Documente Academic
Documente Profesional
Documente Cultură
Human Anatomy
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Essentials of
Human Anatomy
BK Tandon
MBBS MS (ANATOMY)
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Former
Professor and Head, Department of Anatomy,
Maulana Azad Medical College, New Delhi, India
Professor of Anatomy, AI Fateh University, Tripoli, Libya
Professor and Head of Anatomy, AI Ameen Medical College, Bijapur, India
Professor and Head of Anatomy, BLDEAs Medical College, Bijapur, India
Professor and Head of Anatomy, Nepal Medical College, Kathmandu, Nepal
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Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
Corporate Office
4838/24, Ansari Road, Daryaganj, New Delhi 110 002, India, Phone: +91-11-43574357
Fax: +91-11-43574314
Registered Office
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Essentials of Human Anatomy
2009, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means:
electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of
material, but the publisher, printer and author will not be held responsible for any inadvertent error (s). In case of any dispute, all legal
matters are to be settled under Delhi jurisdiction only.
First Edition: 1995
Second Edition: 2009
ISBN 978-81-8448-720-6
Typeset at JPBMP typesetting unit
Printed at
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To
my dear wife
and darling daughters
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The second edition of Essentials of Human Anatomy is being released after a long waiting period.
The book is thoroughly revised in its contents and is being presented in a new format. However, the
main theme of the book i.e. presenting the basic facts of different structures and organs of human body
in a simple correlated manner in easily understandable language, is left untouched.
The unnecessary details and complicated descriptions are avoided so that studying facts of anatomy
becomes a pleasing experience.
Care has been taken to emphasize applied anatomy of structures wherever applicable.
Multiple choice questions (MCQs) with explanatory answers at the end of each section of the book
help in quick revision of the text.
Simple figures in each chapter further help in understanding the facts.
The study of anatomy of human body forms a basic prerequisite for not only medical students but
also for the students of dentistry, nursing, physiotherapy, and other paramedical subjects. The book will
prove a useful guide for them.
Hope the book in its revised edition will be helpful in learning the difficult subject of anatomy in an
interesting way.
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BK Tandon
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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:
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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.
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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.
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I hope that the book will be helpful in learning anatomy in an interesting way.
BK Tandon
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Acknowledgements
I am thankful to Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Duneja (DirectorPublishing), Mr SK Choudhary, Mr Ram Murti and Mrs Neeti Dobriyal of M/s Jaypee Brothers Medical
Publishers (P) Ltd. towards publishing this book.
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Contents
Section One: Introduction to Anatomy
1.
2.
3.
4.
5.
6.
7.
The
The
The
The
The
The
The
Basics ................................................................................................................................... 1
Skin and Its Appendages .................................................................................................. 4
Bones, Cartilages and Joints ............................................................................................ 9
Muscles and the Fasciae .................................................................................................. 16
Blood Vascular System .................................................................................................... 21
Lymphatic System ........................................................................................................... 26
Nervous System ............................................................................................................... 29
xiv
The Anterior Abdominal Wall and the Inguinal Region ................................................... 243
The Peritoneum ..................................................................................................................... 259
The Gastrointestinal System-1 ............................................................................................ 271
The Gastrointestinal System-2 ............................................................................................ 289
The Kidneys, Suprarenals and the Posterior Abdominal Wall ......................................... 303
The
The
The
The
The
Section Eight: The Spinal Cord, Brain, Eyes and the Ears
43.
44.
45.
46.
47.
48.
49.
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Introduction to
Anatomy
ONE
1
CHAPTER
The Basics
The term Anatomy is derived from Greek word
anatome (= cutting up). Anatomy, therefore, is the
study of structure of human body after dissection.
Human anatomy is the oldest medical science. The
first person to describe the structure of human body
was the Greek philosopher, Aristotle, nearly 2,300
years ago.
2.
3.
4.
5.
6.
7.
3. Medial-intermediate-lateral
Medial is nearer the median plane of the
body.
Intermediate is in between medial and lateral.
Lateral is away from the median plane of
the body.
4. Cranial-caudal
Cranial is towards the head end of the body.
Caudal is towards the lower end of the trunk
or cauda (tail)
These terms are used in cases of embryo
and fetus usually.
5. Proximal-distal
Proximal is closer to the median plane of
the body or the origin of the structure.
Distal is farther from the median plane of
the body or the origin of the structure.
6. Superficial-deep
Superficial (external) is closer to the surface
of the body.
Deep (internal) is farther from the surface
of the body.
7. Palmer-plantar
Palmer refers to the ventral aspect of the
hand.
Plantar refers to the sole of the foot.
8. Peripheral-central
Peripheral is away from the median plane
of the body.
Central is closer to the median plane of the
body.
THE TERMS RELATED TO THE
MOVEMENTS
The movements take place mostly at various joints
of the body and are responsible for changing
position of diferent parts of the body.
1. Flexion-extension takes place at the transverse
axis of the joint.
Flexion is the angular movement which
consists of bending at the joint.
Extension is the straightening movement,
whereby a joint is made straight.
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The Basics
2. Abduction-adduction takes place at an anteroposterior axis of the joint.
Abduction is the movement of the joint away
from the median plane of the body or a fixed
axis.
Adduction is the opposite movement
towards the median plane of the body or a
fixed axis.
3. Circumduction is combined movement of
flexionextension and abductionadduction
at a joint. This movement is possible only in
very mobile joints, e.g. shoulder joint and hip
joint.
4. Medial rotation-lateral rotation takes place at
the vertical axis of the joint.
Medial rotation consists of rotating the
ventral surface of the part towards the
median plane.
Lateral rotation consists of rotating the
ventral surface of the part away from the
median plane.
5. Elevation-depression
Elevation is the movement whereby the part
is raised towards the head end of the body.
Depression is the movement of lowering the
part towards the foot end of the body.
6. Protraction-retraction
Protraction is moving a joint or a structure
towards the front of the body.
Retraction is moving a joint or a structure
backwards.
7. Inversion-eversion
Inversion is the movement of rotating the
foot so that sole faces inwards.
Eversion is the movement of rotating the
foot so that the sole faces outwards.
These movements occur in relation to
the foot only.
8. Pronation-supination
Pronation is the movement of rotating the
forearm and hand so that the front of the
forearm and palm faces backwards.
Supination is the opposite movement of
rotating the forearm and hand so that the
front of the forearm and palm face
forwards.
These movements occur in relation to
the forearm and hand only.
Most of the anatomical names are derived
from the Latin and Greek languages. There are
nearly 5,000 terms in anatomy, which are used for
naming the structures. These terms were adopted
at a meeting of the German Anatomical Society,
held at Basle in the year 1895. Therefore, these
terms are called BNA (Basle Nomina Anatomica).
These terms are universally accepted all over the
world.
Subsequently, some revisions were made at the
Fifth International Congress of Anatomists held at
Oxford in the year 1950. In the meeting a new
body called International Anatomical Nomenclature
Committee has been formed for subsequent
revisions of terms.
CHAPTER
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Development
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CHAPTER
The Bones,
Cartilages and Joints
THE BONES
The bones of the body form the skeleton
(endoskeleton, as it lies deep to the muscles)
The skeleton can be divided into:
1. The axial skeleton consisting of the skull,
mandible, hyoid bone, vertebral column
(including sacrum and the coccyx), sternum
and the ribs.
2. The appendicular skeleton consisting of bones
of the upper and lower extremities.
The skeleton is bilaterally symmetrical and has
approximately 206 bones.
The axial skeleton has 80 bones as under:
The skull
Cranial bones
8
Facial skeleton (including mandable)
14
The ear ossicles
6
The hyoid bone
1
The vertebrae
26
7 Cervical
12 Thoracic
5 Lumbar
1 Sacrum
(Formed by fusion of 5 sacral vertebrae)
1 Coccyx
(formed by fusion of 4 coccygeal vertebrae)
The sternum
1
The ribs
24
Total
80
The appendicular skeleton has 126 bones as under:
1. The upper extremity
Scapula
1
Clavicle
Humerus
Radius
Ulna
Carpal bones
Metacarpals
Phalanges
1
1
1
1
8
5
14
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1
1
1
1
1
7
5
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Types of Bones
1. Long bones are present in the extremities.
They have a main part or shaft called
diaphysis.
The two ends form the epiphysis.
There is medullary cavity containing bone
marrow tissue in the shaft.
Examples: Femur, humerus.
2. Short bones are small size bones usually cuboidal
in shape.
Examples: Tarsals, Carpals.
3. Flat bones consist of two layers of compact
bone with spongy or cancellous bone in between
called diploe. They are expanded like a plate.
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Functional Considerations
The bone is a living tissue capable of growth and
repair.
The growth in length of the long bone takes
place at the epiphyseal cartilage, while the growth
in thickness (appositional growth) takes place deep
to the periosteum. The remodeling of the bone
takes place along with the growth of the bone. It is
done by the osteoclaststhe bone absorbing cells.
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The fracture of epiphyseal plate in developing bone is difficult to detect and it may
interfere with the subsequent growth of the
bone.
The fractures of bone may injure the nerves
and the blood vessels close to the bone.
The fracture of skull bones may result in
compression of the brain and injury to nerves
and blood vessels passing through the
foramina of the bone.
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CHAPTER
The Muscles
and the Fasciae
THE MUSCLES
Each skeletal muscle has at least two attachmentsorigin and insertionand a muscle belly.
1. Location
2. Histological
structure
Skeletal muscle
Visceral muscle
Cardiac muscle
In myocardium of heart
Muscle fibers branch and
anastomose
Faint transverse
striations
Intercalated discs present
Centrally placed nuclei
Autonomic nerves
Involuntary
Autonomic nerves
Involuntary
3. Nerve supply
4. Actions
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Property of rhythmic
contraction
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7. Bicipital where the muscle belly has two headsjoined by a common tendon.
Example: Biceps brachii.
8. Tricipital where the muscle belly is divided into
three heads, that are joined at the common
tendon of insertion (Fig. 4.1)
Example: Triceps brachii.
Types of the Skeletal Muscles
The skeletal muscles are also classified according
to their actions
1. The prime movers are the main muscles
responsible for a particular movement at a joint.
Example: Brachialis a prime flexor of
the elbow joint.
2. The antagonists are the muscles that are just
opposite in action to the prime movers.
Examples: Tricepsa prime extensor of the
elbow joint, is antagonist to the brachialis.
3. The synergists are the muscles which help in
the action of the prime movers by stabilizing
the intermediate joints or preventing unwanted
movements.
Examples: Long flexors of carpals that help
in action of long flexors of the fingers.
4. The fixators are those muscles which contract
isometrically to stabilize the attachment of the
prime movers, so that they may contract more
effectively.
Example:Scapular muscles fix the scapula,
so that deltoid can abduct the shoulder joint.
The Contraction of the Muscle
The contraction of the skeletal muscle may be.
a. Isometric contraction when muscle contracts
and exercises force without producing any
movement.
Example:Flexor muscles of the elbow joint
trying to lift a weight that is too heavy.
b. Isotonic contraction when a muscle shortens
to produce a movement.
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Electromyography
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Types of bursa
a. Sub-cutaneous bursa between the skin and
the bone.
Example: Prepatelar bursa of knee.
b. Sub-tendinosus bursa between the tendon
and the bone.
Example: Deep infra-patellar bursa of
knee
c. Sub-ligamentous bursa deep to the ligament
Example: Sub-acromial bursa of the
shoulder.
4. Inter-tendinous bursa between two or more
tendons.
Example: Inter-tendinous bursa between the
insertions of gracilis, sartorius and
semitendinosus on upper part of shaft of
tibia.
5. Articular bursa in relation to a joint.
Example: Sub-scapular bursa.
The synovial sheath is a synovial bursa that
surrounds a long tendon of a muscle.
It is a tubular sheath with double layers
enclosing a long tendon in relation to a joint.
a. The visceral layer adheres to the tendon
b. The parietal layer lies outside.
The two layers are separated by a small amount
of serous fluid, which lubricates the opposing
surfaces and thus prevents friction between the
tendon and the neighboring structures.
The two layers are continuous at certain places
to form mesotendons, which carry blood
vessels to the tendon for its nourishment. The
mesotendons are called vinculae in certain
situations, e.g. in long flexor tendons of fingers.
Clinical Considerations
1. Infection of bursa is called bursitis. This results
in swelling and pain in the bursa. Later it may
burst on the skin and form a sinus.
2. The synovial sheaths can also be involved in
infections. This leads to tenosynovitis with
collection of inflammatory fluid inside the
sheath. This condition also causes swelling and
pain.
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CHAPTER
The Blood
Vascular System
The blood vascular system includes
The heart
The blood vessels arteries, veins and
capillaries. There are two separate circulatory
cycles in the blood vascular system.
1. The pulmonary circulation in which venous
blood is pumped from the right ventricle of
heart to both the lungs for oxygenation, and
pure blood is returned to the left atrium of
the heart.
2. The systemic circulation in which pure blood
is pumped from the left ventricle of heart to
all parts of the body and venous blood is
returned to right atrium of heart (Fig. 5.1).
THE HEART
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THE ARTERIES
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THE CAPILLARIES
The capillaries are smallest blood vessels, that form
capillary plexuses in organs and tissues.
Their diameter is about 5 microns, i.e. just
sufficient for a single red blood cell to pass
through.
Their walls are lined by a single layer of
endothelium supported by a thin layer of
connective tissue. These two together form the
diffusion barrier of the capillaries.
Gaseous exchange occurs in the walls of the
alveoli of lungs through the diffusion barrier of
capillaries, due to pressure gradient.
The oxygen from the oxygenated blood diffuses
in the tissue spaces, while the carbon dioxide
from the tissue spaces diffuses into the blood,
to be carried to the lungs for oxygenation.
The nutrient fluid is also exchanged through
the diffusion barrier of the capillaries in the
tissues.
At the arterial end of the capillary plexuses the
blood pressure is higher than the tissue osmotic
pressure.
At the venous end of the capillary plexuses, the
blood pressure is less so that the tissue fluid
rich in metabolic waste products passes back
to the venous blood.
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Clinical Considerations
CHAPTER
The Lymphatic
System
The lymphatic system consists of:
1. The lymph vessels: lymph capillaries, lymphatics
and large lymph ducts.
2. The lymph nodes: that act as filters and produce
lymphocytes and plasma cells.
3. The lymphatic organs: Thymus gland, spleen,
tonsils and lymphoid collections in walls of
gastro-intestinal tract (e.g. Peyers patches
appendix). These are described in the respective
regions of body.
The lymph is a clear, colorless fluid from tissue
spaces at capillary plexuses.
The lymph is formed by the excess tissue fluid
in the tissue spaces, that is not taken up by the
venous end of the capillary plexus.
The lymph absorbs fat from the walls of the
intestines and is called chyle (milk) in that
situation.
Composition: The lymph resembles blood
plasma in composition. It contains lymphocytes
only.
The Lymph Vessels
The lymph capillaries begin blindly at tissue spaces
at capillary plexuses.
I. The lymph capillaries have wider lumen than
the blood capillaries.
They are irregular in their diameters.
Their walls are made up of a single layer of
endothelium.
The lymph capillaries are numerous in
The dermis of the skin
Serous surfaces
Mucous membrances
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CHAPTER
The Nervous
System
The nervous system is highly specialized system
of the human body.
FUNCTIONS
1. The nervous system helps in reacting to the
external environment through somatic part of
nervous system.
It receives impulses through sensory
receptors.
It functions consciously and subconsciously
through reflex arcs.
The motor component of somatic nervous
system regulates the motor activity of the
body, controlling the muscle action and the
secretion of glands.
2. The nervous system also controls and regulates
the activities of organs and systems of the body
through visceral nervous system.
It receives the afferent impulses from the
organs.
It controls the functions of internal organs
through its efferents.
3. The central nervous system is responsible for
all higher mental activities, which differentiate
man from other higher animals.
PARTS OF THE NERVOUS SYSTEM
The nervous system is bilaterally symmetrical and
is divided into:
1. The central nervous system (CNS) consists of
brain and spinal cord.
The CNS is center of reception and integration of all sensory impulses general
and special.
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The Brain
The brain is the largest part of the central nervous
system. It is divided into:
1. The forebrain has
I. A median part diencephalon made up
mainly by the thalamus and hypothalamus.
II. Two lateral cerebral hemispheresleft and
rightwhich together constitute the
cerebrum.
The forebrain is the largest and most
dominant part of the brain.
2. The midbrain (mesencephalon)
It is a short portion connecting the forebrain of
the hindbrain.
3. The hindbrain consists of
The cerebellum
Pons
Medulla oblongata (Fig. 7.1)
The brainstem is the straight portion that supports
the cerebrum above and gives attachment to
cerebellum behind. The brainstem is formed by:
The midbrain
Pons
Medulla oblongata
Average weight of the brain is about 1400 gm i.e.
nearly 2% of the total body weight. The brain is
heavier in the males.
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The Neuron
The neuron is the excitable cell of the nervous
system, that is concerned with reception,
transformation, integration and conduction of the
nerve impulse.
Parts of the neuron
1. The cell body (perikaryon) is the main part
of the cell.
2. The processes of the neuron:
a. The dendrites are the afferent processes,
which are usually multiple in a typical
neurone.
b. The axon is the efferent process, which
is usually single in a typical neurone.
Types of neurons
A. According to the shape:
1. Unipolar neuron (or pseudo-unipolar
neuron)
Example: Dorsal root ganglion cells of
the spinal cord.
2. Bipolar neuron
Example: Retina, olfactory cells.
3. Multipolar neuron
Example: Majority of cells in brain and
spinal cord (Fig. 7.2).
B. According to the functions:
1. The receptor neuron that receives the
afferent impulse from the receptor end
organs.
Example: Dorsal root ganglion cells of
the spinal cord.
2. The connector (inter-nuncial) neuron that
conducts impulse from the receptor
neuron to the effector neuron.
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ix.
x.
xi.
xii.
Glosso-pharyngeal
Vagus
Accessory
Hypoglossal
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Pelvic viscera
These fibers are connected with
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Introduction to Anatomy
Multiple Choice Questions
Q.1. Select the one best response to each question from the four suggested answers:
1. In the sympathetic system:
A. The connector neuron lies inside the
central nervous system
B. The postganglionic neuron is situated
close to the organ of supply
C. The white ramus communicans contains
the postganglionic sympathetic fibers
D. The grey ramus communicans contains
the preganglionic sympathetic fibers.
2. In the lymphatic system:
A. The lymph capillaries freely communicate
with the tissue spaces
B. The large lymph vessels contain many
valves
C. The right lymphatic duct is the largest
lymph duct in the body
D. The lymph must pass through one lymph
node before entering blood stream.
3. The superficial fascia:
A. Is a well-defined and definite layer of
connective tissue
B. Contains only elastic fibers
C. Gives shape to the muscles
D. Contains variable amount of fat.
4. The skeletal muscles:
A. Have at least two attachmentsone
relatively fixed and the other mobile
B. Contract very slowly
C. Have no sensory (proprioceptive) fibers
in their motor nerve
D. Possess great power of regeneration
5. The following vessels contain many valves:
A. Veins of the viscera
B. Lymphatics
C. Capillaries
D. Cerebral veins
Q.2. Each question below contains four suggested answers, of which one or more is
correct. Choose the answers:
A. If 1, 2, and 3 are correct
B. If 1 and 3 are correct
C. If 2 and 4 are correct
D. If only 4 is correct
E. If 1, 2, 3, and 4 are correct
6. The anatomical position of the body is the
position in which:
1. The body is standing erect
2. The arms are by the sides of the body
3. The eyes are looking straight forward
4. The feet are placed wide apart
7. The flexion movement at the shoulder joint
involves:
1. Taking the arm forwards and medially
2. Taking the arm straight forward
3. Taking the arm medially at right angles
to the glenoid fossa
4. Taking the arm away from the midline
8. The eversion of the foot:
1. Takes place at the ankle joint
2. Consists of raising the lateral border of
foot
3. Turns the sole of foot medially
4. Takes place at subtalar and midtarsal
joints
9. The lines of cleavage:
1. Are skin creases over the joints
2. Indicate the direction of elastic fibers in
the dermis of skin
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Answers
A1. The answer is A.
The sympathetic connector neuron lies inside
spinal cord. The postganglionic neuron lies
in sympathetic trunk or plexus. The WRC
has preganglionic and GRC has postganglionic
fibers.
A2. The answer is B.
The large lymph ducts have many valves to
help in conduction of lymph fluid. The lymph
capillaries begin blindly. Thoracic duct is the
largest lymph duct; and the lymph may not
pass through a lymph node before entering
blood stream.
A3. The answer is D.
The superficial fascia contains variable
amount of fat. It is not a well-defined layer
and contains both collagen and elastic fibers.
It does not give shape to the muscles.
A4. The answer is A.
The skeletal muscles have at least two
attachments. Their contraction is not very
slow. They have proprioceptive fibers in their
motor nerves. The skeletal muscles do not
have great power of regeneration.
A5. The answer is B.
Only the lymphatics have many valves to help
in conduction of lymph fluids. The veins of
viscera and cerebral veins and capillaries have
no valves.
A6. The answer is A, (1, 2, 3).
The anatomical position of the body is the
position when the body is standing erect with
arms by sides and eyes looking straight front.
The feet, however, are not wide apart.
A7. The answer is B, (1, 3).
The flexion at the shoulder joint involves
taking the arm forward and medially at right
angles to the glenoid fossa. It does not involve
taking arm straight forwards or away from
the midline.
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CHAPTER
THE SCAPULA
General Features
The scapula is a flat bone that lies on posterolateral aspect of upper part of thorax.
The scapula is a part of shoulder girdle.
It is triangular in shape. It has three angles
superior, inferior and lateral.
The scapula has three surfacesupper dorsal,
lower dorsal and costal.
It has three borderssuperior, medial and
lateral (Figs 8.1 and 8.2).
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The Angles
I. The superior angle lies at the level of second
thoracic spine.
II. The inferior angle lies at the level of seventh
thoracic spine.
III. The lateral angle is truncated to form the
shallow, pear-shaped glenoid fossa for
articulating with head of humerus.
The Surfaces
I. The upper dorsal surface lies above the spine
of scapula. It forms the supraspinous fossa
with superior surface of spine of scapula.
II. The lower dorsal surface lies below the spine
of scapula and forms the infraspinous fossa
with inferior surface of spine of scapula.
III. The costal surface is hollow and forms the
subscapular fossa.
It has ridges for attachment of intermuscular septa of subscapularis muscle.
The Borders
I. The superior border is very short. It has a
supra-scapular notch at the root of coracoid
process.
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Infra-spinous fossaInfra-spinatus
Medial border
Costal aspectSerratus anterior
Dorsal aspectLevator scapulae
Rhomboid major
Rhomboid minor
Infraspinatus tubercleLong head of
Triceps
Supraspinatus tubercleLong head of
Biceps brachii
Coracoid processMedial border-Pectoralis
minor
Tip
- Conjoint origin of
- Short head of Biceps brachii and
- Coracobrachialis
Spine and acromion
- Upper edge crest of, crest of spine
Trapezius
- Lateral border acromion and lower edge
of crest of spineMiddle part of Deltoid
Inferior angleA slip of latissimus dorsi
(dorsum)
Suprascapular notchInferior belly of
omohyoid
Ligaments attached to scapula
Lateral border of acromionCoraco-acromial ligament
Superior surface coracoid processTrapezoid part of coraco-clavicular ligament
Root of coracoid processConoid part of
Coraco-clavicular ligament
Inferior surface of coracoid process
Coraco-humeral ligament.
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
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Special Features
Muscles attached to clavicle:
Anterior border lateral 1/3rdDeltoid
Posterior border lateral 1/3rdTrapezius
Superior surface-medial 1/2Sterno-mastoid
(clavicular head)
Anterior surface medial 1/2Pectoralis
major
Posterior surface medial endSternohyoid
Subclavian grooveSubclavius
(on inferior surface)
Applied Anatomy
I. The clavicle helps in transmission of force
from the upper limb to the axial skeleton.
II. The clavicle is easily fractured at the junction
of lateral one-third and medial two-third, that
is, surgically the weak point of the bone.
THE HUMERUS
General Features
The humerus is the long bone of the arm.
It has an upper end, a shaft and a lower end.
1. The upper end of humerus has
a. The headwhich is less than half a sphere,
is covered with hyaline articular cartilage
and articulates with glenoid fossa at the
shoulder joint.
b. The lesser tubercle (tuberosity) is an elevation
on the front of upper end and shows an
impression for muscular attachment.
c. The greater tubercle (tuberosity) forms a
prominence on the lateral aspect of upper
end.
It shows three impressions for muscular
attachments.
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THE RADIUS
General Features
The radius is the lateral bone of the forearm. The
bone has a proximal end, a shaft and a distal end.
1. The proximal (upper) end of radius has a head,
neck, and a tuberosity.
The head of radius is cylindrical in shape
with a concavity on its superior aspect. The
head articulates with capitulum of lower end
of humerus.
The neck is slightly constricted part below
the head.
The tuberosity is rough posteriorly for
muscular attachment. Its anterior part is
smooth and is related to a bursa.
2. The shaft of radius is narrow above but it
broadens below. It is triangular in section.
The shaft has three surfacesanterior,
posterior and lateral.
i. The anterior surface reaches up to the
tuberosity from in front.
ii. The posterior surface also reaches up
to the tuberosity from behind.
iii. The lateral surface encroaches on the
anterior and posterior aspects of upper
part of shaft.
It has a rough impression for
muscular attachment about its middle.
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THE PHALANGES
There are two phalanges in the thumb and three in
other four fingers.
The phalanges are known as proximal, middle
and distal for the fingers. For thumb there are only
proximal and distal phalanges.
The phalanges are classified as short bones.
They have two ends and a short shaft, but have no
medullary cavity.
The phalanges form proximal and distal interphalangeal joints in fingers by their articulations.
In thumb there is only one inter-phalangeal joint.
Ossification of Bones of Hand
The carpal bones are cartilaginous at birth. Each
carpal is ossified by one center. The centers of
ossification appear as followes.
First yearcapitate, hamate
Third yeartriquetral
Fourth yearlunate
Fifth yearscaphoid, trapezium, trapezoid
Pisiformninth or tenth year
The metacarpals ossify by
One primary center for shaftappears eighth
week
One secondary center
For base in first metacarpals (appears third
year)
For heads in second to fifth metacarpals
(appears by third year)
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Movements
The movements occur at the joint, along with
movements of shoulder joint and of scapula.
The movements occur at two axes:
Elevation and depression
Protraction (forward movement) and
retraction (backward movement)
Circumduction occurs as combination of above
movements.
Applied anatomy:The dislocation of the joint,
is very rare as it is strengthened by strong
ligaments. Instead, fracture of clavicle occurs
more commonly.
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Thoraco-acromial artery
Movements: Some gliding movements take place
in the joint along with movements of scapula
and of sternoclavicular joint.
Ligaments
1. The coraco-acromial ligament is triangular
in shape and extends between the tip of
acromion and lateral border of coracoid
process.
This completes along with olecranon and
the coracoid process a secondary socket
for head of humerus.
2. The transverse humeral ligament bridges the
gap between the two tuberosities of
humerus, through which the long tendon
of biceps brachii passes.
3. The coraco-humeral ligament extends
between the inferior surface of coracoid
process and the two tuberosities of
humerus.
