical fascia. The
deep part of fascial capsule becomes thick
to form stylomandibular ligament, that
separates the parotid gland from submandibular gland.
Surfaces and Ends (Fig. 38.1)
The upper end of the gland is in form of
small, concave superior surface related to
cartilaginous part of external acoustic meatus
and mandibular joint.
The lower end is pointed and projects in
upper part of carotid triangle of neck.
Fig. 38.1: The parotid gland
418
a. The superficial (lateral) surface is related to

superficial parotid lymph nodes and branches
of greater auricular nerve.
b. The antero-medial surface is related to masseter,
ramus of mandible and medial pterygoid muscle.
c. The postero-medial surface is related to mastoid
process, sterno-mastoid, posterior belly digastric and styloid process.
The Structures Embedded in the
Gland (Fig. 38.2)
i. The external carotid artery in its terminal part

lies posteriorly.
ii. The retromandibular vein lies superficial to
the artery.
iii. The facial nerve and its terminal branches lie
most superficially in the gland. The nerve
divides the gland into a superficial lobe and a
deep lobe.
iv. The deep parotid lymph node lies within the
fascial capsule.
v. The auriculo-temporal nerve is usually embedded near the upper end.
The Parotid Duct
The parotid duct begins near the anterior border of
the gland. A small accessory lobe is usually attached
above the duct.
The duct is about 5.0 cm long. It crosses upper

border of masseter horizontally, lying about 1.0
cm below zygomatic arch.
At the anterior border of masseter, it turns
medially and pierces the following layers of the
check:
Buccal pad of fat
Buccopharyngeal fascia
Buccinator
Mucous membrane of the cheek
It opens in the vestibule of mouth opposite upper
second molar tooth.
The Arterial Supply

The arterial supply of the gland is from branches
of external carotid arterymaxillary and superficial
temporal.
The Nerve Supply
Sensory supply is by auriculo-temporal nerve.

Sympathetic supply is from plexus around
middle meningeal artery.
Parasympathetic supply is secretomotor.
The pre-ganglionic fibers begin from inferior
salivary nucleus and pass via glossopharyngeal nerve, its tympanic branch,
tympanic plexus and lesser petrosal nerve
that ends in otic ganglion.
Fig. 38.2: The parotid glanda transverse section
tahir99 - UnitedVRG
The Parotid Region, Temporal and Infratemporal Fossae

The post ganglionic fibers begin from otic
ganglion and pass via auriculo-temporal
nerve to reach parotid gland.
Applied Anatomy
i. Parotid abscess is acute inflammation of gland
and involves one side only.
ii. Mumps is a viral disease that involves salivary
glands specially parotid gland.
iii. Mixed parotid tumor usually involves the
superficial lobe. The facial nerve may also be
affected.
THE TEMPORAL FOSSA

The temporal fossa is the region on side of skull.
Boundaries
SuperiorlySuperior temporal line.
InferiorlyThe upper border of zygomatic
arch.
MediallyThe fossa is formed by four
bonesfrontal, parietal, greater wing of
sphenoid and sqamous temporal.
Layers
i. Skin is hairy and has many sebaceous
glands.
ii. Connective tissue is dense and contains rich
plexus of blood vessels.
iii. A thin extension from epicranial aponeurosis.
iv. Temporal fascia is a very thick and dense
layer that covers the temporalis muscle.
It is attached above to the superior
temporal line and below to the upper
border of zygomatic arch.
v. Temporalis muscle.
vi. Pericranium is densely attached to the bones.
419
Boundaries
The roof (superior boundary) is formed by
Infra-temporal surface of greater wing of
sphenoid and squamous temporal bone.
The medial wall has
Lateral pterygoid plate
Lateral pharyngeal wall
The lateral wall is formed by
Medial surface of ramus of mandible with
the mandibular foramen in the center of it.
The anterior wall has
Posterior surface of maxilla
Contents
i. The muscles of masticationtemporalis,
lateral and medial pterygoid.
ii. The maxillary artery and its branches.
iii. The mandibular nerve and its branches.
iv. The pterygoid venous plexus.
v. The deep contents arechorda tympani,
otic ganglion and tensor veli palatini muscle,
and a small part of maxillary nerve.
The Pterygopalatine Fossa

The pterygo-palatine fossa is a narrow space
between the maxilla and the pterygoid process of
sphenoid. It is separated from the nasal cavity by
the perpendicular plate of palatine.
The space communicates with neighboring
regions through the following foramina and
fissures.
i. Middle cranial fossa via foramen rotundum
ii. Infratemporal fossa via pterygo-maxillary
fissure
iii. Nasal cavity via spheno-palatine foramen
iv. Oral cavity via greater palatine canal
v. Pharynx via palatino-vaginal canal
THE INFRATEMPORAL FOSSA
Contents
The infratemporal fossa is the region below

zygomatic arch, between ramus of mandible and
lateral wall of pharynx.
a. The pterygo-palatine (spheno-palatine) ganglion

b. Part of maxillary nerve
c. Third part of maxillary artery.
420
The Muscles of Mastication

There are four muscles of masticationTemporalis, masseter, lateral pterygoid and medial
pterygoid (Table 38.1).
These muscles are supplied by the mandibular
nerve.
The buccinator muscle of face helps in mastication by keeping vestibule of mouth free of
food during mastication.
The Blood Vessels of the Region
The Arteries
The maxillary artery is one of the terminal branches
of external carotid artery (Fig. 38.5).
It arises behind the neck of mandible as the

external carotid artery emerges from the parotid
gland.
Course: The artery passes forwards and
medially and its terminal part lies in the pterygopalatine fossa.
For purpose of description it is divided into
three parts:
a. The first part extends from its origin up
to lower border of lateral pterygoid
muscle.
b. The second part crosses superficially
(sometimes deep) to lower head of lateral
pterygoid muscle.
c. The third part enters the pterygomaxillary fissure and lies inside pterygopalatine fossa.
Table 38.1: The muscles of mastication

S.No.Name
Origin
Muscle belly
I.
Temporalis
(Fig. 38.3)
Muscle belly thick and Tendon on apex

I. Powerful elevator of
fan shaped
and medial surface
mandible
Fibers converge to
of coronoid process II. Posteriot fibers help to
form a tendon
Fleshy fibers on anteretract the protruded
rior border of ramus
mandible
of mandible
II.
Masseter
(Fig. 38.4)
Inferior temporal
line
Four bones of
medial wall of temporal fossa
Deep surface of
temporal fascia
Lower border and
medial surface of
Zygomatic arch
III.
Lateral
pterygoid
(Fig. 38.5)
IV.
Medial
pterygoid
(Fig. 38.6)
Insertion
Muscle belly thick and

quadrangular
Superficial part fibers
pass obliquely downwards
Deep part fibers pass
vertically downwards
Main actions
Lateral surface ramus I. Powerful elevator of

of mandible including
mandible
coronoid process
II. Superficial fibers help
in protraction and deep
fibers help in retraction
of mandible
III. Helps in side to side
movement of mandible
Upper head-Infratem- The fibers of two
Pterygoid fossa an
I. Depressor of mandible
poral surface greater heads pass posteroanterior surface of
and helps in opening the
wing sphenoid
laterally, and join to
neck of mandible
mouth
Lower head-Lateral
form a tendon
Capsule of mandibular II. Protractor of mandible
surface lateral pteryjoint. Some fibers
III. Side to side movement
goid plate
reach articular disc of
of mandible
the joint
Superficial headThe fibers of both
Rough area on medial I. It helps to elevate the
smaller, from maxillary heads pass downsurface of angle of
mandible
tuberosity
wards and laterally
mandible
II. Protractor of mandible
Deep head-larger
III. Helps in side to side
from medial surface
movement of mandible
of lateral pterygoid
plate.
tahir99 - UnitedVRG
Fig. 38.3: The temporalis muscle
Branches
From First Part
i. Anterior tympanic branch enters petrotympanic fissure to supply middle ear.
ii. Deep auricular supplies the external auditory
meatus.
iii. Middle meningeal branch ascends up
between two roots of auriculo-temporal
nerve. It enters skull through foramen
spinosum to supply dura mater.
iv. Inferior alveolar branch enters mandibular
foramen, and runs in the mandibular canal
to supply teeth of lower jaw. It gives a
mental branch to the face.
421
v. Accessory meningeal (sometimes present)

supplies the dura mater by entering skull
via foramen ovale.
From Second part: mainly muscular branches
vi. Anterior and posterior deep temporal arteries ascend deep to temporalis and supply
the muscle.
vii. The masseteric branch enters deep surface
of masseter through mandibular notch and
supplies the muscle.
viii. The pterygoid branches supply the lateral
and medial pterygoid muscles.
ix. The buccal branch accompanies the buccal
nerve in the face.
From third part:
x. The posterior superior alveolar branches
enter the posterior superior alveolar canals
and supply the molar teeth.
xi. The greater palatine branch reaches hard
palate and supplies part of nasal cavity also.
xii. The pharyngeal branch passes backwards
via palatino-vaginal canal and supplies the
roof of pharynx.
xiii. The infra-orbital branch enters the floor of
orbit via inferior orbital fissure. It gives
branches to supply incisor, canine, and premolar teeth. In face it gives branches to
supply, lower eyelid ala of nose and upper
lip.
Fig. 38.4: The masseter muscle
422
Fig. 38.5: The lateral pterygoid muscle and maxillary artery
xiv. The spheno-palatine artery is the terminal

part of maxillary artery that supplies lateral
wall and part of septum of nose.
The Veins
The veins of the region form a pterygoid venous
plexus that lies around the lateral pterygoid muscle.
The venous plexus receives veins from:
The nasal cavitylateral wall and the
septum.
The para nasal sinuses specially maxillary.
The mouth cavityhard and soft palate.
The structures in temporal and infratemporal
fossae.
The pterygoid venous plexus receives communications from:
i. The superficial veins of the face via deep
facial vein.
ii. The pharyngeal venous plexus via the
inferior ophthalmic vein.
iii. The cavernous sinus via the emissary veins
passing through foramen ovale and emissary
sphenoidal foramen.
The Dangerous Area of the Face: The veins
from this part of face (around the external nostril
and medial part of upper lip) do not have valves.

An infection from this region may spread to
pterygoid venous plexus, and may then travel to
the cavernous sinus causing complication.
The pterygoid venous plexus continues as the
maxillary vein posteriorly that joins with superficial
temporal vein to form the retro-mandibular vein.
The Nerves of the Region
A. The mandibular nerve is the nerve of first
branchial arch (Fig. 38.6).
Formation: The mandibular nerve is formed
by:
i. A large sensory root, i.e. mandibular division
of trigeminal nerve.
ii. A small motor root.
The two roots join just below skull after
emerging from foramen ovale, to form the
mandibular nerve.
Type: Mixed nerve.
Course: The mandibular nerve descends almost
vertically in upper part of infratemporal fossa
deep to lateral pterygoid muscle.
After a short distance the nerve divides into
an anterior division and a posterior division.
tahir99 - UnitedVRG
423
Fig. 38.6: The medial pterygoid muscle and mandibular nerve
The nerve is related medially to

Otic ganglion
Tensor veli palatini muscle
The anterior division is smaller and contains
mainly motor fibers. It continues forwards
and emerges in the face as buccal nerve,
that carries all its sensory fibers.
The posterior division is larger and descends
as the continuation of stem. It contains
mostly sensory fibers, and some motor
fibers that come out as mylohyoid nerve.
Branches
From the Stem
i. Meningeal branch that enters skull through
foramen spinosum and supplies dura mater.
ii. The nerve to medial pterygoid that passes
through otic ganglion and also supplies.
Tensor tympani
Tensor veli palatini
From the Anterior Division
iii. Four muscular branches
Anterior deep
temporal
Posterior deep
temporal
to temporalis
muscle
Masseteric nerve
Nerve to lateral pterygoid
iv. Buccal nerve supplies sensory fibers to the

face.
From the Posterior Division
v. The auriculo-temporal nerve arises by two
roots enclosing middle meningeal artery.
It passes behind mandibular joint and
crosses zygomatic arch to enter scalp.
It supplies sensory fibers to
The auricle and external acoustic
meatus
A part of scalp and superficial temporal region
Mandibular joint and parotid gland.
The nerve also carries secretomotor
fibers to parotid gland.
vi. The inferior alveolar nerve enters mandibular foramen and runs in mandibular canal
of the bone.
Before entering mandibular foramen, it
gives mylohyoid nerve that pierces
spheno-mandibular ligament and runs
forwards medially in a groove to supply.
Mylohyoid muscle
Anterior belly of digastric
424
The inferior alveolar nerve gives sensory

fibers to the teeth of lower jaw.
Anteriorly it gives a mental branch, that
comes out of mental foramen and
supplies skin of the chin.
vii. The linguinal nerve is joined by chorda
tympani at an acute angle, deep to lateral
pterygoid.
The nerve passes forwards and medially
and crosses styloglossus to enter submandibular region.
The lingual nerve lies in a groove on
mandible behind last molar tooth,
covered by mucous membrane.
The nerve crosses upper part of hyoglossus deep to mylohyoid and has a
twisting relation with the submandibular
salivary duct.
The linguinal nerve is connected by two
communicating branches with submandibular ganglion.
The nerve supplies sensory fibers to:
Anterior two-third of tongue.
Floor of mouth and gums of lower
jaw.
Submandibular and sublingual salivary glands.
It also carries taste fibers from anterior
two-third of tongue and passes them to
chorda tympani.
Applied Anatomy
i. The trigeminal neuralgiamay involve the
mandibular nerve also.
ii. Fracture of mandiblemay lead to injury
to inferior alveolar nerve in the mandibular
canal.
iii. Faulty extractionof last molar tooth may
injure the lingual nerve as it lies in the groove
on the bone. This leads to:
Loss of general sensation from anterior
two-third of tongue.
Loss of taste sensation from anterior
two-third of tongue (except vallate
papillae).
Interruption of secretomotor supply to

the submandibular and sublingual
salivary glands.
The Maxillary Nerve
The maxillary nerve is the second subdivision of
the trigeminal nerve.
TypePurely sensory
CourseThe nerve leave skull via foramen
rotundum and enters pterygo-palatine fossa,
where it is connected with spheno-palatine
ganglion by two communicating branches.
It comes out of pterygo-maxillary fissure
and lies in a groove on maxilla in deep part
of infra-temporal fossa.
The nerve enters inferior orbital fissure and
continues as infra-orbital nerve in a groove
and canal in the floor of orbit.
The terminal part comes out of infra-orbital
foramen in the face.
Branches
i. Two communicating branches to sphenopalatine (pterygo-palatine) ganglion carrying
sensory fibers for nose and palate.
ii. The zygomatic branch enters orbit through
inferior orbital fissure to supply skin of
upper part of face and scalp.
iii. The posterior superior alveolar nerve
pierces posterior surface of maxilla and
supplies sensory fibers to the maxillary
molar teeth.
both pass downiv. The middle superior
wards along the
alveolar nerve
walls of maxillary
v. The anterior superior air sinus and supply
alveolar nerve
sensory fibers to
maxillary premolar,
canine and incisor
teeth
vi. The terminal branches supply:
The skin of lower eyelied
The skin of ala of nose
The skin of upper lip
tahir99 - UnitedVRG
Applied Anatomy
The trigeminal neuralgia can also involve
maxillary division of trigeminal nerve.
The Parasympathetic Ganglia

There are three peripheral parasympathetic ganglia
associated with branches of trigeminal nerve in the
region.
i. The otic ganglion connected with mandibular
nerve.
ii. The submandibular ganglion associated with
lingual nerve.
iii. The pterygo-palatine (spheno-palatine) ganglion associated with maxillary nerve.
I. The otic ganglion is a smal ganglion that lies
just below skull close to foramen ovale between
the mandibular nerve and tensor veli palatini muscle.
Roots
i. Sensory by auriculo temporal nerve.
ii. Sympatheticby plexus around middle
meningeal artery.
iii. Parasympatheticprovided by lesser petrosal nerve. The fibers relay in the ganglion,
and post-ganglionic (secreto-motor) fibers
arise from here to supply parotid gland.
iv. An additional motor root is provided by
nerve to medial pterygoid.
Branches
a. Nerve to tensor tympani.
b. Nerve to tensor veli palatini.
c. Communicating branch to auriculo temporal
nerve that carries parasympathetic fibers for
parotid gland.
d. Communicating branch to chorda tympani.
e. Communicating branch to nerve of pterygoid canal. These two branches provide an
alternative taste pathway from anterior twothird of tongue.
II. The submandibular ganglion is also a small
ganglion that lies deep to mylohyoid, and superficial
to upper part of hyoglossus, connected to the lingual
nerve by two communicating branches.
425
Roots
The sensory root is from the lingual nerve.
The sympathetic root is from plexus around
facial artery.
The parasympathetic root is from the chorda
tympani nerve. These fibers reach ganglion
via lingual nerve and are relayed in the
ganglion. The post ganglionic parasympathetic (secreto-motor) fibers arise from
ganglion.
Branches
i. The secreto-motor fibers to submandibular
salivary gland reach the deep part of gland
directly from the ganglion.
ii. The secreto-motor fibers to sublingual
salivary gland reach via the lingual nerve.
III. The pterygo-palatine (spheno-palatine)
ganglion is the largest peripheral parasympathetic
ganglion.
It is suspended by two communicating branches from the maxillary nerve in pterygo-palatine
fossa.
Roots
The sensory root is provided by the maxillary
nerve.
The sympathetic root is from plexus around
the internal carotid artery
The parasympathetic root is provided by the
greater petrosal nerve from nerve of pterygoid canal.The pre-ganglionic parasympathetic fibers relay here and post-ganglionic
fibers begin.
Branches
i. The nasopalatine nerve runs along nasal
septum and terminates in the hard palate.
ii. The palatine branches supply the hard and
soft palate. These are posterior palatine
(greater palatine), middle and anterior
palatine (lesser palatine) nerves
iii. The nasal branches are divided into:
Posterior superior medial to supply nasal
septun.
Posterior superior lateral to supply lateral
wall of nose.
426
iv. The orbital branch enters orbit through

inferior orbital fissure to supply orbital
periosteum.
v. The pharyngeal branch is distributed to the
pharyngeal wall. The nasal and palatine
branches also carry postganglionic para-
sympathetic fibers to nasal and palatal

glands.
The secretomotor fibers for lacrimal
gland also relay here and reach gland
via zygomatic nerve.
All branches carry sensory fibers of the
maxillary nerve.
tahir99 - UnitedVRG
CHAPTER
39
The Triangles
of the Neck
THE POSTERIOR TRIANGLE
OF THE NECK
The posterio triangle lies on the side of neck, behind
sternomastoid muscle. It extends from clavicle
below up to the occipital bone above (Fig. 39.1).
Boundaries
Anterior boundary is formed by posterior
border of sternomastoid.
Posterior boundary is formed by anterior
border of trapezius.
The base or inferior boundary is formed by
middle one-third of clavicle.
The apex or superior boundary is formed
by the superior nuchal line of occipital bone.
The roof is formed by the investing layer of
deep cervical fascia, covered by superficial
fascia, platysma and skin.
Above clavicle it splits to enclose a fascial

space (described in Chapter 36).
The floor is formed by the following muscles
Semispinalis capitis
Splenius capitis
Levator scapulae
Scalenus medius
Contents (Fig. 39.2)
A. The arteries are, part of occipital artery, third
part of subclavian artery and its two
branchestransverse cervical and supra
scapular.
i. The occipital artery, a branch of external
carotid artery, can be seen at the apex
of triangle, at superior nuchal line.
Fig. 39.1: The posterior triangle of the neckboundaries
428
Fig. 39.2: The posterior triangle of the neckcontents
ii. Third part of subclavian artery lies in

lower and anterior part of the triangle.
The artery is located deeply, and is
related anteriorly to external jugular
vein, nerve to subclavius and
clavicle.
The deep relations are formed by
lower trunk of brachial plexus and
scalenus nedius muscle
iii. The transverse cervical artery is a branch
of thyro-cervical trunk from first part
of subclavian artery.
It enters the triangle after crossing
scalenus anterior muscle.
It divides into a deep branch that
passes deep to levator scapulae and
a superficial branch that crosses
lower part of triangle and passes deep
to trapezius.
[In about 60% cases the deep branch
arises as dorsal scapular artery from
third part of subclavian artery, and
superficial branch continues as
superficial cervical artery from
thyro-cervical trunk]
iv. The supra-scapular artery is also a

branch of thyrocervical trunk.
It enters posterior triangle below
transverse cervical artery after
crossing in front of scalenus anterior.
It runs laterally accompanied by
suprascapular nerve and passes
behind clavicle to reach suprascapular notch of scapula.
B. The Veins
i. The lower (deep) part of external
jugular vein
The external jugular vein is formed
behind the angle of mandible by union
of posterior auricular vein and
posterior division of retro-mandibular
vein.
The vein lies in superficial fascia deep
to platysma as it crosses sternomastoid muscle obliquely.
About 4.0 cm above clavicle, the vein
pierces deep fascia of roof and lies
for a short distance in the fascial
space. The walls of the vein, here
are adherent to the deep fascia.
tahir99 - UnitedVRG
The Triangles of the Neck

It lies in lower part of posterior
triangle (subclavian triangle), superficial to third part of subclavian
artery.
The vein passes behind clavicle and
terminates in the subclavian vein.
Tributaries
i. The posterior-jugular vein from upper part
of posterior triangle.
ii. The transverse cervical (superficial cervical)
vein that accompanies transverse cervical
artery in lower part of posterior triangle.
iii. The supra-scapular vein that accompanies
the suprascapular artery.
iv. The anterior jugular vein from front of the
neck.
C. The nerves
i. The spinal accessory nerve enters the triangle
after piercing sternomastoid and appears at
about mid-point of posterior border of
sternomastoid.
The nerve passes downwards and
laterally lying just deep fascia of roof.
There are a few lymph nodes near the
nerve.
The spinal accessory nerve disappears
deep to trapezius about 4 to 5 cm above
clavicle.
The spinal accessory nerve supplies
motor fibers to sternomastoid and trapezius muscles.
ii. The branches of the cervical plexus
a. The superficial (cutaneous) branches are
four:
The lesser occipital (ventral ramus
C2) ascends to scalp behind sternomastoid.
The greater auricular branch (ventral
ramus C 2 , C 3 ) passes upwards
towards angle of mandible and gives:
Auricular branches to the auricle
of pinna.
Facial branches to supply the
skin covering the angle of mandible.
429
Branches to the scalp and
superficial temporal region.

The transverse cutaneous nerve of
neck (ventral ramus C2C3) crosses

sternomastoid transversely to reach
front of neck from it divides into
ascending and descending branches
to supply skin of front of neck.
The supra clavicular nerves (ventral
ramus C3, C4) are three in number
anterior, middle and posterior.
These nerves descend, pierce deep
fascia of roof, cross the clavicle and
supply skin of front of pectoral
region.
b. The muscular branches of the cervical
plexus supply
From ventral ramus C2 the sternomastoid.
From ventral ramus C3,C4 the levator
scapulae and trapezius.
From ventral ramus C3,C4 C5 phrenic nerve arises to supply diaphragm.
iii. The supraclavicular part of brachial plexus
(roots and trunks) lies in deeper part of lower
portion of the triangle.
The roots (ventral rami of C5, C6, C7,C8)
appear at lateral border of scalenus
anterior.
Ventral ramus C5 and C6 join to form
upper trunk. The ventral ramus C 7
continues as middle trunk. The ventral
ramus C8 joins with ventral ramus T1 to
form lower trunk.
Branches Four branches are given from
supra-clavicular part of brachial plexus
to muscles of upper limb.
1. The dorsal scapular nerve (ventral
ramus C5) appears after piercing
scalenus medius and passes deep to
levator scapulae to supply rhomboid
muscles.
430
2. The supra-scapular nerve (ventral

ramus C5, C6) passes laterally with
supra-scapular artery to supply the
scapular muscles.
3. The nerve to subclavius (ventral
ramus C 5, C6) passes in front of
subclavian artery to reach behind
clavicle to supply subclavius.
4. The long thoracic nerve (ventral
ramus C5, C6, C7) descends deep to
the roots of brachial plexus to supply
serratus anterior.
D. The lymph nodes and lymphatics
a. The superficial cervical lymph nodes lie
along the external jugular vein, superficial
to sternomastoid muscle.
b. The occipital lymph nodes lie at the apex of
posterior triangle and retro-auricular nodes
lie behind the auricle.
c. The deep cervical lymph nodes are many
and lie deep to the sternomastoid, along
internal jugular vein.
d. The supra-clavicular nodes lie above clavicle
in lower part of posterior triangle.
E. The inferior belly of omohyoid crosses the
lower part of the posterior triangle and divides
the triangle into.
i. An upper largeroccipital triangle above
the inferior belly that contains spinal
accessory nerve and branches of cervical
plexus.
ii. A lower smallersubclavian triangle
(supra-clavicular triangle) below the inferior
belly.
It contains subclavian artery, its two
branches, external jugular vein, and
brachial plexus and its branches.
F. A quantity of fibro-fatty tissue.
Applied Anatomy
I. The spinal accessory nerve is in danger of getting
injured in operations on side of neck.
The injury to the nerve leads to paralysis of

trapezius that causes inability to shrug (or
elevate) the shoulder on affected side.
II. The spinal accessory nerve may be irritated
by enlarged lymph nodes that lie along its course.
This may lead to spasmodic torticollis.
III. The external jugular vein may be used for
demonstrating venous pressure.
Air embolism may occur if the external jugular
vein is cut at a point, where it pierces deep
fascia. (Fig. 39.3).
THE SUBOCCIPITAL TRIANGLE OF NECK
The suboccipital triangle is an intermuscular space
situated in deep part of back of neck below occipital
bone.
Boundaries
Supero-lateral boundary is formed by:
Obliquus capitis superior
Infero-lateral boundary is formed by:
Obliquus capitis inferior
Medial boundary is formed by:
Rectus capitis posterior major
Rectus capitis posterior minor
The floor is formed by:
Posterior arch of atlas
Posterior atlanto-occipital membrane
The roof (superficial boundary) is formed
by:
Semispinalis capitissupplemented by:
Splenius capitis
Longissimus capitis
Contents
1. The vertebral artery along with its sympathetic plexus as it lies on a groove of
posterior arch of atlas.
2. The suboccipital nerve (dorsal ramus of first
cervical nerve) appears below vertebral
artery.
It gives five muscular branches to supply:
Obliquus capitis superior
Obliquus capitis inferior
tahir99 - UnitedVRG
V
d
ti e
431
G
R
Fig. 39.3: The suboccipital triangle
Rectus capitis posterior major

Rectus capitis posterior minor
Semispinalis capitis
n
U
It gives one communicating branch to

greater occipital nerve.
3. The suboccipital venous plexus receives the
following veins:
Occipital veins
Muscular veins of back of neck
Deep cervical vein
Emissary vein of posterior condylar canal
S.No.
Name
1.
h
a
9
ri 9
THE ANTERIOR TRIANGLE

OF THE NECK
The anterior triangle consists of part of neck that
lies in front of sternomastoid muscle.
Boundaries (Fig. 39.4)
Anteriorly
Anterior median line of the neck
Posteriorly
Anterior border of sternomastoid
Superiorly
Base of mandible
Table 39.1: Sub-occipital muscles
Origin
Insertion
Main actions
Rectus capitio
posterior minor
Posterior tubercle
of atlas vetebra
Medial part of area below

inferior nuchal line
on occipital
1. Extends the head
2.
Rectus capitis
posterior major
Spine of axis vertebra
Lateral part of area below

lnferior nuchal line on
occipital
1. Extends the head

2. Turns face to same side
3.
Obliques capitis
inferior
Spine of axis vertebra
Transverse process of
atlas vertebra
4.
Obliques capitis
superior
Transvase process of
atlas vertebra
Lateral area between

superior and inferior nuchal
lives of occipital
432

A line drawn from angle of mandible to
the tip of mastoid process

Apex
Lies below at the suprasternal notch of
manubrium sterni
Subdivisions of the Anterior Triangle
The anterior triangle is subdivided into four smaller
trianglessubmental, digastric, carotid and muscular.
I. The submental triangle (Half portion lies in each
anterior triangle).
The small triangle lies above the body of hyoid
bone.
Boundaries
Apex lies at the symphysis menti.
Base lies at the body of hyoid bone.
Floor (inferior boundary) is formed by the
deep cervical fascia.
Roof (superior boundary) is formed by the
two mylohyoid muscles.
Two sides are formed by anterior bellies of
the two digastric muscles.
Contents: A few submental lymph nodes, that

drain lymph from tip of tongue and median part
of lower lip and chin.
II. The digastric triangle lies in upper part of
front of neck below mandible.
Boundaries
Superiorly
Base of mandible
Antero-inferiorly
Anterior belly of digastric
Postero-inferiorly
Posterior belly of digastric
Stylohyoid muscle
Roof(superficial boundary) deep cervical
fascia
Floor(deep boundary):
Mylohyoid
Hyoglossus
Contents
Submandibular salivary glands that overlaps
both bellies of digastric
Submandibular lymph nodes
Part of facial arteryand its submental
branch
Fig. 39.4: The anterior triangle of the necksubdivisions
tahir99 - UnitedVRG
V
d
ti e
433
G
R
Fig. 39.5: The carotid triangle
n
U
Mylohyoid nerve
Part of hypoglossal nerve
III. The carotid triangle is the largest and most
important part of anterior triangle (Fig. 39.5).
Boundaries
Posteriorly
Anterior border of sternomastoid
Antero-superiorly
Antero-inferiorly
Superior belly of omohyoid
Roof(superficial boundary) deep cervical
fascia
Floor
The lateral wall pharynx formed by
inferior and middle constrictor muscles
Thyrohyoid membrane, thyrohyoid
muscle
Part of hypoglossus above hyoid bone
Contents
a. The arteries
Parts of common carotid, internal carotid
and external carotid arteries.
Five branches of external carotid artery
h
a
9
ri 9
i. The superior thyroid artery

ii. The ascending pharyngeal artery
iii. The lingual artery
iv. The facial artery
v. The occipital artery
b. The Veins
The internal jugular vein, that mostly
lies deep to sternomastoid muscle.
Tributaries of internal jugular vein
Superior thyroid vein
Lingual veins
Pharyngeal veins
Common facial vein
c. The nerves
i. Vagus nerve and its superior laryngeal
branch that divides into external laryngeal
nerve (that supplies cricothyroid muscle)
and
Internal laryngeal nerve (that pierces
thyrohyoid membrane and supplies
sensory fibers to larynx above vocal
cords).
ii. Spinal accessory nerve crosses upper
part of triangle and pierces sternomastoid.
434
Fig. 39.6: Ansa cervicalis
iii. Hypoglossal nerve curves forwards and

medially in upper part of triangle to enter
submandibular region above hyoid bone.
It gives two branches in carotid
triangle
Nerve to thyrohyoid
Superior limb of ansa cervicalis
iv. Ansa cervicalis is a nerve loop that lies
in front of internal and common carotid
arteries. (Fig. 39.6)
It is firmed by two limbs
a. Superior limb from hypoglossal
nerve carrying fibers from
ventral ramus of C1 spinal nerve.
b. Inferior limb from the cervical
plexus, carrying fibers from
ventral rami of C2 and C3 spinal
nerves.
The ansa cervicalis formed by the
two limbs, lies in front of common
carotid artery.
It supplies branches to
Superior belly omohyoid
Inferior belly omohyoid
Sternohyoid
Sternothyroid
d. The lymph nodes Many deep cervical

lymph nodes lie along the internal jugular
vein.
IV. The muscular triangle forms the lower and
anterior part of anterior triangle of neck.
Boundaries
Anteriorly Anterior median line of neck
Postero-inferiorly Lower part of anterior
border of sternomastoid
Postero-superiorly Superior belly of omohyoid
Contents
The infrahyoid muscles [Described in
Chapter 40]
Sternohyoid
Sternothyroid
Thyrohyoid
tahir99 - UnitedVRG
CHAPTER
40
The Muscles, Glands, Blood Vessels

and Nerves of the Front of Neck
A. The muscles of the front of the neck (Table
40.1) are:
1. The prevertebral muscles (Fig. 40.1)
Anterior group
Rectus capitis anterior
Rectus capitis lateralis
Longus capitis
Longus colli
Lateral group
Scalenus anterior
9
ri 9
V
d
ti e
n
U
h
a
G
R
Scalenus medius
Scalenus posterior
Scalenus minimus (pleuralis)
2. The muscles of the anterior triangle
Sternomastoid
Infrahyoid muscles
Sternohyoid, sternothyroid, thyrohyoid
and omohyoid
Supra hyoid muscles
Digastric
Fig. 40.1: The prevertebral muscles
436

Table 40.1: The muscles of the front of neck
S. Name
No.
Origin
Muscle belly
Insertion
Nerve supply
Main actions
Short flat muscle

belly
Inferior surface
basi-occiput
Ventral ramus C1
Flexes head at atlanto occipital joint
Short flat muscle

belly
Inferior surface
Ventral ramus C1
jugular process of
occipital bone
Inferior surface of Ventral rami
basilar part of
C1, C2, C3
occipital bone
The prevertebral musclesAnterior group

1.
Rectus capitis Anterior surface

anterior
lateral mass of
atlas
2. Rectus capitis Upper surface
lateralis
transverse process of atlas
3. Longus
Anterior tubercles
capitis
of transverse processes of third
to sixth cervical
4. Longus colli
Upper oblique
part
Anterior tubercles of fifth and
sixth cervical
vertebrae
Middle vertical
part
Upper three thoracic and lower
three cervical
vertebrae
Lower oblique
part
Upper two thoracic vertebral
bodies
The prevertebral musclesLateral
5. Scalenus
Anterior tubercles
anterior
of third to sixth
cervical vertebra
6.
Scalenus
medius
7.
Scalenus
posterior
(absent
sometimes)
Scalenus
pleuralis
(minimus)
8.
Broad above
narrow below
Upper oblique
part
Muscle belly con- Anterior tubercle Ventral rami
sists of digitations of atlas
C2 to C6
lying on front of
Middle vertical part
vertebral bodies
Bodies of second
to fourth cervical
vertebrae
Lower oblique part
Anterior tubercle
of fifth and sixth
cervical vertebrae
group
Muscle belly becomes narrow
below
Scalene tubercle Ventral rami

and ridge between C4 to C6
subclavian grooves
of first rib
Transverse pro- Muscle belly large, Upper surface of Ventral rami
cess of axis
and long, becomes first rib between
c3 to C8
Posterior tuber- narrow below
tubercle and subcle of third to
clavian groove
seventh cervical
vertebrae
Posterior tuber- Small and deeply Outer surface of Ventral rami
cles of fourth,
placed muscle
second rib behind C6, C7, C8
fifth and sixth
belly
serratus anterior
cervical vertebrae
Muscle fibers associated with supra pleural membrane
(sometimes present).
Lateral flexion of
head
Flexes the head
I. Flexes the neck

forwards
II. The oblique parts
help in lateral
flexion of neck
I. Flexes the neck

antero-laterally
II. Helps to elevate
the first rib
I. Flexes the neck
on same side
II. Helps to raise
first rib
I. Flexes the neck

on same side
second rib
The muscles of the anterior triangleInfrahyoid muscles

1.
Sternomastoid Sternal head

Round tendon
A thick muscle
belly joined by
Lateral half of
superior nuchal
Spinal accessory
(motor) Ventral
I. Bends head same

side turns face to
Contd...
tahir99 - UnitedVRG
The Muscles, Glands, Blood Vessels and Nerves of the Front of Neck
437
Contd...
S. Name
No.
Origin
2.
Sternohyoid
3.
Sternothyroid
Muscle belly
anterior surface
manubrium sterni
Clavicular head
superior surface
of medial third of
clavicle
Posterior aspect
medial end of
clavicle
Posterior aspect
of manubrium
sterni
Posterior surface
of manubrium
sterni
Posterior aspect
of first costal
cartilage
Oblique line of
lamina of thyroid
cartilage
opposite side
II. Raises head from
supine position
III. Elevates thorax if
head fixed
Thin narrow strap- Medial part inferior

like muscle belly
border body of
hyoid bone
Ansa cervicalis
ventrical rami
C1, C2, C3
I. Depresses hyoid
bone during speech mastication
and deglutition
V
d
ti e
G
R
Shorter and wider Oblique line of

muscle belly
lamina of thyroid
cartilage
Ansa cervicalis
(Ventral rami
C1, C2, C3 )
Small and quadri- Lower border

lateral muscle belly greater cornu of
hyoid bone
Branch of hypo- I. Depression of

glossal nerve (fib- hyoid bone or
res of ventral
elevation larynx
ramus C1)
Separate branI. Depression of
ches for both
hyoid bone in
bellies from Ansa
prolonged respicervicalis (Ventral
ratory efforts
rami C1, C2, C3)
5.
Omohyoid
two belies
Inferior belly
From supra
scapular notch
Superior belly
Intermediate
tendon
6.
Platysma
Fascia on upper Thin, broad sheet

part of pectoralis lies in superficial
major
fascia on side of
neck
Main actions
rami C2, C3, C4

(proprioceptive)
Thyrohyoid
n
U
Inferior belly flat,

narrow, band
Superior belly
ascends vertically
9
ri 9
The supra-hyoid muscles:

