Selective Anatomy

Prep Manual for Undergraduates

VOLUME I SECOND EDITION

Vishram Singh, MBBS, MS, PhD(hc), MICPS,

FASI, FIMSA
Adjunct Visiting Faculty, KMC, Mangalore
Manipal Academy of Higher Education, Karnataka, India
Editor-in-chief, Journal of the Anatomical Society of India
Member of Federative International Committee for Scientific Publications (FICSP) of IFAA
Former Professor and Head, Department of Anatomy, Santosh Medical College
Member Academic Council and Core Committee, PhD Course, Santosh University, Ghaziabad,
NCR, Delhi
Examiner in National and International Universities; Member, Editorial Board, Indian Journal
of Otology; Journal of Anatomy and Cell Biology
Ex-Vice President, Anatomical Society of India
Medicolegal Advisor, ICPS, India
Consulting Editor, ABI, North Carolina, USA
Associate Editor, Acta Medica International
Member, COPE Council (England & Wales)
Member British Association of Clinical Anatomists (BACA)
Formerly at: GSVM Medical College, Kanpur
King George’s Medical College, Lucknow
Al-Arab Medical University, Benghazi (Libya)
All India Institute of Medical Sciences, New Delhi
Table of Contents

Cover image

Title page

Copyright

Dedication

Foreword to the first edition

Preface to the second edition

Preface to the first edition

Acknowledgements
SECTION I. Upper Limb

1. Pectoral region and axilla

Pectoral region

Axilla

2. Back of the body and scapular region

Back of the body

Scapular region

3. Arm
4. Forearm

5. Hand

6. Vessels of the upper limb

7. Nerves of the upper limb

8. Joints of the upper limb

SECTION II. Head and Neck

9. Scalp, temple and face

10. Side, front and back of the neck

11. Parotid and submandibular regions

Parotid region

Submandibular region

12. Deep structures of the neck and prevertebral region

Deep structures of the neck

Prevertebral region

13. Oral cavity

14. Pharynx and palate

15. Nose and paranasal air sinuses

Nose

Paranasal air sinuses

16. Larynx

17. Infratemporal fossa, temporomandibular joint and pterygopalatine fossa

Infratemporal fossa

Temporomandibular joint

Pterygopalatine fossa AN33.1

18. Ear and orbit

Ear

Orbit

19. Dural folds, intracranial dural venous sinuses and pituitary gland

20. Cranial nerves

21. Meninges and cerebrospinal fluid

22. Spinal cord

SECTION III. Brain

23. Overview of brain and brainstem

Overview of brain

Brainstem

24. Cerebellum and fourth ventricle

25. Overview of cerebrum and functional areas

26. Cerebrum

27. Basal nuclei, limbic system and lateral ventricle

 Basal nuclei

Limbic system

Lateral ventricle

28. Diencephalon and third ventricle

SECTION IV. General Anatomy

29. Introduction and anatomical terminology

30. Skin, superficial fascia and deep fascia

Skin

Superficial fascia

Deep fascia

31. Skeletal system

32. Joints

33. Muscles

34. Cardiovascular system

35. Lymphatic system

36. Nervous system

SECTION V. General Histology

37. Introduction to histology

38. Epithelial and connective tissues

Epithelial tissue
 Connective tissue AN66.1, AN66.2

39. Special connective tissues

40. Muscle tissue, blood vessels and lymphoid tissue

Muscle tissue AN67.1–67.3

Blood vessels AN69.1–69.3

Lymphoid tissue AN70.2

Index
Copyright

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Selective Anatomy: Prep Manual for Undergraduates, Volume I, 2nd Edition,

Vishram Singh

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Dedication

Dedicated to
My Mother, Late Smt. Ganga Devi Singh
My Father, Late Shri Hari Ram Singh
My Students, Past, and Present
Foreword to the first edition
Professor (Dr) VK Arora, MD, DCD, CTC&E (JAPAN) FNCCP, FIMSA, FGSI, Vice
Chancellor, Santosh Medical College, Santosh University, Ghaziabad, NCR, Delhi, Ex-
Additional Director General, of Health Services Government of India

It gives me a great pleasure to write the Foreword for Professor Vishram Singh’s book
Selective Anatomy Prep Manual for Undergraduates. There was a long-felt need for a
suitable book on anatomy in question-answer format to help students not only to revise
vast course of anatomy before examination in limited time but also present their
knowledge in an easy format.
It is a herculean task to select the frequently asked questions in examinations of
various universities and answer them in a manner as expected by an examiner.
Professor Vishram Singh is an eminent and highly regarded Anatomist. He has
authored about a dozen books and published a number of research papers in national
and international journals.
This book is in two volumes in question-answer format. Volume I covers the
complete syllabus of Paper I and Volume II, the syllabus of Paper II. The book is
profusely illustrated by four-color line diagrams which can be easily reproduced by the
students during examination.
This book is an appropriate comprehensive manual for university examination, thus I
strongly recommend it to the undergraduate medical students.
Wishing Professor Vishram Singh for his future endeavor.
Preface to the second edition
Vishram Singh

It is with great pleasure that I present the second edition of Selective Anatomy: Prep
Manual for Undergraduates, which is widely used by the undergraduate medical students
as well as dental, paramedical and nursing students.
This book is in question–answer format and set in 2 volumes – Volume I covers the
syllabus of Paper I and Volume II the syllabus of Paper II. The popularity of this book
reflects the appeal of its concept-building approach written with my vast experience of
teaching about 45 years. Efforts have been made very carefully to present the text in
concise manner that will be acceptable to most of the examiners. In fact, the huge
syllabus of anatomy is beyond the comprehension of students in 1 year. The main
purpose of this book is to relieve the students of pre-examination stress while revising
the syllabus paper-wise in short available time. However, the students should be aware
that this book is meant only for the purpose of revision and does not replace the
standard textbook.
This book is liked and well appreciated by the students all over India. Based on
enormous suggestions from the students and fellow academicians, many new questions
and answers along with figures and tables have been added in this edition. The
previous text has been thoroughly revised and most of the diagrams have been
completely revised for easy understanding and reproducibility in the examination by
the students.
I strongly feel that the book in its present form will be more useful than the previous
one to students and teachers alike.
I will highly appreciate the comments and suggestions from both students and
teachers for further improvement of this book.
“Nothing is permanent in life except change.”
Preface to the first edition
Vishram Singh

The Medical Council of India has reduced the duration of teaching of 1st year MBBS
course from 1½ years to 1 year. It has also introduced the specific pattern of questions
such as long and short answer questions, short notes, drawing and labeling of
diagrams, providing anatomical, embryological, and genetic basis of clinical problems
and MCQs.
Each student tries his/her best to clear the examination. However, many students do
not know how to present the answers considering the marks allotted.
This book is in question-answer format in 2 volumes. Volume I covers the syllabus of
Paper I, while Volume II will deal with the syllabus of Paper II.
Having 40 years of teaching experience and being an examiner in various medical
colleges and institutions, I have put my best effort in selecting frequently asked
questions (FAQs) and tried to answer them in a concise manner acceptable to most of
the examiners. Most of the diagrams are drawn by myself to ensure the accuracy and to
see that they can be easily reproduced by the students in examination.
Although, initially I was a bit hesitant to write a book in question and answer format
but later my conscience allowed me to do so because the sole aim of a teacher is to solve
the problems faced by the students and inspire them to become good doctors.
I hope that this book will definitely solve the problems of students and relieve them
from pre-examination stress. However, the student should be aware that this book is
meant only for revision purpose and not to replace the standard textbook.
I am confident this book will serve the purpose for which it meant.
Lastly I will highly appreciate comments both good and bad about the book from
both students and faculty because that will help me to improve the book in future.
“Necessity is the mother of invention.”
Acknowledgements
I sincerely thank my colleagues in the Department, especially Prof. Mangla M. Pai
(HOD) and Prof. Latha V. Prabhu and Associate Prof. Murli Manju for their cooperation
and appreciation of my work.
I highly appreciate the help provided by Associate Prof. Preeti Srivastava, NDMC
Medical College and Hindu Rao Hospital, Delhi, for going through the proofs of this
book. I am also thankful to Assistant Prof. Krishna G., Department of Anatomy,
Rajarajeswari Medical College, Bengaluru, Karnataka for providing feedback from
students.
I gratefully acknowledge the feedback and support of all my fellow colleagues in
Anatomy throughout India, particularly:

• Prof. N.C. Goel (Vice principal and former Head of the Department), Hind
Institute of Medical Sciences, Barabanki, Lucknow, Uttar Pradesh.
• Prof. Punita Manik (Head of the Department), King George Medical College,
Lucknow, Uttar Pradesh.
• Prof. P.K. Sharma (Head of the Department), Era Medical College, Lucknow,
Uttar Pradesh.
• Prof. Poonam Kharb (Head of the Department), ITS Dental College, Ghaziabad,
Uttar Pradesh.
• Prof. T.C. Singel, Zydus Medical College, Dahod, Gujarat.
• Prof. T.S. Roy (Head of the Department), AIIMS, New Delhi.
• Profs Vandana Mehta (Head of the Department) and Hitendra Lohiya,
Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi.
• Prof. Vanita Gupta (Head of the Department), Rama Medical College, Hapur,
Uttar Pradesh.
• Profs Deepa Singh (Head of the Department) and Akshya Dubey, Himalayan
Institute of Medical Sciences, Jolly Grant, Dehradun, Uttarakhand.
• Prof. W.M.S. Johnson (Dean), Sree Balaji Medical College, Chennai.
• Prof. Suniti Pandey (Head of the Department), GSVM Medical College, Kanpur.
• Prof. (Dr) S.L. Jethani (Medical Superintendent and Former Head of the
Department of Anatomy), Himalayan Institute of Medical Sciences, Dehradun,
Uttarakhand.
• Prof. G.M. Mahesh (Head of the Department), Basaveshwara Medical College,
Chitradurga, Karnataka.
• Profs Avinash Chandra Agrawal (Head of the Department) and A.K. Srivastava,
Prasad Institute of Medical Sciences, Banthra, Lucknow.
• Prof. Sneh Agrawal (Head of the Department), Lady Harding Medical College,
 New Delhi.
• Prof. Sneha Guruprasad Kalthur (Head of the Department) and Dr Prakash
Babu, KMC, Manipal, Karnataka.
• Prof. Emeritus S.D. Joshi, Sri Aurobindo Institute of Medical Sciences, Indore,
Madhya Pradesh.

Lastly, I thank my daughter Dr Rashi Singh, son Dr Gaurav Singh and daughter-in-
law Anupama Singh for helping me in the preparation of this manuscript.
I gratefully acknowledge the help and cooperation received from the staff of RELX
India Pvt Ltd, especially Arvind Koul (Content Strategist), Shabina Nasim (Head of
Content Project Management) and Goldy Bhatnagar (Content Project Manager), in
completing the project on time.
SECTION I
Upper Limb
OUTLINE

1. Pectoral region and axilla

2. Back of the body and scapular region
3. Arm
4. Forearm
5. Hand
6. Vessels of the upper limb
7. Nerves of the upper limb
8. Joints of the upper limb
1

Pectoral region and axilla

Pectoral region
Breast
❖ What is breast? Describe its structure in brief.  AN9.2
The breast is a modified sweat gland (apocrine type). It is rudimentary in male and well
developed in female at puberty. In adult female, it is seen as a soft hemispherical
protruding organ one on either side in the pectoral region.

Structure
The breast is composed of three components: skin, parenchyma and fibrofatty stroma
(Fig. 1.1).

FIG. 1.1 Structure of the breast: A, parenchyma of the breast (lobes and ducts); B, fibrofatty
(lobes and ducts of the breast); and stroma of the breast (fat and suspensory ligaments of
Cooper).

Skin:
It presents nipple and areola.

• Nipple: It is a dark conical projection of skin in the centre of breast. It is pierced

by 10–15 lactiferous ducts and contains smooth muscle fibres.
• Areola: It is circular blackish discolouration around the nipple. It contains
 numerous modified sebaceous glands. They secrete oily secretion which
lubricates and prevents the nipple from drying and cracking.

Parenchyma:
It consists of glandular part made up of alveoli, lactiferous ducts and lactiferous sinuses.

Fibrofatty stroma:
It consists of fibrofatty tissue.

• Fibrous stroma, consists of fibrous septa (ligaments of Cooper), which extends

from skin to the pectoral fascia and divides the gland into 10–15 lobes.
• Fatty stroma, lies between fibrous septa and glandular part.

N.B.
To drain breast abscess, the incision is given radially to avoid damage to the lactiferous
ducts.

❖ Describe the female breast under the following headings: (a) location and extent,
(b) relations, (c) blood supply, (d) lymphatic drainage and (e) applied anatomy. 
AN9.2

Location (fig. 1.2)

The breast is hemispherical in shape and located one on either side in the superficial
fascia of the pectoral region.

FIG. 1.2 Location and extent of breast.

Extent (fig. 1.2)

• Vertically: It extends from 2nd to 6th rib in midclavicular line.

• Horizontally: It extends from lateral border of the sternum to the midaxillary line.

Relations
Superficial relations

• Skin
• Superficial fascia

Deep relations

• Pectoral fascia (deep fascia covering the pectoralis major).

• Three muscles: pectoralis major (medially), serratus anterior (laterally) and
external oblique (inferomedially).
• Loose areolar tissue of the retromammary space intervenes between the breast
and pectoral fascia.

N.B.

• The structures forming deep relations together constitute the mammary bed.
• Glandular tissue of the breast can be freely moved on deeper structures, i.e.
pectoralis major covered by pectoral fascia.
• The breast prostheses are often inserted in the retromammary space.

Blood supply
Arterial supply:
The breast is highly vascular organ and is supplied by the following arteries:

• Internal thoracic artery through its 2nd, 3rd and 4th perforating branches.
• Lateral thoracic, superior thoracic and acromiothoracic branches of the axillary
artery.
• Lateral branches of the posterior intercostal arteries.

N.B.
Lateral thoracic artery is the main artery supplying the breast.

Venous drainage:
The main veins draining area around areola and parenchyma (glandular tissue) are
deep veins. They form the circular venous plexus at the base of the gland. From here,
they drain into:

• Axillary vein
• Internal mammary vein
• Intercostal veins

Lymphatic drainage (fig. 1.3)

The lymph vessels draining the breast are divided into two sets: (a) A set draining the
parenchyma, nipple and areola; (b) A set draining overlying skin, excluding nipple
and areola.

FIG. 1.3 Mode of lymphatic drainage of the breast.

• Those draining the parenchyma including areola and nipple form subareolar
plexus of Sappey, which drains as follows:
■ Seventy-five per cent (75%) into axillary group of lymph nodes chiefly into
anterior (or pectoral) group. Some reach posterior (subscapular) group.
Efferents from these pass to central and thence into apical group.
■ Twenty per cent (20%) drain into parasternal (internal mammary) nodes.
■ Five per cent (5%) drain into posterior intercostal nodes.
• Those draining the overlying skin excluding areola and nipple drain into:
 ■ Axillary nodes – from outer part
■ Supraclavicular nodes – from upper part
■ Parasternal nodes – from inner part
■ Subdiaphragmatic nodes – from inner part

Applied anatomy
Carcinoma of the breast:
The breast is common site of carcinoma. The important points to know about the
carcinoma breast are

• The cancer cells may infiltrate the suspensory ligaments (Cooper’s ligaments)
and as a result the breast becomes fixed and immobile.
• The contraction of the ligaments causes retraction or puckering of the skin.
• The infiltration of the lactiferous duct and their consequent fibrosis leads to
retraction of the nipple.
• Secondary breast cancer are usually lodged in the liver, ovaries or the
peritoneum making the prognosis worse.
• The cancer cells may migrate transcelomically to ovary producing a secondary
tumour called Krukenberg tumour.
• The cancer cells can also spread to the vertebrae and the brain via venous route,
through the communication between the veins draining the breast and the
vertebral venous plexus.
• Peau d’orange: In breast cancer, the skin over the breast presents an orange peel
appearance. This occurs due to obstruction of cutaneous lymphatics leading to
breast oedema and deepening of the mouths of sweat glands and hair follicles.

❖ Describe the development of the breast/mammary gland in brief.  AN9.3

• The mammary gland develops in the pectoral region from the milk line (Fig.
1.4).
• The milk line is linear thickening of surface ectoderm that appears in the 4th
week of intrauterine life.
• The milk line extends from axilla to the inguinal region on the ventral aspect of
the body wall of the embryo.
• The fibrofatty stroma of the breast develops from the underlying mesoderm.
 FIG. 1.4 Development of the mammary gland: A, mammary ridge (right side) and positions of
accessory nipples (left side); B, stages of development of the mammary glands.

N.B.
The full development of breast occurs at about 19 year of the age.

❖ Enumerate the congenital anomalies of the breast.

• Polymastia: Supernumerary breasts

• Amastia: Absence of breast (rare)
• Athelia: Absence of nipple
• Polythelia: Supernumerary nipples (commonly seen in axilla)

❖ Discuss the microscopic/histological structure of the mammary gland.  AN9.2

• The mammary gland is a modified sweat gland of apocrine variety. It is also called
serous, tubuloalveolar gland according to nature of secretion and secretory
units.
• The histological structure of mammary gland differs according to its
physiological status, i.e. (a) nonlactating and (b) lactating (Fig. 1.5). The
differences are given in Table 1.1.
 FIG. 1.5 Microscopic structure of the mammary gland. Source: (Source: Textbook of
Histology: Atlas and Practical Guide, 3rd Edition: JP Gunasegaran, Fig. 1.5A: Box 15.7 H/P,
Page 331; Fig. 1.5B: Box 15.8 H/P, Page 332, RELX India Private Limited, 2016.)

TABLE 1.1
Differences Between Nonlactating and Lactating Breast

Nonlactating Breast Lactating Breast

Predominantly made of
fibrofatty tissue and a little
glandular tissue
Lumina of duct and alveoli are
not clearly visible and do not
contain secretion (milk)
Alveoli underdeveloped and
represented by solid balls of cells
Predominantly made of glandular tissue and a little fibrofatty
tissue
Lumina of ducts and alveoli are clearly visible and filled with
secretion (milk)
Alveoli are well developed with distended lumen filled with
homogeneous vacuolated material – the milk; the alveoli are lined
by simple cuboidal epithelium
Extensive branching of duct Ducts are few
system
❖ Enumerate the muscles of pectoral region.

• Pectoralis major
• Pectoralis minor
• Subclavius

❖ Give the origin, insertion, nerve supply and actions of the pectoralis major
muscle.  AN9.1

Origin (fig. 1.6)

• Clavicular head: From the anterior surface of the medial 1/2 of clavicle.
• Sternocostal head arises from:
■ Anterior surface of the sternum up to 6th costal cartilage.
■ Medial parts of 2nd to 6th costal cartilages.
■ Aponeurosis of the external oblique muscle.
 FIG. 1.6 Origin and insertion of pectoralis major muscle. Figure in the Inset on the right shows
the insertion of bilaminar tendon insertion of pectoralis major on the lateral lip. Anterior lamina
is formed by clavicular and manubrium fibres while posterior lamina is formed by sternocostal
(minus manubrial fibres) and aponeurotic fibres.

Insertion (fig. 1.6)

By a bilaminar tendon on to the lateral lip of the bicipital groove in a ‘U-shaped manner’
with two laminae continuous with each other inferiorly.

Nerve supply
Medial and lateral pectoral nerves.

Actions
Adduction and medial rotation of the shoulder.

❖ Give the origin, insertion, nerve supply and actions of the pectoralis minor
muscle.  AN9.1

Origin
Arises from 3rd, 4th and 5th ribs anteriorly near their costal cartilages.

Insertion
Medial border and upper surface of the coracoid process of the scapula.

Nerve supply
Medial and lateral pectoral nerves (C6–C8).

Action

• It draws the scapula forward across the chest wall along with serratus anterior.
• It depresses the shoulder as in bringing the arm down from ‘above head position’.
❖ Give the origin, insertion, nerve supply and actions of the serratus anterior
muscle.  AN10.11
Serratus anterior is a broad flat muscle of trunk in the medial wall of axilla. It lies
between the ribs and scapula at the upper lateral part of the chest (Fig. 1.7).

FIG. 1.7 Origin and insertion of serratus anterior muscle.

Origin
Arises by eight digitations from outer surfaces and upper borders of upper eight ribs.
Each digitation arises from the corresponding rib but the 1st digitation arises from both
1st and 2nd ribs.

Insertion
Into whole length of the medial border of costal surface of the scapula.
The 1st digitation is inserted into a triangular area on the superior angle. The next
two or three digitations are inserted in the whole length of the medial border. The lower
four or five digitations are inserted into the large triangular area over the inferior angle.

Nerve supply
By the nerve to serratus anterior (also called long thoracic nerve of Bell), which arises from
C5, C6 and C7 roots of brachial plexus.

Actions

• Rotation of the scapula which helps in the abduction of shoulder beyond 90°.
• Chief muscle concerned with pushing and punching movements as in boxing.
Hence, it is also called ‘boxer’s muscle’.
❖ Write a short note on clavipectoral fascia.
The clavipectoral fascia is the strong fascial sheet deep to the pectoralis major muscle. It
extends from clavicle above to the axillary fascia below.

Attachments (fig. 1.8)

Medial:
Medially, it fuses with anterior intercostal membrane of the upper two intercostal
spaces and attaches to the 1st rib.

FIG. 1.8 Clavipectoral fascia, as seen in sagittal section of anterior axillary wall.

Lateral:
Laterally, it becomes thick and dense and attaches to the coracoid process.

Above:
It splits to enclose subclavius and attaches to the lips of the subclavian groove of
clavicle.

Below:
It splits to enclose pectoralis minor and thereafter it continues downward as suspensory
ligament of axilla, which is attached to the convex dome of the axillary fascia.
Modifications

• Costocoracoid ligament: Thickening of clavipectoral fascia between coracoid

process and 1st rib.
• Suspensory ligament of axilla (vide supra).

Functional significance
Acts as a suspensory ligament of axilla to maintain its concavity.

Applied anatomy
The cancer cells from breast may pass across the clavipectoral fascia to invade the
Rotter’s lymph nodes lying in front of pectoralis minor muscles. Hence, the knowledge
of clavipectoral fascia is of great surgical significance.

❖ Enumerate the structures piercing clavipectoral fascia (Fig. 1.9).

Clavipectoral fascia is pierced by four structures:

• Lateral pectoral nerve

• Thoracoacromial artery
• Cephalic vein
• Lymphatics from infraclavicular nodes and deep part of breast to apical group
of axillary lymph nodes

FIG. 1.9 Structures piercing clavipectoral fascia. PM, pectoralis major; Pm, pectoralis minor.

N.B.
Structures passing inwards are cephalic vein and lymphatics while structures passing
outwards are lateral pectoral nerve and thoracoacromial artery.
Axilla
The axilla is a pyramid-shaped space between upper part of the arm and thorax.

❖ Describe the axilla under the following headings: (a) boundaries, (b) contents and
(c) applied anatomy.  AN10.1

Boundaries (fig. 1.10)

Anterior wall:
It is formed by:

• Pectoralis major
• Subclavius muscle
• Clavipectoral fascia
• Pectoralis minor

FIG. 1.10 Boundaries and contents of axilla as seen in a horizontal section. AA, axillary artery;
AV, axillary vein; L, lateral cord; M, medial cord; P, posterior cord.

Posterior wall:
It is formed by:

• Latissimus dorsi
• Teres major
• Subscapularis
Medial wall:
It is formed by serratus anterior muscle, covering the upper part of lateral thoracic wall
(upper 4–5 ribs).

Lateral wall:
It is narrow and formed by intertubercular sulcus of the shaft of humerus, which
contains coracobrachialis and short head of biceps brachii.

Apex (also called cervicoaxillary canal):

It is triangular and directed upwards and medially towards the root of the neck. It is
bounded:

• Anteriorly, by the posterior border of clavicle

• Medially, by the outer border of 1st rib
• Posteriorly, by the upper border of scapula

Base:
It is formed by the axillary fascia extending between anterior and posterior axillary
folds.

Contents (fig. 1.10)

• Axillary artery and its branches

• Axillary vein and its tributaries
• Cords of brachial plexus
• Axillary lymph nodes AN10.4
• Fibrofatty tissue
• Long thoracic and intercostobrachial nerves
• Axillary tail of breast (tail of Spence)

Applied anatomy
Axillary abscess:
It occurs due to infection and suppuration of axillary lymph nodes. Axillary abscess is
drained by giving an incision midway between the anterior and posterior axillary folds.
The direction of edge of knife should face towards the medial wall. AN10.7

Lymphadenopathy:
Axillary lymph nodes are often infected and enlarged. They should be removed very
carefully because of their relationship to major vessels. AN10.7

Boils:
Due to the presence of abundant hair follicles in axilla, the infection of hair follicles and
sebaceous glands is very common and gives rise to multiple boils in the axilla.
Axillary pulse:
Can be felt against the lower part of the lateral wall of axilla.

❖ Describe the brachial plexus under the following headings: (a) formation, (b)
components, (c) location, (d) branches and (e) applied anatomy.  AN10.3

Formation (fig. 1.11)

It is formed by ventral primary rami of C5, C6, C7, C8 and T1.

FIG. 1.11 Brachial plexus and its branches. DS, dorsal scapular nerve; LS, lower subscapular
nerve; NS, nerve to subclavius; SS, suprascapular nerve; T, thoracodorsal nerve; US, upper
subscapular nerve.

Components (fig. 1.11)

The brachial plexus consists of four components:

• Roots
• Trunks
• Divisions
• Cords

Location
 • Roots and trunks lie in the root of neck.
• Divisions lie behind the clavicle.
• Cords lie in the axilla.

Branches (fig. 1.11)

From roots

• Dorsal scapular nerve (C5) for rhomboids.

• Nerve to serratus anterior (C5, C6 and C7) for serratus anterior as the name
implies.

From trunk (only upper trunk gives branches)

• Suprascapular nerve (C5 and C6) for supraspinatus and infraspinatus muscles.
• Nerve to subclavius.

From cords

• Lateral cord
■ Lateral pectoral nerve (C5–C7)
■ Lateral root of median nerve (C5–C7)
■ Musculocutaneous nerve (C5–C7)
Mnemonic: Laila Loved Majnu.
• Medial cord
■ Medial pectoral nerve for pectoralis major and pectoralis minor
■ Medial cutaneous nerve of arm
■ Medial cutaneous nerve of forearm
■ Medial root of median nerve
■ Ulnar nerve
• Posterior cord
■ Upper subscapular nerve for subscapularis muscle
■ Lower subscapular nerve for subscapularis and teres major muscles
■ Nerve to latissimus dorsi (thoracodorsal nerve)
■ Axillary nerve for deltoid and teres minor muscles
■ Radial nerve
Mnemonic: ULNAR

Applied anatomy

• Erb paralysis: It occurs due to injury of the upper trunk of brachial plexus at the
Erb’s point.
• Klumpke paralysis: It occurs due to injury of the lower trunk of brachial plexus (for
details, see p. 15).
• Horner syndrome: It occurs due to involvement of the sympathetic fibres (T1) (for
 details, see p. 139).
• Winging of scapula: It occurs due to injury of the nerve to serratus anterior.

Erb paralysis (fig. 1.12) AN10.6

• Site of injury: Erb’s point (the region of upper trunk where six nerves meet, i.e.
ventral rami of C5 and C6, anterior and posterior divisions of the upper trunk,
and suprascapular nerve and nerve to subclavius) (Fig. 1.12A).
• Cause: Undue (i.e. too much) separation of head from shoulder, e.g. (a) pulling of fetal
head by forceps during delivery (birth injury) and (b) fall on shoulder.
• Clinical features:
■ Arm hangs by the side. It is adducted and medially rotated, i.e. person is
unable to abduct and laterally rotate the arm.
■ Forearm is extended and pronated, i.e. person is unable to flex and supinate
the forearm.
■ Loss of sensations over a small area on the lower part of the deltoid.

FIG. 1.12 Erb–Duchenne paralysis: A, Erb’s point; B, policeman receiving a tip position of
upper limb.

N.B.
The deformity of upper limb produced in Erb paralysis is termed policeman tip taking
position/Waiter’s tip taking position (Fig. 1.12B).

Klumpke paralysis AN10.6

• Site of injury: Lower trunk of brachial plexus involving C8 and T1, mainly T1.
• Causes: Undue abduction of arm from body, e.g. (a) birth injury (pulling of upper
limb during delivery) (b) reflex catching of something with hand while falling
from a height, i.e. branch of a tree while falling from a tree.
• Clinical features:
 ■ Claw hand, due to paralysis of intrinsic muscles of the hand
■ Sensory loss along the medial border of forearm and hand
■ Horner syndrome due to involvement of sympathetic nerve to head and neck
(for details, see p. 139)

❖ Describe the axillary artery in brief.  AN10.2

Source and extent (fig. 1.13)

• It is a continuation of subclavian artery into axilla.

• It extends from the outer border of 1st rib to the inferior border of teres major.

FIG. 1.13 Course and branches of axillary artery.

Parts
It is divided into three parts by pectoralis minor:

• First part: Proximal to the muscle

• Second part: Deep/behind to the muscle
• Third part: Distal to the muscle

Branches (fig. 1.13)

They are six in number:

• First part gives one branch: Superior thoracic artery.

 • Second part gives two branches: (i) thoracoacromial artery and (ii) lateral thoracic
artery.
• Third part gives three branches: (i) subscapular artery, (ii) anterior circumflex
humeral artery, and (iii) posterior circumflex humeral artery.

Applied anatomy
The axillary artery can be effectively compressed against the upper part of shaft of
humerus (lower part of the lateral wall of axilla).

❖ Describe the axillary vein in brief.  AN10.2

Source and extent (fig. 1.14)

• It begins at the lower border of teres major by the union of basilic vein and venae
comitantes of brachial artery.
• It runs upwards and medially to continue as subclavian vein at the outer border
of 1st rib.

FIG. 1.14 Axillary vein and axillary lymph nodes.

Tributaries

• Veins corresponding to the branches of axillary artery, i.e. lateral thoracic,

subscapular, etc.
• Cephalic vein.
Applied anatomy
Spontaneous thrombosis of axillary vein may occasionally occur following unaccustomed
movements of the arm at shoulder joint.

❖ Describe the arterial anastomosis around scapula.  AN10.9

The arterial anastomosis around scapula is formed between the branches of the first
part of subclavian artery and the branches of third part of the axillary artery (Fig. 1.15).

FIG. 1.15 Anastomosis around the scapula (scapular anastomosis).

The following branches from first part of the subclavian artery and third part of the
axillary artery take part in this anastomosis:

Clinical importance
This anastomosis around scapula provides collateral channels to ensure adequate
circulation to the upper limb in case the subclavian artery or axillary artery is blocked
anywhere between the first part of subclavian artery and third part of axillary artery.

❖ Describe the axillary lymph nodes in brief and discuss their applied importance. 
AN10.4

Location
In fibrofatty tissue of axilla.
Groups
Axillary lymph nodes are 15–20 in number which are divided into five groups (Fig.
1.14):

Anterior group

• Lies along the inferior border of pectoralis minor/lateral thoracic vein.

• It drains most of the lymph from the breast.

Posterior (subscapular) group

• It lies along the subscapular vein and drains lymph from axillary tail of the
breast.

Lateral group

• It lies posteromedial to axillary vein along the upper part of humerus.

• It drains lymph from entire upper limb.

Central group

• It lies in the upper part of axilla.

• It receives lymph from other groups (vide supra).

Apical group

• It lies at the apex of axilla along the medial side of axillary vein. It receives
lymph from central group, breast and thumb.

Applied anatomy

• Axillary lymph nodes are involved and enlarged in breast cancer.

• Axillary lymph nodes are also enlarged if infection occurs anywhere in areas of
their drainage. They are routinely palpated by the clinicians while examining a
patient.
2

Back of the body and scapular region

Back of the body

❖ Give a brief account of posterior axio-appendicular muscles.  AN10.8

• These are the muscles that attach the scapula with the back of the trunk.
• These are arranged into two layers:
■ Superficial layer
– Trapezius
– Latissimus dorsi
■ Deep layer
– Levator scapulae
– Rhomboideus minor
– Rhomboideus major

❖ Give the origin, insertion, nerve supply and actions of trapezius muscle.  AN10.8

Origin (fig. 2.1)

Trapezius muscle arises from:

• Medial one-third of the superior nuchal line of occipital bone.

• Ligamentum nuchae.
• Spinous processes and supraspinous ligaments from C7 to T12.
 FIG. 2.1 Origin and insertion of trapezius and latissimus dorsi muscles.

Insertion (fig. 2.1)

It is inserted as follows:

• Superior fibres, into lateral one-third of the posterior border of clavicle.

• Middle fibres, into medial margin of the acromion and upper lip of the crest of
spine of scapula.
• Lower fibres, into deltoid tubercle of the spine of scapula.

Nerve supply

• Spinal root of accessory nerve (CN XI)

• Ventral rami of C3 and C4 spinal nerves

Actions

• Shrugging of shoulder
• Retraction of scapula
• Rotation of scapula to help abduction of arm beyond 90°
❖ Give the origin, insertion, nerve supply and actions of latissimus dorsi muscle. 
AN10.8

Origin (fig. 2.1)

Latissimus dorsi muscle arises from:

• Spinous processes and supraspinous ligaments from T7 to T12

• Posterior layer of thoracolumbar fascia (attached to spinous processes of lumbar
and sacral spines)
• Last four ribs
• Inferior angle of scapula
• Posterior one-third of iliac crest

Insertion
Into the floor of bicipital groove of humerus after spiralling around the teres major
muscle.

Nerve supply (fig. 2.1)

Thoracodorsal nerve (C6, C7 and C8)

Actions

• Extends, adducts and medially rotates the arm.

• Costal attachment helps in deep inspiration and forced expiration.

❖ Write a short note on the triangle of auscultation.  AN10.9

Location
Back of thorax near the inferior angle of scapula.

Boundaries
Medial:
Lateral border of trapezius muscle.

Lateral:
Medial border of scapula.

Inferior:
Upper border of latissimus dorsi muscle.

Floor:
Sixth and 7th intercostal spaces and rhomboideus major muscle.
Applied anatomy

• Respiratory sounds from the apex of lower lobe of lung can be heard over this
triangle.
• Sounds of swallowed liquids may be auscultated over this triangle.

❖ Give the origin, insertion, nerve supply and actions of levator scapulae,
rhomboideus minor and rhomboideus major muscles.
These are given in Table 2.1.

TABLE 2.1
Origin, Insertion, Nerve Supply and Actions of Levator Scapulae, Rhomboideus
Minor and Rhomboideus Major Muscles

Scapular region
❖ Give the origin, insertion, nerve supply and actions of the deltoid muscle. 
AN10.10
The deltoid is a three-in-one muscle (Fig. 2.2). It is strong triangular muscle covering
the shoulder like a hood. It is responsible for the rounded contour of the shoulder.
 FIG. 2.2 Origin and insertion of the deltoid muscle.

Origin
Anterior unipennate part:
From anterior border and upper surface of lateral one-third of clavicle.

Intermediate multipennate part:

From lateral border of acromion process of scapula.

Posterior unipennate part:

From lower lip of crest of spine of scapula.

N.B.
Architecture of deltoid muscle. The acromial part is multipennate and strongest. The
acromial fibres arise from four intramuscular tendinous septa and are attached on
either side of three tendinous septa ascending from the insertion of the muscle on the
deltoid tuberosity of humerus (Fig. 2.3).
 FIG. 2.3 Architecture of the deltoid muscle.

Insertion
In the V-shaped deltoid tuberosity on the lateral aspect of the shaft of humerus.

Nerve supply
Axillary/circumflex nerve (C5, C6).

Actions

• Lateral (acromial) fibres cause abduction of shoulder joint from 15° to 90°.
• Anterior (clavicular) fibres cause medial rotation and flexion of the shoulder joint.
• Posterior (spinous) fibres cause lateral rotation and extension of the shoulder joint
(i.e. they draw the arm backwards and rotate the humerus laterally).

❖ Enumerate the structures under cover of deltoid muscle.  AN10.10

Following are the structures under cover of deltoid muscle (Fig. 2.4):

• Axillary nerve
• Insertion of all the muscles of rotator cuff (supraspinatus, infraspinatus, teres
minor and subscapularis)
• Circumflex humeral vessels
• Surgical neck of humerus
 FIG. 2.4 Structures under cover of deltoid muscle. C, capsule of shoulder joint; G, glenoid
cavity.

❖ Give the origin and insertion of supraspinatus, infraspinatus, teres minor,

subscapularis and teres major muscles.  AN10.10
The origin and insertion of these muscles are given in Table 2.2 and shown in Figs 2.5
and 2.6.

FIG. 2.5 Origin and insertion of supraspinatus, infraspinatus, teres minor and teres major
muscles. TM, teres minor.
 FIG. 2.6 Origin and insertion of subscapularis muscle.

TABLE 2.2
Origin and Insertion of Supraspinatus, Infraspinatus, Teres Minor, Subscapularis
and Teres Major Muscles

Muscle Origin Insertion

Supraspinatus Medial two-third of the supraspinous fossa of the Upper facet on the greater
scapula tubercle of the humerus
Infraspinatus Medial two-third of the infraspinous fossa of the Middle facet on the greater
scapula and fibrous intermuscular septa tubercle of the humerus
Teres minor Upper two-third of the dorsal surface of the lateral Inferior facet on the greater
border of the scapula tubercle of the humerus
Subscapularis Medial two-third of the subscapular fossa Lesser tubercle of the
humerus
Teres major Lower one-third of the dorsal surface of lateral Medial lip of bicipital groove
border and inferior angle of the scapula of the humerus
❖ Give nerve supply and actions of supraspinatus, infraspinatus, teres minor,
subscapularis and teres major muscles.

Muscle Nerve Supply Action

• Suprascapular nerve (C5,
Supraspinatus C6)
• Infraspinatus Suprascapular nerve (C5,
C6)
• Teres minor Axillary nerve (C5, C6)
• Upper and lower
Subscapularis subscapular nerves (C5,
C6)
• Teres major Lower subscapular nerve
Abduction of shoulder joint from 0° to 15°, i.e. it
initiates the abduction of shoulder joint
Lateral rotation of arm
Lateral rotation of arm
Adduction and medial rotation of arm
Adduction and medial rotation of arm
 (C5, C6)

N.B.
These muscles also help in holding the head of humerus into the glenoid cavity.

❖ Write a short note on musculotendinous cuff/rotator cuff of the shoulder joint. 

AN10.10
The musculotendinous cuff (Fig. 2.7) is a fibrous sheath around the shoulder joint. It is
formed by the flattened tendons of four muscles, which blend with the capsule of
shoulder joint as follows:

• Supraspinatus, superiorly
• Infraspinatus and teres minor, posteriorly
• Subscapularis, anteriorly

FIG. 2.7 Musculotendinous cuff.

N.B.
The musculotendinous cuff provides strength to the capsule of shoulder joint all
around except inferiorly. For this reason, dislocation of the shoulder joint commonly
occurs inferiorly.

❖ Write briefly about the quadrangular space.

The quadrangular space (Fig. 2.8) is one of the subscapular intermuscular spaces
present in the region of axilla.
 FIG. 2.8 Subscapular intermuscular spaces. Q, quadrangular space; U, upper triangular
space; L, lower triangular space.

Boundaries
Superior

• Subscapularis in front
• Teres minor behind
• Capsule of the shoulder joint (in between subscapularis and teres minor)

Inferior:
Teres major

Medial:
Long head of the triceps brachii

Lateral:
Surgical neck of the humerus

Structures passing through the space

• Axillary nerve
• Posterior circumflex humeral vessels

Applied anatomy
The fracture of surgical neck of humerus may damage the axillary nerve leading to
paralysis of deltoid muscle.

❖ Write briefly about the upper triangular space.

The upper triangular space (Fig. 2.8) is one of the subscapular intermuscular spaces
present in the region of axilla.

Boundaries
Superomedial:
Teres minor

Lateral:
Long head of the triceps brachii

Inferior:
Teres major

Structure passing through the space

The circumflex scapular artery which interrupts the origin of the teres minor to reach the
infraspinous fossa.

Applied anatomy
The circumflex scapular artery anastomoses with the suprascapular and deep branch of the
transverse cervical arteries to form an important arterial anastomosis around scapula.

❖ Write briefly about the lower triangular space.

The lower triangular space (Fig. 2.8) is one of the subscapular intramuscular spaces.

Boundaries
Medial:
Long head of the triceps brachii

Lateral:
Shaft of humerus

Superior:
Teres major

Structures passing through this space

• Radial nerve
• Profunda brachii vessels

Applied anatomy
The fracture of middle-third of humerus may damage radial nerve leading to wrist
drop.
3

Arm
❖ Enumerate the muscles on the front of arm and give their nerve supply.  AN11.1
The muscles on the front of arm are

• Biceps brachii
• Coracobrachialis
• Brachialis

All these muscles are supplied by the musculocutaneous nerve.

❖ Draw the transverse section of arm at the level of insertion of coracobrachialis to

show the arrangement of various structures.
The transverse section of arm is given in Fig. 3.1.

FIG. 3.1 Transverse section of arm at the insertion of coracobrachialis.

❖ Give the origin, insertion, nerve supply and actions of biceps brachii.  AN11.1

Origin
Biceps brachii (Fig. 3.2) arises by two heads:

• Long head arises from the supraglenoid tubercle of scapula (origin is

intracapsular but extrasynovial).
• Short head arises from the tip of coracoid process of scapula along with
 coracobrachialis.

FIG. 3.2 Origin and insertion of biceps brachii.

Insertion
By a tendon into the tuberosity of radius (posterior rough part).

Nerve supply
Musculocutaneous nerve.

Actions

• Flexor of elbow joint.

• Supinator of forearm when elbow is flexed.
• Long head keeps the head of humerus in position during abduction of shoulder
joint.

❖ Name the joints at which biceps brachii acts and tell the movements that it
produces at these joints.
 • Biceps brachii acts at three joints: (a) shoulder joint, (b) elbow joint and (c)
superior radioulnar joint.
• Movements produced at these joints are
(a) At shoulder joint: Flexion of arm (by short head)
(b) At elbow joint: Flexion of forearm
(c) At superior radioulnar joint: Supination of forearm when forearm is
semiflexed in midprone position

❖ Give the origin, insertion, nerve supply and actions of coracobrachialis.  AN11.1

Origin
From the tip of coracoid process of scapula along with the short head of biceps brachii.

Insertion
In the middle of the medial border of the shaft of humerus.

Nerve supply
Musculocutaneous nerve.

Actions
Adducts the arm and flexes the shoulder joint.

❖ Give the origin, insertion, nerve supply and actions of brachialis.  AN11.1

Origin
From lower half of the front of humerus and medial and lateral intermuscular septa.

Insertion
Into coronoid process and tuberosity of ulna.

Nerve supply

• Musculocutaneous nerve
• Radial nerve (supplies only a small lateral part)

Action
Flexor of elbow joint.

N.B.
The brachialis is also termed workhorse of the elbow joint.

❖ Describe the musculocutaneous nerve in brief.  AN11.2

The musculocutaneous nerve, as its name implies, supplies the muscles of front of arm
and skin on the lateral side of forearm (Fig. 3.3).

FIG. 3.3 Course and main branches of musculocutaneous nerve.

Origin
From lateral cord of brachial plexus (C5, C6 and C7).

Course
It arises obliquely from the lateral cord of brachial plexus behind pectoralis minor
muscle. There it lies lateral to axillary artery. It pierces coracobrachialis muscle and
reaches the lateral side of the arm. Then it runs laterally downwards between biceps
brachii and brachialis muscles. At the crease of elbow, it pierces the deep fascia lateral
to the tendon of biceps brachii from where it continues as lateral cutaneous nerve of
forearm.

Branches
Muscular:
To coracobrachialis, biceps brachii and brachialis.
Cutaneous:
Lateral cutaneous nerve of forearm to lateral side of forearm.

Articular:
To elbow joint.

Applied anatomy
Isolated lesions of the musculocutaneous nerve are rare.

❖ Describe the brachial artery in brief and discuss its applied anatomy.  AN11.2

Origin
The brachial artery is continuation of the axillary artery below the lower border of teres
major muscle (Fig. 3.4).

FIG. 3.4 Brachial artery.

Course
It runs downward to reach the cubital fossa where it terminates at the level of neck of
radius by dividing into radial and ulnar arteries.

N.B.
It is superficial throughout its course.

Branches
Apart from the muscular branches, the named branches of brachial artery are

• Profunda brachii artery (largest branch)

• Nutrient artery to humerus
• Superior and inferior ulnar collateral arteries

Applied anatomy

• Blood pressure is recorded by auscultating the pulsations of brachial artery in

the cubital fossa medial to tendon of biceps brachii.
• Brachial artery can be compressed digitally at midarm against the tendon of
coracobrachialis on the medial side of the humerus.
• Brachial artery may be ruptured in supracondylar fracture of humerus.

❖ Write a short note on profunda brachii artery.   AN11.2

Origin
It is the largest (main) branch of brachial artery arising just below the lower border of
teres major muscle.

Course
The artery accompanies the radial nerve posteriorly in the radial groove, deep to
triceps. In radial groove, it gives various branches.

Branches (fig. 3.5)

Apart from muscular branches, the name of branches of profunda brachii artery are:

1. Nutrient artery to humerus near the deltoid tuberosity.

2. Ascending branch, ascends between long and lateral heads of triceps to
anastomose with posterior circumflex humeral artery.
3. Radial collateral artery is the continuation of the profunda brachii artery and
pierces the lateral intermuscular septum with the radial nerve, reaches the elbow
and anastomoses with the radial recurrent artery.
4. Middle collateral artery, also called posterior descending branch, descends
through the medial head of triceps, reaches the elbow and anastomoses with the
interosseus recurrent artery.
 FIG. 3.5 Profunda brachii artery.

Applied anatomy
Branches of profunda brachii artery take part in the formation of arterial anastomosis
around elbow.

❖ Enumerate the various anatomical events that occur at the level of insertion of
coracobrachialis.
The anatomical events occurring at the level of insertion of coracobrachialis are:

• Circular shaft of humerus becomes triangular below this level.

• Deltoid and coracobrachialis are inserted at this level.
• Upper end of origin of brachialis extends up to this level.
• Brachial artery passes from medial side of arm to its anterior aspect.
• Basilic vein pierces the deep fascia at this level.
• Median nerve crosses in front of brachial artery from lateral to medial side.
• Radial nerve pierces lateral intermuscular septum to pass from the posterior
compartment of arm to the anterior compartment of arm.
• Ulnar nerve pierces medial intermuscular septum to go from the anterior
compartment of arm to the posterior compartment of arm.
• Medial cutaneous nerves of arm and forearm pierce the deep fascia at this level.
• Nutrient artery pierces the humerus at this level.

Therefore, the site of insertion of coracobrachialis is an important anatomical

landmark in the arm.

❖ Enumerate the contents of posterior compartment of the arm.  AN11.1

The contents of posterior compartment of arm are:

• Triceps brachii muscle

• Radial nerve
• Profunda brachii artery

❖ Give the origin, insertion, nerve supply and actions of triceps brachii.  AN11.1

Origin
Triceps brachii muscle (Fig. 3.6) arises by three heads – long, lateral and medial.

FIG. 3.6 Origin and insertion of triceps brachii.

Long head:
From infraglenoid tubercle of scapula.

Lateral head:
From oblique ridge above the spiral groove (i.e. lateral lip of the spiral groove).

Medial head:
From posterior surface of shaft of humerus below the level of spiral groove.

Insertion
Into the posterior part of the superior surface of olecranon process of ulna.

Nerve supply
Radial nerve (C7, C8).
Note. Each head is supplied by a separate branch. The branch supplying long head
arises in axilla, the branch supplying lateral head arises in spiral groove and the branch
supplying medial head arises both in axilla and spiral groove.

Action
Extensor of elbow.

❖ Write a short note on the arterial anastomosis around the elbow joint.  AN11.6
The arterial anastomosis around the elbow joint (Fig. 3.7) is formed between the
branches of the following arteries:

• Brachial artery
• Radial artery
• Ulnar artery
 FIG. 3.7 Arterial anastomosis around elbow joint. L, lateral epicondyle; M, medial epicondyle.

(For details, see p. 31)

❖ Write a short note on cubital fossa.  AN11.5

Cubital fossa (Fig. 3.8) is a triangular hollow in front of the elbow joint.

FIG. 3.8 Boundaries and contents of cubital fossa.

Boundaries

• Base is formed by an imaginary horizontal line, joining the medial and lateral
epicondyles of the humerus.
• Medial wall is formed by pronator teres.
• Lateral wall is formed by brachioradialis.
• Roof is formed by skin, superficial fascia, deep fascia, and bicipital aponeurosis.
The superficial fascia contains median cubital vein, lateral cutaneous nerve of
forearm and medial cutaneous nerve of forearm.
• Floor is formed by brachialis muscle in the upper and medial part, and supinator
muscle in the lower and lateral part.
• Apex is a point where pronator teres disappears underneath the brachioradialis
muscle.

Contents
From medial to lateral side:

• Median nerve
• Brachial artery
• Biceps tendon
• Superficial branch of radial nerve
Mnemonic: MBBS.

Applied anatomy

• The brachial artery is auscultated in cubital fossa for recording the blood
pressure.
• The median cubital vein is used in the region of cubital fossa for venipuncture,
as it lies superficial to bicipital aponeurosis and is the most fixed vein.
4

Forearm

Front of forearm
❖ Describe the flexor retinaculum at wrist in brief.  AN12.3
The flexor retinaculum is a strong fibrous band formed by the thickening of deep fascia
in front of carpal bones (anatomical wrist). It bridges the anterior concavity of carpus
and converts it into an osseofibrous tunnel called carpal tunnel.

Attachments (fig. 4.1)

It is rectangular in shape and attached as follows:

• Medially, to pisiform bone and hook of Hamate

• Laterally, to tubercle of scaphoid and crest of trapezium

FIG. 4.1 Attachments of flexor retinaculum on carpal bones/bones of carpus.

N.B.
On either side, the retinaculum gives a slip:

(a) A superficial slip on medial side (volar carpal ligament) is attached to the pisiform
bone. The ulnar artery and nerve passes deep to this slip.
(b) A deep slip on lateral side is attached to the medial lip of the groove on trapezium,
converting this groove into a tunnel, which provides passage to the tendon of
flexor carpi radialis.
Features

• Converts the concavity of carpus into an osseofibrous tunnel – the carpal

tunnel.
• Proximally, it gives attachment to the tendon of palmaris longus.
• Distally, it gives attachment to the apex of palmar aponeurosis.

Superficial relations
These are (Fig. 4.2)

• Ulnar artery and nerve

• Palmar cutaneous branch of median nerve
• Tendon of palmaris longus
• Superficial palmar branch of radial artery

FIG. 4.2 Flexor retinaculum: A, formation at the level of proximal row of carpal bones (I) and
formation at the level of distal row of carpal bones (II); B, structures passing deep to the flexor
retinaculum (i.e. through carpal tunnel). FDP, flexor digitorum profundus; FDS, flexor digitorum
superficialis.

❖ Enumerate the structures passing deep to the flexor retinaculum/carpal tunnel. 

AN12.3
The structures passing deep to the flexor retinaculum are (Fig. 4.2)

• Median nerve
• Four tendons of the flexor digitorum superficialis
• Four tendons of the flexor digitorum profundus
• Tendon of the flexor pollicis longus
• Ulnar bursa
 • Radial bursa

N.B.
The tendon of the flexor carpi radialis passes between the two slips of retinaculum
through the groove of the trapezium.

❖ Enumerate the superficial muscles on the front of forearm.  AN12.1

They are five in number. From medial to lateral side, these are

• Flexor carpi ulnaris

• Palmaris longus
• Flexor digitorum superficialis
• Flexor carpi radialis
• Pronator teres

N.B.
All the superficial muscles on the front of forearm are supplied by the median nerve
except flexor carpi ulnaris, which is supplied by the ulnar nerve.

❖ Give the origin, insertion, nerve supply and actions of pronator teres.  AN12.1

Origin
It arises by two heads (Fig. 4.3).
 FIG. 4.3 Origin and insertion of pronator teres.

Humeral head:
From the lower part of the medial epicondyle of the humerus.

Ulnar head:
From the medial border of the coronoid process of ulna.

Insertion (fig. 4.3)

Into the lateral surface of the radius at its maximum convexity (middle of the lateral
border of the radial shaft).

Nerve supply
Median nerve as it passes between its two heads of pronator teres.

Action
Pronation of the forearm.

❖ Give the origin and insertion of superficial muscles of the forearm in a tabular
form.   AN12.1

Muscle Origin Insertion

 Pronator Medial Middle of lateral aspect of shaft of radius
teres epicondyle of
humerus and
coronoid process
of ulna
Flexor carpi Medial Bases of 2nd and 3rd metacarpal bones
radialis epicondyle of
humerus
Palmaris Medial Flexor retinaculum and apex of palmar aponeurosis
longus epicondyle of
humerus
Flexor Muscle divides into four tendons; each tendon divides
digitorum into two slips that are inserted onto the sides of middle
superficialis • Medial epicondyle phalanges of medial four fingers
(FDS) of humerus
• Humeroulnar • Medial border of
head coronoid process of
• Radial head ulna
• Anterior oblique
line of shaft of
radius
Flexor carpi • Medial epicondyle Pisiform bone: Insertion is prolonged further to be
ulnaris of humerus attached to the hook of hamate and base of 5th
• Humeral head • Posterior border of metacarpal bone forming pisohamate and pisometacarpal
• Ulnar head ulna ligaments

N.B.
The five superficial muscles on the front of forearm have common origin from medial
epicondyle of humerus, which is termed ‘common flexor origin’.

❖ Enumerate the deep muscles on the front of forearm.  AN12.1

These are three in number as follows:

• Flexor pollicis longus (FPL)

• Flexor digitorum profundus (FDP)
• Pronator quadratus

❖ Give the origin and insertion of deep muscles on the front of forearm in a tabular
form.  AN12.1

Muscle Origin Insertion

Flexor • Upper three- Muscle forms four tendons to be inserted into medial four
digitorum fourth of the fingers; opposite the proximal phalanx of the corresponding
profundus anterior and digit, each tendon perforates the tendon of the flexor digitorum
(FDP) medial surfaces of superficialis before being inserted on the palmar surface of the
the shaft of ulna base of the corresponding distal phalanx
• Upper three-
fourth of the
 posterior border
of ulna
• Medial surface of
the olecranon and
coronoid
processes of ulna
• Adjoining part of
interosseous
membrane
Flexor • Upper three- Into the palmar surface of the distal phalanx of the thumb
pollicis fourth of the
longus anterior surface of
(FPL) the shaft of radius
below anterior
oblique line
• Adjoining part of
interosseous
membrane
Pronator Lower one- Lower one-fourth of the anterolateral aspect of the shaft of
quadratus fourth of the radius above ulnar notch
anteromedial
aspect of the
shaft of ulna

N.B.
All the deep muscles on the front of forearm are supplied by anterior interosseous nerve
(C8, T1) – a branch of median nerve except medial half of FDP, which is supplied by
ulnar nerve.

❖ Enumerate the structures on the front of the wrist.  AN12.2

From lateral to medial side, these are (Fig. 4.4)

• Radial artery
• Tendon of flexor carpi radialis (FCR)
• Median nerve
• Tendon of palmaris longus
• Tendon of flexor digitorum superficialis (FDS)
• Ulnar artery
• Ulnar nerve
• Tendon of flexor carpi ulnaris
 FIG. 4.4 Structures lying in front of the wrist.

Back of forearm
❖ Describe the extensor retinaculum at wrist in brief.  AN12.14
The extensor retinaculum is a strong fibrous band about 2 cm broad running obliquely
downwards and medially on the back of the wrist. It is formed by the thickening of
deep fascia. It holds the extensor tendons in place.

Attachments

Laterally to: Lower 2 cm of anterior border of radius.

Medially to:
• Styloid process of ulna
• Triquetral bone
• Pisiform bone

Compartments
Space deep to extensor retinaculum is divided into six osseo-fascial compartments by
septa, extending from retinaculum to the ridges on the dorsal aspect of the lower ends
of radius and ulna. The compartments are numbered I–VI from lateral to medial side.

❖ Enumerate the structures passing through various compartments underneath the

extensor retinaculum.  AN12.14
The structures passing through various compartments underneath the extensor
retinaculum are (Fig. 4.5):
 Compartment Structure passing through
I • Abductor pollicis longus (APL)
• Extensor pollicis brevis (EPB)
II • Extensor carpi radialis longus (ECRL)
• Extensor carpi radialis brevis (ECRB)
III • Extensor pollicis longus (EPL)

IV • Extensor digitorum (ED)

• Extensor indicis (EI)
• Posterior interosseous nerve
• Anterior interosseous artery
V • Extensor digiti minimi (EDM)

VI • Extensor carpi ulnaris (ECU)

FIG. 4.5 Transverse section of forearm just above the wrist showing structures passing deep
to the extensor retinaculum.

❖ Enumerate the superficial muscles on the back of forearm.  AN12.11

They are seven in number as follows:

• Anconeus
• Brachioradialis
• Extensor carpi radialis longus
• Extensor carpi radialis brevis
• Extensor digitorum
• Extensor digiti minimi
• Extensor carpi ulnaris

❖ Give the origin and insertion of superficial muscles on the back of forearm. 
AN12.11

Muscle Origin Insertion

Anconeus Posterior aspect of lateral Lateral surface of olecranon process
epicondyle of humerus of ulna
Brachioradialis Upper two-third of lateral Base of styloid process of radius
 supracondylar ridge of humerus
Extensor carpi Lower one-third of lateral Posterior surface of base of 2nd
radialis longus supracondylar ridge of humerus metacarpal bone
(ECRL)
Extensor carpi Anterior aspect of lateral Posterior surface of base of 3rd
radialis brevis epicondyle of humerus metacarpal bone
(ECRB)
Extensor digitorum Anterior aspect of lateral By four tendons on bases of middle
(ED) epicondyle of humerus phalanges of 2nd to 5th digits
Extensor digiti Anterior aspect of lateral Extensor expansion of little finger
minimi (EDM) epicondyle of humerus
Extensor carpi Anterior aspect of lateral Base of 5th metacarpal bone
ulnaris (ECU) epicondyle of humerus

N.B.

• All the superficial muscles on the back of forearm except anconeus and
brachioradialis and ECRL arise by a common extensor tendon from the anterior
aspect of lateral epicondyle of humerus. This is termed common extensor origin.
• All the muscles on the back of forearm are supplied by deep branch of radial nerve
(posterior interosseous nerve except anconeus, brachioradialis and ECRL, which are
supplied by radial nerve directly).

❖ Give the origin, insertion, nerve supply and actions of the brachioradialis. 
AN12.11

Origin
Upper two-third of the lateral supracondylar ridge of the humerus (Fig. 4.6).
 FIG. 4.6 Origin and insertion of brachioradialis.

Insertion
Lateral aspect of lower end of radius just above its styloid process (Fig. 4.6).

Nerve supply
Radial nerve (C5, C6).

Actions

• Flexion of the elbow in the midprone position as required when carrying the
apron over the shoulder.
• Actively involved in alternate movements of flexion and extension of elbow, acting
like a shunt muscle.
• It also helps in both supination and pronation.

N.B.
It is flexor of the elbow, although it is supplied by a nerve of extensor compartment of
forearm.
❖ Enumerate the deep muscles on the back of forearm.  AN12.11
These are five in number and as follows:

• Supinator
• Abductor pollicis longus (APL)
• Extensor pollicis brevis (EPB)
• Extensor pollicis longus (EPL)
• Extensor indicis

❖ Give the origin and insertion of deep muscles on the back of forearm in a tabular
form.  AN12.11

Muscle Origin Insertion

Supinator • Supinator crest and supinator fossa of Neck and upper one-third of shaft of
ulna radius (between anterior and posterior
• Lateral epicondyle of humerus, oblique lines)
annular ligament of superior
radioulnar joint
Abductor Posterior surface of shaft of radius Base of 1st metacarpal bone
pollicis (upper part) and shaft of ulna
longus (middle one-third)
Extensor Lower one-third of posterior surface Base of proximal phalanx of thumb
pollicis of shaft of radius
brevis
Extensor Middle one-third of posterior Base of distal phalanx of thumb
pollicis surface of shaft of ulna
longus
Extensor Lower part of posterior surface of Extensor expansion of index finger
indicis shaft of ulna

N.B.
All the muscles on the back of forearm are supplied by posterior interosseous nerve (deep
branch of radial nerve).

❖ Give the origin, insertion, nerve supply and action of the supinator muscle. 
AN12.11

Origin (fig. 4.7)

Deep part:
From supinator crest of ulna and triangular area in front of it (supinator fossa).
 FIG. 4.7 Origin and insertion of supinator muscle.

Superficial part:
From lateral epicondyle of humerus, radial collateral ligament and annular ligament.

Insertion (fig. 4.7)

Upper one-third of the lateral surface of the radius between anterior and posterior
oblique lines.

Nerve supply
Posterior interosseous nerve (i.e. deep branch of the radial nerve [C6, C7]).

Action
Supination of the forearm.

❖ Describe the posterior interosseous nerve in brief.  AN12.12

It is the deep terminal branch of the radial nerve (Fig. 4.8).
 FIG. 4.8 Branches of posterior interosseous nerve.

Origin
It arises from radial nerve just above cubital fossa in front of lateral epicondyle.

Course
The nerve winds around the lateral side of radius and passes through the supinator
muscle (between its superficial and deep laminae) to appear on the back of forearm.

Termination
On the back of wrist where it ends by forming a pseudoganglion.

Branches

• In the cubital fossa, it supplies:

• Extensor carpi radialis brevis
• Supinator (as it passes through the muscle)
• In the back of forearm, it supplies:
• Abductor pollicis longus
• Extensor pollicis brevis
 • Extensor pollicis longus
• Extensor digitorum
• Extensor indicis
• Extensor digiti minimi
• Extensor carpi ulnaris

Applied anatomy
The lesion of posterior interosseous nerve produces wrist drop due to unopposed
action of the flexor muscles.
5

Hand

Palm of the hand

❖ Describe the palmar aponeurosis briefly and discuss its applied anatomy.
The palmar aponeurosis (Fig. 5.1) is the thick central part of the deep fascia of the palm.
It is triangular in shape with its apex facing proximally and base facing distally. It
overlies the superficial palmar arch, long flexor tendons, terminal part of the median
nerve and superficial branch of the ulnar nerve.

FIG. 5.1 Palmar aponeurosis.

Attachments
Apex:
It is attached to the flexor retinaculum and provides insertion to the tendon of palmaris
longus.
Base:
Just proximal to the heads of metacarpals, divides into four longitudinal slips – one for
each medial four digits. Each slip has a superficial and a deep set of fibres. The
superficial fibres are attached to the skin of fingers at their roots. The deep fibres blend
with the fibrous flexor sheaths and are also connected to deep transverse ligaments of
palm.

Relations

• Between the slips (in the web spaces of fingers), the digital nerve and vessels
emerge to pass distally.
• From the medial and lateral borders of palmar aponeurosis, medial and lateral
intermuscular septa extend inwards and get attached to 5th and 1st
metacarpals, respectively. These septa divide the palm into compartments.

Functions

• Protects the underlying tendons, nerves and vessels

• Helps to improve the grip of hand by fixing the skin of the palm

Applied anatomy
The progressive contraction of medial part of palmar aponeurosis produces a deformity
called Dupuytren’s contracture. The little and ring fingers are usually involved. The
proximal and middle phalanges become flexed and cannot be straightened. The distal
phalanges, however, remain unaffected or may become hyperextended (Fig. 5.2).
 FIG. 5.2 Dupuytren’s contracture.

❖ Enumerate the intrinsic muscles of the hand.  AN12.5

These are given next.

Subcutaneous muscle

• Palmaris brevis

Muscles of thenar eminence

• Abductor pollicis brevis

• Flexor pollicis brevis
• Opponens pollicis

Adductor of thumb

• Adductor pollicis

Muscles of hypothenar eminence

• Abductor digiti minimi

• Flexor digiti minimi
• Opponens digiti minimi
Lumbricals

• Four in number
• Numbered from lateral to medial side (1, 2, 3 and 4)

Interossei

• Palmar interossei (four in number)

• Dorsal interossei (four in number)

N.B.
All the intrinsic muscles of the hand are supplied by ulnar nerve except muscles of
thenar eminence and lateral two (i.e. 1st and 2nd) lumbricals, which are supplied by the
median nerve.

❖ Write a short note on adductor pollicis.  AN12.5

It is a fan-shaped deeply placed muscle in the lateral part of hand (Fig. 5.3).

FIG. 5.3 Origin and insertion of adductor pollicis muscle. H, hamate; C, capitate; T, trapezoid;
Tr, trapezium.

Origin

(a) Oblique head: From capitate, and bases of 2nd and 3rd metacarpals.
(b) Transverse head: From linear ridge on the middle of the palmar surface of 3rd
metacarpal.

Insertion
Two heads converge and meet to form a tendon, which is inserted into the medial side
of base of proximal phalanx of the thumb and often contains a sesamoid bone.

Nerve supply: By deep branch of ulnar nerve (C8, T1).

Action: Adduction of thumb towards other fingers as in power grip.

❖ Give the origin, insertion, nerve supply and actions of lumbrical muscles. 
AN12.5
The origin and insertion of lumbrical muscles are presented in Table 5.1 and Fig. 5.4.

FIG. 5.4 Lumbrical muscles.

TABLE 5.1
Origin and Insertion of Lumbrical Muscles

Origin Insertion
From four tendons of FDP Via extensor expansion on to the dorsum of bases
• First, from lateral side of tendon of 2nd of distal phalanges
digit
• Second, from lateral side of tendon of 3rd
digit
• Third, from adjacent sides of tendons of
3rd and 4th digits
• Fourth, from adjacent sides of tendons of
4th and 5th digits

N.B.
First and 2nd lumbricals are unipennate, while 3rd and 4th lumbricals are bipennate.
Nerve supply
First and 2nd lumbricals are supplied by median nerve, whereas 3rd and 4th lumbricals
are supplied by deep branch of ulnar nerve.

