Anatomy Concept Book Atf

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com
Concept Based Learning
Video Companion on Each Chapter
Next Generation
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Comprehensive Review Series
“ANATOMY”
Active Recall Based
Integrated Edition
Published by Delhi Academy of Medical Sciences (P) Ltd.
HEAD OFFICE
Delhi Academy of Medical Sciences (P.) Ltd.
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Email: info@damsdelhi.com
ISBN : 978-93-89309-32-4
First Published 1999, Delhi Academy of Medical Sciences
© 2021 DAMS Publication AfraTafreeh.com

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Typeset by Delhi Academy of Medical Sciences Pvt. Ltd., New Delhi (India).
Contents
Chapter 1 Upper Limb 01 – 30

Chapter 2 Lower Limb 31 – 60

Chapter 3 Thorax 61 – 90

Chapter 4 Abdomen 91 – 136

Chapter 5 Head & Neck 137 – 172

Chapter 6 Neurology 173 – 208

Chapter 7 General Anatomy 209 – 222

Chapter 8 General Embryology 223 – 241

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1 Upper Limb
CONCEPTS
Â Concept 1.1 Axilla

Â Concept 1.2 Shoulder

Â Concept 1.3 Pectoral region

Â Concept 1.4 Scapular region

Â Concept 1.5 Arm
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Â Concept 1.6 Cubital fossa

Â Concept 1.7 Forearm

Â Concept 1.8 Flexor Retinaculum & Carpal Tunnel

Â Concept 1.9 Anatomical snuff box

Â Concept 1.10 Wrist and hand

2 | Anatomy
Concept 1.1: Axilla
LEARNING OBJECTIVE: To understand boundaries and contents of Axilla with relations

of the structures in continuity with Head ad neck region.
Time Needed
st
1 reading 20 mins
nd
2 look 10 mins
Boundaries :
• Medial wall is formed by the upper ribs and their intercostal muscles and serratus

anterior muscle.
• Lateral wall is formed by the intertubercular groove of the humerus.

• Posterior wall is formed by the subscapularis, teres major, and latlsslmus dorsi

muscles.
• Anterior wall is formed by the pectoral.is major and pectoralis minor muscles and

clavipectoral fascia.
• Base is formed by the axillary fascia and skin.

• Apex is formed by the interval between the clavicle, first rib, and upper border of the

scapula.
Contents of the axilla AfraTafreeh.com
• Brachial plexus and its branches

• Axillary artery has many branches, including the superior thoracic, thoracoacromial,

lateral thoracic, thoracodorsal, and circumflex humeral (anterior and posterior)

arteries.
Upper Limb | 3
• Axillary vein ls formed by the union of the brachial veins (venae romitantes of

the brachlal artery) and the basillc vein, receives the cephalic vein and veins that
correspond to the branches of the axillary artery, and drains into the subclavian vein.
• Lymph nodes and areolar tissue are present.

• Axillary tail (tail of Spence) is a superolateral extension of the mammary gland.

Brachial Plexus :
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• Erb’s Point - Point on the upper trunk - V.R. of C5 & C6, ventral and dorsal divisions

of upper trunk and - Suprascapular is vulnrerable to traction injuries.

Branches:
A. Supraclavicular Branches - Arise in the Neck.

From Roots:
1. Branch to Phrenic Nerve - C5

2. Muscular branches to scalenii & longus colli - C5, C6, C7, C8

3. Dorsal scapular N. C5 (Nerve to Rhomboids)

4. Long thoracic N. C5 C6 C7 (Nerve to serratus anterior or Nerve of Bell)

From Erb’s Point of upper trunk

1. Suprascapular N.
C5 C6
2. Nerve to subclavius
C5 C6
4 | Anatomy
B. Infraclavicular Branches : Arise from cords in axilla

Lateral Cord :
1. Lateral Pectoral N.
C5 C6 C7
2. Musculocutaneous N.
C5 C6 C7
3. Lateral root of Median N.
C5 C6 C7

Medial Cord :
1. Medial Pectoral N.
C8 T1
2. Medial cutaneous N. Of Arm
C8 T1
3. Medial cutaneous N. Of Forearm

C8 T1
4. Medial root of Median N.

C8 T1
5. Ulnar N. C7, C8 T1
Posterior Cord :
1. Upper subscapular N. C5 C6

2. Thoracodorsal N. C6 C7 C8
(N. To Latissimus Dorsi)
3. Lower subscapular C5 C6
4. Axillary (circumflex ) N. C5 C6

5. Radial N. C5 C6 C7 C8 T1
Lesions of the Brachial Plexus
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Erb - Duchenne Paralysis or simply Erb’s palsy
• involves upper trunk.

• Traction injury to Erb’s point mainly involving C5 and C6 fibers

• Muscles paralysed include Deltoid, Biceps, Brachialis, Brachioradialis, supraspinatus,

infraspinatus, supinator.
• Policeman’s tip “ or “ Porter’s tip” or Water’s tip “ position.

Lower Plexus Injuries : Klumpke’s Paralysis or Klumpke Dejerine Paralysis

• Involves lower trunk of brachial plexus - C8 & T1

Muscles paralysed : All intrinsic muscles of Hand and wrist flexors and extensors

are paretic
Movement lost : Weakness of wrist flexion, finger extension and weakness of

intrinsic muscles of Hand.

Position of Hand : A “Claw Hand” deformity occurs.

Autonomic Signs : If the lesion of T1 root is more proximal then Horner’s

syndrome will occur

Upper Limb | 5
Concept 1.2: Shoulder
LEARNING OBJECTIVE: To understand ligaments, Muscles & movements and clinical

anatomy of shoulder joint.
Time Needed
st
1 reading 20 mins
nd
2 look 10 mins
• Ball and socket joint

Factors which protect the joint include :

1) Rotator cuff or Musculotendinous cuff - Formed by blending of tendons of supraspinatus

(superiorly) Infraspinatus & Tere minor (posteriorly) and subscapularis (anteriorly)

to the joint capsule. This cuff is absent inferiorly. Since the inferior capsule is loose
& lax and least protected, dislocations of the shoulder joint usually occurs inferiorly.
2) Long head of biceps tendon passing above the head of Humerus intracapsularly

prevents upward displacement.

3) Coracoacromial arch formed by coracoacromial ligament connecting coracoid and

acromion processes with each other, protects the joint from above.
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6 | Anatomy
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Capsule presents two openings - one, opposite bicipital groove for exit of tendon of long
head of biceps and the other, between superior and middle glenohumeral ligaments,
connects the joint cavity with subscapular bursa.
Bursae :
1. Subacromial and Subdeltoid Bursa :

Separate coracoacromial arch and deltoid muscle from supraspinatus tendon and

joint capsule.
This bursa facilitates abduction and during abduction of arm, it moves beneath the

acromion process.
In Subacromial Bursitis, pain is elicited when the deltoid is pressed just below the

acromion process, but when the arm is abducted to 90° pain cannot be elicited by
pressure on the same point because the bursa disappears under the Acromion -
Dawbarn’s Sign.
2. Subscapular Bursa : Between anterior capsule and subscapularis muscle, is always in

continuity with the joint cavity.

3. Infraspinatus bursa between posterior capsule and the infraspinatus tendon,

sometimes communicates with the joint.

Upper Limb | 7
Movements of the Shoulder Joint
1. Flexion : Pectoralis major, clavicular fibers of Deltoid, coracobrachialis , assisted by

Biceps.
2. Extension : Posterior fibers of Deltoid, Teres major, Latissimus Dorsi.

3. Adduction : Subscapularis, Teres major, Latissimus Dorsi, Pectoralis major

4. Abduction : Supraspinatus (0 - 15°) Deltoid (15 - 90°) Trapezius and serratus anterior

are active during overhead abduction (90 - 180°)

5. Medial (Internal) Rotation : Pectoralis major, anterior fibers of Deltoid, Latissimus

Dorsi, Teres major and subscapularis.

6. Lateral (External) Rotation : Infraspinatus , Teres minor, posterior fibers of Deltoid.

Clinical Anatomy.
• Dislocation of the shoulder joint :

• Frozen Shoulder

• Complete Tear of Rotator cuff (Torn supraspinatus) : inability to initiate

glenohumeral abduction with power to sustain abduction once the limb has been
raised passively beyond 15°.
• Painful arc syndrome :

Characterized by pain in the shoulder and upper arm during the midrange of

glenohumeral abduction (60 - 120°)

freedom from pain during the initial and terminal ranges.

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Pain is produced mechanically by nipping of a tendon structure between greater

tuberosity of humerus and coracoacromial arch.

8 | Anatomy
Concept 1.3: Pectoral region
LEARNING OBJECTIVE: To understand important muscles of the region.
Time Needed
1st reading 20 mins
nd
2 look 10 mins
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Muscles of the Pectoral Region

Muscle Origin Insertion Nerve Action
Pectoralis major Medial half Lateral lip of Lateral and medial Flexes, adducts,
of clavicle; i n t e r t u b e r c u l a r pectoral and medially
manubrium and groove of humerus rotates arm
body of sternum;
upper six costal
cartilages
Pectoralis minor Third, fourth and Coracoid process Medial (and Depresses scapula;
fifth ribs of scapula lateral) pectoral elevates ribs
Subclavius Junction of first rib Inferior surface of Nerve to subclavius Depresses lateral
and costal cartilage clavicle part of calvicle
Serratus anterior Upper eight ribs Medial border of Long thoracic Rotates scapula
scapula upward; abducts
scapula with
arm and elevates
it above the
horizontal
Upper Limb | 9
Clavipectoral Fascia
The clavipectoral fascia is a strong fascial sheet deep to the clavicular head of the
pectoralis major muscle, filling the space between the clavicle and the pectoralis minor
muscle.
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10 | Anatomy
Structures Piercing the Clavipectoral Fascia
These are as follows :
1. Lateral pectoral nerve.

2. Thoraco-acromial artery.

3. Lymphatics from the breast to the apical group of axillary group of lymph nodes.

4. Cephalic vein. The first two structures pass outwards, whereas the lower two structures

pass inwards.
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Mammary Gland (Breast)

Mammary gland is a modified sweat gland present in the superficial fascia of pectoral
region.
Vertical extent - 2nd to 6th rib at midclavicular line.
Horizontal extent : Sternal margin to midaxillary line at the level of 4th rib
Axillary Tail of spence : small part of the mammary gland that extends superolaterally
sometimes through the deep fascia to lie in the axilla.
Areola & Nipple : Deep to the areola are numerous modified sebaceous glands (Glands
of Montgomery) which are enlarged during third trimester of pregnancy to produce small
surface elevations known as Tubercles of Montgomery.
• It is separated from the deep fascia covering the underlying muscles by an area of

loose areolar tissue known as the retromammary space, which allows the breast
some degree of movement over the pectoralis major muscle.
• Has 15 to 20 lobes of glandular tissue, which are separated by fibrous septa that

radiate from the nipple. Each lobe opens by a lactiferous duct onto the tip of the
nipple, and each duct enlarges to form a lactiferous sinus, which serves as a reservoir
for milk during lactation.
• In carcinoma of the breast the suspensory ligaments may be invaded by cancer cells

and may shorten, resulting in retraction of skin and fixation of breast.

Upper Limb | 11
Arterial supply :
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1. Perforating branches of internal mammary artery in II, III, IV intercostal spaces.

2. Thoracoacromial, lateral thoracic & superior thoracic branches of Axillary.

3. Mammary branches from 2nd, 3rd & 4th posterior intercostal arteries.

Venous Drainage : There is an anastomotic circle of veins around the base of Nipple -
the Circulus venosus of Haller.
Lymphatic Drainage :
• Lymph vessels of the breast are grouped into

(a) Superficial lymphatics draining skin also and

(b) Deep lymphatics draining the parenchyma of breast along with nipple & areola.

Just beneath the areola is the Subareolar Plexus of Sappey.

• 75% lymph from breast goes to Axillary group of nodes. 20% goes to Internal

mammary or Parasternal nodes. 5% goes to Posterior intercostal lymph nodes.

12 | Anatomy
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• Parasternal lymph nodes of both the sides are interconnected across the sternum;

moreover lymphatics of one breast communicate with the lymphatics of

contralateral breast across sternum.
• Majority of lymphatics from lateral quadrants accompany Axillary tail and

drain mainly into pectoral group ; some pass to subscapular nodes. From both
these groups lymphatics pass to central & then to Apical group of axillary lymph
nodes.
• Some lymphatic vessels from inferomedial quadrant communicate with subperitoneal

lymphatic plexus. Via this pathway cancer of the breast can spread to peritoneum,
the liver, hepatic lymph nodes & other abdominal viscera.
• From subperitoneal plexus, cancer cells can migrate transcoelomically and aided by

gravity fall into pelvic cavity producing secondaries there. Krukenberg’s tumor is a
secondary tumor of ovary.
• Blockade of cutaneous lymphatics by cancer cells produce a orange peel like

appearance of the skin - Peau d’ orange.

• Dimpling of the skin occurs by retraction and shortening of suspensory ligament

of cooper when cancer invades it.

• Retraction of nipple can occur if carcinoma spreads along lactiferous ducts.

Upper Limb | 13
Concept 1.4: Scapular region
LEARNING OBJECTIVE: To understand important muscles of the region.
Time Needed
1st reading 25 mins
nd
2 look 15 mins
Muscles of the Shoulder

Deltoid Lateral third of Deltoid tuberosity of Axillary Abducts, adducts,
clavicle, acromion, humerus flexes, extends, and
and spine of scapula rotates arm medially
and laterally
Supraspinatus Supraspinous fossa of Superiof facet of Suprascapular Abducts arm
scapula greater tubercle of
humerus
Infraspinatus Infraspinous fossa Middle facet of greater Suprascapular Rotates arm laterally
tubercle of humerus
Subscapularis Subscapular fossa lesser tubercle of Upper and lower Adducts and rotates
humerus subscapular arm medially
Teres major Dorsal surface of
inferior angle of AfraTafreeh.com
Medial lip of
intertubercular groove
Lower subscapular Adducts and rotates
arm medially
scapula of humerus
Teres minor Upper portion of Lower facet of greater Axillary Rotates arm laterally
lateral border of tubercle of humerus
scapula
Latissimus dorsi Spines of T7-T12 Floor of bicipital Thoracodorsal Adducts, extends, and
thoracolumbar fascia, groove of humerus rotates arm medially
iliac crest, ribs 9-12
14 | Anatomy
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Upper Limb | 15
Concept 1.5: Arm
LEARNING OBJECTIVE: To understand compartments of Arm with important structures
Time Needed
1st reading 20 mins
nd
2 look 10 mins
Muscles of the Arm

Coracobrachialis Coracoid process Middle third of medial Musculacutaneous Flexes and adducts arm
surface of humerus
Biceps brachii Long head, supraglenoid Radial tuberosity of Musculocutaneous Flexes arm and forearm,
tubercle; short head radius supinatas forearm
coracoid process
Brachialis Lower anterior surface of Coronoid process Musculocutaneous Flexes foream
humerus of ulna and ulnar
tuberosity
Triceps Long head, infraglenoid Posterior surface of Radial Extend foream
tubercle; lateral head, olecranon process of
superior to radial groove ulna
of humerus; medial head,
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inferior to radial groove
16 | Anatomy
Concept 1.6: Cubital fossa
LEARNING OBJECTIVE: To understand boundaries and contents of Cubital fossa.
Time Needed
1st reading 10 mins
nd
2 look 5 mins
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Triangul ar depression in front of the elbow.

Medially - Pronator Teres
Laterally - Brachioradialis
Apex - distally where brachioradialis crosses pronator teres
Base - Line joining the two epicondyles of Humerus.
Floor - is formed laterally by supinator & medially by Brachialis.
Roof - Median cubital vein crosses obliquely from cephalic to basilic veins in the roof.
Lateral and medial cutaneous nerves of forearm also lie in the roof.
Important contents :
1) Tendon of biceps brachii
2) Brachial artery dividing into ulnar and radial arteries opposite the neck of radius.
3) Median nerve
4) Radial nerve dividing in front of the lateral epicondyle into superficial and deep
terminal branches.
Upper Limb | 17
Concept 1.7: Forearm
LEARNING OBJECTIVE: To understand compartments of Forearm with important

structures
Time Needed
st
1 reading 30 mins
nd
2 reading 15 mins
Muscles of the Anterior Forearm

Pronator teres Medial epicondyle Middle of lateral Median pronates and flexes
and coronoid side of radius forearm
process of ulna
Flexor carpi Medial epicondyle Bases of second Median Flexes foream,

radialis of humerus and third flexes and abducts
metacarpals hand
Palmaris longus Medial epicondyle Flexor median Flexes foream and

of humerus retinaculum, hand
palmar aponeurosis
Flexor carpi
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Medial epicondyle Pisiform, hook o Ulnar Flexes forearm,
ulnaris (humeral head), fhamate, and base flexes and adducts
medial olecranon, of fifth metacarpal hand
and posterior
border of ulna
(ulnar head)
Flexor digitorm Medial epicondyle, Middle phalanges Median Flexes proximal

superficialis coronoid process, of fingers interphalangeal
oblique line of joints, flexes hand
radius and foream
Flexor digitorum Anteromedial Bases of distal Ulnar and median Flexes distal
profundus surface of ulna, phalanges of interphalangeal
interosseous fingers joints and hand
membrane
Flexor pollicis Anterior surface Bases of distal Median Flexes thumb

longus of radius, phalanx of thumb
interosseous
membrane, and
coronoid process
Pronator quadrates Anterior surface of Anterior surface of Median Pronates foream

distal ulna distal radius
18 | Anatomy
Muscles of the Posterior Forearm
Brachioradialis Lateral supracondylar Base of radial styloid Radial Flexes forearm

ridge of humerus process
Extensor carpi Lateral supracondylar Dorsum a base of Radial Extends and

radialis longus ridge of humerus second metacarpal abducts hand
Extensor carpi Lateral epicondyle of Posterior base of third Radial Extends and
radialis brevis humerus metacarpal abducts hands
Extensor Lateral epicondyle of Extensor expansion, Radial Extends and

digitroum humerus base of middle and abducts hands
digital phalanges
Extensor digiti Common extensor Extensor expansion, Radial Extends little

minimi tendon and interosseous base of middle and finger
membrane distal phalanges
Extensor carpi Lateral epicondyle Base of fifth metacarpal Radial Extends and
ulnaris and posterior surface adducts hand
of ulna
Anconeus AfraTafreeh.com
Lateral epicondyle ofOlecranon and upper Radial Extends forearm
humerus posterior surface of
ulna
Supinator Lateral epicondyle, Lateral side of supper Radial Supinates foream

radial collateral and part of radius
annular ligaments,
supinator fossa and
crest of ulna
Abductor pollicis Interosseous Lateral surface of base Radial Abducts thumb

longus membrane, middle third of first metacarpal and hand
of posterior surfaces of
radius and ulna
Extensor pollicis Interosseous membrane Base of distal phalanx Radial Extends distal
longus and middle third of of thumb phalanx of thumb
posterior surface of and abducts hand
ulna
Extensor pollicis Interosseous membrane Base of proximal Radial Extends proximal

brevis and posterior surface of phalanx of thumb phalanx of thumb
middle third of radius and abducts hand
Extensor indicis Posterior surface of Extensor expansion of Radial Extends index

ulna and interosseous index finger finger
membrane
Upper Limb | 19
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20 | Anatomy
Concept 1.8: Flexor Retinaculum & Carpal Tunnel
LEARNING OBJECTIVE: To understand attachment of Flexor retinaculum and important

structures passing through Carpal Tunnel
Time Needed
st
1 reading 20 mins
nd
2 reading 10 mins
Flexor Retinaculum :
• Serves as an origin for muscles of the thenar eminence.

• Forms the carpal tunnel on the anterior aspect of the wrist.

• Is attached medially to the triquetrum, pisiform, and the hook of the hamate and

laterally to the
• tubercles of the scaphoid and trapezium

• Is crossed superficially by the ulnar nerve. ulnar artery, palmaris longus tendon, and

palmar
• cutaneous branch of the median nerve.

Structures Passing through Carpal Tunnel :

(Flexor carpi radialis tendon with its synovial actually passes between flexor retinaculum
and its deep slip i.e. through flexor retinaculum)
• Median nerve

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• Flexor pollicis longus with its synovial sheath (Radial Bursa),

• 4 tendons of Flexor digitorum superficialis

• 4 tendons of Profundus enclosed by common flexor synovial sheath (ulnar bursa).

Upper Limb | 21
Concept 1.9: Anatomical snuff box
LEARNING OBJECTIVE: To understand boundaries and contents of Anatomical snuff

box
Time Needed
st
1 reading 10 mins
nd
2 reading 5 mins
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Boundaries
Anterolaterally:
1. Tendon of abductor pollicis longus.
2. Tendon of extensor pollicis brevis.
Posteromedially: Tendon of extensor pollicis longus.
Floor: It is formed by
1. Styloid process of radius
2. scaphoid
3. trapezium
4. Base of 1st metacarpal
22 | Anatomy
Roof: It is formed by
1. skin and
2. superficial fascia.
Contents: Radial artery.
Structures crossing the roof deep to skin :
1. Cephalic vein, from medial to lateral side.

2. Terminal branches of the superficial radial nerve, from lateral to medial side.

Clinical significance of anatomical snuff box:

• The pulsations of radial artery can be felt in the anatomical box.

• The tenderness in the anatomical box indicates fracture of scaphoid bone.

• The cephalic vein at this site is often used for giving intravenous fluids.

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Upper Limb | 23
Concept 1.10: Wrist and Hand
LEARNING OBJECTIVE: To understand Muscles and important structures of Wrist and

hand with their clinical importance
Time Needed
st
1 reading 30 mins
nd
2 reading 15 mins
Muscles of the Hand

Abductor pollicis Flexor Lateral side of Median Abducts thumb

brevis retinaculum, base of proximal
scaphoid, phalanx of thumb
trapezium
Flexor pollicis Flexor Base of proximal Median Flexes thumb

brevis retinaculum and phalanx of thumb
trapezium
Opponens pollicis Flexor Lateral side of Median Opposes thumb to

retinaculum and first metacarpal other digits
trapezium AfraTafreeh.com
Adductor pollicis Capitate and bases Medial side of Ulnar Adducts thumb
of second and base of proximal
third metacarpals phalanx of the
(oblique head), thumb
palmar surface of
third metacarpal
(transverse head)
Palmaris brevis Medial side Skin of medial Ulnar Wrinkles skin on

of flexor side of palm medial side of palm
retinaculum,
palmar
aponeurosis
Abductor digiti Pisiform and Medial side of Ulnar Abducts little finger
minimi tendon of flexor base of proximal
carpi ulnaris phalanx of little
finger
Opponens digitis Flexor Medial side of Ulnar Opposes little finger

minimi retinaculum and fifth metacarpal
hook of hamate
24 | Anatomy
Lumbricals (4) lateral side lateral side Median (two Flex

of tendons of of extensor lateral) and ulnar metacarpohalangeal
flexor digitorum expansion (two medial) joints and extend
profundus interphalangeal joints
Dorsal interossei Adjacent sides of Lateral sides of Ulnar Abduct fingers, flex
(4) (bipennate) metacarpal bones bases of proximal metacarpophalangeal
phalages, extensor joints, extend
expansion interphalangeal joints
Palmar interossei Medial side Bases of proximal Ulnar Adduct fingers, flex
(3) (Unipennate) of second phalanges in same metacarpophalangeal
metacarpal, lateral sides as their joints, extend
sides of fourth and origins, extensor interphalageal joints
fifth metacarpals expansion
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Upper Limb | 25
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26 | Anatomy
Fascial spaces of the palm
spaces deep to the palmar aponeurosis and are divided by a mldpalmar(oblique) septum
into the thenar space and the midpalmar space.
Thenar space
• lateral space that contains the tlexor polllcls longus tendon and the nexor tendons of

the index finger.

Midpalmar space
• medial space that contains the dexor tendons of the medial three digits.

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Deep palmar arch

• Is formed by the main termination of the radial artery and is usually completed

by the deep palmar branch of the ulnar artery.

• Gives rise to three palmar metacarpal arteries, which descend on the interossei

and join the common palmar digital arteries from the superficial palmar arch.
Superficial palmar arch
• Is the continuation of the ulnar artery and is usually completed by the superficial

palmar branch of the radial artery.

• Gives rise to three common palmar digital arteries, each of which bifurcates into

proper palmar digital arteries, which run distally to supply the adjacent sides of the
fingers.
Upper Limb | 27
Worksheet
• MCQ OF “UPPER LIMB” FROM DQB

• EXTRA POINTS FROM DQB


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
28 | Anatomy
Active recall
1. Label the following diagram
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Upper Limb | 29
2. Structures Piercing the Clavipectoral Fascia are
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30 | Anatomy
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2 Lower Limb
CONCEPTS
Â Concept 2.1 Anterior thigh

Â Concept 2.2 Medial thigh

Â Concept 2.3 Gluteal region

Â Concept 2.4 Posterior thigh

Â Concept 2.5 Popliteal fossa

Â Concept 2.6
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Anterior and lateral leg

Â Concept 2.7 Posterior leg

Â Concept 2.8 Sole

Â Concept 2.9 Hip joint

Â Concept 2.10 Knee joint

Â Concept 2.11 Ankle joint

Â Concept 2.12 Superficial veins of the lower limb

Â Concept 2.13 Lymphatic drainage of the lower

limb
32 | Anatomy
Concept 2.1 : Anterior thigh

Time Needed
1 reading
st
20 mins
2 look
nd
10 mins
Anterior Muscles of the Thigh

Iliacus Iliac fossa, ala of Lesser trochanter Femoral Flexes thigh (with
sacrum psoas major)
Sartorius Anterior-superior Upper medial side Femoral Flexes and rotates
iliac spine of tibia thigh laterally,
flexes and rotates
leg medially
Rectus femoris Anterior-inferior Base of patella, Femoral Flexes thigh,
iliac spine, tibial tuberosity extends leg
posterior-superior
rim of acetabulum
Vastus medialis AfraTafreeh.com
Intertrochanteric Medial side of Femoral Extends leg
line, linea patella, tibial
aspera, medial tuberosity
intermuscular
septum
Vastus lateralis intertrochanteric Lateral side of Femoral Extends leg
line, greater patella, tibial
trochanter, linea tuberosity
aspera, gluteal
tuberosity, lateral
intermuscular
septum
Vastus intermedius Upper shaft of Upper border Femoral Extends leg
femur lower lateral of patella tibial
i n t e r m u s c u l a r tuberosity
septum
Femoral Triangle
• Is bounded by the inguinal ligament superiorly, the sartorius muscle laterally, and the

adductor
• longus muscle medially.

• Contains the femoral nerve, artery, vein, and lymphatics (In the canal).

Lower Limb | 33
Femoral sheath
• Is formed by a prolongation of the Fascia transversalis and Fascia iliaca.

• Contains the femoral artery and vein, the femoral branch of the genitofemoral nerve,

and the femoral canal.

• The femoral nerve lies outside the femoral sheath, lateral to the femoral artery

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Femoral canal
• Lies medial to the femoral vein In the femoral sheath.

• Contains fat, areolar connective tissue, and lymph nodes (of cloquet or rosenmuller)

and vessels.
• Is a potential weak area and a site of femoral herniation, which occurs most frequently

In women because of the greater width of the female pelvis.

34 | Anatomy
Femoral nerve (L2-L4)
Arises from the lumbar plexus within the substance of the psoas major, emerges
between the iliacus and psoas major muscles, and enters the thigh by passing deep to
the inguinal ligament and lateral to the femoral sheath.
Gives muscular branches; articular branches to the hip and knee joints; and cutaneous
branches, including the anterior femoral cutaneous nerve and the saphenous nerve,
with descends through the femoral triangle and accompanies the femoral vessels in the
adductor canal.
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Femoral artery
• Begins as the continuation or the external iliac artery distal to the Inguinal ligament

and descends through the femoral triangle, entering the adductor canal.
• Pulsation may be felt just inferior to the midpoint of the inguinal ligament

branches:
1. Superficial epigastric artery
2. Superficial circumflex iliac artery
3. Superficial external pudendal artery
4. Deep external pudendal artery
5. Profunda femoris (deep femoral) artery
Arises from the femoral artery within the femoral triangle.

Gives the medial and lateral femoral circumflex and muscular branches.

Provides, in the adductor canal, four perforating arteries that perforate and supply

the posterior thigh compartment.

Lower Limb | 35
6. Muscular branches
Clincal Importance: The medial femoral circumflex artery is clinically important

because its branches supply most of the blood to the neck and head of femur
except for the small proximal part that receives blood from the acetabular branch
of the obturator artery.
Adductor canal
• Begins at the apex of the femoral triangle and ends at the adductor hiatus.

• Lies between the adductor magnus and longus muscles and the vastus medialis

muscle and is covered by the sartorius muscle and fascia.

• Contains the femoral vessels, the saphenous nerve, the nerve to the vastus medialis,

and the descending genicular artery.

