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HIGHLIGHTS OF HUMAN ANATOMY

A Compendium of Basic and Applied Anatomical Facts
Oluwole Akinola
Olufunke Dosumu
2nd Edition
Authors: Oluwole Akinola, Olufunke Dosumu
Title: Highlights of Human Anatomy, 2nd edition
Copyright ©2005, 2018
978 – 38206 – 1 – 9
All rights reserved. This book is protected by copyright. No part may be

reproduced or transmitted in any form or by any means without the written
permission of the authors.
DISCLAIMER
Care has been taken to confirm the accuracy and correctness of the
information presented in this book. The authors and publisher are therefore
not responsible for errors or omissions or any consequences whatsoever,
which may arise from the application of the information in this book and
make no warranty, expressed or implied, with respect to the currency,
completeness, or accuracy of the contents of the publication. Application of
this information in a particular situation or for a specific purpose remains the
academic and professional responsibility of the student or practitioner.
Authors
Oluwole B. Akinola B.Sc., Ph.D.

Reader in Anatomy and IBRO Return-Home Fellow
College of Health Sciences
University of Ilorin, Ilorin, Nigeria.
Formerly IBRO Research Fellow,

Uniformed Services University of the Health Sciences,
Maryland, USA.
Olufunke O. Dosumu B.Sc., Ph.D.

Senior Lecturer in Anatomy
College of Medicine
University of Lagos, Lagos, Nigeria
Preface
Highlights of Human Anatomy is a compendium of basic and applied

anatomical facts. It is a concise book written in a simple style, in order to
simplify the basic anatomy and clinical correlates of the complex human
structures. By so doing, students can learn the anatomical sciences with
exceptional ease. The book is an essential anatomical synopsis for medical,
dental, biomedical, physiotherapy, and allied health professions’ students.
The 2nd edition is an improved version, and is aimed at promoting your
understanding of human anatomy as a basic medical subject. Each topic
starts with the basic science and is followed by the applied anatomy and
clinical correlates. All observations and suggestions should be communicated
to the authors in order to make future editions even better.
Oluwole Akinola
TABLE OF CONTENTS
Chapter 1. Cell and Cell Division Chapter 13. Gross Anatomy of
the Male Genital Organs and
Chapter 2. Tissue of the Body
Perineum
Chapter 3. Haemolymphoid
Chapter 14. Histology of the
System
Male Genital Organs
Chapter 4. Basic Anatomy of
Joints
Chapter 15. Gross Anatomy of
Chapter 5. General Embryology the Female Genital Organs
Chapter 6. Gross Anatomy of Chapter 16. Histology of the

the Respiratory System Female Genital Organs

Chapter 7. The Mediastinum the Urinary Organs

Chapter 8. Histology of the Urinary Organs
Respiratory System
Chapter 19. The Upper Limb
the Cardiovascular System
Chapter 20. The Lower Limb
Heart and Blood Vessels
Chapter 21. The Head and Ne

Chapter 22. Cranial Nerves
the Digestive System
Further Reading
Digestive System
CHAPTER 1: CELL AND CELL DIVISION

The Cell
Regarding the cell, note the following points:

 The cell is the basic structural and functional unit of life (Fig. 1)
 Prokaryotic cells lack nuclear envelopes around the genetic material, but possess
a cell wall outside the cell membrane. Such cells include bacteria
 Besides, prokaryotic cells lack histone in their genetic material, and are also
devoid of membrane-bound organelles
 Eukaryotic cells possess well-defined nuclei (bounded by the nuclear envelope),
several membranous organelles, and basic proteins (histone) in their genetic
material. This type of cell is typical of man.
 A typical eukaryotic cell consists of a nucleus, cytoplasm, and the plasma
membrane, which limit the cell externally
 The cytoplasm consists of the cytosol – a matrix in which organelles,
cytoskeleton elements, pigment granules and carbohydrate and lipid deposits are
embedded.
 Cells of the body measure 1–100 µm in diameter. However, certain cells, such as
the megakaryocytes of the bone marrow, could be as large as 200 µm.
 The activity of a cell could be enhanced by the modification of plasma membrane
to form structures such as cilia, microvilli, and flagellum
 Cells are capable of communicating with one another by chemical or electrical
means. Thus, no cells function in isolation.
 A group of cells and associated extracellular matrix, which is capable of
performing specific functions, is referred to as a tissue.
Functions of the Cell
The functions of the cell include:

1. Contractility, as exemplified by muscle cells.
2. Immunity, as exemplified by macrophages and leucocytes.
3. Absorption of nutrients, water and ions, as exemplified by epithelial cells of the
stomach, intestine, and kidney tubules.
4. Transduction (conversion of stimuli into electrical impulse, as exemplified by
sensory cells.
5. Secretory function (including secretion of enzymes, mucus and hormones), as
exemplified by cells of the adrenal gland, pancreas, salivary glands, etc.
6. Protective function, as exemplified by cells of the epidermis.
Intercellular Junction
Intercellular junctions are special regions where adjacent cells appose one another.
They serve purposes such as anchorage of cells, inhibition of diffusion between
contacting cells, and spread of electrical impulses between cells.
-1-
The common intercellular junctions include: desmosomes, hemidesmosomes, zonula

adherens, zonula occludens, gap junctions, and fascia adherens.
Specialization of Cell Surface
In certain organs, the free surface of epithelial cells is modified to enhance the
functions of the membrane. Such modifications include cilia, microvilli, and
stereocilia.
Cilia
Regarding cilia, note the following:

 Each consists of a pair of microtubules surrounded by nine pairs of microtubules
(external to which is the cell membrane)
 They could be up to 250 in number per cell, as in the epithelial cells of the
trachea (unlike the flagellum, which is just one per cell)
Figure 1. The cell
Cell Membrane (Plasmalemma)
Regarding the cell membrane, note the following:

 The cell membrane limits the cell externally; it consists of phospholipids,
proteins, cholesterol, and associated chains of oligosaccharides (Fig. 2)
-2-
 Membrane phospholipids are arranged in a double layer. The hydrophobic chains

of each layer are directed toward the centre of the membrane, while the
hydrophilic heads are directed outwards. Examples of membrane phospholipids
include phosphatidylethanolamine, phosphatidylcholine, phosphatidylserine and
sphingomyelin
 Closely associated with membrane phospholipids are cholesterol and proteins
 Membrane proteins are divisible into two groups: integral proteins and
peripheral proteins (Fig. 2). The latter are found on membrane surface, while
integral proteins are incorporated within phospholipid layer. Some integral
proteins span the entire thickness of the cell membrane and are referred to as
transmembrane proteins
 Externally, the cell membrane of some epithelial cells has a coat of glycocalyx.
This consists of carbohydrate chains that are bound to membrane proteins and
lipids. Other constituents include glycoproteins and proteoglycans secreted by the
cell itself
 Glycocalyx plays a role in cell-to-cell adhesion and cell recognition; and also in
attachment of molecules to cells
 The fluid mosaic model of membrane structure describes the cell membrane as
consisting of a double layer of phospholipid, with the associated proteins. The
organization of the proteins in the membrane differs from one part of the
membrane to the other. Thus, the thickness and structural organization of the
membrane vary (Fig. 2)
 Membrane proteins are synthesized in the rough endoplasmic reticulum,
packaged in the Golgi complex and transported in vesicles to the cell membrane
 The thickness of the cell membrane ranges from 6.5–10 nm. Besides, pores,
which range from 0.7–1.0 µ in diameter, are also associated with the membrane
 The surface membrane could also be specialized to form structures such as cilia
and microvilli, which perform specific functions
Permeability of the Cell Membrane
The cell membrane is selectively permeable. Its permeability depends on the

following:
1. Lipid solubility of the substance. Owing to the lipid nature of the membrane,
lipid-soluble substances readily cross the cell membrane
2. Thickness and structural organization of the membrane
3. Size of the molecule. Relatively large molecule, e.g. proteins, do not cross the
membrane
4. Activity of carrier molecules. These molecules enable the cell membrane to
actively transport substances.
5. Pressure difference across the cell; and ionic charge of the substance to the
transported
-3-
Transport of Substances across the Cell Membrane
Transport of substances across the cell membrane could take the form of:
1. Active transport, a carrier-mediated transport where solutes are transported
against their concentrated gradient
2. Osmosis (movement of water molecule from a region of high to a region of low
water concentration)
3. Simple diffusion, which involves movement of molecules from a region of high
concentration to a region of low concentration.
4. Facilitated diffusion, which involves the use of carriers to transport molecules
along their concentration gradient
5. Pinocytosis, a form of endocytosis that involves uptake of droplets of fluid into
the cell
6. Phagocytosis, also a form of endocytosis that involves uptake of solid particles
into the cell
7. Exocytosis, which is the release of molecules from the cell
Figure 2. The cell membrane
Functions of the Cell Membrane
The cell membrane

 Limits the cell externally and contributes to its skeletal framework (maintenance
of cell shape).
 Controls the transport of substances across the cell by different means (see
above). Thus, the membrane is selectively permeable.
 Maintains cohesion between cells in a tissue by means of established intercellular
junctions (see below).
 Could be specialized so as to confer a sensory function on a cell. For example,
the photoreceptors of the eye.
 Contains receptor proteins that are capable of binding to chemical substances
such as hormones
-4-
 Could facilitate movement of substances through a hollow organ by means of

cilia, e.g., as occurs in the in the uterine tube and trachea
Cell Organelles
Rough (granular) endoplasmic reticulum (RER)
The rough endoplasmic reticulum

 Is a complex network of membrane-bound channels and sacs within the cell (Fig.
1). Numerous ribosomes are attached onto its surface; and its membrane is
continuous with the outer membrane of nuclear envelope
 Is involved in the synthesis of proteins by means of its attached ribosome. The
synthesized proteins are transported through its channels. RER also synthesizes
carbohydrates within its cavity
 Is basophilic in histologic sections (owing to its attached ribosomes)
 Is abundant in cells that are actively involved in protein synthesis, e.g., plasma
cells, osteoblasts, fibroblasts, etc.
Smooth (Agranular) Endoplasmic Reticulum
The smooth endoplasmic reticulum
 Also consists of a network of membrane-bound channels, but the cytosolic

surface of this membrane is devoid of ribosomes. The membrane of smooth
endoplasmic reticulum is continuous with that of the RER (Fig. 1)
 Is largely involved in the synthesis of steroid hormones and cholesterol. Thus, it
is abundant in cells of the adrenal cortex and Leydig cell of the testis, etc.
 Is also involved in the synthesis of phospholipids of the cell membrane
 Plays active role in the detoxification function of the liver, and in the degradation
of certain hormones. Thus, it is prominent in liver cells.
 Is referred to as the sarcoplasmic reticulum in muscle cells. Here, it plays a role
in muscle contraction as it is involved in the release and storage of Ca 2+ (which
regulate muscle contraction)
Ribosome
The ribosome
 Is granular in form, each about 15 nm across. Ribosomes may exists as free
cytoplasmic particles (monosomes), or form several aggregates (polysomes).
Some ribosomes are attached onto the cytosolic surface of RER (Fig. 1)
 Is actively involved in protein synthesis. This organelle translates mRNA during
protein synthesis.
 Consists of several types of proteins (up to 80) and about four segments of
rRNA
-5-
 Is synthesized partly in the nucleus. The nucleus produces the RNA of ribosomes,
while the protein components are produced in the cytoplasm. From the latter, the
protein enters the nucleus where they are linked with the rRNA to form
ribosomes. The latter are then released from the nucleus, via the nuclear pores,
into the cytoplasm
 Is strongly basophilic, owing to its content of RNA. Thus, ribosomes stain with
basic dyes such as haematoxylin and toluidine blue
Golgi Complex
The Golgi complex

 Is composed of stacks of flattened, smooth, membrane-bound cisternae (Fig. 1).
These cisternae are separated from each other by a distance of about 30 nm.
Golgi complex also has some isolated vesicles associated with the cisternae.
 Presents a convex (cis or forming) face that is directed towards the nucleus, and a
concave (trans or maturing) face that faces the cell membrane.
 Plays some role in chemical modification (glycosylation, sulphating, and
phosphorylation) of proteins synthesized by RER. Thus, the Golgi complex is in
close functional relationship with the RER. It is thus prominent in cells that are
highly secretory, such as cells of exocrine pancreas and liver.
 Is also actively involved in the synthesis of carbohydrates and lysosomes; and in
the packaging, concentration and storage of secretory products of the cell prior to
their release.
Lysosomes
Lysosomes
 Are spherical membrane-bound bodies involved in intracytoplasmic digestion.
They measure 0.05–0.5 µm in diameter (Fig. 1).
 Contain several hydrolytic enzymes such as acid phosphatase proteases,
ribonuclease, deoxyribonuclease, lipases and sulphatases. These work optimally
at a low pH.
 Are numerous in macrophages and neutrophils where they play active roles in
intracytoplasmic destruction of foreign bodies. They form residual bodies
following phagocytosis; and large amounts of residual bodies form lipofuscin.
 Also help to degrade aging organelles, besides their roles in cell death.
Lysosomes with their ingested organelles are referred to as autophagosomes.
 May release their enzymes into the extracellular milieu following exposure to
ionizing radiation, asbestos, carcinogens and certain drugs, with consequent
destruction of the tissue.
Besides, note that lysosomes

 Are of importance in the regression of the mammary glands after weaning; and
the return of the uterus to normal size after birth.
-6-
 Have been implicated in the progression of rheumatoid arthritis. They also

produce autolysis of body cells following the death of an organism.
Note: Lysosomal enzymes are synthesized in the RER and packaged in the Golgi
complex.
Peroxisomes (Microbodies)
Peroxisomes
 Are membrane-bound organelles that measure 0.5-1.2 µm in diameter. They are
abundant in hepatocytes and renal tubule cells.
 Contain type II oxidases, which use molecular oxygen to oxidize organic
molecules. Such reactions yield hydrogen peroxide (H2O2), which is toxic and
must be eliminated by catalase (also found in peroxisome). Catalase breaks down
H2O2 into water and oxygen.
 Also contain certain enzymes that degrade very-long-chain fatty acids through β-
oxidation.
 Are implicated in Zellweger (cerebrohepatorenal) syndrome. This is
characterised by hypotonia, cerebral malformation, and lesions of the liver and
kidney. In this syndrome, peroxisomal enzymes are deficient.
Mitochondria
Mitochondria
 Are elongated, membrane-bound, cylindrical (or spherical) organelles that
constitute the powerhouse of the cell.
 Consist of two membranes each (inner and outer membranes, separated by
intermembranous space) (Fig. 1). The inner membrane is folded into cristae,
the number of which is proportional to energy requirement of the cell. Each
mitochondrion also has a matrix that contains DNA, RNAs, ribosomes, certain
enzymes, and Ca2+. Mitochondrial DNA and ribosomes differ from those of the
nucleus and cytoplasm, but are similar to those of bacteria.
 Can be as long as 10 µm in length; and up to 1 µm in width.
 Accumulate in the parts of the cytoplasm that actively use metabolic energy, e.g.,
apical part of ciliated cells. They are numerous in kidney cells, hepatocytes and
muscle cells. Mitochondria are absent in erythrocytes.
 Are capable of dividing by fission. They are also able to move within the cell
along microtubules.
 Generate chemical energy (ATP) for the cell.
 Are inherited almost exclusively from the mother (ovum) at fertilization. Thus,
mitochondrial inheritance is usually maternal.
-7-
Centrioles
The centrioles
 Are a pair of rod-like structures that lie at right angle to each other, in the
centrosome (the part of the cytoplasm containing centrioles). The centrosome is
closely associated with the nucleus and Golgi body (Fig. 1; Fig. 3).
 Measure 0.3-0.5 µm in length and 0.15 µm in diameter. Each consists of nine
triplets of microtubules organized into a cylindrical body.
 Are essential for cell division, during which they duplicate. They also serve as
basal bodies for anchoring cilia
Figure 3. Centriole
Cytoskeleton
The cytoskeleton is made up of microtubules, microfilaments, and intermediate
filaments. These structures give support to the cell (Fig. 2).
The importance of cytoskeleton includes:

 Maintenance of cell shape and form
 Mechanical support for such cytoplasmic processes as cilia
 Localization of organelles in specific regions of the cells; as well as movement of
substances within the cell
 Contractile activity of the cells, as occurs in muscle.
Microfilaments
Microfilaments include actin and myosin filaments.
Actin filament
 Is a protein which consists of globular subunits that are organized into a double-
stranded helix
 Measures 5–7 nm in diameter. Its length varies from cell to cell. In most cells,
actin filaments are diffusely arranged in the cytoplasm.
 Form a thin sheath, the cell cortex, just adjacent to the cell membrane. Thus, actin
filaments are involved in processes such as endocytosis and exocytosis. They are
also actively involved in muscle contraction when acting in conjunction with
myosin filament
-8-
 Is also aggregated just adjacent to desmosomes. Actin filaments are thus involved
in the maintenance of cell shape and structural integrity.
 Is found in close association with cell organelles, secretory vesicles and granules.
Thus, these filaments are involved in intracytoplasmic movements and cellular
organization.
Myosin
 Is abundant in muscle cells where, in association with actin, is involved in muscle
contraction
 Is much thicker than actin; it measures about 15 nm in diameter
Microtubules
 Are cylindrical structures found in cells and cytoplasmic processes such as cilia
and flagella. Microtubules are 20-27 nm in diameter, and are of variable length.
Some are as long as 70 µm
 Are each made up of globular subunits of α and β tubulin. Tubulin consists of
certain amino acids. Participate in intracytoplasmic movements such as the
movement of organelles and vesicles from one part of the cell to the other. Thus,
microtubules are abundant in nerve cells, pigment cells and platelets.
 Form the structural/cytoskeletal basis of centrioles and basal bodies, cilia and
flagella. This function is owing to the stiff nature of microtubules. Microtubules
also play significant roles in cells division.
 Is destroyed by chemicals such as colchicine, vinblastine, colcemide, vincristine,
podophyllin and podophyllotoxin. Some of these chemicals are employed in
karyotyping and cancer chemotherapy, where they arrest cell division by
interfering with microtubule formation.
Intermediate Filaments
Intermediate filaments
 Are a type of cytoplasmic filament that are distinct from actin and myosin
filaments. Each measures 10-12 nm in diameter.
 Consist of several types of proteins, including vimentin, keratins, desmin, etc.
 Are useful in the diagnosis of tumors. The presence of specific intermediate
filaments in tumors is suggestive of the cell of origin of such tumors.
Intermediate filaments are of different types; these include:

1. Vimentin, found in cells of mesenchymal origin such as chondroblasts,
fibroblasts, endothelial cells and macrophages
2. Keratin, found in epithelial cells. Keratins are of different types, and they
prevent epithelial abrasion and loss of water from body surface.
3. Desmin, which is characteristic of smooth muscle cells
4. Neurofilaments, found in somata and processes of neurons; and glial filaments,
found in astrocytes of the central nervous system
-9-
Cell Inclusions (Cytoplasmic Deposits)
Most Cell inclusions are temporal components of the cell. They include glycogen
granules, lipid droplets, secretory vesicles and pigments such as melanin and
lipofuscin.
Note the following points:

 Lipofuscin is a yellowish pigment that forms in the cell as a product of
enzymatic activity of lysosomes. It accumulates in cells as age advances, and is
therefore also called age pigment
 Lipofuscin is prominent in cells such as neurons, and cardiac muscle fibres,
which are long-lived
The Nucleus (Fig. 1)
The nucleus of a eukaryotic cell

 Is the largest organelle within most cells. The nucleus usually appears spherical
or elongated, and it often occupies the centre of the cell. It measures 3-10 µm in
diameter.
 Is the repository of the genome and the information archive of the cell. Thus, it
controls cellular activity.
 Is absent in cells incapable of cell division, e.g., erythrocytes, platelets and lens
fibre of the eye.
 Consists of the nuclear matrix in which the chromatin (genetic material) and
nucleoli are embedded. A nuclear envelope limits the nucleus externally.
 Is numerous in skeletal muscle cells. Liver cells may possess two or more nuclei
each.
Note: Sex chromatin is a heterochromatic mass observable in female cells only. It

represents one of the X chromosomes of the female. Sex chromatin appears as a
drumstick-like appendage in the nuclei of neutrophils. It is useful in determining the
sex of an individual with pseudohermaphroditism.
Nucleolus
The nucleolus
 Is a spherical structure usually located eccentrically within the nucleus (Fig. 1).
Closely associated with the nucleolus is the nucleolus-associated chromatin.
The significance of this chromatin is unknown.
 Is made up of rRNA and protein; thus, it shows a degree of basophilia when
stained with H and E. The nucleolus is largely unstained by the Feulgen method.
- 10 -
 Is actively involved in the formation of ribosomes. After their formation,

ribosome pass from the nucleus into the cytoplasm via the nuclear pores
 Appears relatively large in the embryonic and malignant cells, and in cells that
are active in protein synthesis. During the prophase of cell division, nucleolus
disappears, but reappears at telophase
Nuclear Matrix
The nuclear matrix

 Is the medium in which the chromatin and nucleolus are embedded in the
nucleus. It is made up of proteins, certain ions and metabolites
 Forms the nucleoskeleton, a fibrillar structure that gives support to the nucleus.
The fibrous laminar associated with the inner membrane of the nuclear envelope
is a part of the nuclear matrix
Nuclear Envelope (or Nuclear Membrane)
The nuclear envelope

 Is a double-layered phospholipid membrane that invests the nucleus (Fig. 1). The
two membranes (inner and outer) are separated by the perinuclear space of 40–
70 nm; while the outer membrane is continuous with the RER, and has ribosomes
attached onto its cytosolic surface.
 Is stabilized by the fibrous lamina. The latter is a layer of proteins associated
with the inner aspect of its internal membrane. It binds to chromatin and other
contents of the nucleus.
 Possesses numerous nuclear pores, about 70–100 nm in diameter. These pores
are closed by proteins termed nuclear pore complex. Thus, nuclear pores are
selectively permeable to certain molecules, including histones, nucleotides, ATP
and ribosome subunits. Ions and molecules less than 9 nm pass readily through
the pores.
 Is impermeable to molecules and ions, as these can only pass through the nuclear
pores.
Chromatin
Nuclear chromatin
 Is a DNA-protein complex. It is scattered throughout the nucleoplasm as a thread-
like structure.
 Contains histone and some other basic proteins; and stains positively in Feulgen
reaction
 Appears euchromatic in cells that are active in protein synthesis, e.g, embryonic
cells, stem cells and neurons. Euchromatin occupies much of nuclear interior.
 Appears heterochromatic in synthetically inactive cells such as mature
neutrophils and fibrocytes. Heterochromatin occupies the periphery of the
nucleus.
- 11 -
 Usually possesses a combination of euchromatic and heterochromatic elements.

These condense to form chromosomes during cell division.
Intercellular Junctions
Intercellular junctions are specialized contacts between adjacent cells. In human, they
include desmosomes, zonula occludens, zonula adherens, fascia adherens, etc.
Zonula Occludens (Tight Junction)
Zonula occludens
 Forms a continuous belt around cell perimeter. Thus, it permits no gap between
contacting cells, thereby creating diffusion barrier between them.
 Is found at the apical (juxtaluminal) ends of junctional complexes, where it
maintains the structural integrity of epithelium, etc. It is thus typical of epithelia,
endothelia, and mesothelia of serous membranes.
Zonula Adherens
Zonula adherens
 Firmly binds adjacent cells together. It lies next to zonula occludens in a
junctional complex. Here, the contacting cells are separated by a gap of 15-20
nm. This intercellular gap is devoid of electron-dense materials.
 Has a dense intracytoplasmic network of filaments in the region of the
junction. These filaments are attached to the membranes of the contacting cells.
 Is also typical of endothelia of blood vessels, mesothelia of serous membranes
and epithelia.
Fascia Adherens
Fascia adherens
 Is a form of adhesive strip between cells. The contacting cells also has
intracytoplasmic network of filaments, as in zonula adherens.
 Is found between smooth muscle cells, neurons, and glial cells. It is also
characteristic of intercalated discs of cardiac muscle cells.
Desmosomes (Macula Adherens)
Desmosome
 Is plaque-like in appearance. This type of junction forms a firm anchor between
cells. A gap of about 25 nm exists between contacting cells (Fig. 4)
 Is characterised by the presence of electron-dense filamentous materials in the
intercellular space. Besides, intracytoplasmic filaments also aggregate adjacent
to the junctional membranes. These filaments are anchored to the attachment
plaque adjacent to the membranes.
- 12 -
 Is prominent in the stratum spinosum of epidermis; but small in foetal tissue and
endothelium of capillaries. It is also a feature of junctional complex, where it lies
deep to zonula adherens.
 May depend on Ca2+ for the maintenance of its structural integrity. Thus, it is
destroyed by chelating agents such as EDTA.
Figure 4. Desmosome
Hemidesmosomes (Half-Desmosomes)
Hemidesmosomes
 Are found on the basal aspects of epithelial cells where they anchor these cells to
the underlying basal lamina. They may also exist between skeletal muscle cells
and fibres of tendons
 Possess an intracytoplasmic network of filaments adjacent to the contacting
membrane. These filaments are anchored onto the attachment plaque of the
cells.
 Have varied biochemical constituents compared to desmosomes. While
desmosomes contains cadherins in its attachment plaque, hemidesmosomes have
integrins.
Gap Junction (Communicating Junction)
Gap junction
 Is a site of low electrical resistance between cells. It also allows free passage of
substances with molecular mass less than 1500 Da.
- 13 -
 Closely resembles zonula adherens, but has a space of 2–3 nm between

contacting cells.
 Is found between smooth muscle cells, cardiac muscle cells and some cells of
embryonic tissue. Here, it allows the tissue to act in a coordinated fashion.
Junctional Complex
Junctional complex
 Is a conglomerate of intercellular junctions located between lateral membranes of
epithelial cells.
 Comprises zonula occludens, zonula adherens and desmosome, in that order,
from superficial deeply (from apical to the basal part of the cells).
 Creates a diffusion barrier at the apices of the cells; it also provides a firm anchor
between contacting cells.
Specialization of Cell Surface

The surface of the cell may be modified to form one of the following: microvilli,
stereocilia, cilia, and flagellum.
Microvilli
Microvilli
 Are non-motile finger-like projections of certain epithelial cells. Each measures
0.1 µm in diameter and 1-2 µm in length.
 Form the striated or brush border of cells such as those of renal tubules,
intestine and gallbladder. They form brush border when not orderly arranged; and
striated border when in regular parallel array.
 Increase the surface area of cells up to 40 folds. Thus, they enhance the
absorptive function of these cells.
 Possess a core of actin filaments surrounded by the cell membrane.
Stereocilia
Stereocilia
 Are immotile, longer form of microvilli.
 Are found in the epithelial cells of the deferent duct and epididymis; and the
receptor cells of the cochlea and vestibular apparatus.
 Increase the surface area of cells and enhance absorption. They may also act as
sensory transducer, as in the cochlea.
Cilia
Cilia
 Are longer and more structurally complex than microvilli. They resemble
eyelashes and are highly motile.
- 14 -
 Have a diameter of 0.2–0.25 µm; and a length of about 10 µm

 Are found in the respiratory epithelium, parts of female reproductive tracts (e.g.
uterine tube), and ependymal and mesothelial cells.
 Are anchored to basal bodies (in the cytoplasm), each of which resembles the
centriole, and is about 1 µm in length. Cilia consist of a central pair of
microtubules surrounded by nine pairs of microtubules.
 Are implicated in Cartagena’s immotile cilia syndrome. This is characterised by
respiratory distress and male infertility. The latter is owing to immotility of
sperms.
Flagellum
The flagellum
 Structurally resembles a cilium; and like the latter, it beats in a sinuous manner
 Measures about 0.25 µm in diameter and 15 – 30 µm in length. Thus, it is much
longer than the cilium.
 May be more than 100 µm in length in human spermatozoon.
Cell Division
Cell division
 Is required for growth, reproduction and replacement of dead cells
 Occurs rapidly in cells of intestinal epithelium and epidermis; but slowly in the
thyroid gland and pancreas.
 Does not occur in neurons and skeletal and cardiac muscle cells, which are
terminally differentiated.
 Is enhanced by hormones such as somatotropin, progesterone and thyroid
hormones; and growth factors such as epithelial growth factor (see below).
 Is inhibited in normal cells by chalones. Besides, substances such as colchicine
(and its derivatives: colcemide, podophyllin, and podophyllotoxin), vinblastine
and vincristine, as well as exposure to ionizing radiation, impair cell division.
Types of Cell Division
Cell division may take the form of:

 Mitosis, which occurs in somatic cells
 Meiosis, which occurs in germ cells; and
 Amitosis, which is almost restricted to pathological cases.
- 15 -
Mitosis
Note that mitosis

 Is required for growth and replacement of dead cells in an organism
 Is preceded by the interphase stage, when nuclear DNA quantity is doubled (at
the S phase of the cell cycle).
 Involves two main processes: karyokinesis (division of the nucleus), and
cytokinesis (division of the cytoplasm). Karyokinesis splits the nucleus into two
nuclei; while cytokinesis splits the cytoplasm.
 Occurs in four phases: prophase, metaphase, anaphase and telophase (Fig. 5).
Mitosis takes 1–2 hours.
 Results in the production of two daughter cells that are genetically identical to
each other and to the parent cell
Interphase Stage of Cell Division
Interphase is the phase between two successive mitoses. During interphase:

 The cell prepares for prophase of cell division
 DNA replication (doubling of nuclear DNA quantity) occurs. Each chromosome
thus consists of two sister chromatids, joined at the centromere.
 Chromatin exists as euchromatin and heterochromatin as chromosomes are not
yet visible.
 The nucleolus is still observable; while the centrioles are duplicated (at S phase),
and tubulin is synthesized.
Prophase of Mitosis
The prophase of mitosis is characterised by:

 Progressive shortening and coiling of chromatin to form chromosomes. Forty-six
chromosomes are seen in the human nucleus at prophase. Each has two parallel
chromatids joined at the centromere.
 Positioning of the two pairs of centrioles at opposite poles of the cell. A pair of
centrioles was duplicated at interphase to produce two pairs.
 Formation of mitotic spindle and asters from microtubules. The spindle and
asters are collectively called amphiaster. Tubulin required for formation of the
spindle is synthesized at G2 phase of interphase
 Disintegration of the nucleolus and disappearance of the nuclear envelope.
These mark the end of prophase.
Metaphase of Mitosis
During metaphase of mitosis,
- 16 -
 Chromosomes align at the equatorial plate of the cell. Microtubules of mitotic

spindle are involved in the arrangement of chromosomes at the equatorial plate.
Microtubules are seen to attach to the centromere of chromosomes.
 Karyotyping can be done as the chromosomes are displayed at the equatorial
plate of the cell. In karyotyping, microtubules are destroyed by the use of
colchicine to immobilize the chromosomes, which can then be observed
microscopically.
Figure 5. Mitotic cell division
Anaphase of Mitosis
During anaphase of mitosis,

 The centromere of each chromosome splits along its longitudinal axis to
separate the sister chromatids from each other.
 Spindle microtubules shorten actively, thereby pulling the chromatids towards
opposite poles of the cell. Thus, two groups of 46 chromatids are ultimately
constituted within the cell.
Telophase of mitosis
During telophase of mitosis,
- 17 -
 Chromosomes begin to uncoil and extend, thereby losing their stainability (as
they revert to chromatin form)
 The nucleolus is reconstituted; while the nuclear membrane is formed around
each daughter nucleus
 Cytokinesis (division of the cytoplasm) is proceeding gradually.
Cytokinesis (Division of the Cytoplasm)
During cytokinesis,
 A cleavage furrow (a constriction of the cell) is formed between the two
emerging nuclear groups. This furrow is produced by actin and myosin filaments
that accumulate beneath the cell membrane at the equatorial plate.
 Mitotic spindle begins to disintegrate and the cell eventually separates into two
identical daughter cells. Thus,
 Organelles of the dividing cell are shared between the two daughter cells.
Through mitosis,
 Over 100 billion cells are replaced each day
 The epidermis and digestive tract replace their dead cells rapidly.
Cell Cycle
Figure 6. Cell cycle
- 18 -
Regarding the cell cycle, note the following points:

 Cell cycle consists of a series of events that occurs during the lifespan of a cell. It
includes mitosis, characterised by the physical events that lead to cell
multiplication, and the interphase stage, which precedes mitosis. Interphase
stage includes G1, S, and G2 phases (Fig. 6).
 Active growth and RNA and protein synthesis occur during the G1 phase
(presynthetic phase). This phase succeeds mitosis and lasts for about 25 hrs in
bone tissue.
 The synthetic phase (S phase) follows the G1 phase. It is characterised by DNA
replication, in which the chromosomes double their DNA proportion (but
chromosome number is still diploid). Duplication of centrioles also begins at this
stage. The S phase lasts for about 6 hrs.
 During the G2 phase (post-DNA duplication phase), the cell prepares to enter
mitosis. This phase lasts for about 4 hrs. It is characterised by synthesis of
tubulin (from which spindle microtubules are formed); and synthesis of non-
histone proteins.
 Repair of some damaged DNA also occurs at the G2 phase (in addition to that
which occurs at the G1 phase). This phase is also characterised by accumulation
of the maturation promoting factor (MPF). This protein triggers the onset of
mitosis, the condensation of the chromosomes and the disintegration of nuclear
envelope.
 Mitosis follows the G2 phase; and it proceeds in four stages (see above). Mitosis
lasts for 1-2 hrs.
 Certain cells enter the GO phase. This is characterised by temporal or permanent
suspension of activities relating to mitosis, as occurs in highly differentiated cells
such as neurons, skeletal muscle cells and cardiac muscle cells.
Note: Mitosis is enhanced by growth factors such as fibroblast growth factor, nerve
growth factor, erythropoietin (precursor of erythrocyte growth factor), epithelial
growth factor, etc. Normally, cell division is under the control of a group of genes
called proto-oncogenes. Mutation of proto-oncogenes could result in tumor
formation. Cancer could thus arise from exposure to ionizing radiation, viral
infections, and certain chemical substances that are capable of altering the expression
of proto-oncogenes. Increased number of mitotic figures is seen in malignant tumor.

 Ionizing radiation damages DNA, and could thus inhibit mitosis. A feature of
radiation sickness is the failure of epithelia to replace lost cells, with the
resultant ulceration of the skin and mucosa.
 Neoplasm (tumor) is an abnormal mass of tissue formed by uncoordinated cell
division. It could be benign or malignant.
 Benign tumor is characterised by slow growth and non-invasiveness; while
malignant tumor (cancer) has capacity for rapid growth and invasion of other
tissues.
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 Growth factors such as fibroblast growth factor and erythropoietin enhance cell
division. These proteins are needed in small amounts.
 Proto-oncogenes are a group of genes that control the cell cycle. Mutation of
these genes (e.g. following exposure to certain viral infections, radiation and
chemicals) could result in cancer.
Meiosis
Meiotic cell division

 Occurs in germ cells for the purpose of gamete production
 Occurs in two phases: meiosis I and II. Meiosis I is preceded by the interphase
stage, when nuclear DNA is duplicated.
 Results in the production of four daughter cells, which are genetically dissimilar
to each other and to the parent cell. Each daughter cell has haploid (23)
chromosomes.
 Requires a longer time than mitosis
Meiosis I (reduction or heterotypical division) (Fig. 7)
Meiosis I proceeds in four stages that include:

1. prophase I
2. metaphase I
3. anaphase I, and
4. telophase I
Prophase of Meiosis I (Prophase I)
Prophase I
 Is characteristically long and complex
 Involves 5 successive stages: leptotene, zygotene, pachytene, diplotene and
diakinesis.
At the leptotene stage of prophase I,

 DNA has already been duplicated (in the preceding interphase) to form tetraploid
proportion (while chromosomal number remains diploid)
 Chromosomes appear as thin, beaded strands; and they are undergoing shortening
and coiling.
 Each chromosome is attached to the nuclear membrane at its ends
During the zygotene stage of prophase I,

 Pairing of homologous chromosomes occurs, and this leads to the formation of 22
pairs of autosomes. One pair of sex chromosomes is also formed.
 Chromosomes forming a homologous pair are bound together by the
synaptolemal complex. In male germ cells, Y and X chromosomes are
unidentical and are thus bound at their terminal ends only.
- 20 -
 Crossing-over (exchange) of genetic materials occurs between the paired

chromosomes. This makes each chromosome genetically modified, such that the
daughter germ cells that will be formed through meiosis will differ genetically
from the parent cell and from each other.
At the pachytene stage of prophase I,

 Active coiling and shortening of the paired chromosomes continues. Thus,
chromosome pairs are more distinct and are referred to as tetrads.
 Exchange (crossing-over or decussation) of genetic material between paired
chromosomes continues. This process is essential for variation of traits in a
population.
Diplotene of prophase I is characterised by:

 Gradual separation of members of homologous pairs of chromosomes.
 The presence of chiasmata. The latter indicate the sites of crossing-over of
genetic materials between paired chromosomes.
 Terminalization (breaking up) of chiasmata.
Diakinesis of prophase I
 Is characterised by the presence of distinct bivalent pairs. Separation of
homologous pairs at the points (chiasmata, synaptolemal complexes) where they
have been joined, continues
 Marks the end of prophase I as nucleolus and nuclear membrane disappear
Metaphase I
At metaphase I,
 Chromosomes are arranged at the equatorial plate of the cell (as bivalent pairs)
 Two pairs of centrioles are present. A pair of centrioles is located at a pole of the
cell
 Spindle is formed from microtubules. The latter are attached to the centromeres
of the chromosomes at one end, and to the centrioles at the other end.
Anaphase I
During anaphase I,
 Centromeres of the chromosomes do not split in any way. Instead, whole
chromosomes (members of homologous pairs) are drawn towards opposite poles
of the cells.
Telophase I
At telophase I,
- 21 -
 Two groups of whole chromosomes are produced; and each group has diploid
chromosome number
 Nuclear envelope is formed around each of the newly-formed nuclei.
In meiosis I, note that

 Karyokinesis (division of the nucleus) is closely followed by cytokinesis
(division of the cytoplasm). Thus, two daughter cells are formed at the end of
meiosis I.
 Each of the daughter cells from meiosis I contains 23 chromosomes; and each
chromosome has two chromatids. The genetic make-up of these cells differs from
that of the parent cell.
Meiosis II (Homotypical Division)
Note that meiosis II

 Is much similar to the events of mitosis. Thus, it includes prophase, metaphase,
anaphase and telophase.
 Is not preceded by DNA duplication. DNA duplication precedes meiosis I only.
 Results in the production of two daughter cells that are genetically different from
one another; and each has 23 chromosomes (chromatids) (Fig. 7).
Importance of Meiosis
Meiosis ensures
 Variation of inheritable traits in a population by producing gametes that differ
genetically from the parent germ cell. Such genetic modification occurs during
the crossing-over or decussation of genetic materials that occurs at the zygotene
and pachytene stages of prophase I.
 Consistency of chromosomal number in somatic cells from one generation to the
other. At the end of meiosis, each daughter germ cell (gamete) has 23
chromosomes (haploid number), and this is half of the diploid complement in
somatic cells. In males, four spermatids are formed at the end of the entire
process of meiosis; while in females, an ovum and 3 polar bodies are formed.
- 22 -
Figure 7. Meiotic cell division
Applied Anatomy of Cell Division
Note the following:

 Non-disjunction of chromosomes. This arises when members of homologous
pair fail to separate at meiosis I, or when the chromatid of a chromosome fails to
separate at meiosis II. Thus, the gametes produced in this instance would have an
excess or a shortage of a chromosome.
 Anaphase lag could also occur. Here, movement of a chromatid towards the pole
of the cell at anaphase is slow, such that the chromatid is included in the same
- 23 -
cell as its partner. This produces an extra chromosome in one cell, and shortage
of a chromosome in another.
 When an ovum with haploid chromosome number (23) is fertilized by a sperm
with an extra chromosome (24), or a shortage of a chromosome (22), a zygote
with an abnormal chromosome complement is formed. Such deviation of
chromosomal number from a multiple of haploid is referred to as aneuploidy.
Aneuploidy includes trisomy, in which case there is a chromosome in excess of
diploid (47); or monosomy, where the diploid number is short of one
chromosome (45). Examples of trisomy include Down’s syndrome (trisomy 21)
and Klinefelter’s syndrome. Turner’s syndrome is an example of monosomy.
 Polyploidy occurs when the multiple of haploid is in excess of diploid. Thus, it
includes triploidy, tetraploidy, etc. Polyploid embryos usually suffer spontaneous
abortion. Most spontaneous abortions arise as a result of abnormalities in
chromosomal numbers
 Gene mutation and translocation of chromosomal segments may also occur
during meiosis. This could produce aberrant phenotype in the baby.
 Chromosomal abnormalities associated with meiosis increase with increasing
maternal age, especially in women beyond their mid-thirties.
 When non-dysjunction occurs in the cells of the embryo early in cleavage, then
an individual (a mosaic) with varied cell lines is born. This condition is called
mosaicism. While certain cells of such individual have normal chromosomal
number, others possess abnormal number. Such individuals may show traits
typical of Down’s syndrome, etc.
CHAPTER 2: TISSUES OF THE BODY

Tissue
A tissue is made up of specific cells and their associated extracellular matrix, and it
is specialized to perform specific functions. Tissues exist in four categories. These
include epithelial, connective, nervous and muscular tissues.
Epithelium
Epithelium is the type of tissue that specializes in lining cavities and surfaces.
Besides, epithelium also plays some roles in absorption, secretion, and sensory
functions (as in the olfactory epithelium). Epithelium includes two main types:
covering epithelium and glandular epithelium.
Characteristics of epithelium include:

 The presence of a large number of cells arranged into layers. These cells are
compactly organized owing to the presence of numerous intercellular junctions.
- 24 -
 Scanty extracellular matrix.

 Absence of blood vessels. However, sensory fibres are present.
 Ability of the cells to regenerate rapidly, as in the epidermis and epithelium of the
gut.
 Ability to perform secretory or absorptive function in certain organs. Epithelium
also lines free surfaces and body cavities.
Types of Covering Epithelium
Covering epithelia are classified based on the following criteria:

 The shape of the cells that form the epithelium. On this basis, an epithelium could
be squamous, cuboidal, or columnar.
 The number of layers formed by the cells. Thus, an epithelium could be simple
(with a single layer of cells) or stratified (where more than one cell layer exists).
Types of covering epithelium include:

 Simple squamous epithelium
 Simple cuboidal epithelium
 Simple columnar epithelium
 Pseudostratified columnar epithelium
 Stratified squamous epithelium
 Stratified columnar epithelium
 Transitional epithelium
 Seminiferous (germinal) epithelium
Figure 8. Types of surface epithelium
Simple squamous epithelium

 Is made up of a layer of flattened polygonal cells (Fig. 8). These cells are joined
by zonulae occludentes (tight junctions).
 May be as thin as 0.1 µm
 Is found in the rete testis, loop of Henle, alveoli of lungs, parietal layer of renal
Bowman’s capsule, and membranous labyrinth. It also lines the endothelium and
mesothelium.
 Facilitates the movement of substances across the surface it lines.
- 25 -
Simple cuboidal epithelium

 Consists of a layer of cube-shaped cells that may possess microvilli on their free
surfaces (Fig. 8).
 Is excretory, secretory or protective in function.
 Is found in renal tubules, thyroid gland, pigment epithelium of the retina, surface
of ovary, ducts of certain glands and capsule of the lens.
Simple columnar epithelium

Characteristics of simple columnar epithelium include:
 The presence of a single layer of tall columnar cells (Fig. 8). Located between
these cells are goblet cells (that produce mucin).
 The presence of microvilli or cilia on the free surface of the cells. These enhance
the functions of the epithelium.
 The presence of oval nuclei located at the same levels in all the cells.
The simple columnar epithelium is found in:

 The uterine tubes, where it is ciliated. Cilia aid the transport of the oocyte or
zygote through the tube.
 The gastrointestinal tract. Here, the cells possess microvilli (striated border).
Microvilli increase the surface area for absorption of nutrients.
 The interior of the gallbladder. Here, the cells possess a brush border
(irregularly arranged microvilli) that enhances absorption.
 Most part of the respiratory tract. Here, the epithelium is ciliated and
pseudostratified. Cilia aid the removal of particles from the airway.
 The central canal of the spinal cord, and ventricles of the brain, where the cells
also possess cilia.
 Portions of uterine endometrium and excretory ducts of certain glands.
Pseudostratified columnar epithelium

 Is a form of simple columnar epithelium
 Possesses columnar and cuboidal cells, some of which do not reach the free
surface of the epithelium (Fig. 8). Thus, the nuclei of these cells are arranged at
different levels (thereby giving a false stratification).
 Is found in the respiratory tract (where it is ciliated), male urethra, olfactory
epithelium, parotid duct, auditory tube and lacrimal sac.
 Is endowed with goblet cells. These intersperse the columnar cells and produce
mucus.
Stratified squamous epithelium

 Consists of several layers of cells of different shapes. The most superficial cells
of this epithelium are flattened (squamous); while the deep ones are cuboidal or
columnar (Fig. 8). The cells are joined by desmosomes to enhance coherence
between them.
- 26 -
 May contain keratin (fibrous structural protein) in its cells, as in the epidermis of
the skin. This protein protects against abrasion and prevents loss of water and
heat. It also prevents microbial or chemical invasion of underlying tissues.
 Undergoes repeated mitotic division to replace the superficial cells.
 Is found in surfaces exposed to mechanical stress, e.g., skin, buccal cavity,
vagina, anal canal and distal urethra.
Stratified columnar epithelium

 Consists of several layers of cuboidal and columnar cells. These cells do not
undergo keratinization.
 Does not undergo as much mitosis as stratified squamous epithelium.
 Is found in the ducts of certain glands, including pancreas, large salivary glands
and sweat glands. It also lines the fornix of the conjunctiva and the epiglottis.
Transitional Epithelium (Urothelium)
Transitional epithelium
 Is a stratified type of epithelium (Fig. 8). It may be 4 – 6 cells thick when the
organ is relaxed; and 2 layers thick when stretched.
 Possess rounded superficial cells, which are polyploid. However, these cells
become squamous when the epithelium is stretched. The basal cells of the
epithelium are cuboidal or columnar.
 Is found in organs subjected to repeated distension and relaxation. Thus, it is
typical of the urinary calyces, ureters, urinary bladder and proximal part of the
urethra.
 Does not undergo rapid mitotic division.
Seminiferous (Germinal) Epithelium
The seminiferous epithelium

 Is typical of the seminiferous tubules of the testis
 Possesses a wide spectrum of cells arranged in several layers. This epithelium
contains the male germ cells and their supporting (Sertoli) cells. The former
undergo repeated mitosis and meiosis.
Neuroepithelium
 Is a type of epithelium that performs special sensory functions. Thus, it contains
receptors that convert chemical stimuli to electrical message (transduction).
 Is typical of the olfactory mucosa and taste buds.
- 27 -
Basal Lamina
Basal lamina
 Is a layer of extracellular matrix that gives support to epithelial cells. Thus, basal
lamina separates epithelial cells from underlying connective tissue. It also
supports other cells including muscle, Schwann cells, adipocytes, and neurons
(where these cells appose connective tissue).
 Is observable only by electron microscopy; and has a thickness of 20-100 nm.
 Consists of glycoprotein (laminin and entactin), proteoglycans (perlecan) and
collagen type IV. Basal lamina is partly synthesized by cells of the underlying
connective tissue, which produce the collagen fibres; and those of the epithelium,
which produce the glycoprotein.
 May contain reticular fibres. In this instance, it is referred to as reticular lamina.
The reticular fibres are produced by underlying connective tissue.
Functions of basal lamina include:

 Mechanical support of epithelial cells and other cell that appose connective
tissue, e.g., muscle cells.
 Roles in cell division, cell metabolism and repair.
 Formation of cytoplasmic processes of cells during growth and repair.
Basement membrane
The basement membrane

 Is much thicker than basal lamina. It is formed where adjacent basal laminae
appose each other, or where a basal lamina and a reticular lamina appose.
 Could be observed with the light microscope, and it stains positive with PAS
(periodic acid Schiff), owing to its content of glycoproteins
 Is associated with the glomeruli and renal tubules. It becomes abnormally
thickened in glomerulonephritis and diabetic nephropathy.
Applied Anatomy

 Owing to their relative propensity for rapid cell division, epithelia are prone to
developing tumors (adenoma and adenocarcinoma).
 In adults above 45 years of age, most tumors are of epithelial origin. Malignant
tumors of glandular origin are referred to as adenocarcinoma. Generally,
carcinomas are malignant tumors of epithelial origin. They include cancers of
the skin, digestive tract, etc.
 Metaplasia is a process whereby a particular epithelium is transformed into a
different epithelial type when subjected to a particular condition. In heavy
cigarette smokers for example, the ciliated pseudostratified columnar epithelium
of the airway is gradually transformed into stratified squamous epithelium.
- 28 -
Glands (Glandular Epithelium)

Glands are modifications of the surface epithelium, and are specialized to perform
secretory functions. Associated with the secretory cells (parenchyma) is the non-
secretory tissue – stroma – in which the blood vessels, lymphatics and nerve fibres
are embedded. Secretory functions of glands are under neural and endocrine
influence.
Glands may take the form of

 A single cell (unicellular gland), e.g., goblet cells of the digestive and respiratory
tracts
 Multicellular gland, comprising several cells and their associated stroma, e.g.,
pancreas
Generally, glands may be defined as:

 Exocrine gland, secreting into a duct system, e.g., liver.
 Endocrine gland, secreting directly into the circulatory system, e.g., thyroid
gland.
 Serous gland, secreting watery proteinous secretions.
 Mucous gland, elaborating mucin, and staining positive with periodic acid-
Schiff (PAS).
 Holocrine gland, in which the entire secretory cells disintegrate to release their
products, as occurs in sebaceous glands.
 Apocrine gland, in which part of the apical cytoplasm of the secretory cells are
released with the secretory product, as occurs in mammary glands.
 Merocrine gland, in which secretion is mediated by exocytosis, as occurs in most
glands (liver, pancreas, etc). The cell membrane is therefore not distorted in the
process.
 Paracrine cells, affecting target cells in their immediate environment, e.g., delta
cells of pancreatic islets
Exocrine Glands
An exocrine multicellular gland may be described as a:

 Simple gland, in which the duct is not branched
 Compound gland, in which the duct branches repeatedly
 Tubular gland, in which the parenchyma is tube-shaped
 Acinar gland, in which the parenchyma is flask-shaped
 Tubulo-acinar gland, in which the parenchyma is tubular, with a flask-shaped
end
- 29 -
Types of Exocrine Multicellular Gland
Simple tubular glands

 Are evaginations (out-pocketing) of the epithelial surface; hence, each opens
directly onto the surface of the epithelium via a single simple duct (Fig. 9).
 Are found in the intestinal tract (crypts of Lieberkuhn) where they aid digestion
by their secretion. They are also found in the uterine tubes, etc.
Figure 9. Classification of exocrine multicellular glands
Simple coiled tubular glands

 Are long, coiled, tubes of secretory cells (Fig. 9). Each has a long unbranched
duct.
 Are exemplified by the sweat glands; hence, they are involved in the regulation of
body temperature.
Simple branched tubular glands

 Possess two or more tubular parenchymal portion joined by a single unbranched
duct (Fig. 9). The gland may however open directly onto the surface without a
duct.
 Are found in the stomach, endometrium, oral cavity, oesophagus, tongue and
duodenum (Brunner’s glands).
Simple Acinar (Alveolar) Gland
- 30 -
Simple acinar gland

 Possesses a single rounded secretory mass that drains via a simple (unbranched)
duct.
 Is characteristic of the male seminal vesicle.
Simple branched acinar gland

 Has many flask-shaped secretory masses linked by a single duct (Fig. 9)
 Is typical of the sebaceous and meibomian glands (of the eyelids). Such glands
lubricates body surface.
Compound tubular glands

 Possess several tubular parenchymatous units with arborescent (branched) ductal
system
 Are typical of some Brunner’s glands (of the duodenum), bulbo-urethral gland,
some mucous glands of the buccal cavity and glands of the cardiac region of the
stomach.
Compound acinar (alveolar) glands
Compound acinar glands

 Possess several flask-shaped parenchymatous units that drain via a ducts that
branch repeatedly (Fig. 9)
 Are typical of the mammary, sublingual and submandibular glands
Compound tubulo-acinar gland

 Possesses several tubular secretory units with rounded ends and side outgrowths.
These drain via a branched ductal system (Fig. 9).
 Is typical of the pancreas, prostate and parotid glands.
Connective Tissue
Connective tissue binds other tissue types together to form organs. Thus, they provide
support and give shape to the body.
Characteristics of connective tissue include:

 Presence of varied cell types that are widely-spaced, unlike in epithelia where
these cells are compactly arranged.
 Presence of abundant extracellular matrix. This consists of the ground substance
and various fibre types.
 Presence of numerous blood vessels, lymphatics and nerve fibres. Connective
tissue serves as a medium that conveys blood vessels to other tissues.
 Mesodermal embryonic origin. Connective tissue cells are derived from the
mesenchyme (a derivative of the mesoderm).
Components of Connective Tissue

- 31 -
Typically, connective tissue consists of three basic components that include cells,
fibres, and ground substance. Cells and fibres are embedded in the ground substance
(Fig. 12).
Connective tissue cells

 Are mesenchymal in origin
 May be permanently resident in the tissue (e.g., fibroblasts and adipocytes); or
shuttle between connective tissue and blood (e.g., lymphocytes).
 Are of different types and perform varying functions.
Fibroblasts (Stellate Cells)

Fibroblasts of connective tissue
 Are the most common cells of connective tissue, in which they are permanently
resident. Fibroblasts usually lie between bundles of connective tissue fibres (Fig.
12).
 Possess irregular outline, with several branching cytoplasmic processes. Their
cytoplasm is rich in rough endoplasmic reticulum (RER) and Golgi apparatus;
while the oval nucleus is euchromatic and possesses a large nucleolus.
Fibroblasts appear fusiform in histologic sections.
 Demonstrate a good degree of basophilia in histologic preparations. This is owing
to the abundant RER.
 Are responsible for the synthesis of glycosaminoglycans, proteoglycans and
glycoproteins (that constitute the ground substance of connective tissue). They
also synthesize collagen and elastin (that form reticular, collagen and elastic
fibres).
 Are active in wound healing, during which they may undergo mitosis. Inactive
fibroblasts have scanty RER and Golgi apparatus, and are referred to as
fibrocytes.
Note: myofibroblasts are cells with features of both smooth muscle cells and
fibroblasts. They appear during wound healing and bring about wound contraction
(wound closure).
Adipocytes (Adipose cells or fat cells)
Adipocytes
 Are connective tissue cells that synthesize and store neutral fat (triacylglycerol).
They also generate heat in the body. Fat cells constitute the major components of
adipose tissue.
 Are rounded in outline with a diameter of about 50 µm.
 Possess sparse cytoplasm, which is reduced to a peripheral rim adjacent to the
cell membrane. The nucleus is also displaced peripherally; while the central part
of the cytoplasm is occupied by fat.
- 32 -
 Are numerous beneath the skin (as panniculus adiposus). They are also found in
some quantities between muscles, in intestinal mesentery, around the heart, and
along small blood vessels, etc.
Macrophages
 Appear irregular in outline. The cytoplasm is rich in lysosomes, RER and Golgi
apparatus. Thus, the cells are basophilic.
 Measure 10–30 µm in diameter
 Form part of the mononuclear phagocyte system; and are thus immunological in
function. They phagocytize bacteria, tumor cells and tissue debris. Macrophages
are also active during the involution of the uterus after childbirth.
 Also act as antigen-presenting cells. They partially digest antigens and present
them to other cells.
 Perform synthetic activity, including the production of cytokines and
collagenase.
 Have a long lifespan, which may be several months in connective tissues.
 Include Kupffer cells of the liver, microglia of the CNS, reticular cells of
lymph nodes, bone marrow and spleen; alveolar macrophages of lungs,
histiocytes of subcutaneous tissue, and osteoclasts of bone.
 Are derived from monocytes as the latter invade connective tissue from the blood
stream. Monocytes are blood cells that arise from bone marrow precursors.
Lymphocytes
 Migrate to connective tissue from blood stream or lymphoid tissue. They
constitute a small percentage of connective tissue cells (Fig. 10)
 Measure 6 – 8 µm in diameter
 Exist as either B lymphocytes or T lymphocytes. The former transforms into
plasma cells in connective tissue. Plasma cells produce antibodies.
 Are important for immunity. Lymphocytes increase in number during
pathological conditions.
 Contain sparse mitochondria and Golgi bodies; but numerous ribosomes and
lysosomes. Lymphocytes are thus basophilic.
 Have a varied lifespan, from a few days to several years
 Are capable of mitosis
Note: for more details, see blood.
Plasma cells
 Are connective tissue cells. They are rounded in outline and measure 8–15 µm in
diameter.
 Possess eccentric nuclei that have a clock-face appearance.
 Possess extensive granular endoplasmic reticulum. Hence, they are
synthetically active and basophilic.
- 33 -
 Produce immunoglobulins (antibodies). Immunoglobulins are produced in

response to antigens.
 Differentiate from B lymphocytes in connective tissue.
 Have a lifespan of 10–20 days. Plasma cells do not undergo mitosis.
Figure 10. Human lymphocyte
Mast cells
 Are rounded or oval cells that measure about 12 µ in diameter. Mast cells are
usually numerous around blood vessels, lymphatic vessels, nerves, and in the
skin.
 Possess a highly metachromatic cytoplasm owing to the presence of granules (0.3
– 2.0 µ) that contain heparin and histamine. Mast cell granules also contain
neutral proteases, eosinophil chemotactic factor of anaphylaxis (ECF-A), and
arylsulphatase.
 Exist in two forms: connective tissue mast cells, found in the dermis and
peritoneal cavity, and whose granules contain heparin; and mucosal mast cells, a
smaller form found in intestinal mucosa and lung, and whose granules contain
chondroitin sulphate.
 Are involved in the mediation of immediate hypersensitivity reactions and
inflammatory responses following their stimulation by chemical or mechanical
stimuli.
 Are similar to basophils of the blood though they arise from different stem cells
 Possess receptors for immunoglobulin E (IgE). This substance is usually bound to
the surface of mast cells and basophils. It is produced by plasma cells.
Note the following facts:

 Degranulation of mast cells (release of contents of their granules) occurs in
hypersensitivity and allergic reactions and inflammatory responses. Anaphylactic
shock is a form of immediate hypersensitivity reaction and it could be fatal.
- 34 -
 In hypersensitivity and inflammatory responses, histamine produces increased

permeability in vessels, and causes contraction of bronchiolar smooth muscle.
 Heparin acts as an anticoagulant in blood.
 Metachromasia is a phenomenon whereby a cell picks up a colour different from
the colour of the dye. Mast cells appear purple-red when stained with a blue dye
such as toluidine blue. This metachromasia is a function of the contents of the
granules of this cell, especially heparin.
Pigment Cells (Melanocytes) of Connective Tissue
Pigment cells
 Are responsible for the pigmentation of the skin, etc. They are stellate in outline
and produce melanin pigment.
 Are numerous in the epidermis of the skin and choroid of the eyeball. In these
organs, these cells prevent light rays from invading subjacent tissues.
 Are of neural crest derivative.
 Are under the influence of melanocyte-stimulating hormone of pituitary gland.
 Do not produce melanin in albinism, owing to the absence of the enzyme
tyrosinase. Albinism is transmitted as an autosomal recessive trait
Eosinophils
Eosinophils of connective tissue

 Are similar to those of the blood, from which they migrate to connective tissue by
diapedesis. These cells are less numerous than neutrophils.
 Are similar in size (10-15 µm), shape and motility compared to neutrophils.
Eosinophils possess bilobed nuclei (Fig. 11).
 Possess characteristic specific granules (about 200 per cell), which have affinity
for eosin (acidic dye). This staining property is due to the presence of the major
basic protein in the core of eosinophilic granules. The latter also contain acid
phosphatase, aryl sulphatase, phospholipase, ribonuclease, and cathepsin
 Also possess azurophilic granules (lysosomes). These contain enzymes such as
acid phosphatase, elastase, collagenase, myeloperoxidase, lysozyme,
arylsulphatase and β-galactosidase.
 Stain red with Romanowsky stain; and appear yellowish in the living state
 Increases in number during parasitic (helminthic) infections, and during
hypersensitivity reactions and inflammatory conditions. They are involved in the
phagocytosis of antigen-antibody complexes
 Possess scanty RER and Golgi complex, as they do not produce much protein.
They also have few mitochondria owing to their low energy requirement.
Eosinophils are able to function in regions of low oxygen tension, e.g., inflamed
areas.
 Live in connective tissue for a few days and do not undergo mitosis.
 Eosinophilia (an increase in the number of blood eosinophil) occurs in
hypersensitivity reactions and parasitic infestation
- 35 -
 Corticosteroids cause a decrease in the number of blood eosinophils by

interfering with the release of these cells from bone marrow.
Figure 11. Neutrophil and eosinophil
Neutrophils
Neutrophils
 Are more numerous than eosinophils in the blood and connective tissue. They are
10-15 µm in diameter and each has a multilobed nucleus (a nucleus with 2-5
lobes) (Fig. 11).
 Possess numerous specific granules in their cytoplasm. These neutrophilic
granules contain alkaline phosphatase, lysozyme, collagenase and lactoferrin.
 Also possess azurophilic granules (lysosomes). These are 0.5 µ in diameter and
they contain acid phosphatase, etc. Besides, glycogen granules are found in
neutrophils.
 Stain strongly with neutral red and azure dyes. They also stain pinkish with
Romanowsky stain.
 Are derived from blood neutrophils as these invade connective tissue by
diapedesis. In connective tissue, neutrophils have a lifespan of 1-4 days; and are
incapable of cell division.
 Are capable of engulfing and lysing bacteria by means of the enzymes in their
granules. These cells increase in number during bacterial infections.
 Are capable of surviving in poorly oxygenated environments, such as an inflamed
tissue where they migrate to lyse bacteria and remove tissue debris. In such a
tissue, neutrophils are less dependent on oxygen and thus generate energy by
glycolysis.
 May induce rheumatoid arthritis (an auto-immune disorder) when their
enzymes are inappropriately released.

 Pus is the yellowish fluid formed following an infection. It contains dead
neutrophils, tissue fluid and bacteria.
- 36 -
 Hypersegmented neutrophils possess more than 5 nuclear lobes and they are
old cells. However, in certain pathological conditions, young neutrophils could
possess more than five lobes as well.
 The phagocytic activity of neutrophils is associated with the generation of free
radicals that are also bactericidal. Following the ingestion of bacteria by
neutrophils, the pH of the phagosome (containing the bacteria) is lowered to
about 5.0; this is the optimum pH for the activity of lysosomal enzymes.
Fibres of Connective Tissue
Fibres of connective tissue include:
 Collagen fibres
 Elastic fibres; and
 Reticular fibers
Collagen Fibres
Collagen fibres
 Are strong flexible fibres that consist of proteins called collagens. The most
abundant collagen in these fibres is type I collagen.
 Confer strength on body structures, and are widely distributed throughout the
body.
 Collagen fibres are abundant in tendons, ligaments, bone, aponeurosis, fascia,
dermis, etc.
 Appear whitish in the living state when organized in bundles. However, strands
of collagen fibres are colourless.
 Possess a good degree of birefringence under polarized light. This property is a
means of detecting collagen fibres in tissue.
Collagen
Collagens
 Are the proteins that form collagen fibres. They are widely distributed in the body
and they constitute about 30% of body’s dry weight.
 Are of different types, owing to differences in the chemical structure of the
polypeptide chains that constitute them. Thus, different collagen types are typical
of different tissues.
 Consists of amino acids such as glycine, proline, hydroxyproline and
hydroxylysine. The last two amino acids are characteristic of collagen.
Tropocollagen is the protein unit that forms collagen fibrils. It is an elongated
- 37 -
molecule that measures 280 nm in length and 1.5 nm in width. Tropocollagen is

made up of 3 polypeptide chains arranged in a triple helix.
 Are synthesized by fibroblasts, chondroblasts, odontoblasts and osteoblasts.
These cells produce different collagen types.
 Can be denatured by boiling to produce gelatin. Collagenases and proteases
digest collagen
 Stain with aniline blue, Sirius red and silver stain.
Types of Collagen
There are different types of collagen. These include:

 Collagen type I, found in ligaments, dermis, bone, tendons, etc. it confers
strength on these tissue
 Collagen type II, found in vitreous humour and cartilage. It enables these tissues
to withstand pressure.
 Collagen type III, the collagen that forms reticular fibres.
 Collagen type IV, found in basal lamina and basement membrane. This collagen
supports epithelium and enhances filtration in the renal glomeruli.
 Collagen type V, found in placenta and foetal tissue.
 Collagen type VII, which helps to anchor the epidermis to dermis
 Collagen type IX, also found in cartilage and vitreous humour
 Collagen type XI, which is typical of cartilage
 Collagen type XII, found in embryonic tendon and skin
 Collagen type XIV, also found in foetal skin and tendons.
Applied Anatomy

 Osteogenesis imperfecta is a hereditary disease of connective tissue that is
characterised by abnormal bone formation owing to defective collagen synthesis.
Such an individual suffers spontaneous fracture, etc.
 Keloids are localized swelling formed by excessive accumulation of collagen
during scar formation in the skin. Recurrence following excision is a common
feature.
 Excessive accumulation of collagen (fibrosis) in organs of the body is a feature of
progressive systemic sclerosis. Thus, hardening and functional deficits occur in
such organs.
 Vitamin C (ascorbic acid) acts as a cofactor for proline hydroxylase during
collagen biosynthesis. Thus, deficiency of this vitamin results in degeneration of
connective tissue, a condition referred to as scurvy. This condition is
characterised by loss of teeth (owing to the degeneration of periodontal ligament
and ulceration of gum) etc.
- 38 -
Reticular Fibres
Reticular fibres
 Are extremely thin connective tissue fibres with a diameter between 0.5-2.0 µ.
These fibres usually form network (reticulum) and are made of collagen type III,
in association with some glycoproteins and proteoglycans.
 Stain black with silver salts. They are therefore said to be argyrophilic. They are
also periodic acid-Schiff positive (PAS+), owing to their high sugar content.
Reticular fibres are rich in hexoses.
 Are not readily demonstrable by H and E stain. However, they stain green with
Sirius red when observed under polarizing microscope.
 Are abundant in haemolymphoid organs such as the spleen, bone marrow and
lymph nodes. They are also numerous in the liver, endocrine glands, arteries,
intestine and uterus.
 Are deficient in Ehlers-Danlos type IV disease. This hereditary condition is
characterised by a deficiency of collagen type III, leading to rupture of arteries
and intestine.
Elastic Fibre System

 Elastic fibre system consists of three fibre types: oxytalan, elaunin, and elastic
fibres. These fibres differ in their chemical compositions and mechanical
properties.
 Oxytalan fibres lack the protein elastin. Thus, they are not elastic. These fibres
consist of microfibrils that are made up of glycoproteins such as fibromodulin I
and II and fibrillin. Oxytalan fibres are resistant to pulling forces and are found in
the zonule fibres of the eye.
 Elaunin fibres consist of a mixture of glycoprotein microfibrils and the protein
elastin. Thus, elaunin fibres possess some degree of elasticity, and are found in
the dermis and around sweat glands.
 The protein elastin is the major component of elastic fibres (Fig. 12). Besides
elastin, elastic fibres also contain some microfibrils of glycoproteins. Elastic
fibres are highly adaptable to stretch owing to their rich constituent of elastin.
They are the most abundant member of the elastic fibre system.
Elastic Fibres
Elastic fibres
 Are the most abundant component of the elastic fibre system. They are highly
elastic owing to their rich content of the protein elastin. In addition to the latter,
elastic fibres also contains microfibrils of glycoprotein.
 Stain strongly with orcein and Verhoef’s stain
 Is abundant in ligament flava and ligamentum nuchae.
- 39 -
Elastin
Elastin
 Is the protein that forms elaunin and elastic fibres. In these fibres, elastin is
associated with glycoprotein microfibril. Elastin is highly elastic.
 Is formed from a precursor called proelastin. Proelastin is synthesized by
fibroblasts of connective tissue and smooth muscle cells of blood vessels. It is
made up of amino acids such as glycine, proline, desmosine and isodesmosine.
 Could exist in fibrillar form as in the ligamentum nuchae, or in non-fibrillar form
(fenestrated membrane) as in the walls of elastic arteries.
 Is resistant to boiling and to treatment with acid, alkali, and proteases. However,
it can be hydrolysed by the pancreatic enzyme elastase.
Note the following:

 Marfan’s syndrome (arachnodactyly) is a genetic disease that arises from
mutation in the gene that codes for fibrillin (a component of elastic fibre system);
 In Marfan syndrome, synthesis of defective fibrillin in the wall of elastic arteries
usually results in rupture of vessels such as the aorta.
Ground Substance of Connective Tissue
Regarding the ground substance of connective tissue, note that:

 The ground substance is the amorphous gel-like medium in which connective
tissue cells and fibres are embedded. This substance is characteristically highly
hydrated, viscous, transparent and colourless. Its viscosity serves as a barrier to
invasion by bacteria, etc
 Three main classes of substances constitute the ground substance of connective
tissue. These include glycosaminoglycans (acid mucopolysaccharides),
proteoglycans and glycoproteins.
 Glycosaminoglycans (GAGs) are basically polysaccharides made of repeating
units of disaccharide such as hexosamine (e.g., glucosamine and galactosamine)
and uronic acid (e.g., glucuronic acid and iduronic acid).
 Examples of glycosaminoglycans include hyaluronic acid, chondroitin-4-
sulphate, chondroitin-6-sulphate, keratan sulphate, dermatan sulphate and
heparan sulphate. These substances are distributed in different connective tissue
types and they are highly hydrophilic.
 Proteoglycans are molecules made up of a core of protein to which linear chains
of GAGs are covalently bound. Thus, proteoglycans are rich in carbohydrate. The
latter constitutes 80-90% of its weight. Like GAGs, proteoglycans are highly
viscous when hydrated.
 The main GAGs commonly linked to the protein core of proteoglycans include
heparin sulphate, chondroitin sulphate, dermatan sulphate and keratan sulphate.
 Proteoglycans include aggrecan, predominantly found in cartilage; syndecan and
fibroglycan, both of which are attached to cell surface, especially epithelial cells.
- 40 -
 Multiadhesive glycoproteins consist of proteins to which carbohydrates are

attached. The protein component of glycoprotein usually predominates.
Glycoproteins are important in the mediation of cell adhesion.
 Examples of glycoproteins include fibronectin produced by fibroblasts in
connective tissue; and laminin found in basal lamina. Laminin helps to bind
epithelia to their basal lamina.
 Hyaluronidase is capable of hydrolyzing hyaluronic acid and other GAGs. The
enzyme is produced by bacteria and it enables these organisms to invade tissue.
Failure of normal degradation of proteoglycans by lysosomal enzymes would
result in certain disorders, owing to accumulation of these molecules in tissues.
Types of Connective Tissue

On the basis of the arrangement of the fibres, three types of connective tissue can be
defined. These include loose connective tissue, dense regular connective tissue, and
dense irregular connective tissue. Besides, connective tissue can be classified on the
basis of the predominant components of the tissue. Thus, there are adipose, elastic,
reticular, mucoid and pigmented connective tissues.
Two types of connective tissue perform skeletal (supporting) function, and they
include bone and cartilage.
Loose Connective Tissue
Loose connective tissue

 Serves as a binding and packaging material for many structures. This tissue gives
support to structures, and it contains blood vessel, lymph vessels and nerve fibres.
 Has a wide distribution. It is found between muscle cells, in the eyelids, scrotum,
penis, labia minora, substance of most organs and glands, serous membranes, and
papillary layer of dermis.
 Contains all connective tissue cellular elements, with fibroblasts and
macrophages being predominant. Elastic, reticular and collagen fibres are also
present in moderate quantities, and these are diffusely oriented. The ground
substance of loose connective tissue is relatively copious, with moderate quantity
of interstitial (tissue) fluid.
Dense regular connective tissue

 Is highly resistant to pulling forces owing to the presence of large amount of
collagen fibres arranged in the direction of the traction. Its fibroblasts are found
between collagen bundles; and the long axes of these cells are oriented in the
direction of the collagen fibres.
 Appears silvery white in the fresh state. Examples include tendons, ligaments,
aponeurosis and fasciae
 Is less vascular compared to the loose connective tissue.
- 41 -
Note: Strain occurs when a tendon, ligament or muscle is excessively stretched. On

the other hand, a sprain is characterised by torn ligament. Torn ligaments do not heal
rapidly owing to poor vascularity. Thus, surgical reconstruction may be needed.
A B
Figure 12. A, Dense irregular connective tissue; B, Adipose tissue
Dense Irregular Connective Tissue
Dense irregular connective tissue

 Consists largely of bundles of collagen fibres oriented in different directions (Fig.
12A). Network of elastic fibres are also associated with the collagen bundles.
Thus, this tissue is resistant to stress from all directions.
 Is exemplified by the dermis, sclera, epineurium, perichondrium, adventitia of
blood vessels and fibrous capsule of joints and organs.
Adipose Tissue
Regarding adipose tissue, note the following:

 It is a specialized form of loose connective that contains large numbers of fat
cells (adipocytes) (Fig. 12B). It is widely distributed in the body and represents
15-20% of the body mass in adult males; and 20-25% in adult females.
 Two forms of adipose tissue exist: unilocular (yellow) and multilocular (brown)
adipose tissue. The former has cells (50-150 µm in diameter) with a large central
droplet of fat; while the latter had cells with multiple lipid droplets and numerous
brown mitochondria.
 Yellow (unilocular) adipose tissue predominates in adult human, being found
throughout the body except the scrotum, labia minora, penis, eyelids and auricle
of external ear (except the lobule). It is richly vascularised and innervated; and
connective tissue septa divide it into incomplete lobules. It differentiates from the
mesenchyme.
 Unilocular adipose tissue serves as a store of energy; it also shapes the surface
of the body, acts as a shock absorber and insulator; and gives mechanical support
to certain internal organs. It is abundant around the kidneys, in the sole of the
- 42 -
foot, the omenta and female breasts; in the orbit (as retro-orbital fat); and beneath
the skin as panniculus adiposus.
 Multilocular adipose tissue (brown fat) is scanty in adult human. However, it is
abundant in fetuses and newborns. In the latter, it is found in the interscapular
region, etc. The colour of this tissue is due to its rich capillary network, and to the
presence of numerous mitochondria. The tissue is divided into lobules by fibrous
septa.
 The importance of multilocular adipose tissue is to generate heat. This warms the
body during cold, especially in children. Brown fat has a rich supply of
parasympathetic endings and is well vascularized.
 Benign tumors of unilocular adipose tissue origin are referred to as lipomas.
Liposarcomas (malignant tumors derived from adipocytes) are relatively
uncommon.
Elastic Connective Tissue
Elastic connective tissue

 Has a yellowish appearance and is highly elastic when fresh. This is owing to its
rich content of elastic fibres or elastin. Some thin collagen fibres also exists
between elastic fibres bundles.
 Is the major component of ligamenta flava and ligamentum nuchae. It is also
present in the epiglottis and vocal cord of the larynx, membranous layer of the
superficial fascia of anterior abdominal wall; and the wall of elastic arteries (e.g.
aorta).
Reticular Connective Tissue

 Is a specialised loose connective tissue that contains abundant reticular fibres
and specialised fibroblasts called reticular cells.
 Is associated with haemolymphoid organs such as the spleen, liver, lymph nodes
and bone marrow.
 Stains black with silver salt, owing to its rich content of reticular fibres.
Mucoid tissue
 Contains abundant ground substance (hyaluronic acid), few collagen fibrils, and
fibroblasts. It represents a transition from mesenchyme to connective tissue.
 Is found in Wharton’s jelly of umbilical cord, vitreous humour of the eye,
nucleus pulposus of intervertebral discs, and the pulp of young teeth.
Pigmented connective tissue

 Is a specialised loose connective tissue with abundant melanocytes (pigment
cells)
 Is found in the choroid and lamina fusca of the sclera of the eye.
- 43 -
Cartilage
Cartilage is a specialised connective tissue adapted to perform supportive function,
owing to its ability to withstand compression and shearing forces.
Characteristics of cartilage include:

 Presence of abundant extracellular matrix rich in glycosaminoglycans and
proteoglycans. Collagen type II and elastic fibres are present in the matrix. These
fibres confer resilience on the cartilage.
 Absence of blood and lymphatic vessels and nerve fibres. Thus, cartilage cells
(chondrocytes) have low metabolic rates. Nutrients diffuse to these cells from
blood vessels in the perichondrium (dense connective tissue that surrounds
cartilage).
 Slow rate of healing after injury, owing to its avascularity. However, cartilage
possesses high capacity for rapid growth in certain regions, e. g. epiphyseal plates
of long bones.
Perichondrium
 Is the sheath of dense connective tissue that covers the surface of the cartilage
(except articular cartilage, which is devoid of this covering)
 Is endowed with blood vessels, nerve fibres and lymphatic vessels. Nutrients
diffuse into chondrocytes from blood vessels of the perichondrium. Thus, the
latter is essential for the growth of cartilage.
 Consists of the ground substance in which collagen type I fibres and fibroblasts
are embedded. Cells in the deeper layer of the perichondrium are chondroblasts
(stem cells) that are capable of differentiating to chondrocytes during growth of
cartilage.
Types of Cartilage
Three types of cartilage exist. These include hyaline, yellow elastic and white
fibrocartilage. These cartilage types differ in the compositions of their extracellular
matrix.
Hyaline Cartilage
Hyaline cartilage
 Has a bluish, glassy, opalescent and homogenous characteristic. It is also
translucent when fresh.
 Possesses type II collagen. The collagen fibrils measure 10–20 nm in diameter,
and are not resolvable with the light microscope. These fibrils have a similar
refractive index as the ground substance of the cartilage.
 Lack perichondrium where it covers articular surface of bones as articular
cartilage
- 44 -
 Is prone to calcification after adolescence. Foetal skeleton is initially laid down as

cartilage before ossification commences.
 Is typical of costal cartilage, tracheobronchial tree, larynx, articular cartilage and
epiphysial plates of bones.
Matrix of Hyaline Cartilage
Regarding the extracellular matrix of hyaline cartilage, note the following facts:
 The matrix of hyaline cartilage consists of proteoglycans and glycoproteins
(chondronectin), in which collagen is embedded. The proteoglycans of hyaline
cartilage has a core of proteins covalently linked to chains of glycosaminoglycans
(such as chondroitin 4-sulphate, chondroitin 6-sulphate and keratan sulphate).
The proteoglycans macromolecules are also non-covalently linked to hyaluronic
acid to form proteoglycan aggregates.
 Type II collagen is typical of hyaline cartilage. This forms fine fibrils that can be
resolve with the electron microscope. The collagen and ground substance of
cartilage are synthesized by chondrocytes.
 Owing to the acidic nature of the ground substance of hyaline cartilage, it exhibits
basophilia. It is also PAS positive.
 Extracellular matrix forms about 40% of the dry weight of hyaline cartilage
Figure 13. Types of cartilage
Chondrocytes
Note that chondrocytes

 Are the cells of the cartilage (Fig. 13A). They occupy the lacunae of extracellular
matrix. Here, they are surrounded by the part of the matrix called territorial
(capsular) matrix.
 Appear rounded in outline, with a few cilia and filopodia. They may be found in
groups of up to 8 cells in the deeper part of the cartilage. These groups are called
isogenous group (as each arises from a single chondrocyte). The nucleus of each
chondrocyte is euchromatic, and has one or more nucleoli. At the periphery of the
cartilage, chondrocytes usually appear elliptical.
 Synthesise the extracellular matrix of cartilage. Chondrocytes possess abundant
granular endoplasmic reticulum, and Golgi complex, and are thus basophilic.
- 45 -
 Function under low oxygen tension. Chondrocytes receive nutrients by diffusion

from capillaries in the perichondrium and they produce energy mainly by
anaerobic glycolysis, with lactic acid as end-product.
 Are stimulated to undergo active growth by somatomedin C (insulin-like growth
factor I). This hormone is produced by the liver, under the influence of
somatotropin. The synthetic activity of chondrocytes is enhanced by thyroxin,
somatotropin and testosterone; and is suppressed by estradiol, cortisone and
hydrocortisone. However, chondrocytes are incapable of mitosis when fully
differentiated
 May give rise to chondroma (benign tumor) or chondrosarcoma (malignant
tumor).
 Arise from the mesenchyme during embryonic life. These cells differentiate from
mesenchymal cells. The latter first form chondroblasts, from which chondrocytes
are formed.
White Fibrocartilage
White fibrocartilage
 Is a transition between dense connective tissue and cartilage. Fibrocartilage
appears dense and fasciculated (Fig. 13B).
 Possesses abundant type I collagen, with little or no type II collagen.
Fibrocartilage contains both chondrocytes and fibroblasts, in contrast to hyaline
and elastic cartilages, which have chondrocytes only.
 Is organized such that the chondrocytes appear in rows between bundles of
collagen fibres.
 Has some degree of elasticity. Fibrocartilage is adapted to withstand tension and
compression.
 Is typical of the symphysis pubis, glenoid labrum, acetabular labrum, menisci of
knee joint, intervertebral discs, and articular discs of joints.
 Also covers the articular surfaces of bones that develop by intramembranous
ossification, e.g., clavicle
 Does not undergo ossification with advancing age, neither does it possess
perichondrium.
Yellow elastic cartilage

 Is similar to hyaline cartilage except for the presence of numerous elastic fibres
(Fig. 13C). Thus, it appears yellowish when fresh.
 Possesses chondrocytes and type II collagen, in addition to elastic fibres. Thus,
it combines strength, flexibility and resilience.
 Is found mostly in organs with vibration function, such as the larynx (sound
production), and ear (sound transmission). Therefore it is typical of the pinna,
external auditory meatus, auditory tube, epiglottis; and corniculate, cuneiform
and arytenoids cartilages.
 Is invested by the perichondrium.
- 46 -
Growth of Cartilage
Cartilage grows by two means: appositional and interstitial growth.
Interstitial growth of cartilage

 Is characteristic of immature cartilages. This type of growth occurs from within
the cartilage and requires mitotic division of chondroblasts. Interstitial growth
occurs at the early stages of cartilage formation.
 Is characterised by the formation of isogenous groups of chondroblasts as a
result of repeated cell division (mitosis). These cells then undergo active
secretion of extracellular matrix, thereby increasing the size of the cartilage.
 Proceeds for a longer period in the epiphyseal cartilage of long bones
Appositional growth of cartilage

 Occurs in mature cartilage. In this type of growth, the cartilage increases in size
by the addition of new matrix to the periphery of the tissue.
 Is characterised by the proliferation and differentiation of cells of the
chondrogenic layer of the perichondrium to form chondroblasts. The latter then
undergo active synthesis of cartilage matrix, thus surrounding themselves with
this matrix, and subsequently transforming into chondrocytes.
Repair of injured cartilage

 Progresses slowly owing to the poor vasculature of cartilage.
 Is accomplished mainly by replacement of injured cartilage with dense
connective tissue, especially in the adults.
 May also occur by the differentiation of perichondrial fibroblasts in to
chondroblasts. The latter then secrete new cartilage matrix to replace the injured
part.
Bone
Bone is a specialised connective tissue that gives support and shape to the body. Its
major characteristic is the hardness of its matrix, owing to the deposit of inorganic
salts, especially calcium phosphate. Bones also protect internal organs and
accommodate the bone marrow in their cavities.
Bone is made up of a calcified matrix and differentiated cell types, including
osteoblasts, osteocytes and osteoclasts.
Characteristic features of bones include:

1. High vascularity and high metabolic rates. Bones also have a high capacity for
growth and regeneration.
2. Hardness, rigidity and resilience. This is owing to the presence of Ca salts and
collage type I. In woven (immature) bones, collagen bundles are randomly
arranged. In lamellar (mature) bones, collagen bundles have ordered
arrangement.
- 47 -
3. Presence of varied cell types and a unique extracellular matrix. The latter
contains inorganic salts.
4. Presence of endosteum (a layer of flattened osteoprogenitor cells) on its inner
aspect. Externally, the periosteum (a layer of dense connective tissue) surrounds
the bone.
On gross inspection, a mature bone

 Has a cortex of compact bone; and a framework of bony processes (spongy
bone) in its interior (Fig. 14).
 Is whitish in appearance owing to its content of inorganic salts.
Most long bones

 Possess expanded processes at their ends. These are called epiphyses. Between
the epiphyses is a long process called diaphysis.
 Usually have an external layer of compact bone, deep to which is the spongy
bone.
 Possess a central cavity – the medullary cavity – in the centre of the diaphysis.
This accommodates the bone marrow.
 May possess an epiphyseal plate (growth cartilage) between the epiphysis and
diaphysis. Mitotic division of the cells of this plate may result in an increase in
length of the bone.
 May also possess a metaphysis. The latter is a transitional zone of spongy bone
between the epiphyseal plate and the diaphysis.
Figure 14. Compact and spongy layers of bone
Osteoprogenitor cells of bones

 Are the stem cells of the bone. They are found in the periosteum and endosteum
and are derived from the mesenchyme during embryonic life.
 Remain pluripotent in adults, with a capacity for mitosis and differentiation.
These cells differentiate into osteoblasts during bone formation.
- 48 -
 May also differentiate into fibroblasts, myoblasts, adipocytes, chondroblasts or

pericytes.
 Resemble young fibroblasts.
Osteoblasts
 Are bone-forming cells located on the surface of the bone in a manner similar to a
simple epithelium. They appear cuboidal or columnar in outline; and measure 15–
30 µm across.
 Produce the organic extracellular matrix (collagen type I, proteoglycans and
glycoproteins) of bones. Thus, osteoblasts possess extensive RER and Golgi
apparatus.
 Are basophilic in histological preparations.
 Are able to transform into osteocytes. Osteoblasts differentiate into osteocytes
once surrounded by bone matrix.
 Are characterised by the presence of abundant alkaline phosphatase in their cell
membranes
 Possess receptors for parathyroid hormone (produced by parathyroid glands).
This hormone enhances bone resorption.
 Initiate the activity of osteoclasts. Osteoclasts are involved in bone resorption.
 Are incapable of mitosis.
Osteocytes
 Are the principal cells of mature bones (Fig. 15). They differentiate from
osteoblasts that have been surrounded by bone matrix.
 Appear ellipsoidal in outline and measure 25 µm in their long axis.
 Occupy lacunae of extracellular matrix. Osteocytes interconnect with each other
via several cytoplasmic processes that occupy the canaliculi of bones (Fig. 15).
In these canaliculi, osteocytes form gap junctions with each other.
 Stain weakly with basic dyes owing to the presence of scanty RER and Golgi
complex.
 Form contacts with endosteal cells internally and with osteoblasts at the periphery
of the bone.
 Are long-lived, with an average lifespan of about 25 years.
 May play some role in bone resorption. These cells are involved in the
maintenance of bone matrix.
Osteoclasts
Note that osteoclasts

 Are large multinucleated bone cells with a diameter of 20-100 µm. These cells
are motile and they possess 5-20 nuclei.
 Are found in areas of bone resorption, where they occupy Howship’s lacunae
 Are characterised by the presence of ruffled borders. These borders face the
bone matrix and are endowed with folds. Just deep to the ruffled borders, the
- 49 -
cytoplasm of osteoclasts is devoid of organelles but rich in actin filaments, which

enable the cells to attach to bone matrix. Elsewhere in the cytoplasm,
mitochondria and lysosomes are abundant.
 Secrete enzymes such as collagenase, which digest matrix collagen during bone
resorption.
 Are under the influence of hormones such as calcitonin and parathyroid
hormone. Calcitonin is produced by the thyroid gland, and it reduces plasma
calcium levels; while parathyroid hormone is produced by parathyroid glands and
this increases plasma calcium levels. Osteoclasts have receptors for calcitonin but
not for parathyroid hormone. The latter stimulates osteoblasts, which then
releases a cytokine (osteoclasts-stimulating factor) that acts on osteoclasts to
promote bone resorption.
 Are formed by fusion of mononuclear cells of bone marrow origin. Osteoclasts
have a lifespan of about 16 days.
 Are devoid of ruffled border in osteopetrosis. This condition is characterised by
dense bones (marble bone) owing to impaired bone resorption by osteoclasts.
Collagen of bones
 Belongs to type I form of collagen. It is produced by osteoblasts.
 Exists in fibre form with a diameter of 50–70 nm. These fibres form network in
woven bones but form bundles in lamellar bones.
 Confers tensile and shearing strength on bone; and does not swell when treated
with dilute acid.
Periosteum
The Periosteum
 Is the layer of dense connective tissue that surrounds bone externally. Periosteum
consists of collagen bundle and fibroblasts. Sharpey’s fibres are bundles of
periosteal collagen fibres that bind the periosteum to bone.
 Contains in its inner, more cellular layer, certain osteoprogenitor cells. These are
stem cells that are capable of differentiating into osteoblasts (bone-forming cells).
 Is essential for growth and repair of bones owing to the presence of
osteoprogenitor cells in its deeper layer.
Endosteum
The endosteum
 Is a layer of flattened osteoprogenitor cells that line the interior of bones.
Associated with these cells is a little amount of connective tissue. Endosteal
osteoprogenitor cells are capable of mitosis and can differentiate into osteoblasts.
 Contributes to the growth and repair of bone owing to its numerous
osteoprogenitor cells
 Also assists with nutrition of bones, as does the periosteum.
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Bone Matrix
Regarding bone matrix, note the following facts:
 Bone matrix consists of organic and inorganic matters. The inorganic matter of
bone constitute about 50% of its dry weight
 The organic components of bone matrix consists of type I collagen, proteoglycans
and glycoproteins (see below).
 The inorganic matter of bone is rich in calcium and phosphorus in the form of
hydroxyapatite crystals (each of which is about 5 nm thick, 80 nm wide and 150
nm long). Besides, calcium phosphate is also present in appreciable quantities.
Also found in the inorganic matter of bone are sodium, potassium, bicarbonate,
citrate and magnesium. Constant exchange of calcium occurs between blood and
bones, and this is under strict hormonal control.
 The hardness and strength of bones is a function of its inorganic and organic
constituents.
 Bone salts (inorganic matter) can be removed by chelating agents such as EDTA,
weak acid, or citrate. Bone salts increase in quantities as bone matures.
Bone salts
 Confer hardness and rigidity on bones.
 Consists mainly of calcium phosphate. They are also rich in carbonate and
hydroxyl ions. Bone salts are similar chemically to hydroxyapatite.
 Form bone crystals, each 5 nm thick, 80 nm wide, and 150 nm long. They
increase in quantity as bone matures.
 May have its Ca substituted with lead, radium or strontium, thereby inducing
certain diseases of haemopoietic tissue.
 Can be chelated by EDTA, citrate or weak acid.
Bone Calcium

 Ninety-nine per cent (99%) of body Ca is in the bone. Ca salts are essential for
the hard nature of bones.
 Constant exchange of Ca occurs between the blood and bone. About 10%
turnover occurs in the skeleton every year. Ca turnover is under hormonal
control.
 Secretion of parathyroid hormone increases as blood Ca2+ levels falls. This
hormone enhances Ca absorption by renal tubules and intestinal mucosa.
 Parathyroid hormone also (indirectly) stimulates osteoclasts to commence bone
resorption. The hormone stimulates osteoblasts to release osteoclast-stimulating
factor, which then stimulates osteoclasts.
 Calcitonin decreases the activity of osteoclasts and thus reduces blood Ca levels.
Osteoclasts have receptors for calcitonin. Calcitonin is produced by the C cells of
thyroid gland.
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Primary bone
 Is also referred to as woven (or immature) bone. It is typical of foetal bones.
 Also forms in mature (adult) bones following fracture and rapid bone remodeling;
and following exposure to prostaglandin E2 or certain growth factors.
 Consists of collagen fibres and bone crystals arranged in irregular lattice.
Lamellar (Mature) Bone

In lamellar bone, the arrangement of the lamellae can be:
 Concentric, forming the Haversian system;
 Circumferential, forming the circumferential lamellae; or
 Interstitial, forming the interstitial lamellae
Haversian System (Osteon)
The Haversian system

 Constitutes the basic unit of adult bone construction. It is made up of 4–30 bone
lamellae, each about 3 µm thick. An osteon can be up to 400 µm in diameter and
several millimeters in length.
 Possesses a central Haversian canal that contains neurovascular structures (Fig.
15). Haversian canal is about 50 µm in diameter
 Is connected with adjacent osteons via transverse channels called Volkmann’s
canals.
 Is separated from adjacent osteons by cement lines. The latter is rich in
glycoproteins, but poor in collagen. Cement lines are basophilic.
 May be as many as 21 million in adult bones
Figure 15. Osteon
Circumferential lamellae of bones

 Form complete layers (lamellae) around the circumference of bone.
- 52 -
Interstitial lamellae
 Are irregular angular lamellae located between adjacent Haversian systems.
 Are separated from Haversian systems by cement lines of glycoproteins.
Trabecular bone
In trabecular bone,
 Trabeculae are 50–400 µm in thickness. Haversian systems are usually absent
except in thick trabeculae.
 Bone construction is also in lamellar form (as in compact bones). The lamellae
are arranged parallel to the surface of the bone.
 No blood vessels lie within the bone matrix; and cartilage may occur in the core
of the bone.
Innervation of Bone
Nerves of bones
 Occupy Haversian canals and medullary cavities of bones
 Include myelinated and unmyelinated elements; and they contain both sensory
and autonomic fibres.
 Are most numerous close to the articular ends of bones.
Blood Supply to Bones

Regarding the blood supply of bones, note the following points:
 A single nutrient foramen is usually present. This transmits nutrient arteries.
 Epiphyseal arteries are derived from adjacent systemic vessels; while
metaphyseal arteries usually arise from periarticular vessels.
 Diaphyseal nutrient arteries are directed away from the growing epiphysis
(epiphyseal plate).
 Blood vessels are arranged such that blood flow is centrifugal in the cortex; but
centripetal in the medullary cavity.
 Lymph vessels do not accompany blood vessels
Ossification
Ossification is the process that leads to the formation of bones. Bones either develop
from a preformed cartilaginous framework (endochondrial ossification) or from
connective tissue framework (intramembranous ossification).
Intramembranous ossification
 Transforms a highly vascular connective tissue framework into bone. The process
is indicted by the appearance of strands of eosinophilic matrix in the connective
tissue.
- 53 -
 Involves active bone matrix synthesis by osteoblasts derived from mesenchymal

(connective tissue) osteoprogenitor cells. Osteoblasts synthesize the organic
components of the matrix
 First establishes the ‘woven bone’ in which collagen bundles form network. The
preformed woven bone is then transformed into lamellar bone, which is the
definitive form. This mode of bone formation constructs bone in branching
pattern.
 Occur in the skull, clavicle, and part of the mandible
Endochondrial ossification
 Occurs in most bones of the body, including long bones. This process produces
bones from preformed frameworks of hyalin cartilage.
 Involves the establishment of primary centres of ossification in utero.
Secondary centres of ossification appear after birth.
 Involves the enlargement, vacuolation and subsequent disappearance of
chondroblasts of a preformed hyaline cartilage. Thereafter, as blood vessels
invade the cartilage, the mesenchymal tissue around these vessels occupies the
enlarged lacunae (spaces) vacated by the chondroblasts of the cartilage. Then
osteoprogenitor cells of the invading mesenchymal tissue differentiate into
osteoblasts (cells that form bone matrix). Subsequently, secretion of bone matrix
(collagen type I, proteoglycans, and glycoproteins) by the newly-formed
osteoblasts commences in the primary centres of ossification; and the cartilage
is then gradually transformed into bone.
 Continues after birth in secondary centres of ossification, until the bone is
completely ossified (following the closure of the epiphyseal plate for example),
except articular cartilage (which does not ossify).
Growth of Bones
Note that
 Bones grow mainly by appositional growth (addition of bone matrix to the
surface of the bone).
 Interstitial growth is uncharacteristic of bones (though this occurs in cartilage).
Applied Anatomy of Bones
Note that
 Deficiency of bone calcium (e.g., from excessive bone resorption) results in
osteoporosis. The latter is characterised by bone fragility; and it is common in
older women.
 In adult humans, chronic deficiency of dietary vitamin D and Ca produces
osteomalacia. The latter is characterised by uncalcified bone matrix. In this
disease, bone mineralization is impaired.
 In children, deficiency of vitamin D results in Rickets. It is characterised by
impaired calcification of cartilage frameworks and formation of deformed bones.
- 54 -
 Vitamin C enhances production of collagen and proteoglycans of bone matrix.

Thus, its deficiency leads to bone fragility and delayed healing of fracture.
 Vitamin A has a role in balancing bone removal and deposition.
 Osteoblastoma and osteoclastoma are benign tumors of bones. Osteosarcoma is
a malignant tumor of bones, and it is usually associated with young adults. It is
frequent in the humerus, femur and tibia. Besides, tumors of the breast, prostate
and kidneys, etc, could also form metastases in bones.
Also, note that

 Excessive secretion of parathyroid hormone (e.g., from parathyroid adenoma)
produces osteitis fibrosa cystica. This is characterised by increased activity of
osteoclasts, resulting in rapid removal of bone minerals and formation of kidney
stones.
 Low levels of growth hormone in children result in thinning of growth plates; and
thus, pituitary dwarfism.
 Excessive production of growth hormone in children results in gigantism; and
this is due to excessive growth of long bones.
 Hypersecretion of growth hormone in adults results in acromegaly. The
condition is characterised by thickening of long bones, and arises from pituitary
tumor.
After fracture, bone healing proceeds in stages. These include:

 Inflammatory responses at the site of fracture
 Formation of fibrocartilagenous callus
 Formation of bony callus
 Bone remodeling and internal reconstruction
Note that inflammatory changes following bone fracture

 Last for about four days. Such changes overlap the stage of fibrocartilagenous
callus formation
 Involve the mobilisation of leucocytes, mast cells and macrophages to fracture
sites
 Are also associated with hypoxia and an acidic environment at the fracture site.
Haematoma and pains also occur.
 Result in disturbances of osteocytic activities, release of lysosomal enzymes; and
necrosis of tissue at fracture site.
During bone healing after fracture, formation of soft callus

 Proceeds for about four weeks
 Involves the formation of fibrocartilagenous blastema between bone fragments.
This requires the activity of fibroblasts, osteoblasts and chondroblasts
- 55 -
Following fracture, formation of hard callus

 Commences about four weeks after fracture
 Involves the conversion of the soft callus into bony callus. This is accomplished
by increased vascularity of the soft callus.
 Results in the formation of woven bone by endochondrial ossification.
Intramembranous ossification may also be involved.
 Requires the activity of osteoclasts for the removal of necrotic bone tissue.
Bone remodeling after fracture

 Proceeds simultaneously with the formation of hard callus; and it occurs faster in
children than adults.
 May continues for years as it transforms woven bone into lamellar bone.
 Requires the activity of osteoclasts for the purpose of bone resorption; and it is
satisfactory when the fracture site is no longer recognizable.
 May be accelerated by means of direct current, electromagnetic field and
ultrasound.
Muscle Tissue
Muscle tissue is the type of tissue that confers contractility on certain organs and
body parts. It consists of elongated cells called myocytes or muscle fibres. Three
types of muscle tissue can be defined on the basis of structural and functional
characteristics. These are skeletal, cardiac and smooth muscle.
Regarding muscle tissue, note the following:

 Myocyte (muscle fibre) is the elongated cell that constitutes the structural and
functional unit of the muscle;
 Sarcolemma is the cell membrane of a muscle cell; while sarcoplasm refers to
the cytoplasm of this cell
 Sarcoplasmic reticulum refers to the smooth endoplasmic reticulum of muscle
cells. It plays a role in the storage and release of Ca2+, a process that is essential
for muscle contraction
 Each muscle fibre is invested by a layer of connective tissue termed
endomysium. The latter contains nerve fibres as well as blood and lymphatic
capillaries, and is made of reticular fibres and basal lamina.
 A fasciculus is a bundle consisting of several muscle fibres (within a muscle).
Each fasciculus is invested by the perimysium (made up of connective tissue).
 Epimysium is the dense connective tissue that invests the entire muscle
externally, thereby delineating it from adjacent muscles or tissue.
Skeletal Muscle
Characteristics of Skeletal Muscle Fibres
Note that skeletal muscle fibres

- 56 -
 Are long and cylindrical (Fig. 16C). They have variable lengths, which may be up
to 30 cm, and a diameter of 10–100 µm.
 Are multinucleated, each with several flattened peripherally-placed nuclei.
 Contain abundant contractile myofilaments (actin and myosin). These are
responsible for the contractile activity of muscle.
 Appear striated, owing to the peculiar and highly ordered arrangement of their
myofilaments. This striation is typical of skeletal and cardiac muscles. Thus,
they are also called striated muscles.
 Possess specialised form of agranular endoplasmic reticulum termed
sarcoplasmic reticulum. This reticulum stores Ca2+, which is released during
muscle contraction.
 Also possess numerous mitochondria, which are essential for energy generation.
The cytoplasm of these cells contains glycogen.
 Are innervated by somatic fibers. The junction between the muscle fibre and the
nerve ending is termed myoneural junction or motor end plate. Denervation of a
skeletal muscle leads to its paralysis and atrophy.
 Have a poor capacity for regeneration after injury; and may thus be replaced by
connective tissue scar. This is because skeletal muscle fibres are highly
differentiated, and thus, do not undergo mitosis.
 Develop from the mesenchyme during embryonic life.
Regarding skeletal muscle, note the following points:

 When subjected to repeated rigorous exercise, skeletal muscle undergoes
hypertrophy. The latter is characterised by increases in the volume and size of
muscle fibres as a result of the formation of new myofibrils.
 Skeletal and cardiac muscles do not undergo hyperplasia as they have lost the
capacity for mitosis. Smooth muscle can however undergo hyperplasia.
Hyperplasia is characterised by an increase in the number of smooth muscle
cells (by mitosis) during the growth/enlargement of an organ, e.g. uterus.
 Rigor mortis occurs after death. It is characterised by extreme rigidity of skeletal
muscles; and is due to non-availability of ATP (a condition that leads to the
stability (immobility) of the actin-myosin complex).
 At the myoneural junction, acetylcholine is released from the nerve endings. This
transmitter binds to receptors on the surface of the sarcolemma, thereby
triggering a series of events that leads to muscle contraction. Such events include
increased permeability of sarcolemma (and the T-system); increased
permeability of sarcoplasmic reticulum (which stores Ca2+); liberation of Ca2+
from sarcoplasmic reticulum into the sarcoplasm. The last event leads to the
sliding of the actin filaments between the myosin filaments (sliding filament
mechanism); and this leads to physical contraction of the muscle. (Note that the
actin and myosin filaments do not shorten; rather, they slide past each other).
 In myasthenia gravis, there is a progressive muscular weakness. This auto-
immune disorder is caused by a reduction in the number of active acetylcholine
receptors in the sarcolemma at the neuromuscular junction. Certain antibodies
- 57 -
bind to these receptors, thereby preventing acetylcholine from interacting with

them.
Figure 16. Cardiac (A), smooth (B), and skeletal (C) muscle fibres
Cardiac Muscle
Note that cardiac muscle

 Is peculiar to the heart. It consists of several distinct cylindrical fibres, each of
which has a central nucleus.
 Possesses striation (alternating dark and light bands) similar to that of skeletal
muscle.
 Is under neural (autonomic) and hormonal control. Thus, the muscle is not under
to voluntary control.
- 58 -
Cardiac muscle cells

 Are cylindrical blocks, about 80-100 µm in length. Each measures about 15 µm
in diameter, with a single centrally-placed nucleus (Fig. 16A). These cells usually
bifurcate at their ends before uniting with adjacent cells. Thus, the heart consists
of tightly interconnected cardiac muscle cells.
 Are separated from each other at their ends by transversely-placed dark-staining
‘lines’ located at irregular intervals. These distinguishing features of cardiac
muscle are the intercalated discs. They are junctional complexes consisting of
fasciae adherentes, desmosomes and gap junctions. Fasciae adherentes and
desmosomes help to establish coherence between adjacent cardiac muscle cells;
while gap junctions are regions of low electrical resistance. They provide ionic
continuity between adjacent cells so that several cardiac muscle cells can contract
as a syncytium.
 Possess numerous large mitochondria (that occupy about 40% of the cytoplasm),
owing to the need for high metabolic rates. Cardiac muscle cells also contain
abundant myofilaments (actin and myosin). The filaments form ordered
alternating patterns (as in skeletal muscle cells), thereby making the cells appear
striated. The sarcoplasmic reticulum is not as prominent as in skeletal muscle;
while the arrangement of the T tubules also differs. T tubules are few in atrial
muscle cells.
 Also possess lipid droplets (containing triglycerides) and small amounts of
glycogen. These serve as sources of energy for these cells. Inclusions such as
lipofuscin are also present.
 Contract spontaneously, rhythmically and vigorously. The impulse for this
contraction is generated by the sinuatrial node. However, the force and rate of
cardiac contraction are under autonomic and hormonal influence. Unlike skeletal
muscle cells, nerve endings do not terminate directly on cardiac muscle cells.
 Are capable of undergoing mitosis only during infancy. In adults, cardiac muscle
cells do not divide. They grow by hypertrophy of existing cells. Dead cardiac
muscle cells are therefore replaced by connective tissue scar.
 Arise from the mesenchyme during foetal life.
Smooth Muscle
Regarding smooth muscle cell, note the following:

 Smooth muscle cells are elongated (spindle-shaped) cells, each of which is
surrounded by the basal lamina (containing reticular fibres). Smooth muscle cells
vary in length from 15 µm in arterioles, 200 µm in minute blood vessels, to 500
µm in the gravid uterus. These cells are arranged parallel to one another to form
fasciculi (Fig. 16B).
 The ovoid nucleus of each smooth muscle cell lies midway along its length. Its
cytoplasm contains mitochondria, RER, polyribosomes and Golgi apparatus.
However, the sarcoplasmic reticulum is rudimentary, while T tubules are absent.
 The contractile filaments (actin and myosin) of smooth muscle cells are not
arranged in ordered alternating bands as in skeletal and cardiac muscle. Rather,
- 59 -
these filaments form a network. Hence, the smooth (non-striated) appearance of

these cells. Contraction of smooth muscle cells is by the sliding filament
mechanism (as occurs in skeletal muscle). Influx of Ca 2+ into the cytoplasm
triggers this contraction.
 Contraction of smooth muscle fibres is modulated by neural and hormonal
factors. In the uterus, oestrogens enhance smooth muscle contraction; while
progesterone does the reverse. The autonomic nervous system also supplies
smooth muscle cells. However, the terminals of these fibres lie in the endomysial
connective tissue, and so do not form elaborate myoneural junction.
 Smooth muscle fibres can contract as a syncytium owing to the presence of gap
junctions between adjacent cells. Such junctions are sites of low electrical
resistance; and they enable electrical wave to pass rapidly from cell to cell.
Smooth myocytes do not depend on nervous stimulation for contraction. They
can contract in response to stretch, etc.
 Are found in the walls of gastrointestinal tract (GIT), respiratory tract, blood
vessels and ducts of some glands.
 Are also found in the skin (as arrectore pili muscle), iris and ciliary body of the
eye
 Are involuntary in function and non-striated in structure. Contraction of smooth
muscle cells is relatively slow.
Also note the following:

 Skeletal and cardiac muscle lack the capacity for mitosis. Such tissues thus
enlarge by hyperplasia (increase in size of the muscle fibres as a result of
increased synthesis of myofilaments). Lost cells are therefore usually replaced by
fibrous tissue. In skeletal muscle, certain satellite cells are associated with the
muscle fibres. These cells can proliferate and differentiate into new skeletal
muscle fibres following injury or rigorous exercise.
 Smooth muscle cells are capable of undergoing both hyperplasia and
hypertrophy. These cells have a capacity for mitosis and can thus divide. During
pregnancy, the uterus increases in size by enlargement and multiplication of its
muscle fibres. Similarly, dead smooth myocytes can be replaced by mitotic cell
division.
CHAPTER 3: HAEMOLYMPHOID SYSTEM

Blood
The blood
 Forms about 7% of body weight, with a volume of about 5.5 L in man. It is
specialised connective tissue that is essential for the maintenance of homeostasis.
- 60 -
 Consists of two main components: (1) cells or formed elements; and (2) plasma,
which is the fluid in which the cells are suspended. Serum is the plasma from
which the clotting factors have been removed. It is a yellowish fluid that
separates from the coagulum after the clotting of blood.
 Is reddish in colour with a viscosity of 4.75 at 18 OC. the pH of the blood is 7.35-
7.45
 Belongs to the non-Newtonian class of fluid and has a specific gravity of 1.06 at
15 OC
 Separates into layers when collected in a tube (with anticoagulant) and
centrifuged. The packed cell volume (PCV or haematocrit) is an estimate of the
volume of packed red blood cells (RBCs) per unit volume of blood. The value is
40-50% in men and 35-45% in women. In the haematocrit tube, the lower layer
consists of RBC and it forms about 43% of the volume of blood in the tube.
Above this layer is the buffy coat – a layer made of white blood cells (WBCs),
and which forms about 1% of the blood volume. Platelets form a layer just above
the buffy coat, but this layer is invisible to the naked eye. The yellow supernatant
obtained is the plasma.
Plasma
The plasma
 Is the yellowish, transparent and somewhat viscous fluid in which the formed
elements of the blood are suspended. It consists essentially of water, in which
certain organic and inorganic substances are dissolved. Plasma constitutes about
55% of the blood.
 Contains plasma protein (albumin, lipoproteins and α, β and γ globulins,
fibrinogen, and prothrombin), amino acids, vitamins and hormones. Other
constituents include sodium and chloride ions, as well as bicarbonate, phosphate,
calcium and potassium ions. Albumin maintains the osmotic pressure of the
blood; γ globulin is important for immunity. α and β Globulins help in the
transport of lipids and fat-soluble vitamins; while fibrinogen is important in
haemostasis.
 Appears milky after a meal rich in lipids
 Is used for routine clinical diagnosis
Functions of the blood include:

 Transportation of gases (O2 and CO2). This is a function of RBCs. The blood
also transports nutrients, hormones, etc.
 Immunity, which is a function of WBCs (leucocytes).
 Haemostasis (clotting of blood), a function of platelets (thrombocytes).
Formed Elements of the Blood

The formed elements are the cellular components of the blood. They include
erythrocytes (RBC), leucocytes (WBC) and platelets. These form about 45% of the
total blood volume and perform essential functions.
- 61 -
Platelets (Thrombocytes)
Platelets
 Are small colourless anucleated cells with a diameter of 2-4 µm (Fig. 17B). Each
has an oval biconvex appearance.
 Possess mitochondria and some RER. Each platelet has a peripheral clear zone
called hyalomere and a central granular zone called granulomere. The latter
contains some purple granules.
 Are capable of adhering to each other and to other surfaces. This property is due
to the presence of a glycoprotein-rich coat around the plasmalemma of each cell.
 Have a normal count of 200,000-500,000 cells per µL of blood. These cells arise
from fragmentation of large polyploid megakaryocytes of bone marrow. They
have a lifespan of about 10 days.
 Are involved in haemostasis (blood clotting). Platelets promote clotting of blood
and help to plug gaps in injured blood vessels.

 Haemophilia is a sex-linked recessive disorder that is characterised by prolonged
blood clotting time, and profuse bleeding. Types of haemophilia include
haemophilia A and B and C.
 In haemophilia A, clotting factor VIII is deficient or defective; while in
haemophilia B (Christmas disease), clotting factor IX is deficient. Haemophilia
C is owing to the deficiency of factor XI.
 Haemophiliac patients are usually males. Females are rarely affected. However,
females manifest the condition only when the defective gene is found in both X
chromosomes.
Figure 17. A, Red Blood Cells (RBC); B, Megakaryocyte
Red Blood Cell (Erythrocyte)
Red blood cells

 Are non-nucleated biconcave cells (Fig. 17A). Each measures 7.5 µm in
diameter, 2.5 µm in thickness at the periphery, and 0.8 µm in thickness at the
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centre. Its biconcave shape increases its surface area for gaseous exchange. RBCs
have a total surface area of 3800 m2.
 Are devoid of mitochondria and ribosomes. Thus, they generate energy by
anaerobic respiration; and are incapable of protein synthesis. They contain
enzymes for glycolysis and hexose monophosphate shunt pathway.
 Contain a red pigment called haemoglobin (Hb). This forms about 33% of the
mass of each RBC and confers acidophilia on the cell. Hb is an O2-carrying
protein and is responsible for the red colour of the blood.
 Constitute about 99% of the total cells of the blood, with a count of 4.1-6.0
million per µL in men and 3.9-5.5 million per µL in women.
 Are typically soft and elastic. Thus, they are able to modify their shape when
traversing capillaries. Rouleaux phenomenon is characterised by adherence of
RBCs to each other when blood is stagnant.
 Are referred to as reticulocytes when newly released from the bone marrow.
 Spend an average of 120 days in the circulation. These cells become fragile as
they advance in age.
 Are ingested by macrophages in the spleen and liver when aged. RBCs are
destroyed at an average rate of 5 x 1011 per day.
Reticulocytes
Reticulocytes
 Are young RBCs that are recently released by the bone marrow into the
circulation. These cells contain some granules or network of ribonucleoprotein in
their cytoplasm. Thus, they stain with cresyl blue.
 Constitute about 1% of circulating RBCs. However, their number increases after
haemorrhage and following exposure to a high altitude; and this indicates an
increased demand for O2.
Haemoglobin of Red Blood Cells
Note that haemoglobin

 Is a protein with a molecular weight of 67,000
 Consists of four polypeptide chains (globins), each containing a haem group
 May exist in the form of haemoglobin A (Hb A), comprising two alpha and two
beta polypeptide chains. It may also exist in the form of Hb A2, consisting of two
alpha and two delta polypeptide chains.
 Exist in the foetus as Hb F, consisting of two alpha and two gamma polypeptide
chains
 May be biochemically deformed, in which case conditions such as thalassaemia
and sickle cell disease arise.
 Serve as vehicle for the transportation of oxygen and CO2. A molecule of Hb can
carry up to 4 molecules of O2
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Applied Anatomy
Regarding RBCs, note the following facts:

 Anaemia is characterised by abnormally low haemoglobin concentrations or
RBC count. It is caused by different factor, e.g., increased destruction of RBCs,
etc. Anaemia resulting from reduced Hb concentrations is referred to as
hypochromic anaemia.
 In mountain dwellers, the number of RBcs is relatively high, a condition known
as erythrocytosis or polycythemia. In this condition, blood viscosity increases,
and blood flow through minute vessels may be impaired.
 Anisocytosis is characterised by the presence of RBCs of different sizes.
Macrocytes are abnormally large RBCs, with a diameter greater than 9 µm;
while microcytes are RBC with a diameter less than 6 µm.
 Thalassaemia is a group of disorders that result from defective rate of production
of some of the polypeptide chains of haemoglobin. There are different forms of
this condition.
 Sickle cell disease is caused by point mutation in the DNA of the gene for the β
chain of Hb. This mutation leads to the presence of valine in the polypeptide
chain of Hb, instead of glutamic acid. Upon deoxygenation of this HbS, it
polymerises and becomes rigid, giving the RBC a sickle-shaped appearance. Such
a RBC is fragile and inflexible, with a short lifespan. Anoxia, injury to blood
vessels and thrombosis (formation of blood clot), are associated with this
condition.
 Hereditary spherocytosis is characterised by the presence of spheroidal
erythrocytes. Such cells are more susceptible to destruction by macrophages and
to sequestration; and this condition produces anaemia. Splenectomy usually
improves the condition as a result of the removal of large number of
macrophages.
Leucocytes (White Blood Cells)

Leucocytes are the white blood cells. These cells are larger than erythrocytes and
they constitute 1% of blood volume. They form the buffy coat in the haematocrit
tube after centrifugation. Two forms of WBCs exist: agranulocytes (monocytes and
lymphocytes) and granulocytes (neutrophils, eosinophils and basophils).
Granulocytes are the polymorphonulear leucocytes. In the blood, WBCs are spherical,
but after entering connective tissue by diapedesis, they become amoeboid.
Granular Leucocytes (Polymorphonulear Leucocytes)
Granular leucocytes
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 Are characterised by the presence of specific granules in their cytoplasm. This is

in addition to azurophilic granules (representing lysosomes). These cells also
possess nuclei with two or more lobes.
 Do not undergo mitosis. Each has a short lifespan, and they die in billions each
day (by apoptosis).
 Possess poorly developed RER and Golgi complex. Thus, they are not involved
in active protein synthesis. Mitochondria are also scanty owing to their low
metabolic rate. These cells generate energy by glycolysis and are adapted to
function in regions with low O2 tension, e.g., inflamed areas.
 Are important for immunity. These cells are attracted to sites of inflammation and
infection by chemotaxis. They cross blood vessels by diapedesis to invade
connective tissue.
 Include neutrophils, eosinophils, and basophils. (For description of the former
two cells, see connective tissue).
Basophils
Basophils
 Constitute about 0.5% of WBCs, and are thus difficult to locate in the blood.
They have a count of 25-200 cells/µL of blood.
 Are rounded in outline, with a diameter of 10-15 µm. The nucleus of each cell is
divided into irregular lobes, but this lobulation is usually obscured by the
cytoplasmic granules (Fig. 18A).
 Demonstrates a good degree of metachromasia, owing to the presence of certain
specific granules in their cytoplasm. These granules contain heparin (a natural
anticoagulant) and histamine (that mediates inflammatory responses). Each
basophil contains about 100 of such specific granules. Metachromasia occurs
when a cell picks up a colour different from that of the stain.
 Are similar to connective tissue mast cells. In certain conditions, basophils
migrate to connective tissue to enhance the activity of mast cells, e.g., during
allergy.
 Release the contents of their granules in the presence of certain antigens
(allergens). Basophils are involved in hypersensitivity reactions.
(Note: For neutrophils and eosinophils, see connective tissue).
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Figure 18. A, Basophil (arrow); B. Monocyte (arrow)
Agranular Leucocytes
Agranular leucocytes
 Are devoid of specific granules, but they have azurophilic granules which are
lysosomes
 Are actively involved in immunological function; they include monocytes and
lymphocytes
Monocytes
Monocytes
 Are the largest cells found in the blood. They have a diameter of 12–20 µm, and
possess eccentric nuclei that could be horse-shoe, oval or kidney shaped (Fig.
18B).
 Have a basophilic cytoplasm. This contains some RER, polyribosomes, Golgi
apparatus, numerous mitochondria and lysosomes (azurophilic granules).
 Constitute 3-8% of the circulating leucocytes. With a count of 100-700 cells/µL
of blood.
 Differentiate into connective tissue macrophages after crossing the blood
capillaries
 Cross the blood capillaries (after up to 1½ days in the blood) to enter the
connective tissue, where they differentiate into macrophages. They are the
precursors of the mononuclear phagocyte system.
 Are highly motile and phagocytic
Lymphocytes
Lymphocytes
 Constitute the second most abundant leucocytes in the blood. They represent 20–
35% of total white blood cells, with a count of about 1,500–2,700 cells/µL of
blood.
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 Measure 5–15 µm in diameter. Their rounded nuclei are usually intensely stained
in histological sections (Fig. 10).
 May pass from the blood to extravascular site and vice-versa (leucocyte
recirculation). Lymphocytes arise in the bone marrow and differentiate in the
marrow and thymus.
 Are agranular in nature, hence called agranular leucocytes. They lack specific
granules but may possess azurophilic granules.
 Actively participate in body’s defence against antigen invasion. They may enter
certain secretory products such as saliva.
 May exist as ‘small lymphocytes’ (6-8 µm), which are mature cells; or as ‘large
lymphocytes’ (up to 18 µm), which are immature cells still capable of cell
division.
 Actively secrete proteins. Hence, they possess basophilic cytoplasm with
polyribosomes, RER, Golgi apparatus and a few mitochondria.
 May remain in circulation for several years. Some however have a lifespan of just
a few days.
 May be designated as B, T or natural killer lymphocytes, depending on their
origin and/or functions.
Lymphocytes
 Initially appear in the embryonic yolk sac, spleen and liver before migrating to
the bone marrow. The latter is the main source of lymphocytes after birth.
 May enter the circulation directly (from the bone marrow) as B lymphocytes.
Some however pass from bone marrow to the thymus where they differentiate
into T lymphocytes.
B Lymphocyte
B lymphocytes
 Originate and differentiate fully in the bone marrow. These cells mediate
humoral immunity. They secrete antibodies (immunoglobulins) against specific
antigens. B lymphocytes proliferate rapidly when exposed to these antigens.
 Could enter the connective tissue, where they differentiate into plasma cells. The
latter are also endowed with ribosomes, RER and Golgi body for the synthesis of
immunoglobulins
T Lymphocytes
T lymphocytes
 Are the most numerous type of lymphocyte; they constitute 65-75% of blood
lymphocytes
 Arise in bone marrow but become fully differentiated in the thymus.
 Are of two subtypes: helper T cells and cytotoxic T cells. Cytotoxic T cells act
by attaching to foreign cells or virus-infected cells, thereby destroying them by
releasing perforins or by triggering apoptosis in these cells. Helper T cells
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produce cytokines that induce the phagocytic activity of macrophages; activate

cytotoxic T cells; and enhance the differentiation of B lymphocytes into plasma
cells. In AIDS, the retrovirus kills helper T cells, thereby predisposing the
individual to infections that should ordinarily be prevented if these cells were
intact.
Natural Killer Lymphocytes
Natural killer lymphocytes

 Constitute 10-15% of the circulating lymphocytes. Natural killer cells arise in
the bone marrow.
 Are specialised to destroy cancer cells, virus-infected cells, and foreign
(transplanted) cells without previous activation. Thus, they are said to be
involved in innate immune response.
Mononuclear Phagocyte System (Reticuloendothelial System)

This consists of macrophages sited in specific body organs for phagocytosis.
Components of mononuclear phagocyte system include:

 Kupffer cells of the liver; and macrophages (histiocytes) of connective tissue
 Microglia of CNS; and dendritic (Langerhans) cells of the skin
 Type A and type B synovial cells of synovial joints
 Peritoneal, pleural and alveolar macrophages
 Reticular cells of the spleen, thymus and lymph nodes; and
 Monocytes of blood
All cell of the mononuclear phagocyte system:

 Are capable of phagocytosis (engulfment and destruction of bacteria, viruses,
and other foreign substances). They form part of the line of defence against
antigens.
 Bear on their surface the class II major histocompactibility complex, which
enables them to interact with lymphocytes.
 Arise from stem cells in the bone marrow. Such stem cells differentiate into
monocytes, from which cells of the mononuclear phagocyte system arise.
Bone Marrow
Regarding bone marrow, note the following points:

 The bone marrow (myeloid tissue) is the blood-forming tissue located in the
medullary cavities of cancellous bones.
 Bone marrow is designated as either red bone marrow, owing to the presence of
haemopoietic cells and blood; or yellow bone marrow, owing to the presence of
numerous adipocytes. All marrows are red at birth. However, as age advances
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(especially from the 5th year of life), features of yellow marrow begin to appear.
The latter can revert to red marrow in hypoxia or haemorrhage.
Regarding the red marrow, note the following points:

 Red bone marrow is rich in precursors of blood cells. It consists of the stroma,
haemopoietic cords and sinusoids.
 The stroma of red marrow consists of reticular cells, reticular fibres, type I and
III collagen, laminin, fibronectin and proteoglycans. Embedded in this stroma are
cords of haemopoietic cells, numerous macrophages, pluripotent stem cells, and a
few adipocytes. This stroma is devoid of lymph vessels, and it may be replaced
by fatty tissue in old age.
 The haemopoietic cells of bone marrow are arranged in cords. These cords are
crowded and superimposed, and their cells are capable of forming RBC, WBC
and platelets.
 Mature blood cells are released from the marrow into the circulation under the
influence of releasing factors, including hormones such as androgens and
glucocorticoids. Owing to their motility, leucocytes are able to cross the wall of
marrow sinusoids to enter the circulation; erythrocytes are ‘assisted’ in this
process; while megakaryocytes form long processes that cross the sinusoidal wall
and then break up at their tips as platelets. Haemopoiesis increases in hypoxia and
severe haemorrhage.
 In addition to blood formation, red bone marrow also helps in the destruction of
old red blood cells (a function the spleen also performs). Macrophages of bone
marrow also store iron (obtained from the breakdown of Hb)
 The bone marrow is a good source of stem cells. Owing to the ability of these
cells to proliferate and differentiate into different tissue types, they can be
harvested and cultured in the appropriate medium to differentiate into specific
cell types, which can then be transplanted. Such tissues are not rejected since they
originate from the same person.
Haemopoiesis (Formation of Blood Cells)
Regarding haemopoiesis, note that:

 The earliest blood cells appear in the wall of the yolk sac by the 3rd week of
development.
 The liver begins to form blood cells by the 2nd month of intrauterine life. This
continues till the 7th month of development.
 The spleen begins to form blood cells by the 3rd month of intrauterine life. This
proceeds till the 6th month of development.
 The thymus becomes haemopoietic by the latter part of the 3rd month of
development.
 The bone marrow begins to form all blood types of blood cells from the 3rd
month of intrauterine life onwards. The lymphoid organs (spleen, lymph nodes,
tonsils) also contribute to the formation of lymphocytes.
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 Cartilage, kidney and adipose tissue may be involved in haemopoiesis early in

childhood
 Only the bone marrow (myeloid tissue) and lymphoid tissue are essential for
blood formation after birth.
 Formation of blood cells is controlled by certain growth factors that include
erythropoietin, interleukin 3, macrophage colony-stimulating factor, granulocyte
colony-stimulating factor, etc.
Erythropoiesis (Formation of Red Corpuscles)
Erythropoiesis
Regarding the formation of the red corpuscles, note the following key points:
 Erythropoiesis occurs under the influence of erythropoietin, a glycoprotein
produced by the kidneys. Erythropoietin enhances red cell formation. Substances
such as iron, vitamin B12 (cyanocobalamin) and folic acid are also required.
 The bone marrow is the exclusive source of red corpuscles. The red cell
precursors are the proerythroblasts. Proerythroblasts are basophilic cells (14-19
µm in diameter).
 Proerythroblasts differentiate into basophilic erythroblasts. The strong
basophilia of these cells is as a result of the abundant polyribosomes (involved in
Hb synthesis).
 As Hb begins to appear in the cytoplasm of basophilic erythroblast, its
polyribosomes and basophilia begin to decrease, and the cell is now referred to as
polychromatophilic erythroblasts (owing to the diverse staining property of
these cells).
 Polychromatophilic erythroblasts differentiate into orthochromatophilic
erythroblasts. The latter is characterised by uniformly acidophilic cytoplasm
(owing to the presence of Hb). Basophilia is absent as polyribosomes are largely
reduced.
 Orthochromatophilic erythroblasts soon extrude their nuclei to form reticulocytes.
Reticulocytes contain a small quantity of polyribosomes that stain in a reticular
pattern with cresyl blue (hence the name).
 Loss of polyribosomes from reticulocytes yields mature erythrocytes. The latter
then gain the lumen of sinusoids of bone marrow to enter the circulation. About
1% of circulating RBCs are reticulocytes.
 Erythropoiesis proceeds for about 7 days; it may result in the formation of
macrocytes (abnormally large red cells) or microcytes (abnormally small red
cells).
 Erythropoiesis increases during hypoxia and after severe haemorrhage; and it is
enhanced by erythropoietin.
Granulopoiesis
This is the formation of granular leucocytes (neutrophils, eosinophils, and basophils).
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Formation of Neutrophilic Leucocytes
During the formation of neutrophils,

 Bone marrow stem cells differentiate into myeloblasts (10–20 µm in diameter).
The latter then differentiate into large promyelocytes, with basophilic cytoplasm
and azurophilic granules (lysosomes).
 Promyelocytes differentiate into neutrophilic myelocytes (which contain some
specific granules rich in enzymes). This is followed by reduction in size of
neutrophilic myelocytes to form metamyelocytes. The latter possess horseshoe
nuclei.
 Mature neutrophils eventually arise from metamyelocytes. Neutrophils have
certain specific granules and multilobed nuclei.
 The whole process involves cell division, differentiation and maturation; and
proceeds for about 7 days
Formation of Eosinophils and Basophils
Note that
 Basophils and eosinophils also arise from promyelocytes. In this process,
promyelocytes form basophilic and eosinophilic myelocytes. The latter are
characterised by the presence of specific (basophilic and eosinophilic) granules,
and a characteristic nuclear condensation.
Formation of Monocytes
Regarding the formation of monocytes, note that:

 Bone marrow stem cells give rise to monoblasts.
 Differentiation of monoblasts yields promonocytes (about 18 µm in diameter).
Small lysosomes develop in promonocytes; and these primary lysosomes are
azurophilic granules.
 Proliferation of promonocytes eventfully yields monocytes. The latter have
abundant RER and lysosomes. They spend about 8 hrs in the blood and then enter
connective tissue as macrophages.
Also note the following facts:

 Neutrophilia is increased number of neutrophils in the circulation. However, this
does not necessarily imply increased production of neutrophils in bone marrow.
Neutrophilia could be associated with administration of epinephrine, rigorous
muscular activity, use of glucocorticoids, and bacterial infections. In the last case,
increased production of neutrophils by the bone marrow usually occurs.
 Leukaemias are malignant clones of white blood cell precursors; and they are
characterised by the release of large number of immature leukocytes into the
circulation.
 Leukaemias could be lymphocytic (occurring in lymphoid tissue) or
myelogenous and monocytic (occurring in bone marrow)
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 Leukaemias could originate in lymphoid tissue (lymphocytic leukaemias) or

bone marrow (myelogenous or monocytic leukaemias). In this condition, certain
blood cells are inadequate while others are in excess, and functionally deficient.
Such patients are anemic and highly susceptible to infections.
Formation of Agranular Leucocytes
Regarding the formation of lymphocytes, note the following facts:

 Lymphocytes arise in bone marrow from progenitor cells referred to as
lymphoblasts. Lymphoblasts proliferate and differentiate into prolymphoblasts,
which are smaller cells.
 Prolymphoblasts differentiate into lymphocytes. Some lymphocytes attain full
differentiation in bone marrow (B lymphocytes), while others migrate into the
thymus to gain immunocompetence (T lymphocytes). About 75% of the
circulating lymphocytes are T lymphocytes. These two forms of lymphocytes can
be distinguished by immunocytochemical methods.
 Besides the bone marrow and thymus, circulating lymphocytes also arise in
lymphoid organs (spleen, tonsils, and lymph nodes), although all progenitor
cells of lymphocytes initially originate in bone marrows (from where they
migrate to lymphoid tissue).
Formation of Platelets
During the formation of platelets

 Marrow stem cells differentiate into basophilic megakaryoblasts (15-50 µm in
diameter)
 Basophilic megakaryoblasts is transformed into promegakaryocytes (20-80 µm
in diameter).
 Promegakaryocytes give rise to megakaryocytes (35-200 µm in diameter).
 Platelets arise as fragments of megakaryocytes. The latter form thin processes,
from which platelets are given off.
Regarding megakaryocytes, note the following:

 Megakaryocytes are giant cells of about 35-200 µm in diameter, with irregularly
lobulated nuclei. Their cytoplasm has numerous mitochondria, prominent RER
and extensive Golgi complex
 Fragmentation of megakaryocytes yields platelets. Platelets possess numerous
granules that arise from Golgi complex of megakaryocytes. These granules
contain platelet factor IV (that stimulates coagulation), fibroblast growth factor,
platelet-derived growth factor, and von Willebrand’s factor (that enhances
platelet adhesion to endothelial cells).
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 In thrombocytopenic purpura, the quantity of platelets in blood is reduced. This

could be as a result of a defect in the liberation of platelets from megakaryocytes.
Thymus
The thymus
 Is a primary lymphoid organ. It consists of two lobes.
 It weighs 10-15 g at birth and 30-40 g at puberty
 Involutes gradually after birth such that in old age, it is largely replaced by
fibrofatty tissue
 Is located in the superior and anterior mediastina, and reaches as far down as the
4th costal cartilages. It may reach as far up as the neck in children
 Is related anteriorly to the sternum and upper 4 costal cartilages
 Is related posteriorly to the pericardium, aortic arch and its branches, left
brachiocephalic vein and trachea
 Is supplied by internal thoracic arteries (anterior intercostal and anterior
mediastinal branches) and inferior thyroid arteries.
 Is drained by veins that end in the left brachiocephalic, internal thoracic, and
inferior thyroid veins
 Drains via efferent lymph vessels into parasternal, brachiocephalic, and
tracheobronchial nodes. The thymus lacks afferent lymph vessels.
Structure of the thymus

 Externally, the thymus is invested by a capsule of connective.
 Connective tissue septa also divide the parenchyma of the thymus into
incomplete lobules
 Each lobule of the thymus consists of an outer darker cortex and an inner
medulla
 The cortex of thymus consists of a rich population of T-cell precursors called
thymocytes. Besides, macrophages and epithelial reticular cells are found.
 Certain epithelial reticular cells of thymic cortex form the thymic nurse cells.
These contain maturing lymphocytes in their cytoplasm.
 Thymic medulla contains epithelial reticular cells, differentiated T lymphocytes
and Hassall corpuscles (of unknown functions)
 Hassall corpuscles consist of concentric layers of flattened epithelial reticular
cells filled with keratin filaments. They may become ossified.
Roles of the Thymus

 Thymus is the site of attainment of immunocompetence by the T lymphocytes. T
lymphocytes that differentiate in the thymus enter the circulation, and they
include helper T cells and cytotoxic T cells (see blood for more details about
these cells).
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Lymph Nodes
Note that
 Lymph nodes are small lymphoid organs found throughout the body (axilla, neck,
thorax, etc).
 Afferent lymph vessels drain lymph from tissues into lymph nodes. These vessels
enter through the surface of the nodes. Efferent lymph vessels emerge from the
hila of these nodes
 Structurally, each node is invested by a connective tissue capsule and consists of
outer cortex, inner cortex (paracortical region), and medulla.
 Regarding the outer cortex of lymph node, note the following:
 The outer cortex contains numerous lymphoid nodules, some of which have
germinative centres. The nodules mainly contain B lymphocytes.
 A diffuse cell population comprising T lymphocytes, reticular cells and fibres,
and macrophages is also found in the outer cortex.
 Just beneath the capsule are subcapsular sinuses. These are spaces containing
loose network of reticular fibres and cells, lymph and lymphocytes. The lymph in
these spaces comes from afferent lymph vessels of the node and so may contain
antigens, etc.
 Also found in the outer cortex are intermediate sinuses. These are found between
lymphoid nodules and have similar organisation as subcapsular sinuses.
Inner Cortex of Lymph Node
The inner cortex

 Lies deep to the outer cortex, but without a distinct boundary
 Is poor in or lacks lymphoid nodules, but possesses many T lymphocytes
Medulla of Lymph Nodes
Note the following:

 The medulla contains numerous cord-like, branched medullary cords containing
B lymphocytes. Plasma cells and macrophages may also be found.
 Also found in the medulla of the lymph node are medullary sinuses. These
spaces contain loose network of reticular cells and fibres, lymph, lymphocytes
and macrophages.
 Lymph in the medullary sinuses is drained by efferent vessels of the node.
Applied Anatomy
Note the following:

 Metastasis of cancer cells may occur through lymph nodes and vessels.
 Lymph nodes remove antigens and micro-organisms from the lymph that flows
through them
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 Enlargement and tenderness of the lymph nodes of a region occur following

infection and inflammation of that region.
CHAPTER 4: BASIC ANATOMY OF JOINTS

Joint
A joint (articulation; arthrosis) is the junction between two or more bones. There are
three main types of joints in the body. These include cartilaginous, fibrous and
synovial joints.
Cartilaginous Joints
In cartilaginous joints, the articulating bones are united by cartilage. Two types of this
joint exist, and they include synchondrosis (primary cartilaginous joint) and
symphysis (secondary cartilaginous joint). Like fibrous joints, these joints lack joint
cavities.
Primary Cartilaginous Joint (Synchondrosis)
Primary cartilaginous joint

 Is characterised by the presence of hyaline cartilage between two articulating
bones (i.e., the articulating bones are united by hyaline cartilage).
 Usually occurs at the growing ends of long bones. It is relatively immobile.
 Include joint between epiphysis and diaphysis of long bones, neurocentral joints
of vertebrae, spheno-occipital joints and sternocostal joints, etc.
 May persist throughout life in certain locations, such as sternocostal joints.
 Has the potential to ossify with age. Thus, it may be transformed into a
synostosis
 Is devoid of joint cavity.
Secondary Cartilaginous Joint (Symphysis)
Secondary cartilaginous joints

 Are characterised by the presence of fibrocartilage in the joint. The articulating
bones are thus linked by a fibrocartilagenous pad.
 Are confined to the axial skeleton (except symphysis pubis); and are exclusively
located in the median plane of the body.
 Include the manubriosternal and intervertebral joints, symphysis menti, and
symphysis pubis (Fig. 19)
 Possess limited but useful degree of movement.
 Do not ossify with advancing age. Therefore, they usually persist throughout life.
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Figure 19. Pubic symphysis and intervertebral joint
Fibrous Joints
At fibrous joints, the articulating bones are united by fibrous connective tissue. These
joints lack cavities and they permit little or no movements. The three main types of
fibrous joints include sutures, gomphoses, and syndesmoses.
Sutures
Sutures
 Are fibrous joints between skull bones; they are thus limited to the skull. Each
has a layer of dense irregular connective tissue between articulating skull bones.
 Possess no appreciable movement. However, it confers resilience on the skull.
 May be serrate, squamous or plane, depending on the nature of the articulating
bony edges
 Start to develop about 18 months after birth. They replace the fontanels of the
infants.
 Begin to ossify by late twenties; and are completely ossified with age, to yield
synostoses.
Gomphoses (Dentoalveolar Joints)
Gomphoses
 Are fibrous joints in which bony pegs fit into bony sockets. In these joints, the
articulating bony edges are connected by periodontal ligaments.
 Include joints between the roots of the teeth and alveolar sockets of jaw bones.
 May be affected by periodontal diseases. In this disease, inflammation and
degeneration of the gums and periodontal ligaments do occur, resulting in
loosening of teeth.
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Syndesmoses
In syndesmoses,
 Interosseous ligaments unite bony edges. Fibrous tissue of this joint is more
abundant than in sutures
 Some degree of movement is permitted
 Inferior tibiofibular and tympanostapedial joints are good examples
 Union of the distal parts of the ulna and radius by fibrous tissue is also an
example.
Synovial Joints
Synovial joints are adapted for high degrees of mobility . Movement at these joints
depends on (i) the nature of the articulating bones, (ii) the arrangement of the
ligaments and fibrous capsule of the joint and, (iii) the muscles associated with the
joint.
Note that synovial joints

 Allow free movement, while simultaneously providing some stability of the joints
 Usually possess a layer of articular hyaline cartilage over the articular surfaces
of the bones (Fig. 20). However, some articular cartilage consists of
fibrocartilage.
 Possess a joint cavity containing synovial fluid (Fig. 20). The latter is produced
by the synovial membrane and it enhances free movement of the joint.
 Are strengthened by articular ligaments and muscles. Synovial membrane
separates the ligaments and muscles from the joint cavity (Fig. 20).
 May possess intra-articular structures such as tendons and ligaments, as occurs
in the knee joint.
 Are numerous in the extremities.
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Figure 20. Synovial joint
Synovial fluid
 Is a dialysate of the plasma. However, it contains hyaluronic acid, in addition to
proteins. It also contains varied cells types including type A synovial cells.
 Is slightly alkaline when at rest, and has some degree of viscosity. It is classified
as a non-Newtonian fluid.
 Usually has a volume less than 0.5 ml, though this may increase following injury
or in diseases such as arthritis.
Types of Synovial Joint
Types of synovial joints include:

1. Plane joint
2. Saddle joints
3. Hinge joints
4. Ball and socket joints
5. Condyloid joints; and
6. Ellipsoidal joints
Plane joints
 Is a type of synovial joint with flat articular surfaces. It possesses very limited
movement, which may be gliding in form.
 Is found between the carpal bones of the wrist and the tarsal bones of the foot.
 Also include the sternoclavicular joints
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Saddle joint
 Is a type of synovial joint in which the concavoconvex surface of a bone
articulates with a reciprocal convexoconcave surface of another.
 Is essentially bi-axial; and allows a relatively wide range of movement
 Is typical of the carpometacarpal joint of the thumb
 Also exists between the malleus and incus of the middle ear; as well as in the
ankle and calcaneocuboidal joints.
Hinge joint
 Is the commonest type of synovial joint in the body. It permits movement only
around one axis (uniaxial).
 Include interphalangeal, humero-ulnar and knee joints.
In a pivot joint,
 Movements are permitted around one axis only; and such movements are usually
rotational.
 One articular surface is usually conical or rounded, while the other has a
reciprocal depression. Pivot joints include the proximal radio-ulnar joint, and the
joint between the atlas and the dens of axis.
Ball-and-socket-joint
 Occurs between a rounded (convex) surface of a bone, and a reciprocal cup-like
cavity of another.
 Is multi-axial in nature; and thus allows the greatest range of movements
possible at a synovial joint
 Include the hip and shoulder joints.
Condyloid Joint
In condyloid joints,
 The articulation resembles that of a ball-and-socket joint, but movements occur
only around two axes (bi-axial); and no rotational movements are permitted.
 Metacarpal heads articulate with the bases of the proximal phalanges of the
fingers to form metacarpophalangeal joints.
Ellipsoidal joint
 Is also a modification of the ball-and-socket joint. It possesses ellipsoidal
articular surfaces; and is bi-axial in nature. Rotational movements are impossible.
 Is typical of the radio-carpal (wrist) joint.
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Applied Anatomy
Regarding diseases of the joint, note the following points:

 Arthritis is characterised by inflammation of the joint. The common types
include rheumatoid arthritis, osteoarthritis, and gouty arthritis.
 Rheumatoid arthritis is an autoimmune disorder of joints. It is characterised by
tenderness and thickening of synovial membrane, wearing of articular cartilage,
and accumulation of synovial fluid. It usually begins between 30 and 50 years of
age and is commoner in females. Bilateral occurrence is common and the joint
may become ossified and immobile.
 Osteoarthritis is a degenerative disease of the joint, as a result of irritation and
aging. Progressive softening and wearing of articular cartilage produces pain and
impaired joint movement. Though more common than rheumatoid arthritis, it is
less disabling.
 Gouty arthritis (gout) arises from metabolic disorder, due to abnormally high
levels of uric acid in the blood. This leads to deposition of sodium urate crystal in
joints, with irritation of synovial membrane and articular cartilage, joint swelling
and pain. Males are more affected and joints of the foot are more commonly
involved.
 Arthroscopy is a procedure that uses a device called arthroscope to diagnose
and occasionally treat a joint disorder. In certain cases, diseased joints could be
replaced with joint prostheses (artificial joints).
CHAPTER 5: GENERAL EMBRYOLOGY

Introduction
The first eight weeks of prenatal development is the embryonic period, when
the primordia of most organs and tissues of the body are laid down. The foetal
period begins at week 9 and ends at birth. Exposure of the embryo to
teratogens (some drugs, irradiation, etc) do trigger congenital anomalies. Key
post-fertilization events of the first 8 weeks of pregnancy include:
blastogenesis, implantation, development of chorionic villi, gastrulation,
neurulation, and organogenesis.
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Male Gamete (Sperm, Spermatozoon)
Figure 21a. Human spermatozoon
Regarding a normal human spermatozoon, note the following points:

 Spermatozoon is the male gamete. It is an elongated, highly motile cell, with a
length of about 54 µm
 A mature spermatozoon consists of a head, neck, middle piece, and tail (Fig. 21).
The process that leads to the formation of spermatozoa is termed
spermatogenesis. Spermatogenesis proceeds for about 65 days; and spermatozoa
are stored in the epididymis prior to their release at ejaculation.
 The head of a spermatozoon is the anterior ovoid or piriform end. It is about 4
µm long and 3 µm wide at its widest part. The head contains a densely-parked
nucleus, and the acrosomal cap. The latter overlies the anterior ⅔ of the nucleus,
and it contains enzymes such as acrosin, aryl sulphatase, hyaluronidase (needed
for fertilization). The acrosomal cap is derived from the Golgi apparatus. Just
external to the compact nucleus and acrosome is the cell membrane. No
cytoplasm intervenes between them.
 The neck of a spermatozoon is about 0.3 µm long. It is a small constriction just
caudal to the head. Located in the neck are the centrioles proximally (adjacent to
the nucleus) and the basal body distally (adjacent to the middle piece), with a
little amount of cytoplasm.
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 The middle piece of the spermatozoon is the cylindrical portion (7 µm long) just
caudal to the neck. In the centre of this portion is the axoneme (axial bundle or
axial filament) of microtubules. Axoneme consists of a central pair of
microtubules surrounded by nine pairs of microtubules (as occurs in a cilium).
Also associated with it are dynein and radial spokes (which are protein
complexes). External to the axoneme is the mitochondrial sheath. The latter is
formed by mitochondria of the spermatid, which are arranged in a helical pattern
around the axoneme.
 The most caudal part of a spermatozoon is the tail or principal piece. It is a long
process that measures about 40 µm in length and 0.5 µm in diameter. It resembles
a flagellum. In the core of the tail is the axoneme (axial bundle of microtubules),
similar to, and continuous with that of the middle piece. Externally, the tail is
surrounded by the plasma membrane. It is the repeated movement of the tail that
propels the spermatozoon through the reproductive tracts. Spermatozoon moves
at an average rate of 3 mm/minute.
 A mature spermatozoon is only capable of fertilizing an oocyte after exposure to
the female genital tract. This process is called capacitation.
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Figure 21b: Human spermatozoon
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The Ovum (Female Gamete)
Figure 22. Human oocyte
Regarding the ovum, note the following facts:

 At ovulation, female gamete is released as a secondary oocyte, and not as a
mature ovum. The ovum is not formed except fertilization occurs, at which time
the 2nd meiotic division is completed (with formation of the ovum and 2 nd polar
body).
 The ovum is a relatively large cell (about 200 µm in diameter). Its cytoplasm is
termed the vitellus, yolk, or ooplasm; while its nucleus is the germinal vesicle.
The nucleolus of the ovum is termed germinal spot (Fig. 22).
 The cytoplasm (yolk) of the ovum has two parts: (i) the formative yolk, in which
the mitochondria, centrioles, Golgi body, etc, are embedded; and (ii) the
nutritive yolk or deutoplasm.
 The nutritive yolk contains abundant fat droplets, rich in lecithin. This serves as
a source of nourishment to the embryo early in development. In human, the fat
droplets are evenly distributed throughout the cytoplasm; thus, human ovum is
said to be isolecithal.
 The ovum is surrounded by the zona pellucida (a glycoprotein). External to this
are cells that constitute the corona radiata. Just deep to the zona is the plasma
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membrane of the ovum. Deep to this membrane, the cytoplasm of the ovum has
numerous cortical granules (released during cortical reaction).
Gametogenesis
The process that leads to the formation of male and female gametes is referred to as
gametogenesis. The male gamete is the spermatozoon; while the female gamete is the
ovum. In male, the process of gamete formation is spermatogenesis; while in
females, the process is called oogenesis.
Spermatogenesis
Spermatogenesis is the process that leads to the formation of spermatozoa. It occurs
in the seminiferous tubules of the testes, and is under the influence of hormones such
as the androgens and gonadotropins. In man, spermatogenesis proceeds for about 65
days and it occurs in three successive phases: Spermatocytosis, meiosis, and
spermiogenesis (spermateliosis).
Spermatocytosis
During Spermatocytosis,
 Spermatogonia undergo repeated mitotic division so as to maintain a pool.
Spermatogonia exist in different forms (light type A, dark type A and type B
spermatogonia).
 Dark type A spermatogonia differentiate into type B spermatogonia.
 Type B spermatogonia differentiate into primary spermatocytes (16-18 µm). The
latter then commence meiosis.

 Type A spermatogonia (both light and dark) are characterised by the presence of
eccentric nucleoli; while type B spermatogonia have central nucleoli.
 Light type A spermatogonia possess ‘clear nucleoplasm’; while dark type A
spermatogonia have ‘dark nucleoplasm’
Meiosis
During spermatogenesis, meiosis follows Spermatocytosis; and it occurs in two
successive phases (meiosis I and II). In meiosis I (reduction division), each primary
spermatocyte (with diploid chromosomes) divides into two secondary
spermatocytes, each with haploid chromosome number. Each secondary
spermatocyte then undergoes meiosis II to form spermatids. A spermatid has
haploid (23) chromosomes. Thus, each spermatozoon, derived from a spermatid after
spermiogenesis, has 23 chromosomes.
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Note: see cell division (page 15) for more details.
Spermiogenesis (Spermateliosis)
Regarding spermiogenesis, note the following points:

 Spermiogenesis is the process that converts a rounded, immotile spermatid, to an
elongated, highly motile spermatozoon. It is a form of metamorphosis.
 Coalescence of the Golgi apparatus of the spermatid leads to the formation of the
acrosome. The latter occupies the future head of the sperm, and it contains
enzymes (acrosin, hyaluronidase, etc) needed for the fertilization of the ovum.
 The nuclear chromatin of the chromatid becomes highly compacted. This highly
condensed nature of the nucleus is characteristic of a spermatozoon. Together
with the acrosome, the nucleus occupies the head of the developing
spermatozoon. Acrosome overlies the anterior ⅔ of the nucleus.
 The two centrioles occupy the neck of the sperm. They are placed just caudal to
the nucleus. The caudal centriole forms the basal body, from which the axial
fibrils of the middle piece and tail arise.
 Just caudal to the basal body, the mitochondria are arranged in spirals around the
axial fibrils. This region becomes the middle piece of the spermatozoon.
 Just caudal to the middle piece is the tail. This has a core of axial fibrils,
surrounded by the plasma membrane.
 The residual body is the part of the cytoplasm shed off in this process. Residual
bodies are engulfed by Sertoli cells. Thus, lipid contents of Sertoli cells increase
as they phagocytose the residual bodies.
 Spermatids undergo spermiogenesis (spermateliosis), in close intimacy with
Sertoli cells, to form elongated spermatozoa. Spermatozoa are then transported
successively through straight seminiferous tubules, rete testis, efferent ductules
and epididymis. In the latter, spermatozoa attain full motility, and are stored.
Applied Anatomy
 About 10% of spermatozoa have abnormal morphologic features. The head or tail
may be double. The sperm may also be dwarfish or gigantic.
 Abnormal spermatozoa have impaired motility.
Ovarian Cycle
Regarding the ovarian cycle, note these points:

 Ovarian cycle is characterised by monthly cyclic events that occur in the ovaries.
This cycle is under the influence of hormones such as the hypothalamic GnRH
and the hypophyseal gonadotropins (FSH and LH).
 At the beginning of each ovarian cycle, 5-15 primordial follicles begin to mature
under the influence of FSH. Each primordial follicle consists of a primary
oocyte surrounded by a layer of squamous cells; and it matures to form a
primary follicle. The latter consists of the primary oocyte surrounded by the
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zona pellucida; and external to the zona are layers of cuboidal follicular cells
(Fig. 23).
 In each cycle, only one primary follicle usually grows further to form a mature
follicle. Others degenerate to form corpora atretica.
 As the primary follicle grows, a fluid-filled space (antrum) appears in it, and the
primary oocyte becomes eccentric in position. The follicle is now referred to as a
secondary follicle. The granulosa cells that surround the primary oocyte at this
stage altogether form the cumulus oophorus.
 Externally, the secondary follicle is surrounded by the theca folliculi (derived
from the ovarian stroma). The theca folliculi has two portions: theca interna (the
inner vascular layer), and the theca externa (a capsule-like external layer).
Oestrogens are produced by thecal and granulosa (follicular) cells. These
hormones act on the endometrium during the proliferative phase of the menstrual
cycle. They also stimulate the adenohypophysis to produce LH. The theca interna
also produces androgens; and these are converted to oestrogens by follicular cells.
 The final maturation of the ovarian follicles (formation of Graafian follicle)
requires LH, in addition to FSH. Thus, under the influence of these hormones, a
mature (Graafian) follicle is formed from the secondary follicle (Fig. 23). Around
the middle of the cycle, the Graafian follicle forms a swelling on the surface of
the ovary. This follicle now contains a secondary oocyte that is shed at
ovulation.
 After ovulation (release of the secondary oocyte into the peritoneal cavity), the
Graafian follicle is transformed into a corpus luteum (see below).
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Figure 23. The ovarian cycle, showing maturation of follicles
Ovulation
Regarding ovulation, note the following facts:

 Ovulation is the process that results in the release of the secondary oocyte from
the ovary into the peritoneal cavity. It occurs around the middle of the menstrual
cycle (about the 14th day of a 28-day cycle).
 The trigger for ovulation is the sudden LH surge that occurs about 12-24 hours
prior to ovulation. This LH surge is as a result of the high estrogen level in the
plasma.
 Just prior to ovulation, the Graafian follicle undergoes a sudden growth spurt
under the influence of FSH and LH. This mature follicle has a diameter of about
15 mm; and owing to this larger size, the follicle forms a local bulge on the
surface of the ovary. Soon, a small avascular spot – the stigma – appears on the
bulge. The stigma indicates the point where the oocyte will be extruded.
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 As the Graafian follicle is becoming fully mature (just prior to ovulation), the
primary oocyte, which is in the diplotene stage, resumes and completes meiosis I,
thereby forming the secondary oocyte. Ovulation occurs as the secondary oocyte
begins the metaphase stage of meiosis II.
 Extrusion of the secondary oocyte occurs at about the middle of the menstrual
cycle. The factors responsible include (i) increased intrafollicular pressure; (ii)
local weakening and degeneration of ovarian surface, (iii) contraction of the
smooth muscle fibres of theca externa; and possible enzymatic digestion of
follicular wall. The secondary oocyte is shed into the peritoneal cavity.
 Some cumulus oophorus cells (follicular cells), together with the follicular fluid,
are released with the secondary oocyte. After ovulation, follicular cells that
surround the secondary oocyte constitute the corona radiate. Separating the
latter from the membrane of the secondary oocyte is a layer of glycoprotein
called the zona pellucida.
 The ovarian cycle usually persists throughout the reproductive life of a woman. It
ceases at menopause.
Also note the following facts:

 In certain women, ovulation is accompanied by slight abdominal pain. This is
referred to as middle pain or mittelschmerz. It is a result of slight bleeding into
the peritoneal cavity; and it occurs midway through the cycle.
 Ovulation is usually characterised by a sustained rise in basal body temperature;
and this could thus be a symptom of this process.
 Inadequate release of gonadotropins (Gn) could result in inability to ovulate.
However, ovulation may be induced in such women by the use of Gn or an
ovulatory drug (such as clomiphene citrate) that stimulates the release of
hypophyseal Gn. This will result in multiple ovulation; and multiple pregnancy
may ensue. Incidence of multiple pregnancy increases to about 10 folds in such
women.
Corpus Luteum
Regarding the corpus luteum, note these points:

 Just after ovulation, and under the influence of LH, follicular cells of the ruptured
Graafian follicle and cells of the theca interna become polyhedral and
vascularised. They also accumulate a yellowish pigment and are thus called
luteal cells. The ruptured Graafian follicle at this stage is called a corpus
luteum.
 The corpus luteum is a yellowish, vascular, glandular body that produces
progesterone and some oestrogens. Its fate depends on whether the oocyte is
fertilized or not.
 If the oocyte is fertilized, the corpus luteum becomes the corpus luteum of
pregnancy (graviditatis). It is maintained by the human chorionic Gn (produced
by syncytiotrophoblast); and its synthetic activity increases. The corpus luteum
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produces the progesterone needed to maintain pregnancy prior to attainment of

full functional status by the placenta. The corpus luteum is thus indispensable in
the first 20 weeks of pregnancy
 If fertilization, and thus pregnancy, do not occur, a corpus luteum of
menstruation is formed. In this instance, the corpus luteum undergoes gradual
involution and then becomes atretic about 10 days after ovulation, thereby
forming a corpus albicans. Consequently, the levels of progesterone and
oestrogens fall and menstruation follows.
Menstrual Cycle
Regarding the menstrual cycle, note that:

 The menstrual cycle is the monthly cyclic changes that occur in the
endometrium of a reproductively active woman. It commences at puberty (11-13
years) and ends at menopause (48-55 years).
 Oestrogens and progesterone are essential for the control of the menstrual cycle.
 The endometrial changes associated with this cycle proceed simultaneously with
the events of the ovarian cycle (see above)
 The average duration of the menstrual cycle is 28 days (a range of 23-35 days).
The first day of this cycle is the day the first menstrual flow commences.
 The menstrual cycle proceeds in three successive stages: menstrual phase,
proliferative (follicular) phase, and secretory (progestational) phase (Fig. 24).
Phases of the Menstrual Cycle
Regarding the menstrual phase, note the following points:

 The menstrual phase of the cycle spans 3–7 days. The first day of this phase is
the day of commencement of menses, and it also marks the beginning of the
menstrual cycle. About 20-80 ml of blood is lost during this period.
 Involution of the corpus luteum and thus, decreased secretion of hormones,
especially progesterone, is the major trigger of the menstrual phase. As the levels
of progesterone fall, the spiral arteries constrict; endometrial glandular activity
decreases; and ischaemic necrosis occurs in the superficial tissue of the
endometrium. The latter shrinks and its compact and spongy layers begin to
slough, with bleeding of ruptured blood vessels.
 Menses consists of blood from bleeding spiral arteries and dead endometrial
tissue. This is lost through the vagina.
After menstruation, the endometrium is reconstructed from its basal layer. This
occurs during the proliferative phase of the cycle.
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Figure 24. The menstrual cycle showing changes in body temperature and plasma
hormones. The lower part of the chart shows changes in endometrial thickness with
the progression of the cycle
Proliferative Phase (Follicular Phase)
Proliferative phase of the menstrual cycle

 Occurs simultaneously with the maturation of the ovarian follicles; and is under
the influence of oestrogens produced by these follicles.
 Is characterised by the reconstruction of the endometrium (that was sloughed in
the preceding menstrual phase). The compact and spongy layers of the
endometrium are reconstructed from the basal layer. The latter remains intact
during the menstrual phase. Thus, the endometrium becomes 2–3 times thicker at
the end of the proliferative phase (Fig. 24).
 Lasts for about 9 days.
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Secretory Phase (Progestational Phase)
Regarding the secretory phase of the menstrual cycle, note the following points:
 Secretory phase follows the proliferative phase. It begins 2-3 days after
ovulation, and it coincides with the formation and functioning of the corpus
luteum. It lasts for about 13 days.
 Progesterone produced by the corpus luteum is responsible for the endometrial
changes associated with the secretory phase of the menstrual cycle. During this
phase, (i) the endometrium increases markedly in thickness and is velvet (Fig.
24); (ii) the endometrial glands become tortuous, enlarged and laden with
glycogen-rich materials; (iii) the spiral arteries become coiled; and they extend
into the compact layer of the endometrium. Arteriovenous anastomoses also
occur at this stage. If fertilization of the oocyte does not occur, the corpus luteum
involutes and the levels of progesterone and oestrogens drop markedly. This leads
to shrinkage and ischaemic necrosis of the endometrium, with the associated
rupture of the spiral arteries. Blood from the ruptured vessels and tissue debris
from sloughed endometrium are lost as menstrual flow. The first day of menses
marks the beginning of the menstrual cycle, and the cycle repeats itself.
 If fertilization occurs, the corpus luteum is retained, progesterone levels are
maintained; and the endometrium thus remains thick and velvet, in readiness for
the implantation of the embryo. Cleavage of the zygote occurs and the blastocyst
is formed from the morula. About the 6th day post-fertilization, the blastocyst
begins to implant in the endometrium. The uterus is therefore gravid and the
endometrium is said to be in the gestational phase. Human chorionic Gn
produced by the syncytiotrophoblast is responsible for maintaining the corpus
luteum.
Also note the following medical facts:

 Anovulatory menstrual cycles do occur. This could be due to ovarian
hypofunction or the use of oral contraceptives. The menstrual cycle thus occurs
without ovulation.
 Oral contraceptives contain varying amount of oestrogens and progesterone.
When administered, these pills act on the hypothalamus and hypophysis, thereby
inhibiting the release of GnRH, FSH and LH. Thus, owing to the low
concentrations of Gn, ovulation does not occur. Inhibition of ovulation is the
rationale behind the use of oral contraceptives.
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 In an anovulatory cycle, the endometrium does not show much change. Besides,
the proliferative phase of the cycle does not proceed into the secretory phase (as
no corpus luteum is formed). Thus, the endometrium remains in the proliferative
phase till menstruation starts.
 Following the discontinuation of oral contraceptives, ‘normal’ menstrual cycles
resume, and pregnancy could occur. Conception may occur as early as one month
or as late as 12 months following withdrawal of the pills
Oogenesis (Ovogenesis): Formation of the Female Gamete
Regarding oogenesis, note the following:

 Oogenesis is the series of events that results in the formation of mature oocytes
from primordial germ cells.
 Primordial germ cells are derived from the epiblast. They appear in the wall of
the yolk sac by the 3rd week of development; and by the 5th week, they are found
in the developing gonads. They reach the gonads by amoeboid movement.
 Formation of mature oocytes (oogenesis) commences before birth (in utero), and
is completed after puberty.
Prenatal Maturation of Oocytes
Note these points:

 Following their arrival in the developing female gonads (5th week of
development), germ cells differentiate into oogonia. Oogonia then undergo series
of mitosis to form clusters of cells (by the 4th month). Each cluster is surrounded
by a layer of flattened cells (follicular cells) derived from the surface epithelium
of the ovary.
 Mitotic division of oogonia continues till around the 5th month, by which time
some of them have differentiated into larger cells called primary oocytes. At this
point, each ovary has about 7 million germ cells
 By the 7th month of development, most oogonia have degenerated and majority of
the germ cells at this point are primary oocytes. Each of the latter has replicated
its DNA and has commenced the prophase of meiosis I. A primary oocyte and its
surrounding squamous follicular cells constitute a primordial follicle.
 At birth, each ovary has about 1 million primary oocytes. Each of these cells has
started prophase I at this stage. However, the cells suspend their meiotic division
(at diplotene of meiosis I), and instead of preceding to metaphase I, they enter a
dictyotene stage (resting phase).
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Postnatal Maturation of Oocytes
Note that
 Between birth and puberty, most of the primary oocytes become atretic, so that
only about 400,000 are surviving at puberty. Out of these, only about 400 will
mature and be ovulated during the reproductive life of the individual.
 In the postnatal years, primary oocytes remain in the dictyotene stage until
puberty when oocyte maturation resumes. The arrest of oocyte meiotic division
during the dictyotene phase is mediated by oocyte maturation inhibitor (OMI)
produced by follicular cells.
 Between puberty (11–13 years) and menopause (48–55 years), maturation of the
primary oocytes resumes. About 5–15 follicles begin to mature during each
ovarian cycle. This cycle is under the control of the Gn (FSH and LH)
 Under the influence of FSH, the primary oocyte begins to increase in size, while
the flattened follicular cells of the primordial follicle become cuboidal and
stratified. A primary oocyte with its covering of stratified cuboidal cells is called
a primary follicle. Besides, a layer of glycoprotein (zona pellucida) is produced
by the follicular cells and oocyte. This intimately surrounds the primary oocyte
and separates it from the follicular cells.
 As the primary follicle grows, certain cells of the ovarian stroma surround the
follicular cells to form the theca folliculi. Soon, the theca is organised into an
inner theca interna (containing secretory cells) and an outer theca externa,
made of connective tissue with fibroblast-like cells. Cells of the theca interna
secrete oestrogens and progesterone.
 The primary follicle is transformed into a secondary follicle by the appearance of
an antrum that contains follicular fluid. The primary oocyte thus becomes
eccentric in position, and the follicular cells around it constitute the cumulus
oophorus.
 Under the influence of FSH and LH, the secondary follicle matures further. The
antrum increases, and the follicle is now fully mature, and is referred to as the
Graafian follicle (tertiary follicle or mature follicle). It forms a local elevation on
the surface of the ovary.
 The tertiary follicle is formed around the middle of the menstrual cycle. As this
follicle is formed, the primary oocyte completes the 1st meiotic division (just
prior to ovulation; about the 14th day of a 28-day cycle). It forms a secondary
oocyte and the 1st polar body, each with 23 (double-stranded) chromosomes. The
secondary oocyte retains virtually all the cytoplasm, while the 1st polar body has
sparse cytoplasm.
 About 12-24 hours prior to ovulation, there is an LH surge, and this triggers the
release of the secondary oocyte from a ruptured Graafian follicle. This oocyte is
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at the metaphase stage of meiosis II when it is released into the peritoneal cavity.
However, completion of the 2nd meiotic division by the secondary oocyte only
occurs if this cell is fertilized. Otherwise, it degenerates about 24 hours post-
ovulation. If fertilized however, the secondary oocyte completes meiosis II to
form a mature ovum and 2nd polar body, each with haploid (23) chromosomes.

 Incidence of chromosomal anomalies of the gametes increases with increasing
maternal age. Numerical or structural aberration of the chromosome may occur,
giving rise to conditions such as Down’s syndrome, achondroplasia, Klinefelter’s
syndrome, Turner’s syndrome, etc.
 Only one mature Graafian follicle is usually formed during each ovarian cycle.
However, several mature follicles may be formed when ovulation is enhanced by
the use of gonadotropins or a drug such as clomiphene citrate.
Fertilization
Regarding fertilization, note these points:

 Fertilization is the fusion of the gametes (spermatozoon and secondary oocyte)
to form a zygote. This occurs within 24 hours after ovulation (as gametes are not
viable beyond this period).
 The ampullary region of the uterine tube is the usual site of fertilization. This
locally dilated part of the tube is close to the ovary.
 Fertilization proceeds for about 24 hours. However, for the spermatozoon to
penetrate the oocyte, it has to become fully mature by undergoing capacitation
and acrosome reaction.
 Capacitation is a species-specific process that involves the conditioning of
ejaculated sperms; it is mediated by a reaction between fertilizin (produced by the
oocyte) and antifertilizin of the sperm. During this process (which lasts for about
7 hours), a glycoprotein coat and seminal plasma proteins are removed from the
plasma membrane that overlies the acrosomal region of the sperm. This enables
the sperm to undergo acrosome reaction.
 Once capacitation is completed, spermatozoa are ready to undergo acrosome
reaction. The latter is induced by zona proteins; and it involves binding of the
sperm to the zona pellucida. During acrosome reaction, enzymes required to
penetrate the zona pellucida (surrounding the oocyte) are released. These include
acrosin, neuraminidase, zona lysins, etc.
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 Out of about 300 million spermatozoa released, only 300-500 reach the ampullary
region of uterine tube (site of fertilization), and only one eventually fertilizes the
oocyte.
Phases of Fertilization
Fertilization proceeds in phase and these include:

 Phase 1: Passage of capacitated spermatozoon through the corona radiata. This is
enhanced by the release of hyaluronidase from acrosome of the sperm.
 Phase 2: Penetration of zona pellucida. This process is mediated by certain
enzymes of the acrosome, including acrosin, neuraminidase, and esterases. When
the capacitated sperm comes in contact with zona pellucida, acrosome reaction
occurs. This creates perforations in the acrosome of the sperm, resulting in the
release of its enzymes and the penetration of the zona pellucida. Once the zona is
penetrated, zona reaction occurs. Zona reaction is mediated by the release of
lysosomal enzymes from the cortical granules of the oocyte. These enzymes
cause changes in the composition of zona pellucida and the plasma membrane of
oocyte, thus making them impermeable to other sperms
 Phase 3: Fusion of the plasma membranes of oocyte and spermatozoon. Once the
zona pellucida has been penetrated, the cell membrane of the sperm fuses with
that of the secondary oocyte. The head of the sperm enters the cytoplasm of the
oocyte, leaving the plasma membrane outside the oocyte.
Once the sperm has entered the oocyte, the following immediate reactions occur:
 Zona and cortical reactions: Owing to the release of the cortical granules of the
oocyte (with their contents of lysosomal enzymes), the composition of the zona
membrane is altered (zona reaction), making it impermeable to other sperms. The
plasma membrane of the oocyte also becomes impermeable.
 Second meiotic division of the oocyte resumes, and is soon completed, yielding
a mature ovum and a 2nd polar body. The ovum receives all the cytoplasm of the
oocyte. Its chromosomes (22+X) constitute the female pronucleus.
 Formation of the male pronucleus: The nucleus of the sperm enlarges to form
the male pronucleus.
 Metabolic activation of the oocyte: Penetration of the oocyte by the
spermatozoon is one of the factors that activate the egg to undergo post-fusion
development, including cleavage, etc.
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Results of Fertilization
Fertilization results in the following:

 Completion of the 2nd meiotic division of the oocyte, thereby forming a mature
ovum.
 Restoration of the diploid number of chromosomes in the zygote. The zygote
contains genes that differ in some respects from the genetic complement of either
parent. This results from intermingling of chromosomes from the male and
female pronuclei, with the resultant genetic variation (i.e. the child differs in
certain respects from the parents).
 Determination of the chromosomal sex of the embryo. A Y-chromosome-
carrying sperm will produce a male embryo; while an X-chromosome-carrying
sperm will produce a female embryo.
 Metabolic activation of the oocyte. Penetration of the oocyte by the sperm
activates the fertilized egg to undergo post-fusion development, including series
of mitotic division termed cleavage, etc.
Applied Anatomy
Note the following medical tips:

 Pregnancy can be detected as early as the 1st week owing to the presence of an
immunosuppressant protein – early pregnancy factor. This protein is secreted
by cells of the trophoblast and can be detected in the maternal serum as early as
24–48 hours post-fertilization.
 Incidence of dispermy may occur when two sperms fertilize an oocyte.
Normally, only a sperm penetrates an egg. However, when dispermy occurs, a
triploid embryo (with 69 chromosomes) is conceived. Such embryos usually
abort spontaneously or are delivered as still birth. Some die shortly after birth.
Polyspermy is prevented through cortical and zona reactions.
 Parthenogenesis is the process whereby an unfertilized egg undergoes cleavage
and subsequent development. This may occur in certain animals (e.g. rabbits), but
is rare in human.
 Infertile couples may opt for assisted reproductive techniques. These include in
vitro fertilization (IVF), gamete intrafallopian transfer, intracytoplasmic sperm
injection, zygote intrafallopian transfer, etc.
 Several means of contraception are available (to prevent or arrest pregnancy) (see
below).
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The following are methods of contraception:

 Use of oral contraceptive pills. These pills contain oestrogen and progestin
(progesterone analogue). The pills inhibit the release of pituitary Gn (FSH and
LH). Thus, they prevent ovulation but allow menstruation. They are administered
for 21 days and then stopped to allow menstruation.
 Use of male and female condoms, diaphragm, contraceptive sponge and cervical
cap. These serve as barriers to the passage of sperms.
 Vasectomy and tubal ligation. In vasectomy, the vas deferens is excised or tied
(in males). Tubal ligation involves tying up of uterine tubes.
 Use of the intra-uterine devices (IUDs). These are placed in the uterine cavity
where they may interfere with implantation.
 Use of depo provera and RU 486. The former is injected intramuscularly to
prevent ovulation for 2-3 months. It could also be implanted subdermally to
prevent pregnancy for up to 5 years. Depo provera is a progestin compound. RU
486 acts as an antiprogesterone agent that is capable of causing abortion by
initiating menstruation. It is administered within 2 months of the previous
menses.
Cleavage
Cleavage is the process that transforms a relatively large unicellular zygote into a
multicellular embryo (morula).
Regarding cleavage, note the following points:

 Cleavage follows fertilization and it occurs by mitosis.
 As cleavage proceeds, the cytoplasm-nucleus ratio of the resultant cells
(blastomeres) becomes increasingly reduced.
 The first mitotic division of the zygote yields two blastomeres; this division
begins about 30 hours after fertilization.
 At the 8- or 9-cell stage (i.e. after the 3rd cleavage), blastomeres form a compact
ball of cells through a process called compaction. At this stage, the cells are
closely in contact with each other (by forming tight junctions); and this enhances
cell-cell interaction. Compaction also brings about the segregation of the inner
cells that form the inner cell mass. These cells communicate via gap junctions.
 At about three days after fertilization, the embryo has 12-16 cells and is referred
to as the morula (owing to its resemblance to a mulberry; Fig. 25A.). Cells of the
morula are segregated into a central group (inner cell mass or embryoblast). This
is surrounded by a layer of cells that constitute the outer cell mass (trophoblast).
 By the end of the 3rd day after fertilization, the spherical morula enters the uterine
cavity for further development.
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Also note the following medical facts:

 If the two cells that arise from the first mitotic division of the zygote develop
independent of each other, monozygotic twins will be formed.
 Early in cleavage, non-dysjunction or anaphase lag of chromosomes may occur,
thereby producing an embryo with two (or more) cell lines, with each cell line
having a different number of chromosomes. This condition is referred to as
mosaicism, and the individual is a mosaic (e.g. mosaic Down syndrome).
A B
Figure 25. A. Morula; B. Blastocyst
Blastogenesis (Formation of the Blastocyst)
Regarding blastogenesis, note the following points:

 Blastogenesis is the process that converts the morula to a fluid-filled blastocyst
 Once the morula enters the uterine cavity (end of 3rd day of development), fluid
passes from the uterine cavity through the zona pellucida into the interstices
between the cells of the morula. Subsequently, a single fluid-filled cavity
(blastocyst cavity) is formed and the embryo is then referred to as a blastocyst
(Fig. 25B).
 The blastocyst is made up of a blastocyst cavity (blastocoele), an inner cell
mass or embryoblast (located at the embryonic pole), and an outer cell mass or
trophoblast. The latter is a layer of cells that surrounds the inner cell mass and
blastocyst cavity. External to the trophoblast is a layer of glycoprotein called
zona pellucida.
 The inner cell mass forms the embryo, while the outer cell mass contribute to the
formation of the placenta.
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 Once the blastocyst has been formed, the zona pellucida begins to degenerate.
This allows the blastocyst to come in direct contact with the endometrium, into
which it implants.
 Implantation of the blastocyst commences about the 6th day of development (see
below).
Implantation
Implantation
 Is the embedding of the conceptus in the endometrium. The blastocyst usually
embeds in the posterior uterine wall, closer to the fundus than the cervix. It may
however also embed elsewhere.
 Usually begins by the 6th day after fertilization (ovulation).
 Involves the shedding of the zona pellucida, an important factor in this process
 Also involves the eroding action of enzymes produced by the
syncytiotrophoblast of the blastocyst
 Continues into the 2nd week of development when it is completed.
Note that ectopic implantation of the embryo

 Occurs outside the uterus, usually in the uterine tube (tubal pregnancy).
 May lead to the rupture of the uterine tube after about 8 weeks of tubal
pregnancy. In this instance, severe bleeding occurs from damaged vessels.
 May occur on the surface of the ovary (primary ovarian pregnancy), though this
is relatively rare.
 May also occur in the peritoneal cavity.
Note: placenta praevia is a condition in which the embryo implants close to the
cervical internal os, such that the placenta is sited, and thus, blocks this opening.
Surgical delivery of the baby may be required to prevent fatal bleeding resulting from
the rupture of the placenta during vaginal birth.
Second Week of Development
Early in the second week of development,

 The amniotic cavity is formed and is bounded by the epiblast and amniocytes.
 The inner cell mass forms two layers – epiblast and hypoblast.
 The exocoelomic (Heuser’s) membrane develops from the hypoblast.
 The primary yolk sac is formed. This is bounded by the exocoelomic membrane
and hypoblast.
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 Implantation of the conceptus is still in progress.