The rotator cuff (musculo-tendinous cuff) is
formed by the fusion of tendons of insertions
of the following muscles with articular capsule:
Subscapularis-anteriorly
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Teres major
Latissimus dorsi
Lateral rotation
Posterior part of deltoid
Infraspinatus
Teres minor
Applied anatomy
1. The dislocation of shoulder joint may take
place due to high mobility of the joint.
a. Anterior dislocation: The head of
humerus comes to lie below coracoid
process. It occurs due to weakness of
opening of subscapular bursa.
The labrum glenoidale may be injured
and axillary vein may also be
involved.
b. Inferior dislocation: The head of humerus comes to lie below glenoid fossa. It
occurs due to laxity of lower part of
capsule.
The axillary nerve and circumflex
humeral vessels may be injured.
2. Ankylosis of shoulder joint may take place
in old age with limitation of movements
accompanied by pain.
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Protractors are
Serratus anterior
Pectoralis minor
assisted by upper
part of latissimus
dorsi
Rectractors are
Rhomboid minor and major
Trapezius
3. Rotation of scapula takes place through an
antero-posterior axis between sterno-clavicular
and acromio-clavicular joints
Upward rotation is done by
Lower part of trapezius
Lower part of serratus anterior
Downward rotation is done by
Pectoralis minor
assisted by
Rhomboid minor
gravity
and major
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Ligaments
i. The medial collateral ligament is a strong
fan-shaped ligament having three bands
anterior, oblique and posterior.
The ligament is attached to
Medial epicondyle of humerus above
Medial margin of olecranon process
below
ii. The lateral collateral ligament reinforces
the joint on the lateral side
The ligament is attached to
Lateral epicondyle of humerus above
Annular ligament of radius below
(Fig. 9.4)
The nerve supply of the joint is by
i. The musculo-cutaneous nerve
ii. The radial nerve
iii. The median, ulnar and anterior interosseous
nerves also supply the joint.
The arterial supply is by an arterial anastomosis
around the elbow joint formed by the branches
of brachial, radial and ulnar arteries.
Movements are flexion and extension around a
transverse axis.
The flexors are
Brachialis
assisted by brachio Biceps brachii radialis and flexors of
forearm
The extensors are
Triceps
assisted by gravity and
Anconeus
extensors of forearm
Applied anatomy
i. The dislocation of elbow joint is rare, except
due to some external force.
ii. The tennis elbow is caused by the sprain of
lateral collateral ligament or by injury to
common extensor origin.
The condition may also be caused by
inflammation of bursa deep to triceps.
iii. The pulled elbow of little children is caused
due to traction of elbow leading to the head
of radius escaping from the annular
ligament.
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Ligaments
The Dorsal ligaments are stronger,
connecting the dorsal surfaces of
carpals and metacarpals.
The palmar ligaments are smaller and
cover the ventral aspects of the joints.
Movements: Slight movements take
place at these joints during movements
at metacarpo-phalangeal joints.
During hollowing of the palm
movements occur at these joints.
Muscles producing movements at the
first carpo-metacarpal joint
Flexion
Flexor pollicis longus
Flexor pollicis brevis
Extension
Extensor pollicis assisted by
longus
abductor
Extensor pollicis pollicis longus
brevis
Abduction
Abductor pollicis longus
Abductor pollicis brevis
Adduction: Adductor pollicis
Opposition: Opponens pollicis
2. The metacarpo-phalangeal joints
These joints are formed between
The heads of metacarpals
The bases of proximal phalanges
Type: Condyloid type of synovial joints
Articular capsule: Surrounds the joint on
all sides.
Ligaments
1. The collateral ligaments of the joints are
attached to sides of articulating bones.
These ligaments become tense in
flexed position and are relaxed in
extended position of fingers.
2. The deep transverse metacarpal
ligaments: They inter-connect the heads
of medial four metacarpals and prevent
their separation.
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Nerve supply is by
Medial pectoral nerve (C5,C6)
Lateral pectoral nerve (C 7, C 8, T 1 )
(Fig. 10.1)
Actions
1. The entire muscle acts as a powerful
adductor and medial rotator of upper
arm.
2. The clavicular part helps in flexion of
arm along with anterior fibers of deltoid
and coracobrachialis.
3. The sternocostal part helps in extension
of arm along with posterior fibers or
deltiod, latissimus dorsi and teres major.
4. The muscles helps in climbing by pulling
up the trunk.
5. The muscles also helps in deep inspiration.
Relations
Anteriorly
Skin, superficial fascia, platysma, supraclavicular nerves and mammary gland.
Deep fascia (pectoral fascia)
PosteriorlySternum, ribs, costal cartilages,
intercostal muscles
Clavipectoral fascia, pectoralis minor
and serratus anterior.
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Latissimus dorsi
Teres major
c. The medial wall is formed by
Serratus anterior covering upper part of
lateral thoracic wall.
d. The lateral wall is narrow and formed by
Shaft of humerus
Coraco-brachialis
Short head of biceps brachii
The apex is triangular and directed upwards and
medially towards root of neck. It is bounded by
Clavicle anteriorly
First rib medially
Upper border scapula posteriorly
The base of axilla is formed by axillary fascia
(Fig. 10.3).
Contents of the axilla are:
i. The axillary artery and its branches
ii. The axillary vein and its tributaries
iii. The three cords of brachial plexus and their
branches.
iv. The axillary lymph nodes
v. Fibrofatty tissue
vi. The axillary tail of mammary gland in
females.
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Musculo-cutaneous (C5,C6,C7)
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Origin
Anterior border and superior surface of
lateral third of clavicle (anterior part)
Lateral border of acromion (middle part)
Lower edge of crest of spine of scapula
(posterior part).
Muscle belly is thick, curved and triangular.
The anterior and posterior fibers converge
towards its tendon of insertion.
The middle part is multipennate. Four intermuscular septa descened from four tubercles
on acromion and interdigitate with three
septa ascending from deltoid tuberosity.
Insertionis on V-shaped, rough deltoid
tuberosity on middle of anterolateral surface of
shaft humerus.
Nerve supplyis by axillary nerve (C5, C6) (Fig.
10.6)
Actions
i. Anterior fibers help pectoralis major in
flexion and medial rotation of arm.
ii. Posterior fibers help latissimus dorsi and
teres major in extension and lateral rotation
of arm.
iii. The multipennate middle part is powerful
abductor of arm up to 90, assisted by
supraspinatus. During abduction, the
anterior and posterior fibers help to steady
the humerus.
Relations
Superficial
Skin, superficial fascia containing
platysma and lateral supraclavicular
nerve.
Deep fascia
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Deep
Coracoid, process, coraco-acromial ligament. Subacromial bursa
Tendons of biceps brachii, coracobrachialis.
Supraspinatus, infraspinatus, teres
minor.
Tendon of pectoralis major and long head
of triceps.
Axillary nerve and circumflex humeral
vessels.
Surgical neck, tuberositiesgreater and
lesserand upper part shaft of
humerus.
Anterior border is separated from pectoralis
major by infra-clavicular fossa containing
cephalic vein and deltoid branch of thoracoacromial artery.
Posterior borderoverlies infraspinatus and
triceps muscles.
Appllied anatomy
The deltoid muscle is paralyzed due to
an injury to axillary nerve.
In later stages, the muscle atrophies
leading to flattening of the shoulder.
The axillary nerve - (circumflex nerve)
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Name
Origin
3. Teres minor
4. Teres major
5. Subscapularis
Muscle belly
Insertion
Nerve supply
Muscle belly
coverages
towards the
greater tuberosity
of humerus
Muscle belly
converges to form
a tendon that
passes behind
shoulder joint
A narrow elongated muscle
belly
Supra scapular
(C5, C6)
Main actions
It initiates abduction
It helps to steady
head of humerus
(part of rotator cuff)
Middle facet of
Supra scapular
greater tuberosity (C5, C6)
of humerus
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Origin
Muscle belly
Insertion
Nerve supply
Trapezius
External occipital
protuberance
Medial one-third
of superior nuchal
line
Ligamentum nuchae
Spine of 7th cervical
vertebra
Spines of all twelve
thoracic vertebrae
and supra-spinous
ligaments
Latissimus
dorsi
Thoraco-dorsal
(C6, C7, C8)
Main actions
1. The muscle retracts the scapula
2. Upper fibers help
to elevate scapula
with levator
scapulae
3. Lower fibers
along with lower
part of serratus
anterior help in
rotation of scapula in overhead
abduction of arm.
4. Trapezius also
helps to steady
scapula during
movements of
shoulder joint
1. It helps in adduction extension
and medial rotation of arm
2. It also helps in
elevating trunk
during climbing
Contd...
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Contd...
Name
Origin
Lower three or
four ribs
Levator
scapulae
Rhomboid
minor
Rhomboid
major
Muscle belly
border of teres
major and forms
a tendon
Insertion
Nerve supply
Main actions
3. It also helps in
deep inspiration
and voluntary
expulsive efforts
1. It helps to elevate
Transverse proces The muscle belly Dorsal surface
C3, C4 VR
scapula with
ses of atlas and axis
descends to
medial border of Dorsal scapular (C5)
Posterior tubercles
superior angle
scapula between
trapezius
of transverse procesof scapula
superior angle and
2. It also helps to
ses of third and
root of spine
retract scapula
fourth cervical
with rhomboids
vertebrae
Lower part of
Slender muscle Base of the tria- Dorsal scapular
1. It helps to retract
the scapula
ligamentum nuchae
belly
ngular area at
(C5)
Spines of 7th
root of spine of
2. It also helps to
cervical and 1st
scapula
steady scapula
thoracic vertebrae
along with other
scapular muscles
Spines of 2nd to
Flat and thin
Dorsal surface
Dorsal scapular
1. It helps to retract
scapula
6th thoracic
belly, descends to medial border of (C5)
vertebrae and
medial border of
scapula from root
2. It also helps to
supraspinous
scapula
of spine to the
steady the scapula
ligaments
inferior angle
during movements at shoulder
joint.
CHAPTER
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Origin
Muscle belly
Insertion
Nerve supply
Main actions
Coracobrachialis
Tip of coracoid
process of scapula
(in conjunction with
short head of biceps
brachii)
Two heads of
origin
Short head from
tip of coracoid
along with
coracobrachialis
Long head from
supraglenoid
tubercle inside the
capsule of shoulder
joint
Lower half of
anterolateral and
anteromedial
surfaces of
humerus
Front of lateral
and medial
intermuscular
septa
Short, rounded
muscle belly
Impression on
middle of medial
border of humerus
Musculo-cutaneous
(C5, C6, C7)
Large, fusiform
muscle body
Flat tendon
attached to rough,
posterior part of
radial tuberosity
The tendon gives
a broad expansion
medially that
blends with deep
fascia of forearmbicipital aponeurosis
Coronoid process,
of ulna and ulnar
tuberosity
Musculo-cutaneous
(C5, C6)
separate branches
for two heads
1. The muscle is
powerful supinator of flexed
elbow
2. It also helps to
flex the elbow
3. The long head
helps to check
upward displacement of head of
humerus
Powerful flexor
of the elbow joint
Biceps
brachii
Brachialis
Muscle belly is
closely applied
to front of
humerus
Fibers converge to
form a thick
tendon
Musculo-cutaneous
(C5, C6)
Radial nerve (C7)
supplies a small
lateral part
The arteries
The brachial artery is the main arterial trunk of
upper extremity.
BeginningThe artery begins at the distal
border of teres major as continuation of axillary
artery.
CourseThe brachial artery proceeds distally
and lies medial to the shaft of humerus in upper
part of arm.
The artery gradually passes in front of
humerus in lower part of arm.
It is overlapped by biceps brachii muscle
and is separated from the elbow joint by
brachialis muscle.
TerminationThe brachial artery bifurcates into
radial and ulnar arteries, in the cubital fossa,
1.0 cm below elbow joint at level of neck of
radius.
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Applied Anatomy
1. The supra-condylar fracture of humerus may
injure the brachial artery as well as the median
nerve.
The traction of brachialis pulls the lower
segment of humerus forwards, thus injuring
the artery and the nerve.
2. The Volkmanns ischemic contracture results
from ischemia of forearm and hand due to
compression of main vessels.
The Veins
1. The superficial veins of the arm are
a. The cephalic vein lies in front of lateral
epicondyle of humerus and ascends upwards
along the lateral border of the arm.
It lies in delto-pectoral groove and
pierces the clavipectoral fascia to end in
the axillary vein.
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The Arteries
Muscle belly
The long head descends between teres minor
and teres major and then medial to the lateral
head and superficial to medial head.
The lateral head overlaps the medial head.
The medial head lies on a deeper plane.
All three heads join to form a common
tendon.
Subanconeus is formed by deep fibers of
medial head.
Insertion of tendon of triceps is on superior
surface of olecranon.
It is separated from articular capsule by a
bursa.
Subanconeus fibers are attached to fibrous
capsule.
Nerve Supply
Radial nerve gives separate branches to the three
heads.
Actions
1. Triceps is the main extensor of the elbow.
2. The long head supports the shoulder joint
from below, when the arm is raised.
3. The subanconeus (articularis cubiti) retracts
the fibrous capsule during extension.
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The Region
of Forearm
The region of forearm is divided into two
compartments:
An anterior or flexor compartment
A posterior or extensor compartment
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Name
Origin
Palmaris
longus
Medial epicondyle
by common flexor
origin
Muscle belly
Insertion
Nerve supply
Main actions
Muscle belly
Rough area on
crosses upper
middle of lateral
part forearm
surface of radius
and forms a flat
tendon
Median
(C5, C6)
Fusiform muscle
belly ends in
tendon in middle
of forearm
Tendon passes in
a groove of trapezium deep of
flexor retinaculum
Slender fusiform
muscle belly
Long tendon
passes superficial
to flexor rentinaculum
Two heads joined
by a fibrous arch
The muscle belly
is most medial
on front of forearm
Gives rise to a
tendon in lower
half of forearm
Palmar aspect
base of second
metacarpal
A slip to base of
third metacarpal
Median
(C6, C7)
1. It is a flexor of
wrist joint
2. It abducts the
hand
3. It is a weak flexor
of elbow joint
Palmar
aponeurosis
Median
(C7, C8)
1. It helps in flexion
of wrist joint
2. It is a tensor of
palmar aponeurosis
Pisiform bone
Insertion prolonged by pisohamate ligament
to hook of
hamate and pisometacarpal ligament to base
of fifth metacarpal
Ulnar
(C7, C8)
1. It is a flexor of
wrist joint
2. It helps in adduction of hand
3. It is a weak flexor
of elbow joint
Large muscle
belly lies deep to
other flexors
Divides into four
tendons
Two superficial
for middle and
ring fingers
Two deep for
index and little
fingers
Median
(C7, C8, T1)
1. If flexes middle
and proximal
phalanges of four
fingers
2. It also helps in
flexion at wrist
and elbow joints
Muscle belly is
unipennate
Tendon passes
Palmar aspect
base of first
metacarpal
Contd...
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Name
Flexor
digitorum
profundus
Origin
Muscle belly
ment of pronator
quadratus
Upper three-fourths
of anterior and
medial surfaces of
ulna
Front of interosseous membrane
of forearm
deep to flexor
retinaculum
Large muscle
Gives rise to
four tendons
that pass deep to
flexor retinaculum
at wrist
Insertion
Nerve supply
Main actions
Four tendons
Medial part ulnar 1.
reach four fingers Lateral partInserted on
anterior interosPalmar aspect base seous branch of
of distal phalanges
median (C8, T1)
2.
3.
Pronator
quadratus
Oblique ridge on
front of distal
part of ulna
1.
2.
in flexion of
wrist joint
It flexes distal
phalanges of
fingers after
flexion of middle
phalanges by
superficialis
It also helps in
flexion of metacarpo-phalangeal
joints of fingers
It also helps in
flexion of wrist
joint
It is the principal
pronator of forearm
It prevents separation of lower
ends of two bones
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Effects of injury
Paralysis of three thenar muscles,
which may give rise later to atrophy
of these muscles giving rise to Ape
hand.
Loss of skin sensation in lateral part
of palm and lateral three and half
digits.
B. The ulnar nerve arises from the ventral
division of ventral rami of C7, C8 and T1
spinal nerves and supplies flexor muscles
of forearm.
Course in anterior compartment
The ulnar nerve enters the anterior
compartment of forearm by passing
between two heads of flexor carpi
ulnaris, from back of medial epicondyle.
The nerve courses distally along the
medial border of forearm lying
between flexor carpi ulnaris and
flexor digitorum profundus.
The ulnar vessels lie lateral to the
nerve in lower two-third of front of
forearm.
The ulnar nerve, along with ulnar
vessels passes superficial to flexor
retinaculum and enters the palm.
Branches in anterior compartment
a. The muscular branches supply
Flexor carpi ulnaris
Flexor digitorum profundus
(medial part)
b. The cutaneous branches
The dorsal cutaneous branch
passes backwards to supply skin
of back of hand and medial one
and half fingers.
The palmar cutaneous branch
passes superficial to flexor retinaculum and supplies skin of medial
side of palm.
c. The articular branches supply
Radio-carpal joints
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Origin
Muscle belly
Insertion
Extensor
carpi radialis
longus
Extensor
carpi
radialis
brevis
Distal one-third
Muscle belly ends
lateral suprain a tendon at
condylar ridge
junction of upper
of humerus
third and middle
Lateral interthird of forearm
muscular septum
Lateral epicondyle
Muscle belly ends
by common extensor
in a tendon about
origin
middle of forearm
Nerve supply
Main actions
1. It helps in flexion
of elbow in mid
prone position
2. Acts as a shunt
muscle during
rapid flexion and
extension at
elbow
1. It acts as extensor of wrist
2. It helps to abduct
the hand
1. It acts as extensor
of wrist
2. It helps to abduct
the hand
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Name
Origin
Extensor
digitorum
Extensor
digiti
minimi
Lateral epicondyle
Slender muscle belly Dorsal digital exby common extensor gives rise to a long
pansion of little
origin
tendon
finger
Extensor
carpi
ulnaris
Lateral epicondyle
by common extensor origin
Common aponeurosis attached to
posterior border
to ulna
Posterior surface
of lateral epicondyles of humerus
Anconeus
Muscle belly
Insertion
of humerus
Radial collateral
ligament
Annular ligament
Supinator crest of
ulna and the depression in front of it
Abductor
Posterior surface
pollicis
upper part ulna
longus
Interosseous membrane
Middle third posterior
surface of radius
Extensor
Posterior surface radius
pollicis
distal to abductor
brevis
pollicis longus
Nerve supply
Tubercle on
medial side base
of fifth metatarsal
Lateral surface
Radial
alecranon
(C7, C8, T1)
Upper one-fourth
posterior surface
of ulna
Main actions
1. It extends interphalangeal and
metacarpo-phalangeal joints of
four fingers
2. It also helps in
extension of
wrist joint
1. It helps in extension of joints of
little finger
2. It also helps in
extension of
wrist joint
1. It acts as extensor
of wrist joint
2. It also helps in
adduction of hand
It helps in extension
of elbow joint
It supinates the
forearm assisted by
biceps brachii
Muscle belly ends Dorsi-lateral sur- Posterior interin a tendon above face base of proxi- osseous (C7, C8)
wrist
mal phalanx thumb
Extensor
pollicis
longus
Extensor
indicis
Posterior surface of
ulna distal to extensor pollicis longus
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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
Fig. 12.4: The deep extensor muscles of forearm
Applied Anatomy
Injury to radial nerve at elbow joint produces
Paralysis of all extensor muscles of forearm
leading to inability to extend radio-carpal joint
and the joints of the digits. This condition is
known as Wrist drop.
Loss of skin sensation along the lateral border
of dorsum of hand and lateral two and half (or
three and half) digits.
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13
The Region of
Wrist and Hand
The region of wrist and hand includes:
The dorsum of wrist and hand
The palm
THE DORSUM OF WRIST AND HAND
There are two fascial spaces on back of hand.
a. The dorsal subcutaneous space is limited by the
deep fascia extending on dorsum of hand along
with extensor tendons.
The skin on the dorsum of hand is freely
movable on underlying structures.
There is a rich lymphatic plexus in this space
that produces swelling on back of hand in
cases of infections of palm.
b. The dorsal sub-aponeurotic space lies between
the deep fascia on the dorsum of hand and the
extensor tendons.
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Applied Anatomy
Fibrosis and shortening of palmar aponeurosis may
result from infections of the palm. The condition
is known as Dupuytrens contracture.
The shortening is more severe on the ulnar side
of palm.
The fascial compartments of the palm.
The palm is divided into four fascial
compartments (Fig. 13.4).
A thenar compartment containing thenar
muscles
A hypothenar compartment containing
hypothenar muscles
An adductor compartment contains adductor
pollicis
A central compartment lies deep to palmar
aponeurosis and contains
a. The superficial palmar arch
b. The digital branches of median and ulnar
nerves
c. The long flexor tendons and their synovial
sheaths
The palmar spaces lie in deep portion of central
part of palm behind the synovial sheaths of long
flexor tendons.
There are two palmar spaces
i. The mid-palmar spaces
ii. The thenar space
The two spaces are separated by an intermediate septum attached to
The front of third metacarpal
The deep surface of synovial sheath of long
flexor tendons
The shape of both the spaces is triangular.
The two palmar spaces communicate with the
webs of fingers through the lumbrical canals,
formed by connective tissue around lumbrical
muscles.
Applied anatomy
The palmar spaces may be involved in the
infections of palm.
The spaces can be surgically approached at the
webs of fingers through the lumbrical canals.
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Origin
Muscle belly
Insertion
Abductor
pollicis
brevis
Flexor retinaculum
Tubercle of scaphoid
Flexor
pollicis
brevis
Distal border of
flexor retinaculum
Tubercule of
scaphoid
Opponens
pollicis
Crest of trapezium
Flexor retinaculum
Adductor
Pollicis
1. Obligue head
Capitate
Bases of second and
third metacarpal
2. Transverse head
Distal two-third
palmar aspect
third metacarpal
Nerve supply
Lateral border
and lateral half
palmar surface
first metacarpal
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Lateral terminal
branch median
(C8, T1)
V
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Main actions
It flexes metacarpal
and rotates it medially so thumb can be
opposed to fingers
and palm
It adducts thumb to
the side of palm
Name
9
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Origin
Muscle belly
Palmaris
brevis
Insertion
Flexor retinaculum
Thin, quadran- Skin on medial
Medial border of palgular muscle
border of hand
mar aponeurosis
belly
Covers proximal
part of hypothenar eminence
Abductor
Pisiform
Thin, lies along Ulnar side base
digiti
Tendon of flexor
medial side of
of proximal
minimi
carpi ulnaris and
hypothenar emiphalanx of little
piso-hamate
nence
finger
ligament
Flexor
Hook of hamate
Thin, lies lateral Ulnar side
digiti
Flexor retinaculum
to the abductor
base of proximal
minimi
digiti minimi
phalanx of little
finger
Opponens Hook of hamate
Triangular muscle Medial border
digiti minimi Flexor retinaculum
belly, lies deep to palmar surface of
abductor and
fifth metacarpal
flexor digiti
minimi
h
a
Nerve supply
Main actions
Superficial branch
ulnar (C8, T1)
It wrinkles skin on
medial side of palm
thus helping in
palmar grip
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Name
Origin
Muscle belly
Insertion
Nerve supply
Main actions
First
lumbrical
Slender and
unipennate
muscle belly
Lateral side of
dorsal digital
expansion of
index
Median
(C8, T1)
Second
lumbrical
Slender and
unipennate
muscle belly
Lateral side of
dorsal digital
expansion of
middle finger
Median
(C8, T1)
Flexion at metacarpophalangeal
and extension of
inter-phalangeal
joint of index finger
Same action on
middle finger
Deep branch
ulnar (C8, T1)
Same action on
little finger
Third
lumbrical
Fourth
lumbrical
Figs 13.7 A and B: (A) The palmar interossei (B) The dorsal interossei
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Origin
Muscle belly
Insertion
Nerve supply
Main actions
Small, slender
muscle belly
Deep branch
ulnar (C8, T1)
Third
Whole length palpalmar
mar surface fourth
interosseous
metacarpal
Small, slender
muscle belly
Fourth
Whole length
palmar
palmar surface
interosseous
fifth metacarpal
Small, slender
muscle belly
Small slender
muscle belly
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Same actions in
relation to little
finger
Name
Origin
Muscle belly
Adjacent sides
of first and second
metacarpals
h
a
Second
Adjacent sides of
dorsal
second and third
interosseous
metacarpal
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Adjacent sides of
third and fourth
metacarpal
Insertion
Nerve supply
Main actions
1. Abducts index
finger from neutral axis of middle
finger
2. Flexion at metacarpophalangeal
joints and extension at inter
phalangeal joints
of index
1. Lateral abduction
of middle finger
2. Same action on
middle finger
Deep branch
ulnar (C8, T1)
1. Medial abduction
middle finger
2. Same action on
middle finger
Deep branch
ulnar (C8, T1)
1. Abduction of
little finger
2. Same action on
ring finger
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C. Long thoracic
nerve
D. Median nerve
muscles:
A. Supra
supinatus
B. Biceps brachii
C. Flexor carpi
ulnaris
D. Flexor digitorum
profundus
Answers
A1. The answer is A.
The strong ligament that binds clavicle to the
upper limb is coraco-clavicular ligament. The
other ligaments are not so strong.
A2. The answer is A.
The ulnar nerve lies behind medial epicondyle
of humerus. The median and ulnar nerves
cross in front of elbow joint, the musculocutaneous nerve pierces deep fascia above
elbow joint and continues as lateral cutaneous
nerve of forearm.
A3. The answer is D.
The lunate bone has no muscular attachments.
Scaphoid gives attachment to thenar and hook
of hamate to hypothenar muscles, capitate
and trapezoid give attachment to oblique head
of adductor pollicis.
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The Lower
Extremity
Three
CHAPTER
14
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Special Features
[Important muscles and ligaments attached to the
box]
I. The ilium
Ventral segment of iliac crest
External oblique - (outer lip)
Internal oblique - (Intermediate area)
Transversus abdominis (inner lip)
Dorsal segment of iliac crest - Erector spinae
Dorsal surface between gluteal linesThe
three gluteal muscles - maximus, medius and
minimus.
Anterior superior iliac spine and upper half
of notch below itSartorius.
Anterior superior iliac spineLateral end
of inguinal ligament.
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III.The Pubis
Anterior surface of body - Adductor longus
Inferior ramus - lateral surface - Adductor
brevis
Ischio pubic ramus - Adductor part of
adductor magnus
Margins of obturator foramen
Lateral aspct - Obturator externus
Medial aspect - Obturator internus
Pectineal surface of body - Pectineus
Pubic tubercle - Medial end of Inguinal
ligament and cremaster muscle (in males
only)
Pubic crest and pectineal line - Conjoint
tendon.
Ossification
The hip bone ossifies from three primary centers:
One for ilium appears at eight week.
One for ischium appears at fourth month
One for pubis appears at fifth month
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THE FEMUR
General Features
The femur is the long bone of the thigh. It hasa
proximal end, a shaft and a distal end.
1. The Proximal end consists of head, neck greater
trochanter and lesser trochanter.
a. The head is approximately two-thirds of a
sphere
It is covered by hyaline articular cartilage
except at a depressionfovea
centralisthat gives attachment to
ligamentum teres of femur.
b. The neck joints the head to the shaft.
It makes an angle of nearly 125
(slightly less in females) with the shaft.
It is also turned forwards by about 15.
c. The greater trochanter is a quadrangular
projection on the lateral aspect of upper end.