• Adductor hiatus Is the aperture in the tendon of insertion of the adductor magnus. It

allows the passage of the femoral vessels into the popliteal fossa.
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36 | Anatomy
Concept 2.2 : Medial thigh

Time Needed
1 reading
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5 mins
2 look
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5 mins
Medial Muscles of the Thigh

Adductor longus Body of pubis Middle third of Obturator Adducts and flexes
below its crest linea aspera thigh
Adductor brevis Body and inferior Pectineal line, Obturator Adducts and flexes
pubic ramus upper part of linea thigh
aspera
Adductor magnus Ischiopubic ramus, Linea aspera, Obtruator and Adducts, flexes,
ischial tuberosity medial sciatic (tibial part) and extends thigh
supracondylar line,
adductor tubercle
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Pectineus Pectineal line of Pectineal line of Obturator and Adducts and flexes
pubis femur femoral thigh
Gracilis Body and inferior Medial surface of Obturator Adducts and

pubic ramus upper quarter of flexes thigh, flexes
tibia and rotates leg
medially
Obturator externus Margin of Intertrochanteric Obturator Rotates thigh

obturator foramen fossa of femur laterally
and obturator
membrane
Lower Limb | 37
Concept 2.3 : Gluteal region

Time Needed
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15 mins
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10 mins
Muscles of the Gluteal Region

Gluteus maximus Ilium, sacrum, Gluteal tuberosity, Inferior gluteal Extends and rotates
coccyx, iliotibial tract thigh laterally
sacrotuberous
ligament
Gluteus medius Ilium between iliac Greater trochanter Superior gluteal Abducts and rotates
crest and anterior thigh medially,
and posterior stabilizas pelvis
gluteal lines
Gluteus minimus Ilium between Greater trochanter Superior gluteal Abducts and rotates
anterior and inferior thigh medially
gluteal lines AfraTafreeh.com
Tensor fasciae latae Iliac crest, anterior Iliotibial tract Superior gluteal Flexas, abducts,
superior iliac spine and rotates thigh
medially
Piriformis Pelvic surface Upper end of Sacral (S1-S2) Rotates thigh
of sacrum, greater trochanter laterally
sacrotuberous
ligament
Obturator internus Ischiopubic Greater trochanter Nerve to obturator Abducts and rotates
rami, obturator internus thigh laterally
membrane
Superior gemellus Ischial spine Obturator internus Nerve to obturator Rotates thigh
tendon internus laterally
Interior gemellus Ischial tuberosity Obturator internus Nerve to quadratus Rotates thigh
tendon femoris laterally
Quadratus femoris Ischial tuberosity Intertrochanteric Nerve to quadratus Rotates thigh
crest femoris laterally
lliotibial tract
• A thick lateral portion of the fascia lata.

• Provides insertion for the gluteus maximus and tensor fascia lata muscles.

• Helps form the fibrous joint capsule of the knee and is important in maintaining

posture and locomotion.

38 | Anatomy
Greater Sciatic foramen
Provides a pathway for:-
• Piriformis muscle,

• Superior and inferior gluteal vessels and nerves,

• Internal pudendal vessels and pudendal nerve,

• Nerves to the obturator internus

• Sciatic nerve, posterior femoral cutaneous nerve

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Lesser sciatic foramen

Provides a pathway for:-
• Tendon of the obturator internus,

• Pudendal nerve

• Internal pudendal vessels

• Nerve to the obturator internus,

Structure that pass through both the greater and the Lesser sciatic foramina
• pudendal nerve, internal pudendal vessels, and the nerve to the obturator internus

(PIN)
Lower Limb | 39
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Superior gluteal nerve (L4-S1)
• Arises from the sacral plexus and enters the buttock through the greater sciatic

foramen above
• the piriformis.

• Innervates the gluteus medius and minimus, the tensor fasciae latae, and the hip

joint
• Injury to the superior gluteal nerve causes a characteristic motor loss, resulting

• in weakened abduction of the thigh by the gluteus medius, a disabling limp, and

lurching gait.
Inferior gluteal nerve (L5-S2)
• Arises from the sacral plexus and enters the buttock through the greater sciatic

foramen inferior
• to the piriformis.

• Innervates the overlying gluteus maximus.

40 | Anatomy
Concept 2.4 : Posterior thigh

Time Needed
1 reading
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10 mins
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Posterior Muscles of the Thigh

Semitendinosus Ischial tuberosity Medial surface of Tibial portion of Extends thigh,

upper part of tibia sciatic nerve flexes and rotates
leg medially
Semimembranosus Ischial tuberosity Medical condyle Tibial portion of Extends thigh,

of tibia sciatic nerve flexes and rotates
leg medially
Biceps femoris Long head Head of fibula Tibial (long head) Extends thigh,
from ischial and common flexes and rotates
tuberosity, short peroneal (short leg laterally
head from linea
AfraTafreeh.com head) divisions of
aspera and upper sciatic nerve
supracondylar line
Adductor magnus Ischiopubic ramus, Linea aspera, Obturator and Adducts, flexes,
ischial tuberosity medial sciatic (tibial part) and extends thigh
supracondylar line,
adductor tubercle
Sciatic narve (L4-S3)

• Arises from the sacral plexus and is the largest nerve in the body.

• Enters the buttock through the greater sciatic foramen inferior to the piriformis.

• Divides at the superior border of the popliteal fossa into the tibial nerve, which runs

through the fossa to disappear deep to the gastrocnemius, and the common fibular
nerve, which runs along the medial border of the biceps femoris and superficial to the
lateral head of the gastrocnemius.
• The tibial division innervates the hamstring
muscles (semitendinosus,
semimembranosus, biceps femoris long head).
• The short head of the biceps femoris is innervated by the common fibular division.

• Provides articular branches to the hip and knee Joints.

Lower Limb | 41
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42 | Anatomy
Concept 2.5 : Popliteal fossa

Time Needed
1 reading
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2 look
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Diamond shaped depression behind knee joint.

Superolaterally - Biceps femoris
Inferolaterally - Lateral head of Gastrocnemius, Plantaris.

Superomedially - Semi membranous, semitendinosus, supplemented by gracialis,
sartorius & adductor magnus
Inferomedially - Medial head of Gastrocnemius.
Floor (Anterior wall) - From above downwards formed by
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1. Popliteal surface of Femur

2. Posterior capsule knee joint & oblique popliteal ligament
3. Popliteus muscle covered by Fascia derived as an expansion from
semimembranosus tendon.
Lower Limb | 43
Contents
• Popliteal artey and its branches,

• Popliteal vein and its tributaries,

• Tibial nerve, common peroneal nerve,

• Popliteal lymph nodes

• Pad of fat

Common fibular(peroneal) nerve (L4-S2)

• Arises as the smaller terminal portion of the sciatic nerve at the apex of the popliteal

fossa, descends through the fossa, and superficially crosses the lateral head of the
gastrocnemius muscle.
• Passes behind the head of the fibula, then winds laterally around the neck of the

fibula, and pierces the fibularis longus, where it divides into the deep fibular and
superficial fibular nerves.
• it winds around the neck of the fibula, where it also can be palpated.

• Gives rise to the lateral sural cutaneous nerve, which supplies the skin on the lateral

part of the back of the leg, and the recurrent articular branch to the knee Joint
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44 | Anatomy
Concept 2.6 : Anterior and lateral leg

Time Needed
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Anterior and Lateral Muscles of the Leg

Anterior
Tibialis anterior Lateral tibial First cuneiform, Deep paroneal Dorsiflexes and
condyle, first metatarsal (fibular) inverts foot
interosseous
membrane
Extensor hallucis Middle half of Base of distal Deep peroneal Extends big toe,
longus anterior surface of phalanx of big toe (fibular) dorsiflexes and
fibula, interosseous inverts foot
membrane
Extensor digitorum Lateral tibial Bases of middle Deep peroneal Extends toes,
longus condyle, upper AfraTafreeh.com
and distal (fibular) dorsiflexes and
two thirds of phalanges everts foot
fibula, interosseous
membrane
Fibularis Distal one-third of Base of fifth Deep peroneal Dorsiflexes and
(peroneus) tertius fibula, interosseous metatarsal (fibular) everts foot
membrane
Lateral
Fibularis Lateral tibial Base of first Superficial Everts and plantar
(peroneus) longus condyle, head and metatarsal, medial peroneal (fibular) flexes foot
upper lateral side cuneiform
of fibular
Fibularis Lower lateral Base of fifth Superficial Everts and plantar
(peroneus) brevis side of fibula, metatarsal peroneal (fibular) flexes foot
intermuscular septa
Deep fibular (peroneal) nerve

• Arises from the common fibular nerve in the substance of the fibularis longus on

the lateral side of the neck or the fibula (where it Is vulnerable to Injury but less
vulnerable than the common fibular nerve).
• Enters the anterior compartment by passing through the extensor digitorum longus

muscle.
Lower Limb | 45
• Descends on the interosseus membrane between the extensor digitorum longus and

the tibialis anterior and then between the extensor digitorum longus and the extensor
hallucis longus muscles.
• Innervates the anterior muscles of the leg and then divides into a

lateral branch, which supplies the extensor hallucis brevis and extensor digitorum

brevis
medial branch, which accompanies the dorsalis pedis artery to supply the skin on

the adjacent sides of the first and second toes.
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Superficial fibular (peroneal) nerve

• Arises from the common fibular nerve in the substance of the fibularis tertius on

the lateral side of the neck of the fibula (where it is vulnerable to injury but less
vulnerable than the common fibular nerve).
• Innervates the fibularis longus and brevis muscles and then emerges between the

two muscles by piercing the deep fascia at the lower third of the leg to become
subcutaneous.
46 | Anatomy
• Descends in the lateral compartment and Innervates the skin on the lateral side of the

lower leg and the dorsum of the foot
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Lower Limb | 47
Concept 2.7: Posterior leg

Time Needed
1 reading
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15 mins
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Posterior Muscles of the leg

Superficial group
Gastrocnemius Lateral (lateral Posterior aspect of Tibial Flexes knee,

head) and medial calcaneus via tendo plantar flexes foot
(medial head) calcaneus
femoral condyles
Soleus Upper fibula head, Posterior aspect of Tibial Plantar flexes foot
soleal line on tibia calcaneus via tendo
calcaneus
Plantaris Lower AfraTafreeh.com

lateral Posterior surface
Tibial Flexes log, plantar
supracondylar line of calcaneus flexes foot
Deep group
Popliteus Lateral condyle of Upper posterior Tibial flexes by unlocking

femur, popliteal side of tibia knee and rotates
ligament leg medially
Flexor hallucis Lower two- Base of distal Tibial Plantar flexes

longus thirds of fibula, phalanx of big toe foot, flexes distal
interosseous phalanx of big toe
membrane,
intermuscular septa
Flexor digitorum middle posterior Distal phalanges of Tibial Flexes lateral four
longus aspect of tibia lateral four toes toes, plantar flexes
foot
Tibialis posterior Interosseous Tuberosity Tibial Plantar flexes and

membrane, upper of navicular, inverts foot
parts of tibia and sustentaculum tali,
fibula three cuneiforms,
cuboid, bases of
metatarsals, 2-4
48 | Anatomy
Tibial nerve (L4-Sl)
• Descends 1hrough the popliteal fussa and then lies on the posterior surface of the

popliteus muscle.
• Articular branches, to the knee joint.

• Muscular branches to the posterior muscles of the leg.

• Medial sural cutaneous nerve, the medial calcaneal branch to the skin of the heel and

sole
• Articular branches to the ankle joint.

• Terminates deep to the f1exorr retinaculum where it divides into 1he medial and

lateral plantar nerves.
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Lower Limb | 49
Concept 2.8 : Dorsum of foot & Sole

Time Needed
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Muscles of the Foot

Dorsum of foot
Extensor digitorum Dorsal surface of Tendons of extensor Deep peroneal Extends toes
brevis calcaneus digitorum longus
Extensor hallucis Dorsal surface of Base of proximal Deep peroneal Extends big toe
brevis calcaneus phalanx of big toe
Muscles of the Foot

Sole of foot
First layer
Abductor hallucis Medical tubercle of
calcaneus
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Base of proximal Medial plantar
phalanx of bit toe
Abducts bit toe
Flexor digitorum Medial tubercle of Middle phalanges of Medial plantar Flexes middle
brevis calcaneus lateral four toes phalanges of lateral
four toes
Abductor digit Medial and lateral Proximal phalanx of Lateral plantar Abducts little toes
minimi tubercles of little toe
calcaneus
Second layer
Quadratus plantae Medial and lateral Tendons of flexor Lateral planter Aids in flexing toes
side of calcaneus digitorum longus
Lumbricals (4) Tendons of flexor Proximal phalanges, First by medial Flex
digitorum longus extensor expansion plantar, lateral three metatarsophalangeal
by lateral plantar joints and extend
interphalangeal joints
Third layer
Flexor hallucis brevis Cuboid, third Proximal phalanx of Medial plantar Flexes big toe
cuneiform big toe
Adductor hallucis
Oblique head Bases of metatarsals Proximal phalanx of Lateral plantar Adducts big toe
2-4 big toe
Transverse head Capsule of lateral four
metatarsophalangeal
joints
Flexor digiti minimi Base of metatarsal 5 Proximal phalanx of Lateral plantar Flexes little toe
brevis little toe
50 | Anatomy
Fourth layer
Plantar interossei (3) Medial sides of medial sides of Lateral plantar Adduct toes, flex
metatarsals 3-5 base of proximal proximal, and extend
phalanges 3-5 distal phalanges
Dorsal interossei (4) Adjacent shafts of proximal phalanges Lateral plantar Abduct toes, flex
metatarsals of second toe (medial proximal, and extend
and lateral sides), and distal phalanges
third and fourth toes
(lateral sides)
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Arches of foot
Features Medial Longitudinal Arch Lateral Longitudinal Arch
Higher, more mobile, shock absorber Lower, limited mobility, transmits weight.
Anterior end Heads of 1st, 2nd & 3rd metatarsals Heads of 4th & 5th metatarsal
Posterior end Medial tubercle of calcaneum Lateral tubercle of calcaneum
Summit Superior articular surface of talus Articular facet on superior surface of
calcaneum
Anterior pillar Talus, navicular, 3cueniform & first three Cuboid, 4th & 5th metatarsal bones
metatarsal bones
Main joint talocalcaenonavicular Calcaenocuboid
Intersegmental tiers Spring ligament Short & long plantar ligament
Tie beams Plantar aponeurosis, abductor hallucis, Plantar aponeurosis, abductor digiti minimi
Medial part of flexor digitorum brevis brevis, lateral part of flexor digitorum brevis
Sling Tibialis anterior, tibialis posterior Peroneus longus & brevis.
Lower Limb | 51
Concept 2.9: Hip joint
LEARNING OBJECTIVE: To understand boundaries and contents of Anatomical snuff

box
Time Needed
1 reading
st
10 mins
2 look
nd
5 mins
Movements Muscle Producing movements
Flexion • Psoas major and iliacus (chief flexor)

• Sartorius, rectus femoris and pectineus

Extension • Gluteus maximum (chief extensor)

• Hamstring muscle

Abduction • Gluetues medius and minimum (chief abductors)

• Tensor fascile latae and sartorius

Adduction • Adductor longue, adductor brevis and adductor magnus (chief adductors)

• Pectineus and gracilis

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Medial rotation • Anterior fibers of gluteus minimus and medius (cheif nedial rotators)

• Tensor fasciae latae

Lateral rotation Piriformis, obturator externus, obturator internus and associated gemelli, quadratus
femoris (These muscle are generally termed short rotators)
• Is a multiaxial ball-and-1ockat 1ynovial joint between the acetabulum of the hip bone

and the head of the femur and allows abduction and adduction, flexion and extension,
and circumduction and rotation
Fibrous joint capsule
• Is attached proximally to the margin of the acetabulum and to the transverse

acetabular ligament.
• Is attached distally to the neck of the femur as follows: anteriorly to the intertrochanteric

line and the root of the greater trochanter and posteriorly to the intertrochanteric
crest.
• encloses part of the head and most of the neck of the femur.

• Is reinforced anteriorly by the iliofemoral ligament, posteriorly by the ischiofemoral

ligament, and inferiorly by the pubofemoral ligament.

52 | Anatomy
Concept 2.10 : Knee joint

Time Needed
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10 mins
A. Antlrior cruciate ligament

• Lies outside the synovial joint cavity but within the fibrous joint capsule.

• Arises from the anterior lntercondylar area of the tibia and passes superoposteriorly

and laterally to Insert Into 1he medial surface of the lateral femoral condyle.
• Is slightly longer than the posterior cruciate ligament.

• Prevents forward sliding of the tibia on the femur (or posterior displacement of the

femur on the tlbia) and prevents hyperextension of the knee joint.

• Is taut during extension of the knee and is lax during flexion.

• May be tom when the knee is hyperextended.

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B. Posterior cruciate ligament

• Lies outside the synovial joint cavity but within the fibrous joint capsule.

• Arises from the posterior intercondylar area of the tibia and passes superoanteriorly

and medially to Insert into the lateral surface of the medial femoral condyle.
• Is shorter, straighter, and stronger 1han the anterior cruciate ligament.

• Prevents backward sliding of the tibia an the femur (or anterior displacement of the

femur on the tibia) and limits hyperflexion of the knee.

• Is taut during flexion of the knee and is lax during extension.

Lower Limb | 53
Bursae
1. Suprapatallar bursa: Lies deep to the quadriceps femoris muscle and Is the major

bursa communicating with the knee joint cavity.

2. Prepatellar bursa: lies over the superficial surface of the patella.

Prepatellar bursitis (housemaid kneel is inflammation and swelling of the prepatellar

bursa.
3. Infrapatellar bursa
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Consists of a subcllblneous infrapatellar bursa oveI the patellar ligament and a

deep infrapatellar bursa deep to the patellar ligament

infrapatellar (superficial) bursitis (clergyman kneel is inflammation of the

infrapatellar bursa

4. Anaerine bursa (pe anserinus) Lies between the tibial collateral ligament and the

tendons of the sartorius, gracilis, and semitendinosus muscles.

5. Popliteal (Baker) cyst is a swelling behind the knee, commonly found in association

with intra-articular knee disorders, such as arthritis and meniscus injury. It impairs
flexion and extension of the knee joint.
54 | Anatomy
Concept 2.11: Ankle joint

Time Needed
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10 mins
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5 mins
• hinge-type synovial joint between the tibia and fibula superiorly and the trochlea of

the talus inferiorly, permitting dorsiflexion and plantar flexion.
Ligaments
1. Medial (deltoid) ligament

Has four parts: the tibionavicular, tibiocalcaneal, anterior tibiotalar, and posterior

tibiotalar ligaments.
Extends from the medial malleolus to the navi.cular bone, calcaneus, and talus.

Prevents over eversion of the foot and helps maintain the medial longitudinal arch.

2. Lateral ligament

Consists of the anterior talofibular, posterior talofibular, and calcaneofibular

(cordllke) ligaments.
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Resists inversion of the foot and maybe tom during an ankle sprain (inversion injury).
Lower Limb | 55
Concept 2.12: Superficial veins of the lower limb

Time Needed
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A. Great saphenous vein
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• Begins at the medial end of the dorsal venous arch of the foot.

56 | Anatomy
• Ascends anterior to the medial malleolus and along the medial aspect of the tibia

along with the saphenous nerve, passes behind the medial condyles of the tibia and
femur; and then ascends along the medial side of the femur.
• Passes through the saphenous opening in the fascia lata and pierces the femoral

sheath to join the femoral vein.

• Receives the external pudendal, superficial epigastric, superficial circumflex iliac,

lateral femoral cutaneous, and accessory saphenous veins.

• Is a suitable vessel for use in coronary artery bypass surgery and for venipuncture.

• The great saphenous vein accompanies the saphenous nerve, which is vulnerable to

injury when the vein is harvested surgically.

• It is commonly used for coronary artery bypass surgery in which the vein is reversed

so its valves do not obstruct blood flow in the graft.

• This vein and its tributaries become dilated, and varicosities commonly occur in the

posteromedial portion of the lower limb.
B. Small (short) saphenous vein

• Begins at the lateral end of the dorsal venous arch and passes superiorly along the

lateral side of the foot with the sural nerve, posterior to the lateral malleolus
• Ascends accompanying the aural nerve and passes to the popliteal fossa, where it

perforates the deep fascia and terminates In the popliteal vain.
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Lower Limb | 57
Concept 2.13: Lymphatic drainage of the lower limb

Time Needed
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5 mins
Lymph nodes
1. Superficial inguinal group of lymph nodes

Is located subcutaneously near the saphenofemoral junction and drains the

superficial thigh and medial leg regions.

Receives lymph from the anterolateral abdominal wall below the umbilicus, gluteal

region lower parts of the vagina and anus, and external genitalia except the glans,
and drains into the external iliac nodes.
2. Deep inguinal group of lymph nodes

Lies deep to the fascia lata on the medial side of the femoral vein.

Receives lymph from deep lymph vessels that accompany the femoral vessels

and from the glans penis or glans clitoris and drains into the external iliac nodes
through the femoral canal.
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58 | Anatomy
Worksheet
• MCQ OF “LOWER LIMB” FROM DQB



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
Lower Limb | 59
Important Tables (Active recall)
Features Medial Longitudinal Arch Lateral Longitudinal Arch
Anterior end
Posterior end
Summit
Anterior pillar
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Main joint
Intersegmental
tiers
Tie beams
Sling
60 | Anatomy
Structure that pass through both the greater and the Lesser sciatic
foramina are :-
• Major part of Gluteus maximus is inserted into

• In inversion sprain most commonly injured ligament is –

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3 Thorax
CONCEPTS
Â Concept 3.1 Joints of Thorax

Â Concept 3.2 Muscles of Thorax

Â Concept 3.3 Azygos venous system

Â Concept 3.4 Pleura
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Â Concept 3.5 Lung

Â Concept 3.6 Pericardium

Â Concept 3.7 Heart

Â Concept 3.8 Fetal Circulation

Â Concept 3.9 Mediastinum

62 | Anatomy
Concept 3.1: Joints of Thorax

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• Sternoclavicular joint saddle-type synovial joint with two separate synovial cavities

and provides the only bony attachment between the appendicular and axial skeletons.
• Sternocostal (sternochondral) joints articulation of the sternum with the first

seven rib cartilages. The sternum (manubrium) forms a synchondrosis with the first
costal cartilage, whereas the second to seventh costal cartilages form synovial plane
joints with the sternum.
• Costochondral joints synchondroses in which the ribs articulate with their respective

costal cartilages.
• Manubriosternal joint symphysis (secondary cartilaginous joint) between the

manubrium and the body of the sternum..

• Xiphisternal joint symphysis articulation between the xiphoid process and the body

of the sternum.
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• Costovertebral joints synovial plane joints of heads of ribs with corresponding and

supraadjacent vertebral bodies.

• Costotransverse joint synovial plane joint of the rib tubercle with the transverse

process of corresponding vertebra.

• lnterchondral joints synovial plane joints between the 6th and the 10th costal

cartilages of ribs.
Thorax | 63
Concept 3.2: Muscles of Thorax

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Muscles of the Thoracic Wall

External Lower border of ribs Upper border of rib Intercostal Elevate ribs in
intercostals below inspiration
Internal Lower border of ribs Upper border of rib Intercostal Depress ribs (costal
intercostals below par); elevate ribs
(interchondral part)
Innermost Lower Border ribs Upper border of rib Intercostal Elevate ribs
Intercostals below
Transversus Posterior surface of Inner surface of costa Intercostal Depresses ribs
thoracis lower sternum and cartilages 2-6
xiphoid
Subcostalis
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Inner surface of lower Upper borders of ribs Intercostal Depresses ribs
ribs near their angles 2 or 3 below
64 | Anatomy
Diaphragm
• Arises from the xiphoid process (sternal part}, lower six costal cartilages (costal

part}, medial and lateral lumbocostal arches {lumbar part), vertebrae L1 to L3 for the
right crus, and vertebrae L1 to L2 for the left crus.
• Inserts into the central tendon and Is the principal muscle of inspiration.

• Receives somatic motor fibers solely from the phrenic nerve. Its central part receives

sensory fibers from the phrenic nerve, whereas the peripheral part receives sensory
fibers from intercostal nerves.
• Receives blood from the musculophrenic, pericardiophrenic, superior phrenic, and

inferior phrenic arteries.

• Descends when it contracts, causing an increase in thoracic volume by increasing the

vertical diameter of the thoracic cavity and thus decreasing intrathoracic pressure.
• Ascends when it relaxes, causing a decrease in thoracic volume, resulting in increased

thoracic pressure.
Right crus
• ls larger and longer than the left crus.

• Originates from vertebrae Ll to 13 (the left crus originates from Ll to L2).

• Splits to enclose the esophagus.

Medial arcuate ligament

• Extends from the body of Ll to the transverse process of LI and passes over the psoas
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• muscle and the sympathetic trunk.

Lateral arcuate ligament

• Extends from the transverse process of L1 to rib 12 and passes over the quadratus

lumborum.
Major openings of the diaphragm:-

Name of Opening Vertebral level Structures Passing through
Vena caval T8 1. Inferior vena cava

2. right Phrenic nerve
Esophageal T10 1. Esophagus

Hiatus 2. Anterior & Posterior vagal trunk
3. Esophageal branches of Left gastric Artery
4. Lymphatics
Aortic Orifice T12 1. Descending Aorta

Osseo aponeurotic (lower Border) 2. Thoracic Lymph Nodes
3. Lymphatics
4. Sometimes Azygos vein
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Development:
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Diaphragm develops from 4 structures derived from mesoderm which unite to form a
sheet. These are
1) Septum Transversum : Gives origin to sternal part and central tendinous region.

2) Pleuroperitoneal membrane : On either side the membranes, separate pleural

from peritoneal cavities and form central part of domes of diaphragm.

3) Dorsal mesentery of Oesophagus : Gives origin to crural part of diaphragm.

4) Lateral Body Walls : Gives origin to peripheral costal portion of diaphragm.

Respiratory Movements
Increase during Inspiration Movement Muscle
Vertical Diameter Descent of Diaphragm chief muscle of inspiration
Transverse Diameter “Bucket - handle” movements Lower ribs (7th to 10th) move
outwards
Antero Posterior Diameter “Pump handle” movement upper six ribs whose elevation
pushes the sternum upwards and
forwards
66 | Anatomy
Type of respiration Inspiration Expiration

Quiet •
Diaphragm, • Passive

•
External intercostal, • No muscles

•
Interchondral portion of internal intercostal,
•
Levatores costarum,
•
serratus posterior superior
Forced •
serratus anterior, • Internal intercostal
•
scaleni, • innermost intercostals,
•
sternocleidomastoid, • subcostalis,
•
Pectoralis major • Transversus thoracis,
•
Pectoralis minor, • serratus posterior inferior
•
erector spinae. • latissimus dorsi
• The neurovascular bundle lies in the costal groove present along the inferior border

of rib (vein – artery – nerve ). The order is reverse in first space i.e. (nerve – artery
– vein).
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Aspiration of pleural fluid is done in the midaxillary line, in the 8th intercostals space.
The needle is passed through the lower part of intercostal space.( upper border of lower
rib ), to avoid injury to the neurovascular bundle, which lies in the costal groove.
Arterial supply of chest wall:
• Each of the upper 9 intercostal spaces have one posterior intercostal artery & two

anterior intercostal arteries

• The 10th & 11th intercostal spaces have only one posterior intercostal artery

Thorax | 67
Anterior intercostal arteries :
• In the upper six spaces arise from Internal thoracic or internal mammary artery (br.

of I part of subclavian)Q
• For 7th, 8th 9th spaces are branches of Musculophrenic, one of the terminal division

of internal thoracic arteryQ

Posterior intercostal artery - Main artery of the space running in the costal groove
• Posterior intercostal arteries in the upper two spaces are branches of superior

intercostal artery, (branch of costocervical trunks from II part of subclavian artery )Q

• 3rd to 11th (Lower nine) posterior intercostal arteries of both sides are branches of

Descending thoracic aorta

Venous Drainage:
Anterior intercostal veins : Two in each of the upper 9 spaces
a) 7th, 8th & 9th anterior intercostal veins drain into Musculophrenic vein, a tributary

of internal thoracic vein

b) 1st to 6th anterior intercostal veins drain directly into internal thoracic vein which

drains into Brachiocephalic vein
Mode of termination of right and left posterior intercostals veins

Right posterior intercostals veins Left posterior intercostals veins
1st (highest) drains into the right brachiocephalic 1st (highest) drains into left brachiocephalic vein
vein AfraTafreeh.com
2nd, 3rd and 4th join to form right superior 2nd, 3rd, and 4th joint to form left superior
intercostals vein, which in turn drains into the azygos intercostals vein, which in turn drains into left
vein brachiocephalic vein
5th – 11th drain into the azygos vein • 5th-8th drain into accessory azygos vein

• 9th-11th drain into hemiazygos vein

Subcostal vein drains into the azygos vein Subcostal vein drains into the hemiazygos vein
68 | Anatomy
Concept 3.3: Azygos venous system

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Tributaries :
1. Hemiazygos Vein: Formed by union of left subcostal and left ascending lumbar veins.
Enters thorax piercing left crus. Drains 9th , 10th, 11th left posterior intercostal veins,
some mediastinal and oesophageal veins. Crosses midline at T8 level and drains into
azygos.
2. Accessory Hemiazygos : Receives 4th to 8th left posterior intercostal veins and crosses
midline at T7 level to drain into azygos. It also receives left bronchial veins.
3. Right posterior intercostal veins : From 4th to 11th
4. Right superior intercostal vein : From by 2nd & 3rd posterior intercostal vein.
5. Some oesophageal, pericardial, mediastinal and
6. Right bronchial vein
Thorax | 69
Concept 3.4: Pleura

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1. Parietal pleura
• Lines the inner surface of the thoracic wall and the mediastinum.

