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Anatomy
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 1. The anatomical position, directional terms, axes and the planes of the body.

For descriptive purposes the body is always imagined to be in the anatomical position, standing
erect, arms by sides, palms of hands facing forwards. In this position directions are given by
superior, inferior, anterior, posterior. These are equivalent to the zoologist's cephalic, 7caudal,
ventral and dorsal. Thus the eyes are always superior to the mouth, even if the patient is lying
down or standing on his head. These terms are not quite equivalent to above, below, in front of
and behind. To a layman acrobats' feet are above her head when she is dangling from a trapeze:
to an anatomist they are inferior. Other dimensions are referred to the midline – median, medial
or lateral, or to their closeness to the body surface, superficial or deep. In the limbs structures
near the trunk are proximal, those further away are distal. We have a problem with the hands and
feet: the palms of the hands resemble the soles of the feet and the thumb is equivalent to the great
toe. But the palmar surface of the hand faces anteriorly and the back is dorsal. In the foot we
defy logic and call the inferior surface plantar (equivalent to palmar) and the superior surface
dorsal, even though it faces upwards. But we are still not out of the wood because the great toe is
medial but the thumb is lateral. To get around this the term preaxial is often used to describe the
thumb or great toe side. Postaxial is the little toe or little finger side. The axis referred to runs to
the tip of the middle finger or the second toe. The other small problem, the penis, is described in
its erect position, so that its dorsal surface faces anteriorly and superiorly when detumescent. We
also need to define planes, mutually at right angles. The horizontal plane is clear enough: the
other two are a little less so. The sagittal plane (L. sagitta, an arrow) probably refers to the
sagittal suture which runs from anterior to posterior in the newborn skull, and has an arrowhead
in the form of the frontal fontanelle. Coronal is also difficult since it means crown, and I always
think of a crown as being horizontal. But this is an older usage, as in the crown of an arch or a
tooth, or the road, meaning something more like a halo. Once again these refer to the anatomical
position.

2. Definition of the skeleton, the main functions of the skeleton.

Skeleton - a usually rigid supportive or protective structure or framework of an

organism; especially: the bony or more or less cartilaginous framework supporting the
soft tissues and protecting the internal organs of a vertebrate

3. Classification of bones. Development of the bones.

Long bones, as their name suggests, are considerably longer than they are wide. A long bone has
a shaft plus two ends which are often expanded. All limb bones except the patella (kneecap) and
the wrist and ankle bones are long bones. Notice that these bones are named for their elongated
shape, not their overall size. The three bones in each of your fingers are long bones, even though
they are small. Short bones are roughly cube shaped.

The bones of the wrist and ankle are examples. Sesamoid bones are a special type of short bone
that form in a tendon (for example, the patella). They vary in size and number in different

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individuals. Some sesamoid bones act to alter the direction of pull of a tendon. The function of
others is not known. Flat bones are thin, flattened, and usually a bit curved. The sternum
(breastbone),scapulae (shoulder blades), ribs, and most skull bones are flat bones. Irregular
bones have complicated shapes that fit none of the preceding classes. Examples include the
vertebrae and the hip bones.

4. Peculiarities of the cervical, thoracic and lumbar vertebrae.

Peculiarities of the III-VII Cervical Vertebrae

 Transverse process carry foramen transversarium.

 Spinous process is bifurcated.
 The transverse process has an anterior tubercle and a posterior tubercle, between them
we find a groove, the sulcus for the spinal nerve.
 Articular surfaces lay in horizontal plane.

1st Cervical Vertebra, the Atlas differs basically from the other vertebrae: It has not any
vertebral body. In the atlas we therefore describe a smaller anterior arch and a larger posterior
arch. Both arches have small protuberances: the anterior and posterior tubercles. Lateral to the
large vertebral foramen of the atlas lie the lateral masses, each of which have a superior and an
inferior articular facet. On the inner side of the anterior arch is the articular facet for the dens,
fovea dentis. From the foramen of the transverse process, which is located in the processus
transversus, a groove, the sulcus arteriae vertebralis, extends across the posterior arch for the
reception of the vertebral artery.

