Professional Documents
Culture Documents
Text Book of Anatomy
Text Book of Anatomy
Human Anatomy
BHARATI ADHIKARI
Anatomy is a vast and difficult subject comprising many facts with complicated description of different
parts and systems of the human body. At the same time, study of this subject is very important for
undergraduate and postgraduate medical students because anatomy forms the backbone of all clinical
and applied medical sciences.
It is necessary for a teacher of the subject to cut out the unnecessary details and make the subject
more palatable and easy. The present book is an attempt to present the essential facts of human anatomy
in a correlated and simplified manner.
Following are the objectives of this book:
To give a working knowledge of basic human anatomy with the help of illustrations, figures and tables.
To cut down the detailed description and present the main facts in a point-wise manner.
To minimise the time taken for study of different regions of the body.
To serve as a framework of human anatomy upon which the students or medical practitioners can build
up details.
To include the clinical importance and applied anatomy of different parts of the body.
To include multiple choice questions with answers at the end of each chapter for revision of the text.
The book presents the different parts of the body in a region-wise manner. However, the bones and
joints of the part have been discussed in the beginning of each chapter. This treatment of the subject is
different from other textbooks of anatomy. This has been done with a view that when a student learns
about one region of a part of human body (e.g. shoulder region of upper limb) he should revise all the
structures of the region, viz. muscles, blood vessels, lymphatics and nerves. In this attempt, some
repetitions of the structures are unavoidable. But then, anatomy is best learnt by repetition.
I hope that the book will be helpful in learning anatomy in an interesting way.
BHARATI ADHIKARI
Contents
Section Eight: The Spinal Cord, Brain, Eyes and the Ears
43. The Spinal Cord ............................................................................................................................. 481
44. The Meninges and Blood Supply of Brain ................................................................................. 486
45. The Hind-Brain and Mid-Brain .................................................................................................. 492
46. The Forebrain................................................................................................................................. 502
47. The Cranial Nerves........................................................................................................................ 517
48. The Eyes .......................................................................................................................................... 525
49. The Ears .......................................................................................................................................... 536
Index ................................................................................................................................................ 551
Introduction to
Anatomy ONE
CHAPTER 1
The Basics
The term Anatomy is derived from Greek word Abdomen and pelvis
anatome (= cutting up). Anatomy, therefore, is Upper extremity
the study of structure of human body after Lower extremity.
dissection. Human anatomy is the oldest medical 2. Microscopic anatomy (Histology): Study of
science. The first person to describe the structure the minute structure of the body with the help
of human body was the Greek philosopher, of a microscope.
Aristotle, nearly 2,300 years ago. 3. Developmental anatomy (Embryology): Study
of the embryo and fetus within the uterus or
THE SUBDIVISIONS OF ANATOMY the womb.
4. Applied anatomy (Clinical anatomy): Study
1. Gross-anatomy: Macroscopic study of human
of those aspects of anatomy which are
body after dissection. It can be studied as:
applicable to the clinical disciplines and help
A. Systemic (Systematic) anatomy: Study of
to explain and provide a background for the
different systems of the body:
clinical signs and symptoms.
Osteology: Study of the bones
5. Functional anatomy: Study of structure of
Arthrology: Study of the joints
different parts of the body related to their
Myology: Study of the muscles
functions.
Angiology: Study of the cardiovascular
6. Surface anatomy: Study of the landmarks, e.g.
system
bony prominences and muscular elevations, and
Splanchnology: Study of the internal
projections of outlines of viscera and other
organs
structures on the surface of the body.
Neurology: Study of the nervous system
7. Radiological anatomy: Study of different
Endocrinology: Study of the
parts of body, specially bones and joints, with
endocrines or the ductless glnds
the help of X-rays.
Integumentary system: Study of the
skin and its derivatives. THE POSITIONS OF THE BODY
B. Regional anatomy: Study of the different
regions of human body: 1. The anatomical position: The body is
Head and neck standing erect with arms by the sides and
Brain palms facing forwards. The legs and feet are
Thorax together and eyes look directly to the front.
2 Essentials of Human Anatomy
The proximal edge of the plate is the root These glands lie in the deeper part of the
of the nail, while the distsal edge projects dermis and have long ducts, that pass through
beyond the nail bed and become dead; so it dermis and the layers of the epidermis to open at
can be cut or trimmed. minute pores on the surface of the skin.
The surface of the skin covered by the nail The sweat glands are distributed on all
plate is called the nail bed. surfaces of the body except:
The nail is surrounded by the nail folds Red margin of the lips
except at the free edge. Nail beds
2. The hair follicies: These are invaginations of Glans penis in males and clitoris in females.
the epidermis that grow obliquely in the
deeper part of the dermis. The Nerve Supply of the Skin
The hair grow out of the hair follicles.
The skin receives sensory nerve supply from the
Their roots form the hair bulbs with concave
spinal and the cranial nerves.
bases occupied by vascular connective tissue
forming hair papillae. The sensory nerve fibers begin from the
receptor end organs and free nerve endings
The arrector pili are smooth muscle fibers
that connect the lower part of hair follicles to located in the dermis of the skin.
the deeper layer of the epidermis. Basically, the sensory nerve supply of the
The arrector pili are supplied by skin follows a segmental pattern. The skin area
sympathetic fibers supplied by one pair of spinal nerves (i.e. one
Their contraction causes hair follicles to spinal segment) is called a dermatome.
become more erect causing socalled goose There is overlapping in the nerve supply of a
flesh dermatome from the adjoining dermatomes.
Their contraction also causes compression The spinal nerves also carry post-ganglionic
of the sebaceous glands and helps in extru- sympathetic fibers that supply:
ding their secretion, sebum, in the hair The blood vessels of the skin
follicles. The sweat glands
The hair are distributed all over the surface The arrector pili muscles.
of the body except in
Palms and soles Clinical Importance of Skin
Lips
1. Systemic diseases often produce
Sides of fingers and toes
manifestations on the skin in the form of:
Labia majora and labia minora (external
genitals) in the females. Vasoconstriction
3. The sebaceous glands: These are branched Vasodilatation
alveolar glands that secrete sebum (natural Eruptions
oil) in the hair follicles. Edema
These glands are present between the 2. The skin is very important for plastic surgery,
arrector pili muscles and the sloping surface viz:
of the hair follicles. The sebum keeps the hair Skin grafting
flexible and also oils the skin surface. Cosmetic surgery.
4. The sweat glands: These are coiled tubular 3. Loss of skin in cases of burn injuries causes
glands that secrete sweat. extensive fluid loss.
The Skin and Its Appendages 7
3. Joints: The bones form the joints, which act II. The compact bone lies deep to the periosteum
as levers and provide movements. and looks like ivory with naked eye.
4. Storehouse: The bones act as store houses of The compact bone is made up of haversian
Ca, PO4 and CO3 ions. systems and canals.
5. Hemopoiesis: The bone marrow is the source III. The cancellous bone consists of of bony lamellae
of red blood cells, white blood cells, and the enclosing narrow spaces containing the bone
platelets. marrow tissue.
The cancellous bone fills up the interior of
The Structure of the Bone the bone.
IV. The medullary cavity is present in most of the
The bone is calcified connective tissue. It consists
long bones.
of: It is located mainly in the shaft of the bone
1. An organic matrix (nearly 33%) made up of and contains bone marrow tissue (Fig. 3.1).
collagenous tissue. This forms the basic
framework of the bone.
2. An inorganic content (nearly 66%) that
impregnates the organic matrix. It is made up
of crystalline hydroxyapatite of calcium. The
inorganic content gives the sheer strength to
the bone.
3. The osteocytes (bone forming cells) that lie in
the spaces within the bone tissue called lacunae.
By keeping the bone in weak, mineral acid for
some time, the inorganic content of the bone is
removed and the bone becomes decalcified. Such
a bone becomes soft and malleable.
By incinerating, the bone loses the organic
matter. The remaining inorganic matter maintains
the shape of the bone, but becomes very brittle.
A transverse section through the long bone Fig. 3.1: LS through a long bone
shows:
I. The periosteum: That lines the external Types of Bones
surface of all parts of the bone except those 1. Long bones are present in the extremities.
that are covered by hyaline articular cartilage
They have a main part or shaft called
at the joints. The periosteum consists of:
diaphysis.
An outer fibrous layer
An inner vascular layer with plexus of fine The two ends form the epiphysis.
blood vessels (periosteal plexus). It has also There is medullary cavity containing bone
a layer of osteocytes, that are modified marrow tissue in the shaft.
fibroblasts. Examples: Femur, humerus.
The functions of the periosteum are: 2. Short bones are small size bones usually
1. It protects the bone. cuboidal in shape.
2. It nourishes the bone through its vascular Examples: Tarsals, Carpals.
plexus. 3. Flat bones consist of two layers of compact
3. It helps in growth and repair of the bone bone with spongy or cancellous bone in between
by its osteocytes. called diploe. They are expanded like a plate.
The Bones, Cartilages and Joints 11
Examples: Skull bones, e.g. frontal, parietal. There is an epiphyseal plate or cartilage
4. Irregular bones have irregular shapes separating the epiphysis from the diaphysis. This
They have compact bone surrounding epiphyseal plate disappears, when the growth in
spongy bone in between. length of the bone stops.
Examples: Vertebrae, hip bones The epiphyseal end of diaphysis is called
5. Sesamoid bones (= seedlike) are small metaphysis.
nodules of bone, developed in tendons of This is the most vascular and active area of
certain muscles at sites of friction or pressure. growth of the long bone.
Examples: Patella, pisiform. The growing end of the long bone is that end
6. Pneumatic bones are skull bones having air- of the bone whose epiphysis fuses with the
filled cavities called air sinuses. diaphysis (shaft) later than the other end (i.e. it
Examples: Frontal, maxilla. continues to grow in length a little longer).
The growing end of the long bone lies
Ossification of the Bones
opposite to the direction of the nutrient canal of
The ossification is the process of bone formation the bone (Fig. 3.2).
by the bone forming cells- osteoblasts.
The osteoblasts form centers of occification in
the developing bone.
For growth and remodelling another type of
bone cellsthe osteoclastsare also required.
There are two types of ossification:
1. Intra-cartilaginous type (enchondral ossifica-
tion): In this type, first a cartilaginous model
of bone is formed. The centers of ossification
appear within the cartilaginous model and
replace it with bone.
Examples: Most of the limb bones.
2. Intra-membranous type: In this type the
centers of ossification appear in the
mesenchymatous model itself without
forming the cartilaginous model.
Fig. 3.2: Parts of a developing long bone
Examples: Clavicle, Skull bones, e.g. frontal
parietal.
Functional Considerations
The primary center of ossification of the bone
usually appears before birth and forms the main part The bone is a living tissue capable of growth and
of the bone. In long bone it forms the diaphysis. repair.
The secondary centers of ossification usually The growth in length of the long bone takes
appear after birth and form small parts of the place at the epiphyseal cartilage, while the growth
bone called epiphyses. in thickness (appositional growth) takes place deep
In case of long bones, there is usually one (or to the periosteum. The remodeling of the bone takes
more than one) epiphysis at either end of the place along with the growth of the bone. It is done
bone. by the osteoclaststhe bone absorbing cells.
12 Essentials of Human Anatomy
The lamellae of the spongy bone, specially The fracture of epiphyseal plate in deve-
towards the ends of the long bone, develop along loping bone is difficult to detect and it
the lines of force transmission. may interfere with the subsequent growth
The ridges, crests and tubercles, etc. on the of the bone.
bone develop at the sites of attachment of the The fractures of bone may injure the nerves
muscles and tendons, due to the traction and the blood vessels close to the bone.
exercised by them on the bone. The fracture of skull bones may result in
compression of the brain and injury to
The Blood Supply of the Bones nerves and blood vessels passing through
The bones receive their blood supply from three the foramina of the bone.
sources: The repair of the fractures
1. The nutrient vessels enter through the nutrient The fracture results in loss of function of the
foramen, in long bones, they pass through the bone in that region.
nutrient canal directed away from the growing As a first step towards repair, a collar of collagen
end of the bone. called callus is formed by the fibroblasts lying in
The nutrient vessels provide main blood the deeper part of periosteum.
supply of the bone. The callus calcifies later and forms a temporary
In long bone, they also supply the bone union between the fractured pieces of the bone.
marrow in the medullary cavity. Both osteoblasts (bone forming cells) and
2. The periosteal vessels are derived from the osteoclasts (bone absorbing cells) become
periosteal plexus, which is nourished by the active at the site of callus formation and result
muscular vessels supplying muscles attached in the formation and remodelling of the bone,
to the bone. so that the original size and shape of the bone
The periosteal vessels supply the is restored.
superficial part of the compact bone only.
3. The epiphyseal and juxta-epiphyseal vessels THE CARTILAGES
are derived from the vessels supplying the The cartilage is a firm and resilient structure that
articular capsule of the joint. forms a small part of skeleton.
These are mostly present at the ends of the The cartilage is a form of connective tissue in
long bone and pass through the vascular which the living cellschondrocytesare
foramina located there. embedded in the intercellular matrix
composed of muco-polysaccharides.
Clinical Considerations
Except for the cartilage present on the
The fractures of the bones are caused due to articular surfaces of the joints, the cartilages
abnormal pressure or traction applied to the located elsewhere are covered by a fibrous
bones. Fractures are classified according to: membrane called perichondrium.
a. Degree of displacement of broken bone pieces. There are three types of cartilageshyaline,
b. Compression of the bone. white fibrocartilage and yellow elastic cartilage.
c. Whether the skin over the fracture is also torn 1. The hyaline cartilage has no demonstrable
leading to compound fracture. fibers, by ordinary H and E stain, in the
The fractures can be seen and diagnosed intercellular matrix, which is very large in
with the help of X-ray photographs. amount.
The Bones, Cartilages and Joints 13
The hyaline cartilage has great a. The suture is the joint between two flat
resistance to wear and tear. skull bones.
The hyaline cartilage is found at The outer and inner fibrous layers of
Costal cartilages the two bones become continuous and
Articular surfaces of the joints there is a fibrous sutural ligament in
Epiphyseal plate of growing bones. between the bones.
The hyaline cartilage is incapable of Examples: Coronal suture, sagittal
repair; the defect is filled up by fibrous suture.
tissue. b. The syndesmosis is the fibrous joint where
2. The white fibro-cartilage has large number the two bones are connected by ligaments
of collagen fiber bundles embedded in the only (Fig. 3.3).
matrix, which is small in amount. Examples: Inferior tibio-fibular joint.
The white fibro-cartilage is a resistant c. The gomphosis (peg and socket joint) is the
and durable form of cartilage. fibrous joint between the root of the tooth
The white fibro-cartilage is found at and the bony socket provided by the upper
Intra-articular disc of the joints jaw or lower jaw bone.
Inter-vertebral discs of the vertebral 2. The amphiarthroses (cartilaginous joints) may
column. allow a limited movement.
3. The yellow elastic cartillage has a large These joints can be further devided into
number of elastic fibers embedded in the two types:
matrix. a. The primary cartilaginous joint (synchon-
The yellow elastic cartilage is drosis) is a joint, where two bones are
stretchable and more resilient than joined together by hyaline cartilage.
other two forms of cartillage. No movement is possible in these joints:
The yellow elastic cartilage is found at Examples: First chondro-sternal joint.
Cartilage of external acoustic meatus Epiphyseal cartilage between diaphysis
Cartilage of pinna or auricle and epiphysis.
Cartilage of auditory tube b. The secondary cartilaginous joint (symp-
Epiglottis hysis) is a joint, where the two bones are
covered by hyaline articular cartilage and
THE JOINTS united by a plate of fibro-cartilage.
The joints are formed, where two or more than
two bones meet and get united.
The joints can be classified broadly into three
groupssynarthroses, amphiarthroses and
diarthroses.
1. The synarthroses (fibrous joints) are
immovable or hardly movable.
These joints can be further divided into
three types: Fig. 3.3: Fibrous joints
14 Essentials of Human Anatomy
The joint is surrounded by ligaments. 2. Biaxial where movements take place at two
A limited movement is possible in axes.
these joints. Examples: Metacarpo-phalangeal joints,
Examples: radio-carpal (wrist) joint
Pubic symphysis 3. Multiaxial where movements take place at
Intervertebral disc between the two more than two axes.
vertebral bodies (Fig. 3.4). Examples: Shoulder joint, hip joint.
3. The diarthroses (synovial joints) permit Classification of synovial joints (according to the
relatively free movements. shape of the articular surfaces):
The articular surfaces are covered by hyaline a. Plane type where the two joint surfaces are
articular cartilage, that can withstand pres- plane.
sure and change in shape to some extent. Examples: Acromio-clavicular joint
The joint is surrounded by a fibrous b. Hinge type where the two joint surfaces are
articular capsule, that keeps the bones reciprocally curved to allow movement in one
together, and prevents their separation axis only.
during movements of the joint. Examples: Elbow joint, ankle joint.
The fibrous capsule is reinforced by strap- c. Pivot type where one joint surface forms the
like fibrous bands called ligaments. central pivot, while the other is shaped like a
The joint cavity has synovial membrane, ring.
which lines the inner surface of fibrous Examples: Superior radio-ulnar joint median
capsule, and also covers all intra-articular atlanto-axial joint.
structures. The synovial membrane, how- d. Condyloid type Where one joint, surface is
ever, does not cover the articular surface convex and other is concave.
of the bones. Examples: Metacarpo-phalangeal joints.
A fibro-cartilaginous, intra-articular disc e. Ellipsoid type where the two joint surfaces,
is also found in some synovial joints. The are convex and concave and shaped like an
disc makes the joint more stable (Fig. 3.5). ellipsoid.
Classification of synovial joints (according to the Examples: Radio-carpal (wrist) joint.
movements): f. Ball and socket type where one joint surface
1. Uniaxial where movements take place in one is shaped like a sphere, while the other
axis only. presents a socket-like joint surface.
Examples: Elbow joint, ankle joint. Examples: Shoulder joint, hip joint.
g. Saddle type where the two joint surfaces are The stretch receptors in the articular capsule
reciprocally concavo-convex. and the ligaments send proprioceptive
Examples: Calcaneo-cuboid joint impulses to the central nervous system, about
First carpo-metacarpal joint the position of the joint.
Overstretching of the capsule and ligaments
The Blood Supply of the Joints produces reflex contraction of muscles around
The blood supply of the joints is provided by the joint, causing pain.
small vessels from the attachment of the muscles The ligaments are cord-like or strap-like
near the joint. structures made up of dense connective tissue.
The large joints have arterial anastomoses The ligaments firmly connect the bones
around the joints to supply adequate amount of forming the joints.
blood. Most of the ligaments are composed of thick
Examples: Elbow joint, knee joint. bundles of collagen fibers, and are unstre-
tchable. Such ligaments contribute to the
The Nerve Supply of the Joints stability of the joint.
The nerve supply to the joints is usually derived A few ligaments are composed of elastic fibers
from the main nerve of the region. and therefore, can be stretched normally.
Hiltons law states that a nerve supplying a joint Example:Ligamenta flava of vertebral column.
also supplies the muscle moving the joint, and the Injury to the ligament causes sprain of the
skin over the insertion of the muscle. joint with pain and limitation of movements.
The articular capsule and the ligaments Healing of such injury to the ligament is slow,
receive a rich sensory nerve supply. as ligaments are comparatively less vascular.
The articular cartilage covering the joint surfaces Example: Ilio-femoral ligament of the hip
has only a few nerve endings near its edges. joint.
CHAPTER 4
The Muscles
and the Fasciae
THE MUSCLES 1. The origin of the muscle is usually the proximal
and more fixed attachment of the muscle.
There are three types of muscles in the body:
2. The insertion of the muscle is usually the distal
1. Skeletal (striated)
and relatively mobile attachment of the muscle.
2. Visceral (non-striated, smooth or plain)
3. The muscle belly is the main part of the
3. Cardiac
muscle between the two attachments.
The main features of three types of muscles
Tendon is cylindrical cord-like structure,
are given in Table 4.1.
that replaces the muscle fibers towards the
Skeletal Muscles insertion of the muscle usually.
The tendon is made up of dense, regularly
The skeletal muscles form nearly 50% of body arranged collagen fiber bundles.
weight. These muscles are made up of bundles of The tendon has a smaller cross-sectional
muscle fibers, which are specialized muscle cells area and occupies smaller space on the
with special property of contraction. bone of attachment.
Example: Tendo-calcaneus
Parts of the Skeletal Muscle
Aponeurosis is that fibrous sheet which replaces a
Each skeletal muscle has at least two attachments- flat muscle towards insertion.
origin and insertionand a muscle belly. Example: Aponeurosis of external oblique muscle.
Raphe is a fibrous structure, formed by the inter - b. Bipennate: muscle where bundles of
digitation of muscle fibers of the two sides. muscle fibers are attached to both
Example: Fibrous median raphe of the two mylo- sides of the tendon.
hyoid muscles. Example: Flexor hallucis longus.
c. Multipennate: muscle where a series of
Shapes of the Muscle Belly bipennate muscles lie alongside one
another in the muscle belly.
1. Fusiform where the muscle fibers lie along
Example: Deltod (middle part).
the long axis of the muscle.
d. Circumpennate muscle where muscle
2. Pennate where the muscle fibers lie at an fibers converge from all sides to reach
angle to the long axis of the muscle. a centrally placed tendon.
The pennate muscles have many more Example: Tibialis anterior.
muscle fibers as compared to the fusiform 3. Quadrilateral (Quadrangular) where the
muscles. muscle belly is short and quadrangular.
The pennate muscles have, therefore, Example: Quadratus femoris.
more powerful contraction than fusiform 4. Strap like where the muscle belly is long and
muscles. Their contraction,may be slow strap or ribbon like with parallel muscle
and the range of contraction may be less. fibers. Example: Sartorius
The pennate muscles are classified as 5. Triangular where muscle belly is shaped like
follows: a triangle.
a. Unipennate muscle where bundles of Example: Obturator externus.
muscle fibres are attached to one side 6. Digastric where two muscle bellies are joined
of the tendon. by a common tendon.
Example: Flexor pollicies longus. Example: Digastric
7. Bicipital where the muscle belly has two Example: Flexor muscles of the elbow
heads-joined by a common tendon. joint lifting a weight, that is manageable.
Example: Biceps brachii.
8. Tricipital where the muscle belly is divided The Nerve Supply of the Muscle
into three heads, that are joined at the The nerve supply of the skeletal muscle is by a
common tendon of insertion (Fig. 4.1) motor nerve. The nerve contains about 60%
Example: Triceps brachii. motor nerve fibers and 40% afferent or pro-
prioceptive nerve fibers.
Types of the Skeletal Muscles The neuro-vascular hilum is present in most
The skeletal muscles are also classified according of the skeletal muscles. It is the site where the
to their actions motor nerve and the main blood vessels enter
1. The prime movers are the main muscles the muscle belly.
responsible for a particular movement at a joint. The motor nerve fibers supplying the muscle
are of two types:
Example: Brachialis a prime flexor of
a. Large alfa motor efferents are derived
the elbow joint.
from large motor neurons of anterior grey
2. The antagonists are the muscles that are just
column of the spinal cord.
opposite in action to the prime movers.
b. Small gamma efferents are derived from the
Examples: Tricepsa prime extensor of the
small neurons in the anterior grey column
elbow joint, is antagonist to the brachialis.
of the spinal cord.
3. The synergists are the muscles which help in
Both types of motor nerve fibers are
the action of the prime movers by stabilizing
myelinated and end by dividing into many
the intermediate joints or preventing
branches, which terminate in individual muscle
unwanted movements.
fibers at the motor end plate.
Examples: Long flexors of carpals that help
The sensory or afferent nerve fibers are also
in action of long flexors of the fingers.
myelinated, and arise from specialized sensory
4. The fixators are those muscles which contract
nerve endings within the muscle called neuro-
isometrically to stabilize the attachment of the
muscular and neuro-tendinous spindles.
prime movers, so that they may contract more
These receptor endings are stimulated by the
effectively.
tension in the muscle, during active
Example:Scapular muscles fix the scapula,
contraction or passive stretching.
so that deltoid can abduct the shoulder joint. These afferent fibers carry proprioceptive
impulses from the receptor nerve endings to
The Contraction of the Muscle
the spinal cord and brain.
The contraction of the skeletal muscle may be. The afferent fibers help in maintenance of the
a. Isometric contraction when muscle contracts posture and carrying on complex, coordinated
and exercises force without producing any movements.
movement. The motor point is the point on the skin covering
Example:Flexor muscles of the elbow joint the muscle, that marks the site of entry of motor
trying to lift a weight that is too heavy. nerve in the muscle.
b. Isotonic contraction when a muscle shortens The point is located, often, about the middle
to produce a movement. of the muscle, or nearer to its origin.
The Muscles and the Fasciae 19
The motor unit consists of a single motor nerve Electrodes are applied to the muscle of a
fiber (alpha efferent) and the number of muscle living person and the movement is performed.
fibers innervated by it. The difference in the electric action potential of
The motor unit varies in different muscles the muscle is amplified and recorded.
according to the precision in the muscular
movements. THE FASCIAE
Examples: Extraocular muscles have motor The fascia is composed of connective tissue
units with 6-12 muscle fibers.
fibroblasts, collagen fiber bundles and elastic fibers.
In major limb muscles, the motor units have
The superficial fascia is the loose connective tissue
about 200 muscle fibers.
layer that lies deep to the dermis of the skin.
The muscle tone: Each skeletal muscle in resting
condition remains in a state of partial contraction. The superfacial fascia consists of
This is referred to as muscle tone. a. Superficial blood vessels
In muscle tone some groups of muscle fibers b. Cutaneous nerves
are fully contracted,while other groups are c. Superficial lymphatics
relaxed. d. Variable amount of fat (more in females)
To avoid fatigue different groups of muscle e. Superficial muscle fibers, that are derivatives
fibers contract alternately. of panniculus carnosus a superficial
The muscle tone depends on a simple reflex muscle sheetpresent in superficial fascia of
are composed of two neurons. of cattle and horses. The remnants of
a. Receptor neuron in dorsal root ganglion, panniculus carno-sus in human beings are:
which receives proprioceptive impulse Platysma
from the neuro-muscular and neuro- Muscles of scalp, face and auricle
tendinous spindles. Sub-areolar muscle
It sends its axon to motor neuron in the Palmaris brevis.
anterior grey column of the spinal cord. f. Mammary gland in females lies in superficial
b. The axon of the motor neuron reaches the fascia of front of thorax.
muscle fibers. The superficial fascia in anterior abdominal wall
In case of injury to the motor nerve of the below umbilicus and in perineum is divided into
muscle, this reflex arc is interrupted, and the two layers:
muscle loses its muscle tone and becomes a. Outer fatty layer(Campers fascia) contains
flaccid. superficial vessels and nerves.
b. Inner membranous layer(Scarpas fascia) is
Electromyography thin and consists of an elastic membranous
sheet.
Electromyography is the study of actions of In palm and sole, the superficial fascia is
muscle with the help of electrical changes in the quite thick and contains dense connective
muscle during contraction. tissue.
Electric excitation of a muscle passes along The superficial fascia serves as a loose
the nerve fibers to the muscle. This is the basis of packing material. It also serves for insu-
nerve conduction studies. lation and padding of the body.
There is a direct relation between tension This layer is sensitive to oestrogenic
developed in a muscle and its electrical activity. hormones.
20 Essentials of Human Anatomy
Oxygenation of blood in fetus takes place in These arteries divide into smaller
the placenta, as lungs are not functioning. branches to supply organs and tissues.
Very little amount of blood passes to the liver These arteries take the most direct and
and lungs, and shunts operate to bypass these shortest route usually. In limbs they lie
structures. on flexor surface in between muscles,
The left ventricle of fetal heart pumps blood to avoid compression when the
to the placenta and systemic circulation. muscles contract.
The following fetal structures are functioning Structure of the arteries
in the fetal circulation: The elastic arteries have plenty of elastic
1. The foramen ovale allows the blood from the tissue in the tunica media to withstand higher
right atrium to reach left atrium, bypassing blood pressure. The amount of elastic tissue is
the pulmonary circulation. proportional to the pressure inside the
2. The ductus arteriosus connects the pulmonary arteries, i.e. greater the pressure, larger the
trunk to the aorta, bypassing the lungs. amount of elastic tissue.
3. The ductus venosus conducts the oxygenated The muscular arteries have mostly smooth
blood from the umbilical vein to inferior vena muscle fibers in their tunica media.
cava bypassing liver. The arterial anastomosis: The arterial
These short-circuiting channels or shunts close anastomosis provides alternate channels of
after birth, and adult circulation is established supply to the organs.
with blood passing through lungs and liver. In some parts, only potential arterial anasto-
mosis exists, which may not be functional,
Clinical Considerations and may take time to enlarge.
In arterial anastomosis, collateral channels
Failure of closure of these shunts after birth leads
develop to keep up the arterial supply, when
to congenital heart disease.
one of the arteries supplyin the organ is
Examples: Patent foramen ovale, patent ductus
occluded.
arteriosus, patent ductus venosus.
In large joints, e.g. knee joint, elbow joint
an arterial anastomosis exists all around the
THE ARTERIES
joint to supply sufficient amount of blood.
The arteries are thick-walled vessels, that carry The end arteries: The end arteries are those
blood from the heart to the capillary plexuses in arteries, that do not anastomose with their
organs and tissues of the body. neighboring arteries. The end arteries have a
The arteries carry oxygenated blood, except the separate well-developed area of supply. The
pulmonary arteries that carry deoxygenated end arteries are present in following organs:
blood from the right ventricle to the lungs. Heart
The arteries are divided into two types: Kidneys
1. The conducting arteries (elastic arteries) Liver
these are large size arteries. Brain
Example: Aorta, pulmonary trunk. Parts of gastro-intestinal tract
2. The distributing arteries (muscular In case of blockage of an end artery, due to a
arteries) these consist of rest of medium thrombus, the part supplied by it under-goes
and small size arteries. ischemia and later avascular necrosis.
24 Essentials of Human Anatomy
The functional end arteries are those arteries, whose In following organs, the venous pattern is
terminal branches do anastomose, but the quite separate and distinct than the arterial
anastomosis, being with much smaller arteries, is pattern
not sufficient to maintain blood supply of the part. Brain
Example: Coronary arteries. Liver
Lungs
The arterioles are the terminal branches of the
Penis
arteries that join with the capillary plexus.
The venous flow is dependent upon the
They are nearly as small as the capillaries in
pressure gradient between the periphery and
size.
the right atrium of the heart.
They have smooth muscle fibers in their
The venous flow is assisted by the following
walls, which run in spiral direction.
factors
The size of their lumen can be controlled by
1. The arterial pressure of nearly 10 mm of Hg
the sympathetic nerves which supply them.
transmitted through the capillary bed to the
THE VEINS venous side.
2. The suction force during the right ventricular
The veins are thin-walled vessels, that collect diastole.
venous blood from the capillary plexuses in 3. The negative pressure relative to the
organs and tissues and bring it back to the heart. atmospheric pressure produced by the
The veins carry deoxygenated blood except thoracic cage during inspiration.
the pulmonary veins, that carry oxygenated 4. The contraction of the muscles of extremities
blood from the lungs to the heart. that milks the venous system blood towards
The veins have larger lumen than the arteries. the heart.
The veins have thin tunica media with smooth This action is helped by the two sets of
muscle fibers. veins in the limbs deep and superficial.
The large veins have elastic fibers also in When the muscles contract, the venous
their tunica media to resist right atrial systole. blood from the deep veins is pushed
The veins have valves in their lumen, which towards the heart guided by the valves
permit flow of blood in one direction only, present inside the veins.
i.e. towards the heart. The movement of parts of limbs helps to
The valves are absent in case of:
push the blood in the superficial veins.
Cerebral veins
Portal veins and its tributaries. THE ARTERIO-VENOUS ANASTOMOSIS
The venous pattern: The venules start from
the venous end of capillary plexuses. They These are sites, where blood is transferred from
come together to form the veins the arteries to the veins without passing through
The veins usually run along the arteries, capillary plexus.
except very large veins, that run singly. The AV anastomoses are widely distributed in
The medium-size veins run in pairs the body.
venae comitanteswhich accompany the These channels may also arise as side branch of
arteries. one arteriole, and may directly join a venule.
The venous pattern of a part is far more The AV anastomoses have thick muscular walls,
variable than the arterial pattern. that are supplies by vasomotor nerve fibers of
The Blood Vascular System 25
the sympathetic system. Such AV The capillary plexuses are very rich in organs
anastomosis is called a Glomus. and tissues, whose metabolic needs are higher,
Such type of AV anstomoses act as sphincters while other tissues like cartilages with poor
controlling the blood flow. metabolic needs are relatively avascular.
The AV anastomoses lie in organs, whose The sinusoids are dilated capillaries found in
functions are intermittent. These also help in certain organs.
temperature regulation. Examples: Liver, spleen, endocrines.
Examples: Skin of apical part of fingers The sinusoids have similar structure as the
Nose capillaries.
Lips Their walls may, sometimes, be incomplete,
Ears. in some situations, to allow blood cells to
pass out of their lumen.
THE CAPILLARIES Their walls may, sometimes, contain
The capillaries are smallest blood vessels, that phagocytic cells.
form capillary plexuses in organs and tissues. The blood circulation in sinusoids is much
Their diameter is about 5 microns, i.e. just slower.
sufficient for a single red blood cell to pass The vasa vasorum are small vessels, that supply
through. the coats of large blood vessels.
Their walls are lined by a single layer of Examples: Aorta, inferior vena cava, pulmonary
endothelium supported by a thin layer of trunk.
connective tissue. These two together form
the diffusion barrier of the capillaries. Clinical Considerations
Gaseous exchange occurs in the walls of the 1. The hematoma results from injury to the
alveoli of lungs through the diffusion barrier capillary plexus.
of capillaries, due to pressure gradient. The condition is usually seen in superficial
The oxygen from the oxygenated blood diffuses fascia of certain regions, e.g. scalp.
in the tissue spaces, while the carbon dioxide The hematoma causes edema, with blue
from the tissue spaces diffuses into the blood, to and black discoloration.
be carried to the lungs for oxygenation. 2. The edema is collection of excess fluid in the
The nutrient fluid is also exchanged through tissue spaces.
the diffusion barrier of the capillaries in the It can be caused by
tissues. Higher hydrostatic pressure in veins,
At the arterial end of the capillary plexuses that causes transudate passing back
the blood pressure is higher than the tissue into the tissue spaces from the
osmotic pressure. capillary plexu-ses.
At the venous end of the capillary plexuses, Trauma or infection, when inflammatory
the blood pressure is less so that the tissue fluid passes into tissue space due to
fluid rich in metabolic waste products passes increased capillary permeability. This
back to the venous blood. edema fluid is rich in proteins.
CHAPTER 6
The Lymphatic
System
The lymphatic system consists of: The lymph capillaries are absent in
1. The lymph vessels: lymph capillaries, Brain and spinal cord
lymphatics and large lymph ducts. Eyeball
2. The lymph nodes: that act as filters and Bone marrow
produce lymphocytes and plasma cells. Nails, hairs and epidermis.
3. The lymphatic organs: Thymus gland, spleen, II. The lymphatics are the lymph vessels formed
tonsils and lymphoid collections in walls of
by the union of the lymph capillaries.
gastro-intestinal tract (e.g. Peyers patches
As the lymphatics increase in size, their
appendix). These are described in the
respective regions of body. walls acquire small number of smooth
The lymph is a clear, colorless fluid from tissue muscle fibers
spaces at capillary plexuses. The lymphatics have many paired valves
The lymph is formed by the excess tissue in their lumen, which given them a beaded
fluid in the tissue spaces, that is not taken up appearance, when they are full.
by the venous end of the capillary plexus. The lymphatics are more in number in
The lymph absorbs fat from the walls of the tissues than the veins.
intestines and is called chyle (milk) in that The superficial lymphatics accompany the
situation. veins.
Composition: The lymph resembles blood The lymphatics are interrupted by the
plasma in composition. It contains lymph nodes.
lymphocytes only. III. The lymph ducts are the largest lymph vessels.
The Lymph Vessels The lymph ducts are formed by the union of
many lymphatics.
The lymph capillaries begin blindly at tissue The large lymph ducts are:
spaces at capillary plexuses. 1. The lumbar lymph duct begins from
I. The lymph capillaries have wider lumen than lymphatics of pelvis and lymph nodes
the blood capillaries.
that drain lymph from the lower exter-
They are irregular in their diameters.
mity.
Their walls are made up of a single layer
of endothelium. The lumbar lymph duct terminates in
The lymph capillaries are numerous in cisterna chyli.
The dermis of the skin 2. The cisterna chyli is a dilated lymph sac
Serous surfaces present in front of 1st and 2nd lumbar
Mucous membrances vertebrae, behind the abdominal aorta.
The Lymphatic System 27
The cisterna chyli contains smooth The thoracic duct receives lymph
muscle fibers in its walls and can from:
pulsate. a. The cisterna chylibringing
It receives thetwo lumbar lymph lymph from
ducts. Both lower extremities
3. The intestinal lymph duct brings the Pelvis
chyle (lymph with dissolved fat) from Abdominal cavity including
the intestines. It terminates in the gastrointestinal tract
cisterna chyli. Abdominal wall
4. The thoracic duct is the great lymph Near its termination,
duct of the body, which drains lymph thoracic duct receives the
from all parts of the body except: following lymph ducts:
Right side of head and neck b. Left brancho-mediastinal lymph
Right upper extremity duct bringing lymph from left side
Right side of thorax including right of thorax including lung.
lung c. Left subclavian lymph duct
The thoracic duct begins at the upper bringing lymph from left upper
end of cisterna chyli, at the lower extremity.
border of 12th thoracic ver-tebra d. Left jugular lymph duct
(aortic opening of diaphragm). bringing lymph from left side
The thoracic duct ascends vertically in of head and neck.
front of thoracic vertebrae, lying to 5. The right lymphatic duct recieves the
the right side of median plane, in the following lymph ducts:
posterior mediastinum of thorax. a. Right broncho-mediastinal lymph
duct bringing lymph from right
On front of 5th thoracic vertebra,
side of thorax including lung.
thoracic duct crosses over to the
b. Right subclavian lymph duct bringing
left side of median plane and lymph from right upper extremity.
ascends along the left border of c. Right jugular lymph duct bringing
esophagus, in the superior lymph from right side of head and
mediastinum of thorax. neck.
It ascends through the inlet of thorax
The lymphatic-venous communications exist
and lies at the root of neck.
between the lymph ducts and the neighboring
It curves laterally behind the carotid
veins of the region.
sheath and terminates in the beginn-
Normally no or very little lymph passes
ing of left brachiocephalic vein.
through these channels.
Near its termination, thoracic duct
But when the lymph ducts are blocked, these
often contains venous blood, due to channels open up and convey lymph to the
higher pressure in the left brachio- venous blood.
cephalic vein. Example: Communications between thoracic
The thoracic duct has many valves, duct and herniazygos veins.
that give it a beaded appearance, Communications between abdominal lymph
when it is full. ducts and inferior vena cava.
28 Essentials of Human Anatomy
The flow of the lymph towards the large veins at Chyluria: Passing of chyle via urine. It may
the root of the neck is helped by the following be caused due to backup in the lymph
factors: vessels in kidney or the urinary tract. This
1. Hydrostatic pressure of tissue fluid taken up condition is seen in cases of filariasis,
by the lymph capillaries. where main lymph ducts are blocked.
2. Mechanical factors: In abdominal cavity, the lymph gets absor-
Contraction of the voluntary muscles bed mainly from the peritoneal surface of
Repiratory movements diaphragm. Very little lymph is absorbed
Pulsations of the neighboring blood vessels by the omenta.
Contractions of smooth muscles in the The rate of absorption of lymph from
walls of lymph ducts, to some extent. the peritoneal cavity is very rapid, i.e.
3. Valves inside the lymph ducts prevent about 1 litre per day. This forms the
backflow of lymph. These valves also give a basis of peritoneal dialysis.
beaded appearance to the lymph ducts, when The lymph from the liver passes from the
they are full. hepatic nodes directly into cisterna chyli.
The lymph nodes vary in size from a pins head to This lymph from liver forms a large
part of lymph in thoracic duct. The
a pea.
ascitic fluid is partly transudated from
They are present in groups mostly.
Example: Axillary lymph nodes, inguinal the dilated hepatic lymphatics.
In lungs the lymph is drained by broncho-
lymph nodes.
pulmonary lymph nodes. The pulmonary
The nodes are pink in color in the young.
edema is caused mainly by increased
The shape of the nodes is bean-shaped, with a capillary permeability in pulmonary
hilum on the inner side from where a few vascular bed with fluid accumulation in
efferent lymphatics come out. The afferent tissue spaces around alveoli.
lymphatics enter at the periphery.
Hydrothorax is caused through the transu-
Functions:
date accumulating is the pleural cavity.
1. The lymph nodes act as filters for the From limbs the lymph follows two sets of
lymph, and collect all the foreign particles lymph channels:
in the lymph flow. 1. The superficial lymphatics accompany
2. The lymph nodes also produce the superficial veins. The infections may
lymphocytes and plasma cells and thus spread along superficial lymphatics
help in fighting the infections. causing fine red streaks in the skin.
Clinical considerations 2. The deep lymphatics accompany the
The secondary deposits (metastases) of deep veins.
cancer spread mainly by lymphatics. The lymph edema in case of filariasis is
The cancer cells may be held up at the lymph caused by accumulation of tissue fluid as a
nodes and develop secondary growth. result of lymphatic obstruction, and the
The cancer cells may reach venous blood hypertrophy of the connective tissue.
stream via lymphatics, and thus reach The bacterial and other antigens (foreign
distant organs. particles) passing through lymph nodes
Surgical removal of cancer also includes cause painful enlargement of lymph nodes
removal of major lymph nodes of the area. (lymphadenitis).
Blockage of thoracic duct (or its injury) Wound healing results in regeneration of
may cause chylothorax accumulation lymph capillaries along with the blood
of chyle in one of the pleural cavities. capillaries.
CHAPTER 7
The Nervous
System
The nervous system is highly specialized system The CNS initiates all motor activity of the
of the human body. body.
The brain is the center of all higher mental
FUNCTIONS activities.
1. The nervous system helps in reacting to the 2. The peripheral nervous system (PNS) includes:
external environment through somatic part of Twelve pairs of cranial nerves attached to
nervous system. the brain.
It receives impulses through sensory Thirty one pairs of spinal nerves attached
receptors. to the spinal cord.
It functions consciously and The PNS conveys sensory and motor
subconsciously through reflex arcs. impulses to and from brain and spinal cord
The motor component of somatic nervous to muscles and glands.
system regulates the motor activity of the
body, controlling the muscle action and Functional Classification of Nervous
the secretion of glands. System
2. The nervous system also controls and
1. The somatic nervous system: Includes the
regulates the activities of organs and systems
most parts of the central nervous system and
of the body through visceral nervous system.
It receives the afferent impulses from the peripheral nervous system.
organs. 2. The autonomic nervous system (Visceral
It controls the functions of internal organs nervous system) controls the activities of
through its efferents. internal organs and tissues.
3. The central nervous system is responsible for The autonomic nervous system consists of
all higher mental activities, which two parts:
differentiate man from other higher animals. A. The parasympathetic system (cranio-
sacral outflow) has
PARTS OF THE NERVOUS SYSTEM I. A central component consisting of
The nervous system is bilaterally symmetrical nuclei of III, VII, IX, and X nerves.
and is divided into: Lateral grey column in S2, S3,
1. The central nervous system (CNS) consists of and S4 spinal segments.
brain and spinal cord. II. A peripheral component consisting
The CNS is center of reception and inte- of
gration of all sensory impulses general Parasympathetic fibers in III,
and special. VII, IX, and X cranial nerves.
30 Essentials of Human Anatomy
The venous sinuses are enclosed between The sub-dural hematoma is due to injury
the two layers. of venous sinuses, and it takes a long
The cerebral dura mater forms four folds time for absorption.
to separate the cranial cavity into compart- The sub-arachnoid space is a wide space
ments and to support the weight of brain. that surrounds the brain and spinal cord.
The spinal dura mater has only one layer, This space is filled up by the CSF
that is continuous with the inner layer of (cerebro-spinal fluid). It also contains
cerebral dura mater. The spinal dura mater large blood vessels lying on the
ends at the level of 2nd sacral vertebra. surface of brain and the spinal cord.
2. The arachnoid mater is thin, transparent and An injury to these vessels leads to
delicate covering. collection of blood in this spacesub-
The arachnoid mater is relatively avascular. arachnoid hemorrhage.
It closely follows the dura mater and is The CSF acts as a shock absorber for the
separated from dura mater by subdural delicate tissue of brain and spinal cord.
space.
The arachnoid mater is connected to the Due to buoyancy of CSF, 1400 gm
pia mater by delicate trabeculae and is weight of the brain weighs only 50 gm
separated from pia mater by a wider sub- on being immersed in CSF.
arachnoid space.
Enlarged sub-arachnoid spaces are called The Spinal Cord
sub-arachnoid cisterns, located mostly at
The spinal cord is the continuation of medulla
the base of brain.
oblongata of brain.
3. The pia mater is the intimate vascular covering
The spinal cord occupies upper 2/3rd of the
that lines the surface of brain and spinal cord.
vertebral canal.
The pia mater is continued from the lower
Extent and lengthThe spinal cord is about
end of spinal cord as filum terminale.
45 cm long in young adult male.
The pia mater also sends vascular folds
It extends
inside the ventricles of brain that from
Superiorlyfrom upper border of atlas
choroid plexuses.
vertebra.
The epidural space is a potential space
Inferiorlyup to lower border of 1st
between dura of spinal cord and the lumbar vertebra
periosteum of the vertebral canal. In child it extends up to 3rd lumbar
It containsinternal vertebral venous vertebra; it ascends upwards due to greater
plexus growth in length of vertebral canal. At
Small arteries puberty it reaches the adult level.
Fat (small quantity) Conus medullaris is the lower tapering end of
The epidural hematoma is a high the spinal cord. It is surrounded by long nerve
pressure arterial hemorrhage. roots on either side, giving it an appearance of
The subdural space is a potential space a horse-tail (cauda equina).
between meningeal dura mater and The filum terminale is the non-nervous
arachnoid mater. filament made up of pia mater. It is about 20
It contains a very small amount of serous cm long and connects conus medullaris to the
fluid to lubricate the opposing surfaces first piece of coccyx.
32 Essentials of Human Anatomy
The Neuron
The neuron is the excitable cell of the nervous
system, that is concerned with reception,
transformation, integration and conduction of the
nerve impulse.
Parts of the neuron Fig. 7.2: Types of neurons
1. The cell body (perikaryon) is the main part
of the cell.
2. The processes of the neuron:
a. The dendrites are the afferent Example: Posterior grey column cells
processes, which are usually multiple of the spinal cord.
in a typical neurone. 3. The effector neuron from where the
b. The axon is the efferent process, which efferent impulse begins for the effector
is usually single in a typical neurone. end organsthe muscles and the
Types of neurons glands. Examples: Pyramidal cells of
A. According to the shape: motor cortex, anterior grey column
1. Unipolar neuron (or pseudo-unipolar cells of the spinal cord.
neuron)
Example: Dorsal root ganglion cells of The Neuroglia
the spinal cord. The neuroglia is the connective tissue of the
2. Bipolar neuron
central nervous system.
Example: Retina, olfactory cells.
The neuroglia has the following types of cells:
3. Multipolar neuron
Example: Majority of cells in brain Astrocytes are of the two types
and spinal cord (Fig. 7.2). Fibrous astrocyte
B. According to the functions: Protoplasmic astrocyte
1. The receptor neuron that receives the Oligodendrocytes
afferent impulse from the receptor end Microglial cells are of mesodermal origin
organs. Ependymal cells
Example: Dorsal root ganglion cells of Functions of the neuroglia
the spinal cord. 1. The neuroglia provides mechanical support
2. The connector (inter-nuncial) neuron to the neurons.
that conducts impulse from the 2. The neuroglial cells separate the neurons
receptor neuron to the effector neuron. and act as insulators.
The Nervous System 33
3. The microglial cells act as phagocytic Outside central nervous system, the
cells of the central nervous system. myelin sheath is formed by the activity
4. The oligodendrocytes form and maintain of Schwann cells.
the myelin sheaths of the nerve fibers in Inside the central nervous system, the
brain and spinal cord. myelin sheath is formed by the activity
5. The ependymal cells are columnar cells, of oligodendrocytes (Fig. 7.3).
that line ventricles of brain and central Functions of the myelin sheath:
canal of the spinal cord. These cells are 1. The myelin sheath protects and insulates the
also concerned with the secretion and
nerve fibers.
transport of cerebrospinal fluid.
2. The myelin sheath also increases the rate of
6. The neuroglial cells also perform an
conduction of nerve impulse and reduces their
essential metabolic function of regulating
energy requirements.
the biochemical environment of the neurons.
The nerve fibers are also classified according
The Nerves Fibers to presence of the myelin sheath as
A. The medullated (myelinated) nerve fibers.
The nerve fibers are the axons and long dendrites B. The non-medullated (non-myelinated) nerve
of the neurons.
fibers.
The nerve fibers form the nerve tracts of the
brain and the spinal cord. The Lumbar Puncture
The nerve fibers form the bulk of the
peripheral nerves and nerve plexuses. The lumbar puncture is a diagnostic procedure, that
Types of the nerve fibers: is done to take out a sample of cerebro-spinal fluid
i. The sensory (afferent) fibers carry afferent from the lumbar cistern surrounding the nerve roots
impulses from the peripheral end organs below the conus medullaris of the spinal cord.
towards the higher centers in brain and The puncture is done usually between 3rd
spinal cord. lumbar and 4th lumbar vertebra at the back
ii. The motor (efferent) fibers carry efferent between the spinous processes of the lumbar
or motor impulses from the higher centers vertebrae.
in the brain and spinal cord to the muscles
and the glands.
The sheaths of the nerve fibers:
a. The neurilemma sheath is thin nucleated
sheath, that lies outside the myelin sheath.
It is also known as nucleated sheath of
Schwann.
The neurilemma sheath is responsible
for the regeneration of nerve fibers.
This sheath is absent in nerve fibers
inside the brain and spinal cord.
Therefore, the nerve fibers inside the
brain and spinal cord do not regenerate.
b. The myelin sheath (medullary sheath) is
laminated lipoprotein sheath, that is
interrupted at the nodes of Ranvier. Fig. 7.3: Sheaths of nerve fibers
34 Essentials of Human Anatomy
It also contains sympathetic fibers for the giving out motor impulses for control of skeletal
blood vessels of the vertebral canal. muscles.
The rami communicans are twowhite and I. The somatic afferent part (sensory part)
greyand connect the ventral ramus to the receives sensory impulses from receptor end
corresponding sympathetic ganglion. organs and free nerve endings.
1. The white ramus communicans (WRC) Types
carries preganglionic sympathetic fibers a. The general somatic afferent (GSA)
from the spinal nerve to the sympathetic conveys
ganglion. They also carry visceral afferent i. Exteroceptive sensations: i.e. pain,
fibers. touch, temperature and pressure
The WRC are present from T1 to L1 sensations.
spinal nerves. ii. Proprioceptive sensations: i.e.
2. The grey ramus communicans (GRC) carries muscle, tendon, bone, and joint
postganglionic sympathetic fibers from the sensations.
sympathetic ganglion to the spinal nerve to b. The special somatic afferent (sp. SA)
supply sweat glands, arractor pili muscles conveys special sensations of vision,
and the blood vessels. They are present in hearing, balance and taste to the brain
relation to all spinal nerves. and spinal cord.
The spinal segment is the part of the spinal cord The somatic afferent part has more than two
that gives attachment to one pair of spinal nerves. neurons concerned with conduction of sensory
There are 31 (thirty-one) spinal segments impulse.
corresponding to the number of spinal 1. The peripheral (receptor) neuron is pseudo-
nerves. unipolar neuron located, in dorsal root
The dermatome is the skin area supplied by ganglion of the spinal nerves.
the sensory fibers of one pair of spinal nerves The peripheral process of the neuron
(one spinal segment). (dendrite) begins from receptor end organ
The adjacent dermatomes overlap; so the loss of or free nerve ending.
one dermatome (i.e. spinal nerve) only results in The central process of the neuron (axon)
the dimunition of sensations and not complete enters the spinal cord to synapse with the
loss of sensations in the affected dermatome. connector neuron.
2. The connector (internuncial) neuron is situated
The C1 and coccygeal nerves have only in the posterior grey column of the spinal cord.
ventral nerve roots, so there are no 3. The efferent neuron is usually located in thala-
dermatomes for these nerves.
mus, where all sensory impulses are received
The myotome is the group of muscles supplied
before passing on the cerebral cortex.
by the efferent fibers of one spinal nerve.
II. The somatic efferent part (motor part) is
FUNCTIONAL PARTS OF THE concerned with voluntary muscular movements
NERVOUS SYSTEM and maintenance of balance and posture.
The Somatic Nervous System Types
a. The general somatic efferent (GSE)
The somatic nervous system (both in CNS and supplies the muscles of head and neck,
PNS) is concerned withreceiving and modifying body wall and both the extremities,
conscious and unconscioussensory impulses and which develop from the somites.
36 Essentials of Human Anatomy
cranial nerves and lateral grey column of d. The neuro-transmitter for the
S2, S3 and S4 segments of spinal cord. preganglionic synapses of the
3. Postganglionic neuron is located outside CNS sympathetic system, is acetyl-
In sympathetic system, it is located in sym- choline.
pathetic chain, Great sympathetic plexuses. B. The postganglionic sympathetic fibers arise
In parasympathetic system, it is located from:
close to the organ that it innervates. i. Postganglionic neurons in sympathetic
Types chain.
A. General visceral efferent (GVE) controls the ii. Postganglionic neurons in ganglia of the
internal organs, blood vessels, glands and sweat sympathetic plexuses.
glands and arrector pili muscles of the skin. The postganglionic sympathetic fibers
This type is actually the autonomic nervous reach back into spinal nerves through
systemcomposed of two components GRC from the corresponding sympathe-
sympathetic and parasympathetic. tic ganglia. These fibers supply
The activities of this system do not come Smooth muscles of blood vessels
under the level of conciousness. Sweat glands
I. The sympathetic system (Thoraco- Arrector pili muscles of skin
lumbar outflow) has its connector The postganglionic sympathetic
(preganglionic) neurons located in fibers from the ganglia in
lateral grey column of T1 to L1 sympathetic plexuses reach the
segments of spinal cord. thoracic, abdo-minal and pelvic
The sympathetic system stimulates organs along the blood vessels.
the activities of organs and systems The neuro-transmitter for the post-
during condition of stress or emergency ganglionic synapses of sympathetic
(so-called flight and fright reactions). system is norepinephrine.
A. The preganglionic sympathetic The cells of suprarenal medulla are
fibers arise from the connector specialized postganglionic sympathetic
neurons and pass via ventral nerve neurons and secrete norepinephrine.
roots to anterior primary rami of In the sympathetic system the preganglionic
spinal nerves. fibers are shorter and postganglionic fibers are
a. Then, these fibers pass via WRC longer.
to corresponding sympathetic II. The parasympathetic system (Cranio-sacral
ganglia in the sympathetic chain. outflow) controls the activities of organs and
b. The preganglionic fibers end by systems during conditions of rest i.e. ordinary
making synapses with post- vegetative state.
ganglionic neurons in sympa- The connector neurons are located in:
thetic ganglia. Nuclei of 3rd, 7th, 9th, and 10th cranial
c. Or the preganglionic fibers pass nerves
through the sympathetic chain S2, S3, and S4 segments of spinal cord in
without relay and come out as the laterals grey column.
splanchnic nerves, and form A. The preganglionic parasympathetic
synapses with postganglionic fibers that arise from these connector
neurons in ganglia of sympathetic neurons pass through the cranial nerves
plexuses. and make synapses with postganglionic
38 Essentials of Human Anatomy
Answers
A14. The answer is E, (1, 2, 3, 4). A16. The answers are B, C, A and D, E (1-III).
The spinal nerve is a mixed nervewith Syndesmosisis inferior tibio fibular
both motor and sensory fibers. It is attached joint.
by two nerve rootsventral and dorsalto Saddle jointis calcaneo-cuboid joint.
Hinge jointis elbow joint.
the spinal cord. The dorsal ramus supplies
Ball and socket jointis hip joint.
the skin and muscles of the back only. The Plane jointis an acromio-clavicular
skin area supplied by a spinal nerve is joint.
called a dermatome. A17. The answers are C, A, B and D, E (I-III).
A15. The answer is A, (1, 2, 3). Ankle jointhas dorsiflexion movement.
The developing long bone has two epiphyses Shoulder jointhas medial rotation.
at the two ends. It has at least one nutrient Sterno-clavicular jointhas gliding
movements.
foramen for the nutrient vessels. The meta-
Metacarpo-phalangeal jointhas
physis is the site of maximum growth of the adduc-tion movement.
long bone. The epiphyseal plates disappear, Radio-ulnar jointshave pronation
when the bone growth in length ends. movement.
The Upper Extremity TWO
CHAPTER 8
The Bones of the Upper Extremity
Both the upper and lower extremities are THE SCAPULA
homologous in their development and are built on General Features
same plan.
The scapula is a flat bone that lies on postero-
FEATURES OF THE UPPER EXTREMITY lateral aspect of upper part of thorax.
The scapula is a part of shoulder girdle.
1. The upper extremity has developed greater It is triangular in shape. It has three angles
mobility so that hands can be used for superior, inferior and lateral.
prehension or grasping. The scapula has three surfacesupper dorsal,
2. The upper extremity has undergone lateral lower dorsal and costal.
rotation by 90 from its premitive position. So It has three borderssuperior, medial and
that flexor surface faces anteriorly and lateral (Figs 8.1 and 8.2).
extensor surface faces posteriorly.
3. The thumb and radius bones are situated on
cranial side in prenatal life and they form the
preaxial border of the limb.
4. The little finger and ulna bone are similarly,
situated along caudal side in prenatal life and
they form postaxial border of the limb.
5. The muscles of hand permit complex and
delicate movements for all skilled activities.
6. The rich sensory supply of tips of fingers make
the hand and a sensitive tactile apparatus.
The bones of the upper limb are
The scapula and claviclethat form shoulder
girdle
The humerusthe bone of arm
The radius and ulnathe bones of forearm
The bones of wrist and handcarpals, meta-
carpals and phalanges Fig. 8.1: The scapulaanterior aspect
44 Essentials of Human Anatomy
Ossification
The scapula ossifies from eight centers
One primary center appears in the body in
eight weeks of intrauterine life.
Seven secondary centers appeartwo for
coracoid (precoracoid center appears in first
year, subcoracoid center at puberty), two for Fig. 8.3: The claviclesuperior aspect
46 Essentials of Human Anatomy
Ossification
Fig. 8.4: The clavicleinferior aspect
The clavicle is first bone to ossify. It ossifies in
2. The medial two-third part is nearly membrane by two primary centers that appear in
cylindrical and has convexity facing 6th week of intrauterine life and fuse soon.
forwards A secondary center for sternal end appears at
It has four surfaces puberty and fuses by twentieth year.
Anterior surface is rough for mus-
cular attachment Applied Anatomy
Posterior surface is smooth
I. The clavicle helps in transmission of force
Superior surface is also smooth
from the upper limb to the axial skeleton.
Inferior surface has a subclavian
II. The clavicle is easily fractured at the junction
groove in its medial one-third and a
of lateral one-third and medial two-third, that
rough area near the medial end for
attachment of costo-clavicular is, surgically the weak point of the bone.
ligament.
THE HUMERUS
The lateral end bears an oval facet for the
acromio-clavicular joint. General Features
The medial end is expanded and articulates The humerus is the long bone of the arm.
with clavicular notch of manubrium sterni at It has an upper end, a shaft and a lower end.
sterno-clavicular joint. 1. The upper end of humerus has
a. The headwhich is less than half a
Special Features Muscles
sphere, is covered with hyaline articular
attached to clavicle: cartilage and articulates with glenoid fossa
Anterior border lateral 1/3rdDeltoid at the shoulder joint.
Posterior border lateral 1/3rdTrapezius b. The lesser tubercle (tuberosity) is an elevation
Superior surface-medial 1/2Sterno-mastoid on the front of upper end and shows an
(clavicular head) impression for muscular attachment.
Anterior surface medial 1/2Pectoralis c. The greater tubercle (tuberosity) forms a
major prominence on the lateral aspect of upper
Posterior surface medial endSternohyoid end.
Subclavian groove It shows three impressions for muscular
Subclavius (on inferior surface) attachments.
The Bones of the Upper Extremity 47
d. The inter-tubercular sulcus (bicipital b. The antero-medial surface has muscular
groove) separates the two tubercles and attachment in lower part.
has a medial lip and a lateral lip for muscular c. The antero-lateral surface has a V-shaped
attachments. rough deltoid tuberosity about its middle.
The anatomical neck is a slight The lower half of the shaft has a medial and a
constriction that separates head from lateral supra-condylar ridge, that give attachment
the rest of the bone. to the intermuscular septa (Figs 8.5 and 8.6).
The surgical neck is the junction of upper 3. The lower end of humerus has two epicon-
end with rest of the shaft. It is a common dylesa medial and a lateralon either end.
site for the fracture of the bone. a. The medial epicondyle is more prominent
2. The shaft of humerus is cylindrical in upper and is related to ulnar nerve behind. It shows
half and triangular in section in lower half. rough surface for attachment of flexor
The shaft has three surfacesposterior, muscles of forearm.
anteromedial and anterolateral. b. The lateral epicondyle is much less promi-
a. The posterior surface has a spiral groove nent, and also shows rough surface for
behind deltoid tuberosity. attachment to extensor muscles of forearm.
(second year), lesser tubercle (fifth year). By The shaft has three bordersanterior,
sixth year the three epiphyses fuse and join posterior and medial.
with shaft by twentieth year. The upper end is i. The anterior border (anterior
the growing end of the bone. oblique line) is sharp and converges
For lower end: Four secondary centers towards the tuberosity.
appearmedial epicondyle (fourth year), ii. The posterior border also converges
medial edge of trochlea (ninth year), lateral towards the tuberosity.
edge of trochlea and capitulum, (first year), iii. The medial (interosseous) border is
and lateral epicondyle (twelfth year). The sharp and gives attachment to the
interosseous membrane of forearm
epiphysis for medial epicondyle remains
(Fig. 8.7A).
separate and fuses by twentieth year.
3. The distal (lower) end of radius has a styloid
The other three epiphyses fuse together and process and an ulnar notch.
join the shaft by fourteen to sixteen years. The styloid process is a pointed process on
lateral aspect of lower end. Its tip is about
THE RADIUS 1.2 cm lower than the styloid process of
General Features ulna.
The ulnar notch on the medial aspect of the
The radius is the lateral bone of the forearm. The distal end articulates with head of ulna at
bone has a proximal end, a shaft and a distal end. the inferior radioulnar joint.
1. The proximal (upper) end of radius has a The dorsal aspect of lower end has a prominent
head, neck, and a tuberosity. dorsal (Listers) tubercle with a narrow groove
The head of radius is cylindrical in shape medial to it for tendon of extensor pollicis longus.
with a concavity on its superior aspect. The dorsal aspect of lower end has other
The head articulates with capitulum of grooves also for tendons of extensor muscles.
lower end of humerus. The inferior surface of lower end articulates
with scaphoid and lunate bones at the
The neck is slightly constricted part below
radiocarpal joint.
the head.
The tuberosity is rough posteriorly for Special Features
muscular attachment. Its anterior part is
smooth and is related to a bursa. Muscles attached to radius
2. The shaft of radius is narrow above but it Radial tuberosity (Posterior part)Biceps
broadens below. It is triangular in section. brachii
The shaft has three surfacesanterior, Lateral surface (Upper half)Supinator
posterior and lateral. Impression on middle of lateral surface
Pronator teres
i. The anterior surface reaches up to
Anterior oblique lineFlexor digitorum
the tuberosity from in front.
super-ficialis
ii. The posterior surface also reaches
Anterior surface (Upper 2/3rd) below anterior
up to the tuberosity from behind.
borderFlexor pollicis longus
iii. The lateral surface encroaches on Anterior surface (distal 1/4th) - Pronator
the anterior and posterior aspects of quad-ratus
upper part of shaft. Base of styloid processBrachio-radialis
It has a rough impression for Posterior surface (upper part)Abductor
muscular attachment about its middle. pollicis longus, Extensor pollicis brevis
50 Essentials of Human Anatomy
i. The anterior surface is smooth and Supinator crest and depression in front of it
presents an oblique ridge for muscular Supinator
attachment in its distal part. It has a Anterior and medial surface (upper 3/4th)
nutrient foramen in upper part. Flexer digitorum profundus
ii. The posterior surface extends above up to Oblique ridge on front of lower part of
lateral border of olecranon process. shaft Pronator quadratus
iii. The medial surface between anterior and Posterior surfaceAbductor pollicis longus,
posterior borders is smooth. Extensor pollicis longus and Extensor indices
The shaft of ulna has three borders Lateral border of olecranonAnconeus
anterior, posterior and lateral (interosseous) Ligaments attached to ulna
border. Margins of radial notchAnnular ligament
i. The anterior border begins from medial Lower border of radial notchQuadrate liga-
border of coronoid process and extends up ment
to styloid process below. Tip of styloid processUlnar collateral
ii. The posterior border descends from back ligament of wrist joint
of olecranon process, and curving laterally
Ossification of Radius and Ulna
reaches up to styloid process.
iii. The lateral (interosseous) border is sharp The radius ossifies by the three centersone
and extends from a depression below radial primary center for shaft appears at eighth week of
notch (supinator crest) up to lower end. intra-uterine life, one for upper end (appears
It gives attachment to the interosseous fourth year) and one for lower end (first year).
membrane of forearm. The lower epiphysis fuses by nineteenth year.
3. The distal end has a head and a styloid process. The proximal epiphysis fuses by fourteenth year.
i. The head of ulna is round and articulates The ulna also ossifies by three centersone
with the ulnar notch of lower end of radius primary center of shaft (eighth week), one for upper
to form inferior radio-ulnar joint. end (eleventh year) and distal end (sixth year). The
ii. The styloid process is a pointed process on distal epiphysis fuses by eighteenth year the
proximal epiphysis fuses by fourteenth year.
the postero-medial aspect of the lower end.
The styloid process is grooved on its
The lower ends of radius and ulna are the
growing ends.
posterior aspect by extensor carpi ulnaris
tendon.The lower end of ulna does not
Applied Anatomy of Radius and Ulna
take part in the formation of radio-carpal
(wrist) joint. It is separated from the 1. Fracture of head or neck of radius may occur
triquetral bone by the articular disc of due to fall on out-stretched hand.
inferior radio-ulnar joint. 2. Pulled elbowresults in very young children,
when head of radius slips out of annular
Special Features ligament. It is caused when arm is pulled
forcibly
Muscles attached to ulna 3. Colles fractureis fracture of distal end of
Superior surface olecranon processTriceps radius due to fall on outstretched hand.
Coronoid processBrachialis 4. Tennis elbowis caused by sprain of lateral
Medial border of coronoid process - Pronator collateral ligament of elbow or by injury to
teres common extensor origin.
52 Essentials of Human Anatomy
The epiphyses join the shaft by fifteen to Applied Anatomy of Bones of Hand
seventeen years. i. Fracture of scaphoiddue to fall on out-
The phalanges ossify by stretched hand is common in young adults.
One primary center for shaft The fragments usually do not unite. The blood
One secondry center for lower end supply enters distally, so the proximal
The center for distal phalanx appears in segment may undergo avascular necrosis.
eighth week ii. Dislocation of lunateoccurs sometimes
The center for middle phalanx appears in due to fall on outstreched hand causing
twelfth week hyper-extension of wrist. Involvement of
The center for proximal phalanx appears in median nerve commonly takes place.
tenth week iii. Bennetts fractureis fracture of base of
The epiphysis for bases for phalanges fuse metacarpal of thumb caused when injury is
with shaft by eighteen years. along long axis of thumb.
CHAPTER 9
The Joints of the
Upper Extremity
THE STERNO-CLAVICULAR JOINT
It is the joint between the medial end of clavicle
and manubrium sterni.
TypeSaddle type of synovial joint
Articular surfaces
Articular surface of medial end of clavicle
Clavicular notch of manubrium sterni.
These surfaces are covered by hyaline
articular cartilage.
Articular capsule surrounds the joint on all
sides. It is reinforced by anterior and posterior
sterno-clavicular ligaments.
Ligaments
Costo-clavicular ligament is a strong Fig. 9.1: The sterno-clavicular jointsanterior aspect
ligament that firmly connects medial end Movements
of clavicle to the first costal cartilage. The movements occur at the joint, along with
Inter-clavicular ligament is T-shaped movements of shoulder joint and of scapula.
ligament connecting upper parts of medial The movements occur at two axes:
ends of two clavicles with vertical limb Elevation and depression
attached to supra-sternal notch. Protraction (forward movement) and
Articular discA complete intra-articular retraction (backward movement)
disc separates the joint into two joint cavities. Circumduction occurs as combination of
It is attached above to the medial end of clavicle above movements.
and below to the first costal cartilage Applied anatomy:The dislocation of the joint,
The articular disc gives stability to the joint. is very rare as it is strengthened by strong
The nerve supply of the joint is by ligaments. Instead, fracture of clavicle occurs
more commonly.
i. Nerve to subclavius
ii. Anterior supra-clavicular nerve
THE ACROMIO-CLAVICULAR JOINT
The arterial supply of the joint is by
i. Internal thoracic artery It is the joint between the lateral end of clavicle
ii. Supra-scapular artery (Fig. 9.1) and acromion process of scapula.
56 Essentials of Human Anatomy
Movements at these joints occur at two axes: In middle finger there are two dorsal
At transverse axisflexion and interossei and cause medial and lateral
extension take place abduction.
At antero-posterior axisabduction and In little finger abductor digiti minimi
adduction take place with reference to Adduction (in fingers)
the neutral axis passing through Palmar interossei.
middle finger. 3. The inter-phalangeal joints are formed
Muscles producing movements: between the phalanges
The proximal inter-phalangeal joint is
Flexion
Flexor digitorum } in four fingers
assisted by lumbricals
between the head of first phalanx and base
of second phalanx.
superficialis and interossei The distal inter-phalangeal joint is
Flexor digitorum
between the head of second phalanx and
profundus
base of terminal phalanx. The thumb has
Flexor pollicis longus
only one inter-phalangeal joint.