The internal thoracic wall and vertebral bodies are covered by the costovertebral

pleura,
the thoracic surface of the diaphragm. By the diaphragmatic pleura,

lateral boundary of the mediastinum is lined by the mediastinal pleura.

The cervical pleura (cupulal is a dome of pleura that projects into the neck
above the neck of the first nb to cover the apex of the lung. Cervical pleura is
reinforced by a suprapleural membrane (Sibson fascia), which is a thickening of
the endotharacic fascia, and ill attached to the first rib and the transverse process
of the seventh cervical vertebra.
• Intercostal nerves innervate the costal pleura and the peripheral portion of the

diaphragmatic
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• pleura; phrenic nerves innervate the central portion of the diaphragmatic pleura

• and the mediastinal pleura.

2. Visceral pleura (pulmonary pleura)

• Adheres to the surface of the lungs and dips Into all of the fissures.

• lt is supplied by bronchial arteries and drained by pulmonary veins.

• Visceral pleura is insensitive to pain but is sensitive to stretch and contains vasomotor

fibers and sensory endings of vagal origin, which may be involved in respiratory
reflexes.
Pleural cavity
Is a potential space between the parietal and the visceral pleurae.
1. Costodiaphragmatic recesses
Are the pleural recesses formed by the reflection of the costal and diaphragmatic

pleurae
beyond the inferior margin of the lung.

Can accumulate fluid when in the erect position.

Allow the lungs to be pulled down and expanded during Inspiration.

2. Costomediastinal recesses
Are part of the pleural cavity where the costal and mediastinal pleurae meet

anteriorly behind the sternum.

70 | Anatomy
Concept 3.5: Lung

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• Structures passing through Hilum from before backwards are - Pulmonary vein,

Pulmonary artery and bronchus (VAB)

• Structures passing through hilum from above downwards –

Right lung Left Lung

Eparterial bronchus Pulmonary artery
Pulmonary artery Bronchus
Hyparterial Bronchus Pulmonary vein
Pulmonary vein
Relations of mediastinal surface of Lungs

Mediastinal surface of the right lung Mediastinal surface of the left lung
Right atrium Left ventricle
Superior and inferior vena cavae Ascending aorta
Azygos vein Arch of aorta and descending
thoracic aorta
Right brachiocephalic vein Left subclavian and left common carotid arteries
Esophagus and trachea Esophagus and thoracic duct
Thorax | 71
Three neural structures Four neural structures
• Right phrenic nerve

• Left phrenic vein

• Right vagus nerve

• Left vagus nerve

• Right sympathetic chain

• Left sympathetic chain

• Left recurrent laryngeal nerve

Bronchopulmonary Segment
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Pyramidal shaped unit, apex directed towards hilum, base directed towards surface
characterized by:
a. Largest subdivision of a lobe.
b. Independent respiratory unit
c. Pyramidal in shape with apex facing towards the hilum & base towards pleural surface.
d. Tertiary (Segmental) bronchus lying centrally
e. Usually a segmental br. of pulmonary artery accompanying the bronchus
f. An intersegmental septum of connective tissue
g. Drained by intersegmental veins (more than one vein)Q
h. It is not a bronchovascular segment (does not have its own vein)Q
i. Surgically resectableQ
• There are 10 Tertiary bronchi & so 10 bronchopulmonary segments in each lung

Lung Left Lung

UPPER LOBE (3) UPPER LOBE (5)
• Apical
Apical Sometimes as
• Posterior
Posterior Apico-Posterior
• Anterior
Anterior
72 | Anatomy
MIDDLE LOBE (2)

• Lateral
Superior Lingular
• Medial
Inferior Lingular
LOWER LOBE (5) LOWER LOBE (5)
• Superior (Apical)
Superior (Apical)
• Medial basal
Medial basal - may be absent
• Anterior basal
Anterior basal
• Lateral basal
Lateral basal
• Posterior basal
Posterior basal
• RightLeft lung sometimes has only 8 or 9 segments. Medial basal (cardiac) segment may be absent

completely or very much reduced in size. The upper lobe may have apico - posterior segment
• Lingula of the left lung is equal to middle lobe of the right lung

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Thorax | 73
Concept 3.6: Pericardium

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A fibro serous sac that encloses the heart and roots of the great vessels and occupies
the middle mediastinum.
• Is composed of the fibrous pericardium and serous pericardium.

• Receives blood from the pericardiophrenic, bronchial, and esophageal arteries.

• Is innervated by sensory fibers from the phrenic nerve and vasomotor fibers from the

vagus nerves and the sympathetic trunks.

A. Fibrous pericardium
Is a strong, dense, fibrous layer that blends with the adventitia of the roots of the great
vessels and the central tendon of the diaphragm.
B. Serous pericardium
Consists of the parietal layer, which lines the inner surface of the fibrous pericardium,
and the visceral layer, which forms the outer layer (epicardium) of the heart wall and
roots of the great vessels. AfraTafreeh.com
Pericardial Sinuses
1. Transverse sinus
Is a subdivision of the pericardial sac, lying posterior to the ascending aorta and
pulmonary trunk, anterior to the SVC, and superior to the left atrium and the pulmonary
veins.
Is of great importance while performing cardiac surgery. A ligature can be passed
through the sinus and tightened around the aorta and pulmonary artery while diverting
circulation through the bypass machine.
2. Oblique sinus
Is a subdivision of the pericardial sac behind the heart, surrounded by the reflection of
the serous pericardium around the right and left pulmonary veins and the inferior vena
cava (IVC).
74 | Anatomy
Concept 3.7: Heart

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External Features:
• Base or Posterior surface: Formed mainly by Left atrium and partly by posterior

aspect of Right Atrium.

• Apex : This is the anatomical apex of the conical left ventricle overlapped by left

lung & pleura. It is located most commonly in the left 5th intercostal space a little
medial to midclavicular line. An apical pulse or Point of maximal impulse (PMI) can be
palpated in left 5th intercostal space, just beneath the nipple.
• Anterior or Sternocostal Surface : Right ventricle forms major portion of this surface,

present on both the sides of the midline. Right Atrium , left ventricle & left Auricle also
contributes to this surface. (Penetrating wounds through anterior chest wall close to
the left sternal margin cause damage to right ventricle).
• Inferior or Diaphragmatic Surface : 2/3 part formed by left ventricle and 1/3 part

formed by right ventricle.

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• Anterior Atrio ventricular groove - separates the right atrium from right ventricle on
the sternocostal surface. It is occupied by the right coronary artery and small cardiac
vein.
• Anterior inter ventricular groove : Representing the anterior edge of the interventricular

septum, separates right & left ventricles on the sternocostal surface. It is occupied
by Anterior inter ventricular branch (Anterior descending) of Left coronary artery and
Great cardiac vein.
• Posterior interventricular sulcus : Representing the edge of the interventricular

septum separate the wo ventricles on the diaphragmatic surface. It contains the

posterior descending (Posterior interventricular) branch of right coronary artery and
middle cardiac vein.
• Posterior atrio – ventricular groove / Coronary sulcus : Separates the diaphragmatic

and posterior surfaces. It is occupied by the coronary sinus and circumflex branch of
Left coronary artery.
Right Border : Formed by right atrium - separates it from right surface.
Left Border or Obtuse margin : Formed by left ventricle and a small part of left
auricle. Separates sternocostal from left surface.
Inferior border or Acute margin : Most prominent, sharp, nearly Horizontal margin
separates the sternocostal from diaphragmatic surface. Mostly formed by right ventricle
and close to the apex a small contribution by left ventricle. A notch called Apical Incisure
lies on this border just to the right of the apex
Crux of the Heart is the junction of interatrial , interventricular and coronary sulci.
Thorax | 75
Internal anatomy of the heart
1. Right atrium
• Has an anteriorly situated rough-walled atrium proper and the auricle lined with

pectinate muscles and a posteriorly situated smooth-walled sinus venarum, into

which the two venae cavae open.
• Is larger than the left atrium but has a thinner wall, and its sinus venarum between

two venae cavae is separated from the atrium proper by the crista termilnalis.
• Contains the valve (Eustachian) of the IVC and the valve (Thebesian) of the coronary

sinus.
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a) Right auricle Is the conical muscular pouch of the upper anterior portion of the right

atrium, which covers the first part of the right coronary artery.
b) Sinus venarum (sinus venarum cavarum)

Is a posteriorly situated, smooth-walled area that is separated from the more

muscular atrium proper by the crisla teminalis.

Develops from the embryonic sinus venosus and receives the SVC, IVC, coronary

sinus, and anterior cardiac veins.

c) Pectinate muscles Are prominent ridge of atrial myocardium located in the interior of

both auricles and the right atrium.

d) Crista terminalis Is a vertical muscular ridge running anteriorly along the right atrial

wall from the opening of the SVC to the opening of the IVC, providing the origin of
the pectinate muscles.
e) Fossa Ovalis

Is an oval-shaped depression in the interatrial septum and represents the site

of the foremen ovale, through which blood runs from the right atrium to the left
atrium before birth. The upper rounded margin of the fossa is called the limbus
Fossa Ovalis
76 | Anatomy
2. Left atrium
Is smaller and has thicker walls than the right atrium, and its walls are smooth, except
for a few pectinate muscles in the auricle.
3. Right ventricle
• Makes up the major portion of the anterior (sternocostal) surface of the heart.

Contains the following structures:

a) Trabeculae carnae cordis - anastomosing muscular ridges of myocardium in the

ventricles.
b) Papillary muscles

Are cone-shaped muscles enveloped by endocardium.

Extend from the anterior and posterior ventricular walls and the septum.

Their apices are attached to the chordae tendineae.

Papillary muscles contract to tighten the chordae tendineae, preventing the

cusps or the tricu1pid valves from being everted into the atrium by the pressure
developed by ventricular contractions. This prevents regurgitation of ventricular
blood into the right atrium.
c) Chordae tendineae

Extend from one papillary muscle to more than one cusp of the bicuspid valve.

Prevent eversion of the valve cusps into the atrium during ventricular contractions.

d) Conu1 arteriosus (infundibulum)

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Is the upper smooth-walled portion of the right ventricle, which leads to the

pulmonary trunk.
e) Septomarginal trabecula (moderator band)

Is an isolated band of trabeculae carneae that forms a bridge between the

interventricular septum and the base of the anterior papillary muscle In the
anterior wall of the right ventricle.
Is called the moderator band for its ability to prevent overdistension of the ventricle

and carries the right limb (Purkinje fibers) of the AV bundle from the septum to
the sternocostal wall of the ventricle.
4. Left ventricle
• Lies at the back of the heart, and its apex is directed downward, forward, and toward

the left.
• Is divided into the left ventricle proper and the aortic vestibule, which is the upper

anterior Part of the left ventricle that leads into the aorta.
• Contains two papillary muscles (anterior and posterior) with their chordae tendineae

and a Meshwork of muscular ridges. The trabeculae carnae cordis.

• Performs harder work; has a thicker (two to three times as thick) wall; and is longer,

narrower, and more conical shaped than the right ventricle.

Thorax | 77
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Coronary Arteries
Right Coronary Artery (RCA):
Arises from anterior (Right Coronary) aortic sinus (of Valsalva) of Ascending aorta.
Descends vertically downwards in the anterior part of the coronary sulcus, winds round
the inferior border and extend into the posterior part of coronary sulcus. It terminates
by anastomosing with circumflex branch of left coronary artery just to the left of crux
of the Heart.
Branches & Distribution:
1. Right conus artery : It is usually the first branch of right coronary - Supplies

Infundibulum of right ventricle and forms - Annulus of Vieussens with Left conus
artery. it may arise separately from the anterior aortic sinus as “Third Coronary Artery
“.
2. Artery of S.A. Node : In 65% cases it is a branch of right coronary and supplies S.A.

node & part of right atrium. In 35% cases it is a branch of Left circumflex artery.
3. Right Anterior Ventricular Rami : Run horizontally from right coronary artery and

supply Sternocostal surface of right ventricle.

4. Right Marginal Artery : (Acute marginal A.) - Run horizontally to the apex just

above the inferior margin and supply both sternocostal & diaphragmatic surfaces of
right ventricle.
78 | Anatomy
5. Right posterior ventricular rami : Arise from RCA in the posterior part of coronary

sulcus and supply the Diaphragmatic surface of right ventricle.

6. Posterior interventricular (Posterior Descending) branch : In majority of cases,

a branch of RCA & descends in the posterior interventricular sulcus and anastomose
with anterior interventricular branch of LCA on the diaphragmatic surface close to the
apex. It supplies :
a) Posterior 1/3 of Interventricular septum.

b) Diaphragmatic surface of Right & Left ventricles adjoining posterior interventricular

sulcus.
c) A-V Nodal artery-Arises from a deep loop of posterior descending branch of RCA

and supplies A.V. node.

Left Coronary Artery
a. Shorter and larger in calibre; supply greater volume of myocardium than RCA.

b. Arises from Left Posterior (Left coronary) Aortic Sinus (of Valsalva).

c. Runs to the left between pulmonary trunk and left auricle to reach the coronary sulcus

where it generally bifurcates into anterior interventricular & circumflex branches

(sometimes LCA trifurcates into circumflex, anterior interventricular and diagonal
branches).
1. Anterior interventricular (anterior Descending) Branch:
A Large branch, descend in the anterior interventricular groove, winds round the acute
margin to run for a short distance in the posterior interventricular groove to anastomose
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with posterior descending branch of RCA.
a) Left Conus Artery : A small branch supplying the infundibulum of right ventricle

and form annulus of Viensseus with right conus artery.

b) Left anterior ventricular rami : 2 - 9 in number run obliquely downwards on

the anterolateral wall of left ventricle. The largest of these branches is known as
Diagonal artery supply Sternocostal surface of left ventricle.
c) Septal branches : Supply anterior 2/3 of interventricular septum including left

branch of A - V bundle (of HIS). It may also supply posterior third of septum for a
variable distance from cardiac apex.
2. Circumflex branch :
Runs in the posterior part of the coronary sulcus towards the crux of heart and ends by
anastomosing with terminal part of RCA.
a) Anterior & Posterior Atrial Rami - Supply Left Atrium.

b) Left marginal (obtuse marginal) - a large branch descending on the left surface of

heart to supply lateral wall of Left ventricle.

c) Posterior ventricular rami - Small branches supplying diaphragmatic surface of left

ventricle.
In 35% cases artery to the SA node arises from circumflex artery.

In 20% cases artery to the AV node arises from circumflex branch.

In 10 - 15% cases posterior descending branch arises from circumflex branch.

Thorax | 79
Area of Distribution:
Right Coronary Artery Left Coronary Artery
Right Atrium Left atrium
Right ventricle except small strip along anterior Right ventricle (small part) along anterior
interventricular groove interventricular groove
Left ventricle (small part) along posterior and Left ventricle except small strip along posterior and
inferior surface inferior surface
Posterior 1/3 of interventricular septum Anterior 2/3 of interventricular septum
Coronary sinus
• Is the largest vein draining the heart and lies in the coronary sulcus, which separates

the atria from the ventricles.

• Opens into the right atrium between the opening of the IVC and the AV opening.

• Receives the great, middle, and small cardiac veins; the oblique vein of the left

atrium; and the posterior vein of the left ventricle.
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Great cardiac vein

• Begins at the apex of the heart and ascends along with the IV branch of the left

coronary artery.
• Turns to the left to lie in the coronary sulcus and continues as the coronary ainut.

Middle cardiac vein

• Begins at the apex: of the heart and ascends in the posterior IV groove, accompanying

the posterior IV branch or the right coronary artery.

• Drains into the right end of the coronary sinus.

Small cardiac vein

• Runs along the right margin of the heart In company with the marginal artery and

then posteriorly in the coronary sulcus to end in the right end of the coronary sinus.
80 | Anatomy
Oblique vein of the left atrium
• Descends to empty into the coronary sinus, near its left end.

Anterior cardiac vein

• Drains the anterior right ventricle, crosses the coronary groove, and ends directly in

the right atrium.

Thebasian veins (cordis venae minimarum)
• Begin in the wall of the heart and empty directly into its chambers

Development:
Primitive heart tube
• It is formed by fusion of two endocardial heart tubes in the cardiogenic region of the

embryo.
• It forms dilations, including the bulbus cordis, primitive ventricle, primitive atrium,

and sinus venosus.

• It undergoes folding into a U-shape, bringing the arterial and venous ends of the

heart together, moving the ventricle caudally and the atrium cranially.
Further development of dilations of the primitive heart tube as shown in the
image below
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Heart divides into its four chambers by formation of its septa and valves.
Four main septa involved in dividing the heart include the aorticopulmonary septum, the
atrial septum, the AV septum, and the IV septum.
1. Partition of the truncus arteriosus and bulbus cordis
The truncal ridge and the bulbar ridge derived from neural crest mesenchyme

grow in a spiral fashion and fuse to form the aorticopulmonary septum

The aorticopulmonary septum divides the truncus arteriosus into the aorta and

pulmonary trunk.
2. Partition of the primitive atrium
Septum primum grows toward the AV endocardial cushions from the roof of the

primitive atrium.
Septum secundum forms to the right of the septum primum and fuses with the

septum primum to form the atrial septum, which separates the right and left atria.
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Foramen primum forms between the free edge of the septum primum and the
aorticopulmonary septum, allowing a passage between the right and left atria.
The foramen is closed by growth of the septum primum.

Foramen secundum forms in the center of the septum primum.

Foremen ovale is an oval opening In the septum secundum that provides a
communication between the atria.
82 | Anatomy
3. Partition of the AV canal
The dorsal and ventral endocardial cushions fuse to form the AV septum.

The AV septum partitions the AV canal into the right and left AV canals.

4. Partition of the primitive ventricle

Muscular IV septum develops as an outgrowth of the muscular wall in the floor of

the primitive ventricle and grows towards the AV septum but stops to create the
IV foramen, leaving the septum incomplete.
Membranous IV septum forms by fusion of the bulbar ridges with the proliferation

of fusedendocardial cushion, the AP septum, and the muscular part of the IV

septum. The membranous IV septum closes the IV foramen, completing partition
of the ventricles.
Derivatives of the Aortic Arches

Arch Arterial Derivative
1. Maxillary arteries
2. Hyoid and stapedial arteries
3. Common carotid and first part of the internal carotid arteriesa
4 left side Arch of the aorta from the left common carotid to the left subclavian arteriesb
Right side Right subclavian artery (proximal portion)c
6. Left side Left pulmonary artery and ductus arteriosus
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Right side Right pulmonary artery
a
Remainder of the internal carotid arteries are derived from the dorsal aorta; the external carotid arteries sprout from the
third aortic arch
b
The proximal portion of the aortic arch is derived from the left horn of the aortic sac; the right horn of this sac forms the
brachiocephalic artery.
c
The distal portion of the right subclavian artery, as well as the left subclavian artery, form from the seventh intersegmental
arteries on their respective sides.
Thorax | 83
Concept 3.8: Fetal Circulation

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Three shunts that partially bypass the lungs:

1. Foramen ovale
Is an opening in the septum secundum.
Usually closes functionally at birth, with anatomic closure occurring later.
Shunts blood from the right atrium to the left atrium, partially bypassing the lungs
(pulmonary circulation).
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84 | Anatomy
2. Ductus arteriosus
• Is derived from the sixth. aortic arch and connects the bifurcation of the pulmonary

trunk with the aorta.

• Closes functionally soon after birth, with anatomic closure requiring several weeks.

• Becomes the ligamentum arteriosum, which connects the left pulmonary artery (at its

origin from the pulmonary trunk) to the concavity of the arch of the aorta.
• Shunts blood from the pulmonary trunk to the aorta, partially bypassing the lungs

(pulmonary circulation).
3. Ductus venosus
• Shunts oxygenated blood from the left umbilical vein (returning from the placenta) to

the IVC, partially bypassing the liver (portal circulation).

• Joins the left branch of the portal vein to the IVC and is obliterated to become the

ligamentum venosum after birth.

4. Umbilical arteries
• Carry blood to the placenta for reoxygenation prior to birth.

• Become medial umbilical ligaments after birth, after their distal parts have atrophied.

5. Umbilical veins
• Carry highly oxygenated blood from the placenta to the fetus.

• Consist of the right vein, which is obliterated during the embryonic period, and the

left vein, which is obliterated to form the ligamentum teres hepatis after birth.
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Thorax | 85
Concept 3.9: Mediastinum

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1. Mediastinum is interpleural space bounded on either side by mediastinal pleurae,

anteriorly by sternum and posteriorly by thoracic vertebral column.

2. Divided into superior and inferior mediastinum by a line passing through sternal angle

and lower border of T4 vertebra.

3. Inferior mediastinum is further subdivided into anterior mediastinum in front of

Pericardium, Middle mediastinum includes Pericardium and Heart and posterior

mediastinum behind the pericardium.
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86 | Anatomy
Superior Mediastinum : Continuous above with the Neck.
Contains : Upper part of SVC, Brachiocephalic veins, Arch of aorta & its branches.
Trachea, oesophagus, Thoracic duct, Thymus, Vagus nerves, Phrenic nerves, Left
recurrent laryngeal nerve, sternohyoid, sternohyoid & longus colli.
Inferior Mediastinum : further subdivided into –
Anterior Mediastinum : contains superior & inferior sterno-pericardial ligaments.

Middle Mediastinum : Pericardium, Heart, Phrenic nerves, Roots of great vessels

(ascending aorta, pulmonary trunk, pulmonary veins, lower part of SVC, terminal
part of IVC ) and right & left principal bronchi.
Posterior Mediastinum : Oesophagus, descending thoracic aorta, thoracic duct,

azygos & hemiazygos veins.
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Thorax | 87
Worksheet
• MCQ OF “THORAX” FROM DQB



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
88 | Anatomy
Name of Opening Vertebral Level Structures Passing through
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Thorax | 89
Changes after birth
a) Umbilical artery –
b) Umbilical vein –
c) Ductus venosus –
d) Ductus Arteriosus –
e) Foramen ovale –
Label the following diagram
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90 | Anatomy
Right Coronary Artery Left Coronary Artery
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4 Abdomen
CONCEPTS
Â Concept 4.1 Anterior Wall muscles

Â Concept 4.2 Abdominal Aorta & IVC

Â Concept 4.3 Inguinal region

Â Concept 4.4 Rectus sheath

Â Concept 4.5 Peritoneum

Â Concept 4.6 Stomach

Â Concept 4.7 Small intestine, Large intestine &
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Appendix
Â Concept 4.8 Rectum and Anal canal

Â Concept 4.9 Liver & Gall bladder

Â Concept 4.10 Pancreas

Â Concept 4.11 Spleen

Â Concept 4.12 Portal vein

Â Concept 4.13 Kidney, Ureter & Urinary Bladder

Â Concept 4.14 Uterus

Â Concept 4.15 Perineum

Â Concept 4.16 Development

92 | Anatomy
Concept 4.1 : Anterior Wall muscles

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Muscles of the Anterior Abdominal Wall

External oblique External surface Anterior half Intercostal (T7- Compresses
of lower eight ribs of iliac crest; T11); subcostal abdemen; flexes
(5-12) anterior superior (T12) trunk; active in
iliac spine; pubic forced expiration
tubercle; linea alba
Internal oblique Lateral two- Lower four costal Intercostal Compresses
thirds of inguinal cartilages; linea (T7-T11); abdomen; flexes
ligament; alba; pubic crest; subcostal (T12); trunk; active in
iliac crest; pectineal line iliohypogastric and forced expiration
thoracolumbar ilioinguinal (L1)
fascia
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Transverse Lateral one-third of Linea alba; pubic Intercostal Compresses
abdominis inguinal ligament, crest; pectineal line (T7-T12); abdemen;
iliac crest; subcostal (T12); depresses ribs
thoracolumbar ilichypogastric and
fascia; lower six ilioinguinal (L1)
costal cartilages
Rectus abdominis Pubic crest and Xiphoid process Intercostal (T7- Depresses ribs:
pubic symphysis and costal T11); subcostal flexes trunk
cartilages fifth to (T12)
seventh
Pyramidal Pubic body Linea alba Subcostal (T12) Tenses linea alba
Cremaster Middle of inguinal Pubic tubercle and Genitofemoral Retracts testis
ligament; lower crest
margin of internal
oblique muscle
Abdomen | 93
Concept 4.2 : Abdominal Aorta & IVC

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Abdominal Aorta
It is a continuation of thoracic aorta at T12. It divides at the lower border of T4 into two
common iliac arteries.
Branches.
1. Ventral branches.

a. Coelic trunk - arises at T12. (T12 – L1). It gives the following branches –
b. Superior mesenteric artery – lower border of L1
c. Inferior mesenteric artery – Lower border of L3.
2. Lateral branches –

a. Inferior phrenic
b. Middle suprarenal
c. Renal d. Gonadal
3. Dorsal branches.

a. Four pairs of lumbar arteries

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b. One median sacral artery.
4. Terminal branches – common iliacs.

94 | Anatomy
Branches of Coelic trunk
a. Left gastric
b. Splenic – gives the following –
1. Pancreatic, short gastric & left gastroepiploic.

c. Common hepatic artery. – gives the following branches –

1. Right gastric

2. Gastroduodenual – which further divides into right gastroepiploic & superior

pancreaticoduodenual
3. Hepatic artery proper.

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Branches of Superior Mesentric artery
a. Inferior pancreaticoduodenual
b. Jejunal &ileal branches
c. Middle colic
d. Right colic
e. Iliocolic – gives ascending & descending branches. The descending branch gives
Anterior caecal, posterior caecal, Appendicular & ileal branches.
Branches of Inferior Mesentric
a. Left colic b. Sigmoid branches
c. Superior rectal artery.
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INFERIOR VENA CAVA

• Formed by joining of two common iliacs at L5 vertebrae.

• Enters the thorax through the vena caval opening in the central tendon at T8.

• It orifice is guarded by Eustachian valve.

Tributaries:-
1. Common Iliacs 2. Right gonadal vein
3. Right suprarenal vein
4. Renal veins
5. Inferior phrenic veins
6. Hepatic veins
7. Third & fourth lumbar veins
96 | Anatomy
Concept 4.3 : Inguinal region

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Inguinal rings
1. Superficial inguinal ring
Is a triangular opening in the aponeurosis of the external oblique muscle that Iies

just lateral to the pubic tubercle.

2. Deep inguinal ring
Is an opening in the transversalis fascia, just lateral to the inferior epigastric

vessels.
Inguinal canal

Begins at the deep inguinal ring and terminates at the superficial ring.

Transmits the spermatic cord or the round ligament of the uterus and the genital
branch of the genitofemoral nerve, both of which run through the deep inguinal
ring and the inguinal canal.

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An indirect inguinal hernia (if present) passes through this canal. Although the
Ilioinguinal nerve runs through part of the inguinal canal and the superficial
inguinal ring, it does not pass through the deep inguinal ring.
Walls:-
1. Anterior wall. Aponeurosis of the external oblique muscle and is reinforced laterally
by fibers of the internal oblique muscle.
2. Posterior wall. Aponeurosis of the transverse abdominal muscle and transversalis
fascia and is reinforced medially by the conjoint tendon (fused fascias of the transverse
abdominis and internal oblique muscles).
3. Superior wall (roof). Arching fibers of the internal oblique and transverse muscles.
4. Inferior wall (floor). Inguinal and lacunar ligaments.
Umbilical folds or ligaments
1. Median umbilical ligament or fold
Is a fibrous cordlike remnant of the obliterated urachus covered by peritoneum.

Lies between the transversalis fascia and the peritoneum and extends from the

apex of the bladder to the umbilicus.

2. Medial umbilical ligament or fold
Is a fibrous cordlike remnant of the obliterated umbilical artery covered by

peritoneum and extends from the side of the bladder to the umbilicus.
3. Lateral umbilical fold
Is a fold of peritoneum that covers the inferior epigastric vessels and extends from

the medial side of the deep inguinal ring to the arcuate line.
Abdomen | 97
Inguinal triangle of HASSELBACH : Special region in the posterior wall of the inguinal
canal.
• Medial boundry : Lateral border of rectus abdominis below the level of arcuate line

• Lateral : Inferior Epigastric vessels

• Base : Medial half of inguinal ligament

• Apex : Junction of arcuate line and linea semilunaris. At this point inferior epigastric

vessels enter the rectus sheath.

• Obliterated umbilical artery (medial umbilical ligament) embedded in the

extraperitoneal fat divides the triangle into medial and lateral parts.
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Concept 4.4 : Rectus Sheath

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Encloses the rectus abdominis muscle. Consists of an anterior & posterior walls.
Anterior Wall
1. Above the costal margins – formed by external oblique aponeurosis.

