The Vessels of Systemic (Greater) Circulation

The Aorta is the main arterial trunk of the systemic circulation. It carries
blood from the left ventrical of the heart. The aorta consists of three sections: (1)
the ascending aorta (aorta ascendens) located in the pericardial sac and carries
blood to the heart; (2) the arch of the aorta (arcus aorta) is between the
ascending aorta and aortic isthmus (isthmus aortae), it carries blood to the head,
neck and upper limbs and to the bronchi and thymus; (3) the descending aorta
(aorta descendens) begins from the aortic isthmus and ends with two common iliac
arteries on the level of the fourth lumbar vertebra. It carries blood to all other parts
of the body.
The aortic isthmus is constriction of the aorta located between the left
subclavian artery and the arterial ligament (lig. arteriosum) which is late arterial
duct (Botalli) and stretches between aortic arch and bifurcation of the pulmonary
trunk.

Branches of the arch of the aorta

The concavity of the aortic border gives off arteries to the bronches and
thymus, and its convexity gives off three trunks, which stretch upward, from right
to left they are: the brachiocephalic trunk, the left common carotid artery and the
left subclavian artery (Fig. 1).
The brachiocephalic trunk (trunkus brachiocephalicus) is about 3-4cm in
length. It runs obliquely upward, anteriorly of the trachea, gives off a branch to the
thyroid gland (a. thyroidea ima) and behind the right sternoclavicular joint it
divides into its terminal branches – the right common carotid and right subclavian
arteries.

The Arteries of the Head and Neck

The Common Carotid Artery

The common carotid artery (a. carotis communis) arises from the
brachiocephalic trunk on the right and from the arch of the aorta on the left sides.
Both common carotid arteries run upwards on the side of the trachea and
oesophagus. The right common carotid artery consists of a cervical section only
and is shorter than the left, which consists of a thoracic section and a cervical
section. The common carotid artery passes in the carotid triangel and on the level
of the superior border of the thyroid cartilage it branches into its terminal branches
– the external and internal carotid arteries. This division is called bifurcation
(bifurcatio carotidis). Before the bifurcation common carotid artery forms dilation
called the carotid sinus (sinus caroticus). Along its entire length the common
carotid artery gives off small branches to the surrounding vessels and nerves (vasa
vasorum and vasa nervorum) (Fig. 1, 2 ).

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 The External Carotid Artery

The external carotid artery (a. carotis externa) supplies blood to the external
part of the head and to the neck. From the point of its origin it runs upward, pierces
the parotid gland and divides into its terminal branches behind the neck of the
mandibular condyloid process. The external carotid artery gives off the branches,
nine in number, which may be divided into three groups, each containing three
arteries – the anterior, middle and the posterior groups (Fig. 3-7) .

The anterior group. Arteries of this group arise from the anterior surface of the
external carotid artery.
1. The superior thyroid artery (a. thyreoidea superior) arises from the external
carotid artery immediately above its origin, below the level of the greater horns of
the hyoid bone and runs downward and anteriorly to the thyroid gland and ends on
the upper pole of the thyroid lobe with the anterior, posterior and lateral branches
(rr. glandularis anterioris, posterioris and lateralis). It gives off branches to the
sternocleidomastoid muscle (r. sternocleidomastoideus), to the hyoid bone (r.
infrahyoideus), to the larynx (a. laryngea superior), to the cricothyroid muscle of
the larynx (r. cricothyroideus). The superior laryngeal artery penetrates hyothyroid
membrane and carries blood to the muscles and mucous of the larynx and partly to
the hyoid bone and to the epiglottis.
2. The lingual artery (a. lingualis) arises on the level of the greater horns of the
hyoid bone, runs upward through Pirogov’s triangle and then passes to the inferior
surface of the tongue into its depth. It gives off branches: to the hyoid bone (r.
suprahyoideus); dorsal branches (rr. dorsales linguae) pass to the posterior part of
the back of the tongue and to the palate tonsils; sublingual artery (a. sublingualis)
carries blood to the sublingual gland and to the surrounding muscles and ends in
the mucous of the floor of the mouth and in the lower gums. The lingual artery
extends to the tip of the tongue with the name a. profunda linguae, it supplies
blood to own muscles and mucous of the tongue.
3. The facial artery (a. facialis) arises above the lingual artery at the level of the
mandibular angle runs through submandibular triangle, penetrates submandibular
salivary gland and reaches the anterior border of the masseter muscle where it
bends over the border of the mandibule onto the face and passes between
superficial and deep facial muscles to the medial angle of the eye, where its
terminal branch, a. angularis, anastomoses with the dorsal artery of the nose (a
branch of the ophthalmic artery from the system of the internal carotid artery).
Numerous small branches of the facial artery supply blood to the muscles of the
facial expression, to the skin of the face. The facial artery gives off the following
branches: a. palatina ascends, r. tonsillaris, a. submentalis, rr. glandulares, aa.
labialis inferior and superior, r. septi nasi, r. lateralis nasi, which carry blood to
the pharynx, soft palate, palatine tonsils, submandibular glands, oral diaphragm
and small salivary glands, to the chin, to the upper and lower lips.

2
The posterior group. Arteries of this group arise from the posterior surface of the
external carotid artery.
1. The occipital artery (a. occipitalis) arises below the posterior belly of the
digastric muscle, lies in the occipital sulcus of the mastoid process, emerges under
the skin in the occipital region, and gives off the following branches: r.
mastoideus, r. auricularis, rr. sternocleidomastoidei, rr. occipitales, r. meningeus,
r. descendens which carry blood to the vertex, to the surrounding muscles, to the
auricle, to the dura mater of the posterior cranial fossa.
2. The posterior auricular artery (a. auricularis posterior) arises above the
posterior belly of the digastric muscle, runs upward and to the back (to the skin
behind auricle, to the muscles of the back of the head) and passes into the facial
canal. Its branches are: a. stylomastoidea, a. tympanica posterior, rr. mastoidei, r.
stapedius, r. auricularis, r. occipitalis, r. parotideus. They supply tympanic cavity
and stapedius muscle, auricle, parotid gland.
3. The sternocleidomastoid artery (a. sternocleidomastoidea) arises on the level
of the origin of the facial artery and runs to the muscle of the same name.

The middle group. One arteriy of this group arises from the medial surface of the
external carotid artery, two other are its terminal branches.
1. The ascending pharyngeal artery (a. pharyngea ascendens) ascends along the
lateral wall of the pharynx and gives off the following branches: a. meningea
posterior, rr. pharyngeales, a. tympanica inferior. These branches supply blood to
the pharynx, the soft palate, the palatine tonsils, the auditory tube, the tympanic
cavity and the dura mater of the brain.
2. The superficial temporal artery (a. temporalis superficialis) is one of two
terminal branches of the external carotid artery. It arises on the level of the neck of
the mandibule, stretches as the continuation of the external carotid artery in front
of the external acoustic meatus penetrates the parotid gland and runs to the temple
under its skin. On the level of the superior orbital border it divides into two
terminal branches: ramus frontalis and ramus parietalis. The artery gives off
branches to the parotid gland (rr. parotidei), to the auricle (rr. auriculares
anteriores), to the muscles of the facial expession of the head (a. transversa faciei,
a. zygomaticoorbitalis, r. frontalis), to the skin of the temple (r. parietalis), and to
the temporal muscle (a. temporalis media).
3. The maxillary artery is second terminal branch of the external carotid artery.
From the site of its origin it passes forward and is subdivided into three sections:
the first-curves medially from the neck of the mandibule; the second-passes in the
infratemporal fossa and the third-penetrates the pterygopalatine fossa.
The branches of the first section:
1. The anterior tympanic artery (a. tympanica anterior) ascends to the external
acoustic meatus and runs into the tympanic cavity through petrotympanic fissure
and supplies the mucous of the tympanic cavity.
2. The middle meningeal artery (a. meningea media) passes to the dura mater of
the middle cranial fossa through spine opening and separates into frontal, parietal,
orbital and petrosal branches.
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3. The inferior alveolar artery (a. alveolaris inferior) passes into the mandibule
through the mandibular canal, and gives off the following branches: rr. dentales,
rr. peridentales, r. mentalis, r. mylohyoideus. These branches supply the
mylohyoid muscle, the lower teeth and gums, and the skin and muscles of the chin.

The branches of the second section supply the mucous membrane of the
maxillary sinus, upper molars and all muscles of the mastication and the cheek
muscle. They are called: a. masseterica, aa. temporales profundae anterior and
posterior, rr. pterygoidei, a. buccalis, a. alveolaris posterior superior. The
posterior alveolar artery passes through apertures of 2-3 alveolar canals of the
maxillar tuber to the upper molars.

The branches of the third section:

1. The inferior orbital artery (a. infraorbitalis) enters the orbit through the
inferior orbital fissure, then passes through the infraorbital canal to the anterior
surface of the maxilla. It gives off branches to the muscles of the eyeball (m. rectus
inferior and m. obliquus inferior), to the lower eyelid, to the lacrimal sac, to the
upper lip and cheek, to the upper teeth (premolars, canine and incisors), to the
upper gums, to the mucous membrane of the maxillary sinus.
2. The descending palatine artery (a. palatina descendens) descends through the
greater and lesser palate canals and supplies the pharynx, the auditory tube, the soft
and hard palates.
3. The sphenopalatine artery (a. sphenopalatina) runs through the
sphenopalatine foramen into the nasal cavity and carries blood to the upper part of
the pharinx, to the mucous membrane of the superior and middle nasal conchae,
lateral nasal wall, nasal septum and ends in the mucous of the frontal and maxillary
sinuses.

The Internal Carotid Artery

The internal carotid artery (a. carotis interna) runs upward from its point of
the origin to the base of skull and enters the carotid canal of the temporal bone. It
is subdivided into four parts: cervical, petrosal, cavernosal and cerebral. It does not
give off branches in the region of the neck; at its origin, at first, it lies lateraly to
the external carotid artery and then it lies on the medial surface of this artery. In
the carotid canal the internal carotid artery, at firs, runs vertically and then curves
anteriomedially towards apex of the temporal pyramid. At the top of the temporal
bone, the artery enters into the cavity of the skull through the internal carotid
foramen. Bending upwards, it runs along the carotid sulcus of the sphenoid bone
through the cavernous sinus. On the level of the optic canal the artery makes turn
upward and posteriorly, giving off its first large branch, a. ophthalmica, after
which it perforates the dura and arachnoid maters and branches into its terminal
branches on the base of the brain (Fig. 7-9).

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The branches of the internal carotid artery:
1. The caroticotympanic branches (aa. caroticotympanicae) are small, thin
branches, penetrating the posterior wall of the carotid canal, pass into the tympanic
cavity.
2. The ophthalmic artery (a. ophthalmica) together with n. opticus penetrates the
optic canal and passes into the orbital cavity, here it crosses optic nerve and passes
along medial orbital wall to the medial angel of the eye where it ends with the
supratrochlear artery and dorsal nasal artery (Fig. 8). Along its course it gives off
several branches to:
- the dura mater of the middle cranial fossa (a. meningea);
- the lacrimal gland (a. lacrimalis );
- the vascular coat of the eyebal (aa. ciliares posteriores breves and longae)
- the retina of the eyeball (a. centralis retina), it passes inside optic nerve and
reaches the nervous coat of the eye;
- the muscles of the eyeball (rr. musculares);
- the eyelids (aa. palpebrales mediales and laterales branch from the lacrimal
artery);
- the mucosa of the nasal cavity and mucosa of the ethmoid air cells (aa.
ethmoidales anterior and posterior);
- the skin and muscles of the medial part of the forehead (a. supratrochlearis);
- the ridge of the nose and lacrimal sac (a. dorsalis nasi), it anastomoses with the
angular artery (branch of the facial artery).
3. The anterior cerebral artery (a. cerebri anterior) runs forward medially to the
start of the longitudinal sulcus of the brain, curves around the knee of the callous
body and stretches along the inner surface of the cerebral hemisphere to the back.
It gives off the branches to the cerebral cortex of the medial surface of the
hemispheres. At the origin of the longitudinal sulcus of the brain it joines with
artery of the same name from the opposite side by means of a transverse trunk
called a. communicans anterior.
4. The medial cerebral artery (a. cerebri media) passes laterally to the depth of
the lateral cerebral sulcus. On the surface of the insula, it divides into branches that
emerge the superolateral surface of the hemisphere and supply this surface of the
frontal, temporal and parietal lobes with blood.
5. The anterior choroid artery (a. choroidea anterior) enters the inferior horn of
the lateral ventricle in the temperal lobe and terminates in the choroid plexus.
6. The posterior communicating artery (a. communicans posterior) passes back
and drains into a. cerebri posterior (branch of the vertebral artery).
As result of the anastomoses between branches of the internal carotid
arteries and posterior cerebral arteries the important anastomotic arterial circle is
formed on the base of the brain which is called circulus arteriosus cerebri (or
Willi’s circle) (Fig. 9). It consists of two anterior cerebral arteries, anterior
communicating artery, two posterior cerebral arteries and two posterior
communicating arteries. It surrounds the optic chiasma, tuber cinereum and
mammillary bodies.
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The Subclavian Artery
The left subclavian artery (a. subclavia) is a branch of the aortic arch, the
right subclavian artery is a branch of the brachiocephalic trunk (Fig. 2, 3, 5, 6, 10-
12). As a result, the right artery is slightly shorter than the left one. Both arteries
form a convex arches, curving around the cupola of the pleurae. They leave the
thoracic cavity through the superior thoracic aperture, approach the clavicle and
lies into the sulcus of a. subclaviae of the first rib.The artery proceedes towards the
axillary fossa and, beginning with the external edge of the first rib, it has been
given the name axillary artery. Along the way the subclavian artery passes through
the interscalene space (between the anterior and middle scalene muscles, which are
attached to the first rib in front of and behind the sulcus of the subclavian artery).
Thus the subclavian artery can be subdivided into three segments: the first - from
the beginning of the artery to the medial side of the anterior scalene muscle, the
second - behind this muscle (in the interscalene space), the third - from lateral side
of this muscle to the external edge of the first rib.

The branches of the first segment of the subclavian artery:

1. The vertebral artery (a. vertebralis) is the first branch of the subclavian artery,
passes upward into the transverse foramen of the sixth cervical vertebra and rises
through the openings in the transverse processes of the cervical vertebrae, after
living of these opernings it lies in the groove of the vertebral artery of the first
cervical vertebra and then perforates the posterior atlantooccipital membrane and
enters the cranial cavity through the foramen magnum. As a result the vertebral
artery is subdivided into four parts:
1 - prevertebral part (pars prevertebralis) – from the beging to the transverse
foramen of CVI;
2 - transverse part (pars transversaria);
3 – atlantic part (pars atlantica);
4 –intracranial part (pars intracranialis).
Within the skull, the both vertebral arteries pass along the medulla oblongata
toward the median line and form a single unpaired artery near the posterior edge of
the pons. Along its way the vertebral artery gives off small branches to the deep
muscles of the neck (rr. musculares), to the spinal cord (rr. spinales, rr.
radiculares and a. meddularis segmentalis) and to the dura-matter of the posterior
cranial fossa (rr. meningei).
In addition it gives off following branches:
(1) The anterior spinal artery (a. spinalis anterior) branches off in the cranial
cavity near the junction of two vertebral arteries and passes down to meet with the
same artery from the contralateral side. They merge into a single trunk which
descends along anterior surface of the spinal cord. As a result, two vertebral
arteries and two anterior spinal arteries form a closed arterial circle on the ventral
surface of the medulla oblongata which is called the Zakharchenkov’s circle,
which is important in the collateral circulation of the medulla oblongata.