Actions
Flexion of metacarpophalangeal (MP) joints and extension of proximal and distal
interphalangeal (PIP + DIP) joints.

❖ What are interossei muscles? Describe their origin, insertion, nerve supply and
actions in brief.   AN12.5
The interossei are small muscles present between the metacarpals. They are divided
into two groups: palmar interossei and dorsal interossei; each group consists of four
muscles.

Origin and insertion

The origin and insertion of interossei muscles are presented in Table 5.2 and Fig. 5.5.

FIG. 5.5 Interosseous muscles: A, palmar interossei; B, dorsal interossei.

TABLE 5.2
Origin and Insertion of Interossei Muscles

Muscle Origin Insertion

Palmar interossei • Arise from
(unipennate, four in metacarpals
number) • First from medial side
of base of 1st
metacarpal
• Second from medial
• Inserted through dorsal digital expansion
• First and 2nd on the medial side of the bases
of proximal phalanges of thumb and index
finger, respectively
• Third and 4th on the lateral side of the bases of
phalanges of ring and little finger, respectively
 side of 2nd metacarpal
• Third from lateral side
of 4th metacarpal
• Fourth from lateral
side of 5th metacarpal
Dorsal interossei • First from adjacent Via extensor expansion into dorsum of bases of
(bipennate, four in sides of 1st and 2nd proximal phalanges of 2nd, 3rd and 4th digits
number) metacarpals
• Second from adjacent
sides of 2nd and 3rd
metacarpals
• Third from adjacent
sides of 3rd and 4th
metacarpals
• Fourth from adjacent
sides of 4th and 5th
metacarpals

Nerve supply
All the interossei are supplied by the deep branch of the ulnar nerve.

Actions
Palmar interossei adduct the digits while dorsal interossei abduct the digits.

Mnemonic: PAD and DAB

(D, dorsal; P, palmar; AD, adductor; AB, abductor)

❖ Write a short note on dorsal digital expansion.  AN12.9

Each tendon of extensor digitorum flattens to form an aponeurotic expansion over the
dorsal aspect of MCP joint, which covers the dorsum and sides of the proximal phalanx
like a hood. At the PIP joint, the aponeurotic expansion divides into three slips: a central
slip and two collateral slips. The central slip is attached to the base of the middle
phalanx and the two lateral slips join each other to form a single slip which is attached
to the dorsal aspect of the base of distal phalanx.
The margins of the extensor expansion are reinforced by intrinsic muscles of the hand
– the interossei and lumbrical muscles (Fig. 5.6).
 FIG. 5.6 Dorsal digital expansion of left middle finger and insertion of lumbricals and interossei
into it.

Functional significance of the dorsal digital expansion

The intrinsic muscles arising from the palmar aspect of the hand and inserting along the
dorsal aspect of the fingers can have unique function in that they flex the
metacarpophalangeal (MP) joints, and extend the proximal and distal interphalangeal
(i.e. PIP and DIP) joints.

❖ What are fascial spaces of the hand?  AN12.10

A number of fascial spaces in the region of hand are formed due to arrangement of
fasciae and fascial septa. These are as follows.

Palmar spaces

• Midpalmar space
• Thenar space
• Pulp space

Dorsal spaces

• Dorsal subcutaneous space

• Dorsal subaponeurotic space

Parona’s space

• Fascial space in front of distal forearm

❖ Write a short note on midpalmar space.  AN12.10

It is a triangular space located under the inner half of the hollow of the palm.

Boundaries (fig. 5.7)

Anterior:
From superficial to deep, the structures forming anterior boundary are palmar
aponeurosis, superficial palmar arch, ulnar bursa enclosing flexor tendons of middle,
ring and little fingers, and 2nd, 3rd and 4th (medial three) lumbricals.

FIG. 5.7 Cross-section of hand showing palmar spaces and spaces on the dorsum of the
hand.

Posterior:
Fascia covering the interossei of the 3rd and 4th spaces.

Lateral:
Oblique intermediate palmar septum extending from palmar aponeurosis to 3rd metacarpal
bone, which separates it from thenar space.

Medial:
Medial palmar septum extending from palmar aponeurosis to 5th metacarpal bone, which
separates it from hypothenar muscles.

Proximally:
It is continuous with the Parona’s space situated deep to the flexor tendons and in front
of pronator quadratus.

Distally:
It continues as extensions around lumbrical canals to web spaces of medial three fingers.
Applied anatomy
This space is primarily infected by puncture wounds. It may be involved secondarily due to
infection spreading from digital synovial sheaths of flexor tendons. From here, the
infection may spread to Parona’s space. If this space is infected, then there is tenderness
in the palm over the area of midpalmar space and painful flexion of little, ring and
middle fingers. The pus from midpalmar space can be drained by an incision into 3rd or
4th web space, depending on where the pus points.

❖ Write a short note on thenar space.   AN12.10

It is a triangular space located under the outer half of the hollow of palm.

Boundaries (fig. 5.7)

Anterior:
Flexor tendons of index finger, 1st lumbrical and palmar aponeurosis.

Posterior:
Fascia covering transverse head of adductor pollicis and 1st dorsal interosseous muscle.

Medial:
Oblique intermediate palmar septum, which separates it from midpalmar space.

Lateral:
Lateral palmar septum extending from palmar aponeurosis to 1st metacarpal.

Proximally:
It is continuous with Parona’s space.

Distally:
Extends around the 1st lumbrical (1st lumbrical canal) to 1st web space.

Applied anatomy
Primary infection to thenar space occurs through puncture wounds. Secondary infection
may be due to infection spreading from digital synovial sheath of index finger. This
space can be drained by an incision in the 1st web space or where the pus points.

❖ Write a short note on pulp space.  AN12.10

It is a closed subcutaneous space in front of distal phalanx of each digit (Fig. 5.8).
 FIG. 5.8 Pulp space of finger.

Boundaries
In front and sides:
Skin.

Behind:
Distal two-third of distal phalanx.

Features
The space is divided into many compartments by fibrous septa extending between the
skin and the bone. The proximal one-fifth of the distal phalanx is outside the pulp space and
corresponds to the epiphysis of the bone, which receives its blood supply from
epiphyseal artery – a branch of digital artery that does not pass through pulp space.
The distal four-fifth of distal phalanx lies within the space and receives its blood
supply from digital artery, which runs through the space.

Applied anatomy
The infection of the pulp space is called whitlow. It can produce necrosis of the distal
four-fifth of the phalanx due to occlusion of digital artery. The complete regeneration is
possible because the proximal epiphyseal portion of phalanx remains unaffected.

❖ Write a short note on Parona’s space.  AN12.10

It is a rectangular fascial space located in front of distal forearm.

Boundaries
Proximally:
It extends up to the origin of flexor digitorum superficialis from anterior oblique line of
radius.

Distally:
It is continuous with fascial spaces in palm.

Superficially:
Long flexor tendons.

Deep:
Pronator quadratus.

Applied anatomy
Infection from palmar spaces may extend proximally into this space and form an
hourglass swelling.

❖ Describe the ulnar and radial bursae in brief.  AN12.9

Ulnar bursa (fig. 5.9)

• It is a large synovial sac that encloses the tendons of flexor digitorum profundus
(FDP) and flexor digitorum superficialis (FDS).
• Proximally, it extends up to 2.5 cm above the flexor retinaculum and distally up
to proximal one-third of the metacarpal bones.
• Distally, on the medial side, it is continuous with the digital synovial sheath of
the little finger.

FIG. 5.9 Synovial sheaths of long flexor tendons of thumb and fingers.
Radial bursa (fig. 5.9)

• It is synovial sheath around the tendon of flexor pollicis longus.

• Proximally, it extends about 2.5 cm above the flexor retinaculum and distally
continuous with the synovial sheath of the thumb.

N.B.
Digital synovial sheaths enclose the long flexor tendons in front of digits and extend from
the level of the neck of the metacarpal bones up to the insertion of these tendons into
the base of distal phalanges.

Dorsum of the hand

❖ Write a short note on anatomical snuffbox.
It is an elongated triangular depression seen on the dorsal aspect of 1st metacarpal when the
thumb is hyperextended.

Boundaries (fig. 5.10)

Medial:
Tendon of extensor pollicis longus.

FIG. 5.10 Boundaries and contents of anatomical snuffbox.

Lateral
 • Tendon of abductor pollicis longus
• Tendon of extensor pollicis brevis

Floor:
Scaphoid, trapezium.

Roof:
Deep fascia stretching between the medial and lateral boundaries.

Contents

• Radial artery

Structures crossing the roof

• Cephalic vein
• Terminal branches of superficial radial nerve

Applied anatomy

• Tenderness in the region of anatomical box indicates fracture of scaphoid.

• Pulsations of radial artery can be felt at this site.

❖ What is dorsal subaponeurotic space? Give its applied importance.  AN12.10

The dorsal subaponeurotic space (Fig. 5.7) lies between the aponeurotic sheath and the dorsal
surfaces of medial four metacarpals and the dorsal interossei.
On the dorsum of hand, the extensor tendons of the fingers are bound to one another
by oblique bands of deep fascia in such a manner as to form an aponeurotic sheath, which
is attached to the borders of 2nd and 5th metacarpals on the lateral and medial sides,
respectively.

Applied anatomy
The primary infection of this space is due to wounds on the dorsum. The space may be
involved secondarily due to infections spreading from midpalmar space via the
lymphatics.

❖ Give sensory innervation of the palmar aspect of the hand.  AN12.7

• Lateral two-third of palm and lateral 3½ digits are supplied by the median
nerve.
• Medial one-third of palm and medial 1½ digits are supplied by the ulnar nerve.
• It is shown in Fig. 5.11.
 FIG. 5.11 Sensory innervation of palmar aspect of the hand.

❖ Give sensory innervation of the dorsal aspect of the hand.  AN12.7

• Lateral two-third of the dorsum of hand and lateral 3½ digits are innervated
by the radial nerve.
• Medial one-third of the dorsum of hand and medial 1½ digits are innervated
by the ulnar nerve.
It is shown in Fig. 5.12.
 FIG. 5.12 Sensory innervation of dorsal aspect of the hand.

N.B.
The skin on the dorsal aspect of distal phalanges of lateral 3½ digits is innervated by
the median nerve, while that of medial 1½ digits by the ulnar nerve.
6

Vessels of the upper limb

Arteries
❖ What is axis artery of upper limb? Enumerate the various arteries that represent
the axis artery in the adult.

• The axis artery is formed by the 7th cervical intersegmental artery.

• In the adult, it persists in the form of the following arteries:
■ Axillary artery
■ Brachial artery
■ Anterior interosseous artery
■ Deep palmar arch

❖ Give a brief account of the axillary artery.  AN10.2

See p. 15.

❖ Give a brief account of the brachial artery.  AN11.2

See p. 30.

❖ Describe the radial artery in brief.  AN12.2

Origin
It is the artery of lateral side of the forearm. It arises in the cubital fossa, 1 cm below the
bend of the elbow, as a smaller terminal branch of the brachial artery.

Course and termination

It runs downwards along the lateral side of the front of forearm to reach the distal end
of radius.
At the wrist, the radial artery winds dorsally passing deep to the tendons of abductor
pollicis longus and extensor pollicis brevis to enter the anatomical snuffbox on
dorsolateral part of the hand.
It enters the palm by passing between the two heads of 1st dorsal interosseous muscle
and terminates by forming the deep palmar arch.

Branches

1. Radial recurrent artery

 2. Dorsal carpal branch
3. Palmar carpal branch
4. First dorsal metacarpal artery – on dorsum of hand
5. Superficial palmar branch.
6. Arteria princeps pollicis
7. Arteria radialis indicis

Applied anatomy
The pulsations of radial artery can be felt at two sites: (a) laterally in front of the distal
one-third of radius (radial pulse) and (b) in the anatomical snuffbox.

❖ Write a short note on ulnar artery.  AN12.2

Origin

• Ulnar artery is the larger terminal branch of the brachial artery.

• It arises in the cubital fossa at the level of neck of radius 1 cm below the bend of
the elbow.
• In the upper one-third, it runs obliquely, downwards and medially while in the
lower two-third, it runs vertically downwards along the medial side of the front
of forearm to the lateral side of pisiform bone.
• It enters palm by passing superficial to flexor retinaculum. In the palm, it forms
superficial palmar arch.

❖ Enumerate the branches of ulnar artery.  AN12.2

• Anterior ulnar recurrent artery

• Posterior ulnar recurrent artery
• Common interosseous artery
• Posterior interosseous artery through common interosseous artery
• Palmar carpal branch
• Dorsal carpal branch

❖ Describe the superficial palmar arch in brief and discuss its applied anatomy. 
AN12.7
The superficial palmar arch is an important anastomosis between ulnar and radial
arteries in the palm of the hand.

Formation (fig. 6.1)

It is formed by the superficial palmar branch of the ulnar artery (the main continuation
of ulnar artery). The arch is completed on the lateral side by one of the following
arteries (Fig. 6.1):

• Superficial palmar branch of the radial artery (most common)

 • Princeps pollicis artery
• Radialis indices artery

FIG. 6.1 Superficial and deep palmar arterial arches.

Note: The princeps pollicis and radial indices arteries are not the branches of deep
palmar arch.

Location and branches

• The superficial palmar arch lies superficial to the long flexor tendons with
convexity directed distally.
• It lies at the level of distal border of the fully extended thumb.
• It gives off four palmar digital arteries, which supply medial 3.5 digits.

Applied anatomy
The superficial palmar arch is one of the important anastomotic arterial channels for
efficient blood supply to the hand in case of blockage of the radial or ulnar artery.

❖ Describe the deep palmar arch in brief and discuss its applied anatomy.  AN12.7

Formation
It is formed by the continuation of radial artery in the palm. The arch is completed on
the medial side by the deep branch of the ulnar artery (Fig. 6.1).

Location and branches

The arch lies deep to long flexor tendons with convexity directed distally. It lies about 1
cm proximal to the superficial palmar arch (at the level of proximal border of the fully
extended thumb).
It gives off the following branches:

• Three palmar metacarpal arteries (to second, third and fourth interosseous
spaces)
• Three perforating arteries
• Recurrent branches

Applied anatomy
The deeper palmar arch is one of the important anastomotic arterial channels between
the radial and ulnar arteries for efficient blood supply to the hand in the event of
blockage of the radial or ulnar artery.

❖ Give a brief account of arterial anastomosis around the scapula and discuss its
applied anatomy.   AN10.9
See p. 17.
❖ Give a brief account of anastomosis around the elbow joint (Fig. 6.2).  AN11.6
It is an arterial anastomosis around the elbow between the branches of brachial artery
with the branches from upper ends of ulnar and radial arteries. The anastomoses take
place in front and behind the two epicondyles of the humerus (also see Fig. 3.7).

FIG. 6.2 Arterial anastomosis around elbow joint.

In front of lateral epicondyle:

Between the anterior descending branch (radial collateral artery) of the profunda brachii
artery and the radial recurrent artery – a branch of the radial artery.

Behind the lateral epicondyle:

Between the posterior descending branch (middle collateral artery) of the profunda
brachii artery and the interosseous recurrent branch of the posterior interosseous artery.

In front of medial epicondyle:

Between the inferior ulnar collateral branch of the brachial artery and the anterior ulnar
recurrent branch of the ulnar artery.

Behind the medial epicondyle:

Between the superior ulnar collateral branch of the brachial artery and the posterior
ulnar recurrent artery – a branch of the ulnar artery.

❖ Enumerate the sites in the upper limb where arterial pulsations can be felt. 
AN13.7

• Pulsations of axillary artery can be felt against the lateral wall of the axilla.
• Pulsations of brachial artery can be felt: (a) on the medial side of midarm where
it lies on the tendon of insertion of coracobrachialis and (b) in the cubital fossa
medial to the tendon of biceps brachii.
• Pulsations of radial artery can be felt:
■ At the wrist in front of lower end of radius lateral to the tendon of flexor
carpi radialis
■ In the anatomical snuff box
• Pulsations of ulnar artery can be felt at the wrist just lateral to the pisiform
bone.

Veins
❖ Enumerate the veins of the upper limb.  AN13.7

Deep veins

• Venae comitantes of radial and ulnar arteries

• Venae comitantes of brachial artery
• Brachial vein
• Axillary vein

Superficial veins

• Cephalic vein
• Basilic vein
• Median vein of forearm
❖ Give a brief account of axillary vein.  AN10.2

Commencement
It begins as the continuation of basilic vein at the lower border of teres major.

Course
It passes upwards to reach the axilla where it lies medial to axillary artery. At the outer
border of 1st rib, it continues as the subclavian vein.

Tributaries

• Brachial veins (at its commencement)

• Cephalic vein near its termination
• Veins corresponding to branches of the axillary artery, i.e. lateral thoracic vein,
subscapular vein, etc.

❖ Give a brief account of cephalic vein.  AN12.2

The cephalic vein is the superficial preaxial vein of the upper limb (Fig. 6.3).

FIG. 6.3 Superficial veins on the front of upper limb.

Commencement, course and termination

Begins from the lateral side of dorsal venous arch of hand.
It passes upwards across the roof of anatomical snuffbox on the dorsum of hand; then
it curves around the radius to reach the front of forearm. It ascends on the lateral part of
the front of forearm. One inch below the elbow, it gives the median cubital vein which
joins the basilic vein on the medial side. Then it ascends lateral to biceps, and pierces
deep fascia at the lower border of pectoralis major to enter the deltopectoral groove to
reach the infraclavicular fossa. Here it takes a sharp turn backwards to pierce the
clavipectoral fascia and ends in the axillary vein.
At elbow, the greater part of its blood is drained into basilic vein through median
cubital vein.

Tributaries

• Unnamed veins from front and back of lateral side of forearm

• Median cephalic vein (if present)

Applied anatomy
It is used for intravenous injection.

N.B.
Occasionally, a persistent embryonic vein passes in front of the clavicle linking the
cephalic vein to external jugular vein.

❖ Describe the basilic vein in brief and discuss its applied anatomy.  AN12.2
It is the superficial postaxial vein of the upper limb (Fig. 6.3).

Commencement, course and termination

• Begins from the medial side of the dorsal venous arch of hand.
• Ascends on the medial border of the forearm. Then it curves forwards a little
below elbow, to ascend on the front of the elbow.
• One inch above the elbow, it is joined by the median cubital vein.
• Then, it ascends on the medial side of the biceps and pierces the deep fascia in
the middle of the arm.
• Thereafter, it ascends medial to the brachial artery; and at the lower border of
teres major it continues into the axilla as axillary vein.

Tributaries

• Unnamed veins from front and back of medial side of forearm

• Median cubital vein

Applied anatomy
It is used for:
 • Giving intravenous injections
• Performing cardiac catheterization

❖ Give a brief account of the median cubital vein and discuss its applied anatomy.
  AN11.2, AN11.3
The median cubital vein (Fig. 6.3) is a large communicating venous channel on the front
of the elbow joining the cephalic vein with the basilic vein. It begins from cephalic vein
2.5 cm below the bend of elbow and runs upward and medially to join the basilic vein
2.5 cm above the bend of elbow. It shunts the blood from cephalic vein to the basilic
vein. It is the most superficial vein in the body.

N.B.
The median cubital vein is separated from brachial artery and median nerve by bicipital
aponeurosis.

Applied anatomy
The median cubital vein is the most preferred site for intravenous injections because:

• It is easy to access, as the vein is superficial and prominent.

• It is well supported by the underlying bicipital aponeurosis when elbow is
extended.
• It is anchored by a perforating vein to the deep veins so that it does not slip
during the venepuncture.
7

Nerves of the upper limb

❖ Enumerate five main nerves that supply the upper limb.
These are

• Axillary nerve
• Musculocutaneous nerve
• Radial nerve
• Median nerve
• Ulnar nerve

❖ Describe the axillary nerve in brief and discuss its applied anatomy.  AN10.3,
AN10.13

Root value
Ventral rami of C5 and C6 (Fig. 7.1).

FIG. 7.1 Axillary nerve and its main branches.

Course and relations

The axillary (or circumflex) nerve arises from the posterior cord of brachial plexus
posterior to third part of axillary artery. It passes posteriorly through the quadrangular
space. Here it lies below the capsule of the shoulder joint. As it is about to pass behind
the surgical neck of humerus, it terminates by dividing into anterior and posterior
branches.
The anterior branch (along with posterior circumflex artery) runs deep to deltoid
muscle and supplies deltoid muscle and skin over it. The posterior branch supplies
posterior part of deltoid and teres minor muscles. It pierces deep fascia to become upper
lateral cutaneous nerve of arm.

Branches
Muscular:
To deltoid and teres minor. Nerves to teres minor possesses pseudoganglion.

Cutaneous

• Upper lateral cutaneous nerve of arm

• Sensory innervation of skin over the lower half of deltoid

Applied anatomy
The damage of axillary nerve in inferior dislocation of the shoulder joint and fracture of
surgical neck of humerus will result in:

• Paralysis of deltoid leading to loss of power of abduction from 15° to 90°

• Loss of rounded contour of shoulder
• Prominence of greater tubercle of humerus
• Loss of cutaneous sensations over lower half of deltoid ‘regimental badge area of
sensory loss’

❖ Give a brief account of musculocutaneous nerve. AN11.2

See p. 30.

❖ Describe the radial nerve under the following headings: (a) root value; (b) origin,
course and relations, (c) branches and distribution and (d) applied anatomy. AN12.2
The radial nerve is the thickest and largest nerve of the upper limb (Fig. 7.2).
 FIG. 7.2 Radial nerve and its main branches.

Root value
Ventral rami of C5, C6, C7, C8 and T1.

Origin, course and relations

• It arises from the posterior cord of brachial plexus in axilla behind the third part
of the axillary artery. It is the thickest and largest branch of the brachial plexus.
• It courses successively through three regions: axilla, radial groove on the back of
arm and front of forearm. On the front of forearm, it ends by dividing into
superficial and deep terminal branches. The course and relations of radial nerve
in three regions traversed by it are as follows.

Axilla:
In the axilla, the radial nerve lies against the muscles forming the posterior wall of
axilla, i.e. subscapularis, teres major and latissimus dorsi. Then it passes through the
lower triangular space between teres major, long head of triceps brachii and shaft of
humerus. In axilla, it gives two muscular branches to supply long and medial heads of
triceps and one cutaneous branch (posterior cutaneous nerve of arm).

Radial groove
The radial nerve from axilla enters the radial groove through the lower triangular space,
where it lies between the long and medial heads of triceps brachii along with profunda
brachii artery. It leaves the radial groove by piercing the lateral intermuscular septum.
In the radial groove, it gives three muscular branches to supply long and medial heads
of triceps and anconeus and two cutaneous branches, i.e. lower lateral cutaneous nerve
of arm and posterior cutaneous nerve of forearm.

Front of arm:
The radial nerve enters the lower anterolateral part of the front of arm and lies between
brachialis on the medial side and brachioradialis and extensor carpi radialis longus on
the lateral side. It supplies all these muscles.

Forearm:
The radial nerve enters the cubital fossa where in front of lateral epicondyle it ends by
dividing into two terminal branches: (a) superficial terminal branch (superficial radial nerve)
and (b) deep terminal branch (posterior interosseous nerve).

Deep terminal branch (posterior interosseous nerve):

It lies in the lateral part of cubital fossa, where it supplies extensor carpi radialis brevis
and supinator muscles. Then it enters the back of forearm by passing through supinator
muscle. Here, it supplies abductor pollicis longus, extensor pollicis brevis, extensor
pollicis longus, extensor digitorum, extensor indicis, extensor digiti minimi and
extensor carpi ulnaris. At the back of wrist, it ends in a pseudoganglion, branches of
which supply the wrist and distal radioulnar joints.

Superficial branch (superficial radial nerve):

It is regarded as the downward continuation of the trunk of radial nerve. It runs on the
lateral side of the front of forearm accompanied by the radial artery in the upper two-
third of forearm with radial artery being on its medial side. About 7 cm above the wrist,
it curves posteriorly deep to tendon of brachioradialis to reach the anatomical snuff box.
Here, it divides into four or five digital branches, which supply the skin of lateral half of
dorsum of hand and lateral 2½ digits till their distal interphalangeal joints.

Branches and distribution

In axilla

• Muscular branches: Long and medial heads of triceps brachii

• Cutaneous branches: Posterior cutaneous nerve of arm

In radial groove

• Muscular
■ Lateral head of triceps brachii
■ Medial head of triceps brachii
 ■ Anconeus
• Cutaneous
■ Lower lateral cutaneous nerve of arm
■ Posterior cutaneous nerve of forearm
• Vascular
■ To profunda brachii artery

In the arm

• Muscular
■ Brachioradialis
■ Extensor carpi radialis longus
■ Lateral part of brachialis (proprioceptive)

In the forearm

• Superficial terminal branch: Digital branches to supply the skin of lateral half of
dorsum and lateral 3½ digits up to distal interphalangeal (DIP) joints.
• Deep terminal branch (posterior interosseous nerve): Muscular branches to all the
muscles of back of forearm except anconeus, brachioradialis and extensor carpi
radialis longus.

Applied anatomy
The effects of injury to the radial nerve at different levels are given in Table 7.1.

TABLE 7.1
Sites of Radial Nerve Injury and Their Effects
 FIG. 7.3 Wrist drop resulting from radial nerve injury.

❖ Give the effects of injury to the posterior interosseous nerve. AN12.2

The posterior interosseous nerve supplies all the muscles on the back of forearm except
anconeus, brachioradialis and extensor carpi radialis longus.
The posterior interosseous nerve is commonly injured in fracture or dislocation of
the head of radius.

Effects

• Paralysis of all the muscles on the back of forearm except extensor carpi radialis
longus, brachioradialis and anconeus (which are supplied by radial nerve
directly).
• There is no wrist drop because extensor carpi radialis longus being a powerful
muscle keeps the wrist joint extended.

❖ Describe the median nerve under the following headings: (a) root value, (b) course
and relations, (c) branches and distribution and (d) applied anatomy. AN10.3,
AN12.2
The median nerve is so called because it runs in the median plane of the forearm.

Root value
Ventral rami of C5 to C8 and T1 (Fig. 7.4).
 FIG. 7.4 Median nerve and its main branches.

Course and relations

The median nerve is formed in the axilla by two roots – lateral root from lateral cord of
brachial plexus and medial root from medial cord of brachial plexus. Then it courses
successively through four regions: axilla, arm, forearm and palm of the hand. The
medial root crosses the axillary artery to join the lateral root.

Axilla:
In the axilla, the median nerve lies first anterior and then lateral to the axillary artery.

Arm:
In the arm, the median nerve continues to run on the lateral side of brachial artery till
the midarm (i.e. insertion of coracobrachialis), where it crosses in front of the brachial
artery to lie on its medial side, and then passes anterior to elbow joint to enter the
forearm.

Forearm:
In the forearm, the median nerve passes through cubital fossa lying medial to the
brachial artery. It leaves the fossa between the two heads of pronator teres before
crossing superficial to the ulnar artery from medial to lateral side and giving its anterior
interosseous branch below this.
 Then it passes deep to fibrous arch of flexor digitorum superficialis. It adheres to
deep surface of flexor digitorum superficialis, and leaves the muscle, along its lateral
border. About 5 cm above the wrist, it lies between the tendons of palmaris longus and
flexor carpi radialis. It enters the palm through carpal tunnel under the flexor
retinaculum, but in front of common synovial sheath enclosing tendons of flexor
digitorum superficialis (FDS) and flexor digitorum profundus (FDP).

Palm:
In the palm at the distal border of flexor retinaculum, it ends by dividing into lateral
and medial terminal branches. Before dividing into terminal branches, the median
nerve gives off a recurrent muscular branch from its lateral side.

Branches and distribution (fig. 7.4)

In axilla:
No branch

In arm:
Muscular branch to pronator teres

In the cubital fossa

• Muscular branches to:

■ Flexor carpi radialis
■ Palmaris longus
■ Flexor digitorum superficialis

In the forearm

• Anterior interosseous nerve, which supplies:

■ Lateral half of FDP
■ Flexor pollicis longus
■ Pronator quadratus
• Palmar cutaneous branch to supply lateral two-third of palm

In the palm

• Recurrent muscular branch, which supplies muscles of thenar eminence, i.e.,

abductor pollicis brevis, flexor pollicis brevis and opponens pollicis
• Lateral terminal branch, which gives off digital nerves to supply both the sides of
thumb and radial side of index finger
Note: The digital branch to lateral side of index finger also supplies 1st
lumbrical muscle.
• Medial terminal branch, which gives off digital nerves to supply the adjacent sides
of index and middle fingers and adjacent sides of index and little fingers
 Note: The digital nerve to adjacent side of middle and ring finger also supplies
2nd lumbrical muscle.

N.B.
The median nerve in the palm supplies: (a) all thenar muscles, (b) 1st and 2nd
lumbricals, (c) skin of the lateral half of palm, and (d) skin of the lateral 3½ fingers
including dorsal aspects of their distal phalanges.

Applied anatomy
The effects of lesion to the median nerve depend on the site of lesion (Table 7.2).

TABLE 7.2
Effects of Lesions of the Median Nerve

N.B.
In case of suicidal cut above wrist, there is sensory loss over the thenar eminence
because palmar cutaneous nerve is given just above the flexor retinaculum; but in case
of carpal tunnel syndrome there is no sensory loss over the thenar eminence for the
same reason.

❖ Write a short note on carpal tunnel syndrome. AN12.4

It occurs due to compression of median nerve in the carpal tunnel. The carpal tunnel is
an osseofibrous tunnel formed by the anterior concavity of the corpus bridged by the
flexor retinaculum. This tunnel is tightly packed with long flexor tendons of the fingers
with their surrounding synovial sheaths and the median nerve.
Clinical features

• Painful paraesthesia (i.e. burning pain or pins and needles) along the
distribution of the median nerve to the palm and lateral 3½ fingers.
• Weakness and wasting of thenar muscles.
• No paraesthesia over the skin of thenar eminence because this area of skin is
supplied by the palmar cutaneous branch of median nerve, which arises in the
forearm proximal to flexor retinaculum.
• It is more frequent in women than in men.
• Intermittent attacks of pain are more common at night.

N.B.
The causes of compression of median nerve in carpal tunnel include tenosynovitis and
thickening of synovial sheaths of the long flexor tendons, myxoedema, arthritic
changes in the carpal bones, etc.

❖ Describe the ulnar nerve under the following headings: (a) root value, (b) course
and relations, (c) branches and distribution and (d) applied anatomy. AN10.3,
AN12.2
The ulnar nerve is so named because it runs along the ulnar side of the upper limb.

Root value
Ventral rami of C8 and T1 (Fig. 7.5). It also gets contribution from ventral ramus of C7.
 FIG. 7.5 Ulnar nerve and its main branches. DT, deep terminal branch; ST, superficial
terminal branch.

Course and relations

It is the continuation of the medial cord of brachial plexus in the axilla. It courses
successively through four regions: axilla, arm, forearm and hand, where it terminates by
dividing into superficial and deep branches. The course and relations of ulnar nerve in
these regions are as follows.

Axilla:
In axilla, the ulnar nerve lies between the axillary vein and the axillary artery on a
deeper plane, medial to 3rd part of axillary artery.

Arm
It enters the arm by running downwards on the medial side of the brachial artery in its
proximal part. At the midarm (i.e. at the level of insertion of coracobrachialis), it pierces
the medial intermuscular septum to enter the back of arm. Here it descends to run in a
groove on the back of medial epicondyle of humerus, where it can be palpated.

Forearm:
The ulnar nerve enters the front of forearm by passing between two heads of flexor carpi
ulnaris. Here it lies on medial part of flexor digitorum profundus. It is accompanied by
the ulnar artery on its lateral side in the lower two-third of forearm.

Hand:
The nerve enters the palm by passing superficial to the flexor retinaculum and medial to
ulnar artery. At the distal border of flexor retinaculum, it ends by dividing into
superficial and deep terminal branches.

Branches and distribution

In axilla and arm:
No branches

In forearm

• Muscular branches to supply:

■ Flexor carpi ulnaris
■ Flexor digitorum profundus (medial half)
• Palmar cutaneous branch: It arises at about midforearm and provides cutaneous
innervation to skin of the hypothenar eminence.
• Dorsal cutaneous branch: It arises about 5 cm above the wrist and gives off dorsal
digital nerves to supply sensory innervation to dorsal aspects of the medial 1½
digits excluding their distal phalanges.

In hand

• Superficial terminal branch, which supplies:

■ Palmaris brevis muscle
■ Cutaneous innervation to medial one-third of palm and medial 1½ fingers,
including their nail beds
• Deep terminal branch, which supplies:
■ Medial two lumbricals
■ Muscles of hypothenar eminence (abductor digiti minimi, flexor digiti
minimi and opponens digiti minimi)
■ All the interossei (three palmar and four dorsal)
■ Adductor pollicis

Applied anatomy
The effects of lesion to the ulnar nerve depend on the site of lesion. The details are given
in Table 7.3.

TABLE 7.3
Effects of the Ulnar Nerve Lesions
 Site of Causes Effects
Lesion
Elbow • Fracture • Atrophy and flattening of hypothenar muscles
dislocation of • Loss of adduction of thumb
the elbow joint • Loss of adduction and abduction of medial four digits
• Entrapment of • Ulnar claw hand
nerve in the • Loss of sensation on medial 1½ digits, on both the dorsum and the
cubital tunnela palm of hand
• Loss of sensation on anterior and posterior surfaces of medial 1½
digits including their nail beds
Wrist • Cut wounds Same effects as in lesion at elbow except that there will be no loss of
• Compression by sensation on the medial side of dorsum of hand and posterior
volar carpal surfaces of medial 1½ digits
ligament
• Compression in
Guyon’s tunnel
aCubital tunnel: It is formed by a tendinous arch connecting the two heads of flexor carpi ulnaris.
8

Joints of the upper limb

❖ Enumerate the components of shoulder complex. AN10.12
The shoulder complex consists of the following five components:

• Glenohumeral joint (shoulder joint proper)

• Acromioclavicular joint
• Sternoclavicular joint
• Subacromial joint (between coracoacromial arch and subacromial bursa)
• Scapulothoracic joint (linkage between scapula and thoracic wall)

The last two components are functional joints.

❖ Describe the shoulder joint (glenohumeral joint) under the following headings: (a)
classification, (b) articular surfaces, (c) ligaments, (d) relations, (e) nerve supply, (f)
movements and (g) applied anatomy. AN10.12

Classification
Synovial joint of ball and socket type.

Articular surfaces
They are formed by the large hemispherical head of humerus and shallow glenoid
cavity of scapula (Fig. 8.1).
 FIG. 8.1 Coronal section of shoulder joint.

The glenoid articular surface is deepened by the glenoid labrum.

Glenoid labrum

• It is a rim of fibrocartilage attached to the peripheral margin of the glenoid

cavity.
• It is triangular in cross-section and deepens the shallow glenoid cavity.

Ligaments
Capsular ligament

• Attachments (Fig. 8.1)

■ Medially: To peripheral margin of glenoid cavity outside the glenoid labrum.
The supraglenoid tubercle is intracapsular.
■ Laterally: To anatomical neck of humerus except on medial side where it
descends about 2–3 cm on the shaft, up to the surgical neck of humerus.
• Muscles strengthening the capsule: In general, the capsule is loose and lax, but it is
strengthened by the musculotendinous (rotator) cuff formed by the following
muscles:
 • Openings in the capsule: The capsule presents two openings/deficiencies:
■ One in front, for communicating with subscapular bursa
■ One at the intertubercular sulcus to provide the passage for the tendon of
long head of biceps brachii
Transverse humeral ligament: This ligament bridges across the bicipital groove.
Glenohumeral ligaments: These are thickenings in the anterior part of the capsule
and are seen when the capsule is exposed from the behind. They are three in
number and named superior, middle and inferior glenohumeral ligaments
according to their location.
Coracohumeral ligament: It is a wide, strong fibrous band on the superior surface
of the joint, extending from the base of coracoid process to the anterior aspect of
greater tubercle of humerus.
Coracoacromial ligament: It extends between the lateral side of coracoid process
and the medial border of acromion.

Relations (fig. 8.2)

Superiorly

• Coracoacromial arch
• Subacromial bursa
• Supraspinatus
• Tendon of long head of biceps brachii (intracapsular)
• Deltoid

FIG. 8.2 Relations of shoulder joint as seen in sagittal section. B, long head of biceps; G,
glenoid cavity.
Anteriorly

• Subscapularis
• Coracobrachialis
• Short head of biceps
• Deltoid

Posteriorly

• Infraspinatus
• Teres minor
• Deltoid

Inferiorly

• Long head of triceps

• Axillary nerve
• Posterior circumflex humeral vessels

Nerve supply
The nerves supplying the joint are

• Suprascapular nerve
• Axillary nerve
• Musculocutaneous nerve

Movements
The movements and muscles producing them, with their nerve supply, are given in
Table 8.1.

TABLE 8.1
Movements of Shoulder Joint and Muscles Producing Them with Their Nerve
Supply

Movements Muscles Nerve Supply

Flexion • Pectoralis major (clavicular fibres) • Lateral and medial
• Deltoid (anterior fibres) pectoral nerves
• Coracobrachialis • Axillary (circumflex)
nerve
• Musculocutaneous nerve
Extension • Deltoid (posterior fibres) • Axillary nerve
• Teres major • Lower subscapular nerve
• Latissimus dorsi • Thoracodorsal nerve
Abductiona Initiated by supraspinatus up to 15°, and then by the Suprascapular and axillary
acromial fibres of deltoid up to 90° nerves, respectively
 Adduction • Pectoralis major • Medial and lateral
• Latissimus dorsi pectoral nerves
• Thoracodorsal nerve
Medial • Pectoralis major (sternal fibres) • Lateral pectoral nerve
rotation • Deltoid (anterior fibres) • Axillary nerve
• Teres major • Lower subscapular nerve
• Latissimus dorsi • Thoracodorsal nerve
Lateral • Infraspinatus • Suprascapular nerve
rotation • Deltoid (posterior fibres) • Axillary nerve
• Teres minor • Axillary nerve
aAbduction: (a) 1°–15° by supraspinatus; (b) 15°–90° by middle fibres (acromial fibres) of deltoid; (c) 90°–120° by
serratus anterior; and (d) 120°–180° by serratus anterior and trapezius.

Applied anatomy
Dislocation of shoulder joint

• The shoulder joint is the most commonly dislocated joint in the body due to
(i) disproportionate size of articular surfaces – head of humerus and glenoid
cavity of the scapula (the head of humerus is much larger to fit properly into
smaller glenoid cavity of scapula [4:1 ratio]) and (ii) laxity of joint capsule.
• Dislocation most commonly occurs inferiorly because the joint is least supported
below.

Frozen shoulder (adhesive capsulitis)

It is a clinical condition characterized by painful and uniform restriction of all
movements of shoulder joint. It occurs due to shrinkage of joint capsule leading to
adhesion between rotator cuff and head of humerus.

❖ Enumerate the factors providing stability to shoulder joint. AN10.12

• Musculotendinous (rotator) cuff

• Glenoid labrum
• Long head of biceps brachii muscle
• Coracoacromial arch

❖ Enumerate the synovial bursae related to the shoulder joint. AN10.12

• Subscapular bursa: Lies deep to subscapularis and communicates with joint cavity
through a gap between superior and middle glenohumeral ligaments.
• Subacromial bursa: Lies deep to acromion and upper part of deltoid. It is the
largest synovial bursa in the body.
• Between tendons of infraspinatus and teres major.
• Between coracoid process and joint capsule.
• Between teres major and long head of triceps brachii.
❖ Write a short note on coracoacromial arch.
It is bony-fibrous arch lying above the shoulder joint formed by (a) coracoid process, (b)
coracoacromial ligament and (c) acromial process.
The coracoacromial ligament is a flat triangular ligament which extends from the
medial border of acromion (narrow end) in front of acromioclavicular articulation to the
lateral border of the coracoid process (broad end).
Just below this arch, the supraspinatus muscle passes above the head of humerus on
its way to greater tubercle of humerus for insertion. The coracoacromial arch is
separated from this muscle by subacromial bursa to allow free movements of shoulder
during contraction of supraspinatus (Fig. 8.3).

FIG. 8.3 Coracoacromial arch.

Applied Anatomy: The coracoacromial arch acts as a secondary socket of

shoulder joint and prevents its superior dislocation.

❖ What are various types of sternoclavicular joint? AN8.2, AN13.4

The sternoclavicular joint is of following types: synovial, saddle, compound and
complex. The details are as under:

(a) Synovial, because it has synovial cavity filled with synovial fluid
(b) Saddle, because articulating surfaces are concavo-convex in shape
(c) Compound, because more than two bones are articulating, i.e. sternal end of
clavicle, clavicular notch of manubrium sterni and upper surface of 1st costal
cartilage (last two form a continuous concavo-convex surface)
(d) Complex, because its articular surfaces are covered by fibrocartilage and its cavity
is divided into two parts by an intra-articular fibrocartilaginous disc

❖ Write a short note on abduction at shoulder joint. AN10.12

• The abduction at shoulder joint is a complex movement.

 • It is performed by conjoint action of both prime movers and synergists.

FIG. 8.4 Sternoclavicular joint.

• Prime movers are

(a) Middle fibres of deltoid
(b) Supraspinatus
• Synergist muscles are
(a) Subscapularis
(b) Infraspinatus
(c) Teres minor

The sequence of events occurring during abduction at shoulder is as follows (Fig. 8.5):

(a) Natural range of abduction at shoulder joint is only 60°.

(b) When the humerus is rotated medially, range of movement of abduction is
increased up to 90°.
(c) When humerus moves in the plane of body of scapula, range of movement is
increased up to 120°.
(d) When humerus is rotated laterally by contraction of infraspinatus and teres
minor, range of movement is increased up to 180°.
 FIG. 8.5 Abduction at shoulder joint. CP, coracoid process; AC, acromion process; G, glenoid
cavity; H, humerus.

N.B.

• Out of total 180° elevation

■ Humerus moves 120° at shoulder joint
■ Scapula moves 60° at joint of shoulder girdle
• In every 15° elevation
■ Shoulder joint contributes 10°
■ Girdle joint contributes 5°
(i.e. in ratio of 2:1)

❖ Describe the elbow joint under the following headings: (a) classification, (b)
articular surfaces, (c) ligaments, (d) relations, (e) nerve supply, (f) movements and (g)
applied anatomy. AN13.3

Classification
Synovial joint of hinge variety.
Articular surfaces
It is a compound joint consisting of two articulations (Fig. 8.6).

Humeroradial: Between capitulum of humerus and head of radius.

Humeroulnar: Between trochlea of humerus and trochlear notch of ulna.

FIG. 8.6 Components of the elbow joint: A, schematic diagram; B, radiograph of normal elbow
joint (anteroposterior view). Source: (Drake, Richard L; Vogl, Wayne; Mitchell, Adam WM.
Gray’s Anatomy for Students. Philadelphia: Elsevier Inc., 2005.)

The elbow joint communicates with superior radioulnar joint.

Ligaments
Capsular ligament

• Attachments
■ In front
• Superiorly, it is attached to the humerus above the coronoid and radial
fossae.
• Inferiorly, it is attached to the coronoid process of ulna and annular
ligament of superior radioulnar joint.
■ Behind
• Superiorly, it is attached to the margins of the olecranon fossa.
• Interiorly, it is attached to the upper margins of olecranon process and
annular ligament of superior radioulnar joint.
• On either side: The capsule becomes continuous with medial and lateral collateral
ligaments of the elbow joint.

Medial (ulnar) collateral ligament:

It is triangular in shape and consists of the following three parts:

• Anterior part, which extends from front of medial epicondyle of humerus to the
 medial margin of coronoid process of ulna
• Posterior part, which extends from back of medial epicondyle of humerus to the
medial margin of the olecranon process of ulna
• Inferior part, which extends between lower ends of anterior and posterior parts
and stretches between the olecranon and coronoid processes of ulna

N.B.
Medial collateral ligament is crossed superficially by the ulnar nerve.

Lateral (radial) collateral ligament:

It extends from lateral epicondyle of humerus above to the annular ligament below.

Relations
Anterior

• Brachialis
• Tendon of biceps brachii
• Median nerve
• Brachial artery

Posterior

• Tendon of triceps brachii

• Anconeus

Medial

• Flexor carpi ulnaris

• Ulnar nerve
• Common flexor origin

Lateral

• Supinator
• Common extensor origin

Nerve supply

• Radial nerve
• Musculocutaneous nerve
• Median nerve
• Ulnar nerve

Movements
The movements and muscles producing them with their nerve supply are given in
Table 8.2.

TABLE 8.2
Movements of the Elbow Joint and Muscles Producing Them with Their Nerve
Supply

Movements Muscles Nerve Supply

Flexion • Brachialis • Musculocutaneous and radial nerves
• Biceps brachii • Musculocutaneous nerve
• Brachioradialis • Radial nerve
Extension • Triceps brachii • Radial nerve
• Anconeus • Radial nerve
• Supinator (humeral origin) • Posterior interosseous nerve

Applied anatomy
Dislocation:
The dislocation of elbow joint usually occurs posteriorly and is often associated with
fracture of coronoid process.

Effusion:
The effusion of elbow joint causes distension on the posterior aspect of elbow because
the joint capsule is weak posteriorly.

Tennis elbow (lateral epicondylitis)

It presents with pain and tenderness over lateral epicondyle of humerus. It occurs due
to:

• Sprain of lateral collateral ligament of the elbow joint

• Tearing of fibres of extensor carpi radialis brevis (ECRB)
• Inflammation of bursa underneath the ECRB
• Tear of common extensor origin

❖ What is carrying angle? Give its clinical significance.

• It is an angle formed between long axes of arm and forearm when the elbow is
fully extended (Fig. 8.7).
• This angle occurs because the medial flange of trochlea lies 6 mm lower than
that of lateral flange of trochlea.
• It varies from 10° to 15° in males and 15° to 30° in females.
 FIG. 8.7 Carrying angle.

Functional significance

• It helps in holding and carrying the objects.

• It prevents rubbing of forearm with pelvis in females.
• It helps to put food in mouth during eating.

Applied anatomy
An increase in carrying angle causes cubitus valgus deformity of the elbow.

❖ Give a brief account of radioulnar joints and discuss the movements occurring at
these joints. AN13.3
There are three radioulnar joints (Fig. 8.8), i.e. superior, middle and inferior.
 FIG. 8.8 Interosseous membrane.

• Superior Radioulnar Joint: It is a pivot type of synovial joint between head of

radius and radial notch of ulna. The annular ligament surrounds the head of
radius and keeps it in contact with the radial notch of ulna. A fibrous band – the
quadrate ligament extending from inferior border of radial notch of ulna to the
neck of radius – closes the joint from below.
• Intermediate Radioulnar Joint: It is a fibrous joint of syndesmosis type between
the shafts of radius and ulna.
Here radius and ulna are joined by an interosseous membrane whose fibres are
directed downwards and medially.
It binds the radius and ulna but allows some movement.
• Inferior Radioulnar Joint: It is also a pivot type of synovial joint between head
of ulna and ulnar notch of radius.
A triangular articular disc of fibrocartilage extends from depression near the
styloid process of ulna to the articular margins of ulnar notch of radius. It
separates this joint from wrist joint.
The synovial membrane of inferior radioulnar joint projects upwards to form a
pouch in front of interosseous membrane – the recessus sacciformis.

Movements
Movements occurring at radioulnar joints are
 • Supination
• Pronation

❖ Write a short note on interosseous membrane (Fig. 8.8). AN13.3

• It is a fibrous membrane which extends between interosseous borders of radius

and ulna.
• The direction of fibres in this membrane is downwards and medially towards
ulna.
• It forms intermediate (middle) radioulnar joint of syndesmosis type.
• Superiorly the gap between oblique cord and upper border of membrane,
provides passage to posterior interosseous artery to go into the posterior
compartment.
• Inferiorly interosseous membrane blends with capsule of inferior radioulnar
joint.
• An opening in the inferior part of membrane provides passage to anterior
interosseous artery to enter the posterior compartment.
• Membrane is related anteriorly to flexor pollicis longus (FPL), flexor digitorum
profundus (FDP) and pronator quadratus (PQ).
• Membrane is related posteriorly to supinator, abductor pollicis longus (APL),
extensor pollicis longus (EPL), extensor pollicis brevis (EPB), extensor indicis
and posterior interosseous nerve and vessels.

Functional significance
Interosseous membrane: (a) helps in transmission of force from the radius (received
from wrist joint) to the ulna for onward transmission to the humerus and (b) helps in
supination and pronation.

❖ Give a brief account of movements of supination and pronation and discuss their
functional significance. AN13.3

Movements

• Supination: It is the movement of forearm in which the palm of hand is turned

forwards/upwards.
• Pronation: It is the movement of forearm in which the palm of hand is turned
backwards/downwards.

The details of movements of supination and pronation are given in Table 8.3 and
shown in Fig. 8.9.
 FIG. 8.9 Movements of supination and pronation.

TABLE 8.3
Movements of Supination and Pronation

N.B.

• Movements of supination and pronation occur mainly at superior and inferior

radioulnar joints.
• Axis of movements of supination and pronation is an oblique axis that passes
from the head of radius to the head of ulna.
• During supination and pronation, ulna remains relatively stationary, while the
radius moves.
 • All the muscles producing supination and pronation are inserted into radius.
• Movements of supination and pronation are homologous to the movements of
inversion and eversion of the foot.

Functional significance

• They help in picking up food and putting it into the mouth.

• They are used in mechanical jobs, e.g. opening and tightening the screws with
screw driver.

❖ Describe the wrist joint under the following headings: (a) classification, (b)
articular surfaces, (c) ligaments, (d) relations, (e) nerve supply, (f) movements and (g)
applied anatomy. AN13.3

Classification
Structural:
Synovial joint of ellipsoid variety.

Functional:
Diarthrosis.

Articular surfaces (fig. 8.10)

Proximally

• Inferior articular surface of the lower end of the radius

• Inferior surface of the articular disc of the inferior radioulnar joint

FIG. 8.10 Coronal section through wrist region.

Distally

• Scaphoid
• Lunate
• Triquetral

N.B.
Ulna does not form the articular surface of the wrist joint; hence, wrist joint is also
called radiocarpal joint.

Ligaments
Capsule:
It is attached above to the peripheral margins of the proximal and distal articular
surfaces including the articular disc. Distally, it blends with the palmar and dorsal
radiocarpal ligaments.

Radial collateral ligament:

It extends from the styloid process of radius to the lateral aspects of scaphoid and
trapezium.

Ulnar collateral ligament:

It extends from the styloid process of ulna to the medial aspects of triquetral and
pisiform bones.

Palmar and dorsal radiocarpal ligaments:

These are the thickenings on the palmar and dorsal aspects of the fibrous capsule.

Relations
Anterior

• Superficial: Tendons of flexor carpi radialis and palmaris longus

• Intermediate: Radial artery median nerve and flexor digitorum superficialis
• Deep: Tendons flexor pollicis longus and flexor digitorum profundus

Posterior:
Extensor tendons of the wrist and fingers with their synovial sheaths.

Lateral:
Radial artery.

Nerve supply
 • Anterior interosseous nerve
• Posterior interosseous nerve

Movements
Movements and muscles producing them with their nerve supply are given in Table 8.4.

TABLE 8.4
Movements of the Wrist Joint

Movement Muscles Producing Them Nerve Supply

Flexion • Flexor carpi radialis • Median nerve
• Flexor carpi ulnaris • Ulnar nerve
Extension • Extensor carpi radialis longus • Radial nerve
• Extensor carpi radialis brevis • Posterior interosseous
• Extensor carpi ulnaris nerve
• Posterior interosseous
nerve
Abduction • Abductor pollicis longus • Posterior interosseous
• Extensor pollicis brevis nerve
• Posterior interosseous
nerve
Adduction • Flexor carpi ulnaris • Ulnar nerve
• Extensor carpi ulnaris • Posterior interosseous
nerve
Circumduction Combination of flexion, extension, abduction and
adduction

Applied anatomy
Colles fracture:
It is fracture of distal end of radius due to fall on outstretched hand with distal fragment
being displaced upwards and backwards.

Smith fracture:
It is reverse of Colles fracture due to fall on the back of the hand with distal fragment
being displaced upwards and forwards (i.e. palm is flexed).

❖ Enumerate the range of movement at the wrist joint. AN13.3

• Flexion = 60°–85°
• Extension = 50°–60°
• Abduction = 15°
• Adduction = 30°–45°

❖ Write a brief note on the 1st carpometacarpal joint. AN13.4

Classification

Structural: Synovial joint of saddle variety

Functional: Diarthrosis

Articular surfaces

Proximally: Distal surface of trapezium

Distally: Proximal surface of the base of 1st metacarpal (MC) bone

Ligaments

Capsular ligament: It is a loose fibrous sac, which encloses the joint cavity. It is
thickest dorsally and laterally.
Lateral ligament: Broad fibrous band extending from the lateral surface of
trapezium to the lateral surface of 1st MC.
Anterior ligament: Extends obliquely from the palmar surface of trapezium to the
ulnar side of base of 1st MC.
Posterior ligament: Extends obliquely from the dorsal surface of trapezium to the
ulnar side of 1st MC.

Relations

Anterior: Muscles of thenar eminence

Posterior: Long and short extensors of thumb
Medial: First dorsal interosseous muscle
Lateral: Abductor pollicis longus
Posteromedial: Radial artery

Nerve supply

Median nerve

Movements
The movements and muscles producing them with their nerve supply are given in
Table 8.5.

TABLE 8.5
Movements of 1st Carpometacarpal Joint

Movement Muscles Nerve Supply

1. Flexion (occurs in the plane of • Flexor pollicis brevis • Median nerve
palm) • Opponens pollicis • Median nerve
2. Extension (occurs in the plane of • Extensor pollicis longus • Posterior
 palm) • Extensor pollicis brevis interosseous
nerve
• Posterior
interosseous
nerve
3. Abduction (occurs at right angle • Abductor pollicis longus • Posterior
to the plane of palm) • Abductor pollicis brevis interosseous
nerve
• Median nerve
4. Adduction (occurs at right angle • Adductor pollicis Ulnar nerve
to the plane of palm)
5. Opposition • Opponens pollicis Median nerve
6. Circumduction Combination of flexion, extension,
abduction and adduction

N.B.
Movements of the medial and lateral rotation also occur at the 1st carpometacarpal
(CM) joint. Movements at 1st CM joint are much more free than at any other
corresponding carpometacarpal joints because it is the only CM joint which has a
separate joint cavity (Fig. 8.11).

FIG. 8.11 First carpometacarpal joint. A, formation; B, showing various movements of thumb.

❖ Give the classification of metacarpophalangeal (MP), proximal intraphalangeal

(PIP) and distal interphalangeal (DIP) joints, and discuss the movements occurring at
these joints. AN13.4
The classification and movements of MP, PIP and DIP joints are given in Table 8.6.
TABLE 8.6
Classification and Movement of MP, PIP and DIP joints

Joints Classification Movement

MP Synovial joint of ellipsoid variety • Flexion
• Extension
• Abduction
• Adduction
PIP Synovial joint of hinge variety Flexion and extension
DIP Synovial joint of hinge variety Flexion and extension
❖ Write a short note on 1st metacarpophalangeal joint. AN13.4, AN12.6

• Type: Ellipsoid type of synovial joint (Fig. 8.12)

• Articular surfaces: Convex articular head of 1st metacarpal and curved articular
base of proximal phalanx
• Ligaments: Capsular ligaments, palmar ligaments, and medial and lateral
collateral ligaments
■ Capsular ligament: Thick in front and thin behind
■ Palmar ligament: Fibrocartilaginous plate which replaces deep transverse
metacarpal ligaments
■ Medial and lateral collateral ligament: Oblique bands extending downwards
and forwards from head of metacarpal to the base of proximal phalanx

FIG. 8.12 First right metacarpophalangeal joint.

Movements and muscle producing them

• Flexion: Flexor pollicis brevis

• Extension: Extensors of thumb
• Abduction: Abductor pollicis brevis
• Adduction: Adductor pollicis
❖ Enumerate the chief flexors of MP, PIP and DIP joints. AN13.4

MP joints: Lumbricals and interossei

PIP joints: Flexor digitorum superficialis
DIP joints: Flexor digitorum profundus

❖ Which movements of thumb are tested to confirm the integrity of radial, ulnar and
median nerves? AN12.6

(a) To test integrity of radial nerve: Test extension of thumb, because this movement
of thumb is lost if radial nerve is damaged.
(b) To test integrity of ulnar nerve: Test adduction of thumb, because this movement
of thumb is lost if ulnar nerve is damaged.
(c) To test integrity of median nerve: Test abduction and opposition of thumb,
because both these movements of thumb are lost if median nerve is damaged.
SECTION II
Head and Neck
OUTLINE

9. Scalp, temple and face

10. Side, front and back of the neck
11. Parotid and submandibular regions
12. Deep structures of the neck and prevertebral region
13. Oral cavity
14. Pharynx and palate
15. Nose and paranasal air sinuses
16. Larynx
17. Infratemporal fossa, temporomandibular joint and pterygopalatine
fossa
18. Ear and orbit
19. Dural folds, intracranial dural venous sinuses and pituitary gland
20. Cranial nerves
21. Meninges and cerebrospinal fluid
22. Spinal cord
9

Scalp, temple and face

❖ Describe the scalp under the following headings: (a) definition, (b) layers, (c)
arterial supply, (d) venous drainage, (e) nerve supply and (f) applied anatomy. 
AN27.1
The soft-tissue structures covering the vault of skull form the scalp. The boundaries of
scalp are as follows.

Anteriorly:
Superciliary arches of the frontal bone.

Posteriorly:
Superior nuchal lines of the occipital bone.

On each side:
Superior temporal line.

Layers of scalp
The scalp consists of five layers, which can be easily remembered by the initial letter of
each layer, i.e. SCALP. From superficial to deep, these are (Fig. 9.1)

• S: Skin
• C: Connective tissue
• A: Aponeurosis (epicranial aponeurosis)
• L: Loose areolar tissue
• P: Pericranium (outer periosteum)
 FIG. 9.1 Layers of the scalp.

Mnemonic: SCALP

Arterial supply (fig. 9.2)

Each lateral half of the scalp is supplied by five arteries:

FIG. 9.2 Arteries (right half) and sensory nerves (left half) supplying the scalp. ST,
supratrochlear; SO, supraorbital; T, supraficial temporal; PA, posterior auricular; O, occipital;
ZT, zygometicotemporal; AT, auriculotemporal; GA, great auricular; LO, lesser occipital; GO,
greater occipital; TO, third occipital.
Venous drainage
Each lateral half of the scalp is supplied by five veins:

• Three in front of the auricle

■ Supratrochlear vein
■ Supraorbital vein
■ Superficial temporal vein
• Two behind the auricle
■ Posterior auricular vein
■ Occipital vein

Nerve supply
Sensory
Each lateral half of the scalp is supplied by eight nerves:

• Four in front of the auricle (i.e. anterior quadrant)

• Four behind the auricle (i.e. posterior quadrant)

■ Great auricular, GA (C2, C3)
■ Lesser occipital, LO (C2, C3)
■ Greater occipital, GO (C2)
■ Third occipital, TO (C3)

Motor
Each lateral half of the scalp is supplied by two nerves – one in front of the auricle and
one behind the auricle.

• In front of the auricle

■ Temporal branch of the facial nerve
• Behind the auricle
■ Posterior auricular branch of the facial nerve

Applied anatomy

• Wounds of the scalp bleed profusely because:

■ Walls of torn vessels fail to retract because they are adhered to the dense
connective tissue.
■ It is profusely supplied with blood.
 • Wounds of the scalp heal quickly because of profuse blood supply.
• Scalp is the commonest site of sebaceous cysts because it contains maximum
number of sebaceous glands as compared to anywhere else in the body.
• Dangerous layer of the scalp: The layer of loose areolar tissue (i.e., fourth layer
of the scalp) is called dangerous layer of the scalp because if the pus collects in
this layer, the infection from here may travel through emissary veins into the
intracranial dural venous sinuses causing their thrombosis and associated
meningitis.
• Black eye: If blood collects in the fourth layer of scalp due to trauma on head. It
tracks anteriorly in the subcutaneous tissue of eyelids in a couple of days where
it clots. As a result, the eyelids appear black (black eye).

❖ Give the origin, insertion, nerve supply and actions of occipitofrontalis muscle. 
AN27.1
The occipitofrontalis muscle along with epicranial aponeurosis forms the third layer of
the scalp. This muscle consists of four bellies: two occipital bellies and two frontal
bellies (Fig. 9.2).

Origin (fig. 9.3)

FIG. 9.3 Occipitofrontalis muscle.

Occipital bellies:
From lateral two-third of superior nuchal lines of the occipital bone.

Frontal bellies:
From subcutaneous tissue of eyebrows and root of the nose where it blends with
orbicularis oculi muscle.
Insertion (fig. 9.3)
Into epicranial aponeurosis (galea aponeurotica).

Nerve supply (fig. 9.3)

Posterior auricular and temporal branches of the facial nerve.

Actions

• Moves the scalp forward and backward by alternate contractions of frontal and
occipital bellies.
• Occipital bellies draw the epicranial aponeurosis backwards, allowing the
frontal bellies to contract, and cause transverse wrinkles in the skin of forehead.

❖ Write a short note on superficial temporal artery.

• It is the smaller terminal branch of the external carotid artery. It begins in the
parotid gland behind the neck of mandible.
• It runs vertically upwards across the root of zygoma in front tragus. About 5 cm
above the zygoma, the artery divides into terminal anterior and posterior
branches which supply temporal fossa and scalp.

Branches

1. Transverse facial artery arises within parotid gland and runs forwards over the
masseter muscle. It supplies TMJ, parotid gland and masseter muscle.
2. Anterior auricular branch: It supplies lateral surface of auricle and part of external
auditory meatus.
3. Middle (deep) temporal artery: It pierces temporal fascia to supply temporalis
muscle.
4. Zygomatico-orbital branch runs towards orbit along the upper border of zygomatic
arch.
5. Anterior terminal branch runs forwards towards the frontal tuberosity to supply
soft tissues of the region. It often becomes noticeably tortuous in old age.
6. Posterior terminal branch runs upwards, backwards and towards the occipital
region to supply the soft tissues in the region.

❖ Give the origin, insertion, nerve supply and actions of the platysma. AN28.1
The platysma is a thin, quadrilateral, broad sheet of muscle in the superficial fascia of
the side of the neck (Fig. 9.4).
 FIG. 9.4 Origin and insertion of the platysma.

Origin
From skin and deep fascia covering pectoralis major and anterior part of deltoid.

Insertion
Into lower border of mandible and angle of mouth.

Nerve supply
By cervical branch of facial nerve.

Actions

• Forms wrinkles in the skin of neck

• Releases pressure of the skin on the underlying superficial veins of the neck to
help in venous return
• Draws the angle of mouth downward and laterally as seen clearly in the faces of
marathon runners.

❖ Enumerate the characteristic features of the muscles of facial expression. AN28.1

• Lie in the superficial fascia

• Develop from 2nd pharyngeal arch
• Supplied by the facial nerve
• Represent (morphologically) panniculus carnosus
❖ Give origin, insertion, nerve supply and actions of buccinator muscle. AN28.1

Origin (fig. 9.5)

• Upper fibres, from alveolar process of maxilla, opposite upper molar teeth.
• Lower fibres, from alveolar process of mandible, opposite lower molar teeth.
• Middle fibres, from pterygomandibular raphe.

FIG. 9.5 Buccinator muscle: A, origin; B, location in face and insertion.

Insertion

• Upper fibres pass straight to be inserted into the upper lip.

• Lower fibres pass straight to be inserted into the lower lip.
• Middle fibres decussate before passing to the respective lips.

Nerve supply
By facial nerve.

Actions

• Flattens cheek against gum and teeth.

• Prevents accumulation of food into the vestibule of mouth.
• Helps in blowing the cheek (hence is also called whistling muscle).

❖ Define temple (superficial temporal region) and enumerate the layers of soft tissue
present in this region. AN27.1
Temple is an area on the side of skull between the superior temporal line and the
zygomatic arch.

Soft-tissue layers:
There are six layers of soft tissue in this region. From superficial to deep, these are:
 • Skin
• Superficial fascia
• Thin extension of epicranial aponeurosis
• Temporal fascia
• Temporalis muscle
• Pericranium

❖ Describe the sensory innervation of the face in brief. AN28.2

The sensory innervation to the skin of whole face is derived from the branches of
trigeminal nerve except the skin over the angle of lower jaw, which is innervated by the
great auricular nerve, a branch of cervical plexus (C2 and C3; Fig. 9.6).

FIG. 9.6 Sensory innervation of the face.

The details are given in Table 9.1.

TABLE 9.1
Sensory Innervation of the Head and Face

Source Cutaneous Nerves Area of Distribution

Ophthalmic division of • Supratrochlear nerve • Upper eyelid and forehead
trigeminal nerve (V1) • Supraorbital nerve • Scalp up to vertex
• Lacrimal nerve • Eyelids
• Infratrochlear nerve • Root, dorsum and tip of the
• External nasal nerve nose
Maxillary division of • Infraorbital nerve • Lower eyelid, side of ala of
trigeminal nerve (V2) • Zygomaticofacial nerve nose and upper lip
 • Zygomaticotemporal nerve
Mandibular division of • Auriculotemporal nerve
trigeminal nerve (V3) • Buccal nerve
• Mental nerve
Cervical plexus • Anterior division of great auricular
nerve (C2 and C3)
• Upper division of transverse
(anterior) cervical nerve of neck (C2
and C3)
❖ Write a short note on dangerous area of face.
• Upper part of the cheek
• Anterior part of temple
• Upper two-third of the
lateral side of auricle and
temple
• Lower part of the cheek
• Chin and lower lip
• Skin over angle of the jaw
and over the parotid gland
• Lower margin of the lower
jaw

Dangerous area of the face:

This includes (Fig. 9.7):

• Upper lip
• Lower part of the nose including nasal septum
• Adjoining parts of the cheek

FIG. 9.7 Dangerous area of the face.

