EMBRYOLOGY

Neural tube

Neural crest cells

Ectoderm

Mesoderm
Notochord
Endoderm

Para-axial
meso
Intermediate
meso

Lateral plate
meso
 ✓ Dermis of back
✓ Axial skeleton
✓ Skeletal muscles (except pharyngeal arches)

Para-axial meso Somites

Genital ducts (mesonephric &

Intermediate meso Urogenital system
paramesonephric ducts)

▪ Dermis of front & limbs

Somatopleuric LPM
▪ Appendicular skeleton
Lateral plate meso
▪ Smooth muscles
Splanchnopleuric LPM
▪ Cardiac muscles
▪ Brain & spinal cord
▪ Oligodendrocytes
▪ Astrocytes
▪ Ependymal cells
▪ Retina & pigment

Neural tube

Neural crest cells

▪ All ganglion
▪ Enteric plexus
▪ Schwann cells
▪ Adrenal medulla
▪ Parafollicular C cells
▪ Melanoblast/cyte
▪ Skull bones (most)
▪ Dentine
▪ Pharyngeal arch cartilage
Notochord ▪ Dermis of H&N
▪ Conotruncal septum
Remnants
• Nucleus pulposus
• Apical ligament of dens
• Tectorial membrane
 A- Body Wall mesoderm Muscular part

B- Dorsal mesentery of Oesophagus Crura

C- Septum transversum Central Tendon

D- Pleuroperitoneal membrane Incorporated by muscles

Failure of muscle tissue to develop inside

Eventration of Diaphragm
• Similar to CDH
• Not a True Hernia
Persistence of Pleuroperitoneal canal

Bochdalek foramen

Congenital Diaphragmatic Hernia

• Common on left side
• Complication→ left lung Hypoplasia
 POUCHES
CLEFT

ECTODERM MESODERM ENDODERM

 External auditory canal & outer layer of tympanic membrane

Obliterates

Persistence

Branchial cyst
 1st pouch – Inner layer of TM, tympanic cavity, auditory tube & mastoid antrum

2nd pouch- Palatine tonsil

3rd pouch- Thymus & inferior parathyroid gland

4th pouch- Superior parathyroid gland

Remnant of 5th pouch- Ultimobranchial body

Most common micro-deletion syndrome

DiGeorge syndrome (22q11 deletion syndrome)

Absent thymus & hypoparathyroidism

 Arch of Aorta Descending Aorta Brachiocephalic trunk

• Aortic Sac • Left dorsal aorta Right horn of AS

• Left horn of AS • Fused dorsal aorta
• Left 4th Arch artery
 Obliteration of right 4th arch artery

Persistence of caudal
part of right dorsal Abnormal right Subclavian arteries
aorta

Subclavian arteries

Right Left

Right 4th arch artery Left 7th cervical intersegmental artery

Right 7th cervical intersegmental artery
 CCA ICA

Proximal part of 3rd arch artery • Distal part of 3rd arch artery
• Cervical part of dorsal aorta
 Pulmonary artery Ductus arteriosus

• Proximal part of 6th arch artery Distal part of left 6th arch artery

Left RLN has a longer course than the right RLN. This is because it hooks
under the left sixth arch artery which persists in extra-uterine life as the
ductus arteriosus, a fibrous remnant. On the right side, neither the sixth
nor fifth arch arteries persist.
 Mesonephric duct (Wolffian duct)
Intermediate
mesoderm
Male Female
Posterior wall of urethra Posterior wall of urethra
(till EDs)
Ureteric bud & derivatives
Ureteric bud & derivatives
Trigone
Trigone
Remnant- GARTNER’S
Spermatic pathway DUCT (In broad ligament)

Appendix of epididymis

Paramesonephric duct (Wolffian duct)

Male Female

Appendix of testis Fallopian tube

Prostatic utricle Uterus
Upper vaginal wall
UPPER LIMB
 Pectoralis minor
Short hd of biceps
Coracobrachialis