2 between the costal margin & Arcuate line - external oblique & anterior lamina of

internal oblique.
3. Below the Arcuate line - Aponeurosis of all three flat muscles of abdomen.

Posterior Wall
1. Above the costal margins – deficit. The rectus abdominis rests on 5th, 6th, & 7th

costal cartilages.
2. Between the costal margins & arcuate line – posterior laminal of internal oblique &

transverse abdominis
3. Below the arcuate line - it is deficit. The rectus abdominis rests on fascia

transversalis.
Contents of Rectus Sheath
1. Rectus abdominis & Pyramidalis muscles
2. Superior & inferior epigastric artery.
3. Superior & inferior epigastric veins
4. Lower six thoracic nerves.
100 | Anatomy
Concept 4.5 : Peritoneum

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• It is a serous membrane lined by mesothelial cells.

Parietal peritoneum
• Lines the abdominal and pelvic walls and the inferior surface of the diaphragm.

• Is innervated by somatic nerves, such as the phrenic, lower intercostal, subcostal,

iliohypogastric and ilioinguinal nerves.

Visceral peritoneum
• Covers the viscera, is innervated by visceral nerves, and is insensitive to pain.

• Support the viscera and provide pathway for associated neurovascular structures.

Lesser omentum
• Is derived from the embryonic ventral mesogastrium.

• ls a double layer of peritoneum extending from the porta hepatis of the liver to the

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lesser curvature of the stomach and the beginning of the duodenum.
• Consists of the hepatogastric and hepatoduodanal ligaments and forms the anterior

wall of the lesser sac of the peritoneal cavity.

• Transmits the left and right gastric vessels, which run between its two layers along

the lesser curvature of the stomach.

• Contains the proper hepatic artery, bile duel, and portal vain within its right free

margin.
Greater omentum
• ls derived from the embryonic dorsal mesogastrium.

• Hangs down like an apron from the greater curvature of the stomach, covering the

transverse colon and other abdominal viscera.

• Can prevent loops of small intestine from passing into a herniated sac by plugging

the entrance.
• Transmits the right and left gastroepiploic vessels along the greater curvature. Wraps

and adheres around inflamed abdominal organs, thus preventing diffuse peritonitis
Has the following subdivisions:
a. Gastrosplenic ligament - Extends from the greater curvature of the stomach to the

hilum of the spleen and contains the short gastric and left gastroepiploic vessels.
b. Lienorenal ligament - Runs from the hilum of the spleen to the left kidney and

contains the splenic vessels and the tail of the pancreas.

c. Gastrophrenic ligament - Runs from the upper part of the greater cu.rvarure of the

stomach to the diaphragm.

Abdomen | 101
d. Gastrocolic ligament - Runs from the greater curvature of the stomach to the

transverse colon.
Mesenteries
1. Mesentery of the small intestine (mesentery proper) - Is a fan-shaped double

fold of peritoneum that suspends the jejunum and the ileum from the posterior
abdominal wall and transmits nerves and blood vessels to and from the small intestine.
Forms a root that mewls from the duodenojejunal flexure to the right iliac fossa

and is approximately 15 cm (6 in,) long.

Has a free border that encloses the small intestine, which is approximately 6 m

(20 ft) long.

Contains the superior mesenteric and intestinal jejunal and ileal) vessels, nerves,

and lymphatics.
2. Transverse mesocolon

Connects the posterior surface of the transverse colon to the posterior abdominal

wall.
fuses with the greater omentum to form the gastrocolic ligament.

Contains the middle colic vessels, nerves, and lymphatics.

3. Sigmoid mesocolon – Connects the sigmoid colon to the pelvic wall and contains

the sigmoid vessels. Its line of attachment may form an inverted V.

4. Mesoappendix – Connects the appendix to the mesentery of the ileum and contains

the appendicular vessels.

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Other peritoneal ligaments
1. Phrenicocolic ligament – Runs from the left colic flexure to the diaphragm

2. Falciform ligament

Is a sickle-shaped peritoneal fold connecting the liver to the diaphragm and the

anterior abdominal wall.

Contains the ligamentum tires hepatis and the paraumbilical vein, which connects

the left branch of the portal vein with the subcutaneous veins in the region of the
umbilicus.
Is derived from the embryonic ventral mesentery.

3. Ligamentum tires hepatis (round ligament of the liver)

Lies in the free margin of the falciform ligament and ascending from the umbilicus

to the inferior (visceral) surface of the ~ lying in the fissure that forms the left
boundary of the quadrate lobe of the liver.
Is a remnant of the left umbilical vain, which carries oxygenated blood from the

placenta to the left branch of the portal vein in the fetus. (The right umbilical vein
is obliterated during the embryonic period)
4. Coronary ligament

Is a peritoneal reflection from the diaphragmatic surface of the liver onto the

diaphragm and encloses a triangular area of the right lobe, the bare area of the
liver.
Has right and left extensions that form the right and left triangular ligaments.

102 | Anatomy
5. Ligamentum venosum

Is the fibrous remnant of the ductus venosus.

Lies in the fissure on the inferior surface of the liver, forming the left boundary of the
caudate lobe of the liver.
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Peritoneal Cavity
A. Lesser sac (omental bursa)

Is an irregular space that lies behind the liver, lesser omentum, stomach, and
upper anterior

Part of the greater omentum.

Is a closed sac, except for its communication with the greater sac

Presents three recesses: (a) superior recess,, which lies behind the stomach,
lesser omentum, and Left lobe of the liver; (b) inferior recess, which lies behind
the stomach, extending into the layers of the greater omentum; and (c) splenic
recess,, which extends to the left at the hilum of the spleen.
B. Greater sac
Extends across the entire breadth of the abdomen and from the diaphragm to the

pelvic Door and presents numerous recesses.

1. Subphrenic (suprahepatic) recess
Is a peritoneal pocket between the diaphragm and the anterior and superior part

of the liver and ls separated into right and left recesses by the falciform ligament
2. Subhepatic recess or hepatorenal recess (Morrison pouch)
Is a deep peritoneal pocket between the liver anteriorly and the kidney and

suprarenal gland posteriorly and communicates with the right paracolic gutter
(and thus the pelvic cavity) and the lesser sac via the epiploic foramen.
Abdomen | 103
3. Paracolic recesses (gutters)
Lateral to both the ascending colon (right paracolic gutter) and the descending

colon (left paracolic gutter).

C. Epiploic or omental (Winslow) foreman
Is a natural opening between the lesser and greater sacs.
Is bounded superiorly by the caudate lobe of the liver, inferiorly by the first part of
the duodenum, anteriorly by the free edge of the lesser omentum, and posteriorly
by the IVC.
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Concept 4.6 : Stomach

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Stomach Bed
1. Left crus of the diaphragm
2. Left suprarenal gland
3. Anterior Surface of Lt kidney
4. Tortuous splenic artery
5. Ant. Surface of the pancreas
6. Ant. Layer of transverse mesocolon
7. Lt colic flexure (sometimes)
8. Spleen and recess of greater sac
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Arterial Supply :
Along Lesser Curvature -
(1) Left gastric - branch of Coeliac Trunk.
(2) Right gastric - branch of Hepatic artery
Along Greater Curvature
(1) 4 - 5 short gastric branches of splenic artery supply Fundus
(2) Left gastroepiploic - branch of Splenic A.
(3) Right gastroepiploic - branch of gastroduodenal artery which is a branch of common
hepatic artery
Abdomen | 105
Lymphatic Drainage:
Divided into 4 sectors
Sector A - Body of stomach close to lesser curvature drain into - Left gastric or superior
gastric nodes
Sector B - Fundus of Stomach - drain into Pancreatico splenic nodes
Sector C - Lower part of Body of Stomach close to greater curvature & pyloric antrum
drain into rt. gastroepiploic (Inferior gastric ) nodes and sub pyloric nodes
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Sector D - Pyloric canal region drains into sub pyloric and hepatic nodes
Finally all the lymphatics from these nodes drain into coeliac group of lymph nodes
Nerve supply of Stomach:

Sympathetic supply
• T6 - T9 via greater splanchnic nerves to reach coeliac ganglia. postganglionic fibers

accompany the arteries to supply stomach.

• Pain afferents from stomach pass along T6 - T9, That’s why Referred pain of gastric

origin is felt in T6 - T9 dermatomes - Epigastrium

• Parasympathetic Supply –

• Via vagus nerves

• Relay in ganglion cells of Auerbach’s plexus.

• Left and right Vagi enter the abdomen as Anterior Vagal Trunk and posterior vagal

trunk along with esophagus through esophageal hiatus of diaphragm

• Anterior Vagal Trunk gives (1) main gastric nerve of Latarjet which runs along lesser

curvature & supply several gastric brs. to acid secreting area and ends in pyloric
antrum. (2) ) Coeliac branch which joins coeliac plexus. (3) Hepatic br. which supply
Liver, gall bladder, CBD, pyloric canal, I part of Duodenum & Head of Pancreas.
• Posterior Vagal Trunk gives (1) N. of Grassi to Fundus (2) Coeliac branch which joins

coeliac plexus. (3) Main gastric N. of Latarjet

106 | Anatomy
Concept 4.7 : Small intestine, Large intestine & Appendix

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A. Duodenum
• Is a C-shaped tube surrounding the head of the pancreas and is the shortest (25 cm

(10 in.] long) and widest part of the small intestine.

• Is retroperitoneal except for the first part, which is connected to the liver by the

hepatoduodenal ligament of the lesser omentum.

• Receives blood from the celiac {foregut) and superior mesenteric {midgut) arteries.

• Is divided into four parts:

1. Superior (first) pad:

• Has a mobile or free section, termed the duodenal cap (because of its appearance on

radiographs), into which the pylorus invaginates.

2. Descending second part
• The junction of the foregut and midgut lies just below the major duodenal papilla

where the common bile and main pancreatic ducts open.

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• The minor duodenal papilla, which lies 2 cm above the major papilla, marks the site

of entry of the accessory pancreatic duct

3. Transverse (third) part
• Is the longest part and crosses the IVC, aorta, and vertebral column from right to left

• Is crossed anteriorly by the superior mesenteric vessels.

4. Ascending (fourth) part

• Ascends to the left of the aorta to the level of the second lumbar vertebra and terminate&

at the duodenojejunal junction, which is fixed in position by the suspensory ligament

(of Treitz). This fibromuscular band is attached to the right crus of the diaphragm.
B. Jejunum
• Lies between the duodenum and the ileum.
• Is emptier, larger in diameter, and thicker walled than the ileum.
• Has plica circulares (circular folds), which are tall and closely packed.
• Has translucent areas called windows between the blood vessels of its mesentery.
• Has less prominent arterial arcades (anastomotic loops) in its mesentery compared
with the ileum.
• Has longer vasa recta (straight arteries) compared with the ileum.

C. ileum
• Is longer than the jejunum and occupies the iliac fossa in the right lower quadrant

• Is characterized by the presence of Peyer patches (aggregations of lymphoid tissue),

shorter plicae circulares and vasa recta, and more mesenteric fat and arterial arcades
when compared with the jejunum.
Abdomen | 107
• The ileocecal fold (bloodless fold of Treves named after a surgeon at the London

Hospital who drained the appendicular abscess.

Large Intestine
A. Colon
• Has ascending and descending colons that are retroperitoneal and transverse and

sigmoid colons that are surrounded by peritoneum.

• The ascending and transverse colons are supplied by the superior mesenteric artery

and the vagus nerve proximal to the left colic (splenic) flexure; the descending and
sigmoid colons are Supplied by the inferior mesenteric artery and the pelvic splanchnic
nerves.
Three characteristic features:
1. Taeniae coli. Three narrow bands of the outer longitudinal muscular coat

2. Sacculations or haustrations. Produced by the taeniae, which are slightly shorter than

the gut tube.

3. Epiploic appendages. Peritoneum-covered sacs of fat, attached in rows along the

teniae coli.
B. Cecum
• blind pouch of the large intestine. It lies in the right iliac fossa and is usually surrounded

by peritoneum but has no mesentery.

C. Appendix
• Is a narrow, hollow, muscular tube with large aggregations of lymphoid tissue in its

wall.
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• Is suspended &om the terminal ileum by a small mesentery, the mesoappendix, which

contains the appendicular vessels.

• causes spasm and distention when inflamed, resulting in pain that’s referred to the

periumbilical region and moves down and to the right.

• base lies deep to McBurney point, which occurs at the Junction of the lateral one-third

of an imaginary line between the right anterior superior iliac spine and the umbilicus.
This is the site of maximum tenderness in acute appendicitis.
108 | Anatomy
Concept 4.8 : Rectum and Anal canal

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• 12cm long. Most dilated part of large intestine. Lies in the Pelvic cavity in front of

lower part of sacrum & coccyx

• Rectum has no taenia coli, appendices epiploicae

• Anatomically rectosigmoid junction lies at the level of S3 vertebra where the sigmoid

mesocolon ends. The tenia coli of the sigmoid colon ends 5cm above the rectum and
blends to form a continuous longitudinal coat
• Anorectal junction lies 2 - 3cm in front of and slightly below the tip of coccyx

• Upper two thirds of rectum is covered anteriorly by the Peritoneum. Lower third is

completely devoid of Peritoneum

Permanent folds or Houston’s valves
Semilunar (crescentic) transverse folds situated against the concavities of the lateral
curvatures of the rectum.
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According to Houston, they are four in number and are numbered from above downward
as follows:
1. First fold (or upper fold) lies near the upper end close to the rectosigmoid junction. It

projects from the right or left wall.

2. Second fold lies about 1 inch (2.5 cm) above the third fold and projects from the left

rectal wall along the concavity of upper lateral curvature.

3. Third valve is the largest, most constant, and most important. It projects from the

anterior and right wall of the rectum along the concavity of middle lateral curvature.
It lies at the level of upper end of ampulla.
4. Fourth valve projects from the left wall of the rectum along the concavity of lower

lateral curvature. It lies about 2.5 cm below the third valve.

The presence of transverse folds and the direction of flexures and curvatures are
important while passing a sigmoidoscope
Per-rectal examination (P.R.) Structures Palpable through anterior rectal wall

Male Female
1. Bulb of Penis Uterine cervix
2. Prostate Vagina
3. Seminal vesicle Ovary
4. Base of Bladder Uterine tubes
Broad ligaments
Rectouterine Pouch
Abdomen | 109
Through Posterior rectal wall : in both sexes coccyx and lower part of sacrum are
palpable
Laterally - Ischial spine, ischial tuberosity and enlarged internal iliac lymph nodes.
* In both sexes tenderness of inflamed pelvic appendix can be elicited
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Ligaments of Rectum:
1. Fascia of Waldeyer: thickening of fascia between posterior aspect of anorectal
junction to lower part of sacrum
2. Lateral Ligament - connect rectum to posterolateral pelvic wall. Contains Middle
rectal vessels
110 | Anatomy
Anal Canal
3.8cm (4cm) long muscular tube is present in the anal triangle of Perineum related on
either side to Ischiorectal fossa. Lining epithelium divisible into three parts.
1. Upper Part : First 15mm. Epithelium simple columnar, mucosa shows 6 - 10

longitudinal folds
Anal columns of Morgagni : Lower ends of these folds united by short transverse
folds - Anal Valves; Slight depression above each anal valve is known as Anal Sinus.
Anal glands open into anal sinuses. Line of attachment of anal valve is known as
Pectinate or Dentate Line
2. Middle Part: Next 15mm - Pecten or Transitional zone. Mucosa lined by Stratified

Squamous non - keratinising epithelium. Extends from Pectinate line to white line of
Hilton (Anal intersphincteric groove)
3. Lower Part: Last 8 - 10mm - Epithelium is True Skin - Stratified squamous keratinizing

epithelium, with sweat glands and sebaceous glands.
Anatomical & Surgical importance of Dentate or Pectinate Line

Features Upper and canal Lower anal canal
Development From endoderm of the hind gut From ectoderm of proctodeum
Innervation Autonomic nerves, hence Somatic nerves, hence sensitive to
insensitive to pain and temperature pain and temperature
Epithelial lining simple columnar Stratified squamous
Arterial supply
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Superior rectal artery Inferior rectal artery
Venous drainage Superior rectal vein draining into Inferior rectal vein draining into
portal system caval system
Lymphatic drainage Internal iliac lymph nodes Superficial inguinal lymph nodes
(horizontal set)
Hemorrhoids Internal hemorrhoids External hemorrhoids
Abdomen | 111
Concept 4.9 : Liver & Gall bladder

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Liver is covered by a connective tissue subserous Glisson’s Capsule. Stretching of

Glisson’s capsule in Hepatomegaly and transient venous congestion produces pain
Lobes :
Anatomical Lobes - A large rt. lobe & a small left lobe by line of attachment of Falciform
ligament and fissures for ligamentum teres and Ligamentum Venosum. Quadrate Lobe
(between Fissure for ligament Teres and Fossa for Gall Bladder ) and Caudate Lobe
(between Fissure for Ligamentum Venosum & groove for IVC) are parts of Anatomical
Right Lobe
Physiological Lobes - Equally divided into right and left lobes by an imaginary line
running from fossa for gall bladder to the centre of caudate lobe dividing it into two parts
Right & Left physiological lobes have separate biliary drainage and vascular supply
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112 | Anatomy
Quadrate lobe belongs to Physiological left lobe because it is supplied by a br. of left
hepatic A & br. of Lt. br. of Portal V. and drained into Left Hepatic duct
Caudate lobe is functionally part of Both rt. & lt. lobes because it receives blood from rt.
& lt. hepatic As. and rt. & lt. brs of Portal V. and drain bile into both rt. & lt. hepatic ducts.
Each functional lobe of liver is divided into four segments each and hence liver is divided
into 8 segemnts
• Liver has a tremendous regenerative capacity.

• Riedel’s lobe is a tongue shaped downwards projection from the lower border of the

rt. lobe on the right side of gall bladder

Gall Bladder:
• Develops from distal dilated part of cystic bud which arises from Hepatic diverticulum.

Proximal narrow part of cystic bud gives rise to cystic duct

• 7 to 10cm long, 3cm wide ; capacity 30 - 50ml ;

• Upper surface of body - non peritoneal - embedded in the fossa for gall bladder on the

inferior surface of rt. lobe of liver, to the right of Quadrate lobe of liver
• Fundus projects beyond inferior border of liver ; covered on both surfaces by

Peritoneum
Fundus lies behind the tip of right ninth costal cartilage, at the point of intersection

of rt. linea semilunaris with rt. costal margin - Murphy’s Point

Murphy’s Sign is tenderness elicited at Murphy’s point in cholecystitis

• Neck is continuous with cystic duct. Spinal valve of Heister is present in the cystic

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duct. Hartman’s pouch is a small projection from the rt. side of neck
• Gall bladder mucosa is - simple columnar Epithelium with brush border

Cystic Duct : 3 - 4 cm long and joins the rt. margin of common Hepatic duct at an acute
angle to form common bile duct
Arterial Supply : Cystic artery, br. of right hepatic ar. arising in the cysto - hepatic
Triangle of Calot
Boundaries -
(Boundaries according to Gray’s 41)
• Common hepatic duct

• Cystic artery

• Cystic duct

Abdomen | 113
Concept 4.10 : Pancreas

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Pancreas
• lies largely in the floor of the lesser sac where it forms a major portion of the stomach

bed.
• Is a retroperitoneal organ except for a small portion of its tail, which lies in the

lienorenal
• (splenorenal) ligament.

• Has a head that lies within the C-shaped concavity of the duodenum. If tumors are

present in
• The head, bile flow can be obstructed, resulting in jaundice. it occurs when bile

pigments accumulate In the blood, giving the skin and eyes a yellow tinge.
• The uncinate process ls a projection of the Inferior part of the head that extends

medially behind the superior mesenteric vessels. The uncinated process is formed
from the ventral pancreatic bud during development.
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• The neck connects the head and body of the pancreas and lies anterior to the junction

of the
• superior mesenteric and splenic veins, forming the hepatic portal vein.

• The body mends from the neck to the tail and is the longest part of the pancreas.

• The tail projects toward the hilum. of the spleen.

• Receives blood from branches of the splenic artery and &om the superior and inferior

pancreaticoduodenal arteries
114 | Anatomy
Concept 4.11 : Spleen

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• Spleen lies entirely undercover of left costal margin. Normal sized spleen is not

palpable
• Upper border of spleen lies parallel to left 9th rib, lower border parallel to 11th rib and

long axis to 10th rib

• Anterior end extends upto mid axillary line. Upper border close to anterior end present

splenic notches
• In Splenomegaly Splenic Notches are palpable just below left costal margin

• Posterior end lies 4cm to the left of 10th thoracic spine

• Diaphragmatic surface related to diaphragm which separates the spleen from (1)

Left 9th, 10th & 11th ribs , (2) Left costodiaphragmatic pleural recess (3) Thin lower
border of Left lung
• Visceral surface related to stomach, left kidney , left colic flexure and Tail of Pancreas

• Spleen is completely invested by Visceral Peritoneum and is surrounded by Greater

sac AfraTafreeh.com
• Spleen is separated from the stomach by greater sac

• Gastrosplenic and lienorenal ligaments connect it to stomach and left kidney

• Phrenicocolic ligament connecting Left colic flexure to diaphragm supports the anterior

end of the spleen and prevents its displacement

• Lymphatic drainage of the spleen is limited only to the capsule & Trabeculae. White

pulp of the spleen ( Lymphoid tissue ) & Red pulp has no lymphatics
• Spleen can be damaged by fracture of 9th, 10th, 11th ribs of left side or blunt injuries

to left costal margin. Splenic rupture with severe hemorrhage occurs. Blood collecting
under left dome of diaphragm produce referred pain on the top of left shoulder -
Kehr’s sign
Abdomen | 115
Concept 4.12 : Portal vein

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Portal venous system is characterized by
1) Veins begin from a capillary plexus and end in a capillary plexus by dividing into
branches like an artery
2) Venous blood circulates through an organ before reaching Heart
Largest Portal system is Hepatic Portal System formed by Portal Vein
• Portal vein - 8cm long. Formed by the union of Superior Mesenteric Vein and Splenic

Vein behind the neck of pancreas and in front of I.V.C.

• Portal vein passes behind the I part of Duodenum lies in the right free margin of Lesser

Omentum (Hepatoduodenal ligament) forming anterior wall of Epiploic foramen.

Before entering the liver through Porta Hepatis divides into rt. & lt. branches
• Left branch of Portal vein - longer; gives branches to caudate lobe and Quadrate lobes

of liver and then ends in Left lobe of liver. Two embryonic remnants are attached to it.
Anteriorly - Ligamentum Teres Hepatis ( remnant of Left umbilical vein )
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• Posteriorly - Ligamentum Venosum ( remnant of Ductus Venosus )

• Rt. br. of Portal vein gives branches to right lobe of liver and part of caudate lobe

Tributaries :
A. Superior mesenteric vein
1. 2. Splenic vein
Formative Tributaries

2. Right Gastric Vein

3. Left gastric vein ( coronary vein )
4. Cystic vein - opens into Rt. br.
5. Paraumbilical vein - opens into Lt. br.
6. Sometimes Superior Pancreatico duodenal vein
Portal vein has no valves

Tributaries of hepatic portal system anastomose with tributaries of systemic

circulation : Porto - caval anastomosis “

116 | Anatomy
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Sitesof Portocaval Anastomosis :
Anatomical Site Portal vein tributary Systemic vein tributary Clinical Effect,
1. Lower end of Esophageal br. of left Hemiazygos&Azygosvein Esophageal varices -
esophagus (in the gastric V. (S.V.C. Tributaries) Ruputure causes fatal
mucous coat) Haematemesis
2. Submucosa of upper Superior rectal V. Middle and inferior rectal Internal Hemorrhoids
part of Anal canal (continues as inferior vein
mesenteric which opens
into splenic)
3. Anterior abdominal Paraumbilical vein Epigastric veins (Superior Caput Medusae
wall - Around umbilicus (runs through Falciform - SVC Inferior - I.V.C.) &
Ligament) other abdominal veins
4. Bare area of Liver Portal vein brs. Diaphragmatic -
(intrahepatic) (Phrenic) veins
5. Posterior Abd. wall Colic veins Duodenal Veins of Dorsal body wall -
(veins of Retzius) veins (Retroperitoneal (Renal, Lumbar)
structures)
6. Intrahepatic Left branch of Portal Connected by Ductus -
vein Venosus directly to I.V.C.
Abdomen | 117
Concept 4.13 : Kidney, Ureter & Urinary Bladder

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Kidney
• Is retroperitoneal and extends from Tl2 to L3 vertebrae in the erect position. The right

kidney lies a little lower than the left owing to the large size of the right lobe of the
liver. The right kidney usually ls related to rib 12 posteriorly, whereas the left kidney
is related to ribs 11 and 12 posteriorly.
• Is invested by a firm, fibrous renal capsule and is surrounded by the renal fascia, which

divides the fat into two regions. The perirenal (perinephric)fat lies in the perinephric
space between the renal capsule and renal fascia, and the pararenal (paranephric) fat
lies external to the renal fascia.
• Has an indentation (hilus) on its medial border, through which the ureter, renal

vessels, and nerves enter or leave the organ.

• Consists of the medulla and cortex, containing 1 to 2 million nephrons (in each kidney),

which are the anatomic and functional units of the kidney. Each nephron consists of
a renal corpuscle (found only in the cortex), a proximal convoluted tubules, loop of
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Henle, and a distal convoluted tubule.
• Has arterial segments, including the superior, anterosuperior, anteroinferior, inferior,

and posterior segments, which are of surgical importance.

• Filters blood to produce urine; reabsorbs nutrients; ucrate1 urine (by which metabolic

or toxic waste products are eliminated) and foreign substances; regulates salt, ion
(electrolyte), and water balance; and produc11 erythropoietin.
• Juxtaglomerular cells (in the wall of the afferent arterioles) produce renin. This

hormone converts angiotensinogen (plasma protein from the liver) to angiotensin I

(inactive decapeptide ), which is then converted in the lungs by angiotensin-Converting
enzyme to angiotensin II (potent vasoconstrictor ). Angiotensin II increases blood
pressure and volume and stimulates aldosterone production by the suprarenal cortex,
thereby regulating salt, ion, and water balance.
Posterior surface:
118 | Anatomy
Anterior surface:
Left kidney - is present in the floor of Lesser Sac, forming part of Stomach bed. Related
to –
(1) Left suprarenal gland
(2) Visceral surface of spleen
(3) Posteroinferior surface of Stomach
(4) Splenic A. & Body of Pancreas and splenic vein
(5) Descending colon AfraTafreeh.com
(6) Coils of Jejunum & ascending br. of Lt. colic A.
Right Kidney –
(1) Rt. Suprarenal gland
(2) Inferior surface of Rt. lobe of liver
(3) Descending part of duodenum
(4) Rt. colic flexure & Transverse colon
(5) Coils of Jejunum
Ureter
• Is a muscular tube that begins with the renal pelvis, extending from the kidney to the

urinary bladder.
• Is retroperitoneal, where it descends on the transverse processes of the lumbar

vertebrae and the psoas muscle, is crossed anteriorly by the gonadal vessels, and
crosses the bifurcation of the common iliac artery.
• May be obstructed by renal calculi (kidney stones) that tend to lodge at three

anatomical constrictions; where it joins 1he renal pelvis (ureteropelvic junction),

where it crosses the pelvic brim over the distal end of the common mac artery, or
where it enters the wall of the urinary bladder (ureterovesical junction).
• Receives blood from the aorta and renal, gonadal, common and internal iliac, umbilical,

superior and inferior vesical, and middle rectal arteries.

• Is innervated by lumbar (sympathetic) and pelvic (parasympathetic) splanchnic

nerves.
Abdomen | 119
Urinary Bladder
Position : Adult - When empty - Pelvic organ - Tetralateral in shape ; when distended
Abdomino - pelvic organ, related to infraumbilical anterior abdominal wall , ovoid in
shape.
Relations of the urinary bladder

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Parts Relations
Base • Rectovesical pouch in the male

• Vesico uterine pouch in the female

• Vasa deferentia and seminal vesicles (separated

from the rectum by fascia of Denonvilliers)

Superior surface • Peritoneal cavity containing loops of ileum
• Coils of ileum
• Sigmoid colon
• Uterine cervix (in female)
Anterior surface (inferolateral surfaces) • Retropubic space

• Puboprostatic ligaments

• Obturator internus and levator ani muscles

Apex Median umbilical ligament

Neck • Prostate gland (in male)

• Urogenital diaphragm (in female)

Arterial Supply:
1. Superior vesical A. br. of anterior trunk of internal iliac A. (Proximal part of superior
vesical represents the non - obliterated part of fetal umbilical A. The distal part of
umbilical A. is obliterated to form medial umbilical ligament)
2. Obturator A.
3. Inferior gluteal A. Additionally in male - inferior vesical; in female - Uterine & vaginal A.
120 | Anatomy
Venous Drainage :
• Vesical venous plexus communicating with prostatic venous plexus drains into internal

iliac V.
• Due to direct communication with internal vertebral venous plexus , bony metastases

can occur in carcinoma of bladder & prostate

Nerve Supply:
Parasympathetic: Preganglionic fibers arise from S2 - S4 cord segments,
Sympathetic : T10 - L2 cord
• Stimulate sphincter vesciae (Internal urethral sphincter) via α1 Adrenoceptors

• Cause relaxation of Detrusor muscle via β2 adrenoceptors. It can also inhibit

presynaptically the parasympathetic ganglia via α2 adrenoceptors.