6
(2) The posterior spinal artery (a. spinalis posterior) branches off the vertebral
artery as soon as it enters the cranial cavity and also runs down on both sides of the
spinal cord. As a result, three arterial trunks (two posterior and one anterior spinal
arteries) descend along the spinal cord to its lower end. They form anastomoses
with spinal branches of the vertebral, intercostal and lumbar arteries.
(3) The inferior posterior artery of the cerebellum (a. inferior posterior cerebelli)
arises near the pons and branches out on the lower surface of the cerebellum.
(4) The basilar artery (a. basilaris) is formed by the junction of both vertebral
arteries. It is unpaired and lies in the median basilar sulcus of the pons. On the
anterior margin of the pons it divides into two cerebral posterior arteries (a.
cerebri posterior) which branch out on the lower, inner and outer surfaces of the
occipital lobes. The posterior cerebral arteries participate in the formation of the
circulus arteriosus cerebri together with the branches of the internal carotid artery
(Willi’s circle).
Small branches arise from the basilar artery and pass to the pons (aa. pontis),
to the internal ear (a. labyrinthi), and to the cerebellum (a. inferior anterior
cerebelli, a. superior cerebelli and a. vermis superior), to the midbrain (aa.
mesencephalici).
2. The thyrocervical trunk (truncus thyrocervicalis) branches off upwards from
the subclavian artery at the median margin of m. scalenus anterior. The trunk runs
at about 4mm distance from subclavian artery and then divides into three branches:
(a) The inferior thyroid artery (a. thyroidea inferior) passes to the posterior surface
of the thyroid gland, to the larynx, trachea, pharynx oesophagus;
(b) The ascending cervical artery (a. cervicalis ascendens) passes up and supplies
the deep muscles of the neck, and gives off branches to the spinal cord (rr.
spinales);
(c) The suprascapular artery (a. suprascapularis) passes down and laterally to the
suprascapular notch, branches out in the dorsal muscles of the shoulder blade and
the shoulder joint.
3. The internal thoracic artery (a. thoracica interna) arises from a.subclavia
opposite to the origin of a.vertebralis and descends vertically at about 12mm
distance from the edge of the sternum. When it reaches the lower edge of the
seventh rib’s cartilage, it divides into two terminal branches:
(a) a. musculophrenica stretches laterally along the line of the attachment of the
diaphragm and gives rise to small branches to it and to the nearest intercostal
spaces;
(b) a. epigastrica superior continues the internal thoracic artery, penetrates the
sheath of the rectus abdominis muscle, reaches the level of the navel and
anastomoses here with a. epigastrica inferior (branch of the external iliac artery).
The internal thoracic artery gives off branches to the connective tissue of the
anterior mediastinum (rr. mediastinales), thymus (rr. thymici), trachea (rr.
tracheales), bronchi (rr. bronchiales), to six upper intercostal spaces (rr.
intercostales anteriores), to the mammary gland (rr. mammarii mediales), to the
pleura and pericardium (a. pericardiacophrenica).

7
The branches of the second segment of the subclavian artery:
(4) The costocervical trunk (trunkus costocervicalis) branches off in the
interscalene space and passes back and up to the neck of the first rib where it
divides into two branches:
(a) The deep cervical artery (a. cervicalis profunda) supplies the posterior muscles
of the neck (rr. dorsales) and the spinal cord (rr. spinales);
(b) The most superior intercostal artery (a. intercostalis suprema) supplies the
muscles of the first and second intercostal spaces (aa. intercostales posterior
prima and secunda).

The branch of third segment of the subclavian artery:

5) The transverse cervical artery (a. transversa colli) descends along the
vertebral edge of the scapule to its inferior corner and supplies the neighbouring
muscles of the back.

The Veins of the Head and Neck

The veins of the head and neck carry dioxciginated blood into the system of
the superior vena cava.

The superior Vena Cava

The superior vena cava (v. cava superior) is a thick (about 2.5cm), but short
(5-6cm) trunk located to the right and somewhat posteriorly of the ascending aorta
(Fig. 13). It collects blood from the head, neck, upper limbs and thoracic cavity. It
is formed by the merger of the right and left brachiocephalic veins behind the
junction of the first right rib with sternum. From there it passes downward and
drains into the right atrium on the level of the junction of the cartilage of the right
third rib with the sternum. The anterior wall of the superior vena cava is separated
from the anterior thoracic wall by the stratum of the right lung. Vv. mediastinales,
vv. pericardicae and v. azygos drain into the superior vena cava. The superior vena
cava has no valves.

The right and left brachiocephalic veins (v.v. brachiocephalica dextra and
sinistra) are formed by the merger of the subclavian and internal jugular veins
behind the right and left sternoclavicular joints. They collect blood from the head,
neck and upper limbs. The left brachiocephalic vein is about twice the length of the
right one. V. thyreoidea inferior, plexus v. thyreoideus impar, v. vertebralis, v.
cervicalis profunda, vv. thoracicae internae, v. intercostalis suprema, v.
intercostalis superior sinistra and numerous small veins of the anterior
mediastinum drain into the brachiocephalic veins. V. vertebralis collects blood
from the vertebral venous plexuses.

8
The Internal Jugular Vein

The internal jugular vein (v. jugularis interna) collects blood from the cavity
of the skull and organs of the neck (Fig. 14, 15). Beginning at the jugular foramen,
where it forms a distention called bulbus superior venae jugularis interna, the vein
passes downward laterally from the internal carotid artery and more lower laterally
from the common carotid artery. A second distention, bulbus inferior, is formed on
the lower end of the v. jugularis interna before it joints with the subclavian vein.
There are one or two valves in the vein in the region of the neck above its inferior
distention. The internal jugular vein is covered by the sternocleidomastoid and
omohyoid muscles. The veins which drain into the internal jugular vein are
subdivided into two groups: 1) the intracranial veins and 2) the extracranial veins.

The intracranial veins:

1. The sinuses of the dura mater of the brain (Fig. 16). The walls of the sinuses
are formed by the laminae of the dura mater. The flowing of the blood is realized
in following order: from the superior sagittal sinus blood flows into the transverse
sinus; from the inferior sagittal sinus blood flows into the straight sinus and then
into the transverse sinus; from the occipital sinus blood flows into the transverse
sinus; the transverse sinus continues with the sigmoid sinus. In the jugular foramen
of the skull the sigmoid sinus continues with the internal jugular vein.
The sphenoparietal sinus drains into the cavernous sinus, and from the cavernous
sinus blood flows into the superior and inferior petrosal sinuses. Superior one
drains into the sigmoid sinus, and inferior one drains directly into the internal
jugular vein.
2. Vv. ophthalmicae superior and inferior collect blood from the eyeballs,
eyebrows, muscles of the eye, lacrimal gland, eyelids, ethmoidal labyrinths and
drain into the cavernous sinuses.
3. Vv. labyrinthi collect blood from the internal ear and drain into the inferior
petrosal sinus.
4. Vv. diploicae collect blood from the bones of the skull-cap and drain into the
sinuses or into the vv. emissariae, which connect veins of the outer surface of the
skull and internal veins of the skull.
5.6. Vv. meningae and vv. cerebri collect blood from the brain and its meninges
and drain into different sinuses of the dura mater.

The extracranial veins:

1. The facial vein (v. facialis) arises in the medial angel of the eye, it collects
blood from the facial, submental regions, palate, palate tonsils, salivary glands.
Deep facial vein (v. profunda faciei) is in the infratemporall fossa, it collects
blood from the deep regions of the head, from the pterygoid plexus and drains into
the facial vein.
The posterior facial vein (v. retromandibularis) runs in front of the auricle
and collects blood from the temporal region, from the parotid gland, auricle,

9
temporomandibular joint, lateral surface of the face and pterygoid plexus and
drains into the facial vein.
Pterygoid plexus (plexus pterygoideus) is located on the pterygoid muscles
and is connected with the cavernous sinus (Fig. 15).
2. The pharyngeal veins (v. pharyngeae) form plexus on the pharynx and drain
directly into v. jugularis interna.
3. The maxillary vein (v. maxillaris) is situated behind the neck of the mandibule,
it has valves and collects blood from the pterygoid venous plexus.
4. The lingual vein (v. lingualis) accompanies the artery of the same name.
5. The superior thyroid veins (vv. thyreoideae superiores) collect blood from the
upper part of the thyroid gland and the larynx.
6. The middle thyroid veins (vv. thyreoideae mediae) arise on the lateral border
of the thyroid gland.

The Superficial Veins of the Neck

Two main superficial or subcutaneous veins are located on the neck. They are
the external and anterior jugular veins (Fig. 14, 17).

The External Jugular Vein

The external jugular vein (v. jugularis externa) originates behind the auricle
on the level of the angle of the mandibule. The external jugular vein is formed by
the merger of the posterior auricular vein with the large anastomosis between the
external jugular vein and the retromandibular vein. It descends into the
subcutaneous tissue covered by the platysma muscle and travels along the external
surface of the sternocleidomastoid muscle. On reaching the posterior of this muscle
in the supraclavicular region it drains into the subclavian vein, usually in a
common trunk with the anterior jugular vein, or into the internal jugular vein, or
into the venous angel - site of the junction between v. jugularis interna and v.
subclavia. The external jugular vein has valves.
The posterior auricular vein (v. auricularis posterior) collects blood from
the superficial venous plexus behind auricle, it is connected with the v. emissaria
mastoidea. It drains into the external jugular vein.
The occipital vein (v. occipitalis) collects blood from the venous plexus of
the occipital region, it drains into the external jugular vein below posterior
auricular vein.
The suprascapular vein (v. suprascapularis) and transverse vein of the
neck (vv. transversae colli) collect blood from the superficial tissues above scapule
and from lower posterior regions of the neck and drain into the external jugular
vein.

10
The Anterior Jugular Vein

The anterior jugular vein (v. jugularis anterior) is formed by the merger of
the small branches located over the hyoid bone (submental region), from here it
descends closer to the midline of the neck on the outer surface of the mylohyoid
muscle and then on the anterior surface of the sternohyoid muscle. Above stenal
jugular notch right and left anterior jugular veins perforate the pretrachial fascia of
the neck, enter the interaponeuvrotic suprasternal space and drain into the external
jugular vein or into the subclavian vein.
In the suprasternal space above jugular notch the right and left anterior
jugular veins anastomose and form the venous arch (arcus venosus jugularis). In
some cases the anterior jugular vein is a single unpaired vein which descends along
the midline of the neck and drains into the venous arch. In this case the venous
arch is formed by the anastomosis between right and left external jugular veins.

The Subclavian Vein

The Subclavian Vein is a direct continuation of the the axillary vein. It is

located below and to the front of the subclavian artery from which it is separated
by anterior scalene muscle. The subclavian vein lies in the sulcus of v. subclavia of
the first rib. Behind the sternoclavicular joint the subclavian vein merges with v.
jugularis interna. The place of this connection is called right and left venous angel.
The following veins drain into the subclavian vein: v. scapularis dorsalis, vv.
pectorales and v. thoracoacromialis (unconstant) (Fig. 14).

The Nerves of the Head and Neck

The Spinal Nerves

Each of the 31 pairs of the spinal nerves (nn. spinales) is formed by the
peripheral axon of the spinal ganglion and anterior root of the spinal cord (Fig. 18).
The 31 pairs of spinal nerves are: 8 pairs of the cervical, 12 pairs of the thoracic, 5
pairs of the lumbar, 5 pairs of the sacral and 1 pair of the coccygeal nerves. The
spinal nerve is mixed nerve. On emerging from the intervertebral orifice every
spinal nerve divides into the following branches:
1. The communicating branches (ramus communicans) pass to the ganglions of
the sympathetic trunk for innervating the internal organs.
2. The menigeal branches or recurrent branches (r. menigeus, r. recurrens) for
innervating the dura mater of the spinal cord. These branches run back into the
vertebral canal through intervertebral openings and form plexus, plexus nervorum

11
spinalium, which supplies periosteum, vertebrae, spinal meninges, venous plexuses
and arteries in the vertebral canal.
Besides these another two kinds of branches arise from the spinal nerves.
3. The posterior branches (rr. posterioriores) are thinner then the anterior ones.
They give off branches:
a, b – The medial and lateral branches (rr. medialis and lateralis) supply skin and
deep muscles of the back and neck. Medial branch is mixed, it contains motor and
sensory fibres; and lateral branch contains only motor fibres.
c – The greater occipital nerve (n. occipitalis major) supplies skin of the occipitum
and semispinal muscles of the head.
d – The third occipital nerve (n. occipitalis tertius) supplies skin of the posterior
surface of the neck.
4. The anterior branches (rr. anteriores) innervate the superficaial muscles of the
back, the muscles of the ventral wall of the trunk and the muscles of the limbs and
the skin covering the ventral wall of the trunk and the skin covering the limbs.
They preserve their original metameric structure only in the thoracic segments. In
the other spinal segments the anterior branches form the nervous plexuses. The
anterior branch of every spinal nerve sends its fibres into the several peripheral
nerves. Most of the nerves emerging from the plexuses are mixed, they are
composed of the motor, sensory and vegetative fibres.
The large plexuses are formed by the anterior branches of the spinal nerves,
they are: the cervical, the brachial and the lumbosacral plexuses, the last one is
subdivided into the lumbar, sacral and coccygeal ones.

The Cervical Plexus

The cervical plexus (plexus cervicalis) is formed by the anterior branches of

four superior cervical spinal nerves (from C1 to C4) which are located laterally of
the transverse processes, between the deep muscles of the neck under
sternocleidomastoid muscle. The nerves of the cervical plexus anastomose with the
accessory, hypoglossal nerves and sympathetic trunk. The branches arising from
the plexus are divided into cutaneous, muscular and mixed ones (Fig. 19-22).
The cutaneous branches:
1. The lesser occipital nerve (n. occipitalis minor) runs to the skin of the lateral
part of the occipital region.
2. The greater auricular nerve (n. auricularis magnum) innervates the skin of the
auricle, skin behind auricle and skin which covers parotis gland.
3. The transverse cutaneous nerve of the neck (n. transversus colli) innervates
the skin of the anterior and lateral surfaces of the neck.
4. The supraclavicular nerves (nn. supraclaviculares) innnervate the skin above
the clavicle and shoulder joint.
The muscular branches run to the deep muscles of the neck, to the levator
scapulae muscle, to the scalene muscles, to the sternocleidomastoid muscle and to
the upper part of the trapezius muscle. The cervical plexus gives off the radix
inferior which joints with the radix superior of the hypoglossal nerve forming a
12
cervical loop (ansa cervicalis), the branches of this loop innervate infrahyoid
muscles of the neck.
The mixed branch is called the phrenic nerve (n. phrenicus). It is longest branch
of the cervical plexus. It descendes along m. scalenus anterior and enters into the
thoracic cavity. Right phrenic nerve passes laterally from the right atrium, crosses
root of the right lung anteriorly and reaches the diaphragm. Left one passes
laterally from the aortic arch, crosses root of the left lung more superficially then
the right phrenic nerve and reaches the diaphragm more anteriorly.
The motor branches of the phrenic nerve innervate the muscles of the diaphragm.
Its sensory branches innervate the mediastinal pleura, the pericardium, the heart,
the lungs, the thymus gland. Some of the terminal branches (rr.
phrenicoabdominales) pass through the diaphragm into the abdominal cavity and
innervate the peritoneum on extend from the diaphragm to the gall bladder and
pancreas, the hepatic ligaments, the liver. It is connected with the solar and hepatic
plexuses through which it innervates certain internal organs.

The Vagus Nerve

The vagus nerve (n. vagus) is the longest cranial nerve. It supplies the
respiratory organs, a considerable part of the digestive tract, the heart (Fig. 23, 24).
On leaving the cranial cavity the vagus nerve descends to the neck between the
internal jugular vein laterally and internal carotid artery medially and then lower
between the same vein and the common carotid artery. These vessels and vagus
nerve are covered with one sheath and are called the vasculonervous fasciculus of
the neck. The vagus nerve gives rise to the cranial, cervical, thoracic and
abdominal branches.
1. The cranial branches:
1) the meningeal branch (r. meningeus);
2) the auricular branch (r. auricularis).
2. The cervical branches:
1) The pharyngeal branches (r. pharyngei);
2) The superior laryngeal nerve (n. laryngeus superior);
3) The upper cardiac cervical branches (r. cardiaci cervicales superiores) contain
the sensory and parasympathetic fibres which are distributed in the cardiac plexus.
The parasympathetic fibres conduct impulses that slow the heart beat and dilate the
smooth muscles of the vessel’s walls. As a result it is named the depressor nerve
(n. depressor);
4) The lower cardiac cervical branches (rr. cardiaci cervicales inferiores) are more
numerous and more thick than the upper ones. They participate in formation of the
cardiac plexus too;
5) The recurrent laryngeal nerve (n. laryngeus recurrens) branches off from the
vagus nerve in front of the aortic arch (on the left) and in front of the subclavian
artery (on the right). They go round these vessels from the below and from the
back and ascend between trachea and oesophagus. The recurrent laryngeal nerve
innervates the oesophagus, the trachea, some of laryngeal muscles, the mucous of
13
the larynx below the vocal cords. The nerve which innervates larynx is known as
inferior laryngeal nerve (n. laryngeus inferior);
Complete discribtion of the nuclei, cranial and some cervical branches of the
vagus nerve look in the text-book “The science of the sensory organs and cranial
nerves”.