0-15° Abduction

Supraspinatus
Infraspinatus
Teres minor

Adduction & ER

Lat to Med
M- Pectoralis major
L- Latissimus dorsi
M- Teres major

Adduction and IR Subscapularis

 Axillary nerve injury

Radial nerve injury

Median nerve (AIN injury)

Ulnar nerve injury

Tardy Ulnar nerve injury Cubitus valgus deformity

 Book test for ulnar nerve / Froment’s Sign
ULNAR NERVE
MEDIAN NERVE

Adductor Pollicis

Flexor digiti minimi Flexor pollicis brevis

Abductor digiti minimi
Abductor pollicis brevis

Opponens digiti minimi Opponens pollicis

Palmaris brevis
(subcutaneous)
 ULNAR NERVE MEDIAN NERVE

3rd Lumbrical 2nd Lumbrical

4th Lumbrical
1st Lumbrical
 PALMAR INTEROSSEI PAD DORSAL INTEROSSEI DAB ALL INTEROSSEI- ULNAR NERVE

• Unipennate • Bipennate
• Absent on middle finger • Absent on thumb & Little finger
• Thumb PI may not be present • Middle finger- 2nd & 3rd dorsal int.
• TEST- CARD Test • TEST- EGWA Test
 CLAVIPECTORAL FASCIA

Subclavius

Pectoralis Minor

Suspensory ligament of axilla

Structures Piercing the Clavipectoral Fascia :

1. Lateral pectoral nerve.
2. Thoraco-acromial artery.
3. Cephalic vein
4. Lymphatics
 C5

C6

C7

C8

T1

Musculocutaneous nv.

Radial nv.

Ulnar nv.
 Erb’s palsy

Upper trunk

C5, C6

Axillary nerve Musculocutaneous nerve

Deltoid Biceps

Adducted Extended elbow

shoulder Pronated forearm

Policeman’s tip hand

 Klumpke’s palsy

Lower trunk

C8, T1

Intrinsic muscles of hand

Hyperextension at MCP joints

Flexion at IP joints

CLAW HAND
 RADIAL NERVE (C5-T1)
• FLEXED ELBOW
• WRIST DROP
• FINGER DROP
• SEN LOSS
TRICEPS
• WEAK EXTENSION AT ELBOW
• WRIST DROP
• FINGER DROP TRICEPS
• SEN LOSS

ECRL • FINGER DROP

• SENSORY LOSS

SUPERFICIAL BRANCH POSTERIOR INTEROSSEOUS NERVE

• FINGER DROP
• NO SENSORY LOSS ON
OTHER EXTENSORS THE DORSUM OF HAND
 MEDIAN NERVE (C5-T1)
• APE THUMB DEFORMITY
• HAND OF BENEDICTION/POINTING
INDEX FINGER (WHILE MAKING FIST)

• WEAK OK SIGN

ANTERIOR INTEROSSEOUS NERVE

FDP (LATERAL PART)
FPL FDS

PALMAR CUTANEOUS BRANCH • APE THUMB DEFORMITY

• NO SENSORY LOSS ON PALM

THENARS + LAT 2 LUMBRICALS

(EXCEPT ADDUCTOR POLLICIS)
 LESS PROMINENT ULNAR NERVE (C7-T1)
ULNAR CLAW HAND

CUBITAL TUNNEL
FCU

FDP (MEDIAL HALF)

MORE
PROMINENT
CLAW HAND

DEEP BRANCH GUYON’S CANAL

SUPERFICIAL BRANCH PALMARIS BREVIS
ADDUCTOR POLLICIS
3RD & 4TH LUMBRICALS
INTEROSSEI HPYOTHENARS
LOWER LIMB
 Nerve vulnerable to
injury behind kidney
Subcostal nerve (T12)

Iliohypogastric & ilioinguinal nerve (L1)

Psoas major
Genitofemoral nerve (L1-L2)
Nerve vulnerable to
Iliacus
Lateral cut nerve of thigh (L2-L3) injury behind caecum
Femoral nerve (L2-L4)

Obturator nerve (L2-L4)

Closely related to ovary
✓ Afferent & Efferent limbs of cremasteric reflex
✓ Femoral branch - Anesthetized in femoral vein cannulation

Genitofemoral nerve (L1-L2)

Genital branch of GFN Cremasteric muscle

Femoral branch of GFN

Skin over
femoral
triangle
 Lateral cutaneous nerve of thigh (L2-L3)

compression

sensations of aching, burning, numbness, or

stabbing in the lateral thigh area.

