Give the attachments, nerve supply and actions of: Trapezius, 

deltoid,  serratus  anterior,  triceps  brachii,  biceps  brachii, 

pronator teres, flexor digitorum superficialis, flexor digitorum 
profundus, supinator, muscles of thenar eminence, lumbricals. 
TRAPEZIUS : 
      a)  Flat muscle. 
      b)  It covers back of neck and upper part of trunk 
 

  

  1
Origin : 

External occipital protuberance 
Medial one‐third of superior nuchal line 
Ligamentum nuchae 
Spine of 7th cervical vertebra 
Spines all twelve thoracic vertebrae and supraspinous ligaments 
 

Insertion : 

Posterior border of lateral one third of clavicle (superior fibres) 
Medial margin of acromion and superior edge of crest of spine of scapula (middle fibres. 
Apex of triangular area at the root of spine of scapula (inferior fibres) 

Nerve supply : 

Motor supply from spinal accessory nerve. 
Proprioceptive fibres from ventral rami of C3, C4 nerves 

Main actions 

DELTOID 
        It is a triangular muscle 

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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). 
The anterior and posterior fibres converge towards its tendon of insertion. 
The middle part is multipennate.  Four inter‐muscular septa descend from four tubercles on acromion or 
interdigitate with three septa ascending from deltoid tuberosity. 
 

Insertion  
Is on V‐shaped rough deltoid tuberosity on middle of anterolateral surface of shaft of humerus. 
 

Nerve supply 
Nerve supply is by axillary nerve (C5, C6). 

Actions : 

Anterior fibres help pectoralis major in flexion and medial rotation of arm. 
Posterior fibres help latissimus dorsi and teres major in extension and lateral rotation of arm. 
The multipennate middle part is powerful abductor of arm up to 90°, initiated by supraspinatus.  During 
abduction, the anterior and posterior fibres help to steady the humerus. 

SERRATUS ANTERIOR MUSCLE 
 

Serratus anterior muscle connects the medial border of scapula to lateral 
 thoracic wall. 
 

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Origin: 

By eight fleshy digitations from outer surfaces and superior borders of 
pper eight ribs. 

 
Muscle belly 

A large muscular sheet that covers lateral thoracic wall. 
The first digitation reaches superior angle of scapula. 
Next two or three digitations spread out for their insertion on medial border of scapula. 
The lower four or five digitations converge towards the lower angle of scapula. 

  4
Insertion 

On strip along costal surface of medial border of scapula from superior angle to inferior angle. 
The lower four or five digitations are inserted on a broad area on costal surface of inferior angle. 

Nerve Supply : Long thoracic nerve (C5, C6, C7) 

Actions 

It is a powerful protractor of scapula and is used in all pushing and punching movements. 
The lower part of muscle, along with lower part of trapezius helps in rotation of scapula during overhead 
abduction of arm. 

Clinical Anatomy 
In  case  of  paralysis  of  the  muscle,  the  protraction  of  scapula  is  weakened  and  the  medial  border  of 
scapula gets away, becomes quite prominent (winging of scapula). 

THE TRICEPS BRACHII  

Origin of the muscle is by three heads‐ 

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The long head arises from the infraglenoid tubercle of scapula. 
The  lateral  head  is  attached  to  a  narrow  oblique  ridge  on  posterior  surface  of  upper  part  of  shaft  of 
humerus. 
 

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 lateral head and long head overlap the medial head. 
The medial head lies on a deeper plane. 
All three heads join to form a common tendon. 

Insertion  

Insertion of tendon of triceps is on superior surface of olecranon.  It is separated from articular capsule 
by a bursa. 

Nerve Supply 
Radial nerve gives separate branches to the three heads. 

Actions 

Triceps is the main extensor of the elbow. 
The long head supports the shoulder joint from below, when the arm is raised. 

THE BICEPS BRACHII   
Large, fusiform muscle belly 

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Origin 

Two heads of origin 

Short head from tip of coracoid along with coraco‐brachialis 
Long head from supraglenoid tubercle inside the capsule of shoulder joint 
 

Insertion 

Flat tendon to rough posterior part of radial tuberosity 
The  tendon  gives  a  broad  expansion  medially.  This  bicipital  aponeurosis  blends  with  deep  fascia  of 
forearm. 

Nerve Supply  

Musculocutaneous (C5, C6), gives separate branches for two heads 

Main actions 

The muscle is powerful supinator of flexed elbow 
It also helps to flex the elbow. 
The long head helps to check upward displacement of head of humerus 

THE SUPERFICIAL FLEXORS—PRONATOR TERES  

Muscle belly crosses upper part forearm and forms a flat tendon 

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Humeral head: 
Medial epicondyle 
Ulnar head (smaller): 
Medial border of coronoid process of ulna 

Insertion  
Rough area on middle of lateral surface of radius 
Nerve supply  
Median (C5, C6) 

Main actions 
It is an important pronator of forearm. It is a weak flexor of elbow joint. 

FLEXOR DIGITORUM SUPERFICIALIS 

Origin: 

Humeroulnar head : 
Medial epicondyle of humerus. Also from tubercle on medial border of coronoid process of ulna. 
Radial head : 
Anterior border of radius from tuberosity to insertion of pronator teres. 

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Insertion  
The four tendons course towards wrist forming 2 layers — two superficial for  
middle and ring fingers and two deep for index and little fingers. Each tendon splits into two slips, at the 
metacarpophalangeal  joint  and  forms  a  tunnel  through  which  passes  the  tendon  of  flexor  digitorum 
profundus.  Each of two slips gets inserted into the two sides of middle phalanx. 
Nerve Supply 
Median nerve supplies the fleshy part of the muscle. 
Actions: 
It flexes proximal interphalangeal joints of four fingers. 
It flexes metacarpophalangeal joints of all four fingers. 
It helps in flexion of wrist and elbow joints. 
 

  12
FLEXOR DIGITORUM PROFUNDUS 
It has large muscle belly lying deep to flexor digitorum superficialis. Gives rise to four tendons that pass 
deep to flexor retinaculum of wrist. 
 

  13
Origin 
Upper three fourths of the anterior and medial surfaces of ulna and front of interosseous membrane of 
forearm. 
 

Insertion  
The four tendons are meant for the four fingers.  Each tendon passes through the tunnel formed by slips 
of tendon of flexor digitorum superficialis to get inserted into the base of distal phalanx. 
 

Nerve Supply  
Its  medial  half  is  supplied  by  ulnar  nerve  and  lateral  half  by  anterior  interosseous  branch  of  median 
nerve.  Thus it is a composite or hybrid muscle. 
 

Actions: 

Only flexor of distal phalanges of the fingers i.e. acts on distal interphalangeal joints (DIP). 
Also  flexor  of  proximal  interphalangeal  (PIP),  metacarpophalangeal  (MP),  intercarpal  joints  and  wrist 
joints. 
 

SUPINATOR 
It is named according to its action. 
 

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Origin 
From lateral epicondyle of humerus, radial collateral lig and annular ligament.   
The muscle belly has a superficial and deep part. 
 

  15
Insertion 
Into  the  lateral  surface  of  proximal  third  of  radius,  extending  on  to  its  anterior  and  posterior  aspects.  
Thus it embraces most of the upper part of radius. 
 

Nerve Supply 
Post interosseous nerve.  Then the nerve traverses between its two heads to reach the back of forearm. 
Actions  

It supinates the forearm. 
 

MUSCLES OF THENAR EMINENCE 
ABDUCTOR POLLICIS BREVIS 
 

  16
Origin  
From tubercle of scaphoid and flexor retinaculum. 
 

Insertion 
Radial side of base of proximal phalanx of thumb. 
 

Nerve Supply 
Median nerve 
 

Actions  
Abductor of thumb. 
 

FLEXOR POLLICIS BREVIS 
 

Origin 

Insertion 
Half muscle is inserted into radical side of base of proximal phalanx of thumb and other half into ulnar 
side of base of proximal phalanx of thumb.  
 

Nerve supply 
Median nerve. The medial part of the muscle may be supplied by the ulnar nerve. 
 

Action  
Flexor of first metacarpophalangeal joint 
 

OPPONENS POLLICIS 
 

Origin  
Crest of trapezium and flexor retinaculum.  Muscle lies deep to abductor and flexor pollicis brevis. 
 

Insertion  
Into the lateral half of palmar surface of first metacarpal. 
 

Nerve Supply  

  17
Median nerve. 
 

Action  

Opposes the thumb to the fingers by flexing and rotating the first metacarpal.   
Thus we can count on the fingers. 
 

LUMBRICALS 

Type: 

First lumbrical ‐ Unipennate 
Second lumbrical ‐ Unipennate 

  18
Third lumbrical ‐ Bipennate 
Fourth lumbrical ‐ Bipennate 
 

Origin 

Radial side and palmar surface of the tendon of flexor digitorum profundus to index finger. 
Radial side and palmar surface of the tendon of flexor digitorum profundus to middle finger 
Adjoining sides of tendons of flexor digitorum profundus to middle and ring fingers 
Adjoining sides of tendons of flexor digitorum profundus to ring and little fingers 
 

Insertion 

Lateral side of dorsal digital expansion of index finger 
Lateral side of dorsal digital expansion of middle finger 
Lateral side of dorsal digital expansion of ring finger 
Lateral side of dorsal digital expansion of little finger 
 

Nerve supply 

Median (C8, T1) 
Median (C8, T1) 
Deep branch of ulnar (C8, T1) 
Deep branch of ulnar (C8, T1) 
 

Main actions 
Flexion at metacarpophalangeal and extension of inter‐phalangeal joints of index finger 
Same action on middle finger 
Same action on ring finger 
Same action on little finger 
 

Origin  
Tubercle of scaphoid and flexor retinaculum. 
 It is a thin muscle belly placed medial to abductor pollicis brevis. 
 

 
 

  19
 (i)   Enumerate the boundaries, contents of axilla, name the 
various branches of axillary artery  
(ii)  Discuss the anastomoses around scapula.  
(iii) Discuss the anastomoses around elbow joint.  
(iv) Describe superficial and deep palmar arches.  
 
(i) THE AXILLA  
The axilla is the space between upper part of medial side of arm and lateral side  
of thorax.  Shape is pyramidal 
 

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Boundaries 
The 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 
    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 
    Coracobrachialis 

  23
    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 of scapula posteriorly 
The base of axilla is formed by axillary fascia. 
Contents of the axilla are: 
    a. The axillary artery and its branches 
    b. The axillary vein and its tributaries 
    c. The three cords of brachial plexus and their branches. 
    d. The axillary lymph nodes 
    e. Fibrofatty tissue 
    f.  The axillary tail of Spence of mammary gland in females. 
 

THE AXILLARY ARTERY  

The axillary artery is the main arterial trunk of the upper extremity.∙ 
Beginning 
The axillary artery begins at the outer border of first rib as continuation of third part of subclavian 
artery. 
Course 
The artery passes laterally and downwards. 
    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. 
Branches 
The artery gives six branches. 
From first part: one branch 
    1.The superior thoracic artery is a small branch supplying first intercostal space. 
   
From second part: two branches 
    2. The thoracoacromial artery pierces clavipectoral fascia and divides into four 
       branches. 
      a. The deltoid branch lies in deltopectoral groove. 
      b. The clavicular branch supplies sternoclavicular joint and subclavius muscle. 
      c. The pectoral branch for the pectoral muscles. 
      d. The acromion branch takes part in anastomosis over acromion process. 
    3. The lateral thoracic artery runs along the lateral border of pectoralis minor 

  24
      In females, it is large and supplies the mammary gland. 
From third part: three branches 
    4. The anterior circumflex humeral curves around the surgical neck of humerus 
       from front. 
    5. The posterior circumflex humeral is a larger branch that accompanies axillary 
       nerve through quadrangular space. 
    6. The subscapular artery is large artery that follows lateral border of scapula. 
 

(ii) THE ANASTOMOSES AROUND THE SCAPULA 
The  anastomoses  around  scapula  is  an  arterial  anastomosis  around  both  surfaces  of  scapula  bone 
between the branches of subclavian and axillary arteries. 
The arteries taking part in this anastomoses are‐ 
1.      The  suprascapular  artery  from  thyrocervical  trunk  of  first  part  of  subclavian  artery.  The  artery 
reaches upper border of scapula and passes above suprascapular ligament to reach supraspinous fossa, 
then it curves around spinoglenoid notch to reach infraspinous fossa. 
2.   The deep branch of transverse cervical artery‐also from thyrocervical trunk. 
      The  artery  descends  along  medial  border  of  scapula  deep  to  levator  scapulae            and  rhomboids 
(sometimes the artery arises from third part of subclavian artery and is known as dorsal scapular artery). 
3.   The subscapular artery from third part of axillary. Its circumflex scapular branch passes between the 
two  origins  of  teres  minor,  enters  infraspinous  fossa.  Another  branch  accompanies  the  thoraco‐dorsal 
nerve. 
Functional importance 
    a.  The  anastomoses  provides  sufficient  amount  of  blood  to  scapular  muscles  and  upper  extremity 
during movements of shoulder joint from lateral border of scapula on its dorsal surface. 
    b. In case of blockage of main arterial trunk‐distal to the origin of thyrocervical        trunk and proximal 
to  the  origin  of  subscapular  artery,  this  anastomoses  provides  an  alternative  route  for  the  supply  of 
blood to upper extremity. 