The Vegetative Autonomic part of the Nervous System

The vegetative nervous system keeps up the constancy of the internal

environment of the organism, accomplishes innervation of the heart, blood and
lymphatic vessels, internal organs which contain smooth muscles and glandular
epithelium, controls the activity of all organs concerned with the vegetative
functions of the body (nutrition, respiration, excretion, reproduction and fluid
circulations) and accomplishes trophic innervation. The vegetative nervous system
intensifies or weakens the functions of the organs and therefore it is separated into
two parts: the sympathetic and parasympathetic systems, which are ontogonists to
one another. But antagonism and synergism are two aspects of a single process.
The normal functions of our organism is ensured by the coordinated actions of
these two parts of the vegetative nervous system (Fig. 25, 26).
The sympathetic system is mainly concerned with the trophic functions. It is
responsible for intensification of oxidation processes, nutrient consumption and
respiration, stimulates the rate of the cardiac activity, supplies oxygen to the
muscles, enlarges the pupil and depresses the tonus of the muscles of the bronchi
and digestive tract.
The parasympathetic system carries a protective role: inhibition of cardiac
activity, constriction of the pupil in bright light, evacuation of the cavity organs,
constriction of the bronchi, stimulation of the work of the intestine and sex organs.
The vegetative nervous system has the central and peripheral parts.
The higher vegetative centres are concerned with regulation of the
functions of both parts of the vegetative nervous system. These centres are situated
in the brain, they are:
- the striated body of the basal nodes of the telencephalon;
- the hypothalamus (tuber cinereum) in the diencephalon;
- the central grey matter of the cerebral aqueduct in the mesencephalon;
- the vasomotor centre in the medulla oblongata;
- the nuclei of the cerebellum which regulate some of the vegetative functions,
such as vasomotor reflexes, skin trophies, the rate of wound healing.
The hypothalamic region is the most essential in vegetative regulation. Its
nuclei are connected with the hypophysis to form the hypothalamo-hypophyseal
system, which is a regulator of the functions of all endocrine glands. The
hypothalamic region regulates the activity of all organs of vegetative life.
The centres of the parasympathetic system: the vegetative nuclei of the
III-rd, VII-th, IX-th and X-th pairs of the cranial nerves and the nuclei of the spinal
cord for the space of SII-SIV segments.

14
 The centres of the sympathetic system: the intermediolateral nuclei of the
lateral horns of the spinal cord for the space of CVIII to LII segments.
The peripheral part of the vegetative nervous system is composed of the
nerve ganglia, peripheral nerves, plexuses and peripheral nerve endings.
The simplex reflex vegetative arch consists of few links.
First links are the sensory neurons of the spinal ganglia or the sensory
ganglia of the cranial nerves. Their peripheral axons take origin from the receptors
of the organs and tissues. Their central axons pass to the spinal nuclei (as parts of
the posterior roots of the spinal cord) or to the nuclei of the above named cranial
nerves.
Second links are efferent pathways of the vegetative reflex arch which are
double-neuron structure:
- the first neurons are the internuncial (or interposed) neurons whose bodies are in
the vegetative nuclei of the cranial nerves (for the parasympathetic system) or in
the lateral horns of the spinal cord (for the sympathetic system) and their axons run
to a ganglia. The internuncial neurons are located between the sensory (afferent)
link and efferent link of the vegetative reflex arch.
- the second neurons are the efferent neurons with the bodies located in the
different ganglia and their axons reach the working organs.
The second neurons of the parasympathetic system are located in the
paraorganic ganglia lying near the organs or within the organs. They are:
vegetative nodes of the head – gangliaon ciliaris, ganglion oticum, ganglion
pterygopalatinum and ganglion submandibularis.
The second neurons of the sympathetic system are located in the ganglia of
the sympathetic trunk or in the intermediate ganglia lying between the sympathetic
trunk and organs (e. g. the mesenteric ganglia).
The postganglionic fibres of the sympathetic nervous system which arise
from the ganglia of the sympathetic trunk diverge in two directions: some pass to
the viscera, other fibres form the grey communicating branches connecting the
sympathetic trunk with the spinal nerves.

The Sympathetic Trunk

The peripheral part of the sympathetic nervous system is formed by two

symmetrical, right and left, sympathetic trunks (trunkus sympaticus dexter and
sinister) stretching on either side of the spine from the upper cervical vertebrae to
the coccyx where the caudal ends of both trunks meet to form a single common
ganglion. Each sympathetic trunk is composed of a series of a nerve ganglia (gang.
trunci sympatici) connected by a longitudinal interganglionic branches (r.
intergangliones) which are the nerve fibres. Each of two sympathetic trunks is
subdivided into 4 parts: cervical, thoracic, lumbar and sacral (Fig. 25).
All ganglia of the sympathetic trunk are connected with the spinal nerves by
means of the grey communicating branches (rami communicantes grisei) which are
a segments of the postganglionic fibres. They are not covered with the myelin
sheathes (amyelin), therefore their grey colour.
15
As a components of the spinal nerves, these sympathetic fibres reach the motor
apparatus and the skin where they innervate the smooth muscles of the vessels and
of the skin, and the glands. Therefore, the sympathetic nervous system innervates
not only the viscera but also the soma in which it responsible for the metabolic and
trophic processes.
The ganglia of the thoracic part of the sympathetic trunk and two - three
superior lumbar ganglia are connected with the nuclei of the lateral horns of the
spinal cord by means of the white communicating branches (rami communicantes
albi) which are covered with the myelin sheathes. They run from the centres of the
sympathetic nervous system through the anterior roots of the spinal cord to the
ganglia of the sympathetic trunk.

The Cervical part of the Sympathetic Trunk

The cervical part of the sympathetic trunk consists of three cervical

sympathetic ganglia: superior, middle and inferior. The cervical part stretches from
the base of the skull to the neck of the first rib; it lies behind the carotid arteries on
the deep muscles of the neck (Fig. 25, 27-29).
The superior cervical ganglion (gang. cervicale superius) is largest ganglion
of the sympathetic trunk (2cm long). It lies on the level of the C II and CIII vertebra,
1-2cm below from the base of the skull.
The middle cervical ganglion (gang. cervicale medium) is smallest, often it
is absent or separated into two. Vertebral ganglion (gang. vertebrae) is small,
accessory ganglion, located in front of the vertebral artery on the level of the
transverse process of CVI.
The inferior cervical ganglion (gang. cervicale inferioris) is quite large; it is
often fused with the first thoracic ganglion to form a common inferior cervical
ganglion (gang. cervicothoracium), very often its shape looks like a start, therefore
its second name is ganglion stellatum.
The cervical ganglia send nerves to the head, neck and chest. These
sympathetic nerves pass in the attendance to arteries and form plexuses around
them; these plexuses are called with the same names of the arteries. Each ganglion
gives off the grey communicanting branches (rr. communicantes grisei) which
run to and connect with the cervical spinal nerves.

The branches of the superior cervical ganglion:

1. The jugular nerve (n. jugularis) passes along internal jugular vein to the
inferior ganglion of the glossopharyngeal nerve and to the superior ganglion of the
vagus nerve.
2. The internal carotid nerve (n. caroticus internus) form plexus around internal
carotid artery.
3. The external carotid nerves (nn. carotici externi) pass around external carotid
artery and along its branches, and form plexuses which attend these vessels.

16
 Above-named nerves innervate the walls of the cerebral vessels, the meninges,
the hypophysis, the trunks of III, IV, V, VI pairs of cranial nerves, gives roots to
the vegetative nodes of the head, innervate vessels and glands of the head, the
smooth muscles of the hairs and the dilator muscle of the pupil of the eyeball.
4. The pineal nerve (n. pinealis) passes to the gland with same name.
5. The laryngopharyngeal branches (rr. laryngopharyngei) run to the larynx and
to the pharynx, and form plexuses of these organs together with the branches from
IX and X cranial nerves.
6. The superior cervical nerve of the heart (n. cardiacus cervicalis superior)
descends to the heart and takes part in the formation of the extracardiac plexuses.
The only branch of the middle cervical ganglion:
The middle cervical nerve of the heart (n. cardiacus cervicalis medius) takes
part in the formation of the deep extracardiac plexus.
The branches of the inferior cervical ganglion:
1. The inferior cervical nerve of the heart (n. cardiacus cervicalis inferior) takes
part in the formation of the deep extracardiac plexus.
2. The vertebral nerve (n. vertebralis) passes behind vertebral artery and form the
vertebral plexus.
3. The subclavian loop (ansa subclavia) surrounds subclavian artery.

The Arteries of the Upper Limb

The Axillary Artery

The axillary artery (a. axillaris) is a direct continuation of the subclavian

artery. The proximal border of the axillary artery is on the level of the external
edge of the first rib, the distal border is on the inferior edge of m.teres major (at the
origin of the brachial artery). The axillary artery lies in the axillary cavity, which is
medial of the shoulder joint and the humerus. The nerve fasciculi of the brachial
plexus are on its sides. The axillary vein is located in front and medial from the
artery. The axillary artery consists of three segments which are situated in:
(1) the trigonum claviopectorale - from the clavicle to the superior margin of the
lesser pectoral muscle.
(2) the trigonum pectorale - posteriorly of the lesser pectoral muscle.
(3) the trigonum subpectorale - from the inferior margin of the lesser pectoral
muscle to the inferior margin of the greater pectoral muscle or teres major muscle
(Fig. 11, 30, 31).

The branches of the axillary artery in the trigonum claviopectorale:

1. The superior thoracic artery (a. thoracica superior) supplies m. subclavius, m.
seratus anterior and nearest intercostal muscles. This artery is not present always.
2. The acromiothoracic artery (a. thoracoacromialis), starts on the level of the
upper margin of the the lesser pectoral muscle and supplies the acromion (r.
acromialis, rete acromialis); the clavicle and the subclavian muscle (r.
17
clavicularis); deltoid and greater pectoral muscle (r. deltoideus), greater and lesser
pectoral muscle, anterior serrate muscle (rr. pectorales).

The branch of the axillary artery in the trigonum pectorale:

3. The lateral thoracic artery (a. thoracica lateralis) descends along the lateral
wall of the chest and gives off branches to the mammary gland (rr. mammarii
laterales) and to the surrounding muscles.

The branches of the axillary artery in the trigonum subpectorale:

4. The subscapular artery (a. subscapularis) is a largest branch of the axillary
artery, it starts on the level of the lateral margin of the subscapular muscle.
It separates into two trunks:
(a) a. circumflexa scapulae which passes through the triangular opening to the
dorsal surface of the scapula where it anastomoses with a. suprascapularis from the
subclavian artery. It supplies m. subscapularis, m. teres major, m. teres minor, m.
latissimus dorsi and m. infraspinatus.
(b) a. thoracodorsalis which is a continuation of the subscapular artery and passes
along the lateral border of the scapula. It supplies m. teres major and m. latissimus
dorsi.
5. The anterior circumflex humeral artery (a. circumflexa humeri anterior)
begins on the same level with the posterior circumflex humeral artery below the
tendon of the m. latissimus dorsi, passes in the lateral direction, curving around the
neck of the humerus anteriorly, anastomosing with a. circumflexa humerus
posterior and giving off branches to the coracobrachial and deltoid muscles and to
the shoulder joint.
6. The posterior circumflex humeral artery (a. circumflexa humeri posterior)
passes through the quadrangular opening to the back and passes posteriorly around
the surgical neck of the humerus. It gives off branches to the deltoid muscle and to
the shoulder joint and anastomoses with the a. circumflexa humeri anterior, a.
suprascapularis and a. thoracodorsalis.
All branches of the axillary artery anastomose widely with the branches of
the subclavian artery.

The Brachial Artery

The brachial artery (a. brachialis) is continuation of the axillary artery.

Beginning at the lower border of m. teres major, it passes to the medial bicipital
groove and on the level of the neck of the radius, it divides into two terminal
branches: the radial and the ulnar arteries. On its way it is attended by two brachial
viens and some nerves (Fig. 32). The brachial artery gives off many small
branches to the bone and muscles of the arm and three large branches:
1. The deep brachial artery (a. profunda brachii) starts from brachial artery soon
after its origin. It passes into the spiral canal, and gives off arteries that supply the
humerus (aa. nutriciae humeri) and deltoid muscle (r. deltoideus) and then divides
into two branches:
18
(a) posterior descending branch called (a. collateralis media) which penetrates the
thickness of m. triceps and anastomoses with a. interossea recurrens (branch of the
ulnar artery) on the posterior surface of the lateral epicondyle;
(b) anterior descending branch (a. collateralis radialis) which emerge through the
inferior opening of the spiral canal, passes forward from the lateral epicondyle and
anastomoses with a. recurrens radialis (branch of radial artery).
These branches carry blood to the elbow joint and form the arterial network of the
elbow joint (rete articulare cubiti) (Fig. 34).
2. The ulnar collateral artery (a. collateralis ulnaris superior), starts from the
brachial artery in the middle of the arm and settles into the sulcus ulnaris on the
posterior surface of the medial epicondyle where it anastomoses with a. recurrens
ulnaris posterior (branch of the ulnar artery). It supplies the elbow joint with blood
and drains into the rete articulare cubiti.
3. The supratrochlear artery (a. collateralis ulnaris inferior), begins from the
brachial artery above medial epicondyle of the humerus. It anastomosis anteriorly
from the medial epicondyle with a. recurrens ulnaris anterior (branch of the ulnar
artery), supplies the elbow joint and drains into the rete articulare cubiti.

The Radial Artery

The radial artery (a. radialis) is direct continuation of the brachial artery
(Fig. 33-36, 38). It passes medially from m. brachioradialis, at first under its cover
and then in the radial groove (between m. brachioradialis laterally and m. flexor
carpi radialis medially). In the lower one - third of the forearm, a radial artery is
located superficially and is covered only by the fascia and skin. The pulse can be
easily taken here. On reaching the top of the styloid process of the radial bone,
radial artery passes to the back of the hand curving around the lateral egde of the
carpus and settling in the “anatomical snuffbox” (between the tendon of the
extensor pollicis longus muscle and the tendons of the extensor pollicis brevis and
abductor pollicis longus muscles). Then the radial artery goes out to the palm
through the first interosseus space. On the palm radial artery continues with the
deep palmar arch.

The branches of the radial artery:

1. The recurrent radial artery (a. recurrens radialis) originates in the cubital
fossa, and passes upward towards the anterior surface of the lateral epicondyle
where it anastomoses with the a.collateralis radialis. It supplies the elbow joint
with the blood.
2. The muscular branches (rr. musculares) supply the surrounding muscles of the
forearm with blood.
3. The superficial palmar branch (r. palmaris superficialis) starts on the level of
the base of the radial styloid process, passes over the thenar and, joining the end of
the ulnar artery, participates in the formation of the superficial palmar arch.

19
4. The anterior carpal branch (r. carpalis palmaris) originates in the lower part
of the forearm on the level of the distal margin of the square pronator muscle and
passes on the anterior surface of carpal where it forms a network with the same
branch of the ulnar artery. It supplies the hand’s joints with blood.
5. The posterior carpal branch (r. carpalis dorsalis) arises in the region of
“anatomical snuffbox”, passes on the posterior surface of the carpal under tendons
of the extensor muscles, where it forms a dorsal carpal network with the same
branch of the ulnar artery.
6. The radial artery of the index (a. radialis indicis) runs along radial side of the
index and supplies blood to it.
7. The artery of the thumb (a. princeps pollicis) runs over the palmar surface of
the hand through the first interosseus space and on the level of the base of the
thumb separates into two branches which supply the both sides of thumb on its
palmar surface.
8. The artery of the radius (a. nutricia radii) carries blood to this bone.

The Ulnar Artery

The ulnar artery (a. ulnaris) is the larger of two terminal branches of the
brachial artery. It runs under m. pronator teres in the ulnar groove between m.
flexor digitorum superficialis and m. flexor carpi ulnaris, in the lower one third of
the forearm its position becomes more superficial and it passes into the ulnar canal
and crossing over to the palm, continues with the superficial palmar arch (Fig. 33-
36, 38).

The branches of the ulnar artery:

1. The recurrent ulnar artery (a. recurrens ulnaris), originates in the cubital
fossa, passes upward and divides into two branches – anterior and posterior (r.
anterior, r. posterior). These branches run anteriorly and posteriorly of the medial
epicondyle anastomosing with the aa. collateralis ulnares superior and inferior
from the brachial artery. All anastomoses between branches of the brachial, radial
and ulnar arteries form the arterial networks of the elbow joint.
2. The common interosseus artery (a. interossea communis) is a short trunk that
branches off the ulnar artery at its beginning and runs towards the interosseus
membrane. At the proximal border of the membrane it divides into two branches:
(a) a. interossea anterior passes along the anterior surface of the interosseus
membrane and reaches m. pronator quadratus where it pierces the membrane and
ends in the dorsal carpal network. This artery supplies the bone (a. nutricia ulnae)
and the surrounding muscles. It gives off branch which accompanies the median
nerve (a. comitans nervi mediani).
(b) a. interossea posterior passes through the superior orifice of the interosseus
membrane to its dorsal surface and lies between the superficial and deep layers of
the extensor muscles. In the region of the wrist a. interossea posterior anastomoses

20
with a. interossea anterior and takes part in the formation of the dorsal carpal
network.
A. interossea posterior gives of the a. interossea reccurens which passes upward
under m. anconeus and anastomoses with a. collateralis media on the posterior
surface of the lateral epicondyle.
3. The anterior carpal branch (r. carpalis palmaris) arises on the level of the
ulnar’s head, passes down and anastomoses with the carpal branch of the radial
artery.
4. The posterior carpal branch (r. carpalis dorsalis) passes to the dorsal surface
of the hand and unites with the dorsal carpal network.
5. The deep palmar branch (r. palmaris profundus) branches off the ulnar artery
on the level of the pisiform bone and joining the end of the radial artery,
participates in the formation of the deep palmar arch.