Meralgia paresthetica
 ASIS- Inguinal ligament
Sartorius

AIIS- Rectus femoris

Flexion at hip joint

Gluteus minimus

IR and abduction at hip

Muscles of Perineum

P- Pudendal nerve
I- Internal pudendal vessels
N- Nerve to obturator internus

Ischial spine

Gluteus medius
IR & Abduction at hip

Iliopsoas Gluteus maximus (on gluteal tuberosity)

Flexion at hip joint Extension & ER at hip joint
 TFL

Gluteus maximus

Inserts on ITB

Iliotibial band Contracture in Polio

Modification of
Fascia Lata of thigh

Hip joint- F AB ER Knee joint- F ER

 FLOOR OF FEMORAL TRIANGLE
Iliacus

Psoas major

Pectineus

Adductor longus

SARTORIUS
Flexion, ER & Abduction at hip
Flexion at knee joint

RECTUS FEMORIS
Flexion at hip joint
Extension at knee joint
 FEMORAL NERVE
L2 L3 L4

Iliacus

Inguinal lig
Pectineus

PD AD
Hip joint Sartorius
Quadriceps Medial cut nerve of thigh
femoris Intermediate cut nerve of thigh
Great saphenous vein

Saphenous nerve

Skin of medial side of leg & foot

 Gluteus medius

Piriformis

Gemellus superior
Obturator internus
Gemellus inferior

Quadratus femoris
SUPERIOR GLUTEAL NERVE INJURY
 SCIATIC NERVE L4, L5, S1, S2, S3 TIBIAL NERVE injury
Deep to Piriformis
Plantar flexors
Major invertors
Hamstrings

Dorsiflexed & Everted foot

(Calcaneovalgus)
TIBIAL NERVE
Calcaneal gait

Neck of fibula

DPN
SPN CPN injury
(evertors)

PL Dorsiflexors Plantar flexors Dorsiflexors

Evertors
PB
Tibialis Tibialis posterior
(invertor) Foot drop & Inverted foot
anterior
(equinovarus)
(invertor)

High steppage gait

Skin of dorsum MPN LPN

of foot

Skin of 1st web space

Plantar calcaneonavicular ligament Supports Head of Talus

Spring ligament

Long and short plantar calcaneocuboid ligament

Supporting ligaments of Lateral longitudinal arch

 Combination with fractures
of the lateral malleolus

Injury
•Medial malleolus
•Navicular
•Calcaneus
•Talus

m/c involved in
Inversion injury
Calcaneonavicular ligament (CNL)

BIFURCATE
LIGAMENT

Calcaneocuboid ligament (CCL)

HEAD, NECK & FACE
 GSE SVE GVE GVA SVA GSA SSA
MIB BRAIN III EW
Mesencep
IV halic nu.

PONS V3 SSN
VI LN Principal
VII sensory V C
ISN
nu.
MEDULLA
IX Dorsal
XII X nu of X Spinal nu.
XI

NA NTS
 GSE SVE GVE GVA SVA GSA SSA
MIB BRAIN III EW
Mesencep
IV halic nu.