Flexor pollicis brevis } in thumb Type: Hinge type of synovial joint.
Extension
Ligaments: The collateral ligaments rein-
Extensor digitorumassisted in second
force the sides of the joints.
and fifth fingers by extensor indicis The ligaments are lax when finger is
and extensor digiti minimi extended.
longus } in thumb
Extensorpollicis
Movements are possible in one transverse
axis only
Extensor pollicis Flexion is done by long flexors.
brevis Extension is done by long extensors.
Abduction (in fingers) Nerve supply of small joints of hand is by
Dorsal interossei for second and fourth the digital branches of ulnar and median
fingers nerves.
CHAPTER 10
The Shoulder Region and
Superficial Back Region
The shoulder region includes: posterior lamina of the tendon at higher level.
1. The pectoral region and the axilla. This arrangement forms the anterior fold of
2. The shoulder region proper axilla.
3. The scapular region Insertion is by a bilaminar tendon on the
lateral lip of inter-tubercular sulcus
THE PECTORAL REGION (bicipital groove) of humerus. The
1. The pectoral region lies on front of upper part posterior lamina extends to a higher level.
of thorax. Nerve supply is by
In the superficial fascia of the region, in Medial pectoral nerve (C5,C6)
females, lies the mammary gland Lateral pectoral nerve (C7, C8,T1) (Fig.
(described in Chapter 2). 10.1)
The muscles of the pectoral region are: Actions
a. The pectoralis major 1. The entire muscle acts as a powerful
b. The pectoralis minor adductor and medial rotator of upper
c. The subclavius arm.
a. The pectoralis major is a large and powerful 2. The clavicular part helps in flexion of
muscle. arm along with anterior fibers of
Origin is by two heads deltoid and coracobrachialis.
i. The clavicular head arises from anterior 3. The sternocostal part helps in extension
surface medial half of clavicle. of arm along with posterior fibers or
ii. The sternocostal head arises from deltiod, latissimus dorsi and teres major.
Anterior surface of sternum 4. The muscles helps in climbing by
Upper six costal cartilages pulling up the trunk.
Aponeurosis of external oblique 5. The muscles also helps in deep inspi-
muscle. ration.
Muscle belly is thick and triangular Relations
The clavicular fibers pass downwards and Anteriorly
laterally for insertion on anterior lamina of Skin, superficial fascia, platysma, supra-
the tendon. clavicular nerves and mammary gland.
The upper sternocostal fibers are attached Deep fascia (pectoral fascia)
to deeper part of anterior lamina. PosteriorlySternum, ribs, costal
The lower sternocostal fibers are twisted cartilages, intercostal muscles
in such a manner, that each lower fiber passes Clavipectoral fascia, pectoralis
deep to the upper fiber and is inserted on minor and serratus anterior.
66 Essentials of Human Anatomy
The axillary artery is the main arterial trunk of supplying first intercostal space.
From second parttwo branches.
the upper extremity.
2. The thoraco-acromial artery pierces
BeginningThe axillary artery begins at the
clavipectoral fascia and divides into four
outer border of first rib as continuation of branches.
subclavian artery. a. The deltoid branch lies in deltopectoral
CourseThe artery passes laterally and groove.
downwards with a concavity below, when b. The clavicular branch supplies sterno-
arm is by side of the body. clavicular joint.
For purpose of description, it is divided into c. The acromial branch reaches the
three parts: superior surface of acromion.
a. First part extends from outer border of d. The pectoral branch supplies pectoral
first rib to medial border of pectoralis muscles.
minor 3. The lateral thoracic artery runs along the
b. Second part is the short segment of lateral border of pectoralis minor.
artery that lies behind pectoralis minor c. In females, it is large and supplies the
Third part is the longest part that extends mammary gland.
From third partthree branches.
from lateral border of pectoralis minor
4. The anterior circumflex humeralpasses
to lower border of teres major. deep to the muscles and curves around the
The lower half of third part is quite surgical neck of humerus from in front.
superficial covered by skin, superficial 5. The posterior circumflex humeralis a
fascia and deep fascia (Fig. 10.4). larger branch that accompanies axillary
BranchesThe artery gives six branches. nerve through quadrangular space and
From first part one branch. curves around surgical neck of humerus.
ii. Muscular branchesto prevertebral muscles III. Posterior cordgives five branches
from ventral rami of C5, C6, C7 and C8. Upper subscapular (C5,C6)
iii. Contribution to phrenic nerve from ventral
Thoraco-dorsal (C6,C7,C8)
ramus of C5.
Lower subscapular (C5,C6)
iv. Four motor branches to muscles of upper
limb. Axillary (C5,C6)
a. Dorsal scapular (C5) Radial (C5,C6,C7,C8,T1)
b. Supra scapular (C5,C6) Applied anatomy
c. Nerve to subclavius (C5,C6)
1. Compression of roots of branchial plexus may
d. Long thoracic nerve (C5, C6, C7)
be caused by cervical spondylitis.
From the infra-clavicular part
The condition causes pain in the dermatomes
I. Lateral cordgives three branches.
supplied by the affected spinal nerve.
Lateral pectoral (C5, C6, C7)
2. Upper trunk injury(Erb-Duchenne paralysis)
Musculo-cutaneous (C5,C6,C7)
Lateral root of median (C5, C6,C7) Causes
II. Medial cord gives five branches. Violent downward displacement of arm.
Medial pectoral (C8, T1) Birth injury due to pulling of arm at
Medial cutaneous of arm (C8,T1) childbirth.
Medial cutaneous of forearm (C8,T1) Effects of injuryParalysis of all the muscles
Medial root median (C8,T1) supplied by anterior and posterior divisions of
Ulnar (C7,C8,T1)the contribution of C7 upper trunk (C5 and C6 spinal nerves). This
to ulnar comes from lateral root of median leads to
nerve. Loss of abduction (deltoid)
The Shoulder Region and Superficial Back Region 71
ii. The medial border of scapula falls away then it curves around great scapular
from thoracic wall and becomes quite notch and reaches infraspinous fossa.
prominent (Winging of scapula). ii. The deep branch of transverse cervical
arteryalso from thyro-cervical trunk.
The Blood Supply of Scapular Muscles
The artery descends along medial border
The Scapular anastomosis is an arterial anasto- of scapula deep to levator scapulae and
mosis around scapula bone between the branches rhomboids (Some times the artery arises
of subclavian and axillary arteries (Fig.10.8). from third part of subclavian artery and
The arteries taking part in this anastomosis
is known as dorsal scapular artery).
are
iii. The subscapular artery from third part of
i. The suprascapular artery from thyro-
cervical trunk of first part of subclavian axillary artery descends along the lateral
artery. border of scapula.
The artery reaches upper border of Its circumflex scapular branch pierce
scapula and passes above suprascapular the origin of teres minor, and grooving the
ligament to reach supraspinous fossa bone enters infraspinous fossa.
The Shoulder Region and Superficial Back Region 75
Contd...
Name Origin Muscle belly Insertion Nerve supply Main actions
Lower three or border of teres 3. It also helps in
four ribs major and forms deep inspiration
a tendon and voluntary
expulsive efforts
Levator Transverse proces- The muscle belly Dorsal surface C3, C4 VR 1. It helps to elevate
scapulae ses of atlas and axis descends to medial border of Dorsal scapular (C5) scapula with
Posterior tubercles superior angle scapula between trapezius
of transverse proces- of scapula superior angle and 2. It also helps to
ses of third and root of spine retract scapula
fourth cervical with rhomboids
vertebrae
Rhomboid Lower part of Slender muscle Base of the tria- Dorsal scapular 1. It helps to retract
minor ligamentum nuchae belly ngular area at (C5) the scapula
Spines of 7th root of spine of 2. It also helps to
cervical and 1st scapula steady scapula
thoracic vertebrae along with other
scapular muscles
Rhomboid Spines of 2nd to Flat and thin Dorsal surface Dorsal scapular 1. It helps to retract
major 6th thoracic belly, descends to medial border of (C5) scapula
vertebrae and medial border of scapula from root 2. It also helps to
supraspinous scapula of spine to the steady the scapula
ligaments inferior angle during move-
ments at shoulder
joint.
CHAPTER 11
The Upper Arm and
the Elbow Region
The region of upper arm is divided into two
osseofascial compartments
Anterior (flexor) compartment
Posterior (extensor) compartment.
Branches
From lateral side of artery
i. A number of small muscular branches are
given to the muscles of anterior compart-
ment
From medial side of artery
ii. The profunda brachii artery accompanies
the radial nerve to the posterior
compartment of arm.
iii. The superior ulnar collateral artery
pierces medial intermuscular septum,
along with ulnar nerve and descends in the
posterior compartment of arm.
iv. The nutrient artery is given to humerus at
level of insertion of coraco-brachialis.
v. The inferior ulnar collateral artery (supra-
trochlear artery) descends to front of
medial epicondyle.
b. The basilic veinascends in front of medial Lower down, in front of arm the nerve
epicondyle of humerus and then passes descends between biceps brachii and
upwards along the medial border of biceps brachialis.
brachii muscle. TerminationJust above the bend of elbow,
The basilic vein pierces deep fascia about the musculo-cutaneous nerve pierces deep
the middle of arm at level of insertion of fascia of arm at lateral border of biceps
coraco-brachialis. brachii.
The basilic vein joins with venae comi- The nerve continues as lateral cutaneous
tantes of brachial artery at distal border nerve of arm.
of teres major to form axillary vein. Branches
c. The median cubital vein connects the cepha- a. Muscular branches are given to
lic and basilic veins in front of the cubital Coracobrachialis
fossa. Both headsshort and long of
The vein lies in front of bicipital aponeu- biceps brachii (separate branches)
rosis. Brachialis (medial part)
The medial cubital vein is commonly used b. Articular to elbow joint
for giving intravenous injection. c. Cutaneous lateral cutaneous nerve of
2. The deep veins forearm supplying skin of lateral aspect
There are two venae comitantes accompanying of forearm up to ball of thumb.
the brachial artery. Applied Anatomy
The venae comitantes receive venous blood Injury to musculo-cutaneous nerve results
from the veins accompanying the branches in
of brachial artery. Inability to strongly flex the elbow
Loss of sensations along the lateral
The Lymphatics of the Arm border of forearm.
The superficial lymphatics accompany the super- 2. The median nerve (C5, C6, C7, C8, T1) is formed
ficial veins and drain into axillary lymph nodes. by
The deep lymphatics accompany the brachial The lateral root from lateral cord of brachial
vessels and also end in axillary lymph nodes. There plexus.
are one or two supra-trochlear lymph nodes in distal The medial root from medial cord of brachial
part of arm just proximal to medial epicondyle. They plexus.
can be easily palpated, if enlarged. Course
The median nerve descends lateral to the
The Nerves of the Anterior brachial artery up to the insertion of
Compartment of Arm coracobrachialis.
The nerves of anterior compartment aremusculo- In lower half of front of arm, the median
cutaneous, median ulnar nerve and small part of nerve descends medial to brachial artery
radial nerve. after crossing the brachial artery.
1. The musculo-cutaneous nerve (C5, C6, C7) is a The median nerve enters cubital fossa
branch of lateral cord of brachial plexus. medial to the brachial artery, deep to
CourseThe nerve pierces the coraco- bicipital apponeurosis.
brachialis muscle and descends between BranchesThe median nerve gives no
coraco-branchialis and biceps brachii. branches in the arm.
82 Essentials of Human Anatomy
The deltoid (ascending) branch ascends It descends behind medial epicondyle and
upwards to anastomose with anastomoses with posterior ulnar recurrent
descending branch of posterior artery.
circumflex humeral artery.
The posterior descending branch The Nerves of the Posterior
(middle collateral) descends behind Compartment (Fig. 11.4)
lateral malleolus to anastomose with I. The radial nerve (C5, C6, C7, C8, T1) is a
interos-seous recurrent artery. branch of posterior cord of brachial plexus.
The anterior descending branch (radial CourseThe radial nerve lies behind the
collateral) is the arterys continuation. third part of axillary artery and uppermost
It accompanies the radial nerve and part of brachial artery.
pierces lateral intermuscular septum. The nerve, accompanied by profunda
It runs between brachialis and brachii artery passes between lateral
brachioradialis and anastomoses and medial heads of triceps and enters
with radial recurrent artery. posterior compartment.
2. The superior ulnar collateral branch of The nerve descends laterally, lying in
brachial artery accompanies ulnar nerve in spiral groove on back of shaft of
posterior compartment piercing medial humerus, covered by lateral head of
intermuscular septum. triceps.
Contd...
Name Origin Muscle belly Insertion Nerve supply Main actions
ment of pronator deep to flexor in flexion of
quadratus retinaculum wrist joint
Flexor Upper three-fourths Large muscle Four tendons Medial part ulnar 1. It flexes distal
digitorum of anterior and belly lies deep reach four fingers Lateral part- phalanges of
profundus medial surfaces of to superficial Inserted on anterior interos- fingers after
ulna flexors Palmar aspect base seous branch of flexion of middle
Front of interos- Gives rise to of distal phalanges median (C8, T1) phalanges by
seous membrane four tendons superficialis
of forearm that pass deep to 2. It also helps in
flexor retinaculum flexion of meta-
at wrist carpo-phalangeal
joints of fingers
3. It also helps in
flexion of wrist
joint
Pronator Oblique ridge on Muscles belly flat Anterior surface Anterior inter- 1. It is the principal
quadratus front of distal and quadrangular distal one-fourth ossous branch pronator of fore-
part of ulna of radius of median (C8, T1) arm
Deep fibers on 2. It prevents sepa-
triangular area ration of lower
above ulnar notch ends of two bones
of radius
The oblique part of the artery is into an anterior and a posterior branch.
separated from the median nerve by
deep (ulnar) head of pronator teres. a. The anterior interosseous branch
The artery passes distally along the descends in front of interosseous
medial border of forearm lying membrane along with anterior
between flexor carpi ulnaris and flexor interosseous nerve
digitorum profundus. It terminates by piercing intero-
The artery leaves anterior compartment sseous membrane deep to pro-
by passing superficial to flexor nator quadratus and reaches
retinaculum along with ulnar nerve posterior compartment of fore-
and enters palm. arm.
Branches in anterior compartment It gives
i. The anterior ulnar recurrent passes in Nutrient arteries to both
front of medial epicondyle to anasto- radius and ulna
mose with inferior ulnar collateral Median artery to accompany
artery. median nerve
ii. The posterior ulnar recurrent passes b. The posterior interosseous branch
behind medial epicondyle to joint with passes backwards through a gap at
superior ulnar collateral artery. upper border of interosseous mem-
iii. The common interosseous branch is a brane and enters posterior compart-
large branch that divides immediately ment of forearm.
The Region of Forearm 89
Near its origin, it gives intero-iii. The median antebrachial vein is only
sseous recurrent that takes part sometimes present in the midline of front
in anastomosis around elbow of forearm
joint. It drains venous blood from palm and
iv. The anterior carpal branch completes front of forearm and ends in the basilic
anterior carpal arch on front of carpal vein near the elbow.
bones with corresponding branch of The deep veins
radial artery. The radial and ulnar arteries are accompanied
v. The posterior carpal branch joints the by venae comitantes.
corresponding branch of radial artery to These veins join in cubital fossa to form
complete posterior carpal arch on back the venae comitantes of brachial artery.
of wrist. 3. The lymphatics of anterior compartment
vi. Many small muscular branches are given The superficial lymphatics accompany the
to supply the muscles of anterior superficial veins, and the deep lymphatics
compartment. accompany the deep veins of the forearm.
4. The nerves of the anterior compartment
Applied Anatomy
A. The median nerve arises in axilla from
1. The radial pulse can easily be felt at the
two roots medial and lateral-carrying
wrist as the radial artery lies quite
fibers from ventral divisions of ventral
superficially there. It can be compressed
rami of C5,C6,C7,C8, and T1spinal nerves
against the distal end of radius.
to supply the flexor muscles of forearm.
2. The ulnar pulse is not easily palpable, as
Course in forearm
the ulnar artery cannot be pressed against The median nerve lies medial to the
the narrow lower end of ulna. brachial artery in the cubital fossa.
The veins The nerve enters the anterior
The superficial veins compartment by passing between
i. The cephalic vein begins from the lateral two heads of pronator teres, the ulnar
side of dorsal venous arch on back of hand head separating it from ulnar artery.
It courses upwards behind styloid The median nerve descends deep to
process of radius, along lateral border flexor digitorum suerficialis up to
of forearm, up to the bend of elbow. wrist.
The cephalic vein receives superficial At wrist, the median nerve lies quite
veins from the forearm. superficially between tendons of
ii. The basilic vein begins from medial side of palmaris longus and flexor carpi
dorsal venous arch on back of hand. radialis.
The basilic vein ascends more anteriorly The nerve passes deep to flexor
along medial border of forearm, up to retinaculum through carpal tunnel to
the bend of elbow. enter palm.
The cephalic and basilic veins are joined Branches in forearm
together at the bend of elbow by medial i. The Muscular branches are given to supply:
cubital vein. Pronator teres
90 Essentials of Human Anatomy
Effects of injury
Paralysis of hypothenar muscles,
THE POSTERIOR COMPARTMENT OF
all interossei, adductor pollicis and FOREARM (FIG. 12.3)
medial three lumbricals. 1. The muscles of posterior compartment are
Loss of skin sensations on medial divided into two groups (Table 12.2):
part of palm and medial one and A. The superficial extensors
half fingers. Brachio-radialis
Contd...
Name Origin Muscle belly Insertion Nerve supply Main actions
Extensor Lateral epicondyle by Muscle belly divi- The four tendons Posterior inter- 1. It extends inter-
digitorum common extensor des into four diverge to reach osseous (C7, C8) phalangeal and
origin tendons that pass four fingers metacarpo-pha-
deep to extensor Inserted on dorsal langeal joints of
retinaculum on digital expansion four fingers
dorsum of hand on dorsum of first 2. It also helps in
phalanx extension of
wrist joint
Extensor Lateral epicondyle Slender muscle belly Dorsal digital ex- Posterior inter- 1. It helps in exten-
digiti by common extensor gives rise to a long pansion of little osseous (C7, C8) sion of joints of
minimi origin tendon finger little finger
2. It also helps in
extension of
wrist joint
Extensor Lateral epicondyle Muscle belly is most Tubercle on Posterior inter- 1. It acts as extensor
carpi by common ex- medial on back of medial side base osseous (C7, C8) of wrist joint
ulnaris tensor origin forearm of fifth meta- 2. It also helps in
Common aponeu- The tendon lies tarsal adduction of hand
rosis attached to in a groove on
posterior border styloid process
to ulna of ulna
Anconeus Posterior surface Muscle belly Lateral surface Radial It helps in extension
of lateral epicon- small and trian- alecranon (C7, C8, T1) of elbow joint
dyles of humerus gular lies behind Upper one-fourth
the elbow joint posterior surface
of ulna
The Deep Extensors (Fig. 12.4)
Supinator Lateral epicondyle Muscle belly has Lateral surface Posterior inter- It supinates the
of humerus a superficial and proximal third osseous (C5, C6) forearm assisted
Radial collateral a deep part radius, encroaches by biceps brachii
ligament It is wrapped on anterior and
Annular ligament around upper posterior aspects
Supinator crest of third of radius
ulna and the depress-
ion in front of it
Abductor Posterior surface Muscle belly ends Radial side base Posterior inter- It abducts the thumb
pollicis upper part ulna in a tendon above of first meta- osseous (C7, C8)
longus Interosseous membrane the wrist carpal
Middle third posterior
surface of radius
Extensor Posterior surface radius Muscle belly ends Dorsi-lateral sur- Posterior inter- 1. It extends proxi-
pollicis distal to abductor in a tendon above face base of proxi- osseous (C7, C8) mal phalanx of
brevis pollicis longus wrist mal phalanx thumb thumb
2. It helps in exten-
sion of thumb also
Extensor Middle third posterior Muscle belly ends Base of distal Posterior inter- 1. It extends distal
pollicis surface of ulna in a tendon above phalanx of thumb osseous (C7, C8) phalanx of thumb
longus wrist 2. It helps in exten-
sion of thumb and
radio-carpal joint
(wrist joint)
Extensor Posterior surface of Narrow elongated Joins dorsal distal Posterior inter- It helps in extension
indicis ulna distal to exten- muscle belly expansion of osseous (C7, C8) of index and radio-
sor pollicis longus Ends in a tendon index finger carpal joint
above wrist
The Region of Forearm 93
Branches
1. Muscular branches supply
Extensor digitorum
Extensor digiti minimi
Extensor carpi ulnaris
Extensor pollicis longus
Extensor indicis
Abductor pollicis longus
Extensor pollicis brevis
Supinator
Extensor carpi radialis brevis
2. Articular branches supply
Radiocarpal joint
Carpal joints
brachioradialis in front of lateral epicondyle Injury to radial nerve at elbow joint produces
of humerus. Paralysis of all extensor muscles of forearm
leading to inability to extend radio-carpal
Course joint and the joints of the digits. This
The nerve pierces supinator and passes between condition is known as Wrist drop.
the superficial and deep parts of the muscle. Loss of skin sensation along the lateral border
The nerve, as it descends lies between of dorsum of hand and lateral two and half (or
superficial and deep extensors. three and half) digits.
CHAPTER 13
The Region of
Wrist and Hand
The region of wrist and hand includes: The space covers the interossei and the
The dorsum of wrist and hand metacarpals
The palm The extensor retinaculum of the wrist is formed by
thickening of deep fascia on the dorsum of wrist.
THE DORSUM OF WRIST AND HAND
Attachment
There are two fascial spaces on back of hand.
Medially: Tip of styloid process of ulna and
a. The dorsal subcutaneous space is limited by
triquetral bone
the deep fascia extending on dorsum of hand
Laterally: Anterior border of styloid process
along with extensor tendons.
The skin on the dorsum of hand is freely of radius
movable on underlying structures. The retinaculum forms a strong, fibrous band
There is a rich lymphatic plexus in this that lies obliquely on dorsal aspect of carpal
space that produces swelling on back of bones.
hand in cases of infections of palm. From the deep surface of retinaculum, connec-
b. The dorsal sub-aponeurotic space lies tive tissue septa are given to ridges on dorsal
between the deep fascia on the dorsum of aspect of lower end of radius to divide the space
hand and the extensor tendons. deep to it into six compartments (Fig. 13.1).
The first compartment contains The radial artery leaves the space by passing
Tendon of abductor pollicis longus between the two heads of first dorsal
Tendon of extensor pollicis brevis interosseous muscle and enters palm.
The second compartment contains Branches
Tendon of external carpi radialis longus The posterior carpal branch joins with
Tendon of external carpi radialis brevis corresponding branch of ulnar artery to
The third compartment contains form posterior carpal arch
Tendon of extensor pollicis longus The first dorsal metacarpal artery divides
The fourth compartment contains into two branches to supply adjacent
Four tendons of extensor digitorum sides of thumb and index finger
Tendon of extensor indicis 2. The posterior carpal arch lies on dorsal
Terminal part of anterior interosseous artery aspect of carpal bones.
Posterior interosseous nerve The arch is formed by dorsal carpal
The fifth compartment has branches of radial and ulnar arteries.
Tendon of extensor digiti minimi Branches
The sixth compartment has Three dorsal metacarpal branches
Tendon of extensor carpi ulnaris descends on dorsum of hand and supply
adjacent sides of fingers by dividing into
Synovial Sheaths of Extensor Tendons two dorsal digital branches.
The extensor tendons, as they pass deep to the These arteries anastomose with
extensor retinaculum, have synovial sheaths superficial and deep palmar arches
around them to prevent friction and facilitate by perforating branches
their contractions. A dorsal digital branch to medial side of
The synovial sheaths begin proximal to the little finger is also given.
3. The terminal part of anterior interosseous artery
retinaculum and are prolonged for some
descends on dorsal aspect of carpal bones.
distance on back of hand.
It joins the posterior carpal arch.
The Blood Vessels on Dorsum of Hand
The Veins
The Arteries
The superficial veins
1. The radial artery enters the dorsum of hand The dorsal venous arch lies on dorsal aspect of
by passing deep to tendons of abductor hand.
pollicis longus and extensor pollicis brevis. The arch receives three dorsal metacarpal
The radial artery on dorsum of carpal veins that receive dorsal digital veins from
bones lies in a depression called sides of fingers
Anatomical snuff-box
The dorsal venous arch is drained
The depression is bounded
Medially by basilic vein
Laterally by tendons of abductor pollicis
Laterally by cephalic vein
longus and extensor pollicis brevis
Medially by tendon of extensor pollicis
The Deep Veins
longus
The radial artery lies on trapezium covered The venae comitantes accompany the arteries on
only by skin, superficial and deep fascia. dorsum of hand.
The Region of Wrist and Hand 97
The Nerves on the Dorsum of Hand The flexor retinaculum keeps the long flexor
1. The superficial terminal branch of radial tendons in position during flexion at the wrist
nerve enters dorsum of hand, after piercing joint.
deep fascia lateral to brachio-radialis. The retinaculum also provides additional
surface for attachment of thenar and
The nerve divides into five dorsal digital
hypothenar muscles (Fig. 13.2).
nerves that descend on dorsum of hand.
Structures passing superficial to flexor
These nerves supply the skin of lateral
retinaculum are
part of dorsum of hand.
1. Ulnar nerve
They also supply skin on dorsum of lateral
2. Ulnar vessels
three and half (sometimes two-and-half)
3. Palmar cutaneous branch of ulnar nerve
digits, up to middle of middle phalanx.
4. Tendon of palmaris longus
2. The dorsal branch of ulnar nerve pierces deep
5. Palmar cutaneous branch of median nerve
fascia, about 5.0 cm proximal to the wrist and The carpal tunnel is an osseo-aponeurotic
passes backwards deep to flexor carpi ulnaris. tunnel formed between the flexor retinaculum
and the concave anterior surface of carpal
The nerve descends on back of hand and bones.
divides into three dorsal digital nerves. The carpal tunnel transmits
The dorsal digital nerves supply the skin i. Four tendons of flexor digitorum
on medial part of dorsum of hand super-ficialis
They also supply skin on dorsal aspect of ii. Four tendons of flexor digitorum pro-
medial one-and-half (sometimes, two-and- fundus
half) fingers. These eight tendons are enclosed in a
common synovial sheaththe ulnar
THE PALM OF THE HAND bursa
The superficial fascia of the palm is thick, iii. Tendon of flexor pollicis longus is
and consists of fibrous bands connecting skin enclosed in a synovial sheaththe
radial bursa
to the deep fascia.
iv. The median nerve lies between the
The superficial fascia has
ulnar bursa and the radial bursa.
The palmaris brevis muscle covering
The tendon of flexor carpi radialis with its
proximal part of hypothenar eminence.
synovial sheath lies in a separate compartment
The palmar cutaneous branches of median
and ulnar nerves.
The deep fascia on the front of carpal bones
forms a thick bandthe flexor retinaculum.
Attachments of flexor retinaculum
Medially
Pisiform
Hook of hamate
Laterally
Tubercle of scaphoid
Crest of trapezium Fig. 13.2: The carpal tunnel
98 Essentials of Human Anatomy
The Long Flexor Tendons in the Palm The two parts of each tendon, again
(Fig. 13.5) separate out and are inserted on sides of
middle phalanx.
1. The tendon of palmaris longus passes
4. The four tendons of flexor digitorum
superficial to flexor retinaculum and is
profundus also diverge on reaching palm from
attached to the apex of palmar aponeurosis.
carpal tunnel, to reach the four fingers.
2. The tendon of flexor pollicis longus has a
In each finger, the tendon of flexor
separate synovial sheath (radial bursa) as it
digitorum profundus lies deep to the
passes through the carpal tunnel deep to
tendon of flexor digitorum superficialis on
flexor retinaculum.
proximal phalanx.
The tendon passes deep to the thenar
The tendon of flexor digitorum profundus
muscles to reach the palmar surface of base
passes through fibrous tunnel formed by
of distal phalanx of thumb for insertion.
flexor digitorum superficialis tendon on
3. The four tendons of flexor digitorum
middle phalanx.
superficialis diverge on reaching palm from
The tendon of flexor digitorum profundus is
carpal tunnel, to reach the four fingers.
finally inserted on palmar surface base of
Each tendon on the proximal phalanx splits
distal phalanx of finger.
into two parts to enclose a fibrous tunnel for
The long flexor tendons, as they pass through
flexor digitorum profundus tendon.
carpal tunnel, deep to flexor retinaculum, are
enclosed in a common synovial sheath, the ulnar
bursa, that extends up to middle of palm.
The long flexor tendons in each finger are
also enclosed in digital synovial sheaths.
The digital synovial sheath of little finger is
continuous with the common synovial sheath-
ulnar bursa.
Applied anatomy
The inflammation of the synovial sheath teno-
Fig. 13.5: The long flexor tendons in finger synovitis may compress the vinculaeslender
100 Essentials of Human Anatomy
fibrous bandsthat convey blood vessels to They are further classified into:
long flexor tendons. The palmar interosseifour (Table 13.4).
This may lead to necrosis of the tendons in The dorsal interosseifour (Table 13.5).
the palm. The interossei are also numbered from lateral
The muscles of the palm can be divided into to medical side.
four groups:
1. The thenar muscles and adductor pollicis The Blood Vessels of the Palm
(Fig. 13.6 and Table 13.1)
The Arteries
Abductor pollicis brevis
Flexor pollicis brevis 1. The ulnar artery enters the palm by crossing
Opponens pollicis superficial to flexor retinaculum, lateral to
Adductor pollicis pisiform and medial to hook of hamate, along
2. The hypothenar muscles (Table 13.2). with ulnar nerve.
Palmaris brevis The ulnar artery just distal to flexor
Adductor digiti minimi retinaculum gives a deep branch and
Flexor digiti minimi continues as superficial palmar arch.
Opponens digiti minimi The deep branch joins with terminal part
3. The lumbricals are four slender muscle bellies of radial artery to form the deep palmar
attached to the tendon of flexor digitorum arch.
profundus in palm (Table 13.3). 2. The superficial palmar arch is formed by
These are numbered from lateral to medial (Fig. 13.8)
side. Medially by continuation of ulnar artery.
4. The interossei fill up the gap between the Laterally by superficial palmar branch of
metacarpals (Fig. 13.7). radial artery
Figs 13.7 A and B: (A) The palmar interossei (B) The dorsal interossei
The Region of Wrist and Hand 103
Table 13.4: Palmar interossei
Name Origin Muscle belly Insertion Nerve supply Main actions
First palmar Ulnar side palmar Small, slender Ulnar side base Deep branch Adducts thumb to-
interosseous surface base of first muscle belly proximal phalanx ulnar (C8, T1) wards neutral axis of
metacarpal of thumb middle finger
Second Whole length pal- Small slender Ulnar side base Deep branch ulnar 1. Adducts index
palmar mar surface second muscle belly proximal pha- (C8, T1) towards neutral
interosseous metacarpal lanx index finger axis of middle
Dorsal digital ex- finger
pansion of index 2. Flexes metacar-
pophalangeal
and extension of
interphalangeal
joints
Third Whole length pal- Small, slender Radial side base Deep branch ulnar Same actions in
palmar mar surface fourth muscle belly proximal phalanx (C8, T1) relations to ring
interosseous metacarpal of ring finger finger
Dorsal digital
expansion
Fourth Whole length Small, slender Radial side base Deep branch ulnar Same actions in
palmar palmar surface muscle belly proximal phalanx (C8, T1) relation to little
interosseous fifth metacarpal of little finger finger
Dorsal digital
expansion
If this, branch is absent, then the arch is arteries before they divide, at the
completed by either of the following web of fingers.
branches of radial artery: Thus the blood supply to the finger
Princeps pollicis artery is maintained even when the
Radialis indicis artery superficial palmar arch is com-
Position: The superficial palmar arch lies pressed during gripping of an
at the level of fully extended thumb object.
Relation 3. The radial artery enters the deep part of palm
Superficial:The palmar aponeurosis by passing between the two heads of first
Deep dorsal interosseous muscle, from anatomical
The digital branches of median and snuff box.
ulnar nerves The radial artery appears in palm between
The long flexor tendons with the two headsoblique and transverse
synovial sheaths of adductor pollicis.
Branches Before joining the deep branch of ulnar
A Palmar branch to medial side of little artery the radial artery gives two branches:
finger a. The princeps pollicis artery divides
Three Common palmar digital branches into two branches to supply the sides
that divide at the web of fingers into two of thumb.
palmar digital branches to supply the b. The radialis indicis artery supplies the
sides of medial three and half digits. lateral side of index finger.
The three palmar metacarpal 4. The deep palmar arch is the smaller and
branches of the deep palmar arch deeply placed arterial arch in the palm. It is
join the three common palmar digital formed (Fig. 13.9):
Laterally by continuation of radial artery iii. Recurrent branches are given from the
Medially by deep branch of ulnar artery deep arch that ascend up to supply the
Position: The deep palmar arch lies just carpals and their articulations.
distal to the flexor retinaculum.
Relations The Veins of the Palm
Superficial: Synovial sheaths of flexor The radial and ulnar arteries and the two palmar
tendons arterial arches are accompanied by paired venae
Deep: Bases of metacarpals comitantes.
Fascia covering the interossei muscles.
Branches The Nerves of the Palm (Fig. 13.10)
i. Three Palmar metacarpal branches, 1. The medial nerve enters the palm through the
that joint the three common palmar carpal tunnel
meta-carpal branches of superficial On entering the palm the median nerve gives
palmar arch, before they bifurcate at a recurrent muscular branch to three
the web of fingers. thenar muscles and then divides into two
ii. Three perforating branches, which terminal brancheslateral and medial.
pass through the gaps between two a. The lateral terminal branch divides
heads of second, third, and fourth into three palmar digital nerves, to
dorsal inter-osseous muscles. supply the two sides of thumb, and
These perforating branches joint lateral side of index finger.
dorsal metacarpal branches of post- b. The medial terminal branch bifurcates
erior carpal arch. into two common palmar digital nerves.
106 Essentials of Human Anatomy
The two common palmar digital nerves III.A cummunicating branch to ulnar
divide into two palmar digital nerves to nerve from most medial palmar digital
supply the sides of index, middle and ring branch.
fingers. Applied Anatomy
Branches The lesion of median nerve can be
I. The muscular branches are: Near elbow joint
a. Recurrent muscular branch, that In the carpal tunnel
supplies the three thenar muscles Over the thenar eminence due to a
Abductor pollicis brevis piercing wound.
Flexor pollicis brevis Effects of Injury
Paralysis of flexor muscles of forearm,
Opponens pollicis
if the injury is at the elbow joint
b. Muscular branch to first lumbrical
Paralysis of three thenar muscles,
is given from palmar digital nerve
leading to weakness of movements of
to lateral side of index finger
thumb
c. Muscular branch to second
Sensory loss overlateral part of palm and
lumbrical is given from common
lateral three and half digits.
palmar digital nerve that supplies Late effects of lesionwasting of thenar
sides of index and middle fingers muscles, leading to Ape hand
II. The cutaneous branches are the 2. The ulnar nerve enters the palm by passing
palmar digital nerves. superficial to flexor retinaculum, medial to
a. These nerves supply the skin of the ulnar vessels.
lateral three and half digits on The ulnar nerve and ulnar vessels lie lateral to
palmar aspect. pisiform and medial to the hook of hamate
b. They also supply the skin on On reaching the hypothenar eminence, the
dorsum of digits up to middle of ulnar nerve divides into a superficial
middle phalanx branch and a deep branch.
The Region of Wrist and Hand 107
Q.1. Select the best response to each question 7. The structures passing through
from the four suggested answers: quadrangular space are:
1. The strong ligament that connects the A. Radial nerve
clavicle with upper limb is: B. Ulnar nerve
A. Coraco-clavicular ligament C. Axillary nerve and posterior circumflex
B. Costo-clavicular ligament humeral artery
C. Inter-clavicular ligament D. Anterior circumflex humeral artery
D. Acromio-clavicular ligament 8. The nerve passing through carpal tunnel at
2. The nerve that lies behind medial the wrist is:
epicondyle of humerus is: A. Ulnar nerve
A. Ulnar nerve B. Median nerve
B. Median nerve C. Anterior interosseous nerve
C. Radial nerve D. Radial nerve
D. Musculo-cutaneous nerve
9. The movements of supination and pronation
3. The carpal bone that has no muscular of forearm take place at:
attachment is: A. Superior and inferior radio-ulnar joints
A. Scaphoid B. Hamate B. Elbow joint
C. Capitate D. Lunate C. Superior radio-ulnar joint only
4. The overhead abduction of arm is caused by D. Inferior radio-ulnar joint only
contraction of: 10. The carpal bones taking part in radio-carpal
A. Supraspinatus joint are:
B. Deltoid A. Scaphoid only
C. Trapezius B. Lunate only
D. Lower part of trapezius and lower
C. Lunate nad triquetral
digitations of serratus anterior D. Scaphoid and lunate
5. The ulnar nerve has the following root value:
C T Q.2. Each question below contains four
A. 8, 1 B. C5,C6
sugges-ted answers, of which one or more
C ,C T
C. 7 8, 1 D. C 5,C6 ,C7 is correct. Choose the answer:
6. The pectoralis minor muscle is inserted on: A. If 1, 2 and 3 are correct
A. Greater tuberosity of humerus B. If 1 and 3 are correct
B. Acromion process of scapula C. If 2 and 4 are correct
C. Coracoid process of scapula D. If only 4 is correct
D. Lesser tuberosity of humerus E. If 1, 2, 3 and 4 are correct
Multiple Choice Questions 109
11. The muscles inserted on greater tuberosity 2. Runs along lateral border of arm and
of humerus are: forearm
1. Supra spinatus 3. Is connected with basilic vein on front
2. Infra spinatus of elbow by medial cubital vein
3. Teres minor 4. Terminates in axillary vein after
4. Subscapularis piercing clavi-pectoral fascia
12. The structures passing deep to the flexor 18. The mammary gland:
retinaculum are: 1. Lies in superficial fascia except the
1. Median nerve axillary tail part
2. Ulnar artery 2. Remains active and secretory in adult
3. Flexor pollicis longus tendon females only during lactation phase
4. Radial nerve 3. Has its secretion controlled by the
13. The median nerve in hand supplies: prolactin hormone of pituitary gland
1. Adductor pollicis 4. Has its lymphatics drain mainly in the
2. Three thenar muscles para-sternal lymph nodes
3. Dorsal interossei 19. The first carpo-metacarpal joint
4. First and second lumbricals 1. Is a condyloid type of synovial joint
14. The following muscles take origin from the 2. Is a saddle type of synovial joint
medial epicondyle of humerus: 3. Is joint between base of first metacarpal
1. Pronator teres and trapezoid
2. Flexor carpi radialis 4. Is joint between base of first metacarpal
3. Palmaris longus and trapezium
4. Flexor carpi ulnaris 20. The radial nerve gives the following
15. The abductors of hand at the wrist joint are: branches in posterior compartment of arm:
1. Flexor carpi radialis 1. Nerve its anconeus
2. Flexor carpi ulnaris 2. Posterior interosseous nerve
3. Extensor carpi radialis longus 3. Nerve to medial head of triceps
4. Brachio radialis 4. Nerve to brachioradials
16. The brachial artery: Q.3. Match the following on the left side with
1. Begins at lower border of teres major their appropriate answers on the right side
muscle 21. The nerves and their origins:
2. In cubital fossa lies superficial to i. Axillary A. Upper trunk
bicipital aponeurosis ii. Lateral pectoral B. VRC5
3. Bifurcates at level of neck of radius iii. Dorsal scapular C. Lateral cord
4. Lies lateral to the shaft of humerus in iv. Suprascapular D. Posterior cord
upper part of arm
22. The clinical signs after nerve injury:
17. The cephalic vein: i. Ape hand A. Radial nerve
1. Begins on dorsum of hand from lateral ii. Winging of B. Ulnar nerve
end of dorsal venous arch scapula
110 Essentials of Human Anatomy
iii. Claw hand C. Long thoracic 24. The movements of the muscles:
nerve i. Abduction of A. Supra
iv. Wrist drop D. Median nerve shoulder joint supinatus
23. The muscles and their nerve supply: ii. Adduction at B. Biceps brachii
i. Trapezius A. Radial nerve radiocarpal joint
ii. Supinator B. Thoraco-dorsal iii. Supination at C. Flexor carpi
nerve radio-ulnar joint ulnaris
iii. Latissimus dorsi C. Ulnar nerve iv. Flexion at dorsal D. Flexor digitorum
iv. Palmaris brevis D. Spinal accessory inter-phalangeal profundus
nerve joint of index
Answers
inferior radioulnar joints. The elbow joint is It bifurcates into radial and ulnar arteries at
pure hinge joint where only flexion and level of neck of radius. The artery at cubital
extension of forearm take place. fossa lies deep to bicipital aponeurosis. The
A10. The answer is D. brachial artery lies medial to the shaft of
The carpal bones taking part in radiocarpal humerus, in upper part of arm.
joint are scaphoid and lunate. The triquetral A17. The answer is E, (1, 2, 3, 4).
is separated by the articular disc of inferior The cephalic vein begins on dorsum of
radioulnar joint. hand from lateral end of dorsal venous arch.
A11. The answer is A, (1, 2, 3). It runs along lateral broder of forearm and
The three muscles attached to greater arm. It is connected with basilic vein on
tuberosity of humerus aresupraspinatus, front of elbow by median cubital vein. The
infraspinatus and teres minor. The sub- cephalic vein ends in axillary vein.
scapularis is inserted on lesser tuberosity of A18. The answer is A, (1, 2, 3).
humerus. The mammary gland lies in superficial fascia
A12. The answer is B, (1, 3). on front of thorax. It is active only during
The median nerve and flexor pollicis longus lactation phase in females. Its secretion is
tendon pass deep to flexor retinaculum. The controlled by prolactin hormones of pituitary
ulnar artery passes superficial to flexor gland. The lymphatics of mammary gland end
retinaculum, and radial nerve has no mainly in axillary lymph nodes.
relation with flexor retinaculum.
A19. The answer is C, (2, 4).
A13. The answer is C, (2, 4). The first carpo-metacarpal joint is between
The median nerve in palm supplies the three trapezium and base of first metacarpal. It is
thenar muscles and first and second lumbri- a saddle type of synovial joint. The
cals. The adductor pollicis is supplied by deep trapezoid does not take part in this joint.
branch of ulnar nerve and palmaris brevis is
supplied by superficial branch of ulnar nerve.
A20. The answer is B, (1, 3).
The radial nerve in posterior compartment
A14. The answer is E, (1, 2, 3, 4). of arm gives nerve to anconeus and nerve to
All the four muscles pronator teres, flexor medial head of triceps. The posterior intero-
carpi radialis, palmaris longus and flexor sseous nerve arises on front of lateral
carpi ulnaris take origin from medial epicondyle. The nerve to brachio-radialis is
epicondyle of humerus. given in lower part front of arm.
A15. The answer is B, (1, 3). A21. The answers are D, C, B and A.
The abductors of hand at wrist joint are flexor
The axillary nerve is a branch of
carpi radialis and extensor carpi radialis
posterior cord of branchial plexus.
longus. The flexor carpi ulnaris is adductor of
The lateral pectoral is a branch of
hand and the brachioradialis does not take
lateral cord.
part in adduction and abduction at wrist joint. The dorsal scapular arises from VR of
A16. The answer is B, (1, 3). C5 spinal nerve.
The brachial artery begins at lower border of The suprascapular nerve is a branch of
teres major as continuation of axillary artery. upper trunk of branchial plexus.
112 Essentials of Human Anatomy
A22. The answers are D, C, B, A. The latissimus dorsi receives its nerve
The Ape hand results from injury to supply from thoraco-dorsal nerve.
medial nerve. The palmaris brevis is supplied by the
The Winging of scapula is the results of superficial branch of ulnar nerve.
injury to long thoracic nerve. A24. The answers are A, C, B, D.
The Claw hand deformity results from The abduction at shoulder joint is
injury to ulnar nerve. initiated by supraspinatus.
The Wrist drop results from injury to The adduction at radiocarpal joint is
the radial nerve. done by flexor carpi ulnaris.
The supination at radio-ulnar joint is
A23. The answers are D, A, B, C. done by biceps brachii.
The trapezius is supplied by spinal The flexion at distal interphalangeal
accessory nerve. joint of index finger is done by flexor
The supinator is supplied by radial nerve. digitorum profundus.
The Lower
Extremity Three
CHAPTER 14
The Bones of the
Lower Extremity
As mentioned before, both the upper and lower The bones of the lower extremity are:
extremities are homologous in development. The hip bone (innominate bone) that forms
However, due to different functions performed by pelvic girdle
the two extremities, there are structural differences. The femurbone of thigh
The patellaknee cap
FEATURES OF THE LOWER EXTREMITY The tibia and fibulathe bones of the leg
The bones of the foot:
1. The lower extremities are adapted for giving Tarsals
support to the body and for forward pro- Metatarsals
gression. Phalanges
2. The lower extremity has undergone a medial
rotation by 90 from the embryonic position, THE HIP BONE (INNOMINATE BONE)
so that the primitive extensor surface faces General Features
anteriorly, and primitive posterior surface
faces posteriorly. The hip bone is a large, irregular bone that forms
3. The bones forming the pelvic girdle are fused a part of bony pelvis.
and firmly connected with axial skeleton as a The hip bone articulates with opposite bone to
complete the pelvic girdle.
result of assumption of erect posture.
The bone consists of three bonesIlium,
4. The joints of the lower extremity develop greater
ischium and pubisthat are fused in a cup shaped
stability and are adapted for weight bearing.
depression on lateral surface called acetabulum.
5. The bones of the foot develop arches to help A. The ilium is the expanded upper part of the
in the dual function of weight bearing and hip bone.
forward progression. It has an upper end that forms an
6. Since the big toe and tibia lie on the cranial elongated iliac crest and a lower end.
side of embryo, they are said to be on pre- 1. The iliac crest has a ventral segment,
axial border. The little toe and fibula lie that forms anterior two-third part of
towards the caudal side of embryo, hence they crest, and a dorsal segment that forms
are said to be on the postnatal side. the posterior one-third part.
114 Essentials of Human Anatomy
The ventral segment of iliac crest has The upper part of this surface forms
an outer lip, an intermediate area and the articular surface for sacro-iliac
an inner lip, that give attachment to joint (Fig. 14.1).
the three oblique muscles of anterior The lower part of this surface forms
abdominal wall. the lateral wall of bony pelvis.
The dorsal segment of iliac crest has B. The ischium forms the lower and posterior
an outer sloping area and an inner part of the hip bone.
sloping surface. The ischium has a bodythe main part
The iliac crest extends from anterior and a ramus.
superior iliac spine to posterior The body of ischium has
superior iliac spine. A femoral surfacepointing forwards.
The highest point of ilaic crest lies A dorsal surfacecontinuous with the
at the level of 4th lumbar spine. gluteal surface of ilium.
The iliac crest has a tuberosity on the A smooth pelvic surfacefacing
outer lip about 5.0 cm from medially.
anterior superior iliac spine. The lower end of the body of ischium
2. The lower end of ilium forms nearly forms the ischial tuberosity, that is
upper two-fifth part of acetabulum. divided by a transverse ridge into:
An upper quadrangular
The lower end is fused with pubis
areaA lower triangular
and ischium both inside and
area
outside acetabulum.
The upper quadrangular area is further
The ilium has two borders
divided into an upper lateral and an
anterior and posterior.
upper medial part.
The anterior border of ilium extends from
The ischial spine projects downwards and
the anterior superior iliac spine to anterior
medially from the ischial tuberosity. It is
inferior iliac spine, located just above the a pointed process that gives attachment
acetabulum. to sacro-spinous ligament.
The posterior border of ilium begins at The ramus of ischium fuses with the
the posterior superior iliac spine (vertebral inferior ramus of pubis to complete the
level 2nd sacral spine) and continues conjoint ramus. The conjoint ramus has an
through posterior inferior iliac spine and anterior and a posterior surface and two
upper part of greater sciatic notch. borders superior and inferior.
The ilium has three surfaces: C. The pubis forms the anterior part of the hip
a. The gluteal surface (or dorsal surface) bone and joins with the bone of the opposite
is divided into four areas by the three side to form the pubic symphysis.
gluteal linesposterior, middle and The pubis bone consists of a body or main
inferior. part and two ramisuperior and inferior.
b. The iliac fossa is the internal surface, 1. The body of pubis has three surfaces:
that is gently hollowed for muscular An anterior-femoral surface
attachment. A medial-symphyseal surface
c. The sacro-pelvic surface is the A posterior-pelvic surface
posterior-inferior surface on medial The body of pubis has a thick upper
aspect of the bone. borderthe pubic crest that ends laterally
in a pubic tubercle.
The Bones of the Lower Extremity 115
Six secondary centers appeartwo for iliac The trochanteric crest lies on the
crest, one for acetabulum, one for ischial poste-rior aspect of proximal end,
tuberosity. One for anterior inferior iliac spine between the two trochanters. It has a
and one for symphyseal surface of pubis. quadrate tubercle in the upper part for
Secondary centers of ossification appear by muscular attachment (Fig. 14.3).
puberty and fuse with rest of the bone by 2. The shaft of femur is covered anteriorly by
twentieth year. the extensor muscles.
a. The shaft has three surfacesanterior,
THE FEMUR medial and lateral.
General Features The anterior surfaceis smooth and
gently curved.
The femur is the long bone of the thigh. It hasa The medial surfaceis also smooth
proximal end, a shaft and a distal end. and directed postero-medially.
1. The Proximal end consists of head, neck The lateral surfaceis directed
greater trochanter and lesser trochanter. postero-laterally.
a. The head is approximately two-thirds of a b. On posterior aspect of middle one-third of
sphere shaft, there is a double ridge called linea
It is covered by hyaline articular asperaa for muscular attachments.
cartilage except at a depression The linea aspera has a medial lip that
fovea centralisthat gives attachment is continuous above with spiral line.
to ligamentum teres of femur. The spiral line is joined proximally by
b. The neck joints the head to the shaft. inter-trochanteric line.
It makes an angle of nearly 125 The lateral lip of linea aspera is conti-
(slightly less in females) with the shaft. nuous above with a thick ridge
It is also turned forwards by about 15. gluteal tuberosity.
c . The greater trochanter is a quadrangular Both medial and lateral lips of linea
projection on the lateral aspect of upper end. aspera are continued below as medial
It projects upwards and has three and lateral supra-condylar ridges.
surfaces. Between the two supra-condylar ridges
An anterior surface below lies a triangular area on
A lateral surface, that has a pro- posterior aspect of shaft known as
minent oblique ridge on it. popliteal surface.
A medial surface that has a 3. The distal end of femur consists of two con-
depression called trochanteric fossa. dylesmedial and lateraland an articular
The greater trochanter has a thick surface (Fig. 14.3).
upper border. It gives attachment to i. The medial condyle projects distally and
the gluteal muscles. medially. The exaggerated medial
d. The lesser trochanter is a small elevation angulation (more in females) causes
on the medial aspect, just distal to the knock-knee (genu valgum).
junction of neck with the shaft. The most salient point on medial
The trochanteric line is a slight ridge condyle is called medial epicondyle.
on the anterior aspect of proximal end This gives attachment to the medial
that separates neck from the shaft. collateral ligament of the knee point.
118 Essentials of Human Anatomy
bony trabeculae inside head, neck and the Trochanteric fossaobturator externus
trochanters of femur are arranged according Quadrate tubercle on trochanteric crest
to lines of force transmission up to compact Quadratus femoris
bone of the shaft. Lesser trochanter and line below of
iii. The articular surfaceof the lower end psoas major and iliacus
of femur is divided into: ii. The shaft
A patellar articular surface. Upper part trochanteric line, anterior and
lateral border of greater trochanter and
A tibial articular surface.
lateral lip of linea asperaVastus lateralis
a. The patellar articular surface is
Lower part trochanteric line, spiral line,
placed anteriorly and is more on medial lip of linea aspera and medial
lateral condyle than medial condyle. supra condylar ridgeVastus medialis
It is separated from tibial arti- Anterior and medial surfaces (upper 3/4
cular surfaces of the two con- th) Vastus intermedius
dyles by faint ridges. Line descending from lesser trochanter to
b. The tibial articular surfaceis on linea asperaPectineus
the inferior aspect of medial and Linea asperaAdductor longus and
lateral condyles. Adduc-tor brevis
Line descending medial to gluteal
Special Features tuberosity, medial lip of linea aspera, and
medial Supracondylar ridgeAdductor
[Important muscles and ligaments attached to the part of Adductor magnus
bone] Gluteal tuberositylower and deeper
i. Upper end: 1/4th part of Gluteus maximus
Superior border of greater trochanter Lateral lip of linea asperaShort head of
piriformis biceps femoris
Oblique ridge on lateral aspect of greater iii. The lower end:
trochanterGluteus medius Popliteal surface and lower part of lateral
Anterior surface of greater trochanter supra-condylar ridgePlantaris
Gluteus minimus Popliteal surface and depression above
Medial surface of greater trochanter lateral femoral condyleLateral head of
Obturator internus and gemelli Gastrocnemius
120 Essentials of Human Anatomy
Popliteal surface above medial femoral For distal end one center appears just before
condyleMedial head of Gastrocnemius birth in ninth month of intra-uterine life and
Posterior part of popliteal groove on fuses by twentieth year.
lateral surface of lateral femoral The distal end is the growing end of femur.
condylePopli-teus
Medial epicondyleMedial collateral THE TIBIA
liga-ment of knee joint General Features
Lateral epicondyleLateral collateral
liga-ment of knee joint. The tibia is medial, stout and weight bearing
Nutrient foramen bone of the leg.
The nutrient foramen for femur are usually two The tibia has a proximal end, a shaft and a
One situated near proximal end of linea distal end.
aspera. I. The proximal endis expanded to form two
The second located near the distal end of condylesmedial and lateralwhich articulate
linea aspera. with the two femoral condyles to form the
The nutrient arteries are provided by second femoro-tibial part of the knee joint (Fig. 14.5).
and third perforating branches of profunda a. The medial tibial condyleis concave
femoris artery. both in coronal plane and sagittal plane.
Applied anatomy It is larger and semi-circular in outline.
i. The head of femur can be palpated just below b. The lateral tibial condyle is concave in
inguinal ligament lateral to femoral artery coronal plane but convex in sagittal plane.
ii. The neck of femur joins the shaft at an It is smaller in diameter and nearly
angle of 125 in adults (160 in children) circular in shape.
Coxa valga is the condition where this c. The inter condylar eminence lies between
the two tibial condyles.
angle is increased as is seen in
It gives attachment to the medial and
Congenital dislocation of lip joint
lateral semilunar cartilages (menisci)
Coxa vara is decrease in neck-shaft angle.
of the knee joint and the two cruciate
It occurs in fracture of neck of femur.
ligamentsanterior and posterior.
iii. The fracture of neck of femur interferes
d. The tibial tuberositylies on the anterior
with the blood supply of head of femur
surface of upper end. It gives attachment to
and ischemic necrosis may set in. It occurs
the patellar ligament (ligamentum patellae)
mostly in elderly people.
Ossification
One primary centre of ossification appears in
the shaft in eighth week of intra-uterine life.
For proximal endthree secondary centers of
ossification appear.
One for head in first year.
One for greater trochanter in fourth year.
One for lesser trochanter in twelfth year. All
these epiphyses fuse separately with the
shaft by sixteenth year. Fig. 14.5: Upper end of tibiasuperior aspect
The Bones of the Lower Extremity 121
II. The shaft of the tibia is triangular in section and It has a groove on its posterior aspect
becomes narrow towards medial malleolus. for the tendon of tibialis posterior.
The shaft has three surfacesmedial, To the apex and a depression near it,
lateral and posterior. is attached the deltoid ligament of
a. The medial surface is subcutaneous the ankle joint.
throughout. Its upper part gives attach- The lateral surface of medial malleo-
ment to the three muscles of thigh lus has a comma shaped articular
sartorius, gracilis and facet for articulating with medial
semitendinosis and medial collateral surface of talus at the ankle joint.
ligament of the knee joint. b. The fibular notch lies on the lateral
b. The lateral surface is broad and smooth aspect of the distal end of tibia.
and lies between the anterior and To the edges of fibular notch are
interosseous borders. attached the anterior and posterior
c. The posterior surfacein its upper part tibio-fibular ligaments of inferior
has a triangular area for attachment of tibio-fibular joint.
popliteus. c. The articular surface of the distal end
The triangular area is limited below of tibia is wider anteriorly and concave
by a thick ridgethe soleal line that in shape (Fig 14.6).
gives attachment to soleus muscle. It articulates with the superior
Below the soleal line, the posterior trochlear surface of talus at the
surface is divided by a faint vertical ankle joint.
line into a medial and a lateral area.
The shaft has three borders also
anterior, medial and lateral or inter-
osseous border.
The anterior borderbegins as
continuation of tibial tuberosity
and is subcutaneous throughtout.
It is slightly curved in its lower
part towards medial malleolus.
The medial border is well-
defined in middle one-third part
of the shaft only. It separates
medial and posterior surfaces.
The lateral (interosseous)
border is sharp and gives
attachment to the interosseous
membrane of the leg.
III. The distal end of the tibia is expanded and
articulates with talus at the talo-crural (ankle)
joint.
The distal end has a medial malleolus, a
fibular notch and an articular surface.
a. The medial malleolus is a stout pro-
jection on the medial aspect of the
distal end. Fig. 14.6: The tibia and fibulaanterior aspect
122 Essentials of Human Anatomy
c. The shaft of the fibula is narrow and has The shaft of fibula has three bordersanterior,
three surfacesmedial, lateral and posterio. posterior and medial or interosseous border.
The medial surface is very narrow and a. The anterior border extends from the inferior
lies between anterior and interosseous aspect of head up to the apex of triangular
borders. area above lateral malleous.
This surface gives attachment to b. The posterior border is rounded in its proximal
the extensor muscles of the leg. part but is distinct distally.
The lateral surfacegives attachment to c. The medial (interosseous) border extends up to a
the peroneal muscles. triangular area on medial aspect of lower end of
The lower one-fourth of this surface
fibula, for the inferior tibio-fibular joint.
twists behind the lateral malleolus.
The posterior surface is the largest It gives attachment to interosseous
surface. It lies between the membrane.
interosseous and posterior borders. d. The distal end of fibula projects distally and
Special Features
[Important muscles and ligaments attached to the
bone]
i. The head
Lateral surface of headbiceps femoris and
lateral collateral ligament of knee joint.
Posterior surface of headSoleus
ii. The shaft
Lateral surface (proximal 2/3rd) Peroneus
longus
Lateral surface (distal 2/3rd ) Peroneus
Fig. 14.7: The tibia and fibulaposterior aspect brevis
124 Essentials of Human Anatomy
THE BONES OF THE FOOT B. The calcaneum is the largest tarsal bone and
The bones of the foot are the tarsals, metatarsals projects posteriorly.
and the phalanges. The calcaneum is irregularly cuboidal in
I. The tarsals are seven bones arranged in three rows. shape, having superior, inferior (plantar),
The proximal row has talus and calcaneum anterior, posterior, medial, and lateral
The middle row has navicular surfaces.
The distal row has cuboid and three cuneiform a. The superior surface has three articular
bonesmedial, intermediate and lateral. facets for talus, forming sub-talar joint.
A. The talus has a round head, a neck and a body Its proximal part is rough, while its
(Fig. 14.9). distal part has a depressionsulcus
The head of talus is directed distally and calcaneithat completes sinus tarsi
articulates with the navicular bone. with talus.
The plantar surface of head has three faces b. The inferior (plantar) surfaceis rough
for articulating with calcaneum. and has a prominent medial tubercle and
The neck is the narrow region between the a smaller lateral tubercle for attachment
head and the body. of muscles and ligaments of the sole.
Its plantar surface has a deep groove. c. The anterior surface is small and has a
The body of talus is cuboidal in shape. concavo-convex articular facet for
The dorsal surface (trochlear surface) cuboid bone.
articulates with inferior surface of distal d. The posterior surface is divided into
end of tibia at the ankle joint. (Figs 14.10 A and B)
The medial surface has a comma shaped A smooth proximal area for a bursa.
articular facet for medial malleolus. A middle larger rough area for
The lateral surface has a triangular
attachment of tendo-calcaneus
articular facet for lateral malleolus
A distal (inferior) area related to a
The posterior surface has a projecting
fibro-fatty cushion, that forms the
process and an oblique groove for ten-
heel.
don of flexor hallucis longus.
The inferior (plantar surface) articulates e. The medial surfacehas a prominent
with calcaneum. shelf like projectionthe sustentaculum
The talus has no muscular attachment. talithat supports talus and gives attach-
ment to spring ligament.
Only ligaments are attached to the bone.
The sustentaculum tali is grooved on
its inferior surface by tendon of
flexor hallucis longus.
f. The lateral surface is almost flat.
It presents a small and variable
elevation
The peroneal tubercle (trochlealies)
about 2.0 cm distal to the tip of lateral
malleolus.
The peroneal tubercle has a
shallower groove above for peroneus
brevis tendon and an obligue groove
Fig. 14.9: The talussuperior aspect below for peroneus longus tendon.
126 Essentials of Human Anatomy
Lateral triangular part for the base of They connect the tarsal bones to the phalanges.
fifth metatarsal. The metatarsals are short bones with a promi-
E. The cuneiform bones are three wedge shaped nent base, a shaft and a smaller head of distal
tarsal bones that form the distal row. end.
a. The medial cuneiform is the largest cunei- The bases of metatarsals are thicker and
form. It is quadrangular in shape. articulate with the distal row of tarsal bones.
It articulates distally with the base of The heads articulate with the bases of
first metatarsal. proximal phalanges.
Proximally it has a smaller facet for The first metatarsal is shortest and thickest.
articulating with navicular. The fifth metarsal has a tuberosity on the
The medial surface of medial cuneiform lateral side of the base.
is thick, rough and subcutaneous.
III. The phalanges of the foot resemble those in
The lateral surface presents a facet for the hand.
the intermediate cuneiform.
There are two phalanges in the big toe.
b. The intermediate cuneiform is nearly
The rest of the toes have three phalanges.
square in shape.
The phalanges of the foot are much shorter,
It articulates distally with base of
specially their shafts,
second metatarsal.
The base of proximal phalanx articulates with
Proximally it has a facet for
articulating with navicular bone. the head of the metatarsal.
Medially it has a facet for intermediate The head of proximal phalanx articulates with
cuneiform. concave base of middle phalanx.
Laterally it has a facet for articulating The middle phalanx is short but broader than
with cuboid. proximal phalanx .
The head of middle phalanx articulates with
Ossification of Tarsal Bones base of distal phalanx.
In big toe, the proximal phalanx articulates with
The calcaneum ossifies by a center appearing
base of terminal phalanx.
in third month of intrauterine life. It has a
The distal phalanges have a rough projection or
secondary center for posterior surface that
tuberosity on plantar surfaces for attachment
appears by eighth year and units by sixteenth
year. of the pulp of the toe.
The talus ossifies by a center that appears in
Ossification of the Metatarsals and
sixth month of intrauterine life.
The cuboid develops by a center that appears Phalanges
in ninth month of intrauterine life. The metatarsals ossifies by two centers
The navicular ossifies by a center appearing For the shaft
in third year after birth. In first metatarsal center of ossification
The medial cuneiform ossifies in second year, appears in tenth week.
the intermediate cuneiform in third year and For other four metatarsals the center
lateral cuneiform in first year. appears in ninth week.
II. The metatarsals For the heads of lateral four metatarsals the
There are five metatarsals in the skeleton of secondary center appears in third to fourth year
foot. and unites with the shaft by twentieth year.
128 Essentials of Human Anatomy
For base of first metatarsal the secondary Applied Anatomy of Bones of Foot
center appears by third year and unites with
the shaft by twentieth year. i. Fracture of talusOccurs due to violent
The phalanges ossify by two centersone for dorsi-flexion of ankle joint.
the shaft and one for the base. ii. Compression fracture of calcaneum results
For shaft from a fall from a height.
For proximal phalanx the center for shaft Sustentaculum tali can be fractured due to
appears in eleventh week. voilent inversion of foot.
For middle phalanx the center for shaft iii. Fracture of metatarsalsBase of 5th meta-
appear after fifteenth week.
tarsal may be fractured due to forced inver-
For distal phalanx the center for shaft
sion.
appears by ninth week.
For base Stress fracture of metatarsals (distal
For the bases of phalanges the center 1/3rd of second, third, and fourth
appears by fifth to sixth year and unites metatarsals) occurs commonly in soldiers
with the shaft by eighteenth year. after long marches.
CHAPTER 15
The Joints of the
Lower Extremity
THE HIP JOINT
The hip joint is a large joint between the lower limb
and the pelvic girdle.
Type: A ball and socket type of synovial joint.
Articular surface:
i. The head of femuris more than half a
sphere. Except for a small depression
fovea centralisit is covered by hyaline
articular cartilage.
ii. The acetabulum is a cup shaped depression
on lateral surface of hip bone.
It has a horse-shoe shaped articular
surface covered by hyaline articular
cartilage, that encloses a non-articular Fig. 15.1: The hip jointanterior aspect
acetabular fossa.
Posteriorlyto back of neck of femur
It is deepened by a fibro-cartilaginous proximal to trochanteric crest.
rim called the labrum acetabulare. Mediallyto the spiral line.
Stability of the joint: The hip joint is a very There are two types of fibers in the articular
stable joint for transmission of force to and from capsule.
the pelvis to the limb. i. The longitudinal fibers are in form of three
The factors responsible for the stability of the thickenings that can be seen externally as
joint are: iliofemoral, pubofemoral and ischiofemoral
i. The shape of articular surfaces ligaments.
ii. The strong ligaments surrounding it. ii. The circular fibers run circumferentially deep
iii. The strong muscles around the joint. to the longitudinal fibers. These fibers are
Articular capsulesurrounds the joint on all known as zona orbicularis.
sides (Fig. 15.1). The retinacular fibers of the capsule are
Attachments: those fibers that are reflected along the neck
On thehip boneall around the margins of femur towards the head of femur. They
of acetabulum and transverse acetabular carry small blood vessels for the head of
ligament. femur. In case of intra-capsular fracture of
On femur - on the neck of femur. neck of femur, they help to keep the pieces
Anteriorlyto trochanteric line. of neck together.
130 Essentials of Human Anatomy
The ligaments of the hip joint The synovial membrane lines the non-
i. The iliofemoral ligament is thick, strong articular part of the neck of femur and
and V-shaped ligament on anterior aspect surrounds the ligamentum teres of head of
of the joint. femur (Fig. 15.2).
It is one of the strongest ligaments of the The nerve supply is by:
body. i. Femoral: via nerve to rectus femoris.
It is attached above to anterior-inferior
ii. Obturator.
iliac spine and below the trochanteric
iii. Accessory obturator (if present).
line.
iv. Nerve to quadratus femoris.
ii. The pubofemoral ligament lies on medial
aspect of the joint. v. Superior gluteal.
It is attached above the iliopectineal The arterial supply is by:
eminence and below lower part of i. The superior gluteal artery.
trochanteric line and upper end of ii. The inferior gluteal artery.
spiral line. iii. The obturator artery.
iii. The ischiofemoral ligament lies on the iv. The medial circumflex femoral artery.
posterior aspect of the capsule. Movements of the joint
It is attached above the posterior aspect The hip joint is a multiaxial joint, so the
of acetabulum and below the back of movements are possible in more than two
neck of femur. axes.
The fibers of this ligament are arranged Flexion and extension occur along a
spirally.
transverse axis.
iv. The transverse acetabular ligament bridges
Abduction and adduction take place
the gap on the inferior aspect of acetabulum.
along an antero-posterior axis.
The ligament is continuous with labrum
acetabulare. Circumduction is combination of all
It leaves a gap below it through which above movements.
articular nerves and vessels enter the Medial and lateral rotation occur along
joint. a vertical axis.
v. The ligament of head of femur
(ligamentum teres) is attached to the pit
fovea centralison the head of femur.
The other end of the ligament is attached
to the margins of acetabulum and
transverse acetabular ligament.
The ligament is triangular in shape (not
round) and carries a small artery to
supply the head of femur.
The ligament has hardly any role in the
stability of the joint.
The synovial membrane lines the deep surface
of the capsule.
It lines the acetabular pad of fat and covers
both surfaces of labrum acetabulare. Fig. 15.2: The hip joint (section through joint)
The Joints of the Lower Extremity 131
iii. The lateral (fibular) collateral ligament is posterior part of inter-condylar area of
a strong cord-like structure attached above tibia (Fig. 15.3).
the lateral epicondyle of femur and below The ligament prevents anterior
the lateral surface of head of fibula. bending of femur on tibia. It is a
It is related laterally to the tendon of big stabilizer of the knee joint.
insertion of biceps femoris. The menisci (semilunar cartilages) of the knee
It is not fused with the fibrous capsule, joint.
and is separated from lateral meniscus There are two menisci, medial and lateral
by popliteus muscle. present above the tibial condyles.
It is supposed to be phylogenetically The menisci are made up of fibrocartilage
fibrosed part of peroneus longus muscle. and serve to deepen somewhat the
iv. The oblique popliteal ligament is a strap- articular surfaces of tibial condyles.
like expansion from the insertion of semi- 1. The lateral meniscus is smaller and
membranosus. It strengthens the posterior nearly circular.
part of capsule and is attached to It is attached by two horns to
intercondylar line of femur. theintercondylar area of tibia
v. The coenary ligaments are thickenings of inside the medial meniscus.
the capsule, that are loosely attached to It is separated from the lateral
the margins of the two menisci. colla-teral ligament of the joint by
A transverse ligament sometimes popliteus muscle.
connects the anterior margins of two 2. The medial meniscus is larger and
menisci. semi-circular in outline.
vi. The cruciate ligaments are twoanterior It is attached by two horns on
and posteriorand are present inside the theinter-condylar area of upper
joint. end of tibia.
a. The anterior cruciate ligament is a It is fused with articular capsule
strong cord-like band connecting the andmedial collateral ligament. It
medial surface of lateral femoral is more prone to injury.
condyle to intercondylar area of tibia. The important bursae in relation to the joint
b. The posterior cruciate ligament is also a (Fig. 15.4).
strong cord-like band connecting lateral i. The suprapatellar bursa lies deep to the
surface of medial femoral condyle to tendon of quadriceps femoris in relation to
Fig. 15.3: Superior aspect of tibia Fig. 15.4: Sagittal section through the knee joint
The Joints of the Lower Extremity 133
ii. Injury to the ligaments especially cruciate Facets on lateral and medial aspects of
ligaments can take place due to violent talus.
hyper-extension. Articular capsule surrounds the joint on all sides.