The Arteries of the Hand

On the palmar surface of the hand there are superficial and deep palmar arches
(Fig. 33, 35-38).

The Superficial palmar arch (arcus palmaris superficialis) lies under the
palmar aponeurosis. It is a continuation of the ulnar artery and is composed with
the superficial palmar branch of the radial artery. The distal convexity gives rise to
three arteries called aa. digitales palmares communes which pass towards the folds
of the skin between fingers. On the level of the metacarpal heads three aa.
metacarpales palmares (from the deep palmar arch) drain into them. After that
each artery separates into two aa. digitales palmares propriae which pass along
contiguos surfaces of the adjacent fingers (from II to V). These arteries give off
branches to the palmar surfaces of the fingers and to the dorsal surfaces of the
middle and distal phalanges of these fingers. They form wide anastomotic
networks on the distal phalanges. Artery to the ulnar surface of the little finger
branches from the ulnar artery.

The deep palmar arch (arcus palmaris profundus) lies deeply on the bases
of the metacarpal bones, proximally to the superficial arch. Formed mainly by the
radial artery, it is composed with the deep palmar branch of the ulnar artery. The
convexity of this arch gives rise to 3 arteries called aa. metacarpales palmares that
pass distally to the 3 interosseus spaces along palmar surfaces of the interosseus
muscles. Here each artery gives off one perforating branch (r. perforans) which
perforates muscles, passes to the dorsal surface of the hand and anastomoses with
the aa. metacarpales dorsales (from the dorsal carpal network).
On the dorsal surface of the hand in the region of the retinaculum
extensorum there is a dorsal carpal network (rete carpale dorsale) which is
formed by union of the posterior carpal branches of the radial and ulnar arteries
and anterior and posterior interosseus arteries.

21
It is subdivided into the superficial arterial network located between the skin and
retinaculum extensorum and deep one located on the dorsal surfaces of the carpal
bones.
It gives off branches:
(a) to the nearest joints;
(b) to the dorsal metacarpal arteries (aa. metacarpales dorsales) - three or four in
number, they pass to the interosseus spaces between the extensor’s tendons. On the
level of the heads of the metacarpal bones each of them separates into two dorsal
arteries of the fingers (aa. digitales dorsales), which carry blood to the dorsal
surfaces of the proximal and middle phalanges of the 2-5 fingers.
So, the first finger of the hand and the radial side of the second finger
receive blood with the branches of the radial artery. The ulnar surface of the little
finger receives blood from the ulnar artery. Other fingers of the hand receive blood
with branches of the carpal network and with the branches of the superficial and
deep palmar arches. When hand performs grasping actions its vessels are often
compressed and the flow of blood in superficial vessels is disturbed. In this case
the supply of blood to the fingers of the hand does not suffer since it flows along
the deep vessels. This is an important adjustment function. The articular networks
are the similar adjustments.

The Veins of the Free Upper Limb

The veins of the free upper limb are subdivided into deep and superficial.
The deep and superficial veins contain numerous valves, and they are connected
with one another by means of the veins which have no valves (Fig. 30, 39-42).
The deep veins (vv. profundae membri superiores) collect blood from the
muscles, bones, joints.
Deep veins attend arteries, usually two veins for the every artery. The names
off these veins are same as for the arteries. Thus there are two brachial, two ulnar,
two radial, and two (anterior and posterior) interosseus veins.
Vv. ulnares and vv. radiales continue superficial and deep venous arches of
the hand. They ascend along same arteries and unite in the region of the elbow
flection forming two vv. brachiales. Last ones collect blood from the arm and form
axillary vein on the level of the lower edge of the teres major muscle.
The axillary vein (v. axillaris) lies in the axillaryfossa in front of the
axillary artery. It collects blood from the deep and superficial veins of the free
upper limb. V. thoracica lateralis, v. subcapularis, v. circumflexa humeri anterior
and posterior also drain into the axillary vein.
The superficial veins (vv. superficiales membri superiores) are located in
the subcutaneus tissue and collect blood from the skin, subcutaneus tissues and
superficial venous networks. On the palmar surfaces of the fingers there are the
networks of the venous vessels which are formed by vv. digitales palmares. These
networks are connected widly with the venous networks on the dorsal surfaces of
the fingers. On the palmar surfaces of the bases of the fingers (from II to V) small
veins unite, form arches and drain into the vv. metacarpales palmares. Last ones
22
carry blood to the superficial and deep venous arches (arcus venosi palmares
superficialis and profundus). From these arches vv. ulnares and vv. radiales start.
On the dorsal surface of the hand there is the venous network (rete venosum
dorsale manus) which is good developed. More superficially on the dorsal surface
of the hand there are vv. metacarpales dorsales which continue with the v.
cephalica and v. basilica.
1. The cephalic vein (v. cephalica) or lateral subcutaneus vein is continuation of
the first v. metacarpalis dorsalis. It ascends along the radial side of the forearm,
and then passes to its anterior surface, reaches the elbow joint and then ascends
along the lateral bicipital groove and drains into the axillary vein.
2. The basilica vein (v. basilica) or medial subcutaneus vein is continuation of the
fourth v. metacarpalis dorsalis. It ascends along the ulnar side on the dorsal and
then on the anterior surface of the forearm to the elbow flexion where it
anastomoses with the cephalic vein by means of the median cubital vein, then it
passes into the medial bicipital groove and, perforating the fascia in the middle of
the arm, drains into one of the brachial veins.
3. The median cubital vein (v.mediana cubiti) is an obliquely positioned
anastomosis connecting v. basilica and v. cephalica in the region of the elbow
flection. It receives blood from the median forearm’s vein (v. mediana
antebrachii) which collects blood from the palmar surface of the hand and forearm.
The median cubital vein is important in practice as the site of intravenous
injections.

The Nerves of the Upper Limb

The Brachial Plexus

The brachial plexus (plexus brachialis) is composed of the anterior branches

of four inferior cervical spinal nerves and the greater part of the first thoracic
spinal nerve, it is often joined by the thin branch from fourth cervical spinal nerve.
The brachial plexus is located in the interscalene space. Three thick nerve trunks
arise from it (superior, medius and inferior), then trunks pass into the axillary fossa
continue with three fasculi which surround the axillary artery from 3 sides: from
the lateral (fasciculus lateralis), from the medial (fasciculus medialis) and from the
posterior (fasciculus posterior). The brachial plexus is subdivided into two parts:
supraclavicular part (pars supraclavicularis) continues till superior clavicular
margin and infraclavicular part (pars infraclavicularis) is located between superior
clavicular margin and site of the divisions of the fasciculi into the peripheral
nerves (Fig. 30, 32, 43-51).
The brachial plexus gives off the short and long peripheral branches. The
short branches arise from the supraclavicular part of the plexus and supply some
cervical muscles, the superficial muscles of the chest, muscles of the shoulder
girdle and the shoulder joint.

23
 The long branches arise from three fasciculi in the infraclavicular part of the
plexus and innervate muscles and skin of the free upper limb.

The short branches:

1. The nerve to the rhomboids (n. dorsalis scapulae) passes along the medial
edge of the shoulder blade and innervates m. levator scapulae and mm.
rhomboidei.
2. The long thoracic nerve (n. thoracicus longus) descends along the external
surface of the m. serratus anterior and innervates it.
3. The suprascapular nerve (n. suprascapularis) passes through the
suprascapular notch and innervates mm.supra- and infraspinatus and capsule of the
shoulder joint.
4. The lateral and medial pectoral nerves (nn. pectoralis medialis and lateralis)
runs to mm. pectoralis major and minor.
5. The nerve to the subclavius muscle (n. subclavius) passes to the m.subclavius.
6. The subscapular nerve (n. subscapularis) supplies m. subscapularis, m. teres
major, m. latissimus dorsi.
7. The thoracodorsal nerve (n. thoracodorsalis) branches off the subscapular
nerve and runs along the lateral edge of the shoulder blade to m. latissimus dorsi.
8. The circumflex nerve, (n. axillaris) is the thickest nerve among short branches
of the brachial plexus. Very often it starts from the posterior fasciculus. It passes
through foramen quadrillaterum to posterior surface of the surgical neck of the
humerus and innervates m. deltoideus, m. teres minor and the shoulder joint. It
gives off cutaneous branch, n. cutaneous brachii lateralis superior, that innervates
the skin which coveres the deltoid muscle and the skin of the upper part of the
posterolateral region of the arm.

The long branches:

1. The musculocutaneous nerve (n. musculocutaneous) originates from the lateral
fasciculus of the brachial plexus and innervates all anterior (flexors) muscles of the
arm: m. coracobrachialis, m. biceps brachii and m. brachialis. It continues on the
forearm as the lateral cutaneous nerve of the forearm (n. cutaneus antebrachii
lateralis) suppling the skin of the lateral surface of the forearm. The
musculocutaneus nerve gives off branches to the periostenum of the humerus and
to the articular capsule of the elbow joint.
2. The median nerve (n. medianus) arises from the medial and lateral fasciculi
with two roots which embrace the axillary artery in front and passes into the
medial bicipital sulcus. On the arm the median nerve gives off no branches. On the
forearm it gives off the muscular branches to all flexors and pronator muscles of
the forearm with the exception of the m. flexor carpi ulnaris and the medial half of
m. flexor digitorum profundus. It innervates the radiocarpal joint, and the small
joints of the hand. The median nerve passes to the hand through carpal canal and
separates into branches, which innervate the muscles of the thenar with exception
of the m. adductor pollicis and the deep head of the m. flexor pollicis brevis, the
first and the second vermiform muscles, the skin of 3,5 fingers (I, II, III and radial
24
side of the IV fingers), the skin of the palm corresponding to these 3,5 fingers and
the skin of the dorsal surfaces of the distal phalanx of the 1st, distal and medial
phalanges of the 2d and 3d and radial side of the same phalanges of the 4th fingers.
3. The ulnar nerve (n. ulnaris) arises from the medial fasciculus of the brachial
plexus, passes into medial bicipital sulcus to the posterior surface of the medial
epicondyle (here it lies superficially under the skin and that is why it gets hurts
often) and then extends in the ulnar grooves of the forearm and further it runs
through ulnar carpal canal to the palm.
On the arm the ulnar nerve gives off no branches. It gives off branches to
articular capsule of the elbow joint, to the m. flexor carpi ulnaris and to the medial
half of the m. flexor digitorum profundus. On the hand the ulnar nerve innervates
all muscles of the hypothenar, all mm. interossei, the 3rd and the 4th mm.
lumbricales and 1,5 muscles of the thenar (m. adductor pollicis and the deep head
of the m. flexor pollicis brevis). It gives off the skin branches which innervate the
skin of hypothenar. The skin of the ulnar side of palm and the skin of 1,5 fingers
(both sides of the 5th finger and the ulnar side of the 4th finger) and the skin of the
dorsal surfaces of the 2,5 fingers (4th, 5th and the ulnar side of the 3rd fingers),
with the exception of the dorsal surfaces of the skin on the fingers which are
innervated by the median nerve (look above).
4. The radial nerve (n. radialis) is a continuation of the posterior fasciculus of the
brachial plexus. It passes to the posterior surface of the arm together with the deep
brachial artery, runs in the humeromuscular canal and then emerges between m.
brachioradialis and m. brachialis.
The radial nerve gives off the branches to all extensors and supinators of the
arm and forearm and m. brachioradialis. It supplies the capsules of the elbow and
wrist joints, and radial epicondyle of the humerus. Its sensory branches innervate
the skin of the posterior and inferior parts of the posterolateral surface of the arm
(n.n. cutanei brachii posterior and lateralis inferior), and the skin of the posterior
surface of the forearm (n. cutaneus antebrachii posterior). On the hand the radial
nerve innervates the skin of posterior surface of 2,5 fingers (I, II and radial side of
the III finger), with the exception of the dorsal surfaces of the fingers which are
innervated by the median and ulnar nerves (look above).
5. The medial cutaneus nerve of the arm (n. cutaneus brachii medialis) arises
from the medial fasciculus of the brachial plexus and supplies skin on the medial
surface of the arm up to the elbow joint.
6. The medial cutaneus nerve of the forearm (n. cutaneus antebrachii medialis)
also arises from the medial fasciculus and supplies the skin on the medial side of
the forearm down to the radiocarpal joint.

25
 The Arteries of the Thoracic Cavity
The descending aorta (aorta descendens) is part of the posterior
mediastinum to the left of the spine. It is subdivided into the thoracic part (aorta
thoracica) and abdominal part (aorta abdominalis). The boundary between these
two parts is the hiatus aorticus of the diaphragm on the level of the 12-th thoracic
vertebra.The branches of the descending aorta are subdivided into the parietal
branches (rr. parietalis), stretching to the walls of the cavities, and the visceral
branches (rr. visceralis), running to the organs (Fig. 2).

The Thoracic Aorta

The thoracic aorta gives off the following visceral branches (Fig. 52, 53):
1. The bronchial branches (rr. bronchiales), which supply nutrients to the lung as
an organ, carry blood to the bronchial tree till respiratory bronchioli, interlobular
connective tissue and visceral pleura.
2. The oesophageal branches (rami oesophagei) pass to the oesophagus.
3. The mediastinal branches (rami mediastinalis) pass to the lymph nodes and
connective tissue of the posterior mediastinum.
4. The pericardiac branches (rami pericardiaci) carry blood to the posterior wall
of the pericardium.

Parietal branches of the thoracic aorta:

1. The posterior intercostal arteries (aa. intercostales posteriores), ten pairs of
these branches run from the aorta to the 3rd - 11th intercostal spaces. The 10-th
intercostal artery passes below the 12-th rib and is called the subcostal artery (a.
subcostalis). At the beginning of the intercostal spaces, each posterior intercostal
artery gives off a dorsal branch (r. dorsalis), extending to the deep muscles and
skin of the back and to the spinal cord (rr. spinales). Then each posterior
intercostal artery passes along the groove of the rib on the inferior border of the
inner surface of the rib. The artery is in direct contact with pleura up to the costal
angle, after that it lies between the external and internal intercostal muscles and
gives off branches to them, to the ribs, to the skin (rr. cutaneus medialis and
lateralis), to the mammary gland (rr. mammarii laterales), to the parietal pleura.
The lower 6 posterior intercostal arteries give off branches to the parietal
peritoneum, to the muscles and skin of abdominal wall.
2. The superior phrenic arteries (aa. phrenicae superiores) are small branches of
the thoracic aorta, which branch out on the superior surface of the diaphgram.

26
 The Veins of the Thoracic Cavity

Vena azygos (unpaired vein) and inferior vena hemiazygos (semiunpaired

vein) collect blood from the walls and organs of the thoracic cavity. They are
continuations of the ascending lumbar veins which connect the lumbar veins on the
posterior wall of the abdominal cavity. They pass upward behind m. psoas major
and make their way into the thoracic cavity between the muscular bundles of the
diaphragm’s crura (Fig. 13).
In the thoracic cavity v. azygos is continuation of the right ascending lumbar
vein, it rises along the right lateral side of the spine, closely adhering to the
posterior wall of the oesophagus. At the level of the 4-th or the 5-th thoracic
vertebra it departs from the spine and, bending over the root of the right lung, drain
into the posterior wall of the superior vena cava.
Nine right inferior posterior intercostal veins drain into the unpaired vein.
The posterior intercostal veins collect blood from the veins of the vertebral
plexuses and from the veins of the deep muscles of the back. V. azygos also
receives blood from the right superior intercostal vein (v. intercostalis superior
dextra) which is formed by the merger of three right superior intercostal veins. The
oesophageal veins (vv. oesophageales), the bronchial veins (vv. bronchiales) and v.
hemiazygos also drain into the v. azygos.
V. hemiazygos is continuation of the left ascending lumbar vein, it lies on
the left lateral surface of the spine behind the thoracic aorta. It ascends only up to
the 7-th or 8-th thoracic vertebra, then turns right and passing obliquely upward
over the anterior surface of the vertebral column behind the thoracic aorta and
thoracic lymphatic duct and drains into v. azygos. It collects blood from the organs
of the mediastinum and from the lower 6-th left posterior intercostal veins, as well
as veins of the vertebral plexuses and v. hemiazygos accessoria. V. hemiazygos
accessoria collects blood from the upper 6 left posterior intercostal veins. It runs
from top to bottom on the left lateral side of the spine and drains into v.
hemiazygos, or directly into the v. azygos on the level of 7-th thoracic vertebra.

Veins of the walls of the trunk

The posterior intercostal veins (vv. intercostales posteriores) accompany

arteries of the same names, one vein accompanies every artery (look above). The
internal thoracic vein (v. thoracica interna) rises along lateral side of the
sternum, it is binary vessel but near the 1st rib both viens merge into a single trunk,
which drain into v. brachiocephalica of the same side.
The venous vertebral plexuses. There are two internal and two external
venous vertebral plexuses (plexus venous vertebrales externus (internus) anterior
(posterior)) (Fig. 54).
The internal ones (anterior and posterior) are located in the vertebral canal
between dura mater and periosteum along anterior and posterior walls of the canal.