It projects upwards and has three
surfaces.
An anterior surface
A lateral surface, that has a prominent oblique ridge on it.
A medial surface that has a
depression called trochanteric fossa.
The greater trochanter has a thick upper
border. It gives attachment to the gluteal
muscles.
d. The lesser trochanter is a small elevation on
the medial aspect, just distal to the junction
of neck with the shaft.
The trochanteric line is a slight ridge on
the anterior aspect of proximal end that
separates neck from the shaft.
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The trochanteric crest lies on the posterior aspect of proximal end, between the
two trochanters. It has a quadrate
tubercle in the upper part for muscular
attachment (Fig. 14.3).
2. The shaft of femur is covered anteriorly by the
extensor muscles.
a. The shaft has three surfacesanterior,
medial and lateral.
The anterior surfaceis smooth and
gently curved.
The medial surfaceis also smooth and
directed postero-medially.
The lateral surfaceis directed posterolaterally.
b. On posterior aspect of middle one-third of
shaft, there is a double ridge called linea
asperaa for muscular attachments.
The linea aspera has a medial lip that is
continuous above with spiral line. The
spiral line is joined proximally by intertrochanteric line.
The lateral lip of linea aspera is continuous above with a thick ridgegluteal
tuberosity.
Both medial and lateral lips of linea aspera
are continued below as medial and lateral
supra-condylar ridges.
Between the two supra-condylar ridges
below lies a triangular area on posterior
aspect of shaft known as popliteal
surface.
3. The distal end of femur consists of two condylesmedial and lateraland an articular
surface (Fig. 14.3).
i. The medial condyle projects distally and
medially. The exaggerated medial angulation
(more in females) causes knock-knee (genu
valgum).
The most salient point on medial condyle
is called medial epicondyle. This gives
attachment to the medial collateral
ligament of the knee point.
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THE TIBIA
General Features
The tibia is medial, stout and weight bearing bone
of the leg.
The tibia has a proximal end, a shaft and a distal
end.
I. The proximal endis expanded to form two
condylesmedial and lateralwhich articulate
with the two femoral condyles to form the
femoro-tibial part of the knee joint (Fig. 14.5).
a. The medial tibial condyleis concave both
in coronal plane and sagittal plane.
It is larger and semi-circular in outline.
b. The lateral tibial condyle is concave in
coronal plane but convex in sagittal plane.
It is smaller in diameter and nearly
circular in shape.
c. The inter condylar eminence lies between
the two tibial condyles.
It gives attachment to the medial and
lateral semilunar cartilages (menisci) of
the knee joint and the two cruciate
ligamentsanterior and posterior.
d. The tibial tuberositylies on the anterior
surface of upper end. It gives attachment
to the patellar ligament (ligamentum patellae)
Ossification
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Special Features
Ossification
Nutrient foramen
The nutrient foramen of tibia is present in
upper part of posterior surface below soleal
line.
The nutrient artery is a large branch of
posterior tibial artery.
THE FIBULA
General Feature
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The synovial membrane lines the nonarticular part of the neck of femur and
surrounds the ligamentum teres of head of
femur (Fig. 15.2).
The nerve supply is by:
i. Femoral: via nerve to rectus femoris.
ii. Obturator.
iii. Accessory obturator (if present).
iv. Nerve to quadratus femoris.
v. Superior gluteal.
The arterial supply is by:
i. The superior gluteal artery.
ii. The inferior gluteal artery.
iii. The obturator artery.
iv. The medial circumflex femoral artery.
Movements of the joint
The hip joint is a multiaxial joint, so the
movements are possible in more than two
axes.
Flexion and extension occur along a
transverse axis.
Abduction and adduction take place along
an antero-posterior axis.
Circumduction is combination of all
above movements.
Medial and lateral rotation occur along a
vertical axis.
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talus.
Articular capsule surrounds the joint on all sides.
It is attached to the margins of articular
surfaces of bones.
Ligaments
i. The medial collateral (Deltoid) ligament is
a strong triangular ligament on medial aspect
of the joint (Fig. 15.7).
Apex is attached to the tip of medial
malleolus.
Base or lower attachment.
The superficial fibers are attached
to
Sustentaculum tali of calcaneum.
Spring (calcaneo-navicular)
ligament.
Navicular.
Medial tubercle of talus.
The deep fibers are attached to
Medial surface of talus.
ii. The lateral collateral ligament consists of
three separate bands:
a. The anterior talo-fibular extends from
the tip of lateral malleolus to talus
anteriorly.
b. The posterior talo fibular extends from
the malleolar fossa of fibula to talus
posteriorly.
c. The calcaneo-fibular extends from the
tip of lateral malleolus to lateral surface
of calcaneum (Fig. 15.8).
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Applied anatomy
The flat foot is a condition, where the
arches are flattened due to weakness of its
supports.
The condition causes pain and discomfort
in walking and running.
Low arches of foot can be corrected to some
extent by specially designed shoes with builtin arch supports.
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16
Superficial
Skin
Superficial fascia containing plenty of fat
Origin
Muscle belly
Insertion
Largest muscle in
body
Thick quadrilateral
muscle belly
Dorsal surface of
sacrum and side of
coccyx
Sacro-tuberous ligament
Deep fascial covering
gluteus medius
2. Gluteus Posterior surface of
medius
ilium between posterior and middle
gluteal lines
Deep fascia covering
it
3. Gluteus Posterior surface of
minimus
ilium between middle
and inferior gluteal lines
4. Tensor Anterior 5 cm
fascialata of outer lip of
liac crest
Fan shaped
muscle belly
Fibers converge to
form a flat tendon
Short flat musde
belly
Nerve supply
Main actions
Antero-lateral
surface of greater
trochanter of
femur
Ilio-tibial
tract
Superior
gluteal
L5, S1
Superior
gluteal
142
Deep fascia
Deep
Bones - Ilium, sacrum and coccyx, ischial
tuberosity, greater trochanter.
Ligament
Sacro-tuberous ligament.
Muscles
Gluteus medius
Piriformis
Tendon of obturator internus
Gemelli-superior and inferior
Quadratus femoris
Attachments of semi-membranosus,
semi-tendinosus and biceps femoris.
Vessels and nerves
Superficial branch of superior gluteal
artery
Inferior gluteal artery and nerve
Sciatic nerve
Internal pudendal vessels
Pudendal nerve
Posterior cutaneous nerve of thigh
First perforating branch of profunda
femoris artery
Superficial
Skin, superficial fascia
Deep fascia
Overlapped by gluteus maximus
Deep
Gluteus minimus
Superior gluteal vessels
Superior gluteal nerve
Trochanteric bursa
Superficial
Gluteus medius
Deep
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2. Obturator
internus
3. Gemellus
superior
Gemellus
inferior
4. Obturator
externus
5. Quadratratus femoris
Origin
By three digitations
from front of middle
three pieces of sacrum
Upper margin of
greater sciatic notch
Pelvic surface of ilium
and margins of obturator foramen-Internal
surface of obturator
membrane
Dorsal aspect of
ischial spine
Ischial tuberosity
along lesser sciatic
notch
Outer surface of
pubic bone and margins of obturator
foramen
Outer surface of
obturator membrane
Upper part external
surface of ischial
tuberosity
Muscle belly
Tapering muscle belly
gives rise to a round
tendon
Insertion
Nerve supply
Upper border of
L5, S1, S2 VR
greater trochanter
of femur
Main actions
I. It rotates extended
thigh laterally
II. It abducts the
flexed thigh
Nerve to
obturator
internus
(L5, S1)
I. It rotates extended
thigh laterally
II. It abducts the
flexed thigh
Nerve to
obturator
internus
L5, S1
Nerve to quadratus femoris
L5, S1
It helps in action
of obturator internus
Posterior branch
of obturator
L5, L4
It laterally rotates
the hip joint
Quadrate tubercle
on trochanteric
crest of femur
It helps in action
of obturator
internus
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The Veins
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CHAPTER
17
The Region of
the Thigh
The region of the thigh includes:
A. The anterior compartment of thigh including
femoral triangle and adductor canal.
B. The medial compartment of the thigh.
C. The posterior compartment of the thigh.
D. The popliteal fossa at the back of knee.
THE ANTERIOR COMPARTMENT OF THE
THIGH (Table 17.1)
The muscles of the anterior compartment are:
I. Iliacus
II. Psoas major
Muscle belly
Insertion
Nerve supply
1. Iliacus
Name
Lesser trochanter
of femur For 2.5
cm below lesser
trochanter on
the shaft of femur
Summit of lesser
trochanter along
with iliacus
Femoral
(L2, L3)
2. Psoas
major
Base of patella
Insertion is carried
by ligamentum
patellae to the tuberosity of tibia
(patella being sesamoid bone) Medial
and lateral patellar
Femoral
L2, L3, L4
(Separate
branches are
given to the
four heads of
quadriceps
femoris)
3. Quadriceps
temoris
Ventral rami
L1, L2 from
lumbar plexus
Main actions
I. Powerful flexor of
hip joint with
psoas major
II. Helps to maintain
posture at hip joint
I. Same as iliacus
II. Helps to bend
trunk on lower
limb while getting
up.
III. Does not act as
medial rotator of
hip joint; rather
helps in lateral
rotation
I. Powerful extensor
of knee joint
II. Rectus femoris
helps in flexing of
of hip joint
III. Helps to maintain
posture at knee
joint
Contd...
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Contd...
Name
Origin
line
b. Vastus lateralis
Intertrochanteric line
Anterior and inferior
borders of greater trochanter Lateral lip of linea
aspera
Proximal half
lateral supracondylar
line
c. Vastus intermedius
Proximal two-third
anterior and lateral
surfaces of femur
d. Rectus femoris
I. Straight head-anterior inferior iliac spine
II. Reflected headgroove above acetabulum
4. Sartortus Anterior superior iliac
spine
Upper half of the
notch below it.
5. Psoas
From sides of
minor
12th thoracic and 1st
(absent Lumbar vertebra
in 40%
subjects)
Muscle belly
Insertion
Nerve supply
retinacula are expansions attached
to sides of patella
Some lower fibers
of vastus medialis
are directly attached
to medial border of
patella
Main actions
IV. Lowest fibers of
vastus medialis
stabilize patella
by preventing its
lateral displacement during
contraction of
quadriceps femoris
Pecten
pubes
VRL 1
I. Flexion and
abduction of hip
joint
II. It also helps in
lateral rotation of
hip joint.
III. It also helps in
flexion of knee
joint (The combination of these
movements helps
the tailor to work
his foot-operatedsewing machine.
1. Weak flexor of
trunk
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Boundaries
Lateral Medial border of sartorius
Medial Medial border of abductor longus
Apex lies below, where sartorius overlaps
adductor longus
Base Inguinal ligament
Floor (deep boundary) is formed by
Iliacus
Psoas major
Pectineus
Adductor longus
Roof (superficial boundary) is formed by
Skin, superficial fascia with superficial
inguinal lymph nodes.
Deep fascia (fascia lata) of thigh.
Contents
I. Arteries Femoral artery and its branches
Three superficial branches
Superficial external pudendal
Superficial epigastric
Superficial circumflex iliac
Deep external pudendal
Profunda femoris and its two branches
Lateral circumflex femoral
Medial circumflex femoral
II. Veins Femoral vein and its tributaries
III.Nerves
Femoral nerve and its branches
Part of lateral femoral cutaneous
Femoral branch of genito femoral nerve
IV. Deep inguinal lymph nodes
V. Fibro-fatty tissue
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CourseThe femoral branch of genitofemoral enters femoral triangle by descending inside femoral sheath lateral to the
femoral artery.
The nerve pierces anterior wall of rectus
sheath and deep fascia of front of thigh
It supplies skin of upper part of femoral
triangle.
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Origin
Muscle belly
Insertion
Nerve supply
Linea aspera
between vastus
medialis and
adductor magnus
Main actions
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156
Fig. 17.5: The muscles of gluteal region and posterior compartment of leg
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Origin
Muscle belly
Insertion
Nerve supply
Two heads
a. Long head arises from
lower medial area of
ischial tuberosity in
conjunction with semitendinosis
b. Short head from
lateral lip of aspera
Lateral surface
head of fibula
The tendon is
grooved by
fibular collateral ligament
Long head-tibial
Short headcommon peroneal L5, S1, S2
3. Semimembranosus
Groove on
Tibial
posterior
L5, S1,2
aspect medial
condyle of tibia
Two expansions
given from
insertion
a. Fascia convering popliteus
b. Oblique popliteal ligament
of knee joint
Main actions
I. It flexes the knee
joint
II. It helps in extension of hip joint
III. It helps in lateral
rotation of leg
I. It flexes the knee
joint
II. It helps in extension of hip joint
III. It helps in medial
rotation of leg
I. It flexes the knee
joint
II. It helps in extension of hip joint
III. It helps in medial
rotation of leg
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CHAPTER
18
The Region of
the Leg
The region of the leg is divided into three osseofascial compartment by the deep fascia of the leg
and two inter-muscular septa, anterior and
posterior:
1. The anterior (extensor) compartment
2. The lateral (peroneal) compartment
3. The posterior (flexor) compartment
THE ANTERIOR (EXTENSOR)
COMPARTMENT OF THE LEG
The Muscles of the Anterior
Compartment (Fig. 18.1 and Table 18.1)
I.
II.
III.
IV.
Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius
The arteries
A. The anterior tibial artery is the smaller
terminal branch of popliteal artery.
Beginning: The artery begins at the
lower border of popliteus, where the
popliteal artery bifurcates at back of the
knee.
Course: The anterior tibial artery enters
the anterior compartment by passing
through a gap at the upper border of
interosseous membrane.
It descends on the front of interosseous membrane of the leg along
with the deep peroneal nerve.
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Name
1. Tibialis
anterior
Origin
Proximal half or twothird of lateral surface
of tibia
Anterior surface of
interosseous membrane
Muscle belly
Muscle belly gives
rise to a tendon in
distal third of leg
2. Extensor
hallucis
longus
Insertion
Nerve supply
Medial surface
Deep peroneal
medial cuneiform (L4, L5)
and adjoining part
base of first metatarsal
Dorsal surface
base of distal
phalanx of big
toe
Deep peroneal
(L4, L5)
Main actions
I. It dorsiflexes and
inverts the foot
II. It helps in maintaining medial
longitudinal arch of
foot
I. It helps in dorsiflexion
II. It extends the
big toe
I. It dorsiflexes the
foot
II. It extends the
lateral four toes
I. It helps in dorsiflexion
II. It is evertor of
foot
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Branches
I. The muscular branches supply
Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius
II. The articular branch: supplies
The ankle joint.
Muscle belly
Insertion
1. Peroneus
longus
Name
Lateral side of
Superficial pero- I.
base of first meta- neal L5, S1, S2
tarsal and adjacent
II.
medial cuneiform
bone
III.
2. Peroneus
brevis
Lateral surface
base of fifth
metatarsal
Nerve supply
Superficial
peroneal
L5, S1, S2
Main actions
It is an evertor of
foot
It helps in plantar
flexion of foot
It supports and
helps to maintain
lateral longitudinal
arch and transverse arches of
foot
I. It is an evertor
of foot
II. It helps in plantar
flexion of foot
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The Arteries
The posterior tibial artery: is the larger terminal
branch of popliteal artery.
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Origin
Distal two-third of
posterior surface of
fibula
Interosseous membrane of leg
7. Tibialis
posterior
Muscle belly
Insertion
Nerve supply
Main actions
Tibial
S1, S2
Rudimentary
muscle
I. Acts with gastrocnemius
Tibial
S1, S2
I. Powerful plantar
flexor of foot
II. Action slow and
sustained
III. Helps to steady
leg on foot
Medial two-third
Tibial L4-L5 I. Unlocks knee joint
II. Rotates tibia mediof popliteal surand S1
face of tibia above
ally and femur
soleal line
laterally
III. Helps in flexion of
knee joint
The bipennate muscle Divides into four Tibial
I. Flexor of lateral
four toes
belly gives rise to a
tendons in sole for S2, S3
tendon that crosses
lateral four toes.
II. Helps in plantar
tibialis posterior and
Each is attached to
flexion of foot
passes behind medial
base of distal phamalleolus
lanx
Thicker bipennate
Receives a slip
Tibial
I. Flexor of big toe
II. Helps in plantar
muscle belly
from flexor digi- S2, S3
Gives rise to a tendon
torum longus in
flexion of foot
that grooves posterior sole
Helps to maintain
surface lower end, of
Inserted on base
medial longitudinal
tibia and enters sole
of distal phalanx
arch
of big toe
Bipennate muscle belly Superficial part Tibial L4-L5 I. Main invertor
Tendon grooves back
on tuberosity
of foot
of medial malleolus
of navicular
II. Helps in plantar
Deeper part
flexion of foot
sends slips to all
III. Helps in maintain
short bones of
medial longitudinal
tool except talus
arch of foot
and base of first
metatarsal
Muscle is attached
to fibrous capsule
A flat, triangular
muscle belly
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Tributaries
i. The superficial veins from the back
of the leg.
ii. The perforating veins that connect
the short saphenous vein with deep
veins of the leg.
iii. The communicating veins with the
long saphenous vein.
Applied anatomy
a. The varicose veins are dilated and
enlarged veins of the back of the leg.
These are caused by
The incompetence of valves in
the perforating veins which
allows venous blood from the
deep veins to enter the superficial
veins.
The venous stasis associated with
long periods of standing, that
reduces the efficiency of valves
and thus acts as a causative factor
for the varicose veins.
The varicose veins may give rise
to varicose ulcers.
The treatment consists of ligating
the perforating veins with
incompetent valves.
b. In bypass surgery, pieces of long
saphenous vein are utilized to replace
the arteriosclerosed and blocked
segments of coronary arteries.
B. The deep veins
A pair of venae comitants accompany the
posterior tibial artery.
These veins join with venae comitants of
anterior tibial artery at the lower border of popliteus
to form the popliteal vein.
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CHAPTER
19
The Region of
the Foot
The region of foot consists of
A. The dorsum of the foot
B. The plantar region or the sole
THE DORSUM OF THE FOOT
The Muscles and Tendons on
Dorsum of Foot
There is only one muscle on the dorsum of foot
extensor digitorum brevis.
The tendons of extensor muscles of the leg
diverge on the dorsum of foot to reach their insertions.
a. The extensor digitorum brevis
Origin: Anterior part of lateral surface of
calcaneum
Muscle belly: Thin, short muscle belly, lies
deep to the extensor tendons and divides
into four slips for medial four toes.
Insertion
First slip (extensor hallucis brevis) is
attached to the base of proximal phalanx
of big toe
Second, third, and fourth slips join the
lateral sides of tendons of extensor
digitorum longus to second, third, and
fourth toes.
Nerve supply lateral terminal branch of deep
peroneal nerve (S1,S2)
Actions Extension of phalanges of medial
four toes.
b. The extensor tendons
i. The tendon of tibialis anterior passes deep
to both superior and inferior extensor
retinacula and turns medially.
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Branches
i. The tarsal branchesmedial and lateral
that supply small joints of foot and extensor
digitorum brevis.
They anastomoses with anterior lateral
malleolar artery and perforating branch
of peroneal artery.
ii. The arcuate artery courses laterally across
the bases of metatarsals deep to the extensor
tendons.
It gives second, third, and fourth dorsal
metatarsal arteries, that passes distally
and divide at the web of the toes into
two dorsal digital arteries that supply the
sides of lateral four toes.
The dorsal metatarsal arteries are
connected:
a. To the plantar arch by proximal
perforating branches.
b. To the plantar metatarsal arteries by
the distal perforating branches.
iii. The first dorsal metatarsal artery arises from
the dorsalis pedis, just before it passes between the two heads of first dorsal interosseous muscle.
It divides into two dorsal digital branches
to supply the sides of first and second
toes.
The 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.
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Attachments
Proximally to medial tubercle of
calcaneum
Distally divides into five slips for five
toes. These slips become continuous
with fibrous flexor sheaths of the toes.
Functions
i. It covers and protects the deeper structures of the sole.
ii. It acts as a Tie Beam, and helps to
maintain the longitudinal arches of foot.
The Muscles of the Sole (Table 19.1)
The muscles of sole are arranged in four layers:
A. The first layer has three muscles
Abductor hallucis (Fig. 19.4)
Flexor digitorum brevis
Abductor digit minimi
B. The second layer has two muscles and two
tendons (Fig. 19.5)
The muscles are four lumbricals and flexor
digitorum accessorius
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Origin
A. First layer
1. Abductor Flexor retinaculum
hallucis
Medial tubercle
of calcaneum
2. Flexor
Medial tubercle of
digitorum calcaneum
brevis
3. Abductor
digiti
minimi
B. Second
layer
1. Flexor
digitorum
accessorius
2. The lumbrical
muscles
(Four
bellies)
C. Third layer
1. Flexor
Cuboid proximal to
hallucis
groove for peroneus
brevis
longus
-Lateral cuneiform
2. Adductor
hallucis
Muscle belly
Insertion
Nerve supply
Medial plantar
(S2, S3)
Medial plantar
(S2, S3)
Main actions
I. Abductor of big toe
from neutral axis
of second toe
I. Helps in flexion
of lateral four toes
Lateral plantar
S2, S3
I. Abductor of little
toe from neural
axis of second toe
Lateral plantar
(S2, S3)
I. It is a direct flexor
of lateral four toes
(by bringing flexor
digitorum longus
tendons in line
with toes.
On two sides of
Medial plantar
base of proximal (S2, S3)
phalanx of big toe
Two heads
a. Oblique head from
Two heads give rise to Lateral side of
Lateral plantar
bases of second to
two bellies, that join
base of proximal (deep branch)
fourth metatarsals
and are inserted tophalanx of big toe (S2, S3)
and sheath of pergether
oneus longus tendon
b. Transverse head from
plantar metatarso-phalangeal ligaments of
third to fifth toes.
Contd...
174
Contd...
Name
Muscle belly
Insertion
3. Flexor
Base of fifth metatarsal
digiti
minimi
brevis
D. Fourth layer
1. Dorsal
Adjacent sides of metainterossei tarsal bones
(Four
bellies)
2. Plantar
Bases and medial sides
interossei of third, fourth and
(three
fifth metatarsals
bellies)
Unipennate, slender
muscle bellies
Tendons pass on
medial sides of third,
fourth, and fifth toes
Origin
Bipennate muscle
Bases of proximal
bellies, fills up gaps
phalanges and dorbetween metasal digital expantarsals
sion of toes
A fibrous arch between First on medial
two heads at proximal Second and third
end of inter-metatarsals on lateral sides of
spaces
third toe
Fourth on lateral
side of fifth toe
Nerve supply
Main actions
I. Helps in flexion of
little toe
First, Second,
Third
Lateral plantar I.
(deep branch)
(S2, S3)
Fourth dorsal
II.
interosseous (by
superficial branch
lateral plantar)
III.
Abductors of toes
from neutral axis
of second toe
First and second
cause medial and
lateral abduction
of second toe
Flexion of metatarso-phalangeal
and extension of
inter-phalalangeal
joints
Medial sides bases First and
I. Adductors of third
and dorsal digital Second by
fourth and fifth
expansions of
lateral plantar
toes towards the
third, fourth, fifth (deep branch)
neutral axis of
toes
second toe
Third by lateral II. Flexor of metaplantar (supertarso-phalangeal
ficial branch)
and extensor of
(S2, S3)
inter-phalangeal
joint of third,
fourth, and fifth
toes.
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Branches
The digital branch to medial side of big
toe
The superficial digital branches, which
join the three plantar metatarsal branches
of the lateral plantar artery.
The superficial branches emerge along
medial border of plantar aponeurosis to
supply the skin of sole
Small muscular branches.
b. The lateral plantar artery is the larger terminal
branch of the posterior tibial artery.
Origin: The artery arises deep to flexor
retinaculum of ankle where the posterior
tibial artery divides.
176
Branches
Small muscular branches to the muscles
of the sole.
The superficial branches emerge along
lateral border of plantar aponeurosis to
supply the skin of sole.
Anastomotic branches join with
branches of lateral tarsal artery.
c. The plantar arterial arch is the arterial arch
placed deeply in the sole.
Formation: The plantar arch is formed by
The continuation of lateral plantar artery
The dorsalis pedis artery in first inter
metatarsal space.
Course: The arch lies across the bases of
metatarsal bones, superficial to the
interossei and deep to the adductor hallucis.
Branches
A plantar digital branch that supplies the
lateral side of little toe
Four plantar metatarsal arteries, that
divide to supply the sides of toes
(The first plantar metatarsal artery is
considered to be the branch of terminal part
of dorsalis pedis artery.)
The lateral three plantar metatarsal
arteries receive the three distal
perforating branches that join them with
dorsal metacarpal arteries
The three proximal perforating branches
pass through fibrous arches to second,
third and fourth dorsal interossous
muscles.
They join the plantar arch with dorsal metacarpal
arteries.
The Veins
The superficial veins of the sole form a plantar
cutaneous arch across the roots of toes.
The venous arch joins with medial and lateral
marginal veins.
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Branches
a. From the stem of the nerve
Muscular
Flexor digitorum accessorius
Abductor digiti minimi
Cutaneous
Skin of lateral side of sole
b. From the superficial branch
Muscular
Flexor digiti minimi brevis
Third plantar and fourth dorsal
interossei
Cutaneous two digital nerves that
supply
Skin of lateral one and half toes
c. From the deep branch
Muscular
Adductor hallucis
Medial two plantar interossei
Medial three dorsal interossei
Lateral three lumbricals
Articular to
Tarso metatarsal joints of the
foot.
C. Compression
D. Hyperflexion
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2. Tibialis posterior
3. Tendo-calcaneus
4. Calcaneo-navicular (spring) ligament
A. Superior tibiofibular
B. Inferior tibiofibular
180
C. Hip joint
D. Calcaneo-cuboid
joint
A. Sacral plexus
B. Femoral
C. Common peroneal
D. Tibial
Answers
A1. The answer is A.
The neck of femoral hernia lies at the femoral
ring. The deep inguinal ring is concerned with
oblique inguinal hernis. The obturator canal
gives passage to the obturator nerve and
vessels. The saphenous opening is defect in
deep fascia below inguinal, and femoral hernia
may bulge through it.
A2. The answer is D.
The main flexor of hip joint is iliopsoas. The
other three muscles pectineus adductor longus
and rectus femoris help in flexion of hip joint.
A3. The answer is C.
The two muscles inserted on iliotibial tract
are gluteus maximus and tensor fascia lata.
A4. The answer is B.
The upper lateral quadrant of gluteus
maximus is preferred for giving deep intramuscular injection, because no nerve or large
blood vessel lies deep here. Other quadrants
are related to nerves and blood vessels deep
to the muscle.
A5. The answer is A.
The superior gluteal nerve passes through
greater sciatic foramen. The obturator internus tendon comes out of lesser sciatic
foramen. The obturator externus and gluteus
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The Thorax
Four
CHAPTER
20
184
Ossification
Sternum is formed by fusion of two cartilaginous sternal plates. Incomplete fusion leads
to a sternal foramen.
Manubrium sterni ossifies from one to three
centers appearing in third to fifth month of
intrauterine life.
First and second pieces (sternebrae) ossify at
the same time by one center each.
Third and fourth pieces of sternum usually
ossify by two centers each that appear in fifth
and sixth months.
Xiphoid process ossifies by one center appearing
in third year.
The fusion of pieces of sternum begins at
puberty and is completed by twentyfifth year.