The collateral ligaments may also be It is attached to the margins of articular
involved in traumatic lesions. surfaces of bones.
iii. Acute synovitis with accumulation of fluid Ligaments
inside the joint is also a common condition. i. The medial collateral (Deltoid) ligament
iv. Osteoarthritis in old age results from is a strong triangular ligament on medial
damage to the articular cartilage. It results aspect of the joint (Fig. 15.7).
in pain and limitation of movements. Apex is attached to the tip of medial
v. The bursae around knee joint may be malleolus.
involved in inflammatory process. Base or lower attachment.
Inflammation of prepatellar bursa causes The superficial fibers are attached
painful swelling in front of patella to
Housemaids knee. Sustentaculum tali of calcaneum.
Inflammation of subcutaneous infra- Spring (calcaneo-navicular)
patellar bursa causes painful swelling ligament.
in front of tibial tuberosity Navicular.
Clergymans knee. Medial tubercle of talus.
The deep fibers are attached to
THE ANKLE (TALO-CRURAL) JOINT
Medial surface of talus.
The ankle joint is a big joint between lower ends ii. The lateral collateral ligament consists of
of tibia, fibula and the talus (Fig. 15.6). three separate bands:
Type: A hinge type of joint. a. The anterior talo-fibular extends from
Articular surfaces the tip of lateral malleolus to talus
Upper articular surface is formed by: anteriorly.
Lower end of tibia b. The posterior talo fibular extends from
Medial malleolus of tibia the malleolar fossa of fibula to talus
Lateral malleolus of fibula posteriorly.
Lower articular surface is formed by: c. The calcaneo-fibular extends from the
Superior articular (trochlear) surface of tip of lateral malleolus to lateral
talus. surface of calcaneum (Fig. 15.8).
iii. The long plantar ligament is the longest II. The tarso-metatarsal joints are the joints
ligament of the foot, between bases of metatarsals and distal row
Attachment of tarsal bones.
ProximallyPlantar surface of Type - Plane type of synovial joints.
calcaneum Ligaments
Distallysuperficial fibers pass to The dorsal ligaments are strong and flat
the bases of second, third, and and cover the dorsal aspects of the joint.
fourth metatarsals. The deep fibers The plantar ligaments cover the plantar
are attached to the ridge of cuboid aspects of the joints.
con-verting the groove of peroneus Movements some gliding movements
lon-gus into a tunnel. occur at these joints.
The long plantar ligament also plays a III. The metatarso-phalangeal joints are joints
role in maintaining longitudinal arch bet-ween the heads of metatarsals and bases
of the foot. of proximal phalanges.
iv. The plantar calcaneo-cuboid (short Type condyloid type of synovial joints.
plantar) ligament is a short, wide band Articular capsules surround the joints.
that lies deep to the long plantar ligament. Ligaments:
It extends from anterior tubercle of
The plantar ligament reinforces the
calcaneum to plantar surface of cuboid.
plantar aspect of joint.
Movements The deep transverse metatarsal ligaments
Some gliding and rotational movements
are short wide bands that firmly connect
occur at this joint along with sub-talar and the heads of metatarsals.
talo-calcaneo-navicular joints during
The collateral ligaments are two strong
inversion and eversion of foot.
bands that firmly connect the sides of
THE SMALL JOINTS OF THE FOOT bones.
Movements at these joints are possible on
The small joints of the foot are:
two axes.
i. The intertarsal joints Flexion and extension occur at transverse
ii. The tarso-metatarsal joints axis.
iii. The metatarso-phalangeal joints Abduction and adduction take place at an
iv. The inter-phalangeal joints. antero-posterior axis in relation to the
I. THe inter-tarsal joints are the joints between neutral axis of the second toe.
adjacent tarsal bones. Muscles producing
Type Plane type of synovial joints. movements. Flexion
Ligaments Flexor digitorum longus
a. The dorsal ligaments cover the dorsal Flexor digitorum brevis
aspect of the joint. Flexor digitorum accessorius
b. The plantar ligaments cover the Flexor hallucis longus (for big toe).
plantar aspect of the joint. Extension
MovementsSome gliding movements Extensor digitorum longus
occur at these joints, which help to change Extensor digitorum brevis
transverse arches of foot. Extensor hallucis longus (for big toe).
The Joints of the Lower Extremity 139
on postero-lateral aspect of greater II. The articular branch supplies the hip
trochanter of femur. joint.
II. The inferior gluteal artery anastomoses 2. The inferior gluteal nerve is a branch of sacral
with superior gluteal artery and gives plexus and derives its root value from
an articular branch to the hip joint. posterior division of ventral rami of L5,S1,S2.
CourseThe nerves leaves the pelvis through
The Veins greater sciatic foramen below piriformis along
with inferior gluteal vessels.
The venae comitantes accompany the superior On entering gluteal region, the nerve
and inferior gluteal arteries. passes to the deep surface of gluteus
These veins end in internal iliac vein. maximus, to supply it.
These deep veins are connected by gluteal Branches
perforating veins with the superficial veins of I. The muscular branch supply gluteus
gluteal region, which drain in the femoral vein. maximus.
II. The articular branch supplies the hip
The Lymphatic Drainage of the joint.
Gluteal Region 3. The sciatic nerve is the thickest nerve in the
body. It is branch of sacral plexus.
The superficial lymphatics of the gluteal region
The sciatic nerve consists of two nerves
end in the superficial inguinal lymph nodes. enclosed in a common sheath.
a. The tibial nerve is a branch of ventral
The Nerves of the Gluteal Region divisions of ventral rami of L4 L5, S1,
1. The superior gluteal nerveis a branch of S2, S3.
sacral plexus and derives its root value from b. The common peroneal nerve is a branch
of posterior divisions of ventral rami of
posterior division of ventral rami of L4,L5,S1. L L S ,S .
CourseThe nerve leaves the pelvis by 4, 51, 1 2
CourseThe sciatic nerve leaves the pelvic
passing through greater sciatic foramen,
wall by passing through greater sciatic
along with superior gluteal vessels, above foramen below piriformis. The sciatic neve
piriformis. does not give a branch in gluteal region.
The nerve passes deep to gluteus medius The nerve lies deep to gluteus maximus.
and divides intoa superior branch The nerve descends with convexity
and an inferior branch. between ischial tuberosity and greater
The superior branchaccompanies the trochanter, to enter posterior compart-
superior branch of superior gluteal ment of thigh.
artery and supplies gluteus medius. It crosses obturator internus tendon with
The inferior branch runs along the two gemelli and quadratus femoris in
inferior branch of superior gluteal its course.
artery and supplies gluteus medius, 4. The nerve to quadratus femoris is a branch of
gluteus minimus and tensor fascia lata. sacral flexus, and arises from ventral divisions
Branches of ventral rami of L4,L5, and S1 nerves.
I. The muscular branches supply: Course
Gluteus medius The nerve leaves pelvis by passing
Gluteus minimus through the greater sciatic foramen
Tensor fascia lata below piriformis.
The Hip Region 145
It enters gluteal region and lies deep to 6. The pudendal nerveis a branch of sacral
the sciatic nerve. plexus from ventral divisions of ventral rami
Then it passes deep to obturator internus of S2,S3 and S4 nerves.
tendon and gemelli and reaches the CourseThe nerve enters gluteal region
deep surface of quadratus femoris. by passing through greater sciatic
foramen, below piriformis.
Branches
It lies deep to gluteus maximus muscle.
I. Muscular branches supply It crosses the tip of ischial spine and
Quadratus femoris enters lesser sciatic foramen, accom-
Inferior gemellus panied by internal pudendal vessels
II. Articular branch supplies and nerve to obturator internus.
Hip joint From gluteal region, the pudendal nerve
5. The nerve to obturator internus is a branch of enters pudendal canal in ischio-rectal
sacral plexus and arises from ventral divisions fossa of perineum.
It does not give any branch, in gluteal
of ventral rami of L5,S1 and S2 nerves.
region.
CourseThe nerve leaves pelvis, by 7. The posterior femoral cutaneous nerve is a
passing through greater sciatic foramen branch of sacral plexus and arises from dorsal
below piriformis. divisions of S1 and S2 and ventral divisions of
It enters gluteal region and lies deep to S2 and S3 ventral rami.
the gluteus maximus. CourseThe nerve enters gluteal region
The nerve crosses the base of ischial by passing, through greater sciatic
spine along with internal pudendal foramen below piriformis.
vessels and enters lesser sciatic notch. The nerve lies superficial to sciatic
It enters the obturator internus muscle to nerve and deep to gluteus maximus as
it descends down.
supply it.
The nerve enters posterior compartment
Branches of thigh at lower border of gluteus
I. Muscular branches supply maximus.
Obturator internus It does not give any branch in gluteal
Superior gemellus region.
CHAPTER 17
The Region of
the Thigh
The region of the thigh includes: III. Psoas minor
A. The anterior compartment of thigh including IV. Quadratus femoris having four heads
femoral triangle and adductor canal. Vastus medialis
B. The medial compartment of the thigh. Vastus lateralis
C. The posterior compartment of the thigh. Vastus intermedius
D. The popliteal fossa at the back of knee.
Rectus femoris
THE ANTERIOR COMPARTMENT OF THE V. Sartorius
THIGH (Table 17.1)
The Femoral Triangle (Fig. 17.1)
The muscles of the anterior compartment are:
I. Iliacus The femoral triangle is a triangular intermuscular
II. Psoas major space on front of upper one-third of thigh.
Table 17.1: Muscles of the anterior compartment
Name Origin Muscle belly Insertion Nerve supply Main actions
1. Iliacus Upper two-third of iliac Flat, triangular muscle Lesser trochanter Femoral I. Powerful flexor of
fossa, Ala of sacrum belly Fibers converge of femur For 2.5 (L2, L3) hip joint with
Anterior sacro-iliac towards lateral side to cm below lesser psoas major
ligament form a strong tendon trochanter on II. Helps to maintain
with psoas major the shaft of femur posture at hip joint
2. Psoas Anterior surface and Long fusiform muscle Summit of lesser Ventral rami I. Same as iliacus
major lateral borders of trans- belly lies lateral to trochanter along L1, L2 from II. Helps to bend
verse processes of five lumbar part of verte- with iliacus lumbar plexus trunk on lower
lumbar vertebrae bral column limb while getting
Five digitations from Descends along pelvic up.
sides of two lumbar inlet and its tendon is III. Does not act as
vertebrae and the inter joined by iliacus from medial rotator of
vertebral discs lateral side hip joint; rather
From four tendonous helps in lateral
arches joining the two rotation
digitations from side of
lumbar vertebrae
3. Quadri- Four heads Large muscle belly, Base of patella Femoral I. Powerful extensor
ceps a. Vastus medialis covers front and Insertion is carried L2, L3, L4 of knee joint
temoris Distal part of inter tro- sides of shaft of by ligamentum (Separate II. Rectus femoris
chanter line femur patellae to the tub- branches are helps in flexing of
Spiral line Tendons of four erosity of tibia given to the of hip joint
Medial lip of linea heads unite to form (patella being sesa- four heads of III. Helps to maintain
aspera Proximal part a strong tendon moid bone) Medial quadriceps posture at knee
medial supracondylar above patella and lateral patellar femoris) joint
Contd...
The Region of the Thigh 147
Contd...
Name Origin Muscle belly Insertion Nerve supply Main actions
line retinacula are ex- IV. Lowest fibers of
b. Vastus lateralis pansions attached vastus medialis
Intertrochanteric line to sides of patella stabilize patella
Anterior and inferior Some lower fibers by preventing its
borders of greater trochan- of vastus medialis lateral displace-
ter Lateral lip of linea are directly attached ment during
aspera to medial border of contraction of
Proximal half patella quadriceps femoris
lateral supracondylar
line Articularis genu are
c. Vastus intermedius deepest and lowest
Proximal two-third fibers of vastus inter-
anterior and lateral medius attached to
surfaces of femur synovial membrane
d. Rectus femoris of knee joint.
I. Straight head-anter-
ior inferior iliac spine
II. Reflected head-
groove above acetabulum
4. Sartortus Anterior superior iliac Long, strap like Upper part medial Femoral I. Flexion and
spine muscle belly surface of tibia in abduction of hip
Upper half of the Crosses the front front of gracitis (L , L ) joint
notch below it. of thigh obliquely and semi-tendinosus 2 3 II. It also helps in
to reach medial side lateral rotation of
of tibia hip joint.
III. It also helps in
flexion of knee
joint (The combi-
nation of these
movements helps
the tailor to work
his foot-operated-
sewing machine.
5. Psoas From sides of Small muscle belly Pecten VRL 1 1. Weak flexor of
minor 12th thoracic and 1st with long tendom pubes trunk
(absent Lumbar vertebra
in 40%
subjects)
The Blood Vessels of the Anterior The lateral circumflex femoral passes
Compartment laterally deep to sartorius and rectus
The Arteries femoris and divides into three bran-
chesascending, transverse and
The femoral artery is the main arterial trunk of descending.
the lower extremity. The medial circumflex femoral artery has
BeginningThe artery begins deep to mid- a very short course in femoral triangle. It
inguinal point as continuation of external iliac leaves the triangle between psoas
artery. major and pectineus.
CourseThe femoral artery descends almost In the adductor canal
vertically in the femoral triangle up to its apex. IV. The descending genicular branch
The lower part of the artery descends in the descends from adductor canal and joins
adductor canal, medial to the shaft of the anasto-mosis around the knee joint.
femur.
In femoral triangle, the femoral artery lies The Veins
quite superficially on the muscles of the The venous return from the front of thigh is by
floorpsoas major, pectineus and two sets of veinssuperficial and deep.
adductor longus A. The superficial veins
In adductor canal it is separated from shaft The long saphenous veinis the longest
of femur by vastus medialis. superficial vein in the body.
TerminationThe femoral artery passes CourseIt ascends on the medial side of
through the hiatus magnus and enters the knee and then gradually ascends a
popliteal fossa as popliteal artery. little laterally to reach the saphenous
Branches opening in upper part of front of thigh.
In the femoral triangle. There are many valves in long
I. The three superficial branches saphenous vein that direct the venous
a. Superficial external pudendal passes blood, against gravity upwards.
medially to supply external genitals TerminationThe long saphenous vein
b. Superficial epigastric is directed up-wards pierces the cribriform fascia by hooking
and medially in anterior abdominal around lower sharp margin of saphenous
wall towards umbilicus opening and ends in femoral vein.
c. Superficial circumflex iliac: passes late- Tributaries
rally towards iliac crest. I. Three superficial veins that
II. The deep external pudendalpasses accompany the three superficial
medi-ally deep to femoral vein to supply branches of femoral artery.
external genitals. Superficial external pudendal
III. The profunda femoris arteryis a large Superficial epigastric
branch that arises from lateral side of Superficial circumflex iliac
highest part of the femoral artery. II. Other superficial veins from the front
The profunda artery gives two bran- of thigh
cheslateral and medial circumflex III. Perforating veins that connect the long
femoraland leaves the triangle by saphenous vein to the deep veins of
passing deep to adductor longus. front of thigh.
150 Essentials of Human Anatomy
The Nerves of the Medial Compartment The nerve arises from the lumbar plexus
taking its origin from ventral divisions of
1. The obturator nerve is a branch of lumbar
plexus and arises from ventral divisions of ventral rami of L3 and L4 nerves.
ventral rami of L2, L3 and L4 nerves. CourseThe accessory obturator nerve
CourseIt enters medial compartment of descends superficial to the superior ramis
thigh through upper part of obturator fora- of pubis, medial to psoas major muscle.
men along with obturator vessels. Branches
As it passes through the obturator fora- I. Muscular branch to
men, it divides into an anterior and a Pectineus
posterior branch. II. Articular branch to hip joint
a. The anterior branchdescends in [Sometimes the nerve may take up the
the medial compartment of thigh supply of anterior division of obturator
between adductor longus and pecti- nerve].
neus superficially and adductor
THE POSTERIOR COMPARTMENT
brevis deep to it.
b. The posterior branchdescends in OF THE THIGH
the medial compartment between The posterior compartment of the thigh is also
adductor brevis and adductor mag- known as the flexor compartment of the thigh.
nus. 1. The muscles of the posterior compartment are
Branches (Fig. 17.5 and Table 17.3):
From the anterior division i. Biceps femoris
I. Muscular branches supply ii. Semi-tendinosus
Adductor longus iii. Semi-membranosus
Adductor brevis iv. Ischial part of adductor magnus (described
Gracilis earlier)
Pectineus (sometimes) These muscles are known as hamstring muscles.
II. Cutaneous branches supply Their common features are:
Skin of medial side of thigh a. These muscles take origin from the ischial
Subsartorial plexus: a plexus of tuberosity.
cutaneous nerves deep to sartorius b. These muscles are inserted in one of the
formed by three nerves: bones of leg.
Saphenous c. The nerve supply of hamstring muscles is
Medial femoral cutaneous by the tibial nerve [part of sciatic nerve]
Anterior division of d. The hamstring muscles are flexors of the
obturator III.Articular to hip joint knee joint and extensors of the hip joint.
IV. Vascular to femoral artery
From the posterior division The Blood Vessels of the
I. Muscular branches supply Posterior Compartment
Obturator externus The blood supply of the posterior
Adductor magnus (adductor part) compartments is done by a chain of arterial
II. Articular to knee joint anastomosis at the back of thigh.
2. The accessory obturator nerve is a small This anastomosis supplies the muscles and
nerve that is sometimes present. skin of the back of thigh.
156 Essentials of Human Anatomy
Fig. 17.5: The muscles of gluteal region and posterior compartment of leg
The following arteries take part in this anasto- a. The tibial nerveL4,L5,S1,S2,S3
mosis: (ventral divisions of ventral rami).
i. The descending branch of inferior gluteal b. The common peroneal nerveL4,
artery L5,S1,S2 (dorsal divisions of ventral
ii. The ascending and descending branches of rami).
the four perforating branches of profunda Course in posterior compartment
femoris artery. The sciatic nerve as it descends lies deep
iii. The superior muscular branches of to biceps femoris and superficial to
popliteal artery. adductor magnus.
It bifurcates about the middle of back of
The Nerves of the Posterior thigh into its two terminal branches the
Compartment tibial and common peroneal nerves.
1. The sciatic nerveDescends in the posterior The two branches enter the popliteal
compartment from the gluteal region. fossat the back of knee.
OriginThe sciatic nerve is a composite Branches
nerve made up of two separate nerves I. The muscular branches from the tibial
enclosed in a common sheath. nerve part are
The Region of the Thigh 157
Table 17.3: The muscles of the posterior compartment
Name Origin Muscle belly Insertion Nerve supply Main actions
1. Biceps Two heads
femoris a. Long head arises from The long head forms Lateral surface Long head-tibial I. It flexes the knee
lower medial area of a funiform muscle head of fibula Short head- joint
ischial tuberosity in belly, joined by short The tendon is common pero- II. It helps in exten-
conjunction with semi- head grooved by neal L5, S1, S2 sion of hip joint
tendinosis Forms a narrow ten- fibular colla- III. It helps in lateral
b. Short head from don, that passes teral ligament rotation of leg
lateral lip of aspera laterally
2. Semi- Lower medial part of Fusiform muscle badly Upper part Tibial I. It flexes the knee
tendino- ischial tuberosity in Gives rise to a long medial surface L5, S1, S2 joint
sus conjunction with long tendon in middle of of tibia, behind II. It helps in exten-
head of biceps femosis thigh gracilis and sion of hip joint
sartorius III. It helps in medial
rotation of leg
3. Semi- Upper lateral part of Upper half of muscle Groove on Tibial
mem- ischial tuberosity brano- L,S
is aponeurotic posterior 5 1,2 I. It flexes the knee
Lower half is muscular aspect medial joint
sus Lower end forms a condyle of tibia II. It helps in exten-
tendon Two expansions sion of hip joint
given from III. It helps in medial
insertion rotation of leg
a. Fascia conver-
ing popliteus
b. Oblique popli-
teal ligament
of knee joint
IV. The common peroneal nerve and its branches Inferior medial genicular
V. Popliteal lymph nodes Inferior lateral genicular
VI. Fibro-fatty tissue Middle genicular
II. The popliteal vein is formed at the lower
Applied Anatomy border of popliteus by the union of venae
a. The aneurysm of popliteal artery forms a comitantes of anterior tibial and posterior
pulsatile tumor behind the knee. It can be tibial arteries.
surgically treated by ligating femoral artery in The popliteal vein ascends in the popliteal
the adductor canal. fossa first medial, then posterior and findly
b. The popliteal artery can be compressed against postero-lateral to the popliteal artery.
the popliteus muscle, when the knee is flexed. The popliteal vein passes through hiatus
magnus and continues as femoral vein in
I. The popliteal artery is the main arterial trunk adductor canal.
of the lower limb in the popliteal fossa. Tributaries
BeginningThe popliteal artery begins at a. The veins accompanying the branches
the hiatus magnus (in adductor magnus of popliteal artery.
muscle) as continuation of femoral artery. b. The short saphenous vein.
CourseThe artery descends in the deep III. The tibial nerve is the larger terminal branch
part of the fossa with a lateral inclination. of sciatic nerve arising from ventral divisions
The artery passes between the two con- of ventral rami of L4,L5,S1,S2, and S3 nerves.
dyles of femur at the back of knee joint. The tibial nerve begins, about the middle
The artery descends on fascia covering of back of thigh, by bifurcation of sciatic
popliteus, overlapped by gastrocnemius nerve.
The artery is crossed from behind by the Course: The tibial nerve descends
popliteal vein and the tibial nerve. vertically in the popliteal fossa, from its
Termination At the lower border of upper angle, lying superficial to popliteal
popliteus, the popliteal artery bifurcates vesels in between two femoral condyles.
into its two terminal branches: the anterior At the lower border of popliteus, the
tibial and posterior tibial arteries. tibial nerve enters the back of leg.
Branches Branches in popliteal fossa
a. The muscular branches I. The muscular branches are five and
they are given in the lower part of
The superior muscular branches
popliteal fossa to:
supply the hamstring muscles at
Medial head of gastrocnemius
back of thigh.
Lateral head of gastrocnemius
The inferior muscular branches Plantaris
supply the muscles of calf. Soleus
b. The cutaneous branches supply the skin Popliteus
of the back of leg. II. The cutaneous branch is:
c. The genicular branches (five) pass deep Sural nerve
to the muscles of side boundaries and III. The genicular (articular) branches are
take part in anastomosis around the Superior medial
knee joint. Middle
Superior medial genicular Inferior medial
Superior lateral genicular They supply the knee joint.
160 Essentials of Human Anatomy
IV. The common peroneal nerve is the Branches in the popliteal fossa
smaller terminal branch of sciatic nerve, I. The genicular (articular) branches are:
arising from dorsal division of ventral Superior lateral
rami of L4, L5, S1, and S2 nerves. Inferior lateral
The common peroneal nerve begins They supply the knee joint.
about the middle of back of thigh, II. The cutaneous branches are:
by bifurcation of sciatic nerve. The lateral cutaneous nerve of calf
Course: The nerve enters popliteal fossa Sural communicating
lateral to the tibial nerve. III.The terminal branches
The common peroneal nerve inclines The superficial peroneal nerve
The deep peroneal nerve
laterally, and follows the medial
Applied anatomy
border of biceps femoris muscle.
In case of fracture of neck of fibula, the
The nerve curves around the lateral
common peroneal nerve may be
surface of neck of fibula. injured.
The common peroneal nerve terminates Effects of injury
in the substance of peroneus longus I. Paralysis of extensors and evertors of
muscle by dividing into two terminal foot. This condition leads to Foot
branches: the superficial and deep drop.
peroneal nerves. It gives a recurrent II. Loss of skin sensations on lateral side
genicular branch near termination. and back of leg and dorsum of foot.
CHAPTER 18
The Region
of the Leg
The region of the leg is divided into three osseo-
fascial compartment by the deep fascia of the leg
and two inter-muscular septa, anterior and
posterior:
1. The anterior (extensor) compartment
2. The lateral (peroneal) compartment
3. The posterior (flexor) compartment
ii. The posterior tibial recurrent also moses with anterior lateral malleolar
takes part in the anastomosis branch of anterior tibial artery.
around knee joint The perforating branch of peroneal
iii. Many small muscular branches artery may be enlarged sometimes, and
supply the extensor muscles. may continue as dorsalis pedis artery.
iv. The anterior medial malleolar The Veins
branch passes medially deep to the The superficial veins
extensor tendons and anastomoses The long saphenous vein ascends
with branches of posterior tibial along the medial border of tibia and
artery. receives the superficial veins from
v. The anterior lateral malleolar the front of leg:
branch passes laterally, deep to the The deep veins
extensor tendons and anastomoses The anterior tibial artery is accom-
with branches of peroneal artery. panied by a pair of venae comitantes,
B. The perforating branch of peroneal artery: that are continuation of the paired
pierces the interosseous membrane about 5.0 venae comitantes accompanying
cm proximal to the lateral malleolus and dorsalis pedis artery.
enters the anterior compartment. The perforating branch of peroneal
Course:The artery descends in front of artery is also accompanied by a
inferior tibio-fibular joint and anasto- pair of venae comitantes.
The Region of the Leg 163
The Veins
A. The superficial veins
a. The long saphenous vein is formed on the
dorsum of foot, from the medial end of
dorsal venous arch of foot.
Course: The long saphenous vein
ascends on front of medial malleolus,
and then along medial border of tibia,
Fig. 18.3: The posterior compartment of leg accompanied by saphenous nerve.
the deep muscles of calf The vein lies on the medial side of
b. The peroneal artery is a large branch knee and ascends a little laterally to
given from uppermost part of the artery. the front of thigh.
Course: The peroneal artery descends The long saphenous vein has about
along the medial crest of fibula twelve valves in the leg part.
between tibialis posterior and flexor Tributaries
hallucis longus. i. The superficial veins from the leg.
It terminates as lateral calcaneal ii. The perforating veins which piece
branches. the calf muscles and joint with deep
Branches veins of the posterior compartment.
i. Muscular branches supply the b. The short saphenous veins begin behind
muscles of calf and curve laterally lateral malleolus as continuation of lateral
to supply the peroneal muscles. side of dorsal venous arch joining with
ii. Perforating branch is given in lateral marginal vein from little toe.
distal part of leg. It pierces Course: The vein ascends behind
interosseous membrane and enters lateral malleolus and then on
anterior compartment of leg. posterolateral aspect of the leg.
iii. Nutrient artery is given to fibula. It pierces the deep fascia of roof of
iv. Communicating branch is given to popliteal fossa and terminates in
posterior tibial artery. popliteal vein.
The Region of the Leg 167
Structures passing deep to retinaculum (from The Blood on the Dorsum of Foot
medial side) The Arteries
i. Tendon of tibialis anterior
ii. Tendon of extensor hallucis longus The dorsals pedis artery is the continuation of
iii. Anterior tibial artery. anterior tibial artery on the dorsum of foot.
iv. Deep peroneal nerve Beginning The dorsalis pedis artery begins on
the front of ankle joint below the superior
v. Tendon of flexor digitorum longus
extensor retinaculum.
vi. Tendon of peroneus tertius.
Course The artery passes distally on the
The inferior extensor retinaculum is a thick Y- dorsum of foot lying between the tendons of
shaped band of deep fascia, just below ankle joint extensor hallucis longus, medially and
on the dorsum of foot. extensor digitorum longus laterally.
Attachments The dorsalis pedis artery is accompanied by
Lateral end (stem) is attached to superior deep peroneal nerve and its medial
surface of calcaneum. terminal branch on its lateral side.
The artery can be compressed against the
Proximal band is attached to the medial
tarsal bone for feeling the pulse.
malleolus.
Termination The artery passes between the
Distal band is attached to the deep fascia two heads of first dorsal interosseous muscle
of sole. and enters the sole.
The extensor tendons pass through the loops in In the sole the dorsalis pedis artery joins the
the retinaculum, while the anterior tibial vessels and lateral plantar artery to complete the
peroneal nerve lie behind the retinaculum. plantar arterial arch.
170 Essentials of Human Anatomy
The Veins
The superficial veins
The dorsal venous arch on dorsum of foot
recieves the dorsal metatarsal veins that are
formed by the dorsal digital veins, draining
the sides of the toes.
On either side there are medial and lateral
marginal veins from the big toe and little
toe.
The long saphenous vein begins from the
medial end of dorsal venous arch
The short saphenous vein begins from the
lateral end of dorsal venous arch. Fig. 19.2: The cutaneous supply of the dorsum of foot
The Region of the Foot 171
Contd...
Name Origin Muscle belly Insertion Nerve supply Main actions
3. Flexor Base of fifth metatarsal Slender muscle belly Lateral side of base Lateral plantar I. Helps in flexion of
digiti of proximal pha- (superficial little toe
minimi lanx of little toe branch) (S2, S3)
brevis
D. Fourth layer
1. Dorsal Adjacent sides of meta- Bipennate muscle Bases of proximal First, Second,
interossei tarsal bones bellies, fills up gaps phalanges and dor- Third
(Four between meta- sal digital expan- Lateral plantar I. Abductors of toes
bellies) tarsals sion of toes (deep branch) from neutral axis
A fibrous arch between First on medial (S2, S3) of second toe
two heads at proximal Second and third Fourth dorsal II. First and second
end of inter-metatarsals on lateral sides of interosseous (by cause medial and
spaces third toe superficial branch lateral abduction
Fourth on lateral lateral plantar) of second toe
side of fifth toe III. Flexion of meta-
tarso-phalangeal
and extension of
inter-phalalangeal
joints
2. Plantar Bases and medial sides Unipennate, slender Medial sides bases First and I. Adductors of third
interossei of third, fourth and muscle bellies and dorsal digital Second by fourth and fifth
(three fifth metatarsals Tendons pass on expansions of lateral plantar toes towards the
bellies) medial sides of third, third, fourth, fifth (deep branch) neutral axis of
fourth, and fifth toes toes second toe
Third by lateral II. Flexor of meta-
plantar (super- tarso-phalangeal
ficial branch) and extensor of
(S2, S3) inter-phalangeal
joint of third,
fourth, and fifth
toes.
The tendons are those of flexor digitorum The Blood Vessels of the Sole
longus and flexor hallucis longus The Arteries
C. The third layer has three muscles (Fig. 19.6) a. The medial plantar artery is the smaller
terminal branch of posterior tibial artery.
Flexor hallucis brevis Origin: The artery arises deep to flexor
Adductor hallucis retinaculum of ankle where the posterior
Flexor digiti minimi brevis tibial artery divides.
D. The fourth layer has two sets of muscles and Course: The medial plantar enters the
two tendons (Fig. 19.7) sole, by passing distally deep to abductor
hallucis and plantar aponeurosis, with
The muscles are four dorsal interossei and medial plantar nerve lateral to it
three planter interossei The artery appears in the gap between
The tendons are peroneus longus tendon, abductor hallucis and flexor digitorum
and tibialis posterior tendon. brevis and divides into branches.
The Region of the Foot 175
4. For giving deep intramuscular injection, which 10. The movements of inversion and eversion
quadrant of gluteus maximus is preferred: of foot that take place at:
A. Inferior tibiofibular joint
A. Upper medial quadrant
B. Ankle joint
B. Upper lateral quadrant
C. Subtalar joint
C. Lower medial quadrant
D. Subtalar and mid-tarsal joints
D. Lower lateral quadrant
Q.2. Each question below contains four
5. The following structure passes through sugges-ted answers, of which one or more
greater sciatic foramen: is correct, choose the answers
A. Superior gluteal nerve A. If 1, 2 and 3 are correct
B. Obturator internus tendon B. If 1 and 3 are correct
C. Obturator externus C. If 2 and 4 are correct
D. Gluteus minimus muscle D. If only 4 is correct.
6. The tear of the menisci usually results from E. If 1,2,3 and 4 are correct
the following conditions of the knee joint: 11. The muscles inserted on greater trochanter
A. Rotation in partial flexion of femur are:
B. Rotation in full extension 1. Gluteus medius
Multiple Choice Questions 179
Answers
tibialis posterior. The long saphenous vein stability of ankle joint. The spring ligament
ascends in front of medial malleolus. The plays a role in maintaining medial
flexor hallucis longus tendon lies most longitudinal arch of foot. The calcaneo-
posteriorly deep to flexor retinaculum. fibular ligament is a weak ligament.
A10. The answer is D. A16. The answer is C, (2, 4).
The movements of inversion and eversion take The femoral vessels and the saphenous
place at subtalar and mid-tarsal joints. The nerve are the contents of the adductor canal.
inferior tibio-fibular joint is a syndesmosis,
The obturator nerve lies in the medial
where hardly any movements take place. The
compartment of thigh. The long saphenous
ankle joint is a pure hinge type of joint where
vein is a superficial vein lying on medial
only dorsiflexion and plantar flexion occur.
aspect of knee and thigh.
A11. The answer is A, (1, 2, 3).
A17. The answer is B, (1, 3).
The three muscles inserted on greater
trochanter are gluteus medius, piriformis The muscles helping in abduction at the hip
and gluteus minimus. The gluteus maximus joint are gluteus medius and gluteus
is inserted on gluteal tuberosity of femur minimus. Piriformis is a short lateral rotator
and iliotibial tract. of hip joint. Obturator externus also helps
in lateral rotation of hip joint.
A12. The answer is B, (1, 3).
The biceps femoris forms the upper lateral A18. The answer is C, (2, 4).
boundary and the semi-membranosus forms The medial longitudinal arch of foot is
the upper medial boundary. The quadratus maintained by tibialis posterior and the
femoris is a deep muscle of gluteal region. spring ligament. The peroneus longus helps
The peroneus longus lies in the lateral in maintaining lateral longitudinal arch of
compartment of leg. foot. The tendo-calcaneus is a strong
A13. The answer is E, (1, 2, 3, 4). plantar-flexor of the foot.
All the four musclestibialis anterior, A19. The answer is A, (1, 2, 3).
exten-sor hallucis longus, extensor The three muscles that act both on hip joint
digitorum longus and peroneus tertius and knee joint are biceps femoris, sartorius
belong to the extensor compartment of leg.
and rectus femoris. The adductor magnus
A14. The answer is C, (2, 4). acts only on hip joint.
The two muscles supplied by tibial portion
A20. The answer is B, (1, 3).
of sciatic nerve in back of thigh are long
head of biceps femoris and semitendinosus. The dorsalis pedis artery enters sole by
The short head of biceps femoris is supplied passing between the two heads of first
by the common peroneal part of sciatic dorsal intrerosseous muscle and between
nerve. The vastus lateral is a muscle of the bases of first and second metatarsals.
extensor compartment of thigh, supplied by A21. The answers are C,D,B,A.
femoral nerve. The foot drop, is a caused by injury to
A15. The answer is B, (1, 3). common peroneal nerve.
The shape of trochlear surface of talus and The lurching joint is symptom of para-
deltoid ligament are responsible for the lysis of gluteus medius.
182 Essentials of Human Anatomy
THE STERNUM
General Features
The sternum forms the front of thoracic cage and
consists of three parts manubrium, body and
xiphisternum (Figs 20.1 and 20.2)
i. The manubrium sterni - (upper part) has a thick
upper border called supra - sternal notch
Its posterior surface is related to arch of
aorta its three large branches and two
brachiocephalic veins.
The manubrium articulates with body
of sternum below forming manubrio-
sternal joint, that is marked in front by Fig. 20.1: The sternumanterior aspect
184 Essentials of Human Anatomy
Ossification
Sternum is formed by fusion of two carti-
laginous sternal plates. Incomplete fusion
leads to a sternal foramen.
Manubrium sterni ossifies from one to three
centers appearing in third to fifth month of
intrauterine life.
Fig. 20.2: The sternumposterior aspect First and second pieces (sternebrae) ossify at
the same time by one center each.
It has an anterior surface and a Third and fourth pieces of sternum usually
posterior surface. ossify by two centers each that appear in fifth
Laterally, the body of sternum has and sixth months.
facets for articulation with 2nd to 7th Xiphoid process ossifies by one center
costal cartilages. appearing in third year.
The lower end of body of sternum arti- The fusion of pieces of sternum begins at
culates with xiphisternum at the xiphi-
puberty and is completed by twentyfifth year.
sternal joint.
The body of sternum is a favourite site
THE RIBS
for bone-marrows aspiration, as the
bone is quite superficial and there is not General Features
much fat covering it.
iii. The xiphisternum (lower part) is variable in There are twelve pairs of ribs in the thoracic cage.
size and shape and may be perforated. The ribs are classified as:
It has an anterior and a posterior a. The true ribs (vertebro-sternal) are first to
surface and fuses with body of sternum seventh. They articulate with sides of sternum
after the age of forty years. in front, through costal cartilages and sides of
thoracic vertebrae behind.
Special Features b. The false ribs are those which do not reach
[Muscles attached to the sternum] the sides of sternum in front. The false ribs
Anterior surface of manubrium sterni - sterno- are further subdivided as:
mastoid i. The vertebro-costal ribs ribs are eighth,
Posterior surface of manubrium sterni - ninth and tenth. These articulate with next
Upper part - Sternohyoid higher cartilage in front and sides of
Lower part - Sternothyroid thoracic vertebrae behind.
The Bones and Joints of Thorax 185
ii. The vertebral ribs are eleventh and twelfth. The inner surface is smooth and
They only articulate with sides of thoracic related to pleura. There is a costal
vertebrae. Their anterior ends are free, hence groove lying along the lower border on
they are known as floating ribs also. the inner surface. It lodges the
The ribs are further classified as: intercostal vein, artery and nerve.
a. The typical ribs that show all typical common The angle is present posteriorly, where
features. The third to ninth are typical ribs. the shaft changes its direction.
b. The atypical ribs are those that show some
b. The atypical ribs (Fig. 20.4)
atypical features, the first, second, tenth,
eleventh, and twelfth are atypical ribs. i. The first rib is short and wide.
a. A typical rib has a head, a neck, a tubercle It has a superior surface, that shows
and a shaft (Fig. 20.3) grooves for the subclavian artery and
i. The head is expanded posterior end of the vein separated by a ridge.
rib, that articulates with sides of corres- The inferior surface is smooth and
ponding vertebra and next higher vertebra related to pleura.
to form costo-vertebral joint. On the inner border of first rib there is
It presents two facets separated by a scalene tubercle for insertion of
ridge. scalenus anterior.
ii. The neck is the narrow portion between There is no angle in the shaft of first rib.
head and the tubercle. There is no costal groove in first rib.
iii. The tubercle has an articular facet for
It articulates with side of first thoracic
articulating with facet on tip of transverse
vertebra only posteriorly.
process of corresponding vertebra.
It has a non-articular facet for attach- ii. The second rib has an upper surface that
ment of lateral costo-transverse-liga- faces partly outwards, and a lower surface
ment. that faces inwards (Fig. 20.5).
iv. The shaft has an upper thick border and a It has a shallow costal groove
sharp lower border. The shaft is curved The head of second rib articulates
The outer surface is rough for attach- posteriorly with sides of first and
ment of muscle. second thoracic vertebra.
Fig. 20.5: The second rib-superior aspect Fig. 20.7: The twelfth ribposterior aspect
The Bones and Joints of Thorax 187
There are three secondary centersone for The third to seventh costal cartilages
head, one each for articular and nonarticular articulate with side of body of sternum
part of tubercle. These centers appear at forming synovial joints.
puberty. The eighth, ninth, and tenth costal cartilages
First rib has only two secondary centersone articulate with next higher costal cartilage
for head and one for tubercle. forming synovial joints.
Eleventh and twelfth ribs have only one The eleventh and twelfth costal cartilages are
secondary center for the head. present on anterior ends of their ribs.
The secondary centers appear at puberty and
fuse by twentieth year. The Thoracic Vertebrae
It makes joints with adjacent vertebrae The vertebral arch has also two paired articular
at the intervertebral discs. processes to articulate with adjacent vertebrae.
The sides of the body have two costal The superior articular facet faces
demifacets for articulating with heads posteriorly and articulates with inferior
of the ribs. articular facet of next higher vertebra.
The upper costal demifacet is larger The inferior articular facet faces anteriorly
and articulates with the head of and articulates with superior articular facet
same or corresponding rib. of next lower vertebra.
The lower costal demifacet is There is an intervertebral notch at the inferior
smaller and articulates with the border of pedicle.
head of next lower rib. This together with similar small notch on
II. The vertebral arch encloses a vertebral the superior border of pedicle of next
canal in which spinal cord lies along with lower vertebra completes the
its meninges. The vertebral arch is made intervertebral foramen, through which the
up of: spinal nerve leaves the vertebral canal.
Two pedicles anteriorly b. The atypical thoracic vertebrae (Fig. 20.10)
Two laminae posteriorly I. The first thoracic vertebra has a complete,
The spinous process (vertebral spine) arises in round upper costal facet for head of first
midline where the two laminae, meet rib. The lower costal demifacet, however,
posteriorly. The spines of thoracic vertebrae is incomplete for the head of second rib.
are long and slope downwards The spinous process of first thoracic
Two transverse processes arise on either side vertebra is horizontal and not sloping.
from the junction of pedicles and laminae. II. The ninth thoracic vertebra has only
They have facets on their tips for articulating upper costal demifacet for ninth rib.
with tubercles of the ribs. There is no lower costal facet for tenth rib.
The Bones and Joints of Thorax 189
Ossification
The thoracic vertebrae are ossified by three
primary centersone for body (centrum) and
two for each half of vertebral arch. The center
for body appears early and for the arch appear
a little later in ninth to tenth week.
There are five secondary centers
Two for superior and inferior surface of
body of vertebra
Two for apex of transverse processes
One for the spinous process.
These centers appear at puberty and fuse by
twentyfifth year.
bodies only. They have plane type of synovial laterally, and to the intervertebral disc
joints. medially.
The second to ninth rib articulate with sides of
bodies of two vertebraecorresponding
II. The Costo-Transverse Joints
vertebrae and next higher vertebrae. These The costo-transverse joints are joints between the
ribs have plane type of double synovial facets on tips of transverse processes of thoracic
joints with an intra-articular ligament. vertebrae and tubercles of the ribs (Fig. 20.12)
The articular capsule surrounds the joint, and The elventh and twelfth ribs have no tubercles,
is reinforced by ligaments. hence they have no costo-transverse joints.
The ligaments of the joint are Type
a. Radiate ligament strengthens the anterior- Plane type of synovial joints
aspect of the articular capsule. In relation to upper six thoracic ribs the
It is attached just beyond the head and joint surfaces are slightly curved reci-
has three sets of fibers. procally.
Upper fibers reach the side of vertebra
above
Middle fibers are short and attached to
the intervertebral disc
Lower fibers reach the side of the
vertebra below
b. The intra-articular ligament is present in
costovertebral joints of second to ninth-
ribs that have double joint cavities.
It is attached to the crest between the
two demifacets on the heads of ribs Fig. 20.12: The costo-transverse joints
The Bones and Joints of Thorax 191
The herniated nucleus pulposus may press Remains of thymus, inferior thyroid
upon adjacent nerve roots causing back veins
pain called sciatica Trachea and oesophagus
This condition is quite common in lower Left recurrent laryngeal nerve
lumbar region. Thoracic duct
B. On right side
THE INLET OF THORAX In front of neck of first rib
The inlet of thorax is the opening through which Sympathetic chain
the thorax communicates with root of the neck. First posterior intercostal vein
Shapekidney shaped Superior intercostal artery
Plane of inlet is sloping downwards and Ventral ramus of first thoracic nerve
forwards from upper border of first thoracic Internal thoracic artery and vein ante-
vertebra to supra-sternal notch. riorly
Boundaries Brachiocephalic artery
Posteriorly Upper border of first thoracic Right brachiocephalic vein
vertebra Right vagus and right phrenic nerves
Anteriorly Upper border of manubrium C. On left side
sterni (supra-sternal notch) Four structures crossing front of neck of
On two sides Inner border of first rib and first rib (same as on right side)
costal cartilage. Internal thoracic artery and vein
Structures passing through inlet of Left common carotid artery
thorax A. Midline structures Left subclavian artery
Lower parts sternohyoid, sternothyroid Left brachiocephalic vein
and longus colli muscles Left vagus and left phrenic nerves.
CHAPTER 21
The Musculature of
the Thoracic Wall
THE EXTRINSIC MUSCLES The scalene muscles elevate first and second
These muscles are attached to the external surface ribs during deep inspiration.
of thoracic cage. They help in the movements of
THE INTRINSIC MUSCLES
shoulder girdle, upper extremity and the neck.
Some of these muscles also help to a great The intrinsic muscles consist of three layers of
extent in the respiratory movements of thoracic intercostal muscles, that fill up the intercostal
cage. spaces.
I. The pectoralis major connects medial half of a. The outer layer has external intercostal
clavicle, upper six costal cartilages and front muscles (Fig. 21.1).
of sternum to the lateral lip of bicipital groove b. The intermediate layer has internal intercostal
of humerus. muscles
The muscle elevates upper six ribs during c. The inner layer is incomplete and consists of i.
forced inspiration. Sternocostals (transversus thoracic)
II. The pectoralis minor connects third, fourth, anteriorly
and fifth ribs to coracoid process of scapula. ii. Innermost intercostal (intercostalis
It helps to elevate third, fourth, and fifth intimus) located in middle two-fourth part
ribs during deep inspiration. of inter-costal space
III. The sterno-cleidomastoid muscle passes from iii. Subcostalisposteriorly.
manubrium sterni and medial one-third of
clavicle to mastoid process and superior The External Intercostal Muscles
nuchal line of skull.
There are eleven pairs of external intercostals
It elevates manubrium sterni
IV. The scalene muscles filling up all eleven intercostal spaces.
a. The scalenus anterior connects anterior
tubercles of transverse processes of third
to sixth cervical vertebrae to scalene
tubercle of first rib
b. The scalenus medius connects posterior
tubercles of transverse processes of second
to sixth cervical vertebrae to first rib
c. The scalenus posterior (when present)
connects posterior tubercles of transverse
processes of fifth and sixth cervical verte- Fig. 21.1: Part of thoracic wall showing
brae to second rib. three layers of muscles
The Musculature of the Thoracic Wall 195
Attachments Attachments
UpperSharp inferior border of the rib Upperthe floor of the costal groove of the
above rib above
LowerOuter edge of thick superior border Lowermiddle part of thick superior
of the rib below border of rib below
Extent Extent
AnteriorlyThe external intercostal extends AnteriorlyThe muscle extends up to the
up to costo-chondral junction. It is replaced side of sternum
in between the costal cartilages by anterior PosteriorlyIt extents up to the angle of
(external) intercostal membrane the rib, beyond that it is replaced by
PosteriorlyThe muscle extends up to the internal (posterior) intercostal membrane
posterior end of the intercostal space. Direction of fibers is upwards, forwards and
Direction of fibersis downwards forwards medially in anterior part of chest wall, nearly
and medially in front of chest wall. at right angles to the fibers of external
Nerve supplyis by the corresponding inter- intercostal muscle.
costal nerve (i.e. ventral ramus of thoracic Nerve supplyis by the corresponding inter-
nerve) costal nerve (ventral ramus of thoracic nerve).
ActionsElevation of the rib during inspiration. Actions
i. The intra-cartilaginous part helps to
The Internal Intercostal Muscles
elevate the anterior ends of the rib.
There are eleven pairs of internal intercostal ii. The rest of the muscle helps in depression
muscles, that fill up all eleven intercostal spaces. of the rib (Fig. 21.2).
Fig. 21.2: TS thoracic wall showing intercostal muscles and intercostal arteries
196 Essentials of Human Anatomy
pectoralis major and its fascia and comes border of rib below. It may rejoin the
out as the anterior cutaneous nerve. parent stem.
Branches b. Small muscular branches supply the
I. The communicating branches are two and three layers of intercostal muscles,
connect the intercostal nerve to the corres- sub-costalis and sterno-costalis.
ponding sympathetic ganglion. III. The cutaneous branches are twolateral
a. The white ramus communicans (WRC)
cutaneous and anterior cutaneous.
lies laterally and contains
a. The lateral cutaneous branches
preganglionic sympathetic fibers from
pierces the muscles along mid-axillary
the nerve to the ganglion.
b. The grey ramus communicans (GRC) line and divides into anterior and
lies medially and contains posterior branches to supply skin of
postganglionic sympathetic fibers from lateral part of thoracic wall.
the ganglion to the intercostal nerve. b. The anterior cutaneous branch pierces
II. The muscular branches are two the muscles, about 1.2 cm lateral to the
collateral and smaller muscular branches sternum. It divides into a medial and a
a. The collateral branch is given near the lateral branch to supply skin of
angle of the rib, and runs along the upper anterior part of thoracic wall.
CHAPTER 22
The Pleura and
Lungs
THE PLEURA d. Mediastinal pleuralines the lateral
The pleura is a closed serous sac, that surface of mediastinum.
surrounds lung on all sides, except the hilum. 2. The visceral pleura (pulmonary pleura) lines
The pleura consists of two layers: parietal and the outer surface of lung intimately. It lines
the fissures of the lung, but does not cover the
visceral.
hilum:the site on the medial surface
1. The parietal pleura is the layer that lines the
where the lung root is attached.
inner surface of thoracic cavity, beneath
endothoracic fascia. The Lines of Pleural Reflection
The parietal pleura is named according to (Fig. 22.1)
its position in thoracic wall:
a. Cervical pleurabulges in the root of The lines of leural reflection indicate on the
neck through inlet of thorax (dome of surface of thorax, the extent of pleural sacs.
pleura)
b. Costal pleuralines the inner surface I. The Anterior Lines of Pleural Reflection
of ribs and intercostal spaces separated It begins from the dome of pleura at the
by endothoracic fascia. neck about 2.5 cm above the junction
c. Diaphragmatic pleura lines the superior between the middle and medial third of
surface of diaphragm. clavicle.
From this point, at lower border of neck of The Pleural Recesses (Fig. 22.2)
first rib the line passes downwards and
The Pleural sacs are larger in size than the lungs.
medially through sterno-clavicular joint,
The pleural recesses are the spaces between
to reach the sternal angle by side of
two layers of parietal pleura, in the pleural
median plane.
cavities, that are not filled up by the lungs
On right sidethe anterior line of pleural
during quiet inspiration.
reflection passes vertically up to level of
In deep inspiration, the lungs tend to occupy
xiphisternal joint from here. It may reach
the pleural recesses, but they never fill up
below costal margin of right costo-sternal
these recesses completely.
angle. An incision beginning at this angle
There are three pleural recesses:
may injure right pleura. i. Right costo-diaphragmatic recess
On left sidethe anterior line passes
ii. Left costo-diaphragmatic recess
vertically from sternal angle up to the level iii. Left costo-mediastinal recess
of fourth costal cartilage. Then it describes The costo-diaphragmatic recesses are lower
a cardiac notch and descends along left parts of the pleural cavities.
sternal margin up to the sternal end of left These recesses lie between lower margin of
sixth (or seventh) costal cartilage. It does not lungs (two ribs higher) and lower margin of
descends below costal margin. pleural sacs.
Here the costal pleura lies in contact with
II. The Inferior Lines of Pleural Reflection diaphragmatic pleura. These are most
The inferior lines of pleural reflection lie superior dependent parts of pleural cavities, when a
to the costal margin, except on right side at the person is standing erect.
right costo-sternal angle. Fluid may collect in the recess and obliterate
It begins on right side at xiphisternal joint and the recess.
on left side at sternal end of sixth (or seventh) In X-ray of chest, these recesses appear as
costal cartilage. costo-diaphragmatic angles.
It crosses eighth rib at mid-clavicular line The left costo-mediastinal recess is a part of
approximately at costo-chondral junction. left pleural cavity.
It crosses tenth rib at mid-axillary line and
middle of shaft of eleventh rib.
Finally it crosses twelfth rib and reaches the
side of twelfth thoracic vertebra.
On both sides, inferior lines of pleural
reflection descend below costal margins by
the side of twelfth thoracic vertebra forming
right and left costo-vertebral angles.
It is formed because cardiac notch of left lung is III. The pleural recesses are potential spaces of
deeper than cardiac notch of left pleural sac. the pleural cavities, that provide additional
Here the costal pleura lies in contact with the space for lungs to expand in deep inspiration.
mediastinal pleura lining the pericardium.
The depth of this recess is variable. Applied Anatomy
A needle inserted medial to the recess (just by 1. Pleurisyis inflammation of parietal pleura:
side of sternal margin) will avoid pleura and It can be dry pleurisy: causing pain in the
reach pericardial cavity, for tapping affected area, accentuated by respiratory
pericardial fluid. movements.
A pleural rub: (a friction sound) can be
The Nerve Supply of Pleura heard on the affected area on auscultation.
The parietal pleura is supplied by the somatic Pleurisy with effusion: is collection of
nerves. fluid in the pleural cavity.
The costal pleura is supplied by the intercostal
The fluid collects in the costo-
diaphragmatic recess and causes collapse
and subcostal nerves (T1 to T12 ventral rami). of basal part of lung (atelectasis of lung).
The diaphragmatic pleura is supplied by the 2. Pneumothorax: is collection of air in the pleural
phrenic nerves. The peripheral parts are cavity. The air from outside may enter via:
supplied by the intercostal nerves. External perforating injury of thoracic wall.
The mediastinal pleura is supplied by the Rupture of lung alveoli.
phrenic nerves 3. Hemothoraxmay results from collection of
The cervical pleura is supplied by the phrenic blood in the pleural cavity, due to rupture of the
nerves blood vessels (intercostal vessels) of thoracic
The visceral pleura is supplied by the wall in case of injury to the chest wall.
autonomic nerves. 4. Chylothoraxis a rare condition, in which
due to blockage of main lymphatic ducts (e.g.,
The Blood Supply of the Pleura thoracic duct), chyle or lymph mixed with fat,
The parietal pleura is supplied by: from intestines may leak in the pleural cavity.
5. Thoracocentesisis removal of fluid from
The internal thoracic vessels
the pleural cavity.
The posterior intercostal vessels
The fluid level is determined by the per-
The visceral pleura is supplied by: cussion in intercostal spaces and also by
The bronchial vessels that supply the lungs. X-ray of the chest.
The pleural cavity is the potential cavity that It is usually done in ninth intercostal
contains a small amount of serous fluid that lubri- space in mid-axillary line with patient in
cates the opposing surfaces. sitting position.
The pleural fluid provides great surface A needle is inserted immediately above
tension between parietal and visceral layers of the superior margin of the rib to avoid
pleura and keeps the lungs inflated. injury to intercostal nerves and vessels,
that run along the lower border of the rib.
The Functions of Pleura
THE LUNGS (PULMONES)
I. The pleura gives protection to the lung.
II. It facilitates the movements of the lung and The lungs are essential organs of respiration. The
prevents friction with neighboring struc- lungs are covered by the visceral layer of pleura
tures. except at the hilum, where the lung root is attached.
The Pleura and Lungs 209
During development, the lung buds invaginates a. The apexbulges in the root of neck
pleural sac from medial side, forming the parietal up to the neck of first rib.
and visceral layers connected around the hilum. b. The base(diaphragmatic surface) is
External features: related to the dome of diaphragm and is
Shapeconical hollow.
Differences between the two lungs: c. The costal surfaceis convex and is
i. Right lung is shorter and wider, as liver related to the ribs and intercostal spaces.
pushes it higher on the right side. d. The medial surfaceis divided into:
ii. Left lung is longer and narrower, as the heart i. A vertebral surfacerelated to the
and pericardium lie more on left side. bodies of vertebral bodies.
iii. There is a cardiac notch in the anterior: ii. A mediastinal surfacerelated to the
border of the left lung with a tongue-shaped lateral aspect of mediastinum.
lingula below it. iii. This surface has a hilum, which has
iv. The right lung has a larger capacity than lung root attached to it.
the left lung. The lung root consists of structures passing to
v. The right lung has two fissures and three and from the hilum of lung to the mediastinum.
lobes. The left lung has one fissure and two The structures of lung root are embedded
lobes. in connective tissue and surrounded by
vi. The right lung is also heavier (weight625 extension of mediastinal pleura around them
gm) than the left lung (weight565 gm). (Fig. 22.3).
Surfaces: The lung has The right lung root has the following
An apex (cupola) structures:
A base 1. Hyparterial bronchus
Two surfacescostal and medial 2. Eparterial bronchus
3. Pulmonary artery ii. Provides dead space for the inferior pul-
4. Superior pulmonary vein monary vein to expand.
5. Inferior pulmonary vein The fissures of the lung
6. Other smaller structures The right lung has two fissuresoblique and
One bronchial artery transversethe left lung has only one fissure:
Two bronchial veins oblique fissure.
Sympathetic plexuses: (anterior The oblique fissure begins at second
and posterior pulmonary plexuses) thoracic spine at the back, curves forwards
Lymphatics and lymph nodes.
across the chest wall and reaches sternal
The left lung root has the following structures
end of sixth costal cartilage.
(Fig. 22.4):
1. Left principal bronchus On left side it is more vertical.
2. Left pulmonary artery The transverse fissureis on front only. It
3. Superior pulmonary vein passes from sternal end of right fourth costal
4. Inferior pulmonary vein cartilage to join the oblique fissure in
5. Other smaller structures midaxillary line.
Two bronchial arteries
Two bronchial veins The Lobes of the Lung
Sympathetic plexus (anterior and pos-
The right lung has three lobes: Upper, middle,
terior pulmonary plexuses)
Lymphatics and lymph nodes and lower.
The pulmonary ligament is the lower part of The left lung has only two lobes: Upper and
the lung root, that extends from the lower part lower.
of hilum to the mediastinum. Each lobe of the lung is supplied by:
The pulmonary ligament A lobar (secondary) bronchus
i. Supports the lung and firmly connects it to A lobar branch of pulmonary artery
the mediastinum. The lobar tributaries of pulmonary veins.
B. The bronchial vessels supply the substance of The left bronchial veins end in
the lung with oxygenated blood and carry accessory hemiazygos vein.
back the deoxygenated blood from the lungs
to the systemic veins. The Lymphatic Drainge of Lungs
a. The bronchial arteries follow the The lymph vessels from the alveoli of lung,
branching of bronchi and supply the non- proceed to the pulmonary lymph nodes,
respiratory part of bronchial tree: associated with lobar bronchi.
The right lung has one bronchial artery From there, the lymphatics terminate in bro-
that arises from first aortic intercostal ncho-pulmonary lymph nodes, located in the
artery of right side. lung roots.
The left lung has two bronchial arteries The lymph from broncho-pulmonary nodes,
that arise from descending thoracic then passes to tracheo-bronchial and tracheal
aorta. lymph nodes.
b. The bronchial veins are two for each lungs: The lymphatics from the tracheal lymph nodes
The right bronchial veins end in unite with those from para-sternal nodes to form
azygos vein. broncho-mediastinal lymph trunk, that ends in
The Pleura and Lungs 213
right lymph duct on right side and thoracic II. Bronchoscopy is a special endoscopic procedure
duct on the left side. to visualize the interior of bronchial tree.
The lymphatics provide pathways for secondary An accurate knowledge of anatomy of
deposits (metastases) of lung carcinoma. broncho-pulmonary segments is required
In case of secondary deposits of cancer of lung, for conducting this investigation.
there may be a back flow of lymph towards the III. Bronchography is a special X-ray procedure,
contralateral lung, or towards the coeliac lymph where the bronchial tree is visualized after
nodes in upper part of abdomen. introducing a radiopaque dye in the lobar
bronchi.
Nerve Supply of Lungs For interpretation of bronchogram, a know-
The nerve supply of the lungs is provided by the ledge of bronho-pulmonary segments is
autonomic nerves. required.
I. The sympathetic supply is provided by the IV. Pulmonary embolism is usually caused by
branches from T2 to T5 ganglia of the venous stasis in right side of heart due to
sympathetic chain. some valvular disease of heart or myocardial
The sympathetic fibers join the two infarction.
pulmo-nary plexuses. The pulmonary embolism is one of the
Anterior and posterior flexuses are located greatest causes of death in elderly people
in the anterior and posterior parts of the after injury or in post-operative cases.
lung roots. V. Carcinoma of lung is also a common type of
The sympathetic supply vasoconstrictor tumor seen in a large percentage of persons
fibers to pulmonary vasculature and secreto- who smoke.
motor fiber to the bronchial glands. The lung carcinoma may have metastases in
II. The parasympathetic supply is by branches lymph nodes draining lung parenchyma.
from the vagus nervesright and left.
These parasympathetic fibers also join the THE BRONCHIAL TREE
two pulmonary plexuses.
The parasympathetic fibers supply the The bronchial treea part of respiratory
bronchial smooth musculature. Excessive passage consists of:
stimulation produces asthmatic syndrome An extrapulmonary part and
by broncho-constriction. An intrapulmonary part
The parasympathetic fibers also carry the The extrapulmonary part of bronchial tree
afferent sensation from the lungs. consists of :
The trachea
Applied Anatomy The two primary bronchiright and left
I. Surgical resection of broncho-pulmonary seg- The intrapulmonary part of bronchial tree
ments may be done, in case of lesions of few consists of:
segments. The lobar bronchi: three for the right lung
Examples of such lesions are lung and two for the left lung.
abscesses and bronchiectasis. The segmental (tertiary) bronchi that supply
However, some diseases of lung involve the broncho-pulmonary segments.
many segments like pulmonary The branches of tertiary bronchi, which divide and
tuberculosis and lung cancer. In such subdivide and finally their terminal branches the
conditions lobec-tomy is preferred. bronchioles end in the alveoli or the air sacs.
214 Essentials of Human Anatomy
I. The parietal layer: lines the deep It is related behind to the two
surface of fibrous pericardium. atria: right and left of the heart.
II. The visceral layer: covers the heart During cardiac surgery, a tempo-
externally (epicardium). rary ligature or clamp is passed
It also covers the roots of great through it to occlude the two
vessels enclosed within peri- great vessels.
cardium. II. The oblique sinus is in form of a cul-
The sinuses of pericardium are spaces de-sac of pericardial cavity behind
inside serous pericardium (Fig.23.2): the base of the heart.
The reflection of visceral layer over It lies between the right and
the roots of greater vessels in form
left limbs of common J-shaped
of two sheaths:
sheath.
a. A tubular sheath that includes the
On the right side are: superior
roots of ascending aorta and pul-
vena cava, two right pulmonary
monary trunk.
veins and inferior vena cava.
b. An inverted J-shaped sheath that
encloses six veinssuperior On the left side are two left pul-
vena cava, inferior vena cava, monary veins
two right pulmonary veins and The oblique sinus opens downwards
two left pulmonary veins. and towards the left.
These two sheaths of visceral pleura Inpericardial effusion, fluid collects
are responsible for formation of the in the oblique sinus, when person lies
two sinuses inside serous peri- in the supine position. The fluid in
cardium. the oblique sinus may compress the
I. The transverse sinus: is a transverse descending aorta and esophagus
passage behind the tubular sheath causing compression symptoms.
enclosing the ascending aorta and The blood supply of pericardium
pulmonary trunk. I. The fibrous pericardium and the parietal
layer of sinus pericardium are supplied by b. The para-sternal route: The needle is
the blood vessels of the thoracic wall: introduced in pericardial cavity,
Internal thoracic vessels through left 4th or 5th intercostal
Branches from descending thoracic aorta space just adjacent to the sternum.
The venous blood is drained by the This procedure also involves very
azygos and hemiazygos veins. little risk of injuring pleura as
II. The visceral layer of pericardium (epicar- anterior margin of left pleura has a
dium) is supplied by the coronary arteries cardiac notch here.
of the heart. III. Dry pericarditis is caused due to inflam-
The venous blood is drained by the mation of the parietal layer of serous peri-
tributaries of coronary sinus. cardium.
The nerve supply of pericardium The pain of pericarditis is referred to the
I. The fibrous pericardium and the parietal epigastrium usually.
layer of serous pericardium are supplied A pericardial friction sound is heard on
by the phrenic nerves. auscultation.
II. The visceral layer of serous pericardium
is supplied by the autonomic nerves that THE HEART
supply the heart. The heart is a muscular organ, that pumps blood
The functions of pericardium
to all parts of body.
I. The pericardium protects the heart.
Locations: The heart lies in middle mediastinum
II. It facilitates the contractions of heart by
of thorax, surrounded by the pericardium.
preventing friction with other structures.
The heart lies obliquely one-third to the right
III. The fibrous pericardium being inelastic,
and two third to the left of the median plane.
prevents overdistention of heart.
Shape is conical with apex pointing downwards,
Applied anatomy
and to the left and base pointing posteriorly.
I. Pericardial tamponade: In pericarditis with
Weight: About 300 gm in adult male; 250 gm
effusion, or collection of blood in peri-
in adult female.
cardium compresses heart and decreases the
Size: Transverse diameter: 8.0-9.0 cm
cardiac output with increase in heart rate.
Antero posterior diameter: 6.0 cm
The condition is accompanied by a weak
(From base to apex)
and rapid pulse. Increased venous
pressure causes jugular vein distention External Features
and pulsating liver with dyspnea are
significant symptoms of the pericardial The heart has an apex and a base (Fig. 23.3)
effusion. Three surfaces
II. Pericardio-centesis is removal of Sterno costal
pericardial fluid. It may be done from the Diaphragmatic
following two routes: Left surface
a. The left subcostal angle adjacent to the Four borders
xiphoid process; angling upwards and Superior, inferior, right and left.
to the left at an angle of 45C. The risk I. The apex of heart is formed by the left
of injuring pleura is less in this proce- ventricle. It lies in left fifth intercostal
dure. space, about 9.0 cm from the median plane.
218 Essentials of Human Anatomy
b. The inferior border extends from the root of The right coronary artery arises from the
inferior vena cava to the apex of heart. anterior aortic sinus.
c. The left border is formed mainly by the left The left coronary artery arises from the left
ventricle. Its uppermost part is formed by the posterior aortic sinus.
left auricle. Course
d. The superior border is formed by the upper The right coronary artery lies deep to the
borders of the two atria. right auricle at its origin.
It is obscured by the attachment of
It courses downwards in the anterior
ascending aorta and pulmonary trunk.
part of coronary sulcus, and curves
The Blood Supply of the Heart backwards at the junction of right and
The Arteries inferior borders of the heart.
It runs towards left in the posterior part
The heart is supplied by two arteries: right and of coronary sulcus.
left coronary arteries (Fig. 23.5). It terminates usually by anastomosing
Features with the terminal branches of left coro-
i. The coronary arteries are highly enlarged nary artery.
vasa vasorum. The left coronary artery turns towards left
ii. These arteries get filled up during diastole between pulmonary trunk and ascending aorta
of the heart.
to reach the coronary sulcus.
iii. These are the first branches of the aorta
It bifurcates into anterior inter-ventricular
arising near its root.
iv. The coronary arteries are functional end branch and circumflex branch.
arteries, i.e. there is hardly any anastomosis The anterior inter-ventricular branch
between their smaller branches. descends in the anterior interventricular
Origin: The coronary arteries arise from the groove. It terminates by anastomosing
aortic sinuses (dilatations opposite the cusps with posterior interventricular branch of
of the aortic valve) at the root of ascending right coronary artery on diaphragmatic
aorta. surface near apex.
The circumflex branch represents the
continuation of the left coronary artery. It
runs in the coronary sulcus, curves around
the left border and reaches posterior part
of coronary sulcus.
The circumflex branch terminates by
anastomosing with terminal branches of
left coronary artery.
Distribution and branches
The right coronary artery gives
i. Small branches to roots of ascending aorta
and pulmonary trunk.
ii. Branches to right atrium, including a
nodal branch to supply sino-atrial node.
iii. Branches to superior part of right ventricle.
iv. Right marginal artery passes along the
Fig. 23.5: The arterial supply of the heart-sterno- inferior border of the heart towards the
costal surface apex, supplying portion of right ventricle.
220 Essentials of Human Anatomy
b. The middle cardiac vein lies in posterior Obstruction to flow of blood in coronary
inter-ventricular groove along with arteries produces ischemia of myocardium
posterior inter-ventricular artery. causing pain: angina pectoris.
It drains venous blood from posterior The cardiac pain originates from the
parts of both ventricles and posterior precordial region and is referred to:
part of inter-ventricular septum. Epigastrium
It ends in the middle of coronary sinus. Left shoulder
c . The small cardiac vein: lies along the Inner side of left arm frequently
interior border of heart. The myocardial ischemia may lead to
It drains venous blood from the right coronary thrombosis or heart attack.
ventricle. If a large branch of coronary artery is
d. The oblique vein of left atrium: involved, the infarct following heart attack,
[Marshalls Vein] is a small vein on may prove fatal.
posterior aspect of left atrium.
It joins the left end of coronary sinus. The Nerve Supply of the Heart
It is embryonic remnant of left common The heart rate and the cardiac output are
cardinal vein (that may develop into controlled by the autonomic nerves.
left superior vena cava sometimes). The parasympathetic fibers are provided by
II. The anterior cardiac veins are several small the cardiac branches of two vagus nerves.
veins, that drain venous blood from anterior The preganglionic fibers synapse with post-
aspect of right ventricle. ganglionic neurones located in myocardium.
They course across the coronary sulcus, The vagal activity slows heart rate and
lying anterior to the right coronary artery. reduces the stroke volume.
They open independently in the right atrium. The sympathetic fibers are provided by the
III. The minute cardiac veins [venae cordis minimae, cardiac branches of superior, middle and
Thebesian veins) drain venous blood from inferior cervical ganglia and T2 to T5 ganglia
endocardium and deeper part of myocardium. of sympathetic chains.
They open directly into the chambers of heart. The sympathetic are cardiac accelerator
They are more in atria than ventricles. nerves.