2nd Cervical Vertebra. The axis carries the dens or odontoid process. On the cranial surface of
the body the axis carries a tooth-like process, the dens axis, which ends by the apex dentis. The
surfaces of the dens have an anterior articular facet and the posterior articular facet. The anterior
tubercle of the 6th cervical vertebra can be very large and is designated as the carotid tubercle.
The 7th cervical vertebra has a particularly large spinous process, which is usually the highest
palpable spinous process of the vertebral column; it is therefore called the vertebra prominens.

Peculiarities of the Thoracic Vertebrae

 Laterally, the vertebral body usually has two costal facets, each of which is half of an
articular facet for articulation with the head of a rib.
 Transverse processes carry a costal facet for articulation with the costal tubercle.
 The spinous processes of the 1st through the 9th thoracic vertebrae overlap each other
like roof tiles.
 Articular surfaces lay in frontal plane.

The 1st thoracic vertebra has a complete articular facet at the cranial border of its body and a half
facet at the caudal border. The 10th vertebra has only a half articular facet, while the 11th has a

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complete articular facet at its cranial border. The 12th thoracic vertebra has the articular facet for
the head of the rib in the middle of the lateral surface of the body. There may be an accessory
process and a mamillary process each side.

Peculiarities of the Lumbar Vertebrae

 The bodies are much larger than those of the other vertebrae.
 The spinous process is flat and is directed sagittally.
 The flattened lateral processes of the lumbar vertebrae may be called costal processes,
and since they originate from rib aniagen.
 Articular surfaces of the articular process lay in sagittal plane.

5. The structure of the sacral bone and coccyx.

Sacrum is a collection of five fusedvertebrae. It is described as an upside down triangle, with the
apex pointing inferiorly. On the lateral walls of the sacrum are facets, for articulation with the
pelvis at the sacro-iliac joints.

The coccyx is a small bone, which articulates with the apex of the sacrum. It is recognised by its
lack of vertebral arches. Due to the lack of vertebral arches, there is no vertebral canal, and so
the coccyx does not transmit the spinal cord.

6. The vertebral column as a whole. Sections of vertebral column, curvatures.

The vertebral column (also known as the backbone or the spine), is a column of approximately
33 small bones, called vertebrae. The column runs from the cranium to the apex of the coccyx,
on the posterior aspect of the body. It contains and protects the spinal cord.

The most important functions of the vertebral column are as follows:

o Protection: it encloses the spinal cord, shielding it from damage.
o Support: it carries the weight of the body above the pelvis (below the pelvis, the
lower limbs take over).
o Axis: the vertebral column forms the central axis of the body.
o Movement: it has roles in both posture and movement.
o Kyphosis: Excessive thoracic curvature, causing a hunchback deformity.
o Lordosis: Excessive lumbar curvature, causing a swayback deformity.
o Scoliosis: A lateral curvature of the spine, usually of unknown cause

7. Classification of ribs. Structure of the I-XII ribs.

In each rib we distinguish a bony part, the os costale, and at the anterior end the costal cartilage.

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  There are twelve pairs of ribs, of which the upper seven are connected directly to the
sternum and are called true ribs.

 The lower five ribs, false ribs, are joined indirectly (8th-l0th) or not at all (11th-12th) to
the sternum.

 The 11th and 12th rib can be contrasted with the others as floating ribs.

Each rib has a head, neck and a body. The junction between the neck and the body is at the
tubercle. The head and the tubercle each have an articular facet. From the 2nd to the 10th rib, the
articular facet of the head is divided into two by the crest of the head of the rib. Lateral and
ventral to the tubercle is the angle of the rib. With the exception of the 1st, 11th and 12th, all ribs
have a costal sulcus on the lower surface. The 1st rib is small and flattened. On the inner
circumference of its cranial surface is an area of roughness, the scalene tubercle. Posterior to it
lies the sulcus of the subclavian artery, and in front of it is the sulcus of the subclavian vein. The
2nd rib has tuberosity for the serratus anterior muscle.