 
(iii) The Arterial Anastomoses around the Elbow Joint    
There  is  a  rich  arterial  anastomoses  around  the  elbow  joint,  the  arteries  participating  are  branches  of 
brachial, radial and ulnar arteries. 
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) 

  25
Behind lateral epicondyle 
Interosseous recurrent artery from posterior interosseous branch common interosseous of ulnar artery 
anastomoses with posterior descending branch of profunda brachii artery. 
 

Clinical Anatomy  
 

    a. The supracondylar fracture of humerus may injure the brachial artery as well 
        as the median nerve. 
    b. The traction of brachialis pulls the lower segment of humerus forwards, thus 
        injuring the artery and the nerve. 
    c. The Volkmann’s Ischemic contracture results from ischemia of forearm and 
        hand due to compression of main vessels. 
 

(iv) THE SUPERFICIAL PALMAR ARCH  
    a.  Formed by continuation of ulnar artery. 
    b.  Laterally by superficial palmar branch of radial artery. 
(If this branch is absent, then the arch is completed by either of the following branches of radial 
artery): 
    c.  Princeps pollicis artery, or 
    d.  Radialis indicis artery 
b. Position:  The superficial palmar arch lies at the level of fully extended thumb. 
Branches 
    1.  A palmar branch to medial side of little finger. 
    2.  Three common palmar digital branches that divide at the web of fingers into two palmar 
digital branches to supply the sides of medial three and half digits. 
             
The three palmar metacarpal branches of the deep palmar arch join the three common palmar 
digital arteries before they divide, at the web of fingers. 
Thus the blood supply to the finger is maintained even when the superficial palmar arch is 
compressed during gripping of an object 
 

DEEP PALMAR ARCH 
The deep palmar arch is the smaller and deeply placed arterial arch in the palm.   
It is formed: 
    a.  Laterally by continuation of radial artery 
    b.  Medially by deep branch of ulnar artery 
c.  Position: The deep palmar arch lies just distal to the flexor retinaculum, and 
     proximal to the superficial palmar arch. 
The radial artery enters the deep part of palm by passing between the two heads of first dorsal 

  26
 interosseous muscle, from anatomical snuff box. The radial artery appears in palm between the 
two heads‐oblique and transverse‐of adductor pollicis. Before joining the deep branch of ulnar 
artery the radial artery gives two branches: 
    i).  The princeps pollicis artery divides into two branches to supply the sides of 
         thumb. 
    ii). The radialis indicis artery supplies the lateral side of index finger. 
    d.  Branches 
    i). Three palmar metacarpal branches, that join the three common palmar 
        metacarpal branches of superficial palmar arch, before they bifurcate at the 
        web of fingers. 
   ii). Three perforating branches, which pass through the gaps between two 
       heads of second, third and fourth dorsal interosseous muscles. These 
       perforating branches join dorsal metacarpal branches of posterior carpal 
       arch. 
   ii). Recurrent branches are given from the deep arch that ascend up to supply 
       the carpals and their articulations.  
 

It gives a large circumflex scapular branch which take part in the ‘scapular  
anastomoses’.  It gives branches to muscles of post wall of axilla. 
 

  27
 (i)   Enumerate the attachments and structures passing 
superficial and deep to the flexor retinaculum of hand.  
(ii)  Enumerate attachments and structures traversing under 
the extensor retinaculum of hand.  
(iii) Describe the boundaries of fascial spaces of hand.  
 

(i) FLEXOR RETINACULUM 
The deep fascia on the front of carpal bones forms a thick band‐the flexor retinaculum. 
 

 
 
Attachments of flexor retinaculum 
Medially :  pisiform and hook of hamate 
Laterally : tubercle of scaphoid and crest of trapezium 
 •  The flexor retinaculum keeps the long flexor tendons in position during flexion  
at the wrist joint. 

  28
  •  The retinaculum also provides additional surface for attachment of thenar and  
hypothenar muscles. 
 •  Structures passing superficial to flexor retinaculum from medial to lateral side  
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 osseoaponeurotic tunnel formed between the flexor  
retinaculum and the concave anterior surface of carpal bones. It contains: 
    i.    Four tendons of flexor digitorum superficialis 
    ii.   Four tendons of flexor digitorum profundus 
These eight tendons are enclosed in a common synovial sheath‐the ulnar bursa 
    iii.  Tendon of flexor pollicis longus is enclosed in a synovial sheath‐the radial 
          bursa 
    iv.  The median nerve lies between the ulnar bursa and the radial bursa. 
    V.  The  tendon  of  flexor  carpi  radialis  with  its  synovial  sheath  lies  in  a  separate 
compartment deep to flexor retinaculum, occupying the groove of trapezium. 
 
(ii)  EXTENSOR RETINACULUM 
The extensor retinaculum of the wrist is formed by thickening of deep fascia on the dorsum 
of wrist 
 

 
 
 
    •  Attachments 
    •  Medially: Tip of styloid process of ulna and triquetral bone 
    •  Laterally: Anterior border of styloid process of radius 

  29
 The retinaculum forms a strong, fibrous band that lies obliquely on dorsal aspect of carpal 
bones 
  From the deep surface of retinaculum, connective tissue septa are given to ridges on dorsal 
aspect of lower end of radius to divide the space deep to it into six compartments 
 
•  The first compartment contains: 
      Tendon of abductor pollicis longus 
      Tendon of extensor pollicis brevis  
•  The second compartment contains: 
      Tendon of extensor carpi radialis longus 
      Tendon of extensor 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 
 
(iii)  FASCIAL SPACES OF HAND AND FOREARM  
There are spaces in hand both on its dorsum and in the palm including the forearm These 
spaces if infected get filled with fluid and pus. Due to use of antibiotics these spaces rarely 
need to be drained. 
 

  30
  
 
 
 •  Palmar spaces are thenar, mid palmar, and pulp space. 
 •  Dorsal spaces are subcutaneous and subaponeurotic. 
 •  Forearm space 
Thenar Space‐ Thenar Space is triangular in shape situated under the lateral half of the 
palm. Its proximal margin is till the flexor retinaculum and distal margin till the proximal 
transverse palmar crease. 
It communicates with the fascial sheath of first and second lumbricals i.e.  
(lumbrical canals). 
 Lateral boundary is tendon of flexor pollicis longus with synovial sheath (radial bursa) and 
lateral palmar septum attached to 1st metacarpal. Medial boundary is the intermediate 
palmar septum attached to third metacarpal. 
 

Describe gross features and lymphatic drainage of 
breast.  
 
 
MAMMARY GLAND 
Adult female mammary gland lies in the superficial fascia of the pectoral region.  
After delivery it secretes milk for the new born baby. 
Extent: It extends from lateral border of sternum to midmaxillary line and from second to 
sixth ribs. The nipple is situated in the 4th intercostal space 10 cm. from the median plane. 
Situation : Most of it is situated in the superficial fascia of pectoral region. A small part from 
its upper lateral quadrant (tail of Spence) pierces the deep fascia to lie in the axilla. 
 

  31
  
 
 
 
Relations : Deep to the breast : the superficial  fascia gets condensed. Strands of Fascia 
connect the dermis of overlying gland to this condensed fascia deep to the gland (breast). 
These are called suspensory ligament of Cooper. These maintain the protuberance of the 
gland. If these strands lose the elasticity, the gland becomes pendulous. If afflicted by 
certain cancer cells, these cause dimpling of the skin over the gland.  
(ii) Retromammamary space with loose areolar tissue.  
Due to this the breast is mobile on pectoralis major. 
(iii)  Pectoral fascia covering pectoralis major.  
(iv)  Pectoralis major, serratus anterior and external oblique of the abdomen. Two thirds of gland 
lies on pectoralis major, one third  on serratus anterior and external oblique muscles. 
 

  32
  
 
 

  33
 Structure of the Breast : It consists of skin, stroma, and parenchyma. 

 
 
 
Skin : A conical projection called the nipple is situated below the centre  of the breast. The 
skin around it is pigmented and is called the areola. Areola contains modified sebaceous 
glands, whose oily secretion lubricate the nipple and areola. 
 
Parenchyma : The gland consists of 15–20 lobes, each lobe comprised of  
numerous acini, is drained by a lactiferous duct. 15–20 lactiferous ducts open on the nipple. 
Just before its opening there is a slight dilatation, called the lactiferous sinus. 
 
Stroma : Fibrous septa extend from the condensed fascia behind the gland to the dermis 
over the gland. These septa support the glandular tissue and also enclose the fatty tissue 
which gives rounded contour to the gland. 
 
Blood Supply : Internal thoracic artery through its perforating branches. 
 

  34
  
 
Lateral thoracic and Superior thoracic branches of axillary artery. Lateral branches of 
posterior intercostal arteries. Veins follow the arteries. 
 
Lymph Drainage :  Lymphatic drainage of breast is extremely important as  
cancer of breast is very common. Since cancer cells spread via lymphatics, the enlargement 
of lymph nodes draining the breast give information about the spread of the cancer. These 
also direct the treating physician about the line of treatment to be undertaken. In case of 
any disease of the breast, the whole breast including the axillary, supraclavicular lymph 
nodes of same and opposite side must be examined. Even lymph nodes of the abdomen 

  35
 must be palpated. 

 
 

  36
  
 

  37
  
 
The superficial lymphatics from skin over the breast except nipple and areola drain radially 
into axillary, supraclavicular and internal mammary group of lymph nodes. 
Deep lymphatics from the parenchyma, nipple and areola drain as follow: 
Axillary lymph   nodes: 75% of lymph drains mostly  into anterior, some into posterior and 
apical  group  of  lymph  nodes.  These  also  communicate  with  lateral  and  central  groups  as 

  38
 well.  The  subclavian  lymph  trunk  starts  from  apical,  drains  into  right  lymphatic  duct  or 
thoracic duct and then into the superior vena cava.  
Thus cancer cells can spread to any part of the body. 
20% of the lymph drains into the internal mammary nodes. These Communicate with those 
of  the  opposite  side  through  vessels  which  cross  the  sternum.  So  cancer  can  spread  to 
opposite breast and lymph nodes. 
5%  of  lymph  drains  into  the  posterior  intercostal  nodes.  These  lymphatics  pass  along  the 
branches  of  posterior  intercostal  arteries.  Lymphatics  from  the  lower  medial  quadrant 
communicates with subperitoneal lymph nodes through the  
rectus sheath. 
Thus cancer can metastasise to any part of the body. Since early diagnosis of the disease is 
important it is strongly advised to palpate own’s breast, for any nodules. 
 
Clinical Anatomy  
In breast abscess, the incision is to be given radially to avoid injury to the  
lactiferous ducts. 
Cancer of breast to be treated according to its spread into lymph nodes. 
 

(i)   Discuss the formation of brachial plexus. Name the 
branches from roots, 
      trunks and cords.  
(ii)  What is the clinical significance of Erb’s Point.  
(iii) Enumerate the losses in Klumpke’s paralysis. 
(iv) Describe the course branches and applied anatomy 
of axillary nerve.  
(v)    Describe  radial  nerve  under  the  headings  of  root 
value, course, distribution and applied aspects. 
(vi)  Describe  median  nerve  in  forearm  and  hand 
and  what  are  the  effects  ofcarpal  tunnel 
syndrome. 
(vii)  Describe  the  branches  of  ulnar  nerve  in  the 
palm.  Indicate  the  sensory  loss            and 
  39
 deformities associated with its injury.  
(viii) Describe the musculoculaneous nerve. 
 
(i) Brachial Plexus 
It is the plexus formed by ventral rami of C5, C6, C7, C8 and T1 nerves. These  
rami  or  roots  unite,  divide,  unite  again  and  divide  so  that  most  of  the  muscles  get  nerve 
supply from more than one root. Also each branch of brachial plexus gets formed by one, 
two,  three  or  more  roots/rami.  So  damage  to  one  root  will  not  cause  paralysis  of  one 
muscle.  These  nerve  roots  carry  motor,  sensory  and  sympathetic  fibres  to  the  skin  and 
muscles  supplied  by  them.  The  nerve  roots  receive  sympathetic  fibres  from  middle  and 
inferior cervical ganglia, which reach them from lateral horn of T1–T4 spinal segments. 
 