The afferent fibers from heart run along
The Myocardial Circulation sympa-thetic and parasympathetic via
Normally, there is very little anastomosis thoracic and cervical cardiac nerves to reach
between the branches of right and left coronary T2 to T5 spinal segments, and dorsal vagal
arteries in the substance of myocardium, in a nucleus in medulla oblongata.
normal healthy person. The cardiac plexuses are twosuperficial
Thus, most of the branches of coronary and deep:
arteries are functional end arteries. I. The superficial cardiac plexusis located
Any anastomosis present, is not sufficient to below the arch of aorta, in front of right
maintain effective circulation in the event of pulmonary artery.
sudden occlusion of a large branch of It is formed by:
coronary artery. Cardiac branch of superior cervical
However, with slow onset of atherosclerosis, ganglion of left sympathetic chain.
in elderly persons, some collateral circulation Inferior cervical cardiac branch of
develops. left vagus.
222 Essentials of Human Anatomy
II. The deep cardiac plexus is located behind septum medial to the opening of coronary
the arch of aorta, in front of tracheal bifur- sinus and above the septal cusp of
cation. tricuspid valve.
It is formed by: It gives rise to atrioventricular bundle
Cardiac branches of superior, (bundle of His).
middle and inferior cervical III. The atrio-ventricular bundle crosses the
ganglia of both sympathetic chains annulus fibrosus and descends along
(except the branch of superior posterior margin of membranous part of
cervical ganglion of left side). inter-ventricular septum to enter muscular
Cardiac branches of T2 to T5 part of septum.
ganglia of both sympathetic trunks. It divides into two branches: right
Superior, inferior and recurrent ventricular branch and left ventricular
cardiac branches of both vagi (ex- branch.
cept the inferior cardiac branch of The two branches descend along the
left vagus). interventricular septum and spread out
The two cardiac plexuses contain in the walls of ventricles along cardiac
contributions of both sympathetic and muscle fibers, carrying the cardiac
parasympathetic. The plexuses give branches to: impulse.
Both coronary plexuses that accompany the
right and left coronary arteries. Applied Anatomy
Pulmonary plexuses. If an infarct or any other vascular lesion
The conducting system of the heart (neuro- interferes with the impulse propagation in atrio-
myocardium). The neuro-myocardium consists of ventricular bundle, it causes heart block, resulting
specialized cardiac muscle fiberscalled Purkinje in asymmetrical beating of atria and ventricles.
fibers, enclosed in a sheath of connective tissue. An artificial pacemaker is implanted for
This system has developed a high degree of correcting the cardiac rhythm in cases of heart
sensitivity and autorhythmicity. block.
The neuro-myocardium ensures proper
spread of cardiac impulse to all chambers of The Interior of the Chambers
heart and regulates their contraction in a of the Heart
proper sequence. 1. The right atrium: is the venous receiving
The conducting system consists of: chamber of the heart (Fig. 23.7).
I. The sinu-atrial node (SA Node or Pace- It has the thinnest walls of all the four chambers.
maker), that initiates the cardiac impulse The crista terminalis: A thick muscular ridge
(about 72 per minute) that spreads to both separates the cavity of right atrium into two
atria and atrio-ventricular node. parts.
It is about 7 mm 2 mm 1 mm in size. An anterior part: atrium proper
A posterior part: sinus venarum.
It is situated in myocardium between the I. The atrium proper: has the crista terminalis,
opening of superior vena cava and that extends from the opening of superior vena
crista terminalis. cava to the opening of inferior vena cava.
II. The atrio-ventricular node (AV node) is This ridge runs along the right border of the
situated in right atrium, near interatrial heart.
The Pericardium and the Heart 223
The right ventricle is divided into two parts The septal papillary muscle:
by supra-ventricular crest, lying between smallest in size, attached to the
septal cusp of tricuspid valve and pulmonary septal wall.
orifice. The right atrioventricular opening
The right ventricle proper is elliptical in shape and about 3.0
The infundibulum
cm long.
a. The right ventricle proper is the inflow It leads from right atrium to the
part of the cavity of right ventricle. right ventricle and is guarded
It has rough muscular walls with
by tricuspid valve.
three types of muscular ridges
The tricuspid valve has a
called trabeculae carnae.
fibrous ring surrounding the
Ridges
opening and three cusps
Bridges
anterior, posterior and septal.
Papillary muscles
The cusps are formed by folding
The papillary muscles are largest
of the endocardium with some
type of trabeculae carnae. They are
connective tissue in between.
coni-cal in shape, with base
attached to the muscular wall. The chordae tendinae from the
From the apices of papillary muscles, three papillary muscles are atta-
fibrous cord-like structureschor- ched alternately to the three
dae tendinaepass to the free mar- cusps.
gin and ventricular surfaces of the The papillary muscles contract
cusps of the tricuspid valves. during ventricular systole and
There are three papillary muscles firmly oppose the cusps of tri-
in right ventricle: cuspid valve, thus preventing
b. The infundibulum is the outflow part It gives the left auricular appendage from left
of the right ventricle. anterior part. The appendage has a network of
It is funnel shaped smooth lined muscular ridges in its interior.
upper part of the cavity of right The left atrium opens, in left ventricle via the
ventricle. left atrioventricular opening guarded by
It has pulmonary opening in its upper mitral valve.
end guarded by pulmonary valve. 4. The left ventricle is the main arterial
The pulmonary opening is 2.0 cm chamber of the heart, that receives oxygenated
wide oval opening. blood from left atrium and sends it via aorta to all
The pulmonary valve has a fibrous parts of body.
ring surrounding the opening with The walls of left ventricle are three times as
three semilunar cusps: thick as walls of right ventricle, to overcome
Right anterior the resistance of systemic vascular bed.
Left anterior The left ventricle is divided into two parts:
Posterior The left ventricle proper
The cusps are formed by folding of The aortic vestibule
the endothelium with some connec- a. The left ventricle proper is the inflow part of
tive tissue in between. the left ventricle.
The free edges of the cusps are The cavity is conical, and appears round
directed upwards towards pulmo- in a transverse section, as the inter-
nary trunk. ventricular septum bulges towards the
The free margins of the cusps are right ventricle.
strengthened by thickening in center The walls have thicker trabeculae carnae
called nodule for proper opposition, of three types: ridges, bridges and
when the valve is closed. papillary muscles.
The pulmonary valve prevents There are two papillary muscles anterior and
regurgitation of blood from pulmo- posteriorin the cavity of left ventricle. The
nary trunk to the right ventricle. papillary muscles are thick and large.
3. The left atrium is the arterial chamber of Their chordae tendinae are attached
heart that receives oxygenated blood from the alternately to margins and ventricular
two lungs via the pulmonary veins, and sends it surface of two cusps of mitral valve.
to the left ventricle. The left atrioventricular openings is
The left atrium is cuboidal in shape and due to elliptical in shape and about 2.0 cm wide.
rotation of heart lies on left side and behind the The mitral valve: guards the left atrio-
right atrium separated by inter-atrial septum. ventricular opening.
The left atrium has slightly thicker walls than The valve has a fibrous ring around the
right atrium to overcome elasticity of opening and two cuspsanterior and
extremely thick left ventricular walls. posteriorformed by folding of
It receives usually two right pulmonary veins, endothelium with connective tissue in
and two left pulmonary veins, but there may between.
be variations (commonest being one left and Incompetence of mitral valve leads to
two or three right pulmonary veins). transmitting the left ventricular systolic
226 Essentials of Human Anatomy
pressure to left atrium and pulmonary The membranous part is the common
vasculature leading to right sided heart site of ventricular septal defect (VSD),
failure or cor pulmonale. that is the principal defect in Fallots
Mitral stenosis (narrowing of valve) is tetralogy.
one of the commonest valvular
condition of heart. The Structure of the Heart The
b. The aortic vestibule: is situated anterior and
heart consists of (Fig. 23.9):
to the right of mitral valve.
It is the smooth lined part of cavity of left i. Epicardium is made up of visceral layer of
ventricle and has aortic opening at its serous pericardium, lining outer surface of
upper end. heart.
The aortic opening is 2.0 cm wide, oval ii. Myocardium is the main muscular part
opening guarded by aortic valve. made up of cardiac muscle.
The aortic valve has a fibrous ring surroun- iii. Endocardium is the inner lining of the
ding it and three semilunar cusps formed chambers of the heart, and consists of a
by folding of endothelium with connective single layer of endothelium.
tissue in between.
The cardiac muscle fibers form thicker layer
The positions of cusps of aortic valve is just
in ventricles than in atria. They are arranged
opposite to those of the pulmonary valve.
They are: in spiral form to produce a wringing
Right posterior movement during systole of heart.
Left posterior Some specialized parts of myocardium form
Anterior the conducting system of the heart.
The structure and disposition of cusps is The annulus fibrosus: (Fibrous ring) is a layer
similar to the cusps of pulmonary valve. of dense connective tissue arranged in atrio-
The aortic valve prevents regurgitation of
ventricular plane.
blood from aorta to left ventricle during
The annulus fibrosus forms is the skeleton
left ventricular disastole.
Aortic stenosis in aged results from ano- of the heart and provides attachment to the
malous aortic valve and manifests a high cardiac muscle fibers.
pitched systolic murmur.
Arch of aorta and its three branches The Superior Vena Cava
brachio-cephalic, left common carotid and
The superior vena cava is great venous trunk
left subclavian.
draining venous blood from all parts of body
Nerves Two vagus nervesleft and right
above diaphragm except heart.
Left recurrent laryngeal nerve
Two phrenic nervesleft and right Formation: The superior vena cava is formed
Cardiac branches of vagus and sym- by the union of right, and left brachio-
pathetic chain. cephalic veins at the lower border of first
The lower half of superior vena cava lies in Location: The arch of aorta lies behind lower
the middle mediastinum to the right of half of manubrium sterni.
ascending aorta. Extent: Anteriorly from the right half of
Termination: The vena cava opens in the sternal angle to posteriorly up to lower border
upper posterior part of cavity of right atrium. of fourth right thoracic vertebra.
Tributaries: The superior vena cava receives Curvatures: The arch of aorta has two curva-
the azygos vein on its posterior aspect at level tures.
of second costal cartilage. a. Convex above and concave below.
Development: The superior vena cava b. Convex towards left side and in front and
develops from. concave towards right side and behind.
Right common cardinal vein. The arch of aorta has four surfaces:
Proximal part of right anterior cardinal Left anterior surface
vein. Anomalies Right posterior surface
i. Left superior vena cava may be present, due Superior surface
Inferior surface
to persistence of left common cardinal vein.
Relations:
ii. Both right and left superior vena cavae may
The left anterior surface is related to:
be present sometimes.
i. Left mediastinal pleura and left lung
The Brachiocephalic Veins ii. Left phrenic and left vagus nerve
iii. Left superior intercostal vein
The right brachio-cephalic vein is short and iv. Cardiac branches of sympathetic and
vertical in course. The left brachio-cephalic vein vagus nerves.
is longer and passes obliquely from left to the The right posterior surface is related to:
right behind upper half of manubrium sterni. i. Esophagus
Formation both brachio-cephalic veins are ii. Trachea, including bifurcation of trachea
formed by the union of internal jugular and Deep cardiac plexus
subclavian veins behind medial end of clavicle. Left recurrent laryngeal nerve
Termination The two brachio-cephalic veins Thoracic duct
join to form the superior vena cava, at the The superior surface is related to:
lower border of first right costal cartilage. Origin of three branchesbrachio-cephalic,
Tributaries left common carotid and left subclavian.
i. Vertebral vein Remains of thymus gland
ii. Inferior thyroid vein Left brachio-cephalic vein
iii. Internal thoracic vein The inferior surface is related to
iv. First posterior intercostal vein Bifurcation of pulmonary trunk
v. Thoracic duct (joins left brachiocephalic Left recurrent laryngeal nerve
vein) Ligamentum arteriosum
Superficial cardiac plexus
vi. Right lymphatic duct (joins the right bra-
Branches: The arch of aorta gives three large
chiocephalic vein)
branches
The Arch of Aorta i. Brachio-cephalic artery
ii. Left common carotid artery
The arch of aorta is the convex part of aorta iii. Left subclavian artery.
between ascending and descending parts of aorta. The branching pattern may be anomalous.
The Mediastinum 231
iv. Thyroidea ima arteryis occasionally and passes behind left long root to
present. It supplies isthmus of thyroid gland. divide into branches for posterior
v. One of the vertebral artery may arise pulmonary plexus.
directly from arch of aorta. From posterior pulmonary plexus vagal
Development: The arch of aorta develops from: branches descend to form esophageal
Aortic sac and left horn of aortic sac plexus.
Left fourth aortic arch Branches
Part of left dorsal aorta i. The left recurrent laryngeal nerve
arises in superior mediastinum. It
The Vagus Nerves curves below the arch of aorta and
The vagus nerves are the tenth cranial nerves. ascends up in the tracheo-oeso-
The vagus nerves pass through neck and phageal goove.
thorax into abdomen and supply ii. Branches to the pulmonary plexus.
parasympathetic fibers to cervical, thoracic iii. Branches to the esophageal plexus.
viscera and foregut and midgut. From the plexus anterior gastric
a. The right vagus nerve passes behind the nerve arises and enters abdominal
internal jugular vein and crosses in front of
cavity.
first part of subclavian artery to enter thorax.
It descends behind right brachio- The Phrenic Nerves (Right and Left)
cephalic vein in superior mediastinum,
on right side of trachea. The phrenic nerves arise from ventral rami of C3,
The nerve passes behind right lung root C4 and C5 spinal nerves in the neck.
and divides into branches for posterior Course
pulmonary plexus. i. The right phrenic nerve enters thorax by
From lower part of the plexus, vagal passing behind right subclavian vein.
branches descend to form esophageal It crosses the internal thoracic artery and
plexus. lies lateral to right brachio-cephalic
Branches in thorax vein, and superior vena cava.
i. The right recurrent laryngeal nerve It runs lateral to fibrous pericardium
that curves around right pulmonary covering right atrium of heart and
artery at root neck and lies in
inferior vena cava to reach diaphragm
tracheo-oesophageal groove
which it supplies.
ii. Branches to posterior pulmonary
ii. The left phrenic nerve passes anterior to
plexus.
iii. Branches to esophageal plexus. left subclavian artery behind thoracic duct
From this plexus posterior gastric and enters thorax.
nerve carrying fibers of right vagus It crosses the internal thoracic artery and
nerve to the abdomen. runs down between left subclavian and
b. The left vagus nerve descends between left left common carotid arteries.
common carotid and left subclavian arteries It crosses on left side of arch of aorta and
behind the left brachiocephalic vein. descends along fibrous pericardium
It descends through superior media- covering left ventricle of heart to reach
stinum lying a left side of arch of aorta diaphragm which it supplies.
232 Essentials of Human Anatomy
Upper right aortic intercostal arteries for Course: The upper part of descending aorta
third, fourth, fifth, and sixth spaces. (i.e. from lower border of fourth thoracic
c. Other structures vertebra to eighth thoracic vertebra lies on left
Three splanchnic nervesgreater, lesser side of vertebral bodies.
and loweston both sides The lower part of descending aorta (i.e.
The mediastinal lymph nodes. from eighth thoracic vertebra to the lower
border of twelfth thoracic vertebra lies in
The Descending Thoracic Aorta the median plane.
The descending thoracic aorta lies behind
The descending thoracic aorta is continuation of
fibrous pericardium and is crossed by
arch of aorta in posterior mediastinum (Fig. 24.4): esophagus from in front.
Beginning: The descending aorta begins at the Termination: at the lower border of twelfth
lower border of fourth thoracic vertebra. thoracic vertebra the descending thoracic
aorta passes through aortic opening of
diaphragm and continues as abdominal aorta.
Branches
i. The posterior intercostal arteries (paired)
for lower nine intercostal spaces.
ii. The bronchial arteries
Two for left lung
One for right lung (from first right aortic
intercostal artery)
iii. The esophageal branches
iv. The mediastinal branches for mediastinal
lymph nodes
v. The superior phrenic arteries for superior
surface of diaphragm
vi. The pericardial arteries for fibrous peri-
cardium.
The Esophagus
The esophagus (gullet) is a muscular tube that
conveys food from lower end of pharynx to the
stomach.
Beginning: The esophagus begins in the neck
at the lower border of cricoid cartilage (verte-
bral level sixth cervical vertebra) as
continuation of pharynx.
Course: The esophagus descends in front of
bodies of vertebrae and behind trachea in its
cervical part.
It descends in superior mediastinum and
Fig. 24.4: The descending thoracic deviates towards the left side still lying
aorta and thoracic duct behind the trachea
234 Essentials of Human Anatomy
iii. Left bronchomediastinal lymph trunk received Course: The azygos vein enters posterior
near its termination, bringing lymph from left mediastinum through aortic opening of
half of thoracic cavity and lung. dia-phragm lying to the right side of
iv. Left jugular lymph trunk from left side of thoracic duct.
head and neck. The azygos vein ascends up in front of
v. Left subclavian lymph trunk from left thoracic vertebrae in posterior mediastinum.
upper limbs Termination: At the level of fourth thoracic
Development of thoracic duct is from vertebra, the azygos vein arches forwards
a. Caudal part of right primitive lymph trunk above the right lung root and ends in the
b. Transverse communication between two back of superior vena cava.
primary lymph trunks on front of fifth Tributaries
thoracic vertebra i. Right subcostal vein
c. Cranial part of left primitive lymph trunk. ii. Posterior intercostal veins from fifth to
Anomalies eleventh intercostal spaces of right side
i. Double thoracic ducti.e. present on both iii. Two right bronchial veins
sides iv. Two hemiazygos veins at level of
ii. Right thoracic duct (mirror image of the eighth thoracic vertebra
original) v. esophageal veins
Applied anatomy vi. Mediastinal veins
a. The chylo thorax is seen, when chyle leaks vii. Pericardial veins
into a pleural cavity from ruptured or viii. Superior phrenic veins
obstructed thoracic duct ix. Right superior intercostal veins.
b. The chyluria results from blocked lympha-
tics or thoracic duct communicates with The Hemiazygos Veins
urinary passage. a. The superior hemiazygos (accessory hemiazygos)
vein is formed by the posterior intercostal veins of
The Azygos Vein fifth, sixth, seventh, and eighth spaces.
The azygos vein is a large vein in posterior It descends on front of thoracic vertebrae on
mediastinum that drains venous blood from: left side of median plane.
Most of the thoracic wall It terminates by turning towards right side in
Esophagus front of eighth thoracic vertebra and ends in
Pericardium azygos vein.
Lungs Tributaries
Diaphragm i. Posterior intercostal veins from third to
Other contents of posterior mediastinum. eighth spaces on right side.
The azygos vein also forms an important ii. Two left bronchial vein.
link or connection between inferior vena iii. Esophageal veins
cava and superior vena cava. iv. Pericardial veins
Beginning: The azygos vein begins in v. Mediastinal veins.
posterior abdominal wall by union of: b. The inferior hemiazygos (hemiazygos) vein
Lumbar azygos vein connecting it to the begins in posterior abdominal wall by union of:
interior vena cava and ascending lumbar Left subcostal vein
vein formed by first and second right Left ascending lumbar vein formed by union
lumbar veins. of first and second right lumbar veins.
The Mediastinum 237
It enters posterior mediastinum by piercing ii. White rami communicans (WRC) from the
left crus of diaphragm ventral rami of thoracic nerves carrying
It ascends up in front of thoracic vertebrae to preganglion sympathetic fibers to the
the left of median plane corresponding sympathetic ganglia.
It terminates by turning towards right on front iii. Greater splanchnic nerve arises from fifth to
of eighth thoracic vertebra and ends in the tenth ganglia. It has preganglionic sympathetic
azygos vein. fibers that synapse in the coeliac ganglia and
Tributaries supply abdominal organs.
i. Posterior intercostal veins from ninth to iv. Lesser splanchnic nerve arises from tenth
eleventh intercostal spaces of left side and eleventh ganglia. It also carries
preganglionic sympathetic fibers that
ii. Esophageal vein
synapse in the coeliac ganglia.
iii. Pericardial vein
v. Lowest splanchnic nerve arises from
iv. Mediastinal veins
eleventh ganglion and accompanies the
v. Superior phrenic veins. other two splanchnic nerves. It also carries
preganglionic sympathetic fibers that
THE SYMPATHETIC TRUNKS synapse in coeliac ganglia. The three
(THORACIC PART) splanchnic nerves pierce the left crus of
The thoracic parts of sympathetic trunks descend on diaphragm to enter abdomen.
front of neck of ribs (therefore, they are not vi. Branches from second to fifth ganglia to
included in the contents of posterior mediastinum. posterior pulmonary plexus.
vii. Branches from second to fifth ganglia to
There are eleven ganglia (paravertebral in
the deep cardiac plexus.
position) in thoracic part of sympathetic trunks.
viii. Medial branches from upper five ganglia
Branches from aortic plexus on thoracic aorta and
i. Grey rami communicans (GRC) to the its branches.
ventral rami of thoracic nerves, carrying ix. Branches from second to fifth ganglia and
post ganglionic sympathetic fibers from greater splanchnic nerves to esophageal
corresponding ganglia. plexus.
The Thorax
Multiple Choice Questions
Q.1. Select the one best response to each 6. The costo-diaphragmatic recess:
question from the four suggested ans- A. Space between the lung and diaphragm
wers: B. Space between parietal and visceral
1. The first chondro-sternal joint is: pleura
A. Primary cartilaginous joint C. Space between diaphragm and costal
B. Secondary cartilaginous joint cartilages
C. Fibrous joint D. Space between costal and diaphragmatic
D. Synovial joint. pleura at the lower border of lung.
2. The sternal angle lies at the level of: 7. The blood clot entering circulation from a
A. Upper border fourth thoracic vertebra larger vein is likely to be lodged and
B. Lower border second thoracic vertebra produce local infarct in:
C. Lower border fourth thoracic vertebra A. The lung
D. Lower border fifth thoracic vertebra. B. The brain
3. The cervical rib arises as enlargement of: C. The heart
A. Costal element of sixth cervical vertebra D. The liver
B. Costal element of seventh cervical 8. The anterior inter-ventricular branch of left
vertebra coronary artery is accompanied by:
C. Transverse process of seventh cervical A. Middle cardiac vein
vertebra B. Coronary sinus
D. Transverse process of sixth cervical C. Great cardiac vein
vertebra D. Oblique vein of left atrium
4. The sternocostalis muscle: 9. The myocardial infarction limited to the
A. Is attached to posterior surface of interverticular septum is likely to produce:
manu-brium sterni A. Disturbance in cardiac impulse con-
B. Is attached to posterior surface of xi-
duction
phoid cartilage only
B. Mitral valve incompetence
C. Is attached to lower ribs
C. Tricuspid valve incompetence
D. Is attached to lower third of posterior
D. Aortic valve insufficiency
surface of body sternum.
5. The neuro-vascular bundle of the intercostal 10. The sinuatrial node:
space lies: A. Is the pacemaker for initiating cardiac
A. Above superior border of the rib impulse
B. Midway in intercostal space B. Located in myocardium at opening of
C. In the costal groove of rib along lower inferior vena cava
border C. Is continued as atrio-ventricular bundle
D. Below the inferior border of rib. D. Is supplied by left coronary artery.
Multiple Choice Questions 239
Q.2. The questions below contain four sugges- 2. Remains of thymus gland
ted answers of which one or more or 3. Superior vena cava
correct. Choose the answers 4. Two sterno-pericardiac ligaments
A. If 1, 2 and 3 are correct
17. The coronary arteries:
B. If 1 and 3 are correct
C. If 2 and 4 are correct 1. Are branches of the ascending aorta
D. If only 4 is correct 2. Are filled up during diastole of the heart
E. If 1, 2, 3 and 4 are correct 3. Can be classified as functional end
arteries
11. The following structures pass through inlet 4. Have sufficient extracardial
of thorax:
anastomoses with pericardial arteries
1. Esophagus
2. Trachea 18. The arch of aorta:
3. Brachio-cephalic veins 1. Begins and ends at the same vertebral
4. Azygos vein level, i.e. lower border of fourth
12. The right lung: thoracic vertebra
1. Has usually three lobes and two fissures 2. Extends in the root of neck in adults
2. Is longer and narrower than the left lung 3. Has usually three main branches
3. Inhaled foreign bodies are more likely 4. Is closely related to the right lung
to enter right bronchus 19. The esophagus in superior mediastinum:
4. Is related directly to the arch of aorta 1. Lies behind trachea in front of thoracic
and descending aorta vertebrae
13. The broncho-pulmonary segments: 2. Is deviated towards left side
1. Are separated by connective tissue septa 3. Has thoracic duct related to its left
2. Are supplied by a tertiary [segmental] border
bronchus 4. Has esophageal plexus of nerves
3. Are pyramidal in shape with apex lying related to it
at the hilum of lung
20. The azygos vein
4. Have intersegmentally arranged pulmo-
1. Begins in posterior mediastinum by
nary arteries
union of posterior intercostal veins
14. The right border of heart is formed by: 2. Begins in posterior abdominal wall by
1. The right ventricle union of lumbar azygos and right
2. The right auricle ascending lumbar veins
3. The right atrium and right ventricle
3. Enters thorax by piercing right crus of
4. The right atrium only
diaphragm
15. The venous blood of heart is drained by: 4. Terminates by joining superior vena cava
1. Thebesian vein
2. Anterior cardiac veins Q.3. Match the structures on the left with
3. Coronary sinus suitable answers given on the right
4. All of the above 21. Structures in the chambers of heart:
16. The anterior mediastinum of thorax contains: 1. Fossa ovalis A. Left ventricle
1. Phrenic nerves 2. Moderator band B. Right ventricle
240 Essentials of Human Anatomy
Answers
The phrenic nerves lie on the lateral aspect The right pulmonary veins open in the
of mediastinum. The superior vena cava lies left atrium
partly in middle mediastinum and partly in Aortic vestibule is the upper outflow
superior mediastinum. part of the left ventricle
A17. The answer is A, (1, 2, 3) A22. The answers are D, A, B, C
The coronary arteries are branches of The coronary sinus develops from left
ascending aorta. They are filled up during horn of sinus venosus
The left common cardinal vein persists
diastole of the heart. They can be classified
as the oblique vein of left atrium
as functional end arteries, as they have very
Ligamentum arteriosum is remnant of
little anastomoses between their smaller ductus arteriosus of fetal heart
branches. They, however, do not have, Bulbus cordis of fetal heart gives rise to
sufficient extracardiac anastomoses. the infundibulum of right ventricle
A18. The answer is B, (1, 3) from its right half portion
The arch of aorta begins and ends at the same A23. The answers are A, B, D, C
vertebral level, i.e. lower border of fourth The right internal thoracic vein ends in
thoracic vertebra. The arch does not extend in right brachiocephalic vein
the root of neck in adults. It has three main The hemiazygos veins end in azygos vein
branchesbranchiocephalic, left common The left bronchial veins drain in the
carotid and left subclavian. The arch of aorta accessory hemiazygos vein
is related to the mediastinal surface of left The great cardiac vein is a tributary of
lung and not right lung. the coronary sinus.
A24. The answers are B, C, A, D
A19. The answer is A, (1, 2, 3)
The bifurcation of trachea is at level of
The esophagus in the superior mediastinum
lower border of fourth thoracic vertebra
lies behind trachea in front of thoracic
The suprasternal notch (upper border of
vertebrae. It is deviated towards left side and manubrium sterni) is at level of lower
has thoracic duct related to its left border. But border of second thoracic vertebra
the esophageal plexus of nerves is related to The mitral opening of heart is opposite
esophagus in posterior mediastinum. fourth left costal cartilage
A20. The answer is C, (2, 4) The apex of heart is located in left fifth
The azygos vein begins in posterior intercostal space, 9.0 cm from median
abdominal wall by union of lumbar azygos plane
and right ascending lumbar vein. It does not A25. The answers are C, A, B, D
pierce right crus of diaphragm, but enters The crista terminalis is present in the
thorax through the aortic opening. It interior of anterior wall of right atrium
terminates by joining superior vena cava. along right border
Thoracic duct enters posterior media-
A21. The answers are D, B, C, A. stinum of thorax through aortic opening
The fossa ovalis is located on the septal of diaphragms
wall of right atrium The three splanchnic nerves pierce the
The moderator band passes from the left crus of diaphragm
septal wall to root of anterior papillary The oblique sinus is located in the serous
muscle in the right ventricle pericardium, behind left atrium of heart.
The Abdomen
Five
CHAPTER 25
The Anterior Abdominal
Wall and the Inguinal Region
THE BONES AND JOINTS OF v. The laminae are short, thick, and broad
ABDOMINAL WALL vi. The spinous process forms a quadrilateral plate
and is directed almost directly backwards
The bones at the back of abdominal wall are
vii. The superior articular process bears a
the five lumbar vertebrae and the inter-
concave facet facing medially and backwards.
vertebral discs between them.
viii. The inferior articular process bears convex
The upper parts of two hip bones with their
facet that faces laterally and forwards
iliac crests lie in lower part of abdominal
ix. The posterior border of superior articular
wall. The iliac fossa of hip bones also lie
process is marked by a rough elevation
below. [Detail description of hip bones is
mamillary process.
given in Chapter 16].
Fifth lumbar vertebra - has some atypical fea-
THE LUMBAR VERTEBRAE tures
The transverse process is thick, short and
There are five lumbar vertebrae. These vertebrae
pyramidal in shape. The process appears
are quite large and become progressively larger
turned upwards. Their base is attached to
towards sacrum.
whole thick-ness of pedicle.
The characteristics of typical lumbar
The spine is small and rounded at the tip.
vertebrae [upper four] are:
The body is largest of all lumbar vertebrae. Its
i. The body of vertebra is wider transversely
anterior surface is much wider than posterior
and the vertebral canal is triangular
surface.
ii. The pedicles are very short
The superior articular facet looks more
iii. The transverse processes are thin and have
no costal facets or foramen transversarium. backwards and inferior articular facet looks
These are homologous with ribs of thoracic more forwards.
region
Variations of Lumbar Vertebrae
iv. A small acessory process lies at the root of
transverse process. This represents true The fifth lumbar vertebra may be fused with
transverse process sacrum. The condition is known as sacralization
244 Essentials of Human Anatomy
The linea alba has the umbilical scar just formed by the aponeuroses of three oblique
below its midpoint. muscles of the anterior abdominal wall, to lodge
It is wider above umbilicus and narrow the rectus abdominis muscle.
below umbilicus. Location: The rectus sheath is located on the
It is surgically important for giving the
front of anterior abdominal wall between linea
midline incision for emergency surgery of
alba medially and linea semilunaris laterally.
abdomen.
Formation
The Rectus Sheath The posterior wall of the rectus sheath is
The rectus sheath is an aponeurotic envelope incomplete above the costal margin, and
below the arcuate line (linea semicircularis) a. Above the costal margin (Fig. 25.4)
that marks the lower limit of posterior wall. Anterior: wall is formed by
External oblique aponeurosis
The anterior wall is complete all over. The
Posterior: wall is absent and the
formation of rectus sheath can be studied rectus abdominis rests on costal
at following three levels: cartilages
Fig. 25.5: The rectus sheath (TS from costal margin to mid-point)
In case of portal obstruction this venous anasto- ii. The lateral cutaneous branches pierce the
mosis between superficial veins of anterior interocostal muscles and external oblique
abdominal wall and paraumbilical veins enlarges at the mid-axillary line.
giving rise to caput medusae (enlarged tortuous The lateral cutaneous branches divide
veins radiating from umbilicus). into anterior and posterior branches to
The deep veins supply the lateral aspect of abdominal
The deep veins of the anterior abdominal wall wall.
The lateral cutaneous branch of sub-costal
accompany the arteries.
crosses iliac crest and supplies the skin
The Lymphatic Drainage of the of anterior part of gluteal region.
iii. The anterior cutaneous branches divide
Anterior Abdominal Wall
into a medial and a lateral branch to
Above umbilicus the lymphatics pass upwards supply skin of front of abdominal wall.
and end in the axillary lymph nodes. The dermatomes (skin area supplied by one
Below umbilicus the lymphatics descend and spinal segment) are arranged horizontally
end in the superficial inguinal lymph nodes. parallel to each other in the abdominal wall.
b. The iliohypogastric nerve (ventral ramus of
The Nerve Supply L1 nerve) appears at lateral border of psoas major
The nerve supply of the anterior abdominal wall: The muscle, and pierces transversus abdominis muscle.
skin and muscles of the anterior abdominal wall are It passes forwards in the neuro-vascular plane
supplied by lower five intercostals (ventral rami of T7 of abdominal wall.
It pierces internal oblique and external
to T11 spinal nerves), subcostal (ventral ramus of T12)
oblique aponeuroses close to median plane
iliohypogastric and ilioinguinal nerves (both from
and comes out as anterior cutaneous nerve.
ventral ramus of L1 spinal nerve).
The iliohypogastric nerve supplies the skin of
a. The lower five intercostals and subcostals
hypogastric region above public symphisis.
enter the anterior abdominal wall from the costal
It also supplies the lower parts of oblique
margin.
muscles of the abdominal wall.
CourseThese nerves course forwards and The lateral cutaneous branch of
medially lying in the neuro-vascular plane of iliohypogastric nerve also supplies skin of
anteior abdominal wall between internal anterior part of gluteal region.
oblique and transversus abdominis muscles. c. The ilio-inguinal nerve (ventral ramus of
These nerves enter the rectus sheath by
L1 nerve) also appears at the lateral border of
piercing the posterior lamina of internal psoas major muscle.
oblique aponeu-rosis. It pierces transversus abdominis near anterior
They pass forwards through lateral half of end of iliac crest.
rectus abdominis and anterior wall of rectus It pierces internal oblique and passes forwards
sheath, and come out in superficial fascia as in inguinal canal, and comes out from
anterior cutaneous nerves. superficial inguinal ring.
Branches The ilio-inguinal nerve supplies skin of external
i. The muscular branches are given to genitals and upper part medial side of thigh.
supply anterolateral and anterior The nerve also supplies lower part of oblique
abdominal mus-cles. muscles of the abdominal wall.
252 Essentials of Human Anatomy
The inguinal region is surgically a weak part b. The posterior wall is formed by:
of the anterior abdominal wall, and inguinal Fascia transversalis throughout.
hernias take place in this region. Conjoint tendon in medial one-third.
In males, this region is concerned with the Reflected part of inguinal ligament in
descent of testes. medial one-fourth.
The inguinal canal is an oblique intermuscular The roof (superior wall) is formed by the lower
space formed in the inguinal region due to arching fibers of internal oblique muscle.
descent of testes in males (round ligament of The floor (inferior wall) is formed by:
uterus in females) (Fig. 25.7). Superior grooved surface of inguinal liga-
LocationThe inguinal canal lies a little ment.
above and parallel to medial half of the Superior surface of lacunar ligament.
inguinal ligament. The structures transmitted by the inguinal canal.
ExtentLaterally deep inguinal ring medially In males
superficial inguinal ring (Table 25.2). Spermatic cord.
Direction is downwards, forwards and medially. Cremasteric artery
Length is about 4.0 cm. Genital branch genito-femoral nerve
Ilioinguinal nerve
The Walls of the Inguinal Canal (Fig. 25.8) In females
The walls of the inguinal canal are formed by Round ligament of uterus
the layers of the anterior abdominal wall. Artery of the round ligament
The inguinal canal has anterior wall, posterior Nerve of the round ligament
wall, roof and floor. Ilioinguinal nerve
a. The anterior wall is formed by:
Sex Difference
External oblique aponeurosis.
Fleshy part of internal oblique in lateral The inguinal canal is wider in males, as it is
half. caused by the descent of testis
For this reason, the inguinal hernias are
commoner in males than females.
The normal mechanism of the inguinal canal. The
inguinal canal is potentially a weak part of
the anterior abdominal wall. The hernia through
the canal is normally prevented by the following
factors:
i. The obliquity of the canal is an important
factor preventing hernia.
ii. The increase in intra-abdominal pressure and
contraction of internal oblique muscle pushes
the posterior wall of canal firmly against the
anterior wall, thus preventing hernia.
iii. The contractions of internal oblique and the
transversus abdominis muscles, flatten their
lower borders, and thus exercise a safety
Fig. 25.7: The inguinal canal valve mechanism on the deep inguinal ring.
254 Essentials of Human Anatomy
Fig. 25.8: A section through inguinal region showing walls of inguinal canal
The Anterior Abdominal Wall and the Inguinal Region 255
Differences Between Oblique and The factors causing descent of testes are:
Direct Inguinal Hernia i. Hormonal factors gonadotropins and andro-
i. The direct hernia is situated mostly above gens.
the pubic bone, while oblique hernia ii. Relative growth of different parts of
descends to scrotum. posterior abdominal wall.
ii. The inferior epigastric artery is lateral to the iii. Mechanical factorgubernaculum testes
neck of direct hernia, while the artery is a fibro-muscular band, that is attached to
medial to the neck of indirect hernia. the lower end of developing testes and to
iii. The spermatic cord lies directly behind in the skin of future scrotum.
oblique hernia. In direct hernia the The gubernaculum shortens progressi-
spermatic cord lies postero-laterally. vely and pulls down the testes, along
with a tube of peritoneumthe pro-
The Descent of the Testes (Fig. 25.9) cessus vaginalis.
The gonad or sex gland (testes/ovary), develops
Sequence of Descent of Testes
behind peritoneum from the genital ridge in
upper lumbar region. The testes in males descend a. By third month of intra-uterine life, the testis
towards the perineum (future scrotum). comes to lie in the iliac fossa.
It supplies the skin of hypogastric region i. The genital branch is known as cremasteric
above pubic crest and symphysis. nerve in males. It lies lateral to the spermatic
Both ilio-inguinal and ilio- hypogastric cord and supplies cremaster muscle.
nerves also supply the lower parts of the three In females it is known as nerve of the
oblique muscles. An injury to first lumbar round ligament of uterus and supplies the
nerve weakens the lower parts oblique fibromuscular tissue of the round ligament.
muscles (i.e. in inguinal region) and makes ii. The femoral branch passes deep to
the person more prone to inguinal hernias. inguinal ligament lying lateral to femoral
c. The genitofemoral nerve is also a branch of artery in femoral sheath.
lumbar plexus (ventral ramus of L1- L2). The It pierces femoral sheath and deep fascia
nerve divides into a genital branch and a of front of thigh and supplies skin of
femoral branch. front of thigh below inguinal ligament.
CHAPTER 26
The Peritoneum
The abdominal cavity, more correctly called the The plane passes through
abdomino-pelvic cavity, is the largest cavity in i. The tips of ninth costal cartilages
the body: ii. Pylorus of stomach
It is divided intoabdominal cavity proper iii. The hila of both kidneys
and the pelvic cavity. iv. Origin of superior mesenteric
artery from front of abdominal
The Abdominal Cavity aorta
The abdominal cavity proper is bounded by [The subcostal plane was previously
its fascial linings. used in place of transpyloric plane.
Superiorly is diaphragmatic fascia This plane passes through third
Inferiorly it communicates with the pelvic lumbar vertebra.]
cavity at the inlet of pelvis. b. The trans-tubercular plane encircles the
Antero-laterally is fascia transversalis trunk at level of fifth lumbar vertebra.
Posteriorly is fascia iliac. The plane passes through tubercles
Contents of the iliac crest.
i. Most parts of gastro-intestinal tract. The vertical planes
ii. The accessory glandsthe liver, its excre- There are two vertical planesright and
tory apparatus and the pancreas. left extend vertically from the mid-
iii. The spleen inguinal points up to mid-clavicular points
iv. The kidneys, ureters and supra-renal glands. above (Fig. 26.1).
v. The blood vessels The abdominal cavity proper is divided into
Abdominal aorta and its branches nine regions with the help of two horizontal and
Inferior vena cava and its tributaries two vertical planes.
Portal vein and its tributaries Above transpyloric plane
vi. Peritoneal folds or mesenteries 1. The right hypochondrium
vii Fat 2. The epigastrium
viii Mesenteric lymph nodes 3. The left hypochondrium
The regions of the abdominal cavity proper: The Between transpyloric and trans-tubercular
abdominal cavity proper is divided into regions planes
to help in the topographical study of the organs. 4. The right lumbar region
The division is done with the help of two 5. The umbilical region
horizontal planes and two vertical planes. 6. The left lumbar region
The horizontal planes Below the trans-tubercular plane
a. The transpyloric plane encircles the 7. The right iliac fossa
trunk at level of lower border of first 8. The hypogastrium
lumbar vertebra 9. The left iliac fossa
260 Essentials of Human Anatomy
THE PERITONEUM the digestive tube to ventral and dorsal body wall,
respectively.
The peritoneum is the largest and most complex
serous sac in the body. The ventral mesentery gives rise to the
The peritoneum consists of two layersparietal following peritoneal folds in the adults
and visceralenclosing a potential cavity. i. The ligaments of the liver
A. The parietal layer forms the inner lining of a. The coronary ligament has two
the abdominal walls and diaphragm. layers anterior and posteriorand
The layer develops from the somatopleure connects liver to the diaphragm.
part of secondary mesoderm. b. The triangular ligamentsright and
B. The visceral layers covers the outer surface of leftalso connect the liver to the dia-
abdominal viscera partially or completely phragm
It also forms peritoneal foldsmesen- c. The falciform ligament is a large, sickle-
teriesto connect the viscera to the body shaped fold that connects the liver to
wall. anterior abdominal wall and diaphragm.
The visceral layer develops from the It contains ligamentum teres of liver
splanchnopleure part of secondary meso- in its lower bordera remnant of
derm. left umbilical vein of fetal life.
ii. The lesser omentum is a fold of peritoneum
The Mesenteries connecting the liver with lesser curvature of
The mesenteries or folds of peritoneum suspend stomach and duodenum.
parts of digestive tube from the body wall. It is divided into two parts:
In the fetal life the developing digestive tube a. The hepato-gastric part is the larger
has two mesenteriesventral mesentery up to part between the liver and the sto-
umbilicus and a dorsal mesenteryconnecting mach.
The Peritoneum 261
b. The meso-duodenum is present in fetal The peritoneal cavity is the potential space between
life only. the parietal and visceral layers of peritoneum.
262 Essentials of Human Anatomy
Normal content is a small amount of serous The lesser sac is a closed space and
fluid that lubricates the opposing surfaces and communicates with greater sac through an
this facilitates the movements of intestines. opening the epiploic foramen.
Abnormal contents can be: Boundaries of the lesser sac
a. Collection of inflammatory fluid in patho- a. The anterior wall is formed by
logical conditions called ascitis. The lesser omentum
b. Air or gas (pneumo-peritoneum) from Peritoneum covering postero-inferior
external injury or perforation of hollow surface of stomach and 2.0 cm of
viscus. duodenum.
c. Blood (hemo-peritoneum) may collect in the Anterior two layers of greater omen-
peritoneal cavity due to external injury or tum.
perforation of a viscus leading to rupture of b. The posterior wall is formed by:
blood vessels. The organs commonly Posterior two layers of greater
involved are liver, spleen, gastric ulcer and omentum
tubal pregnancy in females. Transverse colon and transverse
mesocolon fused with posterior
Subdivisions of Peritoneal Cavity layers of greater omentum.
The peritoneal cavity is divided into Peritoneum covering upper part of
A. The lesser sac or omental bursa. posterior abdominal wall.
B. The greater sac The borders of the lesser sac (omental bursa)
A. The lesser sac of peritoneum (omental bursa) is are fourinferior, superior, right and left.
the smaller part of peritoneal cavity that lies a. The inferior border developmentally is
behind stomach and lesser omentum (Fig. 26.2). the lower border of greater omentum.
Fig. 26.2: A vertical section of abdomen showing lesser sac (omental bursa)
The Peritoneum 263
ii. The right posterior subphrenic space ii. The left posterior subphrenic space
(Hepato-renal or Morrisons pouch) is corresponds to the superior recess of
situated between the inferior surface of the lesser sac.
right-lobe of liver and upper pole of B. The infracolic compartment of greater sac of
right kidney. peritoneum is divided into following regions:
The hepato-renal pouch is the most i. The right infracolic space lies below the
dependent part of the peritoneal transverse mesocolon and to the right side
cavity when person is in supine of mesentery of small intestine.
position. The space becomes narrow below,
The pouch communicates with where the vermiform appendix lies.
The lesser sac or omental bursa The space does not communicate with
The right paracolic gutter
the pelvic cavity.
The right anterior subphrenic
ii. The left infra-colic space is a wide space
space.
limited above by the transverse mesocolon:
An infection in any part of peritoneal
It lies to the left side of mesentery of
cavity may give rise to collection of
infected material in hepato-renal small intestine and communicates
pouch, when patient is put in supine freely with the pelvic cavity via the
position. inlet of pelvis.
iii. The right extra-peritoneal subphrenic iii. The right and left paracolic gutters lie
space corresponds to the bare area of lateral to the ascending colon and
liver, where the posterior surface of descending colon respectively.
right lobe of liver lies in direct contact The right paracolic gutter communicates
with the diaphragm. superiorly with the hepatorenal pouch.
2. The left subphrenic space are two in number The left paracolic gutter is closed above
i. The left anterior subphrenic space lies by the phrenico-colic ligament connec-
between the diaphragm and anterior and ting the left colic flexure to the dia-
superior surfaces of left lobe of liver. phragm.
The Peritoneum 265
The left paracolic gutter communicates iii. The paraduodenal recess is seen in
below with the pelvic cavity. only about 2% of adults.
It is a large recess guarded by a
The Peritoneal Recesses paraduodenal vascular fold, that
The peritoneal recesses are small spaces of the contains inferior mesenteric vein, and
peritoneal cavity guarded by peritoneal folds, ascending branch of left colic artery.
some of which may contain blood vessels. This recess may be a site of internal
The peritoneal recesses may be site of hernia as a developmental anomaly
internal hernia when a small part of intestine seen in children.
iv. The retroduodenal recess is rarely present
may be held up in one of them.
The omental bursa is the largest peritoneal It is a large recess present behind the
recess. third and fourth parts of duo-
A. The duodenal recesses (Fig. 26.5) denum.
i. The superior duodenal recess present v. The mesocolic recess present in about
in about 50% cases. It is guarded by a 20% cases.
small fold attached to the left side of It lies between the transverse meso-
terminal part of duodenum. colon and duodeno-jejunal junction.
ii. The inferior duodenal recess present in vi. The mesenterico-parietal fossa of
about 75% cases. Waldeyer is present more frequently in
It is usually present along with the the newborn.
superior recess. In adults, it is present in about 2%
It is also guarded by a small fold cases. In this recess, the duodenum
attached to left side of terminal part invaginates the root of mesentery.
of duodenum. B. The Cecal recess (Fig. 26.6)
i. The superior ileocecal recess is
guarded by a vascular fold containing
anterior cecal artery.
It lies at the ileocecal junction, and is
limited behind by the mesentery.
Fig. 26.5: The duodenal recesses Fig. 26.6: The cecal recesses
266 Essentials of Human Anatomy
ii. The inferior ileocecal recess is guarded The Blood Supply of the Peritoneum
by a bloodless fold (of Treeves) i. The parietal peritoneum is developed from
It is also limited behind by the mes- the somatopleure part of secondary meso-
entery. derm.
iii. The retrocecal recess lies behind the It is supplied by the somatic blood
cecum vessels of the abdominal and pelvic
It is variable in size and may ascend walls.
behind ascending colon. ii. The visceral peritoneum is developed from
The recess is bounded on either sides the splanchnopleure part of secondary
by the two cecal folds. mesoderm.
It frequently contains the vermiform It is supplied by the blood vessels
appendix. supplying the viscera that it covers.
C. The intersigmoid recess is usually present
in fetal life and in infants. The Lymphatic Drainage of the
It lies behind the apex of inverted V- Peritoneum
shaped attachment of pelvic mesocolon. The parietal peritoneum is drained by the
It varies in size and left ureter lies in its lymphatics joining those of the body wall, and
posterior wall. draining into regional parietal lymph nodes.
It is potential site for internal hernia, The visceral peritoneum has its lymphatics join
involving pelvic colon or terminal coil lymphatics of the viscera and end in the visceral
of ileum. lymph nodes.
D. The fossae in the anterior abdominal wall
i. The lateral inguinal fossa is a shallow The Nerve Supply of the Peritoneum
depression that lies lateral to the lateral The parietal peritoneum is supplied by the
umbilical fold (formed by the inferior somatic nerves, that also innervate the body wall.
epigastric artery) The parietal peritoneum is very sensitive to
The fossa is site for oblique (indirect all exteroceptive sensations.
inguinal hernia) The visceral peritoneum is supplied by the
ii. The medial inguinal fossa lies medial autonomic nerves, hence it is insensitive to
to the lateral umbilical fold and lateral ordinary exteroceptive sensations.
to medial umbilical fold (raised by However, tension causes pain when applied to
medial umbilical ligament, a remnant viscera or visceral peritoneum. Also spasms
of umbilical artery) of visceral muscles cause colic type of pain.
The fossa is site for direct inguinal
hernia. Applied Anatomy
iii. The supra-vesical fossa lies above the The peritonitis is an acute inflammatory
apex of urinary bladder, between medial condition of the peritoneal cavity.
umbilical fold and median umbilical fold The inflammation of parietal peritoneum causes
(raised by median umbilical ligament, a tension and guarding of the anterior abdominal
remnant of urachus). wall muscles, thereby causing a rigid abdomen.
The Peritoneum 267
The nerve supply of parietal peritoneum by The three parts of gut have their main arterial
the somatic nerves makes the abdomen supply by the three branches of abdominal aorta
extremely tender and painful. For foregutcoeliac axis artery
The inflammation of visceral peritoneum is For midgutsuperior mesenteric artery
secondary to the inflammation of the organ. For hind gutinferior mesenteric artery.
The condition causes colic type of abdominal The abdominal part of gut (i.e. caudal part of
pain due to stretching of the automatic nerves. foregut, midgut and hind gut) is suspended by
The paracentesis consists of removal of fluid of mesenteries from the body wall.
ascitis that is collected in the peritoneal cavity. 1. The dorsal mesentery connects the gut to
The fluid that is inflammatory in nature (rich the dorsal body wall.
in proteins) may collect in 2. The ventral mesentery is only present up to
Hepatorenal pouch foregut portion and connects it to the
Pelvic cavity ventral body wall above umbilicus.
The fluid level can be percussed through the Development and Rotation of Stomach
anterior abdominal wall or seen in X-ray of
the abdomen. The stomach develops as a fusiform dilatation
The fluid is removed by a cannula introduced from the caudal part of foregut in fifth week of
through the sides of the abdomen. intra-uterine life.
Due to development of liver on right side of
The Rotation of Gut the abdominal cavity, the developing stomach
undergoes a 90 rotation to the right.
Stage before of gut
As a result of rotation, the left surface
The gut or digestive tube developes from becomes anterior surface and the right surface
the part of yolk sac included within the becomes posterior surface.
embryo after formation of head, tail and
Along with rotation, the dorsal surface (left
lateral folds.
after rotation) grows more rapidly and forms
By fifth week of intrauterine life the gut is
the greater curvature of stomach.
divided into three parts:
The greater omentum is formed by
a. The foregut extends from the stomo-
deum or primitive mouth cavity up to enlargement and folding of dorsal mesentery
beginning of hepatic diverticulum of stomach (mesogastrium). The omental
(opening of bile duct). The foregut is bursa also develops along with it.
divided into: Rotation of Duodenum
1. A cranial part that lies above dia-
phragm Due to rotation of stomach, the duodenum moves
2. A caudal part that lies below dia- posteriorly and forwards to the right and assumes
phragm a C-shaped position.
b. The midgut extends from the opening The meso-duodenum also becomes fused with
of bile duct up to junction of right two- the peritoneum of dorsal body wall, thus making
third and left one-third of transverse the duodenum, a retro-peritoneal structure.
colon. The pancrease, that develops in the mesoduo-
c. The hindgut portion extends from the denum also becomes retroperitoneal.
left one-third of transverse colon up to The duodenum in second month of intrauterine
the anal canal. life passes through a solid state and later
268 Essentials of Human Anatomy
canalises. This condition may result in place between tenth and eleventh weeks of intra-
narrow-ing of lumen of duodenum. uterine life (Fig. 26.8).
The abdominal cavity grows larger in size, so
The Rotation of the Midgut the physiological hernia is reduced.
The midgut portion undergoes rotation in three The cranial (right) limb reduces first and
stages. passes behind the superior mesenteric artery
i. The first stage (stage of physiological to come to lie in the left upper quadrant. This
umbilical hernia): This stage takes place between explains the position of jejunum in left upper
fifth and tenth weeks of intrauterine life (Fig. 26.7). part of abdomen, and the superior mesenteric
The midgut grows rapidly and forms a U-loop artery passing in front of duodenum.
that herniates through umbilicus into the extra-
embryonic coelom of the umbilical cord.
The midgut loop is connected to the yolk sac
by vitello-intestinal duct, that may persist
later as Meckels diverticulum.
The midgut loop, inside umbilical cord undergoes
a 90 rotation anticlockwise around the axis
of superior mesenteric artery.
The right (cranial) limb develop into:
The caudal part of duodenum
The jejunum and ileum up to Meckels
diverticulum (vitello-intestinal duct)
The left (caudal) limb develops into:
The terminal part ileum
The ascending colon
The right two-third of transverse colon
ii. The second stage of rotation (Stage of
reduction of physiological hernia): This stage takes Fig. 26.8: The second stage of rotation of midgut
The Peritoneum 269
The caudal (left) limb reduces last and the The transverse attachment of transverse
cecum comes to lie below liver on the right meso-colon on dorsal body wall divides the
side. peritoneal cavity into:
The withdrawal of hernia also results in anti- A supracolic compartment
clockwise rotation of midgut by 180, so that An infracolic compartment
the total rotation of 270 around axis of
superior mesenteric artery takes place. Anomalies of Rotation of Mid-Gut
iii. The third stage of rotation (Stage of retroperi-
1. Non rotation of gut: The midgut loop does not
tonization or fixation of gut): This stage takes
undergo any rotation as it returns to the abdo-
place from eleventh week till end of intra-uterine
minal cavity.
life (Fig. 26.9).
The cecal diverticulum of the caudal (left) limb In such cases the jejunum and ileum lie on
of midgut loop descends from the subhepatic right side of abdominal cavity.
position to its adult position in right iliac fossa. The colon lies on the left side of
The cecal diverticulum differentiates into abdominal cavity.
vermiform appendix (from terminal part) and The small intestine may undergo twisting
cecum (from basal part). around the superior mesenteric artery,
The ascending mesocolon and descending resul-ting in volvulus, causing obstruction
mesocolon fuse with the parietal peritoneum in the intestine that may lead to necrosis.
of dorsal body wall and thus the ascending 2. The reverse rotation of gut is a rare condition
and descending colon become retroperitoneal. and may involve other organs also
The posterior two layers of greater omentum In this condition, the position of different
fuse with the two layers of transverse meso- parts of gut is exactly opposite (mirror
colon. image of the normal) while external
appearance remains normal.
3. The malrotation of gut consists of various
stages of incomplete rotation of midgut loop.
More frequently, it involves cecum, which
may remain in sub-hepatic or lumbar
position.
Malrotation may also cause paraduodenal
hernia.
4. The congenital umbilical hernia results from
incomplete reduction of physiological
umbilical hernia of the embryo.
The child is born with a loop of small
intes-tine in the umbilical cord covered by
a layer of peritoneum and amnion.
It is a rare condition, but it should be
recog-nized before ligating the umbilical
cord after birth.
5. The Meckels diverticulum is the persistent
remnant of proximal part of vitello-intestinal
Fig. 26.9: The third stage of rotation of midgut duct.
270 Essentials of Human Anatomy
(The gastric surface of spleen is i. The cardiac part is further divided into:
separated from the postero superior a. The fundus is convex bulging part that
surface of stomach by the greater lies above the level of cardiac opening.
sac of peritoneum. b. The body is the remaining portion of the
The stomach is divided into two partsthe cardiac part.
cardiac part and pyloric part (Fig. 27.2). ii. The pyloric part is the narrow tubular
portion and is further divided into:
An imaginary plane passing from the angular
a. The pyloric antruma slightly dilated
notch of lesser curvature is joined to the left
part below the angular notch.
end of the bulge on greater curvature to divide
b. The pyloric canalabout 3.0 cm long,
the stomach. narrow part that lies proximal to the
pyloric sphincter.
The pyloric sphincter, that guards the pyloric
opening is sometimes abnormally thick in
infants(Congenital pyloric stenosis) requiring
surgical correction.
The interior of stomachPresents
i. The gastric rugae or folds of mucous mem-
brane in empty state of stomach.
These folds are temporary and disappear
when stomach becomes full.
ii. The gastric canal consists of permanent
longitudinal folds along the lesser curvature
Fig. 27.2: The stomachbed enclosing a canal.
274 Essentials of Human Anatomy
Right renal vessels The fourth part ascends to the left side
Right edge of inferior vena cava of abdominal aorta and second lumbar
The second part receives the opening of vertebra upto duodeno-jeunal flexure.
hepato-pancreatic ampulla on summit It is related
of major duodenal papilla, about Anteriorly to
middle of its postero-medial wall. The left layer of mesentery
c. The third part (Horizontal part) is about Transverse mesocolon and
10.0 cm long and is also retro-peritoneal trans-verse colon.
(Fig. 27.7). Posteriorly to
The third part crosses the front of third Left psoas major
lumbar vertebra from right to the left
Left testicular (ovarian) vessels
of median plane.
Inferior mesenteric vein
It is related
Left sympathetic chain
Anteriorly to coils of jejunum,
A fibro-muscular bandsuspensory ligament of
except near its left end where the
Treitzis present sometimes, connecting the
root of mesentery and the superior
mesen-teric vessels cross it. fourth part of duodenum to the right crus of
Posteriorly to diaphragm. Its upper part has striated muscle
Right psoas major fibers and lower part has smooth muscle fibers.
Right ureter The blood supply of duodenum
Inferior vena cava The arteries supplying duodenum are
Right testicular (ovarian) vessels branches of coeliac axis artery and superior
Abdominal aorta mesenteric arteries (Fig. 27.8).
Origin of inferior mesenteric artery i. The superior pencreatico-duodenal is a
d. The fourth part (Ascending part) is the branch of gastroduodenal artery (from
shortest part and is only about 2.5 cm long. common hepatic artery).
ii. The inferior pancreatico-duodenal artery is The veins end in portal vein and superior
a branch of superior mesenteric artery. mesenteric vein (Fig.27.9)
iii. The supra-duodenal artery (of Wilkie) is a The lymphatic drainage
branch of common hepatic artery. The lymphatics of duodenum end in sub-
This artery supplies first part of pyloric nodes, situated between the head
duodenum. It is present in about 30% of pancreas and duodenum.
cases and is supposed to be an end Some lymphatics end in superior mesenteric
artery. A thrombosis or blockage of lymph nodes.
this artery is said to be one of the The nerve supply of duodenum
causative factors of duodenal ulcer. The sympathetic supply of duodenum is
The veins provided by the coeliac plexus.
The veins of the duodenum accompany the The parasympathetic supply is by the vagus
artery, except supra-duodenal artery. nerves and reaches via coeliac plexus.
bladder fossa and fissure for ligamentum c. The colic impression for right colic
teres. flexure and beginning of transverse
The inferior surface presents following colon is present on right lobe and
impressions (better seen in the hardened anterior part of quadrate lobe.
specimen) for the organs (Fig. 27.12) d. The renal impression is prominently
a. The gastric impression is present present on the right lobe behind colic
on left lobe; the pyloric portion in impression. It is related to upper part
the quadrate lobe. of right kidney.
b. The duodenal impression is located e. The suprarenal impression is
on the right lobe just to the right of located above renal impression. It
gall bladder fossa. lies partly in the bare area.
The gall bladder fossa lies on right side vessels. Their bile drainage is also in
of quadrate lobe. The body and neck the left hepatic duct.
of the gall bladder lie here in direct Thus the dividing line between the
relation to the liver. functional (physiological) right and
The porta hepatis is a wide gap in post- left lobes passes from gall bladder
erior part of inferior surface. It trans- fossa and groove for inferior vena
mits. cava on inferior and posterior sur-
Two hepatic ducts right and left faces.
anteriorly The segmentation of liver (Fig. 27.13)
Two branches of hepatic artery in The liver is divided into segments, depending
the middle upon the principal branches of hepatic artery
Two branches of portal vein post- and accompanying hepatic ducts.
eriorly Although, the segments are regarded as
Sympathetic nerves and lymphatics functionally independent with least intrahepatic
The caudate process is a narrow bridge of arterial anastomoses, there are exceptions to
liver tissue that connects the caudate
this. However, before segmental resection of
lobe with remaining part of right lobe.
liver, portal venography and cholangiography is
The fissure for ligamentum teres is a
needed to find out individual variations.
deep fissure on left boundary of
The peritoneal attachments
quadrate lobe.
a. The falciform ligament extends from the
The quadrate lobe is a quadrangular part
anterior abdominal and diaphragm to the
of liver between inferior border and
liver.
porta hepatis. It has fissure for
It is a sickle-shaped fold, and contains
ligamen-tum teres on left side and gall
the ligamentum teres (remnant of left
bladder fossa in right side.
The liver has only one sharp inferior umbilical vein) in its free border.
border, that separates the anterior and b. The coronary ligament has two layers
right lateral surface from the inferior superior and inferior. It connects posterior
surface. surface of liver to the diaphragm and
The lobes of the liver encloses the bare area of liver.
The liver is divided into two lobesright and c. The right triangular ligament is formed by
left by: the meeting of two layers of coronary
Attachment of falciform ligament
Fissure for ligamentum venosum
Fissure for ligamentum teres
The right lobe has two smaller lobes
i. The caudate lobe on posterior surface
ii. The quadrate lobe on inferior surface
Functionally the caudate and quadrate
lobes belong to the left lobe; as their
blood supply (portal vein and hepatic
artery) is from the left branches of these Fig. 27.13: The segmentation of liver
282 Essentials of Human Anatomy
ligament. It forms the apex of the bare area The right and left branches of
and connects the right lobe to diaphragm. hepatic artery and portal vein
d. The left triangular ligament is a small fold supply the right and left
that connects the left lobe of liver to the physiological lobes of the liver.
diaphragm. The veins
e. The lesser omentum connects the liver to The hepatic veins (2-3) collect venous blood
the lesser curvature of stomach and first from the central veins of the hepatic lobules.
2.5 cm of duodenum. The hepatic veins pierce the inferior vena caval
The bare areas of the liver groove and open directly in inferior vena cava.
The bare areas are parts of liver surface that The lymphatic drainage of liver
are not covered by visceral layer of The superficial lymphatics end in the lymph
peritoneum. nodes around terminal part of inferior vena
The main bare areas are: cava. Some open directly into thoracic duct.
a. The bare area proper is a large triangular
The deep lymphatics are divided into two
area on posterior surface between two
groups.
layers of the coronary ligament.
Ascending trunks end in the lymph nodes
b. The groove for inferior vena cava is a
around inferior vena cava.
wide shallow groove on posterior
Descending trunks end in hepatic lymph
surface that lodges the highest part of
nodes.
inferior vena cava.
The nerve supply of the liver
c. The gall bladder fossa is a shallow
The nerve supply of liver is via the hepatic
depression on inferior surface that lies
plexus of nerves accompanying hepatic
in direct contact with body and neck of
artery, from the coeliac plexus.
gall bladder.
The hepatic plexus carries both sympathetic
In bare area proper, the liver lies
and parasympathetic fibers.
directly in relation to diaphragm,
Applied anatomy
so any hepatic abscess or cyst can
i. Hepatitis or inflammation of liver can
burst through diaphragm into the
occur due to viral infection.
pleural cavity or any pulmonary
This condition can lead to jaundice due
abscess can burst through dia-
to liver damage.
phragm into liver.
ii. Cancer of liverThe liver is a common
The blood supply of liver site for metastasis (or secondary deposit)
The afferent supply of cancer of some parts of digestive tract.
The liver has two sources of blood supply. Primary carcinoma of liver is a rare
a. The arterial blood is brought by the condition.
hepatic artery. It supplies nearly 20% iii. Abscess of liver may occur due to amoebic
of the total blood to the liver. infection. The abscess can burst through
b. The portal blood carrying absorbed bare area of liver into lung.
nutrients from the intestines is brought iv. Regenerationthe liver has great power
by the portal vein. of regeneration. After injury or operation a
The portal vein supplies nearly portion of liver can be removed without
80% of the total blood to the liver. much damage to its functions.
The Gastrointestinal System1 283
iv. The common bile duct is formed by the union iii. Anomalies of hepatic ducts
of cystic duct with common hepatic duct. Accessory hepatic duct.
Length is about 8.0 to 10.0 cm. Applied anatomy
CourseThe bile duct descends in the i. Cholecystitis is inflammation of gall bladder.
free border of lesser omentum in front The condition may give rise to biliary
of portal vein and to the right of colic, that is referred to T5 to T8
hepatic artery (supra-duodenal part) derma-tome.
It then passes deep to the first part The condition is common in fat females
of duodenum (retro-duodenal part). above the age of forty and may
The bile duct descends in a groove become chronic.
on posterior surface of head of Gallstones (cholesterol stones), usually
pancreas and (infra-duodenal part). multiple, may develop in cases of
It turns laterally for termination. chronic cholecystitis.
Termination of bile duct The common bile Small stones may pass through bile duct,
duct joins with the main pancreatic duct but the bigger stones may get impacted
to form the common hepato-pancreatic in the bile duct or hepato-pancreatic
ampulla (Ampulla of Vater). ampulla giving rise to the obstructive
The ampulla pierces the duodenal wall type of jaundice.
very obliquely and opens on the ii. Cholecystogram is special X-ray procedure
summit of major duodenal papilla to visualize the healthy gall bladder.
located about middle of postero- A radiopaque dye is given, which is
medial wall of duo-denum. excreted by the liver in the bile.
Sometimes the two ducts may not join to The bile is concentrated in gall bladder
form a common ampulla, and open and a shadow of dye in gall bladder is
separately in the duodenum. seen.
A thickening of circular muscle coat of Since a diseased gall bladder cannot
duodenum surrounds the common concentrate bile, it is not visualized.
ampulla and form the Sphincter of
Oddi. A similar sphincter also THE PANCREAS
encircles the terminal parts of the bile The pancreas is lobulated greyish pink gland that
duct and main pancreatic duct. lies in the curvature of duodenum.
The variations in the biliary passages are quite Type
common. Some important ones are as follows: The pancreas is mixed gland. It has
i. Anomalies of gall bladder a. An exocrine part that secretes
Congenital absence pancreatic juice.
Double gall bladder b. An endocrine part that secretes insulin
Septate gall bladder and other hormones.
Sessile gall bladder LocationThe pancreas lies behind
Solid gall bladder peritoneum in upper part of posterior
ii. Anomalies of cystic duct abdominal wall, at back of epigastrium and
Congenital absence left hypochondriac region.
Very short PartsThe pancreas hasa head, neck, body
Very long and tail (Fig. 27.15).
The Gastrointestinal System1 285
It has two or three notches near the lateral The lymphatics from the capsule end in
end indicating the lobulated origin of spleen. the pancreatico-splenic lymph nodes.
ii. The inferior border separates the renal There are no lymphatics in the splenic pulp.
impression from the diaphragmatic The nerve supply
surface. The nerves of the spleen are derived
The peritoneal relations: The spleen is com- from the coeliac plexus and reach
pletely covered by peritoneum except at the along the splenic artery.
hilum. The sympathetic nerves are vasomotor in
The spleen is supported by two peritoneal nature.
folds. The functional significance of spleen The
a. The gastro-phrenic ligament connects spleen performs a number of functions.
the spleen to the greater curvature of i. Destruction of red blood cells in adults.
sto-mach. ii. Formation of lymphocytes.
It contains the short gastric arteries iii. Part of reticulo-endothelial system. It
(5-7) and left gastro-epiploic artery. helps to catch the toxins and other
b. The lieno-renal ligament connects the harmful substances, e.g. enlargement
hilum of spleen to the front of left kidney. of spleen in cases of malaria.
It contains the splenic vessels and iv. Immunological functionsby
the tail of pancreas between the producing antibodies.
two layers. In fetal life, the spleen, also has
The phrenico-colic ligament (sustentaculum hemopoietic function.
lienis) connects the left colic flexure to the In humans, the spleen does not act as
diaphragm. reser-voir of blood.
It supports the lateral end of spleen. Applied anatomy
The blood supply of the spleen. i. Enlargement of spleen (splenomegaly)
The arteries may occur in number of conditions, e.g.
The spleen is supplied by the splenic Parasitic infections like malaria
arterya large and tortuous branch of and kala azar.
coeliac axis artery. Hemopoietic deseases due to in-
The splenic artery divides into five to six creased red blood cell breakdown.
branches before entering the hilum. Portal obstruction.
The veins Enlarged spleen becomes very
The splenic vein is formed by five or six friable and can be easily lacerated.
large tributaries emerging from the hilum. ii. Splenectomy is done to remove
The splenic vein joins with superior mes- enlarged spleen. Spleen is not a vital
enteric vein to form the portal vein. organ, as its functions can be taken up
The lymphatic drainage by other lym-phoid organs.
CHAPTER 28
The Gastrointestinal
System2
THE JEJUNUM AND THE ILEUM flexure on the left to the ileocecal junction
on the right. The root contains superior
The jejunum and ileum constitute the large part mesenteric vessels between the two layers.
of small intestine extending from duodeno- The root of mesentery crosses the following
jejunal flexure up to junction of cecum and structures on posterior abdominal wall
ascending colon (Fig. 28.1 and Table 28.1) Abdominal aorta
Length about 6 metres (20 feet) Inferior vena cava
The jejunum constitutes proximal two-fifth Right psoas major
part (nearly 8 feet) Right ureter
Right testicular (ovarian) vessels
The ileum constitutes distal three-fifth part
(nearly 12 feet) Table 28.1: Differences between jejunum and ileum
The mesentery The jejunum and ileum are
Jejunum Ileum
completely covered by peritoneum, and are
1. Position in Mostly in upper Mostly in hypo-
suspended by a large peritoneal foldthe
abdominal left portion gastroic region above
mesenteryfrom the posterior abdominal wall. cavity pubic symphysis
The root (attachment) of mesentery is 2. Diameter About 4.0 cm About 3.0 cm
oblique and extends from duodeno-jejunal 3. Walls Thick Thinner
Contd...
II. The small intestine can be resected up to Size: The cecum is about 6.0 cm long and 7.5
one third of its total length without seriously cm broad.
impairing its junction. Shape: Four types of cecum are described by
III. Gastro-jejunostomy is one of the Treeves, so far as the shape is concerned (Fig.
operations done in cases of peptic ulcer. 28.2).