8. Structure of sternum.

The sternum consists of the manubrium sterni, the body and the xiphoid process. Between the
manubrium and the body lies the sterna angle. At the cranial end of the manubrium sterni is the
jugular notch and lateral to it on either side the clavicular notches. The sternum has costal
notches for a continuous cartilaginous joint with the I-VII ribs.

9. Neurocranium: parts, bones that form it, demonstrate on the preparation bones that form
the calvaria and of skull base.

The cranium (also known as the neurocranium), is formed by the superior aspect of the skull. It
encloses and protects the brain, meninges and cerebral vasculature. Anatomically, the cranium
can be subdivided into a roof (known as the calvarium), and a base:

o Calvarium: Comprised of the frontal, occipital and two parietal bones.

o Cranial base: Comprised of six bones – the frontal, sphenoid, ethmoid, occipital,
parietal and temporal bones. These bones are important as they provide an
articulation point for the 1st cervical vertebra (atlas), as well as the facial bones
and the mandible (jaw bone).

10. Occipital bone: parts, their structure.

Occipital bone consists of occipital squama, lateral and basilar parts. Squama is situated above
and behind the foramen magnum and possesses external occipital protuberance and external crest
on outer surface and it. Also there are the superior and inferior nuchal lines. The internal surface
is deeply concave and carries a crucial eminence. At the point of intersection of the four

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divisions of the crucial eminence and internal occipital protuberance. Right and left sides of them
is a deep groove, the superior sagittal sulcus, lower there is the internal occipital crest. Lateral
Parts (pars lateralis) are situated at the sides of the foramen magnum; on their under surfaces are
the condyles with and the hypoglossal canal. Behind either condyle is the condyloid fossa.
Laterally is the jugular process, excavated in front by the jugular notch. Basilar Part (pars
basilaris) extends forward and upward from the foramen magnum and form the back part of the
clivus. On its lower surface is the pharyngeal tubercle which gives attachment to the fibrous
raphe of the pharynx.

11. Frontal bone: parts, their structure.

The Frontal Bone (Os Frontale) consists of three portions – the squama, and an orbital and nasal
portions, which enters into the formation of the roofs of the orbital and nasal cavities. Squama in
the external surface has tuber frontale and the superciliary arches; are joined to one another by a
smooth elevation named the glabella. At the supraorbital margin is a notch, sometimes converted
into a foramen. The supraorbital margin ends laterally in the zygomatic process. Nasal part
presents the ethmoid notch and a sharp spine. In nasal part they can find aperture for frontal
sinus. The internal surface of the squama is concave and contains the superior sagittal sulcus and
the frontal crest. The crest ends below in a small notch which is converted into a foramen, the
foramen cecum. Orbital part presents the lacrimal gland fossa and the fovea trochlearis with
trochlear spine.

12. Parietal bone: surfaces, margins, angles. Identify the bones (right or left).

The Parietal Bone (Os Parietale) form, by their union, the sides and roof of the cranium. Each
bone is irregularly quadrilateral in form and has convex external (with tuber parietale) surface
and concave internal surfaces. Bone has four corners: frontal, sphenoid, mastoid and occipital;
and four margins. Near the sagittal margin are several depressions for the arachnoid granulation.

13. Ethmoid bone: parts, their structure.

Ethmoid bone (Os Ethmoidale) is situated at the anterior part of the base of the cranium, between
the two orbits, at the roof of the nose. It ñonsists of cribriform plate, a perpendicular plate,
constituting part of the nasal septum; and two lateral labyrinths. Cribiform Plate (lamina
cribrosa) is perforated by foramina carries the crista galli which borders the foramen coecum.
The Labyrinth (labyrinthus ethmoidalis) consists of a number of thinwalled cellular cavities, the
ethmoidal cells, arranged in three groups, anterior, middle, and posterior, and interposed between
two vertical plates of bone; the lateral plate forms part of the orbit – lamina frontalis. Medially
labyrinth has concha nasalis superior and concha nasalis media. There is superior nasal meatus
between them.