 
 

  40
  
 A. Five ventral rami C5, C6, C7, C8, T1 form brachial plexus. 
Branches from Rami 
    1.    Dorsal scapular or nerve to rhomboids are given off from C5 for  
           rhomboideus major and rhomboideus minor. 
    2.   Long thoracic from C6, C7, C8 for serratus anterior. Paralysis of long 
          thoracic nerve leads to “winging of scapula”.  
B. VR of C5 and C6 join to form upper trunk, VR of C7 remains single to form middle trunk; 
VR of C8 and T1 join to form lower trunk. 
Branches from upper trunk  
    3.    Suprascapular nerve for supraspinatus and infraspinatus. 
    4.    Nerve to subclavius for subclavius and root to phrenic nerve. 
C.  Each  trunk  divides  into  dorsal  and  ventral  divisions.  Thus  there  are  three  ventral 
divisions and three dorsal divisions. 
D.  Ventral  divisions  of  upper  and  middle  trunks  join  to  form  lateral  cord.  Branches  of 
lateral cord are: 
    5.   Lateral pectoral nerve for pectoralis major and minor. 
    6.   Musculocutaneous nerve for coracobrachialis, two heads of biceps brachii 
         and brachialis, including skin of lateral side of the forearm. 
    7.   Lateral root of median nerve joins with medial root of median nerve to form median 

  41
 nerve. 
E. Ventral division of lower trunk remains single and forms medial cord. Its branches are: 
    8.   Medial pectoral nerve for pectoralis major and minor. 
    9.   Medial cutaneous nerve of arm. 
    10. Medial cutaneous nerve of forearm 
    11.  Medial  root  of  median  joins  with  the  lateral  root  to  form  median  nerve  for  the 
muscles of forearm and lateral side of palm. 
    12. Ulnar nerve supplies 1½ muscles of forearm, 15 intrinsic muscles of palm. 
 
F. Dorsal divisions of upper, middle and lower trunks join together to form  
posterior cord. Its branches are: 
  13. Upper subscapular for subscapularis. 
  14. Thoracodorsal nerve for latissimus dorsi 
  15. Lower subscapular for subscapularis and teres major. 
  16. Axillary nerve for deltoid and skin over its lower half and teres minor. 
  17.  Radial  nerve  for  the  extensors  of  elbow,  wrist,  metacarpophalangeal  jointsand 
supinator. 
Thus  a  total  of  17  branches  are  given  off  from  the  plexus,  including  2  from  roots,  2  from 
trunks and 13 from cords. 
(ii) Erb’s point is the segment where C 5 and C 6 roots join to form the upper  
trunk,  suprascapular  and  nerve  to  subclavius  are  given  and  ventral  and  dorsal  divisions  of 
upper trunk start. In injury to this point the abductors and lateral rotators of shoulder and 
supinators  are  paralysed.  Arm  hangs  by  the  side.  It  is  rotated  medially  extended  at  elbow 
joint,  pronated  at  forearm  with  cutaneous  loss  on  lateral  side  of  arm  and  forearm 
(policeman taking a tip) 
 

  42
  
 

  43
  
(iii) Damage to C8 and T1 segments is called Klumpke’s paralysis; the small intrinsic 
muscles of hand are affected. It leads to “claw hand”, i.e. extension of metacarpophalangeal 
joints and flexion of interphalangeal joints, loss of sensation on medial side of forearm. 
    (iv) Axillary or Circumflex Nerve 
It is called axillary as it runs through the upper part of axilla though it does not supply any 
structure there. It used to be called circumflex as it goes round the surgical neck of 
humerus. 
Root value: Ventral rami of C5, C6 segments of spinal cord. 
Course: It is the smaller terminal branch of posterior cord. It passes backwards  
through the quadrangular space (bounded by subscapularis above, teres major below, long 
head of triceps brachii medially and surgical neck of humerus laterally). Here it lies below 

  44
 the capsule of the shoulder joint. As it is about to pass behind the surgical neck of humerus 
it divides into an anterior and posterior divisions. Their branches are:  

 
 

  45
 Clinical anatomy:  
Injury to axillary/circumflex nerve causes paralysis of deltoid muscle.  

 
 
There is flattening of the shoulder region. 
Motor loss: Paralysis of deltoid muscle.  
Active movement of abduction of shoulder 20°–90° is not possible. 
Sensory loss: Loss of sensation over lower half of deltoid muscle. 
(v)RADIAL NERVE  
It is the thickest branch of posterior cord of brachial plexus. 
Root value‐Ventral rami of C 5, C6, C7, C8, T1 segments of spinal cord. 
Course:  
Axilla: It lies against the muscles forming the posterior wall of axilla, i.e.  
subscapularis,  teres  major  and  latissimus  dorsi.  It  then  lies  in  the  lower  triangular  space 
between teres major, long head of triceps brachii and shaft of humerus. It gives 2 muscular 
and 01 cutaneous branch in the axilla. 
 Radial  sulcus:  It  enters  through  the  lower  triangular  space  into  the  radial  sulcus,  where  it 
lies  between  the  long  and  medial  heads  of  triceps  brachii  along  with  profunda  brachii 
vessels.  Long  and  lateral  heads  form  the  roof  of  the  radial  sulcus.  It  leaves  the  sulcus  by 
piercing the lateral intermuscular septum. In the sulcus it gives 3 muscular and 2 cutaneous 
branches. 
 Front  of  arm:  It  enters  the  lower  lateral  part  of  arm  and  lies  between  brachialis  on  the 
medial  side  and  brachioradialis  with  extensor  carpi  radialis  longus  on  the  lateral  side.  It 
supplies the latter two muscles and also brachialis (lateral part).  
The nerve descends deep in this interval to reach the lateral epicondyle, where it ends by 
dividing  into  its  two  terminal  branches‐the  superficial  and  deep  or  posterior  interosseous 
branches. 
 

  46
  
 
 
 Posterior interosseous nerve: It lies in the lateral part of cubital fossa, where it supplies 
extensor carpi radialis brevis and supinator muscles. Then it enters into the back of forearm 
by passing through supinator muscle. There the nerve supplies abductor pollicis longus, 
extensor pollicis brevis, extensor pollicis longus, extensor digitorum, extensor indicis, 
extensor digiti minimi and extensor carpi ulnaris. It ends by supplying the wrist joint. 
 

  47
  
 Superficial branch: It is given off in the cubital fossa and runs on the lateral side of forearm 
accompanied by radial artery in the upper two‐thirds of forearm. Then it bends posteriorly to supply 
lateral half of dorsum of hand and lateral 2½ digits till distal interphalangeal joints. Its branch cross over 
the anatomical snuff box. 

  48
  

 
 
      Supraspinatus:    Suprascapular nerve from the upper trunk of brachial plexus.  
      Infraspinatus:          The  suprascapular  nerve  enters  the  infraspinatus  by  passing  through 
spinoglenoid notch (C5, C6) 
      Teres minor:   Posterior division of axillary nerve. This nerve has a pseudoganglion on it. 
(iii) Abduction of shoulder joint 
Supraspinatus  initiates  abduction,  which  is  taken  over  by  deltoid.  The  middle,  acromial 
multipennate  fibres  of  deltoid  abduct  the  arm  till  90°.  If  abduction  goes  on,  the  greater 
tubercle  impinges  on  the  acromion.  To  prevent  this  there  occurs  the  lateral  rotation  of 
humerus  by  infraspinatus  and  teres  minor  muscles.  To  increase  abduction  beyond  90°  the 
scapula  needs  to  rotate  laterally  so  that  glenoid  cavity  faces  laterally.  This  rotation  of 
scapula is achieved by lower fibres of trapezius (arising from T1–T12 spines and inserted into 
the root of the spine of scapula) and lower fibres of serratus anterior i.e. lower 5 digitations 
(arising  from  4th  to  8th  ribs  to  be  inserted  into  the  inferior  angle  of  scapula  on  its  costal 
aspect).  These  two  muscles  act  as  a  couple  pushing  the  lateral  angle  or  glenoid  cavity  of 
scapula upwards, taking the arm till 180° abduction. During these movements the pectoralis 

  55
 minor  attached  to  coracoid  process  of  scapula  fixes  the  coracoid  process  for  the  efficient 
rotation of scapula. 
Supraspinatus supplied by suprascapular nerve, deltoid by axillary nerve, trapezius by spinal 
accessory  nerve  and  serratus  anterior  by  long  thoracic  nerve.  As  glenoid  cavity  faces 
forwards  and  laterally,  so  movements  of  shoulder  joint  occur  in  oblique  planes  around 
oblique  axes.  Flexion  and  extension  take  place  around  transverse  axis  facing  forwards,  so 
flexion occurs forwards and medially as if tips of fingers would touch the opposite shoulder, 
and  extension  backwards  and  laterally.  Abduction  and  adduction  occur  around 
anteroposterior axis which is also oblique. 
 

  56
  

(iv) WRIST JOINT  
 Type 
It is ellipsoid type of synovial joint. It is formed between the lower end of radius, articular 
disc  of  inferior  radioulnar  joint  and  proximal  row  of  carpal  bones  i.e  scaphoid,  lunate  and 
triquetral.  The  bones  are  covered  by  hyaline  cartilage.  The  ends  are  enclosed  in  articular 
capsule. The capsule is supplemented by thin anterior, posterior and thick radial collateral 
and ulnar collateral ligaments. 
Thin anterior radiocarpal ligament is attachment to anterior margin of lower end of radius 
and to scaphoid, lunate and triquetral. Movements are depicted in table 
 

  57
  

 
 

Thin posterior radiocarpal ligament is on the posterior part of the capsule. 
Radial collateral ligament is the thick ligament between styloid process of radius to scaphoid. 
Ulnar collateral ligament is the thick ligament stretching between ulnar styloid process and the 
triquetral. 
Nerve supply: Anterior and post interosseous nerves. 
Blood supply: Anterior interosseous artery, and carpal branches of radial and ulnar arteries. 

  58
Table 6.2 Movements of wrist joint 
 

 
(v) SUPINATION AND PRONATION  
These are the movements which occur between the bones of forearm i.e. radius and ulna. In pronation 

  59
the lower half of radius moves over ulna taking the hand with it. So a pronated forearm shows the hand 
in “picking up” position. Supinated forearm has the bones parallel to each other with the palm 
forwards/upwards. 
 

  60
  

 
 
      Supraspinatus:    Suprascapular nerve from the upper trunk of brachial plexus.  
      Infraspinatus:          The  suprascapular  nerve  enters  the  infraspinatus  by  passing  through 
spinoglenoid notch (C5, C6) 
      Teres minor:   Posterior division of axillary nerve. This nerve has a pseudoganglion on it. 
(iii) Abduction of shoulder joint 
Supraspinatus  initiates  abduction,  which  is  taken  over  by  deltoid.  The  middle,  acromial 
multipennate  fibres  of  deltoid  abduct  the  arm  till  90°.  If  abduction  goes  on,  the  greater 
tubercle  impinges  on  the  acromion.  To  prevent  this  there  occurs  the  lateral  rotation  of 
humerus  by  infraspinatus  and  teres  minor  muscles.  To  increase  abduction  beyond  90°  the 
scapula  needs  to  rotate  laterally  so  that  glenoid  cavity  faces  laterally.  This  rotation  of 
scapula is achieved by lower fibres of trapezius (arising from T1–T12 spines and inserted into 
the root of the spine of scapula) and lower fibres of serratus anterior i.e. lower 5 digitations 
(arising  from  4th  to  8th  ribs  to  be  inserted  into  the  inferior  angle  of  scapula  on  its  costal 
aspect).  These  two  muscles  act  as  a  couple  pushing  the  lateral  angle  or  glenoid  cavity  of 
scapula upwards, taking the arm till 180° abduction. During these movements the pectoralis 

  55
 minor  attached  to  coracoid  process  of  scapula  fixes  the  coracoid  process  for  the  efficient 
rotation of scapula. 
Supraspinatus supplied by suprascapular nerve, deltoid by axillary nerve, trapezius by spinal 
accessory  nerve  and  serratus  anterior  by  long  thoracic  nerve.  As  glenoid  cavity  faces 
forwards  and  laterally,  so  movements  of  shoulder  joint  occur  in  oblique  planes  around 
oblique  axes.  Flexion  and  extension  take  place  around  transverse  axis  facing  forwards,  so 
flexion occurs forwards and medially as if tips of fingers would touch the opposite shoulder, 
and  extension  backwards  and  laterally.  Abduction  and  adduction  occur  around 
anteroposterior axis which is also oblique. 
 