The stomach is anastomosed with jejunum i. The first type (Infantile type) is seen in
bypassing duodenum. about 2 percent cases.
In this type cecum is represented as a
THE LARGE INTESTINE conical sac with appendix attached to
The large intestine begins in right iliac fossa at its tip
ii. The second type (Quadrate type) is seen in
cecum, where terminal ileum ends.
about 3 percent cases.
The parts of the large intestine are
In this type, there are two equal saccu-
The cecum
lationsright and leftand appendix
The vermiform appendix
is attached to the depression between
The colonascending, transverse, descen-
the two saccules
ding and sigmoid (pelvic)
iii. The third type (Normal type) is seen in
The rectum
about 90 percent cases.
The anal canal In this type, the right saccule is larger
The main function of the large intestine (chiefly
and left saccule is smaller. The
colon) is absorption of fluids and solutes
appendix is pushed toward the
The features of the large intestine are ileocecal junction medially.
a. It has greater caliber in most parts than small iv. The fourth type (Exaggerated type) is seen
intestine and it has greater distensibility.
in nearly 4 percent cases.
b. Most parts of large intestine are fixed or
retro-peritoneal.
c. The longitudinal muscle coat (except
rectum and anal canal) is incomplete. It is
concen-trated in form of three taenia coli.
d. The large intestine shows sacculations.
e. It has small pouches of peritoneum filled
with fat (appendices epiploiceae) attached
to the surface (exception rectum and anal
canal).
The length of the large intestine is nearly 1.5
metres (6 feet).
Cecum
The cecum is the enlarged sac, that forms the first
part of large intestine.
Location: The cecum lies in the right iliac
fossa below the trans-tubercular plane. Fig. 28.2: The four types of caecum
292 Essentials of Human Anatomy
In this type the right saccule is much ii. The appendicular opening is small, oval
larger, and left saccule is nearly opening situated about 2.0 cm below the
atrophic. The appendix is attached just ileocecal opening.
close to the ileocecal junction. There is, sometimes, a semilunar fold of
Relations mucous membrane forming an
The cecum is a retroperitoneal organ, incomplete valve at the opening.
covered by peritoneum on front and sides. The Blood supply of cecum
Anteriorly it is related to coils of terminal The arteries The cecum is supplied by the
ileum separating it from anterior anterior and posterior cecal branches of
abdominal wall. ileocolic artery.
Posteriorly it is related to The veins of the cecum end in the ileocolic
Iliacus and lateral border of psoas vein, that joins the superior mesenteric vein.
majormuscle. The lymphatic drainage of cecum: The
Femoral nerve and lateral lymphatics of the cecum end in the ileocolic
femoralcutaneous nerve of thigh. lymph nodes (15-20) situated along the
A retro-cecal recess is present fre- ileocolic vessels.
quently and it contains vermiform The ileocolic nodes include anterior cecal
appendix. nodes and posterior cecal nodes
Interior of cecum: The interior of cecum An appendicular node is present in meso-
shows two openings appendix
i. The ileocecal opening is situated on the The nerve supply of cecum: The nerve supply
postero-medial wall at junction of cecum is both by sympathetic and para sympathetic.
and ascending colon (Fig. 28.3). The sympathetic nerves are branches of the
The opening is elliptical in shape and coeliac plexus
guarded by an ileo-cecal valve The parasympathetic nerves are derived
The ileo-cecal valve is formed by from the vagus nerves.
thickening of the circular muscle coat
of terminal ileum. THE VERMIFORM APPENDIX
It prevents regurgitation of contents of The vermiform appendix is a narrow tubular
cecum into terminal ileum. structure attached to the postero-medial wall of
cecum, about 2.0 cm below the terminal ileum.
Location: The appendix lies in the right iliac
fossa along with cecum
Length varies from 2.0 to 20.0 cm (average is
9.0 cm)
PositionsSince the appendix has a mesentery,
it can change its position (Fig. 28.4)
The various positions are
a. The retrocecal (Retrocolic) position
where the appendix is present in retro-
cecal recess behind cecum (or ascen-
Fig. 28.3: The interior of cecum ding colon if it is long enough)
The Gastrointestinal System2 293
McBurneys point is the junction of medial B. The transverse colon is the second part of
two-third and lateral one-third of a line colon.
connecting umbilicus to the anterior The transverse colon begins at the right colic
superior iliac spine flexure in front of right kidney
The point marks the base of appendix and It ends at the left colic flexure near lateral end
also the site for incision for the operation of spleen
of appendicectomy. Length is about 45-50 cm
LocationThe transverse colon extends from
Colon the right lumbar region, and crosses upper
The colon is divided into four parts: ascending, part of umbilical region and ends in left hypo-
transverse, descending and sigmoid (pelvic). chondriac region, making a U-shaped curve.
A. The ascending colon is the first part of colon. The position also depends upon the degree
LocationThe ascending colon ascends in of distention of transverse colon and sto-
the right lumbar region from the trans- mach
tubercular plane to midway between subcostal The transverse colon is suspended by a
and transpyloric planes. peritoneal foldtransverse mesocolon
Length is about 15-20 cm from the posterior abdominal wall
The ascending mesocolon is lost during The transverse mesocolon is fused in adults
development, so the ascending colon is a with posterior layers of greater omentum.
retroperitoneal structure, covered on front Relations
and sides by peritoneum SuperiorlyLiver and gall bladder
Relations Greater curvature of stomach
Anteriorcoils of ileum and greater Lateral end of spleen
omentum separate it from anterior InferiorlyCoils of small intestine
abdominal wall. AnteriorlyGreater omentum
Posteriorly the acending colon is connected The left colic flexure is the terminal part of
by areolar tissue to: transverse colon, joining at an acute angle
The iliac fascia covering iliacus muscle with the beginning of descending colon.
Renal fat and fascia in front of right The left colic flexure is higher and lies on
kidney a more posterior plane than the right colic
Laterally it is related to right paracolic gutter flexure.
The right colic flexure is the terminal part of C. The descending colon is the third part of
ascending colon bending at nearly right angles the colon.
to continue as the beginning to transverse colon The descending colon begins at the left colic
RelationsAnteriorly Right lobe of liver flexure and ends at the pelvic inlet where it is
Fundus of gall bladder continuous with the sigmoid (pelvic) colon
Posteriorly Front of right kidney LocationLeft hypo-chondrium and left
surrounded by renal fat and fascia. lumbar region.
The Gastrointestinal System2 295
Iliac fascia covering iliacus and psoas The marginal artery gives long and short colic
major branches to supply the coats of parts of colon
Laterally it is related to the left paracolic The marginal artery may be deficient at
gutter junction of right two-third and left one third
D. The sigmoid (pelvic) colon is the fourth of trans-verse colon (junction between midgut
and last part of the colon and hindgut)
The sigmoid colon begins at the pelvic inlet At pelvi-rectal junction, the anastomosis
where the descending colon ends. It ends on between the last sigmoid artery and superior
front of third piece of sacrum, where rectum rectal artery may be very poor. This region is
begins. called critical point of Sudeck.
LocationLeft iliac fossa and upper part of
pelvic cavity. The Veins
The position depends upon its state of
The colic veins accompany the colic arteries
distension, and length and mobility of
sigmoid mesocolon. The colic veins accompanying colic branches
LengthAbout 40 cm of superior mesenteric artery end in superior
The sigmoid mesocolon is a peritoneal fold mesenteric vein
that suspends the sigmoid colon from the The colic veins accompanying colic branches
pelvic inlet and front of upper part of sacrum of inferior mesenteric artery end in inferior
The sigmoid colon depicts an S-shaped cur- mesenteric vein.
vature
The Lymphatic Drainage of the Colon
The loop first reaches the left pelvic wall then
crosses the pelvic cavity between rectum and The lymphatics from ascending and transverse
urinary bladder in males and between rectum colon end in superior mesenteric lymph nodes.
and uterus in females The lymphatics from descending and sigmoid
Finally, the loop of sigmoid colon turns back- colon end in small nodes along left colic arteries
ward, to reach front of sacrum in midline to and finally drain in preaortic nodes around the
terminate in rectum. origin of inferior mesenteric artery.
296 Essentials of Human Anatomy
The Nerve Supply of the Colon The diverticula usually lie close to the taenia
coli adjacent to the penetrating blood vessels
The ascending colon and right two-third of
The diverticulitis is associated with chronic
transverse colon (midgut) have
constipation, leading to increased intra-abdo-
The sympathetic supply from coeliac plexus
minal pressure.
The parasympathetic supply from the vagus This condition may lead to perforation,
nerves bleeding inside colon and peritonitis.
The left one-third of transverse colon, des- II. The Hirschsprungs disease (congenital
cending colon and sigmoid colon (hindgut) mega-colon) is a condition, where the colon
have: becomes enormously enlarged.
The sympathetic supply from lumbar part of The condition is caused by the congenital
sympathetic trunks and superior hypo- absence of the myenteric plexus in the
gastric plexus terminal part of sigmoid colon
The parasympathetic supply from the pelvic This leads to interruption of peristaltic move-
splanchnic nerves (derived from S2, S3 ments and junctional blockage of colon
and S4 segments of spinal cord) The condition is seen in young children and
The sympathetic supply of the colon also leads to chronic constipation
carries the pain afferents. The referred The treatment consists of surgical resection of
pain from the colon is felt in the the affected part of colon.
associated skin dermatomes.
THE ARTERIES OF THE GASTRO-
Applied Anatomy INTESTINAL TRACT
I. The diverticulitis occurs more commonly in the A. The coeliac axis artery supplies the abdominal
sigmoid colon and descending colon part of foregut and the structures derived from
The diverticula are small protrusions of the itthe liver, excretory apparatus of liver,
mucosa of colon through its walls pancreas and the spleen (Fig. 28.5).
OriginThe coeliac axis artery arises from The artery divides into five or more
the front of abdominal aorta, just below the segmental branches, which enter the
aortic opening of diaphragm. hilum of spleen
CourseThe artery passes almost Branches
horizontally forwards for 1.2 cm, behind a. The pancreatic branches are small
peritoneum and divides into its three branches branches that supply the neck,
that diverge from it body and tail of pancreas
Relations Anteriorly is omental bursa One large branch arteria pan-
Right side is Right coeliac ganglion creatica magna is given near the
Right crus of diaphragm tail and follows a recurrent course
The coeliac artery is surrounded by the c. The left gastro-epiploic artery reaches
the greater curvature through the
coeliac plexus of nerves
gastro-splenic ligament.
The suspensory muscle of duodenum may
d. The terminal spenic branches (5-6)
encircle the artery (when present)
enter the hilum of spleen.
Branches
iii. The common hepatic artery is intermediate
i. The left gastric artery is the smallest branch
in size to the other two branches
It ascends to the left to reach cardiac end
The artery passes forwards and to the
of stomach; then it runs between the
right behind peritoneum to reach upper
two layers of lesser omentum along border of first part of duodenum.
lesser curvature of stomach It gives a large gastro-duodenal branch
It anastomoses with the right gastric and ascends upwards and to the right
artery within right border of lesser omentum
Branches in front of portal vein to reach porta
a. Gastric branches supply both hepatis.
surface of stomach It terminates by dividing into right and
b. Esophageal branches (2-3) left hepatic branches that enter porta
supply the abdominal part of hepatis.
esophagus Branches
ii. The splenic artery is the largest branch of a. The right gastric artery runs
coeliac artery. upwards along the lesser curvature
of stomach between two layers of
The artery runs tortuously upwards and
lesser omentum.
to the left behind peritoneum, along
It anastomoses with the left
upper border of body of pancreas to gastric artery.
reach the hilum of spleen. b. The gastro-duodenal artery is a
The terminal part of artery along with large branch given from the
splenic vein and tail of pancreas lies common hepatic artery, just above
inside lieno-renal ligament first part of duodenum.
298 Essentials of Human Anatomy
The artery descends deep to and supply the two functional lobes
first part of duodenum in front of liver.
of portal vein. e. The cystic artery usually arises
The artery divides into from the right hepatic artery and
The right gastro-epiploic supplies the gall bladder.
artery that supplies the lower B. The superior mesenteric artery supplies
part of greater curvature and structures developed from the mid-gut (i.e. lower
anstomoses with left gastro- part duodenum, jejunum, ileum, caecum,
epiploic artery. appendix, ascending colon and right two-third of
The superior pancreatico- transverse colon) (Fig. 28.6).
duodenal that runs between OriginThe superior mesenteric artery arises
the head of pancreas and from the front of abdominal aorta, about 1.0
curvature of duodenum. cm below the coeliac axis (vertebral level-
It anastomoses with inferior lower border of first lumbar vertebra)
pancreatico-duodenal branch At origin the artery is related
of superior mesenteric AnteriorlyBody of pancreas
artery Splenic vein
c. The supra-duodenal artery (of PosteriorlyLeft rectal vein
Wilkie) is an inconstant branch. Front of abdominal aorta
It supplies first part of duo- Course
denum. The artery passes downwards and forwards
d. The two terminal hepatic branches in front of uncinate process of pancreas
right and leftenter porta hepatis and third part of duodenum
The artery along with superior mesenteric v. The middle colic artery arises from the
vein enters the root of mesentery and superior mesentery artery just below the
passes downwards and forwards towards pancreas
the right iliac fossa, crossing the structures The artery descends between the two
on posterior abdominal wall layers of transverse mesocolon and
The artery describes a gentle curvature divides into right and left branches to
convex towards the right side supply the right two-third of transverse
The artery terminates by anastomosing with colon.
ileal branches of iliocolic artery in The two branches of the artery contri-bute
terminal coil of ileum. to the formation of marginal artery.
Branches The left branch of the artery anasto-
i. The inferior pancreatico-duodenal branch moses with ascending branch of
divides into an anterior and a posterior superior left colic artery (junction of
branch, that anastomose with similar midgut and hindgut). This anastomosis
branches of superior pancreatico-duodenal may be absent sometimes.
artery lying in the curvature of duodenum. C. The inferior mesenteric artery supplies the
ii. The jejunal and ileal branches (12-15 portions of gastro-intestinal tract derived from the
arise from the convexity of the artery and hindgut (i.e. left third of transverse colon, des-
pass downwards between the two layers of cending colon, sigmoid colon, rectum and upper
mesentery. part of anal canal.
These branches form arterial arcades OriginThe inferior mesenteric artery arises
and from terminal arcades vasa recta from front of abdominal aorta behind the third
are given to supply jejunum and ileum. part of duodenum (vertebral level 3rd lumbar
iii. The iliocolic artery arises from the con- vertebra).
cavity of the artery The origin is about 4.0 cm above the
It passes downwards and to the right to bifurcation of abdominal aorta
reach ileo-caecal junction CourseThe artery descends in front of
It divides into an ascending branch and abdominal aorta, and then the left psoas major
a descending branch, that gives four muscle behind peritoneum (Fig. 28.7).
sets of branches. The artery forms a curvature convex
a. Anterior cecal towards the left side.
b. Posterior cecal
The artery crosses the left common iliac
c. Appendicular
artery medial to left ureter and then
d. Ileal
crosses the pelvic inlet.
iv. The right colic artery may arise in
In the pelvis, the inferior mesenteric artery
common with iliocolic artery
The artery passes towards the right colic descends between the two layers of pelvic
flexure and divides into an ascending mesocolon as superior rectal artery, that
branch and a descending branch. supplies rectum and upper part of anal canal.
These branches join to form a part of the Branches
marginal artery supplying the i. The superior left colic artery ascends
ascending colon, right colic flexure towards the left colic flexure behind peri-
and transverse colon. toneum.
300 Essentials of Human Anatomy
BeginningThe portal vein begins behind the iv. The paraumbilical veins connect the
neck of pancreas (vertebral level 2nd lumbar left branch to the veins of anterior
vertebra) by union of two large veinssplenic abdominal wall.
vein and superior mesenteric vein (Fig. 28.8). These veins accompany the round
Length is 8.0 cm nearly ligament of liver up to the umbilicus.
CourseThe portal vein ascends towards B. The tributaries of superior mesenteric vein.
right side behind the first (superior) part of i. The jejunal and ileal veins (12-15)
duo-denum in front of inferior vena cava. ii. The middle colic vein
The vein enters the right border of lesser iii. The inferior pancreatico-duodenal vein
omentum and ascends in front of the iv. The right colic vein
epiploic foramen with bile duct and v. The iliocolic vein
hepatic artery in front of it. vi. The right gastro-epiploic vein.
C. The tributaries of the splenic vein
Reaching the porta hepatis the portal vein
i. The short gastric veins (5-7)
divides into a right branch and a left
ii. The left gastro epiploic veins
branch that enter porta hepatis to supply
iii. The terminal splenic vein (5-6)
the functional right and left lobes of liver. iv. The inferior mesenteric vein, that receive
Tributaries Superior rectal vein
A. The direct tributaries Superior left colic vein
i. The right and left gastric veins Sigmoid veins (2-3)
ii. The pancreatico-duodenal veins v. The pancreatic veins (including vena
iii. The cystic vein ends in the right branch pancreatica magna)
Applied Anatomy iii. In the submucous coat of the anal canal the
tributaries of superior rectal vein join with
The portal obstruction (hypertension)In this
the tributaries of the inferior rectal vein.
condition the blood of the hepatic-portal system
Enlargement of the anastomosis causes
is not able to flow freely into the systemic
the piles (hemorrhoids)
circulation via the hepatic veins
The piles can be internal piles if lined by
Causes of portal obstruction
mucous membrane only
i. The common cause is cirrhosis of liver
External piles if lined by the skin
ii. Compression of portal vein by
onlyor internor-external piles if
A tumor in the nearby organs, e.g. liver
lined both by mucous membrane and
Enlarged lymph nodes along the right
skin
border of lesser omentum
The piles cause lot of bleeding during
Carcinoma of head of pancreas.
defecation.
iii. Partial thrombosis of portal vein
iv. The retro-peritoneal veins (veins of Retzius).
In portal obstruction the sites of porto-systemic
These veins communicate with the veins of
anastomosis become enlarged in an attempt to
the retro-peritoneal organs, viz. colon,
send the portal blood into the systemic cir-
duodenum and pancreas.
culation.
These veins are very small and are not
These sites are
important as far as the drainage of portal
i. Abdominal part of esophagusWherein the blood is concerned.
submucous coat, the tributaries of left v. The patent ductus venosus is rarely present.
gastric vein join with tributaries of azygos This anastomatic channel directly connects
and hemiazygos veins. the left branch of portal vein with the inferior
The esophageal varices caused by the vena cava.
enlargement of this anastomosis may The surgical treatment of portal obstruction
rupture causing excessive bleeding in consists of making alternate channels or shunts
stomach leading to hematemesis. to push the portal blood into systemic circu-
ii. The umbilicus where paraumbilical veins lation.
from left branch of portal vein join with a. The porto-caval shunt is made by the side-
veins of anterior abdominal wall to-side anastomosis between the portal vein
Enlargement of this anastomosis causes and inferior vena cava.
a conditionCaput medusae where b. The splenic-renal shuntAfter splenectomy
enlarged tortuous veins radiate from the splenic vein is joined with the left renal
umbilicus like spokes of a wheel vein.
CHAPTER 29
The Kidneys, Suprarenals and
the Posterior Abdominal Wall
THE KIDNEYS Size and Shape
The kidney is nearly 11.0 cm long, 6.0 cm
The kidneys are a pair of essential organs of
broad, and 3.0 cm thick.
excretion
The average weight in males is 150 gm and
They remove excess of water and waste in females 135 gm.
products of metabolism from the body. The upper pole is broader and lies nearer
The kidneys also perform endocrine function,
the median plane.
producing a number of hormones, e.g. renin,
The lower pole is smaller and tapering and
that influences blood pressure and erythro-
lies farther from the median plane.
poietin, that affects blood formation.
The shape of kidney is like a bean with
LocationThe kidney is located in lumbar
concavity on its medial aspect.
region on the posterior abdominal wall behind
peritoneum. Surfaces, Borders and Ends
The upper pole lies at the level of 12th
thoracic vertebra. The lower pole lies at The kidneys has two surfacesanterior and
the level of 3rd lumbar vertebra. posterior.
The hilum of kidney lies at the transpyloric I. The anterior surface is gently convex and is
plane (lower border of 1st lumbar vertebra). related to other abdominal organs.
The right kidney lies a little lower due to The anterior surface of right kidney is related
presence of liver on the right side. to (Fig. 29.1).
The kidney is embedded in large amount of The right suprarenal glandnear its upper pole
prerenal and pararenal fat. The right colic flexureat its middle
proximal and the distal convoluted tubules The Blood Supply of the Kidney
(parts of nephrons or kidney tubules).
The Arteries
The cortex has also light colored medullary
rays consisting of collecting ducts. The blood supply of kidney is very profuse.
The cortex, close to medulla, is designated The renal artery is a large branch of abdominal
as juxta-medullary cortex. aorta and arises at level of inter-vertebral disc
b. The renal medulla consists of 9-14 conical between 1st and 2nd lumbar vertebrae.
striated renal pyramids. The renal artery before it enters the hilum of
The bases of pyramids lie towards the kidney gives:
cortex a. The inferior suprarenal artery
The apices of pyramids point medially and b. Small branches to the ureter
are called renal papillae On entering the hilum of kidney the renal artery
The renal papillae are received in the minor gives five lobar (segmental) branches that
calyces and are pierced by the openings of supply the five vascular segments of the kidney.
large collecting ductsthe ducts of Bellini. The vascular segments of the kidney are (Fig.
III. The renal sinus is the cavity inside kidney 29.5.):
that is not occupied by the renal subtance. a. Apical
The structures in the renal sinus are: b. Superior (anterior)
a. The renal pelvis, dividing into 2-3 major c. Middle (anterior)
calyces each further dividing with 2-5 d. Inferior
minor calyces. e. Posterior
The minor calyces receive the apices of There are very little anastomoses between the
renal pyramidsthe renal papillae. four anterior segments and posterior segment.
b. The lobar (segmental) branches of renal An avascular plane (Brdels plane) lies along
artery. this junction on posterior aspect of lateral
c. The lobar (segmental) veins. border. An incision along this plane produces
d. The renal plexus of sympathetic nerves. very little bleeding.
e. The lymphatics Obstruction or ligation of a segmental artery
f. The peri-renal fatthat enters through the leads to avascular necrosis of the vascular
hilum and fills up the renal sinus. segment.
The segmental (lobar) artery gives rise to inter The sympathetic supply is mainly vasomotor
lobar arteries that pass between the pyramids to and sympathectomy produces vasodilation
reach the boundary zone. Where they divide The efferent pain fibers from kidney reach T 12
dichotomously to form the arcuate arteries.
to L2 segments of spinal cord, and the referred
The arcuate arteries give rise to interlobular pain is felt in the lumbar and inguinal regions
arteries that course towards renal surface and
give afferent arteriole to the glomerulus. Applied Anatomy
Accessory (super numerary) renal arteries
exist in about 30% cases. These arise from the I. The renal calculus (stone) is formed in the
renal artery before it enters hilum and mostly renal pelvis and may pass down the ureter to
reach the lower pole. reach urinary bladder.
The renal calculus may cause renal colic and
The Veins hematuria (bleeding along with urine)
The venous pattern inside the kidney follows The renal calculus, if not removed, may increase
that of the renal artery. in size and cause blockage to the passage of
The renal vein comes out of the hilum in front urine leading to hydronephrosis and damage to
of renal artery. the kidney substance.
The right renal vein is short and opens II. Mobile (floating) kidney may result due to
directly with superior vena cava. depletion of renal fat, which fixes the kidney to
The left renal vein is larger and crosses in the posterior abdominal wall
front of abdominal aorta just below the origin The renal fat is absorbed slowly in wasting
of superior mesenteric artery. disease and prolonged starvation.
The left renal vein also receives III. The intra-venous pyelography is a special X-
a. The left supra renal vein rays procedure done to visualize the urinary
b. The left testicular (ovarian) vein. passage and also assess kidney function.
The Lymphatic Drainage of the Kidney A radiopaque medium is injected very slowly
intravenously
There are three lymphatic plexuses in relation The dye is excreted by the kidney and concen-
to kidney trated in the urinary tract, thus visualizing it.
i. One around renal tubules A series of X-ray are taken at intervals.
ii. One deep to the renal capsule
iii. One in the peri-renal fat THE URETER
The efferent lymphatics from these plexuses
follow the renal vein and end in lateral aortic The ureters are two muscular tubes that conduct
lymph nodes. urine by peristaltic movements from the renal
pelvis to the urinary bladder.
The Nerve Supply of the Kidney BeginningThe ureters begins from the
The sympathetic nerves are derived from the lower end of renal pelvis at the level of lower
Lowest splanchnic nerve (T11 ganglion) pole of kidney (pelvi-ureteric junction).
Lumbar part of sympathetic chain (L1, L2 Length25.0 cm
ganglia) CourseThe ureter descends in front of psoas
There is an aortico-renal ganglion, where these major muscle along the tips of transverse
fibers relay and postganglionic fibers begin. processes of lumbar vertebrae
308 Essentials of Human Anatomy
The ureter lies behind peritoneum. It crosses The lymphatics from lower abdominal part of
the pelvic inlet at bifurcation of common ureter end in common iliac lymph nodes
iliac artery and enters pelvic cavity The lymphatics from the pelvic part of
[The pelvic part of ureter is described in ureter end in common, external and
Chapter 33]. internal iliac lymph nodes.
Constrictions of ureter: There are three
constrictions in the course of ureter, where a The Nerve Supply of the Ureter
small renal calculus may lodge and cause The sympathetic fibers of the ureter are
obstruction to the flow of urine: derived from lumbar part of sympathetic clain
i. The pelvi-ureteric junction
(T10, T12 and L1 segments of spinal cord),
ii. At the pelvic inlet
and superior hypogastric plexus.
iii. At its opening in the urinary bladder. The parasympathetic supply is derived from
Relations (abdominal part of motor)
the pelvic splanchnic nerves (S2, S3 and S4
i. The right ureter is crossed anteriorly by:
spinal segments)
The third part of duodenum The afferent fibers reach spinal cord via the
The root of mesentery with superior
lowest splanchnic nerve.
mesenteric vessels
Iliocolic and right colic vessels Applied Anatomy
The right testicular (ovarian) vessels
ii. The left ureter is crossed anteriorly by: The ureteric calculus: A small renal stone may be
The superior left colic vessels lodged at one of the three constrictions in the
The inferior left colic vessels course of ureter.
The left testicular (ovarian) vessels This may lead to ureteric colic, referred to the
Apex of pelvic mesocolon. abdominal wall according to the part of ureter
The blood supply of the ureter where the stone is impacted:
The arteriesThe ureter receives its blood a. From upper part obstruction, the pain is
supply from a number of arteries in form referred to the region (T10-T12)
of small branches: b. From middle part obstruction the pain is
The renal arterysupplies the upper part referred to the inguinal and pubic regions
Abdominal aortasupplies the middle (L1)
part c. From lower part obstruction the pain is
Testicular (ovarian supply the referred to the perineum or to the back of
artery) lower part. thigh (S2, S3 and S4 segments)
Common iliac artery The ureteric stone may lead to hydronephrosis
Too much mobilization of ureter during and consequent damage to the kidney.
removal of ureteric calculus (stone) should
be avoided, so that the blood supply by THE SUPRARENAL (ADRENAL) GLANDS
small branches may not be interrupted.
The veins follow the arteries and end in The suprarenal glands are a pair of important
corresponding veins. endocrine glands.
The lymphatic drainage of the ureter LocationThe suprarenal glands lie on the
The lymphatics from upper abdominal part upper pole of the kidneys in front of
of ureter end in lateral aortic lymph nodes. diaphragm and behind peritoneum (Fig. 29.6).
The Kidneys, Suprarenals and the Posterior Abdominal Wall 309
The condition is known as Addisons disease the aponeurotic origin of transversus abdominis
with muscular weakness, low blood pressure muscle.
and cutaneous pigmentation. The psoas major and iliacus muscles are
III. Bilateral adrenelectomy is done for some covered by the iliopsoas fascia (fascia iliaca).
inoperable mammary or prostatic carcinoma in i. The quadratus lumborum lies lateral to the
which malignant changes are supposed to occur
psoas major muscle on the posterior abdo-
due to excess of androgens and estrogens.
minal wall.
THE POSTERIOR ABDOMINAL WALL Origin fromIliolumbar ligament
The posterior abdominal wall has the following Adjacent part of inner lip of iliac
muscles (Fig. 29.9): crest for about 5.0 cm.
Quadratus lumborum Muscle belly is quadrangular in shape
Psoas major and is broad inferiorly
Iliacus The upper part of the muscle lies
The quadratum lumborum muscle is covered deep to the lateral arcuate ligament
by the thoraco-lumbar fascia. At the lateral of diaphragm.
border of the muscle the fused anterior and Insertion is on medial half lower border
middle lamina of thoraco-lumbar fascia form of twelfth rib
The deep veinsthat connect the inferior Lymphatics from lateral aortic,
vena cava to the superior vena cava and superior mesenteric and coeliac
are enlarged are: lymph nodes.
The azygos and hemiazygos veins The nerves of the posterior abdominal wall
The lumbar veins The lumbar parts of the sympathetic trunks
The vertebral venous plexus also The sympathetic trunk enters posterior
affords an important site for colla- abdominal wall deep to the medial
teral circulation. arcuate ligament of diaphragm
The lymphatics and lymph nodes of posterior
The sympathetic trunk descends bet-
abdominal wall
ween the medial margin of psoas major
The common iliac lymph nodes are grouped
and the bodies of lumbar vertebrae.
along the common iliac vessels
The lumbar part of sympathetic trunk
These nodes drain lymph from the
has five ganglia corresponding to the
external and internal iliac nodes and in
five lumbar spinal nerves. The fifth
turn drain into aortic lymph nodes
ganglion is variable.
They receive lymph from
Branches
Lower limb including gluteal region
Grey rami communicans(GRC)
Perineum
connect the sympathetic ganglia to
Pelvic cavity
The aortic (lateral aortic) lymph nodes lie the corresponding lumbar spinal
by the side by abdominal aorta along the nerves
medial margin of psoas major muscle. White rami communicans(WRC) are
They drain lymph from the structures usually given from the first lumbar
on the posterior abdominal wall, kidney, spinal nerve to the first sympathetic
suprarenal gland, abdominal part of ganglion [sometimes the second
ureter and testis (ovary) uterine tube and lumbar spinal nerve also gives a white
upper part of uterus in females. ramus communicans to the corres-
Efferent lymphatics from there lymph ponding sympathetic ganglion]
nodes end in the cisterna chyli and The lumbar splanchnic nervesare
lumbar lymph trunk. usually four from upper four ganglia
The cisterna chyli is a dilated lymph sac that a. The lumbar splanchnic nerves
is present on front of first and second give branches to the coeliac,
lumbar vertebral body aortic, mesenteric and superior
LocationThe cisterna chyli lies behind hypogastric plexuses.
the right crus of diaphragm and to the b. The lumbar splanchnic nerves
right of abdominal aorta also carry afferent pain fibers
The cisterna chyli continues as the from the descending colon,
thoracic duct through the aortic opening sigmoid colon and from upper
of diaphragm and middle parts of ureter
TributariesThe cisterna chyli receives The aortic plexus of sympathetic nerves
The two intestinal lymph trunks lies in front of abdominal aorta
bringing chyle from the walls of small Superiorly it communicates with
intestine superior mesenteric plexus and
The two lumbar lymph trunk bringing coeliac plexus
lymph from the lower extremities, Inferiorly it communicates with the
pelvis and perineum superior hypogastric plexus
The Kidneys, Suprarenals and the Posterior Abdominal Wall 315
Q1. Select the one best response to each A. Left gastric artery
question from the four suggested ans- B. Left gastroepiploic artery
wers: C. Short gastric arteries
1. The cremaster muscle in males is D. None of the above
continuous with the muscle fibers of: 8. The medial umbilical fold overlies the:
A. External oblique A. Urachus or median umbilical ligament
B. Internal oblique B. Obliterated umbilical artery
C. Transversus abdominis C. Inferior epigastric artery
D. Rectus abdominis D. Lateral border of rectus abdominis
2. The deep inguinal ring is the gap in the: 9. The length of ureter in normal adult male is:
A. External oblique aponeurosis A. 10.0 cm B. 25.0 cm
B. Internal oblique aponeurosis C. 30.0 cm D. 50.0 cm
C. Transversus abdominis aponeurosis
D. Fascia transversalis 10. The left supra renal vein ends in:
A. Left renal vein
3. The dermatome at the level of umbilicus is:
T B. Inferior vena cava
A. 10 B. T11
T C. Splenic vein
C. 12 D. L1 D. Left testicular (ovarian) vein
4. The spleen lies inside abdominal cavity in the:
Q2. Each question below contains four
A. Left hypochondrium
sugges-ted answers of which one or more
B. Left lumbar region
is correct. Choose the answers:
C. Epigastrium
D. Partly in left hypochondrium and partly A. If 1, 2 and 3 are correct
in epigastrium B. If 1 and 3 are correct
C. If 2 and 4 are correct
5. The portal vein is formed by the union of: D. If only 4 is correct
A. Superior mesenteric vein and inferior E. If 1, 2, 3 and 4 are correct
mesenteric vein
B. Superior mesenteric and splenic vein 11. The stomach:
C. Splenic and inferior mesenteric veins 1. has lesser curvature along which left
D. Splenic and short gastric veins and right gastric arteries lie
2. has parasympathetic innervation from
6. The normal capacity of gall bladder is: two gastric nerves, that carry vagal fibers
A. 250 ml B. 500 ml 3. has fundusthe highest part of greater
C. 100 ml D. 30-50 ml curvature, that contains gas
7. The arteries supplying the fundus part of 4. has a thick sphincter at the cardiac
greater curvature are: opening
Multiple Choice Questions 317
Answers
main pancreatic duct usually joins with the A18. The answer is A, (1, 2, 3).
bile duct to form the common hepato- The three constrictions of the ureter are one
pancreatic ampulla. where ureter crosses the pelvic brim second
A13. The answer is C, (2, 4). at its opening in the urinary bladder and
The superior mesenteric artery terminates third at pelvi-ureteric junction. There is no
about two feet from ileocecal junction, at con-striction where the testicular (ovarian)
Meckels diverticulum (if present). It gives an vessels cross the ureter.
appendicular branch. It is, however, artery of A19. The answer is D, (4).
midgut and not hindgut and it supplies only The referred pain of cholecystitis is felt at the
right two-third of transverse colon. right shoulder tip, as this condition irritates
the inferior surface of diaphragm supplied by
A14. The answer is A, (1, 2, 3).
the phrenic nerve (C3, C4, C5, V, R), the
The lesser sac of peritoneum is a part of
peritoneal cavity, and has lesser omentum ventral rami of C3 and C4 spinal nerves
in its anterior wall. It communicates with supra-clavicular nerves also supply the skin
covering the right shoulder tip.
rest of the peritoneal cavity by one
openingthe epiploic foramen. However, A20. The answer is C, (2, 4).
in adults it does not extend up to lower The blood and fluid collected in the
border of greater omentum, it extend only Morrisons (Hepatorenal) pouch comes from
up to transverse colon. the lesser sac of peritoneum through epiploic
foramen. The right paracolic gutter superiorly
A15. The answer is B, (1, 3).
also communicates with the Morrisons
The oblique (indirect) inguinal hernia passes
pouch. The right intra-colic compartment is
through the deep inguinal ring. It is usually
separated from Morrisons pouch by the right
associated with incomplete fusion of pro-
colic flexure. The left paracolic gutter is on
cessus vaginalis. The oblique hernia is com- the other side of the peritoneal cavity.
moner in young adults and enters the scrotum.
A21. The answer are B, D, A and C.
A16. The answer is C, (2, 4). The ligamentum teres of liver is a remnant
The right suprarenal gland is usually of the left umbilical vein of fetal life.
smaller than left suprarenal gland. It is The Meckels diverticulum is remnant
related anteriorly to the inferior vena cava. of vitello intestinal duct.
The right suprarenal gland lies in a separate The urachus persists as median
compartment of renal fascia, but the right umbilical ligament.
suprarenal vein opens directly in the The umbilical artery, after birth, gets
inferior vena cava. fibrosed to form the medial umbilical
A17. The answer is E, (1, 2, 3, 4). ligament.
The liver is endodermal in origin from hepatic A22. The answers are B, C, D and A.
diverticulum of foregut. It receives 80 per The coeliac axis artery supplies a part
cent of its blood supply from the portal vein. of head of pancreas via superior pan-
At bare area, the posterior surface lies directly creatico-duodenal artery.
in relation with diaphragm. The two or three The superior mesenteric artery supplies
hepatic veins draining venous blood from the vermiform appendix by a separate
liver open directly in inferior vena cava. appendicular artery.
Multiple Choice Questions 321
Posteriorlyby the sacral promontory The pelvic outlet is closed by the pelvic dia-
Laterallyby ala of sacrum, and Iliopec- phragm formed mainly by two levator ani
tineal line muscles.
The diameters of the pelvic inlet are: The pelvic diaphragm separates the cavity of
i. The antero-posterior diameter is lesser pelvis from the ischio-rectal fossae.
measured from sacral promontory in The diameters of the pelvic outlet are:
midline up to the upper end of pubic i. The transverse diameter is the distance
symphysis. between two ischial tuberosities.
It is about 10.0 cm in normal adult This diameter is approximately as wide
females. as the clenched fist.
ii. The oblique diameter is measured ii. The transverse mid-plane diameter is the
from the sacro-iliac joint to the distance between two ischial spines.
opposite ilio-pectineal eminence. The distance normally is 9.5 cm or
It is about 12.5 cm in normal adult more; if it is less than 9.5 cm, the
females. delivery of the child may be difficult.
iii. The transverse diameter is the widest iii. The antero-posterior diameter is
distance across the pelvic inlet. measured from the lower margin of pubic
It is about 13.5 cm in normal adult symphysis to the sacro-coccygeal joint.
female (Fig. 30.1). The diameter is nearly 13.5 cm in adult
2. The pelvic outlet is bounded: females.
Anteriorly by the lower end of pubic The contents of the lesser pelvis are
symphysis Pelvic colon, rectum and upper part of anal
Posteriorly by the tip of coccyx canal.
Antero-laterally by the conjoint ramus of Urinary bladder, pelvic parts of two ureters.
ischium and pubis In males, seminal vesicles, the two vas
Laterally by the ischial tuberosity deferens and the prostate gland.
Postero-laterally by sacro-tuberous In females uterus, the ovaries, the two uterine
ligament. tubes and upper part of vagina.
The diameters of bony pelvis are measured for
the inlet and the outlet. They helps to establish
the diagnosis of pelvic disproportions in females.
4. The platypaloid type (flat pelvis) is another i. The base of sacrum - or upper surface of Ist
abnormal type with a rather long transverse sacral vertebra articulates with fifth lumbar
diameter and a short antero-posterior diameter. vertebra The anterior projecting edge of body
of sacrum is called sacral promontory.
The Sex Differences of the Bony Pelvis On either side, the superior surface or
The differences in the bony pelvis are the most base of sacrum is formed by alae that are
characteristic sex differences in male and female formed by fusion of transverse processes
skeletons. These differences are even obvious to and costal elements.
a lesser degree in fetal and early post-natal life ii. The apex or caudal end of sacrum
(Table 30.1). articulates with the coccyx.
In adults the differences are limited to the iii. The pelvic surface - of sacrum is concave. It
functions of the bony pelvis. has four pairs of anterior sacral foramina
The primary function of the bony pelvis in that transmit ventral rami of upper four
both sexes is to bear body weight and help in sacral nerves.
locomotion. There are faint ridges separating the
In females, the bony pelvis is adapted for sacral vertebrae on pelvic surface.
parturition (delivery of the newborn). iv. The dorsal surface of sacrum is convex and
and raised dorsally by median sacral crest.
THE SACRUM It has four pairs of dorsal sacral formina,
that transmit the dorsal rami of upper four
General Features
sacral nerves.
The sacrum is formed by fusion of five sacral v. The lateral surface is formed by fusion of
vertebrae transverse processes. If broad upper part bears
The sacrum is a large triangular bone located the articular surface for sacro-iliac joint.
between two hip bones forming posterior wall of vi. The sacral canal is triangular in section. It
pelvic cavity. contains sacral and coccygeal nerve roots,
the filum terminale and dural tube (up to Two primary centers for each 1/2 of
second sacral vertebra) vertebral arch
vii. The sacral hiatus is the caudal opening of These centers appear between 10th and 20th
sacral canal. It transmits fifth sacral and weak of intra-uterine life.
coccygeal nerves and filum terminale. Primary centers for costal elements appear us
upper 3 sacral vertebrae between 6th to 8th
Variations fetal month. Costal elements fuse with the
Sometimes sacrum may contain six vertebrae due to vertebral arch between 2nd and 5th year.
an additional sacral element or by incorporation of Vertebral arches and body fuse by 8th year
fifth lumbar vertebra, the condition is called the
Upper and lower surfaces of each sacral body
are covered by epiphyseal plate of hyaline
sacralization of lumbar vertebrae.
cartilage
Special Features
THE COCCYX
[Muscles and ligaments attached to sacrum]
The coccyx is a small triangular bone that is
Pelvic surface - 2nd to 4th segment - piriformis
formed by fusion of four rudimentary
Pelvic surface - supro-lateral part - Iliacus coccygeal vertebrae
Pelvic surface - infro-lateral part - Coccygeus
The base or upper surface articulates with
Dorsal surface - U-shaped aponeurosis of apex of sacrum
erector spinae Two coccygeal cornua project upwards to
Dorsal surface - [Within erector spinae] articulate with sacral cornua
Multifidus Second to fourth diminish in size and are like
Lateral border - [below auricular surface] fused no dules.
Gluteus maximus The pelvic surface gives attachment to levator
Lateral border (ventral aspect) Coccygeus ani and coccygeus muscles.
Lateral border (dorsal aspect) Sacro-tuberous The dorsal surface gives attachment to gluteus
and sacro-spinous ligaments maximus and sphincter ani externus. The
filum terminale blends with dorsal surface
Sex-difference
The female sacrum is shorter and wider Ossification
forming a wider pelvic cavity. Each coccygeal segment is ossified by one
The ventral concavity is deeper and it faces primary center.
more downwards The center for 1st segment appears at birth
The articular surface of female sacrum is shorter and its cornua may ossify by separate centers
The male sacrum: Sacral promontory is more The other three segments of coccyx ossify by
prominent. centers which appear much later up to 20th
The first sacral vertebra forms a larger part of year.
base of sacrum. Its transverse diameter is The coccyx fuses with sacrum in old age
longer than ala specially in females.
The male sacrum is less curved also.
The Joints of the Bony Pelvis
Ossification The joints of the bony pelvis are
Ossification of sacrum resembles typical vertebra The sacro-iliac joints
Each sacral vertebra has The public symphysis
One primary center for body The sacro-coccygeal joint
326 Essentials of Human Anatomy
The sacro-iliac joint is formed by the lateral Ligaments surround the joint.
surface of ala of sacrum and the auricular surface 1. The anterior pubic ligament covers the
of ilium. anterior surface of the joint.
Type: Plane type of synovial joint. 2. The posterior pubic ligament covers the
Stability: One of the most stable joints in the posterior surface of the joint.
body due to strong ligaments that surround it. 3. The inferior pubic ligament lies on the
Reciprocal irregularities in the joint surfaces inferior aspect of the joint. It is also called
of the two bones also contributes to the arcuate ligament.
strength of the joint. 4. The superior pubic ligament lies on the
Articular capsule: surrounds the joint. superior aspect.
Ligaments: Articular disc is a fibro-cartilaginous disc that
1. The anterior sacro-iliac ligament reinforces separates the two articular surfaces.
the articular capsule on the anterior aspect. Movements: slight displacement and rotation
2. The posterior sacro-iliac ligament passes movements are possible at this joint.
The sacro-coccygeal joint is the joint between
between posterior superior iliac spine and
the lower end of sacrum and the coccyx.
the posterior surface of sacrum.
Type: Secondary cartilaginous joint
3. The interosseous sacro-iliac ligament con-
Ligaments: Surround the joint
nects the rough part of non-articular
1. The anterior sacro-coccygeal ligament
surface between the two bones.
lies on the anterior aspect of the
It is one of the strongest ligaments of the articulating bones
body. 2. The posterior sacro-coccygeal ligament has
Movements: Slight antero-posterior rotatory a. A superficial part extends between sac-
movements are possible in the joint. During ral hiatus to posterior aspect of coccyx.
pregnancy, in females, weeks before b. A deep part passes between back of
parturition more movements are possible. 5th sacral vertebra and the coccyx.
Applied Anatomy 3. The lateral sacro-coccygeal ligaments on
Sprain or dislocation of the sacro-iliac joint either side connect the sacrum to
is extremely rare. coccygeal transverse processes.
Low back pain (sciatica) is usually either of 4. The inter-cornual ligament connects the
muscular origin or due to herniated disc at sacral and coccygeal cornua on either side.
4th and 5th lumbar vertebrae. Articular disc is a fibro-cartilaginous inter-
The public symphysis is a secondary cartilagi- vertebral disc between the body of sacrum
nous joint, between the symphyseal surfaces of and coccyx.
the two public bones. Movements: Very slight movements are
Type: Secondary cartilaginous joint. possible in females, during later months of
Articular surfaces are coated with hyaline pregnancy, more separation is possible prior
articular cartilage. to the partu-rition.
CHAPTER 31
The Fasciae, Muscles,
Blood Vessels and
Nerves of the Pelvis
THE PELVIC FASCIA The ligaments of the pelvic organs are
conden-sations of pelvic fascia around the
The pelvic fascia is present in the cavity of pelvis
neuro-vascular bundles of pelvic organs.
as:
These ligaments play an important role in
i. The parietal pelvic fascia
support of pelvic organs; specially important
ii. The visceral pelvic fascia
for the uterus and urinary bladder.
The parietal pelvic fascia is continuation of the
fascia transversalis of the anterior abdominal wall. THE PELVIC MUSCLES
The various parts of parietal pelvic fascia are:
a. The obturator fascia covers the obturator The pelvic musculature consists of:
internus muscle at the lateral pelvic wall. The levator ani muscles together with coccygeus
It is attached above the ilio-pectineal line. muscles form pelvic diaphragm, that lies in the
Over the obturator internus, it forms a floor of pelvic cavity (Fig. 31.1).
tendinous arch of origin of levator ani Origin: The levator ani arises from
muscle. Pelvic surface of body of pubis
b. The pelvic fascia at the tendinous arch splits Obturator fascia at the tendinous arch.
into two layers to cover both superior and Medial surface of ischial spine.
inferior surfaces of levator ani.
These two layers form the superior and
inferior fasciae of the pelvic diaphragm.
c. The piriform fascia is a very thin layer of
parietal pelvic fascia that covers the
piriformis muscle.
The visceral pelvic fascia is the condensation of
connective tissue that covers the pelvic organs.
This layer also forms condensation around the
blood vessels of the pelvic organs.
The fascial capsule of prostate gland in males
is formed by the visceral pelvic fascia. Fig. 31.1: The pelvic diaphragm
328 Essentials of Human Anatomy
Muscle belly is a broad, thin, muscular sheet. The muscle may be absent; it is, in fact, a
The muscle fibers pass downwards and degenerate part of sacro-spinous ligament.
medially with varying obliquity. Nerve supply:
Insertion: Is from fourth and fifth sacral nerves.
a. Most anterior fibers are attached to Actions:
perineal body a. Together with levator ani, it forms the
In males: They sweep around prostate pelvic diaphragm.
gland to form levator prostatae. b. The coccyx muscle pulls forwards the
In females: They cross lateral to vagina coccyx during defecation and parturition.
forming an additional sphincter for vagina. The piriformis muscle is attached on front of
b. The intermediate fibers form a muscular middle three pieces of sacrum.
sling at the ano-rectal junction forming It has a piriform muscle belly that passes out
pubo-rectalis, an important factor of pelvis through greater sciatic foramen and
preventing fecal incontinence. lies behind the hip joint.
Some intermediate fibers blend with longi- The obturator internus muscle is attached to the
tudinal coat of anal canal to form conjoint pelvic surface of lower half of hip bone and the
longitudinal coat. obturator membrane.
c. The posterior fibers mingle with those of It gives rise to a tendon that passes out of
external anal sphincter. Most posterior lesser sciatic foramen to the gluteal region.
fibers are attached to ano-coccygeal body The above two muscles belong to the inferior
and last two pieces of coccyx. extremity. [Detail description in Chapter 15]
Nerve supply:
Inferior rectal nerve THE PELVIC PERITONEUM
Perineal branch of 4th sacral nerve.
Actions The peritoneum in the pelvic cavity lines the
1. Levator ani supports pelvic viscera and by walls and covers the pelvic viscera.
its tone keeps them in position. The peritoneum lines on front and sides of
2. It helps in maintaining the intra-abdominal upper one-third of rectum and front of middle
pressure and thus is used in all voluntary one-third of rectum.
expulsive efforts. On either side of upper one-third of rectum,
3. The pubo-rectalis sling is an important the peritoneum is reflected on front of sacrum
factor in preventing fecal incontinence. forming the para-rectal fossae, which allow
4. In females the pelvic diaphragm supports for distension of rectum.
and maintains uterus and also helps in From front of middle one-third of rectum:
parturition. a. In males: The peritoneum is reflected on
The coccygeus muscle is a musculo-tendinous sheet base of urinary bladder, forming recto-
that lies on deep surface of sacro-spinous ligament vesical pouch, that is 7.5 cm deep from
Origin: the perineal skin.
Is from pelvic surface and tip of ischial spine. b. In females: The peritoneum is reflected on
Insertion: back of uppermost part of vagina forming
Is on lateral margin of coccyx and fifth sacral recto-uterine pouch (pouch of Douglas),
vertebra. that is 5.5 cm deep from the perineal skin.
The Fasciae, Muscles, Blood Vessels and Nerves of the Pelvis 329
The peritoneum covers both anterior and The external iliac vein accompanies it on
posterior surfaces of uterus and is the medial side.
reflected on superior surface of urinary The artery passes deep to the inguinal
bladder as utero-vesical pouch. ligament at mid-inguinal point and continues
On either side of the uterus, the pelvic as femoral artery on front of the thigh.
peritoneum forms two large foldsthe Branches
broad ligamentsthat connect the i. The inferior epigastric artery passes
uterus to the lateral pelvic walls. upwards and medially and pierces fascia
Clinical Considerations transversalis behind rectus abdominis
muscle to enter rectus sheath.
The recto-uterine pouch in females is accessible It gives two small but important bran-
surgically through the uppermost part of posterior ches:
wall (posterior fornix) of vagina. a. The cremasteric branch accompanies
Any collectionblood, pus or fluidcan be the spermatic cord in males. In
easily felt and aspirated out from the recto-
females, the artery is known as
uterine pouch.
artery of the round ligament.
The Blood Vessels of the Pelvis b. The pubic branch anastomoses with
the pubic branch of obturator artery
The Arteries
on deep surface of pubic bone and
A. The common iliac arteryright and leftare lacunar ligament. In 30% of adults,
the terminal branches of abdominal aorta. this anastomosis continues as the
Beginning: The common iliac artery begins at abnormal obturator artery.
the lower border of fourth lumbar vertebra, ii. The deep circumflex iliac artery runs
where the abdominal aorta bifurcates. along the inner lip of the iliac crest and
Course: The common iliac arteries diverge as supplies the muscles attached to it.
they descend. It gives an ascending branch that runs
The common iliac artery bifurcates into its upwards between the internal oblique
two terminal branchesinternal iliac and
and transversus abdominis muscles of
external iliacat level of lumbo-sacral inter-
the anterior abdominal wall.
vertebral disc.
C. The internal iliac artery is the smaller terminal
Branches
branch of the common iliac artery (Fig. 31.2).
i. Small muscular branches to psoas major
Course: From its origin at the level of lumbo-
and iliacus
ii. Small branches to ureter sacral disc in front of sacro-iliac joint, the artery
iii. Ilio-lumbar artery (sometimes) passes backwards up to the upper margin of
iv. External iliac artery }
greater sciatic notch, where it divides into two
v. Internal iliac arterterminal branches. trunksanterior and posterior.
B. The external iliac artery is the larger 1. The anterior trunk gives the following
terminal branch of common iliac artery. branches:
Course a. The superior vesical that gives
The artery descends laterally along the branches to the urinary bladder.
medial border of psoas major muscle The artery forms the proximal part of
follow-ing the inlet of pelvis. umbilical artery of fetal life.
330 Essentials of Human Anatomy
The distal part of umbilical artery, in The artery supplies uterus, medial
adults, becomes fibrosed to form two-third of uterine tube and upper
medial umbilical ligament up to part of vagina.
umbilicus. During pregnancy, the artery hyper-
b. The obturator artery passes forwards trophies greatly.
along the lateral pelvic wall to reach e. The vaginal artery (in females) may be
obturator canal. two or three and may arise from the
The artery enters medial compart- uterine artery.
ment of thigh along with obturator The artery is also homologous with
nerve. inferior vesical artery of the males.
It gives muscular branches to iliacus It also gives small branches to the
and a pubic branch in pelvis. rectum.
c. The inferior vesical artery (in males) f. The middle rectal artery is a small
reaches the neck of urinary bladder. branch that supplies the muscular coat
It supplies of rectum.
The urinary bladder The artery anastomoses with supe-rior
The prostate gland rectal and inferior rectal arteries.
The seminal vesicles g. The internal pudendal artery is the
The vas deferens (via artery to smaller terminal branch of the anterior
the vas deferens) trunk.
d. The uterine artery (in females) is It passes out of the pelvic cavity
homologous with inferior vesical through greater sciatic foremen
artery of the males. below piriformis, crosses the ischial
It is a large, tortuous artery that runs spine and enters ischiorectal fossa
along the lateral border of uterus. Branches in the pelvis:
The Fasciae, Muscles, Blood Vessels and Nerves of the Pelvis 331
It begins from glomus coccygeum on front of 2. The external iliac lymph nodes are arranged
coccyx along the external iliac vessels:
It receives small tributaries from back of They drain lymph from:
rectum Inguinal lymph nodes
It terminates in left common iliac vein. Anterior abdominal wall
Genital organs
The Venous Plexuses of the Pelvic Viscera Superior surface of urinary bladder.
Their efferents reach common iliac
The pelvic organs are drained by the venous nodes.
plexuses along their walls. 3. The internal iliac lymph nodes lie around the
i. The rectal venous plexus is formed by the internal iliac vessels.
superior rectal vein joining with middle They receive lymphatics from
rectal veins and the inferior rectal veins. The pelvic viscera
ii. The vesical venous plexus lies around the The deeper parts of perineum
base of the urinary bladder. The gluteal region and back of thigh.
In males, it also lies around the prostate Their efferents reach the common iliac
gland and drains venous blood from lymph nodes.
the prostate gland, vas deferens and 4. The sacral lymph nodes lie along the median
sacral and lateral sacral vessels.
the seminal vesicles.
These are members of the internal iliac
iii. The uterine venous plexus accompanies the
lymph nodes and receive some lymphatics
uterine artery and lies along the lateral
from the rectum.
border of the uterus between two layers of
broad ligament. The Nerves of the Pelvis
iv. The vaginal venous plexus lies along the
The lumbo-sacral plexus supplies the structures
walls of vagina. It is connected with uterine
of the pelvis, perineum and the inferior extremity.
and rectal venous plexuses. Formation: The lumbosacral plexus is formed
by the ventral rami of L4, L5, S1, S2,S3, and
The Lymphatic Drainage of the
S4 spinal nerves (Fig. 31.3).
Pelvic Organs Position: The lymbo-sacral plexus lies in the
The lymphatic drainage of the pelvic organs is quite posterior wall of the pelvis behind the parietal
variable, but it is of great clinical importance in pelvic fascia.
relation with spread of cancer of pelvic organs. Branches
The different groups of lymph nodes in the 1. The tibial nerve (L4, L5, S1, S2, S3
pelvis are: anterior devisions of ventral rami).
2. The common peroneal nerve (L4,L5,S1 and
1. The common iliac lymph nodes are few in
S2 posterior divisions of ventral rami).
number
These two nerves are enclosed in a
These nodes are present below the bifur- common sheath forming the sciatic
cation of abdominal aorta on front of fifth nerve.
lumbar vertebra. Sometimes there is High division of
They drain lymphatics from the external sciatic nerve, when these two nerves
and internal iliac nodes and send their do not join and remain separate from
efferents to the aortic lymph nodes. the beginning.
The Fasciae, Muscles, Blood Vessels and Nerves of the Pelvis 333
It leaves pelvis through greater sciatic From upper two ganglia join inferior
foramen below piriformis. hypogastric (pelvic) plexus
It lies superficial to the sciatic nerve in II. The sympathetic plexuses
gluteal region. The inferior hypogastric (pelvic) plexus
It supplies skin on back of thigh and divides into two partsright and left.
popliteal fossa. Each part lies lateral to the rectum and
10. The perforating cutaneous (S2,S3 contain many small ganglia.
posterior divisions of ventral rami).
Superiorly, the plexus is connected with
The nerve pierces sacro-tuberous liga-
ment and supplies skin over lower part superior hypogastric plexus (Presacral
of gluteus maximus. nerve).
The preganglionic sympathetic fibers arise from
The Autonomic Nerves in the Pelvis T11,T12,L1 and L2 segments of spinal cord. The
A. The sympathetic: There are two sympathetic postganglionic sympathetic fibers arise from the
trunks in the pelvisright and leftand they sympathetic ganglia of sympathetic plexus
descend medial to the anterior sacral foramina. and accompany the visceral branches of
I. The two sympathetic trunks end in a median internal iliac artery.
ganglion impar on front of first piece of coccyx. B. The parasympathetic is in form of pelvic
Branches: splan-chnic nerves (Nervi erigentes) from S2,S3,
a. Grey rami communicans (GRC): Connect
S4 spinal segments.
the sympathetic ganglia to ventral rami of
They carry preganglionic parasympathetic
sacral nerves. They carry vascular
branches for the arteries. fibers that join the pelvic plexuses and are
b. Medial branches distributed along them.
Form a plexus around medial sacral The pelvic splanchnic nerves constitute the
artery. sacral outflow of parasympathetic.
CHAPTER 32
The Perineum
The perineum is the lower end of the trunk, that anal columns joined together by crescentic
lies between the two ischial tuberosities. foldsanal valvesenclosing anal sinuses.
The perineum covers the pelvic outlet and This part is limited below by pectinate
extends from the pubic symphysis in front to line that forms the junction between
coccyx behind. endodermal and ectodermal parts.
Parts: The perineum is divided by an imaginary 2. The middle transitional zone-pecten-
plane passing between two ischial tuberosities into: (about 15 mm) is lined by stratified
i. Anal triangleposteriorly squamous non-keratinizing epithelium.
ii. Urogenital triangleanteriorly This part is limited below by white line
of Hilton.
THE ANAL TRIANGLE 3. The lower part (about 7 mm) is lined by
The anal triangle contains true skin, having hair follicles, sebaceous
The anal canal surrounded by external and and sweat glands.
internal sphincters in median plane.
The Musculature of the Anal
Two ischio-rectal fossae on either side of anal
Canal (Fig. 32.1)
canal containing pads of fat.
The anal canal remains closed except during
The Anal Canal defecation due to tonic contraction of sphincters
The anal canal is the last subdivision of the surrounding it.
digestive tube that opens at anus. A. The internal anal sphincter is formed by
Location: It lies in median part of anal thickening of circular muscle coat,
triangle of perineum. surrounding upper 30 mm of anal canal.
Direction : The anal canal is directed It is made up of smooth muscle fibers and
downwards and backwards from lower end of is supplied by autonomic nerves.
rectum at tip of coccyx up to anus. B. The external anal sphincter is voluntary
Length 3.8 cm. sphincter made up of striated muscle fibers.
Relations It has three parts:
Anteriorly: Perineal body separating it from i. The deep part is thick annular band
bulb of penis in males and posterior that encircles upper part of anal canal.
vaginal wall in females. ii. The superficial part is attached
Posteriorly: Ano-coccygeal body and tip of Anteriorly to the perineal body
coccyx. posteriorly to the ano-coccygeal raphe
Laterally: ischio-rectal fossa and tip of coccyx.
Parts: The anal canal is divided into three parts: iii. The subcutaneous part surrounds the
1. Upper endodermal part (about 15 mm) has lowest part of anal canal, below white
8-10 vertical folds of mucous membrane line.
336 Essentials of Human Anatomy
The Blood Supply of the Anal Canal The endodermal part is supplied by autonomic
nerves.
The Arteries Sympathetic fibers from pelvic plexuses.
The upper endodermal part is supplied by Parasympathetic fibers from the pelvic splan-
superior rectal artery. chnic nerves.
The Perineum 337
The ectodermal part is supplied by inferior Inferior surface of levator ani, covered
rectal nerve. by pelvic fascia.
Lateral:
Clinical Considerations Ischial tuberosity
1. The piles (Hemorrhoids)develop in cases of Obturator fascia covering obturator
portal obstruction, due to enlargement of the internus muscle.
venous plexus in the submucous coat, Pudendal canal (Alcocks canal) lies
between the tributaries of superior rectal and in the lateral wall.
inferior rectal veins. Anterior: Posterior border of urogenital
The piles can be diaphragm.
a. Internal piles that develop in relation to Posterior:
endodermal part only Posterior border of gluteus maximus
b. External piles that develop below pectinate Sacro-tuberous ligament.
line in relation to ectodermal part The two ischio-rectal fossae communi-
c. Interno-external piles that are covered cate with each other behind the anal
partly by mucous epithelium of canal.
endodermal part and partly by stratified Contents
squamous epithelium of ectodermal part. 1. Ischio-rectal pad of fat that supports
2. The anal fistula is an abnormal passage in the anal canal.
anal triangle, by side of anus, through which
2. Inferior rectal nervea branch of
fecal matter comes out.
pudendal nerve. Its motor fibers
The anal fistula may be formed by the
supply external anal sphincter. Its
infection of anal glands, which open in
sensory fibers supply ectodermal part
anal sinuses.
Sometimes, a neglected ischio-rectal abscess
of anal canal and perianal skin.
may burst in wall of anal canal and on the 3. Inferior rectal vessels that are branches
perineal skin forming anal fistula. from the internal pudendal vessels.
3. The anal fissure is caused by rupture of one 4. Perineal branch of fourth sacral nerve
of the anal columns by hard fecal matter. that enters ischiorectal fossa between
The fissure usually extends below the anal coccyges and levator ani.
column in the pecten or transitional zone, It supplies external anal sphincter,
and becomes very painful. levator ani and coccyges. It also
supplies the skin between anus and
The Ischio-Rectal Fossa coccyx.
The ischio-rectal fossa forms the lateral part of Clinical Considerations
the anal triangle.
It lies by the side of the anal canal. The ischio-rectal abscess is a very painful condition.
Shapewedge shaped A large abscess may extend to the opposite
Boundaries side behind the anus, thus making a
Superior: Origin of levator ani from the horseshoe-shaped abscess.
obturator fascia. A neglected ischio-rectal abscess may burst
Inferior: Perianal skin through its medial wall into the anal canal. It
Medial: may later burst through skin, causing anal
External anal sphincter fistula.
338 Essentials of Human Anatomy
motor fibers to external anal sphincter; and 2. The dartos muscle is the involuntary muscle
sensory fibers to lower end of anal canal, that replaces the fat in subcutaneous tissue.
ischio-rectal fossa and perianal skin. It is supplied by sympathetic nerves and
2. The perineal branch is the larger terminal it wrinkles the skin of scrotum.
branch. 3. The membranous layer of superficial
It lies in pudendal canal below the fascia (Colles fascia) forms a thin layer
internal pudendal vessels. deep to dartos.
It gives two posterior scrotal (labial) The Blood Vessels
branches to supply the skin of posterior The arteries are:
two-third of scrotum (labium majus). Two external pudendal branchessuper-
It supplies motor fibers to all the ficial and deepfrom femoral artery.
perineal muscles. Two posterior scrotal branches of internal
3. The dorsal nerve of penis (clitoris) lies on pudendal artery.
the dorsum of penis (clitoris) deep to the The cremasteric branch of the inferior
fascia. epigastric artery.
It supplies sensory fibers to the penis The veins follow the corresponding arteries.
(clitoris) including its glans. The lymphatics of the scrotum drain into the
superficial inguinal lymph nodes.
Clinical Consideration The nerves
Anterior one-third of scrotum is supplied by
The pudendal nerve can be blocked by infiltrating
ilio-inguinal nerve (L1 spinal segment).
a local anesthetic in the nerve. The needle is
Posterior two-third of scrotum is supplied
introduced just medial to ischial tuberosity, and
by posterior scrotal branches of perineal
directed towards the ischial spine.
nerve (S3 spinal segment).
THE UROGENITAL TRIANGLE
The Penis (Male Copulatory Organ)
IN THE MALES
The penis consists of a body and an attached
The urogenital triangle in the males has:
portionthe root.
i. The male external genital organs
1. The body of penis has three structures made up
The scrotum with spermatic cord
of cavernous erectile tissue.
The penis.
i. One corpus spongiosum situated ventrally and
ii. Two perineal pouchessuperficial and
contains penile (spongy) part of urethra. It
deepcontaining muscles, vessels, nerves
terminates anteriorly as the glans penis.
and structures of root of penis.
ii. Two corpora cavernosa that lie dorsally
The Scrotum and have a thick tunica albuginea made up
of fibrous tissue.
It is a pendulous sac made up of skin and fasciae The two corpora cavernosa are incom-
that lodges both testes and lower parts of the two pletely separated by a pectiniform
spermatic cords. septum.
Layers of the scrotum The layers of the body of penis (Fig. 32.2)
1. The skin is thin, dark colored and has no i. The skin is thin and dark in color. It is
fat. loosely connected to the deeper structures.
340 Essentials of Human Anatomy
Two ischio-cavernosus
Two superficial transverse perinei
c. Other contents
Perineal branch of posterior cutaneous
nerve of thigh.
Posterior scrotal nerves and vessels
(paired)
Nerve Supply
All the superficial perineal muscles are supplied
by the branches of perineal nerve (a branch of
pudendal nerve).
Fig. 32.4: The superficial perineal pouch in males
The Deep Perineal Pouch in Males
It is the space between parietal layer of pelvic
Anteriorly the pouch is open and communi-
fascia (superior fascia of urogenital
cates with space in anterior abdominal
diaphragm) and the perineal membrane
wall between membranous layer (Scarpas
(inferior fascia of urogenital diaphragm).
fascia) and external oblique muscle. Boundaries
Contents On two sides: The pouch is closed as the
a. Structures of root of penis two layers of fascia are attached to the
Bulb of penis conjoint rami.
Two crura of penis The pouch is closed due
b. Superficial perineal muscles (Table 32.1) Posteriorly: to fusion of the two fascial
Bulbo-spongiosus Anteriorly: layers
iii. The labia minora are two small cutaneous vi. The external urethral meatus is located
folds located inside labia majora. They do not about 2 cm anterior to the vaginal orifice.
contain fat.
The two labia minora are seprated by The Superficial Perineal Pouch in
vestibule of vagina. Females (Fig. 32.5)
Anteriorly the labia minora are divided into The superficial pouch has the same
two parts boundaries as in the males.
Above they from the prepuce of clitoris. Contents
Below they form the frenulum of clitoris. iv. a. Structures of the root of clitoris
The clitoris is an elongated erectile structure 1. Two crura of clitoris
that is homologous with penis of males. 2. Two bulbs of the vestibulethat join
The body od clitoris is composed of: on the ventral aspect of clitoris to form
Two corpora cavernosa made of erectile a commissure that is continuous
cavernous tissue. anteriorly as glans of clitoris.
The glans is continuation of a commissure b. Superficial perineal muscles (Table 32.3)
formed by the two vestibular bulbs. Two superficial transverse perinei
The root of clitoris is the attached part and is Two ischio-cavernosus
made up of: Bulbo-spongiosuspaired
Two crura of clitoris attached to the c. Other contents
conjoint rami and continuous with the Greater vestibular (Bartholins)
corpora cavernosa. glands paired.
Two bulbs of the vestibule made up of Posterior labial vessels and nerves
erectile tissue and lie on either side of paired.
vaginal orifice. Perineal branch of posterior cutaneous
v. The vaginal orifice (introitus) is a sagittal nerve of thigh.
orifice covered by a membranehymen.
Nerve Supply
The hymen is ruptured during first coitus and
small remnantscarunculae hymenales Superficial perineal muscles are supplied by
remain. perineal nerve, a branch of pudendal nerve.
Course: The ureter enters the pelvic cavity by The terminal part of ureter is supplied by the
crossing the common iliac artery, near its pelvic plexus (S2, S3, and S4 segments of
bifurcation at the pelvic inlet. spinal cord). The referred pain from this part
The ureter runs downwards and backwards of ureter is felt in perineum and back of thigh.
along the lateral pelvic wall lying just deep to
the peritoneum in extraperitoneal tissue. Clinical Considerations
It crosses the obturator nerve, branches of
1. Ureteric stone: Causes abnormal uretrine
anterior division of internal iliac artery and
contractions and spasm leading to ureteric colic.
obturator internus muscle, covered by obturator
The ureteric stone is liable to be impacted at one
fascia up to the level of ischial spine.
of the following three constrictions:
Then, ureter bends forwards above levator ani.
a. At the pelvi-ureteric junction
In males: It is crossed from lateral to medial
b. At pelvic inlet
side by the vas deferens, and reaches posterior
c. At site of piercing the bladder wall.
superior angle at the base of urinary bladder.
2. The left ureter, in females, is more closely related
In females: The ureter passes forwards by side
to the lateral vaginal wall. Thus, it is more likely to
of upper part of vagina, lying just below the
uterine artery and broad ligament of uterus to be lacerated in cases of difficult childbirth.
reach the base of urinary bladder.
THE URINARY BLADDER
The ureter pierces the bladder wall very
obliquely through its muscle coat, and opens in The urinary bladder is a hollow muscular organ
the cavity of urinary bladder at upper angle of the that stores urine for a short period, till the next
trigone of the bladder. act of micturation (Fig. 33.2).
