Essentials of

Human Anatomy

BHARATI ADHIKARI

Tribhuvan University Teaching Hospital

Maharajgunj, Kathmandu ,Nepal

 Preface to the First Edition

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:
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.
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.
I hope that the book will be helpful in learning anatomy in an interesting way.
BHARATI ADHIKARI
 Contents

Section One: Introduction to Anatomy

1. The Basics............................................................................................................................................ 1
2. The Skin and Its Appendages .......................................................................................................... 4
3. The Bones, Cartilages and Joints .................................................................................................... 9
4. The Muscles and the Fasciae .......................................................................................................... 16
5. The Blood Vascular System ........................................................................................................... 21
6. The Lymphatic System ................................................................................................................... 26
7. The Nervous System ........................................................................................................................ 29

Section Two: The Upper Extremity

8. The Bones of the Upper Extremity ............................................................................................... 43
9. The Joints of the Upper Extremity ............................................................................................... 55
10. The Shoulder Region and Superficial Back Region ................................................................... 65
11. The Upper Arm and the Elbow Region........................................................................................ 78
12. The Region of Forearm ................................................................................................................... 85
13. The Region of Wrist and Hand ...................................................................................................... 95

Section Three: The Lower Extremity

14. The Bones of the Lower Extremity.............................................................................................. 113
15. The Joints of the Lower Extremity.............................................................................................. 129
16. The Hip Region ............................................................................................................................... 141
17. The Region of the Thigh ................................................................................................................ 146
18. The Region of the Leg.................................................................................................................... 161
19. The Region of the Foot .................................................................................................................. 168

Section Four: The Thorax

20. The Bones and Joints of Thorax .................................................................................................. 183
21. The Musculature of the Thoracic Wall....................................................................................... 194
22. The Pleura and Lungs ................................................................................................................... 206
23. The Pericardium and the Heart ................................................................................................... 215
24. The Mediastinum ........................................................................................................................... 228
xiv Essentials of Human Anatomy

Section Five: The Abdomen

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

Section Six: The Pelvis

30. The Bones and Joints of the Pelvis .............................................................................................. 322
31. The Fasciae, Muscles, Blood Vessels and Nerves of the Pelvis ............................................... 327
32. The Perineum ................................................................................................................................. 335
33. The Pelvic Viscera-1 ...................................................................................................................... 346
34. The Pelvic Viscera-2 ...................................................................................................................... 359

Section Seven: The Head and Neck

35. The Bones of the Head and Neck ................................................................................................ 371
36. The Joints, Fasciae and Deep Muscles of the Back of Head and Neck ................................. 391
37. The Scalp, Face and the Cranial Cavity..................................................................................... 400
38. The Parotid Region, Temporal and Infratemporal Fossae ..................................................... 417
39. The Triangles of the Neck ............................................................................................................ 427
40. The Muscles, Glands, Blood Vessels and Nerves of the Front of Neck ................................. 435
41. The Viscera of the Head and Neck-1 .......................................................................................... 452
42. The Viscera of the Head and Neck-2 .......................................................................................... 460

Section Eight: The Spinal Cord, Brain, Eyes and the Ears
43. The Spinal Cord ............................................................................................................................. 481
44. The Meninges and Blood Supply of Brain ................................................................................. 486
45. The Hind-Brain and Mid-Brain .................................................................................................. 492
46. The Forebrain................................................................................................................................. 502
47. The Cranial Nerves........................................................................................................................ 517
48. The Eyes .......................................................................................................................................... 525
49. The Ears .......................................................................................................................................... 536
Index ................................................................................................................................................ 551
 Introduction to
Anatomy
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.
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
ONE
CHAPTER 1
The Basics
Abdomen and pelvis
Upper extremity
Lower extremity.
2. Microscopic anatomy (Histology): Study of
the minute structure of the body with the help
of a microscope.
3. Developmental anatomy (Embryology): Study
of the embryo and fetus within the uterus or
the womb.
4. 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.
5. Functional anatomy: Study of structure of
different parts of the body related to their
functions.
6. 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.
7. 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.
2 Essentials of Human Anatomy
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.
 The Basics
2. Abduction-adduction takes place at an antero-
posterior 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.
3
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.

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
CHAPTER 2
The Skin and Its
Appendages
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.
 The Skin and Its Appendages 5

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
Fig. 2.2: The cleavage lines of skin
limbs they follow a longitudinal pattern.
The cleavage lines are important from point of At the sites of the skin creases, the skin is
view of surgical incisions on the skin (Fig. 2.2). thinner and firmly attached to the underlying
structures.
The Skin Creases The Appendages of the Skin
The skin over the joints always folds at some The appendages of the skin are the nails, hair
places causing skin creases. The skin creases are follicles, sebaceous glands and the sweat glands.
also present in the palm and to a lesser extent in 1. The nails: These are keratinised plates on
the skin of the sole. dorsal surface of tips of fingers and toes.
6 Essentials of Human Anatomy
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 extru-
ding 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.
 The Skin and Its Appendages 7

THE MAMMARY GLAND forms a membranous capsule on its deep

The mammary gland is a secondary sex gland in surface, that is separated from deep fascia of
females for production of milk. pectoralis major by retro-mammary space.
It consists of highly enlarged and modified 3. The suspensory ligaments (Ligaments of
Cooper) are fibro-elastic bands, which act as
sweat glands placed on the front of upper part of
connective tissue septa inter-connecting the
thorax.
lobes.
Areola is a circular patch of colored skin that They also connect the lobes of the gland
surrounds the nipple. to the skin and underlying deep faseta.
It has large sweat glands, that become In old age, these ligaments lose their
enlarged during pregnancy and form raised elasticity causing sagging of the breast.
tubercles of Montgomery In cases of tumor of the breast, these
It is lighter in color, but during second month ligaments are shortened, thereby causing
of first pregnancy, its color becomes perma- retraction of the overlying skin (Fig. 2.3).
nently darker.
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 Fig. 2.3: Sagittal section through breast

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
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.
8 Essentials of Human Anatomy
The Blood Supply
The mammary gland is supplied mainly by
the branches of the axillary artery thoraco-
acromial 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 supra-
clavicular lymph nodes
Some superficial lymphatics may
communicate across midline with the
lymphatics of the opposite breast.
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 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 non-
eversion 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.
 CHAPTER 3
The Bones,
Cartilages and Joints
THE BONES Clavicle 1
The bones of the body form the skeleton Humerus 1
Radius 1
(endoskeleton, as it lies deep to the muscles)
Ulna 1
The skeleton can be divided into:
Carpal bones 8
1. The axial skeleton consisting of the skull,
Metacarpals 5
mandible, hyoid bone, vertebral column
Phalanges 14
(including sacrum and the coccyx), sternum
32
and the ribs.
Total bones for two upper extremities
2. The appendicular skeleton consisting of bones
32 2 = 64
of the upper and lower extremities.
2. The lower extremity
The skeleton is bilaterally symmetrical and
Innominate bone 1
has approximately 206 bones.
(Hip bone)
The axial skeleton has 80 bones as under: Femur 1
The skull Patella 1
Cranial bones 8 Tibia 1
Facial skeleton (including mandable) 14 Fibula 1
The ear ossicles 6 Tarsals 7
The hyoid bone 1 Metatarsals 5
The vertebrae 26 Phalanges 14
7 Cervical 31
12 Thoracic Total bones for two lower extremities
5 Lumbar 31 2 = 62
1 Sacrum Thus the bones in the appendicular skeleton
(Formed by fusion of 5 sacral vertebrae) are 126(64+62); and total number of bones in the
1 Coccyx body are (80+64+62)=206.
(formed by fusion of 4 coccygeal vertebrae)
The sternum 1 The Main Functions of the Bones
The ribs 24 1. Shape: The bones give shape to the body by
Total 80 providing a rigid framework.
The appendicular skeleton has 126 bones as under: 2. Protection: The bones provide protection to
1. The upper extremity the vital internal organs, e.g. brain, heart,
Scapula 1 lungs, and liver.
10 Essentials of Human Anatomy

3. Joints: The bones form the joints, which act II. The compact bone lies deep to the periosteum
as levers and provide movements. and looks like ivory with naked eye.
4. Storehouse: The bones act as store houses of The compact bone is made up of haversian
Ca, PO4 and CO3 ions. systems and canals.
5. Hemopoiesis: The bone marrow is the source III. The cancellous bone consists of of bony lamellae
of red blood cells, white blood cells, and the enclosing narrow spaces containing the bone
platelets. marrow tissue.
The cancellous bone fills up the interior of
The Structure of the Bone the bone.
IV. The medullary cavity is present in most of the
The bone is calcified connective tissue. It consists
long bones.
of: It is located mainly in the shaft of the bone
1. An organic matrix (nearly 33%) made up of and contains bone marrow tissue (Fig. 3.1).
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 Fig. 3.1: LS through a long bone
shows:
I. The periosteum: That lines the external Types of Bones
surface of all parts of the bone except those 1. Long bones are present in the extremities.
that are covered by hyaline articular cartilage
They have a main part or shaft called
at the joints. The periosteum consists of:
diaphysis.
An outer fibrous layer
An inner vascular layer with plexus of fine The two ends form the epiphysis.
blood vessels (periosteal plexus). It has also There is medullary cavity containing bone
a layer of osteocytes, that are modified marrow tissue in the shaft.
fibroblasts. Examples: Femur, humerus.
The functions of the periosteum are: 2. Short bones are small size bones usually
1. It protects the bone. cuboidal in shape.
2. It nourishes the bone through its vascular Examples: Tarsals, Carpals.
plexus. 3. Flat bones consist of two layers of compact
3. It helps in growth and repair of the bone bone with spongy or cancellous bone in between
by its osteocytes. called diploe. They are expanded like a plate.
 The Bones, Cartilages and Joints 11

Examples: Skull bones, e.g. frontal, parietal. There is an epiphyseal plate or cartilage
4. Irregular bones have irregular shapes separating the epiphysis from the diaphysis. This
They have compact bone surrounding epiphyseal plate disappears, when the growth in
spongy bone in between. length of the bone stops.
Examples: Vertebrae, hip bones The epiphyseal end of diaphysis is called
5. Sesamoid bones (= seedlike) are small metaphysis.
nodules of bone, developed in tendons of This is the most vascular and active area of
certain muscles at sites of friction or pressure. growth of the long bone.
Examples: Patella, pisiform. The growing end of the long bone is that end
6. Pneumatic bones are skull bones having air- of the bone whose epiphysis fuses with the
filled cavities called air sinuses. diaphysis (shaft) later than the other end (i.e. it
Examples: Frontal, maxilla. continues to grow in length a little longer).
The growing end of the long bone lies
Ossification of the Bones
opposite to the direction of the nutrient canal of
The ossification is the process of bone formation the bone (Fig. 3.2).
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 ossifica-
tion): 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.
Fig. 3.2: Parts of a developing long bone
Examples: Clavicle, Skull bones, e.g. frontal
parietal.
Functional Considerations
The primary center of ossification of the bone
usually appears before birth and forms the main part The bone is a living tissue capable of growth and
of the bone. In long bone it forms the diaphysis. repair.
The secondary centers of ossification usually The growth in length of the long bone takes
appear after birth and form small parts of the place at the epiphyseal cartilage, while the growth
bone called epiphyses. in thickness (appositional growth) takes place deep
In case of long bones, there is usually one (or to the periosteum. The remodeling of the bone takes
more than one) epiphysis at either end of the place along with the growth of the bone. It is done
bone. by the osteoclaststhe bone absorbing cells.
12 Essentials of Human Anatomy
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 deve-
loping 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.
 The Bones, Cartilages and Joints
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 (synchon-
drosis) 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 (symp-
hysis) 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 Essentials of Human Anatomy
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 pres-
sure 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 strap-
like 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, how-
ever, 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.
Fig. 3.4: Cartilaginous joints
2. Biaxial where movements take place at two
axes.
Examples: Metacarpo-phalangeal joints,
radio-carpal (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.
 The Bones, Cartilages and Joints
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.
15
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 unstre-
tchable. 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.

THE MUSCLES
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
Each skeletal muscle has at least two attachments-
origin and insertionand a muscle belly.
CHAPTER 4
The Muscles
and the Fasciae
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
Aponeurosis is that fibrous sheet which replaces a
flat muscle towards insertion.
Example: Aponeurosis of external oblique muscle.

Table 4.1: Main features of muscles

Skeletal muscle Visceral muscle Cardiac muscle
1. Location Attached to the skeleton Related to the viscera In myocardium of heart
2. Histological Cylindrical muscle fibers Spindle shaped muscle Muscle fibers branch and
structure fibers anastomose
Muscle fibers show both No transverse striations Faint transverse
transverse and longitudinal Single oval nucleus striations
striations present in the middle of Intercalated discs present
muscle fiber Centrally placed nuclei
Have multiple peripheral
nuclei
3. Nerve supply Somatic nerves Autonomic nerves Autonomic nerves
4. Actions Mostly voluntary Involuntary Involuntary
with few exceptions
Muscle action quick Muscle action slow Property of rhythmic
and sustained 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 mylo-
hyoid 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.
Fig. 4.1: Shapes of skeletal muscles
17
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.
3. Quadrilateral (Quadrangular) where the
muscle belly is short and quadrangular.
Example: Quadratus femoris.
4. Strap like where the muscle belly is long and
strap or ribbon like with parallel muscle
fibers. Example: Sartorius
5. Triangular where muscle belly is shaped like
a triangle.
Example: Obturator externus.
6. Digastric where two muscle bellies are joined
by a common tendon.
Example: Digastric
18 Essentials of Human Anatomy
7. Bicipital where the muscle belly has two
heads-joined 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.
 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.
Electromyography
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.
19
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.
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 carno-sus 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 insu-
lation and padding of the body.
This layer is sensitive to oestrogenic
hormones.
20 Essentials of Human Anatomy
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.
Clinical Considerations
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.
Clinical Considerations
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.

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
The heart is a muscular pump that pumps blood to
all parts of body and lungs through blood vessels.
Fig. 5.1: Two circulatory cycles
CHAPTER 5
The Blood
Vascular System
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 move-
ments 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 Essentials of Human Anatomy
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 pace-
maker passes through other parts of neuro-
myocardium 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.
Clinical Considerations
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
under-goes 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:
 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.
Clinical Considerations
Failure of closure of these shunts after birth leads
to congenital heart disease.
Examples: Patent foramen ovale, patent ductus
arteriosus, patent ductus venosus.
THE ARTERIES
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.
23
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 anasto-
mosis 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 under-goes
ischemia and later avascular necrosis.
24 Essentials of Human Anatomy
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
 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.
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.
The vasa vasorum are small vessels, that supply
the coats of large blood vessels.
Examples: Aorta, inferior vena cava, pulmonary
trunk.
Clinical Considerations
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 plexu-ses.
Trauma or infection, when inflammatory
fluid passes into tissue space due to
increased capillary permeability. This
edema fluid is rich in proteins.

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
CHAPTER 6
The Lymphatic
System
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 exter-
mity.
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.
 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 ver-tebra
(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
The lymphatic-venous communications exist
and lies at the root of neck.
between the lymph ducts and the neighboring
It curves laterally behind the carotid
veins of the region.
sheath and terminates in the beginn-
ing of left brachiocephalic vein.
Near its termination, thoracic duct
often contains venous blood, due to
higher pressure in the left brachio-
cephalic 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.
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 Essentials of Human Anatomy
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 absor-
bed 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 broncho-
pulmonary 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 transu-
date 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.

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 inte-
gration of all sensory impulses general
and special.
CHAPTER 7
The Nervous
System
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 (cranio-
sacral 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 Essentials of Human Anatomy

Pelvic splanchnic nerves from

S2, S3, and S4 segments of
spinal cord.
B. The sympathetic system (Thoraco-
lumbar outflow) has
I. A central component in lateral grey
column of T1 to L2 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 white matter and the grey matter

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 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.
 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 compart-
ments 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 sub-
arachnoid 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 spacesub-
arachnoid 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 Essentials of Human Anatomy

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.
 The Nervous System 33

3. The microglial cells act as phagocytic Outside central nervous system, the
cells of the central nervous system. myelin sheath is formed by the activity
4. The oligodendrocytes form and maintain of Schwann cells.
the myelin sheaths of the nerve fibers in Inside the central nervous system, the
brain and spinal cord. myelin sheath is formed by the activity
5. The ependymal cells are columnar cells, of oligodendrocytes (Fig. 7.3).
that line ventricles of brain and central Functions of the myelin sheath:
canal of the spinal cord. These cells are 1. The myelin sheath protects and insulates the
also concerned with the secretion and
nerve fibers.
transport of cerebrospinal fluid.
2. The myelin sheath also increases the rate of
6. The neuroglial cells also perform an
conduction of nerve impulse and reduces their
essential metabolic function of regulating
energy requirements.
the biochemical environment of the neurons.
The nerve fibers are also classified according
The Nerves Fibers to presence of the myelin sheath as
A. The medullated (myelinated) nerve fibers.
The nerve fibers are the axons and long dendrites B. The non-medullated (non-myelinated) nerve
of the neurons.
fibers.
The nerve fibers form the nerve tracts of the
brain and the spinal cord. The Lumbar Puncture
The nerve fibers form the bulk of the
peripheral nerves and nerve plexuses. The lumbar puncture is a diagnostic procedure, that
Types of the nerve fibers: is done to take out a sample of cerebro-spinal fluid
i. The sensory (afferent) fibers carry afferent from the lumbar cistern surrounding the nerve roots
impulses from the peripheral end organs below the conus medullaris of the spinal cord.
towards the higher centers in brain and The puncture is done usually between 3rd
spinal cord. lumbar and 4th lumbar vertebra at the back
ii. The motor (efferent) fibers carry efferent between the spinous processes of the lumbar
or motor impulses from the higher centers vertebrae.
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. Fig. 7.3: Sheaths of nerve fibers
34 Essentials of Human Anatomy
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.
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
ix. Glosso-pharyngeal
x. Vagus
xi. Accessory
xii. Hypoglossal
The Spinal Nerves
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 ventro-
laterally 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.
 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 pseudo-
unipolar 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 thala-
mus, 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 Essentials of Human Anatomy
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 cranial-
nerves 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) con-
veys 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 seg-
ment 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
 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 sym-
pathetic 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 (Thoraco-
lumbar 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 post-
ganglionic neurons in sympa-
thetic 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 acetyl-
choline.
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 sympathe-
tic 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, abdo-minal and pelvic
organs along the blood vessels.
The neuro-transmitter for the post-
ganglionic 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 Essentials of Human Anatomy
nerves located outside CNS. The post-
ganglionic 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 eri-
gentes 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 acetyl-
choline.
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.
 Introduction to Anatomy
Multiple Choice Questions
Q.1. Select the one best response to each ques-
tion 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 sug-
gested 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 Essentials of Human Anatomy

3. Are finger prints 2. Is connected to the spinal cord by two

4. Indicate the direction of collagen fiber nerve rootsventral and dorsal
bundles in the dermis of skin 3. Has a dorsal ramus that supplies the
10. The lymphatic drainage of breast: skin and muscles of back only
4. Supplies an area of skin called dermatome.
1. Is mainly in the axillary lymph nodes
2. Some lymphatics from superior quad- 15. A developing long bone:
rants reach supra-clavicular lymph nodes 1. Has two epiphyses at the two ends, that
3. From medial quadrants lymphatics are developed from secondary centers
reach parasternal lymph nodes of ossification
4. Superficial lymphatics cross midline and 2. Has at least one nutrient foramen
communicate with those of opposite side. through which main nutrient vessels
11. The stability of the joint: enter the bone
1. Depends upon the shape of the articular 3. Has metaphysissite for maximum
surfaces growthtowards epiphyseal plate
2. Is helped by the powerful ligaments 4. Has epiphyseal plates at the two ends
surrounding the joint that persist in the adult bone.
3. Is also helped by the articular disc
inside the joint Q.3. Cross match the following with appro-
4. Is mainly maintained by the articular priate answers on the left:
capsule. 16. For each joint below give the most appropriate
12. In the circulatory system: answer from the list given on right side:
1. The arterioles are the smallest branch I. Syndesmosis A. Elbow joint
of the arteries II. Saddle joint B. Interior tibiofibular
2. The capillaries have only a single layer joint
of endothelium in their walls III. Hinge joint C. Calcaneo-cuboid
3. The end arteries are those arteries, that joint
have no anastomosis with neighboring IV. Ball and socket D. Hip joint
arteries
joint
4. The venules are the smallest veins and
V. Plane joint E. Acromio-clavicular
contain valves.
joint
13. The synapses in the nervous system:
17. For each joint below give the movement
1. Are sites of physical continuity
between processes of two neurons associated with it from the list given on right
2. Are sites where a chemical mediator side:
substance is liberated I. Ankle joint A. Medial rotation
3. Allow both ways passage of the nerve II. Shoulder joint B. Gliding
impulse III. Sterno-clavi- C. Dorsiflexion
4. Are sites where the processes of two cular joint
neurons come in close proximity IV. Metacarpo- D. Adduction
14. A spinal nerve: phalangeal joint
1. Is a mixed nerve having both sensory V. Radio-ulnar E. Pronation
and motor fibers joints
 Multiple Choice Questions
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.
A4. The answer is A.
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.
A5. The answer is B.
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.
41
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.
A11. The answer is A, (1, 2, 3).
The stability of a joint depends on the shape
of articular surfaces, presence of intra-
articular 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.
A13. The answer is C, (2, 4).
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 synap-ses. The synapses allow
unidirectional flow of impulse.
42 Essentials of Human Anatomy
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.
A15. The answer is A, (1, 2, 3).
The developing long bone has two epiphyses
at the two ends. It has at least one nutrient
foramen for the nutrient vessels. The meta-
physis 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
adduc-tion movement.
Radio-ulnar jointshave pronation
movement.
 The Upper Extremity TWO

CHAPTER 8
The Bones of the Upper Extremity
Both the upper and lower extremities are THE SCAPULA
homologous in their development and are built on General Features
same plan.
The scapula is a flat bone that lies on postero-
FEATURES OF THE UPPER EXTREMITY lateral aspect of upper part of thorax.
The scapula is a part of shoulder girdle.
1. The upper extremity has developed greater It is triangular in shape. It has three angles
mobility so that hands can be used for superior, inferior and lateral.
prehension or grasping. The scapula has three surfacesupper dorsal,
2. The upper extremity has undergone lateral lower dorsal and costal.
rotation by 90 from its premitive position. So It has three borderssuperior, medial and
that flexor surface faces anteriorly and lateral (Figs 8.1 and 8.2).
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, meta-
carpals and phalanges Fig. 8.1: The scapulaanterior aspect
44 Essentials of Human Anatomy
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 inter-
muscular septa of subscapularis muscle.
The Borders
I. The superior border is very short. It has a
supra-scapular notch at the root of coracoid
process.
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 infra-
clavicular 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
Muscles attached to scapula
Subscapular fossaSubscapularis
Supraspinous fossaSupraspinatus
 The Bones of the Upper Extremity
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-acro-
mial ligament
Superior surface coracoid processTrape-
zoid part of coraco-clavicular ligament
Root of coracoid processConoid part of
Coraco-clavicular ligament
Inferior surface of coracoid process
Coraco-humeral ligament.
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
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.
Fig. 8.3: The claviclesuperior aspect
 46 Essentials of Human Anatomy
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 mus-
cular 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
sterno-clavicular 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 groove
Subclavius (on inferior surface)
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
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.
 The Bones of the Upper Extremity
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 epicon-
dylesa 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 promi-
nent, and also shows rough surface for
attachment to extensor muscles of forearm.

Fig. 8.5: The humerus

48 Essentials of Human Anatomy
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.
Special Features Muscles
attached to humerus:
Upper end
Lesser tuberositySubscapularis
Greater tuberositySupraspinatus Infra-
spinatus 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 ridgeBrachio-
radialis 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 inter-
muscular septum
Lateral supra-condylar ridgeLateral inter-
muscular 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
 The Bones of the Upper Extremity
(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
super-ficialis
Anterior surface (Upper 2/3rd) below anterior
borderFlexor pollicis longus
Anterior surface (distal 1/4th) - Pronator
quad-ratus
Base of styloid processBrachio-radialis
Posterior surface (upper part)Abductor
pollicis longus, Extensor pollicis brevis
50 Essentials of Human Anatomy
Ligaments attached to radius
Below radial tuberosityOblique cord
Tip of styloid processRadial collateral liga-
ment of wrist joint
Ridge on inferior surface of lower endArti-
cular 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 promi-
nent hook-like process that extends up-
wards from the posterior aspect of upper
end.
Figs 8.7A and B: The radius and ulna
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 shelf-
like 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 radio-
ulnar joint.
2. The shaft of ulna is broad above, but it is narrow
below. It has three surfacesanterior, medial
and posterior (Fig. 8.7B).
 The Bones of the Upper Extremity
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 liga-
ment
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 Essentials of Human Anatomy
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
Fig. 8.8: The carpals and metacarpalsanterior aspect
Proximallywith inferior surface of
lower end of radius at radio-carpal joint.
The lunate bone is concerned with trans-
mission 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.
 The Bones of the Upper Extremity
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-medialanterior 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 inter-
phalangeal 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 Essentials of Human Anatomy
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 out-
stretched 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
hyper-extension 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.
 CHAPTER 9
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 Fig. 9.1: The sterno-clavicular jointsanterior aspect
ligament that firmly connects medial end Movements
of clavicle to the first costal cartilage. The movements occur at the joint, along with
Inter-clavicular ligament is T-shaped movements of shoulder joint and of scapula.
ligament connecting upper parts of medial The movements occur at two axes:
ends of two clavicles with vertical limb Elevation and depression
attached to supra-sternal notch. Protraction (forward movement) and
Articular discA complete intra-articular retraction (backward movement)
disc separates the joint into two joint cavities. Circumduction occurs as combination of
It is attached above to the medial end of clavicle above movements.
and below to the first costal cartilage Applied anatomy:The dislocation of the joint,
The articular disc gives stability to the joint. is very rare as it is strengthened by strong
The nerve supply of the joint is by ligaments. Instead, fracture of clavicle occurs
more commonly.
i. Nerve to subclavius
ii. Anterior supra-clavicular nerve
THE ACROMIO-CLAVICULAR JOINT
The arterial supply of the joint is by
i. Internal thoracic artery It is the joint between the lateral end of clavicle
ii. Supra-scapular artery (Fig. 9.1) and acromion process of scapula.
56 Essentials of Human Anatomy
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.
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.
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 thick-
eningssuperior, 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.
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
 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).
Fig. 9.2: Section through shoulder joint
Bursae around the joint: There are a number
of bursae around the joint:
Fig. 9.3: The shoulder joint
57
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 nerve supply of the joint is by
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
58 Essentials of Human Anatomy

Movements: The shoulder joint is the most Teres major

mobile joint of the body Latissimus dorsi
The factors responsible for mobility are Lateral rotation
laxity of the capsule and large articular Posterior part of deltoid
surface of head as compared with glenoid Infraspinatus
cavity. Teres minor
The shoulder joint is multiaxial joint with Applied anatomy
movements ocurring around three axes 1. The dislocation of shoulder joint may take
i. Around an antero-posterior axis place due to high mobility of the joint.
abduction and adduction take place. a. Anterior dislocation: The head of
ii. Around transverse axis flexion and humerus comes to lie below coracoid
extension take place. process. It occurs due to weakness of
iii. Around a vertical axis medial and opening of subscapular bursa.
lateral rotation take place. The labrum glenoidale may be
Muscles responsible for injured and axillary vein may also
movements Flexion be involved.
Clavicular head of pectoralis major b. Inferior dislocation: The head of
Anterior part of deltoid hume-rus comes to lie below glenoid
fossa. It occurs due to laxity of lower
Coracobrachialis
part of capsule.
Biceps brachii
The axillary nerve and circumflex
Extension
humeral vessels may be injured.
Posterior fibers of deltoid
2. Ankylosis of shoulder joint may take place
Teres major
in old age with limitation of movements
Latissimus dorsi accompanied by pain.
Sterno-costal head of pectoralis major
Abduction THE MOVEMENTS OF SHOULDER
Supraspinatus (initiates the movement) GIRDLE (SCAPULA)
Deltoid (up to 90)
The movements of scapula are caused by the
Lower part of trapezius and lower part of
muscles that connect it to the axial skeleton.
serratus anterior cause overhead abduction
1. Elevation and depression of scapula take
of arm by rotation of scapula
place through an axis passing through both
Adduction sterno-clavicular joints.
Pectoralis major Elevation is done by
Latissimus dorsi Upper part of trapezius
Teres major Levator scapulae
Coraco-brachialis Depression is done by
Biceps brachii Subclavius }assisted by the
Long head of triceps Pectoralis minor weight of the limb
Medial rotation Lower part of trapezius
Pectoralis major 2. Protraction and retraction take place through
Anterior part deltoid a vertical axis passing through sterno-
Subscapularis clavicular joint
 The Joints of the Upper Extremity
Protractors are
Serratus anterior } assisted by upper
part of latissimus
Pectoralis minor
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
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
The articular surfaces are covered by
hyaline articular cartilage.
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
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)
The nerve supply of the joint is by
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
Biceps brachii }radialis and flexors
of forearm
TheextensorsareBrachialis assisted by brachio-
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.
60 Essentials of Human Anatomy
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 mem-
brane is downwards and medially
from radius to ulna.
The interosseous membrane per-
forms 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
 The Joints of the Upper Extremity
Fig. 9.5: The radio-ulnar joints
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
61
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 antero-
medially 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 despira-
lized and regains its original position.
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 The
articular surfaces are covered by hyaline
articular cartilage.
Articular capsule surrounds the joint.
Ligaments
62 Essentials of Human Anatomy

1. The anterior radio-carpal ligament is a There is anteroposterior axis for movements

broad membrane on anterior aspect of the of adduction and abduction.
joint. Muscles producing
It passes from anterior margin of lower movements Flexors
end of radius to front of scaphoid, Flexor carpi radialis}assisted by other
lunate and triquetral. Flexor carpi ulnaris long flexors
2. The posterior radio-carpal ligament Extensors
strengthens the posterior aspect of the joint. Extensor carpi
3. The radial collateral ligament connects the radialis longus assisted by other
tip of styloid process of radius to scaphoid.
4. The ulnar collateral ligament connects the
tip of styloid process of ulna to triquetral

Extensor carpi
radialisbrevis
Extensor carpi
}
long extensors

(Fig. 9.6). ulnaris

The nerve supply is by
Anterior interosseous nerve
Posterior interosseous nerve
The arterial supply is by
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
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

These joints lie between the adjacent carpal bones
Type: Plane type of synovial joints
Ligaments of the joint are
The dorsal carpal ligament
Fig. 9.6: Section through carpal joints The palmar carpal ligament
 The Joints of the Upper Extremity
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 circum-
2. The metacarpo-phalangeal joints
duction that opposes thumb to the
These joints are formed between
palm and other fingers.
The rotation is combination of
flexion, extension, abduction and
adduction.
b. The second, third, fourth, and fifth carpo-
metacarpal 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 arti-
culate with hamate.
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
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
inflexed 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.
64 Essentials of Human Anatomy

Movements at these joints occur at two axes: In middle finger there are two dorsal
At transverse axisflexion and interossei and cause medial and lateral
extension take place abduction.
At antero-posterior axisabduction and In little finger abductor digiti minimi
adduction take place with reference to Adduction (in fingers)
the neutral axis passing through Palmar interossei.
middle finger. 3. The inter-phalangeal joints are formed
Muscles producing movements: between the phalanges
The proximal inter-phalangeal joint is
Flexion
Flexor digitorum } in four fingers
assisted by lumbricals
between the head of first phalanx and base
of second phalanx.
superficialis and interossei The distal inter-phalangeal joint is
Flexor digitorum
between the head of second phalanx and
profundus
base of terminal phalanx. The thumb has
Flexor pollicis longus
only one inter-phalangeal joint.
Flexor pollicis brevis } in thumb Type: Hinge type of synovial joint.
Extension
Ligaments: The collateral ligaments rein-
Extensor digitorumassisted in second
force the sides of the joints.
and fifth fingers by extensor indicis The ligaments are lax when finger is
and extensor digiti minimi extended.

longus } in thumb
Extensorpollicis
Movements are possible in one transverse
axis only
Extensor pollicis Flexion is done by long flexors.
brevis Extension is done by long extensors.
Abduction (in fingers) Nerve supply of small joints of hand is by
Dorsal interossei for second and fourth the digital branches of ulnar and median
fingers nerves.

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
CHAPTER 10
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 (C7, C8,T1) (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 inspi-
ration.
Relations
Anteriorly
Skin, superficial fascia, platysma, supra-
clavicular nerves and mammary gland.
Deep fascia (pectoral fascia)
PosteriorlySternum, ribs, costal
cartilages, intercostal muscles
Clavipectoral fascia, pectoralis
minor and serratus anterior.
66 Essentials of Human Anatomy

Fig. 10.1: The pectoralis major

Upper borderDelto-pectoral groove It lies deep to clavicular head of pectoralis major

(infra-clavicular fossa) with cephalic vein, Below it splits to enclose pectoralis minor and
deltoid branch of thoraco-acromial artery, descends to fuse with axillary fascia
separates it from deltoid Above it splits to enclose subclavius and is
Lower borderforms anterior axillary attached to the margins of subclavian groove
fold. of clavicle.
b. The pectoralis minor The clavipectoral fascia is pierced by
Originupper margin and outer surface of i. Cephalic vein
third to fifth costal cartilages. ii. Thoraco-acromial vessels
Muscle belly is thin and triangular iii. Lateral pectoral nerve
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.
The Clavipectoral Fascia
It is a thick fibrous membrane that fills up the gap
between pectoralis minor and subclavius (Fig.
10.2). 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 pecto-
ralis 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
Fig. 10.3: TS through axilla
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.
68 Essentials of Human Anatomy
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.
Fig. 10.4: The axillary artery
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 sterno-
clavicular 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.
 The Shoulder Region and Superficial Back Region
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 Essentials of Human Anatomy
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)
 The Shoulder Region and Superficial Back Region
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 (C8,T1 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 (promi-
nence 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 inter-
muscular 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 Essentials of Human Anatomy
Fig. 10.6: TS through deltoid muscle
Deep
Coracoid, process, coraco-acromial
liga-ment. Subacromial bursa
Tendons of biceps brachii, coraco-
brachialis.
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
thoraco-acromial 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 quadran-
gular 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 divisions
anterior 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.
 The Shoulder Region and Superficial Back Region 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 Fig. 10.7: The scapular muscles
Inferior dislocation of shoulder joint.
The first digitation reaches superior angle of
Effects of injury scapula.
1. Paralysis of deltoid, leading to inability to Next two or three digitations spread out for
abduct the arm up to 90. their insertion on medial border of scapula.
2. Loss of skin sensation over deltoid and The lower four or five digitations converge
upper lateral part of arm. towards the lower angle of scapula.
3. Late effectFlattening of shoulder due to InsertionOn a strip along costal surface of
atrophy of the muscle. medial border of scapula from superior angle
to inferior angle.
THE SCAPULAR REGION The lower four or five digitations are inserted
on a broad area on costal surface of inferior
The scapular region consists of muscles attached angle.
to scapula, their blood supply and nerve supply Nerve Supply
(Fig. 10.7 and Table 10.1). Long thoracic nerve (C5, C6, C7)
Actions
Serratus Anterior Muscle i. It is a powerful protractor of scapula and
is used in all pushing and punching move-
Serratus anterior muscle connects the medial
ments.
border of scapula to lateral thoracic wall.
ii. The lower part of muscle, along with
OriginBy eight fleshy digitations from lower part of trapezius help in rotation of
outer surfaces and superior borders of upper scapula during overhead abduction of arm.
eight ribs. Applied Anatomy
Muscle belly i. In case of paralysis of the muscle, due to
A large muscular sheet that covers lateral injury to long thoracic nerve the
thoracic wall. protraction of scapula is weakened.
74 Essentials of Human Anatomy

Table 10.1: The Scapular muscles

Name Origin Muscle belly Insertion Nerve supply Main actions
1. Supraspinatus Medial two- Muscle belly Highest impres- Supra scapular It initiates abduction
third of coverages sion of greater (C5, C6) It helps to steady
supaspinous towards the tuberosity of head of humerus
fossa greater tuberosity humerus (part of rotator cuff)
of humerus
2. Infraspinatus Medial two- Muscle belly Middle facet of It acts as lateral
Supra scapular
third of infra converges to form greater tuberosity (C5, C6) rota-tor of arm
spinous fossa a tendon that of humerus It helps to steady
passes behind head of humerus
shoulder joint (part of rotator cuff)
3. Teres minor Upper two-third A narrow elon- Lower facet of Axillary nerve It helps in lateral
of flat strip on gated muscle greater tuberosity (C5, C6) (The rotation of arm
dorsal aspect belly of humerus nerve has a It helps to steady
of lateral border pseudo-ganglion) head of humerus
of scapula (part of rotator cuff)
4. Teres major 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
inferior angle of flat tendon that sulcus (bicipital (C5, C6) of arm
scapula passes laterally groove) of shaft
of humerus
5. Subscapularis Medial two-third Large and trian- Lesser tubercle Upper and It helps to steady
of subscapular gular muscle of upper end of lower sub- the head of humerus
fossa of scapula belly humerus scapular nerves (part of rotator cuff)
Tendinous septa (C5, C6) It also helps in
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 anasto-
mosis around scapula bone between the branches
of subclavian and axillary arteries (Fig.10.8).
The arteries taking part in this anastomosis
are
iii. The subscapular artery from third part of
i. The suprascapular artery from thyro-
cervical trunk of first part of subclavian
artery.
The artery reaches upper border of
scapula and passes above suprascapular
ligament to reach supraspinous fossa
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).
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.
 The Shoulder Region and Superficial Back Region
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 alter-native route for the
supply of blood to upper extremity.
The Nerves of Scapular Region
1. The suprascapular nerve (C5,C6)
75
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 Essentials of Human Anatomy

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 Main actions

Trapezius External occipital Flat and trian- Posterior border Motor supply 1. The muscle re-
protuberance gular lateral one-third from spinal tracts the scapula
Medial one-third It covers back of clavicle accessory nerve 2. Upper fibers help
of superior nuchal of neck and (superior fibers) Proprioceptive to elevate scapula
line upper part of Medial margin fibers from C3, with levator
Ligamentum nuchae trunk acromion and C4 ventral rami scapulae
Spine of 7th cervical superior edge of 3. Lower fibers
vertebra crest of spine of along with lower
Spines of all twelve scapula (middle part of serratus
thoracic vertebrae fibers) anterior help in
and supra-spinous Apex of triangular rotation of sca-
ligaments area at the root pula in overhead
of spine of scapula abduction of arm.
(inferior fibers) 4. Trapezius also
helps to steady
scapula during
movements of
shoulder joint
Latissimus Lower six thoracic Large flat and Floor of inter- Thoraco-dorsal 1. It helps in adduc-
dorsi spines and supra- triangular tubercular sulcus (C6, C7, C8) tion extension
spinous ligaments It covers lower of humerus in and medial rota-
Thoraco-lumbar part of back of front of teres tion of arm
fascia trunk major 2. It also helps in
Posterior part of The muscles cur- elevating trunk
iliac crest ves around lower during climbing
Contd...
 The Shoulder Region and Superficial Back Region 77

Contd...
Name Origin Muscle belly Insertion Nerve supply Main actions
Lower three or border of teres 3. It also helps in
four ribs major and forms deep inspiration
a tendon and voluntary
expulsive efforts
Levator Transverse proces- The muscle belly Dorsal surface C3, C4 VR 1. It helps to elevate
scapulae ses of atlas and axis descends to medial border of Dorsal scapular (C5) scapula with
Posterior tubercles superior angle scapula between trapezius
of transverse proces- of scapula superior angle and 2. It also helps to
ses of third and root of spine retract scapula
fourth cervical with rhomboids
vertebrae
Rhomboid Lower part of Slender muscle Base of the tria- Dorsal scapular 1. It helps to retract
minor ligamentum nuchae belly ngular area at (C5) the scapula
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
Rhomboid Spines of 2nd to Flat and thin Dorsal surface Dorsal scapular 1. It helps to retract
major 6th thoracic belly, descends to medial border of (C5) scapula
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 move-
ments 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 Fig. 11.1: The front of arm and brachial artery
Contents
1. Tendon of biceps brachii
2. Brachial arterybifurcating into radial and 4. Radial nervedoes not form a direct
ulnar arteries opposite neck of radius. content as it lies deep to brachioradialis, and
3. Median nerve divides into a superficial and a deep branch.
 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
Coraco- Tip of coracoid Short, rounded Impression on Musculo-cutaneous It flexes and adducts
brachialis process of scapula muscle belly middle of medial (C5, C6, C7) the arm
(in conjunction with border of humerus
short head of biceps
brachii)
Biceps Two heads of Large, fusiform Flat tendon Musculo-cutaneous 1. The muscle is
brachii origin muscle body attached to rough, (C5, C6) powerful supi-
Short head from posterior part of separate branches nator of flexed
tip of coracoid radial tuberosity for two heads elbow
along with The tendon gives 2. It also helps to
coracobrachialis a broad expansion flex the elbow
Long head from medially that 3. The long head
supraglenoid blends with deep helps to check
tubercle inside the fascia of forearm- upward displace-
capsule of shoulder bicipital aponeu- ment of head of
joint rosis humerus
Brachialis Lower half of Muscle belly is Coronoid process, Musculo-cutaneous Powerful flexor
anterolateral and closely applied of ulna and ulnar (C5, C6) of the elbow joint
anteromedial to front of tuberosity Radial nerve (C7)
surfaces of humerus supplies a small
humerus Fibers converge to lateral part
Front of lateral form a thick
and medial tendon
intermuscular
septa

The Blood Vessels of the Upper Arm

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
Fig. 11.2: The cubital fossa
fossa, 1.0 cm below elbow joint at level of
neck of radius.
80 Essentials of Human Anatomy

Branches
From lateral side of artery
i. A number of small muscular branches are
given to the muscles of anterior compart-
ment
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 (supra-
trochlear 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 anasto-
moses 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.
 The Upper Arm and the Elbow Region 81

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 fascia of arm at lateral border of biceps
coraco-brachialis.
The basilic vein joins with venae comi-
tantes of brachial artery at distal border
of teres major to form axillary vein.
c. The median cubital vein connects the cepha-
lic and basilic veins in front of the cubital
fossa.
The vein lies in front of bicipital aponeu-
rosis.
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 super- 2. The median nerve (C5, C6, C7, C8, T1) is formed
ficial 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 aremusculo-
cutaneous, 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 coraco-
brachialis muscle and descends between
coraco-branchialis and biceps brachii.
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
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.
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 Essentials of Human Anatomy
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 posterior compartment of arm has only one
muscletriceps brachii.
The Triceps Brachii
Origin of the muscle is by three heads
i. The long headarises from the infra-
glenoid 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.
The Blood Vessels of
Posterior Compartment
The Arteries
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.
 The Upper Arm and the Elbow Region
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
interos-seous 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.
Fig. 11.4: The posterior compartment of arm and radial nerve
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.
 84 Essentials of Human Anatomy
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 } Effects of injury
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.
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.