1. Digastric
Posterior belly
Mastoid notch of
temporal bone
Anterior belly
Digastric fossa
at lower border
of mandible
Nerve supply
clavicular head be- line Lateral surcomes flattened

face of mastoid
above as it asprocess
cends obliquely
in the neck
4.
h
a
Insertion
Posterior belly
longer and tapering Anterior belly
shorter
I. Depresses larynx
(Thyroid cartilage)
during speech
and swallowing
Inferior belly on
intermediate tendon
Superior belly
lateral part lower
border body of
hyoid bone
Anterior fibres
Cervical branch of I. It causes ridges
decussate in midfacial nerve
in skin of neck
line attached to
II. Helps in depressymphysis menti
sing mandible
Middle fibres lower
III. Pulls lower lip and
border mandible
angle of mouth
Posterior fibres
downwards
Cross mandible and
masseter attached
to skin of lower
part of face
Intermediate tendon passes
through a fibrous
pulley attached to
hyoid bone
Posterior belly I. Helps in depressFacial nerve

ion of mandible
Anterior belly
Mylohoid nerve
the hyoid bone
Contd...
438
Contd...
S. Name
No.
2.
Stylohyoid
3.
Mylohyoid
4.
Geniohyoid
Origin
Muscle belly
Insertion
Round tendon
Narrow slender
posterior surface
muscle belly
near base of
styloid process
At insertion tendon
of digastric divides
into two parts
attached to hyoid
bone at junction
with greater cornu
Whole length of
Flat, triangular
Fibrous median
mylohyoid line
muscle belly
raphe Posterior
of mandible
Forms floor of
fibres body of
mouth with fellow hyoid bone
of opposite side
Lower mental
Narrow muscle
Anterior aspect
spine of mandible belly lies in parabody of hyoid
median position
bone
Nerve supply
Main actions
Facial nerve
I. Helps to elevate
and retract hyoid
bone
Mylohyoid
branch of inferior alveolar
nerve
I. Elevates floor of
mouth
II. Helps to depress
mandible and elevate hyoid bone
I. Elevates hyoid
bone
II. Helps in depressing mandible
Branch of hypoglossal carrying

fibres of Ventral
ramus C1
Stylohyoid
Mylohyoid
Geniohyoid
THE THYROID GLAND
The thyroid gland is an important endocrine gland
that controls the metabolism of the body (Fig.
40.2).
Secretion: It produces thyroxin and thyrocalcitonin.
Location: The gland lies in front of lower part
of neck.
Parts: The thyroid gland has:
A median part called isthmus
Two lateral lobes
The isthmus is rectangular in shape
It is nearly 1.2 cm vertically and transversely.
It lies in front of second to fourth tracheal
rings.
It is a midline structure of neck, covered
only by skin and fasciae.
The lateral lobes are conical in shape
Each lobe is about 5.0 cm long, 3.0 cm
broad and 2.0 cm wide.
Fig. 40.2: The thyroid glandanterior aspect
The upper pole extends up to the oblique

line of thyroid cartilage.
The lower end reaches up to fifth tracheal
ring.
The lateral surface is covered by three
layers of muscles (Fig. 40.3):
Sternomastoid
Sternohyoid and superior belly omohyoid
Sternothyroid
tahir99 - UnitedVRG
V
d
ti e
Fig. 40.3: TS of neckshowing relations of thyroid gland
The medial surface is related to:

Lateral wall of pharynx
Trachea
External laryngeal nerve and cricothyroid
muscle
Recurrent laryngeal nerve in tracheoesophageal groove
The posterior surface is related to (Fig. 40.4):
The carotid sheath (common carotid artery)
Inferior thyroid artery
9
ri 9
h
a
Fig. 40.4: The thyroid glandposterior surface

showing parathyroid gland
439
G
R
Two parathyroid glandssuperior and

inferior
A small conical pyramidal lobe is often present,
along upper border of isthmus of gland.
A fibrous cord thyroglossal duct may also be
present from the apex of pyramidal lobe to body of
hyoid bone. It may rarely, contain some muscle
fibers and is called levator glandulae thyroideae.
n
U
The Capsules
The thyroid gland has two capsules.
i. A true capsule formed by the connective
tissue all around the gland.
ii. A fascial capsule formed by the pretracheal
fascia.
The thyroid vessels pierce both capsules and
ramify deep to true capsule.
The Blood Supply of Thyroid Gland
The arteries: There are two paired arteries

supplying thyroid gland.
i. The superior thyroid artery branch of
external carotid, enters gland at the upper
pole of thyroid lobe. It gives a branch to
supply larynx.
440
ii. The inferior thyroid artery is a large branch

of thyro-cervical trunk, and reaches
posterior surface of thyroid lobe. It also
supplies parathyroid glands and gives a
branch to larynx.
iii. Thyroidea ima artery is an occasional branch
from arch of aorta that supplies isthmus.
The veins: There are three paired veins draining
venous blood from thyroid gland.
The veins do not accompany the arteries.
i. The superior thyroid
vein
ii. The middle thyroid
vein
end in internal
jugular vein
iii. The inferior thyroid vein passes downwards

on front of trachea and ends in brachiocephalic vein.
Anomalies of Thyroid Gland

Ectopic Thyroid
The Nerve Supply
The sympathetic nerves are derived from middle

cervical ganglia of sympathetic trunks. These
supply the blood vessels of the gland.
The secretion of gland is under control of
thyrotropic hormone of pituitary gland.
Development of Thyroid Gland

DevelopmentThyroid gland develops from an
endodermal diverticulumMedian thyroid
diverticulum from floor of primitive pharynx
The site of diverticulum is marked by foramen
cecum in adult tongue.
The lower end of diverticulum enlarges to form
the gland.
The lingual thyroid

The suprahyoid thyroid
The infrahyoid thyroid
The retrosternal thyroid
Applied Anatomy

The lymph vessels of thyroid gland may contain
colloid material.
The lymphatics end in pre-laryngeal, pre-tracheal
and deep cervical lymph nodes.
The lymph finally reaches thoracic duct and
right lymphatic duct.
The rest of diverticulum may persist as a fibrous

cordthyroglossal duct
Parafollicular cells of thyroid gland develop
from - IVth pharyngeal pouch.
Enlargement of thyroid gland is called goiter.

i. A simple goiter results from deficiency of
iodine.
ii. A toxic goiter (adenoma) is due to over
production of hormone and causes symptoms.
Thyroidectomy is done in cases of thyroid
enlargement.
A part of posterior lobes having parathyroid
glands is left behind to preserve parathyroid
glands (subtotal thyroidectomy).
Two nerves external laryngeal and recurrent
laryngeal are closely related to thyroid lobe.
Care is taken during thyroidectomy to preserve
the parathyroids.
Injury to external laryngeal nerve causes
paralysis of cricothyroid muscle of larynx,
leading to a temporary huskiness of voice.
Injury to recurrent laryngeal nerve causes
paralysis of most of intrinsic muscles of larynx
and this leads to a permanent huskiness of voice.
THE PARATHYROID GLANDS

These are two pairs of small and important ductless
glands, closely related to thyroid gland.
Secretionis parathyroid hormone, that controls
the calcium metabolism of the body.
tahir99 - UnitedVRG
LocationThe superior parathyroid is more

constant in position. It is located on middle of
posterior border of thyroid lobe.
The inferior parathyroid may be
Inside of fascial capsule of thyroid gland
Outside fascial sheath and above inferior
thyroid artery
Inside lower pole of the gland.
Size and Shape
Each parathyroid gland is lentiform or ovoid
in shape.
Color is pale brownish, due to vascularity.
Size is 4.0 mm long, 3.0-4.0 mm wide and
1.0-2.0 mm in thickness.
Weight is about 50 mgm.
The blood supply is from the inferior thyroid
vessels.
The superior parathyroid is also known as
parathyroid IV as it develops from fourth
pharyngeal pouch.
The inferior parathyroid is also known as
parathyroid III as it develops from third
pharyngeal pouch.
Applied Anatomy
i. Removal of parathyroids during thyroidectomy leads to gradual fall in serum calcium
level and may lead to a fatal condition called
tetany.
ii. In case of parathyroid tumor, there is
depletion of calcium from the bone.
THE THYMUS GLAND

The thymus gland is an important gland of lymphoid
system, that is particularly large in size in children
and undergoes regression in adults.
LocationThe gland consists of two elongated
lobes that lie side by side in front of
Cervical part of trachea
In front of great vessels at root of neck and
superior mediastinum
In front of pericardium
The gland may be attached to lower end of
thyroid gland.
441
Functional importanceThe thymus gland is

the mother colony of lymphoid tissue. In
produces T-lymphocytes that migrate and settle
in developing lymphoid organs. Thus the gland
is concerned with development of cellular
immunity mechanisms.
Development The thymus gland develops from
endoderm of IIIrd pharyngeal pouch along with
inferior parathyroid (Parathyroid III) gland.
BLOOD VESSELS OF THE

FRONT OF NECK
The Arteries
1. The common carotid artery is the main artery of
the head and neck.
Origin: The right common carotid artery arises
from the brachio-cephalic trunk, the left artery
arises directly from the arch of aorta.
Course and relations: The common carotid
artery passes upwards and laterally from the
upper border of sterno-clavicular joint up to its
bifurcation.
The artery bifurcates at level of upper border
of thyroid cartilage (vertebral levelintervertebral disc between third and fourth
cervical vertebrae).
Two special receptors are present at its
bifurcation:
a. The carotid sinus is fusiform dilatation
with nerve endings. It acts as a baroreceptor.
b. The carotid body is a neuro-vascular
body at back of bifurcation. It acts as a
chemo-receptor. It may give rise to a
tumor.
The common carotid artery is enclosed in
fascial tubethe carotid sheathalong
with internal jugular vein and vagus nerve.
Branches: The common carotid artery gives
two terminal branchesthe internal carotid and
the external carotid.
a. The internal carotid artery supplies
structures inside skull including brain.
442
Course: The artery passes upwards and

laterally to reach the lower opening of
carotid canal at the base of the skull.
It enters skull by passing through
bony carotid canal in the petrous
temporal bone.
The internal carotid artery, along with
internal jugular vein and vagus nerve
lies inside fascial tube the carotid
sheath.
The artery in upper part lies deep to
styloid process and its associated
muscles, that separate it from the
The sympathetic plexus from the
superior cervical ganglion of
sympathetic chain accompanies the
artery inside skull.
Branches: The internal carotid artery
does not give any branch in the neck.
b. The external carotid artery supplies
structures outside skull in upper part of neck.
(Fig. 40.5).
Course: The artery ascends upwards

through upper part of carotid triangle
and passes deep to posterior belly of
digastric.
The upper part of the artery lies in
the substance of parotid gland.
The artery comes out of parotid gland
and bifurcates behind the neck of
mandible into two terminal branchessuperficial temporal and
maxillary.
Branches
1. The superior thyroid artery is the first
branch. It reaches the upper pole of
thyroid lobe and supplies the gland.
It also givesA superior laryngeal branch, that pierces thyrohyoid membrane, along with
internal laryngeal nerve, and
supplies larynx.
A sternomastoid branch that
supplies sternomastoid muscle.
Fig. 40.5: The external carotid artery
tahir99 - UnitedVRG
2 The ascending pharyngeal artery
ascends upwards along the pharyngeal wall between the internal and
external carotid arteries.
It also gives:
A meningeal branch to dura
mater
An inferior tympanic branch
to the middle ear.
3. The lingual artery is a tortuous vessel
given near greater cornu of hyoid
bone.
It forms a loop crossed by the
hypoglossal nerve in the carotid
triangle.
It passes deep to hypoglossus
and passes forwards to reach the
tongue.
It also gives:
A supra-hyoid branch.
Two or three large dorsal
linguae branches that supply
the posterior part of tongue,
oral cavity, tonsil, and palate.
A sublingual branch to the
sublingual salivary gland.
The terminal profunda
branch, that runs on inferior
surface of tongue to supply
it.
4. The facial artery arises opposite the
angle of mandible.
It ascends deep to the mandible
and forms a loop grooving
posterior part of submandibular
salivary gland.
It enters face at the lower border
of mandible at anterior inferior
angle of masseter.
[The course and branches in face
described in Chapter 37).
443
Branches in the neck

A tonsillar branch to the palatine
tonsil.
An ascending palatine branch that
supplies palate and pharynx.
A submental branch that lies in the
digastric triangle.
The glandular branches to supply the
submandibular salivary gland.
5. The occipital artery arises from the
posterior aspect of external carotid
artery.
It passes backwards along the
lower border of posterior belly
of digastric.
It lies in a bony groove on medial
surface of mastoid process and
appears at the apex of the posterior triangle of neck.
It pierces trapezius and reaches
the back of scalp to supply it.
It also givesupper and lower
sternomastoid branches to supply
the muscleA mastoid branch
to supply the mastoid air cells and
dura mater.
6. The posterior auricular artery arises
from the external carotid above
posterior belly of digastric and passes
deep to the parotid gland to reach
back of auricle and supply scalp.
It givesA stylomastoid branch,
that enters stylomastoid foramen
and supplies middle ear.
The auricular branches supply
the auricle or external ear.
7. The maxillary artery
[Described in Chapter 38].
8. The superficial temporal artery
crosses the zygomatic arch and
ascends upwards in the temporal
region and scalp.
444

It gives
A transverse facial artery to

the upper part of the face.
The auricular branches to
supply the auricle.
A zygomatico-orbital branch
that runs along upper border
of zygomatic arch.
A middle temporal branch
that pierces the temporal
fascia and temporalis muscle
and lies in a groove on side
of skull.
The two terminal branches
frontal and temporal,that
supply scalp (including forehead) and superficial temporal region.
SUBCLAVIAN ARTERY
The subclavian artery is an important artery at root
of neck. It continues as the main artery of upper
limb, but it also supplies important structures of
neck and part of brain by its branches.
Origin
On right sidethe subclavian artery arises
from brachio-cephalic artery
On left sidethe subclavian artery arises
from arch of aorta. It ascends and enters
the neck behind left sterno-clavicular joint.
Course
Both arteries have a similar course in neck.
Each artery curves laterally above the
cervical pleura and apex of lung in the root
of neck.
The artery passes from the sterno-clavicular
joint to outer border of 1st rib, where it ends
by continuing as axillary artery.
For purpose of description the artery is
divided into three parts by scalenus anterior
muscle.
First partextends from sternoclavicular
joint to medial border of scalenus anterior
Second partis short segment of artery that
lies behind scalenus anterior
Third partextends from lateral border of

scalenus anterior to outer border of 1st rib.
Relations
First part
Anterior
Common caroted artery
Vagus nerve
Cardiac branches of vagus and sympathetic trunk
Vertebral vein
Phrenic nerve
on left side
Thoracic duct
Ansa subclavia
Posterior
Suprapleural membrane
Cervical pleura
Apex of lung
Recurrent langugeal nerve (Right side)
Ansa subclavia
Second part
Anterior
Scalenus anterior
Structures in front of scalenus anterior
Right phrenic nerve
Transverse cervical and suprascapular
artery
Sternomastoid
Posterior
Cervical pleura
Apex of lung
Superior
Upper and middle trunks of brachial
plexus
Third part
Anterior
Suprascapular vessels
Subclavian vein
External jugular vein
Transverse cervical vein
Subclavius
Middle 1/3rd of clavicle
Sternomastoid
tahir99 - UnitedVRG
Posterior
Scalenus medius
Lower trunk of brachial plexus
Cervical pleura and apex of lung
Inferior
Ist rib
Branches
The subclavian artery gives five branches
From first part
1. Vertebral artery
2. Internal thoracic artery
3. Thyro-cervical trunk
From second part
4. Costo-cervical trunk
5. Dorsal scapular artery
From third part
No branch is given normally.
Vertebral arteryis the first and largest
branch of subclavian artery.
It is divided into four parts
The first partextends vertically through
foramina transversarium of 6th cervical
vertebra.
The second partascends vertically
through foramina transversaria of upper
six cervical vertebra.
The third partlies in suboccipital
triangle [Described in Chapter 39]
The fourth partascends through
foramen magnum and enters skull. In
ends at lower border of pons by uniting
with fellow of opposite side to form the
basilar artery.
Internal thoracic artery
[Described in Chapter 21]
Thyro-cervical trunkis a short wide vessel
that arises close to medial border of scalernus anterior muscle.
The trunks immediately divides into three
branches
a. Inferior thyroid artery ascends up and
then turns medially to reach posterior
surface of thyroid lobe.
i.
ii.
iii.
445
In addition to giving branches to
thyroid and parathyroid gland. The

artery also gives
Ascending cervical artery
Inferior laryngeal artery
Branches to supply pharynx
trachea and esophagus
b. Supra-scapular arterypasses downwards and laterally, crossing scalenus
anterior behind sternomastoid muscle.
It crosses lower part of posterior triangle
of neck in front of brachial plexus and
then runs behind clavicle to reach
superior border of scapula
It passes above supra scapular
ligament and takes part in arterial
anastomosis around scapula.
c. Superficial cervical arterypasses
laterally above supra-scapular artery. It
also crosses scalenus anterior behind
sternomastoid muscle and then passes
in front of brachial plexus in lower part
of posterior triangle of neck.
The artery passes deep to trapezius
supplying it
[The artery may be replaced by
superficial branch of transverse
cervical artery]
iv. The Costo cervical trunkis a large branch
that arises from posterior surface of second
part of subclavian artery.
The artery arches backwards over
cervical pleura and divides into
a. The superior intercostal arterythat
descends in front of neck Ist rib and
divides to give rise to posterior intercostal artery for 1st and 2nd intercostal space.
b. The deep cervical arterypasses
backwards between transverse
process of 7th cervical vertebra and
neck of 1st rib.
446
It ascends between semispinalis

capitis and semispinalis cervicis
at back of neck and anastomoses
with occipital and vertebral
arteries.
v. The dorsal scapular arteryIt arises from
third part of subclavian artery [or sometimes
it is replaced by deep branch of transverse
cervical artery from 1st part of subclavian
artery]
The artery passes backwards and
laterally crossing scalenus medius and
deep to levator scapulae and then runs
along medial border of scapula deep to
rhomboid muscles
The artery takes part in anastomosis
around scapula.
The Veins
A. The anterior jugular vein is the superficial vein
of the front of the neck.
It starts just below mandible by some superficial
veins.
It descends almost vertically with the fellow
of opposite side in the median region of neck.
About 4.0 cm above manubrium sterni, it pierces

deep fascia and joins with its fellow by a
transverse channel the jugular venous arch that
lies in the suprasternal space.
The vein terminates by turning laterally deep to
the sternomastoid muscle and ends in the
external jugular vein.
B. The external jugular vein (described in
Chapter 39).
C. The internal jugular vein is the large vein
of the neck that collects venous blood from inside
skull, brain superficial parts of the face and most
of the structures in the neck (Fig. 40.6).
Course: It begins at the base of skull as continuation of sigmoid sinus in posterior part of
jugular foramen.
It passes downwards, forwards and mediallyenclosed in carotid sheath, lying lateral to the
internal and common carotid arteries and vagus
nerve.
It has two dilatations in its course.
i. The superior bulb is lodged in jugular fossa
of petrous temporal bone and is present at
the beginning of the vein.
Fig. 40.6: The internal jugular veins
tahir99 - UnitedVRG
ii. The inferior bulb is present just above the

terminal end of the vein. There is a pair of
valves just above it.
The internal jugular vein terminates behind the
medial end of clavicle by joining with the
subclavian vein to form the brachio-cephalic
vein.
The right internal jugular vein is more vertical.
Tributaries
i. The inferior petrosal sinus from inside the
skull.
ii. The pharyngeal veins from the pharyngeal
venous plexus.
iii. The lingual veins from the tongue.
iv. The common facial vein.
v. The superior and middle thyroid veins.
THE SUBCLAVIAN VEIN

The subclavian vein is continuation of axillary vein.
It begins at outer border of 1st rib and ends at
medial border of scalenus anterior by joining
with internal jugular vein to form the
brachiocephalic vein.
The vein lies in front of subclavian artery and
scalenus anterior muscle behind clavicle.
Its tributaries are
1. The external jugular vein
2. The thoracic duct on left side and right
lymphatic duct on right side (sometimes)
Head and Neck
A. The pericervical chain of lymph nodes lie at the
junction of head and neck. They are:
i. The occipital nodes at upper part of trapezius
muscle.
ii. The retro-auricular (mastoid) nodes lie behind
the auricle.
iii. The parotid nodes lie in the relation with
parotid gland.
iv. The submandibular nodes lie in relation to
the submandibular salivary gland.
447
v. The submental nodes lie just below the

symphysis menti.
These nodes drain lymph from scalp, temporal
region and superficial parts of face.
B. The superficial cervical nodes lie along the
external jugular vein, and drain lymph from
superficial parts of side of neck.
C. The anterior cervical nodes, lie along the
anterior jugular vein on front of the neck and drain
lymph from superficial structures on front of neck.
D. The deep cervical nodes lie along the internal
jugular vein deep to sternomastoid.
These lymph nodes drain lymph from the other

four groups in the neck.
They also drain lymph from the deep structures
of head and neck.
The following two groups of this set are
important:
a. The jugulo-digastric nodes lie at the angle
of mandible just below the posterior belly
of digastric.
This node collects lymph from palatine
tonsil, tongue, and upper pharyngeal
region.
It is also known as tonsillar node.
b. The jugulo-omohyoid node lies a little lower
down, where the internal jugular vein is
crossed by the superior belly of omohyoid.
It collects lymph from the tongue and
other deeper structures of the neck.
At the root of neck, the lymphatics from the
deep cervical nodes join to form the jugular lymph
trunk. On right side, it joins the right lymphatic
duct, and on left side it ends in the thoracic duct.
THE NERVES OF THE FRONT OF NECK
The nerves on the front of neck are the last

four cranial nerves (i.e. from ninth to twelfth)
and the sympathetic chain.
1. The Glosso-Pharyngeal Nerve

The glosso-pharyngeal nerve (IX cranial nerve) (Fig.
40.7).
448
Fig. 40.7: The great vessels and nerves of front of neck
Typemixed nerve.
Functional components and distribution
(Described in Chapter 47)
Coursethe glosso-pharyngeal nerve enters the
neck by passing through middle part of jugular
foramen, enclosed in a separate dural sheath.
There are two ganglia in its uppermost part.
a. The superior ganglion is small.
b. The inferior ganglion is larger and relays
all the sensory fibers (general and special
sensation) of the nerve.
The nerve descends between the internal and
external carotid arteries.
It curves medially across stylopharyngeus
muscle and supplies it.
It passes in the pharyngeal wall between
superior and middle constrictor muscles, and
divides into its terminal branches.
Branches
Communicating branches are given to:
Superior cervical ganglion of sympathetic chain
Vagus nerve
Facial nerve
Branches of distribution
i. The tympanic branch (Jacobson nerve)
enters middle ear cavity, through a
minute tympanic canaliculus.
It forms a tympanic plexus on the
medial wall of middle ear that
supplies sensory fibers to the middle
ear and auditory lube.
The tympanic plexus also carries
preganglionic parasympathetic fibers
for parotid gland, that come out as
lesser petrosal nerve.
tahir99 - UnitedVRG
ii. The sino-carotid nerve supplies the
carotid sinus and the carotid body.
iii. The tonsillar branch supplies sensory
fibers to the palatine tonsil.
iv. The lingual branches supply sensory
and taste fibers to posterior one-third of
tongue including vallate papillae.
v. The pharyngeal branches join the
pharyngeal plexus of nerves and supply
sensory fibers to pharynx and palate.
vi. Muscular branch to stylopharyngeus.
iii.
iv.
2. The Vagus Nerve (the X cranial nerve)
v.
vi.
Type mixed nerve.

(Chapter 47)
Course and relationthe vagus nerve also
enters the neck by passing through middle part
of jugular foramen enclosed in a common dural
sheath with the accessory nerve.
There are two ganglia in upper part of the
vagus nerve.
i. The superior ganglion is small and relays
the somatic sensory fibers of the nerve.
ii. The inferior ganglion is larger and
cylindrical. It relays all visceral sensory
fibers (including the taste fibers) of the
nerve.
The vagus nerve descends in the neck
enclosed in the carotid sheath along with
internal (common) carotid artery and
internal jugular vein.
Branches in the neck
The communicating branches are given to:
Superior cervical ganglion of sympathetic chain.
Hypoglossal nerve.
Glossopharyngeal nerve.
Accessory nerve.
The branches of distribution
i. The meningeal branch is given to the
dura mater of posterior cranial fossa.
ii. The auricular branch (Arnolds nerve)
supplies sensory fibers to auricle,
449
external acoustic meatus and outer

surface of tympanic membrane.
The pharyngeal branch joins the
pharyngeal plexus of nerves and
provides its motor component.
The superior laryngeal branch divides
into:
The external laryngeal nerve that
supplies the cricothyroid muscle.
The internal laryngeal nerve that
provides sensory fibers to upper part
of larynx.
The cardiac branches two to three in
number, join the cardiac plexuses.
The right recurrent laryngeal nerve is
given in the lower part of neck and
curves around the first part of subclavian
artery.
The recurrent laryngeal nerve
supplies the intrinsic muscles of
larynx (except cricothyroid) and
gives sensory fibers to lower part of
larynx.
3. The Accessory Nerve

(The XI Cranial Nerve)
Typepurely motor.
(Chapter 47)
Course and relationThe accessory nerve also
enters the neck by passing through middle part
of jugular foramen enclosed in a common dural
sheath with the vagus nerve.
It consists of two partscranial and spinal.
a. The cranial part joins the vagus nerve
just below the skull.
The motor fibers of the cranial part
are distributed along with the
pharyngeal and recurrent laryngeal
branches of vagus nerve.
b. The spinal part descends in the neck
between the internal carotid artery and
the internal jugular vein.
450

It turns laterally, crosses upper part
Branches of distribution
a. The hypoglossal nerve carries fibers of
ventral ramus of first cervical nerve that
are given in:
i. The meningeal branch that supplies
the dura mater of posterior cranial
fossa.
ii. Superior limb of ansa cervicalis joins
with the inferior limb to form the
ansa cervicalis that supplies the infrahyoid muscles.
[Ansa cervicalis is described in
Chapter 39].
iii. The nerve to thyrohyoid muscle.
iv. The nerve to geniohyoid muscle.
b. The terminal branches of the hypoglossal
nerve supply all the extrinsic and intrinsic
muscles of the tongue (except palatoglossus).
of internal jugular vein (superficially

but sometimes deep to it).
It enters sternomastoid muscle and
supplies it.
It appears at about middle of posterior border of sternomastoid and
descends laterally deep to the roof
of posterior triangle.
It enters deep to trapezius about
4.0 cm above clavicle and supplies it.
4. The Hypoglossal Nerve
(The XII Cranial Nerve)
Typepurely motor nerve.

(Chapter 47)
Course and relationsthe hypoglossal nerve
enters the neck through the anterior condylar
canal.
It lies deep to the ninth, tenth, and eleventh
cranial nerves at base of skull.
It descends in between the internal carotid
artery and the internal jugular vein.
It curves around the vagus nerve, as it
passes deep to the posterior belly of digastric
muscle.
The hypoglossal nerve makes a wide curve
medially in upper part of carotid triangle,
crossing the internal carotid, external carotid
and loop of lingual arteries.
The nerve passes above the hyoid bone in
submandibular region, lying superficial to
hyoglossus and deep to mylohyoid and ends
in its terminal branches.
Branches
Communicating branches are given to:
Superior cervical ganglion of sympathetic chain.
Vagus nerve.
Ventral ramus of first cervical nerve.
Lingual nerve (in submandibular region).
Applied Anatomy
In case of injury to the hypoglossal nerve, the

tongue muscles of same side are paralyzed
(except palatoglossus).
If the paralyzed tongue is protruded, it deviates
towards the affected side due to unopposed
action of the muscles of the sound half of the
tongue.
THE CERVICAL SYMPATHETIC TRUNK

The cervical part of sympathetic trunk runs
vertically in the neck from the base of skull up to
the neck of first rib at the root of the neck.
The sympathetic trunk lies behind the carotid
sheath in front of the prevertebral muscles.
The preganglionic sympathetic fibers from
upper thoracic ganglia reach the cervical
sympathetic trunk and relay in the three
ganglia.
a. The superior cervical ganglion lies just
below skull. It is about 2.5 cm long and
spindle shaped.
tahir99 - UnitedVRG
Branches
i. Grey rami communicans are given to
the ventral rami of upper four
cervical nerves.
ii. The cardiac branch joins the cardiac
plexuses.
iii. The laryngo-pharyngeal branch joins
the pharyngeal plexus.
iv. The communicating branches are
given to the ninth, tenth, and twelfth
cranial nerves.
v. The internal carotid nerve forms a
plexus around the internal carotid
artery and enters the skull along with
the artery.
vi. The external carotid nerve forms a
plexus around the external carotid
artery and accompanies its branches.
b. The middle cervical ganglion is the smallest
of the three ganglia of sympathetic trunk.
The ganglion lies in relation to inferior
thyroid artery at level of sixth cervical
vertebra.
Branches
i. The grey rami communicans are
given to join the ventral rami of fifth
and sixth cervical nerves.
ii. The cardiac branch joins the deep
cardiac plexus.
iii. The thyroid branches supply the
blood vessels of thyroid and parathyroid glands.
451
iv. The ansa subclavia forms a loop that

curves around the subclavian artery
and joins the inferior cervical
ganglion.
c. The inferior cervical ganglion lies between
the transverse process of seventh cervical
vertebra and neck of first rib.
It is sometimes fused with the first
thoracic ganglion to form the cervicothoracic ganglion (Stellate ganglion).
Branches
i. The grey rami communicans are
given to the ventral rami of seventh
and eighth cervical nerves.
ii. The cardiac branch joins the deep
cardiac plexus.
iii. The vertebral branch forms a plexus
around vertebral artery.
iv. The subclavian branch accompanies
the subclavian artery and its branches
as subclavian plexus.
Applied Anatomy
Injury to the cervical sympathetic chain
causes Horners syndrome consisting
of:
Constriction of pupil (meiosis)
Slight drooping of upper eyelid
(ptosis)
Enophthalmos
Absence of sweating on same half of
head and neck (anhidrosis).
CHAPTER
41
The Viscera of the

Head and Neck1
THE RESPIRATORY SYSTEM
The parts of the respiratory system in the head and

neck are:
The nasal cavity
The larynx
The cervical part of trachea
The nasal cavity is the first part of the respiratory

tract. The nasal cavity is divided into two
halvesthe right and the leftby a median
nasal septum.
Each half of the nasal cavity opens on the
face through the external nare or nostril, a
piriform aperture 1.52.0 cm long and 0.5
1.0 cm wide.
It opens posteriorly in anterior wall of
nasopharynx by posterior nasal aperture
(choana) an oval opening about 2.5 cm long
and 1.25 cm wide.
Each half of nasal cavity hasa roof, a
floor, a lateral wall and a medial wall.
Fig. 41.1: Coronal section through nasal cavities
The roof is very narrow and has three parts:

(Fig. 41.1)
The anterior (fronto-nasal part) is sloping
forwards.
The middle (ethmoidal part) is horizontal and
formed by cribriform plate of ethmoid. It is
only few millimeters wide.
The posterior (sphenoidal part) slopes
backwards.
The floor is concave transversely and is almost
horizontal.
It is formed by superior surface of palatal
process of maxilla and horizontal plate of
palatine bone.
The medial wall is formed by nasal septum. It
is formed:
Antero-superiorly by the septal cartilage.
Postero-superiorly by the perpendicular plate
of ethmoid.
Postero-inferiorly by the vomer bone.
The nasal septum is usually deviated towards
one side, so that the two nasal chambers
are not equal in size.
The nasal septum is covered by a thick layer
of muco-periosteum (muco-perichondrium)
containing a plexus of minute veins and
many mucous glands.
The lateral wall has the following parts: (Fig.
41.2)
a. The vestibule of the nose lies just above
external nase, is lined by skin and has thick,
curved, sensitive hairs called vibrissae.
b. The atrium of the middle meatus lies above
the vestibule. It shows in upper part an
tahir99 - UnitedVRG
The Viscera of the Head and Neck1
453
Fig. 41.2: The lateral wall of the nasal cavity
ill-defined swelling agger nasi representing

a rudimentary concha.
c. The region of conchae and meatuses is the
larger posterior part of nasal chamber.
There are three nasal conchaesuperior,
middle and inferior. These are curved
bony plates lined by muco-periosteum.
The three conchae separate the lateral
wall into four meatuses.
i. The spheno-ethmoidal recess is a
narrow space above superior concha.
ii. The superior meatus lies between the
superior and middle concha.
iii. The middle meatus is the largest and
lies between middle and inferior
concha.
There is a round swelling bulla
ethmoidalis limited below by
curved gutter hiatus semilunaris
in the upper part of the meatus.
iv. The inferior meatus lies between the
inferior concha and the floor of the
nasal chamber.
The lateral wall of nose is also lined by mucoperiosteum containing a plexus of minute veins
and many mucous glands. The inhaled air

circulates through the meatuses. It is warmed,
moistened and purified (of dust particles) in the
nasal cavity.
The muco-periosteum is also continuous with
the lining of the paranasal air sinuses that open
in the lateral wall of nasal chamber.
The Openings in the Lateral Wall

The paranasal sinuses and the naso-lacrimal duct
open in the lateral wall of the nasal chamber. These
openings are:
a. Opening of sphenoidal air sinus is in the
spheno-ethmoidal recess.
b. Opening of posterior ethmoidal air sinuses
is located in the superior meatus.
c. Opening of middle ethmoidal air sinuses is
located above the bulla ethmoidalis.
d. Opening of fronto nasal duct from the frontal
air sinus is present in anterior part of hiatus
semilunaris.
f. Opening of maxillary air sinus is located in
the lower part of hiatus semilunaris.
g. Opening of nasolacrimal duct is located in
anterior part of inferior meatus of nose.
454
The Blood Supply of the Nasal Cavity