 Lacunae (spaces) appear in the syncytiotrophoblast (though they are void of
blood at this stage).
In the latter part of the second week of development,

 The conceptus (embryo and its membranes) is completely embedded in the
endometrium
 Primitive uteroplacental circulation is established to nourish the embryo
 The extraembryonic mesoderm is formed from the cells of the yolk sac. This
lines the inner aspect of the cytotrophoblast.
 The extraembryonic coelom (chorionic cavity) arises. This separates the
splanchnic and parietal layers of the extraembryonic mesoderm from each other.
 The definitive (secondary) yolk sac develops
 The primary chorionic villi arise from the extraembryonic mesoderm and its
overlying trophoblast
 The prechordal plate develops in the hypoblast. This plate marks the head
region of the embryo.
 The bilaminar embryo is ultimately suspended in the chorionic cavity by the
connecting stalk. This cavity is bounded by the chorionic sac.
Third Week of Development
During the 3rd week, the following major events occur:

 Gastrulation, the establishment of the trilaminar embryo.
 Neurulation, formation of the neural tube (primordium of the central nervous
system)
 Angiogenesis, the formation of blood cells and vessels. The primitive heart also
forms and begins to function by about the 21st day of development
 Formation of the tertiary chorionic villi (a component of the placenta).
During gastrulation,
 The primitive streak is formed. This plays a major role in the establishment of
the trilaminar embryo (consisting of the endoderm, mesoderm and ectoderm)
 The intraembryonic endoderm, mesoderm and ectoderm are formed from cells
of the epiblast of the bilaminar embryo.
 The definitive notochord is also formed. This serves as the skeleton of the
trilaminar embryo.
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Formation of the Primitive Streak
The primitive streak

 Becomes visible by the 15th day post-ovulation, on the dorsum of the epiblast.
The primitive streak is formed by the proliferation of the cells of the epiblast to
form a median longitudinal elevation. Its appearance marks the beginning of
gastrulation.
 Is located on the dorsal aspect of the embryo, closer to the caudal end. It appears
as a median longitudinal elevation, with a median groove – the primitive groove.
 Has an expanded cranial end termed the primitive node, which bears a central
primitive pit
 Has highly proliferative cells with a capacity to migrate widely.
 Disappears by the end of the 4th week. However, it may persist till birth, thereby
forming a tumor – sacrococcygeal teratoma.
 Is the source of the primordial germ cells that later invade the developing
gonads
As the cells of the epiblast ingress through the primitive groove,

 The intraembryonic mesoderm is formed. This lies between the hypoblast and
the epiblast.
 The intraembryonic endoderm is established as cells of the hypoblast are
displaced by the ingressing cells of the epiblast.
 The cardiogenic plate is formed in the midline, just cranial to the prochordal
plate. This plate forms the heart primordium.
 The remaining cells of the epiblast transforms into the ectoderm.
Formation of the Notochord
The definitive notochord

 Forms the skeleton of the trilaminar embryo, and it is the basis of the axial
skeleton. It stretches longitudinally between the primitive pit and the prochordal
plate.
 Is derived from those cells of the epiblast that traverse the primitive pit to reach
the prochordal plate, in the 3rd week.
 Appears first in the form of a hollow notochordal process; and then a solid
notochordal plate. The latter is transformed into the definitive notochord.
 Becomes the nucleus pulposus of the adult intervertebral disc. The larger part of
the notochord however disappears.
 Induces the development of the neural plate, thereby initiating neurulation.
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Cells of the epiblast give rise to the following:

 Intraembryonic mesoderm, the middle germ layer of a trilaminar embryo
 Intraembryonic endoderm, the innermost layer of the trilaminar embryo
 Intraembryonic ectoderm, the outermost layer of the trilaminar embryo
 Definitive notochord, the skeleton of the trilaminar embryo,
 Primordial germ cells, the source of the male and female gametes
 Cells of the central nervous system, derived from the neuro-ectoderm
 Heart and the pericardium
Neurulation
Neurulation
 Is the process that leads to the formation of the neural tube (primordium of the
CNS). It requires the inductive influence of the notochord and paraxial
mesoderm.
 Begins in the 3rd week of development; and is completed in the 4th week.
 Involves the proliferation of ectodermal cells that overly the notochord
longitudinally, in the median plane. These proliferating cells form the neural
plate.
 Also involves the formation of the neural groove from the neural plate. The
neural groove is a longitudinal furrow bounded on each side by a neural fold. It
lies dorsal to the notochord.
 Proceeds as the two neural folds fuse over the neural groove (in the 3rd week),
starting in the hindbrain region. Two neuropores are therefore formed in the
process: rostral and caudal neuropores. Rostral neuropore usually closes by the
25th day, while the caudal neuropore closes by the 27th day.
Neural Crest
Cells of the neural crests

 Are of ectodermal origin. They occupy the junction between the general ectoderm
and the neural folds.
 Lose their epithelial (compact) arrangement to become mesenchymatous. Hence,
they constitute the ectomesenchyme.
 Form a large part of the peripheral nervous system, owing to their ability to
migrate over a wide range.
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Derivatives of the neural crests are numerous. They include:

 Dorsal root ganglia of spinal nerves.
 Ganglia of cranial nerves V, VII, IX and X.
 Autonomic ganglia, e.g., those of the sympathetic chains, and those in the wall
of the gut.
 Cell of the adrenal medulla that produce the catecholamines (e.g., epinephrine).
 Muscles, connective tissue and bones of the head.
 Melanoblasts of the skin.
 Leptomeninges (arachnoid and pia maters) and Schwann cells (that form myelin
of peripheral nerves).
 Odontoblasts (cells that give rise to the dentine of the teeth).
Somites
Regarding the formation of somites, note that

 Intraembryonic mesoderm lies adjacent to the notochord as paraxial mesoderm,
in the 3rd week.
 Cells of the paraxial mesoderm give rise to small bilaminar cylinders termed
somatomeres. Cells of somatomeres are tightly compacted.
 The 1st pair of somatomeres lies adjacent to the prochordal plate, in the future
head region. By the 8th somatomere stage, somites begin to form. Somites are
cuboidal blocks of cells
 Each somite has a temporal cavity called myocoele
Somites
 First appear in the occipital region by the 3rd week of development. Additional
pairs appear cranial and caudal to the first one; and they continue to form until
the 5th week. Somites develop roughly at the rate of 3 pairs per day.
 Are 35 pairs in all by the 30th day of development; and up to 44 pairs by the end
of the 5th week. They are arranged in a longitudinal pattern just adjacent to the
neural tube.
 Contain epitheloid cells that later become mesenchymatous.
 Contribute largely to the formation of the axial bones and their associated
muscles
 Give rise to the sclerotome (from its ventromedial wall); and to the
dermomyotome (from its dorsolateral wall).
 Can be used to estimate the age of the embryo (during the 4th week).
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Lateral Plate Mesoderm
Following the formation of the lateral plate mesoderm,

 The intraembryonic coelom is formed
 The intraembryonic somatopleuric mesoderm also forms beneath the
ectoderm.
 The intraembryonic splanchnopleuric mesoderm forms around the developing
gut.
 The intraembryonic somatopleuric mesoderm becomes continuous with the
mesoderm over the amnion.
 The intraembryonic splanchnopleuric mesoderm becomes continuous with the
mesoderm over the yolk sac.
 The intra- and extraembryonic coeloms become continuous with each other.
Intermediate Mesoderm
The intermediate mesoderm

 Is derived from cells of the coelomic epithelium. It is present in the early somite
stage
 Is found from the 6th pair of somite caudally
 Does not show segmentation (when compared with the paraxial mesoderm)
 Forms the permanent nephric tubules in its caudal part; hence, it plays a major
role in the formation of the excretory units of the kidneys.
 Also gives rise to the mesonephric duct (the primordium of the male genital
ducts)
Early Development of the Vascular System

During the formation of blood cells and vessels,
 Mesodermal cells of the conceptus differentiate into angioblasts (blood-forming
cells)
 Angioblasts aggregate to form several blood islands, first in the wall of the yolk
sac (by the 3rd week). Shortly thereafter, blood islands also appear in the chorion
and body stalk.
 Several blood islands are linked up to form primitive blood vessels.
 Some cells of the blood islands also give rise to primitive blood cells.
 Formation of blood cells begins within the embryo in the 5th week of
development; and this proceeds rapidly through the embryo.
 It is initially difficult to differentiate arteries and veins (as blood flows in both
directions at this early stage).
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 Blood-forming cells (angioblasts) invade all mesenchymal tissue of the embryo

(except brain tissue)
Formation of Villi
Note that
 Primary chorionic villi arise in the latter part of the 2nd week. They consist of
cores of cytotrophoblast surrounded by the overlying syncytiotrophoblast.
 Secondary chorionic villi possess cores of mesenchyme, surrounded by the
cytotrophoblast and syncytiotrophoblast. They arise early in the 3rd week.
 Tertiary chorionic villi are formed later in the 3rd week as blood vessels invade
the mesenchymal core of secondary villi. They are designated as stem tertiary
villi and branch tertiary villi.
 Stem tertiary villi extend from the chorion to the cytotrophoblastic shell. They
attach the embryo to the endometrium.
 Branch tertiary villi arise from the stem villi. They play active roles in the
exchange of materials between maternal and foetal circulation.
Germ Layers and their Derivatives
Endoderm
The endoderm of the embryo

 Is derived from cells of the epiblast that ingress through the primitive groove (to
replace the cells of the hypoblast)
 Consists of flattened cells. These are located beneath (ventral to) the mesoderm
and notochord
 Forms the roof of the secondary yolk sac
Derivatives of the endoderm include:

 Epithelium of the gut, except the distal part of the anal canal
 Parenchyma of the liver, pancreas and intestinal glands
 Parenchyma of the thyroid and parathyroid glands
 Epithelial cells of the palatine tonsils.
 Epithelial lining of the auditory tube, tympanic cavity and tympanic antrum
 Epithelial lining and glands of the respiratory tract
 Epithelial lining of the urinary bladder and urethra
 Epithelium of the upper part of the vagina
 Parenchyma of the prostate and urethral glands
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General Surface Ectoderm
Derivatives of the general surface ectoderm include:

 Epithelial lining of parts of the buccal cavity
 Anterior lobe of the hypophysis cerebri (pituitary gland). This arises as
Rathke’s pouch from the roof of the primitive pharynx.
 Lens of the eye, derived from the lens placode
 Enamel of the tooth
 Epithelial cells and glands of the nasal cavities and paranasal sinuses
 Epithelial cells of the external acoustic meatus
 Parenchyma of the salivary, sebaceous, sweat and mammary glands
 Epidermis of the skin and its appendages such as nail, hair, etc
 Epithelial linings of the distal parts of the anal canal and urethra
Neuroectoderm
Derivatives of the neuroectoderm include:

 The central nervous system (CNS) (brain and spinal cord)
 Cranial nerves that attach to the brain.
 Glial cells (astrocytes and oligodendrocytes) of the CNS, except microcytes
 Lower motor neurons of the spinal cord
 Neuron of the retina
Intraembryonic Mesoderm
Derivatives of the intraembryonic mesoderm include:

 Bones of the axial skeleton
 Most skeletal muscles of the body
 Dermis of the skin
 Fibrous pericardium of the heart
 Smooth muscle fibres and connective tissue of viscera
 The metanephros that forms the permanent kidney
 Blood vessels of the body (consisting of the tunica intima, tunica media and
tunica adventitia)
 Blood cells (erythrocytes, leucocytes, and thrombocytes)
 Uterus and uterine tubes (from the paramesonephric ducts)
 Larger parts of the male genital tract (except the distal portion)
 Stroma (connective tissue) of glands.
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 Serous membranes (peritoneum, pleura and serous pericardium) of body cavities

 Cells of the adrenal cortex.
Folding of the Embryo
Folding of the embryo

 Occurs as a result of rapid development of the neural tube and the somites during
the period of organogenesis
 Results in the conversion of a flat piriform embryo to a cylindrical one. It also
leads to the separation of the intra- and extra-embryonic coeloms from each
other; and of the gut tube from the yolk sac.
 Includes the head fold, tail fold and lateral folds.
Head Fold
The head fold

 Forms as a result of the rapid development of the forebrain.
 Re-positions the developing brain such that it becomes the most cranial structure
of the embryo
 Re-positions the oropharyngeal membrane such that it lies caudal to the
forebrain. The former separates the stomodeum from the primitive gut.
 Leads to the formation of the foregut from the embryonic endoderm and the
endoderm of the yolk sac.
 Re-positions the primitive pericardium such that it lies ventral to the heart. The
latter and the pericardium then lie ventral to the foregut.
 Also re-positions the septum transversum so that it lies caudal to the primitive
pericardium.
Tail Fold
The tail fold

 Is formed as a result of the rapid development of the spinal cord
 Re-positions the cloacal membrane such that it lies cranial to the spinal cord
 Also re-positions the primitive streak such that it lies caudal to the cloacal
membrane
 Incorporates the allantois into the cloaca; and leads to the formation of the
hindgut from the embryonic and yolk sac endoderm.
 Brings the connecting stalk onto the ventral aspect of the embryo.
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Lateral Folding of the Embryo
Lateral folding of the embryo

 Occurs as a result of the rapid development of the somites.
 Gives rise to the anterolateral body wall of the embryo.
 Leads to the formation of the midgut from the intraembryonic mesoderm and the
endoderm of the yolk sac.
 Constricts the yolk sac to form the vitelline duct.
CHAPTER 6: GROSS ANATOMY OF THE RESPIRATORY SYSTEM

The respiratory system can be divided structurally into upper and lower
respiratory tracts. Structures included in the upper respiratory tract are the nose,
pharynx and associated structures. The lower respiratory tract includes the larynx,
trachea, bronchial tree and lungs. For highlights of the nose, pharynx and larynx, see
volume 2 of this book.
Trachea (Windpipe)
The trachea
 Is the rigid tube that connects the larynx to the main (principal) bronchi (Fig. 26).
It lies partly in the neck and partly in the thorax.
 Is mainly a midline structure, though it deviates to the right near its termination
 Commences above at the lower border of the cricoid cartilage (at C6); and ends
below at the sternal angle of Louis (at T4/T5). It may reach as far down as the 6 th
thoracic vertebra (T6) in deep inspiration, partly owing to its ability to extend
 Has 16–20 C-shaped rings of hyaline cartilage. The concavity of these cartilages
face posteriorly and they keep the trachea patent. The last cartilage is keel-like,
and is referred to as the carina.
 Possesses no cartilages in its posterior part where it adjoins the esophagus. This
allows the latter to expand during deglutition.
 Is somewhat moveable and may adjust its length in response to respiratory
movement.
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Dimensions of the Trachea
Note that the trachea

 Measures is 4 cm in length at birth; and 9-15 cm in length in adult human
 Has an external diameter of 2 cm in adult males and 1.5 cm in adult females.
 Has a maximum internal diameter of 3 mm in infants; and 12 mm in adults.
 Has an internal diameter (in mm) that corresponds to age (in years) during
childhood
 Has a larger diameter in cadavers than in the living.
Relations of the Trachea
Cervical part of the trachea is related anteriorly to the following:

 Pretracheal fascia (below the isthmus of thyroid gland)
 Isthmus of thyroid gland. This lies transversely across 2nd-4th tracheal rings.
 Remains of the thymus, jugular arch, sternothyroids and sternohyoids, superficial
and investing layers of cervical fasciae, and the skin.
 Inferior thyroid vein and (occasionally) thyroidea ima artery (below the level of
isthmus of thyroid gland)
 Brachiocephalic trunk and left brachiocephalic vein (in children)
 Arterial anastomoses formed by the superior thyroid arteries, just above the
isthmus of thyroid gland.
 Tracheal lymph nodes that drain the trachea and adjoining structures.
Posterior relations of the cervical part of the trachea include:

 Cervical part of the esophagus, which lies directly behind it
 Recurrent laryngeal nerves (in the groove between esophagus and trachea)
 Some branches of inferior thyroid artery
 Vertebral column
Laterally, cervical part of the trachea is related to:

 Right and left lobes of the thyroid gland. Each lobe reaches as far down as the
level of the 5th or 6th tracheal ring
 Carotid sheath. This is located posterolateral to the lobe of thyroid gland, and
contains the common carotid artery, internal jugular vein and vagus nerve
 Inferior thyroid artery. This ascends from the thyrocervical trunk.
- 110 -
Relations of the Thoracic Part of the Trachea
Anterior relations of the thoracic part of the trachea include:

 Manubrium sterni, which bounds the superior mediastinum anteriorly
 Lower part of the inferior thyroid vein, which drains the upper part of the
trachea
 Brachiocephalic trunk and left common carotid artery. These arise from the
aortic arch
 Left brachiocephalic vein. This which crosses to the right of the midline, where
it joins the right brachiocephalic vein to form the superior vena cava (behind the
right 1st costal cartilage)
 Remains of the thymus
 Deep cardiac plexus of nerves. This lies anterior to tracheal bifurcation and
supplies the heart
 Aortic arch and some lymph nodes (into which the trachea and adjacent
structures drain)
 Origins of the sternothyroids and sternohyoids.
Posterior relations of the thoracic part of the trachea include:

 Esophagus, which lies directly behind it
 Vertebral column and its anterior longitudinal ligament
Located to the right of the thoracic part of the trachea are the following:
 Right pleural cavity and the right lung
 Superior vena cava (SVC). This enters the right atrium at the level of the right
3rd costal cartilage
 Right brachiocephalic vein, which joins the left vein at the level of the right 1st
costal cartilage, to form the SVC.
 Azygos vein, which ascends over the vertebral column, on the right of midline. It
ends by arching forwards over the right root of the lung, to join the SVC at the
level of the right 2nd costal cartilage.
 Right vagus nerve, which descends behind the right root of the lung.
Left relations of the thoracic part of the trachea include:

 Aortic arch, which passes backwards to the lower border of T4, where it
continues with the descending aorta (to the left of the midline)
 Left recurrent laryngeal nerve. This curves backwards, round the aortic arch,
to ascend to the neck (between the trachea and the esophagus)
 Left subclavian artery, which arises from the aortic arch
- 111 -
 Left common carotid artery, which ascends to the neck, from the aortic arch
Blood Supply and Lymphatic Drainage of the Trachea
The trachea
 Receives arterial supply from the inferior thyroid arteries. These are branches
of the thyrocervical trunks
 Also receives arterial blood from the bronchial arteries. These arise from the
descending thoracic aorta, and supply the lower part of the trachea
 Is drained by the inferior thyroid veins, which join the respective
brachiocephalic veins. However, these veins may unite to form a single vein
which usually ends in the left brachiocephalic vein
 Drains into the paratracheal and pretracheal nodes.
Innervation of the Trachea
The trachea
 Receives sensory fibres from the recurrent laryngeal nerves. These supply its
mucosa
 Receives parasympathetic fibres from the vagus nerves; and these are
secretomotor to tracheal glands.
 Receives sympathetic fibres from the sympathetic chains. These fibres produce
vasoconstriction of tracheal vessels, thereby reducing the secretory activity of
tracheal glands.
Applied Anatomy of the Trachea

 The trachea may be constricted when aortic aneurysm occurs in its
neighborhood.
 Abnormal enlargement of the thyroid gland and thymus may also compress the
trachea
 When an object obstructs the larynx, the trachea may be incised in the midline,
above the isthmus of the thyroid gland (high tracheotomy); or at the level of the
6th or 7th tracheal ring, below thyroid isthmus (low tracheotomy). A tube could
then be introduced to enhance ventilation (tracheostomy).
 Greater risk is associated with a low tracheotomy owing to the possibility of
excising the inferior thyroid vein, thyroidea ima artery (when present), left
brachiocephalic vein or the brachiocephalic trunk (in children).
- 112 -
 The common carotid artery and recurrent laryngeal nerves are at risk during
tracheotomy
 Biopsies may be taken and the interior of the trachea examined during
bronchoscopy
 Foreign bodies and fluid may also be removed from the trachea with the aid of a
bronchoscope.
Bronchi
Bronchi exist as:

 Principal bronchi that arise from the trachea at the level of the sternal angle (Fig.
26)
 Secondary or lobar bronchi that arise from the principal bronchi and supply the
lobes of the lungs
 Tertiary or segmental bronchi that arise from the secondary bronchi and supply
the bronchopulmonary segments of the lungs
 Series of smaller tubes that branch repeatedly to supply the lungs
The right principal bronchus

 Is shorter and wider than the left principal bronchus
 Forms an angle of 1550 with the trachea, from which it arises
 Is 2.5 cm long; this is half the length of the left principal bronchus
 Is the more common site for the lodgment of objects that enter the trachea
 Is related anteriorly to the SVC, ascending aorta, right pulmonary artery and
veins. It lies below the arch of the Azygos vein
 Enter the hilum of the right lung medial to the oblique fissure
 Gives off a right superior lobar (eparterial) bronchus before it reaches the hilum
of the right lung. It ends by diving into middle and inferior lobar bronchi at the
hilum of the right lung.
 Is easier to approach surgically than the left, which is closer to the aorta.
- 113 -
Figure 26. Trachea, main bronchi, lobar bronchi and segmental bronchi (B1–B10).
Left principal bronchus
The left principal bronchus

 Is narrower and longer than the right principal bronchus
 Measure 5 cm in length (double the length of the right one)
 Makes an angle of 1350 with the trachea. Thus, it is more transversely-disposed
than the right one.
 Enters the root of the left lung opposite the T6 vertebra
 Is related posteriorly to the esophagus (at T5), thoracic duct, and descending
thoracic aorta. It lies below the aortic arch
 Lies initially behind and then below the left pulmonary artery
 Is situated behind and just above the plane of the transverse sinus of the heart
 Ends by dividing into the left superior and inferior lobar bronchi.
Secondary (Lobar) Bronchi
The secondary bronchi
- 114 -
 Arise from the primary bronchi. They are usually three on the right and two on
the left (Fig. 26)
 Enter the lungs through the hila of these organs. Here, they all lie below the
pulmonary arteries, except the eparterial bronchus, which enters the hilum
above the right pulmonary artery.
 Supply a lobe of the lungs each. Here, they end by dividing into series of smaller
tubes called segmental bronchi.
The right superior lobar bronchus (eparterial bronchus)

 Arises from the lateral aspect of the right principal bronchus (Fig. 26); it passes
superolaterally, above the level of the right pulmonary artery
 Is the highest-placed structure in the hilum of the right lung
 Ends about 1 cm from its origin by dividing into 3 segmental bronchi: apical,
anterior, and posterior segmental bronchi (Fig. 26). These supply the
respective bronchopulmonary segments of the superior lobe of the right lung.
The middle lobar bronchus

 Arises from the anterior aspect of the right principal bronchus, 2 cm distal to the
origin of eparterial bronchus
 Passes anterolaterally through the middle lobe of the right lung
 Ends by dividing into medial and lateral segmental bronchi, which supply the
respective bronchopulmonary segments of the middle lobe of the right lung.
The right inferior lobar bronchus

 Is the continuation of the right principal bronchus, beyond the origin of the
middle lobar bronchus
 Gives rise to the superior, medial basal, lateral basal, anterior basal and
posterior basal segmental bronchi. These supply the respective
bronchopulmonary segments of the inferior lobe of the right lung.
 May also give rise to a subsuperior segmental bronchus in about 50% of
individuals. This supplies a small segment of the right lung between the superior
and posterior basal segments.
The left superior lobar bronchus

 Arises from the anterolateral part of the left principal bronchus
 Has two main divisions: upper and lower (lingular) divisions. These correspond
to the right superior and middle lobar bronchi respectively.
- 115 -
 Supplies the apical, anterior and posterior bronchopulmonary segments of the

superior lobe of the left lung through its upper division.
 Also supplies the superior and inferior lingular bronchopulmonary segments (of
the lingula) of the superior lobe of the left lung through its lower (lingular)
division.
The left inferior lobar bronchus

 Is the continuation of the left principal bronchus
 Divides in the same manner as does the right inferior lobar bronchus
 Gives rise to the left superior segmental bronchus from its posterior aspect.
This supplies the superior bronchopulmonary segment of the left inferior lobe.
 Also gives rise to the left anterior basal and medial basal segmental bronchi
via a common tem. These supply bronchopulmonary segments of the same name
(in the inferior lobe of the left lung)
 Is also the source of the left posterior basal and lateral basal segmental
bronchi that arise via a common stem. They supply bronchopulmonary segments
of the same name in the inferior lobe of the left lung.
 May give rise to a subapical segmental bronchus similar to that of the right
side, in about 30% of individuals.
The Bronchioles

 Each segmental (tertiary) bronchus divides repeatedly and dichotomously to
produce several generations of smaller tubes termed bronchioles. These exist in
different categories.
 Terminal bronchioles lead into respiratory bronchioles
 Respiratory bronchioles lead into alveolar ducts, which in turn lead into the
atria
 The atria end in the alveoli or air sacs. Most of these structures are microscopic.
Roots of the Lungs
The roots of the lungs

 Consist of structures that connect the lungs to the mediastinum. Thus, these
structures supply the lungs; they enter each lung through its hilus.
 Are each invested by a sleeve of pleura.
 Extend from T5–T7.
- 116 -
Structures in each root of the lung include:

 Principal bronchus, the most posterior major structure. The bronchial arteries
pass to the lung behind the principal bronchus
 Superior pulmonary vein, the most anterior major structure.
 Inferior pulmonary vein, the most inferiorly-placed structure.
 Pulmonary artery, located between the superior pulmonary vein anteriorly and
the principal bronchus posteriorly
 Pulmonary plexuses of nerves that innervate the lung
 Bronchial arteries. These supply the trachea, bronchi, and lungs with
oxygenated blood
 Bronchopulmonary lymph nodes and vessels that drain the lungs and bronchi
 Associated loose connective tissue that occupies the interstices of the above
organs.
Relations of the Root of the Lung
Relations of the root of the lung include the following:

 Anteriorly: Phrenic nerve, pericardiacophrenic vessels, and anterior pulmonary
plexus of nerves
 Posteriorly: vagus nerve and posterior pulmonary plexus of nerves. Additional
posterior relations include SVC on the right; and descending thoracic aorta on the
left
 Inferiorly: pulmonary ligament
 Superiorly: arch of azygos vein on the right; and arch of the aorta on the left.
Vertical Disposition of Structures in the Root of the Lung
In the root of the right lung,

 The right superior (eparterial) bronchus is the highest-placed structure
 The right pulmonary artery lies immediately below the eparterial bronchus
 The right principal bronchus lies below the pulmonary artery
 The inferior pulmonary vein is the lowest-placed structure. It lies adjacent to
the pulmonary ligament
In the root of the left lung,

 The left pulmonary artery is the highest-placed structure (not the principal
bronchus)
 The left principal bronchus lies immediately below the pulmonary artery
- 117 -
 The left inferior pulmonary vein is the lowest-placed structure. It also lies
adjacent to the pulmonary ligament
Pleura
Each pleura
 Is a serous membrane that invests the lung and lines the structures which
surround it
 Consists of two layers. The visceral pleura intimately invests the lung and dips
into its fissures; while the parietal pleura lines the thoracic wall, diaphragm and
mediastinum.
 Encloses, between its layers, a closed ‘potential space’ termed the pleural cavity.
This cavity contains a thin film of serous fluid for lubrication.
Visceral (Pulmonary) Pleura
The visceral pleura

 Intimately invests the lung and cannot be dissected or separated from it. It is
continuous with the parietal pleura around the root of the lung
 Dips deep into the fissures of the lung, thereby investing individual lobes. It
makes the surface of the lung appear smooth and slippery (Fig. 27)
 Is absent where the pleura is reflected downwards as pulmonary ligament; and
also at the hilum of the lung, where structures enter and leave the lung.
 Has similar blood supply, lymph nodes and innervation as the lung. Hence, it
nerve fibres are autonomic.
Parietal Pleura
The parietal pleura

 Bounds the pleural cavity externally and separates it from the surrounding
structures
 Line the ribs and intercoastal spaces as costal pleura; and the mediastinum as
mediastinal pleura
 Lines the thoracic surface of the diaphragm as diaphragmatic pleura; and the
apex of the lung as cervical pleura
 Comes in contact with the opposite parietal pleura behind the manubrium sterni
 Is reflected in certain regions to form the lines of pleural reflection (see below)
 Has different blood supply, lymph vessels, and innervation compared to the lung
and visceral pleura
- 118 -
 May become attached to the visceral pleura by fibrous tissue following

inflammatory changes
Costal Pleura
On each side, the costal pleura

 Is the strongest part of the parietal pleura. It lines the ribs, costal cartilages,
intercoastal spaces, sternum, transversus thoracis muscles, and sides of the bodies
of thoracic vertebrae (Fig. 27).
 Is separated from the thoracic wall by the endothoracic fascia of areolar tissue.
Hence, it can be readily separated from the thoracic wall in living persons
 Has the same innervation, blood supply and lymphatic draining as the thoracic
wall. Its innervation is somatic.
 Becomes reflected as the mediastinal and diaphragmatic pleurae, along the line of
pleural reflection (see below)
Line of Pleural Reflection
The line of pleural reflection

 Occurs where the parietal pleura lining a surface becomes reflected onto another
surface (Fig. 27)
 Is sharp anteriorly where the costal pleura is reflected to join the mediastinal
pleura as the costomediastinal (or sternal) line of pleural reflection.
 Is also sharp inferiorly where the costal pleura is reflected onto the
diaphragmatic pleura as the costodiaphragmatic (or costal) line of pleural
reflection.
 Is blunt posteriorly where the costal pleura is reflected forwards over the
thoracic vertebrae to join the mediastinal pleura as the vertebral line of pleural
reflection.
 Differs in arrangement on either sides
The right line of pleural reflection

 Commences behind the right sternoclavicular joint, where the costal and
cervical pleurae become continuous (Fig. 27).
 Runs inferomedially behind the manubrium sterni, to reach the midline at the
level of the sternal angle.
 Continues downwards from the sternal angle, in close apposition to the opposite
pleura, down to the level of the 4th costal cartilage. From here, it continues
vertically downwards, to the level of the right xiphisternal joint. Then, it
- 119 -
 Deviates inferolaterally (to the right), from the level of the xiphisternal joint,
crossing the right midclavicular line at the 8th costochondral junction; and the
right midaxillary line at the level of the 10th rib.
 Continues behind (on the posterior thoracic wall) to end at the level of the spine
of T12, close to the midline (posteriorly).
The left line of pleural reflection

 Commences behind the left sternoclavicular joint. From here, it passes
inferomedially to reach the midline at the level of the sternal angle
 Continues downwards along the midline, behind the sternum and in close
proximity to the opposite pleura, to the level of the 4th costal cartilage. From
here, it deviates to the left, and descends along the left sternal margin, to the
level of the 6th costal cartilage (Fig. 27). Then, it
 Runs inferolaterally (to the left) thereafter, crossing the left midclavicular line at
the 8th costochondral junction; and the left midaxillary line at the 10th rib.
 Ends close to the midline (behind), at the level of the spine of T12
The diaphragmatic pleura

 Is relatively thin. It lines the thoracic surface of the diaphragm (except the
central tendon, which is related to the fibrous pericardium) (Fig. 27).
 Is reflected upwards to join the mediastinal pleura around the attachment of the
fibrous pericardium.
 Forms, at its junction with the costal pleura, the costodiaphragmatic (costal) line
of pleural reflection
 Forms a costodiaphragmatic recess, just as it is reflected to join the costal
pleura.
Cervical Pleura (Cupola)
The cervical pleura

 Is essentially a continuation of the costal and mediastinal pleurae into the root of
the neck. Here, the cervical pleura lies above the superior aperture of the thorax;
and forms a dome over the apex of the lung
 Extends for 3–4 cm above the 1st costal cartilage and about 2.5 cm above the
medial 3rd of the clavicle. It does not rise above the level of the neck of the 1st rib
 May be represented by a line convex upwards, drawn from the sternoclavicular
joint to the junction of the medial and middle thirds of the clavicle, the summit of
which is about 2.5 cm above the latter.
- 120 -
 Is covered on its superior surface by an extension of the endothoracic fascia – the

suprapleural membrane
In addition, note the following:

 The apex of the cervical pleura reaches the spine of C6, and is about 2.5 cm
from the median plane
 Scalenus anterior and scalenus medius muscles are lateral relations of the
cervical pleura
 the brachiocephalic veins and subclavian vessels are anterior relations of the
cervical pleura
 The neck of the 1st rib lies behind the cervical pleura
 A small scalene minimus muscle may be present. This arises from the transverse
process of C7; and inserts into the inner border of the 1st rib and the suprapleural
membrane. Therefore, it tenses the latter on contraction.
 Scalene muscles also send some fibres into the suprapleural membrane, to
tense this membrane.
Mediastinal Pleura
The mediastinal pleura

 Separates the mediastinal (medial) surface of the lung from the structures that
constitute the mediastinum (Fig. 27).
 Extends from the sternum anteriorly to the vertebral column behind, above the
root of the lung
 Is reflected around the root of the lung to become continuous with the visceral
(pulmonary) pleura
 Is also continuous with the diaphragmatic pleura below
 Is reflected laterally (along its anterior and posterior margins) to join the costal
pleura
 Is continuous above, beyond the root of the neck, with the cervical pleura
 Forms, on each side, a retro-esophageal recess, behind the esophagus, and
below the root of the lung
 Has different relations on both sides
The right mediastinal pleura is related to the following mediastinal structures:
- 121 -
 Above the root of the lung: Right vagus and phrenic nerves, arch of the azygos
vein, and SVC; right brachiocephalic vein, brachiocephalic trunk, trachea, and
esophagus.
 Anterior to the root of the lung: Fibrous pericardium, phrenic nerve, and
pericardiacophrenic vessels.
 Behind the root of the lung: Azygos vein, esophagus and vertebral bodies
 Below the root of the lung: Inferior vena cava (IVC) and esophagus.
Relations of the left mediastinal pleura include:

 Above the root of the lung: Left phrenic and vagus nerves, aortic arch, left
common carotid and subclavian arteries, left brachiocephalic and superior
intercostal veins, thoracic duct and esophagus.
 Anterior to the root of the lung: Fibrous pericardium, phrenic nerve and
pericardiacophrenic vessels.
 Behind the root of the lung: Descending thoracic aorta and vertebral bodies
 Below the root of the lung: Esophagus
Blood Supply and Innervation of the Pleura
The visceral (pulmonary) pleura

 Receives arterial blood from bronchial arteries; and drains into the bronchial
veins
 Drains into lymph vessels that end in the bronchopulmonary nodes
 Receives autonomic nerve fibres. Thus, it is not sensitive to most stimuli. It is
therefore similar to the lung in terms of its neurovasculature.
The parietal pleura

 Has similar blood supply and innervation as the thoracic wall
 Receives fibres of the intercostal nerves, which innervate the costal pleura and
peripheral part of diaphragmatic pleura
 Also receives fibres of the phrenic nerve, which innervate the mediastinal pleura
and the central part of diaphragmatic pleura.
 Is supplied by branches of intercostal, internal thoracic and musculophrenic
arteries
 Drains venous blood into intercostal, internal thoracic and musculophrenic veins
- 122 -
 Is drained by lymph vessel that end in diaphragmatic, parasternal and intercostal

lymph nodes
The pleural cavity

 Is a closed ‘potential space’ between the visceral and parietal pleurae.
 Surrounds each lung, though the lung does not lie within the pleural cavity. Thus,
the cavity enables the lung to move relative to the thoracic wall.
 Contains a thin film of serous fluid produced by the mesothelial cells that line
the pleural surfaces. This fluid minimizes friction between the lung and the
thoracic wall
 Has a costomediastinal recess that lies behind the sternum, along the line of
continuity of the costal and mediastinal pleurae.
 Also has a costodiaphragmatic recess, along the line of continuity of the costal
and diaphragmatic pleurae.
Note the following:

 The anterior border of the lung does not occupy the costomediastinal recess in
quiet respiration
 The inferior border of the lung lies about 5 cm above the costodiaphragmatic
line of pleural reflection
 The pleural cavity is at risk in a posterior approach to the kidney, as this cavity
overlaps the kidney posteriorly
Applied Anatomy of the Pleura

 Pleuritis (pleurisy) is the inflammation of the pleurae. In this condition, the
pleurae may adhere to each other in certain loci – pleural adhesion
 No appreciable sound is detectable during auscultation of the lung except in
pleuritis, when the characteristic pleura rub is produced.
 Fractured ribs, penetrating wound or rupture of the lung may produce air-filled
pleural cavity, a condition known as pneumothorax
 Watery fluid may also accumulate in the pleural cavity, producing hydrothorax.
This occurs most commonly when fluid seeps from congested lungs into the
pleural cavity as a result of impaired pulmonary circulation (in chronic heart
failure). Hydropneumothorax is the presence of both fluid and air in the pleural
cavity.
 Injury to a major blood vessel or wound involving the lung, may lead to
accumulation of blood in the pleural cavity, a condition known as haemothorax.
- 123 -
 Rupture of the thoracic duct may also result in escape of lymph into the pleural
cavity, a condition known as chylothorax.
Also, note the following:

 Collapse of the lung is associated with hydrothorax or haemothorax; thus, the
heart is displaced to one side
 Recurring spontaneous pneumothorax may be prevented by pleurectomy or
pleural poundrage
 Pleurectomy is the surgical excision of part of the pleural membrane.
 Pleural poundrage involves the application of a powder onto pleural surface to
enhance the adhesion of visceral and parietal layers
 Relatively higher position of the cervical pleura and lung in the root of the neck
in children and infants makes these structures more susceptible to injury.
 Injury involving the root of the neck may damage the cervical pleura and lung,
causing hydrothorax and/or haemothorax.
Lungs
The lungs of adult human

 Are essential for respiratory function. Each is surrounded by the pleurae and
pleural cavity
 Lie freely within the thorax, except where they are attached by their roots to the
mediastinum
 Are separated from each other by the mediastinum. The latter consists of
structures that lie between the two pleural cavities.
 Are characteristically light, soft, porous and spongy. Thus they crepitate when
handled, owing to the presence of air in them.
 Possess the ability to recoil and get smaller when freed from the thoracic wall.
This is owing to the presence of abundant elastic tissue in these organs.
 Float in water, owing to the presence of air in them.
Also note that the lungs:

 Possess smooth, glistening surfaces, owing to the presence of the visceral pleura
around them.
 Possess numerous fine lines on their surface; these intersect each other and
delineate the lobules of the lungs
 Are rose-pink during infancy but become grey and mottled in adults. This is
owing to the deposition of inhaled particles in their connective tissue. They are
more mottled in males than females
- 124 -
 Are heavier in males than female and on the right than the left. They weigh an
average of 625 g on the right and 565 g on the left (in males).
 Has an apex, a base, three borders (anterior, inferior and posterior), and two
surfaces (costal and medial).
Figure 27. Thoracic cavity (anterior view)
In stillborn and fetuses, the lungs

 Are firm to touch; and do not crepitate when pressed
 Contain no air, and so can sink in water.
Apex of the Lung
The apex of each lung

 Lies in the root of the neck, just beneath the cervical pleura
 Projects for about 2.5 cm above the medial 3rd of the clavicle and is 2.5 cm from
the midline
 Rises for about 3 cm above the first costal cartilage, but does not rise beyond the
neck of the first rib (behind)
- 125 -
Relations of the apex of the lung include the following:

 Anteriorly: subclavian artery and scalene anterior muscle
 Posteriorly: neck of the 1st rib, cervicothoracic ganglion and the 1st intercostal
nerve
 Laterally: scalene medius
 Medially (on the right): brachiocephalic trunk, right brachiocephalic vein, and
trachea
 Medially (on the left): left subclavian artery, and left brachiocephalic vein.
The base of the lung:

 Corresponds to the diaphragmatic surface of this organ (Fig. 27)
 Is deeply concave, as it rests on the convexity of the dome of the diaphragm. It
has a deeper concavity on the right than the left.
 Is separated from the right lobe of the liver on the right by the diaphragm
 Is separated from the left lobe of the liver, gastric fundus, spleen and splenic
flexure of the colon by the left dome of the diaphragm.
 Is separated from the mediastinal surface of the lung by a blunt margin; and from
the costal surface by the sharp inferior margin. This lies about 5 cm above the
costodiaphragmatic recess (in quiet respiration).
The costal surface of the lung:

 Is smooth and convex, except when hardened in situ; in the latter case, it is
grooved by the overlying ribs
 Is related to the costal pleura, the part of the parietal pleura that lines the thoracic
wall (Fig. 27)
 Is separated by the costal pleura from the ribs, innermost intercostal muscles,
intercostal membranes, costal cartilages, endothoracic fascia and vertebral
bodies.
 Is thicker and darker posteriorly where it adjoins the vertebral bodies.
The medial surface of the lung:

 Consists of the vertebral and mediastinal parts
 Has a hilum in its central part
 Is closely related to the mediastinal pleura. This separates it from mediastinal
structures.
 Bears the impressions produced by the vertebral column and mediastinal
structures
The vertebral part of the mediastinal surface of the lung

- 126 -
 Is the smaller of the two parts of the medial surface; it adjoins the bodies of
thoracic vertebrae.
 Is continuous with the costal surface of the lung at the blunt posterior border
 Is related to the intervertebral discs, posterior intercostal vessels and splanchnic
nerves.
Mediastinal Part of the Medial Surface of the Lung

 The mediastinal part of the medial surface of the lung is concave; it adjoins the
structures of the mediastinum
 The concavity of the mediastinal surface of the left lung is deeper than that of the
right. This is because about ⅔ of the heart lies to the left of midline
 The mediastinal surface bears a triangular depression termed the hilus (or hilum).
Here, structures enter and leave the lung.
 Each lung bears a deep cardiac impression just antero-inferior to its hilus.
 The left cardiac impression (produced by the left ventricle) is deeper than the
right impression (produced by the right atrium).
Regarding the mediastinal surface of the right lung (Fig. 28), note the following:
 The right atrium and part of the right ventricle produce the cardiac impression
of the right lung. This impression continues vertically upwards, anterior to the
hilus, with a groove that lodges the SVC (Fig. 28)
 The azygos vein occupies a curved groove that lies above the hilus, and which
joins the groove for the SVC
 A shallow vertical groove that descends behind the hilus indicates the position of
the oesophagus
 The oesophageal impression does not reach the inferior border of the right lung
as the oesophagus inclines to the left near the diaphragm
 The inferior vena cava forms a small impression on the posterior aspect of the
lower part of the right cardiac impression.
 The trachea is related to the portion of the lung between the groove for the
azygos vein and the apex. This organ does not usually form a recognizable
groove in a fixed lung specimen.
 Also related to this surface are the right vagus and phrenic nerves, and the
mediastinal pleura
Regarding the mediastinal surface of the left lung (Fig. 28), note the following:
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 A deep cardiac impression is seen antero-inferior to the hilus (Fig. 28). This
impression is formed by the left ventricle below and the infundibulum of the right
ventricle above.
 The left cardiac impression continues upwards, anterior to the hilus, with the
groove for the pulmonary trunk.
 The aortic arch forms a deep groove, convex upwards, just above the hilus of the
lung
 A deep vertical groove descends behind the hilus and lodges the descending
thoracic aorta.
 The left subclavian artery occupies a groove that ascends from the groove for
the aortic arch, antero-inferior to the apex of the lung
 Also related this surface are the trachea, oesophagus, mediastinal pleura, left
phrenic nerve, pericardiacophrenic artery, and left vagus nerve (and its cardiac
and left recurrent laryngeal branches)
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Lingul
a
impression
Lingula
Figure 28. A, mediastinal surface of the right lung; B, mediastinal surface of the left
lung
- 129 -
Hilus of the Right Lung (Fig. 28)
In the hilus of the right lung,

 The eparterial bronchus is the highest-placed structure.
 The inferior pulmonary vein is the lowest-placed structure. It adjoins the
pulmonary ligament
 The right pulmonary artery lies just antero-inferior to the eparterial bronchus
 The right principal bronchus is located postero-inferior to the right pulmonary
artery
 The superior pulmonary vein lies anterior to the pulmonary artery.
Hilus of the Left Lung (Fig. 28)
In the hilus of the left lung, note that:

 The left pulmonary artery is the highest-placed structure
 The left principal bronchus lies just below the pulmonary artery
 The superior pulmonary vein is located anterior to the bronchus
 The inferior pulmonary vein is the lowest-placed structure
 Bronchopulmonary lymph nodes lie among the above structures (as they do on
the right side)
Borders of the Lung (Fig. 28)
Anterior border of the right lung

 Is sharp and thin. It separates the anterior and mediastinal surfaces of the lung (as
it does on the left)
 Extends variably into the costomediastinal recess, depending on the depth of
respiration
The anterior border of the left lung
 Is also thin and sharp (Fig. 28)
 Has a cardiac notch, where the heart encroaches on it
 Does not occupy the costomediastinal recess in the region of the cardiac notch.
Here, it outlines the area of superficial cardiac dullness detectable on percussion.
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The inferior border of the lung

 Is sharp and thin where it separates the costal and diaphragmatic surfaces of the
lung; but blunt and rounded where it separates the diaphragmatic and mediastinal
surfaces (Fig. 27, 28)
 Extends variably into the costodiaphragmatic recess
 Crosses the 6th rib at the midclavicular line; and the 8th rib at the midaxillary
line. This borders ends behind at the level of the spine of T10, 2 cm from the
midline.
Posterior border of the lung

 Is blunt and not as distinct as the other two borders
 Separates the costal and medial surfaces of the lung
 Lies along the line of the heads of the ribs (behind)
Fissures and Lobes of the Lungs
Regarding the left lung, note the following:

 An oblique fissure usually divides the left lung into superior and inferior lobes
(Fig. 27). This fissure is more vertically-disposed compared with the right one.
 Oblique fissure cuts through the inferior border of the left lung near the
anterior end of this border; and through the posterior border about 6 cm below
the apex
 The lingula is a tongue-like process of the superior lobe of the left lung (Fig. 27).
It is located between the cardiac notch and the oblique fissure.
 The left lung may possess three lobes. In this instance, a horizontal fissure is
present.
Regarding the right lung, note the following:

 Two fissures are usually present; these include oblique and horizontal fissures
(Fig. 27, 28)
 Three lobes are usually present; these include superior, middle and inferior
lobes (Fig. 28)
 The oblique fissure of the right lung is less vertically-disposed compared to that
of the left. It separates the superior and middle lobes from the inferior lobe.
 The horizontal fissure separates the superior and middle lobes. Absence of this
fissure will result in a right lung with two lobes only.
 The superior and middle lobes of the right lung correspond to the superior lobe
of the left lung.
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 An azygos lobe is found in about 1% of the population. In these individuals, the

azygos vein arches over the apex of the right lung, cutting deep into it.
Bronchopulmonary Segments of the Lung
The bronchopulmonary segments

 Are functionally independent subdivisions of each lobe of the lung
 Are pyramidal in outline, their bases being directed peripherally, while their
apices are directed towards the hilus.
 Are separated from each other by connective tissue septa
 Are each supplied by a segmental (tertiary) bronchus; and a segmental branch
of the pulmonary artery.
 Are drained by veins that are not confined to a single segment, but are
intersegmental.
 Can be resected surgically in certain pathologic state without interference with
the functions of the other segments.
 Bear names that correspond to those of the segmental bronchi that supply them.
Regarding bronchopulmonary segments of the right lung, note the following

points:
 The superior lobe has 3 bronchopulmonary segments. These include apical,
anterior and posterior bronchopulmonary segments
 The middle lobe has two segments. These include medial and lateral
bronchopulmonary segments. The two segments rest on the diaphragm.
 The inferior lobe usually has five segments. These include superior (or apical),
anterior basal, posterior basal, medial basal and lateral basal
bronchopulmonary segments
 A small subsuperior (subapical) segment may be found between the superior
and posterior basal segments of the inferior lobe in about 50% of the population.
It is supplied by a subsuperior segmental bronchus.
Regarding bronchopulmonary segments of the left lung, note that:

 The superior lobe has 3 bronchopulmonary segments. These include apical,
anterior, and posterior bronchopulmonary segments
 The segmental bronchi that supply the apical and posterior bronchopulmonary
segments usually arise via a single stem termed apicoposterior segmental
bronchus (that divides into apical and posterior segmental bronchi).
 The lingula (see above) is similar to the middle lobe of the right lung.
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 Bronchopulmonary segments of the lingula include superior and inferior

lingular segments. These are supplied by superior and inferior lingular
segmental bronchi respectively.
 The inferior lobe has five segments. These include superior (apical), medial
basal, lateral basal, anterior basal and posterior basal segments. They are
supplied by segmental bronchi of the same name (Fig. 26).
 A small ‘subsuperior (subapical) segment’ may be found between the superior
and posterior basal segments in 30% of the population
Blood Supply to the Lung

 Pulmonary arteries convey deoxygenated blood to the lungs (Fig. 28)
 Lobar and segmental branches of the pulmonary supply the lobes and
bronchopulmonary segments of the lung, respectively. In the lungs, these vessels
lie posterolateral to the bronchi, which they accompany.
 In the lung, most branches of the pulmonary artery do not cross the
intersegmental connective tissue septa. That is, they are confined to a particular
bronchopulmonary segment.
 Branches of pulmonary artery end in capillary plexuses around alveolar sacs,
where exchange of gas occurs.
 Veins of the lung arise from capillaries around the alveoli. These veins are
intersegmental in their arrangement. That is, they drain adjacent
bronchopulmonary segments by crossing the connective tissue septa between
them.
 Most veins of the lung lie ventromedial to the bronchi, which they accompany.
Arteries are posterolateral to the bronchi.
 Each lung is usually associated with two (superior and inferior) pulmonary veins
(Fig. 28). These convey oxygenated blood to the left atrium of the heart.
Bronchial Arteries
Regarding bronchial arteries, note the following points:

 Bronchial arteries supply the lungs with oxygenated blood and nutrients. They
run on the posterior aspect of the main bronchi to reach the lungs.
 In addition to supplying lung tissues, the bronchial arteries also supply the
trachea, bronchi, visceral pleura and lymph nodes.
 There are usually one right and two left bronchial arteries
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 The left bronchial arteries arise from the thoracic aorta; while the right
bronchial artery may arise from the aorta, right 3rd posterior intercoastal artery
or left superior bronchial artery.
Venous Drainage of the Lungs
Regarding pulmonary veins, note the following:

 The left superior and inferior pulmonary veins normally drain into the left
atrium. However, they may end in the right atrium or the systemic veins, a
condition referred to as total anomalous pulmonary connections.
 One of the pulmonary veins may drain into the right atrium (or systemic vein),
while the other ends in the left atrium. This condition is referred to as partial
anomalous pulmonary connection
 The left pulmonary veins may unite to form a single trunk that enters the left
atrium.
 Anomalous termination of the right pulmonary veins may also occur (see
above). Normally, the veins drain into the left atrium
 The three lobes of the right lung may possess three pulmonary veins that open
separately into the left atrium.
Bronchial Veins
The bronchial veins

 Run behind the bronchi, with the bronchial arteries.
 Drain part, but not all of the blood reaching the lungs from the bronchial
arteries. They communicate with the pulmonary veins.
 Also drain the pulmonary pleura and bronchi.
 Receive some tributaries from the esophageal veins.
 Drain into the azygos vein on the right; and the accessory hemiazygos (or left
superior intercostal vein), on the left.
Regarding the lymphatic drainage of the lungs, note the following points:
 Two lymphatic plexuses exist in the lungs. These are superficial and deep
lymphatic plexuses.
 The Superficial lymph plexus lies beneath the pulmonary pleura; it drains the
latter and the parenchyma of the lung. Vessels from this plexus drain into the
bronchopulmonary nodes, in the hilus of the lung.
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 The deep lymphatic plexus commences in the submucosa of the bronchi, which
they drain. Vessels from this plexus drain into pulmonary nodes, located on the
bronchi.
 Efferent vessels from the pulmonary nodes drain into the bronchopulmonary
nodes (in the hilus of the lung). The latter also receive vessels from the
superficial lymphatic plexus.
 Efferent vessels from the bronchopulmonary nodes drain into the superior and
inferior tracheobronchial nodes.
 The inferior tracheobronchial nodes (or carinal nodes) lie beneath the
bifurcation of the trachea, between the main bronchi.
 The superior tracheobronchial nodes are located around the lower end of the
trachea.
 Efferent lymph vessels from the tracheobronchial nodes drain into the
paratracheal nodes. These nodes lie along the thoracic part of the trachea.
Also note the following points:

 Union of efferent vessels from the paratracheal, brachiocephalic and parasternal
lymph nodes forms the bronchomediastinal trunks.
 Each bronchomediastinal trunk usually ends at the junction of the internal jugular
and subclavian veins (venous angle) of its own side.
 The right bronchomediastinal trunk may join the right lymphatic trunk; while
the left bronchomediastinal trunk may join the thoracic duct.
 The bulk of the lymph from the inferior lobe of the left lung enters the right
superior tracheobronchial nodes to reach the right bronchomediastinal trunk.
Innervation of the Lungs
Regarding the pulmonary plexuses, note the following:

 Associated with each root of the lungs are the anterior and posterior pulmonary
plexuses of nerves.
 Anterior pulmonary plexus of each side is formed by about three anterior
pulmonary branches of vagus nerve and rami from the sympathetic chain.
 Posterior pulmonary plexus is formed by the posterior pulmonary branches of
vagus and rami from the 2nd–4th sympathetic ganglia. It is more prominent than
the anterior plexus.
 Pulmonary plexuses are distributed along the bronchial tree to the smooth muscle
fibres of the bronchioles, blood vessels and glands.
- 135 -
Also note that:

 Sympathetic innervation of the lung ensures relaxation of the smooth muscle
fibres of the bronchi and bronchioles (bronchodilatation).
 Stimulation of the sympathetic fibres to the lung suppresses the activity of its
glands. This is owing to reduction in blood supply to these glands.
 Stimulation of the parasympathetic fibres of the lungs produces
bronchoconstriction. This may result in dyspnoea (difficult breathing).
 Parasympathetic fibres are vasodilators to the vessels of the lungs. They are
also secretomotor to its glands (i.e., they enhance he secretory activity of these
glands, and this may result in airway congestion.
 Sensory fibres from the visceral pleura reach the spinal cord via the autonomic
(sympathetic) pathway.
Applied Anatomy of the Lung

 Epithelial cells of the bronchial tree may be involved in carcinoma. Bronchiolar
carcinoma is more common in cigarette smokers
 Cancer cells from the lungs may metastasize to bones, suprarenal glands and
brain via the venous route.
 Haemoptysis (expectoration of blood from the lung or bronchi and trachea)
accompanies carcinoma of the bronchi.
 Enlargement of the supraclavicular lymph nodes may be an index of
bronchogenic carcinoma. Cancer cells from the lungs may spread to these nodes;
hence, they are called sentinel lymph nodes.
 Conditions such as carcinoma of the lungs may necessitate pneumonectomy,
lobectomy or segmentectomy
 Cancer of the apical segment of the lung may paralyse the recurrent laryngeal
nerve, with the attendant hoarseness of the voice.
 Deposition of carbonaceous particles in the axillary lymph nodes may be an
indication of pleural adhesion.
 Asthma is an inflammatory/allergic condition characterised by breathlessness.
Spasmic contraction of bronchiolar smooth myocytes, congestion of the airway
by secretory products or oedema of bronchial mucosa occur in bronchial asthma.
 The lung of the foetus or still born floats in water; while that which has respired
does not
 Auscultation of the lung could be done on the posterior thoracic wall, at the level
of T10. In this instance, the inferoposterior part of the lung is examined.
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 Collapse of the lung is associated with pneumothorax, haemothorax or

hydrothorax, with the attendant respiratory distress
The Ribs
Regarding the ribs, note the following key points:

 Ribs are the curved, flat bones that (together with the thoracic vertebrae) form the
thoracic cage (Fig. 29B). In all, there are 12 pairs of ribs; and these are varied
anatomically
 The upper seven ribs are true (vertebrocostal) ribs. Each articulates with the
thoracic vertebra behind and with a costal cartilage anteriorly (Fig. 29B). Via the
latter, it articulates with the sternum
 The 8th, 9th and 10th ribs are false (vertebrochondral) ribs. Each extends from the
vertebrae behind to the costal margin anteriorly (Fig. 29B). Thus, it is indirectly
linked with the sternum
 The 11th and 12th ribs are floating (vertebral or free) ribs. These do not reach the
costal margin or sternum anteriorly
 Typical ribs are those with similar anatomic features. These include the 3rd–9th
ribs. Atypical ribs include the 1st, 2nd, 10th, 11th and 12th ribs.
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Figure 29. A, a typical ribs; B, rib cage
Regarding a typical rib,

 Each typical rib has a head, a neck, a tubercle and a shaft (Fig 29A)
 The wedge-shaped head of a typical rib bears two facets. The latter are separated
by the crest of the head. One facet articulates with the numerically corresponding
vertebra, while the other articulates with the vertebra superior to it
- 138 -
 The neck of the rib links the shaft (or body) with the head of the rib. Its upper
border is the crest of the neck. Besides, each rib has a tubercle at the junction of
the neck and shaft of the rib. The articular part of the tubercle articulates with
the transverse process of its own vertebra, while the non-articular part gives
attachment to the costotransverse ligament
 The shaft of the rib is the flat curved part. It has a costal angle at the point where
it bends anterolaterally. Internally, the shaft presents a costal groove near its
lower border. This accommodates the intercostal nerve and vessels.
Atypical Ribs
Regarding atypical rib, note these points:

 The first rib bears a single facet on its head; and this facet articulates with the T1
vertebra. Its shaft is the broadest and this has upper and lower surfaces, and
internal and external borders. The upper surface bears a scalene tubercle (for
scalene anterior muscle). This separates the grooves for the subclavian artery
and vein (which cross the upper surface of the 1st rib, posterior and anterior to the
scalene tubercle respectively)
 The second rib is thinner and longer than the 1st rib, and its shaft is less curved
 Each of the 10th, 11th and 12th ribs has only one facet on its head (as does the 1st
rib)
 The 11th and 12th ribs are short ribs and each has neither a neck nor a tubercle.
The 11th rib has a shallow costal groove and a slight costal angle, but the 12th rib
has none.
 Between adjacent ribs are the intercostal spaces. Thus, there are 11 pairs of
intercostal spaces
Note: A rib may be fractured at any point; however, the commonest point is just
anterior to the angle of the rib, which is its weakest part.
Intercostal Space
Regarding intercostal spaces, note these facts:

 Intercostal spaces are the intervals between adjacent ribs (Fig. 27). Thus, there
are 11 pairs of intercostal spaces
 Each intercostal space has intercostal muscles, intercostal nerves, and
intercostal vessels.
 Muscles of a typical intercostal space include, from external internally, external
intercostal, internal intercostal and innermost intercostal muscles. Between the
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internal and innermost intercostal muscles are the neurovascular structures of

each space. These are arranged, from above downwards, as intercostal vein,
intercostal artery and intercostal nerve (at the upper part of the space, where these
structures are lodged in the costal groove)
 Fibres of the external intercostal muscle are directed infero-anteriorly, from the
upper rib of its own space to the lower rib. This muscle is involved in
inspiration. Anteriorly, external intercostal muscle is replaced by an external
intercostal membrane
 Fibres of the internal intercostal muscle are at right angles to those of external
intercostal. These fibres are directed inferoposteriorly, from the costal groove of
the upper rib of that space to the upper border of the rib below. The muscle is
involved in expiration. Posteriorly, internal intercostal muscle is replaced by an
internal intercostal membrane.
 Innermost intercostal muscle is similar to the internal intercostal muscle, from
which it is separated by the intercostal nerves and vessels
 Intercostal muscles are innervated by the intercostal nerves of their own space
Intercostal Nerves
Regarding intercostal nerves, note the following:

 Intercostal nerves are the ventral rami of T1–T11 nerves. The ventral ramus of
T12 is the subcostal nerve, which lies beneath the 12th rib
 In the intercostal spaces, intercostal nerves run between the internal intercostal
and innermost intercostal muscles of these spaces. In this position, each nerve lies
close to the upper rib of its own space, just below the intercostal vessels
 The 3rd–6th intercostal nerves are typical. Each has a lateral cutaneous, collateral
and anterior cutaneous branches. The lateral cutaneous branch arises at the
midaxillary line. The collateral branch arises near the angle of the rib, while the
anterior cutaneous branch is the anterior end of intercostal nerve (as this turns
forwards near the sternal margin)
 The first intercostal nerve is the smaller of the two divisions of the ventral
ramus of the first thoracic spinal nerve (T1). Usually, it has no lateral cutaneous
branch
 The second intercostal nerve is the larger of the two divisions of the ventral
ramus of T2 nerve. Its lateral cutaneous branch is the intercostobrachial nerve.
This emerges from the 2nd interspace, at the midaxillary line, and then innervates
the floor of the axilla. It also communicates with the medial cutaneous nerve of
the arm (to supply the medial surface of the arm)
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Intercostal Arteries
Note the following:

 Each of the upper nine intercostal spaces has a posterior intercostal artery and a
pair of anterior intercostal arteries. The 10th and 11th intercostal spaces have no
anterior intercostal arteries; each has a posterior intercostal artery
 The posterior intercostal arteries of the 1st and 2nd intercostal spaces arise from
the superior (or supreme) intercostal artery (a branch of costocervical trunk)
 The posterior intercostal arteries of the 3rd–11th intercostal spaces arise from
the descending thoracic aorta
 The anterior intercostal arteries of the upper six interspaces arise from the
internal thoracic artery; while those to the 7th–9th spaces arise from the
musculophrenic artery. (each space has a pair of anterior intercostal arteries
(except the last two spaces, which have none)
 Each posterior intercostal artery has a lateral cutaneous and a dorsal branch.
It anastomoses with its own anterior intercostal arteries
Intercostal Vein
Note the following:

 Intercostal veins accompany intercostal arteries and are the highest placed in the
costal groove
 Anterior intercostal veins are tributaries of internal thoracic veins
 The highest posterior intercostal vein drains the first interspace; it joins the
corresponding brachiocephalic vein
 Most posterior intercostal veins join the azygos system of veins
Applied Anatomy of the Intercostal Space
Note the following:

 Thoracocentesis is the aspiration of the pleural cavity, done by passing a needle
through the intercostal space. In this procedure, the needle is passed close to the
lower rib of that space (to avoid the neurovascular structures that lies adjacent to
the upper rib of the space)
 Intercostal nerve block involves infiltration of an anaesthetic around the trunk
and collateral branch of the intercostal nerve. The needle is inserted between the
paravertebral line (a vertical line drawn at the level of the tips of the transverse
processes of the vertebrae) and the area to be anaesthetized
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 Liver biopsy may be obtained by inserting a needle through the right 10th
intercostal space, at the midaxillary line. The biopsy is taken with the subject in
full expiration, to reduce the costodiaphragmatic recess and the risk of damaging
the lung or entering the pleural cavity
CHAPTER 7: THE MEDIASTINUM

The mediastinum
 Is defined as a septum or partition between the two pleural cavities. It extends
from the level of the superior thoracic aperture above to the diaphragm below.
 Is bounded anteriorly by the sternum and costal cartilages, and posteriorly by
the thoracic part of the vertebral column. The mediastinal pleura bounds it on
either side.
 Is continuous above with the midline structures of the neck (oesophagus, larynx,
trachea, and pharynx).
 Could lengthen or shorten in response to diaphragmatic excursions.
 Has a degree of mobility as most of its contents are filled with blood or air. These
structures may therefore alter their positions relative to posture or in conditions
such as pneumothorax.
 Comprises superior and inferior mediastina. The latter is divisible into anterior,
middle, and posterior mediastina (Fig. 30)
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Figure 30. Parts of the mediastinum; (IV and V= T4 and T5 vertebrae)
Superior Mediastinum
The superior mediastinum

 Is bounded above by the thoracic inlet. Here, it is continuous with the midline
structures of the neck (e.g., trachea).
 Is limited below by an imaginary transverse plane that stretches from the
sternal angle anteriorly to the intervertebral disc between T4 and T5 posteriorly
(Fig. 30)
 Is bounded anteriorly by the manubrium sterni, and posteriorly by the upper four
thoracic vertebrae (T1–T4).
Contents of the superior mediastinum are numerous. They include:

 Muscles: parts of the sternothyroids, sternohyoids and longus colli
 Superior sternopericardial ligaments. These connect the fibrous pericardium to
the upper part of the manubrium sterni
 Remnant of the thymus, located anteriorly
 Lymph nodes: paratracheal, brachiocephalic and some tracheobronchial nodes
- 143 -
 Large arteries: aortic arch, brachiocephalic trunk, and left common carotid and
left subclavian arteries. The three latter vessels are branches of the aortic arch
 Veins: right and left brachiocephalic veins, part of the SVC and the left superior
intercostal vein
 Nerves: phrenic nerve, vagus nerve, cardiac and left recurrent laryngeal nerves
 Hollow organs: trachea and oesophagus
 Thoracic duct, the largest lymphatic vessel on the body
Anterior Mediastinum
The anterior mediastinum

 Is the smallest of the three subdivisions of the inferior mediastinum. It is
narrower above the level of the 4th costal cartilage but widens below this level
 Is bounded anteriorly by the sternal body and posteriorly by the fibrous
pericardium (Fig. 30)
 Is limited below by the diaphragm but is continuous above with the superior
mediastinum
 Contains few structures. These include some lymph nodes, mediastinal branches
of internal thoracic arteries, loose connective tissue and the inferior
sternopericardial ligament (connecting the xiphoid process to the fibrous
pericardium).
Middle Mediastinum
The middle mediastinum

 Is the largest part of the inferior mediastinum
 Is bounded anteriorly and behind by the fibrous pericardium; and on each side
by the mediastinal pleura
Contents of the middle mediastinum include:

 The heart and the vessel vessels associated with it
 Large arteries: ascending aorta, pulmonary trunk, and pulmonary arteries
 Large veins: lower half of SVC, pulmonary veins, and inferior vena cava
(thoracic part of),
 Arch of the azygos vein
 Bifurcation of the trachea and the main bronchi
 Nerves: phrenic nerves and deep cardiac plexus
 Some tracheobronchial lymph nodes
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Posterior Mediastinum
The posterior mediastinum

 Is bounded anteriorly (from above downwards) by the bifurcation of the
trachea, pulmonary vessels, fibrous pericardium and the posterior part of the
thoracic surface of the diaphragm (Fig. 30)
 Is bounded behind by the lower eight thoracic vertebrae (T5 –T12); and on each
side by the mediastinal pleura. It is continuous above with the superior
mediastinum
 Extends lower than the middle and anterior parts of the inferior mediastinum
 Contents of the posterior mediastinum include:
 Descending thoracic aorta and its branches
 Azygos and hemiazygos veins (which drain the thoracic wall)
 Vagus nerves and the lower thoracic splanchnic nerves
 Oesophagus, located a little to the right of the midline
 Thoracic duct and the posterior mediastinal lymph nodes.
Applied Anatomy of the Mediastinum
Note the following:

 The heart and the great vessels form the mediastinal shadow, in an
anteroposterior (AP) chest radiograph.
 The left subclavian artery, aortic arch, left auricle and left ventricle (from above
downwards) form the left border of the mediastinal shadow.
 The right border of the mediastinal shadow is formed by the right
brachiocephalic vein, SVC, right atrium and adjacent part of the inferior vena
cava.
 The pulmonary vessels form the hilar shadow in an anteroposterior radiograph
of the chest
 The trachea forms a median shadow in the superior mediastinum (in an AP
radiograph of the chest)
 The aortic arch forms a knuckle – aortic knuckle – in AP radiographs of the
chest
In lateral radiographs of the thorax,

 The heart forms a large cardiac shadow
 The anterior mediastinum appears as retrosternal space, anterior to the cardiac
shadow.
 The posterior mediastinum forms a retrocardiac space in which the descending
thoracic aorta can be seen.
 The oesophagus is conspicuous when filled with a barium meal
 The shadows of the trachea and main bronchi are usually observable just above
the cardiac shadow
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 In pneumothorax, haemothorax or hydrothorax, the mediastinum deviates
towards the unaffected pleural cavity.
 Enlargement of the mediastinum usually occurs in malignant tumor of the
mediastinal lymph nodes. This can be seen in chest radiographs.
 Bleeding from the large vessels of the mediastinum can also result in its
enlargement
 The inferior mediastinum becomes widened in congestive heart failure (when
enlargement of the heart occurs)
 The mediastinum can be examined and biopsies of its lymph nodes taken during
mediastinoscopy, using a mediastinoscope.
Anatomical Events at the Sternal Angle of Louis
At the level of the sternal angle,

 Manubrium sterni articulates with the body of the sternum to form the
manubriosternal joint (a secondary cartilaginous joint or symphysis)
 Second costal cartilage articulates with the sternum (on each side)
 Superior and inferior mediastina are continuous (at the imaginary transverse
sternal plane)
 T4 and T5 vertebrae articulate with each other (an intervertebral disc intervening
between them)
 Trachea bifurcates into right and left main bronchi
 Pulmonary trunk divides into right and left pulmonary arteries
 Ascending aorta is continuous with the aortic arch anteriorly, while the aortic
arch is continuous with the descending thoracic aorta posteriorly
 Tracheobronchial nodes surround the tracheal bifurcation
 Azygos vein joins the SVC from behind
 Thoracic duct crosses from the right to the left of midline as it ascends on the
vertebral column
 Deep cardiac plexus of nerves lies anterior to the bifurcation of the trachea
 Ligamentum arteriosum connects the aortic arch to the left pulmonary artery
Diaphragm
The diaphragm
 Is a dome-shaped, musculotendinous partition between the thoracic and
abdominal cavities (Fig. 27, 30)
 Has a concave inferior surface and a convex superior surface. It is related to
thoracic organs (heart, lungs, etc) above and to the abdominal organs (liver,
stomach, spleen, etc) below
 Has two domes (right and left), separated by an aponeurotic central tendon. The
fibrous pericardium is apposed to, and partly fused with this tendon. The right
dome is higher up than the left, owing to the presence of the liver beneath this
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dome. During expiration, the right dome reaches as high up as the 5th rib, while
the left dome reaches the 5th intercostal space (in the midclavicular line). The
level of the dome varies with respiration, posture and the state of abdominal
organs
 Is the chief muscle of inspiration. During inspiration, the domes of the
diaphragm descend (towards the abdominal cavity), thereby increasing
intrathoracic volume
Parts of the Diaphragm
Based on peripheral attachment of its fibres, the diaphragm may be divided into the
following parts:
 Sternal part, which consists of two muscular slips attached to the xiphoid
process
 Costal part, which consists of slips that arise from the lower six costal cartilages
and their ribs. Its fibres form the domes of the diaphragm
 Lumbar part, which consists of fibres that arise from the arcuate ligaments and
crura of the diaphragm
Peripheral Attachment of the Diaphragm

1. Posterior surface of the xiphoid process. This gives rise to fibres of the sternal
part
2. Lower six costal cartilage and adjoining parts of their ribs. These give rise to the
costal part of the diaphragm
3. Median, medial and lateral arcuate ligaments. These give rise to some posterior
fibres of the diaphragm
4. Right and left crura, which also give rise to some posterior fibres of the
diaphragm

 The right crus of the diaphragm is attached to the upper 3 lumbar vertebrae
 The left crus is attached to the upper 2 lumbar vertebrae
 The median arcuate ligament is a fibrous arc that links the right and left crura
across the midline. It lies anterior to the aortic hiatus, and thus, to the descending
aorta
 The medial and lateral arcuate ligaments are fibrous thickening of the fascia of
psoas major and quadratus lumborum, respectively
Central Attachment of the Diaphragm

From the peripheral sites of attachment, fibres of the diaphragm converge on the
central tendon. The central tendon is trifoliate and lies near the centre of the
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diaphragm. It is connected to the fibrous pericardium by pericardiacophrenic

ligaments but has no bony attachment
Innervation of the Diaphragm
1. Motor fibres: Phrenic nerve (C3–C5)

2. Sensory fibres (central part of the diaphragm): Phrenic nerve (C3–C5)
3. Sensory fibres (peripheral part of the diaphragm): Lower intercostal (T5–T11)
and subcostal (T12) nerves
Arterial Supply of the Diaphragm
The diaphragm is supplied by the following vessels:

1. Superior phrenic arteries (from the thoracic aorta)
2. Musculophrenic and pericardiacophrenic arteries (from internal thoracic arteries)
3. Inferior phrenic arteries (from abdominal aorta)
Venous Drainage of the Diaphragm
The diaphragm is drained by the following veins:

1. Musculophrenic veins (tributaries of internal thoracic veins)
2. Pericardiacophrenic veins (tributaries of internal thoracic veins)
3. Superior phrenic vein (right side only) (tributary in inferior vena cava [IVC])
4. Inferior phrenic veins. The right vein drains into the IVC, while the left one
drains into the IVC and left suprarenal vein
Lymphatic Drainage of the Diaphragm
Lymph vessels from the diaphragm drain into the following nodes:
1. Diaphragmatic nodes. From these nodes, lymph drains into phrenic, parasternal
and posterior mediastinal nodes
2. Upper lumbar nodes
Apertures of the Diaphragm
The diaphragm has certain openings via which neurovascular structures and the
oesophagus pass. The major apertures of the diaphragm include:
 Aortic hiatus
 Oesophageal hiatus
 Vena caval foramen (caval opening)
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The aortic hiatus

 Is a median opening located between the right and left crura and behind the
median arcuate ligament of the diaphragm, at the level of T12 vertebra
 Transmits the descending aorta from the thoracic to the abdominal cavity.
Because the aorta does not pierce the fibres of the diaphragm, blood flow through
this vessel is not disturbed by the contraction of the diaphragm
 Also transmits the thoracic duct and occasionally the azygos vein
The oesophageal aperture

 Is an opening in the muscle of the right crus of the diaphragm, at the level of T10.
This opening lies above and to the left of aortic hiatus
 Transmits the oesophagus, as this enters the abdomen from the thorax. Here,
fibres of the right crus of the diaphragm surround the oesophagus. Thus, these
fibres form a sphincter for the oesophagus, and thus constricts it when the
diaphragm contracts
 Also transits the right and left vagal trunks and oesophageal branches of the left
gastric vessels
Caval opening
 Is an aperture in the central tendon of the diaphragm, to the right of the median
plane, and at the level of the disc between T8 and T9 vertebrae. This opening is at
the junction of the right and middle leaves of the central tendon
 Transmits the IVC. It also transmits the terminal part of the right phrenic nerve
and some lymph vessels. The caval opening is adherent to the wall of the IVC.
Thus, when the diaphragm contracts, the IVC widens, and this enhances venous
return to the heart
Besides, note the following points:

 The diaphragm also has a small sternocostal foramen (or triangle). This lies (on
each side) between the sternal and costal attachments of the diaphragm. It
transmits the superior epigastric vessels and lymph vessels
 Each sympathetic chain descends into the abdomen behind the medial arcuate
ligament
 The greater and lesser splanchnic nerves enter the abdomen by piercing the crus
of the diaphragm
Applied Anatomy of the Diaphragm
Note these points:

 Paralysis of a hemidiaphragm occurs following injury to the phrenic nerve of
that side. Thus, muscle fibres of half of the diaphragm atrophy. Such paralysed
hemidiaphragm does not descend during inspiration; rather, it is forced upwards
by increased abdominal pressure
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 In certain subjects, accessory phrenic nerve is present. Thus, injury to the main
phrenic nerve does not result in paralysis of a hemidiaphragm
 Pain arising from irritation of the diaphragmatic pleura or diaphragmatic
peritoneum is referred to the shoulder region, which is innerved by the C3 – C5
segments of the spinal cord (same nerve roots as the phrenic nerve)
 Pain from the irritation of the peripheral part of the diaphragm is referred to the
skin over the costal margin
 Hiccups are associated with involuntary spasmodic contractions of the
diaphragm. It may be caused by cerebral lesions, irritation of the diaphragm,
indigestion, alcoholism or abdominal/thoracic lesions. In these instances, the
phrenic nerve is disturbed
 Herniation of abdominal organs (e.g stomach, intestine, spleen, etc) into the
thoracic cavity may occur following the rupture of the diaphragm (as may
occur in auto accident, when there is a sudden increase in intrabdominal pressure)
 Hiatal hernia is characterised by protrusion of part of the stomach into the
thorax through the oesophageal hiatus
 The diaphragm may also be congenitally defective. In most cases, posterolateral
defect of the diaphragm occurs. Thus, abdominal organs are prone to herniation
(through this defect) into the thorax
CHAPTER 8: HISTOLOGY OF THE RESPIRATORY SYSTEM

Structure of the Pleura
The pleura
 Is covered on its free surface (the aspect facing the pleural cavity) by the
mesothelium, a layer of squamous cells.
 Has a layer of basal lamina that supports the mesothelium. The basal lamina is a
layer of loose connective tissue that contains fibroblasts, macrophages, abundant
elastic fibres, numerous blood and lymphatic vessels and nerve fibres.
 Possesses some microvilli on the free surfaces of its mesothelial cells
 Resembles the peritoneum in its structures
Structure of the Trachea and Extrapulmonary Bronchi

 The trachea and large bronchi consist of the mucosa, submucosa, hyaline
cartilage and smooth muscle cells. The last two structure lies in a fibrous
membrane
 An external layer of deep fascia – adventitia – surrounds the trachea and
extrapulmonary bronchi
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Concerning the mucosa of the trachea and large bronchi, note the following:
 The epithelium is the ciliated pseudostratified columnar type (Fig. 8, 31)
 Goblet cells intersperse the ciliated cells of the epithelium
 All cells of the epithelium – ciliated columnar and goblet cells – are in contact
with the underlying basal lamina
 Ciliary movement, created by cilia of the columnar cells, drives the overlying
mucus towards the pharynx
 Just external to the epithelium is the lamina propria – a layer of loose
connective tissue rich in longitudinally-disposed elastic fibres. It also possesses
occasional lymphoid aggregations.
The submucosa of the trachea

 Is of loose connective tissue. It lies external to the lamina propria of the mucosa
 Contains numerous blood vessels, nerve fibres and scattered lymphoid tissue
 Possesses some tubular glands that produce mucin (mucoprotein).
Figure 31. Transverse section through the trachea
Tracheal Cartilages and Smooth Muscle Fibres (Trachealis)

 External to the submucosa of the trachea and large bronchi is a layer of fibrous
membrane
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 The fibrous membrane consists of collagen and elastic fibres. It is essentially of

dense irregular connective tissue.
 16–20 C-shaped rings of hyaline cartilage are embedded within the fibrous
membrane of the trachea (Fig. 31). These cartilages are arranged one on top of
the other, from above downwards. Each is surrounded by the perichondrium,
and is deficient posteriorly .
 Transversely-disposed smooth muscle fibres – trachealis – occupy the gaps
between successive rings of cartilage and between their posterior ends (Fig. 31).
Longitudinal smooth muscle fibres are also found external to the transverse ones.
 Contraction of the smooth muscle fibres of the trachea and of the large bronchi
reduces the cross-sectional area of these organs.
 Tracheal hyaline cartilage does not ossify with age though it becomes
increasingly fibrous
 The entire tracheal and bronchial tubes are surrounded externally by fibrous
connective tissue – the adventitia
Structure of the Lung
In the substance of each lung are the following:

 Intrapulmonary air passages of variable calibres (bronchi, bronchioles, alveolar
ducts, etc).
 Alveolar sacs and alveoli. These are associated with the terminal ends of
intrapulmonary air passages.
 Connective tissue septa that surround the air passages, and which separate the
alveoli
 Branches of the pulmonary artery and tributaries of pulmonary veins. These
supply the air passages and alveoli.
 Plexuses of blood capillaries associated with the alveoli
Respiratory Passages
Each lung contains the following air passages:

 Intrapulmonary bronchi. These include terminal parts of lobar bronchi,
segmental bronchi and bronchi of smaller calibres
 Several generations of bronchioles that continue distally from the bronchi. The
smallest and most distal of the bronchioles are the respiratory bronchioles.
 Alveolar ducts and atria. These continue distally from the respiratory
bronchioles
 Alveolar sac (air saccules), which arise from the atria and contain the alveoli (for
gaseous exchange). The latter are up to 300 million in adults.
Lobules of the Lungs
Regarding the lobules of the lungs, note the following:

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 The lobules of the lungs are the functional units of the lung and are of varying
sizes
 The smallest lobule is a primary lobule. It consists of a respiratory bronchiole,
associated alveolar duct, atria, alveolar sacs, alveoli, blood vessels, lymphatics,
nerve fibres, and the surrounding connective tissue
 The lobules are delineated by connective tissue septa
 Each lobule is pyramidal, with the base peripherally directed and the apex facing
the hilus
 The base of each lobule is recognizable on the surface of the lung as a polygonal
area bounded by connective tissue septa.
Intrapulmonary Bronchi

 In the lung, intrapulmonary bronchi divide dichotomously into several
generations of smaller tubes
 The mucosa of intrapulmonary bronchi is longitudinally ridged. It is lined by
pseudostratified ciliated columnar epithelium similar to that of the
extrapulmonary bronchi
 Goblet and Clara cells also intersperse the ciliated columnar cells of the bronchial
epithelium.
 external to the epithelium is the basal lamina (of bronchial mucosa)
 External to the basal lamina is the lamina propria, rich in reticular and elastic
fibres. The lamina propria is the most external part of the bronchial mucosa
 External to the lamina propria is the submucosa. This layer of loose connective
tissue contains two helical bands of smooth muscle fibres. These bands run in
opposite directions.
 Mucous and serous tubular glands are also found in the bronchial submucosa.
The ducts of these glands traverse the mucosa to reach the bronchial lumen
 Hyaline cartilage of intrapulmonary bronchi is reduced into small plates scattered
along the bronchial tubes.
Bronchioles
Regarding the bronchioles, note the following:

 Intrapulmonary bronchi continue distally as bronchioles.
 The structure of the bronchioles is similar to that of the intrapulmonary bronchi
except that cartilaginous plates are absent.
 The mucosa of the bronchioles is lined largely by a layer of ciliated columnar
cells, and is folded into longitudinal ridges (that permit adjustment of bronchiolar
diameter).
 Goblet cells are absent in the epithelium of the bronchioles. However, some
apocrine Clara cells are present; these non-ciliated cells produce proteins that
protect the bronchiolar lining against pollutants and inflammation.
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 Numerous smooth muscle cells exist external to the lamina propria of

bronchiolar mucosa. Contraction of these fibres is under neural and hormonal
control. They relax slightly during inspiration but contract during expiration.
 Locally released substances such as serotonin and histamine may produce spasm
of bronchiolar wall.
The terminal bronchiole

 Is the most distal conductive part of the bronchioles (Fig. 32). No gaseous
exchange occurs at the level of the terminal bronchiole owing to the absence of
alveoli in its wall.
 Is lined by ciliated columnar epithelium devoid of goblet cells. Clara cells are
however present (see above)
 Possesses no cartilage but has abundant elastic and smooth muscle fibres
The respiratory bronchiole

 Arises from the terminal bronchiole. It gives rise to 2–11 alveolar ducts; and
supplies the primary lobule of the lung.
 Bears a few scattered alveoli on its wall (opposite the side along which the
branch of the pulmonary artery runs).
 Is lined by non-ciliated simple cuboidal epithelium (Fig. 8). This is devoid of
goblet cells
 Possess smooth muscle cells and abundant elastic fibres external to the
epithelium
 Is involved in the process of gaseous exchange (by means of the associated
alveoli)
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Figure 32. Structure of bronchioles and alveoli
The alveolar duct

 Arises from the respiratory bronchiole (Fig. 32)
 Pursues a tortuous course and gives rise to expanded channels termed atria.
These lead into the alveolar sacs, which contain the alveoli.
 Is lined by a non-ciliated low cuboidal epithelium
 Possesses some smooth muscle cells and elastic fibres in its wall.
Alveolar Sacs and Alveoli
Note that
 Alveoli sacs arise from alveolar ducts. They possess numerous alveoli in their
walls (Fig. 32). A complement of about 300 million alveoli is found in the adult
human
 Alveolar sacs and alveoli are supported by a network of reticular and elastic
fibres. Adjacent alveoli are separated by interalveolar connective tissue septa
 Numerous plexuses of blood capillaries also surround the alveoli, and so are
lymph vessels, macrophages and fibroblasts.
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 Gaseous exchange occurs mainly across the alveoli

 Following trauma, alveolar cells may be replaced by connective tissue scar
Structure of the Alveolus
Regarding the alveolus, note that:

 An alveolus is lined by two types of epithelial cells. These are type I and type II
alveolar epithelia cells
 Type I alveolar epithelia cells are the most numerous. They are squamous cells,
about 0.05 µm in thickness. Each has sparse organelles and a bulging nucleus. It
is connected to adjacent type I cells by zonulae adherentes.
 The basement membrane of alveolar cells and that of capillary endothelium
form a single continuous layer, about 0.1 µm thick.
 The diffusion barrier (air-blood barrier) between alveolar air and capillary blood
is just about 0.2 µm across.
 Type I alveolar epitheliocytes have a lifespan of about 3 weeks.
 Type II alveolar epithelial cells are rounded and rich in organelles and secretory
vesicles. These cells produce surfactant, which reduces alveolar surface tension
and prevents the alveoli from collapsing during respiration

 Alveolar phagocytes (dust cells) remove particulate materials from alveolar
surface.
 Alveolar phagocytes are macrophages similar to those of connective tissue.
These cells migrate to the alveoli from adjacent connective tissue.
 In addition to removing foreign bodies, alveolar phagocytes engulf red blood
cells that enter the alveoli in such conditions as congestive heart failure. Thus,
they are also called ‘heart failure cells’.
 Alveolar phagocytes appear brick red following phagocytosis of red blood cells.
This gives the sputum a brick red colouration, which is of diagnostic importance.
 The lifespan of alveolar phagocytes is about 4 days.
Airway Defence Mechanisms
Factors that defend the airway against infections include:

 Ciliary rejection current, in which the current created by cilia of the respiratory
epithelium drives particulate matters (trapped in mucus) towards the pharynx
 Forceful removal of particulate materials in muscular activity such as coughing
 Secretions from goblet cells and tubular glands of the airway in response to
irritation or neural stimulation
 The presence of lysozyme and immunoglobulin A in the glandular secretions.
These prevent bacterial invasion of the airway.
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 Moisturizing effect of the glands of the airway. This protects the airway against
desiccation.
CHAPTER 9: GROSS ANATOMY OF THE CARDIOVASCULAR

SYSTEM
Fibrous Pericardium
The fibrous pericardium

 Is the external fibrous part of the fibroserous sac (pericardium) that invests the
heart and adjacent parts of the great vessels. It forms a tough conical covering for
the heart (Fig. 27).
 Extends from the 2nd–6th costal cartilages anteriorly; and from the 5th–8th
thoracic vertebrae posteriorly.
 Blends above with the pretracheal fascia of the neck
 Is attached to the central tendon and adjacent muscular part of the diaphragm by
the pericardiacophrenic ligament of loose fibro-areolar tissue
 May be separated from the diaphragm with little effort except over a small area
where it adheres strongly to the central tendon
 Is attached to the sternum at its upper and lower ends by the superior and inferior
sternopericardial ligaments, respectively
 Is connected to structures of the posterior mediastinum by loose connective
tissue.
 Has a base that rests on the diaphragm and an apex that continues upwards
around the aorta and pulmonary trunk. It also invests the lower half of the SVC.
 Is very tough and inelastic, thereby holding the heart in place
Relations of the Fibrous Pericardium
Regarding the relations of the fibrous pericardium, note the following points:
 Anteriorly, the pericardium is separated from the sternum by the lungs and
pleural cavity (above the level of the 4th pair of costal cartilages) (Fig. 27)
 The fibrous pericardium is also closely related anteriorly to the transversus
thoracis muscles (between the 4th and 6th costal cartilages of the left side)
 The lateral relations of the pericardium include (on each side) the phrenic nerve,
pericardiacophrenic artery, mediastinal pleura, pleural cavity and the lung
 The posterior relations of the pericardium include the main bronchi,
oesophagus, descending thoracic aorta and the oesophageal plexus of nerves
 Inferiorly, the pericardium is separated from the fundus of the stomach and the
liver by the diaphragm.
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Pericardium and the Great Vessels
The fibrous pericardium

 Invests the four pulmonary veins as these vessels enter the left atrium; and the
SVC as it enters the right atrium.
 Also invests the ascending aorta, pulmonary trunk and the right and left
pulmonary arteries
 Does not invest the thoracic part of the inferior vena cava.
Serous Pericardium
Note that the serous pericardium:

 Is the serous membrane that bounds the pericardial cavity. The cavity surrounds
the heart, and contains a thin film of serous fluid that prevents friction as the
heart contracts within the tough fibrous pericardium.
 Has a parietal layer that lines the internal surface of the fibrous pericardium; and
a visceral layer (epicardium) that intimately invests the external surface of the
heart and associated great vessels.
 Forms a common investment for the ascending aorta and pulmonary trunk
 Also forms a common tube for the SVC, inferior vena cava and pulmonary veins
As the visceral layer of the serous pericardium is reflected to join the parietal
pericardium, two sinuses (local dilatations of the pericardial cavity) are formed.
Note that
 The transverse sinus is a transverse channel between the aorta and pulmonary
trunk anteriorly and the right and left atria posteriorly. It is of importance during
cardiac surgery
 The oblique sinus is formed as the visceral pericardium that lines the pulmonary
veins and venae cavae is reflected onto the fibrous pericardium (as parietal
pericardium), behind the left atrium. This sinus forms a blind sac that opens
downwards and to the left.
Arterial Supply of the Pericardium
The pericardium receives arterial blood from the following:

 Pericardiacophrenic artery, a branch of the internal thoracic artery. This
accompanies the phrenic nerve as it descends between the fibrous pericardium
and mediastinal pleura
 Musculophrenic artery, also a branch of the internal thoracic artery
 Some branches of the descending thoracic aorta, including the oesophageal,
bronchial and superior phrenic arteries. These supply the posterior aspect of
the pericardium.
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 Coronary arteries, which supply the heart and the visceral layer of the serous
pericardium.
Venous Drainage and Innervation of the Pericardium
Note that:
 The pericardium is drained by the pericardiacophrenic veins. The latter drain
into the internal thoracic or brachiocephalic veins.
 Some veins of the pericardium also end as tributaries of the azygos system of
veins
 The phrenic nerves supply sensory fibres to the fibrous pericardium, as well as
the parietal layer of serous pericardium
 Autonomic fibres (from the vagus nerves and sympathetic chains) supply the
visceral layer of serous pericardium
Applied Anatomy of the Pericardium

 Pain from the pericardium is referred to the supraclavicular (shoulder) region
 Inflammation of the pericardium – pericarditis – may occur. This is associated
with chest pain and pericardial rub
 Calcification of the pericardium may occur in certain inflammatory conditions
 The pericardial cavity may become a ‘real’ space when filled with pathological
fluid, as in congestive heart failure, pericarditis, etc
 Compression of the heart – cardiac tamponade – occurs when large amounts of
fluid accumulate in the pericardial cavity, from variable sources (e.g., bleeding
into the cavity, pericardial effusion, etc).

 Excess fluid in the pericardial cavity can be drained by pericardiocentesis
 Pericardiocentesis is performed by inserting a needle through the left 5th or 6th
intercostal space, close to the sternum
 The internal thoracic artery is at risk when approaching the pericardial cavity
through the left 5th intercostal space
 A second approach to the pericardial cavity in pericardiocentesis is to insert the
needle through the left costoxiphoid angle and then direct it posterosuperiorly.
 Haemopericardium may arise from a penetrating chest wound, perforation of
the heart in myocardial infarction, or may be a complication of cardiac surgery. It
is characterised by accumulation of blood in the pericardial cavity and may result
in cardiac tamponade
 The transverse sinus is of great importance to cardiothoracic surgeons in
operations of the heart. It permits clamping of the ascending aorta and pulmonary
trunk.
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Heart (Cor)
The heart
 Is a conical, hollow muscular organ that pumps blood through the vessels of the
body. It has an apex, a base, three surfaces and four borders
 Lies obliquely in the middle mediastinum such that its apex is directed forwards
and to the left, while the base faces backwards and to the right. The larger part
(⅔) of the heart is to the left of midline, while ⅓ is to the right.
 Is divided internally (by interatrial and interventricular septa) into four chambers.
These are two atria and two ventricles
 Contracts about 42 million times in a year (average of 72 times a minute when at
rest). Heart rate can reach 120 times a minute during exercise.
Concerning its dimension, the heart

 Weighs 20–25 g at birth, and 280–340 g (average of 310 g) in adult males (about
0.5% of body weight). It has an average weight of 225 g in adult females
 Is roughly the size of the individual’s clenched fist.
 Measures about 12 cm from base to apex
 Is 9 cm transversely at its widest part and about 6 cm anteroposteriorly. Thus, it is
somewhat flattened transversely.
 Has two ventricles, each of which has a volume of 90–120 ml.
External Features of the Heart
Note that
 The heart contains four chambers: two atria and two ventricles.
 A coronary sulcus runs transversely round the heart, close to its base. This
sulcus separates the atria posterosuperiorly from the ventricles anteroinferiorly
(Fig. 33). It lodges the coronary arteries.
 A non-prominent, vertically-disposed interatrial groove marks the junction of
the atria, on the posterior surface of the heart.
 An interatrial groove is also present between the atria anteriorly, but this is
hidden from view by the pulmonary trunk and aorta
 The position of the interventricular septum (between the ventricles) is indicated
on the external surface by the anterior and posterior interventricular grooves.
 The anterior interventricular groove lies on the sternocostal surface of the
heart, closer to the left cardiac border. It lodges the anterior interventricular
artery and the great cardiac vein (Fig. 33)
 The posterior interventricular groove runs on the diaphragmatic surface of the
heart, closer to the right cardiac border. It lodges the posterior interventricular
artery and the middle cardiac vein (Fig. 34).
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 The two interventricular grooves commence at the base of the ventricles and end
by being continuous with each other just a little to the right of the apex of the
heart (apical incisure)
The Base of the Heart

 Is flattened and quadrilateral in outline
 Is not the surface resting on the diaphragm, but that which is directed posteriorly
towards the vertebral column
 Is formed largely by the left atrium (with a little contribution from the right one)
(Fig. 34)
 Extends from the pulmonary arteries above to the level of coronary sinus below
 Is bounded on the right by the right border of the right atrium and on the left by
the left atrium
 Receives the openings of the left pulmonary veins near its left margin; and those
of the right pulmonary veins just to the left of the interatrial groove
 Receives the SVC and IVC into the upper and lower angles, respectively, of the
part formed by the right atrium
 Is separated from the four middle thoracic vertebrae (T5-T8) by the oesophagus,
descending thoracic aorta, thoracic duct, pericardium, vagus nerves, azygos veins
and pericardial cavity
 Is anterior to the oblique sinus of the pericardial cavity
 Lies a little lower in the erect position
The apex of the heart

 Is formed completely by the left ventricle (Fig. 33)
 Is directed downwards, forwards and to the left. It is under the cover of the left
pleura and lung
 Lies at the level of the left 5th intercostal space, about 7.5–9 cm (a hand breadth)
from the midline, just medial to the left midclavicular line. It is just below the left
nipple in males
 Could be as high as the 4th intercostal space in children and as low as the 6th space
in tall slim adults.
 Corresponds to the position of the apex beat and the site for the detection of the
sound of the mitral valve.
Surfaces of the Heart
The sternocostal surface of the heart

 Faces forwards, upwards and to the left
 Is related to the pericardium, pleurae, lung, transversus thoracis muscles and 3 rd–
6th costal cartilages (Fig. 27)
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 Is closely apposed to the thoracic wall in the region of the cardiac notch, between
the left 4th–6th costal cartilages (where the left line of pleural reflection deviates to
the left)
 Is more to the left of the midline (⅔) than to the right (⅓)
 Receives variable contributions from all the chambers of the heart, but mainly
from the ventricles (especially the right ventricle)
 Is separated into the atrial part (that lies above and to the right of the anterior part
of the coronary sulcus) and the ventricular part (that lies below and to the left of
the same sulcus)
Figure 33. Sternocostal surface of the heart
Note that
 The atrial portion of the sternocostal surface is formed largely by the right atrium,
with a little contribution from the right and left auricles (as these curve forwards
and medially round the roots of the ascending aorta and pulmonary trunk)
 ⅔ of the ventricular part of the sternocostal surface is formed by the right
ventricle, while ⅓ is formed by the left ventricle
 The anterior interventricular groove lies on the sternocostal surface; it separates
the ventricles from each other.
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The diaphragmatic surface of the heart

 Is directed inferiorly and somewhat posteriorly (Fig. 34). It rests on the central
tendon and adjacent left dome of the diaphragm
 Is formed largely by the left ventricle, with a little contribution from the right
ventricle. The ventricles are separated on this surface by the posterior
interventricular groove (which lodges the posterior interventricular artery and
middle cardiac vein)
 Is separated from the base of the heart by the coronary sulcus
Figure 34. Diaphragmatic surface and base of the heart
The left surface of the heart

 Is directed upwards, backwards and to the left
 Is convex from above downwards, and from anterior posteriorly
 Is crossed in its upper part by the coronary sulcus
 Is formed by the left ventricle (below the level of the coronary sulcus) and by the
left atrium and its auricle (above the level of the coronary sulcus).
 Is related to the left phrenic nerve and pericardiacophrenic vessels. These
structures descend to the diaphragm (over the left cardiac surface). Besides, it is
also related to the left pleura and lung
 Produces the cardiac impression of the left lung (just anteroinferior to the hilus of
this lung)
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Borders of the heart
The superior border of the heart

 Is rounded in outline. It is formed by the upper margins of the atria (mainly of the
left)
 Lies at the level of the 3rd costal cartilage
 Is hidden from anterior view by the ascending aorta and pulmonary trunk
 Is related above to the right and left pulmonary arteries (that lie just above it)
 Receives the SVC at its right end
The right border of the heart

 Is rounded and gently convex to the right. It is formed by the right atrium (Fig.
33)
 Is continuous above and below, respectively, with the right margins of SVC and
IVC
 Has a shallow vertically-disposed groove – sulcus terminalis – that runs between
the SVC (above) and the IVC (below). This groove marks the position of an
internal ridge – the crista terminalis
 Forms part of the right margin of the mediastinal shadow seen in AP
radiographs of the thorax
The left border of the heart

 Separates the sternocostal and the left surfaces of the heart. It is rounded and
slightly convex to the left
 Is formed largely by the left ventricle, with a little contribution from the left
auricle
 Forms the lower part of the left margin of the mediastinal shadow seen in AP
radiographs of the thorax
The inferior border of the heart

 Is sharp, in contrast to the others, which are rounded
 Lies horizontally at the level of the xiphisternal joint
 Separates the sternocostal and diaphragmatic surfaces of the heart
 Extends from the apex of the heart to the lower end of the right margin of this
organ
 Bears an apical incisure, just to the right of the apex of the heart. Here, the
anterior and posterior interventricular grooves meet
 Is formed mainly by the right ventricle, with a little contribution from the left
ventricle (the junction between these being the apical incisure).
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Surface Marking (Surface Projection) of the Heart

 The apex of the heart commonly lies at the left 5th intercostal space, about 9 cm
from the midline, and just medial to the left midclavicular line
 The apex of the heart may however be found at the 4th–6th intercostal spaces, 6-
10 cm from the midline, depending on the build of the individual
 The right border of the heart is slightly convex to the right. It lies at a maximum
distance of 4 cm from the midline (at the level of the 4th intercostal space), and
extends from the right 3rd to the right 6th costal cartilages
 The left border of the heart is convex. It is directed to the left and slightly faces
upwards. It extends from the left 2nd costal cartilage (about 1.2 cm from the
midline) above, to the apex of the heart below
 A line, which joins the upper ends of the right and left borders of the heart,
represents the upper border of this organ. This border is formed by the atria
 The inferior border of the heart lies horizontally behind the xiphisternal joint. It
extends from the lower end of the right border to the apex of the heart.
Chambers of the Heart
The right atrium

 Is roughly quadrangular in outline (Fig. 35)
 Possesses an auricle that extends forwards from its upper part. This surrounds the
root of the ascending aorta
 Receives the openings of the SVC, IVC and coronary sinus
 Bears a vertical sulcus terminalis on the external aspect of its lateral (right) wall
 Forms the right border of the heart, and contributes to its sternocostal surface
 Is covered anteriorly by the anterior part of the right pleura and lung. These
separate it from the anterior thoracic wall
 Is related laterally to the phrenic nerve and pericardiacophrenic vessels. These
separate it from the right mediastinal pleura and lung
 Lies anterior and to the right of the left atrium, the interatrial septum separating
them
 Is crossed behind by the right pulmonary veins (as these approach the left
atrium). The inferior pulmonary vein lies just above the middle of the right atrium
 Is related medially, in its upper part, to the ascending aorta
- 165 -
Figure 35. Chambers of the heart and direction of blood flow
Interior of the Right Atrium
Regarding the interior of the right atrium, note the following:

 The right atrium has two distinct parts: a posterior smooth part – sinus venarum
– and an anterior rough part – atrium proper. The latter extends into the right
auricle
 The crista terminalis (a vertical ridge) is located on the lateral aspect of the
interior of the right atrium. It separates the smooth and rough parts of the right
atrium.
 The sinus venarum is a derivative of the absorbed right horn of the sinus
venosus
 The rough part of the right atrium (atrium proper) is derived from the primitive
atrium proper
 Several, nearly parallel muscular ridges – musculi pectinati – line the wall of the
atrium proper
 Musculi pectinati commence at the crista terminalis and run on the lateral and
anterior walls of atrium proper, towards the right atrioventricular orifice
 The muscular ridges of the right auricle are mainly in the form of network, not
parallel ridges.
Orifices associated with the sinus venarum
Note the following:
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 The SVC opens into the posterosuperior part of the right atrium. Its orifice is
directed downwards and forwards, and has no valves.
 The inferior vena cava (IVC) opens into the lower end of the right atrium (at a
more posterior level than the orifice of SVC).
 The orifice of IVC has a small crescentic valve – valve of IVC – that is attached
to the anterior margin of IVC orifice.
 The concave free (posterior) margin of the valve of IVC is continuous with the
crista terminalis on the right, and the limbus fossae ovalis on the left
 During foetal life, the valve of IVC directs blood through the foramen ovale into
the left atrium. It may be cribriform or absent
 The right atrioventricular orifice links the right atrium and the right ventricle
together
 The opening of the coronary sinus is located between the right atrioventricular
orifice and the orifice of IVC
 A small valve of coronary sinus guards the orifice of the coronary sinus. This
valve prevents backflow of blood into this sinus. It is a semilunar fold of
endocardium
 The valve of coronary sinus is unicuspid and semicircular. It may be cribriform
(perforated) or duplicated
In addition, note the following points:

 Foramina venarum minimarum are the openings of minute venae cordis
minimae (Thebesian veins) in the right atrium and other chambers of the heart.
These veins are more numerous on the atrial septa wall
 The anterior cardiac vein opens independent of the coronary sinus, into the right
atrium.
 The right marginal vein may open into the right atrium directly
 Just below the orifice of the SVC is an indistinct venous tubercle on the
posterior wall of the right atrium. This tubercle may direct the superior caval
blood into the right atrioventricular orifice in the foetus.
Musculi Pectinati
 Are found on the wall of the atrium proper and the wall of the right auricle
 Commence at the crista terminalis and run on the lateral and anterior walls of
atrium proper, towards the right atrioventricular orifice
 Are parallel muscular ridges in the atrium proper, but form network in the right
auricle
 Are absent in the sinus venarum. Thus, this appears smooth.
The crista terminalis

 Is a vertical ridge on the internal aspect of the right wall of the right atrium
- 167 -
 Is indicated on the external surface of the right wall of the right atrium by a
sulcus terminalis
 Commences above in the upper part of the atrial septum, crosses first anterior to
the orifice of the SVC, and then descends on its right side, to continue
downwards on the right wall of the right atrium. Below, it ends to the right of the
orifice of IVC.
 Separates the sinus venarum from atrium proper
 Represents the remains of the embryonic right venous valve
The fossa ovalis (oval fossa)

 Is an oval depression on the atrial septum. It has the size of a thumbprint. This
fossa represents the site of the embryonic foramen ovalis, which allows blood to
shunt from the right atrium to the left atrium
 Lies more to the lower part of atrial septum (above and to the left of IVC orifice)
 Has a floor formed by the septum primun of embryonic heart
 Has a raised margin – limbus fossae ovalis – at its upper border and adjacent part
of its sides. This margin is a derivative of the septum secundum
 May possess an abnormal opening – patent foramen ovale – in 25% of
newborns. This is an atrial septal defect that allows oxygenated blood to shunt
from the left to the right atrium.
Right Ventricle
External Features
The right ventricle

 Extends from the right atrioventricular orifice to a point near the apex of the heart
(Fig. 35)
 Forms the larger part of the sternocostal and a small part of the diaphragmatic
surface of the heart
 Forms the major part of the inferior border of the heart
Relations of the right ventricle include:

 Above, behind and to the right: right atrium
 Anteriorly: anterior thoracic wall, with a variable part of the pleurae and lungs
interposed between them
 Inferiorly: central tendon and adjoining part of the left dome of the diaphragm
 Behind and to the left: interventricular septum and the left ventricle
The Walls of the Right Ventricle
When sectioned, note that:

 The wall of the right ventricle form a crescentic outline transversely
 The wall of the left ventricle is about three times thicker than that of the right.
The latter has a thickness of about 4 mm
- 168 -
 The wall of the right ventricle is thicker towards its base but thinner towards the
apex
 The interventricular septum is very thick. It has a convexity directed towards the
right ventricle.
Interior of the Right Ventricle
Regarding the interior of the right ventricle, note the following:

 Two parts are defined: a lower inflow part and an anterosuperior outflow part.
The latter is the infundibulum or conus arteriosus
 A thick muscular ridge – supraventricular crest – separates the inflow and
outflow parts of the right ventricle
 The supraventricular crest lies in the posterosuperior part of the right ventricle,
between the right atrioventricular and pulmonary orifices
 The inflow part receives blood from the right atrium through the tricuspid (right
atrioventricular) orifice. It is roughened and ridged by muscular ridges called
trabeculae carneae
 The infundibulum (outflow part) is funnel-shaped. Thus, it tapers superiorly to
become continuous with the pulmonary trunk through the pulmonary orifice.
The infundibulum lies above and anterior to the inflow part
 The wall of the infundibulum is smooth owing to the absence of trabeculae
carneae
The infundibulum of the right ventricle

 Is a derivative of the embryonic bulbus cordis
 Maintains its muscular tone during ventricular diastole, thereby giving
mechanical support to the pulmonary valve (in diastole). Thus, it prevents this
valve from giving way to the back pressure of blood in the pulmonary trunk.
Right Atrioventricular (Tricuspid) Orifice
The tricuspid orifice

 Is located at the base of the right ventricle. It links the right atrium and right
ventricle together (Fig. 35)
 Is guarded by the tricuspid valve. This closes the orifice at ventricular systole
 Is oval in outline and larger than the left atrioventricular orifice
 Admits the tips of three or even four fingers
 Has a fibrous ring around it. This prevents its distension as blood passes through
it from the right atrium to the right ventricle under pressure
 Lies behind the sternum at the level of the 4th intercostal space
 Is separated from the pulmonary orifice by a distance of about 2.5 cm. The
anterior cusp of tricuspid valve intervenes between the two orifices.
Right Atrioventricular (Tricuspid) Valve
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The tricuspid valve

 Has three roughly triangular cusps, namely anterior, posterior and septal cusps
 Consists of fibrous tissue covered by the endocardium (a layer of squamous cells)
 Has a smooth atrial and a rough ventricular surface
 Is attached, through the bases of its cusps, to the fibrous ring around the tricuspid
orifice
 Frequently has accessory cusps between the three major ones
Regarding the cusps of the tricuspid valve, note the following points:
 The anterior cusp is the largest. It lies superiorly, between the infundibulum of
the right ventricle and the right atrioventricular orifice
 The posterior cusp lies towards the inferior aspect of the tricuspid orifice
 The septal cusp is apposed to the interventricular septum
 The bases of these cusps (main and accessory) are attached to the fibrous ring
that surrounds the tricuspid orifice; and these bases are linked to each other
 Each cusp is thick centrally but thin at the peripheral margin, where it is
irregularly notched
 The apices, ventricular surfaces and borders of the cusps give attachment to
chordae tendineae. The latter are fibrous strings that connect the cusps to the
papillary muscles
 Blood vessels and nerve fibres are limited to the bases of the cusps
The trabeculae carneae of the right ventricle

 Are muscular ridges in the inflow part of the right ventricle. These make this part
appear rough. Trabeculae carneae are absent in the infundibulum.
 May exist either as small ridges or large papillary muscles
 Form a relatively large septomarginal trabecula (moderator band) that extends
from the ventricular septum to the anterior papillary muscle. It conveys the right
limb of atrioventricular bundle (of His)
Regarding the papillary muscles of the right ventricle, note the following points:
 The right ventricle has three papillary muscles, namely anterior, posterior and
septal papillary muscles
 Each papillary muscle (being conical) is attached at its base to the ventricular
wall. Its apex gives attachment to numerous chordae tendineae.
 chordae tendineae connect the apices of papillary muscles to the ventricular
surfaces and margins of the cusps of tricuspid valve
 The anterior papillary muscle (the largest) is attached to the anterior wall of the
right ventricle. It sends chordae tendineae to the anterior and posterior cusps of
tricuspid valve
 The posterior papillary muscle, usually comprising two or three bands, sends
chordae tendineae to the posterior and septal cusps.
 Septal papillary muscles constitute a group that sends chordae tendineae to the
septal and anterior cusps of tricuspid valve.
- 170 -
 Contraction of papillary muscles ensures apposition of the cusps of tricuspid

valve, and thus, closure of the tricuspid orifice during ventricular systole.
 Eversion of the tricuspid valve into the right atrium is also prevented by the
action of papillary muscles at ventricular systole.
Pulmonary Valve and Orifice
The pulmonary valve

 Guards the pulmonary orifice. Thus, it lies at the junction of the infundibulum
(of the right ventricle) and the pulmonary trunk.
 Comprises three cusps: right, left, and anterior
 Consists of fibrous tissue covered by the endothelium on its arterial aspect and
the endocardium on its ventricular aspect
 Is attached, through the bases of its cusps, to the origin of the pulmonary trunk
 Lies behind the sternal end of the left 3rd costal cartilage
Each cusp of the pulmonary valve

 Is located opposite a pulmonary sinus (an outpouching of the wall of the
pulmonary trunk at its root)
 Is attached at its base to the root of the pulmonary trunk
 Is concave on its upper surface. Thus, it appears convex when viewed from
below
 Bears a thick fibrous nodule at the middle of its free margin. This presses against
other nodules during diastole, when elastic recoil of the pulmonary trunk forces
blood towards (but not into) the right ventricle
 Has some fibrous tissue radiating through it, from the nodule to its attached
margin (except at the crescentic lunule, which lies along is free margin, adjacent
to the nodule). The lunule also presses against other lunules at diastole.
 Is pushed towards the pulmonary trunk (by the outflowing blood) at ventricular
systole. In this instance, it lies against the pulmonary sinus.
Left Atrium
The left atrium

 Is smaller than the right atrium, though it has thicker walls (about 3 mm thick)
 Is cuboidal in outline
 Has a small conical projection – the left auricle. This arises from the upper left
angle of the left atrium, and lies anterior to the root of the pulmonary trunk.
 Constitutes the major part of the base of the heart
 Is separated from the right atrium by the obliquely set interatrial septum
 Is formed mainly by the absorption of the pulmonary veins into its wall during
embryonic development
- 171 -
 Usually receives two pulmonary veins on each side. These convey oxygenated
blood from the lungs
Relations of the Left Atrium

 Anterior and to the right: the right atrium. The two atria are separated by the
interatrial septum
 Anteriorly: the transverse sinus. This is a dilated portion of the pericardial
cavity; it separates the upper part of the anterior surface of the left atrium from
the pulmonary trunk and ascending aorta
 Above: tracheal bifurcation and pulmonary arteries
 Posteriorly: descending thoracic aorta and oesophagus. The oblique sinus also
lies behind the left atrium (between the openings of the right and left pulmonary
veins). Like the transverse sinus, it is a dilated part of the pericardial cavity.
Interior of the Left Atrium
The left atrium

 Has a smooth interior, except in the left auricle, where musculi pectinati are
present. These are smaller and fewer compared to those of the right auricle
 Receives two pulmonary veins on each side, the openings of which lie in the
upper part of the posterior aspect of the left atrium, one on top of the other. No
valves guard the openings of pulmonary veins into the atrium
 Also receives the foramina of venae cordis minimae (Thebesian veins), as does
the right atrium
 Bears a crescentic ridge on the interatrial septal surface. This ridge indicates the
position of the fossa ovalis of the right atrium
 Communicates with the left ventricle via the left atrioventricular orifice. This
orifice is guarded by the mitral valve
Left Auricle
The left auricle

 Is narrower, longer and more curved than the right one
 Is slightly constricted at its junction with the left atrium
 Possesses smaller and fewer musculi pectinati on the internal surface of its wall
(compared to the right auricle)
 Has deeper indentations along its margin when compared to the right auricle
 Overlaps the root of the pulmonary trunk anteriorly and forms part of the
sternocostal surface of the heart
Left Ventricle
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The left ventricle

 Forms the apex of the heart (Fig. 33)
 Forms a small part (⅓) of the sternocostal, but a larger part (⅔) of the
diaphragmatic surface of the heart
 Forms much of the left surface and margin of the heart. The remainder of this
margin being formed by the left auricle.
 Has an oval or rounded outline on transverse section (with a relatively thick wall)
 Is longer (from its base to apex) and more conical than the right ventricle
 Is much more muscular and thicker than the right ventricle. The left ventricle is
about 12 mm thick (about 3 time the thinness of the right ventricle). It is thickest
near its base and thinnest near the apex
 Is separated from the right ventricle by the interventricular septum. This
septum is concave towards the left ventricle; and it is located anterior and to the
right of the left ventricle.
 Communicates postero-inferiorly with the left atrium through the left
atrioventricular orifice; and anterosuperiorly with the ascending aorta through
the aortic orifice.
Relation of the Left Ventricle
Relations of the left ventricle include the following:

 Anteriorly: sternum, left costal cartilages, left lung and pleura
 Posteriorly: left atrium
 Inferiorly: diaphragm (this separates it from the fundus of the stomach)
 Anteriorly and to the right: right ventricle
 To the left: phrenic nerve, pericardiacophrenic vessels, mediastinal pleura and
lung of the left side
Interior of the Left Ventricle
Regarding the interior of the left ventricle, note these points:

 Trabeculae carneae line the interior of the left ventricle. These are fine muscular
ridges covered by the endocardium.
 The trabeculae carneae are finer and more numerous than those of the right
ventricle. They are much more prominent and numerous in the apex and posterior
wall of the left ventricle.
 Two papillary muscles (anterior and posterior papillary muscles) are present.
 Blood is directed from the mitral orifice towards the apex of the left ventricle,
and out through the aortic orifice.
The left atrioventricular orifice

 Is located at the base of the left ventricle (Fig. 35). It conveys blood from the left
atrium to the left ventricle.
 Lies just below, behind and to the left of the aortic orifice
- 173 -
 Is smaller than the right atrioventricular orifice. It admits the tips of two or
three fingers
 Is oval in outline, and has a margin lined by the fibrous ring. This ring gives
attachment to the mitral valve that guards the orifice.
Left Atrioventricular (Mitral) Valve
Regarding the mitral valve, note that:

 This valve has two triangular (anterior and posterior) cusps that are attached at
their bases to the fibrous ring of the mitral orifice
 Each cusp of the mitral valve consists of fibrous tissue covered by the
endocardium
 The cusps of the mitral valve are larger, thicker and stronger than those of the
tricuspid valve
 The anterior cusp of mitral valve is larger (15-18 mm long) than the posterior
cusp (10-12 mm long). It lies between the mitral orifice below and the aortic
orifice above.
 The anterior cusp is also smooth on both surfaces, as chordae tendineae are
attached along its margin only. Its ventricular surface is devoid of such
attachment
 The posterior cusp is smaller than the anterior one. It is located below and to the
left of the mitral orifice (while the anterior cusp lies above and to the right of this
orifice).
 The posterior cusp is rough on its ventricular but smooth on its atrial surface.
 The two cusps of mitral valve are continuous with one another at their sides
(close to their bases). They are however separate near their apices
 Each cusp receives chordae tendineae from the two papillary muscles of the left
ventricle
 Blood flows into the left ventricle on the atrial surface of the anterior cusp, and
out through the ascending aorta on the ventricular surface of this cusp. Thus, both
surfaces of the anterior cusp are smooth
 Accessory cusps are rare, though these may be present in the intervals between
the two major cusps
Papillary Muscles of the Left Ventricle
Note that
 Two papillary muscles – anterior and posterior papillary muscles – are present in
the left ventricle
 The base of the anterior papillary muscle is attached to the sternocostal wall of
the left ventricle. This muscle sends chordae tendineae, from its apex, onto both
cusps of the mitral valve.
 The posterior papillary muscle is attached to the diaphragmatic wall of the left
ventricle. It also sends chordae tendineae to both cusps of the mitral valve.
 Septal papillary muscle is absent in the left ventricle
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The aortic orifice

 Is circular in outline, and measures about 2.5 cm in diameter
 Lies above, in front of, and to the right of the mitral orifice (from which it is
separated by the anterior cusp of mitral valve)
 Has a valve – aortic valve – that separates the ascending aorta above from the
aortic vestibule below.
The aortic valve

 Guards the aortic orifice, such that blood flows from the aortic vestibule of the
left ventricle to the ascending aorta (and not in the reverse direction) (Fig. 35)
 Has three semilunar cusps: right, left and posterior. Each lies opposite an aortic
sinus
 Is attached (via the bases of its cups) to the fibrous ring of the aortic orifice
 Possesses larger, stronger and thicker cusps compared to the pulmonary valve
 Is comparable to the pulmonary valve in morphology and in the arrangement of
its cusps (see above)
The interventricular septum

 Separates the two ventricles from each other. It extends from a point just to the
right of the apex of the heart anteriorly, to the interval between the pulmonary
and tricuspid orifices on one part, and the aortic and mitral orifices on the other,
posteriorly
 Is obliquely set such that one surface faces anteriorly and to the right, while the
other faces posteriorly and to the left.
 Is attached to the sternocostal and diaphragmatic walls of the heart. The lines of
such attachment are indicated externally by the anterior and posterior
interventricular grooves (on the sternocostal and diaphragmatic surfaces,
respectively)
 Bulges into the right ventricle, such that its right surface is convex, while its left
aspect is concave
 Has two parts: a small posterior, oval fibrous part termed the membranous part
(about 1 mm in thickness) and a large, thick anterior muscular part.
The membranous part of interventricular septum

 Is the small oval posterior portion. It is transparent in the fresh state.
 Is located just below and to the right of the interval between the right and
posterior cusps of aortic valve
 Is crossed on its right surface by the line of attachment of the septal cusp of
tricuspid valve, such that it may be defined as having an anterior and a
posterior part
 Separates the two ventricles from each other in its anterior part (the part anterior
to the attachment of the septal cusp)
 Separates the right atrium from the aortic vestibule of the left ventricle in its
posterior part. Thus, the latter is also called the atrioventricular septum
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 May be malformed and defective in its anterior part, thereby giving rise to a form
of ventricular septal defect. In this condition, the right and left ventricles
communicate.
Factors that influence the position of the heart
The surface marking of the heart varies between individuals. It depends on:
 The build, age and sex of the individual
 Respiratory movements
 Position of the individual (erect or recumbent)
 Contractile activity of the heart (heart beat)
Besides, note that:

 The heart is more vertically-disposed in slim individuals
 The heart is more horizontally-disposed in thick-set individuals
 The surface markings of the valves of the heart do not correspond to auscultation
sites
Surface Projection of the Orifices and Valves of the Heart
Regarding the surface anatomy of heart valves, note that

 Pulmonary valve and orifice are the highest-placed of all the valves and orifices
of the heart. They are indicated on the anterior thoracic wall by an outline, 2.5 cm
wide, placed over the left sternal margin, at the level of the left 3rd costal cartilage
 The aortic orifice is located at the level of the 3rd intercostal space, over the left
half of the sternum
 The outline of the mitral orifice is about 3 cm wide. It is placed over the left half
of the sternum, at the level of the 4th costal cartilage
 The tricuspid orifice is located at the level of the 4th intercostal space,
immediately to the right of the midline. Its outline being about 4 cm wide.
Heart Sounds and Auscultation Areas
The sounds produced by valves of the heart are detectable as follows:

 Pulmonary area (for detecting the sound of the pulmonary valve): Over the left
2nd intercostal space or the left 3rd costal cartilage, close to the left sternal margin
 Aortic area: Over the right 2nd intercostal space or the right 2nd costal cartilage,
close to the sternal margin
 Tricuspid area: Over the lower end of the sternal body or xiphoid process
 Mitral area: Over the left 5th intercostal space, about 9 cm from the midline. This
corresponds to the apex beat of the heart.
Radiological Anatomy of the Heart (see the mediastinum)
Blood Supply of the Heart

- 176 -
Regarding the blood supply of the heart,

 The heart receives arterial blood from the right and left coronary arteries (Fig.
36)
 Large branches of the coronary arteries anastomose with one another. However,
terminal branches of coronary arteries do not anastomoses. Thus, these branches
are end-arteries
 The heart is drained mainly by the coronary sinus
 Certain small veins (venae cordis minimae) terminate in the chambers of the
heart, independent of the coronary sinus.
The left coronary artery

 Arises from the left aortic sinus. Initially, it passes forwards and to the left,
between the root of the pulmonary trunk and the left auricle. Then, it enters the
coronary sulcus, where it immediately divides into anterior interventricular
and circumflex branches. The latter continues in the coronary sulcus, reaching
the level of the posterior interventricular groove (behind)
 Is accompanied by the distal part of the great cardiac vein
 Is relatively larger than the right coronary artery
Figure 36. Coronary arteries
Branches of the left coronary artery include the following:

1. Anterior interventricular artery (Fig. 36). This traverses the anterior
interventricular groove, crosses the apical notch, and enters the posterior
interventricular groove. Here, it anastomoses with the posterior interventricular
artery
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2. Sinuatrial nodal branch. This is found in about 40% of the population. It

supplies the sinuatrial node
3. Circumflex artery. This traverses the coronary sulcus, where it anastomoses
with the right coronary artery, on the posterior surface of the heart. It gives off a
left marginal branch that supplies the left ventricle
Parts of the heart supplied by the left coronary artery include:

 Left atrium, through the circumflex branch
 Left surface of the heart, through the left marginal branch of circumflex artery
 Whole of the sternocostal surface of the left ventricle, and part of the same
surface of the right ventricle, via the anterior interventricular artery
 Sinuatrial node, through a (sinuatrial nodal) branch that arises near the origin of
the left coronary artery in about 40% of individuals
 Anterior ⅔ of the interventricular septum, through the branches of the anterior
interventricular artery
 Part of the diaphragmatic surface of the left ventricle

 The anterior interventricular artery is larger than the circumflex branch of left
coronary artery
 In about 15% of the population, the posterior interventricular artery (which is
normally a branch of the right coronary artery) arises from the left coronary
artery
 The left coronary artery may supply the entire heart. In this instance, the right
coronary artery is absent
 The circumflex branch of the left coronary artery may arise directly from the
right aortic sinus
 In about 4% of individuals, an accessory coronary artery may be present.
The right coronary artery

 Arises from the right aortic sinus. Initially, it runs forwards and to the right,
between the right auricle and the root of the pulmonary trunk. Then, it descends
through the coronary sulcus, on the sternocostal surface of the heart, gradually
inclining towards the right as it does so, down to the junction of the right and
inferior borders of the heart (Fig. 36).
 Continues in the posterior aspect of the coronary sulcus, to end just to the left of
the posterior interventricular groove
Branches of the right coronary artery include:

1. Sinuatrial nodal branch (in about 60% of the population). This arises near the
origin of the right coronary artery.
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2. Right marginal artery, given off at the lower end of the right border of the heart
(Fig. 36). This runs towards the apex of the heart, along the inferior border of this
organ.
3. A small atrioventricular nodal branch, which arises near the termination of the
right coronary artery
4. A large posterior interventricular artery, which runs through the posterior
interventricular groove, towards the apex of the heart (Fig. 36)
5. Other smaller branches that arise along its course.

 The posterior interventricular artery does not usually reach the apex of the
heart (as it anastomoses with the anterior interventricular artery in the anterior
part of the posterior interventricular groove)
 The right marginal artery is larger than the remainder (distal part) of the right
coronary artery. This artery usually does not reach as far distally as the apex of
the heart.
 The sinuatrial nodal branch of the right coronary artery runs on the anterior
surface and roof of the right atrium, to the sinuatrial node.
 The coronary sinus accompanies the distal part of the right coronary artery,
while the middle and small cardiac veins accompany its posterior
interventricular and right marginal branches respectively.
Parts of the heart supplied by the right coronary artery include:

 Part of the sternocostal surface of the right ventricle and right atrium, through
branches that arise from the main trunk of the artery
 Both (sternocostal and diaphragmatic) surfaces of the right ventricle through, the
right marginal artery
 Part of the diaphragmatic surface of the left ventricle, through the posterior
interventricular branch
 Posterior surface of the right atrium and part of the same surface of the left atrium
 Posterior ⅓ of the interventricular septum, through the posterior interventricular
branch of the right coronary artery
 The sinuatrial and atrioventricular nodes (in 60% and 80% of the population
respectively).
Anastomoses between Coronary Arteries

 Large branches of coronary arteries anastomose with one another to a variable
extent
 Terminal branches of coronary arteries (that supply the myocardium) do not
form sufficient anastomoses. Thus, they are largely end-arteries.
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 Anastomoses formed between branches of coronary arteries are not sufficient to

establish adequate collateral circulation following sudden occlusion of a
coronary artery or its major branches (by an embolus, thrombus, etc).
 Anastomoses also exist between branches of coronary arteries and certain arteries
of the thorax
Venous Drainage of the Heart
Coronary Sinus
The coronary sinus

 Is formed by the union of the great cardiac vein and the oblique vein of the left
atrium. It is short (2–3 cm long) but wide (Fig. 34)
 Runs in the posterior part of the coronary sulcus, between the left atrium and the
left ventricle
 Receives most, but not all the veins that drain the heart
 Ends in the right atrium, where it opens through an orifice located between the
right atrioventricular orifice and the orifice of the IVC
 Has a small valve – valve of coronary orifice. This guards the orifice of the
sinus in the right atrium (see the right atrium above)
Tributaries of the coronary sinus include:

1. Great cardiac vein. This initially accompanies the anterior interventricular artery
(in the anterior interventricular groove), and then the left coronary artery and its
circumflex branch (in the coronary sulcus)
2. Small cardiac vein. This accompanies the right marginal and right coronary
arteries
3. Middle cardiac vein. This accompanies the posterior interventricular artery (in
the posterior interventricular groove)
4. Posterior vein of the left ventricle; and
5. Oblique vein of the left atrium. This represents the embryonic left common
cardinal vein.
The great cardiac vein

 Commences at the apex of the heart and ascends in the anterior interventricular
sulcus, to the left part of the coronary sulcus. It runs in this sulcus to the
posterior part of the heart.
 Accompanies the anterior interventricular artery through the anterior
interventricular sulcus; and the circumflex artery through the left part of
coronary sulcus
 Drains the two ventricles and the left atrium
 Is joined by the oblique vein of the left atrium in the coronary sulcus (behind) to
form the coronary sinus
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 Has a valve (where it joins the coronary sinus)

 Receives the left marginal vein
The small cardiac vein

 Begins near the apex of the heart, and runs to the right, along the inferior border
of the heart. Distally, it continues in the coronary sulcus. Thus, it accompanies
the right marginal and (distal part of) right coronary arteries
 Terminates near the terminal part of the coronary sinus. Here, it possesses an
incompetent valve
 Drains most of the territories supplied by the right marginal artery
The middle cardiac vein

 Also begins at the apex of the heart
 Accompanies the posterior interventricular artery through the posterior
interventricular sulcus
 Ends by joining the coronary sinus nears its termination
 Drains most of the territories supplied by the posterior interventricular artery
The posterior vein of the left ventricle

 Lies on the diaphragmatic surface of the left ventricle, which it drains
 Runs posteriorly to drain into the coronary sinus. It may drain into the great
cardiac vein
Oblique vein of the left atrium

 Is a small vein that lies obliquely behind the left atrium (Fig. 34)
 Is continuous above with the ligament of the left vena cava
 Represents the embryonic left common cardinal vein
Other veins of the heart
Cardiac veins that do not join the coronary sinus include:

 About four anterior cardiac veins that drain the right ventricle. They cross the
coronary sinus on the sternocostal surface of the heart, and open into the right
atrium
 Venae cordis minimae. These are small veins that drain the muscular wall of the
heart. They drain directly into all heart chambers, especially the atria
Lymphatic Drainage of the Heart
Regarding the lymphatic drainage of the heart, note that:

 Three lymphatic plexuses exist in the heart. These are the subepicardial,
myocardial, and endocardial plexuses
 The endocardial and myocardial plexuses drain into the subepicardial plexus
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 Efferent vessels from the subepicardial plexus form the right and left lymphatic
trunks of the heart
The right lymphatic trunk of the heart
 Is usually a single trunk
 Drains the right atrium and the diaphragmatic surface of the right ventricle
 Initially ascends between the right atrium and the right ventricle (in the anterior
part of the coronary sulcus, where it accompanies the right coronary artery).
Subsequently, it ascends on the anterior aspect of the ascending aorta
 Ends in the brachiocephalic node, usually those of the left side
The left lymphatic trunks of the heart

 Exist initially as two or three relatively large vessels. These traverse the anterior
interventricular groove (with the anterior interventricular artery)
 Form a single trunk that ascends between the pulmonary trunk and the left
atrium. This trunk ends in the inferior tracheobronchial nodes, usually to the
right of the midline.
Innervation of the Heart
Superficial Cardiac Plexus
The superficial cardiac plexus

 Is located below the aortic arch, anterior to the ligamentum arteriosum
 Receives the left superior cervical cardiac branch of the superior cervical
ganglion. This contains sympathetic fibres
 Also receives the left inferior cervical cardiac branches of the left vagus. These
contain parasympathetic fibres
 Possesses a small ganglion termed cardiac ganglion. This lies to the right of the
ligamentum arteriosum
 Gives branches to the left anterior pulmonary plexus, deep cardiac plexus and the
right coronary artery
Deep Cardiac Plexus
The deep cardiac plexus

 Lies anterior to the bifurcation of the trachea, behind the aortic arch, and above
the bifurcation of the pulmonary trunk
 Receives the upper and lower cervical cardiac, as well as the thoracic cardiac
branches of the vagus nerve and sympathetic chains (except those to the
superficial cardiac plexus)
 Also receives the cardiac branches of the recurrent laryngeal nerves, as well as
branches of the superficial cardiac plexus
 Supplies the heart (via branches that run on the pulmonary trunk, ascending aorta
and pulmonary veins)
 Supplies the sinuatrial node via branches that descend on the SVC
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 Also sends some branches to the right and left pulmonary and coronary
plexuses. These run along the roots of the lungs and the coronary arteries
respectively.
The left coronary plexus of nerves

 Accompanies the left coronary artery. It is larger than the right coronary plexus
 Receives fibres from the deep cardiac plexus (via the ascending aorta and
pulmonary trunk)
 Supplies the left atrium and left ventricle
The right coronary plexus of nerves

 Accompanies the right coronary artery
 Receives fibres from the superficial and deep cardiac plexuses
 Supplies the right atrium and the right ventricle
Regarding autonomic innervation of the heart, note the following points:

 Presynaptic sympathetic fibres that supply the heart arise from the upper 4–5
thoracic segments of the spinal cord (T1 – T4 [or T5])
 Postsynaptic sympathetic fibres to the heart arise from the cervical and upper
thoracic ganglia of the sympathetic chains
 Stimulation of the sympathetic fibres of the heart increases the rate and force of
cardiac contraction, and also produces vasodilatation of coronary vessels
 Presynaptic parasympathetic fibres of the heart arise from the dorsal nucleus
of the vagus nerve, in the medulla oblongata
 Postsynaptic parasympathetic fibres to the heart arise from ganglia located in
the cardiac plexuses, and in the walls of the atria
 Stimulation of parasympathetic fibres of the heart reduces the rate and force of
contraction of the heart and produces and produces vasoconstriction of coronary
arteries
 Several nerve cells lie in the vicinity of the sinuatrial and atrioventricular
nodes, and in the subepicardial connective tissue
Applied Anatomy of the Heart

 The membranous part of ventricular septum may be defective, with an aperture
that may be up to 25 mm in diameter.
 Nodules may form in the valves of the heart, mostly in the mitral valve
 Shortening of the cusps of heart valves occurs when scar tissue form in the
nodules. This results in valvular insufficiency, e.g., mitral insufficiency, which
is the commonest. In this instance, blood regurgitates into the left atrium at
ventricular systole.
 Regurgitation of blood into the left atrium, as occurs in mitral insufficiency,
produces a characteristic heart murmur that is detectable on auscultation.
- 183 -
 Narrowing of the mitral orifice – mitral stenosis – may occur, with the resultant
murmur that is detectable at the apex beat.
 In valvular stenosis, valve prosthesis may be employed to replace the defective
valve
 Functional heart murmurs are produced in children during exercise. These are
however not pathological.
Besides, note the following facts:

 The electrical activity of the heart is monitored with an electrocardiograph
 Narrowing of the coronary artery (e.g. by a thrombus, or in coronary
atherosclerosis) results in insufficient blood supply to the heart – ischaemia. This
results in angina pectoris, which may be induced by exercise.
 Angina pectoris is characterised by pain that starts over the chest. The pain may
be referred to the left shoulder and arm. The right shoulder and arm, as well as
the back, may also be involved.
 Complete obstruction of a coronary artery or its major branch (e.g., by a
thrombus) results in necrosis of myocardial tissue – myocardial infarction (heart
attack). Extensive myocardial infarction results in cardiac arrest
 The great saphenous vein is usually harvested to replace a stenosed or occluded
coronary artery in coronary bypass graft
 The internal thoracic artery may be anastomosed to a coronary artery in coronary
bypass
Great Vessels
The great vessels (of the thorax) include the aorta (comprising ascending aorta, arch
of aorta, and descending aorta), pulmonary trunk and arteries, superior vena cava,
inferior vena cava, and brachiocephalic veins.
Ascending Aorta
The ascending aorta

 Arises directly from the aortic vestibule of the left ventricle. It commences at the
aortic orifice, behind the left half of the sternum, at the level of the 3rd intercostal
space
 Passes upwards, forwards and to the right, behind the body of sternum
 Becomes continuous with the aortic arch behind the right 2nd costal cartilage
 Measure about 5 cm in length and 2.5 cm in diameter
 Shares the same fibrous and serous pericardial investment with the pulmonary
trunk
 Has a local dilatation (of its wall) where it continues with the aortic arch. This is
referred to as the bulb of the aorta
 Also has three small dilatations (of its wall) at its commencement. These are the
aortic sinuses, and they include the right, left and posterior aortic sinuses (Fig.
36)
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Relations of Ascending Aorta
Relations of the ascending aorta include:

 Anteriorly: infundibulum of the right ventricle, root of the pulmonary trunk,
right auricle, remains of the thymus, right pleura and lung, and sternum
 Posteriorly: transverse sinus of the pericardium, left atrium, right pulmonary
artery, and the right main bronchus
 To the right: superior vena cava and right atrium
 To the left: left atrium and pulmonary trunk.
Branches of the ascending aorta include the following:

 Right coronary artery. This arises from the right aortic sinus (Fig. 36)
 Left coronary artery, which arises from the left aortic sinus
Applied Anatomy of the Ascending Aorta
Note the following:

 The bulb of the aorta is a common site of aneurysm
 The aortic valve may be congenitally stenosed – congenital aortic stenosis –
such that extra force is required to pump blood into the ascending aorta.
 The aortic valve may also be defective and incompetent. This results in aortic
insufficiency.
 Heart murmur and collapsing pulse are associated with aortic insufficiency
Surface Anatomy of the Ascending Aorta
The ascending aorta is represented by a band, about 2.5 cm in diameter, directed

obliquely upwards and to the right, from a point over the left half of the sternum
below (level of the 3rd intercostal space), to the right half of the sternum above (level
of the 2nd costal cartilage).
Arch of the Aorta
The aortic arch

 Is located in the superior mediastinum, behind the lower half of the manubrium
sterni.
 Is continuous with the ascending aorta (anteriorly) and the descending thoracic
aorta (posteriorly) at the level of the 2nd costal cartilage
 Commences behind the sternal margin, at the level of the right 2nd costal
cartilage; and runs at first upwards, backwards and to the left; then backwards
and downwards, describing a downward concavity as it does so.
 Ends just to the left of the lower border of the body of the 4th thoracic vertebra,
at the level of the 2nd costal cartilage
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 Has a summit that normally lies midway up the manubrium sterni. However, this
may be as low as the sternal angle, or as high as the upper border of manubrium
sterni
 Is essentially convex upwards and concave downwards, its summit being about
2.5 cm below the upper border of manubrium sterni
 Is disposed more sagittally than coronally; and is slightly convex to the left and
concave to the right.
Relations of Aortic Arch
Regarding the relations of the aortic arch, note the following:

 Inferiorly: left main bronchus, left recurrent laryngeal nerve, pulmonary trunk,
superficial cardiac plexus, and ligamentum arteriosum
 Superiorly: brachiocephalic trunk, left common carotid artery and left subclavian
artery. These arise from the convexity of the aortic arch. The left
brachiochephalic vein is also a superior relation of the aortic arch. This vessel
runs towards the right, crossing the branches of the aortic arch as it does, to join
the right brachiocephalic vein, with which it forms the SVC
 Four nerves cross the left surface of aortic arch. These include, from anterior
posteriorly, the left phrenic nerve, inferior cervical cardiac branch of the left
vagus, superior cervical cardiac branch of the left sympathetic chain, and the
left vagus nerve.
 The left superior intercostal vein also crosses the left surface of the aortic arch.
This vein runs backwards, upwards and to the left, to join the left brachiocephalic
vein.
 The left vagus nerve gives rise to the left recurrent laryngeal nerve as it crosses
the left surface of aortic arch. This branch winds round the arch, and ascends
towards the neck (in the left trachea-oesophageal groove).
 The left mediastinal pleura and lung are also related to the left surface of the
aortic arch and they separate the aorta from the thoracic wall.
 To the right of the aortic arch are the deep cardiac plexus, trachea, left recurrent
laryngeal nerve, oesophagus and thoracic duct.
 The aortic arch ends posteriorly, to the left of the lower border of the 4th thoracic
vertebra. Here, it is continuous with the descending thoracic aorta.
Branches of the Arch of the Aorta
Branches of the aortic arch arise from the convexity of this vessel, and they include:
 The brachiocephalic trunk. This divides behind the right sternoclavicular joint
into right common carotid and right subclavian arteries (Fig. 34).
 The left common carotid artery, which arises behind the origin of the
brachiocephalic trunk. It supplies the left half of the head (Fig. 34).
 The left subclavian artery, the most posterior branch of aortic arch. It supplies
the left upper limb
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Variations of the aortic arch and its branches
Note these points:

 A right aortic arch may be present. In this instance, the aortic arch arches over
the right root of the lung, and then descends on the right of the midline (or
crosses behind the oesophagus to descend on the left of the midline).
 In a right aortic arch, branches of the arch include left brachiocephalic trunk,
and right common carotid and subclavian arteries
 The aortic arch may be duplicated – double aortic arch. In this case, a vascular
ring encircles the trachea and oesophagus
 In 27% of the population, the left common carotid artery arises from the
brachiocephalic trunk
 In about 5% of the population, the left vertebral artery arises directly from the
aortic arch (between the origin of the left common carotid and subclavian
arteries).
 Rarely, the right subclavian and common carotid arteries arise separately from the
aortic arch (as do the left arteries)
 In 1% of the population, the left common carotid and subclavian arteries arise via
a single trunk – left brachiocephalic trunk.
 The right subclavian artery may spring directly from the aortic arch (as the
most posterior branch of the arch). In this instance, it ascends to the right, behind
the oesophagus, forming a retro-oesophageal right subclavian artery.
 The thyroidea ima artery may also arise from the aortic arch. It ascends to the
thyroid gland.
 One or both bronchial arteries may arise from the aortic arch
 The two common carotid arteries may arise as a single trunk. In this instance,
the subclavian arteries arise separately.
 As many as six vessels may arise from the aortic arch, including right and left
common carotid, right and left subclavian, and right and left vertebral arteries
Applied Anatomy of Aortic Arch
Note the following:

 A double aortic arch may compress the trachea, causing dyspnoea and
necessitating surgical intervention
 A retro-oesophageal right subclavian artery may compress the oesophagus,
causing dysphagia (difficulty in swallowing)
 Aneurysm of aortic arch may adversely affect the integrity of the left recurrent
laryngeal nerve, with the associated dysphonia
 The aortic arch forms an aortic knuckle in AP radiographs of the chest
 In left anterior oblique radiograph of the chest, the aortic arch outlines an aortic
window, in which the shadow of the pulmonary trunk may be seen.
Brachiocephalic Trunk
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The brachiocephalic trunk

 Is the largest branch of the aortic arch. It is 4–5 cm in length.
 Arises from the convexity of the aortic arch, behind the middle of the manubrium
sterni
 Passes upwards, backwards and to the right; and terminates behind the right
sternoclavicular joint
 Ends by dividing into the right common carotid and right subclavian arteries
 Lies anterior to the trachea and behind the left brachiocephalic vein (in the initial
part of its course)
Relations of the Brachiocephalic Trunk
These include:
 Anteriorly: thymus, right inferior thyroid vein, left brachiocephalic vein,
sternohyoid and sternothyroid muscles.
 Posteriorly: trachea (below) and right pleura (above)
 To the left: left common carotid artery, inferior thyroid vein and trachea
 To the right: right brachiocephalic vein, SVC, and mediastinal pleura
Branches of the brachiocephalic trunk
The brachiocephalic trunk

 Terminates behind the right sternoclavicular joint by dividing into the right
common carotid and subclavian arteries
 May give rise to the thyroidea ima artery
 May also give rise to one of the bronchial arteries
 May give a branch to the thymus
Left Common Carotid Artery (Thoracic Part)
The left common carotid artery

 Arises from the aortic arch, behind the origin of the brachiocephalic trunk
 Ascends in the superior mediastinum to a point behind the left sternoclavicular
joint. Here, it becomes continuous with its cervical part
Relations of the Left Common Carotid Artery
These include:
 Anteriorly: left pleura and lung, left brachiocephalic vein, thymus,
sternothyroids and sternohyoids. These separate it from the manubrium sterni
 Posteriorly: left subclavian artery, trachea, left recurrent laryngeal nerve and
thoracic duct
 To the left: left phrenic and vagus nerves, left mediastinal pleura and lung.
- 188 -
 To the right: brachiocephalic trunk (below), trachea (above) and inferior thyroid
vein.
Left Subclavian Artery (Thoracic Part)
The left subclavian artery

 Is the 3rd (most posterior) branch of the aortic arch
 Arises from the convexity of the aortic arch, behind the origin of the left
common carotid artery, at the level of the intervertebral disc between T3 and T4
 Ascends to the root of the neck, where it arches laterally over the 1 st rib, to
continue into the axilla as the axillary artery
 Does not give rise to any branches in the thoracic cavity.
Relations of the Left Subclavian Artery
These include:
 Anteriorly: common carotid artery, brachiocephalic vein, vagus, phrenic and
cardiac nerves of the left side. Other anterior relations include the sternothyroid
and sternohyoid muscles.
 Posteriorly: thoracic duct, longus colli muscle and oesophagus.
 Medially: left recurrent laryngeal nerve, trachea, oesophagus and thoracic duct
 Laterally: left mediastinal pleura and lung
Pulmonary Trunk
The pulmonary trunk

 Arises from the infundibulum of the right ventricle, behind the sternal end of the
left 3rd costal cartilage. Then, it runs upwards, backwards, and to the left.
 Ends just below the aortic arch, at the level of the intervertebral disc between the
T4 and T5 (where it bifurcates into right and left pulmonary arteries).
 Measures about 5 cm in length and 3 cm in diameter
 Has, at its commencement, 3 outpocketings of its wall. These are the anterior,
right and left pulmonary sinuses
 Shares the same fibrous and serous pericardial investments with the ascending
aorta.
Relations of the Pulmonary Trunk
Relations of the pulmonary trunk include:

 Anteriorly: left pleura, left lung, and sternal end of the left 2nd intercostal space
 Posteriorly: root of the ascending aorta, left coronary artery and left atrium
 Superiorly: aortic arch and superficial cardiac plexus (Fig. 34)
 To the right: upper part of ascending aorta, right auricle, and right coronary
artery
 To the left: left coronary artery and left auricle
- 189 -
Branches of Pulmonary Artery (see above for details)
Applied Anatomy of Pulmonary Artery
It is important to note the following:

 Scaring and thickening of the cusps of pulmonary valve would result in
incomplete closure of the pulmonary orifice at ventricular diastole – pulmonary
valve incompetence.
 Pulmonary valve incompetence is characterised by regurgitation of blood into
the right ventricle at ventricular diastole.
 A characteristic heart murmur, detectable with a stethoscope, is also associated
with pulmonary valve incompetence
 the pulmonary orifice is reduced to an abnormally narrow opening in pulmonary
valve stenosis
 pulmonary valve stenosis results in hypertrophy of the right ventricle (as
additional force is needed to pump blood through the narrowed orifice)
 Infundibular pulmonary stenosis is a condition characterised by narrowing of
the infundibulum of the right ventricle. It may occur simultaneously with
pulmonary valve stenosis
Surface Anatomy of the Pulmonary Trunk

The pulmonary trunk is represented by a band 3 cm in diameter, drawn from the
sternal end of the left 3rd costal cartilage below, to the left 2nd costal cartilage above.
Descending Thoracic Aorta
The descending thoracic aorta

 Is the direct continuation of the arch of the aorta
 Commences at the left aspect of the lower border of the body of T4.
 Descends initially on the left side of the midline, but gradually lies in the midline
(on the vertebral column) in the lower part of the thoracic cavity.
 Ends anterior to the lower border of T12, where it becomes continuous with the
descending abdominal aorta (by traversing the aortic hiatus of the diaphragm)
 Lies entirely in the posterior mediastinum, where it supplies the surrounding
organs (e.g., oesophagus), as well as the thoracic wall (by means of the posterior
intercostal arteries)
Relations of the descending thoracic aorta

 Anteriorly: root of the left lung, pericardium, and left atrium (above); and the
oesophagus and diaphragm (below).
 Posteriorly: T5–T12 vertebrae. Besides, the hemiazygos and accessory
hemiazygos veins cross behind it, from left to right, at the level of T8 and T7
vertebrae respectively.
 To the right: azygos vein, thoracic duct, right mediastinal pleura and right lung.
Oesophagus is also a right relation of the upper part of the artery.
- 190 -
 To the left: left mediastinal pleura and lung
Surface Anatomy of the Descending Thoracic Aorta

The descending thoracic aorta is represented by a band, about 2.5 cm wide, drawn
from the left 2nd costal cartilage above, to a point 2 cm above the transpyloric plane
below (in the midline).
Branches of the Descending Thoracic Aorta
Note: Descending thoracic aorta has visceral and parietal branches.
Visceral branches of descending thoracic aorta include:

 A few pericardial branches. These supply the posterior aspect of the
pericardium
 Bronchial arteries. These supply oxygenated blood and nutrients to the bronchi
and lungs
 About 5 oesophageal branches. These arise from the front of the aorta and
supply the oesophagus
Parietal branches of the descending thoracic aorta include:

 Superior phrenic arteries. These arise from the lower part of the thoracic aorta
and supply the diaphragm. They also anastomose with musculophrenic and
pericardiacophrenic arteries.
 Mediastinal branches. These arise from the front of the descending aorta; they
supply the lymph nodes and areolar tissue of the posterior mediastinum.
 Paired subcostal arteries, each of which passes laterally to accompany the
subcostal nerve below the 12th rib. They run between the respective transversus
abdominis and internal oblique muscles (supplying these and adjacent structures).
 The lower nine pairs of posterior intercostal arteries. These arise from the
posterior aspect of the descending thoracic aorta and traverse the intercostal
spaces
Besides, note the following:

 The subcostal arteries are the last pair of vessels that arise from the descending
thoracic aorta
 The right subcostal artery passes to the right, behind the thoracic duct and
azygos vein
 Each subcostal artery runs laterally, anterior to the quadrates lumborum and
behind the lateral arcuate ligament.
 Anastomoses exist between the subcostal and superior epigastric arteries, as
well as between the lumbar and posterior intercostal arteries
 The 2nd–4th intercostal arteries give rise to mammary branches. These supply the
breast, and are enlarged during lactation.
- 191 -
Each posterior intercostal artery

 Has a dorsal branch that passes backwards, between the necks of the ribs. This
supplies muscles and skin of the back.
 Supplies the spinal cord, its meninges and the thoracic vertebrae via a spinal
branch (from its dorsal branch).
 Also supplies the intercostal muscles, pectoral muscles and serratus anterior, via
its muscular branches. These anastomoses with the superior and lateral thoracic
arteries (branches of axillary artery).
 Has lateral cutaneous branches that supply the skin of the lateral aspect of the
thorax
 Gives a collateral branch near the angle of the rib. This runs forwards, above the
lower rib of an intercostal space
 Anastomoses with the anterior intercostal arteries (branches of internal
thoracic or musculophrenic arteries) via its collateral branch
 Is accompanied by an intercostal nerve (that runs below it) and a posterior
intercostal vein (that runs above it) in the same intercostal space. These
structures are closer to the upper rib of their own intercostal space.
Applied Anatomy of the Aorta
Note these facts:

 Coarctation (narrowing) of the aorta may occur in an adult, as occurs in the
foetus.
 Preductal (infantile) coarctation of the aorta occurs proximal to the ligamentum
arteriosum. In the foetus, narrowing of the aorta is a normal feature, and it is seen
between the origin of the subclavian artery and the ductus arteriosum.
 Coarctation of the aorta may also occur beyond the attachment of ligamentum
arteriosum (postductal type). Postductal coarctation arises partly as a result of
the extension of the tissue of ligamentum arteriosum into the aorta.
 Coarctation of the aorta occurring proximal to the origin of the brachiocephalic
trunk is usually incompatible with extra-uterine life (as collateral circulation is
difficult to establish in this instance)
 Preductal coarctation occurring between the origins of brachiocephalic trunk
and the left subclavian artery will produce reduced pulse pressure in the left
upper limb.
 In postductal coarctation of the aorta, collateral circulation is usually established
between the posterior intercostal and anterior intercostal arteries. Enlargement of
the posterior intercostal arteries occurs in cases where these vessels are involved
in the establishment of such collateral circulation.
 Notching of the rib above each posterior intercostal artery may occur when this
vessel enlarges as a result of its involvement in collateral circulation.
 Occasionally, the anastomoses around the scapula may enlarge in preductal
coarctation, such that pulse may be felt in the interscapular region – pulsating
scapula.
- 192 -
The internal thoracic artery

 Arises from the inferior aspect of the first part of the subclavian artery, opposite
the origin of the thyrocervical trunk (about 2 cm above the sternal end of the
clavicle).
 Descends through the thoracic cavity, about 1 cm lateral to the sternal margin,
behind the upper six costal cartilages and their intercostal spaces (Fig. 27).
 Ends at the 6th intercostal space, by dividing into the musculophrenic and
superior epigastric arteries.
 Is accompanied (in its lower part) by venae comitantes; and by the internal
thoracic vein in its upper part. The artery is lateral to the vein.
Relation of Internal Thoracic Artery
Note the following:

 Phrenic nerve crosses the anterior aspect of internal thoracic artery, from lateral
medially.
 Anterior to the internal thoracic artery are the upper six costal cartilages,
associated intercostal spaces, pectoralis major, and the anterior ends of the upper
six intercostal nerves
 Behind the internal thoracic artery are transversus thoracis muscles and costal
pleura
 Above the level of the 3rd costal cartilage, the internal thoracic artery is related
medially to the internal thoracic vein
 Below the level of the 3rd costal cartilage, the internal thoracic artery is
accompanied by its venae comitantes.
 Parasternal lymph nodes and lymph vessels lie along the internal thoracic artery
Surface Marking of Internal Thoracic Artery
The internal thoracic artery is represented by a vertical line that extends from the 1st
costal cartilage above, to the 6th intercostal space below, about 1 cm from the sternal
margin.
Branches of internal thoracic artery include:

 Pericardiacophrenic artery
 Mediastinal artery
 Pericardial and sternal branches
 Anterior intercostal arteries
 Perforating branches
 Musculophrenic artery; and
 Superior epigastric artery
Pericardiacophrenic artery
- 193 -
 Is a long slender vessel that accompanies the phrenic nerve (between the
mediastinal pleura and fibrous pericardium), en route to the diaphragm.
 Supplies the pleura, fibrous pericardium, parietal layer of serous pericardium and
the diaphragm
 Anastomoses with musculophrenic and superior phrenic arteries.
Mediastinal arteries
 Are small branches of internal thoracic artery that enter the anterior mediastinum
 Supply the lymph nodes and loose connective tissue of the anterior mediastinum
 Also supply the thymus and sternum
 Anastomose with branches of the posterior mediastinal and bronchial arteries
Pericardial branches of internal thoracic artery

 Are small vessels that supply the anterior aspect of the pericardium
 Anastomose with branches of posterior intercostal and bronchial arteries
Sternal branches of internal thoracic artery

 Supply the sternum and transversus thoracis muscles
 Anastomose with branches of the posterior intercostal and bronchial arteries
Anterior intercostal branches of internal thoracic artery

 Supply the upper six intercostal spaces and are distributes as two branches in
each space
 Run laterally between the innermost and internal intercostal muscles (in each
intercostal space)
 Anastomose with the posterior intercostal arteries. The latter are branches of
the descending thoracic aorta
 Supply the intercostal and pectoral muscles, as well as the breast and overlying
skin
Perforating branches of internal thoracic artery

 Pierce the intercostal spaces of the anterior thoracic wall. They accompany the
anterior cutaneous branches of intercostal nerves to the overlying skin.
 Are distributed as one vessel per intercostal space in the upper six intercostal
spaces. In the 2nd–4th intercostal spaces, they supply the mammary gland.
 Also supply pectoral muscles and skin.
The musculophrenic artery

 Is one of the two terminal branches of internal thoracic artery. The other being
the superior epigastric artery
 Passes downwards and laterally on the thoracic aspect of the diaphragm, behind
the 7th, 8th and 9th costal cartilages
 Pierces the diaphragm near the 9th costal cartilage, and continues inferolaterally
on the abdominal aspect of this muscle. It ends opposite the 11th intercostal space.
- 194 -
 Supplies two anterior intercostal arteries to each of the 7th, 8th, and 9th
intercostal spaces
 Also supplies the diaphragm, adjacent abdominal muscles and pericardium
 Anastomoses with the lower posterior intercostal arteries, ascending branch of the
deep circumflex iliac artery and the inferior phrenic artery.
The superior epigastric artery

 Is also a terminal branch of internal thoracic artery
 Leaves the thoracic cavity for the anterior abdominal wall through the interval
between the costal and xiphoid origins of the diaphragm.
 Enters the rectus sheath, where it descends behind the rectus abdominis
 Gives rise to branches that pierce the rectus abdominis and the anterior layer of
rectus sheath, supplying these and the overlying skin
 Anastomoses with the opposite superior epigastric artery via a branch that
crosses to the opposite side (anterior to the xiphoid process).
 Also anastomoses with the inferior epigastric artery (a branch of external iliac
artery) within the rectus sheath.
 Supplies the diaphragm and anastomoses with the hepatic artery (via branches
that run on the falciform ligament).
Veins of the Thorax
Veins of the thorax include:

 Brachiocephalic veins
 Superior vena cava (SVC)
 Interior vena cava (terminal end)
 Azygos system of veins and its tributaries
 Internal thoracic veins and their tributaries
Brachiocephalic Veins
The brachiocephalic veins

 Lie in the root of the neck and adjacent part of the thoracic cavity
 Are formed on each side by the union of the internal jugular and subclavian
veins, behind the medial end of the clavicle
 Do not possess valves
The right brachiocephalic vein

 Commences behind the medial end of the right clavicle. It is formed by the union
of the right internal jugular and right subclavian veins.
 Descends vertically in the thorax, to end behind the right 1st costal cartilage.
Here, it joins the left brachiocephalic vein to form the SVC
 Measures about 2.5 cm in length
- 195 -
Tributaries of the right brachiocephalic vein include:

 Right vertebral vein (from the neck)
 Right internal thoracic vein (from the anterior thoracic wall)
 Right inferior thyroid vein (from the thyroid gland)
 Occasionally, the right highest intercostal vein (from the right 1st intercostal
space)
 Right lymphatic duct. This drains the right half of the head and neck, right
upper limb and part of the right half of the thorax
Relations of the right brachiocephalic vein

 Posteromedial to the right brachiocephalic vein are the brachiocephalic trunk and
right vagus nerve
 Behind the upper part of the right brachiocephalic vein are the right phrenic
nerve, internal thoracic artery and pleura
 Lateral to the lower part of the right brachiocephalic vein are the right pleura and
lung
Left brachiocephalic vein
The left brachiocephalic vein

 Is formed behind the sternal end of the left clavicle, by the union of the left
internal jugular and subclavian veins.
 Crosses the midline behind the upper half of manubrium sterni, as it passes to the
right from the medial end of the left clavicle to the sternal end of the right 1st
costal cartilage. Here, it joins the right brachiocephalic vein to form the SVC.
 May lie in the root of the neck, just a little above the upper border of the
manubrium sterni, especially in children
 Is about 6.5 cm long
Relations of the Left Brachiocephalic Vein
The left brachiocephalic vein is related to the following:

 Inferiorly: aortic arch
 Anteriorly: thymus, right pleura, left sternoclavicular joint, upper half of
manubrium sterni, sternohyoid and sternothyroid muscles.
 Posteriorly: brachiocephalic trunk and the left subclavian, internal thoracic and
common carotid arteries. Others include left vagus and phrenic nerve, and the
trachea.
Tributaries of the left brachiocephalic vein include:

 Left vertebral vein (from the neck)
 Inferior thyroid vein (from the thyroid gland)
- 196 -
 Left internal thoracic vein (draining the anterior thoracic wall)

 Left superior intercostal vein. This receives the 2nd–4th posterior intercostal
veins.
 Occasionally the left 1st posterior intercostal vein.
 Few thymic and pericardial veins
 Occasionally the right inferior thyroid vein (from the thyroid gland)
 Thoracic duct. This opens into the left venous angle (between the left subclavian
and left internal jugular veins).
Surface Anatomy of Brachiocephalic Veins
Brachiocephalic veins can be represented by two bands, each 1.5 cm wide, drawn
from the medial ends of both clavicles to the medial end of the right 1st costal
cartilage.
Variation of Brachiocephalic Veins
Note the following:

 The left brachiocephalic vein may lie in the root of the neck, just above the level
of the manubrium sterni, especially in children. It is therefore at risk during
tracheotomy.
 The two brachiocephalic veins may open separately into the right atrium. In this
instance, two (right and left) superior venae cavae are present.
 The left SVC arises as a result of the persistence of the left common cardinal
and precardinal veins. This vena cava descends anterior to the root of the left
lung, to the posterior surface of the heart. Here, it follows the course of the
oblique vein of the left atrium and the coronary sinus.
 When present, the left SVC receives all the tributaries of the coronary sinus.
Superior Vena Cava
The superior vena cava

 Is formed by the union of the two brachiocephalic veins
 Begins behind the lower border of the right 1st costal cartilage, close to the
sternal margin
 Descends vertically to open into the upper end of the right atrium, behind the
right 3rd costal cartilage
 Measures about 7 cm in its craniocaudal extent; and 2 cm in diameter
 Receives blood from the upper half of the body (head, neck, upper limbs and
thorax)
 Does not possess any valves
 Is invested by the fibrous pericardium in its lower half. The sides and anterior
aspect of this part are also surrounded by the serous pericardium.
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 Receives the azygos vein at the level of the right 2nd costal cartilage. This opens
into its posterior aspect, at this level.
Relations of the Superior Vena Cava
Relations of the SVC include:

 Anteriorly: part of the right ling and pleura, internal thoracic vessels, anterior
thoracic wall
 Posteriorly: root of the right lung
 Posteromedially: trachea and right vagus nerve
 To the right: right phrenic nerve, pleura and lung
 To the left: brachiocephalic trunk and aorta (Fig. 34)
Surface Anatomy of SVC
The SVC is represented by a band 2 cm wide, drawn over the right sternal margin,
from the lower border of the right 1st costal cartilage to the lower border of the right
3rd costal cartilage.
Tributaries of the SVC
These include:
 Azygos vein, which drain the thoracic wall
 Small pericardial and mediastinal veins
Variations of the SVC (see brachiocephalic veins, above)
Internal Thoracic Veins
The internal thoracic veins

 Accompany the internal thoracic artery in the thorax. Below the level of the 3rd
costal cartilage, these veins exist as two vessels – venae comitantes. They unite
at the level of the 3rd costal cartilage to form a single vein that ascends medial to
the internal thoracic artery, behind the sternum
 Drain into the brachiocephalic vein of the same side
 Possess no valves
 Receive the pericardiacophrenic vein and other tributaries that correspond to
the branches of the internal thoracic artery.
The left superior intercostal vein

 Receives the 2nd–4th posterior intercostal veins of the left side.
 May also receive the left pericardiacophrenic and left bronchial veins
 Passes obliquely upwards and forwards, over the left aspect of the aortic arch.
Here, it lies superficial to the left vagus and deep to the left phrenic nerve
 Drains into the left brachiocephalic vein.
- 198 -
 Communicates with the accessory hemiazygos vein. The latter drains the 5th–8th
intercostal spaces of the left side.
Inferior Thyroid Veins

 Inferior thyroid veins arise by the union of tributaries from the isthmus and
lobes of the thyroid gland.
 Right and left inferior thyroid veins do exist, and these may form a plexus
anterior to the trachea. These veins may however unite to form a single vein that
usually drains into the left brachiocephalic vein.
 The left inferior thyroid vein descends anterior to the trachea to join the left
brachiocephalic vein in the thorax
 The right inferior thyroid vein descends obliquely to the right, crossing the
brachiocephalic trunk anteriorly, to end in the right brachiocephalic vein.
 Inferior thyroid veins communicate with the middle and superior thyroid veins
 A valve guards the orifice (terminal end) of each inferior thyroid vein.
 The oesophagus and trachea are also partly drained by the inferior thyroid veins.
Azygos System of Veins
The Azygos system of veins consists of:

 Azygos vein and its tributaries
 Hemiazygos vein and its tributaries; and
 Accessory hemiazygos vein and its tributaries
Azygos Vein
The Azygos vein

 Has certain variations in its arrangement, as do other veins of the azygos system
 May arise in some subjects as a direct continuation of the right subcostal vein
 May also arise by the union of the right subcostal and ascending lumbar veins
 May as well arise in the lumbar region, from the posterior aspect of the IVC, at
the level of the renal vein, or just below this level. In this instance, it is termed the
lumbar azygos, and it is joined at the level of T12 by a vein formed by the union
of the right subcostal and ascending lumbar vein.
 May pierce the right crux of the diaphragm, pass lateral to this, or traverse the
aortic hiatus, as it ascends from the lumbar region as a lumbar azygos.
 Ascends on the vertebral column in the posterior mediastinum, to reach the level
of the sternal angle of Louis (Fig. 37). Here, it arches forwards over the root of
the right lung to open into the posterior aspect of the SVC.
 Possesses valves that are largely imperfect
- 199 -
Figure 37. Azygos system of veins
Relation of the Azygos Vein
Relations of the azygos vein include:

 Anteriorly: diaphragm, oesophagus, right lung and pleura, and the root of the
right lung
 Posteriorly: T5–T12 vertebrae, anterior longitudinal ligament, and the right
posterior intercostal arteries
 To the right: right mediastinal pleura, right lung, right greater splanchnic nerve
 To the left: descending thoracic aorta, thoracic duct, trachea, oesophagus and left
vagus nerve
Tributaries of Azygos Vein
The azygos vein receives the following veins:

 Right superior intercostal vein. This receives the right 2nd–4th posterior
intercostal veins.
 Right 5th–11th right posterior intercostal veins (Fig. 37)
 Hemiazygos vein. This crosses the midline at T8 to join the azygos vein
 Accessory hemiazygos vein. This crosses the midline at T7 to join the azygos
vein
- 200 -
 Right subcostal vein or a common trunk formed by this and the right ascending
lumbar vein. This trunk joins the azygos vein at T12
 Numerous oesophageal, mediastinal and pericardial veins
 Two right bronchial veins. These join the azygos vein near its termination.
Variations of Azygos Vein

 The arch of azygos vein may arch over the apex of the right lung, sinking into it,
and cutting off an azygos lobe. This lobe lies medial to the azygos vein and its
pleural mesentery.
 The left posterior intercostal veins may open directly into the azygos vein, rather
than into hemiazygos and accessory hemiazygos veins.
Hemiazygos Vein
The hemiazygos vein

 Arises either as a continuation of the left subcostal vein, or a continuation of the
common trunk formed by the left subcostal and ascending lumbar veins. In the
latter case, the hemiazygos vein ascends deep to the left crus of the diaphragm
(Fig. 37).
 May arise in the lumbar region, from the posterior aspect of the left renal vein. In
this instance, the hemiazygos vein pierces the left crus of the diaphragm (as it
ascends from the lumbar region), and is joined (at T12) by a common trunk
formed by the left subcostal and ascending lumbar veins.
 Ascends on the vertebral column, on the left side of the midline. At the level of
T8, the hemiazygos vein crosses the midline to the right, to join the azygos vein.
As it does so, it lies behind the thoracic duct, descending thoracic aorta, and the
oesophagus.
 Communicates with the accessory hemiazygos vein above, and the left renal
vein below.
Tributaries of hemiazygos vein include:

 The left 9th, 10th, and 11th posterior intercostal veins (Fig. 37)
 The left subcostal vein, left ascending lumbar vein, or the common trunk
formed by these veins
 Few oesophageal and mediastinal veins
Accessory Hemiazygos Vein
The accessory hemiazygos vein

 Descends on the vertebral column, on the left of the midline, from T5–T7. At the
level of T7, it crosses the midline from left to right, to join the azygos vein (Fig.
37). As it does so, it lies behind the thoracic duct and descending thoracic aorta.
- 201 -
 Receives the left 5th–8th posterior intercostal veins (and occasionally the 4th
one).
 Occasionally receives the left bronchial veins
 Communicates with the left superior intercostal vein above, and the hemiazygos
vein below
 Drains into the azygos vein
Highest Posterior Intercostal Veins
Note the following:

 Each of the two highest posterior intercostal veins ends in the corresponding
brachiocephalic (or vertebral) vein. It drains the 1st intercostal space.
Applied Anatomy of Azygos System of Veins
Note these facts:

 Azygos vein links the SVC and IVC together, thereby creating alternative venous
channels for tributaries of these large veins.
 Obstruction of the SVC above the entry of the azygos vein would result in a
situation where blood flows through the veins of the abdominal wall, the IVC,
azygos vein and finally into the right atrium
 Obstruction of the IVC results in an arrangement where blood flows through the
common iliac vein, ascending lumbar vein and hemiazygos vein, SVC and finally
into the right atrium
 The azygos vein may receive all the blood of the lower half of the body (except
the digestive organs)
Lymph Nodes of the Thorax
Groups of lymph nodes associated with the thorax include:

 Intercostal lymph nodes
 Parasternal lymph nodes
 Diaphragmatic lymph nodes
 Brachiocephalic lymph nodes
 Posterior mediastinal lymph nodes
 Paratracheal lymph nodes
 Superior tracheobronchial lymph nodes
 Inferior tracheobronchial lymph nodes
 Bronchopulmonary lymph nodes
 Pulmonary lymph nodes
Intercostal Lymph Nodes
Intercostal lymph nodes
- 202 -
 Exist as one or two nodes at the posterior end of each intercostal space
 Receive afferent lymph vessels from the parietal pleura, deep tissues of the
posterolateral thoracic wall and the mammary gland
 Give rise to efferent vessels (from nodes in the upper intercostal spaces) that
drain into the thoracic duct on the left and the right lymphatic duct on the right.
 Give rise to efferent vessels (from nodes in the lower 4 or 5 intercostal spaces)
that drain via the descending intercostal trunk into the cisterna chyli.
Parasternal (Internal Thoracic) Nodes
The parasternal nodes

 Are located along the internal thoracic artery, at the sternal ends of the intercostal
spaces
 Are four or five in number, on each side
 Drain the mammary gland and the anterior thoracic wall
 Also receive some afferent vessels from the liver, diaphragm, pericardium and
anterior abdominal wall (above the umbilicus). These drain into those nodes
located behind the xiphoid process
 Give rise to efferent vessels that unite with those from the tracheobronchial and
brachiocephalic nodes to form the bronchomediastinal trunk, on each side.
Diaphragmatic Lymph Nodes

The diaphragmatic lymph nodes exist in groups. These include posterior group,
anterior group and lateral groups.
Posterior group of diaphragmatic nodes

 Lies behind the crura of the diaphragm, in the posterior mediastinum
 Drains the diaphragm. It also receives afferent vessels from the lateral (middle)
diaphragmatic nodes
 Drain into the posterior mediastinal nodes.
Anterior group of diaphragmatic nodes

 Consists of about 5 nodes located behind the base of the xiphoid process and the
7th costochondral junction.
 Receives afferent vessels from the diaphragm and liver
 Drains into the parasternal nodes
Lateral (or middle) group of diaphragmatic nodes

 Exists as two or three nodes on each side, around the point of entry of the phrenic
nerve into the diaphragm
 Also include nodes that lie anterior to the IVC, within the fibrous pericardium (on
the right side)
 Receives afferent vessels from the diaphragm and liver
- 203 -
 Drain into the parasternal, posterior mediastinal and brachiocephalic nodes
Brachiocephalic nodes
 Are located in the superior mediastinum, anterior to the brachiocephalic veins,
brachiocephalic trunk and the left subclavian and common carotid arteries.
 Receive afferent vessels from the thyroid gland, thymus, and pericardium. They
also receive vessels that drain the lateral group of diaphragmatic nodes
 Give rise to efferent vessels that unite with those from the tracheobronchial and
parasternal nodes to form the bronchomediastinal trunk.
The posterior mediastinal lymph nodes

 Are located around the oesophagus, in the posterior mediastinum.
 Receive afferent vessels from the oesophagus, pericardium, diaphragm, and
occasionally the left lobe of the liver.
 Also receive vessels from the lateral and posterior groups of diaphragmatic
nodes
 Drain (via efferent vessels) into the thoracic duct, descending intercostal lymph
trunk and tracheobronchial nodes.
Paratracheal lymph nodes

 Lie along each side of the thoracic part of the trachea
 Receive afferent lymph vessels from the trachea and surrounding structures
 Give rise to efferent vessels that join the bronchomediastinal trunks
Superior tracheobronchial nodes

 Are located at the junction of the lower end of the trachea and the origin of the
main bronchus, on each side.
 Are continuous on each side with the bronchopulmonary nodes (located along
the extrapulmonary bronchus)
 Drain the trachea, main bronchi, and the left aspect of the heart
 Give rise to vessels that drain into the paratracheal nodes
Inferior tracheobronchial nodes

 Occupy the angle between the two main bronchi (below the bifurcation of the
trachea)
 Receive lymph vessels from the trachea and bronchi
 Drain into the superior tracheobronchial nodes
 Bronchopulmonary nodes
 Are located in the hilus of the lung
 Receive afferent vessels from the visceral pleura, lung and bronchi
 Drain into the tracheobronchial nodes
Pulmonary lymph nodes
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 Are located along the intrapulmonary bronchi. Thus, they drain the deep tissues
of the lung
 Drain into the bronchopulmonary nodes
Bronchomediastinal Trunk
Note the following:

 Each bronchomediastinal trunk is formed by the union of efferent lymph
vessels from the tracheobronchial, parasternal and brachiocephalic nodes. Thus, it
drains these lymph nodes.
 Each bronchomediastinal trunk opens into the junction of the internal jugular
and subclavian veins of its own side
 The left bronchomediastinal trunk may drain into the thoracic duct
 The right bronchomediastinal trunk may join the right lymphatic duct
Cisterna Chyli
The cisterna chyli

 Appears as a dilated sac in most individuals (Fig. 38). It may however exist as an
anastomotic network between the two lumbar lymph trunks
 Is 5–7 cm long and 6 mm wide
 Is situated in the abdominal cavity, on the bodies of L1 and L2 vertebrae (to the
right of the abdominal aorta)
 Lies behind the right crus of the diaphragm, anterior to the lumbar azygos vein
(when this is present) and the upper two right lumbar arteries.
Tributaries of cisterna chyli include:

 Right and left lumbar trunks. These drain the lumbar lymph nodes
 The intestinal trunks. These receive efferent vessels from the coeliac and
superior mesenteric nodes.
 Occasionally the descending intercostal trunks (that drain the intercostal nodes
of the lower 5 intercostal spaces)
Thoracic Duct
The thoracic duct

 Is one of the major lymph vessels of the body
 Is 38–45 cm long and 2 mm wide (on average). It may however be as wide as 5
mm at its lower end.
 Commences at the level of the lower border of T12, as a continuation of the
cisterna chyli (Fig. 38)
 Traverses the aortic hiatus, and ascends on the vertebral column (on the right of
the midline) to the level of the T5 vertebra. At this level, the thoracic duct
deviates from the right to the left of the midline, and then ascends in this position
to the root of the neck.
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 Enters the neck, where it ascends for about 4 cm above the clavicle (behind the
left common carotid and internal jugular vessels), and then arches laterally to
open into the junction of the left subclavian and internal jugular veins (Fig.
38).
 Possesses several paired valves
 Drains lymph from all parts of the body, except the right halves of the head, neck
and thoracic wall, right upper limb, right lung and right aspect of the heart (Fig.
38)
Figure 38. Thoracic duct and right lymphatic duct
Tributaries of the thoracic duct include:

 Some efferent vessels from the posterior mediastinal nodes
 Efferent vessels from the intercostal nodes of the left upper six intercostal spaces
 The descending intercostal trunk that drains the intercostal nodes of the lower 5
intercostal spaces (one on each side)
 A trunk (one on each side) that pierces the crus of the diaphragm, and which
receives vessels from the upper lumbar nodes
 The left jugular and subclavian lymph trunks that drain the left half of the head
and neck and the left upper limb respectively. These however may open
independent of the thoracic duct, into the left jugular or subclavian vein.
 The left bronchomediastinal trunk, which may also open independent of the
thoracic duct, into the left venous angle (junction of the left internal jugular and
subclavian veins)
Right Lymphatic Duct

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The right lymphatic duct

 Is found only in about 20% of the population; and is formed by the union of the
right jugular, subclavian and bronchomediastinal trunks. It measures 1 cm in
length.
 Is located in the root of the neck, where it opens into the right venous angle
(junction of the right internal jugular and subclavian veins) (Fig. 38)
 Possesses a pair of valves it its terminal end
 Drains lymph from the right aspects of the head and neck via the right jugular
trunk; and from the right upper limb via the right subclavian trunk (Fig. 38)
 Receives the right bronchomediastinal trunk that drains the right half of the
thorax.
Applied Anatomy
Note the following:

 The thoracic duct is liable to injury in surgical operations of the posterior
mediastinum, owing to its colourless appearance and the thinness of its wall.
 Rupture of the thoracic duct may produce chylothorax – presence of lymph in
the pleural cavity
 The thoracic duct may be duplicated along its length
 Metastases may form in lymph nodes of the thoracic cavity in carcinoma of
thoracic organs. For example, CA of the lung can produce metastases in
tracheobronchial nodes.
CHAPTER 10: HISTOLOGY OF THE HEART AND BLOOD VESSELS

Structural Plan of Blood Vessels
Large blood vessels have three structural layers:

1. Tunica intima (innermost layer)
2. Tunica media (middle layer)
3. Tunica adventitia (most external layer)
Tunica intima
The tunica intima has the following layers:

 Endothelium, a layer of flattened polygonal cells that line the interior of all
blood vessels. Endothelial cells are supported by the basal lamina
 Subendothelial layer of loose connective tissue. This lies beneath the basal
lamina of endothelium
 Internal elastic lamina, a layer of elastic laminae and fibres found only in
arteries
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Tunica Media
Tunica media of blood vessels has the following structural components:

 Smooth muscle fibres. These are arranged in concentric layers, and its
prominence depends on the type of vessel.
 Elastic fibres and laminae. This layer is most prominent in elastic arteries, and
consists of fibres and laminae of elastin, which intersperse the smooth muscle
fibres.
 Collage type III fibres (reticular fibres)
 Ground substance of glycoproteins and proteoglycans
Tunica Adventitia
Note the following:

 Tunica adventitia is the most external structural layer of blood vessels. It
consists of collagen type I
 Elastic fibres are also found in tunica adventitia
 Certain small blood vessels – vasa vasorum – traverse the tunica adventitia to
supply the wall of large blood vessels.
Blood Capillaries
Blood capillaries
 Are distal continuations of the arterioles. They are microscopic vessels smaller in
diameter than sinusoids
 Possess a fairly uniform diameter (about 8 µm across on average)
 Have an endothelium of flattened polygonal cells that rest on a basal lamina.
Certain perivascular cells – pericytes – are closely associated with this basal
lamina.
 Are separated from the extravascular structures by a thin reticular tissue
containing fibroblasts
 Drain distally into venules. Like the latter, capillaries are sites of exchange of
materials between the blood and extravascular tissues.
 May be defined as either continuous, as in skin, lung, connective tissue and
muscle, or fenestrated, as in renal glomeruli, pancreas and endocrine glands.
Fenestrated (Visceral) Capillaries
Fenestrated capillaries
 Have endothelial cells with extremely thin cytoplasm, which is perforated by
fenestrae (pores). The latter measure 30–100 nm across and are closed by thin
diaphragm
 Are typical of the kidney, endocrine glands and pancreas.
Continuous (Somatic) Capillaries

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Continuous capillaries
 Are lined by endothelial cells with sparse organelles (including Golgi apparatus,
ribosomes, RER, mitochondria and centrioles).
 Lack pores in their wall.
 Are found in connective tissue, muscle, skin, lung and brain.
Sinusoids
Sinusoids
 Are larger than capillaries. They are 30–40 µm across
 May be fenestrated in type, as in certain endocrine glands (adenohypophysis,
adrenal cortex, and pancreatic islets)
 May be discontinuous in type, as in the liver, where they possess flattened
phagocytic (Kupffer) cells.
 Possess basal lamina that is very thin. This lamina may be discontinuous or even
absent.
 Permit easy exchange of materials between the blood and extravascular tissue
Venules
Venules
 Arise from capillaries; and are 0.1 – 0.5 mm in diameter
 Possess a tunica intima consisting of the endothelium and a subendothelial layer
of connective tissue. External to this is an adventitia of connective tissue
(containing collagen fibres and fibroblasts).
 Allow exchanges of materials between the blood and extravascular tissue (as do
capillaries and sinusoids). They are also involved in inflammatory response
(e.g., oedema)
Arterioles
Arterioles may exist as:

 Relatively large vessels, about 50 – 100 µm across
 Terminal arterioles, which are less than 50 µm across
 Small vessels – metarterioles – about 12 µm across. These branch off from the
terminal arterioles to supply capillaries.