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 carpi ulnaris
Flexor digitorum superficialis
B. The deep group of muscles: These are
Flexor pollicis longus
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 brachio-
radialis in the upper part. At wrist the
artery lies quite superficially on the
lower end of radius.
CHAPTER 12
The Region
of Forearm
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
Flexor pollicis longus
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 Essentials of Human Anatomy

Table 12.1: Muscles of anterior compartment of forearm

Name Origin Muscle belly Insertion Nerve supply Main actions
The superficial flexors
Pronator 1. Humeral head Muscle belly Rough area on Median 1. It helps in pro-
tetres Medial epicondyle crosses upper middle of lateral (C5, C6) nation of fore-
2. Ulnar head part forearm surface of radius arm
(smaller) and forms a flat 2. It is a weak flexor
Medial border of tendon of elbow joint
coronoid process of
ulna
Flexor carpi Medial epicondyle Fusiform muscle Palmar aspect Median 1. It is a flexor of
radialis by common belly ends in base of second (C6, C7) wrist joint
origin tendon in middle metacarpal 2. It abducts the
of forearm A slip to base of hand
Tendon passes in third metacarpal 3. It is a weak flexor
a groove of trape- of elbow joint
zium deep of
flexor retinaculum
Palmaris Medial epicondyle Slender fusiform Palmar Median 1. It helps in flexion
longus by common flexor muscle belly aponeurosis (C7, C8) of wrist joint
origin Long tendon 2. It is a tensor of
passes superficial palmar apone-
to flexor renti- urosis
naculum
Flexor carpi 1. Humeral head Two heads joined Pisiform bone Ulnar 1. It is a flexor of
ulnaris (smaller) by a fibrous arch Insertion pro- (C7, C8) wrist joint
Medial epicondyle The muscle belly longed by piso- 2. It helps in adduc-
by common flexor is most medial hamate ligament tion of hand
origin on front of fore- to hook of 3. It is a weak flexor
2. Ulnar head arm hamate and piso- of elbow joint
Medial margin of Gives rise to a metacarpal liga-
olecranon and pro- tendon in lower ment to base
ximal two-third of half of forearm of fifth meta-
posterior border carpal
ulna by common
aponeurosis (with
flexor digitorum
profundus and
extensor carpi
ulnaris)
Flexor digi- 1. Humero-ulnar head Large muscle The four tendons Median 1. If flexes middle
torum super- Medial epicondyle belly lies deep to pass to four fingers (C7, C8, T1) and proximal
ficialis by common flexor other flexors and are inserted on phalanges of
origin and medial Divides into four sides of middle four fingers
side of coronoid tendons phalanx 2. It also helps in
process of ulna Two superficial flexion at wrist
Radial head for middle and and elbow joints
Anterior border ring fingers
of radius from tube- Two deep for
rosity to insertion of index and little
pronator fingers
teres
The Deep Flexors (Fig. 12.2)
Flexor Anterior surface of Muscle belly is Palmar aspect Anterior interos- 1. It flexes phalan-
pollicis radius from tuber- unipennate base of first seous branch of ges of thumb
longus osity to the attach- Tendon passes metacarpal median (C8, T1) 2. It also helps
Contd...
 The Region of Forearm 87

Contd...
Name Origin Muscle belly Insertion Nerve supply Main actions
ment of pronator deep to flexor in flexion of
quadratus retinaculum wrist joint
Flexor Upper three-fourths Large muscle Four tendons Medial part ulnar 1. It flexes distal
digitorum of anterior and belly lies deep reach four fingers Lateral part- phalanges of
profundus medial surfaces of to superficial Inserted on anterior interos- fingers after
ulna flexors Palmar aspect base seous branch of flexion of middle
Front of interos- Gives rise to of distal phalanges median (C8, T1) phalanges by
seous membrane four tendons superficialis
of forearm that pass deep to 2. It also helps in
flexor retinaculum flexion of meta-
at wrist carpo-phalangeal
joints of fingers
3. It also helps in
flexion of wrist
joint
Pronator Oblique ridge on Muscles belly flat Anterior surface Anterior inter- 1. It is the principal
quadratus front of distal and quadrangular distal one-fourth ossous branch pronator of fore-
part of ulna of radius of median (C8, T1) arm
Deep fibers on 2. It prevents sepa-
triangular area ration of lower
above ulnar notch ends of two bones
of radius

Fig. 12.1: The superficial flexor muscles and radial artery

88 Essentials of Human Anatomy
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.
Branches in anterior compartment
i. The anterior ulnar recurrent passes in
front of medial epicondyle to anasto-
mose 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
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 intero-
sseous membrane deep to pro-
nator quadratus and reaches
posterior compartment of fore-
arm.
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 mem-
brane and enters posterior compart-
ment of forearm.
 The Region of Forearm
Near its origin, it gives intero-iii. The median antebrachial vein is only
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
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 Essentials of Human Anatomy
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
Flexor pollicis longus
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 frac-
ture of lower end of radius
Effects of injury
Paralysis of three thenar muscles,
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
epicon-dyle.
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.
Branches in anterior compartment
a. The muscular branches supply
Flexor carpi ulnaris
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
retina-culum and supplies skin
of medial side of palm.
c. The articular branches supply
Radio-carpal joints
 The Region of Forearm 91

Applied anatomy About 7.0 cm from the wrist, the nerve

The ulnar nerve may be involved in
Supra-condylar fracture of lower
end of humerus
Fracture of medial epicondyle of
humerus
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.

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.
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

Later effect will be wasting of all Extensor carpi radialis longus

short muscles of hand supplied by Extensor carpi radialis brevis
ulnar nerve. This leads to Ulnar Extensor digitorum
Extensor digiti minimi
claw hand.
Extensor carpi ulnaris
C. The superficial branch of radial nerve
Anconeus
Courses in anterior compartment B. The deep extensors
From lateral epicondyle the nerve Supinator
descends along lateral border of Abductor pollicis longus
forearm deep to brachio-radialis. Extensor pollicis brevis
The nerve lies lateral to the radial artery Extensor pollicis longus
in middle third of forearm. Extensor indicis

Table 12.2: The muscles of posterior compartment of forearm

Name Origin Muscle belly Insertion Nerve supply Main actions

The Superficial Extensors
Brachio- Proximal two-third Muscle belly ends Distal end of Radial (C5, C6, C7) 1. It helps in flexion
radialis lateral supracondylar in a flat tendon radius above its of elbow in mid
ridge of humerus about middle of styloid process prone position
Lateral intermuscular forearm 2. Acts as a shunt
septum muscle during
rapid flexion and
extension at
elbow
Extensor Distal one-third Muscle belly ends Radial side dorsal Radial (C6, C7) 1. It acts as exten-
carpi rad- lateral supra- in a tendon at aspect of base sor of wrist
ialis condylar ridge junction of upper of second metacar- 2. It helps to abduct
longus of humerus third and middle pal the hand
Lateral inter- third of forearm
muscular septum
Extensor Lateral epicondyle Muscle belly ends Radial side dorsal Posterior inter- 1. It acts as extensor
carpi by common extensor in a tendon about aspect of base of osseous (C7, C8) of wrist
radialis origin middle of forearm third metacarapal 2. It helps to abduct
brevis the hand
Contd...
92 Essentials of Human Anatomy

Contd...
Name Origin Muscle belly Insertion Nerve supply Main actions
Extensor Lateral epicondyle by Muscle belly divi- The four tendons Posterior inter- 1. It extends inter-
digitorum common extensor des into four diverge to reach osseous (C7, C8) phalangeal and
origin tendons that pass four fingers metacarpo-pha-
deep to extensor Inserted on dorsal langeal joints of
retinaculum on digital expansion four fingers
dorsum of hand on dorsum of first 2. It also helps in
phalanx extension of
wrist joint
Extensor Lateral epicondyle Slender muscle belly Dorsal digital ex- Posterior inter- 1. It helps in exten-
digiti by common extensor gives rise to a long pansion of little osseous (C7, C8) sion of joints of
minimi origin tendon finger little finger
2. It also helps in
extension of
wrist joint
Extensor Lateral epicondyle Muscle belly is most Tubercle on Posterior inter- 1. It acts as extensor
carpi by common ex- medial on back of medial side base osseous (C7, C8) of wrist joint
ulnaris tensor origin forearm of fifth meta- 2. It also helps in
Common aponeu- The tendon lies tarsal adduction of hand
rosis attached to in a groove on
posterior border styloid process
to ulna of ulna
Anconeus Posterior surface Muscle belly Lateral surface Radial It helps in extension
of lateral epicon- small and trian- alecranon (C7, C8, T1) of elbow joint
dyles of humerus gular lies behind Upper one-fourth
the elbow joint posterior surface
of ulna
The Deep Extensors (Fig. 12.4)
Supinator Lateral epicondyle Muscle belly has Lateral surface Posterior inter- It supinates the
of humerus a superficial and proximal third osseous (C5, C6) forearm assisted
Radial collateral a deep part radius, encroaches by biceps brachii
ligament It is wrapped on anterior and
Annular ligament around upper posterior aspects
Supinator crest of third of radius
ulna and the depress-
ion in front of it
Abductor Posterior surface Muscle belly ends Radial side base Posterior inter- It abducts the thumb
pollicis upper part ulna in a tendon above of first meta- osseous (C7, C8)
longus Interosseous membrane the wrist carpal
Middle third posterior
surface of radius
Extensor Posterior surface radius Muscle belly ends Dorsi-lateral sur- Posterior inter- 1. It extends proxi-
pollicis distal to abductor in a tendon above face base of proxi- osseous (C7, C8) mal phalanx of
brevis pollicis longus wrist mal phalanx thumb thumb
2. It helps in exten-
sion of thumb also
Extensor Middle third posterior Muscle belly ends Base of distal Posterior inter- 1. It extends distal
pollicis surface of ulna in a tendon above phalanx of thumb osseous (C7, C8) phalanx of thumb
longus wrist 2. It helps in exten-
sion of thumb and
radio-carpal joint
(wrist joint)
Extensor Posterior surface of Narrow elongated Joins dorsal distal Posterior inter- It helps in extension
indicis ulna distal to exten- muscle belly expansion of osseous (C7, C8) of index and radio-
sor pollicis longus Ends in a tendon index finger carpal joint
above wrist
 The Region of Forearm
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.
93
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 inter-
osseous) nervearises from radial deep to
94 Essentials of Human Anatomy
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.
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 carpi ulnaris
Extensor pollicis longus
Extensor indicis
Abductor pollicis longus
Extensor pollicis brevis
Supinator
Extensor carpi radialis brevis
2. Articular branches supply
Radiocarpal joint
Carpal joints
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.

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.
Fig. 13.1: The extensor retinaculum
CHAPTER 13
The Region of
Wrist and Hand
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, connec-
tive 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).
96 Essentials of Human Anatomy
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 called
Anatomical 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 superficial 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.
 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-and-
half) fingers.
THE PALM OF THE HAND
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
97
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
super-ficialis
ii. Four tendons of flexor digitorum pro-
fundus
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
Fig. 13.2: The carpal tunnel
 98 Essentials of Human Anatomy
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 inter-
mediate 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.
 The Region of Wrist and Hand 99

Fig. 13.4: The fascial compartments of the palm

The Long Flexor Tendons in the Palm The two parts of each tendon, again
(Fig. 13.5) separate out and are inserted on sides of
middle phalanx.
1. The tendon of palmaris longus passes
4. The four tendons of flexor digitorum
superficial to flexor retinaculum and is
profundus also diverge on reaching palm from
attached to the apex of palmar aponeurosis.
carpal tunnel, to reach the four fingers.
2. The tendon of flexor pollicis longus has a
In each finger, the tendon of flexor
separate synovial sheath (radial bursa) as it
digitorum profundus lies deep to the
passes through the carpal tunnel deep to
tendon of flexor digitorum superficialis on
flexor retinaculum.
proximal phalanx.
The tendon passes deep to the thenar
The tendon of flexor digitorum profundus
muscles to reach the palmar surface of base
passes through fibrous tunnel formed by
of distal phalanx of thumb for insertion.
flexor digitorum superficialis tendon on
3. The four tendons of flexor digitorum
middle phalanx.
superficialis diverge on reaching palm from
The tendon of flexor digitorum profundus is
carpal tunnel, to reach the four fingers.
finally inserted on palmar surface base of
Each tendon on the proximal phalanx splits
distal phalanx of finger.
into two parts to enclose a fibrous tunnel for
The long flexor tendons, as they pass through
flexor digitorum profundus tendon.
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 teno-
Fig. 13.5: The long flexor tendons in finger synovitis may compress the vinculaeslender
100 Essentials of Human Anatomy

fibrous bandsthat convey blood vessels to They are further classified into:
long flexor tendons. The palmar interosseifour (Table 13.4).
This may lead to necrosis of the tendons in The dorsal interosseifour (Table 13.5).
the palm. The interossei are also numbered from lateral
The muscles of the palm can be divided into to medical side.
four groups:
1. The thenar muscles and adductor pollicis The Blood Vessels of the Palm
(Fig. 13.6 and Table 13.1)
The Arteries
Abductor pollicis brevis
Flexor pollicis brevis 1. The ulnar artery enters the palm by crossing
Opponens pollicis superficial to flexor retinaculum, lateral to
Adductor pollicis pisiform and medial to hook of hamate, along
2. The hypothenar muscles (Table 13.2). with ulnar nerve.
Palmaris brevis The ulnar artery just distal to flexor
Adductor digiti minimi retinaculum gives a deep branch and
Flexor digiti minimi continues as superficial palmar arch.
Opponens digiti minimi The deep branch joins with terminal part
3. The lumbricals are four slender muscle bellies of radial artery to form the deep palmar
attached to the tendon of flexor digitorum arch.
profundus in palm (Table 13.3). 2. The superficial palmar arch is formed by
These are numbered from lateral to medial (Fig. 13.8)
side. Medially by continuation of ulnar artery.
4. The interossei fill up the gap between the Laterally by superficial palmar branch of
metacarpals (Fig. 13.7). radial artery

Fig. 13.6: The thenar and hypothenar muscles

 The Region of Wrist and Hand 101
Table 13.1: The thenar muscles and adductor pollicis
Name Origin Muscle belly Insertion Nerve supply Main actions
Abductor Flexor retinaculum A thin, superficial Radial side base of Lateral terminal It abducts the thumb
pollicis Tubercle of scaphoid muscle belly proximal phalanx branch median to right angles to the
brevis of thumb (C8, T1) palm
Flexor Distal border of Thin muscle belly Radial side base Lateral terminal It flexes the proxi-
pollicis flexor retinaculum lies medial to of proximal branch median mal phalanx of
brevis Tubercule of abductor muscle phalanx of thumb (C8, T1) thumb
scaphoid
Opponens Crest of trapezium Muscle belly lies Lateral border Lateral terminal It flexes metacarpal
pollicis Flexor retinaculum deep to abductor and lateral half branch median and rotates it medi-
muscle and flexor palmar surface (C8, T1) ally so thumb can be
pollicis brevis first metacarpal opposed to fingers
and palm
Adductor 1. Obligue head The transverse Ulnar side base Deep branch It adducts thumb to
Pollicis Capitate head is triangular of proximal ulnar (C8, T1) the side of palm
Bases of second and The two heads phalanx of thumb
third metacarpal converge towards
2. Transverse head base of first
Distal two-third phalanx
palmar aspect
third metacarpal

Table 13.2: The hypothenar muscles

Name Origin Muscle belly Insertion Nerve supply Main actions

Palmaris Flexor retinaculum Thin, quadran- Skin on medial Superficial branch It wrinkles skin on
brevis Medial border of pal- gular muscle border of hand ulnar (C8, T1) medial side of palm
mar aponeurosis belly thus helping in
Covers proximal palmar grip
part of hypo-
thenar eminence
Abductor Pisiform Thin, lies along Ulnar side base Deep branch ulnar It abducts little finger
digiti Tendon of flexor medial side of of proximal (C8, T1) from neutral axis of
minimi carpi ulnaris and hypothenar emi- phalanx of little middle finger
piso-hamate nence finger
ligament
Flexor Hook of hamate Thin, lies lateral Ulnar side Deep branch ulnar It flexes the little
digiti Flexor retinaculum to the abductor base of proximal (C8, T1) finger
minimi digiti minimi phalanx of little
finger
Opponens Hook of hamate Triangular muscle Medial border Deep branch ulnar It flexes little finger
digiti minimi Flexor retinaculum belly, lies deep to palmar surface of (C8, T1) and rotates it medi-
abductor and fifth metacarpal ally so that it can be
flexor digiti opposed to other
minimi fingers and palm
102 Essentials of Human Anatomy

Table 13.3: The lumbricals

Name Origin Muscle belly Insertion Nerve supply Main actions
First Radial side and pal- Slender and Lateral side of Median Flexion at meta-
lumbrical mar surface tendon unipennate dorsal digital (C8, T1) carpophalangeal
of flexor digitorum muscle belly expansion of and extension of
profundus to index index inter-phalangeal
joint of index finger
Second Radial side and pal- Slender and Lateral side of Median Same action on
lumbrical mar surface tendon unipennate dorsal digital (C8, T1) middle finger
of flexor digitorum muscle belly expansion of
profundus to middle middle finger
finger
Third Adjoining sides of Slender bipennate Lateral side of Deep branch ulnar Same action on ring
lumbrical tendons of flexor muscle belly dorsal digital (C8, T1) finger
digitorum profundus expansion of
to middle and ring ring finger
fingers
Fourth Adjoining sides of Slender bipennate Lateral side of Deep branch Same action on
lumbrical tendons of flexor muscle belly dorsal digital ulnar (C8, T1) little finger
digitorum profundus expansion of
to ring and little little finger
fingers

Figs 13.7 A and B: (A) The palmar interossei (B) The dorsal interossei
 The Region of Wrist and Hand 103
Table 13.4: Palmar interossei
Name Origin Muscle belly Insertion Nerve supply Main actions
First palmar Ulnar side palmar Small, slender Ulnar side base Deep branch Adducts thumb to-
interosseous surface base of first muscle belly proximal phalanx ulnar (C8, T1) wards neutral axis of
metacarpal of thumb middle finger
Second Whole length pal- Small slender Ulnar side base Deep branch ulnar 1. Adducts index
palmar mar surface second muscle belly proximal pha- (C8, T1) towards neutral
interosseous metacarpal lanx index finger axis of middle
Dorsal digital ex- finger
pansion of index 2. Flexes metacar-
pophalangeal
and extension of
interphalangeal
joints
Third Whole length pal- Small, slender Radial side base Deep branch ulnar Same actions in
palmar mar surface fourth muscle belly proximal phalanx (C8, T1) relations to ring
interosseous metacarpal of ring finger finger
Dorsal digital
expansion
Fourth Whole length Small, slender Radial side base Deep branch ulnar Same actions in
palmar palmar surface muscle belly proximal phalanx (C8, T1) relation to little
interosseous fifth metacarpal of little finger finger
Dorsal digital
expansion

Table 13.5: The dorsal interossei

Name Origin Muscle belly Insertion Nerve supply Main actions

First dor- Adjacent sides Bipennate muscle Lateral side base Deep branch 1. Abducts index
sal inter- of first and second belly, fills up gap of proximal phal- ulnar (C8, T1) finger from neu-
osseous metacarpals between the first anx of index tral axis of middle
and second meta- Dorsal digital finger
carpal expansion 2. Flexion at meta-
carpophalangeal
joints and exten-
sion at inter
phalangeal joints
of index
Second Adjacent sides of Bipennate muscle Lateral side base Deep branch ulnar 1. Lateral abduction
dorsal second and third belly, fills up gap of proximal of (C8, T1) of middle finger
interosseous metacarpal between second phalanx of middle 2. Same action on
and third meta- finger middle finger
carpal Dorsal digital ex-
pansion
Third dor- Adjacent sides of Bipennate muscle Medial side base of Deep branch 1. Medial abduction
sal inter- third and fourth belly, fills up gap proximal phalanx ulnar (C8, T1) middle finger
osseous metacarpal between third and of middle finger 2. Same action on
fourth metacarpal Dorsal digital middle finger
expansion
Fourth dor- Adjacent sides of Bipennate muscle Medial side base Deep branch 1. Abduction of
sal inter- fourth and fifth belly fills up gap of proximal pha- ulnar (C8, T1) little finger
osseous metacarpal between fourth anx of ring finger 2. Same action on
and fifth meta- Dorsal digital ring finger
carpal expansion
 104 Essentials of Human Anatomy

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 4. The deep palmar arch is the smaller and
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 com-
pressed 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.
deeply placed arterial arch in the palm. It is
formed (Fig. 13.9):

Fig. 13.8: The superficial palmar arch

 The Region of Wrist and Hand
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
meta-carpal 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 inter-osseous muscles.
These perforating branches joint
dorsal metacarpal branches of post-
erior carpal arch.
105
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 Essentials of Human Anatomy
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
Abductor pollicis brevis
Flexor pollicis brevis
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
Paralysis of three thenar muscles,
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.
 The Region of Wrist and Hand
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 (one-and half-digits)
Branches
a. A muscular branch to palmaris-
brevis
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
107
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 epicon-
dyle
At wrist as the nerve lies superficial to
flexor retinaculum
Effects of injury
Paralysis of flexor carpi ulnaris and
medial part of flexor digitorum pro-
fundus, 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.
 The Upper Extremity
Multiple Choice Questions
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:
C T
A. 8, 1 B. C5,C6
C ,C T
C. 7 8, 1 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
Q.2. Each question below contains four
sugges-ted answers, of which one or more
is correct. Choose the answer:
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
 Multiple Choice Questions 109

11. The muscles inserted on greater tuberosity 2. Runs along lateral border of arm and
of humerus are: forearm
1. Supra spinatus 3. Is connected with basilic vein on front
2. Infra spinatus of elbow by medial cubital vein
3. Teres minor 4. Terminates in axillary vein after
4. Subscapularis piercing clavi-pectoral fascia
12. The structures passing deep to the flexor 18. The mammary gland:
retinaculum are: 1. Lies in superficial fascia except the
1. Median nerve axillary tail part
2. Ulnar artery 2. Remains active and secretory in adult
3. Flexor pollicis longus tendon females only during lactation phase
4. Radial nerve 3. Has its secretion controlled by the
13. The median nerve in hand supplies: prolactin hormone of pituitary gland
1. Adductor pollicis 4. Has its lymphatics drain mainly in the
2. Three thenar muscles para-sternal lymph nodes
3. Dorsal interossei 19. The first carpo-metacarpal joint
4. First and second lumbricals 1. Is a condyloid type of synovial joint
14. The following muscles take origin from the 2. Is a saddle type of synovial joint
medial epicondyle of humerus: 3. Is joint between base of first metacarpal
1. Pronator teres and trapezoid
2. Flexor carpi radialis 4. Is joint between base of first metacarpal
3. Palmaris longus and trapezium
4. Flexor carpi ulnaris 20. The radial nerve gives the following
15. The abductors of hand at the wrist joint are: branches in posterior compartment of arm:
1. Flexor carpi radialis 1. Nerve its anconeus
2. Flexor carpi ulnaris 2. Posterior interosseous nerve
3. Extensor carpi radialis longus 3. Nerve to medial head of triceps
4. Brachio radialis 4. Nerve to brachioradials

16. The brachial artery: Q.3. Match the following on the left side with
1. Begins at lower border of teres major their appropriate answers on the right side
muscle 21. The nerves and their origins:
2. In cubital fossa lies superficial to i. Axillary A. Upper trunk
bicipital aponeurosis ii. Lateral pectoral B. VRC5
3. Bifurcates at level of neck of radius iii. Dorsal scapular C. Lateral cord
4. Lies lateral to the shaft of humerus in iv. Suprascapular D. Posterior cord
upper part of arm
22. The clinical signs after nerve injury:
17. The cephalic vein: i. Ape hand A. Radial nerve
1. Begins on dorsum of hand from lateral ii. Winging of B. Ulnar nerve
end of dorsal venous arch scapula
110 Essentials of Human Anatomy

iii. Claw hand C. Long thoracic 24. The movements of the muscles:
nerve i. Abduction of A. Supra
iv. Wrist drop D. Median nerve shoulder joint supinatus
23. The muscles and their nerve supply: ii. Adduction at B. Biceps brachii
i. Trapezius A. Radial nerve radiocarpal joint
ii. Supinator B. Thoraco-dorsal iii. Supination at C. Flexor carpi
nerve radio-ulnar joint ulnaris
iii. Latissimus dorsi C. Ulnar nerve iv. Flexion at dorsal D. Flexor digitorum
iv. Palmaris brevis D. Spinal accessory inter-phalangeal profundus
nerve joint of index

Answers

A1. The answer is A. of brachial plexus. The contribution of C7

The strong ligament that binds clavicle to the
upper limb is coraco-clavicular ligament. The
other ligaments are not so strong.
A2. The answer is A.
The ulnar nerve lies behind medial
epicondyle of humerus. The median and
ulnar nerves cross in front of elbow joint,
the musculo-cutaneous nerve pierces deep
fascia above elbow joint and continues as
lateral cutaneous nerve of forearm.
A3. The answer is D.
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.
A4. The answer is D.
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.
A5. The answer is C.
The root value of ulnar nerve is C7,C8,T1.
The ulnar nerve is a branch of medial cord
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.
A7. The answer is C.
The axillary nerve and posterior circumflex
humeral vessels pass through the quadran-
gular 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.
A8. The answer is B.
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 radio-
carpal joint. The anterior interosseous nerve
ends deep to pronator quadratus.
A9. The answer is A.
The supination and pronation movements of
forearm take place at both superior and
 Multiple Choice Questions
inferior radioulnar joints. The elbow joint is
pure hinge joint where only flexion and
extension of forearm take place.
A10. The answer is D.
The carpal bones taking part in radiocarpal
joint are scaphoid and lunate. The triquetral
is separated by the articular disc of inferior
radioulnar joint.
A11. The answer is A, (1, 2, 3).
The three muscles attached to greater
tuberosity of humerus aresupraspinatus,
infraspinatus and teres minor. The sub-
scapularis is inserted on lesser tuberosity of
humerus.
A12. The answer is B, (1, 3).
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.
A13. The answer is C, (2, 4).
The median nerve in palm supplies the three
thenar muscles and first and second lumbri-
cals. 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.
A15. The answer is B, (1, 3).
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.
A16. The answer is B, (1, 3).
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.
A18. The answer is A, (1, 2, 3).
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.
A19. The answer is C, (2, 4).
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.
A20. The answer is B, (1, 3).
The radial nerve in posterior compartment
of arm gives nerve to anconeus and nerve to
medial head of triceps. The posterior intero-
sseous 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 Essentials of Human Anatomy
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.
 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 pro-
gression.
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.
Three
CHAPTER 14
The Bones of the
Lower Extremity
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 Essentials of Human Anatomy
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 borders
anterior 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
posterior-inferior 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
areaA 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.
 The Bones of the Lower Extremity
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).
115
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 Essentials of Human Anatomy
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
Gemel-lus 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
 The Bones of the Lower Extremity
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 depression
fovea 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 pro-
minent 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
poste-rior 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
postero-laterally.
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
inter-trochanteric line.
The lateral lip of linea aspera is conti-
nuous above with a thick ridge
gluteal 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 con-
dylesmedial 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 Essentials of Human Anatomy

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 intra-
capsular 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
 The Bones of the Lower Extremity
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 arti-
cular surfaces of the two con-
dyles by faint ridges.
b. The tibial articular surfaceis on
the inferior aspect of medial and
lateral condyles.
Special Features
[Important muscles and ligaments attached to the
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
119
Trochanteric fossaobturator externus
Quadrate tubercle on trochanteric crest
Quadratus femoris
Lesser trochanter and line below of
psoas 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
Adduc-tor 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 Essentials of Human Anatomy
Popliteal surface above medial femoral
condyleMedial head of Gastrocnemius
Posterior part of popliteal groove on
lateral surface of lateral femoral
condylePopli-teus
Medial epicondyleMedial collateral
liga-ment of knee joint
Lateral epicondyleLateral collateral
liga-ment 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.
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.
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)
Fig. 14.5: Upper end of tibiasuperior aspect
 The Bones of the Lower Extremity 121
II. The shaft of the tibia is triangular in section and It has a groove on its posterior aspect
becomes narrow towards medial malleolus. for the tendon of tibialis posterior.
The shaft has three surfacesmedial, To the apex and a depression near it,
lateral and posterior. is attached the deltoid ligament of
a. The medial surface is subcutaneous the ankle joint.
throughout. Its upper part gives attach- The lateral surface of medial malleo-
ment to the three muscles of thigh lus has a comma shaped articular
sartorius, gracilis and facet for articulating with medial
semitendinosis and medial collateral surface of talus at the ankle joint.
ligament of the knee joint. b. The fibular notch lies on the lateral
b. The lateral surface is broad and smooth aspect of the distal end of tibia.
and lies between the anterior and To the edges of fibular notch are
interosseous borders. attached the anterior and posterior
c. The posterior surfacein its upper part tibio-fibular ligaments of inferior
has a triangular area for attachment of tibio-fibular joint.
popliteus. c. The articular surface of the distal end
The triangular area is limited below of tibia is wider anteriorly and concave
by a thick ridgethe soleal line that in shape (Fig 14.6).
gives attachment to soleus muscle. It articulates with the superior
Below the soleal line, the posterior trochlear surface of talus at the
surface is divided by a faint vertical ankle joint.
line into a medial and a lateral area.
The shaft has three borders also
anterior, medial and lateral or inter-
osseous 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 pro-
jection on the medial aspect of the
distal end. Fig. 14.6: The tibia and fibulaanterior aspect
122 Essentials of Human Anatomy
Special Features
[Important muscles and ligaments attached to the
bone]
i. The upper end
Tuberosity of TibiaLigamentum patellae
Groove on back of medial condyleSemi-
membranosus
Lateral condyleIlio-tibial tract
Intercondylar area on superior surface of
upper endAnterior and posterior
cruciate ligaments
Superior surface of medial and lateral con-
dylesMedial and lateral semilunr carti-
lages (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
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.
Ossification
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.
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 post-
eriorly.
The head has a small round facet
on its medial aspect for superior
tibio-fibular joint.
The lateral surface of head gives
attachment to fibular collateral
liga-ment of knee joint and biceps
femoris muscle.
A blunt apexthe styloid
process projects proximally from
the postero-lateral 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.
 The Bones of the Lower Extremity
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 attach-
ment to tibialis posterior.
The rest lateral part of posterior
surface gives attachment to flexor
muscles of the leg (Fig. 14.7).
Fig. 14.7: The tibia and fibulaposterior aspect
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
tibio-fibular joint.
Near the tip of lateral malleolus, on medial
aspect lies malleolar fossa for giving attach-
ment to posterior talo-fibular ligament.
Special Features
[Important muscles and ligaments attached to the
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 Essentials of Human Anatomy
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 attach-
ment to medial and lateral patellar
retinacula-expansions 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.
 The Bones of the Lower Extremity
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 ten-
don 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 attach-
ment 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 Essentials of Human Anatomy
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
calcaneo-navicular ligament) (Fig. 14.11).
The navicular bone has a concavity proxi-
mally 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 navi-
cular.
Proximallythe cuboid has a
concavo-convex facet for articulating
with calca-neum.
Distallythe articular area is divided
into two parts.
Medial quadrangular part for the base
of fourth metatarsal.
 The Bones of the Lower Extremity
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 cunei-
form. 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 promi-
nent 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 Essentials of Human Anatomy
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 meta-
tarsal may be fractured due to forced inver-
sion.
Stress fracture of metatarsals (distal
1/3rd of second, third, and fourth
metatarsals) occurs commonly in soldiers
after long marches.

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
articular cartilage.
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 thehip boneall around the margins
of acetabulum and transverse acetabular
ligament.
On femur - on the neck of femur.
Anteriorlyto trochanteric line.
CHAPTER 15
The Joints of the
Lower Extremity
Fig. 15.1: The hip jointanterior aspect
Posteriorlyto back of neck of femur
proximal to trochanteric crest.
Mediallyto 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 Essentials of Human Anatomy

The ligaments of the hip joint The synovial membrane lines the non-
i. The iliofemoral ligament is thick, strong articular part of the neck of femur and
and V-shaped ligament on anterior aspect surrounds the ligamentum teres of head of
of the joint. femur (Fig. 15.2).
It is one of the strongest ligaments of the The nerve supply is by:
body. i. Femoral: via nerve to rectus femoris.
It is attached above to anterior-inferior
ii. Obturator.
iliac spine and below the trochanteric
iii. Accessory obturator (if present).
line.
iv. Nerve to quadratus femoris.
ii. The pubofemoral ligament lies on medial
aspect of the joint. v. Superior gluteal.
It is attached above the iliopectineal The arterial supply is by:
eminence and below lower part of i. The superior gluteal artery.
trochanteric line and upper end of ii. The inferior gluteal artery.
spiral line. iii. The obturator artery.
iii. The ischiofemoral ligament lies on the iv. The medial circumflex femoral artery.
posterior aspect of the capsule. Movements of the joint
It is attached above the posterior aspect The hip joint is a multiaxial joint, so the
of acetabulum and below the back of movements are possible in more than two
neck of femur. axes.
The fibers of this ligament are arranged Flexion and extension occur along a
spirally.
transverse axis.
iv. The transverse acetabular ligament bridges
Abduction and adduction take place
the gap on the inferior aspect of acetabulum.
along an antero-posterior axis.
The ligament is continuous with labrum
acetabulare. Circumduction is combination of all
It leaves a gap below it through which above movements.
articular nerves and vessels enter the Medial and lateral rotation occur along
joint. a vertical axis.
v. The ligament of head of femur
(ligamentum teres) is attached to the pit
fovea 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. Fig. 15.2: The hip joint (section through joint)
 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
The ligaments of the joint
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 retin-
acular 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 inter-
condylar 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.
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 Essentials of Human Anatomy
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 strap-
like expansion from the insertion of semi-
membranosus. 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
theintercondylar area of tibia
inside the medial meniscus.
It is separated from the lateral
colla-teral ligament of the joint by
popliteus muscle.
2. The medial meniscus is larger and
semi-circular in outline.
It is attached by two horns on
theinter-condylar area of upper
end of tibia.
It is fused with articular capsule
andmedial 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
 The Joints of the Lower Extremity
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
ligamen-tum 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 begin-
ning 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.
Muscles producing movements
Flexion: Hamstring muscles Semimem-
branosus, 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 Essentials of Human Anatomy
ii. Injury to the ligaments especially cruciate
ligaments can take place due to violent
hyper-extension.
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 infra-
patellar bursa causes painful swelling
in front of tibial tuberosity
Clergymans 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.
Fig. 15.6: The ankle jointtransverse section
Facets on lateral and medial aspects of
talus.
Articular capsule surrounds the joint on all sides.
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).
 The Joints of the Lower Extremity
Fig. 15.7: The ankle jointmedial aspect
The nerve supply is by
i. Deep peroneal nerve.
ii. Tibial nerve.
The arterial supply is by
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 plantar-
flexion occur along a transverse axis passes
Fig. 15.8: Coronal section through ankle
joint and sub-talar joint
135
through lateral malleolus and trochlear
surface of talus.
Muscles producing movements
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
There are three tibio-fibular jointsproximal,
middle and the distal (Fig. 15.9).
136 Essentials of Human Anatomy

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.
Fig. 15.9: The tibio-fibular joints ii. The posterior tibio-fibular ligament
a. The proximal tibio-fibular joint is the joint is stronger ligament and lies on
between lateral tibial condyle and the head of posterior aspect.
fibula. iii. The interosseous tibio-fibular liga-
Type: A plane type of synovial joint. ment firmly connects the lower ends
Articular surfaces are formed by round of the two bones.
facets on lateral condyle of tibia and It is continuous above with the
medial surface head of fibula. interosseous membrane of the
Articular capsule surrounds the joint on leg.
all sides and is attached to the margins of The nerve supply is by
articular facets. i. Deep peroneal
The capsule is reinforced by two thick- ii. Tibial
eningsanterior ligament and iii. Saphenous
posterior ligament. The arteial supply is by
The nerve supply is by i. Medial malleolar branches of
Common peroneal nerve anterior and posterior tibial arteries.
Nerve to popliteus ii. Perforating branch of peroneal artery.
The lateral supply is by The movements is by
Anterior and posterior recurrent bran- Very slight movement of separation of
ches of anterior tibial artery. two bones is possible in this joint.
 The Joints of the Lower Extremity 137

THE SUBTALAR JOINT ii. The plantar calcaneo-navicular ligament

The subtalar joint is between inferior surface of (spring ligament) is present on plantar
talus and calcaneum. aspect of the joint.
Type: A plane type of synovial joint. The joint It is a broad thick band, conecting the
surfaces are somewhat curved reciprocally. sustentaculum tali of calcaneum to the
Articular surfaces navicular bone.
A concave facet on posterior part of inferior The spring ligament supports the head of
surface of talus. talus and plays an important role in
A posterior facet on superior surface of maintaining medial longitudinal arch
calcaneum. of the foot.
Articular capsule surrounds the joint on all sides. Movements: Gliding and rotational
Ligaments movements at this joint result in inversion and
i. The lateral talo-calcaneal ligament is a eversion of foot.
short flat band between lateral surfaces of A small amount of dorsiflexion and plantar
the two bones. flexion also occur at this joint.
ii. The medial talo-calcaneum ligament con- Muscles producing movements
nects the talus to sustentaculum tali of Inversion:
calcaneum. Tibialis anterior
Its fibers blend with deltoid ligament. Tibialis posterior
iii. The interosseous ligament is a flat band in Assisted by long flexors of toesflexor
the sinus tarsi. digitorum longus and flexor hallucis
This ligament provides axis for the longus.
rotational movement at this joint. Eversion:
Movements Inversion (adduction) and Peroneus longus
eversion (abduction) of foot takes place at this Peroneus brevis
joint. These movements involve gliding and Peroneus tertius.
rotation at this joint.
B. The Calcaneo-Cuboid Joint
THE MID-TARSAL JOINT
(TRANSVERSE TARSAL JOINT) Type: A saddle type of synovial joint
Articular surfaces are formed by
This joint consists of two joints.
Distal facet of calcaneum
A. Talo-calcaneo-navicular joint.
Proximal facet of cuboid.
B. Calcaneo-cuboid joint.
Articular capsulesurrounds the joint
A. Talo-Calcaneo-Navicular Joint Ligaments
Type: A ball and socket type of joint. i. The dorsal calcaneo-cuboid ligament is
Articular surfaces are formed by thickening of dorsal aspect of articular
i. Ovoid head of talus cap-sule.
ii. Navicular, spring ligament and anterior ii. The bifurcate ligament is a Y-shaped
articular facet of calcaneumthat form strong band.
the socket. Stem is attached to dorsal surface of
Ligaments calcaneum.
i. The talo-navicular ligament is a broad The two limbs of the Y are attached to
thin band connecting the dorsal surface of Dorsal surface of cuboid
neck of talus to the navicular bone. Navicular
 138 Essentials of Human Anatomy
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
con-verting the groove of peroneus
lon-gus 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
aspect of the joint.
b. The plantar ligaments cover the
plantar aspect of the joint.
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
bet-ween 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).
 The Joints of the Lower Extremity
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.
Muscles producing
movements Flexion
Flexor digitorum longus
Flexor digitorum accessorius
Flexor hallucis longus (for big toe)
Extension
Extensor digitorum longus
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 calcaneo-
navicular 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 cal-
caneum, cuboid and fourth and fifth meta-
tarsals.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 Essentials of Human Anatomy

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. Fig. 15.11: The lateral longitudinal arch of foot
c. The short muscles of foot by their tone help
in maintaining the arch.
d. The plantar aponeurosis acts as a tie beam c. The peroneus longus tendon crossing the
of this longitudinal arch as well. sole obliquely ties the ends of the arches
e. The tendon of peroneus longus suspends together.
the lateral longitudinal arch from above.
d. The peroneus longus and brevis tendons also
III.The transverse arches are formed by the bases
suspend the arch from above.
of the metatarsal bones, cuboid and three cunei-
form bones. The arch is incomplete, shaped Applied anatomy
like a halfdome. The flat foot is a condition, where the
The maintenance of transverse arch is done arches are flattened due to weakness of its
by: supports.
a. The shape of bones whose dorsal surface The condition causes pain and discomfort
is more extensive than plantar surface. in walking and running.
b. The deep transverse ligaments of the sole Low arches of foot can be corrected to some
by tying the metatarsal heads together help extent by specially designed shoes with built-
maintain transverse area. in arch supports.
 CHAPTER 16
The Hip Region
The hip region of the lower extremity consists of B. The small lateral rotators of the hip joint.
gluteal region at the back of lower end of trunk. Piriformis
Obturator internus
THE MUSCLES OF THE Gemelli: superior and inferior
GLUTEAL REGION Obturator externus
The muscles of the gluteal region are divided into Quadratus femoris
two groups:
A. The gluteal muscles (Table 16.1) Relations of Gluteus Maximus (Fig. 16.1)
Gluteus maximus Superficial
Gluteus medius Skin
Gluteus minimus Superficial fascia containing plenty of fat
Table 16.1: The gluteal muscles

Name Origin Muscle belly Insertion Nerve supply Main actions

1. Gluteus Posterior gluteal line Largest muscle in Upper, larger Inferior gluteal I. Powerful extensor
maximus and posterior surface body and superficial (L5, S1, S2) of hip joint
of ilium above it Thick quadrilateral three fourth II. Straightens trunk
Aponeurosis of muscle belly attached to on limb and limb
erector spinae iliotibial tract on trunk in all
Lower and walking, running
deeper fourth and jumping
attached to movements
Dorsal surface of gluteal tuber- III. Upper fibers help
sacrum and side of osity in abduction of hip
coccyx joint
Sacro-tuberous liga- IV. Supports hip and
ment helps to maintain
Deep fascial covering erect posture
gluteus medius
2. Gluteus Posterior surface of Thick muscle belly Oblique ridge Superior I. They abduct the
medius ilium between pos- Fibers converge to on lateral as- gluteal thigh and rotate it
terior and middle form a flat tendon pect of greater (L5, S1) medially
gluteal lines trochanter of II. They supports the
Deep fascia covering femur pelvis, when foot
it is raised off the
3. Gluteus Posterior surface of Fan shaped Antero-lateral Superior ground thus help
minimus ilium between middle muscle belly surface of greater gluteal in walking and
and inferior gluteal lines Fibers converge to trochanter of L5, S1 running
form a flat tendon femur
4. Tensor Anterior 5 cm Short flat musde Ilio-tibial Superior I. It assists in
fascialata of outer lip of belly tract gluteal abduction and
liac crest medial rotation
of thigh
II. It helps to steady
the pelvis
142 Essentials of Human Anatomy

Fig. 16.1: The structures under cover of gluteus maximus

Deep fascia Branches of medial circumflex femoral
Deep artery.
Bones - Ilium, sacrum and coccyx, ischial Bursatrochanteric bursa.
tuberosity, greater trochanter. Proximal bordercrosses gluteus medius
Ligament Distal bordersloping downwards and
Sacro-tuberous ligament. laterally crosses the posterior gluteal fold.
Muscles
Gluteus medius Relations of Gluteus Medius
Piriformis
Tendon of obturator internus Superficial
Gemelli-superior and inferior Skin, superficial fascia
Quadratus femoris Deep fascia
Attachments of semi-membranosus, Overlapped by gluteus maximus
semi-tendinosus and biceps femoris. Deep
Vessels and nerves Gluteus minimus
Superficial branch of superior gluteal Superior gluteal vessels
artery Superior gluteal nerve
Inferior gluteal artery and nerve Trochanteric bursa
Sciatic nerve
Internal pudendal vessels Relations of Gluteus Minimus
Pudendal nerve
Posterior cutaneous nerve of thigh Superficial
First perforating branch of profunda Gluteus medius
femoris artery Deep
 The Hip Region 143

Reflected head of rectus femoris inferior ramus to supply the gluteal

Articular capsule of hip joint muscles.
Trochanteric bursa The deep branch anastomoses with
lateral and medial circumflex femoral
The Blood Vessels of the Gluteal Region and inferior gluteal arteries.
The Arteries It also gives an articular branch to the
hip joint.
1. The superior gluteal artery is a branch of
2. The inferior gluteal artery is a branch of
posterior division of internal iliac artery.
anterior division of internal iliac artery.
CourseThe artery leaves pelvis by passing CourseThe artery leaves pelvis by passing
through greater sciatic foramen above through greater sciatic foramen, below
piriformis along with superior gluteal nerve. piriformis along with inferior gluteal nerve.
The artery divides into a superficial The artery enters the deep surface of
branch and a deep branch. gluteus maximus muscle and supplies it.
The superficial branchpasses deep to Branches
gluteus maximus and anastomoses I. The descending branch anastomoses
with inferior gluteal artery. with the ascending branch of first per-
The deep branch passes deep to gluteus forating artery and transverse branches
medius along with superior gluteal of lateral and medial circumflex femoral
nerve, and divides into a superior and artery to form cruciate anastomosis
Table 16.2: Small lateral rotators of hip joint

Name Origin Muscle belly Insertion Nerve supply Main actions

1. Piriformis By three digitations Tapering muscle belly Upper border of L5, S1, S2 VR I. It rotates extended
from front of middle gives rise to a round greater trochanter thigh laterally
three pieces of sacrum tendon of femur II. It abducts the
Upper margin of flexed thigh
greater sciatic notch
2. Obturator Pelvic surface of ilium Muscle belly flat forms Medial surface of Nerve to I. It rotates extended
internus and margins of obtur- a tendon that enters greater trochater obturator thigh laterally
ator foramen-Internal gluteal region through of femur internus II. It abducts the
surface of obturator lesser sciatic foramen (L5, S1) flexed thigh
membrane
3. Gemellus Dorsal aspect of Muscle fibers blend Tendon of obtu- Nerve to It helps in action
superior ischial spine with upper border rator internus obturator of obturator inter-
of tendon of obtur- Medial surface of internus nus
ator internus greater trochanter L5, S1
Gemellus Ischial tuberosity Muscle fibers blend, Tendon of obtu- Nerve to quad- It helps in action
inferior along lesser sciatic with lower border rator internus ratus femoris of obturator
notch of tendon of obtu- Medial surface of L5, S1 internus
rator internus greater trochanter
4. Obturator Outer surface of Flat and triangular Trochanteric fossa Posterior branch It laterally rotates
externus pubic bone and mar- muscle belly on medial surface of obturator the hip joint
gins of obturator Tendon crosses of greater tro- L5, L4
foramen behind and then chanter
Outer surface of below hip joint
obturator membrane
5. Quadratra- Upper part external Flat and quadran- Quadrate tubercle Nerve to quadralus It laterally rotates
tus femoris surface of ischial gular Fibers pass on trochanteric femoris L51, 51 the hip joint
tuberosity behind hip joint crest of femur
 144 Essentials of Human Anatomy
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
L L S ,S .
4, 51, 1 2
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 compart-
ment 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.
 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
I. Muscular branches supply
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, accom-
panied 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.