The arteries: There is a rich anastomosis between
the branches of internal carotid and external carotid
arteries in the walls of nasal cavity.
i. The ethmoidal arteriesanterior and posterior
from the ophthalmic branch of internal carotid
artery supply the anterior and superior parts.
ii. The spheno-palatine artery, a branch of
maxillary artery supplies the posterior part.
iii. The greater palatine artery also a branch of
maxillary artery supplies anterior and inferior
parts.
iv. The superior labial branch of facial artery
supplies the lower part of septal cartilage and
lateral wall.
The veins: The veins form a rich submucus venous
plexus in the mucoperiosteum. The venous plexus
drains mainly in the pterygoid venous plexus.
The vasodilation of the venous plexus due to
infection or allergy causes blockage of the nasal
chamber.
The Nerve Supply of the Nasal Cavity
I. The nerves of special sense of smell, the olfactory
nerves, about twenty in number begin from the
special receptor cells in the nasal mucosa and pass
through the cribriform plate to end in the olfactory
bulb.
The olfactory nerves mainly supply the upper
part of the nasal cavity.
II. The nerves of general sensation
For the anterior part of nasal cavity the nerves
are branches from the ophthalmic division of
trigeminal nerve. These nerves are:
The anterior ethmoidal nerve.
The posterior ethmoidal nerve.
For the posterior part of nasal cavity the nerves
are the branches of maxillary division of
trigeminal nerve. These are:
The naso-palatine nerve that runs along the
nasal septum and enters the hard palate
through incisive canal to supply it.
The posterior superior nasal branches

medial and lateral supplythe nasal septum
and the lateral wall.
The anterior superior alveolar nerve
supplies a small area around anterior part of
the inferior concha.
PARANASAL AIR SINUSES
The paranasal air sinuses are air-filled spaces

in the cranial bones around the nasal cavities.
They open in the lateral wall of nasal cavity
and their lining epithelium is continuous with
the mucoperiosteum of nasal cavity.
They are rudimentary at birth and gradually
increase in size with age. They are smaller in
females.
The air sinuses make the cranial bones
pneumatic and lighter. They also help in the
resonance of voice (The male voice is deeper
due to same reason).
The different paranasal sinuses are
Frontal air sinuses - paired
Sphenoidal air sinuses - paired
Maxillary air sinuses - paired
Ethmoidal air sinuses - anterior, middle, and
posterior groups.
Frontal air sinusesare located in anterior part of

frontal bone just above the root of nose.
They are asymmetrical in size and separated by
a bony septum. They are about 2-3 cm in height
and width.
They are smaller in females. They open by a
funnel shaped - infundibulum - in middle meatus
of nasal cavity.
Sphenoidal air sinuses are inequal pair of air sinuses
separated by a deviated septum.
They lie within body of sphenoid and may
extend into base of greater wings and pterygoid
processes.
The sphenoidal sinus is related anteriorly to nasal
cavity, inferiorly to pharying and posteriorly to
posterior cranial fossa, basilar artery and pons.
tahir99 - UnitedVRG
Above the sphenoidal sinus lies the hypophysis

cerebri and cavernous sinuses on either side.
Each sinus opens by a small round opening in
spheno-ethmoidal recess above superior concha
in lateral wall of nasal cavity.
Maxillary air sinuses [Antrum of Highmore] are
the largest paranasal sinuses.
Each maxillary sinus occupies whole of body
of maxilla and has shape of an irregular three
sided pyramid.
Its apex extends into zygomatic process of
maxilla and the base is formed by lateral wall of
nasal cavity. The three sides are formed by
anterior, orbital and infra-temporal surfaces of
maxilla.
The lowest part of sinus is opposite the second
premolar and first molar tooth and is
approximately 1 cm below the level of floor of
nasal cavity.
The infra-orbital groove and canal lie in the
roof of sinus. The alveolar nerves and vessels
lie along its surfaces.
The sinus opens in middle meatus of nasal cavity
by a large openingmaxillary hiatus.
Ethmoidal air sinusesare then walled cavities or
cells that occupy whole of ethmoidal labyrinths on
either side.
They are about 10-16 in number and are
arranged in three groupsanterior, middle, and
posterior.
The anterior and middle groups open by
common openings in middle meatus and posterior group opens in the superior meatus of nasal
cavity.
The middle ethmoidal sinuses bulge in the
middle meatus forming a round smelling bulla
ethmoidalis.
Applied Anatomy
The sinusitis or the infection of paranasal sinuses

are the complication of infection of nasal
cavities, as the muco-periosteum is common
for both.
455
The opening of maxillary air sinus is situated at

a higher level so the infected mucus collects in
the sinus. Sometimes a surgical procedure
Antral puncture is done to exacuate the infected
material from the sinus.
THE LARYNX
The larynx is the upper modified end of trachea
for the production of voice.
The larynx also acts as a compound sphincter
of the respiratory passage.
The Skeletal Framework
(Figs 41.3 and 41.4)
The skeleton of the larynx is formed by a rigid
framework of bones, cartilages, membranes and
ligaments.
I. The bones and the cartilages are:
a. The hyoid bone in uppermost part of neck,
gives attachment to the membranes and
extrinsic muscles of larynx. (Described in
Chapter 35).
b. The cartilages of the larynx are three large
unpaired cartilagesepiglottis, thyroid, and
cricoid and three small paired cartilages
arytenoid, corniculate, and cuneiform.
The epiglottis is a leaf-like elastic fibrocartilage.
It is attached to hyoid bone by hyoepiglottic ligament and angle of
thyroid cartilage by thyro-epiglottic
ligament.
The superior surface is connected
to the dorsum of tongue by one
median and two lateral glossoepiglottic folds.
The inferior surface faces the upper
part of the cavity of larynx.
The thyroid cartilage consists of two
laminae fused in median plane to form
an angle of nearly 90 in males (120 in
females).
456
Fig. 41.4: The skeletal framework of the larynx

posterior aspect
Fig. 41.3: The skeletal framework of the

larynxanterior aspect
The lateral surface of thyroid lamina

has an oblique line, a raised ridge for
attachment of muscles.
The posterior border of thyroid
lamina is thick and ends above in
superior cornu and below in inferior
cornu.
The cricoid cartilage is shaped like a
signet ring with narrow arch anteriorly
and broad lamina posteriorly.
The inferior horn of thyroid cartilage
makes a plane type of synovial joint
with the arch of cricoid cartilage.
The arytenoid cartilages are small,
triangular pieces with three angles and
three surfaces:
It has an apex, a thick muscular
process and a vocal process.
The surfaces arethe medial,
antero-lateral and posterior.
The base of arytenoid forms a plane
type of synovial joint with superior
border of lamina of cricoid cartilage.
The corniculate and cuneiform cartilages
are small cartilaginous nodules, attached
to the apex of arytenoid cartilage.
c. The membranes and ligaments

Thyrohyoid membrane extends between
the superior border of thyroid cartilage
and inferior surface of greater cornu and
body of hyoid bone.
The membrane is thick anteriorly and
on two sides to form the median and
two lateral thyrohyoid ligaments.
The hyo-epiglottic and thyro-epiglottic
ligaments connect the epiglottis to
body of hyoid and angle of thyroid
cartilage.
The median cricothyroid ligament
connects the inferior border of thyroid
cartilage to arch of cricoid cartilage.
The fibro-elastic membrane lines the
walls of the larynx. It consists of two
parts:
Above vocal folds it is known as
quadrangular membrane and
extends between arytenoid cartilage
and the epiglottis.
Below vocal folds it is known as
cricovocal membrane and extends
from upper border of cricoid cartilage to the vocal folds.
tahir99 - UnitedVRG
457
Figs 41.5A to C: The intrinsic muscles of the larynx
The Muscles of the Larynx

The muscles of the larynx are divided in two groups:
a. The extrinsic muscles connect the cartilages of
larynx with neighboring bones and lie outside
laryngeal wall.
These are infra-hyoid muscles.
b. The intrinsic muscles form a part of laryngeal
wall (Table 41.1 and Fig. 41.5).
These are further divided into:
i. The cricothyroid, the only intrinsic muscle
that lies outside laryngeal wall, in the median
region of the neck.
ii. The rest of the intrinsic muscles lie inside
the laryngeal wall.
These muscles help in the movements
of vocal cords, and make the inlet
narrow or wide.
Inferiorly by interarytenoid fold

On two sides aryepiglottic folds
Corniculate and cuneiform tubercles
The cavity of the larynx is divided into three
parts: (Fig. 41.7)
a. The upper part above the vestibular fold, is
known as vestibule of larynx.
b. The middle part is a small recess between
the vestibular and vocal folds.
The Cavity of the Larynx

The laryngeal inlet is an oblong aperture in
the anterior wall of laryngeal part of pharynx (Fig.
41.6).
It is bounded:
Superiorly by epiglottis
Fig. 41.6: The inlet of the larynx
458
It is called the sinus of the larynx. A pouch of

mucous membrane, the saccule of larynx,
extends upwards in persons who have profession of air blowing.
c. The lower part of the cavity of larynx extends
from the vocal folds to the lower border of cricoid
cartilage.
This part is continuous below with trachea.
The Vocal Folds
Fig. 41.7: The cavity of the larynxcoronal section
The vocal folds are a pair of prominent folds in the

lateral wall of larynx, between the middle and lower
subdivisions of the cavity of larynx.
Table 41.1: The intrinsic muscles of the larynx

S. Name
No.
Origin
Muscle belly
Insertion
1.
Arch of cricoid
cartilage
Small triangular
muscle belly
Lower border and External laryngeal 1. Tensor of vocal

inferior cornu of
nerve
cord
thyroid cartilage
Cricothyroid
Nerve supply
Main actions
The rest of the intrinsic muscles

2. Posterior crico Posterior surface
arytenoid
lamina of cricoid
cartilage
Recurrent laryngeal nerve
1. Only abductor of
vocal cords
3.
Oblique
arytenoid
Same
1. Adductor of
vocal cords
4.
Transverse
arytenoid
Recurrent laryngeal nerve
1. Adductor of
vocal cord
5.
Aryepiglotticus
Same
1. Narrows the inlet

of larynx
6.
Lateral cricoarytenoid
Same
1. Adductor of the
vocal cord
7.
Thyroarytenoid
Same
1. Relaxes the vocal

cords
8.
9.
Vocalis
Thyroepigloticus
Same
1. Widens the inlet

of larynx
Flat muscle belly Posterior surface

Fibers converge muscular process
above for
arytenoid cartilage
insertion
Apex of
Two muscle slips Muscular process
arytenoid
cross each other of opposite arylike X
tenoid
Posterior surface Muscle fibers
Posterior surface
of one arytenoid
pass transversely of opposite ary Muscle belly
tenoid
lies in median
plane
Apex of ary Muscle belly
Side of epiglottis
tenoid cartilage
slender
Appears as
continuation of
oblique arytenoid
Superior surface Muscle fibers con- Anterior surface
of arch of cricoid verge towards
muscular process
cartilage
insertion
of arytenoid
cartilage
Inner surface
Muscle belly fills
Antero lateral
thyroid cartilage
the space deep to surface of arynear angle
thyroid cartilage
tenoid cartilage
Is the part of thyro-arytenoid that lies within vocal folds.
Inner surface
Muscle belly
Epiglotticus
of thyroid cartislender
lage near its
angle
tahir99 - UnitedVRG
Structure
i. The vocal folds are lined by stratified
squamous epithelium.
ii. They have no submucus coat so there can
be no edema or collection of fluid in vocal
folds.
iii. They have inside
The vocal ligament upper thick edge
of crico-vocal membrane.
The vocalis muscle part of thyroarytenoid.
There are no mucous glands in the vocal folds
also.
Rima glottidis (glottis) is the gap between two
vocal folds. It is the narrowest part of the
respiratory passage.
The vocal folds (true vocal cords) are subject
to different movements during respiration (quiet
and deep) and phonation.
The movements of the vocal folds are possible
due to movements of arytenoid cartilage.
These movements are adduction, abduction,
tension and relaxation.
The Blood Supply of the Larynx

The Arteries
There are two paired arteries supplying larynx.
i. The superior laryngeal artery is a branch of
superior thyroid artery. It enters larynx by
piercing thyrohyoid membrane.
ii. The inferior laryngeal artery is a branch of
inferior thyroid artery. It enters larynx at the
lower border of inferior constrictor muscle
of pharynx.
The Veins
The Veins accompany the arteries and end in
superior thyroid and inferior thyroid veins.
The Nerve Supply of the Larynx
The sensory nerves of the larynx are:
Above vocal cordsthe internal laryngeal nerve.
459
Below vocal cordsthe recurrent laryngeal

nerve.
The motor nerves of the larynx are:

The external laryngeal nerve supplies cricothyroid muscle.
The recurrent laryngeal nerve supplies the rest
of the intrinsic muscles.
Applied Anatomy
i. The two motor nerves are liable to be injured
during thyroidectomy operations (Described
in Chapter 40).
ii. The cancer of the larynx begins from the
stratified squamous epithelium of the vocal
folds.
THE CERVICAL PART OF TRACHEA
The trachea (windpipe) begins at the lower end of
cricoid cartilage (vertebral level sixth cervical
vertebra).
Position the trachea lies in median plane in the
lower part of the front of neck.
Relations
Anterior
Superficial and deep cervical fascia.
Jugular venous arch and anterior
thyroid veins.
Isthmus of thyroid gland (second to
fourth tracheal rings).
Inferior thyroid veins.
Overlapped by sternohyoid and
sternothyroid muscles.
Posterior esophagus separating it from
the bodies of sixth and seventh cervical
vertebrae.
Recurrent laryngeal nerve lies in
tracheo esophageal groove.
Lateral thyroid lobes
The trachea is kept patent by the semicircular,
cartilaginous tracheal rings.
CHAPTER
42
The Viscera of the

Head and Neck2
THE DIGESTIVE SYSTEM
THE PALATE
The parts of the digestive system, that lie in head

and neck are:
The mouth cavity (oral cavity)
The palate hard and soft
The tongue
The salivary glandsparotid, submandibular
and sublingual
The pharynxpalatine tonsil
The cervical part of esophagus
The palate forms a partition between the mouth

cavity and the nasal cavity.
Thr palate is made up of two partshard palate
and the soft palate.
The hard palate (bony palate) forms the anterior
and larger part of the palate. It is formed by:
a. The palatal processes of the two maxillae.
b. The horizontal plates of the two palatine
bones.
The soft palate forms a fold of mucous membrane, that is attached to the posterior border
of hard palate, a conical projectionuvula
hangs downwards from its middle.
The superior surface of the soft palate, forms a
sloping floor of the nasopharynx and is lined
by columnar epithelium.
The inferior surface forms the roof of the
oropharynx and is lined by stratified squamous
(non-keratinised) epithelium.
The main structure in the soft palate is palatine
aponeurosis that is expanded tendon of tensor
veli palatini muscle.
The muscle of the soft palate (Table 42.1)
THE MOUTH CAVITY

The mouth cavity is the first subdivision of the
digestive tract.
The mouth cavity extends from the oral fissure
to the oro-pharyngeal isthmus.
Boundaries
Superiorly the hard palate forms a vaulted
roof.
Inferiorly the oral diaphragm formed by
the two mylohyoid muscles, forms the
floor.
The tongue lies in the floor of the
mouth cavity supported by the oral
diaphragm.
Laterally the fleshy walls are formed by the
inner surface of the cheeks.
Parts: The mouth cavity is divided into two
parts.
i. The mouth cavity proper.
ii. The vestibule of mouth is the outer part of
the mouth cavity between gums and teeth
inside and the cheeks outside.
The Blood Supply of the Palate

The Arteries
i. The greater palatine artery a branch of
maxillary artery enters through a bony canal
from the pterygo-palatine fossa, and supplies
hard and soft palate both.
ii. The ascending palatine artery a branch of
facial artery supplies soft palate.
tahir99 - UnitedVRG
461
Table 42.1: The muscles of the soft palate

S. Name
No.
Origin
1. Tensor veli
palatini
(Tensor
palati)
Scaphoid fossa of
pterygoid process
Lateral surface
cartilage of auditory tube
Spine of sphenoid
2. Levator veli
Rough area on
palatini
inferior surface
(Levator
of petrous tempalati)
poral
3. Palatoglossus Inferior surface
of palatine aponeurosis
4. Palato Posterior fascipharyngeus

culus
(two bundles) Superior aspect
of palatine aponeurosis
Anterior fasciculus-palatine
aponeurosis and
posterior border
of hard palate
5. Musculus
Posterior nasal
uvulae
spine of palatine
bone
Muscle belly
Insertion
Nerve supply
Thin and triangular

muscle belly
Fibers converge
to form a tendon
that hooks around
pterygoid hamulus
Cylindrical muscle
belly
Palatine aponeurosis
Mandibular nerve
I. Tenses soft palate

by tightening
palatine aponeurosis
II. Helps to open the
auditory tube
Superior surface Cranial part of
I. Elevates the soft
of palatine
accessory via the
palate
aponeurosis
pharyngeal
branch of vagus
Small narrow
Side of tongue
Same
I. Elevates the root
fasciculus
of tongue
Lies inside
II. Closes the oropalato-glossal
pharyngeal isthfold
mus
The fasciculus
I. Posterior fasci- Cranial accessory I. Pulls the pharynx
descend in palato- culi joins the fellow via the pharyngeal
upwards and forpharyngeal arch
in median plane
branch of vagus
wards during
swallowing
Two fasciculis
Posterior border
are separated by of thyroid
levator veli palatini cartilage
Two fasciculi lie

Muscus
inside the split
membrane
palatine aponeuro- of uvula
sis
iii. The tonsillar branch of facial artery also

supplies the soft palate.
iv. The dorsal linguae branches of lingual artery
also supply the soft palate.
The Veins
The veins of the palate drain mainly in the pterygoid
venous plexus and the tonsillar veins.
The Nerve Supply of the Soft Palate
The sensory nerves of the palate are:

i. The greater palatine nerve.
ii. The terminal part of supply hard palate
nasopalatine nerves
Main actions
Same
I. Helps to elevate
and retract the
uvula
iii. The lesser palatine nerves supply soft palate.

These nerves carry sensory fibers of maxillary nerve, that pass via the pterygo-palatine
ganglion.
iv. The glossopharyngeal nerve also supplies
soft palate.
The motor nerves are:
i. The mandibular nerve via nerve to medial
pterygoid and otic ganglion supplies the
tensor veli palatini muscle.
ii. The cranial part of accessory via the pharyngeal branch of vagus supplies the rest of
the muscles of soft palate.
462
THE TEETH
The teeth form a part of masticatory apparatus and
are fixed to the two jaws.
In humans, the teeth are diphyodont i.e. they
are replaced only once.
In non-mammalian vertebrates, the teeth are
polyphyodont i.e. they are replaced a number
of times throughout life.
i. In humans the first set of teeth (dentition)
are called Milk or Deciduous teeth. These
are 20 in number. In each half of jaw there
are two incisors, one canine and two molars.
2 i 1c 2 m
ii. The second set of teeth (dentition) in humans
are called Permanent teeth. These are 32 in
number. In each half of jaw there are two
incisors, one canine two premolars and three
molars.
2i 1c 2 pm 3 m
Structure of A Tooth
Each tooth has three parts
i. A crown that projects above the gum.
ii. A root that is embedded in the jaw beneath
the gum.
iii. A neck - between the crown and root that is
surrounded by gum.
The structure of tooth is composed of the
following
The dentinethat forms the main part surrounding the pulp.
The enamelthat cover the projecting part of
dentine of crown.
The pulp cavity in center.
The cementumsurrounding the embedded
part.
The peridontal membrane.
The dentine is a made up of calcified material
containing spiral tubules radiating from pulp cavity
each tubule is occupied by protoplasmic process
of one odontoplast.
The dentine is made up of organic matter and

calcium in same proportion as a bone.
The enamel is the hardest substance in body. It is
made up of crystalline prisms lying at right angles
to the surface of tooth.
The pulp cavity consists of loose fibrous tissue
containing blood vessels, nerves and lymphatics,
all of which enter through apical foramen.
The pulp cavity is covered by a layer of tall
columnar cellsodontoblasts, that are capable of
replacing dentine any time in life.
The Cementumresembles bone in structure but
it has no blood supply or nerve supply.
The cementum covers the embedded part of
dentine and over the neck it may also overlap the
enamel. Rarely it may stop short of enamel (10%)
and leave the denture at the neck of tooth covered
only by gum.
The peridontal membrane holds the root of tooth
in its socket. The membrane acts as a periosteum
to both cementum as well as the bony socket.
Shape and Functions of Teeth
The shape of tooth is adapted to its functions
The incisor teeth are cutting teeth. These are
used for biting or cutting soft food.
The canine teeth are tearing teeth. These are
better developed in carnivores.
The premolars and molars are grinding teeth.
These are used for mastication or chewing of
food.
The incisors, canine and premolars have a single
root with exception of 1st upper premolar which
has a bifid root.
The upper molars have three roots while the
lower molars have two roots.
Eruption of Teeth
i. The deciduous or milk teeth begin to erupt at
about 6th month and all have erupted by end
of 2nd year. The teeth of lower jaw erupt
slightly earlier than those of upper jaw.
tahir99 - UnitedVRG

The sequence of cruption is
Lower central incisor 6th month
Upper central incisor 7th month
Lateral incisors 8th-9th month
First molar 1st year
Canines 18 months
Second molar 2nd year

ii. The permanent teeth crupt in the following
sequence.
First molar - 2nd year
Medial incisors - 7th year
Lateral incisors - 8th year
First premolar - 10th year
Canines - 11th year
Second molar - 12th year
Third molar - 18-24th year (wisdom
tooth)
The pulp and peridontal membrane have same nerve

supply different from overlying gum.
The upper jaw teeth are supplied by posterior
superior dental, middle superior dental and
anterior superior dental nerves call carrying
sensory fibers of maxillary nerve.
The lower jaw teeth are supplied by inferior

alveolar nerve, a branch of mandibular
nerve.
THE TONGUE
The tongue is a mobile muscular organ, in the floor
of the mouth cavity, that is concerned with.
Mastication of food
Deglutition of food
Speech
Taste
The tongue is divided into two parts by an
inverted V-shaped sulcusthe sulcus terminalis
(Fig. 42.1).
i. Anterior two-thirdthe oral part.
ii. Posterior one thirdthe pharyngeal part.
Nerve Supply of Teeth
463
The two parts of the tongue have different

functions and development.
At the apex of V-shaped sulcus is foramen
caecum, that marks the beginning of median
thyroid diverticulum.
a. The oral part has a dorsal surface and a less

extensive ventral surface.
Fig. 42.1: The dorsum of tongue
464
The dorsal surface of tongue is divided into

two halves by a median sulcus.
There are three types of lingual papillae on
the dorsum of tongue, formed by the stratified
squamous epithelium with a central core of
lamina propria (Fig. 42.2).
a. The circumvallate papillae form a single
row of large 8-10 papillae just in front of
sulcus terminalis. These papillae are depressed from the surface and surrounded by a
vallium (wall). They bear taste buds.
b. The fungiform papillae are club shaped.
These are scaltered on the dorsum. They
also bear the taste buds.
c. The filiform papillae are numerous on the
dorsum of tongue. These are conical projections of epithelium, to make the surface
rough. They do not bear the taste buds.
d. Small transverse folds at lateral surface of
tongue from the foliate papillae. These are
rudimentary in human tongue.
The ventral surface of the oral part of tongue
has the following features.
In midline, there is frenulum linguaea fold
of mucous membrane.
Two fimbriated folds of mucus membrane
lie on the two sides.
Between the frenulum and fimbriated fold,
the profunda vein is visible through the
mucous membrane.
On the floor of the mouth cavity below
tongue, are placed the sublingual folds,
formed by the sublingual salivary glands.
At the medial ends of these folds, there are

openings of submandibular salivary ducts.
b. The pharyngeal part (posterior part) of
tongue is also lined by stratified squamous epithelium.
The surface of this part of tongue is irregular
due to low elevations caused by large number
of lymphoid follicles.
This part is also known as lingual tonsil.
There are taste buds in this part scattered in the
epithelium.
The root of the tongue occupies most of the
ventral surface of tongue and connects the
tongue to the mandible and hyoid bone.
The Muscles of Tongue
The muscles of tongue are striated and voluntary.
The muscles are divided into (Table 42.2):
An extrinsic group consisting of muscles, that
connect the tongue to neighboring structures
and help in movements of tongue. (Fig. 42.3)
An intrinsic group consisting of muscles, that
form the bulk of tongue and help to change the
shape of tongue.
The muscles of tongue are supplied by the
hypoglossal nerve (twelfth cranial nerve) except
palatoglossus supplied by cranial accessory nerve
through pharyngeal branch of vagus (Fig. 42.4).
The Blood Vessels of the Tongue
The Arteries
The paired lingual arteries provide the main arterial
supply to the tongue.
Fig. 42.2: The lingual papillae
tahir99 - UnitedVRG
465
Table 42.2: The muscles of the tongue

S. Name
No.
Origin
Muscle belly
Insertion
Main actions
Flat and quadrangular

Fibers ascend up
vertically
Slender muscle belly
Descends forwards
and medially
Fan shaped muscle
belly Fibers ascend
upwards deep to
hyoglossus
Lateral border of
tongue
I. Depreses the side

of tongue
Lateral border of
tongue lateral to
hyoglossus
Inferior (ventral)
surface of tongue
Lower fibers superior surface body
of hyoid
I. Draws the tongue

upwards and
backwards
I. Makes the dorsum hollow
II. Helps to protrude
the tongue
I. Turns the tip upwards

II. Makes tongue
shorter and wider
I. Turns the tip
downwards
II. Makes tongue
shorter and wider
A. The Extrinsic Muscles

I.
Hyoglossus
II.
Styloglossus
III.
Genioglossus
IV.
Palatoglossus
Superior surface of
greater cornu of
hyoid bone
Antero lateral surface
near tip of styloid
process
Upper mental tubercle
of mandible
[Described along with muscles of soft palate]
B. The Intrinsic Muscles

1.
Superior
longitudinal
Submucous tissue
near epiglottis
Muscle belly forms a

bundle just deep to
the dorsal epithelium
Mucous membrane
near dorsum of tip of
tongue
2.
Inferior
longitudinal
Submucous tissue
near root of tongue
Mucous membrane
on ventral surface
near tip of tongue
3.
Transversal
linguae
Fibrous median septum of tongue
Muscle belly forms a

fasciculus that turns
forwards between
Hyoglossus and
genioglossus
Muscle fibers cross
transversely
4.
Vertical
linguae
Dorsum of tongue
Muscle fibers descends vertically
Ventral surface
of tongue
Fig. 42.3: The extrinsic muscles of tonguelateral view
Lateral border of
tongue
I. Makes the tongue

longer and
narrower
II. Makes the tongue
wider
The lingual artery arises from the external carotid

artery above the greater cornu of hyoid bone
(sometimes it may arise from a common
(linguo-facial) trunk in the carotid triangle.
Course and relationsthe lingual artery courses
forwards, medially and tortuously to allow for
the movements of tongue.
It forms a loop crossed by the hypoglossal
nerve above the greater cornu of hyoid bone
in carotid triangle.
The artery enters the submandibular region
by passing deep to hyoglossus above hyoid
bone.
466
Fig. 42.4: Coronal section through tongue showing the intrinsic muscles
The artery courses forwards and then

ascends vertically along anterior border of
hyoglossus, deep to the sublingual gland.
The lingual artery continues as profunda
artery on the ventral surface of tongue up
to its tip.
Branches
i. The suprahyoid branch runs above the
greater cornu of hyoid bone, superficial to
hyoglossus.
ii. The dorsal linguae branches (2-3) ascend
deep to hyoglossus. They supply posterior
part of tongue, tonsil, pharynx and soft
palate.
iii. The sublingual branch supplies the sublingual salivary gland.
iv. The profunda artery is the continuation of
lingual artery. It supplies deeper structures
of the anterior part of tongue.
The Veins
There are two venae comitantes accompanying

the lingual artery deep to hyoglossus.
The hypoglossal nerve is accompanied by a vena
comitans formed by the profunda vein joining
the sublingual vein.
At the posterior border of hyoglossus these

veins join to form one (or two) lingual veins,
that end in the internal jugular vein.
The Lymphatic Drainage of the Tongue

The lymphatics draining the tongue are important
for the spread of cancer of tongue.
There are two lymph plexuses in the substance
of tongue.
i. The subepithelial plexus lies deep to the
dorsal epithelium.
ii. The intra-muscular plexus lies among the
muscles of the tongue.
The lymphatics from anterior two third of
tongue (except the vallate papillae) are divided
into two sets:
a. The marginal lymphatics draining lymph
from the peripheral parts of tongue.
The lymphatics from the tip end in
submental lymph nodes.
The lymphatics from the rest of anterior
part end in submandibular, jugulodigastric and jugulo-omohyoid lymph
nodes of same side.
b. The central lymphatics drain lymph from
the central part of lymph plexuses.
tahir99 - UnitedVRG
They course medially and pierce the

fibrous median septum of tongue.
They end in submandibular, jugulodigastric and jugulo-omohyoid group of
the opposite side.
The lymphatics from the posterior part of tongue
(including vallate papillae) end in jugulo-digastric
and jugulo-omohyoid group of both sides.
The Nerve Supply of the Tongue

I. The sensory nerve supply
a. The nerves of general sensation
For anterior two-third part lingual nerve
For posterior one-third part, glossopharyngeal nerve
For posterior most part, superior laryngeal
branch of vagus
b. The nerves of special sensation (Taste)
For anterior two third part-chorda tympani
(except vallate papillae)
For posterior third partglossopharyngeal
(including vallate papillae)
For posterior most part superior laryngeal
nerve.
II. The motor nerve supply: All muscles of
tongue, extrinsic and intrinsic, are supplied by
hypoglossal nerve, except palato-glossus supplied
by cranial accessory via pharyngeal branch of
vagus.
SUBMANDIBULAR REGION
The Salivary Glands
There are three paired salivary glands parotid,
submandibular and sublingual.
i. The parotid salivary gland [Described in
Chapter 38].
ii. The submandibular gland is the second largest
of the three salivary glands in human body.
Type: Mixed type of salivary gland with mostly
serous acini and some mucous acini.
Parts: The gland is divided by the posterior
border of mylohyoid into:
467
A large superficial part

A small deep part
a. The superficial (main) part lies in submandibular
fossa and digastric triangle in upper part of neck,
overlapping both bellies of digastric.
Sizeis like a walnut.
SurfacesThe main part has three surfaces
a lateral surface, an infero-lateral surface and a
medial surface.
The lateral surface is related to the submandibular fossa of mandible, mylohyoid
nerve and medial pterygoid muscle.
The infero lateral surface is superficial,
crossed by common facial vein, deep
cervical fascia, platysma and skin.
The medial surface is related to mylohyoid
both bellies and intermediate tendon of
digastric and hypoglossal nerve.
Capsules: The main part has two capsules.
i. A true capsule formed by the connective
tissue all around the tongue.
ii. A fascial capsule formed by deep cervical
fascia. It does not cover the lateral surface.
b. The deep part lies medial to mylohyoid, in
relation to upper part of hyoglossus (Fig. 42.5).
It is a small tongue-shaped part, connected with
the submandibular ganglion.
The sub-mandibular duct begins from here.
The Submandibular Salivary Duct
The submandibular salivary duct (Whartons)
begins from the deep part of the gland and passes
forwards and medially superficial to hyoglossus.
The duct is about 5.0 cm long.
It has a twisting relation with the lingual nerve.
It passes deep to sublingual salivary gland.
It opens in the floor of mouth at medial end of
sublingual fold.
The blood supply is by the glandular branches
of the facial artery.
The Nerve Supply
The sensory nerves are derived from the lingual
nerve.
468
Fig. 42.5: The structures deep to mylohyoid muscle

plexus around facial artery.
The parasympathetic (secretomotor) nerves are
carried by the chorda tympani and reach
submandibular ganglion via the lingual nerve. The
preganglionic fibers end in the ganglion and post
ganglionic branches reach the deep part of the
gland.
The Sublingual Salivary Gland
It is the smallest of the three paired salivary glands.
Type a mixed type of salivary gland with mostly
mucous acini and some serous acini as serous
demilunes.
Location: The sublingual gland occupies the
sublingual fossa of mandible above mylohyoid
muscle.
Size and shape is like that of a large almond.
Relations the gland lies lateral to the genioglossus
and rises above the muscle to raise a sublingual
fold in the floor of mouth.
The lingual nerve and submandibular salivary
duct pass deep to it.
Ducts there are about 15-20 small ducts that
open on summit of sublingual fold in the floor
of mouth.
The blood supply is from the sublingual branch
of lingual artery.
The nerve supply

The sensory nerves are derived from the lingual
nerve.
The sympathetic nerves come from the plexus
around the facial artery.
The parasympathetic (secretomotor) nerves are
derived from chorda tympani and reach submandibular ganglion via lingual nerve. The post ganglionic
fibers from the ganglion reach sublingual salivary
gland via lingual nerve.
THE LINGUAL NERVE
The lingual nerve is one of the two terminal
branches of posterior division of mandibular nerve.
Distribution
Lingual nerve supplies sensory fibers to
Anterior 2/3rd of tongue
Floor of mouth
Lingual nerve also carries fibers of chorda
tympani that supply
Secretomotor fibers to submandibular
and sublingual salivary glands
Taste fibers from anterior 2/3rd of
tongue (except vallate papillae)
Course and Relations
i. Lingual nerve arises in infratemporal fossa
between lateral pterygoid and medial
pterygoid muscles from mandibular nerve.
tahir99 - UnitedVRG
The nerve passes forwards and medially

and is joined by chorda tympani at an
acute angle.
The nerve as it runs forwards, passes
between ramus of mandible and medial
pterygoid.
Next it lies medial to last molar tooth
directly in a groove of mandible.
ii. The nerve enters submandibular region and
passes forwards superficial to hyoglossus
and deep to mylohyoid.
The lingual nerve winds around the
submandibular duct as it passes lateral
to genioglossus muscle.
Finally it breaks up into its terminal
branches to supply tongue.
Branches
Two communicating branches to the
submandibular ganglion.
One communicating branch to the hypoglossal nerve.
Terminal lingual branches.
Applied Anatomy
Faulty extraction of last molar tooth of lower

jaw may injure the lingual nerve as it lies, close
to the bone.
Effects of injury
i. Loss of general sensation from anterior
2/3rd of tongue and floor of mouth.
ii. Loss of taste sensation from anterior 2/3rd
tongue (except vallate papillae)
iii. Interuption of secretomotor nerve supply
of sub-mandibular and sublingual salivary
glands.
THE PHARYNX
The pharynx is a muscular chamber that acts as a
common passage for the respiratory and digestive
tracts.
Location: The pharynx lies behind the nasal
cavity, mouth cavity and the larynx.
469
Extent:
Superiorlyup to base of skull.
Inferiorlyit is continuous with esophagus at the lower border of cricoid
cartilage.
Anteriorlythe pharynx communicates
with two nasal cavities, mouth cavity and
the inlet of larynx.
Parts: The pharynx is divided into: (Fig. 42.6)
i. An upper part nasopharynx
ii. A middle part oropharynx
iii. A lower part laryngopharynx
1. The nasopharynx is a part of respiratory tract.

Boundaries
Superiorly the roof is formed by the
Basilar part of occipital
Body of sphenoid
The roof has naso-pharyngeal tonsil
a collection of lymphoid tissue.
This tonsil gets enlarged in infections
(specially in children. The condition is
called adenoids, a common cause of
mouth breathing by children.
Inferiorly the floor is formed by the superior
sloping surface of soft palate.
The lateral wall of the nasopharynx has the
following features.
a. Opening of the auditory tube is located
at the level of middle meatus.
b. Tubal elevation a round swelling above
the opening of auditory tube. It is caused
by bulging of cartilage of auditory tube.
c. A small tubal tonsil lies close to the tubal
elevation.
d. The salpingo-pharyngeal fold extends
from the tubal elevation along the lateral
wall. It carries a muscle of same name.
e. The pharyngeal recess is the narrow
space between the roof and the tubal
elevation.
2. The oropharynx lies behind the mouth cavity.
470
Fig. 42.6: Sagittal section through the pharynx
Boundaries
Superiorly Nasopharyngeal isthmus is
bounded by:
Lower border of soft palate.
A ridge on posterior wall of pharynxPassavants ridge, caused by the posterior part of palato-pharyngeus.
Anteriorly oropharyngeal isthmus is bounded by:
Dorsum of tongue
Two palatoglossal folds
Soft palate
Laterally is a triangular depressiontonsillar
fossabounded:
Anteriorly by palato-glossal fold
Posteriorly by palato-pharyngeal fold
Palatine tonsil lies in the tonsillar fossa
Inferiorlythe boundary is formed by upper
border of epiglottis.
3. The laryngo-pharynx or lower subdivision
of pharynx extends from cranial border of epiglottis
up to the lower border of cricoid cartilage (vertebral
levelsixth cervical vertebra).
Boundaries
Anteriorly
The dorsum of tongue
The inlet of larynx
Two piriform fossae on either side
Lateral wallshave the continuation of:
The palato-pharyngeal fold
The salpingo-pharyngeal fold
Posterior wallis featureless
Inferiorlythe laryngo-pharynx is continuous with the esophagus.
The Palatine Tonsil

The palatine tonsilis a mass of lymphoid tissue
in the lateral wall of oropharynx (Fig. 42.7).
Location: The tonsil occupies the triangular
tonsillar fossa between palato-glossal and palatopharyngeal arches.
Extent: The palatine tonsil extends from the
dorsum of tongue below up to soft palate above.
Surfaces: The tonsil has two surfacesmedial
and lateral.
tahir99 - UnitedVRG
Fig. 42.7: Coronal section through

pharynx to show palatine tonsil
a. The medial surface is free and projects into

the oropharynx. It presents 12-15 deep
tonsillar crypts.
The upper part of this surface shows a
deep intra-tonsillar cleft (wrongly called
supra-tonsillar fossa).
b. The lateral surface is covered by a fibrous
capsule.
It is related to paratonsillar vein and the
interior of pharyngeal wall (superior
constrictor muscle).
The tonsillar artery from the facial artery also
enters this surface.
The internal carotid artery lies 2.5 cm behind
and lateral to the tonsil.
SizeThe tonsil is variable in size as after
infection it undergoes hypertrophy.
In children up to puberty it is usually larger,
but in adult life remains small in size.
Waldeyers lymphatic ring is a circular collection
of lymphoid tissue at the beginning of pharynx.
The various lymphoid masses are:
SuperiorlyNasopharyngeal tonsil
Laterally
Tubal tonsils
Palatine tonsils
471
Inferiorly Lingual tonsil

The Waldeyers ring forms a protective annulus
at the beginning of pharynx.
The blood supply of palatine tonsil.
The arteries
The main artery is tonsillar branch of facial
artery.
The other arteries are:
The dorsal linguae branches of lingual
artery.
The ascending palatine branch of facial
artery.
The ascending pharyngeal branch of
The greater palatine branch of maxillary
artery.
The Veins: One or more veins from the lateral aspect
pierce superior constrictor and end in pharyngeal
venous plexus or common facial vein.
A large paratonsillar vein lies deep to the tonsil.
The sensory nerve supply of the tonsil is by:
The glossopharyngeal nerve.
The lesser palatine nerves from pterygo-palatine
ganglion carrying fibers of maxillary nerve.
The lymphatic drainageThe lymphatics of the
tonsil and in jugulo-digastric lymph node, situated
at the angle of mandible. It is also known as
tonsillar node.
Applied Anatomy
i. Tonsillitis is the inflammation of tonsil, leading
to its hypertrophy seen commonly in young
children. Tonsillectomy or removal of tonsil
is done in those cases where the infection
affects the growth and health of the child.
ii. The pain of tonsillitis may be referred to the
ear, as the tympanic branch of glossopharyngeal supplies sensory fibers to the middle ear.
The Pharyngeal Musculature
The wall of the pharynx has the following layers:
472
1. The buccopharyngeal fascia.