THE RIBS
General Features
There are twelve pairs of ribs in the thoracic cage.
The ribs are classified as:
a. The true ribs (vertebro-sternal) are first to
seventh. They articulate with sides of sternum
in front, through costal cartilages and sides of
thoracic vertebrae behind.
b. The false ribs are those which do not reach the
sides of sternum in front. The false ribs are
further subdivided as:
i. The vertebro-costal ribs ribs are eighth, ninth
and tenth. These articulate with next higher
cartilage in front and sides of thoracic
vertebrae behind.
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Ligaments
i. Radiate sterno-costal ligaments are attached
from front of costal cartilages to the
corresponding sternal surface.
ii. The intra-articular is present only between
second costal cartilages and the sternum,
where the joint cavity is divided by the
ligaments into two joints cavities.
iii. The costoxiphoid ligament connects the
front of seventh costal cartilage with
xiphisternum.
Movements
Slight gliding movements take place at the
sterno-costal joints during movements of ribs
in respiration.
192
fibrous
An inner nucleus pulposus
Applied Anatomy
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CHAPTER
21
The Musculature of
the Thoracic Wall
THE EXTRINSIC MUSCLES
These muscles are attached to the external surface
of thoracic cage. They help in the movements of
shoulder girdle, upper extremity and the neck.
Some of these muscles also help to a great
extent in the respiratory movements of thoracic
cage.
I. The pectoralis major connects medial half of
clavicle, upper six costal cartilages and front
of sternum to the lateral lip of bicipital groove
of humerus.
The muscle elevates upper six ribs during
forced inspiration.
II. The pectoralis minor connects third, fourth, and
fifth ribs to coracoid process of scapula.
It helps to elevate third, fourth, and fifth
ribs during deep inspiration.
III.The sterno-cleidomastoid muscle passes from
manubrium sterni and medial one-third of
clavicle to mastoid process and superior nuchal
line of skull.
It elevates manubrium sterni
IV. The scalene muscles
a. The scalenus anterior connects anterior
tubercles of transverse processes of third
to sixth cervical vertebrae to scalene
tubercle of first rib
b. The scalenus medius connects posterior
tubercles of transverse processes of second
to sixth cervical vertebrae to first rib
c. The scalenus posterior (when present)
connects posterior tubercles of transverse
processes of fifth and sixth cervical vertebrae to second rib.
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Attachments
UpperSharp inferior border of the rib
above
LowerOuter edge of thick superior border
of the rib below
Extent
AnteriorlyThe external intercostal extends
up to costo-chondral junction. It is replaced
in between the costal cartilages by anterior
(external) intercostal membrane
PosteriorlyThe muscle extends up to the
posterior end of the intercostal space.
Direction of fibersis downwards forwards
and medially in front of chest wall.
Nerve supplyis by the corresponding intercostal nerve (i.e. ventral ramus of thoracic
nerve)
ActionsElevation of the rib during inspiration.
195
Attachments
Upperthe floor of the costal groove of
the rib above
Lowermiddle part of thick superior border
of rib below
Extent
AnteriorlyThe muscle extends up to the
side of sternum
PosteriorlyIt extents up to the angle of
the rib, beyond that it is replaced by internal
(posterior) intercostal membrane
Direction of fibers is upwards, forwards and
medially in anterior part of chest wall, nearly at
right angles to the fibers of external intercostal
muscle.
Nerve supplyis by the corresponding intercostal nerve (ventral ramus of thoracic nerve).
Actions
i. The intra-cartilaginous part helps to elevate
the anterior ends of the rib.
ii. The rest of the muscle helps in depression
of the rib (Fig. 21.2).
Fig. 21.2: TS thoracic wall showing intercostal muscles and intercostal arteries
196
The Subcostalis
The subcostalis is a part of inner layer of intercostal
muscles, that is attached to posterior part of ribs
as digitations. The subcostalis is better developed
in lower part of thoracic cage.
Attachments
UpperInternal surface of one rib near its
angle
LowerInternal surface of second or third
rib below
Direction of fibersSame as internal intercostal
Nerve supplyis by corresponding intercostal
nerves
ActionsThe subcostalis depresses posterior
parts of ribs during expiration.
MUSCLES CONNECTING THORACIC
CAGE TO VERTEBRAL COLUMN
I. The Serratus Posterior Superior
It is a thin quadrilateral muscle covering upper
posterior part of thoracic cage.
Origin
Lower part of ligamentum nuchae
Spine of seventh cervical vertebrae
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Insertion
The muscular fibers from all sidesi.e. from
sternum, costal cartilages and the two crura,
ascend upwards and medially and are inserted
on Central tendona fibrous aponeurosis in
the center, from all sides.
Nerve supply
Motor fibers are supplied by two phrenic
nerves (C3, C4, C5)
Sensory (proprioceptive fibers)
For central portion by the phrenic nerves
For peripheral part of the lower five
intercostals and subcostals (T7 to T12
ventral rami)
Actions
i. The thoracic diaphragm is the main muscle
of inspiration. When it contracts, it descends
and increases the vertical diameter of
thoracic cavity.
ii. The diaphragm helps in all voluntary expulsive efforts, e.g. micturition, defecation,
coughing, sneezing, vomiting and parturition
(in females).
iii. The diaphragm helps to maintain and control
the intra-abdominal pressure.
iv. The fibers of right crus of diaphragm exercise a sphincteric control over esophageal
opening (Table 21.1).
Quadrangular
Inferior vena cava
Branches of right phrenic
nerve
Some lymphatics
5. Effect of conThe inferior vena caval
traction of
opening is dilated (venous
diaphragm
return takes place)
Elliptical
Esophagus
Anterior and posterior gastric nerves
Branches of left gastric artery
Esophageal opening is closed
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Course
The artery descends behind internal
jugular and right brachio-cephalic vein
to enter thoracic inlet behind first costal
cartilage.
As it enters thorax, the phrenic crosses
in front of the artery from lateral to
medial side.
The internal thoracic artery descends
deep to the upper six costal cartilages
and intercostal spaces, lying about
1.2 cm from side of sternum.
TerminationThe artery divides into its two
terminal branchessuperior epigastric and
musculophrenicin the sixth intercostal
space.
Branches
i. The pericardio-phrenic branch: A slender
artery that accompanies phrenic nerve
and after supplying pericardium supplies
the diaphgram.
ii. The mediastinal branches supply lymph
nodes and other structures in mediastinum
iii. The pericardial branches supply the
fibrous pericardium.
iv. The sternal branches supply the sternum
v. The paired anterior intercostal branchessuperior and inferiorfor upper
six intercostal spaces supply anterior part
of thoracic wall
vi. The perforating branches accompany
second to sixth intercostal nerves
In second, third and fourth spaces in
females the perforating branches are large
and supply the mammary gland.
vii. The superior epigastric artery enters the
rectus sheath in anterior abdominal wall,
between sternal and costal slips of orign
of diaphragm.
viii. The musculo-phrenic artery passes
between seventh and eighth costal slips
of diaphrarm and runs along costal
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iii.
iv.
v.
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Pulmonary artery
Superior pulmonary vein
Inferior pulmonary vein
Other smaller structures
One bronchial artery
Two bronchial veins
Sympathetic plexuses: (anterior and
posterior pulmonary plexuses)
Lymphatics and lymph nodes.
The left lung root has the following structures
(Fig. 22.4):
1. Left principal bronchus
2. Left pulmonary artery
3. Superior pulmonary vein
4. Inferior pulmonary vein
5. Other smaller structures
Two bronchial arteries
Two bronchial veins
Sympathetic plexus (anterior and posterior pulmonary plexuses)
Lymphatics and lymph nodes
The pulmonary ligament is the lower part of
the lung root, that extends from the lower part
of hilum to the mediastinum.
The pulmonary ligament
i. Supports the lung and firmly connects it to
the mediastinum.
ii. Provides dead space for the inferior pulmonary vein to expand.
The fissures of the lung
The right lung has two fissuresoblique and
transversethe left lung has only one fissure:
oblique fissure.
The oblique fissure begins at second
thoracic spine at the back, curves forwards
across the chest wall and reaches sternal
end of sixth costal cartilage.
On left side it is more vertical.
The transverse fissureis on front only. It
passes from sternal end of right fourth costal
cartilage to join the oblique fissure in midaxillary
line.
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8. Anterior basal
9. Lateral basal
10. Posterior basal
The broncho-pulmonary segments of the left
lung are (Fig. 22.7):
Upper lobe has five segments.
1. Apical
2. Posterior
3. Anterior
4. Superior lingular
5. Inferior lungular
Lower lobe has five segments
6. Superior basal
7. Medial basal
8. Anterior basal
9. Lateral basal
10. Posterior basal
In left lung, the apical and posterior segments
may be common forming apico-posterior
segment.
Similarly, the medial basal segment and anterior
basal segment of the left lung may form a
common medial-anterior segment.
Thus the left lung may have eight or nine
bronchopulmonary segments instead of ten
segments.
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Anteriorly
Arch of aorta
Three branches of arch of aorta
a. Brachiocephalic
b. Left common carotid
c. Left subclavian
Left branchiocephalic vein
Deep cardiac plexus
Manubrium sterni
Posteriorly:
Esophagus separating it from bodies of upper
four thoracic vertebrae.
The right primary bronchus is wider, shorter
(2.5 cm) and is more vertical than the left
primary bronchus.
The right bronchus divides into:
An eparterial (upper lobar) bronchus.
A hyparterial (middle and lower lobar
bronchus) before it enters the hilum of
right lung.
The foreign bodies are more likely to enter the
right bronchus because of its wider diameter
and it being more in line with trachea.
The left primary bronchus is narrower and
longer (5.0 cm). It arises at an angle with the
trachea at bifurcation.
The left primary bronchus enters the hilum of
left lung before dividing into lobar branches.
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External Features
The heart has an apex and a base (Fig. 23.3)
Three surfaces
Sterno costal
Diaphragmatic
Left surface
Four borders
Superior, inferior, right and left.
I. The apex of heart is formed by the left
ventricle. It lies in left fifth intercostal space,
about 9.0 cm from the median plane.
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CHAPTER
24
The Mediastinum
The mediastinum is the median septum or partition
that separates the two halves of thoracic cavity.
The mediastinum is a complete partition
extending from:
Sternum in front to
Bodies of thoracic vertebrae behind.
The mediastinum is divided by an imaginary
plane passing from sternal angle anteriorly to
the lower border of fourth thoracic vertebra
posteriorly into (Fig. 24.1).
i. Superior mediastinum
ii. Inferior mediastinum, which is further.
Subdivided into
a. Anterior mediastinum
b. Middle mediastinum
c. Posterior mediastinum.
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Boundaries
Anteriorly: anterior mediastinum separating
it from body of sternum.
Posteriorly: posterior mediastinum separating it from bodies of fifth to eighth
thoracic vertebrae.
Inferiorly: thoracic diaphragm
Two sides: right and left mediastinal pleurae
Contents
The heart
Lower half of superior vena cava
Ascending aorta
Pulmonary trunk
Pulmonary veinstwo for each lung
Arch of azygos vein
Fibrous pericardium containing
Right and left phrenic nerves with accompanying pericardio-phrenic vessels
Lymph nodes
Right and left bronchi.
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The Mediastinum
Upper right aortic intercostal arteries for
third, fourth, fifth, and sixth spaces.
c. Other structures
Three splanchnic nervesgreater, lesser
and loweston both sides
The mediastinal lymph nodes.
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The Esophagus
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The Thorax
Multiple Choice Questions
Q.1. Select the one best response to each
question from the four suggested answers:
1. The first chondro-sternal joint is:
A. Primary cartilaginous joint
B. Secondary cartilaginous joint
C. Fibrous joint
D. Synovial joint.
2. The sternal angle lies at the level of:
A. Upper border fourth thoracic vertebra
B. Lower border second thoracic vertebra
C. Lower border fourth thoracic vertebra
D. Lower border fifth thoracic vertebra.
3. The cervical rib arises as enlargement of:
A. Costal element of sixth cervical vertebra
B. Costal element of seventh cervical
vertebra
C. Transverse process of seventh cervical
vertebra
D. Transverse process of sixth cervical
vertebra
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Oblique vein of
left atrium
Ducts arteriosus
Infundibulum of
right ventricle
Coronary sinus
Answers
A1. The answer is A.
The first chondro-sternal joint is a primary
cartilaginous joint. The manubrio-sternal joint
is secondary cartilaginous joint. The second
to seventh chondro-sternal joints are synovial
joints.
A2. The answer is C.
The sternal angle lies at level of lower border
of fourth thoracic vertebra. The upper border
of manubrium sterni (suprasternal notch) lies
at level of lower border of second thoracic
vertebra.
A3. The answer is B.
The cervical rib is an anomalous rib, sometimes present, as an enlargement of costal
element of seventh cervical vertebra. It is
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The Abdomen
Five
CHAPTER
25
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Name
Origin
Muscle belly
2. Internal
oblique
(Fig. 25.2)
3. Transversus
abdominis
(Fig. 25.3)
Lateral two-third of
upper surface of
inguinal ligament
Anterior two-third intermediate ridge of ventral
segment of iliac crest
Thoraco-lumbar fascia
Insertion
Nerve supply
Contd...
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Contd...
Name
Origin
Muscle belly
2. Pyramidalis
(inconstant
muscle)
Insertion
Nerve supply
Ventral ramus of
twelfth thoracic
nerve
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Fig. 25.5: The rectus sheath (TS from costal margin to mid-point)
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Contents
i. The muscles
Rectus abdominis
Pyramidalis
ii. The vessels
Superior epigastric
Inferior epigastric
iii. The nerves parts of lower five intercostals
(T7-T11) and subcostal (T12) nerves.
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In case of portal obstruction this venous anastomosis between superficial veins of anterior
abdominal wall and paraumbilical veins enlarges
giving rise to caput medusae (enlarged tortuous
veins radiating from umbilicus).
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Applied Anatomy
A. The incisions of the anterior abdominal wall:
i. The midline incision through linea alba is done
sometimes, in emergency surgery of the
abdomen.
The healing of such incision is poor and
may produce mid-line ventral hernia.
ii. The paramedian incision (via rectus sheath).
After skin, the incision is made in anterior
wall of rectus sheath.
If rectus abdominis is well developed a
vertical incision is made in medial half
of the muscle (Rectus splitting procedure).
If rectus abdominis is poorly developed
the muscle is reflected laterally (Rectus
reflecting procedure).
Incision is made in posterior wall of
rectus sheath and parietal peritoneum to
open up the abdominal cavity.
This incision is preferred in abdominal
surgery.
iii. The lateral abdominal incisions are made,
sometimes taking into account the direction
of cleavage lines. McBurneys incision for
appendicectomy is made in right lower
quadrant of anterior abdominal wall. The three
oblique muscles are split in the direction of
their fibers to prevent weakness of abdominal
wall.
B. The hernias through anterior abdominal wall.
i. The epigastric hernia is midline hernia
through upper part of linea alba where fat
or some abdominal content comes out.
It is usually a postoperative complication.
ii. The umbilical hernias
a. The congenital umbilical hernia (exomphalos) is caused due to failure of
reduction of physiological umbilical
hernia of fetal life.
A child is born with a loop of intestine in the umbilical cord.
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i. Location
ii. Layer
iii. Shape and size
In
In
females
Round ligamentum of uterus
Artery to the round ligament
Nerve to the round ligament
Ilioinguinal nerve
External spermatic fascia
In
males
Spermatic cord
Cremasteric artery
Genital branch of genito-femoral nerve
In
females
Round ligament of uterus
Artery to the round ligament
Nerve to the round ligament
Fig. 25.8: A section through inguinal region showing walls of inguinal canal
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In the perineum.
At the root of penis.
Above the superficial inguinal ring in anterior
abdominal wall.
In front of upper part of thigh.
The ectopic testis is explained on the basis of
additional extensions of gubernaculum testis.
The Nerves of the Inguinal Region
a. The ilio-inguinal nerve is a branch of lumbar
plexus (ventral ramus of L1 nerve).
It passes through inguinal canal and comes
out of superficial inguinal ring lateral to the
spermatic cord (or round ligament of uterus).
It supplies
Skin of external genitals,
Skin of upper part medial side of
thigh.
b. The ilio-hypogastric nerve is also a branch of
lumbar plexus (ventral ramus of L1nerve).
It pierces external oblique aponeurosis
about 2.0 cm above superficial inguinal
ring.
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The Peritoneum
The abdominal cavity, more correctly called the
abdomino-pelvic cavity, is the largest cavity in the
body:
It is divided intoabdominal cavity proper and
the pelvic cavity.
The Abdominal Cavity
i.
ii.
iii.
iv.
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THE PERITONEUM
The peritoneum is the largest and most complex
serous sac in the body.
The peritoneum consists of two layersparietal
and visceralenclosing a potential cavity.
A. The parietal layer forms the inner lining of the
abdominal walls and diaphragm.
The layer develops from the somatopleure
part of secondary mesoderm.
B. The visceral layers covers the outer surface of
abdominal viscera partially or completely
It also forms peritoneal foldsmesenteriesto connect the viscera to the body
wall.
The visceral layer develops from the
splanchnopleure part of secondary mesoderm.
The Mesenteries
The mesenteries or folds of peritoneum suspend
parts of digestive tube from the body wall.
In the fetal life the developing digestive tube
has two mesenteriesventral mesentery up to
umbilicus and a dorsal mesenteryconnecting
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In adult, the meso-duodenum fuses
c.
d.
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f.
g.
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Fig. 26.2: A vertical section of abdomen showing lesser sac (omental bursa)
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Boundaries
Superiorly: Caudate process of liver.
Posteriorly: Parietal peritoneum covering
a short segment of inferior vena cava.
Anteriorly: Free right border of lesser
omentum containing bile duct, hepatic
artery and portal vein.
Inferiorly: Reflection of peritoneum
above head of pancreas from front of
inferior vena cava to posterior layer of
lesser omentum.
The epiploic foramen opens in the hepatorenal pouch (Morrisons pouch) of greater
sac of peritoneum.
The epiploic foramen may be a site of
internal hernia.
B. The greater sac of peritoneum is divided into
two compartments (Fig. 26.4):
A supracolic compartment
An infracolic compartment
A. The supracolic compartment is further divided
into the right and left subphrenic (subdiaphragmatic) spaces by the attachment of
falciform ligament of liver.
1. The right subphrenic spaces are three in
number:
i. The right anterior subphrenic space lies
between the diaphragm and right lobe
of liver.
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The Peritoneum
The left paracolic gutter communicates
below with the pelvic cavity.
The Peritoneal Recesses
The peritoneal recesses are small spaces of the
peritoneal cavity guarded by peritoneal folds, some
of which may contain blood vessels.
The peritoneal recesses may be site of internal
hernia when a small part of intestine may be
held up in one of them.
The omental bursa is the largest peritoneal
recess.
A. The duodenal recesses (Fig. 26.5)
i. The superior duodenal recess present in
about 50% cases. It is guarded by a small
fold attached to the left side of terminal
part of duodenum.
ii. The inferior duodenal recess present in
about 75% cases.
It is usually present along with the
superior recess.
It is also guarded by a small fold
attached to left side of terminal part
of duodenum.
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place between tenth and eleventh weeks of intrauterine life (Fig. 26.8).
The abdominal cavity grows larger in size, so
the physiological hernia is reduced.
The cranial (right) limb reduces first and passes
behind the superior mesenteric artery to come
to lie in the left upper quadrant. This explains
the position of jejunum in left upper part of
abdomen, and the superior mesenteric artery
passing in front of duodenum.
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The transverse attachment of transverse mesocolon on dorsal body wall divides the peritoneal
cavity into:
A supracolic compartment
An infracolic compartment
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Anomalies of Meckels of
Diverticulum (Fig. 26.10)
a. The diverticulum may be connected by a fibrous
cord to the umbilicus. Volvulus of small intestine
may occur with possible obstruction and strangulation.
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The Gastrointestinal
System1
The major part of gastrointestinal tract lies in the
abdominal cavity, along with associated glands. The
caudal part of foregut, midgut, and nearly entire
part of hind gut (except rectum and anal canal) lie
in the abdominal cavity.
ESOPHAGUS
The abdominal part of esophagus is very small,
only about 2 cm long.
The esophagus enters abdomen through
esophageal opening of diaphragm and ends in
the cardiac opening of stomach.
Relations
Anteriorly left lobe of liver.
Posteriorly the diaphragm.
Right border continues as the lesser curvature of stomach.
Left border is separated from the fundus of
stomach by a cardiac notch.
MusculatureThe lower third of esophagus
(including the abdominal part) has smooth or
plain muscle fibers in its walls.
SphincterThere is a functional sphincter
formed by the circular muscle fibers of abdominal part of esophagus.
The blood supply
The arteries supplying this part of esophagus
are derived from the left gastric artery
The veins end in the left gastric vein. There
is anastomosis between esophageal tributaries of left gastric vein and hemiazygos
vein in the submucous coat of abdominal
part of esophagus.
Thus abdominal part of esophagus is one
of the sites for porto-systemic anastomosis.
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The veins
The veins of the stomach, accompany the
arteries and end in portal vein or its main
tributariesthe splenic vein and superior
mesenteric vein.
The lymphatic drainage of stomach (Fig. 27.4)
The lymphatics generally follow the blood
vessels of the stomach.
The lymphatic areas are divided by an
imaginary plane, passing parallel to the
greater curvature, separating right two-third
area from left one-third area.
i. The left one-third area is further divided
into upper third and lower two third.
The left third of the left lymphatic
area drains into pancreatico-splenic
lymph nodes.
The lower two third of the left
lymphatic area drains into inferior
gastric group and subpyloric nodes.
ii. The right two third lymphatic area drains
into superior gastric nodes, present in
the lesser omentum.
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It is related posteriorly to
Bileduct
Gastro-duodenal artery
Portal vein
b. The second part (Descending part) is
7.5 cm long and is retro-peritoneal.
It is related
Anteriorly to
Right lobe of liver
Beginning of tranverse colon (no
peritoneum)
Coils of jejunum
Posteriorly to
Medial border of right kidney
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Caudate lobe
Fissure for ligamentum venosuma
deep fissurethat gives attachment to
two layers of lesser omentum.
Groove for esophagus is located just to
the left of upper end of fissure for
ligamentum venosum.
Left triangular ligament that connects the
left lobe of liver to the diaphragm.
iii. The right lateral surface is covered by
peritoneum and is gently convex.
It is related to right dome of diaphragm
that separates it from right lung, right
costo-diaphragmatic recess of pleura
and seventh to eleventh ribs.
iv. The superior surface is closely related to
the inferior surface of diaphragm.
It is convex on both sides, but shows in
the middle a depressioncardiac impression.
It is covered by peritoneum except
a small triangular area where the
two layers of falciform ligament
diverge.
v. The inferior (visceral) surface faces downwards and backwards. It is covered by
peritoneum except at porta hepatis, gall
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The veins
The hepatic veins (2-3) collect venous blood
from the central veins of the hepatic lobules.
The hepatic veins pierce the inferior vena caval
groove and open directly in inferior vena cava.
The lymphatic drainage of liver
The superficial lymphatics end in the lymph
nodes around terminal part of inferior vena
cava. Some open directly into thoracic duct.
The deep lymphatics are divided into two
groups.
Ascending trunks end in the lymph nodes
around inferior vena cava.
Descending trunks end in hepatic lymph
nodes.
The nerve supply of the liver
The nerve supply of liver is via the hepatic
plexus of nerves accompanying hepatic
artery, from the coeliac plexus.
The hepatic plexus carries both sympathetic
and parasympathetic fibers.
Applied anatomy
i. Hepatitis or inflammation of liver can occur
due to viral infection.
This condition can lead to jaundice due
to liver damage.
ii. Cancer of liverThe liver is a common site
for metastasis (or secondary deposit) of
cancer of some parts of digestive tract.
Primary carcinoma of liver is a rare
condition.
iii. Abscess of liver may occur due to amoebic
infection. The abscess can burst through
bare area of liver into lung.
iv. Regenerationthe liver has great power of
regeneration. After injury or operation a
portion of liver can be removed without
much damage to its functions.
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THE PANCREAS
The pancreas is lobulated greyish pink gland that
lies in the curvature of duodenum.
Type
The pancreas is mixed gland. It has
a. An exocrine part that secretes pancreatic
juice.
b. An endocrine part that secretes insulin
and other hormones.
LocationThe pancreas lies behind peritoneum
in upper part of posterior abdominal wall, at
back of epigastrium and left hypochondriac
region.
PartsThe pancreas hasa head, neck, body
and tail (Fig. 27.15).
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The Gastrointestinal
System2
THE JEJUNUM AND THE ILEUM
The jejunum and ileum constitute the large part of
small intestine extending from duodeno-jejunal
flexure up to junction of cecum and ascending
colon (Fig. 28.1 and Table 28.1)
Length about 6 metres (20 feet)
The jejunum constitutes proximal two-fifth
part (nearly 8 feet)
The ileum constitutes distal three-fifth part
(nearly 12 feet)
The mesentery The jejunum and ileum are
completely covered by peritoneum, and are
suspended by a large peritoneal foldthe
mesenteryfrom the posterior abdominal wall.
The root (attachment) of mesentery is
oblique and extends from duodeno-jejunal
1. Position in
abdominal
cavity
2. Diameter
3. Walls
Jejunum
Ileum
Mostly in upper
left portion
About 4.0 cm
Thick
Contd...
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Contd...
4. Color
5. Arterial
arcades
6. Vasa recta
7. Fat in
mesentery
8. Circular folds
9. Peyers
patches
(Aggregated
lymphoid
follicles)
10.Barium meal
X-ray
Jejunum
Ileum
Pale pink
Longer, about
2.5 cm long
Less-(windows)
Shorter, about
1.2 cm long
More
Well developed
Few
Incomplete
Many
Shows feathery
appearance and
narrow lumen
Shows dense
appearance
The arteries The jejunal and ileal arteries (1215) are branches of superior mesenteric artery.
These arteries reach the small intestine
between the two layers of mesentery
On approaching small intestine, the jejunal
and ileal arteries branch to form arterial
arcades
The arterial arcades are one to two in case
of jejunum and three to five in cases of
ileum. These arcades provide a route of
collateral circulation.
From the terminal arcades, vasa recta
(straight arteries) are given, that supply
alternately the right and left surfaces of the
intestine
The vasa recta are longer (2.5 cm) in
jejunum and shorter (1.2 cm) in case of
ileum
The vasa recta in the walls of intestine are
end arteries, and they have very few
anastomoses with adjacent arteries.
The veinsThe veins follow the pattern of
arterial supply
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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.
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It divides into two branches. The ascending branch anastomoses with left
branch of middle colic artery to supply
left one-third of transverse colon.
The descending branch forms a part of
marginal artery
ii. The signoid (inferior left colic) branches
(2-3) divide into ascending and descending
branches and complete the marginal artery.
These arteries supply descending colon
and the lower ones enter between the
two layers of pelvic mesocolon to supply
the sigmoid colon.
iii. The superior rectal artery is the continuation
of inferior mesenteric artery in the pelvis.
This artery has poor anastomosis with
the lowest sigmoid artery.
THE PORTAL VEIN
The portal vein belongs to the hepatic-portal venous
system that drains venous blood from
Abdominal part of gastro-intestinal tract (except
terminal part of anal canal)
The Spleen
The pancreas
The liver
The excretory apparatus of liver (gall bladder
and bile duct).