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
Table 17.1: Muscles of the anterior compartment
Name Origin
1. Iliacus Upper two-third of iliac
fossa, Ala of sacrum
Anterior sacro-iliac
ligament
2. Psoas Anterior surface and
major lateral borders of trans-
verse 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
3. Quadri- Four heads
ceps a. Vastus medialis
temoris Distal part of inter tro-
chanter line
Spiral line
Medial lip of linea
aspera Proximal part
medial supracondylar
CHAPTER 17
The Region of
the Thigh
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.
Muscle belly Insertion Nerve supply Main actions
Flat, triangular muscle Lesser trochanter Femoral I. Powerful flexor of
belly Fibers converge of femur For 2.5 (L2, L3) hip joint with
towards lateral side to cm below lesser psoas major
form a strong tendon trochanter on II. Helps to maintain
with psoas major the shaft of femur posture at hip joint
Long fusiform muscle Summit of lesser Ventral rami I. Same as iliacus
belly lies lateral to trochanter along L1, L2 from II. Helps to bend
lumbar part of verte- with iliacus lumbar plexus trunk on lower
bral column limb while getting
Descends along pelvic up.
inlet and its tendon is III. Does not act as
joined by iliacus from medial rotator of
lateral side hip joint; rather
helps in lateral
rotation
Large muscle belly, Base of patella Femoral I. Powerful extensor
covers front and Insertion is carried L2, L3, L4 of knee joint
sides of shaft of by ligamentum (Separate II. Rectus femoris
femur patellae to the tub- branches are helps in flexing of
Tendons of four erosity of tibia given to the of hip joint
heads unite to form (patella being sesa- four heads of III. Helps to maintain
a strong tendon moid bone) Medial quadriceps posture at knee
above patella and lateral patellar femoris) joint
Contd...

Contd...
Name Origin
line
b. Vastus lateralis
Intertrochanteric line
Anterior and inferior
borders of greater trochan-
ter 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-anter-
ior inferior iliac spine
II. Reflected head-
groove 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)
The Region of the Thigh 147
Muscle belly Insertion Nerve supply Main actions
retinacula are ex- IV. Lowest fibers of
pansions attached vastus medialis
to sides of patella stabilize patella
Some lower fibers by preventing its
of vastus medialis lateral displace-
are directly attached ment during
to medial border of contraction of
patella quadriceps femoris
Articularis genu are
deepest and lowest
fibers of vastus inter-
medius attached to
synovial membrane
of knee joint.
Long, strap like Upper part medial Femoral I. Flexion and
muscle belly surface of tibia in abduction of hip
Crosses the front front of gracitis (L , L ) joint
of thigh obliquely and semi-tendinosus 2 3 II. It also helps in
to reach medial side lateral rotation of
of tibia hip joint.
III. It also helps in
flexion of knee
joint (The combi-
nation of these
movements helps
the tailor to work
his foot-operated-
sewing machine.
Small muscle belly Pecten VRL 1 1. Weak flexor of
with long tendom pubes trunk
Fig. 17.1: The femoral triangle
 148 Essentials of Human Anatomy
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
Fig. 17.2: The adductor canal
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-
aponeuro-tic 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)
 The Region of the Thigh
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 mid-
inguinal 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 up-wards
and medially in anterior abdominal
wall towards umbilicus
c. Superficial circumflex iliac: passes late-
rally towards iliac crest.
II. The deep external pudendalpasses
medi-ally 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 bran-
cheslateral 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 bran-
chesascending, 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 anasto-mosis 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 Essentials of Human Anatomy
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 postero-
lateral 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
conti-nues 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.
The Nerves of the Anterior
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
 The Region of the Thigh
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 fas-
cia 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.
Fig. 17.3: The femoral sheath
151
CourseThe femoral branch of genito-
femoral enters femoral triangle by des-
cending 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
 152 Essentials of Human Anatomy
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.
 The Region of the Thigh 153
Table 17.2: The muscles of the medial compartment
Name Origin Muscle belly Insertion Nerve supply Main actions
1. Adductor By a narrow tendon from Flat and triangular Linea aspera Anterior division I. Adduction of hip
longus front of pubic bone muscle belly between vastus of obturator joint
medialis and L2, L3 and L4 II. Help in flexion
adductor magnus 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 divi- II. Helps in lateral
Infero-lateral surface of muscular mass on medial supra sion of obtur- rotation 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 tuber-
cle
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 obtu- joint
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 rota-
semi-tendinosis tion of leg

Fig. 17.4: A section through medial compartment of thigh

154 Essentials of Human Anatomy
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 ansto-
moses with inferior gluteal artery.
b. A transverse branchthat forms
cruciate anastomosis at back of
greater trochanter with:
Transverse branch of medial cir-
cumflex femoral.
Descending branch of inferior
gluteal
Ascending branch of first per-
forating 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 bet-
ween 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 ar-
terial anastomoses
branch
at back of thigh.
2. The obturator artery is a branch of anterior
division of internal iliac artery.
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 ham-
string 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.
 The Region of the Thigh
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 fora-
men along with obturator vessels.
As it passes through the obturator fora-
men, it divides into an anterior and a
posterior branch.
a. The anterior branchdescends in
the medial compartment of thigh
between adductor longus and pecti-
neus superficially and adductor
brevis deep to it.
b. The posterior branchdescends in
the medial compartment between
adductor brevis and adductor mag-
nus.
Branches
From the anterior division
I. Muscular branches supply
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
I. Muscular branches supply
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 Essentials of Human Anatomy
Fig. 17.5: The muscles of gluteal region and posterior compartment of leg
The following arteries take part in this anasto-
mosis:
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.
The Nerves of the Posterior
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 nerveL4,
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
 The Region of the Thigh 157
Table 17.3: The muscles of the posterior compartment
Name Origin Muscle belly Insertion Nerve supply Main actions
1. Biceps Two heads
femoris a. Long head arises from The long head forms Lateral surface Long head-tibial I. It flexes the knee
lower medial area of a funiform muscle head of fibula Short head- joint
ischial tuberosity in belly, joined by short The tendon is common pero- II. It helps in exten-
conjunction with semi- head grooved by neal L5, S1, S2 sion of hip joint
tendinosis Forms a narrow ten- fibular colla- III. It helps in lateral
b. Short head from don, that passes teral ligament rotation of leg
lateral lip of aspera laterally

2. Semi- Lower medial part of Fusiform muscle badly Upper part Tibial I. It flexes the knee
tendino- ischial tuberosity in Gives rise to a long medial surface L5, S1, S2 joint
sus conjunction with long tendon in middle of of tibia, behind II. It helps in exten-
head of biceps femosis thigh gracilis and sion of hip joint
sartorius III. It helps in medial
rotation of leg
3. Semi- Upper lateral part of Upper half of muscle Groove on Tibial
mem- ischial tuberosity brano- L,S
is aponeurotic posterior 5 1,2 I. It flexes the knee
Lower half is muscular aspect medial joint
sus Lower end forms a condyle of tibia II. It helps in exten-
tendon Two expansions sion of hip joint
given from III. It helps in medial
insertion rotation of leg
a. Fascia conver-
ing popliteus
b. Oblique popli-
teal ligament
of knee joint

Long head of biceps femoris THE POPLITEAL FOSSA

Semi-tendinosus The popliteal fossa is a diamond-shaped inter-
Semi-membranosus muscular hollow space at the back of knee
Ischial part of adductor magnus (Fig.17.6).
From common peroneal nerve: Boundaries
Short head of biceps femoris I. The side boundaries
II. Articular branch Upper lateral: Biceps femoris
To hip joint Upper medial: semi-membranosus
Applied anatomy Adductor magnus

I. The sleeping foot: consist of tingling Assisted by semi-tendinosus
and numbness in the back of lower gracilis and sartorius.

limb, caused by compression of sesory Lower lateral: Lateral head of gastro-
fibers of sciatic nerve against the back cnemius

of femur. Assisted by plantaris
II. The sciatica: is the name given to the Lower medial: Medial head of gastro-
low back pain, that radiates to the back cnemius
of lower limb. There may be several II. The superficial boundary (roof)
causes of sciatica; it may be also due Skin, superficial fascia
to involvement of sensory nerve fiber, Deep fascia of back of knee (popliteal
of the sciatic nerve. fascia)
158 Essentials of Human Anatomy

Fig. 17.6: The popliteal fossaboundaries

III. The deep boundary (Floor) Contents (Fig. 17.7)

Popliteal surface of lower end of femur
I. The popliteal artery and its branches
The back of knee joint reinforced by
II. The popliteal vein and its tributaries
oblique popliteal ligament.
Fascia covering popliteus. III. The tibial nerve and its branches

Fig. 17.7: The popliteal fossadeep contents

 The Region of the Thigh
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 con-
dyles 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 Essentials of Human Anatomy
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.
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 osseo-
fascial 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. Tibialis anterior
II. Extensor hallucis longus
III. Extensor digitorum longus
IV. Peroneus tertius

The Blood Vessels of the Anterior

Compartment
The arteries Fig. 18.1: The anterior compartment of leg

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 inter-
osseous membrane of the leg along
with the deep peroneal nerve.
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 Essentials of Human Anatomy

Table 18.1: The muscles of the anterior compartment

Name Origin Muscle belly Insertion Nerve supply Main actions

1. Tibialis Proximal half or two- Muscle belly gives Medial surface Deep peroneal I. It dorsiflexes and
anterior third of lateral surface rise to a tendon in medial cuneiform (L4, L5) inverts the foot
of tibia distal third of leg and adjoining part II. It helps in main-
Anterior surface of base of first meta- taining medial
interosseous membrane tarsal longitudinal arch of
foot
2. Extensor Middle half of medial Muscle belly lies bet- Dorsal surface Deep peroneal I. It helps in dorsi-
hallucis surface of fibula medial ween tibials anterior base of distal (L4, L5) flexion
longus to extensor digitorum and extensor digito- phalanx of big II. It extends the
longus rum longus toe big toe
Anterior surface of It gives rise to a
interosseous mem- tendon in distal
brane part of leg
3. Extensor Proximal three-fourth Muscle belly gives The tendon divi- Deep peroneal I. It dorsiflexes the
digitorum of medial surface of rise to a tendon in des into four (L5, S1) foot
longus of fibula distal part of leg slips on dorsum of II. It extends the
Anterior surface of foot lateral four toes
interosseous mem- Slips are attached
brane to dorsal digital
expansion of the
lateral four toes
4. Peroneus Distal third medial Short muscle belly Base of fifth Deep peroneal I. It helps in dorsi-
tertius surface of fibula gives rise to a tendon metatarsal bone (L5, S1) flexion
II. It is evertor of
foot

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-
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 superficial 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 accom-
panied 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.
 The Region of the Leg 163

The Nerves of the Anterior Branches

Compartment I. The muscular branches supply
The deep peroneal (anterior tibial) nerve is the Tibialis anterior
Extensor hallucis longus
larger terminal branch of the common peroneal
Extensor digitorum longus
nerve.
Peroneus tertius
Beginning: The deep peroneal nerve arises in II. The articular branch: supplies
the substance of peroneus longus muscle, The ankle joint.
lateral to the neck of fibula, where the
common peroneal nerve bifurcates. THE LATERAL (PERONEAL)
Course: The deep peroneal nerve pierces the COMPARTMENT OF THE LEG
lateral intermuscular septum and extensor The muscles of the lateral compartment are
digitorum muscle to enter the anterior com- (Table 18.2):
partment of leg. Peroneus longus
The nerve descends on the front of Peroneus brevis
interosseous membrane along with
anterior tibial vessels. The Blood Vessels of the Lateral
The nerve and the vessels are overlapped by Compartment
the extensor muscles in the anterior There are no separate blood vessels for the lateral
compartment. compartment of leg.
The nerve passes deep to the superior The branches of peroneal artery enter the
extensor retinaculus, crosses the front of lateral compartment by curving laterally and
ankle joint and enters the dorsum of foot piercing the lateral intermuscular septum.
where it divides into its two terminal These muscular branches supply the peroneal
branchesmedial and lateral. muscles.
Table 18.2: The muscles of the lateral compartment
Name Origin Muscle belly Insertion Nerve supply Main actions
1. Peroneus Lateral surface head Muscle belly lies Lateral side of Superficial pero- I. It is an evertor of
longus and proximal two- superficial to base of first meta- neal L5, S1, S2 foot
third of lateral surface peroneus brevis tarsal and adjacent II. It helps in plantar
of fibula Muscle belly ends medial cuneiform flexion of foot
Few fibers from lateral in a long tendon bone III. It supports and
tibial condyle that passes behind helps to maintain
lateral malleolus lateral
and reaches dorsum longitudinal arch
of foot and trans-verse
The tendon curves arches of foot
around lateral
border of foot and
enters sole
2. Peroneus Distal two-third lateral The muscle belly is Lateral surface Superficial I. It is an evertor
brevis surface of fibula overlapped by pero- base of fifth peroneal of foot
neus longus metatarsal L5, S1, S2 II. It helps in plantar
Muscle belly gives flexion of foot
rise to a tendon that
passes behind lateral
malleolus and above
the peroneal tubercle
of calcaneum
164 Essentials of Human Anatomy

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 Fig. 18.2: The posterior compartment of leg
Peroneus brevis superficial muscles of calf

THE POSTERIOR COMPARTMENT OF Beginning: The artery begins at the lower

THE LEG border of popliteus where the popliteal artery
The muscles of the posterior compartment are bifurcates.
Course: The posterior tibial artery descends
divided in two groups (Fig. 18.2 and Table 18.3):
in the posterior compartment along with tibial
A. The superficial muscles of calf
nerve.
i. Gastrocnemius
It lies between tibialis posterior and flexor
ii. Plantaris
digitorum longus and deep transverse
iii. Soleus
fascia of the leg
B. The deep muscles of calf
The artery reaches deep to the flexor
i. Popliteus
ii. Flexor digitorum longus retinaculum of the ankle.
Termination: The posterior tibial artery divides
iii. Flexor hallucis longus
iv. Tibialis posterior into its two terminal branches: medial and
lateral plantar arteriesmidway between
The Blood Vessels of the Posterior medial malleolus and medial tubercle of
Compartment calcaneum, deep to the flexor retinaculum.
Branches
The Arteries
a. The circumflex fibular artery passes
The posterior tibial artery: is the larger terminal laterally and takes part in anastomosis
branch of popliteal artery. around knee joint.
 The Region of the Leg 165
Table 18.3: The muscles of posterior compartment of leg
Name Origin Muscle belly Insertion Nerve supply Main actions
The superficial muscles of the calf
Two heads
1. Gastro- a. Medial head Two muscular bellies Joins with soleus Tibial S1, S2 I. Major plantar
cnemius (larger) form main muscular to form the flexors of foot
Depression on upper mass of calf tendo-calcaneus II. Provides pro-
and posterior part of The two heads join pelling force in
medial condyle to form a broad walking, running
Popliteal surface aponeurosis and jumping
of femur III. Helps in flexion
b. Lateral head (smaller) of knee
Small area on lateral
surface of lateral
condyle of femur
2. Plantaris Distal part of late- Small fusiform muscle Medial border of Tibial Rudimentary
ral supracondylar belly tendo-calcaneus S1, S2 muscle
line Gives rise to a long, I. Acts with gastro-
Oblique popliteal thin tendon cnemius
ligament of knee
joint (Muscle may
be absent)
3. Soleus Posterior surface Broad, flat, muscle Joins with gas- Tibial I. Powerful plantar
head of fibula belly lies deep to trocnemius to S1, S2 flexor of foot
Proximal one-fourth gastrocnemius form tendo- II. Action slow and
posterior surface of A central tendon calcaneus sustained
fibula starts from muscle Inserted on III. Helps to steady
Soleal line of tibia belly middle part leg on foot
Middle third medial of posterior
border of tibia surface of
calcaneum
The deep muscles of the calf (Fig. 18.3)
4. Popliteus Anterior part of pop- Muscle is attached Medial two-third Tibial L -L I. Unlocks knee joint
liteal groove on to fibrous capsule of popliteal sur- and S 4 5 II. Rotates tibia medi-
lateral surface of A flat, triangular face of tibia above 1 ally and femur
lateral condyle of muscle belly soleal line laterally
femur (origin is III. Helps in flexion of
intra-capsular) knee joint
5. Flexor Upper part posterior The bipennate muscle Divides into four Tibial I. Flexor of lateral
digitorum surface tibia below belly gives rise to a tendons in sole for S2, S3 four toes
longus soleal line, medial to tendon that crosses lateral four toes. II. Helps in plantar
tibialis posterior tibialis posterior and Each is attached to flexion of foot
passes behind medial base of distal pha-
malleolus lanx
6. Flexor Distal two-third of Thicker bipennate Receives a slip Tibial I. Flexor of big toe
hallucis posterior surface of muscle belly from flexor digi- S2, S3 II. Helps in plantar
longus fibula Gives rise to a tendon torum longus in flexion of foot
Interosseous mem- that grooves posterior sole Helps to maintain
brane of leg surface lower end, of Inserted on base medial longitudinal
tibia and enters sole of distal phalanx arch
of big toe
7. Tibialis Two heads Tibial head Bipennate muscle belly Superficial part Tibial L4-L5 I. Main invertor
posterior Lateral part posterior Tendon grooves back on tuberosity of foot
surface tibia below of medial malleolus of navicular II. Helps in plantar
soleal line Deeper part flexion of foot
Interosseous membrane sends slips to all III. Helps in maintain
Fibular-head short bones of medial longitudinal
Proximal two third tool except talus arch of foot
medial part posterior and base of first
surface of fibula metatarsal
166 Essentials of Human Anatomy
The Veins
A. The superficial 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
posterior tibial artery.
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.
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.
 The Region of the Leg
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
posterior tibial artery.
These veins join with venae comitants of
anterior tibial artery at the lower border of
popliteus to form the popliteal vein.
167
The Nerves of the Posterior
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 com-
partment 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 digitorum longus
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

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 inser-
tions.
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.
CHAPTER 19
The Region of
the Foot
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.
 The Region of the Foot
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.
169
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 Essentials of Human Anatomy

Branches The deep veins

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 bet-ween the two heads of first
dorsal inter-osseous muscle.
It divides into two dorsal digital
branches to supply the sides of first
and second toes.
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 superficial 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
 The Region of the Foot 171

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
Fig. 19.3: The plantar aponeurosis
Inter-tarsal and tarso-metatarsal
joints Attachments
Second dorsal interosseases muscle Proximally to medial tubercle of
b. The medial terminal branch passes calcaneum
distally on the dorsum of foot, lying Distally divides into five slips for five
lateral to the dorsalis pedis artery. toes. These slips become continuous
It pierces deep fascia at the web, and with fibrous flexor sheaths of the toes.
divides into two branches to supply Functions
the sides of first and second toes i. It covers and protects the deeper struc-
It also supplies the first dorsal tures of the sole.
interosseous muscle and also the ii. It acts as a Tie Beam, and helps to
metatarso-phalangeal joint of big toe. maintain the longitudinal arches of foot.

The Muscles of the Sole (Table 19.1)

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.
The muscles of sole are arranged in four layers:
A. The first layer has three muscles
Abductor hallucis (Fig. 19.4)
Flexor digitorum brevis
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 Essentials of Human Anatomy

Fig. 19.4: The muscles of first layer of sole

Fig. 19.5: The muscles of second layer of sole

 The Region of the Foot 173
Table 19.1: The muscles of the sole
Name Origin Muscle belly Insertion Nerve supply Main actions
A. First layer
1. Abductor Flexor retinaculum Muscle belly lies along Medial side base of Medial plantar I. Abductor of big toe
hallucis Medial tubercle medial border of foot, proximal phalanx (S2, S3) from neutral axis
of calcaneum and ends in a tendon of big toe of second toe
2. Flexor Medial tubercle of Muscle belly lies Each slip divides Medial plantar I. Helps in flexion
digitorum calcaneum deep to plantar into two parts to (S2, S3) of lateral four toes
brevis aponeurosis enclose a fibrous
Divides into four tunnel for the
slips for lateral fourlongus tendon
toes Inserted on
sides of middle
phalanx of the
toe
3. Abductor Both medial and lateral Muscle belly lies along Base of proximal Lateral plantar I. Abductor of little
digiti tubercles of calcaneum lateral border of foot phalanx of little S2, S3 toe from neural
minimi and gives rise to a toe axis of second toe
tendon
B. Second
layer
1. Flexor Two heads separated by The muscle belly joins Plantar surface Lateral plantar I. It is a direct flexor
digitorum lateral plantar ligament the flexor digitorum flexor digitorum (S2, S3) of lateral four toes
acces- a. Medial larger head longus tendon, before longus tandon (by bringing flexor
sorius from medial surface of it divides into four digitorum longus
calcaneum slips tendons in line
b. Lateral smaller and with toes.
tendinous from lateral
surface of calcaneum
2. The lum- First from medial First lumbrical has Medial side dorsal Firstby medial I. The lumbricals
brical side of flexor digi- slender unipennate digital expansions plantar help in flexion of
muscles torum longus tendon muscle belly of lateral four The other three metatarso-phalan-
(Four to second toe The other three toes lateral plantar geal and extension
bellies) The other three have slender bipen- (deep branch) of inter-phalangeal
from adjacent sides nate muscle bellies (S2, S3) joints of lateral
of flexor digitorum The muscle end in four toes
longus tendons tendons that pass
distally on medial
sides of lateral four
toes.
C. Third layer
1. Flexor Cuboid proximal to Muscle belly divides On two sides of Medial plantar I. Flexor of the big
hallucis groove for peroneus into two parts base of proximal (S2, S3) toe
brevis longus medial and lateral phalanx of big toe
-Lateral cuneiform that reach on two
sides of big toe
Sesamoid bones
develop in the two
parts near insertion
2. Adductor Two heads
hallucis a. Oblique head from Two heads give rise to Lateral side of Lateral plantar I. It adducts big toe
bases of second to two bellies, that join base of proximal (deep branch) towards neutral
fourth metatarsals and are inserted to- phalanx of big toe (S2, S3) axis of second toe
and sheath of per- gether
oneus longus tendon
b. Transverse head from
plantar metatarso-pha-
langeal ligaments of
third to fifth toes.
Contd...
174 Essentials of Human Anatomy

Contd...
Name Origin Muscle belly Insertion Nerve supply Main actions
3. Flexor Base of fifth metatarsal Slender muscle belly Lateral side of base Lateral plantar I. Helps in flexion of
digiti of proximal pha- (superficial little toe
minimi lanx of little toe branch) (S2, S3)
brevis
D. Fourth layer
1. Dorsal Adjacent sides of meta- Bipennate muscle Bases of proximal First, Second,
interossei tarsal bones bellies, fills up gaps phalanges and dor- Third
(Four between meta- sal digital expan- Lateral plantar I. Abductors of toes
bellies) tarsals sion of toes (deep branch) from neutral axis
A fibrous arch between First on medial (S2, S3) of second toe
two heads at proximal Second and third Fourth dorsal II. First and second
end of inter-metatarsals on lateral sides of interosseous (by cause medial and
spaces third toe superficial branch lateral abduction
Fourth on lateral lateral plantar) of second toe
side of fifth toe III. Flexion of meta-
tarso-phalangeal
and extension of
inter-phalalangeal
joints
2. Plantar Bases and medial sides Unipennate, slender Medial sides bases First and I. Adductors of third
interossei of third, fourth and muscle bellies and dorsal digital Second by fourth and fifth
(three fifth metatarsals Tendons pass on expansions of lateral plantar toes towards the
bellies) medial sides of third, third, fourth, fifth (deep branch) neutral axis of
fourth, and fifth toes toes second toe
Third by lateral II. Flexor of meta-
plantar (super- tarso-phalangeal
ficial branch) and extensor of
(S2, S3) inter-phalangeal
joint of third,
fourth, and fifth
toes.

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.
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.
 The Region of the Foot 175

Fig. 19.6: The muscles of third layer of sole

Figs. 19.7A and B: The interossei of sole

Branches Course: The artery enters sole by passing

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.
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 Essentials of Human Anatomy
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 comi-
tantes.
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 digitorum brevis
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.
 The Region of the Foot 177

Course: The lateral plantar nerve lies medial Branches

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

Q.1. Select the best response to reach question C. Compression

from the four suggested answers D. Hyperflexion
1. The neck of femoral hernia lies: 7. The following muscle is attached to the
A. At the femoral ring posterior surface of calcaneum:
B. At deep inguinal ring A. Flexor hallucis brevis
C. At the obturator canal B. Abductor hallucis
D. At saphenous opening C. Gastrocnemius and soleus
D. Flexor digitorum accessorius
2. Which of the following muscles is the main 8. The peroneal artery is a branch of:
flexor of thigh: A. Anterior tibial artery
A. Pectineus B. Femoral artery
B. Adductor longus C. Posterior tibial artery
C. Rectus femoris D. Lateral plantar artery
D. Ilio-psoas
9. The most anterior structure deep to flexor
3. The iliotibial tract receives the insertion: retinaculum of ankle is:
A. Gluteus maximus A. Tibial nerve
B. Tensor fascia lata B. Tibialis posterior tendon
C. Both C. Long saphenous vein
D. None D. Flexor hallucis longus tendon

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
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
Q.2. Each question below contains four
sugges-ted 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
11. The muscles inserted on greater trochanter
of femur are:
1. Gluteus medius
 Multiple Choice Questions 179

2. Piriformis 2. Tibialis posterior

3. Gluteus minimus 3. Tendo-calcaneus
4. Gluteus maximus 4. Calcaneo-navicular (spring) ligament
12. The structures contributing to the 19. The muscles that act on both hip joint and
boundaries of popliteal fossa are: knee joint are:
1. Biceps femoris 1. Biceps femoris
2. Quadratus femoris 2. Sartorius
3. Semi-membranosus 3. Rectus femoris
4. Peroneus longus 4. Adductor magnus
13. The muscles of the anterior compartment of 20. The dorsalis pedis artery enters sole by:
leg are:
1. Passing between two heads of first
1. Tibialis anterior
dorsal interosseous muscle
2. Extensor hallucis longus
2. Passing between two heads of second
3. Extensor digitorum longus
dorsal interosseous muscle
4. Peroneus tertius
3. Passing between the bases of first and
14. The tibial portion of sciatic nerve in back of second metatarsals
thigh supplies: 4. Passing between two heads of flexor
1. Short head of biceps femoris digitorum accessorius
2. Long head of biceps femoris
3. Vastus lateralis Q.3. Match the following on the left side with
4. Semi-tendinosus their appropriate answers on the right side
15. The factors responsible for the stability of 21. Clinical signs of injury/inflammation:
the ankle joint are: 1. Foot drop A. Sciatic nerve
1. Trochlear surface of talus 2. Lurching giant B. Prepatellar bursa
2. Spring ligament 3. Housemaids knee C. Common
3. Deltoid ligament peroneal nerve
4. Calcaneo-fibular ligament 4. Sleeping foot D. Gluteus medius
16. The adductor (subsartorial) canal contains: 22. Muscles and their attachments:
1. Obturator nerve 1. Popliteus A. Anterior 5.0 cm
2. Femoral vessels of outer lip of iliac
3. Long saphenous vein crest
4. Saphenous nerve 2. Psoas major B. Calcaneum
17. The muscle that help in abduction at the hip 3. Extensor C. Lateral condyle of
joint are: digitorum brevis femur
1. Gluteus medius 4. Tensor fascia lata D. Lesser trochanter
2. Piriformis of femur
3. Gluteus minimus 23. Types of joints:
4. Obturator externus
1. Syndesmosis A. Superior tibio-
18. The medial longitudinal arch of foot is fibular
maintained by: 2. Saddle joint B. Inferior tibio-
1. Peroneus longus fibular
180 Essentials of Human Anatomy

3. Ball and socket C. Hip joint 25. Actions of muscles:

joint
1. Adductor longus A. Abduction of hip
4. Plane joint D. Calcaneo-cuboid
joint joint
24. Origin of nerves: 2. Piriformis B. Lateral rotation of
1. Saphenous A. Sacral plexus hip joint
2. Sural B. Femoral 3. Popliteus C. Unlocks the knee
3. Superficial C. Common peroneal joint
peroneal 4. Sartorius D. Adducts the hip
4. Superior gluteal D. Tibial joint

Answers

A1. The answer is A. minimus are attached on outer surface of

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.
A2. The answer is D.
The main flexor of hip joint is iliopsoas. The
other three muscles pectineus adductor longus
and rectus femoris help in flexion of hip joint.
A3. The answer is C.
The two muscles inserted on iliotibial tract
are gluteus maximus and tensor fascia lata.
A4. The answer is B.
The upper lateral quadrant of gluteus
maximus is preferred for giving deep intra-
muscular injection, because no nerve or
large blood vessel lies deep here. Other
quadrants are related to nerves and blood
vessels deep to the muscle.
A5. The answer is A.
The superior gluteal nerve passes through
greater sciatic foramen. The obturator inter-
nus tendon comes out of lesser sciatic
foramen. The obturator externus and gluteus
hip bone and they do not pass through
greater sciatic foramen.
A6. The answer is A.
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.
A7. The answer is C.
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.
A8. The answer is C.
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.
A9. The answer is B.
The tibialis posterior tendon lies most
anteriorly deep to flexor retinaculum of the
ankle. The tibial artery lies just behind the
 Multiple Choice Questions
tibialis posterior. The long saphenous vein
ascends in front of medial malleolus. The
flexor hallucis longus tendon lies most
posteriorly deep to flexor retinaculum.
A10. The answer is D.
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.
A11. The answer is A, (1, 2, 3).
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.
A12. The answer is B, (1, 3).
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,
exten-sor hallucis longus, extensor
digitorum longus and peroneus tertius
belong to the extensor compartment of leg.
A14. The answer is C, (2, 4).
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.
A15. The answer is B, (1, 3).
The shape of trochlear surface of talus and
deltoid ligament are responsible for the
181
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.
A16. The answer is C, (2, 4).
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.
A17. The answer is B, (1, 3).
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.
A18. The answer is C, (2, 4).
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.
A19. The answer is A, (1, 2, 3).
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.
A20. The answer is B, (1, 3).
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 para-
lysis of gluteus medius.
182 Essentials of Human Anatomy
The housemaids knee is caused by
inflammation of prepatellar bursa.
The sleeping foot is caused by com-
pression 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 tibio-
fibular 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.
 The Thorax
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.
ii. The body of sternum (middle part) is made up
THE BONES OF THE THORAX
Four
CHAPTER 20
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.
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 manubrio-
sternal joint, that is marked in front by Fig. 20.1: The sternumanterior aspect
184 Essentials of Human Anatomy
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 arti-
culates with xiphisternum at the xiphi-
sternal 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 - sterno-
mastoid
Posterior surface of manubrium sterni -
Upper part - Sternohyoid
Lower part - Sternothyroid
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
Sternum is formed by fusion of two carti-
laginous 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.
 The Bones and Joints of Thorax
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
b. The atypical ribs (Fig. 20.4)
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 corres-
ponding 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 attach-
ment of lateral costo-transverse-liga-
ment.
iv. The shaft has an upper thick border and a
sharp lower border. The shaft is curved
The outer surface is rough for attach-
ment of muscle.
Fig. 20.3: The typical rib
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.
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.
186 Essentials of Human Anatomy
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
Fig. 20.5: The second rib-superior aspect
Fig. 20.6: The twelfth ribanterior aspect
Superior surface Scalenus medius
Superior surface near anterior end
subclavius
Outer border 1st digitation of serratus
anterior
Superior surface near anterior end
Costo-clavicular 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
Each rib ossifies by one primary center for the
shaft appearing in eighth week of intrauterine
life.
Fig. 20.7: The twelfth ribposterior aspect
 The Bones and Joints of Thorax
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
circu-lation 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.
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.
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.
Fig. 20.8: A typical thoracic vertebralateral aspect
188 Essentials of Human Anatomy
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.
 The Bones and Joints of Thorax
Fig. 20.10: The atypical thoracic vertebrae-Lateral
aspect
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
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 Essentials of Human Anatomy

Fig. 20.11: The costo-vertebral joints

bodies only. They have plane type of synovial laterally, and to the intervertebral disc
joints. medially.
The second to ninth rib articulate with sides of
bodies of two vertebraecorresponding
II. The Costo-Transverse Joints
vertebrae and next higher vertebrae. These The costo-transverse joints are joints between the
ribs have plane type of double synovial facets on tips of transverse processes of thoracic
joints with an intra-articular ligament. vertebrae and tubercles of the ribs (Fig. 20.12)
The articular capsule surrounds the joint, and The elventh and twelfth ribs have no tubercles,
is reinforced by ligaments. hence they have no costo-transverse joints.
The ligaments of the joint are Type
a. Radiate ligament strengthens the anterior- Plane type of synovial joints
aspect of the articular capsule. In relation to upper six thoracic ribs the
It is attached just beyond the head and joint surfaces are slightly curved reci-
has three sets of fibers. procally.
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 Fig. 20.12: The costo-transverse joints
 The Bones and Joints of Thorax
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 down-
wards 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 carti-
lages.
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 Essentials of Human Anatomy
The articular surfaces are covered by hyaline
articular cartilage.
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 dis-
placement.
The movements take place during the
respiratory movements of the thoracic cage.
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 narro-
wer 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
verte-bral bodies thus forming the
inter-vertebral symphysis.
Each disc consist of
An outer laminated annulus
fibrous
An inner nucleus pulposus
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 derange-
ment of nucleus pulposus. It may bulge
through the annulus - in posterolateral
direction usually.
 The Bones and Joints of Thorax
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 ante-
riorly
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.

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 verte-
brae to second rib.
CHAPTER 21
The Musculature of
the Thoracic Wall
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 inter-costal space
iii. Subcostalisposteriorly.
The External Intercostal Muscles
There are eleven pairs of external intercostals
filling up all eleven intercostal spaces.
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 inter-
costal 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.
Fig. 21.2: TS thoracic wall showing intercostal muscles and intercostal arteries
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 inter-
costal 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).
196 Essentials of Human Anatomy

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 two-
fourth part of the intercostal space
Direction of fiberssame as internal intercostal
Nerve supplyis by the corresponding inter-
costal nerve (ventral ramus of thoracic nerve) Fig. 21.3: The sternocostalis muscle
Actions
i. Functionally the muscle is part of internal
intercostal. The innermost intercostal is The Subcostalis
separated from the internal intercostal by
The subcostalis is a part of inner layer of
intercostal vessels and nerve (neuro-
intercostal muscles, that is attached to posterior
vascular plane)
ii. The three intercostal muscles also help to part of ribs as digitations. The subcostalis is
prevent bulging in and bulging out of better developed in lower part of thoracic cage.
intercostal spaces during inspiration. Thus Attachments
they maintain the integrity of intercostal UpperInternal surface of one rib near its
spaces. angle
LowerInternal surface of second or third
The Sternocostalis rib below
(Transversus Thoracis) Direction of fibersSame as internal intercostal
The sternocostalis is a part of inner layer of Nerve supplyis by corresponding intercostal
intercostal muscles, that is attached to sternum nerves
(Fig. 21.3). ActionsThe subcostalis depresses posterior
OriginPosterior surface of lower third of parts of ribs during expiration.
body sternum
Muscle bellyconsists of digitations that pass MUSCLES CONNECTING THORACIC
upwards and a little laterally towards costal CAGE TO VERTEBRAL COLUMN
cartilages I. The Serratus Posterior Superior
InsertionInner surface second to sixth
costal cartilages It is a thin quadrilateral muscle covering upper
Nerve supplyThird to sixth intercostal posterior part of thoracic cage.
nerves (ventral rami of thoracic nerves) Origin
ActionsIt depresses anterior ends of second Lower part of ligamentum nuchae
to sixth ribs. Spine of seventh cervical vertebrae
 The Musculature of the Thoracic Wall
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.
Fig. 21.4: The thoracic diaphragm
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.
198 Essentials of Human Anatomy
c . Lumbar is by means of two cruramus-
culo-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 lumbo-
costal arch) is attached from tip of first
lumbar transverse process to lower border
of twelfth rib.
ii. Medial arcuate ligament (Medial lumbo-
costal 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.
Table 21.1: Major openings of diaphragm
Inferior vena caval opening
1. Position In central tendon, between
right and central leaflet
2. Vertebral level 8th thoracic vertebra
3. Shape Quadrangular
4. Structures Inferior vena cava
passing
through
{
5. Effect of con-
Branches of right phrenic
nerve
Some lymphatics
The inferior vena caval
{
traction of opening is dilated (venous
diaphragm return takes place)
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
expul-sive 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 exer-
cise a sphincteric control over esophageal
opening (Table 21.1).
Esophageal opening Aortic opening
Muscular part of diaphragm Behind median arcuate ligament
surrounded by fibre of right crus of diaphragm
10th thoracic vertebra
{ 12th thoracic vertebra (lower
border)
Elliptical Oval
Esophagus Descending aorta
Anterior and posterior gastric nerves
Branches of left gastric artery
Esophageal opening is closed
{ Thoracic duct
Azygos vein
No effect on aortic opening
 The Musculature of the Thoracic Wall
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 thora-
cic 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 Essentials of Human Anatomy
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 intratho-racic pressure tends to pull
the chest wall inwards.
Diseases like emphysema, that reduce the
elasticity of lung tissue, affects this type of
movements.
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
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
intra-thoracic pressure.
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.
b. The Diaphragmatic Expiration
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
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.
 The Musculature of the Thoracic Wall 201

[A negative intrathoracic pressure (as compared withstand the decrease in intra-thoracic

to the atmospheric pressure) and surface tension pressure and during expiration the flat
normally holds the lungs against thoracic wall.] portion moves outwards (paradoxical
a. A sucking pneumothorax is accompanied by respi-ratory movements). This results in
hyper-expansion of chest wall on normal reduced ventilation of lungs.
side. This causes mediastinal flutter, a slight 4. The respirators
shift of mediastinal contents towards normal Negative pressure devices of iron lung or
side during inspiration and injured side respiratory lower the extra thoracic and
during expiration. intra-pulmonary pressure below the
b. A tension penumothorax is created when atmospheric pressure thereby simulating
due to nature of wound air is sucked in natural negative pressure breathing.
Positive pressure devices elevate the
during each thoracic expansion, without
atmospheric pressure above normal, so
expelling out the air. The resultant
that air is forced inside the lung.
pneumothorax pushes mediastinal
contents significantly towards the normal The Blood Vessels of the Thoracic Wall
side, thereby interfering with vital
The Arteries
capacity of normal lungs.
2. Pleural effusion: Fluid may collect in the a. The internal thoracic artery supplies anterior
pleural cavity due to part of the thoracic wall (Fig. 21.5)
a. Inflammation of pleura (pleurisy with OriginThe internal thoracic artery arises
effusion) from inferior surface of first part of sub-
b. Secondary to congestive heart failure, as a clavian artery.
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 (inter-
costal 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 Fig. 21.5: The internal thoracic artery
202 Essentials of Human Anatomy
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
media-stinum
iii. The pericardial branches supply the
fibrous pericardium.
iv. The sternal branches supply the sternum
v. The paired anterior intercostal bran-
chessuperior 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 inter-
costal 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 inter-
costal 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 inter-
costal arteries are branches of superior
 The Musculature of the Thoracic Wall
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 anasto-
moses 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
203
meninges and also give radicular
branch of spinal cord.
ii. The collateral branch supplies the
inter-costal muscles
iii. The small muscular branches are also
given
iv. The lateral cutaneous branch accom-
panies the lateral cutaneous nerve. In
females, the lateral cutaneous branch
in second, third and fourth spaces
supply mammary gland.
v. The right bronchial artery arises from
the first right aortic intercostal artery.
The Veins
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 brachio-
cephalic vein.
The internal thoracic veins receive tribu-
taries 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 corres-
ponding arteries, lying in the neuro-
vascular 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, accom-
panying posterior intercostal artery (Fig.
21.7).
204 Essentials of Human Anatomy
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 neuro-
vascular plane of the thoracic wall.
They drain venous blood from most part
of intercostal space and receives
The Typical intercostal Nerve (Fig. 21.8)
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
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 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 inter-
costo-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.
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,
 The Musculature of the Thoracic Wall
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 corres-
ponding 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 two
collateral and smaller muscular branches
a. The collateral branch is given near the
angle of the rib, and runs along the upper
205
border of rib below. It may rejoin the
parent stem.
b. Small muscular branches supply the
three layers of intercostal muscles,
sub-costalis 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.