  56
  

(iv) WRIST JOINT  
 Type 
It is ellipsoid type of synovial joint. It is formed between the lower end of radius, articular 
disc  of  inferior  radioulnar  joint  and  proximal  row  of  carpal  bones  i.e  scaphoid,  lunate  and 
triquetral.  The  bones  are  covered  by  hyaline  cartilage.  The  ends  are  enclosed  in  articular 
capsule. The capsule is supplemented by thin anterior, posterior and thick radial collateral 
and ulnar collateral ligaments. 
Thin anterior radiocarpal ligament is attachment to anterior margin of lower end of radius 
and to scaphoid, lunate and triquetral. Movements are depicted in table 
 

  57
  

 
 

Thin posterior radiocarpal ligament is on the posterior part of the capsule. 
Radial collateral ligament is the thick ligament between styloid process of radius to scaphoid. 
Ulnar collateral ligament is the thick ligament stretching between ulnar styloid process and the 
triquetral. 
Nerve supply: Anterior and post interosseous nerves. 
Blood supply: Anterior interosseous artery, and carpal branches of radial and ulnar arteries. 

  58
Table 6.2 Movements of wrist joint 
 

 
(v) SUPINATION AND PRONATION  
These are the movements which occur between the bones of forearm i.e. radius and ulna. In pronation 

  59
the lower half of radius moves over ulna taking the hand with it. So a pronated forearm shows the hand 
in “picking up” position. Supinated forearm has the bones parallel to each other with the palm 
forwards/upwards. 
 

  60
  

 
These movements occur at superior and inferior radioulnar joints with a twist at the middle radioulnar 
joint. 
Superior radioulnar joint.  
Type: Pivot variety of synovial joint. 
 

  61
  
 
Bones: Head of radius and radial notch close to the upper end of ulna 
Capsule: Is attached to the anterior margin of radial notch of ulna, around the head of radius and 
laterally to the posterior margin of radial notch of ulna. This capsular ligament is called the Annular 
ligament. It also gives an attachment to the lateral ligament of elbow joint. 
Quadrate ligament stretches between the lower border of radial notch of ulna to the neck of radius. 
 
 

  62
Nerve supply: Median nerve. 
Distal radioulnar joint  
It is also a pivot variety of synovial joint. The bones taking part are head of ulna and ulnar notch at the 
lower end of radius. The capsule is attached around the articular surfaces. The joint is supplemented by 
the articular disc attached to the lower border of ulnar notch of radius and to the depression between 
the head and styloid process of ulna. The disc is fibrocartilaginous in nature and separates this joint from 
the wrist joint. 
Nerve supply:  Anterior interosseous branch of median nerve. 
Pronation  and  supination:  Supination/pronation  occurs  at  both  the  radioulnar  joints.  The  axis  of 
movement  passes  through  the  centres  of  head  of  radius  to  the  attachment  of  apex  of  articular  disc. 
During pronation, the lower part of radius carrying the hand moves anteromedially across the ulna. The 
interosseous  membrane  gets  spiralised.  The  muscles  responsible  are  pronator  teres  and  pronator 
quadratus.  In  supination  the  bones  lie  parallel  to  each  other  and  palm  faces  forwards  or  upwardsIt  is 
done by biceps brachii when the elbow is flexed and by supinator when the elbow is extended. 
Nerve supply  
Pronator teres: Median nerve. 
Pronator quadratus: Anterior interosseous br. of median nerve. 
Biceps brachii: Musculocutaeous nerve 
Supinator: Posterior interosseous nerve. 
INTEROSSEOUS MEMBRANE  
It is a fibrous membrane stretching between the interosseous borders of radius and ulna. The direction 
of its fibres is downwards and medially i.e it transmits the force of hand receivd by radius towards ulna 
and thence towards humerus. It performs following functions:  
  
    1. Increases the surface area for attachment of muscles on both its surfaces. 
    2. It binds the radius and ulna and maintains proper distance between them. 
    3. It transmits the force from radius towards ulna and then via elbow joint to 
        the humerus. 
  
It has foramina for the passage of structures. Near the upper end of membrane the foramen transmits 
posterior  interosseous  artery.  At  its  lower  end  anterior  intersosseous  artery  passes  from  anterior  to 
posterior compartment of forearm. 
Oblique  cord  is  a  rounded  cord  that  passes  in  direction  opposite  to  the  interosseous  membrane.  It 
passes from lateral border of coronoid process of ulna to shaft of radius below the radial tuberosity. 
  
(vi) Movements of Scapula  
Scapula depicts various movements. These muscles connect the scapula to the axial skeleton. 
 

  63
  

       i)   Elevation: Levator scapulae, upper fibres of trapezius 
      ii)   Depression: Pectoralis minor. 
     iii)   Protraction: Serratus anterior as in pushing and punching movements; during these movements 
the scapula rotates laterally on the thoracic wall. 
     iv)  Retraction: The medial border gets closer to the spines of the vertebrae. It is done by 
rhomboideus major and minor muscles. 
     v)   Lateral rotation so that the glenoid cavity faces upwards and laterally. Performed by lower fibres 
of trapezius and lower 4‐5 digitations of serratus  anterior as in overhead abduction of the arm at the 
shoulder joint. 
    vi)  Medial rotation by gravity, pectoralis minor, rhomboideus major and minor muscles. 
  
(vii) MOVEMENTS OF THUMB  
There are variety of movements occurring at 1st carpometacarpal joint. 
 

  64
Branches:
The pericardiacophrenic artery arises in the root of the neck and accompanies the phrenic nerve
to reach the diaphragm. It supplies the fibrous pericardium and the mediastinal pleura.
The mediastinal arteries are small irregular branches that supply the thymus, the front of the
pericardium, and the fat in the mediastinum.
Two anterior inter-costal arteries are given to each of the upper six inter-costal spaces.
The perforating branches, which accompany the anterior cutaneous branches of the inter-costal
nerves. These are large in the second, third and fourth spaces in the female, for they help to
supply the mammary gland.
The superior epigastric artery runs downwards behind the 7th costal cartilage and enters the
rectus sheath by passing between the sternal and costal slips of the diaphragm. Here it
anastomoses with the inferior epigastric branch of the external iliac artery.
The musculophrenic artery runs downwards and laterally behind the 7th, 8th and 9th costal
cartilages. It gives two anterior inter-costal branches to each of the 7th, 8th and 9th spaces.
Near the eighth costal cartilage it pierces the diaphragm and runs on its abdominal surface to
supply it.
Thus, through its various branches the internal thoracic artery supplies the anterior thoracic and
abdominal walls from the clavicle to the umbilicus.

Clinical Aspect

The internal mammary vessels are best ligated in the 3rd inter-costal space where they are 1
cm from side of the sternum. The vessels lie on the pleura above the 3rd costal cartilage. Below
this level they are separated from it by slips of sternocostalis muscle. The 3rd inter-costal space
is thus the site of choice for internal mammary ligation. The course of this artery should be
remembered when evaluating penetrating wounds of the thorax.

Name the lymph drainage of the left lung.

LYMPH DRAINAGE OF LEFT LUNG

The left lung is drained by two sets of lymphatics, both of which drain into the
bronchopulmonary nodes.
A superficial plexus of lymph vessels lie deep to the pulmonary pleura or visceral pleura. It
rains over the surface of the lung toward the root where they enter the bronchopulmonary lymph
nodes in the hilus and along the interlobular septa into deep lymph vessels.

The deep plexus travels along the bronchi and pulmonary vessels toward the root of the lung,
passing through pulmonary nodes located within the lung substance; the lymph then enters the
bronchopulmonary lymph nodes at the root of the lung.

All the lymph from the left lung leaves the lung root and drains into the superior and inferior
tracheobronchial nodes. The tracheobronchial nodes drain through the left bronchomediastinal
trunk to the left brachiocephalic vein or through the thoracic duct to the left brachiocephalic vein.

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Clinical aspects

Though there is no free anastomosis between the superficial and deep lymphatics, some
connections exist which can open up, so that lymph can flow from the superficial to the deep
lymphatics when the deep vessels are obstructed in disease of the lungs or of the lymph nodes.

When the bronchopulmonary nodes are enlarged in disease of the lung, these may be visible in
radiographs as an increased density of shadow at the lung root.

The tracheobronchial and the bronchomediastinal lymph nodes and the bronchomediastinal
trunk serve as pathways for the spread of bronchogenic carcinoma from the mucous membrane
lining the large bronchi to the lower deep cervical lymph nodes just above the level of the
clavicle. Haematogenous spread to bones and brain commonly occurs.

Write a short note on the sensory nerve supply of the

pleura.
SENSORY NERVE SUPPLY OF THE PLEURA

The pleura is a serous membrane which is lined by mesothelium. There are two pleural sacs,
one on each side of the mediastinum. Each pleural sac is invaginated from its medial side by
the lung, so that it has the following 2 layers:

1. An outer layer, the parietal pleura which lines the thoracic wall, covers the thoracic
surface of the diaphragm and the lateral aspect of the mediastinum, and extends into the
root of the neck to line the under surface of the suprapleural membrane at the thoracic
inlet.

2. An inner layer, the visceral or pulmonary pleura, which completely covers the outer
surfaces of the lungs and extends into the depths of interlobar fissures. Nerve Supply of
the Pleura
The parietal pleura develop from the somatopleuric layer of the lateral plate mesoderm,
and is supplied by somatic (body wall or parieties) nerves. These are the inter-costal
nerves and the phrenic nerves. The costal pleura is segmentally supplied by the inter-
costal nerves; the mediastinal pleura is supplied by the phrenic nerve; and the
diaphragmatic pleura is supplied over the domes (central part) by the phrenic nerve and
around the periphery by the lower five inter-costal nerves. The parietal pleura is sensitive
to pain, touch, pressure and temperature.
The visceral pleura develops from the splanchnopleuric layer of the lateral plate
mesoderm, and is supplied by autonomic nerves derived from spinal segments
T3–T5 and from vagi. The nerves accompany the bronchial vessels. It is sensitive to
stretch and ischaemia but is insensitive to common sensations such as pain, touch,
temperature and pressure.

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Clinical aspects

Lung tissue and the visceral pleura are devoid of pain sensitive nerve endings, so that pain in
the chest is always the result of conditions affecting the parietal pleura and surrounding
structures. In the tuberculosis or pneumonia, for example, pain may never be experienced.
Once lung disease crosses the visceral pleura and the pleural cavity to involve the parietal
pleura, pain becomes a prominent feature. Lobar pneumonia with pleurisy for example produces
a severe tearing pain accentuated by inspiring deeply or coughing.
Since the lower part of the costal parietal pleura receives its sensory innervation from the lower
five inter-costal nerves, which also innervate the skin of the anterior abdominal wall, pleurisy in
this area commonly produces pain that is referred to the abdomen. This has sometimes resulted
in a mistaken diagnosis of an acute abdominal lesion.
Pleurisy of the central part of the diaphragmatic pleura, which receives sensory innervation from
the phrenic nerve (VPR of 3rd, 4th, 5th cervical segments), may lead to referred pain over the
shoulder, since the skin of the shoulder is supplied by the supraclavicular nerves (VPR of C3
and C4).

Enumerate the structures at the hilum of right lung.

STRUCTURES AT THE HILUM OF RIGHT LUNG

The hilum of the lung lies on the mediastinal surface of the lung. It is a large depressed area
through which the structures enter and leave the lung via its root.
The mediastinal parietal pleura and the visceral pleura become continuous with each other
around the hilum of the lung.

  83
The structures which enter and leave the right lung at the hilum are:Right pulmonary artery
which distributes venous blood to the lung.Eparterial bronchus and hyparterial bronchus which
transmit air to and from the right lung. Former lies above the pulmonary artery and latter below
it.
Right superior and inferior pulmonary veins which transmit oxygenated blood from the lungs. A
bronchial artery which carries oxygenated blood to the bronchi and it anastomoses with the
branches of the pulmonary artery.Right bronchial vein drain into vena azygos.
Branches of the vagus nerve and sympathetic trunk from thoracic 3–5 segments which form the
small anterior and large posterior pulmonary plexuses and supply all the structures in the right
lung.
Lymphatics and the bronchopulmonary lymph nodes which drain the lung tissue and the
pulmonary pleura.

Areolar tissue

Arrangement of structures in the root of right lung:

Eparterial bronchus – most posterior

Right pulmonary artery – in between 1 and 3 and on an anterior plane.
Hyparterial bronchus – most posterior
Superior right pulmonary vein – most anterior
Inferior right pulmonary vein – most anterior

Write notes on the bronchopulmonary

segments of the lungs.
Bronchopulmonary Segments of the Lungs

The bronchopulmonary segments are the anatomical, functional and surgical units of the lungs.
Each lobar or secondary bronchus, which passes to a lobe of the lung, gives off branches called
segmental or tertiary bronchi. Each segmental bronchus then enters a bronchopulmonary
segment.
The main bronchopulmonary segments of the right and left lungs are as follow:

  84
Right Lung

Superior or upper lobe : (1) Apical, (2) Posterior, (3) Anterior

Middle or lower lobe : (4) Lateral, (5) Medial

Inferior lobe: (6) Apical, (7) Medial basal, (8) Anterior basal
(9) Lateral basal, (10) posterior basal.