Visceral Afferents:
T11 - L2 and S2 - S4 cord segments.

referred pain is felt in lower part of AAW ( hypogastrium) upper part of front

of thigh, scrotum or Labium majus, penis or clitoris and perineum. Centrally

spinothalamic pathway conduct pain impulses from bladder
Stretch Afferents arising from stretch receptors in the bladder wall pass via pelvic

splanchnic nerves enter S2 S3 S4 cord segments and establish reflex connections

with sacral micturition center which innervate Detrusor.
So, Afferent limb and efferent limb of this Micturition reflex is formed by Pelvic
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Splanchnic N.
• Sacral micturition center and the micturition reflex are controlled by facilitatory and

inhibitory centers located in Pons and paracentral lobule of frontal lobe of cerebrum
• Stretch afferents convey conscious awareness of fullness of bladder via fasciculus

gracilis to higher centers.
Neurogenic Bladder:
(1) Automatic Reflex Bladder : Occurs due to spinal cord lesions above the level
of sacral segments. Micturition occurs reflexely every 3 to 4 hours and the cortical
inhibitory control is abolished. Micturition reflex becomes automatic without higher
control. Cerebral cortex exerts inhibitory control on spinal center and suppresses
micturition unless suitable time & space are available. In children before the age of 3
years the cortical inhibitory control is developed.
(2) Atonic Bladder : Due to damage to afferent limb of micturition reflex, there is
loss of conscious awareness of fullness of bladder. Bladder is distended enormously
and overflow incontinence occurs with dribbling of urine. Residual urine is present with
attendant risk of infection and back pressure.
Other types of neurogenic bladders can also occur like Autonomous bladder (when both
motor and sensory pathways are extensively damaged peripherally) and uninhibited
neurogenic bladder (due to excessive facilitation micturition becomes hyperreflexic)
Abdomen | 121
Concept 4.14 : Uterus
LEARNING OBJECTIVE : To understand boundaries and contents of Axilla with relations

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Uterus
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Position : Normal position of uterus in a nulliparous woman when the surrounding
organs are empty is Anteflexed and Anteverted
Anteflexion is the forward angle between the axis of body and cervix of uterus at the
isthmus. Measures 125°
Anteversion is the forward angle between the axis of cervix and that of the vagina.
Measures about 90°
Supports of Uterus:
• Levator Ani muscle forming pelvic diaphragm, muscles of urogenital diaphragm &

perineal body which receive attachment of pelvic and perineal muscles form the most
important support
• Cardinal ligaments of Mackenrodt fixes the cervix to lateral pelvic wall

• Round ligament of uterus maintains the anteversion

• Uterosacral & Pubocervical ligaments also help in maintaining the anteflexion &

anteversion
Broad Ligaments : Double layered peritoneal fold connecting lateral border of uterus
to lateral pelvic wall. Mesovarium suspends the ovary to posterior layer of the broad
ligament & divides the ligament into upper Mesosalphinx and Lower Mesometrium
Contents : Fallopian tube, uterine & ovarian vessels, ligament of ovary and round
ligament of uterus. Embryonic remnants present in the ligament include (1) Epoophoron
(2) Paroophoron
(3) Duct of Epoophoron or Duct of Gartner
122 | Anatomy
Lymphatic drainage :
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Cervix
• Lateral lymphatics - External iliac nodes

• Posterolateral lymphatics- Internal iliac nodes

• Posterior lymphatics - Sacral nodes

• Some cervical lymphatics may reach Obturator or Gluteal nodes

Lower Part of body - External iliac nodes
Fundus & upper part of body

Lymphatics follow ovarian vessels - Preaortic and para aortic nodes
• Some lymphatics from lateral angle of body and intramural part of fallopian tube accompany the round

ligament of uterus and drain into superficial inguinal lymph nodes (medial group of horizontal set)
Nerve Supply : Sympathetic - T12 - L2
Parasympathetic - S2 S3 S4
This autonomic motor nerve supply to uterus is functionally not important
Visceral Afferents :
(1) From body of uterus & fallopian tube pass via sympathetic pathways and enter T12 -

L2 cord segments. Hence pain associated with uterine spasm & Salpingitis is referred
to T12 - L2 dermatomes
(2) Visceral afferents from cervix of uterus pass via parasympathetic pathways and enter

S2S3S4 cord segments. Hence, pain is associated with cervical dilatation is referred to
S2 - S4 dermatomes
Prolapse of Uterus : Retroversion of the uterus predisposes towards prolapse of uterus
Abdomen | 123
Concept 4.15 : Perineum

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Diamond-shaped space that has the same boundaries as following
• Pubic symphysis anteriorly, the ischiopubic rami anterolaterally, the ischiaI tuberosities

laterally, the sacrotuberous ligaments posterolaterally, and the tip of the coccyx
posteriorly. Has a floor that is composed of skin and fascia and a roof formed by the
pelvic diaphragm with its fascial covering.
• Is divided into an anterior urogenital triangle and a posterior anal triangle by an

imaginary line connecting the two ischial tuberosities.

1. Colles fascia

▫ Is the deep membranous layer of the superficial perineal fascia and forms the

inferior boundary of the superficial perineal pouch.

▫ ls continuous with the dartos, superficial fascia of the penis and with Scarpa

fascia of the anterior abdominal wall.

2. Deep Perineal fascia

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▫ Is the investing fascia of the muscles in the superficial perineal space

3. Perineal membrane

▫ Is the inferior fascia of the urogenital diaphragm that forms the boundary

between the deep and the superficial perineal spaces.

▫ The urethra and vagina (females) pass through the membrane.

▫ Lies between the urogenital diaphragm and the external genitalia, is perforated

by the urethra. and is attached to the posterior margin of the urogenital

diaphragm and the ischiopubic rami.
▫ Is thickened anteriorly to form the transverse ligament of the perineum and

inserts into the arcuate pubic

Urogenital Triangle - Urogenital triangle is bounded on either side by conjoint
Ischiopubic rami, anteriorly by lower border of Pubic Symphysis and arcuate pubic
ligament and posteriorly by an imaginary line passing through Ischial tuberosity’s
separating it from anal triangle Urogenital Triangle is subdivided into
A. Superficial Perineal Pouch (space) and
B. Deep Perineal Pouch (space)
124 | Anatomy
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Superficial Perineal Pouch (space): This space is bounded Above by - Perineal

Membrane
Below - Colle’s Fascia ( membranous layer of superficial perinal fascia)
Superficial perineal fascia is divided into a superficial fatty layer & deep membranous
layer (Colle’s fascia) similar to superficial fascia of AAW. Both these layers are continuous
anteriorly through scrotum & penis with camper’s & scarpa’s fascia of AAW respectively
Colle’s Fascia - Attached
Laterally - to conjoint ischiopubic rami
Posteriorly - to posterior margin of perineal membrane thus closing superficial perineal
pouch posteriorly
Anteriorly - continuous with Dartos muscle of scrotum, superficial penile fascia & then
with Scarpa’s layer of superficial fascia of Anterior abdominal wall.
• Because of these attachments fluid collected in the superficial perineal pouch spreads

anteriorly
Abdomen | 125
a) into the Scrotum deep to Dartos
b) Into the penis deep to superficial penile fascia
c) Into the anterior abdominal wall deep to Scarpa’s Fascia
Deep perineal fascia covering the muscles of the superficial perineal pouch divides it
into two compartments, one between Colle’s fascia & deep perineal fascia and the other
between deep perineal fascia and perineal membrane
Important Contents :
(1) On either side - Crura of penis covered by Ischiocavernosus muscles
(2) In the middle - Bulb of Penis covered by Bulbospongiosus muscle
(3) Posteriorly - Transversus perineii superficialis muscles
(4) Posterior scrotal vessels and nerves
Bulb of Penis is transversed by Spongy urethra
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Perineal Membrane: (Inferior Fascia of Urogenital Diaphragm, Triangular lligament)
Structures piercing perineal membrane
1. Urethra - 2 to 3 cm behind the pubic symphysis
2.Ducts of Bulbourethral glands
3. Arteries & nerves to Bulb of penis

4. Deep arteries of Penis - enter crura penis
5. Dorsal arteries of penis - close to anterior border
6. Posterior scrotal nerves & vessels - close to base
126 | Anatomy
Deep Perineal Pouch (Space): Space between the Perineal membrane and superior
Fascia of U.G. diaphragm. Closed both anteriorly and posteriorly.
• Anterior recess of the ischiorectal fossa is a potential space above the deep perineal

pouch lying between superior fascia of U.G. diaphragm and inferior fascia of pelvic
diaphragm
Contents:
1. Membranous Urethra
2. Bulbourethral glands (of Cowper)
3. Transversus perineii profundus
4. Sphincter Urethrae
5. Dorsal nerves of Penis
6. Dorsal arteries of Penis
7. Arteries & nerves to the Bulb of Penis
8. Branches of Perineal nerve
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Abdomen | 127
Concept 4.16 : Development
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Development of Digestive System

Primitive gut tube
• Is a hollow tube lined by endoderm that is covered by splanchnic mesoderm. It is

derived from the yolk sac during craniocaudal and lateral folding of the embryo. The
endoderm forms the epithelial lining and glands of the gut tube mucosa, whereas the
splanchnic mesoderm forms all other layers (smooth muscle and submucosa).
• During development, it opens to the yolk sac through the vitelline duct that divides

the embryonicgut into the foregut, midgut, and hindgut

Liver
Develops as an endodermal outgrowth of the foregut. the hepatic diverticulum, and ls
involved in haematopoiesis from AfraTafreeh.com
Liver parenchymal cells and the lining of the biliary ducts are endodermal derivatives of
the hepatic diverticulum.
a) Hepatic diverticulum

Grows into the mass of splanchnic mesoderm called the septum transversum.

Proliferates to form the liver parenchyma.

Sends hepatic cell cords to surround the vitelline veins, which form hepatic

sinusoids.
b) Septum transversum

Is a mesodermal mass located between the developing pericardial and peritoneal

cavities after embryonic folding.

Gives rise to Kupffer cells and hematopoietic cells, as well as the central tendon

of the diaphragm.
Pancreas
• Arises as ventral and dorsal pancreatic buds from endoderm of the caudal foregut

The ventral bud rotates posteriorly with rotation of the duodenum to fuse with the
dorsal bud.
• The ventral pancreatic bud forms the uncinate process and part of the head of the

pancreas, and the dorsal pancreatic bud forms the remaining part of the head, body,
and tail of the pancreas.
• The main pancreatic duct is formed by fusion of the duct of the ventral bud with the

distal part of the duct of the dorsal bud.

• The accessory pancreatic duct is formed from the proximal part of the duct of the

dorsal bud.
128 | Anatomy
MIDGUT
• The position of Midgut- Hindgut junction in adult is indicated by junction of right with

left 1/3 of Transverse colon.

• Midgut communicate with yolksac through Vitello- intestinal duct which later

disappears completely
• Midgut rapidly elongates and form a U- shaped midgut loop. Superior mesenteric

artery (A of Midgut) extends into the center of midgut loop and divides it into
a) Cranial limb or Prearterial segment
b) Caudal limb or Post arterial segment
• Cranial limb or Prearterial segment of midgut gives rise to

a) Caudal half of duodenum (distal to opening of hepatopancreatic ampulla)

b) Coils of Jejunum
c) Coils of Proximal ileum
• Caudal or Postarterial segment gives rise to

a) Terminal part of ileum

b) Caecum and Vermiform appendix (from Caecalbud)
c) Ascending Colon. Hepatic (Rt. Colic) flexure
d) Right 2/3 of transverse colon
ROTATION OF MIDGUT
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Abdomen | 129
First Stage : Stage of Physiological Umbilical Hernia (6th Week to 10th Week)
Rapidly elongating midgut forms a U- Shape loop with a forward convexity and superior
mesenteric artery extends into the loop. The loop consists of a cranial limb or Pre-
arterial segment and a caudal limb or Post arterial segment. Because of lack of space in
the abdominal cavity.
Midgut loop herniates into extraembryonic coelom
Present in the proximal part of Umbilical cord. This physiological umbilical Hernia occurs
in the beginning of 6th week and persists till 10th week.
• The midgut loop is present in sagittal plan initially

• The Pre--arterial segment undergoes more rapid growth and forms about six primary

intestinal loops.
• Caecal bud appears on the antemesenteric border of post-arterial segment.

• Now the midgut loop within the Hernia undergoes 900 anticlockwise rotation so that

Pre-arterial segment (cranial limb) comes to lie on the right and post arterial segment
(caudal limb) on the left.
Second stage (11th week) – Reduction of Hernia
By the end of the 10th week reduction of physiological umbilical Hernia occurs with
return of the midgut loop into abdominal cavity.
• Pre-arterial segment reduces first, passing behind the superior mesenteric artery to

occupy left half of abdomen.

• Post-arterial segment with caecal bud returns last and in doing so undergoes further

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1800 anticlockwise rotation.
• So totally midgut undergoes 2700 anticlockwise rotation.

At the end of second stage of rotation-

1. Duodenum (Prearterial segment) passes behind superior mesenteric artery

2. Transverse colon (Post arterial segment) passes in front of the artery

3. Descending colon (Hindgut) is pushed to the left.

4. Ceacum lies in a subhepatic position.

Third Stage (12th week onwards) Fixation of Intestines.

• Caecum ‘descends’ from its subhepatic position to the Right iliac fossa. By this

elongation ascending colon is formed.

Certain parts of the gut become fixed to the Posterior abdominal wall by fusion of
their primitive mesenteries with posterior parietal such secondary retroperitoneal parts
include
i) Duodenum (except the initial few cm)
ii) Caecum
iii) Ascending colon
• Certain parts retain their mesenteries which include

i) Coils of Jejunum & Ileum (Mesentery)

ii) Vermiform appendix (meso appendix)
iii) Transverse colon (Transverse mesocolon).
130 | Anatomy
HIND GUT
Hindgut is that part of the contained within the Tail fold and extends from the Posterior
intestinal portal cloacal membrane. Allontoic diverticulum extends from the ventral
aspect of Hindgut into connecting stalk and divides it into Preallantoic and Postallantoic
parts.
• Preallantoic part of Hindgut gives rise to—

1) Left 1/3 of Transverse colon and Left colic flexure

2) Descending colon
3) Sigmoid colon (Pelvic colon)
4) Upper part of Rectum up to the level of middle transverse fold.
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• Postallanoic part of Hindgut is the dilated Endodermal cloaca, which is separated from

surface by cloacal membrane.

• Urorectal septum divides the cloaca into

1) Anterior part in continuity with allantois known as Primitive urogenital sinus which

develops into urinary bladder & urethra.

• Posterior part of Endodermal cloaca is known as Primitive Rectum which is separated

from the ectodermal proctodeum (anal) by the posterior part of cloacal membrane
known as Anal membrane, which later ruptures. The level of the anal membrane
in the adult is indicated by the Dentation line or Pectinate line of the anal canal.
Primitive rectum gives rise to:-
1) Lower part of rectum below the level of middle tranverse fold.
2) Upper part of anal canl above the level of Pectinate line.
• Proctodaecum or anal pit gives origin to lower part of anal canal below the level of

pectinate line.
Kidney
Develops from intermediate mesoderm.
1. The pronephros appears early, degenerates rapidly, and never forms functional

nephrons.
2. The metanephros largely degenerates but forms the mesonephric Wolffian) duct,

which gives rise to the ureteric bud and contributes to the male reproductive tract.
Abdomen | 131
3. The metanephros develops from the ureteric bud and forms the adult kidney, which

ascends from the sacral region to the upper lumbar region.

The ureteric bud forms the ureter, which dilates at its upper end to form the renal

pelvis. The renal pelvis repeatedly divides to form the major calyces, the minor
calyces, and collecting tubules. Derivatives of the ureteric bud are the urine-
collecting portions of the upper urinary tract.
The metanephric blastema (intermediate mesoderm) forms the urine-forming

components of the adult kidney (glomerulus, renal capsule, loops of Henle, and
the proximal and distal convoluted tubules}.
4. The urogenital sinus forms from the hindgut. The urorectal septum divides the cloaca

into the rectum and anal canal posteriorly and the urogenital sinus anteriorly, which
forms the bladder and part of the urethra.
Urinary bladder
Develops from the upper end of the urogenital sinus, which is continuous with the
allantois.
1. The allantois degenerates and forms a fibrous cord in the adult called the urachus.

2. The trigone of the bladder is formed by incorporation of the lower ends of the

mesonephric ducts into the posterior wall of the urogenital sinus.
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132 | Anatomy
Worksheet
• MCQ OF “ABDOMEN” FROM DQB


 AfraTafreeh.com

Abdomen | 133
Anatomical Site Portal vein tributary Systemic vein tributary Clinical Effect
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134 | Anatomy
Features Upper anal canal Lower anal canal
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Abdomen | 135
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136 | Anatomy
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5 Head & Neck
CONCEPTS
Â Concept 5.1 Deep cervical fascia

Â Concept 5.2 Posterior Triangle of Neck

Â Concept 5.3 Anterior Triangle of Neck

Â Concept 5.4 Scalp and Face

Â Concept 5.5 AfraTafreeh.com
Dural Venous sinuses

Â Concept 5.6 Temporomandibular joint &

Muscles of mastication
Â Concept 5.7 Arteries of Head & Neck

Â Concept 5.8 Foramen of Skull

Â Concept 5.9 Parasympathetic ganglia and

supply
Â Concept 5.10 Development of Head & Neck

138 | Anatomy
Concept 5.1 : Deep cervical fascia

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Investing layer
• Surrounds the deeper parts of the neck.

• Splits to enclose the sternocleidomastoid and trapezius muscles.

• Is attached superiorly along the mandible, mastoid process, external occipital

protuberance, and superior nuchal line of the occipital bone.

• Is attached inferiorly along the acromion and spine or the scapula, clavicle, and

manubrium sterni
Prevertebral layer
• Is cylindrical and encloses the vertebral column and its associated muscles. Covers

the scalene muscles and the deep back muscles.

• Attaches to the external occipital protuberance and the basilar part of the occipital bone

and becomes continuous with the endothoracic fascia and the anterior longitudinal
ligament of the bodies of the vertebrae In the thorax.
Pretracheal layer
• Invests the larynx and trachea, encloses the thyroid gland, is continuous with the

buccopharyngeal fascia, and contributes In part to the formation of the carotid

sheath. Attaches superiorly to the thyroid and cricoid cartilages and inferiorly to the
pericardium.
Head & Neck | 139
Alar fascia
Is an ancillary layer of the deep cervical fascia between the Pretracheal (or
buccopharyngeal) and prevertebral fasciae and forms a subdivision of the retropharyngeal
space. Blends with the carotid sheath laterally and extends from the base of the skull to
the level of C7, where it merges with the Pretracheal fascia.
Buccopharyngeal fascia
Covers the buccinator muscles and the pharynx and blends with the pretracheal fascia.
• Is attached to the pharyngeal tubercle of the clivus and the pterygomandibular raphe,

opposite the buccinator muscle.

Pharyngobasilar fascia
• Is the fibrous coat in the wall of the pharynx and is situated between the mucous

membrane and the pharyngeal constrictor muscles.
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Carotid sheath It is a tubular condensation of deep cervicalfascia around the (a) common
carotid and internal carotidarteries, and (b) internal jugular vein and vagus nerve. The
vagus nerve lies posteriorly between the veinand arteries. The carotid sheath is wedged
between the threelayers of the deep cervical fascia, i.e., investing layer,pretracheal fascia,
and prevertebral fascia, and attached to allthese layers by loose areolar tissue. The sheath
is thick aroundcommon and internal carotid arteries but thin over theinternal jugular vein
in order to allow its expansion duringincreased venous return.
140 | Anatomy
Concept 5.2 : Posterior Triangle of Neck

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• Bounded by the posterior border of the sternocleidomastoid muscle, the anterior

border of the trapezius muscle, and the superior border of the clavicle.
• Roof formed by the platysma and the investing (superficial) layer of the deep

cervical fascia.
• Prevertebral layer of deep cervical fascia covering the muscles from above downwards

splenius capitis, levator scapulae, scalenus medius & posterior, first digitations
of serratus anterior and upper surface of first rib. Sometimes close to the apex,
semispinalis capitis forms the floor.
• further divided into the occipital and subclavian trianglesby the posterior belly of the

omohyoid muscle.
Contents :
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A. Occipital Triangle:
1. Spinal Accessory Nerve (XI Cranial N)
2. Great auricular nerve (V.R., C2, C3)
3.Transverse cutaneous nerve of neck(C2 C3)
4. Lesser occipital (VR C2)
5. Supraclavicular nerves (VR C3 C4)
6. Sometimes occipital artery close to the apex
7. A chain of lymph nodes along the posterior border of sternocleidomastoid
Head & Neck | 141
B. Supraclaviaular Triangle:
1. Supraclavicular part of Brachial plexus and its branches like – Dorsal Scapular,

suprascapular,Nerve to Subclavius and Long thoracic nerve.

2. Third part of Subclavian artery and Suprascapular and Transverse cervical artery.

3. Subclavian vein.

4. Terminal part of external jugular vein and its tributaries.

5. Supraclavicular lymph nodes.

▫ Prevertebral fascia of the floor cover the brachial plexus and subclavian artery.

▫ External jugular vein pierces the fascia of roof to enter the triangle

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142 | Anatomy
Concept 5.3 : Anterior Triangle of Neck

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• ls bounded by the anterior border of the sternocleidomastoid, the anterior midline of

the neck, and the inferior border of the mandible.

• Has a roofformed by the pl1tysma and the investing layer of the deep cervical fascia.

• Is further divided by the omohyoid anterior belly and the digastric anterior and

posterior bellies into the digastric(submandibular),submental(suprahyoid), carotid,

and muscular (inferiorcarotid) triangles.
A. Submental Triangle
Contents : Include Submental lymph nodes, Submental vessels and beginning of
anterior jugular vein.
B. Muscular Triangle: Bounded by -
Anteriorly - Midline of neck from hyoid to sternum
Posteriorly - Lower part of anterior border of sternocleidomastoid
Superiorly - Superior belly of omohyoid
Roof - Skin, superficial fascia, general investing layer of
deep fascia
Floor - Sternohyoids and Sternothyroid. Deep to these
muscles lie thyroid gland
Head & Neck | 143
C. Carotid Triangle:
Contents:
1. Bifurcation of common carotid artery and carotid sinus & carotid body

2. Internal carotid artery

3. External carotid artery with its 5 branches – Superior thyroid, Lingual facial, Occipital

& Ascending pharyngeal arteries.

4. Hypoglossal nerve

5. Vagus with its external and internal laryngeal nerves

6. Spinal accessory nerve

7. Ansa cervicalis

8. Internal jugular vein with its superior thyroid, lingual, common facial, pharyngeal

tributaries.
9. Deep cervical group of lymph nodes along the anterior border of sternocleidomastoid

D. Digastric Triangle: Boundaries

Contents : In Anterior Part
1. Submandibular gland

2. Facial artery & anterior facial vein

3. Submental vessels

4. Mylohyoid nerve and vessels

5. Hypoglossal nerve

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6. Submandibular lymph nodes

In Posterior Part:
1. Lower pole of Parotid gland

2. External carotid artery & its posterior auricular branch

3. Styloglossus & Stylopharyngeus muscles

4. Glossopharyngeal nerve

5. More deeply internal carotid artery, Vagus nerve and internal jugular vein

144 | Anatomy
Concept 5.4 : Scalp and Face

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SCALP
1. Skin
Has abundant hairs and contains numerous sebaceous glands.

2. Connactive tissue (dense subcutaneous tissue)

Is composed of dense connective tissue, which contains numerous blood vessels,

nerves, sweat glands, and hairfollicles. The arteries anastomose freely and nourish
the hair follicles.
3. Aponeurosis
Is a 18ndinous sheet that covers the vault of the skull and unites the occipital and

frontal bellies of the occipitofrontal muscles. Wounds superficial to this layer of the
scalp do not gape or bleed excessively because the strength of the aponeurosis
holds the margins or the wound together.
4. Loon connective tissue
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Forms the loose and scanty subaponeurotic space and contains the emissary veins.

Is known as the dangerous area of the scalp because infection can spread easily

in this layer to the intracranialsinusesbyway of emissary veins.

5. Pericranium
Is the periosteum over the surface of the skull.

Head & Neck | 145
MUSCLES OF FACIAL EXPRESSION
1. Smiling & laughing – Zygomaticus major
2. Sadness – Levator labi superioris &levator angularis
3. Grief – Depressor angulioris
4. Anger – Dialator naris, & depressor septi
5. Frowning – Corrugator supercilli& procerus
6. Horror, Terror & fright – Platysma
7. Surprise – Frontalis
8. Doubt – Mentalis
9. Grinning – Risorius
10.
Closing the mouth – Orbicularis oris
11.
Whistling – Buccinator & orbicularis oris.
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Arterial supply
Is by facial artery, a branch of external carotid. It can be palpated at the anteroinferor
angle of masseter .
It is also called Anaesthetics artery.
Venous Drainage.
Facial vein begins at the medial angle of eyr by union of supratrochlear & supraorbital
veins. It joins with anterior division of retromandibular vein to form common facial vein,
which drains into internal jugular vein.
Facial vein communicates with cavernous sinus through –
a. Superior ophthalmic vein

b. Pterygoid plexus through deep facial vein.

146 | Anatomy
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Thus infection in dangerous area of face may spread in retrograde direction leading to
cavernous sinus thrombosis.
Head & Neck | 147
Concept 5.5 : Dural Venous sinuses

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Folds al the dura mater

a) Falx cerebri
Is the sickle-shaped double layer of the dura mater; lying between the cerebral

hemisphere& Is attached anteriorly to the crista galliand posteriorly to the

tentorium cerebelli.
Has a free inferior concave border that contains the inferior sagittal sinus, and its

superior convex border encloses the superior sagittal sinus.

b) Tentorium cerebelli
Is a crescentic fold of dura mater that supports the occipital lobes of the cerebral

hemispheres and covers the cerebellum.

Has a free internal concave border, which bounds the tentoriaI notch, whereas its external
convex border encloses the transverse sinus posteriorly and the superior petrosal sinus
anteriorly. The free border is anchored to the anterior clinoid process, whereas the
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attached border is attached to the posterior clinoid process.
c) Falx cerebelli
Is a small sickle-shaped projection between the cerebellar hemispheres.

Is attached to the posterior and inferior parts of the tentorium.