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.
Fig. 22.1: Anterior and inferior lines of pleural reflections
CHAPTER 22
The Pleura and
Lungs
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 surface
where 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.
 The Pleura and Lungs 207

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.
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 Essentials of Human Anatomy
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 lubri-
cates the opposing surfaces.
The pleural fluid provides great surface
tension between parietal and visceral layers of
pleura and keeps the lungs inflated.
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 struc-
tures.
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 per-
cussion 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 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.
 The Pleura and Lungs
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
Fig. 22.3: Mediastinal surface of right lung
209
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
 210 Essentials of Human Anatomy

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

Fig. 22.4: Mediastinal surface of left lung

 The Pleura and Lungs 211
The lingula of left lung lies below cardiac notch 8. Anterior basal
and corresponds to the middle lobe of right lung. 9. Lateral basal
10. Posterior basal
The Broncho-Pulmonary Segments The broncho-pulmonary segments of the left
The bronchopulmonary segments are functional lung are (Fig. 22.7):
or respiratory units of the lung (Fig. 22.5). Upper lobe has five segments.
They are conical in shape with their bases on 1. Apical
the surface of lung and their apices at the hilum. 2. Posterior
They are separated by connective tissue septa. 3. Anterior
Each broncho-pulmonary segment has: 4. Superior lingular
A segmental (tertiary) bronchus. 5. Inferior lungular
A segmental branch of pulmonary artery. Lower lobe has five segments
Intersegmental veins, that lie in the 6. Superior basal
connective tissue septa. These act as 7. Medial basal
guides for separating the segments during 8. Anterior basal
surgical resection. 9. Lateral basal
There are ten broncho-pulmonary segments in 10. Posterior basal
each lung. In left lung, the apical and posterior segments
The broncho-pulmonary segments of the right may be common forming apico-posterior
lung are (Fig. 22.6): segment.
Upper lobe has three segments: Similarly, the medial basal segment and
1. Apical anterior basal segment of the left lung may
2. Posterior form a common medial-anterior segment.
3. Anterior Thus the left lung may have eight or nine
Middle lobe has two segments bronchopulmonary segments instead of ten
4. Lateral segments.
5. Medial
Lower lobe has five segments The Blood Vessels of the Lungs
6. Superior basal
7. Medial basal A. The pulmonary vessels
a. The pulmonary artery, carries
deoxygenated blood from the heart to the
lung for oxy-genation.
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 oxy-
genated blood from the lung to the left
atrium of heart. Inside the lung the pulmo-
nary veins, lie in between the broncho-
Fig. 22.5: A single broncho-pulmonary pulmonary segments (intersegmental) along
segment (diagrammatic) the connective tissue septa.
212 Essentials of Human Anatomy

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 bro-
ncho-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
 The Pleura and Lungs
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 T2 to T5 ganglia of the
sympathetic chain.
The sympathetic fibers join the two
pulmo-nary 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 secreto-
motor 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.
Applied Anatomy
I. Surgical resection of broncho-pulmonary seg-
ments 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 lobec-tomy is preferred.
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 know-
ledge 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.
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 Essentials of Human Anatomy
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 tracheo-
Esophageal 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.
 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
Fig. 23.1: The fibrous pericardium
and is pierced by:
Superior vena cava.
Pulmonary trunk. the pericardium to the body of ster-
Ascending aorta. num.
The base lies below and is fused with Body of sternum and second to
the central tendon of diaphragm (Both sixth costal cartilages with
structures are developed from same intercostal spaces of both sides.
embryonic structure: Septum trans- Posteriorly
versum Descending thoracic aorta.
Relations Other contents of posterior media-
Antriorly stinum separating it from bodies of
Anterior margins of both pleurae fifth to eighth thoracic vertebrae.
(with cardiac notch on left side) b. The serous pericardium is a closed serous
Anterior margin of both lungs sac into which heart invaginates from
(with cardiac notch in anterior above and behind during development.
margin of left lung). It consists of two layersparietal and
Two sterno-pericardiac ligaments: visceralenclosing a potential peri-
superior and inferiorthat connect cardial cavity.
216 Essentials of Human Anatomy
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 peri-
cardium.
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 pul-
monary 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 peri-
cardium.
I. The transverse sinus: is a transverse
passage behind the tubular sheath
enclosing the ascending aorta and
pulmonary trunk.
Fig. 23.2: The sinuses of pericardium
It is related behind to the two
atria: right and left of the heart.
During cardiac surgery, a tempo-
rary ligature or clamp is passed
through it to occlude the two
great vessels.
II. The oblique sinus is in form of a cul-
de-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 pul-
monary veins
The oblique sinus opens downwards
and towards the left.
Inpericardial 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
 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 (epicar-
dium) 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 peri-
cardium 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 proce-
dure.
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 inflam-
mation of the parietal layer of serous peri-
cardium.
The pain of pericarditis is referred to the
epigastrium usually.
A pericardial friction sound is heard on
auscultation.
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)
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 Essentials of Human Anatomy
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
two-third by left ventricle.
IV. The left (pulmonary) surface is formed
mainly by the left ventricle.
Fig. 23.4: The heartposterior inferior surface
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
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
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 pulmo-
nary surface.
 The Pericardium and the Heart
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-sterno-
costal 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 coro-
nary 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 Essentials of Human Anatomy

v. Posterior inter-ventricular branch gives a The Venous Drainage of the Heart

branch to atrio-ventricular node and (Fig. 23.6)
anastomoses with anterior inter-
The venous blood from the myocardium and
ventricular branch of left coronary artery,
epicardium is drained by three systems of veins
near the apex of heart. It also supplied
coronary sinus and its tributaries, anterior cardiac
posterior third of interventricular septum.
veins and the minute cardiac veins.
The left coronary artery gives
I. The coronary sinus drains most of the venous
i. Small branches to the roots of ascending
blood from the heart.
aorta and pulmonary trunk.
It is a short, wide venous channel, about 2-5
ii. A large anterior inter-ventricular branch,
cm long.
that supplies both ventricles and larger
part of inter-ventricular septum. Course: The coronary sinus lies in posterior
iii. A left marginal branch that runs along the left part of coronary sulcus from left to the right
border of heart and supplies left ventricle. side, superficial to the terminal parts of left
iv. Posterior ventricular branches supply the and right coronary arteries.
left ventricle. Its left end is continuous with the great
v. Small branches to supply the left atrium. cardiac vein. Its right end opens in the
right atrium of heart between the openings
Variations of the Coronary Arteries of inferior vena cava and right atrio-
ventricular opening.
A. Balanced coronary circulation: is when the Tributaries
coronary circulation is shared by the two a. The great cardiac vein lies in the anterior
coronary arteries. It is seen in 60-65 percent inter-ventricular groove with anterior
of the population. inter-ventricular artery.
B. Left dominant coronary circulation: when the It drains venous blood from anterior
posterior interventricular branch arises from aspects of both ventricles and anterior
the left coronary artery.
part of interventricular septum.
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 Fig. 23.6: The coronary sinus and its tributaries
coronary arteries. Posterior-inferior surface
 The Pericardium and the Heart
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 post-
ganglionic 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 T2 to T5 ganglia
of sympathetic chains.
The sympathetic are cardiac accelerator
nerves.
The afferent fibers from heart run along
sympa-thetic 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 Essentials of Human Anatomy

II. The deep cardiac plexus is located behind septum medial to the opening of coronary
the arch of aorta, in front of tracheal bifur- sinus and above the septal cusp of
cation. tricuspid valve.
It is formed by: It gives rise to atrioventricular bundle
Cardiac branches of superior, (bundle of His).
middle and inferior cervical III. The atrio-ventricular bundle crosses the
ganglia of both sympathetic chains annulus fibrosus and descends along
(except the branch of superior posterior margin of membranous part of
cervical ganglion of left side). inter-ventricular septum to enter muscular
Cardiac branches of T2 to T5 part of septum.
ganglia of both sympathetic trunks. It divides into two branches: right
Superior, inferior and recurrent ventricular branch and left ventricular
cardiac branches of both vagi (ex- branch.
cept the inferior cardiac branch of The two branches descend along the
left vagus). interventricular septum and spread out
The two cardiac plexuses contain in the walls of ventricles along cardiac
contributions of both sympathetic and muscle fibers, carrying the cardiac
parasympathetic. The plexuses give branches to: impulse.
Both coronary plexuses that accompany the
right and left coronary arteries. Applied Anatomy
Pulmonary plexuses. If an infarct or any other vascular lesion
The conducting system of the heart (neuro- interferes with the impulse propagation in atrio-
myocardium). The neuro-myocardium consists of ventricular bundle, it causes heart block, resulting
specialized cardiac muscle fiberscalled Purkinje in asymmetrical beating of atria and ventricles.
fibers, enclosed in a sheath of connective tissue. An artificial pacemaker is implanted for
This system has developed a high degree of correcting the cardiac rhythm in cases of heart
sensitivity and autorhythmicity. block.
The neuro-myocardium ensures proper
spread of cardiac impulse to all chambers of The Interior of the Chambers
heart and regulates their contraction in a of the Heart
proper sequence. 1. The right atrium: is the venous receiving
The conducting system consists of: chamber of the heart (Fig. 23.7).
I. The sinu-atrial node (SA Node or Pace- It has the thinnest walls of all the four chambers.
maker), that initiates the cardiac impulse The crista terminalis: A thick muscular ridge
(about 72 per minute) that spreads to both separates the cavity of right atrium into two
atria and atrio-ventricular node. parts.
It is about 7 mm 2 mm 1 mm in size. An anterior part: atrium proper
A posterior part: sinus venarum.
It is situated in myocardium between the I. The atrium proper: has the crista terminalis,
opening of superior vena cava and that extends from the opening of superior vena
crista terminalis. cava to the opening of inferior vena cava.
II. The atrio-ventricular node (AV node) is This ridge runs along the right border of the
situated in right atrium, near interatrial heart.
 The Pericardium and the Heart
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-ven-
tricular 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.
223
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 pulmo-
nary circulation.
 224 Essentials of Human Anatomy
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
coni-cal in shape, with base
attached to the muscular wall.
From the apices of papillary muscles,
fibrous cord-like structureschor-
dae tendinaepass to the free mar-
gin 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.
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 cusps
anterior, 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 atta-
ched alternately to the three
cusps.
The papillary muscles contract
during ventricular systole and
firmly oppose the cusps of tri-
cuspid 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.
 The Pericardium and the Heart
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 connec-
tive tissue in between.
The free edges of the cusps are
directed upwards towards pulmo-
nary 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 pulmo-
nary 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 inter-
ventricular 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 atrio-
ventricular 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 Essentials of Human Anatomy

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 surroun-
ding 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 ano-
malous 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 atrio-
ventricular 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
 The Pericardium and the Heart
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. asso-
ciated 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 THE SUPERIOR MEDIASTINUM
that separates the two halves of thoracic cavity.
The superior mediastinum is the part of media-
The mediastinum is a complete partition stinum that lies between the plane of inlet of thorax
extending from:
and the imaginary plane (Figs 24.2 and 24.3).
Sternum in front to
Boundaries
Bodies of thoracic vertebrae behind.
Anterior: Posterior surface of manubrium
The mediastinum is divided by an imaginary
sterni
plane passing from sternal angle anteriorly to
Posterior: Bodies of upper four thoracic
the lower border of fourth thoracic vertebra
posteriorly into (Fig. 24.1). vertebrae and intervrtebral discs
i. Superior mediastinum Two sides: Right and left mediastinal pleura
ii. Inferior mediastinum, which is further. Contents
Subdivided into Oesophagus
a. Anterior mediastinum Trachea
b. Middle mediastinum Superior vena cava and two brachiocephalic
c. Posterior mediastinum. veinsright and left.

Fig. 24.1: The subdivisions of mediastinum

 The Mediastinum 229

Fig. 24.2: TS through superior mediastinum (level-third thoracic vertebra)

Arch of aorta and its three branches The Superior Vena Cava
brachio-cephalic, left common carotid and
The superior vena cava is great venous trunk
left subclavian.
draining venous blood from all parts of body
Nerves Two vagus nervesleft and right
above diaphragm except heart.
Left recurrent laryngeal nerve
Two phrenic nervesleft and right Formation: The superior vena cava is formed

Cardiac branches of vagus and sym- by the union of right, and left brachio-
pathetic chain. cephalic veins at the lower border of first

Thoracic duct right costal cartilage.

Cardiac plexuses Superficial and deep Course: The upper half of superior vena cava
Lymph nodes lies in superior mediastinum, to the right side
Thymus gland in children of arch of aorta.

Fig. 24.3: TS through superior mediastinum (level-fourth thoracic vertebra)

230 Essentials of Human Anatomy
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 bra-
chiocephalic 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 curva-
tures.
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
Left recurrent laryngeal nerve
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
Left recurrent laryngeal nerve
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.
 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 brachio-
cephalic 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
tracheo-oesophageal 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 media-
stinum 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-oeso-
phageal 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 Essentials of Human Anatomy
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, brachio-
cephalic veins, arch of aorta and fibrous
pericardium.
Functional importance
i. Thymus is the mother colony for T-lympho-
cytes, 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 sepa-
rating 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 accom-
panying 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
 The Mediastinum 233

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.
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 peri-
cardium.

The Esophagus
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 (verte-
bral 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
Fig. 24.4: The descending thoracic deviates towards the left side still lying
aorta and thoracic duct behind the trachea
234 Essentials of Human Anatomy
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 con-
striction 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)
Fig. 24.5: The curvatures of esophagus
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. 24.6: The esophagusrelations
 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
physio-logical stimulation.
Applied anatomy
a. The esophageal varices consist of enlarge-
ment of veins in submucous coat, at
junction of systemic esophageal tributaries
of hemiazygos and azygos veins and eso-
phageal tributaries of left gastric vein, in
cases of portal hypertension. The eso-
phageal varices may rupture and cause
bleeding in stomach (hematemesis).
b. The esophagitis occurs mostly due to
reflux of gastric contents in lower end of
eso-phagus
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 eso-
phagus.
Thoracic duct ascends in superior media-
stinum 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 Essentials of Human Anatomy
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 lympha-
tics 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
dia-phragm 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.
 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
Multiple Choice Questions
Q.1. Select the one best response to each
question from the four suggested ans-
wers:
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
4. The sternocostalis muscle:
A. Is attached to posterior surface of
manu-brium sterni
B. Is attached to posterior surface of xi-
phoid cartilage only
C. Is attached to lower ribs
D. Is attached to lower third of posterior
surface of body sternum.
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.
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
9. The myocardial infarction limited to the
interverticular septum is likely to produce:
A. Disturbance in cardiac impulse con-
duction
B. Mitral valve incompetence
C. Tricuspid valve incompetence
D. Aortic valve insufficiency
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.
 Multiple Choice Questions
Q.2. The questions below contain four sugges-
ted answers of which one or more or
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
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 pulmo-
nary 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 Essentials of Human Anatomy

3. Right pulmonary C. Left atrium 24. Levels of structures:

veins 1. Bifurcation of A. Opposite fourth
4. Aortic vestibule D. Right atrium trachea left costal cartilage
2. Suprasternal B. Lower border of
22. Embryonic structures: notch fourth thoracic
1. Left horn of A. Oblique vein of vertebra
sinus venoses left atrium 3. Mitral opening C. Lower border
2. Left common B. Ducts arteriosus of heart second thoracic
cardinal vein vertebra
3. Ligamentum C. Infundibulum of 4. Apex beat of heat D. Left fifth inter-
arteriosum right ventricle costal space. 9.0
4. Bulbus cordis D. Coronary sinus cm from median
plane
23. Termination of veins:
25. Location of structures
1. Right internal A. Right brachio-
1. Crista terminalis A. Aortic opening of
thoracic vein cephalic vein
diaphragm
2. Hemiazygos vein B. Azygos vein 2. Thoracic duct B. Lest crus of dia-
3. Left bronchial C. Coronary sinus phragm
vein 3. Sphanchnic C. Right atrium
4. Great cardiac D. Accessory nerves
vein hemiazygos 4. Oblique sinus D. Serous pericar-
vein dium

Answers

A1. The answer is A. important clinically, as it may compress lower

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.
A2. The answer is C.
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.
A3. The answer is B.
The cervical rib is an anomalous rib, some-
times present, as an enlargement of costal
element of seventh cervical vertebra. It is
trunk of brachial plexus producing pain.
A4. The answer is D.
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.
A5. The answer is C.
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.
 Multiple Choice Questions
A6. The answer is D.
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
inspi-ration, the lung partly descends in the
costo-diaphragmatic recess.
A7. The answer is A.
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 ventri-cle. The pulmonary trunk and
pulmonary artery carry the blood clot from
the right ventricle to one of the lungs.
A8. The answer is C.
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.
A9. The answer is A.
The myocardial infarction limited to inter-
ventricular septum produces disturbances in
cardiac impulse conduction, because the
right and left ventricular branches of atrio-
ventricular bundle (bundle of His) lie on
two sides of interventricular septum. The
valvular incompetence results from the
disease of the valves.
A10. The answer is A.
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.
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.
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.
A13. The answer is A, (1, 2, 3)
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.
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.
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 sterno-
pericardiac ligamentssuperior and inferior.
242 Essentials of Human Anatomy
The phrenic nerves lie on the lateral aspect
of mediastinum. The superior vena cava lies
partly in middle mediastinum and partly in
superior mediastinum.
A17. The answer is A, (1, 2, 3)
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.
A18. The answer is B, (1, 3)
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.
A19. The answer is A, (1, 2, 3)
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.
A20. The answer is C, (2, 4)
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 media-
stinum 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.
 The Abdomen
Five
CHAPTER 25
The Anterior Abdominal
Wall and the Inguinal Region
THE BONES AND JOINTS OF v. The laminae are short, thick, and broad
ABDOMINAL WALL vi. The spinous process forms a quadrilateral plate
and is directed almost directly backwards
The bones at the back of abdominal wall are
vii. The superior articular process bears a
the five lumbar vertebrae and the inter-
concave facet facing medially and backwards.
vertebral discs between them.
viii. The inferior articular process bears convex
The upper parts of two hip bones with their
facet that faces laterally and forwards
iliac crests lie in lower part of abdominal
ix. The posterior border of superior articular
wall. The iliac fossa of hip bones also lie
process is marked by a rough elevation
below. [Detail description of hip bones is
mamillary process.
given in Chapter 16].
Fifth lumbar vertebra - has some atypical fea-
THE LUMBAR VERTEBRAE tures
The transverse process is thick, short and
There are five lumbar vertebrae. These vertebrae
pyramidal in shape. The process appears
are quite large and become progressively larger
turned upwards. Their base is attached to
towards sacrum.
whole thick-ness of pedicle.
The characteristics of typical lumbar
The spine is small and rounded at the tip.
vertebrae [upper four] are:
The body is largest of all lumbar vertebrae. Its
i. The body of vertebra is wider transversely
anterior surface is much wider than posterior
and the vertebral canal is triangular
surface.
ii. The pedicles are very short
The superior articular facet looks more
iii. The transverse processes are thin and have
no costal facets or foramen transversarium. backwards and inferior articular facet looks
These are homologous with ribs of thoracic more forwards.
region
Variations of Lumbar Vertebrae
iv. A small acessory process lies at the root of
transverse process. This represents true The fifth lumbar vertebra may be fused with
transverse process sacrum. The condition is known as sacralization
244 Essentials of Human Anatomy
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 pro-
cesses
Two centers for the two mammillary pro-
cesses
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 antero-
lateral 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
tuber-cle 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 infra-
umbilical 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.
 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 fundi-
form ligament of penis (in
males more developed).
The Scarpas fascia is conti-
nuous 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 mem-
branous 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
ligamentPectineal line of pubic
bone
Forms anterior wall of
femoralsheath.
It also givesInternal spermatic
fasciaaround 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 Essentials of Human Anatomy
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
2. Internal Lateral two-third of
oblique upper surface of
(Fig. 25.2) inguinal ligament
Anterior two-third inter-
mediate ridge of ventral
segment of iliac crest
Thoraco-lumbar fascia
3. Transversus Costal origin inner
abdominis surface lower six
(Fig. 25.3) 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
Muscle belly 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 atta-
Posterior fibers des- ched to linea alba from
cend more or less xiphisternum to the
vertically upper end pubic sym-
Muscle 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 liga-
ment 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 medi- lower borders of lower (T7 -T12)
ally except lowest three or four ribs Iliohypogastric ilio-
fibers that pass Aponeurosis is attached to inguinal (L1)
downwards forward linea alba from xiphister-
medially 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 con-
joint tendon
Flat muscle belly By aponeurosis on linea Ventral rami lower
Fibers pass almost alba between Xiphisternum six thoracic nerves
horizontally to- and 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 low-
Muscle 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 rein-
forces the defect caused
by superficial inguinal ring
on lower part of anterior
abdominal wall
Contd...
 The Anterior Abdominal Wall and the Inguinal Region
Contd...
Name Origin
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 Front of body of pubis
(inconstant and anterior ligament
muscle) of pubic symphysis
247
Muscle belly Insertion Nerve supply
Muscle belly long strap By three inequal slips Ventral rami lower
like. It is thick and attached to fifth, sixth, six thoracic spinal
narrow below, flat and and seventh costal carti- nerves (T7 -T12)
wider above lages
Three tendinous inter-
sections divide the
belly and shorten the
muscle fibers
one at costal margin
one at umbilicus
one in between
Small triangular muscle, Linea alba midway bet- Ventral ramus of
lies in front of lower ween umbilicus and pubic twelfth thoracic
part of rectus abdominis symphysis nerve

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
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 Essentials of Human Anatomy

Fig. 25.2: The internal oblique muscle

below the arcuate line (linea semicircularis) a. Above the costal margin (Fig. 25.4)
that marks the lower limit of posterior wall. Anterior: wall is formed by
External oblique aponeurosis
The anterior wall is complete all over. The
Posterior: wall is absent and the
formation of rectus sheath can be studied rectus abdominis rests on costal
at following three levels: cartilages

Fig. 25.3: The transversus abdominis muscle

 The Anterior Abdominal Wall and the Inguinal Region 249

Fig. 25.4: The rectus sheath (TS above costal margin)

b. Between the costal margin and mid-way Transversus abdominis apone-

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.
urosis.
c. Below the midpoint (or arcuate line) (Fig.
25.6)
Anterior wall is formed by
External oblique aponeurosis
Internal oblique aponeurosis
Transversus abdominis apone-
urosis
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 Essentials of Human Anatomy
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.
The Blood Vessels of the Anterior
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 obtu-
rator artery.
ii. The cremasteric branch in males accom-
panies 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 anterior cutaneous nerves.
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
The superficial 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.
 The Anterior Abdominal Wall and the Inguinal Region
In case of portal obstruction this venous anasto-
mosis 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.
The Lymphatic Drainage of the
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 aponeu-rosis.
They pass forwards through lateral half of
rectus abdominis and anterior wall of rectus
sheath, and come out in superficial fascia as
anterior cutaneous nerves.
Branches
i. The muscular branches are given to
supply anterolateral and anterior
abdominal mus-cles.
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 sub-costal
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 Essentials of Human Anatomy
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 proce-
dure).
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 (exom-
phalos) is caused due to failure of
reduction of physiological umbilical
hernia of fetal life.
A child is born with a loop of intes-
tine in the umbilical cord.
The condition may show spon-
taneous regression.
b. The infantile umbilical hernia is seen
in infants up to three years of age.
It is caused by stretching of umbi-
lical 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 (para-
umbilical 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 uri-
nary bladder. The umbilical vein is represented
by the ligamentum teres of liver, while urachus
gives rise to median umbilical ligament connec-
ting 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.
 The Anterior Abdominal Wall and the Inguinal Region
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 liga-
ment.
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
i. Location
ii. Layer
iii. Shape and size
iv. Structures transmitted
v. Covering given to sper-
matic cord from margins
Fig. 25.8: A section through inguinal region showing walls of inguinal canal
Essentials of Human Anatomy
Table 25.2: The deep and superficial inguinal rings
Superficial inguinal ring
Above the pubic crest
Aponeurosis of external oblique muscle
Triangular with apex pointing laterally
Two sides formed by two thickenings
(the crurae)
Some intercrural fibers in aponeurosis
prevent separation of crura
In 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
Deep inguinal ring
1.2 cm above mid-inguinal point
Fascia transversalis
Oval with long axis vertical
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
 The Anterior Abdominal Wall and the Inguinal Region
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 hernias
oblique (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 rea-
ches 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
External oblique aponeurosis
Superficial fasciatwo layers
Skin
The direct hernia bulges through post-
erior 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 Essentials of Human Anatomy
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).
Fig. 25.9: The descent of testis
The factors causing descent of testes are:
i. Hormonal factors gonadotropins and andro-
gens.
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 progressi-
vely and pulls down the testes, along
with a tube of peritoneumthe pro-
cessus vaginalis.
Sequence of Descent of Testes
a. By third month of intra-uterine life, the testis
comes to lie in the iliac fossa.
 The Anterior Abdominal Wall and the Inguinal Region 257

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 Fig. 25.10: The ectopic testisaccessory
congnital oblique inguinal hernia. tails of gubenaculum testis

Applied Anatomy of Descent of Tests In the perineum.

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
deve-loped.
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):
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 ute-rus).
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 Essentials of Human Anatomy
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.

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 excre-
tory 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
CHAPTER 26
The Peritoneum
The plane passes through
i. The tips of ninth costal cartilages
ii. Pylorus of stomach
iii. The hila of both kidneys
iv. 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 Essentials of Human Anatomy
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 foldsmesen-
teriesto connect the viscera to the body
wall.
The visceral layer develops from the
splanchnopleure part of secondary meso-
derm.
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 dia-
phragm
c. The falciform ligament is a large, sickle-
shaped 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 sto-
mach.
 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 arteryante-
riorly to the left
The bile ductanteriorly to
the right
The portal veinposteriorly
The free border of lesser omen-
tum 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
connec-ting the highest part of
greater curvature to the diaphragm.
ii. The gastro-splenic ligament
connec-ting 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
with the parietal peritoneum,
except a small portion connected to
first part of duodenum.
The meso-duodenum contains deve-
loping pancreas, that also becomes
retroperitoneal in adults.
c. 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.
d. The ascending mesocolon is also
present in fetal life only.
The ascending mesocolon becomes
fused with parietal peritoneum,
making ascending colon a retro-
peritoneal organ.
e. The transverse mesocolon connects
the transverse colon to the posterior
abdominal wall, almost transversely
across the abdominal cavity.
f. 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.
g. The pelvic mesocolon suspends the pelvic
colon (sigmoid colon) from the inlet of
pelvis and posterior wall to pelvis.
It has inverted V-shaped attach-
ment, 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 Essentials of Human Anatomy
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 patho-
logical 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).
Fig. 26.2: A vertical section of abdomen showing lesser sac (omental bursa)
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 omen-
tum.
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.
 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
inthe 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 Win-
slow) 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 hepato-
renal 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
(subdia-phragmatic) 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 Essentials of Human Anatomy

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 B. The infracolic compartment of greater sac 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.
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 connec-
ting the left colic flexure to the dia-
phragm.
 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 duo-
denum.
v. The mesocolic recess present in about
20% cases.
It lies between the transverse meso-
colon 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 Essentials of Human Anatomy
ii. The inferior ileocecal recess is guarded
by a bloodless fold (of Treeves)
It is also limited behind by the mes-
entery.
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 V-
shaped 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 meso-
derm.
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.
The Lymphatic Drainage of the
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.
 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 stomo-
deum 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 dia-
phragm
2. A caudal part that lies below dia-
phragm
b. The midgut extends from the opening
of bile duct up to junction of right two-
third 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
intra-uterine 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 mesoduo-
denum also becomes retroperitoneal.
The duodenum in second month of intrauterine
life passes through a solid state and later
268 Essentials of Human Anatomy

Fig. 26.7: The first stage of rotation of midgut

canalises. This condition may result in place between tenth and eleventh weeks of intra-
narrow-ing of lumen of duodenum. uterine life (Fig. 26.8).
The abdominal cavity grows larger in size, so
The Rotation of the Midgut the physiological hernia is reduced.
The midgut portion undergoes rotation in three The cranial (right) limb reduces first and
stages. passes behind the superior mesenteric artery
i. The first stage (stage of physiological to come to lie in the left upper quadrant. This
umbilical hernia): This stage takes place between explains the position of jejunum in left upper
fifth and tenth weeks of intrauterine life (Fig. 26.7). part of abdomen, and the superior mesenteric
The midgut grows rapidly and forms a U-loop artery passing in front of duodenum.
that herniates through umbilicus into the extra-
embryonic 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 Fig. 26.8: The second stage of rotation of midgut
 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 anti-
clockwise 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 retroperi-
tonization 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 meso-
colon.
Fig. 26.9: The third stage of rotation of midgut
269
The transverse attachment of transverse
meso-colon 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 abdo-
minal 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,
resul-ting 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
intes-tine in the umbilical cord covered by
a layer of peritoneum and amnion.
It is a rare condition, but it should be
recog-nized before ligating the umbilical
cord after birth.
5. The Meckels diverticulum is the persistent
remnant of proximal part of vitello-intestinal
duct.
270 Essentials of Human Anatomy

Fig. 26.10: The anomalies of Meckels diverticulum

The Meckels diverticulum is seen in b. There may be a patent Meckels diverticulum

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 stran-gulation.
forming a fecal fistula at umbilicus.
c. The vitelline vessels may persist at their attach-
ment 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.

The Gastrointestinal
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 cur-
vature 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 abdo-
minal 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 tribu-
taries 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.
CHAPTER 27
System1
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
porto-systemic 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 Essentials of Human Anatomy
THE STOMACH (GASTER)
The stomach is the most dilatable part of the
gastrointestinal tract.
LocationThe stomach lies in the left hypo-
chondrium 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 (trans-
pyloric 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 pri-
mitive 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 dia-
phragm.
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.
 The Gastrointestinal System1 273

Fig. 27.1: The stomach shape and parts

(The gastric surface of spleen is i. The cardiac part is further divided into:
separated from the postero superior a. The fundus is convex bulging part that
surface of stomach by the greater lies above the level of cardiac opening.
sac of peritoneum. b. The body is the remaining portion of the
The stomach is divided into two partsthe cardiac part.
cardiac part and pyloric part (Fig. 27.2). ii. The pyloric part is the narrow tubular
portion and is further divided into:
An imaginary plane passing from the angular
a. The pyloric antruma slightly dilated
notch of lesser curvature is joined to the left
part below the angular notch.
end of the bulge on greater curvature to divide
b. The pyloric canalabout 3.0 cm long,
the stomach. 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 mem-
brane 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
Fig. 27.2: The stomachbed enclosing a canal.
274 Essentials of Human Anatomy
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.
Fig. 27.3: The arterial supply of stomach
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.
 The Gastrointestinal System1
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
sto-mach.
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 for-
mation of peptic ulcer.
2. The peptic ulcer usually occurs at the non-
acid secreting parts of the stomach and
duodenum.
275
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 sto-
mach.
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 Essentials of Human Anatomy

Fig. 27.5: The duodenum (position and parts)

The duodenum ends at duodeno-jejunal It is related posteriorly to

junction (D-J junction) located on left side Bileduct
of second lumbar vertebra. Gastro-duodenal artery
PartsThe duodenum is divided into four parts: Portal vein
a. The first part (Superior part) is only 5.0 b. The second part (Descending part) is 7.5
cm long (Fig. 27.6). cm long and is retro-peritoneal.
i. The proximal 2.5 cm acts as a mooring
It is related
rope for the pyloric part of stomach.
Anteriorly to
It has lesser omentum attached to its
Right lobe of liver
upper border and anterior two
layers of greater omentum attached Beginning of tranverse colon (no
to its lower border. peritoneum)
ii. The distal 2.5 cm is retro-peritoneal. Coils of jejunum
It is related anteriorly to neck of gall Posteriorly to
bladder and quaderate lobe of liver. Medial border of right kidney

Fig. 27.6: The duodenum (first part)

 The Gastrointestinal System1
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
mesen-teric 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.
Fig. 27.7: The duodenumrelations
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
trans-verse 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).
278 Essentials of Human Anatomy

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 sub-
pyloric 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

 The Gastrointestinal System1
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 sur-
facesanterior, 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.
Fig. 27.10: The liveranterior surface
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 im-
pression.
It is covered by peritoneum except a
small triangular area where the two
layers of falciform ligament diverge.
v. The inferior (visceral) surface faces
down-wards and backwards. It is covered
by peritoneum except at porta hepatis, gall
280 Essentials of Human Anatomy

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

 The Gastrointestinal System1
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 post-
erior part of inferior surface. It trans-
mits.
Two hepatic ducts right and left
anteriorly
Two branches of hepatic artery in
the middle
Two branches of portal vein post-
eriorly
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
ligamen-tum 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 sur-
faces.
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 Essentials of Human Anatomy
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 dia-
phragm 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.
 The Gastrointestinal System1
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 sur-
face.
Superiorly the body and neck lie in direct
relation to liver surface in gall bladder
fossa.
From the right border of neck, a pendu-
lous 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 Hei-
ster. 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 arterysupplying 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 Essentials of Human Anatomy
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 hepato-pancreatic
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 duo-denum.
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
derma-tome.
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).
 The Gastrointestinal System1 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
Fig. 27.15: The parts of the pancreas forms a part of stomach bed (i.e.
related to posterior-inferior surface
of sto-mach).
i. The head is located within the curvature of b. The inferior surface covered by
duodenum. peritoneum of lower layer of trans-
From its lower left portion, a hook-like verse mesocolon and is related to
uncinate process projects behind Duodeno-jejunal flexure
superior mesenteric vessels. Coils of jejunum
a. Anterior surface in upper part is Left colic flexure
related to transverse colon, the lower c. The posterior surface is devoid of
part is covered with peritoneum and peritoneum and is related to the
related to coils of jejunum. structures in upper part of posterior
The uncinate process is related abdominal wall:
anteriorly to superior Aorta and origin of superior
mesenteric vessels. mesenteric artery
b. Posterior surface is related to Left crus of diaphragm
Inferior vena cava Part of left kidney and left

Right renal vessels supra-renal

Right crus of diaphragm Left renal vessels

Splenic vein (lies closely
Bile duct (lies in a groove on
attached to the posterior surface)
posterior surface)
The anterior border of the body of pancreas
Abdominal aorta (behind
gives attachment ot transverse mesocolon.
uncinate process)
iv. The tall is the narrow end of the body that
ii. The neck is about 2.0 cm long
lies between the two layers of lieno-renal
On right side is groove for gastro-
ligament along with splenic vessels.
duodenal artery. The tail of pancreas reaches the lateral
On left side and behind is beginning of end of hilum of spleen.
portal vein by union of superior mes- The tail contains maximum concen-
enteric and splenic veins. tration of islets of Langerhans.
Its anterior surface is related to omental In operation of splenectomy care is
bursa separating it from first part of taken to preserve the tail of pancreas
duodenum. while ligating the splenic vessels.
286 Essentials of Human Anatomy
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
vaso-motor.
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 con-
dition.
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 hyper-
tension and the resultant compli-
cation 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
duo-denum.
iv. Ectopic pancreatic tissue may be
found in gall bladder and Meckels
diverti-culum.
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
 The Gastrointestinal System1
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 post-
erior.
i. The anterior (Lateral) end is expanded and
related to left colic flexure and phrenico-
colic 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 diaphrag-
matic surface from the gastric impression.
Fig. 27.18: The Spleenvisceral surface
 288 Essentials of Human Anatomy
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 com-
pletely 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
sto-mach.
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 mes-
enteric 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
reser-voir 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 in-
creased 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 lym-phoid organs.
 CHAPTER 28
The Gastrointestinal
System2
THE JEJUNUM AND THE ILEUM flexure on the left to the ileocecal junction
on the right. The root contains superior
The jejunum and ileum constitute the large part mesenteric vessels between the two layers.
of small intestine extending from duodeno- The root of mesentery crosses the following
jejunal flexure up to junction of cecum and structures on posterior abdominal wall
ascending colon (Fig. 28.1 and Table 28.1) Abdominal aorta
Length about 6 metres (20 feet) Inferior vena cava
The jejunum constitutes proximal two-fifth Right psoas major
part (nearly 8 feet) Right ureter
Right testicular (ovarian) vessels
The ileum constitutes distal three-fifth part
(nearly 12 feet) Table 28.1: Differences between jejunum and ileum
The mesentery The jejunum and ileum are
Jejunum Ileum
completely covered by peritoneum, and are
1. Position in Mostly in upper Mostly in hypo-
suspended by a large peritoneal foldthe
abdominal left portion gastroic region above
mesenteryfrom the posterior abdominal wall. cavity pubic symphysis
The root (attachment) of mesentery is 2. Diameter About 4.0 cm About 3.0 cm
oblique and extends from duodeno-jejunal 3. Walls Thick Thinner
Contd...

Fig. 28.1: The jejunum and ileumblood supply

290 Essentials of Human Anatomy

Contd... About 12-15 jejunal and ileal veins end in

Jejunum Ileum the superior mesenteric vein.
4. Color Deep red due to Pale pink
more vascularity
The Lymphatic Drainage of the
5. Arterial Less, about 1-2 More, about 2-5 Jejunum and Ileum
arcades
6. Vasa recta Longer, about Shorter, about
There are nearly 100-150 lymph nodes in the
2.5 cm long 1.2 cm long mesentery of small intestine.
7. Fat in Less-(windows) More The lymph from the jejunum and ileum is
mesentery drained by three sets of lymph nodes.
8. Circular folds Well developed Incomplete
i. The distal set is present in relation to the
9. Peyers Few Many
patches terminal branches of jejunal and ileal arteries
(Aggregated ii. The intermediate set is located among the
lymphoid jejunal and ileal arteries
follicles)
10.Barium meal Shows feathery Shows dense
iii. The proximal set is present in relation to
X-ray appearance and appearance superior mesenteric vessels.
narrow lumen The mesenteric lymph nodes are enlarged in
several conditions like tuberculosis, typhoid
The Blood Supply of the fever and malignant tumors.
Jejunum and Ileum The lymphatics of jejunum and ileum mainly
The arteries The jejunal and ileal arteries (12- transport the absorbed fat (as chyle) to the
15) are branches of superior mesenteric artery. thoracic duct)
These arteries reach the small intestine
The Nerve Supply of Jejunum and Ileum
between the two layers of mesentery
On approaching small intestine, the jejunal The sympathetic and parasympathetic nerves are
and ileal arteries branch to form arterial derived from the coeliac plexus and the vagus
arcades nerves respectively.
The arterial arcades are one to two in case There are two nerve plexuses in the coats of
of jejunum and three to five in cases of small intestine
ileum. These arcades provide a route of a. The mysenteric plexus is located between
collateral circulation. the circular and longitudinal muscle coats
From the terminal arcades, vasa recta b. The submucous plexus is located in the
(straight arteries) are given, that supply submucous coat
alternately the right and left surfaces of Both plexuses have the nerve fibers and ganglia
the intestine
where the parasympathetic fibers are relayed.
The vasa recta are longer (2.5 cm) in
jejunum and shorter (1.2 cm) in case of Applied Anatomy
ileum
The vasa recta in the walls of intestine are I. The Meckels diverticulum is a blind
end arteries, and they have very few diverticulum from antemesenteric border of
anastomoses with adjacent arteries. ileum about two feet from ileocecal junction.
The veinsThe veins follow the pattern of It is a remnant of vitello intestinal duct
arterial supply (detailed description given in Chapter 26)
 The Gastrointestinal System2 291

II. The small intestine can be resected up to Size: The cecum is about 6.0 cm long and 7.5
one third of its total length without seriously cm broad.
impairing its junction. Shape: Four types of cecum are described by
III. Gastro-jejunostomy is one of the Treeves, so far as the shape is concerned (Fig.
operations done in cases of peptic ulcer. 28.2).
The stomach is anastomosed with jejunum i. The first type (Infantile type) is seen in
bypassing duodenum. about 2 percent cases.
In this type cecum is represented as a
THE LARGE INTESTINE conical sac with appendix attached to
The large intestine begins in right iliac fossa at its tip
ii. The second type (Quadrate type) is seen in
cecum, where terminal ileum ends.
about 3 percent cases.
The parts of the large intestine are
In this type, there are two equal saccu-
The cecum
lationsright and leftand appendix
The vermiform appendix
is attached to the depression between
The colonascending, transverse, descen-
the two saccules
ding and sigmoid (pelvic)
iii. The third type (Normal type) is seen in
The rectum
about 90 percent cases.
The anal canal In this type, the right saccule is larger
The main function of the large intestine (chiefly
and left saccule is smaller. The
colon) is absorption of fluids and solutes
appendix is pushed toward the
The features of the large intestine are ileocecal junction medially.
a. It has greater caliber in most parts than small iv. The fourth type (Exaggerated type) is seen
intestine and it has greater distensibility.
in nearly 4 percent cases.
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
concen-trated 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).