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THE KIDNEYS
The kidneys are a pair of essential organs of
excretion
They remove excess of water and waste
products of metabolism from the body.
The kidneys also perform endocrine function,
producing a number of hormones, e.g. renin,
that influences blood pressure and erythropoietin, that affects blood formation.
LocationThe kidney is located in lumbar
region on the posterior abdominal wall behind
peritoneum.
The upper pole lies at the level of 12th
thoracic vertebra. The lower pole lies at the
level of 3rd lumbar vertebra.
The hilum of kidney lies at the transpyloric
plane (lower border of 1st lumbar vertebra).
The right kidney lies a little lower due to
presence of liver on the right side.
The kidney is embedded in large amount of
prerenal and pararenal fat.
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Applied Anatomy
I. The renal calculus (stone) is formed in the renal
pelvis and may pass down the ureter to reach urinary
bladder.
The renal calculus may cause renal colic and
hematuria (bleeding along with urine)
The renal calculus, if not removed, may increase
in size and cause blockage to the passage of
urine leading to hydronephrosis and damage to
the kidney substance.
II. Mobile (floating) kidney may result due to
depletion of renal fat, which fixes the kidney to the
posterior abdominal wall
The renal fat is absorbed slowly in wasting
disease and prolonged starvation.
III. The intra-venous pyelography is a special
X-rays procedure done to visualize the urinary
passage and also assess kidney function.
A radiopaque medium is injected very slowly
intravenously
The dye is excreted by the kidney and concentrated in the urinary tract, thus visualizing it.
A series of X-ray are taken at intervals.
THE URETER
The ureters are two muscular tubes that conduct
urine by peristaltic movements from the renal pelvis
to the urinary bladder.
BeginningThe ureters begins from the lower
end of renal pelvis at the level of lower pole of
kidney (pelvi-ureteric junction).
Length25.0 cm
CourseThe ureter descends in front of psoas
major muscle along the tips of transverse
processes of lumbar vertebrae
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Applied Anatomy
The ureteric calculus: A small renal stone may be
lodged at one of the three constrictions in the course
of ureter.
This may lead to ureteric colic, referred to the
abdominal wall according to the part of ureter
where the stone is impacted:
a. From upper part obstruction, the pain is
referred to the region (T10-T12)
b. From middle part obstruction the pain is
referred to the inguinal and pubic regions
(L1)
c. From lower part obstruction the pain is
referred to the perineum or to the back of
thigh (S2, S3 and S4 segments)
The ureteric stone may lead to hydronephrosis
and consequent damage to the kidney.
THE SUPRARENAL (ADRENAL) GLANDS
The suprarenal glands are a pair of important
endocrine glands.
LocationThe suprarenal glands lie on the
upper pole of the kidneys in front of diaphragm
and behind peritoneum (Fig. 29.6).
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A single supra-renal vein comes out of hilum.
The right suprarenal vein ends in the inferior
vena cava.
The left suprarenal vein ends in the left renal
veins.
The Lymphatic Drainage of the Gland
The lymphatics of the suprarenal gland end in the
lateral aortic lymph nodes.
The Nerve Supply of the Gland
The supra renal cortex is controlled by the ACTH
(adreno-corticotropic hormone) secreted by the
anterior pituitary gland.
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The inferior vena cava is the great venous trunk
that collects venous blood from all parts of body
below diaphragm and takes it to right atrium of
heart.
BeginningThe inferior vena cava begins on
front of body of fifth lumbar vertebra by union
of the two common iliac veins-right and left.
The beginning is located to the right side of
the median plane.
CourseThe inferior vena cava ascends in front
of the lumbar vertebral bodies lying to the right
side of the abdominal aorta
The upper part of inferior vena cava bends
anteriorly and lies in a deep groove on the
posterior surface of right lobe of liver.
The inferior vena cava passes through the
opening in the central tendon of diaphragm
and ends in posterior part of right atrium of
heart.
Relation
Anteriorly
Right common iliac artery
Root of mesentery with superior mesenteric vessels
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Parietal peritoneum
Third part of duodenum
Right testicular (ovarian) vessels
Head of pancreas, bile duct, portal vein
First part of duodenum
Peritoneum of posterior wall of epiploic
foramen
Right lobe of liver
Posteriorly
Bodies of lower three lumbar vertebrae
Inter-vertebral discs
Right psoas major
Right sympathetic chain
Right crus of diaphragm
Right suprarenal gland
Right renal, suprarenal and inferior
phrenic arteries
Right side
Right ureter
Second part of duodenum
Medial border of right kidney
Right lobe of liver
Left side
Abdominal aorta
Right crus of diaphragm
Tributaries
The two common iliac veinsright and left
Third and fourth lumbar veins of both sides
Right testicular (ovarian) vein
Right supra-renal vein
Inferior phrenic veins
Renal veins
Two-three hepatic veins.
Applied anatomy
Thrombosis of the inferior vena cava is
usually partial and collateral circulation
develops by enlargement of both superficial
and deep veins.
The following superficial veins connect
the inferior vena cava to the superior
vena cava:
The epigastric veins
The lateral thoracic vein
The thoraco-epigastric vein
The posterior intercostal veins.
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The Abdomen
Multiple Choice Questions
Q1. Select the one best response to each
question from the four suggested answers:
1. The cremaster muscle in males is continuous
with the muscle fibers of:
A. External oblique
B. Internal oblique
C. Transversus abdominis
D. Rectus abdominis
2. The deep inguinal ring is the gap in the:
A. External oblique aponeurosis
B. Internal oblique aponeurosis
C. Transversus abdominis aponeurosis
D. Fascia transversalis
3. The dermatome at the level of umbilicus is:
A. T10
B. T11
C. T12
D. L1
4. The spleen lies inside abdominal cavity in the:
A. Left hypochondrium
B. Left lumbar region
C. Epigastrium
D. Partly in left hypochondrium and partly
in epigastrium
5. The portal vein is formed by the union of:
A. Superior mesenteric vein and inferior
mesenteric vein
B. Superior mesenteric and splenic vein
C. Splenic and inferior mesenteric veins
D. Splenic and short gastric veins
6. The normal capacity of gall bladder is:
A. 250 ml
B. 500 ml
C. 100 ml
D. 30-50 ml
7. The arteries supplying the fundus part of
greater curvature are:
A.
B.
C.
D.
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22. Arterial supply:
i. Coeliac axis
artery
ii. Superior
mesenteric artery
iii. Inferior mesenteric artery
iv. Inferior phrenic
artery
Gall bladder
Kidney
Ampulla of Vater
Liver
A. Splenic vein
B. Superior mesenteric vein
C. Left renal vein
D. Left branch of
portal vein
C. Thoracic part
of sympathetic
trunk
D. Superior hypogastric plexus
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Answers
A1. The answer is B.
The cremaster muscle is continuous with the
muscle fibers of internal oblique muscle. The
external oblique has a triangular gap above
pubic crestthe superficial inguinal ring. The
transversus abdominis forms the main part
of conjoint tendon. The rectus abdominis is
placed more medially.
A2. The answer is C.
The deep inguinal ring, is an oval gap 1.2 cm
above the mid-inguinal point in the fascia
transversalis. The lower margins of internal
oblique and the transversus abdominis leave
wider gaps above the inguinal ligament.
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The fundus part of greater curvature of stomach is supplied by the short gastric
arteriesbranches of splenic artery. The left
gastric artery lies along the lesser curvature
of stomach. The left gastro-epiploic artery
supplies lower part of greater curvature.
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The Pelvis
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The pelvic outlet is closed by the pelvic diaphragm formed mainly by two levator ani
muscles.
The pelvic diaphragm separates the cavity of
lesser pelvis from the ischio-rectal fossae.
The diameters of the pelvic outlet are:
i. The transverse diameter is the distance
between two ischial tuberosities.
This diameter is approximately as wide
as the clenched fist.
ii. The transverse mid-plane diameter is the
distance between two ischial spines.
The distance normally is 9.5 cm or
more; if it is less than 9.5 cm, the delivery
of the child may be difficult.
iii. The antero-posterior diameter is measured
from the lower margin of pubic symphysis
to the sacro-coccygeal joint.
The diameter is nearly 13.5 cm in adult
females.
The contents of the lesser pelvis are
Pelvic colon, rectum and upper part of anal
canal.
Urinary bladder, pelvic parts of two ureters.
In males, seminal vesicles, the two vas deferens
and the prostate gland.
In females uterus, the ovaries, the two uterine
tubes and upper part of vagina.
The diameters of bony pelvis are measured for
the inlet and the outlet. They helps to establish the
diagnosis of pelvic disproportions in females.
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Male pelvis
Female pelvis
1.
2.
3.
4.
5.
6.
7.
8.
9.
Less pronounced
Lighter
Gynaecoid type
Oval with transverse diameter more
Smaller part of a larger cone
Smaller
Shallower
80-85 (Nearly right angle)
Thinner and lightly built
10.
11.
12.
13.
14.
15.
16.
Ischial spines
Sacrum
Sacral promontory
Auricular surface
Sacral index (Ratio of Breadth: Length)
Diameters of pelvic inlet
Diameters of pelvic outlet
More pronounced
Heavier
Android type
Heart shaped
Larger part of a smaller cone
Larger
Deeper
50-60 (acute angle)
Thicker, bear an everted area
for attachment of crus of penis
Closer to each other
More evenly curved
More prominent
Larger
105%
Less in males
Less in males
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Variations
Sometimes sacrum may contain six vertebrae due
to an additional sacral element or by incorporation
of fifth lumbar vertebra, the condition is called the
sacralization of lumbar vertebrae.
Special Features
THE COCCYX
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Ossification
Each coccygeal segment is ossified by one primary
center.
The center for 1st segment appears at birth and
its cornua may ossify by separate centers
The other three segments of coccyx ossify by
centers which appear much later up to 20th
year.
The coccyx fuses with sacrum in old age
specially in females.
The Joints of the Bony Pelvis
Ossification
Ossification of sacrum resembles typical vertebra
Each sacral vertebra has
One primary center for body
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The ligaments of the pelvic organs are condensations of pelvic fascia around the neurovascular bundles of pelvic organs.
These ligaments play an important role in support
of pelvic organs; specially important for the
uterus and urinary bladder.
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pelvic wall.
Vesical branches to neck of the
urinary bladder, and seminal
vesicles and prostate gland in the
males.
h. The inferior gluteal artery is larger
terminal branch that comes out of greater
sciatic foremen and supplies gluteus
maximus muscle.
ii. The posterior trunk gives the following
branches:
a. The ilio-lumbar artery passes upwards
behind the external iliac vessels to reach
iliac fossa and divides into:
Iliac branches to supply iliacus
muscle.
Lumbar branches ascend to supply
psoas major, and quadratus lumborum. They anastomose with fourth
lumbar artery.
b. The lateral sacral branchessuperior
and inferiordivide into two branches
each. Thus superior one supplies
branches to first and second sacral
foramina; and inferior lateral sacral
artery gives branches to enter third and
fourth sacral foramina.
c. The superior gluteal artery is the largest
branch of internal iliac artery.
The artery leaves pelvis through
greater sciatic foramen above piriformis and enters gluteal region to
supply gluteal muscles.
d. Median sacral arteryrepresents
continuation of dorsal aorta in pelvis.
Origin: The artery arises from back of
abdominal aorta just above its bifurcation.
Course: The artery runs downwards in
median plane in front of sacrum accompanied by median sacral vein.
It ends on front of coccyx by joining
the glomus coccygeum
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The Perineum
The perineum is the lower end of the trunk, that
lies between the two ischial tuberosities.
The perineum covers the pelvic outlet and
extends from the pubic symphysis in front to
coccyx behind.
Parts: The perineum is divided by an imaginary
plane passing between two ischial tuberosities into:
i. Anal triangleposteriorly
ii. Urogenital triangleanteriorly
THE ANAL TRIANGLE
The anal triangle contains
The anal canal surrounded by external and
internal sphincters in median plane.
Two ischio-rectal fossae on either side of anal
canal containing pads of fat.
The Anal Canal
The anal canal is the last subdivision of the digestive
tube that opens at anus.
Location: It lies in median part of anal triangle
of perineum.
Direction : The anal canal is directed downwards
and backwards from lower end of rectum at
tip of coccyx up to anus.
Length 3.8 cm.
Relations
Anteriorly: Perineal body separating it from
bulb of penis in males and posterior vaginal
wall in females.
Posteriorly: Ano-coccygeal body and tip of
coccyx.
Laterally: ischio-rectal fossa
Parts: The anal canal is divided into three parts:
1. Upper endodermal part (about 15 mm) has
8-10 vertical folds of mucous membrane
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The Veins
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Clinical Considerations
1. The piles (Hemorrhoids)develop in cases of
portal obstruction, due to enlargement of the
venous plexus in the submucous coat, between
the tributaries of superior rectal and inferior
rectal veins.
The piles can be
a. Internal piles that develop in relation to
endodermal part only
b. External piles that develop below pectinate
line in relation to ectodermal part
c. Interno-external piles that are covered partly
by mucous epithelium of endodermal part
and partly by stratified squamous epithelium
of ectodermal part.
2. The anal fistula is an abnormal passage in anal
triangle, by side of anus, through which fecal
matter comes out.
The anal fistula may be formed by the
infection of anal glands, which open in anal
sinuses.
Sometimes, a neglected ischio-rectal
abscess may burst in wall of anal canal and
on the perineal skin forming anal fistula.
3. The anal fissure is caused by rupture of one of
the anal columns by hard fecal matter.
The fissure usually extends below the anal
column in the pecten or transitional zone,
and becomes very painful.
The Ischio-Rectal Fossa
The ischio-rectal fossa forms the lateral part of the
anal triangle.
It lies by the side of the anal canal.
Shapewedge shaped
Boundaries
Superior: Origin of levator ani from the
obturator fascia.
Inferior: Perianal skin
Medial:
External anal sphincter
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by pelvic fascia.
Lateral:
Ischial tuberosity
Obturator fascia covering obturator
internus muscle.
Pudendal canal (Alcocks canal) lies
in the lateral wall.
Anterior: Posterior border of urogenital
diaphragm.
Posterior:
Posterior border of gluteus maximus
Sacro-tuberous ligament.
The two ischio-rectal fossae communicate with each other behind the anal
canal.
Contents
1. Ischio-rectal pad of fat that supports the
anal canal.
2. Inferior rectal nervea branch of
pudendal nerve. Its motor fibers supply
external anal sphincter. Its sensory fibers
supply ectodermal part of anal canal and
perianal skin.
3. Inferior rectal vessels that are branches
from the internal pudendal vessels.
4. Perineal branch of fourth sacral nerve
that enters ischiorectal fossa between
coccyges and levator ani.
It supplies external anal sphincter,
levator ani and coccyges. It also
supplies the skin between anus and
coccyx.
Clinical Considerations
The ischio-rectal abscess is a very painful condition.
A large abscess may extend to the opposite side
behind the anus, thus making a horseshoeshaped abscess.
A neglected ischio-rectal abscess may burst
through its medial wall into the anal canal. It
may later burst through skin, causing anal
fistula.
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The Perineum
motor fibers to external anal sphincter; and
sensory fibers to lower end of anal canal,
ischio-rectal fossa and perianal skin.
2. The perineal branch is the larger terminal
branch.
It lies in pudendal canal below the
internal pudendal vessels.
It gives two posterior scrotal (labial)
branches to supply the skin of posterior
two-third of scrotum (labium majus).
It supplies motor fibers to all the perineal
muscles.
3. The dorsal nerve of penis (clitoris) lies on
the dorsum of penis (clitoris) deep to the
fascia.
It supplies sensory fibers to the penis
(clitoris) including its glans.
Clinical Consideration
The pudendal nerve can be blocked by infiltrating
a local anesthetic in the nerve. The needle is
introduced just medial to ischial tuberosity, and
directed towards the ischial spine.
THE UROGENITAL TRIANGLE
IN THE MALES
The urogenital triangle in the males has:
i. The male external genital organs
The scrotum with spermatic cord
The penis.
ii. Two perineal pouchessuperficial and
deepcontaining muscles, vessels, nerves
and structures of root of penis.
The Scrotum
It is a pendulous sac made up of skin and fasciae
that lodges both testes and lower parts of the two
spermatic cords.
Layers of the scrotum
1. The skin is thin, dark colored and has no
fat.
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Clinical Importance
Varicocele is congestion and enlargement of the
pampiniform plexus due to venous stasis.
The condition is quite common, and mostly
occurs on the left side as the left testicular vein
is likely to be compressed by loaded pelvic
colon.
The Superficial Perineal Pouch in
Males (Fig. 32.4)
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Anteriorly the pouch is open and communicates with space in anterior abdominal wall
between membranous layer (Scarpas
fascia) and external oblique muscle.
Contents
a. Structures of root of penis
Bulb of penis
Two crura of penis
b. Superficial perineal muscles (Table 32.1)
Bulbo-spongiosus
Origin
Muscle belly
Insertion
Actions
Perineal body
1. Help to empty
urethra
Inferior surface of
perineal membrane
2. Ischiocavernosus
3. Superficial
transverse
perinei
Medial aspect of
ischial tuberosity
and ramus of
ischium
Medical aspects
of ischial
tuberosity
Dorsum of corpus
spongiosum
Extension on dorsum
of penis
Aponeurosis attached
to sides and inferior
aspect of crus of penis
Perineal body
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2. Helps in erection of
penis
The Perineum
Contents
a. Membranous part of male urethra
b. Deep perineal muscles (Table 32.2)
Two deep transverse perinei
Sphincter urethrae
c. Other contents
Bulbourethral glands(Cowpers glands)
paired
Artery and nerve of the bulb of penis
Internal pudendal vessels
Pudendal nerve.
Nerve Supply
Deep perineal muscles are supplied by perineal
nerve.
The urogenital diaphragm forms a partition
between the pelvic cavity, and the superficial part
of perineum.
The diaphragm fills up the space between the
two conjoint rami, leaving a small gap anteriorly
below inferior pubic ligament.
The urogenital diaphragm consists of
1. The parietal layer of pelvic fascia (superior
fascia or urogenital diaphragm)
2. The deep perineal muscles
Two deep transverse perinei
Sphincter urethrae
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Origin
Muscle belly
Insertion
Actions
1. Deep transverse
perinei
Medial aspect of
ramus of ischium
Perineal body
2. Sphincter
Urethrae
(a) External
part
Medial aspect of
conjoint ramus
Two partsanterior
and posteriorthat
pass in front and
behind the urethra
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Nerve Supply
Superficial perineal muscles are supplied by perineal
nerve, a branch of pudendal nerve.
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Origin
Muscle belly
Insertion
Actions
Corpora cavernosa of
clitorisfasciculus on
dorsum of clitoris
1. It contracts vaginal
orifice
2. It helps in erection
of clitoris
2. Ischio-cavernosus
3. Bulbo-spongiosus
Anterior part of
perineal body
Origin
Muscle belly
Insertion
2. Sphincter urethrae
Superior fibers
Surround the female urethra circumferentially
Inferior fibers
Transverse
Muscle belly sweeps
Some fibers interlace
perineal ligament backwards on each side
with opposite side
of urethra
Some fibers are attached
to vaginal wall
Actions
Contents:
1. A part of female urethra.
2. A part of vagina.
3. Deep perineal muscles
It compresses the
urethra
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Clinical Considerations
1. Ureteric stone: Causes abnormal uretrine
contractions and spasm leading to ureteric colic.
The ureteric stone is liable to be impacted at
one of the following three constrictions:
a. At the pelvi-ureteric junction
b. At pelvic inlet
c. At site of piercing the bladder wall.
2. The left ureter, in females, is more closely related
to the lateral vaginal wall. Thus, it is more likely
to be lacerated in cases of difficult childbirth.
THE URINARY BLADDER
The urinary bladder is a hollow muscular organ
that stores urine for a short period, till the next act
of micturation (Fig. 33.2).
Location
In adults: It lies in the anterior part of pelvic
cavity behind pubic symphysis. When full,
the bladder rises above the pubic symphysis
in hypogastric region of abdominal cavity.
In infants at birth, the urinary bladder, is an
abdominal organ since there is no pelvic
cavity.
It progressively descends with age and
reaches its adult position in pelvis by
puberty.
Shape
When emptyTetrahedron
When fullOvoid
Capacity
In adult male: It is about 120-320 ml (average about 220 ml)
In adult female: It is less
The bladder can hold up to 500 ml, but it
becomes painful.
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THE EPIDIDYMIS
The epididymis is a helmet-like structure that lies
along the postero-lateral aspect of testis. The
epididymis consists of:
1. Head: Enlarged upper end connected to the
upper pole of testis by the efferent ductules.
2. Body is slender part that is separated from the
lateral surface of testis by sinus of epididymis
formed by reflection of visceral layer of tunica
vaginalis.
3. Tail is the narrow lower end of epididymis
connected to lower pole of testis by some connective tissue.
The tail of epididymis is continued as the vas
deferens.
Structure
The head of epididymis consists of 15-20 conical
lobules (about 15-20 cm long) that are convoluted
ducts continuous with the efferent ductules.
The body and tail have a highly-coiled duct of
epididymis, formed by union of lobules of the head.
The duct is nearly six metre long. It acquires
thick walls and continues as vas deferens.
Functions
The epididymis helps in maturation and storage of
sperms.
The blood supply of epididymis is by the artery of
vas deferens, that is usually a branch of inferior
vesical artery.
The nerve supply is by the pelvic splanchnic nerves
(nervi erigentes) from S2, S3, and S4 segments of
spinal cord.
The nerves reach via the pelvic plexus.
The Vas Deferens
The vas deferens is a thick-walled male genital duct
that conveys sperms from the epididymis to the
ejaculatory duct.
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Applied Anatomy
1. Tubectomy (Male family planning operation): By
a midline incision at the root of scrotum below
penis, both vas deferens are secured by identifying
them by their cord-like feel. Then 1.0 cm parts of
both vas deferens are cut off and the cut ends are
ligated.
After this operation, the person becomes sterile
(incapable of fertilizing) but is not impotent.
2. Recanalization operation: This operation is done
in selected cases, when the ligated ends of the vas
deferens are joined again, to establish the continuity
of lumen of vas deferens.
The Seminal Vesicles
These are two sacculated glandular structures
located at the base of urinary bladder.
Length: About 5.0 cm, but where uncoiled it is
nearly 15.0 cm.
Shape: Pyramidal. The seminal vesicle consists
of a single coiled tube with diverticula.
Relations
Anteriorly: Base of urinary bladder.
Posteriorly: Recto-vesical fascia separating
it from rectum.
Medially: Ampulla of vas deferens.
Functions: The seminal vesicles act as secreting
glands in humans.
Their secretion adds to the seminal fluid and
contains fructose, choline and a coagulating
enzymevesiculase.
They do not store sperms in humans.
The Blood Supply
The arteries are derived from the inferior
vesical and middle rectal arteries.
The veins accompany the arteries.
The Nerve Supply
The seminal vesicles are supplied by the pelvic
plexuses carrying autonomic nerves.
Clinical Considerations
1. The seminal vesicles can be palpated through
the anterior wall of rectum by the rectal examination.
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Clinical Considerations
Benign enlargement: After the age of sixty years,
sometimes the prostate gland enlarges due to
poliferation of the glandular tissue.
The enlargement involves median lobe mostly
causing obstruction to the internal urethral
meatus.
The condition results in difficulty in passing
urine.
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Clinical Considerations
1. The ovarian tumors are quite common in
elderly females.
2. The ectopic ovary: Sometimes the ovary fails
to descend from posterior abdominal wall to its
normal position.
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The arteries
The uterine artery supplies medial two-third part
of uterine tube.
The ovarian artery supplies lateral one-third part
of uterine tube.
The Veins follow the arteries.
From the medial part, the veins end in the uterine
venous plexus.
From the lateral part, the veins join the ovarian
venous plexus.
The Lymphatic Drainage
Clinical Considerations
1. In females, pelvic peritonitis may occur more
frequently, as infection from vagina and uterus can
travel via the uterine tubes into the peritoneal cavity.
Salpingitis or inflammation of the tube leads to
blockage of lumen of tube. This is the most common
cause of female infertility.
2. Tubal ligation (TubectomyFemale Family
Planning Operation).
The operation is done preferably 4-5 days after
childbirth, when the uterus lies midway
between umbilicus and pubic symphysis.
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The Pelvis
Multiple Choice Questions
Q1. Give the one best response to each question
from the given four answers:
1. The fertilization of the ovum takes place in:
A. Body of the uterus
B. Ampulla of the uterine tube
C. Peritoneal cavity
D. Ovarian follicle
2. The remnant of peritoneal cavity present in
the scrotum is:
A. Gubernaculum
B. Ductus deferens
C. Tunica vaginalis
D. None of the above
3. The length of the anal canal is:
A. 1 1/2 inches
B. 6.0 inches
C. 10.0 inches
D. 12.0 inches
4. The prostatic hypertrophy involves mainly.
A. Anterior lobe
B. Two lateral lobes
C. Median lobe
D. B and C
5. The urogenital diaphragm is formed by:
A. Sphincter urethrae
B. Levator ani
C. Deep transverse perineal
D. A and C
6. Which of the following structures cannot be
palpated by rectal examination in males:
A. Bulb of the penis
B. Seminal vesicles
C. Ureter
D. Anorectal ring
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B. Conveys sperms
from epididymis
to ejaculatory duct
iii. Cowpers gland C. Situated in deep
perineal pouch
iv. Vas deferens
D. Secretes fructose
for nutrition of
sperms
22. Embryonic remnants:
i. Prostatic utricle A. Cranial end of
paramesonephric
duct
ii. Appendix of test B. Caudal end of
paramesonephric
duct
iii. Appendix of epi- C. Mesonephric duct
didymis
in females
iv. Gartners duct
D. Mesonephric
tubule
23. Lymphatic drainage:
i Cervix of uterus A. Para-aortic lymph
nodes
ii. Prostate gland
B. Internal iliac
lymph nodes
Answers
A1. The answer is B.
The fertilization of ovum takes place in the
ampullary part of uterine tube. The
implantation of fertilized ovum takes place in
the body of uterus. Abnormal implantation
may be in uterine tube, ovarian follicle or even
in peritoneal cavity.
A2. The answer is C.
The remnant of peritoneal cavity in the
scrotum is tunica vaginalis. Actually, during
descent of testis, a tube of peritoneum
processus vaginalisdescends along with
testis, and later its lower end persists as tunica
vaginalis.
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35
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Maxilla - anteriorly
Zygomatic bone forming zygomatic arch on
side
Sphenoid bone - on side anteriorly
Temporal bone - with external acoustic
meatus
The features of skull in this view are
The two temporal lines - curving on side of
skull from zygomatic process of frontal to
supra-mastoid crest of temporal bone
The zygomatic arch - is formed on side of
skull by temporal process of zygomatic and
zygomatic process of temporal bone
(zygoma)
External acoustic meatusan oval bony
aperture on side in the temporal bone
Suprameatal triangle (Macowens triangle)
is a small depression on postero-superior
aspect of external acoustic meatus. This
triangle forms the lateral wall of mastoid
antrum and is used for surgical approach to
middle ear.
Mastoid process forms a triangular bony
mass behind external acoustic meatus.
Styloid processis a pointed bony projection
from in front of mastoid process
Pterion is an area on side of skull where
four bonesfrontal parietal, greater wing
of sphenoid and temporal - meet deep to
pterion lie middle meningeal vessels
Temporal fossais the name given to the
area on side of skull that is bounded by
temporal lines above and upper border of
zygomatic arch below.