27
 The veins of the spinal cord drain into the internal vertebral plexuses. Vv.
basivertebrales are inside vertebral bodies and drain also into the anterior internal
venous vertebral plexus.
The external plexuses (anterior and posterior) located on the vertebral bodies
and behind their arches. Blood from the vertebral plexuses is drained throught vv.
intervertebrales into vv. intercostales posteriores (in the thoracic cavity), into vv.
lumbales (in the abdominal cavity) and into v. vertebralis (in the neck).

The Nerves of the Thoracic Cavity

The Intercostal Nerves

The intercostal nerves (nn. intercostales) are the anterior branches of the
thoracic spinal nerves (Fig. 55). They are located in the intercostal spaces but the
twelfth nerve runs along the lower edge of the twelfth rib and is called the
subcostal nerve (n. subcostalis). Each intercostal nerve is connected with the
symphathetic trunk by a grey communicating branch to and, at the first, is covered
only by the pleura; but then it passes down from the posterior intercostal artery and
enters the space between the external and internal intercostal muscles and then
passes along the inferior edge of the rib forward. The upper six intercostal nerves
reach the edge of the sternum; the lower six - penetrate the thickness of the
peritoneal wall, pass between the transverse and the internal oblique muscles and
reach the rectus muscles. The twelfth intercostal nerve lies on the m. quadratus
lumborum and ends near the pubic symphysis in the lower part of the rectus and
pyramidal muscles. The intercostal nerves give off muscular branches to all deep
muscle of the thoracic walls, to ventral muscles of the abdominal wall and to
muscles of the back (mm. serrati posteriores superiores and inferiores and mm.
levatores costarum). They also innervate the pleura and peritoneum and the skin of
the lateral surface of the thorax and abdomen (r. cutaneus lateralis pectoralis and
abdominalis), the skin of the anterior surface of the thorax and abdomen - (r.
cutaneus anterior pectoralis and abdominalis), the mammary glands – (rr.
mammarii laterales and medialles).

The Thoracic part of the Vagus Nerve

On leaving the neck the vagus nerve enters through the superior thoracic
aperture into the thoracic cavity where the right one lies in front of the subclavian
artery, while the left one extends on the anterior surface of the aortic arch. Both
vagus nerves descend and go around the roots of the lungs on both sides dorsally
and then run along the anterior and posterior surfaces of the oesophagus, forming
the anterior and posterior vagal trunks on its walls (truncus vagalis anterior and
posterior). The anterior vagal trunk is left vagus nerve and the posterior one is
right vagus nerve (Fig. 24).
28
Thoracic branches of the vagus nerve:
1. The cardiac branches (rami cardiaci thoracici) pass to the cardiac plexus;
2. The bronchial branches (rr. bronchiales) form plexus on the walls of the
bronchi together with the branches of the sympathetic trunk;
3. The pulmonary plexus (plexus pulmonalis) is formed by the bronchial branches
and branches of the thoracic sympathetic trunk;
4. The oesophageal plexus (plexus oesophagealis) connects with the sympathetic
nerves and runs to the walls of the oesophagus.

The Thoracic part of the Sympathetic Trunk

The thoracic part of the sympathetic trunk consists of 10-12 ganglia more or
less triangular shapes (Fig. 56). These ganglia lie in front of the necks of the ribs
and are covered anteriorly by the pleura. The thoracic trunk is characterized by the
presence of white communicating branches which connect the anterior roots of the
spinal nerves with the sympathetic ganglia.

The branches of the thoracic part of the sympathetic trunk:

1. The white communicating branches (rami communicates albi).
2. The grey communicating branches (rami communicates grisei) arise from all
ganglia of the symphathetic trunk and run to the intercostal nerves.
3. The cardiac branches (rr. cardiaci thoracici) contain postganglionic
symphathetic and afferent (painful) nerve fibres.
4. The pulmonary branches (rr. pulmonares thoracici).
5. The aortic branches (rr. aorticae thoracici).
6. The oesophageal branches (rr. oesophageales).
Four last groups of the branches arise from the 4 superior thoracic ganglia
and participate in formantion of cardiac plexus, pulmonary plexus, thoracic aortic
plexus and oesophageal plexus together with afferent fibres of the vagus nerve;
7. The greater splanchnic nerve (n. splanchnicus major) arises from the 5-th to
9-th thoracic ganglia and then pass medially to the level of 12-th thoracic vertebra
where they fuse into one common trunk, which is transmitted through the space
between the muscular bundles of the diaphragmatic crura into the abdominal cavity
in which it becomes a component of the coeliac plexus.
8. The lesser splanchnic nerve (n. splanchnicus minor) arises from the 10-th and
11-th thoracic ganglia, penetrates the diaphragm together with the greater
splanchnic nerve and also becomes a component of the coeliac plexus.
The splanchnic nerves contain vasoconstricting fibres, the fibres inhibiting
motor activity of the stomach and intestine and fibres conducting sensations from
the viscera of the upper part of the abdominal cavity.

29
 The Arteries of the Abdominal Cavity

The Abdominal Aorta

The abdominal aorta (aorta abdominalis) is a continuation of the thoracic aorta,
on the level with 4-th lumbar vertebra it divides into two large terminal branches
-the common iliac arteries.The abdominal aorta gives off the parietal branches and
two groups of the visceral branches – paired and unpaired ones, which supply
blood to paired and unpaired organs of the abdominal cavity (Fig. 57, 61).

The unpaired visceral branches of the abdominal aorta:

1. The coeliac trunk (truncus coeliacus) is a short thick artery arising at the level
of 12-th thoracic vertebra, in the hiatus aorticus of the diaphragm. It passes
forward above the superior border of the pancreas where it separates into three
branches (this site of its division is called the tripus coeliacus) (Fig. 58):
(a) the left gastric artery (a. gastrica sinistra) passes upwards to the cardiac part
of the stomach and then passes along the lesser curvature of the stomach and gives
off branches to the stomach and to the abdominal part of the oesophagus;
(b) the common hepatic artery (a. hepatica communis) passes along the superior
margin of the head of the pancreas to the superior border of the duodenum. Here it
gives off two branches - a. gastroduodenalis and a. hepatica propria.
Last one lies between 2 layers of the hepatoduodenal ligament with the portal vein
and the common bile duct and reaches the porta hepatis where it divides into right
and left branches. The right branch carries blood to the gall bladder.
The common or proper hepatic artery gives off a branch to the lesser curvature of
the stomach called right gastric artery (a. gastrica dextra) which stretches to meet
a. gastrica sinistra to form an arterial arch of the lesser curvature of the stomach.
The gasroduodenal artery (a. gastroduodenalis) passes behind upper part of the
duodenum and divides into 2 branches:
- a. gastroomentalis dextra which passes along the greater curvarture of the
stomach and gives off branches to the stomach and greater omentum;
- aa. pancreaticoduodenales superiores anterior and posterior which branch out
in the head of the pancreas and in the descending part of the duodenum and
anastomose with one another.
(c) the splenic artery (a. lienalis) is the largest branch of the coeliac trunk. It
passes along the superior border of the pancreas to the spleen and its hilum, and
carries blood to it.
The splenic artery gives off a. gastroomentalis sinistra, which passes to the greater
curvature of the stomach and anastomoses with a. gastroomentalis dextra to form
an arterial arch of the greater curvature. The branches of this arch run to the
stomach. In addition, many short arteries (aa. gastricae breves) arise from the
splenic artery and run to the stomach’s walls.
So, around the stomach four main arteries form arterial ring which consists
of two arches situated on the lesser curvature and formed by the left and right
30
gastric arteries and on the greater curvature formed by the left and right
gastroomental arteries. These main arteries also are called the coronary arteries of
the stomach.
So, the branches of the coeliac trunk supply the stomach, the abdominal part
of the oeosophagus, the liver, the gall bladder, the spleen, the superior halves of the
pancreas and of the duodenum.

2. The superior mesenteric artery (a. mesenterica superior) – arises from the
anterior surface of the aorta below the coeliac trunk, on the level of the first lumbar
vertebra, passes forward and downward, into the slit between the inferior border of
the pancreas in front and the horizontal part of the duodenum behind, enters the
mesentery of the small intestine and descends towards the right iliac fossa giving
numerous branches (Fig. 59):
(a) The inferior pancreaticoduodenal artery (a. pancreaticoduodenalis inferior)
passes to the right on the concave surface of the duodenum and anastomoses with
the superior pancreaticoduodenal arteries. It supplies the inferior parts of the
pancreas and duodenum with blood.
(b) The intestinal arteries (aa. jejunales and aa. ileales) are ten or sixteen
branches which pass to the jejunum and to the ileum between two layers of the
their mesenteries. On the way they dichotomize and the neighbouring branches
form anastomoses. As a result of this, three rows of arches are formed between the
branches of aa. jejunales and two rows of arches are formed between the branches
of aa. ileales.
These arches are the result of the functional adjustment for increasing the
supply of blood to the intestine during any movements or positions of its loops.
The arches encircle the intestinal tube with many fine branches.
(c) The ileocolic artery (a. ileocolica) runs inside mesentery to the ileocaecal
angel and gives off branches to the distal part of the ileum and caecum and to the
vermiform process (a. appendicularis).
(d) The right colic artery (a. colica dextra) – passes behind the peritoneum to the
ascending colon and divides near it into two branches – an ascending branch
anastomoses with the middle colic artery and a descending branch, descends to
meet a. ileocolica. These anastomoses give off the branches to the adjoining parts
of the colon.
(e) The middle colic artery (a. colica media) passes between the layers of the
transverse mesocolon and on reaching the transverse colon divides into the right
and left branches which anastomose with the right colic artery and with the left
colic artery. The branches of the middle colic artery supply right two thirds of the
transverse colon. The anastomoses between colic arteries are called the Riolan’s
arches.
So, the branches of the superior mesenteric artery supply the inferior parts of
the pancreas and duodenum, the loops of the jejunum and ileum, the mesentery of
the small intestine and the right half of the large intestine (caecum with the
vermiform process, ascending colon and the right two thirds of the transverse
colon and its mesocolon.
31
3. The inferior mesenteric artery (a. mesenterica inferior) arises from the aorta
on the level of the inferior edge of the third lumbar vertebra, one vertebra above
the aortic bifurcation and passes downward and to the left lying behind peritoneum
on the anterior surface of the left psoas major muscle. It gives off the following
branches (Fig. 60):
(a) The left colic artery (a. colica sinistra) divides into two branches: an
ascending branch passes to the left flexure of the colon to meet the branches of the
middle colic artery and descending branch anastomoses with the sigmoid arteries.
These branches supply the left one third of the transverse colon and desending
colon.
(b) The sigmoid arteries (aa. sigmoidea) (usually two) pass to the sigmoid colon,
their ascending branches anastomose with the branches of the left colic artery and
descending branches - with the superior rectal artery. The anastomose between the
left colic artery and the sigmoid arteries is called arcus marginalis coli or
Drummond anastomose.
(c) The superior rectal artery (a. rectalis superior) is a continuation of the
inferior mesenteric artery. It descends in the root of the sigmoid mesocolon and
behind rectum it passes into the pelvis and supplies upper part of the rectum and
gives off branches which carry blood to the rectal mucous till anal doors (valves).
The branches of the superior rectal artery anastomose with the branches of the
sigmoid artery and with the branches of the middle rectal artery (from the internal
iliac artery).
So, the branches of inferior mesenteric artery supply blood to the left one
third of the transverse colon, to the descending, sigmoid colons and to the upper
part of the rectum.

The paired visceral branches of the abdominal aorta arise in the order of
location of the organs (Fig. 57):
1. The middle suprarenal artery (a. suprarenalis media) arises from the aorta on
the level of the first lumbar vertebra and passes to the suprarenal gland.
2. The renal artery (a. renalis) branches off the aorta almost at the right angle at
the level of second lumbar vertebra and passes transversaly to the hilum of the
kidney. The right renal artery is located behind the inferior vena cava, the head of
the pancreas and the descending part of the duodenum. The left renal artery passes
behind the pancreas. In the hilum of the kidney the renal artery divides into three
branches: anterior and posterior branches (r. anterior, r. posterior) which carry
blood to all segments of the kidney and small branches to the ureter (rr. ureterici).
Also it gives off branches to the capsules of the kidney (rr. capsulares) and to the
inferior part of the suprarenal gland (a. suprarenalis inferior).
3. The testicular artery (a. testicularis) in male is a long vessel arising from the
aorta directly below the renal artery on the level of the second lumbar vertebra. It
descends along the anterior surface of the psoas major muscle, crosses the ureter
anteriorly, sends the branches to the ureter, approaches deep inguinal ring and

32
together with the deferent duct runs in the inguinal canal and reaches the testis.
Here it gives off small branches to the epididymis (rr. epididymales).
The ovarian artery (a. ovarica) is the corresponding artery in female. It starts on
the same level, does not enter the inguinal canal but passes into true pelvis,
descends to the ovary as a component of its suspensory ligament. It gives off
branches to the uterine tube (rr. tubarii).

The parietal branches of the abdominal aorta (Fig. 57):

1. The inferior phrenic artery (a. phrenica inferior) is paired artery which
supplies blood to the lumbar part of the diaphragm and gives off small branches to
the suprarenal gland (aa. suprarenales superiores).
2. The lumbar arteries (aa. lumbales) are four on each side, they supply blood to
the corresponding vertebrae, to the spinal cord, to the muscles and skin of the
lumbar area of the back and abdomen.
3. The median sacral artery (a. sacralis mediana) is an unpaired vessel, branches
off the bifurcation of the aorta, it descends on the anterior midline of two lower
lumbar vertebra, sacrum and coccyx and terminates here as a small branches on the
coccygeal body. It gives off paired lowerest lumbar arteries (aa. lumbales imae),
lateral sacral branches (rr. sacrales laterales). On the end of the median sacral
artery the small coccygeal body (glomus coccygeum) is located. It contains
chromaphin cells and arteriovenous anastomoses.
4. The common iliac arteries (aa. iliacae communes). The right and left arteries
are two final branches into which the aorta divides on the level of the fourth
lumbar vertebra. They supply blood to the pelvis and to the free lower limbs.

The Veins of the Abdominal Cavity

The Inferior Vena Cava

The inferior vena cava (v. cava inferior) is the thickest venous trunk which
lies in the abdominal cavity close to the right side of the aorta (Fig. 61). It is
formed on the level of fourth lumbar vertebra by the merger of two common iliac
veins below the bifurcation of the aorta and to the right of it. The inferior vena
cava passes upward and to the right, its upper segment lies on the lumbar part of
the diaphragm. Then, lying in the sulcus vena cava of the liver, the vein passes
through the foramen vena cava of the diaphragm, into the thoracic cavity and
immediately drains into the posterior wall of the right atrium. The veins which
drain into the inferior vena cava correspond to the parietal and paired visceral
branches of the abdominal aorta, therefore they are subdivided into parietal and
visceral branches.

The parietal branches of the inferior vena cava:

1. The lumbar veins (vv. lumbales) – four veins on each side corresponding to the
lumbar arteries. Only two of them (third and fourth lumbar veins) drain into the

33
inferior vena cava. They collect blood from the vertebral plexuses, skin and
muscles of the lumbar region and are united by the longitudinal trunks called
ascending lumbar veins (vv. lumbales ascendens).
2. The inferior phrenic veins (vv. phrenicae inferiores) – drain into the inferior
vena cava in the region of the sulcus vena cava of the liver. It collects blood from
the inferior surface of the diaphragm.

The visceral branches of the inferior vena cava:

1. The testicular vein (v. testicularis) (in male) or the ovarian vein (vv. ovaricae)
(in female) collect blood from the testis (ovary) and form plexuses with arteries of
the same names. The right testicular or ovarian vein drains directly into the inferior
vena cava at an acute angle; the left one drains into the left renal vein at the right
angle. This right angle hampers the flow of blood and causes the more frequent
occurence of varicocele in the left spermatic cord in male. The vine-shaped plexus
(plexus pampiniformis) is formed around the spermatic cord. In female v. ovarica
begins in the hilum of the ovary.
2. The renal veins (vv. renales) pass in front of renal arteries; the left renal vein is
longer than the right and runs ahead of the aorta. They collect blood from the
kidneys, from their capsules (vv. capsulares are located in the depth of the fatty
capsule). Two venous vessels collect blood from the left suprarenal gland and from
the left sex gland. V. suprarenalis sinistra drains into the left renal vein in front of
the aorta. V. testicularis sinistra or v. ovarica sinistra also drains into the left renal
vein.
3. The right suprarenal vein (v. suprarenalis dextra) – drains into inferior vena
cava immediately above the renal vein.
4. The hepatic veins (vv. hepaticae) are short vessels inside liver, they drain into
the inferior vena cava as it passes over the posterior surface of the liver. The
hepatic veins collect blood from the liver which receives it through the portal vein
and hepatic artery.