This area is called dangerous because infective emboli from this area can reach the
cavernous sinus and cause cavernous sinus thrombosis. As a result, cranial nerves
present within the cavernous sinus are compressed leading to paralysis of the muscles
of eyeball.
 Route of spread: The venous blood from dangerous area of the face is drained into
cavernous sinus as follows (Fig. 9.8):
Deep facial vein → pterygoid venous plexus → emissary vein → cavernous sinus

FIG. 9.8 Venous drainage of the face.

❖ Write a short note on the lacrimal apparatus. AN31.4

The group of structures concerned with the formation and drainage of lacrimal fluid
(tear fluid) constitutes the lacrimal apparatus.

Components
Lacrimal apparatus consists of the following components (structures; Fig. 9.9):

• Lacrimal gland and its ducts

• Conjunctival sac
• Lacrimal puncta and lacrimal canaliculi
• Lacrimal sac
• Nasolacrimal duct
 FIG. 9.9 Lacrimal apparatus.

N.B.
The opening of nasolacrimal duct in the inferior meatus of the nose is guarded by a fold
of mucous membrane called valve of Hasner.

Route of drainage

Applied anatomy
Dacryocystitis
It is an inflammation of lacrimal sac and presents with pain, oedema and redness at the
medial angle of the eye.

Epiphora:
The obstruction of lacrimal fluid pathway (i.e. at the level of puncta, canaliculi or
nasolacrimal duct) causes overflow of tears on the cheek. It is called epiphora.

❖ Describe the development of the face in brief.  AN43.4

The face develops from five mesenchymal processes, which appear around the
stomodeum (primitive mouth). These processes (facial primordia) are (Fig. 9.10)

• Frontonasal process – unpaired

• Maxillary processes – paired
• Mandibular processes – paired

FIG. 9.10 Ventral aspect of a fetal head showing the five processes around the stomodeum.

Frontonasal process:
It lies above the stomodeum and is formed by the proliferation of mesenchyme deep to
the ectoderm in front of the forebrain.
On either side of the frontonasal process, the ectoderm thickens to form olfactory
placodes. As each olfactory placode depresses from the surface, the olfactory pit is formed.
A horseshoe-shaped elevation is formed around each olfactory pit. The medial limb of
horseshoe-shaped elevation is called medial nasal process, while its lateral limb is called
lateral nasal process.

Maxillary processes:
These develop from the mesenchyme of the first arch. They are dorsolateral to lateral
nasal processes and are separated from them on each side by the optic vesicle and a
lineal furrow of ectoderm termed nasolacrimal groove. Ectodermal cells in the floor of
this groove proliferate to form the solid ectodermal cord. The canalization of this cord
gives rise to nasolacrimal duct.

Mandibular processes:
These are derived from the mesenchyme of the 1st pharyngeal arch.
The various parts of the face derived from the above-mentioned processes are given
in the box below.

Facial primordia Parts of face

Frontonasal processes give rise to Forehead, external nose and philtrum of the upper lip
Maxillary processes give rise to Lateral parts of the upper lip and upper parts of the cheek
Mandibular processes give rise to Lower lip, lower parts of the cheek and chin

Applied anatomy

• Cleft upper lip (Fig. 9.11)

■ Median cleft (or hare lip) occurs if the frontonasal process fails to form
philtrum.
■ Lateral cleft develops if the frontonasal process fails to fuse with the
maxillary process. It can be unilateral or bilateral.
• Cleft lower lip occurs if two mandibular processes fail to fuse with each other. It
is very rare (Fig. 9.11).
• Oblique facial cleft occurs if the maxillary process fails to fuse with the lateral
nasal process. The oblique cleft extends from the median angle of eye to the
upper lip.

FIG. 9.11 Types of cleft lip: A, unilateral; B, bilateral; C, median cleft lip (hare lip); D, cleft
lower lip.
10

Side, front and back of the neck

❖ Enumerate the structures present in the superficial fascia of the neck.
The superficial fascia of the neck contains:

• Platysma
• Cutaneous nerves
• Superficial veins
• Superficial lymph vessels and lymph nodes

N.B.
The cutaneous nerves and veins lie deep to platysma.

❖ Write a short note on platysma.

See p. 92.

❖ Write a short note on external jugular vein. AN35.4

Formation
The external jugular vein is formed on the sternocleidomastoid muscle below and
behind the angle of mandible by the union of the posterior auricular vein and posterior
division of the retromandibular vein. It has two valves – one before its termination and
another an inch above the middle of clavicle (Fig. 10.1).
 FIG. 10.1 External jugular vein. Other superficial veins of the neck are also shown.

Course
It descends obliquely downwards and backwards across the sternocleidomastoid. It
pierces the superficial lamina of investing layer of deep cervical fascia above clavicle in
the region of the subclavian triangle. Here it crosses the third part of the subclavian
artery and after piercing a deep lamina of investing layer of the deep cervical fascia
ends in the subclavian vein deep to clavicle.

Tributaries
These are

• Anterior jugular vein

• Transverse cervical vein
• Suprascapular vein

Applied anatomy

• Air embolism: If external jugular vein is cut an inch above the clavicle, its lumen
is held open because its margins are adhered to the deep fascia. As a result, the
air is sucked into the lumen of the external jugular vein during inspiration,
leading to air embolism that may subsequently cause death.
• External jugular vein is used by the clinicians to measure the external jugular
venous pressure and/or pressure in the right atrium.

❖ Enumerate the various layers of the deep cervical fascia. AN35.1

The deep cervical fascia consists of the following three layers (Fig. 10.2):
 • Investing layer
• Pretracheal fascia/layer
• Prevertebral fascia/layer

FIG. 10.2 Diagrammatic transverse section through neck at the level of the 6th cervical
vertebra to show the horizontal disposition of the three layers of deep cervical fascia.

❖ Describe the investing layer of the deep cervical fascia in brief. AN35.1

It surrounds the neck like a collar (Fig. 10.2).

Attachments
Superiorly

• External occipital protuberance

• Superior nuchal line
• Mastoid process
• Base of mandible

Inferiorly

• Spine of scapula
• Acromion process of scapula
• Clavicle
• Manubrium sterni

Anteriorly

• Symphysis menti
• Hyoid bone
• Oblique line of thyroid cartilage

Posteriorly
 • Ligamentum nuchae
• Spine of 7th cervical vertebra

Features

• Splits to enclose:
■ Two muscles: Trapezius and sternocleidomastoid
■ Two salivary glands: Parotid and submandibular
■ Two spaces: Suprasternal and supraclavicular
• Forms two pulleys/slings – one each for intermediate tendon of digastric and
omohyoid
• Thickens to form two structures: Stylomandibular ligament and parotidomasseteric
fascia

❖ What is suprasternal space (of Burns)? Give its contents. AN35.1

It is a triangular space above the suprasternal notch enclosed between the two layers of
investing layer of deep cervical fascia.

Contents

• Sternal heads of sternocleidomastoid muscles

• Jugular venous arch
• Interclavicular (‘T’) ligament
• Lymph node (sometimes)

❖ Write a short note on pretracheal fascia. AN35.1

The pretracheal fascia is so called because it is a layer of deep cervical fascia that lies in
front of trachea (Fig. 10.2).

Attachments
Superiorly

• Hyoid bone in the median plane

• Oblique line of thyroid cartilage
• Cricoid cartilage

Inferiorly:
It splits to enclose thyroid gland, i.e. forms capsule of thyroid gland and finally blends
with the arch of the aorta.
On either side, it fuses with the front of the carotid sheath.

N.B.
The posterior layer of thyroid capsule, on either side of midline thickens to form
suspensory ligament of thyroid gland (ligament of Berry).

Functions

• Provides a slippery surface for the free movements of trachea during deglutition
• Supports thyroid gland and does not allow it to sink into the mediastinum

Applied anatomy
Thyroid swelling moves up and down during swallowing because it is enclosed in the
pretracheal fascia, which is attached to laryngeal skeleton (i.e. cricoid and thyroid
cartilages and hyoid bone). Since larynx moves up and down during swallowing, the
thyroid gland also moves up and down during swallowing.

❖ Write a short note on prevertebral fascia. AN35.1

It is so called because it lies in front of the cervical part of vertebral column (Fig. 10.2).

Attachments
Superiorly:
Base of the skull.

Inferiorly:
Bodies of T3 and T4 vertebra.

Laterally:
Merges with posterior lamina of investing layer of the deep cervical fascia enclosing
trapezius muscle.

Features to remember

• Forms the fascial carpet of the floor of posterior triangle.

• Cervical and brachial plexuses of nerves lie deep to it.
• Forms axillary sheath, which extends into the axilla. (Note: The subclavian and
axillary veins lie outside the sheath, so that they could dilate during increased
venous return from the limb.)

❖ Write a short note on carotid sheath. AN35.1

Formation

• It is formed by the condensation of fibroareolar tissue around common and

internal carotid arteries and internal jugular vein (Fig. 10.3).
• It extends from the base of the skull to the arch of the aorta.
• Its anterior wall is connected to the pretracheal fascia while its posterior wall is
 connected to the prevertebral fascia.

FIG. 10.3 Carotid sheath: A, surface view; B, sectional view.

Thickness
It is thick around common and internal carotid arteries, and thin around internal
jugular vein to allow the free expansion of vein during increased venous return.

Relations
Anteriorly:
Ansa cervicalis is embedded in the wall or sheath.

Posteriorly:
Sympathetic trunk is present behind the sheath.

Contents (fig. 10.3)

• Common and internal carotid arteries

• Internal jugular vein
• Vagus nerve

Applied anatomy
It is frequently exposed in block dissection of the neck during surgical removal of the
deep cervical lymph nodes.

❖ Write a short note on cervical lymph nodes. AN28.5, AN35.5

The cervical lymph nodes are divided into two groups: (a) superficial and (b) deep
(Fig. 10.4).
 FIG. 10.4 A, Superficial cervical nodes; B, deep cervical nodes. SM1, submental; SM2,
submandibular; RP, retropharyngeal; Pr.T, pretracheal; Pa.T, paratreacheal.

Superficial lymph nodes

Following groups of superficial lymph nodes are present at the craniocervical junction.

(a) Submental nodes

(b) Submandibular lymph nodes
(c) Preauricular (superficial parotid) nodes
(d) Retroauricular nodes
(e) Occipital nodes

Others

(a) Nodes lying along the facial vein

(b) Node lying along the anterior jugular vein
(c) Nodes lying along the external jugular vein

Deep lymph nodes

Groups of lymph nodes lying along the internal jugular vein

(a) Jugulo-digastric nodes

(b) Jugulo-omohyoid nodes

Others

(a) Retropharyngeal
(b) Prelaryngeal
(c) Pretracheal and paratracheal
❖ Describe the sternocleidomastoid muscle in brief. AN29.1
The sternocleidomastoid muscle is a large superficial muscle of the neck. It lies
obliquely on the side of the neck between anterior and posterior triangles (Fig. 10.5). It
stands out prominently when head is turned to the opposite side.

FIG. 10.5 Origin and insertion of sternocleidomastoid muscle.

Origin
It arises by two heads – sternal and clavicular.

Sternal head:
By a rounded tendon from the upper part of the anterior surface of the manubrium
sterni.

Clavicular head:
By the musculoaponeurotic fibres from the superior border and anterior surface of
medial one-third of clavicle.

Insertion
By a strong tendon into the lateral surface of mastoid process and by thick aponeurosis
into the lateral half of superior nuchal line of the occipital bone.

Nerve supply
 • Spinal accessory nerve (motor)
• Ventral rami of C2 and C3 (proprioceptive)

Actions

• Tilts the head towards the shoulder on the same side and simultaneously rotates
the head in such a way that the face is turned to the opposite side and upwards.
• Both the muscles acting together draw the head forwards and downwards, as in
lifting/elevating the head from the pillow when lying down on bed in supine
position.

Applied anatomy
Torticollis:
It is a deformity of the neck in which the head is bent to one side and chin faces towards
the opposite side. It occurs due to spasm or contracture of the sternocleidomastoid
muscle.

❖ Describe the posterior triangle under the following headings: (a) boundaries, (b)
contents and (c) applied anatomy. AN29.1–29.4
It is a triangle on the side of neck.

Boundaries (fig. 10.6)

 FIG. 10.6 Posterior triangle: A, muscles forming the floor of the posterior triangle; B,
subdivisions and main contents of posterior triangle.

Anterior:
Posterior border of sternocleidomastoid.

Posterior:
Anterior border of trapezius.

Inferior (or base):

Middle one-third of clavicle.

Apex:
Meeting point of sternocleidomastoid and trapezius at superior nuchal line of the
occipital bone.

Floor:
It is muscular and formed by the following muscles from above to downwards (Fig.
10.6):

• Semispinalis capitis
• Splenius capitis
• Levator scapulae
• Scalenus medius

N.B.
Floor is covered by the prevertebral layer of the deep cervical fascia (fascial carpet).

Roof
 • Investing layer of the deep cervical fascia
• Superficial fascia containing platysma

Contents
The main contents are (Fig. 10.6)

• Roots and trunks of the brachial plexus

• Third part of the subclavian artery
• Subclavian vein
• Spinal accessory nerve
• Occipital artery
• Lymph nodes
• Inferior belly of omohyoid

Applied anatomy

• Pus from tubercular abscess of cervical spine may track into the posterior
triangle, deep to prevertebral layer of the deep cervical fascia (i.e. underneath
the fascial carpet of posterior triangle), and may produce swelling.
• Left supraclavicular lymph nodes (Virchow lymph nodes) may be enlarged in
malignancy of stomach and other abdominal organs.

❖ What are the subdivisions of the posterior triangle? AN29.1–29.4

The posterior triangle is divided into two parts by an inferior belly of omohyoid:

• A larger upper part is called occipital triangle because it contains occipital

artery.
• A smaller lower part is called subclavian triangle because it contains
subclavian artery. It is also called supraclavicular triangle.

❖ Enumerate the structures piercing the roof of the posterior triangle. AN29.1–29.4

The roof of the posterior triangle is pierced by the following structures.

Four cutaneous nerves

• Lesser occipital nerve (C2)

• Great auricular nerve (C2 and C3)
• Transverse cervical nerve (C2 and C3)
• Supraclavicular nerves (anterior, middle and posterior; C3 and C4)

One vein

• External jugular vein

❖ Describe the digastric (submandibular) triangle in brief. AN32.2

Boundaries (fig. 10.7)

FIG. 10.7 Digastric (submandibular) triangle: boundaries and contents. SG, submandibular
gland.

Anteroinferiorly:
Anterior belly of digastric.

Posteroinferiorly:
Posterior belly of digastric and stylohyoid.

Superiorly (base)

• Base of mandible
• Imaginary line, joining the angle of mandible to the mastoid process

Floor:
From anterior to posterior, it is formed by three muscles:

• Mylohyoid
• Hyoglossus
• Middle constrictor of pharynx

Roof:
It is formed by:
 • Investing layer of the deep fascia enclosing submandibular gland
• Superficial fascia containing:
■ Cervical branch of the facial nerve
■ Cutaneous branch of great auricular nerve
■ Common facial vein

Contents
These are:

(a) In Anterior Part (b) In Posterior Part

• Submandibular • Parotid gland

gland • External carotid artery
• Submandibular • Styloid process and muscles attached to it (styloglossus,
lymph nodes stylopharyngeus and stylohyoid muscles)
• Submental artery • Upper part of carotid sheath with its contents
• Mylohyoid nerve
and vessels
• Facial artery
• Facial vein
❖ Describe the boundaries and contents of the carotid triangle. AN32.2

Boundaries (fig. 10.8)

FIG. 10.8 Carotid triangle: boundaries and contents.

Anterosuperiorly:
Posterior belly of the digastric and the stylohyoid.

Anteroinferiorly:
Superior belly of the omohyoid.

Posteriorly:
Anterior border of the sternocleidomastoid.

Contents
Arteries

• Common carotid artery

• Internal carotid artery
• External carotid artery and its first five branches (superior thyroid, lingual,
facial, ascending pharyngeal and occipital arteries)

Veins

• Internal jugular vein

• Common facial vein
• Pharyngeal vein
• Lingual vein

Nerves

• Vagus nerve
• Superior laryngeal branch of the vagus nerve, dividing into the external and
internal laryngeal nerves
• Spinal accessory nerve running obliquely backwards and downwards over the
internal jugular vein
• Hypoglossal nerve running horizontally forwards over the external carotid,
internal carotid and lingual (loop) arteries
• Ansa cervicalis
• Sympathetic chain

Lymph nodes
Deep cervical lymph nodes

Special structures

• Carotid sinus
• Carotid body
❖ Write a short note on the ansa cervicalis. AN35.1
The ansa cervicalis is a ‘U’-shaped nerve loop derived from ventral rami of C1, C2 and
C3 nerves (Fig. 10.9).

FIG. 10.9 Formation and distribution of ansa cervicalis.

Location
It lies on the anterior wall of the carotid sheath in the carotid triangle.

Roots

• Superior root (limb) is formed by descendens hypoglossi (a branch of hypoglossal

nerve), which contains the fibres of the ventral ramus of C1 nerve.
• Inferior root (limb) is formed by descendens cervicalis, which contains the fibres of
the ventral rami of C2 and C3 nerves.

Distribution

Superior root → superior belly of omohyoid

Inferior root → sternohyoid, sternothyroid and inferior belly of omohyoid

❖ Describe briefly carotid sinus and carotid body.

Carotid sinus
It is a dilatation in the terminal part of common carotid artery and/or the beginning of
internal carotid artery. It is richly innervated by glossopharyngeal and sympathetic
nerves. It functions as baroreceptor. The pressure on the carotid sinuses (in individuals
with carotid sinus hypersensitivity) can lead to slowing of heart rate (bradycardia) and
syncope (carotid sinus syndrome).

Carotid body
It is a small, reddish-brown oval body that lies behind the bifurcation of common
carotid artery. It is supplied by glossopharyngeal, vagus, and sympathetic nerves. It acts
as chemoreceptor and responds to O2 and CO2 level, and pH of the blood.

❖ Describe the external carotid artery in brief. AN43.5, AN43.6, AN43.8, AN43.9

Origin and extent

• It is one of the two terminal branches of the common carotid artery.

• It extends from the level of upper border of thyroid cartilage to the back of the
neck of mandible, where it terminates by dividing into superficial temporal and
maxillary arteries.

Branches (fig. 10.10)

They are eight in number which corresponds to the number of alphabets in the term
‘EXTERNAL’, i.e. 8.
 FIG. 10.10 Branches of the external carotid artery.

From below to upwards, these are

❖ Write a short note on the facial artery. AN28.3

Origin and extent (fig. 10.11)

It arises from the anterior aspect of external carotid artery in the carotid triangle of neck,
just below the level of tip of greater cornu of the hyoid bone.
 FIG. 10.11 Course and branches of the facial artery.

It extends from its site of origin in the neck to the medial angle of eye in the face,
where it terminates by anastomosing with the dorsal nasal artery, a branch of the
ophthalmic artery.

Branches
In the neck

• Ascending palatine artery

• Glandular branches to the submandibular gland
• Tonsillar artery
• Submental artery

In the face

• Superior labial artery

• Inferior labial artery
• Lateral nasal branch
• Unnamed muscular branches

N.B.
Terminal part of the facial artery is called angular artery. The facial artery is tortuous to
allow the movements of pharynx, mandible, lips and cheeks.

Applied anatomy
The pulsations of the facial artery can be felt:
 • On the base of mandible, at the anteroinferior angle of the masseter
• 1.25 cm lateral to the angle of mouth, just lateral to modiolus with index finger
put in the oral cavity and thumb placed on the outer aspect of the cheek

❖ Describe the boundaries and contents of the muscular triangle. AN32.2

Boundaries
Anteriorly:
Anterior median line of the neck.

Posterosuperiorly:
Superior belly of omohyoid.

Posteroinferiorly:
Anterior border of the sternocleidomastoid.

Contents
Infrahyoid (ribbon) muscles:

N.B.
All the infrahyoid muscles are supplied by the branches of ansa cervicalis except
thyrohyoid, which is supplied by the nerve to thyrohyoid – a branch of the
hypoglossal nerve containing C1 fibres.

❖ Describe the boundaries and contents of submental triangle. AN32.2

Boundaries
Lateral (on each side):
Anterior belly of digastric.

Base:
Body of hyoid bone.

Apex:
Symphysis menti.

Floor:
Oral diaphragm (formed by mylohyoid muscles).

Roof:
Investing layer of deep cervical fascia.

Contents

• Submental lymph nodes (three to four in number)

• Submental veins, which unite to form anterior jugular veins

❖ Enumerate the structures in the anterior median line of the neck.

From above to downwards, these are

• Mylohyoid raphe (a fibrous raphe extending from the symphysis menti to the
hyoid bone)
• Body of hyoid bone
• Median thyrohyoid ligament
• Angle of thyroid cartilage (Adam’s apple in male)
• Median cricothyroid ligament
• Cricoid cartilage
• First ring of the trachea
• Isthmus of the thyroid gland lying on 2nd, 3rd and 4th tracheal rings
• Infrahyoid veins and thyroidea ima artery (sometimes)
• Jugular venous arch connecting two anterior jugular veins

N.B.
The anterior median region of the neck includes 2- to 3-cm wide strip in the anterior
midline of the neck, extending from the symphysis menti to the suprasternal notch.

❖ Describe the boundaries, contents and applied anatomy of the suboccipital

triangle. AN42.2
The suboccipital triangle is an intermuscular triangular space situated deep in the
suboccipital region (Fig. 10.12).
 FIG. 10.12 Boundaries and contents of suboccipital triangle.

Boundaries
Superomedially:
Rectus capitis posterior major supplemented by the rectus capitis posterior minor.

Superolaterally:
Obliquus capitis superior.

Inferiorly
Obliquus capitis inferior.

Floor

• Posterior arch of atlas

• Posterior atlanto-occipital membrane

Roof

• Medially
■ Dense fibrous tissue covered by semispinalis capitis
• Laterally
■ Longissimus capitis
■ Splenius capitis

Contents

• Third part of the vertebral artery

• Dorsal ramus of the 1st cervical nerve (suboccipital nerve)
• Greater occipital nerve (dorsal ramus of C2)
• Suboccipital plexus of veins
Applied anatomy
The suboccipital triangle is the

• Site for cisternal puncture

• Site through which neurosurgeons approach the posterior cranial fossa of
cranial cavity
11

Parotid and submandibular regions

Parotid region
❖ What are the boundaries of parotid region? AN28.9

Boundaries
Anterior:
Anterior border of masseter

Posterior:
Mastoid process

Above:
Zygomatic arch

Below:
Line joining the angle of mandible to the mastoid process

❖ What is parotid bed? AN28.9

It is the retromandibular space where the parotid gland lies.

Boundaries
Anterior:
Posterior border of ramus of mandible

Posterior:
Mastoid process

Superior:
External acoustic meatus

Medial:
Styloid process

N.B.
The parotid-bed is made soft by the muscles covering its anterior, posterior and medial
bony boundaries (i.e. ramus of mandible is covered by masseter and medial pterygoid
muscles; mastoid process is covered by sternocleidomastoid and posterior belly of
digastric muscle; and styloid process is covered by styloglossus, stylohyoid and
stylopharyngeus muscles).

❖ Describe the parotid gland under the following headings: (a) external features, (b)
relations, (c) nerve supply and (d) applied anatomy. AN28.9

External features
The parotid gland is the largest salivary gland (weight: 25 g) located in the parotid
region. It resembles three-sided inverted pyramid and presents the following features
(Figs 11.1 and 11.2).

FIG. 11.1 Main features of the parotid region.

Apex:
Directed downwards

Base:
Directed upwards

Three surfaces:

• Superficial (largest)
• Anteromedial
• Posteromedial

Three borders:
 • Anterior
• Posterior
• Medial

Relations (figs 11.2 and 11.3)

Apex:
It is related to posterior belly of digastric.

FIG. 11.2 Horizontal section through parotid gland showing its relations and the structures
passing through it. The figure in the inset shows borders and surfaces of the parotid gland. SG,
styloglossus muscle; SH, stylohyoid muscle; SP, stylopharyngeus muscle.
 FIG. 11.3 Structures emerging at the periphery of the parotid gland.

N.B.
The cervical branch of the facial nerve and anterior and posterior divisions of the
retromandibular vein emerge through the apex.

Base:
It is related to:

• External acoustic meatus

• Posterior aspect of the temporomandibular joint

N.B.
The superficial temporal vessels and auriculotemporal nerve emerge through the base.

Superficial surface:
It is related to:

• Skin
• Superficial fascia containing platysma, branches of great auricular nerve and
superficial parotid lymph nodes
• Parotidomasseteric fascia
 • Deep parotid lymph nodes embedded in the gland

Anteromedial surface:
It is related to:

• Masseter
• Posterior border of ramus of mandible
• Medial pterygoid

Posteromedial surface:
It is related to:

• Mastoid process and muscles covering it

• Styloid process and muscles covering it

N.B.
The facial nerve trunk and external carotid artery enter the gland through this surface.

Anterior border:
The following structures (from above to downwards) emerge underneath this border:

Posterior border:
The following structures emerge from underneath this border:

• Posterior auricular nerve

• Posterior auricular vessels

Medial border:
It is related to the lateral wall of pharynx.

Nerve supply (fig. 11.4)

 FIG. 11.4 Nerve supply of the parotid gland. ATN, auriculotemporal nerve.

Secretomotor (parasympathetic):

• Preganglionic fibres arising from inferior salivatory nucleus and travel to otic
ganglion as follows:
Inferior salivatory nucleus → Glossopharyngeal nerve → Tympanic branch
of glossopharyngeal nerve (Jacobson’s nerve) → Tympanic plexus →
Lesser petrosal nerve → Relay in otic ganglion
• Postganglionic fibres arise from otic ganglion and travel through
auriculotemporal nerve to supply the parotid gland.

Vasomotor (sympathetic):

• Preganglionic fibres arise from T1 segment of spinal cord and relay in the superior
cervical sympathetic ganglion.
• Postganglionic fibres arise from superior cervical sympathetic ganglion, run along
the arteries (e.g. external carotid artery) to supply the gland.

Sensory:

• Auriculotemporal nerve
• Great auricular nerve
N.B.
The sympathetic and sensory fibres pass through the otic ganglion but do not relay in
it.

Applied anatomy
Mumps (viral parotitis):
It is the inflammation of parotid gland by mumps virus. Mumps characteristically do not
suppurate. In adults, the mumps may cause complications like orchitis in male, oophoritis
in female and pancreatitis in both sexes.

Parotid swellings:
These are very painful due to unyielding nature of parotid fascia, which encloses the
gland.

Parotid abscess:
It is drained by a transverse incision in the parotidomasseteric fascia to avoid injuries to
the facial nerve (Hilton’s method).

Frey syndrome:
It occurs due to the damage of branches of auriculotemporal and great auricular nerves
by penetrating wounds in the parotid region. During regeneration, secretomotor fibres
of auriculotemporal nerve join the fibres of great auricular nerve. As a result, the
stimulation of parotid gland causes stimulation of great auricular nerve, which leads to
sweating and redness (hyperaemia) in the area of distribution of great auricular nerve
(e.g. parotid region).  AN28.10

❖ Write a short note on the parotid capsule.  AN28.9

It is a facial capsule that encloses the parotid gland (Fig. 11.5). It is derived from
investing layer of the deep cervical fascia. At the lower end of the gland, the fascia splits
into superficial and deep laminae to enclose the gland.

• The superficial lamina is extremely dense and tough, and is attached to the lower
border of the zygomatic arch. It blends with the perimysium of masseter to form
the parotidomasseteric fascia.
• The deep lamina is relatively thin and is attached to the styloid process, tympanic
plate and mandible. It also forms the stylomandibular ligament.
 FIG. 11.5 Parotid capsule.

❖ Enumerate the structures present within the parotid gland. AN28.9

From superficial to deep, these are as follows (Fig. 11.2):

• Deep parotid lymph nodes

• Facial nerve
• Retromandibular vein
• External carotid artery

N.B.
Sometimes deep parotid lymph nodes are also present within the parotid gland.

❖ Write a short note on the parotid duct (Stensen’s duct). AN28.9

General features

• It is a 5-cm long and 3-mm wide tube.

• It emerges from middle of the anterior border of the parotid gland and opens
into the vestibule of mouth opposite the crown of 2nd upper molar tooth on the
parotid papilla.

Course (fig. 11.6)

• Runs forward over masseter muscle.

• Turns medially (1st bend) at the anterior border of masseter and pierces buccal
pad of fat, buccopharyngeal fascia and buccinator muscle in succession.
• Runs forward (2nd bend) between the buccinator and mucous membrane for
some distance.
• Turns medially (3rd bend) to open on the summit of the parotid papilla to pour
its secretions in the vestibule of mouth.
 FIG. 11.6 Course of parotid duct, showing three bends marked as I, II and III.

Applied anatomy

• The parotid duct can be palpated and rolled on the firm anterior edge of
masseter.
• Sinuous course of the parotid duct serves a valve-like mechanism to prevent the
entry of infective agents in the duct from mouth during violent blowing.

❖ Describe the development of the parotid gland in brief. AN43.4

• It develops as a furrow/groove arising from ectodermal lining of stomodeum

between the mandibular and maxillary arches at the site of future lateral angle
of mouth.
• The ectodermal groove is converted into a tube.
• The anterior part of the tube forms the parotid duct.
• The posterior part of the tube branches rapidly in the substance of cheek and
forms the parenchyma, i.e. glandular substance.
• Supporting tissue of gland develops from surrounding mesenchyme.

❖ Describe the histological features of the parotid gland in brief. AN43.2

It is a compound tubuloalveolar gland and presents the following histological features
(Fig. 11.7).
 FIG. 11.7 A, Histological features of parotid salivary gland; B, the figure in the inset shows
detailed structure of a serous acinus. Source: (Source for Fig. 11.7A: Textbook of Histology:
Atlas and Practical Guide, 3rd Edition: JP Gunasegaran, Box 3.1, Page 43, RELX India Private
Limited, 2016.)

Connective tissue:
The connective tissue (fibrous) septa divide the gland into lobes and lobules.

Acini:

• Presence of large number of serous acini.

• Acini are round and shows biphasic stain with H&E stain, basophilic in basal
part and eosinophilic in apical parts. They have with very small lumen.
• Acini are lined by pyramidal cells with round nuclei placed near the centre.

Ducts:

• Intercalated ducts are lined by simple squamous epithelium.

• Striated ducts are lined by simple columnar epithelium with basal striations.
They are stained dark with eosin.
 • Interlobular ducts are present in connective tissue septa between the lobules and
are lined by stratified cuboidal/low columnar epithelium.

N.B.
The intercalated and striated ducts together form intralobular ducts.

Submandibular region
❖ Write a short note on the digastric muscle. AN32.2

• This muscle lies above hyoid bone in the submandibular region.

• It has two bellies – anterior and posterior.

Origin
Anterior belly:
It is unipennate and arises from the digastric fossa of mandible.

Posterior belly:
It is bipennate and arises from the mastoid notch of occipital bone.

Insertion
The two bellies meet to form an intermediate tendon, which is anchored by a fibrous
pulley to the hyoid bone.

Nerve supply
Posterior belly:
By facial nerve (nerve of second arch)

Anterior belly:
By mandibular nerve through nerve to mylohyoid (nerve of 1st arch)

Action
It elevates the floor of mouth and hyoid bone during the second phase of deglutition.

❖ List the relations of posterior belly of the digastric muscle. AN32.2

Superficial relations

• Skin
• Superficial fascia
• Deep fascia
 • Mastoid process
• Parotid gland

Deep relations (fig. 11.8)

• Transverse process of atlas crossed superficially by spinal accessory nerve.

• Both the internal and external carotid arteries.
• Internal jugular vein.
• Vagus nerve descending between the internal jugular vein and the internal
carotid artery.
• Hypoglossal nerve.
• Along its upper border the posterior auricular branch of external carotid artery and
along its lower border the occipital branch of external carotid artery pass upwards
and laterally.
• Lingual and facial arteries.

FIG 11.8 Deep relations of the posterior belly of digastric muscle.

❖ Describe the origin, insertion, nerve supply and actions of the hyoglossus
muscle. AN39.1
It is the key muscle of the submandibular region.

Origin
From greater cornu and lateral part of the body of hyoid bone.

Insertion
Fibres run upwards and forwards to be inserted into the side of tongue. The
styloglossus muscle interlaces at its insertion.

Nerve supply
Hypoglossal nerve (CN XII).

Action
Depresses the tongue to make its dorsum convex.

❖ Enumerate the relations of the hyoglossus muscle. AN39.1

Superficial relations (fig. 11.9)

FIG. 11.9 Superficial relations of hyoglossus muscle.

From above to downwards, these are as follows:

• Lingual nerve with the submandibular ganglion suspended from it.

• Deep part of the submandibular gland and submandibular duct.
• Hypoglossal nerve and its venae comitantes.
• Loop of communication between the lingual and the hypoglossal nerves.
• Styloglossus muscle.

Deep relations
Two muscles:
Middle constrictor and genioglossus

An artery:
Lingual artery and its dorsal linguae branches

A nerve:
Glossopharyngeal nerve

A ligament:
Stylohyoid ligament

❖ Enumerate the structures passing deep to the posterior border of hyoglossus. 

AN39.1
From above to downwards, these are as follows:

• Glossopharyngeal nerve (CN IX)

• Stylohyoid ligament
• Lingual artery

❖ Describe the submandibular gland under the following headings: (a) location and
parts, (b) external features, (c) relations, (d) nerve supply and (e) applied anatomy. 
AN34.1

Location and parts

The submandibular gland lies in the digastric triangle. It is divided into two parts:

• Superficial
• Deep
The large, superficial part is located below the mylohyoid muscle and almost fills
the digastric triangle.
The small, deep part is located above the mylohyoid muscle.
The two parts are continuous with each other around the free posterior margin of
the mylohyoid muscle (Fig. 11.10).

FIG. 11.10 Horizontal section through submandibular region showing the location and parts of
submandibular gland. The sublingual salivary gland is also seen.
 The gland is enclosed between the two layers of investing layer of deep cervical
fascia. The superficial layer covers the superficial surface of the gland and is attached to
the base of the mandible. The deep layer covers the medial surface of the gland and is
attached to the mylohyoid line of the mandible.

Superficial part of submandibular gland

External features:
It presents:

• Two ends: Anterior and posterior

• Three surfaces: Inferior, lateral and medial

Relations (figs 11.11 and 11.12)

FIG. 11.11 Relations of the superficial (inferior) surface of the submandibular salivary gland.
The relations of anterior part of medial (deep) surface are also seen.
 FIG. 11.12 Relations of the medial (deep) surface of submandibular gland.

Inferior surface
is related to:

• Skin
• Superficial fascia
• Platysma
• Deep fascia
• Common facial vein
• Cervical branch of facial nerve
• Submandibular lymph nodes

Lateral surface
is related to:

• Submandibular fossa of mandible

• Medial pterygoid muscle
• Facial artery

Medial surface:
It is extensive and is divided into three parts: anterior, intermediate and posterior.

• Anterior part is related to:

■ Mylohyoid muscle
■ Mylohyoid nerve and vessels
■ Submental artery (a branch of facial artery)
• Intermediate part is related to:
■ Hyoglossus muscle
 ■ Lingual nerve
■ Submandibular ganglion
■ Hypoglossal nerve
■ Submandibular duct
• Posterior part is related to:
■ Styloglossus muscle
■ Stylopharyngeus muscle
■ Middle constrictor of pharynx
■ Glossopharyngeal nerve
■ Lingual artery

Deep part of submandibular gland

• It is small and lies on hyoglossus muscle.

• Posteriorly, it is continuous with superficial part around the posterior border of
the mylohyoid muscle (Fig. 11.10).
• Submandibular duct emerges from its anterior end.

Nerve supply (fig. 11.13)

FIG. 11.13 Nerve supply of submandibular gland/submandibular ganglion and its connections.

Secretomotor (parasympathetic):

• Preganglionic fibres arise from superior salivatory nucleus, pass successively

through facial nerve, geniculate ganglion, chorda tympani and the lingual
 nerves to reach and relay in the submandibular ganglion.
• Postganglionic fibres arise from submandibular ganglion and enter the
submandibular gland to supply it.

Vasomotor (sympathetic):

• Preganglionic fibres arises from T1 spinal segment and relay in the superior
cervical sympathetic ganglion.
• Postganglionic fibres arises from superior cervical sympathetic ganglion and run
along the arteries to supply the gland. These fibres do not relay in the ganglion.

Sensory:

• Lingual nerve.
• Sensory fibres also do not relay in the ganglion.

Applied anatomy

• Formation of calculi is more common in submandibular gland than in parotid

gland, because of (a) its secretion being more viscous and (b) tortuous upward
course of its duct (i.e. drainage occurs against gravity). This leads to stasis of
secretion which leads to formation of stone. AN34.2
• To excise submandibular gland, the skin incision is given at about 4 cm below
the angle of mandible to avoid injury to the marginal mandibular nerve.
• A stone in submandibular duct can be palpated bimanually in the floor of
mouth and may even be seen if sufficiently large.
• Submandibular gland swelling can be palpated bimanually as it lies on both
the aspects of the oral diaphragm (i.e. mylohyoid muscle).

❖ Describe the histological features of the submandibular salivary gland in brief. 

AN43.2
The important histological features of the submandibular salivary gland (Fig. 11.14):

• Presence of both serous and mucous acini.

• Mucous acini are made up of truncated columnar cells with flattened basal
nuclei. They are stained light pink with H&E.
• Serous acini are described on p. 120. They stain basophilic in the basal part and
pink in the apical part.
• Serous demilunes of Giannuzzi capping some of the mucous acini are seen.
• Moderately developed duct system.
 FIG. 11.14 Histological features of submandibular gland; The figure in the inset on the right
side shows detailed structure of (A) mucous acinus and (B) mucous acinus with serous
demilune. Source: (Source for left side Fig.: Textbook of Histology: Atlas and Practical Guide,
3rd Edition: JP Gunasegaran, Box 3.3, Page 44, RELX India Private Limited, 2016.)

❖ Write briefly about sublingual gland. AN34.1

• It is small, almond-shaped salivary gland located in the floor of mouth on the

mylohyoid muscle underneath the oral mucosa.
• It weighs about 3–4 g.
• About 15–20 ducts emerge from the gland (ducts of Rivinus) and open directly
into the floor of mouth on the sublingual fold.
• Its nerve supply is similar to that of submandibular gland.

Applied anatomy
The cystic degeneration of sublingual gland forms a swelling, which resembles the belly
of a frog; hence, it is called ranula.

❖ Write a short note on the submandibular ganglion. AN34.1

• The submandibular ganglion is a small parasympathetic ganglion lying on the

hyoglossus muscle (see Fig. 11.13).
• Topographically, it is connected to lingual nerve, whereas functionally it is
connected to the facial nerve. (Note: The chorda tympani nerve is a branch of the
facial nerve.)

Roots
Parasympathetic root:

• Preganglionic fibres arise from superior salivatory nucleus. These fibres then pass
successively through nervus intermedius, facial nerve, chorda tympani and
lingual nerves to relay in the ganglion.
• Postganglionic fibres arise from ganglion and supply submandibular and
sublingual salivary glands.

Sympathetic root:

• Preganglionic fibres arise from T1 spinal segment and relay in the superior
cervical sympathetic ganglion.
• Postganglionic fibres arise from the superior cervical sympathetic ganglion,
form plexus around external carotid artery, pass through ganglion without
relay, and supply the submandibular and sublingual glands.

Sensory:

• Lingual nerve.
• Sensory fibres also do not relay in the ganglion.

❖ Describe the chorda tympani nerve in brief. AN28.4

Origin
The chorda tympani nerve is a branch of facial nerve. It arises from facial nerve at about
6 mm above the stylomastoid foramen.

Functional components

• General visceral efferent (GVE) fibres (i.e. postganglionic parasympathetic fibres),

which provide secretomotor supply to the submandibular and sublingual salivary
glands.
 • Special visceral afferent (SVA) fibres, which carry taste sensations from anterior
two-third of the tongue, except from vallate papillae.

Course (fig. 11.15)

Arises from vertical part of the facial nerve → enters middle ear through posterior
canaliculus → runs across the lateral wall of middle ear → enters anterior canaliculus →
enters infratemporal fossa through petrotympanic fissure → crosses medial aspect of
spine of sphenoid → joins lingual nerve.

FIG. 11.15 Chorda tympani nerve. SSN, superior salivatory nucleus; NTS, nucleus tractus
solitarius; SG, submandibular ganglion.

Applied anatomy
The lesions of chorda tympani nerve leads to:

• Decrease in the production of saliva

• Loss of taste sensations in the anterior two-third of tongue
12

Deep structures of the neck and

prevertebral region

Deep structures of the neck

❖ Describe the thyroid gland under the following headings: (a) gross anatomy, (b)
parts and relations, (c) blood supply, (d) development and (e) applied anatomy. 
AN35.2

Gross anatomy (fig. 12.1)

• It is a large endocrine gland situated on the front (and side) of the lower part of
the neck.
• It consists of right and left lobes, joined by an isthmus. Sometimes, a third small
pyramidal lobe may project upwards from isthmus.

FIG. 12.1 Location, parts and extent of the thyroid gland.

Situation and extent (fig. 12.1)

 • The thyroid gland is situated in front of C5 to C7 and T1 vertebrae.
• Each lobe extends from the oblique line of the thyroid cartilage to 4th or 5th
tracheal ring.
• The isthmus extends from 2nd to 4th tracheal ring.

Weight:
25 g (larger in females)

Dimensions

• Each lobe measures 5 × 2.5 × 2.5 cm

• Isthmus measures 1.25 × 1.25 cm

Capsules/coverings
The thyroid gland is enclosed into two capsules: true and false.

• True capsule: It is formed by the condensation of the connective tissue of the

gland itself at its periphery.
• False capsule: It is formed by the pretracheal layer of the deep cervical fascia. It is
thin along the posterior border but thick on the medial surface of the gland,
where it thickens to form a suspensory ligament of Berry connecting the gland
to the cricoid cartilage.

N.B.
A dense capillary plexus is present deep to the true capsule. Hence, to avoid
haemorrhage during thyroidectomy, the thyroid gland is removed along with its true
capsule.

Parts and relations (fig. 12.2)

 FIG. 12.2 Transverse section of anterior part of the neck at the level of thyroid isthmus,
showing relations of thyroid gland.

Thyroid lobe
Each lobe is conical in shape and presents the following features:

• Apex
• Base
• Three surfaces: lateral, medial and posterolateral
■ Lateral/superficial surface is covered from deep to superficial by:
• Sternothyroid
• Sternohyoid, and superior belly of omohyoid
• Anterior border of sternocleidomastoid
■ Medial surface is related to:
• Two tubes: Trachea and oesophagus
• Two muscles: Inferior constrictor and cricothyroid
• Two nerves: External laryngeal and internal laryngeal
■ Posterolateral/posterior surface is related to carotid sheath.
• Two borders: Anterior and posterior
■ Anterior border is related to anterior branch of superior thyroid artery.
■ Posterior border is related to:
• Longitudinal anastomosis between superior and inferior thyroid
arteries
• Superior and inferior parathyroid glands
• Inferior thyroid artery
• Thoracic duct (on left side only)

Isthmus
The isthmus presents:

• Two surfaces: Anterior and posterior

■ Anterior surface is related to:
• Right and left sternothyroid and sternohyoid muscles
• Anterior jugular veins
■ Posterior surface is related to 2nd, 3rd and 4th tracheal rings.
• Two borders: Superior and inferior
■ Upper border is related to anastomosis between the anterior branches of right
and left superior thyroid arteries.
■ Inferior border is related to the inferior thyroid veins.

Blood supply
Arterial supply (fig. 12.3)
 • Superior thyroid artery is a branch of the external carotid artery. It supplies upper
two-third of the thyroid lobe and upper half of the isthmus. Superior thyroid
artery is accompanied by external laryngeal nerve which leaves it near the
upper pole of the gland.
• Inferior thyroid artery is a branch of the thyrocervical trunk. It supplies lower one-
third of the thyroid lobe and lower half of the isthmus. Inferior thyroid artery is
closely related to the recurrent laryngeal nerve near the lower pole of the
thyroid gland.
• Arteria thyroidea ima (if present) is a branch of brachiocephalic trunk or arch of
aorta. It supplies the isthmus.
• Small accessory arteries derived from the oesophageal and tracheal arteries.

FIG. 12.3 Arterial supply of the thyroid gland.

Venous drainage (fig. 12.4)

• Superior thyroid vein: It emerges from the upper pole and drains into internal
jugular vein.
• Middle thyroid vein (a short wide venous trunk): It emerges from middle of the
thyroid lobe and drains into internal jugular vein.
• Inferior thyroid vein: It emerges from lower border of the isthmus and drains into
left brachiocephalic vein.
• A fourth vein (of Kocher), if present, emerges between middle and inferior
thyroid veins and drains into internal jugular vein.
 FIG. 12.4 Venous drainage of the thyroid gland.

Development (fig. 12.5)

• The thyroid gland develops from a median endodermal diverticulum – the

thyroglossal duct, which grows downwards in front of neck from the floor of
primitive pharynx.
• The distal end of thyroglossal duct bifurcates and then differentiates to form
thyroid gland. The remaining part of the duct obliterates.

FIG. 12.5 Development of the thyroid gland; note the different stages in the development.

N.B.
The follicular cells develop from the thyroglossal duct, while the parafollicular (C cells)
cells develop from the neural crest cells of ultimobranchial bodies.

Applied anatomy

• Enlargement of the thyroid gland is called goitre.

• During thyroidectomy (removal of thyroid gland), the superior thyroid artery
should be ligated as near to the superior pole of gland as possible, while inferior
thyroid artery should be ligated as away from the gland as possible to avoid
injuries to external laryngeal and recurrent laryngeal nerves, respectively.
• Swellings arising from thyroid gland moves up and down during swallowing
because thyroid capsule is attached to the laryngeal skeleton.
• Partial thyroidectomy is preferred to total thyroidectomy to avoid postoperative
hypothyroidism due to inadvertent removal of parathyroid glands.
• Compression of structures by large goitre leads to characteristic symptoms of:
■ Dyspnoea, due to compression of trachea.
■ Dysphagia, due to compression of oesophagus.
■ Dysphonia, due to compression of recurrent laryngeal nerves.
Mnemonic: 3D
• Thyroglossal cyst
■ It results from persistence of a portion of thyroglossal duct.
■ It is commonest congenital anomaly of thyroid gland.
■ It is usually located below the hyoid bone (subhyoid).

❖ Describe the histological features of the thyroid gland in brief. AN43.2

Microscopically, the thyroid gland consists of parenchyma and stroma (Fig. 12.6).

FIG. 12.6 Histological features of the thyroid gland.

Parenchyma

• Presence of spheroidal thyroid follicles (about 0.9 mm in diameter).

• Thyroid follicles are lined by simple cuboidal epithelium and filled with
eosinophilic colloid material (thyroglobulin).
• Simple cuboidal epithelium lining the thyroid follicles is made up of follicular
cells.
• Presence of parafollicular cells (C cells) in between the thyroid follicles in the
connective tissue or sometimes within the follicles close to the basement
membrane.

Stroma

• It forms the connective tissue framework of the gland.

• Stroma includes the capsule and sparse intralobular connective tissue rich in
capillaries.

❖ Describe the parathyroid glands in brief. AN43.2

General features

• These are two pairs (superior and inferior) of small endocrine glands.
• The superior and inferior parathyroid glands are located on the posterior border
of each thyroid lobe within the capsule of the thyroid gland.

Each parathyroid gland is small, yellowish-brown, oval or lentiform body measuring 6 × 4

× 2 and weighing about 50 mg (about the size of a split pea).
The superior and inferior parathyroid glands lie on the posterior aspect of the thyroid
lobe along the anastomotic artery between the superior and inferior thyroid arteries,
which is used as a guide to locate them during surgery.

Position/location
Superior parathyroid
It is more constant in position and usually lies at the middle of the posterior border of
the lateral lobe of the thyroid gland at the level of cricoid cartilage. It usually lies
between the true and false capsules of the thyroid gland and dorsal to the recurrent
laryngeal nerve.

Inferior parathyroid
It is more variable in position. It may lie:

• Within the thyroid capsule below the loop of inferior thyroid artery, near the
lower pole of thyroid gland.
 • Outside the thyroid capsule, immediately above the loop of inferior thyroid
artery.
• Within the substance of the thyroid gland near its posterior border.

Function
The parathyroid glands secrete a hormone called parathormone, which plays an
important role in calcium metabolism.

Development

• Superior parathyroid develops from 4th pharyngeal pouch; hence, it is also called
parathyroid IV.
• Inferior parathyroid develops from 3rd pharyngeal pouch; hence, it is also called
parathyroid III.

Applied anatomy

• Hypoparathyroidism: It may occur due to inadvertent removal of the parathyroid

glands during thyroidectomy. It leads to tetany due to low blood calcium level.
Clinically, it presents as carpopedal spasm.
• Hyperparathyroidism: It occurs due to tumours of the parathyroid glands. It leads
to decalcification of bones and formation of renal stones due to high blood
calcium level.

Prevertebral region
❖ What are scalene muscles?

• These are deep muscles on the side of vertebral column of the neck
(paravertebral region).
• They extend from transverse processes of cervical vertebrae to the first two ribs.
• They are usually three in number, i.e.:
■ Scalenus anterior (key muscle at the root of neck)
■ Scalenus medius (largest of the three scalene muscles)
■ Scalenus posterior

❖ Describe the origin, insertion, nerve supply, actions and relations of scalenus
anterior muscle. AN29.4

Origin
From anterior tubercles of transverse processes of C3 to C6 vertebrae (i.e. from all
typical cervical vertebrae; Fig. 12.7).
 FIG. 12.7 Attachments (origin and insertion) of scalenus anterior muscle.

Insertion
Into scalene tubercle on the inner border of 1st rib.

Nerve supply
By ventral rami of C4 to C6 spinal nerves.

Actions

• Acting from below, it bends the neck forwards and laterally.

• Acting from above, it elevates the 1st rib and thus acts as an accessory muscle of
respiration.

Relations
It is key muscle at the root of neck because many important structures are related to it.

Anterior relations:

• Two nerves: Phrenic nerve and descendens cervicalis

• Two arteries: Transverse cervical and suprascapular
• Two veins: Anterior jugular and subclavian
• Two muscles: Inferior belly of omohyoid and sternocleidomastoid
Posterior relations:

• Branchial plexus (lower trunk)

• Subclavian artery (second part)
• Cervical pleura
• Suprapleural membrane

Lateral:
Trunks of brachial plexus

Medial:
Thyrocervical trunk

Applied anatomy

• Scalene syndrome occurs if roots of brachial plexus and subclavian artery are
compressed between scalenus anterior muscle and first rib.
• Cervical rib syndrome occurs when cervical rib passing through a gap between
scalenus anterior and scalenus medius muscles compressing lower trunk of
brachial plexus and subclavian artery.

Clinically these syndromes present as:

• Tingling and numbness in the little finger and medial half of ring fingers due to
involvement of T8 and T1.
• Absence of radial pulse due to compression of subclavian artery.

❖ Describe the scalenus medius muscle in brief. AN29.4

It is the longest and largest scalene muscle (Fig. 12.8).
 FIG. 12.8 Attachments (origin and insertion) of scalenus medius muscle.

Origin
From the posterior tubercles of transverse processes of C2 to C6 vertebrae.

Insertion
On the superior surface of 1st rib behind the groove for subclavian artery and in front of
tubercle of 1st rib.

Nerve supply
Ventral rami of C3 to C8 spinal nerves.

Actions
Same as scalenus anterior (see p. 135).

❖ Describe the boundaries of scalene triangle in brief and enumerate the structures
passing through it. AN29.4

Location
Root of the neck (Fig. 12.9)
 FIG. 12.9 Scalene triangle (yellow coloured area). Note the boundaries and structures passing
through it.

Boundaries
Anterior:
Scalenus anterior

Posterior:
Scalenus medius

Base:
1st rib

Apex:
Meeting point of the scalenus anterior and scalenus medius

Structures passing through this triangle

• Subclavian artery
• Brachial plexus (lower trunk)

Applied anatomy

• Scalene syndrome: Occurs due to compression of the lower trunk of brachial

 plexus and subclavian artery in scalene triangle due to (a) spasm of scalene
muscles or (b) presence of cervical rib.
• Clinically, it presents as:
■ Tingling and numbness in the area of distribution of C8 and T1.
■ Progressive wasting of intrinsic muscles of the hand due to involvement of
C8 and T1.
■ Absence of radial pulse due to compression of the subclavian artery.

❖ Describe the boundaries and contents of scalenovertebral triangle (triangle of

vertebral artery).  AN43.8, AN43.9

Location
Deep, at the front of the root of neck.

Boundaries
Medial:
Longus colli

Lateral:
Scalenus anterior

Apex:
Transverse process of C6 vertebrae

Base:
First part of the subclavian artery

Contents

• First part of the vertebral artery

• Thyrocervical trunk and vertebral artery
• Stellate (inferior cervical sympathetic) ganglion
• Thoracic duct (left side only)
• Ansa subclavia

❖ What are subclavian arteries? List their branches. AN35.3

The right subclavian artery is a branch of brachiocephalic trunk, whereas the left
subclavian artery is a direct branch of arch of aorta. On each side, the subclavian artery
extends up to the outer border of the 1st rib.

Branches
Each subclavian artery is divided into three parts by scalenus anterior muscle:
 • First part (medial to scalenus anterior) gives rise to:
■ Thyrocervical trunk
■ Vertebral artery
■ Internal mammary artery (internal thoracic artery)
■ Costocervical trunk (on the left side)
• Second part (behind the scalenus anterior) gives rise to costocervical trunk on the
right side.
• Third part (lateral to scalenus anterior): Usually does not give any branch, but
sometimes it may give origin to dorsal scapular artery.

❖ Describe the vertebral artery in brief. AN43.8, AN43.9

• It is the largest branch of subclavian artery and is one of the two main sources of
blood supply to the brain.
• It runs upwards to enter the foramen transversarium of C6 vertebra. It then
passes successively through the corresponding foramina of other cervical
vertebrae above to reach the upper surface of C1 vertebra. Here, it turns
medially in the suboccipital triangle to finally enter the cranial cavity through
foramen magnum. Here, it joins the vertebral artery of opposite side at the
lower border of pons to form the basilar artery.

Parts
The vertebral artery is divided into four parts:

• First part: It lies in the triangle of vertebral artery.

• Second part: It passes through the foramina transversaria of C6 to C1 vertebrae.
• Third part: It lies in the suboccipital triangle.
• Fourth part: It lies in the cranial cavity.

Branches

• In the neck:
■ Spinal branches
■ Muscular branches
• In the cranial cavity:
■ Meningeal branch
■ Anterior spinal branch
■ Posterior spinal branch
■ Posterior inferior cerebellar artery
■ Medullary branches

❖ Describe the origin, course and termination of internal carotid artery. List its parts
and their branches. AN43.8, AN43.9
Origin, course and termination

• It begins as one of the two terminal branches of common carotid artery at the
upper border of the thyroid cartilage.
• It enters the cranial cavity through the carotid canal and foramen lacerum.
• In the cranial cavity, it traverses through the cavernous sinus and finally
terminates at the base of brain by dividing into anterior and middle cerebral
arteries.

Parts and branches

• Cervical part:
■ No branch
• Petrous part:
■ Caroticotympanic branches to the middle ear
■ Pterygoid branch, which enters the pterygoid canal
• Cavernous part:
■ Cavernous branches to the wall of cavernous sinus and trigeminal ganglion
■ Hypophyseal branches to the hypophysis cerebri
■ Meningeal branches
• Cerebral part

❖ Describe the cervical sympathetic chain in brief and discuss its applied
anatomy. AN35.6

Location and extent

• It is part of the sympathetic chain that lies in front of the transverse processes of
the cervical vertebrae and neck of 1st rib.
• It continues upwards into the carotid canal as internal carotid nerve and
downwards as thoracic part of the sympathetic chain.

Ganglia
The cervical sympathetic chain possesses three ganglia:

1. Superior cervical ganglion: It lies in front of the transverse processes of C2 and C3,
and represents the fused C1 to C4 primitive ganglia.
2. Middle cervical ganglion: It lies in front of the transverse process of C6 and
represents the fused C5 and C6 primitive ganglia.
3. Inferior cervical ganglion: It lies in front of the transverse process of C7 and neck of
 1st rib, and represents the fused ganglia of C7 and C6 primitive ganglia. It often
fuses with T1 ganglion to form stellate ganglion.

Applied anatomy
Horner syndrome:
It occurs due to the lesion of cervical sympathetic chain involving T1 fibres supplying
head and neck.

Clinical features

• Anhydrosis (loss of sweating)

• Partial ptosis (partial drooping of the upper eyelid)
• Myosis (constriction of pupil)
• Enophthalmos (recession of the eyeball)
• Absence of the ciliospinal reflex

❖ Write a short note on the cervical plexus.

Formation and location (fig. 12.10)

It is formed by the vertebral rami of C1 to C4 nerves, and lies on levator scapulae and
scalenus medius muscles deep to prevertebral layer of deep cervical fascia.

FIG. 12.10 Cervical plexus and its cutaneous branches.

Important named branches (fig. 12.10)

• Lesser occipital
• Great auricular
• Transverse cervical
• Supraclavicular

N.B.
C1 and C2 also contribute to form the inferior root of ansa cervicalis while C3 and C4
contribute to from the phrenic nerve.

❖ Describe the phrenic nerve in brief and discuss its applied anatomy. AN24.4

Origin
It is formed by ventral rami of C3 to C5, with chief contribution being from C4.

Course
It first descends obliquely on the anterior surface of scalenus anterior. Then it runs
vertically downwards on the cervical pleura to enter thoracic cavity behind the 1st
costal cartilage.

Branches and distribution

• Motor branches to diaphragm

• Sensory branches to central part of the diaphragm, pleura, pericardium and
peritoneum (subdiaphragmatic)

Applied anatomy

• Damage of phrenic nerve in the neck leads to paralysis of corresponding half of the
diaphragm. The paralysed half of diaphragm becomes relaxed and pushed up
into thorax by the positive intra-abdominal pressure. This leads to collapse of
the lower lobe of the lung.
• The fibres of C5 instead of joining phrenic nerve at its commencement may join
it at the thoracic inlet through a communication received from nerve to
subclavius. This communication is referred to as accessory phrenic nerve. In
phrenic avulsion, the accessory phrenic nerve if present should be cut, otherwise
C5 fibres will escape and diaphragm may continue to function and defeat the
whole purpose of phrenic crush.
• In pleurisy, the pain from diaphragmatic pleura may be referred to shoulder
region, which receives nerve supply from some spinal segments as that of
phrenic nerve, i.e. C3 and C4.

❖ Describe the internal jugular vein in brief. AN35.4

Formation, course and termination
The internal jugular vein begins as direct continuation of the sigmoid sinus at the jugular
foramen of skull and terminates by uniting with the subclavian vein behind the
sternoclavicular joint to form the brachiocephalic (innominate) vein.

Tributaries

• Inferior petrosal sinus

• Common facial vein
• Pharyngeal veins
• Lingual vein
• Superior thyroid vein
• Middle thyroid vein
• Kocher’s vein (if present)

N.B.
The internal jugular vein is the chief vein of the head and neck. The deep cervical
lymph nodes lie on and along the internal jugular vein.

Applied anatomy

• The internal jugular vein is easily accessible in the lesser supraclavicular fossa
and is used for recording jugular venous pulse pressure.
• In congestive heart failure (CHF), it is the most dilated vein.

❖ Describe the atlanto-occipital joints in brief (Fig. 12.11). AN43.1

FIG. 12.11 Atlanto-occipital and atlantoaxial joints.

These are a pair of joints between the superior articular facets of atlas and condyles of
the occipital bone.

Classification
Synovial joint of ellipsoid variety.

Articular surfaces

• Condyle of occipital bone, superiorly.

• Superior articular facet on the lateral mass of atlas, inferiorly.
• The articular surfaces are reciprocally curved.

Ligaments
These are

• Fibrous capsule.
• Anterior and posterior atlanto-occipital membranes.

Movements
Nodding movements, i.e. the flexion and extension of the head that occurs when
indicating approval; hence, these movements are also called ‘yes movements’.
❖ Describe the atlantoaxial joints in brief (Fig. 12.11). AN43.1

Atlantoaxial joints
These are three in number: median atlantoaxial joint and right and left lateral
atlantoaxial joints.

Classification:
• Median atlantoaxial joint: Pivot type of synovial joint
• Lateral atlantoaxial joint: Plane type of synovial joint

Articular surfaces and ligaments

• Median Atlantoaxial Joint (Fig. 12.12): It is formed between the dens of axis and
the anterior arch of the atlas. The articular facet on the anterior aspect of dens
articulates with the facet on the posterior surface of the anterior arch of atlas.
Posteriorly between the base of dens of axis and transverse ligament of atlas lies
a synovial bursa. It is a pivot type of synovial joint.
• Lateral Atlanto-axial Joints: It is formed between the superior articular facet of
axis and inferior articular facet of atlas. It is a plane type of synovial joint.
 FIG. 12.12 Median atlantoaxial joint.

Movements
The atlanto-occipital joints are responsible for rotation of the head. They permit the
head to be turned from side-to-side, e.g. when rotating the head to indicate disapproval.
Hence, these movements are also called ‘no movements’.

N.B.

• Excessive rotational movements of the head are prevented by alar ligaments.

• During rotation of the head, the dens of axis is held in a collar formed by the
anterior arch and transverse ligament of atlas.
13

Oral cavity
❖ Write a short note on oral cavity. AN36.1–36.5

Boundaries (fig. 13.1)

FIG. 13.1 Subdivisions of oral cavity as seen in its coronal section.

Roof:
Hard palate

Floor:
Oral diaphragm

On either side:
Cheek

Communications
Anteriorly:
To exterior through oral fissure guarded by the upper and lower lips.

Posteriorly:
To oropharynx through oropharyngeal isthmus guarded on either side by the
palatoglossal arch.

Structures present within oral cavity

• Teeth and gums

• Tongue
• Soft palate

❖ What are the parts of oral cavity? List their boundaries.

The oral cavity (mouth) is divided into two parts (Fig. 13.1): (a) an outer smaller part
called vestibule of mouth and (b) an inner larger part called oral cavity proper.

Boundaries of vestibule of mouth

Externally:
Lips and cheeks

Internally:
Teeth and gums

Boundaries of oral cavity proper

Above (roof):
Hard palate

Below (floor):
Oral diaphragm formed by two mylohyoid muscles

On either side (lateral):

Teeth and gums

❖ Enumerate the ducts that open in the oral cavity.

Parotid ducts
One on either side, open in the vestibule of mouth opposite the crown of 2nd upper
molar tooth.

Submandibular ducts
One on either side, open in the floor of oral cavity proper on the summit of sublingual
papilla.

Sublingual ducts
About a dozen in number, on either side, open in oral cavity proper on the sublingual
fold in a row.

❖ Enumerate the layers of cheek.

From superficial to deep, the layers of cheek are as follows:

• Skin
• Superficial fascia containing buccal pad of fat
• Buccopharyngeal fascia
• Buccinator muscle
• Submucosa
• Buccal mucosa

❖ Briefly describe the parts of a tooth.

Parts
Each tooth consists of three parts:

Crown:
A part that projects above the gum

Neck:
A part between crown and root, and surrounded by gum

Root:
A part that is embedded in the alveolar process of jaw

❖ Write a short note on the structure of the tooth.

Structurally, each tooth is made up of five components (Fig. 13.2):

• Pulp – an inner core of soft tissue containing blood vessels and nerves.
• Dentine – a calcified material surrounding the pulp/pulp cavity.
• Enamel – a densely calcified material covering the crown.
• Cementum – a thin bony covering over the dentine.
• Periodontal membrane – a fibrous membrane (akin to periosteum), connecting root
of tooth with the alveolar socket.
 FIG. 13.2 Structure of the tooth.

❖ Write a short note on the development of a tooth.

The tooth develops from two sources: (a) ectodermal epithelial lining the alveolar
process of jaw and (b) underlying neural crest mesenchyme.
The details are summarized as follows:

• Ectodermal epithelium lining of alveolar process → Dental lamina → Tooth

buds/enamel organs → Ameloblasts → Enamel.

The structural components of tooth derived from these two sources are given in Table
13.1

TABLE 13.1
Source of Development of Various Components of the Tooth

Ectoderm Neural Crest Mesenchyme

• Enamel • Pulp
• Dentine
• Cementum
• Periodontal membrane
❖ Briefly describe the stages of tooth development.
The stages in the development of tooth are:

• Dental lamina
 • Enamel organs
• Dental papilla
• Dental sac

❖ Briefly describe the eruption and shedding of teeth.

The human beings are diphyodont animals, i.e. they have two sets of teeth, which
develop at different times of life. The two sets are (a) deciduous teeth, which develop
first and shed off and (b) permanent teeth, which appears later after the shedding of
deciduous teeth and do not shed off.
The usual time of eruption and shedding of the teeth is given in Tables 13.2 and 13.3.