Location
The Blood Supply of Ureter In adults: It lies in the anterior part of pelvic
The arteries supplying pelvic part of ureter are cavity behind pubic symphysis. When full,
Small branches of common iliac artery the bladder rises above the pubic symphysis
Inferior vesical artery (in males) in hypogastric region of abdominal cavity.
Uterine artery (in females). In infants at birth, the urinary bladder, is an
These vessels have longitudinal anastomosis in abdominal organ since there is no pelvic
the walls of the ureter. cavity.
The veins accompany the arteries. It progressively descends with age and
reaches its adult position in pelvis by
The Lymphatic Drainage of Ureter puberty.
Shape
The lymphatics of ureter end in common iliac, When emptyTetrahedron
external iliac and internal iliac lymph nodes. When fullOvoid
Capacity
The Nerves Supply of the Ureter
In adult male: It is about 120-320 ml (aver-
At the pelvic inlet, the ureter is supplied by age about 220 ml)
the hypogastric plexus (L1, L2 segments of In adult female: It is less
spinal cord). The referred pain from this part The bladder can hold up to 500 ml, but it
is felt in inguinal and pubic regions. becomes painful.
The Pelvic Viscera1 349
Surfaces: The urinary bladder has: In males: The neck is related to the base
1. An apex: That lies at upper border of of prostate gland.
pubic symphysis. The median umbilical
ligament (remnant of urachus) connects it The Ligaments of the Urinary Bladder
to the umbilicus. i. The median umbilical ligament ( remnant of
2. The base: Fundus of posterior surface) is urachus) connects the apex of bladder to the
triangular in shape. umbilicus.
In males: It has peritoneal covering in ii. Two medial umbilical ligaments lie on either
median plane. On either side it is side of apex, reaching up to umbilicus. These
related to the ampulla of vas deferens are remnants of umbilical arteries.
and seminal vesicle. iii. Two pairsmedial and lateral pubo-
In females: It is related to the anterior prostatic (pubo-vesical in females)
vaginal wall. ligamentsconnect the neck of bladder to
3. The superior surface is triangular in shape the pelvic surface of pubic bones.
and covered by peritoneum. It is related to
coils of pelvic colon and terminal ileum. The Inferior Urinary Bladder
4. The two infero-lateral surfaces are related Shows mucosal folds in the empty state except at
to pubic bone, retropubic fat and origin of a triangular area in the interior of base of bladder
levator ani from obturator fascia. called trigone of bladder.
5. The neck of urinary bladder is the lowest The trigone has the following features
and most fixed part that lies behind lower 1. The openings of two ureters are located at the
part of pubic symphysis. lateral angles of trigone.
The neck is pierced by internal urethral 2. The internal urethral meatus lies at the
meatus. anterior inferior angle.
350 Essentials of Human Anatomy
3. The two ureteric openings are 2.5 cm apart in The afferent pain fibers stimulated by
an empty bladder. However, when the bladder overdistention, stone or muscle spasm
is full, they become 5.0 cm apart. travel both via sympathetic and parasym-
4. The trigone has a separate trigonal muscle, pathetic. Therefore, simple division of
derived from the muscle coat of ureters. sympathetic pathways (presacral
5. In males: There is a slight swelling uvula neurectomy) does not relieve the bladder
vesicae behind the internal urethral meatus, pain.
caused by the median lobe of prostate gland.
Clinical Considerations
The Blood Supply of the Urinary Bladder
1. Cystoscopy is performed by passing an endo-
The arteries are:
scopic instrumentthe cystoscopevia urethra.
Paired superior vesical artery. This procedure visualizes the interior of bladder.
Paired inferior vesical artery (uterine in females)
2. Vesical calculus(stone in bladder)
Small branches from obturator artery.
causes pain and hematuria.
All these arteries are branches of anterior division
3. Patent urachus is a rare condition, that
of internal iliac artery.
causes a urinary fistula from the apex of bladder
The veins from vesical venous plexus that lies
to umbi-licus.
in relation with infero-lateral surfaces.
In males: The venous plexus joins with the THE URETHRA
prostatic venous plexus.
The venous plexus drains into the internal The urethra is the fibrous canal that carries urine
iliac veins. from urinary bladder to the exterior (Fig. 33.3).
A. The male urethra is about 20.0 cm long and is i. One intrabulbar fossa in the bulb of penis.
divided into three partsprostatic, membranous ii. One navicular fossa in the glans of penis.
and spongy (penile). The ducts of bulbo-urethral (Cowpers)
a. The prostatic urethra begins at the neck of gland open in this part just below
bladder at internal urethral meatus and ends at urogenital diaphragm.
the superior fascia of urogenital diaphragm. The dorsal wall of spongy urethra has
Length: 3.0 cm Openings of many mucus glands.
The prostatic urethra is the widest and
Lacunae or pit-like recesses directed
most dilatable part of male urethra.
forwards. The lacuna magna lies in the
Features: In its posterior wall there is
navicular fossa.
urethral crest with a round swelling
colli-culus seminalisin the middle. While passing an instrumentmetal
There are three openings on the colliculus catheter or bougiethrough urethra, its
seminalis: point may be held up in these openings if
1. One median for prostatic utricle. it is directed towards dorsal wall.
2. Two lateral for the ejaculatory ducts. The spongy urethra ends at external
3. On either side of urethral crest, there is urethral meatus, that is a sagittal slit,
a shallow depressionprostatic about 6 mm long at the tip of the glans.
sinus in which the ducts of the The external meatus is guarded by two lateral
prostatic glands open. labia. It is the narrowest point of male urethra.
b. The membranous urethra lies in the deep If an instrument can pass through it, it can
perineal pouch between two fascial layers easily pass through rest of urethra.
enclosing the urogenital diaphragm. The urethral sphincters: There are two sphincters
This is the narrowest segment of male in relation to male urethra.
urethra.
1. The internal-sphincter vesicaeis
It is surrounded by sphincter urethraethat
present at the neck of the bladder. It is
acts as a voluntary external sphincter.
an involuntary sphincter formed by
The segment of urethra is more susceptible
non-straited muscle, and controlled by
to injury, during passage of instrument
autonomic nerves.
through urethra due to
i. Its narrowness 2. The external-sphincter urethrae
ii. Its delicate walls surrounds the membranous part of
iii. Its angulation with the spongy urethra. urethra. This is a voluntary sphincter
Length: 2.0 cm formed by skeletal muscle and
c. The spongy (penile) urethra is the longest part controlled by somatic nerves.
of male urethra. B. The female urethra is about 4.0 cm long.
Length15 cm. It extends from the neck of bladder to the
It begins at the inferior fascia of urogenital external urethral meatus.
diaphragm and ends at external urethral It is homologous with upper part of prostatic
meatus. urethra of males.
This part lies within the bulb of penis, Location: The female urethra is embedded in
corpus spongiosum and glans of penis. anterior wall of vagina. Thus in cases of difficult
There are two dilatations in this part: child-birth, it is more likely to be lacerated.
352 Essentials of Human Anatomy
The female urethra is more dilatable and iii. Tunica vasculosa is formed by delicate
opens in anterior part of vestibule of vagina connective tissue containing plexus of fine
between two labia minora, about 2.5 cm blood vessels.
behind the glans clitoris. It lines the interior of the lobules (com-
Many small urethral glands open in female partments) of testis.
urethra.
The paraurethral glands (Skenes glands) The Coverings of the Testis
open by paraurethral duct in vestibule of
a. Parietal layer of tunical vaginalis.
vagina close to the urethral orifice.
b. The internal spermatic fascia derived from
MALE REPRODUCTIVE fascia transversalis.
c. The cremasteric muscle and fascia derived
ORGANS Testis from fleshy party of internal oblique muscle.
The testis: The testes are the male gonads (sex d. The external spermatic fascia derived from
glands), that produce the sperms and the male external oblique aponeurosis.
hormone (testosterone). The tunica vaginalis is a closed serous sac
Size: 4-5 cm(l) 2.5 cm (w) 3.0 cm (th). with a parietal and visceral layer that surrounds
Shape: Oval, laterally compressed. testis and epididymis except at its posterior
Location: The testes lie in scrotum outside border.
pelvic cavity; because high intra-abdominal The tunica vaginalis is the persistent lower
temperature is not suitable for production of end of processus vaginalisa tube of
normal, motile sperms. peritoneum that descends along with testis up
The coats of the testis: The testis has three coats: to scrotum.
i. Tunica vaginalis: The visceral layer of The part of processus vaginalis from upper end
tunica vaginalis covers the testis on all of testis up to deep inguinal ring, is obliterated
sides except the posterior border. usually persisting as a fibrous cordvestige of
ii. Tunica albuginea is thick fibrous coat that processus vaginalis (Fig. 33.4).
covers the testis externally.
The coat sends delicate connective tissue Structure of the Testis
septulae in the interior of testis to divide The testis has about 200-300 compartments
it into 200-300 compartments (lobules). (lobules) separated by connective tissue
The tunica albuginea is thickened along septulae.
the posterior border of testis to form Each lobule contains 1-3 seminiferous tubules
the mediastinum testes, that contains: just visible to the naked eye as delicate
Branches of testicular artery threads (length 70-80 cm)diameter 0.01
Venous plexus, that will continue 0.13 mm (Fig. 33.5).
as pampiniform plexus Each seminiferous tubule has
Rete testis: A plexus of efferent a. A coiled part where spermatogenesis
tubules that conducts sperms takes place.
Lymphatics b. A short straight part that opens in the net-
Sympathetic plexus work of efferent tubules in mediastinum
The Pelvic Viscera1 353
rete testis. No spermatogenesis takes place The Blood Supply of the Testis
here. The Arteries
Rete testis lies in the mediastinum and is 1. The testicular artery is a long, slender branch
connected with the seminiferous tubules. from abdominal aorta arising a little below the
From the upper part of mediastinum about 15- renal artery.
20 efferent tubules (vasa afferentia) pierce It descends deep to peritoneum in posterior wall
tunica albuginea and enter the head of epi- of abdomen, then runs along the spermatic cord
didymis. to reach posterior border of testis.
It is the main artery supplying testis.
2. The artery to the vas deferens, a branch of
inferior vesical artery, also reaches posterior
border of testis along with vas deferens.
The artery has some anastomosis with the
testicular artery but that is not adequate.
However, in case of injury or ligature of testi-
cular artery, the testis undergoes avascular
necrosis.
The Veins
The veins issuing from the posterior border of
testis form a pampiniform plexus of veins, that
Fig. 33.5: Structure of testis ascends in the spermatic cord.
354 Essentials of Human Anatomy
2. Vesiculitis is inflammation of seminal vesicle 2. The apex lies below. It rests on the
may lead to abscess formation which may rupture urogenital diaphragm.
in the peritoneal cavity. 3. The posterior surface is separated from the
rectal ampulla by retro-prostatic fascia. The
The Ejaculatory Ducts posterior surface is vertically convex and
presents a groove in the median plane.
The ejaculatory ducts are two narrow ducts
4. The anterior surface is narrow and is
formed by the union ofduct of seminal vesicle
sepa-rated from lower part of pubic
and ampulla of vas deferens
symphysis by some adipose tissue.
Length: About 2.0 cm long
5. The two infero-lateral surfaces are
Course: The ejaculatory duct passes antero-
separated from anterior parts of levator ani
inferiorly through the prostate gland, separating
muscles by plexus of veins embedded in
median lobe from the posterior lobe.
the sheath of prostate gland.
Termination: The ejaculatory duct opens on
Capsules: The prostate gland has two capsules.
the colliculus seminalis by the side of opening
i. A true capsule formed by condensation of
of prostatic utricle, in the prostatic urethra. connective tissue all around it.
ii. A fascial capsule is formed by the visceral
The Prostate Gland
layer of pelvic fascia.
The prostate gland is a glandular structure with The prostatic venous plexus lies
fibro-muscular stroma, that surrounds the beginn- between the two capsules (Fig. 33.6).
ing of male urethra. Size and shape
Location:The prostate gland lies in the lower Anteroposterior diameter 2.0 cm
part of pelvic cavity behind the lower part of Transverse diameter 4.0 cm
pubic symphysis, in front of ampulla of rectum. Vertical diameter 3.0 cm
Surfaces and relations Weight is approximately 8 gm in young adult
1. The base of the prostate gland surrounds male.
the neck of urinary bladder. Shape is like a chestnut.
The Lymphatic Drainage Rarely, the ovaries may descend lower, and
come to the near the deep inguinal ring,
The lymphatics from the ovary accompany the
inguinal canal or even in labium majus.
ovarian vessels and end in pre-aortic and para- An ectopic ovary is usually an
aortic lymph nodes. undeveloped ovary.
The Nerve Supply The Uterus [The Womb] (Fig. 34.1)
The role of autonomic nerve supply of ovary is The uterus, is a thick-walled, hollow muscular
not clear. The sympathetic fibers travel as ovarian organ in females, in which fertilized ovum is
plexus with the ovarian vessels from the aortic implanted and development of embryo and fetus
plexus. takes place.
These are derived from T11,T12,L1, and L2 Location: The uterus lies in the pelvic cavity
segments of spinal cord. between the urinary bladder and rectum.
The parasympathetic fibers are derived from Normal position of the uterus is anteverted
the pelvic splanchnic nerves (nervi erigentes). and ante-flexed.
They carry fibers from S2,S3, and S4 Anteversion: The long axis of uterus makes an
segments of spinal cord. angle of nearly 90 with long axis of vagina.
Anteflexion: The uterus is bent upon itself.
Clinical Considerations The long axis of body of uterus makes an
angle of nearly 125 with long axis of cervix
1. The ovarian tumors are quite common in portion of uterus (Fig. 34.2).
elderly females. Size and shape
2. The ectopic ovary: Sometimes the ovary fails The nulliparous uterus (where embryo and
to descend from posterior abdominal wall to fetus have not developed) is 7.5 cm (l) 5.0
its normal position. cm (w) 2.5 cm (th).
2. Compression and avulsion of ureter may take The ostium is surrounded by 6-8 finger-
place in cases of different child-birth. The ureter like projectionsfimbriaone
may also be accidentally ligated or clamped during fimbria is longer and adherent to the
hysterectomy operation along with uterine vessels. lateral end of ovary. It is called
3. Hystero-salpingography is a special X-ray ovarian fimbria and it helps in transver
procedure in which a radiopaque dye is injected of ovum from the ovary to the tube.
under pressure through the cervix of uterus. ii. The ampulla is thin-walled, dilated part of
The dye passes from the uterus into the uterine uterine tube. It forms nearly half part of
tubes and may leak in peritoneal cavity. tube.
The procedure is adopted to visualize the Fertilization of ovum takes place in this
female genital passage. part of tube.
The Uterine Tubes (Fallopian Tubes) iii. The isthmus is the narrow part of tube that
is attached to the uterus. It forms nearly
The uterine tubes are two muscular tubes, that
1/3rd part of tube.
convey ova from the ovaries to the cavity of uterus.
iv. The Intra-mural (uterine) part is nearly
Length: About 10.0 cm.
1.0 cm long and passes through thickness
Location: The uterine tubes lie in medial
4/5th part of free upper border of broad of muscular wall of the uterus.
ligament on either side of the uterus. It is narrowest part of uterine tube.
Parts: The uterine tube has the following parts: The uterine tube opens in the superior angle of
i. The infundibulum or the lateral end is cavity of body of uterus.
open like a funnel with an abdominal The ova are propelled through the uterine
ostium opening in the abdominal cavity. tube by gentle peristaltic contractions.
364 Essentials of Human Anatomy
The Blood Supply By one incision, both uterine tubes are secured
The arteries and 1.0 cm parts of tubes are cut off and cut
ends ligated.
The uterine artery supplies medial two-third
The operation blocks the passage of ovum
part of uterine tube.
through the tube, and person becomes sterile.
The ovarian artery supplies lateral one-third
3. Tubal pregnancy may occur rarely, due to
part of uterine tube. implantation of fertilized ovum in the ampullary
The Veins follow the arteries. part of tube.
From the medial part, the veins end in the The tubal pregnancy ruptures by tenth week
uterine venous plexus. leading to excessive hemorrhage.
From the lateral part, the veins join the
ovarian venous plexus. The Vagina
The vagina is the copulatory organ of the
The Lymphatic Drainage
females. It is a fibro-muscular canal that extends
The lymphatics from the lateral part of tube from the uterus to the vestibulecleft between
accompany the ovarian lymphatics and end in two labia minora.
pre-aortic and para-aortic lymph nodes. Location: The vagina is located between the
The lymphatics from the medial part of tube urinary bladder and urethra anteriorly, rectum
accompany the uterine lymphatics and end in and anal canal posteriorly.
internal iliac lymph nodes. Length: The anterior wall is nearly 7.5 cm
long, the posterior wall is nearly 9.0 cm long.
The Nerve Supply Cavity of vagina remains collapsed normally
The sympathetic fibers from T 10 to L2 segments and is H-shaped in a TS.
of spinal cord reach via pelvic plexus. The upper part of cavity is wider and
surrounds the vaginal part of cervix.
The parasympathetic fibers from the pelvic
Relations: The upper two-third of vagina lies
splanchnic nerves reach the lateral half of
in the pelvic cavity.
uterine tube.
The lower one-third lies below the pelvic
Afferent autonomic fibers accompany sym-
diaphragm in the perineum.
pathetic nerves.
Anteriorly:
Clinical Considerations Base of urinary bladder
Female urethra
1. In females, pelvic peritonitis may occur more Posteriorly:
frequently, as infection from vagina and uterus can Upper one-thirdRecto-uterine pouch
travel via the uterine tubes into the peritoneal cavity. Middle one-thirdRectal ampulla separated
Salpingitis or inflammation of the tube leads by a septum
to blockage of lumen of tube. This is the most Lower one-thirdPerineal body separating
common cause of female infertility. it from the anal canal.
2. Tubal ligation (TubectomyFemale Laterally
Family Planning Operation). Levator ani muscle
The operation is done preferably 4-5 days after Ureter
childbirth, when the uterus lies midway Uterine artery
between umbilicus and pubic symphysis. Endopelvic fascia
The Pelvic Viscera2 365
The Blood Supply From the part of vagina below hymen, the
The arteries: supplying the vagina are lymphatics end in superficial inguinal lymph
Vaginal branches of uterine artery nodes.
Vaginal artery
Small branches from internal pudendal and The Nerve Supply
middle rectal arteries.
The veins form the vaginal venous plexus and The upper two-third of vagina is supplied by the
drain into the internal iliac vein. utero-vaginal plexus of nerves carrying.
Sympathetic fibers from pelvic plexuses.
The Lymphatic Drainage Parasympathetic fibers from pelvic splanchnic
From the upper part of vagina, the lymphatics nerves.
accompany the uterine vessels and end in internal The afferents from this part travel via the
and external iliac lymph nodes. pelvic splanchnic nerves.
From the middle part, the lymphatics end in The lower one-third of vagina is supplied by the
internal iliac lymph nodes. pudendal nerve.
The Pelvis
Multiple Choice Questions
Q1. Give the one best response to each 7. Which of the following structures cannot be
question from the given four answers: palpated by vaginal examinationin females.
A. Sigmoid colon
1. The fertilization of the ovum takes place in:
B. Urethra
A. Body of the uterus
C. Perineal body
B. Ampulla of the uterine tube
D. Ischial spines
C. Peritoneal cavity
D. Ovarian follicle 8. The ano-rectal ring that prevents fecal
incontinence is formed by:
2. The remnant of peritoneal cavity present in
A. Deep part of external anal sphincter
the scrotum is: B. Internal anal sphincter
A. Gubernaculum C. Pubo-rectalis part of levator ani
B. Ductus deferens D. All of the above
C. Tunica vaginalis
D. None of the above 9. In infants, the internal urethral meatus of
the urinary bladder lies at the level of:
3. The length of the anal canal is: A. Upper border of pubic symphysis
A. 1 1/2 inches B. Midway between umbilicus and pubic
B. 6.0 inches symphysis
C. 10.0 inches C. Middle of pubic symphysis
D. 12.0 inches D. Lower border of pubic symphysis
4. The prostatic hypertrophy involves mainly. 10. The narrowest part of male urethra is:
A. Anterior lobe A. Prostatic part
B. Two lateral lobes B. Membranous part
C. Median lobe C. Internal urethral meatus
D. B and C D. External urethral meatus
5. The urogenital diaphragm is formed by: Q2. Each question below contains four
A. Sphincter urethrae sugges-ted answers, of which one or more
B. Levator ani are correct. Choose the answer:
C. Deep transverse perineal A. If 1, 2 and 3 are correct
D. A and C B. If 1 and 3 are correct
6. Which of the following structures cannot be C. If 2 and 4 are correct
palpated by rectal examination in males: D. If only 4 is correct
A. Bulb of the penis E. If 1, 2, 3 and 4 are correct
B. Seminal vesicles 11. The ischiorectal fossa:
C. Ureter 1. Contains a pad of fat that supports anal
D. Anorectal ring canal
Multiple Choice Questions 367
ii. Prostate gland B. Conveys sperms iii. Lower one-third C. Superficial ingui-
from epididymis of vagina nal lymph nodes
to ejaculatory duct iv. Ovary D. Internal and exter-
iii. Cowpers gland C. Situated in deep nal iliac lymph
perineal pouch nodes
iv. Vas deferens D. Secretes fructose 24. Origin of arteries:
for nutrition of i. Superior rectal A. Abdominal aorta
sperms artery
ii. Testicular artery B. Anterior division
22. Embryonic remnants: of internal iliac
i. Prostatic utricle A. Cranial end of artery
paramesonephric iii. Ilio-lumbar artery C. Posterior division
duct of internal iliac
ii. Appendix of test B. Caudal end of artery
iv.
paramesonephric Uterine artery D. Inferior mesen-teric
duct artery
iii. Appendix of epi- C. Mesonephric duct 25. Root value of nerves:
didymis in females i. Pudendal nerve A. L2,L3,L4 (ventral
iv. Gartners duct D. Mesonephric divisions of vent-
tubule ral rami)
ii. Lumbo-sacral B. S2, S3, S4 ventral
23. Lymphatic drainage: trunk rami
i Cervix of uterus A. Para-aortic lymph iii. Obturator nerve C. L4,L5 ventral rami
nodes iv. Genitofemoral D. L1,L2 (ventral
ii. Prostate gland B. Internal iliac nerve division of ventral
lymph nodes rami)
Answers
A6. The answer is C. from the pubic symphysis. Its length is only
The ureter cannot be palpated by rectal 1 1/2 inches (4.0 cm) and its pierces deep
examination. The bulb of penis, seminal perineal pouch.
vesicles and anorectal ring can be palpated A13. The answer is B, (1, 3)
by rectal examination in the males.
The rectum begins on front of middle
A7. The answer is D. sacrum as continuation of sigmoid colon. It
The ischial spines are not palpated by the has rectal ampulla in lower one-third part.
vaginal examination in females. The The length of rectum is only 5.0 inches (12
sigmoid colon, rectum and perineal body cm), and it has peritoneal covering on front
can be palpated through posterior wall of of middle one-third part also.
vagina. The ureters can be palpated through
A14. The answer is C, (2, 4).
lateral fornices of vagina.
The seminal vesicles are two lobulated
A8. The answer is D. structures, but in humans they act like
The fecal incontinence is prevented by all glands and do not store sperms. They can
three structuresdeep part of external anal be palpated by anterior rectal wall. Their
sphincter, internal anal sphincter and pubo- duct joins with ampulla of vas deferens to
rectalis part of levator ani that form the form ejaculatory ducts. However, they are
ano-rectal ring connected with the base of urinary bladder
A9. The answer is A. by connective tissue and not peritoneum.
In infants, at birth, the internal urethral A15. The answer is E, (1, 2, 3, 4)
meatus lies at the level of upper border of The ovary is suspended from posterior layer
pubic symphysis, because there is no pelvic of broad ligament by mesovarium, and is
cavity. By puberty, it descends to its adult related to ovarian fossa in lateral pelvic wall.
level at lower border of pubic symphysis. The peritoneal covering of ovary is modified
A10. The answer is D. to form germinal epithelium. The lymphatics
The narrowest part of male urethra is its from ovary end in para-aortic lymph nodes.
membranous part. The narrowest point of A16. The answer is E, (1, 2, 3, 4)
male urethra is external urethral meatus. If a The nerve supply of urinary bladder is from
catheter or an instrument can pass through both sympathetic and parasympathetic. The
external meatus. It can easily pass through parasympathetic pre-ganglionic fibers
rest of male urethra.
originate from S2,S3 and S4 segments of
A11. The answer is A, (1, 2, 3) spinal cord and synapse with postganglionic
The ischio rectal fossa contains pad of fat neurones in bladder wall. The sympathetic
and has pudendal canal in its lateral wall. its postganglionic fibers come from inferior
floor is formed by perineal skin; but levator hypogastric (pelvic) plexus. The afferent
ani muscles form its medial wall and not sensations reach spinal cord both via pelvic
lateral wall. splanchnic nerves (parasympathetic) and
A12. The answer is C, (2, 4) sympathetic.
The female urethra is embedded in anterior A17. The answer is B, (1, 3)
wall of vagina, and its external office is The sacrum in females is shorter and wider
located in vestibule of vagina, about 2.5 cm than in males and has shorter articular surface
370 Essentials of Human Anatomy
for sacro-iliac joints. It is less curved than The appendix of testis is remnant of
males and has five sacral vertebrae. cranial end of paramesonephric ducts in
A18. The answer is E, (1, 2, 3, 4) males.
Appendix of epididymis is remnant of
The levator ani muscle forms the main part of mesonephric tubules in males.
pelvic diaphragm and by its normal tone The Gartners duct is remnant of
keeps the pelvic organs in position. If its tone mesonephric duct in females.
is weekend, it may cause prolapse of rectum.
It is supplied by inferior rectal nerve and
A23. The answers are D, B, C, A.
perineal branch of 4th sacral nerve. The lymphatics of cervix of uterus
drain in both internal and external iliac
A19. The answer is C, (2, 4) lymph nodes.
The female bony pelvis is smaller part of a The lymphatics of prostate gland drain
larger cone and has a wider pelvic outlet. It into internal iliac lymph nodes
has a wider subpubic angle and an oval The lymphatics from lower one-third of
pelvic inlet. The narrow subpubic angle and vagina drain in superficial inguinal
heart shaped pelvic inlet are chracteristics lymph nodes
of male bony pelvis. The lymphatics of ovary drain in para-
A20. The answer is B. (1, 3). aortic lymph nodes.
The piles (hemorrhoids) develop from A24. The answers are D, A, C, B.
enlargement of venous plexus in submucus The superior rectal artery is continuation
coat of anal canal. The piles develop in both of inferior mesenteric artery.
endodermal and ectodermal parts of anal The testicular artery is a branch of
canal. The primary piles are formed at 3, 7 abdominal aorta.
and 11 oclock positions. The piles never The iliolumbar artery is a branch of
develop into anal fistula. posterior division of internal iliac artery.
A21. The answes are D, A, C, B. The uterine artery is a branch of
The seminal vesicles secrete fructose anterior division of internal iliac artery.
for nutrition of sperms. A25. The answers are B, C, A, D.
The prostate gland produces seminal The root value of pudendal nerve is
fluid mainly. S2,S3 and S4 ventral rami
Cowpers glands are located in deep The lumbo-sacral trunk comes from
perineal pouch.
ventral rami of L4 and L5 spinal nerves
Vas deferens conveys sperms from
The obturator nerve has L2, L3 and L4
epididymis to the ejaculatory duct.
ventral divisions of ventral rami as its
A22. The answers are B, A, D, C. root value.
The prostatic utricle is remnant of caudal The root value of genito-femoral nerve is
part of paramesonephric ducts in males. L1, L2 ventral divisions of ventral rami.
The Head and Neck
Seven
CHAPTER 35
The Bones of the
Head and Neck
The skeleton of head is formed by the skull and Anatomical position of skullcan be
the mandible or lower jaw bone forming lower visualized by the following planes.
part of facial skeleton. The skull (cranium) is Reids base lineAn imaginary horizontal
divided into an anterior part that forms the upper plane connecting infraorbital margins to the
part of facial skeleton and a posterior part that center of external acoustic meatus
forms the calvaria or the brain box. Frankfurts planeAn imaginary horizontal
The skeleton of the neck is formed by the seven plane connecting infra-orbital margins to the
cervical vertebrae and the inter-vertebral discs. upper margin of external acoustic meatus
There is a small hyoid bone in the front of EXTERIOR OF THE SKULL
upper part of neck.
A. Norina verticalis (Superior view)
THE CRANIUM When viewed from above the skull appears
i. The facial skeleton has fourteen bones wider posteriorly. The bones seen in this view
are:
Vomer 1
Frontal bone anteriorly
Maxillae 2
Occipital bone posteriorly
Nasal 2
Two parietal bones on either sides
Lacrimal 2
The sutures seen in this view are:
Palatine 2 Coronal suture between frontal and two
Zygomatic 2 parietal bones.
Inferior nasal concha 2 Sagittal suture between the two parietal
ii. The Calvaria (brain box) is made up of bones
eight bone. Lambdoid suture between the two parietal
Ethmoid 1 bones and occipital bone.
Sphenoid 1 The Other features of skull in this view are:
Occipital 1 Bregma - point where coronal and sagittal
Frontal 1 suture meet
Parietal 2 Lambda - point where sagittal and
Temporal 2 lambdoid sutures meet
372 Essentials of Human Anatomy
Parietal tubers (eminences) are the points C. Norma Frontalis (Anterior view)
of maximum convexity of parietal bones When viewed from front the skull appears
Parietal emissary foraminaare two wider above. The bones seen in this view are
small foramina or either side of sagittal Frontal bone - forms upper broader part
suture about from lambda. Sometimes a Two maxillae - form the upper jaw
point on sagittal suture between two Two nasal bones - form the upper part of
parietal foramina is known as obelion. skeleton of nose
Temporal lines - superior and inferior - lie Two zygomatic bones - form the bony
on either side. They arch upwards and prominences on either side
backwards across sides of frontal bone The features of skull in this view are
and parietal bones Two frontal tubers (eminences) form low
B. Norma Occipitalis (posterior view) rounded elevations in upper part.
When viewed from behind the skull appears Two superciliary arches -form curved
arched above and flattened below. The bones elevations above the supra-orbital margins.
seen in this view are: Glabella - median elevation joining the
Posterior parts of two parietal bones two superciliary arches
Squamous part of occipital bone below Nasion - point that lies in median plane where
Mastoid parts of two temporal bones on internasal and fronto-nasal sutures meet
either side. Two orbital openings on the skull represent
The sutures seen in thus view are: the openings of orbital cavities. The supra
Lambdoid suture between the two parietal orbital margin is formed by frontal bone.
bones and occipital bone
The infra-orbital margin by zygomatic and
Posterior part of sagittal suture
maxilla. The lateral orbital margin by frontal
Occipito-mastoid suture
and zygomatic and medial orbital margin by
Parieto-mastoid suture
frontal and frontal process of maxilla.
The other features of skull in this view are:
The piriform aparture lies in midline formed
Lambda and parietal foramina
by two nasal bones and two maxillae
External occipital protuberance in midline
on occipital bone. Most salient point is The two zygomaticofacial foramina lie on
called inion the zygomatic bones.
Two superior nuchal linespass on either The anterior nasal spine is present in
side from external occipital protuberence midline at lower end of piriform aperture
as curved bony ridges. Two infra-orbital foramina are present
Two highest nuchal linesare faint bony below the infra-orbital margins in maxillae
ridges sometimes present above superior The alveolar processes of two maxillae
nuchal lines bear the sockets of upper jaw teeth
External occipital crestpasses D. Norma lateralis (Lateral view)
downwards in midline from the external When viewed from side the skull presents an
occipital protuberance arched appearance above. The bones seen in
Two mastoid emissary foraminaare this view are
present on the mastoid bone Frontal bone - anteriorly
Interparietal bonesometimes present is Parietal bone - in middle
the separated upper triangular part of the Occipital bone - behind
occipital bone. Nasal bone - anteriorly
The Bones of the Head and Neck 373
The infra temporal surface of greater wing It presents the occipital condyles situated along
of sphenoid presents three foramina anterior margin of foramen magnum. They
foramen ovale, emissary sphenoidal foramen articulate with superior facets of atlas vertebra
and foramen spinosum Hypoglossal canal (anterior condylar
Sulcus tubaeis the groove between canal) Pierces antero superior part of
greater wing of sphenoid and petrous occipital condyle
temporal. It lodges the cartilaginous part Posterior condylar canalan emissary
of auditory tube. foramen located in floor of condylar fossa
The spine of sphenoid is a pointed spine Jugular process of occipital bone lies
located lateral to foramen spinosum. lateral to occipital condyle and forms
The inferior surface of petrous temporal posterior boundary of jugular foramen
bone is triangular and is wedged between Jugular foramen is a large elongated
the greater wing of sphenoid and basi- foramen situated between jugular process of
occiput. Its apex is pierced by carotid occipital bone and petrous temporal bone
canal and is separated from sphenoid by Tympanic canaliculus is a minute opening
foramen lacerum. between carotid canal and jugular fossa
The tympanic part of temporal boneis a Styloid processa thin long process from
curved bony plate that lies between medial to mastoid process directed down-
petrous and squamous temporal bones. It wards forwards and medially
forms walls of external acoustic meatus. Mastoid processa large conical bony pro-
The squamous part of temporal bone fection behind external acoustic meatus
forms part of mandibular fossa (for head Stylomastoid foramen - situated between
of man-dible) articular tubercle at root of mastoid process and base of styloid process
zygoma and a small part of roof of
infratemporal fossa. INDIVIDUAL BONES OF SKULL
Squamo-tympanic and petro - tympanic 1. Vomeris a thin plate of bone in midline
fissures are present. forming posterior and inferior part of nasal
The posterior part of norma basalis is divided septum
into a median area and two lateral parts It divides into two alae superiorly that
A. The median area presents articulate with rostrum of sphenoid
Foramen magnumthe largest foramen of 2. Maxillaforms the skeleton of upper jaw
skull that opens above in posterior cranial with bone of opposite side
fossa and transmits lower part of medulla It has a pyramidal body occupied by
oblongata bondes other structures. maxillary air sinus. Its anterior surface has
External occipital protubrancea median an infra-orbital foramen and canine
protuberance on occipital bone eminence, while its posterior surface has
External occipital cresta bony ridge that minute vascular canals and forms anterior
extends from external occipital protube- wall of infra-temporal fossa
rance to posterior margin of foramen The superior triangular surface forms floor
magnum of orbital cavity. The medial surface with
B. The lateral area has the following features a large maxillary hiatus forms part of
The condylar part of occipital bone lateral wall of nasal cavity
The Bones of the Head and Neck 375
Maxilla has four processes: temporal fossa and its medial surface
i. Zygomatic processarticulates with forms part of lateral wall and floor of
zygomatic bone orbital cavity
ii. Frontal processforms lateral orbital Zygomatic has three processes
margin and joins with frontal bone i. Frontal processlies along lateral
iii. Alveolar processhas eight sockets for
margin of orbit to join with frontal bone
teeth and has maxillary tuberosity behind
ii. Maxillary processjoins medially
iv. Palatal processlies horizontally and
with maxilla
forms four-fifth part of hard palate
with opposite bony process iii. Temporal processforms the
Age changes in Maxilla: zygomatic arch with zygomatic
At birthbone has no maxillary sinus, process of temporal
Frontal process is prominent. Its transverse 7. Inferior nasal conchais a curved bony plate
diameter is more than vertical diameter that lies in the lateral wall of nasal cavity
In adultlateral diameter is greatest owing to above the inferior meatus
development of teeth. The maxillary sinus is 8. Mandible or the lower jaws bone forms the
fully developed lower half of fascial skeleton
In old ageThe alveolar magin is absorbed Each half of mandible has a horizontal
due to loss of teeth. The height of bone body and a vertical part - ramus
becomes less The two halves of mandible are connected
3. Nasalis a small bone that forms the bridge
by a fibrous joint at birth. Bony fusion
of nose with bone of opposite side
It articulates with nasal part of frontal bone
(syno-stosis) takes by end of first year to
above and frontal process of maxilla laterally from symphysis menti
4. Lacrimalis smallest and thinnest of all The body of mandible has two surfaces
cranial bones i. Lateral surface (Fig. 35.1) - has an
It lies in medial wall of orbit between oblique line an incisive fossa and a
frontal process of maxilla and orbital plate mental foramen
of eth-moid
It has a lacrimal groove on lateral surface-
that lodges lacrimal sac
5. Palatinelies in lateral wall of nasal cavity
and palate
It has two partsa horizontal plate and a
perpendicular plate
The horizontal platejoins the bone of
opposite side to form posterior one-fifth part
of hard palate. It has a nasal spine in midline
The perpendicular part forms posterior
part lateral wall of nasal cavity
6. Zygomatic forms the prominence of cheek
Its lateral surface has a foramen, The
temporal surface forms anterior wall of Fig. 35.1: The mandiblelateral aspect
376 Essentials of Human Anatomy
Body of Mandible
Alveolar margin opposite molar teeth - Buccinator
Anterior oblique line - Depressor anguli oris,
depressor labii inferioris
Fig. 35.2: The mandiblemedial aspect Incisive fossa - Mentalis
Lower border (base) - Platysma, deep cervical
fascia
ii. Medial surface (Fig. 35.2) - has a
Mylohyoid lineMylohyoid and superior
mycolyoid line separating sublingual con-strictor of pharynx
and submandibular fossa, and by side Behind last molar tooth - Pterygo-mandibular
of midline two genial tubercles ligament
There are two borders of the body Genial tubercles - Geniohyoid and genioglossus
a. Superior borderis alveolar border Digastric fossa - Anterior belly of digastric
that bears eight sockets for teeth
b. Inferior borderis thickened to form Ramus of Mandible
the base of mandible. A shallow Lateral surface (except neck) Masseter
digastric fossa lies near symphysis menti Rough area on medial aspect of angle -
The ramus of mandiblejoins the body Medial pterygoid
at an angle that is nearly 90 in adults Lingula-spheno-Mandibular ligament
Coronoid process - Temporalis (medial
a. Superiorlythe ramus is divided surface) Masseter (lateral surface)
into two processes separated by Pterygoid fossa of neck- Lateral pterygoid
mandi-bular notch.
Age Changes of Mandible
b. The coronoid processis thin and
triangular and the condyloid process In children
is divided into a neck and a convex Angle of mandible is obtuse (140).
head. The neck presents anteriorly a Coronoid process is large and projects above
triangular pterygoid fossa condyloid process
The ramus has two surfacesmedial and Alveolar margin presents sockets for
lateral deciduous teeth (five in each half)
i. The medial surfacehas mandibular
Mental foramen is near lower border
foramen in center with a triangular bony
process lingula anterior to it. A mylo- In adults
hyoid groove passes dowwards from the Angle of mandible reduced is 110 (i.e. nearly
foramen. There is a rough area on medial right angle)
The Bones of the Head and Neck 377
Alveolar margin presents sockets for permanent 10. Sphenoidlies in the base of skull between
teeth (eight in each half) (Fig. 35.3) frontal and temporal bones. It has a central part
Mental foramen is located midway between - body and three paired processesgreater
upper and lower borders wings, lesser wings and pterygoid processes
The body of sphenoid is cuboidal and
contains two large sphenoidal air sinuses.
It has six surfaces.
i. Superior surfacebears a sulcus chias-
maticus for optic chiasma, tuberculum
sellae and hypophyseal fossa (sella
turcica). Dorsum sellae with two poste-
rior clinoid processes lie posteriorly
ii. Inferior surfacehas a median ridge -
the rostrum. A triangular vaginal plate
extends on either side from medial
pterygoid plate.
iii. Two lateral surfacesEach has a
Fig. 35.3: The structure of a toothlongitudinal section carotid sulcus for internal corotid artery.
The rest of lateral surface is occupied by
In old age (after 60 years)
attachment of greater wing.
Angle become obtuse again (140)
iv. Anterior surfacepresents sphenoidal
Alveolar margin is absorbed as teeth fall out
crest in midline. On either side are
and height of bone is reduced
openings of sphenoidal air sinuses and
Mental foramen comes to lie near the upper
sphenoidal concha.
border v. Posterior surface of body of sphenoid
9. Ethmoidforms roof, lateral wall of nasal fuses with basilar part of occipital
cavity and part of nasal septum bone by 25th year.
Ethmoid has a cribriform plate superiorly Greater wingsare two strong and curved
two ethmoidal labyrinths and a processes that project laterally from body.
perpendicular plate It has three surfacessuperior (cerebral)
The cribriform plate lies in roof of nasal lateral and orbital.
cavity. It is divided into two halves by crista a. Superior (cerebral) surface is deeply
galli and supports the olfactory bulbs. The concave and lodges temporal lobe of
olfactory nerves pass through its foramina cerebral hemisphere. It has important
The ethmoidal labyrinths form a part of foramina, e.g. foramen ovale, foramen
lateral wall nasal cavities. Its orbital plate spinosum and foramen rotundum.
forms part of medial wall of orbit. The b. Lateral surface is convex and divided
labyrinths have a dozen small air sinuses by infra-temporal crest into temporal
divided into three groupsanterior, and infra-temporal surfaces. A spine of
middle and posterior sphenoid projects downwards and
The perpendicular plate forms posterior gives attachment to spheno-
and superior part of nasal septum mandibular liga-ment.
378 Essentials of Human Anatomy
c . Orbital surfaceis nearly quadrangular 11. Occipitalforms the posterior and inferior
and forms part of lateral wall of orbit. parts of the cranium. (Fig. 35.4) It consists of
Lesser wingsare triangular processes four partssquamous, basilar and two
that project laterally from body above condylar separated by foramen magnum.
greater wings. Its posterior border is sharp Squamous parthas a convex external
and at its medial end is pointed anterior surface and a hollow internal surface.
clinoid process. Inferioly it forms upper The external surface has in center
margin of superior orbital fissure. Optic external occipital protuberance and a
foramen lies between its two roots. crest passing from here to foramen
Pterygoid processes descend vertically from
magnum. There are three bony ridges
nuchal linesradiating from the pro-
the junction of body and greater wings.
tuberance and crest. The superior nu-
Each consists of a lateral and a medial
chal lines are quite well defined
pterygoid plate separated by a highest nucheal lines may be seen in
pterygoid fossa. old skull. Inferior nucheal line arise
A small scaphoid fossa is formed by from middle of crest.
splitting of posterior border of medial The internal surface is divided into four deep
pterygoid plate. A pterygoid hamulus fossae by an internal occipital protuberance
projects from lower end of medial ptery- and one sagittal and two transverse sulci. The
goid plate. The vaginal process pro- superior fossae are occupied by occipital poles
longed on inferior surface of body of of cerebral hemispheres and inferior fossae by
sphenoid forms palatino-vaginal canal. cerebellar hemispheres.
Contd...
S No Name of the bone Ossification in membrane Ossification in cartilage
Two centres one for each lateral parts
appear in eighth week.
One center appears for the basilar part
in sixth week.
12. Frontal Two primary centers appear in eighth
week near frontal eminences. At birth bone
is in two halves separated by a suture.
Fusion starts soon. But remains of metopic
suture may persist in adult skull
13. Parietal Two centers appear in seventh week near
the parietal eminence and fuse soon
14. Temporal Squamous part by one centre appearing in Petromastoid part is ossified by several
seventh week centres appearing in cartilaginous ear
Tympanic part from one centre appearing capsule during fifth month
in third month Styloid process develops from cranial
end of second branchial arch cartilage.
Two centers appear in itone before
birth (tymponohyal) and one another
after birth (stytohyal)
Deep irregular pits for archnoid Orbital plates of two frontal bones
grannulations are seen on either side of Orbital surface of two lesser wings of
sagittal sulcus sphenoid
Vascular markings for branches of middle Jugum sphenoidale at anterior part of body
meningeal vessels are seen on either side of sphenoid in median plane
Impressions for cerebral gyri are also seen The middle cranial fossalodges the temporal
on either side lobes of two hemispheres on either side and base
B. Internal surface of base of skullis divided of brain with bypophysis cerebre in midline
into three cranial fossaeanterior, middle,
The fossa is bounded anteriorly by the
and posterior (Fig. 35.7)
posterior boundary of anterior cranial fossa.
The anterior cranial fossa lodges the frontal
It is bounded posteriorly by dorsum sellae
lobes of two cerebral hemispheres. It is bounded
anteriorly by the frontal bone and posteriorly by posterior clinoid processes, apex and
sharp free margins of two lesser wings of superior border of petrous temporal bone
sphenoid, anterior clinoid processes and anterior The bones forming the floor of middle
margin of optic groove (sulcus chiasmaticus) cranial fossa are
The features of this fossa are: In median plane - optic groove, tuber-
The cribriform plates of ethmoid and the culum sellae and hyphyseal fossa - all
crista galli parts of body of sphenoid
into anterior tubercle and posterior superiorly and a flat facet on inferior aspects
tubercle for superior articular facets of axis vertebra.
The anterior tubercle and inter-tubercular The prominent transverse processes have
lamella (costo-transverse bar) represent the foramen transversarium
costal element in cervical vertebra. 3. Axis vertebra [Second cervical vertebra]
forms the pivot for rotation of head with atlas
vertebra around the dens.
Axis vertebra has the following features (Fig.
35.10):
The dens or odontoid process forms a pro-
jection above the body. It articulates with
facet on back of anterior arch of atlas
vertebra.
of neck. This vertebra forms the first One secondary center for apex of dens appears
prominent spinous process at back of in second year and one for lower surface of
neck, hence the name body at puberty.
The rest of the features resemble those IV. The seventh cervical vertebra
of a typical cervical vertebra. It has the usual centers for ossification like
the typical vertebra. It has usually two
separate centers for the costal elements that
may fuse with the body or remain separate
and form the cervical rib.
The Hyoid Bone
The hyoid bone is a small U-shaped bone that lies
in uppermost part of front of neck (Figs 35.12
and 35.13).
The greater cornu are attached to the body by Upper part of body and lesser cornu - from
a cartilage, but they fuse with body in old age. second arch cartilage.
The greater cornu curve backwards and are Lower part of body and greater cornu from
horizontally flattened. They end in a third arch cartilage.
tuber-cle. There are six centers of ossification two for
The lesser cornu are two small conical projec- body, two for greater cornu and two for lesser
tions at the function of body and greater cornu.
cornu. They are connected to the body by The centers for greater cornu appear at end of
some fibrous tissue. They also may get fused fetal life, for body after birth and lesser cornu at
with the body in old age. puberty.
Special Features The Vertebral Column
Muscles and ligaments attached to hyoid bone At the back of the body, there is vertebral column
(or the spine), that is made up of thirty-three
The Body
vertebrae (7 cervical, 12 thoracic, 5 lumbar, 5
Anterior surface of bodyGeniohyoid and sacral and 4 coccygeal)
mylohyoid on either side of midline. The five sacral vertebral are fused to form the
Junction of body and greater cornu sacrum and four coccygeal vertebrae (that are
Hyoglossus rudimentary) are fused to form the coccyx.
Upper border of body - Lower fibers of genio- The inter-vertebral disc Between the bodies
glossus and thyrohyoid membrane of the vertebrae there are about twenty-four
Lower border of body-Sternohyoid and omo- intervertebral discs (5 in cervical region, 11
hyoid and pretracheal fascia below omohyoid in thoracic region, 4 in lumbar region, 1 or 2
thyrohyoid muscles. in sacral region and 1 between sacrum and
The Greater Cornu coccyx and 1 rudimentary between first and
second piece of coccyx.
Upper surfaceMiddle constrictor medially and
The intervertebral discs constitute about one-
hyoglossus laterally, fibrous pulley of digastric
fourth of the total length of vertebral column.
and stylohyoid at function with body.
Their shape and size conform to the bodies of
Lower surfaceis separated from thyrohyoid
vertebrae in different regions.
membrane by fiber - fally tissue.
Structure: The intervertebral disc consists of
Medial borderThyrohyoid membrane.
two parts
Lateral borderInsertion of thyrohyoid
i. The nucleus pulposus is the inner part. It
muscle and deep fascia of neck.
consists of muco-polysaccharide
The Lesser Cornu complexes with high osmotic pressure
The nucleus pulposus is remnant of
Tip - Stylohyoid ligament.
notochordthe primitive axis of the
Posterolateral aspect - Middle constrictor
body.
muscle.
ii. The annulus fibrosus is the outer part that
Ossification of Hyoidbone surrounds the nucleus pulposus
It consists of dense connective tissue
Hyoid bone is developed from the cartilages of bands, and it binds firmly the adjacent
second and third pharyngeal arches. vertebral bodies.
390 Essentials of Human Anatomy
a. The median atlanto-axial jointis a b. The alar ligaments are two round fibrous cords
pivot type of synovial joint with dens of the axis attached below to either side of tip of dens of the axis
acting as a pivot and anterior arch of atlas and vertebra. Above they are attached to the rough surface
transverse ligament providing the ring. on medial aspect of occipital condyles.
There is a loose fibrous capsule lined by They become taut in flexion and are relaxed
synovial membrane. during extension of the skull. The excess
The tranverse ligament of atlasis a thick rotation movement is checked by the alar
fibrous band attached to medial tubercles on ligaments.
medial aspects of lateral masses of atlas c. The median apical ligament of the dens is
vertebra. attached below to the tip of the dens and above to
b. The lateral atlanto-axial joints are plane the anterior margin of foramen magnum.
type of synovial joints between the inferior The apical ligament is the remnant of
articular facets of atlas and superior articular notochord or the primitive axis of the embryo.
facets of axis vertebra.
5. The Sutures of the Skull
Both articular surfaces are ovoid and sloping.
The fibrous capsule is loose and thin. It is The sutures of the skull - are fibrous joints
attached to the margins of articular surfaces. between serrated edges of flat bones of skull. The
The anterior longitudinal ligamenta strong sutures are immovable joints.
wide band attached above to anterior arch of However, during childhood, due to the
atlas and below to the body of axis. increased intra-cranial pressure, the sutures
Movements occurring at atlanto-axial joints open up. In old age the sutures are gradually
obliterated by fusion of adjoining bones
The movements at all the three atlanto axial
beginning from inner surface of bones.
joints occur together.
The important sutures of skull are
The movement consists of rotation of atlas
and skull on the axis vertebra with its dens Coronal suture between frontal and parietal
acting as a pivot. bones
Sagittal suture - between two parietal
Muscles producing the movements
Obliquus capitis inferior, rectus capitis bones. It is placed in median plane
Lambdoid suture is placed posteriorly
posterior major and splenius capitis of one
between the occipital bone and two
side and sterno-mastoid of the opposite side.
parietal bones
4. The Ligaments Connecting Axis with Metopic suture is present only sometimes
(6-8% individuals) in median plane
the Occipital Bone
between two halves of frontal bone. The
The ligaments aremembrana tectoria, two alar remains of suture are seen at glabella.
ligaments and median apical ligament.
a. The membrana tectoria is a broad strong band, 6. The Joints between the Cervical
that is upward prolongation of posterior Vertebrae
longitudinal ligament of the vertebral column. The cervical vertebrae are connected by:
It is attached below to posterior surface of The cartilaginous joint between the vertebral
body of axis and above it passes through bodies.
foramen magnum and is attached to the The synovial joints between the articular
basilar part of occipital bone. processes.
The Joints, Fasciae and Deep Muscles of the Back of Head and Neck 395
The fibrous joints between their laminae, The inter-spinous ligaments are thin and
transverse processes and spinous processes. connect the adjoining spinous processes
a. The Joints between Vertebral Bodies from their roots up to the apex.
These are secondary cartilaginous joints The inter-transverse ligaments connect the
(symphyses) with inter-vertebral disc adjoining transverse processes. These
between vertebral bodies. ligaments are poorly developed in cervical
The inter-vertebral discs have a central region.
nucleus pulposus surrounded by annulus The nerve supply of the intervertebral joints is
fibrosus. by the corresponding spinal nerves by their dorsal
The bodies are connected by rami. They also have sympathetic supply.
1. The anterior longitudinal ligament in
THE FASCIAE OF THE HEAD AND NECK
front.
2. The posterior longitudinal ligament- A. The superficial fasciae of the head and neck
behind. region contains.
b. The Joints between Articular Processes Loose areolar tissue with variable amount of
(Zygophyseal Joints) fat
There are two paired articular processes in Cutaneous nerves, blood vessels and lymphatics
relation to one vertebrae. They form joints The platysma is a superficial muscular sheet
with similar processes of adjacent vertebrae. that lies on the side of neck. It consists of
These are plane type of synovial joints. striated muscle fibers and is supplied by facial
The joints are surrounded by the fibrous nerve.
capsules. Superficial muscles of face and scalp lie in
the respective regions.
c. The Fibrous Joints between the Vertebrae
B. The deep cervical fascia consists of several of
The ligamenta flava connect the laminae
well-defined layers that can be demonstrated.
of the adjacent vertebrae. These ligaments
The deep fascia surrounds the neck and gives
consist of elastic tissue mainly.
off septa, which separate the neck into fascial
The supraspinous ligaments are strong
compartments.
fibrous bands that connect the apices of
The deep cervical fascia consists of following
spinous processes of vertebrae.
The ligamentum nuchae is a bilaminar, layers.
fibroelastic membrane that forms an a. The investing layer surrounds the neck on all
intermuscular septum between two halves sides deep to the superficial fascia.
of back of neck. Attachments
It is attached above to the external Superiorly
occipital crest and to tips of spinous Lower border of mandible
processes of cervical vertebrae. Mastoid process and superior nuchal
Its free border also gives attachment to line of occipital bone.
muscles of the back. Inferiorly
In quadriped animals, this ligament is Suprasternal notch
much thicker and supports the head of Superior surface of clavicle
the animals. Crest of spine of scapula
396 Essentials of Human Anatomy
PosteriorlyPosterior free border of liga- b. The pretracheal fascia lies deep to the
mentum nuchae infrahyoid muscles on the front of trachea.
AnteriorlyBody of hyoid bone. This layer forms the fascial capsule of thyroid
The investing layer splits repeatedly gland and holds it in position.
i. To enclose two muscles sternomastoid Attachments
and trapezius Superiorly
ii. To form fascial capsules of two salivary Arch of cricoid cartilage.
glands parotid and submandibular. Oblique lines of thyroid cartilage.
iii. To enclose two fascial spaces. Inferiorly
a. Suprasternal space (of Burns) above It continues in the mediastinum of
manubrium sterni. This space contains thorax and fuses with the fibrous peri-
Jugular venous arch and parts of two cardium.
anterior jugular veins. Medially
Sternal heads of sternomastoid Sides of pharynx and trachea.
muscles. c. The carotid sheath is the fascial
Interclavicular ligament. condensation around the carotid arteries, internal
An occassional lymph node. jugular vein and the vagus nerve.
b. A fascial space in lower part of roof of The carotid sheath is attached anteriorly to the
posterior triangle. This space contains investing layer and posteriorly to the
(Fig. 36.5) prevertebral layer of deep fascia.
Suprascapular vessels The carotid sheath extends from the base of
Part of external jugular vein skull to the root of neck.
Parts of three supra-clavicular It is thick around the carotid arteries and thin
nerves. around the internal jugular vein to allow it to
expand.
The sympathetic chain lies behind the carotid
sheath in the neck.
d. The pre-vertebral fascia lies in front of the
prevertebral muscles that cover the front of
bodies of cervical vertebrae.
The prevertebral fascia extends laterally to
cover the scalene muscles.
It also forms the axillary sheath by its lateral
extension that surrounds the axillary artery
and the brachial plexus in axilla.
Attachments
Anteriorly
Bodies and transverse processes of
cervical vertebrae.
Inferiorly
Extends into superior mediasterum up
to third thoracic vertebra to cover the
Fig. 36.5: Fascial space above claviclesagittal section longus colli muscle.
The Joints, Fasciae and Deep Muscles of the Back of Head and Neck 397
e. The retro-vertebral fascia covers the retro- The thoraco-lumbar fascia covers the deep
vertebral muscles and sends fascial septa between muscles of the back.
them. A. The thoracic part is continuous above with
Attachments posterior layer of deep cervical fascia.
Superiorlyextends up to skull. Below, it is continuous with posterior
Inferiorlycontinues with deep fascia on lamina of the lumbar part.
back of thorax. Attachments
f. The buccopharyngeal fascia is thickened Medially the tips of spinous pro-
epimysium that covers buccinator and constrictor cesses of thoracic vertebrae and
muscles of pharynx.
supraspinous ligaments.
g. The pharyngo-basilar fascia lies deep to the
Laterally the angles of the ribs.
constrictor muscles of pharynx. It is thickened at
B. The lumbar part is divided into three
the gaps in the pharyngeal wall.
laminaeposterior, middle and anterior (Fig.
THE DEEP MUSCLES OF THE BACK 36.6).
i. The posterior lamina is attached
Common features Mediallyto the tips of spinous
The deep muscles of the back extend from
processes of lumbar vertebrae and
the occipital bone to the back of sacrum.
supraspinous ligaments.
These muscles consist of muscle slips
Laterallyit fuses with the back of
forming short segmental muscles.
The deep muscles of the back are bound by middle lamina at lateral margin of
thoraco-lumbar fascia to the back of erector spinae muscle.
vertebral column. ii. The middle lamina is attached
These muscles are supplied by the dorsal Medially to the tips of lumbar trans-
rami of the spinal nerves. verse processes.
Functionally these muscles are extensors, Laterally it fuses with anterior lamina
rotators and lateral flexors of vertebral at the lateral border of quadratus
column. lumborum.
iii. The anterior lamina covers the quadratus a. The iliocostalis lumborum from
lumborum muscle. It is attached common aponeurosis to lower
Medially to the anterior aspect of borders of lower six ribs.
lumbar transverse processes. b. The iliocostalis thoracisfrom
Laterally it fuses with the middle upper borders of lower six ribs to
layer at the lateral border of quad- lower borders of upper six ribs.
ratus lumborum to form the apo- c. The iliocostalis cervicis from upper
neurotic origin of transversus borders of upper six ribs to
abdominis. posterior tubercles of transverse
The deep muscles of back are arranged in processes of fourth, fifth, and sixth
three layers. cervical verte-brae.
a. The splenius ii. The middle part is longissimus. It is
b. The erector spinae or sacrospinatis further subdivided into three portions:
c . The transverso-spinalis a. The longissimus thoracis from
A. The splenius muscle has two parts common origin to thoracic trans-
i. The splenius cervicis is attached from verse processes and lower nine or
spinous processes of third and fourth ten ribs.
thoracic vertebrae to transverse processes This is the largest segment of
of second to fourth cervical vertebrae. erector spinae.
ii. The splenius capitis arises from b. The longissimus cervicis from trans-
Lower part of ligamentum nuchae and verse processes of upper four or five
spinous processes of seventh cervical thoracic vertebrae to the transverse
and upper four thoracic vertebrae. processes of second to sixth cervical
It is inserted on lateral part superior vertebrae.
nuchal line of occipital bone and c. The longissimus capitis also extends
mastoid process. from transverse processes of upper
Actions: four or five thoracic vertebrae to
The splenius muscle of both sides the mastoid process of temporal
extends the head. bone deep to splenius capitis.
One side muscle acting rotate the iii. The medial part is the spinalis. It is
poorly developed.
head and neck to the same side.
a. The spinalis thoracis runs between
B. The erector spinae (sacro-spinalis) arises by a
transverse processes of thoracic
thick aponeurosis from
vertebrae.
Back of sacrum and sacrotuberous liga- b. The spinalis cervicis is an inconstant
ment. muscle and is often absent.
Dorsal segment of iliac crest c. The spinalis capitis is fused with
Spinous processes of lumbar and lower medial part of semispinalis capitis.
thoracic vertebrae. C. The transverso-spinalis group of muscles:
Dorsal sacroiliac ligament. These muscle slips fill up the gap on the back
The muscle divides into three partslateral, of vertebral column between the spinous
intermediate and medial. processes and the transverse processes. The
i. The lateral part is iliocosto cervicalis, it muscle group consists of three subdivisions lying
is again subdivided into three portions. deep to one another.
The Joints, Fasciae and Deep Muscles of the Back of Head and Neck 399
4. The loose areolar tissue forms the potential fracture of skull bone, the blood collects
space between the aponeurosis and the in the loose areolar tissue layer, before
pericarnium collec-ting inside skull and causing
It forms a wide sub-aponeurotic space compression of brain.
that extends
Anteriorly into the subcutaneous The Blood Supply of the Scalp
tissue of eyelids, as frontal bellies have A. The arteries
no bony attachment There are three arteries supplying the
Posteriorly up to superior (highest) scalp in front of auricle (Fig. 37.2)
nuchal lines a. The supra trochlear and
On two sides up to superior temporal b. The supra arbitalboth branches of
lines. ophthalmic arteryand emerge from the
Injury to blood vessels in this layer leads orbit at supra-orbital margins
to black eye, i.e. collection of blood in c. The superficial temporal a large branch
the subcutaneous tissue of the eyelids. of the external carotid artery that
This layer is also called the dangerous layer supplies scalp in front of auricle and
of scalp due to presence of emissary veins, the temporal region.
that can carry infection inside the skull. There are two arteries supplying the scalp
5. The pericranium is attached firmly to the behind the auricle
bone in the adults. It is firmly attached to the d. The posterior auriculara branch of
sutural ligament at the sutures external carotid artery
In children, the pericranium is loosely e. The occipital artery also a branch of
attached to the bones. This gives rise to external carotid artery that supplies the
safety valve hematoma (i.e. in cases of posterior part of scalp
The scalp is the site of anastomosis The anterior part of scalp (in front of auricle) is
between the branches of internal carotid supplied by four branches of trigeminal nerve.
and external carotid arteries. i. The supra arise from the ophthalmic
B. The veins of the scalp join the veins of the face.
The veins from deeper layers of the scalp join
trochlear division of trigeminal in the
with the diploic veins and the emissary veins. ii. The supra orbit and come out at the
orbital supra-orbital margin
The emissary veins have no valves, so
blood can flow in either direction in these iii. The zygomatico-temporal is a branch of
veins, and also they can carry infection maxillary division to trigeminal and
inside the skull from outside. emerges after piercing temporal fascia.
iv. The auriculo-temporal is a branch of
The Lymphatic Drainage of the Scalp mandibular division of trigeminal nerve
The lymph from anterior part of the scalp, in and emerges just in front of auricle.
front of the auricle drains in the superficial The posterior part of scalp (behind the
parotid lymph nodes auricle) is supplied by four spinal nerves.
The lymph from the scalp behind the auricle i. The greater auricular nerve is a branch of
drains into the posterior auricular lymph nodes. cervical plexus (VR, C2, C3)
The lymph from the posterior part of scalp ii. The lesser occipital nerve is also a branch
drains into occipital lymph nodes. of cervical plexus (VR, C2)
iii. The greater occipital nerve is a branch
The Nerve Supply of the Scalp
from the dorsal ramus of second cervical
A. The sensory nerves The scalp is richly nerve. It is a thick nerve that supplies
supplied by sensory nerves (Fig. 37.3) posterior part of scalp
iv. The third occipital nerve is a branch from They are developed from the mesoderm of
the dorsal ramus of third cervical nerve. It second branchial arch
supplies a small area of scalp around When these muscles contract, they produce
external occipital protuberance some grooves or ridges on the face denoting
B. The motor nerves of the scalp are branches some expression, hence they are called
of facial nerve (seventh cranial nerve) muscles of facial expression
The temporal branches of facial nerve supply They are arranged around the openings of the
the frontal belly of occipito-frontalis and auri- faceorbital openings, nasal openings and
cularis anterior and superior mouth opening, and they act as their dilators
The posterior auricular branch of facial
and sphincters.
nerve supplies the occipital belly and
auricularis posterior. The Blood Vessels of the Face
THE FACE The arteries of the face are mostly the branches
of the external carotid artery. The largest branch
The face is the region on front of skull and
is the facial artery. Others mostly accompany
mandible below the supra-orbital margins. It is
limited below by the lower border of mandible. the sensory nerves (Fig. 37.5)
The region of forehead, although appears as a. The facial artery arises in the neck from
upper part of face is anatomically a part of scalp. external carotid artery at level of greater
A. The muscles of the face (Table 37.1) have cornu of hyoid bone
the following common features (Fig. 37.4): Course in the face: The facial artery
These are superficial musclesOne end of enters the face at anterior-inferior
the muscles is attached to the bone, the other angle of masseter muscle after piercing
end to the skin deep cervical fascia and platysma.
Fig. 37.4: The muscles of the face, scalp and auricleLateral view
404 Essentials of Human Anatomy
I. The facial vein begins at the medial angle The Lymphatic Drainage of the Face
of the eye by union of supra-trochlear and
The lymphatics of the face follow the veins of the
supra-orbital veins.
face
It courses backwards and laterally lying From anterior part of face the lymphatics end
behind the facial artery in the submandibular lymph nodes
It crosses lower border of mandible, From posterior part of face the lymphatics
pierces platysma and deep cervical end in the superficial parotid lymph nodes
fascia and reaches upper part of neck
It terminates by joining with anterior The Nerve Supply of the Face
division of retro-mandibular vein to
The sensory nerves of the face are branches from
form common facial vein that ends in
the three divisions of trigeminal nerve
internal jugular vein.
ophthalmic, maxillary and mandibular.
Tributaries and communication in the
I. The ophthalmic division supplies medial
face
part of the skin of forehead and face. The
i. The lateral nasal vein
branches are (Fig. 37.7):
ii. The superior labial vein
a. From frontal branch supra-trochlear and supra-
iii. The inferior labial vein orbital nerves supply medial part of forehead
iv. Two important communications b. From lacrimal branch palpebral branch
a. At medial angle of eye with supplies the skin of upper eyelid
superior ophthalmic vein c. From the nasociliary branch infratrochlear and
b. Deep facial vein that connects it external nasal nerves supply the skin of nose
with the pterygoid venous plexus including its tip
II. The superficial temporal vein drains II. From the maxillary division branches
venous blood from the anterior part of supply the skin of eyelid, ala of nose, upper lip
scalp including forehead and upper part of cheek. The nerves are
It joins with the maxillary vein behind a. The zygomatico-facial nerve comes out from
the neck of mandible to form the retro- a foramen in zygomatic bone and supplies
mandibular vein skin of cheek
III. The retro-mandibular vein lies in the b. The infra-orbital nerve is a large branch that
substance of parotid gland superficial to comes out of infraorbital foramen and gives
external carotid artery and deep to the three sets of branches
facial nerve Nasal to supply ala of nose
It terminates inside parotid gland by Labial to supply upper lip
dividing into an anterior division and a Palpebral to supply lower eyelid
posterior division, that emerge at the III. From the mandibular division the
lower pole of the gland branches supply the skin of lower part of face,
The anterior division joins with facial and lower jaw except a small area overlying the
vein to form the common facial vein angle of mandible.The branches are:
The posterior division joins with the a. The auriculo temporal nerve supplies the skin
posterior auricular vein to form the of auricle, external acoustic meatus and also
external jugular vein of temporal region and lateral part of scalp
408 Essentials of Human Anatomy
b. The buccal nerve emerges from under cover The condition is treated by:
of masseter and supplies skin of lower part of i. Injection of alcohol in the stem of the
face affec-ted division that, temporarily
c. The mental nerve comes out of mental foramen degenerates the nerve fibers, thus
and supplies skin covering lower jaw, interrupting the pain-pathway
including chin ii. Partial trigeminal ganglionectomy is done
IV. The skin overlying the angle of mandible to cut off the pain fibers of the affected
is supplied by the greater auricular nerve (VR. division.
iii. Partial rhizotomy cutting off the pain
C2, C3) a branch of cervical plexus. Actually, it is
fibers of the affected division in the
a part of skin of neck that has been pulled
sensory root of trigeminal nerve
upwards to cover the angle of mandible, due to
greater growth of brain and skull. The Motor Nerves
Applied Anatomy The motor nerves of the face are branches of
facial nerve (seventh cranial nerve)
The trigeminal neuralgia (Tic douloureaux) is
The facial nerve comes out of stylomastoid
caused by inflammation of one of the divisions of foramen at the base of skull.
trigeminal nerve It gives a posterior auricular branch that
It produces a very severe and excruciating pain in passes behind the auricle and supplies
the skin area supplied by the affected division. occipital belly and auricularis posterior. It
The pain may be initiated by touching a also gives two muscular branches to supply
trigger area. The severity of the pain may two muscles of the neckstylohyoid and
drive the person to suicide posterior belly of digastric.
The Scalp, Face and the Cranial Cavity 409
The facial nerve enters parotid gland and [Details of the boundaries and the foramina
divides into five sets of branches that emerge present in three cranial fossae are described in
near the anterior border of the gland Chapter 35]
The facial nerve also divides the parotid gland The dural folds are seen after removal of the
into a superficial lobe and a deep lobe. brain from the cranial cavitythere are four
a. The temporal branches cross zygomatic dural folds.
arch and supply the muscles of anterior a. The falex cerebri is a large sickle shaped
part of scalp and forehead dural fold
b. The zygomatic branches reach the Attachments
zygomatic bone and supply the muscles of Apex is attached to the crista galli in
orbit and nose anterior cranial fossa
c. The buccal branches reach the mouth and Base is attached to superior surface of
supply the muscles of the oral fissure tentorium cerebelli
d. The mandibular branch runs along the Attached border (superior border) is
lower jaw and supplies the muscles of the attached to frontal crest and margins of
lower lip sagittal sulcus in calvaria of skull.
e. The cervical branch of facial nerve The free border (inferior border) lies in
emerges at the lower pole of parotid gland the longitudinal fissure between two
and descends in upper part of the neck cerebral hemispheres
Supplies platysma and communicates Venous sinuses enclosed
with the transverse cutaneous nerve of At upper attached bordersuperior
the neck. sagittal sinus
It may cross the lower border of mandi- At lower free borderinferior sagittal
sinus
ble, enter face and supply the muscles
At its basestraight sinus
of lower lip.
b. The falx cerebelli is a small sickle shaped dural
fold that lies in the posterior cerebellar notch
Applied Anatomy
between the two cerebellar hemispheres.