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. Fig. 28.2: The four types of caecum
292 Essentials of Human Anatomy
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
majormuscle.
Femoral nerve and lateral
femoralcutaneous nerve of thigh.
A retro-cecal recess is present fre-
quently 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 meso-
appendix
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 retro-
cecal recess behind cecum (or ascen-
ding colon if it is long enough)
 The Gastrointestinal System2
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
mid-inguinal 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 anasto-
mosis, 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
meso-appendix 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 emer-
gency and requires immediate surgery
The appendicular pain is felt in the right iliac
fossa due to involvement of peritoneum
 294 Essentials of Human Anatomy
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 The left colic flexure is the terminal part of
by areolar tissue to:
The iliac fascia covering iliacus muscle
Iliolumbar ligament
Quadratus lumborum
Aponeurotic origin of transversus
abdo-minis
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 the colon.
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 hypo-
chondriac region, making a U-shaped curve.
The position also depends upon the degree
of distention of transverse colon and sto-
mach
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
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 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.
 The Gastrointestinal System2
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
Aponeurotic origin of transversus
abdo-minis
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 cur-
vature
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 back-
ward, 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 trans-verse 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 Essentials of Human Anatomy
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, des-
cending colon and sigmoid colon (hindgut)
have:
The sympathetic supply from lumbar part of
sympathetic trunks and superior hypo-
gastric 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.
Applied Anatomy
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
Fig. 28.5: The coeliac axis artery
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-abdo-
minal pressure.
This condition may lead to perforation,
bleeding inside colon and peritonitis.
II. The Hirschsprungs disease (congenital
mega-colon) 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 move-
ments 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.
THE ARTERIES OF THE GASTRO-
INTESTINAL TRACT
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).
 The Gastrointestinal System2
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
Right crus of diaphragm
Caudate lobe of liver
Left side is Left coeliac ganglion
Left crus of diaphragm
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
iii. The common hepatic artery is intermediate
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 pan-
creatica 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.
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 Essentials of Human Anatomy
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 gastro-
epiploic artery.
The superior pancreatico-
duodenal 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 duo-
denum.
d. The two terminal hepatic branches
right and leftenter porta hepatis
Fig. 28.6: The superior mesenteric artery
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 level-
lower 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
 The Gastrointestinal System2
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 con-
cavity 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 contri-bute
to the formation of marginal artery.
The left branch of the artery anasto-
moses 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, des-
cending 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 peri-
toneum.
300 Essentials of Human Anatomy
Fig. 28.7: The inferior mesenteric artery
It divides into two branches. The ascen-
ding 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 gastro-
intestinal 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.
 The Gastrointestinal System2
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
duo-denum 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
Fig. 28.8: The portal vein
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)
302 Essentials of Human Anatomy
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 cir-
culation.
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 circu-
lation.
a. The porto-caval shunt is made by the side-
to-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.

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 erythro-
poietin, 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.
Fig. 29.1: The anterior surface of left kidney
CHAPTER 29
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
 304 Essentials of Human Anatomy
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)
Fig. 29.2: The posterior surface of kidney
Psoas majoralong medial border
Quadratus lumborum-about middle
Aponeurotic origin of transversus
abdominis 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).
 The Kidneys, Suprarenals and the Posterior Abdominal Wall
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.
Fig. 29.4: The structure of kidney
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
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
306 Essentials of Human Anatomy
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.
Fig. 29.5: The vascular segments of the kidney
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.
 The Kidneys, Suprarenals and the Posterior Abdominal Wall
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
The sympathetic nerves are derived from the
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 T 12
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 concen-
trated 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 Essentials of Human Anatomy
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).
 The Kidneys, Suprarenals and the Posterior Abdominal Wall 309

Fig. 29.6: The suprarenal glands

SizeEach suprarenal gland is about 50.0 mm Relations (Fig. 29.7)

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.
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 Essentials of Human Anatomy
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 phylo-
genetically 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
insuffi-ciency of cortical secretion.
 The Kidneys, Suprarenals and the Posterior Abdominal Wall
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
Fig. 29.9: The posterior abdominal wall
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 abdo-
minal 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
312 Essentials of Human Anatomy

Apices of transverse processes of Coeliac axis artery and its branches

upper four lumbar vertabrae by four surrounded by coeliac plexus of nerves
small tendons Peritoneum of posterior wall of lesser
Nerve supply ventral rami of T12 and L1, sac
L2 and L3 spinal nerves Body and uncinate process of head of
Actions pancreas
It is a lateral flexor of lumbar part of Origin of superior mesenteric artery
vertebral column Left renal vein
It fixes twelfth rib during inspiration Third part of duodenum and origin of
inferior mesenteric artery
ii. The psoas major muscle lies just lateral to
Root of mesentery and superior mes-
the lumbar vertebral bodies.
enteric vessels
The fusiform muscle belly descends
Parietal peritoneum
along the pelvic inlet medial to iliacus Aortic plexus of nerves and the pre-
muscle, and gives rise to a tendon that aortic lymph nodes.
descends deep to the inguinal ligament Posteriorly
to reach front of thigh Bodies of upper four lumbar vertebrae
[Description given in Chapter 17]. Intervertebral discs
iii. The iliacus muscle arises from the iliac Origin of four pairs of lumbar arteries
fossa and lies lateral to the psoas major Right side
muscle. Cisterna chyli and beginning of thoracic
The muscle also descends deep to the duct
inguinal ligament to reach front of thigh Azygos vein
[Description given in Chapter 17] Right crus of diaphragm
Inferior vena cava
The Blood Vessels of the Posterior Left side
Abdominal Wall Left crus of diaphragm
Fourth part of duodenum
The Arteries Branches of the abdominal aorta are divided into
three groups.
The abdominal aorta is the continuation of the
The ventral splanchnic branches are un-
descending thoracic aorta in the abdomen.
paired and supply the three partsforegut,
BeginningThe abdominal aorta begins at the
midgut and hindgutof the gastrointestinal
aortic opening of diaphragm at level of lower tract.
border of twelfth thoracic vertebra. The coeliac axis artery for the foregut.
CourseThe abdominal aorta descends in the The superior mesenteric artery for the
median plan in front of the bodies of lumbar midgut
vertebrae. The inferior mesenteric artery for the
At the lower border of fourth lumbar hindgut.
vertebra, slightly to the left of median plane, The lateral splanchnic branches are paired
the aorta bifurcates into two common iliac The inferior phrenic artery supplies the
arteries. diaphragm
Relation The middle suprarenal artery supplies
Anteriorly suprarenal gland
 The Kidneys, Suprarenals and the Posterior Abdominal Wall 313

The renal artery supply the kidney Parietal peritoneum

The testicular (ovarian) artery supply Third part of duodenum
the gonad. Right testicular (ovarian) vessels
The dorsal somatic branches are Head of pancreas, bile duct, portal vein
Four pairs of lumbar arteries that First part of duodenum
supply the muscles of the back Peritoneum of posterior wall of
The median sacral artery is a slender epiploic foramen
branch that continues in the posterior Right lobe of liver
pelvic wall Posteriorly
The terminal branches Bodies of lower three lumbar vertebrae
The two common iliac arteries Inter-vertebral discs
Applied anatomy Right psoas major
The aneurysm of the abdominal aorta is usually
Right sympathetic chain
located near the origin of its branches
Right crus of diaphragm
A large aneurysm may erode the Right suprarenal gland
related vertebral body Right renal, suprarenal and inferior
Partial occlusion of aorta below the origin phrenic arteries
of renal arteries results in development of
Right side
collateral circulation between the internal
Right ureter
thoracic artery and the abdominal aorta.
Second part of duodenum
The Veins Medial border of right kidney
The inferior vena cava is the great venous trunk Right lobe of liver
that collects venous blood from all parts of body Left side
below diaphragm and takes it to right atrium of Abdominal aorta
heart. Right crus of diaphragm
BeginningThe inferior vena cava begins on Tributaries
front of body of fifth lumbar vertebra by union The two common iliac veinsright and left
of the two common iliac veins-right and left. Third and fourth lumbar veins of both sides
The beginning is located to the right side of Right testicular (ovarian) vein
the median plane. Right supra-renal vein
CourseThe inferior vena cava ascends in Inferior phrenic veins
front of the lumbar vertebral bodies lying to Renal veins
the right side of the abdominal aorta Two-three hepatic veins.
The upper part of inferior vena cava bends Applied anatomy
anteriorly and lies in a deep groove on the Thrombosis of the inferior vena cava is
posterior surface of right lobe of liver. usually partial and collateral circulation
The inferior vena cava passes through the develops by enlargement of both
opening in the central tendon of superficial and deep veins.
diaphragm and ends in posterior part of The following superficial
right atrium of heart. veinsconnectthe inferior vena
Relation cava to the superior vena cava:
Anteriorly The epigastric veins
Right common iliac artery The lateral thoracic vein
Root of mesentery with superior mes- The thoraco-epigastric vein
enteric vessels The posterior intercostal veins.
314 Essentials of Human Anatomy
The deep veinsthat 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 colla-
teral 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 bet-
ween 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 corres-
ponding sympathetic ganglion]
The lumbar splanchnic nervesare
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
 The Kidneys, Suprarenals and the Posterior Abdominal Wall
The aortic plexus also contains
small sympathetic ganglia, that
relay sympathetic fibers and post-
ganglio-nic 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
compart-ment of thigh
The posterior division supplies the
skin and muscle of anterior (exten-
sor) compartment of thigh.
Branches: The main branches of the
lumbar plexus are
The ilio-hypogastric nerve (L1)
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
femo-ral 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
Multiple Choice Questions

Q1. Select the one best response to each A. Left gastric artery
question from the four suggested ans- B. Left gastroepiploic artery
wers: C. Short gastric arteries
1. The cremaster muscle in males is D. None of the above
continuous with the muscle fibers of: 8. The medial umbilical fold overlies the:
A. External oblique A. Urachus or median umbilical ligament
B. Internal oblique B. Obliterated umbilical artery
C. Transversus abdominis C. Inferior epigastric artery
D. Rectus abdominis D. Lateral border of rectus abdominis
2. The deep inguinal ring is the gap in the: 9. The length of ureter in normal adult male is:
A. External oblique aponeurosis A. 10.0 cm B. 25.0 cm
B. Internal oblique aponeurosis C. 30.0 cm D. 50.0 cm
C. Transversus abdominis aponeurosis
D. Fascia transversalis 10. The left supra renal vein ends in:
A. Left renal vein
3. The dermatome at the level of umbilicus is:
T B. Inferior vena cava
A. 10 B. T11
T C. Splenic vein
C. 12 D. L1 D. Left testicular (ovarian) vein
4. The spleen lies inside abdominal cavity in the:
Q2. Each question below contains four
A. Left hypochondrium
sugges-ted answers of which one or more
B. Left lumbar region
is correct. Choose the answers:
C. Epigastrium
D. Partly in left hypochondrium and partly A. If 1, 2 and 3 are correct
in epigastrium B. If 1 and 3 are correct
C. If 2 and 4 are correct
5. The portal vein is formed by the union of: D. If only 4 is correct
A. Superior mesenteric vein and inferior E. If 1, 2, 3 and 4 are correct
mesenteric vein
B. Superior mesenteric and splenic vein 11. The stomach:
C. Splenic and inferior mesenteric veins 1. has lesser curvature along which left
D. Splenic and short gastric veins and right gastric arteries lie
2. has parasympathetic innervation from
6. The normal capacity of gall bladder is: two gastric nerves, that carry vagal fibers
A. 250 ml B. 500 ml 3. has fundusthe highest part of greater
C. 100 ml D. 30-50 ml curvature, that contains gas
7. The arteries supplying the fundus part of 4. has a thick sphincter at the cardiac
greater curvature are: opening
 Multiple Choice Questions 317

12. The pancreas: 17. The liver:

1. has splenic artery running along its 1. is developed from endodermal hepatic
upper border diverticulum
2. has a tailthe tapering end of the 2. receives 80 percent supply from the
body-that reaches up to hilum of spleen portal vein
3. has an uncinate process from lower part 3. is related directly with diaphragm at the
of head that lies behind superior mes- bare area
enteric vessels. 4. has two-three hepatic veins draining
4. has a main pancreatic duct that mostly into inferior vena cava
joins with the bile duct to from a
18. The three constrictions in the course of
common ampulla.
ureter are:
13. The superior mesenteric artery: 1. Where ureter crosses the pelvic inlet
1. is the artery of hindgut 2. At its opening in the urinary bladder
2. terminates about two feet from 3. At pelvi-ureteric junction
ileocecal junction at Meckels 4. Where testicular (ovarian) vessels cross
diverticulum (if present) it anteriorly
3. supplies the entire transverse colon
4. gives an appendicular branch to supply 19. The referred pain of cholecystitis is felt at:
vermiform appendix 1. Umbilical region
2. Right lumbar region
14. The lesser sac of peritoneum (omental bursa):
3. Right inguinal region
1. is a part of peritoneal cavity 4. Right shoulder tip
2. has lesser omentum in its anterior wall
3. communicates with rest of the peritoneal 20. Upon exploration of abdominal cavity, blood
cavity by one openingepiploic foramen and some fluid is observed in Morrisons
4. extends up to lower border of greater pouch. The collection may be from:
omentum in adults 1. Left paracolic gutter
2. Lesser sac of peritoneum
15. The oblique (indirect) inguinal hernia:
3. Right infracolic compartment
1. passes through the deep inguinal ring
4. Right paracolic gutter
2. is commoner in older age group
3. is usually associated with incomplete Q3. Match the structures on the left with
fusion of processus vaginalis their related structures on the right:
4. seldom enters the scrotum 21. Embryonic remnants:
16. The right suprarenal gland: i. Ligamentum A. Median umbilical
1. is larger than left suprarenal gland teres of liver ligament
2. is related anteriorly to the inferior vena ii. Meckels B. Left umblical vein
cava diverticulum
3. has its suprarenal vein draining into iii. Urachus C. Medial umbilical
right renal vein ligament
4. lies in a separate compartment of renal iv. Umbilical artery D. Vitello-intestinal
fascia duct
318 Essentials of Human Anatomy

22. Arterial supply: iii. Presacral nerve C. Thoracic part

i. Coeliac axis A. Suprarenal gland of sympathetic
artery trunk
ii. Superior B. Head of pancreas iv. Greater splan- D. Superior hypo-
mesenteric artery chnic nerve gastric plexus
iii. Inferior mesen- C. Vermiform
teric artery appendix Q4. Find the wrong answer (except) in the
iv. Inferior phrenic D. Rectum following questions:
artery 27. The following structures are present in the
23. Related structures: free border of lesser omentumexcept:
i. Sphincter of Oddi A. Gall bladder A. Portal vein
ii. Falciform B. Kidney B. Main pancreatic duct
ligament C. Bile duct
iii. Hartmanns C. Ampulla of Vater D. Hepatic artery
pouch
iv. Ducts of Bellini D. Liver 28. The following veins form important porto-
systemic anastomosisexcept:
24. Drainage of veins:
A. Veins of bare area of liver and phrenic
i. Left testicular A. Splenic vein
veins
vein
B. Superior rectal vein and inferior rectal
ii. Middle colic B. Superior mes-
vein enteric vein vein
iii. Para-umbilical C. Left renal vein C. Paraumbilical veins and superficial
veins veins of anterior abdominal wall
iv. Inferior mesen- D. Left branch of D. Esophageal tributaries of left gastric
teric vein portal vein vein and tributaries of azygos vein.
25. Fascial layers of the abdomen: 29. The following structures form part of
i. Fascia A. Kidney stomach bedexcept:
transversalis A. Splenic artery
ii. Campers fascia B. Fatty layer of B. Body of pancreas
superficial fascia C. Coeliac trunk
iii. Renal fascia C. Membranous D. Upper part front of left kidney
layer of super-
ficial fascia 30. The following statements about inferior
iv. Scarpas fascia D. Inner fascia of the mes-enteric artery are correctexcept:
anterior abdominal A. Its colic branches supply descending
wall colon
26. Origin of nerves: B. It gives inferior pancreatico-duodenal
i. Ilio-inguinal nerve A. Lumbar plexus branch
(VRL1) C. It continues as superior rectal artery
ii. Genito-femoral B. Lumbar plexus D. Its branches contribute to the formation
(VRL1, L2) of marginal artery.
nerve
 Multiple Choice Questions
Answers
A1. The answer is B.
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.
A2. The answer is C.
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.
A3. The answer is A.
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 derma-
tome of L1 spinal nerve lies in the hypogastric
region just above pubic symphysis.
A4. The answer is A.
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.
A5. The answer is B.
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.
A6. The answer is D.
The normal capacity of gall bladder is
between 30 and 50 ml.
A7. The answer is C.
319
The fundus part of greater curvature of sto-
mach 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.
A8. The answer is B.
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.
A9. The answer is B.
The length of ureter in normal adult male is
nearly 25.0 cm.
A10. The answer is A.
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.
A11. The answer is A, (1, 2, 3).
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 Essentials of Human Anatomy
main pancreatic duct usually joins with the
bile duct to form the common hepato-
pancreatic ampulla.
A13. The answer is C, (2, 4).
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.
A14. The answer is A, (1, 2, 3).
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.
A15. The answer is B, (1, 3).
The oblique (indirect) inguinal hernia passes
through the deep inguinal ring. It is usually
associated with incomplete fusion of pro-
cessus vaginalis. The oblique hernia is com-
moner in young adults and enters the scrotum.
A16. The answer is C, (2, 4).
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.
A18. The answer is A, (1, 2, 3).
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
con-striction 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, C4, C5, V, R), the
ventral rami of C3 and C4 spinal nerves
supra-clavicular nerves also supply the skin
covering the right shoulder tip.
A20. The answer is C, (2, 4).
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 pan-
creatico-duodenal artery.
The superior mesenteric artery supplies
vermiform appendix by a separate
appendicular artery.
 Multiple Choice Questions
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.
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
abdo-minal 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.
A26. The answers are A, B, D and C.
The ilio-inguinal nerve, is a branch of
lumbar plexus (VR L1).
321
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 T9 ganglia of thoracic part
of sympathetic trunk.
A27. The answer is B.
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.
A28. The answer is A.
The veins of the bare area of liver and
the phrenic veins are quite small and do
not form an important site of porto-
systemic anastomosis.
The important sites are the other three.
A29. The answer is C.
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.
A30. The answer is B.
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 des-
cending colon and helps to form a part
of marginal artery.
It continues as superior rectal artery in
the pelvic cavity.
 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
aceta-bulum.
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
compart-ment 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.
Six
CHAPTER 30
The Bones and
Joints of the Pelvis
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 of 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
 The Bones and Joints of the Pelvis
Posteriorlyby the sacral promontory
Laterallyby ala of sacrum, and Iliopec-
tineal 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 ilio-pectineal eminence.
It is about 12.5 cm in normal adult
females.
iii. The transverse diameter is the widest
distance across the pelvic inlet.
It is about 13.5 cm in normal adult
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.
Fig. 30.1: The diameters of pelvic inlet
323
The pelvic outlet is closed by the pelvic dia-
phragm 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.
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 Essentials of Human Anatomy

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. Thickness of bones and muscle markings More pronounced Less pronounced
2. Weight of the bones Heavier Lighter
3. Shape of the bones Android type Gynaecoid type
4. Bony inlet Heart shaped Oval with transverse diameter more
5. Cavity Larger part of a smaller cone Smaller part of a larger cone
6. Acetabulum Larger Smaller
7. Iliac fossa Deeper Shallower
8. Subpubic angle 50-60 (acute angle) 80-85 (Nearly right angle)
9. Ischio-pubic rami Thicker, bear an everted area Thinner and lightly built
for attachment of crus of penis
10. Ischial spines Closer to each other Farther from each other
11. Sacrum More evenly curved Less curved
12. Sacral promontory More prominent Less prominent
13. Auricular surface Larger Smaller
14. Sacral index (Ratio of Breadth: Length) 105% 11.5%
15. Diameters of pelvic inlet Less in males More in females
16. Diameters of pelvic outlet Less in males More in females
 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.
Special Features
[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
Sex-difference
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.
Ossification
Ossification of sacrum resembles typical vertebra
Each sacral vertebra has
One primary center for body
325
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
THE COCCYX
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
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
The joints of the bony pelvis are
The sacro-iliac joints
The public symphysis
The sacro-coccygeal joint
326 Essentials of Human Anatomy
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 con-
nects 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 cartilagi-
nous joint, between the symphyseal surfaces of
the two public bones.
Type: Secondary cartilaginous joint.
Articular surfaces are coated with hyaline
articular cartilage.
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 sac-
ral 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 inter-
vertebral 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 partu-rition.
 CHAPTER 31
The Fasciae, Muscles,
Blood Vessels and
Nerves of the Pelvis
THE PELVIC FASCIA The ligaments of the pelvic organs are
conden-sations of pelvic fascia around the
The pelvic fascia is present in the cavity of pelvis
neuro-vascular bundles of pelvic organs.
as:
These ligaments play an important role in
i. The parietal pelvic fascia
support of pelvic organs; specially important
ii. The visceral pelvic fascia
for the uterus and urinary bladder.
The parietal pelvic fascia is continuation of the
fascia transversalis of the anterior abdominal wall. THE PELVIC MUSCLES
The various parts of parietal pelvic fascia are:
a. The obturator fascia covers the obturator The pelvic musculature consists of:
internus muscle at the lateral pelvic wall. The levator ani muscles together with coccygeus
It is attached above the ilio-pectineal line. muscles form pelvic diaphragm, that lies in the
Over the obturator internus, it forms a floor of pelvic cavity (Fig. 31.1).
tendinous arch of origin of levator ani Origin: The levator ani arises from
muscle. Pelvic surface of body of pubis
b. The pelvic fascia at the tendinous arch splits Obturator fascia at the tendinous arch.
into two layers to cover both superior and Medial surface of ischial spine.
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. Fig. 31.1: The pelvic diaphragm
328 Essentials of Human Anatomy
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 longi-
tudinal 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
one-third 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 recto-
vesical 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.
 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.
Clinical Considerations
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 recto-
uterine pouch.
The Blood Vessels of the Pelvis
The Arteries
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
branch of the common iliac artery (Fig. 31.2).
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 arterterminal 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
follow-ing the inlet of pelvis.
329
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 bran-
ches:
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
Course: From its origin at the level of lumbo-
sacral 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.
330 Essentials of Human Anatomy
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 compart-
ment 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 hyper-
trophies 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 supe-rior
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:
 The Fasciae, Muscles, Blood Vessels and Nerves of the Pelvis
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 lumbo-
rum. 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 piri-
formis 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 accom-
panied 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 Essentials of Human Anatomy
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.
The Lymphatic Drainage of the
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 bifur-
cation 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.
 The Fasciae, Muscles, Blood Vessels and Nerves of the Pelvis
Fig. 31.3: The lumbo-sacral plexus
3. The superior gluteal nerve (L4,L5,S1
poste-rior 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
poste-rior divisions of ventral rami).
It leaves pelvis below piriformis through
the greater sciatic foramen to enter
gluteal region.
5. The pudendal nerve (S2, S3, S4 anterior
divisions of ventral rami).
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 erigen-
tesS2, S3, and S4 segments of spinal cord).
They belong to the cranio-sacral outflow
of autonomic nervous system and con-
333
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 supe-
rior 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 divisions of ventral rami).
334 Essentials of Human Anatomy
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 divisions of ventral rami).
The nerve pierces sacro-tuberous liga-
ment 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
splan-chnic 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.

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
CHAPTER 32
The Perineum
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 non-keratinizing 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 Essentials of Human Anatomy
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 exami-
nation 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 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.
The Lymphatic Drainage of the
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
The endodermal part is supplied by autonomic
nerves.
Sympathetic fibers from pelvic plexuses.
Parasympathetic fibers from the pelvic splan-
chnic nerves.
 The Perineum
The ectodermal part is supplied by inferior
rectal nerve.
Clinical Considerations
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 communi-
cate 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.
Clinical Considerations
The ischio-rectal abscess is a very painful condition.
A large abscess may extend to the opposite
side behind the anus, thus making a
horseshoe-shaped 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 Essentials of Human Anatomy
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 division of internal iliac artery.
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 caver-
nosum.
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
 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 branchessuper-
ficial 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 incom-
pletely 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 Essentials of Human Anatomy
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 corres-
ponding 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 crura are continuous with corpora cavernosa
of the body of penis. The struc-tures of the root
of penis lie in the superficial perineal pouch of
urogenital triangle.
The Blood Vessels of the Penis
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 spon-
giosum, 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 (S3,S4,S5) 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).
 The Perineum
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 fas-
ciais 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
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.
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 Essentials of Human Anatomy

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
The Deep Perineal Pouch in Males
It is the space between parietal layer of pelvic
Anteriorly the pouch is open and communi-
fascia (superior fascia of urogenital
cates with space in anterior abdominal
diaphragm) and the perineal membrane
wall between membranous layer (Scarpas
(inferior fascia of urogenital diaphragm).
fascia) and external oblique muscle. Boundaries
Contents On two sides: The pouch is closed as the
a. Structures of root of penis two layers of fascia are attached to the
Bulb of penis conjoint rami.
Two crura of penis The pouch is closed due
b. Superficial perineal muscles (Table 32.1) Posteriorly: to fusion of the two fascial
Bulbo-spongiosus Anteriorly: layers

Table 32.1: Superficial perineal muscles in the male

Name Origin Muscle belly Insertion Actions

1. Bulbo spongiosus Perineal body Muscle belly lies in Inferior surface of 1. Help to empty
mid-line perineal membrane urethra
Covers bulb of penis
Dorsum of corpus 2. Helps in erection of
spongiosum penis
Extension on dorsum
of penis
2. Ischio- Medial aspect of Muscle belly covers Aponeurosis attached Help to maintain the
cavernosus ischial tuberosity medial and inferior to sides and inferior erection of penis
and ramus of aspects of crus of aspect of crus of penis
ischium penis
3. Superficial Medical aspects Muscle belly lies along Perineal body The two muscles help
transverse of ischial posterior border of to steady the perineal
perinei tuberosity superficial perineal body
pouch
 The Perineum 343

Contents 3. The perineal membrane (inferior fascia of

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
Two deep transverse perinei
Sphincter urethrae
Table 32.2: Deep perineal muscles in the male
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.

Name Origin Muscle belly Insertion Actions

1. Deep transverse Medial aspect of Muscle belly lies along Perineal body 1. The two muscles help
perinei ramus of ischium posterior border of to steady perineal
perineal membrane body
2. Sphincter 1. It helps to compress
Urethrae the membranous ure-
(a) External Medial aspect of Two partsanterior Attached to the opposite thra (external sphinc-
part conjoint ramus and posteriorthat conjoint ramus ter)
pass in front and 2. It helps to express
behind the urethra last drops of urine or
semen.
(b) Internal part Surrounds mem-
branous urethra
circumferentially
344 Essentials of Human Anatomy
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.
Fig. 32.5: The superficial perineal pouch in females
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.
 The Perineum 345
Table 32.3: Superficial perineal muscles in the female

Name Origin Muscle belly Insertion Actions

1. Superficial
transverse Same attachments and actions, except that
perinei they are much smaller
2. Ischio-cavernosus
3. Bulbo-spongiosus Anterior part of Muscle belly surrounds Corpora cavernosa of 1. It contracts vaginal
perineal body vaginal orifice and clitorisfasciculus on orifice
covers the vestibular dorsum of clitoris 2. It helps in erection
bulbs of clitoris

Table 32.4: Deep perineal muscles in the female

Name Origin Muscle belly Insertion Actions

1. Deep transverse
perinei 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 It compresses the
perineal ligament backwards on each side with opposite side urethra
of urethra Some fibers are attached
to vaginal wall

The Deep Perineal Pouch in Females Two deep transverse perinei

Sphincter urethrae.
The deep perineal pouch has the same boundaries
4. Internal pudendal vessels.
as in the males (Table 32.4). 5. Dorsal nerve of clitoris.
Contents:
1. A part of female urethra. Nerve Supply
2. A part of vagina. The deep perineal muscles are supplied by the
3. Deep perineal muscles 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 Fig. 33.1: The flexures of rectum
Vas deferens Uterus The rectal ampulla is the lower dilated portion of
Seminal vesicles Vagina rectum just above the pelvic floor.
Prostate gland The rectum differs from the pelvic colon in
following respects:
THE RECTUM The rectum has no sacculations and taenia coli,
The rectum is part of gastro-intestinal tract that because its longitudinal muscle coat is complete.
lies between pelvic colon and the anal canal. It has no appendices epiploiceae (pouches of
Location: The rectum lies in front of lower half peritoneum full of fat).
of sacrum, in posterior part of pelvic cavity. The rectum has no mesentery.
Extent: It begins on front of 3rd sacral
vertebra, where pelvic colon ends. Peritoneal Relations
It is continuous with anal canal, about 1 cm
The peritoneum covers front and sides of upper
below and in front of tip of coccyx.
one-third of rectum.
Length: About 12 cm.
It covers only front of middle one-third of
Flexures: The rectum is not a straight tube
(Fig. 33.1). rectum. The lower one-third has no peritoneal
It shows two anteroposterior flexures. covering.
a. Upper: sacral flexure, is concave anteriorly. In males: The peritoneum from front of middle
b. Lower: perineal flexure, is convex anteriorly. one-third of rectum passes to the base of urinary
The rectum also shows three lateral flexures. bladder forming recto-vesical pouch.
i. Upper: convex towards right. In females: The peritoneum from front of
ii. Middle: quite prominent and convex middle one-third of rectum passes to the back
towards left. of upper part of vagina forming recto-uterine
iii. Lower: convex towards right. pouch (pouch of Douglas).
 The Pelvic Viscera1
Interior 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 endo-
dermal cloaca, along with endodermal part
of anal canal.
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.
347
The Lymphatic Drainage of Rectum
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 rectum is supplied by the autonomic nerves.
The sympathetic is contributed by pelvic
plexu-ses.
The parasympathetic is supplied by the pelvic
splanchnic nerves (nervi erigentes) derived
from S2, S3 and S4 segments of spinal cord.
Clinical Considerations
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 Essentials of Human Anatomy
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.
Clinical Considerations
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 (aver-
age about 220 ml)
In adult female: It is less
The bladder can hold up to 500 ml, but it
becomes painful.
 The Pelvic Viscera1
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.
349
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 Essentials of Human Anatomy

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 parasym-
pathetic. Therefore, simple division of
sympathetic pathways (presacral
neurectomy) does not relieve the bladder
pain.
Clinical Considerations
1. Cystoscopy is performed by passing an endo-
scopic 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 umbi-licus.
THE URETHRA
The urethra is the fibrous canal that carries urine
from urinary bladder to the exterior (Fig. 33.3).

The Lymphatic Drainage of the

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 para-
sympathetic nerves. 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 swelling
colli-culus 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
non-straited 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 Essentials of Human Anatomy
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 (com-
partments) 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 0.01
0.13 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 net-
work of efferent tubules in mediastinum
 The Pelvic Viscera1
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 15-
20 efferent tubules (vasa afferentia) pierce
tunica albuginea and enter the head of epi-
didymis.
Fig. 33.5: Structure of testis
353
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 testi-
cular artery, the testis undergoes avascular
necrosis.
The Veins
The veins issuing from the posterior border of
testis form a pampiniform plexus of veins, that
ascends in the spermatic cord.
354 Essentials of Human Anatomy
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 sym-
pathetic nerves. The referred pain of testis is felt in
lower and middle part of anterior abdominal wall.
Clinical Considerations
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 connec-
tive 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.
 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 veins accompany the arteries.
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 veins accompany the arteries.
The Nerve Supply
The seminal vesicles are supplied by the
pelvic plexuses carrying autonomic nerves.
Clinical Considerations
1. The seminal vesicles can be palpated through
the anterior wall of rectum by the rectal exami-
nation.
356 Essentials of Human Anatomy
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 antero-
inferiorly 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 beginn-
ing 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.
Fig. 33.6: Coronal section through prostate gland
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
sepa-rated 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.
 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 ure-
thra. 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
enlarge-ment 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.
Fig. 33.7: The lobes of prostate gland
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 Lymphatic Drainage
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.
358 Essentials of Human Anatomy
Clinical Considerations
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 pro-static venous
plexus and the vertebral venous plexus.

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.
CHAPTER 34
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 Essentials of Human Anatomy
The Lymphatic Drainage
The lymphatics from the ovary accompany the
ovarian vessels and end in pre-aortic and para-
aortic lymph nodes.
The Nerve Supply
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,L1, and L2
segments of spinal cord.
The parasympathetic fibers are derived from
the pelvic splanchnic nerves (nervi erigentes).
They carry fibers from S2,S3, and S4
segments of spinal cord.
Clinical Considerations
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
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 Uterus [The Womb] (Fig. 34.1)
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).
 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 Essentials of Human Anatomy
The veins: The veins accompany the uterine
artery and from uterine venous plexus, that ends
in the internal iliac vein.
The Lymphatic Drainage
The lymphatics from the fundus pass along
the ovarian vessels and end in pre-aortic and
para-aortic 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 parasympathetic fibers are derived from 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.
Clinical Considerations
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.
 The Pelvic Viscera2
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.
363
The ostium is surrounded by 6-8 finger-
like 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 Essentials of Human Anatomy
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 Lymphatic Drainage
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
internal iliac lymph nodes.
The Nerve Supply
The sympathetic fibers from T 10 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 sym-
pathetic nerves.
Clinical Considerations
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
 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.
The Lymphatic Drainage
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
internal iliac lymph nodes.
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
Multiple Choice Questions

Q1. Give the one best response to each 7. Which of the following structures cannot be
question from the given four answers: palpated by vaginal examinationin females.
A. Sigmoid colon
1. The fertilization of the ovum takes place in:
B. Urethra
A. Body of the uterus
C. Perineal body
B. Ampulla of the uterine tube
D. Ischial spines
C. Peritoneal cavity
D. Ovarian follicle 8. The ano-rectal ring that prevents fecal
incontinence is formed by:
2. The remnant of peritoneal cavity present in
A. Deep part of external anal sphincter
the scrotum is: B. Internal anal sphincter
A. Gubernaculum C. Pubo-rectalis part of levator ani
B. Ductus deferens D. All of the above
C. Tunica vaginalis
D. None of the above 9. In infants, the internal urethral meatus of
the urinary bladder lies at the level of:
3. The length of the anal canal is: A. Upper border of pubic symphysis
A. 1 1/2 inches B. Midway between umbilicus and pubic
B. 6.0 inches symphysis
C. 10.0 inches C. Middle of pubic symphysis
D. 12.0 inches D. Lower border of pubic symphysis
4. The prostatic hypertrophy involves mainly. 10. The narrowest part of male urethra is:
A. Anterior lobe A. Prostatic part
B. Two lateral lobes B. Membranous part
C. Median lobe C. Internal urethral meatus
D. B and C D. External urethral meatus
5. The urogenital diaphragm is formed by: Q2. Each question below contains four
A. Sphincter urethrae sugges-ted answers, of which one or more
B. Levator ani are correct. Choose the answer:
C. Deep transverse perineal A. If 1, 2 and 3 are correct
D. A and C B. If 1 and 3 are correct
6. Which of the following structures cannot be C. If 2 and 4 are correct
palpated by rectal examination in males: D. If only 4 is correct
A. Bulb of the penis E. If 1, 2, 3 and 4 are correct
B. Seminal vesicles 11. The ischiorectal fossa:
C. Ureter 1. Contains a pad of fat that supports anal
D. Anorectal ring canal
 Multiple Choice Questions
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 one-
third 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 S2, i.S3, and S4
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
sacro-iliac 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:
Seminal vesicles A. Produces seminal
fluid
368 Essentials of Human Anatomy

ii. Prostate gland B. Conveys sperms iii. Lower one-third C. Superficial ingui-
from epididymis of vagina nal lymph nodes
to ejaculatory duct iv. Ovary D. Internal and exter-
iii. Cowpers gland C. Situated in deep nal iliac lymph
perineal pouch nodes
iv. Vas deferens D. Secretes fructose 24. Origin of arteries:
for nutrition of i. Superior rectal A. Abdominal aorta
sperms artery
ii. Testicular artery B. Anterior division
22. Embryonic remnants: of internal iliac
i. Prostatic utricle A. Cranial end of artery
paramesonephric iii. Ilio-lumbar artery C. Posterior division
duct of internal iliac
ii. Appendix of test B. Caudal end of artery
iv.
paramesonephric Uterine artery D. Inferior mesen-teric
duct artery
iii. Appendix of epi- C. Mesonephric duct 25. Root value of nerves:
didymis in females i. Pudendal nerve A. L2,L3,L4 (ventral
iv. Gartners duct D. Mesonephric divisions of vent-
tubule ral rami)
ii. Lumbo-sacral B. S2, S3, S4 ventral
23. Lymphatic drainage: trunk rami
i Cervix of uterus A. Para-aortic lymph iii. Obturator nerve C. L4,L5 ventral rami
nodes iv. Genitofemoral D. L1,L2 (ventral
ii. Prostate gland B. Internal iliac nerve division of ventral
lymph nodes rami)

Answers

A1. The answer is B. A3. The answer is A.