TABLE 13.2
Eruption and Shedding of Deciduous Teeth

Teeth Eruption Time Shedding Time

Medial incisor 6–8 months 6–7 years
Lateral incisor 8–10 months 7–8 years
First molar 12–16 months 8–9 years
Canine 16–20 months 10–12 years
Second molar 20–24 months 10–12 years

TABLE 13.3
Eruption and Shedding of Permanent Teeth

❖ Define tongue and list its functions. AN39.1

The tongue is a mobile, muscular organ situated in the floor of the mouth. It performs
the following functions:

• Taste
• Speech
• Mastication
• Deglutition

❖ Enumerate the external features of the tongue. AN39.1

 • Tongue has apex, tip and body.
• Body presents:
(a) Dorsal surface (also called dorsum)
(b) Ventral surface
(c) Right lateral margin
(d) Left lateral margin

Dorsum of tongue
Anatomically and developmentally, the dorsum of tongue is divided into two parts:
anterior two-third (oral part) and posterior one-third (pharyngeal part). The two parts
are separated from each other by a V-shaped sulcus – the sulcus terminalis. A blind
foramen at the apex of sulcus is called foramen caecum. The foramen caecum represents
the site of development of endodermal thyroglossal duct which grows down into the
neck during embryonic development.

Features on the dorsal surface of tongue (fig. 13.3)

• Posterior one-third presents:

■ A large number of lymphoid follicles, which together form lingual tonsil.
■ A large number of openings of mucous and serous glands.
• Anterior two-third presents:
■ A median furrow.
■ A large number of papillae.

FIG. 13.3 Features on the dorsal surface of the tongue.

Ventral surface of tongue

Features on the ventral surface of tongue (fig. 13.3)
The ventral surface of tongue presents:
 • Frenulum linguae: A median fold of mucous membrane extending between the
tongue and floor of the mouth.
• Plica fimbriata: Two, fringed corrugated folds of mucous membrane, one on
either side of frenulum linguae converging towards the tip of the tongue.
• Prominences of deep lingual veins: These are visible, one on either side, between
frenulum linguae and plica fimbriata.

❖ Enumerate the features in the sublingual region.

These are shown in Fig. 13.4.

FIG. 13.4 Features on the ventral (inferior) surface of the tongue and sublingual region.

Sublingual papillae
Two rounded elevations – one on either side of the root of frenulum linguae for the
opening of the submandibular gland duct.

Sublingual folds
Two elongated elevations – one on either side of frenulum linguae on the floor of mouth
produced by an underlying sublingual salivary gland.
The sublingual ducts open on these folds.

❖ Enumerate the various types of papillae of tongue. AN39.1

Vallate papillae
They are of large size (1–2 mm in diameter) and are located in front of sulcus terminalis.
They are 8–12 in number and surrounded by a ditch (trench). The taste buds are found
in the wall of the ditch.

Fungiform papillae
They are numerous and located near the tip and margins of the tongue. They have a
narrow pedicle and rounded head.

Filiform papillae
These are the smallest and most numerous, and cover the dorsum of the anterior two-
third of the tongue and give it a characteristic velvety appearance.

Foliate papillae
These are transverse mucosal folds on the lateral margins of the tongue, in front of
palatoglossal arch. The papillae of tongue are shown in Fig. 13.3.

❖ Describe the tongue under the following headings: (a) muscles of tongue, (b)
nerve supply, (c) blood supply, (d) lymphatic drainage and (e) applied anatomy. 
AN39.1

Muscles of tongue
The muscles of tongue are paired and divided into two groups: intrinsic and extrinsic.

Intrinsic Muscles (arise and are inserted within the tongue). These are as follows:
• Superior longitudinal
• Inferior longitudinal
• Transverse
• Vertical
Extrinsic Muscles (arise outside the tongue but are inserted into the tongue).
These are as follows:
• Genioglossus
• Hyoglossus
• Styloglossus
• Palatoglossus

The origin, insertion and actions of extrinsic muscles are given in Table 13.4.

TABLE 13.4
Origin, Insertion and Actions of Extrinsic Muscles of the Tongue
 The origin and insertion of extrinsic muscles of the tongue are shown in Fig. 13.5.

FIG. 13.5 Extrinsic muscles of the tongue.

Nerve supply

Motor Supply: All the intrinsic and extrinsic muscles of the tongue are supplied
by the hypoglossal nerve, except palatoglossus which is supplied by the cranial
root of accessory nerve via pharyngeal plexus.

Sensory supply:

Anterior two-third of the tongue • General sensations • Lingual nerve

• Taste sensations • Chorda tympani nerve
 Posterior one-third of the tongue • General sensations • Glossopharyngeal nerve
• Taste sensations • Glossopharyngeal nerve
Posteriormost part of the tongue • General sensations • Internal laryngeal nerve
• Taste sensations • Internal laryngeal nerve

Blood supply

• Lingual artery (chief artery of tongue), a branch of external carotid artery

supplies the oral part of the tongue.
• Tonsillar and ascending palatine arteries, branches of the facial artery supply the
pharyngeal part of the tongue.

Lymphatic drainage (fig. 13.6)

The lymph from the tongue is drained by the following three sets of lymph vessels:
marginal, central and posterior.

Marginal Vessels:
• From tip, drains bilaterally into the submental lymph nodes.
• From margins and lateral part of the dorsum of tongue, drains into the
submandibular and jugulo-omohyoid lymph nodes.

Central Vessels: From central region of the dorsum of anterior two-third of

tongue descends between genioglossi muscles and drains bilaterally into the
submandibular lymph nodes.
Posterior Vessels:  From posterior one-third of tongue drains bilaterally into the
deep cervical lymph nodes, principally into the jugulodigastric lymph node
(also called lymph node of the tongue; Fig. 13.6).

FIG. 13.6 Lymphatic drainage of the tongue: showing course and direction of apical, marginal
 and basal lymph vessels.

Applied anatomy

• Injury of hypoglossal nerve causes paralysis of muscles of the tongue on the

side of lesion; hence, protruded tongue deviates to the same side (i.e. the side of
injury) due to unopposed action of muscles on the healthy side.
• In unconscious patient, the tongue may fall backward into oropharynx and
obstruct the air passage to cause choking. This can be prevented by turning the
head to one side and pulling the mandible forwards.
• Carcinoma of tongue most commonly occurs along the margin of tongue.
Cancer in posterior one-third of tongue has bad prognosis because of bilateral
lymphatic drainage.

❖ Describe the development of tongue in brief and correlate the nerve supply of
tongue with its development. AN43.4
The tongue develops in the floor of primitive pharynx from 1st, 2nd, 3rd and 4th
pharyngeal arches.
The epithelium, muscles and connective tissue of tongue develop as follows.

Epithelium (table 13.5)

The epithelium of tongue develops from four swellings (Fig. 13.7):

FIG. 13.7 Development of the tongue: A, four swellings forming tongue with subdivision of
hypobranchial eminence into cranial and caudal parts; B, definitive tongue.

TABLE 13.5
Correlation of Nerve Supply of Tongue with Its Development
Structure Source of Development Nerve Supply
• Muscles of Occipital myotomes Hypoglossal nerve
tongue
• Epithelium of
tongue
■ Anterior two- • 1st arch (lingual • Lingual nerve supplemented by chorda tympani
third of the swellings) (pretrematic branch of nerve of 2nd arch, i.e.
tongue facial)
■ Posterior one- • 3rd arch (cranial part of • Glossopharyngeal nerve
third of the the hypobranchial
tongue eminence)
■ Posteriormost • 4th arch (caudal part of • Internal laryngeal nerve (a branch of the vagus
part of the the hypobranchial nerve)
tongue eminence)
The various parts of the tongue develops from above-mentioned four swellings as
follows:

• Epithelium of anterior two-third of the tongue develops from two lingual

swellings and tuberculum impar derived from 1st arch. The contribution from
tuberculum impar is insignificant.
• Epithelium of posterior one-third of the tongue develops from cranial (anterior)
part of the hypobranchial eminence, derived from 3rd arch.
• Epithelium of posteriormost part develops from caudal (posterior) part of the
hypobranchial eminence derived from 4th arch.

Muscles (table 13.5)

The muscles of tongue develop from occipital myotomes (Fig. 13.8).

FIG. 13.8 Development of muscles of the tongue.

Connective tissue
The connective tissue of tongue develops from local mesenchyme.

❖ Give the embryological basis of tongue-tie (Fig. 13.9). AN43.4

FIG. 13.9 Tongue-tie.

• The tongue-tie (ankyloglossia) occurs when frenulum linguae is overdeveloped

and extend up to the tip of tongue.

The overdevelopment of frenulum linguae occurs due to incomplete separation of

tongue from floor of primitive mouth by alveololingual sulcus.

• Clinically it presents as:

(a) Disturbed speech, i.e. difficulty in speaking
(b) Restriction of tongue movements specially one which prevents protrusion
14

Pharynx and palate

❖ Describe the pharynx under the following headings: (a) parts, (b) structure, (c)
muscles and (d) nerve supply. AN36.1–36.5
The pharynx is funnel-shaped muscular tube situated behind the nose, mouth and
larynx.

Parts of pharynx (fig. 14.1)

The pharynx is subdivided into three parts:

• Nasopharynx, lying behind the nose.

• Oropharynx, lying behind the mouth.
• Laryngopharynx, lying behind the larynx.

FIG. 14.1 Location and subdivisions of the pharynx.

Functions

• The nasopharynx provides passage to air only.

• The oropharynx provides passage to both air and food.
• The laryngopharynx provides passage to air only.
Structure of pharynx
The pharyngeal wall consists of four layers. From within to outwards these are as
follows:

• Mucosa
• Pharyngobasilar fascia
• Muscular coat
• Buccopharyngeal fascia

Muscles of pharynx
Three pairs of constrictors
(forming outer circular layer of muscle coat):

• Superior constrictor
• Middle constrictor
• Inferior constrictor

Three pairs of longitudinal muscles

(forming inner longitudinal layer of muscular coat):

• Stylopharyngeus
• Palatopharyngeus
• Salpingopharyngeus

Nerve supply
Motor:
All the muscles of pharynx are supplied by cranial root of accessory nerve (CN XI) via
pharyngeal plexus, except stylopharyngeus which is supplied by glossopharyngeal
nerve (CN IX).

Sensory:

• Glossopharyngeal nerve
• Internal laryngeal nerve

❖ Discuss the origin and insertion of the constrictors of the pharynx. AN36.1–36.5

Origin

Superior Constrictor: It arises from the pterygoid hamulus, pterygomandibular

raphe, posterior end of mylohyoid line and the side of the tongue.
Middle Constrictor: It arises from the lower part of the stylohyoid ligament,
 lesser and greater cornua of the hyoid bone.
Inferior Constrictor: It consists of two parts – thyropharyngeus and
cricopharyngeus.
• Thyropharyngeus: From the oblique line of thyroid cartilage.
• Cricopharyngeus: From the side of cricoid cartilage.

Insertion
All the constrictors of pharynx are inserted into a median raphe, on the posterior wall
of the pharynx. The upper end of this raphe is attached to the pharyngeal tubercle on
the basilar part of the occipital bone.

❖ Write a short note on nasopharynx. AN36.1–36.5

Nasopharynx is the upper portion of pharynx lying behind the nasal cavities with
which it communicates. Internally it is lined by mucous membrane.

Boundaries (fig. 14.2)

Roof and lateral wall are formed by body of sphenoid which forms a continuous
sloping surface, and the basilar part of the occipital bone.

FIG. 14.2 Nasopharynx. TE, tubal elevation; Spa, salpingopalatine fold; Sph,
salpingopharyngeal fold.

Floor is formed by sloping upper surface of the soft palate.

Features

• Presence of nasopharyngeal tonsil at the junction of roof and posterior wall,

deep to the mucous membrane, more prominent in children. When enlarged it
is called as adenoid.
• Pharyngeal opening of pharyngotympanic tube which maintains equilibrium
of air pressure on both sides of tympanic membrane.
• Tubal tonsil is an aggregation of lymphoid tissue along the upper and posterior
 margin of tubal opening deep to mucous membrane producing elevation called
tubal elevation.
• Salpingopharyngeal and salpingopalatine folds. Out of these two folds, one extends
downwards towards the wall of pharynx enclosing salpingopharyngeus muscle
and is called salpingopharyngeal fold, while other extends downwards and
forward to the soft palate enclosing levator palati muscle and is called
salpingopalatine fold.
• Pharyngeal recess is a depression behind the tubal elevation.

❖ What is gag reflex? AN36.1–36.5

It is a protective reflex characterized by elevation of palate and contraction of
pharyngeal muscles with associated retching and gagging in response to stimulation of
mucosa of oropharynx. The afferent limb of this reflex is formed by the
glossopharyngeal nerve, while its efferent limb is formed by the vagus nerve.

❖ Write a short note on Killian’s dehiscence and pharyngeal diverticulum. AN36.5

There is a small, triangular region in the lower part of the posterior wall of the pharynx
(the junctional region between the thyropharyngeus and cricopharyngeus), which is not covered
by muscles. This weak area is termed Killian’s dehiscence. The mucosa and submucosa
of pharyngeal wall may bulge out through this weak area to form pharyngeal
diverticulum/Zenker’s diverticulum (Fig. 14.3).

FIG. 14.3 Pharyngeal diverticulum.

This diverticulum occurs due to neuromuscular incoordination between propulsive

thyropharyngeus muscle (supplied by external laryngeal nerve) and sphincteric
cricopharyngeus muscle (supplied by recurrent laryngeal nerve).
❖ Write a short note on Waldeyer’s ring. AN36.2
It is a ring of submucous aggregations of lymphoid tissue, which surrounds the
beginning of respiratory and digestive tracts.

Formation (fig. 14.4)

The Waldeyer’s ring is formed as follows:

• Above and behind, by pharyngeal tonsil

• Below and in front, by lingual tonsil
• On each side, by palatine tonsil
• Superolaterally on each side, by tubal tonsil

FIG. 14.4 Waldeyer’s ring.

Applied anatomy
The Waldeyer’s ring provides the first line of defence to respiratory and digestive tracts
by preventing the spread of infection from nasal and oral cavities to these tracts.

❖ Describe tonsil under the following headings: (a) location, (b) external features, (c)
tonsillar bed, (d) nerve supply, (e) arterial supply, (f) venous drainage and (g) applied
anatomy.  AN36.1, AN36.4

Location
The palatine tonsil is an almond-shaped mass of lymphoid tissue (dimension of about 2
cm) located in the tonsillar fossa on each side in the lateral wall of the oropharynx.
The tonsillar fossa is a triangular recess that is bound in front by palatoglossal fold and
behind by palatopharyngeal fold.

External features of tonsil (fig. 14.5)

The tonsils present the following features:

• Two surfaces: medial and lateral

• Two borders: anterior and posterior
• Two ends: upper and lower

FIG. 14.5 Horizontal section through tonsillar fossa showing medial and lateral surfaces of the
tonsil and tonsillar bed.

The lateral surface is covered by a sheath of condensed connective tissue called

hemicapsule of tonsil (Fig. 14.5).

Tonsillar bed (fig. 14.5)

From deep to superficial, it is formed by:

• Pharyngobasilar fascia
• Superior constrictor muscle supplemented by palatopharyngeus
• Buccopharyngeal fascia

N.B.
Loose areolar tissue between tonsillar capsule and tonsillar bed is called peritonsillar
space.
Structures deep to tonsillar bed are facial and ascending pharyngeal arteries,
glossopharyngeal nerve, styloglossus muscle and submandibular salivary gland.

Nerve supply

• Glossopharyngeal nerve
• Lesser palatine nerves

Arterial supply of the tonsil (fig. 14.6)

The tonsil is supplied by the following five sets of arteries:

• Tonsillar branch of the facial artery (principal artery)

• Dorsal lingual branches of the lingual artery
• Ascending pharyngeal artery – a branch of the external carotid artery
• Ascending palatine artery – a branch of the facial artery
• Greater/descending palatine artery – a branch of the maxillary artery

FIG. 14.6 Arteries supplying the tonsil.

Venous drainage
By paratonsillar vein into pharyngeal venous plexus, which in turn drains into internal
jugular vein.

Lymphatic drainage
Lymph vessels from tonsil drain into jugulodigastric lymph nodes. These lymph nodes
lie in the angle formed between posterior belly of digastric (inferior border) and internal
jugular vein (anterior aspect) deep to the mandible.

Applied anatomy

• Tonsillitis: It is an infection of tonsil, which is usually of viral origin. This leads

to the enlargement of jugulodigastric lymph nodes.
 • Quinsy (peritonsillar abscess): It is the name given to collection of pus in the
peritonsillar space.
• Referred pain: Pain of tonsil is referred to middle ear because both are supplied
by the glossopharyngeal nerve.
• Commonest source of bleeding after tonsillectomy. It is due to damage of the
paratonsillar vein.
• After tonsillectomy, all blood clots in the tonsillar fossa are removed to prevent
bleeding as removal of these clots allows the retraction of blood vessels due to
muscle contraction. The only other organ in the body where such removal of
blood clots is done is uterus.

❖ Write a short note on the development of tonsil. AN43.4

The tonsil develops form 2nd pharyngeal pouch in the 4th week of intrauterine life.

• The epithelial lining of the tonsil develops from endoderm of 2nd pharyngeal
pouch.
• The stroma of tonsil develops from local mesenchyme.
• The lymphocytes of tonsil are derived from either local mesenchyme or from
circulating lymphocytes.

❖ Discuss the histological features of a tonsil.  AN43.2

The histological features of tonsil are as follows (Fig. 14.7):

• Surface is lined by stratified, squamous, nonkeratinized epithelium.

• Surface epithelium dips at places into the substance of tonsil to form tonsillary
crypts.
• Presence of subendothelial lymph nodules underneath the stratified squamous
epithelium, along the crypts.
• Presence of mucous glands in the deeper part.
• Fibrous capsule on outer side.

FIG. 14.7 Histological features of a palatine tonsil.

N.B.
The invaginations of epithelium at places deep into the substance of tonsil form crypts.

❖ Briefly describe the pharyngotympanic tube/auditory tube/eustachian tube. 

AN40.2

General description (fig. 14.8)

• It is a funnel-shaped osseocartilaginous tube that connects the middle ear cavity

(tympanum) with the nasopharynx.
• It is about 4 cm (36 mm) long.
• It is directed downwards, forwards and medially.
• Its bony part forms lateral one-third of the tube, while its cartilaginous part
forms medial two-third of the tube.
• Its bony part (12 mm long) lies at the base of skull, lateral to carotid canal below
the tympanic plate of temporal bone.
• Its cartilaginous part (24 mm long) lies in sulcus tubae – a groove between the
greater wing of sphenoid and apex of petrous temporal bone.

FIG. 14.8 Pharyngotympanic tube.

Function
Maintains equilibrium of air pressure on either side of the tympanic membrane for its
proper vibration by the sound waves.

Applied anatomy
This provides passage for infection to travel from the upper respiratory tract (URT) to
middle ear causing otitis media. The otitis media is common in children because the
auditory tube is much shorter (18 mm) and straight in them.

❖ Briefly discuss the hard palate. AN36.1

It is a bony partition between nasal and oral cavities.

Formation

• Anterior two-third of hard palate is formed by palatine processes of the maxillae.

• Posterior one-third of hard palate is formed by horizontal plates of the palatine
bones.

Development

• Small triangular part anteriorly (premaxilla) opposite to incisor teeth develops

from frontonasal process.
• Remaining part develops from palatine shelves of maxillary processes.

❖ Describe the soft palate in brief. AN36.1

It is movable, muscular flap suspended from the posterior border of hard palate. It
separates nasopharynx from oropharynx.

Muscles of soft palate (fig. 14.9)

Palate has five pair of muscles:

• Tensor palati
• Levator palati
• Musculus uvulae
• Palatoglossus
• Palatopharyngeus
 FIG. 14.9 Muscles of the soft palate.

Nerve supply
All the muscles of palate are supplied by cranial root of accessory nerve (CN XI) via
pharyngeal plexus, except tensor palati which is supplied by the mandibular nerve
(through nerve to medial pterygoid).

Applied anatomy
The paralysis of soft palate leads to:

• Nasal regurgitation of food

• Nasal twang of voice
• Flattening of palatal arch on the side of lesion
• Deviation of uvula opposite to the side of lesion

❖ Describe development and congenital anomalies of palate. AN43.4

Development

The primary palate, the small triangular anterior part opposite incisor teeth (i.e.
premaxilla), develops from frontonasal process (strictly speaking from
intermaxillary segment formed by the fusion of medial nasal processes of
frontonasal process).
The secondary palate, the remaining large posterior part, develops from two
shelf-like outgrowths, the palatine shelves, on each side from maxillary
processes.
Congenital anomalies
The congenital anomalies of palate are common due to failure of fusion of its primitive
parts, viz. premaxilla and right and left palatine shelves. These are as follows:

a) Complete cleft: It may be unilateral or bilateral (Fig. 14.10A and B). It is usually
associated with cleft lip as the philtrum (the median triangular part) of upper lip
also develops from’ frontonasal process.
b) Incomplete cleft lip: It may present as bifid uvula or cleft of soft palate
(involving only uvula or whole of soft palate.

FIG. 14.10 Complete cleft palate: A, unilateral; B, bilateral. The actual clinical photographs are
also given below each type. Source: (Source for clinical photographs: The Developing Human:
Clinically Oriented Embryology, 8th edition: Keith L. Moore and T.V.N. Persaud, ISBN:
9781416037064. Source for For Fig. A: Page 190, Fig. 9.39; Source for Fig. B: Page 192,
Fig. 9.41 Copyright Elsevier, 2008.)

❖ Write a short note on pharyngeal apparatus. AN43.4

The pharyngeal apparatus consists of the following components (Fig. 14.11):

a) Five pharyngeal arches

b) Four pharyngeal pouches
c) Four pharyngeal clefts
d) Four pharyngeal membranes
 FIG. 14.11 Components of pharyngeal apparatus.

All these components develop in the lateral wall of primitive pharynx caudal to the
primitive mouth/stomodeum.

❖ Write a short note on pharyngeal arches. AN43.4

These are horseshoe-shaped cylindrical bars/elevations on either side in the
anterolateral portion of wall of primitive pharynx.
Each pharyngeal arch consists of four components (Fig. 14.12):

1. A core of mesoderm
2. A cartilaginous bar
3. A pharyngeal arch artery
4. A nerve
 FIG. 14.12 Structure of pharyngeal arch.

❖ Enumerate the mesodermal derivatives of 1st and 2nd pharyngeal arches in tabular
form.  AN43.4
These are as follows:

Teeth Skeletal Derivatives Muscle

First arch (mandibular • Malleus • Muscles of mastication
arch)
• Anterior ligament of malleus • Anterior belly of digastric and
mylohyoid
• Incus • Tensor tympani
• Sphenomandibular ligament • Tensor palati
• Remnants of Meckel’s
cartilage
• Maxilla
• Mandible
Second arch (hyoid • Stapes • Stapedius
arch)
• Styloid process • Stylohyoid
• Stylohyoid ligament • Posterior belly of digastric
• Lesser cornua of hyoid bone • Muscle of facial expression
• Superior part of body of • Auricular muscles
hyoid bone
• Occipitofrontalis
• Platysma
❖ Discuss the embryological basis of branchial cyst/cervical cyst. AN43.4

• It is congenital cyst (lined by ectoderm) which appears on the side of neck along
the anterior border of the sternocleidomastoid below and behind the angle of
mandible (Fig. 14.13).
• It appears when 2nd, 3rd and 4th pharyngeal clefts fail to obliterate (Fig. 14.13
inset).
 FIG. 14.13 A cervical cyst. The figure in the inset on the right shows development of
branchial/cervical cyst. 1, 2 and 3 = 1st, 2nd and 3rd pharyngeal clefts; I, II and III = 1st, 2nd
and 3rd pharyngeal arches; SCM, sternocleidomastoid muscle.

N.B.
If branchial cyst ruptures on the surface of neck, it is called external branchial fistula. On
the other hand, if it opens into tonsillar sinus of pharynx, it is called internal branchial
fistula.
15

Nose and paranasal air sinuses

Nose
❖ What is nose? List its functions. AN37.1
The nose is a pyramidal-shaped projection in the midface. It presents tip (apex), alae,
dorsum, root and nostrils or nares. Its cavity is divided into two halves by a median
nasal septum. Each cavity (also called nasal cavity) communicates anteriorly to the
exterior through nostril (anterior nare) and posteriorly with the nasopharynx through
choana (posterior nare).

Functions

• Is the organ of smell.

• Plays a significant role in respiration.
• Provides protection to the lower respiratory tract.
• Performs air conditioning of inspired air.
• Provides vocal resonance to voice.

❖ Enumerate the bones and cartilages forming the skeleton of external nose. 
AN37.1

Bones (four in number)

• Two nasal bones

• Frontal processes of maxillae

Cartilages (five in number)

• Two lateral nasal cartilages/superior nasal cartilages

• A single, median septal cartilage
• Two major alar cartilages/inferior nasal cartilages

❖ Describe the nasal septum under the following headings: (a) formation, (b) arterial
supply, (c) nerve supply and (d) applied anatomy. AN37.1

Formation (fig. 15.1)

The nasal septum is a median osseocartilaginous partition between two nasal cavities
covered on each side by the mucous membrane.

• Bony part is formed by:

■ Vomer, below and behind
■ Perpendicular plate of ethmoid, above
• Cartilaginous part is formed by:
■ Septal cartilage
■ Septal processes of major alar cartilages
• Cuticular part is formed by:
■ Fibrofatty tissue

FIG. 15.1 Formation of nasal septum.

N.B.
The median partition of soft tissue separating two nostrils is called columella.

Arterial supply

• Anterosuperior part, by anterior ethmoidal artery

• Posteroinferior part, by sphenopalatine artery
• Anteroinferior part, by superior labial and greater palatine arteries
• Posterosuperior part, by sphenopalatine artery

Nerve supply
General sensory:

• Anterosuperior part by internal nasal branches of the anterior ethmoidal nerve

• Anteroinferior part by anterior superior alveolar nerve
• Posterosuperior part by medial, posterior and superior nasal branches of
pterygopalatine ganglion
• Posteroinferior part by nasopalatine nerve – a branch of pterygopalatine ganglion
Special sensory
by olfactory nerve.

Applied anatomy
Deviated nasal septum (DNS):
It may occur as a sequel to postnasal trauma (most common cause) or due to congenital
malformation. Excessive deviation of nasal septum may cause nasal obstruction. It is
treated by submucous resection (SMR) of septum.

Epistaxis:
It is nose bleeding that commonly occurs due to trauma of Kiesselbach’s plexus in the
Little’s area (for details, see Little’s area, Fig. 15.2).

FIG. 15.2 Arterial supply of the nasal septum.

❖ What is Little’s area? Describe its clinical importance. AN37.1

It is an area in the anteroinferior part of the nasal septum where four arteries
anastomose to form an arterial plexus called Kiesselbach’s plexus (Fig. 15.2).
The arteries forming this plexus are as follows:

• Septal branch of sphenopalatine

• Septal branch of greater palatine
• Septal branch of anterior ethmoidal artery
• Septal branch of superior labial artery – a branch of facial artery

Clinical importance
The Little’s area is the most common site of nose bleeding (i.e. epistaxis) in young
adults, usually due to fingernail trauma (nose picking)/small ulcer. Septal branch of the
sphenopalatine artery is largest, longest and tortuous. It is the main source of bleeding.
Hence, it is also termed artery of nose bleeding/rhinologist’s artery.

❖ Enumerate the characteristic features of lateral wall of the nose. AN37.1

The lateral wall of nose presents the following features (Fig. 15.3):

FIG. 15.3 Features of the lateral wall of the nasal cavity.

Three conchae/turbinates
Superior concha:
It is a curved bony projection from medial surface of the ethmoid bone. It is smallest
concha.

Middle concha:
It is a curved bony projection from medial surface of the ethmoid bone.

Inferior concha:
It is an independent bone.

Three meatuses
Three meatuses are passages beneath the overhanging conchae.

Superior meatus:
Lies below the superior concha.

Middle meatus:
Lies underneath the middle concha. It presents:

• Ethmoidal bulla, a rounded elevation produced by underlying middle ethmoidal

sinus.
• Hiatus semilunaris, a deep semicircular sulcus below the bulla.
Inferior meatus (largest):
Lies underneath the inferior concha.

Sphenoethmoidal recess
It is a triangular recess situated just above and behind the superior concha.

Opening of paranasal air sinuses and nasolacrimal ducts

The features of lateral wall of the nose are shown in Fig. 15.4.

FIG. 15.4 Lateral wall of the nose with conchae removed showing openings of various sinuses
and nasolacrimal duct.

❖ Enumerate the openings into the lateral wall of the nose. AN37.1

The following structures open in the lateral wall of the nose (Fig. 15.4):

1. Sphenoidal air sinus: Opens into the sphenoethmoidal recess.

2. Posterior ethmoidal air sinuses: Open into the superior meatus.
3. Middle ethmoidal air sinuses: Open on the bulla ethmoidalis in the middle meatus.
4. Maxillary air sinus: Opens into the posterior part of hiatus semilunaris at its
posterior end in the middle meatus.
5. Anterior ethmoidal air sinuses: Open into the anterior part of hiatus semilunaris in
the middle meatus.
6. Frontal air sinus: Opens into the infundibulum at the anterior end of hiatus
semilunaris in the middle meatus.
7. Nasolacrimal duct: Opens into the anterior part of the inferior meatus.

❖ Enumerate the structures opening in the middle meatus of the nose. AN37.1

These are as follows (Fig. 15.4):

1. Middle ethmoid air sinus

2. Frontal sir sinus
3. Anterior ethmoidal air sinus
4. Maxillary air sinus
Paranasal air sinuses
❖ What are the paranasal air sinuses? Name them and enumerate their functions. 
AN37.2
The paranasal air sinuses are air-filled cavities in the paranasal bones, such as frontal,
ethmoid, sphenoid and maxilla.
They are named according to the bones in which they are present, i.e.:

• Frontal air sinuses are present in the frontal bone.

• Ethmoidal air sinuses are present in the ethmoid bones.
• Sphenoidal air sinuses are present in the body of sphenoid bone.
• Maxillary air sinuses (largest air sinuses) are present in the body of maxillae.

Functions
The functions of air sinuses are as follows:

• Make the skull lighter.

• Add resonance to the voice.
• Humidify the air during inspiration.
• Provide adult shape to the facial skeleton.

❖ Describe the maxillary air sinus under the following headings: (a) location, (b)
boundaries, (c) drainage, (d) development and (e) applied anatomy. AN37.2, AN37.3

Location
The maxillary air sinus is the largest paranasal air sinus located into the body of
maxilla.

Boundaries
It is pyramidal-shaped cavity in the body of maxilla. Its boundaries are as follows (Fig.
15.5):
 FIG. 15.5 Location and relations of maxillary air sinus.

Apex:
It is directed towards zygoma and often extends into the zygomatic bone.

Base:
It is formed by the lateral wall of the nasal cavity.

Roof:
It is formed by the floor of the orbit.

Floor:
It is narrow and formed by the alveolar process of the maxilla. It lies about 1 cm below
the level of the floor of the nose.

N.B.
The roots of maxillary teeth, particularly those of first two molars, often protrude into
the floor of maxillary sinus and may even perforate it.

Drainage
It drains in the middle meatus of nose in the posterior part of hiatus semilunaris.
Note: The ostium for the maxillary air sinus is located near its roof – a
disadvantageous location for a natural drainage.

Development
It is the 1st paranasal air sinus to develop. It develops in the 4th month of IUL. It grows
rapidly during 6–7 years of life and reaches the adult size after the eruption of
permanent teeth.

Applied anatomy
Maxillary sinusitis (most common):
The maxillary sinus is most commonly infected because its ostium is located near the
roof, which hampers its drainage. The infection may reach the sinus either from nasal
cavity or from caries of the upper molar teeth.

Referred pain:
Pain of the maxillary sinus may be referred to the upper teeth due to same nerve
supply.

❖ Write briefly about frontal air sinuses. AN37.2

These are located in the frontal bone between its outer and inner tables behind
superciliary arches. The right and left frontal air sinuses are rarely of equal size, and the
septum separating them is rarely situated in the median plane.
The frontal sinus drains through frontonasal duct inferiorly into a funnel-shaped
infundibulum at the anterior end of hiatus semilunaris of middle meatus.
The infection of frontal sinus (frontal sinusitis) usually causes severe and localized
pain in the forehead (frontal headache). The frontal headache shows characteristic
periodicity, i.e. it increases as the sun rises and decreases as the sun sets. The pain of
frontal air sinus may extend up to vertex through supraorbital nerves which supply it.
The frontal sinusitis can lead to brain abscess in the frontal lobe.
16

Larynx
❖ Define larynx and list its functions. AN38.1
The larynx is the first part of the lower respiratory tract (LRT). It is located on the front
of neck opposite C3 to C6 vertebrae.

Functions

• Phonation
• Respiration
• Protection
• Deglutition

❖ Enumerate the cartilages forming the skeleton of larynx. List their types. AN38.1
The skeleton of larynx is formed by nine cartilages (three unpaired and three paired;
Fig. 16.1):

• Unpaired cartilages
■ Epiglottis
■ Thyroid
■ Cricoid
• Paired cartilages
■ Arytenoid
■ Corniculate
■ Cuneiform

FIG. 16.1 Skeleton of the larynx: A, anterior view; B, posterior view.

Types

• The thyroid, cricoid and most of arytenoid are made up of hyaline cartilage.
• The epiglottis, corniculate, cuneiform and apices of arytenoids are made of
yellow elastic cartilage.

❖ Name the safety muscle of larynx and give the reason why it is so named.
The posterior cricoarytenoid is a safety muscle of larynx.
It is so named because it is the only intrinsic muscle of larynx, which abducts the
vocal cords to allow the entry of air into the LRT. All the other intrinsic muscles of
larynx adduct the vocal cords and restrict the entry of air into the LRT.

❖ What are the boundaries of laryngeal inlet?

• Anterior: Epiglottis
• On each side: Aryepiglottic fold
• Posterior: Interarytenoid fold

❖ List the subdivisions of laryngeal cavity. Mention the narrowest part of the
laryngeal cavity.
The laryngeal cavity is divided into three parts (Fig. 16.2):

• Vestibule: Between laryngeal inlet and vestibular folds.

• Ventricle (sinus): Between vestibular folds above and vocal folds below.
• Infraglottic part: Below the vocal folds, and up to the lower border of cricoid
cartilage.

FIG. 16.2 Coronal section of laryngeal cavity showing its subdivisions.

 The glottis (i.e. space between the two vocal folds) is the narrowest part of the
laryngeal cavity.

❖ Enumerate the intrinsic muscles of larynx.

The intrinsic muscles of larynx are:

• Cricoarytenoid
• Posterior cricoarytenoid
• Lateral cricoarytenoid
• Transverse arytenoid
• Oblique arytenoid
• Aryepiglotticus
• Thyroarytenoid
• Thyroepiglotticus

N.B.

• All the intrinsic muscles of larynx are paired except transverse arytenoid, which is
unpaired.
• Cricothyroid is the only intrinsic muscle that lies outside the larynx, i.e. on the
external aspect of larynx.
• All the intrinsic muscles of larynx are supplied by recurrent laryngeal nerve
except cricothyroid, which is supplied by the external laryngeal nerve.

❖ List the origin, insertion, nerve supply, actions and applied anatomy of
cricothyroid muscle.

Origin
Anterolateral part of the arch of cricoid cartilage (Fig. 16.3).

FIG. 16.3 Action of cricothyroid muscle.

Insertion
Inferior cornu and adjoining part of the lower border of thyroid cartilage.

Nerve supply
External laryngeal nerve.

Actions
It lengthens and tenses vocal cords by tilting the thyroid cartilage forwards. It also
causes adduction of vocal cords.

Applied anatomy
The cricothyroid muscle is an important muscle for pitch and tone of voice. Hence, its
paralysis may alter the voice significantly, which is noticeable especially in singers.

❖ What is rima glottidis? Mention its boundaries.

The rima glottidis is the narrowest part of the laryngeal cavity. It is an anteroposterior
cleft, bounded in front by angle of thyroid cartilage, behind by interarytenoid fold and on
each side by vocal fold (in anterior three-fifth) and by vocal process of arytenoid cartilage
(in posterior two-fifth).

❖ Draw a labelled diagram to show structures seen in the laryngeal cavity during
laryngoscopy.
The structures seen in the laryngeal cavity during laryngoscopy are presented in Fig.
16.4.

FIG. 16.4 Laryngoscopic view of the laryngeal cavity during moderate respiration. Note the
location of rima glottidis in the center.

❖ Write a short note on vocal cords.

They are a pair of folds extending anteroposteriorly within the laryngeal cavity. The
gap between the right and left vocal folds is called rima glottidis. Each vocal cord is
made up of vocal ligament (medially) and vocalis muscle (laterally).
 The vocal ligament extends from the tip of vocal process of arytenoid cartilage
posteriorly to the inner aspect of thyroid cartilage anteriorly. The vocalis muscle (the
detached medial part of thyroarytenoid muscle) also extends from inner aspect of
thyroid cartilage (anteriorly) to the vocal process of the arytenoid cartilage (posteriorly).
The posterior part of vocal folds is formed by arytenoid cartilages. Each vocal cord is
covered by mucous membrane.

❖ Write a note on changes in size and shape of rima glottidis.

Functionally rima glottidis consists of two parts:

a. Intramembranous part (anteriorly three-fifth) between vocal cords

b. Intracartilaginous part (posteriorly one-fifth) between arytenoid cartilage

The changes in size and shape of rima glottidis takes place during respiration and
speech. These are:

• During quiet respiration, vocal cords lie only, at some distance.

• During full respiration, vocal cords move apart.
• During whispering, only intracartilaginous part widens.
• During high-pitched voice, both intramembranous and intracartilaginous parts
adduct and rima glottidis is reduced to a linear chink.

❖ Why vocal cords do not swell much in laryngitis? Explain its anatomical basis. 
AN38.2
The laryngitis is the inflammation of the larynx. The vocal cords do not swell much in
laryngitis due to the following reasons:

• They are lined by stratified squamous epithelium (cf. rest of the laryngeal cavity
is lined by pseudostratified ciliated columnar epithelium).
• The mucous membrane of the vocal cords is firmly attached to the vocal
ligaments.
• There is no submucous tissue and glands in the vocal cords.

❖ What are vocal nodules/singer’s nodules?

The vocal nodules are bilateral swellings in the vocal cords at the junction of their
anterior one-third and posterior two-third (Fig. 16.5).
 FIG. 16.5 Vocal nodules.

When the vocal cords vibrate during phonation, they come in maximum contact with
each other at the junction of their anterior one-third and posterior two-third. The
inflammatory swellings (inflammation due to friction) which appear at these sites are
called vocal nodules.
The size of vocal nodules varies from pin-head to split-pea and their colour varies
from reddish (in early stage) to whitish (in later stage).

❖ Enumerate the effects of lesions of laryngeal nerves. AN38.3

The effects of lesions of laryngeal nerve are given in Table 16.1.

TABLE 16.1
Effects of Lesions of Laryngeal Nerves

❖ Describe piriform fossa in brief and discuss its clinical importance. AN36.3

The piriform fossa is a deep recess in the lateral wall of the laryngopharynx, one on
each side of laryngeal inlet (see Fig. 16.2; p. 170).

Boundaries

Medially: Aryepiglottic fold

 Laterally: Thyrohyoid membrane and thyroid cartilage

Clinical importance
The foreign bodies like fish bones and safety pins may be lodged in piriform fossa. If
care is not taken during the removal of these foreign bodies, the instrument used for the
removal of foreign bodies may pierce the mucous membrane lining, the floor of fossa
and damage the internal laryngeal nerve and vessels, which lies just beneath it.

N.B.
Piriform fossa is also called smuggler’s fossa because in earlier bygone days it was
artificially deepened by smugglers to smuggle out precious stones, diamonds, etc.
17

Infratemporal fossa, temporomandibular

joint and pterygopalatine fossa

Infratemporal fossa
❖ Define infratemporal fossa and enumerate its boundaries and contents. AN33.1
The infratemporal fossa is a large irregular space beneath the zygomatic arch between
side wall of pharynx and ramus of mandible.

Boundaries

Anterior: Posterior (infratemporal) surface of the body of maxilla.

Posterior: Styloid process.
Medial: Lateral pterygoid plate and pyramidal process of palatine bone.
Lateral: Ramus of mandible.
Roof: Infratemporal surface of the greater wing of sphenoid.
Floor: Open and extends up to the base of mandible.

Contents

Two muscles: Lateral and medial pterygoids. (Note: In addition to these muscles,
the tendon of temporalis muscle also lies in this fossa.)
Two nerves: Mandibular and chorda tympani.
One artery: Maxillary artery.
Two venous structures: Pterygoid venous plexus and maxillary vein.
One ganglion: Otic ganglion.

❖ Enumerate the muscles of mastication. AN33.2

• Chief muscles of mastication (Fig. 17.1)

■ Masseter (most superficial)
■ Temporalis
■ Lateral pterygoid
■ Medial pterygoid
• Accessory muscles of mastication (Fig. 17.1)
■ Buccinator muscle
■ Digastric muscle
 FIG. 17.1 Muscles of mastication. Source: (The chief muscles of mastication are labelled in
boldface.)

❖ Discuss the origin, insertion, nerve supply and action of masseter muscle. 
AN33.2

Origin (fig. 17.2)

Superficial part: From the anterior two-third of the lower border of zygomatic
arch and adjoining part of zygomatic process of maxilla.
Deep part: From the inner surface of zygomatic arch.

FIG. 17.2 Origin and insertion of masseter muscle.

Insertion (fig. 17.2)
Into the outer surface of the ramus of mandible.

Nerve supply
Masseteric nerve from the anterior division of the mandibular nerve.

Action
Elevation of mandible to close the mouth (as required during biting).

❖ Discuss the origin, insertion nerve supply and actions of temporalis muscle. 
AN33.2

Origin (fig. 17.3)

From the floor of temporal fossa and deep surface of temporal fascia.

FIG. 17.3 Origin and insertion of temporalis muscle.

Insertion (fig. 17.3)

Into the coronoid process (tip, inner surface and anterior border) of the ramus of
mandible.
Nerve supply
Two deep temporal nerves from the anterior division of the mandibular nerve.

Actions

• Elevation of mandible
• Retraction of mandible
• Helps in side-to-side movement of the lower jaw during grinding

❖ Discuss the origin, insertion, nerve supply and actions of lateral pterygoid muscle.
 AN33.2
The lateral pterygoid is the key muscle of infratemporal region.

Origin (fig. 17.4)

By two heads:

• Upper smaller head arises from the infratemporal crest and infratemporal surface
of the greater wing of the sphenoid.
• Lower larger head arises from the lateral surface of the lateral pterygoid plate.

FIG. 17.4 Origin and insertion of lateral pterygoid muscle.

Insertion (fig. 17.4)

Into the pterygoid fovea present on the front of the neck of mandible. Some fibres are also
inserted into the articular disc and capsule of the temporomandibular joint.
Nerve supply
A branch from the anterior division of the mandibular nerve.

Actions

• Depression of mandible to open the mouth; while doing so, muscle pulls the
articular disc forwards.
• Protrusion of mandible.
• Along with ipsilateral medial pterygoid muscle, it pushes the chin to the
opposite side.

❖ Discuss the origin, insertion, nerve supply and actions of medial pterygoid
muscle.  AN33.2

Origin (fig. 17.5)

By two heads:

• Smaller superficial head arises from the tuberosity of maxilla.

• Larger deep head from the medial surface of the lateral pterygoid plate.

FIG. 17.5 Origin and insertion of medial pterygoid muscle.

Insertion (fig. 17.5)

Into the medial surface of the ramus of mandible, above the angle of mandible and
below the mandibular foramen.

Nerve supply
Nerve to medial pterygoid, a branch from main trunk of the mandibular nerve.
Actions

• Elevation of mandible
• Helps in protrusion of mandible
• Along with ipsilateral, lateral pterygoid pushes the chin to opposite side

N.B.

• All the chief muscles of mastication are supplied by the mandibular nerve.
• All the muscles of mastication close the mouth except lateral pterygoid, which
opens the mouth. Thus, closing of mouth is much more powerful action than the
opening.

❖ Why lateral pterygoid muscle is regarded as the key muscle of the infratemporal
region? List its relations. AN33.2
The lateral pterygoid muscle is regarded as the key muscle of the infratemporal region
because its relations provide the fair idea of the layout of the structures in the
infratemporal fossa.

Relations (fig. 17.6)

Superficial relations

• Masseter
• Ramus of mandible
• Tendon of temporalis
• Maxillary artery
 FIG. 17.6 Relation of lateral pterygoid muscle.

Deep relations

• Mandibular nerve
• Middle meningeal artery
• Sphenomandibular ligament
• Deep head of medial pterygoid

Structures emerging from the upper border

• Deep temporal nerves

• Masseteric nerve

Structures emerging from its lower border

• Lingual nerve
• Inferior alveolar nerve
• Middle meningeal artery (in fact passes upward deep to muscle)

Structures passing between two heads

• Maxillary artery (enters)

• Buccal branch of mandibular nerve (comes out)

❖ Describe the mandibular nerve under the following headings: (a) origin, (b)
course, (c) branches and (d) distribution. AN33.1
Origin and course (fig. 17.7)
The mandibular nerve is the largest division of trigeminal nerve. It arises from the
trigeminal ganglion and enters the infratemporal fossa through foramen ovale. In the
foramen ovale, it is joined by the small motor root of the trigeminal nerve, and thus
emerges from the skull as a mixed nerve. After emerging from foramen ovale, it divides
almost immediately into the anterior and posterior divisions.

FIG. 17.7 Course and distribution of mandibular nerve. SM, submandibular ganglion.

Branches and distribution (fig. 17.7)

From the trunk

• Meningeal branch (nervus spinosus), which enters the skull through foramen
spinosum and supplies the dura mater.
• Nerve to medial pterygoid, it passes through otic ganglion and supplies the medial
pterygoid muscle. In addition to it, it also supplies twigs to the tensor palati and
tensor tympani muscles.

From the anterior division

• Muscular branches to the temporalis (deep temporal nerves), masseter (masseteric

nerve) and nerve to the lateral pterygoid.
• Buccal nerve (sensory to the skin and mucosa of the cheek).

From the posterior division

 • Auriculotemporal nerve (sensory to the auricle and temple).
• Lingual nerve (sensory to the anterior two-third of tongue).
• Inferior alveolar nerve: Gives the mylohyoid nerve and then enters into the
mandibular canal to supply sensory fibres to the lower teeth and gums. It gives
mental nerve, which supplies the skin of the chin, and skin and mucosa of the
lower lip.

Note: The nerve to mylohyoid supplies mylohyoid muscle and anterior belly of
digastric.

N.B.

• All the branches from the anterior division of mandibular nerve are motor except buccal
nerve, which is sensory to skin and mucous membrane of the cheek.
• All the branches from the posterior division of mandibular nerve are sensory except
mylohyoid nerve, which is motor to mylohyoid and anterior belly of digastric.

❖ Describe the otic ganglion in brief under the following headings: (a) location, (b)
roots and (c) distribution. AN33.1

Location
It is a small parasympathetic ganglion of 2–3 mm in size (about the size of pin-head)
and is located in the infratemporal fossa, just below the foramen ovale. It lies medial to
mandibular nerve and lateral to tensor palati muscle.

Roots (fig. 17.8)

Parasympathetic root: From lesser petrosal nerve.

Sympathetic root: From sympathetic plexus around middle meningeal artery.
Sensory root: From auriculotemporal nerve.
Motor root: From nerve to medial pterygoid.
 FIG. 17.8 Otic ganglion and its connections.

Distribution (fig. 17.8)

Parasympathetic (secretomotor) fibres: Supply parotid gland through

auriculotemporal nerve.
Sympathetic (vasoconstrictor) fibres: Supply blood vessels of parotid gland
through auriculotemporal nerve.
Sensory fibres: Provide sensory innervation to parotid gland through
auriculotemporal nerve.
Motor fibres: Supply three muscles through nerve to medial pterygoid – medial
pterygoid, tensor palati and tensor tympani.

❖ Draw a flowchart to show the secretomotor pathway to the parotid gland. 

AN33.1, AN28.9
Below is the Flowchart 17.1, showing secretomotor pathway to the parotid gland.

FLOWCHART 17.1 The secretomotor pathway to the parotid gland.

❖ Write briefly about chorda tympani nerve. AN28.4

It is described in Chapter 11 (p. 127 and 128).
❖ Describe the maxillary artery under the following headings: (a) origin and extent,
(b) parts, (c) branches and (d) applied anatomy. AN33.1

Origin and extent (fig. 17.9)

The maxillary artery is the larger of two terminal branches of the external carotid artery.
It extends from behind the neck of the mandible to the sphenopalatine foramen, where
it continues as the sphenopalatine artery.

FIG. 17.9 Origin, extent and branches of the maxillary artery.

Parts (fig. 17.9)

For descriptive purposes, the maxillary artery is divided into three parts by lateral
pterygoid (inferior head).

First part: It extends from the neck of the mandible to the point where it crosses
the lower border of lateral pterygoid (inferior head).
Second part: It lies superficial or deep to lateral pterygoid.
Third part: It is beyond the upper border of lateral pterygoid. It passes between
two heads of lateral pterygoid, passes through pterygomaxillary fissure to enter
into pterygopalatine fossa, where it terminates by dividing into sphenopalatine
and greater palatine arteries.

Branches (fig. 17.9)

From first part:

■ Anterior tympanic artery
■ Deep auricular artery
■ Middle meningeal artery
 ■ Accessory meningeal artery
■ Inferior alveolar artery
From second part: Muscular branches to supply temporalis (deep temporal
arteries), pterygoids, masseter and buccinator (buccal branch) muscles.
From third part:
■ Posterior superior alveolar arteries
■ Greater palatine artery
■ Infraorbital artery
■ Pharyngeal branch
■ Artery of pterygoid canal
■ Sphenopalatine artery (the continuation of maxillary artery)

Applied anatomy

Middle meningeal artery: It often ruptures inside the cranial cavity following a
trauma on the lateral aspect of the skull and leads to the formation of extradural
haematoma.
Inferior alveolar artery: Sometimes it may rupture during extraction of tooth of
the lower jaw leading to osteomyelitis of the lower jaw.
Sphenopalatine artery: Its septal branch (rhinologist’s artery) takes part in the
formation of Kiesselbach’s plexus in Little’s area of nose. It is the most common
source of nose bleeding.

❖ Write a short note on middle meningeal artery. AN33.1

The middle meningeal artery arises from first part of the maxillary artery in the
infratemporal fossa deep to lateral pterygoid muscle.

• The artery ascends upwards and enters into middle cranial fossa through
foramen spinosum.
• On entering the cranial cavity, it lies in the groove deep to corresponding vein
and divides into anterior (frontal) and posterior (parietal) terminal branches.

The larger anterior branch ascends crossing the greater wing of sphenoid in a groove
just deep to the pterion of lateral wall of skull. Then it runs obliquely upwards and
backwards parallel to and little in front of central sulcus, on precentral gyrus.

• The smaller posterior branch runs backwards over the superior temporal sulcus
of cerebrum about 4 cm above the zygomatic arch.

Branches
Predominantly, middle meningeal artery is periosteal artery which supplies bone and
red marrow within the dipole.
Within the cranial cavity it gives rise to the following branches:
 1. Anterior branch supplies dura mater and skull bones in the frontal region of
skull.
2. Posterior branch supplies dura mater and skull bone in the parietal region.
3. Ganglionic branches to trigeminal ganglion.
4. Petrosal branch enters the hiatus of greater petrosal nerve to supply facial nerve.
5. Superior tympanic branch to supply tensor tympani muscle.
6. Temporal branches pass through foramina in the greater wing of sphenoid to
enter in the temporal fossa.
7. Anastomotic branch which anastomoses with the recurrent meningeal branch of
lacrimal artery.

Applied anatomy (fig. 17.10)

Middle meningeal artery is the commonest source of extradural haemorrhage. Fractures
on the lateral side of skull involving pterion tear the middle meningeal artery (anterior
branch) producing extradural haematoma lying over premotor area of cerebral cortex.
This leads to pressure symptoms, e.g. contralateral hemiplegia. Hence, extradural
haematoma is an acute surgical emergency.

FIG. 17.10 Middle meningeal artery. A, course and termination; B, extradural haematoma. P,
parietal bone; F, frontal bone; T, temporal bone; S, sphenoid bone.
Temporomandibular joint
❖ Describe the temporomandibular joint (TMJ) under the following headings: (a)
classification, (b) articular surfaces, (c) ligaments, (d) relations, (e) nerve supply, (f)
movements and (g) applied anatomy. AN33.3

Classification
It is synovial joint of condylar variety.
Special features of TMJ:

• It is atypical synovial joint because its articular surfaces are covered by

fibrocartilage instead of hyaline cartilage.
• It is a complex synovial joint because its cavity contains an articular disc.
• Two condyles of mandible articulate with a mechanically single bony
component, the cranium; hence, two TMJs together function as single unit and
form a single craniomandibular joint of bicondylar variety.

Articular surfaces (fig. 17.11)

Above: Articular fossa and articular tubercle/eminence of temporal bone. It is

concavoconvex from behind to forward and is covered by a fibrocartilage.
Below: Head of mandible. It is elliptical and is also covered by a fibrocartilage.

FIG. 17.11 Articular surfaces of the temporomandibular joint.

The joint cavity is divided into two parts by an articular disc: (a) upper
meniscotemporal compartment that permits gliding movements and (b) lower
meniscomandibular compartment that permits rotational as well as gliding
movements.

Ligaments (fig. 17.12)

Main ligaments
 • Capsular ligament: It is attached above to the articular tubercle, the circumference
of mandibular fossa and squamotympanic fissure, and below to the neck of
mandible.
• Lateral ligament/temporomandibular ligament: It is a thick band of fibrous tissue
that covers the lateral aspect of capsule and strengthens it. It extends from
articular tubercle on root of zygoma above to the lateral aspect of the neck of
mandible below. Its fibres run downwards and backwards.

FIG. 17.12 Ligaments of the temporomandibular joint: A, fibrous capsule and lateral ligament;
B, accessory ligaments.

Accessory ligaments

• Stylomandibular ligament: It extends from styloid process of temporal bone to the

angle of mandible. It is formed due to thickening in the investing layer of deep
cervical fascia.
• Sphenomandibular ligament: It extends from spine of sphenoid to the lingula of
mandible. It is derived from the first pharyngeal arch cartilage.

N.B.
Lateral and accessory ligaments limit the range of movements of condyles and prevent
them from coming in contact with tympanic plate behind and the articular tubercles in
front.

Relations
Lateral

• Skin and fasciae

• Parotid gland
• Temporal branches of facial nerve

Medial
 • Tympanic plate of temporal bone
• Spine of the sphenoid and sphenomandibular ligament
• Auriculotemporal and chorda tympani nerves
• Middle meningeal artery

Anterior

• Lateral pterygoid
• Masseteric nerve and artery

Posterior

• Parotid gland, which separates the joint from the external auditory meatus
• Superficial temporal vessels
• Auriculotemporal nerve

Superior

• Middle cranial fossa

• Middle meningeal vessels

Inferior

• Maxillary artery and vein

Nerve supply

• Auriculotemporal nerve
• Masseteric nerve

Movements
The movements of the temporomandibular joints and muscles producing them are
given in Table 17.1.

TABLE 17.1
Movements of TMJ and Muscles Producing Them

Movements Muscles
Elevation (closing of mouth) • Medial pterygoid
• Masseter, temporalis
Depression (opening of mouth) • Lateral pterygoid
• Anterior belly of digastric
• Geniohyoid
• Mylohyoid
 Protraction (i.e. protrusion of mandible)
Retraction (backward movement of
mandible)
Side to side movements (chewing
movements)
• Temporalis (posterior fibres)
• Lateral and medial pterygoids of each side acting
alternatively

N.B.
Most movements occur simultaneously at the right and left temporomandibular joints.

Applied anatomy

• Dislocation of temporomandibular joints (TMJs): The TMJs are mostly

dislocated anteriorly. When the mouth is open, the mandibular condyles lie
underneath the articular eminences of the temporal bone (the most unstable
position of TMJ). In this position, if mouth is opened widely or even a severe
muscular spasm (e.g. a convulsive yawn) it may displace the heads of mandible
forward and upwards to be locked into the infratemporal fossa, leading to
anterior dislocation of TMJ. As a result, there is inability to open mouth (Fig.
17.13). AN33.5
The reduction of joint can be easily achieved by pressing the molar teeth
downwards with thumbs, and at the same time pushing the chin upward
and backward.
• Jaw clicking: The articular disc of TMJ may become partially detached from the
capsule. As a result, movements of jaw becomes noisy and produces an audible
click during movements of the TMJ.

FIG. 17.13 Dislocation of TMJs. A, normal; B, dislocation.

❖ Write briefly about articular disc of TMJ. AN33.3

General features

• It is an oval plate of fibrocartilage, which divides the cavity TMJ into two
 compartments: (a) an upper meniscotemporal compartment and (b) a lower
meniscomandibular compartment.
• It presents a thick peripheral margin and a thin central part.
• It has concavoconvex superior surface and a concave inferior surface.
• Its periphery is firmly attached to the fibrous capsule.
• Morphologically, it represents the tendon of lateral pterygoid muscle.

Parts of articular disc

In sagittal section, it presents five parts. From before to backwards these are (Fig. 17.14):

• Anterior extension
• Anterior thick band
• Intermediate thin part
• Posterior thick band
• Posterior bilaminar extension

FIG. 17.14 Parts of articular disc of the temporomandibular joint as seen in sagittal section.

Pterygopalatine fossa AN33.1

The pterygopalatine fossa is a pyramidal-shaped space that lies in the depth of
pterygomaxillary fissure.

❖ Define pterygopalatine fossa and enumerate its boundaries and contents. AN33.1

Boundaries

Anterior: Posterolateral surface of maxilla.

Posterior: Pterygoid process and greater wing of sphenoid.
Medial: Perpendicular plate of palatine.
 Lateral: Fossa presents pterygomaxillary fissure.
Floor: Angle between the anterior and posterior walls of fossa.
Roof: Body of sphenoid.

Contents

• Maxillary nerve
• Pterygopalatine ganglion
• Maxillary artery (3rd part)

❖ Describe the maxillary nerve under the following headings: (a) origin, (b) course
and (c) branches. AN33.1

Origin and course (fig. 17.15)

The maxillary nerve arises from trigeminal ganglion in the middle cranial fossa. It
passes forward and traverses foramen rotundum to reach the upper part of the
pterygopalatine fossa. From fossa, it enters the orbit by passing through the inferior
orbital fissure. As it enters the orbit, it is called infraorbital nerve. In the orbit it first
runs in the infraorbital groove, and then passes through the infraorbital canal, to finally
appear on the face by emerging through the infraorbital foramen.

FIG. 17.15 Origin, course and branches of the maxillary nerve.

Thus, the maxillary nerve traverses through four successive regions during its course:
(a) middle cranial fossa, (b) pterygopalatine fossa, (c) orbit and (d) face.
Note: The infraorbital nerve is considered as the continuation of maxillary nerve.

Branches (fig. 17.15)

They are given in Table 17.2.

TABLE 17.2
Branches of Maxillary Nerve

Region Branches
Middle cranial fossa • Meningeal branch
Pterygopalatine ganglion • Ganglionic branches
• Posterior superior alveolar nerves
• Zygomatic nerve
Orbit • Middle superior alveolar nerve
• Anterior superior alveolar nerve
Face • Three terminal branches (palpebral, nasal and labial)
❖ Describe the pterygopalatine ganglion (sphenopalatine ganglion) in brief under
the following headings: (a) location, (b) roots, (c) branches, (d) distribution and (e)
applied anatomy. AN33.1

Location
The pterygopalatine ganglion is the largest peripheral parasympathetic ganglion. It is
located in the pterygopalatine fossa.

N.B.
Topographically, it is related to the maxillary nerve, but functionally it is related to the
facial nerve.

Roots (fig. 17.16)

It has following three roots:

Parasympathetic root: From greater petrosal nerve.

Sympathetic root: From sympathetic plexus around internal carotid artery
through deep petrosal nerve.
Sensory root: From maxillary nerve.
 FIG. 17.16 Pterygopalatine ganglion, its roots and branches. PG, pterygopalatine ganglion.

Branches

• Orbital branches
• Palatine branches
• Nasal branches

Distribution

Parasympathetic (secretomotor) fibres: Supply the lacrimal, nasal and palatine

glands.
Sympathetic (vasomotor) fibres: Supply the mucous membrane of nose, paranasal
air sinuses and nasopharynx.
Sensory fibres: Provide sensory innervation to periosteum of orbit and mucous
membrane of nose, palate and pharynx.

N.B.
The distribution of different types of fibres from pterygopalatine ganglion takes place
through its orbital, nasal, palatine and pharyngeal branches (vide supra).

Applied anatomy
The allergic conditions such as hay fever or cold causes irritation of pterygopalatine
ganglion, which leads to running of nose and eyes. For this reason, the pterygopalatine
ganglion is also termed ganglion of hay fever.
The alcohol injection is occasionally used to relieve/treat the intractable cases of
allergic rhinitis.
18

Ear and orbit

Ear
❖ What is ear? List its subdivisions. AN40.1
The ear is the organ of hearing and balance. It is subdivided into the following three parts
(from lateral to medial):

• External (outer) ear

• Middle ear
• Internal (inner) ear

❖ Discuss the sensory nerve supply of the auricle/pinna. AN40.1

Lateral (facial) surface

• Lower one-third by great auricular nerve (C2, C3)

• Upper two-third by auriculotemporal nerve

Medial (cranial) surface

• Lower one-third by great auricular nerve (C2, C3)

• Upper two-third by lesser occipital nerve (C2)

N.B.
In addition to above, the concha on the lateral surface of pinna is supplied by an
auricular branch of vagus nerve and eminentia conchae on the medial surface of pinna is
supplied by a sensory twig of facial nerve.

❖ Write a short note on external auditory (acoustic) meatus. AN40.1

• The external acoustic meatus is an ‘S’-shaped osseocartilaginous tube, which

extends from bottom of concha to the tympanic membrane.
• It is about 24 mm long, of which medial two-third (16 mm) is bony and lateral
one-third (8 mm) is cartilaginous.
• It conducts sound waves from concha to the tympanic membrane.
• It develops from first pharyngeal cleft.
❖ Write a short note on tympanic membrane. AN40.1, AN40.2

Introduction

• The tympanic membrane or ear drum is a semitransparent oval membrane, which

separates the external acoustic meatus from the middle ear cavity.
• Its diameter measures about 9 × 10 mm and is placed obliquely at an angle of 55°
with the floor of external acoustic meatus. It faces downwards, forwards and
laterally. The circumference of membrane is made up of fibrocartilaginous ring.
The sulcus is absent between anterior and posterior malleolar folds. The part of
membrane enclosed between malleolar folds is called pars flaccida.

Structure
It consists of three layers:

• An outer cuticular layer (ectodermal in origin), continuous with the skin of

external auditory meatus.
• A middle fibrous layer (mesodermal in origin), consisting of superficial radiating
fibres and deep circular fibres.
• An inner mucous layer (endodermal in origin), lined by ciliated columnar
epithelium, continuous with the mucosa of middle ear.

Features (fig. 18.1)

• Most of tympanic membrane is tightly stretched and called pars tensa. A small
upper part between two malleolar folds is loose and called pars flaccida (vide
supra). The pars flaccida is crossed internally by the chorda tympani nerve.
• The tympanic membrane has outer and inner surfaces. The outer surface is
concave. The inner surface is convex and provides attachment to the handle of
malleus, which extends up to its centre. The point of maximum convexity on the
inner surface is called umbo. The cone of light is the reflection of light from the
otoscope.
• The handle of malleus is embedded in the middle fibrous layer.
 FIG. 18.1 External surface of tympanic membrane as seen through otoscope: 1,
posterosuperior quadrant; 2, anterosuperior quadrant; 3, posteroinferior quadrant; 4,
anteroinferior quadrant.

Applied anatomy

• The otoscopic examination may reveal the bulging, perforation or retraction of

tympanic membrane.
• The membrane is incised (myringotomy) to drain the pus present in the middle
ear. The incision should be given in the posteroinferior quadrant of membrane
to avoid injury to the chorda tympani nerve.
• The rupture of tympanic membrane usually occurs in pars flaccida.

❖ Describe the middle ear under the following headings: (a) location, shape and
dimension, (b) contents, (c) boundaries, (d) nerve supply and (e) applied anatomy. 
AN40.2

Location
The middle ear is narrow, slit-like, air-filled cavity in the petrous part of temporal bone.
It communicates anteriorly with nasopharynx through auditory tube and posteriorly
with mastoid antrum through aditus ad antrum.

Shape
Biconcave hollow disc, resembling the red blood cell (RBC).

Dimension

Vertical: 15 mm
Transverse:
■ 6 mm: At roof
■ 2 mm: In the centre
■ 4 mm: At floor
Contents

• Air
• Two muscles: Tensor tympani and stapedius
• Three ear ossicles: Malleus, incus and stapes
• Two nerves: Chorda tympani nerve and tympanic plexus.

N.B.
Air is actual content. The remaining structures are covered by the mucosa of the middle
ear.

Boundaries (fig. 18.2)

Roof or tegmental wall:
Formed by tegmen tympani, a thin plate of bone that separates middle ear from middle
cranial fossa.

FIG. 18.2 Schematic diagram showing the boundaries (and their relations) of the middle ear.
The middle ear is akin to a six-sided box. Note its lateral side is opened out. O, oval window; P,
pyramid; PC, processus cochleariformis; PM, promontory; R, round window; S, sinus tympani;
TP, tympanic plexus.

Floor or jugular wall

• Formed by jugular fossa of temporal bone.

• Separates middle ear from superior bulb of internal jugular vein.

Anterior wall or carotid wall

 • Upper part presents: Canals for tensor tympani and auditory tube.
• Lower part forms: Posterior wall of carotid canal.

N.B.
The bony septum between canals for tensor tympani and auditory tube extends
backward along the medial wall of tympanic cavity and upturns at its distal end to
form a hook-like process. It is called processus cochleariformis.

Medial or labyrinthine wall:

It separates middle ear from internal ear and presents the following features:

• Promontory: A rounded elevation produced by first turn of cochlea.