  85
Left Lung

Superior or upper lobe: (1) Apical, (2) Posterior, (3) Anterior

(4) Superior lingular (5) Inferior lingular
Inferior or lower lobe: (6) Apical, (7) Medial basal,
(8) Anterior basal (9) Lateral basal,
(10) Posterior basal

A bronchopulmonary segment has the following characteristics:

It is a subdivision of a lung lobe.

  86
It is pyramidal in shape with its apex toward the lung root.

Each bronchopulmonary segment is surrounded by connective tissue which is continuous on

the surface with pulmonary pleura. Thus the bronchopulmonary segments are independent
respiratory units. The connective tissue septa between adjoining segments form intersegmental
planes which are crossed by the pulmonary veins.
Each bronchopulmonary segment contains segmental bronchus, segmental artery, lymph
vessels, and autonomic nerves.
The branches of the pulmonary artery accompany the bronchi. The artery lies dorsolateral to the
bronchus. Thus each segment has its own separate artery.
The segmental pulmonary vein lies in the connective tissue between adjacent
bronchopulmonary segments.
The pulmonary veins do not accompany the bronchi or pulmonary arteries but run in the
intersegmental planes. Thus each segment has more than one vein and each vein drains more
than one segment. Near the hilum the veins are ventromedial to the bronchus.
The bronchopulmonary segment is not a bronchovascular segment because it does not have its
own vein.

Clinical Significance

Usually the infection of a segment remains restricted to it, although some infections (e.g.
tuberculosis) may spread from one segment to another.Segments are no barriers to the spread
of bronchogenic carcinoma.
Knowledge of the detailed anatomy of the bronchial tree helps considerably in the following:-

Surgical removal of a segment or segmental resection. A localised chronic lesion such as that of
tuberculosis or a benign neoplasm may require surgical removal. If it is restricted to
abronchopulmonary segment, it is possible to dissect out a particular segment and remove it,
leaving the surrounding lung intact. This is called segmental resection.
Drainage of infections (e.g. lung abscess or bronchiectasis) by making the patient adopt a
particular posture called postural drainage so that the gravity assists in the process of drainage.
Visualising the interior of the bronchi through an instrument passed through the mouth and
trachea. The instrument in called a bronchoscope and the procedure is called bronchoscopy.

Write short notes on the transverse sinus and oblique

sinus of the pericardium.
TRANSVERSE SINUS AND OBLIQUE SINUS OF THE PERICARDIUM TRANSVERSE SINUS
The epicardium at the roots of the great vessels is arranged in form of two tubes. The arterial
tube encloses the ascending and the pulmonary trunk arterial end of the heart tube, and the
venous tube encloses the superior vena cava, inferior vena cava and the four pulmonary veins
(venous end of the heart tube). The passage between the two tubes is known as the transverse
sinus of the pericardium.

  87
Thus the transverses sinus is a short passage that lies between the reflection of serous
pericardium around the aorta and pulmonary trunk and the reflection around the large veins. It is
bounded anteriorly by the ascending aorta and the pulmonary trunk; posteriorly by the superior
vena cava and left atrium; on each side it opens into the general pericardial cavity. The
transverse sinus of the pericardium is lined by serous membrane.

OBLIQUE SINUS
The oblique sinus is a cul-de-sac of the pericardial cavity behind the base of the heart. It lies
between the long right and short left limbs of the common J- shaped sheath enveloping the six
veins entering the two atria, i.e. two vane cavae in the right atrium and four pulmonary veins in
the left atrium. Its boundaries are:
Right side: Superior vena cava, upper and lower right pulmonary veins, inferior vena cava.
Left side: Upper and lower left pulmonary veins.
Above: Two layers of pericardium extending between right and left pulmonary veins.
Below: Opens in the rest of the pericardial cavity.
Anterior: Left atrium.
Posterior: Parietal layer of serous pericardium, fibrous pericardium and oesophagus.

  88
Describe the arterial supply of the heart. Add notes on
collateral circulation, cardiac dominance and clinical
anatomy of heart.
ARTERIAL SUPPLY OF THE HEART

The heart, a muscular pump is supplied by two coronary arteries which are functional “end
arteries”.Right coronary artery:
Origin: From the anterior aortic sinus.

Course: Passes between the infundibulum of right ventricle and right auricle to run downwards
in the right anterior atrioventricular (AV) groove.
Turns backwards at the inferior border of heart to run in right posterior AV groove.Termination:
Ends by anastomosing with circumflex branch of left coronary artery near the central fibrous
body. Usually this is the end. At times is may just bury in the myocardium without the
anastomosis.

  89
Branches: Conus artery which passes on the front of the infundibulum of right ventricle to
anastomose with a similar branch of left coronary artery.
SA nodal artery passes backwards to supply SA node in 60% subjects. Gives branches to AV
node, AV bundle and its right branch.
Right marginal artery passes to the left along the right ventricle.
Posterior atrioventricular branch is given off on the posterior surface of the heart. It runs in the
post interventricular (1V) groove and anastomoses with longer anterior 1V artery. During its
course it supplies both the ventricles besides supplying the posterior half of 1V septum.

Left coronary artery:

Origin: from left posterior aortic sinus.

Course: Emerges between left auricle and infundibulum of right ventricle. It has a short course.
Termination: Ends by dividing into its terminal branches, ant. 1V branch and circumflex branch.

  90
Enumerate the contents of typical inter-costal space

CONTENTS OF A TYPICAL INTER-COSTAL SPACE

Contents of typical inter-costal space: It is a space between two adjacent ribs, i.e. between the
lower border of upper rib and its costal cartilage and the upper border of lower rib and its costal
cartilage. There are ten ribs on the anterior aspect of body so the inter-costal spaces anteriorly
are nine, while posteriorly there are eleven spaces.

Each space contains:

• External inter-costal muscle and anterior inter-costal membrane.

• Internal inter-costal muscle and post inter-costal membrane.

  75
 • Innermost inter-costal muscle, supplemented by sternocostalis and subcostalis.

• The neurovascular bundle situated in between internal and innermost inter-costal

muscles comprises of posterior inter-costal vein, posterior inter-costal artery and inter-
costal nerve. These lie in the upper part of the inter-costal space (VAN).

• Lying in the lower part of the space are tributary of the posterior inter-costal vein,
collateral branch of post inter-costal artery and collateral branch of the inter-costal nerve.
These are placed in the lower part of inter-costal space.

• Out of all these only inter-costal nerve reaches the anterior most part of the space.

• In the anterior part of the space are two inter-costal arteries given off from the internal
thoracic artery with its vena comitantes. Thus two arteries from the anterior part

  76
 anastomose with two larger arteries i.e. inter-costal and its collateral branch from the
posterior aspect of thoracic wall.

Describe the course & branches of typical inter-costal nerve

TYPICAL INTER-COSTAL NERVE

Typical inter-costal nerves are any of the nerves belonging to 3rd to 6th inter-costal nerves
(ICN).

Beginning: Typical spinal nerve after it has given off dorsal primary ramus or dorsal ramus is
called the ICN. It runs in the inter-costal space, i.e. between the lower border of rib above and
upper border of rib below.Course: Typical inter-costal nerve enters post part of inter-costal
space by passing behind the posterior inter-costal vessels. So the ICN lies lowest in the
neurovascular bundle. At first the bundle runs between posterior inter-costal membrane and
subcostalis, then between inner inter-costal and innermost inter-costal and lastly between inner
inter-costal and sternocostalis muscles. At the anterior end of inter-costal space the inter-costal
nerve passes in front of internal thoracic vessels, pierces internal inter-costal muscle and
anterior inter-costal membrane to continue as anterior cutaneous branch which ends by dividing
into medial and lateral cutaneous branches.

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Branches:

• Communicating branches to the sympathetic ganglion close to the beginning of ventral

ramus. The ant. ramus containing sympathetic fibres from lateral horn of spinal cord
gives off a white ramus communicans to the sympathetic ganglion. These fibres get
relayed in the ganglion. Majority of these relayed fibres pass via grey ramus
communicans to ventral ramus. A few pass backwards in the dorsal ramus. These
sympathetic fibres are sudomotor, pilomotor and vasomotor to the skin.

• Before the angle, nerve gives a collateral branch that runs along the upper border of
lower rib. This branch supplies inter-costal muscles, costal pleura and periosteum of the
rib.

• Lateral cutaneous branch arises along the mid-axillary line. It divides into anterior and
posterior branches.The nerve also gives muscular, periosteal and costal pleural
branches during its course.

• Anterior cutaneous branch is the terminal branch of the nerve.

Discuss briefly inter-costal arteries and veins

INTER-COSTAL ARTERIES
Each inter-costal space contains two pairs of arteries. One pair is posterior inter-costal artery
and its collateral branch. These are relatively large and supply two-thirds of the space. Another
pair is the two smaller anterior inter-costal arteries running in the anterior one-third of the space
.

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Anterior inter-costal arteries for upper 1–6 spaces are branches of internal thoracic artery while
for 7th–9th spaces are branches of musculo phrenic artery.

Posterior inter-costal arteries of 1st and 2nd inter-costal spaces are branches of superior inter-
costal artery from 2nd part of subclavian artery. 3rd to 11th posterior inter-costal arteries are
branches of thoracic aorta, right being longer than the left ones. Each of these arteries run as a
component of neurovascular bundle in the neurovascular plane. These give collateral branches
which run in the lower part of the respective inter-costal spaces. These two arteries end by
anastomosing with the respective anterior inter-costal arteries.

INTER-COSTAL VEINS

Anterior aspect: Two ant. inter-costal veins from 9th , 8th , 7th inter-costal spaces drain into
musculophrenic venae comitantes, which drain into internal thoracic vena comitantes. Two inter-
costal veins from 6th–3rd spaces drain into internal thoracic venae comitantes, from 2nd and 1st
spaces these end into internal thoracic vein which finally drains into brachiocephalic
vein.Posterior aspect: 1st post inter-costal vein drain into respective brachiocephalic veins. 2nd,
3rd, and 4th of right side form superior Inter-costal vein which drains into vena azygos. 5th–11th
post inter-costal veins after receiving various tributaries also end in the vena azygos.2nd, 3rd
and 4th veins of left side form left superior ICV and drains into left brachiocephalic vein.5th, 6th,
7th and 8th drain into accessory hemiazygos vein which in turn ends into vena azygos at the
level of 8th thoracic vertebra.9th, 10th, 11th posterior inter-costal veins end into hemiazygos
vein which also crosses the median plane to end into vena azygos.

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Mention the branches of internal thoracic artery in order as they are given off.
Internal Thoracic Artery
The internal thoracic artery (also known as the internal mammary artery since it supplies the
mammary gland in the female), arises from the lower border of the first part of the subclavian
artery opposite the thyrocervical trunk, in the neck. The origin lies 2 cm above the internal end
of the clavicle. It enters the thorax by descending behind the medial end of the clavicle and the
first costal cartilage in front of the pleura. The artery descends about 1 cm from the margin of
the sternum, anterior to the pleura and posterior to the upper six costal cartilages, the spaces
between them, and the terminal parts of the inter-costal nerves. It ends by dividing into superior
epigastric and musculophrenic arteries in the sixth inter-costal space.

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Branches:
The pericardiacophrenic artery arises in the root of the neck and accompanies the phrenic nerve
to reach the diaphragm. It supplies the fibrous pericardium and the mediastinal pleura.
The mediastinal arteries are small irregular branches that supply the thymus, the front of the
pericardium, and the fat in the mediastinum.
Two anterior inter-costal arteries are given to each of the upper six inter-costal spaces.
The perforating branches, which accompany the anterior cutaneous branches of the inter-costal
nerves. These are large in the second, third and fourth spaces in the female, for they help to
supply the mammary gland.
The superior epigastric artery runs downwards behind the 7th costal cartilage and enters the
rectus sheath by passing between the sternal and costal slips of the diaphragm. Here it
anastomoses with the inferior epigastric branch of the external iliac artery.
The musculophrenic artery runs downwards and laterally behind the 7th, 8th and 9th costal
cartilages. It gives two anterior inter-costal branches to each of the 7th, 8th and 9th spaces.
Near the eighth costal cartilage it pierces the diaphragm and runs on its abdominal surface to
supply it.
Thus, through its various branches the internal thoracic artery supplies the anterior thoracic and
abdominal walls from the clavicle to the umbilicus.

Clinical Aspect

The internal mammary vessels are best ligated in the 3rd inter-costal space where they are 1
cm from side of the sternum. The vessels lie on the pleura above the 3rd costal cartilage. Below
this level they are separated from it by slips of sternocostalis muscle. The 3rd inter-costal space
is thus the site of choice for internal mammary ligation. The course of this artery should be
remembered when evaluating penetrating wounds of the thorax.

Name the lymph drainage of the left lung.

LYMPH DRAINAGE OF LEFT LUNG

The left lung is drained by two sets of lymphatics, both of which drain into the
bronchopulmonary nodes.
A superficial plexus of lymph vessels lie deep to the pulmonary pleura or visceral pleura. It
rains over the surface of the lung toward the root where they enter the bronchopulmonary lymph
nodes in the hilus and along the interlobular septa into deep lymph vessels.