 Tunica intima of arterioles consists of the endothelium and a thin subendothelial
layer. The internal elastic lamina is absent
 Tunica media of arterioles contains few layers of circularly-disposed smooth
muscle fibres. Interspersing these are elastic fibres and fibroblasts. External
elastic lamina is absent. Metarterioles have just a layer of smooth muscle fibres.
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 A thin tunica adventitia invests arterioles externally. This contains collagen

fibres and fibroblasts.
Veins
Regarding veins, note these points:

 Veins are defined as small, medium or large. Most are 1 – 9 mm in diameter, and
are small or medium-sized vessels.
 Tunica intima of veins consists of the endothelium and the subendothelial layer
of connective tissue containing fibroblasts and elastic fibres
 Tunica media of veins is not as thick as in arteries. It consists of connective
tissue containing elastic and collagen fibres, fibroblasts and circularly-disposed
smooth muscle fibres.
 Tunica adventitia of veins contains elastic fibres, collagen fibres and fibroblasts
 SVC and IVC have element of cardiac muscle fibres in their tunica adventitia
(close to the heart)
 The coronary sinus possesses cardiac muscle fibres in its entire length
 The hepatic, portal, external iliac, renal and azygos veins also have element of
smooth muscle fibres in their tunica adventitia
Elastic Arteries
Like veins, arterial wall has three structural layers: tunica intima, tunica media and
tunica adventitia. Elastic arteries are large and include the aorta and its large braches.
Their elasticity enable them to accommodate the high blood pressure at ventricular
systole.
Tunica intima of elastic arteries is arranged in layers. These include, from internal
externally:
1. The endothelium.
2. Subendothelial connective tissue containing a network of elastic and collagen
fibres, fibroblasts and mast cells
3. Internal elastic lamina. This is a layer of fenestrated sheet of elastic tissue.
Tunica media of elastic arteries consists of the following:

 Concentric layers of fenestrated elastic membranes. These layers could be up to
40 in the newborn and 70 in adult.
 Layers of smooth muscle fibres found between the elastic laminae. Also present
are collagen type III fibres.
 External elastic lamina, located adjacent to the tunica adventitia. It is made up
of elastin.
Tunica adventitia of elastic arteries
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Tunica adventitia of elastic arteries is made up of connective tissue containing

collagen and elastic fibres and fibroblasts. It contains vasa vasorum; and merges
with perivascular connective tissue.
Muscular Arteries
Tunica intima
Tunica intima of muscular arteries is similar to that of elastic arteries (see above).
Regarding tunica media of muscular arteries, note that

 Several layers of smooth muscle fibres are present (up to 40 layers in certain
vessels). These are arranged spirally in large muscular arteries and circularly in
small ones.
 Interspersing the smooth muscle fibres are elastic fibres and laminae, collagen
type III fibres, proteoglycans and glycoproteins. These are produced by the
smooth myocytes.
 An external elastic lamina lies adjacent to the tunica adventitia.
Tunica adventitia of muscular arteries

 Is a layer of connective tissue that contains longitudinally-disposed collagen and
elastic fibres
 Is loose in its outer part such that considerable movements are possible between
the artery and perivascular structure
Pericardium

 The fibrous pericardium consists of dense connective tissue. The latter is rich in
collagen fibres.
 The serous pericardium consists of a single layer of squamous cells –
mesothelium. This rests on a layer of loose connective tissue
 The loose connective tissue of the parietal layer of serous pericardium blends
with the fibrous pericardium; while that of the visceral layer of serous
pericardium blends with the connective tissue of the myocardium, and it contains
abundant fat in the interventricular grooves, coronary sulcus and inferior border
of the heart.
Structure of the Heart
The heart has three structural layers; these include:

1. Epicardium – the most external layer
2. Myocardium – the intermediate muscular layer; and
3. Endocardium – the most internal layer
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The endocardium
 Is made up of the endothelium and the subendothelial connective tissue
 Line the chambers of the heart; and is continuous with the tunica intima of
blood vessels.
 Is smooth, glistening and thin.
 Forms the valves of the heart by its folding and duplication.
The endothelial layer of the endocardium

 Is the most internal layer of the endocardium. It lines the cavities of the heart
 Consists of a single layer of flattened polygonal cells. These rest on the
subendothelial connective tissue (that lies external to it).
The subendothelial tissue of the endocardium

 Lies just beneath the endothelium, with which it forms the endocardium
 Contains collagen fibres, elastic fibres and fibroblasts
The subendocardial layer of the heart

 Is located just beneath the endocardium, which it binds to the myocardium.
 Consists of loose connective tissue (containing blood vessels, nerve fibres and the
conducting tissue of the heart).
 Is absent in the papillary muscles and chordae tendineae
Myocardium
The myocardium
 Consists of specialised cardiac muscle cells. These are arranged in an intricate
manner (Fig. 16).
 Is arranged differently in the atria and ventricles.
 Is absent in the fibrous interventricular septum and fibrous rings of the heart.
Thus, the atrial and ventricular musculature is discontinuous.
Atrial Musculature

 Atrial cardiac muscle fibres are arranged in two layers: superficial and deep
layer
 Superficial layer of atrial muscle fibres is common to both atria
 Deep layer of atrial muscle fibres is confined to each atrium. It forms circular
rings in the auricles and around venal caval openings
Ventricular Musculature
Regarding ventricular musculature, Note the following points:
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 Cardiac muscle fibres of the ventricles are arranged in several layers. These form
spirals around each ventricle
 In the wall of each ventricle, spiraling layers of muscle fibres sweep from the
atrioventricular orifice to the apex of the ventricle, and back to the orifice.
 A muscular spiral, which is superficially placed as it extends from the
atrioventricular orifice to the ventricular apex, becomes deeply placed as it
returns from the apex to the orifice
 Muscular spirals in the ventricular walls are attached to the fibrous rings around
the atrioventricular orifices
 Papillary muscles and trabeculae carneae of the ventricles are formed from
deeply placed cardiac muscle fibres.
Cardiac Conduction System
The conduction system of the heart consists of the following:

1. Sinoatrial node (SAN)
2. Atrioventricular node (AVN)
3. Atrioventricular bundle of His (AV bundle)
4. Right and left limbs of AV bundle
5. Purkinje fibres (in the walls of the ventricles)
Figure 39. Conduction system of the heart

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Sinoatrial Node
The sinoatrial node

 Is a horse-shoe shaped body located in the wall of the right atrium, at the junction
of the latter with the SVC (Fig. 39). It occupies the whole thickness of the atrial
musculature, from the epicardium to the endocardium.
 Consists of specialised cardiac muscle cells (termed nodal fibres). These are
smaller in calibre than the ordinary cardiac muscle cells. some fine unmyelinated
nerve fibres are also found in the node; while numerous nerve cells lie adjacent
to, but not within the node.
 Generates the electrical impulse required for the contraction of the heart. Thus, it
is referred to as the pacemaker.
 Is not linked to the AV node by any specialised conducting pathways or nerve
fibres. Rather, impulse generated by SAN spreads through the atrial musculature
to the AV node
 Receives autonomic innervation from the cardiac plexus. Stimulation of the
sympathetic fibres increases the rate and force of cardiac contraction, while
parasympathetic fibres do the opposite.
Regarding the SA node, note the following:

 Cells of the SA node are directly in contact with those of the right atrium, such
that impulse generated by this node can readily spread through the right atrium, to
the left one.
 Nodal fibres have a higher rate of intrinsic rhythmical contraction but a slower
rate of impulse conduction (compared to Purkinje fibres, where the opposite is
the case)
 SAN generates impulse for the contraction of cardiac muscle at approximately 70
time per minute
The atrioventricular node

 Is located above the orifice of the coronary sinus, in the postero-inferior part of
the interatrial septum (Fig. 39).
 Is smaller in size than the SA node
 Receives impulse from the SAN. This impulse reaches the AVN by myogenic
conduction (via the atrial musculature).
 Is continuous distally with the atrioventricular (AV) bundle. This conveys
impulse from the AVN.
 Is devoid of nerve cells

 Impulses generated by the SAN reaches the AVN by myogenic conduction (by
means of the atrial muscle fibres)
 The fibrous interventricular septum and the fibrous rings (around the AV
orifices) are devoid of cardiac muscle fibres, and thus, prevent electrical impulse
- 214 -
from travelling directly from the SAN or AVN to the ventricles. Thus, there is a
time lag between atrial and ventricular contraction.
 Impulse reaches the ventricles from the AV node only via the AV bundle and its
limbs.
The atrioventricular bundle

 Traverses the fibrous part of ventricular septum where it lies beneath the
attachment of the septal cusp of tricuspid valve. It terminates adjacent to the
upper border of the muscular ventricular septum, by dividing into right and left
limbs (Fig. 39). These run distally on the ventricular septum, just deep to the
endocardium.
 Possesses conducting fibres that are similar to ordinary cardiac muscle cells; but
these have higher speed of impulse conduction.
 Is invested by a delicate connective tissue sheath that insulates it
 Is devoid of nerve cells in man. However, it contains a few nerve fibres
 Is the only means of transmitting electrical impulse from the atrial to the
ventricular musculature.
Right Limb (Right Bundle) of AV Bundle
The right limb of AV bundle

 Runs forwards in the subendocardial tissue, from the AV bundle, towards the
apex of the heart, on the right surface of the muscular part of the interventricular
septum (Fig. 39).
 Traverses the septomarginal trabecula (moderator band) to reach the base of
the anterior papillary muscle of the right ventricle
 Divides (at the base of the right papillary muscle) into numerous strands made of
Purkinje fibres. These strands spread over the surface of the right ventricle, to
terminate in close proximity to its muscle fibres
 Possesses (in its proximal part) conducting fibres that resemble ordinary cardiac
muscle cells
 Is invested by a delicate connective tissue sheath that insulates it
 Is rounded, in contrast to the left limb, which is flattened.
The Left Limb (Left Bundle) of AV Bundle
The left limb of AV bundle

 Runs on the left surface of the muscular interventricular septum, deep to the
endocardium (Fig. 39)
 Splits into two or more smaller bundles a short distance from its origin. These
bundles run in the subendothelial tissue to the bases of the left papillary
muscles, which they reach via the trabeculae carneae
 Forms a network of tiny fibres at the bases of the left papillary muscles. These
spread over the surface of the left ventricle, deep to the endocardium; and are
continuous with the ordinary muscle fibres of this ventricle.
- 215 -
 Is also invested by a delicate connective tissue sheath, which insulates it from

adjacent structures as it traverses the subendothelial tissue.
 Possesses (in its proximal part) conducting fibres that resemble ordinary cardiac
muscle cells
 Is flattened in outline
Purkinje Fibres
In human, Purkinje fibres

 Are relatively larger than ordinary cardiac muscle cells.
 Are seen in the subendocardial plexuses of the ventricles and in the distal parts
of the limbs of AV bundle
 Are specialised to conduct impulse to the ventricular musculature, papillary
muscles and trabeculae carneae (at a relatively high speed of 1.5 – 4 m/sec).
Blood Supply to the Conducting Pathway

 In about 60% of the population, the SAN receives arterial supply from the
sinoatrial nodal branch of the right coronary artery.
 In about 80% of the population, the AVN is supplied by a branch of the right
coronary artery
 Branches of the right coronary artery often supply the AV bundle and its right
limb. The left limb of AV bundle usually receives branches of both coronary
arteries
Applied Anatomy of the Conducting System of the Heart

 Certain arteries that supply the conducting tissue of the heart constitute common
sites of arterial occlusion. Such vessels include posterior interventricular branch
of the right coronary artery, and the anterior interventricular and circumflex
branches of the left coronary artery.
 Coronary arterial diseases, which affect the vessels of the AV node, AV bundle,
or its limbs, could result in heart block. In this condition, conduction of electrical
impulse from atrial musculature to the ventricles is impaired.
 Heart block (resulting from damage to the AV node or its bundle) is
characterised by slower rate of rhythmic contraction of the ventricles (as these
contract independent of the atria at 15 – 40 beats/min.)
 In heart block, an artificial pacemaker may be used. This helps to coordinate
ventricular contraction (as impulse cannot normally reach the ventricles from the
SAN)
 Damage to one of the limbs of the AV bundle will result in bundle branch
block. In this instance, electrical impulse spreads from the normal ventricle to the
- 216 -
one supplied by the damaged limb; and contraction of the ventricle supplied by
the damaged limb is dictated by the normal ventricle
 Electrocardiogram is the procedure that uses an electrocardiograph to record
the electrical activity of the heart
 Atrial fibrillation is the most common type of cardiac arrhythmia, and is
characterised by irregular rhythm of contraction of the atria (and irregularity of
the pulse). It arises when cardiac muscle cells in the wall of the atria undergo
changes that interfere with the proper propagation of electrical impulses (e.g.,
increases in fibrous tissue associated with aging).
 Ventricular fibrillation is a type of arrhythmia characterized by irregular and
uncoordinated contraction of the ventricles; and may result in death unless
emergency interventions are instituted. Ventricular fibrillation may arise from
myocardial infarction, electric shock, deprivation of oxygen, abnormally high
levels of potassium or low levels of calcium in the blood, or the use of certain
drugs.
CHAPTER 11: GROSS ANATOMY OF THE DIGESTIVE SYSTEM

Planes and Regions of the Abdomen
Planes of the abdominal region include:

 Transpyloric plane of Addison;
 Transtubercular plane;
 Midclavicular plane;
 Subcostal plane; and
 Supracristal plane
 Transumbilical plane
 Interspinous plane
The transpyloric plane

 Is a transverse abdominal plane located midway between the suprasternal notch
and symphysis pubis, at the level of L1
 Crosses the costal margin at the tip of the 9th costal cartilage
 Indicates the approximate position of the pylorus of the stomach and fundus of
the gallbladder
The transtubercular plane

 Is a transverse plane located at the level of L5. It is drawn at the level of the iliac
tubercles, hence the name
 Is below the level of the umbilicus (Fig. 40)
The midclavicular line

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 Is a vertical plane located about 9 cm from the midline (Fig. 40)

 Passes through the middle of the clavicle, as well as the midinguinal point
 Is also called the lateral plane or mammary line
The subcostal plane

 Is a transverse plane drawn at the level of the most dependent parts of the 10th
costal cartilages (Fig. 40)
 Corresponds to the level of upper border of the body of L3 vertebra
 May be used in place of the transpyloric plane
The supracristal plane

 Is a transverse plane located at the level of the highest parts of the two iliac crests
 Corresponds to the level of the spinous process of the L4 vertebra
 Is useful in identifying individual vertebral spinous processes (on the back)
The transumbilical plane

 Is a transverse plane located at the level of the umbilicus
 Corresponds to the level of the disc between L3 and L4
The interspinous plane

 Is a horizontal plane passing through the anterior superior iliac spine,
 Can be used to separate the lateral and umbilical regions superiorly from
the inguinal and pubic regions inferiorly.
Regions of the Abdomen

Regions of the abdominal cavity are nine (Fig. 40). They are delineated by two
vertical lines (right and left midclavicular lines) and two horizontal lines (subcostal
and transtubercular lines).
The regions of the abdomen include:

 Epigastric region
 Right hypochondriac region
 Left hypochondriac region
 Umbilical region
 Left lumbar region
 Right lumbar region
 Hypogastric region
 Left iliac (or inguinal) region; and
 Right iliac (or inguinal) region
- 218 -
Figure 40. Regions of the abdominal cavity and the organs in each
Quadrants of the Abdomen
Note that abdominal quadrants:

 Are four in number: right upper, right lower, left upper and left lower quadrants
 Are delineated by the median plane and transumbilical plane. The latter is
transverse plane located between L3 and L4 vertebrae
- 219 -
 Contain the abdominal viscera. Specific organs occupy specific quadrants (see
below).
The right upper quadrant contains the following organs:

 Right lobe of the liver
 Gallbladder
 Head of the pancreas
 Pylorus of the stomach
 Right kidney and suprarenal gland
 First, 2nd, and 3rd parts of the duodenum
 Right colic flexure
 Upper part of ascending colon
 Right half of transverse colon
The left upper quadrant contains the following organs:

 Spleen
 Left lobe of the liver
 Stomach
 Body and tail of pancreas
 Left kidney and suprarenal gland
 Jejunum and proximal part of ileum
 Upper part of descending colon
 Left colic flexure
 Left half of transverse colon
The right lower quadrant contains the following organs:

 Caecum and vermiform appendix
 Larger part of the ileum
 Right ovary
 Lower part of ascending colon
 Right uterine tube
 Part of the right spermatic cord
 Abdominal part of right ureter
 Urinary bladder (if distended)
 Uterus (if gravid)
The left lower quadrant contains the following organs:

 Lower part of descending colon
 Sigmoid colon
 Left ovary
 Left uterine tube
 Abdominal part of left ureter
 Part of the left spermatic cord
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 Urinary bladder (when distended)

 Uterus (when pregnant)
Peritoneum
The peritoneum
 Is the largest and the most complexly folded serous membrane
 Lines the abdominopelvic cavity
 Forms a closed peritoneal cavity in males. In females, this cavity is ‘open’. In
this instance, the peritoneal cavity communicates with the exterior via the genital
tract.
 Exists in two layers: parietal and visceral peritoneum. Parietal peritoneum lines
the abdominopelvic wall; while visceral peritoneum invests abdominopelvic
organs.
 Is lined on its free surface by the mesothelium – a layer of flattened polygonal
cells
 Develops from the lateral plate mesoderm of the embryo
 Prevents adhesion between adjacent viscera, in the abdominopelvic cavity
The parietal peritoneum

 Is the part of the peritoneum that lines the wall of the abdominopelvic cavity
 Is separated from the abdominal wall by extraperitoneal connective tissue
 May be readily stripped from the abdominal wall. It is reflected at certain points
to form mesenteries and folds
 Is innervated by somatic nerves (in contrast to the visceral peritoneum, which
has autonomic innervation)
 Is extremely painful in peritonitis (inflammation of the peritoneum)
The visceral peritoneum

 Is the part of the peritoneum that invests most abdominopelvic organs (either
partially or completely)
 Is an integral part of the wall of the gastrointestinal tract, where it forms the
serosa
 Cannot be readily stripped from the organs in invests.
 Is innervated by autonomic fibres; and may produce ‘dull’ pain when inflamed.
The peritoneal cavity

 Is the potential space between the parietal and visceral layers of the peritoneum.
It contains a film of fluid (for lubrication).
 Is lined by mesothelial cells that rest on a basal lamina
 Is ‘open’ in females (i.e., it communicates with the exterior via the vagina); but is
closed in males.
 Provides a warm, moist and aseptic environment for the abdominal viscera.
 Does not contain any organs
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 Is divisible into two compartments: lesser sac (or omental bursa) and greater
sac. These sacs communicate via an epiploic foramen.
Omental Bursa
The omental bursa

 Is the smaller of the two compartments of the peritoneal cavity (Fig. 41)
 Is related anteriorly to the stomach, caudate lobe of the liver, lesser omentum,
and anterior wall of greater omentum
 Is related posteriorly to the pancreas, transverse colon, left kidney and
suprarenal gland
 Communicates with the greater sac of the peritoneal cavity via the epiploic
foramen of Winslow.
Figure 41. Greater and lesser sacs of the peritoneal cavity
Epiploic Foramen of Winslow (Aditus to the Lesser Sac)

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The epiploic foramen

 Is a vertical slit of about 3 cm; it connects the greater and lesser sacs of the
peritoneal cavity
 Is bounded anteriorly by the right margin of the lesser omentum. This contains
the portal vein, hepatic artery proper and bile duct
 Is bounded posteriorly by the inferior vena cava
 Has a roof formed by the caudate process of the liver
 Has a floor formed by the superior (1st) of the duodenum.
The lesser omentum

 Is a double fold of peritoneum that connects the stomach and initial 2 cm of the
duodenum to the portal hepatis of the liver
 Has a free right margin that contains the portal vein, bile duct and hepatic artery
proper
 Encloses lymph nodes, hepatic nerve plexus, and right and left gastric vessels
between its two layer of peritoneum
 Is thicker in its right than the left part
The greater omentum

 Is the largest of the peritoneal folds (Fig. 41). It is a derivative of the dorsal
mesogatrium
 Connects the stomach and proximal duodenum to the posterior abdominal wall
 Is continuous with the gastrosplenic ligament. The latter links the stomach with
the spleen
 Is folded on itself to form the inferior recess of omental bursa
 Has some capacity to store fat
 Wraps itself around an inflamed organ, thereby limiting the spread of infections
 Encloses the gastro-epiploic vessels in its layers, adjacent to the greater
curvature of the stomach
 Usually appears thin and cribriform; and may be absent or surgically removed
without adverse effects
 Lies above the transverse colon and mesocolon as it passes towards the posterior
abdominal wall
 Contains numerous macrophages that aggregate to form milky spots.
Organs of the Alimentary Tract
Oesophagus
The oesophagus
 Is a long muscular tube that connects the pharynx above to the stomach below
 Is 25 cm long and 2 cm in diameter
 Commences at C6 (lower border of cricoid cartilage) and ends at T11
 Has 3 parts: cervical, thoracic and abdominal parts
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 Receives arterial blood from the inferior thyroid arteries, oesophageal branches of
descending thoracic aorta, and the bronchial, left inferior phrenic and left gastric
arteries
 Drains into the inferior thyroid and left gastric veins, as well as the azygos system
of veins. It is a site of portocaval anastomoses (in its lower part)
 Receives parasympathetic fibre from the vagus nerves and sympathetic fibres
from the sympathetic chains
 Drains into deep cervical, posterior mediastinal and left gastric lymph nodes
 Is the narrowest part of the alimentary tract, next to the vermiform appendix
Oesophageal Constrictions
The oesophagus is constricted

 At its junction with the pharynx, about 15 cm from the incisor teeth
 By the aortic arch, about 22.5 cm from the incisor teeth
 By the left main bronchus, about 27.5 cm from the incisor teeth
 At the point where it pierces the diaphragm, about 40 cm from the incisor teeth
Relations and Applied Anatomy
The oesophagus
 Is related anteriorly to the trachea in its upper part
 Is related posteriorly to the vertebral column and thoracic duct
 Is related laterally to the pleural cavity (in the thoracic cavity)
 May elicit pain – pyrosis or heartburn – as a result of regurgitation of acidic
gastric contents into its lower part
 May develop cancer, especially in males above 45 years
Stomach
The stomach
 Is the most dilated part of the alimentary tract. It lies between the oesophagus
proximally and the duodenum distally
 Has an average volume of 30 ml at birth, 1000 ml at puberty and 1500 ml in the
adults. It can hold as much as 3000 ml of food.
 Occupies the left hypochondriac, epigastric and umbilical regions
 Has two orifices: cardiac orifice and pyloric orifice (Fig. 42)
 Has two curvatures (or borders): lesser curvatures and greater curvature (Fig.
42)
 Has two surfaces: anterosuperior and posteroinferior surfaces
 Consists of three main parts: fundus, body and pyloric part
 Secretes acidic gastric juice that enhances enzymatic digestion of food
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Figure 42. Parts of the stomach
Orifices of the Stomach
The cardiac orifice

 Lies at the proximal part of the stomach where it links this organ with the
oesophagus
 Is located at a distance of about 40 cm from the incisors, at the level of T11
vertebra. It is 3 cm from the midline and 10 cm behind the left 7th costal cartilage.
 Has no recognizable anatomical sphincter
The pyloric orifice

 Lies at the distal end of the stomach where it links this organ with the duodenum
 Has a recognizable pyloric sphincter (Fig. 42). The latter is a thickening of the
circular muscle layer of muscularis externus of the stomach
 Is located about 1.25 cm to the left of the midline at L1 (level of the 9th costal
cartilage), with the stomach empty and the subject supine.
 May lie as far down as L4 vertebra (with the stomach full and the subject erect).
In this instance, it is to the right of the midline
 Is more mobile than the cardiac orifice
 Is in indicated (on its external surface) by a prepyloric vein (tributary of the right
gastric vein).
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Anatomical Parts of the Stomach
The stomach has the following anatomical parts:

 Fundus
 Body; and
 Pyloric part
The fundus of the stomach

 Is the part that lies above a horizontal plane drawn across the cardiac orifice
(Fig. 42). It lies to the left of the cardiac notch, beneath the left dome of the
diaphragm
 May reach as high up as the 5th intercostal space
 Usually contains gas bubbles
The body of the stomach

 Is the largest anatomical part of the stomach
 Lies between the fundus and pyloric part of the stomach (Fig. 42)
The pyloric part of the stomach

 Is located between the body of the stomach proximally and the pyloric sphincter
distally (Fig. 42)
 Is divisible into a dilated proximal pyloric antrum and a narrow distal pyloric
canal. The latter is about 2.5 cm long.
 Terminates at the pyloric constriction, about 1.25 cm to the left of the midline,
at the level of L1
Curvatures of the Stomach
The stomach has two curvatures; these include:

 Lesser curvature; and
 Greater curvature
The lesser curvature of the stomach

 Is the right concave border of the stomach; it stretches between the cardiac and
pyloric orifices (Fig. 42)
 May present an angular notch in its most dependent part
 Gives attachment to the lesser omentum (a double-layered fold of peritoneum)
 Is closely related to the gastric arteries and veins, as these run between the
layers of the lesser omentum
The greater curvature of the stomach
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 Is the convex left border of the stomach. It also extends from the cardiac to the
pyloric orifices
 Is about four times the length of the lesser curvature
 Has its highest part at a point just below the left nipple in males (level of the left
5th intercostal space)
 Usually presents a bulge just opposite the angular notch of the lesser curvatures.
This serves as a useful landmark.
 Gives attachment to the gastrosplenic ligament in the region of the fundus
 Also gives attachment to the greater omentum in its lower part.
 Is closely related to the gastro-epiploic vessels as these run between the layers of
the greater omentum
Relations of the Stomach
Anterior relations of the stomach include:

 Left and quadrate lobes of the liver
 Anterior abdominal wall (6th – 9th costal cartilages and the associated intercostal
spaces)
 Diaphragm
The posterior relations of the stomach form the ‘stomach bed’. These include:
 Diaphragm, spleen and splenic artery
 Left kidney and suprarenal gland
 Transverse colon and mesocolon; and
 Body and tail of the pancreas
Interior of the Stomach
The interior of the stomach

 Appears reddish-grey in the living
 Has a gastric canal along the lesser curvature
 Possesses extensive longitudinal gastric folds or rugae
Blood Supply, Lymphatics and Innervation of the Stomach
The stomach
 Is supplied by the left and right gastric arteries (from the coeliac trunk and
common hepatic arteries respectively), and the short gastric arteries (from the
splenic artery).
 Is also supplied by the left and right gastro-epiploic arteries (from splenic and
gastroduodenal arteries respectively)
 Is drained by the right and left gastric veins (tributaries of hepatic portal
vein); short gastric and left gastro-epiploic veins (tributaries of splenic
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vein); right gastro-epiploic vein (tributary of superior mesenteric veins);

and prepyloric vein (tributary of the right gastric vein)
 Gives rise to efferent lymph vessels that drain into gastric, gastroepiploic,
pancreaticosplenic and pyloric nodes
 Receives parasympathetic fibres from anterior and posterior vagal trunks.
These are secretomotor to gastric glands, in addition to enhancing its
contraction.
 Receives sympathetic fibres from the coeliac plexus. The presynaptic fibres
arise from T6 – T9 spinal segments while postganglionic fibres arise from ganglia
in coeliac plexus.
Applied Anatomy of the Stomach
The stomach
 May elicit pain that may be referred to the epigastric region of the abdomen
 Has a higher incidence of cancer in males
 May be predisposed to peptic ulcer from Helicobacter pylori infestation and
chronic use of nonsteroidal anti-inflammatory drugs.
 May be removed partially or completely in gastrectomy
Small Intestine
In its entirety, the small intestine

 Extends from the pylorus to the ileocaecal junction
 Occupies the central and lower parts of the abdominal cavity
 Has an average length of 6 m in adult males
 Has three successive parts: duodenum, jejunum and ileum
Duodenum (Fig. 43)
The duodenum
 Is the shortest, widest and the least movable part of the small intestine
 Extends from the pylorus to the duodenojejunal junction, and has a C-shaped
course
 Measures about 25 cm in length and 4-5 cm in diameter
 Is retroperitoneal and thus devoid of mesentery (except in its proximal 2 cm)
 Has four parts: superior, descending, horizontal and ascending parts.
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Figure 43. The duodenum and associated organs (1, 2, 3, and 4 indicates 1st, 2nd, 3rd
and 4th parts of duodenum respectively).
Superior (or 1st) Part of the Duodenum
The superior part of the duodenum

 Commences about 1 cm to the right of midline, at the level of L1. It is about 5 cm
long
 Passes upwards, backwards and to the right, towards the neck of the gallbladder
 Is related anteriorly to the gallbladder and caudate lobe of the liver
 Is related posteriorly to the gastroduodenal artery, bile duct and portal vein
 Is related to the neck of the pancreas below and the neck of the gallbladder
above
 Forms a duodenal cap in radiography
Descending (2nd) Part of the Duodenum
The descending part of the duodenum

 Extends from L1 vertebra above to L3 vertebra below, just to the right of the
midline. It is 8–10 cm long
 Is related anteriorly to the liver and transverse colon
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 Is related posteriorly to the right kidney and right renal vessels

 Is related medially to the pancreas and laterally to hepatic flexure of the colon
 Receives the opening of the hepatopancreatic ampulla (of Vater) at a point
about 8 – 10 cm from the pylorus. The liver and exocrine pancreas drain into the
duodenum via this ampulla
Horizontal (3rd or Inferior) Part of the Duodenum
The horizontal (inferior) part of the duodenum

 Lies transversely across the posterior abdominal wall at L3
 Is about 10 cm long
 Is related anteriorly to the superior mesenteric vessels and the root of the
mesentery of the small intestine
 Is related behind to the IVC, aorta, right ureter and gonadal vessels
 Is related above to the pancreas, and below to the jejunum
Ascending (4th) Part of the Duodenum
The ascending (4th) part of the duodenum

 Is the shortest segment of the duodenum. It is about 2.5 cm in length
 Ascends from L3 vertebra below to L2 vertebra above, on the left aspect of the
midline
 Ends at the duodenojejunal flexure (at the level of L2), just to the left of the
midline
 Is related posteriorly to the inferior mesenteric artery, left gonadal and renal
vessels and the left sympathetic chain
 Is related anteriorly to the transverse colon; and above to the body of the
pancreas
 Has the left kidney and ureter on its left side
 Gives attachment to the suspensory muscle of the duodenum (ligament of Treitz)
– a fibromuscular band that stretches from the diaphragm to the duodenum
Blood Supply to the Duodenum
Owing to its dual embryologic origin (from foregut and midgut), the duodenum
 Is supplied by the superior pancreaticoduodenal arteries – indirect branches of
the coeliac trunk (artery of the foregut).
 Is also supplied by the inferior pancreaticoduodenal arteries – branches of
superior mesenteric artery (artery of the midgut).
 Provides a site of anastomoses between the coeliac trunk and superior mesenteric
artery
 Is drained by splenic and superior mesenteric veins.
Innervation of the Duodenum
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Nerves of the duodenum include:

 Sympathetic fibres, derived from the coeliac and superior mesenteric plexuses.
Stimulation of these fibres decreases peristalsis and secretory activity of duodenal
glands.
 Parasympathetic fibres, from the vagal trunks. Stimulation of these fibres
enhances peristalsis and secretory activity of duodenal glands.
 General visceral afferent fibres (that accompany the sympathetic fibres). They
convey impulse from the duodenum to the spinal cord.
Lymphatic Drainage of the Duodenum
Lymph vessels from the duodenum drain into the following nodes:
 Superior mesenteric nodes
 Pyloric nodes
 Pancreaticoduodenal nodes
Applied Anatomy of the Duodenum
Note the following:

 Duodenal ulcer usually involves the posterior wall of the superior (1st) part of
the duodenum
 The superior part of the duodenum forms a duodenal cap in an anteroposterior
radiograph of the abdomen
 Gallstone may enter the duodenum from a perforated gall bladder
 Inferior mesenteric vessels are at risk in surgical reduction of a paraduodenal
hernia
Jejunum (Fig. 44)
The jejunum
 Is 2/5 of the jejuno-ileal length; it is about 2.4 m long and 4 cm in diameter
 largely occupies the umbilical and left lumbar regions
 Has thicker wall when compared to the ileum; and it also possesses larger plicae
circulares and villi.
 Possesses fewer aggregated lymphoid follicles
 Is more vascular and thus appears reddish in the living
Ileum (Fig. 44)
The ileum
 Is the distal 3/5 of the jejuno-ileal length; it is about 3.6 m long and 3 cm in
diameter
 Largely occupies the hypogastric and pelvic regions of the abdominopelvic
cavity
- 231 -
 Has a thinner wall compared to the jejunum; it also possesses smaller plicae
circulares and villi
 Contains numerous aggregated lymphatic follicles – Peyer’s patches
 Is less vascular and is thus paler in appearance compared to the jejunum.
Blood Supply, Lymphatics, and Innervation of the Jejunum and Ileum
The ileum and jejunum

 are supplied by 12-18 ileal and jejunal arteries; these arise from the right side of
the superior mesenteric artery
 are drained by the superior mesenteric vein
 drain into the superior mesenteric lymph nodes
 receive parasympathetic fibres from the posterior vagal trunk, via the superior
mesenteric plexus. Postganglionic fibres arise in ganglia within the gut
 receive sympathetic fibres from T8-T11 spinal segments. These reach
coeliac and superior mesenteric plexuses via sympathetic chains, and
synapse in coeliac and superior mesenteric ganglia; postganglionic fibres
reach intestine by accompanying the arteries
 may develop ileus from ischaemia of a segment
- 232 -
Figure 44. Jejunum and ileum
Ileal Diverticulum (of Meckel)
The ileal diverticulum

 Is the remnant of the embryonic yolk stalk
 Is found in about 2% of the population
 Is located about 2 feet (50 m) from the ileocaecal valve, on the antimesenteric
border of the ileum
 measures about 2 inches (5 cm) in length
 May be connected to the umbilicus by a fibrous strand (in 26% of the cases). The
diverticulum is however usually free in most individuals
 May also contain gastric, pancreatic or ileal tissue
 May become inflamed; and in this instance, it elicits pain that is similar to that of
appendicitis.
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Mesentery of the Small Intestine
The mesentery
 Is a double-layered fold of peritoneum that attaches the ileum and jejunum to the
posterior abdominal wall
 Is fan-shaped in outline; and measures 6 m along its intestinal border.
 Has an oblique root that is 15 cm long. This extends (downwards and to the
right) from the left of the L2 vertebra to the upper part of the right sacro-iliac
joint; it crosses, successively, the 3rd part of the duodenum, abdominal aorta, IVC,
right ureter and psoas muscle
 Encloses between its layers, the superior mesenteric vessels and plexus, ileal
and jejunal vessels, lymph vessels and nodes, as well as adipose tissue.
 Possesses more fat in its caudal (ileal) part, but less fat in its jejunal part.
 Prevents the ileum and jejunum from becoming twisted or kinked
Large Intestine (Fig. 45)
The large intestine

 extends from the ileocaecal junction proximally to the anus distally
 Consists of the caecum, colon (described as ascending, transverse, descending
and sigmoid), rectum and anal canal.
 Is 1.5 m long and 6.5 cm in diameter
 Has 3 longitudinal bands – taeniae coli – on its surface (except in the appendix,
rectum and anal canal). These are formed by longitudinal muscle fibres of the
large intestine.
 Possesses puckered and sacculated wall (in the colon). These sacculations are
referred to as haustrations
 Also possesses fat-filled peritoneal sacs termed appendices epiploicae. These are
attached to its wall, but are absent from the appendix, caecum, rectum and anal
canal
 Absorbs water and electrolytes from its contents
Caecum (Fig. 45)
The caecum
 Is the first part of the large intestine. It is a cul-de-sac (blind sac)
 Occupies the right iliac fossa, below the level of the transtubercular plane and
lateral to the right midclavicular line. The caecum lies below the level of the
ileocaecal valve.
 Is 6 cm long and 7.5 cm wide
 Is completely invested by the peritoneum. It may however possess a mesentery,
in which case it becomes mobile, and may thus herniate into the right inguinal
canal.
 Possesses neither sacculations nor appendices epiploicae
- 234 -
 Rest behind on the right iliacus, psoas major, lateral cutaneous nerve of the thigh,
and femoral nerve. It lies above the lateral half of the right inguinal ligament
 Is related anteriorly to the anterior abdominal wall, but the greater omentum and
coil of small intestine may intervene
 Receives the opening of the terminal ileum – the ileocaecal orifice – on its
posteromedial wall, at its junction with the ascending colon.
 Also receives the opening of the vermiform appendix on its posteromedial wall,
2 cm below the ileocaecal orifice.
 Has a retrocaecal space behind it. This contains the vermiform appendix in
about 65% of the population.
Figure 45. The large intestine
Blood Supply, Lymphatics and Innervation of the Caecum
The caecum
 Is supplied by the anterior and posterior caecal branches of ileocolic artery
 Is drained by the ileocolic vein, a tributary of the superior mesenteric vein
 Drains via efferent lymph vessels into ileocolic nodes
 Receives its parasympathetic fibres from the vagal trunks
 Receives its sympathetic fibres from the superior mesenteric plexus
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Vermiform Appendix (Fig. 45)
The vermiform appendix

 Is a blind, worm-like tube attached to the posteromedial wall of the caecum,
about 2 cm below the ileocaecal orifice
 Measures 2–20 cm in length (an average of 9 cm)
 Possesses abundant lymphoid tissue in its submucosa. This feature greatly
narrows the lumen of the appendix and makes it of irregular outline
 Lacks taeniae coli, sacculations or appendices epiploicae
 Has a base (opening) that corresponds to the McBurney’s point. The latter
corresponds to the junction of the lateral and middle thirds of a line linking the
umbilicus to the right anterior superior iliac spine (about 2.5 cm superomedial to
the right anterior superior iliac spine). The gridiron (muscle-splitting) incision
for appendectomy is made at the McBurney’s point.
 Possesses a triangular meso-appendix that transmits the appendicular artery.
This peritoneal fold attaches the appendix to the lower part of the mesentery of
the small intestine
 Serves no appreciable digestive functions
Blood Supply, Lymphatics and Innervation of the Appendix
The vermiform appendix

 Is supplied by the appendicular artery (a branch of ileocolic artery)
 Is drained by ileocolic vein (a tributary of superior mesenteric vein)
 Drains via efferent lymph vessels into ileocolic nodes
 Receives parasympathetic fibres from the vagus nerve and sympathetic fibres
from the T10 segment of the spinal cord, via the superior mesenteric plexus.
Sensory fibres from the appendix end at the T10 segment of the spinal cord.
Position of the Vermiform Appendix
In terms of its position, the appendix may be

 Retrocaecal in position – 65% of the population
 Pelvic in position – 31% of the population
 Subcaecal in position – 2% of the population
 Pre-ileal in position – 1% of the population
 Post-ileal in position – 0.5% of the population
Note: In few instances of malrotation of the intestine, or failure of descent of

the caecum, the appendix does not lie in the lower right quadrant. If the cecum
is subhepatic, the appendix lies in the right hypochondriac region and the pain
of appendicitis localizes there (and not in the lower right quadrant).
Applied Anatomy of the Vermiform Appendix
- 236 -
Appendicitis is inflammation of the appendix. In this condition,

 The lumen of the appendix is occluded by a faecalith or by hyperplasia of the
lymphoid tissue of this organ
 Loss of appetite, vomiting and rigidity of anterior abdominal wall occur. White
blood cell count also increases.
 Pain is referred to the periumbilical region via the T10 nerves. Tenderness also
occurs in the right lower quadrant of the abdomen; and flexion of the thigh
reduces pains
 Thrombosis of the appendicular artery may occur, leading to ischaemia of the
organ
 The appendix may also rupture – burst appendix. This will result in peritonitis
(inflammation of the peritoneum)
 Appendectomy (excision of the appendix) is usually performed through a
gridiron (muscle splitting) incision
Ascending Colon (Fig. 45)
The ascending colon

 Ascends from the ileocaecal junction below (level of transtubercular plane) to
the hepatic flexure above. It lies to the right of the vertebral column, lateral to
the right midclavicular line
 Is retroperitoneal and non-mobile (owing to the absence of a mesentery).
However, it possesses an ascending mesocolon in about 25% of the population.
 Is endowed with haustrations, 3 taeniae coli, and appendices epiploicae
 Rests (behind) on the quadratus lumborum, iliacus, transversus abdominis, iliac
crest and right kidney
 Is also crossed behind by the lateral femoral cutaneous , iliohypogastric and
ilioinguinal nerves
 Is related anteriorly to the anterior abdominal wall and greater omentum
Blood Supply, Lymphatics, Innervation and Applied Anatomy of the Ascending

Colon
The ascending colon

 Receives arterial supply from the right colic artery and ascending branch of
ileocolic artery
 Is drained by the right colic and ileocolic veins. These are tributaries of superior
mesenteric vein
 Drains via efferent lymph vessels into epicolic, paracolic, ileocolic, right colic
and superior mesenteric nodes
- 237 -
 Receives parasympathetic fibres from the vagus nerve via the superior
mesenteric plexus
 May become mobile and thus be predisposed to volvolus (twisting). The latter
can be prevented by surgically fixing the colon to the posterior abdominal wall –
cecopexy.
Transverse Colon (Fig. 45)
The transverse colon

 Links the ascending and descending colon. it is 45–50 cm long.
 Loops transversely across the abdominal cavity, between the right and left colic
flexures. It stretches from the right lumbar to the left hypochondriac regions.
 Usually reaches to the level of the umbilicus in its most dependent part, but may
reach as far down as the pelvic cavity
 Possesses haustrations, taeniae coli and appendices epiploicae
 Is related behind to loops of small intestine, and the duodenojejunal flexure
 Is related anteriorly to the greater omentum and anterior abdominal wall
Blood Supply, Lymphatics and Innervation of the Transverse Colon
The transverse colon

 Is supplied by the middle colic and right colic arteries (from superior
mesenteric artery), and left colic artery (from inferior mesenteric artery)
 Is drained by middle and right colic veins (tributaries of superior mesenteric
vein), and left colic vein (tributary if inferior mesenteric vein)
 Drains via lymph vessels that end in the middle colic nodes
 Receives sympathetic and parasympathetic (vagal) fibres from the superior
mesenteric plexus. Its distal part is however supplied by the inferior mesenteric
plexus, whose parasympathetic fibres arise from the pelvic splanchnic nerves
(S2–S4).
Transverse Mesocolon
The transverse mesocolon

 Is a double fold of peritoneum that attaches the transverse colon to the posterior
abdominal wall
 Has a transverse root attached to the 2nd part of the duodenum and the pancreas,
on the posterior abdominal wall
 Separates the peritoneal cavity into a supracolic and an infracolic
compartment
 Transmits the middle colic artery and plexus of nerves to the transverse colon
 Lies just beneath the greater omentum, to which it is apposed.
Right Colic (Hepatic) Flexure
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The right colic flexure

 Is the junction of the ascending and transverse colon. Here, the ascending colon
turns forwards, downwards, and to the left, to become the transverse colon.
 Is related anterolaterally and above to the right lobe of the liver, with which it is
intimately associated. Anteromedially, it is related to the fundus of the
gallbladder.
 Is related behind to the right kidney. Here, its posterior surface is devoid of
peritoneum, so that it is in direct contact with renal fascia.
 Is a site of anastomoses between the right and middle colic arteries
 Is less acute compared to the left colic flexure.
Left Colic (Splenic) Flexure
The left colic flexure

 Is the junction of the transverse and descending colon. At this flexure, the
transverse colon turns backwards and downwards, to become the descending
colon.
 Is located in the left hypochondriac region of the abdominal cavity
 Is more acute, and lies at a higher and deeper plane compared to the hepatic
flexure
 Is related above to the spleen and tail of the pancreas; and posteromedially to the
left kidney
 Is attached to the diaphragm by the phrenicocolic ligament (a fold of
peritoneum)
 Is a site of anastomoses between the middle colic and left colic arteries.
Descending Colon
The descending colon

 Extends from the splenic flexure above to the pelvic brim (pelvic inlet) below
 Is located partly in the left hypochondriac, left lumbar, and left iliac regions of
the abdominal cavity
 Lies vertically to the left of the vertebral column, just lateral to the left
midclavicular line
 It is about 25 cm long; and is thus longer than the ascending colon (see above)
 Is retroperitoneal, being covered by peritoneum only on its anterior surface and
sides. However, it possesses a mesentery in about 33% of the population. In this
instance, it is prone to volvolus.
 Also possesses haustrae, taeniae coli and appendices epiploicae
Relations of the Descending Colon

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 Is related posteriorly to the left kidney, quadratus lumborum, psoas major and
transversus abdominis
 Is also crossed behind by the left 4th lumbar artery, left subcostal vessels, and the
iliohypogastric, ilioinguinal, lateral femoral cutaneous, femoral and
genitofemoral nerves of the left side
 Is related anteriorly to jejunal loops and the anterior abdominal wall
Blood Supply, Lymphatics and Innervation of the Descending Colon

 Is supplied by the left colic artery; the latter is a branch of the inferior
mesenteric artery (artery of the hindgut)
 Is drained by the left colic vein, a tributary of the inferior mesenteric vein
 Drains via lymph vessels into paracolic, intermediate colic and inferior
mesenteric nodes
 Receives parasympathetic fibres from the pelvic splanchnic nerves (S2–S4);
and sympathetic fibres from the superior hypogastric plexus (via the inferior
mesenteric plexus)
Sigmoid Colon (Fig. 45)
The sigmoid colon

 Is the continuation of the descending colon (distal to the pelvic brim). It ends in
the midline, at S3, where it continues with the rectum (at the rectosigmoid
junction)
 Occupies the pelvic cavity. However, it may be suprapelvic in position (e.g.,
when pelvic viscera, such as urinary bladder and rectum, are distended)
 Is about 40 cm long; and is intraperitoneal and relatively mobile
 Has a mesentery – sigmoid mesocolon – the root of which appears like an
inverted V. This mesentery transmits the sigmoid vessels
 Is related anteroinferiorly to the urinary bladder (male) and uterus (female).
Posteriorly are the rectum, internal iliac vessels, ureters, sacral plexus,
piriformis, and sacrum.
 Is related on its left side to the external iliac vessels, obturator nerve, ovary (in
female), ductus deferens (in male), and lateral pelvic wall; and on the right side
to the terminal ileum
 Possesses taeniae coli, haustrations and relatively long appendices epiploicae
Blood Supply, Lymphatics and Innervation of the Sigmoid Colon
The sigmoid colon

 Is supplied by 2–3 sigmoid arteries (from inferior mesenteric artery). These
vessels are conveyed by the sigmoid mesocolon; and they anastomose with the
left colic and superior rectal arteries
 Is drained by sigmoid veins (tributaries of inferior mesenteric vein).
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 Drains via efferent lymph vessels into inferior mesenteric nodes

 Receives sympathetic fibres from the superior hypogastric plexus; and
parasympathetic fibres from the pelvic splanchnic nerves
Sigmoid Mesocolon (Fig. 45)
The sigmoid mesocolon

 Is a double fold of peritoneum that attaches the sigmoid colon to the pelvic wall.
It confers mobility on the sigmoid colon.
 Has an inverted V-shaped root, the apex of which is located at the bifurcation of
the left common iliac artery, with the left ureter descending behind it. The left
limb of this root descends on the external iliac vessels, while the right root
descends on the posterior pelvic wall, where it ends in the midline, at S3
(rectosigmoid junction)
 Also has an intestinal border, which is attached to the sigmoid colon
 Transmits the sigmoid vessels, superior rectal vessels, and their associated nerve
plexuses
Applied Anatomy of the Colon

 Ulcerative colitis is chronic inflammation of the colon. It may be caused by
amoebic or bacillary dysentery. However, its cause may be unknown. Chrohn
disease is characterized immune-mediated ulceration of the bowel
 Colectomy may be performed to remove part or all of the colon, in ulcerative
colitis for example
 Following a partial colectomy, a colostomy or sigmoidostomy is
performed. This creates an artificial cutaneous opening for the terminal
part of the colon. If the entire colon is removed, an ileostomy is performed
 Colonoscopy and sigmoidoscopy involve examination of the interior of the colon
with the use of optic devices (colonoscope and sigmoidoscope). Biopsy may also
be taken for examination
 Diverticulosis is the presence of multiple mucosal evaginations in the
colon; the sigmoid colon is more frequently involved, and the condition
affects middle-aged and elderly persons more often. Colonic diverticula
may be infected (diverticulitis) and ruptured, and haemorrhage may occur
owing to erosion of vessels in the wall of the colon. Diet rich in fibres aid
bowel mvt and may reduce incidence of diverticulosis
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Rectum (Fig. 45)
The rectum
 Extends from the rectosigmoid junction (in the midline, at S3) and ends at the
anorectal junction, anterior to coccygeal tip. It describes an anteroposterior
curve – sacral flexure – that conforms to sacral concavity.
 Has three lateral outpouchings of its wall – the lateral flexures. The upper and
lower flexures are to the right, while the middle one is to the left
 Also possesses three internal transverse folds. The upper and lower folds usually
lie to the left, while the largest middle fold lies to the right.
 Has a local dilatation termed rectal ampulla, just above the anorectal junction.
 Is covered by peritoneum on its front and sides in its upper third; but only on its
front in its middle third; while its lower 3rd has no peritoneal covering
 Is essential for the initiation of defaecation
 Is about 12 cm long and 4 cm in diameter (when empty)
 Lacks taeniae coli, haustrations, appendices epiploicae and mesentery
Relations of the Rectum
The rectum has the following relations:

 Posteriorly: lower three sacral pieces, superior rectal vessels, coccyx,
anococcygeal ligament and ganglion impar. Others are levator ani, coccygeus,
piriformis, sacral plexus and sympathetic chains
 Anteriorly (males): seminal vesicles, vas deferentes, prostate gland and urinary
bladder
 Anteriorly (females): vagina, recto-uterine pouch and its contents, rectovaginal
septum and uterus
 Anteriorly (both sexes): loops of ileum and sigmoid colon
 Laterally: levator ani, coccygeus and branches of superior rectal arteries
 Below: to the ischio-anal fossae
Blood Supply, Lymphatics and Innervation of the Rectum
The rectum
 Is supplied by superior, middle and inferior rectal arteries. These arise from
inferior mesenteric, internal iliac and internal pudendal arteries respectively
 Is drained by the superior rectal veins (tributaries of inferior mesenteric vein,
which belongs to the portal system)
 Is also drained by the middle and inferior rectal veins; these are tributaries of
the internal iliac and internal pudendal veins respectively, and they belong to the
caval system
 Is a site of portocaval venous anastomoses, owing to the presence of tributaries
of the portal and caval systems in its wall
 Drains, via efferent lymph vessels, into pararectal and internal iliac nodes
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 Receives parasympathetic fibres from the pelvic splanchnic nerves (S2 – S4)
and sympathetic fibres from the superior hypogastric plexus
 Is supplied by general afferent fibres that reach the spinal cord by
accompanying the pelvic splanchnic nerves
Applied Anatomy of the Rectum
The rectum
 Allows for the palpation of adjoining organs (e.g prostate) through its wall, as is
done during rectal examination of a patient
 May be examined with the aid of a proctoscope, during proctoscopy
 Also serves as a route for the administration of barium enema, for anaesthetic or
diagnostic purpose.
Anal Canal
The anal canal

 Is the terminal part of the large intestine; it extends from the anorectal junction
to the anal opening (anus). It is directed downwards and backwards, from its
commencement to its termination
 Possesses an involuntary internal anal sphincter of smooth muscle fibres in its
upper ⅔; and a voluntary external anal sphincter of skeletal muscle fibres in its
entire length
 Is related posteriorly to the anococcygeal ligament and coccyx; and anteriorly
to the perineal body, lower vagina (female) and bulb of the penis (male)
 Is also related laterally to the ischio-anal fossa
 Possesses 6 – 10 vertically-disposed, vascular mucosal folds termed anal
columns
 Is 4 cm long
Blood Supply, Lymphatics and Innervation of the Anal Canal
The anal canal

 Is supplied by the superior, middle and inferior rectal arteries (see blood supply
to rectum).
 Is drained by the superior, middle and inferior rectal veins; and it is a site of
portocaval anastomoses
 Drains, via efferent lymph vessels, into internal iliac and superficial inguinal
nodes
 Receives autonomic fibres from inferior hypogastric plexus. These innervate the
smooth muscle fibres of the canal, as well as the part of its mucosa above the
pectinate line
 Receives somatic fibres from the inferior rectal nerves (branches of pudendal
nerves). These supply motor fibres to the external anal sphincter and sensory
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fibres to the interior of the canal below the pectinate line. Thus, this part is
sensitive to stimuli like pain and touch.
Applied Anatomy of the Anal Canal
The anal canal

 May develop anal fissure, which may become infected. Pus from such infected
fissures may collect in the ischio-anal fossa, forming ischio-anal abscesses
 May develop internal and external haemorrhoids. The former (piles) may result
from weakening of the muscularis mucosae of the canal
 Possesses varicose veins, even in healthy individuals and neonates. In portal
hypertension and hepatic cirrhosis, the anal canal develops unusually enlarged
veins.
 Is sensitive to various stimuli (touch, pain, temperature) below the pectinate line.
Above this line however, the mucosa is insensitive to such stimuli
 Is always occluded by its sphincters except during defaecation and passage of a
flatus.
Accessory Digestive Organs

These include the liver, pancreas and gallbladder.
Liver (Fig. 46)
The liver
 Is the largest gland in the body. It is reddish-brown in the fresh state, and has a
soft and pliable texture.
 Occupies the right hypochondriac, epigastric and part of the left hypochondriac
regions of the abdomen
 Is about 2% of the body weight (1500 g) in adult and about 5% of the body
weight in children
 Is wedge-shaped, its apex reaching as far as the left midclavicular line
 Is invested by a capsule of connective tissue termed Glisson’s capsule
 Synthesizes bile for digestive purpose. It is also involved in numerous metabolic
functions, including glucose homeostasis, synthetic activities and detoxification
processes.
Surfaces and Borders of the Liver
The liver
 Has a sharp inferior border. Other borders of the liver are rounded and indistinct
 Possesses a diaphragmatic and a visceral (posteroinferior) surface. The former
is divisible into anterior, superior, right and posterior parts
 In invested by the peritoneum, except at the bare area, where it is directly
apposed to the central tendon of the diaphragm
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 Is largely under the cover of the ribs and costal cartilages. These thus protect the
liver
Surface Anatomy of the Liver
Note that the liver

 Reaches as far up as the 5th rib in the right midclavicular line; and the 5th
intercostal space in the left midclavicular line
 Extends from the 7th – 11th ribs in the right midaxillary line. Biopsy of the liver
is usually taken along this line, at the 10th intercostal space
 Crosses the right and left costal margins (its inferior border) at the tips of the
right 9th and left 8th costal cartilages respectively. A line joining the above points
marks the position of the liver
Lobes of the Liver (Fig. 46)
Based on certain anatomical landmarks on its visceral surface, the lobes of the liver
include:
 Right lobe, to the right of a vertical line through the groove for the IVC and fossa
for the gall bladder
 Left lobe, to the left of a vertical line through the fissures for ligamentum
venosum and ligamentum teres hepatis. On the diaphragmatic surface of the liver,
the falciform ligament delineates the right and left lobes of the liver.
 Caudate lobe, located just above the porta hepatis (and between the groove for
IVC and the fissure for ligamentum venosum). It possesses a small caudate
process
 Quadrate lobe, located just below the porta hepatis (and between the fossa for
the gall bladder and the fissure for ligamentum teres)
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Figure 46. Diaphragmatic and visceral surfaces of the liver
Functional Lobes of the Liver
From the point of view of its biliary drainage, functional lobes of the liver include:
 A right lobe, formed by the ‘anatomical’ right lobe and caudate process of
caudate lobe. This lobe is drained by the right hepatic duct
 A left lobe, formed by the caudate, quadrate and ‘anatomical’ left lobes. This
lobe is drained by the left hepatic duct
Ligaments of the Liver (Fig. 46)
Ligaments of the liver include:

 Falciform ligament, a double fold of peritoneum that connects the anterior
surface of the liver to the diaphragm and supra-umbilical anterior abdominal wall.
It delineates the right and left lobes of the liver on the diaphragmatic surface of
this organ; and it contains the ligamentum teres hepatis and para-umbilical veins
in its free margin
 Left triangular ligament. This connects the left lobe of the liver to the
diaphragm
 Right triangular ligament. This connects the right lobe of the liver to the
diaphragm
 Coronary ligament. This consists of an upper and a lower layer and bounds the
bare area of the liver
 Ligamentum teres hepatis (remnant of the embryonic left umbilical vein). It
stretches from the umbilicus to a fissure on the visceral surface of the liver. It is
conveyed to the liver by the falciform ligament
 Ligamentum venosum – remnant of the embryonic ductus venosum. It lodges
in a fissure on the visceral surface of the liver
Blood Supply, Lymphatics and Innervation of the Liver
The liver
 Is highly vascular. It is connected to the stomach and proximal part of the
duodenum by the lesser omentum. This conveys blood vessels and nerves to the
liver.
 Receives nutrient-laden blood from the portal vein. The latter drains the
gastrointestinal tract (GIT)
 Receives oxygenated blood from hepatic artery proper (from common hepatic
artery)
 Is drained by the right and left hepatic veins; these join the IVC
 Gives rise to right and left hepatic ducts; these unite just outside the porta
hepatis to form a common bile duct. The latter joins the cystic duct to form the
bile duct (that conveys bile to the duodenum)
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 Produces a large volume of lymph. This drains into hepatic, paracardial, coeliac,
posterior mediastinal, parasternal and diaphragmatic nodes. Some lymph
however drains directly into the cisterna chyli without intervening nodes
 Receives parasympathetic (vagal) and sympathetic fibres from the coeliac plexus.
These fibres accompany the hepatic artery proper and portal vein as hepatic
plexus
Applied Anatomy of the Liver

 Owing to its rich blood supply, the liver bleeds profusely when lacerated
 In ⅓ of the population, the superior mesenteric, inferior mesenteric and splenic
veins unite to form the portal vein. Normally, the latter is formed by the union of
the superior mesenteric and splenic veins, behind the head of the pancreas
 The right hepatic artery may arise from the superior mesenteric artery.
Normally, it arises from hepatic artery proper
 The left hepatic artery may arise from the left gastric artery
 The liver may be transplanted in certain terminal diseases such as liver cirrhosis
 Liver cirrhosis usually arises from chronic alcoholism and is characterised by
necrosis of hepatocytes, fibrosis of the liver and portal hypertension
 Cancer cells may metastasize to the liver from the right breast, via the lymphatic
route
 In hepatomegaly, the inferior border of the liver may reach as far down as the
pelvic inlet. This condition may be associated with chronic alcoholism, diabetes
mellitus, etc
 Segments of the liver may be removed during segmentectomy, e.g., in
malignancy
 Abdominal position of the liver is largely maintained by intra-abdominal pressure
 Liver biopsy is taken with the needle inserted through the right 10th intercostal
space, in the midaxillary line
Pancreas (Fig. 47)
The pancreas
 Is soft and lobulated, and is greyish-pink in the fresh state
 Is 12–15 cm long and about 2.5 cm in thickness. It weighs 90 g on average
 Is located on the posterior adnominal wall, in the epigastric and left
hypochondriac regions; here, it stretches across the midline at the level of L2/L3,
from the duodenum on the right to the spleen on the left
 Is retroperitoneal, i.e., it lies behind the peritoneum, which covers its anterior
surface
 Consists of four anatomical parts: head, neck, body and tail (Fig. 47)
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The head of the pancreas

 Is the enlarged portion that lies within the concavity of the duodenum (to the
right of the superior mesenteric vessels). It is flattened anteroposteriorly (Fig. 47)
 Possesses an uncinate process, which projects to the left, behind the superior
mesenteric vessels
 Is related posteriorly to the IVC, right renal vessels, bile duct, right crus of the
diaphragm and terminal part of the left renal vein
 Is related anteriorly to the transverse colon, transverse mesocolon and jejunum
Figure 47. The pancreas and its relations
The neck of the pancreas

 Is the short portion between the head and body, just to the left of the
gastroduodenal artery (which descends anterior to the pancreas)
 Is related anteriorly to the pylorus of the stomach and posteriorly to the portal
and superior mesenteric veins
The body of the pancreas

 Stretches towards the spleen, on the posterior abdominal wall
 Has three surfaces: anterior, posterior and inferior borders
 Has three borders: anterior, superior and inferior borders. The splenic and
common hepatic arteries run along the superior border
 Gives attachment to the root of the transverse mesocolon. This attaches to its
anterior aspect
 Is related anteriorly to the omental bursa and stomach; and posteriorly to the
abdominal aorta, superior mesenteric artery, splenic vein, and the left kidney,
suprarenal gland and renal vessels.
The tail of the pancreas

 Is the terminal part of the pancreas that lies adjacent to the hilus of the spleen. It
is contained within the lienorenal ligament, together with the splenic vessels
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 Is related behind to the left kidney, as it passes towards the hilus of the spleen
 Terminates just below the hilus of the spleen, usually in contact with the gastric
surface of this organ
Ducts of the Pancreas
Regarding pancreatic ducts, note the following points:

 The pancreas has two ducts; these are the main and accessory pancreatic ducts
 The main pancreatic duct drains the body, tail and part of the head of the
pancreas. It joins the bile duct to form the hepatopancreatic ampulla, which
opens onto the tip of the greater duodenal papilla (in the 2nd part of the
duodenum, 8 – 10 cm from the pylorus). This ampulla has a hepatopancreatic
sphincter of Oddi
 The accessory pancreatic duct drains the uncinate process and the lower part of
the head of the pancreas. It opens onto the tip of the minor duodenal papilla
(about 2 cm above the major papilla)
Blood Supply, Lymphatics, Innervation, and Applied Anatomy of the Pancreas
The pancreas
 Is supplied by branches of splenic, superior and inferior pancreaticoduodenal
arteries
 Is drained by the splenic and superior mesenteric veins
 Drains via efferent lymph vessels into pancreaticosplenic and pyloric nodes
 Is supplied by the vagus nerve (parasympathetic fibres) and the lower thoracic
splanchnic nerves (sympathetic fibres)
 May be inflamed – pancreatitis – following obstruction of its ducts or reflux of
bile into these ducts. This may necessitate pancreatectomy
 May become malignant. Cancer of the pancreas is associated with pains in the
back, and may necessitate the removal of the tail and body of this organ. The bile
duct, IVC and portal vein may be obstructed in this condition.
Gall Bladder (Fig. 46, 47)
The gallbladder
 Stores and concentrates the bile produced by the liver. In the living, it appears
slate blue
 Is piriform, and consists of a fundus, body and neck. The fundus adjoins the
right costal margin at the tip of the 9th costal cartilage
 Is 7–10 cm long and 3 cm wide in its widest part. It has a capacity of 30–50 ml
 Is related anteriorly to the right lobe of the liver; here, the bladder occupies a
fossa, and may even be completely embedded in the liver.
 Is related posteriorly to the transverse colon and 1st and 2nd parts of the
duodenum
 Possesses a mesentery in about 4% of the population.
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 Has a duct – cystic duct – that joins the common hepatic duct to form the bile
duct
Blood Supply, Lymphatics and Innervation of the Gallbladder
The gall bladder

 Is supplied by the cystic artery, which is usually a branch of the right hepatic
artery. However, it may arise from the common hepatic or gastroduodenal
arteries
 Is drained by the cystic vein (a tributary of the portal vein). It also drains directly
into the liver
 Is drained by lymph vessels that end in the cystic and hepatic nodes
 Receives sympathetic and parasympathetic (vagal) fibres from the coeliac
plexus
Applied Anatomy of the Gall Bladder

 A diverticulum of the right wall of the neck of the gall bladder may occur. This
Hartmann’s pouch may contain gallstone.
 Gallstone is a concretion composed of crystalline substances (cholesterol, bile
pigments, and calcium salts) embedded in some protein. It usually forms in the
gallbladder but may lodge in the hepatopancreatic ampulla, cystic duct, hepatic
ducts or Hartmann’s pouch
 Cholecystitis is inflammation of the gall bladder, and may be associated with the
presence of gallstone. In this condition, pain is referred to the right shoulder,
owing to the irritation of the diaphragm
 Cholecystectomy is excision of the gall bladder. It could be performed in
cholecystitis
 During cholecystectomy, Calot’s (cystohepatic) triangle is a useful guide to the
common hepatic duct, cystic duct and cystic artery. These structures bound the
triangle.
 An accessory hepatic duct may exist, in addition to the main hepatic ducts. Such
accessory duct is at risk in cholecystectomy.
CHAPTER 12: HISTOLOGY OF THE DIGESTIVE SYSTEM

Peritoneum
The peritoneum
 Is the largest serous membrane in the body. It consists of the mesothelium,
beneath which is a layer of loose connective tissue. The mesothelium consists of
a layer of squamous cells
 Is endowed with numerous macrophages
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Structure of the Oesophagus
Structurally, the oesophagus consists of four layers. These include, from external
internally:
 Adventitia, the most external layer
 Muscularis externa, just deep to the adventitia
 Submucosa, just external to the mucosa; and
 Mucosa (most internal layer)
The Adventitia of the Oesophagus
The adventitia of the oesophagus

 Is of dense irregular connective tissue. It invests the oesophagus externally (in its
thoracic and cervical parts). In the abdominal part of the oesophagus, the
adventitia is replaced by a serosa
 Is rich in elastic fibres
Muscular Coat of the Oesophagus
Muscularis externa of the oesophagus

 Is arranged in two layers: an outer longitudinal and an inner circular layer. The
former is thicker. Between the two layers is the myenteric (Auerbach’s) plexus
of nerves
 Consists of skeletal muscle fibres in its upper 3rd, smooth muscle fibres in its
lower 3rd; and an admixture of skeletal and smooth myocytes in its intermediate
3rd
 Forms upper and lower oesophageal sphincters in the upper and lower parts of
the oesophagus, respectively
The submucosa of the oesophagus

 Lies deep to the muscularis externa; it is a layer of connective tissue rich in
collagen and elastic fibres
 Contains blood vessels, nerve fibres and mucous compound tubulo-alveolar
glands (oesophageal glands)
Oesophageal mucosa
 Is the most internal structural layer of the oesophagus. It is 200–400 µm thick
 Consists of three layers. From internal outwards, these include epithelium,
lamina propria and muscularis mucosae

 The oesophagus has a non-keratinizing stratified squamous epithelium. The
epithelial cells are supported by a basal lamina
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 Just external to oesophageal epithelium is the lamina propria. This consists of

loose connective tissue containing collagen and elastic fibres, blood vessels,
nerves, lymphocytes and lymph vessels
 Muscularis mucosae of the oesophagus consists largely of longitudinal smooth
muscle fibres. It lies external to the lamina propria of the mucosa.
 Oesophageal mucosa is thrown into longitudinal folds. These disappear when
the organ is distended
 Mucous oesophageal cardiac glands are found in the lower part of oesophageal
mucosa
Applied Anatomy
Gastroesophageal reflux disease: This results from weakened lower oesophageal
sphincter or from hiatus hernia. Escape of acid and pepsin into the oesophagus causes
reflux oesophagitis and pyrosis (heartburn). Relaxation of lower oesophageal
sphincter is aggravated by over-distension of the stomach, smoking, beverages such
as tea and coffee (rich in xanthine); and these can predispose to reflux oesophagitis.
Structure of the Stomach (Fig. 48)
The stomach has four layers; they include, from external inwards:
 Serosa, the most external layer of peritoneum
 Muscularis externa of smooth muscle fibres
 Submucosa of loose connective tissue
 Mucosa, the most internal layer
Serosa of the stomach

 Is formed by the visceral peritoneum of the stomach; thus, it is firmly adherent to
this organ
 Is reflected from the curvatures of the stomach as double-layered lesser and
greater omenta. These are attached to the lesser and greater curvatures of the
stomach, respectively
Muscular coat of the Stomach (Fig. 42, 48)
Note these points:

 Muscularis externa of the stomach has three layers of smooth muscle fibres;
these include, from external inwards, longitudinal, circular and oblique layers
 Longitudinal muscle layer of the stomach is thicker along the curvature of this
organ
 Circular muscle layer of the stomach is uniformly distributed. However, it is
locally thickened at the pylorus (junction of the stomach and duodenum) to form
the pyloric sphincter
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 Oblique muscle layer of the stomach is confined to the fundus and body of this
organ. It is well marked at the cardiac orifice, from where its fibres spread to the
surfaces of the stomach
Submucosa of the stomach

 Consists of loose connective tissue rich in eosinophils, mast cells and elastic
fibres
 Also contains blood vessels, lymphatics and nerve fibres
Mucous membrane of the stomach

 Is the internal layer of the stomach. It is about 2 mm thick in adult and appears
reddish-brown in life
 Has several longitudinal folds (rugae) that smoothen when the organ is distended
 Is lined by a secretory simple columnar epithelium. This is the most internal layer
of gastric mucosa
 Possesses several gastric pits (0.2 mm in diameter); these pits give the gastric
mucosa a honeycomb appearance (Fig. 48)

 Just external to gastric epithelium is a layer of connective tissue – lamina
propria. The latter contains blood and lymph vessels, lymphoid cells, smooth
muscle cells and nerve fibres
 External to the lamina propria of gastric mucosa is the muscularis mucosae. Its
smooth muscle fibres are arranged into outer longitudinal and inner circular
layers (Fig. 48)
 Several glands are associated with the gastric mucosa. These include cardiac
glands, main glands and pyloric glands
Glands of the Stomach (Fig. 48)
Main Gastric Glands
The main gastric glands

 Are simple branched tubular glands; they lie perpendicular to gastric surface,
and open into the bases of gastric pits
 Are the most numerous, being found in the body and fundus of the stomach.
They could be as many as 15 million
 Possess highly differentiated and certain undifferentiated cells. These include
chief cells, oxyntic cells, mucous cells, argentaffin cells, etc.
Chief (Zymogenic) Cells of the Main Gland of the Stomach
The chief cells of gastric glands

 Are found at the base (lower half) of gastric glands (Fig. 48)
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 Are strongly basophilic; they possess abundant RER, ribosomes and Golgi
complex
 Synthesize pepsinogen, the antecedent of pepsin
 Disintegrate almost immediately after death
B
A
A B
Q
Figure 48. A, Structural layers of the stomach; B, Gastric gland
Oxyntic (Parietal) Cells of Gastric Gland (Fig. 48)
Oxyntic cells of gastric glands

 Are large, rounded or pyramidal cells scattered among other cells of gastric
gland, especially close to the neck of this gland
 Possess some sinuous invaginations of their membranes; such intracellular
canaliculi are endowed with abundant microvilli
 Also possess numerous mitochondria; this indicates a high energy requirement
(for the action of the H+/K+ pump)
 Synthesize HCl, and the intrinsic factor required for vitamin B12 absorption.
The latter is a glycoprotein that binds to vitamin B12, thereby enhancing its
uptake (in the ileum). B12 deficiency results in pernicious anaemia
 Stain positively with eosin
Applied Anatomy
Peptic ulcer is characterised by erosion of gastric/duodenal mucosa by HCl and

pepsin, etc. Peptic ulcer can result from infestation by Helicobacter pylori, the use of
non-steroidal anti-inflammatory drugs (such as aspirin and indomethacin), stress, etc.
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Mucous (Neck) Cells of Gastric Glands (Fig. 48)
Mucous cells of gastric glands

 Are a few cells found in the neck of gastric glands
 Produce mucus and thus stain with PAS (periodic acid-Schiff)
Argentaffin (Enterochromaffin or Enteroendocrine) Cells of Gastric Glands
Argentaffin cells of gastric gland

 Are small cells situated near the base of the gland (Fig. 48)
 Stain strongly with silver and chromium salts (hence the name)
 Are unicellular endocrine cells that produce 5-hydroxytryptamine (serotonin),
histamine and gastrin. Gastrin and histamine induce gastric acid secretion.
Serotonin increases gastric motility and suppresses appetite.
Applied Anatomy
Carcinoids are tumours of serotonin-producing argentaffin cells, and are
characterised by overproduction of serotonin and thus, mucosal vasoconstriction and
damage.
Cardiac Glands
Cardiac glands of the stomach

 Are simple tubular or simple branched tubular glands found in the cardiac
region of the stomach
 Possess numerous mucous cells and a few argentaffin, oxyntic and zymogenic
cells. Most of the cells also produce lysozyme, which attacks bacteria
 Produce mucus for the lubrication of cardiac orifice of the stomach
Pyloric Glands
Pyloric glands of the stomach

 Are simple branched tubular gland found in the pyloric region of the stomach
 Possess mucous and argentaffin cells
 Also produce gastrin (that enhances gastric secretion and motility), in addition to
mucus
Structure of the Small Intestine

The small intestine is arranged in four structural layers, which from internal
externally, include: mucosa, submucosa, muscularis externa and serosa.
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Figure 49. Structure of the duodenum
Mucosa of the Small Intestine (Fig. 49)
Regarding the mucosa of small intestine, note these points:

 Mucosa of the small intestine has three layers; these include, from internal
externally, epithelium, lamina propria and muscularis mucosae
 The epithelium of intestinal mucosa is simple columnar in type; and the
columnar cells are endowed with microvilli (1 µm tall and 0.1 µm in diameter)
that form striated border. Interspersing these absorptive epithelial cells are
mucous goblet cells. Epithelial cells are replaced nearly every three days (by
mitosis).
 Deep to the epithelium is a lamina propria (of loose connective tissue)
containing blood vessels, lymph vessels and nerve fibres.
 Muscularis mucosae of the intestine consists of smooth muscle fibres. These
fibres arranged as outer longitudinal and inner circular layer.
 The entire intestinal mucosa is thrown into transversely disposed folds termed
plicae circulares. These folds slow down the passage of food substance through
the organ
 Also found in the mucosa are numerous finger-like surface projections – villi.
These are prominent proximally but less distinct distally. They increase the
surface area for absorption.
Plicae Circulares (Kerckring’s Valves)
Plicae circulares of intestinal mucosa

 Are transverse folds of mucosa and adjacent submucosa. They span about ⅔ of
intestinal circumference
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 Commence in the duodenum, about 5 cm distal to the pylorus; and disappear in

the distal part of the ileum. They are most prominent in the distal duodenum and
proximal jejunum. Here, they may be as tall as 8 mm and as thick as 3 mm
 Greatly increase intestinal surface area available for absorption of nutrients; and
they do not disappear when the intestine is distended.
Intestinal Villi
Intestinal villi
 Are finger-like processes of the mucosa of small intestine. They are most
numerous and large in the duodenum and jejunum.
 Have a density of 10 – 40 villi/mm2; and measure 0.5 – 1.0 mm in height. They
increase the surface area of the mucosa about eight times, to enhance digestion
and absorption.
 Appear as broad ridges in the proximal duodenum, tall foliate in distal
duodenum and proximal jejunum and finger-like in the distal jejunum and ileum
 Consist of a core of loose connective tissue containing a central lacteal, blood
capillaries, smooth myocytes, unmyelinated fibres, and lymphocytes. The surface
of each villus is covered by columnar epithelial cells.
Intestinal Glands (Crypts of Lieberkuhn)
Crypts of Lieberkuhn
 Are simple tubular intestinal glands that extend deep into the mucosa, between
the bases of the villi
 Possess varied cell types. These include argentaffin cells, which are endocrine,
and are scattered among other cells of intestinal glands.
 Also possess Paneth (zymogenic) and goblet cells. Paneth cells are located in the
basal part of intestinal glands; and they produce lysozyme – a bactericidal
substance. Goblet cells produce mucus
 Have numerous undifferentiated (stem) cells; these divide rapidly to replace the
intestinal surface epithelium.
Lymphoid Follicles of the Small Intestine

Lymphoid follicles of the small intestine include solitary and aggregated follicles.
Regarding solitary lymphoid follicles, note the following:

 Solitary lymphoid follicles are collections of lymphocytes embedded in reticular
tissue and permeated by capillaries; they are scattered in the lamina propria of
intestinal mucosa, and may extend into the submucosa when large enough
 Solitary lymphoid follicles are most numerous in the distal ileum; each may be
up to 4 mm in diameter. They are most prominent at puberty, after which they
begin to reduce in quantity
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 Certain M cells, rather than columnar epithelial cells, line the part of intestinal
mucosa that overlies the lymphoid follicles. Besides, this mucosa possesses
rudimentary glands and villi.
Aggregated Lymphoid Follicles (Peyer’s Patches)
Aggregated lymphoid follicles

 Are aggregates of 10–260 solitary follicles, found in the mucosa and submucosa
of the antimesenteric border of the small intestine. Each is oval in outline and
may be as wide as 10 cm in its longer axis.
 Occur sparsely in the duodenum, are few in the jejunum, but numerous in the
ileum. They become very prominent at puberty but diminish in size and density
thereafter
 Release lymphocytes for immunity of the gut; and may be predisposed to
ulceration and perforation in typhoid fever.
Submucosa
Intestinal submucosa
 Is a layer of loose connective tissue that lies just external to the muscularis
mucosae of the mucosa
 Contains blood vessels, lymphatics and nerve fibres. These fibres and their
associated ganglia constitute the submucosal (Meissner's) plexus.
Brunner’s Glands (Fig. 49)
Brunner’s glands
 Are compound tubulo-alveolar glands located in the submucosa of the
duodenum. Their density and size diminish from the pylorus to the
duodenojejunal junction.
 Produce mucin and bicarbonate, which protect the duodenal lining and
neutralize the acidic chyme, respectively
 May also produce trypsinogen-activating factor, which converts trypsinogen to
trypsin
Muscularis Externa
Note that:
 Muscularis externa is a layer of smooth muscle fibres that lie external to the
submucosa of the intestine
 Smooth muscle fibres of muscularis externa are arranged as inner circular and
outer longitudinal layers. Between these layers is the myenteric (Auerbach's)
plexus of nerve fibres and ganglia.
 Muscularis externa is responsible for the peristaltic movement of the small
intestine
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 The serosa invests the small intestine externally. It is the visceral layer of the
peritoneum, but it is firmly adherent to the gut.
Structure of the Large Intestine

The large intestine is arrange in layers, including (from internal outwards) mucosa,
submucosa, muscularis externa and serosa
The mucosa of the large intestine

 Consists of three structural layers; these include, from internal externally,
epithelium, lamina propria and muscularis mucosae.
 Is lined by a simple columnar epithelium. Interspersing the columnar epithelial
cells are mucous goblet cells. These cells are supported by a basal lamina
 Possesses numerous solitary lymphoid follicles (located in its lamina propria).
These follicles are lost abundant in the appendix, caecum and rectum
 Also possesses large and more densely packed intestinal glands. However, it does
not form plicae circulares, neither does it possess villi
 Is darker, more vascular and thicker in the rectum
Besides, note that:

 Just external to the mucosa of the large intestine is the submucosa. This is a layer
of loose connective tissue that contains nerve fibres (submucosal plexus), and
blood and lymphatic vessels
 Muscularis externa of the large intestine consists of smooth myocytes. It lies
just external to the submucosa and its muscle fibres are arranged into an inner
circular and an outer longitudinal layer. Between these layers is the myenteric
plexus of nerves.
 The serosa is the most external layer of the large intestine. It is the visceral layer
of peritoneum that invests this organ
Glands of the Larger Intestine
Crypts of Lieberkuhn of the large intestine

 Are simple tubular glands. They are more numerous, closely sited and longer
than those of the small intestine
 Lack Paneth cells but possess numerous goblet, argentaffin and undifferentiated
cells
 May be as tall as 0.7 mm in the rectum
Anal Canal
Regarding the anal canal, note these points:

 Its epithelium is simple columnar in its upper part; and this is invaginated to
form crypts of Lieberkuhn (intestinal glands)
 The intermediate part (pectin) of anal canal is lined by non-keratinizing
stratified squamous epithelium.
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 A transverse pectinate line lies at the level of anal valves (see below). This
marks the junction of the simple columnar and stratified squamous epithelia of
the upper and intermediate parts of the canal respectively.
 The pectinate line also indicates the position of the embryonic anal membrane
 The terminal (perianal) part of anal canal is lined by skin. A white line (Hilton
line) marks the mucocutaneous junction between the stratified squamous
epithelium of the intermediate part and skin of the terminal part of the anal canal.
It also marks the lower end of the internal anal sphincter. Below this line, the
anal canal is sensitive to exteroceptive stimuli
 Mucosa of the upper half of the anal canal is raised into 6–10 vascular vertical
folds termed anal columns. The lower ends of anal columns are linked by anal
valves; and above is valve is a depression termed anal sinus.
 The internal anal sphincter is a thickening of the smooth myocytes of the
circular layer of muscularis externa of anal canal. It is found in the upper ¾ of the
canal; and it is autonomically innervated.
 The external anal sphincter consists of skeletal muscle fibres. It is innervated by
somatic nerve, and is thus under voluntary control.
Accessory Organs of Digestion
Structure of the Liver (Fig. 50)
The liver
 Is both endocrine and exocrine. It has a parenchyma consisting of cords of
hepatocytes; and a stroma of connective tissue. This stroma forms septa that
divide the parenchyma into lobules
 Is invested externally by a thin layer of connective tissue termed Glisson’s
capsule
 May be arranged in three major microscopic forms. These are hepatic lobule,
portal lobule, and hepatic acinus
Hepatocytes (Liver Cells)
Hepatocytes
 Are the main cells of the liver. They constitute 60% of liver cells. Each is
polygonal, with up to twelve sides
 Possess polyploid nucleus, which may be two or three per cell. Each hepatocyte
also possesses abundant RER, ribosomes, mitochondria, Golgi complex and
lysosomes
 Are arranged into cords (or plates), each of which is one cell thick. The cords
branch and anastomose with one another, thus forming a complex array.
Intervening between adjacent cords are sinusoids (blood channels).
 Are metabolically active. Hepatocytes synthesize plasma proteins and bile, etc.
They also store glucose as glycogen and iron as ferritin and haemosiderin.
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Lobules of the Liver (Fig. 50)
Lobules of the liver include:

 Hepatic (or classical) lobule
 Portal lobule; and
 Hepatic acinus
Each hepatic lobule

 Is a microscopic unit of the liver that is centred on a central vein. It appears
polygonal in section; and it is about 1 mm across (Fig. 50)
 Consists of several hepatic laminae (hepatic plates) radially arranged around a
single central vein. Between adjacent laminae are lacunae (spaces). The latter
are occupies by sinusoids and perisinusoidal spaces (of Disse)
 Is surrounded by the portal triads (each consisting of a branch of hepatic artery,
a branch of portal vein and a bile ductule). Portal triad are located at the angles of
the lobule.
Figure 50. Structure of the liver (CV= Central vein)
The portal lobule

 Is a microscopic unit of the liver that is centred on a bile ductule. It takes into
consideration the functional organisation of the liver as an exocrine gland.
 Consists of adjoining parts of three hepatic lobules. Thus, it is triangular in
section and has a boundary that traverses adjacent central veins (Fig. 50).
 Is organised such that bile flow is centripetal (towards the centre), while blood
flow is centrifugal (away from the centre).
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The liver acinus

 Considers hepatic organisation from the metabolic point of view. It is centred on
preterminal branches hepatic artery and portal vein.
 Is diamond-shaped in outline, and consists of adjoining parts of two classical
lobules (Fig. 50)
 Is arranged such that blood flow is towards the periphery of the lobule, while bile
flow is towards the centre
 Is used for describing zones of glycogen deposition, inflammation or anoxic
damage, etc, within the liver.
Other Cells of the Liver
In addition to hepatocytes, the liver also contains the following cells:

 Kupffer cells; these are macrophages located on the luminal surface of hepatic
sinusoids. They are essential for phagocytosis
 Endotheliocytes; these cells line the endothelium of the sinusoids
 Ito’s cells (vitamin A-storing or stellate cells); these are located in the
perisinusoidal space. Ito’s cells contain vitamin A-rich inclusions; and they are
involved in the uptake, storage and release of retinoids, synthesis of extracellular
matrix and secretion of growth factors and cytokines.
Perisinusoidal Space (of Disse)
The perisinusoidal space

 Is a space of 0.2–0.5 µm that separates the endothelium of sinusoids from the
membranes of hepatocytes
 Contains microvilli of hepatocytes (which project into it) and a network of
reticular fibres. Besides, Ito’s cells are also found in it.
 Is continuous with the space of Mall, which surrounds the portal triad. The
perisinusoidal space becomes larger in anoxic conditions
Biliary Channels

 Biliary channels commence as bile canaliculi between the membranes of
adjacent hepatocytes. Here, the membranes are joined by tight junction.
 Bile canaliculi unite at the periphery of hepatic lobules to form intralobular bile
ductules (or canals of Hering)
 Intralobular bile ductules drain into interlobular ductules in the portal triads
 Interlobular ductules drain into larger ducts that form right and left hepatic ducts
at the porta hepatis. Both hepatic ducts form a common hepatic duct that unites
with the cystic duct to form the bile duct.
Portal Triad
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The porta triad

 Occupies the portal canal at the peripheral angle of hepatic lobule. It consists of
interlobular branches of portal vein and hepatic artery, and an interlobular bile
ductule, with their associated connective tissue.
 Is surrounded by a space of Mall, which is rich in lymph
 Supplies hepatic sinusoids with blood from radicles that arise from preterminal
branches of portal vein and hepatic artery
Sinusoids of the Liver
Hepatic sinusoids
 Are minute blood vessels that are larger than capillaries; they occupy the hepatic
lacunae between adjacent hepatic plates (Fig. 50)
 Are lined by fenestrated endothelium. Thus, they communicate with the space
of Disse through such fenestrae. Besides, Kupffer cells are found on the luminal
surface of sinusoidal endothelium
 Receive oxygenated and nutrient-laden blood from branches of hepatic artery and
portal vein respectively. Sinusoids drain into central vein located in the centre of
hepatic lobule.
Gall Bladder
Structurally, the gall bladder

 Consists of the mucosa, muscular layer and serosa, from internal externally
 Lacks a submucosa
Mucosa of the gall bladder

 Is the innermost layer of the gall bladder. It is lined by a simple columnar
epithelium, external to which is a lamina propria of loose connective tissue
 Possesses several folds (rugae) that disappears when the organ is distended
 Appears yellowish-brown in the living

 Muscular layer of the gall bladder consists of smooth myocytes; these are
arranged into longitudinal, circular and oblique layers, from external inwards.
Collagen and elastic fibres mingle with the smooth muscle cells
 Externally, the gall bladder is covered by a serosa of visceral peritoneum
Exocrine Pancreas (Fig. 51)
The exocrine pancreas

 Is a compound acinar gland. Each acinus consists of a single layer of pyramidal
cells, and it is associated with an intercalated (intracinar) duct and cuboidal
centro-acinar cells. Acini form lobules; and each lobule is delineated by loose
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connective tissue septa. Externally, the pancreas is covered by connective tissue

capsule (which sends septa into the gland)
 Is the source of the alkaline pancreatic juice. Exocrine pancreas produces 1500–
3000 ml of this juice per day, and the juice contains at least nine types of
enzymes. These include amylase, proteases (trypsinogens, chymotrysinogen),
lipases, nucleases (ribonuclease, deoxyribonuclease), and phospholipase A2, etc.
Moreover, the watery pancreatic juice is also rich in ions (including bicarbonate)
Acinar cells of the pancreas

 Are pyramidal serous zymogenic cells. They are basophilic, owing to the
presence of abundant RER
 Have a basal nucleus, with well-developed Golgi apparatus in the supranuclear
region. Secretory granules are also abundant, especially during fasting hours
 Disintegrate rapidly after death, owing to the action of their hydrolytic enzymes
Figure 51. Structure of the pancreas
The Duct System of the Pancreas
Note these points:

 Within each acinus is an intercalated (intra-acinar) duct. Intercalated ducts drain
into intralobular ducts. The latter form interlobular ducts that give rise to the
main and accessory pancreatic ducts. These enter the duodenum
 Pancreatic ducts are lined by columnar epithelial cells, which become stratified
towards the duodenum. Pancreatic ducts add water and bicarbonate to the
pancreatic juice
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Control of Exocrine Pancreas Secretion
Note the following:

 Hormonal and neural control mechanisms are involved in the control of
pancreatic secretion
 Entrance of acidic chyme into the duodenum stimulates the release of secretin
and cholecystokinin (CCK) into the circulation by the duodenal epithelial cells.
Secretin stimulates the release of water and bicarbonate by pancreatic ductal
and acinar cells, thereby neutralizing the acidity of chyme in the duodenum. CCK
stimulates the release of bile from the gallbladder, and enzyme-rich pancreatic
juice from the exocrine pancreas. This enhances digestion of food.
 Vagal (parasympathetic) stimulation also facilitates the release of pancreatic
juice
Clinical Anatomy of the Exocrine Pancreas
Note these points:

 In acute necrotizing pancreatitis, pancreatic proenzymes are activated within
the pancreas, and this leads to digestion of the organ. The condition may arise
from alcoholism, presence of gallstone, infections, use of certain drugs, etc
 In kwashiorkor, pancreatic acinar cells atrophy, with loss of the granular
endoplasmic reticulum and impaired enzyme production by the exocrine pancreas
Endocrine Pancreas (Islets of Langerhans) (Fig. 51)
Islets of Langerhans
The islets of Langerhans

 Are rounded bodies that constitute the endocrine pancreas (Fig. 51). They are
most numerous in the tail of the pancreas, and each is 100–200 µm across.
 Are scattered among the exocrine pancreas, from which they are separated by a
capsule of reticular fibres. They are estimated to be as many as 1 million
 Appear pale in histologic section compared to the surrounding acinar tissue.
Like, other endocrine organs, the islets are well vascularised
 Possesses certain polyhedral cells arranged into cords; these cords are separated
by sinusoids. Cells of the islets include α, β, δ, and PP cells. Alpha cells
constitute about 20% of islet cells; beta cells constitute about 70% of islet cells;
while delta cells constitute 5% of islet cells. PP cells are sparse.

 Alpha cells produce glucagon, β cells produce insulin; δ cells produce
somatostatin, while PP cells produce pancreatic polypeptide
 Insulin and glucagon are required for glucose homeostasis. Insulin enhances
glucose uptake into cells such as hepatocytes, skeletal muscle cells and
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adipocytes, thereby decreasing plasma glucose. Glucagon enhances

glycogenolysis and gluconeogenesis, thereby increasing plasma glucose.
 Delta cells inhibit the activity of alpha and beta cells in a paracrine manner by the
release of somatostatin
 Pancreatic polypeptide is produced by PP cells. This substance possibly
modulates gastric secretion and motility.
Applied Anatomy of the Endocrine Pancreas
Note these points:

 Diabetes mellitus is a chronic metabolic disorder characterised by fasting
hyperglycemia and glucose intolerance. In this disease, levels and/or action of
insulin are insufficient
 In type 1 diabetes mellitus, β cells of the islets are destroyed by auto-immune
processes; while insulin resistance and impaired β cell function are characteristic
of type 2 diabetes
 Diabetes is associated with complications such as retinopathy, nephropathy,
neuropathy, and cardiovascular complications (such as coronary atherosclerosis),
etc.
 Glucagonomas are glucagon-producing tumours of the pancreatic islets. In this
condition, plasma glucagon levels rise, resulting in elevated blood glucose (and
diabetes mellitus)
 Insulinoma (hyperinsulinism) is an insulin-producing tumour of the pancreatic
islets. In this condition, plasma insulin levels rise, resulting in hypoglycaemia
 Insulitis refers to inflammation of the pancreatic islets of Langerhans
CHAPTER 13: GROSS ANATOMY OF THE MALE GENITAL ORGANS

AND PERINEUM
Male External Genitalia

The male external genitalia include the scrotum and penis (Fig. 52).
Scrotum
The scrotum
 Is a cutaneous, darkly pigmented, fibromuscular sac located inferior to the
symphysis pubis
 Has neither deep fascia nor fat cells, but possesses sparse hair and abundant
sebaceous and sweat glands
 Is divided into two compartments by a scrotal septum; and it hangs lower on the
left side owing to the longer length of the left vas deferens
 Appears compacted and wrinkled during cold or in young subjects, but is smooth
and flaccid when warm or in the elderly
- 266 -
 Consists, from external inwards, of skin, dartos (comprising smooth muscle

fibres), external spermatic fascia, cremasteric fascia and internal spermatic
fascia (Fig. 52).
A B
Figure 52. A, scrotum and its contents; B, root of the penis in superficial pouch
Blood Supply, Lymphatic Drainage and Innervation
The scrotum
 Is supplied by the external pudendal and posterior scrotal arteries (from
femoral and perineal arteries respectively). Cremaster branch of inferior
epigastric artery also contributes.
 Is drained by external pudendal and dorsal scrotal veins (tributaries of great
saphenous and internal pudendal veins respectively)
 Drains via efferent lymph vessels into superficial inguinal nodes
 Is innervated by ilioinguinal nerve, genital branch of genitofemoral nerve,
perineal branches of posterior cutaneous nerve of the thigh and posterior
scrotal nerves (branches of pudendal nerves). Ilioinguinal nerve gives rise to
anterior scrotal nerves, which innervate the anterior part of the scrotum.
Applied Anatomy of the Scrotum

 The Scrotum may enlarge greatly in orchitis (inflammation of the testis) and in
direct inguinal hernia
 Cancer of the scrotum metastasizes to superficial inguinal nodes; and that of the
testis to lumbar nodes
- 267 -
 Complete anaesthesia of the scrotum requires blockages of the ilioinguinal

nerves that innervate the anterior part of this organ (in addition to pudendal nerve
block).
Penis (Fig. 52, 53)
The penis
 Is the male organ of copulation; it consist of the root, body and glans penis
 Is rich in erectile cavernous tissue; thus, it becomes tough and erect when
engorged with blood
 Has suspensory and fundiform ligaments, which arise respectively from the
pubic bone and linea alba; they support the weight of the penis and blend with its
fascia.
Root of the Penis (Fig. 52)
The root of the penis

 Is the attached, fixed part of the penis. It is located in the superficial perineal
pouch of the urogenital triangle
 Consists of an enlarged median bulb (attached to perineal membrane); and two
crura, each attached to the ischiopubic ramus
 Is associated with the bulbospongiosus and ischiocavernosus muscles; these
surround the bulb and crura of the penis respectively
Body of the Penis (Fig. 53)
The body of the penis

 Consists of paired corpora cavernosa and an unpaired corpus spongiosum.
Each corpus cavernosum is continuous proximally with a crus of the penis and is
separated from its fellow by a median fibrous septum. The corpus spongiosum
transmits the spongy part of the urethra; and is continuous proximally with the
bulb of penis and distally with the glans penis (Fig. 52, 53)
 Is arranged such that the unpaired, median corpus spongiosum lies ventral to the
paired paramedian corpora cavernosa. These structures are invested by the white
tunica albuginea (dense connective tissue that invests corpora cavernosa), deep
fascia, superficial fascia and skin
 Is devoid of muscle fibres, except near its junction with the root of the penis
 Transmits the deep dorsal vein of the penis, dorsal arteries of the penis and
dorsal nerves of the penis on its dorsum, just deep to the deep fascia; these are
arranged from medial laterally. In the subcutaneous tissue of the dorsum of penis
is the superficial dorsal vein of the penis.
 Is pigmented but lacks hair and fats cells
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Glans Penis
The glans penis

 Is the expanded, conical, distal end of the corpus spongiosum, into which the
distal ends of the corpora cavernosa fit. It is covered by thin skin that is richly
endowed with nerve endings and receptors (for sexual arousal)
 Is surrounded by a fold of skin called prepuce. A frenulum connects the ventral
surface of glans penis to the prepuce. In phimosis, the prepuce becomes tight and
non-retractable. Paraphimosis is characterised by impaired blood supply of the
glans, owing to the presence of a tight, retracted prepuce. Circumcision may be
performed in such cases.
 Contains a navicular fossa, which is the expanded terminal part of the spongy
urethra. At the tip of the glans is a slit-like vertical opening – external urethral
orifice
 Is separated from the body of the penis by a transverse groove – neck of the
penis. This is overhanged by the corona glans (base of the glans)
 Drains into lymph node of Cloquet (a deep inguinal node)
Figure 53. Body of penis (transverse section)
Blood Supply, Lymphatics and Innervation of the Penis
The penis
 Is supplied by dorsal arteries of the penis, deep arteries of the penis and arteries
of the bulb (all branches of internal pudendal arteries)
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 Drains into prostatic plexus of vein (via the deep dorsal vein of penis) and into
the external pudendal vein (tributary of great saphenous vein)
 Drains via efferent lymph vessels into superficial inguinal nodes. However, the
glans penis drains into deep inguinal node (lymph node of Cloquet).
 Receives parasympathetic fibres from the pelvic splanchnic nerves via the
lesser and greater cavernous nerves (from the prostatic plexus); and sensory
fibres from pudendal nerve. Parasympathetic innervation enhances erection of
the penis (through vasodilatation of helicine arteries, thereby causing
engorgement of the cavernous spaces with blood).
Male Internal Genitalia
Testis (Fig. 52, 54)
The testis
 Is an oval organ located in the scrotum (outside the main body cavity) (Fig. 52).
It is homologous to the ovary
 Is 4 cm long, 3 cm anteroposteriorly and 2.5 cm in breadth; it weighs 10.5–14 g.
 Has upper and lower poles; medial and lateral surfaces, and anterior and
posterior margins. The upper pole is related to appendix testis (a remnant of
paramesonephric ducts) (Fig. 52).
 Is related posteriorly to the vas deferens and epididymis; the latter is lateral to
the vas deferens.
 Produces spermatozoa (male gametes) and male sex hormones (androgens)
Figure 54. Testis and epididymis (sectioned)
Testicular Coverings
Regarding the testis, note the following:
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 Tunica albuginea is a white, tough, fibrous tissue that forms an intimate

investment for the parenchyma of the testis (Fig. 54)
 Just deep (internal) to tunica albuginea is the tunica vasculosa, a layer of blood
vessels
 Just external to tunica albuginea is the visceral layer of the tunica vaginalis (a
serous membrane). The testis moves freely within the scrotum owing to the
presence of a film of fluid in the cavity of tunica vaginalis
 The testis is divisible into 200–300 lobules by septula testis (Fig. 54); the latter
are fibrous septa that project into the testis from the tunica albuginea. The lobules
contain 400–600 seminiferous tubules
 Between the epididymis and posterolateral aspect of the testis is a vertical slit
referred to as the sinus of the epididymis
 The temperature of the testis is slightly less than the core body temperature
(about 2 oC below the body temperature). This is essential for spermatogenesis to
progress satisfactorily. Through spermatogenesis, more than 100 million
spermatozoa are produced per day.
Blood Supply, Lymphatics and Innervation of the Testis
The testis
 Receives arterial blood from the testicular artery – a branch of the abdominal
aorta at L2
 Is drained by pampiniform plexus of 8–12 veins. This is located in the scrotum
and spermatic cord; and it forms the testicular vein at the deep inguinal ring.
Testicular vein ends in the IVC on the right and the left renal vein on the left
 Has a rich vascular layer, the tunica vasculosa, located deep to the tunica
albuginea. This extends into the substance of the testis, along septula testis, to
supply the parenchyma
 Is innervated by the testicular plexus. This receives parasympathetic fibres
from vagus nerve and sympathetic fibres from T10 and T11 spinal segments.
 Drains into lumbar lymph nodes.
Applied Anatomy of the Testis
It should be noted that

 The testis in undescended in 1% of 1-year-old boys, 3% of full term babies and
30% of premature babies. This condition is known as cryptorchidism.
 An undescended testis may lie in the abdominal cavity or inguinal canal; and it is
associated with a higher incidence of cancer. Unilateral cryptorchidism may be
associated with testicular histologic alterations in the contralateral (descended)
testis
 When both testes do not descend, the condition anorchism. This is associated
with sterility
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 Orchiopexy is the surgical re-positioning of a cryptorchid testis into the scrotum.

It may also be done to correct testicular torsion
 Hydrocoele of the testis is characterized by excess fluid in the cavity of tunica
vaginalis (Fig. 55); while haematocoele is characterised by the presence of blood
in this cavity
Figure 55. Hydrocoele of the testis
 Hydrocoele of the testis transilluminates during clinical examination, while

haematocoele does not. Hydrocoele may communicate with the peritoneal cavity
through a patent processes vaginalis
 In orchitis (inflammation of the testis), the testis may become swollen. Orchitis
may be secondary to mumps (a communicable viral infection of parotid glands).
 Cancer of the testis metastasizes, via lymphatic vessels, to lumbar lymph nodes
(not superficial inguinal nodes, as is the case with the scrotum)
 Orchidectomy: surgical removal of the testis (e.g., as a result of malignancy, etc)
 Varicocoele is commoner in the left pampiniform plexus and testicular vein. In
this condition, these vessels become swollen and tortuous. It results from valvular
defect in the testicular vein; and higher blood pressure in the left renal vein may
be a contributory factor. Varicocoele is aggravated when erect or straining.
Epididymis (Fig. 54)
The epididymis
 Is a highly compacted and convoluted duct, measuring about 5.5 m in length
when uncoiled
 Is comma-shaped and has a head, body and tail (from above downward) (Fig.
54).
 Is located posterolateral to the testis (within the scrotum). A sinus of the
epididymis separates the epididymis from the posterolateral aspect of the testis
 Is invested by tunica vaginalis (except at the posterior aspect of its body)
- 272 -
 Bears a sessile vestigial body – appendix of the epididymis – on its head (Fig.
52). Appendix of the epididymis is the remnant of the cranial part of embryonic
mesonephric duct
 Provides an environment for the maturation and storage of spermatozoa
 Receives 12–20 efferent ductules from the testis; and is continuous at its caudal
end (or tail) with the vas deferens

 The head of the epididymis is the enlarged cranial part of the organ, which
overhangs the testis. It consists of 12–20 conical lobules of the epididymis. These
lobules are the convoluted distal ends of the efferent ductules. The latter connect
the epididymis with the rete testis
 The body of the epididymis lies behind the testis. It consists of a single highly
convoluted and compacted duct of the epididymis. This duct is formed by the
confluence of lobules of the epididymis
 The tail of the epididymis is the caudal tapered end of the organ. It contains the
convoluted duct of the epididymis, and it is continuous with the vas deferens.
Blood Supply, Lymphatics, Innervation and Applied Anatomy
The epididymis
 Is supplied by branches of deferential and testicular arteries (from the inferior
[or superior] vesical artery and abdominal aorta respectively)
 Drains into pampiniform plexus of veins
 May become inflamed, a condition known as epididymitis. This may result from
bacterial infections (e.g., gonococcal infection, etc). inflammation of the testis
from bacterial infections (e.g., gonococcal infection, etc). There is oedema, and
lymphocyte infiltration; abscess may form in the epididymis, and sterility may
result (from fibrous scarring of epididymis and testis)
 May develop a fluid-filled local dilation anywhere along its length; this is
referred to as epididymal cyst. Spermatocoele is a collection of milky fluid
(sperm) near the head of the epididymis.
Vas Deferens (Fig. 56)
The vas deferens

 Links the epididymis (in the scrotum) to the ejaculatory duct (in the pelvic
cavity) (Fig. 56). It is tortuous at its commencement and termination
 Is characteristically thick, cord-like and firm; and it occupies the posterior aspect
of the spermatic cord.
 Is about 45 cm in length and 2.5 mm in thickness
 Commences at the tail of the epididymis, and then ascends medial to this organ,
behind the testis
- 273 -
 Traverses the spermatic cord (in the inguinal canal), where it forms the most
posterior structure
 Enters the pelvis (through the deep inguinal ring), just lateral to the inferior
epigastric artery (and anterior to the external iliac vessels); then, it turns
downwards, backwards and medially, on the lateral pelvic wall. In the pelvis, the
vas deferens passes above the ureter and seminal vesicle, from lateral medially.
Finally, it turns downward and forwards, medial to the seminal vesicle and close
to the base of the urinary bladder. Here, it forms an ampulla (a local dilatation).
 Terminates by joining the duct of the seminal vesicle to form the ejaculatory
duct. The latter traverses the prostate to open into the prostatic urethra (on the
summit of seminal colliculus).
Figure 56. Vas deferens, seminal vesicle and prostate gland
Blood Supply, Lymphatics, Innervation and Applied Anatomy of the Vas

Deferens
The vas deferens
 Receives arterial blood from the deferential artery – a branch of the superior or
inferior vesical artery
 Is innervated by the inferior hypogastric plexus (the sympathetic and
parasympathetic components being from the lumbar and pelvic splanchnic nerves
respectively)
 Drains into external iliac nodes
 Contracts rapidly at ejaculation. This is a function of its sympathetic nerve
supply. Ejaculation is preceded by emission. In man, the total volume of the
ejaculate is 2–5 ml
 May be ligated or excised during deferentectomy (vasectomy), to control birth
Ejaculatory Duct (Fig. 56)
The ejaculatory duct
- 274 -
 Is a short, slender tube formed by the union of the vas deferens and the duct of
the seminal vesicle, near the base of the prostate gland (Fig. 56). It is 2–2.5 cm
long
 Traverses the posterior part of the substance of the prostate, lateral to the
prostatic utricle
 Opens onto the summit of the seminal colliculus, within or just outside the
prostatic utricle, in the prostatic part of the urethra
 Conveys sperm and the secretion of seminal vesicle to the prostatic urethra
Blood Supply, Lymphatic Drainage and Innervation
The ejaculatory duct

 Is supplied by branches of deferential arteries; the latter arises from the inferior
or superior vesical artery
 Is drained by the prostatic venous plexus
 Is innervated by the inferior hypogastric plexus of nerves (the sympathetic and
parasympathetic components being from the lumbar and pelvic splanchnic nerves
respectively)
 Drains via efferent lymph vessels into external iliac nodes
Spermatic Cord (Fig. 52)
The spermatic cord

 Occupies the inguinal canal; it transmits the structures associated with the testis.
The spermatic cord commences in the scrotum and ends at the deep inguinal
ring
 Is invested by an external spermatic fascia, derived from the aponeurosis of the
external oblique muscle; it is the most external covering of the cord.
 Is also invested by a cremasteric fascia and muscle; these are derived from the
aponeurosis and muscle fibres of internal oblique muscle, and they constitute the
intermediate covering of the cord. Cremasteric muscle coat is absent in the
medial half of spermatic cord
 Has an additional covering of internal spermatic fascia, derived from the
transversalis fascia; it is the most internal covering of the cord
Contents of the Spermatic Cord
The spermatic cord transmits the following:

 Vas deferens, in its posterior aspect (Fig. 52)
 Pampiniform plexus of veins; this forms the largest constituent of the cord
 Deferential artery and vein
 Testicular artery and lymph vessels of the testis
 Genital branch of genitofemoral nerve; this innervates cremaster muscle
 Cremaster artery – a branch of inferior epigastric artery
- 275 -
 Plexuses of nerves (from the inferior hypogastric plexus)
Testicular Thermoregulation
Factors responsible for testicular thermoregulation include:

 External location of the testis (outside the main body cavity)
 The presence of scanty hair on the scrotum
 Presence of numerous sweat glands in the scrotum
 Absence of fat in the scrotal wall
 Thinness of scrotal skin, which enhances heat loss
 Ability of dartos and cremaster muscles to vary the surface area of the scrotum
and the position of the testis (relative to body wall), respectively
 Presence of the pampiniform plexus of about twelve veins around the testicular
artery; this serves as a counter-current mechanism of heat exchange between the
artery and veins of the testis
Male Accessory Reproductive Organs
Seminal Vesicle (Fig. 56, 57)
The seminal vesicle

 Resembles a pyramid, the base of which is directed upwards and laterally and the
apex downwards and medially, behind the base of the urinary bladder
 Is actually a single coiled tube with irregular diverticula; bound together by
connective tissue
 Is 5–7 cm long and 2-3 cm in diameter in its coiled (undisturbed) state; but may
be as long as 10-15 cm when uncoiled. The tube has a diameter of 3-4 mm;
 Is related anteriorly to the base of the urinary bladder and posteriorly to the
rectovesical fascia and rectum
 Is related medially to the ampulla (convoluted terminal part) of the vas deferens.
It lies beneath the peritoneum, ureter and part of the vas deferens
 Is not a store for semen, as the name suggests
 Produces a sticky, viscous alkaline fluid that is contains fructose, coagulating
proteins, citric acid, prostaglandins and proteins. This constitutes about 60% of
semen. Fructose acts as energy source for sperm, while prostaglandins aid the
movement of sperm toward the ovum with peristaltic contractions of the uterus
and uterine tubes.
Blood Supply, Lymphatic Drainage, Innervation and Applied Anatomy
The seminal vesicle
- 276 -
 Is supplied by the inferior vesical and middle rectal arteries (both branches of
internal iliac artery)
 Drains into internal iliac vein
 Is drained by efferent lymph vessels that end in internal iliac nodes
 Is innervated by fibres from the inferior hypogastric plexus
 May be palpable during physical rectal examination
 May contain pus when infected. It may also rupture, and its contents may escape
into the peritoneal cavity
Prostate Gland (Fig. 56, 57)
The prostate gland

 Is located very low in the lesser pelvis, where it surrounds the prostatic part of
the urethra. It has the size and shape of a chestnut.
 Has a base that is directed upwards, and which adjoins the neck of the bladder;
and an apex that is directed downwards, and which abuts on the urogenital
diaphragm (Fig. 57)
 Possesses four surfaces: anterior, posterior, and right and left inferolateral
surfaces
 Is related posteriorly to the rectum; anteriorly to the pubic symphysis; laterally
to the levator ani muscle and prostatic venous plexus; superiorly to the urinary
bladder; and inferiorly to the urogenital diaphragm
 Measures 3 cm from apex to base, 4 cm transversely and 2 cm anteroposteriorly.
It weighs about 8 g; but may weigh up to 40 g (and as much as 150 g) in BPH
 Produces approximately 15–40% of the semen
- 277 -
Figure 57. Male pelvis and perineum
Prostatic Capsule, Sheath and Lobes
The prostate gland

 Is made up of glandular tissues embedded in a dense fibromuscular stroma. It
is intimately invested by a thin fibrous prostatic capsule.
 Is also invested by a prostatic sheath – a fibrous covering located external to the
prostatic capsule. In the interval between prostatic sheath and capsule is the
prostatic plexus of veins.
 Is described as possessing five anatomical lobes
Anatomical lobes of the prostate gland include:
 Anterior lobe, located anterior to the prostatic urethra; this lobe is poor in
glandular tissue
 Posterior lobe, located behind the prostatic urethra and below the level of the
ejaculatory duct
 Two lateral lobes, each of which lies lateral to the prostatic urethra
 A median lobe, which lies between the ejaculatory ducts, adjacent to the neck of
the urinary bladder
Zones of the Prostate Gland
Three zones are defined for the prostate gland: transitional zone, central zone
and peripheral zone
Transitional zone
 Surrounds the distal part of prostatic urethra, just proximal to openings of
ejaculatory ducts
 Is often affected by BPH, causing dysuria
 Constitutes 5% of the prostate by volume
Central zone of the prostate

 Surrounds ejaculatory ducts, posterior to prostatic urethra
 Rarely involved in disease; and is possibly derived from Wolffian duct
 Constitutes about 25% by of the prostate by volume
Peripheral zone of the prostate

 Is cup-shaped and encloses the central and transitional zones
 Is the part often involved in malignancy
 Is derived from the urogenital sinus, as is the case for transitional zone
 Constitutes 70% of the prostate by volume
Blood Supply, Lymphatics, Innervation and Applied Anatomy

- 278 -
The prostate gland

 Is supplied by prostatic arteries, which are branches of inferior vesical and
middle rectal arteries
 Drains into prostatic venous plexus, and thence, into internal iliac veins
 Communicates, via venous channels, with the vesical and internal vertebral
venous plexuses. This is of importance in the spread of cancer cells from the
prostate to certain other organs, including the brain
 Drains, via efferent lymph vessels, into internal iliac and sacral nodes
 May enlarge after midlife (benign prostatic hypertrophy, BPH). BPH is of
uncertain origin. In this condition, urination becomes difficult.
 May be inflamed (prostatitis) owing to bacterial (gonococcal) infection, etc. The
gland may also be involved in malignant tumor – prostate cancer. This may
occur in the elderly, and cancer cells from the gland may spread to other sites
such as the vertebrae and brain, etc (via the venous and lymphatic channels).
 May be removed during prostatectomy. This may be accompanied by
orchiectomy (to reduce testosterone levels that promote prostate cancer)
 Secretes a watery, milky and slightly acidic fluid, which contains acid
phosphatase (measured clinically to assess prostate function), prostaglandins,
citric acid, proteolytic enzymes, fibrolysin, and prostate specific antigen (that
liquefies seminal coagulum), etc. Prostatic fluid constitutes 15–40% of semen.
Bulbo-Urethral Gland (Fig. 57)
The bulbo-urethra gland

 Is a pea-shaped gland located in the deep perineal pouch, posterolateral to the
membranous urethra (Fig. 57)
 Appears yellowish and lobulated; and is difficult to located in old age as it
diminishes in size with advancing age
 Measures about 1 cm in diameter
 Has a duct, 2.5 cm long, which opens into the proximal part of the spongy
urethra, in the superficial perineal pouch (Fig. 57), about 2.5 cm below the
perineal membrane
 Produces a mucous secretion that lines the urethra and lubricates the penile tip
during sexual arousal
 Is supplied by artery of the bulb of penis (a branch of internal pudendal artery)
Perineum (Fig. 57, 58)
The perineum
 Is the region of the body between the uppermost parts of the thigh and below the
pelvic cavity (from which it is separated by the pelvic diaphragm)
 Is bounded anteriorly by the symphysis pubis and arcuate pubic ligament; and
posteriorly by the coccyx
 Is bounded anterolaterally by the ischiopubic rami; posterolaterally by the
sacrotuberous ligament; and laterally by the ischial tuberosities
- 279 -
 Is divided into two triangles – an anterior urogenital and a posterior anal

triangle – by a transverse line that joins the anterior ends of ischial tuberosities
(Fig. 58)
 Refers to the region between the vaginal opening and anus in obstetrics
Male Urogenital Triangle (Fig. 57, 58)

The urogenital triangle is the part of the perineum that lies anterior to the ischial
tuberosities. It consists of superficial and deep perineal pouches.
Superficial Perineal Pouch (Fig. 58)
In males, the superficial perineal pouch

 Lies anterior to anal triangle, and ventral to the deep perineal pouch
 Is bounded anteriorly by the symphysis pubis, and posteriorly by the superficial
transverse perineal muscles and perineal body
 Is bounded below by superficial perineal fascia. This is an extension of the
superficial fascia of the anterior abdominal wall into the perineum
 Is bounded above by the perineal membrane (inferior fascia of the urogenital
diaphragm)
 Is bounded laterally by the ischiopubic ramus (to which the deep layer of
superficial fascia of the perineum [Colle’s fascia] is attached)
 Communicates with the scrotum and anterior abdominal wall. Thus, extravasated
urine from a ruptured spongy urethra (in the superficial pouch) could flow into
these regions
Figure 58. Male superficial perineal pouch

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Contents of the Male Superficial Perineal Pouch
In males, the superficial perineal pouch contains:

 Bulb of the penis, a median structure covered by the bulbospongiosus muscles
 Crura of the penis, each covered by the ischiocavernosus and attached to the
ischiopubic ramus
 Superficial transverse perineal muscles, at its posterior end
 A small part of the spongy urethra (not included in the bulb of the penis)
 Arteries of the bulb of penis and the perineal nerves; the latter arise from
pudendal nerves and supply the muscles of the pouch
 Ischiocavernosus muscle, which arises from the ischial ramus and inserts into
the crus of the penis (which it surrounds) (Fig. 58)
 Bulbospongiosus muscle, which arises from the perineal tendon and inserts into
the dorsum of the bulb of the penis and the corpus spongiosum; it surrounds the
bulb of the penis (Fig. 58)
Male Deep Perineal Pouch (Fig. 57)
In males, the deep perineal pouch

 Is the part of the urogenital triangle that lies above the superficial perineal pouch,
just beneath the levator ani and prostate gland (Fig. 57)
 Is bounded above by the superior fascia of urogenital diaphragm, and below by
the inferior fascia of urogenital diaphragm (or perineal membrane)
 Does not reach as far forward as the symphysis pubis.
Contents of the Deep Perineal Pouch in Males
In males, contents of the deep perineal pouch include:

 Membranous urethra (intermediate part of the urethra)
 External urethra sphincter; this surrounds the membranous urethra, and
consists of skeletal muscle fibres
 Dorsal arteries and dorsal nerves of the penis; these are branches of the internal
pudendal arteries and pudendal nerves respectively
 Bulbo-urethral glands, each of which lies posterolateral to the membranous
urethra (Fig. 57)
 Proximal parts of the ducts of bulbo-urethral glands
 Deep transverse perineal muscles, each of which extends from the ischial ramus
to the perineal body, and is innervated by the perineal nerves
Anal Triangle
The anal triangle

 Is the part of the perineum located behind the urogenital triangle
- 281 -
 Is limited laterally by the sacrotuberous ligament, anteriorly by the deep

transverse perineal muscles and perineal tendon, and posteriorly by the coccyx
 Contains the ischioanal fossae and terminal part of the anal canal
Ischioanal Fossae (Ischiorectal Fossae)
Each ischioanal fossa

 Is the part of the anal triangle that lies lateral to the anal canal
 Is wedge-shaped, its apex being directed upwards (and formed by the junction of
obturator internus and levator ani muscles); while its base is directed downwards
and is formed by skin.
 Is bounded laterally by the obturator fascia and ischial tuberosity. Located on
this lateral wall is the pudendal canal (a fibrous tunnel derived from obturator
fascia). It transmits the pudendal nerve, internal pudendal vessels and nerve to
obturator internus
 Is bounded medially by levator ani and external anal sphincter
 Contains pockets of fats, which are delineated by fibrous strands; and is traversed
by the inferior rectal nerve and vessels, and by the perineal (S4) and perforating
(S2, 3) branches of sacral plexus
 Is linked to the opposite fossa through the deep postanal space (behind); this
space lies behind the anal canal and above the anococcygeal ligament
 Has an anterior recess that extends forwards, above the urogenital diaphragm,
and may approach the pubic body
 Allows for the expansion of the anal canal during defaecation
 Could contain a collection of pus – ischioanal abscess. The abscess may result
from infection of an anal fissure, or may be due to a perforating injury in the
perianal skin. The abscess may also communicate with the anal canal via an anal
fistula
CHAPTER 14: HISTOLOGY OF THE MALE GENITAL ORGANS

Testis (or Testicle) (Fig. 54, 59)
From external internally, the testicular capsule is described as consisting of:

 Viscera layer of tunica vaginalis
 Tunica albuginea – a white dense layer of interlacing bundles of collagen and
smooth muscle fibres
 Tunica vasculosa, a layer of loose connective tissue rich in blood vessels; it lies
deep to tunica albuginea
- 282 -
Structure of the Testis

 The tunica albuginea completely invests the testis; and it forms a mediastinum
testis (a thickening) that projects into the posterior aspect of the testis
 The mediastinum testis is a vertical septum that projects forwards into the
posterior aspect of the testis. It contains a complex network of spaces termed rete
testis.
 Septula testis are fibrous strands that traverse the substance of the testis, from the
tunica albuginea. They divide the testis into 200–300 lobules (Fig. 52)
 From the tunica vasculosa, loose vascular connective tissue extends along the
septula testis, into the substance of the testis.
Lobules of the Testis (Fig. 52)
The lobules of the testis

 Are pyramidal compartment within the testis; they are delineated from each other
by septula testis (but interconnect with one another where these are partially
deficient)
 Are invested by loose vascular connective tissue that extends into the substance
of the testis from the tunica vasculosa, along septula testis
 Range from 200–300 in each testis. Each contains 1-3 convoluted seminiferous
tubules
 Also contain connective tissue cells (fibroblast, macrophages, mast cells and
mesenchymal cells), as well as Leydig cells. The latter, together with other
connective tissue elements, form the interstitial tissue of the testis
Seminiferous Tubules (Fig. 52, 59)
The seminiferous tubules

 Constitute the basic exocrine element of the testis. They have a convoluted and a
straight part (Fig. 52)
 Are highly convoluted within the lobule of the testis; here, they are referred to as
convoluted seminiferous tubules
 Become straightened as they approach the rete testis (in the mediastinum testis).
These parts are thus referred to as straight seminiferous tubules. They are less
numerous than the convoluted tubules
Convoluted Seminiferous Tubules
Convoluted seminiferous tubules

 Are closed loops that open at both ends into the straight seminiferous tubules
(and thus into the rete testis)
- 283 -
 Occupy the lobules of the testis. In each lobule, there are 1–3 convoluted tubules,
and these are loosely bound to each other by loose connective tissue. Each testis
may have up to 600 seminiferous tubules.
 Measure 70–80 cm in length (when uncoiled), with a maximum diameter of 0.3
mm
 Contain both spermatogenic and sustentacular (Sertoli) cells (Fig. 59)
 Rest on a basement membrane consisting of connective tissue, with numerous
elastic fibres
 Appear pale in young subjects, but become yellowish in the elderly, owing to the
deposition of fat
Figure 59. Seminiferous tubules
Spermatogenic Cells of the Testis
Regarding spermatogenic cells, note that

 The seminiferous tubule is a germinal epithelium consisting of germ cells at
different stages of differentiation and maturation
 Spermatogonia are germ cells located close to the basement membrane of
seminiferous tubules
 Both mitosis and meiosis occur simultaneously in the different germ cells of
seminiferous tubules
 During their maturation, germ cells are intimately associated with, and are thus
supported by Sertoli cells
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 Germ cells that are advanced in maturation are located closer to the lumen of the
seminiferous tubule
 Spermatozoa are free, highly differentiated cells, found in the lumen of
seminiferous tubules (Fig. 59).
Sertoli (Sustentacular) Cells of the Testis
Sertoli cells
 Are large polymorphic cells located in the wall of seminiferous tubules (Fig. 59).
They give support and nourishment to germ cells as they develop in the wall of
these tubules
 Form recesses that harbour spermatids, spermatozoa and other germ cells as these
differentiate and mature during spermatogenesis. Besides, Sertoli cells possess
indented nuclei that stain weakly with Feulgen reaction
 Possess abundant cellular organelles including mitochondria, endoplasmic
reticulum, ribosomes, Golgi apparatus, microtubules and microfilaments. The last
two organelles enhance the sustentacular (supporting) function of these cells
 Perform phagocytic functions as they engulf residual bodies (shed by spermatids
during spermiogenesis), etc.
Leydig (Interstitial) Cells of the Testis
Leydig cells
 Are polyhedral cells located in the interstitial (connective) tissue of the testis
(between adjacent seminiferous tubules) (Fig. 59)
 Possess scanty, poorly-staining cytoplasm. Each has an eccentric nucleus with 1–
3 nucleoli
 Are rich in fat, phospholipids and cholesterol; and they resemble luteal cells of
corpus luteum
 Produce the androgens, especially testosterone. This activity is under the
influence of interstitial cell stimulating hormone (ICSH)
 Are absent in undescended testis (cryptorchism)
Straight Seminiferous Tubules and Rete Testis
Note that
 Rete testis occupies the mediastinum testis; it is a complex network of channels
lined by simple squamous epithelium
 Convoluted seminiferous tubules join each other close to the rete testis to form
about thirty straight seminiferous tubules, which drain into the rete testis
 Each straight seminiferous tubule is about 0.5 mm in diameter; and it is lined by
simple cuboidal epithelium
 Rete testis is linked to the head of the epididymis by up to twenty efferent
ductules
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Efferent Ductules
Efferent ductules
 Are the tubules that link the rete testis to the head of epididymis (Fig. 52). They
may be up to twenty in number.
 Are convoluted at their distal ends (in the head of the epididymis) to form lobules
of the epididymis
 Unite in the epididymal head to form a single duct of the epididymis (that
becomes highly coiled in the body and tail of the epididymis; subsequently, it
straightens out as the vas deferens).
Structure of the Epididymis
The epididymis
 Is lined by pseudostratified columnar epithelium. The epithelial cells are
endowed with long non-motile processes termed stereocilia. These project into
its lumen of the epididymis
 Has a coat of smooth muscle fibres, just external to the epithelium; this coat is
arranged into two layers – an outer longitudinal and an inner circular layer. The
muscle coat increases in thickness distally; and here, a third (inner longitudinal)
layer is added.
 Is the site for the storage and maturation of spermatozoa
Structure of the Vas Deferens

 The vas deferens has a mucosa that is thrown into longitudinal folds (Fig. 60).
This mucosa is lined by a simple (pseudostratified) columnar epithelium, and it is
secretory in function
 Just external to the mucosa is a coat of smooth muscle fibres. This coat is
arranged into external longitudinal, middle circular and inner longitudinal layers
(Fig. 60); and it is about 1 mm thick.
 External to the muscular coat of the vas deferens is the adventitia (of loose
connective tissue)
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Figure 60. Structure of the vas deferens
Structure of Ejaculatory Duct

 The epithelium of ejaculatory duct is simple columnar in type
 The muscular coat of ejaculatory duct is arranged into inner longitudinal and
outer circular layers
 The ejaculatory duct also has an adventitia of connective tissue, which invests it
externally.
Structure of Seminal Vesicle
The seminal vesicle

 Has a mucosa that is lined by a simple columnar epithelium. The latter possesses
several outpocketings, and its cells are endowed with microvilli. Goblet cells
also intersperse the epithelial cells.
 Possesses an intermediate muscular coat (external to mucosa). This is arranged
into inner longitudinal and outer circular layers
 Has an external adventitia of connective tissue
 Produces an alkaline secretion that constitutes about 60% of the ejaculate; this
secretion is rich in fructose (for nourishing the spermatozoa) and prostaglandins.
Structure of the Prostate Gland
The prostate
 Has a thin capsule made of fibrous tissue. This lines the surface of the gland
 Consists of a dense fibromuscular stroma that is rich in smooth muscle fibres,
collagen and elastic fibres
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 Has a parenchyma consisting of secretory follicles (of columnar cells); these

follicles are embedded in the dense fibromuscular stroma; and are scanty in the
anterior lobe of this gland
 Usually contains some colloidal amyloid bodies in its follicles. Amyloid bodies
are derived from condensation of the secretion of prostate gland
 Secretes a slightly acidic, clear fluid that is rich in acid phosphatase, citric acid,
etc. This drains via 12–20 ducts that open into the floor of the prostatic sinus, in
the prostatic part of the urethra.
Structure of Bulbo-Urethral Gland
The bulbo-urethral gland

 Is a compound tubulo-alveolar gland, with columnar secretory cells
 Has a stroma of connective tissue, in which the parenchyma is embedded; and it
invested externally by a fibrous capsule
 Produces a mucous secretion
Structure of the Penis

 The penis possesses minute cavernous spaces; these are delineated by numerous
tiny trabeculae that extend inwards from the tunica albuginea and septum of the
penis
 Cavernous spaces are largest in the central parts of corpora cavernosa. These
spaces are vascular spaces; they are thus lined by endothelial cells. This
endothelium is not fenestrated
 The trabeculae (that delineate cavernous spaces) consist of collagen, elastin and
smooth muscle fibres (same structure as tunica albuginea). Elastic fibres are more
abundant in the trabeculae of corpus spongiosum; while smooth muscle fibres are
less numerous here
 Numerous blood vessels and nerve fibres are associated with the trabeculae of
the cavernous spaces. In a flaccid penis, the arteries appear coiled, and are thus
referred to as helicine arteries
 Cavernous spaces are almost completely devoid of blood in a flaccid penis.
However, they are engorged with blood when the penis is erect
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CHAPTER 15: GROSS ANATOMY OF THE FEMALE GENITAL

ORGANS
Female External Genitalia (Vulva or Pudendum Femininum)
The vulva consists of:

 Mons pubis, the most anterior part (Fig. 61)
 Labia majora, which are homologous to the scrotum
 Labia minora, which are homologous to the penile urethra
 Vestibule of the vagina, which contains the vaginal and urethral orifices
 Bulb of the vestibule, which is homologous to the bulb of the penis
 Clitoris, which is homologous to the penis
 Greater vestibular glands, which is homologous to the bulbo-urethral glands
The mons pubis

 Is a rounded eminence that lies anterior to the symphysis pubis (Fig. 61). It
consists of subcutaneous adipose tissue covered externally with skin.
 Acquire coarse hair at puberty. This forms a triangular outline, with the base
anterior. Some of the hair is lost after menopause
 Serves as a cushion for the symphysis pubis and vulva during coitus
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Figure 61. Female external genitalia (vulva)
Labia Majora
The labia majora

 Are prominent ridges that form the lateral boundaries of the pudendal cleft (Fig.
61). Thus, they surround and protect other components of the vulva
 Extend from the mons pubis anteriorly towards the anus posteriorly. Anteriorly,
they Join each other to form the anterior commissure
 End close to each other posteriorly, and together with the skin between them,
form the posterior commissure. The latter bounds the vulva posteriorly (anterior
to the anus)
 Consists of thick skin and the underlying loose connective tissue and smooth
muscle fibres. The skin is darkly pigmented and is covered by crisp hair after
puberty. However, they are devoid of hair on their pinkish internal surfaces
 Are endowed with numerous sebaceous and sweat glands
 Are supplied by branches of external pudendal and dorsal labial arteries (from
femoral and perineal arteries respectively)
 Are drained by external pudendal and internal pudendal veins. Their lymph
vessels drain into superficial inguinal nodes
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 Are innervated by dorsal labia, perineal branch of posterior femoral cutaneous,

and ilioinguinal nerves
 Give attachment to the round ligaments of the uterus. These are remnants of the
embryonic gubernaculum
Labia Minora
Each labium minus

 Is a longitudinal fold of skin located medial to each labium majus (Fig. 61). It
appears pinkish and does not possess hair and fat
 Possesses abundant sebaceous glands; and numerous nerve endings (for sexual
arousal)
 Splits anteriorly into upper and lower divisions. These unite with those of the
opposite side, dorsal and ventral to the clitoris to form the prepuce and frenulum
of the clitoris, respectively
 Is linked to the opposite labium (posteriorly) by a transverse fold of skin –
frenulum of the labia minora – especially in virgins
 Become swollen and bluish from the 8th wk of gestation onwards, owing to
venous congestion and increased vascularity
Clitoris
The clitoris
 Is homologous to male penis (Fig. 61). It has a root consisting of two crura only.
Each of this is attached to the ischiopubic ramus, and is covered by
ischiocavernosus
 Possesses a body consisting of two corpora cavernosa. These are separated by a
pectiniform septum, and invested by a dense fibrous tissue
 Does not transmit the urethra, as does the penis
 Has a glans clitoridis at its terminal end. The glans has a prepuce on its dorsum
and is endowed with numerous nerve endings. Thus, it is essential for sexual
arousal
 Measures about 2 cm in length and 0.5–1 cm in diameter. It is connected to the
symphysis pubis by the suspensory ligament of the clitoris
 Is supplied by the deep and dorsal arteries of the clitoris (from internal
pudendal artery)
 Is supplied by branches of the inferior hypogastric plexus and pudendal nerve.
The latter gives rise to the dorsal nerve of the clitoris. The clitoris drains into
superficial inguinal nodes
 Possesses an erectile tissue that becomes engorged with blood during coitus,
such that the clitoris becomes tough.
 Is often excised, with or without the labia minora, during circumcision – a
practice that is medically unacceptable.
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Vestibule of the Vagina
The vestibule of the vagina

 Is the region of the vulva between the two labia minora (Fig. 61)
 Contains the external urethral orifice, located about 2.5 cm behind the glans
clitoridis. It also contains the vaginal orifice, located just posterior to the external
urethral orifice.
 Receives the openings of the ducts of the para-urethral glands, just lateral to the
external urethral orifice; and those of the mucous lesser vestibular glands,
between the orifices of the vagina and urethra
 Also receives the opening of the duct of the greater vestibular gland, between
the vaginal orifice and the frenulum of the labium minus (on each side)
 Has a depression – vestibular fossa – located posteriorly, between the vaginal
orifice and the frenulum of the labia minora
The hymen vaginae

 Is a fold of mucous membrane that covers, to a variable extent, the vaginal
orifice
 May completely cover the vaginal orifice – imperforate hymen – thereby
necessitating surgical incision (to create the vaginal orifice)
 Degenerates after childbirth to form small tags called hymenal caruncles
Bulb of the Vestibule
The bulbs of the vestibule

 Are elongated masses of vascular erectile tissue, one on each side of the vaginal
and urethral orifices. They are homologous to the bulb of the penis and corpus
spongiosum
 Taper at their anterior ends as they join each other to form the commissure of the
bulb (anterior to the vaginal and urethra orifices). This commissure is connected
to the clitoris by two strands of erectile tissue
 Are expanded posteriorly. Here, they overlap the greater vestibular glands,
which lie deep to them, lateral to the vaginal orifice
 Measure 3 cm in length; and they are covered by the bulbospongiosus muscles
 Receive branches of the internal pudendal arteries. These supply their
cavernous spaces with blood
 May be involved in vascular injury that may result in the formation of
haematoma in the vulva
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Greater Vestibular Glands (Bartholin’s Glands)
Each of the two greater vestibular glands

 Is a small, reddish-yellow, oval body located lateral to the vaginal orifice, deep to
the enlarged posterior end of the bulb of the vestibule. It has the size and shape
of a bean
 Produces mucus that lubricates the vagina during intercourse. This gland drains
via a duct (about 3 cm long) that opens into the vestibule of the vagina, lateral to
the vaginal orifice
 Measures about 0.5 cm in diameter; and is also covered by bulbospongiosus
muscle
 Becomes enlarged, and thus, palpable when inflamed (bartholinitis). In this
instance, its diameter may be up to 5 cm.
 Is usually a site for the development of adenocarcinoma in the vulva. It may also
form a Bartholin cyst following the occlusion of its duct. This cyst is painful.
 Is the homologue of the bulbo-urethral gland of the male
Female Internal Genital Organs

The female internal genital organs include the ovaries, uterus, uterine tubes and
vagina
Ovary (Fig. 62, 63)
The ovary
 Is the homologue of the testis; it is almond-shaped (ovoid), and measures 2.5–3.5
cm in length, 1.5 cm in width and 1 cm in thickness
 Appears grayish-pink and smooth prior to puberty, but becomes scarred after
puberty owing to repeated ovulation
 Is located in the ovarian fossa, on the lateral wall of the lesser pelvis (Fig. 63).
This fossa is bounded anteriorly by the obliterated umbilical artery and
posteriorly by the ureter and internal iliac artery
 Rests on the posterosuperior aspect of the broad ligament of the uterus
 Is variably mobile. Its position changes markedly during pregnancy

 The ovarian fossa is bounded anteriorly by the obliterated umbilical artery and
posteriorly by the internal iliac artery and ureter. It accommodate the ovary
 On the lateral wall of the pelvis, the ovary lies adjacent to the parietal
peritoneum that lines the ovarian fossa
 The suspensory ligament of the ovary is a fold of peritoneum that attaches the
ovary to the pelvic wall (Fig. 62). It conveys the ovarian vessels and nerves to
this organ.
 The mesovarium is a fold of peritoneum that attaches the ovary to the broad
ligament of the uterus
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 In nulliparous women, the ovary is vertically-disposed

 The ovaries are not invested by the peritoneum, but lie within the peritoneal
cavity
Surfaces and Borders of the Ovary
Each ovary has:

 A superior extremity (tubal extremity), to which the uterine tube and the
suspensory ligament of the ovary are attached
 A narrow inferior extremity (uterine extremity), to which the ligament of the
ovary is attached. The latter lies within the broad ligament and connects the
ovary to the tubo-uterine junction.
 A free border (posterior border), which faces the internal iliac artery.
 A mesovarian border (anterior border), which faces the broad ligament. It gives
attachment to the mesovarium (see above)
 A medial surface, which is covered by fimbrae of the uterine tube
 A lateral surface, which adjoins the parietal peritoneum that lines the ovarian
fossa
Blood Supply, Lymphatics, Innervation and Applied Anatomy of the Ovary
The ovary
 Is supplied by branches of the ovarian artery; the latter arises from the
abdominal aorta, at L2
 Is drained by the pampiniform plexus of veins; this plexus unites to form the
ovarian vein. The left ovarian vein ends in the left renal vein, while the right
ends in the IVC
 Is innervated by the ovarian plexus of nerves, which accompanies the ovarian
artery. The parasympathetic fibres are derived from the inferior hypogastric
plexus and are probably for vasodilatation; while the sympathetic fibres are
from the lower thoracic splanchnic nerves (T10-T11 spinal segments, and are
probably for vasoconstriction),
 Drains via efferent lymph vessels that end in para-aortic nodes
 Is normally not palpable in healthy individuals. However, it may become
palpable when enlarged or displaced (as may be observed during vaginal
examination)
 Releases a secondary oocyte during each menstrual cycle. About 30% of women
experience a cramp-like pain during this period, and this may be mistaken for the
pain of appendicitis. The ovary undergoes atrophy after menopause (when
menstrual periods cease).
 May be excised in ovariectomy (oophorectomy), as may be required in
conditions such as ovarian tumor, etc
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Figure 62. Uterus and adnexa
Uterine Tube (Fig. 62, 63)
The uterine tube

 Is a muscular tube that extends from the ovary laterally to the uterus medially
(Fig. 62, 63); it transports the ovum and zygote from the peritoneal cavity to the
uterus
 Occupies the upper border of the broad ligament (mesosalpinx). It is about 10
cm in length and 0.7 cm in diameter
 Communicates with the peritoneal cavity via an abdominal ostium (which is 2–3
mm in diameter); and with the uterine cavity via the uterine ostium
 Consists of four parts that include, from medial laterally, intramural (uterine)
part, isthmus, ampulla and infundibulum (Fig. 62)
Uterine Part of Uterine Tube (Intramural Part)
The uterine part of the uterine tube

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 Is the part of the tube that lies within the wall of the uterus
 Is the shortest segment of the tube; it measures 1 cm in length
 Communicates via the uterine ostium (about 1 mm in diameter) with the uterine
cavity
The isthmus of the uterine tube

 Is the part between the ampulla and the uterine part of the tube
 Is narrow, thick-walled, rounded and firm
The ampulla of the uterine tube

 Is the widest part of the tube; this part appears slightly tortuous
 Constitutes more than half of the entire length of the tube
 Is a common site of fertilization
The infundibulum of the uterine tube

 Is the funnel-shaped, lateral end of the tube
 Opens into the peritoneal cavity via an abdominal ostium, which is about 2 mm
in diameter
 Possesses several finger-like processes called fimbrae. The latter cover the
superior and medial aspects of the ovary at ovulation. An exceptionally long
ovarian fimbra attaches the tube to the superior pole of the ovary
 Receives the ‘egg’ from the ovary at ovulation
Blood Supply, Lymphatics, Innervation and Applied Anatomy of Uterine Tube
The uterine tube

 Is supplied by branches of the uterine and ovarian arteries
 Is drained by uterine and ovarian veins
 Receives parasympathetic fibres from the vagus nerve in its lateral half; and
from the pelvic splanchnic nerves in its medial half (via the ovarian and uterine
plexuses of nerves)
 Receives sympathetic fibres from T10–L2 segments of the spinal cord. Sensory
fibres from the tube accompany the sympathetic fibres (in a retrograde
fashion) to the spinal cord.
 Drains via efferent lymph vessels into lumbar nodes
 May be ligated to control birth – this may be by abdominal or laparoscopy
approach
 May develop a local collection of pus – pyosalpinx – when infected
 Is the commonest site of ectopic (tubal) pregnancy. In this condition, the tube
may rupture at about the end of 2nd month of pregnancy, with severe
haemorrhage. This necessitates surgical intervention.
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Uterus (Fig. 62, 63)
The uterus
 Is a piriform, hollow, thick-walled muscular organ. it is located in the lesser
pelvis, between the rectum posteriorly, and the urinary bladder antero-inferiorly
 Is continuous with the uterine tubes at its superolateral angles (or horns); and
with the vagina at its lower end
 Measures 7.5 cm in length, 5 cm in its broadest part and 2.5 cm in thickness. It is
larger in the multiparous than the nulliparous state
 Weighs 30–40 g (in nulliparous women)
 Consists of the body and cervix. These are joined at the isthmus (Fig. 62)
 May be anteverted in position. In this instance, the uterus is angulated forwards
on the vagina
 May also be retroverted in position. In this instance, the uterus tilts backward on
the vagina (towards the rectum). The uterus usually inclines to the left of the
midline
The uterine body

 Is the upper part of the uterus, above the isthmus of this organ (Fig. 62). It
measures 5 cm in length, 5 cm in its widest part and 2.5 cm in thickness
 Lies above the vesico-uterine pouch and urinary bladder; and it is related
posteriorly to the recto-uterine pouch, sigmoid colon, and rectum
 Has a rounded upper border called the fundus . This lies above the level of
attachment of the uterine tubes
 Lies absolutely below the pelvic inlet in a nulliparous female; and it is completely
invested by the peritoneum
Note that the body of the uterus

 Is continuous with the cervix (lower part of the uterus) at the narrow isthmus
 May be anteflexed in position. In this instance, it is angulated forwards on the
cervix, thereby resting on the urinary bladder
 May be retroflexed in position. In this instance, it is angulated backwards on the
cervix, towards the rectum
 Has two surfaces: an anterior (vesical) and a posterior (intestinal) surface
 Has two lateral borders to which the broad ligament of the uterus is attached
 Is relatively more mobile than the cervix and its position varies with the level of
distension of the urinary bladder and rectum
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Figure 63. Female pelvic organs (sagittal section)
The cervix of the uterus

 Is the lower, cylindrical, relatively fixed part of the uterus. It extends from the
isthmus of the uterus to the uppermost part of the vagina (Fig. 62)
 Measures about 2.5 cm in length; and has a fusiform cavity
 Has two parts: a vaginal part (within the vagina), and a supravaginal part
(above the vagina)
 Lies between the base of the urinary bladder anteriorly, and the rectum and
recto-uterine pouch posteriorly. It is separated from the urinary bladder by a
cellular connective tissue termed parametrium
 Communicates with the uterine cavity via the internal os, and with the vagina via
the external os. The internal os is at the level of the isthmus. The external os is
guarded by two lips – anterior and posterior lips. The posterior lip is longer and
more rounded.
 Is devoid of peritoneal covering on its anterior aspect. However, its posterior
surface is lined by peritoneum.
The isthmus of the uterus

 Is the part of the uterus between the body and cervix (Fig. 62)
 Is taken up into the body of the uterus from the second month of pregnancy,
thereby forming the lower uterine segment
Ligaments of the Uterus
Ligaments of the uterus include the:
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 Round ligament, about 12 cm long. It extends from the tubo-uterine angle to the
labium majus, traversing the inguinal canal as it does so. It is the remnant of the
lower gubernaculum in female
 Broad ligament, a double fold of peritoneum that extends from the lateral
margin of the uterus to the lateral wall and floor of the pelvis (Fig. 62). It contains
the uterine tube in its upper part
 Transverse cervical ligament, a band of fibrous tissue that passes from the side
of the cervix and lateral fornix of the vagina to the lateral pelvic wall (Fig. 62).
 Uterosacral ligament, a band of fibrous tissue and smooth muscle fibres that
extends posterosuperiorly, from the cervix to the sacrum (one on each side)
 Anterior ligament, a fold of peritoneum formed as the peritoneum is reflected
from urinary bladder to the uterus
 Posterior ligament, formed as the peritoneum is reflected from the posterior
vaginal fornix to the rectum
Blood Supply, Lymphatics and Innervation of the Uterus
Regarding the uterus, note the following points:

 It receives arterial blood mainly from the uterine arteries (branches of internal
iliac arteries). Ovarian and vaginal arteries also contribute to its blood supply.
 It is drained by the uterine plexus of veins. The latter drains via the uterine
veins into the internal iliac veins.
 Lymph vessels from the fundus of the uterus drain into superficial inguinal nodes
(via vessels that accompany the round ligament), lumbar nodes, and external
iliac nodes; those from uterine body drain into external iliac nodes (via vessels
that accompany the broad ligament); while those from the cervix drain into
sacral and internal iliac nodes
 The uterus receives parasympathetic fibres from the pelvic splanchnic nerves
(S2–S4) (via the inferior hypogastric and uterovaginal plexuses of nerves)
 The uterus receives sympathetic fibres from T12–L1 segments of the spinal cord
(via the lumbar splanchnic nerves, and the intermesenteric, superior hypogastric,
inferior hypogastric and uterovaginal plexuses)
 Afferent (pain) fibres from uterine body accompany the sympathetic fibres (in a
retrograde fashion) to end at the T12 and L1 spinal segments
 Pain fibres from the lower (cervical) part of the uterus accompany the
parasympathetic fibres (pelvic splanchnic nerves) to end at the S2–S4 segments
of the spinal cord.
Applied Anatomy of the Uterus
Note the following:

 The uterus becomes about 16 times its non-gravid weight during pregnancy
 The cervix is a common site of malignancy. Cancer of the cervix is relatively
common in women, and it is largely caused by human papillomavirus infection.
 The ureters are at risk during hysterectomy (excision of the uterus)
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 Early in pregnancy, the isthmus of the uterus becomes significantly softened –

Hegar’s sign
 The uterus of a neonate has an adult proportion (⅔ being the body and ⅓ the
cervix)
 An infant’s cervix is 50% of the size of the uterus; and the latter is mainly
abdominal in location
 Caudal epidural block does not anaesthetize the body of uterus, and does not
produce spinal headache; while spinal block (performed during childbirth for
example) anaesthetizes all parts of the uterus but also produces spinal headache
 The uterus may prolapse through the vagina when the support provided by the
perineal body and levator ani muscle is weakened (from repeated childbirth, etc).
Vagina (Fig. 62, 63)
The vagina
 Is a fibromuscular tube that extends from the vestibule of the vagina below, to the
uterus above. It forms an angle of 90o with the cervix (though this varies)
 Has an anterior wall that is about 7.5 cm in length; and a posterior wall that is
about 9 cm in length
 Is largely transversely flattened, such that its anterior and posterior walls are
apposed
Relations of the Vagina (Fig. 63)
Regarding the vagina, note the following:

 The upper part of the vagina is expanded as the fornix, which surrounds the
vaginal part of the cervix. The fornix consists of four parts that include anterior,
posterior and two lateral fornices.
 The posterior fornix is deep; it is overlaid by the peritoneum and related behind
to the recto-uterine pouch and rectum.
 Each of the two lateral fornices is related to the ureter and uterine artery
 Anterior relations of the vagina include the urinary bladder and urethra. The
latter is intimately associated with it
 Lateral relations of the vagina include the levator ani muscle, ureter and
uterine artery (on each side)
 Posterior relations of the vagina include the rectum, recto-uterine pouch and its
contents of sigmoid colon and terminal ileum
Blood Supply, Lymphatics and Innervation of the Vagina
Regarding the vagina, note that:

 It is supplied by the uterine, middle rectal and vaginal arteries. These are
branches of internal iliac artery
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 It is drained by the uterovaginal venous plexus; this plexus drains into the
internal iliac veins (via the uterine veins)
 Lymph vessels from the upper part of the vagina drain into external and internal
iliac nodes; those from its middle part into internal iliac nodes; while those
from its lower part drain into sacral and superficial inguinal nodes
 The vagina receives parasympathetic fibres from the pelvic splanchnic nerves
(S2–S4), via the inferior hypogastric and uterovaginal plexuses of nerves.
 The vagina receives sympathetic fibres from the T12 and L1 spinal segments
(via the lumbar splanchnic nerves and the intermesenteric, inferior hypogastric
and uterovaginal plexuses of nerves)
 Afferent (sensory) fibres from the upper ¾ of the vagina accompany the pelvic
splanchnic nerves to the spinal cord.
 The lower ¼ of the vagina is innervated by the deep perineal branches of
pudendal nerves. Thus, this part is sensitive to exteroceptive stimuli
Applied Anatomy of the Vagina
Regarding the vagina, note that:

 It may be examined during physical examination with the aid of a vaginal
speculum
 Spasmic contraction of bulbospongiosus, superficial transverse perineal muscles
and levator ani may occlude the vagina. This condition is referred to as
vaginismus, and it is associated with dyspareunia (painful coitus)
 The vagina has a high a potential for distension, but this is limited laterally by the
ischial spine
 Pelvic organs such as the ovaries and uterine tubes may be examined with a
culdoscope. This endoscope is inserted into the recto-uterine pouch through the
posterior vaginal fornix
 Pus, blood, etc, in the recto-uterine pouch (of Douglas) can be drained in
culdocentesis. In this procedure, an incision is made through the posterior
vaginal fornix
Breasts (Mammae)
The breasts
 Exist in both males and females. They are rudimentary in prepubertal females and
throughout life in males
 Secrete milk in females, for the nourishment of the baby. The breasts attain their
greatest development in the latter part of gestation and during lactation
 Consist of the parenchyma – mammary gland proper – and connective tissue
stroma
Female Breast (Fig. 64)
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The female breast

 Begins to develop at puberty in response to the increased concentrations of
oestrogens. In postpubertal females, it consists largely of adipose tissue, except
during lactation when its glandular tissue increases
 Lies in the superficial fascia of the anterolateral wall of the thorax. Thus, it
overlies, to a variable extent, the pectoralis major, serratus anterior and external
oblique (and its aponeurosis) (Fig. 64)
 Is separated from the underlying muscles by the deep fascia. Between this fascia
and the breast is a retromammary or submammary space of connective tissue,
which allows the breast some degree of movement
 Has a shape that depends on age and race; this may be conical, hemispherical or
pendulous
Figure 64. The mammary gland (breast)
Note that
 In the vertical plane, the base of a well-formed breast extends from the 2nd–6th
ribs; while in the horizontal plane, it extends from the side of the sternum to the
midaxillary line.
 The superolateral part of the breast extends towards the axilla as the axillary tail.
This tail extends along the lower border of pectoralis major and may lie in close
proximity to the pectoral group of lymph nodes, in the axilla.
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Nipple (Mammary Papilla)
The nipple
 Is a cylindrical or conical body that projects outwards from a point just below the
centre of the breast. It is pinkish or light brown in colour
 Usually lies at the level of the 4th intercostal space in the nulliparous and
prepubertal females, and in males. However, its position is variable in pregnancy
and lactation, and with advancing age.
 Has a wrinkle tip, which receives the openings of 15–20 lactiferous ducts (Fig.
64). The base of the nipple is surrounded by an area of pigmented skin termed
areola
 Possesses numerous smooth muscle fires, most of which are circularly disposed.
Their contraction makes the nipple stand erect
 May not evert during prenatal life. Such a retracted position of the nipple may
persist in the adult, thereby making suckling difficult for the baby
Areola
The areola
 Is the pigmented skin that encircles the base of the nipple; it is pinkish in
nulliparous females, but dark-brown during pregnancy and thereafter. Its size and
pigmentation increase as pregnancy advances
 Contains numerous sebaceous glands termed areolar glands (glands of
Montgomery); these become larger during gestation and lactation, thereby
forming ‘tubercles’ beneath the skin
 Is devoid of fat in its superficial fascia, as is the case with the nipple
Blood Supply, Innervation and Lymphatics of the Breast

 The breast is supplied by the 2nd–4th perforating branches of the internal thoracic
artery. It is also supplied by the lateral thoracic and thoraco-acromial branches
of the axillary artery
 The breast is drained by the axillary, internal thoracic, intercostal and lateral
thoracic veins
 Just beneath the areola of the breast is a subareolar plexus of lymph vessels.
Lymph vessels from the breast accompany the veins to the axillary, parasternal
and (occasionally) intercostal nodes. The pectoral, subscapular and apical groups
of axillary nodes receive the bulk of lymph from the breast
 More than 75% of the lymph from the breast drains into the axillary nodes. The
parasternal lymph nodes receive lymph from the medial and lateral halves of
the breast; they receive the bulk of the lymph from the breast, next to the axillary
nodes.
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 Few lymph vessels from the breast may drain into infraclavicular and
interpectoral lymph nodes
Regarding the innervation of the breast, note these points:

 The breast receives nerve fibres from the lateral and anterior cutaneous branches
of the 2nd–6th intercostals nerves
 Sensory fibres to the breast supply its skin (including that of the areola and
nipple). These fibres are associated with numerous tactile receptors (e.g.
Meckel’s discs, Meissner’s corpuscles and free nerve endings) that are essential
for signal transduction (e.g. during suckling)
 Sympathetic fibres accompany the above nerves to supply the blood vessels and
glandular tissue of the breast, as well as the smooth muscle fibres of the nipple
and areola
Note: The secretory activity of the mammary gland is under hormonal control. For
example, prolactin (luteotropic hormone or luteotropin) is essential for milk
secretion.
Applied Anatomy of the Breast

 Carcinoma (CA) of the breast is the most common malignancy in women. It is
common in the superolateral quadrant of this organ
 Pathogenesis of CA of the breast is largely unknown, but both environmental
and genetic factors are involved; women over 35 years are most susceptible, and
death usually occurs between 40 and 50 years
 The skin over the site of breast CA usually becomes thickened and dimpled,
forming a “peau d’orange” (orange skin)
 In CA of the breast, cancer cells invade the retromammary space and the organ
becomes attached to the deep fascia over pectoralis major. Thus, contraction of
this muscle produces (upward) movement of the breast. The suspensory
ligament also become shortened (hence the dimpling of the skin).
 Cancer cells from the breast form metastases mainly in axillary nodes.
Enlargement of these nodes may therefore be an indication of CA of the breast.
 Cancer cells may spread to the opposite breast, the neck, or abdominal organs,
via the lymphatic and venous routes.
 Owing to the connection between the posterior intercostal veins (draining the
breast) and the vertebral venous plexuses, cancer cells from the breast can also
spread to the vertebrae, and thence, to the skull and brain.
 In women below 35, fibroadenoma may occur. This is benign carcinoma of the
breast. Mastitis is the inflammation of the parenchyma of the breast; it may occur
during lactation.
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 Confirmation of CA of the breast requires mammography, a radiographic
procedure in which the breasts are x-rayed.
 In the management of CA of the breast, mastectomy may be performed; this is
the surgical removal of the breast.
 In the simple mastectomy, the entire breast is removed, with the exception of its
lymph nodes. In modified radical mastectomy, the entire breast, its lymphatics
and perhaps the pectoralis major, are removed
 Radical mastectomy involves the removal of the entire breast, pectoral muscles,
all the lymph nodes of the axilla and pectoral region, and associated tissues. The
procedure is less common presently.
 Damage to the long thoracic nerve during the removal of axillary nodes (in CA
of the breast) results in winged scapula. This is owing to the paralysis of serratus
anterior muscle, which the nerve supplies.
 Recently, management of CA of the breast involves lumpectomy. In this
procedure, the tumor and its associated tissues are the only structures excised.
 Males may also develop CA of the breast. About 1% of the latter occurs in males;
women are about 100 times more susceptible than men.
 In Klinefelter’s syndrome, males experience noticeable breast development, a
condition termed gynaecomastia. This condition may also arise transiently at
puberty, owing to imbalance in androgen and oestrogen levels.
CHAPTER 16: HISTOLOGY OF THE FEMALE GENITAL ORGANS

Structure of the Ovary (Fig. 65)
Regarding the ovary, note the following:

 In young females, ovarian surface is lined by a layer of cuboidal cells that form
the germinal epithelium. In the elderly however, ovarian surface is lined by
flattened cells.
 Just beneath the germinal epithelium, the ovary has a layer of dense connective
tissue termed tunica albuginea.
 Deep to the tunica albuginea, the ovary consists of a superficial cortex and a deep
medulla (Fig. 65).
 The ovary appears smooth in the young but becomes progressively puckered and
scarred as age advances
The cortex of the ovary

 Lies just deep to the tunica albuginea (Fig. 65)
 Has a stroma consisting of fibro-areolar connective tissue
 Contains thousands of maturing ovarian follicles
 Releases a secondary oocyte during each menstrual cycle
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Figure 65. Structure of the ovary
The ovarian medulla

 Lies in depth of the ovary, deep to the cortex. It consists of vascular loose
connective tissue
 Possesses numerous contorted blood vessels, which are relatively large compared
to the size of the ovary
 Is devoid of ovarian follicles
Structure of Uterine Tube
Regarding the uterine tube, note the following:

 It consists of a mucosa, submucosa, muscular coat and serosa, from internal
externally.
 Its external surface is lined by a layer of peritoneum – the serosa. Beneath the
serosa is a subserous coat of loose connective tissue.
 The muscular coat of the uterine tube consists of smooth muscle fibres just
beneath the subserous layer. This coat is arranged into two layers – an outer
longitudinal and a thick inner circular layer. The muscular coat is thicker in the
medial part of the tube.
 The submucosa is a layer of loose connective tissue located internal to the
muscular coat. This layer is rich in blood vessels, lymphatics and nerve fibres.
 The most internal layer of the uterine tube is the mucosa; this lies just deep to the
submucosa.
 Conveys the ovum, zygote or morula through its lumen, basically as a function of
muscular contraction and ciliary current
The mucosa of the uterine tube

 Is thrown into numerous longitudinal folds, which almost fill the cavity of the
tube. The mucosa is thicker in the lateral part of the tube
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 Is lined by a ciliated simple columnar epithelium. Besides, the epithelium has

two other cell types – secretory and intercalated cells – which intersperse the
columnar epithelial cells.
 Facilities the passage of the ovum or zygote through its lumen by means of (a) its
ciliary wave (which sweeps towards the uterus), (b) rhythmic muscular
contractions of the tube, and (c) presence of a serous fluid in its lumen; the fluid
is produced by the secretory cells.
 Shows increased secretory activities in the luteal phase of menstrual cycle
Structure of the Uterus
Regarding the structure of the uterus, note that:

 The bulk of uterine wall is made of interlacing smooth muscle fibres that
constitute the myometrium (Fig. 62)
 Uterine mucosa – endometrium – lies just deep to the myometrium (Fig. 62); the
submucous coat is absent.
 Uterine fundus, body, and the posterior aspect of the supravaginal cervix have an
external serous membrane – the serosa or perimetrium. This is separated from
the myometrium by loose connective tissue – subserosa
The muscular coat of the uterus

 Constitutes the bulk of uterine wall; it has a thickness of about 1.25 mm, and it is
firm and greyish in nulliparous women. It adjoins the mucosa directly, without
any intervening submucosa
 Consists of bundles of smooth muscles fibres, which run in different directions;
these are intermingled with areolar tissue, numerous blood vessels, nerve fibres
and lymph vessels.
 Contains abundant collagen and elastic fibres in the cervix; thus, the greater
firmness and denseness of this part of the uterus
 Hypertrophies greatly in pregnancy, its smooth muscle cells measuring more
than 500 m in length
Note that:
 The smooth muscle fibres of the myometrium may be arranged in 3 layers:
external, middle and internal
 The external layer of the myometrium contains longitudinally-disposed bundles
of smooth muscle cells
 The middle layer of the myometrium contains smooth muscle fibres that are
disposed longitudinally, obliquely and circularly
 The internal layer of the myometrium contains circularly disposed smooth
muscle fibres
Endometrium
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The endometrium
 Is the mucous membrane of the uterus. Prior to puberty, it is lined by ciliated
simple columnar epithelium. In adult females, this epithelium is variably ciliated.
 Has a lamina propria (beneath the epithelium) that is rich in fibroblasts and
ground substance. This tissue is rich in coiled blood vessels and lymph vessels
 Is endowed with numerous simple tubular glands. These are formed by
evagination of the surface epithelium (and thus possess columnar cells). They
extend as deep as the underlying muscle coat.
 Undergoes cyclic changes – menstrual cycle – during which the bulk of its tissue
is sloughed off and lost in the menstrual flow. Thus, endometrial thickness is
variable and depends on the phase of the cycle
 Shows little or no changes during the menstrual cycle in the region of the
isthmus
The endometrium is described as consisting of two main layers; these include:

 Lamina basalis. This is the deeper of the two layers; it lies adjacent to the
myometrium and consists of connective tissue. It is not sloughed during
menstruation
 Lamina functionalis. This is the superficial of the two layers; it consists of the
surface epithelium, part of the lamina propria and associated tubular glands. It is
sloughed during menstruation, and its thickness varies with the menstrual cycle.
The mucosa of the cervix

 Is lined by a layer of tall columnar cells, which are variably ciliated and filled
with mucin. Near the external os, the cervix is lined by stratified squamous cells.
 Possesses relatively dense and more fibrous stroma compared to the body of the
uterus
 Is about 2 mm thick, and has characteristic branching folds (plicae palmatae) on
its surface.
 Has extensively branched tubular glands that secrete mucus. Blockage of the
ducts of these glands gives rise to Nabothian cysts, each of which may be up to 5
mm in diameter
Structure of the Vagina
Structurally, the vagina

 Has an inner mucosa which adheres strongly to the underlying muscular coat
 Has a layer of smooth muscle fibres (external to the mucosa). The muscle fibres
are arranged into external longitudinal and inner circular layer, the former
being more prominent.
 In surrounded externally by a layer of loose connective tissue (external to the
muscle coat). This contains venous plexuses
Regarding the mucosa of the vagina, note these points:
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 It is lined by non-keratinized stratified squamous epithelium, which becomes

thickened after puberty. This epithelium becomes keratinized when exposed to
external surface, as occurs in a prolapsed vagina
 After puberty, the epithelial cells of the vagina contain abundant glycogen. The
glycogen increases in quantity following ovulation.
 The surface of vaginal mucosa is coated by an acidic vaginal fluid. This acidity
is a result of the production of lactic acid by bacterial action on the glycogen of
epithelial cells. Thus, growth of pathogens is discouraged.
 Anterior and posterior vaginal columns are longitudinal folds of mucosa found
on the anterior and posterior vaginal walls, respectively. These columns are
joined by numerous transverse folds of mucosa
 The lamina propria of the vagina is of dense connective tissue. It is rich in
lymphocytes, which migrate into the epithelium (from the lamina propria).
 Vaginal mucosa is devoid of glands and is therefore lubricated by mucus from
the cervix.
Greater Vestibular Gland
The greater vestibular gland

 Is compound tubulo-alveolar in type
 Produces a mucous secretion that lubricates the vaginal orifice at intercourse
 Gradually involutes after age thirty
Structure of the Breast

 The mammary gland is a modified sweat gland; it is compound acinar in type.
 Structurally, the breast consists of glandular tissue (parenchyma), adipose tissue
(fat) and fibrous elements. No distinct fibrous capsule invests the gland
externally
 The fibrofatty tissue of the breast fills up the interstices between the glandular
elements, thereby surrounding and supporting them
 Milk is secreted by the parenchyma of the breast. This parenchyma is organised
into lobes and lobules
 Some fibrous bands, the suspensory ligaments of Cooper, run between the skin
of the breast and the deep fascia (of pectoral muscles). Thus, they anchor the
breast to this fascia
Lobes and Lobules of the Breast
Note that the following:

 The breast is a compound acinar (alveolar) gland. Each has 15–20 lobes
 Each lobe of the breast drains through a single lactiferous duct. Thus, each
breast has 15–20 lactiferous ducts; and these open separately onto the tip of the
nipple.
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 Each lobe of the breast has several lobules. Lobules are smaller secretory units
(alveoli) whose ducts join the lactiferous duct
 Each lactiferous duct has a local dilation – lactiferous sinus – just beneath the
areola. The sinus serves as reservoir for milk.
 Lactiferous ducts converge towards the areola and open separately onto the tip
of the nipple
 The epithelium of the lactiferous duct is of columnar cells, which may be one or
more layers thick. However, it becomes stratified squamous near the tip of the
nipple.