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.
A2. The answer is C.
The remnant of peritoneal cavity in the
scrotum is tunica vaginalis. Actually,
during descent of testis, a tube of
peritoneum processus vaginalis
descends 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.
A4. The answer is D.
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.
A5. The answer is D.
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.
 Multiple Choice Questions
A6. The answer is C.
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.
A7. The answer is D.
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.
A8. The answer is D.
The fecal incontinence is prevented by all
three structuresdeep part of external anal
sphincter, internal anal sphincter and pubo-
rectalis part of levator ani that form the
ano-rectal ring
A9. The answer is A.
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.
A10. The answer is D.
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.
A11. The answer is A, (1, 2, 3)
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.
A12. The answer is C, (2, 4)
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.
A13. The answer is B, (1, 3)
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.
A14. The answer is C, (2, 4).
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.
A17. The answer is B, (1, 3)
The sacrum in females is shorter and wider
than in males and has shorter articular surface
370 Essentials of Human Anatomy
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.
A19. The answer is C, (2, 4)
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 Gartners 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 para-
aortic 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 division of internal iliac artery.
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.
 The Head and Neck
Seven
CHAPTER 35
The Bones of the
Head and Neck
The skeleton of head is formed by the skull and Anatomical position of skullcan be
the mandible or lower jaw bone forming lower visualized by the following planes.
part of facial skeleton. The skull (cranium) is Reids base lineAn imaginary horizontal
divided into an anterior part that forms the upper plane connecting infraorbital margins to the
part of facial skeleton and a posterior part that center of external acoustic meatus
forms the calvaria or the brain box. Frankfurts planeAn imaginary horizontal
The skeleton of the neck is formed by the seven plane connecting infra-orbital margins to the
cervical vertebrae and the inter-vertebral discs. upper margin of external acoustic meatus
There is a small hyoid bone in the front of EXTERIOR OF THE SKULL
upper part of neck.
A. Norina verticalis (Superior view)
THE CRANIUM When viewed from above the skull appears
i. The facial skeleton has fourteen bones wider posteriorly. The bones seen in this view
are:
Vomer 1
Frontal bone anteriorly
Maxillae 2
Occipital bone posteriorly
Nasal 2
Two parietal bones on either sides
Lacrimal 2
The sutures seen in this view are:
Palatine 2 Coronal suture between frontal and two
Zygomatic 2 parietal bones.
Inferior nasal concha 2 Sagittal suture between the two parietal
ii. The Calvaria (brain box) is made up of bones
eight bone. Lambdoid suture between the two parietal
Ethmoid 1 bones and occipital bone.
Sphenoid 1 The Other features of skull in this view are:
Occipital 1 Bregma - point where coronal and sagittal
Frontal 1 suture meet
Parietal 2 Lambda - point where sagittal and
Temporal 2 lambdoid sutures meet
372 Essentials of Human Anatomy
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
 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.
Occa-sionally two anterior and posterior
incisive foramina also exist.
Greater palatine foramina are located in
posterior part of hard palate. A groove leads-
from 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 Essentials of Human Anatomy
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 basi-
occiput. 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 protube-
rance 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 down-
wards forwards and medially
Mastoid processa large conical bony pro-
fection 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
 The Bones of the Head and Neck 375

Maxilla has four processes: temporal fossa and its medial surface
i. Zygomatic processarticulates with forms part of lateral wall and floor of
zygomatic bone orbital cavity
ii. Frontal processforms lateral orbital Zygomatic has three processes
margin and joins with frontal bone i. Frontal processlies along lateral
iii. Alveolar processhas eight sockets for
margin of orbit to join with frontal bone
teeth and has maxillary tuberosity behind
ii. Maxillary processjoins medially
iv. Palatal processlies horizontally and
with maxilla
forms four-fifth part of hard palate
with opposite bony process iii. Temporal processforms the
Age changes in Maxilla: zygomatic arch with zygomatic
At birthbone has no maxillary sinus, process of temporal
Frontal process is prominent. Its transverse 7. Inferior nasal conchais a curved bony plate
diameter is more than vertical diameter that lies in the lateral wall of nasal cavity
In adultlateral diameter is greatest owing to above the inferior meatus
development of teeth. The maxillary sinus is 8. Mandible or the lower jaws bone forms the
fully developed lower half of fascial skeleton
In old ageThe alveolar magin is absorbed Each half of mandible has a horizontal
due to loss of teeth. The height of bone body and a vertical part - ramus
becomes less The two halves of mandible are connected
3. Nasalis a small bone that forms the bridge
by a fibrous joint at birth. Bony fusion
of nose with bone of opposite side
It articulates with nasal part of frontal bone
(syno-stosis) takes by end of first year to
above and frontal process of maxilla laterally from symphysis menti
4. Lacrimalis smallest and thinnest of all The body of mandible has two surfaces
cranial bones i. Lateral surface (Fig. 35.1) - has an
It lies in medial wall of orbit between oblique line an incisive fossa and a
frontal process of maxilla and orbital plate mental foramen
of eth-moid
It has a lacrimal groove on lateral surface-
that lodges lacrimal sac
5. 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
6. Zygomatic forms the prominence of cheek
Its lateral surface has a foramen, The
temporal surface forms anterior wall of Fig. 35.1: The mandiblelateral aspect
376 Essentials of Human Anatomy
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
mandi-bular 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 mylo-
hyoid groove passes dowwards from the
foramen. There is a rough area on medial
surface of angle for muscular attach-
ment
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
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
con-strictor 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)
 The Bones of the Head and Neck
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 chias-
maticus for optic chiasma, tuberculum
sellae and hypophyseal fossa (sella
turcica). Dorsum sellae with two poste-
rior 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 liga-ment.
378 Essentials of Human Anatomy
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 ptery-
goid plate. The vaginal process pro-
longed on inferior surface of body of
sphenoid forms palatino-vaginal canal.
Fig. 35.4: The occipitalexternal aspect
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 pro-
tuberance and crest. The superior nu-
chal 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.
 The Bones of the Head and Neck
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 pharyn-geal
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.
Fig. 35.5: The frontalexternal aspect
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 inferior
radiate 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.
380 Essentials of Human Anatomy
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 corres-
ponds 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 inter-nal acoustic meatus.
Its inferior surface has a quadran-
gular 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.
 The Bones of the Head and Neck 381
Table 35.1: The ossification of the cranial bones

S No Name of the bone Ossification in membrane Ossification in cartilage

1. Vomer Two centres appear in eight weeks on
either side of midline; fuse by twelfth week
2. Maxilla 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
3. Nasal One centre appears in third month of
intrauterine life
4. Lacrimal One center appears in twelfth week
5. Palatine One center appears in eighth week in
perpendicular plate
6. Zygomatic One center appears in eighth week
7. Inferior nasal concha One center appears in fifth month in the
lower border of cartilaginous nasal capsule
8. Mandible Each half is ossified by one center, that Ossification spreads in condylar carti-
appears in sixth week, near mental lage, extending from mandibular head
foramen down to the ramus
9. Ethmoid 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
10. Sphenoid a. Presphenoidal part (in front of tuber-
culum 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
pro-cesses) has eight centres
[The rest portions of greater wings and lateral Two for the two greater wings in
pterygoid plates ossify in membrane from eighth 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 ptery-
appearing in ninth week goid hamulus during third fetal month
11. Occipital 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
post-erior margin of foramen magnum
in sixteenth week
Contd...
382 Essentials of Human Anatomy

Contd...
S No Name of the bone Ossification in membrane Ossification in cartilage
Two centres one for each lateral parts
appear in eighth week.
One center appears for the basilar part
in sixth week.
12. Frontal 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
13. Parietal Two centers appear in seventh week near
the parietal eminence and fuse soon
14. Temporal Squamous part by one centre appearing in Petromastoid part is ossified by several
seventh week centres appearing in cartilaginous ear
Tympanic part from one centre appearing capsule during fifth month
in third 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. Supra-orbital foramen Frontal Supra-orbital nerve and vessels
2. Intra-orbital foramen Maxilla Intra-orbital nerve and vessels
3. Zygomatico-facial foramen Zygomatic Zygomatico-facial nerve and vessels
4. Zygomatico-temporal Zygomatic Zygomatico-temporal nerve
foramen
5. External acoustic meatus Temporal Sound waves
6. Petro-tympanic fissure Temporal Chorda tympani
Anterior tympanic artery
7. Pterygo-maxillary fissure Between pterygoid Third part of maxillary artery
process and maxilla Maxillary nerve
8. Inferior orbital fissure Between greater wing Maxillary nerve
sphenoid and maxilla Zygomatic branch of maxillary nerve
Intraorbital vessels
Emissary vein connecting the interior
ophthalmic vein with pterygoid venous
plexus
9. Posterior superior dental canals Maxilla Posterior superior alveolar nerve and
vessels
10. Stylomastoid foramen Temporal Facial nerve
Stylomastoid artery
11. Posterior condylar canal Occipital Emissary vein connecting the sigmoid
sinus with suboccipital venous plexus
12. Anterior condylar canal Occipital Hypoglossal nerve
13. Mastoid foramen Mastoid temporal Emissary vein joining the veins of scalp
with transverse sinus
Contd...
 The Bones of the Head and Neck 383
Contd...
S No Name Bone Structures passing through
14. Parietal foramen Parietal Emissary vein joining veins of the scalp
with superior sagittal sinus
15. Jugular foramen Between condylar part of Inferior petrosal sinus
occipital and petrous Ninth, tenth and eleventh cranial nerves
temporal bone Sigmoid sinus
16. Carotid canal Petrous temporal Internal carotid artery with its sym-
pathetic plexus
17. Foramen lacerum Between apex of petrous Emissary vein joining the pharyngeal
temporal and sphenoid veins with cavernous sinus
Meningeal branch of ascending pharyn-
geal artery
Internal carotid artery with its sym-
pathetic plexus, passes through upper
part
18. Foramen ovale Greater wing of sphenoid Mandibular division of trigeminal nerve
Motor root of trigeminal
Emissary vein joining pterygoid venous
plexus with cavernous sinus
Accessory meningeal artery (some-
times)
19. Foramen spinosum Greater wing of sphenoid Middle meningeal artery
Meningeal branch of mandibular nerve
20. Greater palatine foramen Horizontal plate of palatine Greater palatine nerve
Greater palatine vessels
21. Lesser palatine foramina Palatine Lesser palatine nerves
22. Incisive fossa Between palatal processes Anterior foramenLeft nasopalatine
(It has four foramina anterior, of two maxillae nerve
posterior and two lateral) Posterior foramenRight nasopalative
nerve
Two lateral foraminaTerminal parts
of greater palatine arteries
23. Foramen magnum Occipital bone 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 Essentials of Human Anatomy

Table 35.3: Important foramina inside the skull

S No Name Bone Structures passing through

Anterior cranial fossa
1. Foramen cecum Between crista galli of Emissary vein connecting the veins of
(1% skulls) ethmoid and frontal crest roof of nose
of frontal bone with beginning
of superior sagittal sinus
2. Foramina in cribriform plate Ethmoid Olfactory nerves
3. Anterior ethmoidal canal Between cribriform plate and Anterior ethmoidal nerve and vessels
orbital plate of frontal
4. Posterior ethmoidal canal Between cribriform plate and Posterior ethmoidal vessels
orbital plate of frontal
Middle cranial fossa
5. Optic canal Sphenoid Optic nerve with its three sheaths
Ophthalmic artery
6. Superior orbital fissure Sphenoid Lacrimal, frontal and nasociliary
nerves
Trochlear nerve
Two divisions of oculomotor nerve
Abducent nerve
Superior and inferior ophthalmic veins
7. Foramen rotundum Sphenoid Maxillary division of trigeminal nerve
8. Foramen ovale
9. Foramen spinosum (described in Table 35.2)
10. Foramen lacerum
11. Hiatus for greater petrosal nerve Petrous temporal Greater petrosal nerve
12. Hiatus for lesser petrosal nerve Petrous temporal Lesser petrosal nerve
Posterior cranial fossa
13. Internal acoustic meatus Petrous temporal Facial nerve
Vestibulo-cochlear nerve
Labyrinthine vessels
14. Jugular foramen
15. Posterior condylar canal (described in the Table 35.2)
16. Anterior condylar canal
17. Foramen magnum

A minute tympanic canaliculus lies INTERIOR OF THE SKULL

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.
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
 The Bones of the Head and Neck
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
Fig. 35.7: The cranial cavityshowing the cranial fossae
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, tuber-
culum sellae and hyphyseal fossa - all
parts of body of sphenoid
386 Essentials of Human Anatomy
On either side - greater wing of
sphenoid with foramen rotundum fora-
men 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 cere-
bellum 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 tempo-
ral, 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
addi-tional 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
respecti-vely.
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 features (Fig. 35.8)
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
 The Bones of the Head and Neck
into anterior tubercle and posterior
tubercle
The anterior tubercle and inter-tubercular
lamella (costo-transverse bar) represent the
costal element in cervical 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)
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 pro-
jection above the body. It articulates with
facet on back of anterior arch of atlas
vertebra.
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
poste-rior 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 features (Fig. 35.11)
It has a long spinous process that is visible
at lower end of ligamentum nuchae at back
388 Essentials of Human Anatomy

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
Fig. 35.12: The hyoid bonesuperior aspect
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. Fig. 35.13: The hyoid bonelateral aspect
II. The atlas vertebra ossifies by three centers
one in each lateral mass appearing in seventh
General Features
weak. One center appears in anterior arch by end
of first year. Hyoid bone consists ofa median body, paired
III. The axis vertebra ossifies by five primary greater cornu and paired lesser cornu.
centers and two secondary centers. The body is roughly quadrangular. Its
The vertebral arch by two centers, (seventh to anterior surface faces antero-superiorly. The
eight week) the centrum by one center, (fourth posterior surface is smooth and concave and
month), the dens by two centers (sixth month). related to a bursa.
 The Bones of the Head and Neck
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
tuber-cle.
The lesser cornu are two small conical projec-
tions 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.
Special Features
Muscles and ligaments attached to hyoid bone
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 genio-
glossus and thyrohyoid membrane
Lower border of body-Sternohyoid and omo-
hyoid 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.
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.
The Vertebral Column
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 one-
fourth 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.
390 Essentials of Human Anatomy
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
exagger-ated 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 com-
pression 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.

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
CHAPTER 36
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 squamo-
tympanic 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 Essentials of Human Anatomy
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 fibro-
cartilage 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 move-
ments 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 apposi-tion.
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.
Muscles producing movements
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
 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.
Fig. 36.4: The atlanto-axial jointmedian sagittal section
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.
Muscles producing movements
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.
394 Essentials of Human Anatomy
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.
 The Joints, Fasciae and Deep Muscles of the Back of Head and Neck
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 ligament-
behind.
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 Essentials of Human Anatomy
PosteriorlyPosterior free border of liga-
mentum 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 peri-
cardium.
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.
 The Joints, Fasciae and Deep Muscles of the Back of Head and Neck
e. The retro-vertebral fascia covers the retro-
vertebral 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.
Fig. 36.6: The thoraco-lumbar fascia
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 pro-
cesses 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
Mediallyto the tips of spinous
processes of lumbar vertebrae and
supraspinous ligaments.
Laterallyit 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 trans-
verse processes.
Laterally it fuses with anterior lamina
at the lateral border of quadratus
lumborum.
 398 Essentials of Human Anatomy
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 quad-
ratus lumborum to form the apo-
neurotic 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 liga-
ment.
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 verte-brae.
ii. The middle part is longissimus. It is
further subdivided into three portions:
a. The longissimus thoracis from
common origin to thoracic trans-
verse processes and lower nine or
ten ribs.
This is the largest segment of
erector spinae.
b. The longissimus cervicis from trans-
verse 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.
 The Joints, Fasciae and Deep Muscles of the Back of Head and Neck
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 verte-
brae.
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 1. The skin is mostly having hairs and has many
sebaceous glands.
The scalp is the region on top of the skull and The skin of scalp is a frequent site for
includes forehead also sebaceous cysts
Boundaries 2. The connective tissue is quite dense and firmly
AnteriorlyThe supra-orbital margins binds the skin to the underlying aponeurosis
On two sidesSuperior temporal lines It is richly supplied with blood vessels and
cutaneous nerves.
PosteriorlyExternal occipital protu-
The incised wounds of this layer bleed
berance and superior nuchal lines profusely, but heal well if properly stitched
LayersThere are five layers in the scalp A blunt injury here causes a localized but
(Fig. 37.1) very painful hematoma
1- S Skin 3. The aponeurosis belongs to the occipito-
frontalis (epicranius) mucle
2- C Connective tissue
Attachments: The two large frontal bellies
3- A Aponeurosis have no bony attachment. They are
4- L Loose areolar tissue attached to the skin of eyebrows.
5- P Pericranium 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
Fig. 37.1: The layers of the scalpcoronal section forehead.
 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
Fig. 37.2: The blood supply of the scalp
401
fracture of skull bone, the blood collects
in the loose areolar tissue layer, before
collec-ting 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
402 Essentials of Human Anatomy
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.
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)
Fig. 37.3: The nerve supply of the scalp
The anterior part of scalp (in front of auricle) is
supplied by four branches of trigeminal nerve.
i. The supra 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
 The Scalp, Face and the Cranial Cavity
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 auri-
cularis 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
Fig. 37.4: The muscles of the face, scalp and auricleLateral view
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.
404 Essentials of Human Anatomy

Table 37.1: The muscles of the face

S.No. Name Origin Insertion Main actions

I. The muscles of the orbit
a. Orbicularis ocult
Orbital part Medial orbital margin It surrounds the It tightly closes the eye
Medial palpebral ligament orbital openings against external injury
Palpebral part Medial palpebral ligament Lateral palpebral raphe It depresses the eyelid
during blinking
Lacrimal part Posterior lacrimal crest Lateral palpebral raphe It dilates lacrimal sac
Lacrimal fascia and helps in drainage of
tears
b. Corrugator Medial part of superciliary Skin of eyebrow It produces vertical
supercilli arch furrows in forehead to
express annoyance
c. Levator palpebrae (described with extra-ocular muscles in Chapter 48)
superioris
II. The muscles of the nose
a. Procerus Fascia covering bone Skin at the root of the It produces transverse
nose (continuous with furrows at root of the
medial parts of frontal nose
bellies)
b. Nasalis
Compressor Maxilla along margin Aponeurosis across the It compresses the ante-
naris of piriform aperture bridge of nose with rior nasal opening acting
opposite muscle as sphincter
Dilator naris Maxilla along margin of Alar cartilage in ala It dilates the anterior
piri-form aperture below of nose nasal opening
com-pressor naris
c. Depressor septi Incisive fossa of maxilla Septal cartilage It depresses anterior
nasi part of septal cartilage
III. The muscles of the mouth
a. Orbicularis oris Surrounds the oral fissure Compound sphincter It purses and puckers
forming a series of muscle of oral fissure the lips
elliptical loops It helps in all move-
ments of lips
b. The labial retractors
Upper lip
1. Levator labii Frontal process of maxilla Medial partalar It elevates upper lip and
superioris carti-lage of nose dilates the nostril
alaque nosi Lateral partupperlip
2. Levator labii Maxilla Fibers blend in It elevates and everts
superioris substance of upper lip the upper lip
3. Zygomaticus Zygomatic Upper lip It elevates the angle of
minor mouth in laughing
4. Zygomaticus Zygomatic Upper lip It elevates the angle of
major mouth in laughing
Lower lip
5. Depressor Oblique line of mandible Fibers blend in sub- It depresses lower lip
labii inferioris stance of the lower lip
Contd...
 The Scalp, Face and the Cranial Cavity 405
Contd...
S.No. Name Origin Insertion Main actions
6. Facial part Continuation of some fibers of Lower lip It depresses the lower
of platysma platysma in face lip
c. The modiolar muscles (cruciate modiolar muscles)
a. Levator anguli Maxillacanine fossa Fibers decussate at It elevates the angle of
oris modiolus-a knot of mouth
muscles 1.0 cm from
angle of mouth
Depresser Mandible Fibers decussate at It depresses the angle of
anguli oris modiolous and enter mouth
upper lip
(Transverse modiolar muscles)
Buccinator Alveolar margins of maxilla Upper and lower fibers It helps to blow out air
(Buccina- and 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 decus- by keeping vestibule
sate at modiolus and pass of 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 Essentials of Human Anatomy
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
Fig. 37.6: The venous drainage of the face
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
zygomatico-facial 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)
 The Scalp, Face and the Cranial Cavity
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 retro-
mandibular 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 nerve
ophthalmic, 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 supra-
orbital 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 Essentials of Human Anatomy
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 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
affec-ted division that, temporarily
degenerates the nerve fibers, thus
interrupting the pain-pathway
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
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 Scalp, Face and the Cranial Cavity
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 mandi-
ble, 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 para-
lysis. 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 sur-
face 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 Essentials of Human Anatomy
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 trans-
verse 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 infundi-
bulum 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 postero-
superior 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
 The Scalp, Face and the Cranial Cavity
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:
Fig. 37.8: Coronal section through cavernous venous sinuses
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 con-
necting 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.
 412 Essentials of Human Anatomy
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 parahippo-
campal 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.
 The Scalp, Face and the Cranial Cavity 413
Table 37.2: The emissary veins of skull

S.No. Name Foramen of skull Venous sinus Veins outside skull

1. Emissary vein (1%) Foramen cecum Superior sagittal sinus Veins of roof of nose
2. Parietal emissary vein Parietal foramen Superior sagittal sinus Veins of scalp
3. Mastoid emissary vein Mastoid foramen Transverse sinus Veins of scalp
4. Emissary vein Hypoglossal canal Sigmoid sinus Internal jugular vein
5. Condylar emissary vein Posterior condylar canal Sigmoid sinus Suboccipital venous
plexus
6. Emissary vein Foramen ovale Cavernous sinus Pterygoid venous plexus
7. Emissary vein Emissary sphenoidal Cavernous sinus Pterygoid venous plexus
foramen
8. Two or three emissary Foramen lacerum Cavernous sinus Pharyngeal veins
veins Pterygoid venous plexus
9. Internal carotid venous Carotid canal Cavernous sinus Internal jugular vein
plexus
10. The ophthalmic vein Superior orbital tissue Cavernous sinus Facial veinpterygoid
venous plexus

They start developing after birth. There are
many small diploic veins that open in the
neigh-boring venous sinuses.
The large diploic veins are
i. The frontal diploic vein that opens in
supra-orbital vein by a minute foramen in
supra-orbital notch.
ii. The anterior temporal (parietal) diploic
vein draining venous blood from frontal
and parietal bone ends in the spheno-
ii. The cavernous partThe artery on entering
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
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 ptery-
goid canal
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
Thecavernous branchesare small
andsupply trigeminal ganglion, and
the dura mater of cavernous sinus
Hypophyseal branches
superiorand inferiorsupply the
hypophysis cerebri
Meningealbranches supply the
duramater of anterior cranial fossa
414 Essentials of Human Anatomy
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
rayers-endosteal 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
The preganglionic parasympathetic
fibers of lacrimal gland
The preganglionic parasympathetic
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 communi-
cation 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 para-
sympathetic 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
 The Scalp, Face and the Cranial Cavity
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 caver-
nous and two intercavernous
surround 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 hypo-
physis cerebri.
The chiasma lies closely applied to the
anterior surface of infundibulum
iv. Relations with other structures
Superiorlylies base of brain and inter-
peduncular 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 hypo-
thalmo-hypophyseal portal system. By
this portal system the hormone releasing
factors (HRF) and hormone inhibiting
factors (HIF) reach from hypothalmic
nuclei to the adeno-hypophysis
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 hypo-thalmic
nuclei and reach neurohypophysis
The adenohypophysis produces
i. Somatotropin (growth hormone)
416 Essentials of Human Anatomy
ii. Corticotropes (Adrenocorticotropic hor-
mone (ACTH)
Thyrotropic hormone (TSH) from baso-
phil cells
Gonadotropic hormone (FSH and LH)
Applied Anatomy
Enlargement of pituitary gland (tumors) produce
two types of symptoms
i. Constitutional symptoms due to over pro-
duction of certain hormones
ii. Neighborhood symptoms due to com-
pression on neighboring structures.
Theses are
i. The visual signs produced due to com-
pression of optic chiasma.
Bitemporal hemianopialoss of
temporal nasal fields of both sides
Paralysis of third, fourth, and sixth
nerves by laterally growing tumor
ii. Deepening of sella turcica is seen is lateral
X-ray of skull
iii. Pressure on uncus leads to aura of different
types of smell
iv. Pressure on crus cerebri leads to paresis or
paralysis of voluntary muscle groups of
opposite half of body
v. Pressure on inter-ventricular foramen may
lead to internal hydrocephalus of lateral
ventricle
vi. The pituitary tumor by raising the
intracranial pressures leads to papilledema
or swelling of optic disc that can be
visualized by ophthal-moscope.

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 irre-
gular, lobulated, yellowish mass. It weighs
about 25 gm.
Fig. 38.1: The parotid gland
CHAPTER 38
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
submandi-bular 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.
418 Essentials of Human Anatomy
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 digas-
tric 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
embed-ded 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.
Fig. 38.2: The parotid glanda transverse section
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
glosso-pharyngeal nerve, its tympanic
branch, tympanic plexus and lesser
petrosal nerve that ends in otic ganglion.
 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 apo-
neurosis.
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.
THE INFRATEMPORAL FOSSA
The infratemporal fossa is the region below
zygomatic arch, between ramus of mandible and
lateral wall of pharynx.
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
Contents
a. The pterygo-palatine (spheno-palatine) ganglion
b. Part of maxillary nerve
c. Third part of maxillary artery.
420 Essentials of Human Anatomy

The Muscles of Mastication It arises behind the neck of mandible as the

external carotid artery emerges from the
There are four muscles of masticationTempo- parotid gland.
ralis, masseter, lateral pterygoid and medial Course: The artery passes forwards and
pterygoid (Table 38.1). medially and its terminal part lies in the
These muscles are supplied by the mandibular pterygo-palatine fossa.
nerve. For purpose of description it is divided into
The buccinator muscle of face helps in masti- three parts:
cation by keeping vestibule of mouth free of a. The first part extends from its origin
up to lower border of lateral pterygoid
food during mastication. muscle.
b. The second part crosses superficially
The Blood Vessels of the Region (sometimes deep) to lower head of
The Arteries lateral pterygoid muscle.
c. The third part enters the pterygo-
The maxillary artery is one of the terminal maxillary fissure and lies inside
branches of external carotid artery (Fig. 38.5). pterygo-palatine fossa.

Table 38.1: The muscles of mastication

S.No.Name Origin Muscle belly Insertion Main actions

I. Temporalis Inferior temporal Muscle belly thick and Tendon on apex I. Powerful elevator of
(Fig. 38.3) line fan shaped and medial surface mandible
Four bones of Fibers converge to of coronoid process II. Posteriot fibers help to
medial wall of tem- form a tendon Fleshy fibers on ante- retract the protruded
poral fossa rior border of ramus mandible
Deep surface of of mandible
temporal fascia
II. Masseter Lower border and Muscle belly thick and Lateral surface ramus I. Powerful elevator of
(Fig. 38.4) medial surface of quadrangular of mandible including mandible
Zygomatic arch Superficial part fibers coronoid process II. Superficial fibers help
pass obliquely down- in protraction and deep
wards fibers help in retraction
Deep part fibers pass of mandible
vertically downwards III. Helps in side to side
movement of mandible
III. Lateral Upper head-Infratem- The fibers of two Pterygoid fossa an I. Depressor of mandible
pterygoid poral surface greater heads pass postero- anterior surface of and helps in opening the
(Fig. 38.5) 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 ptery- joint. Some fibers III. Side to side movement
goid plate reach articular disc of of mandible
the joint
IV. Medial Superficial head- The fibers of both Rough area on medial I. It helps to elevate the
pterygoid smaller, from heads pass down- surface of angle of mandible
maxillary wards and laterally mandible II. Protractor of mandible
(Fig. 38.6) tuberosity III. Helps in side to side
Deep head-larger movement of mandible
from medial surface
of lateral pterygoid
plate.
 The Parotid Region, Temporal and Infratemporal Fossae
Fig. 38.3: The temporalis muscle
Branches
From First Part
i. Anterior tympanic branch enters petro-
tympanic 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.
Fig. 38.4: The masseter muscle
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
arte-ries 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
pre-molar teeth. In face it gives branches
to supply, lower eyelid ala of nose and
upper lip.
422 Essentials of Human Anatomy
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
communi-cations 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.
 The Parotid Region, Temporal and Infratemporal Fossae 423

Fig. 38.6: The medial pterygoid muscle and mandibular nerve

The nerve is related medially to Masseteric nerve

Otic ganglion Nerve to lateral pterygoid
Tensor veli palatini muscle iv. Buccal nerve supplies sensory fibers to the
The anterior division is smaller and contains face.
mainly motor fibers. It continues forwards From the Posterior Division
and emerges in the face as buccal nerve, that v. The auriculo-temporal nerve arises by two
carries all its sensory fibers. roots enclosing middle meningeal artery.
The posterior division is larger and descends It passes behind mandibular joint and
as the continuation of stem. It contains crosses zygomatic arch to enter scalp.
mostly sensory fibers, and some motor It supplies sensory fibers to
fibers that come out as mylohyoid nerve. The auricle and external acoustic
Branches meatus
From the Stem A part of scalp and superficial
i. Meningeal branch that enters skull through tempo-ral region
foramen spinosum and supplies dura mater. Mandibular joint and parotid gland.
ii. The nerve to medial pterygoid that passes The nerve also carries secretomotor
through otic ganglion and also supplies. fibers to parotid gland.
Tensor tympani vi. The inferior alveolar nerve enters mandi-
bular foramen and runs in mandibular
Tensor veli palatini
canal of the bone.
From the Anterior Division
Before entering mandibular foramen, it
iii. Four muscular branches
gives mylohyoid nerve that pierces
Anterior deep spheno-mandibular ligament and runs
temporal to temporalis forwards medially in a groove to supply.
Posterior deep muscle Mylohyoid muscle

temporal Anterior belly of digastric
 424 Essentials of Human Anatomy
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 sub-
mandibular region.
The lingual nerve lies in a groove on
mandible behind last molar tooth,
covered by mucous membrane.
The nerve crosses upper part of hyo-
glossus deep to mylohyoid and has a
twisting relation with the
submandibular salivary duct.
The linguinal nerve is connected by two
communicating branches with sub-
mandibular ganglion.
The nerve supplies sensory fibers to:
Anterior two-third of tongue.
Floor of mouth and gums of lower
jaw.
Submandibular and sublingual sali-
vary 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 spheno-
palatine (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 down-
iv. 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
 The Parotid Region, Temporal and Infratemporal Fossae
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) gan-
glion 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 petro-
sal 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 ptery-
goid canal. These two branches provide an
alternative taste pathway from anterior
two-third 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
parasym-pathetic (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 bran-
ches 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
ptery-goid canal.The pre-ganglionic
parasym-pathetic 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 Essentials of Human Anatomy

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.
 CHAPTER 39
The Triangles
of the Neck
THE POSTERIOR TRIANGLE Above clavicle it splits to enclose a fascial
OF THE NECK space (described in Chapter 36).
The posterio triangle lies on the side of neck, behind The floor is formed by the following mus-
sternomastoid muscle. It extends from clavicle cles
below up to the occipital bone above (Fig. 39.1). Semispinalis capitis
Boundaries Splenius capitis
Anterior boundary is formed by posterior Levator scapulae
border of sternomastoid. Scalenus medius
Posterior boundary is formed by anterior Contents (Fig. 39.2)
border of trapezius.
A. The arteries are, part of occipital artery, third
The base or inferior boundary is formed by
middle one-third of clavicle. part of subclavian artery and its two
The apex or superior boundary is formed branchestransverse cervical and supra
by the superior nuchal line of occipital bone. scapular.
The roof is formed by the investing layer of i. The occipital artery, a branch of external
deep cervical fascia, covered by superficial carotid artery, can be seen at the apex
fascia, platysma and skin. of triangle, at superior nuchal line.

Fig. 39.1: The posterior triangle of the neckboundaries

428 Essentials of Human Anatomy
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 supra-
scapular 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
sterno-mastoid 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.
 The Triangles of the Neck
It lies in lower part of posterior
triangle (subclavian triangle),
super-ficial 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.
iii. The supraclavicular part of brachial
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
trape-zius 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 sterno-
mastoid.
The greater auricular branch (ventral
ramus C2, C3) 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 man-
dible.
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 sterno-
mastoid.
From ventral ramus C3,C4 the
levator scapulae and trapezius.
From ventral ramus C3,C4 C5 phre-
nic nerve arises to supply diaphragm.
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 C7
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 Essentials of Human Anatomy
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 C5, 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 sym-
pathetic 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
 The Triangles of the Neck 431

Fig. 39.3: The suboccipital triangle

Rectus capitis posterior major THE ANTERIOR TRIANGLE

Rectus capitis posterior minor OF THE NECK
Semispinalis capitis The anterior triangle consists of part of neck that
It gives one communicating branch to lies in front of sternomastoid muscle.
greater occipital nerve. Boundaries (Fig. 39.4)
3. The suboccipital venous plexus receives Anteriorly
the following veins: Anterior median line of the neck

Occipital veins
Posteriorly
Muscular veins of back of neck Anterior border of sternomastoid
Deep cervical vein Superiorly
Emissary vein of posterior condylar canal Base of mandible

Table 39.1: Sub-occipital muscles

S.No. Name Origin Insertion Main actions

1. Rectus capitio Posterior tubercle Medial part of area below 1. Extends the head
posterior minor of atlas vetebra inferior nuchal line
on occipital
2. Rectus capitis Spine of axis vertebra Lateral part of area below 1. Extends the head
posterior major lnferior nuchal line on 2. Turns face to same side
occipital
3. Obliques capitis Spine of axis vertebra Transverse process of 1. Turns face to same side
inferior atlas vertebra
4. Obliques capitis Transvase process of Lateral area between 1. Turns face to same side
superior atlas vertebra superior and inferior nuchal
lives of occipital
 432 Essentials of Human Anatomy

A line drawn from angle of mandible Contents: A few submental lymph nodes, that
to the tip of mastoid process drain lymph from tip of tongue and median
Apex part of lower lip and chin.
Lies below at the suprasternal notch of II. The digastric triangle lies in upper part of
manubrium sterni front of neck below mandible.
Boundaries
Subdivisions of the Anterior Triangle Superiorly
Base of mandible
The anterior triangle is subdivided into four
Antero-inferiorly
smaller trianglessubmental, digastric, carotid
Anterior belly of digastric
and mus-cular.
I. The submental triangle (Half portion lies in Postero-inferiorly
Posterior belly of digastric
each anterior triangle). Stylohyoid muscle

The small triangle lies above the body of Roof(superficial boundary) deep cervical
hyoid bone. fascia

Boundaries Floor(deep boundary):
Apex lies at the symphysis menti. Mylohyoid Hyoglossus
Base lies at the body of hyoid bone.
Floor (inferior boundary) is formed by the Contents
deep cervical fascia. Submandibular salivary glands that
Roof (superior boundary) is formed by the overlaps both bellies of digastric
two mylohyoid muscles. Submandibular lymph nodes
Two sides are formed by anterior bellies of Part of facial arteryand its submental
the two digastric muscles. branch

Fig. 39.4: The anterior triangle of the necksubdivisions

 The Triangles of the Neck 433

Fig. 39.5: The carotid triangle

Mylohyoid nerve i. The superior thyroid artery

Part of hypoglossal nerve ii. The ascending pharyngeal artery
III. The carotid triangle is the largest and most iii. The lingual artery
important part of anterior triangle (Fig. 39.5). iv. The facial artery
Boundaries v. The occipital
Posteriorly artery b. The Veins
Anterior border of sternomastoid The internal jugular vein, that mostly
Antero-superiorly lies deep to sternomastoid muscle.
Posterior belly of digastric Tributaries of internal jugular vein
Antero-inferiorly Superior thyroid vein
Superior belly of omohyoid Lingual veins

Roof(superficial boundary) deep cervical Pharyngeal veins

fascia Common facial vein

Floor c. The nerves

The lateral wall pharynx formed by i. Vagus nerve and its superior laryngeal
inferior and middle constrictor muscles branch that divides into external
laryngeal nerve (that supplies
Thyrohyoid membrane, thyrohyoid
cricothyroid muscle) and
muscle
Internal laryngeal nerve (that
Part of hypoglossus above hyoid bone pierces thyrohyoid membrane and
Contents supplies sensory fibers to larynx
a. The arteries above vocal cords).
Parts of common carotid, internal ii. Spinal accessory nerve crosses upper
carotid and external carotid arteries. part of triangle and pierces sterno-
Five branches of external carotid artery mastoid.
 434 Essentials of Human Anatomy

Fig. 39.6: Ansa cervicalis

iii. Hypoglossal nerve curves forwards and

It supplies branches to
medially in upper part of triangle to enter Superior belly omohyoid
submandibular region above hyoid bone. Inferior belly omohyoid
It gives two branches in carotid Sternohyoid
triangle Sternothyroid
Nerve to thyrohyoid d. The lymph nodes Many deep cervical

Superior limb of ansa cervicalis lymph nodes lie along the internal jugular

iv. Ansa cervicalis is a nerve loop that lies vein.

in front of internal and common IV. The muscular triangle forms the lower
and anterior part of anterior triangle of neck.
carotid arteries. (Fig. 39.6)
Boundaries
It is firmed by two limbs
Anteriorly Anterior median line of neck
a. Superior limb from hypoglossal
Postero-inferiorly Lower part of anterior
nerve carrying fibers from ventral
border of sternomastoid
ramus of C1 spinal nerve. b. Postero-superiorly Superior belly of omo-
Inferior limb from the cervical hyoid
plexus, carrying fibers from ventral Contents
rami of C2 and C3 spinal The infrahyoid muscles [Described in
nerves. Chapter 40]
The ansa cervicalis formed by the Sternohyoid
two limbs, lies in front of common Sternothyroid
carotid artery. Thyrohyoid
 CHAPTER 40
The Muscles, Glands, Blood Vessels
and Nerves of the Front of Neck
A. The muscles of the front of the neck (Table Scalenus medius
40.1) are: Scalenus posterior
1. The prevertebral muscles (Fig. 40.1) Scalenus minimus (pleuralis)
Anterior group 2. The muscles of the anterior triangle
Rectus capitis anterior Sternomastoid
Rectus capitis lateralis Infrahyoid muscles
Longus capitis Sternohyoid, sternothyroid, thyrohyoid
Longus colli and omohyoid
Lateral group Supra hyoid muscles
Scalenus anterior Digastric

Fig. 40.1: The prevertebral muscles

436 Essentials of Human Anatomy

Table 40.1: The muscles of the front of neck

S. Name Origin Muscle belly Insertion Nerve supply Main actions
No.
The prevertebral musclesAnterior group
1. Rectus capitis Anterior surface Short flat muscle Inferior surface Ventral ramus C 1 Flexes head at at-
anterior lateral mass of belly basi-occiput lanto occipital joint
atlas
2. Rectus capitis Upper surface Short flat muscle Inferior surface Ventral ramus C 1 Lateral flexion of
lateralis transverse pro- belly jugular process of head
cess of atlas occipital bone
3. Longus Anterior tubercles Broad above Inferior surface of Ventral rami Flexes the head
capitis of transverse pro- narrow below basilar part of C1, C2, C3
cesses of third occipital bone
to sixth cervical
4. Longus colli Upper oblique Upper oblique I. Flexes the neck
part part forwards
Anterior tuber- Muscle belly con- Anterior tubercle Ventral rami II. The oblique parts
cles of fifth and sists of digitations of atlas C2 to C6 help in lateral
sixth cervical lying on front of Middle vertical part flexion of neck
vertebrae vertebral bodies Bodies of second
Middle vertical to fourth cervical
part vertebrae
Upper three tho- Lower oblique part
racic and lower Anterior tubercle of
three cervical fifth and sixth
vertebrae cervical vertebrae
Lower oblique
part
Upper two tho-
racic vertebral
bodies
The prevertebral musclesLateral group
5. Scalenus Anterior tubercles Muscle belly be- Scalene tubercle Ventral rami I. Flexes the neck
anterior of third to sixth comes narrow and ridge between C4 to C6 antero-laterally
cervical vertebra below subclavian grooves II. Helps to elevate
of first rib the first rib
6. Scalenus Transverse pro- Muscle belly large, Upper surface of Ventral rami I. Flexes the neck
medius cess of axis and long, becomes first rib between c3 to C8 on same side
Posterior tuber- narrow below tubercle and sub- II. Helps to raise
cle of third to clavian groove first rib
seventh cervical
vertebrae
7. Scalenus Posterior tuber- Small and deeply Outer surface of Ventral rami I. Flexes the neck
posterior cles of fourth, placed muscle second rib behind C6, C7, C8 on same side
(absent fifth and sixth belly serratus anterior II. Helps to elevate
sometimes) cervical vertebrae second rib
8. Scalenus Muscle fibers associated with supra pleural membrane
pleuralis (sometimes present).
(minimus)
The muscles of the anterior triangleInfrahyoid muscles
1. Sternomastoid Sternal head A thick muscle Lateral half of Spinal accessory I. Bends head same
Round tendon belly joined by superior nuchal (motor) Ventral side turns face to
Contd...
 The Muscles, Glands, Blood Vessels and Nerves of the Front of Neck 437

Contd...
S. Name Origin Muscle belly Insertion Nerve supply Main actions
No.
anterior surface clavicular head be- line Lateral sur- rami C2, C3, C4 opposite side
manubrium sterni comes flattened face of mastoid (proprioceptive) II. Raises head from
Clavicular head above as it as- process supine position
superior surface cends obliquely III. Elevates thorax if
of medial third of in the neck head fixed
clavicle
2. Sternohyoid Posterior aspect Thin narrow strap- Medial part inferior Ansa cervicalis I. Depresses hyoid
medial end of like muscle belly border body of ventrical rami bone during spee-
clavicle hyoid bone C1, C2, C3 ch mastication
Posterior aspect and deglutition
of manubrium
sterni
3. Sternothyroid Posterior surface Shorter and wider Oblique line of Ansa cervicalis I. Depresses larynx
of manubrium muscle belly lamina of thyroid (Ventral rami (Thyroid cartilage)
sterni cartilage C1, C2, C3) during speech
Posterior aspect and swallowing
of first costal
cartilage
4. Thyrohyoid Oblique line of Small and quadri- Lower border Branch of hypo- I. Depression of
lamina of thyroid lateral muscle belly greater cornu of glossal nerve (fib- hyoid bone or
cartilage hyoid bone res of ventral elevation larynx
ramus C1)
5. Omohyoid Inferior belly Inferior belly flat, Inferior belly on Separate bran- I. Depression of
two belies From supra narrow, band intermediate ten- ches for both hyoid bone in
scapular notch Superior belly don bellies from Ansa prolonged respi-
Superior belly ascends vertically Superior belly cervicalis (Ventral ratory efforts
Intermediate lateral part lower rami C1, C2, C3)
tendon border body of
hyoid bone
6. Platysma Fascia on upper Thin, broad sheet Anterior fibres Cervical branch of I. It causes ridges
part of pectoralis lies in superficial decussate in mid- facial nerve in skin of neck
major fascia on side of line attached to II. Helps in depres-
neck symphysis 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
The supra-hyoid muscles:
1. Digastric Posterior belly Posterior belly Intermediate ten- Posterior belly I. Helps in depress-
Mastoid notch of longer and taper- don passes Facial nerve ion of mandible
temporal bone ing Anterior belly through a fibrous Anterior belly II. Helps to elevate
Anterior belly shorter pulley attached to Mylohoid nerve the hyoid bone
Digastric fossa hyoid bone
at lower border
of mandible
Contd...
438 Essentials of Human Anatomy

Contd...
S. Name Origin Muscle belly Insertion Nerve supply Main actions
No.
2. Stylohyoid Round tendon Narrow slender At insertion tendon Facial nerve I. Helps to elevate
posterior surface muscle belly of digastric divides and retract hyoid
near base of into two parts bone
styloid process attached to hyoid
bone at junction
with greater cornu
3. Mylohyoid Whole length of Flat, triangular Fibrous median Mylohyoid I. Elevates floor of
mylohyoid line muscle belly raphe Posterior branch of in- mouth
of mandible Forms floor of fibres body of ferior alveolar II. Helps to depress
mouth with fellow hyoid bone nerve mandible and ele-
of opposite side vate hyoid bone
4. Geniohyoid Lower mental Narrow muscle Anterior aspect Branch of hypo- I. Elevates hyoid
spine of mandible belly lies in para- body of hyoid glossal carrying bone
median position bone fibres of Ventral II. Helps in depress-
ramus C1 ing mandible

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 thyro-
calcitonin.
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 Fig. 40.2: The thyroid glandanterior aspect
It is nearly 1.2 cm vertically and trans-
The upper pole extends up to the oblique
versely.
line of thyroid cartilage.
It lies in front of second to fourth tracheal
The lower end reaches up to fifth tracheal
rings. ring.
It is a midline structure of neck, covered The lateral surface is covered by three
only by skin and fasciae. layers of muscles (Fig. 40.3):
The lateral lobes are conical in shape
Sternomastoid
Each lobe is about 5.0 cm long, 3.0 cm Sternohyoid and superior belly omohyoid
broad and 2.0 cm wide. Sternothyroid
 The Muscles, Glands, Blood Vessels and Nerves of the Front of Neck 439

Fig. 40.3: TS of neckshowing relations of thyroid gland

The medial surface is related to: Two parathyroid glandssuperior and

Lateral wall of pharynx inferior
Trachea A small conical pyramidal lobe is often
External laryngeal nerve and present, along upper border of isthmus of gland.
cricothyroid muscle A fibrous cord thyroglossal duct may also be
Recurrent laryngeal nerve in tracheo-
present from the apex of pyramidal lobe to body of
esophageal groove
hyoid bone. It may rarely, contain some muscle
The posterior surface is related to (Fig. 40.4):
The carotid sheath (common carotid artery) fibers and is called levator glandulae thyroideae.
Inferior thyroid artery
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
Fig. 40.4: The thyroid glandposterior surface pole of thyroid lobe. It gives a branch to
showing parathyroid gland supply larynx.
440 Essentials of Human Anatomy
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 end in internal
ii. The middle thyroid jugular vein
vein
iii. The inferior thyroid vein passes
downwards on front of trachea and ends in
brachio-cephalic vein.
The Lymphatic Drainage
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 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 rest of diverticulum may persist as a
fibrous cordthyroglossal duct
Parafollicular cells of thyroid gland develop
from - IVth pharyngeal pouch.
Anomalies of Thyroid Gland
Ectopic Thyroid
The lingual thyroid
The suprahyoid thyroid
The infrahyoid thyroid
The retrosternal thyroid
Applied Anatomy
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 symp-
toms.
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.
 The Muscles, Glands, Blood Vessels and Nerves of the Front of Neck
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 thyroid-
ectomy 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
levelinter-vertebral 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 baro-
receptor.
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 Essentials of Human Anatomy
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
external carotid artery.
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).
Fig. 40.5: The external carotid artery
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
bran-chessuperficial 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
laryn-geal branch, that pierces
thyro-hyoid membrane, along
with internal laryngeal nerve,
and supplies larynx.
A sternomastoid branch that
supplies sternomastoid muscle.
 The Muscles, Glands, Blood Vessels and Nerves of the Front of Neck
2 The ascending pharyngeal artery
ascends upwards along the pharyn-
geal 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 poste-
rior 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 Essentials of Human Anatomy

It gives Third partextends from lateral border of

Atransverse facial arteryto scalenus anterior to outer border of 1st rib.
the upper part of the face. Relations
Theauricular branchesto First part
supply the auricle. Anterior
Azygomatico-orbital branch Common caroted artery
that runs along upper border Internal jugular vein
of zygomatic arch. Vagus nerve
Amiddle temporal branch
Cardiac branches of vagus and sym-
that pierces the temporal
pathetic trunk
fascia and temporalis muscle
Vertebral vein
and lies in a groove on side
Phrenic nerve
of skull. on left side
The two terminal branches Thoracic duct
frontal and temporal,that Ansa subclavia
supply scalp (including fore- Posterior
head) and superficial tem- Suprapleural membrane
Cervical pleura
poral region.
Apex of lung
SUBCLAVIAN ARTERY Recurrent langugeal nerve (Right side)
The subclavian artery is an important artery at root Ansa subclavia
of neck. It continues as the main artery of upper Second part
limb, but it also supplies important structures of Anterior
neck and part of brain by its branches. Scalenus anterior
Origin Structures in front of scalenus anterior
On right sidethe subclavian artery arises Right phrenic nerve
from brachio-cephalic artery Transverse cervical and suprascapular
On left sidethe subclavian artery arises artery
from arch of aorta. It ascends and enters the Sternomastoid
neck behind left sterno-clavicular joint. Posterior
Course Suprapleural membrane
Both arteries have a similar course in neck. Cervical pleura
Each artery curves laterally above the Apex of lung
cervical pleura and apex of lung in the Superior
root of neck. Upper and middle trunks of brachial
The artery passes from the sterno-clavicular plexus
joint to outer border of 1st rib, where it Third part
ends by continuing as axillary artery. Anterior
For purpose of description the artery is Suprascapular vessels
divided into three parts by scalenus Subclavian vein
anterior muscle. External jugular vein
First partextends from sternoclavicular Transverse cervical vein
joint to medial border of scalenus anterior Subclavius
Second partis short segment of artery that Middle 1/3rd of clavicle
lies behind scalenus anterior Sternomastoid
 The Muscles, Glands, Blood Vessels and Nerves of the Front of Neck
Posterior
Scalenus medius
Lower trunk of brachial plexus
Suprapleural membrane
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.
i. 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
iv.
foramen magnum and enters skull. In
ends at lower border of pons by
uniting with fellow of opposite side to
form the basilar artery.
ii. Internal thoracic artery
[Described in Chapter 21]
iii. Thyro-cervical trunkis a short wide
vessel that arises close to medial border of
scaler-nus 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.
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 down-
wards 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]
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 artery
that descends in front of neck Ist
rib and divides to give rise to
posterior inter-costal artery for 1st
and 2nd inter-costal space.
b. The deep cervical arterypasses
backwards between transverse
process of 7th cervical vertebra and
neck of 1st rib.
 446 Essentials of Human Anatomy
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.
Fig. 40.6: The internal jugular veins
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 conti-
nuation of sigmoid sinus in posterior part of
jugular foramen.
It passes downwards, forwards and medially-
enclosed 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.
 The Muscles, Glands, Blood Vessels and Nerves of the Front of Neck
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)
The Lymphatic Drainage of the
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 Essentials of Human Anatomy
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 sym-
pathetic 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 atympanic plexuson 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.
 The Muscles, Glands, Blood Vessels and Nerves of the Front of Neck
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.
2. The Vagus Nerve (the X cranial nerve)
Type mixed nerve.
Functional components and distribution
(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 sym-
pathetic 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.
iii. The pharyngeal branch joins the
pharyngeal plexus of nerves and
provides its motor component.
iv. 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.
v. The cardiac branches two to three in
number, join the cardiac plexuses.
vi. 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.
Functional components and distribution
(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 Essentials of Human Anatomy
It turns laterally, crosses upper part
of internal jugular vein (superficially
but sometimes deep to it).
It enters sternomastoid muscle and
supplies it.
It appears at about middle of poste-
rior 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.
Functional components and distribution
(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 sym-
pathetic chain.
Vagus nerve.
Ventral ramus of first cervical nerve.
Lingual nerve (in submandibular region).
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
infra-hyoid 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 palato-glossus).
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.
 The Muscles, Glands, Blood Vessels and Nerves of the Front of Neck
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 para-
thyroid 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 cervico-
thoracic 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).