Two zygomatico-temporal foramina pierce
the temporal surface of zygomatic bone
E. Norma basalis (Inferior view)
The inferior view of skull is studied in three
partsanterior, middle, and posterior.
The anterior part is formed by the hard plate
and the alveolar arches. The features in anterior
two third are:
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3.
4.
5.
6.
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376
Ramus of Mandible
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378
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Ossification in membrane
1.
Vomer
2.
Maxilla
3.
Nasal
4.
5.
Lacrimal
Palatine
6.
7.
Zygomatic
Inferior nasal concha
8.
Mandible
9.
Ethmoid
10.
Sphenoid
11.
Occipital
Ossification in cartilage
Contd...
382
Contd...
S No Name of the bone
Ossification in membrane
Ossification in cartilage
12.
Frontal
13.
Parietal
14.
Temporal
Bone
1.
2.
3.
4.
Frontal
Maxilla
Zygomatic
Zygomatic
5.
6.
Supra-orbital foramen
Intra-orbital foramen
Zygomatico-facial foramen
Zygomatico-temporal
foramen
External acoustic meatus
Petro-tympanic fissure
Temporal
Temporal
7.
Pterygo-maxillary fissure
8.
Between pterygoid
process and maxilla
Between greater wing
sphenoid and maxilla
9.
Maxilla
10.
Stylomastoid foramen
Temporal
11.
Occipital
12.
13.
Occipital
Mastoid temporal
Sound waves
Chorda tympani
Anterior tympanic artery
Third part of maxillary artery
Maxillary nerve
Maxillary nerve
Zygomatic branch of maxillary nerve
Intraorbital vessels
Emissary vein connecting the interior
ophthalmic vein with pterygoid venous
plexus
Posterior superior alveolar nerve and
vessels
Facial nerve
Stylomastoid artery
Emissary vein connecting the sigmoid
sinus with suboccipital venous plexus
Hypoglossal nerve
Emissary vein joining the veins of scalp
with transverse sinus
Contd...
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Contd...
S No Name
Bone
14.
Parietal foramen
Parietal
15.
Jugular foramen
16.
Carotid canal
17.
Foramen lacerum
18.
Foramen ovale
19.
Foramen spinosum
20.
21.
22.
Palatine
Between palatal processes
of two maxillae
23.
Foramen magnum
Occipital bone
384
S No Name
Anterior cranial fossa
1.
Foramen cecum
(1% skulls)
2.
3.
4.
Bone
Olfactory nerves
Anterior ethmoidal nerve and vessels
Sphenoid
6.
Sphenoid
7.
Foramen rotundum
Sphenoid
8.
9.
10.
Foramen ovale
Foramen spinosum
Foramen lacerum
11.
12.
Petrous temporal
Petrous temporal
Petrous temporal
Facial nerve
Vestibulo-cochlear nerve
Labyrinthine vessels
14.
15.
16.
17.
Jugular foramen
Posterior condylar canal
Anterior condylar canal
Foramen magnum
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Deep irregular
pits for archnoid
grannulations are seen on either side of
sagittal sulcus
Vascular markings for branches of middle
meningeal vessels are seen on either side
Impressions for cerebral gyri are also seen
on either side
B. Internal surface of base of skullis divided into
three cranial fossaeanterior, middle, and
posterior (Fig. 35.7)
The anterior cranial fossa lodges the frontal
lobes of two cerebral hemispheres. It is bounded
anteriorly by the frontal bone and posteriorly
by sharp free margins of two lesser wings of
sphenoid, anterior clinoid processes and anterior
margin of optic groove (sulcus chiasmaticus)
The features of this fossa are:
The cribriform plates of ethmoid and the
crista galli
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386
forming fontanelles
There are six fontanelles
1. The anterior fontanelle is largest and
diamond shaped. It closes by eighteen
months.
This fontanelle is clinically important, as
it is used for assessing intra-cranial
pressure in dehydration of infants, and
also for giving intra-venous injections
in infants.
2. The posterior fontanelle is small and
triangular and closes by end of first year
3. Two antero-lateral fontanelles are small and
irregular and close by first year
4. Two postero-lateral fontanelles are also small
and irregular and close by first year.
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General Features
Hyoid bone consists ofa median body, paired
greater cornu and paired lesser cornu.
The body is roughly quadrangular. Its anterior
surface faces antero-superiorly. The posterior
surface is smooth and concave and related to a
bursa.
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Special Features
The Body
Ossification of Hyoidbone
Hyoid bone is developed from the cartilages of
second and third pharyngeal arches.
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The movements
The movements of the joint take place in
relation to the occlusal position (position of
rest) of mandible, when jaws are together
and molar teeth of both jaws are in apposition.
The mandible can be depressed (opening of
mouth) or elevated. It can be protruded or
retracted.
Both joints always act together, although
they may be having different types of
movement.
The axis of movement passes through
mandibular foramina of the two sides, as
the neuro-vascular bundles pass through
them.
Muscles producing movements
Depression
Lateral pterygoids helped by
Digastric, geniohyoid and mylohyoid
muscles.
ElevationTemporalis, masseter, medial
pterygoid of both sides. During depression,
the head of mandible is pushed downwards
and forwards so that it comes to lie below
articular eminence. During elevation it is
pushed backwards in articular fossa.
ProtractionLateral and medial pterygoid
muscles
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The Joints, Fasciae and Deep Muscles of the Back of Head and Neck
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The Joints, Fasciae and Deep Muscles of the Back of Head and Neck
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The Joints, Fasciae and Deep Muscles of the Back of Head and Neck
e. The retro-vertebral fascia covers the retrovertebral muscles and sends fascial septa between
them.
Attachments
Superiorlyextends up to skull.
Inferiorlycontinues with deep fascia on
back of thorax.
f. The buccopharyngeal fascia is thickened
epimysium that covers buccinator and constrictor
muscles of pharynx.
g. The pharyngo-basilar fascia lies deep to the
constrictor muscles of pharynx. It is thickened at
the gaps in the pharyngeal wall.
THE DEEP MUSCLES OF THE BACK
Common features
The deep muscles of the back extend from
the occipital bone to the back of sacrum.
These muscles consist of muscle slips
forming short segmental muscles.
The deep muscles of the back are bound by
thoraco-lumbar fascia to the back of
vertebral column.
These muscles are supplied by the dorsal
rami of the spinal nerves.
Functionally these muscles are extensors,
rotators and lateral flexors of vertebral
column.
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The Joints, Fasciae and Deep Muscles of the Back of Head and Neck
i. The semispinalis is the superficial part.
ii. The multifidus is the intermediate part.
iii. The rotators is the deep part.
I. The semispinalis is further subdivided into
a. The semispinalis thoracic extends from
transverse processes of lower six thoracic
vertebrae to the spinous processes of lower
two cervical and upper four thoracic
vertebrae.
b. The semispinalis cervicis extends upper six
thoracic transverse processes to spinous
processes of second to fifth cervical vertebrae.
c. The semispinalis capitis lies superficial to
semispinalis cervicis.
It arises from transverse processes of
upper six thoracic and lower four
cervical vertebrae.
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402
i. The supra
trochlear
division of trigeminal in the
ii. The supra
orbit and come out at the
orbital
supra-orbital margin
iii. The zygomatico-temporal is a branch of
maxillary division to trigeminal and emerges
after piercing temporal fascia.
iv. The auriculo-temporal is a branch of
mandibular division of trigeminal nerve and
emerges just in front of auricle.
The posterior part of scalp (behind the auricle)
is supplied by four spinal nerves.
i. The greater auricular nerve is a branch of
cervical plexus (VR, C2, C3)
ii. The lesser occipital nerve is also a branch
of cervical plexus (VR, C2)
iii. The greater occipital nerve is a branch from
the dorsal ramus of second cervical nerve.
It is a thick nerve that supplies posterior
part of scalp
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THE FACE
403
Fig. 37.4: The muscles of the face, scalp and auricleLateral view
404
S.No. Name
I.
Origin
Insertion
It surrounds the
orbital openings
Lateral palpebral raphe
b. Corrugator
supercilli
Skin of eyebrow
c. Levator palpebrae
superioris
b. Nasalis
Compressor
naris
Dilator naris
c. Depressor septi
nasi
Maxilla
Zygomatic
Zygomatic
Main actions
It produces transverse
furrows at root of the
nose
Septal cartilage
It depresses anterior
part of septal cartilage
Compound sphincter
muscle of oral fissure
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Contd...
S.No. Name
Origin
Insertion
6. Facial part
Continuation of some fibers of
of platysma
platysma in face
c. The modiolar muscles (cruciate modiolar muscles)
a. Levator anguli
Maxillacanine fossa
oris
Depresser
anguli oris
Mandible
Main actions
Lower lip
Fibers decussate at
modiolus-a knot of
muscles 1.0 cm from
angle of mouth
Fibers decussate at
modiolous and enter
upper lip
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408
Applied Anatomy
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Applied Anatomy
Lesion of facial nerve in the bony facial canal or
near the stylo-mastoid foramen leads to Bells
paralysis
The symptoms are :
Drooping of angle of mouth or affected side
Inability to close the eye, and resulting loss
of conjunctival reflexes
Difficulty in mastication, as the food collects
in the vestibule of the mouth
There is no effective treatment of Bells paralysis. Most cases recover spontaneously often
with no permanent damage
THE CRANIAL CAVITY
The cranial cavity is divided into three cranial fossae
Anterior, middle, and posterior.
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left
The right transverse sinus begins at internal
occipital protuberance and is usually the
continuation of the superior sagittal sinus and
is, therefore, larger in size
The left transverse sinus is continuation of
straight venous sinus and is smaller in size.
The transverse sinus occupies transverse sulcus
of squamous occipital and parietal bone, lying
along the attached margin of tentorium cerebelli
It becomes continuous with sigmoid sinus at
the base of petrous temporal bone
Tributaries
i. Inferior cerebral veins
ii. Inferior cerebellar veins
iii. Small diploic veins
iv. Inferior anastomotic vein
It is connected by superior petrosal sinus with
the cavernous venous sinus.
C. The sigmoid sinuses are also tworight and
left.
Each sigmoid sinus is continuation of transverse
sinus at base of petrous temporal bone
The sigmoid sinus occupies the S-shaped
sigmoid sulcus on deep surface of:
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Foramen of skull
Venous sinus
1.
2.
3.
4.
5.
Foramen cecum
Parietal foramen
Mastoid foramen
Hypoglossal canal
Posterior condylar canal
6.
7.
Emissary vein
Emissary vein
Cavernous sinus
Cavernous sinus
8.
Foramen ovale
Emissary sphenoidal
foramen
Foramen lacerum
Carotid canal
Cavernous sinus
Cavernous sinus
9.
10.
Cavernous sinus
Pharyngeal veins
Pterygoid venous plexus
Internal jugular vein
Facial veinpterygoid
venous plexus
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416
ii.
iii.
Applied Anatomy
Enlargement of pituitary gland (tumors) produce
two types of symptoms
i. Constitutional symptoms due to over production of certain hormones
ii. Neighborhood symptoms due to compression on neighboring structures.
Theses are
i. The visual signs produced due to compression of optic chiasma.
iv.
v.
vi.
Bitemporal hemianopialoss of
temporal nasal fields of both sides
Paralysis of third, fourth, and sixth
nerves by laterally growing tumor
Deepening of sella turcica is seen is lateral
X-ray of skull
Pressure on uncus leads to aura of different
types of smell
Pressure on crus cerebri leads to paresis or
paralysis of voluntary muscle groups of
opposite half of body
Pressure on inter-ventricular foramen may
lead to internal hydrocephalus of lateral
ventricle
The pituitary tumor by raising the intracranial
pressures leads to papilledema or swelling
of optic disc that can be visualized by ophthalmoscope.
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38
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Boundaries
The roof (superior boundary) is formed by
Infra-temporal surface of greater wing of
sphenoid and squamous temporal bone.
The medial wall has
Lateral pterygoid plate
Lateral pharyngeal wall
The lateral wall is formed by
Medial surface of ramus of mandible with
the mandibular foramen in the center of it.
The anterior wall has
Posterior surface of maxilla
Contents
i. The muscles of masticationtemporalis,
lateral and medial pterygoid.
ii. The maxillary artery and its branches.
iii. The mandibular nerve and its branches.
iv. The pterygoid venous plexus.
v. The deep contents arechorda tympani,
otic ganglion and tensor veli palatini muscle,
and a small part of maxillary nerve.
Contents
420
Origin
Muscle belly
I.
Temporalis
(Fig. 38.3)
II.
Masseter
(Fig. 38.4)
Inferior temporal
line
Four bones of
medial wall of temporal fossa
Deep surface of
temporal fascia
Lower border and
medial surface of
Zygomatic arch
III.
Lateral
pterygoid
(Fig. 38.5)
IV.
Medial
pterygoid
(Fig. 38.6)
Insertion
Main actions
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Branches
From First Part
i. Anterior tympanic branch enters petrotympanic fissure to supply middle ear.
ii. Deep auricular supplies the external auditory
meatus.
iii. Middle meningeal branch ascends up
between two roots of auriculo-temporal
nerve. It enters skull through foramen
spinosum to supply dura mater.
iv. Inferior alveolar branch enters mandibular
foramen, and runs in the mandibular canal
to supply teeth of lower jaw. It gives a
mental branch to the face.
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Anterior deep
temporal
Posterior deep
temporal
to temporalis
muscle
Masseteric nerve
Nerve to lateral pterygoid
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Applied Anatomy
The trigeminal neuralgia can also involve
maxillary division of trigeminal nerve.
425
Roots
The sensory root is from the lingual nerve.
The sympathetic root is from plexus around
facial artery.
The parasympathetic root is from the chorda
tympani nerve. These fibers reach ganglion
via lingual nerve and are relayed in the
ganglion. The post ganglionic parasympathetic (secreto-motor) fibers arise from
ganglion.
Branches
i. The secreto-motor fibers to submandibular
salivary gland reach the deep part of gland
directly from the ganglion.
ii. The secreto-motor fibers to sublingual
salivary gland reach via the lingual nerve.
III. The pterygo-palatine (spheno-palatine)
ganglion is the largest peripheral parasympathetic
ganglion.
It is suspended by two communicating branches from the maxillary nerve in pterygo-palatine
fossa.
Roots
The sensory root is provided by the maxillary
nerve.
The sympathetic root is from plexus around
the internal carotid artery
The parasympathetic root is provided by the
greater petrosal nerve from nerve of pterygoid canal.The pre-ganglionic parasympathetic fibers relay here and post-ganglionic
fibers begin.
Branches
i. The nasopalatine nerve runs along nasal
septum and terminates in the hard palate.
ii. The palatine branches supply the hard and
soft palate. These are posterior palatine
(greater palatine), middle and anterior
palatine (lesser palatine) nerves
iii. The nasal branches are divided into:
Posterior superior medial to supply nasal
septun.
Posterior superior lateral to supply lateral
wall of nose.
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39
The Triangles
of the Neck
THE POSTERIOR TRIANGLE
OF THE NECK
The posterio triangle lies on the side of neck, behind
sternomastoid muscle. It extends from clavicle
below up to the occipital bone above (Fig. 39.1).
Boundaries
Anterior boundary is formed by posterior
border of sternomastoid.
Posterior boundary is formed by anterior
border of trapezius.
The base or inferior boundary is formed by
middle one-third of clavicle.
The apex or superior boundary is formed
by the superior nuchal line of occipital bone.
The roof is formed by the investing layer of
deep cervical fascia, covered by superficial
fascia, platysma and skin.
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430
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d
ti e
431
G
R
n
U
S.No.
Name
1.
h
a
9
ri 9
Origin
Insertion
Main actions
Rectus capitio
posterior minor
Posterior tubercle
of atlas vetebra
2.
Rectus capitis
posterior major
3.
Obliques capitis
inferior
Transverse process of
atlas vertebra
4.
Obliques capitis
superior
Transvase process of
atlas vertebra
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d
ti e
433
G
R
n
U
Mylohyoid nerve
Part of hypoglossal nerve
III. The carotid triangle is the largest and most
important part of anterior triangle (Fig. 39.5).
Boundaries
Posteriorly
Anterior border of sternomastoid
Antero-superiorly
Posterior belly of digastric
Antero-inferiorly
Superior belly of omohyoid
Roof(superficial boundary) deep cervical
fascia
Floor
The lateral wall pharynx formed by
inferior and middle constrictor muscles
Thyrohyoid membrane, thyrohyoid
muscle
Part of hypoglossus above hyoid bone
Contents
a. The arteries
Parts of common carotid, internal carotid
and external carotid arteries.
Five branches of external carotid artery
h
a
9
ri 9
434
It supplies branches to
Superior belly omohyoid
Inferior belly omohyoid
Sternohyoid
Sternothyroid
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40
9
ri 9
V
d
ti e
n
U
h
a
G
R
Scalenus medius
Scalenus posterior
Scalenus minimus (pleuralis)
2. The muscles of the anterior triangle
Sternomastoid
Infrahyoid muscles
Sternohyoid, sternothyroid, thyrohyoid
and omohyoid
Supra hyoid muscles
Digastric
436
S. Name
No.
Origin
Muscle belly
Insertion
Nerve supply
Main actions
Inferior surface
basi-occiput
Ventral ramus C1
Inferior surface
Ventral ramus C1
jugular process of
occipital bone
Inferior surface of Ventral rami
basilar part of
C1, C2, C3
occipital bone
Scalenus
medius
7.
Scalenus
posterior
(absent
sometimes)
Scalenus
pleuralis
(minimus)
8.
Broad above
narrow below
Upper oblique
part
Muscle belly con- Anterior tubercle Ventral rami
sists of digitations of atlas
C2 to C6
lying on front of
Middle vertical part
vertebral bodies
Bodies of second
to fourth cervical
vertebrae
Lower oblique part
Anterior tubercle
of fifth and sixth
cervical vertebrae
group
Muscle belly becomes narrow
below
Lateral flexion of
head
Flexes the head
A thick muscle
belly joined by
Lateral half of
superior nuchal
Spinal accessory
(motor) Ventral
Contd...
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The Muscles, Glands, Blood Vessels and Nerves of the Front of Neck
437
Contd...
S. Name
No.
Origin
2.
Sternohyoid
3.
Sternothyroid
Muscle belly
anterior surface
manubrium sterni
Clavicular head
superior surface
of medial third of
clavicle
Posterior aspect
medial end of
clavicle
Posterior aspect
of manubrium
sterni
Posterior surface
of manubrium
sterni
Posterior aspect
of first costal
cartilage
Oblique line of
lamina of thyroid
cartilage
opposite side
II. Raises head from
supine position
III. Elevates thorax if
head fixed
Ansa cervicalis
ventrical rami
C1, C2, C3
I. Depresses hyoid
bone during speech mastication
and deglutition
V
d
ti e
G
R
Ansa cervicalis
(Ventral rami
C1, C2, C3 )
5.
Omohyoid
two belies
Inferior belly
From supra
scapular notch
Superior belly
Intermediate
tendon
6.
Platysma
Main actions
Thyrohyoid
n
U
9
ri 9
Nerve supply
4.
h
a
Insertion
Posterior belly
longer and tapering Anterior belly
shorter
I. Depresses larynx
(Thyroid cartilage)
during speech
and swallowing
Inferior belly on
intermediate tendon
Superior belly
lateral part lower
border body of
hyoid bone
Anterior fibres
Cervical branch of I. It causes ridges
decussate in midfacial nerve
in skin of neck
line attached to
II. Helps in depressymphysis menti
sing mandible
Middle fibres lower
III. Pulls lower lip and
border mandible
angle of mouth
Posterior fibres
downwards
Cross mandible and
masseter attached
to skin of lower
part of face
Intermediate tendon passes
through a fibrous
pulley attached to
hyoid bone
Contd...
438
Contd...
S. Name
No.
2.
Stylohyoid
3.
Mylohyoid
4.
Geniohyoid
Origin
Muscle belly
Insertion
Round tendon
Narrow slender
posterior surface
muscle belly
near base of
styloid process
At insertion tendon
of digastric divides
into two parts
attached to hyoid
bone at junction
with greater cornu
Whole length of
Flat, triangular
Fibrous median
mylohyoid line
muscle belly
raphe Posterior
of mandible
Forms floor of
fibres body of
mouth with fellow hyoid bone
of opposite side
Lower mental
Narrow muscle
Anterior aspect
spine of mandible belly lies in parabody of hyoid
median position
bone
Nerve supply
Main actions
Facial nerve
I. Helps to elevate
and retract hyoid
bone
Mylohyoid
branch of inferior alveolar
nerve
I. Elevates floor of
mouth
II. Helps to depress
mandible and elevate hyoid bone
I. Elevates hyoid
bone
II. Helps in depressing mandible
Stylohyoid
Mylohyoid
Geniohyoid
THE THYROID GLAND
The thyroid gland is an important endocrine gland
that controls the metabolism of the body (Fig.
40.2).
Secretion: It produces thyroxin and thyrocalcitonin.
Location: The gland lies in front of lower part
of neck.
Parts: The thyroid gland has:
A median part called isthmus
Two lateral lobes
The isthmus is rectangular in shape
It is nearly 1.2 cm vertically and transversely.
It lies in front of second to fourth tracheal
rings.
It is a midline structure of neck, covered
only by skin and fasciae.
The lateral lobes are conical in shape
Each lobe is about 5.0 cm long, 3.0 cm
broad and 2.0 cm wide.
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G
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The Capsules
The thyroid gland has two capsules.
i. A true capsule formed by the connective
tissue all around the gland.
ii. A fascial capsule formed by the pretracheal
fascia.
The thyroid vessels pierce both capsules and
ramify deep to true capsule.
The Blood Supply of Thyroid Gland
440
end in internal
jugular vein
Applied Anatomy
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2 The ascending pharyngeal artery
ascends upwards along the pharyngeal wall between the internal and
external carotid arteries.
It also gives:
A meningeal branch to dura
mater
An inferior tympanic branch
to the middle ear.
3. The lingual artery is a tortuous vessel
given near greater cornu of hyoid
bone.
It forms a loop crossed by the
hypoglossal nerve in the carotid
triangle.
It passes deep to hypoglossus
and passes forwards to reach the
tongue.
It also gives:
A supra-hyoid branch.
Two or three large dorsal
linguae branches that supply
the posterior part of tongue,
oral cavity, tonsil, and palate.
A sublingual branch to the
sublingual salivary gland.
The terminal profunda
branch, that runs on inferior
surface of tongue to supply
it.
4. The facial artery arises opposite the
angle of mandible.
It ascends deep to the mandible
and forms a loop grooving
posterior part of submandibular
salivary gland.
It enters face at the lower border
of mandible at anterior inferior
angle of masseter.
[The course and branches in face
described in Chapter 37).
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The Muscles, Glands, Blood Vessels and Nerves of the Front of Neck
Posterior
Scalenus medius
Lower trunk of brachial plexus
Suprapleural membrane
Cervical pleura and apex of lung
Inferior
Ist rib
Branches
The subclavian artery gives five branches
From first part
1. Vertebral artery
2. Internal thoracic artery
3. Thyro-cervical trunk
From second part
4. Costo-cervical trunk
5. Dorsal scapular artery
From third part
No branch is given normally.
Vertebral arteryis the first and largest
branch of subclavian artery.
It is divided into four parts
The first partextends vertically through
foramina transversarium of 6th cervical
vertebra.
The second partascends vertically
through foramina transversaria of upper
six cervical vertebra.
The third partlies in suboccipital
triangle [Described in Chapter 39]
The fourth partascends through
foramen magnum and enters skull. In
ends at lower border of pons by uniting
with fellow of opposite side to form the
basilar artery.
Internal thoracic artery
[Described in Chapter 21]
Thyro-cervical trunkis a short wide vessel
that arises close to medial border of scalernus anterior muscle.
The trunks immediately divides into three
branches
a. Inferior thyroid artery ascends up and
then turns medially to reach posterior
surface of thyroid lobe.
i.
ii.
iii.
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Typemixed nerve.
Functional components and distribution
(Described in Chapter 47)
Coursethe glosso-pharyngeal nerve enters the
neck by passing through middle part of jugular
foramen, enclosed in a separate dural sheath.
There are two ganglia in its uppermost part.
a. The superior ganglion is small.
b. The inferior ganglion is larger and relays
all the sensory fibers (general and special
sensation) of the nerve.
The nerve descends between the internal and
external carotid arteries.
It curves medially across stylopharyngeus
muscle and supplies it.
It passes in the pharyngeal wall between
superior and middle constrictor muscles, and
divides into its terminal branches.
Branches
Communicating branches are given to:
Superior cervical ganglion of sympathetic chain
Vagus nerve
Facial nerve
Branches of distribution
i. The tympanic branch (Jacobson nerve)
enters middle ear cavity, through a
minute tympanic canaliculus.
It forms a tympanic plexus on the
medial wall of middle ear that
supplies sensory fibers to the middle
ear and auditory lube.
The tympanic plexus also carries
preganglionic parasympathetic fibers
for parotid gland, that come out as
lesser petrosal nerve.
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ii. The sino-carotid nerve supplies the
carotid sinus and the carotid body.
iii. The tonsillar branch supplies sensory
fibers to the palatine tonsil.
iv. The lingual branches supply sensory
and taste fibers to posterior one-third of
tongue including vallate papillae.
v. The pharyngeal branches join the
pharyngeal plexus of nerves and supply
sensory fibers to pharynx and palate.
vi. Muscular branch to stylopharyngeus.
iii.
iv.
v.
vi.
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Typepurely motor.
Functional components and distribution
(Chapter 47)
Course and relationThe accessory nerve also
enters the neck by passing through middle part
of jugular foramen enclosed in a common dural
sheath with the vagus nerve.
It consists of two partscranial and spinal.
a. The cranial part joins the vagus nerve
just below the skull.
The motor fibers of the cranial part
are distributed along with the
pharyngeal and recurrent laryngeal
branches of vagus nerve.
b. The spinal part descends in the neck
between the internal carotid artery and
the internal jugular vein.
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Branches of distribution
a. The hypoglossal nerve carries fibers of
ventral ramus of first cervical nerve that
are given in:
i. The meningeal branch that supplies
the dura mater of posterior cranial
fossa.
ii. Superior limb of ansa cervicalis joins
with the inferior limb to form the
ansa cervicalis that supplies the infrahyoid muscles.
[Ansa cervicalis is described in
Chapter 39].
iii. The nerve to thyrohyoid muscle.
iv. The nerve to geniohyoid muscle.
b. The terminal branches of the hypoglossal
nerve supply all the extrinsic and intrinsic
muscles of the tongue (except palatoglossus).
Applied Anatomy
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Branches
i. Grey rami communicans are given to
the ventral rami of upper four
cervical nerves.
ii. The cardiac branch joins the cardiac
plexuses.
iii. The laryngo-pharyngeal branch joins
the pharyngeal plexus.
iv. The communicating branches are
given to the ninth, tenth, and twelfth
cranial nerves.
v. The internal carotid nerve forms a
plexus around the internal carotid
artery and enters the skull along with
the artery.
vi. The external carotid nerve forms a
plexus around the external carotid
artery and accompanies its branches.
b. The middle cervical ganglion is the smallest
of the three ganglia of sympathetic trunk.
The ganglion lies in relation to inferior
thyroid artery at level of sixth cervical
vertebra.