 At birth, only the lactiferous ducts and the connective tissue stroma are present
in the breast; no alveoli are developed yet
 In nulliparous women, the parenchyma of the breast is rudimentary. However, it
enlarges significantly in pregnancy and lactation
 During and after puberty, alveoli begin to develop from the terminal ends of
lactiferous ducts, in response to oestrogen. Progesterone has similar effects in
pregnancy
 Reduction in the levels of oestrogens and progesterone triggers the release of
prolactin by the mammotropic cells of adenohypophysis. Prolactin stimulates
milk production by the alveoli of mammary gland
 True milk secretion begins after parturition; and the early secretion from the
mammary gland is termed colostrum. Colostrum appears creamy or yellowish; it
contains certain cells termed colostral corpuscles, antibodies and essential amino
acids
CHAPTER 17: GROSS ANATOMY OF URINARY ORGANS

Kidneys (Fig. 66)
Each kidney
 Is a bean-shaped organ located on the posterior abdominal wall, from T12
vertebra above to L3 vertebra below
 Is retroperitoneal in position (i.e., it lies behind the peritoneum of the posterior
abdominal wall)
 Appears reddish-brown in the living, and measures 10–11 cm in length, 5–6 cm
in width and 2.5–3 cm in thickness. It weighs 150 g in male and 135 g in female.
 Has two poles: superior and inferior; two surfaces: anterior and posterior; and
two borders: medial and lateral. It has a hilum at the middle of its medial border.
Structures enter and leave the organ through the hilum.
Renal Investment
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Regarding the kidney, note these points:

 Each kidney is intimately invested by a thin fibrous connective tissue termed
renal capsule. This is the innermost of renal coverings
 Just external to the renal capsule, the kidney is covered by a layer of adipose
tissue termed perirenal fat. Outside this sheath of fat is a layer of fibrous
connective tissue called renal fascia
 The pararenal fat is a layer of adipose tissue external to the renal fascia
 The kidney is not supported by renal fascia inferiorly. The two layers of this
fascia do not fuse at the inferior pole of the kidney, though they do elsewhere
 Is maintain in position by the adjacent viscera, the presence of renal fascia and
tonic contraction of anterior abdominal wall muscles
Renal Sinus
The renal sinus is a hollow cavity within the kidney; it contains

 A funnel-shaped renal pelvis
 Major and minor renal calyces
 Branches of renal artery; and tributaries of renal veins
 Lymph vessels and nerve plexus
 Variable amount perirenal fat, which extends into the sinus
 Six to 14 conical projections termed renal papillae, which extend into the floor
of the sinus
Position of the Kidneys
The kidneys
 Are located in the abdominal cavity where they lie on the posterior abdominal
wall, from T12–L3 vertebrae (Fig. 66). They move variably with respiratory
movements
 Do not lie at the same level, the right kidney being about 2 cm lower than the
left (owing to the presence of the liver in the right upper abdominal quadrant)
 Are about 2.5 cm lower in the standing position than in the recumbent position
 Are just a finger breadth (2.5 cm) above the iliac crest. The kidneys are usually
not palpable, except the right one, which may be felt during bimanual
examination of the abdomen
 May “sag” significantly – renal ptosis – especially in thin elderly individuals
suffering from anorexia nervosa
Surface Anatomy of the Kidney
Note that
 The hilum of the kidney lies at the level of the transpyloric plane (at L1), 5 cm
from the midline
 The superior pole of the kidney lies closer to the midline (2.5 cm) than the
inferior pole; this pole is capped by the suprarenal (adrenal) gland
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 The inferior pole of the kidney is 7.5 cm from the midline and 2.5 cm above the
iliac crest
 The kidney is usually approached surgically via the posterior abdominal wall
Figure 66. Kidneys, renal pelvis and ureter (shown from behind)
Relations of the Kidney (Fig. 66)
Posteriorly, the kidneys are related to:

 Muscles, which include psoas major, quadratus lumborum, transverses
abdominis and diaphragm
 Medial and lateral arcuate ligaments of the diaphragm
 Diaphragmatic pleura (in instances where the diaphragmatic fibres from the
lateral arcuate ligament are absent)
 Subcostal arteries and veins, below the 12th rib
 Ilioinguinal, iliohypogastric, and subcostal nerves.
 Eleventh and 12th ribs, on the left side; and the 12th rib only, on the right side
Anteriorly, the right kidney is related to the:

 Second part of the duodenum, right colic flexure, jejunum, part of the suprarenal
gland and the right lobe of the liver
 Hepatorenal recess of peritoneum. This lies between the right kidney and the
liver. It opens inferiorly.
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Anteriorly, the left kidney is related to the:

 Spleen, on its superolateral aspect; and the stomach, on its superomedial aspect
 Splenic flexure, on its inferolateral aspect; and coil of jejunum, on its
inferomedial aspect
 Body of the pancreas and accompanying splenic vessels; these are related to the
intermediate portion of the left kidney
Blood Supply, Lymphatics and Innervation of the Kidneys

 Each kidney receives a single large renal artery (in 70% of individuals) (Fig.
67). The renal artery arises from the abdominal aorta at L1/L2
 Accessory renal arteries supply the kidney in 25–30% of individuals. These
arteries arise from the abdominal aorta, just above or below the origin of the main
renal artery. Accessory renal arteries may also arise from the common iliac and
superior mesenteric arteries or the celiac trunk
 The kidney may develop hydronephrosis when an accessory renal artery enters
its inferior pole by crossing anterior to the ureter. Such an artery thereby
impeding flow of urine through it.
 Have five vascular segments (each of which receives a segmental artery). These
include the superior, inferior, anterosuperior, anteroinferior and posterior renal
segments. The segmental arteries, which supply them, correspond to their names.
 Have a bloodless plane of Brodel, which corresponds to a line along the lateral
border, at the junction of the anterior ⅔ and posterior ⅓ of the kidney.
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Figure 67. Renal artery and its branches
Arteries of the Kidney
The arrangement of the arteries of each kidney is such that:

 Each renal artery divides into an anterior and a posterior division, close to the
hilum of the kidney
 The posterior division of renal artery lies behind the renal pelvis; it continues as
the posterior segmental artery, which supplies the posterior segment of the
kidney
 The anterior division of the renal artery lies between the renal vein and renal
pelvis; it gives rise to segmental arteries that supply the remaining four segments
of the kidney (Fig. 67)
 Each segmental artery divides into 2–3 interlobar arteries that pierce the renal
substance and run towards the cortex, between the renal pyramids (Fig. 67)
 Interlobar arteries give rise to arcuate arteries that run parallel to the bases of
renal pyramids
 Arcuate arteries give rise to interlobular arteries that run into the renal cortex,
towards the periphery of the kidney (Fig. 67)
 From the interlobular arteries, tiny afferent arterioles arise to supply the renal
glomeruli
 Efferent arterioles emerge from the glomeruli to join the capillaries around the
convoluted tubules (peritubular capillary plexus)
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 No anastomoses exist between the arteries of the kidney; they are thus described
as “end arteries”
Venous Drainage of the Kidney
Veins of each kidney are arranged such that:

 Venous tributaries commence as stellate veins that drain the renal cortex; these
veins lie just beneath the renal capsule
 Stellate veins unite to form interlobular veins that accompany the interlobular
arteries. Interlobular veins receive tributaries from the peritubular capillary
plexus and vasa recta
 Interlobular veins drain into the arcuate veins, which accompany the arcuate
arteries
 Arcuate veins converge to form interlobar veins. The latter enter the renal sinus
to form the renal vein
 Renal vein ends in the inferior vena cava
Lymphatic Drainage and Innervation of the Kidneys
Regarding the lymphatic drainage and innervation of the kidney, note the following:
 Lymph vessels from the kidney accompany the renal veins to the lumbar lymph
nodes (para-aortic nodes)
 Nerve fibres arise from the coeliac plexus and reach the kidney via the renal
plexus (a plexus of nerves around the renal artery). Parasympathetic fibres in
this plexus are from the vagus nerve; while sympathetic fibres are mainly from
the T12 and L1 spinal nerves.
 Afferent (sensory) fibres from the kidney join the sympathetic route (and travel
in a retrograde fashion) to the spinal cord.
Applied Anatomy of the Kidneys

 Renal calculi (kidney stones) may develop in the renal calyces, renal pelvis or
ureter. Severe ureteric colic accompanies the presence of calculi in the ureter
 Pain of ureteric colic may be referred to the scrotum, labium majus, inguinal
region, thigh or loin, depending on the location of the calculus
 The kidneys may be congenitally pelvic in position; in this instance, the common
iliac arteries supply them. The kidney may also be congenitally absent on one or
both sides – renal agenesis
 Lobulation of the kidney occurs in the foetus; however, in adults, the surface of
the kidney is not lobulated
 Nephrectomy: removal of the kidney, either as a result of damage from diseases
such as cancer (renal cell carcinoma), diabetes; or for donation to a recipient
 Renal transplantation: Indicated for end stage renal disease resulting from e.g.,
diabetic nephropathy, renal cell carcinoma, etc.
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Gross Anatomy of the Suprarenal Glands (Adrenal Glands)
Regarding the suprarenal gland, note the following:
 suprarenal glands are two yellowish pyramidal bodies that cap the superior poles
of the kidneys
 Each suprarenal gland is embedded in adipose tissue; and is retroperitoneal and
flattened anteroposteriorly. It shares the renal fascia with the kidney (from which
it is separated by fibrous tissue)
 In health, each adult suprarenal gland measures about 50 mm vertically, 30 mm
transversely, and 10 mm anteroposteriorly. It weighs about 5 g (the left gland is a
bit larger than the right)
 At birth, each suprarenal gland is ⅓ of the size of the kidney, while in adulthood,
it is ⅟30 of kidney size
 Each suprarenal gland consists of a cortex peripherally, and a medulla deeply.
The latter is ⅟10 of the gland. Developmentally, structurally, and functionally, the
cortex and medulla of the suprarenal gland are different
 Suprarenal cortex produces steroids (corticosteroids), while the suprarenal
medulla produce catecholamines (especially epinephrine)
 The suprarenal gland is well vascularised, being supplied by numerous branches
of suprarenal arteries
Relations of the Suprarenal Glands
Relations of the left suprarenal gland are as follows:

 Inferiorly: left kidney
 Anteriorly: omental bursa, stomach, pancreas, and splenic artery
 Posteriorly: left crus of diaphragm
 Medially: left coeliac ganglion, left gastric artery, left inferior phrenic artery
Relations of the right suprarenal gland include the following:

 Inferiorly: upper pole of the right kidney
 Anteriorly: Inferior vena cava (IVC), right lobe of the liver
 Posteriorly: diaphragm, right kidney
 Medially: right coeliac ganglion, right inferior phrenic artery
Blood Supply of the Suprarenal Gland
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Each suprarenal gland receives arterial blood from the following arteries:
 Six to eight superior suprarenal arteries. These arise from the inferior phrenic
artery
 Middle suprarenal arteries. These arise from the abdominal aorta
 Inferior suprarenal arteries. These arise from the renal artery
Regarding the venous and lymphatic drainage of the suprarenal gland, note the
following:
 Each suprarenal gland is drained by a large suprarenal vein
 The right suprarenal vein drains into the IVC; while the left suprarenal vein
drains into the left renal vein
 Lymph vessels from the suprarenal gland drain into the lumbar lymph nodes
Innervation of the Suprarenal Gland
Note the following:

 Autonomic fibres to the suprarenal gland arise from the coeliac ganglion and
thoracic splanchnic nerves. These fibres are myelinated presynaptic
sympathetic nerves, whose cell bodies are located largely in the T10 and T11
spinal segments. They innervate the chromaffin cells of the adrenal medulla
 Secretory activity of the adrenal cortex is controlled by hormones (corticotropin
from the adenohypophysis, and corticotropin releasing hormone from the
hypothalamus)
Ureter (Fig. 66)
The ureter
 Is a long muscular tube. It is about 25 cm long and nearly 1 cm in diameter near
the urinary bladder
 Extends from the renal pelvis above to the urinary bladder below. Thus, it lies
partly in the abdominal cavity (upper ½) and partly in the pelvic cavity (lower ½)
 Is completely retroperitoneal, as it descends on the posterior wall of the
abdominopelvic cavity.
Constrictions of the Ureter
Constriction of the ureter occurs:

 At its junction with the renal pelvis (i.e. at its commencement)
 At the pelvic inlet, where its crosses the common iliac artery (medial to psoas
major); and
 In its intravesical course (within the urinary bladder)
Relations of the Abdominal Part of the Ureter (Fig. 66)
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Relations of the abdominal part of the ureter include:

 Posteriorly (on each side): genitofemoral nerve, psoas major, transverse processes
of lumbar vertebrae, and bifurcation of the common iliac artery
 Anteriorly (on each side): gonadal vessels and parietal peritoneum
 Anteriorly (on the right): 2nd part of duodenum, right colic and ileocolic arteries
and mesentery of the small intestine
 Anteriorly (on the left): sigmoid mesocolon, sigmoid colon and left colic artery
 Medially (on the right): inferior vena cava
Relations of the Pelvic Part of the Ureter
Regarding the pelvic part of the ureter, note these points:

 Behind the pelvic part of the ureter are the internal iliac vessels
 In females, the ureter forms the posterior boundary of the ovarian fossa; hence it
is related anteriorly to the ovary
 Lateral to the pelvic ureter are obturator nerve and vessels, obliterated umbilical
artery, and the inferior vesical and middle rectal arteries (all branches of internal
iliac artery).
 The ureter is crossed above (from lateral medially) by the vas deferens (in
males); and by the uterine artery in females
 Close to urinary bladder, the ureter crosses the upper pole of seminal vesicle (in
males). In females, it runs very close to lateral vaginal fornix, below the broad
ligament of uterus
 The ureter enters the superolateral angle of the urinary bladder and then
continues obliquely (inferomedially) through the vesical wall, to terminate in the
ureteric orifice (at the superolateral angle of the trigone)
Blood Supply and Lymphatic Drainage of the Ureter
The ureter
 Is supplied by branches of the renal artery in its upper part. These branches
reach the ureter from its medial aspect
 Is supplied by branches of the gonadal artery and abdominal aorta in its
intermediate part
 Is supplied by branches of uterine artery (female) and inferior vesical artery
(male) in its lower part; these reach it from its lateral aspect
 Drains into the lumbar and common iliac lymph nodes, in its abdominal part; and
into the internal iliac and common iliac nodes in its pelvic part
Innervation and Applied Anatomy of the Ureter
The ureter
 Receives nerve fibres from the inferior hypogastric, renal, gonadal and aortic
plexuses. These contain both sympathetic and parasympathetic fibres
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 Derives its sympathetic fibres from T11–L2 spinal segments; and

parasympathetic fibres from pelvic splanchnic nerves (nervi erygentes).
Afferent (sensory) fibres from the ureter end in the lower thoracic and upper
lumbar spinal segments (T11–L2)
 Contracts in a peristaltic fashion as it conveys urine from the kidney to the
urinary bladder
 Evokes pain following excessive distension or spasmic contraction. Such pain
could be referred to body regions innervated by the T11–L2 spinal nerves e.g.
lower abdominal wall, inguinal region, scrotum, labium majus, etc.

 Ureteritis is inflammation of the ureter.
 Ureterectomy is the surgical removal of the ureter
 Ureteric calculi refer to the lodgment of stone in the ureter. This elicits ureteric
colic (pain)
Urinary Bladder (Fig. 57, 63, 68)
The urinary bladder

 Serves as a temporary reservoir for urine. It lies completely in the lesser pelvis
when empty (in adults)
 Is located in the abdominal cavity in children. It enters the greater pelvis by the
6th year and the lesser pelvis after puberty
 Has a variable position, size and shape, depending on the level of its distension,
and the contents of adjacent viscera. It assumes a pyramid form in its empty state.
 Has a base or fundus (directed posteriorly), a body (with superior surface and
two inferolateral surfaces), and an apex. The apex is connected to the umbilicus
by median umbilical ligament (a remnant of the urachus)
 Also has a neck, which is the most inferior and most fixed part of the bladder; the
neck is adjacent to the prostate gland in males
 Possesses two lateral borders, each of which separates the superior and
inferolateral surface from each other. It also has a posterior border that
delineates the superior surface from the base of the bladder.
Relations of the Urinary Bladder (Fig. 57, 63)
The urinary bladder is related to the following:

 Anteriorly: Symphysis pubis and retropubic space (containing areolar tissues)
 Above (in males): Rectovesical pouch and its contents of sigmoid colon and
ileum
 Above (in females): Body of the uterus (when this organ is anteverted) and
vesico-uterine pouch
 Laterally (in both sexes): Levator ani and obturator internus muscles
 Posteriorly (in males): Ampulla of ductus deferens, seminal vesicles,
rectovesical fascia and rectum
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 Posteriorly (in females): Vagina and rectum
Note: the bladder is covered by the peritoneum only on its superior aspect
Change in Position of the Urinary Bladder Relative to Age and Volume
The urinary bladder

 May reach the umbilicus when fully distended, in which case the organ becomes
almost rounded. A fully distended bladder is in direct contact with the anterior
abdominal wall (without the peritoneum intervening)
 Has a capacity of 120–320 ml in adult males. It may however contain as much as
500 ml of urine (and even more) in full distension. The bladder elicits the urge to
micturate when it fills up to about 200 ml
 Is largely abdominal in children. However, it descends into the greater pelvis by
the 6th year of postnatal life; and finally enters the lesser (true) pelvis after
puberty.
Interior of the Urinary Bladder (Fig. 68)
Regarding the interior of the urinary bladder, note the following:

 The inner surface of the bladder is lined by a mucosa. This possesses several
folds when the organ is empty
 The trigone is a smooth triangular area on the inner aspect of the fundus (Fig.
68). Its base is directed upwards, while the apex points downwards.
 The ureters open into the bladder at the superolateral angles of the trigone (Fig.
68). These opening are linked by a fold of mucosa termed interureteric crest.
The crest forms the base of the trigone.
 At the internal urethral orifice, the bladder is continuous with the urethra. This
orifice lies at the apex of the trigone
 The uvula is an elevation of the trigone. It lies adjacent to the internal urethral
orifice, and is produced by the median lobe of the prostate. The uvula becomes
enlarged in the elderly, especially in those with carcinoma or hyperplasia of the
prostate (in which case the internal urethral orifice may be occluded).
- 320 -
Figure 68. Urinary bladder (cut open)
Ligaments of the Bladder
Regarding the ligaments of the urinary bladder, note these points:

 Two pubovesical ligaments connect the neck of the bladder to the pubic bones
 The median umbilical ligament is a fibrous cord that connects the apex of the
bladder to the umbilicus. This ligament is the remnant of the urachus
 The bladder also has weak false ligaments, which are peritoneal folds. They
include the median and medial umbilical folds (anteriorly), and the lateral and
posterior false ligaments. The median and medial folds overlie the median
umbilical ligament and the obliterated umbilical artery, respectively.
Blood Supply and Lymphatic Drainage of the Urinary Bladder
The bladder
 Is supplied by branches of superior vesical arteries (from obliterated umbilical
artery), inferior vesical arteries (in males) and vaginal arteries (in females)
 Has a vesical venous plexus around its base (in males) or neck (in females) and
on its inferolateral surfaces. This plexus drains mainly via the inferior vesical
veins (in males) or the vaginal veins (in females), into the internal iliac veins, and
may also drain via the sacral veins into the internal vertebral venous plexus.
 Drains into external iliac lymph nodes (from its superior surface), internal iliac
nodes (from its fundus) and the sacral nodes (from its neck).
Innervation of the Urinary Bladder
Note that
 The bladder is innervated by the vesical plexus of nerves. This has sympathetic
and parasympathetic fibres
 Parasympathetic fibres reach the bladder from the pelvic splanchnic nerves
(S2–S4)
 Sympathetic fibres to the bladder arise from the T11–L2 spinal segments. These
transverse the inferior hypogastric plexus to reach the vesical plexus
 Sensory fibres from the lower part of the bladder reach the S2–S4 spinal
segments (via the pelvic splanchnic nerves); while those from the upper part
reach the T12–L2 spinal segments (via the sympathetic route).
Applied Anatomy of the Urinary Bladder
Note that
 Suprapubic cystotomy may be performed on a fully distended bladder; the
organ is approached via the anterior abdominal wall without having to enter the
peritoneal cavity
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 Weakening of bladder ligaments and supporting structures may result in

cystocoele – prolapse of the bladder into the vagina
 Pain is elicited from the bladder when it is over-distended; this may occur when
the organ contains more than 500 ml of urine
 The bladder can be examined by inserting a cystoscope through the urethra
(during cystoscopy)
 The urinary bladder is easily infected (cytistis) in females because of the
relatively short urethra. Such infections may spread to the ureter and kidney
(pyelonephritis)
Note the following:

 Abdominal injury may involve the bladder, especially when it is distended, and
thus, abdominal in position. Extravasated urine from a ruptured bladder may
reach the peritoneal cavity
 When obstruction to urinary outflow is prolonged, the bladder becomes larger
and trabeculated – trabeculated bladder
 Automatic (unchecked) voiding of urine occurs when the spinal cord is injured
above the sacral levels. This is due to the disruption of the autonomic and sensory
innervation of the bladder.
 Tabes dorsalis, which causes damage to the fasciculus gracilis of the spinal cord,
produces loss of desire to micturate.
Male Urethra (Fig. 56, 57)
The male urethra

 Is a conduit that extends from the internal urethral orifice (at the apex of the
trigone) to the external urethral orifice (at the tip of glans penis)
 Is 18–20 cm long. It consists of four parts: preprostatic, prostatic, membranous
and spongy parts
 Conveys both urine and semen to the exterior, though not simultaneously.
The preprostatic part of male urethra

 Extends from the neck of the urinary bladder to the base of the prostate gland. It
is 1–1.5 cm long.
 Is surrounded by the internal urethral sphincter. This consists of circularly
disposed smooth muscle fibres
 Receives numerous sympathetic fibres. Thus, it contracts strongly during
ejaculation to prevent semen from entering the bladder
 Has a star shaped lumen in transverse section
The prostatic part of the male urethra

 Lies within the prostate gland. It extends from the base to the apex of the gland,
closer to the anterior aspect of this organ
 Is the widest and the most dilatable part of the urethra. It measures 3–4 cm in
length
- 322 -
 Has a median longitudinal ridge, the urethral crest, on its posterior wall. This
projects into the lumen of the urethra. Located midway along the urethral crest is
a rounded eminence, the seminal colliculus (or verumontanum)
 Has two longitudinal grooves, the prostatic sinuses, one on each side of the
urethral crest (and parallel to which it lies).
 Is crescentic in transverse section.

 The summit of the seminal colliculus bears the opening of the prostatic utricle.
The prostatic utricle is a blind sac directed posterosuperiorly (for about 6 mm)
into the prostate gland (behind the median lobe of this gland).
 The prostatic utricle is the homologue of the vagina and uterus in females; and it
is thus derived from the paramesonephric ducts.
 The ejaculatory ducts open into the orifice of prostatic utricle or onto the
summit of seminal colliculus
 The (12–20) ducts of prostate gland open into the floor of the prostatic sinus
The membranous (intermediate) part of male urethra

 Is the shortest (1-2 cm) and the least dilatable part of the urethra. It connects the
prostatic urethra proximally to the spongy urethra distally
 Lies largely in the deep perineal pouch. Here, it is surrounded by the external
urethral sphincter (of skeletal muscle)
 Has a very narrow lumen (next to the external urethral orifice in this respect)
 Is about 2.5 cm posteroinferior to the symphysis pubis; and it is related, on its
inferolateral aspect, to the bulbo-urethral gland (in the deep perineal pouch)
 Has a small portion that is not surrounded by the external urethral sphincter, in
the superficial perineal pouch, just before it pierces the bulb of the penis to
become the spongy urethra. Thus, the membranous urethra may be ruptured in the
superficial perineal pouch (e.g., when inserting a catheter through the urethra).
This would result in escape of urine into the loose connective tissue of the
scrotum and the anterior abdominal wall
The spongy part of the urethra

 Is the longest part of the urethra. It is about 15 cm in length; and has a diameter
of about 6 mm when not distended.
 Traverses the bulb of the penis and the corpus spongiosum. In the latter, it is
close to the ventral surface of the penis
 Possesses two fossae: the intrabulbar fossa (proximally, in the bulb of the
penis), and the navicular fossa (distally, in the glans penis).
- 323 -
 Receives the openings of the ducts of bulbo-urethral glands. These ducts enter
the superficial perineal pouch, pierce the bulb of the penis, and end in the spongy
urethra, about 2.5 cm from the perineal membrane.
 Ends as a vertical slit – external urethral orifice – at the tip of the glans penis.
This orifice is the narrowest and the least dilatable part of the urethra.
Blood Supply, Lymphatics and Innervation
Note the following:

 Arterial blood reaches the male urethra from the inferior vesical and middle
rectal arteries (both branches of internal iliac artery)
 Venous blood from the urethra drains into the internal iliac vein, via the inferior
vesical and middle rectal veins
 Lymph vessels from the urethra end in internal iliac nodes
 Nerve fibres reach the urethra from the prostatic plexus and pudendal nerves.
Sensory fibres from the urethra end in the S2–S4 spinal segments (via the pelvic
splanchnic nerves)
Female Urethra
The female urethra

 Begins at the internal urethral orifice, opposite the middle of symphysis pubis.
Then, it descends anteriorly, in the anterior wall of the vagina
 Pierces the urogenital diaphragm, as it approaches the vestibule of the vagina. In
this diaphragm, it is surrounded by the external urethral sphincter (of skeletal
muscle fibres)
 Ends at the external urethral orifice, in the vestibule of the vagina, about 2.5 cm
behind the glans clitoridis (and just anterior to the vaginal orifice).
 Has several longitudinal folds of mucosa. The posterior median fold is termed the
urethral crest
 Is associated, along its length, with mucous para-urethral glands. These drain
via the para-urethral ducts that open into the vestibule of the vagina, lateral to
the urethral orifice.
 Measures 4 cm in length and 6 mm in diameter
Blood Supply, Lymphatics and Innervation of Female Urethra
Note the following:

 The vaginal artery, which supplies the female urethra, is a branch of the internal
iliac artery. It is the equivalence of the male inferior vesical artery
 Venous blood from the female urethra drains into the internal iliac vein, via the
vaginal vein
 Lymph vessels from the female urethra end in the internal iliac and sacral nodes
 Nerve fibres reach the urethra via the pudendal nerves. Sensory fibres end at the
S2–S4 spinal segments; they accompany the pelvic splanchnic nerves.
- 324 -
Applied Anatomy
Note that
 The characteristic short length of the female urethra makes the female urinary
tract more susceptible to infections
 Inflammation of the urethra is referred to as urethritis. Such an infection could
spread to the urinary bladder (cystitis), ureter (ureteritis) and kidney (nephritis)
 The female urethra may prolapse into the vagina, and the condition is referred to
as urethrocoele
CHAPTER 18: HISTOLOGY OF THE URINARY ORGANS

Structure of the Kidney (Fig. 69, 70a,b)
Structurally, the kidney is organized such that

 The cortex adjoins the renal capsule (Fig. 69); it consists of renal corpuscles and
the associated convoluted tubules
 The medulla lies deep to the cortex; it contains several renal pyramids, whose
bases adjoin the cortex. Cortical tissues extend inwards, between the renal
pyramids, as renal columns
 Each renal pyramid with adjacent portions of renal columns form a lobe of the
kidney (Fig. 69)
Figure 69. Interior of the kidney
- 325 -
In the kidney,
 Uriniferous tubules extend throughout the substance of this organ. They consist
of nephrons and collecting tubules
 The nephrons filtrate and modify the plasma. Each consists of a renal corpuscle
and renal tubules (Fig. 70a,b)
 Each renal corpuscle consists of a tuft of blood vessels called glomerulus. The
glomerulus is surrounded by the glomerular (Bowman’s) capsule (Fig. 70a).
 The renal tubule lies partly in the cortex and partly in the medulla; it consists of
the convoluted and straight parts.
 Collecting tubules convey urine from the renal tubules to the minor calyces.
They (the collecting tubules) open onto the apices of renal papillae, via the
papillary ducts of Bellini. Renal papillae are conical bodies that project into the
renal sinus
 Connective tissue occupies the interstices between the uriniferous tubules, thus
binding them together.
Renal Corpuscle (Fig. 70a)
Renal corpuscles
 Are found in the renal cortex, except the outermost part of the latter (cortex
cortices), which is devoid of corpuscles. They are also found variably in the renal
columns (the cortical tissue between the renal pyramids)
 Consist of the glomerulus and glomerular (Bowman’s) capsule. Each has a
vascular pole and a urinary pole
 Are spherical in outline; and each is about 0.2 mm across
 May be as numerous as 2 million in each kidney. However, they decrease in
number as age advances.
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Figure 70a. Renal corpuscle and juxtaglomerular apparatus
Glomerulus
The glomerulus
 Is a complex tuft of capillary blood vessels. The glomerulus is surrounded by a
Bowman’s capsule (Fig. 70a); and between the vascular loops are connective
tissue elements
 Receives arterial blood from an afferent arteriole (a branch of interlobular
artery). This enters the glomerulus via the vascular pole of the glomerular capsule
 Drains arterial blood into an efferent arteriole. This exits the glomerulus via the
vascular pole of glomerular capsule, and then enters the peritubular capillary
plexus
 Is lined by finely fenestrated endothelium. Beneath this endothelium is a
basement membrane (about 0.33 m in thickness)
 Continues to mature till as late as the 6th year of postnatal life, or even more
Glomerular Capsule (Bowman’s Capsule) (Fig. 70a)
The glomerular capsule

 Is the cup-shaped, double walled part of the renal corpuscle that accommodates
the glomerulus; its (parietal) wall is continuous with the renal tubule
 Has an inner visceral wall made up of a specialized epithelium. This epithelium
consists of certain stellate cells called podocytes
- 327 -
 Has an outer parietal wall made of simple squamous epithelium. Between the
parietal and visceral walls of the glomerular capsule is the urinary space. This
space is continuous with the lumen of the proximal convoluted tubule.
Podocytes (Fig. 70a)
Podocytes
 Are specialized stellate epithelial cells that form the visceral (glomerular) layer
of glomerular capsule
 Possess numerous, extensive, primary processes that interdigitate with each
other, and by so doing, closely surround the glomerulus
 Also have numerous minute foot processes (pedicles) that branch off the primary
processes. These also interdigitate with each other as they surround the
glomerulus.
 Have a basement membrane that is continuous directly with that of the
glomerular endothelium, thereby forming a single membrane that is essential for
filtration
 Constitute, by means of their extensive interdigitations, part of the filtration
barrier
Glomerular Filtration Barrier
The glomerular filtration barrier is formed by:

 Finely fenestrated endothelium of the glomerulus;
 Basement membrane of glomerular endothelium;
 Basement membrane of podocytes. This merges with that of glomerular
endothelium to form a single membrane;
 Glomerular slit diaphragm. This consists of fine filaments that occupy the spaces
(slits) between the pedicles of podocytes.
Mesangial Cells
Mesangial cells
 Are stellate in outline. They surround the glomerular capillary tuft
 Have contractile and phagocytic functions. Thus, they clear the glomerular filter
of particulates that may clog it.
Renal Tubules (Fig. 70b)
Each renal tubule consists of the following:

 Proximal tubule, located in the cortex and made up of a convoluted part
proximally, and a straight part distally. The latter approaches the renal medulla.
 Descending limb of the loop of Henle. This lies in the renal medulla
 Ascending limb of the loop of Henle. This passes towards the renal cortex, from
the medulla
- 328 -
 Distal tubule, located in the cortex and consisting initially of a straight portion
that continues as the convoluted portion. The latter drains into a collecting tubule.
Figure 70b. Uriniferous tubule and associated blood vessels
The proximal tubule

 Is the first part of the renal tubule; it occupies the cortex of the kidney, and it is
continuous directly with the parietal layer of glomerular capsule
 Is initially convoluted (in the cortex), but becomes straightened as it approaches
the renal medulla. Here, it is continuous with the descending limb of Henle’s loop
 Is lined by a simple cuboidal epithelium, whose cells are richly endowed with
tall microvilli (brush border)
 Measures about 14 mm in length and 60 m in diameter
Cuboidal cells of proximal tubule

 Possess centrally placed nuclei, and strongly eosinophilic cytoplasm
 Also possess infoldings of their basal membranes; these contain mitochondria
oriented perpendicular to the basal membrane. Mitochondria generate energy for
active transport across tubular cells
 Possess Na/K ATPase in their luminal and basal membranes (for active
transport). Cells of proximal tubule transport ions and organic molecules from
tubular fluid to peritubular tissue. They also absorb water from tubular lumen.
The loop of Henle

 Lies in the renal medulla. It extends deeply into the medulla, from the straight
portion of the proximal tubule
- 329 -
 Has a thin segment that describes a U-shaped pattern. From this segment, the
loop ascends again, towards the cortex, to continue with the straight part of the
distal tubule
The thin segment of the loop of Henle

 Lies deep in the medulla, where it forms a U-shaped limb that links the straight
portions of the proximal and distal tubules together. It is about 30 m in diameter
 Is lined by a single layer of squamous cells, whose cytoplasm possesses scanty
organelles
 Transports ions and water from its lumen into the peritubular tissue. This occurs
by passive process
The distal tubule

 Is located mainly in the renal cortex
 Has a straight part (about 9 mm long) that is continuous with the ascending limb
of the loop of Henle, and a convoluted part that joins the collecting tubule. The
convoluted part is about 5 mm long and 50 m across.
 Is lined by a single layer of cuboidal cells
 Lies in part, very close to the vascular pole of glomerular capsule. Here, it is
thickened to form the macula densa
The cuboidal cells of the distal tubule

 Possess fewer microvilli compared to those of proximal tubule
 Also possess numerous infoldings of their basal membranes, which lodge
mitochondria
 Possess Na/K ATPase for active transport of ions across their membranes.
 Are under the influence of the rennin-angiotensin-aldosterone system. The
latter enhances the absorption of sodium from tubular lumen, while facilitating
excretion of potassium.
Juxtaglomerular Apparatus (Fig. 70a)
The juxtaglomerular apparatus

 Is formed by the juxtaglomerular cells (myocytes of afferent arterioles that have
become large, ovoid and epitheliod) and cells of the macula densa (a region at
the junction of the straight and convoluted parts of distal tubule, which contains
clusters of tubular cells)
 Also contains some lacis cells. These which intersperse the juxtaglomerular cells
 Produces the enzymes rennin, in response to decreased blood pressure. Thus, it
forms part of the mechanisms that regulates the blood pressure.
The collecting tubules

 Extends deep into renal medulla, from the cortex. The distal convoluted tubules
drain into the collecting tubules
- 330 -
 Are lined by simple cuboidal epithelium that becomes columnar in the distal
part of the tubules
 End in large ducts located in the medulla – the papillary ducts of Bellini (about
150 m in diameter). Papillary ducts open onto the summits of renal papillae (in
the area cribrosa)
 Become more permeable to water in response to vasopressin (anti-diuretic
hormone). Aldosterone also acts on cells of the collecting tubules to increase
sodium absorption (from tubular fluid) and potassium excretion.
 Have an average length of 21 mm
Structure of the Suprarenal Gland
Regarding the structure of the suprarenal gland, note the following points:
 The external surface of each suprarenal gland is covered by a capsule of dense
connective tissue, which send trabeculae into the gland
 Each suprarenal gland consists of an outer cortex and an inner medulla. In fresh
specimens, the cortex appears yellowish, while the medulla is dark red
 Being endocrine organs, the suprarenal glands are highly vascularised (see above)
The Suprarenal Cortex (Fig. 71)
Note these points:

 The suprarenal cortex appears yellowish in the fresh state. It constitutes about
90% of the suprarenal gland
 The suprarenal cortex is rich in steroid-producing cells. These cells produce
corticoids (corticosteroids)
 Cells of the suprarenal cortex are endowed with smooth endoplasmic reticulum,
cholesterol (precursor of steroid hormones), and fatty acids, etc
 Secretory cells of suprarenal cortex do not store steroids; rather, they produce and
release steroids as the need arises
 Structurally, the suprarenal cortex is divisible into 3 zones; these include, from
external internally, zona glomerulosa, zona fasciculata, and zona reticularis
 Developmentally, the suprarenal cortex is derived from the coelomic epithelium
Zona Glomerulosa of Adrenal Cortex (Fig. 71)
The zona glomerulosa of the suprarenal cortex

 Is the most external zone of the cortex. It is about 15% of the entire cortex
 Contains small polyhedral cells that are arranged into rounded and arched
cords. Interspersing the cords are blood capillaries. These cells are endowed with
smooth endoplasmic reticulum
 Mainly produce mineralocorticoids, especially aldosterone
- 331 -
Zona Fasciculata of the Suprarenal Cortex (Fig. 71)

 The zona fasciculata lies just deep to the zona glomerulosa. It constitutes about
75% of the cortex
 The zona fasciculata contains columns (cords) of large polyhedral secretory cells;
these columns of cells are arranged parallel to one another and perpendicular to
the surface of the gland. Between adjoining columns are blood capillaries
 The secretory cells of the zona fasciculata are rich in smooth endoplasmic
reticulum, Golgi apparatus, and mitochondria. These cells are also called
spongyocytes (as they appear vacuolated in histologic sections)
 Zona fasciculata mainly produces glucocorticoids, especially cortisol
(hydrocortisone)
Figure 71. Zones of the suprarenal cortex
Zona Reticularis of Suprarenal Cortex (Fig. 71)
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The zona reticularis of suprarenal cortex

 Is the innermost layer of the suprarenal cortex. It constitutes about 7% of the
entire cortex
 Contains rounded cells arranged into irregular, branching and anastomosing
cords. Some of the cells contains lipofuscin, while others have pyknotic nuclei
(suggesting cell death)
 Mainly produces androgens (gonadocorticoids), especially
dehydroepiandrosterone (DHEA). It also produces some glucocorticoids
Hormones of the Adrenal Cortex (Fig. 71)
Hormones of the suprarenal cortex (corticosteroids) are in 3 classes:

 Glucocorticoids; these include cortisol (hydrocortisone) and corticosterone
 Mineralocorticoids, mainly aldosterone
 Gonadocorticoids (adrenal androgens), especially dehydroepiandrosterone
Cortisol

 Cortisol is the most abundant endogenous glucocorticoid. It is released in
stressful conditions such as trauma, surgery, disease, fasting and starvation
 Cortisol is involved in carbohydrate, protein and fat metabolism. It promotes
gluconeogenesis and glycogenesis; mobilises amino acids from muscles, and
fatty acids from adipose tissue. Moreover, cortisol decreases glucose uptake by
peripheral tissues
 Cortisol also has anti-inflammatory effects; it stabilises lysosome membrane
and reduces leucocyte migration to injured tissues. Moreover, cortisol
demonstrates some mineralocorticoid effect
Note: Secretion of cortisol is controlled by the adenohypophysis and hypothalamus,

which release, respectively, corticotropin (adrenocorticotropic hormone, ACTH) and
corticotropin-releasing hormone (CRH). Corticotropin promotes the release of
cortisol by the adrenal cortex. Corticotropin also facilitates the release of
mineralocorticoids from the cortex.
Mineralocorticoids (Aldosterone)
Aldosterone
 Is produced mainly by cells of the zona glomerulosa
 Promotes Na+ uptake from the kidneys (distal and collecting tubules), stomach,
colon, saliva and sweat
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 Also promotes water uptake from the kidneys and facilitates urinary excretion of
K+ and H+
Gonadocorticoids (Adrenal Androgens)
Adrenal androgens are produced by cells of the zona reticularis. The main androgen
produced is dehydroepiandrosterone (DHEA). DHEA can be converted to, and
produces similar effects as, testosterone.
Suprarenal Medulla
Regarding the suprarenal medulla,

 It constitutes about 10% of the suprarenal gland; and it occupies the core of this
gland
 It contains irregularly-arranged cords of chromaffin cells (phaeochromocytes).
These cells are supported by reticular fibres. Between the cellular cords of
suprarenal medulla are sinusoids (wide capillaries)
 Chromaffin cells are postsynaptic sympathetic cells that lack axons and
dendrites. They are derived from neural crest cells
 Adrenomedullary chromaffin cells are innervated by cholinergic presynaptic
sympathetic fibres (mainly from T10 and T11 spinal segments). These fibres
facilitate the release of catecholamines from chromaffin cells
 Chromaffin cells of the adrenal medulla produce catecholamines, mainly
epinephrine. Some nor-epinephrine is also produced
 Chromaffin cells of adrenal medulla stain positively with chromic salt, and their
cytoplasm contain granules with catecholamines, chromogranins, encephalins,
etc. Chromaffin cells also has basophilic cytoplasm rich in granular endoplasmic
reticulum, Golgi apparatus and mitochondria (suggesting active secretory
activity).
Applied Anatomy of the Suprarenal Gland

 Abnormal activities of the suprarenal gland can manifest as either adrenal
hyperfunction or hypofunction
 Adrenal hyperfunction is exemplified in Cushing’s disease/syndrome and
Conn’s syndrome. Adrenocortical hypofunction manifests as Addison’s disease
 Cushing’s disease is a consequence of chronic elevation of plasma cortisol,
resulting from adenohypophysial tumour, for example. Cushing’s syndrome
arises from tumours of the adrenal cortex (with elevated plasma cortisol)
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 Cushing’s disease is characterised by hyperglycaemia, truncal obesity, moon-

shaped face, buffalo hump, hirsutism and dysmenorrhoea (in females), etc
 Conn’s syndrome (primary hyperaldosteronism) results from adrenal tumours –
aldosteronomas. It is characterised by hypertension, hypokalaemia (due to K
diuresis), and muscle weakness
 Excessive adrenal androgen production early in foetal life (3rd and 4th months)
will result in female pseudohermaphroditism. The girl child is born with
ambiguous (masculinised) external genitalia, characterised by enlarged clitoris
and fused labia
 Excess of adrenal androgens in adult females will result in hirsutism. In boy,
excess of adrenal androgens will result in precocious puberty, while in girls,
virilisation of external genitalia will occur
 Addison’s disease is a result of adrenocortical hypofunction (following atrophy
or tuberculosis of adrenal cortex). It is characterised by muscle weakness, low
blood pressure, skin pigmentation, etc
Phaeochromocytomas are tumours of adrenal medulla. These tumours are

characterised by hypertension, palpitation, headache, excessive sweating, and pallor
of the skin (as a result of excessive epinephrine and nor-epinephrine
Structure of the Ureter
From internal externally, the ureter consist of:

 Mucosa. This is lined by the urothelium (or transitional epithelium; (Fig. 8)
 Muscular coat. This is usually not distinctly laminated; and abundant connective
tissue mingles with the muscle fibres of this coat
 Fibrous adventitia. This is rich in collagen and elastin fibres, and fibroblasts
The mucosa of the ureter

 Has a surface lining of transitional epithelium (or urothelium). External to the
epithelium is a layer of connective tissue – the lamina propria. This is rich in
collagen and elastin fibres, blood vessels, unmyelinated nerve fibres and
fibroblasts.
 Contains longitudinal folds (up to 700 m thick) that make the lumen appear
stellate on transverse section. Ureteric mucosa has no true glands
Muscular Coat of the Ureter

 Large quantity of connective tissue intersperse bundles of muscle fibres. The
latter intermingle with one another, and are thus not distinctly laminated.
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 The upper and middle parts of the ureter have, roughly, three muscular layers.
These include inner and outer longitudinal layers, and a middle circular layer.
The circular layer of the middle part of the ureter is thicker than that of the upper
part
 The lower part of the ureter consists mainly of longitudinally disposed bundles
of muscle fibres.
 Most ureteric muscle fibres are about 350 m in length and 6 m across
 The ureter undergoes repeated rhythmical contraction (peristalsis), from the
renal pelvis towards the bladder
Renal Calyces
Each calyx of the kidney

 Has a mucosa lined by the urothelium. The latter is about 3 cells thick
 Has a coat of smooth muscle fibres (external to the mucosa). These are arranged
into outer circular and inner longitudinal layers
 Also has an external adventitia of connective tissue
 Contracts rhythmically to drain urine into the renal pelvis and ureter
Structure of the Urinary Bladder
The urinary bladder

 Has a mucosa lined by the urothelium. It possesses no distinct submucosa (as in
the ureter and calyces).
 Has an intermediate muscular coat, whose fibres are arranged into 3 layers
 Has an external covering of connective tissue adventitia, except on its superior
surface. The latter is covered by peritoneum (serosa)
The mucosa of urinary bladder

 Is lined by the urothelium, which may be up to six cells thick; it appears pinkish
 Has a thick lamina propria (500 m) that is rich in collagen and elastin fibres, as
well as blood vessels. This connective tissue layer lies external to the urothelium
 May possess some mucous glands, though no true glands normally exist
 Forms numerous thick folds when the bladder is empty. However, the mucosa is
smooth over the trigone, where the lamina propria is more densely packed
Muscular Coat of Urinary Bladder (Detrusor) (Fig. 68)
The muscular coat of the urinary bladder

 Consists of bundles of smooth muscle fibres that are largely mingled with one
another. Intermixed with the smooth muscle fibres is abundant connective tissue
 May be defined as having 3 layers: outer and inner longitudinal layers and a
middle circular layer of smooth muscle fibres
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 Is essentially arranged into two layers over the trigone: an inner layer, which is
continuous with the remaining muscular coat of the bladder, and an outer layer
made of smaller smooth muscle fibres; the outer layer is confined to the trigone.
Urethra
Mucosa of Male Urethra
Note the following:

 The prostatic urethra is lined by a transitional epithelium (urothelium); while
the membranous and spongy parts of the urethra are lined by stratified columnar
epithelium. Mucous cells are common among the columnar epithelial cells
 Patches of stratified squamous epithelium also occur in the spongy urethra
 The navicular fossa and the external urethral orifice are lined by keratinized
stratified squamous epithelium.
 The lamina propria of urethral mucosa consists of loose connective tissue, with
abundant elastic fibres. This layer lies external to the epithelium
 Several recesses, termed lacunae, occur in the mucosa of the spongy part of the
urethra. The open ends of these lacunae are directed forwards
 Branched tubular glands (glands of Littre) open into the depth of urethral
lacunae
The mucosa of the female urethra

 Possesses numerous longitudinal folds. It is lined proximally by the urothelium,
and distally by stratified squamous epithelium. At the external urethral orifice,
the stratified squamous epithelium is keratinized.
 Has a lamina propria of loose connective tissue, rich in elastic fibres, numerous
thin-walled veins and nerve fibres. The lamina propria lies external to the
epithelium
 Possesses numerous outpocketings of its wall. These outpocketings are lined by
mucous-secreting cells, and thus resemble Littre’s glands of the male urethra
Muscular coat of the female urethra

 Adjoins the mucosa directly, without a submucosa
 Consists of both skeletal and smooth muscle fibres. The smooth muscle fibres
are deep to the skeletal muscles fibres and are arranged into inner longitudinal
and outer circular layers
 Is augmented by the sphincter urethrae (external urethral sphincter), the skeletal
muscle fibres of which are circularly disposed. These fibres surround the smooth
muscle layer of the urethra, which lies deep to it. The sphincter urethrae is
innervated by the pudendal nerve, and is under voluntary control.
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CHAPTER 19: THE UPPER LIMB

Introduction
The upper limb is characterized by high degrees of mobility, in contrast to the lower
limb, which is less mobile. However, the stability of the upper limb is considerably
reduced at the expense of this exceptional mobility.
Parts (Regions) of the Upper Limb
The upper limb may be described as consisting of the following major parts:
 Scapular and pectoral regions;
 Axilla;
 Arm (brachium);
 Elbow;
 Forearm (or antebrachium);
 Wrist; and
 Hand
Scapular and Pectoral Regions of the Upper Limb

 The scapular region overlies the thorax posteriorly;
 The pectoral region overlies the thorax anteriorly,
 The pectoral girdle is the incomplete bony ring of the scapular/pectoral regions
that articulates with the bones of the arms (humerus).
The Pectoral Girdle
The following are the bones of the pectoral girdle:

 Paired scapulae, located in the scapular regions;
 Paired clavicles, located in the pectoral regions;
 Unpaired (median) manubrium sterni, which articulates with the clavicles at the
sternoclavicular joints.
Scapula (Fig. 72)
The Scapula
 Is a flat triangular bone located in the superolateral part of the dorsal surface of
the thorax; it overlies the 2nd to 7th ribs (dorsally)
 Has two surfaces: posterior and costal surfaces
 Has three borders: superior, medial and lateral borders
 Has three angles: lateral, superior and inferior angles;
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 Has three bony projections: coracoid process, acromial process and spinous
process
 Gives attachment to fifteen muscles. Thus, it is largely non-palpable.
Figure 72. Scapula (dorsal surface)
Surfaces of the Scapula
These include:
 Costal surface; and
 Dorsal surface
The costal surface of the scapula

 Is the concave surface that overlies the 2nd – 7th ribs (dorsally);
 Is deepened by the presence of the subscapular fossa;
 Faces anteromedially when arm is pendent.
The dorsal surface of scapula

 Has a spine that is placed obliquely across it, closer to its upper border than to its
lower end. This divides the dorsal surface into a smaller upper supraspinous
fossa and a larger lower infraspinous fossa (Fig. 72);
 Has a great scapular (spinoglenoid) notch between the spine and the posterior
surface of the ‘neck’ of the scapula. This notch transmits neurovascular structures
from supraspinous to the infraspinous fossa.
The lateral border of scapula
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 Is directed superolaterally, from the inferior angle to lateral scapular angle, which
it links together
 Widens at its superolateral end into an infraglenoid tubercle, for the attachment
of long head of triceps brachii;
 Is not readily palpable, as it is covered by muscles
 Is also referred to as the axillary border, because it adjoins the axilla.
The medial border of the scapula

 Links the inferior and superior angles of the scapula together
 Is parallel to the vertebral column, and is about 5 cm from the midline. Thus, it
also called the vertebral border
 May be palpable in its lower ⅔, but its upper ⅓ is not readily palpable
The superior border of the scapula

 Is the shortest and thinnest of the borders
 Is separated from the base of the coracoid process by the suprascapular notch.
This transmits the suprascapular vessels and nerves
The inferior angle of the scapula

 Overlies the 7th rib (dorsally)
 Links the lateral and medial borders of the scapula together
 Is covered by muscles, through which it may be palpated
The superior angle of the scapula

 Links the superior and medial borders of the scapula
 Overlies the 2nd rib (dorsally)
The lateral angle of the scapula

 Is the thickest part of the scapula
 Is broadened and truncated to form the head of the scapula. This is separated
from the rest (body) of the scapula by a narrow neck
 Bears the glenoid cavity, a shallow oval depression, about 2 cm wide and 4 cm
long. This cavity articulates with the head of the humerus at the glenohumeral
joint
Processes of the scapula (Fig. 72)
These include:
 Spinous process,
 Acromial process, and
 Coracoid process
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The spinous process (spine) of the scapula

 Commences at the junction of the upper ⅓ and lower ⅔ of the medial border of
the scapula. It is directed superolaterally towards the glenoid cavity. At its lateral
end, it turns forwards to become the subcutaneous acromial process
 Is separated from the dorsal aspect of scapular neck by the spinoglenoid notch.
This transmits the suprascapular vessels and nerves from the supraspinous to the
infraspinous fossa
 Divides the dorsal surface of the scapular into a small upper supraspinous fossa
and a large lower infraspinous fossa
 Has a dorsal border termed the crest of the spine. This is subcutaneous
 Gives attachment to adjacent muscles
Acromial Process (Acromion)
The acromial process

 Is a bony projection that points forwards, almost at a right angle, from the lateral
end of the spine of the scapula.
 Is largely subcutaneous and palpable. The only non-palpable parts are its medial
border and inferior surface
 Articulates with the lateral end of the clavicle at the acromioclavicular joint
 Gives attachment to the coracoacromial ligament
The coracoid process of the scapula

 Is a beak-like projection that arises from the summit of the glenoid cavity, and is
directed anterolaterally. It is close to the supraglenoid tubercle at its root
 Can be palpated at about 2.5 cm below the junction of the medial ¾ and lateral ¼
of the clavicle
 Gives attachment to the coracobrachialis, short head of biceps brachii and the
coracoacromial ligament.
Applied Anatomy of the Scapula

 The scapula is less frequently involved in fracture owing to the fact that it is
surrounded by muscles. However, the acromion, being subcutaneous, is prone to
fracture
Ossification of the Scapula
The scapula
 Ossifies from about 8 centres by endochondrial ossification. This begins at
about the 8th week of intra-uterine life
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 Completes its entire ossification process by the 20th year, when all the
ossification centres have fused with one another.
Clavicle (Collar Bone) (Fig. 73)
The clavicle
 Is roughly S-shaped (Fig. 73). It is the bone that connects the upper limb to the
trunk (as it stretches between the manubrium sterni and the acromion)
 Helps to strut (support) the shoulder
 Has two ends: a sternal end, which articulates with the manubrium sterni at the
sternoclavicular joint, and an acromial end, which articulates with the acromion
at the acromioclavicular joint (Fig. 73)
 Has a sinuous shaft (body), which is convex anteriorly in its medial ⅔ and
concave anteriorly in its lateral ⅓. Thus, its S-shaped outline
 Is largely subcutaneous. Thus, its outline can be seen and readily palpated
 Bears certain surface features that include the following: conoid tubercle,
subclavian groove, impression for costoclavicular ligament and trapezoid line
 Appears shorter, smoother, less curved and thinner in females, with the acromial
end being a little lower than its sternal end
 Is stronger and usually shorter on the right than the left side
 Does not possess a medullary cavity
The medial ⅔ of the clavicle

 Is convex forwards (Fig. 73)
 Bears an impression for the costoclavicular ligament on the medial part of its
inferior surface. This gives attachment to the costoclavicular ligament
 Possesses a subclavian groove, just lateral to the impression for the
costoclavicular ligament, on the inferior surface of the clavicle. This gives
attachment to the to the subclavius
 Has a nutrient foramen, which is located in the lateral part of the subclavian
groove, and the opening of which is directed laterally
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Figure 73. Right clavicle (inferior surface)
The lateral ⅓ of the clavicle

 Is concave forwards
 May bear a deltoid tubercle on its anterior border. This gives attachment to the
deltoid
 Bears a conoid tubercle on its inferior surface. This gives attachment to the
conoid ligament (medial part of the strong coracoclavicular ligament)
 Also bears a trapezoid line, just lateral to the conoid tubercle. This gives
attachment to the trapezoid ligament (lateral part of coracoclavicular ligament)
Importance of the Clavicle
The clavicle
 Helps to support (strut) the upper limb by transmitting the weight of the limb onto
the axial skeleton (manubrium sterni). Thus, it ensures that the upper limb does
not sag when it is pendent
Applied Anatomy of the Clavicle

 The clavicle is commonly involved in fracture; this usually occurs at the junction
of its lateral ⅓ and medial ⅔
 Drooping (sagging) of the affected upper limb occurs following fracture of the
clavicle
 Fracture of the clavicle occurs more frequently in children than in adults. In the
former, it is often incomplete and of the greenstick type.
Ossification of the Clavicle
The clavicle
 Ossifies primarily by intramembranous ossification. It begins to ossify by the
5th/6th week of intra-uterine life, being the first bone to commence ossification
 May be the last long bone to complete ossification, as this process is usually
completed between the 25th – 31st year postnatal (when its epiphysis finally fuses
with the diaphysis)
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 May undergo abnormal ossification, such that it becomes (bilaterally) shorter

than normal; and a bony defect may also occur at the junction of its lateral ⅓ and
medial ⅔ (which can be identified radiologically)
Cutaneous Nerves of the Pectoral Region
The following nerves supply the skin of the pectoral region:

 Supraclavicular nerves (C4, C5)
 Anterior and lateral cutaneous branches of the upper intercostal nerves
Supraclavicular Nerves (C4, C5)
The supraclavicular nerves

 Exist as three nerves. These are the medial, intermediate and lateral
supraclavicular nerves
 Arise from the cervical plexus of nerves. They descend in the anterolateral
aspect of the neck, passing over the clavicle to reach as far down as the 2 nd costal
cartilage
 Innervate the skin of the neck and upper part of the pectoral region (down to the
level of the 2nd costal cartilage)
Upper Intercostal Nerves
These nerves
 Give rise to lateral and anterior cutaneous branches that supply the skin of the
pectoral region
Note: Cutaneous branches of the above nerves overlap one another considerably
Muscles of the Pectoral Region (Anterior Thoraco-Appendicular Muscles)
Anterior thoraco-appendicular muscles include the following:

 Pectorales major and minor
 Serratus anterior and
 Subclavius
Pectoralis major
 Is a large triangular muscle that overlies the thorax (anteriorly), superficial to
pectoralis minor (Fig. 74).
Proximal attachment: Pectoralis major has two heads of origin: a sternocostal and a
clavicular head. The former is the larger.
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a) Sternocostal head: anterior aspects of manubrium and body of sternum, as well

as adjacent parts of the upper six costal cartilages
b) Clavicular head: medial half of the clavicle
Distal attachment: Lateral lip of the bicipital groove of the humerus
Innervation: Medial and lateral pectoral nerves.
Note: C5 and C6 fibres innervate the clavicular head, while C7–T1 fibres supply
the sternocostal head.
Figure 74. Pectoral region
Action: Assists in the adduction and medial rotation of the humerus. It also assists
in deep inspiration.
a) Clavicular head: Flexes the humerus
b) Sternocostal head: Extends the humerus (against resistance) from a flexed
position.
Test of Integrity: Adduct the arm against resistance and observe the muscle.
Applied Anatomy
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 The whole or part (especially the sternocostal head) of pectoralis major may be
absent. But this produces no serious disability
 In Poland syndrome, both pectorales major and minor are absent.
 In radical mastectomy (performed in advanced cases of breast cancer), the
pectorales major and minor are removed
Pectoralis Minor (Fig. 75)
The pectoralis minor

 Is also triangular in outline, but is smaller than the pectoralis major, deep to
which to lies
 Forms part of the anterior axillary wall
 Is invested by the clavipectoral fascia
Proximal attachment: The 3rd, 4th and 5th ribs
Distal attachment: Coracoid process of scapula
Innervation: Medial and lateral pectoral nerves
Note: The branch of the lateral pectoral nerve that supplies pectoralis minor is
conveyed to this muscle by the medial pectoral nerve.
Actions:
a) Acts with serratus anterior to draw the scapula (and hence, pectoral girdle)
forwards and downwards
b) Assists with deep inspiration
Test of integrity: This is difficult, as the muscle lies deep to pectoralis major.
Applied Anatomy: See pectoralis major (above)
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Figure 75. Pectoralis minor, serratus anterior and subclavius
Subclavius (Fig. 75)
The subclavius
 Is a small triangular muscle that lies beneath the clavicle (hence the name)
Proximal attachment: The junction of the first rib and its costal cartilage
Distal attachment: Subclavian groove (on the inferior aspect of the middle 3rd of the
clavicle)
Innervation: Nerve to subclavius (C5, C6)
Action:
a) Anchors and stabilizes the clavicle on the sternoclavicular joint
b) Also depresses the clavicle
Test of integrity: It is difficult to test this muscle.
Applied Anatomy: The subclavius produces no serious disability when paralyzed.

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Serratus Anterior (Fig. 75)
The serratus anterior

 Is a large sheet of muscle that overlies the lateral wall of the thorax (externally).
It forms the medial wall of the axilla
 Interdigitates (at its origin) with the upper five slips of external oblique
Proximal attachment: External surface of the upper eight ribs
Note: This muscle derives its name from the resemblance of its numerous slips of
origin to the teeth of a saw.
Distal attachment: Anterior aspect of the medial border of the scapula
Innervation: Long thoracic nerve (C5, C6, C7)
Action:
The serratus anterior
 Protracts the scapula, i.e., it draws the scapula forwards, as occurs when
pushing, punching (boxing) or reaching forwards for an object. It is thus called
the boxer’s muscle.
 Acts with the trapezius to rotate the scapula laterally, thereby tilting the glenoid
cavity upwards and forwards, as occurs when raising the hand above the head.
Serratus anterior is more powerful than the trapezius in this respect.
Applied Anatomy
Note these points:

 Paralysis of serratus anterior produces ‘winged scapula’, in which the medial
border of the scapula is drawn away from the thorax when pushing against
resistance
 Operation or injuries involving the axilla may cause damage to the long thoracic
nerve. This produces paralysis of serratus anterior and winging of the scapula.
Test of integrity: The subject is asked to push against resistance. Absence of a

winged scapula indicates a functional serratus anterior.
Posterior Thoracoappendicular Muscles
The posterior thoracoappendicular muscles

 Are much more numerous than the anterior thoracoappendicular muscles.
 Include some muscles of the back, which are attached to the scapula and thorax
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 May be divided into three groups:

– Superficial posterior thoracoappendicular muscles
– Deep posterior thoracoappendicular muscles , and
– Scapulohumeral muscles (Scapular muscles)
Superficial Posterior Thoracoappendicular Muscles
These include:
 Trapezius and
 Latissimus dorsi
Trapezius (Fig. 74)
The Trapezius
 Is a flat triangular muscle located on the dorsal aspects of the neck and upper part
of thorax
 Forms a trapezium-like outline with the opposite trapezius (hence the name)
 Overlies the scapular and most posterior thoracoappendicular muscles.
Proximal attachment:
a) Medial 3rd of superior nuchal line and external occipital protuberance of
occipital bone
b) Ligamentum nuchae, which overlies the spines of the cervical vertebrae (except
that of C7)
c) Spinous processes of C7–T12 and the supraspinous ligaments associated with
them
Distal attachment
The trapezius converges towards the scapula and inserts as follows:
a) Upper fibres – posterior margin of the lateral 3rd of the clavicle

b) Middle fibres - Acromion and adjacent part of scapular spine
c) Lower fibres – Medial part of the spine of the scapula
Innervation
Note: Motor and sensory fibres to the trapezius have different sources.
a) Motor: Spinal accessory nerve (cranial nerve XI)

b) Sensory: Ventral rami of C3 and C4 spinal nerves (for proprioception and
nociception).
Actions:
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Note: Different parts of trapezius perform different functions.
a) Upper fibres – Elevate scapula

b) Middle fibres – Retracts scapula (i.e. draw it closer to the midline)
c) Lower fibres – Depress scapula
d) Upper and Lower fibres – Act with serratus anterior to rotate the scapula
superiorly, such that the glenoid cavity faces upwards and forwards (as in raising
the hand above the head).
Test of Integrity: This muscle is tested by elevating the shoulder against resistance.
Applied Anatomy
Note the following:

 When the trapezius is paralyzed, the scapula is drawn forwards on the thorax,
with its inferior angle tilting medially
 Full abduction is still possible following paralysis of the trapezius, as the
serratus anterior can also rotate the scapula superiorly (see above).
Latissimus Dorsi
The latissimus dorsi

 Is a large, sheet-like, triangular muscle, which stretches over the dorsal aspect of
the lower thoracic and lumbar regions
 Connects the trunk and humerus together
a) Spinous processes of the lower six thoracic vertebrae (T7–T12)

b) Spinous processes of lumbar and sacral vertebrae, their associated supraspinous
ligaments, and the iliac crest (via the posterior layer of thoracolumbar fascia)
c) Lower four ribs; and
d) Inferior angle of the scapula
Distal attachment: Floor of intertubercular groove of the humerus
Note the following:

 As latissimus dorsi converges towards the humerus, it winds (spirals)
round the lower border of teres major, in the posterior axillary fold,
before it inserts into the bicipital groove.
 At the point of its insertion (into the bicipital groove of humerus),
latissimus dorsi lies between pectoralis major (anteriorly) and teres
major (posteriorly).
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 A bursa separates the tendons of latissimus dorsi and teres major near
their insertion.
Innervation: Thoracodorsal nerve (C6, C7, C8)
Actions:
The latissimus dorsi

 Adducts, extends and medially rotates the humerus
 Is of good use when lifting the trunk off the ground (as occurs in climbing)
 Assists in forced expiratory movements (as in sneezing or coughing).
Test of Integrity: Latissimus dorsi may be felt in the posterior axillary fold as the
subject adduct an abducted arm (against resistance); or as the individual coughs.
Applied Anatomy
Following the paralysis of latissimus dorsi,

 The individual is unable to lift the trunk satisfactorily off the ground. Thus, an
action such as climbing become difficult
 The use of crutches also becomes difficult.
Deep Thoracoappendicular Muscles
The deep thoracoappendicular muscles

 Lie deep to the superficial thoracoappendicular muscles. They connect the
pectoral girdle (scapula) with the thoracic wall
 Play major roles in the stability and rotation of the scapula
 Include levator scapulae, rhomboid major and rhomboid minor
Levator Scapulae
The levator scapulae lies obliquely in the neck such that:

 Its upper third lies deep to sternocleidomastoid muscle;
 The middle third contributes to the floor of posterior triangle of the neck ;
 Its lower third lies deep to trapezius.
Proximal attachment: Posterior tubercles of the transverse processes of the upper

four cervical vertebrae.
Distal attachment: Medial border of the scapula (between the superior angle and the
spine).
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Innervation: Ventral rami of C3 and C4 spinal nerves and the dorsal scapular
nerve (C5).
Actions:
Levator scapulae
 Elevates the scapula (just as its name implies)
 Rotates the scapula such that the glenoid cavity faces inferiorly and the
shoulder is depressed
 Helps to support the limb when this is bearing weight (that is suspended on
it)
 Also retracts the scapula; and flexes the neck (laterally)
Applied Anatomy
Note that
 Paralysis of levator scapulae does not usually result in serious disability because
certain muscles act synergistically with it.
Rhomboid Major
The rhomboid major

 Lies deep to trapezius, and parallel to rhomboid minor
 Often becomes continuous with rhomboid minor, the two appearing rhomboidal
in outline, hence the name;
 Forms the floor of the triangle of auscultation.
Proximal attachment: Spinous processes of T2–T5 vertebrae and their associated

supraspinous ligaments.
Distal attachment: Medial border of the scapula (between the root of scapular spine
and its inferior angle).
Innervation: Dorsal scapular nerve (C4, C5).
Actions:
Rhomboid major
 Retracts scapula (i.e. draws it medially, towards the midline)
 Rotates the scapula medially (such that the glenoid cavity faces inferiorly)
Test of Integrity: The individual braces the shoulder against resistance, and the
muscle may then be felt.
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Applied Anatomy: Same as for levator scapulae
Rhomboid Minor
The rhomboid minor

 Lies between (and parallel to) the levator scapulae above and rhomboid major
below
 Is directed inferolaterally, from the midline of the neck to the scapula
Proximal attachment: Lower part of ligamentum nuchae, spines of C7 and T1
and the supraspinous ligament between them.
Distal attachment: Medial border of the scapula (at the level of the spine).
Innervation: Dorsal scapular nerve (C4, 5).
Actions: Same as for rhomboid major.
Test of Integrity: Same as for rhomboid major (see above).
Applied Anatomy: Same as for levator scapulae (see above)
Scapular Muscles (Scapulohumeral Muscles)
Scapulohumeral muscles
 Connect the scapula to the humerus; they are relatively short muscles
 Closely surround and act on the shoulder joint
Scapulohumeral muscles are six; they include:

 Deltoid and subscapularis
 Teres major and teres minor
 Supraspinatus and infraspinatus.
Deltoid (Fig. 74)
Deltoid
 Is a coarse, thick, multipennate muscle. It is triangular in outline; overlies the
shoulder joint; and forms the round prominence of the shoulder
 Has scapular attachment that is comparable to that of trapezius
 Passes above, behind and in front of the shoulder joint as it converges towards
its insertion. Thus, it exerts multiple actions on this joint.
Proximal attachment: Lateral 3rd of the clavicle, spine of scapula and the acromion
Distal attachment: Deltoid tuberosity (at the middle of the lateral surface of humeral
shaft)
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Innervation: Axillary nerve (C5, C6)
Actions:
Note: In terms of its action, the anterior, posterior and intermediate fibres of deltoid
are considered separately.
 Anterior fibres: Flexes and medially rotates the arm (as does pectoralis major;
see above).
 Posterior fibres: Extends and laterally rotates the arm
 Intermediate fibres: Abducts the arm
Note that
 The intermediate portion of deltoid is the chief abductor of the arm. However,
abduction is normally initiated (up to the first 180) by supraspinatus
 If abduction is not initiated by supraspinatus, the pull of deltoid (intermediate
fibres) will be directed upwards rather than outwards. Thus, the subject has to tilt
the trunk sideway to initiate abduction.
Test of Integrity: The individual’s arm is abducted to 450; he is then asked to abduct
against resistance. If unparalyzed, the muscle’s contraction can be felt.
Applied Anatomy

 Fracture of the surgical neck of the humerus may injure the axillary nerve
(which winds round this neck), thereby paralysing deltoid.
Subscapularis (Fig. 76)
The subscapularis
 Is a large triangular muscle that occupies the subscapular fossa of the scapula. It
forms part of the posterior wall of the axilla;
 Passes anterior to the shoulder joint en route to its insertion. Thus, it is a flexor
of this joint
 It is separated from the neck of the scapula by a subscapular bursa
 Forms the superior border of the triangular and quadrangular spaces.
Proximal attachment: Subscapular fossa of the scapula
Distal attachment: Lesser tubercle of the humerus and capsule of the shoulder joint.
Innervation: Upper and lower subscapular nerves (C5, C6, C7)
Actions:
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In terms of its actions, the subscapularis:
 Produces medial rotation and adduction of the humerus

 Acts with other ‘rotator cuff muscles’ (see below) to stabilize the head of the
humerus in the shoulder joint, so it is not dislocated during movement.
Applied Anatomy

 Owing to the poor stability of the shoulder joint, the rotator cuff muscles, by
virtue of their proximity to the joint, hold the humeral head in the glenoid cavity,
thereby stabilizing the joint
 Rotator cuff muscles may be injured in forceful, violent, rapid movements of the
shoulder joint – ‘rotator cuff injury’ e.g. in baseball players
Figure 76. Rotator cuff muscles
Teres Major
The teres major

 Is a thick rounded muscle located in the posterior axillary fold, which
it forms with latissimus dorsi. In this fold, teres major lies behind latissimus
dorsi, and the two are separated by a bursa
 Lies below and in front of the shoulder joint (as it passes towards its
insertion on the humerus). It forms the lower boundary of the triangular and
quadrangular spaces.
 Has similar actions as latissimus dorsi;
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Proximal attachment: An oval area on the dorsum of inferior angle of the

scapula.
Distal attachment: Medial lip of the intertubercular groove of the humerus
Innervation: Lower subscapular nerve (C6, C7)
Actions:
a) Adduction and medial rotation of the arm (as does latissimus dorsi);
b) Extension of the arm (from a flexed position).
Test of Integrity: The muscle may be felt when the arm is adducted against
resistance
Teres Minor (Fig. 76)
The teres minor

 Is an elongated muscle, much narrower than teres major.
 Lies behind the shoulder joint as it passes towards its insertion on the
humerus. It forms the upper border of the triangular and quadrangular
spaces (from behind)
 Is intimately associated with infraspinatus
Proximal attachment: Upper ⅔ of the dorsal aspect of the lateral border of the
scapula.
Distal attachment:
a) Inferior facet of the greater tubercle of the humerus;

b) Capsule of the shoulder joint.
Innervation: Axillary nerve (C5, C6)
Actions:
a) Lateral rotation of the arm;
b) Adduction of the arm;
c) Also acts as an adjustable ‘ligament’ of the shoulder joint; and by so
doing helps to steady humeral head on the glenoid cavity during movement
Test of Integrity: This is usually difficult
Applied Anatomy: Rotator cuff injury (see subscapularis, above)
Supraspinatus (Fig. 76)
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The supraspinatus
 Is located in the supraspinous fossa, above the spine of the scapula
(hence the name)
 Passes above the shoulder joint and below the acromion and
coracoacromial ligament, towards its insertion on the humerus. It is separated
from the acromion and coracoacromial ligament by a large subacromial
bursa.
a) Medial ⅔ of the supraspinous fossa of the scapula. (A bursa separates it
from the lateral ¼ of this fossa)
b) The fascia around supraspinatus.
Distal attachment:
a) Superior facet of the greater tubercle of the humerus
b) Capsule of the shoulder joint. (A fibrocartilage is usually found in the
tendon of insertion of supraspinatus).
Innervation: Suprascapular nerve (C5, C6)
Actions:
a) Initiates abduction of the arm (initial 180)
b) Produces lateral rotation of the arm. Supraspinatus is a member of
rotator cuff muscles (see above)
Test of Integrity: Place the limb by the side of the body and abduct it against
resistance.
Applied Anatomy:
Note the following:

 Paralysis of supraspinatus produces difficulty in initiating abduction.
To achieve this, the individual leans sideway
 Supraspinatus may be torn in rotator cuff injury. It is the most
commonly ruptured muscle in this group
 Following the inflammation of the subacromial bursa (subacromial
bursitis), contraction of supraspinatus becomes painful (painful arc
syndrome). This occurs during abduction.
Infraspinatus (Fig. 76)
The infraspinatus
 Is a thick triangular muscle located in the infraspinous fossa, below the spine of
the scapula. It may be fused with teres minor.
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 Lies deep to deltoid, trapezius and acromion, in its upper part; and it is separated
from the neck of the scapula and capsule of the shoulder joint by a bursa
 Passes behind the shoulder joint; and thus, acts on this joint
a) Medial ¾ of the infraspinatus fossa of the scapula;
b) The fascia around infraspinatus.
Distal attachment: Middle facet of the greater tubercle of the humerus (between
supraspinatus and teres minor)
Innervation: Suprascapular nerve (C5, C6).
Actions:
a) Produces lateral rotation of the arm
b) Steadies and stabilizes humeral head on glenoid cavity. It is a member of the
rotator cuff muscles (see above).
Test of Integrity: With the arm by the side, the elbow is flexed to a right angle and
the arm is rotated laterally against resistance.
Applied Anatomy: As a member of the rotator cuff muscles, infraspinatus may be

involved in rotator cuff injury (see below)
Rotator Cuff (Fig. 76)
Rotator cuff consists of four muscles. These include:

 Supraspinatus and infraspinatus
 Subscapularis and teres minor. (For details of these muscles, see above)
The rotator cuff muscles

 Intimately surround the shoulder joint; these muscles pass anterior, posterior and
superior to the joint.
 Act as adjustable ‘ligaments’ for the shoulder joint. Thus, they help to steady
and stabilize the head of the humerus on the glenoid cavity of the scapula.
Applied Anatomy:
Certain members of the rotator cuff may be injured during forceful, rapid, and violent
movements of the shoulder joint. The supraspinatus is especially vulnerable.
Triangles associated with Anterior and Posterior Thoracoappendicular muscles
These include:
 Deltopectoral triangle anteriorly; and
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 Triangle of auscultation and lumbar triangle posteriorly.

Deltopectoral triangle (Fig. 74)
Location: Pectoral region
Boundaries:
 Medially: Clavicular head of pectoralis major
 Laterally: Deltoid
 Superiorly (base): Middle part of the clavicle
 Apex: Junction between deltoid and pectoralis major
 Floor: Clavipectoral fascia.
Contents:
Deltopectoral triangle contains the following:

 Terminal (upper) part of the cephalic vein
 Deltopectoral lymph nodes (and vessels)
 Deltoid branch of thoraco-acromial artery
Triangle of Auscultation
Location: Back
Boundaries:
 Medially: Trapezius
 Laterally: Medial border of the scapula
 Inferiorly: Latissimus dorsi
 Floor: 6th intercostal space
Importance:
This triangle is an auscultation site for the examination of the posterior segments of
the lung (from behind).
Lumbar Triangle
Location: Lower part of the back
Boundaries:
 Medially: Latissimus dorsi
 Laterally: External oblique muscle
 Inferiorly: Iliac crest
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Shoulder (Glenohumeral) Joint (Fig. 77, 78)
The shoulder joint

 Is a multi-axial, ball-and-socket type of synovial joint
 Is formed between the hemispherical head of the humerus and the concave,
shallow glenoid cavity of the scapula
 Has a high degree of mobility. However, it is relatively unstable
 Is strengthened and stabilized by the rotator cuff muscles, which intimately
surround it
 Contains the long head of biceps within its joint cavity.
Bony Articular Surfaces (Fig. 77)
In the shoulder joint,

 Hyaline articular cartilage covers the hemispherical surface of humeral head
and the concavity of glenoid cavity
 The shallow glenoid cavity is much smaller than the humeral head. Thus, it is
deepened by a ring of fibrocartilage – glenoid labrum – which is applied around
its margin.
Figure 77. Glenohumeral articulation
Fibrous Capsule of Shoulder Joint (Fig. 78)
The fibrous capsule of shoulder joint

 Forms a loose external investment for the joint. Thus, it has a dependent, loose
fold, when the arm is by the side
 Is attached proximally to the margin of the glenoid cavity, external to glenoid
labrum (to which it is also partially attached). Distally, it is attached to the
anatomical neck of the humerus
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 Is extremely weak in its inferior part, which is only supported by tendon of the
long head of triceps brachii
 Has two openings, one of which is located anteriorly and allows communication
between the cavity of shoulder joint and the subscapular bursa. The other is
located superiorly, at the upper end of the bicipital groove. It transmits the tendon
of the long head of biceps brachii
 May also possess an opening posteriorly. This enables the bursa deep to
infraspinatus to communicate with the joint cavity.
Synovial Membrane of the Shoulder Joint
The synovial membrane of the shoulder joint

 Lines the fibrous capsule of the joint, from which it is reflected onto the
anatomical neck of the humerus and the glenoid labrum
 Also invests the long head of biceps brachii as this traverses the bicipital groove
of the humerus to enter the joint cavity
 Communicates with the large subscapular bursa through the opening in the
fibrous capsule. it may also communicate with the bursa of infraspinatus
 Forms a pouch in its lower part when the arm is dependent
 Secretes synovial fluid for the lubrication of the joint.
Ligaments of the Shoulder Joint (Fig. 78)
Ligaments of the shoulder joint include:

 Superior, middle and inferior glenohumeral ligaments;
 Coracohumeral ligament; and
 Transverse humeral ligaments
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Figure 78. Ligaments of the shoulder joint (CAL= coracoacromial ligament; CCL=
coracoclavicular ligament; SGHL= superior glenohumeral ligament; MGHL=
middle glenohumeral ligament; IGHL= inferior glenohumeral ligament)
Glenohumeral Ligaments (Fig. 78)
Note the following:

 The three glenohumeral ligaments (superior, middle and inferior) are
thickenings of the internal aspect of the anterior part of the fibrous capsule,
which they reinforce
 The superior, middle and inferior glenohumeral ligaments are arranged from
above downwards. They stretch between the scapula and the humerus
 Between the superior and middle glenohumeral ligaments is the opening in the
fibrous capsule, via which the subscapular bursa communicates with shoulder
joint cavity.
The superior glenohumeral ligament

 Stretches inferolaterally from the glenoid labrum (at a point adjacent to the
supraglenoid tubercle) to a point just above the lesser tubercle of the humerus
 Lies anterior and parallel to the tendon of biceps brachii
The middle glenohumeral ligament

 Passes inferolaterally from the glenoid labrum (at a point adjacent to the
supraglenoid tubercle) to the front of the lesser tubercle of the humerus.
The inferior glenohumeral ligament
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 Has a similar proximal attachment as the middle glenohumeral ligament; distally,

it is attached to the lowest part of the anatomical neck of the humerus
 Is usually described as the best developed of the three glenohumeral ligaments;
but it may be absent or indistinct.
The coracohumeral ligament

 Is a strong, broad ligament formed by the thickened upper part of the fibrous
capsule
 Stretches from the base of the coracoid process medially to the greater tubercle
of the humerus laterally
 Strengthens the upper part of the fibrous capsule.
The transverse humeral ligament

 Is a broad band that stretches between the greater and lesser tubercles of the
humerus; it converts the intertubercular (bicipital) sulcus into a canal
 Keeps the tendon of the long head of biceps brachii in place, thereby serving as a
retinaculum for it.
Accessory Ligament of the Shoulder Joint

The accessory ligament of the glenohumeral joint include the coracoacromial
ligament (Fig. 78).
The coracoacromial ligament

 Lies above the shoulder joint. It stretches between the coracoid process and the
acromion
 Forms, together with the coracoid process and acromion, an osseofibrous
coracoacromial arch. This prevents the head of the humerus from being
dislocated upwards.
 Is separated from the tendon of supraspinatus (which lies beneath it) by a
subacromial bursa
Stability of the Shoulder Joint

Owing to its high degree of mobility, the stability of the shoulder joint is
compromised.
The following contribute to the stability of the shoulder joint:

 The fibrous capsule of the joint.
 The ligaments of the joint. These include glenohumeral and coracohumeral
ligaments
 Rotator cuff muscles. These include teres minor, subscapularis, supraspinatus
and infraspinatus.
Bursae Associated with the Shoulder Joint
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The following bursae are associated with the shoulder joint:

 Subscapular bursa: Between tendon of subscapularis and the anterior aspect of
the fibrous capsule. This bursa usually communicates with the joint cavity.
 Bursa of infraspinatus: Between infraspinatus and the posterior aspect of the
joint capsule
 Subacromial bursa: Between the coracoacromial arch and deltoid above and the
tendon of supraspinatus and joint capsule below.
 A bursa between the coracoid process and the joint capsule
Movements of the Shoulder Joint
The wide range of movement obtainable at the shoulder joint is due to:
 The shallow depth of the glenoid cavity relative to the large size of humeral
head
 The looseness of the fibrous capsule and paucity of ligaments around the joint.
Movements occurring at the shoulder joint and the axes involved include:
 Flexion and extension – around a transverse axis
 Abduction and adduction – around an anteroposterior axis
 Medial and lateral rotation – around a vertical axis
 Circumduction – a combination of the above movements and their axes.
Muscles associated with the Movements of the Shoulder Joint
Movements of the shoulder joint and the muscles that produce them include:
 Flexion – Clavicular fibres of pectoralis major, anterior fibres of deltoid, biceps
brachii and coracobrachialis
 Extension – Posterior fibres of deltoid, latissimus dorsi and teres major
(assisted by sternocostal fibres of pectoralis major and long head of triceps
brachii [especially when acting from the flexed position of the joint])
 Abduction – Supraspinatus and middle fibres of deltoid;
 Adduction – Teres major, latissimus dorsi, pectoralis major, subscapularis,
infraspinatus and teres minor
 Lateral rotation – Infraspinatus, teres minor and posterior fibres of deltoid
 Medial rotation – Subscapularis, latissimus dorsi, teres major, anterior fibres of
deltoid and pectoralis major.
Blood Supply of the Shoulder Joint
The following vessels supply the glenohumeral joint:

 Suprascapular artery – a branch of thyrocervical trunk;
 Anterior circumflex humeral artery – a branch of the 3rd part of axillary
artery
 Posterior circumflex humeral artery – a branch of the 3rd part of axillary artery.
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Innervation of the Shoulder Joint
The following nerves give sensory fibres to the shoulder joint:

 Suprascapular nerve
 Axillary nerve; and
 Lateral pectoral nerve.
Applied Anatomy of the Shoulder Joint

 Owing to its relative instability and the laxity of its fibrous capsule, the shoulder
joint is frequently involved in dislocation
 Superior dislocation of the shoulder joint is rare, owing to the presence of
osseofibrous coracoacromial arch
 Anterior dislocation of the shoulder joint is common. This is owing to the
inadequate support provided by the infraglenoid tubercle and the long head of
triceps brachii. Thus, humeral head is prone to inferior, then anterior
displacement
 In anterior dislocation of the shoulder joint, humeral head is displaced anterior
to the infraglenoid tubercle and long head of triceps
 Posterior dislocation of the shoulder joint may also occur, but this is relatively
rare
 Injury to the axillary nerve may occur in (anterior) dislocation of humeral head.
This may result in paralysis of deltoid and anaesthesia of the skin over the central
part of this muscle
 Forceful subluxation of humeral head may produce a tear in the glenoid labrum,
with the associated pains, especially when throwing objects.
 Subacromial bursitis (inflammation of subacromial bursa) and supraspinatus
tendinitis may occur, with associate pain (e.g., on abduction).
Rotator Cuff Injuries
Rotator cuff injuries

 Often occur in forceful repetitive movements of shoulder joint, as in swimming,
baseball, etc
 Commonly involve tearing of supraspinatus owing to relative avascularity of
this muscle
 Produces pain during shoulder joint movements, especially when initiating
abduction.
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Axilla
The axilla
 Is the pyramidal region between the upper part of the lateral wall of the thorax
and the arm. It deepens when the arm is by the side but almost disappears when
the arm is abducted
 Has an apex, a base, and four walls (anterior, posterior, lateral and medial walls)
 Allows the passage of vessels and nerves between the neck/thoracic cavity and
the arm. The axilla contains axillary vessels, infraclavicular part of the brachial
plexus (of nerve), lymph nodes and adipose tissue
Boundaries of the Axilla (Fig. 79)
Anterior Wall of the Axilla
The anterior wall of the axilla

 Extends from the clavicle above to the anterior axillary fold below
 Is formed by pectorales major and minor, subclavius and clavipectoral fascia
(see below).
The clavipectoral fascia

 Is a fascial sheet that stretches from the clavicle above to the axillary fascia
below, in the anterior wall of the axilla. Between these attachment sites, it splits
to enclose subclavius and pectoralis minor
 Is pierced by thoraco-acromial artery, cephalic vein and lymph vessels, just
above the medial border of pectoralis minor
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Figure 79. A transverse section through the axilla
Posterior Wall of the Axilla (Fig. 79)
The posterior wall of the axilla

 Is formed above by subscapularis and its fascia; and below by teres major and
latissimus dorsi. The latter winds round the inferior border of teres major, from
posterior anteriorly, and together they form the posterior axillary fold.
Medial Wall of the Axilla (Fig. 79)
The medial wall of the axilla

 Is formed by the upper four ribs and their associated intercostal muscles, and the
upper part of serratus anterior
 Is convex from anterior posteriorly.
Lateral Wall (Fig. 79)
The lateral ‘wall’ of the axilla

 Is formed by the intertubercular groove of the humerus, and the
coracobrachialis, which overlies it
 Is extremely narrow (as anterior and posterior axillary walls converge towards it)
Base of the Axilla
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The base of the axilla

 Is formed by skin, subcutaneous tissue and axillary fascia. The latter stretches
between the inferior borders of pectoralis major and latissimus dorsi;
 Has a convexity that faces the axilla, and a concavity that corresponds to the
armpit
 Is broadens towards the medial wall of the axilla but narrows towards the lateral
wall
Apex of the Axilla
The apex of the axilla

 Is truncated and directed superomedially, towards the root of the neck
 Is bounded by the external border of the first rib medially, upper border of
subscapularis (and scapula) posteriorly, and the clavicle anteriorly
 Is linked to the root of the neck by the cervico-axillary canal. This canal
transmits neurovascular structures between the axilla and the neck
Contents of the Axilla (Fig. 79, 80, 81)
The axilla contains the following:

 Axillary artery and its branches
 Axillary vein and its tributaries
 Infraclavicular part of the brachial plexus
 Lymph vessels and five groups of lymph nodes
 Adipose Tissue (between the above structures)
Axillary Artery (Fig. 80)
The axillary artery

 Is the direct continuation of the subclavian artery. It commences at the outer
border of the 1st rib and ends at the lower border of teres major; here, it becomes
the brachial artery
 Lies close to the humerus; and is related medially to the axillary vein
 Is described as consisting of three parts (first, second and third parts), in relation
to pectoralis minor
 Is intimately related to the infraclavicular part of brachial plexus
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Figure 80. Axillary artery and its branches
The first part of the axillary artery

 Is the part between the 1st rib and the medial border of pectoralis minor
 Is related behind to the medial cord of the brachial plexus; anteriorly to the
clavipectoral fascia and pectoralis major; medially to the axillary vein; and
laterally to the lateral and posterior cords of the brachial plexus
 Is enclosed, together with the axillary vein and cords of the brachial plexus, by
the axillary sheath – an extension of the prevertebral fascia of the neck into the
axilla
 Has just one branch – superior thoracic artery. This supplies the muscles of the
anterior axillary wall; and anastomoses with adjacent intercostal and internal
thoracic arteries.
The second part of axillary artery

 Is the part that lies behind pectoralis minor
 Is related posteriorly, laterally and medially to the posterior, lateral and medial
cords of the brachial plexus, respectively; and anteriorly to pectoralis minor
and major
 Has two branches – thoracoacromial and lateral thoracic arteries
The thoracoacromial artery

 Is a short trunk that arises from the second part of the axillary artery
 Runs forwards, medial to pectoralis minor, to pierce the clavipectoral fascia. It
terminates deep to pectoralis major
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 Divides into four branches: pectoral branch (to pectoral muscles), acromial
branch (to acromial rete), clavicular branch (to sternoclavicular joint) and
deltoid branch (to deltoid).
The lateral thoracic artery

 Also arises from the second part of the axillary artery; and descends along the
lateral border of pectoralis minor. It may arise from thoracoacromial, subscapular
or suprascapular arteries
 Supplies adjacent muscles and the axillary lymph nodes. It also supplies the
lateral part of the mammary gland via the lateral mammary branches
 Anastomoses with pectoral branch of thoracoacromial artery, and the
subscapular, intercostal and internal thoracic arteries
The third part of axillary artery

 Is the part between the lateral border of pectoralis minor and the lower border of
teres major
 Is surrounded by branches of the cords of the brachial plexus; and its lateral part
is subcutaneous
 Is related posteriorly to radial and axillary nerves; anteriorly to skin and
fascia; medially to medial cutaneous nerve of forearm, ulna nerve and axillary
vein; and laterally to median and musculocutaneous nerves
 Has three branches: subscapular, anterior circumflex humeral, and posterior
circumflex humeral arteries
The subscapular artery

 Is the largest branch of the axillary artery; it descends along the lower border of
subscapularis
 Divides, about 4 cm from its origin, into thoracodorsal and circumflex scapular
arteries (see below)
 Supplies adjacent muscles and the posterior wall of the axilla (via its branches).
The circumflex scapular artery

 Arises from the subscapular artery (about 4 cm from the origin of this vessel),
and then runs backwards, through the triangular space. Beyond the latter, it
winds round the lateral border of the scapula, to reach the infraspinous fossa
 Supplies adjacent muscles; and sends a branch to subscapular fossa to supply
subscapularis
 Anastomoses with suprascapular artery and the deep branch of transverse
cervical artery (dorsal scapular artery), to form the anastomoses around the
scapula
The thoracodorsal artery

 Also arises from the subscapular artery (about 4 cm from the origin of this
vessel)
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 Descends (with the thoracodorsal nerve) along the lateral border of scapula
(between teres minor posteriorly and teres major anteriorly)
 Anastomoses with the deep branch of transverse cervical artery (dorsal scapular
artery), and by so doing contributes to the anastomoses around the scapula
 Supplies adjacent muscles, including latissimus dorsi
The anterior circumflex humeral artery

 Arises from the 3rd part of the axillary artery, opposite the origin of the
subscapular artery. It is the smaller of the two circumflex humeral arteries
 Runs laterally, anterior to the surgical neck of the humerus, and deep to
coracobrachialis and the two heads of biceps brachii
 Gives rise to a branch that accompanies the long head of biceps through the
bicipital groove. This supplies the shoulder joint and humeral head
 Anastomoses with the posterior circumflex humeral artery
The posterior circumflex humeral artery

 Arises from the lateral aspect of the 3rd part of the axillary artery, opposite the
origin of the subscapular artery
 Passes posteriorly, through the quadrangular space, to the posterior aspect of
the surgical neck of the humerus. It is accompanied by the axillary nerve
 Supplies the surrounding muscles, including deltoid, and the shoulder joint
 Anastomoses with the anterior circumflex humeral artery and, via a
descending branch, with the ascending branch of profunda brachii artery
Applied Anatomy of Axillary Artery

 Aneurysm of axillary artery may occur. This causes compression of parts of the
brachial plexus, with the resultant anaesthesia of the skin supplied by such
nerves
 To control bleeding in the upper limb, the axillary artery (especially its 3rd part)
may be compressed against the humerus.
 In stenosis of the axillary artery, blood cannot reach the distal part of this vessel
except through collateral channels provided by the arterial anastomoses around
the scapula (see below)
 Accidental laceration of the axillary artery may occur, the frequency being higher
when the vessel is diseased
Axillary Vein (Fig. 81)
The axillary vein

 Commences at the lower border of teres major as the direct continuation of the
basilic vein. It ends at the outer border of the 1st rib, where it becomes continuous
with the subclavian vein. It possesses a pair of valves near the 1st rib
- 371 -
 Receives the brachial veins near the subscapularis, and the cephalic vein near
the first rib
 Also receives the veins that drain the structures supplied by branches of the
axillary artery (except some of the veins that drain the territories supplied by
thoracoacromial artery)
 Is related laterally to medial cutaneous nerve of the forearm, ulnar nerve, medial
cord of the brachial plexus, medial pectoral nerve and the axillary artery
 Is related medially to medial cutaneous nerve of the arm; and posteromedially
to lateral group of axillary lymph nodes (which lies along it)
Applied Anatomy of Axillary Vein
Note that
 Increased blood flow from the upper limb causes expansion of the axillary vein;
this is possibly owing to the absence of the fibrous axillary sheath around the
proximal (lateral) part of this vessel
 The axillary vein bleeds profusely if lacerated, with the risk of air emboli getting
into the bloodstream
Axillary Lymph Nodes (Fig. 81)
Axillary lymph nodes

 Are found in the fatty tissue of the axilla. They are numerous and arranged in five
groups: pectoral, subscapular, humeral, central and apical groups.
Figure 81. Axillary lymph nodes

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Pectoral group of axillary nodes

 Consists of 3–5 nodes located along the lateral thoracic vessels, on the anterior
axillary wall
 Receives afferent lymph vessels from the anterolateral wall of the trunk (above
the umbilicus); and from the centrolateral part of the mammary gland. It
receives more than 75% of lymph from the mammary gland
 Gives rise to efferent lymph vessels that drain into central and apical groups of
axillary nodes
Subscapular group of axillary nodes

 Consists of 6–7 lymph nodes located along the subscapular vessels, on the
posterior axillary wall
 Drains the lower part of the back of the neck, and the posterior aspect of the
trunk (down to the level of the iliac crest)
 Gives rise to efferent lymph vessels that drain into the central and apical groups
of axillary nodes
Central group of axillary nodes

 Consists of 3–4 large lymph nodes that lie along the 2nd part of the axillary
artery (deep to pectoralis minor)
 Receives afferent lymph vessels from the pectoral, subscapular and humeral
groups of axillary nodes
 Gives rise to efferent vessels that that drain into apical group of axillary nodes
Humeral group of axillary nodes

 Consists of 4–6 lymph nodes located posteromedial to the axillary vein
 Receives afferent vessels from the whole of the upper limb (except those
vessels that accompany the cephalic vein to the apical nodes)
 Is drained by efferent vessels that end in the central and apical groups of axillary
nodes, as well as the inferior deep cervical nodes
Apical group of axillary nodes

 Consists of 6–12 nodes that lie medial to the axillary vein and the 1st part of the
axillary artery (at the apex of the axilla)
 Receives afferent vessels from other groups of axillary nodes; as well as vessels
that accompany the cephalic vein from the upper limb; and those from the upper
part of the mammary gland
 Gives rise to efferent vessels that unite to form the subclavian trunk
Note: The right subclavian trunk may end in the right lymphatic duct (or drain into
the right venous angle directly); while the left subclavian trunk drains into the
thoracic duct.
- 373 -
Applied Anatomy of Axillary Nodes

 The presence of carbonaceous particles in the axillary lymph nodes is suggestive
of pleural adhesion
 Enlargement of axillary lymph nodes may be indicative of breast cancer. Cancer
cells from the breast usually metastasize (spread) to these nodes
 Removal of the axillary nodes becomes necessary to check the spread of
malignant cells from the breast
 When removing the axillary nodes (in carcinoma of the breast), part of the
axillary vein may be excised (as some nodes may adhere to it)
 The long thoracic and thoracodorsal nerves are also at risk when dissecting the
axillary lymph nodes. The latter may be sacrificed without noticeable disabilities
 Infections of the upper limb, anterolateral abdominal wall (above the umbilicus)
and the breast usually produce enlarged and painful axillary lymph nodes
Infraclavicular Part of the Brachial Plexus (See the brachial plexus below)
Sternoclavicular Joint
The sternoclavicular joint

 Is a saddle type of synovial joint. Functionally however, it resembles a ball-and-
socket joint
 Is formed between the sternal end of the clavicle and the clavicular notch of
manubrium sterni, together with upper surface of the 1st costal cartilage
 Contains a fibrocartilagenous articular disc that divides the joint cavity into two
compartment
 Is a very strong articulation, owing to the presence of strong articular ligaments;
thus, it is rarely dislocated
The articular surfaces of sternoclavicular joint

 Are formed by the large medial end of the clavicle and the relatively small
conjoint surface formed by clavicular notch of the manubrium and the upper
surface of the 1st costal cartilage
 Are separated by an articular disc of fibrocartilage, which may be perforated
centrally
 Are lined by fibrocartilage (not hyaline cartilage)
The fibrous capsule of sternoclavicular joint

 Is attached to the margins of the clavicular and sternochondral articular surfaces.
The peripheral margins of the articular disc of the joint is attached to it
 Is weak inferiorly but strengthened anteriorly, posteriorly and superiorly by
articular ligaments
The articular disc of sternoclavicular joint

- 374 -
 Is a flat circular disc of fibrocartilage that divides the joint cavity into two (a
larger lateral part and a small medial part). It is covered on both surfaces by
synovial membrane
 Is attached above to the superior border of the articular surface of the clavicle;
and below to the sternal end of the first costal cartilage
 Is thickened at its periphery, and here, it is attached to the articular capsule.
Centrally, it is thin and may be perforated here
 Serves as a shock absorber for the sternoclavicular joint
Synovial membrane of sternoclavicular joint

 Lines the internal aspect of the fibrous capsule, and both surfaces of the articular
disc
Ligaments of Sternoclavicular Joint
The ligaments of sternoclavicular joint include:

 Anterior sternoclavicular ligament
 Posterior sternoclavicular ligament
 Interclavicular ligament; and
 Costoclavicular ligament
The anterior sternoclavicular ligament

 Is the thickened anterior part of the fibrous capsule of the sternoclavicular joint.
It stretches inferomedially from the clavicle to the manubrium sterni and the 1st
costal cartilage
 Is stronger than the posterior sternoclavicular ligament
The posterior sternoclavicular ligament

 Is the thickened posterior part of the articular capsule of the sternoclavicular
joint; thus, it strengthens the joint posteriorly
 Stretches inferomedially from the posterior aspect of the clavicle to the
manubrium sterni
The interclavicular ligament

 Stretches between the superior aspects of sternal ends of the two clavicles. Thus,
it lines the floor of the jugular notch of the manubrium
 Strengthens the fibrous capsule of the sternoclavicular joint superiorly
 Is continuous above with the deep cervical fascia (in the neck)
The costoclavicular ligament

 Attaches the first rib and the 1st costal cartilage to an impression on the inferior
aspect of the medial end of the clavicle
- 375 -
 Strengthens the upper part of the fibrous capsule; and thus prevents upward and
horizontal displacement of the clavicle during the movement of the
sternoclavicular joint
Movements of Sternoclavicular Joint

 The sternoclavicular joint moves relative to the movement of the shoulder and
acromioclavicular joints
Neurovascular Supply of the Sternoclavicular Joint
Note that
 Branches of the internal thoracic and suprascapular arteries supply arterial blood
to the joint
 The sternoclavicular joint is innervated by nerve to subclavius and the anterior
supraclavicular nerve
Applied Anatomy
Note the following:

 The sternoclavicular joint is an especially strong joint; this is owing to its
articular disc and ligaments. Thus, dislocation of the joint is rare; rather, the
clavicle fractures instead
 The costoclavicular ligament and articular disc prevent upward displacement
of the medial end of the clavicle (e.g., when bearing heavy weight)
Acromioclavicular joint
The acromioclavicular joint

 Is a plane type of synovial joint between the clavicle and the medial margin of
acromion of the scapula
 Usually contains an incomplete articular disc, which partially separates the joint
cavity. The disc may however be absent. It may also form a complete partition for
the joint cavity
Fibrous Capsule and Articular Surfaces of the Joint
Regarding the acromioclavicular joint, note that

 The articular surfaces of the acromion and clavicle are lined by fibrocartilage,
not hyaline cartilage
 The weak fibrous capsule surrounds the joint. This is attached to the margins of
articular surfaces of the clavicle and acromion
- 376 -
Ligaments of Acromioclavicular Joint
Ligaments of acromioclavicular joint include:

 Acromioclavicular ligament; and
 Coracoclavicular ligament
The acromioclavicular ligament

 Strengthens the upper aspect of the joint. It stretches between the upper surfaces
of clavicle and acromion
The coracoclavicular ligament

 Is a strong accessory ligament of acromioclavicular joint. It anchors the clavicle
to the coracoid process
 Has two parts: a medial conoid part (between the conoid tubercle of the clavicle
and the coracoid process) and a lateral trapezoid part (between the trapezoid line
of the clavicle and the coracoid process). The two parts are separated by fatty or a
bursa
Movements of Acromioclavicular Joint
Note that
 Acromioclavicular joint moves relative to the movement of the scapula (as no
muscle moves the joint directly)
Blood Supply and Innervation of Acromioclavicular Joint
Note that
 The joint is supplied by the suprascapular and acromial branches of
thoracoacromial arteries
 Branches of suprascapular, lateral pectoral and axillary nerves, supply the
acromioclavicular joint
Applied Anatomy
Note that
 Owing to the relative weakness of the capsule of acromioclavicular joint, a heavy
blow or a fall may lead to the dislocation of the point
 Tear of the strong acromioclavicular and coracoclavicular ligaments may occur
so that the shoulder separates from the clavicle – shoulder separation
Arterial Anastomoses around the Scapula
Arteries that anastomose around the scapula include:

 Suprascapular artery – a branch of thyrocervical trunk (from the first part of
subclavian artery)
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 Dorsal scapular artery – the deep branch of transverse cervical artery (also from
the first part of subclavian artery)
 Circumflex scapular artery – a branch of subscapular artery (from the 3rd part
of axillary artery)
 Thoracodorsal artery – a branch of subscapular artery (also from the 3rd part of
axillary artery)
Importance of Scapular Anastomoses
Note the following:

 Scapular anastomoses ensure adequate supply of blood to the highly mobile
scapula
 Scapular anastomoses permit the ligation of the axillary artery proximal to the
origin of subscapular artery (e.g., to arrest bleeding following laceration of this
vessel)
 Progressive narrowing (stenosis) of the axillary artery (e.g. in atherosclerosis)
may occur. However, blood could still reach the distal part of this vessel, and thus
the upper limb, via the anastomoses around the scapula
Brachial Plexus (Fig. 82, 83)

The brachial plexus is the network of nerves that supplies the skin, muscles and joints
of the upper limb. It extends laterally and downwards from the lower part of the neck,
passing behind the clavicle, to enter the axilla.
- 378 -
Figure 82. Brachial plexus and its branches
The brachial plexus

 Is a network of nerves that innervates the upper limb
 Has five roots commonly formed by ventral rami of C5, C6, C7, C8 and T1
spinal nerves (with minor contributions from the C4 and T2 nerves).
 Is defined as ‘prefixed’ when the contribution from C4 is relatively large, that
from T2 is absent (or small), while that from T1 is reduced
 Is defined as ‘postfixed’ when the contribution from T2 is large, that from the C4
is absent or small, while that from C5 is reduced
 Is defined as having a superomedial supraclavicular part, which lies above the
clavicle, in the posterior triangle of the neck; and an inferolateral infraclavicular
part, which lies below the clavicle, in the axilla
 Consists of the roots, trunks, divisions, cords and branches, from medial laterally
 Receives sympathetic fibres from grey rami communicantes of the middle
cervical ganglion (to C5 and C6 roots of the plexus) and inferior cervical (or
cervicothoracic) ganglion (to C7, C8 and T1 roots)
Supraclavicular part of the brachial plexus

 Is the part that lies above and medial to the clavicle, in the lower part of the neck
(posterior triangle). It joins the infraclavicular part of the plexus behind the
clavicle
 Comprises the roots and trunks of the brachial plexus
- 379 -
Infraclavicular part of the brachial plexus

 Is the part that lies below and lateral to the clavicle, in the axilla
 Consists of cords of the brachial plexus and the branches that arise from these
cords (in the axilla)
Roots of the Brachial Plexus (Fig. 82, 83)
The roots of the brachial plexus

 Are usually formed by the ventral rami of C5, C6, C8 and T1 spinal nerves
 Emerge from the vertebral canal above their respective vertebrae, except C8 and
T1 nerves, which emerge below the C7 and T1 vertebrae, respectively
 Pass laterally, between scalene medius (behind) and scalene anterior (anteriorly),
to enter the posterior triangle of the neck. In the latter, they lie above the 3 rd part
of the subclavian artery
 Are invested, together with the trunks of the brachial plexus, by an extension of
the prevertebral fascia of the neck
Branches of the Roots of the Brachial Plexus (Fig. 82)
Nerves that arise from the roots of the brachial plexus include:
 Dorsal scapular nerve (C5)
 Long thoracic nerve (C5, C6, C7)
 Nerves to scalene anterior, scalene medius, scalene posterior and longus colli
muscles (C5, C6, C7 and C8)
 A ramus to phrenic nerve (C5)
Dorsal Scapular Nerve (C5)
The dorsal scapular nerve

 Arises from the ventral ramus of C5
 Pierces scalene medius and descends behind levator scapulae, rhomboid major
and rhomboid minor, which it supplies
 Is accompanied by the dorsal scapular artery (along the medial border of the
scapula)
Long Thoracic Nerve (C5, C6, C7)
The long thoracic nerve

 Arises from the ventral rami of C5, C6 and C7 nerves. However, the contribution
from C7 may be absent
 Runs downwards behind the trunks of the brachial plexus to enter the axilla
(behind the first part of axillary artery)
 Descends on the axillary surface of serratus anterior (on the medial wall of the
axilla). It supplies serratus anterior
- 380 -
Note the following:

 Phrenic nerve is formed by rami from the ventral divisions of C3, C4 and C5
spinal nerves. The ramus from C5 joins the others anterior to scalene anterior
muscle
 Nerve rami to the scaleni and longus colli arise from C5, C6, C7 and C8 nerves
(close to the intervertebral foramina)
Figure 83. Relation of the brachial plexus to the axillary artery
Trunks of the Brachial Plexus (Fig. 82, 83)
The trunks of the brachial plexus

 Include the superior, middle and inferior trunks, all of which lie in the lower
part of the posterior triangle of the neck, above the 3rd part of the subclavian
artery (except the inferior trunk, which lies behind this vessel)
 Are crossed anteriorly by nerve to subclavius, transverse cervical artery and
suprascapular vessels

 Ventral rami of C5 and C6 spinal nerves normally unite to form the superior
trunk of the brachial plexus
- 381 -
 Ventral ramus of C7 continues as the middle trunk of the brachial plexus

 Ventral rami of C8 and T1 normally unite to form the inferior trunk of the
brachial plexus
 Each trunk of the brachial plexus divides into an anterior and a posterior division
(behind the medial ⅔ of the clavicle)
 As the trunks and divisions of the brachial plexus enter the axilla (from the neck),
they traverse the cervico-axillary canal
Branches of the trunks of the brachial plexus include:

 Suprascapular nerve (C5, C6); and
 Nerve to subclavius (C5, C6)
Suprascapular Nerve (C5, C6)
The suprascapular nerve

 Is a large branch that arises from the superior trunk of the brachial plexus. It
passes inferolaterally, above and parallel to the superior trunk of the plexus (deep
to trapezium and omohyoid)
 Traverses the suprascapular notch of the scapula (accompanied by
suprascapular artery) to enter the supraspinous fossa where it innervates
supraspinatus. Then it enters the infraspinous fossa via the spinoglenoid notch
(behind the ‘neck’ of the scapula) to innervate infraspinatus
 Sends an articular branch to the shoulder joint, and may give rise to a
cutaneous branch that innervates the proximal 3rd of the lateral aspect of the arm
(part of the territory supplied by axillary nerve).
Nerve to Subclavius (C5, C6)
Nerve to subclavius
 Arises from the ventral rami of C5 and C6 spinal nerves. It may communicate
with the phrenic nerve
 Descends anterior to the brachial plexus and the 3rd part of subclavian artery (in
the posterior triangle of the neck)
 Innervates subclavius muscle
Divisions of the Brachial Plexus (Fig. 82, 83)

 Each of the trunks of the brachial plexus divides into anterior and posterior
divisions, behind (or just above) the medial ⅔ of the clavicle. These divisions are
of equal size, except the posterior division of the lower trunk
 The anterior divisions innervate flexor muscles of the upper limb; while the
posterior divisions innervate extensor muscles
 The divisions of the brachial plexus combine in the axilla to form three cords of
the brachial plexus.
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Cords of the Brachial Plexus (Fig. 82, 83)
The cords of the brachial plexus

 Arise from the union of the divisions of the brachial plexus. They are designated
as medial, lateral and posterior cords
 Are all located in the axilla, in close relation to the axillary vessels
 Are arranged around the 2nd part of axillary artery according to their names; i.e.,
the lateral cord is lateral to axillary artery (Fig. 83)
 Give rise to several branches. These bear a similar relationship to the (3rd part of)
axillary artery as the cord from which they arise (except the medial root of
median nerve) (Fig. 83). That is, branches arising from the lateral cord lie lateral
to the axillary artery.
Regarding the formation of the cords of the brachial plexus

 The lateral cord is formed by the union of the anterior divisions of the upper and
middle trunks of brachial plexus
 The medial cord is the direct continuation of the anterior division of the lower
trunk of brachial plexus
 The posterior cord is formed by the union of the three posterior divisions of the
trunks of brachial plexus
The lateral cord of the brachial plexus

 Is formed by the union of the anterior divisions of the upper and middle trunks
of the brachial plexus. Thus, its nerve roots include C5, C6 and C7
 Runs inferolaterally (in the axilla), lateral to the 1st and 2nd parts of axillary artery
 Gives rise to three branches, all of which lie lateral to the 3rd part of axillary
artery. These include lateral pectoral and musculocutaneous nerves, and the
lateral root of median nerve; and each has nerve roots C5, C6 and C7.
Lateral Pectoral Nerve (C5, C6, C7)
This nerve
 Arises from the lateral cord of the brachial plexus (hence the name). However, it
may arise directly from the anterior divisions of the upper and middle trunks of
the plexus
 Passes anteromedially (anterior to axillary vessels), to pierce the clavipectoral
fascia and pectoralis major
 Is larger than the medial pectoral nerve (with which it communicates in the
axilla, via a branch). In the anterior axillary wall, the lateral pectoral nerve is
medial, not lateral, to the medial pectoral nerve
 Innervates pectorales major and minor. The latter is supplied via a
communicating branch to medial pectoral nerve in the axilla. It also supplies the
shoulder joint.
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Musculocutaneous Nerve (C5, C6, C7)
The musculocutaneous nerve

 Arises from the lateral cord of the brachial plexus. Initially, it descends between
axillary artery and coracobrachialis (in the axilla). Then, it pierces
coracobrachialis to continue inferolaterally (in the arm), between biceps brachii
and brachialis
 Reaches the lateral aspect of the elbow, where it pierces the deep fascia (between
biceps and brachioradialis) to continue distally in the forearm as the lateral
cutaneous nerve of the forearm
 Innervates coracobrachialis (via a branch that arises before the nerve pierces that
muscle), biceps and brachialis
 Also innervates the elbow joint (via the branch to brachialis)
Medial Cord of Brachial Plexus (C8, T1)
The medial cord of the brachial plexus

 Is the continuation of the anterior division of the lower trunk of the brachial
plexus. It receives a branch from C7
 Descends first behind the 1st part of axillary artery, and then runs laterally (medial
to the 2nd part of this artery)
 Give rise to medial root of median nerve, medal pectoral nerve, medial
cutaneous nerves of the forearm and ulnar nerve, all of which lie medial to the 3 rd
part of axillary artery (except the medial root of median nerve, which crosses this
vessel anteriorly)
Note that
 Each branch of the medial cord (C8, T1) has contributions from ventral rami of
C8 and T1 spinal nerves
Medial Root of Median Nerve (C8, T1)
Median root of median nerve

 Passes laterally from the medial cord, anterior to the 3rd part of axillary artery, to
join the lateral root of the nerve (with which it forms the median nerve)
Medial Pectoral Nerve (C8, T1)
The medial pectoral nerve

 Is the first side branch of the medial cord of brachial plexus. It arises as this cord
descends behind the 1st part of axillary artery
 Passes forwards, between the axillary artery and vein, and is joined (anterior to
the artery) by a communicating branch from the lateral pectoral nerve
 Pierces pectoralis minor to innervate this muscle and the overlying pectoralis
major
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Medial Cutaneous Nerve of the Arm (C8, T1)
The medial cutaneous nerve of the arm

 Arises from the medial cord of the brachial plexus (next to the origin of the
medial pectoral nerve), and then crosses anterior (or posterior) to axillary vein
 Lies medial to axillary vein as it passes towards the arm
 Communicates with the intercostobrachial nerve (in the axilla). Its size varies
inversely with that of this nerve
 Pierces the deep fascia halfway down the medial aspect of the arm to innervate
the skin of the distal half of the medial aspect of the arm
Medial Cutaneous Nerve of the Forearm (C8, T1)
The medial cutaneous nerve of the forearm

 Arises in the axilla from the medial cord of the brachial plexus
 Runs laterally, between the axillary artery and vein, to enter the arm, where it
lies medial to the brachial artery
 Pierces the deep fascia, with the basilic vein, halfway down the medial aspect of
the arm. Then, it
 Divides into two branches: a larger anterior branch, which passes distally,
anterior to the median cubital vein, to the anteromedial aspect of the forearm; and
a smaller posterior branch, which descends anterior to the medial humeral
epicondyle (medial to basilic vein) to the posteromedial aspect of the forearm
 Innervates the skin of the distal part of the anterior aspect of the arm (via its
anterior branch), and that of the medial and adjoining anterior and posterior
surfaces of the forearm, down to the wrist, via both branches
 Communicates with the medial cutaneous nerve of the arm and the dorsal
branch of ulnar nerve
Ulnar Nerve (C8, T1)
The ulnar nerve

 Arises from the medial cord of the brachial plexus. It is one of the two terminal
branches of this cord
 Lies between the axillary artery and vein (in the axilla). Here, it is behind the
medial cutaneous nerve of the forearm. In the arm, it descends on the medial
aspect of the brachial artery (down to the middle of the arm)
 Pierces the medial intermuscular septum at mid-arm level, and then continues
inferomedially, along the anterior border of the medial head of triceps
(accompanied by the superior ulnar collateral artery)
 Enters the elbow between the olecranon and the medial epicondyle of the
humerus, and then runs distally, in a groove on the dorsal aspect of the medial
epicondyle
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 Enters the forearm by passing between the two heads of flexor carpi ulnaris. It
continues distally between this muscle superficially and flexor digitorum
profundus deeply
 Lies lateral to flexor carpi ulnaris, in the distal half of the forearm, where it is
deep to the skin and fascia
 Pierces the deep fascia (with the ulnar artery), just proximal to flexor
retinaculum. It then continues distally, superficial to the latter and lateral to
pisiform
 Divides finally into superficial and deep branches, deep to palmaris brevis
 Has no branches in the axilla and arm
Note: For the distribution of the ulnar nerve in the forearm and hand, see the
respective regions.
Posterior Cord of Brachial Plexus (C5 – T1)
The posterior cord of the brachial plexus

 Is formed by the union of the posterior divisions of the three trunks of the
brachial plexus
 Lies lateral to the 1st part of axillary artery, but passes behind the 2nd part of this
vessel (in the axilla)
 Gives rise to five branches, all of which lie posterior to the 3rd part of axillary
artery.
Branches of the posterior cord of the brachial plexus include:

 Upper and lower subscapular nerves
 Thoracodorsal nerve;
 Axillary and radial nerves.
Upper Subscapular Nerve (C5, C6)
The upper subscapular nerve

 Arises from the posterior cord of brachial plexus at a higher level compared to
the lower subscapular nerve
 Runs posteromedially onto the subscapularis, which it innervates. It also
innervates the shoulder joint
 Is smaller than the lower subscapular nerve; and may exist as two or three
separate nerves
Lower Subscapular Nerve (C5, C6)
The lower subscapular nerve

 Arises from the posterior cord of the brachial plexus, close to the origin of the
axillary nerve. It descends (in the axilla) behind the subscapular artery
 Innervates the inferolateral part of subscapularis and teres major
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Thoracodorsal Nerve (C5, C7, C8)
The thoracodorsal nerve

 Arises from the posterior cord of brachial plexus, between the origins of upper
and lower subscapular nerves
 Descends inferomedially, first over subscapularis (accompanied by subscapular
artery), and then over the anterolateral aspect of latissimus dorsi (accompanied
by thoracodorsal artery)
 Innervates the latissimus dorsi
Axillary Nerve (C5, C6)
The axillary nerve

 Is one of the terminal branches of the posterior cord o brachial plexus
 Descends over subscapularis, through the quadrangular space (accompanied
by circumflex humeral vessels), to the inferior aspect of the shoulder joint
 Divides into anterior and posterior branches
The anterior branch of axillary nerve

 accompanies the posterior circumflex humeral vessels as it winds round the
surgical neck of the humerus, deep to the deltoid (to reach the anterior border of
humeral surgical neck)
 Innervates deltoid. A few fibres descend through this muscle to the skin over its
lower part
The posterior branch of axillary nerve

 Gives a branch to teres minor; this bears a pseudoganglion
 Also gives a few branches to the posterior part of deltoid
 Pierces the deep fascia at the lower part of the posterior border of deltoid, passing
round this border to end in the overlying skin (as the upper lateral cutaneous
nerve of the arm
 Innervates the skin over the lower part of deltoid and lateral head of triceps,
down to the middle of the arm (as the upper lateral cutaneous nerve of the
arm)
Radial Nerve (C5 – T1)
The radial nerve

 Is the direct continuation of the posterior cord of the brachial plexus. It is the
largest branch of this plexus.
In the axilla, the radial nerve

 Runs laterally, behind the 3rd part of axillary artery, and anterior to subscapularis
teres major and latissimus dorsi
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 Gives rise to the posterior cutaneous nerve of the arm, which innervates the
skin of posterior aspect of arm (down to the olecranon)
 Also gives rise to nerve to the long head of triceps brachii
In the arm, the radial nerve

 Initially accompanies the other elements of the neurovascular bundle of the
arm; in this bundle, it lies behind the brachial artery
 Is the first structure to leave the neurovascular bundle of the arm, as it turns
inferolaterally to pass between the long and medial heads of triceps (accompanied
by profunda brachii artery)
 Runs (further inferolaterally) in the spiral groove for the radial nerve, on the
posterior aspect of the shaft of the humerus, deep to the lateral head of triceps
 Reaches the lateral border of the distal 3rd of humeral shaft, where it pierces the
lateral intermuscular septum of the arm
 Continuous distally in the anterior compartment (of the arm), passing anterior
to the lateral epicondyle of the humerus (as it does so)
 Divides into a superficial and a deep branch, anterior to the lateral epicondyle
of the humerus (between brachialis and brachioradialis)
Braches of the radial nerve in the arm include:

 Lower lateral cutaneous nerve of the arm. This innervates the skin of the lower
part of lateral of lateral aspect of the arm
 Posterior cutaneous nerve of the forearm, to the skin of the dorsal aspect of
forearm
 Medial muscular branches, which arise on the medial aspect of the arm. They
innervate the medial and long heads of triceps
 A posterior muscular branch, which arises as the radial nerve traverses the
radial groove of the humerus. It innervates the medial and lateral heads of triceps
and the anconeus. The latter is innervated via a branch that descends through
medial head of triceps
 Lateral muscular branches, which arise anterior to the lateral intermuscular
septum of the arm. They innervate brachialis, brachioradialis and extensor carpi
radialis longus
Note: For the course and distribution of radial nerve (superficial and deep branches)
in the forearm and hand, see the respective regions.
Median Nerve (C5 – C8, T1)
Regarding the median nerve, note the following:

 It arises from the brachial plexus in the axilla; the median nerve is formed by the
union of two roots: a medial root (C8, T1) from the medial cord, and a lateral
root (C5, C6, C7) from the lateral cord. The medial root passes inferolaterally,
anterior to the 3rd part of axillary artery, to join the lateral root
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 In the axilla, the median nerve lies lateral to the 3rd part of axillary artery. In the
arm, it is a content of the neurovascular bundle
 Median nerve has no branches in the axilla. However, it gives muscular
branches to the forearm and muscular and cutaneous branches to the hand.
Note: For the course and distribution of the median nerve distal to the axilla, see the
respective regions.
Applied Anatomy of the Brachial Plexus

 In a postfixed type of brachial plexus (see above), the inferior trunk may be
compressed by the first rib. This produces certain neurological deficits
 Brachial block (anaesthesia of the larger part of the upper limb) can be effected
by injecting an anaesthetic into the angle between the clavicle and the posterior
border of sternocleidomastoid
 Erb-Duchenne palsy involves injury to the C5/C6 nerve roots or upper trunk of
the plexus. In this palsy, the arm hangs loosely at the side, with the forearm
pronated, while the elbow is extended (‘waiter’s tip position’). This is due to
paralysis of deltoid, biceps brachii, brachialis and brachioradialis; anaesthesia
of lateral aspect of the limb also occurs
 In Klumpke’s palsy, the C8/T1 nerve roots (or lower trunk) of the brachial
plexus are injured. This produces paralysis of the muscles of the forearm and
hand, resulting in clawhand. Cervical sympathetic nerves are also involved,
resulting in pupillary disturbances
 Erb-Duchenne palsy has a higher frequency than Klumpke’s palsy
 In hyperabduction syndrome of the upper limb, the brachial plexus and axillary
vessels are compressed between the coracoid process and pectoralis minor; this
produces pain, etc, in the limb
 Crutch palsy involves damage to the radial nerve in the axilla (as does sleep
palsy or Saturday night palsy). This results from repeated pressure of the crutch
on the radial nerve, and is characterised by paralysis of extensor muscles of the
wrist, fingers and thumb.
The Arm
The arm (or brachium) is the part of the upper limb between the shoulder and the
elbow. The bone of the arm is the humerus, while its muscles are arranged into
flexor and extensor groups. Besides, certain neurovascular structures traverse the
arm en route to the forearm and hand.
Cutaneous Innervation of the Arm
The skin of the arm is innervated by the following nerves:

 Intercostobrachial nerve
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 Medial cutaneous nerve of the arm

 Upper lateral cutaneous nerve of the arm
 Lower lateral cutaneous nerve of the arm; and
 Posterior cutaneous nerve of the arm.
Note: Medial and posterior cutaneous nerves of the forearm also give some rami
to the arm (see below).
Intercostobrachial nerve (T2)
The intercostobrachial nerve

 Is the lateral cutaneous branch of the ventral ramus of T2 spinal nerve
 Enters the axilla by piercing the intercostal muscles of the 2nd intercostal space
and the serratus anterior
 Runs postero-inferiorly through the axilla and then pierce the deep fascia, close to
the posterior axillary fold, to enter the medial aspect of the arm
 Communicates with the medial cutaneous nerve of the arm (in the axilla), and
with the posterior cutaneous nerve of the arm (in the arm)
 Varies inversely in size with the medial cutaneous nerve of the arm
 Innervates the skin of the floor of the axilla and the posteromedial aspect of the
upper half of the arm
Medial Cutaneous Nerve of the Arm (C8, T1)

The medial cutaneous nerve innervates the distal half of the medial aspect of the arm.
Note: For details, see the medial cord of the brachial plexus.
Upper Lateral Cutaneous Nerve of the Arm (C5, C6)

The upper lateral cutaneous nerve of the arm innervates the skin of the upper part of
the lateral aspect of the arm. It arises from the axillary nerve.
Note: For details, see axillary nerve.
Lower Lateral Cutaneous Nerve of the Arm (C5, C6)
The lower lateral cutaneous nerve of the arm

 Arises from the radial nerve (in the arm)
 Pierces the lateral head of triceps, distal to deltoid tuberosity of the humerus, to
reach the front of the elbow
 Innervates the skin of the lower part of the lateral aspect of the arm.
Posterior Cutaneous Nerve of the Arm
The posterior cutaneous nerve of the arm

 Arises from the radial nerve (in the axilla)
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 Enters the arm by piercing the deep fascia near the posterior axillary fold
 Innervates the skin of the posterior surface of the arm.
Note: Medial and posterior cutaneous nerves of the forearm contribute to the
cutaneous innervation of the distal parts of the anteromedial and posterolateral
aspects of the arm, respectively.
Bone of the Arm
Humerus (Fig. 84)
The humerus
 Is the only bone of the arm (Fig. 84)
 Articulates proximally with the glenoid cavity of the scapula at the shoulder
joint (Fig. 77), and distally with the bones of the forearm (radius and ulna) at the
elbow joint
 Is surrounded by muscles, such that it is, to a very large extent, impalpable
(except in its distal part)
 Has a proximal end, a shaft, and a distal end (Fig. 84).
The proximal end of the humerus consists of:

 A hemispherical head (for glenohumeral articulation)
 An anatomical neck (which circumscribes and separates the head from the
tubercles) (Fig. 84)
 Two tubercles: greater and lesser tubercles (for muscular attachment)
The head of the humerus

 Is a hemispherical surface, covered by hyaline articular cartilage. It articulates
with scapular glenoid cavity at the shoulder joint
 Is directed upwards and posteromedially (when the arm is by the side).
The anatomical neck of the humerus

 Is a narrow constriction that encircles humeral head and delineates its margin
from the tubercles
 Gives attachment to the capsule of shoulder joint (except inferiorly)
 Is relatively strongly and rarely fractured.
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A B
Figure 84. The humerus. A, Posterior surface; B, Anterior surface
The greater tubercle of the humerus

 Is the most lateral bony prominence of the proximal end of the humerus. It is
overlaid by deltoid (as it projects beyond the acromion laterally)
 Gives attachment to supraspinatus, infraspinatus and teres minor (from above
downwards)
 Has a crest that descends onto the shaft of the humerus. This gives attachment to
pectoralis major
The lesser tubercle of the humerus

 Is a prominence on the anterior aspect of the humerus, just distal to the
anatomical neck. It gives attachment to subscapularis
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 Can be felt through the deltoid, just lateral to the tip of the coracoid process (3
cm below the tip of the acromion)
 Has a crest that descends onto the shaft of the humerus. This gives attachment to
teres major
 Is separated from the greater tubercle by an intertubercular groove. This
continues onto the shaft of the humerus (between the crests of the lesser and
greater tubercles)
The intertubercular (bicipital) groove of the humerus

 Is a vertical tunnel on the anterior aspect of the proximal end of the humerus and
adjacent part of the shaft (i.e., between the lesser and greater tubercles and their
crests)
 Is converted into a canal by the transverse humeral ligament (which stretches
between the greater and lesser tubercles)
 Transmits the tendon of the long head of biceps brachii
The surgical neck of the humerus

 Is the region where the proximal end of the humerus narrows into the shaft (i.e. it
links the head, tubercles and anatomical neck to the shaft of the humerus)
 Is related medially and posteriorly to the axillary nerve and the posterior
circumflex humeral artery. These wind round it
 Is more frequently involved in fracture compared to the anatomical neck; and the
axillary nerve is at risk in such fractures. Injury to this nerve results in paralysis
of deltoid
 Gives attachment to the lower part of the fibrous capsule of the shoulder joint
The shaft of the humerus

 Is the roughly cylindrical part that links the proximal and distal ends of the
humerus (Fig. 84)
 Has three border – anterior, lateral and medial borders. These separate the three
surfaces of the shaft, which include anterolateral, anteromedial and posterior
surfaces
 Widens transversely in its lower part where its medial and lateral borders become
sharp and are referred to as the medial and lateral supracondylar ridges (or
crests), respectively. The ridges end below at the medial and lateral epicondyles
 Presents a deltoid tuberosity midway down its anterolateral surface; this gives
attachment to deltoid
 Is crossed obliquely (from medial laterally), at the middle 3rd of its posterior
surface, by a groove for the radial nerve. The upper end of this groove usually
contains a nutrient foramen
 Bears a nutrient foramen just anterior to the middle of its medial border
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The spiral groove for radial nerve

 Descends obliquely (from medial laterally) behind the middle 3rd of the humerus
(Fig. 84)
 Transmits the radial nerve and profunda brachii artery
 Usually presents a nutrient foramen in its upper part
The distal end of the humerus

 Is the condyle of the humerus; it lies distal to humeral shaft
 Is widened transversely, such that it has anterior and posterior surfaces
 Has an articular and a non-articular part. The former consists of the capitulum
and trochlea; while the latter consists of the medial and lateral epicondyles,
olecranon fossa, radial fossa and coronoid fossa
 Articulates with the ulna and radius at the elbow joint, via its articular part
(capitulum and trochlea)
The articular part of the distal end of the humerus

 Consists of the trochlea and capitulum. These articulates with the bones of the
forearm at the elbow joint
The trochlea of the humerus

 Lies medial to the capitulum, on the inferior and adjacent anterior and posterior
surfaces of humeral condyle
 Resembles a pulley (hence the name)
 Articulates with the trochlea notch of the ulna
The capitulum
 Lies lateral to trochlea, on the inferior (and adjacent anterior) aspect of humeral
condyle. It does not extend to the posterior surface of condyle
 Articulates with the head of the radius.
The non-articular part of humeral condyle

 Consists of the medial and lateral epicondyles, olecranon fossa, radial fossa and
coronoid fossa
 Is not involved in the formation of the elbow joint.
The medial epicondyle of the humerus

 Is located superomedial to the trochlea, and is subcutaneous. It is more
prominent than the lateral epicondyle
 Is continuous above with the medial supracondylar ridge of humeral shaft
 Bears (on its posterior aspect) a shallow sulcus for the ulnar nerve and ulnar
collateral vessels
 Gives attachment to the common flexor tendon, pronator teres and ulnar
collateral ligament.
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The lateral epicondyle of the humerus

 Is located superolateral to the capitulum, and it is subcutaneous. It is less
prominent compared to the medial epicondyle
 Is continuous above with the lateral supracondylar ridge
 Gives attachment to common extensor tendon, anconeus and radial collateral
ligament.
The radial fossa

 Lies on the anterolateral aspect of humeral condyle, just above the capitulum, and
lateral to the coronoid fossa
 Accommodates the margin of head of the radius in full flexion of the elbow
joint.
The coronoid fossa

 Is a depression on the anterior surface of humeral condyle, just above the trochlea
(and medial to the radial fossa)
 Accommodates the coronoid process of the ulna in full flexion of the elbow
joint.
The olecranon fossa

 Lies above the trochlea, on the posterior surface of humeral condyle;
 Accommodates the apex of the olecranon (when the elbow joint is extended)
 Has a floor which is usually thin or partially deficient.
Ossification of the Humerus
The humerus
 Begins to ossify by the 8th week of intrauterine life
 Ossifies from 8 centres (located in its shaft, head, greater and lesser tubercles,
capitulum, trochlea, medial epicondyle and lateral epicondyle)
 Is usually completely ossified by 20–22 postnatal years in males and 18–20 years
in female. By this time, all ossification centres finally fuse.
Applied Anatomy of the Humerus

 The surgical neck of the humerus is more frequently involved in fracture,
especially in the elderly, who suffer from osteoporosis
 In fracture of humeral surgical neck, the axillary nerve is at risk. Injury to the
axillary nerve will produce paralysis of deltoid and teres minor, and anaesthesia
of the skin over the lower part of deltoid
 In mid-shaft fracture of the humerus, the radial nerve is at risk. Injury to this
nerve will result in wrist drop (owing to paralysis of extensor muscles of the
forearm)
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 The nerve to the long head of triceps is spared when the radial nerve is injured
in the arm. Thus, this head of triceps is not paralysed
 Fracture of the medial epicondyle of the humerus may injure the ulnar nerve
(which lies in a groove behind this epicondyle)
 Because the medial epicondyle fuses with humeral shaft at a later time than the
lateral epicondyle, radiological examination of the distal end of the humerus may
result in a wrong diagnosis of fracture of this bone
 The median nerve is also at risk in fracture of the distal part of the humerus
 During a fall on the point of the shoulder, avulsion fracture of the greater
tubercle of the humerus may occur, especially in the elderly
 Following amputation of the arm in young subjects, the proximal humeral stump
continues to grow because longitudinal growth of the humerus is largely a
function of the proximal growth cartilage.
Anterior (Flexor) Compartment of the Arm (Fig. 75)
The anterior compartment of the arm

 Lies anterior to the humerus and the medial and lateral intermuscular septa.
These separate it from posterior compartment
 Contains three flexor muscles, blood vessels and nerves.
Muscles of the Anterior Compartment of the Arm
Muscles of the anterior compartment of the arm include:

 Biceps brachii
 Brachialis; and
 Coracobrachialis
Biceps Brachii (Fig. 75)
The biceps brachii

 Arises by two heads; these are the short and long heads
 Inserts by two tendons
 Acts on three joints (elbow, shoulder and proximal radio-ulnar joints)
 Is spindle-shaped (fusiform) in outline.
a) Short head: tip of the coracoid process
b) Long head: supraglenoid tubercle of the scapula
Note: Tendon of the long head traverses the shoulder joint and the bicipital groove.
Distal attachment:
a) Radial tuberosity (via a strong tendon)
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b) Deep fascia over the origins of flexors of the forearm (via the bicipital
aponeurosis)
Innervation: Musculocutaneous nerve (C5, C6)
Actions:
a) Supinates the forearm (at the proximal radio-ulnar joint)
b) Flexes the elbow joint
c) Flexes the shoulder joint
Test of integrity: The forearm is supinated and the elbow joint is flexed against
resistance.
Applied Anatomy

 The long head of biceps brachii may be displaced from the bicipital groove.
However, this can be corrected with little difficulty
 Inflammation of the long head of biceps (biceps tendinitis) may occur following
repetitive microtrauma of the synovial sheath that invests its tendon. This
produces pain in the shoulder
 In biceps tendinitis or when lifting heavy weight, etc, the long head of biceps
may be detached from its supraglenoid attachment.
Brachialis (Fig. 75)
The brachialis
 Is a flattened muscle located deep to biceps brachii, in the distal part of the arm. It
lies anterior to the elbow joint, and thus forms the floor of the cubital fossa
 Is the chief flexor of the elbow joint
 Has double innervation.
a) Distal half of the anterior surface of the humerus
b) Adjacent intermuscular septa
Distal attachment:
a) Coronoid process and tuberosity of the ulna (via a broad thick tendon)
b) Fibrous capsule of the elbow joint.
Innervation:
a) Musculocutaneous nerve (C5, C6)
b) Radial nerve (C7); this supplies the lateral part of the muscle
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Actions:
a) Flexes the elbow joint
b) Prevents the fibrous capsule of the elbow joint from becoming trapped in the joint
during flexion
Coracobrachialis (Fig. 75)
The coracobrachialis
 Lies in the upper part of the medial aspect of the arm. It is anterior to the
shoulder joint
 Is pierced by the musculocutaneous nerve.
Proximal attachment: Tip of the coracoid process of the scapula (together with
bicep’s short head.
Distal attachment: A point midway along the medial border of the humerus
(between brachialis anteriorly and triceps posteriorly).
Innervation: Musculocutaneous nerve (C5, C6, C7)
Action:
a) Flexes the arm
b) Adducts the shoulder joint.
Posterior Compartment of the Arm
This compartment contains:

 Triceps brachii; and
 Certain vessels and nerves, including profunda brachii vessels and radial
nerve.
Triceps Brachii (Fig. 85)
The triceps brachii

 Is the only muscle of the posterior compartment of the arm
 Has three heads of origin: long, medial and lateral heads.
 Has a common tendon of insertion (distally). This is separated from the olecranon
by a subtendinous bursa
 Passes beneath the shoulder joint (long head only) and behind the elbow joint.
Thus, it acts on both joints
 Is the chief extensor of the elbow joint.
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Long head: Infraglenoid tubercle of the scapula; and labrum glenoidale and fibrous
capsule of the shoulder joint.
Medial head:
a) Posterior surface of humeral shaft (below and medial to radial groove)
b) Posterior aspects of lateral and medial intermuscular septa
Lateral head:
a) Posterior aspect of the upper part of the humerus (above and lateral to radial
groove)
b) Lateral intermuscular septum.
Note: The medial head is larger than the lateral head and is overlapped by the lateral
and long heads of the muscle.
Distal attachment:
 Proximal part of the olecranon of ulna; and
 Adjacent deep fascia of the forearm (via a broad flattened tendon).
Innervation: Radial nerve (C6, 7, 8).
Figure 85. Posterior compartment of the arm

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Actions:
a) Extends the elbow joint (main action);
b) Supports the head of the humerus (from below) when the arm is abducted (long
head alone).
Test of Integrity: First abduct the arm to the horizontal plane (90o), and then extend
the flexed forearm against resistance.
Articularis Cubiti
This muscle
 Is formed by some deep fibres of the medial head of triceps
 Inserts into the posterior aspect of the capsule of the elbow joint
 Prevents the capsule of elbow joint from being trapped in this joint during
extension of the elbow.
Neurovascular Bundle of the Arm

 In the upper medial part of the arm, several nerves and blood vessels run together,
thereby forming a neurovascular bundle
 Proximal to the insertion of coracobrachialis, the neurovascular bundle of the
arm contains the median, radial and ulnar nerves, medial cutaneous nerve of
the forearm, as well as the brachial artery, brachial veins and basilic veins
 Nerves and vessels of the neurovascular bundle of the arm leave the bundle in
sequence as they approach the elbow
 The radial nerve is the first to leave the neurovascular bundle, followed in
succession, by the ulnar nerve and the medial cutaneous nerve of the forearm
(accompanied by basilic vein)
 Only the brachial artery, brachial veins and median nerve remain in the
neurovascular bundle in the distal part of the arm.
Nerves of the Arm
These include:
 Radial nerve
 Musculocutaneous nerve
 Median nerve; and
 Ulnar nerves.
Note: For the course and distribution of the radial, ulnar and musculocutaneous
nerves in the arm, see the brachial plexus.
- 400 -
For the course and distribution of the medial cutaneous nerve of forearm, see the
brachial plexus also.
Median Nerve
Regarding the median nerve, note these points:

 In the proximal part of the arm, the median nerve lies lateral to the brachial
artery (as a content of the neurovascular bundle)
 At the mid-arm level, the median nerve usually lies anterior to the brachial
artery (as it crosses from the lateral to the medial side of this vessel). However, it
may cross behind this artery
 In the distal part of the arm, the median nerve lies on brachialis. Here, it is
medial to the brachial artery
 The median nerve enters the cubital fossa by passing between brachialis (behind)
and bicipital aponeurosis (anteriorly). Here, the nerve is medial to the brachial
artery
 The median nerve is the only nerve that traverses the whole length of the
neurovascular bundle of the arm.
Branches of the Median nerve in the Arm (Fig. 86)
Note that
 In the arm, the median nerve innervates neither skin nor muscles
 The only branches given off by median nerve in the arm are vascular branches
to the brachial artery and a branch to pronator teres (a forearm muscle).
Brachial Artery (Fig. 86)
The brachial artery

 Is the main artery of the upper limb. It commences at the lower border of teres
major as a continuation of the 3rd part of axillary artery
 Traverses the entire length of the arm (as a content of brachial neurovascular
bundle), accompanied by the median nerve and two brachial veins
 Ends distally in the cubital fossa, at the level of the neck of the radius. Here, it
divides into radial and ulnar arteries.
 Is superficial and thus palpable throughout its course, being covered only by skin
and fasciae anteromedially.
Relations of the Brachial Artery in the Arm
In the proximal part of the arm, relations of the brachial artery include:
 Anteriorly: skin, fasciae and biceps brachii (which overlaps it)
 Laterally: median nerve, coracobrachialis and humerus
 Medially: medial cutaneous nerve of the forearm, ulnar nerve and basilic vein
 Posteriorly: long head of triceps, radial nerve and profunda brachii artery.
- 401 -
In the distal part of the arm, relations of brachial artery include:

 Anteriorly: skin, fasciae, biceps brachii (which overlaps it) and median nerve
(which crosses it from lateral medially)
 Laterally: biceps brachii
 Medially: median nerve and basilic vein (the two being separated by the deep
fascia)
 Posteriorly: brachialis, medial head of triceps and humerus
In the cubital fossa, relations of the brachial artery include:

 Anteriorly: skin, fasciae, median cubital vein and bicipital aponeurosis. The
latter separates the brachial artery from the median cubital vein and skin
 Laterally: biceps tendon, radial nerve and brachioradialis
 Medially: median nerve and pronator teres muscle
 Posteriorly: brachialis and elbow joint.
Branches of the Brachial Artery
In the arm, branches of the brachial artery include:

 Profunda brachii artery – the main artery of the arm
 Nutrient artery – to the humerus
 Superior ulnar collateral artery – this joins the anastomoses around the elbow
joint
 Inferior ulnar collateral artery – also joins the anastomoses around the elbow
joint
 Muscular branches – to muscles of the flexor compartment of the arm.
Note: The two terminal branches of the brachial artery are the radial and ulnar
arteries.
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Figure 86. Brachial artery and its branches
Profunda Brachii Artery (Deep Artery of the Arm)
The profunda brachii artery

 Is the first and the largest branch of the brachial artery. It arises from the
posteromedial aspect of this vessel
 Runs inferolaterally through the radial groove (behind humeral shaft), where it
accompanies the radial nerve (between the lateral and medial heads of triceps)
 Divides terminally (behind the humerus) into radial collateral artery (or anterior
descending artery) and middle collateral artery (or posterior descending artery).
Branches of Profunda Brachii Artery
These include:
 Muscular branches, which supply muscles of the posterior compartment of the
arm
 Nutrient artery, which supplies the humerus
 Deltoid (or ascending) branch, which supplies deltoid
 Radial collateral artery (see below);
 Middle collateral artery (see below).
Radial Collateral Artery (or Anterior Descending Branch)

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Radial collateral artery

 Is the continuation of the profunda brachii artery. It accompanies the distal part
of the radial nerve
 Pierces the lateral intermuscular septum of the arm, and passes anterior to the
lateral epicondyle of the humerus (accompanied by radial nerve)
 Ends by anastomosing with the radial recurrent artery (a branch of radial
artery).
Middle Collateral Artery (or Posterior Descending Branch)
The middle collateral artery

 Is the larger of the two terminal branches of profunda brachii artery. It arises
from the latter in the radial groove (behind the humerus), and then descends
through the medial head of triceps
 Descends as far down as the posterior surface of the lateral humeral epicondyle
below
 Anastomoses with the interosseous recurrent artery.
The nutrient artery

 Enters the humerus behind the deltoid tuberosity.
 Supplies the humerus, but may be absent.
The deltoid branch

 Ascends between the long and lateral heads of triceps
 Anastomoses with the descending branch of the posterior circumflex humeral
artery (from the axillary artery)
Superior Ulnar Collateral artery
The superior ulnar collateral artery

 Arises from the brachial artery, near the middle of the arm. However, it may
arise from profunda brachii artery
 Pierces the medial intermuscular septum of the arm (with the ulnar nerve), and
descends in the posterior compartment of the arm (behind this septum)
 Descends behind the medial epicondyle of the humerus (accompanied by the
ulnar nerve) to reach the deep aspect of flexor carpi ulnaris
 Anastomoses with the posterior ulnar recurrent and inferior ulnar collateral
arteries.
Inferior Ulnar Collateral Artery
The inferior ulnar collateral artery

 Arises from the brachial artery about 5 cm above the elbow. It then runs
inferomedially behind median nerve
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 Divides into two branches that pass anterior and posterior to the medial
epicondyle of the humerus
 Anastomoses with the anterior ulnar recurrent artery through its anterior
branch (anterior to the medial epicondyle)
 Anastomoses with the posterior ulnar recurrent and the superior ulnar
collateral arteries through its posterior branch (behind the medial epicondyle).
Nutrient Artery of the Humerus
The nutrient artery of the humerus

 Arises from brachial artery in the upper part of the arm
 Enter the nutrient foramen of the humerus near the middle of the anteromedial
surface of this bone.
Applied Anatomy of the Brachial Artery

 Compression of the brachial artery in the arm can readily be done almost at all
levels
 When compressing the brachial artery, the pressure is directed laterally in the
upper arm; posteriorly in the lower arm; and posterolaterally at the mid-arm level
(the best site)
 The brachial artery offers a suitable site for the estimation of blood pressure
(with the aid of a sphygmomanometer and a stethoscope)
 Clamping of the brachial artery distal to the origin of profunda brachii artery does
not produce ischaemia owing to the collateral circulation afforded by the
anastomoses around the elbow joint
 The brachial artery may be lacerated in fracture of the humerus
Veins of the Arm (Fig. 87)
Vein of the arm include:

 Superficial veins: cephalic and basilic veins
 Deep veins: a pair of brachial veins
Cephalic Vein (Fig. 87)
The cephalic vein

 Is the ‘preaxial vein’ of the upper limb. It ascends through the subcutaneous
tissue of the anterolateral aspect of the arm
 Is accompanied by the deltoid branch of thoracoacromial artery as it ascends in
the deltopectoral groove (between deltoid and pectoralis major)
 Enters the deltopectoral triangle where it turns posteriorly to pierce the
clavipectoral fascia
 Terminates at the upper end of the axillary vein, near the apex of the axilla.
- 405 -
The basilic vein

 Lies in the subcutaneous tissue of the medial aspect of the lower half of the arm
 Pierces the deep fascia near the middle of the arm and then ascends medial to the
brachial artery, in the upper half of the arm
 Continues as the axillary vein at the lower border of teres major.
Figure 87. Superficial veins of the upper limb
Basilic Vein (Fig. 87)
Brachial Veins
- 406 -
These veins
 Begin in the cubital fossa by the union of the radial and ulnar veins
 Accompany the brachial artery through the arm (as a pair of veins
interconnected by anastomotic vessels)
 Join the basilic vein at the lower border of teres major. The basilic vein becomes
the axillary vein at the same point
 Possess valves along their length. These ensure unidirectional flow of blood
towards the axilla.
Major Anatomical Events Represented at (or near) the Mid-Arm Level
At the mid-shaft region of the arm,

 The radial groove descends laterally behind the humerus. This groove transmits
the radial nerve and profunda brachii artery
 The radial nerve descends laterally through the radial groove (behind the
humerus)
 Profunda brachii artery accompanies the radial nerve through the radial groove
 The humerus presents a deltoid tuberosity (for deltoid)
 A nutrient foramen opens onto the anteromedial surface of the humerus
 The superior ulnar collateral artery arises from the brachial artery
 The ulnar nerve, basilic vein, and superior ulnar collateral artery pierce the
deep fascia
 The median nerve crosses the brachial artery anteriorly (from lateral medially)
 Deltoid and coracobrachialis insert onto the lateral and medial aspects of the
humerus, respectively
 Medial cutaneous nerve of the forearm pierces the deep fascia to become
subcutaneous.
Forearm
The forearm
 Is the region of the upper limb between the elbow proximally and the wrist
distally
 Has two long bones: the ulna (medially) and the radius (laterally)
 Is divided into a flexor compartment (anteriorly) and an extensor compartment
(posteriorly)
 Contains several muscles, nerves (ulnar, median and [branches of] radial nerves)
and blood vessels.
Cutaneous Innervation of the Forearm
Nerves that innervate the skin of the forearm include:

 Medial cutaneous nerve of the forearm. This innervates the skin of the medial
and adjacent anterior and posterior surfaces of the forearm
- 407 -
 Lateral cutaneous nerve of the forearm. This innervates the skin of the lateral
and adjacent anterior and posterior surfaces of the forearm
 Posterior cutaneous nerve of the forearm. This innervates the skin of the
posterior aspect of the forearm.
Medial Cutaneous Nerve of the Forearm (C8, T1)
The medial cutaneous nerve of the forearm

 Divides into two (anterior and posterior) branches in the arm. Through these
branches, it innervates the skin of the medial and adjacent anterior and posterior
surfaces of the forearm, down to the wrist.
Note: See the medial cord of the brachial plexus for details.
Lateral Cutaneous Nerve of the Forearm (C5, C6)
The lateral cutaneous nerve of the forearm

 Is the direct continuation of the musculocutaneous nerve that innervates the
muscles of the anterior compartment of the arm
 Pierces the deep fascia (about 3 cm proximal to the elbow) to become
subcutaneous (lateral to biceps)
 Divides into an anterior and a posterior branch. The latter reaches the ball of
the thumb (base of the thenar eminence)
 Innervates the skin of the anterolateral and posterolateral aspects of the forearm
(via its anterior and posterior branches)
 Communicates with the lower lateral cutaneous nerve of the arm, superficial
branch of radial nerve, and palmar cutaneous branch of median nerve.
Posterior Cutaneous Nerve of the Forearm (C6, C7, C8)
This nerve
 Arises (with the lower lateral cutaneous nerve of the arm) from the radial nerve
(just before this nerve pierces the lateral intermuscular septum of the arm)
 Pierces the lateral head of triceps and descends in the dorsum of the forearm,
down to the wrist (or dorsum of the hand)
 Innervates a strip of skin along the dorsal aspect of the forearm (between the
parts supplied by the medial and lateral cutaneous nerves of the forearm).
Flexor (Anterior) Compartment of the Forearm
The flexor compartment of the forearm

 Occupies the ventral aspect of the forearm. It contains the flexors and pronators
of the forearm. These muscles are arranged into two groups: superficial and deep
 Is separated from the extensor compartment by ulna and radius and the
interosseous membrane between them
- 408 -
 Also contains nerves (ulna and median nerves) and the ulnar and radial vessels.
Muscles of the Flexor Compartment of the Forearm (Fig. 88, 89)
Muscles of flexor compartment of forearm

 Largely arise from the medial epicondyle of the humerus; and some of them
extend into the hand
 Are arranged into superficial and deep groups. These muscles are innervated by
the ulnar and median nerves.
Superficial Group of Forearm Flexor Muscles (Fig. 88)
This group contains five muscles. They include:

 Pronator teres and flexor carpi radialis;
 Palmaris longus and flexor carpi ulnaris; and
 Flexor digitorum superficialis.
Pronator Teres (Fig. 88)
The pronator teres

 Lies obliquely across the upper part of the forearm, being directed inferolaterally
from its origin
 Forms the medial boundary of the cubital fossa
 Has two heads of origin: humeral and ulnar heads. The median nerve enters
the forearm between these heads
 Lies anterior to the elbow and proximal radio-ulnar joints. Thus, it acts on them
a) Humeral head: medial epicondyle of humerus (via the common flexor tendon)
b) Ulnar head: coronoid process of ulna
Distal attachment: middle of the lateral surface of radius
Innervation: median nerve
Note: The branch of the median nerve to pronator teres arises proximal to the elbow.
Actions:
a) Pronates the forearm at the proximal radio-ulnar joint (main action)
b) Flexes the forearm at the elbow joint.
Test of Integrity: Pronate a supinated forearm against resistance and observe the
muscle.
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Flexor Carpi Radialis (Fig. 88)
The flexor carpi radialis

 Lies medial to pronator teres in the upper part of the forearm and to
brachioradialis in the lower part
 Is long and fusiform. It becomes tendinous in the distal half of the forearm
 Lies anterior to, not within, the carpal tunnel. At the wrist, it lies between the
radial artery laterally and the median nerve medially
 Crosses the anterolateral aspect of the wrist joint, on which it acts
Proximal attachment: medial epicondyle of the humerus (via the common flexor
tendon)
Distal attachment: base of the 2nd and 3rd metacarpal bones (palmar aspects)
Actions:
a) Flexes the wrist
b) Abducts the hand (i.e., it bends it laterally at the wrist)
Test of Integrity: Flex the wrist against resistance (and observe the contraction of the
muscle).
- 410 -
Figure 88. Flexor compartment of forearm (superficial muscles)
Palmaris Longus (Fig. 88)
The palmaris longus

 Is an elongated, fusiform muscle, which lies medial to flexor carpi radialis. It
becomes tendinous halfway down the forearm
 Crosses the wrist anteriorly, passing anterior to the flexor retinaculum, to reach
the palmar aponeurosis of the hand
 Lies superficial (anterior) to the median nerve at the wrist
 Usually sends a tendinous slip that covers the thenar muscles (small muscles of
the thumb)
 May be absent on one or both sides in about 14% of the population.
Proximal attachment: medial epicondyle of the humerus (via the common flexor
tendon)
- 411 -
Distal attachment:
a) Distal half of the anterior surface of the flexor retinaculum
b) Apex of palmar aponeurosis
Actions:
a) Flexes the wrist
b) Tenses palmar aponeurosis
c) May flex the metacarpophalangeal joints
Test of Integrity: Same as for flexor carpi radialis.
Flexor Carpi Ulnaris (Fig. 88)

The flexor carpi ulnaris
 Is the most medial of the superficial flexor muscles of the forearm. It becomes
tendinous in the distal part of the forearm
 Lies superficial to ulnar nerve and ulnar vessels in the upper part of the
forearm, but medial to these structures distally. Thus, it is a guide to them
 Has two heads of origin (humeral and ulnar heads). The ulnar nerve passes
between these heads, to enter the forearm
 Passes over the anteromedial aspect of the wrist. It does not traverse the carpal
tunnel
a) Humeral head: medial epicondyle of humerus
b) Ulnar head: medial margin of olecranon and proximal ⅔ of the posterior border
of ulna
Distal attachment:
a) Pisiform bone
b) Hook of hamate (via the pisohamate ligament)
c) Base of the 5th metacarpal bone (via the pisometacarpal ligament)
Innervation: ulnar nerve
Actions:
a) Flexes the hand at the wrist joint
b) Adducts the hand at the wrist joint
c) Fixes pisiform during abduction of the little finger (to stabilize the origin of
abductor digiti minimi).
Test of Integrity: Same as for flexor carpi radialis

- 412 -
Flexor Digitorum Superficialis (FDS) (Fig. 88)
The flexor digitorum superficialis

 Is the largest of the superficial muscles of the flexor compartment of the
forearm. It lies deep to other muscles of this group
 Has two heads of origin (radial and humero-ulnar heads) between
which the median nerve and ulnar artery pass into the forearm
 Becomes tendinous in the distal part of forearm, where it forms four
tendinous slips
 Traverses the carpal tunnel (deep to the flexor retinaculum) as four
tendinous slips, which enter the hand
 Passes anterior to the wrist joint, and metacarpophalangeal and proximal
interphalangeal joints of the medial four digits. Thus, it can flex them
a) Humero-ulnar head
– medial humeral epicondyle
– ulnar collateral ligament
– coronoid process of ulna
b) Radial head – upper half of anterior border of radius
Distal attachment:

 In the distal half of the forearm, FDS forms four tendinous bands (arranged in
pairs)
 The pair of tendons to the middle and ring fingers is superficial to that to the
little and index fingers. This relationship is maintained as the tendinous bands
traverse the carpal tunnel
 In the carpal tunnel and hand, tendons of FDS are superficial (anterior) to those
of flexor digitorum profundus ( FDP)
 At the level of metacarpophalangeal joints, each of the four tendons of FDS
divides into two slips (behind and between which a tendon of FDP passes distally
 The two slips formed by each of the tendons of FDS continue distally to insert
onto the palmar surface of the body of the middle phalanx of each of the medial
four digits.
Actions:
a) Flexes the middle phalanges of the medial four digits (primarily), at the
proximal interphalangeal joints
- 413 -
b) Flexes the proximal phalanges of medial four digits (secondarily) at the

metacarpophalangeal joints
c) Also flexes the hand (at the wrist joint)
d) Assists in flexing the elbow
Test of Integrity: With the fingers in an extended position, flex one against
resistance (at the proximal interphalangeal joint).
Deep Group of Flexor Muscles of the Forearm
Muscles of this group include:

 Flexor digitorum profundus
 Flexor pollicis longus; and
 Pronator quadratus.
Flexor Digitorum Profundus (FDP) (Fig. 89)
The flexor digitorum profundus

 Is a long flexor of the medial four digits, as does FDS. However, it is the only
muscle that can flex the distal interphalangeal joints
 Is located deep to FDS and medial to flexor pollicis longus (in the forearm)
 Becomes tendinous in the distal part of the forearm, where the tendinous slip to
the index finger separates from the remaining part of this muscle. Altogether,
FDP forms four tendons; these lie deep to the flexor retinaculum and the
tendons of FDS
 Enters the hand (as four tendons), deep to tendons of FDS, with which it is
ensheathed in a common synovial sheath
 Gives attachment to the lumbricals (which arise from its tendons in the hand)
 Receives motor fibres from both median and ulnar nerves
 Lies anterior to the wrist joint, proximal and distal interphalangeal, and
carpometacarpal joints of the medial four fingers. Thus, it can flex them.
- 414 -
Figure 89. Deep muscles of forearm flexor and extensor compartments
a) Proximal ¾ of the anterior and medial surfaces of ulna

b) Medial half of the anterior surface of the interosseous membrane
c) Proximal ¾ of the posterior border of ulna
Distal attachment

 Deep to the flexor retinaculum and FDS, the FDP divides into four tendons; the
tendon to the index finger arises in the distal part of the forearm
 The tendons of FDP pass distally into the hand, deep to those of FDS, with which
they are ensheathed in a common synovial sheath
 At the level of metacarpophalangeal joint, each tendon of FDP pass into the
finger between and behind the two slips formed by the splitting of each tendinous
band of FDS.
 At the level of metacarpophalangeal joint, each tendon of FDP continue
distally by emerging between the two slips formed by the splitting of the
respective tendon of FDS , to enter the digit;
- 415 -
 In the medial four digits, each tendon of FDP traverses the fibrous sheath of a
finger, and inserts onto the anterior surface of the base of the distal phalanx of
that finger.
Innervation:
a) Median nerve, to the lateral part of FDP (which flexes the index and middle
fingers);
b) Ulnar nerve, to the medial part of FDP (which flexes the ring and little fingers)
Actions:
a) Flexes the distal phalanges at the distal interphalangeal joints (main action);
b) Assists in flexing the proximal interphalangeal, metacarpophalangeal and carpal
joints.
Test of Integrity: Keep the middle phalanx extended against a surface, then attempt
flexing the distal phalanx of that finger.
Flexor Pollicis Longus
The flexor pollicis longus

 Lies deeply in the anterior compartment of the forearm, lateral to FDP
 Becomes tendinous just proximal to the wrist; and its tendon traverses the carpal
tunnel, deep to the flexor retinaculum
 Is surrounded by a synovial sheath as it traverses the carpal tunnel to gain the
hand and thumb. In the latter, it lies within a fibrous sheath (and is invested by a
synovial sheath)
 Passes over the palmar aspects of metacarpophalangeal and interphalangeal joints
of the thumb. Thus, it flexes them.
a) Anterior surface of radius (between radial tuberosity and radial attachment of
pronator quadratus)
b) Lateral (radial) aspect of the anterior surface of interosseous membrane
c) Lateral border of coronoid process of ulna.
Distal attachment: Anterior aspect of the base of the distal phalanx of the thumb
Innervation: Anterior interosseous nerve (a branch of median nerve)
Actions:
- 416 -
a) Flexes interphalangeal joint of the thumb (the main action and the only flexor of
this joint)
b) Also flexes metacarpophalangeal and carpometacarpal joints of the thumb
c) Assists in flexing the wrist.
Test of Integrity: Hold the proximal phalanx of the thumb down, and flex the distal
phalanx against resistance.
Pronator Quadratus
The pronator quadratus

 Is a flat quadrangular muscle that occupies the deepest plane of the flexor
compartment of the forearm
 Stretches between the distal parts of the anterior surfaces of ulna and radius
 Is more powerful than pronator teres
 Cannot be palpated in the forearm.
Proximal attachment: Distal ¼ of the anterior surface the body of ulna
Distal attachment: Distal ¼ of the anterior surface of the body of radius
Innervation: Anterior interosseous nerve (a branch of median nerve)
Actions:
a) Pronates the forearm (chief action). It is more powerful than pronator teres in this
regard
b) Holds ulna ad radius together distally, preventing their separation.
Test of Integrity: Same as for pronator teres (see above)
Note: The muscle cannot be observed when being tested.
Neurovascular Structures of the Flexor Compartment of the Forearm
These include:
 Median and ulnar nerves
 Radial and ulnar vessels
Median Nerve
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 In the cubital fossa, the median nerve lies medial to the brachial artery (between
brachialis behind and the bicipital aponeurosis anteriorly)
 The median nerve usually leaves the cubital fossa for the forearm by passing
between the two heads of pronator teres (though it may pierce the humeral head
of this muscle).
In the forearm, the medial nerve

 Passes behind the tendinous arch that joins the two heads of FDS; it continues
distally between FDS (anteriorly) and FDP (behind). It is adherent to the
posterior surface of FDS.
 Emerges from behind the lateral edge of FDS, about 5 cm proximal to the wrist.
Near the latter, the median nerve lies deep to the tendon of palmaris longus
(between the tendons of FDS medially and that of flexor carpi radialis laterally)
 Leaves the forearm by traversing the carpal tunnel, deep to the flexor
retinaculum (beyond which it enters the hand).
 Is accompanied by the median branch of the anterior interosseous artery.
Branches of the Median Nerve in the Forearm
These include the following:

 Articular branches to the elbow and proximal radio-ulnar joints
 Anterior interosseous nerve
 Palmar cutaneous branch
 A communicating branch to ulnar nerve; and
 Muscular branches.
Articular branches of the median nerve arise just distal to the elbow joint; they
innervate the latter and the proximal radio-ulnar joint.
The anterior interosseous nerve

 Arises from the median nerve as this passes between the two heads of pronator
teres
 Traverse the forearm anterior to the interosseous membrane, and between flexor
pollicis longus (laterally) and FDP (medially), to the deep surface of pronator
quadratus
 Is accompanied by the anterior interosseous artery, a branch of the common
interosseous artery. The latter arises from the ulnar artery
 Innervates flexor pollicis longus, lateral part of FDP, pronator quadratus, and the
distal radio-ulnar, carpal and radiocarpal joints.
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The palmar cutaneous branch of median nerve

 Arises just proximal to the flexor retinaculum. It enters the subcutaneous tissue
by piercing the deep fascia or flexor retinaculum; and then divided into medial
and lateral branches
 Innervates the skin of the thenar eminence through its lateral branches; and that
of the central part of the palm through its medial branches
 Communicates with the lateral cutaneous nerve of the forearm and the palmar
cutaneous branch of ulnar nerve, via its lateral and medial branches, respectively.
Muscular branches of median nerve

 Arise just distal to the elbow (except the branch to pronator teres, which arises
proximal to the elbow, in the arm)
 Innervate all flexor muscles of the forearm, except flexor carpi ulnaris, flexor
pollicis longus and ulnar part of FDP.
Ulnar Nerve
Regarding the ulnar nerve, note the following facts:

 The ulnar nerve runs in a groove on the dorsum of humeral medial epicondyle (as
it passes towards the forearm)
 The ulnar nerve enters the forearm by passing between the two heads of flexor
carpi ulnaris.
In the forearm, the ulnar nerve

 Runs on the medial aspect of the limb, deep to flexor carpi ulnaris (i.e., between
flexor carpi ulnaris superficially and FDP deeply)
 Is accompanied by the ulnar artery, which runs on its lateral aspect (except
proximally where the two are distant)
 Emerges from beneath flexor carpi ulnaris, in the distal part of the forearm; here,
it lies lateral to this muscle and deep to the skin and fasciae. At the wrist, the
ulnar nerve lies superficial to the medial part of the flexor retinaculum
 Pierces the flexor retinaculum and continues deeply in an osseofibrous canal
(Guyon’s canal), between pisiform and the hook of hamate.
Branches of Ulnaris Nerve in the Forearm
These include:
 Articular and muscular branches;
 Palmar cutaneous branch; and
 Dorsal branch.
Note: Superficial and deep (terminal) branches of ulnar nerve arise at the wrist.
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In the forearm, articular branches of ulnar nerve

 Arise between humeral medial epicondyle and ulnar olecranon
 Innervate the elbow joint.
The muscular branches of ulnar nerve

 Arise just distal to the elbow joint
 Innervate flexor carpi ulnaris and ulnar half of FDP.
Palmar cutaneous branch of ulnar nerve

 Arises from the ulnar nerve halfway down the forearm; and then lies superficial
(anterior) to the ulnar artery (in the forearm)
 Pierces the deep fascia in the distal 3rd of the forearm to enter the medial aspect
of the palm
 Innervates the skin of the medial part of the palm; it may also innervate palmaris
brevis
 Communicates with the palmar branch of median nerve
The dorsal branch of ulnar nerve

 Arises about 5 cm proximal to the wrist, in the distal half of the forearm. It runs
postero-distally, between the ulna and flexor carpi ulnaris
 Pierces the deep fascia in the distal 4th of the forearm, and continues distally on
the posteromedial side of the wrist and hand
 Divides into two (or three) dorsal digital nerves (in the hand)
 Innervates the skin of the medial aspect of the dorsum of the wrist and hand
 Also innervates (via its dorsal digital nerves) the dorsum of the little and medial
part of the dorsum of the ring fingers (except their terminal ends). It may
innervate adjacent sides of the ring and middle fingers (via the 3rd dorsal digital
nerves [when present])
 Communicates with branches of the radial nerve (on the dorsum of the hand).
Note: For the deep and superficial terminal branches of ulnar nerve, see the hand.
Applied Anatomy

 The ulnar nerve may be injured as it passes into the forearm behind the medial
epicondyle of the humerus. The nerve is also prone to compression as it passes
behind the tendinous arch that joins the two heads of flexor carpi ulnaris
 Injury to ulnar nerve produces loss of sensations in the skin areas supplied by
this nerve, as well as paralysis of flexor carpi ulnaris, medial part of FDP, and
most intrinsic muscles of the hand. Similar deficits occur in cubital tunnel
syndrome
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 Claw-hand develops following ulnar nerve injury; this is owing to the paralysis
of the intrinsic muscles of the hand (and the interplay between extensor muscles
of the digits and FDP)
 Injury to the median nerve near the elbow will produce loss of flexion of the
proximal interphalangeal joints of the three lateral digits;
 Loss of flexion of the distal interphalangeal joints of the 2nd and 3rd digits also
occurs in median nerve injury. This results in extension of these digits when
fisting the hand – hand of benediction
 The median nerve may be compressed as it passes between the two heads of
pronator teres; this produces pains in the forearm
 Injury to median nerve around the middle of the forearm weakens flexion of the
index finger – ‘pointing index finger’. This is because the branch of median
nerve to the part of FDS that flexes the index finger arises near the middle of the
forearm.
Radial Artery (Fig. 90)
The radial artery

 Arises from the brachial artery at the level of the neck of the radius about 1 cm
distal to the elbow. It is the direct continuation of the brachial artery, though it is
smaller than the ulnar artery
 Runs distally, on the lateral aspect of the forearm, to the wrist. It lies deep to
brachioradialis in the proximal part of the forearm; and between the tendon of
flexor carpi radialis (medially) and that of brachioradialis (laterally), in the distal
part of the forearm. Here, the radial pulse can be taken.
 Is related to the anterior aspect of radial styloid process, at the distal end of the
forearm (deep to the tendons of abductor pollicis longus and extensor pollicis
brevis) it continues postero-distally through the anatomical snuffbox, and then
enters the hand (between the two heads of the first dorsal interosseous muscle)
 Forms, together with the deep branch of ulnar artery, the deep palmar arch of
the hand
 Is accompanied, in its middle 3rd, by the superficial branch of radial nerve,
which lies lateral to it
 Is also accompanied by a pair of veins – venae comitantes
 Can be readily felt in the distal part of the forearm, just lateral to the tendon of
flexor carpi radialis.
Branches of the radial artery in the forearm include:

 Muscles branches
 Radial recurrent artery
 Superficial palmar branch
 Palmar carpal branch
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The muscular branches of radial artery

 Supply flexor and extensor muscles of the radial side of the forearm.
The radial recurrent artery

 Runs towards the elbow to anastomose with the radial collateral branch of
profunda brachii artery (around the elbow joint).
The superficial palmar branch of radial artery

 Arises in the distal of the forearm, just proximal to the wrist
 Supplies the muscles of the thenar eminence usually (through which it runs)
 Usually anastomoses with the terminal end of the ulnar artery to form the
superficial palmar arch.
The palmar carpal branch of radial artery

 Arises in the forearm, near the distal border of pronator quadratus
 Supplies the carpal bones and joints
 Anastomoses with the palmar carpal branch of ulnar artery (deep to long flexor
tendons) to form a cruciate palmar carpal arch (at the wrist).
Figure 90. Ulnar and radial arteries
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Ulnar Artery (Fig. 90)
In the forearm, the ulnar artery

 Is the larger of the two terminal branches of the brachial artery. It arises from
the latter in the cubital fossa, anteromedial to the neck of radius
 Runs distally, initially deep to pronator teres, flexor carpi radialis, palmaris
longus and FDS, in the upper half of forearm. In the middle 3rd of the forearm, it
is deep to flexor carpi ulnaris (and superficial to FDP); while in the distal 3rd of
the forearm, it lies between the tendon of flexor carpi ulnaris (medially) and that
of FDS (laterally)
 Becomes superficial, as it lies just deep to the skin and fasciae, in the distal part
of the forearm (near the wrist)
 Enters the wrist by running deep to the superficial layer of flexor retinaculum,
just lateral to the ulnar nerve and pisiform bone
 Continues into the hand by turning laterally, deep to the palmar aponeurosis, to
join the superficial palmar arch
 Is accompanied, from the middle of the forearm distally, by the ulnar nerve,
which lies medial to it. It is also accompanied by a pair of veins – venae
comitantes.
Branches of Ulnar Artery in the Forearm (Fig. 90)
The branches of ulnar artery in the forearm include:

 Muscular branches
 Anterior ulnar recurrent artery
 Posterior ulnar recurrent artery
 Common interosseous artery
 Dorsal carpal branch
 Palmar carpal branch
 Superficial and deep palmar branches
Muscular branches of ulnar artery:

 Supply muscles in the ulnar aspect of the forearm.
Anterior ulnar recurrent artery

 Arises from ulnar artery, just distal to the elbow joint
 Ascends towards the elbow joint, between brachialis and pronator teres, which
it supplies
 Anastomoses with the inferior ulnar collateral artery, anterior to the medial
humeral epicondyle (thus contributing to the anastomoses around the elbow
joint).
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The posterior ulnar recurrent artery

 Is larger than the anterior ulnar recurrent artery. It arises from ulnar artery,
distal to the origin of the anterior ulnar recurrent artery
 Ascends posteromedially, behind the medial epicondyle of the humerus, and
between FDS and FDP (which it supplies)
 Anastomoses with the interosseous recurrent and superior and inferior ulnar
collateral arteries. (Thus, it contributes to the anastomoses around elbow joint).
The common interosseous artery

 Arises from the ulnar artery in the distal part of the cubital fossa (Fig. 90). Then,
it runs inferolaterally for a short distance (being a short vessel)
 Divides into anterior and posterior interosseous arteries at the upper border of
the interosseous membrane of the forearm.
Anterior interosseous artery

 Is usually the larger of the two interosseous arteries. It lies on the anterior aspect
of the interosseous membrane of the forearm (Fig. 90)
 Is accompanied by the anterior interosseous nerve, and overlapped by flexor
pollicis longus and FDP
 Pierces the interosseous membrane, just proximal to pronator quadratus, to enter
the extensor compartment of the forearm; thus, it reaches the dorsal aspect of
the wrist, where it joins the dorsal carpal arch
 Gives rise to the median artery (close to its origin). This accompanies and
supplies the median nerve. It also gives rise to branches that supply adjacent
muscles of the flexor and extensor compartments of the forearm
 Has a branch that descends deep to pronator quadratus to join the palmar carpal
arch
 Supplies nutrient arteries to ulna and radius; and anastomoses with the postero
interosseous artery.
The posterior interosseous artery

 Arises from the common interosseous artery, just above the interosseous
membrane. Then, it descends posteriorly, between abductor pollicis longus and
supinator, to the extensor compartment of the forearm (Fig. 90)
 Continues distally into the forearm, between the superficial and deep muscles of
the extensor compartment, which it supplies. It ends by anastomosing with the
anterior interosseous artery (in the distal part of extensor compartment)
 Is accompanied by the deep branch of the radial nerve (as it descends on
abductor pollicis longus)
 Gives rise to the interosseous recurrent artery (which anastomoses with the
ulnar collateral and middle collateral arteries).
The dorsal carpal branch of ulnar artery

 Arises just proximal to pisiform bone
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 Runs posterolaterally, deep to the tendon of flexor carpi ulnaris, to reach the
dorsum of the wrist (where it continues laterally, deep to extensor tendons)
 Ends by anastomosing with the dorsal branch of radial artery, with which it
forms the dorsal carpal arch.
The palmar carpal branch of ulnar artery

 Arises from the ulnar artery in the distal part of the forearm
 Joins the palmar carpal branch of radial artery to form the palmar carpal arch.
Note: for superficial and deep palmar branches of ulnar artery, see the hand.
Applied Anatomy of Radial and Ulnar arteries

 The site where the radial artery passes anterior to the distal end of radius, and
lateral to the tendon of flexor carpi radialis, is a suitable site for taking the
radial pulse
 The radial artery may arise in the axilla, from the axillary artery; it may also
arise high up in the arm, from the brachial artery
 In a few subjects (about 3%), the ulnar artery may pursue a superficial course
by passing superficial (rather than deep) to the flexor muscles of the forearm
 The radial (or ulnar) artery may be subcutaneous (i.e., it lies superficial to the
deep fascia). Such a subcutaneous radial (or ulnar) artery may be mistaken for a
vein during venepuncture (with the attendant risks).
Major Veins of the Forearm (Fig. 87)
Note: Veins of the forearm are arranged as superficial and deep veins.
Superficial Veins of the Forearm
Superficial veins of the forearm include:

1. Cephalic and basilic veins
2. Median antebrachial; and
3. Median cubital veins.
Cephalic Vein (Fig. 87)
The cephalic vein

 Arises over the anatomical snuffbox from tributaries that drain the radial side of
the dorsal venous plexus of the hand
 Ascends in the subcutaneous tissue of the anterolateral aspect of the forearm,
towards the elbow. In the latter, it is usually linked to the basilic vein by a
median cubital vein
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 Ascends further in the subcutaneous tissue of the arm, lateral to biceps, to reach
the deltopectoral groove (between deltoid and pectoralis major). Then, it enters
the deltopectoral triangle, where it turns posteriorly to pierce the clavipectoral
fascia
 Drains into the terminal part of axillary vein, in the axilla; it may however end in
the external jugular vein (or may be linked to it by a vein).
 Is accompanied by deltoid branch of thoraco-acromial artery (in the
deltopectoral groove).
Basilic Vein (Fig. 87)
The basilic vein

 Is formed by tributaries from the medial aspect of the dorsal venous plexus
 Initially ascends in the subcutaneous tissue of the medial aspect of the posterior
surface of the forearm; and just below the elbow, it crosses to the anteromedial
aspect of the forearm
 Ascends further, in the subcutaneous tissue of the anteromedial aspect of the
elbow and lower half of the arm (medial to biceps)
 Pierces the deep fascia at the mid-arm region and then ascends medial to the
brachial artery (deep to the deep fascia)
 Becomes the axillary vein at the lower border of teres major.
Tributaries of Basilic Vein
The basilic vein

 Commonly receives the median vein of the forearm (in the upper part of the
forearm)
 Is often joined by the median cubital vein, which connects it to the cephalic vein
(over the cubital fossa)
 Receives several unnamed tributaries along its length (as does cephalic vein).
Median Vein of the Forearm (Median Antebrachial Vein) (Fig. 87)
The median vein of the forearm

 Commences at the superficial palmar venous plexus. It ascends in the
subcutaneous tissue of the anterior aspect of the wrist and forearm, towards the
elbow (Fig. 87)
 Usually ends on the anterior aspect of the elbow by joining the basilic vein. It
may however join the median cubital vein
 May divide, just below the elbow, into a median basilic and a median cephalic
vein, which joins the basilic and cephalic veins, respectively. The median basilic
vein, when present, replaces the median cubital vein
 Drains the subcutaneous tissue of the wrist and elbow, as well as the superficial
palmar venous plexus.
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Median Cubital Vein (Fig. 87)
The median cubital vein

 Runs superomedially, in the subcutaneous tissue over the cubital fossa, where it
connects the cephalic and basilic veins. It is superficial to the brachial artery
(and median nerve), from which it is separated by the bicipital aponeurosis
 Receives tributaries from the deep and superficial veins of the forearm. It may
also receive the median vein of the forearm
 May be absent; and in this instance, it is replaced by the median basilic vein
Applied Anatomy

 The median cubital vein is one of the largest veins of the forearm; it offers a
good site for obtaining blood. Several forearm veins are also useful for
venepuncture
 The part of the cephalic vein just proximal to the anatomical snuff box offers a
good site for cannulation (especially when fluid or blood is to be introduced for
a long period)
 The arrangement of the superficial veins of the forearm varies between
individuals, and even between the two upper limbs of an individual
 The median cubital vein is replaced by median basilic vein in about 20% of
subjects.
Deep Veins of the Forearm
These include:
 Radial veins
 Ulnar veins; and
 Interosseous veins.
Radial Veins
These veins
 Arise from and drain the deep palmar venous arch. They accompany the radial
artery to the cubital fossa (as paired veins)
 Join the ulnar veins (in the cubital fossa) to form the brachial veins
 Receives several tributaries, including the deep dorsal veins of the hand.
Ulnar Veins
The ulnar veins

 Arise from and drain the superficial palmar venous arch. They accompany the
ulnar artery to the cubital fossa (as paired veins – venae comitantes)
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 Join the radial veins (in the cubital fossa) to form the brachial veins. They are
larger than radial veins
 Receive the anterior and posterior interosseous veins near the elbow (in
addition to several other tributaries)
 Are connected to the median cubital vein (a superficial vein) by a large branch.
Cubital Fossa (Fig. 91)
The cubital fossa

 Is a triangular intermuscular depression located anterior to the elbow joint
 Contains large arteries and nerves, which enter the forearm from the arm.
Boundaries of the Cubital Fossa (Fig. 91)
The cubital fossa is bounded by the following:

 Medial border: lateral border of pronator teres
 Lateral border: medial border of brachioradialis
 Base: interepicondylar line (an imaginary line that joins the two humeral
epicondyles)
 Floor: supinator and brachialis
 Roof: bicipital aponeurosis, deep and superficial fasciae, and skin.
Contents of the Cubital Fossa (Fig. 91)
The cubital fossa contains the following:

 A tendon: bicipital tendon
 Two nerves: median and radial nerves
 Three arteries: brachial, radial and ulnar arteries
 Three paired veins: brachial, radial and ulnar veins.
In the cubital fossa, note that

 Only segments (parts) of the above structures are present
 The bicipital tendon is lateral while the median nerve is medial to the brachial
artery. Thus, the brachial artery is intermediate in position (between bicipital
tendon laterally and median nerve medially)
 The brachial artery divides (anteromedial to the neck of the radius) into radial
and ulnar arteries
 The radial nerve is concealed between supinator and brachioradialis (in the
lateral aspect of the fossa).
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Figure 91. Cubital fossa
Relations of the Cubital Fossa (Fig. 87, 91)
These include:
 Anteriorly:
a) Median cubital vein (separated from the fossa by the bicipital aponeurosis)
b) Medial and lateral cutaneous nerves of the forearm (in the subcutaneous
tissue).
 Posteriorly: Elbow joint
Applied Anatomy
Note that
 The brachial artery may be accidentally punctured in the cubital fossa while
attempting to cannulate the median cubital vein; the latter lies in the subcutaneous
tissue and is separated from the artery by the bicipital aponeurosis.
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Extensor (Posterior) Compartment of the Forearm (Fig. 89)
Muscles of the extensor compartment of the forearm

 Include those muscles that extend the wrist and digits; abduct the thumb; and
supinate the forearm. They are all innervated by the radial nerve
 Are also arranged into superficial and deep groups (as do those of the flexor
compartment)
Superficial Group of the Extensor Compartment (Fig. 89)
Muscles of the superficial group of the extensor compartment are seven; they include:
 Brachioradialis
 Extensor carpi radialis longus
 Extensor carpi radialis brevis
 Extensor carpi ulnaris
 Extensor digitorum
 Extensor digiti minimi; and
 Anconeus.
Brachioradialis
 Lies along the radial side of the forearm; its medial margin forms the lateral
border of the cubital fossa (proximally) (Fig. 91)
 Becomes tendinous at about the middle of the forearm. In the distal part of the
forearm, the radial artery is medial to its tendon
 Passes over the anterolateral aspect of the elbow joint; thus, it acts on this joint.
 Is crossed superficially (near its insertion) by tendons of abductor pollicis longus
and extensor pollicis brevis
a) Proximal ⅔ of the lateral supracondylar line of the humerus
b) Lateral intermuscular septum of the arm.
Distal attachment: Lateral aspect of the radius, just proximal to the styloid process
Innervation: Radial nerve
Actions: it flexes the elbow joint (especially when the forearm is in the mid-prone
position)
Test of Integrity: Forearm is brought into mid-prone position and then flexed against
resistance.
Extensor Carpi Radialis Longus (Fig. 89)
The extensor carpi radialis longus

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 Lies posteromedial to, and is thus overlapped by brachioradialis