The deep plexus travels along the bronchi and pulmonary vessels toward the root of the lung,
passing through pulmonary nodes located within the lung substance; the lymph then enters the
bronchopulmonary lymph nodes at the root of the lung.

All the lymph from the left lung leaves the lung root and drains into the superior and inferior
tracheobronchial nodes. The tracheobronchial nodes drain through the left bronchomediastinal
trunk to the left brachiocephalic vein or through the thoracic duct to the left brachiocephalic vein.

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Clinical aspects

Though there is no free anastomosis between the superficial and deep lymphatics, some
connections exist which can open up, so that lymph can flow from the superficial to the deep
lymphatics when the deep vessels are obstructed in disease of the lungs or of the lymph nodes.

When the bronchopulmonary nodes are enlarged in disease of the lung, these may be visible in
radiographs as an increased density of shadow at the lung root.

The tracheobronchial and the bronchomediastinal lymph nodes and the bronchomediastinal
trunk serve as pathways for the spread of bronchogenic carcinoma from the mucous membrane
lining the large bronchi to the lower deep cervical lymph nodes just above the level of the
clavicle. Haematogenous spread to bones and brain commonly occurs.

Write a short note on the sensory nerve supply of the

pleura.
SENSORY NERVE SUPPLY OF THE PLEURA

The pleura is a serous membrane which is lined by mesothelium. There are two pleural sacs,
one on each side of the mediastinum. Each pleural sac is invaginated from its medial side by
the lung, so that it has the following 2 layers:

1. An outer layer, the parietal pleura which lines the thoracic wall, covers the thoracic
surface of the diaphragm and the lateral aspect of the mediastinum, and extends into the
root of the neck to line the under surface of the suprapleural membrane at the thoracic
inlet.

2. An inner layer, the visceral or pulmonary pleura, which completely covers the outer
surfaces of the lungs and extends into the depths of interlobar fissures. Nerve Supply of
the Pleura
The parietal pleura develop from the somatopleuric layer of the lateral plate mesoderm,
and is supplied by somatic (body wall or parieties) nerves. These are the inter-costal
nerves and the phrenic nerves. The costal pleura is segmentally supplied by the inter-
costal nerves; the mediastinal pleura is supplied by the phrenic nerve; and the
diaphragmatic pleura is supplied over the domes (central part) by the phrenic nerve and
around the periphery by the lower five inter-costal nerves. The parietal pleura is sensitive
to pain, touch, pressure and temperature.
The visceral pleura develops from the splanchnopleuric layer of the lateral plate
mesoderm, and is supplied by autonomic nerves derived from spinal segments
T3–T5 and from vagi. The nerves accompany the bronchial vessels. It is sensitive to
stretch and ischaemia but is insensitive to common sensations such as pain, touch,
temperature and pressure.

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Clinical aspects

Lung tissue and the visceral pleura are devoid of pain sensitive nerve endings, so that pain in
the chest is always the result of conditions affecting the parietal pleura and surrounding
structures. In the tuberculosis or pneumonia, for example, pain may never be experienced.
Once lung disease crosses the visceral pleura and the pleural cavity to involve the parietal
pleura, pain becomes a prominent feature. Lobar pneumonia with pleurisy for example produces
a severe tearing pain accentuated by inspiring deeply or coughing.
Since the lower part of the costal parietal pleura receives its sensory innervation from the lower
five inter-costal nerves, which also innervate the skin of the anterior abdominal wall, pleurisy in
this area commonly produces pain that is referred to the abdomen. This has sometimes resulted
in a mistaken diagnosis of an acute abdominal lesion.
Pleurisy of the central part of the diaphragmatic pleura, which receives sensory innervation from
the phrenic nerve (VPR of 3rd, 4th, 5th cervical segments), may lead to referred pain over the
shoulder, since the skin of the shoulder is supplied by the supraclavicular nerves (VPR of C3
and C4).

Enumerate the structures at the hilum of right lung.

STRUCTURES AT THE HILUM OF RIGHT LUNG

The hilum of the lung lies on the mediastinal surface of the lung. It is a large depressed area
through which the structures enter and leave the lung via its root.
The mediastinal parietal pleura and the visceral pleura become continuous with each other
around the hilum of the lung.

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The structures which enter and leave the right lung at the hilum are:Right pulmonary artery
which distributes venous blood to the lung.Eparterial bronchus and hyparterial bronchus which
transmit air to and from the right lung. Former lies above the pulmonary artery and latter below
it.
Right superior and inferior pulmonary veins which transmit oxygenated blood from the lungs. A
bronchial artery which carries oxygenated blood to the bronchi and it anastomoses with the
branches of the pulmonary artery.Right bronchial vein drain into vena azygos.
Branches of the vagus nerve and sympathetic trunk from thoracic 3–5 segments which form the
small anterior and large posterior pulmonary plexuses and supply all the structures in the right
lung.
Lymphatics and the bronchopulmonary lymph nodes which drain the lung tissue and the
pulmonary pleura.

Areolar tissue

Arrangement of structures in the root of right lung:

Eparterial bronchus – most posterior

Right pulmonary artery – in between 1 and 3 and on an anterior plane.
Hyparterial bronchus – most posterior
Superior right pulmonary vein – most anterior
Inferior right pulmonary vein – most anterior

Write notes on the bronchopulmonary

segments of the lungs.
Bronchopulmonary Segments of the Lungs

The bronchopulmonary segments are the anatomical, functional and surgical units of the lungs.
Each lobar or secondary bronchus, which passes to a lobe of the lung, gives off branches called
segmental or tertiary bronchi. Each segmental bronchus then enters a bronchopulmonary
segment.
The main bronchopulmonary segments of the right and left lungs are as follow:

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Right Lung

Superior or upper lobe : (1) Apical, (2) Posterior, (3) Anterior

Middle or lower lobe : (4) Lateral, (5) Medial

Inferior lobe: (6) Apical, (7) Medial basal, (8) Anterior basal
(9) Lateral basal, (10) posterior basal.

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Left Lung

Superior or upper lobe: (1) Apical, (2) Posterior, (3) Anterior

(4) Superior lingular (5) Inferior lingular
Inferior or lower lobe: (6) Apical, (7) Medial basal,
(8) Anterior basal (9) Lateral basal,
(10) Posterior basal

A bronchopulmonary segment has the following characteristics:

It is a subdivision of a lung lobe.

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It is pyramidal in shape with its apex toward the lung root.

Each bronchopulmonary segment is surrounded by connective tissue which is continuous on

the surface with pulmonary pleura. Thus the bronchopulmonary segments are independent
respiratory units. The connective tissue septa between adjoining segments form intersegmental
planes which are crossed by the pulmonary veins.
Each bronchopulmonary segment contains segmental bronchus, segmental artery, lymph
vessels, and autonomic nerves.
The branches of the pulmonary artery accompany the bronchi. The artery lies dorsolateral to the
bronchus. Thus each segment has its own separate artery.
The segmental pulmonary vein lies in the connective tissue between adjacent
bronchopulmonary segments.
The pulmonary veins do not accompany the bronchi or pulmonary arteries but run in the
intersegmental planes. Thus each segment has more than one vein and each vein drains more
than one segment. Near the hilum the veins are ventromedial to the bronchus.
The bronchopulmonary segment is not a bronchovascular segment because it does not have its
own vein.

Clinical Significance

Usually the infection of a segment remains restricted to it, although some infections (e.g.
tuberculosis) may spread from one segment to another.Segments are no barriers to the spread
of bronchogenic carcinoma.
Knowledge of the detailed anatomy of the bronchial tree helps considerably in the following:-

Surgical removal of a segment or segmental resection. A localised chronic lesion such as that of
tuberculosis or a benign neoplasm may require surgical removal. If it is restricted to
abronchopulmonary segment, it is possible to dissect out a particular segment and remove it,
leaving the surrounding lung intact. This is called segmental resection.
Drainage of infections (e.g. lung abscess or bronchiectasis) by making the patient adopt a
particular posture called postural drainage so that the gravity assists in the process of drainage.
Visualising the interior of the bronchi through an instrument passed through the mouth and
trachea. The instrument in called a bronchoscope and the procedure is called bronchoscopy.

Write short notes on the transverse sinus and oblique

sinus of the pericardium.
TRANSVERSE SINUS AND OBLIQUE SINUS OF THE PERICARDIUM TRANSVERSE SINUS
The epicardium at the roots of the great vessels is arranged in form of two tubes. The arterial
tube encloses the ascending and the pulmonary trunk arterial end of the heart tube, and the
venous tube encloses the superior vena cava, inferior vena cava and the four pulmonary veins
(venous end of the heart tube). The passage between the two tubes is known as the transverse
sinus of the pericardium.

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Thus the transverses sinus is a short passage that lies between the reflection of serous
pericardium around the aorta and pulmonary trunk and the reflection around the large veins. It is
bounded anteriorly by the ascending aorta and the pulmonary trunk; posteriorly by the superior
vena cava and left atrium; on each side it opens into the general pericardial cavity. The
transverse sinus of the pericardium is lined by serous membrane.

OBLIQUE SINUS
The oblique sinus is a cul-de-sac of the pericardial cavity behind the base of the heart. It lies
between the long right and short left limbs of the common J- shaped sheath enveloping the six
veins entering the two atria, i.e. two vane cavae in the right atrium and four pulmonary veins in
the left atrium. Its boundaries are:
Right side: Superior vena cava, upper and lower right pulmonary veins, inferior vena cava.
Left side: Upper and lower left pulmonary veins.
Above: Two layers of pericardium extending between right and left pulmonary veins.
Below: Opens in the rest of the pericardial cavity.
Anterior: Left atrium.
Posterior: Parietal layer of serous pericardium, fibrous pericardium and oesophagus.

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Describe the arterial supply of the heart. Add notes on
collateral circulation, cardiac dominance and clinical
anatomy of heart.
ARTERIAL SUPPLY OF THE HEART

The heart, a muscular pump is supplied by two coronary arteries which are functional “end
arteries”.Right coronary artery:
Origin: From the anterior aortic sinus.

Course: Passes between the infundibulum of right ventricle and right auricle to run downwards
in the right anterior atrioventricular (AV) groove.
Turns backwards at the inferior border of heart to run in right posterior AV groove.Termination:
Ends by anastomosing with circumflex branch of left coronary artery near the central fibrous
body. Usually this is the end. At times is may just bury in the myocardium without the
anastomosis.

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Branches: Conus artery which passes on the front of the infundibulum of right ventricle to
anastomose with a similar branch of left coronary artery.
SA nodal artery passes backwards to supply SA node in 60% subjects. Gives branches to AV
node, AV bundle and its right branch.
Right marginal artery passes to the left along the right ventricle.
Posterior atrioventricular branch is given off on the posterior surface of the heart. It runs in the
post interventricular (1V) groove and anastomoses with longer anterior 1V artery. During its
course it supplies both the ventricles besides supplying the posterior half of 1V septum.

Left coronary artery:

Origin: from left posterior aortic sinus.

Course: Emerges between left auricle and infundibulum of right ventricle. It has a short course.
Termination: Ends by dividing into its terminal branches, ant. 1V branch and circumflex branch.

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Branches:
It gives a conus branch which also anastomoses with similar branch of right coronary artery.
The interventricular branch runs sinuously in the anterior 1V groove. Then it turns backwards to
anastomose with post 1V branch of right coronary artery. In addition it also gives branches to
left and right ventricles. One large one to left ventricle is named as diagonal artery. It also
supplies anterior 1/2 of 1V septum.
The cirumflex branch runs in the left anterior AV groove, turns round the left border to run in left
posterior AV groove and ends by anastomosing with right coronary artery near the central
fibrous body.
Cardiac dominance: The post 1V artery is a the deciding factor for the dominance of the
coronary arteries. If it is a branch of right coronary as usually is the case, the heart is said to be
‘right dominant’. In contrast its origin from the left coronary makes the heart ‘left dominant’. In
that case left coronary gives anterior 1V, posterior 1V, and circumflex branches.
Collateral Circulation: Anastomoses are present at the arteriolar level between the conus
arteries, anterior and posterior 1V arteries and right coronary and circumflex branch of left
coronary arteries. There is slight anastomoses even with the pericardial arteries. Sadly these
anastomoses are not enough to compensate for the blockage of any coronary or their large
branches. Though these arteries anatomically are not end arteries functionally these are end
arteries. It there is sudden blockage, these anastomoses are not able to open up, while in slow
occlusion these manage to open up to varying extent.
Applied anatomy: In case of sudden narrowing any of the coronary these arteries, there may be
pain in the precordium extending even to the medial sides of both arms, more often to the left
arm. Afferents from heart pass along the sympathetic fibres reach the sympathetic ganglia, pass
express along the white ramus communicans to the ventral ramus of spinal nerve (e.g.Th 1)
then it travels backwards to the trunk of the nerve, then through the dorsal root into the spinal
cord.
This dorsal root of thoracic one is also receiving afferent fibres from medial side of arm. Since
somatic pain fibres and visceral pain fibres reach the same segment and get interconnected, it
is referred to the spinal nerve. Thus the pain is referred to medial side of arms along Th1 and to
precordium along Th 2–Th 5 nerves.
These impulses probably travel more along nerves of left side, making the left side more
vulnerable for the site of referred pain.