Contains the occipital sinus in its posterior border.
d) Diaphragmasellae
Is a circular, horizontal fold of dura that forms the roof of the sella turcica. covering the
pituitary gland (hypophysis}.
Has a central aperture for the infundibulum. (hypophyseal stalk).
Dural Venous Sinuses

A. Superior sagittal sinus
Lies in the midline along the convex border of the falx cerebri.
Begins at the crista galliand receives the cerebral, diploic meningeal, and parietal
emissary veins.
B. Inferior sagittal sinus
Lies in the free edge of the fab: cerebri and is joined by the great cerebral vein of
Galen to form the straight sinus.
C. Straight sinus
Runs along the line of attachment of the falx cerebrito the tentorium cerebelli
Is formed by union of the inferior sagittal sinus and the great vein of Galen.
148 | Anatomy
D. Transverse sinus
Runs laterally from the confluence of sinuses &along the posterior attached edge
of the tentorium cerebelli.
E. Sigmoid sinus

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Is a continuation of the transverse sinus; arches inferiorly and medially in an
S-shaped groove on the mastoid part of the temporal bone.
Enters the superior bulb of the internal Jugular vein.
F. Cavernous sinus
Are located on each side of the sella turcica and the body of the sphenoid bone and
lie between the meningeal and periosteal layers of the dura mater.
The internal carotid artery and the abducens nerve pass through these sinuses. In
addition, the oculomotor, trochlear, ophthalmic, and maxillary nerves travel in the
lateral wall of these sinuses.
Head & Neck | 149
Structures in the lateral wall of the sinus :
Between the endothelium and lateral dural wall, from above downwards are :
1. Oculomotor Nerve

2. Trochlear Nerve

3. Ophthalmic Nerve

4. Maxillary Nerve

Gray’s 41stUpdate:-
Unlike the ophthalmic division of the trigeminal nerve, the maxillary division of the
trigeminal nerve does not run through the cavernous sinusor its lateral wall, but courses
beneath the dura of the middle cranial fossa below the level of the cavernous sinus
Tributaries :
a) From the orbit :
1. Superior Ophthalmic Vein

2. Inferior Ophthalmic Vein

3. Central vein of Retina

b) From Meninges :
1. Sphenoparietal Sinus: Runs along lesser wing of sphenoid

2. Frontal trunk of middle meningeal vein

c) From Brain:
1. Superficial middle cerebral vein - Lies in the posterior ramus of lateral sulcus

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draining the lower part of lateral surface of the cerebrum. It is connected to
superior sagittal sinus via superior anastomotic vein and to the transverse sinus by
the Inferior anastomotic vein.
2. Inferior cerebral vein - Draining the temporal lobe of cerebral hemisphere

Communications :
The cavernous sinus communicates with:
1. Transversesinusvia
(a) Superior petrosalsinus
(b) Superficial middle cerebral vein and Inferior anastomotic vein
2. Internal Jugular vein via:
(a) Inferior petrosal sinus which drains outside the skull into I.J.V. passing through
Jugular Foramen.
(b) Venous plexus around internal carotid artery passing through carotid canal
3. Pterygoid venous plexus via emissary veins which pass through:
(a) Foramen ovale
(b) Foramen Lacerum
(c) Emissary sphenoidal foramen (of Vesalius)
4. Facial vein via two routes:
(a) Superior ophthalmic vein
(b) Emissary veins - Pterygoid venous plexus - deep facial vein
(Facial vein drains the dangerous area of face.)
150 | Anatomy
5. Opposite cavernous sinus via anterior and posterior intercavernous sinuses
6. Superior sagittal sinus via superficial middle cerebral vein and superior
anastomotic vein.
7. Internalvertebralvenous plexus via Basilarvenous plexus.
Cavernous Sinus Thrombosis:
The septic thrombosis of cavernous sinus may be caused, most commonly, due to
passage of septic emboli from the Dangerous area of Face via its communications with
Facial vein. It leads to:
a) Severe pain in the eye and forehead due to involvement of ophthalmic nerve.
b) Ophthalmoplegia due to involvement of III, IV and VI cranial nerve.
c) Marked oedema of eyelids with exophthalmos due to congestion of ophthalmic
veins.
Infections from sphenoidal and ethmoidal air sinuses can also produce septic cavernous
sinus thrombosis.
G. Confluence of sinuses
Is the junction point of the superior sagittal. straight, and occipital sinuses.
H. Superior petrosal sinus
Lies in the margin of the tentorium cerebelli, running from the posterior end of the
cavernous sinus to the transverse sinus.
I. Inferior petrosal sinus AfraTafreeh.com
Drains the cavernous sinus into the bulb of the internal jugular vein.
Runs in a groove between the petrous part of the temporal bone and the basilar
part of the occipital bone.
J. Sphanoparietal sinus
Lies along the posterior edge of the lesser wing of the sphenoid bone and drains
into the cavernous sinus.
K. Occipital sinus
Lies in the falx cerebelli and drains into the confluence of sinuses.
Head & Neck | 151
Concept 5.6 : Temporomandibular joint & Muscles of mastication

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It is a synovial, bicondylar joint between the mandibular fossa and articular tubercle
of the Temporal bone above and the head of mandible below. The joint is completely
divided into two compartments by a fibrocartilaginous articular disc
1. Lateral (Temporomandibular) Ligament: Extends from tubercle on the root of

zygoma to the posterior border of mandibular neck covering lateral aspect of

capsule.
2. Sphenomandibular Ligament: Attached above to spine of Sphenoid, below to

Lingula of mandible. Nerve to mylohyoid pierces it. Derivative of I arch mesoderm.

3. Stylomandibular Ligament: Styloid process of temporal bone to posterior border of

mandibular ramus. Thickened part of investing layer of deep cervical fascia passing
deep to parotid gland, separating it from submandibular gland.
Nerve supply : Auriculotemporal nerve & Masseteric nerve
Movements :
Protraction - Lateral and medial pterygoid muscles of both sides acting together.
Retraction- Posterior fibers of Temporalis assisted by deep fibers of Masseter, digastric,
genihyoid.
Elevation- Masseter, Temporalis, Medial pterygoid of both sides. Temporalis muscles
maintain position of rest.
Depression- Both lateral ptergoids assisted by Digastric, mylohyoid, geniohyoid
muscles.
Side to side movement - Lateral & medial petrygoid of one side acting alternately with
the other.
152 | Anatomy
Dislocation of Temporomandibular joint can occur when the mouth is opened too widely.
The dislocation is always anterior into infratemporal fossa.
Muscles of Mastication
Muscle Origin Insertion Nerve Action on
Mandible
Temporalis Temporal fossa Coronoid process Trigeminal Elevates; retracts
and ramus of
mandible
Masseter Lower border and Lateral surface of Trigeminal E l e v a t e s
medial surface of coronoid process, (superficial part);
zygomatic arch ramus and angle of retracts (deep Part)
mandible
Lateral pterygoid Superior head Neck of mandible; Trigeminal Depresses
from infratemporal articular disk (superior head);
surface of and capsule of protracts (inferior
sphenoid; inferior temporomandibular head)
head from lateral Joint
surface of lateral
pterygoid plate of
sphenoid
Medial pterygoid AfraTafreeh.com
Tuber of maxilla Medial surface of Trigeminal
(superficial head), angle and ramus of
Elevates; protracts
medial surface of mandible

lateral pterygoid
plate Pyramidal
process of palatine
bone (deep head)
Head & Neck | 153
Concept 5.7 : Arteries of Head & Neck

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Subclavian Artery
• Is a branch of the brachiocephalic trunkon the right but arises directly from the arch

of the aorta on the left.

Is divided into three parts by the anterior scalene muscle: the first part passes from the
origin of the vessel to the medial margin of the anterior scalene; the second part lies
behind this muscle; and the third part passes from the lateral margin of the muscle to
the outer border of the first rib. Its branches include the following:
1. Vertebral artery
Arises from the first part of the subclavian artery and ascends between the anterior
scalene and longus colli muscles.
• Ascends through the transverse foramina of vertebrae Cl to CG, winds around posterior

to the superior articular process of the atlas, over the posterior arch of the atlas, and
passes through the foramen magnum into the posterior cranial cavity.
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2. Thyrocervicaltrunk
• Is a short trunk from the first part of the subclavian artery that divides into the

following arteries:
(a) Inferior thyroid artery
Ascends anterior to the anterior scalene muscle, turns medially to course between

the carotid sheath and the vertebral vessels, and then arches downward to the
lower pole of the thyroid gland.
b)Transverse cervical artery
Runs laterally across the anterior scalene muscle, phrenic nerve, and trunks of the

brachial plexus, passing deep to the trapezius.

Divides into a superficialbranch (which supplies the trapezius) and a deep branch

(which sometimes takes the place of the dorsal scapular artery).

(c) Suprascapular artery
Passes anterior to the anterior scalene muscle and the brachial plexus just posterior to
the clavicle and parallel to, but inferior to the transverse cervical artery.
Passes superior to the superior transverse scapular ligament lateral to the inferior

attachment {origin) of the omohyoid {whereas the suprascapular nerve passes

inferior to this ligament).
3. Internal thoracic artery
Arises from the first part of the subclavian artery, descends through the thorax
behind the upper 6costal cartilages, and bifurcates at the sixth intercostal space
into the superior epigastric and musculophrenic arteries.
154 | Anatomy
4. Costocervical trunk
Arises from the posterior aspect of the second part of the subclavian artery
behind the anterior scalene muscle and divides into the following arteries:
(a) Deep cervical artery
Passes between the transverse process of vertebra C7 and the neck of the first
rib, ascends between the semispinalis capitis and semispinalis cervicis muscles,
and anastomoses with the deep branch of the descending branch of the occipital
artery.
(b) Superior intercostal artery
Descends posterior to the cervical pleura and anterior to the necks of the first
two ribs and gives rise to the first two posterior intercostal arteries.
5. Dorsal (descending) scapular artery
Arises from the third part of the subclavianartery or arises as the deep (descending)
branch of the transverse cervical artery.
Subclavian Steal Syndrome : Occurs when the subclavian artery of one side is

blocked proximal to the origin of vertebral A. In an attempt to establish collateral

circulation, blood from opposite vertebral artery will flow in a retrograde manner
through vertebral artery of the affected side to reach subclavian artery. In this way
some amount of the blood for brain is “ stolen “ by the vertebral and subclavian
arteries of the affected side to supply the upper limb.
Common carotid artery AfraTafreeh.com
Right common carotid artery beginsat the bifurcation of the brachiocephalic artery,

and left common arises from the aortic arch.

Ascend within the carotid sheath and divide at the level of the upper border of the

thyroid cartilage
Head & Neck | 155
1. Receptors
(a) Carotid body
lies at the bifurcation of the common carotid artery as an ovoid body.
Is a chemoreceptor that helps control respiration by sensing chemical changes
(e.g.,lack of oxygen, excess of carbon d.l.oxl.de, and increased hydrogen ion
concentration) in the circulating blood.
Is innervated by the nerve to the carotid body, which arises from the pharyngeal branch
of the Vagus nerve, and by the carotid sinus branch of the glossopharyngeal nerve.
(b) Carotid sinus
Is a spindle shaped dilatation located at the origin of the internal carotid artery, which
functions as a baroreceptor, and Is stimulated by changes in blood pressure. When
stimulated, itcauses a slowing of the heartrate, vasodilation, and a decrease in blood
pressure.
ls innervated primarily by the carotid sinus branch of the glossopharyngeal nerve but Is
also innervated by the nerve to the carotid body of the Vagus nerve
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2. Internal carotid artery

Hasno branches in the neck, ascends within the carotid sheath in company with thevagus
nerve and the Internal jugular vein, and enters the cranium through the carotid canal In
the petrous part of the temporal bone.
In the middle cranial fossa, it gives rise to the ophthalmic artery and the anterior and
middle cerebral arteries. It participates in the formation of the circle of Willis (circulus
arteriosus), which ls an important anastomosis between four arteries: the two
vertebral and the two internal carotids. It is formed by the posterior cerebral, posterior
communicating, internal carotid, anterior cerebral, and anterior communicating arteries.
156 | Anatomy
3. External carotid artery
Extends from the superior aspect of the thyroid cartilage to the neck of the mandible,
where it divides in the parotid gland into the maxillary and superficial temporal arteries.
Has eight named branches:
(a) Superior thyroid artery
Arises below the level of the greater horn of the hyoid bone.
Gives rise to an infrahyoid, stemocleldomastoid, superior laryngeal. cricothyroid,
and several. glandular branches.
(b) Lingual artery
Arises at the level of the tip of the greater horn of the hyoid bone and passes deep
to the hyoglossus to reach the tongue.
Gives rise to suprahyoid, dorsal lingual, sublingu.al, and deep lingual branches.
(c) Facial artery
Arises just superior to the lingual artery and ascends forward, deep to the posterior belly
of the digastric and stylohyoid muscles.
Hooks around the lower border of the mandible at the anterior margin of the

masseter to enter the face.

(d) Ascending pharyngeal artery
Arises from the deep surface of the external carotid artery in the carotid triangle
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and ascends between the internal carotid artery and the wall of the pharynx.
Gives rise to pharyngeal, palatine, inferior tympanic, and meningeal branches.
e) Occipital artery
Arises from the posterior surface of the external carotid artery, just above the level of
the hyoid bone.
Passes deep to the digastric posterior belly, occupies the groove on the mastoid

process, and appears on the skin above the occipital triangle.

Gives rise to the following:
1. Sternocleidomastoid branch
Descends inferiorly and posteriorly over the hypoglossal nerve and enters the

substance of the muscle.

Anastomoses with the sternocleidomastoid branch of the superior thyroid artery.

2. Descending branch
Its superficial branch anastomoses with the superficial branch of the transverse cervical
artery.
Its deep branch anastomoses with the deep cervical artery of the costocervical trunk.
(f) Posterior auricular artery
Arises from the posterior surface of the external carotid artery just above the digastric
posterior belly.
Ascends superficial to the styloid process and deep to the parotid gland and ends

between the mastoid process and the external acoustic meatus. Gives rise to
stylomastoid, auricular; and occipital branches.
Head & Neck | 157
(g) Maxillary artery
Is the larger terminal branch of the external carotid artery.
Branches of Maxillary Artery:
FIRST PART SECOND PART THIRD PART
1. Deep Auricle - Supplies outer 1. Buccal - Supplies Buccinator. 1. Posterior Superior Alveolar
surface of tympanic membrane Cheeks (Dental) A: Runs on the posterior
and external auditory meatus wall of maxillary air sinus to
supply upper molar & premolar
teeth
2. Anterior Tympanic : Enters 2. Masseteric 2. Infraorbital Artery: Passes
middle ear through Petrotympanic successively through Inferior
fissure orbital fissure, infraorbital canal
& foramen to emerge in the face.
Gives off Antr. Superior alveolar
A. which descends through the
canalissinuosus in the anterior
wall of maxillary sinus to supply
upper incisors & canine
3. Accessory Meningeal : Enters 3. Artery to the Pterygoids 3. Pharyngeal A : Passes through
middle cranial fossa through Palatovaginal canal to supply
Foramen ovale Nasopharynx
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4. Inferior Alveolar (Dental) 4. Deep Temporal: These 4. A. of Pterygoid Canal : Passes
Artery : Enters mandibular canal branches supply muscles of through Pterygoid canal
through the mandibular foramen . mastication
Supply molar and premolar teeth
and divides into Incisive branch ,
which supplies canine & Incisors
. Mental br. supplies chin coming
out through Mental Foramen
5. Middle Meningeal Artery 5. Greater Palatine A : Descends
: Clinically the most important through greater palatine canal to
branch of maxillary and discussed enter Palate. Supplies soft palate,
separately mucosa of hard palate, palatine
tonsil. Terminal part enters Nasal
cavity through Incisive foramen to
take part in the anastomosis in the
Little’s area
6. Sphenopalatine A :
Enters Nasal cavity through
sphenopalatine foramen & supply
lateral wall & septum of nose and
anastomose in Little’s area.
158 | Anatomy
(h) Superficial temporal artery
Arises posterior to the neck of the mandible as the smaller terminal branch of the
external carotid artery.
Gives rise to the transversefacial artery, which runs between the zygomatic arch

and the parotid duct.

Ascends anterior to the external acoustic meatus into the scalp, accompanying the

auriculotemporal nerve and the superficial temporal vein.
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Head & Neck | 159
Concept 5.8 : Foramen of Skull

Time Needed
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I. Foramina in the Interior of base of skull :

A. Anterior Cranial Fossa:
Foramen Cranial Fossa:
a) Emissary Vein: From the Nasal mucosa of the anterior end of superior sagittal sinus
Foramina in the cribiform plate of Ethmoid:
a) Olfactory Nerves: 15 – 20 bundles on each sides surrounded by Leptomeninges

(I. Cranial N.) extended from olfactory epithelium in the roof of nasal cavity to the
olfactory bulb.
b) Anterior Ethmoidal Nerve & Vessels: Enter Nasal cavity through a slit like opening

on either side of crista galli

Anterior Ethmoidal Canal: Connects medial wall of orbital cavity with anterior cranial
fossa
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a) Anterior Ethmoidal N: Br. of Nasociliary Nerve

b) Anterior Ethmoidal Vessels

Posterior Ethmoidal canal : Connects medial wall of orbit anterior cranial fossa
a) Posterior ethmoidal N: Br. of Nasociliary Nerve

b) Posterior ethmoidal vessels

B. Middle Cranial Fossa:

Optic Canal or Foramen:
Optic Nerve: Along with the sheaths of meninges i.e., dura, arachnoid and pia (II
Cranial N.) and prolongations of subdural & subarachnoid spaces
Ophthalmic Artery: Surrounded by sympathetic plexus derived from superior cervical
sympathetic ganglion.
a) Central vein of Retina: Opens into cavernous sinus

Superior Orbital Fissure: Divided into 3 parts by common tendinous ring of Zinn
Middle part within the ring:
a) Upper & Lower divisions of Oculomotor (III) N.

b) Nasociliary Nerve: Br. of ophthalmic (V) between the two divisions of Oculomotor

c) Abducent N (VI N.): Lateral to nasocilairy nerve

Medial part below the ring:

a) Inferior ophthalmic vein

160 | Anatomy
Lateral part above the ring:
a) Trochlear N. (VI Cranial N.)

b) Frontal N.
Brs of ophthalmic nerve

c) Lacrimal N.

d) Superior ophthalmic vein

e) Recurrent meningeal br. of Lacrimal A.

f) Orbital br. of middle meningeal A.

g) Meningeal br. of ophthalmic A – Sometimes pass through a separate foramen

Foramen Rotundum: connects middle cranial fossa with pterygopalatine fossa

a) Maxillary Nerve
Emissary Sphenoidal Foramen (of Vesalius): Occasionally present between Foramen
rotundum & ovale. Communicates with infratemporal fossa
a) Emissary vein: Connecting cavernous sinus with pterygoid venous plexus

Foramen Ovale: Communicates with infratemporal fossa

a) Mandibular N : From Trigeminal ganglion

b) Motor root of Trigeminal N.

[These two unite below Foramen ovale to form mixed Mandibular N. in infratemporal
fossa]
c) Acessory meningeal A.

d) Lesser Petrosal nerve

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e) Emissary vein: Connecting cavernous sinus with pterygoid venous plexus

[Pneumonic: M. MALE]
Foramina Spinosum: Communicates with infratemporal fossa
a) Middle meningeal A.

b) Nervus spinosum: Meningeal br. of Mandibular N.

c) Parietal trunk of middle meningeal vein : Drains into pterygoid venous plexus

Canaliculus Innominatus: Occasionally present between the foramen ovale and spinosum
and transmit Lesser Petrosal nerve to the infratemporal fossa.
Foramen Lacerum:
a) Meningeal br. of ascending pharyngeal A:

b) Two or three Emissary veins: Connect cavernous sinus with Pharyngeal veins &

pterygoid venous plexus

Carotid canal transmitting internal carotid A. opens into the upper part of posterior

wall of Foramen Lacerum.

Greater Petrosal N. unites with deep petrosal N. (from sympathetic plexus around

internal carotid A.) to form the Nerve of Petrygoid canal (Vidian N.) which then
enters Pterygoid canal. The posterior orifice of the pterygoid canal lies in the
lower part of anterior wall of the foramen lacerum. The pterygoid canal connects
foramen lacerum with pterygopalatine fossa.
Caroticoclinoid Foramen: Occasionally present between the anterior clinoid process and
middle clinoid process transmit Internal Carotid A.
Head & Neck | 161
Carotid Canal:
a) Internal carotid Artery

b) Sympathetic plexus around the I.C.A.

c) Emissary vein (venous plexus): Connects cavernous sinus with internal jugular

vein.
C. Posterior Cranial Fossa:

Internal Auditory Meatus:
a) Facial N. (VII cranial N.) : Motor Root of VII N.

b) Nervus intermedius of Wrisberg : Sensory Root of VII N.

c) Vestibulocochlear Nerve (VIII cranial N.)

d) Internal auditory (Labyrinthine) vessels

Jugular Foramen: May be divided into 3 parts

Anterior Part:
a) Inferior Petrosal Sinus: Cranial venous sinus draining outside the skull. Connect the

cavernous sinus with internal jugular vein.

Middle Part : Anterior to posterior
a) Glossopharyngeal (IX) N: With its dural sheath

b) Vagus (X) N

c) Accesssory (XI) N[ X and XI Nerves are enclosed by a common duralsheath ]

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Posterior Part:
a) Sigmoid sinus: Continues as Internal Jugular Vein

b) Meningeal branches of occipital artery and ascending pharyngeal artery

Mastoid Canaliculus: Present in the lateral wall of jugular foramen transmit Auricular
br. of vagus (Arnold’s N. or Alderman’s N.)
Hypoglossal (Anterior condylar) canal:
a) Hypoglossal (XII) Nerve

b) Meningeal branch of ascending pharyngeal artery

c) Emissary vein (venous plexus), Connecting sigmoid sinus with internal jugular vein.

Posterior Condylar Canal : Only sometimes present

a) Emissary vein: Connecting sigmoid sinus with suboccipital venous plexus

Foramen Magnum: Divided into a small anterior and a large posterior parts
Anterior Part:
a) Apical ligament of Dens

b) Superior longitudinal band of cruciform ligament

c) MembranaTectoria - Continuation of posterior longitudinal ligament

Posterior Part :
a) Medulla oblongata - Along with its meninges i.e., dura, arachnoid & pia maters &

subdural, subarachnoid spaces

b) Right & Left posterior spinal arteries

c) A single median anterior spinal artery

162 | Anatomy
d) Right & left vertebral arteries - Surrounded by sympathetic plexus derived from

inferior cervical ganglion

e) Right & left spinal part accessory nerves (XI N.)

f) Veins connecting basilar venous plexus with internal vertebral venous plexus

Tonsils of cerebellum may project on each side of medulla oblongata

II. Foramina on the exterior of skull:

A. Norma Verticalis:
Parietal Foramen:
a) Emissary vein - Connecting veins of scalp with superior sagittal sinus

b) Meningeal br. of occipital artery

B. Norma Frontalis:
Supra orbital Foramen (Sometimesnotch)
a) Supraorbital Nerve

b) Supra orbital artery

c) Frontal Diploic vein

Zygomatic Facial Foramen:

a) Zygomatico facial nerve: Branch of zygomatic nerve (br. of maxillary nerve)

b) Zygomatico facial vessels

Infraorbital Foramen: AfraTafreeh.com

a) Infraorbital Nerve - Continuation of maxillary

b) Infra orbital vessels

C. Norma Lateralis:
Zygomatico temporal foramen:
a) Zygomatico temporal nerve

b) Zygomatico temporal vessels

Pterygomaxillary Fissure:
a) 3rd part of maxillary artery

b) Maxillary nerve

Inferior orbital fissure:

a) Infra orbital vessels

b) Maxillary N. continuing as Infra orbital N.

c) Zygomatic Nerve

d) Veins connecting inferior ophthalmic vein with pterygoid venous plexus

Sphenopalatine Foramen: Connects nasal cavity with pterygopalatine fossa

a) Sphenopalatine vessels

b) Nasopalatine nerve

Mastoid Foramen:
a) Emissary vein - Connects sigmoid sinus with posterior auricular or occipital veins

b) Meningeal br. of occipital artery

Head & Neck | 163
Greater Palatine Canal:
a) Anterior (greater palatine), middle & posterior (Lesser palatine) palatine nerves

b) Greater palatine vessels

c) Lesser palatine vessels

d) Norma Basalis:

Incisive Fossa:
1. Lateral incisive foramina : Right & left present in the lateral wall of incisive fossa
and lead to floor of nasal cavity
a) Greater palatine vessels

b) Nasopalatine nerve - Only when median foramina are absent

2. Median Incisive Foramina: Two in number, one in the Anterior wall & the other in
the Posterior wall of incisive fossa
a) Left nasopalatine nerve: Passes through anterior median incisive foramen

b) Right nasopalatine nerve: Passes through posterior median incisive foramen.

Greater Palatine Foramen:

a) Greater palatine nerve

b) Greater palatine vessels

Lesser palatine foramina:

a) Lesser palatine nerve

b) Lesser palatine vessels

Petrotympanic Fissure:
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a) Chorda tympani br. of VII N.

b) Anterior tympanic artery

c) Anterior ligament of malleus

Palato Vaginal Canal:

a) Pharyngeal Nerve: Br. of pterygopalatine ganglion

b) Pharyngeal artery

Vomero Vaginal Canal: If present provides passage to:

a) Pharyngeal Nerve

b) Pharyngeal Artery

Pterygoid canal:
a) Nerve of petrygoid canal (Vidian Nerve)

b) Vessels of petrygoid canal

Tympanic Canaliculus: Located on the crest between carotid and jugular foramen
a) Tympanic br. of IX N. (Jacobson’s Nerve)

b) Tympanic br. of ascending pharyngeal artery

Stylomastoid Foramen:
a) Facial Nerve

b) Stylomastoid Artery: Branch of posterior auricular or sometimes occipital arteries

164 | Anatomy
Concept 5.9 : Parasympathetic ganglia and supply

Time Needed
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Nucleus of Preganglionic Fibres RELAY - Postganglionic Fibers

origin Parasympathetic
Ganglion
Exit from Preganglionic Postganglionic Effector
Brain stem Pathway Pathway Supplied
Edinger- Occulmotor Oculomotor CILIARY Short ciliary Cilliaris&
Westphal Nerve III Cr. N- Its inferior GANGLION nerves Sphincter
Nu in upper N. division – Located in orbit Puppillae
midbrain Nerve to muscles
inferior oblique
Lacrimatory Facial Nerve Sensory PTERYGO- a) Maxillary Lacrimal
nucleus in VII Cr. N Root (Nervus PALATINE Nerve- Gland
Lower Pons intermedius) GANGLION Zygomatic Br.-
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of VII N. (Meckel’s Zygomaticot-
Geniculate ganglion in emporal Br.
ganglion- Pterygopalatine
Greater Petrosal Communicating Nasal glands,
fossa) Br.
N-Nerve of Palatine glands
Pterygold canal Lacrimal Nerve
(Vidian N) b) Greater
Palatine
Nerve, Lesser
Platine nerve &
Nasal branches
of the ganglion
Superior Facial Nerve Sensory Submandibular Back to Lingual Sublingual and
Salivary VII Cr. N. Root- Facial ganglion Nerve submandibular
Nucleus in Nerve –its (Langley’s Salivary glands
Lower Pons ordatympanibr- ganglion)
Lingual
nerve (br of
mandicular N)
Inferior Glosso- Glosso- OTIC Communication Parotid
Salivary pharyngeal pharyngeal- Its GANGLION with gland
Nucleus in Nerve IX. tympanic br. Auricotemporal
uppermost N. (Jacobson’s nerve.
part of N) Tympanic
medulla Plexus- Lesser
Petrosal N.
Head & Neck | 165
Concept 5.10 : Development of Head & Neck

Time Needed
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Pharyngeal Apparatus
The pharyngeal apparatus consists of the pharyngeal arches, pharyngeal pouches,
pharyngeal grooves, and pharyngeal membranes, all of which contribute greatly to
the formation of the head and neck. The pharyngeal apparatus is first observed in week
4 of development and gives the embryo its distinctive appearance.
A. Pharyngeal arches (1, 2, 3, 4, 6) contain somitomeric mesoderm and neural

crest cells. The somitomeric mesoderm differentiates into muscles and arteries
(i.e., aortic arches 1–6), whereas the neural crest cells differentiate into bone
and connective tissue. In addition, each pharyngeal arch has a cranial nerve
associated with it.
B. Pharyngeal pouches (1, 2, 3, 4) are evaginations of endoderm that lines the

foregut.
C. Pharyngeal grooves (1, 2, 3, 4) are invaginations of ectoderm located between
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each pharyngeal arch.

D. Pharyngeal membranes (1, 2, 3, 4) are structures consisting of ectoderm,

intervening mesoderm andneural crest, and endoderm. The pharyngeal

membranes are located between each pharyngeal arch.
Derivatives of pharyngeal pouches
Pouch Derivatives
First pouch Pharyngotympanic tube

Tympanic (middle ear) cavity
Second pouch Palatine tonsil

Intratonsillar cleft
Third pouch Inferior parathyroid gland

Thymus
Fourth pouch Superior parathyroid gland Caudal pharyngeal

complex (ultimopharyngeal body)
166 | Anatomy
Nerves and derlvatlves of the pharyngeal
Pharyngeal arch Nerve/nerves Muscles Skeleton Ligaments
First arch (a) Maxillary and Muscles of Premaxilla, Anterior ligament

(mandibular mandibular nerves mastication maxilla, zygomatic of malleus, and
and maxillary (b) Chord tympani (temporalis, bone, part of sphenomandibular
processes) nerve masseter, medial temporal bone, ligament
and lateral Meckel’s cartilage,
pterygoids), mandible, malleus,
mylohyoid, and incus
anterior belly of
digastrics, tensor
veli palatine, and
tensor tympani
Second arch Facial nerve Muscles of Stapes, styloid Stylohyoid

facial expression process, lesser ligament
(buccinators, cornu of the hyoid
auricularis, bone, and upper
occipitofrontalis, part of body of the
platysma, hyoid bone
orbicularis oris,
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orbicularis oculi),
posterior belly
of digastrics
stylohyoid, and
stapedius
Third arch Glossopharyngeal Stylopharngeus Greater cornu and

nerve lower part of body
of the hyoid bone
Fourth and sixth Superior Cricothyroid, Laryngeal

arches laryngeal branch levator palate, cartilages
of vagus nerve constrictors of (thyroid, cricoids,
(nerve of fourth pharynx, and arytenoids,
arch) Recurrent intrinsic muscles corniculate,
laryngeal branch of of the larynx cuneiform)
vagus nerve (nerve
of sixth arch)
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Development of tongue. A Appearance of four swellings (tuberculum impact), two lingual swellings,
and hypobranchial (eminence), which give rise to the various parts of the tongue.
B. Subdivision of hypobranchial eminence into cranial and caudal parts
168 | Anatomy
Worksheet
• MCQ OF “HEAD & NECK” FROM DQB


 AfraTafreeh.com

Head & Neck | 169
Pharyngeal arch Nerve Muscles Skeleton Ligament
1.
2.
3.
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4.
5.
6.
170 | Anatomy
(Active recall)
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Head & Neck | 171
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172 | Anatomy
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6 Neurology
CONCEPTS
Â Concept 6.1 Spinal cord

Â Concept 6.2 Brainstem

Â Concept 6.3 Diencephalon

Â Concept 6.4 Basal nuclei

Â Concept 6.5 Cerebellum

Â Concept 6.6 AfraTafreeh.com
Cerebrum

Â Concept 6.7 Blood supply

Â Concept 6.8 CSF & Ventricles

174 | Anatomy
Concept 6.1 : Spinal cord

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Spinal Nerves:-
• 31 pairs of nerves that emerge from the spinal cord: 8 cervical, 12 thoracic, 5 lumbar,

5 sacral, and 1 coccygeal.