2. The constrictor musclessuperior, middle and
inferior.
The other pharyngeal musclesstylopharyngeus, palato-pharyngeus and salpingopharyngeus.
3. The pharyngo basilar fasciathick at the gaps
between constrictor muscles.
4. The submucous coat.
5. The mucous membrane.
The constrictor muscles of the pharynx (Table

42.3) are arranged like three vases put inside
the other, i.e. the upper border of inferior
constrictor overlaps middle constrictor muscle
and the upper border of middle constrictor
overlaps the superior constrictor muscle (Fig.
42.8).
There are also gaps between the constrictor
muscles in the pharyngeal wall through which
the vessels and nerves enter the pharyngeal wall.
The Gaps in the Pharyngeal Wall

I. The highest gap is between the base of skull
and upper border of superior constrictor muscle.
Two musclestensor veli palatini and levator
veli palatine fill up this gap.
II. The gap betwen superior and middle
constrictors.
The stylopharyngeus
enters through
muscle
this gap
The glosso pharyngeal nerve
III.The gap between middle and inferior
constrictor.
The internal laryngeal

enters through
nerve
this gap
The superior laryngeal artery
IV. The gap at the lower border of inferior

constrictor.
The inferior laryngeal
passes through
artery
this gap.
The recurrent laryngeal nerve
Fig. 42.8: The muscles of pharynx
tahir99 - UnitedVRG
473
Table 42.3: The constrictor muscles of the pharynx

S. Name
No.
1.
Inferior
constrictor
Origin
Side of cricoid
cartilage
Oblique line of
thyroid cartilage
2.
3.
4.
Middle
constrictor
Lower part stylohyoid ligament

Lesser cornu
hyoid bone
Whole length
upper border
greater cornu
of hyoid bone
Superior
Pterygoid
constrictor
hamulus
Pterygomandibular
ligament
Posterior end
of mylohyoid
line
Side of tongue
Stylo Medial side base
pharyngeus of styloid process
Muscle belly
Insertion
Nerve supply
Thick and triangular muscle

belly
Fibers ascend
upwards and
medially
Fan shaped
muscle belly
Fibrous median
raphe on back of
pharynx
Pharyngeal
I. Helps in passage
plexus of nerves of food
(cranial part of
accessory)
Recurrent
Laryngeal nerve
Same
Same
Thin and
quadrangular
muscle belly
Fibrous median
raphe
Some fibers
reach pharyngeal tubercle of
basi-occiput
Fibrous median
raphe
Long and
Posterior border
slender muscle of thyroid cartilage
belly
Passes between
middle and
superior constrictor muscles
Thin and long mus- Posterior border
cle belly lies in a
of thyroid cartifold
lage
5.
SalpingoTubal elevation
pharyngeus
6.
Palato[Described along with muscles of soft palate]

pharyngeus
The Blood Supply of the

Pharyngeal Wall
The arteries of the pharynx are:
The ascending pharyngeal artery from the
The ascending palatine and tonsillar branches
of facial artery.
The greater palatine, pharyngeal and artery of
the pterygoid canal from the maxillary artery.
The dorsal linguae branches of lingual artery.
Main actions
Same
Same
Glossopharyngeal nerve
I. Elevates the
pharynx during
swallowing and
speech
Pharyngeal
plexus of nerves
(cranial
accessory)
I. Elevates the
pharynx during
swallowing and
speech
The veins form a pharyngeal plexus of veins that

lies along the lateral wall.
The venous plexus communicates with
pterygoid venous plexus.
The pharyngeal veins drain into the internal
jugular vein.
The Nerve Supply of the Pharynx
The nerves of the pharynx form a pharyngeal
plexus.
474
The sensory nerves contributing to the plexus

are derived from the glossopharyngeal.
The pharyngeal branch of pterygopalatine
ganglion carrying fibers of maxillary nerve.
The motor nerves contributing to the pharyngeal
plexus are derived from the cranial part of
accessory nerve via the pharyngeal branch of
vagus.
The pharyngeal plexus is also joined by the
sympathetic fibers from the superior cervical
ganglion of the sympathetic trunk via the
laryngo-pharyngeal branch.
THE CERVICAL PART OF ESOPHAGUS
The esophagus (gullet) begins at the lower

border of cricoid cartilage (vertebral level
sixth cervical vertebra), as continuation of

pharynx.
The esophagus descends in front of seventh
cervical vertebra behind trachea.
The esophagus deviates slightly towards the left
side and passes through thoracic inlet to enter
the superior mediastinum of thorax.
The recurrent laryngeal nerve lies in tracheoesophageal groove. The thoracic duct lies along
its left border.
The blood supply of cervical part of esophagus is

derived from the inferior thyroid artery.
The nerve supply is from parasympathetic(vagus
nerves) and sympathetic (cervical part of sympathetic trunk).
tahir99 - UnitedVRG
The Head and Neck

Q.1. Select the one best response to each
question from the four suggested
answers:
1. Which layer of the scalp is known as the
dangerous layer of the scalp:
A. Dense connective tissue
B. Epicranial aponeurosis
C. Loose areolar tissue
D. Pericranium
2. The facial vein terminates usually in:
A. Pterygoid venous plexus
B. External jugular vein
C. Anterior jugular vein
D. Internal jugular vein
3. The parotid duct opens in the vestibule of
mouth opposite:
A. Second upper molar tooth
B. First upper molar tooth
C. Third upper molar tooth
D. Canine tooth
4. The muscle used for blowing out air from
the mouth is:
A. Zygomaticus major
B. Levator labii superioris
C. Risorius
D. Buccinator
5. The crista galli gives attachment to:
A. Falx cerebri
B. Falx cerebelli
C. Diaphragma sellae
D. Tentorium cerebelli
6. Which of the following nerves have motor
supply:
A. Lesser occipital B. Suboccipital
C. Greater occipital D. Third occipital
7. The maxillary nerve leaves the skull by:

A. Foramen ovale
B. Foramen spinosum
C. Foramen lacerum
D. Foramen rotundum
8. The air sinus that drains by gravity is:
A. Maxillary sinus
B. Frontal sinus
C. Ethmoidal sinuses
D. Sphenoidal sinus
9. The taste sensation is lost from posterior third
of tongue, which of the following cranial
nerves are involved:
A. Facial
B. Vagus
C. Glossopharyngeal nerve
D. Maxillary nerve
10. Which of the following muscles is partly
inserted on the articular disc of temporomandibular joint:
A. Lateral pterygoid
B. Medial pterygoid
C. Masseter
D. Temporalis
11. The skin of the tip of nose is innervated by:
A. Buccal nerve
B. Infraorbital nerve
C. External nasal nerve
D. Facial nerve
12. The superior laryngeal artery is a branch of:
A. Facial artery
B. Lingual artery
C. Superior thyroid artery
D. Vertebral artery
476
13. The hypoglossal nerve leaves the cranial

cavity through the following foramen:
A. Jugular foramen
B. Posterior condylar canal
C. Foramen ovale
D. Anterior condylar canal
14. The muscle of pharynx supplied by the glossopharyngeal nerve is:
A. Stylo-pharyngeus
B. Palato-pharyngeus
C. Salpingopharyngeus
D. Inferior constrictor
15. The anterior belly of digastric is supplied by:
A. Hypoglossal nerve
B. Mylohyoid nerve
C. Facial nerve
D. Ventral ramus of first cervical nerve
Q.2. Each question below contains four
suggested answers, of which one or more
is correct. Choose the answer.
16. In the posterior triangle of neck:
1. The spinal part of accessory nerve
crosses the lower part of the triangle.
2. The roots of brachial plexus emerge in
the triangle between scalenus anterior and
scalenus medius.
3. The inferior belly of omohyoid divides
the triangle intoan upper occipital and
a lower subclavian triangles.
4. The second part of subclavian artery
17. The thyroid gland
1. Is a highly vascular, important endocrine
gland.
2. Is developed from the mesoderm of first
branchial arch.
3. Is related to parathyroid glands on its

posterior aspect.
4. Does not move with deglutition.
18. The carotid body:
1. Is present at bifurcation of common
carotid artery.
2. Is a pressure receptor.
3. Is chemoreceptor.
4. Is sometimes absent.
19. The air sinus that drains in the superior meatus
of the nasal cavity.
1. Sphenoidal air sinus
2. Middle ethmoidal air sinus
3. Frontal air sinus
4. Posterior ethmoidal sinus
20. The palatine tonsil receives its sensory nerve
supply from:
1. Greater auricular nerve
2. Glossopharyngeal nerve
3. Mandibular nerve
4. Maxillary nerve
21. The abductor muscles of the vocal cords are:
1. Cricothyroid
2. Oblique arytenoid
3. Lateral crico-arytenoid
4. Posterior crico-arytenoid
22. Injury to the left facial nerve at the stylo
mastoid foramen leads to:
1. Hyperacusis of left ear
2. Loss of lacrimation in left eye
3. Loss of secretion of left parotid gland
4. Facial paralysis of left half of face
23. The chorda tympani contains the following
fibers:
1. Parasympathetic fibers for submandibular and sublingual salivary glands.
2. Sensory fibers from anterior two-third
of tongue.
3. Taste fibers from anterior two-third of
tongue.
4. Motor fibers for stylopharyngeus.
tahir99 - UnitedVRG
477

24. The cranial nerves that pass through the
cavernous venous sinus:
1. Oculomotor
2. Trochlear
3. Abducent
4. Ophthalmic division of trigeminal
25. The nasal septum is formed by:
1. The perpendicular plate of ethmoid
2. Septal cartilage
3. Vomer
4. Maxilla
Q.3. Match the structures on the left with their
26. Foramina of skull
1. Foramen ovale
2. Foramen spinosum
3. Posterior condylar canal
4. Foramen magnum
A. Vertebral artery
B. Emissary vein
spinosum
C. Middle meningeal
artery
D. Mandibular nerve
27. Nerve supply of muscles:

1. Sternomastoid
A. Mandibular
2. Orbicularis
B. External laryngeal
oculi
nerve
3. Lateral pterygoid C. Facial

4. Cricothyroid
D. Spinal accessory
28. Important features
1. Thyroid gland
2. Posterior third
tongue
3. Bulla ethmoidales
4. Tubal elevation
A. Lingual tonsil
B. Middle meatus
of nose
C. Isthmus
D. Naso pharynx
29. Branch of main arterial trunk

1. Thyro-cervical A. Arch of aorta
trunk
2. Lingual artery
B. Subclavian artery
3. Ophthalmic
C. External carotid
artery
4. Thyroidea ima
D. Internal carotid
30. Type of joint
1. Temporomandibular joint
2. Symphysis menti
3. Median at lantooccipital joint
4. Intervertebral
disc
A. Synostosis
B. Pivot joint
C. Condyloid joint
D. Secondary cartilaginous joint
Answers
The dangerous layer of scalp is the loose
areolar tissue layer, due to its potential large
extent and presence of emissary veins, that
may carry infections inside the skull.
The facial vein joins with the anterior division
of retromandibular vein to form the common
facial vein that ends in internal jugular vein.
The pterygoid venous plexus receives veins
from nasal cavities, palate, pharynx and
structures in temporal and infra temporal
fossae. The external jugular and anterior

jugular veins drain venous blood from superficial structures of neck and scalp.
The parotid duct opens in the vestibule of
mouth opposite second upper molar tooth.
The submandibular salivary duct opens in the
floor of mouth at medial end of sublingual
fold. The sublingual salivary gland has several
small ducts that open on summit of sublingual
fold.
478

The muscle that is used for blowing out air
from the mouth cavity is buccinator. The
zygomaticus major is a laughing muscle. The
levator labii superioris elevates the upper lip
and risorius muscle is used for grinning.
The crista galli gives attachment of falx
cerebri. The falx cerebelli is attached to the
internal occipital crest. The diaphragma seltae
is attached to middle and posterior clinoid
process. The tentorium cerebelli is attached
anteriorly to the anterior clinoid process.
T suboccipital nerve is the dorsal ramus of
C 1 spinal nerve. It gives five muscular
branches to the boundary muscles of suboccipital triangle. The lesser occipital, greater
occipital and third occipital carry only sensory
fibers for the skin of scalp.
The maxillary nerve leaves the skull by
foramen rotundum to enter pterygopalatine
fossa. The foramen ovale gives passage to
the mandibular division of trigeminal nerve.
The foramen spinosum gives passage to
middle meningeal artery. The foramen lacerum
from its upper part gives passage to internal
carotid artery.
The air sinus that drains by gravity is frontal
air sinus. The opening of maxillary sinus is
located at a higher level in hiatus semilunaris.
The ethmoidal sinusesposterior, middle and
anterior drain in superior meatus, bulla ethmoidalis and hiatus semilunaris respectively.
The sphenoidal air sinus opens in sphenoethmoidal recess. All these sinuses do not
drain by gravity.

The taste sensation from the posterior third
of tongue is carried by glossopharyngeal
nerve. The chorda tympani (branch of facial
nerve) carries taste sensation from anterior
two-third of tongue. The vagus nerve carries
taste fibers from posteriormost part of tongue
and epiglottis. The maxillary nerve does not
carry taste fibers.
The muscle that is partly inserted on the
articular disc of temporomandibular joint is
lateral pterygoid muscle. The articular disc
of the joint is supposed to be the fibrosed
part of tendon of lateral pterygoid that is
included inside the joint during development.
The medial pterygoid is inserted on medial
surface of angle of mandible. The temporalis
is inserted on tip and medial surface of
coronoid process, while masseter is attached
to outer surface of ramus of mandible.
The skin of the tip of nose is supplied by the
external nasal nerve. The buccal nerve
supplies the skin of check. The infraorbital
nerve supplies skin of lower eyelid, ala of
nose and upper lip. The facial nerve is the
motor nerve for the muscles of face and
scalp.
The superior laryngeal artery is a branch of
superior thyroid artery. The facial artery
supplies the tonsil and pharynx in the neck.
The lingual artery mainly supplies the tongue,
but also gives branches to pharynx. The
vertebral artery gives only small branches to
the vertebral canal of the neck region.
The hypoglossal nerve leaves the skull through
anterior condylar canal. The jugular foramen
tahir99 - UnitedVRG

transmits the glossopharyngeal, vagus and
accessory nerves. The foramen ovale gives
passage to the mandibular nerve. The
posterior condylar canal transmits only an
emissary vein.
The only muscle of pharynx that is supplied
by glossopharyngeal is stylopharyngeus. The
palatopharyngeus salpingopharyngeus and
inferior constrictor muscles of pharynx are
supplied by pharyngeal plexus (cranial part
of accessory).
The anterior belly of digastric is supplied by
mylohyoid nerve, that is a branch from the
inferior alveolar branch of mandibular nerve.
The hypoglossal nerve supplies the muscles
of tongue. The facial nerve is motor to
muscles of scalp and face. The ventral ramus
of first cervical nerve gives fibers via
hypoglossal nerve to supply infra-hyoid
muscles.
A16. The answer is A (1, 2, 3).
The spinal accessory nerve crosses lower part
of posterior triangle. The roots of brachial
plexus emerge between scalenus medius and
scalenus anterior. The inferior belly of
omohyoid divides the triangle into an upper
occipital and a lower subclavian triangles. But
it is the third part of subclavian artery that
A17. The answer is B (1, 3).
The thyroid gland is a highly vascular
endocrine gland. It is related to the parathyroid
glands on its posterior aspect. However, the
thyroid gland is endodermal in origin and it
moves with deglutition.
The carotid body is present at the bifurcation
of common carotid artery. It is a chemoreceptor, not a pressure receptor. The carotid
body is always present.
479
A19. The answer is D (4).

The air sinuses that drains in the superior
meatus of nose is posterior ethmoidal sinuses.
The sphenoidal sinus has an opening in the
spheno-ethmoidal recess. The middle
ethmoidal sinuses open on bulla ethmoidalis
in middle meatus of nose. The frontal air sinus
drains by frontonasal duct in middle meatus
of nose.
A20. The answer is C (2, 4).
The palatine tonsil receives its sensory supply
from the glossopharyngeal nerve and lesser
palatine branches of sphenopalatine ganglion
carrying fibers of maxillary nerve. The greater
auricular nerve supplies sensory fibers to skin
of auricle, scalp and angle of mouth. The
mandibular nerve gives sensory fibers to
anterior two-third of tongue, lower jaw, floor
of mouth and part of scalp and face.
The abductor muscles of the vocal cords are
the two posterior cricoarytenoids. The
cricothyroid is the tensor of vocal cords,
while the oblique arytenoid and lateral
cricoarytenoid muscles are the adductors of
vocal cords.
The injury to the left facial nerve at the
stylomastoid foramen leads to facial paralysis
of left half of face. The hyperacusis, due to
paralysis of stapedius, and loss of lacrimation
of left eye would take place if the injury to
the facial nerve is in the middle ear. Loss of
secretion of left parotid gland would not
occur in this case, as the secretomotor fibers
of parotid are supplied by the glossopharyngeal nerve.
The chorda tympani nerve carries the
parasympathetic fibers for the submandibular
and sublingual salivary glands, and taste fibers
480

from the anterior two-third of tongue are
carried by the lingual branch of mandibular
nerve. The motor fibers to the stytopharyngeus are supplied by the glossopharyngeal.
A24. The answer is E (1, 2, 3, 4).

The cranial nerves that pass through the
cavernous venous sinus arethe oculomotor,
trochlear and ophthalmic and maxillary
divisions of fifth nerve along the lateral wall,
and the abducent nerve along the medial wall,
lying inferolateral to the internal carotid artery.
The nasal septum is formed by the
perpendicular plate of ethmoid (the posterior
superior part), the septal cartilage (the anterior
inferior part) and the vomen (the posterior
inferior part). The maxilla bone does not
contribute any major part to the nasal septum.
A26. The answers are D, C, B and A.
The foramen ovale transmits mandibular
nerve. The foramen spinosum gives passage
to the middle meningeal artery. The posterior
condylar canal transmits an emissary vein and
vertebral artery passes through foramen
magnum.
A27. The answers are D, C, A and B.
The sternomastoid is supplied by the
spinal accessory.
The orbiculasis oculi is supplied by the
facial nerve.
The lateral pterygoid is supplied by the

mandibular nerve.
The cricothyroid is innervated by the
external laryngeal nerve.
A28. The answers are C, A, B and D.

The isthmus is the median part of thyroid
gland.
The lingual tonsil lies in the posterior third
of the tongue.
The bulla ethmoidalis lies in the middle
meatus of nose.
The tubal elevation lies in lateral wall of
nasopharynx.
A29. The answers are B, C, D and A.
The thyrocervical trunk is a branch of
first part of subclavian artery.
The lingual artery is a branch of external
carotid artery.
The ophthalmic artery is a branch of
internal carotid artery.
The thyroidea ima is a branch of arch of
aorta.
A30. The answers are C, A, B and D.
The temporo-mandibular joint is a condyloid type of joint.
The symphysis menti is actually a synostosis between two halves of mandible.
The median atlanto-occipital joint is a
pivot type of synovial joint.
The intervertebral disc is a secondary
cartilaginous joint.
tahir99 - UnitedVRG
The Spinal Cord, Brain, Eyes

and the Ears
Eight
CHAPTER
43
The Spinal Cord

THE SPINAL CORD
The spinal cord is the cylindrical part of central
nervous system that lies in upper two-third of
vertebral canal.
The spinal cord begins from upper border of
atlas vertebra and ends at lower border of first
lumbar vertebra (at birth it ends at lower border
of third lumbar vertebra).
The spinal cord had two enlargements:
a. The cervical enlargement is associated with
attachment of nerves supplying upper
extremity (extends from C4 spinal segment
to T1 segment).
b. The lumbar enlargement is associated with
attachment of nerves supplying the lower
extremity (extends from L2 spinal segment
to S4 segment).
The lower tapening end of spinal cord is called
the conus medullaris.
The filum terminale is the non-nervous filament
that connects the conus medullaris to the first
piece of coccyx.
Since spinal cord ends at a higher level than the
vertebral canal, the lumbar, sacral and coccygeal
nerve roots are long (to reach their respective
intervertebral foramina).
The conus medullaris, and filum terminale
surrounded on each side by the lumbar, sacral
and coccygeal nerve roots give an appearance
called cauda equina (horse tail).
The spinal segmentsa spinal segment is a part

of spinal cord that gives attachment to one pair
of spinal nerves. Thus there are thirty-one spinal
segments (8 cervical, 12 thoracic, 5 lumbar,
5 sacral and 1 coccygeal).
The vertebral levels of the spinal segments are
important in relation to injuries of the vertebral
column.
All eight cervical segments lie up to sixth cervical
spine.
Upper six thoracic segments lie from sixth
cervical spine up to fourth thoracic spine.
The lower six thoracic segments lie from fourth
thoracic spine to ninth thoracic spine.
The five lumbar, five sacral and coccygeal
segments lie from ninth thoracic spine to first
lumbar spine.
The Meninges of the Spinal Cord
(Fig. 43.1)
The spinal cord is also surrounded by three
coverings or meninges.
I. The spinal dura mater is tough and fibrous and
is continuous with inner meningeal layer of cerebral
dura mater.
It forms a loose covering of the spinal cord
and extends up to second sacral vertebra.
It is attached above to the margins of foramen
magnum and in front to the posterior longitudinal
ligament of the vertebral column.
482
Fig. 43.1: TS of spinal cord and its meninges
The epidural space is the space between the

outer surface of dura mater and vertebral canal.
It contains:
a. Internal vertebral venous plexus
b. Few small arteries
c. A quantity of fat
II. The spinal arachnoid mater is thin, delicate and
transparent and closely follows the dura mater. It
also extends up to second sacral vertebra.
The subdural space is a potential space between
the dura mater and arachnoid mater. It contains
a small amount of serous fluid to moisten the
opposing surfaces.
III. The spinal pia mater is thicker and more fibrous
and less vascular than cerebral pia mater.
It lines the outer surface of spinal cord
intimately, and makes the following:
a. The linea splendensis a longitudinal
thickening lying along the ventral median
fissure.
b. The subarachnoid septuma perforated
septum, attached to posterior median
sulcus.
c. The ligamenta denticulatatwo extensions
of pia mater attached on either side of spinal
cord.
Each ligamentum denticulatum has
twenty-one tooth processes that pierce
arachnoid and are attached to the dura

mater in between nerve roots.
The subarachnoid space is a wide space that
lies between pia mater and arachnoid matter. It
contains:
Cerebrospinal fluid
Large spinal blood vessels
The Blood Supply of Spinal Cord
The arteries
There are three spinal arteries, two posterior
spinal and one anterior spinal from vertebral
artery that descend on the surface of spinal
cord.
These spinal arteries are reinforced by the
radicular arteries that are derived from the
regional arteries of the body wall, and accompany the spinal nerve roots.
The Veins
There are six longitudinal venous channels that drain
venous blood from the spinal cord.
These veins drain into the internal vertebral
venous plexus and finally in the regional veins of
the body wall.
There are no valves in the spinal veins and the
venous blood from spinal cord can reach directly
into regional veins.
tahir99 - UnitedVRG
The Spinal Cord

The spinal nerve rootsEach spinal nerve is
attached by two spinal nerve roots on the side of
spinal cord:
a. The posterior (dorsal) nerve root carries afferent
somatic and visceral nerve fibers.
It has got a dorsal root ganglion (DRG)
near the inter-vertebral foramen, that has
pseudo-unipolar nerve cells and relays all
the sensory fibers of the dorsal nerve
root.
b. The anterior (ventral) nerve root carries the
efferent somatic fibers and preganglionic
visceral motor fibers.
The two nerve roots pierce the dural tube
separately and unite in the intervertebral foramen
to form the stem of the spinal nerve.
The Internal Structure
The spinal cord has grey matter inside (forming an
H-shaped appearance in TS) surrounded by white
matter.
The grey matter consists of following parts:
i. The posterior grey column (PGC) containing
connector (sensory) neurons.
ii. The anterior grey column (AGC) containing
efferent (motor) neurons.
iii. The central grey commissure that surrounds
the central canal and has mostly neurolgial
tissue.
There is also a lateral grey column (LGC) (from
T1 spinal segment to L 1 spinal segment) that
contains visceral connector (preganglionic)
neurons.
The white matter of the spinal cord is divided into
three partscolumns or funiculi.
a. The posterior white column lies between
posterior median septum and postero-lateral
sulcus.
b. The lateral white column lies between the
postero-lateral sulcus and most lateral
attachment of rootlets of anterior nerve root.
483
c. The anterior white column lies between the most

lateral attachment of rootlets of anterior nerve
root and ventral median fissure.
Each of these three columns contains three
types of nerve tracts (Table 43.1):
i. The ascending (sensory) nerve tracts carry
sensory impulses from the spinal cord to
different parts of brain.
ii. The descending (motor) nerve tracts carry
motor impulses from different parts of brain
to the spinal cord.
iii. The inter-segmental tracts (fasciculi proprii)
are short relay tracts, interconnecting
segments of the spinal cord. There are three
inter-segmental tracts one for each anterior,
posterior and lateral white columns (Fig.
43.2).
The Nerve Tracts in Posterior
White Column
Ascending Tracts
Fasciculus gracilis
Fasciculus cuneatus
Descending Tracts
Nil
The Nerve Tracts in Lateral
White Column
Ascending Tracts
Dorso-lateral
Posterior spino-cerebellar
Anterior spino-cerebellar
Spino-olivary
Spino-tectal
Lateral spinothalamic
Descending Tracts
Rubrospinal
Lateral corticospinal
Lateral reteculospinal
Olivospinal
484

Table 43.1: The ascending and descending tracts of the spinal cord
S. Name
No.
Function
Crossed
uncrossed
Spinal
segment
Beginning
Termination
Uncrossed
S5 to T7
Dorsal root ganglion

cells
Nucleus gracilis
Uncrossed
T1 to T6

cells
cells
Nucleus cuneatus
The Ascending Tracts

1.
Fasciculus
gracilis
2.
Fasciculus
cuneatus
Dorsolateral
(Lissauers)
3.
4.
Lateral
spinothalamic
5.
Anterior
spinothalamic
6.
Spinotectal
7.
Posterior
spinocerebellar
Anterior
spinocerebellar
Spinoolivary
8.
Conscious proprioception
Discriminatory
touch
Vibratory sense
Stereognosis
Pain and
Temperature
Uncrossed
C1 to S5
Ascends for 1-5
segments
Crossed
C1 to S5
Pain and
Temperature from
opposite half of
body
Touch (crude) and Crossed
pressure from opposite half of body
Afferent limb of
Crossed
reflex movement
of eyes and head
towards source
of stimulation
Unconscious pro- Uncrossed
prioception
Substantia gelatinosa
of posterior grey
column
C1 to S5
Posterior grey column

of opposite side
C1 to C8

of opposite side
C1 to L2
Thoracic nucleus of
posterior grey clumn
Cerebellum adjustments of muscle

tone
9.
Proprioceptive
sense
The Descending Tracts
1. Lateral
Main motor
corticospinal tract
Uncrossed
C1 to L2

same opposite side
Uncrossed
C1 to S5
Crossed
C1 to S5
Motor area of cortex

(upper motor neurons)
2.
Uncrossed
C1 to S5
Motor area of cortex

(upper motor neurons)
Red nucleus of mid
brain
3.
Anterior
corticospinal
Rubrospinal
4.
Lateral reticulospinal
5.
Anterior reticulospinal
Olivospinal
6.
7.
8.
Main motor tract
Efferent pathway Crossed

for cerebellum and
corpus stratum
Extra pyramidal
Crossed
tract
Extra pyramidal
tract
Extra pyramidal
tract
Vestibulospinal Efferent pathway
for equilibratory
control
Tectospinal
Efferent pathway
for visual reflexes
C1 to S8
C1 to S5
Reticular formation of
grey matter of medulla
oblongata
Reticular formation
of grey matter of pons
Inferior olivary nucleus
Substantia gelatinosa of posterior

grey column
Postero lateral ventral nucleus of
thalamus
Postero-lateral
ventral nucleus of
thalamus
Tectum-superior
colliculus of midbrain
Vermis of cerebellum (via inferior

cerebellar peduncle)
Vermis of cerebellum (via superior
cerebellar peduncle)
Dorsal and medial accessory olivary nuclei
Anaterior grey column
cells alpha motor
neurons
Anterior grey column
alpha motor neurons
Anterior grey
column cells
cells (interneurons)
Uncrossed
mainly
Uncrossed
C1 to S5
Uncrossed
C1 to S5
Lateral vestibular
nucleus

cells (inter neurons)
cells
cells
Crossed
C1 to S5
Superior colliculus
C1 to S8
tahir99 - UnitedVRG
The Spinal Cord
485
Fig. 43.2: TS of spinal cordcervical partshowing nerve tracts
The Nerve Tracts in Anterior

White Column
Ascending Tract
Anterior spinothalamic
Descending Tracts
Anterior Renculospinal
Vestibulo-spinal
Tectospinal
Anterior corticospinal
Applied Anatomy
I. The lumbar puncture is a diagnostic procedure,
that is done to obtain a sample of cerebrospinal
fluid.
The lumbar puncture is done usually between
fourth and fifth lumbar spinous processes.
(sometimes between third and fourth lumbar
spinous processes).
The needle after piercing the skin and superficial

fascia, passes through supraspinous, interspinous ligaments, dura and arachnoid mater
to reach the subarachnoid space.
The lumbar puncture is done to diagnose:
An intra-cranial hemorrhage
A hemorrhage in vertebral canal
Increased intracranial pressure due to a
tumor
Infection of meninges
II. The spinal anesthesia is done to anesthetise the
spinal nerve roots within the dural tube.
The spinal anesthetic is introduced by the lumbar
puncture.
The number of spinal nerves to be anesthetised
is controlled by:
Amount of the spinal anesthetic substance
The position of the patient.
CHAPTER
44
The Meninges and Blood

Supply of Brain
THE MENINGES OF THE BRAIN
The brain lies inside the cranial cavity surrounded
by three coverings or meningesdura mater,
arachnoid mater and pia mater (Fig. 44.1).
I. The cerebral dura mater is thick, fibrous and
protective outer covering.
The cerebral dura mater has two layers
endosteal and meningealwhich are fused
together except where they separate to enclose
venous sinuses.
The functions of dura mater are:
i. Protection of the brain
ii. Inner lining of skull bones
iii. Enclosing venous sinuses between two
layers
iv. Forming folds or duplications to divide the
cranial cavity into freely communicating
compartments.
There are four such folds.

The dural folds are four in number:
1. Falx cerebria large sickle shaped fold that
lies in longitudinal fissure between two
hemispheres.
2. Falx cerebelli is a small sickle shaped fold
that lies in posterior cerebellar notch
between the two cerebellar hemispheres.
3. Tentorium cerebellia large tent-shaped
fold that roofs over the posterior cranial
fossa. It has a tentorial notch through which
the brain stem passes.
4. Diaphragma sellae a small circular fold that
roofs over the hypophyseal fossa. It has a
central aperture for the infundibulum of
hypophysis cerebri.
The blood supply of dura mater is by meningeal
arteries.
Fig. 44.1: Coronal section showing the meninges
tahir99 - UnitedVRG
The Meninges and Blood Supply of Brain
In anterior cranial fossa these are branches

from the anterior and posterior ethmoidal
arteries.
In middle cranial fossa these are branches from
the middle meningeal, accessory meningeal and
ascending pharyngeal arteries.
In posterior cranial fossa these are branches
of vertebral artery.
The middle meningeal artery is the largest
meningeal artery that supplies most part of dura
mater lining the vault of the skull.
This a branch of maxillary artery and enters
the skull via foramen spinosum. It divides into
an anterior branch and a posterior branch.
The anterior branch passes through a bony tunnel
at pterion on side of skull and is liable to be
ruptured in fracture of skull bones at that point.
The posterior branch ascends up to a point
lambdaon top of skull.
The sensory nerve supply of dura mater is by
ophthalmic division of trigeminal nerve for
anterior cranial fossa.
For middle cranial fossa and large part of dura
mater lining the vault of skull is supplied by
maxillary nerve.
For posterior cranial fossa the sensory nerves
are mandibular nerve and ventral rami of upper
cervical nerves.
II. The cerebral arachnoid mater is thin,
transparent and delicate covering that is separated
from dura mater by a potential space, the subdural
space.
It does not dip in the sulci and fissures of brain
and bridges over the irregularities of brain
surface.
Arachnoid villi and granulationsThe arachnoid mater forms minute projectionsthe
villiin fetal life. The projections become large
called arachnoid granulations in later life.
These granulations pierce dura mater and bulge
in venous sinuses specially superior sagittal
sinus.
487
The granulation lie in groups or clusters. These

are the sites through which cerebrospinal fluid
goes back to venous blood.
The subarachnoid space is the wide space that
separates the arachnoid mater from pia mater.
It contains cerebrospinal fluid (CSF) and large
blood vessels of brain.
The subarachnoid cisterns are enlarged
subarachnoid spaces at the base of the brain
and around brain stem. These spaces contain a
larger amount of CSF. The important subarachnoid cisterns are:
a. The cerebello-medullary cistern between
back of medulla oblongata and cerebellum.
b. The inter-peduncular cistern surrounds the
inter-peduncular fossa.
c. The superior cistern lies behind the splenium
of corpus callosum.
d. The cisterna pontis lies along ventral surface
of pons.
e. The cistern of lateral sulcus lies on each
side in front of temporal pole.
III. The cerebral pia mater is the vascular
covering that intimately covers the surface of brain.
It contains a plexus of fine blood vessels.
The telachoroidea are folds of pia mater that
bulge inside the ventricles of brain.
These folds contain many blood vessels in
margins that are lined by the ependyma of the
ventricles forming choroid plexuses.
The choroid plexuses secrete cerebrospinal fluid,
by an active process of secretion by ependymal
cells.
The Blood Supply of the Brain
The Arteries
The brain is supplied blood by four large arteries,
they are: (Fig. 44.2)
Paired internal carotid artery.
Paired vertebral artery.
a. The internal carotid artery enters the cranial
cavity through bony carotid canal.
488
Fig. 44.2: The brain stemanterior aspect with arteries
It passes within the dural walls of

cavernous venous sinus and then pierces
the roof of the sinus.
It ascends up to anterior perforated
substance, lateral to the optic chiasma
and divides into its terminal branches.
Branches
1. Ophthalmic artery enters orbit
through optic canal.
2. Anterior choroidal artery supplies
choroid plexus of inferior horn of
lateral ventricle.
3. Posterior communicating artery
completes the circle of Willis.
4. Anterior cerebral
artery
are terminal
5. Middle cerebral
branches
artery
b. The vertebral artery arises from first part
of subclavian artery and enters skull via
foramen magnum.
It lies by side of medulla oblongata, then
gradually crosses on front of medulla
oblongata and at lower border of pons
joins with its fellow to form the basilar
artery.
Branches
i. Anterior spinal and posterior spinal
arteries supply front of medulla
oblongata and then descend to supply
the spinal cord.
ii. Small medullary branches supply the
peripheral parts of medulla oblongata.
iii. Posterior inferior cerebellar artery
passes laterally and supplies lateral
part of medulla oblongata and
cerebellum.
c. The basilar artery is the median anastomotic
channel formed by union of two vertebral
arteries.
It lies in basilar sulcus on ventral surface
of pons.
At upper border of pons it bifurcates
into two posterior cerebral arteries.
Branches are paired
a. Anterior inferior cerebellar artery
supplies inferior surface of cerebellum.
b. Labyrinthine artery enters internal
acoustic meatus and supplies the
internal ear.
c. Small pontine branches are given to
the ventral surface of pons.
d. Superior cerebellar supplies superior
surface of cerebellum.
e. Posterior cerebral are the terminal
branches.
The circle of Willis(circulus arteriosus) is an
anastometic circle formed by union of main arteries
at the base of the brain (Fig. 44.3).
The circle is shaped like a polygon and lies
in the inter-peduncular cistern surrounding
the interpeduncular fossa on the base of the
brain.
tahir99 - UnitedVRG
489
iii. Postero-medial group from beginning of

posterior cerebral arteries.
iv. Postero-lateral group (two) from lateral part
of posterior cerebral arteries.
Fig. 44.3: The circle of Willis
Formation
Anteriorly by anterior communicating artery.
Antero-laterally by anterior cerebral artery.
Laterally by posterior communicating artery.
Posteriorly by bifurcation of basilar artery into
two posterior cerebral arteries.
The circle of Willis shows variations in about
30% cases.
Normally, there is little blood flow through the
thin communicating branches, so it is doubtful
that this anastomosis helps to equalise the blood
flow of the two arterial systems supplying
brain.
If, however, one of the major arteries forming
the circle is blocked gradually, this anastomosis
may provide an alternative route of blood flow.
Branchesthe circle of Willis gives six groups
of long, ganglionic (central branches) that
pierce the surface of brain and supply deeper
structures. These are:
i. Antero-medial group from anterior cerebral
and anterior communicating arteries.
ii. Antero-lateral group (two) from beginning
of middle cerebral arteries. These are also
called striate arteries and are divided into
two groupsmedial and lateral.
The arteries of cerebral hemispheres (cerebrum).

i The deeper structuresbasal nuclei, internal
capsule and central white matter is supplied
by the ganglionic branches.
ii The cerebral cortex and subjacent white matter
is supplied by the three paired cerebral
arteries.
a. The anterior cerebral artery arises from
internal carotid artery and supplies most
part of medial surface and a narrow strip
of lateral surface adjoining medial border.
b. The middle cerebral artery is also a branch
of internal carotid artery. It supplies most
part of lateral surface, temporal pole and
submerged area of cortexthe insula.
c. The posterior cerebral artery is a branch
of basilar artery. It supplies most of inferior
surface of hemisphere and the occipital
lobe.
Applied Anatomy
I. The cerebral vascular lesions ocur commonly in
elderly people specially those suffering from high
blood pressure since the cerebral arteries are end
arteries. Their lesions give rise to well-defined
vascular syndromes.
The common vascular lesion is thrombosis
or rupture of Charcots arteryone of the
lateral striate arteries, that supplies internal
capsule. The lesion produces contralateral
hemiplegia and sensory loss in opposite half
of the body.
II. The cerebral angiography is a special X-ray
technique of visualizing the cerebral arteries by
injecting a radiopaque dye in the main arterial
trunk.
490
Fig. 44.4: The external cerebral veins
The Veins of the Brain

The veins of the brain drain into neighboring dural
venous sinuses.
The cerebral veins have no valves and their walls
are quite thin with few muscle fibers.
The veins of the cerebrum are divided into three
groups (Fig. 44.4):
I. The external cerebral veins drain venous blood
from the cortex and subjacent white matter. These
are further subdivided into superior cerebral veins,
inferior cerebral veins and superficial middle
cerebral vein.
The superior cerebral veins (8-12) course over
the lateral surface and follow a peculiar course
at their termination in superior sagittal sinus.
They run parallel to the sinus for a short distance
then open against the direction of flow of blood
in the venous sinus. This is probably due to a
backward growth of hemisphere.
The inferior cerebral veins drain venous blood
from lower part of lateral surface and inferior
surface. They drain into cavernous sinus and

transverse sinus.
The superficial middle cerebral vein runs along
lateral surface, connecting superior sagittal
sinus, with transverse sinus.
II. The internal cerebral veins lie inside the
telachoroidea of third ventricle.
Each internal cerebral vein is formed at the interventricular foramen (foramen of Monro) by
union of:
a. Thalmostriate vein draining venous blood
from thalamus and corpus structum.
b. Choroidal vein draining venous blood from
choroid plexus.
The internal cerebral veins run parallel to each
other and come out of transverse fissure below
splenium of corpus callosum.
The two veins join to form the great cerebral
vein. The great cerebral vein lies in the
superior cistern and joins the inferior sagittal
sinus.
tahir99 - UnitedVRG
It receives the two basal veins, inferior cerebral

veins, some cerebellar veins and veins from back
of midbrain.
III. The basal veins are two large veins, that lie
along the inferior (tentorial) surface of hemisphere.
Each vein is formed at anterior perforated
substance by union of three veins:
a. Anterior cerebral vein from the medial
surface of hemisphere.
491
b. Striate veins draining venous blood from

corpus striatum, internal capsule and
thalamus.
c. Deep middle cerebral vein that drains
venous blood from insula (submerged
area of cortex in depth of lateral surface).
The basal vein terminates in the great cerebral
vein.
CHAPTER
45
The Hind-Brain and

Mid-Brain
THE HIND-BRAIN AND MID-BRAIN
The brain is the dominant part of the central nervous

system, that controls all somatic and visceral
activities of the body. It is also the center for all
higher mental functions.
Subdivisions
The brain is divided functionally and developmentally into three parts:
i. The forebrain: Prosencephalon consists of
TelencephalonThe two cerebral
hemispheres (cerebrum).
DiencephalonThe median part.
ii. The midbrain: Mesencephalon.
iii. The hindbrain: Rhomhencephalon consists of
MetencephalonThe pons and cerebellum.
MyelencephalonThe medulla oblongata.
The Brain Stem
Appears as continuation upwards of the spinal cord.
It consists of:
The medulla oblongata
The pons
The mid brain
The cerebellum is attached to the back of brain
stem and the forebrain lies above it.
Location: It lies in posterior cranial fossa in

relation to basilar part of occipital bone.
Size and Shape: The medulla oblongata is about
3.0 cm long and is cylindrical in shape.
Parts: It is divided into:
i. Lower closed part having central canal
ii. Upper open part, that forms the lower part
of floor of fourth ventricle.
Surface Characters
The anterior aspect of medulla oblongata
has two swellings.
a. The pyramida triangular elevation by
side of the ventral median fissure, with
it apex directed below.
b. The olivesan oval swelling about
1.0 cm long that lies by side of pyramid.
On the lateral aspect is the inferior cerebellar pedunclea rope like bundle, that
connects the medulla oblongata with the
cerebellum.
On the posterior aspect are continuation of
gracile and cuneate tracts, at upper ends of
which are the gracile and cuneate tubercles.
The upper part of posterior surface, forms
the lower part of floor of fourth ventricle
and shows three triangular elevations.
i. Medial: hypoglossal triangle
ii. Intermediate: vagal triangle
iii. Lateral : lower part of vestibular area
The Medulla Oblongata
Internal Structure
The medulla oblongata appears as upper dilated end

of the spinal cord.
The grey matter shows the following nuclei.