• Oval window (fenestra vestibuli): An oval opening posterosuperior to the
promontory that leads to vestibule of internal ear. It is occupied by the base of
stapes.
• Round window (fenestra cochleae): A round opening posteroinferior to the
promontory that leads to scala tympani of cochlea and closed by secondary
tympanic membrane.
• Sinus tympani: A depression behind promontory.
• Prominence of facial canal, just above the oval window.
• Prominence of lateral semicircular canal, above the prominence of facial canal.

Lateral or membranous wall

• Separates middle ear from external ear.

• It is formed:
■ Mainly by tympanic membrane.
■ Partly by squamous part of temporal bone in the region of epitympanic
recess.

Posterior wall or mastoid wall:

It presents the following features. From above downwards these are:

• Aditus to mastoid antrum (aditus ad antrum)

• Fossa incudis: Depression for incus.
• Pyramid: A conical bony projection. The apex of pyramid presents an opening
for tendon of stapedius.
• Posterior canaliculus for chorda tympani, lateral to pyramid.

Nerve supply

• Tympanic branch of glossopharyngeal nerve.

• Superior and inferior caroticotympanic nerves from sympathetic plexus around
internal carotid artery.
Applied anatomy
Otitis media:
The throat infections commonly spread to the middle ear through auditory tube. It is
more common in children because in children the tube is shorter, wider and
horizontal. AN40.4
The longstanding otitis media often leads to collection of pus in the middle ear – a
condition called chronic suppurative otitis media (CSOM). The pus from middle ear:

• May be discharged in the external ear following the rupture of tympanic

membrane.
• May erode the roof leading to meningitis and temporal lobe abscess.
• May erode the floor causing thrombosis of internal jugular vein.
• May spread backward into mastoid antrum leading to mastoid abscess.

Bleeding from ear:

Fracture of middle cranial fossa can cause bleeding through the ear.

❖ Write a short note on mastoid antrum.  AN40.2

• The mastoid antrum is an air space in mastoid portion of temporal bone (Fig.
18.3).
• It communicates anteriorly with the tympanic cavity through aditus ad antrum
(entrance to the mastoid antrum).

FIG. 18.3 Mastoid antrum as seen in section along the long axis of petromastoid bone.

Boundaries

Roof is formed by tegmen tympani.

Lateral wall is formed by a plate of bone about 1.5 cm thick just deep to
suprameatal triangle.
 Posterior wall is formed by a thin plate of bone which separates it from sigmoid
sinus.

Functions

1. Provides resonance to voice.

2. Acts as acoustic insulator and provides protection to middle ear from physical
damage.
3. Acts as sound receptor.

Applied anatomy

• Mastoid air cells are major contributor to the middle ear inflammatory disease.
• Lateral wall of antrum is approached for surgery, through suprameatal triangle.

❖ Write a short note on ear ossicles. AN40.2

• There are three tiny bones present in the middle ear cavity.
• From medial to lateral, these are malleus (hammer), incus (anvil) and stapes
(stirrup) (Fig. 18.4).
Malleus is the lateral ossicle. It has head, neck and three processes, i.e. handle,
lateral process and anterior process.
■ Head articulates with incus
■ Handle passes downwards and is attached to the tympanic membrane.
Medial aspect of handle receives insertion of tensor tympani.
■ Anterior process is attached to the spine of sphenoid by a ligament.
■ Lateral process is attached to the tympanic sulcus (bony) by anterior and
posterior malleolar folds.
Incus is the middle bone. It has body, short process and long process.
■ Body articulates with the head of malleus.
■ Short crus is attached to the floor of aditus by a ligament.
■ Long crus articulates with the head of stapes.
Stapes is the most medial (innermost) ossicle. It has head, neck, anterior and
posterior limbs and footplate.
■ Head articulates with the long process of the incus.
■ Footplate is held in fenestra vestibule (oval window) by annular ligament.
■ Neck of stapes receives an insertion of stapedius.
 FIG. 18.4 Ear ossicles.

Applied anatomy
The vibrations of sound waves are transmitted from tympanic membrane to the fluid
(perilymph) of inner ear by the ossicular chain.

• Paralysis of stapedius leads to hyperacusis.

• Otosclerosis (abnormal ossification of annular ligament which anchors the
footplate of stapes leads to conduction deafness).

❖ Briefly describe the internal ear. AN40.3

The internal ear is involved in both hearing and balance.
It consists of two components: membranous labyrinth and bony (osseous) labyrinth.

Membranous labyrinth
It consists of four membranous parts/structures:

• Cochlear duct
• Saccule
• Utricle
• Three semicircular ducts

All these parts are interconnected to each other to form a labyrinth.

Functions

• The sensory receptor within the cochlear duct is spiral organ of Corti. It is
concerned with hearing.
• The sensory receptors present within saccule and utricle are maculae. They are
concerned with static balance.
• The sensory receptors within the semicircular ducts are cristae ampullaris. They
are concerned with kinetic balance.
Bony labyrinth
It consists of intercommunicating bony spaces in the petrous part of temporal bone.
The bony labyrinth consists of three parts:

• Cochlea
• Vestibule
• Three semicircular canals

❖ Write a short note on the spiral organ of Corti. AN40.3

It is an end organ of hearing, located on the basilar membrane of cochlear duct.

Components (fig.18.5)
Microscopically, organ of Corti consists of five components:

• Basilar membrane: A fibrous membrane that extends from osseous spiral lamina
to the outer wall of cochlear duct.
• Tunnel of Corti: Formed by inner and outer rod cells and contains corticolymph.
• Hair cells are receptor cells of hearing located on the basilar membrane. These
cells bear stereocilia and form the most important component of spiral organ of
Corti. They are divided into inner and outer hair cells.
The hair cells perform the following functions:
■ Detect movements of endolymph
■ Detect vibrations of basilar membrane
■ Transfer vibrations into nerve impulse to the cochlear nerve
• Supporting cells: The inner hair cells are supported by phalangeal cells, while the
outer supporting cells are called Henson’s cells.
• Membrana tectoria: It is a gelatinous membrane that overlies the hair cells. The
shearing force between the hair cells and tectorial membrane stimulates the hair
cells.
 FIG. 18.5 Spiral organ of Corti as seen in a section through the cochlear duct.

Innervation of organ of corti

The hair cells are innervated by the peripheral processes of bipolar neurons of spiral
ganglion located within the modiolus near the base of spiral lamina. There are two types
of neurons:

Type I neurons: They are myelinated and afferent. They innervate inner hair cells
and responsible for auditory sensation.
Type II neurons: They are unmyelinated and efferent from contralateral superior
olivary nucleus. They innervate outer hair cells and are responsible for auditory
discrimination.

Orbit
❖ Enumerate the structures present in the orbit. AN31.1, AN31.2
These are:

• Eyeball
• Extrinsic muscles of eyeball
■ Four recti
■ Superior rectus (SR)
■ Inferior rectus (IR)
■ Medial rectus (MR)
■ Lateral rectus (LR)
■ Two obliques
■ Superior oblique (SO)
■ Inferior oblique (IO)
• Levator palpebrae superioris muscle
• Nerves
■ Optic nerve
■ Three divisions of ophthalmic nerve:
■ Nasociliary
■ Lacrimal
■ Frontal
■ Three motor nerves:
■ Oculomotor (upper and lower divisions; CN III)
■ Trochlear (CN IV)
■ Abducent (CN VI)
• Ciliary ganglion
• Ophthalmic artery
• Ophthalmic veins
• Lacrimal gland
 • Orbital pad of fat

❖ Write about the origin, insertion, nerve supply and actions of the extrinsic muscles
of eyeball. AN31.1

Origin (fig. 18.6)

Four recti: From common tendinous ring.

Superior oblique: From the body of sphenoid superomedial to the optic canal.
Inferior oblique: From rough impression in anteromedial part/angle of floor of
orbit.

FIG. 18.6 Origin and nerve supply of extraocular muscles. NC, nasociliary nerve.

Insertion

Four recti: Into sclera, a little posterior to the limbus (i.e. corneoscleral junction).
Distance from cornea is as follows:
SR = 7.7 mm; IR = 6.5 mm; MR = 5.5 mm; LR = 6.9 mm
Superior oblique: Into sclera, behind the equator in the posterosuperior quadrant
of eyeball between SR and LR.
Inferior oblique: Into sclera, behind the equator in the posteroinferior quadrant of
eyeball.

Nerve supply
All the extrinsic muscles of the eyeball are supplied by CN III, except superior oblique,
which is supplied by CN IV and lateral rectus which is supplied by CN VI.

Mnemonic: LR6SO4 (LR, lateral rectus; SO, superior oblique)

Actions (fig. 18.7)
These are given in Table 18.1.

FIG. 18.7 Schematic diagram Source: (modified after Starling) showing actions of various
extraocular muscles. IO, inferior oblique; IR, inferior rectus; LR, lateral rectus; MR, medial
rectus; SR, superior rectus; SO, superior oblique.

TABLE 18.1
Actions of Extrinsic Muscles of the Eyeball

Muscle Actions
Superior oblique • Depression
• Abduction
• Intorsion
Inferior oblique • Elevation
• Abduction
• Extorsion
Superior rectus • Elevation
• Adduction
• Intorsion
Inferior rectus • Depression
• Adduction
• Extorsion
Medial rectus • Adduction
Lateral rectus • Abduction
❖ Write about the origin, insertion, nerve supply and actions of the levator
palpebrae superioris muscle. AN31.1

Origin
From undersurface of lesser wing of sphenoid near the apex of orbit.

Insertion

• Upper major skeletal part, into the skin of upper eyelid.

• Lower minor smooth part (also called Müller’s muscle), into the superior border of
tarsal plate of upper eyelid.

Nerve supply

• Larger part of skeletal muscle, by oculomotor nerve

• Smaller part of smooth muscle, by sympathetic fibres derived from superior
cervical sympathetic ganglion

Action
Elevation of the upper eyelid to open the eye.

Eyeball AN41.1
Eyeball is the organ of sight (vision) located in the anterior two-third of the orbital
cavity.

❖ Write a short note on Tenon’s capsule and mention its applied anatomy. AN41.1

General features

• It is a membranous (fibrous) sac, which envelops the eyeball. It extends from the
optic nerve to the corneoscleral junction.
• It is separated from the eyeball by an episcleral space.
• It forms a socket of the eyeball for its free movements.

Applied anatomy
During enucleation of eyeball, the Tenon’s capsule is left intact to allow the
movements of the implanted artificial eyeball.

❖ Enumerate the coats of eyeball. AN41.1

The eyeball consists of the following three coats from superficial to deep these are:

• Outer fibrous coat called sclera in its posterior five-sixths and cornea in its
anterior one-sixth
• Middle vascular coat called uveal tract (consisting of choroid, ciliary body and
iris)
• Inner neural coat called retina
❖ Write a note on microscopic structure of retina. AN43.2
The cells of retina are arranged in the following four layers, from outside to inside:

1. Pigment cell layer

2. Layer of rods and cones
3. Layer of bipolar cells
4. Layer of ganglion cells

N.B.
Axons from ganglion cells form the optic nerve.

❖ What are the compartments of eyeball? AN41.1

The interior of eyeball is divided into two compartments by the lens within the eyeball
(Fig. 18.8).

FIG. 18.8 Compartments of the eyeball.

Anterior compartment
It is small and lies in front of the lens. It is filled with aqueous humour. It is further
subdivided into two parts:

• A smaller anterior chamber, between iris and cornea.

• A larger posterior chamber, between iris and lens.
 These two portions of anterior chamber communicate with each other through a
circular aperture in the iris, the pupil.

Posterior compartment
It is large (four-fifth) and lies behind the lens. It is filled with colourless, transparent
jelly-like material called vitreous humour/vitreous body.

• The vitreous humour is enclosed in a delicate hyaloid membrane.

• Anteriorly, the vitreous body presents a shallow depression (hyaloid fossa) to
accommodate the lens.

❖ Enumerate the various refractive media of the eyeball. AN41.1

The four refractive media in the eyeball, from before backwards are as follows:

• Cornea
• Aqueous humour
• Lens
• Vitreous body

❖ What are eyelids? Enumerate the layers of the eyelid and discuss the related
applied anatomy.  AN43.3
The eyelids are mobile curtains of soft tissue to close and open the eyes. They protect
the eye from dust particles and help in its moistening.

The layers of eyelid

From outside to inside, these are as follows:

• Skin
• Superficial fascia
• Orbicularis oculi
• Tarsal plate of palpebral fascia
• Conjunctiva

Applied anatomy

• Ptosis (drooping of upper eyelid): It occurs due to paralysis of levator palpebrae

superioris muscle.
• Stye (hordeolum): It is suppurative inflammation of glands of Zeis (i.e. sebaceous
glands present in the eyelashes).
• Chalazion: It is the inflammation of tarsal (meibomian) gland (a modified
sebaceous gland in the tarsal plate).

❖ Enumerate the branches of ophthalmic artery. AN41.1

The ophthalmic artery is a branch of internal carotid artery. It gives rise to the following
branches within the orbit (Fig. 18.9):

• Central artery of retina

• Lacrimal artery
• Posterior ciliary arteries
• Supraorbital artery

FIG. 18.9 Branches of the ophthalmic artery.

❖ Write a short note on central retinal artery. AN41.2

It is the first and most important branch of ophthalmic artery. It pierces optic nerve 1.25
cm behind the eyeball and reaches the optic disc through the central part of the disc and
divides into four branches, one for each quadrant. These branches are superior nasal,
inferior nasal, superior temporal and inferior temporal. It supplies optic nerve and
inner six or seven layers of retina.

Applied anatomy
Any blockage of a central retinal artery leads to loss of vision.

❖ Write about the origin, course and distribution of ophthalmic nerve. AN41.1

The ophthalmic nerve is the first and smallest division of the trigeminal nerve. It arises from
the trigeminal ganglion and enters the lateral wall of the cavernous sinus. Here it
divides into three branches, nasociliary, frontal and lacrimal, which enter the orbit
through superior orbital fissure (Fig. 18.10).

• The nasociliary nerve runs forwards and medially crossing optic nerve
obliquely from lateral to medial side, then runs along the medial wall of orbit to
terminate by dividing into anterior ethmoidal and infratrochlear nerves.
It gives rise to the following branches (Fig. 18.10):
■ Sensory root to the ciliary ganglion
■ Two or three long ciliary nerves
■ Posterior ethmoidal nerve
■ Anterior ethmoidal nerve
■ Infratrochlear nerve
• The frontal nerve (largest branch) runs forward and terminates by dividing into
supraorbital and supratrochlear nerves.
• The lacrimal nerve (smallest branch) runs along the lateral wall of the orbit end
and ends in the lacrimal gland.
It gives rise to the following branches:
■ Branches to the lacrimal gland
■ Lateral palpebral branch to the skin of the lateral part of the upper
eyelid
 FIG. 18.10 Branches and distribution of the ophthalmic nerve.

❖ Write about the location, roots and distribution of the ciliary ganglion. AN41.1

Location
It is a small peripheral parasympathetic ganglion of pin-head size (about 2 mm in
diameter), located near the apex of orbit, between the optic nerve and lateral rectus
muscle.

Roots (fig. 18.11)

The roots are 3 in number as follows:

• Parasympathetic root: It is derived from inferior division of oculomotor nerve. The

preganglionic fibres arise from Edinger–Westphal nucleus, run in inferior division
of oculomotor nerve and pass through the nerve to the inferior oblique to relay
in the ciliary ganglion. The postganglionic parasympathetic fibres arise from
ganglion and run through short ciliary nerves.
• Sympathetic root: It is derived from sympathetic plexus around internal carotid
artery. The preganglionic sympathetic fibres arise from T1 spinal segment and
relay in the superior cervical sympathetic ganglion. The postganglionic fibres
arise from this ganglion, form plexus around internal carotid artery and pass
through the ciliary ganglion without relay to enter into short ciliary nerves.
• Sensory root: It is derived from nasociliary nerve – a branch of ophthalmic nerve
 passes through the ganglion without relay.

FIG. 18.11 Roots and distribution of the ciliary ganglion. TG, trigeminal ganglion.

Distribution (fig. 18.11)

The distribution of its branches is as follows:

• Parasympathetic fibres: They supply sphincter pupillae and ciliary muscles

through short ciliary nerves.
• Sympathetic fibres: They supply dilator pupillae and blood vessels of the
eyeball through short ciliary nerves.
• Sensory fibres: They provide sensory innervation to whole eyeball, except
conjunctiva, through short ciliary nerves. The sensory supply of conjunctiva is
derived from frontal, lacrimal and infraorbital nerves.
19

Dural folds, intracranial dural venous

sinuses and pituitary gland
❖ Enumerate the dural folds (folds of dura mater). AN30.3
The dural folds are generally formed by folding of the meningeal layer of cranial dura,
which projects into the cranial cavity to divide it into various compartments, which
lodge the different lobes/parts of the brain (Fig. 19.1).

FIG. 19.1 Dural folds and dural venous sinuses enclosed within them, viewed from
superolateral aspect.

The folds of dura mater are as follows:

• Falx cerebri
• Tentorium cerebelli
• Falx cerebelli
• Diaphragma sellae

❖ Briefly describe falx cerebri. AN30.3

Falx cerebri is a large, sickle-shaped fold of dura mater that lies in the median
longitudinal fissure between the two cerebral hemispheres.

Features (fig. 19.1)

It presents two ends – anterior and posterior; two margins – upper and lower; and two
surfaces – right and left.
 Anterior end: It is narrow and attached to the frontal crest of the frontal bone and
crista galli of the ethmoid bone.
Posterior end: It is broad and attached along the median plane to the upper
surface of the tentorium cerebelli.
Upper attached margin: It is convex and attached to the lips of the sagittal sulcus
on the inner aspect of the cranial vault as far back as the internal occipital
protuberance.
Lower free margin: It is concave, free and lies close to the corpus callosum.
Right and left surfaces: Each of these surfaces is related to the medial surface of
the corresponding cerebral hemisphere.

Venous sinus enclosed in the falx cerebri (fig. 19.1)

• Superior sagittal sinus along the upper margin

• Inferior sagittal sinus along the lower margin
• Straight sinus along the line of attachment of the falx cerebri to the tentorium
cerebelli

Applied anatomy
Thrombosis of superior sagittal sinus may occur due to spread of infection into it from
nose, scalp and diploic veins. It interferes with the absorption of CSF, leading to
increased intracranial pressure.

❖ Briefly describe tentorium cerebelli. AN30.3

Tentorium cerebelli is a tent-shaped fold of dura mater, which forms the roof of the
posterior cranial fossa. It separates the cerebellum from the occipital lobes of the
cerebrum.

Features (fig. 19.1)

It has two margins and two surfaces.

Margins

• The inner free margin is U-shaped and encloses the tentorial notch for the passage
of the midbrain. The anterior ends of concave free margin are attached to the
anterior clinoid processes.
• The outer attached margin is convex and attached on each side (from anterior to
posterior) to the posterior clinoid process, superior border of petrous temporal bone,
posteroinferior angle of parietal bone and lips of transverse sulcus on occipital bone.

N.B.
The free and attached margins of tentorium cerebelli cross each other near the apex of
the petrous temporal bone to enclose a triangular hollow, which is pierced by
oculomotor nerve.
Surfaces

• The convex upper surface slopes on either side from the median plane. In the
median plane, it provides attachment to falx cerebri.
• The concave inferior surface provides attachment to the falx cerebelli in its
posterior part.

Venous sinus enclosed in tentorium cerebelli (fig. 19.1)

• Superior petrosal sinus within the anterolateral part of the attached margin.
• Transverse sinus within the posterior part of the attached margin.
• Straight sinus along the line of attachment between falx cerebri and tentorium
cerebelli.

❖ Define intracranial dural venous sinuses. Discuss their characteristic features and
applied anatomy.  AN30.3, AN30.4

Definition
The intracranial dural venous sinuses are endothelial-lined venous channels lying between
the two layers of dura mater.

N.B.
All the intracranial dural venous sinuses are present between endosteal and meningeal
layers of dura mater except inferior sagittal sinus and straight sinus, which lie between
two meningeal layers of dura mater.

Characteristic features

• Are devoid of smooth muscle in their wall.

• Are devoid of valves in their lumen.
• Are lined by endothelium.
• Drain CSF through arachnoid villi and granulations.
• Receive emissary veins.
• Communicate with extracranial veins through emissary veins.
• Communicate with vertebral venous plexus through basilar venous plexus.
• Receive veins from brain and diploic veins from cranial bones.
• Noncompressive in nature (i.e. always kept patent) and equalize pressure
within and outside the skull.

Applied anatomy
The infection from extracranial sources can spread to the dural venous sinuses and then
to the brain.

❖ Write about the classification of intracranial dural venous sinuses. AN30.3

The intracranial dural venous sinuses are classified into two types – paired and
unpaired. The details are given in Table 19.1.

TABLE 19.1
Classification of Intracranial Dural Venous Sinuses

Paired Unpaired
• Cavernous • Superior sagittal
• Superior petrosal • Inferior sagittal
• Inferior petrosal • Straight
• Transverse • Occipital
• Sigmoid • Anterior intercavernous
• Sphenoparietal • Posterior intercavernous
• Petrosquamous • Basilar venous plexus
• Middle meningeal vein
❖ Describe the cavernous sinus under the following headings: (a) formation and
location, (b) relations, (c) contents, (d) tributaries and communications and (e)
applied anatomy. AN30.3

Formation and location (fig. 19.2)

The two cavernous sinuses are situated one on either side of the pituitary fossa and
body of sphenoid. Each cavernous is large venous space (2 cm long and 1 cm wide)
formed by the separation of endosteal and meningeal layers of dura mater, lined by
endothelium. Its floor is formed by endosteal layer, whereas its lateral wall, roof and
medial wall are formed by meningeal layer of the dura mater.

FIG. 19.2 Formation, location, relations and contents of cavernous sinuses.

Relations (fig. 19.2)

 Superior: Optic chiasma, internal carotid artery and anterior perforated substance.
Inferior: Foramen lacerum and greater wing of sphenoid.
Medial: Hypophysis cerebri and sphenoidal air sinus.
Lateral: Temporal lobe of the brain (uncus) and cavum trigeminale with
trigeminal ganglion within it.

Contents (fig. 19.2)

Structures present in the lateral wall:
From anterior to posterior, these are

• Oculomotor nerve (CN III)

• Trochlear nerve (CN IV)
• Ophthalmic nerve (CN V1)
• Maxillary nerve (CN V2)

N.B.
In section anterior looks superior and posterior looks inferior.

Structures passing through the sinus

• Internal carotid artery with sympathetic plexus around it

• Abducent nerve – below and lateral to the internal carotid artery

Tributaries (fig. 19.3)

• Superior and inferior ophthalmic veins from orbit • From eyeball
• Central vein of retina
• Sphenoparietal sinus • From meninges
• Anterior (frontal) trunk of middle meningeal vein • From cranial wall
• Superficial middle cerebral vein • From brain
• Inferior cerebral veins (some)
 FIG. 19.3 Tributaries and communications of cavernous sinus. A, anterior intercavernous
sinus; E, emissary vein; P, posterior intercavernous sinus.

Communications (fig. 19.3)

• Superior petrosal sinus connects it with the transverse sinus.

• Inferior petrosal sinus connects it with the internal jugular vein.
• Emissary veins connect it with the pterygoid venous plexus.
• Ophthalmic vein connects it with the facial vein.
• Anterior and posterior intercavernous sinuses connect it with the opposite cavernous
sinus.

N.B.
All these communications are valveless and blood can flow in either direction.

Applied anatomy

• Thrombosis of Cavernous Sinus: It may be caused by spread from septic

infection in the dangerous area of face.
The clinical features of cavernous sinus thrombosis are as follows:
■ Severe pain in the eye due to involvement of ophthalmic nerve.
■ Ophthalmoplegia due to involvement of CN III, IV and VI.
■ Oedema of eyelids due to congestion of orbital veins.
 ■ Exophthalmos due to congestion of orbital veins.
• Arteriovenous Fistula: It is caused by rupture of the internal carotid artery into
the cavernous sinus. It results into:
■ Unilateral pulsating exophthalmos
■ Loud systolic thrill/murmur over eye

❖ Define emissary veins. Enumerate the important emissary veins and discuss their
functional and clinical importance. AN27.2
The emissary veins are thin-walled venous channels that connect the extracranial veins
to the intracranial dural venous sinuses.
Following are the important emissary veins:

• Parietal emissary vein

• Mastoid emissary vein
• An emissary vein passing through the foramen ovale or emissary sphenoidal foramen
• Small emissary veins passing through the foramen lacerum and connecting the
cavernous sinus to the pterygoid plexus of veins
• An emissary vein passing through the posterior condylar canal and connecting the
sigmoid sinus to the suboccipital plexus of veins
• Ophthalmic veins can also act as emissary veins

Functions
The emissary veins help to maintain the constant intracranial pressure because blood
passing through them can flow in either direction according to the state of intracranial
pressure.

Clinical importance
They can carry infection from outside the skull to inside the skull (i.e. the cranial cavity).

❖ Describe pituitary gland under the following headings: (a) definition and location,
(b) gross features, (c) relations, (d) microscopic structure, (e) blood supply, (f) nerve
supply, (g) development and (h) applied anatomy. AN30.1, AN30.5, AN43.2, AN43.4

Definition and location

The pituitary gland/hypophysis cerebri is a small neuroendocrine gland located in the
hypophyseal fossa (sella turcica) of the body of sphenoid (Fig. 19.4).
 FIG. 19.4 Location of the pituitary gland.

Shape and measurements

Shape = Oval
Size = Anteroposterior: 8 mm
Transverse: 12 mm
Weight = 500 mg

Gross features (fig. 19.5)

The pituitary gland consists of two parts, which are embryologically, morphologically and
functionally different from each other:

• Adenohypophysis (anterior pituitary)

• Neurohypophysis (posterior pituitary)
 FIG. 19.5 Subdivisions of the pituitary gland.

Adenohypophysis (anterior pituitary):

It is highly cellular and presents an intraglandular cleft. It is further subdivided into
three parts/lobes:

• Anterior lobe (pars distalis): It is the major part of the adenohypophysis.

• Intermediate lobe (pars intermedia): It is a thin strip of the glandular tissue between
the intraglandular cleft in front and neurohypophysis behind.
• Tuberal lobe (pars tuberalis): It is an upward extension of the anterior lobe that
surrounds the part of the infundibulum.

Neurohypophysis (posterior pituitary):

It is continuous above with the infundibulum, which extends downward and forward
from the floor of 3rd ventricle and enters the hypophyseal fossa after piercing the
diaphragma sellae. It is subdivided into three parts:

• Posterior lobe (pars posterior): It is smaller than the anterior lobe and lies in the
posterior concavity of the larger anterior lobe.
• Infundibulum (neural stalk): It contains the neural connections of the
neurohypophysis.
• Median eminence of the tuber cinereum: It is continuous with the infundibular
stem.

Relations
 Anterior:
■ Anterior intercavernous sinus
Posterior:
■ Posterior intercavernous sinus
■ Dorsum sellae
■ Basilar artery
■ Pons
Superior:
■ Diaphragma sellae
■ Optic chiasma
■ Tuber cinereum
■ Infundibular recess of the 3rd ventricle
Inferior:
■ Hypophyseal fossa
■ Body of the sphenoid
■ Sphenoidal air sinuses
Lateral (on each side):
■ Cavernous sinus with its contents

Microscopic structure (fig. 19.6) AN43.2

Anterior lobe (pars anterior/distalis):
It forms three-fourth of the gland. It consists of two types of glandular cells arranged in
irregular cords or clumps:

• Chromophilic cells (50%) having affinity to colours, i.e. staining

■ Acidophils/alpha cells (about 43% of cells): Secrete GH, ACTH and prolactin
■ Basophils/beta cells (about 7% of cells): Secrete TSH, LH, FSH and MSH
• Chromophobic cells (50%), which do not take the colour of stain: Resting cells,
no secretion
 FIG. 19.6 Structure of pituitary gland (highly schematic diagram).

Intermediate lobe (pars intermedia):

It is made up of numerous basophilic and chromophobic cells. The cells are arranged in
the form of small follicles containing colloid material.

Posterior lobe (pars posterior/nervosa):

It consists of:

• Large number of nonmyelinated nerve fibres.

• Modified neuroglial cells called pituicytes.
• Presence of Herring bodies, the small, spherical masses that stain deeply with
chrome–alum haematoxylin.

Blood supply

Arterial supply:

Venous drainage: Small short veins emerge from the surface of gland and drains
into neighbouring dural venous sinuses.

Nerve supply
By hypothalamo-hypophyseal tract, which arises from preoptic and paraventricular nuclei
of hypothalamus.

Development AN43.4
The pituitary gland develops from two distinct sources:
 • Adenohypophysis develops from Rathke’s pouch – an ectodermal diverticulum
(outpocketing) from the roof of stomodeum that grows cranially in front of
buccopharyngeal membrane.
• Neurohypophysis develops from infundibulum – a downgrowth from the floor
of 3rd ventricle.

Applied anatomy
The pituitary gland produces number of hormones that control the secretions of other
endocrine glands of the body.

• Pituitary adenoma: It is not uncommon. It compresses the central part of optic

chiasma leading to bitemporal hemianopia (tunnel vision). (For details, see
Textbook of Anatomy: Head, Neck and Brain, Volume III, 3rd edition, p. 329 by
Vishram Singh.) AN30.5
• Gigantism and acromegaly: The gigantism occurs due to excessive secretion of
growth hormone (GH) before adolescence; hence, the person becomes very tall
(8–9 feet) due to excessive length of the bone. The acromegaly occurs due to
excessive secretion of GH in adults leading to coarse facial features with
protrusion of jaw (prognathism).
• Pituitary dwarfism: Occurs due to hyposecretion of GH causing shortening of
limbs.
20

Cranial nerves
❖ Enumerate the various cranial nerves. AN30.2, AN62.1
There are 12 pairs of cranial nerves. They are serially numbered from 1 to 12 in
craniocaudal order of their attachment on the surface of the brain and designated by
Roman numerals as follows:

• Olfactory (I)
• Optic (II)
• Oculomotor (III)
• Trochlear (IV)
• Trigeminal (V)
• Abducent (VI)
• Facial (VII)
• Vestibulocochlear (VIII)
• Glossopharyngeal (IX)
• Vagus (X)
• Accessory (XI)
• Hypoglossal (XII)

❖ Describe the olfactory nerve in brief.

The olfactory nerve consists of about a dozen filaments, which represent the central
processes of the bipolar neurons present in the olfactory epithelium. It is a sensory
nerve and carries sense of smell.

Functional component

• Special somatic afferent fibres

Origin and course

The cell bodies of the olfactory nerves are located in the olfactory epithelium of nasal
mucosa. The olfactory nerve begins as a dozen of filaments representing axons of
bipolar neurons from the olfactory mucosa of the nasal cavity. These filaments pass
through the cribriform plate of ethmoid to synapse within olfactory bulb in the anterior
cranial fossa.

N.B. Olfactory pathway:

The olfactory bulb leads posteriorly to the olfactory tract, which lies on inferior
surface of the frontal lobe of cerebral hemisphere and conveys fibres to the prepyriform
cortex, anterior perforating substance and septal area.

Applied anatomy
The lesions of olfactory nerve result in loss of smell, which is called anosmia. The sense
of smell is also responsible for the finer appreciation of taste of the food.

❖ Describe the optic nerve in brief and mention its unique features.
The optic nerve is the nerve of sight, i.e. vision.

Functional components

• Special somatic afferent fibres for the special sense of sight.

Origin and course

The optic nerve extends from eyeball to the optic chiasma, which lies above the
pituitary fossa containing pituitary gland. Its fibres arise from the retina and leave the
eyeball at the optic disc. The fibres arising from nasal half of retina decussate in optic
chiasma with that of the opposite side and then course along the optic tract of the
opposite side, whereas those arising from temporal half of retina do not decussate in the
optic chiasma and thus run in the optic tract of the same side. The fibres of the optic
tract relay in the lateral geniculate body.

Unique features of optic nerve

• It is not a true peripheral nerve, rather it is a tract of the forebrain.

• It is surrounded by meninges, i.e. dura mater, arachnoid mater and pia mater,
and thus by a subarachnoid space containing CSF.
• Its fibres are myelinated by oligodendrocytes and not by Schwann cells. (cf. The
fibres of peripheral nerves are myelinated by the Schwann cells.)
• It cannot regenerate if damaged.

Applied anatomy
The damage of optic nerve leads to complete blindness on the side of lesion.

❖ Describe the oculomotor nerve under the following headings: (a) functional
components, (b) origin, course and distribution and (c) applied anatomy. AN31.5,
AN30.2
The oculomotor nerve is purely motor and responsible for the movements (largely) and
accommodation of the eye.

Functional components (fig. 20.1)

 • General somatic efferent (GSE) fibres, to supply the extrinsic muscles of eyeball.
They arise from large somatic component of oculomotor nucleus.
• General visceral efferent (GVE) fibres, to supply the intrinsic muscles of eyeball
(ciliaris and sphincter pupillae). They arise from small parasympathetic
component of oculomotor nucleus (Edinger–Westphal nucleus).
• General somatic afferent (GSA) fibres, to carry proprioceptive sensations from the
muscles (vide supra).

FIG. 20.1 A, Nuclei and functional components of oculomotor nerve. B, Distribution of

oculomotor nerve.

Origin, course and distribution (fig. 20.1)

The oculomotor nerve arises from oculomotor nucleus, located in the upper part of the
midbrain. The nerve emerges from midbrain in the interpeduncular fossa, then runs
between the posterior cerebral and superior cerebellar arteries, and passes on to the
lateral side of the posterior communicating artery. Now it runs forwards and upwards
piercing the dura mater near the posterior clinoid process and travels forwards in the
lateral wall of the cavernous sinus. After emerging from cavernous sinus, it divides into
upper and lower divisions which enter the orbit through superior orbital fissure where:

• The upper division supplies superior rectus of the eyeball and levator palpebrae
superioris.
• The lower division supplies medial rectus, inferior rectus, and inferior oblique
of the eyeball. The nerve to inferior oblique gives a motor root to the ciliary
ganglion.

N.B.
The preganglionic parasympathetic fibres (GVE fibres) arise from Edinger–Westphal
nucleus, and run successively through the undivided trunk, lower division of
oculomotor nerve and nerve to inferior oblique to relay in the ciliary ganglion. The
postganglionic parasympathetic fibres from ganglion run through short ciliary nerves
to supply ciliary and sphincter pupillae muscles of the eyeball.

Applied anatomy
The lesion of oculomotor nerve (infranuclear lesion) leads to:

• Ptosis, due to paralysis of levator palpebrae superioris

• Loss of accommodation, due to involvement of ciliaris muscle
• Lateral squint, due to paralysis of medial rectus muscle and unopposed action
of healthy lateral rectus
• Diplopia, due to paralysis of medial rectus muscle
• Dilatation of pupil, loss of pupillary reflex, due to paralysis of sphincter
pupillae

Note: In paralysis of oculomotor nerve, the person cannot look upwards, downwards
and medially.

❖ Describe trochlear nerve in brief. AN31.5, AN30.2

Trochlear nerve is the smallest cranial nerve.

Functional components

• General somatic efferent (GSE) fibres to supply superior oblique muscle of the
eyeball.
• General somatic afferent (GSA) fibres to carry proprioceptive fibres from superior
oblique to mesencephalic nucleus of CN V.

Origin, course and distribution

The trochlear nerve arises from 4th nerve nucleus located in the lower part of the
midbrain. Before emerging on the dorsal aspect of midbrain, its fibres decussate with
the fibres of nerve of opposite side. After emerging, it passes forward in the
subarachnoid space and pierces the dura mater to run in the lateral wall of the
cavernous sinus. The nerve enters the orbit through superior orbital fissure and
supplies the superior oblique muscle of the eyeball.

Applied anatomy
The damage of trochlear nerve causes diplopia on looking downwards and laterally.

❖ Describe trigeminal nerve under the following headings: (a) functional

components, (b) origin and course, (c) distribution and (d) applied anatomy. 
AN30.2, AN33.1
Trigeminal nerve is a mixed nerve but mainly sensory.

Functional components

• Special visceral efferent (SVE) fibres to muscles of mastication.

• General somatic afferent (GSA) fibres to carry:
■ Pain and temperature sensations from the head and face
 ■ Proprioceptive sensations from the muscles of mastication

Origin and course

It arises by two roots:

• The large sensory root arises from sensory nuclei of the trigeminal nerve located in
the brainstem and upper part of the spinal cord.
• The small motor root arises from motor nucleus of the trigeminal nerve located in
the pons.

The sensory and motor roots emerge from the anterior surface of the pons, the motor
root lying medial to the sensory root. After emerging from brainstem, the nerve passes
upwards, forward and laterally in the posterior cranial fossa. On reaching the
depression on the apex of petrous temporal bone in the middle cranial fossa, it expands
to form the trigeminal ganglion. (Remember motor root passes deep to the ganglion,
whereas sensory root forms the ganglion.)
The anterior border of the trigeminal ganglion gives rise to three divisions of the
trigeminal nerve:

• Ophthalmic division: It is purely sensory and enters the orbit through superior
orbital fissure.
• Maxillary division: It is purely sensory and enters the pterygopalatine fossa
through foramen rotundum.
• Mandibular division: It enters the infratemporal fossa through foramen ovale. It is
joined by the motor root (which also passes through foramen ovale) just below
this foramen. Hence, it is both sensory and motor.

Distribution

Sensory distribution:
■ Most of the skin of the head and face
■ Mucous membrane of nasal cavities, oral cavity and paranasal air sinuses
■ Teeth of both the jaws
■ Cornea and conjunctiva of the eye
Motor distribution: Muscles of the mastication

Applied anatomy
Trigeminal neuralgia (tic douloureux): A clinical condition characterized by intermittent
attacks of severe lancinating pain in the region of sensory distribution of one or more
divisions of trigeminal nerve in face, usually the 2nd and 3rd divisions (Fig. 20.2).
 FIG. 20.2 Sensory distribution of trigeminal nerve on face.

The pain is so intense that it makes the patient to screw up his/her face.

❖ Describe the origin, course and distribution of the mandibular nerve. AN30.2,

AN33.1
It is described on p. 177 and 178.

❖ Describe the origin, course and distribution of the maxillary nerve. AN30.2,

AN33.1
It is described on p. 186 and 187.

❖ Describe the origin, course and distribution of the ophthalmic nerve. AN30.2,

AN33.1
It is described on p. 200 and 201.

❖ Write a short note on nuclei of trigeminal nerve. AN58.3, AN59.3, AN62.1

The trigeminal nerve has the following four nuclei:

1. Principal sensory nucleus lies in the dorsolateral region of the tegmentum of

upper part of the pons lateral to the motor nucleus of trigeminal nerve. It
receives all sensory fibres of trigeminal nerve.
2. Mesencephalic nucleus lies in the midbrain above the main sensory nucleus. It
receives proprioceptive impulses from muscle of mastication, TMJ and teeth.
 3. Spinal nucleus lies in the spinal cord below main sensory nucleus. It receives
pain and temperature sensations from face.
4. Motor nucleus lies in the upper part of bones. It gives motor fibres to muscles of
mastication.

❖ Describe the abducent nerve under the following headings: (a) functional
components, (b) origin, course and distribution and (c) applied anatomy. AN31.5,
AN62.1
The abducent is CN VI. It is purely a motor nerve and supplies only one muscle – the
lateral rectus of the eyeball.

Functional components

• General somatic efferent (GSE) fibres to supply lateral rectus. They arise from
abducent nucleus in the lower part of the pons.
• General somatic afferent (GSA) fibres, which carry proprioceptive sensation from
lateral rectus to the mesencephalic nucleus of the trigeminal nerve.

Origin, course and distribution (fig. 20.3)

The abducent nerve arises from abducent nucleus in the lower part of the pons, and
emerges from anterior surface of brainstem at the junction of the pons and medulla
oblongata. After emerging from brain, it runs at first upwards, forwards and laterally in
the posterior cranial fossa and pierces the dura mater over the clivus. It then turns
sharply forwards, crossing the sharp superior border of the petrous temporal bone
before entering the cavernous sinus. It traverses the cavernous sinus, lying at first
lateral and then inferolateral to the internal carotid artery. The nerve enters the orbital
cavity through the superior orbital fissure and supplies the lateral rectus muscle.
 FIG. 20.3 Origin, course and distribution of abducent nerve.

Applied anatomy
The abducent nerve is a thin motor nerve that takes the longest intracranial course, and
hence it is often damaged in increased intracranial pressure associated with coning of
the brainstem.
The paralysis of abducent nerve results in:

• Medial squint
• Diplopia

❖ Describe the facial nerve under the following headings: (a) functional
components, (b) origin and course, (c) branches and distribution and (d) applied
anatomy. AN62.1, AN28.4, AN28.7
The facial nerve is the CN VII. It is a mixed cranial nerve (i.e. motor and sensory) but
predominantly motor.

Functional components

• Special visceral efferent (SVE) fibres to supply the muscles of facial expression, etc.
• General visceral efferent (GVE) fibres to supply the lacrimal, submandibular and
sublingual salivary glands.
• Special visceral afferent (SVA) fibres, which carry taste sensations from anterior
two-third of the tongue, except those from vallate papillae.
• General somatic afferent (GSA) fibres, which carry general sensation from concha
of the external ear.

Origin and course (fig. 20.4)

The facial nerve has two roots: (a) a large medial motor root and (b) a small lateral,
sensory root – the nervus intermedius.
 FIG. 20.4 Origin, course and distribution of facial nerve. T, temporal; Z, zygomatic; UB, upper
buccal; LB, lower buccal; M, mandibular; C, cervical.

The motor root arises from motor nucleus of facial nerve in the pons. The sensory root
(nervus intermedius) arises from nucleus tractus solitarius, and superior salivatory and
lacrimatory nuclei in the pons.
The two roots of facial nerve emerge on the anterior surface of the brainstem at the
lower border of the pons. They pass forwards and laterally in the posterior cranial fossa
along with vestibulocochlear nerve and enter the internal acoustic meatus. At the distal
end of internal acoustic meatus, the two roots join to form a single nerve. At the bottom
of meatus, the nerve enters the facial canal. Now, it takes a dubious course in the facial
canal through temporal bone and comes out of skull through stylomastoid foramen.
Now it winds around the lateral aspect of styloid process to enter the parotid gland,
where it divides into five terminal branches.

Branches and distribution (fig. 20.4)

In the facial canal:

■ Greater petrosal nerve, which joins the deep petrosal nerve to form the nerve of
pterygoid canal (Vidian’s nerve). This nerve carries parasympathetic
secretomotor fibres to the lacrimal, nasal and palatine glands.
■ Nerve to stapedius.
■ Chorda tympani nerve: It arises about 5 cm above the stylomastoid foramen
and joins the lingual nerve in the infratemporal fossa. The chorda tympani
 nerve serves the following functions:
■ Carries taste sensations from the anterior two-third of the tongue,
except from vallate papillae.
■ Supplies secretomotor fibres to the submandibular and sublingual
salivary glands.
At the stylomastoid foramen (after emerging from facial canal):
■ Nerve to posterior belly of digastric
■ Nerve to stylohyoid
■ Posterior auricular nerve to supply occipital belly of occipitofrontalis
In the parotid gland, it gives rise to five terminal branches to supply muscles of
facial expression:
■ Temporal
■ Zygomatic
■ Buccal (upper and lower buccal)
■ Mandibular
■ Cervical

Applied anatomy

• Facial nerve paralysis:

The effects of paralysis of CN VII depend on the site of lesion. The complete
paralysis of facial nerve manifests as follows:
1. Loss of lacrimation due to involvement of lacrimal nerve and inability
to close the eye to paralysis of orbicularis oculi. This leads to:
a. Inability to close the eye on affected side due to paralysis of
orbicularis oculi.
b. Exposing cornea to the air and loss of lacrimation due to
involvement of secretomotor fibres to this gland, which leads to
corneal dryness and keratitis.
2. Angle of mouth goes down and dribbling of saliva due to paralysis of
orbicularis oris.
3. Accumulation of food bolus in the vestibule of the mouth on the
affected side due to paralysis of buccinator muscle.
4. Speech becomes defective due to paralysis of lip muscles.
5. Hyperacusis as a result of loss of control of movements of stapes
following paralysis of stapedius.
6. Loss of taste sensations in the anterior two-third of tongue, due to
paralysis of chorda tympani nerve.
• Bell palsy: It is lower motor neuron type of facial palsy, which occurs due to
compression of facial nerve into the facial canal just above the stylomastoid
foramen following its inflammation and swelling, probably due to viral
infection.

Clinical features (fig. 20.5)

 ■ Facial asymmetry, i.e. face of the paralysed side is pulled to the
opposite/healthy side
■ Loss of wrinkles on the forehead
■ Inability to close the eye causing wide palpebral fissure
■ Inability of angle of mouth to move up during laughing
■ Loss of nasolabial furrow
■ Accumulation of food in the vestibule mouth
■ Dribbling of saliva from the angle of mouth
■ Inability to inflate/blow the cheek properly

FIG. 20.5 Bell palsy.

❖ Briefly describe vestibulocochlear nerve.

It is nerve of hearing and balance (i.e. special sense).
It consists of two parts: vestibular and cochlear. Both are purely sensory.
The vestibular nerve helps in maintaining the balance, whereas cochlear nerve carries
sense of hearing.
The cochlear nerve carries sensations from spiral organ of Corti within the cochlear
duct of internal ear. It is formed by the central processes of nerve cells of spiral ganglion
of the cochlea. It comes out of temporal bone through the internal acoustic meatus, and
reaches the lower border of the pons. Here, it enters the pons to end in ventral and
dorsal cochlear nuclei situated on the ventral and dorsal aspects of the inferior
cerebellar peduncle, respectively.
The vestibular nerve carries sensations from maculae of utricle and saccule, and
cristae ampullaris of semicircular ducts of the internal ear. It is formed by the central
processes of nerve cells of vestibular ganglion in the distal part of the external acoustic
meatus. It passes into the cranial cavity through internal acoustic meatus, and reaches
the lower border of the pons, where it enters the pons to end in the vestibular nuclei
located in the floor of 4th ventricle.

N.B.
On the surface of brain, the vestibulocochlear nerve emerges at the lower border of
pons in the region of cerebellopontine angle and traverses the subarachnoid space to
enter the internal acoustic meatus.

❖ Describe the glossopharyngeal nerve under the following headings: (a) functional
components, (b) origin and course, (c) branches and distribution and (d) applied
anatomy. AN35.7
The glossopharyngeal nerve is CN IX. It is a mixed nerve (motor and sensory) but
predominantly sensory.

Functional components

• Special visceral efferent (SVE) fibres to supply the stylopharyngeus muscle.

• General visceral efferent (GVE) fibres, which supply the secretomotor fibres to the
parotid gland.
• Special visceral afferent (SVA) fibres, which carry taste sensations from posterior
one-third of the tongue including vallate papillae.
• General visceral afferent (GVA) fibres, which carry general sensations from skin of
the auricle.

Origin and course (fig. 20.6)

The glossopharyngeal nerve arises from its nuclei in the brainstem and emerges on
surface from the lateral aspect of the medulla in the groove between olive and inferior
cerebellar peduncle and enters the jugular foramen. After emerging from jugular
foramen, it descends vertically between the internal jugular vein and internal carotid
artery for some distance, then curves around the lateral surface of the stylopharyngeus,
and passes forward into the tongue.

N.B.
In the jugular foramen, it has two small sensory ganglia (superior and interior).
 FIG. 20.6 Course and distribution of glossopharyngeal nerve.

Branches and distribution (fig. 20.6)

• Tympanic nerve (Jacobson’s nerve), carrying secretomotor fibres to the parotid

gland
• Nerve to stylopharyngeus
• Pharyngeal branch to the pharyngeal plexus
• Sinus nerve to carotid sinus and carotid body
• Terminal branches to the posterior one-third of the tongue including vallate
papillae, tonsil, soft palate and epiglottis

Applied anatomy
The paralysis of glossopharyngeal nerve leads to loss of gag reflex and loss of general
and taste sensations in the posterior one-third of the tongue.
The glossopharyngeal nerve is tested clinically by:

• Eliciting gag reflex: The tickling of posterior wall of oropharynx/soft

palate/tonsillar region causes reflex contraction of pharyngeal muscles leading
to gagging and retching.
■ Note: The afferent limb of gag reflex is formed by the glossopharyngeal
nerve, while its efferent limb is formed by the vagus nerve.
• Testing sensations (general and taste) in the posterior one-third of the tongue
 including vallate papillae.

❖ Describe the origin, course and branches of the vagus nerve in the neck. AN35.7
The vagus nerve is CN X. It is the longest cranial nerve and has a vague course.

Origin and course

The vagus nerve arises from nuclei within the brainstem and emerges on surface from
the lateral aspect of medulla in the groove between olive and inferior cerebellar
peduncle, and comes out of cranial cavity through jugular foramen. After emerging
from cranial cavity, it descends vertically between internal jugular vein and internal
carotid artery. At the root of neck, the nerve enters the thorax. The right vagus nerve
enters the thorax by crossing in front of right subclavian artery, while the left vagus
nerve does so by passing between left common carotid and left subclavian arteries.

Branches of vagus nerve in the neck

• Meningeal branch to dura mater of posterior cranial fossa

• Auricular branch (Aldermen’s nerve/Arnold’s nerve) to the skin of external
acoustic meatus
• Pharyngeal branch to pharyngeal plexus
• Superior laryngeal nerve
• Recurrent laryngeal nerve (on the right side only)
• Cardiac branches (cervical)

❖ Describe the origin, course, distribution and applied anatomy of the accessory
nerve. AN35.7
The accessory nerve is the CN XI. It is purely a motor nerve and consists of two roots –
cranial and spinal.

Origin and course

• The cranial root arises from nucleus ambiguus in the medulla oblongata. It
emerges on the surface of medulla between olive and inferior cerebellar
peduncle.
• The spinal root arises from the upper five cervical spinal segments.
• The spinal root ascends to enter the cranial cavity through foramen magnum. It
then turns laterally to join the cranial root. The united roots leave the skull
through the jugular foramen, but just outside the foramen they separate again.

Distribution
The spinal root descends in the neck to supply the sternocleidomastoid and trapezius
muscles. The cranial root joins the vagus and is distributed through its branches.
The distribution of cranial root of accessory nerve is as follows:
 • It supplies all the muscles of palate through pharyngeal plexus except tensor
tympani, which is supplied by mandibular nerve.
• It supplies all the muscles of pharynx through pharyngeal plexus except
stylopharyngeus, which is supplied by glossopharyngeal nerve.
• It supplies all the intrinsic muscles of larynx through superior and recurrent
laryngeal nerves (branches of vagus nerve).

Applied anatomy
The lesion of accessory nerve leads to paralysis of sternocleidomastoid and trapezius. It
is tested clinically:

• By asking the patient to shrug his/her shoulder (trapezius) against the

resistance.
• By asking the patient to turn his/her face to the opposite side
(sternocleidomastoid) against the resistance.

❖ Describe the hypoglossal nerve under the following headings: (a) functional
components, (b) course and relations, (c) branches and distribution and (d) applied
anatomy.   AN35.7, AN39.2
The hypoglossal nerve is CN XII. It is purely a motor nerve.

Functional components

• General somatic efferent (GSE) fibres to supply the muscles of the tongue.

Course and relations (fig. 20.7)

The hypoglossal nerve arises from hypoglossal nucleus located in the upper part of the
medulla oblongata. It emerges from the anterior surface of the medulla between the
olive and pyramid as 10–15 rootlets. The fibres run anterolaterally and leave the
posterior cranial fossa through the hypoglossal canal (anterior condylar canal). After
emerging from skull, it runs vertically downwards between the internal jugular vein
and internal carotid artery.
 FIG. 20.7 Course and distribution of hypoglossal nerve.

At the lower border of digastric (i.e. at the level of angle of mandible), the nerve
curves forward horizontally, crossing in front of internal and external carotid arteries,
hooking round the origin of occipital artery, crossing in front of loop of lingual artery,
and then runs on the superficial surface of hyoglossus. At the anterior border of
hyoglossus muscle, it enters the genioglossus and breaks up into terminal branches.

Branches and distribution (fig. 20.7)

• Branches of the hypoglossal nerve proper: They supply all the muscles of tongue
(intrinsic and extrinsic) except palatoglossus, which is supplied by the cranial
root of accessory via pharyngeal plexus.
• Branches of hypoglossal nerve containing C1 fibres:
■ The ventral ramus of 1st cervical nerve, C1 joins the hypoglossal nerve
below the skull. The fibres of C1 are distributed through the following
branches of hypoglossal nerve as follows:
■ Meningeal branchn
■ Descendens hypoglossi/superior root of ansa cervicalisn
■ Nerve to thyrohyoidn
■ Nerve to geniohyoid

Applied anatomy
The lesion of hypoglossal nerve leads to paralysis of all the muscles of tongue on the
side of the lesion. This leads to deviation of tongue on the side of lesion on protruding
the tongue.
Clinical Testing: The hypoglossal nerve is tested clinically by asking the patient to
protrude his/her tongue.
In the lesion of hypoglossal nerve, the protruded tongue deviates to the same side, i.e.
side of lesion. Thus, the deviated position of protruded tongue indicates the side of
lesion.
21

Meninges and cerebrospinal fluid

❖ Give a brief account of the meninges. AN56.1
The brain and spinal cord are enclosed in three protective membranes called meninges.
From outwards to inwards these are (i) dura mater, (ii) arachnoid mater and (iii) pia
mater.
The dura mater is mesodermal in origin, while arachnoid and pia mater are
ectodermal in origin.

Dura mater
The dura mater is the thick outermost covering of the brain and spinal cord. The part
enclosing the brain is called cranial/cerebral dura, while the part enclosing the spinal cord
is called spinal dura. It is very tough, opaque, inelastic membrane of fibrous tissue
(Greek, dura = tough, mater = mother). It is also called pachymeninx (pachy = thick).

Arachnoid mater
The arachnoid mater (Greek, arachnoid = cobweb like, mater = mother) is a delicate
avascular membrane deep to dura mater. Many thread-like trabeculae extend from its
inner aspect to the pia mater.

Pia mater
The pia mater (Greek, pia = tender, mater = mother) is a thin, transparent, vascular
membrane, closely adherent to the surface of the brain and spinal cord.
The arachnoid mater and pia mater together are termed leptomeninges (lepto = thin).

❖ Describe subarachnoid cisterns in brief. AN56.2

The subarachnoid space is the space between the arachnoid mater and pia mater. It
surrounds the CNS. The subarachnoid space around the brain is continuous with the
subarachnoid space around the spinal cord. In the region of brain, it communicates with
the ventricular system of brain.

Subarachnoid cisterns
In certain situations, the subarachnoid space around the brain enlarges to form pools of
cerebrospinal fluid (CSF) called subarachnoid cisterns.
The principal subarachnoid cisterns are (Figs 21.1 and 21.2):

Cerebellomedullary cistern: It is largest cistern (also called cisterna magna) and

lies in triangle formed by cerebellum, medulla oblongata and occipital bone. It
 receives the CSF from 4th ventricle through a foramen Magendie and foramina
of Luschka.
Pontine cistern: It lies on the ventral aspect of the pons and contains basilar artery.
Interpeduncular cistern (basal cistern): It lies in the region of interpeduncular
fossa and contains circle of Willis.
Cistern of lateral sulcus (Sylvian cistern): It occupies the lateral sulcus and
contains middle cerebral artery.
Cistern of great cerebral vein (cisterna ambiens): It occupies the interval between
splenium of corpus callosum and superior surface of cerebellum.

FIG. 21.1 Sagittal section of the brain showing location of principal subarachnoid cisterns.
 FIG. 21.2 Circulation of cerebrospinal fluid from its sites of formation in the choroid plexuses
of lateral ventricle to its sites of absorption into the superior sagittal sinus. Note the location of
various cisterns.

❖ Describe the cerebrospinal fluid under the following headings: (a) formation, (b)
circulation, (c) absorption, (d) functions and (e) applied anatomy. AN56.2
The cerebrospinal fluid (CSF) is a modified tissue fluid similar to blood plasma and
interstitial tissue fluid. It is present in the ventricles of brain and subarachnoid space
around the brain and spinal cord.

Formation (fig. 21.2)

• The bulk of the CSF (80%–90%) is formed by choroid plexuses of lateral

ventricles.
• The small amount is formed by choroid plexuses of 3rd and 4th ventricles.
• In an adult, the total quantity of CSF is about 150 mL, out of which only 30 mL
lies in the ventricular system.

Circulation (fig. 21.2)

It is given in the form of flowchart given below:
Absorption (fig. 21.2)
The CSF is chiefly absorbed through the arachnoid villi and arachnoid granulations into
the superior sagittal sinus.
It is also absorbed partly by the perineural lymphatics around the cranial and spinal
nerves and also via pial veins.

Functions

• Provides protection to the CNS.

• Provides nutrition to the CNS.
• Removes waste products from the CNS.

Applied anatomy

• Withdrawal of CSF: The CSF can be obtained by lumbar puncture, cisternal

puncture and ventricular puncture for diagnostic and therapeutic purposes.
• Hydrocephalus: The excessive accumulation of CSF within the skull due to
either obstruction to the flow of CSF in the ventricular system or impairment of
its absorption into the intracranial dural venous sinuses through arachnoid
granulations, leads to hydrocephalus in children and raised intracranial
pressure in adults.

The characteristic clinical features of hydrocephalus are (Fig. 21.3) as follows:

■ Abnormally large head

■ Bossing of forehead
■ Wide, tense anterior fontanelle
■ ‘Setting-sun appearance’ of the eyes
■ Thin scalp with dilated scalp veinsn
■ Cracked-pot sound on skull percussionn
■ Dementia
FIG. 21.3 Clinical features of hydrocephalus in infants and young children.
22

Spinal cord
❖ What is spinal cord? List its functions. AN57.2
The spinal cord is a long lower cylindrical part of the central nervous system. It is about
45 cm long and lies in the upper two-third of the vertebral canal. It extends from the
lower border of medulla oblongata to the lower border of L1 vertebra. It encloses the
central canal of spinal cord which cntains CSF. It gives off 31 pairs of the spinal nerves.

Functions

• Transmission of sensory information from most of the body to the brain

• Transmission of motor information from the brain to the body
• Execution of simple reflexes

❖ Enumerate the main ascending and descending tracts present within the spinal
cord. AN57.4
In each half of the spinal cord, the white matter is divided into three regions called white
columns.
The important ascending and descending tracts in each white column of spinal cord
are given in Table 22.1.

TABLE 22.1
Ascending and Descending Tracts in White Columns
 The main ascending and descending tracts as seen in the transverse section of the
spinal cord are shown in Fig. 22.1.

FIG. 22.1 Transverse section of the spinal cord at mid-cervical region showing main
descending (motor) tracts in the left half and ascending (sensory) tracts in the right half of the
spinal cord.

❖ Enumerate the arteries supplying the spinal cord. AN57.1

The spinal cord is supplied by the following arteries.

Anterior spinal artery

It is the artery formed by union of anterior spinal branches of the vertebral arteries. It
descends on the front of the spinal cord in the anterior median fissure.

Posterior spinal arteries

These are two posterior spinal arteries, one on each side. They are the branches of
vertebral arteries. Each posterior spinal artery divides into two branches, which
descend one on either side of the dorsal nerve roots of corresponding side in the
posterolateral sulcus.

Radicular arteries (segmental arteries)

They run along the spinal nerve roots to reach the spinal cord. Their sources of origin
vary in the different regions. From above downwards, they are branches of the deep
cervical and ascending cervical in cervical region, posterior intercostals in thoracic
region and subcostal and upper lumbar arteries.

N.B.
The anterior spinal artery supplies the anterior two-third of the spinal cord, while the
posterior spinal arteries supply the posterior one-third of the spinal cord.

The segmental/radicular arteries at the level of T1 and T11 spinal segments are very
large and are termed arteria radicularis magna.

❖ Write a short note on cauda equina. AN57.1

It is a leash of nerve roots of lumbar (except L1), sacral and coccygeal nerves around the
filum terminale (Fig. 22.2). It is called cauda equina because of its fancied resemblance
to the tail of a horse (cauda = tail, equina = horse).
 FIG. 22.2 Lower end of the spinal cord with filum terminale and lumbar, sacral and coccygeal
nerve roots. The spinal nerve roots forming the cauda equina are encircled.

N.B.
The filum terminale is a silvery white, glistening, thin, thread-like prolongation of pia
mater extending from the tip of lower conical end of the spinal cord (tip of conus
medullaris) to the dorsal aspect of first piece of the coccyx.

❖ Write a short note on the lateral spinothalamic tract. AN57.4

It is a part of spinothalamo-cortical pathway. It carries pain and temperature
sensations from the opposite side of the body to the brain (Fig. 22.3).

• First-order neurons are found in the dorsal root ganglia. Their central processes
(axons) enter the spinal cord through the lateral division of the dorsal root of
spinal nerve and relay in the posterior horn of spinal cord.
• Second-order neurons are found in the posterior horn. Their axons cross to the
opposite side in the anterior white commissure and ascend in the contralateral
white column (lateral spinothalamic tract). These axons terminate in the thalamus
(ventral posterolateral [VPL] nucleus).
• Third-order neurons are found in the VPL nucleus of thalamus. They project
through the posterior limb of internal capsule to the primary somatosensory
cortex (Brodmann areas 3, 1 and 2).
 FIG. 22.3 Lateral and anterior spinothalamic tracts.

Applied anatomy
The damage of the lateral spinothalamic tract results in contralateral loss of pain, touch
(simple/crude) and temperature sensations.

❖ Write a short note on the ventral spinothalamic tract. AN57.4

The ventral spinothalamic tract carries light/simple touch (crude touch), pressure and
itching sensations from the opposite half of the body.
The course of this tract is same as that of lateral spinothalamic tract, except that the
second-order neurons after crossing to the opposite side ascend in the contralateral
ventral white column of the spinal cord (Fig. 22.3).

Applied anatomy
The damage of ventral spinothalamic tract leads to loss of light touch (crude touch) and
pressure on the opposite side of the body below the level of lesion.

N.B.
The discriminative touch (fine touch) will still be present because it is carried by
fasciculus gracilis and fasciculus cuneatus – the tracts in the posterior white column of
the spinal cord.

❖ Write a short note on the dorsal column–medial lemniscal pathway. AN57.4

The dorsal column–medial lemniscal pathway carries proprioceptive sensations (e.g.
muscle and joint sense, fine touch, vibration sensations) from the opposite side of the
body.

• First-order neurons are located in the dorsal root ganglia. Their axons enter the
spinal cord through medial root of the spinal nerves, ascend in the ipsilateral
dorsal white column as fasciculus gracilis and fasciculus cuneatus, and
terminate in gracile and cuneate nuclei, respectively, located in the caudal part
of medulla.
• Second-order neurons are located in the gracile and cuneate nuclei of medulla.
Their axons (internal arcuate fibres) decussate with those of opposite side in the
midline. After decussation, they form a compact fibre bundle (medial
lemniscus), which ascends in the contralateral half of brainstem and terminate
in the ventral posterolateral (VPL) nucleus of thalamus.
• Third-order neurons are located in the VPL nucleus of thalamus. Their axons
project to the primary somatosensory cortex (areas 3, 1 and 2; Fig. 22.4).
 FIG. 22.4 Posterior column–medial lemniscal pathway.

Applied anatomy
The damage of dorsal column–medial lemniscal pathway above the sensory decussation
causes contralateral loss of proprioceptive sensations, while below the sensory
decussation it causes ipsilateral loss of proprioceptive sensations.

❖ Describe the corticospinal (pyramidal) tract in brief and discuss its applied
anatomy. AN57.4
The pyramidal tract is a motor tract consisting of both corticospinal and corticonuclear
tracts. However, conventionally it refers to only corticospinal tract.

Origin, course and termination

• Most of the fibres of pyramidal tract arise from pyramidal cells of motor and
premotor areas (areas 4 and 6) of the cerebral cortex.
• These fibres descend and traverse the following parts of the CNS in succession,
viz. corona radiata, internal capsule (anterior two-third of the posterior limb and
genu), crus cerebri (middle three-fifth), basilar part of pons and pyramid of medulla.

Note that after emerging from pons, they condense to form pyramid-shaped bundles
in the upper part of the medulla oblongata.
In the lower part of medulla oblongata, about 70%–80% fibres of pyramidal tract
cross to the opposite side and then descend in the lateral white column of the spinal
cord on opposite side as lateral corticospinal/crossed pyramidal tract and terminate on
the anterior horn cells.
About 20%–30% fibres of pyramidal tract do not cross to the opposite side and
descend in as uncrossed pyramidal tract/anterior corticospinal tract in the anterior
white column of the spinal cord of same side. These fibres finally also cross to the
opposite side and terminate on the anterior horn cells (Fig. 22.5).

FIG. 22.5 Course and termination of the fibres of corticospinal tract. The inset on the right side
shows an abbreviated form of motor pathway. INN, internuncial neuron; LMN, lower motor
neuron; UMN, upper motor neuron.

Function
The pyramidal tract is concerned with voluntary movements of the body.

Applied anatomy

• Lesion of pyramidal tract: It produces upper motor neuron (UMN) type of

paralysis.

If the lesion is above the level of motor decussation, it causes spastic paralysis on the
opposite side of body, i.e. contralateral hemiplegia; while if the lesion is below the level
of motor decussation, it leads to ipsilateral hemiplegia.
 • Effects of upper and lower motor neuron type of paralysis: The lesions of
upper motor neurons (UMNs) leads to:
(a) Spasticitic paralysis
(b) Increased muscle tone
(c) Exaggeration of tendon reflexes
(d) No wasting of muscles except disuse atrophy.

The above signs and symptoms occur due to hyperactivity of LMNs, as the control of
UMNs on LMNs is lost.
The lesions of lower motor neurons (LMNs) leads to:

(a) Flaccid paralysis

(b) Decreased muscle tone
(c) Loss of tendon reflexes
(d) Wasting of muscle i.e. muscle atrophy

All these signs and symptoms occur due to loss of nerve supply of the muscle.