• contain both motor and sensory fibers.

1. Special considerations
• The first cervical nerve and the coccygeal nerve usually have neither the posterior

(sensory)
• roots nor the corresponding dermatomes.

• The first cervical nerve passes between the atlas and the skull.

• The second cervical nerve passes between the atlas and the axis.

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• With the exception of C 1, spinal nerves exit the vertebral canal via intervertebral or

sacral foramina.
2. Functional components of spinal nerve fibers
General somatic afferent (GSA) fibers
a. convey sensory input from skin, muscle, bone, and joints to the central nervous

system (CNS).
General visceral afferent (GVA) fibers
a. convey sensory input from visceral organs to the CNS.

General somatic efferent (GSE) fibers

a. convey motor output from anterior horn motor neurons to skeletal muscle.

General visceral efferent (GVE) fibers

a. convey motor output from intermediolateral cell column neurons, via paravertebral

or prevertebral ganglia, to glands, smooth muscle, and visceral organs (sympathetic

divisions of the autonomic nervous system).
b. convey motor output from the sacral parasympathetic nucleus to the pelvic viscera

via intramural ganglia.

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Internal Structure of the Spinal Cord
Grey matter
• Toward the center of the spinal cord.
• Butterfly- or H-shaped that varies according to spinal cord level.
• Contains a central canal.
• Divided into cytoarchitectural areas called Rexed laminae, expressed with Roman
numerals divided into three horns or cell columns on each side:
1. Posterior horn (column) AfraTafreeh.com
• Receives and processes sensory input.
• Found at all levels.
• Includes the following nuclei:
a. Posteromarginal nucleus (Rexed lamina I)
Found at all cord levels.

Associated with light touch, pain, and temperature sensation.

Origin of some fibers of anterolateral system.

b. Substantia gelatinosa (Rexed lamina ll)


Homologous to the spinal trigeminal nucleus.



c. Nucleus proprius (Rexed laminae Ill and IV)




Posterior thoracic nucleus (also known as nucleus dorsalis of Clarke) (Rexed

lamina VII)
Found at the base of the posterior horn.

Extends from (C8) T1 to L2.

176 | Anatomy
Homologous to the accessory cuneate nucleus of the medulla.
Subserves unconscious proprioception from muscle spindles and Golgi tendon
organs (GTOs)
The origin of the posterior spinocerebellar tract.
2. Lateral horn (column) (Rexed lamina VII)
• Receives viscerosensory input.
• Found between the posterior and the anterior horns.
• Extends from T1 to L2.
• Contains the intermediolateral nucleus (column), a visceromotor nucleus that extends
• From T1 to L2.
• Contains preganglionic sympathetic neurons (GVE).
• Contains, at T1—T2, the ciliospinal center of Budge (sympathetic innervation of the
eye).
3. Anterior horn (column) (Rexed laminae VII, VIII, and IX)
• Contains predominantly motor nuclei.
• Found at all levels.
• Includes the following nuclei:
a. Spinal border cells
Extend from L2 to SS.

Subserve unconscious proprioception from GTOs and muscle spindles.

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The origin of the anterior spinocerebellar tract.

b. Sacral parasympathetic nucleus (Rexed lamina VII)

Extends from S2 to S4.

Gives rise to preganglionic parasympathetic fibers that innervate the pelvic viscera

via the pelvic splanchnic nerves.

c. Somatic motor nuclei (Rexed lamina IX)
Found at all levels.

Subdivided into medial and lateral groups that innervate axial and appendicular

muscles, respectively.
Neurology | 177
Concept 6.2 : Brainstem

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Medulla Oblongata
It is continuous with spinal cord at the upper border of C1.
Connected to cerebellum by inferior cerebellar peduncle.
T S of medulla at Pyramidal decussation
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Grey Matter
a. Nucleus gracialis & cuneatus.
b. Decussating Pyramidal fibres.
c. Spinal nucleus of trigeminal nerve
d. Spinal nucleus of accessory nerve
White Matter
a. Pyramids
b. Fasciculus grcialis & cuneatus
c. Lateral corticospinal, vestibulospinal, rubrospinal, tectospinal olivospinal tracts
d. Lateral & anterior spinothalamic, ventral & dorsal spinocerebellar traces.
T S of medulla at the level of sensory decussation (crossing of fibres from nucleus
gracialis & cuneatus)
178 | Anatomy
Grey matter
a. Nucleus gracialis & cuneatus
b. Accessory cuneate nucleus
c. Inferior olivary nucleus
d. Nucleus of spinal tract of trigeminal nerve
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e. Hypoglossal nucleus, dorsal nucleus of vagus & nucleus of tractus solitarius.
White matter
a. Internal arcuate fibres.
b. Medial leminiscus
c. Pyramidal tract
d. Spinocerebellar, spinothalamic, tracts
e. Rubrospinal, vestibulospinal & olivospinal tract.
T S of medulla in the fourth ventricle
Neurology | 179
Grey matter
a. Nuclei in the floor – vagal, hypoglossal & vestibular nuclei, nucleus of tractus solitarius
b. Nucleus ambigues, dorsal & ventral cochlear nuclei, Nuclei of spinal tract of trigeminal
nerve, arcuate nucleus.
White matter
a. Olivocerebellar tract, stria medullaris
b. Fibres of 9th, 10th & 11th cranial nerves.
Blood Supply of medulla – Vertebral artery through anterior spinal, posterior spinal
& PICA, Basilar artery.
Medial Medullary Syndrome
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Thrombosis of Anterior spinal artery. The midline structures in the medulla are affected.
Hypoglosal nucleus – Ipsilateral paralysis of tongue muscles

Pyramids – contralateral hemiplegia

Medial leminiscus – contralateral loss of fine sensations.

This is also known as Alternating Hypoglossal Hemiplegia.

Lateral Medullary Syndrome / Wallenbergs Syndrome.
Thrombosis of Vertebral / PICA.

Spinothalamic tract – contralateral loss of crude sensations

Spinal nucleus & tract of trigeminal nerve - Ipsilateral analgesia of face

Nucleus Ambigues – dysphagia, dysarthria.

Vestibular apparatus – giddiness

Inferior cerebellar peduncle – Ipsilateral ataxia

Cervical sympathetic – Horners syndrome.

180 | Anatomy
PONS
Connects midbrain to medulla. It is connected to cerebellum by middle cerebellar
peduncle. The trigeminal nerve is located at the junction of pons with the middle
cerebellar peduncle. 6th, 7th & 8th nerves are attached to pontomedullary junction.
Pons is divided into ventral (basilar) & dorsal (tegmental) parts.
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Basillar part is uniform in upper & lower parts.

Grey matter.
a. Pontine nuclei
White matter
Contains Fibres, Theses are –
a. Transverse – pontocerebellar
b. Longitudinal – corticopontine, corticobulbar & corticospinal fibres.
Neurology | 181
Tegmentum (dorsal part)
In the Lower part of pons (fourth ventricle)
Grey matter – 6th, 7th, 8th nerve nuclei, salivatory & lacrymatory nuclei, spinal nucleus
of trigeminal nerve
White matter – Trapezoid body, spinal lemniscus, facial colliculus
In the upper part of pons (closed part)
Grey matter – Motor & three sensory nuclei of trigeminal nerve
White matter – Trigeminal, spinal & lateral lemniscus, medial longitudinal bundle.
Blood Supply of Pons – Basilar artery, Anterior inferior cerebellar & superior cerebellar
arteries.
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Millard Gubler Syndrome

Involves the lower part of pons.
It includes the lower part of Pyramids, & the emerging 6th & 7th nerves.

Ipsilateral medial squint.

Ipsilateral facial paralysis.

Contralateral hemiplegia.

Pontocerebellar angle syndrome

Tinnitus, progressive deafness, and vertigo due to damage of VIIIth cranial nerve.

I psilateral ataxia and staggering gate due to compression of cerebellar peduncle.

I psilateral lower motor neuron type of facial palsy, due to involvement of facial

nerve.
182 | Anatomy
Midbrain
Midbrain connects the forebrain to hind brain. The cavity od midbrain is called Aqueduct
of Sylvius, which connects the third ventricle to fourth ventricle. Midbrain is divided into
the following parts –
a. Tectum – Lies posterior to aqueduct. It consists of superior & inferior colliculus.
b. Cerebral peduncles – Lies anterior to aqueduct. It is made up of the following –
1. Crus cerebri – Anteriorly
2. Substantia nigra
3. Tegmentum – Posteriorly.
T S of midbrain at the level of Inferior colliculus.
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Grey Matter contains –

a. Nucleus of trochlear nerve
b. Mesencephalic nucleus of trigeminal nerve
c. Inferior colliculus
d. Substantia nigra.
White matter contains –
a. Crus cerebri contains frontopontine fibres in medial 1/6, corticonucleur & corticobulbar

fibres in middle 2/3 & temporopontine, parietopontine & occipitopontine fibres in its
lateral 1/6.
Neurology | 183
b. Tegmentum contains

1. Leminisci (medial, trigeminal spinal & lateral)

2. Tectospinal & rubrospinal tracts

3. Decussation of superior cerebellar peduncles

4. Medial longitudinal bundle.

T S of Midbrain at the level of Superior colliculus
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Grey matter contains –

a. Nucleus of occulomotor nerve & E W nucleus
b. Mesencephalic nucleus of trigeminal nerve
c. Superior colliculus
d. Pretectal nucleus
e. Red nucleus
f. Substantia nigra.
White matter contains –
a. Crus cerebri - Same as inferior colliculus.
b. Tegmentum contains –
1. Lemenisci – (Medial, trigeminal & spinal)

2. Dorsal tegmental decussation (Decussation of tectospinal & tectobubar tract)

3. Ventral tegmental decussation (Decussation of rubrospinal tract)

4. Medial longitudinal bundle.

184 | Anatomy
Blood Supply
Posterior cerebral, Superior cerebellar & basilar arteries.
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Webers Syndrome.
• Occurs in the basal region of the peduncle due to occlusion of a branch of posterior

cerebral.
• Lesion involves the 3rd nerve & crus cerebri.

• Ipsilateral Lateral Squint.

• Contralateral Hemiplegia.

• Drooping of the upper eyelid.

• Pupil is dialated & fixed.

Benedikt’s syndrome
Benedikt’s syndrome occurs due to the vascular ischaemia of the tegmentum of midbrain
involving the medial lemniscus, spinal lemniscus, red nucleus, superior cerebellar
peduncle and fibres of oculomotor nerve. It is characterised by following signs and
symptoms:
• Ipsilateral lateral squint and ptosis, due to involvement of oculomotor nerve fibres.

• Contralateral loss of pain and temperature sensation, due to involvement of trigeminal

and spinal lemnisci.

• Contralateral loss of tactile, muscle, joint and vibration sense, due to involvement of

medial lemniscus.
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• Contralateral tremors and involuntary movements in the limbs, due to involvement of

red nucleus and fibres of superior cerebellar peduncle entering into it.
• Parinaud’s syndrome: Parinaud’s syndrome results from a lesion of the superior

colliculi as occurs when this area becomes compressed by the tumours of the pineal
gland. It is characterised by the loss of upward gaze without affecting the other eye
movements (the anatomical basis for this is obscure but experiments indicate that
the area involved may contain a centre for upward movements of the eyes).
• Argyll Robertson pupil: The Argyll Robertson’s pupil is a clinical condition in which

light reflex is lost but the accommodation reflex remains intact. Generally, it occurs
because of lesion in the vicinity of pretectal nucleus.
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Concept 6.3 : Diencephalon

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Divisions and subdivisions of the diencephalon

Divisions Subdivisions
Pars dorsalis
• Thalamus (dorsal thalamus)
Medial and lateral geniculate bodies Pineal gland
• Metathalamus

(body), habenular nuclei and commussure, and
• Epithalamus

posterior commissure
Pars Ventralis
• Subthalamus (ventral thalamus)
Subthalamic nucleus, and zone inserta
• Hypothalamus

A. Consists of –
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a. Thalamus – sensory relay & integrative centre. Except Reticular nuclei every thalamic
nuclei sends axons to different parts of cortex. The output of reticular nucleus is mainly
to other thalamic nuclei.
Scheme to Show the Connections of the thalamus

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b. Hypothalamus
Ventro-posterolateral nucleus – relay of Spinal & Medial leminiscus.
Ventro-posteromedial nucleus – trigeminal leminiscus & solitarothalamic tract.
The hypothalamus is also subdivided anteroposteriorly into the following four regions:
1. Preoptic region adjoining the lamina terminalis.
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2. Supraoptic region above the optic chiasma.
3. Tuberal region includes the tuber cinereum, infundibu-lum and area around it.
4. Mammillary region includes the mammillary bodies and area around it.
The preoptic region lies anterior to the hypothalamus between the optic chiasma and
anterior commissure. Anatomically it belongs to the telencephalon but functionally to
the hypothalamus.
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The tuber cinereum is the region bounded, caudally by mammillary bodies and rostrally
by optic chiasma. The infundibulum connects the posterior lobe of the hypophysis cerebri
with the tuber cinereum. The tuber cinereum around the base of the infundibulum is
raised to form a median eminence.
Nucleus/nuclei Functions
Prebiotic nucleus • Regulates release of gonadotrophic hormones

Supraoptic and Paraventricular • Produce antidiuretic hormone (ADH) and Oxytodin

Nuclei • Regulate water balance

Anterior nucleus • Regulates body temperature by dissipation of heat

• Stimulates parasympathetic nervous system

Arcuate (infundibular) nucleus • Produces hypothalamic releasing factors

Ventromedial Nucleus • It is considered as a ‘satiety centre’.

• Its stimulation inhibits the urge to eat.

Dorsomedial Nucleus • lts stimulation causes obesity and results in savage behaviour

Posterior nuclei • Regulates body temperature by conservation of heat

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• Stimulates sympathetic nervous system

Mammillary nuclei • Receives input from hippocampal formation through fornix

Lateral nucleus • Its stimulation induces eating

Major hypothalamic nuclei and their functions

c. Epithalamus

Lies in the Habenular trigone & consists of pineal body, posterior & Habenular
commissure.
d. Metathalamus -

Consists of Medial & Lateral geniculate bodies.

e. Subthalamus –

Consists of subthalamic nucleus, Zona incerta, cranial end of red nucleus & substantia
nigra extends into it.
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Concept 6.4 : Basal Nuclei

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Basal Ganglia
Consists of
• Caudate nucleus, Globus Pallidus, Putamen, Substantia nigra & Subthalamic nucleus.
• Caudate nucleus & Putamen constitute the Striatum - receives the afferent input
• Globus Pallidus & Substantia nigra constitute the efferent.
• Basal Ganglia is concerned with planning & programming of movement. Or a process
in which thought is converted into action.
• Regulation of tone & posture.

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Chief afferent and efferent connections of corpus striatum.
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192 | Anatomy
Concept 6.5 : Cerebellum

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Cerebellum consists of two cerebellar hemispheres joined by Vermis.
It is divided by Superior & Inferior surfaces by horizontal fissure.
The Primary & posterolateral fissures divides the cerebellum into Anterior, Middle &
floculonodular lobes.
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The cerebellar cortex contains five type of neurons.

a. Purkenje cell b. Granule cell
c. Basket cell
d. Stellate cell
e. Golgi cell.
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The Purkenje are the sole output from cerebellar cortex & pass to the deep cerebellar
nuclei. The axons of deep nuclei are the final efferent output from cerebellum.
The cerebellar cortex is arranged in three layers –
1. Outer Molecular Layer – contains basket & stellate cells.
2. Middle Purkenje cell layer
3. Inner Granular cell Layer – made up of granular & Golgi cells.
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The deep cerebellar nuclei are (lateral to medial)

a. Dentate
b. Emboliform
c. Globose together also known as Nucleus Interpositus.
d. Fastigi
Functionally Cerebellum is classified as –
a. Vestibulocerebellum / Archicerebellum – Consists of floculo-nodular lobe

(floculus & nodulus). It receives afferent fibres from vestibular Apparatus & project
on the vestibular nuclei without projecting on the deep nuclei. Helps in equilibrium &
coordinates movements of eyes with movements of head (vestibule – ocular reflex).
b. Spinocerebellum / Paleocerebellum – Concerned with co-ordination of

movements.
c. Cerebrocerebellum / Neocerebellum – Most recent. Concerned with planning &

programming of movements.
Blood Supply – Superior cerebellar artery, Anterior inferior & posterior inferior
cerebellar artery.
194 | Anatomy
Cerebellar Peduncles.
Peduncle Afferent fibres Efferent fibres
Inferior Posterior spinocerebellar, Olivocerebellar, Cerebelloolivary, Cerebellovestibular,
Vestibulocerebellar, Cuneocerebellar, Cerebelloreticular.
Reticulocerebellar
Middle Pontocerebellar
Superior Anterior spinocerebellar, Tectocerebellar, Cerebellorubral, Dentatorubral,
Hypothalamocerebellar Dentatothalamic.
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Concept 6.6 : Cerebrum

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There are two cerebral hemispheres connected to each other by Corpus Callosum. Each
hemisphere encloses the Lateral Ventricle & shows the following features –
Three surfaces – Superolateral, medial & inferior.
Three Poles – Frontal, occipital & temporal.
Three Borders – Superomedial, Inferolateral & medial border.
Four Lobes – Frontal, parietal, temporal & occipital.
Types of Sulci
1. Limiting Sulcus – Separates two cortical areas. Eg. Central sulcus – separates motor

from sensory area. Anterior part of calcarine sulcus.

2. Complete sulcus – Is the one which produce an elevation in the wall of ventricles.

Eg. Calcarine sulcus – Produces an elevation in the wall of posterior horn called Calcar
Avis. Collateral sulcus – produces an elevation in the inferior horn called Collateral
Eminence. AfraTafreeh.com
3. Axial Sulcus – Grows in the axis of a lobe. Eg. Posterior part of calcarine sulcus.

4. Operculated Sulcus – Similar to limiting suclus, separates two areas, but separation

occurs at the lip. Eg – Lunate sulcus – separates the striate from the peristriate area.
Functional Areas of Cerebral Hemisphere
196 | Anatomy
Frontal Lobe –
1. Primary motor area – no 4.
2. Premotor area – 6 &8.
3. Prefrontal area – 9, 10, 11, 12.
4.
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Brocas area – 44, 45 – In the dominant hemisphere.
Parietal lobe –
1. Primary sensory area- 3, 1, 2.
2. Sensory association areas- 5, 7
Temporal Lobe
1. Primary auditory area – 41, 42

2. Auditory association area/ Wernicke’s area – 22 – posterior part of superior temporal

gyrus.
Occipital Lobe.
1. Primary visual area – 17
2. Visual association area – 18 (Para striate), 19 (peristriate)
White Matter of Cerebrum
The fibers of bain are classified into three main types –
1. Commissural Fibers – Connect similar areas in opposite hemisphere. Eg. Corpus

callosum, Anterior commissure, Posterior, Habenular commissure & Hippocampal

commissures.
2. Projection Fibers – Connect cerebral cortex to other parts of brain & spinal cord. Eg.

Internal capsule, fornix, corona radiate, fimbria.

3. Association fibers – Connect different areas in the same hemisphere. Eg. Uncinate

fasciculus, Cingulum, Superior & inferior longitudinal fasciculus.

Neurology | 197
Corpus Callosum.
a. Largest commissural fibers. Connect all the parts of cerebral hemispheres except

lower & anterior temporal lobes which are connected by anterior commissure.
b. 10 cm long. Consists of Rostrum, Genu, Trunk & Splenium.

c. Genu lies 4cm behind frontal pole & splenium lies 6cm in front of occipital pole.

d. Forceps minor are fibers which begins from genu, which connect the two frontal

lobes.
e. Forceps major are fibers which begins from splenium & connect occipital lobes.

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Internal Capsule
Example of projection fibers. V shaped on horizontal section. Consists of Anterior limb,
Genu, Posterior limb, Retrolentiform part & Sublentiform parts.
198 | Anatomy
Concept 6.7 : Blood supply

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Brain is supplied by Vertebral, Basilar & Internal Carotid arteries.
Vertebral artery – it is a branch of first part of subclavian artery. Enters the foramen
transversariun of C6. Crosses the arch of Atlas, enters the skull & both join to form
Basilar artery.
Branches
1. Anterior Spinal artery – Supplies the midline structures of medulla

2. Posterior spinal artery – Supplies the posterior part of medulla.

3. Posterior Inferior Cerebellar artery – Supplies lateral part of medulla & posterior

inferior aspect of cerebellum.

4. Medullary branches

5. Meningeal branches

Basilar Artery – Single artery lies in the cisterna pontis / basilar sulcus of pons.
Branches AfraTafreeh.com
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1. Pontine branches
2. Labrynthine artery
3. Anterior inferior cerebellar artery
4. Superior cerebellar artery
5. Posterior cerebral artery – Gives following branches –
a. Central – Supplies midbrain, thalamus, lentiform nucleus, geniculate bodies.

b. Cortical branches – Supplies temporal & occipital lobe ( visual striate cortex)

c. Posterior choroidal artery – Supplies choroids plexus of third & lateral

ventricles.
Internal Carotid Artery
Branches
1. Cavernous branches.

2. Hypophyseal branches.

3. Opthalmic artery

4. Anterior choroidal artery – Supplies the choroids plexus of inferior horn, optic

tract, uncus, amygdyla, LGB & internal capsule.

5. Posterior communicating artery

6. Middle cerebral – Supplies the superolateral surface of brain.

7. Anterior cerebral – Medial striate artery / Recurrent artery of Hebneur – is a branch

of anterior cerebral. Supplies caudate nucleus, putamen & internal capsule.

Circle of Willis AfraTafreeh.com
Formed by the following arteries –
a. Anterior – Anterior communicating artery

b. Antero-lateral – Anterior cerebral

c. Lateral – MCA

d. Postero-lateral – Posterior communicating artery

e. Posterior – Posterior cerebral artery.

Circle of Willis lies in the Interpeduncular fossa.

Venous drainage
Superficial veins
1. Superior Cerebral vein – Drains

blood from superolateral & medial

surfaces of brain, drains into
superior sagittal sinus.
2. Superficial
Middle Cerebral
Vein – Runs in the lateral sulcus,
communicates with superior sagittal
sinus through vein of Trolard &
inferior sagittal sinus through vein
of Labbe.
200 | Anatomy
Deep Veins.
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a. Internal Cerebral Vein – Formed by union of Septal, Thalamostriate & Choroidal

veins.
b. Basal Vein – Formed by anterior cerebral vein, deep middle cerebral vein & striate

vein
c. Great Cerebral Vein of Galen – Formed by union of two internal cerebral veins.it

drains into Straight sinus.

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Concept 6.8 : CSF & Ventricles

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Ventricles of Brain
Lateral Ventricle
There are two lateral ventricles in each hemisphere connected to a single third ventricle
through Foramen of Munro.
Each lateral ventricle has anterior horn, Body, Posterior horn & Inferior horn.
Anterior Horn – Lies in the frontal lobe
Lies in front of Interventricular foramen.
Floor – Rostrum of corpus callosum, head of caudate nucleus.
Anterior – Genu
Roof – Trunk of Corpus callosum
Medial – Septum pellicudum & fornix.
Central part / Body – Present infrontal & parietal lobes.
Roof – Trunk of corpus callosum
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Floor – Thalamus, thalamostriate vein, stria terminalis & caudate nucleus ( medial to
lateral).
Medial wall – Septum pellicudum & fornix.
202 | Anatomy
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Posterior Horn – Lies in the occipital lobe. May be absent.

Roof & lateral wall – Tapetum
Floor & medial wall – Bulb of posterior horn produced by fibres of forceps major &
calcar avis produced by calcarine sulcus.
Inferior Horn – Lies in the temporal lobe. It is the largest horn.
Roof & lateral wall – Tapetum, tail of caudate nucleus, stria terminalis & amygdaloid
body.
Floor - Collateral eminence caused by collateral sulcus.
Choroid plexus is present in the body & inferior horn of lateral ventricle.
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Third Ventricle
It ia a cavity of Diencephalon, lies between thalamus & hypothalamus of both sides.
Communicates with lateral ventricles through foramen of Munro & fourth ventricle
through Aqueduct of Sylvius.
Anterior – Lamina terminalis, anterior commissure.
Roof – fornix. The choroids plexus projects from the roof.
Posterior – Pineal gland, posterior & habenular commissure.
Floor – Optic chiasma, tuber cineriun, pituitary stalk, mamillary bodies, posterior
perforated substance & crus cerebri.
Lateral wall – Thalamus & hypothalamus.
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Fourth Ventricle.
It is a cavity of rhombencephalon. Lies between Pons & medulla anteriorly & cerebellum
posteriorly. It communicates with the third ventricle superiorly through aqueduct of
Sylvius & central canal inferiorly.
Lateral Boundaries
Superolateral – Superior cerebellar peduncles
Inferolateral – Gracile & cuneate tubercle & inferior cerebellar peduncles.
Roof - superior & inferior medullary velum. Roof posses a pair of choroids plexus.
Floor / Rhomboid Fossa.
Formed by lower half of Pons & upper half of medulla.
204 | Anatomy
It shows the following features –

a. Median sulcus
b. Medial eminence
c. Superior & inferior fovea.
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d. Locus Coeruleus – a bluish area
due to pigmented neurons containing
Substantia Feruginea.
a. Facial Colliculus in the Pons (Formed by fibers of facial nerve as they wind around
abducens nerve nucleus)
b. Hypoglossal & Vagal triangles lie in medulla.
c. Vestibular area - lies partly in pons & partly in medulla..
Neurology | 205
Worksheet
• MCQ OF “NEUROLOGY” FROM DQB


 AfraTafreeh.com

206 | Anatomy
Peduncle Afferent fibres Efferent fibres
Inferior
Middle
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Superior
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(Active recall)
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208 | Anatomy
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7 General Anatomy
CONCEPTS
Â Concept 7.1 Bone

Â Concept 7.2 Ossification, epiphysis & Blood supply

Â Concept 7.3 Cartilage
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Â Concept 7.4 Joints

Â Concept 7.5 Epithelium

210 | Anatomy
Concept 7.1 : Bone

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Bone
• Bone is a special form of connective tissue & consists of cells, fibers and extracellular

matrix.
• The matrix is calcified because of the mineral deposition; as a result it can bear more

weight than the cartilage.

Functions:
• Forms a rigid skeleton and provides attachment to the muscles.
• Provides protection to the vital organs.
• Site of haemopoiesis.
• Serve as crucial reservoirs for calcium, phosphate and other minerals. 99% calcium
in the body is stored in bones
Ossification AfraTafreeh.com
The process of bone formation is known as ossification. It is of two types:
• ENDOCHONDRAL / CARTILAGENOUS (most of the long bones ossify by this methord)

• INTRAMEMBRANOUS eg. Skull vault, maxilla, mandible, clavicle.

Bone Matrix
• It has of both organic and inorganic components.

• It is calcified and highly vascularized.

• Organic components enable bones to resist tension whereas the inorganic components

enables bone to resist compression

Inorganic Components
• Calcium and phosphate in form of hydroxyapatite crystals

• The association between collagen fibers and hydroxyapatite crystals provides

hardness, durability and strength. Also the stored calcium and phosphate deposits in
the matrix can be mobilized by hormones to maintain proper mineral content in the
blood.
Organic Components
• Type-I collagen fibers
• Sulphated glycosaminoglycans
• Hyaluronic acid
• Osteopontin and osteocalcin-bind to calcium crystals during mineralization of bone
General Anatomy | 211
Bone Cells
Developing and adult bone contain four type of cells:
• Osteoprogenator cells

• Osteoblasts – bone forming cells.

• Osteocyte - derived from osteoblast.

• Osteoclasts – causes bone resorption. These are multinuclear giant cells formed by

fusion of mononuclear cells (monocytes & macrophages).

Compact Bone
Osteon (HARVESIAN SYSTEM) is the basic structural unit of compact bone.
Each osteon consists of layers of concentric layers/lamellae that are arranged around
the central harvesian canal. The lamellae are thin plates of bone that contain osteocytes
in almond shaped spaces known as lacunae.
Radiating from each lacunae in all directions are tiny canals called canaliculi.
These canaliculi penetrate the lamellae and anastomose with the canaliculi of other
lacunae and form communication channels between osteocytes.
Small irregular areas of bone between osteons are interstitial lamellae.
External circumferential lamellae form external wall of compact bone beneath the
connective tissue periosteum and parallel to each other and long axis of bone
The internal wall of the bone (endosteum along the marrow cavity) is lined by internal
circumferential lamellae
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The boundary between each osteon is outlined by modified bone matrix known as
COMPACT BONE (transverse

cement line
Anastomosis between central canals are called as perforating/VOLKMANN’S CANAL.
section)
Compact Bone low Low
(Transverse Section) magnification
Magnification
212 | Anatomy
Spongy / Cancellous Bone
• It consist of slender bone trabeculae that ramify, anastomose and enclose irregular

marrow cavities with blood vessels.