PONS V3 SSN
VI LN Principal
VII sensory V C
ISN
nu.
MEDULLA
IX Dorsal
XII X nu of X Spinal nu.
XI

NA NTS
Columns for III nerve- GSE and GVE

All Columns except first and last

VII, IX and X nerves

 GSA
TRIGEMINAL NUCLEI

Mesencephalic nu. Proprioception ✓ Centre for jaw reflex

✓ Only site for pseudo-unipolar neuron in CNS

Principal sensory nu. Touch & pressure

Spinal nu. Pain & temperature

 GVE
Ciliary Ganglion
EW nucleus
III nerve
Sphincter pupillae & Ciliaris muscles

Pterygopalatine Ganglion
GPN
Sup. Sal. Nu Lacrimal gland
VII nerve
Chorda tympani nv
Submandibular & sublingual gland
Submandibular Ganglion
Inf. Sal. Nu Otic Ganglion
IX nerve
Parotid gland

Dorsal nu of X

X nerve
Sm & glands of thorax and abdomen

Parasympathetic outflow- craniosacral outflow- III, VII,IX, X, S2, S3, S4

Sympathetic outflow- thoracolumbar outflow- T1 to L2 nerve
 RULE OF 17

X + VII XII + V

CONTRALATERAL DEVIATION IPSILATERAL DEVIATION

X nerve lesion XII nerve lesion

VII nerve lesion V nerve lesion

RLN – Tracheoesophageal groove

X nerve- Inside carotid sheath

Sympathetic chain- between carotid sheath and prevertebral fascia

Phrenic nerve- Ant to scalenus anterior & posterior to PVF

Cervical nerves/roots of brachial plexus- between Scalenus anterior and medius

 Buccopharyngeal fascia

Dysphagia & Dyspnea

Retropharyngeal space

Alar fascia Infection/abscess descends down

to posterior mediastinum

DANGER SPACE OF NECK Open below till diaphragm

Prevertebral fascia
 Carotid sheath
Ansa cervicalis

Contents
1. CCA
CCA IJV 2. ICA
3. IJV
X
4. X nerve

Sympathetic chain

Investing layer of Investing layer: Rule of 2

✓ 2 muscles: SCM & Trapezius
✓ 2 glands: Parotid & Submandibular
✓ 2 ligaments: Stylomandibular & Sphenomandibular
✓ 2 spaces: Suprasternal & Supraclavicular
Carotidocavernous fistula

Pulsatile proptosis
 ELEVATION

RETRACTION

ELEVATION

TEMPORALIS MASSETER

ELEVATION

PROTRACTION

DEPRESSION

MEDIAL PTERYGOID LATERAL PTERYGOID

Facial div Mastoid div
POSTERIOR TRIANGE OF NECK

Great auricular nerve • Root value: C2-C3

• Runs with EJV
• Supplies lobule of ear
• Supplies skin at angle of mandible & parotid region
• In Frey’s syndrome- ATN communicates to GAN
• Injured in parotid Sx- sensory loss in shaving area

• Runs between investing layer and prevertebral layer

• Injury in posterior triangle

SCM- spared Trapezius- affected

▪ Difficulty in shrugging of shoulder

▪ Difficulty in retraction of scapula
▪ Difficulty in overhead abduction
 FORAMEN LACERUM 1. Sphenoid bone
2. Apex of the petrous temporal bone
3. Basilar part of the occipital bone

Traversing structures Fills up

1. Meningeal branches of 1. ICA
ascending pharyngeal art. 2. Sympathetic plexus
2. Emissary veins 3. DPN
4. GPN

JUGULAR FORAMEN

IX, X, XI

Meningeal br of
Asc phy art &
occipital art.

Inferior
petrosal Sigmoid
sinus sinus
 Parietal bone Frontal bone

Pterion

Squamous portion of Greater wing of the sphenoid

the temporal bone
 Fractures in the region

Rupture of anterior division of the MMA

Extradural haemorrhage

Relations-
▪ Anterior division of the middle meningeal vessels
▪ Middle cerebral vessels
▪ Sylvain fissure
▪ Insula
▪ Broca's motor speech area (on the left)
II