N.B.
UMNs don’t supply muscles directly but through LMNs.
SECTION III
Brain
OUTLINE

23. Overview of brain and brainstem

24. Cerebellum and fourth ventricle
25. Overview of cerebrum and functional areas
26. Cerebrum
27. Basal nuclei, limbic system and lateral ventricle
28. Diencephalon and third ventricle
23

Overview of brain and brainstem

Overview of brain
❖ Define brain and enumerate its major parts.
The brain is that part of the CNS, which lies within the cranial cavity (hence it is also
called cranial cargo). The brain weighs about 1400 g in males and 1200 g in females. The
brain is the highest centre for various sensory and motor functions of the body. It is also
the seat of intelligence, cognizance, memory, emotions, etc.

Major parts of the brain

The brain consists of six major parts (Fig. 23.1):

• Cerebrum consisting of two cerebral hemispheres.

• Diencephalon consisting of thalamus, hypothalamus, metathalamus,
subthalamus and epithalamus
• Midbrain
• Pons
• Medulla oblongata
• Cerebellum (Fig. 23.1)
 FIG. 23.1 Parts of central nervous system. Note 6 major parts of brain (labelled in bold).

Brainstem
❖ What is brainstem? Discuss its functions.
The brainstem is the stem-like lower part of brain consisting of three parts – midbrain,
pons and medulla oblongata.

Functions

• Provides passages to various ascending and descending tracts.

• Contains vital (autonomic) centres – cardiac centre, vasomotor centre and
respiratory centre.
• Contains reticular formation responsible for consciousness and sleep.
• Provides attachments to last 10 cranial nerves and contains their nuclei.

Medulla oblongata
❖ Enumerate the main structures seen in the transverse section of medulla oblongata
at the level of pyramidal decussation. AN58.2
The main structures seen in the transverse section of medulla oblongata at the level of
pyramidal decussation are (Fig. 23.2) as follows:

• Decussation of pyramidal tracts

• Appearance of nucleus gracilis and nucleus cuneatus
 • Formation of nucleus of spinal tract of trigeminal nerve
• Appearance of reticular formation
• Detachment of anterior horns due to decussation of pyramidal tracts

FIG. 23.2 Transverse section through the lower closed part of the medulla oblongata at the
level of pyramidal decussation.

❖ Enumerate the main structures seen in the transverse section of medulla oblongata
at the level of sensory decussation. AN58.2
The main structures seen in the transverse section of medulla oblongata at the level of
sensory decussation are (Fig. 23.3) as follows:

• Sensory decussation (decussation of arcuate fibres)

• Formation of medial lemnisci
• Formation of nucleus gracilis and nucleus cuneatus
• Formation of nucleus of spinal tract of trigeminal nerve
• Appearance of accessory cuneate nucleus
• Formation of central grey matter and nuclei within it (e.g. hypoglossal nucleus,
dorsal nucleus of vagus and nucleus tractus solitarius)
• Appearance of inferior olivary nucleus

FIG. 23.3 Transverse section of medulla oblongata at the level of sensory decussation.

❖ Enumerate the main structures seen in the transverse section of medulla oblongata
at the level of upper part of olives. AN58.2
The main structures seen in the transverse section of medulla oblongata at the level of
upper part of olives are (Fig. 23.4) as follows:
 • Fully developed inferior olivary nucleus.
• Appearance of medial and dorsal accessory olivary nuclei.
• Appearance of hypoglossal nucleus, dorsal nucleus of vagus and vestibular
nuclei underneath the floor of 4th ventricle.
• Appearance of nucleus ambiguus.
• Appearance of nucleus tractus solitarius.

FIG. 23.4 Transverse section of medulla at the level of upper parts of olives. 1, Medial
longitudinal fasciculus; 2, tectospinal tract; 3, medial lemniscus. NA, nucleus ambiguus.

❖ Write a short note on lateral medullary syndrome (posterior inferior cerebellar

artery syndrome of Wallenberg). AN58.4

Cause
Ischaemia of posterolateral part of medulla due to occlusion of posterior inferior
cerebellar artery (Fig. 23.5).
 FIG. 23.5 Transverse section of the upper part of the medulla. The red shaded areas indicate
the sites of lesions. 1, Dorsal nucleus of vagus; 2, nucleus of tractus solitarius; 3, vestibular
nuclei; 4, inferior cerebellar peduncle; 5, spinal tract of trigeminal nerve; 6, spinal nucleus of
trigeminal nerve; 7, descending sympathetic tract; 8, nucleus ambiguus; 9, lateral
spinothalamic tract; 10, inferior olivary nucleus; 11, hypoglossal nerve; 12, pyramidal tract; 13,
arcuate nucleus. M, medial lemniscus.

Clinical features

• Contralateral loss of pain and temperature in the body due to involvement of

spinothalamic tract.
• Ipsilateral loss of pain and temperature on the face due to involvement of
spinal nucleus and tract of CN V.
• Ipsilateral paralysis of palatal, pharyngeal and laryngeal muscles due to
involvement of nucleus ambiguus.
• Ipsilateral ataxia due to involvement of inferior cerebellar peduncle.
• Nausea and vertigo due to involvement of vestibular nuclei.

❖ Write a short note on medial medullary syndrome. AN58.4

Cause
Ischaemia of medial region of medulla due to thrombosis of anterior spinal artery (Fig.
23.5).

Clinical features

• Contralateral hemiplegia (UMN type of paralysis) due to involvement of

pyramid (pyramidal tract)
 • Ipsilateral paralysis of tongue due to involvement of hypoglossal nerve (LMN
type of paralysis)
• Contralateral loss of proprioceptive sensations due to involvement of medical
meniscus

Pons
❖ Enumerate the main structures seen in the transverse section of pons at the level of
facial colliculi. AN59.2
The main structures seen in the transverse section of pons at the level of facial colliculi
are (Fig. 23.6) as follows:

• Abducent nucleus
• Motor nucleus of facial nerve
• Internal genu of facial nerve
• Dorsal and ventral cochlear nuclei
• Trapezoid body

FIG. 23.6 Transverse section through the lower part of the pons. M, medial longitudinal
bundle; R, rubrospinal tract; T, tectospinal tract.

❖ Enumerate the main structures seen in the transverse section through the upper part
of the pons. AN59.2
The main structures seen in the transverse section through the upper part of the pons
are (Fig. 23.7) as follows:

• Chief (main) sensory nucleus of trigeminal nerve

• Motor nucleus of trigeminal nerve
• Mesencephalic root of trigeminal nerve
• Trigeminal lemniscus
• Lateral lemniscus
 FIG. 23.7 Transverse section through the upper part of the pons. M, medial longitudinal
bundle; R, rubrospinal tract; T, tectospinal tract.

❖ Write a short note on pontocerebellar angle syndrome.

Cause
Involvement of lateral region of caudal part of pons near pontocerebellar angle by
Schwannoma of CN VIII.

Clinical features

• Ipsilateral deafness due to involvement of cochlear nerve.

• Ipsilateral imbalance and asynergia due to involvement of vestibular nerve.
• Ipsilateral lower motor neuron type of facial palsy due to involvement of facial
nerve.
• Ipsilateral loss of pain and temperature on face due to involvement of spinal
nucleus and tract of CN V.

Midbrain
❖ Enumerate the main structures seen in the transverse section of midbrain at the
level of inferior colliculus. AN61.2
The main structures seen in the transverse section of midbrain at the level of inferior
colliculus are (Fig. 23.8) as follows:

• Decussation of superior cerebellar peduncles

• Trochlear nerve nucleus
• Mesencephalic nucleus of trigeminal nerve
• Termination of lateral lemniscus
• Nucleus of inferior colliculus
 FIG. 23.8 Transverse section of the midbrain at the level of inferior colliculi. M, medial
longitudinal fasciculus; R, rubrospinal tract; T, tectospinal tract.

❖ Enumerate the main structures seen in the transverse section of midbrain at the
level of superior colliculus. AN61.2
The main structures seen in the transverse section of midbrain at the level of superior
colliculus are (Fig. 23.9) as follows:

• Oculomotor nucleus
• Red nucleus
• Nucleus of superior colliculus
• Dorsal tegmental decussation (of Meynert)
• Ventral tegmental decussation (of Forel)

FIG. 23.9 Transverse section of the midbrain at the level of superior colliculi.

❖ Write a short note on medial longitudinal fasciculus/medial longitudinal

bundle. AN61.2
The medial longitudinal fasciculus (MLF) also called medial longitudinal bundle (MLB)
is an important association tract one on either side of median plane in the brainstem. It
extends cranially to the interstitial nucleus of Cajal (accessory oculomotor nucleus) and
caudally it becomes continuous with the intersegmental fasciculus of the spinal cord.

• It connects the nuclei of the cranial nerves that move the eyeballs and in this
way it coordinates the movements of both eyeballs.
• It connects the nuclei of the cranial nerves responsible for articulation, and in
this way it associates together the movements of the organs responsible for
articulation.
• It connects both the vestibular and cochlear nuclei with the nuclei of the nerves
of the eyeball and with the anterior horn cells of the spinal nerves; and in this
way, it associates movements of eyes and those of the body in response to
movements of the head or in response to the sound.

Functions

• Coordination of the conjugate movements of the eyeball.

• Coordination of the movements of head and neck in response to audiovisual
reflexes.
24

Cerebellum and fourth ventricle

❖ Define cerebellum and list its functions.
The cerebellum (Latin, cerebellum = little brain) is the largest part of the hindbrain and
second-largest part of the brain as a whole. It weighs about 150 g and is located in the
posterior cranial fossa underneath the tentorium cerebelli, behind the pons and medulla
oblongata.

Functions
The functions of cerebellum include:

• Maintenance of equilibrium
• Maintenance of muscle tone
• Maintenance of posture

N.B.
It was regarded as the head ganglion of the proprioceptive system by Sherrington.

❖ What are the parts of cerebellum? AN60.1

The cerebellum consists of three parts:

• Two large lateral hemispherical parts called cerebellar hemispheres.

• A narrow median worm-like part which unites two cerebellar hemispheres
called vermis.

❖ What are the anatomical lobes of the cerebellum? AN60.1

Anatomically, the cerebellum is divided into three lobes (Fig. 24.1):

• Flocculonodular lobe: It is the smallest lobe that comprises two flocculi and their
peduncles and the nodule. Together with the lingula of vermis, it forms the
vestibular part of the cerebellum (archicerebellum).
• Anterior lobe: It lies on the superior surface of cerebellum anterior to the fissura
prima excluding the lingula; together with the pyramid and uvula of vermis, it
forms the spinal part of the cerebellum (paleocerebellum).
• Middle (posterior) lobe: It is the largest lobe and lies between fissura prima on the
superior surface and posterolateral fissure on the inferior surface excluding the
pyramid and uvula of vermis. It forms the cerebral part of the cerebellum
(neocerebellum).
 FIG. 24.1 Anatomical functional and morphological subdivisions of the cerebellum. The organ
is being opened out (schematically) to show both superior and inferior surfaces together. The
parts seen above the horizontal fissure form the superior surface and those below the fissure,
inferior surface of the cerebellum. AL, ala; BL, biventral lobule; C, central lobule; CL, culmen;
D, declive; F, folium; ISL, inferior semilunar lobule; LS, lobulus simplex; P, pyramid; QL,
quadrate lobule; SSL, superior semilunar lobule; T, tuber; U, uvula.

❖ Enumerate the intracerebellar nuclei and discuss their connections. AN60.2

There are four intracerebellar nuclei on either side of the midline. From lateral to medial
side these are (Fig. 24.2) as follows:

• Dentate nucleus
• Nucleus emboliformis
• Nucleus fastigii
• Nucleus globosus
Dentate nucleus: It is the largest and has the shape of a crumpled bag (crenated
crescent) with its hilum facing anteromedially. It receives afferents from the
neocerebellum and sends efferents through the superior cerebellar peduncle to
the red nucleus of the opposite side, which in turn projects the spinal cord.
Nucleus emboliformis and nucleus globosus: The nucleus emboliformis is oval in
shape, whereas nucleus globosus is round in shape. They receive afferents from
the paleocerebellum and send efferents through the superior cerebellar
peduncle to the red nucleus of the opposite side. These two nuclei together
represent ‘nucleus interpositus’ of lower mammals, e.g. monkey.
Nucleus fastigius: It lies near the midline in the region of vermis. It receives
afferents from the archicerebellum and sends efferents through inferior
cerebellar peduncle to the vestibular nuclei and the reticular formation of the
medulla oblongata.
 FIG. 24.2 Intracerebellar nuclei (also called central nuclei of the cerebellum).

❖ What are cerebellar peduncles? Enumerate their constituent fibres. AN60.2

The cerebellar peduncles are large bundles of afferent and efferent fibres that connect
the cerebellum with other parts of the brain. They are three in number:

Superior cerebellar peduncle is the most medial and connects the cerebellum with
the midbrain.
Middle cerebellar peduncle is the largest and connects the cerebellum with the
pons.
Inferior cerebellar peduncle connects the cerebellum with the medulla oblongata.

The constituent fibres of three cerebellar peduncles are given in Table 24.1.
 FIG. 24.3 Components of the inferior cerebellar peduncle. Afferent components are not
shown. RF, reticular formation; VN, vestibular nucleus.

TABLE 24.1
Main Constituent Fibres of Cerebellar Peduncles

Peduncle Afferent Fibres Efferent Fibres

Superior cerebellar peduncle
Middle cerebellar peduncle
Inferior cerebellar peduncle (Fig.
24.3)
❖ Enumerate the important signs and symptoms seen in the cerebellar lesions.
AN60.3
• Anterior spinocerebellar
fibres
• Tectocerebellar fibres
• Pontocerebellar fibres
• Posterior spinocerebellar
fibres
• Olivocerebellar fibres
• Parolivocerebellar fibres
• Cuneocerebellar fibres
• Vestibulocerebellar fibres
• Reticulocerebellar fibres
• Dentatorubral fibres
• Dentatothalamic fibres
• Dento-olivary fibres
•No efferent fibres
• Cerebellovestibular
fibres
• Cerebello-olivary fibres
• Cerebelloreticular fibres

• Asthenia: Muscular hypotonia due to loss of muscle tone.

• Asynergia: Jerky movements due to incoordination of muscles.
■ Ataxia: Staggering gait and inability to walk in a straight line due to
 incoordination of different muscle groups in the lower limb.
■ Adiadokokinesis (disdiadokokinesis): Inability to perform alternate movements
in rapid succession such as pronation and supination.
■ Dysmetria: Loss of ability to measure the distance for reaching the intended
goal.
■ Dysarthria (or scanning speech): Loss of incoordination of muscles concerned
with speech.
■ Rebound phenomenon: Inability to check the action of agonist muscles by the
corresponding antagonist muscles.
• Intention tremor: Due to dysmetria. The tremors are evident during purposeful
movements, and are diminished or absent at rest.

❖ Define 4th ventricle and discuss its boundaries, communications and recesses. 
AN63.1
The 4th ventricle is a tent-like cavity of hindbrain lined with ependyma. It lies behind
the pons and medulla and in front of the cerebellum.

Boundaries (fig. 24.4)

Lateral (on each side):

• Superolaterally by the superior cerebellar peduncle
• Inferolaterally by the inferior cerebellar peduncle
Floor: It is formed by the posterior surfaces of pons and upper part of the medulla
oblongata. It is rhomboidal in shape; hence, it is often called ‘rhomboid fossa’.
Roof: It is formed by
• Superior medullary velum, in the upper part
• Inferior medullary velum, in the lower part
 FIG. 24.4 Rhomboid fossa or floor of the 4th ventricle. Note important features of fossa are
marked in bold.

Communications
It communicates above with 3rd ventricle through cerebral aqueduct (aqueduct of
Sylvius) and below with the central canal of the spinal cord. Posterolaterally, it
communicates with the subarachnoid space through three foramina in its roof (foramen
of Magendie and foramina of Luschka).

Recesses
They are five in number:

• Two lateral recesses

• Median dorsal recess
• Two lateral dorsal recesses

❖ Discuss the features of rhomboid fossa in brief. AN63.1

The features of rhomboid fossa are as follows (Fig. 24.4):

• It is rhomboidal in shape and has four angles: rostral, caudal and two lateral.
• The floor is divided into two equal halves by a median sulcus. Each half of the
floor is further divided into two parts (pontine and medullary) by fibres of stria
medullaris, which run from the median sulcus to the lateral boundary.

Features above the medullary striae (i.e. in the pontine part)

 ■ Presence of facial colliculus, on either side of median sulcus. It is an oval
elevation produced by the fibres of the motor nucleus of facial nerve hooking
around the abducent nucleus (internal genu of facial nerve).
■ A depression at the upper end of sulcus limitans called superior fovea.
■ A bluish-grey area (locus coeruleus), above superior fovea. The bluish colour is
imparted by the underlying group of nerve cells containing melanin pigment.

Features below the stria medullaris (i.e. in the medullary part)

■ Inferior fovea, a triangular depression

■ Hypoglossal triangle, medial to inferior fovea
■ Vestibular triangle, lateral to inferior fovea
■ Vagal triangle, inferior to inferior fovea
■ Funiculus separans, a fine translucent ridge crossing the vagal triangle
■ Area postrema, a small area below the funiculus separans
25

Overview of cerebrum and functional

areas
❖ Define cerebrum and discuss the surfaces of cerebral hemisphere. AN62.2
The cerebrum is the largest part of the brain. It is divided into two equal halves by a
median longitudinal cerebral fissure. Each half is called cerebral hemisphere. The cerebrum is
highly evolved in human beings.

Surfaces of cerebral hemisphere

Each cerebral hemisphere has three surfaces.

Superolateral surface: It is convex in conformity with the shape of the skull cap. It
is most convex and most extensive of the three surfaces.
Medial surface: It is flat and vertical. It is separated from its fellow of the opposite
side by the falx cerebri lying in the median longitudinal fissure, but below the
falx cerebri the two hemispheres are joined together by a large bundle of white
fibres – the commissure called corpus callosum. In a separated cerebral
hemisphere, the corpus callosum is seen as a C-shaped mass of white fibres.
Inferior surface: It is uneven to adopt the floors of anterior and middle cranial
fossae. It is divided by a deep horizontal fissure (the stem of the lateral sulcus)
into an anterior orbital part (related to the floor of the anterior cranial fossa) and
a posterior tentorial part (related to the floor of the middle cranial fossa and to
the upper surface of the tentorium cerebelli).

❖ Name the sulci which help in demarcating the superolateral surface of cerebral
hemisphere into four lobes. Discuss central sulcus in detail. AN62.2
The sulci which help in demarcating the superolateral surface of cerebral hemisphere
into four lobes:

a. Central sulcus
b. Lateral sulcus (posterior ramus)
c. Parieto occipital sulcus (terminal portion)

Central sulcus (of rolando)

Features

a. Presents on the superolateral surface of cerebral hemisphere

 b. Begins at superomedial border of the cerebral hemisphere about 1 cm behind its
midpoint
c. Runs vertically downwards and slightly forwards and ends just above the lateral
sulcus

Significance

a. Gyri lying in front and behind it are called precentral gyrus and postcentral
gyrus, respectively.
b. Precentral gyrus is motor in function and most of fibres of pyramidal tract arise
in this gyrus to supply opposite half of the body (i.e. contralateral half of the
body).
c. Postcentral gyrus is sensory in function and receives sensory impulses from
opposite half of the body (i.e. contralateral half of the body).
d. Frontal branch of middle meningeal artery ascends parallel and in front of
central sulcus, just deep to the pterion. The bone is thin here, and fracture at this
site causes haemorrhage from artery and presses upon the precentral gyrus
leading to pressure symptoms like hemiplegia.

❖ Discuss the demarcation of lobes of cerebral hemisphere on its superolateral

surface. AN62.2
The superolateral surface of cerebral hemisphere is demarcated into four lobes as
follows (Fig. 25.1):

Frontal lobe: It lies anterior to central sulcus and above the lateral sulcus. It is so
named because it is related to the frontal bone of skull.
Parietal lobe: It lies posterior to central sulcus, above the lateral sulcus, and in
front of an imaginary vertical line connecting parieto-occipital sulcus with the
preoccipital notch. It is so named because it is related to the parietal bone of skull.
Temporal lobe: It lies below the lateral sulcus and in front of imaginary vertical
line extending from parieto-occipital sulcus to the preoccipital notch. It is so
called because it is related to the temporal bone of skull.
Occipital lobe: It lies behind the imaginary vertical line connecting parieto-
occipital sulcus with the preoccipital notch. It is so named because it is related
to the occipital bone of skull.
 FIG. 25.1 Division of superolateral surface of the left cerebral hemisphere into four lobes.

❖ Write a short note on insula. AN62.2

The insula is a submerged portion of cerebral cortex in the floor of lateral sulcus. It is
hidden from surface view by overgrown adjacent areas of frontal, parietal and temporal
lobes called opercula/lids.

• It is triangular in shape and surrounded by a circular sulcus.

• It is divided by central sulcus into anterior region having small gyri (gyri
brevia) and posterior region bearing long gyri (gyri longa).
• It is believed to be involved in consciousness and linked to emotion.

❖ Draw a labelled diagram to show the functional areas on the superolateral surface
of cerebral hemisphere. AN62.2
Functional areas on the superolateral surface of the cerebral hemisphere are shown in
Fig. 25.2, see p. 249.

FIG. 25.2 The functional areas on the superolateral surface of the left cerebral hemisphere.

❖ Draw a labelled diagram to show the functional areas on the inferomedial surface
of cerebral hemisphere. AN62.2
Functional areas on the inferomedial surface of the cerebral hemisphere are shown in
Fig. 25.3, see p. 249.
 FIG. 25.3 The functional areas on the inferomedial surface of the right cerebral hemisphere.

❖ Write a short note on the primary motor area. AN62.2

Location
The primary motor area (Brodmann area 4) is located in (see Fig. 25.2):

• Precentral gyrus
• Anterior wall of central sulcus
• Anterior part of paracentral lobule

Representation of body
The body is represented upside down (inverted homunculus) in the primary motor
area.
The sequence of representation of body parts from above to downward is leg, thigh,
trunk, upper limb, face, larynx, lips, jaws, tongue and pharynx.
The area of cortex representing a part of the body is not proportional to the size of that
part, but to the skill of movements performed by that part. Thus, movements of the
hands, lips, tongue and larynx are represented by relatively large areas of the cortex.

Functions

• It controls the voluntary movements of the opposite side of the body.

• It also controls the acts of micturition and defecation.

Applied anatomy
A lesion in this area gives rise to upper motor neuron (UMN) type of paralysis on the
opposite side of the body.

❖ Define paracentral lobule and mention its functions. AN62.2

The paracentral lobule is the area on the medial surface of cerebral hemisphere around
the central sulcus. It is bounded above by superomedial border of the cerebral
hemisphere, below by cingulate sulcus, posteriorly by upturned posterior end of
cingulate sulcus and anteriorly by upturned ramus of cingulate sulcus (see Fig. 25.3).

Functions

• It acts as cortical centre for micturition and defecation.

• It is responsible for movements of the contralateral foot.

❖ Write a short note on motor speech area. AN62.2

Location
The motor speech area (Brodmann areas 45 and 44) is located in the pars triangularis
(area 45) and pars posterior (area 44) in the inferior frontal gyrus of frontal lobe in the
dominant hemisphere (i.e. left hemisphere in right-handed persons; Fig. 25.2).

Function
The motor speech area is essential for the production of expressive speech.

Applied anatomy
If the motor speech area is damaged, the individual will suffer from motor aphasia. In
this condition, there is inability to articulate properly, though there is no paralysis of
muscles of lips, tongue, palate and vocal cords.
The speech of person becomes nonfluent, dysarthric, telegraphic and incomprehensive.

N.B.
The person can understand both written and spoken speech (i.e. he/she has good
comprehension).

❖ Write a short note on primary sensory area. AN62.2

Location
The primary sensory area (Brodmann areas 3, 1 and 2) is located in the postcentral
gyrus and posterior wall of the central sulcus (Fig. 25.2).

Representation of body
The body is represented upside down in primary sensory area similar to that in primary
motor area (see p. 249).

Functions
The primary sensory area is concerned with perception of exteroceptive (pain, light touch
and temperature) and proprioceptive (muscle and joint sense) sensations from opposite
half of the body.

Applied anatomy
The lesions of primary sensory area lead to loss of appreciation of exteroceptive and
proprioceptive sensations in the opposite half of the body.

❖ Write a short note on sensory speech area (Wernicke’s area). AN62.2

Location
The sensory speech area (Brodmann areas 22, 39 and 40) is located in:

• Posterior part of the superior temporal gyrus (Brodmann area 22) of the
dominant cerebral hemisphere (Fig. 25.2).
• Parts of the inferior parietal lobule, including the supramarginal and angular
gyri corresponding to Brodmann areas 40 and 39, respectively.

Functions

• Understanding the written and spoken languages, i.e. it is concerned with the
understanding and interpretation of language through visual and auditory
input.
• Essential for constant availability of learned word patterns.
• Essential for the process of learning such as reading, writing and computing.

Applied anatomy
If the sensory speech area is damaged, the affected individual will suffer from receptive
or sensory aphasia. In this condition, the affected individual cannot understand spoken
words though his hearing is normal; consequently, he/she is unaware of meaning of the
words he/she uses. As a result, he/she uses incorrect words or even nonexistent words.
To others his/her speech sounds like an incomprehensive foreign language.
Other defects seen in sensory aphasia are as follows:

• Alexia: Disability in reading.

• Agraphia: Disability in writing.
• Acalculia: Disability in computing.
• Anomia: Inability in recognition of names of objects.

❖ Write a short note on visual cortex. AN62.2

The visual cortex is present over the occipital lobe.

• It is located along the lips and floor of posterior part of calcarine sulcus (also
called postcalcarine sulcus).
• Anteriorly, it extends up to parieto-occipital sulcus and posteriorly it extends on
the outer surface of the occipital pole and is limited by the lunate sulcus.
 • It includes cuneus and lingual gyrus.

N.B.
The visual cortex is granular type of cortex and is thinner than the cerebral cortex
elsewhere. The inner granular layer of cerebral cortex presents a prominent band of
horizontally arranged fibres called visual stria (or white line of Gennari).
The visual cortex is highly sensitive to light, hence also called koniocortex.

❖ Write a short note on visual areas. AN62.2

Location (fig. 25.3)

• The primary visual area (Brodmann area 17) is located in the walls and floor of
postcalcarine sulcus.
• The secondary visual areas (Brodmann areas 18/peristriate area and 19/parastriate
area) surround the primary visual area and occupy most of the remaining visual
cortex.

Functions

• The primary visual area is concerned with reception and perception of isolated
visual impressions such as colour, size and form.
• The secondary visual areas relate the isolated visual impressions received by the
primary visual area with past experience, thus enabling the individual to
recognize and interpret what he/she is seeing.

Applied anatomy

• Lesions of the primary visual area result in loss of vision in the opposite visual
field (crossed homonymous hemianopia).
• Lesions of the secondary visual areas result in loss of ability to recognize the
objects (visual agnosia).

❖ Describe cerebral dominance in brief. AN62.2

The term cerebral dominance refers to that cerebral hemisphere, which is concerned with
the perception and production of language/speech. In 90% of people, the left cerebral
hemisphere subserves these functions; hence, it is termed dominant hemisphere.
There is an important relationship between cerebral dominance and handedness. If
the left cerebral hemisphere is dominant, the individual will be right-handed and if the
right cerebral hemisphere is dominant, the individual will be left-handed.

❖ Enumerate the main functions of left and right cerebral hemispheres. AN62.2

The main functions of left and right cerebral hemispheres are shown in Fig. 25.4.
FIG. 25.4 Lateralization of functions in the dominant and nondominant hemispheres.
26

Cerebrum

Blood supply of cerebrum

❖ Write a short note on the blood supply of the brain.
The proper blood supply of the brain is the most essential because consciousness is lost
within 10 seconds of the cessation of the blood supply and if this state continues, an
irreversible brain damage starts at 4 minutes and is completed within 10 minutes.

❖ Write a short note on circle of Willis. AN62.6

Formation and location (fig. 26.1)

The brain is supplied by two pairs of major arteries: (a) a pair of vertebral arteries and (b)
a pair of internal carotid arteries. The branches of these arteries anastomose in the region
of interpeduncular fossa at the base of brain to form somewhat circular anastomosis
called circle of Willis. The two vertebral arteries unite at the lower border of pons to
form the basilar artery, which divides at the upper border of the pons into right and left
posterior cerebral arteries. The internal carotid artery of each side terminates in the region
of anterior perforated substance by dividing into a smaller anterior cerebral artery and a
larger middle cerebral artery. The posterior communicating artery (a branch of internal
carotid artery) on each side communicates with the posterior cerebral artery. A single
short anterior communicating artery connects the two anterior cerebral arteries.
 FIG. 26.1 Circle of Willis and the branches of arteries supplying the brain. The central
branches of cerebral arteries are shown by abbreviations: AL, anterolateral group; AM,
anteromedial group; PL, posterolateral group; PM, posteromedial group.

The circle of Willis (circulus arteriosus) is thus formed by the anterior communicating
artery and the anterior cerebral arteries anteriorly, the termination of the internal carotid
artery and the posterior communicating artery on each side, and bifurcation of basilar artery
including posterior cerebral arteries posteriorly (Fig. 26.1).

Function
Provides various alternate routes for collateral circulation.

Applied anatomy
The sites where two arteries unite to form circle of Willis may dilate to form berry-
shaped dilatations called berry aneurysms. The rupture of these aneurysms leads to
subarachnoid haemorrhage at the base of brain in the region of interpeduncular fossa.

N.B.
The most common cause of subarachnoid haemorrhage is the rupture of berry
aneurysms.

❖ Write a short note on basilar artery. Give its branches.

Formation and termination

• It is formed by the two vertebral arteries at the lower border of the pons.
• It runs upwards and forwards in the midline groove on the ventral aspect of
pons.
 • On reaching the upper border of pons, it divides into right and left terminal
branches – the posterior cerebral arteries.

Branches
The branches of basilar artery are (Fig. 26.1):

• Anterior inferior cerebellar arteries

• Labyrinthine arteries
• Pontine branches
• Superior cerebellar arteries
• Posterior cerebral arteries (terminal branches)

❖ Enumerate the branches of cerebral part of internal carotid artery.

❖ Describe briefly arterial supply of the superolateral surface of the cerebral

hemisphere. AN62.2

• The narrow strip of about an inch breadth along its superomedial border as far as the
parieto-occipital sulcus is supplied by the anterior cerebral artery.
• The occipital lobe and narrow strip along the lower border of temporal lobe excluding
the temporal pole (the inferior temporal gyrus) is supplied by the posterior
cerebral artery.
• The rest of the superolateral surface is supplied by the middle cerebral artery.

N.B.
Most of the superolateral surface is supplied by the middle cerebral artery.

The arterial supply of the superolateral surface of the cerebral hemisphere is shown in
Fig. 26.2.
 FIG. 26.2 Arterial supply of the superolateral surface of the cerebral hemisphere.

❖ Describe briefly arterial supply of the inferomedial surface of the cerebral

hemisphere. AN62.2

• Medial surfaces of the frontal and parietal lobes are supplied by the anterior cerebral
artery.
• Medial surfaces of the occipital and most of the temporal lobes (except temporal pole)
are supplied by the posterior cerebral artery.
• Medial surface of the temporal pole is supplied by the middle cerebral artery.
• Medial part (one-third) of the orbital surface (of inferior surface) is supplied by
the anterior cerebral artery. The lateral part (two-third) of the orbital surface as
well as the temporal pole on inferior surface is supplied by the middle cerebral
artery.
• Rest of the tentorial surface (of inferior surface) is supplied by the posterior
cerebral artery.

N.B.
Most of the medial surface is supplied by the anterior cerebral artery.

❖ Write a short note on great cerebral vein of Galen.

The great cerebral vein of Galen is formed by the union of two internal cerebral veins
below the splenium of the corpus callosum (Fig. 26.3). It joins the inferior sagittal sinus
to form the straight sinus. The tributaries of great cerebral vein are as follows:

• Internal cerebral veins

• Basal veins
 FIG. 26.3 Formation, course and tributaries of the internal cerebral veins and the great
cerebral vein of Galen.

❖ Enumerate the deep cerebral veins.

The deep cerebral veins are (Fig. 26.3):

• Thalamostriate veins
• Choroid veins
• Septal veins

N.B.
These veins one from each side unite in the region of interventricular foramen of
Monro to form the internal cerebral vein (vide supra).

White matter of cerebrum

❖ Define white matter and discuss its various types. AN62.3
The white matter of cerebrum is made up of myelinated nerve fibres, which connect
various parts of cerebral cortex on the same side, with opposite side and also with the
other parts of the CNS.

Types of white fibres

There are three types of white fibres in the cerebrum: association fibres, commissural fibres
and projection fibres.
 Association fibres (intrahemispheric): These fibres connect different areas of
cerebral cortex of the same hemisphere. They are further classified into two
types: (a) short association fibres, which connect the adjacent gyri and (b) long
association fibres, which connect the distant gyri.
Commissural fibres: These fibres connect the cortical areas of one cerebral
hemisphere with the corresponding cortical areas of the opposite hemisphere.
The bundles of such fibres are called commissures. The important commissures
in the brain are (a) corpus callosum, (b) anterior commissure and (c) posterior
commissure.
Projection fibres: These fibres connect the cortical areas with the subcortical
centres such as corpus striatum, thalamus, hypothalamus, brainstem and spinal
cord. They include both motor and sensory fibres of long tracts. The most
important bundles of projection fibres are (a) internal capsule and (b) fornix.

❖ Enumerate the various commissures of the brain. AN62.3

The important commissures of the brain:

• Corpus callosum
• Anterior commissure
• Posterior commissure
• Hippocampal commissure
• Habenular commissure

❖ Describe the corpus callosum under the following headings: (a) definition, (b)
parts, (c) course of fibres, (d) functions and (e) applied anatomy. AN62.3

Definition
The corpus callosum is the largest commissure of the brain. It is 10 cm long, which is
nearly half of the anteroposterior length of the cerebrum. It consists of 300 million
fibres. The corpus callosum connects all the parts of neocortex, except for the lower and
anterior parts of temporal lobes, which are connected by the anterior commissure.

Parts
In sagittal section, the corpus callosum is divided into four parts, from before to
backwards (Fig. 26.4):

• Rostrum
• Genu
• Body/trunk
• Splenium
 FIG. 26.4 Median sagittal section of the cerebrum showing shape and parts of corpus
callosum.

The corpus callosum begins at the anterior commissure in the upper part of lamina
terminalis, which passes upwards and forwards as the rostrum, then bends sharply
upwards and backwards to form the genu and finally it extends backwards as the body
and ends posteriorly as a thick massive extremity called splenium.
Its inferior surface is connected in the midline with the upper surface of the fornix by
septum pellucidum, which lies between two lateral ventricles.
Its superior surface is related to indusium griseum and medial and lateral longitudinal
striae.

Course of fibres of corpus callosum (fig. 26.5)

• The fibres of the genu curve forwards on each side towards the frontal cortex
forming the forceps minor.
• The fibres of the body spread out laterally on each side to form the roof of the
central part of the lateral ventricle. These fibres are intersected by the vertically
running fibres of the corona radiata.
• The fibres of the splenium curve backwards on each side towards the occipital
cortex forming the forceps major. Its fibres form the upper part of the medial
wall of the posterior horn of the lateral ventricle.
• The fibres of the posterior part of the body together with some fibres from the
splenium extend laterally to form the roof of the posterior horn of the lateral
ventricle and then turn downwards to form the lateral wall of both the posterior
and inferior horns.
 FIG. 26.5 Median sagittal section of the cerebrum showing course of fibres from different parts
of corpus callosum.

N.B.
The tapetum is a thin lamina of white fibres, which forms the roof and lateral wall of
the posterior horn, and lateral wall of the inferior horn of the lateral ventricle. It is
formed by those fibres of body and splenium of corpus callosum, which are not
intersected by the fibres of corona radiata.

Functions

• Interhemispheric transfer of learned/visual memory.

• Interhemispheric transfer of speech function.
• Coordination of activities of two cerebral hemispheres for proper bilateral
coordination and responses.

Applied anatomy

• Patients with lesion of corpus callosum respond as if they have two separate
brains – a condition called Split-brain effect/syndrome.
• A surgical section of corpus callosum has been attempted in the past to prevent
spread of seizures.

❖ Write a short note on anterior commissure. AN62.3

The anterior commissure is a small, round bundle of commissural fibres that crosses the
midline in the upper part of the lamina terminalis. It consists of two components:

• A large, posterior neocortical component, which interconnects the cortical areas

of the lower and anterior parts of the temporal poles.
• A smaller, anterior paleocortical component, which interconnects the olfactory
regions, such as olfactory bulbs and olfactory tubercles, of two sides.

❖ Describe the internal capsule under the following headings: (a) definition and
location, (b) gross anatomy, (c) fibres, (d) arterial supply and (e) applied anatomy. 
AN62.3

Definition and location

The internal capsule is a compact bundle of projection fibres lying in the inferomedial part
of the cerebral hemisphere. Hence, it lies in a narrow space between the lentiform
nucleus laterally, and the caudate nucleus and thalamus medially.
The internal capsule connects the cerebral cortex to the brainstem and spinal cord.
It contains important fibres belonging to pyramidal tract and sensory fibres from
the opposite half of the body.

Gross anatomy (fig. 26.6)

Shape: In horizontal section, it appears as a ‘V’-shaped mass of white fibres.

Parts: It consists of five parts:
■ Anterior limb: Lies between the lentiform nucleus and the caudate nucleus.
■ Genu (bend of internal capsule): Lies in the angle between the caudate nucleus,
thalamus and lentiform nucleus.
■ Posterior limb: Lies between the lentiform nucleus and the thalamus.
■ Retrolentiform part: Lies behind the lentiform nucleus.
■ Sublentiform part: Lies deep to the lentiform nucleus.
 FIG. 26.6 Location, shape, boundaries and parts of the internal capsule. The sublentiform part
is not seen.

N.B.
The internal capsule continues above as corona radiata and below as cerebral peduncle.

Fibres (fig. 26.7)

The constituent fibres in the different parts of the internal capsule are given in Table
26.1.
 FIG. 26.7 Parts of the internal capsule and fibres/tracts passing through them.

TABLE 26.1
Constituent Fibres in the Different Parts of the Internal Capsule

Part Descending Fibres Ascending Fibres

Anterior limb • Frontopontine fibres • Anterior thalamic radiation
Genu • Corticonuclear and corticospinal fibres • Anterior part of superior
for head and neck thalamic radiation
Posterior limb • Corticospinal fibres for upper limb, • Superior thalamic radiation
trunk and lower limb
• Corticorubral fibres
Retrolentiform • Occipitopontine fibres • Posterior thalamic radiation
part (optic radiation)
Sublentiform • Temporopontine fibres • Inferior thalamic radiation
part (auditory radiation)

Arterial supply
The arterial supply of different parts of the internal capsule is as follows:

• Anterior limb is supplied by the middle and anterior cerebral arteries.

• Genu is supplied by the middle cerebral artery and recurrent artery of Heubner.
 • Posterior limb is supplied by Charcot’s artery of cerebral haemorrhage and
anterior choroidal artery.
• Sublentiform part is supplied by the anterior choroidal artery.
• Retrolentiform part is supplied by the posterior cerebral artery.

Applied anatomy

• A small lesion in the internal capsule results in widespread paralysis and

sensory loss because huge number of motor and sensory fibres are packed
densely in the internal capsule.
• The commonest lesion in the internal capsule occurs due to cerebral
haemorrhage or cerebral thrombosis. It causes complete hemiplegia on the
opposite side (i.e. contralateral hemiplegia).
• The most common cause of cerebral haemorrhage is the rupture of Charcot’s
artery of cerebral haemorrhage and it usually involves posterior limb of internal
capsule leading to contralateral hemiplegia.

❖ Write a short note on thalamic radiation. AN62.5

With few exceptions, all the afferent fibres to brain relay in the thalamus. From
thalamus, the thalamocortical fibres radiate in different directions to reach the
widespread area of the cerebral cortex (thalamic radiation). The important
thalamocortical fibres (or thalamic radiations) are as follows:

• Sensory radiation from the thalamus to the sensory cortex in the postcentral
gyrus.
• Auditory radiation from the medial geniculate body to the auditory cortex in the
temporal lobe.
• Optic radiation from the lateral geniculate body to the visual cortex in the
occipital lobe.
27

Basal nuclei, limbic system and lateral

ventricle

Basal nuclei
❖ What are basal nuclei? List their functions. AN62.4
The basal nuclei are large masses of grey matter located in the basal part of the cerebral
hemisphere. They include corpus striatum, claustrum and amygdaloid body.

N.B.
Functionally, the term basal nuclei also include substantia nigra, red nucleus and
subthalamus.

Functions

• To control the automatic associated movements like swinging of arms during

walking.
• To help in smoothening the voluntary motor activities of the body.
• To prevent the occurrence of involuntary movements.

❖ Write a short note on corpus striatum. AN62.4

The corpus striatum is situated lateral to the thalamus. Topographically, it is almost
completely divided into two parts: the caudate and lentiform nuclei by a band of fibres
of the internal capsule. However, anteroinferiorly the two parts are connected with each
other by a thin band of grey matter across the anterior limb of internal capsule (Fig.
27.1).
 FIG. 27.1 Corpus striatum: A, lateral aspect of the left corpus striatum; B, relationship of the
corpus striatum to the internal capsule.

Caudate nucleus
The caudate nucleus (Fig. 27.2) is large, comma-shaped mass of grey matter that
surrounds the thalamus and is itself surrounded by the lateral ventricle. It is divided
into three parts – head, body and tail.

• The head is large and rounded, and lies in the floor and lateral wall of the
anterior horn of the lateral ventricle. Its lower part is connected with the
putamen by thin bands of grey matter.
• The body is long and narrow. It lies in the lateral part of the central part of the
lateral ventricle.
• The tail is long and slender. It runs forward in the roof of inferior horn of the
lateral ventricle and merges with the amygdaloid nucleus.

FIG. 27.2 Relationship of caudate nucleus with the cavity of the lateral ventricle and thalamus.
Note that the stria terminalis, the main efferent tract of amygdaloid body projects to the septal
area, anterior perforated substance and anterior hypothalamus.
Lentiform nucleus
The lentiform nucleus is a large, lens-shaped (biconvex lens) nucleus. In the horizontal
section of cerebrum, it appears wedge shaped. It has three surfaces: lateral, medial and
inferior. Its lateral surface is highly convex. It is related to the external capsule, which
separates it from the claustrum. Its medial surface is also highly convex. It is related to
the internal capsule, which separates it from the head of the caudate nucleus and the
thalamus. Its inferior surface is related to the sublentiform part of the internal capsule
and lies close to the anterior perforated substance.

N.B.
The lentiform nucleus is divided by a thin, white lamina into two parts: the larger
lateral part called putamen, while the smaller, medial part called the globus pallidus.
The putamen has densely packed smaller cells and is darker in colour. The globus
pallidus consists of loosely packed larger cells and is paler in colour.

❖ Enumerate the disorders that may occur due to the lesions of basal nuclei. 
AN62.4
The lesions of basal nuclei lead to various forms of involuntary movements such as:

• Parkinsonism (see below).

• Chorea, choreiform movements as in break dancing.
• Athetosis, athetoid movements, i.e. slow, sinuous and writhing movements.
• Ballismus, violent burst of irregular movements in trunk, girdles and limbs.

❖ Write a short note on parkinsonism. AN62.4

The parkinsonism is a degenerative disease involving substantia nigra and/or
nigrostriatal fibres causing deficiency of dopamine in the striatum. The disease usually
occurs after 50 years of age.
The clinical signs of parkinsonism include (Fig. 27.3):

• Bradykinesia
• Stooped posture
• Shuffling gait
• Cog-wheel rigidity
• Pill-rolling tremors
• Masked facies
• Resting tremors
 FIG. 27.3 Clinical features of a patient suffering from parkinsonism.

N.B.
The treatment of parkinsonism includes:

(a) Administration of L-dopa – a precursor of dopamine.

(b) Stereotactic surgery by placing small lesions in globus pallidus.
(c) Striatal implants of dopamine-containing neurons of fetal origin.

Limbic system
❖ What are the components of hippocampal formation? AN62.4
This hippocampal formation consists of:

• Hippocampus
• Dentate gyrus
• Indusium griseum
• Medial and lateral longitudinal striae

❖ Write a short note on hippocampus. AN62.4

• Hippocampus is the area of cerebral cortex that has rolled on itself in the floor of
inferior horn of the lateral ventricle during fetal life.
 It is so named because of its resemblance to ‘sea horse’ in coronal section (Fig. 27.4).

• Histologically, it consists of three layers (Fig. 27.4):

■ Superficial polymorphic layer
■ Middle pyramidal cell layer
■ Deep molecular cell layer

FIG. 27.4 Coronal section of the hippocampus and related structures.

The ventricular surface of hippocampus is covered by thin layer of white fibres called
alveus. Near the medial border, the fibres of alveus converge to form the fimbria of
hippocampus.

Function
It plays an important role in recent memory.

Applied anatomy
The lesions of hippocampus lead to loss of recent memory (amnesia).

❖ Describe the fornix in brief. AN62.4

The fornix is a large bundle of projection fibres (mainly) that connect the hippocampus
with the mammillary body. On the medial surface of cerebral hemisphere, it is seen as
an arched bundle of white fibres beneath the corpus callosum.

Parts (fig. 27.5)

It consists of:

• Fimbriae
• Crura
 • Body
• Columns (anterior columns)

FIG. 27.5 Main parts of the fornix.

Types of fibres present in the fornix

• Projection fibres, which project from hippocampus to mammillary body.

• Commissural fibres, which connect the two hippocampi.
• Association fibres, which connect the hippocampus with cingulate gyrus of the
same side.

N.B.
The fornix is the only fibre bundle in brain which contains all the three types of white
fibres of the cerebrum – projection fibres, commissural fibres and association fibres.

Lateral ventricle
❖ Write a short note on lateral ventricle. AN63.1

• It is a c-shaped cavity within the cerebral hemisphere.

• There are two lateral ventricles, one in each cerebral hemisphere of the
cerebrum.
• It is C-shaped and wraps itself around the thalamus, lentiform nucleus and
caudate nucleus.
• Each lateral ventricle is situated lateral to septum pellucidum and below the
corpus callosum.
• It is lined by an ependyma and is filled with CSF.
• It has a capacity of about 7–10 mL.
• It communicates with the 3rd ventricle through interventricular foramen (of
 Monro).

Parts
Each lateral ventricle is divided into four parts (Fig. 27.6):

• Central part/body
• Anterior horn
• Posterior horn
• Inferior horn

FIG. 27.6 Ventricular system of the brain; lateral view. Note the different parts of the lateral
ventricle (labelled in bold letters).

Applied anatomy
The blockage of interventricular foramina leads to excessive accumulation of CSF in the
lateral ventricles causing a clinical condition called hydrocephalus.

❖ Discuss the boundaries of central part of the lateral ventricle. AN63.1

Boundaries (fig. 27.7)

It is triangular in shape in coronal section and presents roof, floor and medial wall.

Roof: It is formed by the inferior surface of the corpus callosum.

Floor: From lateral to medial side, it is formed by:
■ Body of caudate nucleus
■ Stria terminalis
 ■ Thalamostriate vein
■ Lateral part of the upper surface of thalamus
■ Choroid plexus
■ Body of fornix (upper surface)
Medial wall: The medial wall is formed by septum pellucidum.

FIG. 27.7 Boundaries of central part of the lateral ventricle.

❖ Discuss the boundaries of anterior horn of the lateral ventricle. AN63.1

Boundaries
It is roughly triangular in coronal section and presents roof, floor, anterior wall, medial wall
and lateral wall (Fig. 27.8).

Roof: It is formed by the anterior part of the body of corpus callosum.

Floor: It is formed by the upper surface of the rostrum of corpus callosum.
Anterior wall: It is formed by genu of the corpus callosum.
Medial wall: It is formed by the septum pellucidum.
Lateral wall: It is formed by the head of corpus callosum.
 FIG. 27.8 Boundaries of anterior horn of the lateral ventricle.

❖ Discuss the boundaries of posterior horn of the lateral ventricle. AN63.1

Boundaries
It is quadrangular or diamond shaped in coronal section and presents roof, lateral wall,
floor and medial wall (Fig. 27.9).

Roof, lateral wall and floor: These are formed by tapetum.

Medial wall: It is formed:
■ In the upper part by bulb of the posterior horn (an elevation/raised area
formed by the forceps major).
■ In the lower part by calcar avis (a raised area formed by the anterior part of
calcarine sulcus).

FIG. 27.9 Boundaries of posterior horn of the lateral ventricle.

❖ Discuss the boundaries of inferior horn of the lateral ventricle. AN63.1

Boundaries
It appears on a transverse slit in coronal section and presents roof and floor (Fig. 27.10).

Roof: It is formed by:

■ Tapetum, covered on its superficial surface by optic radiation and inferior
longitudinal fasciculus
■ Tail of caudate nucleus
■ Stria terminalis
■ Amygdaloid body (sometimes)
Floor: From lateral to medial side, it is formed by:
■ Collateral eminence, formed by collateral sulcus
■ Hippocampus covered by thin layer of its white matter called alveus
■ Fimbria, formed by alveus
■ Choroid plexus

FIG. 27.10 Boundaries of inferior horn of the lateral ventricle.

28

Diencephalon and third ventricle

❖ What is diencephalon? List its subdivisions. AN62.5
The diencephalon is the part of brain that lies between brainstem and cerebrum. The
cavity within it is called 3rd ventricle.

Subdivisions
The major subdivisions of diencephalon are as follows:

• Thalamus
• Metathalamus, consisting of medial and lateral geniculate bodies
• Epithalamus, consisting of pineal body and habenular nuclei
• Hypothalamus

❖ What is thalamus? Enumerate its major nuclei. AN62.5

Anatomically, the thalamus is a large, egg-shaped mass of grey matter lying above the
brainstem, from which it is separated by a small amount of neural tissue called
subthalamus. Functionally, the thalamus is the great sensory relay station (gateway) to the
cerebral cortex. It receives sensory impulses from the opposite half of the body and
transmits them to the sensory cortex. There are two thalami situated one on each side of
a slit-like cavity called 3rd ventricle. Thus, medial surface of each thalamus forms the
side wall of the 3rd ventricle. The anterior end of thalamus is narrow and forms the
tubercle of the thalamus. Its posterior end is expanded and free, which is called pulvinar.

N.B.
All the sensory pathways relay in the thalamus, except olfactory pathways.

Major nuclei of thalamus

The major nuclei of thalamus are (Fig. 28.1) as follows:

• Anterior nucleus
• Mediodorsal (dorsomedial) nucleus
• Pulvinar
• Ventral tier of nuclei:
■ Ventral anterior nucleus (VA)
■ Ventral lateral nucleus (VL)
■ Ventral posterior nucleus (VP)
• Ventral posterolateral nucleus (VPL)
 • Ventral posteromedial nucleus (VPM)

FIG. 28.1 Horizontal section of the thalamus (schematic) showing the location of various
thalamic nuclei. The inset is the coronal section of thalamus passing in front of pulvinar
showing ventral posteromedial (VPM), ventral posterolateral (VPL) nuclei and centromedian
nucleus. LD, lateral dorsal nucleus; LP, lateral posterior nucleus; MN, mediodorsal nucleus; P,
pulvinar; VA, ventral anterior nucleus; VL, ventral lateral nucleus.

N.B.

• The VPL nucleus receives spinothalamic tract and medial lemniscus.

• The VPM nucleus receives trigeminothalamic tract (trigeminal lemniscus).

❖ Write a short note on metathalamus. AN62.5

The metathalamus consists of medial and lateral geniculate bodies, which are rounded
elevations on the inferior aspect of the pulvinar.

Lateral geniculate body

The lateral geniculate body (LGB) is a small ovoid swelling that projects downwards
and laterally form the pulvinar of the thalamus. It is visible at the terminal end of each
optic tract. It is the thalamic visual nucleus. It receives fibres from the optic tract and
gives fibres (optic radiation) to the visual cortex of the occipital lobe (areas 17, 18 and 19).
It is the last relay station on the visual pathway.
Structurally, the LGB consists of six laminae, numbered 1–6 from ventral to dorsal
side. Laminae 1, 4 and 6 receive fibres from contralateral retina and laminae 2, 3, and 5
from the ipsilateral retina.

Medial geniculate body

The medial geniculate body is a small oval swelling on the inferior surface of the
pulvinar and more prominent than the LGB. It is the thalamic auditory nucleus. It receives
the fibres from the lateral lemniscus through the inferior colliculus and inferior
brachium, and gives fibres (auditory radiation) to the auditory cortex in the temporal lobe
(area 41 and 42). It is the last relay station on the auditory pathway.

❖ Write a short note on pineal gland. AN62.5

The pineal gland is a small cone-shaped body (only 3 × 5 mm in size) projecting
downwards in the midline from the posterior wall of the 3rd ventricle. It is located in
the groove between the superior colliculi below the splenium of corpus callosum.
Its stalk divides into two laminae – ventral and dorsal. The ventral lamina is
continuous with posterior commissure, while the dorsal lamina is continuous with the
habenular commissure.

Functions

• Produces melatonin – a hormone that inhibits the secretion of gonadotrophins

(GnRH) from the hypothalamus. The melatonin probably holds back the
development of reproductive organ till a suitable age (i.e. puberty). In other
words, the melatonin is believed to regulate the onset of the puberty.
• Acts as a biological clock and is responsible for circadian rhythm.
• Regulates the secretion of all other endocrine glands.

N.B.
Morphologically, the pineal gland represents parietal (3rd) eye that has disappeared
during evolution.

Applied anatomy

• Tumours of pineal gland cause precocious puberty.

• Calcification of pineal gland: The calcareous concretions appear in the pineal
gland after 17 years of age and form aggregations called brain sand or corpora
arenacea.

The calcification of pineal gland is seen as a radiopaque shadow in 50% of individuals

in midline and provides a useful landmark to detect any shift of brain due to tumour,
etc.

❖ Describe the hypothalamus under the following headings: (a) introduction, (b)
boundaries, (c) regions/parts and nuclei, (d) functions and (e) applied anatomy. 
AN62.5

Introduction
The hypothalamus is a small part of diencephalon that lies below the thalamus. It forms
the floor and lower part of the lateral walls of 3rd ventricle. The hypothalamus controls
the various autonomic activities of the body. The sympathetic activities are controlled
by its posterior part, while parasympathetic activities are controlled by its anterior part.
Hence, it is also called head ganglion of the autonomic nervous system.
Boundaries
The hypothalamus is bounded:

• Anteriorly by the lamina terminalis

• Posteriorly by the subthalamus
• Laterally by the internal capsule
• Medially by the cavity of 3rd ventricle
• Superiorly by the thalamus
• Inferiorly by the structures in the floor of the 3rd ventricle, i.e. tuber cinereum,
stalk of infundibulum and mammillary bodies (these are actually parts of
hypothalamus)

Regions/parts and nuclei (fig. 28.2)

The various regions of hypothalamus and nuclei present in them are as follows:

• Preoptic region adjoining the lamina terminalis: It contains preoptic nucleus.

• Supraoptic region (above the optic chiasma). It contains:
■ Supraoptic nucleus
■ Anterior nucleus
■ Paraventricular nucleus
• Tuberal region includes tuber cinereum, infundibulum and area around it. It
contains:
■ Arcuate (infundibular) nucleus
■ Ventromedial nucleus
■ Dorsomedial nucleus
• Mammillary region (includes mammillary bodies and area around it). It
contains:
■ Posterior nucleus
■ Mammillary nuclei
 FIG. 28.2 Different nuclei of hypothalamus in sagittal section. The lateral nucleus of the
hypothalamus is not shown.

N.B.
The whole of hypothalamus is a derivative of diencephalon except its preoptic region,
which is a derivative of the telencephalon.

Functions

• Autonomic control: The anterior part controls the parasympathetic nervous

system, while the posterior part controls the sympathetic nervous system.
• Endocrine control: By producing releasing hormones or release-inhibiting
hormones, it controls the functions of endocrine glands of the body.
• Neurosecretion: The oxytocin and antidiuretic hormone (ADH)/vasopressin are
synthesized in the supraoptic and paraventricular nuclei, respectively, and are
transported to the posterior pituitary via hypothalamo-hypophyseal tract.
• Regulation of food and water intake: The medial zone is responsible for hunger,
thirst and drinking, while lateral zone acts as a ‘satiety centre’.
• Temperature regulation: The anterior portion prevents rise in temperature, while
the posterior portion promotes heat production and conservation.
• Control of sexual behaviour and reproduction: By influencing the secretion of
gonadotrophin (GnRH) by the pituitary gland.
• Control of emotional behaviour like laughing, crying, sweating and flushing.
• Acts as biological clock, i.e. regulates the cyclic activities of the body (sleep and
wake cycle called circadian rhythm).

N.B.
The important subcortical centres for autonomic system are (a) vasomotor centre, (b)
cardiovascular centre and (c) respiratory centre. These are present in the brainstem.
Applied anatomy
The impaired secretion of ADH/vasopressin leads to diabetes insipidus characterized by
polyuria and polydipsia. The absence of glycosuria differentiates it from diabetes mellitus.

❖ Describe the 3rd ventricle under the following headings: (a) gross anatomy, (b)
boundaries, (c) recesses and (d) applied anatomy. AN63.1
The 3rd ventricle is a midline slit-like cavity of diencephalon, which extends from
lamina terminalis anteriorly to the upper end of cerebral aqueduct posteriorly. The 3rd
ventricle communicates with the lateral ventricles through interventricular foramina (of
Monro) and with 4th ventricle through cerebral aqueduct (of Sylvius).

Boundaries (fig. 28.3)

The 3rd ventricle presents anterior wall, posterior wall, floor, roof and lateral walls.

• Anterior wall is formed from above downwards by:

■ Anterior column of fornix
■ Anterior commissure
■ Lamina terminalis
• Posterior wall is formed from above downwards by:
■ Pineal gland
■ Posterior commissure
■ Commencement of cerebral aqueduct
• Floor is formed from before backwards by:
■ Optic chiasma
■ Tuber cinereum
■ Infundibulum (stalk of pituitary gland)
■ Mammillary bodies
■ Posterior perforated substance
■ Tegmentum of midbrain
• Roof is formed by the ependyma stretching across the upper limits of the two
thalami.
• Lateral wall is formed by:
■ Medial surface of the anterior two-third of thalamus (forms the lateral wall
above the hypothalamic sulcus)
■ Medial surface of the hypothalamus (forms the lower part of the lateral wall
below the hypothalamic sulcus)
 FIG. 28.3 Boundaries and recesses of 3rd ventricle as seen in sagittal section. 1, Infundibular
recess; 2, optic recess; 3, anterior recess; 4, suprapineal recess; 5, pineal recess. HS,
hypothalamic sulcus; I, interthalamic adhesion.

Recesses (fig. 28.3)

These are extensions (pocket-like protrusions) of the cavity of 3rd ventricle into the
surrounding structures:

• Suprapineal recess: Above the stalk of pineal gland

• Pineal recess: Between the superior and inferior laminae of the stalk of pineal
gland
• Infundibular recess: Into the stalk of pituitary gland
• Anterior recess (also called vulva of the ventricle): Between the diverging anterior
columns of fornix in front of the interventricular foramen and behind the
anterior commissure

Applied anatomy

• The obstruction of 3rd ventricle leads to accumulation of excessive CSF in it and

two lateral ventricles, which causes increase in intracranial pressure in adults
and hydrocephalus in infants.
• The ventriculography is often done to visualize the obstruction/dilatation of 3rd
ventricle.
SECTION IV
General Anatomy
OUTLINE

29. Introduction and anatomical terminology

30. Skin, superficial fascia and deep fascia
31. Skeletal system
32. Joints
33. Muscles
34. Cardiovascular system
35. Lymphatic system
36. Nervous system
29

Introduction and anatomical terminology

❖ What is anatomy?
The anatomy is the science which deals with the structure of the body from
submicroscopic to the macroscopic level. The term anatomy is derived from a Greek
word ‘anatome’ meaning to ‘cut up’ (ana = apart, tomy = cut). The term dissection is the
Latin equivalent of the Greek term ‘anatome’.

❖ Enumerate the major subdivisions of the anatomy. AN1.1

The major subdivisions of the anatomy are as follows:

• Gross anatomy, which includes cadaveric anatomy, living anatomy/surface

anatomy, endoscopic and radiological anatomy.
• Histology/microscopic anatomy
• Embryology
• Genetics
• Imaging/radiological anatomy

❖ Who is the father of anatomy? Briefly describe his life and achievements.
Herophilus (325–280 BC) (Fig. 29.1) is considered as the father of anatomy.
 FIG. 29.1 Herophilus.

He was a Greek physician and was regarded as the founder of school of medicine at
Alexandria, the then capital of Egypt. He taught anatomy in this medical school
through vivisections (dissections of living humans) and dissections of human cadavers.
Herophilus provided great descriptions of the skull, eye, various visceral organs and
their relationships. He also described functional relationship of the spinal cord to the
brain. Herophilus regarded the brain as the seat of intelligence and described many of
its structures such as cerebrum, cerebellum and the 4th ventricle. He was the first to
identify that nerves are either sensory or motor. He is also credited with the discovery of the
ovum. Two monumental works of Herophilus were titled On Anatomy and On the Eyes.

❖ Who is the father of modern anatomy? Briefly describe his life and achievements.
Andreas Vesalius (1514–1564) (Fig. 29.2) is considered as the father of modern
anatomy. He was born in Brussels to a family of physicians. He studied anatomy and
medicine for 3 years in the University of Paris. He became Professor of Anatomy and
Surgery at the age of 23 years at the University of Padua in Italy. He performed human
dissections and initiated the use of live models to determine the surface landmarks for
internal structures. His masterpiece anatomical treatise De humani corporis fabrica (On the
Workings of the Human Body) written in seven volumes at the age of 28 years
revolutionized the teaching of anatomy and remained an authoritative text for two
centuries. The various body systems and individual organs were beautifully illustrated
and described in the fabrica. In his book, he boldly challenged hundreds of Galen’s
erroneous concepts that were taught as facts. Bitter controversies ensued between
Vesalius and Galenic anatomists. Vesalius became so incensed by the relentless attacks
that he destroyed much of his unpublished work and stopped doing dissections.
However, by freeing anatomy from many of the Galen’s errors, Vesalius laid the
foundation on which many subsequent advances in medicine and surgery could take
place.

FIG. 29.2 Andreas Vesalius.

He started the era of anatomical basis of surgery. Another credit of Vesalius is that,
unlike other anatomists of his time (Sylvius, Fallopius, Eustachius, etc.), he chose not to
have his name attached to the parts of the body that he described. He remained a
bachelor and a teacher of anatomy throughout his life. Vesalius was the greatest
anatomist of his time and is now regarded as the Father of Modern Anatomy. He is also
called ‘reformer of anatomy’.

❖ Enumerate the characteristic features of humans.

The characteristic features of humans are as follows:

• Bipedal locomotion
• Well-developed cerebrum (brain)
• Skilled hand with opposable thumb
• Well-developed articulated speech
• Prominent chin
 • Stereoscopic vision

❖ What are the parts/regions of the human body?

For descriptive purposes, the human body is divided into following six parts/regions:

• Head1
• Neck
• Thorax
• Abdomen
• Upper limb
• Lower limb

Anatomical terminology
Anatomical language is one of the fundamental languages of medicine. The medical
doctors throughout the world use a common language of special anatomical terms
while referring to the structures of the body in any position to avoid any ambiguity. The
anatomical terms are mostly Greek or Latin in origin.

❖ Define the anatomical position and give its significance.  AN1.1

In anatomical position, it is presumed that the body is standing erect, the upper limbs
hanging by the sides of body with palms of the hands facing forwards, the feet parallel
to each other, digits facing forwards and eyes directed forwards (Fig. 29.3).
 FIG. 29.3 Anatomical position.

Significance
Since the interrelationship of various parts of the body keep changing with various
positions of the body (supine, prone, hanging upside down, etc.), all descriptions in the
human body are expressed in relation to the anatomical position.

❖ Define the fundamental position.

The fundamental position is same as the anatomical position, except that the person
stands erect with upper limbs hanging by the side of the body and palms of the hands
face medially towards the sides of the body.

❖ Briefly discuss fundamental planes of the body and give their significance. 
AN1.1
There are four fundamental planes of the body:

• Midsagittal (median) plane: It is an imaginary vertical plane that passes through

the central axis of the body and divides the body into right and left halves. It
corresponds to the sagittal suture of skull, hence the name midsagittal plane.
• Sagittal plane: Any vertical plane parallel to the median plane is called sagittal
plane. It may be present on right or left side of the median plane. It divides the
body into two unequal halves.
• Coronal plane: It is vertical plane that passes at right angle to the median plane
and divides the body into anterior and posterior parts. It corresponds to the
coronal suture of the skull, hence the name coronal plane.
• Transverse/horizontal plane: It passes horizontally and divides the body into
upper and lower parts. This plane passes at right angle to both sagittal and
coronal planes and is perpendicular to the long axis of the body or limbs.

Note: The radiologists refer to transverse plane as transaxial. Convention dictates that
the axial anatomy is viewed as though looking from feet towards the head.

N.B.
Any plane passing through the body or any of its parts other than the above-mentioned
planes is termed oblique plane.

❖ Briefly describe the following movements: (a) circumduction, (b) supination and
pronation, (c) inversion and eversion and (d) opposition. AN1.1

Circumduction

• This movement is a combination of flexon, extension, abduction and adduction

in a sequence.
 • It is a cone-like circular movement in which the distal portion of moving part
moves in a circle. For example, during bowling of a cricket ball, there is
circumduction of upper limb at the shoulder joint, while hand, holding the
cricket ball moves in a circle. Such movements are possible at shoulder, hip
joints, etc.