 Is muscular in its upper part but becomes tendinous halfway down the forearm.
Its tendon grooves the distal end of the radius
 Is overlapped (in the distal part of the forearm) by tendons of abductor pollicis
longus and extensors pollicis longus and brevis (as these become superficial)
 Is closely associated with extensor carpi radialis brevis (with which it shares
the same synovial sheath, deep to extensor retinaculum)
 Crosses the elbow joint proximally and the wrist distally. Thus, it acts on both.
a) Distal ⅓ of the lateral supracondylar ridge
b) Lateral intermuscular septum; and
c) Common extensor tendon (attached to lateral epicondyle).
Distal attachment: dorsal aspect of the base of 2nd metacarpal bone
Innervation: Radial nerve
Action:
a) Extends the wrist (with extensor carpi ulnaris)
b) Abducts the wrist( with flexor carpi radialis)
c) Flexes elbow joint (as a synergist).
Test of Integrity: Pronate the forearm; then extend it against resistance. The muscle
may then be felt on the posterolateral aspect of the forearm, distal to the elbow.
Extensor Carpi Radialis Brevis (Fig. 89)
The extensor carpi radialis brevis

 Lies medial to extensor carpi radialis longus, which partly overlaps it. It
becomes tendinous halfway down the forearm
 Is crosses (distally) by tendons of abductor pollicis longus and extensors pollicis
longus and brevis (as these become superficial)
 Occupies a groove on the dorsal aspect of the radius (deep to extensor
retinaculum), just medial to that occupied by extensor carpi radialis longus
 Crosses the elbow and wrist joints; hence, it acts on both.
a) Lateral epicondyle (via the common extensor tendon)
b) Radial collateral ligament; and
c) Adjoining fascia and fibrous septa
Distal attachment: dorsal aspect of the base of the 3rd metacarpal bone
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Innervation: Posterior interosseous nerve (deep branch of radial nerve)
Action: Same as for extensor carpi radialis longus
Extensor Digitorum (Fig. 89)
The extensor digitorum

 Is a large extensor muscle, which lies medial to extensor carpi radialis brevis and
lateral to extensor digiti minimi. It becomes tendinous in the distal part of the
forearm. Here, it divides into four tendons
 Passes deep to the extensor retinaculum (at the wrist) to enter the dorsum of the
hand. Deep to the retinaculum, it shares the same synovial sheath with extensor
indicis
 Crosses the wrist, metacarpophalangeal and proximal interphalangeal joints (of
the lateral four digits) posteriorly; thus, it is capable of extending them
 Does not play any appreciable role in flexing the elbow joint, though it crosses it
anterolaterally.
a) Lateral epicondyle of the humerus (via the common extensor tendon)
b) Adjacent intermuscular septa and fascia
Regarding the tendons of insertion of extensor digitorum, note the following:

 Extensor digitorum becomes tendinous just proximal to the wrist (where it
divides into four tendinous slips)
 Deep to the extensor retinaculum, the tendons of extensor digitorum are
enclosed in a single synovial sheath (with the tendon of extensor indicis)
 On the dorsum of the hand, the four tendons of extensor digitorum spread out,
such that each enters a finger. Three oblique intertendinous connections join
adjacent sides of these tendons
 Each of the tendons of extensor digitorum forms an extensor expansion on the
dorsum of its own metacarpophalangeal joint and proximal phalanx
 Each extensor expansion gives attachment to the interossei and lumbricals of
that finger, on the dorsum of the proximal phalanx
 Proximal to the proximal interphalangeal joint of the finger, each extensor
expansion divides into three slips (a central and two collateral slips)
 The central slip of each extensor expansion contains fibres of a tendon of
extensor digitorum. It inserts onto the base of the middle phalanx of that finger
 The two collateral slips of the extensor expansion contain tendinous fibres of
interossei and lumbricals; these slips reunite on the dorsum of the middle phalanx
before inserting onto the base of the distal phalanx. Thus,
 Each tendon of extensor digitorum crosses the metacarpophalangeal and proximal
interphalangeal joints of its own finger (through the extensor expansion)
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Actions:
a) Mainly extends the metacarpophalangeal joint of the lateral four digits
b) Also extends the proximal and distal interphalangeal joints of each finger (via
extensor expansion)
c) Assists in extending the wrist joint also.
Test of Integrity: Pronate the forearm, and then extends the metacarpophalangeal
joints against resistance.
Applied Anatomy

 Because extensor digitorum cannot extend the interphalangeal joints
simultaneously when the metacarpophalangeal joints are fully extended, the
lumbricals and interossei must come into play (through extensor expansion) if
the interphalangeal joints must be extended at the same time. Thus,
 Damage to the ulnar nerve and consequent paralysis of the interossei and 3rd and
4th lumbricals will produce a ‘claw hand’. This is due to the unopposed flexion
of the middle and distal phalanges by the long digital flexors (owing to paralysis
of interossei and lumbricals) and the simultaneous hyperextension of the
metacarpophalangeal joint by extensor digitorum.
Extensor Digiti Minimi (Fig. 89)
Extensor digiti minimi

 Is a long slender muscle that lies medial to extensor digitorum (in the forearm). In
the distal part of the forearm, it is tendinous
 Lies in a groove, behind the distal radio-ulnar joint, as it passes towards the hand
(deep to the extensor retinaculum). Here, it is invested a synovial sheath
a) Lateral humeral epicondyle (via the common extensor tendon);
b) Adjacent fascia and intermuscular septum.
Distal attachment: Extensor expansion of the little finger
Action: Extends the little finger and wrist
Extensor Carpi Ulnaris (Fig. 89)
The extensor carpi ulnaris

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 Is located on the medial aspect of the dorsum of the forearm. It is the most medial
superficial extensor; and it becomes tendinous just proximal to the wrist
 Lies in a groove on the dorsum of the distal end of the ulna (deep to the extensor
retinaculum). Here, it is invested by a synovial sheath
a) Lateral humeral epicondyle (via the common extensor tendon)
b) Posterior border of ulna (together with flexor carpi ulnaris and FDP)
Distal attachment: Base of the 5th metacarpal bone
Actions:
a) Extends the wrist (with extensors carpi radiales longus et brevis)
b) Adducts the wrist (with flexor carpi ulnaris)
c) Extends and adducts the wrist simultaneously (when acting alone)
Test of Integrity: With the forearm pronated (and the wrist and fingers extended),
the extended wrist is adducted against resistance.
Anconeus
The anconeous
 Is a small muscle located behind the elbow joint
 Merges partly with the triceps brachii or extensor carpi ulnaris
 Posterior surface of the lateral epicondyle of humerus
 Capsule of elbow joint.
Distal attachment:
 Lateral aspect of olecranon of ulna
 Proximal ¼ of posterior surface of the shaft of ulna
Innervation: Radial nerve (via a branch that descends through the medial head of
triceps, to innervate this muscle and anconeus)
Action: Extends elbow joint (as does triceps).
Deep Group of Extensor Compartment Muscles (Fig. 89)
Muscles of the deep group of extensor compartment are five; they include:
 Supinator
 Abductor pollicis longus
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 Extensor pollicis longus

 Extensor pollicis brevis; and
 Extensor indicis
The supinator
 Surrounds the proximal 3rd of the radius
 Has two heads of origin (humeral and ulnar heads) between which the posterior
interosseous nerve (deep branch of radial nerve) passes into the forearm
 Has fibres that are directed inferolaterally, from its origin
 Forms the floor of the cubital fossa (with brachialis)
a) Lateral epicondyle oh humerus
b) Radial collateral ligament of elbow joint
c) Annular ligament of radius
d) Supinator crest and fossa of ulna
Distal attachment: Proximal 3rd of radius
Innervation: Posterior interosseous nerve
Action: Supinates the forearm (prime mover)
Abductor Pollicis Longus (APL) (Fig. 89)
The abductor pollicis longus

 Is located deeply in the proximal part of the forearm, but becomes superficial
distally; it crosses the tendons of brachioradialis and extensors carpi radialis
longus and brevis, as it does so
 Is accompanied by the tendon of extensor pollicis brevis at the wrist (deep to the
extensor retinaculum); the tendons of the two muscles share a common synovial
sheath
 Forms the anterior border of the anatomical snuff box (together with extensor
pollicis brevis)
 May be completely or partially duplicated along its length
a) Dorsal surface of ulna (distal to the insertion of anconeus)
b) Dorsal surface of radius (distal to the insertion of supinator)
c) Posterior surface of interosseous membrane of the forearm
Distal attachment:
a) Base of the 1st metacarpal
b) Trapezium (via an additional slip)
- 435 -
Innervation: posterior interosseous nerve
Action:
a) Abducts the thumb at the carpometacarpal joint (with abductor pollicis brevis)
b) Extends the thumb at the carpometacarpal joint (with extensors pollicis longus
and brevis)
Test of integrity: Abduct the thumb against resistance (at the carpometacarpal joint)
Extensor Pollicis Brevis (EPB) (Fig. 89)
Extensor pollicis brevis

 Lies medial to, and is partially overlapped by abductor pollicis longus (in the
forearm)
 Crosses superficial to the tendons of extensors carpi radiales longus and brevis
(in the distal part of the forearm) as it becomes superficial in position
 Occupies, together with the tendon of abductor pollicis longus, a groove on the
lateral aspect of the radius, deep to the extensor retinaculum; here, the two
tendons share the same synovial sheath
 Forms, together with abductor pollicis longus, the anterior border of the
anatomical snuff box
 May be absent or fused with abductor pollicis longus
a) Posterior surface of radius (distal to the origin of APL)
b) Interosseous membrane of the forearm
Distal attachment:
a) Dorsal aspect of the base of the proximal phalanx of the thumb
b) Base of the distal phalanx of the thumb (with extensor pollicis longus). This
attachment is inconsistent
Actions:
a) Extends the proximal phalanx of the thumb (at the metacarpophalangeal joint)
b) Extends the 1st metacarpal (at the carpometacarpal joint)
Test of integrity: Extend the proximal phalanx of the thumb against resistance (at the
metacarpophalangeal joint).
Extensor Pollicis Longus (Fig. 89)
Extensor pollicis longus

- 436 -
 Is larger than and partly overlaps extensor pollicis brevis. It becomes tendinous
just proximal to the wrist
 Traverses a groove on the posterior aspect of the distal end of radius, deep to the
extensor retinaculum; here, it is invested by its own synovial sheath. As it
emerges from this groove, it turns laterally, round the dorsal tubercle of radius
(which acts as a pulley for it), and crosses the tendons of extensor carpi radiales
longus and brevis near the 2nd and 3rd metacarpals (to which these muscles
attach)
 Continues distally into the dorsum of the thumb, on the proximal phalanx of
which it forms an extensor expansion
 Is joined on the dorsum of the proximal phalanx of the thumb by tendon of
abductor pollicis brevis laterally and that of adductor pollicis (and the 1st
palmar interosseous) medially
 Forms the posterior border of the anatomical snuff box
a) Posterior surface of the middle 3rd of ulna
b) Interosseous membrane of the forearm
Distal attachment: Dorsal aspect of the base of the distal phalanx of the thumb
Actions:
a) Extends the interphalangeal and metacarpophalangeal joints of the thumb
b) Assists in the extension and abduction of the wrist
c) Acts as a ‘trick’ adductor of the thumb, especially when acting on a fully
extended or abducted thumb
Test of Integrity: To test this muscle, the thumb is extended against resistance at the
interphalangeal joint
Applied Anatomy: The tendon of extensor pollicis longus may be torn mainly as a
result of avascular necrosis
Extensor Indicis
The extensor indicis

 Is a narrow elongated muscle located deeply in the extensor compartment of the
forearm
 Occupies the same synovial sheath as extensor digitorum, deep to the extensor
retinaculum
 Joins the medial aspect of the tendon of extensor digitorum to the index finger to
form an extensor expansion on the dorsum of that finger
- 437 -
 Crosses the dorsal aspect of the wrist and the 2nd metacarpophalangeal joint
 Extends the index finger, independent of other digital extensors
a) Dorsum of ulna (distal to the attachment of extensor pollicis longus)
b) Interosseous membrane of forearm
Distal attachment: Extensor expansion of index finger
Actions: Extends the index finger and the wrist
Neurovascular Structures of the Extensor Compartment of the Forearm
These include:
 Superficial and deep branches of radial nerve
 Posterior interosseous artery
Radial Nerve
In the forearm, the radial nerve

 Innervates the muscles of the extensor compartment of the forearm
 Has a superficial and a deep branch
The deep branch of radial nerve

 Arises from the radial nerve anterior to the lateral epicondyle of the humerus. It
pierce supinator to enter the forearm
 Turns round the lateral and posterior aspects of the neck of radius (in the
supinator), to enter the posterior compartment of the forearm
 Emerges from supinator and runs initially between the superficial and deep
muscles of the extensor compartment; here, it is referred to as the posterior
interosseous nerve. In the distal part of the forearm, it lies on the dorsum of the
interosseous membrane, deep to extensor pollicis longus
 Ends on the dorsum of the wrist as a pseudoganglion (a swelling)
 Is accompanied by the posterior interosseous artery (as it emerges from
supinator)
Branches of the deep branches of radial nerve (posterior interosseous nerve)

include:
 Several muscular branches to muscles of the extensor compartment of the
forearm
- 438 -
 Articular branches to the carpal, distal radio-ulnar, intercarpal and

intermetacarpal joints
Superficial branch of radial nerve

 Is entirely sensory. It arises from the radial nerve, anterior to the lateral
epicondyle of the humerus
 Runs deep to brachioradialis, along the anterolateral aspect of the proximal ⅔ of
the forearm. In the distal 3rd of the forearm, it turns posteriorly, deep to the
tendon of brachioradialis
 Pierces the deep fascia as it crosses the roof of the anatomical snuffbox, distal to
which it enters the hand
 Divides terminally into four (or five) dorsal digital nerves, to the skin of the
lateral 3½ digits (see the hand [below])
 Is accompanied, on its medial side, by the radial artery (proximal ⅔ of the
forearm); it gives a branch to this vessel
Distribution of the superficial branch of radial nerve
The superficial branch of radial nerve

 Innervates the skin of the lateral aspect of the dorsum of the wrist and hand
 Gives cutaneous branches to the lateral 3½ digits (except the terminal ends of
these digits), via the dorsal digital nerves
 May innervate the dorsum of the lateral 2½ digits only, or the whole of the
dorsum of the hand
Posterior Interosseous Artery (see ulnar artery)
Elbow Joint (Fig. 92, 93)
The elbow joint

 Is largely a uni-axial, hinge type of (compound) synovial joint. It is formed by
the humerus proximally and the radius and ulna distally
 Consists of two articulations; these include humero-ulnar and humeroradial
articulations
 Shares the same fibrous capsule and joint cavity with the proximal radio-ulnar
joint
 Is located in the elbow region, about 2 cm distal to humeral epicondyles
The humeroradial articulation

 Is formed by the convex humeral capitulum proximally and the concave head
of the radius distally
Regarding the articular surfaces of the bones of the elbow joint, note these
points:
- 439 -
 The grooved trochlea of the humerus is not a simple pulley; it projects inferiorly
at its medial end. Thus, the trochlear notch of ulna and the trochlea of the
humerus are not perfectly congruent
 All the bony surfaces (capitulum and trochlea of humerus, trochlear notch of
ulna, and the head of radius) involved in the elbow joint are lined by hyaline
cartilage. These bony surfaces are closely in contact with one another when the
forearm is semi-pronated and flexed at right angle
Figure 92. Bony articular surfaces of elbow joint
The fibrous capsule of elbow joint

 Is thin and weak in its anterior and posterior parts. However, it is strengthen at
the sides by ulnar and radial collateral ligaments
 Is attached anteriorly and above to the humerus (just above the coronoid and
radial fossae, as well as to the front of the medial epicondyle of this bone); and
anteriorly and below to the margin of the coronoid process of ulna and to the
annular ligament of the proximal radio-ulnar joint
 Is attached posteriorly and above to the back of the medial epicondyle, side and
floor of olecranon fossa and posterior margin of capitulum of the humerus; and
posteriorly and below to the margin of the olecranon of ulna, as well as the
capsule of the superior radio-ulnar joint (with which it is continuous)
 Is lined internally by synovial membrane
 Is related anteriorly to brachialis; this muscle separates it from the cubital
fossa; posteriorly, it is related to the tendon of triceps and to the anconeus
 Is related laterally to the common extensor tendon and supinator; and medially
to the common flexor tendon and flexor carpi ulnaris
In the elbow joint, the synovial membrane

 Lines the internal surface of the fibrous capsule of the joint. Besides, it lines the
lower part of the annular ligament of the proximal radio-ulnar joint
- 440 -
 Is reflected from the fibrous capsule to line the humeral olecranon fossa
(behind), and the radial and coronoid fossae of the same bone (in front). In these
fossae, it is overlaid by fatty pads (between the membrane and the fibrous
capsule)
 Forms a projection that extends into the joint from behind, between the radius and
ulna; this partially separates the elbow joint into a humeroradial and a humero-
ulnar articulation
 Is continuous below with the synovial membrane of the superior radio-ulnar
joint
Ligaments of Elbow Joint (Fig. 93)
These include:
 Radial collateral ligament laterally; and
 Ulnar collateral ligament medially
Figure 93. Ligaments of elbow joint
The radial collateral ligament

 Is a strong triangular thickening of the lateral aspect of the fibrous capsule of the
elbow joint. It strengthens the fibrous capsule laterally
- 441 -
 Is attached above, via its apex, to the antero-inferior aspect of the lateral
epicondyle of the humerus; and below, via its base, to the annular ligament and
supinator crest of ulna
 Blends with supinator and extensor carpi radialis brevis at its proximal
attachment
Regarding ulnar collateral ligament, note the following points:

 Ulnar collateral ligament is a thick triangular band that strengthens the articular
capsule of the elbow joint medially
 The anterior, posterior and inferior borders of ulnar collateral ligament form three
thickened bands
 The anterior band of ulnar collateral ligament is the strongest of the three bands
of this ligament; it stretches between the front of humeral medial epicondyle
above, and the coronoid process of ulna below
 The posterior band of ulnar collateral ligament is the weakest; it stretches
between the posterior aspect of humeral medial epicondyle above, and the
olecranon of ulna below
 The inferior oblique band of ulnar collateral ligament (base of this triangular
ligament) connects the lower ends of the anterior and posterior bands; thus, it
stretches between the coronoid process and olecranon of ulna
 The middle part ulnar collateral ligament is relatively weak and lies between the
three thickened band
 The ulnar nerve runs over the medial aspect of the middle part of ulnar collateral
ligament (as it passes to the forearm from the arm)
Innervation of the Elbow Joint
The elbow joint receives sensory fibres from the following nerves:
 Musculocutaneous nerve, via the branch to brachialis
 Radial nerve, via the nerve to anconeus and medial head of triceps (ulnar
collateral nerve)
 Few fibres from ulnar, median, and occasionally, anterior interosseous nerves
Blood Supply to the Elbow Joint
The elbow joint receives blood from arteries that anastomose around the joint (see
below).
Movement of the Elbow Joint
Note the following:

 Movement of the elbow joint occurs at an axis that passes through the humeral
epicondyles
 Being a uni-axial joint, flexion and extension are the main movements of the
elbow joint
- 442 -
 The main flexors of the elbow joint include brachialis, biceps brachii and
brachioradialis
 The main extensors of the elbow joint are triceps brachii and anconeus
Bursae of the Elbow Joint
Bursae reduce friction around joints; those associated with the elbow joint include:
a) Subcutaneous olecranon bursa, located in the subcutaneous tissue that overlies
olecranon
b) Biceps bursa, between biceps’ tendon and tuberosity of radius
c) Radio-ulnar bursa, behind supinator
d) Intratendinous olecranon bursa, associated with the tendon of insertion of
triceps (may be assent)
e) Subtendinous olecranon bursa, deep to the tendon of triceps
Applied Anatomy of the Elbow Joint

 Posterior dislocation of the elbow joint may occur when one falls on the hand
 The ulnar collateral ligament is frequently torn when the elbow joint is
dislocated
 The ulnar nerve is susceptible to injury in dislocation of elbow joint or avulsion
of medial humeral epicondyle, etc. The nerve lies behind the latter
 Some of the bursae (see below) that surround the elbow joint may become
inflamed (bursitis) either owing to repeated overuse or infections.
Carrying Angle
The carrying angle

 Is the angle between the arm and the forearm when the forearm is fully extended
and supinated.
 Is formed as a result of the more prominent medial end of humeral trochlea,
which projects (for about 6 mm) beyond the lateral end, thereby pushing the ulna
(and hence the forearm) laterally
 Is also partly due to the obliquity of the superior articular surface of ulnar
coronoid process
 Is estimated to be about 170o in males; and 160o–165o in females.
 Disappears when the extended forearm is pronated.
Anastomoses Around the Elbow Joint
Arterial anastomoses around the elbow joint

 Are formed by branches of the major arteries associated with the elbow joint
 Ensure adequate supply of arterial blood to the elbow joint.
- 443 -
To form the arterial anastomoses around the elbow joint,

 Radial collateral branch of profunda brachii artery joins the radial recurrent
branch of radial artery;
 Middle collateral branch of profunda brachii joins the interosseous recurrent
branch of posterior interosseous artery;
 Superior ulnar collateral branch of brachial artery joins the posterior ulnar
recurrent branch of ulnar artery; while,
 Inferior ulnar collateral branch of brachial artery joins the anterior ulnar recurrent
branch of ulnar artery.
Radio-Ulnar Joints
Note the following:

 Radio-ulnar joints are a pivot type of synovial joint (between the radius and
ulna)
 Two radio-ulnar joints exist; these include proximal and distal radio-ulnar
joints.
Proximal Radio-Ulnar Joint
The proximal radio-ulnar joint

 Is a uniaxial, pivot type of synovial joint
 Is the articulation between the head of radius and the osseofibrous ring formed
by the ulnar radial notch and annular ligament
 Is strengthened by the fibrous capsule, annular and quadrate ligaments.
Articular Surfaces of Proximal Radio-Ulnar Joint
Note the following:

 The circumference of the head of radius is covered by hyaline articular
cartilage; the radial notch of ulnar is also covered by hyaline cartilage
 A thin layer of fibrocartilage covers the part of the annular ligament apposed
to the head of radius
The fibrous capsule of proximal radio-ulnar joint

 Is continuous with the fibrous capsule of elbow joint. It encloses a joint cavity
that communicates with that of the elbow joint
 Is lined internally by a synovial membrane that is also continuous with that of
the elbow joint.
The synovial membrane of proximal radio-ulnar joint

 Lines the internal aspect of the fibrous capsule of the joint. It is continuous with
the synovial membrane of the elbow joint
- 444 -
 Also lines the distal part of the internal surface of the annular ligament (and
adjacent non-articular parts of the ulna and radius
 Is reflected on itself over the neck of the radius to form a sacciform recess (distal
to the annular ligament).
Ligaments of Proximal Radio-Ulnar Joint
These include:
 Annular ligament; and
 Quadrate ligament.
The annular ligament

 Is a strong fibrous collar attached to the anterior and posterior margins of the
radial notch of ulna. It forms ⅘ of the osseofibrous ring that accommodates the
circumference of the head of radius
 Blends with the radial collateral ligament and the capsule of elbow joint
 Is narrower towards the neck of the radius, thereby clasping over the distal
margin of radial head. This prevents the latter from being pulled distally (out of
its osseofibrous ring)
 Is lined internally in its upper part by fibrocartilage and in its lower part by
synovial membrane.
The quadrate ligament

 Is weak, thin band that stretches between radial neck and the inferior margin of
radial notch of ulna
 Overlies the distal part of synovial membrane.
Movement of the Proximal Radio-Ulnar Joint

 Pronation and supination are the movements that occur at the proximal radio-
ulnar joint
 Pronation and supination occur through an axis that passes through the centre of
radial head (proximally) and ulnar attachment of articular disc of distal radio-
ulnar joint (distally)
 During pronation/supination movement, the radius moves relative to the ulna
 In supination, the radius lies parallel to the ulna, and the palm faces anteriorly (in
the erect position)
 In pronation, the radius lies obliquely across and anterior to the ulna, and the
palm faces posteriorly (in the erect position).
 Pronator quadratus is the prime mover in pronation; it is assisted by pronator
teres (when acting against resistance)
- 445 -
 Supinator is the prime mover in supination. It is assisted by biceps brachii when

acting against resistance.
Innervation and Blood Supply of the Proximal Radio-ulnar Joint
Note the following:

 Genicular branches of musculocutaneous, median and radial nerves innervate
the proximal radio-ulnar joint
 The proximal radio-ulnar joint is supplied by branches of the anterior and
posterior interosseous arteries
Applied Anatomy
Note that
 The annular ligaments may be torn during a fall, with consequent dislocation of
radial head
 Dislocation of radial head often occurs in the young subjects who fall on a
supinated, extended forearm
 Subluxation of radial head often occurs in children, especially in girls; this is
partly owing to the small size of radial head in this age group
 In subluxation of radial head, the head of radius is partly dislocated (pulled
inferiorly) from its osseofibrous ring.
Distal Radio-Ulnar Joint
The distal radio-ulnar joint

 Is also a uniaxial, pivot type of synovial joint; it is located at the distal end of the
forearm, and is formed between the head of ulna and ulnar notch of radius
 Has a strong triangular articular disc, which separates its cavity from that of the
wrist joint
 Permits the movement of the radius on ulna
Articular Surfaces and Bones of the Distal Radio-Ulnar Joint
Note that
 The ulnar notch (on the medial aspect of the distal end of radius) has a lining of
articular cartilage
 The circumference of the head of ulna is lined articular cartilage.
The fibrous capsule of distal radio-ulna joint

 Forms an anterior and a posterior band between the distal ends of the radius and
ulna. Below, it blends with the articular disc of the joint
 Is separated proximally, where a fold of synovial membrane (sacciform recess)
lies between its anterior and posterior bands
 Encloses the L-shaped cavity of the distal radio-ulnar joint
- 446 -
Synovial membrane of the distal radio-ulnar joint

 Lines the internal surface of the fibrous capsule of the joint
 Extends upwards between the ulna and radius (anterior to the lower end of the
interosseous membrane) as a lax fold (sacciform recess), which separates the
proximal margins of anterior and posterior bands of the fibrous capsule.
Articular Disc of the Distal Radio-Ulnar Joint
The articular disc of the distal radio-ulnar joint

 Is a triangular disc of fibrocartilage, which binds the distal ends of the radius
and ulna together. In children, it consists mainly of collagen and elastic fibres
 Is attached, via its base, to the distal end of the radius; and via its blunt apex to
the lateral aspect of the root of the styloid process of ulna.
 Separates the cavity of the radio-ulnar joint (proximally) from that of the wrist
joint (distally)
 Degenerates progressively with advancing age. It may also develop perforations
from the third decade of life onwards (in which case the cavities of the distal
radio-ulnar and wrist joints communicate).
Movement of Distal Radio-Ulnar Joint

This joint is also involved in pronation and supination of the forearm
Note: See the proximal radio-ulnar joint for details of these movements.
Innervation and Blood Supply of the Distal Radio-Ulnar Joint
Regarding the distal radio-ulnar joint, note that

 It is innervated by genicular branches of the anterior and posterior interosseous
nerves
 It receives blood supply from branches of the anterior and posterior interosseous
arteries.
Bones of the Forearm (Fig. 94)

Bones of the forearm include radius and ulna; these lie parallel to one another when
the forearm is supinated, with the ulna being medial to the radius.
Radius (Fig. 94)
Regarding the radius, note the following facts:

 The radius is the shorter of the forearm bones. It lies lateral to the ulna, and has a
proximal end, a body and a distal end
 The proximal end of the radius consists of a head, a neck and a radial
tuberosity
- 447 -
 The upper surface and circumference of the head of radius is covered by articular
hyaline cartilage. It articulates with the capitulum of the humerus to form the
humeroradial articulation. Besides, the circumference of the head of radius
articulates with the radial notch of ulna to form the proximal radio-ulnar joint
 The neck of the radius is the constricted part between the head and tuberosity of
this bone
 The radial tuberosity is a small medially-directed bony prominence that gives
attachment to the tendon of biceps brachii
 The body of radius links the proximal and distal ends of this bone, and gives
attachment to the interosseous membrane and several muscles. It increases in
diameter from proximal distally
 The radius ossifies from three centres located in the shaft, proximal end and
distal end of the bone. Ossification commences in the shaft by 8th week of
pregnancy and is completed in the distal (growing) end by the 19th postnatal year
(in males).
Figure 94. Ulna and radius (anterior view)
In addition, note that:

 The distal end of radius has an ulnar notch, a styloid process and a dorsal
tubercle
 Ulnar-notch of the radius is lined by hyaline cartilage. It articulates with the
head of ulna at the distal radio-ulnar joint
- 448 -
 The radial styloid process projects distally from the lateral aspect of the distal
end of radius. It is longer and larger than ulnar styloid process
 The dorsal tubercle of radius separates the groove for extensor pollicis longus
(medially) from that of extensors carpi radiales longus and brevis (laterally) (as
these enter the wrist). It serves as a pulley for extensor pollicis longus.
Ulna (Fig. 94)
The ulna
 Is the longer of the two bones of the forearm. It lies medial to the radius
 Is relatively fixed during supination-pronation movement (when radius moves
across the ulna)
 Has a proximal end, a body and a distal end (head)
 Ossifies from four main centres: one in the shaft, one at the distal end and two
in the olecranon. Ossification begins in the shaft by the 8th week in utero and
ends by the 18th year (in males), when the distal epiphysis joins the shaft.
Anatomical features at the proximal end of the ulna include:

 Olecranon, which gives attachment to the tendon of triceps, etc
 Coronoid process, which gives attachment to brachialis, etc
 Trochlea notch, which articulates with humeral trochlea (at the humero-ulnar
joint)
 Radial notch, which articulates with the circumference of the head of radius (at
the proximal radio-ulnar joint)
 Tuberosity of ulna; this gives attachment to the tendon of insertion of brachialis;
 Supinator crest, for the attachment of supinator
 Supinator fossa, also for the attachment of supinator.
The body of ulna

 Is a cylindrical shaft, which decreases in diameter from proximal distally
 Gives attachment to the interosseous membrane and several muscles.
Anatomical features of the distal end of ulna include:

 A head, the lateral aspect of which articulates with ulnar notch of radius at the
distal radio-ulnar joint. Its inferior surface apposes the articular disc of the
same joint
 A styloid process, which is smaller and shorter that of the radius.
Applied Anatomy

 A heavy blow on the forearm may result in fracture of the intermediate portion
of the radius and/or ulna. The radio-ulnar joints may also be dislocated
- 449 -
 Colle’s fracture – fracture of the distal end of radius – is the commonest fracture
of the forearm, especially in (female) subjects beyond 50 years of age (owing to
osteoporosis, etc)
 Colle’s fracture may occur when there is a fall on an extended pronated forearm.
The fracture is usually of the commuted type , and the distal segment of the
radius is usually displaced dorsally
 When Colle’s fracture occurs, the tip of ulnar styloid process usually projects
beyond that of the radius (a reversal of the normal arrangement). This results in
dinner fork deformity
 Healing of Colle’s fracture is usually satisfactory owing to the rich blood supply
of the radius.
Hand (Manus)
Regarding the hand, note the following:

 The forearm and the hand are joined at the wrist (carpus)
 The hand has 27 bones; these are arranged as follows:
- 8 bones in the carpus (wrist)
- 5 bones in the metacarpus (hand proper)
- 14 bones in the digits
 The carpus contains 8 carpal bones, flexor retinaculum, extensor retinaculum,
anatomical snuff box and the carpal tunnel
 The hand proper consists of 5 metacarpal bones and the compartments and
spaces of the hand
 Each digit has three phalanges (bones), except the first digit (thumb), which has
two phalanges
 The hand is highly adapted for skilled and selective movements.
Anatomical Snuff Box
The anatomical snuff box

 Is a depression on the lateral aspect of the wrist; it is much obvious when the
thumb is fully extended
 Transmits the radial artery (as this passes from the forearm to the hand)
 Contains branches of the superficial branch of the radial nerve (in the
subcutaneous tissue)
 Has a floor, roof, anterior border and posterior border.
Boundaries of the anatomical snuff box include:

 Floor: scaphoid (proximally) and trapezium (distally)
 Roof: skin and fasciae of the lateral aspect of the wrist
- 450 -
 Anterior border: tendons of abductor pollicis longus and extensor pollicis

brevis
 Posterior border: tendon of extensor pollicis longus
Content: radial artery (the pulsation of which may be felt in this region)
Bones of the Wrist (Carpal Bones) (Fig. 95)

 The wrist contains eight small bones; these are arranged in two rows (proximal
and distal), of four bones each
 The eight carpal bones are arranged such that they form a concavity – carpal
sulcus – that faces anteriorly and a convexity that faces posteriorly
 The carpal sulcus is converted into a carpal tunnel by the flexor retinaculum (see
below)
 The proximal row of carpal bones has four bones; these are, from lateral
medially, scaphoid, lunate, triquetrum and pisiform
 The distal row of carpal bone also has four bones; these are, from lateral
medially, trapezium, trapezoid, capitate and hamate.
Proximal Row of Carpal Bones (Fig. 95)
Note the following:

 The scaphoid is the largest bone of the proximal row; it is boat-shaped (hence the
name), and bears a tubercle for the attachment of the flexor retinaculum
 The lunate is semi-lunar (moon-shaped) in outline, hence the name
 The triquetrum resembles a three-sided pyramid. On its palmar surface is a facet
for the pisiform
 The pisiform (as the name implies) is pea-shaped; it is enclosed by the tendon of
flexor carpi ulnaris, and on its dorsal surface is a facet for triquetrum
- 451 -
Figure 95. Bones of the hand
Distal Row of Carpal Bones (Fig. 95)
Note the following:

 The trapezium has four sides, with a tubercle for the flexor retinaculum and a
groove for flexor carpi radialis on its palmar surfaces;
 The trapezoid is a rough, irregular, wedge-shaped bone; it articulates with the 2nd
metacarpal
 The capitate, the largest of the carpal bones, is centrally placed; it has a rounded
head (on its palmar surface) and articulates with the 3rd metacarpal
 The hamate is wedge-shaped; it bears a hook for the attachment of the flexor
retinaculum, and articulates with the 4th and 5th metacarpals.
Applied Anatomy
Note these points:

 The scaphoid is the most commonly fractured carpal bone (as may occur when
one falls on the palm, etc)
 A fractured scaphoid may take several weeks, even months, to heal. This is
owing to the poor vascularity of its proximal part
 The ulnar nerve may be injured when the hamate is fractured; this is owing to
the close relationship between this nerve and the hamate.
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Carpal Tunnel (Fig. 96)
The carpal tunnel

 Is an osseofibrous canal on the anterior aspect of the wrist. It has a bony wall
formed by the concavity (carpal sulcus) on the anterior aspect of carpal bones;
and a fibrous wall formed by the flexor retinaculum. The latter stretches
transversely across the concavity formed by carpal bones.
 Links the forearm with the hand; thus, it transmits the tendons of FDS, FDP, and
pollicis longus, as well as the median nerve.
Figure 96. Transverse section of the wrist showing carpal tunnel
In the carpal tunnel,

 The four tendons of FDP are the deepest (most posterior) structures; while the
four tendons of FDS lie anterior to those of FDP
 All the tendons of FDP and FDS are enclosed in a common synovial sheath
 The tendon of flexor pollicis longus occupies the lateral angle of the carpal
tunnel; it has its own synovial sheath
 The median nerve lies anterior to the tendons of FDS, just deep to the flexor
retinaculum.
Applied Anatomy

 Carpal tunnel syndrome may result from the inflammation of the synovial
sheath that invests those tendons that traverse the carpal tunnel. This is associated
with accumulation of fluid in the tunnel
 Excessive fluid in the carpal tunnel will compress the tendons and nerve that
traverse this tunnel
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 The median nerve is most adversely affected in carpal tunnel syndrome.

Compression of the median nerve in the carpal tunnel will produce sensory deficit
(hypoesthesia or aesthesia) on the palmar aspects of the lateral 3½ fingers (but
not the palmar aspect of the hand proper)
 Sensory perception in the skin of the palm is not impaired in carpal tunnel
syndrome (as the palmar cutaneous branch of the median nerve arises in the
forearm and does not traverse the carpal tunnel)
 Weakness/paralysis of the thenar muscles (flexor pollicis brevis, abductor
pollicis brevis and opponens pollicis) occurs in carpal tunnel syndrome (as the
recurrent branch of median nerve, which supplies these muscles, arises in the
hand). Thus, fine movements of the thumb are adversely affected
 Management of carpal tunnel syndrome may involves incision of the flexor
retinaculum – carpal tunnel release
Flexor and Extensor Retinacula

The flexor and extensor retinacula are thick transverse bands of deep fascia on the
anterior and posterior aspects of the wrist, respectively.
Flexor Retinaculum (Fig. 96)
The flexor retinaculum

 Is thick transverse band of deep fascia that bridges the carpal sulcus (the
concavity formed by the carpal bones). It is about 3 cm transversely and proximo-
distally
 Forms, together with the carpal sulcus, an osseofibrous carpal tunnel, through
which the long digital flexors and the median nerve reach the hand
 Is attached medially to pisiform and the hook of hamate; laterally, it splits into
superficial and deep laminae. The former is attached to the tubercle of scaphoid
and trapezium, while the latter is attached to the medial lip of the groove of
trapezium
 Transmits the tendon of flexor carpi radialis between its superficial and deep
laminae (as this tendon traverses the groove of trapezium)
 Is crossed on its superficial surface by ulnar nerve and vessels, and by the
palmar cutaneous branch of ulnar nerve (medially) and palmar cutaneous branch
of median nerve (laterally).
 Gives attachment to the tendons of palmaris longus and flexor carpi ulnaris.
Proximally, it is continuous with the deep fascia of the forearm, and distally with
the palmar aponeurosis
 Prevents the long digital tendons from bowstringing during movement; thus, it
acts like a restraint. It also keeps the concavity formed by the carpal bones intact
(as it bridges across it)
 May be incised in carpal tunnel syndrome.
Extensor Retinaculum
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The extensor retinaculum

 Is a thick, strong, oblique band. It lies across the dorsal aspects of the wrist and
distal part of the forearm
 Is continuous proximally and distally with the deep fascia on the dorsum of the
forearm and hand, respectively.
 Is attached medially to the pisiform and triquetrum; and laterally to the anterior
border of the distal end of radius
 Prevents the extensor tendons from bowstringing during movement. These
tendons lie deep to it.
Wrist Joint (or Radiocarpal joint)
Note that the wrist joint

 Is a bi-axial, ellipsoidal type of synovial joint. It is the articulation between the
distal end of the radius and the articular disc of the distal radio-ulnar joint
proximally, and the scaphoid, lunate and triquetrum (as well as the interosseous
ligament between them) distally
 Is indicated on the surface of the wrist by a line joining the styloid processes of
the radius and ulna
 Has a joint cavity that is separated from that of the distal radio-ulnar joint by the
triangular articular disc of this joint.
The fibrous capsule of the wrist joint

 Surrounds the joint cavity. It is attached proximally to the margins of the distal
ends of radius and ulna; and distally to the margins of the articular surfaces of the
scaphoid, lunate and triquetrum
 Is lined internally by a synovial membrane
 Is strengthened by several ligaments. These include radial collateral ligament,
ulnar collateral ligament, etc, which are essentially thickenings of the fibrous
capsule.
The synovial membrane of the wrist joint

 Lines the internal aspect of fibrous capsule of this joint
 Is usually separated from those of the distal radio-ulnar and intercarpal joints
 Is associated with several synovial folds. These include a prestyloid recess,
which ascends ventral to the articular disc of the joint.
Ligaments of the wrist joint include:

 Palmar radiocarpal ligament
 Palmar ulnocarpal ligament
 Ulnar collateral ligament
 Radial collateral ligament; and
 Dorsal radiocarpal ligament.
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The palmar radiocarpal ligament

 Is a broad band that strengthens the fibrous capsule of the wrist joint anteriorly
 Is attached proximally to the anterior margin of the distal end of the radius and to
the styloid process of this bone
 Passes inferomedially to attach distally to the scaphoid, lunate, triquetrum and
capitate
 Is perforated by blood vessels
The palmar ulnocarpal ligament

 Is a rounded bundle of fibrous tissue that strengthens the fibrous capsule of the
wrist joint anteriorly
 Is attached proximally to the base of ulnar styloid process and the articular disc of
the joint
 Passes distolaterally to be attached to lunate and triquetrum
 Is also perforated by blood vessels.
The dorsal radiocarpal ligament

 Strengthens the fibrous capsule of the joint posteriorly; it is thinner than the
palmar radiocarpal ligament
 Is attached proximally to the posterior margin of the distal end of radius
 Passes inferomedially to be attached to the dorsal aspects of scaphoid, lunate,
triquetrum and dorsal intercarpal ligaments
 Blends with the triangular articular disc of the distal radio-ulnar joint.
The ulnar collateral ligament

 Strengthens the fibrous capsule medially. Proximally, it is attached to the apex of
ulnar styloid process
 Passes distally to attach, via a slip each, to the triquetrum and pisiform.
The radial collateral ligament

 Strengthens the fibrous capsule of the joint laterally
 Is attached proximally to the apex of radial styloid process and distally to the
scaphoid and trapezium
 Is related to the radial artery; this runs distally over its lateral surface, to gain
the hand
 Is relatively weak (as is the case with ulnar collateral ligament) compared to other
ligaments of the wrist joint.
Movement of the Wrist Joint
Movements that occur at the wrist and the muscles that produce them include:
 Flexion: flexor carpi ulnaris, flexor carpi radialis, FDS, FDP and palmaris longus
 Extension: extensor carpi ulnaris, extensors carpi radiales longus and brevis, and
extensor digitorum
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 Adduction (ulnar deviation): simultaneous action of flexor carpi ulnaris and

extensor carpi ulnaris
 Abduction (radial deviation): simultaneous action of flexor carpi radialis and
extensors carpi radiales longus and brevis
Innervation and Blood Supply of the Wrist Joint
Note these points:

 The wrist joint receives sensory fibres from the anterior and posterior
interosseous nerves
 Arterial supply to the wrist joint is from the palmar and dorsal carpal arches
Applied Anatomy of the Wrist Joint
Note these points:

 Fracture-separation of the distal epiphysis of the radius (from its diaphysis) may
occur in children (e.g., from a fall on the hand)
 In young subjects, a fall on a flexed wrist may produce transverse fracture of the
radius (Smith fracture), and consequently, ventral deviation of the wrist. Colle’s
fracture (fracture of the distal end of radius) may occur in older people, with the
associated dinner fork deformity
 In fracture of the scaphoid, which may occur following a fall on an open
extended hand, healing progresses slowly owing to the poor vasculature of this
bone
Innervation of the Skin of the Hand
Nerves that innervate the skin of the hand include:

 Palmar cutaneous branch of median nerve
 Palmar digital branches of median nerve
 Palmar cutaneous branch of ulnar nerve
 Superficial terminal branch of ulnar nerve
 Dorsal branch of ulnar nerve
 Superficial branch of radial nerve
Palmar cutaneous branch of median nerve

 Innervates the skin of the lateral aspect of the palm, including thenar skin
Palmar digital branches of median nerve

 Innervates the skin of the whole of the palmar aspect of the lateral 3½ digits
 Also innervates the skin of the distal parts of the dorsum of lateral 3½ digits
Palmar cutaneous branch of ulnar nerve

 Innervates the skin of the medial aspect of the palm
- 457 -
Superficial terminal branch of ulnar nerve

 Innervates the skin of medial aspect of the palm
 Also innervates the skin of the palmar aspect of the medial 1½ digits (via two
palmar digital branches); and that of the distal part of the dorsum of the medial
1½ digits.
Dorsal branch of ulnar nerve

 Supplies the skin of the medial part of the dorsum of the hand
 Also supplies skin of the proximal part of the dorsum of the medial 1½ digits.
Superficial branch of radial nerve

 Innervates the skin of the lateral part of the dorsum of the hand
 Also innervates the skin of the proximal part of the dorsum of the lateral 3½
digits (via dorsal digital branches).
Bones of the Hand Proper and Phalanges
These include:
 Five metacarpals arranged serially, from the lateral to the medial side of the
hand
 Two phalanges (proximal and distal) in the first digit (pollex or thumb)
 Three phalanges (proximal, middle and distal) in each of the medial four (2nd–5th)
digits.
Each metacarpal bone

 Is a long, roughly cylindrical bone
 Has a base, directed proximally; this articulates with the bone(s) of the carpus at
the carpometacarpal joint
 Has a head, directed distally; this articulates with the base of a proximal phalanx
at the metacarpophalangeal joints
 Has a shaft (between the base and the head).
Each phalanx
 Has a head, a shaft and a base
 Articulates with a metacarpal bone (through its base) at the
metacarpophalangeal joints
 Articulates with adjacent phalanx (or phalanges) at the interphalangeal joints.
Deep Fascia of the Hand

The deep fascia of the hand is continuous proximally with that of the forearm. It is
especially thickened in the central part of the palm as the palmar aponeurosis.
Note the following:
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 The deep fascia of the hand completely invests the hand and sends fibrous septa
into it
 In the central part of the palm, the deep fascia is especially thickened to form a
palmar aponeurosis
 From the medial border of the palmar aponeurosis, a medial septum passes
deeply into the hand to attach to the 5th metacarpal. Medial to this septum is the
hypothenar compartment of the hand. It contains the hypothenar muscles, etc
 From the lateral border of the palmar aponeurosis, a lateral septum passes deep
into the hand to attach to the 3rd metacarpal. Lateral to this septum is the thenar
compartment of the hand. It contains the thenar muscles.
 Deep to the thenar compartment is the adductor compartment of the hand; this
contains adductor pollicis, etc
 Located between the lateral and medial septa, and deep to the palmar
aponeurosis, is the central compartment of the hand; this contains the long
digital tendons, etc.
Palmar Aponeurosis
The palmar aponeurosis

 Is a thick, triangular band of deep fascia. It is located centrally in the palm, and it
is firmly connected to palmar skin by fibrous strands
 Has an apex that is directed proximally; here, it is continuous with the flexor
retinaculum and the tendon of palmaris longus (which inserts into it)
 Has a base that is directed distally, and from which four fibrous slips arise; these
pass to the medial four fingers where each blends with the fibrous digital sheath
of its own finger
 Overlies the superficial palmar arch and the tendons of long digital flexors; it
also gives attachment to palmaris brevis (at its medial margin)
 Is involved in the compartmentalization of the hand (in conjunction with the
lateral and medial fibrous septa and adjacent deep fascia of the hand) (see below).
Fibrous Digital (Flexor) Sheaths
In each finger, the fibrous digital sheath

 Is a fibrous channel (on the palmar aspect of the finger). Together with the
underlying phalanges, it forms an osseofibrous channel
 Is attached to the lateral and medial margins of the palmar surfaces of the
proximal and middle phalanges and to the palmar surface of the distal phalanx.
Proximally, it is continuous with a slip of the palmar aponeurosis
 Is organized such that its fibres form four cruciform and five annular bands;
these bands alternate with one another along the length of the sheath
 Transmits the tendons and synovial sheaths of the long digital flexors; these
traverse the osseofibrous channel
 Does not transmit palmar digital nerves (as these lie outside it).
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In the thumb, the fibrous digital sheath

 Transmits the tendon and synovial sheath of flexor pollicis longus;
 Does not receive fibrous slip from the palmar aponeurosis.
Fascial Compartments of the Palm
Note these points:

 The palm may be described as having four fascial compartments: thenar,
hypothenar, central and adductor compartments
 Each fascial compartment of the palm contains muscles, nerves and blood
vessels
 Palmar compartments are separated from each other by the medial and lateral
fibrous septa (which pass deeply from the palmar aponeurosis), the palmar
aponeurosis and the deep fascia of the palm.
Applied Anatomy
Duputren’s contracture of palmar deep fascia

 Is largely of the unknown aetiology, though it may be genetic. It often
commences as nodular swellings of the deep fascia of the medial aspect of the
palm and the palmar aponeurosis
 Produces progressive ‘flexion’ of the little and ring fingers (as the palmar
aponeurosis and deep fascia of the hypothenar eminence shorten progressively
[owing to their gradual degeneration])
 Is commoner in men after middle age and is usually bilateral
 May be corrected surgically by excising the degenerated longitudinal fibres of the
palmar aponeurosis and hypothenar fascia.
Thenar Compartment of the Hand (Fig. 97)
The thenar compartment

 Is bounded by the lateral fibrous septum, deep fascia of the thenar eminence
and the first metacarpal bone
 Contains muscles that constitute the thenar eminence; these muscles include
flexor pollicis brevis, abductor pollicis brevis and opponens pollicis. It does not
contain adductor pollicis.
Flexor Pollicis Brevis (Fig. 97)
The flexor pollicis brevis

 Is an intrinsic muscle of the hand; it is located medial to abductor pollicis
brevis, in the thenar eminence;
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 May possess two heads of origin and usually has a sesamond bone in its tendon
of insertion;
 May fuse partly with opponens pollicis
 Crosses the palmar aspect of carpometacarpal and metacarpophalangeal joints of
the thumb; hence, it acts on both.
a) Superficial head: Flexor retinaculum
b) Deep head (may be absent): Trapezoid and capitate.
Distal attachment: Base of the proximal phalanx of the thumb
Innervation: Recurrent branch of median nerve or deep branch of ulnar nerve (or
both)
Actions:
a) Flexes the proximal phalanx of the thumb
b) Flexes and medially rotates the first metacarpal
c) Assists in ‘opposition’ of the thumb
Abductor Pollicis Brevis (Fig. 97)
Abductor pollicis brevis

 Lies lateral to flexor pollicis brevis in the thenar eminence;
 Crosses the palmar aspects of carpometacarpal and metacarpophalangeal joints of
the thumb; thus, it acts on both.
a) Flexor retinaculum and tendon of abductor pollicis longus;
b) Tubercles of scaphoid and trapezium
Distal attachment:
a) Base of the proximal phalanx of the thumb
b) Radial side of extensor expansion of the thumb
Innervation:
a) Recurrent branch of medial nerve;
b) Deep branch of ulnar nerve (in few subjects)
Actions:
a) Abducts the thumb at the carpometacarpal and metacarpophalangeal joints
- 461 -
b) Medially rotates the thumb at the carpometacarpal and metacarpophalangeal

joints.
Figure 97. Muscles of thenar and hypothenar compartments and the lumbricals
Opponens Pollicis (Fig. 97)
The opponens pollicis

 Is located deep to abductor pollicis brevis in the thenar eminence;
 Moves the thumb such that its tip apposes that of the little finger; this movement
is referred to as opposition
 Crosses the carpometacarpal joint of the thumb; thus, it acts on this joint.
Proximal attachment: Flexor retinaculum and tubercle of trapezium
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Distal attachment: Palmar aspect of the first metacarpal
Innervation:
a) Recurrent branch of median nerve
b) Deep branch of ulnar nerve (in most subjects)
Action:
Opposition of the thumb (i.e., it moves the thumb by flexing and medially rotating it
at the carpometacarpal joint, so that its tip contacts that of any of the fingers).
Adductor Compartment of the Palm
The adductor compartment of the palm
 Is the deepest of the compartments of the palm; it lies deep to the thenar
compartment and thenar space (see below)
 Contains adductor pollicis – the only muscle in this compartment.
Adductor Pollicis (Fig. 97)
This muscle
 Occupies the adductor compartment of the palm. It is the only muscle of this
compartment;
 Has two heads of origin – transverse and oblique – between which the deep
branch of ulnar nerve and the radial artery pass;
 Contains a sesamond bone in its tendon of insertion;
a) Oblique head
– Bases of 2nd and 3rd metacarpal
– Capitate and trapezoid bones
b) Traverses head: distal ⅔ of the palmar aspect of the 3rd metacarpal bone
Distal attachment: Radial side of the base of the proximal phalanx of the thumb
Innervation: Deep branch of ulnar nerve
Action: Adducts the thumb (i.e., draws the thumb onto the palm and pulls it towards
the midline).
Hypothenar Compartment of the Palm (Fig. 97)
The hypothenar compartment of the palm
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 Is bounded by the medial fibrous septum of the hand and the 5th metacarpal
bone; it lies on the medial part of the palm
 Contains muscles of the hypothenar eminence; these include flexor digiti
minimi brevis, abductor digiti minimi and opponens digiti minimi
 Does not contain palmaris brevis; this muscle is in the superficial fascia of the
hypothenar eminence.
Flexor Digiti Minimi Brevis (Fig. 97)
Flexor digiti minimi brevis

 Is a small muscle located lateral to abductor digiti minimi, with which it may be
fused;
 Is of variable size (and may be absent)
 Crosses the palmar aspects of carpometacarpal and metacarpophalangeal joints of
the little finger; thus, it acts on both.
a) Hook of hamate
b) Flexor retinaculum
Distal attachment: Base of the proximal phalanx of the little finger
Actions:
a) Flexes the little finger at the carpometacarpal and metacarpophalangeal
joints;
b) Produces slight lateral rotation of the little finger (at the above joints).
Abductor Digiti Minimi (Fig. 97)
The abductor digiti minimi

 Is the most superficial of the hypothenar muscles; it may fuse with flexor digiti
minimi brevis (medial and parallel to which it lies);
 Crosses the carpometacarpal and metacarpophalangeal joints of the little finger
(minimus). Thus, it acts on both.
Proximal attachment: Pisiform bone and tendon of flexor carpi ulnaris (attached it
to this bone)
Distal attachment: Ulnar side of the extensor expansion of the little finger
Actions:
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a) Abducts the little finger

b) May extend the interphalangeal joints of the little finger (via the extensor
expansion)
Opponens Digiti Minimi
Opponens digiti minimi

 Lies deep to abductor digiti minimi and flexor digiti minimi brevis;
 Is quadrangular in outline and may be pierced by deep branches of ulnar nerve
and ulnar artery
 Crosses the carpometacarpal joint of the little finger, on which it acts
(a) Hook of hamate
(b) Flexor retinaculum
Distal attachment: Ulnar margin and palmar surface of the 5th metacarpal bone
Action: ‘Opposition’ of the little finger (i.e., it draws the little finger anteriorly and
rotates it laterally so that its tip is in contact with that of the thumb).
Palmar Brevis (Fig. 97)
Palmaris brevis
 Is small, thin and quadrangular muscle in the subcutaneous tissue of the medial
aspect of the palm. It is not a content of the hypothenar compartment (as it lies
superficial to the deep fascia);
 Deepens the hollow of the palm and wrinkles the skin of the hypothenar
eminence (when it contracts). It also protects the ulnar nerve and artery (which
lie deep to it)
a) Flexor retinaculum
b) Medial border of the palmar aponeurosis
Distal attachment: Subcutaneous tissue and dermis of the medial border of the palm
Innervation: Superficial branch of ulnar nerve
Actions:
a) Deepens the hollow of the palm
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b) Wrinkles the skin of the hypothenar eminence, thereby making gripping more
efficient.
Central Compartment of the Hand
The central compartment of the hand

 Lies deep to the palmar aponeurosis and superficial to the potential midpalmar
space. It is bounded medially and laterally by the medial and lateral fibrous
septa respectively;
 Contains tendons and synovial sheaths of the long digital flexors (FDS, FDP
and flexor pollicis longus)
 Also contains the lumbrical muscles (which arise from tendons of FDP) and the
palmar digital nerves (branches of median nerve). Also present is the
superficial palmar arch (an arterial arch located immediately deep to the palmar
aponeurosis, and from which the palmar digital arteries arise).
Fascial ‘Spaces’ of the Palm
The palm has two potential spaces: a thenar space and a midpalmar (or central)
space.
Thenar Space
The thenar space

 Lies just deep to the thenar compartment, and superficial to the transverse head
of adductor pollicis. It is limited medially by the lateral fibrous septum (which
separates it from the midpalmar space);
 Is related ventrally to the tendon of flexor pollicis longus, the 1st lumbrical, and
tendons of the long digital flexors of the index finger (and their synovial sheaths)
 Is continuous proximally into the carpal tunnel (behind the common flexor
synovial sheath).
Mid-Palmar (or Central) Space
The mid-palmar space

 Is a potential space that lies immediately deep to the central compartment of the
hand and superficial to the 3rd and 4th interosseous muscles. It is limited laterally
and medially by the lateral and medial fibrous septa, respectively
 Is medial to the thenar space (from which it is separated by the lateral fibrous
septum)
 Is overlaid by tendons of the long digital flexors of the index and middle fingers,
their synovial sheaths, and the 2nd, 3rd and 4th lumbricals (all in the central
compartment)
- 466 -
 Is continuous proximally with the carpal tunnel (behind the common flexor
synovial sheath).
Applied Anatomy

 The potential spaces and the compartments of the palm may become infected;
this may lead to accumulation of pus in them
 Because of the denseness of palmar deep fascia, pus that accumulates in the
fascial compartments of the hand may seep dorsally through the loose tissue of
the web between the roots of the digits, thereby spreading to the dorsum of the
hand (and perhaps, of the forearm)
 Pus in the thenar and midpalmar spaces may drain proximally, beneath the
common flexor sheath, into the carpal tunnel. From the latter, pus may enter the
forearm (ventral to pronator quadratus)
 Pus in the central compartment of the hand may also drain proximally into the
forearm (deep to the flexor retinaculum).
Short Muscles of the Hand
These include:
 Lumbricals,
 Palmar interossei; and
 Dorsal interossei.
Lumbricals
The lumbricals
 Are four short, cylindrical, worm-like muscles (hence their name). They are
closely associated with the tendons of FDP, from which they arise
 Are part of the deep contents of the central compartment of the palm; they are
designated as 1st, 2nd, 3rd and 4th lumbricals, from lateral medially
 Cross ventral to the plane of metacarpophalangeal joints of the fingers, but
dorsal to the interphalangeal joints (via the extensor expansion); thus, they act
differently on these joints.
First Lumbrical
Proximal attachment: Radial side of the tendon of FDP to the index finger
Distal attachment: Radial side of extensor expansion of index finger
Innervation: Median nerve

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Action: See below
Second Lumbrical
Proximal attachment: Radial side of the tendon of FDP to middle finger
Distal attachment: Radial side of extensor expansion of middle finger
Innervation: Median nerve
Third lumbrical
Proximal attachment: Adjoining sides of the tendons of FDP to middle and ring
fingers.
Distal attachment: Radial side of extensor expansion of the ring finger
Innervation: Deep terminal branch of ulnar nerve
Fourth Lumbrical
Proximal attachment: Adjoining sides of the tendons of FDP to ring and little
fingers.
Distal attachment: Radial side of extensor expansion of the little finger
Innervation: Deep terminal branch of ulnar nerve
Actions of Lumbricals
Each lumbrical
 Flexes the metacarpophalangeal joint of its own finger (in conjunction with
interossei);
 Extends the proximal and distal interphalangeal joints of its own finger.
 Palmar Interossei
Palmar Interossei Muscles
The palmar interossei muscles

 Are small muscles on the palmar aspect of metacarpal bones; they are
associated with each metacarpal bone and digiti (except the 3 rd metacarpal and
middle finger)
 Are four in number, designated as 1st – 4th palmar interossei (from lateral
medially)
 Are all innervated by the deep branch of ulnar nerve
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 Cross ventral to the plane of the metacarpophalangeal joints but dorsal to that of
interphalangeal joints of their digits (via the extensor expansion). Palmar
interossei adduct their respective digits, in addition to other actions (see below)
 Are half the size of dorsal interossei.
First Palmar Interosseous Muscle
Proximal attachment: Palmar surface of the base of the 1st metacarpal
Distal attachment:
a) Base of the proximal phalanx of the thumb
b) Medial aspect of extensor expansion of the thumb
Action: See below
Second Palmar Interosseous Muscle
Proximal attachment: medial side of the shaft of the 2nd metacarpal bone
Distal attachment: medial side of extensor expansion of the index finger
Actions: See below
Third Palmar Interosseous Muscle
Proximal attachment: lateral side of the shaft of the 4th metacarpal bone
Distal attachment: lateral side of extensor expansion of the ring finger
Action: see below
Fourth Palmar Interosseous Muscle
Proximal attachment: lateral side of the shaft of the 5th metacarpal bone
Distal attachment: lateral side of extensor expansion of the little finger
Action:
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Each palmar interossei muscle

 Adducts its own finger (i.e. draws it towards the plane of the middle finger)
 Flexes metacarpophalangeal joint of its own finger
 Extends interphalangeal joints of its own finger
Dorsal Interosseous Muscles
The dorsal interosseous muscles

 Are four small, bipennate muscles in the intervals between adjacent metacarpals
(hence the name). Each arises by two heads from adjacent metacarpal bones
 Are designated as 1st, 2nd, 3rd and 4th dorsal interossei, from lateral medially. The
first dorsal interosseous muscle is the largest
 Are roughly double the size of the palmar interossei, dorsal to which they lie
 Cross ventral to the plane of the metacarpophalangeal joints and dorsal to that
of interphalangeal joints of the fingers (except the little finger). Each is capable
of abducting the fingers in which it inserts (i.e., it draws it away from the plane
of the middle finger).
Figure 98. Dorsal interosseous muscles
First Dorsal Interosseous Muscle (Fig. 98)
The first dorsal interosseous muscle
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 Is the largest of the interosseous muscles. It occupies the interval between the 1st
and 2nd metacarpals
 Has (as do the others) two heads of origin, between which the radial artery
enters the palm.
Proximal attachment: Adjacent sides of the shafts of the 1st and 2nd metacarpals
Distal attachment:
a) Radial side of the base of the proximal phalanx of index finger
b) Capsule of metacarpophalangeal joint of index finger
c) Extensor expansion of index finger (to a minimal extent).
Innervation:
a) Deep branch of ulnar nerve
b) Media nerve (rarely)
Action: see below
Second Dorsal Interosseous (Fig. 98)
This muscle occupies the interval between the 2nd and 3rd metacarpals
Proximal attachment: Adjacent sides of the shafts of 2nd and 3rd metacarpals
Distal attachment:
a) Radial side of the base of the proximal phalanx of the middle finger
b) Radial side of extensor expansion of the middle finger
Action: See below
Third Dorsal Interosseous Muscle (Fig. 98)
This muscle occupies the interval between the 3rd and 4th metacarpals
Proximal attachment: Adjacent sides of the shafts of the 3rd and 4th metacarpals
Distal attachment:
a) Ulnar side of the base of the proximal phalanx of the middle finger
b) Ulnar side of extensor expansion of the middle finger
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Action: see below
Fourth Dorsal Interosseous Muscle (Fig. 98)
This muscle occupies the interval between the 4th and 5th metacarpals.
Proximal attachment: Adjacent sides of the shafts of the 4th and 5th metacarpals
Distal attachment:
a) Ulnar side of the base of the proximal phalanx of the ring finger
b) Ulnar side of extensor expansion of the ring finger
Action:
Each dorsal interosseous muscle
 Abducts its own finger at the metacarpophalangeal joint (i.e., it pulls the finger
away from the axis of the middle finger)
 Flexes the proximal phalanx of its own finger at the metacarpophalangeal joint
 Extend the interphalangeal joints of its own finger (via the extensor expansion).
In addition, note that

 The thumb and little finger do not receive the attachment of any dorsal
interosseous muscles. Only the index, middle and ring fingers give attachment
to these muscles
 The middle finger gives attachment to the 2nd and 3rd dorsal interossei.
Applied Anatomy
Note that the following fact:
 Injury to the deep branch of ulnar nerve results in claw hand; this nerve
innervates all intrinsic muscles of the hand (except 1st and 2nd lumbricals, which
are innerved by median nerve).
Nerves of the Hand

Nerves of the hand include median, ulnar and radial nerves.
Median nerve (Fig. 99)
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The median nerve enters the hand through the carpal tunnel, just deep to the flexor
retinaculum. It innervates the skin and certain muscles of the hand (see below).
Figure 99. Palmar digital branches of median nerve
In the hand, the median nerve

 Gives off a recurrent (thenar) branch, which innervates the thenar muscles.
 Gives motor branches to the 1st and 2nd lumbrical muscles. It may innervate the
1st dorsal interosseous
 Divides into about four palmar digital branches (to lateral 3½ digits)
 Innervates the skin of the lateral part of the palmar surface of the thumb via a
proper palmar digital branch (one of the four palmar digital branches)
 Innervates the skin of contiguous sides of the palmar surfaces of the lateral 3½
digits via three common palmar digital branches; each of the latter divides into
two proper palmar digital branches (to adjacent sides of the digits)
 Also innervates the skin of the distal aspects of the dorsum of the lateral 3½
digits via rami from its palmar digital branches.
 Supplies the skin of the lateral part of the palm via a palmar cutaneous branch;
this arises in the forearm and does not traverse the carpal tunnel.
Ulnar Nerve
In the lateral part of the flexor retinaculum (between the superficial and deep layers
of this retinaculum), the ulnar nerve divides into superficial and deep terminal
branches. Here, the nerve is lateral to pisiform.
Superficial Branch of Ulnar Nerve

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This branch of ulnar nerve

 Enters the subcutaneous tissue of the medial side of the palm, distal to the flexor
retinaculum
 Divides into two palmar digital nerves (which can be compressed against the
hook of hamate);
 Innervates the skin of the medial aspect of the palmar surface of the little finger
via a proper palmar digital branch (one of the two palmar digital branches)
 Also innervates the contiguous sides of the palmar surfaces of the little and ring
fingers via a common palmar digital branch; this divides into two proper
palmar digital branches (one to each of these fingers)
 Supplies the skin of the distal part of the dorsum of the little and ring fingers
 Innervates palmaris brevis.
Deep Branch of Ulnar Nerve
In the hand, the deep branch of ulnar nerve

 Passes deeply into the hypothenar eminence (between flexor digiti minimi
brevis and abductor digiti minimi); then, it pierces opponents digiti minimi
(accompanied by the deep branch of ulnar artery)
 Emerges from opponens digiti minimi and the passes laterally, across the bases of
the metacarpal bones; here, it is related to the deep palmar arterial arch. It
continues laterally between the two heads of adductor pollicis to end in the first
dorsal interosseous (which it innervates).
The deep branch of ulnar nerve

 Innervates the three hypothenar muscles; all palmar and dorsal interossei; and
the 3rd and 4th lumbricals
 Also innervates adductor pollicis; and occasionally, flexor pollicis brevis.
Superficial Branch of Radial Nerve
In the hand, the superficial branch of radial nerve

 Gives cutaneous rami to the lateral part of the dorsum of the hand
 Gives dorsal digiti branches to the proximal parts of the dorsum of the lateral
3½ digits
 Does not give any muscular branches.
Applied Anatomy
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Note that
 The ulnar nerve may be compressed in the Guyon’s canal; this produces
hypoesthesia in the medial 1½ fingers, and weakness of the hypothenar and most
intrinsic muscles of the hand.
Arteries of the Hand

The hand has two arterial arches: superficial and deep palmar arches, formed by
ulnar and radial arteries.
Ulnar Artery
The ulnar artery

 Accompanies the ulnar nerve as this runs distally between the superficial and
deep layers of flexor retinaculum; here, the artery is lateral to the nerve
 Traverses the Guyon’s canal, between pisiform bone and the hook of hamate;
and then divides (distal to pisiform) into a deep branch and a superficial
palmar arch.
The deep branch of ulnar artery

 Accompanies the deep branch of ulnar nerve as this enters the hypothenar
eminence (between abductor digiti minimi and flexor digiti minimi brevis)
 Penetrates opponens digiti minimi and then runs laterally, at a deeper plane,
across the bases of the metacarpals (deep to the tendons of long digital flexors)
 Joins the radial artery to contribute to the formations of the deep palmar arch.
Superficial Palmar Arch
The superficial palmar arch

 Is formed mainly by the continuation of the ulnar artery (as this runs laterally,
deep to the flexor retinaculum, after emerging from the Guyon’s canal). Laterally,
the arch is completed by the superficial palmar branch of radial artery, which
often joins it
 Has a convexity, which faces distally, and a concavity, which is directed
proximally (as it lies across the palm)
 Lies across the shafts of the metacarpals at a level indicated by a line drawn
across the palm at the level of the distal border of an extended thumb
 Is located at a more distal plane than the deep palmar arch from which it is
separated by the tendons of the long digital flexors.
Branches of the Superficial Palmar Arch

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 Three common palmar digital arteries arise from the convexity of the
superficial palmar arch; these arteries pass distally, on the 2nd, 3rd and 4th
lumbricals
 As the common palmar digital arteries approach the digits, each is joined a
palmar metacarpal artery (a branch of the deep palmar arch)
 Each common palmar digital artery gives rise to two proper palmar digital
arteries. Each of the latter supplies adjacent sides of two fingers
 The proper palmar digital artery to the medial side of little finger arises directly
from the superficial palmar arch
 In each finger, each proper palmar digital artery gives rise to two dorsal
branches that anastomose with the dorsal digital arteries.
 The proper palmar digital arteries supply the tissue of the fingers, as well as
their metacarpophalangeal and interphalangeal joints
Radial Artery
The radial artery

 Runs posterodistally, across the anatomical snuff box, to enter the hand (from
the forearm). This artery enters the palm by passing between the two heads of the
1st dorsal interosseous; then, it continues medially (in the palm) by passing
between the two heads of adductor pollicis
 Joins the deep branch of ulnar artery to form the deep palmar arch (on the
proximal aspects of the metacarpals).
Superficial Palmar Branch of Radial Artery
This branch
 Arises from the radial artery in the distal part of the forearm. it runs through the
thenar muscles, which it supplies
 May join the lateral end of ulnar artery to form the superficial palmar arch.
Deep Palmar Arch
The deep palmar arch

 Is formed as the radial artery joins the deep branch of ulnar artery (in the depth
of the palm); the radial artery is the larger contributor to this arterial arch
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 Lies across the palmar aspects of the bases of the metacarpals, deep to the
tendons of the long digital flexors
 Is accompanied by the deep branch of ulnar nerve (which runs laterally, in the
concavity of this arch)
 Is about 1 cm proximal to the superficial palmar arch.
Branches of the Deep Palmar Arch
These include:
 Princeps pollicis artery (to the thumb)
 Three palmar metacarpal arteries; these anastomose with the common digital
branches of superficial palmar arch
 Three perforating branches, which anastomose with the dorsal metacarpal
arteries;
 Recurrent branches (to carpal bones).
Princeps Pollicis Artery
Princeps pollicis artery

 Arises from the radial artery, as this enters the palm
 Supplies the thumb (pollex) through its two branches
 Usually gives a nutrient branch to the 1st metacarpal bone
 Is often the source of radialis indicis artery; the latter supplies the radial side of
the index finger.
Palmar metacarpal arteries

 Are three vessels that arise from the convexity of the deep palmar arch. They
run on the interosseous muscles of the 2nd, 3rd and 4th interosseous spaces
 Each joins one of the three common palmar digital branches of the superficial
palmar arch (at the digital cleft)
 Give nutrient branches to the 2nd, 3rd, 4th and 5th metacarpals.
Performing branches of deep palmar arch

 Are three vessels, which pass dorsally through the 2nd, 3rd and 4th interosseous
spaces
 Anastomose with the dorsal metacarpal arteries
Recurrent branches of deep palmar arch

 Pass proximally to enter the anterior aspect of the wrist
- 477 -
 Supply carpal bones and the intercarpal joints

 Join the palmar carpal arch (on the anterior aspect of the wrist).
Veins of the Hand (Fig. 100)

 Associated with the deep and superficial palmar arterial arches are the deep and
superficial palmar venous arches respectively
 The common palmar digital veins join the superficial venous arch; while the
palmar metacarpal veins join the deep venous arch
 The dorsal metacarpal veins join the dorsal venous network (Fig. 100)
 Venae comitantes that arise from the deep and superficial venous arches,
accompany the radial and ulnar arteries respectively, to enter the forearm
 From the dorsal venous network, the cephalic and basilic veins arise and enter
the forearm (Fig. 100)
Figure 100. Dorsal venous network of the hand
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CHAPTER 20: THE LOWER LIMB
Introduction
The lower limb consists of the hip and buttock (both of which constitute the gluteal
region), the thigh, leg and foot. It is adapted for locomotion, support and balancing.
The lower limb is connected to the trunk by the pelvic girdle (formed by the two hip
bones and the sacrum) (Fig. 101).
Gluteal Region
The gluteal region consists of the hip and buttock. The former is on the lateral aspect
of the gluteal region (between the iliac crest above and the thigh below), while the
latter is on the posterior aspect of the gluteal region (between the iliac crest above and
the gluteal fold below).
The bone of the gluteal region is the hip bone (Fig. 101).
Figure 101. The pelvic girdle.
Hip Bone
The hip bone

 Is the skeleton of the gluteal region (Fig. 101)
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 Consists of three bones that meet at the acetabulum. These are the ilium
(superiorly), ischium (postero-inferiorly) and pubis (anteromedially) (Fig. 101)
 Bears a large fossa – acetabulum – on its lateral surface; this articulates with the
head of the femur at the hip joint
 Articulates with the opposite hip bone anteriorly at the median symphysis pubis
and with the sacrum posteriorly at the sacro-iliac joint
 Forms, together with the opposite hip bone and sacrum, the pelvic girdle
 Is essentially a flat bone consisting of three parts (ilium, pubis and ischium)
Ilium
The ilium
 Is the flat upper and largest part of the hip bone (Fig. 101); it is joined to the
pubis and ischium at the acetabulum
 Presents a large wing (ala), the lateral surface of which has three gluteal lines
(posterior, anterior and inferior), and which gives attachment to large gluteal
muscles
 Bears a large iliac fossa on the medial aspect of its wing; this accommodates the
iliacus muscle
 Has an upper margin – the iliac crest; this is convex upwards and marks the
upper limit of the hip and buttocks
 Articulates posteriorly with the sacrum, via its auricular surface, to form the
sacro-iliac joint

 Anteriorly, the ilium presents two spines: anterior superior and anterior
inferior iliac spines (Fig. 108)
 The anterior superior iliac spine is a projection at the anterior end of the iliac
crest; it gives attachment to the inguinal ligament and sartorius
 The anterior inferior iliac spine is located just above the acetabulum; it gives
attachment to the iliofemoral ligament and straight head of rectus femoris muscle
 Posteriorly, the ilium also presents two spines: the posterior superior and
posterior inferior iliac spines
 The posterior superior iliac spine marks the posterior end of the iliac crest; it is
indicated by a skin dimple located about 4 cm lateral to the 2nd sacral spine, and it
gives attachment to the sacrotuberous ligament
 The posterior inferior iliac spine forms the upper limit of the greater sciatic
notch; it gives attachment to the sacrotuberous ligament
 The iliac crest has a prominence termed the tubercle of the iliac crest; this is
located about 5 cm posterosuperior to the anterior superior iliac spine
 The highest point of the iliac crest is behind the tubercle (of the iliac crest), at the
level of the L4 vertebra
 The posterior border of the ilium presents a greater sciatic notch; this notch lies
between the posterior inferior iliac spine above and the ischial spine below
- 480 -
 The ilium forms the upper part of the acetabulum
Ischium
The ischium
 Is the postero-inferior element of the hip bone (Fig. 101); it consists of a body
and a ramus
 Forms the postero-inferior part of the acetabulum; here, it articulates with the
ilium and pubis
 Has a prominence, ischial tuberosity, on which the body rests in the sitting
position
Note the following:

 The body of ischium is the part that articulates with the ilium and pubis in the
acetabulum
 The posterior border of the body of ischium forms the lower part of the greater
sciatic notch
 The ischial spine points posteriorly from the body of ischium, behind the
acetabulum; it separates the greater sciatic notch above from the lesser sciatic
notch below
 Attached to the ischial spine is the sacrospinous ligament; this separates the
greater and lesser sciatic foramina from each other
 The ischial tuberosity is the rounded posteroinferior end of the ischial body; it
gives attachment to hamstring muscles
 Between the ischial spine and tuberosity is the lesser sciatic notch
 The ramus of ischium is directed anteromedially to join the inferior ramus of the
pubis (with which it forms the ischiopubic ramus)
Pubis
The pubis
 Is the antero-inferior element of the hip bone
 Consists of a body, a superior ramus (Fig. 108), and an inferior ramus
 Unites with the opposite pubis at a median symphysis pubis – a secondary
cartilaginous joint
 Bounds, together with the ischium, the obturator foramen (a large aperture
covered by the obturator membrane)
 Forms the antero-inferior part of the acetabulum; here, it articulates with the
ilium and ischium.

 The body of pubis is the anteromedial part of the pubis; and it articulates with the
body of the opposite pubis at the symphysis pubis
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 The superior and inferior pubic rami are directed posterolaterally from the
upper and lower ends of pubic body, respectively
 The pubic crest forms the upper border of the pubic body; it gives attachment to
rectus abdominis and pyramidalis
 The pubic tubercle limits the pubic crest laterally; these bony features are both
palpable.
 The pubic tubercle gives attachment to the medial end of the inguinal ligament;
it is located inferomedial to the superficial inguinal ring
 The spermatic cord overlies the pubic tubercle in males, and partly obscures it
 The bodies of pubes form the anterior wall of the true pelvis, on which the
urinary bladder lies
 The body of pubis has anterior, posterior and symphysial surfaces. The
symphysial surface forms, with the opposite pubis, the symphysis pubis.
The superior pubic ramus

 Is directed upwards, backwards and laterally from the superolateral angle of
pubic body; it extends from the pubic tubercle medially to the iliopubic
eminence laterally
 Articulates with the ischium and ilium at the acetabulum; and forms the superior
boundary of the obturator foramen
 Presents, along its mediolateral extent, a sharp pecten pubis, to which the
lacunar ligament is attached. The pecten pubis forms the anterior part of the
pelvic brim (linea terminalis).
The inferior pubic ramus

 Is directed inferolaterally from the lower end of pubic body; and it joins the
ramus of ischium to form the ischiopubic ramus
 Gives attachment to the crus of the penis in males and the crus of the clitoris in
females
 Also gives attachment to muscles of the adductor compartment of the thigh
 Bounds the obturator foramen inferiorly
The pubic tubercle

 Is located at the junction of the pubic body and superior pubic ramus (in the floor
of the superficial inguinal ring)
 Is overlaid by the spermatic cord in males and the round ligament of the uterus
in females
 Gives attachment to the inguinal ligament and cremaster muscle
The pubic crest

 Forms the upper border of pubic body
 Gives attachment to rectus abdominis and pyramidalis (both of which are
contents of the rectus sheath)
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The pecten pubis

 Is a sharp ridge along the length of the superior ramus of the pubis; it completes
the linea terminalis (pelvic brim) anteriorly
 Gives attachment to the conjoint tendon, pectineal and lacunar ligaments and
(occasionally) psoas minor.
Cutaneous Innervation of the Gluteal Region
The skin of the gluteal region receives sensory fibres from the following nerves:
 Dorsa rami of L1–L3 and S1–S3 spinal nerves, and the perforating cutaneous
nerve (ventral rami of S2 and S3); these supply the medial aspect of gluteal skin
 Lateral cutaneous branches of the subcostal and iliohypogastric nerves; these
supply the superolateral aspect of gluteal skin (as far down as the level of the
greater trochanter)
 Posterior branch of the lateral cutaneous nerve of the thigh; this innervates the
inferolateral aspect of gluteal skin
 Branches of the posterior cutaneous nerve of the thigh; these innervate the
inferior part of gluteal skin.

 The perforating cutaneous nerve pierces the sacrotuberous ligament and gluteus
maximus to innervate the medial aspect of gluteal skin
 The lateral cutaneous branches of the subcostal (T12) and iliohypogastric (L1)
nerves descend over the iliac crest (anterior and posterior to the tubercle of iliac
crest) to innervate gluteal skin
 Branches of the posterior cutaneous nerve of the thigh curve upwards, around the
gluteal fold, to innervate the inferior aspect of gluteal skin.
Ligaments of the Gluteal Region

The gluteal region has two main ligaments; these are the sacrotuberous and
sacrospinous ligaments (Fig. 102).
The sacrotuberous ligament

 Is a large band that stretches between the sacrum, ilium and ischium (on the
gluteal aspect of the pelvic girdle) (Fig. 102)
 Is attached above to the lateral margin and dorsum of sacrum, coccyx, posterior
iliac spines and dorsal sacro-iliac ligament; and converges below to attach to the
medial margin of ischial tuberosity
 Is pierced by the perforating cutaneous nerve and coccygeal branches of inferior
gluteal artery
 Converts, together with the sacrospinous ligament, the greater and lesser sciatic
notches into (greater and lesser sciatic) foramina
- 483 -
 Sends some fibrous strands into the long head of biceps femoris at its attachment
to the ischial tuberosity; and extend along the ischial ramus as a sickle-shaped
falciform process
 Forms the posterolateral boundary of the perineum, on each side
 Holds the sacrum in place, thereby preventing its displacement under the body
weight
 Gives attachment to some fibres of gluteus maximus
The sacrospinous ligament

 Is triangular in outline and much smaller than the sacrotuberous ligament (Fig.
102); it is located anterior (deep) to the sacrotuberous ligament
 Is attached medially to the lateral margin of the last sacral piece and the coccyx,
and laterally to the ischial spine
 Is overlaid on its pelvic aspect by the coccygeus (a muscle); hence, it is
considered as the fibrous remnant of this muscle
 Separates the greater sciatic foramen above from the lesser sciatic foramen below
 Is intimately related to the pudendal nerve and internal pudendal artery as these
wind round its dorsal aspect to enter the ischioanal fossa (via the lesser sciatic
foramen).
Foramina of the Gluteal Region

Two foramina are associated with the gluteal region; these are the greater and lesser
sciatic foramina.
The greater sciatic foramen

 Is the opening that links the pelvic cavity with the gluteal region
 Is bounded medially by the sacrotuberous ligament, above and laterally by the
greater sciatic notch, and below by the ischial spine and sacrospinous ligament
 Transmits piriformis, certain nerves (e.g. pudendal and sciatic nerves) and
arteries (e.g. superior and inferior gluteal artery) from the pelvic cavity to the
gluteal region
 Transmits veins (superior and inferior gluteal veins) from the gluteal region to the
pelvic cavity
 Is much larger than the lesser sciatic foramen.
The lesser sciatic foramen

 Is the opening that links the gluteal region with the perineum
 Is bounded medially by the sacrotuberous ligament, above by the ischial spine
and sacrospinous ligament, and laterally by the lesser sciatic notch
 Transmits the pudendal nerve, internal pudendal artery and nerve to obturator
internus from the gluteal region to the ischioanal fossa (perineum)
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Muscles of the Gluteal Region

Muscles of the gluteal region include three large muscles, which are superficially
placed, and a group of small ones, located deep to them (Fig. 102).
The three large superficial muscles are gluteus maximus, gluteus medius and
gluteus minimus, while the deep (smaller) ones are piriformis, superior gemellus,
obturator internus, inferior gemellus, quadratus femoris and obturator externus.
The gluteus maximus:

 Is the largest and most superficial muscle of the gluteal region (Fig. 102)
 Possesses highly coarse fibres (and is reputed as the heaviest muscle in the body)
 Overlies the upper part of the sciatic nerve and the larger parts of other gluteal
muscles
 Is an extensor of the hip joint; it is required mainly when force is needed e.g.
when climbing the stairs. Thus, it is hardly used when walking leisurely.
 Has coarse fibres that are directed inferolaterally at about 450 to the vertical plane
 Is separated from the greater trochanter, ischial tuberosity and vastus lateralis by
bursae (see below)
 Lies behind the hip joint; hence, it acts on this joint.
 Posterior gluteal line of ilium, and the gluteal surface of this bone (behind the
posterior gluteal line)
 Iliac crest and thoracolumbar fascia
 Dorsum of the sacrum, coccyx and sacrotuberous ligament
 Deep fascia (over gluteus maximus)
Distal attachment:
 Iliotibial tract (which receives the superficial ¾ of the fibres of this muscle)
 Gluteal tuberosity of femur (which receives the deep ¼ of the fibres of this
muscle)
Innervation: Inferior gluteal nerve
Actions:
 Extends hip joint (especially when force is needed)
 Rotates thigh laterally
 Abducts the thigh (its upper fibres)
 Extends the pelvis on the thigh (from a stooping position)
 Stabilizes the femur on the tibia (through the iliotibial tract) in conjunction with
tensor fasciae latae.
Test of Integrity: The individual lies prone and then attempts to extend the thigh in
that position.
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Bursae associated with Gluteus Maximus
These include:
 Ischial bursa, which separates the lower fibres of gluteus maximus from the
ischial tuberosity; this bursa may be absent
 Trochanteric bursae, which separate the upper fibres of gluteus maximus from
the greater trochanter of femur; these bursae are relatively large
 Gluteofemoral bursa, which separates the gluteus maximus from vastus lateralis
(at its insertion into the iliotibial tract).
Figure 102. The gluteal region
The gluteus medius

 Is a large fan-shaped muscle (Fig. 102)
 Is overlaid in its posterior ⅓ by gluteus maximus, while its anterior ⅔ lies just
deep to the deep fascia. Therefore, it can be observed between gluteus maximus
posteriorly and tensor fasciae latae anteriorly
- 486 -
 Is separated from femoral gluteal tuberosity by the trochanteric bursa of

gluteus medius
 Is a powerful abductor and medial rotator of the thigh (as it crosses the hip joint
laterally)
 Prevents sagging of the unsupported side of the body during locomotion
Proximal attachment: External surface of the ilium (between posterior gluteal line
above and anterior gluteal line below)
Distal attachment: Lateral aspect of the greater trochanter of femur.
Innervation: Superior gluteal nerve
Actions:
 Abducts the thigh (main action)
 Rotates the thigh medially (its anterior fibres)
 Keeps the pelvis balanced horizontally when opposite foot is off the ground (as
occurs in walking)
Test of Integrity: The individual lies prone with the knee flexed at right angle; the
thigh is then abducted against resistance.
Applied Anatomy

 Positive Trendelenburg’s sign is observed in paralysis of glutei medius and
minimus (e.g. as a result of injury to the superior gluteal nerve)
 Besides injury to the superior gluteal nerve, Trendelenburg’s sign is also positive
in congenital dislocation of the hip joint, abnormal angulation of femoral neck (as
in coxa vara) or fracture of the greater trochanter and/or neck of the femur
 Sagging of the pelvis to the unsupported side (when the foot of that side is off the
ground) indicates a positive Trendelenburg’s sign
 A waddling gait (lurching gait) is also associated with positive Trendelenburg’s
test.
The gluteus minimus

 Is the smallest of the superficial group of gluteal muscles. It is deep to gluteus
medius (Fig. 102)
 Is separated from the greater trochanter of the femur by trochanteric bursa of
gluteus minimus
 Is fan-shaped in outline (just like gluteus medius).
Proximal attachment: External surface of the ilium (between anterior and inferior
gluteal lines).
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Distal attachment: Anterolateral aspect of the greater trochanter of femur.
Innervation: Superior gluteal nerve
Action: Same as for gluteus medius (above)
Applied Anatomy: Same as for gluteus medius (above)
Small (Deep) Muscles of the Gluteal Region

The small (deep) muscles of the gluteal region include piriformis, superior gemellus,
obturator internus, inferior gemellus, obturator externus and quadratus femoris (Fig.
102).
These short muscles, like the rotator cuff muscles of the shoulder joint, act like
extensile ligaments of the hip joint.
Piriformis
 Is piriform in outline, hence the name (Fig. 102)
 Is located partly on the posterior wall of the lesser pelvis and partly in the gluteal
region
 Passes through the greater sciatic foramen as it leaves the pelvis for the gluteal
region; and it lies behind the hip joint as it does so
 Serves as a good landmark in the gluteal region; here, it lies deep to gluteal
maximus (between gluteus medius above and superior gemellus below)
 May be pierced by the common peroneal nerve (when this nerve arises high up
in the pelvic cavity
 Is indicated on the gluteal surface by a line that links the skin dimple over the
posterior superior iliac spine to the greater trochanter of femur
 May fuse partly with gluteus medius, gemelli or obturator internus.
 Middle three sacral pieces (from their lateral margin and the interval between
their pelvic foramina)
 Margin of the greater sciatic notch
 Pelvic surface of sacrotuberous ligament
Distal attachment: Upper border of greater trochanter of femur
Innervation: Branches of the ventral rami of L5, S1 and S2 spinal nerves.
Actions:
 Rotates the extended thigh laterally
 Abducts a flexed thigh
 Assists in keeping femoral head within the acetabulum.
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Obturator internus
 Overlies the internal aspect of obturator membrane (Fig. 102); thus, it forms the
lateral wall of the lesser pelvis and ischioanal fossa (above and below the linear
origin of levator ani, respectively)
 Possesses a tendon that enters the gluteal region by traversing the lesser sciatic
foramen. As it does so, it is separated from the hyaline cartilage on the lesser
sciatic notch by a bursa
 Crosses behind the hip joint, en route to its insertion on the greater trochanter
of femur
 Is accompanied, along its upper and lower margins respectively, by superior and
inferior gemelli (in the gluteal region) (Fig. 102)
 Is usually separated from the capsule of the hip joint by an elongated bursa
 Inner aspect of obturator membrane
 Margin of obturator foramen
Distal attachment: Medial aspect of greater trochanter of femur (above the

trochanteric fossa)
Innervation: Nerve to obturator internus
Actions:
 Rotates the extended thigh laterally
 Abducts a flexed thigh
 Assists in keeping femoral head in place (within the acetabulum)
Superior gemellus
 Is the smaller of the two gemelli; the gemelli are small muscles that accompany
and assist obturator internus
 Passes laterally from its origin, parallel to and above the tendon of obturator
internus (which partly overlies it)
 Does not traverse the lesser sciatic foramen (as does the obturator internus); it is
thus confined to the gluteal region
 May be absent
Proximal attachment: Gluteal aspect of ischial spine
Distal attachment: Medial aspect of greater trochanter of femur
Innervation: Nerve to obturator internus
- 489 -
Action: Same as for obturator internus
The inferior gemellus

 Passes laterally from its origin, along the lower margin of obturator internus
tendon (which partly overlaps and blends with it)
 Does not traverse the lesser sciatic foramen
Proximal attachment: Upper aspect of ischial tuberosity
Distal attachment: Medial aspect of greater trochanter of femur
Innervation: Nerve to quadratus femoris
Action: As for obturator internus
The quadratus femoris

 Is a flat quadrilateral muscle that occupies the interval between inferior gemellus
above and adductor magnus below (Fig. 102); it lies transversely behind the hip
joint and femoral neck
 Is separated from the capsule of the hip joint and neck of femur by the tendon of
obturator externus and the ascending branch of medial circumflex femoral artery
 Is separated from the upper margin of adductor magnus by the transverse branch
of medial circumflex femoral artery
 May be separated from the lesser trochanter of femur by a bursa
 May be absent
Proximal attachment: Lateral margin of ischial tuberosity
Distal attachment:
 Quadrate tubercle of femur
 Intertrochanteric crest of femur
Innervation: Nerve to quadratus femoris
Actions: Rotates thigh laterally
The obturator externus

 Is a flat triangular muscle that overlies the external surface of obturator
membrane
 Lies initially below, then behind the capsule of the hip joint and femoral neck (as
it passes from its origin to its insertion)
 Has a tendon that ascends laterally, deep to quadratus femoris, to reach the
trochanteric fossa
 May be separated from the capsule of the hip joint and the neck of the femur by a
bursa (which may communicate with hip joint cavity)
- 490 -
 Is pierced by the posterior branch of obturator nerve (as this enters the thigh);
besides, it is crossed at its upper border by the anterior division of obturator nerve
 Is related on its deep aspect to the obturator vessels (i.e. between the muscle and
obturator membrane)
 Medial ⅔ of the external surface of obturator membrane
 Adjacent margin of obturator foramen
Distal attachment: Trochanteric fossa of femur.
Innervation: Posterior division of obturator nerve
Action
 Rotates thigh laterally
 Serves as an extensile ligament of the hip joint (and thus keeps femoral head in
the acetabulum)
Nerve Plexuses of the Lower Limb

The lumbar and sacral plexuses of nerves innervate the skin, muscles and joints of
the lower limb; these plexuses are formed by the ventral rami of the lumbar and sacral
spinal nerves.
Lumbar Plexus
The lumbar plexus of nerves

 Innervates, together with the sacral plexus, the lower limb
 Is formed by the ventral rami of the upper four lumbar nerves (L1 – L4), with a
little contribution from the subcostal (T12) nerve (in 50% of cases) (Fig. 103)
 Is located in the substance of psoas major (anterior to the plane of the transverse
processes of the lumbar vertebrae)
 Receives some postganglionic sympathetic fibres (grey rami communicantes)
from the sympathetic chain
 Gives rise to cutaneous, muscular and articular branches that supply the trunk
and lower limb.
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Figure 103. Lumbar plexus of nerves
Regarding formation of the lumbar plexus, note the following:

 The ventral rami of L1–L4 spinal nerves unite with one another in the substance
of psoas major; in 50% of the population, a branch of the ventral ramus of T12
contributes to this plexus (as it unites with L1 ventral ramus) (Fig. 103)
 The ventral ramus of L1 bifurcates into a larger upper and a smaller lower
division
 The larger upper division of the ventral ramus of L1 further divides into
iliohypogastric and ilioinguinal nerves; while the smaller lower division of the
ventral ramus of L1 joins a small branch of the ventral ramus of L2 to form the
genitofemoral nerve
 Each of the ventral rami of L2, L3 and (a larger part of) L4 divides into a dorsal
and a ventral branch (or division)
 The ventral branches of L2–L4 ventral rami unite to form the obturator nerve;
similarly,
 The dorsal branches of L2–L4 ventral rami unite to form the femoral nerve
 Small rami from the dorsal branches of L2 and L3 ventral rami unite to form the
lateral cutaneous nerve of the thigh; likewise,
 Small rami from the ventral branches of L3 and L4 ventral rami may unite to
form an accessory obturator nerve
 Muscular branches arise directly from the lumbar plexus to innervate quadratus
lumborum and psoas major.
- 492 -
Branches of the Lumbar Plexus (Fig. 103)
Nerves that arise from the lumbar plexus include:

 Muscular branches to quadratus lumborum (T12, L1–L4)
 Muscular branches to psoas major (L1–L4)
 Iliohypogastric and ilioinguinal nerves (L1)
 Genitofemoral nerve (L1, L2)
 Lateral femoral cutaneous nerve (L2, L3; dorsal divisions)
 Femoral nerve (L2–L4; dorsal divisions)
 Accessory obturator nerve (L3, L4; ventral divisions)
 Obturator nerve (L2–L4; ventral divisions)
Note: See individual nerves for more details.
Sacral Plexus (Fig. 104)
The sacral plexus of nerves

 Is formed by the ventral rami of L4 to S4 nerves (L4 – S4) (Fig. 104)
 Is located on the posterior pelvic wall, anterior to the pelvic part of piriformis
 Is related anteriorly to the ureter, internal iliac vessels, terminal ileum and
sigmoid colon
 Is connected above (via L4 ventral ramus) to the lumbar plexus and below (via
S4 ventral ramus) to the coccygeal plexus
 Innervates the skin, muscles and joints of the lower limb and perineum.
The lumbosacral trunk

 Is formed by the union of part of the ventral ramus of L4 and the whole of the
ventral ramus of L5
 Emerges from the medial border of psoas major, behind the common iliac
vessels, and descends into the lesser pelvis, anterior to the sacro-iliac joint.
 Joins the S1 ventral ramus in the lesser pelvis; here, it contributes to the
formation of the sacral plexus.
Regarding the formation of the sacral plexus, note that:

 The lumbosacral trunk, ventral rami of S1–S3 and part of the ventral ramus of
S4 unite with one another to form this plexus (Fig. 104); the ventral rami of L5
and S1 are the largest contributors to the plexus
 As the ventral rami of L4–S4 nerves converge towards the greater sciatic
foramen, each divides into ventral and dorsal divisions (or branches); these
divisions then unite in different proportions to form the nerves that arise from the
sacral plexus (Fig. 104).
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Figure 104. The sacral plexus of nerves
Nerves that arise from Ventral Divisions of Sacral Plexus (Fig. 104)
These include:
 Nerve to quadratus femoris and inferior gemellus (L4, L5, S1)
 Nerve to obturator internus and superior gemellus (L5, S1, S2)
 Posterior cutaneous nerve of the thigh (S2, S3)
 Sciatic nerve, tibial branch (L4, L5, S1, S2, S3)
 Pudendal nerve (S2, S3, S4)
 Nerve to levator ani and coccygeus (S4)
 Pelvic splanchnic nerves [parasympathetic fibres] (S2, S3, S4)
Nerves that arise from the Dorsal Divisions of Sacral Plexus (Fig. 104)
These include:
- 494 -
 Nerve to piriformis (S1, S2)

 Superior gluteal nerve (L4, L5, S1)
 Inferior gluteal nerve (L5, S1, S2)
 Posterior cutaneous nerve of the thigh (S1, S2)
 Sciatic nerve, common peroneal branch (L4, L5, S1, S2)
 Perforating cutaneous nerve (S2, S3)
Note: For more details, see individual nerves in their respective regions.
Several nerves leave the pelvic cavity to enter the gluteal region via the greater
sciatic foramen; of these, some continue into the perineum via the lesser sciatic
foramen, some descend into the thigh, while others innervate structures in the
gluteal region.
Nerves that supply structures in the gluteal region, and are thus confined to this
region, include superior and inferior gluteal nerves, nerve to quadratus femoris and
nerve to obturator internus. Besides, those nerves that traverse the gluteal region to
other regions, and which do not supply any gluteal muscles, include sciatic and
pudendal nerves.
Cutaneous branches of the posterior cutaneous nerve of the thigh to the postero-
inferior aspect of gluteal skin has been noted above (see cutaneous innervation of the
gluteal region).
Sciatic Nerve (L4, L5, S1, S2, S3)
The sciatic nerve

 Is the broadest nerve in the body; it is about 2 cm in diameter
 Arises from the sacral plexus in the pelvic cavity; it leaves the latter for the
gluteal region through the lower part of the greater sciatic foramen
 Enters the gluteal region below piriformis; it is the most lateral of the structures
that traverse the greater sciatic foramen
 Traverses the gluteal region by descending successively on the posterior ischial
surface (from which it is separated by nerve to quadratus femoris), superior
gemellus, tendon of obturator internus, inferior gemellus and quadratus femoris.
As it does so, it lies midway between the ischial tuberosity medially and femoral
greater trochanter laterally (deep to gluteus maximus)
 Is accompanied on its medial aspect (in the gluteal region) by the posterior
cutaneous nerve of the thigh and the inferior gluteal artery
 Does not innervate any muscles in the gluteal region
 Leaves the gluteal region for the thigh where it descends behind adductor
magnus, deep to the long head of biceps femoris
 Is indicated by a line (on the posterior surface of the thigh) drawn from a point
midway between the ischial tuberosity and femoral greater trochanter above, to
the apex of popliteal fossa below
- 495 -
 Usually divides in the thigh into a larger tibial branch and smaller common
peroneal branch
 May bifurcate in the pelvic cavity (in about 12% of individuals). In this instance,
the common peroneal nerve pierces piriformis (or may pass above it), while the
tibial nerve passes below this muscle
 Receives arterial blood from a branch of the inferior gluteal artery.
Applied Anatomy of Sciatic Nerve

 In piriformis syndrome, gluteal pain arises as a result of compression of the
sciatic nerve by a hypertrophied piriformis; overuse of gluteal muscles may
predispose one to this syndrome
 When sciatic nerve divides in the pelvic cavity, the common peroneal nerve
usually pierces piriformis and may thus be compressed by it; the nerve may
however enter the gluteal region above this muscle
 Anaesthetic block of sciatic nerve in the gluteal region will produce
hypoesthesia (paraesthesia) in the sole of the foot
 To avoid injury to nerves of the gluteal region (especially sciatic nerve) during
intragluteal injections, the needle should be restricted to the superolateral
quadrant of this region (Fig. 105)
 Intragluteal injections carry little or no risk when given above a line that joins
the posterior superior iliac spine to the femoral greater trochanter (at the
superolateral part of the gluteal region) (Fig. 105).
Figure 105. Diagram demonstrating intragluteal injection.
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Superior Gluteal Nerve (L4, L5, S1)
The superior gluteal nerve

 Arises from the dorsal divisions of L4, L5 and S1 nerves (Fig. 104)
 Leaves the pelvic cavity for the gluteal region through the greater sciatic
foramen, above piriformis
 Is accompanied by the superior gluteal artery as it enters the gluteal region;
here, it passes laterally (between glutei medius and minimus), and it divides into
a superior and an inferior branch
 Innervates gluteus medius via its superior branch; and glutei medius and
minimus via its inferior branch. The latter continues laterally to supply tensor
fasciae latae
 Is accompanied in the gluteal region by the deep branch of superior gluteal
artery (as it passes laterally between glutei medius and minimus)
Applied Anatomy

 Injury to the superior gluteal nerve will paralyze glutei medius and minimus;
this will result in waddling gait
 Persons with injury to superior gluteal nerve (and thus paralysis of glutei medius
and minimus) will present with positive Trendelenburg’s sign (see above).
Inferior Gluteal Nerve (L5, S1, S2)
The inferior gluteal nerve

 Arises from the dorsal divisions of L5, S1 and S2 ventral rami, in the pelvic
cavity (Fig. 104)
 Enters the gluteal region through the greater sciatic foramen, below piriformis. As
it does so, it lies superficial to the sciatic nerve
 Innervates gluteus maximus via several branches that enter the deep surface of
this muscle
Nerve to Quadratus Femoris (L4, 5, S1)
This nerve
 Arises from the ventral divisions of L4, L5 and S1 nerves, in the pelvic cavity
 Enters the gluteal region through the greater sciatic foramen, below piriformis
 Descends on the dorsum of the ischium, deep to the sciatic nerve; and then
continues downwards, deep to the gemelli, tendon of obturator internus and
quadratus femoris (behind the hip joint)
 Innervates quadratus femoris, inferior gemellus and the hip joint.
Nerve to Obturator Internus (L5, S1, S2)

- 497 -
The nerve to obturator internus

 Arises from the ventral divisions of L5, S1 and S2 nerves, in the pelvic cavity
(Fig. 104)
 Enters the gluteal region through the greater sciatic foramen, below piriformis; as
it does so, it lies lateral to the internal pudendal vessels and medial to the sciatic
nerve. From the gluteal region, it turns round the dorsum of the ischial spine
(lateral to the internal pudendal vessels) to enter the perineum through the lesser
sciatic foramen. In the perineum, it lies on the internal aspect of obturator
internus (in the posterior part of the pudendal canal).
 Innervates obturator internus and superior gemellus.
Pudendal Nerve (S2-S4)
The pudendal nerve

 Arises from the ventral divisions of S2, S3 and S4 nerves, in the pelvic cavity
(Fig. 104)
 Is the most medial of the structures that traverse the greater sciatic foramen
(below piriformis) to enter the gluteal region
 Is accompanied, on its lateral side, by the internal pudendal artery (as it
traverses the gluteal region)
 Winds round the dorsum of the sacrospinous ligament as it leaves the gluteal
region for the perineum, through the lesser sciatic foramen. In the perineum, it
traverses the pudendal canal (on the lateral wall of the ischioanal fossa),
accompanied by the internal pudendal vessels
 Gives rise to the inferior rectal nerve (in the ischioanal fossa); this innervates
the external anal sphincter and perianal skin.
 Divides, in the anterior part of pudendal canal, into the dorsal nerve of the penis
and perineal nerves
Note: See the perineum for more details.
Posterior Cutaneous Nerve of the Thigh (S2, S3)

 The posterior cutaneous nerve of the thigh
 Arises from the dorsal divisions of S2 and S3 ventral rami; this nerve passes
below piriformis as it leaves the pelvis for the gluteal region
 Lies deep to gluteus maximus and medial to the sciatic nerve, in the gluteal
region; here, it is accompanied by the inferior gluteal artery
 Descends through the posterior part of the thigh, where it lies deep to the fascia
lata (deep fascia of the thigh); here, it is separated from the sciatic nerve by the
long head of biceps femoris
 Sends branches into the inferior part of gluteal skin; these curve upwards, round
the inferior border of gluteus maximus
 Also gives rise to a perineal branch that innervates the skin of the perineum and
the superomedial part of the thigh.
- 498 -
Note: For more details, see cutaneous innervation of the thigh (below).
Arteries of the Gluteal Region

The superior and inferior gluteal arteries supply structures in the gluteal region;
these vessels arise from the internal iliac artery in the pelvic cavity.
The internal pudendal artery traverses the gluteal region, en route to the perineum,
where it is distributed.
Superior Gluteal Artery (Fig. 106)
The superior gluteal artery

 Arises from the posterior trunk of the internal iliac artery in the pelvic cavity; it
is the direct continuation of this trunk, and the largest of all the arteries that arise
from the internal iliac artery
 Passes backwards, between the lumbosacral trunk and the ventral ramus of S1 (or
between the ventral rami of S1 and S2), as it leaves the pelvic cavity for the
gluteal region through the greater sciatic foramen (and above piriformis)
 Is accompanied (through the greater sciatic foramen) by the superior gluteal
nerve. In the gluteal region, the superior gluteal artery divides into deep and
superficial branches
 Gives a nutrient artery to the hip bone in the pelvic cavity; it also supplies
piriformis and obturator internus
 May arise from the same stem as the inferior gluteal and internal pudendal
arteries.
Figure 106. The superior and inferior gluteal arteries.
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The superficial branch of superior gluteal artery:

 Runs on the deep aspect of gluteus maximus, which it supplies; it also supplies
the skin over gluteus maximus and sacrum
 Anastomoses with the inferior gluteal artery and the posterior branches of
lateral sacral arteries
The deep branch of superior gluteal artery

 Runs deep to gluteus medius, accompanied by the superior gluteal nerve
 Gives rise to superior and inferior branches that accompany similar branches of
the superior gluteal nerve
 Supplies glutei medius and minimus, as well as the hip joint
 Anastomoses with the deep circumflex iliac, ascending branches of lateral and
medial circumflex femoral, and inferior gluteal arteries.
Inferior Gluteal Artery (Fig. 106)
The inferior gluteal artery

 Arises from the anterior division of the internal iliac artery; it is the larger of
the two terminal branches of this vessel
 Initially descends anterior to piriformis and sacral plexus, in the pelvis. Then it
passes backwards, initially between the ventral rami of S1 and S2 nerves (or
between S2 and S3), and then between piriformis and coccygeus
 Traverses the greater sciatic foramen to enter the gluteal region, below
piriformis. In the gluteal region, it lies medial to the sciatic nerve (as it descends
towards the thigh)
 Supplies gluteus maximus (deep to which it descends)
 May share the same stem of origin with the internal pudendal (or superior gluteal)
artery.
Besides, the inferior gluteal artery

 Gives muscular branches to piriformis, quadratus femoris and obturator internus
 Supplies the uppermost part of hamstring muscles (in the thigh)
 Gives rise to artery to the sciatic nerve; this accompanies the sciatic nerve in the
gluteal region but descends through this nerve in the thigh
 Anastomoses with the superior gluteal and internal pudendal arteries
 Contributes to the formation of the cruciate anastomoses (as it anastomoses with
the lateral and medial circumflex femoral arteries and the first perforating branch
of profunda femoris artery, in the posterior aspect of the thigh)
 Gives articular branches to the hip joint and cutaneous branches to gluteal skin.
- 500 -
Internal Pudendal Artery (Fig. 106)
The internal pudendal artery

 Arises from the anterior division of internal iliac artery, in the pelvis.
Occasionally, it arises in conjunction with the inferior gluteal artery
 Enters the gluteal region through the greater sciatic foramen, below piriformis.
Here, it lies between the pudendal nerve medially and the nerve to obturator
internus laterally
 Turns round the dorsum of the ischial spine (from the gluteal region) to enter the
ischio-anal fossa (in the perineum) through the lesser sciatic foramen. Then it
continues in the pudendal canal, accompanied by the pudendal nerve; this canal
is located in the fascia of obturator internus, on the lateral wall of the ischioanal
fossa
 Supplies perineal structures, scrotum (or labium majus) and penis (or clitoris);
and divides terminally into dorsal and deep arteries of the penis (or clitoris).
Gluteal Veins
Regarding gluteal veins, note the following points:

 Veins of the gluteal region include the superior and inferior gluteal veins
 The superior gluteal vein drains the territory of the superior gluteal artery
(which it accompanies)
 The inferior gluteal vein drains the territory of the inferior gluteal artery (which
it also accompanies)
 The superior and inferior gluteal veins are tributaries of the internal iliac vein
 Communications do exist between tributaries of the gluteal and femoral veins.
Thus, venous blood from the lower limb could return via the gluteal veins when
the femoral vein is occluded or ligated
 The internal pudendal vein drains the territory of the internal pudendal artery. It
passes from the perineum into the gluteal region via the lesser sciatic foramen;
and from the gluteal region into the pelvic cavity (via the greater sciatic
foramen); here, it drains into the internal iliac vein.
Lymphatic Drainage of the Gluteal Region

 Lymph vessels from gluteal skin and subcutaneous tissue drain into the
superficial inguinal nodes; and efferent vessels from the superficial inguinal
nodes terminate in the external iliac nodes.
 Lymph vessels that drain the deep tissue of the gluteal region terminate in the
superior and inferior gluteal nodes; these nodes are located along the respective
blood vessels.
 Efferent lymph vessels from the superior and inferior gluteal nodes drain into the
internal and external iliac nodes
- 501 -
 Efferent lymph vessels from internal and external iliac nodes drain into the
common iliac nodes (along the common iliac vessels)
 Efferent vessels from the common iliac nodes terminate in the lumbar nodes
(along the abdominal aorta)
Hip Joint (Coxal Joint)
The hip joint

 Is a multi-axial, ball-and-socket type of synovial joint
 Is the articulation between the head of the femur (the ball) and the lunate
surface of the acetabulum (the socket) (Fig. 107)
 Is adapted for high degrees of stability and appreciable mobility, and is endowed
with a strong capsule and ligaments that enhance its stability and strength
 Has a lesser range of mobility compared to the shoulder joint, having sacrificed
much of its mobility for higher stability and greater strength
 Helps to transmit the weight of the body from the trunk (through the hip bones) to
the lower limb
Articular Surfaces of the Hip Joint (Fig. 107)
Note these facts:

 The femoral head is about ⅔ of a sphere; thus, it is not a complete ball
 Femoral head is covered by a layer of hyaline cartilage (except at the pit [fovea]
for the ligament of the head of femur)
 The articular part of the acetabulum is the lunate surface; the latter is deficient
antero-inferiorly at the acetabular notch
 The lunate surface of the acetabulum is also lined by hyaline cartilage except at
the acetabular notch (which is bridged by the transverse acetabular ligament)
 Acetabular lunate surface is deepened by a rim of fibrocartilage – the acetabular
labrum; this holds the femoral head securely within the acetabulum
 The femoral pit (fovea) and the transverse acetabular ligament are both covered
by synovial membrane
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Figure 107. The right hip joint.
The fibrous capsule of the hip joint

 Is a strong thick fibrous covering that surrounds the joint, thereby helping to
strengthen it
 Is attached medially (proximally) to the margin of the acetabulum, the
acetabular labrum, and the transverse acetabular ligament
 Is attached laterally (distally) to the intertrochanteric line of femur and the root
of the greater trochanter anteriorly and above, and to the neck of the femur (about
1 cm proximal to the intertrochanteric crest and lesser trochanter), posteriorly and
below

 The fibrous capsule of the hip joint is much thicker anteriorly and above
 The fibrous capsule also exhibits local thickenings in certain regions to form
ligaments; these enhance the strength and stability of the joint
 While some fibres of the fibrous capsule are circularly-disposed, others are
arranged longitudinally
 The circularly-disposed fibres of the fibrous capsule form a zona orbicularis
around the femoral neck; this is deeply placed and is best observed on the
posterior and inferior aspects of femoral neck
- 503 -
 The longitudinal fibres of the fibrous capsule stretch between the acetabular and
femoral attachments of the capsule; these fibres are placed superficial to the
circular fibres and are best observed on the anterior and superior aspect of
femoral neck
 From the femoral attachment of the fibrous capsule, some longitudinal fibres turn
inwards, and run toward the acetabulum; these fibres form the retinacula.
Retinacula are therefore deeply located and even blend with the periosteum of
femoral neck
 Branches of the medial circumflex femoral artery (and few of those of the
lateral circumflex femoral artery) run in the retinacula; and they constitute the
retinacular arteries that supply femoral head and neck
 The retinacula may help to hold fragments of femoral neck together when this is
fractured
 Tearing of the retinacula (from fracture of femoral neck) will result in rupture of
retinacular arteries. As a result, avascular necrosis of femoral head will occur.
The synovial membrane of the hip joint

 Lines the intracapsular part of femoral neck, as well as internal surface of the
fibrous capsule of the joint (Fig. 107)
 Also lines the acetabular labrum, and surrounds the ligament of the head of femur
 Covers the fatty tissue that occupies the non-articular acetabular fossa of the
acetabulum
 Is exceptionally thin on the deep surface of iliofemoral ligament
 May communicate with psoas bursa through an aperture in its anterior part
 Forms a small extracapsular protrusion (on the posterior aspect of femoral
neck) over which the tendon of obturator externus passes
Ligaments of the Hip Joint

The exceptional strength of the hip joint is partly attributable to the presence of strong
ligaments; these include iliofemoral, pubofemoral, and ischiofemoral ligaments
(Fig. 108).
In addition, the transverse acetabular ligament and the acetabular labrum also
lend support to the joint. However, the ‘ligament’ of the head of femur does not
offer much mechanical support.
Iliofemoral Ligament (of Bigelow)

The iliofemoral ligament
 Is a strong thick triangular ligament on the anterior aspect of the hip joint (Fig.
108). It is one of the strongest ligaments in the body, being rivaled only by the
interosseous sacro-iliac ligament
 Is thickened along its medial and lateral margins but thinner centrally; therefore,
it has a Y-shaped outline
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 Is attached at its apex to the lower part of the anterior inferior iliac spine; and at
its base to the intertrochanteric line of femur (Fig. 108)
 Measures more than 0.5 cm in thickness. It only ruptures when subjected to
excessive weight (up to 750 lb.); thus, it is rarely torn in dislocation of the hip
joint
 Prevents the pelvis from tilting backwards on the femur in the erect position;
hence, it is of importance in maintaining an erect posture.
Figure 108. Ligaments of the hip joint.
The pubofemoral ligament

 Is a triangular band of fibrous tissue that strengthens the capsule of the hip joint
antero-inferiorly (Fig. 108)
 Is attached proximally, via its base, to the superior ramus of the pubis, obturator
crest and membrane, and the iliopectineal eminence. Then it passes inferolaterally
(from its proximal attachment) to blend with the antero-inferior aspect of the
fibrous capsule and the medial band of iliofemoral ligament
 Prevents hyper-extension and over-abduction of the hip joint.
The ischiofemoral ligament

 Is not as prominent as the iliofemoral and pubofemoral ligaments
 Arises from the ischial (postero-inferior) part of acetabular margin
 Crosses the posterior and inferior aspects of hip joint as it stretches
superolaterally (from its ischial origin) over the femoral neck
 Is attached laterally to the medial aspect of the root of the greater trochanter (deep
to the iliofemoral ligament)
- 505 -
 Prevents hyper-extension of the hip joint (as do iliofemoral and pubofemoral

ligaments)
The acetabular labrum

 Is a rim of fibrocartilage attached to the margin of the acetabulum. It deepens
the concavity of the acetabulum; and together with the transverse acetabular
ligament, forms a complete rim
 Holds the head of femur within the concavity of the acetabulum (as it closes its
thin peripheral margin over femoral head).
The transverse acetabular ligament

 Is the fibrous part of acetabular labrum, which is devoid of chondrocytes
 Is stretched across the acetabular notch, which it converts into a foramen.
The ligament of the head of femur

 Is a weak flattened triangular band of connective tissue ensheathed by the
synovial membrane
 Is located in the hip joint; however, it does not serve any significant mechanical
purpose in this joint
 Is attached, via its broad base, to the margins of acetabular notch and the
transverse acetabular ligament; and via its apex, to the pit (fovea) on the head of
femur
 May be completely absent. On the other hand, it may consist of synovial sheath
only (without connective tissue core)
 Usually transmits a small artery (from the posterior branch of obturator artery)
 Becomes tense in adduction of hip joint, but relaxes in abduction.
Movements of the Hip Joint
Movements associated with the hip joint include:

 Flexion, which occurs on a transverse axis
 Extension, which also occurs on a transverse axis
 Abduction, which occurs on an anteroposterior axis
 Adduction, which also occurs on an anteroposterior axis
 Medial and lateral rotations, which occur on a vertical axis
 Circumduction; this involves the combination of the above movements

 The thigh may touch the anterior abdominal wall in flexion of the hip joint (when
the knee joint is flexed simultaneously)
 Flexion of hip joint is produced mainly by iliopsoas, rectus femoris, sartorius,
tensor fasciae latae, pectineus and the adductors
 In extension of the hip joint, the thigh cannot be carried far beyond the coronal
plane because of the restriction imposed by the iliofemoral ligament
- 506 -
 Extension of the hip joint is produced mainly by the hamstrings, gluteus

maximus and (posterior part of) adductor magnus
 Abduction of the hip joint occurs at a wider range than adduction
 Abduction is a function of glutei medius and minimus, and the tensor fasciae
latae
 Adduction of hip joint is produced by the three adductors (adductors magnus,
longus, and brevis), gracilis and pectineus
 The deep (small) muscles of gluteal region and the gluteus maximus are lateral
rotators of the hip joint; while medial rotation is produced by glutei medius and
minimus, and the tensor fasciae latae
Blood Supply of Hip Joint
The hip joint receives arterial blood from the following vessels:
 Branches of the medial circumflex femoral artery; these form the retinacular
arteries (contained in the retinacula)
 Branches of the lateral circumflex femoral artery; few of these also contribute
to the retinacular arteries
 Branches of the superior and inferior gluteal arteries
 Artery of the head of femur (from the posterior branch of obturator artery). This
may be insignificant or even absent.
Innervation of the Hip Joint
Articular fibres reach the hip joint from the following nerves:
 Femoral nerve (or its muscular branches) and obturator nerve
 Superior gluteal nerve and nerve to quadratus femoris
 Accessory obturator nerve (which may be absent)
Applied Anatomy of Hip Joint

 Post-traumatic avascular necrosis of the head of femur may occur in children,
from damage to the artery of the head of femur
 Dislocation of the hip joint may be congenital or acquired; the former is more
common, and is more prevalent in females than males
 A form of waddling gait and arthritis are usually associated with congenital
dislocation of the hip
 In acquired dislocation of the hip, the femoral head is usually pushed posteriorly
(as the capsule of the hip joint is weaker here than anteriorly). In this condition,
the sciatic nerve is at risk
 Dislocation of the hip joint may also occur anteriorly, as in forceful
hyperextension
- 507 -
 Fracture of the neck of femur may occur, especially in elderly women who
suffer from osteoporosis. When this happens, the retinacular ligaments, which
transmit the retinacular arteries, may be torn. This will disrupt blood supply to
femoral head; and avascular necrosis of femoral head will occur
 Following disruption of the retinacular arteries, the artery of the head of femur
may however supply (part of) the femoral head.
Thigh, Popliteal Region and Knee Joint
Thigh
The thigh is the part of the lower limb between the gluteal fold (posteriorly) and
inguinal region (anteriorly) above, and the knee below; it contains the femur (the
longest bone in the body) and the patella or knee cap (the largest sesamond bone).
Cutaneous Innervation of the Thigh
Cutaneous fibres of the thigh arise from the following:

 Femoral branch of genitofemoral nerve (L1, L2); this innervates the skin of the
femoral triangle
 Anterior cutaneous nerves of the thigh (branches of femoral nerve; L2-L4);
these innervate the skin of the anterior and medial aspects of the thigh
 Lateral cutaneous nerve of the thigh (from the lumbar plexus; L2, L3); this
supplies the skin of the lateral (and adjacent anterior and posterior) aspect of the
thigh
 Posterior cutaneous nerve of the thigh (S2, S3); this supplies the skin of the
posterior aspect of the thigh
 Anterior branch of obturator nerve (L2-L4); this innervates the skin of the
proximal part of the medial (and adjacent anterior and posterior) aspect of the
thigh.
Femur (Bone of the Thigh)
The femur
 Is the longest and strongest bone in the body (Fig. 109)
 Measures about 45 cm in length, and is roughly cylindrical in outline
 Transmits the weight of the body from the pelvic girdle to the tibia
 Articulate with the hip bone at the hip joint and with the tibia at the knee joint
 Consists of a proximal end, a shaft (or body) and a distal end
The proximal end of the femur

 Consists of the head, neck, and the greater and lesser trochanters
 Is angulated to the shaft of femur at the neck; the latter forms an angle of 1250
with the shaft
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The head of femur

 Is the spheroidal proximal end of this bone; it is about ⅔ of a sphere (Fig. 109)
 Is directed upwards, forwards and medially, to articulate with the acetabulum at
the hip joint
 Has a lining of articular hyaline cartilage, except at the fovea (a pit located near
its centre)
 Gives attachment (at the fovea) to the ligament of the head of femur
 Is connected to femoral shaft by a long neck (Fig. 109)
Figure 109. The right femur
The neck of femur

 Is a relatively long bony process, which measures about 5 cm in length; it
connects the head and shaft of femur to each other (Fig. 109)
 Forms an average angle of 1250 with femoral shaft; and it is separated from
femoral shaft anteriorly and posteriorly by the intertrochanteric line and
intertrochanteric crest of the femur, respectively
 Has several foramina, especially on its superior surface, through which the
retinacular arteries pass
 Enables the lower limb to swing clear of the pelvis during movement (owing to
its long length)
509
The greater trochanter of femur

 Is a large bony prominence that projects upwards at the junction of the neck and
shaft of the femur (Fig. 109)
 Presents a hollow trochanteric fossa at the medial aspect of its base. This gives
attachment to obturator externus
 Can easily be palpated. Thus, it serves as a good anatomic and surgical landmark
 Gives attachment to several muscles, including glutei medius and minimus,
piriformis, etc
The lesser trochanter

 Is a bony prominence that projects posteromedially from the postero-inferior
aspect of the junction of the neck and shaft of femur
 Gives attachment to psoas major
 Is not palpable
The femoral shaft

 Is roughly cylindrical in outline; it inclines a little forward in its craniocaudal
extent
 Is almost entirely smooth, except posteriorly where it has a rough vertical ridge
termed the linea aspera
 Has a triangular popliteal surface in the distal part of its posterior surface.
Note the following:

 The linea aspera of femur has medial and lateral lips (Fig. 1011)
 The medial lip of the linea aspera is continuous above with the spiral line (on
the posterior aspect of the proximal part of the femur)
 The spiral line ascends medially, below the lesser trochanter, to join the
intertrochanteric line (anteriorly)
 The lateral lip of the linea aspera is continuous above with the gluteal tuberosity
(located on the posterior aspect of the proximal part of femur)
 The gluteal tuberosity continues upwards towards the posterolateral aspect of the
greater trochanter of the femur
 Just below the posterior aspect of the greater trochanter is the quadrate tubercle,
for quadratus femoris
 On the posteromedial aspect of the femur, a pectineal line descends from the
lesser trochanter, towards the spiral line
 The lesser and greater trochanters of the femur are united anteriorly and
posteriorly by the intertrochanteric line and intertrochanteric crest,
respectively
 The lateral lip of femoral linea aspera is continuous below with the lateral
supracondylar line – the lateral boundary of the popliteal surface of the femur
 The medial lip of femoral linea aspera is continuous below with the medial
supracondylar line – the medial boundary of the popliteal surface of the femur
510
 The popliteal surface of femur forms the upper part of the floor of the popliteal
fossa
 The shaft of the femur is largely surrounded by the muscles of the thigh
The distal end of femur

 Presents features that include medial and lateral condyles and epicondyles, as
well as the intercondylar fossa
 Articulates with the tibia, through its condyles, to form the knee joint
The medial condyle of the femur

 Articulates with the medial condyle of the tibia and the medial lemniscus (at the
knee joint)
 Bears an adductor tubercle on its proximal aspect, for adductor magnus
 Presents, on its medial surface, a prominent medial epicondyle, for the
attachment of tibial collateral ligament
The lateral femoral condyle

 Articulates with the lateral tibial condyle and the lateral meniscus
 Bears a lateral epicondyle on its lateral surface. The latter is readily palpable
 Is separated from the medial condyle by a deep intercondylar fossa
Ossification of the Femur
Note these points:

 The femur ossifies from five centres located in the shaft, head, greater trochanter,
lesser trochanter and lower end;
 Ossification of the femur begins in the middle of the shaft in the 7th week of
intra-uterine life; and the femoral shaft is largely ossified at birth
 Secondary centres of ossification appear in the following parts of the femur:
distal end (at birth); head (during the first six postnatal months); greater
trochanter (in the 4th postnatal year); lesser trochanter (between the 12th and 14th
years)
 Ossification centres in the head, greater trochanter, and lesser trochanter fuse
with the shaft by 18–19 years
 The lower epiphysial plate is fully ossified approximately by the 16th year in
females, and the 18th year in males.
Applied Anatomy

 Fracture of the neck of the femur may occur. Besides, fracture of the femur may
also occur between the trochanters (intertrochanteric fracture) or through the
trochanters (pertrochanteric fracture)
511
 Fracture of the neck of femur is about the commonest; it usually occurs in

elderly women who suffer from osteoporosis (see above)
 When subjected to severe impact, the shaft of femur may also fracture. In
comminuted fracture of femoral shaft, healing may proceed for as long as 12
months
 The distal end of the femur ossifies just prior to birth; therefore, it serves a good
use in forensic medicine where it could be an index of the viability of a dead
foetus
 Variation usually occurs in the angle of inclination of femoral neck; this angle
depends on sex, age and ossification
 The angle of inclination of femoral neck may be markedly decreased, a condition
referred to as coxa vara; here, the lower limb appears shortened
 In coxa valga, the angle between femoral neck and shaft is increased.
Compartments of the Thigh

The deep fascia of the thigh is the fascia lata. From this fascia, three fibrous
intermuscular septa extend inwards to attach to the linea aspera of the femur. These
are the medial, lateral and posterior intermuscular septa. They separate the muscles
and neurovascular structures of the thigh into three compartments. These include the
anterior, medial and posterior compartments, each of which contains muscles, a
major nerve and blood vessels.
Anterior (Extensor) Compartment of the Thigh

This compartment occupies the anterior and lateral aspects of the thigh; it is bounded
medially by the medial intermuscular septum and posterolaterally by the lateral
septum.
Most muscles of this compartment flex the hip and/or extend the knee joints; they
include pectineus, iliacus, psoas major, tensor fasciae latae, sartorius, rectus femoris,
vastus medialis, vastus lateralis, and vastus intermedius (Fig. 110). The last four
muscles constitute the quadriceps femoris.
The nerve of the anterior compartment is the femoral nerve. This compartment also
has a femoral triangle, which contains femoral vessels, etc.
512
Figure 110. Muscles of the anterior and medial compartments of the thigh.
Pectineus
The pectineus
 Is a flat quadrangular muscle that forms part of the floor of the femoral triangle;
here, it lies between adductor longus medially and psoas major laterally
 Is related anteriorly to the femoral vein (contained in the femoral sheath); this
vein ascends on this muscle
 Lies anteromedial to the hip joint; hence, it flexes and medially rotates this joint.
Proximal attachment: Pecten pubis.
Distal attachment: Pectineal line of femur.
Innervation:
 Femoral nerve
 Accessory obturator nerve (when present)
 Obturator nerve (occasionally)
Actions:
 Flexes the thigh; and
 Rotates the thigh medially
513
Psoas Major
The psoas major

 Is located largely in the posterior abdominal wall, adjacent to the vertebral
column. Its lower part however extends into the thigh, behind the inguinal
ligament (Fig. 110)
 Is joined below, on its lateral aspect, by iliacus; the two muscles form iliopsoas
 Lies anterior and inferior to the hip joint (as it descends to its distal femoral
attachment). It is however separated from the capsule of this joint by a psoas
bursa
 Is a powerful flexor of the hip joint.
 Transverse processes of all lumbar vertebrae
 Bodies of T12–L5 vertebrae
Distal attachment: Lesser trochanter of femur
Innervation: Ventral rami of L1–L3 nerves
Actions:
 Flexes the thigh (main flexor)
 Rotates the thigh medially (to a limited extent); and
 Flexes the trunk on the hip
Applied Anatomy
Note that:
 In appendicitis, the inflamed appendix irritates psoas major, thereby resulting in
spasm of this muscle. As a result, the right thigh is usually flexed and rotated
medially in such patients
Iliacus
The iliacus
 Is triangular in outline (Fig. 110)
 Occupies the iliac fossa, on the pelvic surface of the ilium. Its lower part however
extends into the thigh, behind the inguinal ligament
 Joins the lateral aspect of psoas major as it descends into the thigh; the two
muscles thus form the iliopsoas
 Forms the lateral part of the floor of the femoral triangle (in the thigh). Near its
distal femoral attachment, it lies anterior to, and then below the capsule of the hip
joint.
514
 Iliac crest and upper ⅔ of iliac fossa
 Iliolumbar and ventral sacroiliac ligaments
 Ala of the sacrum
Distal attachment: Lesser trochanter of femur and the area below it.
Innervation: Femoral nerve.
Actions: As for psoas major.
Tensor Fasciae Latae
The tensor fasciae latae

 Is a long spindle-shaped muscle that measures about 15 cm in length
 Is located anterior to gluteus maximus and the plane of the hip joint
 Is closely associated with the fascia lata and iliotibial tract, which enclose it
 Anterior part of outer lip of the iliac crest
 Anterior superior iliac spine
Distal attachment: Iliotibial tract
Innervation: Superior gluteal nerve (inferior branch)
Actions:
 Flexes and medially rotates the thigh
 May abduct the thigh with glutei medius and minimus
 Extends the knee, through the iliotibial tract; and as it does so, it also produces a
slight lateral rotation of the leg
 Steadies the extended thigh on the tibia, through the iliotibial tract (see below)
Sartorius
The sartorius
 Is a long strap-like muscle (Fig. 110); it is the longest muscle in the body
 Descends obliquely across the anterior part of the thigh, from lateral medially.
Then, it continues vertically downwards, in the lower part of the medial aspect of
the thigh, to reach the medial aspect of the knee. As a result, it lies anterolateral
to the hip joint and medial to the knee joint; and can thus act on both joints
 Is referred to as tailor’s muscle because it simultaneously flexes the thigh and
leg (a position adopted in tailoring)
 May be absent
515
 Anterior superior iliac spine
 Upper part of the notch located just below the anterior superior iliac spine.
Distal attachment: Upper part of the medial surface of the tibia (anterior to the
insertion of gracilis)
Innervation: Femoral nerve
Actions:
 Flexes the thigh
 Also abducts and laterally rotates the thigh; and
 Flexes the knee joint
Quadratus Femoris
The quadriceps femoris

 Is a very large mass that overlies the front and sides of the femur (Fig. 110)
 Consists of four muscles: rectus femoris, vastus medialis, vastus intermedius and
vastus lateralis
 Is a powerful extensor of the leg
 Passes anterior to the hip joint (rectus femoris only); hence, it can also flex the
thigh
 Is attached below, via a large quadriceps tendon, to the patella. Distal to the
latter, the muscle is attached to the tibial tuberosity (by means of the patellar
ligament)
 Is separated (its tendon) from the femur by the large suprapatellar bursa.
The rectus femoris

 Is a long fusiform muscle that lies anterior to the other members of quadriceps
femoris
 Is the only member of quadriceps femoris that can act on the hip joint
 Arises from the hip bone by two heads: straight and reflected heads
 Descends vertically, from its proximal attachment, to join the tendon of
quadriceps femoris (via which it is inserted onto the base of the patella)
 Passes anterior to the hip and knee joints; thus, it acts simultaneously on both (see
actions, below)
 Straight head: Anterior inferior iliac spine
 Reflected head: The groove above the acetabulum
 Distal attachment: Base of the patella (via the quadriceps tendon)
Innervation: Femoral nerve.

516
Actions:
 Extends the leg (as do other members of quadriceps femoris)
 Flexes the thigh at the hip joint
Figure 111. Transverse section through the thigh
The vastus medialis

 Is a member of the quadriceps femoris. It lies on the medial aspect of the thigh
(Fig. 110,111)
 Joins the tendon of quadriceps femoris, in the lower of the thigh
 Does not act on the hip joint
 Medial lip of femoral linea aspera
 Spiral line and (lower part of) intertrochanteric line of the femur
517
 Upper part of femoral medial supracondylar line

 Medial intermuscular septum and tendons of adductors magnus and longus
Distal attachment: Base of the patella and the tibial tuberosity (via the patellar
ligament)
Innervation: Femoral nerve
Action: Powerful extensor of the leg
The vastus lateralis

 Is the largest member of quadriceps femoris (Fig. 110,111); it is located in the
lateral aspect of the thigh
 Arises by a broad aponeurosis from several sites (see below)
 Does not act on the hip joint
 Lateral lip of femoral linea aspera
 Upper part of intertrochanteric line of femur
 Greater trochanter and gluteal tuberosity of femur
 Lateral intermuscular septum of the thigh.
Distal attachment, innervation and action: As for vastus medialis
The vastus intermedius

 Is located between vasti medialis and lateralis, deep to rectus femoris (Fig. 111)
 Covers the anterior and lateral surfaces of the body of femur, from which it arises
 Send some fibres (from its deep aspect) to the suprapatellar bursa; these form
articularis genu muscle
 Proximal ⅔ of the anterior and lateral surfaces of femur
 Lateral intermuscular septum
Distal attachment, innervation and action: as for vastus medialis
The articularis genu

 Is a small muscle; it is considered a part of vastus intermedius, with which it
blends
 Arises from the lower part of the anterior surface of the body of femur; and is
attached distally to the suprapatellar bursa and the synovial membrane of the
knee joint
 Retracts (pulls up) the suprapatellar bursa during extension of the knee (thereby
preventing this bursa from being drawn into the joint cavity in the process)
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 Receives motor fibres from femoral nerve
Fascia Lata, Iliotibial Tract and Intermuscular Septa of the Thigh
The fascia lata

 Is the deep fascia of the thigh; it forms a sleeve-like investment for the thigh
 Is especially thick on the lateral aspect of the thigh, where it forms the iliotibial
tract
 Is attached proximally to the sacrum, coccyx, pubic rami, iliac crest, ischial
ramus and tuberosity, and the inguinal and sacrotuberous ligaments
 Is attached distally to femoral and tibial condyles and fibular head
 Gives rise to three intermuscular septa (medial, lateral and posterior). These
septa are attached to femoral linea aspera and help to divide the thigh into three
compartments
 Appears cribriform (perforated) in its upper anteromedial part; here, it forms the
cribriform fascia, which transmits several structures
 Presents a large aperture, the saphenous opening, located about 3–4 cm below
and lateral to the pubic tubercle; this opening transmits the great saphenous
vein, and is covered by the cribriform fascia
Iliotibial Tract
The iliotibial tract

 Is a longitudinal thickening of the lateral aspect of the fascia lata
 Extends from the iliac tubercle above to Gerdy’s tubercle below. Gerdy’s
tubercle is on the lateral aspect of lateral tibial condyle
 Gives attachment to two muscles in its upper part: tensor fasciae latae in front
and gluteus maximus behind
 Is the means by which tensor fasciae latae and gluteus maximus steady the femur
on the tibia (in the erect position)
The lateral intermuscular septum

 Is the strongest and thickest of the three intermuscular septa of the thigh
 Stretches from the fascia lata (iliotibial tract) superficially, to the lateral lip of the
linea aspera and lateral supracondylar line of the femur, internally
 Separates vastus lateralis (in the anterior compartment of the thigh) from the
short head of biceps femoris (in the posterior compartment of the thigh)
 Gives attachment to vastus lateralis and short head of biceps femoris (which it
separates from each other)
The medial intermuscular septum

 Is relatively thin
 Stretches from the fascia lata superficially, to the medial lip of linea aspera
internally
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 Separates the anterior and medial compartments of the thigh from each other
The posterior intermuscular septum

 Is also relatively thin and weak compared to the lateral septum
 Stretches from the fascia lata superficially, to the linea aspera, internally
 Separates the medial and posterior compartments of the thigh from each other
Femoral Triangle
The femoral triangle

 Is a triangular hollow in the upper 3rd of the anterior aspect of the thigh (Fig.
111,112)
 Has a floor, roof, base and apex, and a medial and lateral border
 Contains the femoral vessels (in the femoral sheath), femoral nerve, terminal part
of the great saphenous vein, deep inguinal lymph nodes and the lateral and medial
circumflex femoral arteries (braches of profunda femoris artery)
 Is continuous at it apex (below) with adductor canal (Hunter’s canal)
Regarding the femoral triangle, note the following:

 Its base is directed upwards and is formed by the inguinal ligament (Fig. 112)
 Its apex is directed downwards and is located at the junction of sartorius and
adductor longus
 The lateral border is formed by the medial border of sartorius
 The medial border is formed by the medial border of adductor longus
 Its roof is formed by the cribriform fascia and the overlying subcutaneous tissue
and skin
 Its floor is formed, from medial laterally, by adductor longus, pectineus, psoas
major and iliacus
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Figure 112. Femoral triangle, showing femoral sheath and nerve.
Regarding the roof of the femoral triangle, note the following:

 The skin is innervated by the femoral branch of genitofemoral nerve
 The superficial inguinal nodes are located partly in its subcutaneous tissue and
along the base of the triangle
 The great saphenous vein ascends in it, before entering the femoral triangle
through the saphenous opening
 The superficial branches of the femoral artery (superficial circumflex iliac,
superficial epigastric and superficial external pudendal arteries) run in it, en route
to their territories
Contents of the Femoral Triangle
The femoral triangle contains:

 Femoral sheath and its contents
 Femoral nerve
 Terminal part of the great saphenous vein; and
 Deep inguinal nodes.
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Femoral Sheath
The femoral sheath

 Is a conical fibrous tube that is located in the femoral triangle (Fig. 112); it is 3–4
cm in length, and its apex is directed downwards
 Is formed by the downward continuation (into the thigh) of the transversalis
fascia (on the anterior wall of the sheath) and the iliac fascia (on its posterior
wall)
 Extends from the mid-inguinal region above, to a point near the apex of the
femoral triangle, below; and it lies on psoas major and pectineus muscles
 Is partitioned into three longitudinal compartments; these contain the femoral
artery laterally, femoral vein in the intermediate position, and femoral canal
medially
 Is pierced by the great saphenous vein (as this joins the femoral vein)
 Blends distally with the adventitia of femoral vessels
 Does not contain the femoral nerve
Femoral Canal
The femoral canal

 Occupies the medial compartment of the femoral sheath, medial to the femoral
vein, and anterior to pectineus muscle
 Measures about 1.25 cm in length; hence, it is confined to the upper part of
femoral sheath
 Is conical in outline. Its base, the femoral ring, is directed upwards, while it apex
points downwards
 Contains areolar tissue, in which a lymph node (of Cloquet) and lymph vessels
are embedded. The node of Cloquet drains the glans penis
 Permits the expansion of the femoral vein (during increased venous return from
the lower limb)
Femoral Ring
The femoral ring

 Is the base of the femoral canal; it is directed upwards towards the abdominal
cavity
 Is closed up by the femoral septum (of extraperitoneal tissue) and the parietal
peritoneum
 Is bounded behind by pectineus, in front by inguinal ligament, medially by
lacunar ligament and laterally by femoral vein
 Is wider in females owing to the wider pelvis and smaller femoral vein in this sex
 May permit herniation of intestinal loop through it, into the thigh. Such femoral
hernia is therefore more common in females.
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Femoral Artery
The femoral artery

 Is the direct continuation of the external iliac artery into the thigh (beyond the
mid-inguinal point)
 Commences at the mid-inguinal point above, and then traverses the femoral
triangle, where it lies on psoas major (in the lateral compartment of femoral
sheath, between femoral vein medially and femoral nerve laterally) (Fig. 112)
 Leaves the femoral triangle distally (at the apex of this triangle, deep to
sartorius), to enter the adductor canal
 Can be compressed just below the mid-inguinal point (where it is separated by
psoas tendon from the bony iliopubic eminence. Its pulsation may readily be felt
in the proximal part of the femoral triangle
 Is represented on the body surface by the proximal ⅔ of a line drawn from the
mid-inguinal point above to the adductor tubercle below (with the thigh semi
flexed, abducted and laterally rotated)
Branches of Femoral Artery
In the femoral triangle, the femoral artery gives rise to:

 Superficial circumflex iliac and superficial epigastric arteries
 Superficial and deep external pudendal arteries
 Profunda femoris artery; and
Superficial Epigastric Artery
The superficial epigastric artery

 Arises from the femoral artery in the femoral triangle, about 1 cm below the
inguinal ligament
 Ascends anterior to the inguinal ligament, to enter the subcutaneous tissue of the
anterior abdominal wall
 Supplies the superficial inguinal nodes, subcutaneous tissue and skin of the
infra-umbilical anterior abdominal wall
 Anastomoses with the inferior epigastric artery
Superficial External Pudendal Artery
The superficial external pudendal artery

 Arises from the femoral artery in the femoral triangle
 Enters the superficial fascia of the roof of femoral triangle where it runs medially,
superficial to the spermatic cord (or round ligament of the uterus), to the
perineum
 Supplies the skin of the scrotum (or labium majus) and the penis
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 Anastomoses with the internal pudendal artery
Deep External Pudendal Artery
The deep external pudendal artery

 Also arises from the femoral artery in the femoral triangle
 Runs medially through the femoral triangle (deep to the deep fascia)
 Enters the perineum to supply the skin of the scrotum (or labium majus)
 Also anastomoses with the internal pudendal artery
Superficial Circumflex Iliac Artery
The superficial circumflex iliac artery

 Is the smallest superficial branch of the femoral artery; it arises in the femoral
triangle
 Pierces the deep fascia and runs laterally (in the subcutaneous tissue) towards the
anterior superior iliac spine
 Supplies the superficial inguinal nodes, subcutaneous tissue and skin of the
groin; and anastomoses with the deep circumflex iliac artery (a branch of
external iliac artery)
Profunda Femoris Artery
The profunda femoris artery

 Is the largest branch of the femoral artery and the chief artery of the thigh
 Arises in the femoral triangle from the lateral aspect of the femoral artery,
about 3.5 cm below the inguinal ligament
 Initially passes medially, behind the femoral vessels, in the femoral triangle. Then
it leaves the femoral triangle as it runs postero-inferiorly, between pectineus and
adductor longus; thereafter, it continues downwards, initially between adductor
brevis behind and adductor longus in front, and then between adductor
magnus behind and adductor longus in front
 Pierces adductor magnus in the distal part of the thigh to anastomose with
muscular branches of popliteal artery
 Gives rise to medial and lateral circumflex femoral arteries and about three
perforating arteries
Medial Circumflex Femoral Artery
The medial circumflex femoral artery

 Usually arises from the posteromedial aspect of profunda femoris artery, in the
femoral triangle; however, it may arise directly from the femoral artery (in the
femoral triangle)
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 Leaves the femoral triangle by passing posteriorly, initially between iliopsoas

and pectineus, and then between obturator externus and adductor brevis
(medial to the femur)
 Appears in the gluteal region (behind) between quadratus femoris above and
adductor magnus below; it then divides (in the gluteal region) into ascending and
transverse branches
 Plays a major role in supplying the neck and head of femur via the retinacular
arteries, which arise from it (see the hip joint).
Regarding the branches of the medial circumflex femoral artery, note the
following:
 Its transverse branch is involved in the formation of the cruciate anastomoses
 Its ascending branch passes upwards, deep to quadratus femoris, to the
trochanteric fossa of the femur
 Its acetabular branch enters the hip joint through the acetabular foramen, to
supply the fatty tissue of the acetabular fossa; it also gives a branch to the
ligament of the head of femur
 The retinacular arteries, which supply the head and neck of the femur, mainly
arise from the medial circumflex femoral artery; they traverse the foramina in the
neck of femur
 Anastomoses do exist between the ascending branch of the medial circumflex
femoral artery, lateral circumflex femoral artery, and gluteal arteries, in the
trochanteric fossa.
Lateral Circumflex Femoral Artery
The lateral circumflex femoral artery

 Arises from the lateral aspect of the proximal part of profunda femoris artery;
however, it may arise directly from the femoral artery (in the femoral triangle)
 Runs laterally, between the branches of the femoral nerve, in the femoral
triangle
 Divides into ascending, descending and transverse branches
 Supplies femoral head and neck, as well as the muscles of the thigh, through its
branches
Regarding the branches of the lateral circumflex femoral artery, note the
following:
 The transverse branch is the smallest of the three major branches of this artery;
this branch participates in the formation of the cruciate anastomoses (see below)
 The descending branch runs downwards, on the anterior aspect of vastus
lateralis, which it supplies
 The ascending branch runs upwards, on the intertrochanteric line of the femur,
to supply adjoining structures; it also gives branches to the head, neck and greater
trochanter of the femur, and anastomoses with the superior gluteal artery.
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Perforating Arteries
The perforating arteries

 Are about three vessels that arise from the profunda femoris artery; they
perforate the adductor magnus, close to the femur, to appear on the posterior
surface of this muscle
 Are named, from above downwards, as 1st, 2nd, and 3rd perforating arteries
 Supply several muscles of the thigh, including those of the medial and posterior
compartments; and anastomose with several other vessels

 The 1st perforating artery anastomoses with the inferior gluteal, medial
circumflex femoral artery and lateral circumflex femoral artery, to form the
cruciate anastomosis
 The 2nd perforating artery anastomoses with the 1st and 3rd perforating arteries
 The nutrient artery of the femur usually arises from the 2nd perforating artery
 The 3rd perforating artery anastomoses with the 4th perforating artery (terminal
part of profunda femoris artery)
 The 4th perforating artery is the terminal part of profunda femoris artery (as this
artery pierces adductor magnus); it anastomoses with the 3rd perforating artery
and muscular branches of popliteal artery.
Cruciate Anastomosis
The cruciate anastomosis

 Is located on the posterior aspect of the deep gluteal muscles and the adductor
magnus
 Is formed by the inferior gluteal, transverse branches of medial and lateral
circumflex femoral and the 1st perforating branch of profunda femoris arteries
 Connects the internal iliac, femoral and popliteal arteries together (through the
branches of these vessels)
 Provides an alternative route of blood supply to the lower limb following the
occlusion or ligation of the femoral artery
Femoral Vein
The femoral vein

 Commences at the adductor opening as a continuation of popliteal vein
 Traverses the adductor canal, to reach the femoral triangle
 Lies posterolateral to the femoral artery in the lower part of the adductor canal,
but posterior to this artery in the upper part of the canal
 Is related laterally to the femoral artery in the femoral triangle; here, it occupies
the intermediate compartment of the femoral sheath
526
 Is related medially to the femoral canal; this allows the vein to expand during
increased venous return from the lower limb
 Continues upwards from the femoral triangle, behind the inguinal ligament, as the
external iliac vein
 Possesses 4–5 valves. Those located at the level of the inguinal ligament and at a
level just distal to the termination of profunda femoris vein are usually constant.
Tributaries of Femoral Vein
Tributaries of the femoral vein include:

 Several muscular tributaries
 Medial and lateral circumflex femoral veins; each of these drains the territory
supplied by the respective artery
 Profunda femoris vein; this joins the posterior surface of the femoral vein, about
8 cm below the inguinal ligament
 Great saphenous vein; this joins the anterior surface of the femoral vein, above
the entry of profunda femoris vein
Profunda Femoris Vein
The profunda femoris vein

 Drains much of the territory of profunda femoris artery; it is formed in the
thigh by the union of the four perforating veins
 Ascends through the thigh, behind the adductor longus; here, it lies anterior to
profunda femoris artery
 Terminates by joining the posterior aspect of femoral vein, about 8 cm below the
inguinal ligament
 Communicates, via its tributaries, with tributaries of popliteal and inferior
gluteal veins
 May receive the medial and lateral circumflex femoral veins
 Is guarded by a pair of valves located near its termination
Femoral Nerve (L2-L4)
The femoral nerve

 Is the largest branch of the lumbar plexus (Fig. 103, 112)
 Arises specifically from the dorsal divisions of the ventral rami of L2, L3, and
L4 nerves
 Descends initially through psoas major; then, it emerges from the lateral border
of this muscle, in the lower part of the abdomen
 Enters the femoral triangle between psoas major medially and iliacus laterally,
behind the inguinal ligament
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 Is related medially to the femoral artery, as it descends through the femoral

triangle. However, unlike the artery, the femoral nerve is outside the femoral
sheath
 Divides into several branches; these include muscular, articular, vascular and
cutaneous branches.
Branches of Femoral Nerve

 Femoral nerve has muscular branches; these supply quadriceps femoris,
sartorius, iliacus, pectineus and articularis genu
 Muscular branch of femoral nerve to iliacus arises in the abdominal region; other
muscular branches arise in the femoral triangle
 The articular branch of femoral nerve to the hip joint arises from the nerve to
rectus femoris, while those to the knee joint arise from nerves to vasti lateralis,
intermedius and medialis
 Vascular branches of femoral nerve are postganglionic sympathetic fibres that
arise from the lower thoracic and upper lumbar sympathetic ganglia
 Cutaneous branches of femoral nerve include (i) anterior cutaneous nerve of the
thigh and (ii) saphenous nerve
 Anterior cutaneous nerve of the thigh arises in the femoral triangle; it supplies
the skin of the anteromedial part of the thigh
 The saphenous nerve, the largest and longest cutaneous branch of femoral nerve,
also arises in the femoral triangle; it descends as far down as the foot
 Saphenous nerve descends through the adductor canal, beyond which it enters
the subcutaneous tissue of the leg. It innervates the skin of the anteromedial
aspects of the knee, leg and foot (see adductor canal for more details).
Deep Inguinal Nodes
The deep inguinal nodes

 Are located in the upper part of the femoral triangle, medial to femoral vein; they
are 1–3 in number (Fig. 112)
 Include the node of Cloquet, which is occasionally found in the femoral canal;
this node drains the glans penis (or gland clitoridis)
 Receive afferent vessels from the deep tissues of the thigh, glans penis (or glans
clitoridis), and superficial inguinal nodes
 Drain into the external iliac nodes via efferent vessels that ascend in the femoral
canal
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Adductor (Medial) Compartment of the Thigh
The adductor compartment of the thigh

 Occupies the medial aspect of the thigh, between the medial and posterior
intermuscular septa (Fig. 110, 111)
 Contains the adductor muscles of the thigh; these include adductor longus,
adductor brevis adductor magnus, and gracilis
 Also contains branches of obturator nerve, obturator vessels and profunda
femoris vessels
Adductor Longus
The adductor longus

 Is a large triangular muscle located medial to, and alongside the pectineus; it is
the most anterior of the adductor muscles (Fig. 110, 111)
 Forms, together with pectineus, the medial part of the floor of the femoral
triangle
 Passes from the pubic body above to the femur below, medial to the plane of the
hip joint
 May be duplicated
Proximal attachment: Pubic body, just below the pubic crest
Distal attachment: Middle 3rd of the linea aspera of femur
Innervation: Anterior division of obturator nerve
Action:
 Adducts the thigh
 May assist in medial rotation of the thigh
The adductor brevis

 Is roughly triangular in outline
 Is located behind pectineus and adductor longus, in the medial compartment of
the thigh
 May merge with adductor magnus
Proximal attachment: External aspect of pubic body and inferior pubic ramus
Distal attachment:
 Pectineal line of femur
 Upper part of linea aspera of femur
529
Action: Adducts the thigh
Adductor Magnus
The adductor magnus

 Is the largest of the muscles of the adductor compartment of the thigh; it is
triangular in outline
 Consists of two parts: an adductor part (that arises from ischiopubic ramus) and
a hamstring part (that arises from ischial tuberosity)
 Is located behind adductors brevis and longus; thus, it is the most posterior of the
adductors
 Is related on it posterior surface to the sciatic nerve (that descends on its dorsal
surface) and to the muscles of the posterior compartment of the thigh
 Is pierced, near its femoral attachment, by the four perforating arteries (from
profunda femoris)
 Has a large opening – adductor opening – that connects the adductor canal to the
popliteal fossa, and which transmits the femoral vessels
 Has dual innervation; it is supplied by obturator and sciatic nerves.
 May merge with quadratus femoris at its upper border
 Adductor part: External surface of ischiopubic ramus
 Hamstring part: External surface of ischial tuberosity
Distal attachment:
 Adductor part:
o Gluteal tuberosity of the femur
o Linea aspera and upper part of medial supracondylar line of the femur
 Hamstring part: Adductor tubercle (on the medial condyle of femur)
Innervation:
 Adductor part: Posterior division of obturator nerve
 Hamstring part: Tibial division of sciatic nerve
Actions:
 Adductor part:
o Adducts the thigh
o Flexes the thigh
 Hamstring part:
o Adducts the thigh
o Extends the thigh
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Gracilis
The gracilis
 Is the slender, most superficial muscle of the adductor compartment of the thigh;
it occupies the most medial aspect of the thigh (as it descends vertically to the
knee)
 Is the only adductor muscle that reaches as far down as the leg, and it lies medial
to the knee joint as it does so
 Is separated from the tibial collateral ligament of the knee joint by a bursa
 Acts on the hip and knee joints
 External aspect of pubic body (close to the symphysis pubis)
 Inferior pubic and (adjacent part of) ischial rami
Distal attachment: Upper part of the medial surface of the tibia (between sartorius
anteriorly and semitendinosus posteriorly)
Action:
 Flexes the leg
 Rotates the leg medially; and
 Adducts the thigh
Obturator Nerve (L2–L4)
The obturator nerve

 Arises from the anterior divisions of the ventral rami of L2, L3 and L4 nerves
(from the lumbar plexus)
 Descends through psoas major, in the posterior abdominal wall. At the pelvic
inlet, it emerges from the medial border of psoas major, and descends into the
pelvic cavity (lateral to internal iliac vessels and ureter)
 Continues antero-inferiorly on the fascia of obturator internus, on the lateral
wall of the pelvic cavity (above the obturator vessels)
 Leaves the pelvic cavity, via the obturator canal, to enter the medial part of the
thigh. As it traverses the canal, it divides into anterior and posterior branches.
The anterior branch of obturator nerve

 Arises from the obturator nerve in the obturator canal
 Emerges from the obturator canal to enter the thigh, above obturator externus.
As it does so, it gives a branch to the hip joint
531
 Descends through the medial part of the thigh between pectineus and adductor
longus anteriorly, and obturator externus and adductor brevis posteriorly
 Innervates adductor longus, adductor brevis and gracilis; it may also give
motor fibres to pectineus
 Gives rise to branches that join those of the anterior cutaneous nerve of the thigh
and saphenous nerve to form a subsartorial plexus (see below). Via this plexus,
the obturator nerve supplies the skin of the medial aspect of the thigh.
The posterior branch of obturator nerve

 Arises from the obturator nerve as this enters the obturator canal
 Emerges from the obturator canal, and pierces and supplies obturator externus
as it does so; then it descends through the thigh, between adductor brevis
anteriorly and adductor magnus posteriorly
 Innervates adductor magnus; it may also supply adductor brevis
 Usually gives rise to an articular branch that traverses the adductor opening
distally, to enter the popliteal fossa, where it innervates the knee joint.
Accessory Obturator Nerve
The accessory obturator nerve

 Is absent in most individuals; when present, it arises from the anterior divisions
of the ventral rami of L3 and L4 nerves (from the lumbar plexus)
 Descends along the medial border of psoas major, in the lower part of the
abdominal cavity; then it enters the thigh between pectineus and superior pubic
ramus
 Innervates pectineus and the hip joint.
Obturator Artery
The obturator artery

 Arises from the anterior division of the internal iliac artery
 Runs antero-inferiorly over obturator internus, on the lateral wall of the pelvic
cavity. Here, it lies between obturator nerve above and obturator vein below;
and is crossed on its medial aspect by the ureter and vas deferens (or round
ligament of the uterus)
 Leaves the pelvic cavity for the thigh by traversing the obturator canal (with the
obturator nerve)
 Supplies several muscles, including those of the adductor compartment (via its
anterior and posterior branches)
 Gives an acetabular branch that enters the acetabular fossa via the acetabular
foramen. From this arises a branch that traverses the ligament of the head of
femur to supply the femoral head
 Anastomoses with the medial circumflex femoral and inferior gluteal arteries
through its anterior and posterior branches, respectively.
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Applied Anatomy

 In about 30% of individuals, the obturator artery is replaced by an abnormal
obturator artery. The latter is as an enlarged pubic branch of the inferior
epigastric artery
 An abnormal obturator artery usually descends to the obturator canal lateral to
the femoral ring, close to the external iliac vein. However, this artery may
descend behind the lacunar ligament; and in this instance, it is at risk when
operating a strangulated femoral hernia.
Adductor (Subsartorial) Canal
The adductor canal

 Is an aponeurotic tunnel located in the middle 3rd of the thigh (deep to the
middle 3rd of sartorius)
 Connects the apex of the femoral triangle above to the adductor opening below;
through this opening, the canal communicates with the popliteal fossa
 Is triangular in cross-section, its fascial walls being supported by muscles
 Contains two vessels and two nerves; these include femoral artery, femoral vein,
saphenous nerve and nerve to vastus medialis.
 Is about 15 cm in its proximodistal extent
Boundaries of Adductor Canal
The adductor canal is bounded by the following:

 Anteromedially: sartorius
 Anterolaterally: vastus medialis
 Posteriorly: adductors longus and magnus
Contents of Adductor Canal
Regarding the contents of adductor canal, note the following:

 In the adductor canal, nerve to vastus medialis lies lateral to saphenous nerve
and femoral vessels; this nerve enters the vastus medialis about mid-way along
that muscle (being the first structure to leave the canal, followed by saphenous
nerve).
 The saphenous nerve traverses the adductor canal initially lateral, then anterior,
and finally medial to the femoral artery. It exits the canal proximal to the
adductor opening by piercing its fascial medial wall (to descend behind
sartorius).
533
 The femoral artery and vein traverse the whole length of the adductor canal;
they traverse the adductor opening to enter the popliteal fossa (where they
become popliteal vessels);
 The femoral vein lies posterior to the femoral artery in the upper part of the
adductor canal, but posterolateral to it in the lower (distal) part. In the femoral
triangle, the vein is medial to the artery.
Saphenous Nerve
The saphenous nerve

 Is the longest and largest branch of the femoral nerve. It arises in the femoral
triangle; and here, it is lateral to the femoral artery
 Leaves the femoral triangle at its apex, to enter the adductor canal
 Descends through the adductor canal initially lateral, then anterior and finally
medial to the femoral artery
 Pierces the fascial medial wall of the adductor canal, proximal to the adductor
opening, to emerge on the medial aspect of the knee (between sartorius and
gracilis), where it becomes subcutaneous
 Continues distally on the medial aspect of the knee and leg, where it is
accompanied by the great saphenous vein
 Passes anterior to the ankle, to enter the medial aspect of the foot,
 Innervates the skin of the medial aspects of the knee, leg and foot,
 Gives a branch to the subsartorial plexus in the middle of the thigh. This plexus
innervates the skin of the medial aspect of the thigh.
 Also gives an infrapatellar branch as it exits the adductor canal; this branch
pierces sartorius and the deep fascia to innervate the prepatellar skin.
Posterior (Flexor) Compartment of the Thigh

The posterior compartment of the thigh contains the flexors of the knee joint; hence,
it is also called the flexor compartment. Besides, the muscles of this compartment
are capable of extending the thigh at the hip joint; they are collectively called the
hamstrings. They include semitendinosus, semimembranosus and biceps femoris
(Fig. 111, 113).
The sciatic nerve descends through the posterior compartment of the thigh and thus
innervates its muscles. The posterior cutaneous nerve of the thigh descends just
deep to the fascia lata. It supplies the skin of the posterior surface of the thigh.
The posterior compartment of the thigh

 Occupies the posterior aspect of the thigh, between the posterior and lateral
intermuscular septa
 Contains the hamstring muscles; these include semitendinosus,
semimembranosus and biceps femoris, and they flex the knee
534
 Transmits the sciatic nerve (which innervates the hamstrings), and the posterior
cutaneous nerve of the thigh (which innervates the overlying skin)
 Corresponds to the anterior compartment of the arm
Hamstring Muscles
The hamstring muscles

 Occupy the posterior compartment of the thigh (Fig. 111, 113)
 Include semitendinosus, semimembranosus and long head of biceps femoris
 Arise from the ischial tuberosity above and insert into the bones of the leg (tibia
and fibula) below
 Extend the thigh at the hip joint and flex the leg at the knee joint (though not
simultaneously)
 Are all innervated by the tibial division of sciatic nerve
Figure 113. Hamstring muscles
The semitendinosus
 Is one of the three hamstrings; it stretches from the ischial tuberosity above to the
tibia below (Fig. 111,113)
535
 Has a spindle-shaped muscular belly in its upper ⅔ and a long round tendon in its
lower ⅓
 Is located in the medial aspect of the posterior compartment, superficial to
semimembranosus
 Lies medial to the medial tibial condyle and the tibial collateral ligament near its
distal attachment (to tibia)
 Is separated by a bursa from the tibial collateral ligament
 Is also separated, near its distal attachment, from the tendons of gracilis and
sartorius by a complex bursa anserina. This bursa also separates semitendinosus
from the tibia
Proximal attachment: Inferomedial impression on the ischial tuberosity
Distal attachment: Upper part of the medial surface of the tibia (behind the distal
attachment of gracilis and sartorius)
Innervation: Tibial branch of sciatic nerve
Actions:
 Flexes the leg
 Extends the thigh
 Medially rotates the semiflexed leg
 Medially rotates the thigh (when the hip and knee joints are extended)
The semimembranosus
 Is located on the medial aspect of the posterior compartment of the thigh, deep to
semitendinosus (Fig. 1011, 113)
 Stretches from the ischial tuberosity above to the tibia below
 Derives its name from the flattened aponeurotic nature of its proximal attachment
 May be duplicated or absent
Proximal attachment: Superolateral impression on ischial tuberosity
Distal attachment: Posterior aspect of medial condyle of tibia
Innervation: Tibial branch of sciatic nerve
Actions: As for semitendinosus
The following are derived from the tendon of insertion of semimembranosus:

 The oblique popliteal ligament; and
 The fascia that invests popliteus muscle.
536
The biceps femoris

 Occupies the lateral aspect of the posterior compartment of the thigh (Fig.
1011,113)
 Has two heads of origin: long and short heads (hence the name)
 Is capable of acting on the hip joint (long head only) and the knee joint (both
heads)
 Has a single tendon of insertion; this splits to enclose the fibular collateral
ligament near its distal attachment to fibular head
 Is accompanied by the common fibular nerve; this descends in the popliteal
fossa, on the medial aspect of the tendon of biceps femoris
The long head of biceps femoris

 Is part of the hamstring muscles, as it arises proximally from the ischial
tuberosity
 Shares the same tendon of origin with semitendinosus
 Descends laterally across the thigh (from its ischial origin), to join the short head
of the muscle. As it does so, it separates the sciatic nerve (deep to it) from the
posterior cutaneous nerve of the thigh (superficial to it).
The short head of biceps femoris

 Is not a part of the hamstrings, as it does not arise from the ischial tuberosity;
instead, it arises from femoral linea aspera
 Is joined in the thigh by the long head of biceps femoris; and via a common
tendon with the latter, it is attached distally to fibular head
 May be absent
 Long head: Inferomedial impression of ischial tuberosity
 Short head:
o Lateral lip of the linea aspera of the femur
o Upper part of the lateral supracondylar line of femur
Distal attachment: Fibular head.
Innervation:
Long head: Tibial branch of sciatic nerve
Short head: Common peroneal branch of sciatic nerve.
Actions:
 Flexes the leg
 Laterally rotates the semiflexed leg
 Extends the thigh
 Laterally rotates the thigh (when the hip and knee joints are extended).
537
Applied Anatomy
Note the following:

 In certain conditions, contracture (shortening) of the hamstrings may occur, with
the resultant disabling flexion of the knee
 The common peroneal nerve may be injured in operations involving hamstring
tendons; this nerve descends along the medial aspect of the tendon of biceps
femoris, in the popliteal fossa
 The hamstrings may also be abnormally short, such that flexion of the hip joint
becomes difficult when the knee is simultaneously extended, as in stooping
 Hamstring strain (tearing of hamstring muscles) occurs more frequently than
quadriceps strain; it is accompanied by severe pain, and is common in violent
sports such as football
 The ischial tuberosity may be avulsed when the hip joint is forcibly flexed with
the knee extended (as occurs when kicking hard at a ball).
Sciatic Nerve (L4, L5; S1, S2 and S3)
In the thigh, the sciatic nerve

 Descends vertically on the posterior surface of adductor magnus
 Is crossed obliquely, from medial laterally, by the long head of biceps femoris.
The latter also separates it from the posterior cutaneous nerve of the thigh,
which lies superficial to it
 Innervates semitendinosus, semimembranosus and long head of biceps femoris
through its tibial branch, and the short head of biceps through its common
fibular branch
 Usually divides at a variable point in the lower part of the thigh into tibial and
common fibular (common peroneal) nerves
 May divide high up in the thigh or even in the pelvic cavity (in about 12% of
cases). In the latter case, the common fibular nerve pierces piriformis to enter
the gluteal region, while the tibial nerve passes below this muscle
 Is represented by a line drawn from midway between the ischial tuberosity and
femoral greater trochanter above, towards the apex of the popliteal fossa below
In the thigh, the tibial nerve

 Arises from the sciatic nerve. It is the larger of the two terminal branches of this
nerve
 Descends on the posterior surface of adductor magnus, deep to the hamstring
muscles
 Enters the popliteal fossa (at the apex of this fossa), and then descends
superficial to the popliteal vessels
 Innervates all the hamstring muscles. It usually gives two branches to
semitendinosus
538
 Supplies adductor magnus and semimembranosus through branches that arise by

a common stem.
In the thigh, the common fibular nerve

 Is the smaller of the two terminal branches of the sciatic nerve
 Passes downwards and laterally, on the posterior surface of adductor magnus,
along the medial border of biceps femoris
 Enters the popliteal fossa (at the apex of this fossa), to continue its inferolateral
course along the medial border of biceps femoris (Fig. 114)
 Innervates the short head of biceps femoris
Posterior Cutaneous Nerve of the Thigh
The posterior cutaneous nerve of the thigh

 Descends deep to the fascia lata, in the posterior aspect of the thigh; here, it is
separated from the sciatic nerve by the long head of biceps femoris
 Enters the popliteal fossa initially deep to the fascia lata; then, it pierces the deep
fascia in the roof of popliteal fossa to become subcutaneous,
 Continues its descent in the subcutaneous tissue of the posterior aspect of the leg
(as far distally as midway down the leg)
 Is accompanied, in the leg, by the small saphenous vein
 Gives cutaneous branches to the posterior aspect of the thigh, roof of popliteal
fossa and proximal part of the leg.
Note: For intragluteal course of the posterior cutaneous nerve of the thigh, see the
gluteal region (above).
Popliteal Fossa
The popliteal fossa

 Is the diamond-shaped region located behind the knee joint (Fig. 114)
 Is bounded by the diverging tendons of the hamstrings above and the converging
heads of gastrocnemius below
 Is shallow when the knee is extended but deep when it is flexed (because the
tendons of the hamstrings stand out)
 Has four borders (superomedial, superolateral, inferomedial and inferolateral
borders), a floor and a roof
 Contains popliteal vessels; parts of the tibial, common fibular and posterior
femoral cutaneous nerves; small saphenous vein; lymph nodes; and adipose
tissue.
539
Boundaries of Popliteal Fossa (Fig. 1014)
Regarding the popliteal fossa, note the following:

 The superomedial border is formed by semitendinosus and semimembranosus
 The superolateral border is formed by biceps femoris
 The inferomedial border is formed by the medial head of gastrocnemius
 The inferolateral border is formed by the lateral head of gastrocnemius and
plantaris
 The floor is formed, from above downwards, by the popliteal surface of femur,
oblique popliteal ligament of the knee joint, and the fascia that covers popliteus
 The roof is formed by the popliteal fascia (the deep fascia that overlies the
popliteal fossa)
Contents of Popliteal Fossa (Fig. 114)
In the popliteal fossa, note the following:

 The posterior femoral cutaneous nerve is located just deep to the popliteal
fascia (fascial roof of the popliteal fossa), which it pierces to become
subcutaneous,
 The tibial nerve descends from the upper to the lower angles of the fossa,
thereby bisecting it; it is located superficial (posterior) to popliteal vessels,
 The common fibular nerve passes inferolaterally, along the medial border of the
tendon of biceps femoris. It leaves the fossa at its lateral angle, superficial to the
lateral head of gastrocnemius,
 The popliteal artery is the deepest structure in the popliteal fossa; it enters the
fossa through the adductor hiatus and terminates at the lower border of popliteus
(by dividing into anterior and posterior tibial arteries),
 The popliteal vein ascends behind (superficial to) the popliteal artery; it leaves
the fossa through the adductor hiatus, and ascends in the adductor canal as the
femoral vein
 The popliteal lymph nodes are located around the popliteal vessels; they drain
part of the lower limb (see below).
540
Figure 114. Popliteal fossa, showing nerves and vessels
In the popliteal fossa, the tibial nerve

 Gives rise to the sural nerve (Fig. 114). This innervates the skin of the
posterolateral aspect of the leg and the lateral aspect of the dorsum of the foot,
 Gives motor fibres to popliteus, plantaris, soleus and gastrocnemius
 Gives three articular branches to the knee joint
 Enters the leg deep to soleus and gastrocnemius
 Is represented by a vertical line drawn from the apex of the popliteal fossa above,
to the level of the neck of fibula below
Regarding the branches of the tibial nerve, note these points:

 The sural nerve leaves the popliteal fossa by descending between the two heads
of gastrocnemius. This nerve pierces the deep fascia of the proximal part of the
leg to become subcutaneous (Fig. 114)
 A peroneal communicating nerve (a branch of common fibular nerve) joins the
sural nerve in the leg
 The nerve to soleus enters this muscle through it superficial surface
 The nerve to popliteus initially descends superficial to that muscle; it then
curves round its lower border to enter the muscle via its deep surface
 The three articular branches of the tibial nerve accompany the superior medial,
middle and inferior medial genicular arteries, to innervate the knee joint.
541
In the popliteal fossa, the common fibular nerve

 Passes inferolaterally along the medial border of the tendon of biceps femoris. It
leaves the fossa superficial to the lateral head of gastrocnemius, to enter the leg
 Is represented by an oblique line that extends from the apex of the popliteal fossa
above, to the head of fibula below (just medial to biceps femoris’ tendon)
 Give rise to articular branches that accompany the superior lateral and inferior
lateral genicular arteries, to supply the knee joint
 Also gives rise to lateral cutaneous nerve of the calf (or lateral sural nerve); this
innervates the skin of the lateral (and adjacent anterior and posterior) surface of
the leg
 Sends a peroneal communicating branch to the sural nerve; this joins the sural
nerve at a variable point in the leg
Popliteal Vein
The popliteal vein

 Is formed at the lower border of popliteus by the union of anterior and posterior
tibial veins
 Initially ascends posteromedial to, then posterior, and finally posterolateral to
the popliteal artery (in the popliteal fossa). It lies deep to the tibial nerve as it
ascends in the popliteal fossa
 Leaves the popliteal fossa through the adductor hiatus, and traverses (ascends in)
the adductor canal and femoral triangle as femoral vein
 Receives the small saphenous vein; it also receives tributaries from the knee
joint and adjacent muscles
 Possesses about four valves.
Popliteal Artery
The popliteal artery

 Is the direct continuation of the femoral artery as this traverses the adductor
hiatus to enter the popliteal fossa (from the adductor canal) (Fig. 114)
 Inclines inferolaterally as it traverses the popliteal fossa. Thus, it descends
initially anteromedial, then anterior, and finally anterolateral to the popliteal
vein
 Ends at the lower border of popliteus by dividing into anterior tibial and
posterior tibial arteries,
 Supplies the knee joint, contents of the popliteal fossa and adjacent muscles
 Is closely bound to the popliteal vein by fibrous tissue
542
Branches of Popliteal Artery
The popliteal artery gives rise to:

 Five genicular branches; these include superior medial, superior lateral, inferior
medial, inferior lateral, and middle genicular arteries. They supply the knee joint
 Superior muscular branches, which supply the hamstrings and adductor magnus
 Sural arteries, which supply gastrocnemius, soleus and plantaris
 Cutaneous branches, to the skin of the calf.
Popliteal Artery and its Variations
In the popliteal fossa, the popliteal artery

 May end proximal to popliteus; in this instance, the anterior tibial artery
descends anterior to popliteus
 May also end by dividing into anterior tibial and peroneal arteries. In this
instance, the posterior tibial artery is absent or small
Applied Anatomy

 The superior muscular branches of popliteal artery anastomose with the
perforating branches of profunda femoris. The latter in turn anastomose with the
inferior gluteal and circumflex femoral arteries to form the cruciate anastomoses
(see above)
 The indirect communication between the superior muscular branches of popliteal
artery and the cruciate anastomoses ensures blood supply to the leg when the
femoral artery is obstructed
 The pulse of the popliteal artery is difficult to feel in the popliteal fossa; this is
owing to the deep location of the vessel.
 Popliteal pulse is better felt in the lower part of the popliteal fossa when the
individual is in the prone position, with the knee flexed. Weakening or loss of this
pulse may suggest obstruction of femoral artery.
 The popliteal artery may become abnormally enlarged – popliteal aneurysm.
This causes pain in the popliteal fossa
 Fluid may collect (from infections, etc) in the popliteal fossa; such a popliteal
abscess compresses the contents of the popliteal fossa, thereby causing severe
pain
 Foot drop may result if the common fibular nerve is injured in the popliteal fossa
 Injury to the tibial nerve may occur in the popliteal fossa. This will result in loss
of plantarflexion.
543
Popliteal Lymph Nodes
Note the following:

 Popliteal lymph nodes are about six. They are embedded in the fatty tissue of
the popliteal fossa; and may be divided into superficial and deep groups
 The superficial popliteal nodes are located in the popliteal fat. One of these
usually lies near the termination of the small saphenous vein (the territory of
which it drains)
 The deep popliteal nodes lie along the popliteal vessels; they drain the deep
tissue of the leg and the knee joint. One of these lies between the popliteal artery
and the knee joint; and thus drains the joint
 Injury to the lateral aspect of the heel produces enlargement of popliteal nodes
Knee Joint
The knee joint

 Is the largest and the most complicated joint in the body (Fig. 115). It is a
complex hinge type of synovial joint; and it essentially permits flexion and
extension on a transverse axis
 Is formed between the femoral and tibial condyles, and also between the femur
and patella
 Has both intracapsular and extracapsular ligaments; and these, with associated
muscles, account for its strength and stability
 Has a single joint cavity (despite its complexity).
Articular Surfaces of the Knee Joint
Regarding the knee joint, note these facts:

 The convex femoral condyles articulate with the concave tibial condyles. These
surfaces are however not congruent
 The articular surfaces of the femoral and tibial condyles are covered by articular
hyaline cartilage (to prevent friction)
 Tibial condyles are concave centrally but flattened peripherally (where each is
related to a meniscus)
 The presence of a meniscus on each tibial condyle helps to deepen the concavity
of the articular surface of this condyle (Fig. 115)
 The femur also articulates with the patella (patellofemoral joint) through the
concave patellar surface of the femur
 The concave patellar surface of the femur and the corresponding articular surface
of the patella are each divided into a larger lateral and a smaller medial part (by
an oblique groove and ridge respectively)
 The incongruence of the knee joint is partly owing to the fact that while the tibia
is vertical in position, the femur is tilted medially (on the tibia)
544
 The fibula is not involved in the formation the knee joint (though it gives
attachment to certain ligaments of this joint)
Capsule of the Knee Joint
The fibrous capsule of the knee joint

 Forms a strong investment for this joint
 Is complex; thin and deficient in some regions; but strengthened by ligaments
elsewhere
 Is lined internally by a complex synovial membrane (Fig. 115)
 Is attached internally to the margins of the menisci by short coronary ligaments
 Is deficient posterolaterally, where the tendon of popliteus emerges from the
cavity of the knee joint.
Figure 115. A section through the knee joint
Anteriorly, the fibrous capsule of the knee joint

 Is formed by the patellar ligament and patella (Fig. 115). Thus, it stretches from
the base of the patella above to the tibial tuberosity below
 Blends, at the margins of the patella and patellar ligament, with the medial and
lateral patellar retinacula. These stretch from the medial and lateral vasti,
respectively, to the corresponding condyles of the tibia below.
Posteriorly, the fibrous capsule of the knee joint

545
 Is attached above to the posterior margin of femoral condyles and intercondylar

fossa
 Is attached below to the posterior margins of tibial condyles and intercondylar
area
 Blends with the proximal attachment of gastrocnemius
 Is strengthened by the oblique popliteal ligament. This is an extension of the
tendon of insertion of semimembranosus
 Is interrupted (deficient) where the popliteus tendon emerges from the joint
cavity
Laterally, the fibrous capsule of the knee joint

 Is attached above to femoral lateral condyle (above the popliteus); and below to
tibial lateral condyle and fibular head
 Is strengthened by fibular collateral ligament (which lies lateral to it)
 Is separated from the fibular collateral ligament by the inferior lateral genicular
nerve and vessels, as well as fatty tissue.
Medially, the fibrous capsule of the knee joint

 Is attached above and below to the medial condyles of the femur and tibia
respectively
 Blends with, and is strengthened by the tibia collateral ligament.
The synovial membrane of the knee joint

 Is the most complexly arranged synovial membrane in the body (Fig. 115)
 Lines the joint cavity (and thus separates the intra-articular ligaments and fat
from this cavity)
 Is attached to the margins of the menisci and patella
 Is evaginated (drawn upwards) proximal to the base of the patella and deep to the
tendon of quadriceps femoris to form a large suprapatellar bursa (Fig. 115)
 Covers a large infrapatellar pad of fat, which lies between it and the patellar
ligament (below the patella) (Fig. 115)
 Is reflected from the infrapatellar pad of fat onto the margin of the patella, on
each side, as the alar fold
 Is also reflected from the infrapatellar pad of fat onto the intercondylar fossa of
the femur as the infrapatellar fold. This is continuous anteriorly with the alar
folds
 Is reflected from the posterior aspect of the joint onto the intra-articular cruciate
ligaments, thereby separating these ligaments from the joint cavity
 Forms a subpopliteal recess deep to the tendon of popliteus (and posteroinferior
to the lateral lemniscus).
546
Ligaments of the Knee Joint (Fig. 116)

Ligaments are found within and outside the knee joint capsule. The intracapsular
ligaments of the knee joint (those within the fibrous capsule) include anterior and
posterior cruciate ligaments, transverse ligament of the knee joint and medial and
lateral menisci.
Extracapsular ligaments of the knee joint (those outside the fibrous capsule) include
tibial and fibular collateral, patellar, oblique popliteal and arcuate popliteal
ligaments.
Extracapsular Ligaments of the Knee Joint (Fig. 116)
These include the following:

 Patellar ligament
 Tibial (medial) collateral ligament
 Fibular (lateral) collateral ligament
 Oblique popliteal ligament, and
 Arcuate popliteal ligament
The patellar ligament

 Is the strong flat distal part of quadriceps femoris tendon. Thus, it is continuous
proximally with the tendon of quadriceps femoris, anterior to the patella (Fig.
116)
 Stretches from the apex of the patella above, to the tibial tuberosity below; and it
measures about 8 cm in length
 Forms the anterior part of the fibrous capsule of the knee joint (below the
patella). An infrapatellar pad of fat separates it from the synovial membrane of
this joint
 Is flanked at the sides by the medial and lateral patellar retinacula (from the
tendons of the medial and lateral vasti, respectively)
 Is separated from the tibia by the deep infrapatellar bursa, over which it slides.
The tibial collateral ligament

 Is a flat broad fibrous band that strengthens the fibrous capsule of the knee joint
medially. A bursa may separate it from the capsule (Fig. 116)
 Stretches from the femoral medial epicondyle above, to tibial medial condyle,
medial lemniscus and upper part of the medial surface of the tibia, below
 Is separated from the tendons of semitendinosus, gracilis and sartorius (at its
distal tibial attachment) by the bursa anserina
 Sends some fibres from its deep surface – the deep fibres of tibial collateral
ligament – to the medial meniscus
 Is weaker than the fibular collateral ligament. Thus, it is more frequently torn
 Measures about 10 cm in length
547
The fibular collateral ligament

 Is a strong fibrous cord. It is much stronger than the tibial collateral ligament
 Stretches from femoral lateral epicondyle above, to the head of the fibula below
(Fig. 116)
 Strengthens the fibrous capsule of the knee joint laterally. It is separated from this
capsule by the tendon of popliteus and the inferior lateral genicular nerve and
vessels. Thus, it is not attached to the lateral meniscus of the knee joint by any
fibrous tissue, and is less often torn in knee injuries
 Pierces the tendon of biceps femoris near its fibular attachment
The oblique popliteal ligament

 Is an extension of the tendon of insertion of semimembranosus
 Stretches superolaterally, behind the knee joint, from the posterior aspect of the
medial condyle of the tibia to the lateral condyle of the femur
 Blends with the fibrous capsule of the knee joint, which it strengthens posteriorly
 Forms part of the floor of the popliteal fossa.
The arcuate popliteal ligament

 Arises from the head of the fibula below. It then arches upwards and medially,
superficial to the tendon of popliteus, to blend with the fibrous capsule of the
knee joint
 Strengthens the fibrous capsule of the knee joint posteriorly.
Intracapsular Ligaments of Knee Joint (Fig. 116)
These include:
 Anterior cruciate ligament
 Posterior cruciate ligament
 Transverse ligament of the knee joint
 Medial lemniscus, and
 Lateral lemniscus
548
Figure 116. Ligaments of the knee joint
Cruciate Ligaments
The cruciate ligaments

 Are strong fibrous bands located within the capsule of the knee joint. They
connect the tibia and femur together (Fig. 116)
 Criss-cross each other obliquely along their length (hence their name)
 Are two in number: anterior and posterior cruciate ligaments
 Are not exposed to the joint cavity, though they lie within the fibrous capsule of
the joint. Each ligament is covered by synovial membrane of the knee joint.
The anterior cruciate ligament

 Is the weaker of the two cruciate ligaments
 Is attached below to the anterior intercondylar area of the tibia (behind the
attachment of the anterior horn of the medial lemniscus)
 Ascends backwards and laterally to the posteromedial aspect of femoral lateral
condyle, to which it is attached above
 Is more frequently involved in injuries of the knee, as is the case with tibial
collateral ligament
549
 Becomes taut when the knee is fully extended. This prevents backward
displacement of the femur on the tibia.
The posterior cruciate ligament

 Is much stronger than the anterior cruciate ligament. Thus, it is less frequently
damaged in knee injuries
 Is attached below to the posterior intercondylar area of the tibia (behind the
lateral meniscus)
 Ascends anteromedially, and is attached above to the lateral surface of femoral
medial condyle
 Becomes taut during flexion of the joint, thereby preventing posterior
displacement of tibia on the femur
Menisci of the Knee Joint

The menisci are crescentic laminae of fibrocartilage that deepen the articular
surfaces of tibia condyles. They include the medial and lateral menisci, which are
associated with the medial and lateral tibial condyles, respectively (Fig. 116).
Each meniscus of the knee joint

 Is a fibrocartilagenous plate associated with the articular surface of the
respective tibial condyle
 Possesses a thick convex and vascular peripheral border, which is attached to
the fibrous capsule of the knee joint
 Has a thin, free concave inner border, which is avascular
 Serves as a shock absorber for the knee joint during movement
 Is joined to the opposite meniscus across the midline by the transverse ligament
of the knee joint. This connects the anterior horns of the medial and lateral
menisci.
The medial meniscus

 Is roughly semicircular in outline; and is located on the medial condyle of the
tibia. It is less extensive (i.e. covers less condylar area) than the lateral meniscus
 Is attached at its periphery to the margin of the medial condyle of the tibia by the
coronary ligament (a reflection of the fibrous capsule)
 Is also attached through its anterior horn to the anterior intercondylar area of tibia
(anterior to the anterior cruciate ligament)
 Is connected to the lateral meniscus by the transverse ligament of the knee
joint. The latter stretches between the anterior ends of the two menisci
 Is attached posteriorly, through its posterior horn, to the posterior intercondylar
area of the tibia (behind the attachment of the lateral meniscus)
 Is less mobile than the lateral meniscus. Thus, it is more frequently torn in knee
injuries
550
The lateral meniscus

 Is almost circular in outline; it is more extensive (i.e. covers a larger area) than
the medial meniscus
 Is attached, through its anterior end, to the anterior intercondylar area of the tibia
(posterolateral to the point of attachment of the anterior cruciate ligament)
 Is attached posteriorly, through its posterior end, to the posterior intercondylar
area of the tibia (anterior to the posterior end of the medial meniscus)
 Is separated from the fibular collateral ligament by the tendon of popliteus
 Gives rise to the posterior meniscofemoral ligament. This stretches
superomedially from the posterior end of the lateral meniscus to the medial
condyle of the femur
 May give rise to an anterior meniscofemoral ligament. This also stretches
superomedially from the posterior end of the lateral meniscus to the medial
condyle of femur (anterior to the posterior cruciate ligament)
 Is less frequently injured (owing to its relatively higher mobility)
The transverse ligament of the knee joint

 Connects the anterior ends of the medial and lateral menisci across the midline
 Varies in thickness, and may be absent
Movements of the Knee Joint
Movements that occur at the knee joint include:

 Flexion, produced mainly by the hamstring muscles. These muscles are assisted
by gracilis, sartorius and popliteus
 Extension, produced mainly by quadriceps femoris
 Medial rotation of the leg, produced by popliteus, semimembranosus and
semitendinosus. These are assisted by sartorius and gracilis
 Lateral rotation of the leg, produced by biceps femoris.
Regarding the movement of the knee, note these points:

 Some degree of medial rotation occurs as the knee is being flexed
 When the knee is fully extended (in the standing position), the femur rotates
medially on the tibia, thereby ‘locking’ the knee. This ensures stability of the
knee. Thus,
 Before flexion of the fully extended knee can occur, the popliteus must contract
to rotate the femur laterally on the tibia. This ‘unlocks’ the knee
 The posterior cruciate ligament becomes taut during flexion of the knee
 The anterior cruciate ligament becomes taut when the knee is fully extended.
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Innervation and Blood Supply of the Knee Joint
Note the following:

 Articular fibres reach the knee joint from the femoral, tibial and common fibular
nerves. The posterior division of the obturator nerve also sends an articular
filament to the knee joint
 Arterial blood reaches the knee joint from the femoral and popliteal arteries
 The femoral artery supplies the knee joint through its descending genicular
branch (which arises just proximal to the adductor opening)
 The popliteal artery supplies the knee joint through its medial superior, lateral
superior, medial inferior, lateral inferior and middle genicular branches
 The anterior and posterior tibial recurrent branches of the anterior tibial artery,
and the descending branch of lateral circumflex femoral artery, also supply the
knee joint.
Note: Lymph vessels that drain the knee joint terminate in the deep popliteal nodes.
Bursae of the Knee Joint
Bursae associated with knee joint include:

 Subcutaneous prepatellar bursa, located between the patella and the skin (Fig.
115)
 Deep infrapatellar bursa, located between the patellar ligament and the tibia
(Fig. 115)
 Subcutaneous infrapatellar bursa, located between the patellar ligament/tibial
tuberosity and the skin
 Suprapatellar bursa, located between the femur and the tendon of quadriceps
femoris. This large bursa communicates with the joint cavity (Fig. 115)
 Gastrocnemius bursae, located between the heads of gastrocnemius and the
fibrous capsule of the knee joint. They usually communicate with the joint cavity
(Fig. 115)
 Popliteus bursa, located between the tendon of popliteus and the lateral condyle
of the femur. It also communicates with the joint cavity
 Anserine bursa, a complex bursa located between the tibial collateral ligament
and tendons of semitendinosus, gracilis and sartorius. It may communicate with
the joint cavity.
Applied Anatomy

 In contact sports such as football, the tibial collateral ligament, medial meniscus
and anterior cruciate ligament are more frequently torn or sprained
552
 When aspirating effusion of the knee joint, the (flexed) knee may be approached
laterally through a triangular area, the angles of which are located at the tips of
the lateral tibial condyle, lateral femoral epicondyle and apex of the patella
 Knee joint effusion that spreads upwards into the suprapatellar bursa may be
drained through this bursa
 Excessive (synovial) fluid in the knee joint may arise from chronic effusion. This
may result in a popliteal cyst – herniation of the synovial membrane into the
popliteal fossa
 An arthroscope is used to view the interior of the knee joint, as well as to
remove bony, cartilaginous or ligamentous debris.
Genicular anastomoses
 Are formed around the knee joint by branches of the femoral, popliteal, lateral
circumflex femoral, circumflex fibular and tibial recurrent arteries
 Ensure adequate blood supply to the knee joint
 Provide collateral circulation to the leg when the popliteal artery is stenosed (or
occluded), or when the knee joint remains flexed for a long time.
Arteries that form the genicular anastomoses include:

 Descending genicular branch of femoral artery
 Descending branch of lateral circumflex femoral artery
 Lateral superior, lateral inferior, medial superior, medial inferior, and middle
genicular branches of popliteal artery
 Anterior tibial recurrent branch of anterior tibial artery
 Posterior tibial recurrent branch of anterior tibial artery; and
 Circumflex fibular branch of posterior tibial artery.
Leg and Ankle Joint
The Leg
The leg is the part of the lower limb between the knee and the ankle. It contains two
long bones: the tibia medially and the fibula laterally.
The muscles and neurovascular structures of the leg are contained in three
osseofibrous compartments (anterior, posterior and lateral); these compartments are
separated by the anterior and posterior intermuscular septa and the interosseous
membrane.
Cutaneous Innervation of the Leg
Cutaneous nerves of the leg include:

 Saphenous nerve, to the skin of the medial (and adjacent anterior and posterior)
surface of the leg,
 Lateral cutaneous nerve of the leg, to the skin of the upper part of the lateral
(and adjacent anterior and posterior) surface of the leg,
553
 Sural nerve, to the skin of the lower part of the lateral (and adjacent posterior)
surface of the leg,
 Superficial fibular nerve, to the skin of the lower part of the anterior surface of
the leg.
Besides, note the following facts:

 The saphenous nerve is a branch of the femoral nerve; it arises in the femoral
triangle
 The lateral cutaneous nerve of the leg is a branch of the common fibular nerve; it
arises in the popliteal fossa
 The sural nerve is a branch of the tibial nerve; it also arises in the popliteal fossa.
It receives the peroneal communicating branch of common fibular nerve (which
joins it in the leg)
 The superficial fibular nerve arises from the common fibular nerve (as this winds
round the neck of the fibula). It traverses the lateral compartment of the leg where
it innervates the peroneal muscles before it becomes cutaneous.
Bones of the Leg

The bones of the leg include the tibia medially and the fibula laterally (Fig. 117);
these bones articulate with each other proximally and distally at the tibio-fibular
joints. Between these joints, an interosseous membrane unites the bones.
The tibia
 Is the second largest bone in the body; it is located in the leg, medial to the fibula
(Fig. 117). Developmentally, it is the homolog of the radius
 Articulates with the femur proximally, at the knee joint, and with the talus
distally, at the ankle joint
 Bears the body weight transmitted to it by the femur
 Has a proximal end, a shaft or body, and a distal end (Fig. 117).
554
Fig. 117. Anterior view of the tibia and fibula.
The proximal end of the tibia

 Is larger than the distal end; it articulates with the femur at the knee joint
 Bears the medial and lateral condyles, and the elevated intercondylar area
between them.
The medial tibial condyle

 Has a concave articular surface that is covered by an articular cartilage; this
surface articulates with the convex medial condyle of the femur
 Gives attachment to ligaments and muscles (by means of its non-articular part)
The lateral tibial condyle

 Has a concave articular surface that faces upwards and is covered by an
articular cartilage. It articulates with the convex femoral lateral condyle at the
knee joint
555
 Gives attachment to muscles and ligaments (through its non-articular part)

 Also articulates with the head of the fibula (on the inferior aspect of its
posterolateral part)
The intercondylar area of the tibia

 Is an elevated area between the medial and lateral condyles of the tibia; it fits into
the femoral intercondylar fossa (between the medial and lateral femoral
condyles)
 Gives attachment to the cruciate ligaments and menisci of the knee joint.
The body of the tibia

 Is the portion between the proximal and distal ends of this bone
 Has medial, lateral and posterior surfaces. It also has medial, lateral
(interosseous) and anterior borders
 Is connected to the fibula by the interosseous membrane; this is attached to its
lateral (or interosseous) border
 Is narrowest at the junction of its middle and distal thirds
Anterior Border of Tibia

 The anterior border of the tibia separates the medial and lateral surfaces of this
bone from each other; its upper end presents a prominent tibial tuberosity
 The proximal part of the tibial tuberosity gives attachment to the patellar
ligament
 The distal part of tibial tuberosity and the whole of the anterior border of tibia are
subcutaneous.
The lateral border of tibia

 Is distinct in the upper part of the tibia; it separates the lateral and posterior
surfaces of this bone from each other;
 Gives attachment to the interosseous membrane (that connects tibia to fibula)
The medial border of tibia

 Extends from the medial condyle of the tibia above, to the medial malleolus
below; it separates the medial and posterior surfaces of tibia from each other
 Is sharp in its middle part but indistinct in its upper and lower parts
The medial surface of the tibia

 Lies between the anterior and medial borders of this bone; it is largely
subcutaneous
 Gives attachment to the tendons of sartorius, gracilis and semitendinosus, and
to the tibial collateral ligament, in its upper part
 Is crossed by the great saphenous vein as this ascends in the leg.
556
The lateral surface of the tibia

 Lies between the anterior and lateral borders of this bone
 Gives attachment to tibialis anterior in its proximal ⅔.
The posterior surface of tibia

 Lies between the lateral and medial borders of the tibia
 Bears on oblique soleal line in its upper 3rd; this line passes downwards and
medially, from the lateral to the medial border of tibia
 Gives attachment to popliteus (proximal to the soleal line)
 Also gives attachment to flexor digitorum longus medially and tibialis
posterior laterally, distal to soleal line. These two points of attachment are
separated by a vertical line
 Bears a large nutrient foramen just distal to soleal line.
The distal end of tibia

 Is smaller than the proximal end
 Articulates, on its lateral aspect, with the lower end of the fibula at the distal
tibiofibular joint; and below with the talus at the ankle joint
 Has a projection in its medial aspect – the medial malleolus. This also articulates
with the talus at the ankle joint
Applied Anatomy

 Compound fracture, in which the fractured bone pierces the skin, is the
commonest fracture of the tibia
 Fracture of the tibia usually involves its shaft. This is commonly fractured at the
junction of its middle and distal thirds (the narrowest part of the shaft)
 Persons who go on very long treks may suffer fracture of the tibia; this is referred
to as march fracture.
Ossification of the Tibia
Regarding its ossification, the tibia

 Ossifies from three centres located in the shaft, proximal end, and distal end
 Begins to ossify by the 7th week of development, in the shaft
 Completes its ossification by the 18th year (in males), when the proximal
epiphysis joins the diaphysis.