The Portal Vein

The portal vein (v. portae hepatis) is a thick venous trunk, located in the
hepatoduodenal ligament with the hepatic artery and bile duct (Fig. 62). The portal
vein is formed behind the head of the pancreas by the merger of the splenic vein
and two mesenteric veins (superior and inferior). It collects blood from all
unpaired organs of the abdominal cavity with the exception of the liver. On its way
to the hepatic porta, the portal vein collects blood from the vv. gastricae sinistra
and dextra, v. prepylorica which carry blood from the lesser curvature and anterior
surface of the pyloric part of the stomach; and vv. paraumbilicales that surround
the round ligament of the liver and anastomose with the subcutaneus abdominal
veins. In the porta hepatis it divides into two branches which pass into the
parenchyma of the liver, where they spread into a multitude of small branches
which entwine the hepatic lobule and penetrate the lobule, eventually join in vv.
centrales which merge in two hepatic veins draining into the inferior vena cava.
34
 Thus in distinction from other veins, the system of the portal vein fits
between two networks of the venous capillaries: the network of the venous
capillaries of the gastrointestinal tract, of the spleen and pancreas and the network
of the venous capillaries of the liver.

The roots of the portal vein:

The splenic vein (v. lienalis) runs behind pancreas and carries blood from the
spleen, stomach and pancreas.
The mesenteric veins correspond to the arteries of same names. The superior
mesenteric vein (v. mesenterica superior) collects blood from intestine for the
distance from the distal part of the duodenum to the left colon flexura.
The inferior mesenteric vein (v. mesenterica inferior) originates in the venous
plexus of rectum and collects blood from the sigmoid and descending colon till left
flexura of the colon.
The following biochemical processes take place in the liver: the blood in the
portal vein carries nutrients which were absorbed in the gastrointestinal tract. Here
the proteins are neutralized; the carbohydrates are deposited as glycogen by means
of the effect of the insulin which is in blood, collected from pancreas; and blood
flowing from the spleen yields the products of disintegration of the erythrocytes
used by liver to secrete the bile.

The Portacaval and Cavacaval Anastomoses

The roots of the portal vein anastomose with the roots of the veins from the
system of the superior and inferior vena cava, forming so called portacaval
anastomoses, which are of practical significance. If we imagine the abdominal
cavity in the shape of a cube, these anastomoses are located on four sides of a
cube: on the upper, lower, anterior and posterior ones (Fig. 63-65).
1. The upper portacaval anastomose is located around, the abdominal part of the
oesophagus. It is formed between the roots of v. gastrica sinistra, which empties
into the portal vein and vv. oesophageales which drain into the vv. azygos and
hemiazygos and further into the superior vena cava.
2. The lower portacaval anastomose is located around the rectum. It is formed
between roots of v. rectalis superior which drains through v. mesenterica inferior
into the portal vein and vv. rectalis media and inferior which drain into v. iliaca
interna and further into v. iliaca communis from the system of the inferior vena
cava.
3. The anterior portacaval anastomose is located superficially on the anterior
abdominal wall around the navel. It is formed between the roots of vv.
paraumbicales, which drain into the portal vein and v. epigastrica superior from the
system of the superior vena cava and v. epigastrica inferior from the system of the
inferior vena cava.
This portacaval anastomose provide a bypass for the drainage of blood when
obstacles appear in the liver (e.g., in cirrhosis of the liver). In such cases the veins
around the navel dilate and acquire a typical appearence known as Medusa’s head.
35
4. The posterior portacaval anastomose is located on the posterior abdominal
wall, behind the mesoperitoneal segments of the large intestine. It is formed
between the roots of the superior mesenteric vein (collect blood from the ascending
colon), the roots of the inferior mesenteric vein (collect blood from the descending
colon) which are roots of the portal vein and right and left vv. lumbales which are
branches of the inferior vena cava. These anastomoses form a system what is
known as the Retzius system.
On the posterior wall of the trunk there are two cavacaval anastomoses:
1. Anastomoses between roots of vv. lumbales (venous system of the inferior vena
cava), which are connected by the vv. lumbales ascendens, which continue with
vv. azygos and hemiazygos (venous system of the superior vena cava).
2. Anastomoses between roots of the vv. lumbales and the vv. intervertebrales,
which serve as roots of the superior vena cava in the region of the neck.

The Nerves of the Abdominal Cavity

The Abdominal part of the Vagus Nerve

The vagal trunks, running along the oesophagus, continue to the stomach.
The continuation of the anterior vagal trunk passes to the anterior wall of the
stomach with the name rr. gastrici anteriores. The continuation of the posterior
vagal trunk passes to the posterior wall of the stomach and is named rr. gastrici
posteriores (Fig. 28, 66). Some small branches pass to the liver (rr. hepatici). The
greater part of the vagal fibres, coeliac branches (rr. coeliaci), pass to the coeliac
plexus and from it the vagal branches run to the liver, spleen, pancreas, kidneys,
small and large intestine up to the sigmoid colon along the branches of the
abdominal aorta.

The Abdominal part of the Sympathetic Trunk

The abdominal part of the sympathetic trunk consists of four lumbar ganglia.
Both symphathetic trunks in the abdominal cavity, come closer to each other than
in the thoracic cavity (Fig. 66). The ganglia lie on the anterolateral surfaces of the
lumbar vertebrae on the medial border of psoas major muscle and are covered by
the extraperitoneal fascia. The ganglia are connected by the longitudinal
interganglionic branches and by the transverse interganglionic branches which
connect right and left lumbar ganglia.

The branches of the abdominal part of the sympathetic trunk:

1. The white communicating branches (rr. communicates albi) are branches of
two superior lumbar ganglia which connect ganglia with first and second lumbar
segments of the spinal cord.
2. The grey communicating branches (rr. communicantes grisei) pass to the
lumbar spinal nerves from each lumbar ganglion.
36
3. The lumbar splanchic nerves (nn. splanchnici lumbales) are four in number,
they form nervous network on the anterior surface of the fifth lumbar vertebra and
take part in the formation of the coeliac plexus.

The Vegetative Plexuses of the Abdominal Cavity

The abdominal aortic plexus (plexus aorticus abdominalis) is main and

largest vegetative plexus in the abdominal cavity. It lies on the anterior surface of
the abdominal aorta and continues along its branches. The aortic plexus include in
two plexuses – the coeliac plexus and intermesenteric plexus (Fig. 66).
The coeliac plexus (plexus coeliacus) is large and significant part of the
abdominal aortic plexus which is known also as the “abdominal brain”. It lies on
the anterior surface of the aorta behind the pancreas and surrounds the initial parts
of the coeliac trunk, the superior mesenteric artery and the renal arteries. The
coeliac plexus consists of 5 ganglia – 2 coeliac, 2 aortarenal and 1 superior
mesenteric ganglia. Coeliac ganglia (ganglia coeliaca) are located on both sides of
the root of the coeliac trunk and are in the form of a crescent. Aortarenal ganglia
(ganglia aortarenalia) are on the beginning of the renal arteries. Superior
mesenteric ganglion (ganglion mesentericum superius) is located on the beginning
of the same artery.
The following nerves run to the coeliac plexus:
- The right and left greater and lesser splanchnic nerves;
- The lumbar splanchnic nerves;
- The fibres of the posterior vagal trunk;
- The sensory fibres of the right phrenic nerve.
Two last ones pass through the ganglia as transit goods.
The coeliac plexus gives off the branches which contain postganglionic
sympathetic and preganglionic parasympathetic fibres. They extend along the
courses of the arteries and form the plexuses and ganglia with the same names:
1. The liver’s plexus (plexus hepaticus);
2. The phrenic ganglia (ganglia phrenica);
3. The splenic plexus (plexus lienalis);
4. The gastric plexus (plexus gastrici);
5. The pancreatic plexus (plexus pancreaticus);
6. The renal plexus (plexus renalis);
7. The suprarenal plexus (plexus suprarenalis);
8. The ureter plexus (plexus uretericus);
9. The testicular (ovarian) plexus (plexus testicularis, ovaricus);
10. The superior mesenteric plexus (plexus mesentericus superior);
11. The renal ganglia (ganglia renalia).
The branches of the superior mesenteric ganglion together with other
branches of the aortic plexus run to the superior mesenteric artery and form around
it the superior mesenteric plexus, which continues along the courses of the
branches of the superior mesenteric artery. These plexuses innervate the pancreas,
the small intestine, the caecum, the ascending colon and the transverse colon.
37
 The plexuses of the small intestine lie between the layers of its walls. There
are three groups of the plexuses: subserous plexus (plexus subserosus) is under
peritoneum; intermuscular (plexus myentericus) is located between longitudinal
and circular muscular layers of the small intestine; it regulates the peristaltic
movements of the intestine and submucous plexus (plexus submucous, Meissner)
located under mucous coat of the intestine and innervates smooth muscles of this
coat and its glands.
The intermesenteric plexus is on the anterior surface of the abdominal
aorta between superior and inferior mesenteric arteries. It gives off the inferior
mesenteric plexus which is located along the course of the inferior mesenteric
artery and its branches. This plexus contains inferior mesenteric ganglion
(ganglion mesentericum inferius) and gives off the branches to the descending
colon, the sigmoid colon and the upper part of the rectum. The postganglionic
fibres of the inferior mesenteric ganglion pass to the pelvis as a components of the
hypogastric nerves.

38
 The Arteries of the Pelvic Girdle

The Common Iliac Artery

The right and left common iliac artery (a. iliaca communis) are two terminal
branches into which the aorta divides at the level of the fourth lumbar vertebra
(Fig. 67). The division (bifurcatio aorta) occurs slightly to the left of the midline
as a result of which the right common iliac artery is 6-7mm longer than the left
one. From the site of the bifurcation the common iliac artery passes downward and
laterally to the sacroiliac joint. Here each artery divides into two branches: the
internal iliac artery, supplying the walls and organs of the pelvis with blood, and
the external iliac artery, serving mainly the free lower limb.
The common iliac artery gives off some small braches to the neighbouring
lymphatic nodes, to the ureter and psoas major muscle.

The Internal Iliac Artery

The internal iliac artery (a. iliaca interna) arising from the distal end of
common iliac artery at the level of the sacroiliac joint, descends into the true pelvis
and passes to the superior edge of the greater sciatic foramen, where it divides into
two main trunks: the posterior trunk, which gives rise to the iliolumbar artery, to
the lateral sacral artery and to the superior gluteal artery; and the anterior trunk,
from which the remaining branches of the iliac artery rise (Fig. 67, 68, 70). The
branches of the internal iliac artery are subdivided into two groups: the parietal and
the visceral branches.

The parietal branches of the internal iliac artery:

1. The iliolumbar artery (a. iliolumbalis) runs behind m. psoas major into the
iliac fossa and gives off the branches to the spinal cord (r. spinalis), to the mm.
psoas major and minor, m. quadratus lumborum, m. iliacus and m. transversus
abdominis (r. lumbalis and r. iliacus).
2. The lateral sacral artery (a. sacralis lateralis) descends along the anterior
surface of the sacrum and supplies blood to the m. levator ani, m. piriformis, to the
nerve trunks of the sacral plexus, to the spinal cord (rr. spinales), to m. coccygeus,
to the sacroiliac joint, to the skin of the sacral region. It anastomoses with the
median sacral artery.
3. The superior gluteal artery (a. glutea superior) is a continuation of the
posterior trunk of the internal iliac artery. It leaves the pelvis through the foramen
suprapiriforme, reaches the gluteal muscles and divides into two branches:
superficial branch (r. superficialis) is located between mm. gluteus maximus and
medius and deep branch (r. profundus) - between mm. gluteus medius and
minimus. It supplies these muscles with blood. Also it gives off branches to the m.
piriformis, m. obturatorius internus, m. levator ani and to the hip joint.

39
4. The obturator artery (a. obturatoria) passes along the lateral pelvic wall to the
obturator foramen. Before entering the obturator canal it gives off the pubic branch
(r. pubicus), which extends on the posterior surface of the pubic bone and
anastomoses with the ramus pubicus of the inferior epigastric artery. This
anastomosis is situated very near the femoral ring and is called the corona of the
death (corona mortis). On leaving the obturator canal the obturator artery supplies
the external obturator muscle and the adductors of the thigh and gives rise to the
acetabular branch (r. acetabularis), which passes into the hip joint to the ligament
of the femur’s head and supplies the head of the femur and its ligament with blood.
5. The inferior gluteal artery (a. glutea inferior) passes through the foramen
infrapiriforme and gives off the companion artery of the sciatic nerve (a. comitans
n. ischiadici), and the muscular branches to the m. gluteus maximus, to the hip
joint and to the skin of the buttock.

The visceral branches of the internal iliac artery:

1. The umbilical artery (a. umbilicalis) retains its lumen in the adult only for a
small distance - from its origin to the site where it gives off the superior vesical
arteries, the remaining segment of its trunk to the navel obliterates and transforms
into the medial umbilical ligament. Therefore the umbilical artery is subdivided
into two parts:
a) an opened part (pars patens) is nonobliterated part, it gives off a. ductus
deferentis (in male), which runs to the testis, three rr. ureterici (to the ureter) and
aa. vesicales superiores carry blood to upper and middle parts of the urinary
bladder;
b) an obliterated part (pars occlusa).
2. The inferior vesical artery (a. vesicalis inferior) supplies the ureter, the fundus
of the urinary bladder, gives off the branches to the vagina (in female), to the
prostate gland and seminal vesicles (in male).
3. The uterine artery (a. uterina) (in female) passes medially between two layers
of the lig. latum uteri to the uterine neck, supplies the vagina (rr. vaginales), the
uterine tube (r. tubarius) and the ovary (r. ovaricus).
4. The vaginal artery (a. vaginalis) carries blood to the vagina.
5. The middle rectal artery (a. rectalis media) gives off the branches to the
rectum, to the prostate, and to the lower part of the vagina (in female).
6. The internal pudendal artery (a. pudenda interna) passes out the pelvis
through the foramen infrapiriforme and again enters the pelvis through the small
sciatic foramen (foramen ischiadicum minor) and ends in the fossa ischiorectalis. It
gives off the following branches: a. rectalis inferior, a. perinealis, rr. labiales
posteriores (in female) or rr. scrotales posteriores (in male), a. urethralis, a. bulbi
vestibuli (in female) or a. bulbi penis (in male), a. dorsalis clitoridis (in female) or
a. dorsalis penis (in male), a. profunda clitoridis (in female) or a. profunda penis
and aa. perforantes penis (in male), which carry blood to the corresponding tissues
and organs.

40
The External Iliac Artery

The external iliac artery (a. iliaca externa), beginning on the level of the
sacroiliac joint, stretches down and forward along the medial edge of the psoas
muscle to the inguinal ligament; when it passes from under this ligament through
the lacuna vasorum to the thigh, where its continuation is called the femoral artery
(Fig. 67-70). Besides small branches to psoas muscle, a.iliaca externa gives off two
large branches, which originate very near the inguinal ligament:
1. The inferior epigastric artery (a. epigastrica inferior) passes upward between
the transversal fascia and the peritoneum, then leads upward as a component of the
lateral umbilical ligament along the posterior surface of the rectus muscle to the
region of the navel, where it anastomoses with a.epigastrica superior (from a.
thoracica interna). The inferior epigastric artery gives off two branches:
(a) r. pubicus, which passes towards the femoral ring where it anastomoses with
the same branch of the obturator artery;
(b) - a. cremasterica (in males) which passes to m. cremaster and to the testis; or
a. ligamentum teretis uteri (in females) supplies lig. teres uteri.
2. The deep circumflex iliac artery (a. cirumflexa ilium profunda) passes parallel
to the inguinal ligament toward the iliac crest where it anastomoses with the
iliolumbar artery and supplies m. transversus abdominis and m. iliacus with blood.

The Veins of the Pelvic Girdle

The Common Iliac Veins

The right and left common iliac veins (vv. iliacae communes) are formed by
the merging of the external and internal iliac veins on the level of the sacroiliac
joints (Fig. 70). The right and the left common iliac veins are located behind the
common iliac arteries, right one-laterally and left one-medially from the arteries.
The common iliac veins have no valves. V. sacralis mediana is unpaired vein
which drains into the left common iliac vein. V. iliolumbalis drains into the
common iliac vein or into the internal iliac vein.
On the level of the lover edge of the fourth lumbar vertebra slightly below
the division of the aorta and to the right of it two common iliac veins form the
inferior vena cava.

The External Iliac Vein

The external iliac vein (v. iliaca externa) is the direct continuation of the
femoral vein, it has no valves. It begins above inguinal ligament and passes
medially and posteriorly of the same artery. Two veins drain into it: the inferior
epigastric vein (v. epigastrica inferior) and the deep circumflex iliac vein (v.
circumflexa ilium profunda) which accompany arteries of the same names and

41
collect dioxygenated blood from the corresponding areas of the trunk. These veins
are not binary, but their branches are binary and have numerous valves (Fig. 70).