Supination and pronation

In supination, the forearm and hands are rotated laterally around their longitudinal axes
from midprone position so that palm of the hand faces anteriorly/upwards.
In pronation, the forearm and hand are rotated medially around their longitudinal
axes from the midprone position so that the palm of the hand faces
posteriorly/downward.
The movements of supination and pronation occur at the superior and inferior
radioulnar joints. For details, see p. 80.

Inversion and eversion

In inversion, the medial border of foot is raised, so that the sole of foot faces
inwards/medially, while in eversion, the lateral border of foot is raised so that the sole
of foot faces outwards/laterally. These movements occur at talo-calcaneo-navicular and
subtalar joints.

Opposition
In this movement, the tip of thumb touches the tips of other digits, e.g. when one does
count on fingers. This movement occurs at 1st carpometacarpal joint.

1
The head includes skull, face and brain.
30

Skin, superficial fascia and deep fascia

Skin
❖ What is skin? List its functions. AN4.1
The skin (integument) is the outer covering of the body with a total area of about 20
square feet. It is the largest organ (area wise) of the body constituting about 16% of the
body weight.

N.B.
The skin is considered as an organ because it consists of several different types of
tissues (e.g. epithelial tissue, adipose tissue, glandular tissue, blood vessels and nerves)
that are structurally arranged to function together.

Functions

• Protection of the body from heat, cold, ultraviolet rays, etc.

• Prevention of loss of the body fluids and absorption of water within the body.
• Regulation of the body temperature.
• Acts as a sensory organ.
• Synthesis of vitamin D with the help of ultraviolet rays.
• Absorption of lipid-soluble materials, e.g. vitamins like A, D, E and K; solvents
like acetone; and heavy metals like arsenic, lead and mercury.

❖ What are the layers of the skin? AN4.1

The skin consists of two layers:

• Epidermis: It is the superficial layer. It consists of stratified squamous

epithelium and is derived from ectoderm. It is avascular.
• Dermis: It is the deep layer. It is made up of connective tissue and is derived
from mesoderm. It is highly vascular and contains glands, nerve endings and
hair follicles.

❖ Enumerate the layers of epidermis. AN4.1

The thick skin presents the following five layers, from deep to superficial (Fig. 30.1):

• Stratum basale/stratum germinatum/basal layer

• Stratum spinosum/spiny layer
 • Stratum granulosum/granular layer
• Stratum lucidum/clear layer
• Stratum corneum/cornified layer

FIG. 30.1 Layers of the epidermis. The dermis is also seen.

❖ What are the differences between thin and thick skin? AN4.2

The differences between thin and thick skin are given in Table 30.1.

TABLE 30.1
Differences Between Thin and Thick Skin

Thin skin Thick skin

Epidermis • Thin (0.10–0.15 mm) • Thick (0.6–4.5 mm)
• Stratum corneum thin • Stratum corneum thick
• Stratum lucidum absent • Stratum lucidum
present
Epidermal ridges • Absent • Present
Hair follicles • Present • Absent
Sebaceous glands • Present • Absent
Sweat glands • Few • Numerous
Sensory nerve • Few • Numerous
endings
Distribution • All parts of the body, except palms and • Palms and soles
soles
❖ What are the layers of dermis?
The dermis consists of two layers:
 • Papillary layer: It is superficial and forms one-fifth of the total thickness of
dermis. It sends finger-like projections (called dermal papillae) towards
epidermis.
• Reticular layer: It is a deep layer and contains course bundles of collagen fibres. It
also contains blood vessels and nerves.

❖ What are cleavage lines/Langer’s lines? Mention their clinical significance. 

AN4.2
These are lines on the surface of the skin. They are produced by the pull of collagen
fibres present within the dermis, and radiate in definite directions. They correspond to
the natural orientation of collagen fibres in dermis. In general, the Langer’s lines tend to
run longitudinally in the limbs and circumferentially in the neck and the trunk (Fig.
30.2).

FIG. 30.2 Tension lines/Langer’s lines of the skin: A, front; B, back.

Clinical significance
The knowledge of orientation of these lines is of special interest to surgeons as:

• Incisions made parallel to these lines heal rapidly and produce hair-line scar
(due to formation of less scar tissue).
• Incisions made across these lines heal poorly and produce wide scar (due to
 formation of more scar tissue).

❖ What are the appendages of the skin? AN4.2

Appendages of the skin:

• Hair
• Sweat glands
• Sebaceous glands
• Nails

Superficial fascia
❖ What is superficial fascia?

• It is a layer of loose connective tissue located deep to skin. It connects the skin to
the underlying deep fascia. The superficial fascia contains subcutaneous fat,
nerves and vessels. It is mostly heavily infiltrated with fat in females and
children, which is the main factor responsible for smooth external contours of
the body in females and children. AN4.3
• It allows mobility of the skin on the underlying structures.
• It acts as a distributary layer in which blood vessels, lymphatics and nerves can
travel before entering the dermis.
• It forms a kind of insulating layer over the body surface and accounts for the
increased resistance of the females to cold in comparison with the males.
• It is extremely thin and devoid of fat in the eyelids, the external ear, penis and
scrotum.
• In palms, soles, back of neck and scalp, it is made up of dense connective tissue,
which firmly bind it to the underlying structures.

❖ Enumerate the sites of subcutaneous injections.

The sites of subcutaneous injectionare:

• Posterior aspect of arm

• Anterior aspect of forearm
• Anterior abdominal wall
• Anterior aspect of thigh

❖ What is panniculus carnosus? Enumerate the muscles that represent panniculus

carnosus in humans.
The panniculus carnosus is a thin sheet of striated muscle present in the superficial fascia
of lower animals. Its fibres are inserted into the skin.
The following muscles in the human body represent the panniculus carnosus:

• Muscles of the scalp

 • Muscles of the facial expression
• Platysma (in neck)
• Subareolar muscle (of breast)
• Palmaris brevis (in hand)
• Dartos muscle (of scrotum)
• Corrugator cutis ani (around the anal orifice)

Deep fascia
❖ What is deep fascia? Mention its clinical significance. AN4.4

• It is a dense, inelastic fibrous membrane that separates the superficial fascia

from the underlying structures. It is made up of regularly arranged collagen
fibres.
• It sends septa between muscles from its deep aspect forming intermuscular
septa (Fig. 30.3).
• It ensheaths the muscles, vessels and nerves. The sheath around the muscles
forms tunnels within which muscles can slide independent of the adjacent
muscles.
• It forms thickened bands – the retinacula – at certain sites, such as wrist and
ankle, which hold the tendons in place and prevent their bow stringing during
the movements of the hand and feet at these sites.
 FIG. 30.3 Transverse section through the middle of the right thigh to show the three
intermuscular septa and three osteofascial compartments as seen from above.

Clinical significance
The deep fascia forms fascial planes that are of special interest to surgeons because:

• They can operate along the fascial planes easily with minimal injury to
adjoining structures.
• Deep fascia provide better understanding of the location and the routes of
spread of pus as pus tracks along the fascial planes (i.e. paths of least
resistance).

❖ Enumerate the modifications of deep fascia. AN4.4

• Intermuscular septa, in limbs to form fascial compartments

• Retinacula, i.e. extensor and flexor retinacula around wrist and ankle
• Fibrous flexor sheaths in digits of hand and feet
• Aponeurosis, i.e. palmar aponeurosis in palm and plantar aponeurosis in sole
• Ligaments to connect the bones at joints
• Fascial sheath around certain muscles
• Interosseous membranes in forearm and leg

N.B.
In true sense, aponeurosis is a thick, wide sheet of fibrous tissue that provides
attachments to the muscles.
31

Skeletal system
The skeletal system is made up of bones and cartilages. It provides strong and flexible
framework to the body.

Bones
❖ What is bone?
The bone is a specialized connective tissue with mineralized matrix by calcium salts,
e.g. calcium hydroxyapatite crystals. It provides hardness to the human skeleton.

❖ Classify bones according to their shape.

Classification

Long bones: They consist of a shaft and two ends. The elongated tubular shaft or
body is called diaphysis. It contains medullary cavity within it. The expanded
ends are called epiphyses. Examples: Long bones of limbs such as femur, tibia
and fibula in the lower limb and humerus, radius and ulna in the upper limb.
Short long bones (also called miniature long bones): They have shaft and only one
epiphysis. Examples: Metatarsals, metacarpals and phalanges.
Short bones: They are smaller in size and usually cube shaped. Examples: Carpal
and tarsal bones.
Flat bones: They are flat (plate like) and consist of two layers (plates) of compact
bone with spongy bone, filled with bone marrow between them. Examples:
Bones forming the skull cap such as frontal, parietal and occipital. The ribs,
sternum and scapula are also classified as flat bones.
Irregular bones: They have irregular shape. Examples: Bones of the face and base
of the skull; vertebrae and hip bones.
Pneumatic bones: They contain cavities within them, which are filled with air.
These bones are confined to the skull. Examples: Paranasal bones such as
maxilla, ethmoid, sphenoid and frontal bones.
Accessory bones: They are sometimes present in the limbs and skull. Examples: Os
trigonum (os vesalianum), os cubiti in the limbs and wormian bones in the
skull.
Sesamoid bones: They develop in the tendons of muscles and are devoid of
periosteum. Examples: Patella and fabella.

❖ What are the functions of the bones?

Functions

• Form skeletal framework of the body, thus providing shape to the body.
• Protect vital organs such as brain, spinal cord, heart and lungs.
• Provide surface for attachments to the skeletal muscles.
• Act as a storehouse for mineral salts, e.g. calcium and phosphorus.
• Act as levers for the body movements by the muscles.
• Produce blood cells.

❖ Enumerate the structural components of a long bone.

Structural components

• Mineralized matrix
• Specialized cells, e.g. osteoblasts, osteocytes and osteoclasts
• Periosteum
• Endosteum
• Medullary cavity
• Bone marrow

❖ What are the sites where red bone marrow is present in adults? AN1.2
The sites where red bone marrow is present in adults:

• Proximal ends of femur and humerus

• Ribs
• Sternum
• Skull
• Vertebrae
• Hip bone

❖ What are the parts of a long bone? AN2.1

The long bone consists of the following parts:

• Epiphyses: Ends of a long bone that ossifies from secondary centres.

• Diaphysis: Shaft of a long bone that ossifies from a primary centre. It consists of
an outer cortex of compact bone and inner medullary cavity filled with bone
marrow.

❖ Write a short note on periosteum. AN2.1

The periosteum forms the outer fibrous covering of the bone. It covers whole of the
bone surface, except where bone is covered by articular cartilage. The periosteum is
attached to the bone tissue by Sharpey’s fibres. It consists of two layers:

• An outer fibrous layer, which becomes continuous at the ends of the bone with
the fibrous capsule of a joint. It protects the bone.
 • An inner cellular layer containing osteoprogenitor cells (osteogenic cellular layer),
which ends at the epiphyseal line. This layer is responsible for deposition of
bone on the surface of the shaft and thus adds to the growth of bone in girth. It
is also essential for fracture repair.

Functions

• Protects the bone, as it covers the outer surface of bone.

• Helps in bone formation, helping bone growth in young age and repair of
fracture in adults, as it contains bone-forming cells.
• Helps to provide nutrition to bone, as it is richly supplied with blood vessels.
• Makes bone sensitive to pain as it is supplied with sensory nerves.
• Provides medium for attachment of ligaments, tendons and muscles to the bone.

N.B.
All the bones in the body are covered by periosteum, except sesamoid bones and ear
ossicles.

❖ What are Sharpey’s fibres?

The periosteum is anchored to the outer part of bone tissue by Sharpey’s fibres.
From the inner layer of periosteum, coarse collagen fibres extend inwards to enter the
bone matrix. These are called Sharpey’s fibres (perforating fibres). The Sharpey’s fibres
enter the bone matrix like spikes of a shoe and thus anchoring the periosteum to the
bone.

❖ Classify bones according to their structure.

Structurally, the bones are classified into two types: compact bone and cancellous
bone. The differences between these two types are given in Table 31.1.

TABLE 31.1
Differences Between Compact and Cancellous Bones

Compact Bone Cancellous Bone

• Dense like an • Porous like a sponge
ivory
• No spaces are • Spaces are visible on naked eye examination
visible on naked
eye examination
• Located superficial • Located deep to compact bone
to cancellous bone
• Consists of • No haversian system. Consists of meshwork of bony spicules (small
haversian systems rods and curved plates) with spaces between spicules filled with bone
marrow; no Haversian system
• Lamellae are • Lamellae are arranged in irregular fashion
arranged in regular
 fashion
❖ Enumerate the parts of a growing/developing long bone. AN2.1
The parts of growing long bone (Fig. 31.1):

• Epiphysis: It is the end of long bones that ossifies from secondary centre.
• Diaphysis: It is the shaft/body of long bone that ossifies from secondary centre.
• Metaphysis: It is part of diaphysis near the epiphysis. It is a zone of active bone
growth.
• Epiphyseal plate: It is a plate of hyaline cartilage between epiphysis and
diaphysis. The epiphysial cartilage is responsible for growth of bone in length.
Hence, it is also called growth plate.

FIG. 31.1 Parts of a growing long bone.

❖ Write a short note on the arterial supply of a growing long bone.  AN2.1
The growing long bone is supplied by the following arteries (Fig. 31.2):

• Nutrient artery: It is tortuous and enters the middle of shaft through the nutrient
foramen. It runs obliquely through cortex into medullary cavity, where it divides
into ascending and descending branches. Each branch in turn divides and
redivides into parallel vessels, which run in metaphysis, where they terminate
by forming hairpin bends. The ascending and descending branches also ramify
in the endosteum and give twigs to adjoining canals.
 It supplies medullary cavity and inner two-thirds of cortex. The nutrient
foramen is directed opposite to growing end of long bone.
It anastomoses with periosteal and metaphyseal arteries.
• Juxta-epiphysial (metaphyseal) arteries: These are derived from arterial
anastomosis around the joint. They pierce the metaphysis along the line of
attachment of joint capsule.
• Epiphysial arteries: These are derived from periarticular vascular arcades,
found on nonarticular bony surface and enter the bone distal to epiphyseal
cartilage.
• Periosteal arteries: These ramify beneath the periosteum and supply the outer
two-third of the cortex. The removal of periosteum may cause necrosis of underlying
bone.

FIG. 31.2 Blood supply to a growing long bone.

N.B.
Nutrient arteries are the most source of blood supply to the bone.

❖ Metaphysis is the common site for osteomyelitis in children – mention its

anatomical basis. AN2.1
This is because the metaphysis is a zone of active growth. It is profusely supplied with
blood by end arteries, which form ‘hairpin bends’. The bacteria and emboli are easily
trapped in these hairpin bends leading to infarction and subsequently to osteomyelitis.

❖ Describe sesamoid bones briefly. AN2.3

The sesamoid bones are seed-like bony nodules found embedded in the tendons of
muscles (in Arabic: Sesame = seed).

Characteristic features

• Develop in tendons of the muscles after birth.

• Are devoid of periosteum.
• Are devoid of Haversian systems.
• Ossify by multiple secondary centres.

Functions

• Alter the direction of pull of muscle tendon.

• Minimize the friction of tendon against bone.
• Modify and sustain pressure.
• Provide additional articular surface to a joint.
• Protect the tendons from wear and tear.
• Act as pulleys for muscular contraction.

Sites

• Tendon of quadriceps femoris (patella)

• Lateral head of gastrocnemius muscle (fabella)
• Tendon of flexor carpi ulnaris (pisiform)
• Two bony nodules (sesamoid bones) beneath the head of 1st metatarsal in the
tendon of flexor pollicis brevis
• Bony nodule in the tendon of adductor hallucis
• Bony nodule in the tendon of peroneus longus where it winds around the
cuboid bone

❖ Define ossification and ossification centres. AN2.2

Ossification
It is the process of bone formation.

Ossification centre
The ossification centres are sites where bone formation begins.
There are two types of ossification centres: (a) primary and (b) secondary.

Primary centre: It appears before birth in the centre of shaft or body of bone which
it forms.
 Secondary centre: It appears later, usually after birth at each end of bone which it
forms.

❖ Write a short note on endochondral/cartilaginous ossification. AN2.2

It is the process of formation of bone from the preformed cartilaginous model
(premature long bone) (Fig. 31.3).

• The process of bone formation begins in the centre of the shaft of long bone. This
site where bone formation begins is called primary ossification centre. This
centre forms the diaphysis.
• Later, centres of ossification appear at different interval at each end of
cartilaginous model. These are called secondary ossification centres. These
centres form the epiphyses.
• The plate of hyaline cartilage separating the epiphysis and diaphysis is called
epiphyseal plate/growth plate. It is essential for growth of bone in length.
• When the epiphysis unites with the diaphysis, the epiphyseal plate is replaced
by a linear scar called epiphyseal line.

FIG. 31.3 Cartilaginous ossification of a long bone.

(For details, see Chapter 8, p. 84 of Textbook of Clinical Embryology, 1st ed. by Vishram
Singh.)

❖ Define membranous ossification. AN2.2

It is a process of bone formation from mesenchymal model. (For details, see Chapter 8,
p. 84 of Textbook of Clinical Embryology, 1st ed. by Vishram Singh.)

❖ What are the different types of epiphyses? AN2.1

There are four types of epiphyses:

Pressure epiphyses: They are present at the ends of long bone. They are, therefore,
 articular in nature and take part in the transmission of weight, e.g. head of
femur, lower end of radius and medial end of clavicle.
Traction epiphyses: They are nonarticular in nature and are not involved in
transmission of weight. They provide attachment to one or more muscle
tendons, which exert traction on it, e.g. greater and lesser trochanters of femur,
greater and lesser tubercles of humerus.
Atavistic epiphyses: Phylogenetically, they represent a separate bone, which in
man has become fused secondarily to another bone, e.g. coracoid process of
scapula, posterior tubercle of talus (os trigonum).
Aberrant epiphyses: They are not always present but appear sometimes, e.g.
epiphysis at the head of 1st metacarpal.

Cartilage
❖ What is cartilage? AN2.4
The cartilage is a specialized connective tissue, with rubbery matrix (gel-like matrix)
due to deposition of proteoglycans which provides firmness along with elasticity to
the skeletal framework of the body. Phylogenetically, it is older than the bone tissue.

• It is made up of dense network of collagen or elastic fibres, which provide

tensile strength to it.
• Its fibres are embedded in a firm, jelly-like amorphous substance made up of
mucopolysaccharides, which allows the cartilage to bear weight without
bending.
• It is firm in consistency and has elasticity.
• It is an avascular tissue. The invasion of cartilage by blood vessels results in its
calcification and death.
• It has no lymphatics.
• It is well adapted to coat the articular ends of the bone.

❖ What are the different types of cartilages? AN2.4

The cartilages are classified into three types: (a) hyaline cartilage, (b) yellow elastic
cartilage and (c) fibrocartilage.
For details see Chapter 39, p. 333.
32

Joints
❖ Define joints and describe their classification. AN2.5
The joints are the junctions/meeting points between two or more bones. However, they
can also be formed between bone and cartilage or between bone and tooth.

Classification
Joints are classified in two ways:

• On the basis of type of tissue (fibres or cartilage) binding the articulating bones
or presence or absence of synovial cavity between the articular bones (structural
classification).
• On the basis of range and type of movement they permit (i.e. functional
classification).

Structural classification

• Fibrous joint: It lacks the joint cavity and the articular bones are joined by the
fibrous tissue. These joints are immovable or permit only slight movement.
• Cartilaginous joint: It also lacks the joint cavity and the articular bones are
joined by the cartilage. These joints are immovable or permit only slight
movement.
• Synovial joint: It has a joint cavity. The articular surfaces of the bones are
covered by the articular (hyaline) cartilage. The articular bones are enclosed by
a fibrous capsule. The joint cavity between the articular surfaces contains
viscous synovial fluid. These joints are freely movable and permit maximum
degree of movement.

Functional classification

• Immovable joint (synarthrosis), e.g. fibrous joints (vide supra)

• Slightly movable joints (amphiarthrosis), e.g. cartilaginous joints (vide supra)
• Movable joints (diarthrosis), e.g. synovial joints (vide supra)

❖ What are the different types of fibrous joints? AN2.5

• Sutures: These joints are found in the skull and are immovable (i.e.
synarthrosis). The articulating bones are connected by sutural ligaments or thin
membranes of fibrous tissue.
• Syndesmosis: The articulating bones are connected to each other by
interosseous ligaments, and bones involved lie at some distance apart, e.g.
inferior (distal) tibiofibular joint (Fig. 32.1). Slight movement is permitted at
these joints; hence, functionally it is classified as amphiarthrosis.
• Gomphosis/peg and socket joint (dentoalveolar joint): Here, the cone-shaped
root of the tooth fits into the alveolar socket of the jaw. The tooth is attached to
the alveolar socket by the fibrous tissue (periodontal ligaments) (Fig. 32.2).

FIG. 32.1 Syndesmosis: inferior tibiofibular joint representing syndesmosis.

 FIG. 32.2 The gomphosis (peg and socket joint): tooth in alveolar socket representing
gomphosis.

This type of joint is immovable, hence functionally classified as synarthrosis.

❖ Define a synovial joint and mention the characteristic features of a typical

synovial joint.  AN2.5
A synovial joint is a joint with cavity between the two or more articulating bones. The
cavity is lined by synovial membrane and is filled with a synovial fluid. The synovial joints
permit a free movement, hence functionally classified as diarthrosis.

Characteristic features
The characteristic features of a typical synovial joint (Fig. 32.3):

• Articular surfaces are covered with hyaline (articular) cartilage, which provides
smooth, slippery surface to reduce friction between the articular surfaces of the
bones during movement.
• Articular ends of bones are enclosed by a fibrous capsule; hence, it has joint
cavity.
• Inner surface of capsule and all intra-articular structures, except articular
cartilages, are covered by a synovial membrane, which secretes synovial fluid.
• They are freely movable joints, hence functionally classified as diarthroses.
• Joint cavity is filled with synovial fluid.
 FIG. 32.3 Diagrammatic representation of a typical synovial joint.

❖ What are the differences between atypical, complex and compound synovial
joints?  AN2.5

• If the articular surfaces of a synovial joint are covered by a fibrocartilage, it is

termed atypical synovial joint, e.g. temporomandibular joint.
• If the cavity of a synovial joint is divided completely or incompletely into two
compartments by an intra-articular disc, it is called complex synovial joint, e.g.
temporomandibular joint and sternoclavicular joint.
• If more than two articular surfaces are enclosed in a single fibrous capsule, it is
called compound synovial joint, e.g. elbow joint.

❖ Classify various types of synovial joints. AN2.5

• Plane joints: These are the joints in which the articular surfaces are flat and in
contact. Only gliding movements are possible at these joints. Examples:
Intercarpal joints and intertarsal joints.
• Hinge joints: These are the joints in which one articular surface is convex and
the other is reciprocally concave. The movements take place around a
transverse axis. Examples: Humeroulnar joint, interphalangeal joints, knee joints
and ankle joints.
• Pivot joints: These are joints in which a bony pivot-like process rotates within
an osseofibrous ring or an osseofibrous ring rotates around the bony pivot.
Thus, the movements are possible only around longitudinal axis through centre
of pivot. Examples: Superior radioulnar joint, inferior radioulnar joint and median
atlantoaxial joint.
• Condylar joints: In such joints, the convex condyle or condyles (articular
 surfaces) of one bone articulate with concave articular surface or surfaces of
other bone. Movements occur not only mainly in transverse axis but also partly
in vertical axis (rotation). Examples: Knee joint and temporomandibular joint.
• Ellipsoid joints: These joints are formed by an oval convex surface of one bone
and an elliptical concave surface of the other bone. Examples: Radiocarpal joint
(wrist joint) and metacarpophalangeal joints. Movements that are possible at such
joints are flexion, extension, abduction, adduction and circumduction. No
rotation occurs around central axis.
• Saddle joints: In such joints, the articular surfaces are reciprocally
concavoconvex (saddle shaped). Movements permitted at these joints are same
as in condylar type with some rotational movement. Examples:
Carpometacarpal joint of thumb, sternoclavicular joint, calcaneocuboid joint
and incudomalleolar joint.
• Ball and socket joints: In such joints, the rounded articular surface of one bone
(the ball) fits into a cup-shaped cavity (the socket) of other bone. In these joints,
the movements are possible in every direction around a common centre.
Examples: Hip joint and shoulder joint.

❖ What are the types of cartilaginous joints? AN2.5

There are two types of cartilaginous joints: primary and secondary.

• Primary cartilaginous joints (synchondroses): The bones forming these joints

are united by a hyaline cartilage. They are immovable (synarthroses). After
certain age, the hyaline cartilage is slowly replaced by bone (synostosis).
Examples: Joints between epiphysis and diaphysis of a growing long bone,
costochondral joints, spheno-occipital joint (joint between basiocciput and
basisphenoid at the base of skull) and 1st costosternal joint. These are temporary
joints.

N.B.
The primary cartilaginous joint between basiocciput and basisphenoid is converted into
synostosis at about 25 years of age.

• Secondary cartilaginous joints (symphyses): These joints occur in the median

plane of the body. The articular surfaces are covered by a plate of hyaline
cartilage, which are then connected by a broad, flat fibrocartilaginous disc.
Examples: Manubriosternal joint, pubic symphysis and intervertebral discs.
These are permanent joints and do not disappear with age. Slight movement is
possible (amphiarthrosis) at these joints.

❖ Compare and contrast the primary and secondary cartilaginous joints. AN2.5

Primary Cartilaginous Joint Secondary Cartilaginous Joint

• Articular surfaces are united by a hyaline cartilage • Articular surfaces are united by a
fibrocartilage
 • Immovable • Partially movable
• Temporary, as they ossify with age • Permanent, as they do not ossify with
age
• May or may not lie in midline • Always lie in midline
• Examples are joints between epiphysis and • Examples are symphysis pubis,
diaphysis, and between basiocciput and intervertebral discs, manubriosternal
basisphenoid joint
❖ What are the closed-packed and loose-packed positions of a joint? AN2.5

Closed-packed position
It is the position of a joint in which fibrous capsule and ligaments are taut and articular
surfaces are fully congruent, i.e. have maximum area of contact with each other. This is
the most stable position of joint and therefore dislocations are rare in this position.

Loose-packed position
It is the position of a joint in which articular surfaces are not congruent. The capsule and
ligaments are lax. This is an unstable position of joint; therefore, dislocations commonly
occur in this position.

❖ Enumerate the intra-articular structures found within the synovial joint. AN2.5

• Cartilaginous structures:
■ Articular discs of temporomandibular and sternoclavicular joints
■ Articular menisci (semilunar cartilages) of the knee joint
■ Labrum: Glenoid labrum of the shoulder joint and the acetabular labrum of the
hip joint
• Ligament-traversing joint: They bind articular surfaces, e.g. ligamentum teres
of the hip joint and cruciate ligaments of the knee joint
• Tendons traversing the joint cavity: These arise inside capsule of joint and
transverse the joint cavity, e.g. tendon of long head of biceps traversing the
cavity of shoulder joint and tendon of popliteus traversing the cavity of the
knee joint

❖ List the nerve supply of a synovial joint. AN2.6

The synovial joint is supplied by three types of nerves:

• Sensory nerves carrying pain from articular fibrous capsule, ligaments and
synovial membrane.
• Sensory nerves carrying proprioceptive sensations from articular fibrous capsule and
ligaments.
• Autonomic nerves supplying blood vessels. They regulate the flow of blood in an
articular fibrous capsule.

❖ What is Hilton’s law? AN2.6

This law enunciates that the nerves supplying sensory fibres to the capsule of the joint
also supply the muscles crossing the joint and skin over the joint. Therefore, when the
joint is diseased, the irritation of these nerves cause (a) reflex spasm of muscles to bring
the joint in the position of maximum comfort and (b) the pain of joint is referred to the
overlying skin.

❖ What are the types of movements that commonly occur in the synovial joints? 
AN2.5
Four types of movements commonly occur in the synovial joints:

• Gliding
• Angular
• Circumduction
• Rotation

❖ Write a short note on adjunct and conjunct rotation.

The rotation around a longitudinal axis is called rotation proper. It may be adjunct or
conjunct.
The adjunct rotation takes place actively by some muscles, while the conjunct rotation
takes place passively due to configuration of the articular surfaces or tension of some
ligaments.
The differences between the adjunct and conjunct rotation are summarized in the
following table:

Adjunct Rotation Conjunct Rotation

• Active movement • Passive movement
• Takes place by some muscles • Takes place due to configuration of articular
surfaces or tension of some ligaments
• Examples are rotation of hip, shoulder • Examples are rotation of knee joint during locking
and atlantoaxial joints and unlocking
❖ Enumerate the factors maintaining stability of the joints.

• Configuration of articular surfaces

• Ligaments
• Muscles
• Atmospheric pressure
33

Muscles
❖ What is the muscle? AN3.1
The muscle is a contractile tissue (the muscle cells contain contractile proteins in their
cytoplasm) that brings about the movements of the body. During contraction, the
muscles shorten and convert the chemical energy into mechanical energy.

❖ What are the different types of muscles? AN3.1

There are three types of muscles:

• Skeletal muscle
• Cardiac muscle
• Smooth muscle

❖ What are the properties of the muscles? AN3.1

The properties of muscles are as follows:

• Irritability, i.e. they are sensitive to stimuli.

• Contractility, i.e. they contract in response to stimuli.
• Extensibility, i.e. they can stretch.
• Elasticity, i.e. they can assume a desired shape after being stretched.

❖ Compare and contrast three types of muscles – skeletal, cardiac and smooth. 
AN3.1
This is given in Table 33.1.

TABLE 33.1
Comparison and Contrast Between Skeletal, Cardiac and Smooth Muscles

❖ Classify the various types of muscles according to their shape and direction of
their muscle fibres.  AN3.2

• When the direction of muscle fibres is parallel to each other, i.e. in line of pull
■ Strap muscles: These muscles are like long ribbons. Examples: Sternohyoid,
sternothyroid and sartorius.
■ Fusiform muscles: These muscles are spindle shaped. Examples: Biceps
femoris and biceps brachii.
■ Quadrilateral/quadrate muscles: These muscles are square shaped.
Examples: Pronator quadratus and thyrohyoid.
■ Flat muscles: These muscles are in the form of thin sheets of fleshy fibres.
Examples: Muscles of anterior abdominal wall such as external oblique,
internal oblique, and transversus abdominis.
• When the direction of muscle fibres is oblique to line of pull
■ Triangular, e.g. temporalis and adductor longus.
■ Pennate (feather-like):
■ Unipennate, e.g. extensor digitorum longus, flexor pollicis longus,
palmar and plantar interossei.
■ Bipennate, e.g. rectus femoris, dorsal interossei and flexor hallucis
longus.
■ Multipennate, e.g. deltoid (acromial part) and subscapularis.
■ Circumpennate, e.g. tibialis anterior.
• When the direction of muscle fibres is circular, i.e. they are arranged circularly
around the orifice, e.g. orbicularis oris and orbicularis oculi.
• When the muscle fibres are arranged in a twisted manner, e.g. trapezius,
pectoralis major and latissimus dorsi.
• When the muscle fibres are arranged in two planes in different directions and
cross, these are called cruciate muscles, e.g. masseter, sternocleidomastoid and
adductor magnus.

❖ Enumerate the parts of a typical skeletal muscle. AN3.2

These are given in the following flowchart:

❖ What is the difference between the fleshy and tendinous parts of a muscle. 
AN3.1
The differences are given in Table 33.2.
TABLE 33.2
Differences Between Fleshy and Tendinous Parts of a Muscle

Fleshy Part Tendinous Part

• Highly specialized • Unspecialized
• Contractile • Noncontractile
• Vascular • Avascular
• Cannot withstand friction • Can withstand friction
❖ Write a short note on a tendon. AN3.1

• The tendon is silvery white, fibrous, cord-like part of the muscle, which connects
the muscle to the bone. It is made up of parallel, dense, collagen fibres. The
tendon transmits forces of muscular contraction to the bone. It is attached to the
periosteum and through it to the cortical bone through Sharpey’s fibres.
• The fibres of tendon are twisted or plaited so that the force of muscle pull is
distributed to all the points at the site of insertion.
• The tendon is extremely powerful; for example, a tendon with cross-sectional
area of 1 square inch can support a weight up to 9700–18,000 pounds.

When tendon is subjected to sudden accidental traction at its insertional end, it may
cause avulsion/fracture of the bone without being ruptured itself. This shows
tremendous power of the tendon.

❖ What is ‘aponeurosis’? AN3.2
The aponeurosis is a silvery white, flat fibrous sheet that connects the muscle to the bone
or deep fascia. It is made up of densely arranged collagen fibres. The aponeurosis
provides a wider area of muscular attachment.

❖ Classify muscles according to the force of their action. AN3.3

Classification

• Spurt muscles
• Shunt muscles

When muscle contracts, its force of contraction at the site of insertion is resolved into
two components: (a) swing and (b) shunt. Swing component produces movement at the
joint, while shunt component pulls the distal bone towards the joint.
If the site of insertion is close to the joint and the site of origin is away from the joint,
when the muscle contracts, its swing becomes more powerful than shunt. These
muscles are called spurt muscles, e.g. brachialis.
On the contrary, if the site of insertion is away from the joint and the site of origin is
close to the joint, then shunt becomes more powerful than swing. Such muscles are
called shunt muscles, e.g. brachioradialis.
❖ What are the types of muscles according to their action? AN3.2
A single muscle or a group of muscles alone cannot produce a desired movement at a
particular joint.
Any particular movement of a joint is brought about by a group of muscles, while the
whole range of any movement is brought about by the smooth coordinated actions of
different groups of muscles. These groups of muscles are as follows:

• Prime movers (agonists): These are the muscles that initiate and bring about a
desired movement. They are responsible for the specific movements. Examples:
Biceps brachii and brachialis are prime movers to cause flexion at elbow joint.
• Antagonists: These are the muscles that have opposite action to that of prime
movers, i.e. they oppose prime movers or initiate and maintain a movement
converse to that produced by agonists. Examples: Triceps brachii, which acts as
antagonist during flexion of the elbow joint but helps in smooth flexion of the
elbow joint by gradually relaxing itself.
• Fixators: These are the muscles that stabilize the proximal joint/joints of a limb
to provide a fixed base for the agonist muscle (prime mover) to act on a distal
joint to bring about a desired movement.
• Synergists: These muscles help the prime movers in bringing out the desired
movement. They eliminate the undesired actions at proximal joint when the
prime movers cross two or more joints. Examples: While making a tight fist,
extensors of the wrist act as synergists to long flexor tendons.

❖ Write a short note on the nerve supply of a skeletal muscle. AN3.1

The nerves supplying skeletal muscles are somatic nerves and consist of three
functional components.

Motor fibres: They enter the individual muscle fibres at a point called motor end
plate/neuromuscular junction. The nerve fibres are of following two types:
■ Alpha motor fibres arising from alpha motor neurons of anterior horn cells
and supply the extrafusal muscle fibres.
■ Gamma motor fibres arising from gamma motor neurons of anterior horn cells
and supply the intrafusal muscle fibres of muscle spindle (sensory end
organ of skeletal muscle).
Sensory fibres:
■ Myelinated fibres: They are distributed to muscle spindles, tendon and fascia
of the muscle and carry exteroceptive and proprioceptive sensations. The
fibres carrying pain sensations are free nerve endings around the muscle
fibres, while the fibres carrying sensation of tension and degree of
contraction, end in special sense organs called Golgi tendon organs.
■ Nonmyelinated fibres: Distribution of these fibres is not known as yet.
Autonomic fibres: These fibres innervate the smooth muscle of the blood vessels
present within the muscle. These fibres thus regulate the amount of blood flow
 in the muscle.

❖ Write a short note on motor unit. AN3.1

It is a functional unit of muscle. It consists of a single alpha motor neuron and all the
muscle fibres which it innervates (Fig. 33.1).

FIG. 33.1 Motor unit.

About 150 muscle fibres are innervated by a single alpha motor neuron (Fig. 33.1).
The motor units are of two types: large and small.
The large motor units supply large number of muscle fibres, i.e. 2000–3000. These
units supply muscles responsible for coarse but powerful actions, e.g. gluteus maximus,
gastrocnemius and deltoid.
The small motor units supply small number of muscle fibres, i.e. 10–20. These units
supply muscles responsible for fine and precise movements, e.g. muscles causing eye
movements, finger movements and vocal cord movements.

❖ Write a short note on neuromuscular junction (or motor end plate). AN3.1

It is a junction between the nerve terminal and cell membrane (sarcolemma) of a muscle
fibre. At neuromuscular junction, the axon loses its myelin sheath and breaks up into
number of branches to supply the individual muscle fibres. Each branch becomes
distended to form synaptic knob which contains large number of vesicles containing
acetylcholine. The muscle fibre at this site also becomes specialized into a sole plate
(Fig. 33.2). Here the muscle membrane, i.e. sarcolemma, is thrown into folds and
contain receptors for acetylcholine.
 FIG. 33.2 Neuromuscular junction.

The narrow space between the two plates – the synaptic cleft – is filled by a chemical
substance called acetylcholine (a neurotransmitter). At the time of passage of impulse,
the acetylcholine is broken down by an enzyme called acetylcholinesterase.

N.B.
At neuromuscular junction, the impulse is transmitted from nerve to the muscle.

❖ Define a synovial bursa and mention its types.

The synovial bursa (bursa = purse) is a closed sac of synovial membrane filled with a
capillary film of a synovial fluid. The bursae are supported by an irregular connective
tissue. They reduce friction between two mobile units to permit free movements.

Types
According to the location, the synovial bursae are classified into the following types:

• Subcutaneous, between skin and bone, e.g. prepatellar bursa and subcutaneous
infrapatellar bursa.
• Submuscular, between muscle and bone, e.g. bursa deep to medial head of
gastrocnemius.
• Subtendinous, between tendon and bone, e.g. trochanteric bursa of gluteus
medius.
• Subfascial, between fascia and bone.
• Interligamentous, between ligaments.

❖ What are adventitious bursae?

The adventitious bursae develop in the subcutaneous tissue over bony prominences
where the skin is subjected to pressure and friction. Examples:
• Tailor’s ankle: A bursa develops over lateral malleolus in tailors who sit in
cross-legged position while at work, thus bringing lateral malleolus in contact
with the table leading to pressure and friction.
• Weaver’s bottom: A bursa develops between gluteus maximus and gluteal
tuberosity in weavers who sit for prolonged periods for weaving the cloth.
• Porter’s shoulder: A bursa develops over clavicle in porters who hang heavy
luggage on their shoulders.
34

Cardiovascular system
❖ Define cardiovascular system and mention its functions. AN5.1
The cardiovascular system consists of heart and blood vessels.

Functions

• Distribution of nutrients and oxygen to all body cells

• Distribution of hormones to target tissues
• Thermoregulation
• Removal of metabolic waste products and CO2 from all body cells

❖ Classify blood vessels. AN5.3

The blood vessels are classified into the following types:

• Arteries
• Arterioles
• Capillaries and sinusoids
• Venules
• Veins

❖ What are the differences between the arteries and veins? AN5.3

The differences between the arteries and veins are shown in Table 34.1 and Fig. 34.1.

TABLE 34.1
Differences Between Arteries and Veins

Features Arteries Veins

Thickness of wall Thick walled Thin walled
Valves Absent Present
Lumen Narrow (always patent) Larger (may be collapsed)
Fibromuscular tissue More Less
Elasticity More Less
Internal elastic lamina Well defined Not seen
Tunica media Thicker than tunica adventitia Thinner than tunica adventitia
Thickest coat Tunica media Tunica adventitia
 FIG. 34.1 Microscopic structure of a medium-sized artery and vein as seen in a cross-section:
A, artery; B, vein. Note the lumen is surrounded by three concentric coats: tunica intima, tunica
media and tunica adventitia.

❖ What are types of circulation? Describe each type in brief. AN5.2

There are two types of circulation:

• Pulmonary
• Systemic

Pulmonary circulation
In pulmonary circulation, the blood is pumped by the heart into the lungs through
pulmonary trunk for oxygenation and then the oxygenated blood is returned to the
heart via pulmonary veins.

Systemic circulation
In systemic circulation, the oxygenated blood is pumped by the heart to the entire body
through arteries and then the deoxygenated blood is returned to the heart via veins.

❖ Discuss the portal circulation in brief. AN5.5

The portal circulation begins and ends with capillaries, i.e. blood passes through two
sets of capillaries before it is drained into a systemic vein. The vessels connecting two
sets of capillaries are called portal vessels.
The portal circulation is seen in the liver, hypophysis cerebri, kidney and suprarenal
gland, where it is termed hepatic portal circulation, hypothalamo-hypophyseal portal
circulation, renal portal circulation and suprarenal portal circulation, respectively.

❖ Write a short note on hepatic portal circulation.  AN5.5

In hepatic portal circulation, the venous blood from capillary bed of GIT (also from
spleen and pancreas) passes to the hepatic sinusoids (capillary bed) through the portal
vein before it is drained into a systemic vein – the inferior vena cava (Fig. 34.2).
 FIG. 34.2 Hepatic portal circulation.

❖ What are the various types of arteries? AN5.4

The arteries are of three types:

• Elastic/conducting arteries, e.g. aorta, pulmonary trunk, common carotids,

brachiocephalic trunk and subclavian arteries.
• Muscular/distributing arteries (most common), e.g. branches of carotids, axillary,
brachial, femoral and popliteal arteries.
• Arterioles (smallest type of muscular arteries with diameter <0.1 mm).

❖ Write a short note on arteriole. AN5.4

• These are the smallest muscular arteries.

• The cross-sectional diameter of arteriole is about 100 microns.
• The arteriole at the arterial end possesses all the three coats in its wall.
• The arterioles progressively divide and finally terminate by forming terminal
and meta-arterioles.
■ Terminal arterioles are covered by continuous coat of smooth muscle cells.
■ In meta-arterioles, the smooth muscle coat is replaced by discontinuous
contractile cells called pericytes (Rouget cells).
• The passage of blood into capillaries is regulated by precapillary sphincters.

Functions of arterioles

• Regulate the flow of blood into capillaries by constriction or dilatation of their

muscular walls.
• Regulate systolic blood pressure by offering peripheral resistance.
Applied anatomy
The persistence in the tone of arterial wall leads to hypertension.

❖ Write a note on arterial supply of an artery.

• The tunica adventitia and outer two-third of tunica media is supplied by vasa
vasorum.
• The tunica intima and inner one-third of tunica media is supplied by luminal
blood.

❖ Mention the nerve supply of an artery.

The arteries are supplied by sympathetic nerves via nervi vasorum. These are
vasoconstrictor.

N.B.
The sympathetic fibres supplying arteries are vasoconstrictors, except those that supply
heart, brain and skeletal muscles, which are vasodilators.

❖ What is the difference between capillaries and sinusoids. AN5.7

The differences between capillaries and sinusoids are given in the Table 34.2.

TABLE 34.2
Differences Between Capillaries and Sinusoids

Features Capillary Sinusoid

Lumen Smaller and regular in shape (5–8 Larger and irregular in shape (up to 30
microns) microns)
Endothelial Continuous or fenestrated May be incomplete and some phagocytic
lining cells are present
Basal lamina Thicker Thinner
Adventitial Present Absent
support
Location Connect arterioles and venules Connect arterioles with venule or venule
with venule
❖ Enumerate the organs where fenestrated capillaries are present.

• Pancreas
• Intestine
• Renal glomeruli
• Endocrine glands
• Skin

❖ Enumerate the structures where continuous capillaries are present.

 • Lungs
• Muscles (skeletal and smooth)
• Fascia
• Brain
• Testis

❖ Name the organs where sinusoids are present.

• Liver
• Spleen
• Adrenal medulla
• Carotid body
• Bone marrow

❖ Describe the arterial anastomosis under the following headings: (a) definition, (b)
types and (c) functions. AN5.6
The arterial anastomosis is the communication between the branches of two or more
arteries supplying the same organ or region.
The arteries do not always end in capillaries; they unite with one another through
their branches forming anastomosis.

Types
There are two types of anastomoses:

Actual anastomosis: In this, the two arteries connect to each other end-to-end, e.g.
anastomosis between the labial branches of the facial arteries in the lips; and
right and left gastric arteries along the lesser curvature of the stomach. When
the anastomotic channel is cut, the blood spurts with equal force from the both
cut ends of the anastomotic vessel (i.e. blood spurts from both directions).
Potential anastomosis: In this, the anastomosis occurs between terminal arterioles
of arteries, if given sufficient time. The anastomotic channels formed by the
arterioles can dilate and may provide sufficient blood to area supplied (i.e.
efficient collateral circulation), e.g. coronary arteries, cortical arteries of cerebral
hemispheres and anastomosis around joints of the limbs. When the anastomotic
channel is cut, the blood spurts from only the one cut end of the anastomotic
vessel.

Functions

• Provides alternate route (collateral circulation) for blood to reach the

tissue/organ when one of the vessels is blocked/compressed.
• Equalizes blood pressure over territories which they supply.

❖ Describe the end arteries in brief and mention their clinical significance. AN5.6
These are the arteries that do not anastomose with neighbouring arteries, e.g. central
artery of retina, arteries of spleen, liver, kidneys, metaphyses of long bones, central
branches of the cerebral arteries.

Clinical significance
If an end artery is occluded/blocked, the tissue in area supplied by this vessel is
deprived of blood and suffers from ischaemia and may undergo ischaemic cell necrosis
called infarction (Fig. 34.3).

FIG. 34.3 Anatomical end artery.

❖ Write a short note on functional end arteries. AN5.6

These are the arteries which supply the same organ and also have anastomosis between
them but if one of them is blocked suddenly, the other is unable to supply the sufficient
blood to the organ and maintain its viability (Fig. 34.4), e.g. coronary arteries of the
heart.
 FIG. 34.4 Functional end artery (nonfunctional anastomosis).

N.B.
The anastomosis between functional end arteries does dilate but does so gradually to
provide sufficient collateral circulation.

❖ Briefly describe arteriovenous shunts. AN5.7

The arteriovenous shunts are communicating channels between the arteries and veins,
and when they open, the blood bypasses the capillaries, e.g. in skin of nose, lips,
external ear, mucous membrane of alimentary canal, thyroid gland, palmar skin.

Functions of arteriovenous shunts

• Regulation of the regional blood flow

• Regulation of blood pressure
• Regulation of the temperature

❖ Enumerate the veins devoid of valves.

• Superior vena cava (SVC)

• Inferior vena cava (IVC)
• Hepatic veins
• Portal vein
• Renal veins
• Uterine veins
• Gonadal veins
• Facial veins
 • Emissary veins

❖ Enumerate the veins devoid of muscular tissue in their walls.

• Dural venous sinuses

• Veins of pia mater
• Retinal veins
• Veins of placenta (maternal part)
• Veins of spongy substance of bones

❖ Enumerate the factors that facilitate venous return.

• Negative intrathoracic pressure (for SVC and IVC)

• Muscular contractions
• Arterial pulsations
• Gravity (for veins of head and neck)
35

Lymphatic system
❖ What is lymphatic system? AN6.1
The lymphatic system is a closed system of vessels which drains colloid tissue fluid to
blood vascular system by an alternative route; hence, it is considered as auxiliary
system to the venous system. It essentially consists of a series of lymph vessels and
lymph nodes. It actually drains tissue fluid made up of macromolecules of proteins, fat
droplets, bacteria, etc., which could not be drained by veins. It also helps to protect the
body from harmful agents such as bacteria and viruses.

N.B.
The lymph vessels also transport nutrient-rich lymph called chyle from the small
intestine to the blood.

❖ Enumerate the components of lymphatic system and list its functions. AN6.1

Components

• Lymph vessels
• Peripheral lymphoid organs, e.g. lymph nodes and spleen
• Central lymphoid organs, e.g. bone marrow and thymus
• Epitheliolymphoid system, e.g. MALT (GALT and BALT)
• Lymphocytes, e.g. B lymphocytes and T lymphocytes

Functions

• Helps the venous system to drain the colloidal components of the tissue fluid
• Helps in the absorption of digested fat
• Filters particulate matters and noxious agents (bacteria, etc.) of lymph
• Produces lymphocytes
• Produces antibodies (immune substances)
• In pathological conditions, it provides channels for spread of infection and
cancer cells

❖ What are lymph capillaries and explain how they differ from blood capillaries? 
AN6.2
The lymph capillaries begin blindly in the tissue spaces and form intricate networks.
They differ from blood capillaries in the following ways:
 • They are larger in size and more regular and permeable to bigger molecules (i.e.
macromolecules).
• They form pathways for absorption of colloidal tissue fluid with
macromolecules such as proteins and particulate matter from tissue spaces.

❖ Enumerate the sites where lymph capillaries are absent.

• Epidermis
• Hair
• Nails
• Cornea
• Articular cartilages
• Splenic pulp
• Spinal cord
• Brain
• Bone marrow

❖ Enumerate the factors that facilitate the drainage of lymph.

• Filtration pressure in tissue spaces generated by filtration of fluid from blood

capillaries.
• Contraction of surrounding muscles compressing the lymph vessels.
• Pulsations of arteries adjoining the lymph vessels.
• Respiratory movements and negative intrathoracic pressure.
• Contraction of smooth muscles in the wall of the lymph vessels.

❖ Write a short note on the lymph node.

The lymph nodes are oval or reniform bodies situated in the course of lymph vessels.
The size of lymph nodes varies from pin head to a large bean. They have slight
depression on one side called hilum. The blood vessels enter and leave the node at the
hilum of the node. The several afferent lymph vessels enter the periphery of lymph
node, while only a single efferent lymph vessel emerges at the hilum.
Their normal colour is greyish-pink. They are usually found in groups and depending
on their location they are generally divided into two groups: superficial group of lymph
nodes and deep group of lymph nodes.
Note: The lymph nodes are the only lymphoid organs that possess both afferent
and efferent lymph vessels.

Structure (fig. 35.1)

The lymph node consists of two major components: (a) connective tissue framework
and (b) parenchyma.

• The connective tissue component forms:

■ Capsule
 ■ Trabeculae
■ Reticular stroma
• The parenchyma forms:
■ Cortex
■ Paracortex
■ Medulla

FIG. 35.1 Structure of a lymph node.

The capsule is made up of connective tissue (mainly collagen fibres) and sends
prolongations (trabeculae) within the body of lymph node. Beneath the capsule lies
subcapsular sinus, this receives afferent lymph vessels.
The cortex (the outer peripheral part of the lymph node) contains lymphatic nodules.
The lymph nodules mainly consist of B lymphocytes. The central parts of the lymph
nodules contain germinal centres made up of rapidly dividing, lightly stained cells the
lymphoblasts.
The paracortex (the inner part of cortex) consists mainly of T lymphocytes and is
called thymic-dependent zone.
The medulla (the inner central part of the lymph node) consists of network of
anastomosing medullary cords with intervening medullary sinuses.
The medulla contains mature B lymphocytes, plasma cells and macrophages.

N.B.
Lymph nodule: These are nodular structures of densely packed B lymphocytes. Many of
these nodules show less-dense central region called germinal centre. Thus, nodules of
the lymph nodes are classified into two types:

(a) Primary lymph nodules, i.e. nodules without germinal centres.

(b) Secondary lymph nodules, i.e. nodules with germinal centres.

The germinal centres are not seen in infants and children because in them the
lymphatic nodules are not exposed to antigens. The germinal centres contain
lymphoblasts which form plasma cells, which in turn produce antibodies essential for
body defense.

❖ Enumerate the functions of the lymph nodes.

• Act as filters for lymph, thus preventing entry of foreign particles, pathogens,
etc. into the bloodstream.
• Macrophages in sinuses of the lymph nodes engulf foreign particles.
• Trap the antigens by phagocytes.
• Produce mature B and T lymphocytes.
• Provide site for interaction between antigen-laden phagocytes and lymphocytes
to produce immune response – both cellular and humoral.
• Produce antibodies.
36

Nervous system
❖ Define nervous system and list its functions. AN7.1
The nervous system is the most complicated, widely investigated and least understood
system of the body. It controls all the other systems of the body. Hence, it is also called
the master system of the body.

Functions

• Provides information of the internal and external environment.

• Integrates and processes sensory information.
• Controls motor activities of the body.
• Assimilates experience.
• Responsible for memory, learning and intelligence.

❖ What is neuron? Describe the structure of a typical neuron. AN7.3

The nerve cell along with its processes is called neuron.

Structure of a typical neuron

The typical neuron consists of a cell body (perikaryon) and two types of processes: short
and long. The typical neurons have many short processes called dendrites, and a single
long process called an axon.

• Cell body (perikaryon): It is a mass of cytoplasm bounded by a plasma

membrane. The cytoplasm contains large nucleus with prominent nucleolus and
basophilic Nissl bodies (Nissl substance). The Nissl substance forms the
characteristic feature of nerve cell. It consists of large aggregations of rough
endoplasmic reticulum made of ribonucleic acid and is concerned with the
protein synthesis.
• Dendrites: These are many small processes that conduct impulses towards the
cell body. They branch to form a dendritic tree.
• Axon: It is a single long process, which conducts impulses away from the cell
body. It begins at axon hillock (cone-shaped portion of the cell body) and
terminates by dividing into axon terminals (telodendria).

❖ What are the three main morphological types of neurons? AN7.3

The three main morphological types of neurons are bipolar, multipolar and
pseudounipolar (Fig. 36.1).
 Bipolar neurons: They have two processes arising one at each pole of the cell
body. Such types of neurons are found in retina, olfactory neuroepithelium and
vestibular and cochlear ganglia.
Multipolar neurons: They have several processes arising from cell body (i.e. many
dendrites and a single axon), e.g. lower motor neurons (LMNs) of brain and spinal
cord.
Pseudounipolar neurons: They have a single process arising from the cell body,
which after a short course bifurcates at T-junction into peripheral and central
processes, e.g. neurons of dorsal root ganglia and sensory ganglia of cranial nerves.

FIG. 36.1 Three main morphological types of neurons: A, pseudounipolar; B, bipolar; C,

multipolar.

❖ Briefly describe a typical spinal nerve. What is its distribution and applied
anatomy? AN7.4
There are 31 pairs of spinal nerves. However, only T3 to T6 spinal nerves represent the
typical spinal nerves.
The typical spinal nerve arises from spinal cord by two roots: anterior and posterior.
The anterior root is motor while the posterior root is sensory and possesses a ganglion
called dorsal/posterior root ganglion (Fig. 36.2).
 FIG. 36.2 A typical spinal nerve. DR, dorsal ramus; VR, ventral ramus.

The two roots unite to form the nerve trunk, which divides into two rami: dorsal and
ventral. The small dorsal ramus passes backwards to the muscles on the back of the
vertebral column. Here, it divides into medial and lateral branches which supply the
muscles. Thereafter, one of them divides into medial and lateral cutaneous branches to
supply the overlying skin of the back of the body.
Soon after its formation, the large ventral ramus is connected to the sympathetic
ganglion by two rami communicantes – grey and white.

Grey ramus communicans: It consists of nonmyelinated nerve fibres, which arise

from sympathetic ganglion. These fibres (sympathetic fibres) are distributed to
the blood vessels, hair and sweat glands through the branches of both ventral
and dorsal rami of the spinal nerve.
White ramus communicans: It consists of myelinated nerve fibres, which arise from
lateral grey horn of the spinal cord and leave the ventral ramus to enter into the
ganglion of sympathetic trunk for its distribution.

The large ventral ramus runs laterally into intercostal space and supplies the
intercostal muscles of this space. It also gives rise to lateral and anterior cutaneous
branches.
The cutaneous branches of dorsal and ventral rami of spinal nerve together supply a
strip of skin from the posterior median line to the anterior median line called
dermatome.
N.B.
The strip of skin supplied by a single spinal nerve is known as dermatome and total
mass of muscle supplied by a single spinal nerve is known as myotome.

Applied anatomy

• Spinal neuralgia: It is a sharp burning sensation in the area of skin supplied by

the single spinal nerve (i.e. dermatome). The most important cause of this
neuralgia is Herpes Zoster, a viral infection of spinal ganglia.
• Root pain: Compression of nerve roots during their exit from intervertebral
foramina in cases of spondylitis and disc prolapse cause pain along the
distribution of that nerve.

❖ What are the various types of fibres present in a typical spinal nerve? AN7.4
The following four types of fibres are present in a typical spinal nerve:

• Somatic efferent fibres, which supply the skeletal muscles.

• Somatic afferent fibres, which carry general and proprioceptive sensations from
the skin, joint and muscles.
• Visceral efferent fibres, which supply the smooth muscles of viscera, blood vessels
and glands.
• Visceral afferent fibres, which carry proprioceptive sensations from viscera, blood
vessels and glands.

❖ Write a short note on dermatome.

The area of skin supplied by a single spinal nerve, and therefore a single spinal segment
is termed dermatome. With the exception of the C1 spinal nerve, all the spinal nerves are
associated with a specific dermatome.

❖ Write a short note on synapse. AN7.7

The neurons form long chains along which impulses travel from one neuron to the
other and so on for long distances in different directions.
The site of contact between two neurons where nerve impulses pass from one neuron
to another is called synapse. It is important to know that at synapse, the contact
between the neurons is by contiguity and not by continuity.

Structure
Each synapse consists of (a) presynaptic membrane of one neuron, (b) synaptic cleft
and (b) postsynaptic membrane of other neuron. The pre- and postsynaptic membranes
are separated by a small gap (20 nm wide) called synaptic cleft (Fig. 36.3).
 FIG. 36.3 Synapse: A, structure of synapse (axodendritic); B, mechanism of transmission of
nerve impulse at synapse.

Thus, following are the three essential components of a synapse (Fig. 36.3A):

• Presynaptic knob/membrane
• Synaptic cleft
• Postsynaptic membrane

Mechanism of transmission of impulse (fig. 36.3B)

The arrival of nerve impulse at a presynaptic knob (terminal) causes release of a
neurotransmitter from presynaptic vesicles into the synaptic cleft, which binds with
the receptors on the postsynaptic membrane. This binding produces response in the
postsynaptic membrane in the form of depolarization or hyperpolarization.
The excitatory nerve impulse causes depolarization of postsynaptic membrane, while an
inhibitory impulse causes its hyperpolarization. When the depolarization reaches threshold,
an action potential is produced in the postsynaptic neuron. In this way, action
potentials are transferred from one neuron to another neuron.

❖ Enumerate the different types of synapses. AN7.7

Anatomically, the synapses are of following types:

• Axodendritic synapses (commonest)

• Axosomatic synapses
• Dendrosomatic synapses
• Dendroaxonic synapses
• Dendrodendritic synapses
• Axoaxonic synapses

N.B.
The axodendritic synapse is generally termed typical synapse.

❖ What are neuroglia? Enumerate the different types of neuroglia in central and
peripheral nervous systems. Name the neuralgia responsible for myelination of
nerve fibres in peripheral and central nervous system. AN7.2, AN68.1
The neuroglia are interstitial cells of nervous system that provide structural and
functional support to the neurons.
 The different types of neuroglia present in central nervous system (CNS) and
peripheral nervous system (PNS) are given in Table 36.1.

• The Schwann cells (neurolemmocytes) form myelin sheath around the

peripheral nerve fibres. They also take part in the formation of blood–brain
barrier.
• The oligodendrocytes form myelin sheath around the fibres of central nervous
system.

TABLE 36.1
Different Types of Neuroglia Present in CNS and PNS

Neuroglia Present in CNS Neuroglia Present in PNS

• Astrocytes (largest and most numerous) • Schwann cells (neurolemmocytes)
• Oligodendrocytes • Satellite cells (amphicytes)
• Ependymal cells
• Microglia

N.B.
All the neuroglia (glial cells) are derived from neural crest cells except microglia, which
are derived from mesoderm.

❖ What is peripheral nerve? List its connective tissue sheaths. AN7.4

The peripheral nerve is a bundle of nerve fibres outside the central nervous system. The
examples of peripheral nerves are 12 pairs of cranial nerves and 31 pairs of spinal
nerves.

Connective tissue sheaths of peripheral nerve

They are three in number as follows:

• Endoneurium, which encloses a single nerve fibre.

• Perineurium, which encloses a bundle (group) of nerve fibres.
• Epineurium, which encloses the entire nerve.

❖ Write a short note on myelin sheath and process of myelination of a peripheral

nerve fibre.
The thick axons of peripheral nerves are surrounded by myelin sheath, which is made
up of concentric layers of plasma membrane of Schwann cells and lipids (fatty
substance) between these layers. It is formed by Schwann cells by a process called
myelination.

N.B.
The myelin is composed of about 40% water, 80% lipids, and 20% protein.
Formation of myelin sheath (myelination)
The Schwann cells are first arranged in a linear fashion (end to end) along the nerve
fibre and surround it.

• The axon invaginates the side of Schwann cell. As a result, the plasma
membrane of Schwann cell forms a mesaxon, which suspends the axon within
the Schwann cell (Fig. 36.4).
• The Schwann cell now rotates around the axon again and again, i.e. repeatedly.
Consequently, the axon becomes spirally wrapped by many layers of elongated
mesaxon. Later, the inner layers of plasma membrane fuse with each other so
that the axon becomes surrounded by several layers of modified membrane.
The lipids are deposited between adjacent layers of membrane. These layers of
mesaxon along with lipids constitute the myelin sheath (Fig. 36.4). The nerve
fibres surrounded by myelin sheath are termed myelinated fibres.

FIG. 36.4 Stages in the formation of myelin sheath around a peripheral nerve fibre.

Functions of myelin sheath

• Provides support to nerve fibres.

• Aids speed in conduction of nerve impulse.
• Insulates the axons from extracellular environment.
• Provides white colour to nerve fibres.
• Helps in the regeneration of nerve fibres.

❖ What are the nodes of Ranvier and incisures of Schmidt–Lanterman?

In myelinated nerve fibres, the myelin sheath is segmented. These segments are
separated at regular intervals by nodes of Ranvier.
The incisures of Schmidt–Lanterman are oblique clefts in the myelin sheath and act
as conduction channels for metabolites (nutrition) into depths of myelin sheath and
axon.

❖ Write a short note on reflex action.

A reflex action is an involuntary and almost instantaneous motor response of the body
to sensory stimulus/stimuli, for example, when a pin is pricked in the hand, the pain
impulses reach the spinal cord by sensory neuron. The spinal cord, then, through its
motor neurons moves the muscles of hand to keep it away from the pin. The complete
pathway involved in this act constitutes the reflex arc.
The reflex action is automatic and occurs independent of the higher centres of the
brain.
This reflex arc involved in reflex action consists of following components (Fig. 36.5):

• Receptor, e.g. sensory nerve ending

• Sensory component (sensory neuron)
• Central component (spinal cord/brain)
• Motor component (motor neuron)
• Effector, e.g. muscle

FIG. 36.5 Reflex arc (withdrawal reflex).

N.B.
If the motor neuron synapses directly with the sensory neuron, it is called
monosynaptic reflex arc. If the motor neuron synapses with the sensory neuron
through intervening internuncial or connector neuron, it is termed polysynaptic reflex arc
(Fig. 36.5).

❖ Write a short on Wallerian degeneration.

When the peripheral nerve is injured, it undergoes a process of degeneration. The
changes in the part of axon, distal to the injury are referred to as Wallerian
(anterograde) degeneration. When the myelinated nerve fibre is cut, the distal segment
of cut nerve fibre gets completely fragmented and lost. Its sheath also degenerates;
however, myelin-producing sheath cells (astrocytes) survive. The Schwann cells
proliferate, enlarge in size and form solid cellular cord within the sheath of
endoneurium. Now, the proximal segment of nerve fibre grows into the endoneural
tube (Fig. 36.6).

FIG. 36.6 Degeneration of nerve fibre (Wallerian degeneration).

N.B.
The degeneration also extends proximally from the site of lesion for a short distance as
far as the 1st node of Ranvier. This is referred to as retrograde degeneration. (Fig. 36.6).

❖ Write a short note on referred pain.

The pain arising from viscera is not felt at the site of diseased viscera but referred to an
area of skin supplied by the nerve arising from same spinal segment or segments that
supplies the viscera. For example, pain of appendix (due appendicitis) is referred to the
skin around umbilicus because both appendix and skin around the umbilicus are
supplied by T10 spinal segment. The important sites of referred pain are given in Table
36.2 and shown in Fig. 36.7.

TABLE 36.2
Important Sites of Referred Pain

Viscera Site of Referred Pain

Gall bladder Tip of right shoulder
Kidney and ureter Loin, groin and inner aspect of thigh
Testis and ovary Skin around umbilicus
Spleen Tip of left shoulder (Kehr’s sign)
Heart Left precordium, inner aspect of arm and forearm
Appendix Around umbilicus

FIG. 36.7 Important sites of referred pain.

❖ What is sympathetic and parasympathetic nervous system? AN7.1

The sympathetic and parasympathetic are two main divisions of the autonomic nervous
system.

Sympathetic nervous system: This division of autonomic nervous system is also

called ‘thoracolumbar outflow’ because its preganglionic nerve fibres arise
from thoracic and upper two lumbar (T1 to L2) spinal segments.

In general, the sympathetic nervous system mobilizes the body energy as during
flight and fight, i.e. during emergency.

Parasympathetic nervous system: This division of autonomic nervous system is

also called craniosacral outflow because its preganglionic fibres arise from
brainstem nuclei (e.g. Edinger–Westphal nucleus, lacrimatory nucleus and
superior and inferior salivatory nuclei) and 2nd, 3rd and 4th sacral (S2, S3 and
S4) spinal segments.

In general, parasympathetic nervous system conserves the body energy, as during

sleep.