• Endosteum lines the bony trabeculae in marrow spaces.

CANCELLOUS BONE
• Osteoclast erode part of bone and become housed in the eroded depressions known
as Howship’s lacunae.
low
Cancellous Bone (Low magnification
Magnification)
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Concept 7.2 : Ossification, epiphysis & Blood supply

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Parts of a Long Bone.

1. Diaphysis - The part of bone which develops from Primary centre of ossification is

known as Diaphysis.
Eg . Shaft of a bone.
It is the longest & strongest part of bone.
2. Metaphysis – most vascular part, relatively weak (as it is composed of cancellous

bone) & more prone to osteomyelitis.

3. Epiphysis - The part of bone which develops from secondary centre of ossification is

called Epiphysis.
This is the growing end of bone.
Process involves proliferation & hypertrophy of chondrocytes, their calcification, vascular
invasion & erosion followed by osteogenesis.
Types of Epiphysis. AfraTafreeh.com
1. Pressure Epiphysis – Seen at the ends of long bones subjected to pressure. Eg –
head of humerus, femur, condyles of tibia, fibula.
2. Traction Epiphysis – Produced due to pull of the muscles. Eg – trochanters of femur,
tubercles of humerus, masoid process.
3. Atavastic Epiphysis - Functional in lower animals degenerated in humans. Eg.
Coracoid process of scapula, os trigonum of talus.
4. Abberent Epiphysis - It is an additional epiphysis. Eg. Proximal end of first
metacarpal bone.
The Primary centre of ossification - centre of ossification of Diaphysis. Occurs before
birth. That means the diaphysis of all bones are ossified at birth. Besides these the
centers for talus, calcaneus, cuboid, vertebral column, sternum & ribs also appear
before birth.
Secondary centers of ossification - centre of ossification of Epiphysis. appear after birth
except secondary centre for distal end of femur & proximal tibia appear during last week
of fetal life or at birth.
Blood Supply of a Long bone
a. Nutrient artery
b. Periosteal artery
c. Metaphyseal artery
d. Epiphyseal artery.
214 | Anatomy
Concept 7.3 : Cartilage

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Cartilage
The cartilage is a special type of connective tissue. It exhibits tensile strength, provides
firm structural support for soft tissues, allows flexibility without distortion and is resilient
to compression.
It is avascular, has no nerves & lymphatics.
It is surrounded by perichondrium.
Characteristics of Cartilage.
• Develops from mesenchyme & consists of cells, connective tissue fibers & ground

substance.
• Performs nutritive functions

• Cells includes chondrocytes & chondroblast.

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Hyaline Cartilage
• Commonly found in the body & serves as skeletal model for most of the bones.
• Replaced by bone during endochondral ossification.
• Contains Type 2 collagen fibrils.
• Eg. Articular cartilage, Arytenoid cartilage (lower part), thyroid & cricoid cartilage,
epiphyseal growth plate, costal cartilage, nasal cartilage, tracheal rings & bronchial
cartilage.
• Articular cartilage does not calcify, lacks the ability to repair & regenerate & lacks

perichondrium.
Elastic Cartilage.
• Contains chondrocytes along with elastic fibers.

• Perichondrium is present.

• Eg. Pinna, corniculate, cuneiform, apex of arytenoids, auditory tube & external

auditory meatus.
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Fibrocartilage
• Filled with dense bundles of type 1 collagen fibers, that alternate with cartilage matrix.
• Provides tensile strength, bears weight & resists compression.
• Perichondrium is absent.
• Eg. Intervertebral disc, pubic symphysis, menisci of knee joint, articular disc of TM
joint, radioulnar & sternoclavicular joints. Acetabular & glenoid labrum.
216 | Anatomy
Concept 7.4 : Joints
LEARNING OBJECTIVE :To understand boundaries and contents of Axilla with relations

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Structural Classification.
1. Fibrous Joint – the bones are united by fibrous connective tissue. These are further
classified as Sutures, Syndesmosis & Gomphosis.
Sutures – these are found in the skull. They are of the following types –
a. Plane – eg. intranasal & median palatine.
b. Serrate – eg. Saggital suture
c. Denticulate – eg. Lambdoid suture (parieto-occipital) & coronal (interparietal)
d. Squamous – eg. Tempero-parietal suture.
e. Schindylesis – eg. Junction of vomer & rostrum of sphenoid.
Syndesmosis – Adjacent bones are linked by connective tissue. Eg. Middle radioulnar,
middle tibiofibular joints, inferior tibiofibular joint, joint between adjacent laminae of
vertebrae, tympano-stapedial joint, posterior part of sacroiliac joint.
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Gomphosis – Restricted to teeth fitting in socket (peg & socket type of joints).
2. Cartilagenous Joints - In this the bones are joined by cartilage either hyaline or
fibrocartilage. They are of the following types –
Primary Cartilagenous / Synchondrosis - bones are joined by a plate of hyaline cartilage.
This plate is replaced by bone (Synostosis)
Eg – joint between epiphysis & diaphysis of bone, joint between basi occiput & basi
sphenoid, first chondrosternal joint, costochondral joints.
Secondary cartilaginous/Symphysis
The articular surfaces are covered by a thin layer of hyaline cartilage united by a disc of
fibrocartilage
Eg. Manubriosternal joint, intervertebral joint, pubic symphysis,
Synovial Joints - These joints posses a cavity, articular surfaces are covered by capsule,
articular surfaces are covered by hyaline cartilage except TM joint, Sternoclavicular &
acromioclavicular joints where it is covered by fibrocartilage.
Types
1. Hinge – eg. Elbow, interphalangeal & ankle joint

2. Pivot – Superior atlanto-occipital, radioulnar joint.

3. Condylar – knee, TM joint, metacarpophalangeal (structural)

4. Ellipsoidal – Wrist, metacarpophalangeal (functional)

5. Saddle – 1st carpometacarpel, sternoclavicular, calcaenocuboid, incudomalleolar joint.

6. Ball & socket – Hip, shoulder, talo-calcaeno-navicular, incudo-stapedial joint.

7. Plane – Intercarpel, intertarsel, intermetatarsel, intermetacarpel, cricothyroid,

cricoarytenoid, costovertebral, costotransverse, chondrosternal (except first) , sacroiliac.

Concept 7.5 : Epithelium

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Epithelium
The term epithelium / epithelial tissue is used for the sheet or the layer of cells that
covers the external surfaces of the body & internal lining of all body cavities.
It forms various organs and glands, and line their ducts
Epithelium is derived from three germ layers.
Ectoderm
Epidermis, glandular tissue of breast, cornea, junctional zone of buccal cavity and
junctional zone of anal canal.
Mesoderm
• Lining of internal cavities – Mesothelium

• Endothelium

• Proximal part of urogenital system

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Endoderm
• Internal Lining of alimentary canal and its glands.

• Most of the respiratory tract.

• Distal part of urogenital system

Functions of Epithelium
• It forms a selective barrier

• Protects underlying tissue from dehydration, chemical and mechanical damage.

• Secrete materials into spaces they line.

Structure of Epithelium
• Epithelium comprises of two parts: cellular and extracellular material.

• Cells are typically polygonal which is determined by their cytoplasmic contents and

partly by pressure from surrounding tissues.

• The basal surface of an epithelium is in contact with thin layer of proteoglycan and

filamentous protein termed as basal lamina.

• UNILAMINAR / SIMPLE EPITHELIUM: one cell thick layer resting on the basement

membrane.
• MULTILAMINAR EPITHELIUM : More than one cell thick layer

Unilaminar / Simple Epithelium

1. Simple squamous
Lining of alveoli

Renal corpuscle

218 | Anatomy
Thin segment of nephron (loop of Henle/Ansa nephron)

Inner ear

Endothelium of heart & blood vessels.

Mesothelium of serous cavity – peritoneum & plura.

2. Simple cuboidal
Thyroid follicle

Ovary

Lining of small ducts

PCT & DCT of kidney

3. Simple columnar
Mucosal lining of stomach, large intestine & cervical canal

Gall bladder.( columnar epithelium with brush border )

Uterus, fallopian tube, Eustachian tubes, tympanic cavity, central canal of spinal

cord & ventricles.

Pseudostratified Epithelium
• Trachea
• Bronchi
• Parts of male urethra
• Sensory epithelium of olfactory area
• Epididymis AfraTafreeh.com
Multilaminar Epithelium
A . Stratified Epithelium
1. Stratified squamous
2. Stratified cuboidal
3. Stratified columnar
Stratified Squamous Non-Keratinized Epithelium
• Buccal cavity
• Esophagus
• Vagina
• Cornea
• Conjunctiva.
• Inner surface of eyelids
• Vestibule of nasal cavity
Stratified Squamous Keratinised Epithelium
• Epidermis
• Mucocutaneous junction of lips
• Distal anal canal
• Outer surface of tympanic membrane
• Ducts of sebaceous glands.
Stratified Cuboidal/Columnar Epithelium
• Large ducts of pancreas

• Salivary glands

• Ducts of sweat glands

Stratified Columnar Epithelium

• Large ducts of glands.

B. Transitional Epithelium
This is a stratified epithelium, 4 – 6 layers. The superficial cells are umbrella shaped.
They have an extra reservoir of cell membrane.
▫ Renal pelvis

▫ Calyces

▫ Ureter

▫ Urinary bladder

▫ Proximal part of urethra

▫ Collecting duct of kidneys

Glands
These are specialized epithelial cells which produce secretions.Types –
1. Apocrine - the apex of gland is broken off. Eg – sweat gland.

2. Holocrine – the entire gland disintegrates. eg. sebaceous gland,

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Merocrine - secretions are released by exocytosis without loss of cellular components.

Eg - mammary gland
220 | Anatomy
Worksheet
• MCQ OF “GENERAL ANATOMY” FROM DQB


 AfraTafreeh.com

(Active recall)
Write the examples:-
Joints:
1. Hinge –
2. Pivot –
3. Condylar –
4. Ellipsoidal –
5. Saddle –
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6. Ball & socket –
7. Plane -
Cartilage:-
1. Hyaline
2. Elastic
3. Fibro
222 | Anatomy
Epiphysis:
1. Pressure –
2. Traction –
3. Atavistic –
4. Aberrant –
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8 General Embryology
CONCEPTS
Â Concept 8.1 Gametogenesis

Â Concept 8.2 Fertilization & Implantation

Â Concept 8.3 2nd week of development

Â Concept 8.4
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3rd week of development

Â Concept 8.5 Neurulation

Â Concept 8.6 Derivatives of germ layers

224 | Anatomy
Concept 8.1 : Gametogenesis

Time Needed
1 reading
st
15 mins
2 look
nd
10 mins
Gametogenesis
This includes Spermatogenesis & oogenesis
Spermatogenesis
a. Formation of spermatozoa from primitive germ cells.
b. Begins at puberty & continues throughout life.
c. An average of 74 days are required for a mature sperm to be formed.
d. Spermatogenesis occurs in the seminiferous tubules.
Stages of Spermatogenesis –
Spermatogonia (2n)
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Mitosis
Primary spermatocyte (2n)
Meiosis
Secondary spermatocyte (n)
Spermiogenesis
Spermatids
Spermiation
Sperms
General Embryology | 225
A mature sperm is 55 – 65 mm in length.
• Spermatozoa leaving the testes are not fully mobile.
• They acquire mobility during their passage through the epididymis.
• Further exposure to secretions in the female genital tract improve the mobility &
fertilizing ability of sperms (Capacitation).
• The capacitated sperm moves towards the ampulla where fertilization takes place.

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Oogenesis
a. Formation of Ova from primitive germ cells.
b. Oogenesis begins by 10th week of gestation
226 | Anatomy
Stages of Oogenesis
Primitive Germ Cell
Mitosis
Oogonia (2n)
Meiosis
Primary Oocyte (2n)
Primary oocyte enters into a prolonged Prophase (diplotene) of first meiotic

division & remains in this stage until puberty.
[Arrest is due to OMI (Oocyte Maturation Inhibitor), secreted by surrounding
follicular cells]
At Puberty : Meiosis is complete because of LH which is secreted approx. 37 hours
before ovulation AfraTafreeh.com
Primitive Oocyte
Mitosis
Secondary Oocyte (n) first polor body

• Secondary oocyte begins second meiotic division & remains suspended in metaphase.

• If fertilization occurs it forms mature ovum & second polar body.

Concept 8.2 : Fertilization & Implantation

Time Needed
1st reading 20 mins
2 look
nd
10 mins
Fertilization
• Fertilization, the process by which male and female gametes fuse, occurs in the

ampullary region of the uterine tube. This is the widest part of the tube and is close
to the ovary.
• Spermatozoa are not able to fertilize the oocyte immediately upon arrival in the

female genital tract but must undergo (1) capacitation and (2) the acrosome reaction
to acquire this capability.
• The phases of fertilization include

Phase 1, penetration of the corona radiata

Phase 2, penetration of the zona pellucida

Phase 3, fusion of the oocyte and sperm cell membranes

Stages of development before birth:

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1. Pre-embryonic period ( conception to Three weeks.)
Fertilized ovum or zygote undergoes mitosis. Formation of morula, appearance of
blastocyst. Blastula gets implanted and two layered germ disc is formed.
Teratogens usually cause loss of conceptus during this period
Two cell stage
approximately after 30 hours
Four cell stage
approximately after 40 hours
Twelve to sixteen cell stage( morula)
Approximately after 3 days
Blastocyst stage
Approximately after 4 days
Implantation starts
5 to 6 days of development.
Implantation is completed by 9-12 days.

2. Embryonic period 4th - 8th week.

3. Fetal Period Nine weeks to birth
Growth of all major structures that are already formed. Birth defect in this period are
usually not as severe or obvious
228 | Anatomy
Segment of the ovary at different stages of development. A. Oogonia are grouped in

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clusters in the cortical part of the ovary. Some show mitosis; others have differentiated
into primary oocytes and entered prophase of the fi rst meiotic division. B. Almost all
oogonia are transformed into primary oocytes in prophase of the first meiotic division.
C. There are no oogonia. Each primary oocyte is surrounded by a single layer of follicular
cells, forming the primordial follicle. Oocytes have entered the diplotene stage of
prophase, in which they remain until just before ovulation. Only then do they enter
metaphase of the first meiotic division
A. Vesicular (antral) stage follicle. The oocyte, surrounded by the zona pellucida, is off
center; the antrum has developed by fluid accumulation between intercellular spaces.
Note the arrangement of cells of the theca interna and the theca externa. B. Mature
vesicular (Graafian) follicle. The antrum has enlarged considerably, is fi lled with follicular
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fluid, and is surrounded by a stratifi ed layer of granulosa cells. The oocyte is embedded
in a mound of granulosa cells, the cumulus oophorus.
230 | Anatomy
Concept 8.3 : 2nd week of development

Time Needed
1st reading 10 mins
2 look
nd
5 mins
Second week of development

• At eight day of development blastocyst is partly embedded in endometrial stroma.

earlier the zygote divides to form a sixteen celled Morula. As the morula enters the
uterine cavity, uterine fluid enters the morula, dividing it into an Outer cell mass
(Trophoblast ) & Inner cell mass ( embryoblast ). A cavity is formed called Blastocyst.)
Further differentiation occurs as follows -

Trophoblast / Outer cell mass differentiates into
Inner layer of mononucleated cell Cytotrophoblast
Outer layer of multinucleated cell Syncytiotrophoblast
Embryoblast or inner cell mass
• It is differentiated in two layers
•

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A Layer adjacent to blastocyst cavity is known as hypoblast layer
• A layer of high columnar cell adjacent to hypoblast, is known as the
• epiblast layer
• These two layers are in contact and form bilaminar embryonic disc.
• At the same time a cavity develops in epiblast layer which is known as amniotic cavity
• Those epiblast cells adjacent to cytotrophoblast are known as amnioblast.
• Hypoblast cell proliferate and cover cytotrophoblast and form a membrane known
as Heuser’s membrane. A cavity is formed between hypoblast cells and heuser’s
membrane Primary yolk sac
• Yolk cells proliferate and comes to lie between cytotrophoblast and amniotic membrane
and heuser’s membrane and form extraembryonic mesoderm.
• Cavities are formed in extra-embryonc mesoderm known as extra-embryonic
cavity.
• These cavities unites to form extra-embryonic coelom or chorionic cavity.
• This space surrounds primitive yolk sac and amniotic cavity except where germ disc
is connected to trophblast by connecting stalk.
• Formation of extraembryonic coelom divides extraembyonic mesderm in two layers.
• Layer covering amnion and cyotrophoblast is known as somatopleuric mesoderm.
• Layer covering yolk sac is known as splanchnopleuric mesoderm.
• Cells of endometrium become polyhedral loaded with glycogen and lipids, intercellular
spaces are filled with extravasate Decidual reaction
• By 13th day uterine epithelium is reformed

• Cytotrophoblast starts proliferating and produce finger like projection (villous

structure) into syncytiotrophoblast primary villi.

• In the mean time, the hypoblast produce additional cells that migrate along inside of

exocoelomic membrane and form a new cavity inside exocoelomic cavity.

• This new cavity is known as secondary or definitive yolk sac.

• At the end of second week

syncytio-trophblast starts secreting Human
chorionic gonadotropin(HCG).
• Localized thickening of hypoblastic cells known as prechordal plate (future cephalic

region)
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232 | Anatomy
Concept 8.4 : 3rd week of development

Time Needed
1st reading 15 mins
2 look
nd
10 mins
Third week of development ( Gastrulation)

• Appearance of primitive streak

• Differentiation of three germ layer

• Development of notochord

Primitive streak :-
At the beginning of third week a thickened linear band of epiblast which is known
as primitive steak .
it appears caudally in the median plane of the dorsal aspect of the embryonic disc.
The primitive streak results from movement and proliferation of cells of epiblast
to the median plane
Streak elongates by addition of cells at its caudal end and its cranial end cells
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proliferate and form primitive node.
A pit develops in primitive node known as primitive pit.
As primitive steak is formed embroy’s cranio-caudal axis can be defined.
Gastrulation –formation of three germ layer

Cells of epiblast migrate in direction of primitive steak becomes flask shaped ,
detach from epiblast and slip beneath it.
This inward movement is known as invagination.
Some invaginated cell displace hypoblast and create embryonic endoderm.

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Some cell come to lie between epiblast (now embryonic ectoderm) and hypoblast
cell and form embryonic mesoderm.
The epiblast are replaced by ectoderm.
At this stage bilaminar germ disc is converted into trilaminar germ disc gastrula
(Gastrulation)
Formation of notochord
Notochordal process is formed by primitive streak. It extends from the primitive
node to the prochordal plate.
The blastopore extends into the process converting it into a notochordal canal.
The cells separating the notochordal process from hypoblast merge with each
other.
This layer then breaks off.
At this time the amniotic cavity communicates with the yolk sac (neuro-enteric
canal)
The walls of the canal become flat to form a plate called Notochordal Plate.
The plate becomes curved to form a tube.
A definitive notochord is formed.
Fate - It disappears, except – nucleus pulposus of intervertebral disc & apical
ligament of dens.
234 | Anatomy
AfraTafreeh.com
Concept 8.5 : Neurulation

Time Needed
1st reading 10 mins
2 look
nd
7 mins
Neurulation
• As notochord develops ,it induces the overlying embryonic ectoderm located at and

adjacent to the midline to form thickened epithelial cells, the neural plate.
• Now this ectoderm is known as neuroectoderm and give rise to CNS ---- brain and

spinal cord and other structure like retina

• On approx 18 day neural plate invaginates along its central axis to form a longitudinal

median groove neural groove

• Lateral margin of neural plate fold and form neural fold .

• By the end of third week neural fold begin to fuse at end, converting neural plate into

neural tube.
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236 | Anatomy
• Fusion of neural fold starts in the region of future neck and proceed in cephalic and

caudal direction
• Until fusion is complete, the cephalic and caudal end of neural tube communicates

through cranial and caudal neuropore.

• Cranial neuropore
Closes at 25th day of IUL
• Caudal neuropore
Closes at 28th day of IUL.
• Neural tube separates from surface ectoderm and surface ectoderm becomes a

continuous layer.
• When neural fold develops and fuses neuroectodermal cell at its margin or crest

begin to dissociate from others .this cell population is known as neural crest.
• These neural crest cell give rise to spinal and autonomic ganglion, parts of ganglion

of cranial nerve, Schwan cells, meninges, melanocyte, medulla of suprarenal gland,

bones and connective tissue of cranio-facial structure, cells of conotruncal septum
and endocardial cushion of heart.
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Concept 8.6 : Derivatives of germ layers

Time Needed
1st reading 20 mins
2 look
nd
15 mins
Derivatives of ectodermal layer

Surface Ectoderm -
• Epidermis including hair and nails

• Mucous membrane of oral cavity, nasal cavity, paranasal air sinuses, lower part of

anal canal, terminal part of urethra, lower part of vagina, labia majora & outer surface
of labia minora.
• Lens, epithelium of cornea, conjunctiva & lacrimal gland.

• Outer surface of tympanic membrane

• Exocrine glands (sweat, sebaceous, salivary, lacrimal, mammary) endocrine gland –

anterior pituitary.
• Enamel of teeth.

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• Ectodermal cleft (Pharyngeal clefts).

Neuroectoderm (neural tube & neural crest cells).

Derivatives of neural tube –

Brain & spinal cord, Astrocytes, Oligodendrocytes, ependymal cells, retina, pineal
gland, neurohypophysis, cranial & spinal motor nerves
Derivatives of Neural Crest Cells
a. Neural Derivatives –

Sensory neurons of 5th, 7th, 8th, 9th & 10th cranial nerve ganglia ( trigeminal,
geniculate, sphenopalatine, submandibular, cochlear, vestibular, otic & vagal
parasympathetic ganglia.

Sensory neurons of spinal dorsal root ganglia.

Sympathetic ganglia (aortic, renal, coelic, Auerbachs & Meisseners plexus in GIT)

Schwann cells of peripheral nerves & satellite cells of all ganglia.

Adrenal medulla, Chromaffin cells & parafollicular C cells of thyroid.

Melanoblast & melanocytes.
b. Mesenchymal Dreivatives

Bones of skull (frontal, parietal, temporal, nasal, palatine, maxilla & mandible)

Leptomenenges. (Pia – Arachnoid).

Odontoblast (dentine of teeth)

Eye – choroids, sclera, Iris epithelium, papillary muscles (sphinter & dialator),
ciliaris muscle.
238 | Anatomy
Pharyngeal arch cartilages
Retinal pigment epithelium
Connective tissue of head (dermis, tendons & ligaments)
Bulbar & conal ridges of heart.
Derivatives of mesodermal germ layer

1. Paraxial Mesoderm –
*Sclerotome – forms axial skeleton including vertebrae & parts of neurocranium.
• Myotome – voluntary muscles of head, trunk & limbs

• Dermotome – dermis of the skin over dorsal regions.

2. Intermediate Mesoderm –
• Urinary System – Kidneys, ureter, Trigone of bladder, posterior wall of female urethra,

posterior part of upper half of male urethra, inner glandular zone of prostate.
• Reproductive System – testes, epididymis, vas deferens, seminal vesicle, ejaculatory

duct, ovary, uterus, uterine tubes & upper part of vagina.

3. Lateral Plate mesoderm
a. Somatopleuric layer (Parietal)
All connective tissue, including specialized tissue like bone, cartilage, adipose
tissue,

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Dermis of skin over the ventrolateral body walls & limbs
Fascia (superficial & deep)
Tendon. Ligament & aponeurosis
Parietal pleura, parietal peritoneum & tunica vaginalis of testis
Lid & extraoccular muscles
Duramater
Sclera, choroids & vitreous
Corneal stroma, iris & ciliary body (except epithelium).
b. Splanchopleuric Layer –
Adrenal Cortex.
Smooth muscle & connective tissue of respiratory tract, GIT, blood vessels &heart.
Mesothelium of pleural, peritoneal & pericardial cavities.
Mesenchyme forming myocardium & serous pericardium
Spleen & lymph nodes.
c. Septum Transversum (diaphragm & fibrous pericardium)
d. Angiogenic Mesoderm – (endocardium of heart, endothelium of blood vessels &

lymphatics, Microglia & circulating blood cells.

Derivatives of endodermal germ layer
• Epithelial lining of gastrointestinal tract

• Epithelial lining of Respiratory tract

• Epithelial lining of Urinary System - Urinary bladder except trigone and female

urethra except posterior wall), male urethra except posterior wall of prostatic part
(mesodermal) & penile urethra underlying the Glans (ectodermal), part of vagina,
vestibule & inner surface of labia minora.
• Parenchyma of thyroid, parathyroid, liver, pancreas, glands in the wall of GIT &

prostrate (except inner glandular zone).

• Epithelial lining of tympanic cavity and auditory tube, mastoid antrum & mastoid air

cells,.
• Reticular tissue of thymus & tonsils.

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240 | Anatomy
Worksheet
• MCQ OF “GENERAL EMBRYOLOGY” FROM DQB


 AfraTafreeh.com

(Active recall)
1.Haploid no. of chromosomes is seen in –
2. Sperm acquires motility in –
3. In a female child at birth oocyte is in a stage of –
4. Muscular component of dorsal aorta develops from –
5. Auerbach plexus & Meissner’s ganglion are derived from –

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6. Phases of fertilization –
7. Remnants of notochord –
8. Capacitation takes place in –
9. Oropharyngeal teratoma arises from –
10. Functions of zona pellucida –

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Anatomy Concept Book Atf

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First Published 1999, Delhi Academy of Medical Sciences

© 2021 DAMS Publication AfraTafreeh.com

of the structures in continuity with Head ad neck region.

Contents of the axilla AfraTafreeh.com

• Brachial plexus and its branches

lateral thoracic, thoracodorsal, and circumflex humeral (anterior and posterior)

• Axillary tail (tail of Spence) is a superolateral extension of the mammary gland.

of upper trunk and - Suprascapular is vulnrerable to traction injuries.

2. Muscular branches to scalenii & longus colli - C5, C6, C7, C8

3. Dorsal scapular N. C5 (Nerve to Rhomboids)

4. Long thoracic N. C5 C6 C7 (Nerve to serratus anterior or Nerve of Bell)

From Erb’s Point of upper trunk

3. Medial cutaneous N. Of Forearm

4. Medial root of Median N.

• Traction injury to Erb’s point mainly involving C5 and C6 fibers

• Muscles paralysed include Deltoid, Biceps, Brachialis, Brachioradialis, supraspinatus,

Lower Plexus Injuries : Klumpke’s Paralysis or Klumpke Dejerine Paralysis

intrinsic muscles of Hand.

 Autonomic Signs : If the lesion of T1 root is more proximal then Horner’s

syndrome will occur

anatomy of shoulder joint.

Factors which protect the joint include :

(superiorly) Infraspinatus & Tere minor (posteriorly) and subscapularis (anteriorly)

prevents upward displacement.

continuity with the joint cavity.

sometimes communicates with the joint.

3. Adduction : Subscapularis, Teres major, Latissimus Dorsi, Pectoralis major

are active during overhead abduction (90 - 180°)

Dorsi, Teres major and subscapularis.

• Complete Tear of Rotator cuff (Torn supraspinatus) : inability to initiate

glenohumeral abduction (60 - 120°)

tuberosity of humerus and coracoacromial arch.

Muscles of the Pectoral Region

Mammary Gland (Breast)

and may shorten, resulting in retraction of skin and fixation of breast.

1. Perforating branches of internal mammary artery in II, III, IV intercostal spaces.

2. Thoracoacromial, lateral thoracic & superior thoracic branches of Axillary.

(a) Superficial lymphatics draining skin also and

Just beneath the areola is the Subareolar Plexus of Sappey.

mammary or Parasternal nodes. 5% goes to Posterior intercostal lymph nodes.

moreover lymphatics of one breast communicate with the lymphatics of

appearance of the skin - Peau d’ orange.

of cooper when cancer invades it.

Muscles of the Shoulder

Muscles of the Arm

Triangul ar depression in front of the elbow.

Muscles of the Anterior Forearm

Flexor carpi Medial epicondyle Bases of second Median Flexes foream,

Palmaris longus Medial epicondyle Flexor median Flexes foream and

Flexor digitorm Medial epicondyle, Middle phalanges Median Flexes proximal

Flexor pollicis Anterior surface Bases of distal Median Flexes thumb

Pronator quadrates Anterior surface of Anterior surface of Median Pronates foream

Brachioradialis Lateral supracondylar Base of radial styloid Radial Flexes forearm

Extensor carpi Lateral supracondylar Dorsum a base of Radial Extends and

Extensor Lateral epicondyle of Extensor expansion, Radial Extends and

Extensor digiti Common extensor Extensor expansion, Radial Extends little

Supinator Lateral epicondyle, Lateral side of supper Radial Supinates foream

Abductor pollicis Interosseous Lateral surface of base Radial Abducts thumb

Extensor pollicis Interosseous membrane Base of proximal Radial Extends proximal

Extensor indicis Posterior surface of Extensor expansion of Radial Extends index

structures passing through Carpal Tunnel

• Forms the carpal tunnel on the anterior aspect of the wrist.

Structures Passing through Carpal Tunnel :

Autonomic Signs : If the lesion of T1 root is more proximal then Horner’s