The Internal Iliac Vein

The internal iliac vein (v. iliaca interna) is a short but think trunk located
behind the internal iliac artery on the lateral wall of the true pelvis (Fig. 70). It has
valves very seldom. The veins that drain into the internal iliac vein correspond to
the arteries with the same names. These veins are binary outside the pelvis, but in
the pelvis cavity they are single trunks. A numbers of venous plexuses are formed
among the branches of the internal iliac vein, they anastomose with one another.
The parietal and visceral branches drain into the internal iliac vein.
The parietal veins: the superior and inferior gluteal veins (vv. gluteae
superiores and inferiores), the obturator veins (vv. obturatoriae), the lateral sacral
veins (vv. sacrales laterales) and unpaired iliolumbar vein (v. iliolumbalis). All
these veins have valves.
The visceral veins, which drain into the internal iliac vein, have no valves
with the exception of the veins of the urinary bladder. As a rule they start from the
venous plexuses which surround organs of the pelvis:
1. The sacral venous plexus (plexus venosus sacralis) is located in front of the
sacrum. It is formed at the expense of the anastomoses between roots of vv.
sacrales laterales and v. sacralis mediana.
2. The rectal venous plexus (plexus venosus rectalis) is a plexus in the wall of the
rectum. There are three groups of these plexuses: submucous, subfascial and
subcutaneous. The submucous or internal venous plexus is in the region of the
lower ends of the rectal columnae, it consists of the several venous nodules
arranged in the shape of a ring. The abducent veins of this plexus merge with the
veins of the subfascial or external plexus. V. rectalis superior and vv. rectales
mediae arise from the latter. V. rectalis superior drains into the inferior mesenteric
vein, and vv. rectales mediae drain into the internal iliac vein. The subcutaneous
plexus is formed in the region of the external anal sphincter. V.v. rectales
inferiores collect blood from it and drain into v. pudenda interna, which drains
into the internal iliac vein.
3. The vesical venous plexus (plexus venosus vesicalis) is located in the region of
the fundus of the urinary bladder and its lateral walls; the blood from this plexus
flows into the internal iliac vein through vv.vesicales.
4. The prostatic venous plexus (plexus venosus prostaticus) (in male) is situated
between the urinary bladder and the pubic adhesion, encompassing the prostate and
the seminal vesicles. The unpaired v. dorsalis penis and paired vv. profundae
penis and vv. scrotales posteriores pierce the urogenital diaphragm and drain into
this plexus. V. dorsalis clitoridis in females corresponds to v. dorsalis penis in
males. The blood from the prostate plexus flows into vv. vesicales.
5. The uterine venosus plexus (plexus venosus uterinus) and the vaginal venosus
plexus (plexus venosus vaginalis) (in female) are located in the broad ligaments

42
and around the vagina. The blood from them flows through vv. uterinae into the
internal iliac vein.

The Vegetative Nervous System of the Pelvis

The Sacral or Pelvic part of the Sympathetic Trunk

The sacral part of the sympathetic trunk consists of four ganglia, which are
located on the anterior surface of the sacrum along the medial margins of the
anterior sacral openings (Fig. 66). Both trunks converge to terminate as one
common unpaired ganglion (ganglion impar) on the anterior surface of the coccyx.
The ganglia are connected by the longitudinal and transverse fibres. Few branches
arise from of the sacral ganglia:
1. The grey communicating branches (rr. communicantes grisei) pass to the
sacral spinal nerves.
2. The sacral splanchnic nerves (nn. splanchnici sacrales) pass to the pelvic
plexuses – superior hypogastric plexus and inferior hypogastric plexus or pelvic
plexus.

The Vegetative Plexuses of the Pelvis

The intermesenteric plexus continues with the right and left iliac plexuses
(plexus iliacus dexter and sinister), which are located on the right and left common
iliac arteries, and with the unpaired superior hypogastric plexus (plexus
hypogastricus superior), which is located on the anterior surface of the fifth
lumbar vertebra and the promontory of the sacrum below the bifurcation of the
aorta (Fig. 66, 71).
The superior hypogastric plexus consists of the vegetative ganglia and
postganglionic sympathetic nerve fibres which are: the lumbar splanchnic nerves
(from the lower lumbar ganglia of the sympathetic trunks) and the sacral
splanchnic nerves (from the upper sacral ganglia). Below the promontory of the
sacrum the superior hypogastric plexus divides into two nerve trunks: the right
and left hypogastric nerves (nn. hypogastrici dexter and sinister), which continue
with the pelvic plexus.
The pelvic plexus (plexus hypogastericus inferior) is located on the m.
levator ani at both sides of the rectum (from the sacrum to the urinary bladder) and
consists of postganglionic sympathetic (the sacral splanchnic nerves) and
preganglionic parasympathetic (pelvic splanchnic nerves from the sacral II-IV
segments of the spinal cord) nerve fibres. These parasympathetic nerve fibres
innervate the descending colon, the sigmoid colon and the rectum and the
urogenital organs of the pelvis and external genital organs. The pelvic plexus has
its own ganglia (ganglia pelvina). Each pelvic plexus runs along the branches of
the internal iliac artery and forms some plexuses:
43
1. The vesical plexus (plexus vesicalis) innervating the urinary bladder.
2. The prostatic plexus (pl. prostaticus) (in male) innervating the prostate gland.
3. The plexus of the vas deferens (pl. deferentialis) (in male) innervating the
seminal vesicles and deferent duct.
4. The middle and inferior rectal plexuses (pl. rectalis media and inferior)
supply the rectum.
5. The uterovaginal plexus (pl. uterovaginalis) (in female) sends branches to the
uterus, uterine tube, vagina and ovaries and to the cavernous bodies of the clitoris.

The Arteries of the Free lower limb

The Femoral Artery

The femoral artery (a. femoralis) is a continuation of the external iliac artery
when it passes under the inguinal ligament through the lacuna vasorum near the
middle of this ligament (Fig. 69, 72, 76). Medially from the femoral artery is the
femoral vein, with which the artery passes to the femoral triangle, proceeding first
into the iliopectineal sulcus and then into the anterior femoral sulcus and runs
further through the adductor canal into the popliteal fossa where it continues with
popliteal artery.
The branches of the femoral artery:
1. The superficial epigastric artery (a. epigastrica superficialis) arises near the
very beginning of the femoral artery and passes in front of the inguinal ligament
under the skin to the region of the navel.
2. The superficial circumflex artery (a. circumflexa ilium superficialis) runs
along the inguinal ligament to the skin in the region of the superior anterior iliac
spine.
3. The external pudendal arteries (aa. pudendae externae) usually two in
number, branch out in the region of the hiatus saphenus and lead medially to the
skin of the external genital organs and lower surface of the abdomen.
4. The deep femoral artery (a. profunda femoris) is the main vessel through
which the thigh is supplied with blood. It is a think trunk, which arises from the
posterior surface of the femoral artery 4-5cm below the inguinal ligament, lying
first behind the femoral artery, then appearing from the lateral side, and, giving off
numerous branches, rapidly diminishing in calibre. The branches of the deep
femoral artery:
(a) a. circumflexa femoris medialis passes medially and upward and gives off the
branches to the m. pectineus, to the adductor muscles, to the hip joint, to m.
iliopsoas, m. obturatorius externus, m. piriformis, m. quadriceps femoris.
(b) a. circumflexa femoris lateralis passes laterally under m. rectus femoris and
gives off the branches to m.quadriceps, m. sartorius and to the knee joint.
(c) aa. perforantes (three in number) branch off the posterior surface of the deep
femoral artery and supply posterior muscles of the thigh.

44
5. The descending artery of the knee (a. genus descendens) branches off from
the femoral artery on its way in the adductor canal and, exiting through the
anterior wall of this canal with n. saphenus, supplies m. vastus medialis with blood
and participates in the formation of the arterial network of the knee joint.

The Popliteal Artery

The popliteal artery (a. poplitea) is the direct continuation of the femoral
artery (Fig. 73, 76). In the popliteal fossa the popliteal artery is situated on the very
bone itself, on the posterior surface of the articular capsule of the knee joint to
front from the popliteal vein; still further to the back is the tibial nerve; further
down, the artery lies on the posterior surface of m. popliteus covered by the heads
of m. gastrocneius, and then, approaching under the edge of m.soleus, separates
into two terminal branches: aa. tibiales anterior and posterior.

The branches of the popliteal artery:

1. The superior lateral and medial arteries of the knee (aa. superiores laterales
and mediales genus) branch off at the level of the top edge of the condyles of the
femur, each curving round the knee joint from its own side. They move on the
anterior surface of the joint, where they form an anastomosis and take part in the
formation of the arterial network of the knee joint (rete articulare genus).
2. The inferior lateral and medial arteries of the knee (aa. inferiores lateralis
and medialis genus) branch off at the level of the lower edge of the condyles of the
femur and take part in the formating of the arterial network of the joint.
3. The middle artery of the knee (a. media genus) branches off in the middle
between the superior and inferior arteries of the knee joint, perforates the articular
capsule and supplies the cruciate ligaments and synovial folds.
4. The surral arteries (aa. surales) carry blood to m. triceps surae and to the
tendon of the m. biceps femoris.

The Anterior Tibial Artery

The anterior tibial artery (a. tibialis anterior) is one of two terminal branches
of the popliteal artery (the smaller one in calibre) (Fig. 74, 76). Immediately after
its origion, it perforates the deep flexor muscles of the posterior surface of the leg
and through the opening in the interosseus septum, passes to the anterior region of
the leg between m. tibialis anterior and m. extensor digitorum longus; lower it lies
between m.tibialis anterior and m. extensor hallucis longus.Then it passes
superficially over the ankle joint covered by skin and fascia; its continuation on the
back of the foot is called dorsal artery of the foot. The anterior tibial artery
supplies the anterior muscles of the leg.

The branches of the anterior tibial artery:

45
1. The posterior recurrent artery (a. reccurens tibialis posterior) passes upward
to the knee joint under m. popliteus. It is unconstant artery.
2. The anterior recurrent artery (a. reccurens tibialis anterior) pierces m.
tibialis anterior, passes to the lateral edge of the kneecap and takes part in the
formation of the arterial network of the knee joint.
3. The medial and lateral anterior malleolar arteries (aa. malleolares
anteriores medialis and lateralis) branch off at the level of the upper edge of the
malleolus and take part in the formation of the medial and lateral networks on the
same malleoly (rete malleorale mediale and laterale) and supply the ankle joint
with blood.

The Posterior Tibial Artery

The posterior tibial artery (a. tibialis posterior) is a direct continuation of the
popliteal artery (Fig. 73, 75, 76). Descending along the cruropopliteal canal, in the
lower part of the leg, the posterior tibial artery lies medially from the Achilles
tendon, covered here only with skin, and supplies the posterior muscles of the leg.
Passing the medial malleolus posteriorly, it divides on the sole into two terminal
branches: the lateral and medial plantar arteries. The pulse of the posterior tibial
artery is palpated by pressing it against the medial malleolus.

The branches of the posterior tibial artery:

1. The fibular artery (a. fibularis) is the biggest branch of the posterior tibial
artery it arises from the upper part of the posterior tibial artery, passes downward
and laterally into the inferior musculoperoneal canal and ends on the heel. It
supplies the lateral group of the muscles of the leg and m. triceps surae, fibula,
heel, carries blood to the lateral malleolar network.
2. The circumflex fibular branch (r. circumflexus fibularis) starts at the beginning
of the posterior tibial artery, passes forward, surrounds the fibular head and ends in
the network of the knee.
3. The medial malleolar branches (rr. malleolares mediales) pass behind medial
maleolus and drain into the medial malleolar network.
4. The branches of the heel (rr. calcanei) pass to the medial surface of the heel.
5. The tibial nourishing artery (a. nutricia tibiae) supllies the tibia.

The Arteries of the Foot

The dorsal artery of the foot (a. dorsalis pedis) is a terminal branch of the
anterior tibial artery passing on the back of the foot. It is situated on the metatarsal
bones between the tendons of the m. extensor hallucis longus (medially) and the m.
extensor digitorum brevis (laterally). The pulse of the dorsal artery of the foot can
be palpated by pressing it to the bones laterally from the tendon of the m. extensor
hallucis longus (Fig. 77).

46
The branches of the dorsal artery of the foot:
1. The medial tarsal arteries (aa. tarsales mediales) pass to the medial edge of
the foot.
2. The lateral tarsal artery (a. tarsalis lateralis) starts at the level of the head of
the talus, passes laterally and merges with the arcuate artery.
3. The arcuate artery (a. arcuata) branches off opposite the medial cuneiform
bone, passes laterally along the bases of the metatarsal bones and anastomoses
with the lateral tarsal and plantar arteries.
The arcuate artery gives off the following branches:
a) aa. metatarsales dorsales, four arteries which pass in the metatarsal spaces
forward. Each artery separates into two digital branches on the level of the bases of
the toes;
b) aa. digitales dorsales run along sides of the toes facing each other. Each of
metatarsal arteries gives off perforanting branches, which pass to the sole of the
foot, and meets with the plantar vessels.
4. The deep plantar artery (a. plantaris profunda) is largest perforating branch
which branches off the first metatarsal dorsal artery and joins with the plantar arch.

The Arteries of the Sole

There are two plantar arteries, which are the terminal branches of the
posterior tibial artery (Fig. 78, 79).
1. The medial plantar artery (a. plantaris medialis) is the smalest branch, it is
situated in the medial plantar sulcus. It terminates at the head of the first metatarsal
bone, joining the first plantar metatarsal artery or draining into the plantar arch. It
supplies m. abductor hallucis, m. flexor digitorum brevis; the adjoining joints and
the skin. It ends on the medial side of the big toe.
2. The lateral plantar artery (a. plantaris lateralis) is larger of two, it passes in
the lateral plantar sulcus to the base of the fifth metatarsal bone, then it turns
sharply to the middle and, forming a deep plantar arch (arcus plantaris profundus)
on the bases of the metatarsal bones, terminates laterally of the first metatarsal
bone, anastomosing with the deep plantar artery. Moreover, it gives off a small
branch that joins with the medial plantar artery.
The lateral plantar artery gives off some branches: (a) aa. metatarsales plantares
(four), which branch from the deep plantar arch and run in the metatarsal spaces.
They give off the perforating branches to the aa. metatarsales dorsales and
continue with (b) aa. digitales plantares communes, each of them separates into
two (c) aa. digitales plantares propriae which pass along contacting surfaces of
the toes and beginning from the second phalanx, give off small perforating
branches to the dorsal digital arteries.
As a result, on the foot there are two rows of perforating arteries connecting
the dorsal vessels with the vessels of the sole. All these perforating vessels form
anastomoses between anterior and posterior tibial arteries.

47
 Thus, the arteries of the sole, under constant pressure in standing and
walking, form two arches, which in distinction from the arches of the hand, are
situated not in parallel, but in mutually perpendicular planes: in the horizontal
plane between the medial and lateral plantar arteries and in the vertical plane
between the lateral plantar and deep plantar arteries.

The Veins of the Free Lower Limbs

Just as with the upper limbs, the veins of the lower limbs are subdivided into
deep and superficial (or subcutaneous) veins, which pass irrespective of the arteries
(Fig. 80-82).
The deep veins of the foot and leg are binary and they accompany arteries
of the same names.
The veins of the foot drain into the deep veins of the leg, which are anterior
and posterior tibial veins (vv. tibiales anteriores and vv. tibiales posteriores) and
fibular veins (vv. fibulares).
The Popliteal vein (v. poplitea) is formed by the merging of the anterior
and posterior tibial veins. It constitutes a single trunk lying in the popliteal fossa
posteriorly of the popliteal artery. Vv. surales, vv. geniculares (usually 5 in
number), v. saphena parva drain into the popliteal vein.
The femoral vein (v. femoralis) is a single vessel which continues popliteal
vein. It passes medially of the femoral artery under the inguinal ligament into the
lacuna vasorum. The veins that drain into v. femoralis are binary or single vessels:
vv. pudendae externae, v. circumflexa iliaca superficialis, v. epigastrica
superficialis, vv. dorsales superficiales penis (clitoridis), vv. scrotales (labiales)
anteriores, v. saphena magna.

Superficial veins of the free lower limbs

The long saphenous vein (v. saphena magna) originates on the medial side
of the dorsal surface of the foot from rete venosum dorsale pedis and the arcus
venosus dorsalis pedis. It passes upward along the medial side of the leg and thigh
to the hiatus saphenus where it drains into the femoral vein. This vein has valves.
The accesory saphenous vein (v. saphena accessoria) is formed by the
subcutaneus veins on the medial and posterior surfaces of the thigh and drains into
the v. saphena magna. Its distal end can anastomoses with the v. saphena parva.
The short saphenous vein (v. saphena parva) originates on the lateral side
of the dorsal surface of the foot, passes below and behind the lateral malleolus and
then rises along the posterior surface of the leg and drains into the popliteal vein.
V. saphena parva is joined by branches with v.saphena magna.