❖ Enumerate the functional differences between sympathetic and parasympathetic

nervous systems. AN7.1
The differences are given in Table 36.3.
TABLE 36.3
Differences Between Sympathetic and Parasympathetic Nervous System
Sympathetic Nervous System
• Causes dilatation of pupils
• Increases heart rate
• Decreases intestinal peristalsis
• Closes sphincters
• Inhibits micturition and defecation
• Inhibits secretion of bronchial glands
• Causes bronchodilatation
• Causes ejaculation of semen from penis
Parasympathetic Nervous System
• Causes constriction of pupil
• Decreases heart rate
• Increases intestinal peristalsis
• Relaxes sphincters
• Facilitates micturition and defecation
• Increases secretion of bronchial glands
• Causes bronchoconstriction
• Causes erection of penis
SECTION V
General Histology
OUTLINE

37. Introduction to histology

38. Epithelial and connective tissues
39. Special connective tissues
40. Muscle tissue, blood vessels and lymphoid tissue
37

Introduction to histology
❖ What is histology?
Histology is the study of the various tissues of the body at the microscopic level. The
histology provides the structural and functional correlation of an organ or tissue – an
important prerequisite to study abnormal tissue (i.e. pathology).

❖ Define the terms histology and tissue.

The term histology is derived from Greek words ‘histos’ = tissue and ‘logos’ = a branch of
study. The term tissue is derived from French word ‘tissue’ = weave. The name was so
given because when section of tissue is seen under microscope, it appears as if its
various components are woven with each other.

❖ Enumerate the four basic types of tissues in the body and give their main
functions.
The four basic types of tissues in the body and their functions are given in Table 37.1.

TABLE 37.1
Types and Functions of Basic Tissues

Type of Basic Tissue Function

• Epithelial tissue Protection
• Connective tissue Support
• Muscular tissue Contraction
• Nervous tissue Conduction
❖ Define cell and describe its structure in brief.
The cell is a basic structural unit of the living tissue.

Structure
Each cell consists of a cell membrane enclosing the cytoplasm with nucleus within it.
Thus, three structural components of a cell are (Fig 37.1):

• Cell membrane/plasma membrane

• Cytoplasm
• Nucleus
The cell membrane (also called plasma membrane) forms the boundary of a cell
and acts as a barrier between cytoplasm and external environment.
 The cytoplasm is a fluid material that surrounds nucleus and is itself surrounded
by a cell membrane.
It consists of cytoplasmic matrix with organelles and inclusions suspended in it.
The various metabolic activities of the cell take place in the cytoplasm.
The nucleus is a membrane-bound structure, usually present in the centre of the
cell. It contains various genes that control the development, structure and
various activities of the cell.

FIG. 37.1 Structure of a cell.

The nuclei consist of nuclear envelope, nuclear matrix, chromatin material and
nucleolus.

❖ Enumerate the important organelles present in the cytoplasm.

Organelles are components of a cell which have a specific function, essential for
survival and propagation of the cell.
These are (Fig. 37.1) as follows:

• Mitochondria
• Ribosomes
• Golgi apparatus
• Endoplasmic reticulum
• Lysosomes
• Centrioles
• Microfilaments and microtubules

❖ Write a short note on mitochondria.

• The mitochondria are sausage-shaped double membrane-bound cell organelles

present in the cell cytoplasm (Fig. 37.2).
• They are called power houses of the cell because they generate energy in the
form of adenosine triphosphate (ATP).
 • Each mitochondrion is made up of two parallel membranes, which are
structurally similar to plasma membrane.
• The outer membrane is continuous.
• The inner membrane is arranged in a series of folds called cristae.
• The inner membrane encloses mitochondrial matrix, which contains
mitochondrial DNA.

FIG. 37.2 Structure of mitochondria.

Significance

• The metabolites of cells are utilized by the mitochondria and form high energy
substance – the ATP. The ATP is then utilized for the activity of the cell.
• The number of mitochondria is very high in metabolically active cells, i.e. liver
cells/hepatocytes contain about 2500 mitochondria per cell; in sperm the
mitochondria are clustered around its middle piece; and in ciliated cells, the
mitochondria are located in the apical portion of cell just below the cilia.

N.B.
The mitochondrial DNA consists of double helix in the form of a circle and contains 37
genes. The mitochondrial genes are inherited only from mother and not from father, as
the head of sperm involved in fertilization lacks mitochondria. Thus, genetically children
are closure to mother than father.

❖ Write a short note on endoplasmic reticulum.

The endoplasmic reticulum is a network of a series of flattened interconnecting
membranous tubules and sacs.
It is of two types – smooth and rough.

• Smooth endoplasmic reticulum (SER) is devoid of ribosomal granules. It

synthesizes lipids, glycogen and steroid hormones and is associated with the
detoxification of drugs.
• Rough endoplasmic reticulum (RER) is studded with ribosomes. The ribosomes
are the sites of synthesis of new proteins, e.g. the enzymes and hormones in the
cell, that are exported from the parent cell to be used by other cells of the body.
❖ Write a short note on Golgi apparatus/Golgi complex.
The Golgi complex is a cytoplasmic organelle that is composed of stacks of closely
packed flattened and curved membranous sacs. It is usually located in the juxtanuclear
region. The Golgi complex has a convex and a concave surface. The first one faces
towards the rough endoplasmic reticulum (RER) and nucleus, while the latter faces
towards the cell membrane. The convex surface is called forming face (cis-face) and
concave surface is called maturing face (trans face). The Golgi apparatus is the site of
processing and packaging of proteins synthesized by RER. The proteins move from
RER to the Golgi apparatus, where they are first processed and then packaged into
small, membrane-bound vesicles called secretory granules. These vesicles are stored,
and when needed, move to the plasma membrane through which proteins are exported.

Functions of golgi complex

• Processing and packaging of proteins

• Modification of proteins to form glycoproteins and lipoproteins
• Production of lysosomes with RER
• Involvement in membrane synthesis

❖ What are ribosomes? Give their functions.

• The ribosomes are small granules made up of ribonucleic acid and ribosomal
proteins.
• They are produced in the nucleolus and then migrate into cytoplasm.
• They are attached in groups on the surface of endoplasmic reticulum making it
rough – the rough endoplasmic reticulum.
• They are also scattered singly (free ribosomes) or in groups in cytoplasm
(polyribosomes).

Function
Synthesis of new protein

❖ What is centrosome?

• The centrosome is a small, specialized spherical area of cytoplasm near the

nucleus.
• It consists of two components: pericentriolar area and centrioles. The pericentriolar
area is made up of network of protein fibres.
• The centrioles are two rod-shaped hollow structures located in the centre of
pericentriolar area. The long axis of one centriole is at right angle to the other.
• Each centriole is hollow cylindrical structure with its wall being made up of
three groups of three microtubules (triplets) arranged in a circular fashion.

Functions
 • Pericentriolar area forms the mitotic spindle during cell division.
• Centrioles take part in the formation of cilia and flagella.

❖ Enumerate the various cytoplasmic cell inclusions.

The cytoplasmic inclusions are nonliving and nonfunctional entities of cell cytoplasm.
They do not take part in the cell metabolism.
Various types of cytoplasmic inclusions:

• Glycogen
• Lipid
• Pigments
• Secretory granules

❖ Describe the cell cycle in brief.

The cell cycle is defined as a period of time taken by a cell to divide into two daughter
cells (Fig. 37.3). In most of the adult somatic cells, the cell cycle takes 20–24 hours. It is
divided into four phases of different durations.

FIG. 37.3 Cell cycle.

The four phases of cell cycle occur in sequence as G1→S→G2→M.

G1 phase (12 hours): It is the crucial period of cell cycle during which the cell
determines to undergo cell division. It is the period of synthesis of various
metabolites required for cell division.
 S phase (6 hours): It is the period of DNA synthesis. It is also called synthetic phase.
G2 phase (4 hours): It is the period during which fidelity of DNA replication is
checked, and errors, if any, are corrected.
M phase (2 hours): It is the period during which cell actually divides.

N.B.

• The transition from G2 to M phase is regulated by the mitosis promoting factor

(MPF).
• There are regulatory mechanisms for controlled division of cells, according to the
need.
• The several factors that inhibit cell reproduction are collectively called chalones.

❖ Write a short note on mitosis.

The mitosis is the most common type of cell division and occurs in almost all somatic
cells (Fig. 37.4). It results in two genetically identical cells.

FIG. 37.4 Cell division: mitosis and meiosis.

Features

• In this type of cell division, the diploid parent cell gives rise to two identical
diploid daughter cells. The daughter cells also receive equal amount of
cytoplasm.
• In this type of cell division, the DNA replication occurs prior to cell division,
thus doubling the amount of DNA (46, 4N) and yielding double-stranded
chromosomes.
 • During mitosis, 23 pairs of chromosomes replicate. The two identical sets of
chromosomes move to the opposite poles of the parent cell, which then divides
into two daughter cells. Each daughter cell receives a set of 23 pairs of
chromosomes (diploid number), i.e. 46, 2N.

N.B.
The germ cells (spermatogonia and oogonia) also undergo mitosis to increase their
number within the gonads before the onset of meiosis.

❖ What are the various stages of mitotic cell division?

Various stages of mitotic cell division:

• Prophase
• Metaphase
• Anaphase
• Telophase

The events occurring during these phases of mitotic division are given in Table 37.2.

TABLE 37.2
Events Occurring During Mitotic Cell Division

Mitotic
Events
Phase
Prophase • Condensation and shortening of chromosomes
• Each double-stranded chromosome is made up of two chromatids joined at the
centromere
Metaphase • Chromosomes arrange themselves on the equatorial plane of spindle
Anaphase • Centromere divides
• Separated chromatids (daughter chromosomes) are pulled towards each pole of
cell
• Cleavage furrow appears
Telophase • Daughter chromosomes (single-stranded chromosomes) reach each pole of a cell
in equal number
• Nucleolus and nuclear membrane reform
• Cleavage furrow deepens and divides the cells into portions – the daughter cells
❖ Describe the meiosis in brief without giving its stages.
The meiosis is a special type of cell division that occurs only in germ cells. By meiotic
division, the diploid germ cell gives rise to four haploid gametes. Meiosis involves two
successive cell divisions: meiosis I and meiosis II (Fig. 37.4).
Prior to meiosis, the DNA (2N) replicates to form double the amount of DNA (4N),
but chromosome number remains diploid (2N).
Meiosis I: During meiosis I, the DNA is reduced to diploid (2N) amount but
chromosome number is halved to haploid value (1N).
Meiosis I is reductional division and heterotypical.
 Meiosis II During meiosis II, the amount of DNA is reduced to haploid but the
chromosome number remains haploid.
Meiosis II: The meiosis II is similar to mitosis and homotypical. This means that
when the ovum is fertilized with spermatozoon, the resultant zygote has 46
chromosomes called diploid number. Thus, the child has some characteristics inherited
from the mother and some from the father.

❖ Enumerate the differences between mitosis and meiosis.

The differences between the mitosis and meiosis are given in Table 37.3.

TABLE 37.3
Differences Between Mitosis and Meiosis

Mitosis
• Occurs in somatic cells
• Completes in one sequence
• Forms two daughter cells (containing same
number of chromosome as in mother cell)
• Crossing over of chromatids does not occur
• Daughter cells are identical to mother cell
• No exchange of maternal and paternal DNA
occurs
• Equational division
Meiosis
• Occurs in germ (gametic) cells
• Completes in two sequences (meiosis I and
meiosis II)
• Forms four daughter cells (containing half
number of chromosomes as in mother cell)
• Crossing over of the chromatids occur
• Daughter cells are not identical to mother cell
• Exchange of maternal and paternal DNA
occurs
• Reductional division
38

Epithelial and connective tissues

Epithelial tissue
The epithelial tissue includes epithelium and glands.

Epithelium
❖ Define epithelium and list its characteristic features. AN65.1
The epithelium is a sheet of cells, adhered on its basal surface to the basement
membrane. It is made up of single or more layers of cells. It lines the body surface, body
cavities and interior of tubular organs. It also forms both exocrine and endocrine
glands.

Characteristic features

• Basal surface of epithelium rests on a basement membrane called basal lamina.

• There is minimal amount of intercellular substance.
• It is avascular and nourished by diffusion from underlying connective tissue
capillaries.
• It is derived from all the three germ layers, e.g. epithelium of skin from
ectoderm, epithelium of urinary tract from mesoderm and epithelium of GIT
from endoderm.
• It has a high regeneration capacity.
• Its cells are held together by tight cell junctions.

❖ Classify various types of epithelium. AN65.1

The epithelium is classified into three types:

Simple epithelium: It is made up of single layer of cells.

Pseudostratified epithelium: It is made up of single layer of cells of varying
heights. The nuclei of cells lie at various levels giving a false appearance of
many layers of cells, hence the name pseudostratified.
Compound/stratified epithelium: It is made up of multiple layers of cells.

❖ Classify simple epithelium.

Depending on the shape of the cells forming the epithelium, it is classified into three
types (Fig. 38.1):
 Simple squamous epithelium: It is made up of flattened cells that are bound
together in a mosaic-like pattern.
Simple cuboidal epithelium: It is made up of cube-like cells.
Simple columnar epithelium: It is made up of tall columnar cells.

FIG. 38.1 Types of simple epithelium.

❖ Briefly describe simple squamous epithelium.

It is formed by a single layer of flat cells. They have length and breadth, but hardly any
thickness (Fig. 38.1).

Characteristic features

• Cells are flat and arranged in single layer.

• On the surface view, the cells look polygonal and are arranged in a mosaic-like
pattern.
• Nucleus is flat, centrally located and shows bulging in profile view.
• Cells are bound to each other by tight junctions.
• It forms thin smooth membrane.

Functions

• Helps in active transport of nutrients and rapid diffusion of gases and water.
• Acts as a selective barrier.
• Facilitates movements of viscera in various serous cavities.

Sites

• Alveoli of lungs
• Serous membranes
 • Parietal layer of Bowman’s capsule
• Endothelium of blood and lymph vessels
• Loop of Henle

❖ Write a short note on simple cuboidal epithelium.

It is formed by a single layer of cuboidal cells (Fig. 38.1).

Characteristic features

• Cells are shaped like cubes

• Nucleus is round and centrally placed

Function
Mainly responsible for secretion

Sites

• Thyroid follicles
• Proximal convoluted tubule (PCT) of kidney
• Germinal epithelium of ovary

❖ Write a short note on simple columnar epithelium.

It is formed by a single layer of columnar cells.

Characteristic features

• Cells are elongated and have more length than width. The length of cells is
almost three times more than the width.
• Nucleus is elongated/oval and located near the base.

Functions

• Secretion
• Absorption
• Transport

Sites

• Stomach
• Large intestine
• Cervical canal of uterus

❖ Enumerate the various subtypes of the columnar epithelium.

Depending on surface specializations (e.g. presence of microvilli and cilia), the subtypes
of columnar epithelium are as follows:

• Columnar epithelium with brush border

• Columnar epithelium with striated border
• Columnar epithelium with ciliated border

The details are given in Table 38.1.

TABLE 38.1
Types, Functions and Sites of Columnar Epithelium

Type of Columnar Epithelium Functions Sites/Locations

• Columnar epithelium with brush border Secretion, absorption Gall bladder
and transport
• Columnar epithelium with striated border Secretion, absorption Small intestine
and transport
• Columnar epithelium with ciliated border (ciliated Secretion, absorption • Uterine tube
columnar epithelium) and transport • Auditory tube
• Tympanic cavity
• Efferent
ductules of testis
❖ Write a short note on the pseudostratified epithelium. AN65.1
The pseudostratified epithelium is a simple columnar epithelium giving the false
appearance of stratified epithelium.

Characteristic features

• Cells of variable height are arranged in single layer.

• Long cells reach the surface of lumen.
• Short cells do not reach the surface of lumen.
• Nuclei are basal.
• Nuclei of short and tall cells lie at different levels giving a false appearance of many
layers of cells.

Subtypes of pseudostratified epithelium (fig. 38.2)

Pseudostratified, nonciliated columnar epithelium: The luminal surface of cells

does not possess cilia, e.g. male urethra and ductus deferens.
Pseudostratified, ciliated columnar epithelium (respiratory epithelium): The
luminal surface of cells possesses cilia, e.g. larynx (except vocal cords), trachea,
bronchi, nasal cavity (except olfactory region) and paranasal air sinuses.
 FIG. 38.2 Types of pseudostratified epithelium.

N.B.
A number of goblet cells are interspersed between the cells in this type of epithelium.

❖ Write a short note on the stratified squamous nonkeratinized epithelium. AN65.1

Characteristic features (fig. 38.3)

• Cells are arranged in many layers (i.e. multilayered epithelium).

• Deeper cells are columnar.
• Middle cells are cuboidal/polyhedral.
• Superficial cells are flat/squamous and do not show keratinization.

FIG. 38.3 Stratified squamous nonkeratinized epithelium.

Function
Protection (i.e. prevents wear and tear)

Sites

• Oral cavity
• Tongue
• Oesophagus
• Vagina
• Anal canal
• Cornea
❖ Write a short note on the stratified squamous keratinized epithelium. AN65.1

Characteristic features (fig. 38.4)

They are same as that of stratified squamous nonkeratinized epithelium except that the
surface cells undergo keratinization (i.e. cells become dead, lose their nucleus and get
filled with keratin).

FIG. 38.4 Stratified squamous keratinized epithelium.

Function
Protection (i.e. prevents wear and tear)

Sites

• Skin
• Vestibule of nose
• External auditory meatus
• Lower part of anal canal

❖ Write a short note on the transitional epithelium. AN65.1

The transitional epithelium (urothelium) is special variety of stratified epithelium (Fig.
38.5).
 FIG. 38.5 Transitional epithelium.

Characteristic features

• Cells are arranged in five to six layers.

• Deeper cells are columnar.
• Middle cells are polygonal/pear shaped.
• Superficial cells are umbrella shaped and may show two nuclei.

N.B.
The surface cells are embedded in lipid, which makes it resistant to toxins of urine.

Special features

• The appearance of epithelium varies during relaxed and stretched states of the
hollow organs and tubes which it lines.
• It undergoes two types of transitions.
■ Transition in the surface of cells. When the organ or tube is relaxed, they
are umbrella shaped; but when the organ or the tube is distended, they
become flattened.
■ Transition in the number of layers of cells. When the organ or the tube is
relaxed, it is made up of five to six layers of cells; but when distended or
stretched, it is made up of only two or three layers.

Function
The surface membrane of superficial cells is thick and called cuticle. It forms effective
urine–blood barrier (i.e. it prevents the absorption of toxic substances of urine into the
blood).
Note: The luminal surface of transitional epithelium is covered by a layer of thick
eosinophilic lamella of glycoprotein called cuticle which may account for its
impermeability to urine into blood.

Sites
Epithelial lining of urinary tract, e.g.:
 • Major and minor calyces
• Renal pelvis
• Ureter
• Urinary bladder
• Proximal part of urethra

❖ Enumerate the various specializations of the free surface (apical surface) of the
epithelial cells. List their characteristic features. AN65.2
The epithelial cells present three types of surface specializations on their free surface
(Fig. 38.6):

• Microvilli
• Stereocilia
• Cilia

FIG. 38.6 Specializations on the free apical surface of the epithelial cells.

The characteristic features of three types of surface specializations are given in Table
38.2.

TABLE 38.2
Characteristic Features of Surface Specialization
 Type of
Characteristic Features
Specialization
Microvilli • Small finger-like projections (1–2 microns in length)
• Possess a core of actin filaments
• Motile
• Microvilli are coated with a layer of glycoprotein (glycocalyx)
• Increase surface area for absorption
Stereocilia • Long microvilli (5–10 microns in length)
(false cilia) • Do not possess core of actin filaments
• Nonmotile
• Serve as an absorptive device
Cilia • Short (10 microns in length), fine, hair-like structures
• Possess a core of microtubules
• Core of a cilium consists of a central pair of microtubules with nine pairs of
microtubules around them (9 + 2 arrangement)
• Produce wave-like movements

Glands
❖ Define gland.
A gland is an organ that consists of specialized epithelial cells and produce secretions.
The material secreted by gland is usually in liquid form such as enzyme, hormone,
mucus and fat.

N.B.
Mucus-secreting goblet cells interspersed in the columnar epithelium of respiratory
tract and intestines are termed unicellular glands.

❖ Classify glands according to the mode of their secretion.

According to the mode of secretion, the glands are classified into three types –
merocrine, apocrine and holocrine. The details are as follows (Fig. 38.7):

Merocrine: The secretion is released by exocytosis of the cell membrane in the

form of secretory granules, e.g. most glands of the body such as salivary glands
and pancreas.
Apocrine: The secretion first accumulates in the apical portion of the cell. Then the
apical portion of the cell along with the secretion is pinched off and discharged.
The pinched-off portion of the cell becomes a part of secretion, e.g. mammary
glands.
Holocrine: In this type, the entire secretory cell along with the secretory product is
shed. In this way, the entire cell becomes a part of the secretion, e.g. sebaceous
glands.
 FIG. 38.7 Classification of glands according to their mode of secretion: A, merocrine glands;
B, apocrine glands; C, holocrine gland.

Connective tissue AN66.1, AN66.2

❖ What is connective tissue? Enumerate its three essential components.
The connective tissue as its name indicates binds or supports the other tissues of the
body. It is found throughout the body. It consists of cells that are separated from each
other by abundant extracellular matrix, which is secreted by the cells themselves. The
matrix itself is made up of two components: (a) fibres and (b) ground substance.
Thus, the three essential components of connective tissue are as follows:

• Ground substance
• Fibres
• Cells

N.B.
A tissue cannot be called a connective tissue until it has all the three components:
ground substance, fibres and cells.

❖ Write a short note on the loose connective tissue.

Features (fig. 38.8)

• It is most widely distributed connective tissue in the body.

• It consists of loosely woven network of all the three types of fibres (e.g. collagen,
elastic and reticular).
• It contains almost all kinds of connective tissue cells (e.g. fat cells, fibroblasts,
macrophages, plasma cells and mast cells).
• Its fibres and cells are embedded in semifluid ground substance.
 FIG. 38.8 Loose connective tissue.

Functions

• Provides support to epithelium.

• Acts as a packing material to keep various structures of the body in place.

Sites

• Underneath the epithelium

• In the superficial fascia
• Around muscles, blood vessels, nerves and viscera

❖ Enumerate the cells present in the connective tissue.

The cells present in the connective tissue are of two types: fixed and free cells (Table
38.3). The fixed cells are long-lived cells and always remain in the connective tissue,
while the free cells are short-lived wandering cells that are continuously replaced by
the cells of the blood. The cells of connective tissue are given in the Table 38.3.

TABLE 38.3
Types of Connective Tissue Cells

Fixed Cells Free Cells

Fibroblasts/fibrocytes Neutrophils
Macrophages (histiocytes) Eosinophils
Mast cells Basophils
Fat cells (adipocytes) Monocytes
Pigment cells B and T lymphocytes
Reticular cells Plasma cells
❖ Write a short note on lymphocytes.

• The lymphocytes are type of white blood cells (WBCs) which circulate in the
 blood and present in large numbers in the lymphatic tissue, such as lymph
nodes and spleen.
• Each lymphocyte possesses a large, spherical, dark-staining nucleus, which
occupies most of the cell and is surrounded only by a thin rim of cytoplasm
(Fig. 38.9).

FIG. 38.9 Lymphocyte.

Types of lymphocytes
The lymphocytes develop from pluripotent stem cells in red bone marrow and then
travel through blood into lymphoid tissue where they are activated and become
immunocompetent, i.e. they respond to antigens.
Although lymphocytes originate from one source but functionally they are
differentiated into two main types – B lymphocytes and T lymphocytes.

• B lymphocytes: They are short lived. They are activated by an antigen. When
activated by an antigen, they undergo active division and differentiate to form
plasma cells. The plasma cells synthesize antibodies against antigen to destroy
them. They are short lived and responsible for antibody-mediated (humoral)
immunity.
• T lymphocytes: They are activated in the thymus and become
immunocompetent. They are long lived and are responsible for cell-mediated
immunity.
39

Special connective tissues

The special connective tissues include:

• Cartilage
• Bone
• Haemopoietic tissue
• Blood
• Lymph

Cartilage AN71.2
❖ What is cartilage? List its properties.
Cartilage is a modified connective tissue. It consists of all the three components of
connective tissue, but differs from connective tissue proper in the sense that its ground
substance is made up of gel-like material (containing chondromucoprotein), which
provides it firmness and elasticity.

Properties

• It is firm in consistency.
• It is relatively avascular.
• It derives its nutrition from adjacent tissues by diffusion or through small
vessels passing through cartilaginous canals.
• It has limited regeneration capacity.
• It is prone to undergo calcification with advancing age.
• It is usually surrounded by a fibrovascular membrane called perichondrium.
• It forms part of body skeleton.
• It has no lymphatics.
• It has no nerves; hence, it is insensitive to pain.
• Its growth occurs by appositional growth as well as interstitial growth.

❖ Write a short note on perichondrium.

• The perichondrium is a vascular membrane which forms the covering of a

cartilage.
• It is made up of two layers:
a. Outer fibrous layer made up of collagen bundles. It has rich blood supply.
b. Inner chondrogenic layer made up of chondroblasts. The chondroblast can
 change into chondrocytes. The chondroblasts can divide and secrete matrix,
and it assists in the peripheral growth of the cartilage.

❖ Classify the various types of cartilages.

The cartilages are classified into three types:

• Hyaline cartilage
• Yellow elastic cartilage
• Fibrocartilage

❖ Write a short note on the hyaline cartilage.

It is the most widely distributed cartilage in the body.

Histological features (fig. 39.1)

• It is transparent (Greek, hylos = transparent stone).

• It has homogeneous, basophilic intercellular substance.
• It stains blue (i.e. basophilic) with haematoxylin and eosin stain due to the
presence of chondroitin and keratin sulphate in its ground substance.
• The chondrocytes are present in groups of two to four cells within lacunae to
form cell nests.
• The matrix around the cell nests is stained deeper to form lacunar capsule.
Groups of 2 or more chondrocytes are known as cell nests.
• The fibres are not seen as a distinct entity.
• It is covered by perichondrium.

FIG. 39.1 Hyaline cartilage.

N.B.
The hyaline cartilage appears transparent because it contains very fine collagen fibres
whose refractive indices are same as that of ground substance.

Function
Resists compressive and tensile forces.

Sites
Laryngeal cartilages (e.g. thyroid, cricoid), tracheal ring, costal cartilage, septal cartilage
of nose, most of the fetal skeleton.

❖ Write a short note on the elastic cartilage.

The elastic cartilage is also called yellow elastic cartilage.

Histological features (fig. 39.2)

• It appears yellowish in fresh sections due to the presence of yellow elastic fibres.
• It contains large number of branching and anastomosing yellow elastic fibres in
its ground substance. They are continuous with those of perichondrium.
• Its chondrocytes are larger, more numerous and closely packed than those of
hyaline cartilage.
• The chondrocytes are seen in lacunae simply or in groups of two.
• It is covered by perichondrium.

FIG. 39.2 Elastic cartilage.

Function
Provides not only shape and support to the organ but also elasticity/pliability.

Sites of distribution
Pinna of external ear, epiglottis, eustachian tube, etc.

❖ Write a short note on the fibrocartilage.

Histological features (fig. 39.3)

• Macroscopically, it looks like a dense connective tissue.

• It consists of large bundle of collagen (type I) fibres.
• Its chondrocytes are small and of the same size.
• The chondrocytes are frequently arranged in rows between the collagen
bundles.
• It is not covered by perichondrium.

FIG. 39.3 Fibrocartilage.

Function
Resists compression and shear forces.

Sites of distribution
Intervertebral discs, menisci of the knee joint, intra-articular discs of the synovial joints,
glenoid labrum and acetabular labrum.

❖ List the differences among hyaline, elastic and fibrocartilages.

The differences are given in the Table 39.1.

TABLE 39.1
Differences Between Hyaline, Elastic and Fibrocartilage

Bone AN71.1
❖ Define bone and list its functions.
The bone is a specialized connective tissue in which the matrix is mineralized with
calcium salts, making it hard and rigid. The calcium salts in the matrix also provide
whitish look to the bones.

Functions
The functions of bones are:

• To form rigid framework of the body.

• To provide surface for attachment of the muscles.
• To serve as storehouse of calcium and phosphorus.
• To form cavities to enclose and protect the various viscera.
• To manufacture blood cells, e.g. RBCs, WBCs and platelets.
• To act as levers for various movements of the body.

❖ Enumerate the various types of cells in the bone tissue.

There are four types of cells in the bone tissue:

• Osteogenic cells: They are precursors of other cell types in the bone.
• Osteoblasts: They lay down the matrix of bone tissue.
• Osteocytes: They maintain bone matrix and are the main cells of bone tissue.
• Osteoclasts: They are involved in bone resorption.

❖ Define compact bone and list its histological features.

The compact bone is dense and hard like an ivory, with no visible spaces on naked-eye
examination.

Histological features (fig. 39.4)

 • It consists of Haversian systems. Each Haversian system (osteon) consists of a
Haversian canal surrounded by 6–12 concentric bony lamellae.
• Haversian canals are connected with one another and communicate with
marrow cavity through the bony canals called Volkmann’s canals.
• It has three types of bony lamellae:
■ Concentric lamellae, around the haversian canals.
■ Interstitial lamellae, between the haversian systems.
■ Circumferential lamellae, subjacent to the periosteum and adjacent to the
endosteum.
• It is covered by periosteum.

FIG. 39.4 Structure of a compact bone: A, haversian systems and lamellae; B, an osteon; C,
periosteum and outer circumferential lamellae.

Sites

• Shaft of long bones.

• Outer layer of all bones.

❖ Write a short note on the spongy bone.

The cancellous bone is porous and relatively less hard as compared to compact bone.

Histological features

• It does not have haversian systems.

• The bone tissue is arranged in the form of interconnecting rods and thin plates
called trabeculae.
• It contains large irregular communicating spaces between the adjoining
 trabeculae called marrow spaces filled with red bone marrow.
• The osteocytes are embedded in lacunae within the trabeculae, while osteoblasts
and osteoclasts are present at the surface of trabeculae.
• It is covered by periosteum.

N.B.
The trabecular rods and plates are not more than 0.4 mm in thickness.

Sites

• Epiphyses of long bones.

• All short, flat and irregular bones.

❖ List differences between the compact and spongy bones.

They are given in Table 39.2.

TABLE 39.2
Differences Between the Compact and Spongy Bones

Compact Bone Spongy Bone

Density Dense like an ivory Porous like a sponge
Haversian systems Present Absent
Arrangement of bony Regular Irregular
lamellae
Location in bone Shaft of the long bones Epiphyses, short, flat bones, irregular bones
(outer shell) (inner region)
Bone marrow Absent Present
40

Muscle tissue, blood vessels and

lymphoid tissue

Muscle tissue AN67.1–67.3
❖ Briefly discuss the muscle tissue and classify it.
The muscle tissue (also called muscle) is made up of muscle cells surrounded by
connective tissue. The muscle cells are elongated hence, called muscle fibres. The
muscle fibres contain contractile proteins, mainly actin and myosin.
The muscle fibres are specialized to shorten in length by contraction. The muscle
tissue is responsible for the movements of the various parts of the body.

Classification
Histologically, the muscle tissue is classified into three types:

• Skeletal muscle
• Cardiac muscle
• Smooth muscle

❖ Write a short note on the skeletal muscles.

The skeletal muscles are striated and attached to the bones of the skeleton. They are
found mainly in the limbs and trunk of the body.

Histological features (fig. 40.1)

• Muscle fibres are elongated, cylindrical and multinucleated.

• Muscle fibres present prominent cross-striations with alternating dark ‘A’ and
light ‘I’ bands.
• Nuclei are flat and located at periphery.
• Muscle fibres do not show branching.
 FIG. 40.1 Histological features of a skeletal muscle.

❖ Write a short note on the cardiac muscle.

The cardiac muscle is striated, involuntary and located exclusively in the heart.

Histological features (fig. 40.2)

• Cardiac muscle fibres are short and thick. They branch and anastomose to form
syncytium.
• Cardiac muscle fibres are joined end-to-end at junctional specializations called
intercalated discs.
• Each cardiac muscle fibre has a centrally located single oval nucleus.
• Cardiac muscle fibres present faint cross-striations with alternating dark ‘A’ and
light ‘I’ bands, i.e. they are not as conspicuous as in skeletal muscle.

FIG. 40.2 Histological features of a cardiac muscle.

❖ Write a short note on the smooth muscles.

The smooth muscles are nonstriated, involuntary and are located in the walls of hollow
viscera, like stomach and intestine, and in the walls of blood vessels.
Histological features (fig. 40.3)

• Smooth muscle fibres are spindle shaped.

• Smooth muscle fibres do not present cross-striations.
• Each smooth muscle fibre has a centrally located elongated nucleus.

FIG. 40.3 Histological features of a smooth muscle.

❖ Compare the histological features of three types of muscle tissues (i.e. skeletal,
cardiac and smooth muscles).
The comparison of three types of muscle tissues is given in Table 40.1.

TABLE 40.1
Comparison Between Skeletal, Cardiac and Smooth Muscles

Blood vessels AN69.1–69.3
❖ Enumerate three layers/coats in the wall of the artery.
The three layers/coats in the wall of an artery from inside to outside are as follows:

• Tunica intima
• Tunica media
• Tunica adventitia
 The features of these coats are given in Table 40.2.

TABLE 40.2
Features of Three Coats in the Wall of Artery

❖ Describe the histological features of an elastic artery (large artery) in brief.

Histological features
The characteristic histological features of an elastic artery (syn, large-sized artery) are as
follows:

Tunica intima
■ Subendothelial layer is prominent.
■ Internal elastic lamina is not clearly visible.*
Tunica media
■ The presence of large number of elastic fibres arranged in the form of
concentric and fenestrated laminae or sheets.
■ The concentric layers of smooth muscle fibres in between the elastic
lamellae.
Tunica adventitia
■ Thin and made up of connective tissue. It contains longitudinally running
collagen fibres, which merge with external elastic lamina.
■ Contains vasa vasorum.

Functions

• Conduct blood from heart to medium-sized (muscular) arteries.

• Elastic recoil of vessel wall ensures continuous flow of the blood through
medium-sized arteries.

Examples

• Aorta
• Pulmonary trunk
• Main branches of aorta
 ■ Brachiocephalic trunk
■ Common carotid artery
■ Left subclavian artery

*N.B.
The internal elastic lamina in an elastic artery is not clearly visible because it is
difficult to differentiate it from many elastic lamellae present in the tunica media.

❖ Describe the histological features of a muscular (medium-sized) artery in brief.

Histological features (fig. 40.4)

Tunica intima
■ It presents a folded appearance.
■ Internal elastic lamina is prominent and wavy (i.e. thrown into wavy folds).
■ Subendothelial tissue is not prominent.
Tunica media
■ The presence of large/huge number of smooth muscle fibres arranged
concentrically.
■ About 75% mass of tunica media is formed by the smooth muscle fibres.
Tunica adventitia
■ It is histologically similar to that of elastic artery, but thicker than that.

FIG. 40.4 Histological features of a medium-sized artery: A, cross-section showing different

wall layers and the lumen; B, magnified view of the wall layers.

Functions
Regulates the flow of blood according to need by altering the size of its lumen by
contraction and relaxation of huge number of smooth muscle fibres in its wall.

Examples

• Brachial artery
• Radial artery
 • Popliteal artery

❖ List the histological features of an arteriole.

The arterioles are small arteries with diameter <0.5 mm.

Histological features

Tunica intima
■ Consists of only endothelial lining (the subendothelial layer and internal
elastic laminae are absent).
Tunica media
■ Made up of one to five layers of the smooth muscle fibres.
Tunica adventitia
■ Thin and poorly developed.

Lymphoid tissue AN70.2
❖ What is lymphoid tissue? List its main functions.
The lymphoid tissue is a kind of specialized connective tissue. It is made up of a
meshwork of reticular cells and reticular fibres (supporting framework) and large
number of lymphocytes occupying the spaces within the meshwork. The other cells
present in the lymphatic tissue are plasma cells and macrophages.

N.B.
The supporting framework of thymus is not formed by reticular cells and reticular
fibres, rather it is formed by star-shaped epithelial cells called epithelioreticular cells.

Function
Defence of the body
Note: The lymphoid tissue mainly consists of lymphocytes and macrophages, which
protect the body against invasion of microorganisms, e.g. bacteria and viruses by
producing specific immune response.

❖ Classify lymphoid organs.

The lymphoid organs are classified into following two types:

• Primary lymphoid organs, e.g. bone marrow and thymus

• Secondary lymphoid organs, e.g. lymph nodes and spleen

N.B.

(a) The primary lymphoid organs are the sites where lymphocytes are formed from
stem cells and differentiate into the antigen-independent cells.
 (b) Secondary lymphoid organs serve as sites for differentiation of lymphocytes into
antigen-specific mature effector cells.

❖ Write a short note on ‘MALT’.

The term MALT stands for mucosa-associated lymphoid tissue. It consists of
noncapsulated, dense lymphatic nodules, or follicles formed by the aggregation of
lymphocytes in the submucosa of gastrointestinal (GALT) and respiratory tracts
(BALT).

Function
The MALT provides immunological protection against invasion of the body by
microorganisms, e.g. bacteria and viruses via vulnerably exposed absorptive surfaces of
the gastrointestinal and respiratory tracts.

❖ Enumerate MALT associated with gut (alimentary canal).

The MALT associated with gut includes:

• Tonsils
• Aggregated lymphoid nodules (Peyer’s patches)
• Aggregations lymphoid follicles in vermiform appendix
• Solitary nodules in oesophagus, small intestine and large intestine
Index

A
Abducent nerve, 215
Accessory nerve, 220–221
Actual anastomosis, 302
Adductor pollicis muscle, 45
Adenohypophysis (anterior pituitary), 208–209
ADH (vasopressin), 270
Adjunct rotation, 293t
Adventitious bursae, 298
Anatomical position, 277
Anatomical snuff box, 51
Anconeus, 40t
Andreas Vesalius, 276f
Ansa cervicalis, 108, 109f
Antagonists, 296
Anterior cerebral artery, 254
Anterior spinal artery, 227
Apparatus
pharyngeal, 148t
lacrimal, 95
Apethumb deformity of hand (ape hand/simian hand deformity), 66t
Aponeurosis, 296
Arachnoid mater, 223
Archicerebellum, 248
Areola, 3
Arm, 27
Arteria radicularis magna, 227
Arterial anastomosis around
scapula, 16
elbow joint, 33
Arterial supply of a growing long bone, 285
Arterial supply of the tonsil, 157
Arteries
anterior cerebral, 254
anterior spinal, 227
axillary, 15
axis artery
upperlimb, 54
basilar, 253
brachial, 30
carotid, 109, 110
Charcot’s, 260
elastic, 341
external carotid, 109
facial, 110
inferior alveolar, 181
internal carotid, 138
Juxta-epiphysial, 286
lingual, 149
maxillary, 180–181
middle cerebral, 254
middle meningeal, 181
nutrient, 285–286
ophthalmic, 199
periosteal, 286
posterior spinal, 227
profunda brachii, 31
 radicular, 22, 227
Rhinologist’s, 165
central retinal, 200
subclavian, 137
superficial temporal, 91
thyroid, 131
vertebral, 137–138
Arteriole, 301, 342
Arteriovenous shunts, 303
Artery
brachial, 16
Articular disc of TMJ, 185
Athetosis, 262
Atlanto-occipital joints, 141
Auricle, 189
Axilla, 11–18
Axillary abscess, 12
Axillary artery, 15
Axillary lymph nodes, 17
Axillary nerve, 60
Axillary pulse, 12
Axillary vein, 16
Axioappendicular muscles, 19
Axis artery of upper limb, 54

B
Ballismus, 262
BALT, 305
Basal nuclei, 261–263
Basilar artery, 253
Basilar membrane, 194
Basilary artery, 223
Basilic vein, 58
Bell palsy, 218
Benediction deformity of hand, 66t
Berry aneurysms, 253
Biceps brachii, 28
Bicipital aponeurosis, 59
Black eye, 91
Blood–brain barrier, 311
Blood pressure, 30
Blood supply of the brain, 253
Bone, 283, 336
cells in the bone, 336
Bony labyrinth, 194
Brachial artery, 30
Brachial plexus, 12
Brachioradialis, 41
Bradycardia, 109
Brain, 235
Brainstem, 235–241
Breast, 4
Buccinator muscle, 93

C
Cancellous bone, 285t
Capillary, 301
Carcinoma of breast, 6–8
Carcinoma of tongue, 161
Cardiac muscle, 294, 339
Cardiovascular system, 299
Carotid body, 109
Carotid sheath, 101
Carotid sinus, 109
Carotid triangle, 107
Carpal tunnel, 35
Carpal tunnel syndrome, 66
Carrying angle, 78
Cartilage, 288
Cartilaginous joints, 291
Cauda equina, 227
Caudate nucleus, 261–262
Cavernous sinus, 205
Cell, 319
Cell cycle, 322
Central sulcus (of Rolando), 247
Centrioles, 321
Centrosome, 321
Cephalic vein, 58
Cerebellar peduncles, 243
Cerebellopontine angle, 219
Cerebellum, 242
Cerebral dominance, 252
Cerebral vein of Galen, 255
Cerebrospinal fluid (CSF), 224–225
Cerebrum, 247
Cervical lymph nodes
deep, 103
superficial, 102–103
Cervical rib syndrome, 135
Cervical sympathetic chain, 139
Cervicoaxillary canal, 12
Chalazion, 199
Charcot’s artery of cerebral hemorrhage, 258
Cheek, 144
Chorda tympani nerve, 127
Chorea, 262
Chronic suppurative otitis media (CSOM), 192
Cilia, 330
Ciliary ganglion, 201
Circle of Willis (circulus arteriosus), 253, 254f
Circulation
portal, 300
Cisterns, 223
Cisternal puncture, 113
Clavipectoral fascia, 9
structures piercing, 10
Cleavage lines/Langer’s lines, 280
Cleft lower lip, 97
Cleft upper lip, 97
Cochlear nerve, 218
Colles fracture, 83
Commissures of the brain, 256
anterior commissure, 258
Common extensor origin, 41
Common flexor origin, 37b
Compact bone, 285t
Conchae/turbinates, 165
Conjunct rotation, 292, 293t
Connective tissue, 331
Congenital anomalies of
branchial cyst, 149
breast, 7
cervical cyst, 149
complete cleft, 159
incomplete cleft, 159
 palate, 159
Contralateral hemiplegia, 230
Cooper’s ligaments, 6
Coracoacromial ligament, 195
Coracoacromial arch, 70, 73, 74f
Coracobrachialis, 27
Coracohumeral ligament, 195
Corpus callosum, 256
Corpus striatum, 261
Corticospinal (pyramidal) tract, 229–231
Cover of
deltoid, 23
Cranial nerves, 211
Craniomandibular articulation, 182
Cricothyroid muscle, 171
Cristae ampullaris, 194
Cubital fossa, 33
Cubital tunnel, 69t
Cytoplasmic cell inclusions, 322

D
Dacryocystitis, 96
Dangerous area of the face, 94–95
Deciduous teeth, 145t
Deep cerebral veins, 255
Deep cervical fascia, 99
Deep fascia, 281–282
Deep muscles on the back of forearm, 42
Deep muscles on the front of forearm, 38
Deep palmar arch, 54, 56f
Deltoid muscle, 21
Demilunes of gianuzzi, 126
Dentate nucleus, 243
Dermatome, 310
Development
of the face, 96
of the parotid gland, 119
of pituitary gland, 210
of thyroid, 132
of tongue, 150
of tonsil, 157
of tooth, 145
Deviated nasal septum (DNS), 164
Diencephalon, 267
Differences between the arteries and veins, 299
Digastric muscle, 121
posterior belly of, 121
Digastric (submandibular) triangle, 106
Dislocation of shoulder joint, 72
Dislocation of TMJ, 184–185
Distal Interphalangeal (DIP) joints, 84
Dominance cerebral, 252
Dorsal columnmedial lemniscal pathway, 229
Dorsal digital expansion, 48
Dorsal spaces, 49
Dorsal subaponeurotic space, 52
Ducts of rivinus, 126
Dupuytren’s contracture, 45
Dural folds, 203
Dura mater, 223

E
Ear, 189
Ear ossicles, 193
 incus, 193
malleus, 193
stapes, 193
Elastic artery, 341
Elastic cartilage, 334
Elbow joint, 76
Embryological basis of
branchial cyst, 162
cervical cyst, 162
Emissary veins, 207
End arteries, 303
functional, 289
Endoplasmic reticulum, 321
Epiphora, 96
Epiphyses, 288
Epiphysial arteries, 286
Epistaxis, 164
Epithelial tissue, 325–331
Epithelioreticular cells, 343
Epithelium, 325
Erb paralysis, 14
Erb’s point, 14
Eruption and shedding of teeth, 145
Extensor retinaculum at wrist, 39
External auditory (acoustic) meatus, 189
External carotid artery, 109
External jugular vein, 98
External nose, 163
Extradural hematoma, 181
Extrinsic muscles of eyeball, 195
Eyeball, 198
 coats of eyeball, 198
compartments of eyeball, 198
refractive media of the eyeball, 199
Eyelids, 199

F
Fabella, 286
Facial artery, 110
Facial canal, 105
Facial nerve, 216–218
Facial nerve paralysis, 218
Falx cerebri, 203
Fascia
clavipectoral
prevertebral, 101
Fasciculus cuneatus, 229
Fasciculus gracilis, 229
Fibrocartilage, 336
Fibrous joints, 289
Fibrous membrane, 79
Filiform papillae, 148
First carpometacarpal joint, 84f
First right metacarpophalangeal joint, 85f
Fixators, 296
Flexor carpi radialis, 37t
Flexor carpi ulnaris, 37t
Flexor digitorum superficialis (FDS), 37t
Flexor pollicis longus (FPL), 38t
Flexor retinaculum, 35
volar carpal ligament, 35
Foliate papillae, 148
Follicular cells, 133
Fornix, 263
Fossa
cubital, 33
infratemporal, 174
piriform, 173
pterygopalatine, 186
rhomboid, 245
smuggler, 173b
temporal, 93
Fourth ventricle, 242–246
Frontal air sinuses, 51
Frontal headache, 50
Frontal nerve, 201
Frozen shoulder, 72–76
Fundamental planes of the body, 277
Fundamental position, 277
Fungiform papillae, 148

G
Gag reflex, 155, 220
Ganglia
ciliary, 201
otic, 179f
pterygopalatine, 187–188
submandibular, 126
Ganglion of hay fever, 188
Genioglossus, 148
Gigantism and acromegaly, 210
Glands
apocrine, 330
epithelial, 330
holocrine, 331
 lacrimal, 95
mammary, 45
merocrine, 330
parathyroid, 134
parotid, 114–120
pineal, 268
pituitary, 208
sublingual, 126
submandibular, 123
thymus, 343
thyroid, 129
unicellular, 330
Glenohumeral ligament, 71
Glenoid labrum, 70
Glossopharyngeal nerve, 219–220
Goblet cells, 330
Goitre, 133
Golgi apparatus, 321
Gomphosis, 289

H
Hand, 44–51
Hard palate, 158
Hare lip, 97
Haversian systems, 337
Hay fever, 188
Herophilus, 275
Hilton’s law, 292
Hilton’s method, 118
Hippocampal formation, 263
Hippocampus, 263
Histological features of
 breast, 7
thyroid, 133
parotid gland, 120
submandibular salivary gland, 126
tonsil, 157–158
Horner syndrome, 139
Hyaline cartilage, 333
Hydrocephalus, 225
Hyoglossus muscle, 121
Hyperacusis, 218
Hyperparathyroidism, 134
Hypoglossal nerve, 221–222
Hypoparathyroidism, 134
Hypothalamo-hypophyseal tract, 270
Hypothalamus, 254

I
Imaging/Radiological anatomy, 275
Incisures of schmidt–lanterman, 313
Inferior alveolar artery, 181
Infrahyoid (ribbon) muscles, 111
Infraspinatus, 23
Infratemporal fossa, 174–181
Innervation, sensory
of face, 94
of the dorsal aspect of the hand, 53
of the palmar aspect of the hand, 52
of organ of Corti, 195
Insertion of coracobrachialis, 27, 31
Insula, 248
Internal capsule, 256, 258
Internal carotid artery, 138
Internal cerebral veins, 255
Internal ear, 194
Internal jugular vein, 140
Interossei muscles, 47
Interosseous membrane, 79–80
Intracerebellar nuclei, 243
Intracranial dural venous sinuses, 204
Intrinsic muscles of the hand, 45
Inverted homunculus, 249
Ipsilateral hemiplegia, 230

J
Joints, 289
atlanto-axial, 142
atlanto-occipital, 141
cartilaginous, 289, 291
classification, 289
elbow, 76
Ist carpometacarpal, 83
fibrous, 289
glenohumeral, 70
radioulnar, 78
shoulder, 70, 72
abduction at, 75f
sagittal section, 72f
sternoclavicular, 74, 74f
sutures, 289
synovial, 182, 290
temporomandibular, 182–185
wrist, 81
Jugular venous pulse pressure, 141
Juxta-epiphysial (metaphyseal) arteries, 286
K
Killian’s dehiscence, 155
Klumpke paralysis, 15
Kocher’s vein, 132f
Krukenberg tumor, 6

L
Lacrimal apparatus, 95
Lacrimal nerve, 201
Laryngeal cavity, 170
Laryngitis, 172
Laryngoscopy, 171
Larynx, 169
Lateral atlanto-occipital joints, 142
Lateral geniculate body, 268
Lateral medullary syndrome (posterior inferior cerebellar artery syndrome of
Wallenburg), 237
Lateral pterygoid muscle, 175–176
Lateral spinothalamic tract, 228
Lateral sulcus, 223
Lateral ventricle, 264–266
Lateral wall of the nose, 172
Latissimusdorsi muscle, 25–26
Law, Hilton, 292
Left subclavian artery, 137
Lentiform nucleus, 262–263
Lesions of laryngeal nerve, 172
Levatorpalpebraesuperioris muscle, 197
Levator scapulae, 21t
Ligament of Berry, 101b
Limbic system, 263–264
Lingual artery, 149
Little’s area, 164–165
Loss of taste sensations, 218
Lower triangular space, 26
Lumbar puncture, 115
Lumbrical muscles, 46
Lymphatic drainage, of tongue, 148–149
Lymphatic system, 305
Lymph capillaries, 305
Lymph node/nodes
cervical, 102–103
Lymphocytes, 332
Lymphoid organs, 343
Lymphoid tissue, 343

M
Maculae, 194
MALT, 305, 343
Mammary bed, 4
Mammary gland, 6–7
Mandibular nerve, 177–178
Masseter muscle, 174–175
Mastoid antrum, 192
Maxillary air sinus, 167–168
Maxillary artery, 180–181
Maxillary nerve, 186
Maxillary sinusitis, 168
Medial geniculate body, 268
Medial lemniscus, 229
Medial longitudinal fasciculus (MLF)/medial longitudinal bundle (MLB), 240
Medial medullary syndrome, 238
Medial pterygoid muscle, 176
Median atlantoaxial joint, 142
Median cubital vein, 59
Median nerve, 65
Median vein of forearm, 57
Medulla oblongata, 236–237
Meiosis, 324
Membrana tectoria, 195
Membranous labyrinth, 194
Meninges, 223
Mesencephalic nucleus, 215
Metacarpophalangeal (MP) joint, 84
Metathalamus, 268
Microtubules, 320
Microvilli, 330
Midbrain, 240
Middle cerebral artery, 254
Middle collateral artery, 31
Middle ear, 190
Middle meatus of nose, 168
Middle meningeal artery, 181
Midpalmar space, 49
Mitochondria, 320
Mitochondria
cristae, 320
membrane
inner, 320
outer, 320
Mitosis, 322
Morphological types of neurons, 308
Motor nucleus, 215
Motor speech area, 250
Motor unit, 297
Movements, 278
circumduction, 278
inversion and eversion, 278
of 1st carpometacarpal joint, 84t
opposition, 278
supination and pronation, 80, 278
of thumb, 85
Müller’s muscle, 197
Mumps (viral parotitis), 117
Muscles
adductor pollicis, 46
anconeus, 40
biceps brachii, 28
brachioradialis, 40, 41
buccinator, 93
coracobrachialis, 29
cricothyroid, 171
deltoid, 21
digastric, 121
flexor digitorum profundus, 38
flexor pollicis longus, 38
hyoglossus, 121, 148
interossei, 47
lateral pterygoid, 175–176
latissimus dorsi, 20
levator palpebrae superioris, 197
levator scapulae, 21
masseter, 174–175
medial pterygoid, 176
occipitofrontalis, 91
of eyeball, 195
 of facial expression, 93
of forearm, 37
of hand, 45
of larynx, 170–171
of mastication, 174
of pharynx, 153
of soft palate, 158–159
of tongue, 147
pectoralis major, 8
pectoralis minor, 8
posterior cricoarytenoid, 170
pronator teres, 37, 80
pronator quadratus, 38, 80
rhomboideus major, 21
rhomboideus minor, 21
scalene, 134
shunt, 296
skeletal, 294
sternocleidomastoid, 103
supinator, 42, 43 (f.)
supraspinatus, 23
synergists, 296
temporalis, 175
teres major, 23
teres minor, 23
transverse, 148
trapezius, 19
triceps brachii, 32
vertical, 148
Muscles on the front of forearm, 35
Muscle tissue, 339–340
Muscular (medium sized) artery, 342
histological features, 342
Muscular triangle, 111
Musculocutaneous nerve, 144
Musculotendinous cuff/rotator cuff, 24
Myelination, 312
Myelin sheath, 312
Myringotomy, 190

N
Nasal septum, 163–164
Nasociliary nerve, 200–201
Nasolacrimal ducts, 165
Nasopharynx, 154–155
Nerves
abducent, 215
accessary, 220–221
axillary, 60
chorda tympani, 127, 217
facial, 216–218
frontal, 201
glossopharyngeal, 219
hypoglossal, 221–222
mandibular, 177–178
maxillary, 186
median, 64
musculocutaneous, 29
nasociliary, 200–201
oculomotor, 212–213
olfactory, 211
ophthalmic, 199
optic, 212
 phrenic, 139
posterior interosseous, 43
radial, 61
suboccipital, 113
superficial radial, 61f
trigeminal, 214
trochlear, 213–214
ulnar, 67
vagus, 220
vestibulocochlear, 218–219
Vidian’s, 217
Nervous system, 308
Neuroglia, 311
Neurohypophysis (posterior pituitary), 209
anterior lobe (pars distalis), 209
intermediate lobe (pars intermedia), 209
microscopic structure, 209
posterior lobe (pars posterior/nervosa), 209
Neuromuscular junction, 297
Neuron, 308
Nipple, 3
Nodes of ranvier, 313
No movements, 142
Nose, 163–166
Nose bleeding, 181
Nucleus emboliformis and nucleus globosus, 243
Nucleus fastigius, 243
Nucleus interpositus, 243f
Nutrient artery, 285–286

O
Oblique facial cleft, 97
Occipital myotomes, 151
Occipitofrontalis muscle, 91
Oculomotor nerve, 212
Olfactory nerve, 211
Opening of paranasal air sinuses, 165
Ophthalmic artery, 199
Ophthalmic nerve, 200
Optic nerve, 212
Oral cavity, 153–154
Orbit, 195–202
Ossification, 287
Ossification centres, 287–288
Otic ganglion, 178–179
Otitis media, 158
Oxytocin, 270

P
Palatine tonsil, 156
Palate, 158
primary, 159
Palatoglossus, 148t
Paleocerebellum, 243
Palm, 44–51
Palmar aponeurosis, 44
Palmaris longus, 37t
Palmar spaces, 48
Panniculus carnosus, 281
Papillae of tongue, 147
Paracentral lobule, 249–250
Parafollicular cells, 133
Paralysis
Erb’s paralysis, 14, 15
 Klumpke, 14, 15
Paralysis of, intrinsic muscle, 15
Paranasal air sinuses, 167
Parasympathetic nervous system, 315
Parathyroid glands, 134
Paratonsillar vein, 157
Parietal (3rd) eye, 269
Parietooccipital sulcus, 248
Parkinsonism, 262
Parona’s space, 49
Parotid abscess, 118
Parotid bed, 114
Parotid capsule, 118
Parotid duct (Stensen’s duct), 119, 144
Parotid gland, 114
Parotid region, 114
Parts of a growing/developing long bone, 285
Patella, 286
Pectoralis major muscle, 8
Pectoralis minor muscle, 8
Pectoral region, 7
Perichondrium
layers
inner chondriogenic, 333
outer fibrous, 284, 333
Periosteal arteries, 286
Periosteum, 284
Peripheral nerve, 312
Peritonsillar space, 156f
Permanent teeth, 145
Peyer’s patches, 343
Pharyngeal diverticulum, 155
Pharyngeal recess, 155
Pharyngotympanic tube/auditory tube/eustachian tube, 158
Pharynx, 154
Phrenic nerve, 139
Pia mater, 223
Pineal gland, 268
Pinna, 189
Piriform fossa, 173
Pisiform, 286
Pituitary adenoma, 210
Pituitary dwarfism, 210
Pituitary gland, 208
Platysma, 92
Plexus
brachial, 12
Pons, 238
Pontocerebellar angle syndrome, 239
Positions of a joint, 291
closed-packed position, 291
loose-packed position, 292–293
Postcalcarine sulcus, 251
Posterior cerebral artery, 255
Posterior cricoarytenoid, 170
Posterior interosseous nerve, 43
Posterior spinal arteries, 227
Posterior triangle, 104
Potential anastomosis, 302
Pretracheal fascia, 100
Prevertebral fascia, 101
Prevertebral region, 134–142
Primary and secondary cartilaginous joints, 291
Primary sensory area, 250
Prime movers (agonists), 296
Principal sensory nucleus, 215
Profunda brachii artery, 31
Projection fibres, 256
Pronation of forearm, 37
Pronator quadratus, 38t
Pronator teres, 36
Proximal intraphalangeal (PIP), 84
Pseudoganglion, 62
Pterygopalatine fossa, 186–188
Pterygopalatine ganglion, 187–188
Ptosis, 199
Pulp space, 50
Pulsations of axillary artery, 57
Pulsations of brachial artery, 57
Pulsations of radial artery, 57
Pulsations of the facial artery, 111

Q
Quadrangular space, 25
Quinsy (peritonsillar abscess), 157

R
Radial artery, 54
Radial bursa, 51
Radial collateral artery, 31
Radial groove, 62
Radial nerve, 61
Radial pulse, 55
Radicular arteries, 227
Radioulnar joints, 78
Ranula, 127
Recent memory, 263
Receptive or sensory aphasia, 251
Red bone marrow, 284
Referred pain, 314
Reflex action, 313
Reflex arc, 313
Region, pectoral, 1
Retina, 198
Retinaculum
flexor, 35
extensor, 39
Retinal artery, 200
Retromammary space, 4
Rhinologist’s artery, 165
Rhomboideus major muscle, 21
Rhomboideus minor muscle, 21
Rhomboid fossa, 245
Ribosomes, 321
Rima glottidis, 171, 172

S
Safety muscle of larynx, 170
Salpingopalatine folds, 155
Salpingopharyngeal folds, 155
Scalene muscles, 134
Scalene syndrome, 137
Scalene triangle, 136
Scalenovertebral triangle (triangle of vertebral artery), 137
Scalenus anterior, 135
Scalenus medius, 135
Scalp, 89
Scapular region, 21–26
Secondary, 159
complete cleft, 160f
incomplete, 160f
Sensory innervation of the face, 94
Sensory innervation of the head and face, 94t
Sensory speech area, 250–251
Serratus anterior muscle, 9
Sesamoid bones, 283
Sharpey fibres, 285
Sheath
carotid, 101
Shoulder complex, 70
Shoulder joint (glenohumeral joint), 70
Shunt muscles, 296
Singer’s nodule, 172
Simple cuboidal epithelium, 326
Sinusoid, 301
Sites
germinal epithelium of lung, 326
PCT of kidney, 326
thyroid follicles, 133
Sites of subcutaneous injections, 281
Skeletal muscles, 297
histological features, 339
Skin, 279
Smith fracture, 83
Smooth muscle, 294, 340
Smuggler’s fossa, 173b
Soft palate, 158–159
Spaces
Burn, 100
dorsal space of hand, 48
dorsal subaponeurotic, 52
midpalmar, 49
of hand, 48
Parona’s, 49
quadrangular, 25
subarachnoid, 223
suprasternal, 100
thenar, 50
triangular, 26
lower, 26
upper, 26
Sphenoethmoidal recess, 165
Sphenomandibular ligament, 183
Sphenopalatine artery, 181
Spinal cord, 226
transverse section of the spinal cord, 227f
Spinal nucleus, 215
Spiral organ of corti, 194
Split-brain effect/syndrome, 257
Spongy bone, 337
Spurt muscles, 296
Stereocilia, 330
Sternoclavicular joint, 74, 74f
Sternocleidomastoid, 103
Structure of pharynx, 153
Structures in the anterior median line of the neck, 112
Structures on the front of the wrist, 38
Stye (hordeolum), 199
Styloglossus, 183
Stylomandibular ligament, 183
Subarachnoid cisterns, 223
Subarachnoid space, 223
Subclavian arteries, 137
Sublingual fold, 126, 147
Sublingual gland, 126
Sublingual papillae, 147
Sublingual region, 147
Submandibular and jugulo-omohyoid lymph nodes, 149
Submandibular ganglion, 127
Submandibular gland, 123
Submandibular region, 121–128
Submental triangle, 111
Suboccipital nerve, 113
Suboccipital triangle, 112
Subscapularis, 23
Superficial fascia, 281
Superficial fascia of the neck, 98
Superficial muscles on the back of forearm, 40
Superficial palmar arch, 55
Superficial radial nerve, 62
Superficial temporal artery, 91
Superior radio-ulnar joint, 76
Supination and pronation, 80
Supination of Forearm, 43
Supinator muscle, 42
Supraspinatus, 23
Suprasternal space (space of burn), 100
Sutures, 289
Sympathetic and parasympathetic nervous systems, 315
Sympathetic nervous system, 314
Symphyses, 291
Synapse, 310
Syncope (carotid sinus syndrome), 109
Syndesmosis, 289
Syndromes
carpal tunnel, 66
carotid sinus, 109
Horners, 139
lateral medullary, 237
medial medullary, 238
posterior inferior cerebellar, 237
scalene, 137
split-brain, 257
Wallenburg, 237
Synergists, 296
Synovial bursa, 298
Synovial bursae related to the shoulder joint, 73
Synovial joint, 290
complex synovial joint, 290
compound synovial joint, 290

T
Temple, 93
Temporalis muscle, 175
Temporomandibular joint, 182–185
Tendon, 295–296
Tennis elbow (lateral epicondylitis), 78
Tenon’s capsule, 198
Tentorium cerebelli, 204
Teres major muscle, 23
Teres minor, 23t
Thalamic radiation, 260
Thalamus, 267
Thenar space, 50
Thrombosis of axillary vein, 16
Thrombosis of superior sagittal sinus, 204
Thymus, 343
Thyroglossal cyst, 133
Thyroglossal duct, 132f
Thyroidectomy, 132
Thyroid gland, 129
arterial supply, 131–132
thyroid lobe, 130–131
venous drainage, 132
Tissues, 319
connective tissue, 319t
epithelial tissue, 319t
muscular tissue, 319t
nervous tissue, 319t
Tongue, 146–147
lymphatic drainage of tongue, 146
Tongue-tie
embryological basis of, 152
Tonsil, 156–157
referred pain, 168
tonsillar bed, 156
tonsillitis, 157
Tooth, 144
structure of the tooth, 144
Torticollis, 104
Transverse humeral ligament, 71
Transverse ligament of atlas, 142f
Trapezius muscle, 19
Triangles
carotid, 107
digastric, 106
muscular, 111
of auscultation, 21
of vertebral artery, 137
posterior, 104
scalene, 136
scalenovertebral, 137
submandibular, 106
submental, 111
suboccipital, 112
Triangular articular disc of fibrocartilage, 79
Triceps brachii, 32
Trigeminal ganglion, 214
Trigeminal nerve, 214
nuclei of, 215
Trigeminal nerve on face
sensory distribution of, 214
Trigeminal neuralgia (tic douloureux), 214
Trochlear nerve, 213
Tunnel, 194
carpal, 35
of corti, 194
Tympanic membrane, 189
Types of circulation, 299
hepatic portal circulation, 300
portal circulation, 300
pulmonary circulation, 300
systemic circulation, 300–301
Types of synovial joints, 290–291
Typical nerve, 309

U
Ulnar and radial bursae, 51
Ulnar artery, 55
Ulnar bursa, 51
Ulnar claw hand, 69t
Ulnar collateral ligament, 77
Ulnar nerve, 67
Umbo, 190
Unicellular glands, 330
Upper limb
sites of arterial pulsations, 57
Upper triangular space, 26

V
Vagus nerve, 220
Vallate papillae, 147
Vein/veins
axillary, 16
basilic, 58
cephalic, 58
deep cerebral, 255
external Jugular, 98
internal cerebral, 255
internal jugular, 140
median cubital, 58
median vein of forearm, 59
paratonsillar, 157
superior thyroid, 132
Venous drainage of the face, 95f
Ventral spinothalamic tract, 228
Ventricle
3rd, 224, 270
4th, 224, 245
Ventricular puncture, 225
Vertebral artery, 137–138
Vestibular nerve, 218–219
Vestibule, of mouth, 143
Vestibulocochlear nerve, 218–219
Vidian’s nerve, 217
Visual areas, 251
Visual cortex, 251
Vivisections, 275
Vocal cords, 172
structure of, 172
Vocal nodules/singer’s nodules, 172
Volkmann’s canals, 337

W
Waldeyer’s ring, 155
Wallerian degeneration, 313
Wernicke’s area, 250–251
Whistling muscle, 93
White fibres of cerebrum, 256
association fibres, 256
commissural fibres, 256
White matter of cerebrum, 256
Whitlow, 50
Wrist drop, 63t
Wrist joint, 81

Y
Yes movements, 142

Z
Zenker’s diverticulum, 155