Branches
i. The grey rami communicans are
given to join the ventral rami of fifth
and sixth cervical nerves.
ii. The cardiac branch joins the deep
cardiac plexus.
iii. The thyroid branches supply the
blood vessels of thyroid and parathyroid glands.
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41
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THE LARYNX
The larynx is the upper modified end of trachea
for the production of voice.
The larynx also acts as a compound sphincter
of the respiratory passage.
The Skeletal Framework
(Figs 41.3 and 41.4)
The skeleton of the larynx is formed by a rigid
framework of bones, cartilages, membranes and
ligaments.
I. The bones and the cartilages are:
a. The hyoid bone in uppermost part of neck,
gives attachment to the membranes and
extrinsic muscles of larynx. (Described in
Chapter 35).
b. The cartilages of the larynx are three large
unpaired cartilagesepiglottis, thyroid, and
cricoid and three small paired cartilages
arytenoid, corniculate, and cuneiform.
The epiglottis is a leaf-like elastic fibrocartilage.
It is attached to hyoid bone by hyoepiglottic ligament and angle of
thyroid cartilage by thyro-epiglottic
ligament.
The superior surface is connected
to the dorsum of tongue by one
median and two lateral glossoepiglottic folds.
The inferior surface faces the upper
part of the cavity of larynx.
The thyroid cartilage consists of two
laminae fused in median plane to form
an angle of nearly 90 in males (120 in
females).
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Origin
Muscle belly
Insertion
1.
Arch of cricoid
cartilage
Small triangular
muscle belly
Cricothyroid
Nerve supply
Main actions
1. Only abductor of
vocal cords
3.
Oblique
arytenoid
Same
1. Adductor of
vocal cords
4.
Transverse
arytenoid
1. Adductor of
vocal cord
5.
Aryepiglotticus
Same
6.
Lateral cricoarytenoid
Same
1. Adductor of the
vocal cord
7.
Thyroarytenoid
Same
8.
9.
Vocalis
Thyroepigloticus
Same
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Structure
i. The vocal folds are lined by stratified
squamous epithelium.
ii. They have no submucus coat so there can
be no edema or collection of fluid in vocal
folds.
iii. They have inside
The vocal ligament upper thick edge
of crico-vocal membrane.
The vocalis muscle part of thyroarytenoid.
There are no mucous glands in the vocal folds
also.
Rima glottidis (glottis) is the gap between two
vocal folds. It is the narrowest part of the
respiratory passage.
The vocal folds (true vocal cords) are subject
to different movements during respiration (quiet
and deep) and phonation.
The movements of the vocal folds are possible
due to movements of arytenoid cartilage.
These movements are adduction, abduction,
tension and relaxation.
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THE PALATE
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Origin
1. Tensor veli
palatini
(Tensor
palati)
Scaphoid fossa of
pterygoid process
Lateral surface
cartilage of auditory tube
Spine of sphenoid
2. Levator veli
Rough area on
palatini
inferior surface
(Levator
of petrous tempalati)
poral
3. Palatoglossus Inferior surface
of palatine aponeurosis
Muscle belly
Insertion
Nerve supply
Palatine aponeurosis
Mandibular nerve
Two fasciculis
Posterior border
are separated by of thyroid
levator veli palatini cartilage
Main actions
Same
I. Helps to elevate
and retract the
uvula
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THE TEETH
The teeth form a part of masticatory apparatus and
are fixed to the two jaws.
In humans, the teeth are diphyodont i.e. they
are replaced only once.
In non-mammalian vertebrates, the teeth are
polyphyodont i.e. they are replaced a number
of times throughout life.
i. In humans the first set of teeth (dentition)
are called Milk or Deciduous teeth. These
are 20 in number. In each half of jaw there
are two incisors, one canine and two molars.
2 i 1c 2 m
ii. The second set of teeth (dentition) in humans
are called Permanent teeth. These are 32 in
number. In each half of jaw there are two
incisors, one canine two premolars and three
molars.
2i 1c 2 pm 3 m
Structure of A Tooth
Each tooth has three parts
i. A crown that projects above the gum.
ii. A root that is embedded in the jaw beneath
the gum.
iii. A neck - between the crown and root that is
surrounded by gum.
The structure of tooth is composed of the
following
The dentinethat forms the main part surrounding the pulp.
The enamelthat cover the projecting part of
dentine of crown.
The pulp cavity in center.
The cementumsurrounding the embedded
part.
The peridontal membrane.
The dentine is a made up of calcified material
containing spiral tubules radiating from pulp cavity
each tubule is occupied by protoplasmic process
of one odontoplast.
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Canines 18 months
THE TONGUE
The tongue is a mobile muscular organ, in the floor
of the mouth cavity, that is concerned with.
Mastication of food
Deglutition of food
Speech
Taste
The tongue is divided into two parts by an
inverted V-shaped sulcusthe sulcus terminalis
(Fig. 42.1).
i. Anterior two-thirdthe oral part.
ii. Posterior one thirdthe pharyngeal part.
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Origin
Muscle belly
Insertion
Main actions
Lateral border of
tongue
Lateral border of
tongue lateral to
hyoglossus
Inferior (ventral)
surface of tongue
Lower fibers superior surface body
of hyoid
Hyoglossus
II.
Styloglossus
III.
Genioglossus
IV.
Palatoglossus
Superior surface of
greater cornu of
hyoid bone
Antero lateral surface
near tip of styloid
process
Upper mental tubercle
of mandible
Superior
longitudinal
Submucous tissue
near epiglottis
Mucous membrane
near dorsum of tip of
tongue
2.
Inferior
longitudinal
Submucous tissue
near root of tongue
Mucous membrane
on ventral surface
near tip of tongue
3.
Transversal
linguae
4.
Vertical
linguae
Dorsum of tongue
Ventral surface
of tongue
Lateral border of
tongue
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Fig. 42.4: Coronal section through tongue showing the intrinsic muscles
The Veins
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THE PHARYNX
The pharynx is a muscular chamber that acts as a
common passage for the respiratory and digestive
tracts.
Location: The pharynx lies behind the nasal
cavity, mouth cavity and the larynx.
469
Extent:
Superiorlyup to base of skull.
Inferiorlyit is continuous with esophagus at the lower border of cricoid
cartilage.
Anteriorlythe pharynx communicates
with two nasal cavities, mouth cavity and
the inlet of larynx.
Parts: The pharynx is divided into: (Fig. 42.6)
i. An upper part nasopharynx
ii. A middle part oropharynx
iii. A lower part laryngopharynx
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Boundaries
Superiorly Nasopharyngeal isthmus is
bounded by:
Lower border of soft palate.
A ridge on posterior wall of pharynxPassavants ridge, caused by the posterior part of palato-pharyngeus.
Anteriorly oropharyngeal isthmus is bounded by:
Dorsum of tongue
Two palatoglossal folds
Soft palate
Laterally is a triangular depressiontonsillar
fossabounded:
Anteriorly by palato-glossal fold
Posteriorly by palato-pharyngeal fold
Palatine tonsil lies in the tonsillar fossa
Inferiorlythe boundary is formed by upper
border of epiglottis.
3. The laryngo-pharynx or lower subdivision
of pharynx extends from cranial border of epiglottis
up to the lower border of cricoid cartilage (vertebral
levelsixth cervical vertebra).
Boundaries
Anteriorly
The dorsum of tongue
The inlet of larynx
Two piriform fossae on either side
Lateral wallshave the continuation of:
The palato-pharyngeal fold
The salpingo-pharyngeal fold
Posterior wallis featureless
Inferiorlythe laryngo-pharynx is continuous with the esophagus.
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The stylopharyngeus
enters through
muscle
this gap
The glosso pharyngeal nerve
III.The gap between middle and inferior
constrictor.
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Inferior
constrictor
Origin
Side of cricoid
cartilage
Oblique line of
thyroid cartilage
2.
3.
4.
Middle
constrictor
Muscle belly
Insertion
Nerve supply
Fibrous median
raphe on back of
pharynx
Pharyngeal
I. Helps in passage
plexus of nerves of food
(cranial part of
accessory)
Recurrent
Laryngeal nerve
Same
Same
Thin and
quadrangular
muscle belly
Fibrous median
raphe
Some fibers
reach pharyngeal tubercle of
basi-occiput
Fibrous median
raphe
Long and
Posterior border
slender muscle of thyroid cartilage
belly
Passes between
middle and
superior constrictor muscles
Thin and long mus- Posterior border
cle belly lies in a
of thyroid cartifold
lage
5.
SalpingoTubal elevation
pharyngeus
6.
Main actions
Same
Same
Glossopharyngeal nerve
I. Elevates the
pharynx during
swallowing and
speech
Pharyngeal
plexus of nerves
(cranial
accessory)
I. Elevates the
pharynx during
swallowing and
speech
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A. Vertebral artery
B. Emissary vein
spinosum
C. Middle meningeal
artery
D. Mandibular nerve
A. Lingual tonsil
B. Middle meatus
of nose
C. Isthmus
D. Naso pharynx
A. Synostosis
B. Pivot joint
C. Condyloid joint
D. Secondary cartilaginous joint
Answers
A1. The answer is C.
The dangerous layer of scalp is the loose
areolar tissue layer, due to its potential large
extent and presence of emissary veins, that
may carry infections inside the skull.
A2. The answer is D.
The facial vein joins with the anterior division
of retromandibular vein to form the common
facial vein that ends in internal jugular vein.
The pterygoid venous plexus receives veins
from nasal cavities, palate, pharynx and
structures in temporal and infra temporal
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S. Name
No.
Function
Crossed
uncrossed
Spinal
segment
Beginning
Termination
Uncrossed
S5 to T7
Nucleus gracilis
Uncrossed
T1 to T6
Nucleus cuneatus
Fasciculus
gracilis
2.
Fasciculus
cuneatus
Dorsolateral
(Lissauers)
3.
4.
Lateral
spinothalamic
5.
Anterior
spinothalamic
6.
Spinotectal
7.
Posterior
spinocerebellar
Anterior
spinocerebellar
Spinoolivary
8.
Conscious proprioception
Discriminatory
touch
Vibratory sense
Stereognosis
Pain and
Temperature
Uncrossed
C1 to S5
Ascends for 1-5
segments
Crossed
C1 to S5
Pain and
Temperature from
opposite half of
body
Touch (crude) and Crossed
pressure from opposite half of body
Afferent limb of
Crossed
reflex movement
of eyes and head
towards source
of stimulation
Unconscious pro- Uncrossed
prioception
Substantia gelatinosa
of posterior grey
column
C1 to S5
C1 to C8
C1 to L2
Thoracic nucleus of
posterior grey clumn
Uncrossed
C1 to L2
Uncrossed
C1 to S5
Crossed
C1 to S5
2.
Uncrossed
C1 to S5
3.
Anterior
corticospinal
Rubrospinal
4.
Lateral reticulospinal
5.
Anterior reticulospinal
Olivospinal
6.
7.
8.
Extra pyramidal
tract
Extra pyramidal
tract
Vestibulospinal Efferent pathway
for equilibratory
control
Tectospinal
Efferent pathway
for visual reflexes
C1 to S8
C1 to S5
Reticular formation of
grey matter of medulla
oblongata
Reticular formation
of grey matter of pons
Inferior olivary nucleus
Uncrossed
mainly
Uncrossed
C1 to S5
Uncrossed
C1 to S5
Lateral vestibular
nucleus
Crossed
C1 to S5
Superior colliculus
C1 to S8
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Branches
i. Anterior spinal and posterior spinal
arteries supply front of medulla
oblongata and then descend to supply
the spinal cord.
ii. Small medullary branches supply the
peripheral parts of medulla oblongata.
iii. Posterior inferior cerebellar artery
passes laterally and supplies lateral
part of medulla oblongata and
cerebellum.
c. The basilar artery is the median anastomotic
channel formed by union of two vertebral
arteries.
It lies in basilar sulcus on ventral surface
of pons.
At upper border of pons it bifurcates
into two posterior cerebral arteries.
Branches are paired
a. Anterior inferior cerebellar artery
supplies inferior surface of cerebellum.
b. Labyrinthine artery enters internal
acoustic meatus and supplies the
internal ear.
c. Small pontine branches are given to
the ventral surface of pons.
d. Superior cerebellar supplies superior
surface of cerebellum.
e. Posterior cerebral are the terminal
branches.
The circle of Willis(circulus arteriosus) is an
anastometic circle formed by union of main arteries
at the base of the brain (Fig. 44.3).
The circle is shaped like a polygon and lies
in the inter-peduncular cistern surrounding
the interpeduncular fossa on the base of the
brain.
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Formation
Anteriorly by anterior communicating artery.
Antero-laterally by anterior cerebral artery.
Laterally by posterior communicating artery.
Posteriorly by bifurcation of basilar artery into
two posterior cerebral arteries.
The circle of Willis shows variations in about
30% cases.
Normally, there is little blood flow through the
thin communicating branches, so it is doubtful
that this anastomosis helps to equalise the blood
flow of the two arterial systems supplying
brain.
If, however, one of the major arteries forming
the circle is blocked gradually, this anastomosis
may provide an alternative route of blood flow.
Branchesthe circle of Willis gives six groups
of long, ganglionic (central branches) that
pierce the surface of brain and supply deeper
structures. These are:
i. Antero-medial group from anterior cerebral
and anterior communicating arteries.
ii. Antero-lateral group (two) from beginning
of middle cerebral arteries. These are also
called striate arteries and are divided into
two groupsmedial and lateral.
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45
Subdivisions
The brain is divided functionally and developmentally into three parts:
i. The forebrain: Prosencephalon consists of
TelencephalonThe two cerebral
hemispheres (cerebrum).
DiencephalonThe median part.
ii. The midbrain: Mesencephalon.
iii. The hindbrain: Rhomhencephalon consists of
MetencephalonThe pons and cerebellum.
MyelencephalonThe medulla oblongata.
The Brain Stem
Appears as continuation upwards of the spinal cord.
It consists of:
The medulla oblongata
The pons
The mid brain
The cerebellum is attached to the back of brain
stem and the forebrain lies above it.
Internal Structure
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The Pons
The pons appears as a bridge between the two
halves of the cerebellum, although no fibers pass
as such.
Location: The pons also lies in the posterior
cranial fossa, related to the basilar part of pons
and body of sphenoid.
Parts: The pons is divided into two parts:
a. The ventral part (the basilar part) is a new
addition to the human brain. It continues as
middle cerebellar peduncles.
It forms functionally, an important cell
station in cortico-ponti-cerebellar pathway.
It forms a prominent bulging on front
of pons with basilar sulcus in-between.
b. The dorsal part (the tegmentum) that forms
the upward continuation of the medulla
oblongata.
The dorsal surface of pons forms the
upper part of the floor of fourth ventricle.
Internal Structure
a. The basilar part shows: (Fig. 45.2)
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498
Love
I. Anterior
lobe
THE CEREBELLUM
II. Middle
lobe
Vermis
Lingula (L)
Central
lobule (CL)
Culmen (C)
Declive (D)
Folium (F)
Tuber (T)
Pyramid (Py)
Uvula (U)
Nodule (N)
Hemisphere
Ala
Quadrangular lobe
Lobulus simplex
Superior semilunar lobule
Inferior semilunar lobule
Biventral lobule
Tonsil
Peduncle
Phylogenetic classification
i. Archicerebellum is the oldest part.
It consists of
Flocculonodular lobe
Lingula of anterior lobe
ii. Paleocerebellum is the old part.
It consists of
Anterior lobe (except lingula)
Uvula and pyramid of posterior lobe
iii. Neocerebellum is latest and most dominant
part in scale of evolution.
It consists of posterior lobe (except uvula
and pyramid).
The old parts are concerned with maintenance of equilibrium and muscle tone.
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Connections of cerebellum
Afferent
i. Afferent climbing fibers are mostly
olivocerebellar and they make 1:1
synapse with Purkinje cells of cerebellar
cortex.
ii. Afferent mossy fibers are spinocerebellar, ponto-cerebellar and
vestibulo-cerebellar.
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Fig. 45.5: The brain stemposterior aspect showing floor of fourth ventricle
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CHAPTER
46
The Forebrain
The forebrain (Prosencephalon) consists of:
i. A median portionthe diencephalon.
ii. Two lateral cerebral hemispheresthe
telencephalon.
I. The diencephalon consists of two halves
separated by the median cavity of third ventricle.
Each half consists of a dorsal portion that
includes the thalamus and epithalamus and a
ventral portion that includes subthalamus and
hypothalamus.
a. The thalamus is an ovoid mass of grey matter
that lies in the lateral wall of third ventricle (Fig.
46.1).
Size: The length of thalamus is about 4.0 cm,
width 1.5 cm and thickness 1.0 cm.
Ends and surfaces: The thalamus has two
endsanterior and posteriorand four surfacessuperior, inferior, medial, and lateral.
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calcarine tract.
Medial geniculate bodyis part of
auditory pathway Afferent connectionsInferior colliculus
Part of auditory pathway
Lateral lemniscus
Efferent connection
Acoustic radiation
Functional Significance
i. Thalamus is a great sub-cortical sensory
correlation center. All sensory impulses
somatic and visceralreach here and are
integrated before passing them on to cerebral
cortex for fine discrimination.
ii. Thalamus is concerned with degree of
consciousness, attention and alertness of an
individual.
iii. Thalamus is involved in subjective feeling
states and the emotional behavior of an
individual.
iv. Thalamus also acts as integration center for
motor impulses.
THE EPITHALAMUS
The epithalamus consists of the pineal body and
the habenular nucleus.
A. The pineal body is small red grey body that lies
between the two superior colliculi.
It is connected by a pineal stalk to the posterior
wall of third ventricle.
The pineal body is homologous with the pineal
organ of earlier vertebrates.
Functional importance
i. In humans, it acts as an endocrine gland.
Its secretion has an inhibitory influence
on the secretions of pituitary gland and
adrenal gland (mainly their gonadotropic
functions)
ii. Tumors of pineal body in the young gives
rise to precocious puberty.
B. The habenular nucleus lies in a small
depression.
The habenular trigone by side of medial aspect
of pulvinar of thalamus.
ConnectionsAfferentStria medullaris
thalami from the hippocampal formation.
Opposite habenular nucleus (the habenular
commissure).
EfferentFasciculus retroflexusto the interpeduncular nucleus from where fibers reach
reticular formation of midbrain.
Function: Habenular nucleus is small but
functionally it is important. It provides a nodal
point for integration of large variety of visual,
olfactory and somatic afferent impulses.
C. The Posterior Commissure lies in the inferior
lamina of pineal stalk.
This commissure is very small in human brain.
The fibers contributing to this commissure are
derived from:
Medial longitudinal fasciculus
Pretectal nucleus
Superior colliculus
Posterior thalamic nuclei
THE HYPOTHALAMUS
The hypothalamus lies below and in front of
thalamus separated by the hypothalamic sulcus.
Location: the hypothalamus lies in anterior part
of lateral wall of third ventricle.
The hypothalamus consists of several nuclei
that are concerned with visceral functions. The
mamillary bodies are part of hypothalamus.
Functions of hypothalamus
i. By releasing certain releasing factors and
inhibiting factors, the hypothalamus
influences the secretion of hormones from
the anterior pituitary gland.
ii. The vasopressin (antidiuretic hormone) and
oxytocin are secreted by hypothalamic
nuclei and reach the posterior pituitary gland,
from where they reach blood stream.
iii. Control of sleep and wakefulness.
iv. Temperature regulation of the body.
v. Emotions and behavior of the individual are
also controlled by hypothalamus.
vi. Control of anatonomic activity of sympathetic and parasympathetic systems.
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The Forebrain
THE SUBTHALAMUS
The subthalamus lies below thalamus and is
continuous caudally with the tegmenta of midbrain.
The subthalamus has the following collection
of grey matter:
Cranial end of red nucleus
Cranial end of substantia nigra
Subthalamic nucleus
Small nuclei that act as cell station on
pathways to corpus striatum.
The white matter of subthalamus has following
tracts:
Cranial ends of lemniscimedial, trigeminal
and spinal.
Dentato-thalamic tract
Fasciculus retroflexus
Ansa and fasciculus lenticularis
Fasciculus thalamicus
The subthalamic nucleus is quite prominent in
human brain.
The nucleus lies lateral to the cranial end of
red nucleus.
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Boundaries
i. The roof is formed by ependyma, stretching
between the two thalami. The choroid plexus
bulges through it.
ii. The floor is formed by the following:
The optic chiasma
The tuber cinereum, infundibulum and
the hypophysis cerebri
Two mamillary bodies
Posterior perforated substance
Subthalamus
iii. The anterior boundary is formed by
Lamina terminalis
Anterior commissure
Column of fornix
iv. The posterior wall is formed by
The pineal body
The stalk of pineal body having
Habenular commissure
Posterior commissure
v. The lateral walls is formed by
Medial surface of thalamus with interthalamic adhesion
Hypothalamic sulcus
Medial surface of hypothalamus
The third ventricle has a choroid plexus that
bulges through the ependyma of the roof as
two rows of villous processes.
The posterior choroidal branch of posterior
cerebral artery supplies it.
The recesses of third ventricle are
An infundibular recess
A supraoptic recess above optic chiasma
A pineal recess
Applied anatomy
In case of blockage at interventricular foramen,
there may be internal hydrocephalus of the
affected lateral ventricle. Later the hydrocephalus leads to compression of brain.
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Fig. 46.4: The lateral surface of cerebral hemisphere showing special cortical areas
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Functional Classification
The corpus striatum is divided into
1. The paleostriatum (palladium) is the older part,
consisting of globus pallidus only.
2. The neostriatum (striatum) newer part,
consisting of putamen of lentiform nucleus and
caudate nucleus.
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Functional Significance
i. The corpus striatum is connected with
lower motor centers by polysynaptic pathways. The main outflow, however, is via
thalamus to motor and premotor areas of
the cortex.
ii. The corpus striatum is connected with
motor functions of the body, but its complex
interconnections and functional significance
is not well understood.
Applied Anatomy
i. Lesions of corpus striatum produce
Disturbances in muscle tonemostly
rigidly
Loss of automatic associated movements
Certain unwanted and uncontrollable
movements
ii. Wilsons disease (Hepato-lenticular degeneration) involves liver and lentiform nucleus.
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The Forebrain
d. The inferior longitudinal fasciculus
connects the areas of occipital lobe with
temporal pole.
e. The fronto-occipital fasciculus lies lateral
to the caudate nucleus on a deeper plane
and connects frontal area with occipital
areas.
f. Perpendicular fasciculus connects the
different areas of the occipital lobe.
II. The commissural fibers connect the corresponding areas of the two cerebral hemispheres.
These fibers cross the median plane and are
arranged in well defined bundles.
The different commissural fiber bundles of
forebrain are:
a. The corpus callosum
b. The anterior commissure
c. The habenular commissure
d. The posterior commissure
e. The hippocampal commissure
A. The corpus callosum is the largest commissural
bundle.
It forms a thick curved band that connects
the medial surfaces of two hemispheres.
Parts
i. The anterior end is genu that is bent like
knee. It thins out below to form the
rostrum.
ii. The body is the main part that curves
backwards from the genu and roofs over
the lateral ventricles.
iii. The splenium is thick posterior end that
is separated by transverse fissure from
the pineal body.
Fibers: The fibers of the rostrum connect
the orbital surfaces of two hemispheres.
The fibers of genuforceps minor
radiate laterally and connect the lateral
and medial surfaces of frontal lobes of
the two hemispheres.
The fibers of body are divided into two
groups:
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Boundaries
i. The anterior horn is a wide space that points
forwards and laterally in frontal lobe. (Fig.
46.11)
Roof is formed by under surface of
corpus callosun.
Medial wall by septum pellucidum.
Floor is formed.
Medially by rostrum of corpus callosun
(small part).
Laterally by bulging head of caudate
nucleus
ii. The central part extends from interventricular foramen up to splenium of
corpus callosum.
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CHAPTER
47
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B.
C.
D.
E.
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Carotid sinus
Carotid body
Special Sensory Posterior 1/3rd tongue
Supply (Taste) Circum vallate papillae
Course: The glossopharyngeal nerve is attached
on the postero-lateral sulcus of medulla
oblongata above vagus nerve between olive and
inferior cerebellar peduncle.
The nerve from its attachment turns laterally
grooving the superior surface of jugular
process of occipital bone.
It comes out of skull, through middle part
of jugular foramen enclosed in separate dural
sheath.
[The extra cranial course and branches
described in Chapter 40].
10. The Vagus Nerve (X cranial nerve)
Functional components are:
i. Special visceral efferent (Sp. VE) concerned
with the nerve supply of muscles developed
from branchial musculature.
ii. General visceral efferent (GVE) concerned
with the nerve supply of visceral musculature (of gastro-intestinal system and
respiratory system)
.
iii. General visceral afferent (GVA) concerned
with the receiving sensations from the
viscera.
iv. Special visceral afferent (Sp. VA) is
concerned with special sense of taste from
posteriormost part of tongue and epiglottis.
v. Somatic afferent (SA) is concerned with
reception of general sensations.
The nuclei of the vagus nerve are:
a. The nucleus ambiguous for the supply of
branchial musculature.
b. The dorsal nucleus of vagus considered to
be a mixed nucleus concerned with
Supply of smooth muscles of the viscera
Receiving afferent sensations from the
viscera.
c. The nucleus of tractus solitarius receives
the special sensory fibers of taste.
d. The spinal nucleus of trigeminal nerve
receives the general sensory fibers.
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Distribution
Motor Supply
Viscoral Motor
Supply
Special Sensory
Supply (Taste)
Sensory Supply
Course
The vagus nerve is attached on the posterolateral sulcus of medulla oblongata below
the glosso-pharyngeal nerve.
The nerve turns laterally and comes out of
skull through the middle part of jugular
foramen, enclosed in a common dural
sheath with the accessory nerve.
[The cervical part of course and branches
is described in Chapter 40. The thoracic part
of the course is described in Chapter 24.
The abdominal part of course is described
in Chapter 27].
11. The Accessory Nerve (XI cranial nerve)
Functional component is
Special visceral efferent (Sp. VE) concerned
with the nerve supply of muscles developed
from branchial arches.
The nuclei of origin are
a. The nucleus ambiguous gives origin to the
fibers of the cranial part.
b. The spinal nucleus located in the anterior
grey column of upper five cervical segments
of the spinal cord gives origin to the fibers
of the spinal part.
Distribution
Cranial part
Motor Supply Muscles of soft palate
Intrinsic muscles of
larynx
Spinal part
Motor Supply
Sternomastoid, trapezius
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CHAPTER
48
The Eyes
The two eyeballs and their appendagesmuscles,
vessels, and nerveslie in the bony cavities on
front of the skull called orbits.
THE ORBIT (Fig. 48.1)
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THE EYEBALL
The eyeball is a spherical structure with a diameter
of about 2.5 cm. It is a very durable structure
protected by a tough fibrous coat (Fig. 48.3).
The fascial sheath (Tenons capsule)
The eyeball is surrounded by a connective
tissue sheath. The extra ocular muscles pass
through this sheath for their insertion on
the sclera.
The sheath is separated from the sclera by
an episcleral space.
The sheath is thickened below the eyeball
to form the suspensory ligament (of Lockwood), that stretches across the orbit like a
hammock supporting the eyeball.
The sheaths of lateral and medial rectus
muscles are thickened to form the lateral
and medial check ligaments.These ligaments
prevent overaction of the opposite rectus
muscles of the eyeball.