I. The cranial nerve nuclei
tahir99 - UnitedVRG
The Hind-Brain and Mid-Brain
The nucleus of hypoglossal (twelfth cranial)

nerve.
The nucleus ambiguus (motor nucleus of ninth,
tenth, and cranial eleventh nerves.
The dorsal nucleus of vagus (mixed nucleus of
tenth nerve).
The nucleus of tractus solitarius (Nucleus of
special sense of taste).
Continuation of nucleus of spinal tract of
trigeminal.
II. The olivary nuclear complex consisting of the
main inferior olivary nucleus (large nucleus, with
shape like a crenated vase in TS) and two accessory
olivary nucleimedial and dorsal.
III. The gracile and cuneate nuclei that contain
the second neurons on path of gracile and cuneate
tracts. A small accessory cuneate nucleus is also
present.
IV. Medial and inferior vestibular nucleus lies in the
vestibular area.
V. The reticular formation of grey matter of
medulla oblongata has some vital centers.
493
The White Matter

The white matter of the medulla oblongata shows
the following tracts:
a. The decussation of pyramidal fibers (motor
decussation). The motor (pyramidal) fibers of the
pyramids at their apices decussate. Nearly threefourth of the fibers cross over the opposite side to
form lateral corticospinal tract while one fourth
continue on same side as anterior cortico spinal
tract.
b. The sensory decussationThe second neuron
fibers arising from the gracile and cuneate nuclei
curve ventrally around the central canal as the
internal arcuate fibers cross over to opposite side
or decussate and form the medial lemniscus.
c. The medial longitudinal fasciculus lies in
paramedian position. It is continuation upwards of
the anterior intersegmental tract of the spinal cord.
d. The tectospinal tract lies between medial
longitudinal fasciculus and the medial lemniscus.
e. Other ascending and descending tracts retain
their relative positions (Fig. 45.1).
Fig. 45.1: TS medulla oblongataclosed part (at sensory decussation)
494
The Pons
The pons appears as a bridge between the two
halves of the cerebellum, although no fibers pass
as such.
Location: The pons also lies in the posterior
cranial fossa, related to the basilar part of pons
and body of sphenoid.
Parts: The pons is divided into two parts:
a. The ventral part (the basilar part) is a new
addition to the human brain. It continues as
middle cerebellar peduncles.
It forms functionally, an important cell
station in cortico-ponti-cerebellar pathway.
It forms a prominent bulging on front
of pons with basilar sulcus in-between.
b. The dorsal part (the tegmentum) that forms
the upward continuation of the medulla
oblongata.
The dorsal surface of pons forms the
upper part of the floor of fourth ventricle.
Internal Structure
a. The basilar part shows: (Fig. 45.2)
The grey matter in form of diffuse collection of

grey matter forming nuclei pontis.
The white matter has
i. Longitudinal fibers
Corticopontine fibers that end in nuclei
pontis
form
Corticospinal
separate
Corticonuclear
bundles
ii. Transverse fibers arise from nuclei pontis. These
are second neuron fibers in cortico-ponticerebellar pathway that continue in the middle
cerebellar peduncle of opposite side.
b. The tegmentum of pons shows:
The grey matter as
i. The cranial nerve nuclei
Nucleus of abducent nerve
Nucleus of facial nerve
Nucleus of spinal tract of trigeminal
Motor nucleus of trigeminal
Superior sensory nucleus of trigeminal
The vestibular nuclei lateral, inferior and
superior occupy the lateral part of floor of
fourth vertricle.
Fig. 45.2: TS of pons (at level of facial colliculus)
tahir99 - UnitedVRG

ii. The reticular formation of gray matter occupies
the ventro-lateral part of legmentum.
The white matter has
i. The medial longitudinal fasciculus that lies in
paramedian position close to abducent nucleus.
ii. The tectospinal tract lies close to the medial
longitudinal fasciculus.
iii. The band of lemnisci is placed transversely at
junction of tegmentum with the basilar part.
Medial lemniscus lies medially.
Trigeminal lemniscus (from sensory nuclei
of trigeminal nerve of opposite side) is
placed lateral to medial lemniscus.
Spinal lemniscus (lateral spino-thalamic
tract) lies most laterally.
iv. The corpus trapezoidum (trapezoid body) is
formed mainly by the fibers of ventral cochlear
nucleus, and is placed transversely intersecting
fibers of medial lemniscus.
After decussating at median plane, these
fibers from lateral lemniscus.
v. The emerging fila of facial nerve curve around
abducent nucleus producing the facial colliculusa round swelling in floor of fourth
ventricle.
vi. The other tracts lie in the ventro-lateral part of
tegmentum.
The dorsal surface of pons forms the upper
part of floor of fourth ventricle. It has two medial
eminences on either side of median sulcus, with
facial colliculi at their lower portions.
The vestibular nuclei occupy the vestibular area
in the floor of fourth ventricle, partly in medulla
oblongata and partly in pons.
There are four vestibular nuclei
Medial nucleus is the largest
Superior nucleus
Lateral nucleus
Inferior nucleus
Connections
Afferent
i. Primary vestibular fibers end in all vestibular
nuclei.
495
ii. Cerebello-vestibular fibers.

Efferent
i. Vestibulo-cerebellar fibers.
ii. Vestibulo-spinal (mainly from lateral
nucleus).
iii. Medial longitudinal fasciculus.
i. The vestibular nuclei act as a relay station
on afferent cerebellar pathway and a distribution station in efferent cerebellar
pathway.
ii. The vestibular nuclei influence the movement of eyes, head and muscles of trunk
and limbs so as to maintain equilibrium.
The Cochlear Nuclei

There are two cochlear nuclei, dorsal and ventral,
located in relation to inferior cerebeller peduncle at
the junction of medulla oblongata and pons.
Connections
Afferent
Primary cochlear fibers from the internal ear.
Efferent
i. Ventral acoustic strialargest bundle from
ventral cochlear nucleus courses medially
across tegmentum of pons.
It decussates in median plane to form
corpus trapezoidum.
It ascends up as lateral lemniscus and
relays in superior olivary nucleus.
ii. Dorsal acoustic stria arises from the dorsal
cochlear nucleus and joins the lateral
lemniscus of opposite side.
iii. Intermediate acoustic stria arises from
dorsal part of ventral cochlear nucleus and
join the lateral lemniscus of opposite side.
THE MID-BRAIN (THE MESENCEPHALON)
The mid-brain is the shortest segment of the brain
(only 2.0 cm long).
Location: The midbrain lies above pons, passing
through the tentorial notch.
496
Parts: The midbrain is divided into two part by

the cerebral aqueduct.
i. A dorsal part, tectum, made up of two paired
colliculisuperior and inferior.
ii. A ventral part made up of two cerebral
peduncles
Each peduncle has
a. Crus cerebri: seen at base of brain
b. Substantial nigra: a curved plate of
pigmented grey matter.
c. Tegmentum: that is fused with the
opposite cerebral peduncle.
Internal Structure
A. The tectum (Fig. 45.3)
a. The superior colliculus has a laminated
nucleus and acts as a visual reflex center.
Connection
Afferent
i. Retina
ii. Occipital cortex (area 17,18, and
19)
iii. Inferior colliculus

Efferent fibers form a dorsal tegmental decussation and continue as
tecto-spinal tract.
b. The inferior colliculus has a compact
nucleus and acts as a relay station for
auditory fibers.
Connections
Afferent
i. Lateral leminiscus
ii. Opposite inferior colliculus
Efferent
i. Medial geniculate body
ii. Opposite inferior colliculus
iii. Superior colliculus
c. The pretectal nucleus is an indistinct
mass of grey matter lying dorsal to the
superior colliculus at junction of midbrain and diencephalon.
The pretectal nucleus acts as a center
for pupillary light reflex.
Fig. 45.3: TS of midbrainat level of superior colliculus
tahir99 - UnitedVRG

In Angyll Robertsons pupil, there is
lesion of pretectal area, so that the
pupillary light reflex is lost but
pupillary accommodation reflex is still
present.
B. The cerebral peduncle
a. The crus cerebri forms a rope like bundle
emerging from upper border of pons.
It consists of longitudinal fibers.
Lateral fifth part has temporo
and parieto pontine fibers.
Middle three fifth part has cortico-spinal and cortico-nuclear
fibers.
Medial fifth has fronto-pontine
fibers.
b. The substantia nigra a curved pigmented
mass of grey matter that lies dorsal to
the crus cerebri.
It extends above midbrain up to
subthalamus.
Connection
Afferent
i. Strio-nigral from corpus striatum
ii. Cortico-nigral
Efferent
i. Nigro-striate
ii. Nigro-thalamic
The substantia nigra is rich in dopamine
and enzyme GABA (gamma aminobutyric acid).
It is concerned with metabolic disturbances that underlie parkinsonism
and paralysis agitans.
c. The tegmentum
The grey matter has
i. Cranial nerve nuclei
Oculomotor nucleus at level of
superior colliculus
Trochlear nucleus at level of
inferior colliculus
497
Mesencephalic nucleus of trigeminal nerve

ii. Red nucleus An oval mass of grey
matter in upper part of midbrain that
extends upwards in subthalamus.
It is concerned with the muscle
tone of voluntary muscles.
Connections
Afferent
a. Cortico-rubral: mainly from the
precentral area.
b. Dentatorubral: from dentate nucleus
of cerebellum.
Efferent
Fibers form the ventral tegmental decussation and continue as rubraspinal
tracts.
iii. Reticular formation of grey matter
occupies the ventrolateral part of
tegmentum.
The White Matter
I. The medial longitudinal fasciculus lies in
paramedian position, close to oculomotor and
trochlear nuclei.
It receives main contribution of fibers from
Nuclei of vestibular group
Nuclei of third, fourth, and sixth nerves
Nuclei of seventh and twelfth nerve
Small nuclei at upper end of aqueduct
The medial longitudinal fasciculus ensures
coordinated movement of eyes and head in
response to stimulation of vestibular nuclei.
II. Dorsal tegmental decussation is formed by the
tectospinal tracts.
III. Ventral tegmental decussation is formed by the
rubrospinal tract.
IV. Band of lemnisci medial, trigeminal and spinal
occupies a position in lateral part of tegmentum.
V. Emerging fila of trochlear nerve curves dorsally
around the aqueduct, and decussate before
emerging from the brain.
498
VI. Emerging fila of oculomotor nerve passes

ventro-laterally through red nucleus and substantia
nigra before emerging from the brain.
Love
I. Anterior
lobe
THE CEREBELLUM
II. Middle
lobe
The cerebellum is the largest part of hind

brain.
Location: The cerebellum lies in the posterior
cranial fossa roofed over by tentorium
cerebelli.
It is separated from pons and upper part
of medulla oblongata by the fourth
ventricle.
Parts: It has one median partthe vermis.
Two cerebellar hemispheres.
Subdivision (Fig. 45.4)
The cerebellum can be divided morphologically and
functionally into:
i. A large corpus cerebelli consisting of
An anterior lobe
A posterior (middle) lobe
ii. A small flocculonodular lobe
Each lobe has a part of vermis and a part of
hemisphere.
III. Flocculonodular lobe
Vermis
Lingula (L)
Central
lobule (CL)
Culmen (C)
Declive (D)
Folium (F)
Tuber (T)
Pyramid (Py)
Uvula (U)
Nodule (N)
Hemisphere
Ala
Quadrangular lobe
Lobulus simplex
Superior semilunar lobule
Inferior semilunar lobule
Biventral lobule
Tonsil
Peduncle
Phylogenetic classification
i. Archicerebellum is the oldest part.
It consists of
Flocculonodular lobe
Lingula of anterior lobe
ii. Paleocerebellum is the old part.
It consists of
Anterior lobe (except lingula)
Uvula and pyramid of posterior lobe
iii. Neocerebellum is latest and most dominant
part in scale of evolution.
It consists of posterior lobe (except uvula
and pyramid).
The old parts are concerned with maintenance of equilibrium and muscle tone.
Fig. 45.4: The subdivisions of cerebellum
tahir99 - UnitedVRG
The new part is concerned with coordination of voluntary muscular movement.

Internal structure
The grey matter is in two forms:
a. The deep nuclei, that lie in central white
matter.
i. Nucleus fastigiioldest nucleus
ii. Nucleus globosus
iii. Nucleus emboliformis
iv. Nucleus dentatelargest and shaped like
a crenated vase.
b. The cerebellar cortex has the same thickness
and structure throughout.
It consists of two layers:
1. Outer molecular layer has low cell
density. It has molecular, basket type
and Golgi type II cells.
The deep part of this layer has a
single row of large flask-shaped
Purkinje cellsthe efferent cells
of cerebellar coretex.
2. Inner granular layer has a very high
cell density.
The layer is packed up by many
small granule cellsthe afferent
cells of cerebellar cortex.
The White Matter

The white matter contains three types of fibers:
i. Association fibers: that connect the areas of
cortex of same hemisphere.
ii. Commissural fibers: connect corresponding
areas of the two hemispheres. These fibers
cross midline.
iii. Projection fibers: are of two types:
a. The afferent fibers connect other parts
of brain and spinal cord with the
cerebellar cortex.
b. The efferent fibers connect cerebellar
cortex with other parts of brain and
spinal cord.
The projection fibers reach cerebellum via three
paired peduncles.
499
a. The inferior cerebellar peduncle connects

medulla oblongata with cerebellum.
It contains mainly afferent fibers, viz
The olivo-cerebellar and parolivo-cerebellar
from the olivary nuclei.
The anterior and posterior external arcuate
fibers from arcuate and lateral cuneate
nuclei.
The posterior spinocerebellar tract.
The vestibulocerebellar fibers.
The few efferent fibers are cerebellovestibular and cerebello reticular.
b. The middle cerebellar peduncle connects the
basilar part of pons with cerebellum.
It is also mainly an afferent peduncle: the
bulk of fibers are ponto-cerebellar
(transverse fibers of pons).
A few efferent fibers are from cerebellar
cortex to pontine nuclei.
c. The superior cerebellar peduncle connects the
midbrain with cerebellum.
It contains mainly the efferent fibers of
cerebellum.
These efferent fibers arise from the deep
nuclei of cerebellum and ascend up to tegmentum of mid brain, where they decussate.
After decussation the efferent fibers divide
into:
Ascending fibers that end in red nucleus
and thalamus.
Descending fibers that end in reticular
formation of brain stem.
The two afferent tracts are anterior spinocerebellar and tectocerebellar.
Connections of cerebellum
Afferent
i. Afferent climbing fibers are mostly
olivocerebellar and they make 1:1
synapse with Purkinje cells of cerebellar
cortex.
ii. Afferent mossy fibers are spinocerebellar, ponto-cerebellar and
vestibulo-cerebellar.
500

These fibers on reaching granular
layer end in dilatationglomeruli

that make synaptic connections with
a number of granule cells forming a
rosette-like appearance.
The axons of granule cells reach
molecular layer and divide to form
parallel fibers, that make synaptic
connection with a number of
Purkinje cells.
Efferent: The axons of Purkinje cells begin
from the bottom of their flask-shaped
body.
These efferent fibers relay in the deep
nuclei of cerebellum mainly in the
dentate nucleus and come out in the
superior cerebeller peduncles.
The cerebellum controls the same half of the
body.
It performs the following functions:
i. Maintenance of equilibrium and posture.
ii. Regulation of muscle tone.
iii. Ultimate refinement of muscular coordination.

THE FOURTH VENTRICLE OF BRAIN
The fourth ventricle is the cavity of hind brain that
lies behind pons and upper part of medulla oblongata
and in front of cerebellum (Fig. 45.5).
The fourth ventricle is connected above with
cerebral aqueduct of midbrain and below with
the central canal.
Boundaries: The fourth ventricle has a roof, a
floor and two lateral boundaries.
i. The roofhas an upper sloping part which
is formed by the superior medullary velum
and two superior cerebellar peduncles.
A lower sloping part is formed by:
White matter of cerebellum
Choroid plexus
Median opening
Obexa small tongue-like white matter
between two gracile tubercles.
ii. The floor (fossa rhomboidea)
Fig. 45.5: The brain stemposterior aspect showing floor of fourth ventricle
tahir99 - UnitedVRG
501
Fig. 45.6: Sagittal section of brain stem showing fourth ventricle
The floor is lined by ependyma and a

thick layer of neuroglia. The cranial
nerve nuclei lie deep to it.
Upper pontine part has
A median sulcus
Two medial eminences that show facial
colliculi in their lower parts
A superior fovea lateral to facial colliculus
Superior part of vestibular area
Locus ceruleusa blue green pigmented
area along upper lateral margin.
Lower medullary part has
A median sulcus
Three triangles
a. Hypoglossal triangle is medial
b. Vagal triangle is intermediate in
position
It shows inferior fovea in upper
part
Funiculus separansa thick
ridge of ependyma
Area postremaa vascular
neurogial tissue with nerve cells
of moderate size
c. Inferior vestibular area
The medullary striae are curved bands of white

matter, that emerge from median sulcus and
pass laterally in lateral recess. These are
displaced external arcuate fibers.
The fourth ventricle has five recessesone
dorsal median, two dorsal lateral and two lateral
recesses.
The lateral recesses begin at the lateral angles
and curve around inferior cerebellar peduncles.
Their terminal ends are open at lateral openings
that are closed by tuft of choroid plexuses.
The openings of fourth ventricle (Fig. 45.6).
i. One median opening (foramen of Magendie)
is large, funnel-shaped opening in lower part
of roof. It opens in the cerebello-medullary
cistern.
ii. Two small lateral openings (Foramina of
Luschka) at the ends of lateral recesses are
partially blocked by tuft of choroid plexuses.
The choroid plexus lies in the fold of pia mater,
the tela choroidea. Just above the median
opening.
It is shaped like a T with vertical limb double.
A branch of posterior inferior cerebellar
artery supplies the choroid plexus.
CHAPTER
46
The Forebrain
The forebrain (Prosencephalon) consists of:
i. A median portionthe diencephalon.
ii. Two lateral cerebral hemispheresthe
telencephalon.
I. The diencephalon consists of two halves
separated by the median cavity of third ventricle.
Each half consists of a dorsal portion that
includes the thalamus and epithalamus and a
ventral portion that includes subthalamus and
hypothalamus.
a. The thalamus is an ovoid mass of grey matter
that lies in the lateral wall of third ventricle (Fig.
46.1).
Size: The length of thalamus is about 4.0 cm,
width 1.5 cm and thickness 1.0 cm.
Ends and surfaces: The thalamus has two
endsanterior and posteriorand four surfacessuperior, inferior, medial, and lateral.
Fig. 46.1: The thalamisuperior aspect
The anterior end is narrow and pointed and

forms the posterior boundary of interventricular foramen.
The posterior end is expanded and called
pulvinar. It overhangs the back of mid-brain.
The superior surface is covered by a thin
layer of white matterstratum zonale.
It medial part is covered by choroid
plexus and lateral part is lined by
ependyma and forms a part of floor of
central part of lateral ventricle.
The inferior surface is related to
Hypothalamus anteriorly
Subthalamus posteriorly
The medial surface is covered with ependyma
and forms the lateral wall of third ventricle.
An oval band of grey matter, inter thalamic
adhesion (massa intermedia) connects the
medial surface of two thalami.
The lateral surface is covered by a thin layer
of white matterexternal medullary lamina.
It is related to the posterior limb and retrolentiform part of internal capsule.
Internal structure
a. The white matter:
The thalamus has three layers or laminae of
white matter.
Stratum zonale on the superior surface.
External medullary lamina on the lateral
surface.
Internal medullary laminaa thick Yshaped lamina of white matter, that
divides the grey matter in three parts.
b. The grey matter:
i. Anterior part of grey matter is small part
that lies between the two limbs of
internal medullary lamina.
tahir99 - UnitedVRG
The Forebrain
ii. Medial part of grey matter lies between

medial surface and internal medullary
lamina.
iii. Lateral part of grey matter is the largest
part that lies between the lateral surface
and the internal medullary lamina.
Nuclei of thalamus and their connections (Fig.
46.2)
a. The anterior group of nuclei lie in the
anterior part.
Afferent connectionfrom mamillothalamic tract.
Efferent connectionto gyrus cinguli
b. The medial group of nuclei lie in the medial
part
Afferent connections and Hypothalamic nuclei
Efferent con- Other thalamic nuclei
nections also Pre-frontal areas
c. The lateral part contains
i. The lateral group of nuclei (lateral dorsal,
(LD) lateral posterior (LP) and pulvinar
(P).
These nuclei are connected with:
Posterior part of cingulate gyrus
Other thalamic nuclei
Cortical area
Fig. 46.2: The internal structure and nuclei of thalamus
503
ii. The ventral group of nuclei

Ventral Anterior (VA)
Afferent connections
1. Corpus striatum
2. Reticular formation of brain
stem.
Efferent connections
1. Premotor area of cotex
Ventral Intermediate (VI)
1. Cerebellum
2. Red nucleus
1. Motor and premotor areas of
cortex
Ventral Posterior Lateral (VPL)
Afferent connection
1. Medial lemniscus
2. Spinal lemniscus
1. Sensory areas of the cortex
Ventral Posterior Medial (VPM)
Afferent connection
1. Trigeminal lemniscus
2. Taste fibers
Efferent connection
1. Sensory areas of the cortex
d. The minor nuclei
Intralaminar lie scattered inside internal
medullary lamina.
Mid-line nuclei lie along medial surface.
They are poorly developed in human
brain.
Reticular nuclei lie along lateral surface.
These nuclei are connected with the
reticular formation of brain stem and
all parts of cerebral cortex.
e. The geniculate bodies: medial and lateral lie
on the inferior surface of pulvinar.
Lateral geniculate body is part of visual
pathway
Afferent connections: Retinal fibers
from both sides.
504

Efferent connections: Geniculo-
calcarine tract.
Medial geniculate bodyis part of
auditory pathway Afferent connectionsInferior colliculus
Part of auditory pathway
Lateral lemniscus
Efferent connection
Acoustic radiation
Functional Significance
i. Thalamus is a great sub-cortical sensory
correlation center. All sensory impulses
somatic and visceralreach here and are
integrated before passing them on to cerebral
cortex for fine discrimination.
ii. Thalamus is concerned with degree of
consciousness, attention and alertness of an
individual.
iii. Thalamus is involved in subjective feeling
states and the emotional behavior of an
individual.
iv. Thalamus also acts as integration center for
motor impulses.
THE EPITHALAMUS
The epithalamus consists of the pineal body and
the habenular nucleus.
A. The pineal body is small red grey body that lies
between the two superior colliculi.
It is connected by a pineal stalk to the posterior
wall of third ventricle.
The pineal body is homologous with the pineal
organ of earlier vertebrates.
i. In humans, it acts as an endocrine gland.
Its secretion has an inhibitory influence
on the secretions of pituitary gland and
adrenal gland (mainly their gonadotropic
functions)
ii. Tumors of pineal body in the young gives
rise to precocious puberty.
B. The habenular nucleus lies in a small
depression.
The habenular trigone by side of medial aspect
of pulvinar of thalamus.
ConnectionsAfferentStria medullaris
thalami from the hippocampal formation.
Opposite habenular nucleus (the habenular
commissure).
EfferentFasciculus retroflexusto the interpeduncular nucleus from where fibers reach
reticular formation of midbrain.
Function: Habenular nucleus is small but
functionally it is important. It provides a nodal
point for integration of large variety of visual,
olfactory and somatic afferent impulses.
C. The Posterior Commissure lies in the inferior
lamina of pineal stalk.
This commissure is very small in human brain.
The fibers contributing to this commissure are
derived from:
Medial longitudinal fasciculus
Pretectal nucleus
Superior colliculus
Posterior thalamic nuclei
THE HYPOTHALAMUS
The hypothalamus lies below and in front of
thalamus separated by the hypothalamic sulcus.
Location: the hypothalamus lies in anterior part
of lateral wall of third ventricle.
The hypothalamus consists of several nuclei
that are concerned with visceral functions. The
mamillary bodies are part of hypothalamus.
Functions of hypothalamus
i. By releasing certain releasing factors and
inhibiting factors, the hypothalamus
influences the secretion of hormones from
the anterior pituitary gland.
ii. The vasopressin (antidiuretic hormone) and
oxytocin are secreted by hypothalamic
nuclei and reach the posterior pituitary gland,
from where they reach blood stream.
iii. Control of sleep and wakefulness.
iv. Temperature regulation of the body.
v. Emotions and behavior of the individual are
also controlled by hypothalamus.
vi. Control of anatonomic activity of sympathetic and parasympathetic systems.
tahir99 - UnitedVRG
The Forebrain
THE SUBTHALAMUS
The subthalamus lies below thalamus and is
continuous caudally with the tegmenta of midbrain.
The subthalamus has the following collection
of grey matter:
Cranial end of red nucleus
Cranial end of substantia nigra
Subthalamic nucleus
Small nuclei that act as cell station on
pathways to corpus striatum.
The white matter of subthalamus has following
tracts:
Cranial ends of lemniscimedial, trigeminal
and spinal.
Dentato-thalamic tract
Fasciculus retroflexus
Ansa and fasciculus lenticularis
Fasciculus thalamicus
The subthalamic nucleus is quite prominent in
human brain.
The nucleus lies lateral to the cranial end of
red nucleus.
505
It is shaped like a biconvex lens, in a coronal

section
Connections: are mainly with corpus
striatumboth ways.
Other connections are with red
nucleus, substantia nigra, reticular
formation of brain stem and other
thalamic nuclei.
Functional importance: The subthalamic
nucleus is an important center for integration
of motor impulses.
THE THIRD VENTRICLE (Fig. 46.3)

The third ventricle is the median cavity of the
forebrain.
Location: The cavity lies between the two
thalami and hypothalami.
Shape: is irregular
Communications: The third ventricle communicates.
On two sides with the lateral ventricles
through the inter-ventricular foramina
(foramina of Monro).
Inferiorly with cerebral aqueduct that
connects it with the fourth ventricle.
Fig. 46.3: Sagittal section of brain showing third ventricle
506
Boundaries
i. The roof is formed by ependyma, stretching
between the two thalami. The choroid plexus
bulges through it.
ii. The floor is formed by the following:
The optic chiasma
The tuber cinereum, infundibulum and
the hypophysis cerebri
Two mamillary bodies
Posterior perforated substance
Subthalamus
iii. The anterior boundary is formed by
Lamina terminalis
Anterior commissure
Column of fornix
iv. The posterior wall is formed by
The pineal body
The stalk of pineal body having
Habenular commissure
Posterior commissure
v. The lateral walls is formed by
Medial surface of thalamus with interthalamic adhesion
Hypothalamic sulcus
Medial surface of hypothalamus
The third ventricle has a choroid plexus that
bulges through the ependyma of the roof as
two rows of villous processes.
The posterior choroidal branch of posterior
cerebral artery supplies it.
The recesses of third ventricle are
An infundibular recess
A supraoptic recess above optic chiasma
A pineal recess
Applied anatomy
In case of blockage at interventricular foramen,
there may be internal hydrocephalus of the
affected lateral ventricle. Later the hydrocephalus leads to compression of brain.
It also includes the anteriormost part of third

ventricle with lamina terminalis and anterior
commissure.
The cerebral hemisphere has

Three surfacessupero-lateral, medial and
inferior
Three polesfrontal, occipital and temporal
Three borderssupero-medial, infero-lateral
and medial border divided into medial orbital
and medial occipital
The lobes of the hemisphere.
The cerebral hemisphere is divided into four lobes
frontal, parietal, temporal, and occipital.
The division of lobes on the lateral surface is
bone by
The central sulcus
The posterior ramus of lateral sulcus and
its extension.
An imaginary plane connecting preoccipital
notch with parieto-occipital sulcus
The insula: (Island of Reil) is the submerged
area of the cortex that lies in the depth of lateral
sulcus. The insula is covered by the portions
of the adjoining lobes.
THE CEREBRAL CORTEX
The cerebral cortex varies in thickness from

4.5 mm in motor area to 1.5 mm in the visual
area.
There are six laminae or layers of cerebral cortex
1. Molecular layer
2. Outer granular layer
3. Pyramidal layer
4. Inner granular layer
5. Ganglionic layer
6. Polymorphous layer
The Special Cortical Areas

THE TELENCEPHALON
The telencephalon consists of two cerebral

hemispheres with the commissures connecting
them.
The old classification of Brodmanns areas of

cerebral cortex indicates approximately the
different cortical areas and their location (Fig.
46.4).
tahir99 - UnitedVRG
The Forebrain
507
Fig. 46.4: The lateral surface of cerebral hemisphere showing special cortical areas
Although, recent experimental studies have

shown there are no purely sensory or purely
motor areas, most cortical areas have both
afferent and efferent connections.
The Motor Areas

i. The motor area (Area 4) is located in precentral
gyrus and adjoining part of paracentral lobule.
Voluntary movements of opposite half of body
are represented upside down in the motor
area.
ii. The premotor area (Area 6) is located in
posterior part of superior, middle and inferior frontal
gyri.
The premotor area is concerned with learned
motor activity.
iii. The frontal eyefield is located in posterior part
of middle frontal gyrus. It controls the voluntary
scanning movements of the eyes.
iv. The Brocas area (Motor speech center)-(Area
44-45) is an extension of motor area into inferior
frontal gyrus occupying triangular and opercular
parts.
The Brocas area is present in left hemisphere
in right-handed persons.
A lesion of this area causes aphasia, loss of
speech.
The prefrontal area occupies remaining part of

frontal lobe.
This area is concerned with individuals
personality, depth of feelings, initiative and
judgement.
An operationprefrontal leucotomyis
done in certain types of psychotic patients.
All connections of prefrontal area are cut
off to alter the aggressive personality of
the patient.
The Sensory Area
The sensory (Somesthetic) area (Area 3, 1, 2) is
located in the postcentral gyrus and adjoining part
of paracentral lobule.
In this area all exteroceptive and proprioceptive
sensation of opposite half of body are actually
perceived. The body is represented upside
down.
Area 3 receives the exteroceptive sensations,
Area 2 receives proprioceptive sensations, while
the Area 1 coordinates the two types of sensations.
The association areas occupy the remaining part
of parietal lobe.
508
This area is located close to sensory, visual and

auditory areas and its function is to associate
these sensory impulses.
Stereognosisidentification of an object, without seeing, is the property of this area.
The visual areas are (Fig. 46.5):
i. The visuosensory area (striate areaArea
17) is located in depth of calcarine sulcus
and adjoining gyri on the medial surface of
cerebral hemisphere.
The striate area receives the optic
radiations from the lateral geniculate
body.
It perceives the size, shape, colour,
transparency and illumination of an
object.
ii. The visuo-psychic areas (para striateArea
18 and peristriateArea 19)
These areas surrounding the striate area
and are located in the occipital lobe.
The function of these areas is to store
the visual impressions and help in their
recognition.
The Auditory Areas

i. The audito-sensory area (Area 41, 42) is located
in middle part of superior temporal gyrus and
anterior transverse temporal gyrus.
This area receives the acoustic radiations.
The area perceives the loudness, pitch,
frequency, quality and direction of sound.
ii. The audito-psychic area (Area 22) occupies the
remaining part of superior temporal gyrus.
The function of this area is to interpret and
recognize the auditory sensations from past
experience.
The insular area is located in the insula, the
submerged area of cortex in the lateral sulcus.
This area is supposed to be concerned with
visceral functions.
The cingulate area is located in the anterior part of
(Area 24) cingulate gyrus.
This area is connected with the limbic system
and is involved in individuals personality.
The suppressor area is a vertical strip in anterior
part of Area 4.
If stimulated, it causes suppression of all motor
functions for several minutes.
THE BASAL NUCLEI
Fig. 46.5: The medial surface of cerebral hemisphere

showing special cortical areas
The basal nuclei (ganglia) are large, subcortical

masses of grey matter located in the lower and
medial part of cerebral hemisphere.
There are following basal nuclei (Fig. 46.6)
a. The amygdaloid nucleus
b. The corpus striatum consisting of caudate
nucleus and the lentiform nucleus.
There is also a thin crenated sheet of grey
matterthe claustrumthat lies lateral to the
putamen of lentiform nucleus.
a. The amygdaloid nucleus is an almond-shaped
mass of grey matter, located near temporal pole in
the roof of inferior horn of lateral ventricle.
The tail of caudate nucleus and stria terminalis
end in the nucleus.
tahir99 - UnitedVRG
The Forebrain
509
Functional Classification
The corpus striatum is divided into
1. The paleostriatum (palladium) is the older part,
consisting of globus pallidus only.
2. The neostriatum (striatum) newer part,
consisting of putamen of lentiform nucleus and
caudate nucleus.
Fig. 46.6: The caudate and lentiform

nucleilateral aspect
The amygdaloid nucleus is an important part of

limbic system.
b. The corpus striatum is a large mass of grey
matter that is divided into two parts:
i. Caudate nucleus
ii. Lentiform nucleus
I. The caudate nucleus is elongated and comma
shaped mass of grey matter that bulges in the floor
of lateral ventricle. It consists of:
Headis thick anterior end that bulges in the
anterior horn of lateral ventricle. It is continuous
with putamen of lentiform nucleus.
Body is the curved part, that forms the lateral
part of floor of central part of lateral ventricle.
Tail is narrow tapering part that lies in the roof
of inferior horn and ends in the amygdaloid
nucleus.
II. The lentiform nucleus is large lens shaped mass
of grey matter that is completely buried in the white
matter of hemisphere.
The medial surface is more convex and is related
to the internal capsule.
The lateral surface is less convex and is related
to the external capsule and claustrum.
The lentiform nucleus is divided into two parts
a. An outer putamen
b. An inner lighter partglobus pallidus.
Connections of corpus striatum