The Nerves of the Peivic Girdle and free Lower Limb

The Lumbar Plexus

48
 The lumbar plexus (plexus lumbalis) is formed by the anterior branches of
three superior lumbar spinal nerves and the upper part of the fourth lumbar nerve
and by the small branch from the twelfth intercostal nerve (Fig. 83). The plexus
lies in front of the transverse processes of the lumbar vertebrae in the thickness of
the m.psoas major and gives rise to numerous branches:
1. The muscular branches (rr. musculares) innervate mm. psoas major and
minor, m. quadratus lumborum and m.m.intertransversarii laterales lumborum.
2. The iliohypogastric nerve (n. iliohypogastricus) emerges from under the lateral
edge of the m. psoas major and stretches on the anterior surface of the m.quadratus
lumborum parallel to the twelfth intercostal nerve, then it passes between the
transverse and internal oblique muscles of the abdomen. The iliohypogastric nerve
innervates these muscles, the skin of the upper part of the buttocks and the skin
above the superficial orifice of the inguinal canal.
3. The ilioinguinal nerve (n. ilioinguinalis) emerges from under the lateral edge of
the m. psoas major and runs parallel to and downward of the iliohypogastric nerve
and then it passes in the inguinal canal, goes out through the superficial inguinal
ring and branches out in the skin of the pubis and scrotum (in male) or in the skin
of the greater pudendal lips (in female), and in the skin of the upper thigh. It
innervates also mm. obliquus abdominis externus and internus and m. transversus
abdominis.
4. The genitofemoral nerve (n. genitofemoralis) runs through the thickness of the
m.psoas major to its anterior surface and divides into two branches:
- the femoral branch (r. femoralis) passes under the inguinal ligament and branches
in the skin of the thigh below this ligament;
- the genital branch (r. genitalis) pierces the posterior wall of the inguinal canal
and joins the spermatic cord, supplying m. cremaster and the coats of the testis (in
male), the skin of the greater pudendal lips (in female) and the skin of the thigh
below inguinal ligament.
5. The lateral cutaneous nerve of the thigh (n. cutaneous femoris lateralis)
emerges from under the lateral edge of the m.psoas major and passes to the
anterior superior iliac spine, where it pierces the abdominal wall and through
lacuna musculorum emerges on the thigh, innervating the lateral surface of its skin
(to the knee).
6. The femoral nerve (n. femoralis) is the largest branch of the lumbar plexus.
Through the lacuna musculorum it emerges on the anterior surface of the thigh;
here it lies laterally of the femoral artery. The femoral nerve innervates the m.
quadriceps, m. sartorius and m. pectineus and supplies the skin of the anterior
distal 3/4 surface of the thigh. One of the cutaneous branches of the femoral nerve,
a very long branch, the saphenous nerve (n. saphenus) branches off in the femoral
triangel, runs through the adductor canal, then pierces the vastoadductor membrane
and emerges under the skin between m. sartorius and m. gracilis. It innervates the
skin of the lower part of the knee and the skin of the medial surface of the leg
down to the medial edge of the foot.

49
7. The obturator nerve (n. obturatorius) emerges from under the medial edge of
the m.psoas major, passes through the obturator canal to the thigh and innervates
m. obturatorius externus, mm. adductor, m. gracilis, m. pectineus, the capsule of
the hip joint and the skin of the medial surface of the thigh.
The Sacral Plexus

The sacral plexus (plexus sacralis) is the most significant of all plexuses of
the spinal nerves (Fig. 74, 75, 84-87). It is composed of the anterior branches of
the fourth (lower part) and fifth lumbar nerves and of the anterior branches of four
sacral nerves, which emerge from the anterior sacral foramina. Part of the sacral
plexus is made up of the preganglionic parasympathetic fibres which begin from
the II-IV sacral segments of the spinal cord. These fibres are known as pelvic
splanchnic nerves which pass to the nerve pelxuses of the pelvis (look “The
vegetative plexuses of the pelvis”). The sacral plexus is located near the sacroiliac
joint in front of m. piriformis and has a triangular shape. The branches of the sacral
plexus may be divided into short and long ones.
The short branches branch out in the region of the pelvic girdle and the long
branches supply the muscles and skin of the whole free lower limb except for that
parts which are supplied by the branches of the lumbar plexus.

The short branches of the sacral plexus:

1. The muscular branches (rr. musculares) supply m. piriformis, m. obturatorius
internus, mm. gemelli, m. quadratus femoris, m. levator ani, m. coccigeus and
articular capsule of the hip joint.
2. The superior gluteal nerve (n. gluteus superior) go out from the pelvis through
the foramen suprapiriforme and supplies the m. gluteus medius, m. gluteus
minimus, m. tensor faciae latae.
3. The inferior gluteal nerve (n. gluteus inferior) go out through the foramen
infrapiriforme and supplies m. gluteus maximus.
4. The pudendal nerve (n. pudendus) emerges through the foramen infrapiriforme
and curving around the spina ischiadica, comes back into the pelvis through the
foramen ischiadicum minus and passes along the lateral wall of the fossa
ischiorectalis together with the a. pudenda intrena. It supplies m. sphincter ani
externus, the skin of the region around anus, m. ischiocavernosus, m.
bulbospongiosus, mm. transversus perinea superficialis and profundus, m.
sphincter urethrae, the skin of the perineum, the skin of the posterior side of the
scrotum or the greater pudendal lip, the skin of the glans penis. Numerous
vegetative fibres pass in the composition with the pudendal nerve.

The long branches of the sacral plexus:

1. The posterior cutaneous nerve of the thigh (n. cutaneus femoris posterior)
emerges from the pelvis through the foramen infrapiriforme and then descends
under m. gluteus maximus to the posterior surface of the thigh. It supplies the skin
of the lower part of the buttock and the perineum, the skin of the posterior surface
of the thigh and
50
proximal part of the leg.
2. The sciatic nerve (n. ischiadicus) is the largest nerve of the body and is the
direct continuation of the sacral plexus that contains fibres of all its roots. It
emerges from the pelvic cavity through the foramen infrapiriforme and is covered
here by m.gluteus maximus. Further down it emerges from under the lower edge of
this muscle and descends perpendicularly on the posterior surface of the thigh
under the flexors of the thigh. In the upper part of the popliteal fossa it usually
divides into two main terminal branches: the medial popliteal nerve called also the
tibial nerve and the lateral popliteal nerve called also the common fibular nerve.
First one is more thicker nerve.

The branches of the sciatic nerve:

1. The muscular branches (rr. musculares) for m. semitendionus,
m.semimembranosus and for the long head of m. biceps femoris and also for the
posterior part of the m. adductor magnus.
2. The medial popliteal or tibial (n. tibialis) descends directly through the middle
of the popliteal fossa along the tract of the popliteal vessels, then enters the
cruropopliteal canal, until it reaches the medial malleolus. Behind the latter n.
tibialis divides into its terminal branches: the lateral and medial plantar nerves.
Branches of the tibial nerve:
(a) In the popliteal fossa rr. musculares branch out n. tibialis to the m.
gastrocnemius, m. plantaris, m. soleus and m. popliteus;
(b) Several small branches pass to the knee joint;
(c) A long cutaneous branch - the medial cutaneous nerve of the leg (n. cutaneus
surae medialis) innervates the skin of the posteromedial surface of the leg;
(d) On the leg the tibial nerve supplies all deep muscles of the leg (m. tibialis
posterior, m. flexor hallucis longus, m. flexor digitorum longus), the posterior side
of the talocrural articulation, the skin of the heel and the skin of the medial edge of
the foot;
(e) The medial plantar nerve (n. plantaris medialis) passes in the medial plantar
sulcus and supplies m. flexor digitorum brevis, m. abductor hallucis, the medial
head of the m. flexor hallicus brevis, the first m. lumbricalis and the skin of the
sole corresponding to the region of 3,5 toes (big toe, second, third and medial side
of the fourth toe);
(f) The lateral plantar nerve (n. plantaris lateralis) passes in the lateral plantar
sulcus and innervates m. abductor digiti minimi, m. flexor digiti minimi, m.
opponens digiti minimi, m. quadratus plantae, the second - fourth mm. lumbricales,
all interossei muscles and also m. adductor hallucis and the lateral head of the m.
flexor hallucis brevis, the skin of the sole corresponding to the region of 1,5 toes
(fifth toe and lateral side of the fourth toe).
3. The lateral popliteal nerve or common fibular nerve (n. fibularis communis)
runs laterally of the tibial nerve to the head of the fibula, where it divides into the
superficial and deep branches. The lateral popliteal nerve gives rise to the
following branches:
(a) Branch to the short head of the m. biceps femoris;
51
(b) Branch to the knee joint;
(c) The lateral cutaneous nerve of the leg (n. cutaneus surae lateralis) which
innervates the skin of the proximal 1/3 of the lateral surface of the leg;
(d) Below the middle of the leg the lateral cutaneous nerve joins with the medial
cutaneous nerve to form, the sural nerve (n. suralis) which curves around the
lateral malleolus from the back giving rise to branches to the skin of the lateral
region of the heel, and to the skin of the lateral edge of the dorsal surface of the
foot and the lateral side of the small toe;
(e) The superficial branch of the common fibular nerve (n. peroneus
superficialis) descends between the mm. peronei into the superior musculoperoneal
canal and innervates these muscles. Then it descends to the middle of the dorsal
surface of the foot and innervates here the skin of the medial surface of the big toe,
the skin of the lateral surface of the second toe, and the skin of the third, fourth
toes and medial surface of the fifth toe.
(f) the deep branch of the common fibular nerve (n. peroneus profundus)
passes through the opening of the interosseus membrane to the anterior region of
the leg (together with the a. tibialis anterior), giving branches to m. tibialis
anterior, m. extensor digitorum longus and m. extensor hallucis longus, and to the
talocrual joint. Then it passes to the dorsal surface of the foot and innervates m.
extensor digitorum brevis and the surface of the skin of the big and second toes
facing each other.

The Coccygeal Plexus

The coccygeal plexus (plexus coccygeus) is composed of the anterior

branches of the fourth and fifth sacral and the cocygeal nerves (Fig. 84). It gives
rise to the thin anococcygeal nerves (nn. anococcygei) which join with the
posterior branch of the coccygeal nerve and innervate the skin at the top of the
coccyx.

52
Fig.1. Branches of the aortic arch, anterior aspect.

53
Fig.2. Branches of the aorta, anterior aspect, semischeme.

54
Fig.3. Arteries of the head and neck, right aspect, semischeme.

55
Fig.4. Arteries of the neck, right aspect.

56
Fig.5. Arteries of the head, neck and shoulder girdle.

Fig.6. Arteries of the head, right aspect.

57
Fig.7. Arteries of the head and neck, right aspect.

Fig.8. Branches of the right ophthalmic artery, semischeme.

Fig.9. Arteries of the base of the brain. Willi’s circle.

58
Fig.10. Arteries of the right shoulder girdle and free upper limb, palmar surface,
semischeme.

59
Fig.11. Subclavian and axillary arteries, semischeme.

60
Fig.12. Subclavian artery, scheme. I, II, III – three segments of the subclavian
artery: 1 – prevertebral part, 2 – transverse part, 3 – atlantic part, 4 – intercranial
part of the vertebral artery.

Fig.13. Superior vena cava, unpaired and semiunpaired veins, anterior aspect.

61
Fig.14. Veins of the head and neck, right aspect, semischeme.

62
Fig.15. Veins of the head, right aspect.

63
Fig.16. Sinuses of the dura mater, right aspect.

Fig.17. Superficial veins of the neck, right aspect.

64
Fig.18. Formation of the spinal nerve and connection with the sympathetic trunk,
scheme.

Fig.19. Cervical plexus.

65
Fig.20. Cutaneus branches of the cervical plexus, right aspect.

66
Fig.21. Cutaneus nerves of the head and neck, right aspect, semischeme.

67
Fig.22. Phrenic nerve, right aspect.

68
Fig.23. Nerves of the neck, anterior aspect.

69
Fig.24. Nerves of the neck and thorax, posterior aspect.

70
Fig.25. Sympathetic part of the vegetative nervous system, scheme.
1 – truncus symphaticus; 2 – ganglion cervicothoracicum (stellatum); 3 – ganglion
cervicale medium; 4 - ganglion cervicale superius; 5 – a. carotis interna; 6 – plexus
celiacus; 7 – plexus mesentericus superior; 8 - plexus mesentericus inferior.

71
Fig.26. Parasympathetic part of the vegetative nervous system, scheme.
III – n. ocolomotorius; VII – n. facialis; IX – n. glossopharyngeus; X - n. vagus;
1 - ganglion ciliare; 2 - ganglion pterygopalatinum; 3 - ganglion oticum;
4 - ganglion submandibulare; 5 - ganglion sublinguale; 6 – nuclei parasymphatici
sacrales; 7 - ganglion pelvica.

72
Fig.27. Cervical part of the sympathetic trunk, scheme.

73
Fig.28. Nerves, nervous plexuses of the neck, thoracic and abdominal cavities,
right aspect, semischeme.

74
Fig.29. Nerves of the neck, left aspect.

75
Fig.30. Arteries, veins and nerves of the axillary fossa, right aspect.

Fig.31. Axillary artery, scheme. I, II, III – three segments of the axillary artery.

76
Fig.32. Arteries and nerves of the right arm, anteroinner surface.

77
Fig.33. Arteries of the right forearm and hand, palmar surface.

78
Fig.34. Arteries of the elbow joint, semischeme.

79
Fig.35. Arteries of the hand, palmar surface, superficial palmar arch.

80
Fig.36. Arteries of the hand, palmar surface, deep palmar arch.

81
Fig.37. Arteries of the hand, dorsal surface.

82
Fig.38. Arteries of the wrist joint and hand, semischeme.

83
Fig.39. Veins of the right shoulder girdle and free upper limb, palmar surface,
semischeme.

84
Fig.40. Superficial veins of the forearm and hand, dorsal surface.

85
Fig.41. Superficial veins of the forearm and hand, palmar surface.

86
Fig.42. Superficial veins of the arm, inner surface.

87
Fig.43. Nerves and arteries of the right shoulder girdle and arm.

88
Fig.44. Nerves and arteries of the right forearm and hand.

89
Fig.45. Brachial plexus. Musculocutaneus nerve and cutaneus nerves of the arm
and forearm, scheme.

90
Fig.46. Brachial plexus. Median nerve, scheme.

91
Fig.47. Brachial plexus. Ulnar nerve, scheme.

92
Fig.48. Brachial plexus. Radial nerve, scheme.

93
Fig.49. Cutaneus nerves of the hand, dorsal surface.

94
Fig. 50. Innervation of the skin of the shoulder girdle and free upper limb, palmar
surface, semischeme.

95
Fig.51. Innervation of the skin of the shoulder girdle and free upper limb, dorsal
surface, semischeme.

96
Fig.52. Thoracic aorta, anterior aspect.

97
Fig.53. Intercostal arteries.

98
Fig.54. Veins of the vertebral column, left aspect.

99
Fig.55. Intercostal nerves, arteries and veins.

100
Fig.56. Thoracic part of the sympathetic trunk, nerves and nervous plexuses of the
thoracic cavity.

101
Fig.57. Abdominal aorta, anterior aspect.

102
Fig.58. Coelic trunk, its branches.

103
Fig.59. Superior mesenteric artery, its branches.

104
Fig.60. Inferior mesenteric artery, its branches.

105
Fig.61. Inferior vena cava and abdominal aorta.

106
Fig.62. System of the portal vein, scheme.

107
Fig.63. Portocaval anastomoses, A – anterior, B – posterior, scheme.

Fig.64. Portocaval anastomoses, A – upper, B – lower, scheme.

108
Fig.65. Cavacaval anastomoses, scheme.

109
Fig.66. Nerves and nervous plexuses of the abdominal and pelvis cavities.

110
Fig.67. Arteries of the organs of the female’s pelvis.

111
Fig.68. External and internal iliac arteries, scheme.

112
Fig.69. External iliac artery and femoral artery, right aspect.

113
Fig.70. Veins and arteries of the female’s pelvis.

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Fig.71. Vegetative plexus of the pelvis, scheme.

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Fig.72.Right femoral artery.

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Fig.73. Popliteal artery and arteries of the leg, posterior surface.
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Fig.74. Anterior tibial artery and deep branch of the common fibular nerve, right,
anterior surface of the leg.
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Fig.75. Posterior tibial artery and tibial nerve, right, medial surface of the leg.

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Fig.76. Arteries of the knee joint, semischeme.

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Fig.77. Arteries of the right foot, dorsal surface.

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Fig.78. Arteries of the right foot, plantar surface.

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Fig.79. Arteries of the right foot, plantar surface.

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Fig.80. Superficial veins of the right leg, anteromedial surface.

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Fig.81. Superficial veins of the right leg, posteriior surface.

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Fig.82. Superficial veins of the right thigh, anteromedial surface.

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Fig.83. Lumbar plexus, semischeme.

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Fig.84. Sacral and coccygeal plexuses, semischeme.

128
Fig.85. Innervation of the skin of the right lower limb, anterior surface,
semischeme.
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Fig.86. Innervation of the skin of the right lower limb, posterior surface,
semischeme.

130
Fig.87. Innervation of the skin of the right foot, plantar surface, semischeme.

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