Lesion of facial nerve in the bony facial canal or Attachments
near the stylo-mastoid foramen leads to Bells The posterior border is fixed on internal
paralysis occipital crest
The symptoms are : The apex is divided into two small folds
Drooping of angle of mouth or affected side that reach in either side of foramen
Inability to close the eye, and resulting loss magnum
of conjunctival reflexes The base is attached to the inferior sur-
Difficulty in mastication, as the food face of tentorium cerebelli.
collects in the vestibule of the mouth The venous sinuses enclosedThe
There is no effective treatment of Bells para- occipital venous sinus lies along its
lysis. Most cases recover spontaneously often posterior attached margin.
with no permanent damage c. The tentorium cerebelli is a large tent shaped
fold that roofs over the posterior cranial fossa,
THE CRANIAL CAVITY supporting the occipital lobes of cerebral
hemisphere.
The cranial cavity is divided into three cranial fossae It has a concave free border anteriorly that
Anterior, middle, and posterior. encloses the tentorial notch, through which
410 Essentials of Human Anatomy
the brain stem passes. The anterior border The dural venous sinuses are divided into two
is attached anteriorly to the anterior groups according to their positionthe postero-
clinoid processes. superior group and antero-inferior group.
The posterior margin is attached to (on i. The postero superior group has:
both sides) The superior sagittal sinus
Posterior clinoid process The inferior sagittal sinus
Apex and superior border of petrous The straight sinus
temporal bone Two transverse sinuses
Margins of transverse sulcus up to Two sigmoid sinuses
internal occipital protuberance The occipital venous sinus
The venous sinuses enclosed are ii. The antero-inferior group has:
The superior petrosal sinuses along the Two cavernous sinuses
superior border of petrous temporal Two intercavernous sinusesanterior
bones. and posterior
The transverse sinuses along the trans- Two superior petrosal sinuses
verse sulci Two inferior petrosal sinuses
Two spheno-parietal sinuses
The straight sinus along the attachment
The basilar venous plexus
of base of falx cerebri
Out of these venous sinuses, the large and
d. The diaphragma sellae is a small circular dural
important venous sinuses are the superior
fold that roofs over the hypophyseal fossa.
sagittal, transverse, sigmoid and the cavernous
Attachments venous sinus.
Anteriorlyon tuberculum sellae A. The superior sagittal sinus lies along the
Posteriorlyon dorsum sellae attached margin of falx cerebri, occupying the
On two sidescontinuous with dura frontal crest and the sagittal sulcus.
mater of roof of cavernous sinus It begins at crista galli by union of small dural
It has a central perforation for the infundi- veins. It increases in size as it flows backwards
bulum of hypophysis cerebri It usually ends on the right side of internal
The nerve supply and blood supply of dura occipital protuberance, by becoming
continuous with right transverse sinus
mater is described in Chapter 44.
It is triangular in coronal section and has
groups of arachnoid granulation bulging into
The Venous Sinuses of the Dura Mater
it after piercing the inner layer of dura mater.
These venous sinuses lie between two layers Tributaries
of dura mater. i. The superior cerebral veins
They are lined by endothelium only, that is ii. The meningeal veins from dura mater
continuous with the lining of the veins. iii. Small diploic veins from cranial bones
iv. Two emissary veins
They drain blood from
a. One passing through foramen cecum
Brain (1% only) connecting it with veins of
Dura mater roof of nose
Cranial bones b. Parietal emissary veins passing
They have no valves, so blood in smaller through parietal foramina and
sinuses can flow in either direction connecting it to the veins of scalp
The Scalp, Face and the Cranial Cavity 411
They start developing after birth. There are Then it bends upwards above the
many small diploic veins that open in the cartilage of foramen lacerum to enter
neigh-boring venous sinuses. the middle cranial fossa.
The large diploic veins are This part of artery is surrounded by a
i. The frontal diploic vein that opens in venous plexus and sympathetic plexus
supra-orbital vein by a minute foramen in Branches are two:
supra-orbital notch. Carotico-tympanic branch-supplies
ii. The anterior temporal (parietal) diploic the middle ear
vein draining venous blood from frontal Pterygoid branchenters the ptery-
goid canal
and parietal bone ends in the spheno-
ii. The cavernous partThe artery on entering
parietal sinus.
the cranial cavity turns anteriorly and then
iii. The posterior temporal (parietal) diploic passes forward, inside cavernous sinus along
vein ends in the lateral part of transverse the side of body of sphenoid. It is separated
sinus. from the venous blood by endothelium.
iv. The occipital diploic vein ends in transverse The abducent nerve lies infero-lateral
sinus near confluence of sinuses. and then lateral to the artery
It curves upwards and pierces the roof of
The Intra-cranial Part of Internal cavernous sinus medial to anterior
Carotid Artery clinoid process
The internal carotid artery enters the skull Branches
Thecavernous branchesare small
through the lower opening of carotid canal in
andsupply trigeminal ganglion, and
petrous temporal bone the dura mater of cavernous sinus
The artery is divided into three partsthe Hypophyseal branches
petrous part, the cavernous part and the superiorand inferiorsupply the
cerebral part hypophysis cerebri
i. The petrous partThe artery passes Meningealbranches supply the
forwards and medially in the carotid canal duramater of anterior cranial fossa
414 Essentials of Human Anatomy
iii. The cerebral partThe artery after through a hiatus on anterior surface of
piercing the roof of cavernous sinus, runs petrous temporal bone
backwards on the roof and then ascends It passes forwards and medially in a
up to anterior perforated substance, lateral groove and then reaches foramen
to optic chiasma, where it divides into its lacerum
branches. The greater petrosal nerve joins with
Branches (Described in Chapter 44). deep petrosal nerve to form nerve of
the pterygoid canal
Trigeminal Ganglion
The greater petrosal nerve carries
Trigeminal ganglion is the sensory ganglion of The preganglionic parasympathetic
trigeminal nerve. It contains pseudounipolar fibers of lacrimal gland
neurons that relay all sensory fibers carried by The preganglionic parasympathetic
the three branches of trigeminal neve fibers for the nasal and palatine
ophthalmic maxillary and mandibular. mucosal glands.
LocationThe ganglion lies in a shallow ii. The deep petrosal nerve is formed by the
depression trigeminal impressionon anterior sympathetic plexus around the internal
surface of petrous temporal bone (bear its apex) carotid artery in foramen lacerum.
Cavum trigeminaleis the pocket of dura The deep petrosal nerve joins with greater
mater of posterior cranial fossa between two petrosal nerve in foramen lacerum to
rayers-endosteal and meningeal of middle form nerve of pterygoid canal
cranial fossa. It contains trigeminal ganglion.
iii. The lesser petrosal nerve arises from the
Relations:
tympanic plexus and receives a communi-
Superiorly Temporal lobe
cation from the facial nerve.
Inferiorly Motor root of trigeminal
It appears in middle cranial fossa
Greater petrosal nerve
through a hiatus on anterior surface of
Petrous temporal bone
MediallyPosterior end of cavernous sinus
petrous temporal bone below the
greater petrosal nerve
Curvatures and Shape
The nerve lies in a groove on bone and
Trigeminal ganglion is crescentic
reaches the foramen ovale. It passes out
(semilunar) in shape
Convex distal border gives attachment to through foramen ovale and just below
three branches of nerveophthalmic skull joins with the otic ganglion
maxillary and mandibular The nerve carries preganglionic para-
Concave preximal border is attached to sympathetic fibers of parotid salivary
the sensory root of nerve gland.
Arterial Supplyis from small branches of
internal carotid artery The Hypophysis Cerebri (Pituitary Gland)
The Nerves in the Cranial Cavity The hypophysis cerebri is an important endocrine
The intracranial parts of the cranial nerves are gland. It is sometimes called master endocrine as
described in Chapter 47. it controls the secretion of other endocrines (Fig.
The petrosal nerves are three 37.9).
i. The greater petrosal nerve is a branch of facial Shape and Size: The gland has an ovoid body
nerve. It enters the middle cranial fossa The transverse diameter is 12.0 mm
The Scalp, Face and the Cranial Cavity 415
The vertical diameter is 8.0 mm iii. Relations with optic chiasmaThe optic
The weight is nearly 500 mgm chiasma lies antero-superior to the hypo-
Location the hypophysis cerebri lies in physis cerebri.
hypophyseal fossa roofed over by diaphragma The chiasma lies closely applied to the
sellae. It is connected by the infundibulum anterior surface of infundibulum
with floor of third ventricle iv. Relations with other structures
Parts: The hypophysis cerebri has two parts Superiorlylies base of brain and inter-
the neuro-hypophysis and the adeno-hypophysis peduncular fossa
The Neuro-hypophysis consists of InferiorlyThe two sphenoidal air
The infundibulum sinuses separated by a thin plate of bone
Pars posterior (posterior lobe) LaterallyThe cavernous sinuses and
Medial eminence the structures inside cavernous sinuses
More laterally lies the uncus part of
parahippocampal gyrus
The blood supply
The arteries are superior and inferior
hypophyseal arteries from the internal
carotid artery
The inferior hypophyseal arteries supply
the neuro-hypophysis
The superior hypophyseal arteries break up
into capillariess in medial eminence. From
there a number of efferent vessels descend
in front of infundibulum to reach the pars
Fig. 37.9: The hypophysis cerebriparts distalis where they end in the sinusoids.
Thus the adenohypophysis receives an
The adeno-hypophysis consists of
indirect blood supply through this hypo-
Pars anterior or distalis
thalmo-hypophyseal portal system. By
Pars intermedia
this portal system the hormone releasing
Pars tuberalis
factors (HRF) and hormone inhibiting
The two parts of the hypophysis cerebri are
factors (HIF) reach from hypothalmic
different developmentally and functionally.
Relations nuclei to the adeno-hypophysis
i. Meningeal relationsThe arachnoid and The veins The veins of the hypophysis cerebri
pia mater are not distinguishable in end in the cavernous venous sinus.
hypophyseal fossa The hormones produced by the pituitary
ii. Vascular relations gland The neuro hypophysis produces
The circular venous sinustwo caver- Oxytocin
nous and two intercavernous Vasopressin (Antidiuretic hormone) These
surround the hypophyseal fossa hormones are produced by hypo-thalmic
The circular arteriosus (circle of Willis) nuclei and reach neurohypophysis
also surrounds the hypophysis cerebri, The adenohypophysis produces
but it is located at a higher level. i. Somatotropin (growth hormone)
416 Essentials of Human Anatomy
a. The superficial (lateral) surface is related to The duct is about 5.0 cm long. It crosses
superficial parotid lymph nodes and branches upper border of masseter horizontally, lying
of greater auricular nerve. about 1.0 cm below zygomatic arch.
b. The antero-medial surface is related to masseter, At the anterior border of masseter, it turns
ramus of mandible and medial pterygoid muscle. c. medially and pierces the following layers of
The postero-medial surface is related to mastoid the check:
process, sterno-mastoid, posterior belly digas- Buccal pad of fat
tric and styloid process. Buccopharyngeal fascia
Buccinator
The Structures Embedded in the Mucous membrane of the cheek
Gland (Fig. 38.2) It opens in the vestibule of mouth opposite
i. The external carotid artery in its terminal upper second molar tooth.
part lies posteriorly.
The Arterial Supply
ii. The retromandibular vein lies superficial to
the artery. The arterial supply of the gland is from branches
iii. The facial nerve and its terminal branches of external carotid arterymaxillary and
lie most superficially in the gland. The superficial temporal.
nerve divides the gland into a superficial
lobe and a deep lobe. The Nerve Supply
iv. The deep parotid lymph node lies within the
Sensory supply is by auriculo-temporal nerve.
fascial capsule.
Sympathetic supply is from plexus around
v. The auriculo-temporal nerve is usually
middle meningeal artery.
embed-ded near the upper end.
Parasympathetic supply is secretomotor.
The Parotid Duct The pre-ganglionic fibers begin from
inferior salivary nucleus and pass via
The parotid duct begins near the anterior border glosso-pharyngeal nerve, its tympanic
of the gland. A small accessory lobe is usually branch, tympanic plexus and lesser
attached above the duct. petrosal nerve that ends in otic ganglion.
xiv. The spheno-palatine artery is the terminal and medial part of upper lip) do not have valves.
part of maxillary artery that supplies An infection from this region may spread to
lateral wall and part of septum of nose. pterygoid venous plexus, and may then travel to
the cavernous sinus causing complication.
The Veins The pterygoid venous plexus continues as the
The veins of the region form a pterygoid venous maxillary vein posteriorly that joins with superficial
plexus that lies around the lateral pterygoid muscle. temporal vein to form the retro-mandibular vein.
The venous plexus receives veins from:
The Nerves of the Region
The nasal cavitylateral wall and the
septum. A. The mandibular nerve is the nerve of first
The para nasal sinuses specially maxillary. branchial arch (Fig. 38.6).
The mouth cavityhard and soft palate. Formation: The mandibular nerve is formed
The structures in temporal and by:
infratemporal fossae. i. A large sensory root, i.e. mandibular
The pterygoid venous plexus receives division of trigeminal nerve.
communi-cations from: ii. A small motor root.
i. The superficial veins of the face via deep The two roots join just below skull after
facial vein. emerging from foramen ovale, to form the
ii. The pharyngeal venous plexus via the mandibular nerve.
inferior ophthalmic vein. Type: Mixed nerve.
iii. The cavernous sinus via the emissary Course: The mandibular nerve descends almost
veins passing through foramen ovale and vertically in upper part of infratemporal fossa
emissary sphenoidal foramen. deep to lateral pterygoid muscle.
The Dangerous Area of the Face: The veins After a short distance the nerve divides into
from this part of face (around the external nostril an anterior division and a posterior division.
The Parotid Region, Temporal and Infratemporal Fossae 423
iv. The orbital branch enters orbit through sympathetic fibers to nasal and palatal
inferior orbital fissure to supply orbital glands.
periosteum. The secretomotor fibers for lacrimal
gland also relay here and reach gland
v. The pharyngeal branch is distributed to the
via zygomatic nerve.
pharyngeal wall. The nasal and palatine All branches carry sensory fibers of the
branches also carry postganglionic para- maxillary nerve.
CHAPTER 39
The Triangles
of the Neck
THE POSTERIOR TRIANGLE Above clavicle it splits to enclose a fascial
OF THE NECK space (described in Chapter 36).
The posterio triangle lies on the side of neck, behind The floor is formed by the following mus-
sternomastoid muscle. It extends from clavicle cles
below up to the occipital bone above (Fig. 39.1). Semispinalis capitis
Boundaries Splenius capitis
Anterior boundary is formed by posterior Levator scapulae
border of sternomastoid. Scalenus medius
Posterior boundary is formed by anterior Contents (Fig. 39.2)
border of trapezius.
A. The arteries are, part of occipital artery, third
The base or inferior boundary is formed by
middle one-third of clavicle. part of subclavian artery and its two
The apex or superior boundary is formed branchestransverse cervical and supra
by the superior nuchal line of occipital bone. scapular.
The roof is formed by the investing layer of i. The occipital artery, a branch of external
deep cervical fascia, covered by superficial carotid artery, can be seen at the apex
fascia, platysma and skin. of triangle, at superior nuchal line.
ii. Third part of subclavian artery lies in iv. The supra-scapular artery is also a
lower and anterior part of the triangle. branch of thyrocervical trunk.
The artery is located deeply, and is It enters posterior triangle below
related anteriorly to external transverse cervical artery after
jugular vein, nerve to subclavius crossing in front of scalenus anterior.
and clavicle. It runs laterally accompanied by
The deep relations are formed by suprascapular nerve and passes
lower trunk of brachial plexus and behind clavicle to reach supra-
scalenus nedius muscle scapular notch of scapula.
iii. The transverse cervical artery is a B. The Veins
branch of thyro-cervical trunk from i. The lower (deep) part of external
first part of subclavian artery. jugular vein
It enters the triangle after crossing The external jugular vein is formed
scalenus anterior muscle. behind the angle of mandible by
It divides into a deep branch that union of posterior auricular vein
passes deep to levator scapulae and and posterior division of retro-
a superficial branch that crosses mandibular vein.
lower part of triangle and passes The vein lies in superficial fascia
deep to trapezius. deep to platysma as it crosses
[In about 60% cases the deep sterno-mastoid muscle obliquely.
branch arises as dorsal scapular About 4.0 cm above clavicle, the vein
artery from third part of subclavian pierces deep fascia of roof and lies
artery, and superficial branch for a short distance in the fascial
continues as superficial cervical space. The walls of the vein, here are
artery from thyro-cervical trunk] adherent to the deep fascia.
The Triangles of the Neck 429
2. The supra-scapular nerve (ventral The injury to the nerve leads to paralysis of
ramus C5, C6) passes laterally with trapezius that causes inability to shrug (or
supra-scapular artery to supply the elevate) the shoulder on affected side.
scapular muscles. II. The spinal accessory nerve may be irritated
3. The nerve to subclavius (ventral by enlarged lymph nodes that lie along its course.
ramus C5, C6) passes in front of This may lead to spasmodic torticollis.
subclavian artery to reach behind III. The external jugular vein may be used for
clavicle to supply subclavius. demonstrating venous pressure.
4. The long thoracic nerve (ventral Air embolism may occur if the external
ramus C5, C6, C7) descends deep jugular vein is cut at a point, where it pierces
to the roots of brachial plexus to deep fascia. (Fig. 39.3).
supply serratus anterior.
D. The lymph nodes and lymphatics THE SUBOCCIPITAL TRIANGLE OF NECK
a. The superficial cervical lymph nodes lie The suboccipital triangle is an intermuscular
along the external jugular vein, superficial space situated in deep part of back of neck below
to sternomastoid muscle. occipital bone.
b. The occipital lymph nodes lie at the apex Boundaries
of posterior triangle and retro-auricular Supero-lateral boundary is formed by:
nodes lie behind the auricle. Obliquus capitis superior
c. The deep cervical lymph nodes are many
Infero-lateral boundary is formed by:
and lie deep to the sternomastoid, along Obliquus capitis inferior
internal jugular vein.
Medial boundary is formed by:
d. The supra-clavicular nodes lie above Rectus capitis posterior major
clavicle in lower part of posterior triangle.
Rectus capitis posterior minor
E. The inferior belly of omohyoid crosses the The floor is formed by:
lower part of the posterior triangle and
Posterior arch of atlas
divides the triangle into. Posterior atlanto-occipital membrane
i. An upper largeroccipital triangle above
The roof (superficial boundary) is formed
the inferior belly that contains spinal by:
accessory nerve and branches of cervical
Semispinalis capitissupplemented by:
plexus. Splenius capitis
ii. A lower smallersubclavian triangle
Longissimus capitis
(supra-clavicular triangle) below the Contents
inferior belly. 1. The vertebral artery along with its sym-
It contains subclavian artery, its two pathetic plexus as it lies on a groove of
branches, external jugular vein, and posterior arch of atlas.
brachial plexus and its branches. 2. The suboccipital nerve (dorsal ramus of
F. A quantity of fibro-fatty tissue. first cervical nerve) appears below
vertebral artery.
Applied Anatomy
It gives five muscular branches to
I. The spinal accessory nerve is in danger of supply: Obliquus capitis superior
getting injured in operations on side of neck. Obliquus capitis inferior
The Triangles of the Neck 431
A line drawn from angle of mandible Contents: A few submental lymph nodes, that
to the tip of mastoid process drain lymph from tip of tongue and median
Apex part of lower lip and chin.
Lies below at the suprasternal notch of II. The digastric triangle lies in upper part of
manubrium sterni front of neck below mandible.
Boundaries
Subdivisions of the Anterior Triangle Superiorly
Base of mandible
The anterior triangle is subdivided into four
Antero-inferiorly
smaller trianglessubmental, digastric, carotid
Anterior belly of digastric
and mus-cular.
I. The submental triangle (Half portion lies in Postero-inferiorly
Posterior belly of digastric
each anterior triangle). Stylohyoid muscle
The small triangle lies above the body of Roof(superficial boundary) deep cervical
hyoid bone. fascia
Boundaries Floor(deep boundary):
Apex lies at the symphysis menti. Mylohyoid Hyoglossus
Base lies at the body of hyoid bone.
Floor (inferior boundary) is formed by the Contents
deep cervical fascia. Submandibular salivary glands that
Roof (superior boundary) is formed by the overlaps both bellies of digastric
two mylohyoid muscles. Submandibular lymph nodes
Two sides are formed by anterior bellies of Part of facial arteryand its submental
the two digastric muscles. branch
The lateral wall pharynx formed by i. Vagus nerve and its superior laryngeal
inferior and middle constrictor muscles branch that divides into external
laryngeal nerve (that supplies
Thyrohyoid membrane, thyrohyoid
cricothyroid muscle) and
muscle
Internal laryngeal nerve (that
Part of hypoglossus above hyoid bone pierces thyrohyoid membrane and
Contents supplies sensory fibers to larynx
a. The arteries above vocal cords).
Parts of common carotid, internal ii. Spinal accessory nerve crosses upper
carotid and external carotid arteries. part of triangle and pierces sterno-
Five branches of external carotid artery mastoid.
434 Essentials of Human Anatomy
Superior limb of ansa cervicalis lymph nodes lie along the internal jugular
Contd...
S. Name Origin Muscle belly Insertion Nerve supply Main actions
No.
anterior surface clavicular head be- line Lateral sur- rami C2, C3, C4 opposite side
manubrium sterni comes flattened face of mastoid (proprioceptive) II. Raises head from
Clavicular head above as it as- process supine position
superior surface cends obliquely III. Elevates thorax if
of medial third of in the neck head fixed
clavicle
2. Sternohyoid Posterior aspect Thin narrow strap- Medial part inferior Ansa cervicalis I. Depresses hyoid
medial end of like muscle belly border body of ventrical rami bone during spee-
clavicle hyoid bone C1, C2, C3 ch mastication
Posterior aspect and deglutition
of manubrium
sterni
3. Sternothyroid Posterior surface Shorter and wider Oblique line of Ansa cervicalis I. Depresses larynx
of manubrium muscle belly lamina of thyroid (Ventral rami (Thyroid cartilage)
sterni cartilage C1, C2, C3) during speech
Posterior aspect and swallowing
of first costal
cartilage
4. Thyrohyoid Oblique line of Small and quadri- Lower border Branch of hypo- I. Depression of
lamina of thyroid lateral muscle belly greater cornu of glossal nerve (fib- hyoid bone or
cartilage hyoid bone res of ventral elevation larynx
ramus C1)
5. Omohyoid Inferior belly Inferior belly flat, Inferior belly on Separate bran- I. Depression of
two belies From supra narrow, band intermediate ten- ches for both hyoid bone in
scapular notch Superior belly don bellies from Ansa prolonged respi-
Superior belly ascends vertically Superior belly cervicalis (Ventral ratory efforts
Intermediate lateral part lower rami C1, C2, C3)
tendon border body of
hyoid bone
6. Platysma Fascia on upper Thin, broad sheet Anterior fibres Cervical branch of I. It causes ridges
part of pectoralis lies in superficial decussate in mid- facial nerve in skin of neck
major fascia on side of line attached to II. Helps in depres-
neck symphysis menti sing mandible
Middle fibres lower III. Pulls lower lip and
border mandible angle of mouth
Posterior fibres downwards
Cross mandible and
masseter attached
to skin of lower
part of face
The supra-hyoid muscles:
1. Digastric Posterior belly Posterior belly Intermediate ten- Posterior belly I. Helps in depress-
Mastoid notch of longer and taper- don passes Facial nerve ion of mandible
temporal bone ing Anterior belly through a fibrous Anterior belly II. Helps to elevate
Anterior belly shorter pulley attached to Mylohoid nerve the hyoid bone
Digastric fossa hyoid bone
at lower border
of mandible
Contd...
438 Essentials of Human Anatomy
Contd...
S. Name Origin Muscle belly Insertion Nerve supply Main actions
No.
2. Stylohyoid Round tendon Narrow slender At insertion tendon Facial nerve I. Helps to elevate
posterior surface muscle belly of digastric divides and retract hyoid
near base of into two parts bone
styloid process attached to hyoid
bone at junction
with greater cornu
3. Mylohyoid Whole length of Flat, triangular Fibrous median Mylohyoid I. Elevates floor of
mylohyoid line muscle belly raphe Posterior branch of in- mouth
of mandible Forms floor of fibres body of ferior alveolar II. Helps to depress
mouth with fellow hyoid bone nerve mandible and ele-
of opposite side vate hyoid bone
4. Geniohyoid Lower mental Narrow muscle Anterior aspect Branch of hypo- I. Elevates hyoid
spine of mandible belly lies in para- body of hyoid glossal carrying bone
median position bone fibres of Ventral II. Helps in depress-
ramus C1 ing mandible
Stylohyoid
Mylohyoid
Geniohyoid
ii. The inferior thyroid artery is a large The rest of diverticulum may persist as a
branch of thyro-cervical trunk, and fibrous cordthyroglossal duct
reaches posterior surface of thyroid lobe. Parafollicular cells of thyroid gland develop
It also supplies parathyroid glands and from - IVth pharyngeal pouch.
gives a branch to larynx.
iii. Thyroidea ima artery is an occasional branch Anomalies of Thyroid Gland
from arch of aorta that supplies isthmus. Ectopic Thyroid
The veins: There are three paired veins The lingual thyroid
draining venous blood from thyroid gland. The suprahyoid thyroid
The veins do not accompany the arteries.
The infrahyoid thyroid
i. The superior thyroid The retrosternal thyroid
vein end in internal
ii. The middle thyroid jugular vein Applied Anatomy
vein
Enlargement of thyroid gland is called goiter.
iii. The inferior thyroid vein passes
i. A simple goiter results from deficiency of
downwards on front of trachea and ends in
iodine.
brachio-cephalic vein.
ii. A toxic goiter (adenoma) is due to over
The Lymphatic Drainage production of hormone and causes symp-
toms.
The lymph vessels of thyroid gland may contain Thyroidectomy is done in cases of thyroid
colloid material.
enlargement.
The lymphatics end in pre-laryngeal, pre-
A part of posterior lobes having parathyroid
tracheal and deep cervical lymph nodes.
glands is left behind to preserve parathyroid
The lymph finally reaches thoracic duct and
glands (subtotal thyroidectomy).
right lymphatic duct.
Two nerves external laryngeal and recurrent
The Nerve Supply laryngeal are closely related to thyroid lobe.
Care is taken during thyroidectomy to
The sympathetic nerves are derived from preserve the parathyroids.
middle cervical ganglia of sympathetic trunks. Injury to external laryngeal nerve causes
These supply the blood vessels of the gland.
paralysis of cricothyroid muscle of larynx,
The secretion of gland is under control of
leading to a temporary huskiness of voice.
thyrotropic hormone of pituitary gland. Injury to recurrent laryngeal nerve causes
Development of Thyroid Gland paralysis of most of intrinsic muscles of larynx and
this leads to a permanent huskiness of voice.
DevelopmentThyroid gland develops from an
endodermal diverticulumMedian thyroid THE PARATHYROID GLANDS
diverticulum from floor of primitive pharynx
The site of diverticulum is marked by These are two pairs of small and important
foramen cecum in adult tongue. ductless glands, closely related to thyroid gland.
The lower end of diverticulum enlarges to Secretionis parathyroid hormone, that
form the gland. controls the calcium metabolism of the body.
The Muscles, Glands, Blood Vessels and Nerves of the Front of Neck 441
Course: The artery passes upwards and Course: The artery ascends upwards
laterally to reach the lower opening of through upper part of carotid triangle
carotid canal at the base of the skull. and passes deep to posterior belly of
It enters skull by passing through digastric.
bony carotid canal in the petrous The upper part of the artery lies in
temporal bone. the substance of parotid gland.
The internal carotid artery, along The artery comes out of parotid
with internal jugular vein and gland and bifurcates behind the
vagus nerve lies inside fascial tube neck of mandible into two terminal
the carotid sheath.
bran-chessuperficial temporal
The artery in upper part lies deep
and maxillary.
to styloid process and its associated
Branches
muscles, that separate it from the
1. The superior thyroid artery is the first
external carotid artery.
branch. It reaches the upper pole of
The sympathetic plexus from the
thyroid lobe and supplies the gland.
superior cervical ganglion of
sympathetic chain accompanies the It also givesA superior
artery inside skull. laryn-geal branch, that pierces
ii. The inferior bulb is present just above the v. The submental nodes lie just below the
terminal end of the vein. There is a pair of symphysis menti.
valves just above it. These nodes drain lymph from scalp,
The internal jugular vein terminates behind temporal region and superficial parts of face.
the medial end of clavicle by joining with the B. The superficial cervical nodes lie along the
subclavian vein to form the brachio-cephalic external jugular vein, and drain lymph from
vein. superficial parts of side of neck.
The right internal jugular vein is more vertical. C. The anterior cervical nodes, lie along the
Tributaries anterior jugular vein on front of the neck and drain
i. The inferior petrosal sinus from inside the lymph from superficial structures on front of neck.
skull. D. The deep cervical nodes lie along the
ii. The pharyngeal veins from the pharyngeal internal jugular vein deep to sternomastoid.
venous plexus.
These lymph nodes drain lymph from the
iii. The lingual veins from the tongue.
iv. The common facial vein. other four groups in the neck.
v. The superior and middle thyroid veins. They also drain lymph from the deep
structures of head and neck.
The following two groups of this set are
THE SUBCLAVIAN VEIN important:
a. The jugulo-digastric nodes lie at the angle
The subclavian vein is continuation of axillary vein. of mandible just below the posterior belly
It begins at outer border of 1st rib and ends at of digastric.
medial border of scalenus anterior by joining This node collects lymph from palatine
with internal jugular vein to form the tonsil, tongue, and upper pharyngeal
brachiocephalic vein. region.
The vein lies in front of subclavian artery and It is also known as tonsillar node.
scalenus anterior muscle behind clavicle. b. The jugulo-omohyoid node lies a little lower
Its tributaries are down, where the internal jugular vein is
1. The external jugular vein crossed by the superior belly of omohyoid.
2. The thoracic duct on left side and right It collects lymph from the tongue and
lymphatic duct on right side (sometimes) other deeper structures of the neck.
At the root of neck, the lymphatics from the
The Lymphatic Drainage of the deep cervical nodes join to form the jugular lymph
Head and Neck trunk. On right side, it joins the right lymphatic
A. The pericervical chain of lymph nodes lie at duct, and on left side it ends in the thoracic duct.
the junction of head and neck. They are:
THE NERVES OF THE FRONT OF NECK
i. The occipital nodes at upper part of
trapezius muscle. The nerves on the front of neck are the last
ii. The retro-auricular (mastoid) nodes lie four cranial nerves (i.e. from ninth to twelfth)
behind the auricle. and the sympathetic chain.
iii. The parotid nodes lie in the relation with
parotid gland. 1. The Glosso-Pharyngeal Nerve
iv. The submandibular nodes lie in relation to The glosso-pharyngeal nerve (IX cranial nerve) (Fig.
the submandibular salivary gland. 40.7).
448 Essentials of Human Anatomy
ii. The sino-carotid nerve supplies the external acoustic meatus and outer
carotid sinus and the carotid body. surface of tympanic membrane.
iii. The tonsillar branch supplies sensory iii. The pharyngeal branch joins the
fibers to the palatine tonsil. pharyngeal plexus of nerves and
iv. The lingual branches supply sensory provides its motor component.
and taste fibers to posterior one-third iv. The superior laryngeal branch divides
of tongue including vallate papillae. into:
v. The pharyngeal branches join the The external laryngeal nerve that
pharyngeal plexus of nerves and supply supplies the cricothyroid muscle.
sensory fibers to pharynx and palate. The internal laryngeal nerve that
vi. Muscular branch to stylopharyngeus. provides sensory fibers to upper
part of larynx.
2. The Vagus Nerve (the X cranial nerve)
v. The cardiac branches two to three in
Type mixed nerve. number, join the cardiac plexuses.
Functional components and distribution vi. The right recurrent laryngeal nerve is
(Chapter 47) given in the lower part of neck and
Course and relationthe vagus nerve also curves around the first part of
enters the neck by passing through middle subclavian artery.
part of jugular foramen enclosed in a common The recurrent laryngeal nerve
dural sheath with the accessory nerve. supplies the intrinsic muscles of
There are two ganglia in upper part of the larynx (except cricothyroid) and
vagus nerve. gives sensory fibers to lower part
i. The superior ganglion is small and relays of larynx.
the somatic sensory fibers of the nerve.
ii. The inferior ganglion is larger and 3. The Accessory Nerve
cylindrical. It relays all visceral (The XI Cranial Nerve)
sensory fibers (including the taste
fibers) of the nerve. Typepurely motor.
The vagus nerve descends in the neck Functional components and distribution
enclosed in the carotid sheath along with (Chapter 47)
internal (common) carotid artery and Course and relationThe accessory nerve
internal jugular vein. also enters the neck by passing through
Branches in the neck middle part of jugular foramen enclosed in a
The communicating branches are given to: common dural sheath with the vagus nerve.
Superior cervical ganglion of sym- It consists of two partscranial and spinal.
pathetic chain. a. The cranial part joins the vagus nerve
Hypoglossal nerve. just below the skull.
Glossopharyngeal nerve. The motor fibers of the cranial part
Accessory nerve. are distributed along with the
The branches of distribution pharyngeal and recurrent laryngeal
i. The meningeal branch is given to the branches of vagus nerve.
dura mater of posterior cranial fossa. b. The spinal part descends in the neck
ii. The auricular branch (Arnolds nerve) between the internal carotid artery and
supplies sensory fibers to auricle, the internal jugular vein.
450 Essentials of Human Anatomy
ill-defined swelling agger nasi and many mucous glands. The inhaled air
representing a rudimentary concha. circulates through the meatuses. It is warmed,
c. The region of conchae and meatuses is the moistened and purified (of dust particles) in
larger posterior part of nasal chamber. the nasal cavity.
There are three nasal conchaesuperior, The muco-periosteum is also continuous with
middle and inferior. These are curved the lining of the paranasal air sinuses that
bony plates lined by muco-periosteum. open in the lateral wall of nasal chamber.
The three conchae separate the lateral
wall into four meatuses. The Openings in the Lateral Wall
i. The spheno-ethmoidal recess is a
The paranasal sinuses and the naso-lacrimal duct
narrow space above superior con-
open in the lateral wall of the nasal chamber.
cha.
These openings are:
ii. The superior meatus lies between
the superior and middle concha. a. Opening of sphenoidal air sinus is in the
iii. The middle meatus is the largest spheno-ethmoidal recess.
and lies between middle and b. Opening of posterior ethmoidal air sinuses
inferior concha. is located in the superior meatus.
There is a round swelling bulla c. Opening of middle ethmoidal air sinuses is
ethmoidalis limited below by located above the bulla ethmoidalis.
curved gutter hiatus semilunaris d. Opening of fronto nasal duct from the
in the upper part of the meatus. frontal air sinus is present in anterior part of
The Blood Supply of the Nasal Cavity The posterior superior nasal branches
medial and lateral supplythe nasal
The arteries: There is a rich anastomosis between
septum and the lateral wall.
the branches of internal carotid and external
The anterior superior alveolar nerve
carotid arteries in the walls of nasal cavity.
i. The ethmoidal arteriesanterior and posterior
supplies a small area around anterior part
from the ophthalmic branch of internal carotid of the inferior concha.
artery supply the anterior and superior parts.
PARANASAL AIR SINUSES
ii. The spheno-palatine artery, a branch of
maxillary artery supplies the posterior part. The paranasal air sinuses are air-filled spaces
iii. The greater palatine artery also a branch of in the cranial bones around the nasal cavities.
maxillary artery supplies anterior and They open in the lateral wall of nasal cavity
inferior parts. and their lining epithelium is continuous with
iv. The superior labial branch of facial artery the mucoperiosteum of nasal cavity.
supplies the lower part of septal cartilage and They are rudimentary at birth and gradually
lateral wall. increase in size with age. They are smaller in
The veins: The veins form a rich submucus venous females.
plexus in the mucoperiosteum. The venous plexus The air sinuses make the cranial bones
drains mainly in the pterygoid venous plexus. pneumatic and lighter. They also help in the
The vasodilation of the venous plexus due to resonance of voice (The male voice is deeper
infection or allergy causes blockage of the due to same reason).
nasal chamber. The different paranasal sinuses are
Frontal air sinuses - paired
The Nerve Supply of the Nasal Cavity Sphenoidal air sinuses - paired
Maxillary air sinuses - paired
I. The nerves of special sense of smell, the
Ethmoidal air sinuses - anterior, middle, and
olfactory nerves, about twenty in number begin
from the special receptor cells in the nasal posterior groups.
mucosa and pass through the cribriform plate to Frontal air sinusesare located in anterior part
end in the olfactory bulb. of frontal bone just above the root of nose.
The olfactory nerves mainly supply the upper They are asymmetrical in size and separated
part of the nasal cavity. by a bony septum. They are about 2-3 cm in
II. The nerves of general sensation height and width.
For the anterior part of nasal cavity the nerves They are smaller in females. They open by a
are branches from the ophthalmic division of funnel shaped - infundibulum - in middle
trigeminal nerve. These nerves are: meatus of nasal cavity.
The anterior ethmoidal nerve. Sphenoidal air sinuses are inequal pair of air
The posterior ethmoidal nerve. sinuses separated by a deviated septum.
For the posterior part of nasal cavity the They lie within body of sphenoid and may
nerves are the branches of maxillary division extend into base of greater wings and
of trigeminal nerve. These are: pterygoid processes.
The naso-palatine nerve that runs along the The sphenoidal sinus is related anteriorly to nasal
nasal septum and enters the hard palate cavity, inferiorly to pharying and posteriorly to
through incisive canal to supply it. posterior cranial fossa, basilar artery and pons.
The Viscera of the Head and Neck1 455
Above the sphenoidal sinus lies the hypophysis The opening of maxillary air sinus is situated
cerebri and cavernous sinuses on either side. at a higher level so the infected mucus
Each sinus opens by a small round opening in collects in the sinus. Sometimes a surgical
spheno-ethmoidal recess above superior procedure Antral puncture is done to
concha in lateral wall of nasal cavity. exacuate the infected material from the sinus.
Maxillary air sinuses [Antrum of Highmore] are
the largest paranasal sinuses. THE LARYNX
Each maxillary sinus occupies whole of body
The larynx is the upper modified end of trachea
of maxilla and has shape of an irregular three
sided pyramid. for the production of voice.
Its apex extends into zygomatic process of The larynx also acts as a compound sphincter
maxilla and the base is formed by lateral wall of the respiratory passage.
of nasal cavity. The three sides are formed by
anterior, orbital and infra-temporal surfaces of The Skeletal Framework
maxilla. (Figs 41.3 and 41.4)
The lowest part of sinus is opposite the The skeleton of the larynx is formed by a rigid
second premolar and first molar tooth and is framework of bones, cartilages, membranes and
approximately 1 cm below the level of floor ligaments.
of nasal cavity. I. The bones and the cartilages are:
The infra-orbital groove and canal lie in the a. The hyoid bone in uppermost part of neck,
roof of sinus. The alveolar nerves and vessels gives attachment to the membranes and
lie along its surfaces. extrinsic muscles of larynx. (Described in
The sinus opens in middle meatus of nasal Chapter 35).
cavity by a large openingmaxillary hiatus. b. The cartilages of the larynx are three large
Ethmoidal air sinusesare then walled cavities unpaired cartilagesepiglottis, thyroid, and
or cells that occupy whole of ethmoidal cricoid and three small paired cartilages
labyrinths on either side. arytenoid, corniculate, and cuneiform.
They are about 10-16 in number and are
The epiglottis is a leaf-like elastic fibro-
arranged in three groupsanterior, middle,
cartilage.
and posterior.
It is attached to hyoid bone by hyo-
The anterior and middle groups open by
epiglottic ligament and angle of
common openings in middle meatus and
thyroid cartilage by thyro-
poste-rior group opens in the superior meatus
epiglottic ligament.
of nasal cavity.
The superior surface is connected
The middle ethmoidal sinuses bulge in the
to the dorsum of tongue by one
middle meatus forming a round smelling
median and two lateral glosso-
bulla ethmoidalis.
epiglottic folds.
Applied Anatomy The inferior surface faces the
upper part of the cavity of larynx.
The sinusitis or the infection of paranasal The thyroid cartilage consists of two
sinuses are the complication of infection of laminae fused in median plane to form
nasal cavities, as the muco-periosteum is an angle of nearly 90 in males (120
common for both. in females).
456 Essentials of Human Anatomy
Fig. 41.3: The skeletal framework of the Fig. 41.4: The skeletal framework of the larynx
larynxanterior aspect posterior aspect
Parts: The mouth cavity is divided into two i. The greater palatine artery a branch of
parts. maxillary artery enters through a bony
i. The mouth cavity proper. canal from the pterygo-palatine fossa, and
ii. The vestibule of mouth is the outer part of supplies hard and soft palate both.
the mouth cavity between gums and teeth ii. The ascending palatine artery a branch of
inside and the cheeks outside. facial artery supplies soft palate.
The Viscera of the Head and Neck2 461
iii. The tonsillar branch of facial artery also iii. The lesser palatine nerves supply soft palate.
supplies the soft palate. These nerves carry sensory fibers of maxi-
iv. The dorsal linguae branches of lingual artery llary nerve, that pass via the pterygo-palatine
also supply the soft palate. ganglion.
The Veins iv. The glossopharyngeal nerve also supplies
soft palate.
The veins of the palate drain mainly in the pterygoid
The motor nerves are:
venous plexus and the tonsillar veins.
i. The mandibular nerve via nerve to medial
The Nerve Supply of the Soft Palate pterygoid and otic ganglion supplies the
The sensory nerves of the palate are: tensor veli palatini muscle.
i. The greater palatine nerve. ii. The cranial part of accessory via the pharyn-
ii. The terminal part of supply hard palate geal branch of vagus supplies the rest of
The sequence of cruption is The lower jaw teeth are supplied by inferior
Lower central incisor 6th month alveolar nerve, a branch of mandibular nerve.
Upper central incisor 7th month
Lateral incisors 8th-9th month
First molar 1st year THE TONGUE
Canines 18 months
Second molar 2nd year The tongue is a mobile muscular organ, in the
ii. The permanent teeth crupt in the following floor of the mouth cavity, that is concerned with.
sequence. Mastication of food
First molar - 2nd year Deglutition of food
Medial incisors - 7th year Speech
Lateral incisors - 8th year Taste
First premolar - 10th year The tongue is divided into two parts by an
Canines - 11th year inverted V-shaped sulcusthe sulcus terminalis
Second molar - 12th year (Fig. 42.1).
Third molar - 18-24th year (wisdom i. Anterior two-thirdthe oral part.
tooth) ii. Posterior one thirdthe pharyngeal part.
Nerve Supply of Teeth The two parts of the tongue have different
functions and development.
The pulp and peridontal membrane have same
At the apex of V-shaped sulcus is foramen
nerve supply different from overlying gum.
The upper jaw teeth are supplied by posterior caecum, that marks the beginning of median
superior dental, middle superior dental and thyroid diverticulum.
anterior superior dental nerves call carrying a. The oral part has a dorsal surface and a less
sensory fibers of maxillary nerve. extensive ventral surface.
The dorsal surface of tongue is divided into At the medial ends of these folds, there are
two halves by a median sulcus. openings of submandibular salivary ducts. b.
There are three types of lingual papillae on The pharyngeal part (posterior part) of
the dorsum of tongue, formed by the stratified tongue is also lined by stratified squamous epi-
squamous epithelium with a central core of thelium.
lamina propria (Fig. 42.2). The surface of this part of tongue is irregular
a. The circumvallate papillae form a single due to low elevations caused by large number
row of large 8-10 papillae just in front of of lymphoid follicles.
sulcus terminalis. These papillae are depres- This part is also known as lingual tonsil.
sed from the surface and surrounded by a There are taste buds in this part scattered in
vallium (wall). They bear taste buds. the epithelium.
The root of the tongue occupies most of the
b. The fungiform papillae are club shaped.
ventral surface of tongue and connects the
These are scaltered on the dorsum. They
tongue to the mandible and hyoid bone.
also bear the taste buds.
c. The filiform papillae are numerous on the The Muscles of Tongue
dorsum of tongue. These are conical pro-
jections of epithelium, to make the surface The muscles of tongue are striated and voluntary.
rough. They do not bear the taste buds. The muscles are divided into (Table 42.2):
d. Small transverse folds at lateral surface of An extrinsic group consisting of muscles, that
tongue from the foliate papillae. These are connect the tongue to neighboring structures
rudimentary in human tongue. and help in movements of tongue. (Fig. 42.3)
An intrinsic group consisting of muscles, that
The ventral surface of the oral part of tongue
form the bulk of tongue and help to change
has the following features.
the shape of tongue.
In midline, there is frenulum linguaea
The muscles of tongue are supplied by the
fold of mucous membrane.
hypoglossal nerve (twelfth cranial nerve) except
Two fimbriated folds of mucus membrane
palatoglossus supplied by cranial accessory nerve
lie on the two sides.
through pharyngeal branch of vagus (Fig. 42.4).
Between the frenulum and fimbriated fold,
the profunda vein is visible through the The Blood Vessels of the Tongue
mucous membrane.
On the floor of the mouth cavity below The Arteries
tongue, are placed the sublingual folds, The paired lingual arteries provide the main
formed by the sublingual salivary glands. arterial supply to the tongue.
Fig. 42.4: Coronal section through tongue showing the intrinsic muscles
The artery courses forwards and then At the posterior border of hyoglossus these
ascends vertically along anterior border of veins join to form one (or two) lingual veins,
hyoglossus, deep to the sublingual gland. that end in the internal jugular vein.
The lingual artery continues as profunda
artery on the ventral surface of tongue up The Lymphatic Drainage of the Tongue
to its tip. The lymphatics draining the tongue are important
Branches for the spread of cancer of tongue.
i. The suprahyoid branch runs above the There are two lymph plexuses in the
greater cornu of hyoid bone, superficial to substance of tongue.
hyoglossus.
i. The subepithelial plexus lies deep to the
ii. The dorsal linguae branches (2-3) ascend dorsal epithelium.
deep to hyoglossus. They supply posterior ii. The intra-muscular plexus lies among the
part of tongue, tonsil, pharynx and soft muscles of the tongue.
palate. The lymphatics from anterior two third of
iii. The sublingual branch supplies the sub- tongue (except the vallate papillae) are
lingual salivary gland. divided into two sets:
iv. The profunda artery is the continuation of a. The marginal lymphatics draining lymph
lingual artery. It supplies deeper structures from the peripheral parts of tongue.
of the anterior part of tongue. The lymphatics from the tip end in
submental lymph nodes.
The Veins
The lymphatics from the rest of anterior
There are two venae comitantes accompanying part end in submandibular, jugulo-
the lingual artery deep to hyoglossus. digastric and jugulo-omohyoid lymph
The hypoglossal nerve is accompanied by a nodes of same side.
vena comitans formed by the profunda vein b. The central lymphatics drain lymph from
joining the sublingual vein. the central part of lymph plexuses.
The Viscera of the Head and Neck2 467
The sympathetic nerves are derived from the The nerve supply
plexus around facial artery. The sensory nerves are derived from the
The parasympathetic (secretomotor) nerves lingual nerve.
are carried by the chorda tympani and reach The sympathetic nerves come from the plexus
submandibular ganglion via the lingual nerve. around the facial artery.
The preganglionic fibers end in the ganglion and The parasympathetic (secretomotor) nerves
post ganglionic branches reach the deep part of are derived from chorda tympani and reach
the gland. submandi-bular ganglion via lingual nerve. The
post ganglionic fibers from the ganglion reach
The Sublingual Salivary Gland sublingual salivary gland via lingual nerve.
It is the smallest of the three paired salivary glands.
THE LINGUAL NERVE
Type a mixed type of salivary gland with
mostly mucous acini and some serous acini as The lingual nerve is one of the two terminal
serous demilunes. branches of posterior division of mandibular nerve.
Location: The sublingual gland occupies the Distribution
sublingual fossa of mandible above Lingual nerve supplies sensory fibers to
mylohyoid muscle. Anterior 2/3rd of tongue
Size and shape is like that of a large almond. Floor of mouth
Relations the gland lies lateral to the Lingual nerve also carries fibers of chorda
genioglossus and rises above the muscle to tympani that supply
raise a sublingual fold in the floor of mouth. Secretomotor fibers to submandibular
The lingual nerve and submandibular and sublingual salivary glands
salivary duct pass deep to it. Taste fibers from anterior 2/3rd of
Ducts there are about 15-20 small ducts that tongue (except vallate papillae)
open on summit of sublingual fold in the floor Course and Relations
of mouth. i. Lingual nerve arises in infratemporal
The blood supply is from the sublingual fossa between lateral pterygoid and medial
branch of lingual artery. pterygoid muscles from mandibular nerve.
The Viscera of the Head and Neck2 469
Boundaries Boundaries
Superiorly Nasopharyngeal isthmus is Anteriorly
bounded by: The dorsum of tongue
Lower border of soft palate. The inlet of larynx
A ridge on posterior wall of pharynx- Two piriform fossae on either side
Passavants ridge, caused by the post- Lateral wallshave the continuation of:
erior part of palato-pharyngeus. The palato-pharyngeal fold
Anteriorly oropharyngeal isthmus is boun- The salpingo-pharyngeal fold
ded by: Posterior wallis featureless
Dorsum of tongue Inferiorlythe laryngo-pharynx is conti-
Two palatoglossal folds nuous with the esophagus.
Soft palate
Laterally is a triangular depression The Palatine Tonsil
tonsillar fossabounded:
Anteriorly by palato-glossal fold The palatine tonsilis a mass of lymphoid tissue
The Blood Supply of the The veins form a pharyngeal plexus of veins that
Pharyngeal Wall lies along the lateral wall.
The arteries of the pharynx are: The venous plexus communicates with
pterygoid venous plexus.
The ascending pharyngeal artery from the
The pharyngeal veins drain into the internal
external carotid artery.
The ascending palatine and tonsillar branches jugular vein.
of facial artery.
The Nerve Supply of the Pharynx
The greater palatine, pharyngeal and artery of
the pterygoid canal from the maxillary artery. The nerves of the pharynx form a pharyngeal
The dorsal linguae branches of lingual artery. plexus.
474 Essentials of Human Anatomy
The sensory nerves contributing to the plexus sixth cervical vertebra), as continuation of
are derived from the glossopharyngeal. pharynx.
The pharyngeal branch of pterygopalatine The esophagus descends in front of seventh
ganglion carrying fibers of maxillary nerve. cervical vertebra behind trachea.
The motor nerves contributing to the The esophagus deviates slightly towards the
pharyngeal plexus are derived from the left side and passes through thoracic inlet to
cranial part of accessory nerve via the enter the superior mediastinum of thorax.
pharyngeal branch of vagus.
The recurrent laryngeal nerve lies in tracheo-
The pharyngeal plexus is also joined by the
esophageal groove. The thoracic duct lies
sympathetic fibers from the superior
cervical ganglion of the sympathetic trunk along its left border.
via the laryngo-pharyngeal branch. The blood supply of cervical part of esophagus is
derived from the inferior thyroid artery.
THE CERVICAL PART OF ESOPHAGUS
The nerve supply is from parasympathetic
The esophagus (gullet) begins at the lower (vagus nerves) and sympathetic (cervical part of
border of cricoid cartilage (vertebral level sym-pathetic trunk).
The Head and Neck
Multiple Choice Questions
Q.1. Select the one best response to each 7. The maxillary nerve leaves the skull by:
question from the four suggested A. Foramen ovale
answers: B. Foramen spinosum
1. Which layer of the scalp is known as the C. Foramen lacerum
dangerous layer of the scalp: D. Foramen rotundum
A. Dense connective tissue 8. The air sinus that drains by gravity is:
B. Epicranial aponeurosis A. Maxillary sinus
C. Loose areolar tissue B. Frontal sinus
D. Pericranium C. Ethmoidal sinuses
2. The facial vein terminates usually in: D. Sphenoidal sinus
A. Pterygoid venous plexus 9. The taste sensation is lost from posterior
B. External jugular vein third of tongue, which of the following
C. Anterior jugular vein
cranial nerves are involved:
D. Internal jugular vein
A. Facial
3. The parotid duct opens in the vestibule of B. Vagus
mouth opposite: C. Glossopharyngeal nerve
A. Second upper molar tooth D. Maxillary nerve
B. First upper molar tooth
C. Third upper molar tooth 10. Which of the following muscles is partly
D. Canine tooth inserted on the articular disc of temporo-
mandibular joint:
4. The muscle used for blowing out air from A. Lateral pterygoid
the mouth is: B. Medial pterygoid
A. Zygomaticus major C. Masseter
B. Levator labii superioris
D. Temporalis
C. Risorius
D. Buccinator 11. The skin of the tip of nose is innervated by:
5. The crista galli gives attachment to: A. Buccal nerve
A. Falx cerebri B. Infraorbital nerve
B. Falx cerebelli C. External nasal nerve
C. Diaphragma sellae D. Facial nerve
D. Tentorium cerebelli 12. The superior laryngeal artery is a branch of:
6. Which of the following nerves have motor A. Facial artery
supply: B. Lingual artery
A. Lesser occipital B. Suboccipital C. C. Superior thyroid artery
Greater occipital D. Third occipital D. Vertebral artery
476 Essentials of Human Anatomy
13. The hypoglossal nerve leaves the cranial 3. Is related to parathyroid glands on its
cavity through the following foramen: posterior aspect.
A. Jugular foramen 4. Does not move with deglutition.
B. Posterior condylar canal
18. The carotid body:
C. Foramen ovale
1. Is present at bifurcation of common
D. Anterior condylar canal
carotid artery.
14. The muscle of pharynx supplied by the 2. Is a pressure receptor.
glosso-pharyngeal nerve is: 3. Is chemoreceptor.
A. Stylo-pharyngeus 4. Is sometimes absent.
B. Palato-pharyngeus
19. The air sinus that drains in the superior
C. Salpingopharyngeus
meatus of the nasal cavity.
D. Inferior constrictor
1. Sphenoidal air sinus
15. The anterior belly of digastric is supplied by: 2. Middle ethmoidal air sinus
A. Hypoglossal nerve 3. Frontal air sinus
B. Mylohyoid nerve 4. Posterior ethmoidal sinus
C. Facial nerve 20. The palatine tonsil receives its sensory
D. Ventral ramus of first cervical nerve nerve supply from:
Q.2. Each question below contains four 1. Greater auricular nerve
suggested answers, of which one or more 2. Glossopharyngeal nerve
is correct. Choose the answer. 3. Mandibular nerve
A. If 1, 2 and 3 are correct 4. Maxillary nerve
B. If 1 and 3 are correct 21. The abductor muscles of the vocal cords are:
C. If 2 and 4 are correct 1. Cricothyroid
D. If only 4 is correct 2. Oblique arytenoid
E. If 1, 2, 3 and 4 are correct 3. Lateral crico-arytenoid
16. In the posterior triangle of neck: 4. Posterior crico-arytenoid
1. The spinal part of accessory nerve 22. Injury to the left facial nerve at the stylo
crosses the lower part of the triangle. mastoid foramen leads to:
2. The roots of brachial plexus emerge in 1. Hyperacusis of left ear
the triangle between scalenus anterior 2. Loss of lacrimation in left eye
and scalenus medius. 3. Loss of secretion of left parotid gland
3. The inferior belly of omohyoid divides 4. Facial paralysis of left half of face
the triangle intoan upper occipital
23. The chorda tympani contains the following
and a lower subclavian triangles.
fibers:
4. The second part of subclavian artery
1. Parasympathetic fibers for submandi-
crosses the lower part of the triangle.
bular and sublingual salivary glands.
17. The thyroid gland 2. Sensory fibers from anterior two-third
1. Is a highly vascular, important of tongue.
endocrine gland. 3. Taste fibers from anterior two-third of
2. Is developed from the mesoderm of tongue.
first branchial arch. 4. Motor fibers for stylopharyngeus.
Multiple Choice Questions 477
24. The cranial nerves that pass through the 3. Lateral pterygoid C. Facial
cavernous venous sinus: 4. Cricothyroid D. Spinal accessory
1. Oculomotor
2. Trochlear 28. Important features
3. Abducent 1. Thyroid gland A. Lingual tonsil
4. Ophthalmic division of trigeminal 2. Posterior third B. Middle meatus
25. The nasal septum is formed by: tongue of nose
3. Bulla ethmoi- C. Isthmus
1. The perpendicular plate of ethmoid
2. Septal cartilage dales
3. Vomer 4. Tubal elevation D. Naso pharynx
4. Maxilla 29. Branch of main arterial trunk
Q.3. Match the structures on the left with their 1. Thyro-cervical A. Arch of aorta
related structures on the right: trunk
26. Foramina of skull 2. Lingual artery B. Subclavian artery
1. Foramen ovale A. Vertebral artery 3. Ophthalmic C. External carotid
2. Foramen spino- B. Emissary vein artery
sum spinosum 4. Thyroidea ima D. Internal carotid
3. Posterior condy- C. Middle meningeal 30. Type of joint
lar canal artery
1. Temporomandi- A. Synostosis
4. Foramen mag- D. Mandibular nerve
bular joint
num
2. Symphysis menti B. Pivot joint
27. Nerve supply of muscles: 3. Median at lanto- C. Condyloid joint
1. Sternomastoid A. Mandibular occipital joint
2. Orbicularis B. External laryngeal 4. Intervertebral D.
oculi nerve Secondary carti-
disc laginous joint
Answers
from the anterior two-third of tongue are The lateral pterygoid is supplied by the
carried by the lingual branch of mandibular mandibular nerve.
nerve. The motor fibers to the stytopharyn- The cricothyroid is innervated by the
geus are supplied by the glossopharyngeal. external laryngeal nerve.
A24. The answer is E (1, 2, 3, 4). A28. The answers are C, A, B and D.
The cranial nerves that pass through the The isthmus is the median part of
cavernous venous sinus arethe oculomotor, thyroid gland.
trochlear and ophthalmic and maxillary The lingual tonsil lies in the posterior
divisions of fifth nerve along the lateral wall, third of the tongue.
and the abducent nerve along the medial wall, The bulla ethmoidalis lies in the middle
lying inferolateral to the internal carotid artery. meatus of nose.
The tubal elevation lies in lateral wall
A25. The answer is A (1, 2, 3).
of nasopharynx.
The nasal septum is formed by the
perpendicular plate of ethmoid (the posterior A29. The answers are B, C, D and A.
superior part), the septal cartilage (the anterior The thyrocervical trunk is a branch of
inferior part) and the vomen (the posterior first part of subclavian artery.
inferior part). The maxilla bone does not The lingual artery is a branch of
contribute any major part to the nasal septum. external carotid artery.
The ophthalmic artery is a branch of
A26. The answers are D, C, B and A. internal carotid artery.
The foramen ovale transmits mandibular The thyroidea ima is a branch of arch
nerve. The foramen spinosum gives passage of aorta.
to the middle meningeal artery. The
A30. The answers are C, A, B and D.
posterior condylar canal transmits an
The temporo-mandibular joint is a con-
emissary vein and vertebral artery passes
dyloid type of joint.
through foramen magnum.
The symphysis menti is actually a syno-
A27. The answers are D, C, A and B. stosis between two halves of mandible.
The sternomastoid is supplied by the The median atlanto-occipital joint is a
spinal accessory. pivot type of synovial joint.
The orbiculasis oculi is supplied by the The intervertebral disc is a secondary
facial nerve. cartilaginous joint.
The Spinal Cord, Brain, Eyes
and the Ears Eight
CHAPTER 43
The Spinal Cord
THE SPINAL CORD The spinal segmentsa spinal segment is a part
of spinal cord that gives attachment to one
The spinal cord is the cylindrical part of central
pair of spinal nerves. Thus there are thirty-one
nervous system that lies in upper two-third of
vertebral canal. spinal segments (8 cervical, 12 thoracic, 5
The spinal cord begins from upper border of lumbar, 5 sacral and 1 coccygeal).
atlas vertebra and ends at lower border of first The vertebral levels of the spinal segments
lumbar vertebra (at birth it ends at lower are important in relation to injuries of the
border of third lumbar vertebra). vertebral column.
The spinal cord had two enlargements: All eight cervical segments lie up to sixth
a. The cervical enlargement is associated cervical spine.
with attachment of nerves supplying upper Upper six thoracic segments lie from sixth
extremity (extends from C4 spinal cervical spine up to fourth thoracic spine.
segment to T1 segment). The lower six thoracic segments lie from
b. The lumbar enlargement is associated fourth thoracic spine to ninth thoracic spine.
with attachment of nerves supplying the The five lumbar, five sacral and coccygeal
lower extremity (extends from L2 spinal segments lie from ninth thoracic spine to first
segment to S4 segment). lumbar spine.
The lower tapening end of spinal cord is
The Meninges of the Spinal Cord
called the conus medullaris.
The filum terminale is the non-nervous (Fig. 43.1)
filament that connects the conus medullaris to The spinal cord is also surrounded by three
the first piece of coccyx. coverings or meninges.
Since spinal cord ends at a higher level than I. The spinal dura mater is tough and fibrous and
the vertebral canal, the lumbar, sacral and is continuous with inner meningeal layer of
coccygeal nerve roots are long (to reach their cerebral dura mater.
respective intervertebral foramina). It forms a loose covering of the spinal cord
The conus medullaris, and filum terminale and extends up to second sacral vertebra.
surrounded on each side by the lumbar, sacral It is attached above to the margins of foramen
and coccygeal nerve roots give an appearance magnum and in front to the posterior
called cauda equina (horse tail). longitudinal ligament of the vertebral column.
482 Essentials of Human Anatomy
The epidural space is the space between the arachnoid and are attached to the dura
outer surface of dura mater and vertebral mater in between nerve roots.
canal. It contains: The subarachnoid space is a wide space that
a. Internal vertebral venous plexus lies between pia mater and arachnoid matter. It
b. Few small arteries contains:
c. A quantity of fat Cerebrospinal fluid
II. The spinal arachnoid mater is thin, delicate and Large spinal blood vessels
transparent and closely follows the dura mater. It
also extends up to second sacral vertebra.
The Blood Supply of Spinal Cord
The subdural space is a potential space between The arteries
the dura mater and arachnoid mater. It contains There are three spinal arteries, two posterior
a small amount of serous fluid to moisten the spinal and one anterior spinal from vertebral
opposing surfaces. artery that descend on the surface of spinal
III. The spinal pia mater is thicker and more cord.
fibrous and less vascular than cerebral pia mater. These spinal arteries are reinforced by the
It lines the outer surface of spinal cord radicular arteries that are derived from the
intimately, and makes the following: regional arteries of the body wall, and accom-
a. The linea splendensis a longitudinal pany the spinal nerve roots.
thickening lying along the ventral median
The Veins
fissure.
b. The subarachnoid septuma perforated There are six longitudinal venous channels that
septum, attached to posterior median drain venous blood from the spinal cord.
sulcus. These veins drain into the internal vertebral
c. The ligamenta denticulatatwo extensions venous plexus and finally in the regional veins of
of pia mater attached on either side of the body wall.
spinal cord. There are no valves in the spinal veins and the
Each ligamentum denticulatum has venous blood from spinal cord can reach directly
twenty-one tooth processes that pierce into regional veins.
The Spinal Cord 483
The spinal nerve rootsEach spinal nerve is c. The anterior white column lies between the
attached by two spinal nerve roots on the side of most lateral attachment of rootlets of anterior
spinal cord: nerve root and ventral median fissure.
a. The posterior (dorsal) nerve root carries Each of these three columns contains three
afferent somatic and visceral nerve fibers. types of nerve tracts (Table 43.1):
It has got a dorsal root ganglion (DRG) i. The ascending (sensory) nerve tracts carry
near the inter-vertebral foramen, that has sensory impulses from the spinal cord to
pseudo-unipolar nerve cells and relays all different parts of brain.
the sensory fibers of the dorsal nerve root. ii. The descending (motor) nerve tracts carry
motor impulses from different parts of brain
b. The anterior (ventral) nerve root carries the to the spinal cord.
efferent somatic fibers and preganglionic iii. The inter-segmental tracts (fasciculi
visceral motor fibers. proprii) are short relay tracts,
The two nerve roots pierce the dural tube interconnecting segments of the spinal cord.
separately and unite in the intervertebral foramen There are three inter-segmental tracts one
to form the stem of the spinal nerve. for each anterior, posterior and lateral white
columns (Fig. 43.2).
The Internal Structure
The spinal cord has grey matter inside (forming The Nerve Tracts in Posterior
an H-shaped appearance in TS) surrounded by White Column
white matter. Ascending Tracts
The grey matter consists of following parts: Fasciculus gracilis
i. The posterior grey column (PGC) Fasciculus cuneatus
containing connector (sensory) neurons. Descending Tracts
ii. The anterior grey column (AGC)
Nil
containing efferent (motor) neurons.
iii. The central grey commissure that surrounds
The Nerve Tracts in Lateral
the central canal and has mostly neurolgial
White Column
tissue.
There is also a lateral grey column (LGC) Ascending Tracts
(from T1 spinal segment to L1 spinal segment) Dorso-lateral
that contains visceral connector (preganglionic) Posterior spino-cerebellar
neurons. Anterior spino-cerebellar
The white matter of the spinal cord is divided into Spino-olivary
three partscolumns or funiculi. Spino-tectal
a. The posterior white column lies between Lateral spinothalamic
posterior median septum and postero-lateral Descending Tracts
sulcus. Rubrospinal
b. The lateral white column lies between the Lateral corticospinal
postero-lateral sulcus and most lateral Lateral reteculospinal
attachment of rootlets of anterior nerve root. Olivospinal
484 Essentials of Human Anatomy
Table 43.1: The ascending and descending tracts of the spinal cord
The Nerve Tracts in Anterior The needle after piercing the skin and
White Column superficial fascia, passes through supraspinous,
Ascending Tract inter-spinous ligaments, dura and arachnoid
Anterior spinothalamic mater to reach the subarachnoid space.
The lumbar puncture is done to diagnose:
Descending Tracts
An intra-cranial hemorrhage
Anterior Renculospinal
A hemorrhage in vertebral canal
Vestibulo-spinal
Tectospinal Increased intracranial pressure due to a
Anterior corticospinal tumor
Infection of meninges
Applied Anatomy II. The spinal anesthesia is done to anesthetise
I. The lumbar puncture is a diagnostic procedure, the spinal nerve roots within the dural tube.
that is done to obtain a sample of cerebrospinal The spinal anesthetic is introduced by the
fluid. lumbar puncture.
The lumbar puncture is done usually between The number of spinal nerves to be
fourth and fifth lumbar spinous processes. anesthetised is controlled by:
(sometimes between third and fourth lumbar Amount of the spinal anesthetic substance
spinous processes). The position of the patient.
CHAPTER 44
The Meninges and
Blood Supply of Brain
THE MENINGES OF THE BRAIN There are four such folds.
The brain lies inside the cranial cavity surrounded The dural folds are four in number:
by three coverings or meningesdura mater, 1. Falx cerebria large sickle shaped fold
arachnoid mater and pia mater (Fig. 44.1). that lies in longitudinal fissure between
I. The cerebral dura mater is thick, fibrous and two hemispheres.
protective outer covering. 2. Falx cerebelli is a small sickle shaped fold
The cerebral dura mater has two layers that lies in posterior cerebellar notch
endosteal and meningealwhich are fused between the two cerebellar hemispheres.
together except where they separate to 3. Tentorium cerebellia large tent-shaped
enclose venous sinuses. fold that roofs over the posterior cranial
The functions of dura mater are: fossa. It has a tentorial notch through
i. Protection of the brain which the brain stem passes.
ii. Inner lining of skull bones 4. Diaphragma sellae a small circular fold
iii. Enclosing venous sinuses between two that roofs over the hypophyseal fossa. It
layers has a central aperture for the infundibulum
iv. Forming folds or duplications to divide of hypophysis cerebri.
the cranial cavity into freely The blood supply of dura mater is by
communicating compartments. meningeal arteries.
In anterior cranial fossa these are branches The granulation lie in groups or clusters. These
from the anterior and posterior ethmoidal are the sites through which cerebrospinal fluid
arteries. goes back to venous blood.
In middle cranial fossa these are branches The subarachnoid space is the wide space
from the middle meningeal, accessory that separates the arachnoid mater from pia
meningeal and ascending pharyngeal arteries. mater. It contains cerebrospinal fluid (CSF)
In posterior cranial fossa these are branches and large blood vessels of brain.
of vertebral artery. The subarachnoid cisterns are enlarged
The middle meningeal artery is the largest subarachnoid spaces at the base of the brain
meningeal artery that supplies most part of and around brain stem. These spaces contain a
dura mater lining the vault of the skull. larger amount of CSF. The important sub-
This a branch of maxillary artery and enters the arachnoid cisterns are:
skull via foramen spinosum. It divides into an a. The cerebello-medullary cistern between
anterior branch and a posterior branch. back of medulla oblongata and cerebellum.
The anterior branch passes through a bony tunnel b. The inter-peduncular cistern surrounds the
at pterion on side of skull and is liable to be inter-peduncular fossa.
ruptured in fracture of skull bones at that point. c. The superior cistern lies behind the
The posterior branch ascends up to a point splenium of corpus callosum.
lambdaon top of skull. d. The cisterna pontis lies along ventral
The sensory nerve supply of dura mater is by surface of pons.
ophthalmic division of trigeminal nerve for e. The cistern of lateral sulcus lies on each
anterior cranial fossa. side in front of temporal pole.
For middle cranial fossa and large part of dura III. The cerebral pia mater is the vascular
mater lining the vault of skull is supplied by covering that intimately covers the surface of
maxillary nerve. brain. It contains a plexus of fine blood vessels.
For posterior cranial fossa the sensory nerves The telachoroidea are folds of pia mater that
are mandibular nerve and ventral rami of bulge inside the ventricles of brain.
upper cervical nerves. These folds contain many blood vessels in
II. The cerebral arachnoid mater is thin, margins that are lined by the ependyma of the
transparent and delicate covering that is separated ventricles forming choroid plexuses.
from dura mater by a potential space, the The choroid plexuses secrete cerebrospinal
subdural space. fluid, by an active process of secretion by
It does not dip in the sulci and fissures of ependymal cells.
brain and bridges over the irregularities of
The Blood Supply of the Brain
brain surface.
Arachnoid villi and granulationsThe arach- The Arteries
noid mater forms minute projectionsthe The brain is supplied blood by four large arteries,
villiin fetal life. The projections become large they are: (Fig. 44.2)
called arachnoid granulations in later life. Paired internal carotid artery.