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Describe briefly the venous drainage and nerve
supply of heart.
VENOUS DRAINAGE AND NERVE SUPPLY OF THE HEART
Veins of the heart travel along the coronary arteries and their branches, still these have not
been given similar names Veins draining are coronary sinus, ant. cardiac vein, venae cordis
minimae.

Coronary sinus

Coronary sinus is the largest vein. It runs in the posterior AV groove and drains into the smooth
part of right atrium. Its tributaries are:
Great cardiac vein: It accompanies the anterior 1V branch and proximal part of circumflex
branch to drain into the left extremity of coronary sinus. In its course it receives veins from both
ventricles, and interventricular septum and left auricle.
Middle cardiac vein: It accompanies the posterior 1V branch to drain close to its termination.

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Small cardiac vein: Accompanies the marginal branch, it ends into the atrial end of coronary
sinus.
Posterior vein of left ventricle: Drains the left ventricle and ends in coronary sinus to the left of
middle cardiac vein.
Oblique vein of left atrium: Starts from left atrium, runs downwards to end in left end of coronary
sinus.
Anterior cardiac veins drain the right ventricle to open directly into the right atrium without
passing through the coronary sinus.
Venae cordis minimae are small veins in the walls of all four chambers of heart. These open
directly into their respective chambers.

Nerve supply of heart:

The nerve supply to heart is from autonomic nervous system. Both sympathetic and
parasympathetic components send efferent fibres and receive afferent fibres.
These components form plexuses which reach the myocardium and the nodal tissues of the
heart.

The cardiac plexuses are two in number, superficial and deep. Superficial is contributed by the
nerves of only left side, i.e. superior cervical cardiac branch of left sympathetic and inferior
cervical cardiac branch of left vagus nerve.
Deep cardiac plexus is situated at the bifurcation of trachea; sympathetic fibres are contributed
from three cervical, upper five thoracic ganglia, except left superior cervical ganglion.
Parasympathetic fibres come from right vagus nerve in their cervical course, left inferior branch
and both recurrent laryngeal nerves.
Sympathetic fibres increase the heart rate, dilate the coronaries, whereas parasympathetic has

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opposite effects. Parasympathetic fibres are concerned with cardiovascular reflexes while
sympathetic are concerned with carrying the pain fibres.

Name the arteries with their areas and extent

supplying the interventricular septum.
INTERVENTRICULAR SEPTUM

The ventricular portion of the heart has thick walls and is divided by the ventricular
(interventricular) septum into right and left ventricles. The interventricular septum is as thick as
the wall of the left ventricle that is about three times as thick as the wall of the right ventricle. In
the posterosuperior part of the septum there is as elliptical area about 1 cm in size which is a
thin transparent-membrane, the membranous part of the interventricular septum. The septum is
placed obliquely, with one surface facing forward and to the right and the other backward and to
the left. This even separates right atrium from left ventricle.The main arteries supplying the
interventricular septum are:

The anterior interventricular artery:

It is a branch of the left coronary artery which in turn arises from the left posterior aortic sinus of
the ascending aorta. The anterior interventricular artery supplies the anterior half of the
interventricular septum.

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The posterior interventricular artery:

It is a branch of the right coronary artery which in turn arises from the anterior aortic sinus of the
ascending aorta. The posterior interventricular artery supplies the posterior half of the
interventricular septum.

RIGHT ATRIUM

Right artrium receives the entire systemic blood. It has very thin walls. It forms whole of right
border, part of the base, upper border and a part of the sternocostal surface of the heart.

External features:

Its upper end is prolonged to the left as the auricle, as it has resemblance to a dog’s ear.Along
its right border there is a shallow groove, the ‘sulcus terminalis’ extending from superior vena
caval to inf. vena caval opening below. Opposite this sulcus the interior of atrium presents a
vertical ridge of heart muscle, the ‘crista terminalis’ Arising from crista terminalis are parallel
musculi pectinati’. These pass downwards towards atrioventricular orifice. Those extending into
the auricle form a network arrangement.

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The right atrioventricular groove separates the right atrium from right ventricle and
lodges the right coronary artery and small cardiac vein.

Openings in the right atrium:

Of entry: Superior vena cava, inferior vena cava, coronary sinus, venae cordis
minimi and anterior cardiac veins.
Of exit: Right atrioventricular orifice. This is guarded by a tricuspid orifice which allows venous
blood to flow only from right atrium towards right ventricle.

Interior of right atrium:

Rough anterior part including the auricle: This part contains musculi pectinati and
network arrangement in the auricle.
Smooth posterior part where entry channels drain. Superior vena cava opens in the upper part,
inferior vena cava in the lower part, coronary sinus between opening of inferior vena cava and
right AV orifice, venae cordis minimi open by number of orifices.

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Septal wall is the interatrial septal wall. It presents a thumb-size depression-the fossa ovalis and
its margin is the limbus fossa ovalis.

Conducting tissue:

SA node is present in the upper part of sulcus terminals, while AV node is present above the
opening of coronary sinus.
Right atrium presents many remnants of the foetal circulation.
Inferior vena caval openings is guarded by a valve during fetal life. It guides the blood from right
atrium to left atrium.
Intervenous tubercle of Lower present on the posterior wall of right atrium is a very small
projection in the adult. During foetal life it directs the flow of blood from superior vena cava into
the right AV orifice.
Between upper part of fossa ovalis and limbus fossa ovalis there may be remnant of foramen
ovale. The fossa ovalis represents septum primum, while limbus fossa ovalis represents the free
edge of septum secondum. Foramen ovale during fetal life permits the oxygenated blood of right
atrium to pass into the left atrium.
It is supplied by branches of right coronary artery. Veins drain into the coronary sinus.

Blood Supply:

Development: Smooth posterior part of right atrium develops by the absorption of sinus
venosus.
Rough anterior part develops from the right part of common atrial chamber.
Interatrial septum develops from septum primum (fossa ovalis) and septum secondum (limbus
fossa ovalis).

Describe briefly the right ventricle. Add a note on its

development.
RIGHT VENTRICLE

Right ventricle receives the venous blood from right atrium and pumps it into pulmonary trunk,
pulmonary arteries and lungs for oxygenation. It forms inferior border, two-thirds of sternocostal
surface and one-third of diaphragmatic surface of the heart. It is separated from the right atrium
above by atrioventricular sulcus and from left ventricle by anterior and posterior interventricular
grooves. Thus it is surrounded by arteries, right coronary above, marginal artery below, anterior
interventricular artery to left and anteriorly and posterior interventricular artery to left and
posteriorly.

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INTERIOR:

Inflowing part into which the tricuspid valve opens. This part is rough due to the presence of
trabeculae carnae. These are be in the form ‘ridges’, ‘bridges’ and like ‘papillary muscles’. There
are three papillary muscles, anterior, septal and posterior. One end of papillary muscle is
attached to the ventricular wall and to the other pointed end, cord like structures, ‘chordae
tendinae’ are attached. The chordae tendinae get attached to the cusps of the atrioventricular
valves.

Outflowing part is smooth and conical it gives rise to the pulmonary trunk. This part is also
called as the ‘infundibulum’.
Its cavity is crescentic because the interventricular septum bulges into the right ventricle.
A muscular ridge extends from the interventricular septum to the anterior papillary muscle. This
is called the septomarginal trabecula or moderator band Since right ventricle has to pump blood
only till the lungs its walls are three times thinner than that of left ventricle. High pressure in left
ventricle pushes the septum towards the right side.

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Development:

Most of the right ventrical developes from proximal part of bulbus cordis. The infundibulum
develops from part of middle part of bulbus cordis. Interventricular septum is comprised of
muscular part from floor of the ventricular chamber and membranous part from right and left
bulbar ridges and AV endocardial cushion.

Enumerate the contents of superior mediastinum.

Describe briefly the relations, development and
clinical anatomy of arch of aorta.
SUPERIOR MEDIASTINUM AND ARCH OF AORTA

Boundaries of superior mediastinum:

Posteriorly – Upper thoracic vertebrae and intervening intervertebral discs.
Anteriorly-Manubrium sterni Superiorly-Plane of thoracic inlet. It is oblique and is bounded by
upper border of 1st thoracic vertebra, pair of 1st ribs and their costal cartilages.
Inferiorly - Imaginary plane between lower border of 4th thoracic vertebra and the
manubriosternal angle.

Contents:-

Oesophagus, trachea anterior to oesophagus, left recurrent laryngeal nerve between these two
and thoracic duct to left of oesophagus. These are called unit structures
Pair of sternohyoid, sternothyroid muscles anteriorly and longus colli posteriorly.Arch of aorta
and its three branches.
Right and left brachiocephalic veins and upper half of superior vena cava.
Remains of thymus, Paratracheal, tracheobronchial lymph nodes.

ARCH OF AORTA

It is the continuation of ascending aorta and lies behind the lower half of manubrium sterni. It
continues as the descending thoracic aorta.

Course:
It begins at the upper border of 2nd right costal cartilage at its sternal end. It passes upwards
backwards and to left depicting two curvatures:

Convex above and concave below.

Convex towards the left and anteriorly and concave towards the right and posteriorly.

Thus the arch of aorta has got four surface .

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Left anterior
Right posterior
Superior
Inferior

Relations of these four surface are:-

Left anterior

Left phrenic and left vagus nerves.

Two cardiac branches, one each of sympathetic trunk and left vagus nerve.
Left superior inter-costal vein which crosses superficial to vagus nerve and
deep to phrenic nerve.
Left mediastinal pleura and lung.

Right posterior

This surface is related to unit structures ie oesophagus trachea, left recurrent larygneal nerve
between the two and thoracic duct to left of oesophagus. Deep cardiac plexus at the bifurcation
of trachea.

Superior surface is related

Brachio-cephalic trunk
Left common carotid and
Left subclavian arteries
Crossing all these is left brachiocephalic vein.

Inferior surface is related to

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Division of pulmonary trunk
Ligamentum arteriosum between left branch of pulmonary trunk and arch of aorta just beyond
left subclavian artery.
Left recurrent laryngeal nerve deep to the ligamentum arteriosum.
Superficial cardiac plexus lying superficial to ligamentum arteriosum.

Branches of arch of aorts:-

Brachiocephalic trunk which divides into right subclavian and right common carotid arteries.
Left common carotid.
Left subclavian artery.

Development:
Its developmental components are:-

Left horn of aortic sac i.e. cranial part of truncus arteriosus.

Left fourth aortic arch.
Part of left dorsal aorta.
During foetal life ductus arteriosus connects the left branch of pulmonary trunk to lower border
of arch of aorta beyond left subclavian artery. It conducts the venous blood from right ventricle
to arch of aorta which thus distributes mixed blood to the inter-costal spaces, abdominal viscera
and lower limbs. At the time of birth because of establishment of pulmonary circulation and
functioning of lungs, this blood gets diverted to lungs and ductus arteriosus slowly becomes
fibrous and is named ligamentum arteriosum.

Clinical anatomy:

At times this fibrotic mechanism may extend into the arch of aorta, leading to narrowing or
coarctation of aorta. To supplement the blood supply to abdominal viscera and lower limbs there
occurs an extensive anastomoses between branches of subclavian with those of aorta. There
also occurs anastomoses between branches of anterior and posterior inter-costal arteries. So
the post. arteries enlarge greatly leading to typical notching of the ribs.

Enumerate the boundaries and contents of posterior

mediastinum.

POSTERIOR MEDIASTINUM

Posterior mediastinum is situated in the thoracic cavity behind middle mediastinum and is a part
of inferior mediastinum. Its boundaries are:
Anteriorly: Pericardium with heart, bifurcation of trachea, pulmonary vessels, posterior part of
the diaphragm.

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Posteriorly: Thoracic 5–12 vertebrae with intervening intervertebral discs.Laterally: Mediastinal
pleurae and right and left lungs.

Contents of posterior mediastinum:

Longitudinal structures: Oesophagus, descending thoracic aorta, thoracic duct, vena azgyos,
hemiazygos and accessory hemiazygos veins, sympathetic trunks and greater, lesser and least
splanchnic nerves.

Transverse structures: Thoracic duct at Th 5, hemiazygos and accessory hemiazygos at 8th

vertebra, parts of right inter-costal arteries (3–11).