 Ossification commences in the shaft of the tibia by the 7th week of intra-uterine
life
 Ossification centre of the proximal epiphysis has appeared at birth, while that of
the distal epiphysis appears in the 1st year of life
557
 The proximal epiphysis of the tibia fuses with the diaphysis by the 16 th and 18th
year of life in females and males respectively; while the distal epiphysis fuses
with the diaphysis by the 15th and 17th year of life in females and males
respectively.
Fibula
The fibula
 Is the smaller of the two bones of the leg; it is located lateral to the tibia (Fig.
117). Developmentally, it is the homolog of the ulna
 Is long and slender and is not involved in weight bearing, as does the tibia
 Has a proximal end, a body and a distal end
 Is largely surrounded by muscles, to which it gives attachment.

 The proximal end of the fibula has a head that bears an apex (which points
upwards)
 The apex (or styloid process) of fibular head gives attachment to fibular
collateral ligament
 The medial aspect of fibular head articulates with tibial lateral condyle at the
proximal tibiofibular joint
 The lateral aspect of fibular head gives attachment to biceps femoris
 The neck of the fibula is the constricted part of the shaft immediately below the
head; its posterolateral aspect is closely related to the common fibular nerve,
which can be felt here
 The body of the fibula has three rough surfaces for muscular attachment. These
are medial, lateral and posterior surfaces; and they are separated from each other
by three borders (anterior, posterior and interosseous [medial] borders)
 The distal end of the fibula has a medial facet that articulates with the facet on
the lateral aspect of the distal end of the tibia to form the distal tibiofibular joint
 The lateral (fibular) malleolus projects downwards from the distal end of the
fibula; it articulates with the triangular lateral facet of the talus, and is involved in
the formation of the ankle joint.
Applied Anatomy

 The fibular and tibial malleoli help to stabilize the ankle joint (as they grip the
talus between them)
 The fibula is useful in bone grafting (where a part of it is removed and planted in
another region of the body). Partial removal of the fibula for bone grafting
usually does not impair movement of the affected lower limb
558
 Pott’s fracture (the fracture of the fibula just above the lateral malleolus) may
occur when the foot is subjected to excessive inversion, etc. The medial malleolus
(or distal end of the tibia) may also be involved.
 The common fibular nerve winds round the posterolateral aspect of fibular
neck, and may be injured in fracture of this part of the bone. This could result in
foot drop.
Ossification of the Fibula

 The fibula ossifies from three centres located in the shaft, proximal end, and
distal end of the bone
 Ossification of the fibula begins in the shaft at about the 8th week of intra-uterine
life
 Ossification centres in the distal and proximal ends of the fibula appear at about
the 1st and 4th year of life respectively,
 The union of the distal epiphysis with the shaft occurs by the 15th and 17th year
in the female and male respectively; while the union of the proximal epiphysis
with the shaft occurs by the 17th and 19th year in female and male respectively
 The pattern of ossification of the fibula is a reversal of what obtains in other long
bones.
Anterior Compartment of the Leg
The anterior compartment of the leg

 Is located anterior to the interosseous membrane of the leg (Fig. 118)
 Is bounded medially by the lateral surface of tibia, laterally by the anterior
intermuscular septum, behind by the interosseous membrane and anteriorly by
the deep fascia
 Contains two extensors of the toes: extensor digitorum longus and extensor
hallucis longus; and two dorsiflexors of the foot: tibialis anterior and peroneus
tertius
 Transmits the deep fibular (deep peroneal) nerve and anterior tibial vessels.
559
Figure 118. Transverse section of the leg
Tibialis Anterior
The tibialis anterior

 Is a long muscle located in the anterior compartment of the leg (medial to the
extensor digitorum longus) (Fig. 118)
 Is superficial (in its proximal part) to the deep fibular nerve, anterior tibial
vessels and extensor hallucis longus. In its distal 3rd, it becomes tendinous
 Leaves the leg, deep to the superior and inferior extensor retinacula, to enter
the foot. Here, it is invested by a synovial sheath
 Crosses the anteromedial aspect of the ankle as it approaches its distal attachment
to medial cuneiform bone
 Is a powerful dorsiflexor and invertor of the foot.
 Lateral condyle of tibia
 Lateral surface of tibia
 Interosseous membrane, deep fascia, and anterior intermuscular septum of the leg
Distal attachment:
 Medial cuneiform (medial and inferior surfaces of this bone)
 Base of the 1st metatarsal bone
560
Innervation: Deep fibular nerve
Actions:
 Dorsiflexes the ankle joint
 Inverts the foot (at the subtalar joint)
Test of integrity: Dorsiflex the foot against resistance and feel the tendon of this
muscle.
The extensor hallucis longus

 Is located deep to tibialis anterior and extensor digitorum longus, in the upper
part of the leg (Fig. 118). In the distal 3rd of the leg, it emerges from its deep
position to lie between tibialis anterior medially and extensor digitorum longus
laterally;
 Crosses the anterior tibial artery from lateral medially, in the ankle
 Is invested by a synovial sheath as it passes deep to the superior and inferior
extensor retinacula, to enter the foot
 Continues distally on the dorsum of the foot (towards the big toe), medial to
dorsalis pedis artery and medial branch of the deep fibular nerve
 Inserts onto the dorsum of the base of the distal phalanx of the big toe.
 Middle half of the medial surface of the tibia
 Adjacent interosseous membrane.
Distal attachment: Dorsal aspect of the base of the distal phalanx of the big toe
Actions:
 Extends the big toe (hallux)
 Dorsiflexes the foot
Test of integrity: Dorsiflex the big toe against resistance and observe the tendon of
this muscle on the dorsum of the foot.
The extensor digitorum longus

 Is the most lateral of the anterior crural muscles; it lies superficial to extensor
hallucis longus in the upper part of the leg (Fig. 118). In the distal 3rd of the leg,
it is tendinous, and it lies lateral to extensor hallucis longus and tibialis anterior
 Passes deep to the superior and inferior extensor retinacula to enter the foot,
lateral to extensor hallucis longus, anterior tibial vessels and branches of the
deep fibular nerve. (It is invested by a synovial sheath where it lies deep to the
inferior extensor retinaculum)
561
 Divides into four tendons (to the lateral four toes) as it passes deep to the
inferior extensor retinaculum
 Is intimately associated with peroneus tertius.
Each of the four tendons of extensor digitorum longus

 Passes distally on the dorsum of the foot, to one of the lateral four toes
 Is invested in its proximal part by a common synovial sheath (for tendons of
extensor digitorum longus and peroneus tertius)
 Forms an extensor expansion over the metatarsophalangeal joint and the dorsum
of the proximal phalanx of its own toe. Then it divides into three slips, the central
of which inserts onto the base of the middle phalanx of its own toe, while the
collateral ones continue distally to the base of the distal phalanx of that toe
 Gives attachment to a tendon of the extensor digitorum brevis (in each of the
2nd, 3rd and 4th toes) and the lumbrical. These insert into the extensor expansion.
Proximal Attachment:
 Lateral condyle of the tibia
 Upper ¾ of the medial surface of the fibula
Interosseous membrane, anterior intermuscular septum and deep fascia of the leg.
Distal attachment: Bases of the middle and distal phalanges of the lateral four toes
(via the four tendinous slips)
Actions:
 Extends the lateral four toes
Test of integrity: Extend the lateral four toes against resistance and observe the
tendons of this muscle (in the foot).
The peroneus tertius

 Is considered as the most lateral part of extensor digitorum longus, which does
not insert into the toes. It is confined to the distal part of the anterior compartment
of the leg, where it lies lateral to extensor digitorum longus
 Enters the dorsum of the foot by passing deep to the extensor retinacula. Here, it
shares the same synovial sheath with extensor digitorum longus
 Continues distolaterally (on the dorsum of the foot) onto its insertion at the base
of the 5th metatarsal bone
 May be absent
562
 Distal ⅓ of the medial surface of the fibula

 Interosseous membrane and deep fascia of the leg.
Distal attachment: Dorsomedial aspect of the base of the 5th metatarsal
Actions:
 Also assists with eversion of the foot.
Deep Fibular Nerve (Deep peroneal Nerve)
The deep fibular nerve

 Is one of the terminal branches of the common fibular nerve; it arises from the
latter, between the neck of the fibula and peroneus longus. Then, it enters the
anterior compartment of the leg by passing inferomedially, deep to extensor
digitorum longus (Fig. 118)
 Descends through the anterior compartment of the leg, initially between tibialis
anterior medially and extensor digitorum longus laterally (at a deep plane); and
then between extensor hallucis longus medially and extensor digitorum longus
laterally
 Is accompanied by the anterior tibial artery (in the leg)
 Divides (in the ankle) into two terminal branches: medial and lateral terminal
branches. Thus, it enters the dorsum of the foot as medial and lateral terminal
branches (that emerge deep to the inferior extensor retinaculum).
Branches of the Deep Fibular Nerve
The deep fibular nerve

 Gives muscular branches to tibialis anterior, extensor hallucis longus, extensor
digitorum longus and peroneus tertius
 Gives an articular branch to the ankle joint
 Does not give any cutaneous branches in the leg
The lateral terminal branch of the deep fibular nerve

 Arises from the deep fibular nerve in the ankle
 Passes laterally on the tarsal bones, deep to extensor digitorum brevis
 Terminates in a pseudoganglion, deep to extensor digitorum brevis; this
pseudoganglion gives off branches
 Innervates extensor digitorum brevis and the 2nd dorsal interosseous muscle
 Also innervates the tarsal and the 2nd, 3rd and 4th metatarsophalangeal joints
563
The medial terminal branch of the deep fibular nerve

 Also arises from the deep fibular nerve at the ankle
 Lies between the tendon of extensor hallucis longus medially and that of extensor
digitorum longus laterally (at the ankle)
 Passes distally, on the dorsum of the foot, lateral to dorsalis pedis artery (and
the tendon of extensor hallucis longus). It is also crossed from lateral medially by
extensor hallucis brevis
 Divides, proximal to the 1st interdigital cleft, into two dorsal digital nerves that
innervate the skin of the adjacent sides of the hallux and 2nd toe (i.e. the skin of
the 1st interdigital cleft)
 Also innervates the 1st dorsal interosseous muscle and the 1st
metatarsophalangeal joint.
Anterior Tibial Artery
The anterior tibial artery

 Is the smaller of the two terminal branches of popliteal artery. It arises from the
latter at the lower border of popliteus, and then passes forwards, between the two
heads of tibialis posterior
 Enters the anterior compartment of the leg by traversing the oval aperture in the
upper part of the interosseous membrane, medial to the neck of the fibula
 Descends through the anterior compartment of the leg, initially between tibialis
anterior medially and extensor digitorum longus laterally (on the interosseous
membrane) (Fig. 118); and then between tibialis anterior medially and extensor
hallucis longus laterally (on the tibia)
 Leaves the leg deep to the superior extensor retinaculum, to traverse the ankle
(where it lies lateral to the tendon of tibialis anterior). Here, it is crossed
superficially, from lateral medially, by the tendon of extensor hallucis longus
 Becomes the dorsalis pedis artery distal to the malleoli; this artery runs distally,
on the dorsum of the foot, lateral to the tendon of extensor hallucis longus
 Is accompanied by two veins that communicate with each other.
Branches of the anterior tibial artery include:

 Posterior tibial recurrent artery, which joins the genicular anastomoses to
supply the superior tibiofibular joint. It arises before the anterior tibial artery
enters the anterior compartment of the leg
 Anterior tibial recurrent artery; this vessel ascends through the tibialis
anterior, to join the genicular anastomoses (that supply the knee joint);
 Muscular branches to the surrounding muscles
 Anterior medial malleolar artery, which arises about 5 cm proximal to the
ankle; it joins the medial malleolar network
 Anterior lateral malleolar artery, which arises above the origin of anterior
medial malleolar artery; it joins the lateral malleolar network.
564
Applied Anatomy
Note the following fact:

 Pain may arise in the anterior compartment of the leg following compression of
the deep fibular nerve; this may result from oedema
 Ski boot syndrome arises following the compression of branches of the deep
fibular nerve in the foot (e.g., from the use of a tight-fitting boot); this produces
pain in the dorsum of the foot
 Over-exertion of muscles of the anterior compartment of the leg makes them
swollen and edematous, with pain and tenderness.
Lateral Compartment of the Leg
The lateral compartment of the leg

 Overlies the lateral aspect of the fibula (Fig. 118)
 Is bounded medially by the lateral surface of the fibula, and laterally by the deep
fascia of the leg. It is limited anteriorly and posteriorly by the anterior and
posterior intermuscular septa, respectively
 Contains two muscles (fibulares longus and brevis) and a nerve (superficial
fibular nerve)
The fibularis longus

 Is the superficial of the two peroneal muscles; it lies superficial to fibularis brevis
and the superficial fibular nerve (Fig. 118)
 Becomes tendinous in the distal part of the leg, where it lies in a groove behind
the lateral malleolus (together with the tendon of fibularis brevis, which lies
deep to it). Then, it passes deep to the superior peroneal retinaculum, behind
the lateral malleolus; here, it is invested by a synovial sheath (which it shares
with fibularis brevis).
 Also passes deep to the inferior peroneal retinaculum, below the peroneal
trochlea and the tendon of fibularis brevis, on the lateral aspect of the calcaneus;
its synovial sheath extends as far distally as the latter. Then, it continues distally,
on the lateral aspect of cuboid, beyond which it enters a groove on the planter
aspect of this bone (where it is again invested by a synovial sheath). Finally, it
passes obliquely (distomedially) through the sole of the foot, towards its distal
attachment onto the 1st metatarsal and medial cuneiform bones.
 Head and upper ⅔ of the lateral surface of the fibula
 Anterior and posterior intermuscular septa and deep fascia of the leg
Distal attachment:
 Lateral aspect of the base of the 1st metatarsal bone
 Medial cuneiform
565
Innervation: Superficial fibular nerve
Actions:
 Everts the foot (at the subtalar joint)
 Plantarflexes the foot
 Contributes to the maintenance of the transverse arch of the foot.
Test of integrity: Evert the foot against resistance and then observe the muscle
(behind the lower end of the lateral malleolus).
The peroneus brevis

 Is the smaller of the two muscles of the lateral compartment of the leg (Fig. 118).
It lies deep to fibularis longus; and like the latter, it becomes tendinous in the
distal part of the leg
 Shares a common synovial sheath with fibularis longus (behind the lateral
malleolus and deep to the superior peroneal retinaculum)
 Continues into the foot, on the lateral surface of the calcaneus, above the
peroneal trochlea and the tendon of fibularis longus. Here, it is invested by a
separate synovial sheath (deep to the inferior peroneal retinaculum)
 Continues distally, on the lateral aspect of the foot (above the tendon of peroneal
longus), to the base of the 5th metatarsal, onto which it inserts.
 Lower ⅔ of the lateral surface of the fibula
 Anterior and posterior intermuscular septa of the leg
Distal attachment: Tubercle of the base of the 5th metatarsal
Innervation: Superficial fibular nerve
Actions:
 Everts the foot (at the subtalar joint)
 Plantar-flexes the foot
Test of integrity: As described for fibularis longus.
Superficial Fibular Nerve
The superficial fibular nerve

 Arises from the common fibular nerve, between the neck of the fibula and
fibularis longus
 Descends deep to fibularis longus, in the proximal part of the lateral compartment
of the leg. Then, it continues distally, between fibulares muscles behind and
extensor digitorum longus in front
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 Pierces the deep fascia in the distal 3rd of the leg and divides into medial and
lateral branches (that pass into the dorsum of the foot)
 Innervates fibulares longus and brevis, as well as the skin of the lower part of the
anterior aspect of the leg, the ankle, and the dorsum of the foot,
 Also innervates the skin of the medial side of the foot and big toe, as well as
contiguous sides of the 2nd and 3rd toes, via its medial branch; and the skin of the
contiguous sides of the 3rd, 4th and 5th toes, via its lateral branch
 Communicates with the saphenous, deep fibular and sural nerves, in the foot
Applied Anatomy
Note these point:

 The foot adopts an inverted position when the superficial fibular nerve is injured
high up in the leg
Posterior Compartment of the Leg

The posterior compartment of the leg lies behind the interosseous membrane; its
muscles are arranged in superficial and deep groups, and these are separated by the
transverse intermuscular septum. Besides muscles, this compartment also contains
the tibial nerve and the posterior tibial vessels.
Superficial Muscles of the Posterior Compartment of the Leg
These muscles
 Are separated from the deep group by the transverse intermuscular septum
 Consists of gastrocnemius, soleus and plantaris (Fig. 118, 19); these form the
bulge of the calf
 Form a large powerful tendo calcani (calcaneal tendon) in the distal part of the
leg; through this tendon, they insert onto the calcaneus
 Are very essential in walking, jumping, etc, as they raise the body on the toes
 Are innervated by the tibial nerve.
The gastrocnemius
 Is the most powerful muscle in the posterior compartment of the leg (Fig.
118,119)
 Arises by two heads from the femoral condyles. The medial head is larger than
the lateral head
 Bounds the popliteal fossa inferiorly. Its medial and lateral heads form the
inferomedial and inferolateral borders of this fossa, respectively
 Descends vertically in the leg to form, together with soleus, a large calcaneal
tendon (Achilles’ tendon); the latter is attached onto the calcaneus
 Crosses both the knee and ankle joints; thus, it acts on both
 Is essential for such movements as jumping, running, leaping and walking (as it
powerfully plantar-flexes the ankle)
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 May be absent in part (especially the lateral head), or entirely

 Usually contains a sesamond bone, the fabella, in its lateral head
 Assists in pumping blood from the superficial to the deep veins of the leg, as it
contracts repeatedly during locomotion.
Figure 119. Dorsal view of the leg.
 Medial head: Posterior aspect of medial condyle and adjacent part of the
popliteal surface of the femur
 Lateral head: Lateral condyle and lateral supracondylar line of the femur
Distal attachment: Posterior surface of calcaneus (via the tendo calcani)
Innervation: Tibial nerve
Action:
 Plantarflexes the ankle
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 Also flexes the knee
Test of integrity: The muscle could be observed while plantar-flexing the foot
against resistance.
The soleus
 Is a large flat muscle located immediately deep to gastrocnemius in the posterior
compartment of the leg (Fig. 118,119)
 Is separated from the deep group of posterior compartment muscles by the
transverse intermuscular septum
 Could be felt on either side of gastrocnemius as one stands on the toes
 Is a strong plantar-flexor; it acts on the ankle joint only. Unlike gastrocnemius,
it does not act on the knee joint
 May possess an additional belly (accessory soleus) in about 3% of the
population; this belly lies medial to tendo calcani
 Assists in pumping venous blood from the superficial to the deep veins of the leg,
as it contracts. It contracts less rapidly than gastrocnemius.
 Head and upper ¼ of the posterior aspect of the body of fibula
 Soleal line and middle 3rd of the medial border of the tibia
 Fibrous arch between the fibula and tibia
Distal attachment: Posterior surface of the calcaneus, via the tendo calcani
Action: Plantarflexes the ankle joint (powerfully)
Plantaris
Regarding the plantaris, note the following:

 It is a fusiform muscle with a muscular belly (measuring 7-10 cm) and a long
tendon
 It arises from the lateral supracondylar line of the femur. From this origin, it
passes downwards and medially between gastrocnemius and soleus (and becomes
tendinous as it does so). Near its distal attachment to the calcaneus, its tendon lies
on the medial aspect of tendo calcani
 Its tendon may be harvested for grafting elsewhere in the body, especially in the
upper limb
 It may be duplicated or absent
 Lower part of the lateral supracondylar line of the femur
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 Oblique popliteal ligament of the knee joint
Distal attachment: Posterior surface of the calcaneus, via the tendo calcani
Actions:
 Plantarflexes the ankle joint
 Also flexes the knee joint
Note: Both actions are weak.
Calcaneal Tendon (Tendo Calcani or Achilles Tendon)
The calcaneal tendon

 Is the strongest and largest tendon in the body (Fig. 119); it is about 15 cm long
 Is the common tendon for soleus, gastrocnemius and plantaris; and it stretches
from the middle of the back of the leg above, to the middle of the posterior
surface of the calcaneus below
 Is separated from the upper part of the posterior surface of the calcaneus by the
deep calcaneal bursa; and from the overlying skin by the superficial calcaneal
bursa
 Provides the site (near calcaneus) for eliciting the calcaneal tendon reflex (when
testing for the integrity of the S1 and S2 nerves)
 May be ruptured in calcaneal tendinitis, and during sports, etc.
Deep Muscles of the Posterior Compartment of the Leg

These muscles are located in the leg between the interosseous membrane and
transverse intermuscular septum, and between the tibia and fibula. The transverse
intermuscular septum separates them from the superficial group of muscles.
Included in this deep group of muscles are popliteus, flexor digitorum longus, flexor
hallucis longus and tibialis posterior.
The popliteus
 Is a flat triangular muscle that forms the lower part of the floor of the popliteal
fossa
 Is partly intracapsular (as its tendon of origin is located within the fibrous
capsule of the knee joint); however, it is separated by the synovial membrane
from the cavity of this joint
 Separates, as it passes through the knee joint, the lateral meniscus from the
fibular collateral ligament
 Emerges from the knee joint by piercing the posterior aspect of the fibrous
capsule of the knee joint, deep to the arcuate popliteal ligament; then, it passes
medially, behind the knee joint, to the back of the tibia, onto which it inserts
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 Receives a fascial covering from the tendon of semimembranosus; this forms the
fascia of popliteus
 Assists in ‘unlocking’ the fully extended knee before flexion can commence.
 Lateral aspect of the lateral condyle of the femur
 Arcuate popliteal ligament and lateral meniscus of the knee joint
Distal attachment: Posterior surface of the tibia (proximal to soleal line)
Actions:
 Flexes the knee joint
 Rotates the femur laterally on the tibia (with the foot on the ground) or the tibia
medially on the femur (when the foot is off the ground). This action ‘unlocks’ the
fully extended knee before flexion can commence.
Note: A fully extended knee is ‘locked’. It must however be ‘unlocked’ by the action
of popliteus before flexion can occur.
Flexor hallucis longus

 Is one of the muscles of the deep group of the posterior compartment of the leg; it
lies lateral to flexor digitorum longus (Fig. 118)
 Passes downwards, in the above position, to the posterior surface of the distal end
of the tibia, where it occupies a groove
 Lies deep to the flexor retinaculum, on the medial aspect of the ankle; here, it is
invested by a synovial sheath
 Occupies the groove on the posterior surface of the talus and the inferior aspect of
sustentaculum tali; here, it is also invested by a synovial sheath. Then it
traverses the sole of the foot, towards the hallux (big toe); here, it lies deep to
flexor digitorum longus (which it crosses from lateral medially)
 Enters the plantar aspect of the hallux by passing distally between the two
sesamond bones on the plantar aspect of the head of the 1st metatarsal
 Occupies the osseofibrous tunnel on the plantar surface of the hallux (big toe) as
it passes to the base of the distal phalanx of this toe, where it inserts
 Is larger in size than flexor digitorum longus
 Lower ⅔ of the posterior surface of the fibula
 Interosseous membrane and posterior intermuscular septum of the leg
Distal attachment: Plantar aspect of the base of the distal phalanx of the hallux
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Actions:
 Flexes the metatarsophalangeal and interphalangeal joints of the big toe. This
action propels the body forwards (as in walking, etc)
 Assists in plantar-flexing the ankle joint
 Also assists in maintaining the medial longitudinal arch of the foot
Test of integrity: Observe the tendon of this muscle as the distal phalanx of the big
toe is flexed against resistance.
Flexor digitorum longus

 Lies deeply in the posterior compartment of the leg, medial to flexor hallucis
longus (Fig. 118)
 Becomes tendinous as it passes downwards in the leg, onto the posterior surface
of the medial malleolus. Here (behind the medial malleolus), it shares the same
bony groove with the tendon of tibialis posterior, but it is invested by a separate
synovial sheath
 Continues distally, on the medial side of the ankle, where it lies deep to the flexor
retinaculum and medial to the sustentaculum tali of the calcaneus. Then, it
enters the sole of the foot where it passes distolaterally, superficial to the tendon
of flexor hallucis longus (and deep to flexor digitorum brevis)
 Divides into four tendons in the sole of the foot; these pass to the lateral four toes
 Gives attachment to tendons of flexor accessorius and lumbricals. The former
muscle inserts into, while the latter arise from its four tendons).
Each of the four tendinous slips of the flexor digitorum longus

 Enters the plantar aspect of one of the lateral four toes (where it occupies the
fibrous flexor sheath)
 Perforates the tendon of flexor digitorum brevis of its own toe, to reach the base
of the distal phalanx of that toe, to which it is attached
 Receives the attachment of vincula longus and brevis (located within the fibrous
flexor sheath); these convey blood vessels to it.
 Medial aspect of the posterior surface of the tibia (below the soleal line)
 Fascia of tibialis posterior
Distal attachment: Plantar aspects of the bases of the distal phalanges of the lateral
four toes
Actions:
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 Flexes metatarsophalangeal and proximal and distal interphalangeal joints of

the lateral four toes
 Plantarflexes the ankle joint
 Contributes to the maintenance of longitudinal arch of the foot
Test of integrity: The muscle is tested by attempting to flex the distal phalanges of
the lateral four toes against resistance.
The tibialis posterior

 Is the deepest muscle of the posterior compartment of the leg; it lies deep to (and
between) flexor hallucis longus and flexor digitorum longus (Fig. 118)
 Has two heads of origin, between which the anterior tibial vessels pass
 Passes downwards in the leg (in a deep plane), and becomes tendinous distally
 Lies deep to the tendon of flexor digitorum longus behind the medial malleolus,
where the two muscles share a groove. Here, tibialis posterior is invested by a
separate synovial sheath
 Passes deep to the flexor retinaculum (and superficial to the deltoid ligament of
the ankle joint) to enter the sole of the foot where it lies below the plantar
calcaneonavicular ligament; here, it contains a sesamond fibrocartilage
 Divides, in the sole of the foot, into several fibrous slips that are attached to many
tarsal and metatarsal bones.
 Lateral aspect of the posterior surface of the tibia (below the soleal line)
 Medial part of the upper ⅔ of the posterior surface of the fibula
 Interosseous membrane and intermuscular septa of the leg
Distal attachment:
 Plantar surfaces of tarsal bones (navicular tuberosity, cuneiform bones and
cuboid)
 Bases of the 2nd, 3rd and 4th metatarsal bones
Innervation: Tibial nerve.
Actions:
 Inverts the foot at the subtalar joint (main action)
 Also plantar-flexes the ankle joint
Test of integrity: Invert the plantar-flexed foot against resistance; the tendon may
then be observed behind the medial malleolus.
Tibial Nerve (L4, L5; S1, S2, and S3)
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The tibial nerve

 Is the larger of the two terminal branches of the sciatic nerve; it arises in the
thigh.
 Descends in the lower part of the thigh (behind adductor magnus) and through the
popliteal fossa, to enter the leg (distal to the lower border of popliteus);
 Passes between the two heads of gastrocnemius to descend deep to soleus (and
superficial to tibialis posterior), in the upper ⅔ of the leg,
 Becomes superficial in the distal 3rd of the leg, where it lies between flexor
hallucis longus laterally and flexor digitorum longus medially (deep to the deep
fascia and skin). Then it traverses the posteromedial aspect of the ankle, deep to
the flexor retinaculum (and between flexor hallucis longus laterally and flexor
digitorum longus medially).
 Divides, deep to the flexor retinaculum, into medial and lateral plantar nerves
(see below). These branches enter the sole of the foot distal to the flexor
retinaculum.
 Innervates all the muscles of the posterior compartment of the leg
 Is accompanied in the leg by the posterior tibial vessels.
Posterior Tibial Artery
The posterior tibial artery

 Is the larger of the two terminal branches of the popliteal artery; it arises from
the latter at the lower border of popliteus
 Enters the posterior compartment of the leg where it descends deep to soleus
(between flexor digitorum longus medially and flexor hallucis longus laterally)
 Becomes more superficial in the distal 3rd of the leg where it lies deep to the skin
and deep fascia (between flexor digitorum longus medially and flexor hallucis
longus laterally). Then it descends behind the medial malleolus, from which it is
separated by tendons of tibialis posterior and flexor digitorum longus;
 Enters the posteromedial aspect of the ankle, where it lies deep to the flexor
retinaculum and abductor hallucis
 Divides, deep to the flexor retinaculum, into its two terminal branches: medial
and lateral plantar arteries (see below)
 Is accompanied, in the leg, by two veins and the tibial nerve; the latter first lies
medial, then posterior and finally posterolateral to it.
Branches of the posterior tibial artery include:

 Circumflex fibular artery
 Peroneal artery
 Nutrient artery of the tibia
 Medial and lateral plantar arteries
 Muscular and communicating branches
 Medial malleolar and calcanean branches
574
The circumflex fibular artery

 Arises from the proximal part of the posterior tibial artery; and passes laterally,
round the neck of fibula (within soleus)
 Contributes to the genicular anastomoses as it anastomoses with the genicular
and anterior tibial recurrent arteries
 May arise from the anterior tibial artery.
The nutrient artery of the tibia

 Arises from the proximal part of the posterior tibial artery
 Enters the nutrient foramen of the tibia, below the soleal line, to supply this
bone.
Muscular branches of the posterior tibial artery

 Arise along the course of the posterior tibial artery
 Supply the muscles of the posterior compartment of the leg.
The communicating branch of posterior tibial artery

 Arises from the distal part of the posterior tibial artery
 Passes transversely across the back of the tibia, about 5 cm proximal to the
medial malleolus, and deep to flexor hallucis longus
 Joins the communicating branch of peroneal artery in the distal part of the leg.
Note: For highlights of lateral and medial plantar arteries, see the foot.
Medial malleolar branches of the posterior tibial artery

 Wind round the medial malleolus of the tibia
 Terminate in the medial malleolar network
Calcanean branches of the posterior tibial artery

 Arise from the distal part of the posterior tibial artery
 Pierce the flexor retinaculum, on the medial aspect of the ankle
 Supply the skin around the calcaneal tendon and the heel; they also supply the
muscle on the medial aspect of the sole of the foot
 Anastomose with the medial malleolar arteries and calcaneal branches of
peroneal artery
Peroneal Artery (Fibular Artery)
The peroneal artery

 Arises from the posterior tibial artery near the popliteus; it then runs
inferolaterally onto the posterior aspect of the fibula. From this point, it descends
through the leg, between tibialis posterior and flexor hallucis longus (or in the
substance of the latter)
575
 Terminates in the distal part of the leg, close to the inferior tibiofibular joint, by
dividing into calcaneal branches
 May replace the posterior tibial artery partly or wholly
 May arise from the popliteal artery
Branches of the peroneal artery include:

 Muscular branches to the deep flexors and fibular muscles of the leg,
 A nutrient artery to the fibula; this ascends to this bone
 A perforating branch, which arises close to the lateral malleolus. It enters the
anterior compartment of the leg where it anastomoses with the anterior lateral
malleolar and lateral tarsal arteries
 A communicating artery, which arises about 5 cm above the lateral malleolus; it
joins the communicating branch of posterior tibial artery,
 Calcaneal branches, which arise from the terminal end of the peroneal artery;
they anastomose with calcanean branches of the posterior tibial artery.
Small Saphenous Vein
The small saphenous vein

 Arises in the foot by the union of the lateral dorsal digital vein of the little toe
and the dorsal venous arch of the foot; then, it runs proximally in the
subcutaneous tissue of the lateral aspect of the dorsum of the foot
 Passes first below and then behind the lateral malleolus, from where it ascends
in the subcutaneous tissue of the leg, lateral to tendo calcani. However, it
inclines towards the midline in the upper part of the leg, where it lies on
gastrocnemius;
 Pierces the deep fascia of the leg at the junction of the upper and middle 3rd of the
calf, below the popliteal fossa (which it enters)
 Terminates in the popliteal vein, usually above the level of the knee joint
 Drains the lateral side of the foot, the ankle, and the back of the leg.
In addition, the small saphenous vein

 Communicates with the great saphenous vein in the leg (via venous channels)
 May terminate in the great saphenous vein in the leg or thigh (instead of the
popliteal vein in the popliteal fossa). It may also be connected to the great
saphenous vein in the thigh by a large branch;
 Is connected to the deep veins of the dorsum of the foot and the leg by
perforating veins
 May possess up to 13 valves. One of these is usually located near its termination
 May become varicose when its valves are incompetent
 Is accompanied by the sural nerve in the foot and lower part of the leg.
576
Great Saphenous Vein
Regarding the great saphenous vein, note the following:

 It is the longest vein in the body. It traverses almost the entire length of the lower
limb
 It arises in the foot by the union of the medial dorsal digital vein of the big toe
and the dorsal venous arch of the foot. From this point, it passes proximally
through the subcutaneous tissue of the medial aspect of the dorsum of the foot;
and then ascends, about 3 cm anterior to the medial malleolus, to enter the leg.
 Initially, it ascends obliquely on the distal 3rd of the medial surface of the tibia;
then it continues upwards, along the medial border of this bone, to the
posteromedial aspect of the knee.
 It leaves the knee to ascend in the medial aspect of the thigh, as far up as the
saphenous opening (an aperture in the fascia lata, about 3 cm inferolateral to the
pubic tubercle);
 Finally, it enters the femoral triangle, where it terminates in the femoral vein.
In addition, the great saphenous vein

 Is accompanied in the foot and leg by the saphenous nerve; in the knee by the
saphenous branch of the descending genicular artery; and in the thigh by
branches of the anterior femoral cutaneous nerve
 Lies in the subcutaneous tissue in the greater part of its course, until it pierces the
cribriform fascia to enter the femoral triangle (via the saphenous opening)
 Establishes several connections with the deep veins of the lower limb, especially
those of the leg (via the perforating veins), and with the small saphenous vein
 May possess up to 20 valves. These are more numerous in the leg
 May be duplicated along its length, especially in the leg
 Drains the foot, ankle, leg and thigh. It also receives much blood from the small
saphenous vein.
Tributaries of the Great Saphenous Vein

 As the great saphenous vein ascends in the lower limb, it receives several
tributaries
 An accessory saphenous vein may be present. This ascends in the posteromedial
aspect of the thigh; and connects the small and great saphenous veins
 The small saphenous vein gives several branches to the great saphenous vein; it
may even terminate in it
 The superficial epigastric, superficial external pudendal and superficial
circumflex iliac veins all terminate in the great saphenous vein (near the
saphenous opening).
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Applied Anatomy

 The valves of the great saphenous vein ensure unidirectional flow of blood
(towards the femoral vein)
 The perforating veins, which connect the great saphenous vein to the deep veins
of the lower limb, also possess valves. The latter ensure that blood flows from the
great (and small) saphenous vein to the deep veins of the leg, and not vice-versa
 The pumping action of the calf muscles – calf pump – ensures that the deep
veins of the leg are readily emptied so that blood can flow to them from the great
and small saphenous veins. Thus, incompetence of the valves of the perforating
veins would result in backflow of blood from the deep veins into the great and
small saphenous veins
 Backflow of blood into the great saphenous vein (from the deep veins of the leg),
coupled with incompetence of the valves of this vein, would result in blood
retention, and thus, varicosity of this vein
 Varicosity thus develops in the great saphenous vein when its valves and those of
the perforating veins become incompetent.

 Owing to its superficial position, long length, and the presence of higher
percentage of muscular tissue in the great saphenous vein, it is often harvested for
coronary arterial bypass
 In saphenous cutdown, the great saphenous vein is incised at the point where it
passes anterior to the medial malleolus (to insert a cannula through it, etc)
 The saphenous nerve is prone to injury in saphenous cutdown; when this occurs,
pain is felt along the medial aspect of the dorsum of the foot.
Ankle Joint (Talocrural Joint)

The ankle joint is the articulation between the talus (a bone of the foot) and the tibia
and fibula (bones of the leg) (Fig. 120).
The ankle joint

 Is a uni-axial, hinge type of synovial joint; it is formed between the tibia and
fibula proximally, and the talus distally
 Is located at the level of the anterior margin of the distal end of tibia
 Has great strength and stability; this is owing to the deep nature of the articulating
surfaces and the strong ligaments and tendons that are associated with it.
Articulating Surfaces of the Ankle Joint
Regarding the formation of the ankle joint,
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 The inferior surface of the distal end of the tibia, the medial and lateral malleoli,
and the posterior tibiofibular ligament, altogether form a deep socket (the
proximal articular surface) for the talus
 The trochlea of the talus and the medial and lateral surfaces of this bone form
the distal articular surface of the ankle joint; this prominent pulley-like surface
fits deeply into the inferior surface of the distal end of the tibia
 The medial surface of the talus is comma-shaped, and it articulates with the
medial malleolus of the tibia. The lateral surface of talus is triangular; and it
articulates with the lateral malleolus of the fibula
 The trochlea of the talus is narrow posteriorly such that the ankle joint is less
stable in plantar-flexion
 Articular hyaline cartilage lines the articular surfaces of the bones of the ankle
joint.
The fibrous capsule of the ankle joint

 Surrounds the joint and is lined internally by synovial membrane
 Is attached proximally to the margin of the articular surfaces of the tibia and
malleoli; and distally to the margin of the articular surface of the talus
 Is relatively thin anteriorly and posteriorly. However, it is strengthened on either
side by strong ligaments
The synovial membrane of the ankle joint

 Lines the fibrous capsule of the joint internally, thereby separating it from the
joint cavity
 Forms a recess above, as it extends upwards between the tibia and fibula
(towards the distal tibiofibular joint)
Ligaments of the Ankle Joint

These ligaments strengthen the fibrous capsule laterally and medially. They include
the medial (deltoid) and lateral ligaments.
The medial ligament of the ankle joint

 Is large, strong and triangular in outline (Fig. 120). It is stronger than the lateral
ligament; and it strengthens the fibrous capsule medially
 Fans out from the medial malleolus above to the calcaneus, navicular bone and
talus below
 Consists of tibionavicular, anterior tibiotalar, posterior tibiotalar and
tibiocalcaneal ligaments.

 The tibionavicular ligament stretches forwards from the medial malleolus to the
navicular tuberosity
 The anterior tibiotalar ligament stretches from the tip of the medial malleolus
above to the medial surface of the talus below
579
 The posterior tibiotalar ligament stretches posterolaterally from the medial

malleolus to the medial tubercle of the talus
 The tibiocalcaneal ligament descends from the medial malleolus above to the
sustentacular tali below.
The lateral ligament of the ankle joint

 Is weaker than the medial ligament; it strengthens the capsule of the ankle joint
laterally
 Consists of three ligaments: anterior talofibular, posterior talofibular and
calcaneofibular ligaments (Fig. 120).
Figure 120. Ligaments of the ankle joint
Note these facts:

 The anterior talofibular ligament passes anteromedially from the lateral
malleolus to the neck of the talus (Fig. 120)
 The posterior talofibular ligament passes posteromedially (horizontally) from
the lateral malleolar fossa to the lateral tubercle of the posterior process of the
talus (Fig. 120)
 The calcaneofibular ligament is a long round cord that stretches from the apex
of the lateral malleolus to the lateral surface of the calcaneus (Fig. 120). It is
crossed laterally by tendons of peroneus longus and brevis.
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Relations of the Ankle Joint
The ankle joint is related to the following:

 Anteriorly (from lateral medially): peroneus tertius, extensor digitorum longus,
deep fibular nerve, anterior tibial vessels, extensor hallucis longus and tibialis
anterior,
 Posteriorly (from lateral medially): flexor hallucis longus, tibial nerve, posterior
tibial vessels, flexor digitorum longus and tibialis posterior
 Posterolaterally: tendons of peroneus longus and brevis (behind the lateral
malleolus)
Movements of the Ankle Joint
Note these points:

 Plantarflexion and dorsiflexion are the two major movements that occur at the
ankle joint
 Dorsiflexion-plantarflexion movements occur on a transverse (horizontal) axis
 Muscles of the anterior compartment of the leg produce dorsiflexion; while those
of the posterior compartment produce plantarflexion
 The range of plantarflexion is greater than that of dorsiflexion; thus,
plantarflexion occurs more freely
 Limited abduction, adduction and rotation of the ankle joint are also possible
when the joint is plantarflexed
Blood Supply and Innervation of the Ankle Joint
The ankle joint

 Receives arterial blood from malleolar branches of anterior and posterior tibial
and peroneal arteries
 Is innervated by articular rami of the tibial and deep fibular nerves.
Applied Anatomy
Note that:
 Forceful inversion and plantarflexion of the foot (which could tear the fibrous
capsule of the ankle joint anteriorly) usually results in spraining of the joint, in
the true sense
 The anterior talofibular ligament is also usually torn when the ankle joint is
sprained
 Dislocation of the ankle joint is usually accompanied by fracture of the malleoli
 In forced eversion, Pott’s fracture may occur (fracture of the fibula above the
lateral malleolus). This may also involve dislocation of the ankle joint, with
fracture of the medial malleolus.
581
The Foot
The foot is the part of the lower limb that lies distal to the ankle. It has several
tendons, which enter it from the leg. Its bones are the tarsal and metatarsal bones
and the phalanges. The foot is considered as having a dorsum (superior surface) and
a sole (inferior surface).
Cutaneous Innervation of the Foot
Cutaneous nerves that supply the dorsum of the foot include:

 Superficial fibular nerve, which innervates the larger part of the dorsum of the
foot and toes
 Saphenous nerve, which supplies the posteromedial aspect of the dorsum of the
foot
 Sural nerve, which innervates the lateral aspect of the dorsum of the foot and
little toe
 Deep fibular nerve, which supplies the 1st interdigital cleft of the foot.
Cutaneous nerves of the sole of the foot include:

 Medial calcanean nerves, which pierce the flexor retinaculum to supply the heel
and adjacent part of the sole; they arise from the tibial nerve
 Medial plantar nerve, which supplies the medial aspect of the anterior part of the
sole, as well as the medial 3½ digits (including the distal parts of the dorsum of
these digits)
 Lateral plantar nerve, which supplies the lateral aspect of the anterior part of the
sole, as well as the lateral 1½ digits (including the distal part of the dorsum of
these digits).
Bones of the Foot

Altogether, the foot has 26 bones. These are arranged as tarsus (proximally),
metatarsus (intermediate) and phalanges (distally). The bones of the foot are also
organized such that they form arches (see below).
The foot has:

 Seven tarsal bones; these include calcaneus, talus, cuboid, navicular bone,
medial cuneiform, intermediate cuneiform and lateral cuneiform
 Five metatarsal bones, named from medial laterally as 1st – 5th metatarsals
 Fourteen phalanges, three of which are in each of the lateral four toes, while two
are in the big toe.
Figure 121. Bones of the foot.
Tarsal Bones
The calcaneus
 Is the strongest and largest bone of the foot (Fig. 121); it forms the prominence of
the heel
 Is very essential for locomotion as it transmits the weight of the body to the
ground, from the talus
 Has a medial projection termed sustentaculum tali; this supports the head of
talus
 Has a variable lateral projection termed peroneal trochlea; this separates the
tendons of peroneus longus and brevis as they pass over the lateral aspect of the
calcaneus
 Presents a calcaneal tuberosity on the proximal part of its plantar surface. The
medial process of this tuberosity rests on the ground in the erect position
 Gives attachment to the powerful calcaneal tendon via its posterior surface; the
upper part of this surface is separated from the tendon by a deep calcaneal bursa
 Articulates above with the talus (at the subtalar joint) and in front with the
cuboid.
Talus
Note the following:

 The talus has a cuboidal body proximally, and a head distally; the two being
separated by a neck (Fig. 121)
 The head of talus is directed anteromedially from the neck. It articulates
(distally) with navicular bone; and is supported below by the sustentaculum tali
of calcaneus
 The upper surface of the body of talus has a smooth trochlea for articulation with
the tibia at the ankle joint
 The medial surface of the body of talus bears a comma-shaped facet for the
medial malleolus; while the lateral surface bears a triangular facet for the lateral
malleolus
 The posterior surface of the body of talus has a groove for flexor hallucis
longus; this groove is bounded on the sides by the medial and (the more
prominent) lateral tubercles
 The talus gives no attachment to muscles or tendons
 The tibia transmits the weight of the body to the foot through the talus
The navicular
 Is a flat bone that resembles a boat (Fig. 121)
 Is located on the medial part of the foot, between the talus proximally and the
three cuneiforms (with which it articulates) distally
 Has a tuberosity, which points downwards from its medial surface; this
tuberosity is palpable about 2.5 cm antero-inferior to the medial malleolus.
The cuboid
 Is roughly cuboidal in shape. It is located on the lateral aspect of the foot,
between the calcaneus proximally and the 4th and 5th metatarsals distally. Thus,
it articulates with the calcaneus proximally and with the bases of the 4th and 5th
metatarsal bones distally
 Bears a tuberosity on it lateral aspect. Distal to this is a groove in which
fibularis longus passes, en route to the sole of the foot
 Has an oblique groove on its plantar aspect; this also lodges the tendon of
fibularis longus, in the sole of the foot.
Cuneiform bones
 Are three wedge-shaped bones designated as medial, intermediate and lateral
cuneiforms (Fig. 121). Medial cuneiform is the largest while the intermediate is
the smallest
 Articulates distally with the bases of the medial three metatarsal bones and
proximally with the navicular bone.
Metatarsal Bones
Note the following:

 There are five metatarsal bones, numbered from medial laterally (as 1st – 5th
metatarsals) (Fig. 121)
 Each metatarsal is a long bone with a proximal base, an intermediate shaft and a
distal head
 The bases of the 1st, 2nd, and 3rd metatarsals articulate proximally with the three
cuneiform bones, while the bases of the 4th and 5th metatarsals articulate
proximally with the cuboid
 The head of each metatarsal articulates distally with the base of a proximal
phalanx of a digit (at the metatarsophalangeal joint)
 The 1st metatarsal is the shortest, while the 2nd is the longest
 The base of the 5th metatarsal has a prominent tuberosity on its lateral aspect (for
the attachment of peroneus tertius and brevis)
 Two sesamond bones lie on the plantar aspect of the head of the 1st metatarsal.
The tendon of flexor hallucis longus passes between these bones
 The base of each metatarsal is larger than the head. It articulates with a tarsal
bone at the tarsometatarsal joint
 The metatarsals give attachment to interosseous muscles
Phalanges
Note that:
 The phalanges are fourteen in number; they form the skeleton of the toes (Fig.
121)
 The big toe (hallux) has two phalanges – proximal and distal
 Each of the lateral four toes has three phalanges; these are proximal, middle and
distal phalanges
 Each phalanx is a long bone with a proximal base, intermediate shaft and a distal
head
 The base of each proximal phalanx articulates with the head of a metatarsal to
form a metatarsophalangeal joint
 The phalanges also articulate with each other to form two interphalangeal joints
in each toe (except the 1st toe that has one)
 The middle and distal phalanges of the little toe may fuse in elderly persons
Arches of the Foot
The arches of the foot

 Are formed as a result of the shape and arrangement of the tarsal and metatarsal
bones of the foot (Fig. 121)
 Give the foot an arched outline, for the purpose of locomotion, support and
protection of the soft tissue of the sole of the foot
 Act as shock absorbers and thus support the body in the standing position
 Are maintained by the shapes of the interlocking tarsal and metatarsal bones, as
well as several plantar ligaments and tendons associated with the bones of the
foot
 Are divisible into medial and lateral longitudinal and transverse arches.
Medial Longitudinal Arch of the Foot
Regarding the medial longitudinal arch, note that:

 It is formed by the calcaneus, talus, navicular, medial cuneiform, intermediate
cuneiform, lateral cuneiform and the medial three metatarsal bones. The shapes
of these bones are the major factor in the formation of this arch
 It is maintained mainly by ligaments, including the long and short plantar
ligaments, plantar aponeurosis and spring ligament
 The tendons of tibialis anterior, flexors hallucis longus, flexor digitorum
longus and peroneus longus also contribute to the maintenance of this arch
 Its summit is formed by the superior articular surface of the talus
 Its posterior pillar is the calcaneus, while its anterior pillar is formed by the
heads of the medial three metatarsal bones
 It receives full thrust from the tibia and then passes this to its anterior and
posterior pillars through the talus, navicular and cuneiforms
 It is much more prominent, more mobile and more adjustable than the lateral
arch
Lateral Longitudinal Arch of the Foot
The lateral longitudinal arch of the foot

 Is formed by calcaneus, cuboid and the lateral two metatarsal bones. The
shapes of these bones is the main factor that forms the arch; and it is maintained
by the associated ligaments, which include the long plantar and the plantar
calcaneocuboidal ligaments
 Is also supported and maintained by peroneus longus
 Has a summit located at the subtalar articulation. This summit is however lower
than that of the medial longitudinal arch
 Is less prominent, less mobile and less resilient than the medial arch
 Rests on the ground when standing; thus, it makes more extensive contact with
the ground than the medial arch (in this position).
Transverse Arch of the Foot
The transverse arch of the foot

 Is transversely disposed, from side to side
 Is formed by the cuboid, cuneiforms and the adjoining bases of all metatarsals;
thus, it is well marked at the level of the tarsometatarsal joints
 Is maintained by ligaments of tarsometatarsal, intertarsal and intermetatarsal

joints, as well as the tendon of peroneus longus. The latter runs obliquely across
the sole of the foot.
Applied Anatomy

 Hammer toe could arise usually as a result of paralysis or weakness of the
interossei and lumbrical associated with a toe
 In hammer toe, the proximal phalanx is fully extended at the
metatarsophalangeal joint, while the middle phalanx is flexed at the proximal
interphalangeal joint. Thus, the affected toe points downwards
 Claw toes arise from paralysis or weakness of lumbricals of the lateral four toes.
The affected toes have the appearance of hammer toe, only that several toes are
involved
 In hallux valgus, the big toe deviates laterally at the metatarsophalangeal joint.
This defect is commoner in women
 Hallux valgus usually arises owing to the oblique course of extensors hallucis
brevis and longus. This arrangement tends to overpower abductor hallucis,
thereby resulting in lateral deviation of the big toe
 In hallux valgus, the head of the 1st metatarsal rubs against the shoe; and as a
result, a bunion (swelling) usually develops on its medial aspect
 In pes planus (flat foot), the arches of the foot tend to flatten out under the
weight of the body. Weakening or over-stretching of the plantar ligaments,
especially the plantar calcaneonavicular ligament, is a major factor that
predisposes to pes planus
 In infants, the arches of the foot (though present) are not so obvious; this is owing
to the presence of abundant fat pads in the foot.
Subtalar Joint
The subtalar joint

 Is a modified multi-axial joint
 Is formed between the convex posterior facet on the superior surface of the
calcaneus and the concave posterior facet on the inferior surface of the talus;
thus, it lies beneath the talus (hence the name)
 Allows the movements of inversion and eversion.
The fibrous capsule of subtalar joint

 Consists of short fibres that envelop the joint
 Is attached above to the articular margin of the talus and below to the articular
margin of the calcaneus
 Is lined internally by synovial membrane. This separates the cavity of subtalar
joint from those of the neighbouring joints
 Is strengthened by associated ligaments.
Ligaments of subtalar joint include:

 Lateral talocalcaneal ligament, which strengthens the fibrous capsule laterally.
This ligament stretches from the lateral surface of the talus to that of the
calcaneus
 Medial talocalcaneal ligament, which strengthens the fibrous capsule medially. It
stretches from the medial surface of the talus to the sustentaculum tali of the
calcaneus
 Interosseous talocalcaneal ligament, which stretches between the sulcus tali and
sulcus calcanei. It strengthens the fibrous capsule anteromedially and becomes
taut on eversion
 Cervical ligament, which stretches from the neck of the talus to the calcaneus. It
strengthens the fibrous capsule anterolaterally and becomes taut on inversion.
Movements of the Subtalar Joint
Note the following:

 Inversion and eversion are the two main movements that occur at the subtalar
joint
 In inversion, the foot rotates inwards at the subtalar joint, so that the sole turns
medially
 In eversion, the foot rotates outwards (though to a very limited extent) at the
subtalar joint, so that the sole tends to turn laterally; thus, eversion occurs less
freely compared to inversion.
Applied Anatomy

 In talipes equinovarus (club foot), the subtalar joint is congenitally twisted so
that the foot adopts an abnormally inverted and plantarflexed position
 Talipes makes walking extremely difficult as the dorsum of the foot (instead of
the sole) makes contact with the ground
 In talipes, the ligaments, tendons and muscles of the sole of the foot and posterior
aspect of the ankle are abnormally short, and thus tight
 Club foot occurs more frequently (twice) in males than in females.
Dorsum of the Foot

The dorsum of the foot contains the dorsalis pedis artery, branches of the deep
fibular nerve and extensor digitorum brevis. The deep fascia over these structures is
thin and it separates them from the dorsal venous arch and the venous network
located in the subcutaneous tissue.
Anterior tibial artery
Dorsalis pedis artery
Fig. 122. Artery, nerve and muscles of the dorsum of the foot
Dorsalis Pedis Artery
The dorsalis pedis artery

 Is the direct continuation of the anterior tibial artery (Fig. 122).
 Begins at the anterior aspect of the ankle, midway between the two malleoli (Fig.
122). Then it enters the dorsum of the foot (distal to the inferior extensor
retinaculum), and runs distally to the proximal end of the 1st interosseous space
(where it terminates)
 Lies between the tendon of extensor hallucis longus medially and those of
extensor digitorum longus laterally, in the medial part of the dorsum of the foot
 Is crossed obliquely in the ankle, from lateral medially, by the tendon of extensor
hallucis longus
 Is also crossed obliquely in the dorsum of the foot, from lateral medially, by the
tendon of extensor hallucis brevis
 Terminates at the proximal end of the 1st interosseous space by dividing into deep
plantar and first dorsal metatarsal arteries
 Is accompanied on its lateral aspect by the medial terminal branch of the deep
fibular nerve (Fig. 122)
 May be replaced by an enlarged perforating branch of the peroneal artery
 Is readily felt on the dorsum of the foot, just lateral to the tendon of extensor
hallucis longus (with the foot slightly dorsiflexed).
Branches of dorsalis pedis artery include:

 Lateral and medial tarsal arteries
 Arcuate artery
 First dorsal metatarsal; and
 Deep plantar arteries
The lateral tarsal artery

 Arises from the dorsalis pedis artery as this vessel crosses the navicular bone
 Passes laterally, on the dorsum of the foot, beneath the extensor digitorum brevis
 Supplies extensor digitorum brevis and adjacent tarsal bones
 Anastomoses with the arcuate, lateral plantar and perforating branch of peroneal
arteries.
The medial tarsal arteries

 Are about three vessels. They arise from the dorsalis pedis artery as it crosses the
navicular bone
 Pass towards the medial aspect of the foot, where they contribute to the medial
malleolar network.
The arcuate artery

 Arises from the dorsalis pedis artery just distal to the origin of tarsal arteries
 Describes an arched course as it turns laterally (from its origin) over the bases of
the lateral four metatarsals; and deep to the tendons of the long and short digital
extensors
 Is the source of the 2nd–4th dorsal metatarsal arteries. These pass distally, in the
interosseous spaces between the 2nd–5th metatarsals
 Anastomoses with the lateral tarsal artery
The first dorsal metatarsal artery

 Arises from dorsalis pedis artery at the proximal end of the first interosseous
space; and runs distally on the first dorsal interosseous muscle
 Is the source of the dorsal digital arteries to the medial side of the big toe and
the contiguous sides of the big and second toes.
Note: The 2nd–4th dorsal metatarsal arteries (which arise from the arcuate artery)
pass distally on the dorsum of the foot, in their respective interosseous spaces. They
give off the dorsal digital arteries to the contiguous sides of the 2nd–5th digits and
the lateral side of the 5th toe.
The deep plantar artery

 Arises from the dorsalis pedis artery at the proximal end of the 1st
interosseous space
 Enters the sole of the foot by passing deeply between the two heads of the 1 st
dorsal interosseous muscle. In the sole, it joins the plantar arch
 May be described as the direct continuation of dorsalis pedis artery
Applied Anatomy

 The pulse of dorsalis pedis artery can be taken on the dorsum of the foot, just
lateral to the tendon of extensor hallucis longus (with the foot slightly
dorsiflexed)
 Dorsalis pedis pulse may however be absent or diminished; and this may suggest
occlusive arterial diseases
 Dorsalis pedis pulse is also absent when dorsalis pedis artery is replaced by an
enlarged perforating branch of the peroneal artery.
Extensor Digitorum Brevis
Note the following:

 The extensor digitorum brevis is a small muscle located on the dorsum of the
foot, just anterior to the lateral malleolus (Fig. 122). It arises from the anterior
part of the superolateral aspect of the calcaneus; and then passes distomedially
towards the medial four toes
 On the dorsum of the foot, four tendinous slips arise from extensor digitorum
brevis. The most medial belly and tendon of extensor digitorum brevis is referred
to as extensor hallucis brevis
 The tendon of extensor hallucis brevis crosses the dorsalis pedis artery
superficially as it passes towards its distal (hallucial) attachment
 The remaining three tendons of extensor digitorum brevis joins the lateral sides of
the three middle toes (2nd – 4th toes)
 Anterior part of the superolateral surface of the calcaneus
 Stem of the inferior extensor retinaculum and the interosseous talocalcaneal
ligament
Distal attachment: Bases of the middle and distal phalanges of the 2nd–4th toes (via
the extensor expansion)
Innervation: Lateral terminal branch of deep fibular nerve

Actions: The muscle extends the metatarsophalangeal and interphalangeal joints

of the middle three toes (via the extensor expansion).
The extensor hallucis brevis

 Is derived from the most medial tendon and belly of extensor digitorum brevis
(Fig. 122)
 Passes distomedially towards the big toe, crossing the dorsalis pedis artery
superficially as it does so
 Is attached distally to the dorsal aspect of the base of the proximal phalanx of the
big toe
Proximal attachment: As described for extensor digitorum longus
Distal attachment: Dorsal aspect of the base of the proximal phalanx of the big toe
Innervation: Deep fibular nerve (lateral terminal branch)
Action: The muscle extends the metatarsophalangeal joint of the big toe (hallux)
Sole of the Foot
The skin of the sole of the foot

 Is exposed to stress, abrasions and wears. Thus, it is characteristically thick (and
may be up to 6 mm in thickness)
 Is more sensitive and also thicker than the skin of the dorsum of the foot
 Is innervated by the medial calcaneal nerve in its posterior part (the heel) and by
the lateral and medial plantar nerves in its anterior part
 Is connected to the deep fascia by fibrous strands that traverse the subcutaneous
tissue of the sole. These make it firm
 Contains numerous sweat glands but lacks hair.
The superficial fascia of the sole

 Is relatively thick and dense, especially over the heel and the ball of the foot
 Contains fatty tissue which is divided up into small masses by dense fascial septa
 Is characteristically firm and resilient, thereby serving as a cushion.
The deep fascia of the sole

 Is much more thicker than that of the dorsum of the foot
 Is relatively thin at the lateral and medial aspects of the sole but very thick
centrally, where it forms the longitudinal plantar aponeurosis (Fig. 123)
 Sends fibrous medial and lateral septa into the sole, from the medial and lateral
margins of the plantar aponeurosis, respectively
 Is pierced by cutaneous rami of the medial and lateral plantar nerves and
vessels. These supply the skin and subcutaneous tissue of the sole.
Plantar Aponeurosis
The plantar aponeurosis

 Is the extremely thick central part of the deep fascia of the sole (Fig. 123). It
stretches longitudinally from the heel to the toes, superficial to flexor digitorum
brevis
 Is attached proximally to calcaneal tuberosity. Distally, it splits into five slips,
which join the fibrous flexor sheaths on the plantar aspect of the toes
 Merges at its medial and lateral margins with the relatively thin part of the deep
fascia that overlies the intrinsic muscles of the hallux and little toes, respectively
 Strengthens and maintains the longitudinal arches of the foot; and protects the
plantar structures located deep to it.
Figure 123. The plantar aponeurosis.

Muscle, Nerves and Vessels of the Foot

Deep to the deep fascia of the foot are several muscles, nerves and blood vessels.
These structures are organized in layers (six layers).
Layers of the Sole of the Foot
Structures in the sole are arranged in six layers; these include, from superficial
deeply:
 First layer: abductor hallucis, abductor digiti minimi, flexor digitorum brevis and
plantar digital nerves and vessels
 Second layer: medial and lateral plantar nerves and vessels
 Third layer: tendons of tibialis posterior, flexor digitorum longus, flexor hallucis
longus, lumbricals and flexor accessorius
 Fourth layer: adductor hallucis, flexor hallucis brevis and flexor digiti minimi
brevis
 Fifth layer: deep branches of lateral plantar nerve and artery
 Sixth layer: interosseous muscles and tendon of fibularis longus.
First Layer of the Sole

This contains mainly muscles that include flexor digitorum brevis, abductor hallucis,
and abductor digiti minimi; as well as plantar digital nerves and vessels.
The flexor digitorum brevis

 Is located immediately deep to the plantar aponeurosis (Fig. 123). It stretches
from the calcaneus proximally to the lateral four toes distally
 Divides distally into four tendons; these pass into the lateral four toes
 Flexes the lateral four toes at the metatarsophalangeal and proximal
interphalangeal joints.
Proximal attachment: Medial process of calcaneal tuberosity.
Distal attachment: Middle phalanges of the lateral four toes (sides of the shaft of
these phalanges).
Innervation: Medial plantar nerve.
Action: Flexes the proximal and middle phalanges of the lateral four toes (at the
metatarsophalangeal and proximal interphalangeal joints)
The abductor hallucis

 Is the abductor of the big toe (hallux)
 Is located along the medial border of the sole, medial to flexor digitorum brevis
and just deep to the deep fascia.
 Flexor retinaculum and plantar aponeurosis

 Medial process of calcaneal tuberosity
Distal attachment: Medial aspect of the base of the proximal phalanx of the big toe
Innervation: Medial plantar nerve
Action:
 Abducts the big toe (thereby preventing its lateral deviation, a condition that
occurs in hallux valgus)
 Also flexes the big toe.
Abductor digiti minimi

 Is the abductor of the little toe
 Is located on the lateral margin of the sole, lateral to flexor digitorum brevis and
the lateral plantar nerve and vessels.
Proximal attachment: Medial and lateral processes of calcaneal tuberosity and the
plantar aponeurosis
Distal attachment: Lateral aspect of the proximal phalanx of the little toe
Innervation: Lateral planter nerve
Action: Abducts the little toe (i.e. pulls it laterally)
Arteries and Nerves of the First Layer of the Sole

Arteries and nerves of the first layer of the sole of the foot include plantar digital
nerves and vessels.
The plantar digital nerves

 Arise from the medial and lateral plantar nerves; and they appear in the distal
part of the first layer of the sole
 Innervate the skin of the sole of the foot, plantar surfaces of the toes, and the
distal part of the dorsum of the toes.
Plantar digital nerves include:

 A proper plantar digital nerve to the lateral side of the little toe. This is a branch
of the lateral plantar nerve
 A proper plantar digital nerve to the medial side of the big toe. This arises from
the medial plantar nerve
 Three common plantar digital nerves to the contiguous sides of the 1st, 2nd, 3rd
and 4th toes. These arise from the medial plantar nerve
 A common plantar digital nerve, to the adjacent sides of the 4th and 5th toes. It is
derived from the lateral plantar nerve.
Plantar digital arteries

 Accompany the corresponding plantar digital nerves
 Arise from the plantar arch. The latter is located at a deeper layer, but it appears
in the first layer of the foot distally.
The plantar digital arteries include:

 A proper plantar digital artery, to the medial side of the big toe; it arises from
the first plantar metatarsal artery
 A proper plantar digital artery to the lateral side of the little toe; it arises from
the plantar arch
 Four common plantar digital arteries, derived from the plantar metatarsal
arteries. They supply the contiguous sides of the toes via the proper plantar
digital arteries (which arise from them).
Second Layer of the Foot

This layer of the foot contains the lateral and medial plantar nerves and vessels.
The medial plantar nerve

 Is the larger of the two terminal branches of the tibial nerve. It arises from the
latter, deep to the flexor retinaculum
 Enters the sole of the foot deep to abductor hallucis. Then, it emerges between
abductor hallucis medially and flexor digitorum brevis laterally, and passes
distally towards the toes, in this position (Fig. 124). Ii is accompanied, on its
medial side, by the medial plantar artery
 Divides, near the bases of the metatarsals, into one proper and three common
plantar digital nerves; these innervate the medial side of the big toe and
adjacent sides of the 1st – 4th toes, respectively
 Also innervates abductor hallucis, flexor hallucis brevis, flexor digitorum brevis
and the 1st lumbrical muscle
 Gives sensory rami to the skin of the medial aspect of the anterior part of the sole.
The lateral plantar nerve

 Is the smaller of the two terminal branches of tibial nerve. It arises from the
latter, deep to the flexor retinaculum
 Runs anterolaterally in the sole, between flexor digitorum brevis superficially and
flexor accessorius deeply (Fig. 124)
 Divides distally, between flexor digitorum brevis and abductor digiti minimi, into
superficial and deep branches
 Gives rise to a common plantar digital nerve to the contiguous sides of the 4th
and 5th toes, and a proper plantar digital nerve to the lateral side of the 5th toe.
Both branches arise from its superficial branch.
 Gives motor rami to the 2nd–4th lumbricals, adductor hallucis and the interossei
(except the 4th), via its deep branch. The latter accompanies the plantar arch in
the deeper part of the sole
 Also innervates abductor digiti minimi and flexor accessorius via branches that
arise from its trunk
 Gives sensory rami to the skin of the lateral aspect of the anterior part of the sole
 Is accompanied on its lateral aspect by the lateral plantar artery
The medial plantar artery

 Is the smaller of the two terminal branches of the posterior tibial artery (Fig.
124). It arises from the latter, deep to the flexor retinaculum
 Enters the sole initially deep to abductor hallucis. Then, it continues distally in
the sole, between abductor hallucis medially and flexor digitorum brevis laterally.
It is accompanied on its lateral side by the medial plantar nerve
 Terminates distally on the medial aspect of the big toe by anastomosing with the
medial proper plantar digital branch of the 1st plantar metatarsal artery
 Supplies the intrinsic muscles and other structures on the medial aspect of the
sole
 May give rise to small branches that join the plantar metatarsal arteries
Figure 124. Arteries and nerves of the sole of the foot.
The lateral plantar artery

Regarding the lateral plantar artery, note that:

 It is the larger of the two terminal branches of the posterior tibial artery (Fig.
124). It arises from the latter deep to the flexor retinaculum
 It passes anterolaterally in the sole of the foot, first deep to abductor hallucis;
then, it continues towards the base of the 5th metatarsal, between flexor
accessorius deeply and flexor digitorum brevis superficially
 As it approaches the base of the 5th metatarsal (deep to the deep fascia), it lies
between abductor digiti minimi laterally and flexor digitorum brevis medially.
Finally, it turns medially and continues across the bases of the metatarsal
 In the 1st interosseous space (medial part of the sole), it terminates by joining the
deep plantar branch of dorsalis pedis artery, to form the plantar arch
 It is initially accompanied on its medial aspect by the lateral plantar nerve, and
later by the deep branch of the same nerve (as the artery turns medially to form
the plantar arch)
 Supplies muscles and other structures on the lateral aspect of the sole of the foot
Plantar Arch
The plantar arch

 Is formed by the union of the lateral plantar artery and the deep plantar branch
of dorsalis pedis artery
 Is located at a deep plane, where it lies across the bases of the metatarsals. It
terminates medially in the 1st interosseous space
 Has a convexity which faces distally and from which the plantar metatarsal
arteries arise
 Is related below (superficially) to the oblique head of adductor hallucis and above
to the interossei and metatarsals

 Three perforating arteries arise from the plantar arch; they ascend through the
2nd, 3rd and 4th intermetatarsal spaces, to join the dorsal metatarsal arteries.
Besides, the plantar arch gives rise to four plantar metatarsal arteries
 A plantar metatarsal artery runs distally on the plantar aspect of the
interosseous muscle of its own space, towards the interdigital cleft
 In its distal part, each plantar metatarsal artery is joined to a dorsal metatarsal
artery by a distal perforating branch (which arises from it)
 In the interdigital cleft, two proper plantar digital arteries arise from each
plantar metatarsal artery; they supply the adjoining sides of two digits
 The proper plantar digital artery to the lateral side of the little toe arises
directly from the lateral end of the plantar arch
 The proper plantar digital artery to the medial side of the big toe arises from
the 1st plantar metatarsal artery.
Applied Anatomy
Note: Owing to the depth of the plantar arch (in the 5th layer of the sole), bleeding
from this arch is difficult to arrest in the foot.
Third Layer of the Sole
This layer contains:

 Tendon of tibialis posterior and those of flexors hallucis longus and digitorum
longus
 Flexor accessorius (quadratus plantae) and the lumbricals (which are associated
with the tendons of flexor digitorum longus).
The flexor accessorius

 Has two heads of origin; and is attached distally to the tendons of flexor
digitorum longus
 Assists in bringing the pull of flexor digitorum longus into alignment with the
toes, so that the toes do not deviate sideway when flexed
 May be absent.
 Medial head: Medial margin of the plantar surface of calcaneus
 Lateral head: Lateral margin of the plantar surface of calcaneus
Distal attachment: tendons of flexor digitorum longus (especially those to the 2nd, 3rd
and 4th toes).
Innervation: Lateral plantar nerve
Action:
 Brings the pull of flexor digitorum longus in line with the toes
 Also flexes the toes.
Lumbricals
The lumbricals
 Are small worm-like muscles associated with the tendons of flexor digitorum
longus (from which they arise)
 Are four in number, identified as 1st, 2nd, 3rd, and 4th lumbricals, from medial
laterally
 Cross the metatarsophalangeal, proximal and distal interphalangeal joints of the
lateral four toes (where they are attached to the extensor expansion). Thus they
could act on these joints.
 1st lumbrical: Medial side of the tendon of flexor digitorum longus to the 2nd toe
 2nd – 4th lumbricals: Adjacent sides of the tendons of flexor digitorum longus
Distal attachment:
 Medial side of the extensor expansion of each of the lateral four toes; and
 Medial side of the base of the proximal phalanx of each of the lateral four toes.
Innervation:
 1st lumbrical: Medial plantar nerve
 2nd – 4th lumbricals: Deep branch of lateral plantar nerve.
Actions
Each lumbrical
 Flexes the proximal phalanx of its own toe at the metatarsophalangeal joint
 Extends the middle and distal phalanges of its own toe at the proximal and distal
interphalangeal joints
Applied Anatomy
Note that:
 Weakness or paralysis of the lumbrical (coupled with paralysis of the
interosseous muscle of the same toe) would produce hammer toe
 Paralysis of all lumbricals (and associated interosseous muscles) would produce
claw toes. This is because the interphalangeal joints of the lateral four toes cannot
be extended by the lumbricals and interossei following full extension of the
metatarsophalangeal joints by extensor digitorum longus.
Fourth Layer of the Sole

The 4th layer of the sole of the foot contains flexor hallucis brevis, adductor hallucis
and flexor digiti minimi brevis.
The flexor hallucis brevis

 Is located in the sole, deep to the tendon of flexor hallucis longus, and between
(but deep to) abductor hallucis medially and flexor digitorum brevis laterally
 Arises and inserts by two tendinous slips
 Contains two sesamond bones. These are located at the point where the two
tendons of insertion of this muscle pass distally over the head of the 1st
metatarsal. The tendon of flexor hallucis longus passes to the hallux between
these sesamond bones
 Is joined, near its insertion, by abductor hallucis and adductor hallucis (on its
medial and lateral aspects, respectively).
 Medial head:
o Medial intermuscular septum; and
o Tendon of tibialis posterior
 Lateral head:
o Plantar surface of cuboid
o Medial, lateral and plantar surfaces of lateral cuneiform
Distal attachment: Sides of the base of the proximal phalanx of the big toe (via two
tendons – medial and lateral tendons).
Innervation: Medial plantar nerve.
Action: Flexes the proximal phalanx of the big toe at the metatarsophalangeal joint.
The adductor hallucis

 Arises by two heads – oblique and transverse
 Is located deep to the lumbricals, lateral to flexor hallucis brevis and below the
interossei
 Joins, at its insertion, the lateral tendon of insertion of flexor hallucis brevis.
 Oblique head:
o Bases of the 2nd – 4th metatarsals
o Fibrous sheath around the tendon of fibularis longus.
 Transverse head:
o Transverse metatarsophalangeal ligaments (of the 3rd–5th
metatarsophalangeal joints)
o Deep transverse metatarsal ligament.
Distal attachment: Lateral side of the base of the proximal phalanx of the big toe.
Innervation: Deep branch of lateral plantar nerve.
Action:
 Adducts the great toe (i.e. pulls it towards the 2nd toe)
 Also flexes the great toe.
Flexor digiti minimi brevis

 Is the short flexor of the little toe
 Joins, near it insertion, the tendon of abductor digiti minimi
 Plantar surface of the base of the 5th metatarsal
 Fibrous sheath around the tendon of fibularis longus
Distal attachment: Lateral side of the base of the proximal phalanx of the little toe
Innervation: Superficial branch of lateral plantar nerve
Action: Flexes the little toe (at the metatarsophalangeal joint).
Fifth Layer of the Sole

The 5th layer of the sole of the foot contains the deep branches of the lateral plantar
nerve and artery.
Deep branch of the lateral plantar nerve

 Accompanies the lateral plantar artery as this artery turns medially, across the
bases of the metatarsal bones, deep to the tendons of flexor digitorum longus
 Innervates the 2nd, 3rd and 4th lumbricals, and adductor hallucis
 Also innervates all interosseous muscles except those of the 4th interosseous
space
Note: The deep branch of the lateral plantar artery, the plantar arch, and their
branches have been described with the 2nd layer.
Sixth Layer of the Sole

The 6th layer of the sole of the foot contains the plantar and dorsal interossei and the
tendon of fibularis longus (peroneus longus). The latter passes obliquely
(distomedially) across the sixth layer of the sole, to the medial cuneiform and the base
of the 1st metatarsal, to which it attaches.
The dorsal interosseous muscles

 Are four short bipennate muscles located between the metatarsal bones; they are
numbered as 1st, 2nd, 3rd and 4th dorsal interossei, from medial laterally
 Arise from the adjacent sides of the metatarsal bones (hence the name). Each
possesses two heads of origin; and a perforating branch of the plantar arch passes
between these heads
 Are innervated by the deep branch of lateral plantar nerve, except the 4th, which
is innervated by the superficial branch of this nerve.

 The deep plantar artery enters the sole (from the dorsum of the foot) between
the two heads of the 1st dorsal interosseous
 The 1st dorsal interosseous muscle inserts onto the medial side of the proximal
phalanx of the 2nd toe and to the extensor expansion of this toe
 The 2nd, 3rd and 4th dorsal interosseous muscles insert onto the lateral sides of
the bases of the proximal phalanges of the lateral three toes and their extensor
expansions
 The deep branch of the lateral plantar nerve innervates the dorsal interossei,
except the 4th dorsal interosseous, which is innervated by the superficial branch
of this nerve
 Each dorsal interosseous flexes the metatarsophalangeal and extends the
interphalangeal joints of its own toe. Besides, each muscle also abducts its own
toe (i.e. pulls it away from the long axis of the 2nd toe).
Plantar Interossei
Regarding plantar interossei, note the following facts:

 These are three short muscles located beneath the 3rd, 4th and 5th metatarsal bones;
and they are named as 1st, 2nd and 3rd plantar interossei, from medial laterally
 Each arises from the base and medial aspect of one of the lateral three
metatarsals; and it inserts onto the medial side of one of the lateral three toes and
its extensor expansion
 They flex the metatarsophalangeal and extend the interphalangeal joints of the
lateral three toes; they also adduct the lateral three toes (i.e. pull them towards
the 2nd toe)
 They receive motor fibres from the deep branch of the lateral plantar nerve,
except the 3rd plantar interosseous, which is innervated by the superficial branch
of this nerve.
Applied Anatomy
Note these points:

 Paralysis of the dorsal interosseous muscle of a particular toe will produce
hammer toe
 Injury to the lateral plantar nerve will produce claw toes; this is owing to the
paralysis of the interossei.
Note: Inability to extend the interphalangeal joints (a function of the interossei and
lumbricals) when the metatarsophalangeal joints are fully extended (by extensor
digitorum longus) causes the toes to deviate downwards (from the pull of flexor
digitorum longus). This condition is referred to as claw toes (or hammer toe).
CHAPTER 21: HEAD AND NECK
Skull and Mandible
Skull
Regarding the skull, note these points:

 The skull is the skeleton of the head; its shape is a modified ovoid-ellipsoid (with
its greatest width nearer the occipital pole)
 The skull consists of 8 cranial bones (neurocranium) and 14 facial bones
(viscerocranium).
 The 8 cranial bones include: 1 frontal, 2 parietal, 2 temporal, 1 occipital, 1
sphenoid and 1 ethmoid.
 The 14 facial bones include: 2 maxillae, 2 palatine, 2 zygomatic, 2 lacrimal, 2
nasal, 2 inferior nasal conchae, 1 vomer, and 1 mandible
Anterior Aspect of the Skull (Fig. 125)
Note that
 The anterior aspect of the skull is made up of the frontal and zygomatic bones,
orbits, nasal region and maxillae
 The frontal bone forms the skeleton of the forehead
 The glabella is the median elevation between the superciliary arches
 A superciliary arch extends laterally, on each side, from the glabella
 Below the superciliary arch is the supraorbital margin (arch) that has a
supraorbital notch (or foramen) for the passage of supraorbital nerve and artery
 The junction of the internasal and frontonasal sutures is the nasion
 Associated with the orbits are the superior and inferior orbital fissures; these
link the orbit with the middle cranial and pterygopalatine fossae respectively. An
optic canal lies at the apex of each orbit
 The zygomatic bone lies on the inferolateral side of the orbit; it forms much of
the infraorbital margin of the latter
 A small zygomaticofacial foramen pierces the lateral aspect of each zygomatic
bone; this transmits the zygomaticofacial nerve
 Inferior to the nasal bones are piriform apertures termed anterior nasal apertures
 The maxillae form the upper jaw; their alveolar processes bear the sockets
(alveoli), which lodge the maxillary teeth
 The maxilla has an infraorbital foramen located inferior to the orbit (for the
infraorbital nerve and vessel) (Fig. 125)
 The two maxillae are united at the intermaxillary suture
Figure 125. Frontal view of the skull.
Lateral Aspect of the Skull (Fig. 126)
On the lateral aspect of the skull, note that

 The temporal fossa is delineated by the zygomatic arch, temporal line,
frontozygomatic process and supramastoid crest
 The pterion is an H-shaped sutural zone where the frontal, parietal, sphenoidal
(greater wing) and temporal bones meet; it is a surgical landmark located 4 cm
above the zygomatic arch and 3.5 cm behind the frontozygomatic suture
 The zygomatic arch (formed by the temporal and zygomatic processes) is
palpable and visible where the check and temple meet
 The gap between the arch and the temple is deeper anteriorly; here, the arch is
crossed obliquely downwards and backwards by the zygomaticotemporal suture
 The external acoustic opening is the entrance to the external acoustic meatus
(which leads to the tympanic membrane).
 The zygomatic process of the temporal bone widens as it approaches the squama.
It divides into an anterior and a posterior root
 The mastoid process of the temporal bone is posteroinferior to the opening of the
external acoustic meatus
 The mastoid foramen is close to or in the occipitomastoid suture; it transmits an

emissary vein from the sigmoid sinus
 The styloid process of temporal bone is a slender bony spike attached to the base
of the skull, anteromedial to the mastoid process; it ranges in length from a few
millimeters to a few centimeters, and is often approximately straight, but could be
curved (a ventromedial concavity is more common)
 The infratemporal fossa is an irregular space located inferior and deep to the
zygomatic arch, behind the maxilla. Its anterior and medial walls are separated
above by the pterygomaxillary fissure
 The pterygopalatine fossa is a small pyramidal space below the orbital apex; it
communicates with the infratemporal fossa via the pterygomaxillary fissure
Posterior Aspect of the Skull
Concerning the posterior aspect of the skull, note the following facts:
 The posterior aspect of the skull (occiput) is ovoid or round in outline
 The occiput is formed by the occipital bone, parts of the parietal bones and
mastoid parts of temporal bones
 The main feature of the occiput is the external occipital protuberance (inion);
this elevation is readily palpable in the median plane (especially in males)
 The superior nuchal line extends laterally from each side of the inion; it marks
the superior limit of the neck. The inferior nuchal line is less distinct
 In the centre of the occiput, the lambda indicates the junction of the sagittal and
lambdoid sutures
Superior Aspect of the Skull
On the superior aspect of the skull, note that

 The coronal suture separates the frontal and parietal bones
 The sagittal suture is the median junction between the parietal bones; it extends
from the lambda behind to the bregma in front
 The lambdoid suture joins the posterior borders of the parietal bones to the
superior margin of the occipital bone
 The coronal and sagittal sutures meet at the bregma. This represents the position
of the diamond-shaped membranous anterior fontanelle of the foetus. The latter
persists until about 18 months after birth
 The lambda is at the junction of the sagittal and lambdoid sutures. It is the site of
the posterior fontanelle (which usually closes earlier than the anterior
fontanelle)
 A parietal foramen pierces each parietal bone near the sagittal suture, about 3.5
cm anterior to the lambda. It transmits a small emissary vein from the superior
sagittal sinus (and may be absent)
 The vertex – the most superior point of the skull – is near the midpoint of the
sagittal suture
Figure 126. Lateral view of the skull.
External Aspect of Cranial Base (Fig. 127)
Note these facts:

 The hard palate is formed by the palatine processes of the maxillae anteriorly,
and the horizontal plates of palatine bones posteriorly
 Posterior to the central incisor teeth is a depression, the incisive fossa, which
transmits the nasopalatine nerves
 The sphenoid bone is an irregular unpaired bone that consists of a body and three
pairs of processes: greater wings, lesser wings and pterygoid processes. The last
consist of lateral and medial pterygoid plates
 The groove for the cartilaginous part of the auditory tube lies medial to the spine
of sphenoid
 The mandibular fossae (depressions in the temporal bones) accommodate the
condyles of the mandible when the mouth is closed
 The major structures that pass through the foramen magnum are the spinal cord
and its coverings, vertebral arteries, anterior and posterior spinal arteries and the
spinal root of accessory nerve
 The occipital condyles articulate with the superior articular facets of the atlas at
the atlanto-occipital joints
 The large opening between the occipital bone and the petrous part of temporal
bone is the jugular foramen, from which the internal jugular vein and some
cranial nerves (CN IX-XI) emerge
 The stylomastoid foramen transmits the facial nerve and stylomastoid artery; it
lies behind the base of the styloid process
 The posterior part of cranial base is formed by the occipital bone
Figure 127. Basal surface of the skull
Internal Aspect of Cranial Base (Fig. 128)
The internal aspect of cranial base

 Appears irregular, partly owing to the impressions created by cerebral gyri; these
impressions are more prominent in the anterior and middle cranial fossae
 Is lined by the dura mater, which is firmly attached to the bones. The endosteal
layer of this meninx is continuous with the pericranium at the foramina
 Is arranged into three fossae; these include the anterior, middle and posterior
cranial fossae, from anterior posteriorly
Anterior Cranial Fossa (Fig. 128)
The anterior cranial fossa

 Is the shallowest and most anterior of the cranial fossae
 Is roughened by impressions created by the frontal lobes of the cerebral

hemispheres
Regarding the boundaries of the anterior cranial fossa,

 The walls are formed by the frontal bone
 The orbital part of the frontal bone form the anterior part of the floor of the
fossa; these plates form the larger part of the floor
 Behind, the floor of the fossa is completed on each side by the lesser wings of
sphenoid, and centrally by the jugum sphenoidale
 The cribriform plates of ethmoid form the middle part of the floor of the fossa.
These plates bear foramina that transmit fibres of the olfactory nerves. The
ethmoid articulates anteriorly with the frontal bone (at the fronto-ethmoidal
suture) and posteriorly with the jugum sphenoidale
Regarding the anterior cranial fossa, also note that

 Each cribriform plate of ethmoid separates the fossa from the nasal cavity below
 The foramina of the cribriform plate of ethmoid transmit fibres of the olfactory
nerve (which pass from the olfactory epithelium of the nasal cavity to the
olfactory bulb)
 In the midline (between the cribriform plates), the crista galli of the ethmoid
projects upwards between the two cerebral hemispheres; it gives attachment to
the falx cerebri
 Just anterior to the crista galli is a small pit termed the foramen caecum; in the
foetus, this pit is patent and it transmits a vein. It may also be patent in the adult;
when it does, it links the cranial and nasal cavities (and transmits a vein between
them)
 In front of the foramen caecum, the frontal bone presents a frontal crest which
projects backwards; this gives attachment to the falx cerebri
 On each side of the crista galli, a nasal slit links the anterior cranial fossa with
the nasal cavity; this slit transmits the anterior ethmoidal nerve and vessels to the
nasal cavity
The anterior cranial fossa contains:

 The lower part of the frontal lobes of the cerebral hemispheres and the associated
meninges; it therefore separates these vital structures from the orbital contents
and the nasal cavities
Middle Cranial Fossa (Fig. 128)
The middle cranial fossa

 Lies behind and below the anterior cranial fossa; it is deeper than the latter
 Is separated from the anterior cranial fossa laterally by the posterior margins of
the lesser wings of sphenoid, and centrally by the anterior margin of the sulcus
chiasmatis
 Is deeper laterally than centrally
 Supports the temporal lobes of the cerebral hemispheres
 Is related anteriorly to the orbit, laterally to the temporal fossa and below to the
infratemporal fossa
 Communicates with the orbit and infratemporal fossa via numerous foramina
Fig. 128. The cranial fossae
The middle cranial fossa has

 An anterior boundary formed by the posterior margin of the lesser sphenoidal
wings, anterior clinoid processes and anterior margin of sulcus chiasmatis
 A posterior boundary formed by the upper margins of the petrous part of the
temporal bones and dorsum sellae of the sphenoid
 A lateral wall formed (on each side) by the greater wing of sphenoid, squamous
part of temporal and frontal angle of parietal bones
 A floor formed on each side by the sphenoidal greater wing (in front), petrous
temporal bone (behind) and squamous temporal bone laterally. Centrally the floor
is formed by the body of sphenoid
In the middle cranial fossa, note that

 A transversely disposed sulcus chiasmatis lies anteriorly in the central part of the
floor. However, this sulcus is rarely in contact with the optic chiasma
 Opening into the lateral end of the sulcus chiasmatis, on each side, is the optic
canal; this canal links the fossa with the orbit, and transmits the optic nerve, its
meninges and the ophthalmic artery
 The upper surface of the body of the sphenoid presents a sella turcica (Turkish
saddle). This lies behind the sulcus chiasmatis
 The sella turcica is bounded anteriorly by the tuberculum sellae and posteriorly
by the dorsum sellae; these sellae are associated with the anterior and posterior
intercavernous sinuses respectively
 Located centrally between the tuberculum sellae in front and the dorsum sellae
behind is the hypophyseal fossa. This fossa lodges the hypophysis cerebri, and
beneath it lies the sphenoidal sinus. Thus,
 The tuberculum sellae separates the sulcus chiasmatis in front from the
hypophyseal fossa behind
 Each superolateral angle of the dorsum sellae is prolonged as a posterior clinoid
process; this process gives attachment to the tentorium cerebelli and
petrosphenoidal ligament
 A groove for the internal carotid artery lies on the body of sphenoid, lateral to the
sella turcica; this groove transmits the internal carotid artery

 The anterior surface of the petrous temporal bone presents a trigeminal
impression (near the apex of this bone). This impression lodges the trigeminal
ganglion
 Behind and lateral to the trigeminal impression, the anterior surface of petrous
temporal bone presents an arcuate eminence; this eminence is produced by the
superior semicircular canal of the internal ear (which is thus closely related to
the floor of the middle cranial fossa)
 Anterior and lateral to the arcuate eminence is the tegmen tympani (on the
anterior surface of petrous temporal bone); this plate of bone forms the roof of the
middle ear. It also extends anteriorly and posteriorly to cover the auditory tube
and mastoid antrum respectively
 Lateral to the trigeminal impression, the anterior surface of the petrous temporal
bone also presents the groove for the greater petrosal nerve. The nerve
descends towards the foramen lacerum
The foramina and fissure of the middle cranial fossa include:

 Superior orbital fissure, bounded above and below by the lesser and greater
wings of sphenoid respectively, and medially by the sphenoidal body; it links the
fossa with the orbit anteriorly, and transmits the terminal branches of the
ophthalmic and oculomotor nerves, trochlear and abducent nerves and the
ophthalmic veins
 Foramen rotundum, located in the sphenoidal greater wing (below and behind
the medial end of the superior orbital fissure). It opens anteriorly into the
pterygopalatine fossa, and transmits the maxillary nerve
 Foramen ovale, also located in the greater wing of sphenoid (behind and lateral
to the foramen rotundum). It opens below into the infratemporal fossa, and it
transmits the mandibular division of trigeminal nerve, accessory meningeal
artery, lesser petrosal nerve and emissary vein. Beneath it is the otic ganglion (in
the infratemporal fossa)
 Foramen spinosum, located in the sphenoidal greater wing, (posterolateral to
foramen ovale); it also opens into the infratemporal fossa, and it transmits the
middle meningeal vessels and the meningeal branch of mandibular nerve (nervus
spinosum)
 Foramen lacerum, a short bony canal located behind and lateral to the
hypophyseal fossa; in life, it is closed by a plate of cartilage and its posterior wall
is pierced by the internal carotid artery (which ascends above its cartilaginous
plate into the (cavernous sinus). No major structures pass vertically through this
foramen. Rather, it transmits small meningeal branches of the ascending
pharyngeal artery and small veins. In a dry specimen, the opening of this foramen
appears jagged
Note: The superior orbital fissure, foramen rotundum, foramen ovale and foramen
spinosum form a crescent of four foramina located lateral to the base of the
sphenoidal body, in the middle cranial fossa.
Posterior Cranial Fossa (Fig. 128)
The posterior cranial fossa

 Is the largest and deepest of the cranial fossae; it lies behind and below the
middle cranial fossa
 Accommodates the cerebellum in its posterior part, and the pons and medulla in
its anterior part
The posterior cranial fossa is bounded:

 In front by the dorsum sellae, posterior surface of sphenoidal body and basilar
part of occipital bone; this sloping surface forms the clivus (on which the medulla
and adjacent part of the pons lie)
 Behind by the lower part of squamous occipital bone
 On each side by the petrous and mastoid parts of temporal, mastoid angle of
parietal, and adjacent part of occipital bones
 Below – the floor – by basilar part of occipital bone in front, lateral part of the
occipital bone on each side, and lower part of occipital squama behind. In the
centre of the floor is the foramen magnum – a large opening.
Foramina and Features of the Posterior Cranial Fossa
Note the following:

 The foramen magnum lies in the floor of the posterior cranial fossa; this
foramen communicates with the vertebral canal below, and through it the medulla
becomes continuous with the spinal cord
 The jugular foramen lies at the posterior end of the petro-occipital fissure; this
foramen passes downwards, forwards and laterally to the cranial base. It contains
the sigmoid and inferior petrosal sinuses, internal jugular vein, and cranial nerves
IX, X and XI
 Above the jugular foramen (on the posterior surface of petrous temporal bone) is
the opening of the internal acoustic meatus
 Behind the opening of the internal acoustic meatus is the opening of the
aqueduct of the vestibule; this aqueduct contains the endolymphatic duct, a
small artery and a small vein
 Between the opening of the internal acoustic meatus and the aqueduct of the
vestibule is a small depressed area termed the subarcuate fossa. This fossa
accommodates a small dural process, and it is relatively large in the foetus
 At the junction of the basilar and lateral parts of occipital bone is the opening of
the hypoglossal canal; this canal transmits the hypoglossal nerve and a
meningeal branch of the ascending pharyngeal artery
 Behind and lateral to the opening of the hypoglossal canal is the opening of the
condylar canal; this canal, which may be absent, transmits an emissary vein
from the sigmoid sinus
 The mastoid temporal bone bears a wide groove termed the sigmoid sulcus; this
sulcus, which transmits the sigmoid sinus, ends below at the jugular foramen. It is
usually deeper on the right
 At its upper end, the sigmoid sulcus is continuous with the groove for the
transverse sinus
 Opening into the sigmoid sulcus, along its course, is the mastoid foramen; this
transmits an emissary vein (from the sigmoid sinus), and a meningeal branch of
occipital artery (which may groove the squamous occipital bone)
 The posterior wall of the posterior cranial fossa bears an internal occipital
protuberance; this corresponds to the external occipital protuberance (on the
external aspect of the skull), and is related to the confluence of the sinuses
 Passing downwards and forwards from the internal occipital protuberance to the
foramen magnum is the internal occipital crest; this crest gives attachment to
the falx cerebelli, and it may be grooved by the occipital sinus
 From the internal occipital protuberance, a shallow groove curves laterally to the
mastoid angle of parietal bone; this groove lodges the transverse sinus, and is
continuous at its lateral end with the sigmoid sulcus. Its margins gives attachment
to the tentorium cerebelli
 Below the groove for the transverse sinus, the internal occipital crest divides the
posterior part of the posterior cranial fossa into two hollow fossae (one on each
side); these lodge the cerebellar hemispheres
The Mandible
The mandible is the largest, strongest and lowest bone of the face. It has a curved
horizontal body and two broad vertical rami (Fig. 129).
Concerning the body of mandible, note that

 It is U-shaped in outline (Fig. 129)
 It has internal and external surfaces, separated by upper and lower borders
 Anteriorly, the upper part of the external surface bears a faint median ridge –
symphysis menti – that indicates the line of fusion of the two halves of the foetal
mandible. Inferiorly, this ridge divides to enclose a triangular mental
protuberance, the base of which is raised on each side as the mental tubercle
 On each side (on the external surface), below the 2nd premolar tooth (or below the
interval between the two premolar teeth) is the mental foramen (from which the
mental nerve and vessels emerge)
 A faint oblique line ascends backwards from each mental tubercle (on the
external surface of mandibular body)
 Internally, near the midline and below the anterior end of the mylohyoid line (on
each side), is a rough digastric fossa (for the anterior belly of digastric)
 The upper border (alveolar part) of mandibular body contains 16 alveoli for the
roots of the mandibular teeth
 The internal surface of mandibular body is also divided by an oblique mylohyoid
line (which is sharp and distinct near the molar teeth) into an anterosuperior
sublingual fossa (which lodges the sublingual gland) and a posteroinferior
submandibular fossa (which lodges the superficial part of submandibular gland)
 Above the anterior end of mylohyoid line is a small elevation, which bears the
mental spines or genial tubercles. The upper tubercle gives attachment to
genioglossus while the lower one gives attachment to geniohyoid
Figure 129. The mandible.

Regarding each ramus of the mandible, note the following:
 It is a sagittally-disposed plate of bone which unites with the mandibular body
almost at a right angle – the angle of the mandible (Fig. 129)
 Its external surface appears rough, for the attachment of masseter
 Its internal surface bears a mandibular foramen. This opens into the
mandibular canal and transmits the inferior alveolar nerve and vessels
 Passing downwards and forwards from the mandibular foramen is the mylohyoid
groove. This lodges the mylohyoid nerve and vessels
 Below and behind the mylohyoid groove, the medial aspect of mandibular ramus
(including the angle) is roughened, for the attachment of medial pterygoid
 Projecting upwards from the mandibular ramus, medial to mandibular foramen, is
a small piece of bone known as the lingula. This gives attachment to the
sphenomandibular ligament
 The upper end of mandibular ramus presents two processes – coronoid and
condylar processes. The depression between these processes is the mandibular
notch
 The coronoid process lies anterior to the condylar process. It gives attachment to
temporalis
 The condylar process has an expanded upper end known as the head of the
mandible. This bears a facet lined by fibrocartilage for articulation with the
mandibular fossa of temporal bone at the temporomandibular joint (TMJ). Just
below the head, the condylar process is constricted to form the neck of the
mandible
Ossification of the Mandible

 The mandible develops by intramembranous ossification (from a dense
fibromembranous tissue located lateral to the inferior alveolar nerve and
Meckel’s cartilage)
 Ossification commences in the mandible by the 6th week of development (from a
centre located near the mental foramen)
 The mandible is largely ossified by the end of the 1st year of life
Applied Anatomy of the Mandible
Note the following:

 Following a hard blow to the jaw, the mandible may be fractured. Fracture of
the mandible may involve the neck, body, and angle or coronoid process of this
bone. Fracture of mandibular neck may be bilateral, and this may result in
dislocation of temporomandibular joint
 Loss of mandibular teeth results in the resorption of mandibular alveolar
processes, such that the mental foramen lies close to the upper border of
mandibular body (or disappears, thereby exposing the mental nerve to injury)
Face and Scalp
Face
Concerning the face, note the following:

 It extends from the forehead above to the chin below, and from one auricle to the
other
 Its shape is determined by the underlying bones, facial musculature and buccal fat
pads
 Its muscles are contained in subcutaneous tissue and are largely attached to skin
and mucous membrane. These muscles are largely of neural crest origin
 Retinacula cutis are strands of connective tissue that connect facial skin to the
underlying bones
 Relatively rapid facial growth of the face occurs during infancy owing to the
development of the paranasal sinuses and the eruption of permanent teeth
 The face contains several skeletal muscles, nerve fibres blood and lymphatic
vessels
 It does not possess a distinct deep fascia and its superficial fascia is loose
Muscles of the Face
The muscles of the face

 Are skeletal muscles located in the subcutaneous tissue of the face, and around
the orbits, mouth and nose
 Are attached to bones, subcutaneous tissue and skin of the face
 Are essential for the adjustment of facial expression (as they pull on the skin of
the face)
 Also serve as sphincters and dilators for the buccal, nasal and orbital orifices
 Arise from the mesenchyme of the 2nd pharyngeal (hyoid) arch. Hence, they
 Are innervated by the facial nerve (nerve of the 2nd branchial arch)
Connective Tissue and Musculature of the Face
Regarding the connective tissue and musculature of the face, note that
 Owing to the looseness of facial subcutaneous tissues and the attachment of facial
muscle to skin, wounds of the face are prone to gaping
 Suturing of facial lacerations is necessary owing to the tendency of such
lacerations to gape (as a result of muscular pulls)
 In old age, wrinkles form on the face owing to loss of elasticity of facial skin
 Facial incisions are usually made along wrinkle lines (Langer’s lines) to
minimize scarring
 Swelling of the face occurs following inflammation, owing to the looseness of its
subcutaneous tissue
Muscles of the Forehead
Concerning the muscles of the forehead, not the following:

 The muscles of the forehead consist of paired frontales
 The frontales are the frontal bellies of occipitofrontalis
Each frontalis
 Is located in the subcutaneous tissue of the forehead (Fig. 130)
 Is quadrangular in outline and is larger than the occipitalis
 Has no bony attachments
 Is attached to the subcutaneous tissue of the forehead, especially that of the
eyebrow
 Joins the epicranial aponeurosis just anterior to the coronal sutures
 Blends with the opposite frontalis across the median plane
Proximal attachment: Epicranial aponeurosis
Distal attachment: Skin of the forehead and eyebrow
Innervation: Facial nerve (temporal branch)
Actions:
 Elevates the eyebrow and skin of the forehead (during expression of surprise or
fright)
 Wrinkles the skin of the forehead
Circumorbital Muscles
Included in the circumorbital muscles are:

 Orbicularis oculi, and
 Corrugator supercilii
The orbicularis oculi

 Is a broad elliptical muscle which surrounds the orbital opening and eyelids (Fig.
130)
 Has three parts, which include palpebral, orbital and lacrimal parts
 Assists in closing the eye and wrinkling the forehead vertically. Closure of the
palpebral fissure proceeds from lateral medially
Orbital part of orbicularis oculi

 Surrounds the margins of orbital opening as concentric ellipses
 Also spreads into the forehead, temple and cheek
 Appears reddish and thicker than the palpebral and lacrimal parts
 Has no lateral attachment to bones
 Blends with adjacent muscles
 Is innervated by temporal and zygomatic branches of facial nerve
 Nasal part of frontal bone
 Frontal process of maxilla
 Medial palpebral ligament
Distal attachment: The skin over the orbital margin
Actions:
 Closes the eyelids tightly
 Wrinkles the skin of the forehead vertically
Figure 130. Facial muscles.
Palpebral part of orbicularis oculi

 Is located in the upper and lower eyelids
 Appears pale and thin compared to the orbital part
 Forms the lateral palpebral raphe at the lateral commissure of the eyelids
 Is arranged to form a ciliary bundle along the free margin of each eyelid (behind
the eyelashes)
Proximal attachment: Medial palpebral ligament and adjacent bone
Distal attachment: Lateral palpebral raphe
Action: Closes the eyelids gently
Lacrimal part of Orbicularis Oculi
This relatively small part of orbicularis oculi

 Is located behind the lacrimal sac, from which it is separated by the lacrimal
fascia
 Extends into the eyelids, where it lies deep to the palpebral part of the muscle
 Extends laterally into the lateral palpebral raphe
 Is closely associated with the lacrimal canaliculi
 Lacrimal fascial
 Lacrimal crest (of lacrimal bone)
Distal attachment: Tarsal plates (of both eyelids)
Actions:
 Draws the eyelids and lacrimal puncta medially
 Pulls on the lacrimal fascia, and thus dilates the lacrimal sac, thereby aiding
drainage of tears
 Enhances the release of lacrimal secretion and the flow of tears across the cornea
 Aids the release of secretory products of the tarsal and ciliary glands of the
eyelids
Innervation of orbicularis oculi: Temporal and zygomatic branches of facial nerve
Corrugator supercilii
 Is a small pyramidal muscle located deep to frontalis and orbicularis oculi, at the
medial end of each eyebrow
 Blends with fibres of orbicularis oculi and frontalis
Proximal attachment: Medial end of the superciliary arch (bony attachment)
Distal attachment: Skin of the eyebrow

Actions:
Draws the eyebrow medially and thus produces vertical wrinkles in the supranasal
skin of the forehead
Is also involved in frowning and shielding of the eyes from excessive light
Innervation: Facial nerve (temporal branch)
Nasal Muscles
Muscles associated with the nose include:

 Procerus
 Nasalis, and
 Depressor septi
The procerus
 Is a small pyramidal muscle which overlies the bridge of the nose (as it descends
from the forehead to the dorsum of the nose)
 Blends partially with frontalis
Proximal attachment: Lower part of nasal bone and adjacent part of lateral nasal
cartilage (via an aponeurosis)
Distal attachment: Skin of the forehead (between the eyebrows)
Actions:
 Produces transverse ridges over the nasal bridge
 Assists in reducing the glare of bright sunlight and in frowning
Innervation: Facial nerve (superior buccal branches)
The nasalis
 Is the main muscle of the nose
 Consists of two parts: transverse and alar parts
The transverse part of nasalis

 Is also termed compressor naris
 Compresses the nostril
Proximal attachment: Upper end of the canine ridge of the maxilla

Distal attachment: Its fibres pass superomedially into an aponeurosis that joins it to
the opposite muscle (over the dorsum of the nose)
Action: Compresses the nose
The alar part of nasalis

 Is also termed dilator naris
 Assists in flaring the nostril
Proximal attachment: Maxilla, inferomedial to the origin of the transverse part
Distal attachment: Alar cartilages of the nose
Action: Widens the anterior nasal aperture (as it pulls the nasal ala laterally)
The depressor septi

 Is closely associated with the alar part of nasalis
Proximal attachment: Maxilla (above the central incisor tooth)
Distal attachment: Mobile part of nasal septum
Action: Widens the anterior nasal aperture (an action it performs in conjunction with
the alar part of nasalis)
Buccolabial Muscles (Fig. 130)
Muscles associated with the cheeks and lips are numerous. They include:
1. Levator labii superioris alaeque nasi
2. Levator labii superioris
3. Levator anguli oris
4. Zygomaticus major
5. Zygomaticus minor
6. Mentalis
7. Depressor labii inferioris
8. Depressor anguli oris
9. Buccinator
10. Orbicularis oris
11. Platysma, and
12. Risorius
Levator labii superioris alaeque nasi

 Has the outline of an inverted Y
 Is associated with the upper lip and ala of the nose (Fig. 130)
Proximal attachment: Frontal process of maxilla
Distal attachment:
 Greater alar cartilage of the nose (through a medial slip)
 Muscles and skin of the upper lip (through a lateral slip)
Actions:
 Elevates and everts the upper lip
 Dilates the nostrils
Innervation: Buccal branches of facial nerve
The levator labii superioris

 Is a muscle of the upper lip (Fig. 130)
 Lies superficial to levator anguli oris
Proximal attachment: Inferior orbital margin (just above the infraorbital foramen)
Distal attachment: Upper lip
Actions:
 Elevates and everts the upper lip
 Deepens the nasolabial sulcus
The levator anguli oris

 Is located deep to levator labii superioris (Fig. 130)
Proximal attachment: Maxilla (just below the infraorbital foramen)
Distal attachment: Angle of the mouth (buccal angle)
Actions:
 Raises the angle of the mouth
 Deepens the nasolabial furrow
Zygomaticus major
 Is located between risorius and levator labii superioris
Proximal attachment: Zygomatic bone (anterior to zygomaticotemporal suture)
Distal attachment: Angle of the mouth
Actions: Draws the angle of the mouth superolaterally (as occurs in smiling and
laughing)
Zygomaticus minor
 Is a muscle of the upper lip
 Lies between zygomaticus major and levator labii superioris
Proximal attachment: Zygomatic bone
Distal attachment: Upper lip
Innervation: facial nerve (buccal branches)
Actions:
 Raises the upper lip (as in the expression of contempt or disdain)
 Deepens the nasolabial sulcus (as in the expression of sadness)
Mentalis
 Is a small muscle of the lower lip
 Is located just adjacent to the median plane
Proximal attachment: Mandible (from the incisive fossa, below the incisor teeth)
Insertion: Mental skin (skin of the chin)
Innervation: facial nerve (marginal mandibular branch)
Actions:
 Raises and wrinkles the skin of the chin and the mentolabial sulcus
 Also raises and protrudes (everts) the lower lip (as in the expression of doubt or
disdain)
Depressor labii inferioris

 Is a quadrilateral muscle of the lower lip (Fig. 130)
 Is located lateral to mentalis
 Blends with orbicularis oris and contralateral depressor labii inferioris
Proximal attachment: Oblique line of the mandible (between symphysis menti and
mental foramen)
Distal attachment:
 Lower lip skin
 Orbicularis oris
Actions:
 Pulls the lower lip inferolaterally (as in the expression of irony and melancholy)
 May evert the lower lip
Depressor anguli oris

 Overlaps depressor labii inferioris, and
 Blends with platysma
Proximal attachment: Mental tubercle and oblique line of the mandible
Distal attachment: Angle of the mouth (at the modiolus)
Actions: Depresses the angle of the mouth laterally (as in the expression of sadness
and opening of the mouth)
The risorius
 Is a thin variable muscle which usually fuses with platysma
 Exhibits great variability
 Parotid, mastoid and masseteric fasciae
 Zygomatic arch and fascia of platysma
Distal attachment: Skin of the angle of the mouth
Action: Pulls the angle of the mouth laterally (as occurs in grinning)
The buccinator
 Is a thin, flat quadrilateral muscle that forms the substance of the cheek
 Lies anterior to the superior pharyngeal constrictor (from which it is separated by
the pterygomandibular raphe)
 Is covered by an anterior extension of buccopharyngeal fascia
 Is lined internally by the mucous membrane of the vestibule of the mouth
 Is overlapped behind by masseter (from which it is separated by the buccal pad of
fat)
 Blends with orbicularis oris at the angle of the mouth
 A linear attachment to the external aspects of the alveolar processes of the
maxilla and mandible, opposite the molar teeth
 Pterygomandibular raphe (which stretches from pterygoid hamulus above to the
posterior end of mylohyoid line of mandible below)
Distal attachment:
 Angle of the mouth
 Upper and lower lips
Actions:
 Active during mastication
 Used for forceful expulsion air from the mouth e.g. in whistling/ trumpeting
 Also assists in sucking
The pterygomandibular raphe

 Is a tendinous band that stretches from the pterygoid hamulus above to the
posterior end of mylohyoid line of mandible below
 Separates the superior constrictor of the pharynx behind from the buccinator in
front; it gives attachment to these muscles
 Is covered on its medial aspect by buccal mucous membrane; here, it is easily
palpable
 Is separated from the ramus of the mandible laterally by fatty tissue
Orbicularis oris
 Is the composite sphincter of the oral fissure
 Occupies both lips (as it encircles the oral fissure)
 Extends, in a vertical disposition, from the septum of the nose to a point midway
between the chin and the margin of lower lip
 Blends with most muscles of the lips, as well as with the buccinator
 Maxilla and mandible (near the lateral incisor teeth)
 Skin of the lips
Distal attachment: Mucous membrane of the lips
Actions:
 Serves as the sphincter of the oral fissure
 Is involved in mastication
 Purses the lips (as in whistling)
 Is active in phonation (speech)
Innervation: facial nerve (buccal and marginal mandibular branches)
The platysma
 Is a broad thin sheet of muscle located in the superficial fascia of the neck and
lower part of the face
 Interlaces with its fellow over the chin, and blends with the muscles of the face at
its upper end
 Passes over the clavicle below, and the mandible above, as it ascends from its
origin to its insertion
 Is variably developed and may even be absent
Proximal attachment: Superficial fascia and skin of the upper pectoral and deltoid
regions
Distal attachment:
 Lower border of the body of the mandible
 Angle of the mouth
 Upper and lower lips
Actions:
 Tenses and wrinkles the skin of the neck obliquely
 Tenses the skin of the lower face
 Depresses the mandible against resistance

 Depresses the lower lip and angle of the mouth (as in the expression of surprise
and horror)
Innervation: facial nerve (cervical branch)
Applied Anatomy

 Owing to the attachment of facial muscles to the skin and superficial fascia of the
face, gaping of facial wounds does occur. Thus,
 Suturing of facial lacerations is necessary to enhance healing
 Facial incisions are usually made along wrinkle (Langer’s) lines to minimize
scarring
 Paralysis of the ipsilateral facial muscles occurs following injury to the facial
nerve e.g. during surgery of the parotid gland
 Ulceration of the cornea, dribbling of saliva and food from the mouth,
smoothening of the face (on the affected side) and deviation of the angle of the
mouth (to the unaffected side) are observed in facial nerve palsy
Nerves of the Face
The face receives

 Sensory fibres from branches of trigeminal nerve (Vth cranial nerve); and
 Motor fibres from branches of facial nerve (VIIth cranial nerve)
Sensory Innervation of the Face
The face receives sensory fibres from the following nerves:

 Ophthalmic nerve, the 1st branch of trigeminal nerve
 Maxillary nerve, the 2nd branch of trigeminal nerve
 Mandibular nerve, the 3rd branch of trigeminal nerve
 Great auricular nerves (C2, 3), from the cervical plexuses
Branches of Ophthalmic Nerve to the Face
The ophthalmic nerves give sensory fibres to the face through the following direct
and indirect branches:
 Supratrochlear nerves
 Supraorbital nerves
 External nasal nerves

 Infratrochlear nerves, and
 Lacrimal nerves
The supratrochlear nerve

 Is the smaller of the two branches of the frontal nerve; the latter is the
continuation of the ophthalmic nerve
 Emerges between the trochlea of superior oblique and the supraorbital foramen,
to enter the face
 Is accompanied by the supratrochlear artery, a terminal branch of ophthalmic
artery
 Supplies the conjunctiva and skin of upper eyelid, as well as the skin of the
forehead (adjacent to the median plane)
 Lies medial to supraorbital nerve
The supraorbital nerve

 Is the larger of the two branches of the frontal nerve; the latter arises from
ophthalmic nerve
 Enters the face through the supraorbital foramen
 Gives sensory fibres to the upper eyelid, conjunctiva, and frontal sinus
 Also gives cutaneous branches to the forehead and scalp, as far posteriorly as the
vertex of the head
 Is accompanied by the supraorbital artery, a branch of ophthalmic artery
The external nasal nerve

 Arises from the anterior ethmoidal nerve (a branch of nasociliary nerve)
 Enters the face between the nasal bone and nasal cartilage
 Gives sensory branches to the dorsum, apex, ala and vestibule of the nose
The infratrochlear nerve

 Is a terminal branch of nasociliary nerve, given off near the anterior ethmoidal
foramen
 Enters the face below the trochlea of superior oblique
 Innervates the skin of the eyelids, and the bridge of the nose
 Also innervates the conjunctiva, lacrimal caruncle and lacrimal sac
The lacrimal nerve

 Is the smallest direct branch of ophthalmic nerve
 Enters the orbit through the superior orbital fissure and passes forwards, above
and parallel to the lateral rectus, to the superolateral part of orbital margin
 Is accompanied by the lacrimal artery, a branch of ophthalmic artery
 Gives sensory branches to the lateral part of the skin of upper eyelid and the
conjunctiva
 Also conveys sensory and postganglionic parasympathetic (secretomotor) fibres
to the lacrimal gland. The latter fibres arise from the pterygopalatine ganglion
 May be absent (in which case it is replaced by the zygomaticotemporal nerve)
Branches of the Maxillary Nerves to the Face
The maxillary nerves supply the face through the following direct and indirect
branches:
 Zygomaticofacial nerves
 Zygomaticotemporal nerves, and
 Infraorbital nerves
The zygomaticofacial nerve

 Arises from the zygomatic nerve, in the orbit
 Enters the face through the zygomaticofacial foramen, in the zygomatic bone
 Pierces orbicularis oculi, and
 Innervates the skin of the prominence of the cheek
 May be absent
The zygomaticotemporal nerve

 Arises from the zygomatic nerve, in the orbit
 Enters the temporal region through the zygomaticotemporal foramen of
zygomatic bone
 Ascends deep to temporalis, in the temporal fossa
 Pierces the temporal fascia to innervate the skin of the anterior part of the temple
 Communicates with the lacrimal nerve (via a branch which conveys secretomotor
fibres to lacrimal gland)
The infraorbital nerve

 Is the direct continuation of maxillary nerve as this enters the orbit through the
inferior orbital fissure
 Traverses the infraorbital groove in the floor of the orbit. Then it
 Enters the infraorbital canal, distal to which it emerges in the face through the
infraorbital foramen
 Lies deep to levator labii superioris in the face (where it gives off its branches)
 Innervates the lower eyelid, ala of the nose and skin and mucous membrane of
the upper lip and cheek
Branches of the Mandibular Nerve to the Face
Branches of the mandibular nerve to the face include:

 Auriculotemporal nerve
 Buccal nerve, and
 Mental nerve
The auriculotemporal nerve

 Arises from the posterior division of mandibular nerve, in the infratemporal fossa
(by two roots that encircle the middle meningeal artery)
 Passes backwards, first between lateral pterygoid and tensor veli palatini, and
then between the neck of the mandible and sphenomandibular ligament, to enter
the parotid region
 Ascends behind the superficial temporal vessels (anterior to the auricle) to enter
the temporal region
Auriculotemporal nerve gives rise to:

 Paired anterior auricular branches, which innervate the tragus of the auricle of
external ear
 Two branches to the external acoustic meatus; these pass between the bony and
cartilaginous parts of the meatus to supply its skin and the tympanic membrane
 An articular branch to the temporomandibular joint (this enters the joint from
behind)
 Parotid branches, which convey postganglionic parasympathetic fibres (from
the otic ganglion) and postganglionic sympathetic fibres (from the external
carotid plexus) to the parotid gland
 Superficial temporal branches to the skin of the temple and scalp; these
accompany the branches of the superficial temporal artery
The buccal nerve

 Arises from the anterior division of mandibular nerve, in the infratemporal fossa;
it is a sensory branch
 Passes forwards, under the cover of the mandibular ramus, to gain the external
surface of buccinator
 Pierces but does not supply buccinator
 Gives sensory fibres to the skin and mucous membrane over the anterior part of
buccinator
 Also innervates the posterior part of buccal gingivae (gums), in the region of the
2nd and 3rd molar teeth
 May give sensory fibres to the premolar and 1st molar teeth of the lower jaw
The mental nerve

 Is the cutaneous branch of the inferior alveolar nerve. It arises in the mandibular
canal
 Enters the face through the mental foramen of the mandible
 Supplies the skin of the chin, as well as the skin and mucosa of the lower lip
 Communicates with marginal mandibular branch of facial nerve
Motor Innervation of the Face

Motor innervation of the face is provided solely by the facial nerve. The facial nerve
is the 7th cranial nerve and the nerve of the 2nd branchial arch.
Branches of Facial Nerve to the Face
Branches of the facial nerve to the face include:

1. Temporal branches
2. Zygomatic branches
3. Buccal branches
4. Marginal mandibular branches, and
5. Cervical branches (largely to the neck)
Temporal branches of facial nerve

 Arise from the facial nerve in the parotid gland
 Emerge from the superior border of the parotid gland and ascend over the
zygomatic arch, to the temporal region
 Give motor fibres to auriculares anterior and superior, frontalis, orbicularis oculi
and corrugator supercilii
Zygomatic branches of facial nerve

 Arise from the facial nerve in the parotid gland
 Pass towards the lateral canthus, crossing the zygomatic arch as they do so
 Give motor fibres to orbicularis oculi and other facial muscles located between
the palpebral and oral fissures
Buccal branches of facial nerve

 Also arise from the facial nerve in the parotid gland
 Pass forward over the buccinator, towards the angle of the mouth
 Innervate buccinator and muscles of the upper lip
The marginal mandibular branch of facial nerve

 Arises from the facial nerve in the parotid gland
 Emerges from the lower border of the parotid gland and runs along the lower
border of the mandible to the face
 Supplies risorius and the muscles of the lower lip and chin
The cervical branch of facial nerve

 Also arises from the facial nerve in the parotid gland
 Emerges from the lower part of the parotid gland and passes anteroinferiorly,
beneath the platysma, to the neck
 Innervates platysma
Applied Anatomy

 Bell’s palsy arises following inflammation of the facial nerve near the
stylomastoid foramen; this condition is associated with oedema and compression
of facial nerve in this foramen. However, its cause may be unknown.
 In Bell’s palsy, paralysis of the ipsilateral facial muscles occurs
 Injury to buccal branches of facial nerve results in lodging of food in the
vestibule of the mouth during mastication; this is owing to the paralysis of
buccinator
 Injury to the marginal mandibular branch of facial nerve would result in
drooping of the angle of the mouth; this nerve may be injured when incisions are
made along the lower border of the mandible
 Lesions in the temporal branches of facial nerves would result in inability to
wrinkle the forehead (owing to paralysis of frontales)
 Lesions in the zygomatic branch of facial nerve would result in paralysis of
orbicularis oculi in the lower eyelid; thus, dryness and ulceration of the cornea,
with the resultant impairment of vision, would arise
Blood Supply to the Face
Regarding the vasculature of the face,

 Arteries of the face are mainly branches of external carotid arteries
 Some branches of the internal carotid arteries also reach the face
 Free anastomoses therefore exist between the branches of the external and
internal carotid arteries in the face
 Veins of the face communicate freely with one another. They are subject to
several variations
Arteries of the Face
Arteries of the face include:

 Facial artery, a branch of external carotid artery
 Transverse facial artery, a branch of superficial temporal artery
 Superficial temporal artery, a terminal branch of external carotid artery
 Supraorbital artery, a branch of ophthalmic artery
 Supratrochlear artery, a terminal branch of ophthalmic artery
 Mental artery, a terminal branch of inferior alveolar artery
 Infraorbital artery, a branch of the maxillary artery
Facial Artery
The facial artery

 Arises from the external carotid artery (just above the greater cornu of hyoid
bone)
 Passes forwards into the submandibular triangle, where it grooves the
posterosuperior aspect of submandibular gland
 Leaves the submandibular triangle to enter the face by ascending over the inferior
border of mandibular body, at the anterior border of masseter
 Passes superomedially in the face, over the mandible and buccinator, then
through the modiolus and the side of the nose, to the medial angle of the eye
(where it terminates as angular artery)
 Describes a sinuous course throughout its extents
Branches of Facial Artery in the Face
Branches of the facial artery in the face include:

 Inferior labial artery, to the tissues of the lower lip and chin; this anastomoses
with the mental artery and its fellow of the opposite side
 Superior labial artery, to the upper lip, anterior part of nasal septum and ala; it
anastomoses with its fellow
 Lateral nasal artery, which arises from the facial artery at the side of the nose; it
supplies the ala and dorsum of the nose, and anastomoses with its fellow and with
branches of superior labial, ophthalmic and maxillary arteries
 Angular artery, the terminal branch of facial artery; it runs to the medial angle
of the eye and supplies the lower eyelid, lacrimal sac and upper part of the cheek
Transverse Facial Artery
The transverse facial artery

 Arises from the superficial temporal artery in the substance of the parotid gland
 Emerges from parotid gland and passes forwards over the masseter, between the
parotid duct and zygomatic arch
 Supplies the parotid gland, parotid duct, masseter and skin of the face
 Anastomoses with branches of the facial, maxillary and ophthalmic arteries
Superficial Temporal Artery
The superficial temporal artery

 Is the smaller of the two terminal branches of external carotid artery; it arises
within the parotid gland, behind the neck of the mandible
 Emerges from the upper part of the parotid gland and ascends over the zygomatic
process of temporal bone, to enter the temple and scalp
 Divides, about 2.5–5 cm above the zygomatic arch, into anterior and posterior
branches
 Supplies the parotid gland, face, temporomandibular joint and scalp, through
named branches
Supraorbital Artery
The supraorbital artery

 Arises in the orbit from the ophthalmic artery
 Enters the face through the supraorbital foramen
 Supplies the forehead and anterior part of the scalp
 Anastomoses with the superficial temporal and supratrochlear arteries, as well as
with its fellow
 Is accompanied by the supraorbital nerve (a branch of frontal nerve)
Supratrochlear Artery
The supratrochlear artery

 Is a small terminal branch of ophthalmic artery which arises in orbit
 Enters the face through the superomedial aspect of orbital margin, accompanied
by the supratrochlear nerve
 Ascends into the forehead, adjacent to the median plane
 Supplies the skin and muscle of the forehead
 Anastomoses with its fellow and with the supraorbital artery
Mental Artery
The mental artery

 Is a small terminal branch of inferior alveolar artery

 Enters the chin through the mental foramen, accompanied by the mental nerve
 Supplies the tissues of the chin and anastomoses with the submental and inferior
labial branches of the facial artery
Venous Drainage of the Face
Venous blood is drained from the face by the following vessels:

 Supraorbital vein, a tributary of angular vein
 Supratrochlear vein, also a tributary of angular vein
 Angular vein, which continues as the facial vein
 Deep facial vein, a tributary of facial vein
 Facial vein, which drains the larger part of the face
 Superficial temporal vein, which joins the maxillary vein to form the
retromandibular vein
 Transverse facial vein, a tributary of the superficial temporal vein
Supraorbital Vein
The supraorbital vein

 Begins in the forehead where it anastomoses with the superficial temporal,
middle temporal and supratrochlear veins
 Passes medially, deep to orbicularis oculi, and above the supraorbital margin.
Then, it
 Joins the supratrochlear vein near the medial angle of the eye to form the angular
vein
 Communicates, via a branch which passes through the supraorbital notch, with
the superior ophthalmic vein, and thus with the cavernous sinus
 Also communicates with tributaries of the superficial and middle temporal veins,
the supratrochlear vein, and its fellow
 Drains the forehead and anterior part of the scalp
Supratrochlear Vein
The supratrochlear vein

 Commences in a network of veins in the forehead
 Descends adjacent to the midline and parallel to its fellow, to the root of the nose
 Joins the supraorbital vein at the medial angle of the eye to form the angular
vein; Thus, it
 Drains the forehead and the scalp, and
 Communicate with the supraorbital and superficial temporal veins
Angular Vein
The angular vein

 Is formed at the root of the nose by the union of the supratrochlear and
supraorbital veins
 Descends along the side of the nose to its junction with superior labial vein,
where it continues as the facial vein
 Drains the root and side of the nose, the eyelids and the conjunctiva
 Communicates with the superior ophthalmic vein, and thus with the cavernous
sinus
Deep Facial Vein
The deep facial vein

 Is a large vein which arises from the pterygoid venous plexus in the infratemporal
fossa
 Passes forwards, deep to the mandibular ramus and masseter, and above the
buccinator, to enter the face
 Joins the facial vein from behind, in the face
 Drains structures in the infratemporal fossa
Facial Vein
Note that the facial vein

 May be defined as the continuation of the angular vein distal to the junction of
this vein with the superior labial vein
 Passes postero-inferiorly through the face onto the surface of the masseter
(behind the facial artery). Then it crosses the mandibular body to continue
postero-inferiorly, superficial to the submandibular gland
 Is joined by the anterior division of retromandibular vein just antero-inferior
to the angle of the mandible
 Crosses the carotid arteries and hypoglossal nerve before terminating in the
internal jugular vein near the greater cornu of the hyoid bone (in the carotid
triangle of the neck)
 Is devoid of valves and thus permits blood flow in either directions
 Is less tortuous compound to the facial artery
Tributaries of facial vein correspond largely to branches of the facial artery;

they include:
 Angular vein, which receives the supraorbital, supratrochlear, inferior palpebral,

and lateral nasal veins
 Deep facial vein, which drains the pterygoid plexus of veins
 Superior and inferior labia veins, which drain the upper and lower lips
respectively
 Submental vein, which drains the submental region
 Tonsillar and paratonsillar veins, which drain the palatine tonsil
 Submandibular veins, which drain the submandibular gland
Superficial Temporal Vein
The superficial temporal vein

 Begins in an extensive plexus on the side of the scalp
 Becomes a single trunk anterior to the auricle (by the union of its frontal and
parietal tributaries)
 Descends over the temporal root of zygomatic arch to enter the parotid gland
 Is joined by the maxillary vein behind the neck of the mandible to form the
retromandibular vein (in the parotid gland)
 Drains the scalp, auricle, temporomandibular joint, face and parotid gland
Tributaries of the superficial temporal vein include:

 Its frontal and temporal tributaries, which drain the scalp
 The parotid vein from the parotid gland
 The anterior auricular veins from the auricle of the external ear
 The middle temporal vein, which joins it near the union of its parietal and
frontal tributaries. This vein drains the temple and receives the orbital vein
(formed by the union of the lateral palpebral veins)
 The transverse facial vein, which drains the territory of the transverse facial
artery
Applied Anatomy

 Owing to the free anastomoses between the arteries of the face, facial wounds
bleed freely but heal faster
 Temporal pulse, the pulse of the superficial temporal artery, can be taken where
this artery crosses the zygomatic process of the temporal bone, anterior to the
auricle
 Facial pulse, the pulse of the facial artery, can be taken where this artery ascends
over the inferior border of the body of the mandible, at the anterior margin of
masseter
 The connection of the facial vein with the cavernous sinuses (via the superior
ophthalmic vein) and with the pterygoid plexus (via the deep facial vein) is of
importance in the spread of infections from the face to the dural venous sinuses,
and vice-versa
 In thrombophlebitis of the facial vein, infected clots may be carried to the
cavernous sinuses through the superior ophthalmic and deep facial veins; this
could result in thrombophlebitis of the cavernous sinuses
 The danger triangle of the face surrounds the nose and upper lip, with its base at
the upper lip and its apex at the bridge of the nose
 Wounds in the danger triangle of the face may results in thrombophlebitis of the
facial vein, and secondarily, of the dural venous sinuses
Lymphatic Drainage of the Face
Regarding the lymphatic drainage of the face, note that

 Lymph from the lateral parts of the eyelids, the conjunctiva and the face drains
into the superficial and deep parotid nodes
 Lymph from the medial parts of the eyelids and lacrimal caruncle drains into the
submandibular nodes
 Lymph from the external nose, upper lip, lateral part of lower lip and the cheek
also drains into the submandibular nodes. Besides, lymph from lateral part of the
cheek drains into the parotid nodes
 Lymph from the chin and central part of the lower lip drains into the submental
nodes
 Lymph from the root of the nose and central part of the forehead drains into the
parotid and submandibular nodes
 Lymph vessels from all the nodes mentioned above end in the deep cervical
nodes located along the internal jugular vein (IJV)
 Cancer cells from the central and lateral parts of the lower lip metastasize to the
submental and submandibular nodes respectively
Scalp
The scalp
 Is the five-layered structure that covers the calvaria externally (Fig. 131); it is
made up of skin, connective tissue and associated muscles
 Extends from the superior nuchal lines of occipital bone behind to the
supraorbital margins of frontal bones anteriorly
 Also extends from one zygomatic arch to the other, at the sides
Layers of the Scalp (Fig. 131)

The scalp is arranged in five layers; these include, from superficial deeply,
 Skin,
 Connective tissue (dense and thick)
 Aponeurosis (epicranial aponeurosis) and its associated epicranius muscle
 Loose connective tissue, and
 Pericranium of the calvaria
Fig. 131. Layers of the scalp.
The skin of the scalp

 Is the most external layer of the scalp (Fig. 131)
 Is thin, with numerous hair follicles. It usually possesses hair
 Also possesses numerous sweat and sebaceous glands
 Is well vascularized, has numerous sensory nerve fibres and extensive lymphatic
drainage
Connective (Subcutaneous) Tissue Layer of the Scalp
The subcutaneous tissue of the scalp

 Is the 2nd of the five layers of the scalp (Fig. 131)
 Consists of a dense, thick connective tissue

 Is well vascularized, with numerous sensory fibres
 Is firmly attached to the overlying skin and the underlying epicranial aponeurosis
The aponeurotic layer of the scalp

 Is the 3rd layer of the scalp (Fig. 131)
 Consists of the epicranial aponeurosis (galea aponeurotica) and its attached
epicranius muscle
 Is firmly bound to the overlying dense subcutaneous tissue layer (2nd layer), but
loosely bound to the underlying loose connective tissue layer (4th layer)
The epicranial aponeurosis

 Is a tough tendinous sheet that covers the cranial vault between occipitales behind
and frontales in front (Fig. 131)
 Extends posteriorly between the two occipitales and anteriorly between the two
frontales. Anteriorly, it splits to enclose frontales
 Is attached behind to the external occipital protuberance and superior nuchal lines
 Receives, on each side, the attachment of auriculares superior and anterior and is
here prolonged inferiorly to be attached to the zygomatic arch; it is exceptionally
thin in this region
The epicranius consists of the following muscles:

 Occipitofrontalis, and
 Auricularis superior
Note: Occipitofrontalis consists of paired occipital bellies (occipitales) behind and

paired frontal bellies (frontales) in front.
The occipitales
 Are the occipital bellies of occipitofrontalis
 Are located in the occipital region, one on each side of the median plane
 Appear thin and quadrilateral, and are smaller than the frontales
 Are separated by a narrow posterior prolongation of the epicranial aponeurosis,
which extends between the two bellies
 Lateral ⅔ of the superior nuchal line
 Mastoid temporal bone
Distal attachment: Epicranial aponeurosis

Action: Pull the scalp backwards
Innervation: Posterior auricular branch of facial nerve
Frontales (see the face above)
Loose Connective Tissue Layer of the Scalp
The loose connective tissue layer of the scalp

 Is the 4th layer of the scalp
 Consists of areolar (loose connective) tissue
 Contains numerous potential spaces, which may be distended with fluid
 Allows free movement of the first three layers of the scalp – scalp proper – over
the underlying pericranium of the calvaria
Pericranium (5th Layer of the Scalp)

 The 5th layer of the scalp
 Is formed by the pericranium (the external periosteum) of the calvaria. Thus, it
 Is made of dense connective tissue
 Is firmly attached to the calvaria, from which it can be easily stripped in the
living (except at the sutures)
Innervation of the Scalp
Anterior to the auricles, the scalp receives sensory fibres from branches of the three
divisions of the trigeminal nerves. These include:
 Supratrochlear nerves, from ophthalmic divisions of trigeminal
 Supraorbital nerves, also from ophthalmic divisions of trigeminal
 Zygomaticotemporal nerves, from maxillary divisions of trigeminal
 Auriculotemporal nerves, from mandibular divisions of trigeminal
Posterior to the auricles, the scalp receives sensory fibres from spinal nerves. These
include:
 Lesser occipital nerves, from the ventral rami of C2 and C3 nerves
 Greater occipital nerves, the dorsal ramus of C2, and
 Third occipital nerve, the dorsal ramus of C3
Motor fibres to muscles of the scalp arise from branches of the facial nerve. These
include:
 Temporal branches, to frontales, and
 Posterior auricular branches, to occipitales
Blood Supply to the Scalp
Regarding the arteries of the scalp, note that these vessels:

 Are branches of external and internal carotid arteries
 Are located in the dense subcutaneous tissue (2nd layer) of the scalp
 Anastomose freely with one another
 Bleed profusely when severed as the dense subcutaneous tissue (in which they are
located) tend to keep the cut vessels open, and also because of the free
anastomoses between these arteries
 Link two large vessels, internal and external carotid arteries, with each other
through their abundant anastomoses
Arterial blood reaches the scalp from:

 The supratrochlear arteries, branches of the ophthalmic arteries (from internal
carotid)
 The supraorbital arteries, also branches of ophthalmic arteries (from internal
carotid)
 The superficial temporal arteries, terminal branches of external carotid arteries
 The posterior auricular arteries, branches of external carotid arteries, and
 The occipital arteries, also from external carotid arteries
Venous Drainage of the Scalp

 Veins of the scalp
 Like the arteries, are located in the dense subcutaneous tissue layer of the scalp
 Are accompanied by arteries of the scalp
Veins that drain the scalp include:

 Supratrochlear veins, tributaries of angular veins of the face
 Supraorbital veins, also tributaries of angular veins, and thus of facial veins
 Superficial temporal veins, tributaries of retromandibular veins, and thus of
external jugular veins
 Posterior auricular veins, each of which joins the posterior division of
retromandibular vein to form the external jugular vein
 Occipital veins, tributaries of the deep cervical and vertebral veins (and
occasionally of the internal jugular or posterior auricular veins)
 Deep temporal veins, which drain the deep parts of the temporal regions; they are
tributaries of the pterygoid plexus
Regarding the veins of the scalp, note that

 Occipital veins are linked to the superior sagittal and transverse sinuses by the
parietal and mastoid emissary veins respectively
 Mastoid emissary veins from the sigmoid sinuses end in the posterior auricular
veins
 The stylomastoid veins which drain the auricles also end in the posterior auricular
veins
Lymphatic Drainage of the Scalp
Regarding lymphatic drainage of the scalp, note that

 Lymph vessels from the scalp end directly in the submental, submandibular,
parotid, mastoid (retroauricular) and occipital nodes
 The above nodes altogether constitute the superficial ring of lymph nodes
(pericervical collar of nodes), located at the upper end of the neck
 Lymph from the superficial ring of nodes drains into the deep cervical nodes
(located along the internal jugular vein)
 No lymph nodes are found in the scalp
Applied Anatomy

 Obstruction of the ducts of sebaceous glands (of the skin of the scalp) leads to
retention of glandular secretion, thereby producing sebaceous cysts (which move
freely with the scalp)
 In injuries or surgical incisions of the scalp, the first three layers usually separate
as a single piece – the scalp proper; this contains numerous blood vessels
 In craniotomy, incisions are made convex upwards so as to preserve the major
vessels and nerves of the scalp; thus,
 In incision or avulsion of the scalp, necrosis of the avulsed or incised flap does
not occur as vessels are retained in it
 The loose connective tissue layer (4th layer) of the scalp is referred to as danger
area of the scalp because blood or pus can spread readily through it
 Pus or blood in the 4th layer of the scalp could spread to the eyelids, thereby
causing black eye; it may also spread to the root of the nose
 On the contrary, blood or purulent fluid in the 4th layer does not spread to the
neck owing to the attachment of occipitales to the superior nuchal lines and
mastoid temporal bone, neither does it spread beyond the zygomatic arches owing
to the attachment of epicranial aponeurosis to these arches
 Via the emissary veins, infections of the scalp could also spread to the brain and
meninges (in the cranial cavity)
 Scalp injuries that do not involve the epicranial aponeurosis do not gape
 Deep wounds of the scalp often involve the epicranial aponeurosis and thus gapes
widely, especially when this aponeurosis is lacerated in a coronal plane
 Contraction of the arteries of the scalp during injury is usually prevented by the
dense subcutaneous tissue (of the 2nd layer); thus, bleeding of the scalp is usually
profuse (as the bleeding vessels are held wide open)
 Inflammatory swellings of the scalp are minimal owing to the density and
thickness of the dense subcutaneous tissue (which prevents such swellings)
 In stenosis of the internal carotid arteries (e.g. from atherosclerosis), blood could
still reach the brain from the external carotid artery, owing to the rich
anastomoses between the branches of these two major vessels in the scalp and
face
 Cephalohaematoma may develop in babies following rupture of the periosteal
arteries of the calvaria in difficult birth. Blood thus collects between the
periosteum and calvaria
Orbit, Eyelids and Lacrimal Apparatus
Orbit
The orbit
 Is pyramidal in outline, with a base directed forwards and an apex directed
backwards
 Is located in the facial skeleton. It is separated from its fellow by the nasal
cavities, and more posteriorly, by the ethmoidal and sphenoidal paranasal sinuses
 Has a superior wall (roof), an inferior wall (floor), a medial wall and a lateral
wall
 Is lined by the periorbita (the periosteum of the orbital walls)
 Contains and protects the eyeball and its associated structures (see below)
 Communicates with adjacent cavities via foramina (see below)
The orbit communicates with

 The middle cranial fossa via the superior orbital fissure and optic canal
 The anterior cranial fossa via the anterior and posterior ethmoidal foramina
 The pterygopalatine fossa via the inferior orbital fissure
 The face through the infraorbital canal and foramen, and the supraorbital notch
(or foramen)
 The inferior nasal meatus via the nasolacrimal canal
Base of the Orbit (Orbital Opening) (Fig. 132)
Regarding the base of the orbit, note that

 It is roughly quadrangular in outline
 Its superior margin – supraorbital margin – is formed entirely by the frontal
bone
 A supraorbital notch interrupts the supraorbital margin at the junction of lateral
⅔ and medial ⅓ of this margin. This transmits the supraorbital nerve and artery to
the face
 Its inferior margin – infraorbital margin – is formed by the zygomatic bone
laterally and the maxilla medially
 The infraorbital foramen is not located at the infraorbital margin but about 1 cm
below it, and almost in line with the supraorbital notch
 The medial margin is formed above by the frontal bone and below by the
lacrimal crest of the frontal process of the maxilla
 Its lateral margin is formed above by the zygomatic process of the frontal bone
and below by the frontal process of zygomatic bone
The apex of the orbit

 Is located at the optic canal in the sphenoidal lesser wing (Fig. 132)
 Lies just medial to the (medial end of) superior orbital fissure
Figure 132. The orbit
Superior Wall (Roof) of the Orbit
The roof of the orbit

 Is formed largely by the orbital part of the frontal bone. It is completed behind by
the lesser wing of sphenoid
 Is gently concave inferiorly
 Separates the orbital contents from the anterior cranial fossa and its contents (e.g.
frontal lobe, etc)
 Presents a lacrimal fossa in its anterolateral part; this lodges the orbital part of
lacrimal gland
 Also presents a trochlear fovea anteromedially, for the attachment of the
trochlea (pulley) of superior oblique
 Is related in its anteromedial part to the frontal sinus
Inferior Wall (Floor) of the Orbit
The floor of the orbit

 Is formed mainly by the maxilla; it is completed laterally by the zygomatic bone
and posteriorly by the orbital process of palatine bone
 Slopes anteroinferiorly from the orbital apex to the infraorbital margin
 Is separated from the lateral orbital wall posteriorly by the inferior orbital fissure
 Has an infraorbital groove which passes forwards from the inferior orbital
fissure; this groove continues anteriorly into the infraorbital canal which opens
onto the face at the infraorbital foramen
 Separates the orbital contents from the maxillary sinus below
The lateral wall of the orbit

 Is the thickest of the four orbital walls, especially in its posterior part
 Is formed by the frontal process of zygomatic bone anteriorly, and by the greater
wing of spheroid posteriorly
 Separates the orbit from the temporal fossa anteriorly, and from the middle
cranial fossa posteriorly
 Is directly continuous with the orbital roof anteriorly, but is separated from it
posteriorly by the superior orbital fissure
 Is nearly perpendicular to the contralateral lateral wall
The medial wall of the orbit

 Is exceptionally thin (paper-thin)
 Is formed largely by the ethmoidal bone, with contributions from the lacrimal,
sphenoidal and frontal bones
 Bears a vertical posterior lacrimal crest (of the lacrimal bone) in its anterior part.
Anterior to this crest is a vertical lacrimal groove, which lodges the lacrimal sac
 Separates the orbital contents from the nasal cavity, and the ethmoidal and
sphenoidal air sinuses
Contents of the orbit include:

 The eyeball and its sheath
 Numerous nerves, including optic, divisions of the oculomotor, trochlear,
abducent, ophthalmic (and its branches), zygomatic and infraorbital nerves
 Ciliary ganglion
 Extraocular muscles
 Orbital part of lacrimal gland and the lacrimal sac
 Ophthalmic artery and its branches
 Ophthalmic veins, and
 Adipose tissue (fat)
Applied Anatomy

 Blowout fractures of the orbit usually affect the medial and inferior walls, owing
to their relative thinness
 The ophthalmic artery may rupture in orbital fracture, with the attendant bleeding
into the orbit, and bulging of the eyeball – exophthalmos
 Blood from a bleeding vessel in the orbit may enter the ethmoidal or sphenoidal
air sinuses if the medial orbital wall is fractured, or the maxillary sinus if the
orbital floor is fractured
 Because the lateral wall of the orbit does not reach as far anteriorly as the medial
wall, a lateral approach to the eyeball is easier in surgery
Eyebrow (Fig. 133)
Note that the eyebrow

 Is a fold of skin that surmounts the orbit. It is thickened by the underlying areolar
tissue
 Is endowed with numerous thick short hair, which is directed laterally
 Gives attachment to frontalis, orbicularis oculi and corrugator supercilii
Eyelids (Fig. 133)
Regarding the eyelids, note the following:

 They are thin movable surface folds that cover and protect the eyeball anteriorly
 The larger upper eyelid gives attachment to the aponeurosis of levator palpebrae
superioris. It is more movable than the lower lid
 A palpebral fissure separates the upper and lower lids from each other. This
forms an elliptical space when the lids are parted
 The upper and lower lids meet at the medial and lateral angles (canthi) of the eye
 At the medial angle of the eye, the eyelids are separated by a triangular area
termed the lacus lacrimalis
 Contained in the lacus lacrimalis is a fold of modified skin – the lacrimal
caruncle. This possesses tiny hair and miniature sebaceous glands
 The semilunar fold (plica semilunaris) is a vertical fold of conjunctiva located
lateral to the lacrimal caruncle; it is homologous to the nictitating membrane of
lower vertebrates
 Each eyelid has a free margin endowed with two or three rows of hair (cilia) – the
eyelashes
 The free margin of each eyelid has a small conical elevation – the lacrimal
papilla – located opposite the basal angle of lacus lacrimalis
 Situated on the lacrimal papilla is the lacrimal punctum, which is the opening
into the lacrimal canaliculus
 The orbital septum is a weak membrane that attaches the eyelid to the orbital
margins
From external internally, each eyelid consists of the following:

 Skin
 Subcutaneous loose connective tissue
 Palpebral part of orbicularis oculi
 Tarsal plate and the attached orbital septum, and
 Palpebral conjunctiva
The skin of the eyelid

 Is extremely thin
 Is continuous with the palpebral conjunctiva at the palpebral margin
The subcutaneous connective tissue of the eyelid

 Is loose and delicate
 Lacks fat cells (as in the areola of the breast and subcutaneous tissue of the
scrotum)
Palpebral fibres of orbicularis oculi

 Lie in the subcutaneous loose connective tissue of the eyelid (Fig. 133)
 Appear pale and are arranged parallel to palpebral margin
 Assist in gentle closure of the eyelids (by approximating the palpebral margins)
Tarsal Plates (Tarsi)
Regarding the tarsal plates, note the following points:

 Tarsal plates are thin plates of dense connective tissue; they give support and
shape to the eyelids (Fig. 133)
 Each tarsal plate is 2.5 cm in length, on average
 The superior tarsal plate is larger and firmer than the inferior one. It is about 10
mm in its vertical extent (height)
 The aponeurosis of levator palpebrae superioris is attached to the anterior surface
of the superior tarsus (after piercing the orbital septum)
 The inferior tarsal plate is about half the height of the superior one (5 mm)
 Embedded in each tarsus is a row of 20-30 tarsal glands
 The palpebral part of the conjunctiva lines the internal surface of each tarsal plate
 Each tarsus has a free and an attached margin; the latter is connected by the
orbital septum to the orbital margin
 A lateral palpebral ligament connects the lateral ends of the upper and lower
tarsi to the zygomatic bone
 A strong medial palpebral ligament connects the medial ends of the tarsi to the
crest of the lacrimal and frontal process of maxillary bones
Eyelashes
The eyelashes
 Are located along the free palpebral margins, from the lateral angle of the eye to
the lacrimal papillae
 Consists of short thick hair arranged in 2–3 rows
 Are more numerous and longer in the upper eyelid where they are bent outwards
and upwards. In the lower lid, they curve downwards
Ciliary Glands
Ciliary glands of the eyelids

 Are large modified sweat glands associated with the follicles of the eyelashes
(Fig. 133)
 Are arranged in 2–3 rows near the free margins of the eyelids
 Possess relatively straight ducts which open into the follicles of eyelashes
Tarsal Glands
Tarsal glands
 Are modified sebaceous glands embedded in the posterior aspect of tarsal plates
(Fig. 133)
 Are arranged in a single row. Their ducts open along the free margins of the
eyelids
 Are more numerous (about 30) and longer in the upper lid, but smaller and fewer
in the lower lid
 Are yellowish in appearance and may be observed through the palpebral
conjunctiva
 Are essentially simple tubular glands with several lateral outpouches
 Are involved in the production of an oily secretion which spreads over the
palpebral margins and prevents spilling of lacrimal fluid onto the cheek
Figure 133. The eyelid and conjunctiva
Palpebral Conjunctiva
The palpebral part of the conjunctiva

 Lines the internal surface of the eyelids (palpebrae), to which it intimately
adheres (Fig. 133). Like the ocular conjunctiva, it is a transparent membrane
 Is very vascular
 Is endowed with numerous connective tissue papillae; these are located deep to
its epithelial lining
 Contains lymphoid tissue (adjacent to the fornices)
 Is continuous with the skin of the eyelids at the free palpebral margin
 Is also continuous with the epithelium of the lacrimal canaliculi and sac, as well
as with that of the nasolacrimal duct and nasal mucosa
 Is reflected to becomes continuous with the ocular conjunctiva at the superior
and inferior fornices
 Is lined by non-keratinized stratified squamous epithelium near the palpebral
margin and by stratified columnar epithelium elsewhere. Goblet cells intersperse
the epithelial cells
 Receives numerous sensory fibres
Note: For ocular conjunctiva, see below.