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
CHAPTER 41
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
 The Viscera of the Head and Neck1
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 con-
cha.
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 muco-
periosteum containing a plexus of minute veins
453
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 Essentials of Human Anatomy
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.
 The Viscera of the Head and Neck1
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
poste-rior 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 fibro-
cartilage.
It is attached to hyoid bone by hyo-
epiglottic 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 glosso-
epiglottic 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 Essentials of Human Anatomy
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.
Fig. 41.4: The skeletal framework of the larynx
posterior aspect
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 carti-
lage to the vocal folds.
 The Viscera of the Head and Neck1 457

Figs 41.5A to C: The intrinsic muscles of the larynx

The Muscles of the Larynx Inferiorly by interarytenoid fold

The muscles of the larynx are divided in two On two sides aryepiglottic folds
groups: a. The extrinsic muscles connect the Corniculate and cuneiform tuber-cles
cartilages of larynx with neighboring bones and
lie outside laryngeal wall. The cavity of the larynx is divided into three
These are infra-hyoid muscles. parts: (Fig. 41.7)
[Described in Chapter 40]
a. The upper part above the vestibular fold, is
b. The intrinsic muscles form a part of
laryngeal wall (Table 41.1 and Fig. 41.5). known as vestibule of larynx.
These are further divided into: b. The middle part is a small recess between
i. The cricothyroid, the only intrinsic muscle the vestibular and vocal folds.
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.

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 Essentials of Human Anatomy

It is called the sinus of the larynx. A pouch of

mucous membrane, the saccule of larynx,
extends upwards in persons who have pro-
fession 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

The vocal folds are a pair of prominent folds in
the lateral wall of larynx, between the middle and
Fig. 41.7: The cavity of the larynxcoronal section lower subdivisions of the cavity of larynx.
Table 41.1: The intrinsic muscles of the larynx

S. Name Origin Muscle belly Insertion Nerve supply Main actions

No.
1. Cricothyroid Arch of cricoid Small triangular Lower border and External laryngeal 1. Tensor of vocal
cartilage muscle belly inferior cornu of nerve cord
thyroid cartilage
The rest of the intrinsic muscles
2. Posterior crico Posterior surface Flat muscle belly Posterior surface Recurrent laryn- 1. Only abductor of
arytenoid lamina of cricoid Fibers converge muscular process geal nerve vocal cords
cartilage above for arytenoid cartilage
insertion
3. Oblique Apex of Two muscle slips Muscular process Same 1. Adductor of
arytenoid arytenoid cross each other of opposite ary- vocal cords
like X tenoid
4. Transverse Posterior surface Muscle fibers Posterior surface Recurrent laryn- 1. Adductor of
arytenoid of one arytenoid pass transversely of opposite ary- geal nerve vocal cord
Muscle belly tenoid
lies in median
plane
5. Aryepi- Apex of ary- Muscle belly Side of epiglottis Same 1. Narrows the inlet
glotticus tenoid cartilage slender of larynx
Appears as
continuation of
oblique arytenoid
6. Lateral crico- Superior surface Muscle fibers con- Anterior surface Same 1. Adductor of the
arytenoid of arch of cricoid verge towards muscular process vocal cord
cartilage insertion of arytenoid
cartilage
7. Thyro- Inner surface Muscle belly fills Antero lateral Same 1. Relaxes the vocal
arytenoid thyroid cartilage the space deep to surface of ary- cords
near angle thyroid cartilage tenoid cartilage
8. Vocalis Is the part of thyro-arytenoid that lies within vocal folds.
9. Thyroepiglo- Inner surface Muscle belly Epiglotticus Same 1. Widens the inlet
ticus of thyroid carti- slender of larynx
lage near its
angle
 The Viscera of the Head and Neck1
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 thyroaryte-
noid.
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 crico-
thyroid 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.

THE DIGESTIVE SYSTEM
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 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.
CHAPTER 42
The Viscera of the
Head and Neck2
THE PALATE
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 mem-
brane, 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 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.
 The Viscera of the Head and Neck2 461

Table 42.1: The muscles of the soft palate

S. Name Origin Muscle belly Insertion Nerve supply Main actions

No.
1. Tensor veli Scaphoid fossa of Thin and triangular Palatine aponeu- Mandibular nerve I. Tenses soft palate
palatini pterygoid process muscle belly rosis by tightening
(Tensor Lateral surface Fibers converge palatine aponeu-
palati) cartilage of audi- to form a tendon rosis
tory tube that hooks around II. Helps to open the
Spine of sphenoid pterygoid hamulus auditory tube
2. Levator veli Rough area on Cylindrical muscle Superior surface Cranial part of I. Elevates the soft
palatini inferior surface belly of palatine accessory via the palate
(Levator of petrous tem- aponeurosis pharyngeal
palati) poral branch of vagus
3. Palatoglossus Inferior surface Small narrow Side of tongue Same I. Elevates the root
of palatine apo- fasciculus of tongue
neurosis Lies inside II. Closes the oro-
palato-glossal pharyngeal isth-
fold mus
4. Palato- Posterior fasci- The fasciculus I. Posterior fasci- Cranial accessory I. Pulls the pharynx
pharyngeus culus descend in palato- culi joins the fellow via the pharyngeal upwards and for-
(two bundles) Superior aspect pharyngeal arch in median plane branch of vagus wards during
of palatine apo- swallowing
neurosis
Anterior fasci- Two fasciculis Posterior border
culus-palatine are separated by of thyroid
aponeurosis and levator veli palatini cartilage
posterior border
of hard palate
5. Musculus Posterior nasal Two fasciculi lie Muscus Same I. Helps to elevate
uvulae spine of palatine inside the split membrane and retract the
bone palatine aponeuro- of uvula 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
The motor nerves are:
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
iii. The lesser palatine nerves supply soft palate.
These nerves carry sensory fibers of maxi-
llary nerve, that pass via the pterygo-palatine
ganglion.
iv. The glossopharyngeal nerve also supplies
soft palate.
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 pharyn-
geal branch of vagus supplies the rest of

nasopalatine nerves } the muscles of soft palate.

462 Essentials of Human Anatomy
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
surroun-ding 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.
 The Viscera of the Head and Neck2
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)
Nerve Supply of Teeth
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.
Fig. 42.1: The dorsum of tongue
463
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.
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.
464 Essentials of Human Anatomy
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 depres-
sed 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 pro-
jections 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.
Fig. 42.2: The lingual papillae
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 epi-
thelium.
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.
 The Viscera of the Head and Neck2 465
Table 42.2: The muscles of the tongue

S. Name Origin Muscle belly Insertion Main actions

No.
A. The Extrinsic Muscles
I. Hyoglossus Superior surface of Flat and quadrangular Lateral border of I. Depreses the side
greater cornu of Fibers ascend up tongue of tongue
hyoid bone vertically
II. Styloglossus Antero lateral surface Slender muscle belly Lateral border of I. Draws the tongue
near tip of styloid Descends forwards tongue lateral to upwards and
process and medially hyoglossus backwards
III. Genioglossus Upper mental tubercle Fan shaped muscle Inferior (ventral) I. Makes the dor-
of mandible belly Fibers ascend surface of tongue sum hollow
upwards deep to Lower fibers sup- II. Helps to protrude
hyoglossus erior surface body the tongue
of hyoid
IV. Palatoglossus [Described along with muscles of soft palate]
B. The Intrinsic Muscles
1. Superior Submucous tissue Muscle belly forms a Mucous membrane I. Turns the tip up-
longitudinal near epiglottis bundle just deep to near dorsum of tip of wards
the dorsal epithelium tongue II. Makes tongue
shorter and wider
2. Inferior Submucous tissue Muscle belly forms a Mucous membrane I. Turns the tip
longitudinal near root of tongue fasciculus that turns on ventral surface downwards
forwards between near tip of tongue II. Makes tongue
Hyoglossus and shorter and wider
genioglossus
3. Transversal Fibrous median sep- Muscle fibers cross Lateral border of I. Makes the tongue
linguae tum of tongue transversely tongue longer and
narrower
4. Vertical Dorsum of tongue Muscle fibers des- Ventral surface II. Makes the tongue
linguae cends vertically of 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
Fig. 42.3: The extrinsic muscles of tonguelateral view bone.
466 Essentials of Human Anatomy
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 sub-
lingual 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, jugulo-
digastric and jugulo-omohyoid lymph
nodes of same side.
b. The central lymphatics drain lymph from
the central part of lymph plexuses.
 The Viscera of the Head and Neck2
They course medially and pierce the
fibrous median septum of tongue.
They end in submandibular, jugulo-
digastric 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, glossopharyn-
geal 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 sub-
mandibular 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 Essentials of Human Anatomy
Fig. 42.5: The structures deep to mylohyoid muscle
The sympathetic nerves are derived from the
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
submandi-bular 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.
 The Viscera of the Head and Neck2
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 hypo-
glossal 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 eso-phagus
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 Essentials of Human Anatomy

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 pharynx-
Passavants ridge, caused by the post-
erior part of palato-pharyngeus.
Anteriorly oropharyngeal isthmus is boun-
ded by:
Dorsum of tongue
Two palatoglossal folds
Soft palate
Laterally is a triangular depression
tonsillar fossabounded:
Anteriorly by palato-glossal fold
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 conti-
nuous with the esophagus.
The Palatine Tonsil
The palatine tonsilis a mass of lymphoid tissue

Posteriorly by palato-pharyngeal fold in the lateral wall of oropharynx (Fig. 42.7).

Palatine tonsil lies in the tonsillar fossa Location: The tonsil occupies the triangular
Inferiorlythe boundary is formed by upper tonsillar fossa between palato-glossal and
border of epiglottis. palato-pharyngeal arches.
3. The laryngo-pharynx or lower subdivision of Extent: The palatine tonsil extends from the
pharynx extends from cranial border of epiglottis up dorsum of tongue below up to soft palate above.
to the lower border of cricoid cartilage (vertebral Surfaces: The tonsil has two surfaces
levelsixth cervical vertebra). medial and lateral.
 The Viscera of the Head and Neck2
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
tonsilsPalati
ne 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
external carotid artery.
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 glossopharyn-
geal supplies sensory fibers to the middle ear.
The Pharyngeal Musculature
The wall of the pharynx has the following layers:
472 Essentials of Human Anatomy

1. The buccopharyngeal fascia. The Gaps in the Pharyngeal Wall

2. The constrictor musclessuperior, middle I. The highest gap is between the base of skull
and inferior. and upper border of superior constrictor muscle.
The other pharyngeal musclesstylopharyn- Two musclestensor veli palatini and levator
geus, palato-pharyngeus and salpingo- veli palatine fill up this gap.
pharyngeus. II. The gap betwen superior and middle
3. The pharyngo basilar fasciathick at the constrictors.
gaps between constrictor muscles. The stylopharyngeus enters through
4. The submucous coat. muscle this gap
5. The mucous membrane. The glosso pharyngeal nerve
The constrictor muscles of the pharynx (Table III.The gap between middle and inferior
42.3) are arranged like three vases put inside constrictor.
the other, i.e. the upper border of inferior The internal laryngeal enters through
constrictor overlaps middle constrictor muscle nerve this gap
and the upper border of middle constrictor The superior laryngeal artery
overlaps the superior constrictor muscle (Fig. IV. The gap at the lower border of inferior
42.8). constrictor.
There are also gaps between the constrictor The inferior laryngeal passes through
muscles in the pharyngeal wall through which artery this gap.
the vessels and nerves enter the pharyngeal wall. The recurrent laryngeal nerve

Fig. 42.8: The muscles of pharynx

 The Viscera of the Head and Neck2 473
Table 42.3: The constrictor muscles of the pharynx

S. Name Origin Muscle belly Insertion Nerve supply Main actions

No.
1. Inferior Side of cricoid Thick and trian- Fibrous median Pharyngeal I. Helps in passage
constrictor cartilage gular muscle raphe on back of plexus of nerves of food
belly pharynx (cranial part of
Oblique line of Fibers ascend accessory)
thyroid cartilage upwards and Recurrent
medially Laryngeal nerve
2. Middle Lower part sty- Fan shaped Fibrous median Same Same
constrictor lohyoid ligament muscle belly raphe
Lesser cornu
hyoid bone
Whole length
upper border
greater cornu
of hyoid bone
3. Superior Pterygoid Thin and Fibrous median Same Same
constrictor hamulus quadrangular raphe
Pterygo- muscle belly Some fibers
mandibular reach pharyn-
ligament geal tubercle of
Posterior end basi-occiput
of mylohyoid
line
Side of tongue
4. Stylo- Medial side base Long and Posterior border Glossopharyn- I. Elevates the
pharyngeus of styloid process slender muscle of thyroid cartilage geal nerve pharynx during
belly swallowing and
Passes between speech
middle and
superior cons-
trictor muscles
5. Salpingo- Tubal elevation Thin and long mus- Posterior border Pharyngeal I. Elevates the
pharyngeus cle belly lies in a of thyroid carti- plexus of nerves pharynx during
fold lage (cranial swallowing and
accessory) speech
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
external carotid artery.
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.
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 Essentials of Human Anatomy
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 tracheo-
esophageal 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
sym-pathetic trunk).
 The Head and Neck
Multiple Choice Questions

Q.1. Select the one best response to each 7. The maxillary nerve leaves the skull by:
question from the four suggested A. Foramen ovale
answers: B. Foramen spinosum
1. Which layer of the scalp is known as the C. Foramen lacerum
dangerous layer of the scalp: D. Foramen rotundum
A. Dense connective tissue 8. The air sinus that drains by gravity is:
B. Epicranial aponeurosis A. Maxillary sinus
C. Loose areolar tissue B. Frontal sinus
D. Pericranium C. Ethmoidal sinuses
2. The facial vein terminates usually in: D. Sphenoidal sinus
A. Pterygoid venous plexus 9. The taste sensation is lost from posterior
B. External jugular vein third of tongue, which of the following
C. Anterior jugular vein
cranial nerves are involved:
D. Internal jugular vein
A. Facial
3. The parotid duct opens in the vestibule of B. Vagus
mouth opposite: C. Glossopharyngeal nerve
A. Second upper molar tooth D. Maxillary nerve
B. First upper molar tooth
C. Third upper molar tooth 10. Which of the following muscles is partly
D. Canine tooth inserted on the articular disc of temporo-
mandibular joint:
4. The muscle used for blowing out air from A. Lateral pterygoid
the mouth is: B. Medial pterygoid
A. Zygomaticus major C. Masseter
B. Levator labii superioris
D. Temporalis
C. Risorius
D. Buccinator 11. The skin of the tip of nose is innervated by:
5. The crista galli gives attachment to: A. Buccal nerve
A. Falx cerebri B. Infraorbital nerve
B. Falx cerebelli C. External nasal nerve
C. Diaphragma sellae D. Facial nerve
D. Tentorium cerebelli 12. The superior laryngeal artery is a branch of:
6. Which of the following nerves have motor A. Facial artery
supply: B. Lingual artery
A. Lesser occipital B. Suboccipital C. C. Superior thyroid artery
Greater occipital D. Third occipital D. Vertebral artery
476 Essentials of Human Anatomy
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
glosso-pharyngeal 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.
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
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
crosses the lower part of the triangle.
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 submandi-
bular 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.
 Multiple Choice Questions 477

24. The cranial nerves that pass through the 3. Lateral pterygoid C. Facial
cavernous venous sinus: 4. Cricothyroid D. Spinal accessory
1. Oculomotor
2. Trochlear 28. Important features
3. Abducent 1. Thyroid gland A. Lingual tonsil
4. Ophthalmic division of trigeminal 2. Posterior third B. Middle meatus
25. The nasal septum is formed by: tongue of nose
3. Bulla ethmoi- C. Isthmus
1. The perpendicular plate of ethmoid
2. Septal cartilage dales
3. Vomer 4. Tubal elevation D. Naso pharynx
4. Maxilla 29. Branch of main arterial trunk
Q.3. Match the structures on the left with their 1. Thyro-cervical A. Arch of aorta
related structures on the right: trunk
26. Foramina of skull 2. Lingual artery B. Subclavian artery
1. Foramen ovale A. Vertebral artery 3. Ophthalmic C. External carotid
2. Foramen spino- B. Emissary vein artery
sum spinosum 4. Thyroidea ima D. Internal carotid
3. Posterior condy- C. Middle meningeal 30. Type of joint
lar canal artery
1. Temporomandi- A. Synostosis
4. Foramen mag- D. Mandibular nerve
bular joint
num
2. Symphysis menti B. Pivot joint
27. Nerve supply of muscles: 3. Median at lanto- C. Condyloid joint
1. Sternomastoid A. Mandibular occipital joint
2. Orbicularis B. External laryngeal 4. Intervertebral D.
oculi nerve Secondary carti-
disc laginous joint

Answers

A1. The answer is C. fossae. The external jugular and anterior

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.
A2. The answer is D.
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
jugular veins drain venous blood from
super-ficial structures of neck and scalp.
A3. The answer is A.
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 Essentials of Human Anatomy
A4. The answer is D.
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.
A5. The answer is A.
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.
A6. The answer is B.
T suboccipital nerve is the dorsal ramus of
C1 spinal nerve. It gives five muscular
branches to the boundary muscles of
subocci-pital triangle. The lesser occipital,
greater occipital and third occipital carry
only sensory fibers for the skin of scalp.
A7. The answer is D.
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.
A8. The answer is B.
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 eth-
moidalis and hiatus semilunaris respectively.
The sphenoidal air sinus opens in spheno-
ethmoidal recess. All these sinuses do not
drain by gravity.
A9. The answer is C.
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.
A10. The answer is A.
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.
A11. The answer is C.
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.
A12. The answer is C.
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.
A13. The answer is D.
The hypoglossal nerve leaves the skull through
anterior condylar canal. The jugular foramen
 Multiple Choice Questions
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.
A14. The answer is A.
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).
A15. The answer is B.
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
crosses the lower part of the triangle.
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.
A18. The answer is B (1, 3).
The carotid body is present at the
bifurcation of common carotid artery. It is a
chemo-receptor, 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.
A21. The answer is D (4).
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.
A22. The answer is D (4).
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 glosso-pharyngeal nerve.
A23. The answer is B (1, 3).
The chorda tympani nerve carries the
parasympathetic fibers for the submandibular
and sublingual salivary glands, and taste fibers
480 Essentials of Human Anatomy
from the anterior two-third of tongue are
carried by the lingual branch of mandibular
nerve. The motor fibers to the stytopharyn-
geus 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.
A25. The answer is A (1, 2, 3).
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 con-
dyloid type of joint.
The symphysis menti is actually a syno-
stosis 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.
 The Spinal Cord, Brain, Eyes
and the Ears Eight
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).
CHAPTER 43
The Spinal Cord
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 Essentials of Human Anatomy
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 accom-
pany 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.
 The Spinal Cord 483

The spinal nerve rootsEach spinal nerve is c. The anterior white column lies between the
attached by two spinal nerve roots on the side of most lateral attachment of rootlets of anterior
spinal cord: nerve root and ventral median fissure.
a. The posterior (dorsal) nerve root carries Each of these three columns contains three
afferent somatic and visceral nerve fibers. types of nerve tracts (Table 43.1):
It has got a dorsal root ganglion (DRG) i. The ascending (sensory) nerve tracts carry
near the inter-vertebral foramen, that has sensory impulses from the spinal cord to
pseudo-unipolar nerve cells and relays all different parts of brain.
the sensory fibers of the dorsal nerve root. ii. The descending (motor) nerve tracts carry
motor impulses from different parts of brain
b. The anterior (ventral) nerve root carries the to the spinal cord.
efferent somatic fibers and preganglionic iii. The inter-segmental tracts (fasciculi
visceral motor fibers. proprii) are short relay tracts,
The two nerve roots pierce the dural tube interconnecting segments of the spinal cord.
separately and unite in the intervertebral foramen There are three inter-segmental tracts one
to form the stem of the spinal nerve. for each anterior, posterior and lateral white
columns (Fig. 43.2).
The Internal Structure
The spinal cord has grey matter inside (forming The Nerve Tracts in Posterior
an H-shaped appearance in TS) surrounded by White Column
white matter. Ascending Tracts
The grey matter consists of following parts: Fasciculus gracilis
i. The posterior grey column (PGC) Fasciculus cuneatus
containing connector (sensory) neurons. Descending Tracts
ii. The anterior grey column (AGC)
Nil
containing efferent (motor) neurons.
iii. The central grey commissure that surrounds
The Nerve Tracts in Lateral
the central canal and has mostly neurolgial
White Column
tissue.
There is also a lateral grey column (LGC) Ascending Tracts
(from T1 spinal segment to L1 spinal segment) Dorso-lateral
that contains visceral connector (preganglionic) Posterior spino-cerebellar
neurons. Anterior spino-cerebellar
The white matter of the spinal cord is divided into Spino-olivary
three partscolumns or funiculi. Spino-tectal
a. The posterior white column lies between Lateral spinothalamic
posterior median septum and postero-lateral Descending Tracts
sulcus. Rubrospinal
b. The lateral white column lies between the Lateral corticospinal
postero-lateral sulcus and most lateral Lateral reteculospinal
attachment of rootlets of anterior nerve root. Olivospinal
484 Essentials of Human Anatomy

Table 43.1: The ascending and descending tracts of the spinal cord

S. Name Function Crossed Spinal Beginning Termination

No. uncrossed segment
The Ascending Tracts
1. Fasciculus Conscious proprio- Uncrossed S5 to T7 Dorsal root ganglion Nucleus gracilis
gracilis ception cells
Discriminatory
touch
2. Fasciculus Vibratory sense Uncrossed T1 to T6 Dorsal root ganglion Nucleus cuneatus
cuneatus Stereognosis cells
3. Dorsolateral Pain and Uncrossed C1 to S5 Dorsal root ganglion Substantia gelati-
(Lissauers) Temperature Ascends for 1-5 cells nosa of posterior
segments grey column
4. Lateral Pain and Crossed C1 to S5 Substantia gelatinosa Postero lateral ven-
spinothalamic Temperature from of posterior grey tral nucleus of
opposite half of column thalamus
body
5. Anterior Touch (crude) and Crossed C1 to S5 Posterior grey column Postero-lateral
spinothalamic pressure from oppo- of opposite side ventral nucleus of
site half of body thalamus
6. Spinotectal Afferent limb of Crossed C1 to C8 Posterior grey column Tectum-superior
reflex movement of opposite side colliculus of mid-
of eyes and head brain
towards source
of stimulation
7. Posterior Unconscious pro- Uncrossed C1 to L2 Thoracic nucleus of Vermis of cere-
spinocere- prioception posterior grey clumn bellum (via inferior
bellar cerebellar peduncle)
8. Anterior Cerebellum adjust- Uncrossed C1 to L2 Posterior grey column Vermis of cere-
spino- ments of muscle same opposite side bellum (via superior
cerebellar tone cerebellar peduncle)
9. Spinoolivary Proprioceptive Uncrossed C1 to S5 Posterior grey column Dorsal and medial acc-
sense essory olivary nuclei
The Descending Tracts
1. Lateral Main motor Crossed C1 to S5 Motor area of cortex Anaterior grey column
corticospinal tract (upper motor neurons) cells alpha motor
neurons
2. Anterior Main motor tract Uncrossed C1 to S5 Motor area of cortex Anterior grey column
corticospinal (upper motor neurons) alpha motor neurons
3. Rubrospinal Efferent pathway Crossed C1 to S8 Red nucleus of mid Anterior grey
for cerebellum and brain column cells
corpus stratum
4. Lateral reti- Extra pyramidal Crossed C1 to S5 Reticular formation of Anterior grey column
culospinal tract grey matter of medulla cells (interneurons)
oblongata
5. Anterior reti- Extra pyramidal Uncrossed C1 to S5 Reticular formation Anterior grey column
culospinal tract mainly of grey matter of pons cells (inter neurons)
6. Olivospinal Extra pyramidal Uncrossed C1 to S8 Inferior olivary nucleus Anterior grey column
tract cells
7. Vestibulospinal Efferent pathway Uncrossed C1 to S5 Lateral vestibular Anterior grey column
for equilibratory nucleus cells
control
8. Tectospinal Efferent pathway Crossed C1 to S5 Superior colliculus Anterior grey column
for visual reflexes
 The Spinal Cord 485

Fig. 43.2: TS of spinal cordcervical partshowing nerve tracts

The Nerve Tracts in Anterior The needle after piercing the skin and
White Column superficial fascia, passes through supraspinous,
Ascending Tract inter-spinous ligaments, dura and arachnoid
Anterior spinothalamic mater to reach the subarachnoid space.
The lumbar puncture is done to diagnose:
Descending Tracts
An intra-cranial hemorrhage
Anterior Renculospinal
A hemorrhage in vertebral canal
Vestibulo-spinal
Tectospinal Increased intracranial pressure due to a
Anterior corticospinal tumor
Infection of meninges
Applied Anatomy II. The spinal anesthesia is done to anesthetise
I. The lumbar puncture is a diagnostic procedure, the spinal nerve roots within the dural tube.
that is done to obtain a sample of cerebrospinal The spinal anesthetic is introduced by the
fluid. lumbar puncture.
The lumbar puncture is done usually between The number of spinal nerves to be
fourth and fifth lumbar spinous processes. anesthetised is controlled by:
(sometimes between third and fourth lumbar Amount of the spinal anesthetic substance
spinous processes). The position of the patient.

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.
CHAPTER 44
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

 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 arach-
noid 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 sub-
arachnoid 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 Essentials of Human Anatomy
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
oblon-gata.
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 cere-
bellum.
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.
 The Meninges and Blood Supply of Brain
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.
489
iii. Postero-medial group from beginning of
posterior cerebral arteries.
iv. Postero-lateral group (two) from lateral
part of posterior cerebral arteries.
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 Essentials of Human Anatomy
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
inter-ventricular 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.
 The Meninges and Blood Supply of Brain 491

It receives the two basal veins, inferior cerebral b. Striate veins draining venous blood from
veins, some cerebellar veins and veins from back corpus striatum, internal capsule and
of midbrain. thalamus.
III. The basal veins are two large veins, that lie c. Deep middle cerebral vein that drains
along the inferior (tentorial) surface of hemisphere. venous blood from insula (submerged
Each vein is formed at anterior perforated area of cortex in depth of lateral sur-
substance by union of three veins: face).
a. Anterior cerebral vein from the medial The basal vein terminates in the great cerebral
surface of hemisphere. vein.

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 develop-
mentally 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 cere-
bellum.
MyelencephalonThe medulla oblon-
gata.
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.
The Medulla Oblongata
The medulla oblongata appears as upper dilated
end of the spinal cord.
CHAPTER 45
The Hind-Brain and
Mid-Brain
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 cere-
bellar 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
Internal Structure
The grey matter shows the following nuclei.
I. The cranial nerve nuclei
 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.
Fig. 45.1: TS medulla oblongataclosed part (at sensory decussation)
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 three-
fourth 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).
494 Essentials of Human Anatomy

The Pons The grey matter in form of diffuse collection of

The pons appears as a bridge between the two grey matter forming nuclei pontis.
halves of the cerebellum, although no fibers pass The white matter has
as such. i. Longitudinal fibers
Location: The pons also lies in the posterior Corticopontine fibers that end in nuclei
cranial fossa, related to the basilar part of pontis
pons and body of sphenoid. form
Parts: The pons is divided into two parts: Corticospinal separate
a. The ventral part (the basilar part) is a new Corticonuclear bundles
addition to the human brain. It continues ii. Transverse fibers arise from nuclei pontis.
as middle cerebellar peduncles. These are second neuron fibers in cortico-ponti-
It forms functionally, an important cell cerebellar pathway that continue in the middle
station in cortico-ponti-cerebellar path- cerebellar peduncle of opposite side.
way. b. The tegmentum of pons shows:
It forms a prominent bulging on front of The grey matter as
pons with basilar sulcus in-between. i. The cranial nerve nuclei
b. The dorsal part (the tegmentum) that Nucleus of abducent nerve
forms the upward continuation of the Nucleus of facial nerve
medulla oblongata. Nucleus of spinal tract of trigeminal
The dorsal surface of pons forms the upper
Motor nucleus of trigeminal
part of the floor of fourth ventricle. Superior sensory nucleus of trigeminal
The vestibular nuclei lateral, inferior and
Internal Structure
superior occupy the lateral part of floor of
a. The basilar part shows: (Fig. 45.2) fourth vertricle.

Fig. 45.2: TS of pons (at level of facial colliculus)

 The Hind-Brain and Mid-Brain
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
colli-culusa 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.
Functional importance
i. The vestibular nuclei act as a relay station
on afferent cerebellar pathway and a
distri-bution station in efferent cerebellar
pathway.
ii. The vestibular nuclei influence the move-
ment 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 Essentials of Human Anatomy

Parts: The midbrain is divided into two part by iii. Inferior colliculus
the cerebral aqueduct. Efferent fibers form a dorsal teg-
i. A dorsal part, tectum, made up of two paired mental decussation and continue as
colliculisuperior and inferior. tecto-spinal tract.
ii. A ventral part made up of two cerebral b. The inferior colliculus has a compact
peduncles nucleus and acts as a relay station for
Each peduncle has auditory fibers.
a. Crus cerebri: seen at base of brain Connections
b. Substantial nigra: a curved plate of Afferent
pigmented grey matter. i. Lateral leminiscus
c. Tegmentum: that is fused with the ii. Opposite inferior colliculus
opposite cerebral peduncle. Efferent
Internal Structure i. Medial geniculate body
A. The tectum (Fig. 45.3) ii. Opposite inferior colliculus
a. The superior colliculus has a laminated iii. Superior colliculus
nucleus and acts as a visual reflex center. c. The pretectal nucleus is an indistinct
Connection mass of grey matter lying dorsal to the
Afferent superior colliculus at junction of mid-
i. Retina brain and diencephalon.
ii. Occipital cortex (area 17,18, and The pretectal nucleus acts as a center
19) for pupillary light reflex.

Fig. 45.3: TS of midbrainat level of superior colliculus

 The Hind-Brain and Mid-Brain
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 cor-
tico-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
Functional importance
The substantia nigra is rich in
dopamine and enzyme GABA (gamma
amino-butyric acid).
It is concerned with metabolic dis-
turbances 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 tri-
geminal 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
decus-sation 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 Essentials of Human Anatomy

VI. Emerging fila of oculomotor nerve passes Love Vermis Hemisphere

ventro-laterally through red nucleus and I. Anterior Lingula (L)
lobe Central
substantia nigra before emerging from the brain. lobule (CL) Ala
Culmen (C) Quadrangular lobe
THE CEREBELLUM II. Middle Declive (D) Lobulus simplex
The cerebellum is the largest part of hind brain. lobe Folium (F) Superior semilunar lobule
Tuber (T) Inferior semilunar lobule
Pyramid (Py) Biventral lobule
Location: The cerebellum lies in the posterior Uvula (U) Tonsil
cranial fossa roofed over by tentorium III. Flocculo- Nodule (N) Peduncle
cerebelli. nodular lobe
It is separated from pons and upper part of Phylogenetic classification
medulla oblongata by the fourth ventricle. Archicerebellum is the oldest part.
It consists of
Parts: It has one median partthe vermis. Flocculonodular lobe
Two cerebellar hemispheres. Lingula of anterior lobe
Paleocerebellum is the old part. It
Subdivision (Fig. 45.4)
consists of
The cerebellum can be divided morphologically Anterior lobe (except lingula)
and functionally into: Uvula and pyramid of posterior lobe
A large corpus cerebelli consisting of Neocerebellum is latest and most dominant
An anterior lobe part in scale of evolution.
A posterior (middle) lobe It consists of posterior lobe (except uvula
A small flocculonodular lobe and pyramid).
Each lobe has a part of vermis and a part of The old parts are concerned with main-
hemisphere. tenance of equilibrium and muscle tone.

Fig. 45.4: The subdivisions of cerebellum

 The Hind-Brain and Mid-Brain
The new part is concerned with coordi-
nation of voluntary muscular movement.
Internal structure
The grey matter is in two forms:
The deep nuclei, that lie in central white
matter.
Nucleus fastigiioldest nucleus
Nucleus globosus
Nucleus emboliformis
Nucleus dentatelargest and shaped like
a crenated vase.
The cerebellar cortex has the same thickness
and structure throughout.
It consists of two layers:
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.
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:
Association fibers: that connect the areas of
cortex of same hemisphere.
Commissural fibers: connect corresponding
areas of the two hemispheres. These fibers
cross midline.
Projection fibers: are of two types:
The afferent fibers connect other parts of
brain and spinal cord with the
cerebellar cortex.
The efferent fibers connect cerebellar
cortex with other parts of brain and
spinal cord.
The projection fibers reach cerebellum via
three paired peduncles.
499
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 cerebello-
vestibular and cerebello reticular.
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 teg-
mentum 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 spino-
cerebellar and tectocerebellar.
Connections of cerebellum
Afferent
Afferent climbing fibers are mostly
olivocerebellar and they make 1:1
synapse with Purkinje cells of
cerebellar cortex.
Afferent mossy fibers are spino-cerebellar,
ponto-cerebellar and vestibulo-
cerebellar.
 500 Essentials of Human Anatomy
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.
Functional importance
The cerebellum controls the same half of the
body.
It performs the following functions:
Maintenance of equilibrium and posture.
Regulation of muscle tone.
Fig. 45.5: The brain stemposterior aspect showing floor of fourth ventricle
Ultimate refinement of muscular coordi-
nation.
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.
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.
The floor (fossa rhomboidea)
 The Hind-Brain and Mid-Brain 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 The lateral recesses begin at the lateral angles
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 showsinferior foveain 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.
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.

The forebrain (Prosencephalon) consists of:
A median portionthe diencephalon.
Two lateral cerebral hemispheresthe
telencephalon.
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 sur-
facessuperior, inferior, medial, and lateral.
Fig. 46.1: The thalamisuperior aspect
CHAPTER 46
The Forebrain
The anterior end is narrow and pointed and
forms the posterior boundary of inter-
ventricular 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 retro-
lentiform 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 Y-
shaped lamina of white matter, that
divides the grey matter in three parts.
b. The grey matter:
Anterior part of grey matter is small part
that lies between the two limbs of
internal medullary lamina.
 The Forebrain 503

Medial part of grey matter lies between The ventral group of nuclei
medial surface and internal medullary Ventral Anterior (VA)
lamina. Afferent connections
Lateral part of grey matter is the largest part Corpus striatum
that lies between the lateral surface and Reticular formation of brain
the internal medullary lamina. stem.
Nuclei of thalamus and their connections (Fig. Efferent connections
46.2) Premotor area of cotex
The anterior group of nuclei lie in the anterior Ventral Intermediate (VI)
Afferent connections
part.
Cerebellum
Afferent connectionfrom mamillo-
Red nucleus
thalamic tract.
Efferent connections
Efferent connectionto gyrus cinguli
Motor and premotor areas of
The medial group of nuclei lie in the medial
cortex
part
Ventral Posterior Lateral (VPL)
Afferent con- } Afferent connection
nections and Hypothalamic nuclei Medial lemniscus
Efferent con- Other thalamic nuclei Spinal lemniscus
nections also Pre-frontal areas Efferent connections

c. The lateral part contains Sensory areas of the cortex
The lateral group of nuclei (lateral dorsal, Ventral Posterior Medial (VPM)
(LD) lateral posterior (LP) and pulvinar Afferent connection

(P). Trigeminal lemniscus
These nuclei are connected with: Taste fibers
Posterior part of cingulate gyrus Efferent connection
Other thalamic nuclei Sensory areas of the cortex
Cortical area 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
thereticular formation of brain stem and
all parts of cerebral cortex.
The geniculate bodies: medial and lateral lie
on the inferior surface of pulvinar.
Lateral geniculate body is part of visual
pathway
Afferentconnections: Retinal
Fig. 46.2: The internal structure and nuclei of thalamus fibersfrom both sides.
 504 Essentials of Human Anatomy
Efferent connections: Geniculo-
calcarine tract.
Medial geniculate bodyis part of
auditory pathway Afferent con-
nectionsInferior colliculus
Part of auditory pathway
Lateral lemniscus
Efferent connection
Acoustic radiation
Functional Significance
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.
Thalamus is concerned with degree of
consciousness, attention and alertness of
an individual.
Thalamus is involved in subjective feeling
states and the emotional behavior of an
individual.
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.
Functional importance
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)
Tumors of pineal body in the young gives
rise to precocious puberty.
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
inter-peduncular 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
By releasing certain releasing factors and
inhibiting factors, the hypothalamus
influences the secretion of hormones from
the anterior pituitary gland.
The vasopressin (antidiuretic hormone) and
oxytocin are secreted by hypothalamic
nuclei and reach the posterior pituitary
gland, from where they reach blood stream.
Control of sleep and wakefulness.
Temperature regulation of the body.
Emotions and behavior of the individual are
also controlled by hypothalamus.
Control of anatonomic activity of sym-
pathetic and parasympathetic systems.
 The Forebrain
THE SUBTHALAMUS
The subthalamus lies below thalamus and is
continuous caudally with the tegmenta of mid-
brain.
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.
Fig. 46.3: Sagittal section of brain showing third ventricle
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 communi-
cates.
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.
506 Essentials of Human Anatomy
Boundaries
The roof is formed by ependyma, stretching
between the two thalami. The choroid
plexus bulges through it.
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
The anterior boundary is formed by
Lamina terminalis
Anterior commissure
Column of fornix
The posterior wall is formed by
The pineal body
The stalk of pineal body having
Habenular commissure
Posterior commissure
The lateral walls is formed by
Medial surface of thalamus with inter-
thalamic 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
hydro-cephalus leads to compression of brain.
THE TELENCEPHALON
The telencephalon consists of two cerebral
hemispheres with the commissures connecting
them.
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
5 mm in motor area to 1.5 mm in the visual
area.
There are six laminae or layers of cerebral cortex
Molecular layer
Outer granular layer
Pyramidal layer
Inner granular layer
Ganglionic layer
Polymorphous layer
The Special Cortical Areas
The old classification of Brodmanns areas of
cerebral cortex indicates approximately the
different cortical areas and their location (Fig.
46.4).
 The Forebrain
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.
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.
The frontal eyefield is located in posterior part of
middle frontal gyrus. It controls the voluntary
scanning movements of the eyes.
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.
507
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
sen-sations.
The association areas occupy the remaining part
of parietal lobe.
508 Essentials of Human Anatomy
This area is located close to sensory, visual and
auditory areas and its function is to associate
these sensory impulses.
Stereognosisidentification of an object, with-
out seeing, is the property of this area.
The visual areas are (Fig. 46.5):
i. The visuosensory area (striate areaArea
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.
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.
Fig. 46.5: The medial surface of cerebral hemisphere
showing special cortical areas
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.
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
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)
The amygdaloid nucleus
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.
 The Forebrain
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:
Caudate nucleus
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.
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
An outer putamen
An inner lighter partglobus pallidus.
509
Functional Classification
The corpus striatum is divided into
The paleostriatum (palladium) is the older part,
consisting of globus pallidus only.
The neostriatum (striatum) newer part, consisting
of putamen of lentiform nucleus and caudate
nucleus.
Connections of corpus striatum
Paleostriatum is the afferent part of corpus
striatum.
Afferent connections
Strio-pallidalfrom neostriatum
Subthalamo-pallidal from the sub-
thalamic nucleus
Nigro-pallidal from the substantia nigra.
Efferent connection
Ansa lenticularis
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.
Subthalamic fasciculus
Pallido-hypothalamic fasciculus
Descending fibers to red nucleus, reticular
formation of brain stem and
inferior olivary nucleus.
Neostriatum is the efferent part of corpus
striatum.
Afferent connection
Cortico-striate from all parts of cerebral
cortex.
Thalamo-striate from intra-laminar and
medial group of nuclei of thalamus.
Nigro-striate from substantia nigra.
Efferent connection
Strio-pallidal is the main efferent outflow
Strio-nigral to substantia nigra
510 Essentials of Human Anatomy

Functional Significance There are three types of fibers in the white

The corpus striatum is connected with lower matter.
motor centers by polysynaptic path-ways. The association fibers
The main outflow, however, is via The commissural fibers
thalamus to motor and premotor areas of The projection fibers
the cortex.
I. The association fibers connect the different
The corpus striatum is connected with motor
cortical areas of the same hemisphere: (Fig. 46.7)
functions of the body, but its complex
The association fibers are:
interconnections and functional
Short association fibers that connect
significance is not well understood.
Applied Anatomy adjacent gyri.
Lesions of corpus striatum produce Long association fibers that are arranged in
Disturbances in muscle tonemostly bundles and and connect the distant areas
rigidly of cortex of same hemisphere. The impor-
Loss of automatic associated move- tant association bundles are:
ments Cingulum that lies in the cingulate gyrus.
Certain unwanted and uncontrollable Inferiorly, it spreads in parahippocampal
movements gyrus of temporal lobe.
Wilsons disease (Hepato-lenticular degene- Uncinnate fasciculus connects the motor
ration) involves liver and lentiform nucleus. speech center and orbital gyri with
temporal pole.
THE WHITE MATTER OF c. The superior longitudinal fasciculus is
CEREBRAL HEMISPHERE the largest bundle that connects the
The white matter forms the central white core of frontal lobe with areas of occipital and
the cerebral hemisphere. temporal lobes.