Describe course relations, development and clinical

anatomy of oesophagus.
OESOPHAGUS

The oesophagus is a tubular, muscular structure about 10 inches (25 cm) long, which is
continuous above with the laryngeal part of the pharynx opposite the sixth cervical vertebra. In
the thorax, it passes downward and to the left through the superior mediastinum and then

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through the posterior mediastinum. At the level of the sternal angle the aortic arch pushes the
oesophagus over to the midline. It passes through the diaphragm at the level of the tenth
thoracic vertebra and ends by opening into the stomach (cardiac end) at the level of T 11
vertebra.Relations of the Thoracic part of the oesophagus

Anteriorly:

The trachea and the left recurrent laryngeal nerve, in the superior mediastinum.
The left principal bronchus, right pulmonary artery, in the posterior mediastinum. Here the
oesophagus lies posterior to left atrium, separated from it by the oblique sinus of the
pericardium.
Posterior part of the diaphragm .

Posteriorly:

The bodies of the thoracic vertebra, in the superior mediastinum.

The oesophagus is separated from the vertebral column segmentally by the
(a) longus colli, (b) the thoracic duct, (c) the azygos vein with the terminal parts
of hemiazygos veins, (d) the upper six or seven right posterior inter-costal
arteries, (e) the descending thoracic aorta, and (f) diaphragm.

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To the right side

Right lung and pleura

Azygos vein
Right vagus

To the left side

Arch of aorta, descending thoracic aorta

Left subclavian artery
Thoracic duct
Left lung and pleura
Left recurrent laryngeal nerve

Blood Supply:

The cervical part of the oesophagus:

It is supplied by inferior thyroid artery. It is drained by the veins, which drain into the
brachiocephalic vein via the inferior thyroid veins.
The thoracic part of the oesophagus:
It is supplied by oesophageal branches of descending thoracic aorta.The veins from this part
drain into the azygos vein.
The abdominal part of the oesophagus:
It is supplied by oesophageal branches of left gastric artery, a branch of the coeliac trunk of the
abdominal aorta.
The veins from this part drain into the left gastric vein a tributary of the portal vein.

Nerve Supply

The oesophagus is supplied by parasympathetic and sympathetic efferent and afferent fibres via
the right and left vagi, and upper four thoracic ganglia of the sympathetic trunks respectively. In
the lower part of its thoracic course, the oesophagus is surrounded by the oesophageal nerve
plexus.
The parasympathetic nerves are sensory, motor and secretomotor to the oesophagus while the
sympathetic nerves are vasomotor.

Clinical Anatomy

The lower-third of the oesophagus, is an important site of portosystemic anastomosis. Here,

are oesophageal tributaries of the azygos veins (systemic veins) anastomose with the
oesophageal tributaries of the left gastric vein (which drains into portal vein). Should the portal
vein become distended, as for example, in cirrhosis of the liver, portal hypertension develops,
resulting in the dilatation and varicosity of the portosystemic anastomosis. These dilatations are
called oesophageal varices which may rupture during the passage of food, causing
haematemesis (vomiting of blood), which may prove fatal.

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The lower end of the oesophagus is normally kept closed. It is opened by the stimulus of bolus
of food. In cases of neuromuscular incoordination the lower end of the oesophagus fails to dilate
with the arrival of food which, thus, accumulates in the oesophagus. This condition of
neuromuscular incoordination characterized by inability of the oesophagus to dilate is known
as “achalasia cardia”.
Compression of the oesophagus in cases of mediastinal syndrome cause dysphasia.

Development of the oesophagus

When the embryo is approximately 4 weeks old, a small diverticulum appears at the ventral wall
of the foregut at the border with the pharyngeal gut.
This respiratory or tracheobronchial diverticulum is gradually separated from the dorsal part of
the foregut through a partition, called oesophagotracheal septum.
Thus the foregut is divided into a ventral portion, the respiratory primordium, and a dorsal
portion, the oesophagus.
Initially the oesophagus is very short, but with the descent of the heart and lungs, it lengthens
rapidly.
Developmental anomalies of the oesophagus:
Atresia of oesophagus and oesophagotracheal fistula.
Atresia of oesophagus is often accompanied by abnormal communications between the
In its most common form, the proximal part of oesophagus ends as a blind sac, while the distal
part is connected to the trachea by a narrow canal at a point just above the
bifurcation.Occasionally, the fistulous canal between the trachea and the distal portion of the
oesophagus is replaced by a ligamentous cord.
Rarely do both the proximal and distal portions of the oesophagus open into the trachea.
The distal part of oesophagus ends in a blind sac whereas the proximal part is connected to the
trachea by a narrow canal. The distal part is connected to proximal part by a ligamentous cord.
oesophagus and trachea. This abnormality is thought to result either from a spontaneous
deviation of the oesophagobronchial septum in a posterior direction or from some mechanical
factor pushing the dorsal wall of the foregut anteriorly.
In its most common form, the proximal part of oesophagus ends as a blind sac, while the distal
part is connected to the trachea by a narrow canal at a point just above the bifurcation.
Occasionally, the fistulous canal between the trachea and the distal portion of the oesophagus
is replaced by a ligamentous cord.
Rarely do both the proximal and distal portions of the oesophagus open into the trachea.
The distal part of oesophagus ends in a blind sac whereas the proximal part is connected to the
trachea by a narrow canal. The distal part is connected to proximal part by a ligamentous cord.
Atresia of the oesophagus prevents the normal passage of amniotic fluid into the intestinal tract;
this results in the accumulation of excess fluid in the amniotic sac (polyhydramnios) and
consequently an enlarged uterus. Although a new born child with atresia of oesophagus may
appear normal, at its first attempt to drink, the proximal portion of the oesophagus will fill rapidly
and milk will flow over into the trachea and lungs.Congenital diverticula and congenital cysts
may be related to the oesophagus.

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Enumerate the normal sites where oesophagus is
constricted.

SITES OF NORMAL CONSTRICTIONS OF OESOPHAGUS

The oesophagus is a narrow muscular tube, forming the food passage between the pharynx and
stomach. It extends from the lower part of the neck to the upper part of the abdomen.
Normally the oesophagus has four anatomical and physiological constrictions.

The first is at the pharyngo-oesophageal junction at the beginning of the oesophagus (15 cm.
from the incisor teeth).
The second is where the arch of aorta crosses its anterior surface (22.5 cm from the incisor
teeth).
The third is where the oesophagus is crossed by the left principal bronchus
(27.5 cm from the incisor teeth).
The fourth is where the oesophagus pierces the diaphragm (37.5 cm from the incisor teeth).

Clinical Anatomy

Since a slight delay in the passage of food or fluid occurs at these levels, strictures develop
here following the drinking of corrosive caustic fluids.These constrictions are also the common

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sites of carcinoma of the oesophagus.
The distances of the constriction from the incisor teeth are important in passing instruments into
the oesophagus.
The normal constrictions should be kept in mind during oesophagoscopy.
The normal constrictions of the oesophagus can be visualised by barium swallow.

Enumerate the branches of descending thoracic aorta.

Add a note on its applied aspects.

DESCENDING THORACIC AORTA

The descending thoracic aorta begins as a continuation of the arch of the aorta on the left side
of the lower border of the body of the fourth thoracic vertebra, where it passes through the aortic
opening (at the level of T12 vertebra) of the diaphragm in the midline and becomes continuous
with the abdominal aorta.Branches of descending thoracic aorta.The branches of the
descending thoracic aorta can be divided into 2 groups.

A. Branches from the anterior surface

Two left bronchial arteries. The superior of these may give rise to the right bronchial artery
which usually arises from the third right posterior inter-costal artery.
Oesophageal branches, supplying the middle one-third of the oesophagus. Pericardial
branches, to the posterior surface of the pericardium.
Mediastinal branches, to lymph nodes and areolar tissue of the posterior mediastinum.
Superior phrenic arteries, to the posterior part of the superior surface of the diaphragm.
Branches of these arteries anastomose with those of the musculophrenic artery and
pericardiophrenic artery, both being branches of the
internal thoracic artery.

(B). Branches from the posterior surface

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Nine posterior inter-costal arteries on each side for the 3rd to 11th inter-costal spaces. The right
ones are longer than the left ones .

The subcostal artery on each side.

Clinical aspects

Rupture of the descending thoracic aorta

In road traffic accidents, decelerating forces are encountered which can produce pressures
waves in the aorta. The arch of the aorta is relatively fixed by the brachiocephalic, left common
carotid and left subclavian arteries, but the more mobile descending thoracic aorta continues to
travel forwards. Shearing forces between the relatively fixed and mobile portions of the aorta
lead to rupture in the region of the attachment of the ligamentum arteriosum. If the adventitia of
the aorta remains intact a false aneurysm forms which produces widening of the mediastinum
on chest x-ray. These latter patients usually reach the hospital alive and it is possible to repair
the tear in the aorta.

Coarctation of the aorta

This is the commonest primary cardiovascular cause of heart failure in an acyanotic infant in the
first week of life. Boys are affected twice as often as girls.

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Though this condition may affect any part of the aorta, 98% of coarctations affect the first part of
the descending aorta just beyond the arch. The outstanding clinical features of the condition are
raised arterial pressure in the arm compared with the femoral pressure below this, grooving of
the lower borders of the ribs by enlarging inter-costal arteries and often, visible arterial pulsation
on the back.Operations on the descending thoracic aorta

The incidence of postoperative paraplegia (paralysis of the lower half of the body) following
operations on the descending aorta is largely dependent on the blood supply of the spinal cord,
which is derived from the neck vessels and the descending aorta, with a collateral circulation
between them.
The calibre of the anterior spinal artery is narrowest in the midthoracic region. In this region
(T8–L1), spinal cord blood supply may be largely dependent upon an artery arising directly from
the descending thoracic aorta.

Write briefly on thoracic duct.

THORACIC DUCT

Thoracic duct is the largest lymphatic channel of the body, situated in the upper part of
abdomen, post. mediastinum superior mediastinum and the neck. It drains lymph from the lower
limbs, abdominal cavity, GIT, left half of thoracic cavity including the heart, left half of head and
neck. There is a right lymphatic duct also that only drains the right upper limb, right half of head
and neck, right half of thoracic cavity including the right lung.

Beginning: It is the upward continuation of cisterna chyli at the lower border of

12th thoracic vertebra.

Course: It enters the posterior mediastinum of thorax by passing through the aortic opening of
diaphragm in between vena azygos and descending aorta.It courses upwards along the right
side of median plane. Opposite 5th thoracic vertebra it crosses to the left by passing behind the

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oesophagus to ascend upwards.

Then it passes in the superior mediastinum lying to left of oesophagus. It finally reaches the
neck where it passes behind the vertebral vessels and carotid sheath to reach the beginning of
left brachiocephalic vein.

Termination
It enters the beginning of left brachiocephalic vein.

Tributaries
Through cisterna chyli it receives.
a. Two lumbar lymph trunks from lower limbs, posterior abdominal wall and
pelvic cavity.
b. Intestinal lymph trunk.
Lymph from post.inter-costal nodes.
Left bronchomediastinal lymph trunk from left half of thoracic cavity and left lung.

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Left jugular lymph trunk
Subclavian lymph trunk
Lymph drainage is subjected to numerous variations.

Clinical terms.
CLINICAL TERMS

Site of pericardial tapping :

Removal of pericardial fluid is done in left 4th or 5th inter-costal spaces just left of the sternum
as pleura deviates exposing the pericardium against the medial part of left 4th and 5th inter-
costal spaces. Care should be taken to avoid injury to internal thoracic artery lying at a distance
of one cm from the lateral border of sternum. Needle can also be passed upwards and
posteriorly from the left xiphicostal angle to reach the pericardial cavity.

Foreign bodies in trachea :

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Foreign bodies like pins, coins entering the trachea pass into right bronchus; Right bronchus
wider, more vertical and is in line with trachea. Most of the human beings want to take the path
of least resistance, so the foreign bodies in the trachea travel down into right bronchus and then
into posterior basal segment of the lower lobe of the lung.

Site of bone marrow puncture:

The manubrium sterni is the site for bone marrow puncture in adults. Manubrium is
subcutaneous and easily approachable. Bone marrow studies are done for various
hematological disorders. Another site is the iliac crest; which is the preferred site in children.

Posture of a patient with respiratory difficulty :

Such a patient finds comfort while sitting, as diaphragm is lowest in this position.
In lying position, the diaphragm is highest and patient is very uncomfortable.
In standing position, the diaphragm level is midway, but the patient is too sick to stand. Patient
also fixes the arms by holding the arms of a chair, so that serratus anterior and pectoralis major
can move the ribs and help in respiration.

Site of pleural tapping :

Tapping is done to remove the pleural fluid. Since the fluid level is highest in mid axillary line, it
is done through the lower part of the inter-costal space in midaxillary line. The upper part of the
space contains the inter-costal nerve, artery and vein, to avoid injury to these structures, it is not
done in the upper part of the space, but done in its lower part.

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