Orbital Septum
The orbital septum

 Is a weak membrane attached at one end to the orbital margin and at the other end
to the anterior surface of the tarsi
 Blends above with the aponeurosis of levator palpebrae superioris, and with the
periosteum, at the orbital margin
 Is pierced in its superolateral part by the palpebral part of lacrimal gland and
superiorly by the aponeurosis of levator palpebrae superioris
 Is also pierced by vessels and nerves which leave the orbit to enter the face and
scalp
Blood Supply and Innervation of the Eyelids
Note that
 Each eyelid receives a medial palpebral artery from the ophthalmic artery; this
vessel pierces the orbital septum above or below the medial palpebral ligament
 Lateral palpebral arteries of the eyelids arise from the lacrimal artery
 Palpebral veins are tributaries of the facial vein medially and of the superficial
temporal vein laterally
 Sensory fibres to the upper eyelid arise from the supraorbital and supratrochlear
branches of the frontal nerve
 Sensory fibres to the lower eyelid arise from the infraorbital branch of maxillary
nerve
 Infratrochlear nerve also supplies the medial parts of both eyelids, while the
lacrimal nerve supplies their lateral parts
 Smooth muscle fibres of levator palpebrae superioris are innervated by
(postganglionic) sympathetic fibres derived from the superior cervical ganglion.
The preganglionic fibres are derived from the T1 segment of spinal cord
 Most nerves fibres of the eyelids are located largely deep to the palpebral fibres
of orbicularis oculi
Lymphatic Drainage of the Eyelid
Regarding the lymphatic drainage of the eyelids, note that

 Lymphatic plexuses are associated with both surfaces of each tarsus
 Lymph vessels from the medial parts of the eyelids drain into the submandibular
nodes
 Lymph vessels from the lateral parts of the eyelids drain into the superficial
parotid nodes
Applied Anatomy of the Eyelids

 Infections can spread from the conjunctiva to the nasal mucosa and vice-versa,
via the lacrimal canaliculi and nasolacrimal duct (owing to the continuity of their
epithelial linings)
 Drooping of the upper eyelid occurs in Horner’s syndrome; this may arise from
injury to the superior cervical ganglion or the T1 segment of the spinal cord
(which innervates the smooth fibres of levator palpebrae superioris)
 Owing to the continuity of the loose connective tissue of the upper eyelid with
that of the 4th layer of the scalp, pus or blood in the latter could spread to the
upper lid (and even to the lower lid). This causes black eye
 Ecchymosis is characterized by bleeding into the eyelids and periorbital skin, e.g.
following exposure to traumatizing blows
 Inflammation of the ciliary glands (or obstruction of their ducts) produces a
painful, reddish pus-filled swelling – sty
 Tarsal chalazion arises following obstruction or inflammation of the tarsal
glands; affected glands become swollen and thus rub against the eyeball, causing
painful sensations
Lacrimal Apparatus (Fig. 134)
The lacrimal apparatus consists of:

 Lacrimal gland, which elaborates tears
 Lacrimal canaliculi, which conveys lacrimal fluid (tears) from the lacus
lacrimalis to the lacrimal sac
 Lacrimal sac, the dilated blind upper end of nasolacrimal duct, and
 Nasolacrimal duct, which conveys lacrimal fluid from the lacrimal sac to the
nasal cavity
Lacrimal Gland (Fig. 134)
The lacrimal gland

 Produces lacrimal fluid (tears); the latter is a complex secretion
 Consists of a larger upper orbital part located in the lacrimal fossa of the orbit,
and a smaller lower palpebral part located deep to the aponeurosis of levator
palpebrae superioris, and which extends into the lateral part of the upper eyelid
 Also exists in the form of small accessory lacrimal glands situated near or in the
upper and lower conjunctival fornices (especially in the upper one)
 Is drained by about 12 lacrimal ducts, which open onto the superior conjunctival
fornix
Figure 34. Lacrimal apparatus.
Orbital Part of Lacrimal Gland
The orbital part of lacrimal gland

 Occupies the lacrimal fossa, in the superolateral part of the orbit
 Has the size and shape of an almond
 Measures approximately 2 cm in length
 Lies above the palpebral part of the same gland, the two being separated by the
aponeurosis of levator palpebrae superioris (around the lateral edge of which they
are continuous)
 Is drained by ducts which traverse the palpebral part of the gland; these open into
the conjunctival sac, on the upper conjunctival fornix
 Is related above to orbital periosteum, below to the aponeurosis of levator
palpebrae superioris and lateral rectus, anteriorly to orbital septum and behind to
orbital fat
Palpebral Part of Lacrimal Gland
The palpebral part of lacrimal gland

 Is about ⅓ the size of the of the orbital part

 Arches medially, deep to the aponeurosis of levator palpebrae superioris, into the
lateral part of the upper eyelid
 Is attached to the upper conjunctival fornix
 Is observable through the upper palpebral conjunctiva (when the upper eyelid is
everted)
 Is traversed by all the ducts of the orbital part as these pass to the superior
conjunctival fornix, on which they open
Blood Supply and Innervation of the Lacrimal Gland
Note that
 Arterial blood reaches the lacrimal gland via the lacrimal artery, a branch of
ophthalmic artery
 Superior salivatory nucleus of the brainstem is the source of the preganglionic
parasympathetic fibres to the lacrimal, submandibular and sublingual glands
 Preganglionic parasympathetic fibres to the lacrimal gland are conveyed in
succession by the facial and greater petrosal nerves, and the nerve of the
pterygoid canal
 Postganglionic parasympathetic (secretomotor) fibres to the lacrimal gland arise
from the pterygopalatine ganglion (located in the pterygopalatine fossa)
 From the pterygopalatine ganglion, secretomotor fibres to the lacrimal gland are
conveyed first by the zygomatic nerve (a branch of maxillary) and then by the
lacrimal nerve (a branch of ophthalmic)
 Parasympathetic stimulation enhances the secretory function of the lacrimal gland
 Vasoconstrictive postganglionic sympathetic fibres to the lacrimal gland are
conveyed in succession by the internal carotid plexus, deep petrosal nerve, nerve
of the pterygoid canal, zygomatic and lacrimal nerves
Structure of the Lacrimal Gland
Regarding the structure of the lacrimal gland, note that

 The gland is compound tubuloalveolar in type; its parenchyma is similar to that
of the salivary glands
 Myo-epithelial cells and their processes surround the secretory endpieces of the
lacrimal gland
 Several lymphocytes are also associated with the acini of the lacrimal gland
 The parenchyma of the lacrimal gland appears to possess both serous and mucous
cells
Applied Anatomy of Lacrimal Gland

 Extirpation of lacrimal gland does not result in dryness or ulceration of the
conjunctiva owing to the presence of numerous accessory lacrimal glands in
conjunctival fornices
 Excision of the palpebral part of lacrimal gland would lead to severance of the
ducts of the orbital part, and thus inability of tears to drain from this (orbital)
part. Note that the ducts of the orbital part traverse the palpebral part, en route to
the superior conjunctival fornix (where they open)
Lacrimal Canaliculi
Regarding the lacrimal canaliculi, note the following facts:

 Lacrimal canaliculi drain tears from the lacus lacrimalis to the lacrimal sac; they
are located at the medial ends of the margins of the eyelids (Fig. 134)
 Each lacrimal canaliculus measures about 10 mm in length
 The superior lacrimal canaliculus is shorter and smaller than the inferior one. It
begins at the upper lacrimal punctum, passes first upwards and medially and then
downwards and medially, to end in the lacrimal sac
 The inferior lacrimal canaliculus begins at the inferior lacrimal punctum, passes
initially inferomedially and then superomedially, to end in the lacrimal sac
 Each lacrimal punctum is located on a lacrimal papilla
 The lacrimal papilla is an oval elevation located on each eyelid, a short distance
from the medial canthus of the eye (opposite the basal angle of lacus lacrimalis)
 Each lacrimal canaliculus presents a dilation – the ampulla – at the point where it
is angulated
 The lacrimal canaliculus is lined by non-keratinized stratified squamous
epithelium
 The medial palpebral ligament separates the upper and lower lacrimal canaliculi
from each other
Lacrimal Sac
The lacrimal sac

 Is the enlarged blind upper end of the nasolacrimal duct (Fig. 134)
 Occupies the lacrimal fossa (formed by the lacrimal bone and the frontal process
of maxillary bone)
 Measures about 12 mm in length
 Receives the lacrimal canaliculi in its lateral aspect
 Is covered laterally and above by the lacrimal fascia. This stretches from the
maxillary bone in front to the lacrimal bone behind. A plexus of veins intervenes
between the fascia and the sac
 Is separated from the medial palpebral ligament anteriorly and the lacrimal part of
orbicularis oculi posteriorly by the lacrimal fascia
 Collects tears from the lacrimal canaliculi and passes it to the inferior nasal
meatus through the nasolacrimal duct
 Has a mucosa that is continuous with that of the nasal cavity below (through the
nasolacrimal duct) and with the conjunctiva (through the lacrimal canaliculi).
This is of importance in the spread of infections between these structures
 Is lined by stratified columnar epithelium
Nasolacrimal Duct
The nasolacrimal duct

 Conveys tears from the lacrimal sac to the nasal cavity (Fig. 134)
 Descends from the lacrimal sac through a bony canal bounded by the maxilla,
lacrimal bone and inferior nasal concha, and inclines backwards and laterally as it
does so
 Opens below into the anterior part of the inferior nasal meatus, about 30 mm
from the nostril; this opening is somewhat dilated
 Is guarded by a fold of mucosa – the lacrimal fold – near its nasal opening; this
fold prevents the passage of air into the duct when the nose is blown
 Is lined by stratified columnar epithelium
 Measures 18 mm in length and about 3.5 mm in width
 Is surrounded by a plexus of veins, which when engorged, may obstruct the duct
Applied Anatomy
Note the following:

 Infections can spread from the conjunctiva to the nasal mucosa (through the
lacrimal canaliculi, lacrimal sac and nasolacrimal duct), and vice-versa, owing to
the continuity of their epithelial linings
Eyeball (Fig. 35)
Regarding the eyeball, note the following facts:

 The eyeball is the organ of sight; it receives visual stimuli from the exterior and
converts them to electrical messages, for onward transmission to the brain by the
optic nerve, etc
 Tenon’s capsule or fascial sheath of the eyeball ensheathes the eyeball. This
sheath invests the eye from the optic nerve behind to the corneoscleral junction
anteriorly
 The fascial sheath of the eyeball separates the eye from the orbital fat, and allows
it to rotate
 Though the eyeball appears as a single sphere, it is actually made up of segments
of two unequal spheres
 The anterior corneal segment of the eyeball has a smaller radius of curvature
than the posterior (scleral) segment. This anterior segment is transparent and
constitutes about ⅙ of the whole globe
 The posterior scleral segment of the eyeball has a larger radius of curvature (i.e.
it is part of a larger sphere). It is opaque and forms the posterior ⅚ of the eyeball
 The anterior (corneal) segment of the eyeball is bounded anteriorly by the
transparent cornea and posteriorly by the lens. It is divided into an anterior and a
posterior chamber by the iris
 The two chambers of the anterior segment of the eyeball communicate through
the pupil; they contain aqueous humour
 Sulcus sclerae is a shallow groove at the corneoscleral junction; it indicates the
junction of the two segments of the eye externally
 The posterior segment of the eyeball is located behind the lens; it contains the
vitrous humour
Moreover, note the following terms:

 The anterior pole of the eyeball is the centre of its anterior curvature (or
surface) (Fig. 35)
 The posterior pole of the eyeball is the centre of its posterior (scleral)
curvature
 The optic axis is indicated by a line which joins the anterior and posterior poles
of the eyeball
 The optic axes of the two eyeballs are parallel to each other (in their primary
position)
 The equator of the eyeball is indicated by a line which encircles the eyeball
midway between the anterior and posterior poles
 The visual axis is represented by a line that passes through the centre of the
cornea and the fovea centralis of macula lutea. When focusing on a distant object,
the two visual axes are parallel
 Each eyeball has a volume of about 8 cm3
 The vertical diameter of the eyeball in an average adult male is about 23.5 mm
 The transverse and anteroposterior diameters of the eyeball are equal; each is
about 24 mm in an adult male
 At birth and puberty, the anteroposterior diameter of the eyeball is 17.5 mm and
20.5 mm respectively
Figure 135. The eye
Coats (Layers) of the Eyeball
The eyeball has three structural coats. These include, from external internally:
 An outer fibrous coat, which consists of the sclera and cornea
 A middle vascular coat, which consists of the choroid, ciliary body and iris; and
 An inner coat, the retina
Fascial Sheath of the Eyeball
The fascial sheath of the eyeball

 Is a thin membrane which surrounds the sclera of the eyeball, and thus forms a
fibrous socket for the eye
 Extends from the point of attachment of the optic nerve to the eyeball behind, to
the corneoscleral junction in front
 Separates the eyeball from the ocular conjunctiva anteriorly and the orbital fat
behind
 Fuses with the sclera in front, just behind the corneoscleral junction; behind, the
point of fusion with the sclera is where the optic nerve, ciliary nerves and
posterior ciliary arteries pierce the sclera
 Is smooth on its internal aspect, being separated from the sclera by a potential
episcleral space. Strands of connective tissue traverse this space to connect the
fascial sheath to the sclera
 Is pierced by vorticose veins near the equator of the eyeball
 Sends tubular extensions around the extraocular muscles; those around the recti
blend with the epimysium of these muscles, that of the superior oblique blends
with its fibrous trochlea and that of inferior oblique with the orbital floor

 The tubular extensions of the fascial sheath of the eyeball around the medial and
lateral recti are prolonged outwards to the lacrimal and zygomatic bones, to form
medial and lateral check ligaments
 Between the medial and lateral check ligaments, the inferior part of the fascial
sheath is thickened as the suspensory ligament of the eye. Thus,
 The suspensory ligament passes under the eyeball like a hammock, between the
medial and lateral orbital walls
 The check and suspensory ligaments put an appropriate check (limit) on the range
of movement of the eye
Orbital Fascia (Periorbita)
The orbital fascia

 Is the periosteum that lines the orbital cavity. It Is loosely connected to the orbital
walls
 Blends with the dura of the optic nerve behind and with the orbital septum in
front
 Forms the lacrimal fascia which forms the roof and lateral wall of the lacrimal
fossa (where the lacrimal sac is located)
Ocular Conjunctiva
The ocular conjunctiva

 Lines the cornea and the anterior part of the sclera (Fig. 133); it is separated from
the latter by the fascial sheath of the eye
 Is thin and transparent, and is loosely connected to the eyeball. However, it
adheres firmly to the cornea, where it forms the anterior corneal epithelium (a
non-keratinized stratified squamous epithelium)
 Is lined by stratified columnar epithelium over the sclera
 Lacks subepithelial connective tissue papillae

 Receives sensory fibres from the ophthalmic nerve
 Is slightly vascular
Fibrous Coat of the Eye
This consists of the following:

 Sclera, the opaque posterior part, and
 Cornea, the transparent anterior part
Sclera
The sclera
 Is the firm, fibrous, relatively tough opaque coat that forms the external tunic of
the posterior ⅚ of the eye
 Maintains the shape of the eye owing to its denseness
 Appears whitish externally except in children where it has a bluish tint, (owing to
the underlying choroid), and in old age when it has some yellowish tint
 Is invested externally by the fascial sheath of the eyeball, which separates it from
the orbital fat
 Appears brownish internally (where it is grooved by ciliary nerves and vessels)
 Is connected internally to the choroid by a delicate layer of pigmented areolar
tissue – the suprachoroid lamina. This occupies the perichoroidal space
between choroid and sclera
 Has a thickness of about 1 mm posteriorly and about 0.4 mm near the attachment
of the recti to the eye (about 6 mm behind the corneoscleral junction)
 Is covered anteriorly by the ocular conjunctiva
In addition, the sclera

 Is directly continuous with the cornea at the corneoscleral junction
 Is pierced posteriorly by fibres of the optic nerve. This part is referred to as the
cribriform part of sclera (so named because it is perforated)
 Is also pierced near the equator of the eye by 4–5 vorticose veins; these emerge
from the eye at equidistant points
 Contains an anular endothelium-lined canal – sinus venosus sclerae (canal of
Schlemm). This is located near the corneoscleral junction. It drains aqueous
humour from the anterior chamber of the eye to adjacent veins
 Is made of interlacing bundles of collagen fibres, interspersed by fine elastic
fibres and fibroblasts, some of which are pigmented

 The perichoroidal space separates the sclera and choroid; it contains the
suprachoroid lamina
 The suprachoroid lamina is a delicate layer of pigmented areolar tissue;
embedded in it are ciliary nerves and arteries
 The cribriform part of sclera is the posterior part of the sclera; it is pierced by
fibres of the optic nerve. An exceptionally large central perforation in this region
transmits the central retinal vessels
 Around the circumference of the cribriform part of the sclera are about 15–20
openings for the short ciliary nerves and short posterior ciliary arteries
 On each side, the long posterior ciliary artery and the long ciliary nerve pierce the
sclera just lateral to the point of entry of the short ciliary nerves and arteries
 The weakest part of the sclera is the cribriform part; it usually bulges outwards
in chronic glaucoma
 Just behind the sinus venosus sclerae, the deepest part of the sclera projects
inwards, like a rim. This projection limits the sinus behind (at the corneoscleral
junction)
 The sinus venosus sclerae may be duplicated
Blood Supply and Innervation of the Sclera
Note these facts:

 The sclera is supplied by short posterior ciliary and anterior ciliary arteries; it is
drained by the vorticose and anterior ciliary veins
 Sensory fibres to the sclera are branches of the ciliary nerves
Cornea
The cornea
 Is the anterior ⅙ of the external fibrous coat of the eyeball. It is avascular and
transparent
 Merges with the sclera at the corneoscleral junction, indicated externally by the
sulcus sclerae
 Is an essential refractive medium of the eye
 Is thicker at its periphery (1.2 mm) than at its centre (0.5–0.9 mm). The cornea is
thicker than the sclera
 Is convex and elliptical when viewed externally
 Gives attachment to the iris internally (at its junction with the sclera); the
iridocorneal angle is the junction between the cornea and the iris
 Limits the anterior chamber of the eye anteriorly
Structurally, the cornea is made up of 5 layers; these include, from external

internally:
1. Anterior epithelium of the cornea
2. Anterior limiting membrane of Bowman
3. Substantia propria
4. Posterior limiting membrane of Descemet, and
5. Endothelium of the anterior chamber
The anterior corneal epithelium

 Lines the anterior surface of the cornea
 Is basically of the non-keratinized stratified squamous type
 Consists of 5–8 layers of cells, the deepest of which are columnar while the
peripheral ones are squamous
 Is highly sensitive and regenerates rapidly after injury
The anterior limiting membrane of the cornea

 Lies just deep to the anterior corneal epithelium
 Measure about 8 μm in thickness
 Is structurally similar to the substantia propria (of the cornea), except that its
collagen fibres are randomly arranged, and it is devoid of fibroblasts and elastic
fibres
The substantia propria of the cornea

 Is fibrous and transparent
 Consists of about 250 superimposed layers of type II collagen fibres; fibres of
each layer are parallel but run in a different direction from those of adjacent
layers
 Has a matrix of proteoglycans in which are found some elastic fibres and
fibroblasts, besides collagen bundles
 May be invaded by leucocytes, lymphocytes and wandering macrophages
The posterior limiting membrane of Descemet

 Is located between the substantia propria and the endothelium of the anterior
chamber of the eye
 Appears transparent and homogenous
 Is usually regarded as the basement membrane of the subjacent endothelium (of
the anterior chamber)
 Readily separates from adjacent layers (i.e. from the substantia propria and
endothelium of anterior chamber)
 Has a mesh of collagen fibres

 Is continuous with the pectinate ligament at the periphery of the cornea
The endothelium of the anterior chamber

 Lines the posterior surface of the cornea and the whole of the anterior chamber of
the eye
 Consists of a single layer of large squamous cells
Nutrition and Innervation of the Cornea

 The cornea lacks blood and lymphatic vessels
 Nutrients diffuse to the cornea from adjacent capillaries and from the aqueous
humour of the anterior chamber
 Sensory fibres to the cornea arise mainly from the long ciliary nerves; these form
an anular plexus around the periphery of the cornea, from which nerve fibres
reach the substantia propria
 In the substantia propria, nerve fibres lose their myelin sheath and form a
subepithelial plexus, from which fibres reach the anterior corneal epithelium. In
the latter, these fibres form an intra-epithelial plexus
Applied Anatomy
Note these points:

 Irregularities of corneal surface result in inability to focus images sharply on the
retina, a condition known as astigmatism
 Corneal transplant (keratoplasty) can be done to replace a damaged cornea. The
prognosis for keratoplasty is usually good
Vascular Coat of the Eye (Uvea or Uveal Tract)

From posterior anteriorly, the vascular coat of the eye consists of:
 Choroid
 Ciliary body, and
 Iris

 The choroid occupies the posterior part of the vascular layer of the eye; it ends
anteriorly at the level of the ora serrata of the retina
 The ciliary body continues forwards from the choroid; it ends anteriorly at the
outer margin of the iris
 The iris is the pigmented circular diaphragm observable through the cornea; it
has an adjustable circular aperture – the pupil – in its centre
Choroid
The choroid
 Is a thin, highly vascular dark-brown tissue, located between the sclera and retina
(in the posterior part of the vascular coat of the eye)
 Occupies approximately the posterior ⅚ of the vascular coat of the eye.
Anteriorly, it ends at the ora serrata of the retina
 Is loosely connected to the sclera by the suprachoroid lamina. However, it is
attached firmly to the sclera (posteriorly) where the optic nerve and ciliary
arteries pierce it
 Is continuous with the leptomeninges (pia-arachnoid layer) of the optic nerve at
the optic disc
 Is attached firmly to the pigmented layer of the retina (on its internal aspect)
 Consists of a fibro-elastic tissue in which pigmented stellate cells and
phagocytes are embedded
 Is thicker in its posterior than its anterior part
Structure of the Choroid
From external internally, the choroid may be defined as consisting of the following
layers:
 Suprachoroid lamina
 Vascular lamina
 Capillary lamina or choroidocapillaris, and
 Basal lamina (Bruch’s membrane)
Suprachoroid Lamina
The suprachoroid lamina of the choroid

 Is a thin layer of delicate cellular tissue located adjacent to the sclera. It Occupies
the potential perichoroidal space
 Attaches the choroid loosely to the sclera
 Is traversed by ciliary nerves and long posterior ciliary arteries; these groove the
internal aspect of the sclera
Vascular Lamina of the Choroid
The vascular lamina of the choroid

 Is located immediately deep to suprachoroid lamina

 Is endowed with an extensive array of small arteries and veins; these are mainly
branches of short posterior ciliary arteries and tributaries of vorticose veins
 Also has some elements of loose connective tissue, including scattered pigmented
cells
Capillary Lamina (or Choroidocapillaris)
This layer of the choroid

 Is located just deep to the vascular layer of the choroid
 Consists of a complex meshwork of capillaries. These capillaries are continuous
anteriorly with those of the ciliary processes
 Is separated from the retina only by the thin basal lamina of the choroid
 Supplies nutrients, in part, to the retina
Basal Lamina (Membrane of Bruch)
The basal lamina of the choroid

 Lies just external to the pigment layer of the retina
 Appears thin, glassy and homogeneous; it is just about 3 µ in thickness
 Is formed by the basement membrane of the endothelium of the choroidal
capillaries externally, and that of the retinal pigment epithelium internally
 May be involved in the regulation of passage of solutes and fluid from the
choroid to the retina
Ciliary Body
The ciliary body

 Extends from the choroid behind to the iris in front (or from the ora serrata
posteriorly to the scleral spur anteriorly)
 Is lined on its internal aspect by the ciliary part of the retina; this is a double-
layered columnar epithelium, the external of which is pigmented
 Appears greyish in colour owing to the presence of melanin in the external layer
of its underlying epithelium
 Has a structure similar to that of the choroid except that the suprachoroid lamina
is scanty while the choroidocapillaris is absent. Its stroma consists of loose
fasciculi of collagen fibres. It is in this framework that blood vessels (branches of
ciliary arteries and tributaries of ciliary veins) and ciliary muscle are embedded
 Is highly vascular, as the anterior ciliary and the long and short posterior ciliary
arteries anastomose within it. It contains the major arterial circle in its anterior
end – this is formed mainly by the long posterior ciliary arteries
 Gives attachment to the suspensory ligament of the lens; thus, it keeps the lens in
position
 Is involved in the process of accommodation (for focusing near objects)
 Produces the aqueous humour of the anterior segment of the eye; it may also be
involved in the secretion of glycosaminoglycans of the vitrous body of the
posterior segment of the eye
 Is traversed by the major sensory and autonomic nerves of the eye
The ciliary body consists of:
Ciliary ring
 Ciliary processes
 Ciliary muscle and
 Ciliary epithelium
The ciliary ring

 Extends from the ora serrata of the retina behind, to the external extremities of
the ciliary processes in front. It is somewhat ridged in appearance
 Measures about 4 mm in width
Ciliary processes of the ciliary body

 Are about 70–80 radially disposed folds of ciliary tissue, the free ends of which
are directed towards the periphery of the lens. They radiate from the base of the
iris to the ciliary ring; and each is about 2 mm long
 Give attachment to some fibrils of the suspensory ligament of the lens
 Are endowed with numerous minute folds which characterize their surface
 Produce the aqueous humour of the anterior segment of the eye
The ciliary muscle

 Occupies the interval between the sclera, ciliary ring and ciliary processes,
adjacent to the attached rim of the iris
 Is made of smooth fibres, which are disposed longitudinally (meridionally) and
circularly; the anterior attachment of the ciliary muscle is onto the scleral spur
(from which its fibres are directed either circularly or longitudinally)

 The meridional (longitudinal) fibres of ciliary muscle are more superficial; they
radiate backwards from the scleral spur to the ciliary ring and choroid
 The circular fibres of ciliary muscle are located deep to the meridional fibres;
they are directed circumferentially from the scleral spur
 Contraction of ciliary muscle is required for accommodation. In this process, the

ciliary ring and processes are drawn antero-internally, thereby relaxing the
suspensory ligament of the lens. This increases the convexity of the lens, and thus
decreases its focal length (making it possible to focus near objects)
 The ciliary muscle is innervated by postganglionic parasympathetic fibres from
the ciliary ganglion
 Circular fibres of ciliary muscle are absent in myopia but well developed in
hypermetropia
The ciliary epithelium

 Is the ciliary part of the retina; it lines the internal aspect of the ciliary body
 Consists of two layers of columnar cells, the external of which is filled with
melanin pigment, and is continuous behind with the pigment layer of the retina.
The internal layer is continuous behind with neural layer of the retina
 Is derived from the optic cup of the embryo
Iris
The iris
 Is an adjustable pigmented diaphragm located anterior to the lens
 Has an aperture – the pupil – which is located a little medial to its centre
 Varies in colour from light blue to dark grey; however, it is largely devoid of
pigment at birth
 Joins the cornea at the iridocorneal angle; the iris is also directly continuous
behind with the ciliary body
 Divides the anterior segment of the eye into two chambers – an anterior
chamber between the iris and cornea, and a posterior chamber between the iris
and the lens
 Is bathed on both surfaces by the aqueous humour. This is produced in the
posterior chamber by the ciliary processes; it enters the anterior chamber through
the pupil and is drained by the scleral venous sinus at the iridocorneal angle
(filtration angle) of the anterior chamber
 Has an average diameter of 12 mm
The pupil
 Is a near circular aperture located just medial to the centre of the iris
 Varies from 1–8 mm in diameter; this can be more or less
 Is the opening via which rays of light are incident on the lens
 Can be readily adjusted, as occasion demands, by the sphincter and dilator
muscles of the iris
 Is closed in foetus by a thin vascular membrane – the pupillary membrane
Structure of the Iris
The iris consists of

 A stroma of vascular connective tissue anteriorly, and
 A bilaminar pigmented epithelium posteriorly; this epithelium corresponds to the
iridial part of the retina
The stroma of the iris

 Is the anterior layer of the iris; it is made up of vascular connective tissue
 Consists of a loose collagenous framework in which are embedded fibroblasts,
melanocytes, mast cells, lymphocytes and macrophages
 Does not possess elastic fibres
 Has a ring of smooth muscle fibres – sphincter pupillae – located adjacent to its
pupillary margin
 Also has a dilator pupillae in its posterior aspect; fibres of this muscle are
radially disposed
 Is derived embryologically from the mesoderm between the developing lens and
the optic cup
 Contains the lesser arterial circle; this is located adjacent to its pupillary margin
Sphincter Pupillae (pupillary Sphincter)
The sphincter pupillae

 Is a ring of fusiform smooth muscle fibres located in the pupillary margin of the
iris
 Produces narrowing of the pupil
 Receives postganglionic parasympathetic fibres from the ciliary ganglion (via the
short ciliary nerves); stimulation of these fibres would produce contraction of the
muscle (and thus narrowing of the pupil)
 Is involved in pupillary light reflex – narrowing of the pupil in response to high
intensity light
 Is ectodermal (not mesodermal) in origin
Dilator Pupillae
The dilator pupillae

 Is a layer of contractile elements located on the posterior aspect of iridial stroma,
just adjacent to the anterior layer of the iridial part of the retina
 Does not possess smooth muscle fibres like the sphincter pupillae; rather, it
consists of muscular processes of myoepithelial cells of the anterior layer of the
iridial part of the retina
 Is responsible for widening the pupil
 Receives postganglionic sympathetic fibres from the superior cervical ganglion,
via the internal carotid plexus and the short (and possibly long) ciliary nerves.
These fibres traverse the ciliary ganglion without interruptions
 Is also ectodermal (not mesodermal) in origin
Nerves of the Iris
Nerve fibres of the iris are derived from

 The short ciliary nerves, branches of the ciliary ganglion. These nerves convey
postganglionic parasympathetic fibres to the sphincter pupillae and
postganglionic sympathetic fibres to the dilator pupillae
 The long ciliary nerves, from nasociliary nerves. These nerves may convey
postganglionic sympathetic fibres to dilator pupillae
Vessels of the Iris
Note the following:

 Arteries of the iris are derived from branches of the anterior and long posterior
ciliary arteries
 At the attached margin of the iris, branches of the above arteries form a major
arterial circle (an arterial ring)
 From the major arterial circle, vessels extend radially through the iris to its
pupillary margin; here, they anastomose to form a circumferential minor arterial
circle
 Veins of the iris pass radially outwards to join those of the ciliary body
Pupillary Membrane
The pupillary membrane

 Is a thin vascular membrane which closes the pupil during foetal life
 Is vascularized by branches of the hyaloid artery and later by vessels of the iris
 Begins to breakdown from its centre outwards at about the 6th month of
pregnancy
 Is largely absent at birth, having degenerated as far externally as the minor
arterial circle of the iris
 May persist postnatally, thereby interring with vision

Iridial Part of the Retina
Regarding the iridial part of the retina, note that

 It is a pigmented bilaminar epithelium which lines the posterior aspect of the
stroma of the iris
 It is continuous behind with the ciliary part of the retina
 Its posterior layer is of heavily pigmented epithelial cells; this (posterior) layer
is continuous behind with that of the ciliary part of the retina (which is non-
pigmented)
 Its anterior layer is of pigmented myoepithelial cells; the muscular processes of
these cells extend into the stroma of the iris to form the dilator pupillae
Inner Coat of the Eye
Retina
The retina
 Is the inner sensory layer of the eyeball, which contains the photosensitive cells
 Is divisible into three parts, from posterior anteriorly: optic part (deep to the
choroid), ciliary part (deep to the ciliary processes) and iridial part (deep to the
iris)
 Is largely bilaminar, the outer layer of which is pigmented, while the inner layer
possesses neural tissue (in the optic part only); thus, it
 Is devoid of neural elements in its ciliary and iridial parts, where it is represented
by a thin bilaminar epithelium (the external of which is pigmented in the ciliary
part and both of which are pigmented in the iridial part)
 Varies in thickness, as it diminishes from 0.56 mm near the optic disc posteriorly,
to about 0.1 mm at the ora serrata anteriorly
 Is extremely thin at the fovea centralis and optic disc
 Presents an oval yellow spot – the macula lutea – at the visual axis (posteriorly).
The centre of the macula lutea has a depression – the fovea centralis – where
visual resolution is highest
 Is continuous with the optic nerve at the circular optic disc. The latter is about 3
mm medial to the macula lutea
The retina has three parts; these include:

 Optic part, which lines the internal aspect of the choroid
 Ciliary part, which lines the internal aspect of the ciliary processes, and
 Iridial part, which lines the internal aspect of the iris

 The optic part of the retina extends from the optic disc behind to the ora serrata
in front; it has an outer pigmented epithelial layer and an inner nervous
(cerebral) layer
 The nervous and pigmented epithelial layers of the optic part of the retina are
loosely adherent to each other; however,
 The pigmented epithelial layer is firmly adherent to the overlying choroid. Thus,
 In the event of detachment of the retina, the nervous layer of the optic part of
the retina separates from the pigmented epithelial layer, while the latter usually
remains attached to choroid
Optic Disc
The optic disc

 Is one of the thinnest parts of the retina; it is the region where fibres of the optic
nerve exit the eye
 Is located about 3 mm medial (nasal) to the macula lutea, and a little above this
 Is slightly depressed, with a raised pigmented margin
 Is non-pigmented and insensitive (devoid of photoreceptors); it may appear
pinkish, greyish or whitish in colour
 Measures about 1.5 mm in diameter
 Is pierced (centrally) by the central retinal vessels
Macula Lutea of the Retina
The macula lutea

 Is the small yellowish oval spot of the nervous layer of the retina; it is located in
the visual axis (posteriorly)
 Possesses a central depression – the fovea centralis – where visual resolution is
highest. At the fovea, rods (a type of photoreceptors) are absent and the retina is
extremely thin
Ora Serrata
The ora serrata

 Is the serrated boundary between the optic and ciliary parts of the retina
 Also marks the junction between the choroid and ciliary body
Structure of the Optic Part of the Retina
Structurally, the optic part of the retina can be defined as comprising ten layers (Fig.
136). These include, from external internally:
 Pigment epithelium of the retina
 Processes of rods and cones
 External limiting lamina
 External nuclear lamina
 External plexiform lamina
 Internal nuclear lamina
 Internal plexiform lamina
 Ganglionic cell lamina
 Lamina of optic nerve fibres, and
 Internal limiting lamina
Layer 1: Pigment Epithelium of the Retina (Fig. 136)
The pigment epithelium of the retina

 Is a single layer of heavily pigmented cuboidal cells; these cells increase in
number with age
 Extends from the periphery of the optic disc to as far anteriorly as the iridial part
of the retina
 Possesses basally placed nuclei (closer to the basal lamina of choroid), and apical
microvilli which interdigitate with processes of rods and cones
 Is firmly adherent to the choroid; its basement membrane merges with that of
choroidal capillary endothelium to form the basal lamina of the choroid
(Bruch’s membrane)
 Is loosely attached to the neural layer of the retina; the latter may therefore detach
from it in certain conditions
 Contain abundant melanin pigment in its cells; this accumulates in the microvilli
of these cells in response to increasing illumination
 Also contains lipofuscin (which represents the end product of phagocytic activity
of it cells)
Figure 136. Layers of the retina.
Functions of the pigment layer of the retina include:

 Absorption of light rays which pass through the retina (thereby preventing these
rays from being reflected back into the nervous layer)
 Phagocytic activity
 Stability of the photoreceptors (rods and cones of the nervous layer), and
 A probable nutritive role
Layer 2: Processes of Rods and Cones
The processes of rods and cones

 Are the photoreceptive portions of rods and cones; these processes are directed
radially towards the pigment epithelium of the retina (and thus, towards the
choroid)
 Interdigitate with the microvilli of cells of the pigment epithelium of the retina
 Appear cylindrical in rod and conical in cones
 Are densely and regularly packed; their density decreases towards the ora serrata
 Contain visual pigments, which include rhodopsin in the rods and iodopsin in
the cones
 Are absent in the optic disc but exceptionally of higher density in the macula.
Only cone processes are present in the fovea centralis (the rods being absent)
 Are estimated at 110–125 million for rods and 6–7 million for cones
Layer 3: External Limiting Lamina
The external limiting lamina of the retina

 Is formed by the processes of retinal gliocytes (Muller cells), just external to the
somata of cones
 Lie at the junction of the processes of rods and cones with the somata of cones
and outer fibres of rods
 Is perforated by processes of rods and cones as these radiate towards the pigment
epithelium
Layer 4: External Nuclear Lamina
The external nuclear lamina

 Is located just deep (internal) to the external limiting lamina
 Contains the somata of rods and cones, in which the nuclei of these cells are
located. Nuclei of rods are more deeply placed (closer to the vitrous body) than
those of cones
Layer 5: External Plexiform Lamina
The external plexiform lamina of the retina

 Is located deep to the external nuclear lamina
 Is a complex synaptic zone where the spherules of rods and pedicles of cones (i.e.
the inner synaptic ends of these cells) form synaptic connections with dendrites
and axons of the bipolar and horizontal neurons of the retina
Layer 6: Inner Nuclear Lamina
The inner nuclear lamina of the retina

 Is located just internal (deep) to the external plexiform lamina
 Contains the somata and nuclei of the bipolar, horizontal and amacrine neurons,
as well as those of Muller cells. These nuclei are arranged in layers
In the inner nuclear lamina of the retina, the contained somata are arranged in
layers. These include, from superficial deeply:
 Layer of somata of horizontal neurons

 Layer of somata of bipolar neurons
 Layer of somata of Muller cells, and
 Layer of somata of amacrine neurons
Layer 7: Internal Plexiform Lamina
The internal plexiform lamina of the retina

 Occupies the interval between the internal nuclear lamina externally and the layer
of ganglion cells internally
 Consists of cytoplasmic processes of bipolar, amacrine and ganglion neurons, and
the synaptic junctions between them
Layer 8: Ganglionic Cell Lamina
Regarding the ganglionic cell lamina, note the following:

 This lamina consists of somata of ganglion cells. The latter are usually arranged
in a single layer (though multilayers are formed towards the macula lutea)
 Ganglion cells form the 2nd order neurons in the visual pathway
 Dendrites of ganglion cells extend outwards into the internal plexiform lamina
where they synapse with processes of bipolar and amacrine neurons
 Axons of ganglion cells converge towards the optic disc, forming, as they do so,
the 9th layer of the retina (and as these axons exit the optic disc, they form optic
nerve).
Layer 9: Lamina of Optic Nerve fibres
Regarding the lamina of optic nerve fibres, note the following:

 This lamina occupies the interval between the somata of ganglion cells externally
and the internal limiting lamina internally
 It is formed by axons of ganglion cells (which converge towards the optic disc to
form the optic nerve)
 Axons of ganglion cells are unmyelinated in the retina; myelination of these
axons commences at the optic disc, where the optic nerve is formed
 Processes of retinal gliocytes support the axons of ganglion cells as these
converge towards the optic disc
Layer 10: Internal Limiting Lamina
The internal limiting lamina of the retina

 Limits the retina internally, thereby separating it from the hyaloid membrane of
the vitrous body
 Consists of branching terminals of fibres of the retinal gliocytes and their
associated basal lamina
 Is involved in the exchange of fluid between the retina and the vitreous body
Vessels of the Retina
Regarding the blood supply and nutrition of the retina, note that
 The retina receives direct arterial supply from branches of the central retinal
artery – a branch of ophthalmic artery
 The central retinal artery, having arisen from ophthalmic artery, pierces the optic
nerve about 1.25 cm behind the eyeball. It then passes forwards within this nerve,
to the eyeball
 A central aperture in the lamina cribrosa of the sclera transmits the central retinal
artery; here, the artery divides into a superior and an inferior branch
 Ultimately, the central retinal artery divides into four major branches; these
include superior and inferior nasal and superior and inferior temporal arteries
 Each of the four major branches of the central retinal artery supplies a quadrant of
the retina. These vessels divide dichotomously in the retina and their terminal
branches are end arteries (i.e. they do not anastomose)
 Branches of the central retinal artery and their veins are located in lamina 9 of the
retina (lamina of optic nerve fibres). Smaller branches of this vessel may extend
as far externally as the internal nuclear lamina
 The fovea centralis does not contain blood vessels
Moreover, note the following:

 The superficial (external) layers of the retina receive nutrients from choroidal
vessels (by diffusion)
 Veins of the retina accompany braches of the central artery; they ultimately form
the central retinal vein
 The central retinal vein leaves the eyeball through an aperture in the lamina
cribrosa of the sclera to enter the optic nerve. It then crosses the subarachnoid
space of this nerve, from which it emerges to join the superior ophthalmic vein. It
may end in the cavernous sinus
 Ophthalmoscopy demonstrates the branches of central retinal artery and
tributaries of central retinal vein as these traverse the nerve fibre layer of the
retina (in the living)
 Detachment of the retina (separation of its neural layer from the pigment layer)
interferes with nutrition of the photoreceptors of the affected area, and thus, with
the functional integrity of this part
Refractive Media of the Eye
The refractive media of the eye

 Transmit and refract light rays
 Have different refractive indices. Only the refractive power of the lens can be
varied
 Include the cornea, aqueous humour, vitrous body and lens
Aqueous Humour
The aqueous humour

 Is the watery fluid that occupies the anterior and posterior chambers of the
anterior segment of the eye. It baths both surfaces of the iris
 Is involved in the transmission and refraction of light through the eye. It has a
refractive index of 1.336
 Is produced by the epithelium of the ciliary processes into the posterior chamber
of the anterior segment of the eye (by active transport). Then, it
 Flows into the anterior chamber of the eye through the pupil
 Drains (from the anterior chamber) into the scleral venous sinus, at the
iridocorneal angle. From this sinus, the fluid enters the episcleral veins
 Contains glucose, amino acids, sodium chloride (1.4 %), respiratory gases and
vitamin C
 Serves as a source of nutrients to the cornea and lens
 May accumulate in excess, thereby raising the intra-ocular pressure (a condition
characteristic of glaucoma). This condition may arise if drainage of the fluid (at
the iridocorneal angle) is interrupted or if the iris adheres to the lens thereby
interfering with the flow of aqueous humour. Retinal degeneration and blindness
may thus result
Vitrous Body
The vitrous body

 Is a transparent, colourless and structureless jelly-like substance, which occupies
the vitreous chamber – the posterior 4/5 of the eye (between the lens and the
retina)
 Has a deep concavity on its anterior aspect – the hyaloid fossa – which lodges
the lens
 Is traversed by the sinuous hyaloid canal, which extends from the centre of the
optic disc to the centre of the posterior surface of the lens. It transmits the
hyaloid artery in the foetus but is filled with an aqueous fluid in adults. The
artery degenerates about 6 weeks prior to birth
 Is surrounded by the hyaloid membrane, a condensation of the peripheral part of
the vitrous body. From the anterior thickened part of this membrane, the hyaloid
membrane gives rise to numerous zonular fibres which adhere to the ciliary
processes, and thence pass to the lens, forming the suspensory ligament
In addition, note that the vitrous body

 Consists of 99% water; it also has some salts, glycoprotein and hyaluronic acid
 Also possesses some rounded cells termed hyalocytes
 Is permeated by type II collagen fibrils
 Does not possess blood vessels in postnatal life
 Is nourished by diffusion of nutrients from the retinal and ciliary vessels
Lens
The lens
 Is a biconvex avascular transparent body located between the iris and the vitrous
body (Fig. 135)
 Is enclosed in a transparent, elastic homogeneous capsule (of about 15 μ thick).
This gives attachment to the suspensory ligament of the lens
 Is more convex posteriorly than anteriorly
 Occupies the hyaloid fossa of the vitrous body posteriorly. Anteriorly, it is in
contact with the pupillary margin of the iris and is bathed by aqueous humour
 Is surrounded at it circumferential margin by ciliary processes, from which the
zonular fibres of the suspensory ligament radiate to it
 Has an average transverse diameter of about 10 mm. At birth, this measures
about 6.5 mm
 Has an axial (anteroposterior) diameter of 4–5 mm (in adults). At birth, this
diameter is about 3.5–4.0 mm
 Has a refractive index that ranges from 1.386 in its periphery to 1.406 in its
centre.
Note the following terms:

 The anterior pole of the lens is the centre of its (less convex) anterior surface
 The posterior pole of the lens is the centre of its (more convex) posterior surface
 A line which joins the anterior and posterior poles of the lens is defined as the
axis (of the lens)
 The circumferential margin of the lens is referred to as the equator
Structure of the Lens
Note that
 The ribbon-like cells that form the lens are referred to as lens fibres (or lens
cells)
 The peripheral part of the lens is soft and is referred to as the cortex
 The central part of the lens is firm and is referred to as the nucleus
 Each lens consists of several concentrically arranged laminae of lens fibres.
These laminae are arranged around the axis of the lens
 The lens fibres (cells) in the superficial laminae are nucleated while those in the
deep laminae are devoid of nuclei
 Lens fibres contain semi-stiff transparent proteins termed crystallins. These
proteins confer transparency and malleability on the lens
 A simple cuboidal epithelium lines the anterior surface and equator of the lens;
cells of this epithelium are nucleated
 New lens fibres are derived from the epithelial cells of the lens, at the equator.
Here, nucleated cuboidal epithelial cells differentiate and become elongated to
form lens fibres
Also note that

 The foetal lens is spherical. It receives arterial blood from the hyaloid artery (a
branch of central retinal artery)
 The convexity and thus, the refractive power of the lens can be adjusted by the
action (contraction/relaxation) of ciliary muscle
 When ciliary muscle contracts, the suspensory ligament of the lens is relaxed.
This allows the lens to become more rounded, thereby increasing its convexity
and thus its ability to focus near objects on the retina, a process referred to as
accommodation
 When the ciliary muscle relaxes, it tightens the suspensory ligament of the lens,
thereby making the lens less convex; this enables the latter to focus far objects
sharply on the retina
 As age advances, the lens becomes increasingly firmer and less curved (on both
surfaces). This makes it difficult to focus near objects on the retina – a condition
known as presbyopia
Applied Anatomy of the Eye

 Owing to its endarterial nature, blockage of a major branch of the central retinal
artery would lead to infarction of retinal tissue
 Irritation of the conjunctiva (following exposure to smoke, dust, etc) would
produce dilatation and congestion of its blood vessels, a condition known as
hyperemia of the conjunctiva (bloodshot eyes)
 The conjunctiva may also become inflamed, a condition referred to as
conjunctivitis. This condition is contagious and may be of bacterial or allergic
origin
 Pupillary light reflex – constriction of the pupil in response to a beam of light
incident on the retina – is a routine test in neurological examinations
 In direct pupillary light reflex, the pupil of the same eye constricts in response
to light incident on the retina of that eye; in consensual pupillary light reflex,
the pupils of both eyes constrict in response to light incident on a single eye
 Inequality of the diameter of the pupils is referred to as anisocoria. Argyll-
Robertson pupil is characterised by impairment or loss of pupillary light reflex
but undisturbed accommodation; it is associated with syphilis (tabes dorsalis)
 The retina and branches of its vessels could be examined clinically with an
ophthalmoscope. In this procedure (ophthalmoscopy), the optic disc usually
appears pale, while the retina appears reddish
 Pulsation of branches of the central retinal artery could be observed in
ophthalmoscopy
 Following a blow to the eye, detachment of the retina (separation of part of its
neural layer from the pigment epithelium) may occur; this obscures vision
 In increased intracranial (CSF) pressure, impaired retinal venous return, and thus
retinal oedema, occurs. This produces swelling of the optic disc – papilledema –
which could be observed by ophthalmoscopy
 Insensitivity of the cornea could result from injury to the ophthalmic nerve. This
may lead to ulceration of this organ
 Cataract is characterized by opacity of the lens. This condition could be
corrected surgically (cataract extraction)
 Progressive loss of flexibility of the lens occurs as age advances. This reduces the
focusing power of the lens, thereby making it difficult to appreciate near objects –
a condition referred to as presbyopia
 Thrombophlebitis of the cavernous sinus may adversely affect the central retinal
vein. Blockage of the latter by a clot may lead to visual deficits
Extraocular Muscles (Fig. 137,138)

Extraocular muscles include:

 Four recti (superior, inferior, medial and lateral recti)
 Two oblique (superior and inferior oblique), and
 One levator palpebrae superioris

 The four recti take origin from a common tendinous ring
 The common tendinous ring of the recti surrounds the optic canal and
inferomedial part of superior orbital fissure
 Certain nerves and vessels enter the orbit within the tendinous ring; these include
the two divisions of oculomotor, nasociliary, abducent and optic nerves, and the
ophthalmic artery
 The superior and inferior ophthalmic veins exit the orbit through the superior
orbital fissure, above and below the common tendinous ring respectively. Both
may however pass through the ring
 The lateral and medial recti lie in the same horizontal plane. The superior and
inferior recti likewise lie in the same vertical plane
Fig. 137. Extraocular muscles.
The superior rectus

 Lies above the eyeball (as it stretches from the common tendinous ring behind to
the sclera in front)
 Is located just deep to levator palpebrae superioris
Proximal attachment: Upper part of the common tendinous ring
Distal attachment: Anterosuperior part of the sclera (about 7.7 mm from

corneoscleral junction)
Innervation: Upper division of oculomotor nerve
Actions:
 Elevates and medially rotates the eyeball
 Also adducts the eye
Figure 138. Diagram showing actions of extraocular muscles.
The inferior rectus

 Lies below the eyeball (as it stretches from the common tendinous ring behind to
the sclera in front)
 Lies above the inferior oblique (at its insertion)
Proximal attachment: Lower part of common tendinous ring
Distal attachment: Anteroinferior part of the sclera (about 6.5 mm from

corneoscleral junction)
Innervation: Inferior division of oculomotor nerve
Actions:
 Depresses and medially rotates the eyeball
 Also adducts the eye
The medial rectus

 Is located between the eyeball and the medial orbital wall
Proximal attachment: Medial part of common tendinous ring
Distal attachment: Anteromedial part of the sclera (about 5.5 mm from corneoscleral
junction)
Actions: Adducts the eye (i.e. turns the cornea medially)
The lateral rectus

 Is located between the eyeball and the lateral orbital wall
 Is related, along its upper margin, to the lacrimal nerve
 Is also related, on its medial aspect, to the ciliary ganglion (behind)
Proximal attachment: Lateral part of common tendinous ring
Distal attachment: Anterolateral part of the sclera (about 7.0 mm from corneoscleral
junction)
Innervation: Abducent nerve
Actions: Abducts the eye (i.e. turns the cornea laterally)
The levator palpebrae superioris

 Is located just below the orbital roof (above the superior rectus)
 Is related on its upper aspect to the frontal nerve
 Forms an aponeurosis distally (towards its distal attachment). The middle layer of
this aponeurosis contains smooth muscle fibres and is inserted into the upper
margin of the superior tarsal plate
 Opposes the action of orbicularis oculi. Orbicularis oculi depresses, while levator
palpebrae superioris elevates the upper eyelid
Proximal attachment: Roof of the orbit (lesser wing of sphenoid), just

anterosuperior to the optic canal
Distal attachment (via an aponeurosis):

 Anterior surface of the superior tarsus and skin of the upper eyelid (through the
anterior layer of its aponeurosis)
 Upper margin of superior tarsus (through the middle layer of its aponeurosis; this
layer contains smooth muscle fibres)
 Upper conjunctival fornix (through the posterior layer of its aponeurosis)
Innervation:
 Upper division of oculomotor nerve; this supplies the skeletal muscle part of
levator palpebrae superioris
 Postganglionic sympathetic fibres (from the superior cervical ganglion); these
innervate the smooth muscle part of levator palpebrae superioris
Action: Elevates the upper eyelid
The superior oblique

 Is largely fusiform in outline
 Passes forwards and upwards on the medial orbital wall (from its origin), above
the medial rectus
 Traverses a fibrocartilagenous loop, the trochlea (which is attached to the
trochlear fossa of the frontal bone); here, the muscle forms a rounded tendon that
is surrounded by synovial sheath
 Emerges from its trochlea to pursue a posterolateral course (deep to the superior
rectus). It is ultimately inserted into the sclera, between the superior and lateral
recti, and behind the equator of the eye
Proximal attachment: Spheroidal body (superolateral to optic canal)
Distal attachment: Superolateral part of the sclera, behind the ocular equator (and
between the attachment of superior and lateral recti)
Innervation: Trochlear nerve (cranial nerve IV)
Actions:
 Depresses and medially rotates the eyeball
 Abducts the eyeball
The inferior oblique

 Is located across the anterior part of orbital floor
 Ascends posterolaterally (from its medial bony attachment), first between the
orbital floor and inferior rectus, and then between the eyeball and lateral rectus
 Is attached onto the inferolateral part of the sclera, behind the equator of the eye
and between the inferior and lateral recti
Proximal attachment: Anterior part of orbital floor (just lateral to the lacrimal
groove)
Distal attachment: Inferolateral part of the sclera (behind the ocular equator and
between the attachment of inferior and lateral recti)
Actions:
 Elevates and laterally rotates the eyeball
 Also abducts the eyeball
Applied Anatomy
Regarding the extraocular muscles, note the following:

 Paralysis of the smooth muscle part of levator palpebrae superioris (e.g.
following injury to T1 spinal segment or the cervical sympathetic chain) would
produce drooping of upper eyelid – ptosis
 Ptosis is one of the manifestations of Horner’s syndrome. The latter arises
following damage to the cervical sympathetic fibres (see below)
 Ptosis could also arise following lesion of the oculomotor nerve (in which the
skeletal muscle part of levator palpebrae superioris is paralyzed)
 Injury to the oculomotor nerve leads to paralysis of all extraocular muscles
except lateral rectus and superior oblique. Thus, the affected eye becomes
abducted and depressed (‘down and out’)
 When the lateral rectus is paralyzed (e.g. from injury to abducent nerve), the
affected eye assumes an adducted position (owing to the unopposed action of the
medial rectus). This results in diplopia
 In paralysis of superior oblique (e.g. following injury to the trochlear nerve),
diplopia occurs when looking downwards (owing to the inability to turn the
affected eye inferomedially)
 Paralysis of both the smooth and skeletal muscle parts of levator palpebrae
superioris would lead to total closure of the affected eye (owing to unopposed
action of palpebral part of orbicularis oculi)
Horner’s syndrome arises following interruption of the cervical sympathetic chain

or injury to the T1 segment of the spinal cord. Its characteristic features include:
 Slight enophthalmos (sinking of the eyeball into the socket)
 Ptosis (drooping of upper eyelid)
 Miosis (pupillary constriction)
 Decreased sweating on the affected side of the face
 Vasodilatation of facial, retinal and conjunctival vessels, and
 A rise in facial temperature (on the affected side)
Nerves of the Orbit
Nerves of the orbit consist of those that traverse, arise or end in the orbit; they
include:
 Optic nerve, from the eyeball (retina)
 Upper and lower divisions of oculomotor nerve (3rd cranial nerve)
 Trochlear nerve (IVth cranial nerve)
 Abducent nerve (VIth cranial nerve)
 Lacrimal nerve, a branch of ophthalmic nerve
 Nasociliary nerve, a branch of ophthalmic nerve
 Frontal nerve, also a branch of ophthalmic nerve
 Anterior and posterior ethmoidal nerves, branches of nasociliary nerve
 Infratrochlear nerve, also a branch of nasociliary nerve
 Long ciliary nerves, branches of nasociliary nerve
 Short ciliary nerves, branches of the ciliary ganglion
Oculomotor Nerve (Cranial Nerve III)
The oculomotor nerve

 Enters the orbit through the superior orbital fissure (within the common tendinous
ring of the recti) as superior and inferior divisions
 Innervates superior rectus and levator palpebrae superioris through its superior
division
 Innervates inferior oblique and inferior and medial recti through its inferior
division
 Gives a branch (which contains preganglionic parasympathetic fibres from the

accessory oculomotor nucleus) to the ciliary ganglion. This branch arises from its
inferior division
Optic Nerve (Intraorbital Part)
The intraorbital part of optic nerve

 Emerges from the eyeball through the lamina cribrosa of the sclera (about 3 mm
medial to the posterior pole of the eye)
 Passes posteromedially from the eyeball to the optic canal, where it exits the
orbit. This part of the nerve is sinuous
 Contains about 1.2 million myelinated axons. These axons are those of ganglion
cells of the retina
 Measures about 25 mm in length
 Is surrounded by orbital fat and recti muscles
 Has its own meningeal coverings (pia, arachnoid and dura); the subarachnoid
space lies between the pia and arachnoid layers
 Is pierced on its inferomedial aspect by the central retinal vessels, about 12 mm
behind the eyeball
Trochlear Nerve (Cranial Nerve IV)
The trochlear nerve, the most slender of the cranial nerves,

 Enters the orbit through the superior orbital fissure (above the common tendinous
ring of the recti)
 Passes forwards, medially and upwards (above the origin of levator palpebrae
superioris) to innervate the superior oblique (the only muscle it supplies)
Abducent Nerve (Cranial Nerve VI)
The abducent nerve

 Enters the orbit through the superior orbital fissure, within the common tendinous
ring
 Passes forwards to innervate the lateral rectus. It enters this muscle through its
deep (medial) surface
Lacrimal Nerve
The lacrimal nerve

 Is the smallest of the main branches of ophthalmic nerve

 Arises from the ophthalmic nerve in the lateral wall of the cavernous sinus
(outside the orbit)
 Enters the orbit through the lateral part of the superior orbital fissure (above the
common tendinous ring of the recti)
 Passes forwards, on the lateral wall of the orbit, along the upper border of the
lateral rectus (accompanied by the lacrimal artery)
 Communicates with the zygomaticotemporal branch of maxillary (in the orbit).
Through this communication, the lacrimal nerve receives postganglionic
parasympathetic fibres from the pterygopalatine ganglion
 Gives sensory and secretomotor (postganglionic parasympathetic) fibres to the
lacrimal gland
 Also gives sensory fibres to the upper eyelid and conjunctiva
 May be absent, in which case it is replaced by the zygomaticotemporal nerve
Nasociliary Nerve
The nasociliary nerve

 Arises from the ophthalmic nerve, in the middle cranial fossa
 Enters the orbit through the superior orbital fissure, within the common tendinous
ring, and between the divisions of the oculomotor nerve
 Crosses the upper aspect of the optic nerve from lateral medially (in the orbit).
Then, it
 Continues forwards and medially between the medial rectus and superior oblique,
to the medial wall of the orbit
 Leaves the orbit by traversing the anterior ethmoidal foramen as the anterior
ethmoidal nerve
 Gives rise to infratrochlear and long ciliary nerves. It may also give rise to the
posterior ethmoidal nerve
 Gives sensory fibres to the eyeball, conjunctiva, eyelids, lacrimal sac and
caruncle, ethmoidal sinuses, nasal mucosa and external nose (through its
branches)
 Also sends a branch to the ciliary ganglion
Anterior Ethmoidal Nerve
The anterior ethmoidal nerve

 Is the continuation of the nasociliary nerve; it leaves the orbit through the
anterior ethmoidal foramen and canal
 Enters the anterior cranial fossa where it runs forwards in a groove on the
cribriform plate of ethmoid (deep to the dura mater, which it also supplies)
 Exits the anterior cranial fossa by descending into the nasal cavity through a slit-
like opening located lateral to the crista galli
 Gives rise to medial and lateral internal nasal branches that innervate the
anterosuperior parts of the medial (septal) and lateral nasal walls respectively
 Emerges from the nasal cavity at the lower border of the nasal bone, as the
external nasal nerve. This innervates the nasal ala, apex and vestibule
 Also innervates the ethmoidal air sinuses
Posterior Ethmoidal Nerve
The posterior ethmoidal nerve

 Is a small ramus from the nasociliary nerve
 Leaves the orbit by traversing the posterior ethmoidal foramen
 Innervates the ethmoidal and sphenoidal air sinuses
 May be absent
Infratrochlear Nerve
The infratrochlear nerve

 Arises from the nasociliary nerve near the anterior ethmoidal foramen
 Passes forwards on the medial orbital wall, above the medial rectus. Then it
 Leaves the orbit to enter the face below the trochlea of superior oblique
 Innervates the medial part of the eyelids, the conjunctiva, lacrimal sac and
caruncle and the side of the nose
 Communicates with the supratrochlear nerve in the orbit (near the trochlea), or in
the face
Long Ciliary Nerves
The long ciliary nerves

 Are two or three rami which arise from the nasociliary nerve as it crosses the
upper aspect of the optic nerve (in the orbit)
 Pass forwards alongside the optic nerve, with the short ciliary nerves. The latter
arise from the ciliary ganglion
 Pierce the sclera (with the short ciliary nerves), one on each side of the optic
nerve
 Run through the eyeball (one on each side) between the choroid and sclera
 Give sensory fibres to the ciliary body, iris and cornea
 Also conveys postganglionic sympathetic fibres (from the superior cervical

ganglion) to the dilator pupillae of the iris
Frontal Nerve
The frontal nerve

 Is the largest branch of ophthalmic nerve
 Enters the orbit through the superior orbital fissure, above the common tendinous
ring
 Passes forwards between the orbital roof and levator palpebrae superioris
 Divides into two branches – a smaller supratrochlear and a larger supraorbital
nerve – usually midway between the apex and the base of the orbit
 Gives sensory fibres to the forehead and the anterior part of the scalp, the upper
eyelid and its conjunctiva, as well as the frontal sinus (via its supratrochlear and
supraorbital branches)
Ciliary Ganglion
Note that the ciliary ganglion

 Is a small reddish body located in the orbital fat (near the apex of the orbit),
between the optic nerve and lateral rectus
 Is just about the size of a pin head, with a diameter of about 1 mm
 Is a peripheral parasympathetic ganglion associated with the eye
 Receives a parasympathetic root from the nerve to the inferior oblique (a branch
of inferior division of oculomotor). This conveys presynaptic parasympathetic
fibres from the accessory oculomotor (Edinger-Wesphal) nucleus
 Also has a sensory root (from the nasociliary nerve)
 Receives a sympathetic root from internal carotid plexus; this conveys
postsynaptic sympathetic fibres from the superior cervical ganglion
Also note that

 Of the three roots of the ciliary ganglion, only the fibres of the parasympathetic
root synapse in this ganglion
 Fibres of the sensory and sympathetic roots of the ciliary ganglion do not synapse
in it. Rather, they traverse this ganglion to be distributed via its branches
 Axons of the multipolar neurons of the ciliary ganglion constitute the
postsynaptic parasympathetic fibres that innervate the sphincter pupillae and
ciliary muscle of the eye
 Ciliary ganglion gives rise to about 8–10 short ciliary nerves
 Fibres of the short ciliary nerves are thus of three functional types: postsynaptic
parasympathetic fibres from the ciliary ganglion, postsynaptic sympathetic fibres
from superior cervical ganglion and general sensory fibres (from the eye to the
trigeminal ganglion)
Short Ciliary Nerves
The short ciliary nerves

 Arise from the ciliary ganglion; they are about 8–10 in number
 Pass forwards (in the orbit) around the optic nerve, together with the posterior
ciliary arteries, towards the eyeball
 Pierce the sclera (as 15–20 rami) around the point of attachment of the optic
nerve to the eyeball. Then they
 Continue through the eye in the grooves situated on the inner aspect of the sclera
 Convey postsynaptic parasympathetic fibres (from the ciliary ganglion) to the
ciliary muscle and sphincter pupillae
 Also convey postsynaptic sympathetic fibres to the ciliary, iridial and choroidal
vessels, as well as the dilator pupillae
 Transmit sensory fibres from the eye, en route to the nasociliary and ophthalmic
nerves
Arteries of the Orbit
Arteries of the orbit are numerous and are mostly branches of ophthalmic artery; they
include:
 Long posterior ciliary arteries
 Short posterior ciliary arteries
 Anterior ciliary arteries
 Central artery of the retina
 Supraorbital artery
 Supratrochlear artery
 Lacrimal artery
 Anterior ethmoidal artery
 Posterior ethmoidal artery, and
 Dorsal nasal artery
Ophthalmic Artery
The ophthalmic artery

 Arises from the internal carotid artery as this leaves the cavernous sinus
 Traverses the optic canal where it lies inferolateral to the optic nerve
 Emerges from the optic canal to enter the orbit where it initially lies lateral to the
optic nerve (and medial to the ciliary ganglion, oculomotor nerve and abducent
nerve). Then, it
 Crosses the upper aspect of the optic nerve, from lateral medially, as it passes
towards the medial orbital wall, where it continues forwards (between superior
oblique and medial rectus). It may however pass below the optic nerve (in about
15 % of people)
 Terminates by dividing into supratrochlear and dorsal nasal arteries (in the
anterior part of the orbit)
 Gives rise to several branches that supply the eye, orbit, ethmoidal and frontal air
sinuses, nasal cavity and external nose (see below)
Central Artery of the Retina
The central artery of the retina

 Is the first branch of the ophthalmic artery; it arises in or near the optic canal,
below the optic nerve
 Traverses the optic canal, in the dural sheath of the optic nerve. Then, it
 Pierces the optic nerve halfway along its intraorbital course (about 1.25 cm
behind the eyeball), to continue forwards through the centre of this nerve. Here, it
is accompanied by the central retinal vein
 Enters the eyeball through a large central aperture in the lamina cribrosa of the
sclera, to supply the retina
 Divides dichotomously in the nerve fibre layer of the retina (lamina 9); its
terminal branches are end-arteries
Note: for distribution of the retinal artery, see blood supply to the retina (above).
The long posterior ciliary arteries

 Are two vessels which arise from the ophthalmic artery in the orbit
 Pass forwards to pierce the sclera, one on each side of the optic nerve
 Continue anteriorly through the eyeball (between the sclera and choroid), to the
attached posterior end of the iris. Here, they divide and anastomose with branches
of the anterior ciliary arteries to form the major arterial circle. From the latter,
small branches pass to the pupillary margin of iris to form the minor arterial
circle
 Supply the ciliary body and iris
The short posterior ciliary arteries

 Arise from the ophthalmic artery in the orbit; they are 6–8 vessels
 Pass forwards along the optic nerve, to pierce the sclera around the point of
attachment of the optic nerve to the eyeball
 Supply the choroid and ciliary processes; thus, they indirectly supply the retinal
photoreceptors as nutrients reach these cells (photoreceptors) from the choroidal
capillaries
 Anastomose with small branches of the central retinal artery at the optic disc and
with the long posterior ciliary and anterior ciliary arteries at the ora serrata
The anterior ciliary arteries

 Are small vessels derived from the muscular branches of the ophthalmic artery to
the rectus muscles
 Emerge anteriorly from the tendons of the recti, to form a vascular zone just deep
to the ocular conjunctiva
 Pierce the sclera near the corneoscleral junction to enter the middle (vascular)
coat of the eye
 Anastomose with the long posterior ciliary arteries to form the major arterial
circle at the attached margin of the iris (from which the latter is supplied)
The lacrimal artery

 Is a relatively large vessel which arises from the ophthalmic artery (near the optic
canal)
 Passes forwards and laterally along the upper border of lateral rectus,
accompanied by the lacrimal nerve
 Traverses and supplies the lacrimal gland
 Ends in the eyelids and conjunctiva as lateral palpebral arteries
 Anastomoses in the eyelids (through its lateral palpebral branches) with the
medial palpebral branches of ophthalmic artery
 May be replaced by an enlarged branch of the middle meningeal artery, with
which it usually anastomoses
Branches of the lacrimal artery include:

 Lateral palpebral arteries, to both eyelids
 Zygomatic branches, one of which traverses the zygomaticotemporal foramen
(to the temporal fossa where it anastomoses with the deep temporal arteries); the
other traverses the zygomaticofacial foramen (to the face where it anastomoses
with the transverse facial artery)
 Recurrent meningeal branch; this passes backwards through the superior
orbital fissure to anastomose with a branch of the middle meningeal artery
The supraorbital artery

 Arises from the ophthalmic artery as this vessel crosses the optic nerve (in the
orbit)
 Passes forwards and upwards, between the orbital roof and levator palpebrae
superioris (accompanied by the supraorbital nerve)
 Leaves the orbit for the face by traversing the supraorbital foramen
 Anastomoses, in the face and scalp, with the superficial temporal and
supratrochlear arteries
Note: for distribution of the supraorbital artery in the face, see the face (above).
Anterior Ethmoidal Artery
The anterior ethmoidal artery

 Arises from the ophthalmic artery in the orbit
 Leaves the orbit for the cranial cavity via the anterior ethmoidal foramen
 Continues forwards, deep to the dura of the anterior cranial fossa, on the
cribriform plate of ethmoid
 Enters the nasal cavity (from the cranial cavity) and then descends deep to the
nasal bone; it continues to the tip of the nose by passing between the nasal bone
and upper nasal cartilage
 Is accompanied by the anterior ethmoidal nerve
The anterior ethmoidal artery supplies

 The anterior and middle ethmoidal and the frontal air sinuses
 The dura of the anterior cranial fossa (via its meningeal branches)
 The anterosuperior parts of the nasal septum and the lateral nasal wall (via its
nasal branches)
 The external nose
The posterior ethmoidal artery

 Arises from the ophthalmic artery in the orbit; it then traverses the posterior
ethmoidal foramen to enter the cranial cavity (from where it descends into the
nasal cavity through the cribriform plate of ethmoid)
 Supplies the posterior ethmoidal air cells, dura of the anterior cranial fossa and
the mucosa of the nasal cavity
 Anastomoses with branches of the sphenopalatine artery (in the nasal cavity)
The supratrochlear artery

 Is one of the two terminal branches of the ophthalmic artery; it arises from the
latter in the anterior part of the orbit
 Enters the face through the superomedial part of orbital base, above the trochlea
of superior oblique
 Supplies the forehead, and anastomoses with the supraorbital artery
 Is accompanied by the supratrochlear nerve
The dorsal nasal artery

 Is one of the two terminal branches of the ophthalmic artery
 Enters the face between the medial palpebral ligament and the trochlea of
superior oblique
 Supplies the dorsum of the nose (and the lacrimal sac)
 Anastomoses with the lateral nasal branch of the facial artery (in the face)
Veins of the Orbit
Veins of the orbit include:

 Superior ophthalmic vein
 Inferior ophthalmic vein
 Central vein of the retina, and
 Vorticose veins
The superior ophthalmic vein

 Accompanies the ophthalmic artery and drains the territories of most of its
branches
 Leaves the orbit through the superior orbital fissure, above the tendinous ring, to
enter the cranial cavity
 Ends in the cavernous sinus
 Communicates anteriorly with the supraorbital and facial veins
The inferior ophthalmic vein

 Is formed in the anterior part of orbital floor
 Passes backwards on the inferior rectus
 Traverses the superior orbital fissure, below the tendinous ring
 Ends in the cavernous sinus; it may however end in the superior ophthalmic vein
 Communicates with the pterygoid plexus of veins (via minute vessels which
traverse the inferior orbital fissure)
 Receives some tributaries from the lacrimal sac and eyelids
Central Vein of the Retina
This vein
 Drains the territories supplied by branches of the central retinal artery (i.e. the
retina)
 Initially passes through the optic nerve and then through the subarachnoid space
around this nerve
 Ends in the superior ophthalmic vein or in the cavernous venous sinus
 Receives a small vein which drains the optic nerve itself
Vorticose Veins
The vorticose veins

 Are 4–5 in number; they arise from the veins of the vascular layer of the choroid
 Emerge from the sclera near the equator of the eyeball to terminate in the
ophthalmic veins
Temporal Region, Oral Region and Pterygopalatine Fossa
Temporal Region
Located in the temporal region are two fossae – temporal and infratemporal fossae
– and their contents.
Temporal Fossa
The temporal fossa

 Is located on the side of the skull
 Contains temporalis muscle, its fascia and associated neurovascular structures
 Communicates with the infratemporal fossa deep to the zygomatic arch. The
infratemporal crest of the sphenoid separates the two fossae
The temporal fossa is bounded

 Anteriorly by the frontal process of the zygomatic bone and the zygomatic
process of frontal bone
 Posteriorly and superiorly by the temporal lines
 Inferiorly by the infratemporal crest of the sphenoidal greater wing
 Laterally by the zygomatic arch
 Medially (the floor) by four adjoining bones: frontal, squamous temporal, parietal
and (greater wing of) sphenoidal bones – these bone meet at the pterion
Pterion
The pterion
 Is a small circular area in the floor of the temporal fossa where the (parietal,
frontal, sphenoidal greater wing and squamous temporal) bones of this floor meet
to form an H-shaped suture
 Is located (its centre) about 3.5 cm behind the frontozygomatic suture and about
4. 0 cm above the zygomatic arch
 Is an important surgical and anatomical landmark
 Overlies the frontal branch of middle meningeal artery; this may rupture in
fracture of this region
The temporal fascia

 Is a strong fibrous sheet that covers temporalis and forms the roof of the temporal
fossa
 Is attached above to the superior temporal line and below to the zygomatic arch
The temporalis
 Is a fan-shaped muscle located in the temporal fossa
 Is structured such that its anterior fasciculi are directed almost vertically while its
posterior fasciculi are almost horizontal
 Forms a thick tendon inferiorly. This descends deep to the zygomatic arch, to its
distal (mandibular) attachment
 Is a powerful muscle of mastication
 Floor of the temporal fossa
 Deep surface of temporal fascia
Distal attachment:
 Apex and medial aspect of the coronoid process of the mandible
 Anterior border of mandibular ramus
Innervation: Deep temporal nerves (from the anterior division of mandibular nerve)
Actions:
 Elevates the mandible (and thus closes the mouth) – a function of its anterior
fibres
 Retracts the mandible (from a protruded position) – a function of its posterior
fibres
Infratemporal Fossa
The infratemporal fossa

 Is an irregular space located behind the maxilla
 Contains several structures, which include muscles, vessels and nerves (in close
interrelationship with each other)
 Communicates with the temporal fossa through the interval between the
zygomatic arch and the lower part of the temple
 Also communicates with the middle cranial fossa through the foramina ovale and
spinosum (located in its roof)
Boundaries of the Infratemporal Fossa

With the mandible in place, the infratemporal fossa is bounded
 Superiorly (the roof) by the greater wing of sphenoid and adjacent part of the
squamous temporal bone
 Inferiorly by no anatomical structure
 Medially by the lateral pterygoid plate
 Laterally by the mandibular ramus
 Anteriorly by the posterior surface of the maxilla
 Posteriorly by the mastoid and styloid processes (of the temporal bone) and the
tympanic plate
Contents of the Infratemporal Fossa
Numerous structures are crammed in the infratemporal fossa; these include:

 Muscles – medial and lateral pterygoid and lower part of temporalis
 Arteries – maxillary artery and its numerous branches
 Veins – pterygoid plexus of veins
 Nerves – mandibular nerve and its branches and the chorda tympani
 Ganglion – otic ganglion
Muscles of Infratemporal Fossa
Muscles of the infratemporal fossa include:

 Lower part of temporalis
 Lateral pterygoid, and
 Medial pterygoid
The lateral pterygoid muscle

 Has two heads of origin: upper and lower heads
 Converges posterolaterally from its sphenoidal origin to its mandibular insertion

 Is traversed (between its two heads) by the buccal nerve, as this descends
forwards through the infratemporal fossa
 Is related laterally to the mandibular ramus, masseter and temporalis
 Is related medially to (the upper part of) medial pterygoid, sphenomandibular
ligament, mandibular nerve and middle meningeal artery

 The maxillary artery traverses the infratemporal fossa either deep or superficial
to the lateral pterygoid
 The lingual and inferior alveolar nerves descend through the infratemporal
fossa close to the lower border of lateral pterygoid
 The nerves to masseter and temporalis ascend in the fossa close to the upper
border of lateral pterygoid
 Upper head – infratemporal surface and crest of the greater wing of sphenoid
 Lower head – lateral surface of the lateral pterygoid plate
Distal attachment:
 Fibrous capsule and disc of the temporomandibular joint (TMJ)
 Neck of the mandible
Innervation: Nerve to lateral pterygoid (from the anterior division of the mandibular
nerve)
Actions:
 Protrudes the mandible, thereby opening the mouth (when acting simultaneously
with the opposite muscle)
 Produces side-to-side movements of the mandible (when acting alternately with
the opposite muscle)
The medial pterygoid muscle

 Is a thick quadrilateral muscle located in the infratemporal fossa
 Arises by two heads – superficial and deep heads. These embrace the (lower part
of) lateral pterygoid
 Descends posterolaterally from its pterygoid (and maxillary) origin to its
mandibular insertion
 Is related laterally to the mandibular ramus, lateral pterygoid and
sphenomandibular ligament
 Is related medially to tensor veli palatini
 Deep head – medial surface of the lateral pterygoid plate and the pyramidal
process of palatine bone
 Superficial head – tuberosity and pyramidal process of the maxilla
Distal attachment: Medial aspects of mandibular ramus and angle (behind and below
the mylohyoid groove and mandibular foramen)
Innervation: Medial pterygoid nerve, from the trunk of the mandibular nerve
Actions:
 Elevates the mandible and thus closes the mouth (when acting simultaneously
with the opposite muscle)
 Produces grinding movements, i.e. chewing (when acting alternately with
opposite the medial pterygoid)
 Protrudes the mandible (together with the lateral pterygoids)
Arteries of the Infratemporal Fossa
These include:
 Maxillary artery and its branches
Maxillary Artery (Fig. 139)
The maxillary artery

 Is the larger of the two terminal branches of the external carotid artery; it arises
within the parotid gland (behind the neck of the mandible)
 Passes forwards into the infratemporal fossa between the neck of the mandible
laterally, and the sphenomandibular ligament medially (parallel to and below the
auriculotemporal nerve)
 Lies either superficial or deep to the lateral pterygoid muscle as it traverses the
infratemporal fossa
 Leaves the infratemporal fossa for the pterygopalatine fossa by passing between
the two heads of lateral pterygoid and then through the pterygomaxillary fissure
 Ends in the pterygopalatine fossa where it becomes the sphenopalatine artery
Parts of the Maxillary Artery
The maxillary artery is divisible into three parts. These include:

 Mandibular (or first) part. This extends from its origin to the lower border of
lateral pterygoid
 Pterygoid (or second) part. This lies in the infratemporal fossa, deep or
superficial to the lateral pterygoid, and
 Pterygopalatine (or third) part, which lies in the pterygopalatine fossa
Figure 139. Maxillary artery and its branches.
Branches of the Maxillary Artery (Fig. 139)
Branches of the 1st part of the maxillary artery are five. These include:
 Deep auricular artery
 Anterior tympanic artery
 Middle meningeal artery
 Accessory meningeal artery, and
 Inferior alveolar artery
The deep auricular artery

 Usually arises with the anterior tympanic artery from the 1st part of the maxillary
artery
 Ascends through the parotid gland, behind the temporomandibular joint (TMJ)
 Pierces the cartilaginous (or bony) part of the external acoustic meatus
 Supplies the TMJ, the lining of the external acoustic meatus and the external
aspect of the tympanic membrane
The anterior tympanic artery

 Arises from the 1st part of the maxillary artery
 Ascends behind the TMJ
 Traverse the petrotympanic fissure to enter the middle ear (tympanic cavity)
 Ramifies on the internal aspect of the tympanic membrane; here, it anastomoses
with branches of the stylomastoid artery
 Also anastomoses with branches of artery of the pterygoid canal and the
caroticotympanic branch of internal carotid, in the middle ear
The middle meningeal artery

 Ascends between the roots of the auriculotemporal nerve, from the 1st part of the
maxillary artery (where it arises)
 Traverses the foramen spinosum to enter the middle cranial fossa; here, it is
accompanied by the nervus spinosum (a branch of the mandibular nerve). Then, it
 Ascends in a groove on the inner aspect of the squamous temporal bone
 Terminates by dividing into two branches – a larger frontal and a smaller parietal
branch
 Supplies the meninges and the skull
Branches of the middle meningeal artery include:

 Petrosal branch, which traverses the hiatus for the greater petrosal nerve to
supply the genicular ganglion, facial nerve and middle ear. It anastomoses with
the stylomastoid artery
 Ganglionic branches to the trigeminal ganglion and nerve
 Superior tympanic branch to the tensor tympani and its canal
 Temporal branches to temporalis
 Anastomotic branch, which traverses the superior orbital fissure to anastomose
with the recurrent branch of lacrimal artery
 Frontal branch, which ascends deep to the pterion, to supply the anterior part of
the dura mater and cranium, and
 Parietal branch, which passes backward to supply the posterior part of the dura
mater and cranium
The accessory meningeal artery

 Usually arises from the 1st part of the maxillary artery. However, it may arise
from the middle meningeal artery
 Ascends through the foramen ovale to enter the cranial cavity
 Supplies the dura mater and cranium
 Gives numerous branches to pterygoid muscles, mandibular nerve and otic
ganglion
The inferior alveolar artery

 Arises from the 1st part of the maxillary artery
 Gives rise to a lingual branch near its origin. This accompanies the lingual nerve
to the buccal mucosa
 Descends through the infratemporal fossa, behind the inferior alveolar nerve
 Enters the mandibular canal through the mandibular foramen
 Gives rise to a mylohyoid branch just before it enters the mandibular foramen;
this branch accompanies the mylohyoid nerve through the mylohyoid groove (to
supply mylohyoid muscle)
 Supplies the mandible, mandibular teeth and their sockets
 Anastomoses with its fellow across the midline via its incisor branch
 Gives a mental branch that emerges from the mental foramen of the mandible to
supply the chin. It anastomoses with the inferior labial branch of the facial artery
Branches of the 2nd part of the maxillary artery supply muscles of mastication;
they include:
 Anterior and posterior deep temporal arteries; these ascend deep to temporalis,
which they supply
 Pterygoid branches, to medial and lateral pterygoid muscles
 Masseteric branch, which traverses the mandibular notch (behind temporalis) to
reach the deep aspect of the masseter, which it supplies, and
 Buccal branch, which accompanies the buccal nerve to supply buccinator and the
mucosa of the cheek
Branches of the 3rd part of the maxillary artery include:

 Posterior superior alveolar artery
 Infraorbital artery
 Descending palatine artery
 Artery of the pterygoid canal
 Pharyngeal artery, and
 Sphenopalatine artery
The posterior superior alveolar artery

 Arises from the 3rd part of the maxillary artery (as this enters the pterygopalatine
fossa)
 Descends on the posterior surface of the maxilla
 Supplies the maxillary (upper) molar and premolar teeth, maxillary sinus and
gum
The infraorbital artery

 Usually arises with the posterior superior alveolar artery from the 3 rd part of the
maxillary artery
 Enters the orbit through the inferior orbital fissure
 Passes forwards in the infraorbital groove and canal (beneath the eyeball)
 Emerges through the infraorbital foramen to enter the face
 Gives rise to the anterior superior alveolar arteries that supply the maxillary
(upper) incisor and canine teeth and the mucosa of the maxillary sinus
 Also gives rise to orbital branches that supply the lacrimal sac, inferior rectus
and inferior oblique
 Supplies the lower eyelid, external nose, cheek and upper lip (in the face)
The descending palatine artery

 Passes downwards through the greater palatine canal (accompanied by its nerve)
 Gives rise to 2–3 lesser palatine arteries; these descend through the lesser
palatine canal to supply the soft palate and palatine tonsil. Then, it
 Continues downwards, through the greater palatine foramen, as the greater
palatine artery; this emerges on the oral aspect of the hard palate
 Runs forwards, on the oral aspect of the hard palate (close to the alveolar process
of the maxilla), to the incisive canal; it then
 Ascends through the incisive canal to anastomose with a branch of the
sphenopalatine artery
 Supplies the palatine mucosa and gum
The pharyngeal artery

 Passes backwards, through the pharyngeal (palatovaginal) canal, to the roof of
the pharynx
 Is accompanied by the pharyngeal branch of pterygopalatine ganglion
 Supplies the nasopharynx, roof of the nasal cavity, auditory tube and sphenoidal
sinus
The artery of the pterygoid canal

 Passes backwards through the pterygoid canal
 Is accompanied by nerve of the pterygoid canal

 Supplies the pharynx, middle ear, auditory tube and soft palate
The sphenopalatine artery

 Is the terminal branch of the maxillary artery
 Traverses the sphenopalatine foramen to reach the nasal cavity
 Gives rise to posterior lateral nasal branches (to the lateral wall of the nasal
cavity)
 Also gives rise to posterior septal nasal branches, which supply the nasal
septum. One of these descends towards the incisive canal to anastomose with the
greater palatine artery
Veins of the Infratemporal Fossa
Pterygoid Plexus of Veins
The pterygoid venous plexus

 Is located in the infratemporal fossa between the medial and lateral pterygoid
muscles, and also between the latter and temporalis
 Receives tributaries that drain, to a larger extent, the territories of branches of the
maxillary artery
 Communicates with the facial vein (through the deep facial vein)
 Also communicates with the cavernous sinus (through emissary veins that
traverse foramina ovale and lacerum and the sphenoidal emissary foramen)
 Is drained by the maxillary vein
The maxillary vein

 Drains the pterygoid plexus of veins
 Is accompanied by the 1st part of the maxillary artery as it passes backwards from
its origin (between the mandibular neck laterally and the sphenomandibular
ligament medially)
 Unites with the superficial temporal vein (behind the neck of mandible) to form
the retromandibular vein
Nerves of Infratemporal Fossa
These include:
 The mandibular nerve and its numerous branches, and
 The chorda tympani branch of facial nerve
Mandibular Nerve (Fig. 140)
The mandibular nerve

 Is the largest of the three divisions of the trigeminal nerve
 Has a large sensory root and a small motor root; the latter lies beneath the
trigeminal ganglion as it passes towards the foramen ovale
 Traverses the foramen ovale as two separate roots (sensory and motor), which
unite just beyond the foramen to form the trunk of this nerve
 Divides, in the infratemporal fossa, into a larger posterior and a smaller anterior
division
Branches of the Mandibular Nerve (Fig. 140)
Branches of the mandibular nerve arise from

 The trunk of this nerve
 Its anterior division, and
 The posterior division
Figure 140. Mandibular nerve and its branches.
Nerves that arise from the main trunk of the mandibular nerve include:
 Meningeal branch (nervus spinosus), and

 Nerve to medial pterygoid
The meningeal branch of the mandibular nerve

 Arises from the medial aspect of the mandibular nerve in the infratemporal fossa
 Ascends (with the middle meningeal artery) through the foramen spinosum (to
the middle cranial fossa)
 Gives sensory branches to the dura of the middle and anterior cranial fossae and
that of the calvaria, as well as the mucosa of the mastoid air cells
The nerve to medial pterygoid

 Also arises from the medial aspect of the trunk of the mandibular nerve, in the
infratemporal fossa
 Innervates the medial pterygoid muscle
 Also sends branches to the tensor tympani and tensor veli palatini; these branches
pass through the otic ganglion (without synapsing)
Branches of the anterior division of mandibular nerve are largely motor. They
include:
 Masseteric nerve
 Deep temporal nerves
 Nerve to lateral pterygoid, and
 Buccal nerve
Masseteric nerve
 Passes laterally through the infratemporal fossa, above the lateral pterygoid (and
just anterior to the capsule of TMJ)
 Continues laterally through the mandibular notch (behind temporalis tendon)
 Innervates masseter (through the deep surface of this muscle) and the TMJ
 Is accompanied by the masseteric artery
Deep temporal nerves

 Usually occur as anterior and posterior deep temporal nerves; an intermediate
one may be present
 Pass laterally through the infratemporal fossa, above the lateral pterygoid. Then,
they
 Turn upwards to enter the temporal fossa where they innervate temporalis (via
the deep surface of this muscle)
Nerve to lateral pterygoid

 Supplies the lateral pterygoid (through it deep surface)

 May share a common stem with the buccal nerve
The buccal nerve

 Is the sensory branch of the anterior division of the mandibular nerve
 Lies first between the two heads of lateral pterygoid; it then
 Descends to the cheek deep to (or through) the lower part of temporalis, masseter
and mandibular ramus
 Innervates the skin and mucosa over the anterior part of buccinator
 Also innervates the gums
 May give rise to the anterior deep temporal nerve
 Is joined by the buccal branch of facial nerve (a motor ramus)
Branches of the posterior trunk of mandibular nerve are mainly sensory; they
include:
 Auriculotemporal nerve
 Lingual nerve, and
 Inferior alveolar nerve
Note: For auriculotemporal nerve, see above.
The lingual nerve

 Arises from the posterior trunk of the mandibular nerve, in the infratemporal
fossa
 Descends first between tensor veli palatini medially and lateral pterygoid
laterally; then, it
 Continues downwards and forwards between the medial pterygoid medially and
mandibular ramus laterally (anterior to the inferior alveolar nerve)
 Lies on the mandible near the 3rd molar tooth (below the inferior margin of the
superior pharyngeal constrictor); here, it is covered by the buccal mucosa and can
be felt by a finger in the mouth
 Continues forwards on the stylohyoid and the lateral aspects of hyoglossus and
genioglossus (deep to mylohyoid, and above the deep part of submandibular
gland)
 Crosses the submandibular duct first laterally, inferiorly and then medially,
before ascending on the lateral aspect of genioglossus
 Innervates the mucosa of the anterior 2/3 of the tongue
 Is joined by the chorda tympani (in the infratemporal fossa); this branch of
facial nerve conveys presynaptic parasympathetic fibres to the submandibular
ganglion
 Is also joined by fibres which arise from the submandibular ganglion; these
contain secretomotor (postganglionic parasympathetic) fibres to the sublingual
and anterior lingual glands
Branches of the Lingual Nerve
Branches of the lingual nerve include:

 Sensory fibres to the mucosa of the floor of the mouth
 Sensory branches to the lingual aspect of the lower gingivae (gums)
 Sensory rami to the lower premolar and 1st molar teeth
 Branches to the mucosa of the oral part (anterior 2/3 or presulcal part) of the
tongue
 Secretomotor fibres to the sublingual and anterior lingual glands. These fibres
arise from the submandibular ganglion
 Communicating rami to branches of the hypoglossal nerve (at the apex of the
tongue). Via these rami, sensory fibres may be distributed to the tongue
The inferior alveolar nerve

 Arises from the posterior division of the mandibular nerve, in the infratemporal
fossa
 Descends deep to the lateral pterygoid (behind the lingual nerve)
 Lies between the sphenomandibular ligament medially and the mandibular ramus
laterally as it enters the mandibular canal through the mandibular foramen
 Is accompanied by the inferior alveolar artery (from the 1st part of maxillary
artery)
 Gives rise to mylohyoid nerve just before it enters the mandibular foramen; this
innervates mylohyoid
 Forms an inferior dental plexus from its numerous branches (which arise in the
mandibular canal); this plexus innervates the mandibular teeth, gums and alveolar
processes
 Innervates the mandibular teeth, gums and skin of the chin
Branches of inferior alveolar nerve include:

 Mylohyoid nerve, which pierces the sphenomandibular ligament, and traverses
the mylohyoid groove, to supply mylohyoid. It is accompanied by mylohyoid
artery
 Nerves to the lower molar and premolar teeth; these fibres also supply the gums
and alveolar processes of the mandible
 Incisive nerve, which innervates the lower incisor and canine teeth
 Mental nerve, which emerges from the mental foramen to innervate the skin of
the chin and that of the lower lip (and its mucosa)
Chorda Tympani
The chorda tympani

 Arises from the facial nerve about 6 mm above the stylomastoid foramen; it then
passes forwards and upwards into the middle ear
 Crosses the tympanic membrane from behind forwards (between the fibrous layer
and mucous lining of this membrane), in the lateral wall of the tympanic cavity
 Leaves the middle ear to enter the infratemporal fossa where it joins the lingual
nerve at an acute angle
 Conveys preganglionic parasympathetic fibres to the submandibular ganglion
(via the lingual nerve); these fibres arise from the superior salivatory nucleus (in
the lower pontine tegmentum)
Applied Anatomy

 Inferior alveolar nerve block is performed by injecting an anesthetic agent
around the mandibular foramen; this procedure largely abolishes sensations in the
lower teeth. However,
 Inferior alveolar nerve block usually does not completely abolish sensations in
the lower teeth; this is owing to the fact that nerve fibres also reach the
mandibular teeth from nerves of the muscles attached to the mandible, etc
 Mandibular nerve block anesthetizes the mandibular nerve and its branches in
the infratemporal fossa; the needle is passed into the latter through the
mandibular notch
Otic Ganglion
The otic ganglion

 Is a small reddish oval body located just below the foramen ovale (and medial to
the mandibular nerve), in the infratemporal fossa
 Is one of the peripheral parasympathetic ganglia
 Receives preganglionic parasympathetic fibres from the glossopharyngeal nerve
via the lesser petrosal nerve; these fibres arise from the inferior salivatory
nucleus (located in the upper medullary tegmentum)
 Is the source of postganglionic parasympathetic fibres to the parotid gland. These
fibres are conveyed to the gland by the auriculotemporal nerve
 Is traversed by nerves to tensor tympani and tensor veli palatini (though these do
not synapse in it)
Temporomandibular Joint
The temporomandibular joint

 Is a modified hinge type of synovial joint (or ellipsoidal joint)
 Is formed between the mandibular condyle below and the temporal articular
tubercle and mandibular fossa above. These articular surfaces are covered by
white fibrocartilage
 Is usually completely divided into two cavities by an articular disc (of fibrous
tissue)
 Has a loose fibrous capsule which is lined internally by two separate (upper and
lower) synovial membranes
The fibrous capsule of the TMJ

 Is attached above to the articular tubercle and the margins of the mandibular
fossa, and below to the neck of the mandible
 Is lined internally by synovial membrane
 Is taut below the articular disc but loose above it
Regarding the synovial membrane of the TMJ, note that

 It lines the internal aspect of the fibrous capsule as two separate membranes
(upper and lower)
 The upper synovial membrane lines the part of the fibrous capsule above the
articular disc
 The lower synovial membrane lines the part of the fibrous capsule below the
articular disc
 The synovial membrane does not line the surfaces of the articular disc
The articular disc of the TMJ

 Is an oval sheet of fibrous tissue which completely divides the cavity of the joint
into two (upper and lower)
 Has a concave inferior surface and a concavo-convex superior surface
 Blends with the fibrous capsule at its circumference, and anteriorly with the
tendon of lateral pterygoid
 Moves in unison with the mandibular condyle in protraction-retraction
movements of the joint
 Is occasionally perforated. Perforation and thinning of the disc are part of ageing
Ligaments of TMJ
These include:
 Lateral (or temporomandibular) ligament
 Stylomandibular ligament, and
 Sphenomandibular ligament
The lateral ligament of TMJ

 Is the thickened lateral part of the fibrous capsule of the joint
 Strengthens the TMJ laterally, and
 Prevents posterior dislocation of the joint
The stylomandibular ligament

 Is a thickening of the deep cervical fascia. It stretches from the temporal styloid
process to the angle and posterior border of the ramus of the mandible
 Is an accessory ligament of the TMJ; it is thus of little supportive importance
 Separates the parotid from the submandibular glands
The sphenomandibular ligament

 Is a thin sheet of fibrous tissue that stretches forwards and downwards from the
sphenoidal spine to the mandibular lingula
 Is separated from the TMJ laterally by the maxillary artery and the
auriculotemporal and inferior alveolar nerves
 Is pierced near its mandibular attachment by the nerve to mylohyoid
 Is derived embryologically from the perichondrium of the cartilage of the
mandibular arch (Meckel’s cartilage)
 Is an accessory ligament of the TMJ, with limited supportive function
Movements of the TMJ
Movements that occur at the TMJ, and the muscles responsible, include:
 Protraction, produced by lateral pterygoid (prime mover), and assisted by medial
pterygoid and superficial fibres of masseter
 Retraction, produced by posterior fibres of temporalis (prime mover), and
assisted by the deep fibres of masseter, digastric and geniohyoid
 Elevation, produced by temporalis, masseter and medial pterygoid of both sides
 Depression, produced by gravity (prime mover), lateral pterygoids, digastric,
geniohyoid and mylohyoid
 Lateral rotation, produced by medial and lateral pterygoids of one side acting
alternately with those of the other side
Note that
 Protraction and retraction of the TMJ occur at the superior compartment of this
joint
 The articular disc moves with the mandibular condyle in protraction/retraction
movement of the TMJ
 Depression/elevation of the TMJ occurs at the inferior compartment of this joint
 Movement of the TMJ is essential for mastication (and speech), and is thus
produced mainly by muscles of mastication
 Suprahyoid and infrahyoid muscles are recruited when the mouth is being
depressed against resistance
Innervation of the TMJ
The TMJ receives nerve fibres from branches of

 Auriculotemporal nerve, and
 Masseteric nerve
Blood Supply to the TMJ

 The TMJ receives arterial blood from branches of the
 Superficial temporal artery, and
 Maxillary artery
Applied Anatomy of the TMJ

 The temporomandibular joint is rarely dislocated backwards (owing to the
presence of postglenoid tubercle and lateral ligament of the joint). Anterior
dislocation of this joint is relatively common
 The TMJ may be dislocated (forwards into the infratemporal fossa) when a
sudden force is applied on the lower jaw with the mouth open (as occurs in
convulsive yawning, etc)
 Reduction of a dislocated TMJ is done by depressing the posterior part of the
lower jaw and simultaneously elevating the chin. This relocates the mandibular
condyles in the mandibular fossae
 Crepitus of the TMJ may arise from delayed movement of the articular disc
during the movement of the joint
 The branches of the facial and auriculotemporal nerves which arise around the
TMJ should be preserved in surgery of this joint
 Inflammatory changes – arthritis – may involve the TMJ, with attendant pains
and functional deficits
Oral Region
Note that
 Located in the oral region are the buccal (oral) cavity, gingivae, teeth, palate and
tongue
 Chewing of food substances occurs in the buccal cavity, followed by swallowing
(deglutition)
Oral Cavity (Fig. 141)
The oral cavity consists of two parts; these include:

 A smaller vestibule, and
 A larger oral cavity proper
Vestibule
The vestibule of the oral cavity

 Is the slit-like space between the lips and cheeks externally, and the gums
(gingivae) and teeth internally
 Is bounded above and below by the reflection of the mucous membrane from the
gums onto the lips and cheeks
 Communicates with the exterior through the oral fissure
 Communicates with the oral cavity proper (when the upper and lower teeth are
apposed) through a space located behind the 3rd molar tooth and also through
minute openings between adjoining teeth
 Receives the openings of the parotid ducts on its lateral walls, opposite the upper
2nd molar teeth
Oral Cavity Proper (Fig. 141)
Regarding the oral cavity proper, note that

 It is the larger part of the oral cavity. It is bounded anterolaterally by the alveolar
arches, teeth and gums
 Its roof is formed by the hard and soft palate
 Its floor is formed by the anterior part of the tongue and is completed by the
reflection of the mucosa from the undersurface of the tongue to the mandible
 An oropharyngeal isthmus (between the palatoglossal folds) links the oral
cavity proper with the oropharynx
 Its mucosa is lined by non-keratinized stratified squamous epithelium. This
mucosa is thickened over the bones
 On the floor of the mouth, a small elevation – sublingual papilla – bears the
opening of the submandibular duct, just lateral to the lingual frenulum
 A sublingual fold lies beneath the anterior part of the tongue, on each side. This
contains the sublingual gland, the multiple ducts of which open on the fold
Lips
Regarding the lips, note the following points:

 They are two fleshy folds (upper and lower) that bound the oral fissure
 Each lip consists of fibres of orbicularis oris, blood vessels, nerves and
connective tissue, and is lined externally by skin and internally by mucosa
 The oral fissure (between the lips) is usually placed at the level of the cutting
edges of the upper incisor teeth
 On each side, the lips meet at the labial commissure (angle of the mouth). This
is usually located close to the 1st premolar tooth
 The mucosa of each lip is raised to form a median ridge termed labial frenulum
 Externally, the upper lip presents a shallow vertical depression – the philtrum.
This ends below at a small elevation, the tubercle
 Labial glands are about the size of small peas, and are located between
orbicularis oris and labial mucosa. They are mucous glands whose ducts open on
the labial mucosa
 The lips receive superior and inferior labial branches of the facial artery, are
innervated by the infraorbital and mental nerves, and drain into submandibular
and submental lymph nodes
Cheeks
With respect to the cheeks, note the following:

 The cheeks form the lateral wall of the buccal cavity
 Each cheek is separated from the lips by the nasolabial sulcus; the latter descends
from the side of the nose to the angle of the mouth
 Each cheek consists of muscles (especially buccinator) covered internally by
mucosa and externally by skin, with the associated vessels, nerves, adipose and
areolar tissues and buccal glands
 A buccal pad of fat is located external to the buccinator. This pad is relatively
large in children (to enhance sucking)
 Buccal glands are small salivary glands located between the mucosa of the cheek
and buccinator. They are mucous and serous in type
 Molar glands are 4–5 large buccal glands located around the parotid duct,
external to the buccinator; their ducts pierce this muscle to open into the
vestibule, opposite the upper last molar tooth
 Each parotid duct pierces the buccinator anterior to masseter, to open into the
vestibule opposite the upper 2nd molar tooth
 Each cheek receives the buccal branch of maxillary artery, is innervated by the
buccal branch of mandibular nerve and drains into the submandibular lymph
nodes
Gingivae (Gums)
The gingivae
 Consist of a firm, vascular dense connective tissue
 Have a lining of stratified squamous epithelium, which is lightly keratinized; this
contains melanocytes (for gingival pigmentation)
 Appear pinkish-grey, stippled and pigmented. Its pigmentation (owing to the
presence of melanocytes) is more obvious in coloured races
 Have attached parts, which are firmly connected to the alveolar processes of the
maxilla and mandible, and free parts which surround the neck of each tooth like a
collar
Figure 141. The oral cavity

 The fibrous tissue of the gingivae is continuous with the periosteum of the
alveolar processes of the jaws, for firm anchoring
 The stratified squamous epithelium of the gums is attached to the enamel of the
teeth in young subjects (epithelial attachment); thereafter, this epithelium recedes
from the enamel to the cementum of the teeth
 Sensory fibres pass to the upper gum from branches of the maxillary nerves
(greater palatine, nasopalatine, and the anterior, middle and posterior superior
alveolar nerves)
 Sensory fibres pass to the lower gum from branches of the mandibular nerves
(buccal, inferior alveolar and lingual nerves)
 Lymph vessels from the upper gums drain into the submandibular nodes, while
 Lymph vessels from the lower gums drain into the submandibular and submental
nodes
Applied Anatomy

 Cancer cells from the central part of the lower lip metastasize to the submental
nodes. From the lateral part of this lip, metastases are found in the submandibular
nodes
 Cleft of the upper lip may occur, and this may be unilateral or bilateral. This
defect occurs in about 1 out of 1000 birth and is due to failure of fusion of the
maxillary prominence with the intermaxillary segment during development.
Males are more commonly affected
 Bacterial actions on residual food in the mouth result in production of substances
that may cause inflammation of the gums (gingivitis); in this condition, the gums
become swollen, reddish and painful
 If untreated, gingivitis may result in inflammation of the periodontal membrane,
a condition referred to as periodontitis
Palate
The palate
 Is the arched roof of the mouth; it also forms the floor of the nasal cavity. Thus, it
separates the nasal cavity and nasopharynx above from the oral cavity below
 Consists of two parts, the anterior 2/3 being the bony hard palate, while the
posterior 1/3 is the fibromuscular soft palate
 Is lined by the oral mucosa on its inferior aspect and by the nasal mucosa on its
superior aspect
Hard Palate
The hard palate

 Forms the anterior ⅔ of the palate
 Is formed anteriorly by the palatine processes of maxillae and posteriorly by the
horizontal plates of palatine bones
 Is concave inferiorly, where it presents a linear median raphe
 Is lined on its oral aspect by dense mucoperiosteum, the epithelium of which is
keratinized stratified squamous
 Is lined on its nasal surface by respiratory epithelium (i.e. ciliated
pseudostratified columnar epithelium)
 Is continuous behind with the soft palate, to which it gives attachment;
anterolaterally, it is bounded by the alveolar arch of the maxilla and the gums
 Possesses numerous mucous palatine glands (located between its mucosa and
periosteum, in its posterior half)
Besides, note that

 Immediately behind the central incisor teeth, the hard palate presents a depression
termed the incisive fossa
 Opening into the incisive fossa are the incisive canals and foramina; these
transmit branches of the greater palatine artery and nasopalatine nerve (between
the nasal cavity and the roof of the mouth)
 The hard palate presents a greater palatine foramen in its posterolateral part
(just medial to the 3rd upper molar tooth). The greater palatine nerve and vessels
emerge through this foramen and then run forwards on the oral aspect of the hard
palate
 The lesser palatine foramina lie behind the greater palatine foramen; the lesser
palatine nerves and vessels emerge from them and pass backwards to the soft
palate
 The palatine mucosa has an orange-peel appearance, produced by the openings of
the ducts of the palatine glands
 Immediately anterior to the incisive fossa, the palatine mucosa is elevated to form
an incisive papilla
 Transverse palatine folds (palatine rugae) of mucosa radiate laterally, on each
side, from the incisive papilla
 The palatine raphe is a median streak that runs posteriorly from the incisive
papilla; it indicates the line of fusion of the embryonic palatine processes
Soft Palate
The soft palate

 Is the movable flap that forms the posterior ⅓ of the palate
 Is attached to the posterior border of the hard palate, from which it curves
backwards and downwards (thereby separating the nasopharynx from the
oropharynx
 Is made up of the palatine aponeurosis, muscles, blood vessels, nerve fibres,
lymphoid masses and mucous glands
 Is continuous laterally with the palatoglossal and palatopharyngeal folds
 Is lined by ciliated pseudostratified columnar epithelium on its nasal aspect and
by non-keratinized stratified squamous epithelium on its oral aspect
The soft palate has

 A superior border, which is attached to the posterior margin of the hard palate
 An inferior border, which is free. A median conical process – the uvula –
projects postero-inferiorly from this border
 A concave anterior (oral) surface which has a median raphe, and
 A convex posterior surface which forms the floor of the nasopharynx and which
is continuous with the floor of the nasal cavity
Note that
 The isthmus of the fauces is the narrow passage between the oral cavity proper
and the oropharynx
 Boundaries of the isthmus of the fauces include the soft palate above, dorsum of
the tongue below and the palatoglossal and palatopharyngeal arches on each side
 The palatoglossal arch descends laterally from uvular base to the side of the
tongue; it contains the palatoglossus
 The palatopharyngeal arch descends laterally from the soft palate to the lateral
wall of the pharynx. It lies behind the palatoglossal arch, and contains the
palatopharyngeus
 Between the palatoglossal and palatopharyngeal arches on each side is the
palatine tonsil
 The mucous glands of the soft palate are located just beneath its mucosa. They
are more abundant on its oral surface
 The ducts of the mucous glands of the soft palate converge onto the palatine
fovea, in which they open
 The palatine foveae are a pair of depressions in the mucosa of the soft palate,
adjacent to the palatine raphe and close to its attached upper margin
 The soft palate is also endowed with taste buds
Palatine Aponeurosis of the Soft Palate
The palatine aponeurosis

 Is the fibrous sheet formed by the expanded tendons of the tensors veli palatini; it
is attached to the posterior border of the hard palate
 Strengthens the soft palate and gives attachment to its muscles
 Ensheathes the musculus uvulae near the median plane
 Is thicker anteriorly than posteriorly
Muscles of the Soft Palate
Muscles of the soft palate include:

 Levator veli palatini
 Tensor veli palatini
 Musculus uvulae
 Palatoglossus, and
 Palatopharyngeus
The levator veli palatini

 Is a cylindrical muscle of the soft palate
 Descends anteriorly from its petrous temporal origin to its palatine insertion
 Is located below the auditory tube at its origin but lies medial to this tube further
distally
 Inferior aspect of the petrous temporal bone
 Inferior aspect of the cartilaginous part of auditory tube
Distal attachment: Upper surface of palatine aponeurosis
Innervation: Cranial accessory nerve (via the pharyngeal branch of vagus nerve and
the pharyngeal plexus)
Action: Elevates the soft palate
The tensor veli palatini

 Is a small triangular muscle of the soft palate
 Passes inferiorly from its sphenoidal origin to its palatine insertion. However, it
 Turns medially round the pterygoid hamulus, at its lower tendinous end, before
spreading out in the soft palate as the palatine aponeurosis
 Scaphoid fossa of medial pterygoid plate
 Cartilage of auditory tube
 Spine of sphenoid
Distal attachment: Palatine aponeurosis
Innervation: Nerve to medial pterygoid (a branch of mandibular nerve), via a ramus

that traverses the otic ganglion
Actions:
 Tenses the soft palate (when acting with the opposite muscle)
 Pulls the soft palate laterally (when acting alone)
 Opens the mouth of the auditory tube e.g. when yawning
The musculus uvulae

 Is the muscle of the uvula (one on each side of the midline)
 Is enclosed by the palatine aponeurosis
 Posterior nasal spine of palatine bone
 Palatine aponeurosis
Distal attachment: Uvular mucosa
Innervation: Same as for levator veli palatini
Action: Elevates and shortens the uvula
The palatoglossus
 Is a small strap muscle, narrower at its middle than at is ends
 Has a covering of mucosa with which it forms the palatoglossal arch (or fold)
 Is continuous with its fellow at its palatine origin
 Descends anteriorly and laterally from its palatine origin above, to its lingual
insertion below. It lies anterior to the palatine tonsil
Proximal attachment: Palatine aponeurosis
Distal attachment: Side of the tongue

Action:
 Elevates the posterior part of the tongue
 Depresses the soft palate
 Narrows the isthmus of the fauces (by approximating the palatoglossal arches)
The palatopharyngeus
 Forms, with its covering of mucosa, the palatopharyngeal arch
 Is separated into two fasciculi (anterior and posterior fasciculi) by levator veli
palatini
 Descends laterally, from its palatine origin above, to the side of the pharynx
below (behind the palatine tonsil)
 Hard palate
 Palatine aponeurosis
Distal attachment:
 Thyroid cartilage
 Side wall of the pharynx
Action:
 Pulls the pharynx upwards, forwards and medially, thereby shortening it during
swallowing (both muscles)
 Approximates the palatopharyngeal arches (thereby narrowing the isthmus of the
fauces)
Blood Supply, Innervation and Lymphatics of the Palate
The palate receives arterial blood from the following vessels:

 Greater palatine arteries, a branch of the descending palatine artery. The latter
is a branch of the maxillary artery
 Lesser palatine arteries, also from the descending palatine artery
 Ascending palatine branch of facial artery, and
 Ascending pharyngeal artery, the smallest branch of external carotid artery
Venous Drainage of the Palate

Note that
 Veins of the palate are tributaries of the pterygoid plexus of veins
Innervation of the Palate
Sensory fibres reach the palate via

 The greater palatine nerve, which supplies the hard palate
 The nasopalatine nerve, which innervates the anterior part of the hard palate, and
 The lesser palatine nerve, which innervates the soft palate

 The nerves of the palate (listed above) are fibres of the maxillary nerve; they arise
from the pterygopalatine ganglion in the pterygopalatine fossa
 Postganglionic parasympathetic (secretomotor) fibres to the mucous palatine
glands arise from the pterygopalatine ganglion (and are conveyed by nerves of
the palate)
 Postganglionic sympathetic fibres also reach the palate via the palatine nerves
Lymphatic Drainage of the Palate
Note that
 Lymph vessels of the palate end in the upper deep cervical nodes
Applied Anatomy

 The greater palatine nerve can be blocked by introducing an anesthetic agent into
the greater palatine foramen. This abolishes sensations in the hard palate (on that
side), as far forwards as the upper canine tooth
 Nasopalatine nerve block is performed by injecting an anesthetic into the
incisive fossa, just behind the incisive papilla. This renders the anterior part of the
hard plate insensitive
 Postdiphteritic paralyses may affect the soft palate; these arise from the effect
of the toxin produced by the bacillus (the causative agent) on nerves of the
medulla. Because of the flaccidity of the soft palate in this condition, fluid passes
into the nasal cavities on swallowing, and phonation becomes nasal
 Cleft palate is a congenital anomaly that arises as a result of the failure of the
lateral palatine processes to fuse with each other. It may be associated with cleft
lip, and females are more frequently affected (with a frequency of 1 out of every
2500 births)
Tongue (Fig. 142, 43, 44)
The tongue
 Is a mobile, highly muscular organ, capable of modifying its shape
 Is located partly in the oral cavity and partly in the pharynx
 Is involved in deglutition (swallowing), speech and taste
 Has a root, a body, an apex, a dorsum and an inferior surface
 Is lined by stratified squamous epithelium (which is keratinized in some places)
 Is endowed with numerous epithelial papillae, most of which are equipped with
taste buds
 Appears pinkish and moist in the healthy state
The root of the tongue

 Is the relatively fixed part of the tongue, via which this organ is attached to bones
(hyoid, mandible and styloid process) and soft plate
The body of the tongue

 Consists of the dorsum, inferior surface and apex of the tongue
The dorsum of the tongue

 Is the posterosuperior surface of the body of the tongue. It is generally convex
when the organ is at rest
 Is divided into an anterior oral (or presulcal) part and a posterior pharyngeal (or
postsulcal) part by a V-shaped sulcus terminalis
 Is in contact with the hard and soft palate above
 Appears rough, especially in its oral part
Figure 142. Dorsum of the tongue.
The presulcal part of the tongue

 Is the rough anterior ⅔ of the tongue; it is located in the oral cavity proper (Fig.
142)
 Is separated from the postsulcal part (on the dorsum of the tongue) by the sulcus
terminalis
 Also includes the inferior surface and apex of the tongue
 Is in contact with the (soft and hard) palate above
 Rests on the floor of the mouth below
 Has a longitudinal median sulcus. This indicates the line of fusion of the right
and left lateral lingual swellings (from which it develops); deep to this sulcus is
the fibrous lingual septum
 Is endowed with numerous papillae on its dorsum and sides
Regarding the inferior surface of the tongue, note the following points:
 The mucosa of the inferior surface of the tongue is smooth, thin and transparent,
unlike that of the dorsum which is rough and papillated
 A median fold of mucosa, lingual frenulum, connects the inferior surface of the
tongue to the floor of the mouth
 On each side of the frenulum, the deep lingual vein is visible through the mucosa
of the inferior surface of the tongue
 Lateral to each deep lingual vein (on the inferior surface of the tongue) is a fold
of mucosa termed plica fimbriata. This passes forwards and medially, towards
the apex of the tongue
The apex of the tongue

 Is the pointed anterior end of the tongue (Fig. 142)
 Is in contact with the incisor teeth anteriorly
Regarding the sulcus terminalis, note that

 It is a V-shaped depression which indicates the junction of the oral and
pharyngeal parts of the tongue (on the dorsum of this organ) (Fig. 142)
 Its apex is at the median foramen caecum, while each of its limbs is directed
anterolaterally to meet the palatoglossal arch at the side of the tongue
 The foramen caecum indicates the site of origin of the embryonic thyroglossal
duct
Pharyngeal (Postsulcal) Part of the Tongue

 The pharyngeal part of the tongue
 Is the posterior ⅓ of the tongue; it is located behind the sulcus terminalis and
palatoglossal arches (Fig. 142)
 Bounds the oropharynx anteriorly. Thus, this part of the tongue faces backwards
 Is devoid of papillae. However, it possesses numerous lymphoid follicles which
are collectively referred to as lingual tonsil
 Is derived from the hypobranchial eminence and is thus innervated by the
glossopharyngeal nerve (nerve of the 3rd arch)
 Is continuous (its mucosa) laterally with the pharyngeal wall and posteriorly with
the epiglottic folds
Lingual Papillae (Fig. 142)
Lingual papillae
 Are minute elevations of the lingual epithelium (produced by the underling
lamina propria)
 Are confined to the presulcal part of the tongue. Thus, this part of the organ
appear rough
 Are of different types, some of which are endowed with taste buds
The lingual papillae include:

 Vallate papillae
 Fungiform papillae
 Filiform papillae, and
 Foliate papillae
Vallate papillae
 Resemble inverted truncated cones; they are the largest of the papillae (Fig. 142)
 Are arranged in a V-shaped row, just in front of, and parallel to the sulcus
terminalis (on the dorsum of the tongue)
 Are from 8–12 in number. The largest usually lies anterior to the foramen caecum
 Measure 1–3 mm in diameter each
Each vallate papilla

 Is surrounded by a wall of mucosa (the vallum), from which it is separated by a
circular sulcus; the ducts of serous glands (of von Ebner) open into the latter
 Bears, on its surface, numerous taste buds; these are also found on the mucosal
wall around the papilla
 Possesses several secondary papillae on its free superficial aspect
 Is lined by stratified squamous epithelium
The fungiform papillae

 Are smaller than vallate but larger than filiform papillae (Fig. 142)
 Appear globular in shape (with rounded free ends); they are also reddish in
colour owing to their rich blood supply
 Are more numerous at the sides and tip of the tongue but less numerous on the
dorsum
 Are also endowed with taste buds and subepithelial secondary papillae
Filiform papillae
 Are the most numerous of the lingual papillae; they are located on the dorsum of
the tongue (Fig. 142)
 Appear conical (or cylindrical) in shape and each measures 2–3 mm in length.
Each ends as fine thread-like processes which are subepithelial secondary
papillae
 Are arranged in V-shaped rows anterior and parallel to the sulcus terminalis,
except at the apex of the tongue where they are arranged in transverse rows
 Are lined by keratinized stratified squamous epithelium, which becomes scaly at

the apices of these papillae; this characteristic creates friction over the tongue and
thus enhances chewing
 Possess afferent nerve endings that are sensitive to tactile stimuli
 Are devoid of taste buds
Foliate papillae
 Are small leaf-like folds of mucosa found at the side of the tongue, anterior to the
palatoglossal arches (near the sulcus terminalis) (Fig. 142)
 Contain taste buds as do vallate and fungiform papillae
 Are scanty and not well-developed in man
Taste buds
 Are piriform groups of modified epithelial cells that are provided with sensory
nerve endings
 Are present in the epithelia of the tongue, inferior aspect of the soft palate,
posterior surfaces of the epiglottis and oropharynx, and the palatoglossal arches
 Are most numerous in the walls of the vallate papillae. They are also found in the
foliate and fungiform papillae and in the pharyngeal part of the tongue
 Are absent in the central part of the dorsum of the tongue and in the filiform
papillae
 Are organs of gustation (taste)
Lingual Musculature (Fig. 143)
Regarding the muscles of the tongue, note that

 The tongue is essentially a mass of skeletal muscles; associated with these
muscles are small salivary glands, connective tissue, nerve fibres, blood and
lymph vessels and lymphoid follicles, all covered by mucous membrane
 Each parasagittal half of the tongue consists of four extrinsic and four intrinsic
muscles
 A median fibrous septum separates the two parasagittal halves of the tongue.
This septum is attached below to the hyoid bone and its position is indicated on
the dorsum of the tongue by the median sulcus
 Extrinsic muscles of the tongue arise outside this organ; they are mainly involved
in changing the position of the tongue
 The intrinsic muscles of the tongue are confined to the tongue; they are mainly
involved in changing the shape of this organ
 Lingual muscles are derived from the occipital somites (from which they
migrate)
 The hypoglossal nerves (12th cranial nerve) supply motor fibers to the tongue
Extrinsic Muscles of the Tongue (Fig. 143)
These include:
 Genioglossus
 Hyoglossus
 Styloglossus, and
 Palatoglossus
Figure 143. Muscles of the tongue.
The genioglossus
 Is a fan-shaped muscle of the tongue (Fig. 143); it occupies a paramedian position
and is separated from its fellow by the median fibrous septum
 Radiates (its fibres) forwards, upwards and backwards, from its mandibular
origin, into the substance of the tongue
 Is attached posteriorly to the body of hyoid bone through its lowest fibres; its
anterior fibres pass to the apex of the tongue
 Is related on its lateral aspect to the sublingual gland and artery and the
submandibular duct
 Is the only extrinsic muscle of the tongue that is capable of protruding the tongue
Proximal attachment: Upper part of the mental spine of the mandible
Distal attachment:
 Dorsum of the tongue
 Body of hyoid bone (this gives attachment to the lowest fibres of this muscle)
Innervation: Hypoglossal nerve (12th cranial nerve)
Action:
 Protraction of the tongue (by the posterior fibres of both muscles); when the
posterior fibres of one side act alone, the tongue deviates to the opposite side on
protraction
 Retraction of the tongue (by the anterior fibres of both muscles)
 Depression of the central part of the tongue (by both muscles)
The hyoglossus
 Is a thin quadrilateral muscle which passes upwards and forwards from its hyoid
origin (below) to the tongue (where it lies between genioglossus medially and
styloglossus laterally) (Fig. 143)
 Is related medially to the lingual artery, glossopharyngeal nerve, genioglossus
and inferior longitudinal muscle
 Is related laterally to the lingual and hypoglossal nerves, sublingual and (deep
part of) submandibular glands, and the submandibular duct and ganglion
Proximal attachment: Greater horn and body of hyoid bone
Innervation: Hypoglossal nerve
Action:
 Depresses the tongue, especially the side of the tongue
 Also retracts the tongue (when acting with the anterior fibres of genioglossus)
The styloglossus
 Is a small muscle which passes forwards, medially and downwards, from its
origin (styloid process) to the tongue (Fig. 143)
 Blends with fibres of palatoglossus, hyoglossus and inferior longitudinal muscle
 Styloid process of temporal bone
 Upper end of stylohyoid ligament
Innervation: Hypoglossal nerve
Actions: Retracts and elevates the tongue. Together with hyoglossus, it helps to
convert the tongue to a trough (by elevating the side of this organ while hyoglossus
depresses it) during drinking
Palatoglossus: see the palate (above)
Chondroglossus
 Is the part of hyoglossus that arises from the lesser horn of hyoid
Intrinsic Muscles of the Tongue (Fig. 143)
Intrinsic muscles of the tongue

 Are four bilateral muscles, which are confined to the tongue
 Are mainly involved in altering the shape of the tongue
 Are also skeletal in type, and
 Receive motor fibres from the hypoglossal nerve
Intrinsic muscles of the tongue include:

 Superior longitudinal muscle
 Inferior longitudinal muscle
 Vertical muscle, and
 Transverse muscle
The superior longitudinal muscle

 Is a thin layer of muscle which consists of longitudinal and oblique fibres; it is
located deep to the mucosa of the dorsum of the tongue
 Extends from the submucous fibrous tissue near the epiglottis behind, to the
margin and tip of the tongue in front
 Curls the tip and margin of the tongue upwards
 Submucous fibrous tissue, near the epiglottis, and
 Median fibrous septum of the tongue
Distal attachment:
 Margin and tip of the tongue
 Mucous membrane of the dorsum of the tongue
Action:
 Curls the tip and sides of the tongue upwards, thereby making the dorsum
concave
 Can also shorten the tongue
The inferior longitudinal muscle

 Is a small bundle of skeletal muscle fibres located near the inferior surface of the
tongue (between hyoglossus laterally and genioglossus medially) (Fig. 143)
 Extends from the root to the apex of the tongue
 Blends with fibres of styloglossus
 Body of hyoid bone
 Root of the tongue
Distal attachment: Tip of the tongue
Actions:
 Pulls the apex of the tongue downward (thereby making the dorsum convex)
 Also shortens the tongue
The vertical muscle of the tongue

 Occupies the anterolateral region of the tongue
 Passes downwards and laterally, from the dorsum to the side of the tongue
 Intermingles with fibres of other lingual muscles
Proximal attachment: Mucosa of the dorsum of the tongue

Actions: Flattens and widens the tongue
The transverse muscle of the tongue

 Consists of fibres which run laterally from the median fibrous septum to the
margin of the tongue (deep to the superior longitudinal muscle)
 Blends with palatopharyngeus
Proximal attachment: Median fibrous septum
Distal attachment: Submucous fibrous tissue of the margin of the tongue
Innervation: All intrinsic muscles of the tongue are supplied by the hypoglossal
nerve
Actions: Narrows and elevates the tongue
Innervation of the Tongue (Fig. 144)
The tongue receives

 Motor fibres (which innervate its muscles) from the hypoglossal nerve
 General sensory fibres, which convey exteroceptive sensations (pain, touch,
temperature, etc) from the mucosa
 Special sensory fibres (special visceral afferents), which convey taste sensation
from the mucosa
Figure 144. Sensory and motor innervation of the tongue.

 Motor fibres to all muscles of the tongue (except palatoglossus) arise from the
hypoglossal nerve
 Motor fibres to palatoglossus arise from the cranial accessory nerve. These
fibres are conveyed (to palatoglossus) by the vagus nerve and pharyngeal plexus
 General sensory fibres from the anterior ⅔ (presulcal part) of the tongue are
conveyed by the lingual nerve (a branch of the mandibular nerve) (Fig. 144)
 Special sensory (taste) fibres from the anterior ⅔ of the tongue (except the
vallate papillae) are conveyed by the chorda tympani (a branch of facial nerve)
(Fig. 144)
 Special and general sensory fibres from the posterior ⅓ of the tongue (including
taste fibres from the vallate papillae) are conveyed by the glossopharyngeal
nerve (Fig. 144)
 Special and general sensory fibres from the valleculae (the region just anterior to
the epiglottis) are conveyed by internal laryngeal nerves (from the superior
laryngeal branches of vagus)
 Postsynaptic parasympathetic fibres to lingual glands arise partly from the
submandibular ganglion and are conveyed by the lingual nerve. Similar fibres
also reach the tongue from the internal laryngeal and glossopharyngeal nerves
Blood Supply to the Tongue

The tongue is supplied by

 The lingual arteries, branches of the external carotid arteries
 The tonsillar and ascending palatine arteries, branches of the facial artery, and
 The ascending pharyngeal arteries, branches of the external carotid arteries
The lingual artery

 Is the main artery of the tongue and the floor of the mouth
 Arises from the external carotid artery opposite the tip of the greater cornu of the
hyoid (and between the origins of the superior thyroid and facial arteries)
 Passes forwards, above the hyoid bone and deep to hyoglossus; then, it ascends,
deep to the anterior border of hyoglossus, before running forwards on the inferior
aspect of the tongue as the deep lingual artery. The latter reaches as far forwards
as near the apex of the tongue (where it anastomoses with its fellow)
 May arise via a common stem with the facial or (less commonly) the superior
thyroid arteries
 Has a sinuous course
The branches of the lingual artery to the tongue include:

 Dorsal lingual arteries
 Sublingual artery, and
 Deep lingual artery
The dorsal lingual arteries

 Are 2–3 vessels which arise from the lingual artery, deep to hyoglossus
 Ascend to the posterior part of the dorsum of the tongue, where they supply its
mucosa
 Also supply the palatine tonsil, soft palate, palatoglossal arches and epiglottis
 Anastomose with the opposite dorsal lingual arteries
The sublingual artery

 Arises from the lingual artery at the anterior border of hyoglossus
 Passes forwards, between genioglossus and mylohyoid, to the sublingual gland,
which it supplies
 Also supplies the surrounding muscles,
 mucosa of the floor of the mouth and
 the mandibular gingivae
 Anastomoses with its fellow in the mandibular gingivae
The deep lingual artery

 Is the continuation of the lingual artery, distal to the origin of the sublingual
artery; it is accompanied by the lingual nerve
 Initially ascends along the anterior border of hyoglossus; it then turns forwards,
on the inferior aspect of the tongue, to the apex of this organ, where it lies
adjacent to the frenulum (deep to the mucosa)
 Supplies the anterior part of the tongue, and
 Anastomoses with its fellow at the apex of the tongue
Venous Drainage of the Tongue
Veins of the tongue include:

 Dorsal lingual veins
 Sublingual vein, and
 Deep lingual vein
The dorsal lingual veins

 Drain the dorsum and sides of the tongue
 Pass backwards, deep to the hyoglossus and alongside the lingual artery
 Terminate in the internal jugular vein (IJV), near the tip of the greater horn of
hyoid
The deep lingual vein

 Commences near the apex of the tongue
 Passes backwards, on the inferior aspect of the tongue, just lateral to the lingual
frenulum (and deep to the lingual mucosa, through which it can be observed)
 Joins the sublingual vein at the anterior border of hyoglossus, to form the
accompanying vein of hypoglossal nerve
The accompanying vein of hypoglossal nerve

 Passes backwards, alongside the hypoglossal nerve, on the lateral surface of
hyoglossus
 Terminates in the facial vein (or in the internal jugular or lingual vein)
Lymphatic Drainage of the Tongue
Note that
 Lymph from the tip of the tongue drains into the submental nodes
 Lymph from the medial aspect of the presulcal part of the tongue drains
bilaterally into the inferior deep cervical nodes
 Lymph from the lateral aspect of the presulcal part of the tongue drains first into
the submandibular nodes, and then into the deep cervical nodes
 Lymph from the postsulcal part of the tongue drains bilaterally into the superior
deep cervical nodes
Applied Anatomy

 In unconscious subjects, the tongue is prevented from obstructing the airway by

pulling the mandible forwards (this pulls the tongue forwards, owing to the
attachment of genioglossus to the mandible)
 When one of the hypoglossal nerves is damaged, paralysis of genioglossus of that
side leads to deviation of the tongue (to the affected side) on protraction
 The sublingual mucosa is a good route of administration of certain drugs; the
drug is absorbed into the deep lingual veins
 Ankyloglossia (tongue tie) is characterized by an abnormally short lingual
frenulum
 Frenectomy (excision of lingual frenulum) may be performed to correct
ankyloglossia
 In carcinoma of the tongue, cancer cells may metastasize into the superior or
inferior deep cervical, submandibular or submental nodes, depending on the site
of the malignancy
 A portion of the thyroglossal duct may persist and thus become cystic, forming a
thyroglossal cyst; this swelling is usually painless and is commonly located close
to the body of hyoid (though it may be found elsewhere)
 In certain instances, the thyroid gland fails to descend (sufficiently) from its
origin in the floor of the primitive pharynx. Thus, the gland has an abnormally
high position in the neck (and may even be found in the root of the tongue)
Salivary Glands
Regarding salivary glands, note that

 There are main and minor salivary glands
 The main salivary glands are paired and are located some distance from the oral
cavity (with which they are connected by ducts); these glands include parotid,
submandibular and sublingual glands
 The minor salivary glands are located in the mucosa (and submucosa) of the
tongue and in the walls of the buccal cavity. They include lingual, labial, buccal
and palatal glands
 Saliva is the tasteless, odourless and clear fluid produced by the salivary glands.
It contains digestive amylase, lysozyme, immunoglobulin A (IgA) and some ions
Importance of saliva includes:

 Lubrication of food, to facilitate chewing and swallowing
 Washing of food debris from the teeth; this prevents dental caries and enhances
oral hygiene
 Moistening of the buccal cavity; this enhances speech
 Creation of an appropriate environment for gustation (taste)
 Enhancement of immunity (owing to its contents of lysozyme and IgA)
 Digestion of carbohydrates (owing to its content of amylase)
Main Salivary Glands (Fig. 145)
These include:
 Parotid gland
 Submandibular gland, and
 Sublingual gland
Parotid Gland (Fig. 145)
The parotid gland

 Is the largest of the salivary glands; it resembles an inverted 3-sided pyramid
 Is irregular, lobulated, and yellowish in appearance
 Occupies the parotid region – the wedge-shaped interval between the
mandibular ramus anteriorly, the mastoid process and sternocleidomastoid
posteriorly, the styloid process medially and the external acoustic meatus
superiorly
 Has a small accessory part which lies on the masseter (between the zygomatic
arch above and the parotid duct below
 Weighs about 25 g in an average adult
 Is invested by a condensation of the investing layer of the deep cervical fascia –
the parotid sheath. This prevents the swelling of the gland in certain
pathological conditions
 Is separated from the submandibular gland by the stylomandibular ligament (a
condensation of the deep fascia of the neck); this ligament extends from the
temporal styloid process to the angle of the mandible
 Has several surfaces; these include superficial, superior, anteromedial and
posteromedial surfaces, and an apex that is directed downwards
 Contains some lymph nodes – the parotid nodes; these are located in its
substance and on its superficial surface
 Is traversed by some structures collectively termed intraparotid structures;
these include the retromandibular vein, external carotid artery and facial nerve
 Consists mainly of serous acini; mucous cells are scanty or absent. Thus, it
 Produces a watery serous fluid that is rich in enzymes; this forms about 25% of
total salivary secretion
Fig. 145. Salivary glands.
Anatomic Relations of the Parotid Gland
Regarding the relations of the parotid gland, note the following points:
 Its superficial surface is related to skin, superficial fascia and superficial parotid
nodes
 Its superior surface is related to the cartilaginous part of the external acoustic
meatus and the TMJ
 Its anteromedial surface is related to the masseter, ramus of the mandible and
medial pterygoid; the terminal branches of facial nerve emerge from this surface
 Its posteromedial surface is related to mastoid and styloid processes,
sternocleidomastoid, posterior belly of digastric, internal and external carotid
arteries, internal jugular vein and the muscles attached to the styloid process (e.g.
stylohyoid)
 Its apex is directed downwards into the carotid triangle (on the posterior belly of
digastric)
Intraparotid Structures
Within the parotid glands, note that

 The facial nerve is the most superficial major structure; its five terminal branches
(temporal, zygomatic, buccal, marginal mandibular and cervical) arise within the
gland
 The retromandibular vein descends just deep to the facial nerve (behind the
ramus of the mandible); this vein is formed by the union of the maxillary and
superficial temporal veins (behind the neck of the mandible)
 The external carotid artery is the most internal major structure; this vessel
ascends through the parotid gland, deep to the retromandibular vein and facial
nerve. Its terminal branches (superficial temporal and maxillary arteries), and
occasionally the posterior auricular artery, arise within the gland
 Few (deep parotid) lymph nodes are also found
The parotid duct

 Measures 5 cm in length (same as for submandibular duct) and 3 mm in diameter
 Passes forwards, over the masseter, to the anterior border of this muscle; and then
turns medially, to pierce the buccal pad of fat and the buccinator muscle
 Terminates on a small mucosal papilla located opposite the 2nd upper molar
tooth, where it opens into the vestibule of the oral cavity
 Is related above to the accessory parotid gland, the duct of which joins it
 Is lined by stratified squamous epithelium near its oral end and elsewhere by
columnar epithelium
 Can be readily palpated over a contracted masseter
Blood Supply to the Parotid Gland
The parotid gland

 Receives branches of the external carotid artery
 Is drained by veins which join the retromandibular (and thus the external
jugular) vein
Lymph from the parotid gland drains into the following nodes:
 The superficial and deep parotid nodes, and
 The superficial and deep cervical nodes
Innervation of the Parotid Gland
The parotid gland receives

 Sympathetic fibres from the external carotid plexus, and
 Parasympathetic fibres from the otic ganglion (via the auriculotemporal nerve)
Regarding the parasympathetic innervation of the parotid gland, note the

following:
 Preganglionic parasympathetic fibres arise from the inferior salivatory nucleus of
the upper medulla and are conveyed first by the glossopharyngeal nerve
 The tympanic branch of glossopharyngeal nerve contains preganglionic

parasympathetic fibres; this nerve joins the tympanic plexus (located on the
medial wall of the middle ear)
 From the tympanic plexus, the lesser petrosal nerve arises; this enters the
infratemporal fossa via the foramen ovale where it ends in the otic ganglion
 Postganglionic parasympathetic (secretomotor) fibres from the otic ganglion
are conveyed by auriculotemporal nerve to the parotid gland; these fibres
enhance the secretory function of the gland
Sublingual Gland
The sublingual gland

 Is the smallest of the main salivary glands; it is shaped like an almond (Fig. 145)
 Is located beneath the sublingual fold (underneath the tongue), between the
mandible laterally (where it occupies the sublingual fossa) and the genioglossus
medially
 Weighs about 3.5 g in health
 Is joined to its fellow around the frenulum of the tongue, close to the symphysis
menti
 May possess up to 20 smaller sublingual ducts, which open separately on the
sublingual fold; some of these ducts may unite to form a major sublingual duct
which opens with the submandibular duct on the sublingual papilla
 Consists mainly of mucous acini with serous demilunes. Thus, its secretion is
largely mucous
Relations of the Sublingual Gland
The sublingual gland is related

 Above to the mucosa of the oral floor and the tongue
 Below to mylohyoid
 Laterally to the body of the mandible (where it lies in the sublingual fossa)
 Medially to genioglossus, submandibular duct and lingual nerve
 Anteriorly to the symphysis menti and the anterior end of the opposite
(sublingual) gland
 Behind to the deep part of the submandibular gland
Blood Supply, Innervation and Lymphatics

 The sublingual gland receives branches of the sublingual and submental arteries
(from the lingual and facial arteries respectively)
 Venous drainage of the gland is by the sublingual and submental veins
 Postsynaptic parasympathetic fibres to the sublingual gland arise from the
submandibular ganglion, and are conveyed to the gland by the lingual nerve
Submandibular Gland
The submandibular gland

 Is an irregular gland, just about the size of a walnut (approximately half the size
of the parotid gland) (Fig. 145)
 Consists of a large superficial part and a small deep part, the two being
continuous with each other around the posterior border of mylohyoid
 Is mainly seromucous; it thus consists largely of serous acini with few mucous
ones
 May contain some lymph nodes in its substance
Superficial Part of Submandibular Gland
The superficial part of submandibular gland

 Occupies the digastric (submandibular) triangle between the mandible laterally
(where the gland occupies the submandibular fossa) and the mylohyoid medially
 Reaches as far forwards as the anterior belly of digastric, and is separated behind
from the parotid gland by the stylomandibular ligament
 Is invested by the investing layer of deep cervical fascia; this fascial sheath is
attached below to the greater horn of hyoid and above to the lower border and
mylohyoid line of mandibular body
 Is grooved on its posterosuperior aspect by the facial artery (which later lies
lateral to the gland)
 Is continuous with the deep part (of submandibular gland) around the posterior
border of mylohyoid
 Has inferior, lateral and medial surfaces
The superficial part of the submandibular gland is related

 Medially to mylohyoid, styloglossus, hyoglossus and posterior belly of digastric;
other medial relations include glossopharyngeal, lingual, hypoglossal and
mylohyoid nerves, submandibular ganglion, deep lingual vein, stylohyoid
ligament and the pharynx
 Laterally to the body of the mandible (where the gland occupies the
submandibular fossa), facial artery and medial pterygoid
 Inferiorly to platysma, facial vein, cervical branch of facial nerve, submandibular
lymph nodes and skin
Deep Part of the Submandibular Gland
The deep part of the submandibular gland

 Lies behind the sublingual gland, above the posterior part of mylohyoid
 Is related medially to hyoglossus and styloglossus, above to lingual nerve and
below to hypoglossal nerve
The submandibular duct

 Measures 5 cm in length (same as for the parotid duct)
 Begins as numerous tributaries in the superficial part of the gland
 Traverses the deep part (of the submandibular gland), draining it as it does so. It
then
 Emerges from the deep part of the gland to continue forwards, medial to the
sublingual gland; it crosses the lingual nerve medially as it does so
 Terminates at the tip of the sublingual papilla, just adjacent to lingual frenulum,
on the floor of the mouth
Blood Supply and Lymphatics of the Submandibular Gland
The submandibular gland

 Receives branches of the facial and lingual arteries; the submental branch of
facial artery is a notable source of blood to this organ
 Is drained by veins which accompany the arteries
 Is drained by the submandibular and deep cervical nodes (especially the jugulo-
omohyoid nodes)
Innervation of the Submandibular Gland
Regarding the innervation of the submandibular gland, note that

 Postganglionic sympathetic fibres reach the gland via the nerve plexus around
the facial artery
 Preganglionic parasympathetic fibres to the gland arise from the superior
salivatory nucleus in the lower pontine tegmentum; these fibres are conveyed
first by the facial nerve and then by the chorda tympani (a branch of facial nerve)
 In the infratemporal fossa, the chorda tympani joins the lingual nerve; via the
latter, the preganglionic parasympathetic fibres of chorda tympani reach the
submandibular ganglion
 The submandibular ganglion is located on the lateral aspect of hyoglossus,
below the lingual nerve, to which it is connected by nerve fibres
 Fibres of the chorda tympani (contained in the sheath of the lingual nerve)
synapse on the cells of the submandibular ganglion; from the latter,
postganglionic parasympathetic fibres pass to the submandibular gland. Similar
fibres reach the sublingual gland via the lingual nerve
Applied Anatomy

 Sialography is the radiographic demonstration of the salivary glands (especially
the parotid and submandibular glands); the contrast medium is injected through
the main ducts of these glands. However,
 Owing to the multiplicity of the ducts of the sublingual gland, it is difficult to
demonstrate this gland radiographically
 Sialogram can readily reveal calculi in the ducts of the salivary glands
 In carcinoma of the submandibular gland, surgical removal may be necessary;
the incision is made below the angle of the mandible, to preserve the marginal
mandibular branch of facial nerve
Pterygopalatine Fossa
The pterygopalatine fossa

 Is a narrow pyramidal space located below the apex of the orbit
 Is bounded by bones and it communicates with adjacent bony cavities via
foramina
 Contains important nerves, blood vessels and a ganglion (pterygopalatine
ganglion)
The pterygopalatine fossa is bounded

 Above by the greater wing of sphenoid
 Below (the floor) by the pyramidal process of palatine bone
 Anteriorly by the posterior surface of maxilla
 Posteriorly by the pterygoid process of sphenoid
 Medially by the perpendicular plate of palatine bone
The pterygopalatine fossa communicates

 Anterosuperiorly with the orbit through the inferior orbital fissure
 Posterosuperiorly with the middle cranial fossa through the foramen rotundum
and the pterygoid canal
 Laterally with the infratemporal fossa through the pterygomaxillary fissure
 Medially with the nasal cavity through the sphenopalatine foramen
The pterygopalatine fossa contains:

 Pterygopalatine ganglion
 Pterygopalatine (3rd) part of maxillary artery and its branches
 Maxillary nerve and its branches, and
 Nerve of the pterygoid canal
Maxillary Nerve
The maxillary nerve

 Is the intermediate (second) branch of the trigeminal nerve (Fig. 146); it arises
from the trigeminal ganglion in the middle cranial fossa
 Passes forwards, from the trigeminal ganglion, through the lower part of the
lateral wall of the cavernous sinus
 Leaves the middle cranial fossa for the pterygopalatine fossa via the foramen
rotundum
 Continues forwards through the pterygopalatine fossa (above the pterygopalatine
ganglion). Then, it
 Enters the orbit (from the pterygopalatine fossa) through the inferior orbital
fissure to become the infraorbital nerve
 Is purely sensory in composition
Fig. 146. Maxillary nerve and its branches
Branches of the maxillary nerve include:

 Meningeal nerve
 Paired ganglionic (pterygopalatine) branches
 Zygomatic nerve
 Posterior superior alveolar nerve, and
 Infraorbital nerve (Fig. 146); this is the continuation of the maxillary nerve. It
traverse the infraorbital groove, canal and foramen, in succession, to enter the
face
The meningeal nerve

 Arises from the maxillary nerve near the foramen rotundum
 Innervates the dura of the middle cranial fossa
 Is accompanied by the anterior branch of the middle meningeal artery
The ganglionic nerves

 Are paired branches of the maxillary nerve; they arise from the latter in the
pterygopalatine fossa
 Connect the maxillary nerve to the pterygopalatine ganglion
 Consist of afferent fibres from the palate, pharynx, nasal cavity and the periorbita
(and of postganglionic parasympathetic fibres to the lacrimal gland)
The zygomatic nerve

 Also arises from the maxillary nerve in the pterygopalatine fossa
 Enters the orbit through the inferior orbital fissure; then it
 Passes forwards on the lateral wall of the orbit, where it divides into two
branches, zygomaticofacial and zygomaticotemporal nerves, to the face and
temple respectively
 Gives a branch (which contains postganglionic parasympathetic fibres) to the
lacrimal nerve in the orbit; these fibres supply the lacrimal gland
The posterior superior alveolar nerve

 Arises from the maxillary nerve in the pterygopalatine fossa
 Passes anteroinferiorly to pierce the posterior surface of the maxilla
 Innervates the maxillary molar teeth, maxillary sinus, gums and adjacent part of
the cheek
 Contributes fibres to the superior dental plexus; the latter also receives rami from
the anterior (and occasionally middle) superior alveolar nerves
Infraorbital Nerve: See above.
Pterygopalatine Ganglion (Fig. 146)
The pterygopalatine ganglion

 Is the largest peripheral parasympathetic ganglion; it is flattened and reddish in
appearance
 Occupies the pterygopalatine fossa, where it lies anterior to the pterygoid canal
and close to the sphenopalatine foramen
 Is connected to the maxillary nerve (which lies above it) by two ganglionic
(pterygopalatine) nerves
 Is joined posteriorly by the nerve of the pterygoid canal; this conveys presynaptic
parasympathetic and postsynaptic sympathetic fibres to the ganglion
 Gives rise to several branches, most of which are afferent (sensory) fibres that
traverse the ganglion (without synapsing in it) to reach the maxillary nerve

 Presynaptic parasympathetic fibres to the pterygopalatine ganglion are
conveyed initially by the facial nerve and then by the greater petrosal branch of
this nerve
 The greater petrosal nerve joins the deep petrosal nerve (in the middle cranial
fossa) to form the nerve of the pterygoid canal. The deep petrosal nerve is
derived from the internal carotid plexus and it contains postsynaptic sympathetic
fibres
 The nerve of the pterygoid canal passes forwards through the foramen lacerum
and the pterygoid canal, to the pterygopalatine fossa (where it joins the
pterygopalatine ganglion)
 The postsynaptic sympathetic (vasomotor) component of the nerve of the
pterygoid canal arise in the superior cervical ganglion; these fibres traverse the
pterygopalatine ganglion uninterrupted and are distributed via the branches of
this ganglion (see below)
 Presynaptic parasympathetic component of the nerve of the pterygoid canal

synapse on the nerve cells of the pterygopalatine ganglion
 Postsynaptic parasympathetic fibres from the pterygopalatine ganglion are
distributed via the branches of this ganglion to the lacrimal, nasal, palatal and
pharyngeal glands
 The branches of the pterygopalatine ganglion consist largely of sensory fibres
which traverse the ganglion (uninterrupted) to join the maxillary nerve;
accompanying these are secretomotor and vasomotor fibres
Branches of the Pterygopalatine Ganglion
These include:
 Orbital branches
 Palatine nerves (Fig. 146)
 Nasal nerves, and
 Pharyngeal nerve
Orbital branches of pterygopalatine ganglion

 Are 2–3 rami which ascend through the inferior orbital fissure
 Give sensory fibres to the orbital periosteum and the sphenoidal and ethmoidal
sinuses
 May convey secretomotor fibres to the lacrimal gland
Palatine nerves include:

 Greater palatine nerve, and
 Lesser palatine nerves
The greater palatine nerve

 Descends through the greater palatine canal, from the pterygopalatine ganglion
(where it arises)
 Emerges through the greater palatine foramen on the oral aspect of the hard
palate; it then
 Passes forwards in a groove near the lateral margin (of the oral aspect) of the hard
palate, almost as far forwards as the incisor teeth
 Innervates the glands and mucosa of the hard palate, as well as the gums
 Communicates with rami of the nasopalatine nerve. The latter traverses the
incisive canal and fossa to reach the palate anteriorly
 Gives rise to the posterior inferior nasal nerves; these pierce the perpendicular
plate of palatine bone to supply the mucosa of the inferior nasal concha and the
middle and inferior nasal meatuses
The lesser palatine nerves

 Also descend through the greater palatine canal (behind the greater palatine
nerve), from the pterygopalatine ganglion
 Emerge below through the lesser palatine foramina
 Give sensory fibres to the soft palate, palatine tonsil and adjacent part of the
gums
 Also convey taste fibre from the soft palate
Nasal branches of pterygopalatine ganglion include:

 Lateral posterior superior nasal nerves, and
 Medial posterior superior nasal nerves (including the nasopalatine nerve)
The lateral posterior superior nasal nerves

 Are about six rami; they arise from the pterygopalatine ganglion and then
descend through the sphenopalatine foramen, to enter the nasal cavity
 Innervate the posterior part of the superior and middle conchae and the ethmoidal
air cells
The medial posterior superior nasal nerves

 Are 2–3 rami; they arise from the pterygopalatine ganglion
 Also descend through the sphenopalatine foramen, to enter the nasal cavity
 Cross the posterior part of the nasal roof to the medial nasal wall (nasal septum)
 Innervate the posterior part of nasal roof and the nasal septum
 Include the nasopalatine nerve (which is the largest nerve of this group)
The nasopalatine nerve

 Occupies a groove on the vomer as it passes downwards and forwards on the
nasal septum
 Traverses the incisive canal and fossa (with its fellow), to reach the roof of the
mouth (anterior part of the hard palate)
 Communicates with the rami of the greater palatine nerve in the roof of the mouth
 Gives sensory fibres to the roof, septum and floor of the nasal cavity
 Also innervates the anterior part of the hard palate and the part of the gum
adjacent to the incisor teeth
The pharyngeal nerve

 Arises from the pterygopalatine ganglion in the pterygopalatine fossa
 Passes backwards through the palatovaginal canal, accompanied by pharyngeal
branch of maxillary artery
 Gives sensory fibres to the roof of the pharynx, pharyngeal end of the auditory
tube and the sphenoidal sinus
Nose and Ear

Nose
The nose
 Lies largely within the head, above the oral cavity; however, a part if it projects
forwards onto the face as the external nose
 Can be divided into right and left nasal cavities, which are separated by the nasal
septum
 Contains the olfactory receptors in its roof (where the olfactory epithelium is
located)
 Communicates with the exterior via the anterior nares (or nostrils) and with the
nasopharynx via the posterior nares (or choanae)
 Also communicates with the anterior cranial fossa through foramina in the
cribriform plate of ethmoid
 Is lined in most parts by ciliated pseudostratified columnar epithelium (which is
typical of the respiratory tract)
 Receives the openings of the paranasal sinuses
Functionally, the nose is responsible for

 Perception of smell, i.e., olfaction
 Passage of air in and out of the airway, i.e. respiration, and
 Conditioning of the inspired air, e.g., by humidifying, warming and filtering it
External Nose
With respect to the external nose, note the following:

 It is the part of the nose that project forwards onto the face
 It appears pyramidal, its shape being maintained by bony and cartilaginous
frameworks. However
 Its shape and size vary (to some extent) in different individuals
 Its root is directed upwards; and this is continuous with the forehead at the
nasion; while its apex (tip) points downwards
 The median portion between the root and apex is the dorsum
 Its inferior openings are a pair of ellipsoidal apertures – the anterior or external
nares (nostrils); these are separated from each other in the median plane by a
cartilaginous nasal septum (which extends backwards)
 The ala of the nose is the lateral boundary of each nostril, the free edge of which
contains fibrofatty tissue
 Just behind each nostril is the vestibule of the nasal cavity; this is lined by skin
which bears short stiff hair – vibrissae
 The skeleton of the upper part of the external nose is bony – its bones include
nasal bones, frontal processes of maxillae and nasal parts of frontal bones
 The skeleton of the lower part of the external nose is cartilaginous; its cartilages
include the lateral nasal, septal, major alar and minor alar cartilages
 The bones and cartilages of the external nose are connected with each other by
fibrous tissue; however, the alar cartilages are movable, thereby allowing for the
adjustment of the size of the nostrils
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 The skin of the external nose is movable over the bony skeleton, but is firmly
bound to the cartilages; it is continuous with the skin of the vestibule of the nose
Blood Supply, Lymphatics and Innervation of the External Nose
The external nose receives arterial blood from

 The alar and septal branches of the facial artery
 The infraorbital branch of maxillary artery, and
 The dorsal nasal branch of ophthalmic artery
The veins of the external nose drain into

 The facial veins, and
 The ophthalmic veins
Lymph vessels from the external nose drain into

 The submandibular nodes, and
 The parotid nodes
The skin of external nose is innervated by

 Infratrochlear and external nasal branches of ophthalmic nerve, and
 Infraorbital branch of maxillary nerve
Note: muscles of the external nose, e.g. nasalis, are innervated by the facial nerve.
Nasal Cavities
Each nasal cavity

 Is located above the oral cavity and is separated from its fellow by a mid-sagittal
nasal septum
 Communicates with the exterior via the anterior nasal aperture (nostril) and with
the pharynx via the posterior nasal aperture (choana)
 Is divisible into three regions: vestibule, olfactory and respiratory regions
 Is lined by a mucous membrane that is bound firmly to the underlying periosteum
and perichondrium
 Has a roof, a floor, a lateral wall and a medial wall (septum)
 Receives the openings of the paranasal sinuses
Also note that

 The nostril is ellipsoidal and measures about 1 cm transversely, while
 The choana is oval and measures about 1. 25 cm transversely and 2.5 cm
vertically
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The vestibule of the nasal cavity

 Is the slightly enlarged part of the nasal cavity that lies just behind the nostril
 Is lined by skin which possesses vibrissae (coarse hair)
 Is bounded laterally by the ala and parts of the alar cartilages and medially by the
septal process of the major alar cartilage
 Is limited above by the limen nasi – an elevation on the lateral wall of the
vestibule (produced by the upper margin of the major alar cartilage). At this level,
the skin of the vestibule is continuous with the mucous membrane of the rest of
the nasal cavity
The olfactory region of the nasal cavity

 Covers the superior concha, upper 1 cm of the nasal septum and part of the nasal
roof between them
 Appears brownish-yellow in the living
 Has an average surface area of 10 cm2; this decreases with advancing age
 Is lined by tall pseudostratified columnar epithelium, which contains the somata
and peripheral processes of olfactory receptors (bipolar neurons). The central
processes of these neurons form the olfactory nerves which traverse the
cribriform plate of ethmoid to terminate in the olfactory bulb (located in the
cranial cavity). Olfactory neurons are supported by sustentacular cells
 Is functionally adapted for olfaction (sense of smell)
Respiratory Region of Nasal Cavity
The respiratory region of nasal cavity

 Corresponds to the remaining part of the nasal cavity (outside the olfactory region
and vestibule); thus, it occupies the lower ⅔ of the nasal mucosa
 Is well vascularized, and its mucosa is firmly bound to the underlying periosteum
 Has a lining of ciliated pseudostratified columnar epithelium
Boundaries of the Nasal Cavity
The nasal cavity has the following boundaries:

 Roof
 Floor
 Lateral wall, and
 Medial wall (nasal septum)
Roof of the Nasal Cavity
Note the following:

 The roof of the nasal cavity has three parts; these are, from behind forwards, the
sphenoidal, ethmoidal and frontonasal parts
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 The sphenoidal part of nasal roof is formed by the body of sphenoid; this part
slopes backwards and downwards and receives the opening of the sphenoidal
sinus
 The ethmoidal part of nasal roof is formed by the cribriform plate of ethmoid; it
is horizontally-disposed and bears several foramina, which connect the nasal
cavity with the anterior cranial fossa (and which transmit the olfactory nerves)
 The frontonasal part of nasal roof is formed by the spine of the frontal bone and
the nasal bones; it slopes downwards and forwards and forms part of the external
nose
 Intimately related (above) to the roof of the nasal cavity are the sphenoidal sinus
and anterior cranial fossa; the latter contains the olfactory bulb, frontal lobes of
the cerebral hemispheres and meninges
The floor of the nasal cavity

 Is formed by the upper surface of the hard palate, and thus by the palatine process
of the maxilla anteriorly and the horizontal plate of palatine bone posteriorly
 Slopes downwards and forwards, and is broader than the roof
 Bears the opening of the incisive canal in its anterior part (near the nasal septum)
Medial Wall of the Nasal Cavity (Nasal Septum)
Regarding the nasal septum, note that

 It is the median partition between the nasal cavities; it extends from the nasal roof
above to the floor below
 The vomer forms its posteroinferior part, including the posterior border of this
septum; this bone extends from the sphenoidal body above to the hard palate
below
 The perpendicular plate of ethmoid forms its posterosuperior part; this plate of
bone occupies the interval between the ethmoid above and the vomer and septal
cartilage below
 The hyaline septal cartilage completes the nasal septum anteriorly
 Minor contributions to the nasal septum are provided by the nasal spine of frontal
bone anterosuperiorly, sphenoidal crest posterosuperiorly and the crests of
maxilla and palatine bone inferiorly
 The nasopalatine nerve and sphenopalatine vessels groove the surface of the
vomer as they pass anteroinferiorly over the septum
Lateral Wall of the Nasal Cavity
The lateral wall of the nasal cavity

 Has an irregular appearance, owing to the presence of three scroll-like bony
processes (superior, middle and inferior conchae) that project inferomedially
from it
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 Is separated from the orbit (in its upper part) by the ethmoidal labyrinth
 Is formed mainly by three bones, which include maxillary, palatine and ethmoidal
bones
The lateral wall of the nasal cavity is formed by

 Maxilla antero-inferiorly
 Perpendicular plate of palatine bone posteriorly, and
 Ethmoidal labyrinth superiorly
Owing to the presence of the conchae, each nasal cavity is divisible into four
channels (Fig. 147); from above downwards, these include:
 Spheno-ethmoidal recess
 Superior nasal meatus
 Middle nasal meatus, and
 Inferior nasal meatus
Regarding the conchae, note the following facts:

 The inferior concha is a separate bone and it is also the largest of the conchae; it
is close to the nasal floor and it overhangs the inferior nasal meatus
 Being a separate bone, the inferior concha articulates with the maxillary and
palatine bones
 The middle concha is located above the inferior one, on the lateral wall of the
nasal cavity; it is a medial process of the ethmoidal labyrinth, and it overhangs
the middle nasal meatus
 The superior concha is the smallest of the conchae; it is also a medial process of
the ethmoidal labyrinth, located adjacent to the sphenoidal body. It separates the
sphenoethmoidal recess above from the superior nasal meatus below
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Fig. 147. Nasal cavity; (S.E.R.: Spheno-Ethmoidal Recess).
The sphenoethmoidal recess

 Is the narrow part of the nasal cavity located between the superior concha below
and the sphenoidal body above (Fig. 147)
 Receives the opening of the sphenoidal sinus
The superior nasal meatus

 Is located beneath the superior concha (Fig. 147); it is the shallowest and shortest
of the nasal meatuses
 Receives the opening of the posterior ethmoidal sinuses
Regarding the middle nasal meatus, note that

 It lies beneath the middle concha, which largely hides it from view (Fig. 147)
 On its lateral wall is the rounded ethmoidal bulla – an eminence produced by the
middle ethmoidal air cells
 Just anteroinferior to the ethmoidal bulla, on the lateral wall of the middle nasal
meatus, is a curved narrow process – the uncinate process of ethmoid
 Between the uncinate process of the ethmoid below, and the ethmoidal bulla
above, is a curved groove termed the hiatus semilunaris (on the lateral wall of
middle nasal meatus)
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 At the upper end of the hiatus semilunaris is the opening of the ethmoidal
infundibulum, a narrow funnel-shaped canal into which the anterior ethmoidal
air cells and the frontal sinus open
 Occasionally, the ethmoidal infundibulum ends blindly; in this instance, the
frontal sinus opens, via the frontonasal duct, into the hiatus semilunaris
 The maxillary sinus opens into the lower end of the hiatus semilunaris through a
large ostium
 The middle ethmoidal sinus opens into the middle meatus on or above the
ethmoidal bulla
The inferior nasal meatus

 Is located inferolateral to the inferior concha; it is the largest of the nasal
meatuses, reaching as far down as the nasal floor (Fig. 147)
 Receives the opening of the nasolacrimal duct in its anterior part
Innervation of the Nasal Mucosa
The nasal mucosa receives sensory fibres from

 About six lateral posterior superior nasal nerves; these are branches of the
maxillary nerve and they supply the posterosuperior part of the lateral nasal wall
 About three medial posterior superior nasal nerves; these are also branches of the
maxillary nerve and they supply the posterior part of the nasal roof and septum
 Nasopalatine nerve, also a branch of the maxillary nerve; it supplies the roof,
septum and floor of the nasal cavity
 Posterior inferior nasal nerves; these are branches of the greater palatine nerve
and they supply the posteroinferior part of the lateral nasal wall
 The medial internal nasal nerve, a branch of the anterior ethmoidal nerve; it
innervates the anterior part of the nasal septum
 The lateral internal nasal nerve, also a branch of the anterior ethmoidal nerve; it
innervates the anterior part of the lateral nasal wall
Note the following:

 About 20 olfactory nerves from the olfactory epithelium of the nasal cavity
traverse the cribriform plate of ethmoid to terminate in the olfactory bulb
 Secretomotor fibres to the glands of the nasal mucosa arise from the
pterygopalatine ganglion; they are conveyed to these glands by nasal branches of
the ganglion
Blood Supply to the Nasal Cavity
The nasal cavity receives arterial blood from:

 Anterior and posterior ethmoidal arteries (branches of the ophthalmic artery)
 Sphenopalatine artery, a branch of the maxillary artery; it is the major vessel of
the nasal cavity
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 Greater palatine artery, also a branch of the maxillary artery, and

 Lateral nasal and superior labial branches of facial artery
Note that
 The main arteries of the nasal cavity anastomose in the Kiesselbach’s plexus,
located in the anteroinferior part of nasal septum (Little’s area). This plexus is
usually involved in epistaxis (nose bleed)
Veins of the nasal mucosa drain into:

 Facial vein
 Ethmoidal veins (and thus into the ophthalmic and dural veins)
 Sphenopalatine veins (and thus into the pterygoid plexus and maxillary vein)
Note the following:

 Infections of the nasal mucosa may spread into the cavernous sinus and cerebral
meninges, via the venous channels
 A rich plexus of blood vessels is associated with the nasal mucosa; this warms the
inspired air and assists with thermoregulation
Lymphatics of the Nasal Cavity
From the lymphatic plexuses of the nasal cavity, lymph vessels end in
 Submandibular nodes (from the anterior part of the nasal cavity)
 Retropharyngeal nodes
 Upper deep cervical nodes; these, together with the retropharyngeal nodes, drain
the larger part of nasal mucosa
Applied Anatomy

 Facial deformity may occur following fracture of nasal bones or injury to nasal
cartilages, e.g. in auto crash
 In head injury, the cribriform plate of ethmoid may be fractured; this tears the
meninges, thereby causing leakage of CSF into the nasal cavity – CSF
rhinorrhoea
 The nasal septum may deviate to one side rather than being in the median plane;
this deformity may obstruct the nasal cavity
 Epistaxis (nose bleed) may occur. It usually occurs in the Kiesselbach’s plexus
of Little’s area (anteroinferior part of nasal septum), owing to the rich
anastomoses between the main vessels of the nasal cavity in this area. Epistaxis
may be indicative of certain clinical conditions such as nasal infections and high
blood pressure
 When inflamed – rhinitis – the nasal mucosa swells readily owing to its rich
vascularity. This condition may also obstruct the nasal cavity
758
 Owing to the continuity of the nasal mucosa with those of adjacent regions, nasal
infections may spread to (or from) these regions; such regions or structures
include the lacrimal sac and conjunctiva (via the nasolacrimal duct), cranial
meninges (via the foramina of the cribriform plate of ethmoid), pharynx (via the
choana), tympanic cavity (via the auditory tube) and paranasal sinuses (via the
openings of these sinuses)
 Thrombophlebitis of nasal veins may also spread to the facial and ophthalmic
veins, cavernous sinus and pterygoid plexus
Paranasal Sinuses
The paranasal sinuses

 Are air-filled cavities produced by extension of the nasal mucous membrane into
the bones around the nasal cavities; they vary in size and shape in different
subjects
 Are lined by ciliated pseudostratified columnar epithelium; their mucosa is
thinner and less vascularized compared to that of the nasal cavity (and mucous
glands are present as well)
 Communicates with the nasal cavity via foramina
 Are absent or rudimentary at birth. However, they
 Enlarge greatly during the formation of permanent teeth and after puberty
 Lighten the skull and help with resonance of the voice
 Include the maxillary, frontal, sphenoidal, and ethmoidal air sinuses
Maxillary Sinus
The maxillary sinus

 Is the large pyramidal cavity located in the body of the maxilla; it is the largest of
the sinuses
 Has an apex, a base, a roof and a floor
 Measures, on average, about 35 mm vertically, 25 mm transversely, and 32 mm
anteroposteriorly (in adults)
 Appears as a minute groove on the medial aspect of the maxilla in the 4 th month
of intrauterine life
 Grows slowly prior to puberty; however, it enlarges rapidly in the postpubertal
period, and reaches its full size after the eruption of all permanent teeth
 Opens into the lower end of the hiatus semilunaris through an ostium located in
the upper part of its medial wall; a second ostium may however be present just
below the first
Regarding the boundaries of the maxillary sinus, note that

 Its apex extends into the zygomatic process of the maxilla
 Its base is the lower part of the lateral wall of the nasal cavity
759
 Its roof is the floor of the orbit; this is ridged by the infraorbital canal
 Its floor is the alveolar process of the maxilla; this lies about 12.5 mm below the
nasal floor. Projecting into it are the roots of the 1st and 2nd molar teeth and,
occasionally, those of the 3rd molar, 1st and 2nd premolar and canine teeth
Blood Supply, Lymphatics and Innervation of Maxillary Sinus

 The maxillary sinus is supplied by branches of the facial, infraorbital and greater
palatine arteries
 Veins which drain the maxillary sinus accompany the corresponding arteries
 The anterior, middle and posterior superior alveolar nerves (branches of the
maxillary nerve) innervate the maxillary sinus
 Lymph vessels which drain the maxillary sinus end in the submandibular nodes
Frontal Sinus (Fig. 147)
The frontal sinus

 Lies between the outer and inner tables of the frontal bone, above the superciliary
arch and the root of the nose
 Is separated from its fellow by a bony septum which usually deviates to one side
or the other (thereby making these sinuses asymmetrical)
 Extends variably upwards beyond the supraorbital margin, and backwards
towards the sphenoidal lesser wing (within the frontal bones)
 Measures about 32 mm vertically, 25 mm transversely and 18 mm
anteroposteriorly (in adults)
 Appears rudimentary (or absent) at birth; however, it is well developed by the 7th
year of life, and it reaches its full size after puberty
 May be subdivided into small interconnected cavities by bony septa
 Opens, via the ethmoidal infundibulum, into the upper end of the hiatus
semilunaris of the middle nasal meatus; it may however open directly into the
middle meatus via the frontonasal duct
Regarding the blood supply, lymphatics and innervation of the frontal sinus,
note that
 Its arterial supply is from branches of the anterior ethmoidal and supraorbital
arteries (from the ophthalmic artery)
 Its veins drain into the anastomotic vein in the supraorbital notch
 Its lymph vessels drain into submandibular nodes
 It receives sensory fibres from the supraorbital nerve
Sphenoidal Sinus (Fig. 147)
The sphenoidal sinus
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 Is located in the body of the sphenoid; here, it is separated from its fellow by a
median vertical septum which often deviates to one side (thereby making these
sinuses asymmetrical)
 Measures about 20 mm vertically, 18 mm transversely, 21 mm anteroposteriorly
 Is intimately related to certain vital structures (see below)
 May be replaced, to a large extent, by an extension of the posterior ethmoidal
sinus into the sphenoidal bone
 Appear as a small groove by the 5th month of intrauterine life, and as a minute
cavity at birth. However, it
 Extends into the body of the sphenoid by the 7th or 8th year of life, and is well
developed after puberty
 Opens into the sphenoethmoidal recess via an aperture (about 4 mm in diameter)
located in the upper part of its anterior wall
Each sphenoidal sinus is related

 Above to hypophysis cerebri, optic chiasma and olfactory tract
 Below to the nasopharynx and posterior part of the nasal cavity
 Laterally to the cavernous sinus, internal carotid artery and optic nerve (in the
optic canal)
Regarding its vasculature, lymphatics and innervation, the sphenoidal sinus is

 Supplied by the posterior ethmoidal arteries
 Drained by the posterior ethmoidal veins
 Innervated by the posterior ethmoidal nerve
 Drained by lymph vessels that end in the retropharyngeal lymph nodes
Ethmoidal Sinuses
The ethmoidal sinuses

 Are thin-walled cavities located in the ethmoidal labyrinth; the latter lies between
the nasal cavity and orbit
 Consists of several minute intercommunicating cavities – the ethmoidal air cells
 Extend variably into the adjoining frontal, sphenoidal, maxillary, lacrimal and
palatine bones (with which the ethmoid articulates)
 Are divided into anterior, middle and posterior groups (of ethmoidal air cells),
which open separately into the nasal meatuses
The anterior ethmoidal cells

 May be up to eleven in number
 Open via the ethmoidal infundibulum into the upper end of hiatus semilunaris (of
the middle nasal meatus); they may however open into the frontonasal duct
The middle ethmoidal cells

 Are about three small cavities located deep to the ethmoidal bulla
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 Open, via one or more orifices, on or above the ethmoidal bulla of the middle
nasal meatus
The posterior ethmoidal cells

 May number up to seven in number
 Open into the superior nasal meatus
 Lie adjacent to the optic nerve and canal
Blood Supply, Lymphatics and Innervation

 Ethmoidal sinuses are supplied by branches of the anterior and posterior
ethmoidal and sphenopalatine arteries
 Veins which correspond to the above arteries drain the ethmoidal sinuses
 Ethmoidal sinuses receive sensory fibres from the anterior and posterior
ethmoidal nerves (from the nasociliary branch of ophthalmic nerve)
 The anterior and middle ethmoidal sinuses are drained by the submandibular
nodes, while the posterior ethmoidal sinus is drained by the retropharyngeal
nodes
Applied Anatomy
Note that
 The maxillary and frontal sinuses can be examined (for a growing mass or the
presence of fluid) by transillumination
 The ethmoidal and sphenoidal sinuses cannot be examined by transillumination
 Pus in the frontal and anterior ethmoidal sinuses could flow, via the ethmoidal
infundibulum, into the hiatus semilunaris, and thence, into the maxillary sinus
 Infections of the nasal cavity could invade the paranasal sinuses owing to the
continuity of their mucosae; due to a similar reason, infections of the conjunctiva
and lacrimal apparatus could also affect these sinuses
 Pus that accumulates in the maxillary sinus does not drain readily owing to the
high position of the ostium of this sinus; drainage may however be effected by
puncturing the canine fossa on the anterior aspect of the maxilla or by passing a
cannula through the nostril into the ostium
 Sinusitis is the inflammation of one or more of the sinuses; when this occurs, the
mucosa of the sinus becomes swollen and painful and its opening may be blocked
 Owing to the proximity of the posterior ethmoidal sinus to the optic nerve,
infections of this sinus may affect the nerve, causing optic neuritis; this may
result in blindness
The Ear
The ear
762
 Is the complex apparatus concerned with hearing and equilibrium

 Is divisible into three parts, which include external, middle and internal ear.
External Ear
The external ear

 Is responsible for the collection and transmission of sound waves from the
exterior to the tympanic membrane
 Consists of the auricle and external acoustic meatus
Auricle
The auricle
 Is the part of the external ear which projects from the side of the head (Fig. 148);
it is involved with the collection of sound waves from the exterior, among other
functions
 Is made up of an irregularly folded plate of elastic cartilage (auricular
cartilage), which is covered externally by skin; the latter is adherent to the
cartilage and is equipped with fine hair and sebaceous glands
 Is connected to the skull by ligaments and extrinsic muscles; intrinsic muscles
also connect different parts of the auricle with each other
 Has numerous depressions and elevations on its lateral surface
Fig. 148. The auricle (pinna)
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On the lateral aspect of the auricle, note the following:

 The helix is the curved posterosuperior margin of the auricle (Fig. 148); it ends
anteriorly near the tragus as the crux
 Anterior and parallel to the helix is an elevation termed the antihelix
 The antihelix ends above by dividing into two crura; these bound a depression
referred to as the triangular fossa
 Between the helix and antihelix is the scaphoid fossa (a depression)
 The auricular (Darwin’s) tubercle is an elevation on the posterosuperior part of
the helix
 The tragus is a small flap located below the crus of the helix; it overhangs the
external auditory meatus anteriorly
 Between the antihelix and tragus is a relatively large depression termed the
concha; this leads into the external auditory meatus
 The soft non-cartilaginous lower end of the auricle is the lobule; it is made up of
fibrous and adipose tissues
 Above the lobule is a small tubercle termed the antitragus; separating the
antitragus from the tragus is the intertragic incisure
 The auricular skin and cartilage are continuous with those of the external auditory
meatus. Sebaceous glands are more numerous in the concha, scaphoid and
triangular fossae
Extrinsic Muscles of the Auricle
Regarding extrinsic muscles of the auricle, note the following:

 They are small muscles which attach the auricular cartilage to the skull and
epicranial aponeurosis; they include auriculares anterior, superior and posterior
 The auricularis anterior, the smallest of these muscles, is attached to the
temporal fascia; it moves the auricle forwards, though to a minimal extent
 The auricularis superior, the largest, is attached to the epicranial aponeurosis; it
moves the auricle upwards
 Auricularis posterior is attached to the mastoid process of temporal bone; it
draws the auricle backwards
 All the three auricular muscles are attached to the auricular cartilage
 Auriculares anterior and superior are innervated by temporal branches of facial
nerve
 Auricularis posterior is innervated by posterior auricular branch of facial nerve
Intrinsic Auricular Muscles
Regarding the intrinsic auricular muscles, note that

 These are six rudimentary muscles located within the auricle; four of them are on
the lateral aspect of the auricle, while two are on its cranial aspect
 These muscles may modify the shape of the auricle
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 The four intrinsic auricular muscles on the lateral aspect of the auricle are
innervated by temporal branches of facial nerve, while
 The two intrinsic auricular muscles on the cranial (medial) aspect of the auricle
are innervated by the posterior auricular branch of facial nerve
Blood Supply to the Auricle
The auricle receives arterial blood from

 The anterior auricular branches of superficial temporal artery; these supply the
lateral aspect of the auricle
 The posterior auricular artery; this gives about four branches to the cranial
aspect of the auricle
The auricle is drained by:

 The superficial temporal vein, and
 The posterior auricular vein
Lymph vessels from the auricle drain into:

 The parotid lymph nodes, especially the one located anterior to the tragus
 The superficial cervical nodes
 The upper deep cervical nodes, and
 The retroauricular (mastoid) nodes
Innervation of the Auricle
The following nerves give sensory fibres to the auricle:

 The great auricular nerve (C2,C3); this supplies the cranial surface and lower
part of the lateral surface of the auricle (below the external acoustic meatus)
 The auriculotemporal nerve; this supplies the tragus, as well as the crux and
anterior part of the helix
 The lesser occipital nerve (C2) which supplies the upper part of the cranial
aspect of the auricle
 Auricular branch of the vagus; this innervates the concha and the skin over the
cranial aspect of this depression
 A branch of the facial nerve, which also supplies skin of the concha
External Acoustic Meatus
The external acoustic meatus

 Is an S-shaped passage that leads from the concha of the auricle laterally to the
tympanic membrane medially (Fig. 148)
 Has a longer floor and anterior wall (owing to the obliquity of the tympanic
membrane); it measures about 2.5 cm from the floor of the concha and about 4
cm from the tragus
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 Consists of two parts; these are the cartilaginous part (lateral ⅓) and the osseous
part (medial ⅔)
 Is shorter in newborn in which the bony part is largely absent
 Becomes narrow towards the tympanic membrane
 Is directed, from its lateral end, at first anteromedially and upwards, then
posteromedially and upwards and finally anteromedially and downwards
 Has an isthmus that is located in the osseous part of the meatus, about 2 cm from
the floor of the concha; a second constriction is located just lateral to the isthmus,
in the cartilaginous part of the meatus
 Is lined by thin skin, which is devoid of dermal papillae
The cartilaginous part of the external acoustic meatus

 Forms the lateral ⅓ of the meatus; it is about 8 mm in length
 Is attached at its medial end to the circumference of the bony part. Laterally, it is
continuous with the auricular cartilage
 Is lined by thin skin which is intimately adherent to its cartilage; its subcutaneous
tissue is rich in ceruminous glands, which produce ear wax (cerumen)
The bony part of the external acoustic meatus

 Is the medial ⅔ of the meatus; it is about 16 mm in length
 Is narrower than the cartilaginous part
 Is formed by the tympanic and squamous parts of the temporal bone
 Is largely absent in newborn; thus, the meatus is relatively short in this group
 Is lined by thin skin which is largely devoid of ceruminous glands and hair
(except in the lateral part of its roof)
Regarding the skin of external auditory meatus, note that

 It is thin and intimately adherent to cartilage and bone of the meatus
 Numerous ceruminous glands are contained in the subcutaneous tissue of the
cartilaginous part of the meatus; these are coiled tubular glands, and they
produce earwax (or cerumen). Besides,
 Fine hair and sebaceous glands are also associated with the skin of the
cartilaginous part of the meatus; few of these are however located in the lateral
part of the roof of the osseous part
 No dermal papillae are associated with meatal skin
Blood Supply of the External Acoustic Meatus
The external acoustic meatus is supplied by

 Anterior auricular branches of the superficial temporal artery
 Deep auricular branch of the maxillary artery, and
 Posterior auricular branch of the external carotid artery
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Meatal veins drain into:

 External jugular vein
 Maxillary vein, and
 Pterygoid plexus of veins
Lymph vessels of external acoustic meatus

 Join those of the auricle (see above)
Innervation of the External Acoustic Meatus
Meatal nerves are derived from:

 Auriculotemporal nerve, which innervates the anterosuperior wall of the meatus
 Auricular branch of vagus, which innervates the postero-inferior wall of the
meatus, and
 Facial nerve, via its communicating branch to the auricular branch of vagus
Applied Anatomy

 Developmental anomalies of the auricle include supernumerary auricles and
imperfect auricular development; these are associated with anomalies in the
formation and fusion of the auricular hillocks during development
 The external acoustic meatus and tympanic membrane can be examined using an
otoscope; for easy passage of the latter into the meatus (in adults), the auricle is
pulled posterosuperiorly, thereby straightening out the meatus
 Meatal irritation produces reflex coughing and sneezing owing to the fact that
both the external acoustic meatus and pharynx are innervated by the vagus nerve
 The use of aural syringe (ear syringe) may induce vomiting in children and
reflex slowing of heart rate; this is also due to the innervation of the meatus by
vagus nerve
 Otitis externa is the inflammation of meatal skin; it is a bacterial infection which
produces pain and itching in the external ear
 Earache could occur in association with cancer of the tongue, toothache, etc; this
is owing to the fact that these structure (ear, teeth and tongue) receive sensory
fibres from branches of the same nerve (mandibular nerve)
Tympanic Membrane
The tympanic membrane

 Is a thin oval semitransparent membrane located between the external acoustic
meatus and the middle ear (Fig. 149)
 Is obliquely set, so that it makes an angle of 55o with the meatal floor
 Has a diameter of about 10 mm (its longer diameter)
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 Has a thick margin, the fibrocartilagenous ring, which is inserted into the
tympanic groove (at the junction of the external auditory meatus and middle ear),
except in its upper part where this groove is deficient. Here, the ring passes to the
lateral process of malleus, to form anterior and posterior mallear folds (Fig.
149)
 Has two parts: a flaccid part, which is the small lax upper part (between the
anterior and posterior mallear folds), and a tense part, which is the remaining
taut part of the membrane (Fig. 149)
 Has a concavity that faces laterally (towards the external acoustic meatus)
 Has a centre which is drawn inwards toward the tympanic cavity as the umbo
 Gives attachment to the handle of the malleus; this descends as far down as the
umbo (the centre of the membrane)
Fig. 149. The tympanic membrane. A, lateral surface; B, medial surface.
In addition, note that the tympanic membrane

 Has three layers: an external layer of skin, a middle fibrous layer and an inner
mucous membrane
 Is traversed from behind forwards by the chorda tympani (between the fibrous
and mucous layers of the membrane); this nerve runs over the neck of the malleus
as it does so (Fig. 149 B)
 Vibrates in response to sound waves that reach it via the external acoustic meatus
During clinical examination of the tympanic membrane, note that

 Its centre is seen as an indrawing – the umbo (which is directed toward the
tympanic cavity)
 The membrane appears pearl-grey, with some yellowish tint
 The handle of malleus is seen as a reddish-yellow streak that descends obliquely
backwards onto the umbo
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 The lateral process of malleus appears as a small white rounded elevation at the
upper part of the membrane
 A cone of light (from the illuminator) radiates anteroinferiorly from the umbo (in
the anteroinferior quadrant of the membrane) (Fig. 149 A)
 The anterior and posterior mallear folds are seen in the upper part of the
membrane, with the flaccid part of the latter located between them
Blood Supply, Lymphatics and Innervation of the Tympanic Membrane
Regarding the tympanic membrane, note that

 Its lateral cutaneous surface receives arterial blood from the deep auricular
branch of the maxillary artery
 The internal aspect of the membrane is supplied by the anterior tympanic branch
of the maxillary and the auricular branch of the occipital arteries
 Venous drainage of its external surface is into the external jugular vein
 Veins of its inner mucous layer drain into the transverse sinus and the venous
plexus around the auditory tube
 The external cutaneous surface of the membrane is innervated by the auricular
branch of vagus, while
 The tympanic branch of glossopharyngeal (and probably branches of the facial)
nerve innervates its medial aspect
 Lymph vessels from the external aspect of the membrane drain into the superficial
cervical nodes while those from its medial aspect join vessels from the middle ear
to end in the parotid and upper deep cervical nodes
Applied Anatomy of the Tympanic Membrane
Note that
 It is relatively safe to incise (when necessary) the posteroinferior part of the
tympanic membrane; this preserves the chorda tympani nerve, among other
reasons
 An object in the external acoustic meatus may perforate the tympanic membrane;
this may necessitate surgical intervention
 During Valsalva’s manoeuver, the mobility of the tympanic membrane can be
observed (using an otoscope).
Middle Ear (Tympanic Cavity)
The middle ear

 Is an irregular air-filled space located in the petrous temporal bone (between the
tympanic membrane laterally and inner ear medially) (Fig. 150)
 Is lined by mucous membrane whose epithelium varies from simple squamous to
ciliated columnar; this mucosa also covers the ossicles
 Is devoid of glands, except for few goblet cells
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 Is compressed laterally, as its lateral and medial walls bulge into its cavity
 Is divisible into two parts: the tympanic cavity proper, located just medial to the
tympanic membrane, and the epitympanic recess, located above the level of this
membrane. The recess lodges the larger part of the incus and the upper half of the
malleus
 Measures about 15 mm in its vertical and anteroposterior diameters. However, it
measures 6 mm, 2 mm and 4 mm in transverse diameter in its upper part (in the
epitympanic recess), intermediate part (opposite the umbo) and lower part (near
the floor of the cavity), respectively
 Is continuous with the mastoid antrum in its posterosuperior part, and via this (i.e.
the antrum), with the mastoid air cells
 Is connected anteriorly with the nasal part of the pharynx, via the auditory tube;
through the latter, air reaches the tympanic cavity from the pharynx
 Is narrowest in its intermediate portion, where its lateral and medial walls bulge
into the tympanic cavity
Fig. 150. The ear.
Boundaries of the Tympanic Cavity
The tympanic cavity has a

 Roof (or tegmental wall)
 Floor (or jugular wall)
 Anterior (or carotid) wall
 Posterior (or mastoid) wall
 Lateral (or membranous) wall, and
 Medial (or labyrinthine) wall
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The roof of the middle ear