I. Paleostriatum is the afferent part of corpus
striatum.
i. Strio-pallidalfrom neostriatum
ii. Subthalamo-pallidal from the subthalamic nucleus
iii. Nigro-pallidal from the substantia nigra.
Efferent connection
i. Ansa lenticularis
ii. Fasciculus lenticularis joins the ansa
lenticularis and dentato-thalamic tract to
form thalamic fasciculus that ends in
ventral lateral and ventral lateral nuclei
of thalamus.
Fibers from these nuclei are relayed to
the motor and premotor areas of the
cortex.
iii. Subthalamic fasciculus
iv. Pallido-hypothalamic fasciculus
v. Descending fibers to red nucleus,
reticular formation of brain stem and
inferior olivary nucleus.
II. Neostriatum is the efferent part of corpus
striatum.
Afferent connection
i. Cortico-striate from all parts of cerebral
cortex.
ii. Thalamo-striate from intra-laminar and
medial group of nuclei of thalamus.
iii. Nigro-striate from substantia nigra.
Efferent connection
i. Strio-pallidal is the main efferent
outflow
ii. Strio-nigral to substantia nigra
510
Functional Significance
i. The corpus striatum is connected with
lower motor centers by polysynaptic pathways. The main outflow, however, is via
thalamus to motor and premotor areas of
the cortex.
ii. The corpus striatum is connected with
motor functions of the body, but its complex
interconnections and functional significance
is not well understood.
Applied Anatomy
i. Lesions of corpus striatum produce
Disturbances in muscle tonemostly
rigidly
Loss of automatic associated movements
Certain unwanted and uncontrollable
movements
ii. Wilsons disease (Hepato-lenticular degeneration) involves liver and lentiform nucleus.
THE WHITE MATTER OF

CEREBRAL HEMISPHERE
The white matter forms the central white core

of the cerebral hemisphere.
There are three types of fibers in the white

matter.
i. The association fibers
ii. The commissural fibers
iii. The projection fibers
I. The association fibers connect the different

cortical areas of the same hemisphere: (Fig. 46.7)
The association fibers are:
Short association fibers that connect
adjacent gyri.
Long association fibers that are arranged in
bundles and and connect the distant areas
of cortex of same hemisphere. The important association bundles are:
a. Cingulum that lies in the cingulate gyrus.
Inferiorly, it spreads in parahippocampal
gyrus of temporal lobe.
b. Uncinnate fasciculus connects the motor
speech center and orbital gyri with
temporal pole.
c. The superior longitudinal fasciculus is
the largest bundle that connects the
frontal lobe with areas of occipital and
temporal lobes.
Fig. 46.7: The association fibers of cerebral hemisphere
tahir99 - UnitedVRG
The Forebrain
d. The inferior longitudinal fasciculus
connects the areas of occipital lobe with
temporal pole.
e. The fronto-occipital fasciculus lies lateral
to the caudate nucleus on a deeper plane
and connects frontal area with occipital
areas.
f. Perpendicular fasciculus connects the
different areas of the occipital lobe.
II. The commissural fibers connect the corresponding areas of the two cerebral hemispheres.
These fibers cross the median plane and are
arranged in well defined bundles.
The different commissural fiber bundles of
forebrain are:
a. The corpus callosum
b. The anterior commissure
c. The habenular commissure
d. The posterior commissure
e. The hippocampal commissure
A. The corpus callosum is the largest commissural
bundle.
It forms a thick curved band that connects
the medial surfaces of two hemispheres.
Parts
i. The anterior end is genu that is bent like
knee. It thins out below to form the
rostrum.
ii. The body is the main part that curves
backwards from the genu and roofs over
the lateral ventricles.
iii. The splenium is thick posterior end that
is separated by transverse fissure from
the pineal body.
Fibers: The fibers of the rostrum connect
the orbital surfaces of two hemispheres.
The fibers of genuforceps minor
radiate laterally and connect the lateral
and medial surfaces of frontal lobes of
the two hemispheres.
The fibers of body are divided into two
groups:
511
a. The crossed fibers are intersected by

fibers of corona radiata. They
connect the cortical areas of frontal,
parietal and temporal lobes.
b. The uncrossed fiberstapetum
fiberscurve medially and downwards and form the roof and lateral
walls of posterior and inferior horns
of lateral ventricle.
The fibers of splenium form a thick
curved bundlethe forceps major that
connect the occipital lobes of the two
hemispheres.
The forceps major also forms a swellingthe bulbin posterior horn of
lateral ventricle.
Applied Anatomy
i. Congenital absence of corpus callosum
usually at autopsies has been reported
with very few symptoms.
ii. Surgical division is done sometimes of
the corpus callosum to reach the interior
of lateral ventricle with little loss of
function.
B. The anterior commissure forms a small oval
bundle behind the lamina terminalis in the
anterior wall of third ventricle.
The fibers of this commissure are twisted
like a rope and it grooves the inferior surface
of lentiform nucleus.
The fibers of anterior commissure are
divided in two groups.
The medial small group of fibers
connect the olfactory areas of the
two hemispheres.
The lateral layer group of fibers
connect the frontal lobes of the two
hemispheres.
C. The habenular commissure lies in the anterior
lamina of stalk of pineal body, in posterior wall
of third ventricle.
This commissure connects the habenular
nuclei of the two sides.
512
D. The posterior commissure (described with the

diencephalon).
E. The hippocampal commissure (commissure of
fornix).
It is a thin triangular sheet of white matter
that connects the two crura (posterior
columns) of the fornix.
The fibers of this commissure connect the
hippocampi of the two cerebral hemispheres.
III. The projection fibers connect the cerebral
cortex with other parts of brain and spinal cord.
There are two types of projection fibers:
Ascending or corticopetal fibers from other
parts of brain and spinal cord to the cerebral
cortex.
Descending or corticofugal fibers from
cerebral cortex to other parts of brain and
spinal cord.
The projection fibers of the cerebral hemisphere
lie in:
a. The corona radiata
b. The internal capsule
a. The corona radiata lies just below the
cerebral cortex.
Here, projection fibers from all parts of
cerebral cortex converge towards the
base of the hemisphere.
These fibers intersect the transversely
running crossed fibers of corpus callosun.
b. The internal capsule is a broad curved band
of projection fibers in basal part of hemisphere that is continuous above with corona
radiata and below with crus cerebri of midbrain. (Fig. 46.8)
Location: The internal capsule is located
between:
The thalamus and head of caudate
nucleus medially.
The lentiform nucleus laterally.
Parts
i. The anterior limb lies between the
head of caudate nucleus and lentiform nucleus
Fig. 46.8: The internal capsuleparts

(Horizontal section)
ii. The genu is the bent portion.

iii. The posterior limb is the largest part
between the thalamus and lentiform
nucleus.
iv. The retro-lentiform part lies behind
the lentiform nucleus and lateral to
thalamus.
v. The sub-lentiform part is a small part
below lentiform nucleus.
Fiber tracts of internal capsule
The anterior limb has
The fronto-pontine fibers
The anterior thalamic radiations
connecting anterior and medial nuclei of
thalamus with cortex (Fig. 46.9).
The genu has
The cortico-nuclear fibers connecting
motor area of cortex with motor cranial
nerve nuclei.
Most anterior fibres of superior thalamic
radiations.
The posterior limb has
The cortico-rubral fibers from the
frontal cortex to the red nucleus of midbrain.
The cortico-spinal fibers occupy the
anterior part of posterior limb. They are
in form of three bundles:
tahir99 - UnitedVRG
The Forebrain
513
The acoustic radiations from the medial
Fig. 46.9: The nerve tracts of internal capsule
i. Anterior bundle for head and neck

fibers.
ii. Middle bundle for the fibers of upper
limb and trunk.
iii. Posterior bundle for the fibers of
lower limb.
The posterior thalamic radiationsmain
part lies in the posterior limb.
These radiations connect the ventral
nuclei of thalamus with the cortex.
The retro-lentiform part has
The posterior thalamic radiations
connecting the posterior part of thalamus with cortex.
The parieto-pontine and occipito-pontine
fibers
From visual cortex to superior colliculus
and pretectal area.
The optic radiations (geniculo-calcarine
tract) from lateral geniculate body to the
visual cortex.
The sublentiform part has
The temporopontine fibers
geniculate body to the auditory area of

the hemisphere.
The arterial supply of the internal capsule
i. Most of the internal capsule is supplied by
striate branches of middle cerebral artery.
One lateral striate artery (Charcots artery)
supplies anterior part of posterior limb,
where the cortico-spinal fibers lie.
ii. The anterior limb is also supplied by a
branch of anterior cerebral artery Heubners
artery.
iii. The posterior limb is also supplied by
branches of posterior communicating and
anterior choroidal arteries.
Applied anatomy
The Charcots artery is mainly involved in
the attack of cerebral hemorrhage.
The condition leads to contralateral hemiplegia and widespread sensory loss in
opposite half of the body.
THE LATERAL VENTRICLE

The lateral ventricle is the cavity of the cerebral
hemisphere.
The lateral ventricle of the functionally dominant
hemisphere is called the first ventricle.
The lateral ventricle lies in the lower and medial
part of the hemisphere. The two lateral
ventricles are separated by a thin bilaminar
septumseptum pellucidum.
Parts : The lateral ventricle has the following
parts: (Fig. 46.10)
A central part
Three horns
Anterior horn
Posterior horn
Inferior horn
The lateral ventricle communicates with third
ventricle by inter-ventricular foramen (Foramen
of Monro). It is a slit-like opening bounded :
Anteriorly by column of fornix
Posteriorly by anterior end of thalamus
514
Fig. 46.10: The parts of lateral ventricle
Boundaries
i. The anterior horn is a wide space that points
forwards and laterally in frontal lobe. (Fig.
46.11)
Roof is formed by under surface of
corpus callosun.
Medial wall by septum pellucidum.
Floor is formed.
Medially by rostrum of corpus callosun
(small part).
Laterally by bulging head of caudate
nucleus
ii. The central part extends from interventricular foramen up to splenium of
corpus callosum.

anterior horn of lateral ventricle
Roof by under surface of corpus callosum. (Fig. 46.12)

Medial wall by septum pellucidum.
Floor from lateral side by
Body of caudate nucleus
Stria medullaris
Thalamo-striate vein
Lateral part superior surface of
thalamus
Choroid plexus
iii. The posterior horn is a narrow diverticulum
that passes backwards and medially in
occipital lobe.
This horn is variable in size.
Roof and lateral wall is formed by
tapetum fibers of corpus callosum (Fig.
46.13).
Medial wall has two elevations.
Upper elevation has Bulb of posterior horn formed by forceps major
of corpus callosum.
Lower elevation has Calcar avis
formed by the deep calcarine
sulcus.
iv. The inferior horn is the largest of three horns
that passes from the level of splenium
towards the temporal pole.
tahir99 - UnitedVRG
The Forebrain
515
Fig. 46.12: Coronal section through central part of lateral ventricle
This horn represents the continuation

of the cavity of lateral ventricle (Fig.
46.14).
Roof and lateral wall is formed by
tapetum fibers of corpus callosum.
Tail of caudate nucleus that ends
anteriorly in amygdaloid nucleus.
1. Stria terminalis
Floor is formed by
1. Collateral eminence formed
by deep collateral sulcus.
2. Hippocampusan elevation
of grey matter, shaped like
hippocampus.
3. Fimbriaa band of white
matter on medial side of
hippocampus.
Fig. 46.13: Coronal section through posterior

horn of lateral ventricle
4. Choroid plexus formed by a

fold of pia mater.
The choroid plexus of lateral ventricle
The choroid plexus is located in the central part
and inferior horn only.
In the central part the choroid plexus lies in
the lateral margin of common tela choridea
and passes through choroidal fissure between thalamus and fornix.
In the inferior horn it is formed by a separate
fold of pia mater that bulges through the
choroidal fissure between fimbria and tail
of caudate nucleus.
Applied anatomy
i. Internal hydrocephalus results in case of
blockage at the inter-ventricular foramen.
The ventricle becomes dilated due to excess

inferior horn of lateral ventricle
516

of cerebrospinal fluid and the brain substance undergoes compression.
ii. Pneumo-encephalography is a special
procedure to visualize the ventricles. Air is
introduced through the lumbar puncture.
THE LIMBIC SYSTEM
The limbic system includes phylogenetically

older areas of cortexarchipalliumand other
associated nuclei and their fiber tracts.
The parts of limbic system are
Olfactory bulb and tract
Olfactory areasmedial and lateral
Indusium gresium
Amygdaloid nucleus
Parahippocampal gyrus and gyrus cinguli
Hippocampus
Anterior part of thalamus and mamillary
bodies
The fiber tracts of the limbic system are:

Fimbria and its continuation the fornix and
hippocampal commissure.
Longitudinal striaemedial and lateral.
Mamillo-thalamic tract
Stria terminalis and stria-medullaris thalami
Functional significance
i. The limbic system is concerned with
emotional behavior of an individual, viz.
fear, anger, social response and other
homeostatic responses.
ii. It is also concerned with integration of large
number of impulsesvisceral, olfactory and
somatic.
iii. The limbic system is also involved in recent
memory and memory patterns.
iv. Certain parts of limbic system perform the
olfactory function, but this is a minor
function.
tahir99 - UnitedVRG
CHAPTER
47
The Cranial Nerves

There are twelve pairs of cranial nerves attached
to the brain.
The cranial nerves arise or terminate in certain
nuclei of grey matter in the brain.
The cranial nerves can be classified under the
followingfunctional nervous components to
which their nuclei belong.
i. The somatic efferent nuclei (SE) give out
axons to supply the somatic muscles.
ii. The special visceral efferent nuclei (Sp. VE)
give out axons to supply the muscles
developed from the branchial arches.
iii. The general visceral efferent nuclei (GVE)
give out axons to innervate the glands of
head and neck or the visceral musculature.
iv. The general visceral afferent nuclei (GVA)
receive the afferent sensations from the
viscera.
v. The special visceral afferent nuclei (Sp. VA)
receive the special sense of taste developed
in the region of primitive pharynx.
vi. The general somatic afferent nuclei (SA)
receive the afferent sensations from the skin
and proprioceptors.
vii. The special somatic afferent nuclei (Sp SA)
receive afferent sensations from the special
sensesolfaction, vision, auditory and
balance.
THE FUNCTIONAL CLASSIFICATION
OF CRANIAL NERVES
The cranial nerves can be divided into three groups:
Group I has the oculomotor, trochlear, abducent
and hypoglossal nerves.
These nerves arise from the neurons

belonging to somatic efferent (SE) functional component.
Group II has the trigeminal, facial, glossopharyngeal, vagus and accessory nerves.
These nerves supply the derivatives of the
branchial arches from special visceral
efferent (Sp. VE) and special visceral
afferent (Sp. VA) functional components.
Group III has the nerves related to the special
senses. They belong to special somatic afferent
(Sp. SA) component.
This group includes the olfactory, optic and
the vestibulo-cochlear nerves.
GENERAL DESCRIPTION OF THE

CRANIAL NERVES
1. The Olfactory Nerve (I cranial nerve)
Functional component: Special somatic afferent
(Sp. SA).
Nearly twenty olfactory nerves arise from the
olfactory receptor cells in the nasal mucosa,
and pass through the cribriform plate and end
in the olfactory bulb.
The olfactory bulb lies on the cribriform plate
and continues as olfactory tract to the olfactory
areas of the brain.
Applied anatomy: In head injuries, the olfactory
bulb and tract may be damaged.
Infection may also travel via these nerves to
the meninges of the brain.
2. The Optic Nerve (II cranial nerve)
Functional component Special somatic afferent
(Sp. SA).
The optic nerve begins from the axons of
the ganglion cells of the retina.
518
The optic nerve is, in fact, not a nerve but

a tract of brain that lies outside brain. This
is proved by following two factors:
a. The optic nerve carries around it three
sheaths derived from the three meninges
of the brain.
b. The optic nerve fibers, like the nerve
tracts of the brain, have no neurilemma
sheath, and are, therefore, incapable of
regeneration.
Increase in the intracranial pressure
compresses the central vein and artery of
retina as they lie in the extension of the
subarachnoid space between the sheaths of
the optic nerve. This causes papilloedemas
or swelling of the optic disc inside the
eyeball.
The optic nerve pierces the sclera a few
millimeters medial to the posterior pole of
the eyeball.
The nerve is about 4.0 cm long and is
slightly longer than the distance from back
of eyeball to the optic foramen, to allow for
movements of eyeball.
It leaves the orbit by the optic canal and is
attached to the antero-lateral angle of the
optic chiasma.
The Visual Pathway (Fig. 47.1)
A. The retina of the eyeball receives an inverted
image of the object through the lens. The
B.
C.
D.
E.
photosensitive cells of the retinathe rods

and cones actually perceive the image.
Within retina, there are three sets of
neurons, that relay the visual image.
They are:
a. The rods and cones
b. The bipolar cells
c. The ganglion cells
The axons of the ganglion cells form the
optic nerve.
The optic nerve reaches the optic chiasma,
where a partial crossing of the retinal fibers
takes place.
The nasal retinal fibers of the two retinae
(from the two eyeballs) cross in the optic
chiasma, while the temporal retinal fibers
of the two retinae, continue on the same
side.
The optic tracts carry the crossed nasal
retinal fibers and uncrossed temporal retinal
fibers to the lateral geniculate body.
The lateral geniculate body is a small
nucleus, situated below the pulvinar or
posterior end of thalamus.
The lateral geniculate body has six
laminate of grey matter, the laminae 2,3
and 5 receive the crossed temporal retinal
fibers and the laminae 1,4 and 6 receive
the crossed nasal retinal fibers.
From the lateral geniculate body, the retinal
fibers pass, as the optic radiations or
Fig. 47.1: The visual pathway
tahir99 - UnitedVRG
The Cranial Nerves

geniculo-calcarine tract through the internal
capsule to reach the primary visual area
(Area 17) situated in the calcarine sulcus of
the occipital lobe, where the visual image is
actually perceived.
Applied anatomy
i. A lesion of the optic nerve causes total
blindness in the affected eye.
ii. Lesions of the optic tracts, lateral geniculate
body and optic radiations lead to homonymous hemianopia of the opposite side
(i.e. loss of nasal visual field of the same
side and temporal visual field of the opposite
side).
3. Oculomotor Nerve (III cranial nerve)
It has two functional components:
i. Somatic efferent (SE) that innervates the
extra-ocular muscles including levator
palpebrae superioris developed from the body
wall musculature.
ii. General visceral efferent (GVE) that supplies
the muscles developed from the visceral
musculature.
The Oculomotor nucleus lies in the central grey

matter of mid-brain at level of superior colliculus.
The Oculomotor nucleus is divided into parts
for supplying different extra-ocular muscles
causing movements of the eyeball.
The Edinger-Westphal nucleus gives origin to
the parasympathetic fibers, that relay in ciliary
ganglion and supply two intraocular muscles
sphincter pupillae and ciliary.
Course: The oculomotor nerve comes out of
medial sulcus on medial aspect of crus cerebri
in the interpeduncular fossa of the base of brain.
It passes forwards, pierces the roof of
cavernous venous sinus and then runs along
the lateral wall of cavernous sinus above
trochlear nerve.
In the anterior part of cavernous sinus the
oculomotor nerve divides into superior
ramus and an inferior ramus.
519
The two rami enter the orbit through the

middle part of superior orbital fissure within
the common tendinous ring.
Branches (Fig. 47.2)
A. The superior ramus gives two branches
to
Superior rectus
Levator palpebrae superioris
B. The inferior ramus gives three branches
to
Medial rectus
Inferior rectus
Inferior oblique
The nerve to inferior oblique gives a communicating branch to the ciliary ganglion. This branch
carries preganglionic parasympathetic fibers
that relay in the ciliary ganglion and pass along
short ciliary nerves to supply the two intra-ocular
musclessphincter pupillae and ciliary.
Applied anatomy
A lesion of oculomotor nerve gives the following
symptoms:
i. Ptosis (drooping of upper eyelid)
ii. Dilatation of pupil
iii. Lateral squint or strabismus
iv. Proptosis or slight bulging of the eyeball
v. Loss of accommodation
vi. Double vision or diplopia
4. The Trochlear Nerve (IV cranial nerve)
Functional component is somatic efferent (SE)
The nucleus of the trochlear nerve lies in
the central grey matter of midbrain of level
of inferior colliculus
The trochlear nerve is the most slender
cranial nerve and it completely
decussates inside midbrain before
emerging out.
The trochlear nerve is attached to the dorsal
aspect of midbrain just below inferior
colliculus.
Course: The nerve curves around the crus
cerebri and then passes forwards. It pierces
520
Fig. 47.2: The branches of oculomotor nerve
the roof of the cavernous venous sinus

behind oculomotor nerve.
1. The trochlear nerve runs forwards along
the lateral wall of cavernous venous
sinus below oculomotor nerve.
2. It enters the orbit through the lateral part
of superior orbital fissure.
Branch
The trochlear nerve supplies only one
extraocular musclethe superior oblique.
Applied anatomy
The lesion of trochlear nerve produces.
Inability to turn the eyeball downwards and
laterally.
If attempt is made to turn the eye towards
the action of the muscle, it causes diplopia
(double vision).
5. The Trigeminal Nerve (V cranial nerve)
Functional components are
i. Special visceral efferent (Sp VE) innervates
the muscles developed from the branchial
arches.
ii. Somatic afferent (SA) supplies the
extroceptors and proprioceptors of the head
and neck region.
The nuclei of the trigeminal nerve are:
The motor nucleus of trigeminal nerve lies
in the tegmentum of pons.
The sensory nuclei of the trigeminal are three:
a. The superior sensory nucleus lies in the
tegmentum of pons and recieves touch and
pressure sensation from head and neck region.
b. The spinal nucleus lies in medulla oblongata

and extends downwards up to upper five
cervical segments of the spinal cord. This
nucleus is concerned with pain and temperature sensations from the head and neck
region.
c. The mesencephalic nucleus extends into the
tegmentum of midbrain. It contains pseudounipolar neurones (like dorsal root ganglia
of spinal nerves) and is concerned with
proprioceptive sensations from the head and
neck region.
Course: The trigeminal nerve is attached on the
ventral aspect of pons by a large sensory root
and a small motor root.
The trigeminal ganglion (semilunar ganglion) is the sensory ganglion of trigeminal
nerve. [Described in Chapter 37]
Location: The ganglion lies in a fold of dura
matercavum trigeminalenear the apex
of petrous temporal bone.
The ganglion relays all the exteroceptive
sensory fibers of the three divisions of
trigeminal nerve.
Shape: is semilunar with a convex border
facing forwards and laterally : and a concave
border facing backwards and medially.
The three divisions, ophthalmic, maxillary
and mandibular are attached to the convex
border.
The sensory root is attached to the concave
border.
tahir99 - UnitedVRG
The Cranial Nerves

a. The ophthalmic division is purely sensory nerve
and is smallest of the three divisions.
It passes forwards lying along the lateral
wall of cavernous venous sinus between
trochlear nerve above and maxillary nerve
below.
Inside cavernous sinus the ophthalmic nerve
divides into its three terminal branches
the lacrimal, frontal and naso-ciliary.
The lacrimal and frontal nerves enter the
orbit through the lateral part of superior
orbital fissure.
The nasociliary nerve enters the orbit
through the middle part of superior orbital
fissure between the two rami of oculomotor
nerve.
(Described in Chapter 48).
b. The maxillary division is also purely sensory
nerve and is intermediate in size.
It passes forwards from the ganglion lying
along the lateral wall of cavernous venous
sinus below ophthalmic nerve.
It leaves skull through foramen rotundum
and enters pterigopalatine fossa.
c. The mandibular division is also purely sensory
and largest of the three divisions.
It turns laterally and passes out of skull
through foramen ovale.
Just below skull the mandibular nerve, that
is a mixed nerve.
6. The Abducent Nerve (VI cranial nerve)
Functional component is somatic efferent,
(SE)
The nucleus of the abducent nerve lies deep to
the facial colliculus in the pontine part of floor
of fourth ventricle.
Course: The abducent nerve passes forwards
from its attachment at the lower border of
pons.
It pierces meningeal layer of dura mater,
below dorsum sellae and passes laterally and
forwards between two layers of dura mater
for a short distance.
7.
521
The nerve lies within dural walls of the

cavernous sinus, infero-lateral to the internal
carotid artery.
The nerve enters the orbit through the middle
part of superior orbital fissure lateral to the
two rami of oculomotor nerve.
Branch: The abducent nerve supplies one extraocular musclethe lateral rectus.
Applied anatomy: The lesion of the abducent
nerve produces.
Medial squint or strabismus
Diploma or double vision
The Facial Nerve (VII cranial nerve)
Functional components are:
i. Special vesceral efferent (Sp. VE) that
supplies the muscles developed from the
branchial arches
ii. General visceral efferent (GVE) that
supplies the muscles developed from the
visceral musculature.
iii. Special visceral afferent (Sp. VA) that
receives the special sensation of taste.
The nuclei of the facial nerve are:
a. The motor nucleus of facial lies in the
tegmentum of pons lateral to the abducent
nucleus.
b. The superior salivary nucleus lies in the
tegmenture of pons. It gives out preganglionic parasympathetic fibers that relay in
the pterygo-palatine ganglion and supply the
lacrimal gland.
Some preganglionic parasympathetic
fibers relay in the submandibular
ganglion and supply submandibular and
sublingual salivary gland.
c. The nucleus of tractus solitarius receives
the afferent taste fibers from the anterior
two-third of tongue (except vallate papillae).
Course: The facial nerve is attached at the lower
border of pons by a large motor root and a
laterally placed small sensory root the nervus
intermedius.
The nerve passes laterally, the two roots
join and the nerve enters the internal acoustic
meatus in the posterior cranial fossa.
522
The facial nerve passes through a bony

facial canal that bulges in the medial wall
of the middle ear.
The facial canal opens below at the stylomastoid foramen.
Inside the facial canal, the facial nerve has
a geniculate ganglion that relays the sensory
fibers of the nerve.
The nerve comes out of stylomastoid
foramen, gives a posterior auricular branch
and two muscular branches to muscles of
neck.
It crosses lateral to the base of styloid
process and enters the parotid gland.
Inside parotid gland, the nerve divides into
five sets of branches that supply the muscles
of face and scalp.
Branches
i. Of communication are given to:
Pterygopalatine ganglion
Otic ganglion via lesser petrosal nerve
Vagus and glossopharyngeal nerves
ii. Of distribution
a. Nerve to stapedius is given in bony facial
canal
b. Chorda tympani carries:
The afferent taste fibers from
anterior two-third of tongue (except
vallate papillae).
fibers for submandibular and sublingual salivary glands.
The chorda tympani is also given
inside the bony facial canal and
comes out of petro-tympanic fissure. It joins the lingual nerve at an
acute angle in the infratemporal
fossa.
c. The posterior auricular branch supplies
the occipital belly of epicranius muscle
and the auricularis posterior.
d. The two muscular branches supply:
Stylohyoid
e. The terminal branches in the face are

five sets.
Temporal, zygomatic, buccal mandibular and cervical.
These branches supply
The muscles of scalp
The muscles of face
Auricularis anterior and superior
Platysma
Applied anatomy
Lesions of the facial nerve may occur in
infections of middle ear also.
The facial nerve paralysis (Bells paralysis)
(Described in Chapter 37)
8. The Vestibulo-Cochlear Nerve [VIII cranial
nerve]
Functional component is
Special somatic afferent (Sp.SE)
The nerve consists of two nervesthe
vestibular nerve and the cochlear nerve.
I. The vestibular nerve is concerned with the
function of balance and equilibrium.
The vestibular nuclei are four in number and
they lie in the vestibular area of the floor of
fourth ventricle (party in pons and partly in
medulla oblongata.
The vestibular nuclei are:
a. The medial vestibular nucleus
b. The inferior vestibular nucleus
c. The lateral vestibular nucleus
d. The superior vestibular nucleus
Course: The vestibular nerve arises from the
bipolar neurones of the vestibular ganglion of
the internal ear.
The nerve comes out of the internal acoustic
meatus in posterior cranial fossa and is
attached to the lower border of pons lateral
to the facial nerve.
The nerve ends in the vestibular nuclei.
II. The cochlear nerve is concerned with the
special sense of hearing.
The cochlear nuclei are twothe ventral
cochlear nucleus and the dorsal cochlear nucleus.
tahir99 - UnitedVRG
The Cranial Nerves

These nuclei lie on the ventro-lateral and dorsilateral aspect of the inferior cerebellar peduncle.
Course: The cochlear nerve begins from the
bipolar neurons of the spiral ganglion of the
internal ear.
The nerve comes out of the internal acoustic
meatus and is attached at the lower border
of pons lateral to the facial nerve.
The nerve ends in the cochlear nuclei.
9. The Glossopharyngeal Nerve (IX cranial nerve)
i. Special visceral efferent (Sp. VE) is concerned with nerve supply of muscle
developed from the branchial arches.
ii. General visceral efferent (GVE) is involved
with the nerve supply of parasympathetic
fibers to the parotid salivary glands.
iii. General visceral afferent (GVA) is responsible for general sensation in the pharynx
region.
iv. Special visceral afferent (Sp. VA) is concerned with special sense of taste from
posterior third of tongue (including vallate
papillae).
The nuclei of the glossopharyngeal nerve are
a. The nucleus ambiguus that lies in medulla
oblongata and gives out axons to supply the
branchial arch musculature.
b. The inferior salivary nucleus gives origin
to the preganglionic parasympathetic fibers
for the parotid salivary gland.
c. The spinal nucleus of the trigeminal nerve
is concerned with general sensation.
d. The nucleus of tractus solitarius receives
the special sensory fibers of taste.
Distribution
Motor Supply
Stylopharyngeus
Secretomotor
Parotid gland
Supply
Sensory Supply Posterior 1/3rd tongue
Pharynx
Auditory tube, middle
ear
523
Carotid sinus
Carotid body
Special Sensory Posterior 1/3rd tongue
Supply (Taste) Circum vallate papillae
Course: The glossopharyngeal nerve is attached
on the postero-lateral sulcus of medulla
oblongata above vagus nerve between olive and
inferior cerebellar peduncle.
The nerve from its attachment turns laterally
grooving the superior surface of jugular
process of occipital bone.
It comes out of skull, through middle part
of jugular foramen enclosed in separate dural
sheath.
[The extra cranial course and branches
described in Chapter 40].
10. The Vagus Nerve (X cranial nerve)
i. Special visceral efferent (Sp. VE) concerned
with the nerve supply of muscles developed
from branchial musculature.
ii. General visceral efferent (GVE) concerned
with the nerve supply of visceral musculature (of gastro-intestinal system and
respiratory system)
.
iii. General visceral afferent (GVA) concerned
with the receiving sensations from the
viscera.
iv. Special visceral afferent (Sp. VA) is
concerned with special sense of taste from
posteriormost part of tongue and epiglottis.
v. Somatic afferent (SA) is concerned with
reception of general sensations.
The nuclei of the vagus nerve are:
a. The nucleus ambiguous for the supply of
branchial musculature.
b. The dorsal nucleus of vagus considered to
be a mixed nucleus concerned with
Supply of smooth muscles of the viscera
Receiving afferent sensations from the
viscera.
c. The nucleus of tractus solitarius receives
the special sensory fibers of taste.
d. The spinal nucleus of trigeminal nerve
receives the general sensory fibers.
524
Distribution
Motor Supply
Viscoral Motor
Supply
Special Sensory
Supply (Taste)
Sensory Supply
Muscles of soft palate

pharynx and laryx.
Striated muscle of
esophagus.
Cardiac muscle
Smooth muscle of G.I.
system and
Respiratory system
Lower part, esophagus
Posteriormost part of
tongue epiglottis
External ear
Cutaneous area behind ear
Course
The vagus nerve is attached on the posterolateral sulcus of medulla oblongata below
the glosso-pharyngeal nerve.
The nerve turns laterally and comes out of
skull through the middle part of jugular
foramen, enclosed in a common dural
sheath with the accessory nerve.
[The cervical part of course and branches
is described in Chapter 40. The thoracic part
of the course is described in Chapter 24.
The abdominal part of course is described
in Chapter 27].
11. The Accessory Nerve (XI cranial nerve)
Functional component is
Special visceral efferent (Sp. VE) concerned
with the nerve supply of muscles developed
from branchial arches.
The nuclei of origin are
a. The nucleus ambiguous gives origin to the
fibers of the cranial part.
b. The spinal nucleus located in the anterior
grey column of upper five cervical segments
of the spinal cord gives origin to the fibers
of the spinal part.
Distribution
Cranial part
Motor Supply Muscles of soft palate
Intrinsic muscles of
larynx
Spinal part
Motor Supply
Sternomastoid, trapezius
Course: The accessory nerve is attached on

the postero-lateral sulcus of medulla oblongata
below the vagus nerve.
The spinal part is attached on the lateral
aspect of the spinal cord and ascends
upwards through the foramen magnum to
join the cranial part.
The accessory nerve comes out of skull
through the middle part of jugular foramen,
enclosed in a common dural sheath with
vagus nerve.
The cranial part just below the skull joins
with the vagus nerve and its fibers are
distributed along the pharyngeal and
laryngeal branches of vagus.
[Course and branches of spinal part are
described in Chapter 40].
12. The Hypoglossal nerve (XII cranial nerve)
The functional components
Somatic efferent (SE) concerned with
supply of muscles developed from the body
wall musculature.
The nucleus of hypoglossal nerve lies in medulla
oblongata deep to the hypoglossal triangle in
the floor of fourth ventricle.
Distribution
Motor Supply
All extrinsic and intrinsic muscles of tongue
except palatoglossus
Course: The hypoglossal nerve is attached on
the anterolateral sulcus of medulla oblongata
between the pyramid and olive.
The nerve turns laterally from its attachment
and passes out of skull through the anterior
condylar canal.
[Course and branches described in Chapter
40].
tahir99 - UnitedVRG
CHAPTER
48
The Eyes
The two eyeballs and their appendagesmuscles,
vessels, and nerveslie in the bony cavities on
front of the skull called orbits.
THE ORBIT (Fig. 48.1)
The shape: pyramidal with base at the orbital

opening and apex at the medial end of superior
orbital fissure.
The walls: The bony orbit has a roof, a floor, a
lateral wall and a medial wall.
I. The roof is formed by:
The orbital plate of frontal bone.
The lesser wing of sphenoid (a small
part posteriorly).
There is a depression in lateral part of
roof-lacrimal fossathat lodges the
lacrimal gland.
II. The floor is formed by:
The orbital surface of maxilla.
The zygomatic (a small part anteriorly).
There is an infra-orbital groove and canal
in the floor.
III.The lateral wall is formed by

The greater wing of sphenoid.
The zygomatic bone (a small part anteriorly).
Nearly 1.0 cm below fronto-zygomatic
suture, near lateral orbital margin is
Whitnalls tubercle that gives attachment
to:
Lateral palpebral ligament.
Lateral check ligament of eyeball.
Suspensory ligament of eyeball.
Lateral edge of aponeurosis of
lavator palpebrae superioris.
IV. The medial wall is formed by:
The body of sphenoid.
Orbital plate of ethmoid.
Lacrimal bone.
Frontal process of maxilla.
There is a lacrimal groove in the anterior part
of medial wall limited by an anterior and a
posterior lacrimal crest. The lacrimal sac lies
in the groove.
Fig. 48.1: The bony orbit
526
The foramina and fissures

a. The optic canal lies at the junction of roof
and medial wall.
b. The superior orbital fissure is a large fissure
that lies between the roof and the lateral wall.
It connects the orbit with middle cranial
fossa.
c. The inferior orbital fissure is situated
between the lateral wall and the floor. It
connects the orbit with infra-temporal fossa.
d. The naso-lacrimal canal is located at the
lower end of lacrimal groove. It conducts
the naso-lacrimal duct from the lower end
of lacrimal sac to the lateral wall of the nasal
cavity.
e. The anterior and posterior ethmoidal canals
are situated between the orbital plate of
ethmoid and the roof.
(The structures passing through these
foramina and fissures have been described
in other Chapter).
THE EYELIDS (PALPEBRAE)