Fig. 46.7: The association fibers of cerebral hemisphere

 The Forebrain
The inferior longitudinal fasciculus
connects the areas of occipital lobe
with temporal pole.
The fronto-occipital fasciculus lies lateral
to the caudate nucleus on a deeper
plane and connects frontal area with
occipital areas.
Perpendicular fasciculus connects the
different areas of the occipital lobe.
The commissural fibers connect the corres-
ponding 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:
The corpus callosum
The anterior commissure
c. The habenular commissure
The posterior commissure
The hippocampal commissure
The corpus callosum is the largest commissural
bundle.
It forms a thick curved band that connects the
medial surfaces of two hemispheres.
Parts
The anterior end is genu that is bent like
knee. It thins out below to form the
rostrum.
The body is the main part that curves
backwards from the genu and roofs
over the lateral ventricles.
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
The crossed fibers are intersected by
fibers of corona radiata. They
connect the cortical areas of
frontal, parietal and temporal lobes.
The uncrossed fiberstapetum
fiberscurve medially and down-
wards 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 swell-
ingthe bulbin posterior horn of
lateral ventricle.
Applied Anatomy
Congenital absence of corpus callosum
usually at autopsies has been reported
with very few symptoms.
Surgical division is done sometimes of the
corpus callosum to reach the interior
of lateral ventricle with little loss of
function.
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.
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 Essentials of Human Anatomy

The posterior commissure (described with the

diencephalon).
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 hemi-
spheres.
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 Fiber tracts of internal capsule
cerebral cortex converge towards the
base of the hemisphere.
These fibers intersect the transversely
running crossed fibers of corpus callo-
sun.
b. The internal capsule is a broad curved band
of projection fibers in basal part of hemi-
sphere that is continuous above with corona
radiata and below with crus cerebri of mid-
brain. (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 lenti-
form 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.
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 mid-
brain.
Thecortico-spinalfibers occupy the
anterior part of posterior limb. They are
in form of three bundles:
 The Forebrain
Fig. 46.9: The nerve tracts of internal capsule
Anterior bundle for head and neck
fibers.
Middle bundle for the fibers of upper
limb and trunk.
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 thala-
mus 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
513
The acoustic radiations from the medial
geniculate body to the auditory area of
the hemisphere.
The arterial supply of the internal capsule
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.
The anterior limb is also supplied by a
branch of anterior cerebral artery
Heubners artery.
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 hemi-
plegia 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 Essentials of Human Anatomy

Fig. 46.10: The parts of lateral ventricle

Boundaries Roof by under surface of corpus callo-

The anterior horn is a wide space that points sum. (Fig. 46.12)
forwards and laterally in frontal lobe. (Fig. Medial wall by septum pellucidum.
46.11) Floor from lateral side by
Roof is formed by under surface of Body of caudate nucleus

corpus callosun. Stria medullaris

Medial wall by septum pellucidum. Thalamo-striate vein

Floor is formed. Lateral part superior surface of
Medially by rostrum of corpus callosun thalamus

(small part). Choroid plexus

Laterally by bulging head of caudate The posterior horn is a narrow diverticulum
nucleus that passes backwards and medially in
The central part extends from inter- occipital lobe.
ventricular foramen up to splenium of This horn is variable in size.
corpus callosum. 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 post-
erior horn formed by forceps major
of corpus callosum.
Lower elevation has Calcar avis
formed by the deep calcarine
sulcus.
The inferior horn is the largest of three horns
Fig. 46.11: Coronal section through that passes from the level of splenium
anterior horn of lateral ventricle towards the temporal pole.
 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 wallis formed by
tapetum fibers of corpus callosum.
Tail of caudate nucleus that ends
anteriorly in amygdaloid nucleus.
1. Stria terminalis
Flooris 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.
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 bet-
ween 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

Fig. 46.13: Coronal section through posterior Fig. 46.14: Coronal section through
horn of lateral ventricle inferior horn of lateral ventricle
516 Essentials of Human Anatomy
of cerebrospinal fluid and the brain sub-
stance undergoes compression.
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
The limbic system is concerned with
emotional behavior of an individual, viz.
fear, anger, social response and other
homeostatic responses.
It is also concerned with integration of large
number of impulsesvisceral, olfactory
and somatic.
The limbic system is also involved in recent
memory and memory patterns.
Certain parts of limbic system perform the
olfactory function, but this is a minor
function.

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.
The somatic efferent nuclei (SE) give out
axons to supply the somatic muscles.
The special visceral efferent nuclei (Sp. VE)
give out axons to supply the muscles
developed from the branchial arches.
The general visceral efferent nuclei (GVE) give
out axons to innervate the glands of head
and neck or the visceral musculature.
The general visceral afferent nuclei (GVA)
receive the afferent sensations from the
viscera.
The special visceral afferent nuclei (Sp. VA)
receive the special sense of taste developed in
the region of primitive pharynx.
The general somatic afferent nuclei (SA)
receive the afferent sensations from the
skin and proprioceptors.
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.
CHAPTER 47
The Cranial Nerves
These nerves arise from the neurons
belonging to somatic efferent (SE) func-
tional component.
Group II has the trigeminal, facial, glosso-
pharyngeal, 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
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.
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 Essentials of Human Anatomy
The optic nerve is, in fact, not a nerve but
tract of brain that lies outside brain. This
is proved by following two factors:
The optic nerve carries around it three
sheaths derived from the three
meninges of the brain.
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)
The retina of the eyeball receives an inverted
image of the object through the lens. The
Fig. 47.1: The visual pathway
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:
The rods and cones
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
 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
A lesion of the optic nerve causes total
blindness in the affected eye.
Lesions of the optic tracts, lateral geniculate
body and optic radiations lead to homo-
nymous hemianopia of the opposite side
(i.e. loss of nasal visual field of the same
side and temporal visual field of the
opposite side).
Oculomotor Nerve (III cranial nerve)
It has two functional components:
Somatic efferent (SE) that innervates the extra-
ocular muscles including levator palpebrae
superioris developed from the body wall
musculature.
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 colli-
culus.
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)
The superior ramus gives two branches to
Superior rectus
Levator palpebrae superioris
The inferior ramus gives three branches to
Medial rectus
Inferior rectus
Inferior oblique
The nerve to inferior oblique gives a communi-cating
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 muscles
sphincter pupillae and ciliary.
Applied anatomy
lesion of oculomotor nerve gives the
following symptoms:
Ptosis (drooping of upper eyelid)
Dilatation of pupil
Lateral squint or strabismus
Proptosis or slight bulging of the eyeball
Loss of accommodation
Double vision or diplopia
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 Essentials of Human Anatomy
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 Course: The trigeminal nerve is attached on the
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 temper-
ature sensations from the head and neck
region.
c. The mesencephalic nucleus extends into the
tegmentum of midbrain. It contains pseudo-
unipolar neurones (like dorsal root ganglia
of spinal nerves) and is concerned with
proprioceptive sensations from the head and
neck region.
ventral aspect of pons by a large sensory root
and a small motor root.
The trigeminal ganglion (semilunar gan-
glion) 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.
 The Cranial Nerves
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).
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.
(Described in Chapter 38).
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.
(Described in Chapter 38).
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.
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 extra-
ocular 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:
Special vesceral efferent (Sp. VE) that
supplies the muscles developed from the
branchial arches
General visceral efferent (GVE) that
supplies the muscles developed from the
visceral musculature.
Special visceral afferent (Sp. VA) that
receives the special sensation of taste.
The nuclei of the facial nerve are:
The motor nucleus of facial lies in the
tegmentum of pons lateral to the abducent
nucleus.
The superior salivary nucleus lies in the
tegmenture of pons. It gives out pregan-
glionic 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 Essentials of Human Anatomy
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 stylo-
mastoid 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
Of communication are given to:
Pterygopalatine ganglion
Otic ganglion via lesser petrosal nerve
Vagus and glossopharyngeal nerves
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).
The preganglionic parasympathetic
fibers for submandibular and sub-
lingual salivary glands.
The chorda tympani is also given
inside the bony facial canal and
comes out of petro-tympanic fis-
sure. 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.
The two muscular branches supply:
Posterior belly of digastric
Stylohyoid
The terminal branches in the face are five
sets.
Temporal, zygomatic, buccal mandi-
bular 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)
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:
The medial vestibular nucleus
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.
 The Cranial Nerves
These nuclei lie on the ventro-lateral and dorsi-
lateral 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.
[Described in Chapter 48]
The Glossopharyngeal Nerve (IX cranial nerve)
Functional components are:
Special visceral efferent (Sp. VE) is con-
cerned with nerve supply of muscle
developed from the branchial arches.
General visceral efferent (GVE) is involved
with the nerve supply of parasympathetic
fibers to the parotid salivary glands.
General visceral afferent (GVA) is res-
ponsible for general sensation in the
pharynx region.
Special visceral afferent (Sp. VA) is con-
cerned with special sense of taste from
posterior third of tongue (including vallate
papillae).
The nuclei of the glossopharyngeal nerve are
The nucleus ambiguus that lies in medulla
oblongata and gives out axons to supply
the branchial arch musculature.
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.
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].
The Vagus Nerve (X cranial nerve)
Functional components are:
Special visceral efferent (Sp. VE) concerned
with the nerve supply of muscles developed
from branchial musculature.
General visceral efferent (GVE) concerned
with the nerve supply of visceral muscu-
lature (of gastro-intestinal system and
respiratory system) .
General visceral afferent (GVA) concerned
with the receiving sensations from the
viscera.
Special visceral afferent (Sp. VA) is concerned
with special sense of taste from
posteriormost part of tongue and epiglottis.
Somatic afferent (SA) is concerned with
reception of general sensations.
The nuclei of the vagus nerve are:
The nucleus ambiguous for the supply of
branchial musculature.
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.
The spinal nucleus of trigeminal nerve
receives the general sensory fibers.
524 Essentials of Human Anatomy
Distribution
Motor Supply Muscles of soft palate
pharynx and laryx.
Striated muscle of
esophagus.
Viscoral Motor Cardiac muscle
Supply Smooth muscle of G.I.
system and
Respiratory system
Lower part, esophagus
Special Sensory Posteriormost part of
Supply (Taste) tongue epiglottis
Sensory Supply External ear
Cutaneous area behind ear
Course
The vagus nerve is attached on the postero-
lateral 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].
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
The nucleus ambiguous gives origin to the
fibers of the cranial part.
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
Spinal part } larynx
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].
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].

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.
Fig. 48.1: The bony orbit
CHAPTER 48
The Eyes
III.The lateral wall is formed by
The greater wing of sphenoid.
The zygomatic bone (a small part ante-
riorly).
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.
526 Essentials of Human Anatomy
The foramina and fissures
The optic canal lies at the junction of roof and
medial wall.
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.
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.
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:
The skin: is very thin.
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.
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.
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-
orbitalnerve.
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
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.
The chalazion (internal stye)is caused by
the inflammation of the tarsal glands.
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.
Conjunctivitisis caused by the inflam-
mation 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.
 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:
It has a main part that has the shape and size
of an almond.
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 parasym-
pathetic fibers reach lacrimal gland via the
maxillary nerve, its zygomatic branch and
lacrimal nerve.
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 area
lacus lacrimalis.
The tears wipe and moisten the cornea and
make it bacteria free.
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 Essentials of Human Anatomy
When the eyelids blink, the sac is dilated
due to contraction of orbicularis oculi.
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 naso-
lacrimal 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).
Fig. 48.3: The eyeball
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 Lock-
wood), 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:
Outer fibrous coat
Middle vascular coat
Inner nervous coat
I. The fibrous coat consists of two parts:
The sclera (white of the eye) forms nearly
posterior 5/6 th of the fibrous coat.
 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.
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 opaci-
ties by scarring. These can be
corrected by keratoplasty.
The vascular coat consists of three parts:
The choroid layer has chorio-capillaris
supplied by the short ciliary arteries
and drained by vorticose veins.
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 ante-
riorly, thereby relaxing the zonular
fibers and making lens more convex
for near vision (accommodation).
529
c. The iris is attached to the ciliary body-
anteriorly.
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.
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 photo-
sensitive 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 concen-
tration of cones, producing
most visual acuity.
The cones are also concerned
with colour vision.
The bipolar cells synapse with rods
and cones and their axons
synapse with ganglion cells.
530 Essentials of Human Anatomy
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.
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.
 The Eyes 531
Table 48.1: The extraocular muscles of the orbit
S.No. Name Origin Insertion Nerve supply Main actions
1. Superior Common Superior aspect of Superior ramus of i. Pulls eyeball up-
rectus tendinous ring sclera, about 6.0 mm oculomotor wards and medially
from cornea
ii. Rotates eyeball
inwards (intorsion)
2. Inferior Common tendi- Inferior aspect of Inferior ramus of i. Pulls eyeball down-
rectus nous ring sclera about 6.0 mm oculomotor wards and medially
from cornea ii. Rotates eyeball out-
wards (extorsion)
3. Medial rectus Common tendinous Medial aspect of sclera Inferior ramus of i. Adduction of eyeball,
ring about 6.00 mm from oculomotor i.e. pulls eyeball
cornea medially
4. Lateral rectus Common tendinous Lateral aspect of Abducent nerve i. Abduction of eye-
ring sclera about 6.00 mm ball, i.e. pulls eye-
from cornea ball laterally
5. Superior Sphenoid above Superior aspect of Trochlear nerve i. Pulls eyeball down-
oblique and medial to common sclera at the equator wards and laterally
tendinous ring of eyeball ii. Intorsion of eyeball
6. Inferior Linear notch on maxi- Lateral aspect of Inferior ramus of i. Pulls eyeball up-
oblique lla, in floor of orbit sclera at equator of oculomotor wards and lateral
near naso-lacrimal canal eyeball ii. Extorsion of eyeball
7. Levator pal- Lesser wing Aponeurosis splits Superior ramus of i. Raises upper eye-
pebrae sphenoid above into two lamellae Oculomotor lid and helps in
superioris common tendinous 1. Superior lamella blinking
ring attached to anterior
surface tarsal plate of
and skin of upper Non-striated muscle
eyelid fibers by sympathetic
Inferior lamella
Contains non-striated
muscle fibers attached
to superior border tarsal
plate and conjunctiva

Fig. 48.4: The recte and oblique muscles of eyeball (lateral aspect)
532 Essentials of Human Anatomy

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
supra-trochlear branches.
Branches (Fig. 48.6):
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.
Fig. 48.5: The levator palpebrae superioris
The lacrimal branch runs along the lateral
wall of orbit and gives:
Origin: The Ophthalmic artery arises from the The glandular branches to lacrimal gland.
internal carotid artery near optic canal. Zygomatico-orbital branch that enters a
Course: The artery enters the orbit through the bony foramen and divides into zygo-
optic canal lying in an extension of sub- matico-facial and zygomatico-
arachnoid, space between the middle and temporal branches.
inner sheaths, below the optic nerve. Two lateral palpebral branches to the
Inside the orbit, the artery turns laterally, two eyelids.
pierces middle and outer sheaths of optic The supra orbital artery passes forwards
nerve and lies lateral to the optic nerve above eyeball and comes out at supra-
and gives a large lacrimal branch. orbital notch to supply the forehead.

Fig. 48.6: The ophthalmic artery

 The Eyes
The posterior ciliary branches pierces the
sclera around optic nerve to supply the
eyeball.
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.
The anterior ethmoidal artery enters the
anterior ethmoidal canal and supplies the
ethmoidal sinuses and lateral wall of nose.
It also gives meningeal branches.
Two medial palpebral branches supply the two
eyelids.
The dorsal nasal branch supplies the root of
nose and anastomoses with terminal part
of facial artery.
The supra-trochlear arterysupplies the skin
of forehead.
Small muscular branches supply the
extraocular muscles.
The Veins
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.
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
The motor nerves supplying the extraocular
muscles are threeoculomotor, trochlear and
abducent (Fig. 48.7).
533
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.
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.
The sensory nerves of the orbit are:
The ophthalmic division of trigeminal is
nerve of general sensation.
The optic nerve is nerve of special sense
of sight.
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 Essentials of Human Anatomy

Fig. 48.7: The motor nerves of the orbit

a. The nasociliary nerve enters the orbit Branches:

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.
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

 The Eyes
Posterior ethmoidal nerve enters the
posterior ethmoidal foramen and
supply ethmoidal sinuses.
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.
Infratrochlear supplies lower eyelid
and skin of root of nose.
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 supra-
orbital, 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.
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 parasym-
pathetic 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:
The sensory root is provided by the naso-
ciliary nerve.
The sympathetic root is provided by the
plexus around the internal carotid artery.
The parasympathetic root is provided by the
nerve to the inferior oblique muscle.
This root carries preganglionic parasym-
pathetic 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
The sensory fibers to the inferior of
eyeball.
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.

The two ears lie on either side of skull. Each ear
consists of:
An external ear
A middle ear
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):
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.
The antihelix is another ridge that runs inside
and parallel to the helix.
Fig. 49.1: The pinna
CHAPTER 49
The Ears
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.
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.
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
externalcarotid artery.
The anterior auricular
branchessuperficial 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
nerveUpper two-third by auriculo-
temporal
nerve.
Medial surface
Upper third by lesser occipital nerve
Lower two-third by greater
auricularnerve
 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:
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.
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.
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.
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.
The arterial supply is by:
The posterior auricular artery
The deep auricular branch of maxillary artery
537
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):
A small part superiorly that appears less
tense called pars flaccida.
The rest of the part is quite tense called pars
tensa.
Structure: The tympanic membrane consists of
three layers:
An outer layer of cuticle developed from
ectoderm.
A middle fibrous sheet developed from
mesoderm.
c. An inner epithelium derived from endoderm
The arterial supply is by:
The posterior auricular artery (outer
surface).
Fig. 49.2: The tympanic membrane
 538 Essentials of Human Anatomy
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.
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.
The roof is formed by a plate of bone
tegmen tympanithat also roofs over the
mastoid antrum
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 tym-
panic branch of glosso-pharyngeal nerve.
The lateral wall is formed by: (Fig 49.3)
The medial surface of tympanic mem-
brane.
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.
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.
The upper canal is for tensor tym-pani
muscle.
The lower canal is for bony auditory
tube.
VI. The posterior wall has
An aditus, a wide opening that commu-
nicates 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:
Air that equalises atmospheric pressure on
deep surface of the tympanic membrane
for its proper vibration.
The ear ossicles are threethe malleus, the
incus and stapes. (Fig. 49.5)
These ossicles are fully developed and
adult size at birth.
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.
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 incudo-
stapedial 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 foot-
plate,
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.
The ear muscles are twothe tensor tympani
and the stapedius.
a. The tensor tympani
540 Essentials of Human Anatomy
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
Both tensor tympani and stapedius dampen
loud noises by their reflex contraction and
exercise a protective action to the internal
ear.
Tensor tympani pulls the tympanic mem-
brane inwards to make it tense.
Stapedius opposes the action of tensor tympani
of pulling stapes more firmly in the oval
window.
Applied anatomy
Paralysis of stapedius muscle leads to hyper-
acusis 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 semi-
circular 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
Otitis media or infection of middle ear
cavity, is quite common condition. The
infection usually spreads from the pharynx
via the auditory tube.
 The Ears
The condition, if not treated properly,
becomes chronic.
The complications maybe:
The mastoiditis or infection of the
mastoid air cells.
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.
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 antero-medially
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.
THE INTERNAL EAR
The internal ear lies within the petrous temporal
bone.
The internal ear is made up of:
A bony or osseous labyrinth
A membranous labyrinth
541
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.
The upper one is scala vestibuli, which
receives vibrations in the
perilymph from the oval window.
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.
The vestibule is the central part of the bony
labyrinth that is connected:
Fig. 49.6: The bony labyrinth
542 Essentials of Human Anatomy
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.
The semicircular canals are three in number.
The posterior canal projects vertically
with long axis directed postero-
laterally at about 45.
The superior (anterior) semicircular
canal projects antero-medially at about
45. It is parallel to the posterior semi-
circular 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.
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:
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.
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.
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 semi-
circular ducts.
These dilatations contain special receptor
end organscristae ampullaris.
 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
Special sensory Hair cells
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
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
The supporting cellsare of two types
The pillar cellsare arranged in two rows.
Inner in outer on either side of tunnel of
corti.
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.
 The Spinal Cord, Brain, Eyes and the
Ears
Multiple Choice Questions
Q.1. Select the one best response to each ques- Abducent nerve
tion from the four suggested answers: Trigeminal nerve
The subarachnoid space in the adult ends The extraocular muscle that turns the eyeball
below at the level of: upwards and laterally is:
The coccyx Superior oblique
Second sacral vertebra Superior rectus
Third sacral vertebra Inferior rectus
First lumbar vertebra Inferior oblique

The ligamentum denticulatum has the The artery that supplies the visual area of
following number of tooth processes: cortex is :
A. Twelve B. Thirty-one Anterior cerebral
C. Twenty-one D. Thirty-four Posterior cerebral
Middle cerebral
The internal vertebral venous plexus is found Internal carotid
in:
The facial nerve in its bony canal lies in the
The epidural space
following wall of middle ear:
The subdural space
A. Medial wall B. Lateral wall
The subarachnoid space C. Roof D. Floor
Outside vertebral canal
The cranial nerve that supplies sensory fibers to
The spinal cord, in adults, terminates at level of the middle ear is:
inter-vertebral disc between: Maxillary nerve
Twelfth thoracic and first lumbar vertibra Vestibulocochlear nerve
First lumbar and second lumbar vertebra Facial
Second and third lumbar vertebra Glossopharyngeal
Third and fourth lumbar vertebra
The Brocas area (motor speech center) is
The cerebrospinal fluid enters the venous located in the dominant hemisphere at:
blood stream at: Past central gyrus
Choroid plexus Precentral gyrus
Cisterna magna Inferior frontal gyrus
Subarachnoid veins Superior temporal gyrus
Arachnoid villi and granulations
The purkinje cells lie in the :
The cranial nerve that has dorsal attachment Red necleus
on brain stem is: Granular layer of cerebellar cortex
Trochlear nerve Molecular layer of cerebellar cortex
Oculomotor nerve Dentate nucleus of cerebellum
 Multiple Choice Questions 545

The special visceral afferent (taste) nucleus in A cranial fracture passing through jugular
brain stem is: foramen will injure:
Nucleus of tractus solitarius Hypoglossal nerve
Vestibular nuclei Vagus nerve
Dorsal nucleus of vagus Facial nerve
Spinal nucleus of trigeminal Glosso-pharyngeal nerve
The intraocular muscle supplied by the The lateral geniculate body receives:
sympathetic fibers is: Ipsilateral temporal retinal fibers
Dilator pupillae Contralateral temporal retinal fiber
Sphincter pupillae Contralateral nasal retinal fibers
Ciliary muscle
Ipsilateral nasal retinal fibers
None of the above
The precentral gyrus of cerebral hemisphere: The superior colliculus of midbrain is:
Is sensory area Visual relay center
Receives visual impressions Visual association center
Receives auditory impressions Higher center of vision
Is primary motor area Visual reflex center
The photosensitive cells of the retina are: The cortico-spinal fibers occupy the following
Ganglion cells parts of the internal capsule:
Bipolar cells 1. Genu 2. Anterior limb
Rods and cones 3. Retrolentiform 4. Posterior limb
Pigment cells
The optic nerve is considered a tract of brain
Q.2. Each question below contains four because:
suggested answers, out of which one or It has three sheaths derived from the three
more are correct. Choose the answer: meninges of brain
If 1, 2, and 3 are correct It is attached to the forebrain
If 1 and 3 are correct Its fibers have no Schwann sheath
If 2 and 4 are correct Its fibers have no myelin sheath
If 1,2,3 and 4 are correct
If only 4 is correct The fold of dura mater that lies in the
longitudinal fissure of brain is:
The sensory nerve supply of the pinna (auricle)
is by: Falx cerebelli
Auriculo-temporal nerve Tentorium cerebelli
Greater auricular nerve Diaphragm sellae
Auricular branch of vagus Falx cerebri
Lesser occipital nerve The parts of middle ear that are adult size at
The lesion of oculomotor nerve leads to: birth are:
Ptosis Tympanic membrane
Lateral squint Internal ear
Dilatation of pupil Ear occicles
Diplopia Pinna
 546 Essentials of Human Anatomy

The structures passing through superior orbital Nerve supply of muscles

fissure are: 1. Stapedius A. Abducent nerve
Trochlear nerve 2. Tensor tympani B. Facial nerve
Optic nerve 3. Sphincter pupillae C. Mandibular
Abducent nerve nerve
Ophthalmic artery 4. Lateral rectus D. Oculomotor
Q.3. Match the structures on the left with their nerve
related structures on the right: Special features of parts of brain:
27. Functional nervous components: 1. Spinal ganglion A. Middle ear
1. Somatic efferent A. Trigeminal 2. Geniculate ganglion B. Facial nerve
nerve 3. Optic disc C. Cochlea
2. Somatic afferent B. Vestibulo- 4. Promontory D. Retina
cochlear Arterial supply
3. Special somatic C. Glossopharyn- 1. Lacrimal gland A. Labrynthine
efferent geal artery
4. Special visceral D. Trochlear 2. Internal ear B. Middle cerebral
efferent nerve artery
28. Special features of parts of brain: 3. Auditory area of C. Posterior infer-
1. Facial colliculus A. Pons cortex ior cerebellar
2. Corpus callosum B. Cerebral artery
hemisphere 4. Lateral part of D. Lacrimal
3. Olive C. Midbrain medulla oblongata branch of
4. Red nudeus D. Medulla ophthalmic
oblongata artery

Answers
A1. The answer is B.
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.
A2. The answer is C.
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.
A3. The answer is A.
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 cerebro-
spinal fluid and large spinal vessels.
A4. The answer is B.
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.
 Multiple Choice Questions
A5. The answer is D.
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.
A6. The answer is A.
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.
A7. The answer is D.
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.
A8. The answer is B.
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.
A9. The answer is A.
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.
547
A10. The answer is D.
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.
A11. The answer is C.
The Brocas area (motor speech center) is
located in inferior frontal gyrus (pars orbi-
cularis 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.
A12. The answer is C.
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.
A13. The answer is A.
The special visceral afferent (taste) nucleus in
brain stem is nucleus of tractus solitarius. The
vestibular nuclei receive primary vesti-bular
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.
A14. The answer is A.
The intraocular muscle supplied by sympa-
thetic fibers is dilator pupillae. The
sphincter pupillae and the ciliary muscles
are supplied by the parasympathetic fibers.
548 Essentials of Human Anatomy
A15. The answer is D.
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.
A16. The answer is C.
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.
A17. The answer is A, (1, 2, 3).
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).
A19. The answer is C, (2, 4).
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.
A20. The answer is B, (1, 3).
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.
A23. The answer is B, (1, 3).
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.
A25. The answer is A (1, 2, 3).
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.
A26. The answer is B (1, 3).
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
 Multiple Choice Questions
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 oculo-
motor nerve
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
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 cere-
bellar artery

A B
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
lymphatic drainage 251
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
Index
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
clinical considerations 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 juxta-
epiphyseal vessels 12
nutrient vessels 12
periosteal vessels 12
clinical considerations 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
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
general features 183
ossification 184
special features 184
thoracic vertebrae 187
ossification 189
Bony pelvis 322
sex differences 324
shapes 323
Branches of oculomotor nerve 520
Bronchial tree 213 Bursae 20
clinical considerations 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
lymphatic drainage 295
nerve supply 296 veins
295
Cranial cavity 409
hypophysis cerebri 414
applied anatomy 416
nerves 414
trigeminal ganglion 414
Essentials of Human Anatomy
Cranial nerves 517 functions 354
functional classification 517 prostate gland 356
general description 517 clinical considerations 358
applied anatomy 517 lymphatic drainage 357
olfactory nerve 517 nerve supply 357
optic nerve 517 seminal vesicles 355
Cranium 371 blood supply 355
nerve supply 355
structure 354
D
vas deferens 354
applied anatomy 355
Deep lymphatics 28
blood supply 355
Deep muscles of back 397
Deep palmar arch 105 Epithalamus 504
Esophagus 271
Descriptive anatomical terms 2
anterior-posterior 2 cranial- applied anatomy 271
esophageal 271
caudal 2 medial-
esophagitis 271
intermediate-lateral 2
hiatus hernia 271
palmar-plantar 2 peripheral-
blood supply 271
central 2 proximal-distal 2
nerve supply 271
superficial-deep 2 superior-
Exterior of skull 371
inferior 2
External intercostals muscles 194
Extrahepatic biliary apparatus 283
Dorsal interossei 103 Dorsum
applied anatomy 284
of wrist and hand 95
functions 283
blood vessels on dorsum of
Extrinsic muscles 194
hand 96
Eyes 525
arteries 96
blood vessels 530
deep veins 96
extraocular muscles 530
veins 96
eyeball 528
nerves on the dorsum of hand 97
chambers 530
dorsal branch of ulnar nerve
lens 530
97
eyelids 526
superficial terminal branch of
lacrimal apparatus 526
radial nerve 97
nerves 533
orbit 525
E
F
Ears 536
external ear 536 Face 403
applied anatomy 538 blood vessels 403
internal ear 541 middle lymphatic drainage 407
ear 538 motor nerves 408
Elbow joint 80 applied anatomy 409
arterial anastomosis 80 nerve supply 407
applied anatomy 80 applied anatomy 408
deep veins 81 Fasciae 19
veins 80 clinical considerations 20
Electromyography 19 deep fascia 20 superficial
Epididymis 354 fascia 19
ejaculatory ducts 356 Fasciae of the head and neck 395

Female reproductive organs 359
ovaries 359
blood supply 359
clinical considerations 360
lymphatic drainage 360
nerve supply 360
uterine tubes (fallopian tubes)
363
clinical considerations 364
lymphatic drainage 364
nerve supply 364
uterus 360
blood supply 361
clinical considerations 362
lymphatic drainage 362
nerve supply 362
supports of the uterus 362
vagina 364
blood supply 365
lymphatic drainage 365
nerve supply 365
Femur 117
general features 117
ossification 120
special features 119
Fibula 122
general features 122
ossification 124
special features 123
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 144 Humerus 46
Glosso-pharyngeal nerve 447
H special features 48
Heart 217
applied anatomy 222, 227
dextrocardia 227
Index
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
general features 113
ossification 116
special features 115
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
general features 46
ossification 48
Hyoid bone 388
general features 388
ossification 389
special features 389
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
lymphatic drainage 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 capsule 129
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
articular capsule 131
articular surfaces 131
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
Essentials of Human Anatomy
metatarso-phalangeal
joints 138
tarso-metatarsal joints 138
subtalar joint 137
articular capsule 137
articular surfaces 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
lymphatic drainage 307
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 555

lobes of lung 210 descending thoracic aorta 233 Nerves of the pelvis 332
lymphatic drainage 212 esophagus 233 hemiazygos Nerves of the perineum 338
applied anatomy 213 veins 236 thoracic duct 235 Nervous system 29
nerve supply 213 functional classification 29
Lymph edema 28 superior mediastinum 228 autonomic nervous system 29
Lymph vessels 26 arch of aorta 230 somatic nervous system 29
lymph capillaries 26 brachiocephalic veins 230 functions 29
lymph ducts 26 phrenic nerves 231 parts 29
lymphatics 26 superior vena cava 229 central nervous system 29
Lymphatic drainage of the head vagus nerves 231 peripheral nervous system 29
and neck 447 Meninges of brain 486
Lymphatic drainage of the pelvic blood supply 487 O
organs 332 applied anatomy 489
Lymphatic organs 26 arteries 487 Organ of Corti 543
Lymphatic-venous communications veins of brain 490
27 Metacarpal bones 53 P
Mid-brain 495
white matter 497 Palm of the hand 97
M
Movements of respiration 199 blood vessels of the palm 100
Male reproductive organs 352 applied anatomy 200 arteries 100
testis 352 fracture of rib 201 veins 105
blood supply 353 pleural effusion 201 long flexor tendons in the palm
clinical considerations 354 pneumothorax 200 99
coverings 352 costal movements 199 four tendons of flexor
lymphatic drainage 354 forced costal expiration 200 digitorum profundus 99
nerve supply 354 forced costal inspiration 199 four tendons of flexor
structure 352 normal costal expiration 200 digitorum superficialis
veins 353 normal costal inspiration 199 99
Mammary gland 7 diaphragmatic expiration 200 tendon of palmaris longus 99
architecture 7 diaphragmatic inspiration 200 nerves 105
connective tissue stroma 7 Muscles 16 cutaneous branches 106
glandular 7 features 16 medial nerve 105
suspensory ligaments 7 skeletal muscles 16 Palmar interossei 103
blood supply 8 contraction 18 Pancreas 284
clinical importance 8 nerve supply 18 applied anatomy 286
development 8 parts 16 blood supply 286
anomalies 8 shapes 17 location 284
lymphatic drainage 8 types 18 nerve supply 286
nerve supply 7 Muscles connecting thoracic cage pancreatic ducts 286
Mastoid antrum 540 to vertebral column 196 parts 284
Maxillary nerve 424 serratus posterior inferior 197 type 284
Meckels of diverticulum 270 serratus posterior superior 196 Parasympathetic ganglia 425
Mediastinum 228 Muscles of front of neck 436 Parathyroid glands 440
anterior mediastinum 232 Muscles of mastication 420 Parotid gland 417
boundaries 232 applied anatomy 418
contents 232 N arterial supply 418
middle mediastinum 232 nerve supply 418
boundaries 232 Nerve supply of the thoracic wall parotid duct 418
contents 232 204 Patella (knee cap) 124
posterior mediastinum 232 Nerves of the front of neck 447 general features 124
azygos vein 236 Nerves of the palm 106 ossification 124
556 Essentials of Human Anatomy

Pelvic fascia 327 popliteal vein 159 nerves of the anterior

Pelvic muscles 327 tibial nerve 159 compartment 89
Pelvic part of ureter 347 contents 158 posterior compartment of forearm
blood supply 348 Portal vein 300 91
lymphatic drainage 348 applied anatomy 302 applied anatomy 94
nerves supply 348 features of hepatic-portal system blood vessels 93
clinical considerations 348 300 branches 94
Pelvic peritoneum 328 Positions of body 1 deep extensors 91
Pericardium 215 anatomical position 1 nerves 93
applied anatomy 217 dry lithotomy position 2 superficial extensors 91
pericardititis 217 supine position 2 Region of leg 161
pericardial tamponade 217 Posterior abdominal wall 311 anterior (extensor)
pericardio-centesis 217 blood vessels 312 compartment of leg 161
functions 217 blood vessels 161
applied anatomy 313
location 215 muscles 161
arteries 312
nerve supply 217 nerves 163
veins 313
parts 215 lateral (peroneal) compartment
Pterygopalatine fossa 419
fibrous pericardium 215 of leg 163
Pudendal canal (Alcocks canal) 338
serous pericardium 215 blood vessels 163
Peripheral nervous system 34 nerves 164
cranial nerves 34 R posterior compartment of leg 164
spinal nerves 34 blood vessels 164
Peritoneum 260 Radius 49 nerves 167
applied anatomy 266 general features 49 Region of the thigh 146
blood supply 266 special features 49 anterior compartment of
lymphatic drainage 266 Rectum 346 thigh 146
mesenteries 260 blood supply 347 adductor canal 148
nerve supply 266 arteries 347 blood vessels 149
peritoneal cavity 261 veins 347 femoral canal 152
peritoneal recesses 265 interior of rectum 347 femoral hernia 152
Phalanges 53 lymphatic drainage 347 femoral sheath 151
Planes of body 2 nerve supply 347 femoral triangle 146
coronal plane 2 clinical considerations 347 lymph nodes 150
median sagittal (median) plane 2 peritoneal relations 346 nerves 150
sagittal (para-sagittal) plane 2 supports 347 medial compartment of the
transverse (horizontal) plane 2 Region of foot 168 thigh 152
dorsum of foot 168 blood vessels 152
Pleura 206
blood 169 nerves 155
blood supply 208
muscles and tendons 168 veins 154
functions 208
posterior compartment of the
lines of pleural reflection 206 nerves 170
thigh 155
anterior lines of pleural sole of foot 171 blood
blood vessels 155
reflection 206 vessels 174 muscles
nerves 156
inferior of pleural of sole 171 nerves
Reids base line 371
reflection 207 of sole 176
Rotation of duodenum 267
posterior lines of pleural Region of forearm 85
Rotation of gut 267
reflection 207 anterior compartment 85 Rotation of the midgut 268
nerve supply 208 applied anatomy 89
pleural recesses 207 blood vessels 85 S
Popliteal fossa 157 branches 88
applied anatomy 159 branches in forearm 89 Sacrum 324
popliteal artery 159 muscles 85 general features 324
 Index 557

sex-difference 325 nerve tracts in anterior parts 310

special features 325 while column 483 veins 310
variations 325 nerve tracts in lateral Sympathetic trunks 237
Sagittal section through knee white column 483 branches 237
joint 132 nerve tracts in posterior white greater splanchnic nerve 237
Scalp 400 column 483 grey rami communicans 237
blood supply 401 Spinal curvatures 390 lesser splanchnic nerve 237
lymphatic drainage 402 Spleen 286 lowest splanchnic nerve 237
nerve supply 402 applied anatomy 288 white rami communicans 237
Scapula 43 enlargement of spleen 288 Synovial sheath 20
general features 43 splenectomy 288 clinical consideration 20
angles 44 functional significance
borders 44 288 nerve supply 288
surfaces 44
T
Sternocostalis 196
ossification 45 Stomach (gaster) 272 Telencephalon 506
special features 44 applied anatomy 275 Temporal fossa 419
Scapular anastomosis 74 blood supply 274 Thenar muscles and adductor
Scarpas fascia 19 location 272 lymphatic pollicis 101
Sciatic nerve 144 drainage 274 nerve
Shoulder region 65 Third ventricle 505
supply 275 Thoracic diaphragm 197
axilla 67 opening, surfaces, borders 272
axillary artery 68 development 199
size and shape 272 veins 274 anomalies 199
axillary lymph nodes 69
axillary vein 69 applied anatomy 199
Subclavian artery 444 other structures passing through
brachial plexus 69
Subclavian vein 447 diaphragm 199
pectoral region 65
Subdivision of anatomy 1 hemiazygos veins 199
scapular region 73
applied anatomy 1 lower five intercostal nerves
blood supply of scapular
developmental anatomy 1 199
muscles 74
functional anatomy 1 musculophenic artery 199
nerves of scapular region 75
gross-anatomy 1 subcostal vessels 199
sarratus anterior muscle 73
microscopic anatomy 1 superior epigastric artery 199
shoulder region proper 71
radiological anatomy 1 sympathic trunk 199
deltoid muscle 71
regional anatomy 1 three splanchnic nerves 199
Skin 4
appendages 5 surface anatomy 1 Thoracic duct 27
Subthalamus 505 Thymus gland 441
hair follices 6
nails 5 Superficial back region 75 Thyroid gland 438
sebaceous glands 6 deeper layer 75 applied anatomy 440
sweat glands 6 levator scapulae 75 blood supply 439
clinical importance 6 rhomboid major 75 lymphatic drainage 440
functions 4 rhomboid minor 75 nerve supply 440
protection 4 superficial layer 75 Tibia 120
secretion 4 latissimus dorsi 75 general features 120
sensations 4 trapezius 75 ossification 122
nerve supply 6 Superficial lymphatics 28 special features 122
parts 4 Superficial palmar arch 104 Triangles of the neck 427
inner epidermis 4 Superior aspect of tibia 132 anterior triangle of the neck 431
outer epidermis 4 Suprarenal (adrenal) glands 308 posterior triangle of neck 427
Spinal cord 481 applied anatomy 310 suboccipital triangle of neck 430
blood supply 482 lymphatic drainage 310 Typical intercostal nerve 204
meninges 481 nerve supply 310 Typical synovial joints 15
558 Essentials of Human Anatomy

U superficial perineal pouch Viscera of the head and neck

in females 344 460 digestive system 460
Ulna 50 nerve supply 344 lingual nerve 468
applied anatomy 51 Urogenital triangle in males 339 applied anatomy 469
general features 50 deep perineal pouch in males mouth cavity 460
ossification 51 342 palate 460
special features 51 penis 339 blood supply 460
Upper arm 78 blood vessels 340 nerve supply 461
anterior compartment of arm 78 lymphatics 340 pharyngeal musculature 471
blood vessels 79 nerve 340 blood supply 473
cubital fossa 78 deep scrotum 339 gaps in the pharyngeal
lymphatics 81 lymphatics of wall 472
spermatic cord 340
arm 81 median nerve 81 pharynx 469
clinical importance 341
musculo-cutaneous nerve 81 palatine tonsil 470
superficial perineal pouch in
nerves of anterior submandibular region 467
males 341
nerve supply 342 salivary glands 467 sublingual
compartment of arm 81 salivary gland 468
superficial lymphatics 81
submandibular salivary duct
posterior compartment of arm 82 V 467
blood vessels 82
Vagus nerve 449, 523 teeth 462
nerves of the posterior
eruption 462
compartment 83 Vermiform appendix 292
Upper extremity 43 nerve supply 463
applied anatomy 293
features 43 shape and functions 462
blood supply 293
Ureter 307 structure 462
Vertebral column 389
applied anatomy 308 tongue 463
Viscera of the head and neck 452
nerve supply 308 blood vessels 464
cervical part of trachea 459
Urethra 350 lymphatic drainage 466
anterior 459 muscles 464
female urethra 351 posterior 459
male urethra 351 Vocal folds 458
larynx 455
Urinary bladder 348
blood supply 459
blood supply 350 W
cavity of larynx 457
inferior urinary bladder 349
muscles of larynx 457
ligaments 349 White matter of cerebral
lymphatic drainage 350 skeletal framework 453
nerve supply 459 applied hemisphere 510
nerve supply 350
anatomy 459 Wormian (sutural) bones 386
clinical considerations 350
Urogenital triangle in females 343 paranasal air sinuses 454
deep perineal pouch in females applied anatomy 455 Z
345 respiratory system 452
nerve supply 345 opening in lateral wall 453 Zygomatic bones 379