 Is formed by a thin plate of bone, the tegmen tympani (on the anterior surface of
the petrous temporal bone)
 Separates the middle ear from the middle cranial fossa (and its contents)
 Extends backwards to cover the mastoid antrum, and forwards to cover the canal
for tensor tympani
 Is cartilaginous in children and may be partly deficient in adults
The floor of the tympanic cavity

 Is narrower than the roof
 Is formed by a thin plate of bone which separates the middle ear above from the
superior bulb of the internal jugular vein below
 Has an aperture (near the medial wall of the tympanic cavity) which transmits the
tympanic branch of the glossopharyngeal nerve
The anterior wall of the tympanic cavity

 Is a narrow bony wall that separates the tympanic cavity from the carotid canal
 Bears the openings of the canal for the tensor tympani and the auditory tube in its
upper part; the former is located above the latter
 Transmits the tympanic branch of the internal carotid artery and the superior and
inferior caroticotympanic nerves
Regarding the posterior wall of the tympanic cavity, note that

 It is wider above than below
 It bears a relatively large opening, aditus to the mastoid antrum, in its upper
part
 The aditus to the mastoid antrum leads posteriorly into the mastoid antrum; it
connects the epitympanic recess with the mastoid antrum and mastoid air cells
 Immediately below the aditus is the fossa for the incus; this receives the short
crus of the incus and its posterior ligament
 A small bony conical projection, the pyramid, is also located on the posterior
tympanic wall, close to the fenestra vestibuli (below the fossa for the incus); the
tendon of stapedius emerges from its tip
 The facial nerve descends through the posterior wall of the tympanic cavity,
medial to the aditus to the mastoid antrum (in a bony canal)
The lateral wall of the tympanic cavity

 Is formed largely by the tympanic membrane and the bony ring to which it is
attached
 Is completed above by the lateral wall of the epitympanic recess, (formed by the
squamous temporal bone)
In the lateral wall of the tympanic cavity, note that
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 The handle of the malleus is attached to the tympanic membrane, while its head
projects into the epitympanic recess
 At the level of the upper end of the handle of the malleus, just behind the
tympanic membrane, the posterior canaliculus for chorda tympani opens into the
tympani cavity (in the angle between the lateral and posterior tympanic walls)
 The posterior canaliculus for chorda tympani transmits the chorda tympani and a
branch of the stylomastoid artery into the tympanic cavity
 The chorda tympani passes forwards, over the neck of the malleus, and between
the fibrous and mucous layers of tympanic membrane. It exits the cavity via the
anterior canaliculus
The medial wall of the tympani cavity
 Separates the middle ear from the internal ear
 Contains the tympanic plexus of nerves
 Has certain features which include the promontory, fenestra vestibuli, fenestra
cochleae and the prominence of the canal for the facial nerve
The promontory of medial tympanic wall

 Is the rounded prominence produced by the basal turn of the cochlea of the inner
ear
 Lies below the fenestra vestibuli and the canal of facial nerve
 Is grooved by the tympanic plexus of nerves
The fenestra vestibuli

 Is an oval opening in the bony labyrinth; it is located posterosuperior to the
promontory
 Is oriented such that its longer diameter is horizontal
 Is closed by the stapedial base; an anular ligament attaches the latter to the
margin of the fenestra
The fenestra cochleae

 Is an opening on the medial tympanic wall; it is located posteroinferior to the
fenestra vestibuli, from which it is separated by the promontory (which partially
hides it)
 Connects the tympanic cavity with the scala tympani of the cochlea (in a dry
specimen)
 Is closed by the secondary tympanic membrane; the latter is concave laterally
(towards the tympanum) and consists of a layer of mucosa externally, the
cochlear membrane internally, and a fibrous layer in the middle
The prominence of the facial nerve canal

 Is a horizontal ridge produced by the canal for the facial nerve
 Is located above the fenestra vestibuli, as it extends from before backwards, on
the medial tympanic wall. Then, it
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 Turns downwards into the posterior tympanic wall, medial to the aditus to the
mastoid antrum (and below the prominence produced by the lateral semicircular
canal)
Mastoid Antrum
The mastoid antrum

 Is an air-filled sinus in the base of the mastoid process
 Communicates with the epitympanic recess anteriorly through its aditus; the latter
is an opening in the upper part of the anterior wall of the antrum
 Communicates with mastoid air cells through openings in its floor
 Has a capacity of about 1 ml and an average diameter of about 1 cm (in an
average adult)
 Is present at birth, unlike other sinuses that are either rudimentary or absent at
birth
 Is usually approached surgically through its lateral wall; this wall is only 2 mm
thick at birth, and 15 mm thick in adults. It is located just deep to the cymba
conchae of the auricle (which overlies the suprameatal triangle)
 Is lined by a mucosa which is continuous with that of the middle ear and mastoid
air cells
 Is usually predisposed to infections; these may spread to the tympanic cavity and
mastoid air cells
Boundaries of the Mastoid Antrum
The mastoid antrum has

 A roof, formed by the tegmen tympani; this bone separates the antrum from the
middle cranial fossa and temporal lobe of the cerebral hemisphere
 A floor, formed by the mastoid process; this has several openings via which the
antrum communicates with the mastoid air cells
 A medial wall, formed by the petrous temporal bone; this wall is related to the
posterior semicircular canal
 A lateral wall, formed by the postmeatal process of the squamous temporal
bone. It is via this wall that the antrum is usually approached surgically. It is 1–2
mm thick in newborn and about 15 mm thick in adults, and it is just deep to
cymba conchae of the auricle
 A bony posterior wall, which separates the antrum from the sigmoid sinus of the
posterior cranial fossa
 A close relationship with the descending part of the canal of the facial nerve in its
anteroinferior part
Mastoid Air Cells
The mastoid air cells
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 Are air-filled extensions of the mastoid antrum; they occupy the mastoid process
to a variable extent, and may extend into the tip of this bone
 Arise as the mastoid process develops during childhood; they are variable in size
and distribution. Thus, they
 May be limited to the mastoid process only; the latter is however devoid of
mastoid air cells in about 20 % of skulls
 May extend variably towards the sigmoid sinus in the posterior cranial fossa,
where a thin bone (which is occasionally deficient) separates them from this sinus
 May also extend into the squamous and petrous temporal bone, zygomatic
process of temporal bone, bony roof of the external auditory meatus and the floor
of the middle ear
 Have a lining of mucous membrane with squamous epithelium
Auditory (Pharyngotympanic) Tube
The auditory tube

 Links the tympanic cavity with the nasopharynx. It descends anteromedially from
the middle ear to the nasopharynx, and opens into the lateral wall of the latter
(behind the inferior nasal meatus)
 Measures about 35 mm in length in an average adult; it is about half the adult size
in children
 Consists of two parts: a bony part (posterolateral ⅓) and a cartilaginous part
(anteromedial ⅔); these parts are angulated to each other at 1600
 Has a lining of mucous membrane with ciliated columnar epithelium
 Possesses an isthmus which is located at the junction of its osseous and
cartilaginous parts; from this point, its diameter increases towards the tympanic
cavity and nasopharynx
 Increases in diameter (opens up) during swallowing and yawning; this is due to
the activity of tensor veli palatini and salpingopharyngeus (to which it gives
attachment)
 Allows for the passage of air between the nasopharynx and the middle ear,
thereby equalizing pressure on both aspects of the tympanic membrane
The bony part of the auditory tube

 Is the posterolateral ⅓ of the tube; it is about 12 mm in length
 Opens, at its posterolateral end, into the anterior wall of the tympanic cavity
 Becomes narrow towards its junction with the cartilaginous part
 Has a jagged anteromedial end for the attachment of the cartilaginous part of the
tube
The cartilaginous part of the auditory tube

 Is the anteromedial ⅔ of the tube; it is about 24 mm in length
 Is deficient inferiorly; here, the tube is closed by fibrous tissue
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 Is attached, at its posterolateral end, to the bony part of the tube (by fibrous
tissue)
 Opens at its medial end, into the lateral wall of the nasopharynx. This pharyngeal
opening is below the hard palate in foetus, at the level of the hard palate at birth,
and (about 10 mm) above the hard palate in adults. Here, the tube raises a fold of
mucosa termed the tubal elevation (over the upper and posterior margin of its
pharyngeal opening); a salpingopharyngeal fold (containing
salpingopharyngeus) descends on the pharyngeal wall from the tubal elevation
 Is widest at its pharyngeal end, but narrows towards the isthmus (its junction with
the bony part)
 Contains the tubal tonsil near its pharyngeal end
 Gives attachment to salpingopharyngeus, tensor veli palatini, levator veli palatini
and tensor tympani
The mucous membrane of the auditory tube

 Is thin and tightly bound to the periosteum in the bony part of the tube; here, it is
lined by a layer of ciliated columnar cells
 Is thick and thrown into folds in the cartilaginous part of the tube; here, it is lined
by ciliated pseudostratified columnar epithelium
 Possesses goblet cells and mucous tubuloalveolar glands in its cartilaginous part;
the latter glands are located near the pharyngeal end of the tube
 Also possesses scattered lymphocytes; these may be aggregated into variable
lymphoid masses – the tubal tonsil – near the pharyngeal end of the tube
Blood Supply and Innervation of the Auditory Tube
Regarding the auditory tube, note that

 It receives branches of the ascending pharyngeal artery, middle meningeal artery
and artery of the pterygoid canal
 Its veins drain into the pterygoid and pharyngeal plexuses of veins
 It is innervated by fibres from the tympanic plexus and by the pharyngeal branch
of pterygopalatine ganglion
Auditory Ossicles
Auditory ossicles
 Are three small movable bones which form a jointed arch across the middle ear
(from the tympanic membrane to the fenestra vestibuli)
 Include malleus, incus and stapes
 Transfer sound waves from the external to the internal ear, across the middle ear
 Are lined by mucous membrane of the middle ear; they are however devoid of
periosteum
 Are already well formed and well ossified at birth
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Malleus
The malleus, the largest of the ossicles,

 Has the shape of a mallet (hence the name)
 Is 8–9 mm in length
 Is attached to the tympanic membrane through its handle and lateral process and
to the incus at the incudomalleolar joint
 Has a head, neck, handle and two processes (anterior and lateral)
 Is derived from the dorsal end of Meckel’s cartilage (of the 1st arch); it ossifies
from a single ossification centre which appears at about the 4th month of
development, except the anterior process that ossifies separately
The head of the malleus

 Is the enlarged ovoid upper part of the bone; it is located in the epitympanic
recess
 Bears an articular facet on its posterior aspect (for articulation with incus at the
incudomalleolar joint)
 Is connected to the handle by a neck
 Is connected to the roof of the epitympanic recess by a superior ligament of
malleus
The neck of the malleus

 Is the constricted part that links the head of this bone with the handle; it is also
located in the epitympanic recess
 Is related medially to chorda tympani nerve
The handle of the malleus

 Descends posteromedially from the neck of the bone, onto the umbo of the
tympanic membrane, to which it is attached below
 Appear as a reddish-yellow streak during otoscopic examination
 Gives attachment to the tensor tympani (on the medial aspect of its upper part)
The anterior process of the malleus

 Is a small bony projection that points forwards, just below the neck of the
malleus
 Gives attachment to the anterior mallear ligament; this ligament extends from the
neck and anterior process of the malleus, through the petrotympanic fissure, to
the sphenoidal spine, and is derived from the cartilage of the 1st pharyngeal arch
The lateral process of the malleus

 Projects laterally from the upper end of the handle of the malleus
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 Appears as a small whitish prominence during otoscopy (as it bulges laterally

through the tympanic membrane)
 Gives attachment to the anterior and posterior mallear folds of the tympanic
membrane
Incus
Regarding the incus, note that

 It is shaped like an anvil, hence the name
 Has a body and two processes (long and short)
 Its body is located in the epitympanic recess; this bears a facet on its anterior
aspect, for articulation with the head of the malleus (at the saddle-shaped
incudomalleolar joint)
 Its long process descends from the body, behind and parallel to the handle of
malleus; the lower end of this process curves medially as the lentiform process
(which articulates with the stapes)
 Its short process is conical; it extends from the body of the incus to the fossa for
the incus (on the posterior wall of epitympanic recess), to which it is attached by
the posterior ligament of the incus
 It begins to ossify by the 4th month of development (by endochondral
ossification)
Stapes
The stapes
 Is the smallest of the ossicles; it is shaped like a stirrup
 Has a head, a neck, two limbs and a base
 Also develops by endochondral ossification, starting from the 4th month of
development
 Extends from the incus laterally to the fenestra vestibuli medially
Regarding the stapes, note that

 Its head is directed laterally to articulate with the lentiform process of the incus
(at the ball-and-socket incudostapedial joint)
 It is constricted, medial to the head, as the neck (from which the two limbs or
crura arise)
 Attached to the posterior aspect of its neck is the tendon of stapedius (a muscle)
 Its two (anterior and posterior) limbs connect the neck of this bone to its base; the
anterior limb is shorter and less curved than the posterior
 The base is the flat oval part (footplate) that is applied onto the fenestra vestibuli,
and to which it is connect by an anular ligament
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Muscles of the Tympanic Cavity
These include:
 Tensor tympani, and
 Stapedius
The tensor tympani

 Is a slender muscle that occupies the bony canal located above the osseous part of
auditory tube
 Passes posterolaterally, in its canal, to a tendon which curves laterally round the
processus cochleariformis
 Is attached distally to the handle of the malleus
 Contracts reflexly in response to sounds of high frequencies
 Cartilaginous part of auditory tube
 Greater wing of sphenoid, and
 Walls of the bony canal of this muscle
Distal attachment: Upper end of the handle of malleus
Innervation: A branch of the nerve to medial pterygoid (this traverses the otic
ganglion uninterrupted before supplying the muscle)
Action:
 Tenses the tympanic membrane (by pulling the handle of malleus medially; this
action reduces the amplitude of oscillation of the membrane)
 Also pushes the stapes more firmly into the fenestra vestibuli
Stapedius
The stapedius
 Is the smallest skeletal muscle in the body
 Occupies the cavity of the pyramid, on the posterior wall of the tympanic cavity
 Emerges (its tendon) from the apex of the pyramid to insert onto the neck of
stapes
 Also contracts reflexly in response to sounds of high frequencies
Proximal attachment: The wall of a conical canal that leads backwards and
downwards from the pyramid
Distal attachment: Posterior aspect of the neck of stapes
Innervation: Facial nerve

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Action:
 Pulls the neck of stapes backwards; this tightens the anular ligament, thereby
reducing the oscillatory range and excessive movement of stapes
 Also prevents the tensor tympani from forcing the stapedial base into the fenestra
vestibuli while it contracts
Note: Both tensor tympani and stapedius contract reflexly and simultaneously during
exposure to sounds of high frequencies. This action protects the hearing mechanism
from the adverse effects of such sounds.
Blood Supply to the Tympanic Cavity
The tympanic cavity receives arterial blood from several arteries; these include:
 Anterior tympanic branch of maxillary artery
 Stylomastoid branch of occipital (or posterior auricular) artery
 Petrosal branch of middle meningeal artery
 Tympanic braches of internal carotid
 A branch of the ascending pharyngeal artery
 A branch of the artery of the pterygoid canal
 Superior tympanic branch of middle meningeal artery
Veins of the tympanic cavity end in:

 Pterygoid plexus of veins
 Sigmoid sinus, and
 Superior petrosal sinus
Lymph vessels of the tympanic cavity end in the

 Parotid nodes
 Upper deep cervical node, and
 Retropharyngeal nodes
Innervation
Regarding the nerve supply of the tympanic cavity, note that

 The nerve fibres of this cavity form the tympanic plexus
 The tympanic plexus is located over the promontory, on the medial wall of the
tympanic cavity
 Nerve fibres reach the tympanic plexus from the tympani branch of
glossopharyngeal nerve and the caroticotympanic branches of internal carotid
plexus
 Sensory fibres to the mucosa of tympanic cavity arise from the tympanic plexus;
the chorda tympani also gives some sensory fibres to the lateral tympanic wall
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 Sensory fibres to the mastoid air cells are derived from the meningeal branch of
mandibular nerve
Applied Anatomy

 Inflammation of the mucosa of auditory tube would result in swelling and
occlusion of the tube
 Following occlusion of the auditory tube, the air in the tympanic cavity is
absorbed; thus, vibration of the tympanic membrane is adversely affected
 In inflammation of the auditory tube and middle ear, pus could accumulate in the
latter (as the tube is occluded). Incision of the tympanic membrane may therefore
be necessary, to drain such pus
 Fracture of the middle cranial fossa may involve the roof of the tympanic cavity
and the bony part of the external acoustic meatus. The tympanic membrane may
also be torn
 CSF may escape from the cranial cavity into the middle ear and the external
acoustic meatus (through a ruptured tympanic membrane) in severe head injury
 Infections of the nasal cavity and pharynx may spread via the auditory tube into
the tympanic cavity
 Paralysis of stapedius would result in hyperacusia (excessive acuteness of
hearing), owing to the unchecked movement of stapes. This condition may arise
from injury to the facial nerve (e.g. in the internal acoustic meatus)
 Earache may be referred from the teeth or tongue (e.g. in dental caries and
carcinoma or ulceration of the tongue); this is owing to the common source of
sensory fibres to these structures (from the mandibular nerve)
 Mastoiditis is the inflammation of mastoid antrum and air cells; it may be
secondary to middle air infections
 The mastoid antrum and tympanic cavity may be approached surgically through
the lateral wall of the former; this wall is only about 2 mm thick in children and
about 15 mm thick in adults
In otitis media (inflammation of the middle ear), note that

 This condition may be secondary to infections of the upper respiratory tract
 A bloody purulent fluid may accumulate in the tympanic cavity; this may be
observable through the tympanic membrane. Thus,
 The tympanic membrane appears reddish and bulges out
 Earache also develops
 The auditory tube may also be inflamed; thus the mucosa of this tube swells and
its lumen may be completely occluded
 Mobility of the auditory ossicles may be impaired; thus,
 Hearing deficits may result
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Internal Ear
The internal ear

 Is a complex array of interconnected bony cavities (bony labyrinth) and
associated membranes (membranous labyrinth); it is buried in the petrous
temporal bone (Fig. 150)
 Contains receptors for hearing and equilibrium
Bony Labyrinth
The bony labyrinth

 Is made up of complex interconnected cavities located in the lateral part of the
petrous temporal bone
 Is bounded by exceptionally dense bony walls, which constitute the otic capsule.
The latter can be carved out of the temporal bone
 Is lined by periosteum of the otic capsule
 Contains a similarly complex membranous labyrinth, which is surrounded by
perilymph
 Consists of three interconnected parts: the vestibule, semicircular canals and
cochlea
Note that
 The bony labyrinth is not a bone; rather, it is a complex space which contains
perilymph
 The bony walls, which surround the bony labyrinth, constitute the otic capsule;
this bony capsule is part of, but denser than the rest of the petrous temporal bone.
Thus, It can be dissected out
Vestibule
The vestibule
 Is the oval middle part of the bony labyrinth; it is located medial to the middle ear
 Is continuous anteriorly with the cochlea and posteriorly with the semicircular
canals
 Measures about 5 mm anteroposteriorly and vertically, and about 3 mm
transversely
 Communicates with the posterior cranial fossa via the aqueduct of the vestibule
(which transmits two small veins and the endolymphatic duct); this aqueduct
opens onto the posterior surface of the petrous temporal bone
 Has an oval fenestra vestibuli in its lateral wall; this oval window is closed by
the base of stapes and the anular ligament
 Also has some depressions (and foramina) on its medial wall; this wall
corresponds to the fundus of the internal acoustic meatus
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On the medial wall of the vestibule, note that

 Located on the anterior part of this (medial) wall is a circular depression – the
spherical recess – which lodges the saccule
 The spherical recess is also perforated by 12–15 minute foramina – the macula
cribrosa media – which transmit fibres of the vestibular nerve to the saccule
 Above and behind the spherical recess is a ridge termed the vestibular crest; the
upper end of this crest is referred to as vestibular pyramid
 Below, the vestibular crest splits to enclose a small depression termed cochlear
recess; this recess is pierced by nerve fibres which terminate in the vestibular end
of the cochlear duct
 Posterosuperior to vestibular crest (in the roof and adjacent medial wall of the
vestibule) is the elliptical recess; this lodges the utricle
 The elliptical recess and vestibular pyramid are perforated by 25–30 minute
foramina – the macula cribrosa superior – which transmit nerve fibres to the
utricle and the ampullae of the superior and lateral semicircular canals
 Just behind the cochlear recess is the opening of the aqueduct of the vestibule
 The aqueduct of the vestibule is a bony canal, 8–10 mm long, which links the
vestibule to the posterior cranial fossa (where it opens on the posterior surface of
the petrous temporal bone)
 Contained in the vestibular aqueduct are two small veins and the endolymphatic
duct; the latter is an extension of the membranous labyrinth
Semicircular Canals
The semicircular canals

 Are three curved canals that lie posterosuperior to the vestibule. They
communicate with the latter via five openings
 Measure 1–1.5 mm in diameter each
 Have terminal swellings – ampullae – at their opening into the vestibule; each of
these is almost twice the diameter of the canal
 Are each curved to form about ⅔ of a circle
 Are set at right angles to each other, each being oriented in a different plane
 Contain the semicircular ducts
 Are designated as anterior (or superior), lateral and posterior semicircular
canals
Each semicircular canal

 Is ⅔ of a circle and is angulated to the other canals (at right angles)
 Has a terminal swelling termed ampulla
 Measures 1–1.5 mm in diameter
The anterior (or superior) semicircular canal

 Measures 15–20 mm in length
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 Is oriented vertically, transverse to the long axis of the petrous temporal bone,
and its convexity is directed upwards
 Lies deep to the arcuate eminence of petrous temporal bone
 Has an ampulla at its anterolateral end; here, the canal opens into the upper part
of the vestibule
 Is joined, at its posteromedial end, to the upper end of the posterior semicircular
canal to form the crus commune; the latter is 4 mm long and it opens into the
medial wall of the vestibule
 Is parallel to the opposite posterior semicircular canal
The posterior semicircular canal

 Is 18–20 mm long
 Is also vertically disposed, parallel to the long axis of the petrous temporal bone,
and its convexity is directed backwards
 Has an ampulla at its lower end where it opens into the inferior part of the
vestibule
 Joins, at its upper end, the posterolateral end of the anterior canal, to form the
crus commune
 Is parallel to the opposite anterior canal
The lateral semicircular canal

 Is 12–15 mm long
 Is almost horizontally disposed, and its convexity is directed posterolaterally
 Has an ampulla at its anterolateral end where it opens into the superolateral wall
of the vestibule (above the fenestra vestibuli)
 Also opens into the vestibule at its posteromedial end, just below the opening of
the crus commune
 Is in the same plane as the opposite lateral semicircular canal
Cochlea
The cochlea
 Is the conical shell-shaped anterior part of the bony labyrinth; it is located
anterior to the vestibule
 Is oriented such that its apex (cupola) is directed anterolaterally while its base is
directed medially, towards the internal acoustic meatus
 Is perforated at it base by foramina which transmit fibres of the cochlear nerve
 Forms about 2½ spiral turns (spiral canal) around a central conical bony axis
termed the modiolus
 Measures about 5 mm from apex to base
Regarding the cochlea, note that

 The cochlear canal spirals for about 2½ turns round the central modiolus
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 A delicate bony spiral lamina projects into the cochlear canal from the modiolus;
this partially divides the canal into an upper scala vestibuli and a lower scala
tympani. These two subdivisions communicate at the helicotrema
 The helicotrema is the aperture through which the scala vestibuli and the scala
tympani become continuous with each other; it is located at the apex of the
cochlea
 The basal turn of the cochlea produces a promontory on the medial wall of the
middle ear
The base of the cochlea

 Is directed medially, towards the bottom of the internal acoustic meatus
 Is perforated by numerous foramina for fibres of the cochlear nerve
 Measures 9 mm across
The modiolus of the cochlea

 Is the central conical bone around which the cochlea spirals; it is 3 mm long
 Has a base which is directed medially towards the internal acoustic meatus; this
is pierced by numerous foramina for fibres of the cochlear nerve
 Contains a spiral canal of the modiolus within it; this accommodates the spiral
ganglion
 Gives attachment to the bony spiral lamina
The bony spiral lamina

 Projects into the cochlear (spiral) canal from the modiolus, around which it
spirals
 Begins at the floor of the vestibule (above the scala tympani) and ends at the apex
of the cochlea as the hook-like hamulus; the latter bounds the helicotrema
 Decreases in width towards the apex of the cochlea
 Partly divides the cochlear canal into an upper scala vestibuli and a lower scala
tympani
 Is traversed by numerous canaliculi which transmit the fibres of the cochlear
nerve
The bony cochlear canal

 Is a spiral channel around the modiolus; it is about 35 mm in length
 Bulges towards the middle ear at its first turn, as the promontory
 Is 3 mm in diameter at its beginning, but diminishes from base to apex, where the
canal ends at the cupola
 Is partially subdivided into two (scala vestibuli and scala tympani) by the bony
spiral lamina
The following are associated with the scala tympani of the cochlear canal:
 The fenestra cochleae, a round opening which connects the base of the scala
tympani with the middle ear; it is closed by the secondary tympanic membrane
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 The cochlear canaliculus; this opens onto the medial wall of the scala tympani,
connecting it with the subarachnoid space (from which it conveys CSF to the
bony labyrinth). Its distal end opens onto the inferior surface of the petrous
temporal bone
Perilymph
The perilymph
 Is the fluid that occupies the bony labyrinth (and thus surrounds the membranous
labyrinth)
 Is probably an extension of the CSF into the bony labyrinth from the
subarachnoid space (via the cochlear canaliculus). It could also be derived from
the blood vessels of the perilymphatic space
 Is largely similar in composition to the extracellular fluid (with high Na+ and
Ca2+)
Membranous Labyrinth
The membranous labyrinth

 Is contained within the bony labyrinth, from which it is separated by perilymph
and loose connective tissue
 Consists of a system of intercommunicating sac and ducts
 Is attached to the bony labyrinth at certain points (though perilymph largely
intervenes between them)
 Contains its own fluid – endolymph – which differs in composition from
perilymph
The membranous labyrinth consists of the following:

 Utricle and saccule; these are located in the vestibule of the bony labyrinth
 Semicircular ducts, which occupy the semicircular canals, and
 Cochlear duct, located in the bony cochlea
Utricle
Regarding the utricle, note that

 It is the largest of the vestibular labyrinth
 It occupies the posterosuperior part of the vestibule, partly in the elliptical recess
 Its floor and lateral wall are thickened to form the utricular macula; this
contains numerous receptors (hair cells) and receives the utricular fibres of
vestibulocochlear nerve
 Utricular macula is pale and oval; it measures 3 mm X 2 mm
 Opening into its lateral part are the ampullae of the anterior and lateral
semicircular ducts
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 Each utricular hair cell is endowed with stereocilia and a single kinocilium that
assist with signal sensing
 Utricular hair cells are overlaid with a horizontally-oriented gelatinous otolithic
membrane . This contains crystals of calcium carbonate (otoliths or otoconia or
statoliths)
 Utricle is involved with linear acceleration of the head in any horizontal plane
 Opening into its medial part are the crus commune, ampulla of the posterior
semicircular duct and the posterior end of the lateral semicircular duct
 It is connected to the saccule by the utriculosaccular duct; the endolymphatic
duct arises from the latter
Saccule
The saccule
 Is an oval sac; it measures 3 mm X 2 mm
 Occupies the spherical recess of the vestibule where it lies close to the opening of
the scala vestibuli of the cochlea
 Has a thickening, the saccular macula, which is vertically disposed (on its
anterior wall); this macula has a sensory epithelium endowed with hair cells, and
it receives the saccular fibres of vestibulocochlear nerve. the utricular and
saccular maculae are at right angle to each other
 Each saccular hair cell is endowed with stereocilia and a single kinocilium that
assist with signal sensing
 Saccular hair cells are overlaid with a vertically-oriented gelatinous otolithic
membrane. This contains crystals of calcium carbonate (otoliths or otoconia or
statoliths)
 Saccule is involved with linear acceleration of the head in a vertical plane. It is
therefore a major gravitational sensor
 Is connected to the cochlear duct by the ductus reuniens
 Also communicates with the utricle through the utriculosaccular duct
The endolymphatic duct

 Is an extension of the membranous labyrinth; this duct arises from the
utriculosaccular duct and traverses the aqueduct of the vestibule
 Ends as a blind endolymphatic sac, just deep to the dura of the posterior surface
of the petrous temporal bone
 Contains endolymph
Semicircular Ducts
Regarding the semicircular ducts, note that

 They are three membranous ducts located in the bony semicircular canals
 Each is about ¼ of the diameter of its canal, but has a similar shape as the canal
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 Each duct has a swelling, the ampulla, at one end; this occupies the ampulla of
the bony semicircular canal and has a thick wall
 In the ampulla of each duct is a transverse fold of its lining, the ampullary crest;
this contains receptors for sensing the rotation of the head in the plane of the duct
and is innervated by vestibular fibres
 They are attached at interval (by fibrous band) to the osseous semicircular canals
Cochlear Duct (Fig. 151)
The cochlear duct

 Is a blind spiral tube located in the bony cochlea
 Is triangular in cross-section, its apex pointing towards the bony spiral lamina
 Contains, in its floor, the spiral organ of Corti (Fig. 151); the latter contains
receptors (hair cells) for audition (hearing)
 Contains endolymph and is surrounded by perilymph
 Communicates at its lower end with the saccule, via the ductus reuniens
 Divides the spiral cochlear canal into two parts, each of which contains
perilymph; these are the scala vestibuli above and scala tympani below (Fig. 151)
Figure 51. A section through the cochlear duct.
Regarding the boundaries of the cochlear duct, note the following:

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Vascular lamina
 The thin vestibular (Reissner’s) membrane forms its roof (Fig. 151). This
membrane consists of two layers of squamous cells separated by a basal lamina;
and it stretches from the bony spiral lamina to the lateral wall of the bony
cochlea.
 Its floor is the basilar membrane and the outer part of the bony spiral lamina
(Fig. 151); the basilar membrane stretches from the tip of the spiral lamina to the
spiral ligament on the outer wall of the bony cochlea (below the attachment of
the vestibular membrane)
 The spiral organ of Corti rests on the floor of the cochlear duct; it contains the
receptors (hair cells) for auditory stimuli and receives fibres of the cochlear
division of vestibulocochlear nerve
 Its outer wall is formed by the endosteum of the outer wall of the bony cochlea;
this is especially thick and highly vascular in the region of the cochlear duct
 Above and below the cochlear duct are the scala vestibuli and scala tympani
respectively
Blood Supply to the Internal Ear
The labyrinth receives arterial blood from

 The labyrinthine artery, a branch of the basilar (or anterior inferior cerebellar
artery), and
 The stylomastoid artery, a branch of the occipital or posterior auricular artery
 Regarding venous drainage of the internal ear, note the following:
 The labyrinthine vein is the main vein of the internal ear; it drains into the
superior petrosal, sigmoid or transverse sinuses
 Certain small veins (that drain the internal ear) traverse the cochlear aqueduct to
end in the inferior petrosal sinus or internal jugular vein
 Other small veins traverse the vestibular aqueduct to end in the superior petrosal
sinus
Innervation of the Internal Ear
Note the following:

 The vestibulocochlear nerve (CN VIII) conveys impulses from the internal ear to
the central nervous system
 The cochlear division of CN VIII conveys impulses from the receptors of the
spiral organ of Corti (Fig. 151)
 The somata of cochlear fibres form the spiral ganglion; this is located in the
modiolus of the bony cochlea
 The vestibular division of CN VIII conveys impulses from the maculae of saccule
and utricle and the ampullary crests of the three semicircular ducts
 The somata of vestibular fibres form the vestibular ganglion, located at the
lateral end of internal acoustic meatus
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 The vestibulocochlear nerve traverses the internal acoustic meatus to reach the
pontomedullary junction, where it enters the brainstem
Applied Anatomy of the Internal Ear

 Motion sickness is a syndrome which results from haphazard stimulation of the
utricular and saccular maculae; its symptoms include gastrointestinal discomfort,
nausea, vomiting, headache, vertigo, etc
 Persistent exposure to extremely loud noises could result in high tone deafness;
this is owing to degenerative changes in the spiral organ of Corti
 Labyrinthine (auditory) vertigo may arise from ear diseases or injury; it is
usually characterized by a sense of rotation and dizziness
 In Meniere syndrome, the volume of endolymph is increased; this stretches the
cochlear duct and vestibular labyrinth, causing vertigo, tinnitus and hearing
impairment
 Tinnitus is characterized by noise or ringing in the ear; it may arise from spasm
of aural muscles (muscles of the ear)
Endolymph
The endolymph
 Is the fluid contained in the membranous labyrinth
 Is similar to intracellular fluid in composition. It is rich in K+, but poor in Na+
 May be produced by the utricle, semicircular ducts and cochlear duct
 Is drained into the vascular plexus associated with the endolymphatic sac
 Differs from perilymph in its composition. Perilymph is similar to the CSF and
extracellular fluid
Internal Acoustic Meatus
The internal acoustic meatus

 Is a narrow cylindrical bony channel that passes laterally from the posterior
cranial fossa to the medial wall of the internal ear, in the petrous temporal bone
 Is separated, at its bottom (lateral end), from the internal ear by a perforated plate
of bone; traversing the latter are the facial nerve, fibres of the vestibulocochlear
nerve and blood vessels of the internal ear
 Opens, at its medial end, onto the posterior surface of petrous temporal bone,
anterosuperior to the jugular foramen
 Is 10 mm in length and about 4 mm in diameter
 Contains two major nerves – facial nerve [including the nervus intermedius] and
vestibulocochlear nerve; the former occupies a groove on the anterosuperior
aspect of vestibulocochlear nerve
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 Also transmits the labyrinthine vessels (which supply the internal ear)
 Is located opposite the ipsilateral external acoustic meatus (about 5 cm deep to
this), and it is in line with the contralateral internal acoustic meatus
Applied Anatomy
Note that
 Following a severe head injury, the facial and vestibulocochlear nerves may be
injured in the internal acoustic meatus
 Injury to the facial nerve in the internal acoustic meatus would result in ipsilateral
facial palsy, etc
 Injury to the vestibulocochlear nerve in the internal acoustic meatus would
produce ipsilateral total deafness, tinnitus, etc
Fascia, Muscles and Triangles of the Neck
Introduction to the Neck
The neck
 Is the region of the body that connects the head, upper extremities and trunk with
one another
 Extends from the root of the neck below to the base of the skull above
 Is supported by seven cervical vertebrae
 Transmits large blood vessels (e.g. internal and external carotid arteries, internal
jugular vein etc) between the regions it connects
 Contains the supraclavicular part of the brachial plexus in its lower part
 Also accommodates some vital organs such as the thyroid gland, pharynx, larynx,
trachea and oesophagus
 Possesses several muscles, including the upper part of the trapezius
Skeleton of the Neck
The skeletal framework of the neck is formed by the following:

 Seven cervical vertebrae
 Unpaired hyoid bone, and
 A pair of clavicles
Cervical Vertebrae
Regarding the cervical vertebrae, note that

 There are seven cervical vertebrae
 Cervical vertebrae are relatively small and do not bear much weight
790
 Each cervical vertebra has a foramen transversarium (transverse foramen) in

each transverse process; this is the distinguishing feature of this vertebra
 Typical cervical vertebrae include the 3rd, 4th, 5th and 6th vertebrae
 Atypical cervical vertebrae include the 1st (atlas), 2nd (axis) and 7th (vertebra
prominens) cervical vertebrae
 The lower border of the 3rd cervical vertebra is at the level of the upper border of
the thyroid cartilage, while
 The 6th cervical vertebra is at the level of the lower border of the cricoid cartilage
Typical Cervical Vertebrae (3rd, 4th, 5th, and 6th)
A typical cervical vertebra

 Has a small body whose transverse diameter is greater than the anteroposterior
diameter, and whose upper and lower surfaces are concave and convex
respectively (Fig. 152)
 Possesses a relatively large and triangular vertebral foramen (Fig. 152); this
accommodates the cervical enlargement of the spinal cord
 Has a short and bifid spinous process; the axis also has a similar spinous process
 Possesses a transverse process on each side; this bears a foramen transversarium
(which transmits the vertebral vessels) and ends laterally in anterior and
posterior tubercles (which are connected to each other lateral to the foramen by
an intertubercular lamella)
 Possesses a superior articular facet that is directed posterosuperiorly, and an
inferior articular facet that is directed posteroinferiorly. These articular facets
are placed on the corresponding (superior and inferior) articular processes (Fig.
152).
Atypical Cervical Vertebrae
Atypical cervical vertebrae include:

 Atlas (the 1st cervical vertebra)
 Axis (the 2nd cervical vertebra), and
 Vertebra Prominens (the 7th cervical vertebra)
Atlas
The atlas
 Is the 1st cervical vertebra (Fig. 153); it supports the skull
 Is anular in outline, and it is the widest cervical vertebra (being up to 9 cm in
diameter in males)
 Has neither body nor spinous process
 Has two lateral masses (one on each side); these are united by the anterior and
posterior arches
791
Figure 152. A typical cervical vertebra and its associated neural tissue.
Figure 153. The atlas
Regarding the atlas, note the following facts:

 Its anterior arch is convex anteriorly; this bears an anterior tubercle that gives
attachment to the anterior longitudinal ligament (Fig. 153). On the posterior
surface of this arch is a median articular facet for the dens of axis.
 Its posterior arch forms about ⅖ of the atlantal circumference; it bears a
posterior tubercle, for the attachment of the ligamentum nuchae
 A groove for the vertebral artery is located on the upper aspect of the posterior
arch (on each side) just behind the lateral mass. Besides vertebral artery, this
groove also lodges the 1st cervical spinal nerve
 Each lateral mass of the atlas is roughly ellipsoidal; it bears a superior and an
inferior articular facet (Fig. 153)
 The superior articular facet (on the upper aspect of the lateral mass) is concave
and directed superomedially; it articulates with the occipital condyle of the skull
at the atlanto-occipital joint
 The inferior articular facet is on the inferior aspect of the lateral mass; it is
concave, circular and directed inferomedially to articulate with the superior
articular facet of the axis
792
 It has relatively long transverse processes, each of which bears a foramen

transversarium
 A transverse ligament connects the lateral masses with each other and thus
divides the cavity of the atlas into two (the anterior one contains the dens of axis
while the posterior one transmits the spinal cord) (Fig. 153).
Axis
Regarding the axis, note the following:

 It is the 2nd and the strongest of the cervical vertebrae (Fig. 154)
 Its spinous process is bifid and can be felt in the nuchal groove
 It is distinguished by the presence of the dens (or odontoid process); this is a
tooth-like process (about 15 mm long), which projects upwards from the axial
body (Fig. 154)
 The dens occupies the interval between atlantal anterior arch in front and the
transverse ligament behind; the latter grooves it posteriorly
 The dens bears an oval articular facet on its anterior surface; this articulates with
the facet on the posterior aspect of the anterior arch of the atlas (at a synovial
joint)
 The atlas (and thus the head) rotates (from side to side) around the axial dens; the
latter thus serves as an axle (or pivot)
 The superior articular facet of axis articulates with the inferior facet of the atlas
 The transverse processes of the axis are small compared to those of others; each
has a transverse foramen, and like the atlas, only a posterior tubercle
793
Figure 154. The axis.
7th Cervical Vertebra (Vertebra Prominens)
The 7th cervical vertebra

 Is characterized by the presence of a long, non-bifid spinous process, similar to
those of the thoracic vertebrae (Fig. 155)
 Has large transverse processes, with small foramina; each of these processes
ends in a prominent posterior tubercle (the anterior tubercle being small or
absent). Occasionally, the anterior tubercle is enlarged as a cervical rib
Note: The foramen transversarium of C7 does not transmit vertebral artery.

However, some accessory vertebral veins pass through it.
794
Figure 155. The 7th cervical vertebra (vertebra prominens)
Hyoid Bone
The hyoid bone

 Is a mobile, U-shaped piece of bone located in the anterior part of the neck,
between the tongue above and the larynx below (at the level of C3) (Fig. 156). It
can be felt in the front of the neck, about 2 cm above the laryngeal prominence
 Does not articulate with any bone; however, it gives attachment to numerous
muscles that connect it to the mandible, thyroid cartilage, temporal styloid
process, manubrium sterni and scapulae, and which help to stabilize it
 Is also connected to the styloid process by the stylohyoid ligament
 Moves (up and down) with the tongue during swallowing
 Develops by endochondral ossification; most of its ossification centres appear
just prior to birth (see below)
 Consists of a body, a pair of greater and a pair of lesser horns (Fig. 156)
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Figure 156. The hyoid bone showing sites of muscle attachment.
Regarding the body of the hyoid, note the following:

 It is elongated and quadrilateral, with a convex anterior surface and a concave
posterior one (Fig. 156)
 It is connected to the greater horns by cartilage in early life, but by bone in adults
 It Ossifies (by endochondral ossification) from two centres which appear just
before or after birth
The greater horns of hyoid bone

 Are two long processes that project posterolaterally from the lateral part of the
body of the hyoid; they ascend slightly as they do so (Fig. 156)
 Ossify from two centres which usually arise late in the foetal life
 Are connected to the body of hyoid by bone after middle age
The lesser horns of hyoid

 Are a pair of conical projections located at the junction of the greater horns and
body of hyoid (Fig. 156)
 Are directed upwards and backwards (towards the temporal styloid process)
 Are connected to the body of hyoid by fibrous tissue and to the greater horn by
occasional synovial joints (which may by ankylosed). A stylohyoid ligament
connect each lesser horn to the styloid process of temporal bone
 Begins to ossify from two centres around puberty
 May be partially or wholly cartilaginous in adults
Fasciae of the Neck (Cervical Fascia)

796
The fascia of the neck

 Invests the neck (deep to the skin), and also surround most of the structures of the
neck
 Includes superficial and deep fasciae
The superficial fascia of the neck

 Is a thin layer of loose connective tissue located between the skin and deep fascia
of the neck
 May contain considerable quantity of adipose tissue, especially in females
 Contains platysma (in the anterolateral parts of the neck)
 Also contains blood and lymph vessels, cutaneous nerves and some lymph nodes
Deep Fascia of the Neck
The deep fascia of the neck is arranged to form the following layers:
 Investing layer (superficial layer of deep cervical fascia)
 Prevertebral layer
 Pretracheal layer, and
 Carotid sheath
Investing Layer of Deep Cervical Fascia
The investing layer of the deep cervical fascia

 Is the most external layer of the deep fascia of the neck
 Forms a sleeve-like covering for the neck, just deep to the superficial fascia and
skin
 Splits to enclose sternocleidomastoid and trapezius
 Encloses a suprasternal space anteriorly, just above the manubrium sterni. This
space contains the jugular venous arch, lower ends of the anterior jugular veins,
an occasional lymph node, adipose tissue, and sternal heads of
sternocleidomastoid
 Forms the fibrous sheath of the parotid and submandibular glands
 Is thickened between the styloid process and angle of mandible as the
stylomandibular ligament; this separates the parotid from the submandibular
glands
 Blends behind with the ligamentum nuchae (nuchal ligament) of the neck and the
periosteum of the spinous process of C7
 Also bounds the triangles of the neck superficially, thereby forming their roofs
 Has numerous attachment above and below (see below)
Above, the investing layer of deep cervical fascia is attached to
 The superior nuchal lines of occipital bone
 The mastoid processes of temporal bones
 The zygomatic arches
 The inferior border of the mandible and
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 The hyoid bone
Below, the investing layer of deep cervical fascia is attached to

 The acromial processes and spines of the scapulae
 The clavicles, and
 The manubrium sterni
Prevertebral Fascia
The prevertebral fascia

 Is the deepest layer of the deep cervical fascia
 Covers the prevertebral muscles (e.g, longus colli) anteriorly and extends
laterally to cover scaleni anterior and medius and levator scapulae. Thus, it forms
the floor of the posterior triangle of the neck. Laterally, it becomes less distinct as
it passes beneath trapezius
 Extends from the base of the skull above to the level of T3 below; here, it blends
with the anterior longitudinal ligament (in the superior mediastinum)
 Forms an axillary sheath around the brachial plexus and subclavian vessels (as
these emerge from behind scalenus anterior); this sheath continues into the axilla
(behind the clavicle), around these neurovascular structures. Prevertebral fascia
also surrounds the sympathetic chains
 Covers the fibres of the cervical plexus superficially. The spinal accessory nerve
lies superficial to it (in the occipital triangle)
 Is separated anteriorly from the pharynx and buccopharyngeal fascia by the
retropharyngeal space. This space contains loose connective tissue, in which lie
the retropharyngeal lymph nodes
Pretracheal Layer
The pretracheal layer of deep cervical fascia

 Is the thin intermediate layer of the deep fascia of the neck
 Encloses the thyroid gland and covers the trachea and oesophagus. It also blends
above and behind with the buccopharyngeal fascia
 Encloses the infrahyoid muscles; laterally, it blends with the carotid sheath
 Descends on the trachea into the superior mediastinum where it blends with the
fibrous pericardium
The pretracheal fascia is attached

 Above to the oblique line of thyroid cartilage and hyoid bone
 Below to the fibrous pericardium (with which it blends)
 Anteriorly to the arch of the cricoid cartilage
Carotid Sheath
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The carotid sheath

 Is a condensation of the cervical fascia around the common (and internal) carotid
artery and the internal jugular vein; it is thicker around the artery than the vein
 Is located in the interval between the prevertebral, investing and pretracheal
fasciae, with which it blends
 Extends from the base of the skull above to the root of the neck below, and
 Contains, blood vessels, lymph nodes, nerves and connective tissue
Contents of the carotid sheath include:

 Common carotid artery (below the level of C3 or upper border of thyroid
cartilage)
 Internal carotid artery, above the level of C3; the internal carotid artery is the
continuation of the common carotid artery
 Internal jugular vein, located lateral to the common and internal carotid arteries
 Vagus nerve (located between and behind the common carotid artery and internal
jugular vein)
 Fibres of ansa cervicalis
 Nerve to carotid sinus (from glossopharyngeal nerve)
 Few deep cervical lymph nodes, and
 Carotid plexus of sympathetic nerves (around the common carotid and internal
carotid arteries)
Note: The sympathetic chain is not a content of the carotid sheath.
Applied Anatomy
Note that
 The spread of purulent exudates in the neck is determined mainly by the
arrangement of the cervical fasciae
 Pus in the anterior triangle of the neck may spread to the superior mediastinum,
anterior to the pretracheal fascia. However,
 Owing to the thinness of the anterior part of the investing fascia, pus in the
anterior triangle may ‘point’ superficially above the manubrium sterni, rather
than enter the superior mediastinum
 Purulent fluid, which collects deep to the prevertebral fascia, may spread laterally
into the posterior triangle of the neck, behind the sternocleidomastoid. This may
also drain into the retropharyngeal space to form a retropharyngeal abscess
(that bulges into the pharynx)
 Painful swallowing (dysphagia) and speech impairment (dysarthria) are
associated with retropharyngeal abscess
 Owing to the continuity of the retropharyngeal space with the superior
mediastinum (behind the oesophagus), infections (and pus) can spread between
the neck and mediastinum
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 Cervical fasciae also form cleavage planes for separating structures of the neck
during surgery.
Superficial and Lateral Cervical Muscles
These include:
 Platysma
 Trapezius, and
 Sternocleidomastoid
Note: For trapezius, see page 315; for platysma, see page 570.
Sternocleidomastoid (SCM)
The sternocleidomastoid
 Is a long, thick, rounded muscle, located obliquely in the neck
 Serves a good landmark in the neck as it forms the boundary between the anterior
and posterior triangles, etc
 Has two heads of origin (see below). It ascends posteriorly from its origin below,
to its (mastoid) insertion above
 Is invested (together with trapezius) by the investing layer of the deep cervical
fascia
 Is crossed on its superficial aspect by the external jugular vein (as this vessel
descends in the neck); the great auricular and transverse cervical nerves also pass
superficial to it
 Is related on its deep aspect to the carotid arteries, internal jugular veins, vagus
nerve and deep cervical lymph nodes
Inferior attachment:
 Sternal head: Upper part of the anterior surface of the manubrium sterni
 Clavicular head: Superior aspect of the medial 3rd of the clavicle
Superior attachment:
 Lateral aspect of the temporal mastoid process
 Lateral half of the occipital superior nuchal line
Innervation:
 Motor fibres: Spinal accessory nerve (CN XI)
 Sensory (proprioceptive and pain) fibres: Ventral rami of C2 and C3 spinal
nerves
Action:
 Tilts the head towards the ipsilateral shoulder, thereby turning the face to the
opposite side (when acting alone)
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 Draws the head forwards by flexing the neck (when acting with the opposite
muscle)
 Raises the head, when the individual is in the supine position
 Assists in deep inspiration
Applied Anatomy
Note the following:

 Spasmodic torticolis (wry neck) occurs in adults. This condition is due to tonic
contraction of SCM (and trapezius). The heads is permanently tilted to the
affected side while the face and chin are tilted to the opposite side
 Congenital torticolis may occur as a result of fibrous tissue tumor of SCM in
intrauterine life, or owing to injury to this muscle during difficult childbirth. The
child thus presents a head position similar to that described above
Triangles of the Neck
Note that
 For descriptive purpose, each anterolateral aspect of the neck is divided into two
main triangles by the obliquely set SCM. These are the anterior and posterior
triangles (Fig. 157)
 The anterior triangle of the neck is bounded anteriorly by the midline of the
neck, above by the lower border of the mandible (and a line which extends from
the mandibular angle to the mastoid process) and behind by the anterior border of
SCM (Fig. 157)
 The posterior triangle of the neck is bounded in front by the posterior border of
SCM, behind by the anterior border of trapezius and below by the middle 3rd of
the clavicle (Fig. 157)
 Several vital structures, including blood vessels and nerves are located in the
cervical triangle
 Each of the two main triangles is also divisible into smaller ones
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Figure 157. Triangles of the neck.
Anterior Triangle of the Neck (Fig. 157)
The anterior triangle of the neck has:

 An anterior border formed by the (anterior) midline of the neck
 A posterior border formed by the anterior border of SCM
 A base formed by the lower border of the mandible and a line drawn from the
mandibular angle to the mastoid process
 An apex formed by the manubrium sterni
 A floor formed by the pharynx, larynx and thyroid gland
 A roof formed by skin, subcutaneous tissue and the investing layer of deep
cervical fascia
The anterior triangle is divisible into four smaller triangles by the digastric and
superior belly of omohyoid. These include:
 Submental triangle (unpaired)
 Muscular triangle
 Carotid triangle, and
 Digastric (submandibular) triangle
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Submental Triangle
This unpaired triangle has

 An apex located at the symphysis menti (the chin)
 A base formed by the body of hyoid
 Right and left lateral borders formed by the anterior bellies of digastric
 A floor formed by mylohyoid muscles. The latter are united by a median raphe
Contents of the submental triangle include:

 Submental lymph nodes (which drain the tongue and central part of the lower lip)
 Small veins which form the anterior jugular vein
Muscular Triangle
The paired muscular triangle

 Is bounded anteriorly by the midline (below the hyoid), posterosuperiorly by the
superior belly of omohyoid and posteroinferiorly by the anterior border of SCM
 Contains the infrahyoid muscles (e.g. sternohyoid and sternothyroid), and the
thyroid and parathyroid glands
Digastric (Submental) Triangle
The paired digastric triangle has

 A superior border formed by the inferior border of mandible and a line which
joins the mandibular angle to the mastoid process
 A posteroinferior border formed by the posterior belly of digastric and the
stylomastoid
 An anteroinferior border formed by the anterior belly of digastric
 A floor formed by the mylohyoid, hyoglossus and middle pharyngeal constrictor
 A roof formed by skin, subcutaneous tissue and deep fascia
Contents of digastric triangle include:

 Superficial part of submandibular gland
 Submandibular lymph nodes
 Parts of the facial artery and vein
 Mylohyoid artery and nerve
 Submental artery, and
 Part of the hypoglossal nerve
Carotid Triangle
The carotid triangle has
 A posterior border formed by SCM

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 A superior border formed by posterior belly of digastric and stylohyoid

 An anteroinferior border formed by the superior belly of omohyoid
 A floor formed by the middle and inferior pharyngeal constrictors, hyoglossus
and thyrohyoid
Contents of the carotid triangle include:

 Upper part of the common carotid artery. This vessel bifurcates at the level of C3
(upper border of the thyroid cartilage)
 Commencement of the internal carotid artery. This vessel is the upward
continuation of the common carotid artery. They occupy the carotid sheath (at
different levels)
 External carotid artery and some of its branches (including superior thyroid,
facial, lingual, occipital and ascending pharyngeal arteries)
 Internal jugular vein (which is largely overlapped by SCM)
 Superior thyroid, facial, lingual and ascending pharyngeal veins. These end in the
internal jugular vein
 Part of the hypoglossal nerve
 Some fibres of ansa cervicalis
 Vagus nerve (contained in the carotid sheath), and
 Deep cervical lymph nodes
Posterior Triangle of the Neck (Fig. 157)
The posterior triangle of the neck has

 An anterior border formed by the posterior border of SCM
 A posterior border formed by the anterior margin of trapezius
 A base formed by the middle 3rd of the clavicle
 A blunt apex directed upward and located at the junction of the trapezius and
SCM
 A floor formed by the prevertebral fascia and underlying muscles (scaleni medius
and posterior, levator scapulae, splenius capitis, etc)
 A roof formed by the investing layer of deep cervical fascia
The inferior belly of omohyoid subdivides the posterior cervical triangle into
 A larger occipital triangle, and
 A smaller subclavian (supraclavicular) triangle
Occipital Triangle (Fig. 157)
The occipital triangle has the following boundaries:

 An apex located at the junction of the trapezius and SCM (and which is directed
upward)
 An inferior border formed by the lower belly of omohyoid
 An anterior border formed by SCM
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 A posterior border formed by trapezius

 A floor, formed from above downward, by splenius capitis, levator scapulae,
scalenus medius and scalenus posterior
 A roof formed by skin, subcutaneous tissue (which contains platysma in its lower
part) and deep fascia
The occipital triangle contains:

 The accessory nerve. This emerges from the upper part of SCM and passes
obliquely backwards and downwards on the levator scapulae, to reach the
trapezius, which it supplies
 Occipital artery (near its apex)
 Some branches of the cervical plexus of nerves. These emerge from the posterior
border of SCM
 Part of the brachial plexus (located in the lower part of the triangle)
 Transverse cervical vessels (also located in the lower part of the triangle)
 Deep cervical lymph nodes, which lie along the posterior border of SCM
Subclavian (Supraclavicular) Triangle (Fig. 157)
The subclavian triangle

 Is the smaller of the two divisions of the posterior triangle; it lies in the lower part
of the neck, deep to the supraclavicular fossa
 Is limited below by the middle 3rd of the clavicle, above by the inferior belly of
omohyoid and in front by the SCM
 Has a floor formed by scalene medius, the 1st slip of serratus anterior and the 1st
rib
 Is roofed by skin, superficial fascia (containing platysma) and deep fascia
The subclavian triangle contains:

 The 3rd part of the subclavian artery; here, the artery can be compressed against
the 1st rib and its pulse may be felt
 Occasionally, the subclavian vein, located anterior to subclavian artery
 Supraclavicular part of the brachial plexus. This lies above and behind the
subclavian artery
 Suprascapular artery (from the thyrocervical trunk), suprascapular nerve (from
the brachial plexus) and suprascapular vein
 Suprascapular lymph nodes, and
 Nerve to subclavius
Note: The suprascapular nerve and transverse cervical vessels (or superficial cervical
vessels) are located in the roof of the subclavian triangle.
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Cervical Part of Carotid Arteries
Common Carotid Artery

In the neck, each common carotid artery
 Ascends from behind the sternoclavicular joint below to the upper border of
thyroid cartilage (level of C3) above; it inclines somewhat laterally as it ascends
 Occupies the carotid sheath (which is especially thickened around this vessel),
together with the internal jugular vein and vagus nerve
 Ends above, at the level of the upper border of the thyroid cartilage (C3) by
dividing into internal and external carotid arteries
 Is dilated at its upper end (as does the commencement of the internal carotid
artery) to form the carotid sinus. The latter serves as a baroreceptor and thus
responds to changes in arterial pressure. It receives the carotid sinus nerve (from
the glossopharyngeal nerve)
Relations of the Common Carotid Artery
The common carotid artery is related

 Medially to the trachea, esophagus, recurrent laryngeal nerve, inferior thyroid
artery, larynx, pharynx and thyroid gland
 Laterally to the internal jugular vein
 Posteriorly to the sympathetic trunk, ascending cervical artery, transverse
processes of C4 – C6, vertebral and inferior thyroid arteries and (on the left)
thoracic duct
 Posterolaterally to vagus nerve
 Anterolaterally to skin, superficial fascia, platysma, deep fascia, SCM, superior
and middle thyroid veins and superior root of ansa cervicalis

 The right common carotid artery arises from the brachiocephalic trunk, behind
the right sternoclavicular joint
 The left common carotid artery springs from the convexity of the aortic arch,
behind the brachiocephalic trunk. It ascends for about 2 cm in the superior
mediastinum before entering the neck
Carotid Body
The carotid body

 Is a minute, reddish-brown, ellipsoidal structure located either behind the
bifurcation of the common carotid artery or between (the proximal parts of) its
branches
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 May exist as separate nodules rather than a single structure

 Measures about 6 mm in height and about 3 mm in width
 Receives fibres from the carotid sinus nerve (a branch of the glossopharyngeal
nerve) and from a plexus formed by the sympathetic trunk, glossopharyngeal
nerve and vagus nerve
 Serves as a chemoreceptor. Thus, it is sensitive to the level of circulating oxygen
in the bloodstream
 Is stimulated by hypoxia or hypercapnia. Under these conditions, the carotid body
initiates a reflex increase in the rates and depth of respiration
Internal Carotid Artery
The internal carotid artery

 Arises from the common carotid artery at the level of C3 (upper border of thyroid
cartilage). It is the direct continuation of the common carotid artery
 Ascends in the carotid sheath to the base of the skull, where it enters the carotid
canal (in the petrous temporal bone)
 Emerges from the carotid canal to enter the cranial cavity, where it continues
forwards through the cavernous sinus (on the body of sphenoid)
 Terminates by dividing into anterior and middle cerebral arteries
 Is divisible, along its course, into cervical, petrous, cavernous and cerebral parts
The cervical part of the internal carotid artery

 Begins as the continuation of the common carotid artery at the level of C3 (where
the common carotid bifurcates)
 Ascends in the carotid sheath (of the neck) to the base of the skull, where it enters
the carotid canal; it traverses the carotid triangle as it ascends
 Does not have any branches
 Is dilated at its commencement as the carotid sinus (see above)
Relations of the Cervical Part of Internal Carotid Artery
Cervical part of the internal carotid artery is related to the following:

 Posteriorly: superior laryngeal nerve, superior cervical ganglion, upper three
cervical vertebrae, and vagus nerve
 Anterolaterally: SCM, hypoglossal and glossopharyngeal nerves, occipital and
posterior auricular arteries, and internal jugular vein
 Medially: pharynx and ascending pharyngeal artery
The petrous part of internal carotid artery

 Passes sinuously through the carotid canal (in the petrous temporal bone); here, it
is surrounded by the internal carotid plexus of nerves (derived from a branch of
the superior cervical ganglion)
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 Is separated (in the petrous temporal bone) from the tympanic cavity by a thin
plate of bone (which is cribriform in children)
 Emerges from the carotid canal to pass superomedially (above the cartilage that
fills the foramen lacerum) into the cranial cavity, where it continues as the
cavernous part
 Gives rise to caroticotympanic and pterygoid branches
The cavernous part of internal carotid artery

 Traverses the cavernous sinus, at the side of the body of the sphenoid. Here, it has
a covering of endothelial cells and is surrounded by the internal carotid plexus of
nerves
 Is related laterally to oculomotor, trochlear, ophthalmic and abducent nerves; the
last nerve accompanies the artery through the sinus (while the others traverse the
lateral wall of the sinus)
 Emerges from the roof of the cavernous sinus to continue as the cerebral part
 Gives rise to cavernous, hypophyseal and meningeal branches
The cerebral part of internal carotid artery

 Is the last part of the internal carotid artery. It turns backwards as it emerges from
the dura, to pass between the optic and oculomotor nerves
 Divides into middle and anterior cerebral arteries at the medial end of the lateral
sulcus (adjacent to the anterior perforated substance)
 Supplies the cerebral hemisphere, orbit (including the eye), forehead and part of
the nasal cavity
Branches of cerebral part of the internal carotid artery include:

 Ophthalmic artery (see above)
 Anterior cerebral artery
 Middle cerebral artery
 Posterior communicating artery, and
 Anterior choroidal artery
The anterior choroidal artery

 Is a small branch of the cerebral part of the internal carotid artery; it arises near
the origin of the posterior communicating artery (and passes backwards)
 Supplies the crus cerebri, red nucleus, substantia nigra, lateral geniculate body,
corpus striatum, tuber cinereum, hypothalamus, amygdaloid complex, optic
radiation, optic tract and hippocampus
 Enters the choroid fissure to gain the inferior cornu of the lateral ventricle, where
it ends in the choroid plexus
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External Carotid Artery
The external carotid artery

 Arises in the neck from the common carotid artery (level of C3 vertebra). Here,
its pulsation can be felt
 Ascends first anteromedial, then anterior and finally lateral to the internal carotid
artery
 Lies in the carotid triangle at its origin; however, it ascends through the parotid
gland above (where it lies deep to the retromandibular vein and facial nerve)
 Is of the same calibre as the internal carotid artery. In children, the internal
carotid is larger
 Rapidly diminishes in calibre as it ascends, owing to the numerous branches
which arise from it
 Terminates behind the mandibular neck (within the parotid gland) by dividing
into superficial temporal and maxillary arteries
 Gives rise to branches that mainly supply structures external to the skull (with a
few exceptions, e.g., middle meningeal artery)
Relations of the External Carotid Artery
The external carotid artery has the following relations:

 Superficially: skin, fascia, SCM, posterior belly of digastric, stylohyoid muscle,
parotid gland, hypoglossal and facial nerves, and the retromandibular, facial,
lingual, and superior thyroid veins
 Deeply: pharynx, temporal styloid process, stylopharyngeus, styloglossus,
glossopharyngeal nerve, part of the parotid gland, and the internal carotid artery
Branches of the external carotid artery include:

 Superior thyroid artery, which supplies the thyroid gland. Besides its branches
to thyroid gland, other branches include: i. infrahyoid branch, ii.
sternocleidomastoid branch, iii. superior laryngeal branch, and iv. cricothyroid
branch
 Ascending pharyngeal artery, the smallest branch of external carotid. This
vessel supplies the pharynx and middle ear
 Lingual artery, which supplies the tongue and the floor of the mouth (see above)
 Facial artery, to the face. The cervical branches of this artery include: 1.
Ascending palatine artery, to the soft palate and palatine tonsil. 2. Tonsillar
artery, to the palatine tonsil. 3. Glandular branches, to the submandibular gland,
and 4. Submental artery to muscles of the submental region, chin and lower lip
 Occipital artery, which supplies the posterior part of the scalp. It arises opposite
the origin of the facial artery
809
 Posterior auricular artery, which supplies the posterior part of the scalp,
auricle, tympanic cavity, mastoid antrum and air cells, semicircular canals and
facial nerve
 Superficial temporal artery, which supplies the scalp, auricle, external acoustic
meatus and face. It arises in the parotid gland
 Maxillary artery, which also arises in the parotid gland (as a terminal branch of
external carotid). It passes into the infratemporal and pterygopalatine fossae,
where it gives several branches (see above)
Internal Jugular Vein
The internal jugular vein

 Commences in the jugular foramen as the direct continuation of the sigmoid sinus
 Descends in the neck (in the carotid sheath), lateral to the internal carotid artery
above, and the common carotid artery below
 Ends behind the sternal end of the clavicle by joining the subclavian vein, to form
the brachiocephalic vein
 Drains the brain, skull, part of the face, and the viscera and muscles of the neck
 Has a dilatation at its commencement (below the tympanic cavity), termed the
superior bulb
 Also has a dilatation near its inferior end – the inferior bulb
 Possesses a pair of valves just above its inferior bulb
Relations of the Internal Jugular Vein
Relations of internal jugular vein include:

 Superficially: SCM, posterior belly of digastric, superior belly of omohyoid,
accessory nerve and the occipital and posterior auricular arteries
 Medially: internal and common carotid arteries (in the upper and lower parts of
the neck respectively)
 Posteriorly: phrenic nerve, 1st part of subclavian artery, scaleni anterior and
medius, cervical plexus of nerves and (on the left) the thoracic duct
Tributaries of the IJV include:

 Inferior petrosal sinus, which joins the superior bulb of this vein
 Lingual vein, which drains the tongue
 Superior thyroid vein, which drains the thyroid gland
 Middle thyroid vein, which also drains the thyroid gland
 Pharyngeal veins, which drain the pharynx. These veins join the IJV at the level
of the mandibular angle
 Facial vein, which drains the face. It joins the IJV at or below the level of the
hyoid bone, and it may receive the thyroid or lingual veins
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External Jugular Vein
The external jugular vein

 Is formed by the union of the posterior auricular vein and the posterior division
of the retromandibular vein, behind the angle of the mandible (and within or
below the parotid gland)
 Descends in the neck, superficial to the SCM (which it crosses obliquely), and
deep to platysma
 Enters the subclavian triangle in the lower part of the neck, where it pierces the
deep fascia, to end in the subclavian vein
 Is intimately related to the great auricular nerve (which ascends behind its upper
part)
 Possesses a valve at its termination. A second valve is located about 4 cm above
the clavicle
 Drain the scalp and face, and may communicate with the internal jugular vein
 Stands out in Valsalva’s experiment (or Valsalva’s manoeuver)
The anterior jugular vein

 Is formed near the hyoid bone by the union of several superficial veins from the
submandibular region
 Descends adjacent to the midline of the neck
 Turns laterally in the lower part of the neck, deep to SCM, to join the external
jugular or subclavian vein
 Is united with the opposite vein just above the manubrium sterni by a
transversely-disposed jugular arch (which occupies the suprasternal space)
 Drains the tissues of the neck and receives tributaries from the larynx and thyroid
gland (occasionally)
 Is devoid of valves
 Has a size which is usually inversely proportional to that of the external jugular
vein
Cervical Plexus
The cervical plexus

 Is formed by the ventral rami of the first four cervical spinal nerves; each of these
rami (except the first) divides into ascending and descending branches that form
communicating loops (Fig. 158)
 Is located anterior to scalenus medius and levator scapulae, opposite the C1 – C4
vertebrae
 Receives grey rami communicantes from the superior cervical sympathetic
ganglion
 Gives rise to superficial and deep branches. The former are arranged as
ascending and descending branches
 Innervates structures in the head, neck and chest
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Figure 158. The cervical plexus of nerves.
Branches of the Cervical Plexus (Fig. 158)
These include:
 Ascending superficial branches
 Descending superficial branches, and
 Deep branches
Ascending superficial branches of cervical plexus include:

 Lesser occipital nerve (C2)
 Great auricular nerve (C2, 3), and
 Transverse cutaneous nerve of the neck (C2, 3)
The lesser occipital nerve
812
 Arises from the ventral ramus of C2

 Winds round the accessory nerve and ascends along the posterior border of SCM,
toward the apex of the posterior triangle of the neck
 Pierces the deep fascia at the apex of the posterior triangle. It then ascends to the
scalp behind the auricle
 Innervates the cranial aspect of the auricle and adjacent part of the scalp (behind
the auricle)
 Communicates with the great auricular and greater occipital nerves
 Is of variable size and may be duplicated
Greater Auricular Nerve (C2,C3)
The great auricular nerve

 Is usually the largest cutaneous branch of the cervical plexus (Fig. 158)
 Winds round the SCM and pierces the deep fascia to ascend (on that muscle) to
the auricle, deep to platysma
 Is intimately related to the external jugular vein (which descends anterior to it)
 Divides into anterior, intermediate and posterior branches (as it ascends)
 Innervates the skin of the parotid area through its anterior branch
 Innervates the skin over the mastoid process through its posterior branch
 Also innervates both aspect of the lower part of the auricle through its
intermediate branch
 Communicates with the lesser occipital, posterior auricular and facial nerves
The transverse cutaneous nerve of the neck

 Arises from the ventral rami of the 2nd and 3rd cervical spinal nerves (Fig. 158)
 Curves forward, round the posterior border of SCM, to the anterior border of this
muscle (deep to the external jugular vein). It then
 Pierces the deep fascia to reach the deep aspect of platysma where it divides into
ascending and descending branches
 Innervates the skin and fascia of the anterior triangle of the neck
 Communicates above with the cervical branch of facial nerve (deep to platysma)
Descending Superficial Branches of the Cervical Plexus

The descending superficial branches of cervical plexus include the supraclavicular
nerves (C3, C4).
Supraclavicular nerves
 Arise (as a single trunk) from the ventral rami of C3 and C4 nerves (Fig. 158).
This trunk emerges behind SCM and descends in the posterior triangle of the
neck where it divides into medial, intermediate and lateral branches
 Pierce the deep fascia just above the clavicle, to enter the chest, deep to platysma
 Innervates the skin of the lower part of the side of the neck
813
 Also innervates the skin of the shoulder and chest, down to the level of the sternal
angle of Louis (2nd costal cartilage)
 Gives articular fibres to the sternoclavicular and acromioclavicular joints (via its
medial and lateral branches respectively)
Deep Branches of the Cervical Plexus
The deep branches of the cervical plexus may be classified as

 Communicating branches, and
Communicating Branches
Via its communicating branches, the cervical plexus sends fibres to:
 Vagus nerve,
 Accessory nerve; and
 Hypoglossal nerve. Such communicating fibres leave the hypoglossal nerve as
meningeal branch, superior root of ansa cervicalis and nerve to thyrohyoid
and geniohyoid (Fig. 158)
Note: The superior cervical sympathetic ganglion sends grey rami communicantes
to the ventral rami of C1–C4.
Muscular Branches of Cervical Plexus
Muscular branches of cervical plexus innervate the following muscles:

 Rectus capitis lateralis
 Rectus capitis anterior
 Longus capitis, and
 Longus colli
Other muscular branches of the cervical plexus include:

 Inferior root of ansa cervicalis (C2, C3); and
 Phrenic nerve (C3, C4, C5). The phrenic nerve innervates the diaphragm
Inferior Root of Ansa Cervicalis

 The inferior root of ansa cervicalis is derived from the ventral rami of C2 and
C3 nerves
 Having descended on the lateral aspect of IJV, the inferior root of ansa cervicalis
turns medially (anterior to IJV), just below the middle of the neck to join the
superior root
814
 The superior root of ansa cervicalis (C1) arises from the hypoglossal nerve; it
descends anterior to the common carotid artery, in the carotid sheath
 The superior and inferior roots of ansa cervicalis unite anterior to the common
carotid artery to form the ansa cervicalis
 The ansa cervicalis innervates all infrahyoid muscles except thyrohyoid. The
latter receives motor fibres from the hypoglossal nerve. These fibres arise from
the cervical plexus (C1); and they join the hypoglossal nerve as a communicating
branch.
Phrenic Nerve
The phrenic nerve

 Arises from the ventral rami of C3–C5 nerves (mainly C4), at the upper part of
the lateral border of scalenus anterior (Fig. 158)
 Descends in the neck, anterior to scalenus anterior and deep to the prevertebral
fascia and SCM
 Passes between the subclavian artery and vein to enter the thoracic cavity,
through the thoracic inlet
 Descends through the mediastinum, between the fibrous pericardium and
mediastinal pleura (anterior to the root of the lung) towards the diaphragm
 Gives motor fibres to the diaphragm; it also conveys sensory fibre from the
diaphragm and pericardium
 Is accompanied (in the mediastinum) by the pericardiacophrenic vessels
Applied Anatomy

 In mitral valve incompetence, internal jugular pulse becomes notable as the
right ventricle contracts
 The internal jugular vein can be punctured near the apex of the anterior triangle
of the neck, where it descends behind the lower attachment of SCM. This may be
necessary for diagnostic or therapeutic purposes e.g. for right cardiac
catheterization
 The pulse of the common carotid artery can be taken at the level of the upper
border of the thyroid cartilage, deep to the anterior border of SCM
 In carotid sinus hypersensitivity, pressure on the common carotid artery may
trigger a series of events such as lowering of heart rate, decreases in blood
pressure and even syncope (fainting). Thus, in cardiac diseases, taking the carotid
pulse could trigger such events
 When intrathoracic pressure increases, the external jugular vein could be seen
standing out in the neck, e.g. in Valsalva’s manoeuver (owing to reduced venous
return to the heart)
 Venous air embolism may occur following severance of the external jugular vein
815
 The subclavian vein can be punctured beneath the middle 3rd of the clavicle.
When this is successful, administration of substances, as well as right cardiac
catheterization, could be done
 Phrenic nerve block could be performed by injecting an anaesthetic around the
nerve in the middle 3rd of scalenus anterior (on which this nerve descends). This
transiently paralyzes the corresponding dome of the diaphragm
 If the phrenic nerve is damaged in the neck, the ipsilateral dome of the diaphragm
is paralyzed. If however an accessory phrenic nerve is present, partial paralysis
occurs
 Cervical plexus block could be done by injecting an anaesthetic at the nerve
point of the neck (a point along the posterior border of SCM, at the junction of
the upper and middle thirds of this muscle). This anaesthetizes the structures
innervated by the main branches of the cervical plexus
Hyoid Muscles
These muscles
 Are associated with the hyoid bone; they connect this bone to the skull, mandible,
sternum, etc
 Can be divided into suprahyoid and infrahyoid groups
Suprahyoid Muscles
The suprahyoid muscles

 Connect the hyoid bone to the skull
 Include digastric, stylohyoid, mylohyoid and geniohyoid
The digastric
 Has two bellies (anterior and posterior) joined by an intermediate tendon; a
fibrous sling connects the latter to the body and greater horn of the hyoid and
allows the muscle to slide forth and back
 Has dual innervation, owing to the different embryonic origin of its anterior and
posterior bellies. The former arises from the 1st pharyngeal arch (and is thus
innervated by a branch of the mandibular nerve), while the latter arises from the
2nd pharyngeal arch (and is innervated by a branch of facial nerve)
 Forms the anteroinferior and posteroinferior boundaries of the digastric triangle
 Anterior belly: Digastric fossa of the mandible
 Posterior belly: Mastoid notch of the temporal bone
Distal attachment: Intermediate tendon of digastric. This is anchored to the greater

horn and body of the hyoid bone by a fibrous sling
816
Innervation:
 Anterior belly: Nerve to mylohyoid (from the inferior alveolar branch of
mandibular nerve)
 Posterior belly: Facial nerve
Action:
 Raises the hyoid bone
 Depresses and retracts the mandible (when hyoid is fixed)
The stylohyoid
 Is a small slip of muscle, which passes anteroinferiorly from the styloid process
to the hyoid (parallel to the posterior belly of digastric)
 Splits, near its hyoid attachment, to enclose the intermediate tendon of digastric
Proximal attachment: Styloid process of temporal bone
Distal attachment: Body of hyoid bone
Innervation: A branch of facial nerve
Action: Elevates and retracts the hyoid (thereby elongating the buccal floor)
The mylohyoid muscle

 Gives support to the floor of the mouth (together with its fellow)
 Is located between the geniohyoid above and the anterior belly of digastric below
Proximal attachment: mylohyoid line of the mandible
Distal attachment:
 Body of hyoid
 Median fibrous raphe (which stretches from the hyoid behind to the chin in
front)
Innervation: nerve to mylohyoid (from the inferior alveolar nerve)
Action:
 Elevates the floor of the mouth and the tongue during swallowing
 Also elevates the hyoid bone during swallowing
 Depresses the mandible (against resistance)
The geniohyoid
 Lies above mylohyoid, and like this muscle, gives support to the floor of the
mouth
817
 Is usually fused with its fellow
Proximal attachment: inferior mental spine of the mandible
Distal attachment: body of hyoid
Innervation: C1 nerve (via the hypoglossal nerve)
Action:
 Pulls the hyoid forwards and slightly upwards, thereby shortening the buccal
floor and widening the pharynx (for food reception)
 Retracts (draws back) the mandible (with the hyoid fixed)
Infrahyoid Muscles
Infrahyoid muscles
 Are located below the hyoid, which they connect to the sternum, scapula, clavicle
and thyroid cartilage
 Are ribbon-like in appearance and are thus referred to as strap muscles
 Depress the hyoid bone, and together with the suprahyoid muscles, fix this bone
 Include sternohyoid, sternothyroid, thyrohyoid and omohyoid
The sternohyoid
 Is a strap muscle located in the anterior part of the neck, adjacent to the midline
(and deep to the investing layer of deep fascia)
 Posterior surface of manubrium sterni
 Posterior surface of sternoclavicular joint
 Medial end of the clavicle
Distal attachment: body of hyoid
Innervation: a branch of ansa cervicalis (C1–3)
Action:
 Depresses the hyoid bone following swallowing
 Fixes the hyoid bone when acting with the suprahyoid muscles
 May assist in inspiration (when acting from a fixed hyoid bone)
The sternothyroid
 Stretches from the manubrium sterni below to thyroid cartilage above
 Lies deep to sternohyoid, SCM and omohyoid. It is broader than sternohyoid
 Overlaps the trachea and the lobe of the thyroid gland anteriorly
818
Proximal attachment: posterior surface of manubrium sterni
Distal attachment: oblique line of thyroid cartilage
Innervation: a branch of ansa cervicalis
Action: depresses the larynx and hyoid bone
The thyrohyoid
 Stretches from the thyroid cartilage below to the hyoid bone above (deep to
sternohyoid)
 Appears as the upwards continuation of sternothyroid
Proximal attachment: oblique line of thyroid cartilage
Distal attachment: body and greater horn of hyoid
Innervation: C1 nerve, via the hypoglossal nerve
Action:
 Elevates the larynx, and
 Depresses the hyoid bone
The omohyoid
 Has two bellies (superior and inferior) connected by an intermediate tendon
(located deep to SCM)
 Is anchored to the clavicle and the 1st rib by a fibrous sling which descends from
its intermediate tendon
 Is used as a landmark in the neck. This muscle separates the occipital from the
subclavian triangles (below), and the muscular from the carotid triangles (above)
 Upper border of the scapula (near the suprascapular notch)
 Superior transverse scapular ligament
Distal attachment: lower border of the body of hyoid
Innervation: a branch of ansa cervicalis (C1–C3)
Action:
 Depresses the hyoid bone
 Also assists in fixing the hyoid bone
Deep Structures and Viscera of the Neck
819
Prevertebral Muscles
The prevertebral muscles

 Are located in the neck, deep to the prevertebral fascia
 Form the floor of the anterior and posterior triangles of the neck
The prevertebral muscles include:

 Longus colli, a long muscle that descends on the anterior aspect of the vertebral
column, from the tubercles of atlas (C1) to the body of T3. Thus, it reaches as far
down as the superior mediastinum
 Longus capitis; this muscle passes downwards and medially, from the transverse
processes of C3–C6 to the basilar part of occipital bone
 Rectus capitis lateralis; this flat muscle stretches between the transverse process
of C1 below to the jugular process of occipital bone above
 Rectus capitis anterior; this short muscle passes from the lateral mass of the
atlas to the basi-occipital bone
 Splenius capitis; this is an inconstant muscle which forms part of the floor of the
posterior triangle (when present). It is usually a slip of splenius cervicis
 Scalenus anterior; this muscle passes downwards and laterally, from the
transverse process of C3–C6 above, to the scalene tubercle of the 1st rib below
 Scalenus medius; this also passes downwards and laterally, from the transverse
processes of C2–C7 above, to the 1st rib below
 Scalenus posterior; this descends laterally from the transverse process of C5–C7
above, to the 2nd rib below
 Levator scapulae; this muscle descends from the transverse process of C1–C3
above to the scapula below (see vol. 1)
Root of the Neck
The root of the neck

 Is the junction between the neck and the thorax. Thus, it
 Transmits structures between the thoracic cavity and the neck
 Is bounded by bones; these include the T1 vertebra, 1st ribs and manubrium sterni
The root of the neck is bounded

 Anteriorly by manubrium sterni
 Laterally (on each side) by the 1st rib and the 1st costal cartilage, and
 Posteriorly by the body of T1
Arteries of the Root of the Neck
At (or near) the root of the neck, note that

 The brachiocephalic trunk bifurcates into right subclavian and right common
carotid arteries (behind the right sternoclavicular joint)
820
 The subclavian artery arches laterally over the 1st rib and behind scalenus
anterior (which separates it from the subclavian vein); its branches (e.g.
thyrocervical trunk) arise from it as it does so
 The vertebral artery ascends between scalenus anterior and longus colli (to the
foramen transversarium of C6). This artery arises from the 1st part of the
subclavian artery, and it supplies the spinal cord and brain
 The internal thoracic artery descends anterior to the cervical pleura, to enter the
thorax. It arises from the 1st part of the subclavian artery, and it supplies the
thoracic wall and the diaphragm
Veins of the Root of the Neck
Also at the root of the neck,

 The external jugular vein (EJV) ends in the subclavian vein
 The anterior jugular vein ends in the external jugular or subclavian veins
 A jugular arch unites the two anterior jugular veins (just above the manubrium
sterni)
 The subclavian vein passes medially over the 1st rib, anterior to scalenus anterior
and subclavian artery, to join the internal jugular vein, behind the medial end of
the clavicle. This union forms the brachiocephalic vein
 The right lymphatic trunk ends at the junction of the right subclavian vein and
IJV (i.e. the right venous angle)
 The thoracic duct terminates at the junction of the left subclavian vein and IJV
(i.e. the left venous angle)
Nerves of the Root of the Neck
At the root of the neck,

 The phrenic nerve descends anterior to scalenus anterior, and behind the
subclavian vein, to enter the thoracic cavity
 The right vagus nerve descends anterior to the 1st part of the right subclavian
artery, en route to the thoracic cavity
 The left vagus nerve descends between the left common carotid and subclavian
arteries, to gain the thoracic cavity
 The right recurrent laryngeal nerve arises from the right vagus nerve. It winds
posteriorly and upwards round the right subclavian artery, to ascend in the neck
(in the groove between the trachea and oesophagus)
 The left recurrent laryngeal nerve ascends in the groove between the esophagus
and trachea. This nerve arises from the left vagus, in the superior mediastinum
 Each sympathetic chain descends anterolateral to the vertebral column
 The stellate (cervicothoracic) ganglion is located just above the neck of the 1st
rib, anterior to the transverse process of C7. It is present in about 80% of people,
and is formed by the union of the inferior cervical and 1st thoracic sympathetic
ganglia
821
Also at the root of the neck,

 The apex of the lung reaches as high up as the neck of the 1st rib (behind the
subclavian vessels), about 4 cm above the 1st costal cartilage and 2 cm above the
clavicle
 The cervical pleura (cupola) covers the apex of the lung
 The suprapleural membrane overlies the cervical pleura, thereby strengthening
it. This fascia stretches from the transverse process of C7 to the internal aspect of
the 1st rib, and frequently contains skeletal muscle fibres (scalenus minimus)
Applied Anatomy

 Cervicothoracic ganglion block is performed by injecting an anaesthetic around
the cervicothoracic ganglion in the neck; this may relieve vascular spasm
involving the brain and upper limb
Viscera of the Neck
Viscera of the neck are arranged in layers; these include, from superficial deeply:
 Endocrine layer, which contains the thyroid and parathyroid glands
 Respiratory layer, which contains the larynx and trachea, and
 Alimentary layer, which contains the pharynx and oesophagus
Endocrine Layer of Cervical Viscera
This layer contains:

 Thyroid gland, and
 Parathyroid glands
Thyroid Gland
The thyroid gland

 Is a brownish-red, highly vascular endocrine organ located in the lower part of
the neck (Fig. 159). It extends from the C5 vertebra above to the T1 vertebra
below
 Is invested by a thin fibrous capsule which sends septa into the substance of the
gland
 Is also invested (outside the fibrous capsule) by the pretracheal layer of deep
cervical fascia
 Weighs 20 – 25 g in man. The gland weighs more in females than in males, and
increases in weight during menstruation and pregnancy
 Consists of a median isthmus and two lobes (right and left)
822
 Has a parenchyma whose cells are arranged into follicles. These follicles
elaborate thyroid hormones (tri-iodothyronine and tetra-iodothyronine or
thyroxine)
Figure 159. The thyroid gland and related vessels.
Lobes of the Thyroid Gland
Each conical lobe of the thyroid gland

 Is directed upwards and laterally from the level of the 4th (or 5th) tracheal ring
below to the oblique line of the thyroid cartilage above (Fig. 159)
 Has a base and an apex. The latter is directed upwards
 Measures about 5 cm in length. The greatest transverse and anteroposterior
diameters of the gland are 3 cm and 2 cm respectively
 Has lateral, medial and posterior surfaces
823
The lobe of the thyroid gland is related

 Medially to the pharynx, oesophagus, trachea, larynx, and the external laryngeal
and recurrent laryngeal nerves
 Laterally (superficially) to the sternohyoid and sternothyroid, and
 Posteriorly to the carotid sheath and its contents, parathyroid glands and the
inferior thyroid artery
Isthmus of Thyroid Gland
Regarding the isthmus of the thyroid gland, note that it

 Is the median part of the thyroid gland that connects the two lobes of the gland
(Fig. 159)
 Is located ventral to the 2nd and 3rd tracheal cartilages
 Measures 1.25 cm in transverse and vertical extents
 Is invested by the pretracheal fascia, deep to which is the fibrous capsule of the
gland
 Is related anteriorly to sternothyroids, sternohyoids, anterior jugular veins and
skin
 May possess a conical extension (in 50 % of the population) – the pyramidal
lobe – that projects towards the hyoid. A fibromuscular band, levator of the
thyroid gland, may descend from the hyoid to the pyramidal lobe (or isthmus) of
the gland. It is the remnant of the thyroglossal duct
Blood supply of Thyroid Gland
Note the following:

 The thyroid gland, being an endocrine organ, is highly vascular
 Blood vessels of the thyroid gland are located largely between its fibrous capsule
and the pretracheal layer of the deep fascia of the neck
 Arterial blood reaches the gland from the superior and inferior thyroid arteries
(braches of the external carotid artery and thyrocervical trunk respectively)
 Additional arterial supply to the thyroid gland may arise from the thyroidea ima
artery. This inconstant unpaired artery arises from the aortic arch or
brachiocephalic trunk (and is present only in 10% of individuals)
 Each superior thyroid artery descends towards the apex of the thyroid lobe; it
divides into anterior and posterior branches
 The larger anterior branch of the superior thyroid artery descends on the anterior
border of the thyroid lobe, to anastomose across the midline with its fellow (on
the isthmus)
 The posterior branch of superior thyroid artery descends on the posterior surface
of thyroid lobe to anastomose with the inferior thyroid artery
 Both thyroid arteries anastomose with each other on the surface and in the
substance of the gland
824

 The veins of the thyroid gland form a plexus on the surface of the gland, and on
the trachea
 From the thyroid venous plexus, three veins (superior, middle and inferior
thyroid veins) arise
 The superior and middle thyroid veins drain into the IJV
 The inferior thyroid veins (which arise from the thyroid venous plexus, ventral
to the trachea) descend, anterior to the trachea, to the brachiocephalic veins (in
the thoracic cavity)
Lymphatic Drainage of the Thyroid Gland
Note the following:

 Lymph vessels of the thyroid gland traverse the interlobular connective tissue
(with branches of the arteries) of the gland
 A plexus of lymph vessels also exists in the fibrous capsule of the gland; this
plexus communicates with those in the interlobular connective tissue
 Lymph vessels, which emerge from the thyroid gland end in paratracheal,
pretracheal, prelaryngeal and deep cervical nodes
Innervation of the Thyroid Gland
Regarding the innervation of the thyroid gland, note that

 Nerve fibres reach the gland from the superior, middle and inferior cervical
sympathetic ganglia; such fibres accompany the thyroid arteries
 Nerve fibres of the thyroid gland are vasomotor and not secretomotor
Applied Anatomy
Note the following:

 Physiological enlargement (a slight enlargement) of the thyroid gland normally
occurs during pregnancy and menstruation
 Goiter is the pathological enlargement of the thyroid gland (apart from the
physiological enlargement that occurs in pregnancy and menstruation); this
condition may be endemic
 Various factors could predispose an individual to goiter; these include iodine
deficiency, malignancy, etc
 In goiter, the enlarged gland compresses the trachea, oesophagus and recurrent
laryngeal nerves, causing discomfort
 When the recurrent laryngeal nerves are compressed in goiter, their functional
integrity is compromised. Thus, hoarseness of the voice may occur (as laryngeal
muscles are adversely affected)
825
 The external laryngeal nerves (which innervate cricothyroids) may be

compressed, bruised or injured in thyroid surgery. When this occurs, the pitch of
the voice cannot be altered, and thus, the voice becomes monotonous
 In malignancy of the thyroid gland, partial thyroidectomy (surgical removal)
may be performed. The posterior part of the gland is retained, so as to preserve
the parathyroid glands and laryngeal nerves
 Total thyroidectomy is not usually performed as this will result in myxoedema
(from hypothyroidism)
 In thyroidectomy, ligation of the inferior thyroid artery is done some distance
from (lateral to) the gland. This preserves the recurrent laryngeal nerve (which is
closely associated with the artery close to the gland)
 Ligation of the superior thyroid artery (in thyroidectomy) is done superior to the
gland, to preserve the external laryngeal nerve. Speech becomes monotonous
when this nerve is bruised or injured during this operation
 When the thyroid gland does not descend from its site of origin (the floor of the
primitive pharynx), a lingual thyroid gland arises. Besides, the gland may
assume an abnormally high position in the neck owing to incomplete descent.
Such ectopic gland could be mistaken for a thyroglossal cyst
 Remnants of the thyroglossal duct may persist as accessory thyroid glands;
these may be found above the main thyroid gland
Parathyroid Glands
The parathyroid glands

 Are minute ovoid yellowish-brown endocrine organs
 Are located posterior to the thyroid gland, two on each side (superior and
inferior), within the fibrous capsule of the thyroid gland
 Measure about 6 mm in length and 3.5 mm in width each. Each also weighs about
50 mg
 Are made up of a parenchyma that consists of principal (or chief) cells. These
cells are arranged in columns (separated by sinusoids), and they produce
parathyroid hormone (which is involved in calcium metabolism by facilitating
the mobilization of Ca from bones into the plasma, etc)
The superior parathyroid gland

 Is usually located about midway along the posterior border of the thyroid gland. It
is relatively constant in position
 Is a derivative of the 4th pharyngeal pouch, and is therefore also called
parathyroid IV
The inferior parathyroid gland

 Is usually located behind and close to the lower pole of the lobe of the thyroid
gland
826
 Is more variable in position, and may thus be found in the mediastinum, close to
the thymus. Such a variation is of surgical importance
 Develops from the 3rd pharyngeal pouch, and is thus also called parathyroid III
Blood supply, Innervation and Lymphatic Drainage of Parathyroid Glands

 Arterial blood reaches the parathyroid glands from branches of the inferior (and
superior) thyroid arteries or the anastomoses between these main vessels
 The thyroidea ima, tracheal, laryngeal and oesophageal arteries may also supply
the parathyroid glands
 Parathyroid veins drain into the thyroid venous plexus (on the anterior aspect of
the thyroid gland and trachea)
 Lymph vessels from the parathyroid glands drain into the paratracheal and deep
cervical nodes
 Nerve fibres reach the gland from the cervical sympathetic ganglia via the plexus
around the thyroid arteries. These fibres are probably vasomotor (not
secretomotor)
Importance of the Parathyroid Gland

 Parathyroid gland produces parathyroid hormone (parathormone)
 A rise in plasma calcium levels would inhibit parathormone production, while a
fall stimulates it. Thus,
 Parathyroid hormone is essential for the maintenance of Ca level in the plasma.
Its effect is countered by calcitonin, the hormone produced by the parafollicular
cells (C cells) of the thyroid gland. Calcitonin decreases blood Ca level
Applied Anatomy
Note that
 Removal of the parathyroid gland (e.g. in total thyroidectomy) would result in
tetany – convulsive spasm of muscles
 Because tetany involves respiratory muscles, death usually occurs
 In parathyroid adenocarcinoma, parathyroid hormone is produced in excess.
This will result in osteitis fibrosa cistica (owing to excessive removal of Ca ion
from bones)
 In hypercalcaemia (resulting from excess parathyroid hormone), Ca is deposited
in renal tubules (with the associated renal diseases) and arteries
827
Alimentary Layer of Cervical Viscera
This contains
 The cervical part of the oesophagus, and
 The pharynx
Cervical Part of the Oesophagus
The cervical part of the oesophagus

 Is a muscular tube that descends from the level of the lower border of the cricoid
cartilage (C6) to the root of the neck (where it continues with the thoracic part).
It is constricted at its junction with the pharynx
 Is made of striated (skeletal) muscle fibres
 Is related to certain important structures (see below)
Relations of the Cervical Part of the Oesophagus
The cervical part of the oesophagus is related to the following:

 Posteriorly: prevertebral fascia, longus colli and vertebra column
 Anteriorly: trachea and recurrent laryngeal nerves (one on each side). The
recurrent laryngeal nerves are located in the tracheo-esophageal grooves
 Laterally: lobes of the thyroid gland, common carotid artery, and (on the left
side) the thoracic duct
Blood Supply, Innervation and Lymphatic Drainage of the Cervical Part of the
Oesophagus

 The cervical part of the oesophagus receives arterial blood from branches of the
inferior thyroid arteries
 Veins of the cervical part of the oesophagus drain into the inferior thyroid veins
 Lymph vessels from the cervical part of oesophagus end in the paratracheal and
inferior deep cervical nodes
 Motor fibres to the cervical part of esophagus arise from the recurrent laryngeal
nerves
 Sensory fibres from the esophagus are also conveyed by the recurrent laryngeal
nerves
 Vasomotor (sympathetic) fibres to the cervical part of the oesophagus arise from
the cervical part of the sympathetic chains. These fibres reach the oesophagus via
the plexus around the inferior thyroid artery
828
Pharynx
The pharynx
 Is a funnel-shaped fibromuscular tube located behind the nasal cavities, mouth
and larynx
 Extends from the base of the skull above to the level of the lower border of the
cricoid cartilage (C6) below
 Measures 12–14 cm in length
 Is widest above, where it measures 3.5 cm but narrows below (at its junction with
the esophagus) where it is 1.5 cm wide. The alimentary tract is narrowest at the
pharyngo-esophageal junction (except for the vermiform appendix). This
junction is about 15 cm from the incisor teeth
 Is divisible into three parts; these include the nasopharynx, oropharynx and
laryngopharynx (Fig. 160)
 Is invested externally by the bucopharyngeal fascia
Relations of the Pharynx (Fig. 160)
The pharynx is related

 Above to the posterior part of sphenoidal body and basilar part of occipital bone
 Below to the oesophagus (with which it is directly continuous)
 Behind to the retropharyngeal space (Fig. 160), prevertebral fascia, prevertebral
muscles (longus colli and longus capitis) and cervical part of the vertebral column
 In front to the nasal and oral cavities, and the larynx
 Laterally (on each side) to the styloid process and its attached muscles, carotid
sheath (and its contents), upper end of thyroid lobe, and the glossopharyngeal,
vagus, accessory and hypoglossal nerves
Structure of the Pharynx
Structurally, the pharynx consists of four layers; these include, from internal
externally,
 Mucous membrane (lined by ciliated pseudostratified columnar epithelium in
the nasopharynx, and non-keratinized stratified squamous epithelium in the
oropharynx and laryngopharynx). A zone lined by cuboidal epithelium however
lies between the oropharynx and laryngopharynx
 Fibrous layer, which is thickened above as pharyngobasilar fascia (Fig. 160)
 Muscular layer, which consists of skeletal muscle fibres, and
 Bucopharyngeal fascia, which is a layer of connective tissue
829
Figure 160. The pharynx and buccal cavity.
Nasopharynx (Nasal Part of the Pharynx)
The nasopharynx
 Is the part of the pharynx located above the soft palate, and behind the nasal
cavities (Fig. 160)
 Is respiratory in function and is thus lined by the respiratory (ciliated
pseudostratified columnar) epithelium
 Has a roof formed by the sphenoidal body and the basilar part of occipital bone
 Communicates anteriorly with the nasal cavities via the choanae
 Is linked to the tympanic cavities by the pharyngotympanic (auditory) tubes.
These open onto the lateral walls of the pharynx (one on each side)
 Is continuous below with the oropharynx, through the pharyngeal isthmus. The
latter is closed during swallowing by the soft palate
 Always remains patent
Regarding the nasopharynx, note that

 On each of its lateral walls is the pharyngeal opening of the auditory tube; this
opening is located about 10 mm behind (and slightly below) the posterior end of
the inferior nasal concha
 The pharyngeal opening of each auditory tube is bounded above and behind by a
mucosal elevation – tubal elevation. This is produced by the medial end of the
cartilaginous part of the auditory tube
 Descending from the tubal elevation is a vertical fold of mucosa, the
salpingopharyngeal fold; this contains salpingopharyngeus
830
 Behind the tubal elevation, the pharyngeal wall has a lateral depression termed
the pharyngeal recess
 In the roof and posterior wall of the nasopharynx are the pharyngeal tonsils
(adenoids) (Fig. 160). These are aggregations of lymphoid tissue (and are more
prominent in children). Their inflammation (tonsillitis may necessitate
tonsillectomy [surgical removal]).
Oropharynx (Oral Part of the Pharynx)
The oropharynx
 Extends from the soft palate above to the upper border of the epiglottis below
(Fig. 160)
 Communicates anteriorly with the buccal cavity through the oropharyngeal
isthmus and is related, below this, to the pharyngeal part of the tongue
 Is bounded laterally by the palatoglossal and palatopharyngeal arches. Between
these is a triangular tonsillar fossa that lodges the palatine tonsil
 Is related posteriorly to the C2 and C3 vertebrae
 Has a lining of non-keratinized stratified squamous epithelium
Palatine Tonsil
The palatine tonsil

 Is a mass of lymphoid tissue that occupies the triangular tonsillar fossa on the
lateral wall of the oropharynx (Fig. 141,60)
 Is of variable size; it is roughly almond-shaped when fully formed
 Measures, in a healthy adult, about 25 mm in length, 15 mm in width and 10 mm
in thickness
 Possesses a deep pit in its upper part – the intratonsillar cleft. This is a remnant
of the 2nd pharyngeal pouch
 Has, on its medial surface, 12–15 openings of tonsillar crypts; the latter
penetrate deep into the tonsil
 Is related on its lateral surface to the superior pharyngeal constrictor, from which
it is separated by a fibrous capsule; the latter covers the lateral surface of the
tonsil and can be stripped with ease (together with the tonsil) from superior
constrictor
 Is susceptible to frequent infection and hypertrophy
 Atrophies gradually with advancing age and is almost completely absent in old
age
 Forms part of the ring of lymphoid masses – the Waldeyer’s ring – located in the
pharynx; this ring is formed posterosuperiorly by pharyngeal tonsil,
anteroinferiorly by lingual tonsil and on each side by the palatine tonsil
831
Blood Supply, Innervation and Lymphatics of the Palatine Tonsil
The palatine tonsil

 Is supplied mainly by the tonsillar branch of facial artery; additional vessels may
arise from the dorsal lingual, ascending palatine, ascending pharyngeal and
greater palatine arteries
 Is drained by veins which end in external palatine, pharyngeal or facial veins
 Receives nerve fibres from the lesser palatine branches of the pterygopalatine
ganglion, and the glossopharyngeal nerve
 Is drained by the upper deep cervical nodes (especially the jugulodigastric nodes)
Laryngopharynx (Laryngeal Part of the Pharynx)
The laryngopharynx
 Extends from the upper border of epiglottis above to the lower border of cricoid
cartilage below (Fig. 160)
 Narrows markedly at its lower end where it is continuous with the oesophagus
 Is related anteriorly to the larynx, with which it is continuous (via the laryngeal
inlet)
 Is related posteriorly to the C3–C6 vertebral bodies
 Has, on each side of the laryngeal inlet, a small fossa termed the piriform recess.
This is bounded medially by the aryepiglottic fold and laterally by the thyroid
cartilage and thyrohyoid membrane. Deep to the mucous lining of this recess are
the branches of internal laryngeal nerve (which are therefore at risk during the
removal of an object from the recess)
Pharyngeal Muscles
The pharynx consists of

 Three constrictor muscles; these are the superior, middle and inferior
constrictors (Fig. 143); and
 Three longitudinal muscles; these include palatopharyngeus, stylopharyngeus
and salpingopharyngeus. They reinforce the constrictors internally
Superior Constrictor
The superior constrictor

 Is quadrilateral in outline and is thinner than the other constrictors
 Is separated from the base of the skull by an interval occupied by the
pharyngobasilar fascia (Fig. 143)
 Pterygoid hamulus
 Pterygomandibular raphe
832
 Posterior end of mylohyoid line of mandible, and

 Side of the tongue
Distal attachment:
 Pharyngeal raphe
 Pharyngeal tubercle (on the basilar part of occipital bone)
Innervation and action: See below
Middle Constrictor
The middle constrictor of the pharynx

 Is triangular in outline (Fig. 143)
 Is related at its upper border to the glossopharyngeal nerve and at its lower border
to the internal laryngeal nerve (and laryngeal branch of superior thyroid artery)
 Stylohyoid ligament
 Lesser horn of hyoid, and
 Greater horn of hyoid
Distal attachment: pharyngeal raphe
Innervation and action: See below
The inferior constrictor

 Is the thickest of the pharyngeal constrictors (Fig. 143)
 May be defined as comprising two parts: cricopharyngeus and
thyropharyngeus
 Is related at its lower border to the recurrent laryngeal nerve and inferior
laryngeal artery (as these ascend into the larynx)
 Thyropharyngeus – Oblique line of thyroid cartilage
 Cricopharyngeus – Side of cricoid cartilage
Distal attachment: pharyngeal raphe
Innervation:
 Pharyngeal plexus; this supplies all pharyngeal constrictors
 Recurrent and external laryngeal nerves; these supply inferior constrictor
The pharyngeal plexus is formed by branches of:

 Cranial accessory nerve
833
 Vagus nerve
 Glossopharyngeal nerve, and
 Superior cervical sympathetic ganglion
Action of pharyngeal constrictors: These muscles constrict the pharyngeal wall

(from above downwards) during swallowing.
Longitudinal Muscles of the Pharynx
Longitudinal muscles of the pharynx include:

 Stylopharyngeus
 Palatopharyngeus
 salpingopharyngeus
The stylopharyngeus
 Is a long cylindrical muscle
 Traverses the interval between the superior and middle constrictors (accompanied
by the glossopharyngeal nerve) as it descends into the pharynx from its styloid
origin
 Spreads out on the inner aspect of the middle constrictor, deep to the mucosa of
the pharynx
 Blends with palatopharyngeus (in the pharynx)
Proximal attachment: styloid process of temporal bone
Distal attachment:
 Superior and posterior borders of thyroid cartilage
 Lateral glosso-epiglottic fold
 Side of the pharynx and oesophagus
Innervation: Glossopharyngeal nerve
Action: Elevates the pharynx and larynx during swallowing and speech
Palatopharyngeus (see the palate, above)
Salpingopharyngeus
 Is a small muscle contained in the salpingopharyngeal fold
 Descends internal to the constrictors to blend with palatopharyngeus
Proximal attachment: Inferior end of the cartilaginous part of the auditory tube
Distal attachment: Blends with palatopharyngeus
Innervation: Pharyngeal plexus

834
Action:
 Raises the upper part of the pharynx during swallowing, and
 Pulls open the pharyngeal opening of the auditory tube
Blood Supply of the Pharynx
The pharynx receives arterial blood from:

 Ascending pharyngeal branch of external carotid artery
 Pharyngeal and greater palatine branches of maxillary artery
 Artery of the pterygoid canal, also a branch of the maxillary artery
 Ascending palatine and tonsillar branches of facial artery, and
 Dorsal lingual arteries, branches of the lingual artery
Veins of the pharynx form a plexus that drains into:

 Pterygoid plexus of veins (above), and
 Internal jugular and facial veins (below)
Sensory Innervation of the Pharynx
Regarding innervation of the pharyngeal mucosa, note the following points:

 Sensory fibres to the pharynx are mainly branches of the glossopharyngeal and
vagus nerves
 The nasopharynx is mainly innervated by branches of the maxillary nerve
(which arise from the pterygopalatine ganglion)
 The oropharynx receives sensory fibres from the glossopharyngeal and lesser
palatine nerves, while
 The laryngopharynx is innervated by the internal and recurrent laryngeal nerves
(from the superior laryngeal nerve and vagus respectively)
Lymph vessels of the pharynx end in the following nodes:

 Upper deep cervical nodes (these drain the nasopharynx)
 Retropharyngeal nodes, located in the retropharyngeal space
 Lower deep cervical nodes
Applied Anatomy

 in children (adenoiditis) would result in hypertrophy Inflammation of the
pharyngeal tonsil and obstruction of the upper airway. Thus, breathing occurs
through the mouth
 Hypertrophy of the palatine tonsil also occurs when this organ is inflamed
(tonsillitis). In tonsillitis, the jugulodigastric nodes become enlarged
835
 The palatine tonsil and its fascia can be surgically removed during tonsillectomy.
During this operation, the glossopharyngeal nerve and internal carotid artery are
especially at risk owing to their proximity to the lateral wall of the pharynx
 Otitis media may occur from infections of the nasopharynx. Similarly, the
auditory tube may be blocked as a result of such infections (and hearing
impairment may arise)
 Pharyngoscope is used for the examination of the interior of the pharynx
 When removing a foreign body from the piriform recess, the internal laryngeal
nerve is especially at risk (as it lies just deep to the mucosa of this recess) [see
above]
Respiratory Layer of the Neck
This layer consists of the

 Trachea, and
 Larynx
Trachea (see page 109, 149)
Larynx
The larynx
 Serves as a conduit for air, a phonating organ, and a sphincter device
 Extends from the tongue above to the trachea below (or from C3–C6 vertebrae)
 Communicates above with the laryngopharynx (the anterior wall of which it
forms), and below with the trachea (at the level of C6)
 Is relatively higher in position in children and adult females
 Is remarkably large in adult males
 Measures 44 mm in length, 43 mm in transverse diameter and 36 mm in
anteroposterior diameter (in an average male)
 Consists of cartilages, muscles, ligaments and membranes. It is also lined
internally by a mucous membrane
Relations of the Larynx
The larynx is related to the following:

 Behind: laryngopharynx, retropharyngeal space and C3–C6 vertebrae (Fig. 160)
 Laterally: thyroid gland
 Anterolaterally: infrahyoid muscles, and
 Posterolaterally: carotid sheath
Skeleton of the Larynx
The laryngeal skeleton consists of:
836
 Nine cartilages (made up of three paired and three unpaired cartilages) (Fig.
161). These cartilages are united by ligaments, membranes and muscles.
The unpaired laryngeal cartilages include:

 Thyroid cartilage
 Cricoid cartilage, and
 Epiglottic cartilage
The paired laryngeal cartilages include:

 Arytenoid cartilages
 Corniculate cartilages, and
 Cuneiform cartilage
Figure 161. Laryngeal cartilages. A, Posterior view; B, Anterior view.
Thyroid Cartilage
Regarding the thyroid cartilage, note the following facts:

 It is the largest of the laryngeal cartilages (Fig. 161)
 It is made up of two plate-like laminae, which diverge posteriorly. Anteriorly,
the thyroid laminae meet in the midline at an angle of about 90 0 in males and
1200 in females. This anterior median meeting point of the laminae is the
laryngeal promine nce
 Above the laryngeal prominence, the thyroid cartilage presents a median V-
shaped depression termed the thyroid notch (or superior thyroid notch)
 In men, the thyroid notch and laryngeal prominence can be readily felt
837
 Projecting upwards and downwards from the posterior border of each lamina are
the superior and inferior horns respectively
 The superior horn of the thyroid cartilage is longer than the inferior horn. The
latter bends inferomedially to articulate with the lateral surface of the cricoid
cartilage at the synovial cricothyroid joint
 The lateral surface of each thyroid lamina has an oblique line (located closer to
the posterior border than the laryngeal prominence)
 At the upper and lower ends of the oblique line (on the external aspect of thyroid
lamina) are elevations referred to as superior and inferior tubercles respectively
 Attached to the oblique line are sternothyroid, thyrohyoid, inferior pharyngeal
constrictor (thyropharyngeus) and pretracheal fascia
 The inner aspect of thyroid lamina is smooth, and is lined by mucous membrane
in its upper part
 In the upper part of the angle between the thyroid laminae (internally), the thyroid
cartilage gives attachment to the thyro-epiglottic ligament
 Below the attachment of the thyro-epiglottic ligament, adjacent to the midline,
the thyroid cartilage gives attachment to the vestibular and vocal ligaments
 The superior border of each thyroid lamina gives attachment to thyrohyoid
membrane (which connects this cartilage to the hyoid bone)
 The inferior border of the thyroid lamina is connected (anteriorly in the midline)
to the cricoid cartilage by the anterior cricothyroid ligament
 The thyroid cartage is hyaline in type. It begins to ossify at about the 25th year of
life in man
Cricoid Cartilage
The cricoid cartilage

 Is thicker and stronger than the thyroid cartilage (though of a smaller size) (Fig.
161)
 Has the shape of a signet ring
 Is located below the thyroid cartilage. The cricoid cartilage forms the lower parts
of the anterior and lateral walls and much of the posterior wall of the larynx
 Consists of a posterior quadrate lamina and an anterior arch
 Is smooth and lined by the mucosa internally
 Can be readily felt in front of the neck, just below the thyroid cartilage
 Is also hyaline in type, with a tendency to ossify with advancing age
Regarding the cricoid cartilage, also note that

 Its lower border is at the level of C6
 Its lamina is about 2.5 cm vertically
 On the posterior aspect of its lamina is a median vertical ridge (to which the
longitudinal fasciculi of the oesophagus are attached)
838
 At the junction of the lamina and arch of the cricoid cartilage, on each side, is a
facet for the inferior horn of the thyroid cartilage. The articulation formed is the
cricothyroid joint
 The inferior border of the cricoid cartilage gives attachment to the cricotracheal
ligament, while the superior border gives attachment to cricothyroid ligament
 The upper outer angle of cricoid lamina bears a facet for articulation with the
base of the arytenoid cartilage
Epiglottic Cartilage
The epiglottic cartilage

 Is a thin foliate plate of yellow elastic fibrocartilage (Fig. 161)
 Is covered on both surfaces by mucosa to form the epiglottis
 Is directed upwards behind the thyrohyoid membrane, hyoid bone and tongue,
from its thyroid attachment
 Has a free broad superior end and a narrow inferior end (the stalk). The latter is
connected to the thyroid cartilage, just below the thyroid notch, by the thyro-
epiglottic ligament
 Possesses an anterior and a posterior surface. The former is directed towards the
tongue while the latter faces the pharynx
 Bears minute pits on its posterior surface; these pits lodge small mucous glands.
The posterior surface is also perforated by branches of the internal laryngeal
nerves
With respect to the epiglottic cartilage, also note that

 The upper part of its anterior surface is covered by a mucosa whose epithelium is
non-keratinized stratified squamous in type
 From the anterior surface of the epiglottis, the mucosa is reflected onto the
tongue to form a median glosso-epiglottic fold, on each side of which is a
lateral glosso-epiglottic fold
 Just lateral to the median glosso-epiglottic fold is a depression termed the
vallecula
 Lower down, the anterior aspect of the epiglottic cartilage is separated from the
thyrohyoid membrane by fatty tissue. A hyo-epiglottic ligament connects this
surface to the hyoid
 The concave posterior surface of the epiglottic cartilage is lined by a mucous
membrane whose epithelium is ciliated pseudostratified columnar in type
 On the lower part of its posterior surface, the epiglottic cartilage present a
median tubercle
 Each side of the epiglottis is connected to the arytenoid cartilage by the
aryepiglottic fold
Importance of the Epiglottis
839
Note that
 During swallowing, food bolus passes over the anterior surface of the epiglottis to
the pharynx (as the epiglottis closes the laryngeal inlet). However
 The epiglottis is not essential for swallowing, speech or respiration. Swallowing
could still proceed even when this organ is damaged
Paired Laryngeal Cartilages
Paired laryngeal cartilages include:

 Arytenoid cartilage
 Corniculate cartilage
 Cuneiform cartilage
Arytenoid Cartilage
Each arytenoid cartilage

 Resembles a three-sided pyramid with its base directed downwards. It is located
on the superolateral aspect of the lamina of cricoid cartilage (Fig. 161)
 Has three surfaces, two processes (vocal and muscular), a base and an apex
 Is connected to the side of the epiglottis by an aryepiglottic fold
 Is hyaline in type, except at its apex where it is made of elastic fibrocartilage
Regarding the arytenoid cartilage, note the following:

 It has three surfaces: anterolateral, posterior and medial surfaces
 Its posterior surface forms part of the anterior wall of the laryngopharynx. This
surface is covered by the transverse arytenoid muscle
 The medial surface is lined by mucosa
 Its base articulates with the lamina of cricoid cartilage
 Its muscular process projects posterolaterally from the base; it gives attachment
to laryngeal muscles
 The vocal process projects anteriorly from the base; it gives attachment to the
vocal ligament
 Its apex is directed upwards (with its tip pointing posteromedially). It articulates
with a small corniculate cartilage
Corniculate Cartilage
Each corniculate cartilage

 Is a small conical piece of elastic fibrocartilage located in the posterior end of the
aryepiglottic fold
 Articulates with the apex of the arytenoid cartilage (thereby prolonging this
posteromedially)
 May fuse with arytenoid cartilage
840
Cuneiform Cartilage
Each cuneiform cartilage

 Is a club-like nodule of elastic fibrocartilage located in the aryepiglottic fold
(anterior to the corniculate cartilage)
 Appears as a whitish nodule through the aryepiglottic fold
Laryngeal Ligaments and Membranes
Ligaments and membranes of the larynx are classified as

 Extrinsic, and
 Intrinsic
Extrinsic laryngeal ligaments and membranes include:

 Thyrohyoid membrane
 Hyo-epiglottic ligament, and
 Cricotracheal ligament
Regarding thyrohyoid membrane, note that

 It is a sheet of fibro-elastic tissue that extends from the upper border and superior
horns of the thyroid cartilage below, to the upper border of the body and greater
horns of the hyoid above. It ascends deep to hyoid bone
 Its median part is thickened as the median thyrohyoid ligament
 Each of its posterior borders is also thickened as the lateral thyrohyoid
ligament; the latter usually contains a cartilago triticea
 On each side, the membrane is pierced by the internal laryngeal nerve and
superior laryngeal vessels
 It is separated from the epiglottis by fatty tissue, and it forms the lateral boundary
of the piriform recess of the laryngopharynx
Regarding intrinsic laryngeal ligaments, note the following points:

 The intrinsic ligaments of the larynx altogether constitute a fibro-elastic
membrane which is discontinuous at the interval between the vestibular and
vocal ligaments
 The fibro-elastic membrane has numerous elastic fibres; it lies between the
laryngeal mucosa internally and the intrinsic laryngeal muscles externally
 The upper part of the fibro-elastic membrane is the thin quadrangular
membrane; this extends from the aryepiglottic fold above to the vestibular fold
below, and from the epiglottis anteriorly to the arytenoid cartilage posteriorly
 The lower border of the quadrangular membrane is thickened to form the
vestibular ligament; the latter is covered by mucosa to form the vestibular fold
 The lower part of the fibro-elastic membrane is thicker; it forms the conus
elasticus
841
 Below, the conus elasticus is attached to the upper border of cricoid arch; from
this lower attachment, the conus passes upwards and medially, to the vocal folds
 The free upper margin of the conus elasticus is thickened as the vocal ligament
(deep to the vocal fold); this ligament stretches from the thyroid angle anteriorly
(adjacent to the midline), to the vocal process of the arytenoid cartilage
posteriorly
Laryngeal Cavity
The cavity of the larynx

 Extends from the laryngeal inlet above to the lower border of the cricoid cartilage
below (Fig. 163). Beyond the latter, it continues as the trachea
 Is divided by the paired vestibular and vocal folds into three parts. These include
the vestibule, middle part and infraglottic part
The laryngeal inlet is bounded by the following:

 Anteriorly: upper border of the epiglottis (Fig. 162)
 Posteriorly: mucosa over the arytenoid cartilages; and
 Laterally (on each side): margin of the aryepiglottic fold (Fig. 162)
Note: The laryngeal inlet is directed backwards and slightly upwards; it links the
larynx and pharynx.
842
Figure 162. Laryngeal inlet.
Vestibule of the Larynx
The laryngeal vestibule

 Extends from the laryngeal inlet above to the vestibular folds below; it narrows
from above downwards (Fig. 163)
 Is bounded anteriorly by the posterior surface of the epiglottis, behind by the
mucosa over the arytenoid cartilages (above the level of attachment of the
vestibular folds) and on each side by the aryepiglottic fold
Figure 163. Interior of the larynx.
Middle Part of Laryngeal Cavity
Regarding the middle part of laryngeal cavity, note that
843
 It extends from the vestibular folds above to the vocal folds below (Fig. 163); it is
the smallest division of the laryngeal cavity
 On each side, this part of the larynx extends laterally (between the vestibular and
vocal folds) as the laryngeal ventricle (laryngeal sinus); this ventricle extends
upwards, lateral to the vestibular fold
 Anteriorly, the laryngeal ventricle is continuous with a laryngeal saccule; this
pouch passes anterosuperiorly between the thyroid cartilage and vestibular fold
(and may reach the upper border of the thyroid cartilage)
 The submucosa of laryngeal saccule contains numerous mucous glands, the
secretion of which lubricates the vocal folds
Infraglottic Part of Laryngeal Cavity
The infraglottic part of laryngeal cavity

 Extends from the vocal folds above to the lower border of the cricoid cartilage
below (Fig. 163)
 Widens from above downwards and is continuous below with the trachea
 Has a lining of laryngeal mucosa
Vestibular Folds (False Vocal Folds)
Each vestibular fold

 Is a thick pinkish fold of mucosa deep to which is the vestibular ligament (the
thick lower margin of quadrangular membrane) (Fig. 163)
 Lies above the vocal fold, from which it is separated by the laryngeal ventricle
 Extends from the thyroid angle anteriorly (below the attachment of the thyro-
epiglottic ligament) to the anterolateral surface of the arytenoid cartilage
posteriorly (above the vocal process)
 Forms the lateral boundary of the rima vestibuli – the interval between the two
vestibular folds
 Is lined by ciliated pseudostratified columnar epithelium
 Plays little or no role in phonation
Vocal Folds (True Vocal Folds)
The vocal fold

 Is located below the vestibular fold (Fig. 163). It is a fold of mucosa, deep to
which are the vocal ligament and vocalis muscle
 Extends from the thyroid angle anteriorly (below the attachment of the vestibular
ligament), to the vocal process of the arytenoid cartilage behind
 Appears pearly white, owing to the absence of a submucosa and blood vessels
 Has a lining of non-keratinized stratified squamous epithelium (that is firmly
bound to the underlying vocal ligament)
844
 Forms the anterolateral boundary of the rima glottidis (glottis) – the interval
between the vocal folds
 Plays essential roles in phonation
Note: The vocal ligament is the thick upper margin of the conus elasticus. It extends
from the mid-level of the thyroid angle anteriorly, to the vocal process of the
arytenoid cartilage posteriorly.
Rima Glottidis (Glottis)
The rima glottidis

 Is the adjustable narrow interval between the vocal folds (Fig. 162); it includes
the interval between the arytenoid cartilages behind. Thus, it consists of two
parts: an anterior intermembranous part between the vocal folds (this forms the
anterior ⅗ of the glottis), and a posterior intercartilaginous part between the
arytenoid cartilages (this forms the posterior ⅖ of the glottis)
 Has an average anteroposterior diameter of 23 mm in adult males and 17 mm in
females
 Varies in width during speech and respiration; it is the narrowest part of the
larynx
Muscles of the Larynx
These can be divided into

 Extrinsic muscles, and
 Intrinsic muscles
Extrinsic Laryngeal Muscles
The extrinsic muscles of the larynx

 Attach the larynx to adjacent structures
 Are responsible for changing the position of the larynx
 Include the suprahyoid and infrahyoid muscles (see above)
Intrinsic Laryngeal Muscles
These muscles
 Are confined to the larynx
 Are responsible for altering 1. The tension and length of the vocal folds, and 2.
The size of the rima glottidis
 Are all innervated by the recurrent laryngeal nerves, except cricothyroids,
which are supplied by the external laryngeal nerves
845
Intrinsic laryngeal muscles include:

 Cricothyroid, which tenses and stretches the vocal folds (Fig. 143)
 Posterior crico-arytenoid, which abducts the vocal fold
 Lateral crico-arytenoid, which adducts the vocal fold
 Transverse arytenoid, which closes the (intercartilaginous part of) rima glottidis
 Oblique arytenoid, which adducts the aryepiglottic fold, thereby acting as a
sphincter for the laryngeal inlet
 Aryepiglottic muscle (derived from fibres of oblique arytenoid that extend into
the aryepiglottic fold). It also serves as a sphincter of the laryngeal inlet (by
adducting the aryepiglottic fold and approximating the arytenoid cartilage to the
epiglottis)
 Thyroarytenoid, which relaxes the vocal fold
 Thyroepiglottic muscle (derived from fibres of thyroarytenoid that extend into the
aryepiglottic fold and epiglottis). It widens the laryngeal inlet
 Vocalis, which relaxes the posterior part of the vocal fold, but tenses the anterior
part of this fold
On the basis of their action, intrinsic laryngeal muscles may be grouped as

 Muscles that alter the size of the rima glottidis; these include posterior and lateral
crico-arytenoids and transverse arytenoid
 Muscles that serve as sphincters of the laryngeal inlet; these include oblique
arytenoid, thyroepiglotticus and aryepiglotticus
 Muscles that alter the tension of the vocal fold; these include cricothyroid,
thyroarytenoid, posterior crico-arytenoid and vocalis
Motor Innervation of the Larynx

 Motor fibres to all intrinsic laryngeal muscles (except cricothyroid) are derives
from the recurrent laryngeal nerve (a branch of vagus)
 Cricothyroid receives motor fibres from the external laryngeal nerve, a branch
of the superior laryngeal nerve. These fibres enter the muscle through its external
surface
Sensory Innervation of the Larynx

 Sensory and autonomic fibres to the part of the laryngeal mucosa above the
level of vocal folds (including the upper surfaces of these folds and both surfaces
of the epiglottis) are derived from the internal laryngeal nerves
 Internal laryngeal nerves are branches of the superior laryngeal nerves; they
enter the larynx by piercing the thyrohyoid membrane
846
 Sensory and autonomic fibres to the part of the laryngeal mucosa below the
level of the vocal folds (including the inferior aspects of these folds) are derived
from the recurrent laryngeal nerves
 Recurrent laryngeal nerves are branches of the vagus nerves; the right one
arises at the root of the neck (and winds round the right subclavian artery), while
the left arises in the superior mediastinum (and winds round the aortic arch)
 As the recurrent laryngeal nerves ascend to the larynx in (or just anterior to) the
tracheo-esophageal grooves, they pass deep (medial) to the inferior borders of
inferior pharyngeal constrictors (with the inferior laryngeal arteries), just behind
the cricothyroid joints
Blood Supply to the Larynx
The larynx receives arterial blood from:

 The superior laryngeal artery; this branch of the superior thyroid artery
accompanies the internal laryngeal nerve, with which it pierces the thyrohyoid
membrane, to enter the larynx
 The inferior laryngeal artery; this branch of the inferior thyroid artery
accompanies the terminal part of the recurrent laryngeal nerve, with which it
ascends into the larynx, medial to the inferior border of inferior pharyngeal
constrictor
 The cricothyroid artery; this branch of the superior thyroid artery supplies
cricothyroid muscle
Venous blood from the larynx is drained by:

 The superior laryngeal vein, which accompanies the superior laryngeal artery; it
ends in the superior thyroid vein
 The inferior laryngeal vein, which accompanies the inferior laryngeal artery; it
ends either in the thyroid venous plexus or in the inferior thyroid vein
Regarding the lymphatic drainage of the larynx, note that

 Superior and inferior groups of lymph vessels exist
 The superior group of lymph vessels drain the part of the larynx above the vocal
folds; these vessels accompany the superior laryngeal vessels through the
thyrohyoid membrane, and end in the superior deep cervical nodes
 The inferior group of lymph vessels drain the part of the larynx below the vocal
folds; these vessels either pass between the cricoid cartilage and the 1st tracheal
ring to end in the inferior deep cervical nodes, or pierce the conus elasticus to
join the pretracheal and prelaryngeal nodes
Applied Anatomy
847

 The thyroid, cricoid and (much of the) arytenoid cartilages are considerably
ossified by age 65, such that they become observable in radiographs. Ossification
commences in the thyroid cartilage usually by the 25th year
 In superior laryngeal nerve block, the needle is inserted into the thyrohyoid
membrane midway between the hyoid bone and thyroid cartilage. This procedure
anaesthetizes the laryngeal mucosa above the vocal folds
 Injury to the recurrent laryngeal nerves would adversely affect phonation as the
vocal folds become paralyzed
 Injury to the external laryngeal nerves (that innervate cricothyroids) would result
in monotony of the voice (as the tension of the vocal folds cannot be varied to
adjust pitch)
 Enlargement of the pretracheal and prelaryngeal nodes may suggest carcinoma
of the larynx. In this condition, the voice becomes hoarse (and otalgia and
dysphagia may also develop)
 Incidence of laryngeal carcinoma is higher in individuals who smoke cigarettes
and chew tobacco; in severe cases, laryngectomy (surgical removal of the
larynx) may be performed
 The larynx could be examined with the aid of a laryngeal mirror (indirect
laryngoscopy). Direct laryngoscopy is done with the aid of a laryngoscope
 Entry of objects into the laryngeal vestibule elicits reflex coughing (in an attempt
to expel the object)
 In laryngeal obstruction, chocking may occur, followed by death within 5
minutes. In an attempt to dislodge the object, Heimlich manoeuver may be
performed (by upward subdiaphragmatic abdominal thrusts). However,
 In certain instances, surgical cricothyrotomy (or needle cricothyrotomy) may be
performed to create an opening through which a tracheostomy tube can be
inserted. This bypasses the laryngeal obstruction and allows passage of air into
(and from) the lungs
 Surgical cricothyrotomy is done by incising the skin and the cricothyroid
ligament (below the cricoid cartilage) to access the airway
CHAPTER 22: CRANIAL NERVES

Cranial Nerves
The cranial nerves

 Are 12 pairs of nerves that are attached to the brain (Fig. 164). In contrast, 31
pairs of spinal nerves are associated with the spinal cord
 Are surrounded by variable extension of the meninges as they emerge from the
brain
848
 Are either motor (to muscles and glands), sensory (conveying impulses from
peripheral receptors) or mixed (containing both motor and sensory fibres).
Cranial nerves include paired

 Olfactory nerves
 Optic nerves
 Oculomotor nerves
 Trochlear nerves
 Trigeminal nerves
 Abducent nerves
 Facial nerves
 Vestibulocochlear nerves
 Glossopharyngeal nerves
 Vagus nerves
 Accessory nerves, and
 Hypoglossal nerves
Olfactory Nerves (Cranial Nerve I)

 Olfactory nerves (for olfaction) are formed by the central processes of the
bipolar neurons of the olfactory epithelium of the nasal cavity. They are about 20
bundles; these nerves traverse the cribriform plate of ethmoid, and terminate in
the glomeruli of the olfactory bulb
 Fibres of the olfactory nerves are non-myelinated; they are fine axons ensheathed
by Schwann cells
 General anosmia or hyposmia, can arise from respiratory infections, and are
usually transient. Chronic anosmia or hyposmia can result from damage to the
olfactory epithelium caused by infections; from head injuries that sever the
olfactory nerves traversing the foramina of ethmoidal cribriform plate, which
then become blocked by scar tissue; or from particular diseases, such as
Parkinson disease
 Olfactory hallucinations of foul smells – cacosmia – can occur as a
consequence of epileptic seizures
 Associated with the olfactory nerves are two small nervi terminales
 (See the olfactory pathway for more details)
849
Figure 164. Cranial nerves.
Optic Nerve (Cranial Nerve II)
Note that
 The optic nerve mediates visual modality (Fig. 164)
 Most fibres of the optic nerve are afferent; they are axons of the ganglion cells of
the retina. Some fibres of the optic nerve are however efferent (of unknown
origin)
 Developmentally, the optic nerves and retinae are outgrowths of the brain; their
fibres are thus ensheathed by oligodendroglia, not Schwann cells
 In the retina, fibres of the optic nerve form the stratum opticum. These fibres
converge on the optic disc and pierce the choroid and lamina cribrosa of the
sclera to exit the eye
 As fibres of the optic nerve traverse the lamina cribrosa, they acquire myelin
sheath and form fascicles which (altogether constitute the optic nerve). The nerve
is about 4 cm in length
 In the orbit, the optic nerve is surrounded by four recti, from which it is separated
by orbital fat. Between the optic nerve and lateral rectus is the ciliary ganglion
 About 12 mm behind the eyeball, the optic nerve is pierced on its inferomedial
aspect by the central retinal vessels; these traverse the centre of the nerve to reach
the optic disc
 The optic nerve traverses the optic canal (from the orbit) to enter the cranial
cavity where it joins the optic chiasma. In the optic canal, the optic nerve lies
superomedial to ophthalmic artery
850
 The intracranial part of the optic nerve (about 10 mm) passes posteromedially
from the optic canal to the optic chiasma (where some of its fibres decussate)
 The optic nerve is invested by the meninges; the outer dural sheath is thick and
fibrous and it blends with the sclera, while the arachnoid layer is thin and is
separated from the dura by the subdural space, and from the pia by the
subarachnoid space
 The innermost (pial) covering of the optic nerve, like that of the brain, is vascular
and intimately associated with the nerve. It also invests the central retinal vessels,
as far as the optic disc
 Each optic nerve has about 1.2 million fibres. About 53% of these decussate
(cross to the opposite side) in the optic chiasma. Most of these fibres terminate
in the lateral geniculate body; while some reach the pretectal nucleus, superior
colliculus and hypothalamic nuclei
 The optic nerve receives arterial blood from the plexus in its pial sheath and by
direct intramural vessels
 Venous drainage of the optic verve is by the central retinal vein
 Injury to the optic nerve or retina would result in total blindness
 The optic nerve is also susceptible to neuritis (optic neuritis) or atrophy in
certain demyelinating conditions of the central nervous system (e.g., multiple
sclerosis)
 Papilloedema is characterized by the swelling of the optic disc as a
consequence of oedema (resulting from increased CSF pressure, etc).
Optic Chiasma
Regarding the optic chiasma, note the following:

 It is a flat, roughly quadrangular mass of decussating (optic) nerve fibres, located
in the anterior wall and floor of the 3rd ventricle
 Its anterolateral angles are continuous with the optic nerves, while its
posterolateral angles are continuous with the optic tracts
 It is related above to the lamina terminalis and the optic recess of the 3rd ventricle,
and below to the diaphragma sellae
 Posteriorly, the optic chiasma is related to the tuber cinereum, infundibulum and
3rd ventricle, and laterally to the terminal part of the internal carotid artery and the
anterior perforated substance
 Most chiasmatic fibres commence in the retina and arrive via the optic nerves
 Nerve fibres from the nasal half of each retina cross in the chiasma to the
contralateral optic tract while fibres from the temporal half of the retina
continue through the chiasma into the ipsilateral optic tract
 Macular fibres occupy about 2/3 of the central part of the chiasma
 Myelinated fibres of human optic tracts terminate in the lateral geniculate body,
superior colliculus, and pretectal nucleus
851
 The suprachiasmatic and ventral part of the infundibular nuclei also receive
fibres from the optic tract (as retinohypothalamic projection). This is essential for
the control of circadian rhythm, etc
 The optic chiasma receives blood from the pial plexus and drains into the basal
and anterior cerebral veins

 Bitemporal heteronymous hemianopsia could arise from injury to the decussating
fibres in the central part of the optic chiasma
 Binasal heteronymous hemianopsia could arise from injury to (or compression of)
the lateral angles of the optic chiasma
Optic Tract
Note that
 The optic tract is the bundle of nerve fibres that passes dorsolaterally from the
optic chiasma. It passes between the anterior perforated substance and tuber
cinereum to reach the lateral geniculate body, where it divides into medial and
lateral rami
 The medial ramus of the optic tract is believed to contain supraoptic commissural
fibres, while the lateral ramus contains retinal fibres and a few efferent fibres
(which terminate in the retina)
 Most fibres of the lateral ramus of the optic tract terminate in the lateral
geniculate body. However some reach the superior colliculus and pretectal nuclei
(via the brachium of the superior colliculus)
 Contralateral homonymous hemianopsia would result from injury to the optic
tract and lateral geniculate body
Oculomotor Nerve (Cranial Nerve III)
Note the following:

 The oculomotor nerve innervates all extraocular muscles except the lateral rectus
and superior oblique (Fig. 164, 65); it contains about 24, 000 fibres
 Via the ciliary ganglion and ciliary nerves, the oculomotor nerve also supplies the
sphincter pupillae and ciliary muscle
 Fibres of the oculomotor nerve arise from a complex of nuclei located in the
ventral part of the central grey substance of the midbrain at the level of the
superior colliculus. Located rostral to the main nucleus is the Edinger-Wesphal
nucleus (accessory oculomotor nucleus); this is the source of the preganglionic
parasympathetic fibres to the ciliary ganglion)
852
Course of the Oculomotor Nerve
Regarding its course, the oculomotor nerve

 Emerges from the ventral aspect of the midbrain, and passes forwards in the
interpeduncular fossa (subarachnoid space) where it is covered by pia mater. It
then
 Continues forwards between the posterior cerebral and superior cerebellar
arteries. Thereafter, it traverses (continues forwards in) the lateral wall of the
cavernous sinus, where it lies above the trochlear nerve
 Divides into superior and inferior rami (behind the superior orbital fissure) (Fig.
165). These divisions then traverse the superior orbital fissure within the common
tendinous ring (with the nasociliary nerve between them) to enter the orbit
Figure 165. Oculomotor nerve and its distribution.
Distribution of the Oculomotor Nerve
Note that
 The smaller superior ramus of the oculomotor nerve innervates superior rectus
and levator palpebrae superioris
 The inferior ramus of the oculomotor nerve innervates inferior rectus, inferior
oblique, and medial rectus. The ciliary ganglion also receives a branch from this
ramus; this branch contains preganglionic parasympathetic fibres from the
accessory oculomotor nucleus
853
Applied Anatomy of the Oculomotor Nerve
Lesion in the oculomotor nerve would produce:

 Ptosis, due to paralysis of levator palpebrae superioris
 Lateral strabismus, owing to the unopposed action of lateral rectus and superior
oblique
 Pupillary dilatation, owing to the paralysis of pupillary sphincter
 Loss of accommodation and pupillary light reflex, owing to paralysis of the
ciliary muscle and sphincter pupillae respectively, and
 Proptosis (prominence of the eyeball) due to muscular relaxation. Irritation of
this nerve would produce spasm of the muscles supplied by it
Trochlear Nerve (Cranial Nerve IV)
Note the following:

 Trochlear nerve is the smallest cranial nerve. It innervates only one muscle
(superior oblique) (Fig. 164)
 About 3400 fibres are contained in each adult trochlear nerve; the number is
however greater in foetus
 The trochlear nucleus is located in the lower part of the central grey substance
of the midbrain, at the level of the inferior colliculus (immediately caudal to the
oculomotor nucleus)
Course of the Trochlear Nerve
Regarding the course of the trochlear nerve, note the following:

 From its nucleus, fibres of the trochlear nerve pass backwards, lateral to the
central grey substance, towards the dorsal aspect of the midbrain. These fibres
decussate in the superior medullary velum, and then emerge on the dorsal aspect
of the midbrain, below the inferior colliculus (lateral to the frenulum veli). It is
the only cranial nerve that emerges on the dorsal aspect of the brainstem
 The nerve then passes forwards on the lateral aspect of the cerebral peduncle, just
above the pons and between the posterior cerebral and superior cerebellar
arteries. Thereafter,
 It pierces the arachnoid and dura mater to traverse the lateral wall of the
cavernous sinus (below the oculomotor and above the ophthalmic nerves). Then,
 It enters the orbit via the superior orbital fissure, above the tendinous ring (and
medial to the frontal nerve)
 In the orbit, the trochlear nerve passes medially, above the levator palpebrae
superioris, to innervate the superior oblique via the orbital aspect of this muscle
(the only muscle it supplies)
854
Applied Anatomy of the Trochlear Nerve
Note that
 Injury to the trochlear nerve would paralyze superior oblique; this abolishes
inferolateral ocular movement. In this instance,
 The affected eye is turned upward and outward, with vertical diplopia when
attempting to look downwards (as in descending a stair or reading)
 Diplopia is reduced when the head is tilted to the unaffected side
Trigeminal Nerve (Cranial Nerve V)
The trigeminal nerve

 Is the largest cranial nerve (Fig. 164). It is a mixed type of nerve, containing
sensory and motor fibres
 Emerges from the brainstem at the junction of the pons and the middle cerebellar
peduncle, as a large sensory and a small motor root; the motor root lies medial to
the sensory root
 Gives sensory fibres to the face, greater part of the scalp, teeth, and the oral and
nasal cavities. It also gives motor fibres to the muscles of mastication, tensor veli
palatini and tensor tympani
 Also conveys proprioceptive fibres from the masticatory and probably
extraocular muscles
 Has three divisions: ophthalmic, maxillary and mandibular
Nuclei and Course of the Trigeminal Nerve
Regarding the trigeminal nerve, note the following:

 From the anterior surface of the pons, the trigeminal nerve passes forwards,
below the superior petrosal sinus. Here, it carries with it a dural pouch derived
from meningeal layer of the dura (near the apex of the petrous temporal bone)
 In the middle cranial fossa, the larger sensory root ends in the trigeminal ganglion
 The trigeminal ganglion is crescentic in shape. It lies in a pouch of dura called
the trigeminal cave, in the middle cranial fossa (at a depth of 4.5–5 cm from the
lateral surface of the head)
 The motor root of the trigeminal nerve lies beneath the trigeminal ganglion as it
passes towards the foramen ovale
 The trigeminal nerve has four nuclei (one of which is motor and three are
sensory). They include the principal sensory (or pontotrigeminal), spinal,
mesencephalic and motor nuclei
 On entering the pons, fibres of the sensory root pass dorsomedially towards the
principal sensory nucleus; this nucleus is located in the upper part of the pontine
tegmentum
 However, before reaching the nucleus, about 50% of the fibres of the sensory root
divide into ascending and descending branches
855
 The descending fibres, predominantly finely myelinated or non-myelinated, form

the spinal tract of trigeminal nerve. As they descend, these fibres give off
collateral and terminal branches which synapse on neurons of the spinal nucleus
of trigeminal nerve
 The spinal nucleus of trigeminal nerve is continuous below with the substantia
gelatinosa of the spinal cord; it contains neurons of intermediate sizes
 Fibres which synapse in the spinal nucleus of trigeminal nerve are concerned
mainly with the mediation of pain and thermal modalities
 In the spinal tract of trigeminal nerve, the ophthalmic fibres are ventrally-placed.
These fibres reach as far down as the level of C1
 Maxillary fibres occupy an intermediate position in the spinal tract of trigeminal
nerve; they do not descend beyond the medulla, while
 The mandibular fibres are dorsally-placed in the spinal tract of trigeminal nerve.
They do not extend much below the mid-medullary level
 Some ascending trigeminal fibres (many of which are heavily myelinated)
terminate in the principal sensory neurons
 Other ascending fibres enter the mesencephalic nucleus; the latter is peculiar in
that it contains somata of unipolar (1st order) neurons
 The mesencephalic nucleus is located in the upper pontine tegmentum and
midbrain (where it lies lateral to the periaqueductal grey). It is responsible for the
mediation of proprioceptive modalities from the muscles innervated by the 3rd,
4th, 5th, 6th and 7th cranial nerves

 Fibres that arise from the sensory nuclei of the trigeminal nerve decussate, and
then ascend in the contralateral trigeminal lemniscus, to the thalamic nucleus
ventralis posterior medialis. Some fibres however terminate in ipsilateral
thalamic nucleus
 Nerve fibres which ascend to mesencephalic nucleus may give collaterals to the
motor nucleus of trigeminal nerve
 The motor nucleus of trigeminal nerve is ovoid in outline; it contains
characteristic large multipolar cells interspersed with small ones, and is located in
the upper part of the pontine tegmentum, medial to the principal sensory nucleus
 The motor nucleus of trigeminal nerve also contains relatively discrete sub-
nuclei, whose axons innervate individual muscles
Concerning the connections of the motor nucleus of trigeminal nerve, note that
 This nucleus receives fibres from both corticonuclear tracts
 It also receives afferents from the sensory nuclei of the trigeminal nerve, reticular
formation, red nucleus, tectum, medial longitudinal fasciculus, and possibly, the
locus coeruleus
Note: For the description of the ophthalmic, maxillary and mandibular nerves, see
above.
856
Abducent Nerve (CN VI)
Note that
 The abducent nerve is the VIth cranial nerve; it innervates the lateral rectus only
(Fig. 164)
 Fibres of the abducent nerve arise from the abducent nucleus, in the lower part
of the pontine tegmentum (deep to the facial colliculus). These fibres descend
ventrally through the pons, and emerge from the brainstem through the sulcus
between the lower pontine border and the upper end of the pyramid of the
medulla
 Abducent nucleus contains large and small multipolar neurons (about 22,000
neurons). The large multipolar neurons are the source of the fibres of this nerve
 The small multipolar neurons of abducent nucleus are collectively known as
nucleus para-abducens; the latter is connected with the oculomotor nucleus by
the medial longitudinal fasciculus
Abducent nucleus receives fibres from

 The corticonuclear tract (mainly the contralateral tract)
 Medial longitudinal fasciculus (MLF); this connects it with the nuclei of the 3rd,
4th and 8th cranial nerves
 Tectobulbar tract; this links the abducent nucleus with the visual cortex and other
centres, via the superior colliculus
Course of the Abducent Nerve
The abducent nerve

 Emerges from the brainstem (between the pons and the medullary pyramid), and
then ascends anterolaterally through the pontine cistern (dorsal to the anterior
inferior cerebellar artery)
 Pierces the dura mater lateral to the dorsum sellae, to traverse the cavernous sinus
at first lateral, and then inferolateral to the internal carotid artery. Then, it
 Enters the orbit via the medial end of the superior orbital fissure (within the
common tendinous ring). This nerve innervates the lateral rectus (the ocular
surface of which it pierces)
Applied Anatomy
Note that
 Fracture of the cranial base, etc, may injure the abducent nerve. This would result
in paralysis of the lateral rectus, and thus, convergent (medial) squint and
diplopia
857
Facial Nerve (7th Cranial Nerve)
The facial nerve

 Is a mixed nerve which consists of motor and sensory fibres (Fig. 164). Thus, it
has a motor and a sensory root; the latter is referred to as the nervus intermedius
 Is the nerve of the 2nd branchial arch; it thus innervates all the muscles derived
from this arch (i.e. the muscles of facial expression)
 Has a complex course through the pons and facial canal (of the skull)
 Has a ganglion – the genicular ganglion – located at the point where this nerve
turns backwards, in the facial canal (above the promontory of the middle ear)
 Communicates with the vestibulocochlear, glossopharyngeal and vagus nerves
(including the auricular branch of the latter)
Fibres contained in the facial nerve include:

 Motor fibres to facial muscles, scalp muscles, auricular muscles, buccinator,
stylohyoid, digastric (posterior belly), platysma and stapedius
 Secretomotor fibres to the sublingual, submandibular and lacrimal glands, as
well as the glands of the palate and nasal cavity
 Special visceral afferent (taste) fibres from the anterior 2/3 (presulcal part) of
the tongue (except the vallate papillae) and soft palate
 General sensory fibres from the external ear
Nuclei associated with the facial nerve include:

 Motor nucleus, located in the lower pontine tegmentum (see the pons below);
this is the source of the motor fibres of this nerve
 Superior salivatory nucleus, located at the pontomedullary junction (see below);
it is the source of the (presynaptic) parasympathetic fibres of this nerve
 Upper part of the nucleus solitarius, located in the medulla (see below); it
receives the taste fibres conveyed by this nerve
 Spinal nucleus of trigeminal nerve, located in the lower pons, medulla and
upper part of the spinal cord; it receives the general sensory fibres conveyed by
the facial nerve (from the external ear)
Course of the Facial Nerve
Note: For the intrapontine course of this nerve, see the pons (below)
Regarding the course of facial nerve, note that this nerve

 Emerges from the brainstem as two roots (motor and sensory) through the lateral
part of the pontomedullary sulcus (medial to the vestibulocochlear nerve). The
sensory root is placed lateral to the motor root
 Passes anterolaterally, through the posterior cranial fossa, to the internal acoustic
meatus. In the fossa, the sensory root (nervus intermedius) lies between the
vestibulocochlear nerve behind, and the motor root of facial nerve in front
858
 Traverses the internal acoustic meatus, where it occupies a groove on the

anterosuperior aspect of the vestibulocochlear nerve. Then, it
 Enters the facial canal, where it first runs laterally (above the vestibule of the
bony labyrinth); it then bends sharply backwards, to continue posteriorly (above
the promontory of the middle ear), to the medial wall of the aditus to the mastoid
antrum (behind). The point at which the nerve turns sharply backwards is the
geniculum and the swelling presented here is the genicular ganglion. The nerve
then
 Continues downwards (in its canal) on the posterior wall of the tympanic cavity.
It emerges ultimately through the stylomastoid foramen (between the mastoid and
styloid processes). Then it
 Passes forwards to enter the parotid gland, where it lies superficial to the
retromandibular vein. It gives off its five terminal branches in this gland
Branches of the Facial Nerve
In the facial canal, the facial has the following branches:

 Greater petrosal nerve, which arises from the genicular ganglion; it joins the
deep petrosal nerve to form the nerve of the pterygoid canal. The greater
petrosal nerve contains presynaptic parasympathetic fibres to the pterygopalatine
ganglion and taste fibres from the palatal mucosa
 Nerve to stapedius; this arises as the facial nerve descends behind the middle
ear. It innervates stapedius
 Chorda tympani; this nerve arises from the facial nerve about 6 mm above the
stylomastoid foramen. It ultimately enters the infratemporal fossa where it joins
the lingual nerve at an acute angle; it conveys taste fibres from the anterior 2/3 of
the tongue (except the vallate papillae) and presynaptic parasympathetic fibres to
the submandibular ganglion (via the lingual nerve)
As it emerges from the stylomastoid foramen, the facial nerve gives these
branches:
 Posterior auricular nerve (see below)
 Nerves to stylohyoid and posterior belly of digastric
The posterior auricular nerve

 Arise from the facial nerve as this emerges from the stylomastoid foramen; it then
ascends between the mastoid process and the external acoustic meatus
 Divides into auricular and occipital branches
 Innervates auricularis posterior and the intrinsic auricular muscles of the cranial
aspect of the auricle, through its auricular branch
 Innervates the occipital belly of occipitofrontalis via its larger occipital branch
859
In the parotid gland, the facial nerve has five terminal branches, which radiate
to the face and neck; they include:
 Temporal branches
 Zygomatic branches
 Buccal branches
 Marginal mandibular branch, and
 Cervical branch; this descends to the neck deep to platysma, which it innervates
Blood Supply to the Facial Nerve
The facial nerve receives blood from branches of

 The anterior inferior cerebellar artery, in the cranial cavity
 The superficial branch of middle meningeal and stylomastoid branch of posterior
auricular arteries, in the facial canal, and
 The occipital, posterior auricular, stylomastoid, superficial temporal and
transverse facial arteries, in its extracranial part
Note: Veins of the facial nerve end in the accompanying veins of the stylomastoid
and superficial temporal arteries.
Applied Anatomy of the Facial Nerve
Regarding the facial nerve, note the following:

 Facial paralysis may arise from supranuclear, nuclear or infranuclear Lesions in
this nerve
 Supranuclear lesions of the facial nerve is part of hemiplegia; it thus involves the
upper motor neurons (corticonuclear fibres) which supply the facial nucleus
 In supranuclear lesions of the facial nerve, voluntary movement of the
contralateral lower part of the face is weak or absent. However, because the
upper part of the face is not affected in this type of lesion, movements such as
wrinkling of the forehead, etc, are not abolished
 Nuclear or infranuclear lesions of the facial nerve would produce paralysis of the
ipsilateral part of the face
 Nuclear lesions involve central injury to the motor nucleus of the facial nerve (in
the lower pons)
 Infranuclear Lesions in the facial nerve may occur in the cranial cavity, internal
acoustic meatus or along the extracranial course of the nerve
 Fracture which involves the internal acoustic meatus may damage the facial (and
vestibulocochlear) nerve; this would produce hyperacusia, paralysis of the
ipsilateral facial muscles, etc
 When the facial nerve is injured in the facial canal, the functional deficits
produced depend on the site of injury
 Lesion of the facial nerve (in its canal) proximal to the origin of the nerve to
stapedius would result in hyperacusia (in addition to ipsilateral facial palsy, etc)
860
 Injury to the facial nerve near the stylomastoid foramen would not paralyze
stapedius, neither would lacrimal secretion be adversely affected (as the nerve to
stapedius and the greater petrosal nerve are spared)
 Bell’s palsy arises from inflammation of the facial nerve near the stylomastoid
foramen; its cause is unknown
 The facial nerve is at risk during parotidectomy. When injured in this operation,
ipsilateral facial paralysis occurs
 When facial nerve injury is limited to its extracranial part, the secretory functions
of the submandibular, sublingual and lacrimal glands are not adversely affected,
neither is there any loss of taste sensation from the anterior 2/3 of the tongue and
palate. This is because the chorda tympani and greater petrosal nerves are spared
Vestibulocochlear Nerve (8th Cranial Nerve)
The vestibulocochlear nerve

 Is the 8th cranial nerve; it is purely sensory (Fig. 164)
 Consist of two parts: vestibular and cochlear parts
 Conveys impulses from the organs of hearing (spiral organ) and balancing
(semicircular ducts, utricle and saccule)
 Also conveys the Rasmussen’s (efferent cochlear) fibres from the retro-olivary
nucleus to the cochleae
 Is formed by the central processes of the bipolar neurons of the spiral and
vestibular ganglia
 Traverses the internal acoustic meatus from lateral medially. Here, it lies
posteroinferior to the facial nerve
 Enters the brainstem at the pontomedullary junction, behind the facial nerve
Vestibular Part of Vestibulocochlear Nerve
The vestibular part of the vestibulocochlear nerve

 Is formed by the central processes of the bipolar neurons of the vestibular
ganglion (located at the lateral end of the internal acoustic meatus)
 Conveys impulses relating to equilibrium from the saccular and utricular
maculae, and ampullae of the semicircular ducts
 Terminates in the brainstem vestibular nuclei. The latter include medial, lateral,
superior, and inferior vestibular nuclei (located in the pons and upper medulla)
Cochlear Part of Vestibulocochlear Nerve
The cochlear part of the vestibulocochlear nerve

 Is formed by the central processes of the bipolar neurons of the spiral ganglion
 Conveys auditory impulses from the hair cells of the spiral organ of Corti
 Ends in the cochlear nuclei of the brainstem
861
Applied Anatomy of the Vestibulocochlear Nerve
Note that
 Injury to the vestibulocochlear nerve in the internal acoustic meatus may produce
ipsilateral total deafness, and vertigo
 Carcinoma of the sheath cells of the vestibulocochlear nerve would lead to
irritation and functional deficits of this nerve (with hearing impairment, tinnitus
and vertigo)
Glossopharyngeal Nerve (9th Cranial Nerve)
The glossopharyngeal nerve

 Is the 9th cranial nerve (Fig. 164); it has motor, sensory and autonomic fibres
 Is associated with the nucleus solitarius, spinal nucleus of trigeminal nerve,
nucleus ambiguus and the inferior salivatory nucleus (see below)
 Emerges from the rostral part of the medulla as a series of rootlets located
between the olive and the inferior cerebellar peduncle (in line with the rootlets of
the vagus)
 Passes anterolaterally from the medulla to exit the cranial cavity through the
anteromedial part of the jugular foramen (where it lies anterior to the vagus and
accessory nerves)
 Descends through the neck, anterior to the internal carotid artery, and then
 Accompanies the stylopharyngeus to the pharynx. It enters the latter through the
interval between the superior and middle constrictors
 Innervates the palatine tonsil, pharyngeal mucosa and the pharyngeal part of the
tongue (including the vallate papillae)
 Has two swellings – superior and inferior ganglia. These are located in the
jugular foramen, and they contain pseudounipolar cells
 Communicates with the vagus and facial nerves, and with the sympathetic chain
 Contains preganglionic parasympathetic fibres (meant for the parotid gland)
Brainstem nuclei associated with glossopharyngeal nerve include:

 The upper part of the nucleus ambiguus; this is the source of the motor fibres of
this nerve (to stylopharyngeus)
 Inferior salivatory nucleus, which is the source of the preganglionic
parasympathetic fibres of this nerve. These fibres innervate (not directly) the
parotid gland and glands of the pharyngeal part of the tongue
 Nucleus solitarius, which receives the special visceral afferent (taste) fibres
conveyed by this nerve (from the pharyngeal part of the tongue and vallate
papillae)
 Spinal nucleus of trigeminal nerve, which receives the general sensory fibres
conveyed by CN IX from the pharyngeal part of the tongue, oropharynx, palatine
tonsil and the soft palate
862
Fibres contained in the glossopharyngeal nerve include:

 Motor fibres to stylopharyngeus; these arise from the nucleus ambiguus (part of
the special visceral efferent column)
 Special visceral afferent (taste) fibres, from the posterior 1/3 (pharyngeal part)
of the tongue and vallate papillae
 Fibres that convey general sensations from the oropharynx, posterior ⅓ of the
tongue, palatine tonsil, soft palate, auditory tube, tympanum, mastoid antrum,
mastoid air cells, ear drum (medial surface), carotid sinus and carotid body
 Preganglionic parasympathetic fibres to the parotid gland and mucous glands
of the pharyngeal part of the tongue
Branches of Glossopharyngeal Nerve
Branches of the glossopharyngeal nerve include:

 Tympanic nerve
 Carotid sinus nerve
 Pharyngeal branches
 Tonsillar branches
 Lingual branches
 Muscular branch (to stylopharyngeus)
The tympanic branch of glossopharyngeal nerve

 Arises from the inferior ganglion of glossopharyngeal nerve
 Ascends through the inferior tympanic canaliculus to enter the middle ear
 Forms the tympanic plexus on the medial wall of the middle ear
 Gives sensory branches to the middle ear, auditory tube and mastoid air cells,
mastoid antrum and ear drum
 Gives rise to the lesser petrosal nerve; the later arises from the tympanic plexus
and traverses the foramen ovale to terminate in the otic ganglion (to which it
conveys preganglionic parasympathetic fibres)
The nerve to the carotid sinus

 Arises from the glossopharyngeal nerve just inferior to the jugular foramen
 Descends on the internal carotid artery to the carotid sinus and carotid body,
which it supplies (with sensory fibres)
Pharyngeal branches of the glossopharyngeal nerve

 Join the pharyngeal branch of vagus to form the pharyngeal plexus (see the
pharynx above)
 Conveys sensory fibres from the pharyngeal mucosa
Tonsillar branches of glossopharyngeal nerve

 Form a plexus around the palatine tonsil (together with branches of the lesser
palatine nerves)
863
 Innervate the palatine tonsil, soft palate and the isthmus of the fauces
Lingual branches of glossopharyngeal nerve

 Convey special and general sensory afferent fibres from the pharyngeal part
(posterior 1/3) of the tongue
 Also convey special sensory (taste) fibres from the vallate papillae
Applied Anatomy of Glossopharyngeal Nerve
Note that
 Glossopharyngeal neuralgia is characterized by sudden pain and discomfort
during swallowing or speaking, etc; its cause is unknown
 Lesions in the glossopharyngeal nerve would result in loss of sensations (both
general and taste) from the posterior 1/3 of the tongue and loss of taste sensation
from the vallate papillae
 In jugular foramen syndrome (e.g. as a result of tumor in this foramen),
compression of the glossopharyngeal nerve would result in its functional deficits
Vagus Nerve (10th Cranial Nerve)
The vagus nerve

 Is a mixed nerve; it contains motor, sensory and autonomic fibres (Fig. 164)
 Is the most extensively distributed of the cranial nerves; it innervates structures in
the head, neck, thoracic and abdominal cavities
 Emerges from the brainstem at the interval between the olive and inferior
cerebellar peduncle (as 8–10 rootlets), in line with the glossopharyngeal and
accessory nerves (which emerge above and below it respectively)
 Is the nerve of the 4th and 6th branchial arches; thus, it innervates the muscles
derived from these arches
Fibres of the vagus nerve include:

 Motor fibres to the pharynx, soft palate, larynx (and palatoglossus)
 Parasympathetic (motor) fibres to the thoracic and abdominal viscera
 Secretomotor (parasympathetic) fibres to the thoracic and abdominal glands
 Taste fibres from the epiglottis and vallecula
 Sensory fibres from the laryngopharynx, larynx and thoracic and abdominal
viscera
 General somatic afferent fibres from the external ear
Four nuclei are associated with the vagus nerve. These include:
 Dorsal vagal nucleus, which lies in the medulla, deep to the vagal trigone of the
rhomboid fossa. It is the source of the general visceral efferent fibres to the
bronchi, esophagus, heart, stomach, small intestine and large intestine (as far
distally as the distal 2/3 of the transverse colon)
864
 Nucleus ambiguus; this also lies in the medulla, and it gives rise to the special
visceral efferent fibres of the vagus (which innervate the pharyngeal and intrinsic
laryngeal muscles)
 Nucleus solitarius, which receives the taste fibres conveyed by the vagus nerve
(from the epiglottis and vallecula)
 Spinal nucleus of trigeminal nerve; this receives the general somatic afferent
fibres conveyed by the vagus (from the skin of the external ear)
Note: General visceral afferent fibres from the oesophagus and gastrointestinal tract
may terminate in the dorsal vagal nucleus.
Regarding its course, the vagus nerve

 Emerges from the medulla as rootlets attached along the groove between the olive
and inferior cerebellar peduncle, and below the rootlets of the glossopharyngeal
nerve
 Leaves the cranial cavity through the jugular foramen, behind the
glossopharyngeal nerve (and in the same dural sheath as the accessory nerve)
 Presents a superior ganglion as it traverses the jugular foramen, and an inferior
ganglion located just below this foramen
 Descends vertically in the neck through the carotid sheath; here, it lies initially
between and behind the IJV and internal carotid artery (above C3), and then
between and behind the IJV and common carotid artery (below C3)
 Traverses the thoracic inlet at the root of the neck, to enter the thoracic cavity.
The left nerve descends between the left subclavian and common carotid arteries,
while the right descends anterior to the 1st part of the right subclavian artery.
Then it
 Continues downwards through the thoracic cavity, behind the root of the lung
 Forms, with its fellow, a plexus around the lower part of the oesophagus, in the
thoracic cavity. From this plexus, anterior and posterior vagal trunks arise;
these leave the thoracic for the abdominal cavities through the oesophageal
hiatus (anterior and posterior, respectively, to the esophagus)

 The vagus nerves form a plexus – oesophageal plexus – around the lower part of
the esophagus
 From the oesophageal plexus, anterior and posterior vagal trunks arise
 The anterior vagal trunk is derived mainly from the left vagus nerve; it enters
the abdomen through the oesophageal hiatus (anterior to the esophagus) to
innervate the anterior gastric surface, pyloric canal, pylorus, 1st and 2nd parts of
the duodenum and the pancreatic head
 The posterior vagal trunk is derived mainly from the right vagus nerve; it
innervates the posterior gastric surface and gives a branch to the coeliac plexus
(and small rami to the superior mesenteric, renal, splenic, hepatic and suprarenal
plexuses)
865
Ganglia of the vagus nerve include:

 Superior vagal ganglion, and
 Inferior vagal ganglion
The superior vagal ganglion

 Is a rounded swelling of the vagus nerve located in the jugular foramen
 Measures about 4 mm in diameter
 Gives rise to the auricular (and meningeal) branches of the vagus
The inferior vagal ganglion

 Is an elongated swelling located just below the jugular foramen
 Measures about 25 mm in length and 5 mm across
 Gives rise to the pharyngeal and superior laryngeal branches of vagus
Note: These ganglia mainly contain pseudounipolar neurons.
Branches of the Vagus Nerve
In the jugular foramen, branches of the vagus nerve include:

 Meningeal branch, which arises from the superior vagal ganglion (but is
probably derived from the upper cervical nerves); it innervates the dura of the
posterior cranial fossa
 Auricular branch, which also arises from the superior vagal ganglion. It
innervates the skin of the cranial aspect of the auricle, posteroinferior aspect of
the external acoustic meatus and external aspect of the tympanic membrane
In the neck, branches of the vagus nerve include:

 Pharyngeal branch, which enters the pharynx between the middle and superior
constrictors to end in the pharyngeal plexus; it conveys motor fibres to the
pharynx
 Carotid sinus nerve, which joins branches of the glossopharyngeal nerve to form
a plexus that innervates the carotid body and sinus; this nerve may arise from the
inferior vagal ganglion
 Superior laryngeal nerve; this innerves the upper part of the laryngeal mucosa
(above the level of vocal folds) and the cricothyroid (see below)
 Right recurrent laryngeal nerve; this innervates the lower part of laryngeal
mucosa (below the level of vocal folds) and all the intrinsic laryngeal muscles
(except cricothyroid)
 Upper and lower cardiac branches, to the cardiac plexuses (that supply the
heart)
The superior laryngeal nerve

 Arises from the inferior vagal ganglion
 Descends first behind, then medial to the internal carotid artery
866
 Divides into internal and external laryngeal nerves
The internal laryngeal nerve

 Pierces the thyrohyoid membrane above the superior laryngeal artery
 Innervates the laryngeal mucosa as far down as the vocal fold (including the
upper aspect of this fold); it also innervates both aspects of the epiglottis and the
vallecula
The external laryngeal nerve

 Is the smaller of the two branches of the superior laryngeal nerves
 Innervates cricothyroid (by piercing the external surface of this muscle)
 Also gives some rami to the inferior pharyngeal constrictor
Regarding the recurrent laryngeal nerves, note that

 The right nerve arises from the vagus at the root of the neck (where it winds
round the right subclavian artery)
 The left nerve arises from the vagus in the superior mediastinum (where it winds
round the aortic arch)
 Each nerve ascends in or just anterior to the groove between oesophagus and the
trachea (tracheo-esophageal groove), towards the larynx. Then
 Each continues upwards, deep to the inferior constrictor, and behind the
cricothyroid joint, to enter the larynx
 They innervate all intrinsic laryngeal muscles (except cricothyroids); they also
innervate the mucosa of the larynx, below the level of the vocal folds (including
the inferior aspects of these folds)
In the thorax, branches of the vagus nerve include:

 Two (or three) cardiac branches, to the cardiac plexuses
 Left recurrent laryngeal nerve, to the larynx (see above)
 Anterior and posterior pulmonary branches, to the anterior and posterior
pulmonary plexuses
 Oesophageal branches, which form the oesophageal plexus around the
esophagus (from which this organ is supplied)
In the abdominal cavity, vagal branches include:

 Gastric branches to the stomach; these arise from both vagal trunks
 Coeliac branches to the coeliac plexus; these arise from the posterior vagal trunk
 Hepatic branches to the hepatic plexus; these arise from both vagal trunks and
innervate the liver
 Renal branches to the renal plexus; they also arise from both vagal trunks
 Splenic branches to the spleen
867
Applied Anatomy of the Vagus Nerve
Injury to the vagus nerve may produce:

 Dysphagia (difficulty in swallowing), as a result of damage to the pharyngeal
branches of this nerve
 Monotony of the voice, owing to paralysis of cricothyroid (supplied by the
external laryngeal nerve)
 Anaesthesia of laryngeal mucosa, owing to injury to the internal and recurrent
laryngeal nerve
 Dysphonia and hoarseness of the voice, as a result of damage to the recurrent
laryngeal nerve (and thus, paralysis of the vocal fold)
 Aphonia, as a result of injury to both recurrent laryngeal nerves; this may arise
after thyroidectomy, or in aneurysm of the aortic arch
Accessory Nerve (11th Cranial Nerve)
The accessory nerve

 Is the 11th cranial nerve (Fig. 164); it is formed by two roots: cranial and spinal
 Is motor to the soft palate, pharynx, larynx, SCM and trapezius; the last two are
innervated by the spinal root of this nerve
 Is closely associated with the vagus nerve, and thus may be considered as its
caudal part
 Is invested by the same dura and arachnoid sheath as the vagus
Cranial Root of Accessory Nerve
The cranial root of accessory nerve

 Is smaller than the spinal root
 Arises from neurons in the caudal part of the nucleus ambiguus of the medulla
 Emerges from the medulla as four (or five) rootlets below and in line with the
rootlets of the vagus
 Unites with the spinal root and then passes laterally into the jugular foramen
 Communicates, via a twig, with the superior vagal ganglion (in the jugular
foramen)
 Separates from the spinal root as it emerges from the jugular foramen. It then
joins the inferior vagal ganglion (as internal branch of accessory nerve)
 Is distributed, via the laryngeal and pharyngeal branches of vagus, to muscles of
the soft palate (except tensor veli palatini), lower part of the pharynx and larynx
 Is part of the special visceral efferent fibres
Spinal Root of Accessory Nerve
The spinal root of accessory nerve
868
 Consists of fibres which arise from the accessory nucleus of the spinal cord; this
nucleus is located in the ventral grey column of the upper 5 cervical spinal
segments
 Emerges from the lateral surface of the spinal cord between the ventral and dorsal
roots of the upper spinal nerves. It then
 Ascends behind the ligamentum denticulatum, to enter the cranial cavity through
the foramen magnum
 Continues laterally (in the cranial cavity) towards the jugular foramen, and is
joined by the cranial root (of the accessory nerve). It also shares the same dural
sheath with the vagus
 Separates from the cranial root at the lower end of the jugular foramen (as the
external branch of accessory). It then
 Continues posterolaterally in the neck, behind the IJV (occasionally anterior to it)
 Enters the SCM (through the deep surface of this muscle), giving motor fibres to
it
 Emerges from the posterior border of SCM (just above the midpoint of this
muscle) to enter the posterior triangle of the neck
 Runs posteroinferiorly through the posterior triangle, over the levator scapulae
(from which it is separated by the prevertebral fascia). Here, it is surrounded by
lymph nodes
 Leaves the posterior cervical triangle by passing deep to the anterior border of
trapezius, about 5 cm above the clavicle; it also gives motor fibres to this muscle
Applied Anatomy of the Accessory Nerve
Note that
 The accessory nerve is susceptible to injury in fracture of the jugular foramen
 Lymphadenitis of the nodes in the posterior triangle of the neck may adversely
affect the functional integrity of the accessory nerve. This may result in acute
torticolis, especially in children
 Owing to its course through the posterior cervical triangle, the spinal part of the
accessory nerve is at risk in surgical operations involving this triangle
 When the accessory nerve is irritated centrally, sustained tonic contraction of the
SCM and trapezius (spasmodic torticolis) could occur
 Management of spasmodic torticolis may involve division of the spinal root of
accessory nerve
Hypoglossal Nerve (12th Cranial Nerve)
The hypoglossal nerve

 Consists of fibres that arise from the hypoglossal nucleus. The latter is located in
the medullary tegmentum, deep to the hypoglossal trigone of the rhomboid fossa
 Emerges from the anterolateral sulcus of the medulla as a series of 10–15 rootlets
(in line with the ventral roots of spinal nerves below)
869
 Passes laterally behind the vertebral artery, to traverse the hypoglossal (anterior
condylar) canal as two bundles which unite as they exit this canal
 Emerges from the hypoglossal canal to descend laterally in the neck, behind the
internal carotid artery, glossopharyngeal and vagus nerves. It then
 Continues its descent between the internal carotid artery and internal jugular vein
(and anterior to the vagus), down to the level of the mandibular angle
 Turns forwards by looping round the inferior sternocleidomastoid branch of the
occipital artery, lateral to the internal and external carotid arteries (above the
greater horn of hyoid)
 Continues forwards, on the superficial surface of hyoglossus, (below the
submandibular ganglion and duct and the lingual nerve), and then on the lateral
surface of geniohyoid (which it pierces), to reach as far forwards as the tip of the
tongue
 Forms part of the general somatic efferent (motor) nerves
 Innervates the muscles of the tongue, except palatoglossus (Fig. 164)
 Communicates with other nerves, and by so doing, transmits and distribute their
fibres (see below)
The hypoglossal nerve communicates with:

 The superior cervical ganglion, near the C1 vertebra
 The C1 spinal nerve; fibres of this nerve are distributed to the infrahyoid muscles
(via the superior root of ansa cervicalis) and geniohyoid
 The vagus nerve (close to the base of the skull); these fibres connect the
hypoglossal nerve and the inferior vagal ganglion
 The lingual nerve (on the hyoglossus)
Branches of the Hypoglossal Nerve
These include:
 Meningeal braches
 Upper root of ansa cervicalis (or descending branch)
 Nerves to thyrohyoid and geniohyoid, and
The meningeal branches of hypoglossal nerve

 Arise from the hypoglossal nerve, in the hypoglossal canal
 Ascend in the hypoglossal canal to the posterior cranial fossa
 Innervate the dura of the posterior cranial fossa and the diploe of the occipital
bone
 Are probably derived from the upper cervical spinal nerves
The upper root of ansa cervicalis

 Arises from the hypoglossal nerve as this loops forwards round the occipital
artery. Its fibres are derived from the C1 nerve
870
 Descends anterior to or within the carotid sheath

 Joins the lower root of the ansa cervicalis (derived from the C2 and C3 nerves) to
form the ansa cervicalis
 Innervates (together with the lower root of ansa cervicalis) the infrahyoid muscles
Nerves to the thyrohyoid and geniohyoid

 Are fibres of the C1 spinal nerve
 Arise from the hypoglossal nerve near the posterior border of hyoglossus
 Innervates thyrohyoid and geniohyoid
Muscular (lingual) branches of hypoglossal nerve

 Are numerous; they arise from this nerve in the tongue
 Innervate all intrinsic and extrinsic muscles of the tongue except palatoglossus
 Are derived from the hypoglossal nucleus of the medulla
 Applied Anatomy
 Following injury to the hypoglossal nerve,
 Paralysis and atrophy of the ipsilateral half of the tongue occur
 The tongue deviates to the paralyzed side when protruded (owing to the
unopposed action of the opposite genioglossus)
 Swallowing and speech become difficult
 Taste and other sensory modalities from the tongue are not affected
FURTHER READING
Guyton A. C., Hall J. E. Textbook of Medical Physiology. 11th edition, Saunders,
Philadelphia. 2006
Junqueira L. C., Carneiro J. Basic Histology. 11th edition, New York, McGraw Hill.
2005
Kent V.D.G. Human Anatomy. 5th edition, New York, McGraw Hill. 2000
Kumar P, Clark M. Clinical Medicine. 6th edition, Elsevier Ltd, Edinburgh. 2005
Kumar V., Abbas A. K., Fausto N. Pathologic Basis of Disease. 7th edition,
Saunders, Philadelphia. 2004
Moore K. L., Dalley A. F. Clinically Oriented Anatomy, 4th edition, Philadelphia, W.

B. Saunders Co. 1999
871
Moore K. L., Persaud T. V. N. The Developing Human: Clinically Oriented

Embryology. 6th edition, W. B. Saunders Co, Philadelphia. 1998
Netter F. H. Interactive Atlas of Human Anatomy
Romanes G. J. Cunningham’s Manual of Practical Anatomy, Vol. 1 & 2. 15th

edition, Oxford University Press, Oxford. 1981
Romanes G. J. Cunningham’s Textbook of Anatomy. 12th edition, Oxford University

Press, Oxford. 1986
Sadler T. W. Longman’s Medical Embryology, 8th edition. Lippincott Williams &

Wilkins. 2000
Williams P. L., Warwick R., Dyson M., Bannister L. H. Gray’s Anatomy. 37th
edition, Longman Group, Edinburgh. 1989
872
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Oluwole Akinola Olufunke Dosumu

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HIGHLIGHTS OF HUMAN ANATOMY

Authors: Oluwole Akinola, Olufunke Dosumu

Title: Highlights of Human Anatomy, 2nd edition

Copyright ©2005, 2018

All rights reserved. This book is protected by copyright. No part may be

Oluwole B. Akinola B.Sc., Ph.D.

Formerly IBRO Research Fellow,

Olufunke O. Dosumu B.Sc., Ph.D.

Highlights of Human Anatomy is a compendium of basic and applied

Chapter 6. Gross Anatomy of Chapter 16. Histology of the

Chapter 17. Gross Anatomy of

Chapter 18. Histology of the

Chapter 11. Gross Anatomy of

CHAPTER 1: CELL AND CELL DIVISION

Regarding the cell, note the following points:

Functions of the Cell

The functions of the cell include:

The common intercellular junctions include: desmosomes, hemidesmosomes, zonula

Specialization of Cell Surface

Regarding cilia, note the following:

Figure 1. The cell

Cell Membrane (Plasmalemma)

Regarding the cell membrane, note the following:

 Membrane phospholipids are arranged in a double layer. The hydrophobic chains

Permeability of the Cell Membrane

The cell membrane is selectively permeable. Its permeability depends on the

Transport of Substances across the Cell Membrane

Figure 2. The cell membrane

Functions of the Cell Membrane

The cell membrane

 Could facilitate movement of substances through a hollow organ by means of

Rough (granular) endoplasmic reticulum (RER)

The rough endoplasmic reticulum

Smooth (Agranular) Endoplasmic Reticulum

The smooth endoplasmic reticulum

 Also consists of a network of membrane-bound channels, but the cytosolic

The Golgi complex

Besides, note that lysosomes

 Have been implicated in the progression of rheumatoid arthritis. They also

The importance of cytoskeleton includes:

Intermediate filaments are of different types; these include:

Cell Inclusions (Cytoplasmic Deposits)

Note the following points:

The Nucleus (Fig. 1)

The nucleus of a eukaryotic cell

Note: Sex chromatin is a heterochromatic mass observable in female cells only. It

 Is actively involved in the formation of ribosomes. After their formation,

The nuclear matrix

Nuclear Envelope (or Nuclear Membrane)

The nuclear envelope

 Usually possesses a combination of euchromatic and heterochromatic elements.

Zonula Occludens (Tight Junction)

Desmosomes (Macula Adherens)

Gap Junction (Communicating Junction)

 Closely resembles zonula adherens, but has a space of 2–3 nm between

Specialization of Cell Surface

 Have a diameter of 0.2–0.25 µm; and a length of about 10 µm