There are two eyelidsupper and lower that
protect the anterior part of the eyeball.
The eyelids bound the palpebral fissure in front
of the eye. The upper eyelid is larger and more
mobile.
Structure of the eyelid: The eyelid has the
following layers:
i. The skin: is very thin.
ii. The subcutaneous tissue has no fat. It is very
loose and fluid (edema) or blood (black eye)
can collect here. The palpebral part of
orbicularis oculi lies in the deeper part.
iii. The tarsal plate is a thick condensed plate
of connective tissue. [It is larger for the
upper eyelid].
The tarsal plate contains a single row of
large tarsal (Meibomian) glands.
The palpebral fascia connects the tarsal
plates to the orbital margins.
The aponeurosis of levator palpebrae

superioris is attached to the tarsal plate
of upper eyelid.
iv. The conjunctiva is the vascular layer
consisting of stratified squamous epithelium
supported by vascular connective tissue.
This lines the deep surface of the tarsal plate.
The sensory nerve supply of the eyelids
The upper eyelid is supplied by:
The palpebral branch of lacrimal nerve.
Supra-orbital and supra-trochlear nerves.
Infra-trochlear nerve.
The lower eyelid is supplied by:
The palpebral branches of infra-orbital
nerve.
The arterial supply of the eyelids
The eyelids are supplied by the medial and lateral
palpebral arteries, that form arterial arcades in
the eyelids.
The medial palpebral arteries are branches
from the ophthalmic artery.
The lateral palpebral arteries are branches
from that lacrimal artery.
Applied anatomy
i. The styeis the inflammation of small sweat
and sebaceous glands (gland of Zeis and
Moll) at the free margin of the eyelid in
relation to eyelashes.
ii. The chalazion (internal stye)is caused by
the inflammation of the tarsal glands.
iii. Trachomais a viral disease that affects the
tarsal glands. It later, if untreated, causes
corneal ulceration and later corneal opacity.
It is one of the commonest cause of
blindness in India.
iv. Conjunctivitisis caused by the inflammation of the conjunctiva leading to the
dilatation of the blood vessels.
THE LACRIMAL APPARATUS

The lacrimal apparatus consists of structures
concerned with secretion and disposal of lacrimal
fluid or tears.
tahir99 - UnitedVRG
The Eyes
It
consists of (Fig. 48.2):

The lacrimal gland
The conjunctival sac
The lacrimal canaliculisuperior and
inferior
The lacrimal sac
The naso-lacrimal duct
I. The lacrimal gland secretes tears.
It is a compound tubulo-alveolar type of exocrine
gland.
Location: It lies in the lacrimal fossa of the
roof of the orbit.
Parts:
i. It has a main part that has the shape and
size of an almond.
ii. A small palpebral part that lies in the deep
part of upper eyelid.
About 10-12 ducts begin from the main part
and pass through the palpebral part to open in
the superior fornix of conjunctiva.
Arterial supply: The gland is supplied is by the
lacrimal branch of ophthalmic artery.
Nerve supply:
Sensory is by lacrimal nerve.
Sympathetic is by plexus around the internal
carotid artery.
Fig. 48.2: The lacrimal apparatus
527
Parasympathetic (secretomotor) The

preganglionic fibers start from superior
salivary nucleus and passes via facial nerve,
greater petrosal nerve and nerve of pterygoid
canal.
The fibers relay in the pterygo-palatine
ganglion and post-ganglionic parasympathetic fibers reach lacrimal gland via the
maxillary nerve, its zygomatic branch and
lacrimal nerve.
II. The conjunctival sac is a closed sac when the
eye is closed. The palpebral conjunctiva lines
the deep surface of eyelids. Then it is reflected
at the superior and inferior fornices to the front
of the eye as bulbar conjunctiva, that covers
the sclera of the eye.
The tears circulate in the conjunctival sac
from lateral to medial side.
At medial angle of the eye, there is a small
fold of conjunctivathe plica semilunaris
that encloses a small triangular arealacus
lacrimalis.
The tears wipe and moisten the cornea and
make it bacteria free.
III.The lacrimal canaliculi are two minute tubules
in the medial parts of the eyelids.
Length: is about 10.0 mm.
Course: each canaliculus begins at lacrimal
punctum at medial end of free margin of
the eyelid.
The canaliculus is a bent tubule with a
slight dilatationthe ampullaat the
bent portion.
The canaliculi join and open by a common
opening in the lateral wall of lacrimal
sac.
IV. The lacrimal sac is a fibrous sac, that receives
the tears from the two lacrimal canaliculi and
passes it on to the nasolacrimal duct.
Size: 12.0 mm length 3.0-4.0 mm width.
The sac is covered laterally by lacrimal
fascia, to which is attached lacrimal part of
orbicularis oculi.
528
When the eyelids blink, the sac is dilated

due to contraction of orbicularis oculi.
V. The nasolacrimal duct is continuous with the
lower end of the lacrimal sac.
Length: is about 18.0 mm.
Direction: is downwards, backwards and a
little laterally.
The nasolacrimal duct lies in the bony nasolacrimal canal and opens in anterior part of
inferior meatus of nasal cavity.
A small fold of mucous membrane the
lacrimal fold prevents the nasal secretions
from ascending up in the duct.
The tears after circulating in conjunctival sac,
collect at the medial angle of the eye.
The tears enter the two canaliculi due to capillary
action and the sucking action of the lacrimal
sac, as it is dilated.
The tears on reaching lacrimal sac, pass down
the naso-lacrimal duct.
Excess of tears secreted under emotional stress
cannot be drained by the canaliculi and they
overflow.
Applied anatomy
The lacrimal sac may get infected, this condition
is called dacryocystitis.
If the infection is not checked, sometimes,
the sac has to be surgically removed by an
operation (dacryocystectomy).
THE EYEBALL
The eyeball is a spherical structure with a diameter
of about 2.5 cm. It is a very durable structure
protected by a tough fibrous coat (Fig. 48.3).
The fascial sheath (Tenons capsule)
The eyeball is surrounded by a connective
tissue sheath. The extra ocular muscles pass
through this sheath for their insertion on
the sclera.
The sheath is separated from the sclera by
an episcleral space.
The sheath is thickened below the eyeball
to form the suspensory ligament (of Lockwood), that stretches across the orbit like a
hammock supporting the eyeball.
The sheaths of lateral and medial rectus
muscles are thickened to form the lateral
and medial check ligaments.These ligaments
prevent overaction of the opposite rectus
muscles of the eyeball.
The coats of the eyeball: The eyeball has three
coats:
i. Outer fibrous coat
ii. Middle vascular coat
iii. Inner nervous coat
I. The fibrous coat consists of two parts:
a. The sclera (white of the eye) forms
nearly posterior 5/6 th of the fibrous coat.
Fig. 48.3: The eyeball
tahir99 - UnitedVRG
The Eyes
It is composed of dense connective
tissue. The extraocular muscles are
inserted on the sclera.
The sclera joins with the cornea at
the sclero-corneal junction.
The anterior part of sclera is covered
by the bulbar conjunctiva.
b. The cornea is the transparent anterior
1/6 th part of the fibrous coat.
The cornea has a smaller curvature
than the sclera and is the main
refracting medium of the eye.
The cornea is covered by the anterior
corneal epithelium, that is continuous
with conjunctiva.
Irregularity in the shape of cornea
produces astigmatism.
Injury or inflammation of cornea
(keratitis) may cause corneal opacities by scarring. These can be
corrected by keratoplasty.
II. The vascular coat consists of three parts:
a. The choroid layer has chorio-capillaris
supplied by the short ciliary arteries and
drained by vorticose veins.
b. The ciliary body lies anterior to the
choroid layer.
The ciliary body has about 80 ciliary
processes to which are attached a
large number of zonular fibers that
are attached to the capsule of the
lens.
Inside ciliary body is the ciliary
muscle consisting of rdial and
circular smooth muscle fibers.
The ciliary muscle is supplied by
parasympathetic fibers.
The contraction of the ciliary muscle
draws the ciliary processes anteriorly, thereby relaxing the zonular
fibers and making lens more convex
for near vision (accommodation).
529
c. The iris is attached to the ciliary bodyanteriorly.

It consists of a circular diaphragm
with a central aperturethe pupil.
The iris divides the space in front of
the lens into an anterior chamber and
a posterior chamber.
The iris contains variable amount of
pigment, that gives different shades
of brown, blue or grey to the iris.
The iris also contains myoepithelial
cells around the pupil arranged as:
The sphincter pupillae circularly
around the pupil
The dilator pupillae radially
around the pupil.
The sphincter pupillae is supplied by
the parasympathetic fibers and dilator
pupillae by the sympathetic fibers.
III.The nervous coat is formed by the retina
The retina consists of two layers
developmentally.
a. The outer layer forms the pigment
layer that absorbs the light that
passes through the inner layer
b. The inner layer consists of three
layers of neurons
1. The rods and cones are photosensitive and perceive the light
rays.
The cones are more sensitive
to bright light and rods are
more sensitive to dim light.
At the fovea centralis, at the
posterior pole of the eyeball,
there is maximum concentration of cones, producing
most visual acuity.
The cones are also concerned
with colour vision.
2. The bipolar cells synapse with
rods and cones and their axons
synapse with ganglion cells.
530
3. The ganglion cells give rise to

the axons that collect at the optic
disc to form the optic nerve.
The central artery and vein of retina appear
at the optic disc and then branch in the retinal
layer. The retinal vessels can be examined by
the ophthalmoscope.
Retinal detachment results from the separation
of the outer layer and inner layer and is treated
by a coagulation process.
The photo sensitive part of retina ends just
behind the ciliary body along a wavy margin
called the ora serrata. A thin nonnervous layer
of retina lines the ciliary processes and the inner
surface of iris up to the pupil.
The Chambers of the Eyeball

I. The anterior chamberlies between the cornea and
the iris and front of the lens.
It contains aqueous humoura watery fluid
secreted by the ciliary body.
The aqueous humour maintains a constant
intraocular tension. It drains into the venous
blood through sinus venosus sclerae (Schlemns
canal.) situated in sclera at the sclero-corneal
junction.
If the drainage of aqueous humour is blocked
at the sclero-corneal junction, it leads to a
condition called glaucoma, due to increased
intraocular tension. The condition may impair
retinal blood flow leading to blindness.
II. The posterior chamber is a small space between
the back of iris and the lens.
This space is also filled up by the aqueous
humour.
It communicates freely with the anterior
chamber through the pupil.
III. The viteous chamber lies behind the lens and
occupies the space in front of retina.
In contains a transparent jelly-like substance
called the vitreous body enclosed in a hyaloid
membrane.
The Lens of Eyeball

The eyeball contains a transparent lens suspended
by the zonular fibers from the ciliary processes.
The lens is biconvex with posterior convexity
more than the anterior convexity.
Structure the lens is composed of highly
specialised connective tissue cells arranged
regularly. It is enclosed in an elastic capsule.
The shape of the lens can be adjusted by the
tension of the zonular fibers.
When the ciliary muscle contracts the zonular
fiber are relaxed and the lens becomes more
convex for near vision (accommodation).
The lens loses its elasticity as the age advances.
This causes presbyopia, i.e. inability to
accommodate for the near vision.
In old age the lens gradually becomes opaque.
The condition is known as cataract and it
diminishes the vision. The cataract can be
treated by an operation to remove the opaque
lens. Intraocular transplant of an artificial lens
can also be done.
THE EXTRAOCULAR MUSCLES
There are seven extra-ocular muscles inside the
orbit. (Figs 48.4 and 48.5, Table 48.1)
Out of these, there is levator palpebrae
superioris a muscle of the upper eyelid.
There are four recti musclessuperior rectus,
inferior rectus, medial rectus and lateral rectus.
There are two oblique musclessuperior
oblique and inferior oblique.
The four recti muscles arise from four sides of
a common tendinous ringannulus tendinous
communisattached near the apex of the orbit
and encloses middle part of the superior orbital
fissure, and optic foramen.
The Blood Vessels of the Orbit
The arteries: The ophthalmic artery supplies

the structures inside the orbit including the
eyeball.
tahir99 - UnitedVRG
The Eyes
531
Table 48.1: The extraocular muscles of the orbit

S.No. Name
Origin
Insertion
Nerve supply
Main actions
1.
Common
tendinous ring
Superior aspect of
sclera, about 6.0 mm
from cornea
Superior ramus of
oculomotor
i. Pulls eyeball upwards and medially
Superior
rectus
2.
Inferior
rectus
3.
Medial rectus Common tendinous

ring
4.
5.
6.
7.
Common tendinous ring
Inferior aspect of
sclera about 6.0 mm
from cornea
Medial aspect of sclera

about 6.00 mm from
cornea
Lateral rectus Common tendinous
Lateral aspect of
ring
sclera about 6.00 mm
from cornea
Superior
Sphenoid above
Superior aspect of
oblique
and medial to common sclera at the equator
tendinous ring
of eyeball
Inferior
Linear notch on maxi- Lateral aspect of
oblique
lla, in floor of orbit
sclera at equator of
near naso-lacrimal canal eyeball
Levator pal- Lesser wing
Aponeurosis splits
pebrae
sphenoid above
into two lamellae
superioris
common tendinous
1. Superior lamella
ring
attached to anterior
surface tarsal plate of
and skin of upper
eyelid
2. Inferior lamella
Contains non-striated
muscle fibers attached
to superior border tarsal
plate and conjunctiva
Inferior ramus of
oculomotor
Inferior ramus of
oculomotor
Abducent nerve
Trochlear nerve
Inferior ramus of
oculomotor
Superior ramus of
Oculomotor
Non-striated muscle
fibers by sympathetic
Fig. 48.4: The recte and oblique muscles of eyeball (lateral aspect)
ii. Rotates eyeball

inwards (intorsion)
i. Pulls eyeball downwards and medially
ii. Rotates eyeball outwards (extorsion)
i. Adduction of eyeball,
i.e. pulls eyeball
medially
i. Abduction of eyeball, i.e. pulls eyeball laterally
i. Pulls eyeball downwards and laterally
ii. Intorsion of eyeball
i. Pulls eyeball upwards and lateral
ii. Extorsion of eyeball
i. Raises upper eyelid and helps in
blinking
532
Fig. 48.5: The levator palpebrae superioris
Origin: The Ophthalmic artery arises from the

internal carotid artery near optic canal.
Course: The artery enters the orbit through the
optic canal lying in an extension of subarachnoid, space between the middle and inner
sheaths, below the optic nerve.
Inside the orbit, the artery turns laterally,
pierces middle and outer sheaths of optic
nerve and lies lateral to the optic nerve and
gives a large lacrimal branch.
The artery crosses above the optic nerve

from lateral to medial side and passes
forwards tortuously along the medial wall
of orbit.
The ophthalmic artery terminates anteriorly
by dividing into a dorsal nasal and a supratrochlear branches.
Branches (Fig. 48.6):
i. The central artery of retina lies below the
optic nerve, pierces the nerve 1.2 cm
behind eyeball and enters the eyeball at the
optic disc.
ii. The lacrimal branch runs along the lateral
wall of orbit and gives:
The glandular branches to lacrimal gland.
Zygomatico-orbital branch that enters a
bony foramen and divides into zygomatico-facial and zygomatico-temporal
branches.
Two lateral palpebral branches to the two
eyelids.
iii. The supra orbital artery passes forwards
above eyeball and comes out at supra-orbital
notch to supply the forehead.
Fig. 48.6: The ophthalmic artery
tahir99 - UnitedVRG
The Eyes
iv. The posterior ciliary branches pierces the
sclera around optic nerve to supply the
eyeball.
v. The posterior ethmoidal artery enters the
posterior ethmoidal canal and supplies the
ethmoidal air sinuses and lateral wall of nasal
cavity. It also gives meningeal branch.
vi. The anterior ethmoidal artery enters the
anterior ethmoidal canal and supplies the
ethmoidal sinuses and lateral wall of nose.
It also gives meningeal branches.
vii. Two medial palpebral branches supply the
two eyelids.
viii. The dorsal nasal branch supplies the root
of nose and anastomoses with terminal part
of facial artery.
ix. The supra-trochlear arterysupplies the
skin of forehead.
x. Small muscular branches supply the
extraocular muscles.
The Veins
i. The superior ophthalmic vein drains venous
blood from structures in the upper part of
orbit including eyelids, nose and part of
forehead.The superior ophthalmic vein
communicates with the beginning of facial
vein.
ii. The inferior ophthalmic vein receives
venous blood from lower part of orbit. The
inferior ophthalmic vein communicates with
the pterygoid venous plexus via the inferior
orbital fissure.
The two ophthalmic veins leave the orbit via
the superior orbital fissure and end in the cavernous
venous sinus.
The Nerves of the Orbit
(I) The motor nerves supplying the extraocular
muscles are threeoculomotor, trochlear and
abducent (Fig. 48.7).
533
a. The oculomotor nerve enters as two rami,

superior and inferior, via the middle part of
superior orbital fissure.
The superior ramus on entering orbit turns
upwards lateral to the optic nerve.
It supplies superior rectus, then gives a
branch that pierces superior rectus and
supplies levator palpebrae superioris muscle.
The inferior ramus on entering orbit passes
below optic nerve and divides into three
branches to supply medial rectus, inferior
rectus and inferior oblique.
The nerve to inferior oblique is connected
with ciliary ganglion by a communicating
branch that carries the parasympathetic
fibers to the ciliary ganglion, where there
fibers relay and post ganglionic fibers supply
ciliary and sphincter pupillae muscles of
eyeball.
b. The trochlear nerve enters the orbit through
the lateral part of superior orbital fissure.
On entering the orbit, the nerve passes
medially above the superior rectus and
levator palpebrae superiors to reach the
posterior part of superior oblique muscle,
that it supplies.
c. The abducent nerve enters the orbit through
middle part of superior orbital fissure lateral to
the two rami of oculomotor nerve.
Just after entering the orbitit turns laterally
to reach the medial surface of lateral rectus
muscle, that it supplies.
(II) The sensory nerves of the orbit are:
i. The ophthalmic division of trigeminal is
nerve of general sensation.
ii. The optic nerve is nerve of special sense
of sight.
(i) The ophthalmic division of trigeminal divides
into its three terminal branches in the cavernous
sinus, the naso-ciliary, frontal and lacrimal
nerves (Fig.48.8).
534
Fig. 48.7: The motor nerves of the orbit
a. The nasociliary nerve enters the orbit

through the middle part of superior orbital
fissure between the two rami of oculomotor
nerve.
It crosses the optic nerve from lateral
to medial side along with ophthalmic
artery and runs along the medial wall of
orbit.
Branches:
i. Communicating branch to ciliary
ganglion before crossing the optic
nerve.
ii. Two long ciliary nerves that pierces
sclera on either side of optic nerve.
Inside eyeball, it supplies the dilator
pupillae muscle.
Fig.48.8: The ophthalmic nerve and its branches in the orbit
tahir99 - UnitedVRG
The Eyes
iii. Posterior ethmoidal nerve enters the
posterior ethmoidal foramen and
supply ethmoidal sinuses.
iv. Anterior ethmoidal nerve enters
anterior ethmoidal canal. It supplies
ethmoidal air sinuses, the lateral wall
of nose and reaches the external
nose to supply the skin up to tip of
nose as external nasal nerve.
v. Infratrochlear supplies lower eyelid
and skin of root of nose.
b. The frontal nerve enters orbit through lateral
part of superior orbital fissure.
It passes forwards above the levator
palpebrae superioris and divides into two
branchesthe supra-trochlear and supraorbital, that emerge at the orbital opening to
supply skin of forehead and scalp.
c. The lacrimal nerve also enters the orbit via
the lateral part of superior orbital fissure.
It runs along the lateral wall of orbit and
gives.
Glandular branch to lacrimal gland.
A palpebral branch to upper eyelid
It also receives a communicating branch
from the zygomatic nerve, that carries post
ganglionic parasympathetic fibers for
lacrimal gland.
(ii) The optic nerve pierces the sclera about
3.0 mm medial to the posterior pole.
The nerve is about 4.0 cm long and
passes backwards and medially to
the optic canal.
535
The nerve is slightly longer than the
distance up to optic canal to allow

for movements of eyeball.
[The detailed description of the cranial
nerves is given in Chapter 47]
The ciliary ganglion is the peripheral parasympathetic ganglion associated with the ophthalmic
division of trigeminal nerve.
Location: The ciliary ganglion lies near the apex
of the orbit between the optic nerve and the
lateral rectus muscle.
Roots:
i. The sensory root is provided by the nasociliary nerve.
ii. The sympathetic root is provided by the
plexus around the internal carotid artery.
iii. The parasympathetic root is provided by the
nerve to the inferior oblique muscle.
This root carries preganglionic parasympathetic fibers that relay in the ganglion and
post-ganglionic parasympathetic fibers arise.
Branches: About twelve to sixteen short ciliary
nerves arise from the ganglion in two bundles.
The short ciliary nerves pierces the sclera
around the attachment of optic nerve.
These nerves carry
a. The sensory fibers to the inferior of
eyeball.
b. The sympathetic fibers to supply the
blood vessels of the eyeball.
Some sympathetic fibers also supply
the dilator pupillae muscle.
c. The post ganglionic parasympathetic
fibers supply the ciliary muscle, and
sphincter pupillae muscle.
CHAPTER
49
The Ears
The two ears lie on either side of skull. Each ear
consists of:
i. An external ear
ii. A middle ear
iii. An internal ear
THE EXTERNAL EAR
The external ear consists of the pinna (auricle),
the external acoustic meatus and the tympanic
membrane.
A. The pinna lies on the lateral side of the head. It
collects the sound waves.
The pinna is made up of a single piece of elastic
cartilage covered by perichondrium.
The parts of the pinna are (Fig. 49.1):
a. The helix is the rolled outer edge of pinna.
It begins as crus at the bottom of concha.
A small tuberclethe Darwins
tuberclemay be seen sometimes on the
helix. This represents the tip of the pinna.
b. The antihelix is another ridge that runs inside
and parallel to the helix.
Fig. 49.1: The pinna
It separates the outer scaphoid fossa

from the inner, deeper concha.
The antihelix begins by two crura
superiorly which enclose a triangular
fossa.
c. The antitragus is a small tubercle at the
lower anterior end of antitragus.
d. The tragus is a triangular projection from
the anterior part of pinna.
It partially covers the external acoustic
meatus and is separated from the
antitragus by intert-tragic notch.
e. The lobule is the lower dependent part of
pinna. It has no elastic cartilage and is made
up of fibrofatty tissue.
The lobule is used for piercing to put
some ornament in women.
The blood supply of pinna is by:
The arteries
The posterior auricular branch external
carotid artery.
The anterior auricular branches
superficial temporal artery.
The veins acompany the arteries. There are
many arterio-venous anastomoses in the skin
of the auricle.
The sensory nerve supply of the pinna is by:
Lateral surface
Lower third by greater auricular nerve
Upper two-third by auriculo-temporal
nerve.
Medial surface
Upper third by lesser occipital nerve
Lower two-third by greater auricular
nerve
tahir99 - UnitedVRG
The Ears
The Junctional skin with the scalp is
supplied by the auricular branch of vagus
(Arnoids nerve).
The extrinsic muscles of the auricle are small
and rudimentary in humans. They are:
i. The auricularis anterior arises from the
lateral edge of epicranial aponeurosis and is
attached to the cranial surface of auricle.
It is supplied by temporal branch of
facial. It draws the auricle forwards.
ii. The auricularis superior is the largest. It
also arises from epicranial aponeurosis and
is attached to the cranial surface of auricle.
It is also supplied by the temporal branch
of facial nerve and it elevates the auricle
a little.
iii. The auricularis posterior is attached to the
mastoid temporal bone and cranial surface
of auricle.
It is supplied by the posterior auricular
branch of facial nerve and it draws the
auricle backward.
The intrinsic muscles of the auricle are very
small and connect the different parts of the
cartilage of the pinna.
They alter minimally the shape of the auricle.
B. The external acoustic meatus
It is a bent canal that leads from the bottom of
concha of the auricle to the tympanic membrane.
Length is 2.4 mm from the bottom of concha,
out of which the outer third, i.e. 8.0 mm is
cartilaginous, while the inner two-third, i.e. 16.0
mm is bony.
Direction: The outer third portion is directed
upwards and backwards and is lined by skin
containing hair follicles, sweat and sebaceous
glands secreting earwax (ceruminous glands).
The inner part is directed downwards and
is lined by epithelium having few hair and
glands.
i. The posterior auricular artery
ii. The deep auricular branch of maxillary artery
537
iii. The auricular branches of superficial

temporal artery.
The sensory nerve supply is by:
The auriculo-temporal nerve (anterior and
superior walls).
The auricular branch of vagus (posterior
and inferior walls).
C. The tympanic membrane (eardrum) lies at
the medial end of external acoustic meatus.
The tympanic membrane is bent forwards so
that it makes an angle of 55 with the floor of
external acoustic meatus.
On its central portion the umbo is handle of
malleus attached on the inner surface.
The tympanic membrane has two parts (Fig.
49.2):
i. A small part superiorly that appears less
tense called pars flaccida.
ii. The rest of the part is quite tense called pars
tensa.
Structure: The tympanic membrane consists of
three layers:
a. An outer layer of cuticle developed from
ectoderm.
b. A middle fibrous sheet developed from
mesoderm.
c. An inner epithelium derived from endoderm
The posterior auricular artery (outer
surface).
Fig. 49.2: The tympanic membrane
538
The stylomastoid branch of posterior

auricular artery and anterior tympanic
branch of maxillary artery (inner surface).
The sensory nerve supply:
The outer surface is supplied by:
Auriculo-temporal nerve
Auricular-branch of vagus
The inner surface is supplied by:
Tympanic branch of glosso-pharyngeal nerve
Applied Anatomy of the External Ear

I. Otitis externa is infection in the external acoustic
meatus. It is a very painful condition.
II. The perforation of the tympanic membrane may
result from external trauma or middle ear infection
(otitis media).
THE MIDDLE EAR (TYMPANIC CAVITY)
The tympanic cavity is a narrow, irregular, air-filled
space in the petrous temporal bone.
Location: The middle ear is located between
the tympanic membrane laterally and the internal
ear medially.
Communication: The middle ear communicates:
Anteriorly via the auditory tube with the
nasopharynx.
Posteriorly via the mastoid antrum with
mastoid aircells.
Size
Both antero-posterior and vertical diameters
are 15.0 mm.
The transvers diameter at roof is 6.0 mm
in the middle is 2.0 mm
at the floor is 4.0 mm
Boundaries: The middle ear has six boundaries
a roof, a floor, a lateral wall, a medial wall, an
anterior wall and a posterior wall.
I. The roof is formed by a plate of bone
tegmen tympanithat also roofs over the
mastoid antrum
II. The floor is a thin palte of bone, that forms

the roof of jugular fossa, that lodges the
superior bulb of the internal jugular vein.
Near the medial wall, there is a tympanic
canaliculus which transmits the tympanic branch of glosso-pharyngeal nerve.
III. The lateral wall is formed by: (Fig 49.3)
The medial surface of tympanic membrane.
The epitympanic recess lies above the
tympanic membrane.
The posterior and anterior canaliculus
of chorda tympani. The chorda tympani
enters from the posterior canaliculus,
runs along the lateral wall and then leaves
middle ear via the anterior canaliculus,
that opens below at the petro-tympanic
fissure.
IV. The medial wall is directed towards the
internal ear (Fig. 49.4).
The medial wall has:
The promontorya round eminence
caused by the first turn of cochlea.
The oval window (fenestra vestibuli) is
closed during life by the base of stapes.
The round window (fenestra cochleae)
is closed during life by the secondary
tympanic membrane, thar acts as a
terminal point for vibrations.
tahir99 - UnitedVRG
Fig. 49.3: The lateral wall of middle ear
The Ears
Fig. 49.4: The medial wall of middle ear
V. The anterior wall is very narrow and

separates middle ear from the carotid canal.
It has two bony canals separated by a
bony shelf.
a. The upper canal is for tensor tympani muscle.
b. The lower canal is for bony auditory
tube.
VI. The posterior wall has
An aditus, a wide opening that communicates with mastoid antrum.
A pyramid, a triangular hollow elevation
situated below aditus.
Fossa incudis near the lateral wall, that
lodges the short process of incus.
Contents of the middle ear are:
I. Air that equalises atmospheric pressure on
deep surface of the tympanic membrane for
its proper vibration.
II. The ear ossicles are threethe malleus, the
incus and stapes. (Fig. 49.5)
These ossicles are fully developed and
adult size at birth.
a. The malleus (hammer) has a handle
attached to the deep surface of
tympanic membrane and a head that
projects in the epitympanic recess.
The tensor tympani muscle is
attached to the handle of malleus.
539
Fig. 49.5: The ear ossicles
To its anterior process is attached
the anterior ligament.

It forms incudo-malleolar joint
a saddle type of synovial joint

with the incus.
b. The incus (anvil) has a body that
articulates with head of malleus.
The short process is attached to
the fossa incudis in the posterior
wall of middle ear.
The long process articulates with
the apex of stapes at the incudostapedial jointa ball and socket
type of synovial joint.
c. The stapes (stirrup) consists of an
apex and a neck followed by two
limbs, that are attached to the footplate,
The foot plate is attached to the
oval window in medial wall of
medial wall.
The fusion or osteosclerosis
between the foot plate of stapes
and the oval window is most
common cause of deafness in
old age.
III. The ear muscles are twothe tensor tympani
and the stapedius.
a. The tensor tympani
540
Origin is form cartilaginous part of

auditory tube and adjoining part of
greater wing of sphenoid.
Muscle belly is very slender and lies
in the body canal.
Insertion is on the handle of malleus.
Nerve supply is by mandibular nerve,
through nerve to medial pterygoid,
fibers passing via the otic ganglion.
b. The stapedius
Origin is form canal of pyramid.
Muscle belly a very small. It is the
smallest striated muscle of the body.
Insertion is on posterior surface of
neck of stapes.
Nerve supply is by facial nerve.
Action of the ear Muscles
I. Both tensor tympani and stapedius dampen
loud noises by their reflex contraction and
exercise a protective action to the internal
ear.
II. Tensor tympani pulls the tympanic membrane inwards to make it tense.
III. Stapedius opposes the action of tensor
tympani of pulling stapes more firmly in the
oval window.
Applied anatomy
Paralysis of stapedius muscle leads to hyperacusis or senstivity to loud noises.
The sensory nerve supply of the middle ear
Tympani branch of glossopharyngeal nerve,
that forms a tympanic plexus on promontory
of the middle ear.
The arterial supply of the middle ear is mainly
by:
a. Anterior tympanic branch of maxillary
artery.
b. Stylomastoid branch of posterior auricular
artery.
c. Small arteries supplying middle ear.
Petrosal and superior tympanic branch
of middle meningeal artery.
Tympanic branches of internal carotid

artery.
A branch of ascending pharyngeal artery.
A branch of artery of pterygoid canal.
The veins of the middle ear end in:
The pterygoid venous plexus
The superior petrosal sinus
THE MASTOID ANTRUM

(THE TYMPANIC ANTRUM)
It is a small air-filled space in the petrous temporal
bone that freely communicates with the middle ear
cavity.
Size The diameter of mastoid antrum is nearly
10.0 mm and its capacity is 1 ml.
Boundaries:
Anteriorly there is aditusa wide opening
that communicates with middle ear.
Medially it is related to the posterior semicircular canal.
Posteriorly it is related to the sigmoid sinus
separated by a thin plate of bone.
Superiorly it is bounded by tegmen tympani
that forms the roof of middle ear also.
Inferiorly its floor of several openings that
communicate with mastoid air cells.
Laterally there is squamous temporal bone
at the supra meatal triangle.
The lateral wall is only 2.0 mm at birth. It
grows in thickness at the rate of 1.0 mm every
year, and finally becomes 15.00 mm in the adult.
The mastoid air cells are absent at birth. They
grow to full size by puberty. They vary in
number and fill up the mastoid process.
The mastoid air cells are lined by epithelium
and freely communicate with mastoid antrum.
Applied anatomy
I. Otitis media or infection of middle ear
cavity, is quite common condition. The
infection usually spreads from the pharynx
via the auditory tube.
tahir99 - UnitedVRG
The Ears
The condition, if not treated properly,
becomes chronic.
The complications maybe:
a. The mastoiditis or infection of the
mastoid air cells.
b. Paralysis of the facial nerve due to
involvement of facial nerve in its
bony canal.
c. Perforation of eardrum, that can only
heal if the infection is removed.
II. Surgical approach to the middle ear can be
made through the mastoid antrum, that lies
15.0 mm deep to the supra-meatal triangle
in an adult.
THE AUDITORY TUBE
[PHARYNGO-TYMPANIC TUBE]
The auditory tube connects the middle ear with the
lateral wall of nasopharynx.
Lengthabout 36.0 mm (lateral 12.0 mm is
bony, while medial 24.0 mm is cartilaginous).
Coursethe auditory tube passes anteromedially from the middle ear to the nasopharynx
making an angle of 45 with sagittal plane and
30 with the horizontal plane.
The cartilage of the tube bulges in the lateral
wall of nasopharynx forming tubal
elevation above and behind the opening of
the auditory tube.
There is a small collection of lymphoid tissue
near the opening of the tube called the tubal
tonsil.
The salpingo-pharyngeus muscles arise from
the tubal elevation.
TerminationThe auditory tube opens in the
lateral wall of nasopharynx.
9
ri 9
A. The bony labirinth is composed of cochlea and

the three semicircular canals. (Fig. 49.6)
The bony labyrinth is filled up by a fluid called
perilymph.
Parts of bony labyrinth
1. The cochlea is shaped like a snails shell with
23 4 turns, about a central modiolus.
The cochlea has an osseous spiral lamina
projecting from the central modiolus.
There are three canals enclosed with in
the cochlea.
a. The upper one is scala vestibuli,
which receives vibrations in the
perilymph from the oval window.
b. The lower one is scala tympani
connected with scala vestibuli at the
apex of cochleahelicotrema. It is
also filled with perilymph and
receives the vibrations from the scala
vestibuli.
The scala tympani ends at the
secondary tympanic membrane
fixed at the round window.
c. The cochlear duct is the middle canal
filled with endolymph and is located
between the scala vestibuli and scala
tympani.
2. The vestibule is the central part of the bony
labyrinth that is connected:
V
d
ti e
G
R
n
U
h
a
541
THE INTERNAL EAR

The internal ear lies within the petrous temporal
bone.
The internal ear is made up of:
i. A bony or osseous labyrinth
ii. A membranous labyrinth
Fig. 49.6: The bony labyrinth
542
Anteriorly to the cochlea.