III

IV

VI
VII & VIII

XII
IX, X, XI
NEUROANATOMY
UMN

LMN

LMN

LMN
 Crus cerebri

III
IV

V VI
VII
VIII
IX
X
XI

XII
 CRANIAL NERVE NUCLEI IN THE FLOOR OF IV VENTRICLE
SC VI, VIII, X & XII

IC
ABDUCENT NUCLEUS SURROUNDED
IV Facial colliculus BY LMN OF VII NERVE

Injury

LMNL of VII nerve

I/L facial paralysis

Vestibular area

XII trigone

X trigone
 Body of fornix
Choroid plexus

Anterior commissure
Lamina terminalis
Habenular commissure
III VENTRICLE
Pineal gland (epithalamus)
Posterior commissure
Aqueduct
Optic chiasma
Infundibulum
MB
Post perforating
substance
IV nerve

VII nerve
 Septum pellucidum

Corona radiata Body of Caudate nucleus

Fornix & Choroid plexus

Thalamus

Lentiform nucleus
 TERMINATION OF FORNIX

ORIGIN OF FORNIX
 Forceps minor
Insula

Caudate nucleus
Lentiform nu

Internal capsule Thalamus

Tapetum

Forceps major

Bulb of post horn of

lateral ventricle
 Forceps minor

Insula

Caudate nucleus
Lentiform nu
Internal capsule
Thalamus

Tapetum

Forceps major

Bulb of post horn of

lateral ventricle
 CEREBELLAR CORTEX

INHIBITORY

INHIBITORY

INHIBITORY

EXCITATORY
INHIBITORY

Mossy fibres Climbing fibres

Afferents

• Olivocerebellar & paraolivocerebellar tract are CLIMBING FIBRES

• Rest all are MOSST
 PURKINJE CELLS
EFFERENTS FROM CEREBELLUM

DEEP CEREBELLAR NUCLEI

ONLY EFFERENTS FROM CORTEX
(mainly Dentate nucleus)
 Cerebrum

Dentatothalamic and Dentorubrothalamic tract

VL nucleus (Thalamus) Ventral spinocerebellar tract

MB

PONS
Corticopontocerebellar tract
MO MCP-
• Largest peduncle
• Purely afferent
ABDOMINAL WALL

PERINEUM
Inguinal ligament

• Ligament of Poupart
• Modification of External oblique aponeurosis Linea alba

ASIS Ligament of Cooper

Pectineal ligament

Inguinal ligament
Reflected part of inguinal ligament

Pubic tubercle
Lacunar ligament
• Gimbernat’s Ligament
• Medial to femoral ring
 INTERNAL ILIAC ARTERY

Mnemonic- I Love Going Places Using My Very Unnamed Vehicle

1. Iliolumbar artery
2. Lateral sacral artery Posterior division
3. Gluteal artery Superior gluteal artery

Inferior gluteal artery

4. Pudendal artery
5. Umbilical artery
6. Middle rectal artery Superior vesicular artery Anterior division
7. Vesicular artery
8. Obturator artery Inferior vesicular artery
9. Uterine artery
10. Vaginal artery
 Pelvic Diaphragm

Modifications of Pubococcygeus
Levator ani

Pelvic diaphragm
1. Pubourethralis
Pubococcygeus
2. Pubovaginalis Iliococcygeus

3. Puborectalis Ischiococcygeus

Muscle of continence
Perineal membrane
Inferior layer of UGD Bulb/ bulbospongiosus

Crus/ Ischiocavernosus

Superficial transverse perineal muscle

Perineal body
External anal sphincter
 Perineal body
(10 muscles)

Paired muscles (4) Unpaired muscles (2)

1. Superficial transverse perineal muscle 1. External anal sphincter

2. Deep transverse perineal muscle 2. Longitudinal muscles of anal canal
3. Bulbospongiosus
4. Levator ani
 Pelvic diaphragm

Scarpa’s fascia Superior layer of UGD

DPP
Perineal membrane

SPP

Colle’s fascia

Dartos muscle
EXTRAVASATION OF URINE
ISCHIORECTAL FOSSA/ ISCHIOANAL FOSSA

Obturator internus
Obturator fascia

Ext anal sphincter

Pudendal canal

• Pudendal nerve
• Internal pudendal vessels
Contents of IRF
1. Fat
2. Pudendal canal and its contents
3. Inferior rectal nerves & vessels Can be injured in drainage of IRF infections