These granulations pierce dura mater and Paired vertebral artery.
bulge in venous sinuses specially superior a. The internal carotid artery enters the
sagittal sinus. cranial cavity through bony carotid canal.
488 Essentials of Human Anatomy
Branches
i. Anterior spinal and posterior
spinal arteries supply front of
medulla oblongata and then
descend to supply the spinal cord.
ii. Small medullary branches supply
the peripheral parts of medulla
oblon-gata.
iii. Posterior inferior cerebellar artery
passes laterally and supplies lateral
part of medulla oblongata and
cerebellum.
Fig. 44.2: The brain stemanterior aspect with arteries c. The basilar artery is the median
anastomotic channel formed by union of
two vertebral arteries.
It passes within the dural walls of
cavernous venous sinus and then It lies in basilar sulcus on ventral
pierces the roof of the sinus. surface of pons.
It ascends up to anterior perforated At upper border of pons it bifurcates
substance, lateral to the optic chiasma into two posterior cerebral arteries.
and divides into its terminal branches. Branches are paired
Branches a. Anterior inferior cerebellar artery
1. Ophthalmic artery enters orbit supplies inferior surface of cere-
through optic canal. bellum.
2. Anterior choroidal artery supplies b. Labyrinthine artery enters internal
choroid plexus of inferior horn of acoustic meatus and supplies the
lateral ventricle. internal ear.
3. Posterior communicating artery c. Small pontine branches are given to
completes the circle of Willis. the ventral surface of pons.
4. Anterior cerebral d. Superior cerebellar supplies
artery are terminal superior surface of cerebellum.
5. Middle cerebral branches e. Posterior cerebral are the terminal
artery
branches.
b. The vertebral artery arises from first part
of subclavian artery and enters skull via The circle of Willis(circulus arteriosus) is an
foramen magnum. anastometic circle formed by union of main
It lies by side of medulla oblongata, then arteries at the base of the brain (Fig. 44.3).
gradually crosses on front of medulla The circle is shaped like a polygon and lies in
oblongata and at lower border of pons the inter-peduncular cistern surrounding the
joins with its fellow to form the interpeduncular fossa on the base of the brain.
basilar artery.
The Meninges and Blood Supply of Brain 489
The Veins of the Brain surface. They drain into cavernous sinus and
The veins of the brain drain into neighboring transverse sinus.
The superficial middle cerebral vein runs along
dural venous sinuses.
The cerebral veins have no valves and their lateral surface, connecting superior sagittal
walls are quite thin with few muscle fibers. sinus, with transverse sinus.
The veins of the cerebrum are divided into II. The internal cerebral veins lie inside the
three groups (Fig. 44.4): telachoroidea of third ventricle.
Each internal cerebral vein is formed at the
I. The external cerebral veins drain venous blood
from the cortex and subjacent white matter. inter-ventricular foramen (foramen of Monro)
These are further subdivided into superior by union of:
cerebral veins, inferior cerebral veins and a. Thalmostriate vein draining venous blood
superficial middle cerebral vein. from thalamus and corpus structum.
The superior cerebral veins (8-12) course over b. Choroidal vein draining venous blood
the lateral surface and follow a peculiar course from choroid plexus.
at their termination in superior sagittal sinus. The internal cerebral veins run parallel to
They run parallel to the sinus for a short each other and come out of transverse fissure
distance then open against the direction of flow below splenium of corpus callosum.
of blood in the venous sinus. This is probably The two veins join to form the great cerebral
due to a backward growth of hemisphere. vein. The great cerebral vein lies in the
The inferior cerebral veins drain venous blood superior cistern and joins the inferior sagittal
from lower part of lateral surface and inferior sinus.
The Meninges and Blood Supply of Brain 491
It receives the two basal veins, inferior cerebral b. Striate veins draining venous blood from
veins, some cerebellar veins and veins from back corpus striatum, internal capsule and
of midbrain. thalamus.
III. The basal veins are two large veins, that lie c. Deep middle cerebral vein that drains
along the inferior (tentorial) surface of hemisphere. venous blood from insula (submerged
Each vein is formed at anterior perforated area of cortex in depth of lateral sur-
substance by union of three veins: face).
a. Anterior cerebral vein from the medial The basal vein terminates in the great cerebral
surface of hemisphere. vein.
CHAPTER 45
The Hind-Brain and
Mid-Brain
THE HIND-BRAIN AND MID-BRAIN Location: It lies in posterior cranial fossa in
relation to basilar part of occipital bone.
The brain is the dominant part of the central
Size and Shape: The medulla oblongata is
nervous system, that controls all somatic and
about 3.0 cm long and is cylindrical in shape.
visceral activities of the body. It is also the center
Parts: It is divided into:
for all higher mental functions.
i. Lower closed part having central canal
Subdivisions ii. Upper open part, that forms the lower part
of floor of fourth ventricle.
The brain is divided functionally and develop- Surface Characters
mentally into three parts: The anterior aspect of medulla oblongata
i. The forebrain: Prosencephalon consists of has two swellings.
TelencephalonThe two cerebral a. The pyramida triangular elevation
hemispheres (cerebrum). by side of the ventral median fissure,
DiencephalonThe median part. with it apex directed below.
ii. The midbrain: Mesencephalon. b. The olivesan oval swelling about 1.0
iii. The hindbrain: Rhomhencephalon consists of cm long that lies by side of pyramid.
MetencephalonThe pons and cere- On the lateral aspect is the inferior cere-
bellum. bellar pedunclea rope like bundle, that
MyelencephalonThe medulla oblon- connects the medulla oblongata with the
gata. cerebellum.
On the posterior aspect are continuation of
The Brain Stem gracile and cuneate tracts, at upper ends of
Appears as continuation upwards of the spinal cord. which are the gracile and cuneate tubercles.
It consists of: The upper part of posterior surface, forms
The medulla oblongata the lower part of floor of fourth ventricle
The pons and shows three triangular elevations.
The mid brain i. Medial: hypoglossal triangle
The cerebellum is attached to the back of brain ii. Intermediate: vagal triangle
stem and the forebrain lies above it. iii. Lateral : lower part of vestibular area
Parts: The midbrain is divided into two part by iii. Inferior colliculus
the cerebral aqueduct. Efferent fibers form a dorsal teg-
i. A dorsal part, tectum, made up of two paired mental decussation and continue as
colliculisuperior and inferior. tecto-spinal tract.
ii. A ventral part made up of two cerebral b. The inferior colliculus has a compact
peduncles nucleus and acts as a relay station for
Each peduncle has auditory fibers.
a. Crus cerebri: seen at base of brain Connections
b. Substantial nigra: a curved plate of Afferent
pigmented grey matter. i. Lateral leminiscus
c. Tegmentum: that is fused with the ii. Opposite inferior colliculus
opposite cerebral peduncle. Efferent
Internal Structure i. Medial geniculate body
A. The tectum (Fig. 45.3) ii. Opposite inferior colliculus
a. The superior colliculus has a laminated iii. Superior colliculus
nucleus and acts as a visual reflex center. c. The pretectal nucleus is an indistinct
Connection mass of grey matter lying dorsal to the
Afferent superior colliculus at junction of mid-
i. Retina brain and diencephalon.
ii. Occipital cortex (area 17,18, and The pretectal nucleus acts as a center
19) for pupillary light reflex.
The new part is concerned with coordi- The inferior cerebellar peduncle connects
nation of voluntary muscular movement. medulla oblongata with cerebellum.
Internal structure It contains mainly afferent fibers, viz
The grey matter is in two forms: The olivo-cerebellar and parolivo-cerebellar
The deep nuclei, that lie in central white from the olivary nuclei.
matter. The anterior and posterior external arcuate
Nucleus fastigiioldest nucleus fibers from arcuate and lateral cuneate
Nucleus globosus nuclei.
Nucleus emboliformis The posterior spinocerebellar tract.
Nucleus dentatelargest and shaped like The vestibulocerebellar fibers.
a crenated vase. The few efferent fibers are cerebello-
The cerebellar cortex has the same thickness vestibular and cerebello reticular.
and structure throughout. The middle cerebellar peduncle connects the
It consists of two layers: basilar part of pons with cerebellum.
Outer molecular layer has low cell It is also mainly an afferent peduncle: the
density. It has molecular, basket bulk of fibers are ponto-cerebellar
type and Golgi type II cells. (transverse fibers of pons).
The deep part of this layer has a A few efferent fibers are from cerebellar
single row of large flask-shaped cortex to pontine nuclei.
Purkinje cellsthe efferent c. The superior cerebellar peduncle connects the
cells of cerebellar coretex. midbrain with cerebellum.
Inner granular layer has a very high It contains mainly the efferent fibers of
cell density. cerebellum.
The layer is packed up by many These efferent fibers arise from the deep
small granule cellsthe afferent nuclei of cerebellum and ascend up to teg-
cells of cerebellar cortex. mentum of mid brain, where they decussate.
After decussation the efferent fibers divide
The White Matter into:
The white matter contains three types of fibers: Ascending fibers that end in red nucleus
Association fibers: that connect the areas of and thalamus.
cortex of same hemisphere. Descending fibers that end in reticular
Commissural fibers: connect corresponding formation of brain stem.
areas of the two hemispheres. These fibers The two afferent tracts are anterior spino-
cross midline. cerebellar and tectocerebellar.
Projection fibers: are of two types: Connections of cerebellum
The afferent fibers connect other parts of Afferent
brain and spinal cord with the Afferent climbing fibers are mostly
cerebellar cortex. olivocerebellar and they make 1:1
The efferent fibers connect cerebellar synapse with Purkinje cells of
cortex with other parts of brain and cerebellar cortex.
spinal cord. Afferent mossy fibers are spino-cerebellar,
The projection fibers reach cerebellum via ponto-cerebellar and vestibulo-
three paired peduncles. cerebellar.
500 Essentials of Human Anatomy
Fig. 45.5: The brain stemposterior aspect showing floor of fourth ventricle
The Hind-Brain and Mid-Brain 501
The floor is lined by ependyma and a The medullary striae are curved bands of white
thick layer of neuroglia. The cranial matter, that emerge from median sulcus and
nerve nuclei lie deep to it. pass laterally in lateral recess. These are
Upper pontine part has displaced external arcuate fibers.
A median sulcus The fourth ventricle has five recessesone
Two medial eminences that show facial dorsal median, two dorsal lateral and two lateral
colliculi in their lower parts recesses.
A superior fovea lateral to facial colliculus The lateral recesses begin at the lateral angles
Superior part of vestibular area and curve around inferior cerebellar peduncles.
Locus ceruleusa blue green pigmented Their terminal ends are open at lateral openings
area along upper lateral margin. that are closed by tuft of choroid plexuses.
Lower medullary part has The openings of fourth ventricle (Fig. 45.6).
A median sulcus i. One median opening (foramen of Magendie)
Three triangles is large, funnel-shaped opening in lower part
a. Hypoglossal triangle is medial of roof. It opens in the cerebello-medullary
b. Vagal triangle is intermediate in cistern.
position ii. Two small lateral openings (Foramina of
It showsinferior foveain upper Luschka) at the ends of lateral recesses are
part partially blocked by tuft of choroid plexuses.
Funiculus separansa thick The choroid plexus lies in the fold of pia mater,
ridge of ependyma the tela choroidea. Just above the median
Area postremaa vascular opening.
neurogial tissue with nerve cells It is shaped like a T with vertical limb double.
of moderate size A branch of posterior inferior cerebellar
c. Inferior vestibular area artery supplies the choroid plexus.
CHAPTER 46
The Forebrain
The forebrain (Prosencephalon) consists of: The anterior end is narrow and pointed and
A median portionthe diencephalon. forms the posterior boundary of inter-
Two lateral cerebral hemispheresthe ventricular foramen.
telencephalon. The posterior end is expanded and called
The diencephalon consists of two halves pulvinar. It overhangs the back of mid-brain.
separated by the median cavity of third ventricle. The superior surface is covered by a thin
Each half consists of a dorsal portion that layer of white matterstratum zonale.
includes the thalamus and epithalamus and a It medial part is covered by choroid plexus
ventral portion that includes subthalamus and and lateral part is lined by ependyma
hypothalamus. and forms a part of floor of central part
a. The thalamus is an ovoid mass of grey matter of lateral ventricle.
that lies in the lateral wall of third ventricle (Fig. The inferior surface is related to
46.1). Hypothalamus anteriorly
Size: The length of thalamus is about 4.0 cm, Subthalamus posteriorly
width 1.5 cm and thickness 1.0 cm. The medial surface is covered with ependyma
Ends and surfaces: The thalamus has two and forms the lateral wall of third ventricle.
endsanterior and posteriorand four sur- An oval band of grey matter, inter thalamic
adhesion (massa intermedia) connects the
facessuperior, inferior, medial, and lateral.
medial surface of two thalami.
The lateral surface is covered by a thin layer
of white matterexternal medullary lamina.
It is related to the posterior limb and retro-
lentiform part of internal capsule.
Internal structure
a. The white matter:
The thalamus has three layers or laminae
of white matter.
Stratum zonale on the superior surface.
External medullary lamina on the lateral
surface.
Internal medullary laminaa thick Y-
shaped lamina of white matter, that
divides the grey matter in three parts.
b. The grey matter:
Anterior part of grey matter is small part
that lies between the two limbs of
Fig. 46.1: The thalamisuperior aspect internal medullary lamina.
The Forebrain 503
Medial part of grey matter lies between The ventral group of nuclei
medial surface and internal medullary Ventral Anterior (VA)
lamina. Afferent connections
Lateral part of grey matter is the largest part Corpus striatum
that lies between the lateral surface and Reticular formation of brain
the internal medullary lamina. stem.
Nuclei of thalamus and their connections (Fig. Efferent connections
46.2) Premotor area of cotex
The anterior group of nuclei lie in the anterior Ventral Intermediate (VI)
Afferent connections
part.
Cerebellum
Afferent connectionfrom mamillo-
Red nucleus
thalamic tract.
Efferent connections
Efferent connectionto gyrus cinguli
Motor and premotor areas of
The medial group of nuclei lie in the medial
cortex
part
Ventral Posterior Lateral (VPL)
Afferent con- } Afferent connection
nections and Hypothalamic nuclei Medial lemniscus
Efferent con- Other thalamic nuclei Spinal lemniscus
nections also Pre-frontal areas Efferent connections
c. The lateral part contains Sensory areas of the cortex
The lateral group of nuclei (lateral dorsal, Ventral Posterior Medial (VPM)
(LD) lateral posterior (LP) and pulvinar Afferent connection
(P). Trigeminal lemniscus
These nuclei are connected with: Taste fibers
Posterior part of cingulate gyrus Efferent connection
Other thalamic nuclei Sensory areas of the cortex
Cortical area The minor nuclei
Intralaminar lie scattered inside internal
medullary lamina.
Mid-line nuclei lie along medial surface.
They are poorly developed in human
brain.
Reticular nuclei lie along lateral surface.
These nuclei are connected with
thereticular formation of brain stem and
all parts of cerebral cortex.
The geniculate bodies: medial and lateral lie
on the inferior surface of pulvinar.
Lateral geniculate body is part of visual
pathway
Afferentconnections: Retinal
Fig. 46.2: The internal structure and nuclei of thalamus fibersfrom both sides.
504 Essentials of Human Anatomy
Fig. 46.4: The lateral surface of cerebral hemisphere showing special cortical areas
Although, recent experimental studies have The prefrontal area occupies remaining part of
shown there are no purely sensory or purely frontal lobe.
motor areas, most cortical areas have both This area is concerned with individuals
afferent and efferent connections. personality, depth of feelings, initiative and
judgement.
The Motor Areas An operationprefrontal leucotomyis done in
i. The motor area (Area 4) is located in precentral certain types of psychotic patients. All
gyrus and adjoining part of paracentral lobule. connections of prefrontal area are cut off to
Voluntary movements of opposite half of body alter the aggressive personality of the patient.
are represented upside down in the motor
area.
The premotor area (Area 6) is located in
The Sensory Area
posterior part of superior, middle and inferior
frontal gyri. The sensory (Somesthetic) area (Area 3, 1, 2) is
The premotor area is concerned with learned located in the postcentral gyrus and adjoining
motor activity. part of paracentral lobule.
The frontal eyefield is located in posterior part of In this area all exteroceptive and proprioceptive
middle frontal gyrus. It controls the voluntary
sensation of opposite half of body are actually
scanning movements of the eyes.
perceived. The body is represented upside
The Brocas area (Motor speech center)-(Area
down.
44-45) is an extension of motor area into inferior
frontal gyrus occupying triangular and opercular Area 3 receives the exteroceptive sensations,
parts. Area 2 receives proprioceptive sensations,
The Brocas area is present in left hemisphere in while the Area 1 coordinates the two types of
right-handed persons. sen-sations.
A lesion of this area causes aphasia, loss of The association areas occupy the remaining part
speech. of parietal lobe.
508 Essentials of Human Anatomy
This area is located close to sensory, visual and The Auditory Areas
auditory areas and its function is to associate i. The audito-sensory area (Area 41, 42) is
these sensory impulses. located in middle part of superior temporal gyrus
Stereognosisidentification of an object, with- and anterior transverse temporal gyrus.
out seeing, is the property of this area. This area receives the acoustic radiations.
The visual areas are (Fig. 46.5): The area perceives the loudness, pitch, frequency,
i. The visuosensory area (striate areaArea quality and direction of sound.
is located in depth of calcarine sulcus and The audito-psychic area (Area 22) occupies the
adjoining gyri on the medial surface of remaining part of superior temporal gyrus.
cerebral hemisphere. The function of this area is to interpret and
The striate area receives the optic recognize the auditory sensations from past
radiations from the lateral geniculate experience.
body. The insular area is located in the insula, the
It perceives the size, shape, colour, submerged area of cortex in the lateral sulcus.
transparency and illumination of an This area is supposed to be concerned with
object. visceral functions.
The visuo-psychic areas (para striateArea The cingulate area is located in the anterior part
18 and peristriateArea 19) of (Area 24) cingulate gyrus.
These areas surrounding the striate area
This area is connected with the limbic system and
and are located in the occipital lobe.
is involved in individuals personality.
The function of these areas is to store
The suppressor area is a vertical strip in anterior
the visual impressions and help in their
part of Area 4.
recognition.
If stimulated, it causes suppression of all motor
functions for several minutes.
Functional Classification
The corpus striatum is divided into
The paleostriatum (palladium) is the older part,
consisting of globus pallidus only.
The neostriatum (striatum) newer part, consisting
of putamen of lentiform nucleus and caudate
nucleus.
Connections of corpus striatum
Paleostriatum is the afferent part of corpus
striatum.
Afferent connections
Fig. 46.6: The caudate and lentiform Strio-pallidalfrom neostriatum
nucleilateral aspect Subthalamo-pallidal from the sub-
thalamic nucleus
The amygdaloid nucleus is an important part of
Nigro-pallidal from the substantia nigra.
limbic system.
Efferent connection
b. The corpus striatum is a large mass of grey Ansa lenticularis
matter that is divided into two parts: Fasciculus lenticularis joins the ansa
Caudate nucleus lenticularis and dentato-thalamic tract
Lentiform nucleus to form thalamic fasciculus that ends
I. The caudate nucleus is elongated and comma in ventral lateral and ventral lateral
shaped mass of grey matter that bulges in the nuclei of thalamus.
floor of lateral ventricle. It consists of: Fibers from these nuclei are relayed to
Headis thick anterior end that bulges in the the motor and premotor areas of the
anterior horn of lateral ventricle. It is continuous cortex.
with putamen of lentiform nucleus. Subthalamic fasciculus
Body is the curved part, that forms the lateral part Pallido-hypothalamic fasciculus
of floor of central part of lateral ventricle. Descending fibers to red nucleus, reticular
Tail is narrow tapering part that lies in the roof of formation of brain stem and
inferior horn and ends in the amygdaloid inferior olivary nucleus.
nucleus. Neostriatum is the efferent part of corpus
striatum.
The lentiform nucleus is large lens shaped mass
Afferent connection
of grey matter that is completely buried in the
Cortico-striate from all parts of cerebral
white matter of hemisphere.
cortex.
The medial surface is more convex and is related Thalamo-striate from intra-laminar and
to the internal capsule. medial group of nuclei of thalamus.
The lateral surface is less convex and is related Nigro-striate from substantia nigra.
to the external capsule and claustrum. Efferent connection
The lentiform nucleus is divided into two parts Strio-pallidal is the main efferent outflow
An outer putamen Strio-nigral to substantia nigra
An inner lighter partglobus pallidus.
510 Essentials of Human Anatomy
Fig. 46.13: Coronal section through posterior Fig. 46.14: Coronal section through
horn of lateral ventricle inferior horn of lateral ventricle
516 Essentials of Human Anatomy
of cerebrospinal fluid and the brain sub- The fiber tracts of the limbic system are:
stance undergoes compression. Fimbria and its continuation the fornix and
Pneumo-encephalography is a special hippocampal commissure.
procedure to visualize the ventricles. Air Longitudinal striaemedial and lateral.
is introduced through the lumbar puncture. Mamillo-thalamic tract
Stria terminalis and stria-medullaris thalami
THE LIMBIC SYSTEM Functional significance
The limbic system includes phylogenetically The limbic system is concerned with
older areas of cortexarchipalliumand emotional behavior of an individual, viz.
other associated nuclei and their fiber tracts. fear, anger, social response and other
The parts of limbic system are homeostatic responses.
Olfactory bulb and tract It is also concerned with integration of large
Olfactory areasmedial and lateral number of impulsesvisceral, olfactory
Indusium gresium and somatic.
Amygdaloid nucleus The limbic system is also involved in recent
Parahippocampal gyrus and gyrus cinguli memory and memory patterns.
Hippocampus Certain parts of limbic system perform the
Anterior part of thalamus and mamillary olfactory function, but this is a minor
bodies function.
CHAPTER 47
The Cranial Nerves
There are twelve pairs of cranial nerves attached These nerves arise from the neurons
to the brain. belonging to somatic efferent (SE) func-
The cranial nerves arise or terminate in certain tional component.
nuclei of grey matter in the brain. Group II has the trigeminal, facial, glosso-
The cranial nerves can be classified under the pharyngeal, vagus and accessory nerves.
followingfunctional nervous components to These nerves supply the derivatives of the
which their nuclei belong. branchial arches from special visceral
The somatic efferent nuclei (SE) give out efferent (Sp. VE) and special visceral
axons to supply the somatic muscles. afferent (Sp. VA) functional components.
The special visceral efferent nuclei (Sp. VE) Group III has the nerves related to the special
give out axons to supply the muscles senses. They belong to special somatic
developed from the branchial arches. afferent (Sp. SA) component.
The general visceral efferent nuclei (GVE) give This group includes the olfactory, optic and
out axons to innervate the glands of head the vestibulo-cochlear nerves.
and neck or the visceral musculature.
The general visceral afferent nuclei (GVA) GENERAL DESCRIPTION OF THE
receive the afferent sensations from the CRANIAL NERVES
viscera. The Olfactory Nerve (I cranial nerve)
The special visceral afferent nuclei (Sp. VA) Functional component: Special somatic afferent
receive the special sense of taste developed in (Sp. SA).
the region of primitive pharynx. Nearly twenty olfactory nerves arise from the
The general somatic afferent nuclei (SA) olfactory receptor cells in the nasal mucosa,
and pass through the cribriform plate and end
receive the afferent sensations from the
in the olfactory bulb.
skin and proprioceptors. The olfactory bulb lies on the cribriform plate
The special somatic afferent nuclei (Sp SA) and continues as olfactory tract to the
receive afferent sensations from the olfactory areas of the brain.
special sensesolfaction, vision, auditory Applied anatomy: In head injuries, the olfactory
and balance. bulb and tract may be damaged.
Infection may also travel via these nerves to
THE FUNCTIONAL CLASSIFICATION the meninges of the brain.
OF CRANIAL NERVES The Optic Nerve (II cranial nerve)
Functional component Special somatic afferent
The cranial nerves can be divided into three groups: (Sp. SA).
Group I has the oculomotor, trochlear, abducent The optic nerve begins from the axons of
and hypoglossal nerves. the ganglion cells of the retina.
518 Essentials of Human Anatomy
The optic nerve is, in fact, not a nerve but photosensitive cells of the retinathe rods
tract of brain that lies outside brain. This and cones actually perceive the image.
is proved by following two factors: Within retina, there are three sets of
The optic nerve carries around it three neurons, that relay the visual image.
sheaths derived from the three They are:
meninges of the brain. The rods and cones
The optic nerve fibers, like the nerve The bipolar cells
tracts of the brain, have no neurilemma c. The ganglion cells
sheath, and are, therefore, incapable of The axons of the ganglion cells form the
regeneration. optic nerve.
Increase in the intracranial pressure The optic nerve reaches the optic chiasma,
compresses the central vein and artery of where a partial crossing of the retinal
retina as they lie in the extension of the fibers takes place.
subarachnoid space between the sheaths of The nasal retinal fibers of the two
retinae (from the two eyeballs) cross in
the optic nerve. This causes
the optic chiasma, while the temporal
papilloedemas or swelling of the optic
retinal fibers of the two retinae,
disc inside the eyeball.
continue on the same side.
The optic nerve pierces the sclera a few
The optic tracts carry the crossed nasal retinal
millimeters medial to the posterior pole of fibers and uncrossed temporal retinal fibers
the eyeball. to the lateral geniculate body.
The nerve is about 4.0 cm long and is The lateral geniculate body is a small
slightly longer than the distance from back nucleus, situated below the pulvinar or
of eyeball to the optic foramen, to allow posterior end of thalamus.
for movements of eyeball. The lateral geniculate body has six
It leaves the orbit by the optic canal and is laminate of grey matter, the laminae
attached to the antero-lateral angle of the 2,3 and 5 receive the crossed temporal
optic chiasma. retinal fibers and the laminae 1,4 and 6
The Visual Pathway (Fig. 47.1) receive the crossed nasal retinal fibers.
The retina of the eyeball receives an inverted From the lateral geniculate body, the retinal
image of the object through the lens. The fibers pass, as the optic radiations or
geniculo-calcarine tract through the internal The two rami enter the orbit through the
capsule to reach the primary visual area middle part of superior orbital fissure
(Area 17) situated in the calcarine sulcus of within the common tendinous ring.
the occipital lobe, where the visual image is Branches (Fig. 47.2)
actually perceived. The superior ramus gives two branches to
Applied anatomy Superior rectus
A lesion of the optic nerve causes total Levator palpebrae superioris
blindness in the affected eye. The inferior ramus gives three branches to
Lesions of the optic tracts, lateral geniculate Medial rectus
body and optic radiations lead to homo- Inferior rectus
nymous hemianopia of the opposite side Inferior oblique
(i.e. loss of nasal visual field of the same The nerve to inferior oblique gives a communi-cating
side and temporal visual field of the branch to the ciliary ganglion. This branch carries
opposite side). preganglionic parasympathetic fibers that relay in
Oculomotor Nerve (III cranial nerve) the ciliary ganglion and pass along short ciliary
It has two functional components: nerves to supply the two intra-ocular muscles
Somatic efferent (SE) that innervates the extra- sphincter pupillae and ciliary.
ocular muscles including levator palpebrae
Applied anatomy
superioris developed from the body wall
lesion of oculomotor nerve gives the
musculature.
following symptoms:
General visceral efferent (GVE) that supplies
Ptosis (drooping of upper eyelid)
the muscles developed from the visceral
Dilatation of pupil
musculature.
Lateral squint or strabismus
The Oculomotor nucleus lies in the central grey
Proptosis or slight bulging of the eyeball
matter of mid-brain at level of superior colli-
Loss of accommodation
culus.
Double vision or diplopia
The Oculomotor nucleus is divided into parts for
The Trochlear Nerve (IV cranial nerve)
supplying different extra-ocular muscles
Functional component is somatic efferent (SE)
causing movements of the eyeball.
The nucleus of the trochlear nerve lies in
The Edinger-Westphal nucleus gives origin to the
parasympathetic fibers, that relay in ciliary the central grey matter of midbrain of
ganglion and supply two intraocular level of inferior colliculus
muscles sphincter pupillae and ciliary. The trochlear nerve is the most slender
Course: The oculomotor nerve comes out of medial cranial nerve and it completely
sulcus on medial aspect of crus cerebri in the decussates inside midbrain before
interpeduncular fossa of the base of brain. emerging out.
It passes forwards, pierces the roof of The trochlear nerve is attached to the dorsal
cavernous venous sinus and then runs aspect of midbrain just below inferior
along the lateral wall of cavernous sinus colliculus.
above trochlear nerve. Course: The nerve curves around the crus
In the anterior part of cavernous sinus the cerebri and then passes forwards. It pierces
oculomotor nerve divides into superior
ramus and an inferior ramus.
520 Essentials of Human Anatomy
the roof of the cavernous venous sinus b. The spinal nucleus lies in medulla oblongata
behind oculomotor nerve. and extends downwards up to upper five
1. The trochlear nerve runs forwards along cervical segments of the spinal cord. This
the lateral wall of cavernous venous nucleus is concerned with pain and temper-
sinus below oculomotor nerve. ature sensations from the head and neck
2. It enters the orbit through the lateral part region.
of superior orbital fissure. c. The mesencephalic nucleus extends into the
Branch tegmentum of midbrain. It contains pseudo-
The trochlear nerve supplies only one unipolar neurones (like dorsal root ganglia
extraocular musclethe superior oblique. of spinal nerves) and is concerned with
Applied anatomy proprioceptive sensations from the head and
The lesion of trochlear nerve produces. neck region.
Inability to turn the eyeball downwards and Course: The trigeminal nerve is attached on the
laterally. ventral aspect of pons by a large sensory root
If attempt is made to turn the eye towards and a small motor root.
the action of the muscle, it causes diplopia The trigeminal ganglion (semilunar gan-
(double vision). glion) is the sensory ganglion of trigeminal
5. The Trigeminal Nerve (V cranial nerve) nerve. [Described in Chapter 37]
Functional components are Location: The ganglion lies in a fold of dura
i. Special visceral efferent (Sp VE) innervates matercavum trigeminalenear the apex
the muscles developed from the branchial of petrous temporal bone.
arches. The ganglion relays all the exteroceptive
ii. Somatic afferent (SA) supplies the sensory fibers of the three divisions of
extroceptors and proprioceptors of the head trigeminal nerve.
and neck region. Shape: is semilunar with a convex border
The nuclei of the trigeminal nerve are: facing forwards and laterally : and a concave
The motor nucleus of trigeminal nerve lies border facing backwards and medially.
in the tegmentum of pons. The three divisions, ophthalmic, maxillary
The sensory nuclei of the trigeminal are three: and mandibular are attached to the convex
a. The superior sensory nucleus lies in the border.
tegmentum of pons and recieves touch and The sensory root is attached to the concave
pressure sensation from head and neck region. border.
The Cranial Nerves 521
The ophthalmic division is purely sensory nerve The nerve lies within dural walls of the
and is smallest of the three divisions. cavernous sinus, infero-lateral to the
It passes forwards lying along the lateral wall internal carotid artery.
of cavernous venous sinus between The nerve enters the orbit through the middle
trochlear nerve above and maxillary nerve part of superior orbital fissure lateral to the
below. two rami of oculomotor nerve.
Inside cavernous sinus the ophthalmic nerve Branch: The abducent nerve supplies one extra-
divides into its three terminal branches the ocular musclethe lateral rectus.
lacrimal, frontal and naso-ciliary. Applied anatomy: The lesion of the abducent
The lacrimal and frontal nerves enter the nerve produces.
orbit through the lateral part of superior Medial squint or strabismus
orbital fissure. Diploma or double vision
The nasociliary nerve enters the orbit through The Facial Nerve (VII cranial nerve)
the middle part of superior orbital fissure Functional components are:
between the two rami of oculomotor Special vesceral efferent (Sp. VE) that
nerve. supplies the muscles developed from the
(Described in Chapter 48). branchial arches
The maxillary division is also purely sensory General visceral efferent (GVE) that
nerve and is intermediate in size. supplies the muscles developed from the
It passes forwards from the ganglion lying visceral musculature.
along the lateral wall of cavernous venous Special visceral afferent (Sp. VA) that
sinus below ophthalmic nerve. receives the special sensation of taste.
It leaves skull through foramen rotundum The nuclei of the facial nerve are:
and enters pterigopalatine fossa. The motor nucleus of facial lies in the
(Described in Chapter 38). tegmentum of pons lateral to the abducent
c. The mandibular division is also purely sensory nucleus.
and largest of the three divisions. The superior salivary nucleus lies in the
It turns laterally and passes out of skull tegmenture of pons. It gives out pregan-
through foramen ovale. glionic parasympathetic fibers that relay in
Just below skull the mandibular nerve, that is the pterygo-palatine ganglion and supply
a mixed nerve. the lacrimal gland.
(Described in Chapter 38). Some preganglionic parasympathetic
The Abducent Nerve (VI cranial nerve) fibers relay in the submandibular
Functional component is somatic efferent, (SE) ganglion and supply submandibular and
The nucleus of the abducent nerve lies deep to sublingual salivary gland.
the facial colliculus in the pontine part of c. The nucleus of tractus solitarius receives the
floor of fourth ventricle. afferent taste fibers from the anterior two-
Course: The abducent nerve passes forwards third of tongue (except vallate papillae).
from its attachment at the lower border of Course: The facial nerve is attached at the lower
pons. border of pons by a large motor root and a
It pierces meningeal layer of dura mater, laterally placed small sensory root the nervus
below dorsum sellae and passes laterally intermedius.
and forwards between two layers of dura The nerve passes laterally, the two roots join
mater for a short distance. and the nerve enters the internal acoustic
meatus in the posterior cranial fossa.
522 Essentials of Human Anatomy
The facial nerve passes through a bony The terminal branches in the face are five
facial canal that bulges in the medial wall sets.
of the middle ear. Temporal, zygomatic, buccal mandi-
The facial canal opens below at the stylo- bular and cervical.
mastoid foramen. These branches supply
Inside the facial canal, the facial nerve has a The muscles of scalp
geniculate ganglion that relays the sensory The muscles of face
fibers of the nerve. Auricularis anterior and superior
The nerve comes out of stylomastoid Platysma
foramen, gives a posterior auricular Applied anatomy
branch and two muscular branches to Lesions of the facial nerve may occur in
muscles of neck. infections of middle ear also.
It crosses lateral to the base of styloid The facial nerve paralysis (Bells paralysis)
process and enters the parotid gland. (Described in Chapter 37)
Inside parotid gland, the nerve divides into The Vestibulo-Cochlear Nerve [VIII cranial
five sets of branches that supply the nerve]
muscles of face and scalp. Functional component is
Branches Special somatic afferent (Sp.SE)
Of communication are given to: The nerve consists of two nervesthe
Pterygopalatine ganglion vestibular nerve and the cochlear nerve.
Otic ganglion via lesser petrosal nerve
I. The vestibular nerve is concerned with the
Vagus and glossopharyngeal nerves
function of balance and equilibrium.
Of distribution
a. Nerve to stapedius is given in bony The vestibular nuclei are four in number and they
facial canal lie in the vestibular area of the floor of fourth
b. Chorda tympani carries: ventricle (party in pons and partly in medulla
The afferent taste fibers from oblongata.
anterior two-third of tongue The vestibular nuclei are:
(except vallate papillae). The medial vestibular nucleus
The preganglionic parasympathetic The inferior vestibular nucleus
fibers for submandibular and sub- c. The lateral vestibular nucleus
lingual salivary glands. d. The superior vestibular nucleus
The chorda tympani is also given Course: The vestibular nerve arises from the
inside the bony facial canal and bipolar neurones of the vestibular ganglion of
comes out of petro-tympanic fis- the internal ear.
sure. It joins the lingual nerve at an The nerve comes out of the internal acoustic
acute angle in the infratemporal meatus in posterior cranial fossa and is
fossa. attached to the lower border of pons
c. The posterior auricular branch supplies lateral to the facial nerve.
the occipital belly of epicranius muscle The nerve ends in the vestibular nuclei.
and the auricularis posterior. II. The cochlear nerve is concerned with the
The two muscular branches supply: special sense of hearing.
Posterior belly of digastric The cochlear nuclei are twothe ventral
Stylohyoid cochlear nucleus and the dorsal cochlear nucleus.
The Cranial Nerves 523
Fig. 48.4: The recte and oblique muscles of eyeball (lateral aspect)
532 Essentials of Human Anatomy
The posterior ciliary branches pierces the The oculomotor nerve enters as two rami,
sclera around optic nerve to supply the superior and inferior, via the middle part of
eyeball. superior orbital fissure.
The posterior ethmoidal artery enters the The superior ramus on entering orbit turns
posterior ethmoidal canal and supplies the upwards lateral to the optic nerve.
ethmoidal air sinuses and lateral wall of It supplies superior rectus, then gives a
nasal cavity. It also gives meningeal branch. branch that pierces superior rectus and
The anterior ethmoidal artery enters the supplies levator palpebrae superioris muscle.
anterior ethmoidal canal and supplies the The inferior ramus on entering orbit passes
ethmoidal sinuses and lateral wall of nose. below optic nerve and divides into three
It also gives meningeal branches. branches to supply medial rectus, inferior
Two medial palpebral branches supply the two rectus and inferior oblique.
eyelids. The nerve to inferior oblique is connected
The dorsal nasal branch supplies the root of with ciliary ganglion by a communicating
nose and anastomoses with terminal part branch that carries the parasympathetic
of facial artery. fibers to the ciliary ganglion, where there
The supra-trochlear arterysupplies the skin fibers relay and post ganglionic fibers
of forehead. supply ciliary and sphincter pupillae
Small muscular branches supply the muscles of eyeball.
extraocular muscles. The trochlear nerve enters the orbit through the
The Veins lateral part of superior orbital fissure.
The superior ophthalmic vein drains venous On entering the orbit, the nerve passes
blood from structures in the upper part of medially above the superior rectus and
orbit including eyelids, nose and part of levator palpebrae superiors to reach the
forehead.The superior ophthalmic vein posterior part of superior oblique muscle,
communicates with the beginning of facial that it supplies.
vein. c. The abducent nerve enters the orbit through
The inferior ophthalmic vein receives venous middle part of superior orbital fissure lateral
blood from lower part of orbit. The inferior to the two rami of oculomotor nerve.
ophthalmic vein communicates with the Just after entering the orbitit turns laterally to
pterygoid venous plexus via the inferior reach the medial surface of lateral rectus
orbital fissure. muscle, that it supplies.
The two ophthalmic veins leave the orbit via The sensory nerves of the orbit are:
The ophthalmic division of trigeminal is
the superior orbital fissure and end in the
nerve of general sensation.
cavernous venous sinus.
The optic nerve is nerve of special sense
The Nerves of the Orbit of sight.
The ophthalmic division of trigeminal divides
The motor nerves supplying the extraocular into its three terminal branches in the
muscles are threeoculomotor, trochlear and cavernous sinus, the naso-ciliary, frontal and
abducent (Fig. 48.7). lacrimal nerves (Fig.48.8).
534 Essentials of Human Anatomy
Posterior ethmoidal nerve enters the The nerve is slightly longer than the
posterior ethmoidal foramen and distance up to optic canal to allow
supply ethmoidal sinuses. for movements of eyeball.
Anterior ethmoidal nerve enters anterior [The detailed description of the cranial
ethmoidal canal. It supplies nerves is given in Chapter 47]
ethmoidal air sinuses, the lateral wall The ciliary ganglion is the peripheral parasym-
of nose and reaches the external nose pathetic ganglion associated with the ophthalmic
to supply the skin up to tip of nose as division of trigeminal nerve.
external nasal nerve. Location: The ciliary ganglion lies near the apex
Infratrochlear supplies lower eyelid of the orbit between the optic nerve and the
and skin of root of nose. lateral rectus muscle.
The frontal nerve enters orbit through lateral Roots:
part of superior orbital fissure. The sensory root is provided by the naso-
It passes forwards above the levator ciliary nerve.
palpebrae superioris and divides into two The sympathetic root is provided by the
branchesthe supra-trochlear and supra- plexus around the internal carotid artery.
The parasympathetic root is provided by the
orbital, that emerge at the orbital opening
nerve to the inferior oblique muscle.
to supply skin of forehead and scalp. This root carries preganglionic parasym-
c. The lacrimal nerve also enters the orbit via pathetic fibers that relay in the ganglion and
the lateral part of superior orbital fissure. post-ganglionic parasympathetic fibers arise.
It runs along the lateral wall of orbit and Branches: About twelve to sixteen short ciliary
gives. nerves arise from the ganglion in two bundles.
Glandular branch to lacrimal gland. The short ciliary nerves pierces the sclera
A palpebral branch to upper eyelid around the attachment of optic nerve.
It also receives a communicating branch These nerves carry
from the zygomatic nerve, that carries post The sensory fibers to the inferior of
ganglionic parasympathetic fibers for eyeball.
The sympathetic fibers to supply the blood
lacrimal gland.
vessels of the eyeball.
The optic nerve pierces the sclera about 3.0 Some sympathetic fibers also supply
mm medial to the posterior pole. the dilator pupillae muscle.
The nerve is about 4.0 cm long and c. The post ganglionic parasympathetic
passes backwards and medially to fibers supply the ciliary muscle, and
the optic canal. sphincter pupillae muscle.
CHAPTER 49
The Ears
The two ears lie on either side of skull. Each ear It separates the outer scaphoid fossa
consists of: from the inner, deeper concha.
An external ear The antihelix begins by two crura
A middle ear superiorly which enclose a triangular
An internal ear fossa.
THE EXTERNAL EAR c. The antitragus is a small tubercle at the
lower anterior end of antitragus.
The external ear consists of the pinna (auricle), The tragus is a triangular projection from the
the external acoustic meatus and the tympanic anterior part of pinna.
membrane.
It partially covers the external acoustic
A. The pinna lies on the lateral side of the head.
meatus and is separated from the
It collects the sound waves.
antitragus by intert-tragic notch.
The pinna is made up of a single piece of elastic
The lobule is the lower dependent part of
cartilage covered by perichondrium.
The parts of the pinna are (Fig. 49.1): pinna. It has no elastic cartilage and is
The helix is the rolled outer edge of pinna. It made up of fibrofatty tissue.
begins as crus at the bottom of concha. The lobule is used for piercing to put
A small tuberclethe Darwins some ornament in women.
tuberclemay be seen sometimes on the The blood supply of pinna is by:
helix. This represents the tip of the pinna. The arteries
The antihelix is another ridge that runs inside The posterior auricular branch
and parallel to the helix. externalcarotid artery.
The anterior auricular
branchessuperficial temporal artery.
The veins acompany the arteries. There are
many arterio-venous anastomoses in the
skin of the auricle.
The sensory nerve supply of the pinna is by:
Lateral surface
Lower third by greater auricular
nerveUpper two-third by auriculo-
temporal
nerve.
Medial surface
Upper third by lesser occipital nerve
Fig. 49.1: The pinna Lower two-third by greater
auricularnerve
The Ears 537
The Junctional skin with the scalp is The auricular branches of superficial
supplied by the auricular branch of temporal artery.
vagus (Arnoids nerve). The sensory nerve supply is by:
The extrinsic muscles of the auricle are small and The auriculo-temporal nerve (anterior and
rudimentary in humans. They are: superior walls).
The auricularis anterior arises from the lateral The auricular branch of vagus (posterior
edge of epicranial aponeurosis and is and inferior walls).
attached to the cranial surface of auricle. C. The tympanic membrane (eardrum) lies at
It is supplied by temporal branch of the medial end of external acoustic meatus.
facial. It draws the auricle forwards. The tympanic membrane is bent forwards so that
The auricularis superior is the largest. It also it makes an angle of 55 with the floor of
arises from epicranial aponeurosis and is external acoustic meatus.
attached to the cranial surface of auricle. On its central portion the umbo is handle of
It is also supplied by the temporal malleus attached on the inner surface.
branch of facial nerve and it elevates The tympanic membrane has two parts (Fig.
the auricle a little. 49.2):
The auricularis posterior is attached to the A small part superiorly that appears less
mastoid temporal bone and cranial surface tense called pars flaccida.
of auricle. The rest of the part is quite tense called pars
It is supplied by the posterior auricular tensa.
branch of facial nerve and it draws the Structure: The tympanic membrane consists of
auricle backward. three layers:
The intrinsic muscles of the auricle are very small An outer layer of cuticle developed from
and connect the different parts of the cartilage ectoderm.
of the pinna. A middle fibrous sheet developed from
They alter minimally the shape of the auricle. mesoderm.
The external acoustic meatus c. An inner epithelium derived from endoderm
It is a bent canal that leads from the bottom of The arterial supply is by:
concha of the auricle to the tympanic membrane. The posterior auricular artery (outer
Length is 2.4 mm from the bottom of concha, out surface).
of which the outer third, i.e. 8.0 mm is
cartilaginous, while the inner two-third, i.e.
16.0 mm is bony.
Direction: The outer third portion is directed
upwards and backwards and is lined by skin
containing hair follicles, sweat and sebaceous
glands secreting earwax (ceruminous glands).
The inner part is directed downwards and is
lined by epithelium having few hair and
glands.
The arterial supply is by:
The posterior auricular artery
The deep auricular branch of maxillary artery Fig. 49.2: The tympanic membrane
538 Essentials of Human Anatomy
The stylomastoid branch of posterior The floor is a thin palte of bone, that forms the
auricular artery and anterior tympanic roof of jugular fossa, that lodges the superior
branch of maxillary artery (inner surface). bulb of the internal jugular vein.
The sensory nerve supply: Near the medial wall, there is a tympanic
The outer surface is supplied by: canaliculus which transmits the tym-
Auriculo-temporal nerve panic branch of glosso-pharyngeal nerve.
Auricular-branch of vagus The lateral wall is formed by: (Fig 49.3)
The inner surface is supplied by: The medial surface of tympanic mem-
Tympanic branch of glosso-pharyngeal nerve brane.
The epitympanic recess lies above the
Applied Anatomy of the External Ear tympanic membrane.
The posterior and anterior canaliculus of
I. Otitis externa is infection in the external
chorda tympani. The chorda tympani
acoustic meatus. It is a very painful condition.
enters from the posterior canaliculus, runs
The perforation of the tympanic membrane may
along the lateral wall and then leaves
result from external trauma or middle ear
middle ear via the anterior canaliculus, that
infection (otitis media). opens below at the petro-tympanic
fissure.
THE MIDDLE EAR (TYMPANIC CAVITY)
IV. The medial wall is directed towards the
The tympanic cavity is a narrow, irregular, air- internal ear (Fig. 49.4).
filled space in the petrous temporal bone. The medial wall has:
Location: The middle ear is located between the The promontorya round eminence
tympanic membrane laterally and the internal caused by the first turn of cochlea.
ear medially. The oval window (fenestra vestibuli) is
Communication: The middle ear communicates: closed during life by the base of stapes.
Anteriorly via the auditory tube with the The round window (fenestra cochleae) is
nasopharynx. closed during life by the secondary
Posteriorly via the mastoid antrum with tympanic membrane, thar acts as a
mastoid aircells. terminal point for vibrations.
Size
Both antero-posterior and vertical diameters
are 15.0 mm.
The transvers diameter at roof is 6.0 mm
in the middle is 2.0 mm
at the floor is 4.0 mm
Boundaries: The middle ear has six boundaries a
roof, a floor, a lateral wall, a medial wall, an
anterior wall and a posterior wall.
The roof is formed by a plate of bone
tegmen tympanithat also roofs over the
mastoid antrum Fig. 49.3: The lateral wall of middle ear
The Ears 539
Fig. 49.4: The medial wall of middle ear Fig. 49.5: The ear ossicles
V. The anterior wall is very narrow and To its anterior process is attached
separates middle ear from the carotid canal. the anterior ligament.
It has two bony canals separated by a It forms incudo-malleolar joint a
bony shelf. saddle type of synovial joint
The upper canal is for tensor tym-pani with the incus.
muscle. The incus (anvil) has a body that
The lower canal is for bony auditory articulates with head of malleus.
tube. The short process is attached to the
VI. The posterior wall has fossa incudis in the posterior
An aditus, a wide opening that commu- wall of middle ear.
nicates with mastoid antrum. The long process articulates with the
A pyramid, a triangular hollow elevation apex of stapes at the incudo-
situated below aditus. stapedial jointa ball and socket
Fossa incudis near the lateral wall, that type of synovial joint.
lodges the short process of incus. c. The stapes (stirrup) consists of an
Contents of the middle ear are: apex and a neck followed by two
Air that equalises atmospheric pressure on limbs, that are attached to the foot-
deep surface of the tympanic membrane plate,
for its proper vibration. The foot plate is attached to the
The ear ossicles are threethe malleus, the oval window in medial wall of
incus and stapes. (Fig. 49.5) medial wall.
These ossicles are fully developed and The fusion or osteosclerosis
adult size at birth. between the foot plate of stapes
The malleus (hammer) has a handle and the oval window is most
attached to the deep surface of common cause of deafness in
tympanic membrane and a head that old age.
projects in the epitympanic recess. The ear muscles are twothe tensor tympani
The tensor tympani muscle is and the stapedius.
attached to the handle of malleus. a. The tensor tympani
540 Essentials of Human Anatomy
The condition, if not treated properly, A. The bony labirinth is composed of cochlea and
becomes chronic. the three semicircular canals. (Fig. 49.6)
The complications maybe: The bony labyrinth is filled up by a fluid called
The mastoiditis or infection of the perilymph.
mastoid air cells. Parts of bony labyrinth
Paralysis of the facial nerve due to 1. The cochlea is shaped like a snails shell with
involvement of facial nerve in its 23 4 turns, about a central modiolus.
bony canal. The cochlea has an osseous spiral lamina
c. Perforation of eardrum, that can only
projecting from the central modiolus.
heal if the infection is removed.
There are three canals enclosed with in
Surgical approach to the middle ear can be
the cochlea.
made through the mastoid antrum, that lies The upper one is scala vestibuli, which
15.0 mm deep to the supra-meatal triangle receives vibrations in the
in an adult. perilymph from the oval window.
THE AUDITORY TUBE
The lower one is scala tympani
connected with scala vestibuli at
[PHARYNGO-TYMPANIC TUBE]
the apex of cochleahelicotrema.
The auditory tube connects the middle ear with It is also filled with perilymph and
the lateral wall of nasopharynx. receives the vibrations from the
Lengthabout 36.0 mm (lateral 12.0 mm is bony, scala vestibuli.
while medial 24.0 mm is cartilaginous). The scala tympani ends at the
Coursethe auditory tube passes antero-medially secondary tympanic membrane
from the middle ear to the nasopharynx making fixed at the round window.
an angle of 45 with sagittal plane and 30 with c. The cochlear duct is the middle
the horizontal plane. canal filled with endolymph and is
The cartilage of the tube bulges in the located between the scala vestibuli
lateral wall of nasopharynx forming tubal
and scala tympani.
elevation above and behind the opening of
The vestibule is the central part of the bony
the auditory tube.
There is a small collection of lymphoid labyrinth that is connected:
tissue near the opening of the tube called
the tubal tonsil.
The salpingo-pharyngeus muscles arise from the
tubal elevation.
TerminationThe auditory tube opens in the
lateral wall of nasopharynx.
The senstive cells of the cristae are so turn of cochlea increasing to five rows at the
arranged that they are stimulated by the apex. These number about 25,000.
structural deformation caused by the The hairs of these cells project from the cells
vibrations in the contained endolymph. along a V or W-shaped line and their tips are
The nerve fibers carry these sensations to embedded in tectorial membrane.
the vestibular ganglion where the first The tectorial membrane is a ribbon the structure
neurons of vestibular pathway are consisting of gelatinous type of connective
located. tissue.
The axons of these neurons from the fibers The dendritic turnwals of primary sensory
the vestibular nerve. neurones are in synaptic contact with the hair
cells
ORGAN OF CORTI The supporting cellsare of two types
Organ of corti is the special receptor organ for The pillar cellsare arranged in two rows.
hearing located within cochlea Inner in outer on either side of tunnel of
It consists of corti.
Special sensory Hair cells The phalangeal cells afford intimate support
Supporting cells-pillar cells and phalangeal for the sensory cells.
cells. They are arranged in:
These cells are arranged on basilar membrane a single row of inner phalangeal cells
that is attached is the osseous special lamina. These to five rows of outer phalangeal
I. The Hair cellshave peculiar hair like cells.
projections from there free ends. The organ of corti is completed on the inner
There is single row of inner hair cells - (about side by border cells and on the outer side by cells
7000) and three rows of outer hair cells in basal of Hensen.
The Spinal Cord, Brain, Eyes and the
Ears
Multiple Choice Questions
Q.1. Select the one best response to each ques- Abducent nerve
tion from the four suggested answers: Trigeminal nerve
The subarachnoid space in the adult ends The extraocular muscle that turns the eyeball
below at the level of: upwards and laterally is:
The coccyx Superior oblique
Second sacral vertebra Superior rectus
Third sacral vertebra Inferior rectus
First lumbar vertebra Inferior oblique
The ligamentum denticulatum has the The artery that supplies the visual area of
following number of tooth processes: cortex is :
A. Twelve B. Thirty-one Anterior cerebral
C. Twenty-one D. Thirty-four Posterior cerebral
Middle cerebral
The internal vertebral venous plexus is found Internal carotid
in:
The facial nerve in its bony canal lies in the
The epidural space
following wall of middle ear:
The subdural space
A. Medial wall B. Lateral wall
The subarachnoid space C. Roof D. Floor
Outside vertebral canal
The cranial nerve that supplies sensory fibers to
The spinal cord, in adults, terminates at level of the middle ear is:
inter-vertebral disc between: Maxillary nerve
Twelfth thoracic and first lumbar vertibra Vestibulocochlear nerve
First lumbar and second lumbar vertebra Facial
Second and third lumbar vertebra Glossopharyngeal
Third and fourth lumbar vertebra
The Brocas area (motor speech center) is
The cerebrospinal fluid enters the venous located in the dominant hemisphere at:
blood stream at: Past central gyrus
Choroid plexus Precentral gyrus
Cisterna magna Inferior frontal gyrus
Subarachnoid veins Superior temporal gyrus
Arachnoid villi and granulations
The purkinje cells lie in the :
The cranial nerve that has dorsal attachment Red necleus
on brain stem is: Granular layer of cerebellar cortex
Trochlear nerve Molecular layer of cerebellar cortex
Oculomotor nerve Dentate nucleus of cerebellum
Multiple Choice Questions 545
The special visceral afferent (taste) nucleus in A cranial fracture passing through jugular
brain stem is: foramen will injure:
Nucleus of tractus solitarius Hypoglossal nerve
Vestibular nuclei Vagus nerve
Dorsal nucleus of vagus Facial nerve
Spinal nucleus of trigeminal Glosso-pharyngeal nerve
The intraocular muscle supplied by the The lateral geniculate body receives:
sympathetic fibers is: Ipsilateral temporal retinal fibers
Dilator pupillae Contralateral temporal retinal fiber
Sphincter pupillae Contralateral nasal retinal fibers
Ciliary muscle
Ipsilateral nasal retinal fibers
None of the above
The precentral gyrus of cerebral hemisphere: The superior colliculus of midbrain is:
Is sensory area Visual relay center
Receives visual impressions Visual association center
Receives auditory impressions Higher center of vision
Is primary motor area Visual reflex center
The photosensitive cells of the retina are: The cortico-spinal fibers occupy the following
Ganglion cells parts of the internal capsule:
Bipolar cells 1. Genu 2. Anterior limb
Rods and cones 3. Retrolentiform 4. Posterior limb
Pigment cells
The optic nerve is considered a tract of brain
Q.2. Each question below contains four because:
suggested answers, out of which one or It has three sheaths derived from the three
more are correct. Choose the answer: meninges of brain
If 1, 2, and 3 are correct It is attached to the forebrain
If 1 and 3 are correct Its fibers have no Schwann sheath
If 2 and 4 are correct Its fibers have no myelin sheath
If 1,2,3 and 4 are correct
If only 4 is correct The fold of dura mater that lies in the
longitudinal fissure of brain is:
The sensory nerve supply of the pinna (auricle)
is by: Falx cerebelli
Auriculo-temporal nerve Tentorium cerebelli
Greater auricular nerve Diaphragm sellae
Auricular branch of vagus Falx cerebri
Lesser occipital nerve The parts of middle ear that are adult size at
The lesion of oculomotor nerve leads to: birth are:
Ptosis Tympanic membrane
Lateral squint Internal ear
Dilatation of pupil Ear occicles
Diplopia Pinna
546 Essentials of Human Anatomy
Answers
A1. The answer is B. A3. The answer is A.
The subarachnoid space, between the The internal vertebral venous plexus lies in
arachnoid and pia mater ends below at the the epidural space between the vertebral canal
level of second sacral vertebra, where the and the spinal dura mater. The subdural space
dura and arachnoid mater also end. contains a very small amount of serous fluid
and subarachnoid space contains cerebro-
A2. The answer is C. spinal fluid and large spinal vessels.
The ligamentum denticulatum has twenty-one
A4. The answer is B.
tooth processes. The first tooth process is
The spinal cord, in adults, ends at the
attached to the margin of foramen magnum intervertebral disc between first lumbar and
above the first cervical nerve root. The tooth second lumbar vertebra. In infants, at birth,
processes are attached to the dural tube in it ends at level of intervertebral disc
between the nerve roots. The last tooth between third and fourth lumbar vertebra. It
process (the twenty-first) is attached between ascends up during childhood and by
twelfth thoracic and first lumbar nerve roots. puberty reaches adult level.
Multiple Choice Questions 547
The trigeminal nerve has somatic afferent Lateral rectus is supplied by the abducent
component nerve
The vestibulo-cochlear nerve has special
A30. The answers are C,B,D, and A
somatic afferent component
A spiral ganglion lies in the cochlea of
The glossopharyngeal nerve belongs to
internal ear
special visceral afferent component.
The geniculate ganglion lies on the facial
A28. The answers are A,B,D, and C nerve inside facial canal
The facial colliculus lies in pontine part of The optic disc in retina is the site where
floor of fourth ventricle optic nerve leaves the eyeball
The corpus callosum joins the medial The promontory is a round swelling in
surfaces of two cerebral hemispheres medial wall of middle ear, caused by
The olive forms an oval swelling on front the first turn of cochlea
of medulla oblongata
The red nucleus lies in tegmentum of upper A31. The answers are D,A,B, and C
parts of pons The lacrimal gland is supplied by the
A29. The answer are B,C,D, and A lacrimal branch of ophthalmic artery
The stapedius is supplied by the facial The internal ear is supplied by the
nerve labyrinthine arterya branch of basilar
The tensor tympani is supplied by the artery
mandibular nerve via nerve to medial The auditory area of cortex is supplied by
pterygoid and otic ganglion the middle cerebral artery
Sphincter pupillae is supplied by the para The lateral part of medulla oblongata is
sympathetic fibers carried by the oculo- supplied by the posterior inferior cere-
motor nerve bellar artery
Index
A B sesamoid bones 11
short bones 10
Accessory nerve 449 Basal nuclei 508 Bones of foot 125
Anal triangle 335 Blood cells of the thoracic wall 201 ossification of tarsal bones 127
anal canal 335 Blood vascular system 21 ossification of the metatarsals and
blood supply 365 clinical arteries 23 phalanges 127
considerations 337 functional end arteries 24 Bones of thorax 183
lymphatic drainage 336 structure 23 ribs 184
musculature 335 arterio-venous anastomosis 24 applied anatomy 187
nerve supply 336 capillaries 25 general features 184
clinical considerations 25 ossification 186
Anomalies of rotation of midgut
heart 21 special features 186
269
coronary circulation 22 sternum 183
Ansa cervicalis 434
fetal circulation 22 rate general features 183
Anterior abdominal wall 243 of contraction 22 ossification 184
applied anatomy 252 veins 24 special features 184
blood vessels 250 Blood vessels of the front of thoracic vertebrae 187
layers 244 neck 441 ossification 189
lymphatic drainage 251 Body of mandible 376 Bony pelvis 322
nerve supply 251 Bones 9 sex differences 324
rectus sheath 247 blood supply 12 shapes 323
bones and joints of epiphyseal and juxta- Branches of oculomotor nerve 520
abdominal wall 243 epiphyseal vessels 12 Bronchial tree 213 Bursae 20
joints of lumbar vertebrae 244 nutrient vessels 12
lumbar vertebrae 243 periosteal vessels 12 clinical considerations 20
characteristics 243 clinical considerations 12 function 20
ossification 244 functional considerations 11 types 20
variations 243 functions 9 articular bursa 20 inter-
lumbo-sacral joint 244 protection 9 tendinous bursa 20 sub-
Arteries of the gastrointestinal tract shape 9 cutaneous bursa 20 sub-
296 ossification 11 ligamentous bursa 20
branches 297 intra-cartilaginous type 11 sub-tendinosus bursa 20
intra-membranous type 11
common hepatic artery 297
structure 10 C
left gastric artery 297
inorganic content 10
splenic artery 297 superior Campers fascia 19
organic matrix 10
mesenteric artery osteocytes 10 Carpal bones 52
298 types 10 distal 52
coeliac axis artery 296 flat bones 10 capitate 52
Auditory tube 541 irregular bones 11 hamate 52
Autonomic nerves in the pelvis long bones 10 trapezium 52
334 pneumatic bones 11 trapezoid 52
552 Essentials of Human Anatomy
Female reproductive organs 359 patent ductus arteriosus 227 Hypoglossal nerve 450
ovaries 359 valvular defects 227 Hypothalamus 504
blood supply 359 blood supply 219 Hypothenar muscles 101
clinical considerations 360 arteries 219
lymphatic drainage 360 myocardial circulation 221 I
nerve supply 360 variations of the coronary
uterine tubes (fallopian tubes) arteries 220 Individual bones of skull 374
363 venous drainage 220 Infratemporal fossa 419
clinical considerations 364 borders of heart 218 Inguinal region 252
lymphatic drainage 364 external features 217 applied anatomy 255
nerve supply 364 interior of the chambers of descent of the testes 256
uterus 360 heart 222 applied anatomy 257
blood supply 361
inter-ventricular septum 226 sequence 256
clinical considerations 362
nerve supply 221 nerves 257
lymphatic drainage 362
structure of the heart 226 normal mechanism 253
nerve supply 362
sulci and fissures 218 sex difference 253
supports of the uterus 362
Hiltons law 15 walls of the inguinal canal 253
vagina 364
Hind-brain 492 Inlet of thorax 193
blood supply 365
brainstem 492 boundaries 193
lymphatic drainage 365
medulla oblongata 492 plane of inlet 193
nerve supply 365
internal structure 492 structures 193
Femur 117
pons 494 midlines structures 193
general features 117
internal structure 494 on left side 193
ossification 120
subdivisions 492 white on right side 193
special features 119
matter 493 Innermost intercostal 196
Fibula 122
Hip bone (innominate bone) 113 Interior of the skull 384
general features 122
Internal intercostal muscles 195
ossification 124 general features 113
Intestinal lymph duct 27
special features 123 ossification 116
Intrinsic muscles 194
Fontanelles of the skull 386 special features 115
Forebrain 502 Hip region 141
Fourth ventricle of brain 500 muscles of gluteal region 141 J
Frankfurts plane 371 blood vessels of gluteal region
Functional parts of nervous system Jejunum and the ileum 289
143
35 blood supply 290
lymphatic drainage of
postganglionic neuron 37 lymphatic drainage 290
gluteal region 144
somatic nervous system 35 nerve supply 290
relations of gluteus
somatic afferent part 35 applied anatomy 290
maximus 141
somatic efferent part 35 Joint 13
relations of gluteus amphiarthroses 13
visceral nervous system 36
medius 142 primary cartilaginous joint
visceral afferent part 36
relations of gluteus 13
visceral efferent system 36
minimus 142 secondary cartilaginous joint
nerves of the gluteal region 13
G 144 Humerus 46 blood supply 15
Glosso-pharyngeal nerve 447 general features 46 diarthroses (synovial joints) 14
ossification 48 nerve supply 15
H special features 48 synarthroses 13
Hyoid bone 388 Joint of bony pelvis 325
Heart 217 general features 388 pubic symphysis 326
applied anatomy 222, 227 ossification 389 sacro-coccygeal joint 326
dextrocardia 227 special features 389 sacro-iliac joint 326
554 Essentials of Human Anatomy
Joints of the head and neck 391 metatarso-phalangeal sterno-costal joints 191
atlanto-axial joints 393 atlanto- joints 138 xiphisternal joint 192
occipital joint 393 joints tarso-metatarsal joints 138
between cervical vertebrae subtalar joint 137 K
394 articular capsule 137
ligaments connecting axis articular surfaces 137 Kidneys 303
with occipital bone 394 ligaments 137 anterior surface 303
sutures of skull 394 temporo- movements 137 blood supply 306
mandibular joint 391 type 137 applied anatomy 307
Joints of the lower extremity 129 tibio-fibular joints 135 arteries 306
ankle (talo-crural) joint 134 applied arterial supply 136 lymphatic drainage 307
anatomy 135 ligaments 136 nerve supply 307
arterial supply 135 movements 136 veins 307
articular capsule 134 nerve supply 136 borders 303
articular surfaces 134 type 136 ends 303
ligaments 134 Joints of the upper extremity 55 general structure 305
movements 135 acromio-clavicular joint 55 hilum 304
nerve supply 135 movements 56 posterior surface 304
type 134 elbow joint 59 surfaces 303
arches of foot 139 applied anatomy 59
lateral longitudinal arch 139 nerve supply 59
medial longitudinal arch inter-carpal joints 62 L
139 transverse arches 140 mid-carpal joint 62
hip joints 129 lateral compartment 62 Large intestine 291
applied anatomy 131 medial compartment 62 cecum 291
articular capsule 129 movements 62 type 62 Lateral ventricle 513
articular surface 129 Left brancho-mediastinal lymph 27
ligaments 130 movements of shoulder girdle 58 Left jugular lymph duct 27
movements of joint 130 radiocarpal (wrist) joint 61 Left subclavian lymph duct 27
nerve supply 130 movements 62 Limbic system 516
stability of the joint 129 radio-ulnar joints 60 Liver (hepar) 279
synovial membrane 130 distal radio-ulnar 60 middle applied anatomy 282
knee joint 131 radio-ulnar joint 60 proximal bare areas 282 blood
applied anatomy 133 (superior) radio-ulnar supply 282 lobes of
articular capsule 131 joint 60 liver 281 location
articular surfaces 131 shoulder joint 56 279
attachments 131 small joints of the hand 63 nerve supply 282
ligaments of joint 131 carpo-metacarpal joints 63 segmentation of liver 281
menisci (semilunar cartilages) inter-phalangeal joints 64 surfaces and borders 279
of knee joint 132 metacarpo-phalangeal joints veins 282
movements 133 nerve 63 Lower extremity 113
supply 133 type 131 sterno-clavicular joint 55 features 113
Joints of thorax 189 Lumbar lymph duct 26
mid-tarsal joint 137 calcaneo- costochondral joints 191 Lumbricals 102 Lungs
cuboid joint 137 talo- costo-transverse joints 190 206
calcaneo-navicular joint costo-vertebral joints 189 blood vessels 211
137 interchondral joints 191 bronchial vessels 212
small joints of foot 138 inter- joints between thoracic vertebrae pulmonary vessels 211
phalangeal joints 139 192 broncho-pulmonary
inter-tarsal joints 138 applied anatomy 192 segments 211
Index 555
lobes of lung 210 descending thoracic aorta 233 Nerves of the pelvis 332
lymphatic drainage 212 esophagus 233 hemiazygos Nerves of the perineum 338
applied anatomy 213 veins 236 thoracic duct 235 Nervous system 29
nerve supply 213 functional classification 29
Lymph edema 28 superior mediastinum 228 autonomic nervous system 29
Lymph vessels 26 arch of aorta 230 somatic nervous system 29
lymph capillaries 26 brachiocephalic veins 230 functions 29
lymph ducts 26 phrenic nerves 231 parts 29
lymphatics 26 superior vena cava 229 central nervous system 29
Lymphatic drainage of the head vagus nerves 231 peripheral nervous system 29
and neck 447 Meninges of brain 486
Lymphatic drainage of the pelvic blood supply 487 O
organs 332 applied anatomy 489
Lymphatic organs 26 arteries 487 Organ of Corti 543
Lymphatic-venous communications veins of brain 490
27 Metacarpal bones 53 P
Mid-brain 495
white matter 497 Palm of the hand 97
M
Movements of respiration 199 blood vessels of the palm 100
Male reproductive organs 352 applied anatomy 200 arteries 100
testis 352 fracture of rib 201 veins 105
blood supply 353 pleural effusion 201 long flexor tendons in the palm
clinical considerations 354 pneumothorax 200 99
coverings 352 costal movements 199 four tendons of flexor
lymphatic drainage 354 forced costal expiration 200 digitorum profundus 99
nerve supply 354 forced costal inspiration 199 four tendons of flexor
structure 352 normal costal expiration 200 digitorum superficialis
veins 353 normal costal inspiration 199 99
Mammary gland 7 diaphragmatic expiration 200 tendon of palmaris longus 99
architecture 7 diaphragmatic inspiration 200 nerves 105
connective tissue stroma 7 Muscles 16 cutaneous branches 106
glandular 7 features 16 medial nerve 105
suspensory ligaments 7 skeletal muscles 16 Palmar interossei 103
blood supply 8 contraction 18 Pancreas 284
clinical importance 8 nerve supply 18 applied anatomy 286
development 8 parts 16 blood supply 286
anomalies 8 shapes 17 location 284
lymphatic drainage 8 types 18 nerve supply 286
nerve supply 7 Muscles connecting thoracic cage pancreatic ducts 286
Mastoid antrum 540 to vertebral column 196 parts 284
Maxillary nerve 424 serratus posterior inferior 197 type 284
Meckels of diverticulum 270 serratus posterior superior 196 Parasympathetic ganglia 425
Mediastinum 228 Muscles of front of neck 436 Parathyroid glands 440
anterior mediastinum 232 Muscles of mastication 420 Parotid gland 417
boundaries 232 applied anatomy 418
contents 232 N arterial supply 418
middle mediastinum 232 nerve supply 418
boundaries 232 Nerve supply of the thoracic wall parotid duct 418
contents 232 204 Patella (knee cap) 124
posterior mediastinum 232 Nerves of the front of neck 447 general features 124
azygos vein 236 Nerves of the palm 106 ossification 124
556 Essentials of Human Anatomy