Posteriorly to the three semicircular
canals.
The vestibule contains two small sacs
the utricle and the saccule that belong
to the membranous labyrinth.
3. The semicircular canals are three in number.
I. The posterior canal projects vertically
with long axis directed postero-laterally
at about 45.
II. The superior (anterior) semicircular
canal projects antero-medially at about
45. It is parallel to the posterior semicircular canal of the opposite side.
III.The lateral semicircular canal is nearly
horizontal and projects in the medial wall
of the middle ear.
The three semicircular canals are
arranged in perpendicular planes.
Each semicircular canal has a
terminal swelling called ampulla.
The three canals open in the vestibule
by five openings, one of which is
shared by the two canals.
The semicircular canals contain the
semicircular ducts that are parts of
membranous labyrinth.
B. The membranous labyrinth (Fig. 49.7)
The membranous labyrinth is filled with endolymph
and contains the sensory organs of hearing and
equilibrium.
Fig. 49.7: The membranous labyrinth
It consists of:
I. The cochlear ductthe middle canal of the
cochlea wedged between the scala vestibuli
and scala tympani.
It is bounded above by the vestibular
membrane and below by the basilar
membrane attached to the bony spiral
lamina.
The senstive hair cells belonging to the
organ of corti rest on the basilar
membrane suspended in the endolymph.
The hair cells perceive the vibration and
the nerve fibers carry the sensations to
the spiral ganglion where the first
neurons of the auditory pathway are
located.
The axons of these neurons form the
fibers of the cochlear nerve.
II. The utricle and the saccule are two
membranous sacs situated inside bony
vestibule. They are filled with endolymph.
The utricle is larger sac and is connected
to the three semicircular ducts. A
senstive receptor-macula is situated in
its lateral wall.
The saccule is smaller sac and is
connected with the cochlear duct.
A ductus and saccus endolymphaticus is
connected to both utricle and saccule
and lies under the dura mater of the
posterior cranial fossa on the petrous
temporal bone.
There is also a senstive receptor macula
situated in the anterior wall of saccule.
III. The three semicircular ducts are contained
within the semicircular canals and suspended
in perilymph.
Inside the ampulla of the semicircular
canals lie the dilatations of the semicircular ducts.
These dilatations contain special receptor
end organscristae ampullaris.
tahir99 - UnitedVRG
The Ears
The senstive cells of the cristae are so

arranged that they are stimulated by the
structural deformation caused by the
vibrations in the contained endolymph.
The nerve fibers carry these sensations
to the vestibular ganglion where the first
neurons of vestibular pathway are
located.
The axons of these neurons from the
fibers the vestibular nerve.
ORGAN OF CORTI
Organ of corti is the special receptor organ for
hearing located within cochlea
It consists of
i. Special sensory Hair cells
ii. Supporting cells-pillar cells and phalangeal
cells.
These cells are arranged on basilar membrane
that is attached is the osseous special lamina.
I. The Hair cellshave peculiar hair like projections
from there free ends.
There is single row of inner hair cells - (about
7000) and three rows of outer hair cells in basal
h
a
9
ri 9
543
turn of cochlea increasing to five rows at the

apex. These number about 25,000.
The hairs of these cells project from the cells
along a V or W-shaped line and their tips are
embedded in tectorial membrane.
The tectorial membrane is a ribbon the structure
consisting of gelatinous type of connective
tissue.
The dendritic turnwals of primary sensory
neurones are in synaptic contact with the hair
cells
II. The supporting cellsare of two types
a. The pillar cellsare arranged in two rows.
Inner in outer on either side of tunnel of
corti.
b. The phalangeal cells afford intimate support
for the sensory cells.
They are arranged in:
a single row of inner phalangeal cells
These to five rows of outer phalangeal
cells.
The organ of corti is completed on the inner
side by border cells and on the outer side by cells
of Hensen.
n
U
V
d
ti e
G
R
The Spinal Cord, Brain, Eyes and

the Ears
Q.1. Select the one best response to each question from the four suggested answers:
C. Abducent nerve
D. Trigeminal nerve
1. The subarachnoid space in the adult ends

below at the level of:
A. The coccyx
B. Second sacral vertebra
C. Third sacral vertebra
D. First lumbar vertebra
7. The extraocular muscle that turns the eyeball

upwards and laterally is:
A. Superior oblique
B. Superior rectus
C. Inferior rectus
D. Inferior oblique
2. The ligamentum denticulatum has the

following number of tooth processes:
A. Twelve
B. Thirty-one
C. Twenty-one
D. Thirty-four
8. The artery that supplies the visual area of

cortex is :
A. Anterior cerebral
B. Posterior cerebral
C. Middle cerebral
D. Internal carotid
3. The internal vertebral venous plexus is found

in:
A. The epidural space
B. The subdural space
C. The subarachnoid space
D. Outside vertebral canal
4. The spinal cord, in adults, terminates at level
of inter-vertebral disc between:
A. Twelfth thoracic and first lumbar vertibra
B. First lumbar and second lumbar vertebra
C. Second and third lumbar vertebra
D. Third and fourth lumbar vertebra
5. The cerebrospinal fluid enters the venous
blood stream at:
A. Choroid plexus
B. Cisterna magna
C. Subarachnoid veins
D. Arachnoid villi and granulations
6. The cranial nerve that has dorsal attachment
on brain stem is:
A. Trochlear nerve
B. Oculomotor nerve
9. The facial nerve in its bony canal lies in the

following wall of middle ear:
A. Medial wall
B. Lateral wall
C. Roof
D. Floor
10. The cranial nerve that supplies sensory fibers
to the middle ear is:
A. Maxillary nerve
B. Vestibulocochlear nerve
C. Facial
D. Glossopharyngeal
11. The Brocas area (motor speech center)
is located in the dominant hemisphere at:
A. Past central gyrus
B. Precentral gyrus
C. Inferior frontal gyrus
D. Superior temporal gyrus
12. The purkinje cells lie in the :
A. Red necleus
B. Granular layer of cerebellar cortex
C. Molecular layer of cerebellar cortex
D. Dentate nucleus of cerebellum
tahir99 - UnitedVRG
545
13. The special visceral afferent (taste) nucleus

in brain stem is:
A. Nucleus of tractus solitarius
B. Vestibular nuclei
C. Dorsal nucleus of vagus
D. Spinal nucleus of trigeminal
19. A cranial fracture passing through jugular

foramen will injure:
1. Hypoglossal nerve
2. Vagus nerve
3. Facial nerve
4. Glosso-pharyngeal nerve
14. The intraocular muscle supplied by the

sympathetic fibers is:
A. Dilator pupillae
B. Sphincter pupillae
C. Ciliary muscle
D. None of the above
20. The lateral geniculate body receives:

1. Ipsilateral temporal retinal fibers
2. Contralateral temporal retinal fiber
3. Contralateral nasal retinal fibers
4. Ipsilateral nasal retinal fibers
15. The precentral gyrus of cerebral hemisphere:

A. Is sensory area
B. Receives visual impressions
C. Receives auditory impressions
D. Is primary motor area
21. The superior colliculus of midbrain is:

1. Visual relay center
2. Visual association center
3. Higher center of vision
4. Visual reflex center
16. The photosensitive cells of the retina are:

A. Ganglion cells
B. Bipolar cells
C. Rods and cones
D. Pigment cells
h
a
17. The sensory nerve supply of the pinna

(auricle) is by:
1. Auriculo-temporal nerve
2. Greater auricular nerve
3. Auricular branch of vagus
4. Lesser occipital nerve
18. The lesion of oculomotor nerve leads to:
1. Ptosis
2. Lateral squint
3. Dilatation of pupil
4. Diplopia
22. The cortico-spinal fibers occupy the following

parts of the internal capsule:
1. Genu
2. Anterior limb
3. Retrolentiform
4. Posterior limb
n
U
Q.2. Each question below contains four

suggested answers, out of which one or
more are correct. Choose the answer:
A. If 1, 2, and 3 are correct
D. If 1,2,3 and 4 are correct
E. If only 4 is correct
9
ri 9
V
d
ti e
G
R
23. The optic nerve is considered a tract of brain

because:
1. It has three sheaths derived from the
three meninges of brain
2. It is attached to the forebrain
3. Its fibers have no Schwann sheath
4. Its fibers have no myelin sheath
24. The fold of dura mater that lies in the
longitudinal fissure of brain is:
1. Falx cerebelli
2. Tentorium cerebelli
3. Diaphragm sellae
4. Falx cerebri
25. The parts of middle ear that are adult size at
birth are:
1. Tympanic membrane
2. Internal ear
3. Ear occicles
4. Pinna
546
26. The structures passing through superior

orbital fissure are:
1. Trochlear nerve
2. Optic nerve
3. Abducent nerve
4. Ophthalmic artery
Q.3. Match the structures on the left with their
27. Functional nervous components:
1. Somatic efferent
A. Trigeminal
nerve
2. Somatic afferent
B. Vestibulocochlear
3. Special somatic
C. Glossopharynefferent
geal
4. Special visceral
D. Trochlear
efferent
nerve
28. Special features of parts of brain:
1. Facial colliculus
A. Pons
2. Corpus callosum
B. Cerebral
hemisphere
3. Olive
C. Midbrain
4. Red nudeus
D. Medulla
oblongata
29. Nerve supply of muscles

1. Stapedius
A. Abducent nerve
2. Tensor tympani
B. Facial nerve
3. Sphincter pupillae C. Mandibular
nerve
4. Lateral rectus
D. Oculomotor
nerve
30. Special features of parts of brain:
1. Spinal ganglion
A. Middle ear
2. Geniculate ganglion B. Facial nerve
3. Optic disc
C. Cochlea
4. Promontory
D. Retina
31. Arterial supply
1. Lacrimal gland
2. Internal ear
3. Auditory area of
cortex
4. Lateral part of
medulla oblongata
A. Labrynthine
artery
B. Middle cerebral
artery
C. Posterior inferior cerebellar
artery
D. Lacrimal
branch of
ophthalmic
artery
Answers
The subarachnoid space, between the
arachnoid and pia mater ends below at the
level of second sacral vertebra, where the
dura and arachnoid mater also end.
The ligamentum denticulatum has twenty-one
tooth processes. The first tooth process is
attached to the margin of foramen magnum
above the first cervical nerve root. The tooth
processes are attached to the dural tube in
between the nerve roots. The last tooth
process (the twenty-first) is attached between
twelfth thoracic and first lumbar nerve roots.

The internal vertebral venous plexus lies in
the epidural space between the vertebral canal
and the spinal dura mater. The subdural space
contains a very small amount of serous fluid
and subarachnoid space contains cerebrospinal fluid and large spinal vessels.
The spinal cord, in adults, ends at the
intervertebral disc between first lumbar and
second lumbar vertebra. In infants, at birth,
it ends at level of intervertebral disc between
third and fourth lumbar vertebra. It ascends
up during childhood and by puberty reaches
adult level.
tahir99 - UnitedVRG

The cerebrospinal fluid enters the venous
bloodstream at the arachnoid villi and
granulations.The choroid plexuses produce
the cerebro-spinal fluid inside the ventricles
and it circulates in the sub-arachnoid space
around the brain and spinal cord.
The cranial nerve that has dorsal attachment
on brain stem is trochlear nerve. The
oculomotor nerve is attached ventrally on
medial aspect of crus cerebri of midbrain.
The abducent nerve is attached at lower
border of pons and the trigeminal nerve is
attached by two rootssensory and motor
on ventral surface of pons.
The muscle that turns the eyeball upwards
and laterally is inferior oblique. The superior
oblique turns the eyeball downwards and
laterally. The superior rectus turns the eyeball
upwards and medially, and inferior rectus
turns the eyeball downwards and medially.
9
ri 9

The cranial nerve that supplies sensory fibers
to the middle ear is glossopharyngeal nerve.
The maxillary nerve gives sensory fibers to
the upper jaw, nasal cavity and soft palate
besides a part of face and scalp. The
vestibulo-cochlear nerve carries special sense
of hearing and equilibrium. The facial nerve
is a motor nerve of face and scalp.
G
R

The Brocas area (motor speech center) is
located in inferior frontal gyrus (pars orbicularis and pars triangularis) of functionally
dominant hemisphere. The precentral gyrus
has the primary motor area and the post
central gyrus has the somesthetic (sensory)
area. The superior temporal gyrus has the
auditory area located about its middle.
V
d
ti e
n
U

The artery that supplies the visual area of
cortex is posterior cerebral. The anterior
cerebral artery supplies mostly the medial
surface of hemisphere . The middle cerebral
supplies the large area of lateral surface, where
large parts of motor, sensory area and the
auditory areas are located.
h
a
547

The facial nerve in its bony canal, bulges in
the medial wall of middle ear above the
promontory. The lateral wall is formed by
medial surface of tympanic membrane
mostly. The roof is formed by a thin plate of
bonetegmen tympani. The floor is formed
by a thin plate of bone forming roof of jugular
fossa.

The purkinje cells of cerebellum lie in the
deeper part of molecular layer of cerebellar
cortex. The red nucleus is a lower motor
center. The granular layer of cerebellar cortex
is packed with small granule cells. The dentate
nucleus is a large nucleus that lies inside white
matter of cerebellum.
The special visceral afferent (taste) nucleus
in brain stem is nucleus of tractus solitarius.
The vestibular nuclei receive primary vestibular fibers from the internal ear. The dorsal
nucleus of vagus is a mixed nucleus that
receives afferent and gives efferent fibers to
the viscera. The spinal nucleus of trigeminal
receives pain and temperature sensation from
face and scalp of opposite side.
The intraocular muscle supplied by sympathetic fibers is dilator pupillae. The sphincter
pupillae and the ciliary muscles are supplied
by the parasympathetic fibers.
548

The precentral gyrus of the cerebral
hemisphere is the primary motor area. The
sensory area is located in post central gyrus.
The visual impressions are received in the
visual area located in the occipital lobe in depth
of calcarine sulcus. The auditory area is
located in middle of superior temporal gyrus.
The photo-sensitive cells of retina are the rods
and cones. The bipolar cells and the ganglion
cells form the second and third neurons on
visual pathway. The pigment cells are located
in the outer layer of retina.
The auriculo temporal nerve supplies upper
two third of lateral and upper third of medial
surface of auricle. The greater auricular nerve
supplies the lower third of lateral area lower
two third of medial surface of auricle. The
auricular branch of vagus supplies the
junctional skin of auricle. The lesser occipital
does not supply any part of skin of auricle.
A18. The answer is D, (1, 2, 3, 4).
The lesion of oculomotor nerve shows all the
four signs ptosis (drooping of upper eyelid),
lateral squint, dilatation of pupil and diplopia
(double vision).
A cranial fracture passing through the jugular
foramen will injure the vagus nerve and
glosso-pharyngeal nerve. The hypoglossal
nerve passes out through the anterior
condylar canal. The facial nerve enters internal
acoustic meatus.
The lateral geniculate body receives ipsilateral
temporal retinal fibers (in laminae 1,4 and 6)
and contralateral nasal retinal fibers (in laminae
2,3 and 5).
A21. The answer is E, (4).

The superior colliculus of mid brain is visual
reflex center. It is neither a higher center of
vision nor a visual relay center. It is also not
a visual association center.
A22. The answer is E, (4).
The cortico spinal fibers occupy the anterior
part of posterior limb of internal capsule. The
cortico spinal fibers lie in form of three
bundles one forhead and neck, second for
upper limb and trunk and third for the lower
limb. These fibers do not lie in other parts of
internal capsule.
The optic nerve is considered a tract of brain
because it has three sheaths derived from the
three meninges of brain and its fibers have
no Schwann sheath. Its being attached to
forebrain and its fibers having myelin sheath
do not prove it to be a tract of brain.
A24. The answer is E (4).
The fold of dura mater that lies in the
longitudinal fissure of brain is falx cerebri.
The falx cerebelli lies in posterior cerebellar
notch. The tentorium cerebelli roofs over the
posterior cranial fossa and the diaphragma
sellae roofs over the hypophyseal fossa.
The parts of the ear that are adult size at birth
are the tympanic membrane, the ear ossicles
and the internal ear. The pinna, however,
grows in size as the child grows.
The trochlear nerve passes through the lateral
part and abducent nerve through the middle
part of superior orbital fissure. The optic
nerve and the ophthalmic artery pass through
the optic canal.
A27. The answers are D,A,B and C
The trochlear nerve has somatic efferent
component
tahir99 - UnitedVRG
The trigeminal nerve has somatic afferent

component
The vestibulo-cochlear nerve has special
somatic afferent component
The glossopharyngeal nerve belongs to
special visceral afferent component.
A28. The answers are A,B,D, and C

The facial colliculus lies in pontine part
of floor of fourth ventricle
The corpus callosum joins the medial
surfaces of two cerebral hemispheres
The olive forms an oval swelling on front
of medulla oblongata
The red nucleus lies in tegmentum of
upper parts of pons
A29. The answer are B,C,D, and A
The stapedius is supplied by the facial
nerve
The tensor tympani is supplied by the
mandibular nerve via nerve to medial
pterygoid and otic ganglion
Sphincter pupillae is supplied by the para
sympathetic fibers carried by the oculomotor nerve
h
a
9
ri 9
549
Lateral rectus is supplied by the abducent

nerve
A30. The answers are C,B,D, and A

A spiral ganglion lies in the cochlea of
internal ear
The geniculate ganglion lies on the facial
nerve inside facial canal
The optic disc in retina is the site where
optic nerve leaves the eyeball
The promontory is a round swelling in
medial wall of middle ear, caused by the
first turn of cochlea
V
d
ti e
G
R
A31. The answers are D,A,B, and C

The lacrimal gland is supplied by the
lacrimal branch of ophthalmic artery
The internal ear is supplied by the
labyrinthine arterya branch of basilar
artery
The auditory area of cortex is supplied
by the middle cerebral artery
The lateral part of medulla oblongata is
supplied by the posterior inferior cerebellar artery
n
U
Index
A
Accessory nerve 449
Anal triangle 335
anal canal 335
blood supply 365
clinical considerations 337
lymphatic drainage 336
musculature 335
nerve supply 336
Anomalies of rotation of midgut
269
Ansa cervicalis 434
Anterior abdominal wall 243
applied anatomy 252
blood vessels 250
layers 244
nerve supply 251
rectus sheath 247
bones and joints of abdominal
wall 243
joints of lumbar vertebrae 244
lumbar vertebrae 243
characteristics 243
ossification 244
variations 243
lumbo-sacral joint 244
Arteries of the gastrointestinal tract
296
branches 297
common hepatic artery 297
left gastric artery 297
splenic artery 297
superior mesenteric artery
298
coeliac axis artery 296
Auditory tube 541
Autonomic nerves in the pelvis
334
B
Basal nuclei 508
Blood cells of the thoracic wall 201
Blood vascular system 21
arteries 23
functional end arteries 24
structure 23
arterio-venous anastomosis 24
capillaries 25
heart 21
coronary circulation 22
fetal circulation 22
rate of contraction 22
veins 24
Blood vessels of the front of neck
441
Body of mandible 376
Bones 9
blood supply 12
epiphyseal and juxtaepiphyseal vessels 12
nutrient vessels 12
periosteal vessels 12
functional considerations 11
functions 9
protection 9
shape 9
ossification 11
intra-cartilaginous type 11
intra-membranous type 11
structure 10
inorganic content 10
organic matrix 10
osteocytes 10
types 10
flat bones 10
irregular bones 11
long bones 10
pneumatic bones 11
tahir99 - UnitedVRG
sesamoid bones 11
short bones 10
Bones of foot 125
ossification of tarsal bones 127
ossification of the metatarsals and
phalanges 127
Bones of thorax 183
ribs 184
applied anatomy 187
general features 184
ossification 186
special features 186
sternum 183
ossification 184
thoracic vertebrae 187
ossification 189
Bony pelvis 322
sex differences 324
shapes 323
Branches of oculomotor nerve 520
Bronchial tree 213
Bursae 20
function 20
types 20
articular bursa 20
inter-tendinous bursa 20
sub-cutaneous bursa 20
sub-ligamentous bursa 20
sub-tendinosus bursa 20
C
Campers fascia 19
Carpal bones 52
distal 52
capitate 52
hamate 52
trapezium 52
trapezoid 52
552
proximal 52
lunate 52
pisiform 52
scaphoid 52
triquetral 52
Cartilages 12
hyaline cartilage 12
white fibro-cartilage 13
yellow elastic cartilage 13
Cartilaginous joints 14
Central nervous system 30
brain 30
membranes of brain 30
lumbar puncture 33
nerves fibers 33
sheaths 33
types 33
neuroglia 32
functions 32
types of cells 32
neuron 32
functions 32
parts 32
types 32
spinal cord 31
Cerebellum 498
subdivision 498
white matter 498
Cerebral cortex 506
Cervical part of esophagus 474
Cervical sympathetic trunk 450
Cervical vertebrae 386
Chyluria 28
Cisterna chyli 26, 27
Clavicle (collar bone) 45
applied anatomy 46
general features 45
ossification 46
special features 46
Coccyx 325
ossification 325
Colon 294
applied anatomy 296
blood supply 295
nerve supply 296
veins 295
Cranial cavity 409
hypophysis cerebri 414
applied anatomy 416
nerves 414
trigeminal ganglion 414
D
Deep lymphatics 28
Deep muscles of back 397
Deep palmar arch 105
Descriptive anatomical terms 2
anterior-posterior 2
cranial-caudal 2
medial-intermediate-lateral 2
palmar-plantar 2
peripheral-central 2
proximal-distal 2
superficial-deep 2
superior-inferior 2
Dorsal interossei 103
Dorsum of wrist and hand 95
blood vessels on dorsum of hand
96
arteries 96
deep veins 96
veins 96
nerves on the dorsum of hand 97
dorsal branch of ulnar nerve
97
superficial terminal branch of
radial nerve 97
9
ri 9
h
a
Cranial nerves 517

functional classification 517
general description 517
applied anatomy 517
olfactory nerve 517
optic nerve 517
Cranium 371
functions 354
prostate gland 356
nerve supply 357
seminal vesicles 355
blood supply 355
nerve supply 355
structure 354
vas deferens 354
applied anatomy 355
blood supply 355
Epithalamus 504
Esophagus 271
applied anatomy 271
esophageal 271
esophagitis 271
hiatus hernia 271
blood supply 271
nerve supply 271
Exterior of skull 371
External intercostals muscles 194
Extrahepatic biliary apparatus 283
applied anatomy 284
functions 283
Extrinsic muscles 194
Eyes 525
blood vessels 530
extraocular muscles 530
eyeball 528
chambers 530
lens 530
eyelids 526
lacrimal apparatus 526
nerves 533
orbit 525
V
d
ti e
n
U
G
R
Ears 536
external ear 536
applied anatomy 538
internal ear 541
middle ear 538
Elbow joint 80
arterial anastomosis 80
applied anatomy 80
deep veins 81
veins 80
Electromyography 19
Epididymis 354
ejaculatory ducts 356
F
Face 403
blood vessels 403
motor nerves 408
applied anatomy 409
nerve supply 407
applied anatomy 408
Fasciae 19
deep fascia 20
superficial fascia 19
Fasciae of the head and neck 395
Index
Female reproductive organs 359
ovaries 359
blood supply 359
nerve supply 360
uterine tubes (fallopian tubes)
363
nerve supply 364
uterus 360
blood supply 361
nerve supply 362
supports of the uterus 362
vagina 364
blood supply 365
nerve supply 365
Femur 117
ossification 120
Fibula 122
ossification 124
Fontanelles of the skull 386
Forebrain 502
Fourth ventricle of brain 500
Frankfurts plane 371
Functional parts of nervous system
35
postganglionic neuron 37
somatic nervous system 35
somatic afferent part 35
somatic efferent part 35
visceral nervous system 36
visceral afferent part 36
visceral efferent system 36
G
Glosso-pharyngeal nerve 447
H
Heart 217
applied anatomy 222, 227
dextrocardia 227
patent ductus arteriosus 227

valvular defects 227
blood supply 219
arteries 219
myocardial circulation 221
variations of the coronary
arteries 220
venous drainage 220
borders of heart 218
external features 217
interior of the chambers of
heart 222
inter-ventricular septum 226
nerve supply 221
structure of the heart 226
sulci and fissures 218
Hiltons law 15
Hind-brain 492
brainstem 492
medulla oblongata 492
internal structure 492
pons 494
internal structure 494
subdivisions 492
white matter 493
Hip bone (innominate bone) 113
ossification 116
Hip region 141
muscles of gluteal region 141
blood vessels of gluteal
region 143
lymphatic drainage of
gluteal region 144
relations of gluteus maximus
141
relations of gluteus medius
142
relations of gluteus minimus
142
nerves of the gluteal region 144
Humerus 46
general features 46
ossification 48
special features 48
Hyoid bone 388
ossification 389
tahir99 - UnitedVRG
553
Hypoglossal nerve 450
Hypothalamus 504
Hypothenar muscles 101
I
Individual bones of skull 374
Infratemporal fossa 419
Inguinal region 252
applied anatomy 255
descent of the testes 256
applied anatomy 257
sequence 256
nerves 257
normal mechanism 253
sex difference 253
walls of the inguinal canal 253
Inlet of thorax 193
boundaries 193
plane of inlet 193
structures 193
midlines structures 193
on left side 193
on right side 193
Innermost intercostal 196
Interior of the skull 384
Internal intercostal muscles 195
Intestinal lymph duct 27
Intrinsic muscles 194
J
Jejunum and the ileum 289
blood supply 290
nerve supply 290
applied anatomy 290
Joint 13
amphiarthroses 13
primary cartilaginous joint
13
secondary cartilaginous joint
13
blood supply 15
diarthroses (synovial joints) 14
nerve supply 15
synarthroses 13
Joint of bony pelvis 325
pubic symphysis 326
sacro-coccygeal joint 326
sacro-iliac joint 326
554
Joints of the head and neck 391
atlanto-axial joints 393
atlanto-occipital joint 393
joints between cervical vertebrae
394
ligaments connecting axis with
occipital bone 394
sutures of skull 394
temporo-mandibular joint 391
Joints of the lower extremity 129
ankle (talo-crural) joint 134
applied anatomy 135
arterial supply 135
articular capsule 134
articular surfaces 134
ligaments 134
movements 135
nerve supply 135
type 134
arches of foot 139
lateral longitudinal arch 139
medial longitudinal arch 139
transverse arches 140
hip joints 129
applied anatomy 131
articular surface 129
ligaments 130
movements of joint 130
nerve supply 130
stability of the joint 129
synovial membrane 130
knee joint 131
applied anatomy 133
attachments 131
ligaments of joint 131
menisci (semilunar cartilages)
of knee joint 132
movements 133
nerve supply 133
type 131
mid-tarsal joint 137
calcaneo-cuboid joint 137
talo-calcaneo-navicular joint
137
small joints of foot 138
inter-phalangeal joints 139
inter-tarsal joints 138

metatarso-phalangeal joints
138
tarso-metatarsal joints 138
subtalar joint 137
ligaments 137
movements 137
type 137
tibio-fibular joints 135
arterial supply 136
ligaments 136
movements 136
nerve supply 136
type 136
Joints of the upper extremity 55
acromio-clavicular joint 55
movements 56
elbow joint 59
applied anatomy 59
nerve supply 59
inter-carpal joints 62
mid-carpal joint 62
lateral compartment 62
medial compartment 62
movements 62
type 62
movements of shoulder girdle 58
radiocarpal (wrist) joint 61
movements 62
radio-ulnar joints 60
distal radio-ulnar 60
middle radio-ulnar joint 60
proximal (superior) radio-ulnar
joint 60
shoulder joint 56
small joints of the hand 63
carpo-metacarpal joints 63
inter-phalangeal joints 64
metacarpo-phalangeal joints
63
sterno-clavicular joint 55
Joints of thorax 189
costochondral joints 191
costo-transverse joints 190
costo-vertebral joints 189
interchondral joints 191
joints between thoracic vertebrae
192
applied anatomy 192
sterno-costal joints 191

xiphisternal joint 192
K
Kidneys 303
anterior surface 303
blood supply 306
applied anatomy 307
arteries 306
nerve supply 307
veins 307
borders 303
ends 303
general structure 305
hilum 304
posterior surface 304
surfaces 303
L
Large intestine 291
cecum 291
Lateral ventricle 513
Left brancho-mediastinal lymph 27
Left jugular lymph duct 27
Left subclavian lymph duct 27
Limbic system 516
Liver (hepar) 279
applied anatomy 282
bare areas 282
blood supply 282
lobes of liver 281
location 279
nerve supply 282
segmentation of liver 281
surfaces and borders 279
veins 282
Lower extremity 113
features 113
Lumbar lymph duct 26
Lumbricals 102
Lungs 206
blood vessels 211
bronchial vessels 212
pulmonary vessels 211
broncho-pulmonary segments
211
Index
lobes of lung 210
applied anatomy 213
nerve supply 213
Lymph edema 28
Lymph vessels 26
lymph capillaries 26
lymph ducts 26
lymphatics 26
Lymphatic drainage of the head and
neck 447
Lymphatic drainage of the pelvic
organs 332
Lymphatic organs 26
Lymphatic-venous communications
27
M
Male reproductive organs 352
testis 352
blood supply 353
coverings 352
nerve supply 354
structure 352
veins 353
Mammary gland 7
architecture 7
connective tissue stroma 7
glandular 7
suspensory ligaments 7
blood supply 8
clinical importance 8
development 8
anomalies 8
nerve supply 7
Mastoid antrum 540
Maxillary nerve 424
Meckels of diverticulum 270
Mediastinum 228
anterior mediastinum 232
boundaries 232
contents 232
middle mediastinum 232
boundaries 232
contents 232
posterior mediastinum 232
azygos vein 236
descending thoracic aorta 233

esophagus 233
hemiazygos veins 236
thoracic duct 235
superior mediastinum 228
arch of aorta 230
brachiocephalic veins 230
phrenic nerves 231
superior vena cava 229
vagus nerves 231
Meninges of brain 486
blood supply 487
applied anatomy 489
arteries 487
veins of brain 490
Metacarpal bones 53
Mid-brain 495
white matter 497
Movements of respiration 199
applied anatomy 200
fracture of rib 201
pleural effusion 201
pneumothorax 200
costal movements 199
forced costal expiration 200
forced costal inspiration 199
normal costal expiration 200
normal costal inspiration 199
diaphragmatic expiration 200
diaphragmatic inspiration 200
Muscles 16
features 16
skeletal muscles 16
contraction 18
nerve supply 18
parts 16
shapes 17
types 18
Muscles connecting thoracic cage to
vertebral column 196
serratus posterior inferior 197
serratus posterior superior 196
Muscles of front of neck 436
Muscles of mastication 420
N
Nerve supply of the thoracic wall
204
Nerves of the front of neck 447
Nerves of the palm 106
tahir99 - UnitedVRG
555
Nerves of the pelvis 332
Nerves of the perineum 338
Nervous system 29
functional classification 29
autonomic nervous system 29
somatic nervous system 29
functions 29
parts 29
central nervous system 29
peripheral nervous system 29
O
Organ of Corti 543
P
Palm of the hand 97
blood vessels of the palm 100
arteries 100
veins 105
long flexor tendons in the palm
99
four tendons of flexor
digitorum profundus 99
four tendons of flexor
digitorum superficialis
99
tendon of palmaris longus 99
nerves 105
cutaneous branches 106
medial nerve 105
Palmar interossei 103
Pancreas 284
applied anatomy 286
blood supply 286
location 284
nerve supply 286
pancreatic ducts 286
parts 284
type 284
Parasympathetic ganglia 425
Parathyroid glands 440
Parotid gland 417
applied anatomy 418
arterial supply 418
nerve supply 418
parotid duct 418
Patella (knee cap) 124
ossification 124
556
Pelvic fascia 327
Pelvic muscles 327
Pelvic part of ureter 347
blood supply 348
nerves supply 348
Pelvic peritoneum 328
Pericardium 215
applied anatomy 217
dry pericardititis 217
pericardial tamponade 217
pericardio-centesis 217
functions 217
location 215
nerve supply 217
parts 215
fibrous pericardium 215
serous pericardium 215
Peripheral nervous system 34
cranial nerves 34
spinal nerves 34
Peritoneum 260
applied anatomy 266
blood supply 266
mesenteries 260
nerve supply 266
peritoneal cavity 261
peritoneal recesses 265
Phalanges 53
Planes of body 2
coronal plane 2
median sagittal (median) plane 2
sagittal (para-sagittal) plane 2
transverse (horizontal) plane 2
Pleura 206
blood supply 208
functions 208
lines of pleural reflection 206
anterior lines of pleural
reflection 206
inferior of pleural reflection
207
posterior lines of pleural
reflection 207
nerve supply 208
pleural recesses 207
Popliteal fossa 157
applied anatomy 159
popliteal artery 159

popliteal vein 159
tibial nerve 159
contents 158
Portal vein 300
applied anatomy 302
features of hepatic-portal system
300
Positions of body 1
anatomical position 1
lithotomy position 2
supine position 2
Posterior abdominal wall 311
blood vessels 312
applied anatomy 313
arteries 312
veins 313
Pterygopalatine fossa 419
Pudendal canal (Alcocks canal) 338
R
Radius 49
general features 49
special features 49
Rectum 346
blood supply 347
arteries 347
veins 347
interior of rectum 347
nerve supply 347
peritoneal relations 346
supports 347
Region of foot 168
dorsum of foot 168
blood 169
muscles and tendons 168
nerves 170
sole of foot 171
blood vessels 174
muscles of sole 171
nerves of sole 176
Region of forearm 85
anterior compartment 85
applied anatomy 89
blood vessels 85
branches 88
branches in forearm 89
muscles 85
nerves of the anterior

compartment 89
posterior compartment of forearm
91
applied anatomy 94
blood vessels 93
branches 94
deep extensors 91
nerves 93
superficial extensors 91
Region of leg 161
anterior (extensor) compartment
of leg 161
blood vessels 161
muscles 161
nerves 163
lateral (peroneal) compartment of
leg 163
blood vessels 163
nerves 164
posterior compartment of leg 164
blood vessels 164
nerves 167
Region of the thigh 146
anterior compartment of thigh
146
adductor canal 148
blood vessels 149
femoral canal 152
femoral hernia 152
femoral sheath 151
femoral triangle 146
lymph nodes 150
nerves 150
medial compartment of the thigh
152
blood vessels 152
nerves 155
veins 154
posterior compartment of the
thigh 155
blood vessels 155
nerves 156
Reids base line 371
Rotation of duodenum 267
Rotation of gut 267
Rotation of the midgut 268
S
Sacrum 324
Index
sex-difference 325
variations 325
Sagittal section through knee joint
132
Scalp 400
blood supply 401
nerve supply 402
Scapula 43
general features 43
angles 44
borders 44
surfaces 44
ossification 45
special features 44
Scapular anastomosis 74
Scarpas fascia 19
Sciatic nerve 144
Shoulder region 65
axilla 67
axillary artery 68
axillary lymph nodes 69
axillary vein 69
brachial plexus 69
pectoral region 65
scapular region 73
blood supply of scapular
muscles 74
nerves of scapular region 75
sarratus anterior muscle 73
shoulder region proper 71
deltoid muscle 71
Skin 4
appendages 5
hair follices 6
nails 5
sebaceous glands 6
sweat glands 6
functions 4
protection 4
secretion 4
sensations 4
nerve supply 6
parts 4
inner epidermis 4
outer epidermis 4
Spinal cord 481
blood supply 482
meninges 481
nerve tracts in anterior while

column 483
nerve tracts in lateral white
column 483
nerve tracts in posterior white
column 483
Spinal curvatures 390
Spleen 286
applied anatomy 288
enlargement of spleen 288
splenectomy 288
functional significance 288
nerve supply 288
Sternocostalis 196
Stomach (gaster) 272
applied anatomy 275
blood supply 274
location 272
nerve supply 275
opening, surfaces, borders 272
size and shape 272
veins 274
Subclavian artery 444
Subclavian vein 447
Subdivision of anatomy 1
applied anatomy 1
developmental anatomy 1
functional anatomy 1
gross-anatomy 1
microscopic anatomy 1
radiological anatomy 1
regional anatomy 1
surface anatomy 1
Subthalamus 505
Superficial back region 75
deeper layer 75
levator scapulae 75
rhomboid major 75
rhomboid minor 75
superficial layer 75
latissimus dorsi 75
trapezius 75
Superficial lymphatics 28
Superficial palmar arch 104
Superior aspect of tibia 132
Suprarenal (adrenal) glands 308
applied anatomy 310
nerve supply 310
tahir99 - UnitedVRG
557
parts 310
veins 310
Sympathetic trunks 237
branches 237
greater splanchnic nerve 237
grey rami communicans 237
lesser splanchnic nerve 237
lowest splanchnic nerve 237
white rami communicans 237
Synovial sheath 20
clinical consideration 20
T
Telencephalon 506
Temporal fossa 419
Thenar muscles and adductor pollicis
101
Third ventricle 505
Thoracic diaphragm 197
development 199
anomalies 199
applied anatomy 199
other structures passing through
diaphragm 199
hemiazygos veins 199
lower five intercostal nerves
199
musculophenic artery 199
subcostal vessels 199
superior epigastric artery 199
sympathic trunk 199
three splanchnic nerves 199
Thoracic duct 27
Thymus gland 441
Thyroid gland 438
applied anatomy 440
blood supply 439
nerve supply 440
Tibia 120
ossification 122
Triangles of the neck 427
anterior triangle of the neck 431
posterior triangle of neck 427
suboccipital triangle of neck 430
Typical intercostal nerve 204
Typical synovial joints 15
558
U
Ulna 50
applied anatomy 51
general features 50
ossification 51
special features 51
Upper arm 78
anterior compartment of arm 78
blood vessels 79
cubital fossa 78
deep lymphatics 81
lymphatics of arm 81
median nerve 81
musculo-cutaneous nerve 81
nerves of anterior
compartment of arm 81
superficial lymphatics 81
posterior compartment of arm 82
blood vessels 82
nerves of the posterior
compartment 83
Upper extremity 43
features 43
Ureter 307
applied anatomy 308
nerve supply 308
Urethra 350
female urethra 351
male urethra 351
Urinary bladder 348
blood supply 350
inferior urinary bladder 349
ligaments 349
nerve supply 350
Urogenital triangle in females 343
deep perineal pouch in females
345
nerve supply 345
superficial perineal pouch in

females 344
nerve supply 344
Urogenital triangle in males 339
deep perineal pouch in males
342
penis 339
blood vessels 340
lymphatics 340
nerve 340
scrotum 339
spermatic cord 340
superficial perineal pouch in
males 341
nerve supply 342
V
Vagus nerve 449, 523
Vermiform appendix 292
applied anatomy 293
blood supply 293
Vertebral column 389
Viscera of the head and neck 452
cervical part of trachea 459
anterior 459
posterior 459
larynx 455
blood supply 459
cavity of larynx 457
muscles of larynx 457
skeletal framework 453
nerve supply 459
applied anatomy 459
paranasal air sinuses 454
applied anatomy 455
respiratory system 452
opening in lateral wall 453
Viscera of the head and neck 460

digestive system 460
lingual nerve 468
applied anatomy 469
mouth cavity 460
palate 460
blood supply 460
nerve supply 461
pharyngeal musculature 471
blood supply 473
gaps in the pharyngeal wall
472
pharynx 469
palatine tonsil 470
submandibular region 467
salivary glands 467
sublingual salivary gland 468
submandibular salivary duct
467
teeth 462
eruption 462
nerve supply 463
shape and functions 462
structure 462
tongue 463
blood vessels 464
muscles 464
Vocal folds 458
W
White matter of cerebral hemisphere
510
Wormian (sutural) bones 386
Z
Zygomatic bones 379

Essentials of Human Anatomy

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Essentials of Human Anatomy

Uploaded by

Copyright:

Available Formats

Essentials of

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Preface to the Second Edition

Preface to the First Edition

Section Two: The Upper Extremity

The Bones of the Upper Extremity ........................................................................................ 43

Section Three: The Lower Extremity

The Bones of the Lower Extremity ..................................................................................... 113

Section Four: The Thorax

The Bones and Joints of Thorax .......................................................................................... 183