The coats of the eyeball: The eyeball has three
coats:
i. Outer fibrous coat
ii. Middle vascular coat
iii. Inner nervous coat
I. The fibrous coat consists of two parts:
a. The sclera (white of the eye) forms
nearly posterior 5/6 th of the fibrous coat.
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The Eyes
It is composed of dense connective
tissue. The extraocular muscles are
inserted on the sclera.
The sclera joins with the cornea at
the sclero-corneal junction.
The anterior part of sclera is covered
by the bulbar conjunctiva.
b. The cornea is the transparent anterior
1/6 th part of the fibrous coat.
The cornea has a smaller curvature
than the sclera and is the main
refracting medium of the eye.
The cornea is covered by the anterior
corneal epithelium, that is continuous
with conjunctiva.
Irregularity in the shape of cornea
produces astigmatism.
Injury or inflammation of cornea
(keratitis) may cause corneal opacities by scarring. These can be
corrected by keratoplasty.
II. The vascular coat consists of three parts:
a. The choroid layer has chorio-capillaris
supplied by the short ciliary arteries and
drained by vorticose veins.
b. The ciliary body lies anterior to the
choroid layer.
The ciliary body has about 80 ciliary
processes to which are attached a
large number of zonular fibers that
are attached to the capsule of the
lens.
Inside ciliary body is the ciliary
muscle consisting of rdial and
circular smooth muscle fibers.
The ciliary muscle is supplied by
parasympathetic fibers.
The contraction of the ciliary muscle
draws the ciliary processes anteriorly, thereby relaxing the zonular
fibers and making lens more convex
for near vision (accommodation).
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Origin
Insertion
Nerve supply
Main actions
1.
Common
tendinous ring
Superior aspect of
sclera, about 6.0 mm
from cornea
Superior ramus of
oculomotor
Superior
rectus
2.
Inferior
rectus
3.
4.
5.
6.
7.
Inferior aspect of
sclera about 6.0 mm
from cornea
Inferior ramus of
oculomotor
Inferior ramus of
oculomotor
Abducent nerve
Trochlear nerve
Inferior ramus of
oculomotor
Superior ramus of
Oculomotor
Non-striated muscle
fibers by sympathetic
Fig. 48.4: The recte and oblique muscles of eyeball (lateral aspect)
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iv. The posterior ciliary branches pierces the
sclera around optic nerve to supply the
eyeball.
v. The posterior ethmoidal artery enters the
posterior ethmoidal canal and supplies the
ethmoidal air sinuses and lateral wall of nasal
cavity. It also gives meningeal branch.
vi. The anterior ethmoidal artery enters the
anterior ethmoidal canal and supplies the
ethmoidal sinuses and lateral wall of nose.
It also gives meningeal branches.
vii. Two medial palpebral branches supply the
two eyelids.
viii. The dorsal nasal branch supplies the root
of nose and anastomoses with terminal part
of facial artery.
ix. The supra-trochlear arterysupplies the
skin of forehead.
x. Small muscular branches supply the
extraocular muscles.
The Veins
i. The superior ophthalmic vein drains venous
blood from structures in the upper part of
orbit including eyelids, nose and part of
forehead.The superior ophthalmic vein
communicates with the beginning of facial
vein.
ii. The inferior ophthalmic vein receives
venous blood from lower part of orbit. The
inferior ophthalmic vein communicates with
the pterygoid venous plexus via the inferior
orbital fissure.
The two ophthalmic veins leave the orbit via
the superior orbital fissure and end in the cavernous
venous sinus.
The Nerves of the Orbit
(I) The motor nerves supplying the extraocular
muscles are threeoculomotor, trochlear and
abducent (Fig. 48.7).
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Branches:
i. Communicating branch to ciliary
ganglion before crossing the optic
nerve.
ii. Two long ciliary nerves that pierces
sclera on either side of optic nerve.
Inside eyeball, it supplies the dilator
pupillae muscle.
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The Eyes
iii. Posterior ethmoidal nerve enters the
posterior ethmoidal foramen and
supply ethmoidal sinuses.
iv. Anterior ethmoidal nerve enters
anterior ethmoidal canal. It supplies
ethmoidal air sinuses, the lateral wall
of nose and reaches the external
nose to supply the skin up to tip of
nose as external nasal nerve.
v. Infratrochlear supplies lower eyelid
and skin of root of nose.
b. The frontal nerve enters orbit through lateral
part of superior orbital fissure.
It passes forwards above the levator
palpebrae superioris and divides into two
branchesthe supra-trochlear and supraorbital, that emerge at the orbital opening to
supply skin of forehead and scalp.
c. The lacrimal nerve also enters the orbit via
the lateral part of superior orbital fissure.
It runs along the lateral wall of orbit and
gives.
Glandular branch to lacrimal gland.
A palpebral branch to upper eyelid
It also receives a communicating branch
from the zygomatic nerve, that carries post
ganglionic parasympathetic fibers for
lacrimal gland.
(ii) The optic nerve pierces the sclera about
3.0 mm medial to the posterior pole.
The nerve is about 4.0 cm long and
passes backwards and medially to
the optic canal.
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The nerve is slightly longer than the
CHAPTER
49
The Ears
The two ears lie on either side of skull. Each ear
consists of:
i. An external ear
ii. A middle ear
iii. An internal ear
THE EXTERNAL EAR
The external ear consists of the pinna (auricle),
the external acoustic meatus and the tympanic
membrane.
A. The pinna lies on the lateral side of the head. It
collects the sound waves.
The pinna is made up of a single piece of elastic
cartilage covered by perichondrium.
The parts of the pinna are (Fig. 49.1):
a. The helix is the rolled outer edge of pinna.
It begins as crus at the bottom of concha.
A small tuberclethe Darwins
tuberclemay be seen sometimes on the
helix. This represents the tip of the pinna.
b. The antihelix is another ridge that runs inside
and parallel to the helix.
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The Ears
The Junctional skin with the scalp is
supplied by the auricular branch of vagus
(Arnoids nerve).
The extrinsic muscles of the auricle are small
and rudimentary in humans. They are:
i. The auricularis anterior arises from the
lateral edge of epicranial aponeurosis and is
attached to the cranial surface of auricle.
It is supplied by temporal branch of
facial. It draws the auricle forwards.
ii. The auricularis superior is the largest. It
also arises from epicranial aponeurosis and
is attached to the cranial surface of auricle.
It is also supplied by the temporal branch
of facial nerve and it elevates the auricle
a little.
iii. The auricularis posterior is attached to the
mastoid temporal bone and cranial surface
of auricle.
It is supplied by the posterior auricular
branch of facial nerve and it draws the
auricle backward.
The intrinsic muscles of the auricle are very
small and connect the different parts of the
cartilage of the pinna.
They alter minimally the shape of the auricle.
B. The external acoustic meatus
It is a bent canal that leads from the bottom of
concha of the auricle to the tympanic membrane.
Length is 2.4 mm from the bottom of concha,
out of which the outer third, i.e. 8.0 mm is
cartilaginous, while the inner two-third, i.e. 16.0
mm is bony.
Direction: The outer third portion is directed
upwards and backwards and is lined by skin
containing hair follicles, sweat and sebaceous
glands secreting earwax (ceruminous glands).
The inner part is directed downwards and
is lined by epithelium having few hair and
glands.
The arterial supply is by:
i. The posterior auricular artery
ii. The deep auricular branch of maxillary artery
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The condition, if not treated properly,
becomes chronic.
The complications maybe:
a. The mastoiditis or infection of the
mastoid air cells.
b. Paralysis of the facial nerve due to
involvement of facial nerve in its
bony canal.
c. Perforation of eardrum, that can only
heal if the infection is removed.
II. Surgical approach to the middle ear can be
made through the mastoid antrum, that lies
15.0 mm deep to the supra-meatal triangle
in an adult.
THE AUDITORY TUBE
[PHARYNGO-TYMPANIC TUBE]
The auditory tube connects the middle ear with the
lateral wall of nasopharynx.
Lengthabout 36.0 mm (lateral 12.0 mm is
bony, while medial 24.0 mm is cartilaginous).
Coursethe auditory tube passes anteromedially from the middle ear to the nasopharynx
making an angle of 45 with sagittal plane and
30 with the horizontal plane.
The cartilage of the tube bulges in the lateral
wall of nasopharynx forming tubal
elevation above and behind the opening of
the auditory tube.
There is a small collection of lymphoid tissue
near the opening of the tube called the tubal
tonsil.
The salpingo-pharyngeus muscles arise from
the tubal elevation.
TerminationThe auditory tube opens in the
lateral wall of nasopharynx.
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It consists of:
I. The cochlear ductthe middle canal of the
cochlea wedged between the scala vestibuli
and scala tympani.
It is bounded above by the vestibular
membrane and below by the basilar
membrane attached to the bony spiral
lamina.
The senstive hair cells belonging to the
organ of corti rest on the basilar
membrane suspended in the endolymph.
The hair cells perceive the vibration and
the nerve fibers carry the sensations to
the spiral ganglion where the first
neurons of the auditory pathway are
located.
The axons of these neurons form the
fibers of the cochlear nerve.
II. The utricle and the saccule are two
membranous sacs situated inside bony
vestibule. They are filled with endolymph.
The utricle is larger sac and is connected
to the three semicircular ducts. A
senstive receptor-macula is situated in
its lateral wall.
The saccule is smaller sac and is
connected with the cochlear duct.
A ductus and saccus endolymphaticus is
connected to both utricle and saccule
and lies under the dura mater of the
posterior cranial fossa on the petrous
temporal bone.
There is also a senstive receptor macula
situated in the anterior wall of saccule.
III. The three semicircular ducts are contained
within the semicircular canals and suspended
in perilymph.
Inside the ampulla of the semicircular
canals lie the dilatations of the semicircular ducts.
These dilatations contain special receptor
end organscristae ampullaris.
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The Ears
ORGAN OF CORTI
Organ of corti is the special receptor organ for
hearing located within cochlea
It consists of
i. Special sensory Hair cells
ii. Supporting cells-pillar cells and phalangeal
cells.
These cells are arranged on basilar membrane
that is attached is the osseous special lamina.
I. The Hair cellshave peculiar hair like projections
from there free ends.
There is single row of inner hair cells - (about
7000) and three rows of outer hair cells in basal
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D. Trigeminal nerve
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A. Labrynthine
artery
B. Middle cerebral
artery
C. Posterior inferior cerebellar
artery
D. Lacrimal
branch of
ophthalmic
artery
Answers
A1. The answer is B.
The subarachnoid space, between the
arachnoid and pia mater ends below at the
level of second sacral vertebra, where the
dura and arachnoid mater also end.
A2. The answer is C.
The ligamentum denticulatum has twenty-one
tooth processes. The first tooth process is
attached to the margin of foramen magnum
above the first cervical nerve root. The tooth
processes are attached to the dural tube in
between the nerve roots. The last tooth
process (the twenty-first) is attached between
twelfth thoracic and first lumbar nerve roots.
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Index
A
Accessory nerve 449
Anal triangle 335
anal canal 335
blood supply 365
clinical considerations 337
lymphatic drainage 336
musculature 335
nerve supply 336
Anomalies of rotation of midgut
269
Ansa cervicalis 434
Anterior abdominal wall 243
applied anatomy 252
blood vessels 250
layers 244
lymphatic drainage 251
nerve supply 251
rectus sheath 247
bones and joints of abdominal
wall 243
joints of lumbar vertebrae 244
lumbar vertebrae 243
characteristics 243
ossification 244
variations 243
lumbo-sacral joint 244
Arteries of the gastrointestinal tract
296
branches 297
common hepatic artery 297
left gastric artery 297
splenic artery 297
superior mesenteric artery
298
coeliac axis artery 296
Auditory tube 541
Autonomic nerves in the pelvis
334
B
Basal nuclei 508
Blood cells of the thoracic wall 201
Blood vascular system 21
arteries 23
functional end arteries 24
structure 23
arterio-venous anastomosis 24
capillaries 25
clinical considerations 25
heart 21
coronary circulation 22
fetal circulation 22
rate of contraction 22
veins 24
Blood vessels of the front of neck
441
Body of mandible 376
Bones 9
blood supply 12
epiphyseal and juxtaepiphyseal vessels 12
nutrient vessels 12
periosteal vessels 12
clinical considerations 12
functional considerations 11
functions 9
protection 9
shape 9
ossification 11
intra-cartilaginous type 11
intra-membranous type 11
structure 10
inorganic content 10
organic matrix 10
osteocytes 10
types 10
flat bones 10
irregular bones 11
long bones 10
pneumatic bones 11
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sesamoid bones 11
short bones 10
Bones of foot 125
ossification of tarsal bones 127
ossification of the metatarsals and
phalanges 127
Bones of thorax 183
ribs 184
applied anatomy 187
general features 184
ossification 186
special features 186
sternum 183
general features 183
ossification 184
special features 184
thoracic vertebrae 187
ossification 189
Bony pelvis 322
sex differences 324
shapes 323
Branches of oculomotor nerve 520
Bronchial tree 213
Bursae 20
clinical considerations 20
function 20
types 20
articular bursa 20
inter-tendinous bursa 20
sub-cutaneous bursa 20
sub-ligamentous bursa 20
sub-tendinosus bursa 20
C
Campers fascia 19
Carpal bones 52
distal 52
capitate 52
hamate 52
trapezium 52
trapezoid 52
552
proximal 52
lunate 52
pisiform 52
scaphoid 52
triquetral 52
Cartilages 12
hyaline cartilage 12
white fibro-cartilage 13
yellow elastic cartilage 13
Cartilaginous joints 14
Central nervous system 30
brain 30
membranes of brain 30
lumbar puncture 33
nerves fibers 33
sheaths 33
types 33
neuroglia 32
functions 32
types of cells 32
neuron 32
functions 32
parts 32
types 32
spinal cord 31
Cerebellum 498
subdivision 498
white matter 498
Cerebral cortex 506
Cervical part of esophagus 474
Cervical sympathetic trunk 450
Cervical vertebrae 386
Chyluria 28
Cisterna chyli 26, 27
Clavicle (collar bone) 45
applied anatomy 46
general features 45
ossification 46
special features 46
Coccyx 325
ossification 325
Colon 294
applied anatomy 296
blood supply 295
lymphatic drainage 295
nerve supply 296
veins 295
Cranial cavity 409
hypophysis cerebri 414
applied anatomy 416
nerves 414
trigeminal ganglion 414
D
Deep lymphatics 28
Deep muscles of back 397
Deep palmar arch 105
Descriptive anatomical terms 2
anterior-posterior 2
cranial-caudal 2
medial-intermediate-lateral 2
palmar-plantar 2
peripheral-central 2
proximal-distal 2
superficial-deep 2
superior-inferior 2
Dorsal interossei 103
Dorsum of wrist and hand 95
blood vessels on dorsum of hand
96
arteries 96
deep veins 96
veins 96
nerves on the dorsum of hand 97
dorsal branch of ulnar nerve
97
superficial terminal branch of
radial nerve 97
9
ri 9
h
a
functions 354
prostate gland 356
clinical considerations 358
lymphatic drainage 357
nerve supply 357
seminal vesicles 355
blood supply 355
nerve supply 355
structure 354
vas deferens 354
applied anatomy 355
blood supply 355
Epithalamus 504
Esophagus 271
applied anatomy 271
esophageal 271
esophagitis 271
hiatus hernia 271
blood supply 271
nerve supply 271
Exterior of skull 371
External intercostals muscles 194
Extrahepatic biliary apparatus 283
applied anatomy 284
functions 283
Extrinsic muscles 194
Eyes 525
blood vessels 530
extraocular muscles 530
eyeball 528
chambers 530
lens 530
eyelids 526
lacrimal apparatus 526
nerves 533
orbit 525
V
d
ti e
n
U
G
R
Ears 536
external ear 536
applied anatomy 538
internal ear 541
middle ear 538
Elbow joint 80
arterial anastomosis 80
applied anatomy 80
deep veins 81
veins 80
Electromyography 19
Epididymis 354
ejaculatory ducts 356
F
Face 403
blood vessels 403
lymphatic drainage 407
motor nerves 408
applied anatomy 409
nerve supply 407
applied anatomy 408
Fasciae 19
clinical considerations 20
deep fascia 20
superficial fascia 19
Fasciae of the head and neck 395
Index
Female reproductive organs 359
ovaries 359
blood supply 359
clinical considerations 360
lymphatic drainage 360
nerve supply 360
uterine tubes (fallopian tubes)
363
clinical considerations 364
lymphatic drainage 364
nerve supply 364
uterus 360
blood supply 361
clinical considerations 362
lymphatic drainage 362
nerve supply 362
supports of the uterus 362
vagina 364
blood supply 365
lymphatic drainage 365
nerve supply 365
Femur 117
general features 117
ossification 120
special features 119
Fibula 122
general features 122
ossification 124
special features 123
Fontanelles of the skull 386
Forebrain 502
Fourth ventricle of brain 500
Frankfurts plane 371
Functional parts of nervous system
35
postganglionic neuron 37
somatic nervous system 35
somatic afferent part 35
somatic efferent part 35
visceral nervous system 36
visceral afferent part 36
visceral efferent system 36
G
Glosso-pharyngeal nerve 447
H
Heart 217
applied anatomy 222, 227
dextrocardia 227
tahir99 - UnitedVRG
553
Hypoglossal nerve 450
Hypothalamus 504
Hypothenar muscles 101
I
Individual bones of skull 374
Infratemporal fossa 419
Inguinal region 252
applied anatomy 255
descent of the testes 256
applied anatomy 257
sequence 256
nerves 257
normal mechanism 253
sex difference 253
walls of the inguinal canal 253
Inlet of thorax 193
boundaries 193
plane of inlet 193
structures 193
midlines structures 193
on left side 193
on right side 193
Innermost intercostal 196
Interior of the skull 384
Internal intercostal muscles 195
Intestinal lymph duct 27
Intrinsic muscles 194
J
Jejunum and the ileum 289
blood supply 290
lymphatic drainage 290
nerve supply 290
applied anatomy 290
Joint 13
amphiarthroses 13
primary cartilaginous joint
13
secondary cartilaginous joint
13
blood supply 15
diarthroses (synovial joints) 14
nerve supply 15
synarthroses 13
Joint of bony pelvis 325
pubic symphysis 326
sacro-coccygeal joint 326
sacro-iliac joint 326
554
Joints of the head and neck 391
atlanto-axial joints 393
atlanto-occipital joint 393
joints between cervical vertebrae
394
ligaments connecting axis with
occipital bone 394
sutures of skull 394
temporo-mandibular joint 391
Joints of the lower extremity 129
ankle (talo-crural) joint 134
applied anatomy 135
arterial supply 135
articular capsule 134
articular surfaces 134
ligaments 134
movements 135
nerve supply 135
type 134
arches of foot 139
lateral longitudinal arch 139
medial longitudinal arch 139
transverse arches 140
hip joints 129
applied anatomy 131
articular capsule 129
articular surface 129
ligaments 130
movements of joint 130
nerve supply 130
stability of the joint 129
synovial membrane 130
knee joint 131
applied anatomy 133
articular capsule 131
articular surfaces 131
attachments 131
ligaments of joint 131
menisci (semilunar cartilages)
of knee joint 132
movements 133
nerve supply 133
type 131
mid-tarsal joint 137
calcaneo-cuboid joint 137
talo-calcaneo-navicular joint
137
small joints of foot 138
inter-phalangeal joints 139
inter-tarsal joints 138
K
Kidneys 303
anterior surface 303
blood supply 306
applied anatomy 307
arteries 306
lymphatic drainage 307
nerve supply 307
veins 307
borders 303
ends 303
general structure 305
hilum 304
posterior surface 304
surfaces 303
L
Large intestine 291
cecum 291
Lateral ventricle 513
Left brancho-mediastinal lymph 27
Left jugular lymph duct 27
Left subclavian lymph duct 27
Limbic system 516
Liver (hepar) 279
applied anatomy 282
bare areas 282
blood supply 282
lobes of liver 281
location 279
nerve supply 282
segmentation of liver 281
surfaces and borders 279
veins 282
Lower extremity 113
features 113
Lumbar lymph duct 26
Lumbricals 102
Lungs 206
blood vessels 211
bronchial vessels 212
pulmonary vessels 211
broncho-pulmonary segments
211
Index
lobes of lung 210
lymphatic drainage 212
applied anatomy 213
nerve supply 213
Lymph edema 28
Lymph vessels 26
lymph capillaries 26
lymph ducts 26
lymphatics 26
Lymphatic drainage of the head and
neck 447
Lymphatic drainage of the pelvic
organs 332
Lymphatic organs 26
Lymphatic-venous communications
27
M
Male reproductive organs 352
testis 352
blood supply 353
clinical considerations 354
coverings 352
lymphatic drainage 354
nerve supply 354
structure 352
veins 353
Mammary gland 7
architecture 7
connective tissue stroma 7
glandular 7
suspensory ligaments 7
blood supply 8
clinical importance 8
development 8
anomalies 8
lymphatic drainage 8
nerve supply 7
Mastoid antrum 540
Maxillary nerve 424
Meckels of diverticulum 270
Mediastinum 228
anterior mediastinum 232
boundaries 232
contents 232
middle mediastinum 232
boundaries 232
contents 232
posterior mediastinum 232
azygos vein 236
N
Nerve supply of the thoracic wall
204
Nerves of the front of neck 447
Nerves of the palm 106
tahir99 - UnitedVRG
555
Nerves of the pelvis 332
Nerves of the perineum 338
Nervous system 29
functional classification 29
autonomic nervous system 29
somatic nervous system 29
functions 29
parts 29
central nervous system 29
peripheral nervous system 29
O
Organ of Corti 543
P
Palm of the hand 97
blood vessels of the palm 100
arteries 100
veins 105
long flexor tendons in the palm
99
four tendons of flexor
digitorum profundus 99
four tendons of flexor
digitorum superficialis
99
tendon of palmaris longus 99
nerves 105
cutaneous branches 106
medial nerve 105
Palmar interossei 103
Pancreas 284
applied anatomy 286
blood supply 286
location 284
nerve supply 286
pancreatic ducts 286
parts 284
type 284
Parasympathetic ganglia 425
Parathyroid glands 440
Parotid gland 417
applied anatomy 418
arterial supply 418
nerve supply 418
parotid duct 418
Patella (knee cap) 124
general features 124
ossification 124
556
Pelvic fascia 327
Pelvic muscles 327
Pelvic part of ureter 347
blood supply 348
lymphatic drainage 348
nerves supply 348
clinical considerations 348
Pelvic peritoneum 328
Pericardium 215
applied anatomy 217
dry pericardititis 217
pericardial tamponade 217
pericardio-centesis 217
functions 217
location 215
nerve supply 217
parts 215
fibrous pericardium 215
serous pericardium 215
Peripheral nervous system 34
cranial nerves 34
spinal nerves 34
Peritoneum 260
applied anatomy 266
blood supply 266
lymphatic drainage 266
mesenteries 260
nerve supply 266
peritoneal cavity 261
peritoneal recesses 265
Phalanges 53
Planes of body 2
coronal plane 2
median sagittal (median) plane 2
sagittal (para-sagittal) plane 2
transverse (horizontal) plane 2
Pleura 206
blood supply 208
functions 208
lines of pleural reflection 206
anterior lines of pleural
reflection 206
inferior of pleural reflection
207
posterior lines of pleural
reflection 207
nerve supply 208
pleural recesses 207
Popliteal fossa 157
applied anatomy 159
popliteal artery 159
R
Radius 49
general features 49
special features 49
Rectum 346
blood supply 347
arteries 347
veins 347
interior of rectum 347
lymphatic drainage 347
nerve supply 347
clinical considerations 347
peritoneal relations 346
supports 347
Region of foot 168
dorsum of foot 168
blood 169
muscles and tendons 168
nerves 170
sole of foot 171
blood vessels 174
muscles of sole 171
nerves of sole 176
Region of forearm 85
anterior compartment 85
applied anatomy 89
blood vessels 85
branches 88
branches in forearm 89
muscles 85
S
Sacrum 324
general features 324
Index
sex-difference 325
special features 325
variations 325
Sagittal section through knee joint
132
Scalp 400
blood supply 401
lymphatic drainage 402
nerve supply 402
Scapula 43
general features 43
angles 44
borders 44
surfaces 44
ossification 45
special features 44
Scapular anastomosis 74
Scarpas fascia 19
Sciatic nerve 144
Shoulder region 65
axilla 67
axillary artery 68
axillary lymph nodes 69
axillary vein 69
brachial plexus 69
pectoral region 65
scapular region 73
blood supply of scapular
muscles 74
nerves of scapular region 75
sarratus anterior muscle 73
shoulder region proper 71
deltoid muscle 71
Skin 4
appendages 5
hair follices 6
nails 5
sebaceous glands 6
sweat glands 6
clinical importance 6
functions 4
protection 4
secretion 4
sensations 4
nerve supply 6
parts 4
inner epidermis 4
outer epidermis 4
Spinal cord 481
blood supply 482
meninges 481
tahir99 - UnitedVRG
557
parts 310
veins 310
Sympathetic trunks 237
branches 237
greater splanchnic nerve 237
grey rami communicans 237
lesser splanchnic nerve 237
lowest splanchnic nerve 237
white rami communicans 237
Synovial sheath 20
clinical consideration 20
T
Telencephalon 506
Temporal fossa 419
Thenar muscles and adductor pollicis
101
Third ventricle 505
Thoracic diaphragm 197
development 199
anomalies 199
applied anatomy 199
other structures passing through
diaphragm 199
hemiazygos veins 199
lower five intercostal nerves
199
musculophenic artery 199
subcostal vessels 199
superior epigastric artery 199
sympathic trunk 199
three splanchnic nerves 199
Thoracic duct 27
Thymus gland 441
Thyroid gland 438
applied anatomy 440
blood supply 439
lymphatic drainage 440
nerve supply 440
Tibia 120
general features 120
ossification 122
special features 122
Triangles of the neck 427
anterior triangle of the neck 431
posterior triangle of neck 427
suboccipital triangle of neck 430
Typical intercostal nerve 204
Typical synovial joints 15
558
U
Ulna 50
applied anatomy 51
general features 50
ossification 51
special features 51
Upper arm 78
anterior compartment of arm 78
blood vessels 79
cubital fossa 78
deep lymphatics 81
lymphatics of arm 81
median nerve 81
musculo-cutaneous nerve 81
nerves of anterior
compartment of arm 81
superficial lymphatics 81
posterior compartment of arm 82
blood vessels 82
nerves of the posterior
compartment 83
Upper extremity 43
features 43
Ureter 307
applied anatomy 308
nerve supply 308
Urethra 350
female urethra 351
male urethra 351
Urinary bladder 348
blood supply 350
inferior urinary bladder 349
ligaments 349
lymphatic drainage 350
nerve supply 350
clinical considerations 350
Urogenital triangle in females 343
deep perineal pouch in females
345
nerve supply 345
V
Vagus nerve 449, 523
Vermiform appendix 292
applied anatomy 293
blood supply 293
Vertebral column 389
Viscera of the head and neck 452
cervical part of trachea 459
anterior 459
posterior 459
larynx 455
blood supply 459
cavity of larynx 457
muscles of larynx 457
skeletal framework 453
nerve supply 459
applied anatomy 459
paranasal air sinuses 454
applied anatomy 455
respiratory system 452
opening in lateral wall 453
W
White matter of cerebral hemisphere
510
Wormian (sutural) bones 386
Z
Zygomatic bones 379