14. Sphenoid bone: parts, their structure.

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The Sphenoid Bone (Os Sphenoidale) is situated at the base of the skull and is divided into a
body, two great and two small wings and two pterygoid processes. Body (corpus sphenoidale)
contain the sphenoidal air sinuses. Superiorly there is chiasmatic groove and tuberculum sellae
forward from the sella turcica with the hypophiseal fossa and dorsum sellae. Behind the dorsum
sellae is the clivus. The anterior surface of the body (Fig. 146) presents the sphenoidal crestthat
continuis into rostrum. The Great Wings (alae major) have the cerebral surface with the foramen
rotundum, foramen ovale and foramen spinosum. Also they differ maxillar, temporal (with the
infratemporal crest) and orbital surfaces. The Small Wings (alae minor) arise from the upper and
anterior parts of the body. Between the two roots is the optic canal. Alae minor borders the
superior orbital fissure with alae major. Pterygoid Processes (processus pterygoidei) descend
perpendicularly from the regions where the body and great wings unite. Each process consists of
a medial and a lateral plate, the upper parts of which are fused anteriorly; a vertical sulcus, the
pterygopalatine groove. The plates are separated below by the pterygoid incisura. The two plates
diverge behind and enclose between them a V-shaped fossa, the pterygoid fossa. Pterygoid canal
is in base of process. The medial pterygoid plate has the pterygoid hamulus.

15. Temporal bone: parts, their structure.

The Temporal Bone (Os Temporale) is situated at the sides and base of the skull. Each consists
of the squama, the petrous (pyramid) with mastoid process and tympanic part. The squama has a
groove for the middle temporal artery and the temporal line. It is a long the zygomatic process.
The mandibular fossa is bounded, in front, by the articular tubercle. Pars petrosa [pyramis] has a
base and apex, and anterior, posterior and inferior surfaces, and three angles, and contains the of
the organ of hearing and balance. The base is fused with the internal surfaces of the squama and
mastoid portion. The anterior surface has eminentia arcuata, the tegmen tympani; hiatus and
sulcus canalis nervi petrosi majoris; laterally hiatus and sulcus canalis nervi petrosi minoris; near
the apex of the bone, the termination of the carotid canal (foramen internus); above this canal the
trigeminal impression. The posterior surface has the internal acoustic meatus, the aperture
externa aqueductus vestibuli, the subarcuate fossa. The inferior surface contain foramen
coroticum externus, the jugular fossa, a small opening of the aqueductus cochleae, the styloid
process and the stylomastoid foramen. Mastoid Process is perforated by the mastoid foramen and
carries the sigmoid sinus sulcus. A section of the mastoid process shows it to be hollowed out
into a number of spaces, the mastoid cells and mastoid antrum. Tympanic Part (pars tympanica)
forms the walls and the floor of the bony external acoustic meatus. It borders the
tympanomastoid fissure.

16. Canals of temporal bone: the facial canal, the carotid canal; musculo-tubarius canal;
tympanic and mastoid canaliculus.

Canals of the temporal bone:

1. Carotid canal starts in external carotid foramen on lower surface of the piramis and
finishes by internal opening in apex of the piramis.

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 2. Facial canal starts in internal acoustic meatus on back surface of the piramis and finishes
in stylomastoid foramen on lower surface of the piramis.
3. Musculotubarius canal is divided into semicanalis m. tensoris tympani and semicanalis
tubae auditivae. It starts on anterior margin of the piramis and leads to the tympanic
cavity.
4. Caroticotympanic canaliculi (paired) start on medial wall of the external carotid foramen
and lead to the the tympanic cavity.
5. Canaliculus for chorda tympani starts in facial canal, passes through the tympanic cavity
and finishes in petrotympanic fissura.
6. Tympanic canaliculus starts in the petrosal fossula and finishes in hiatus canalis nervi
petrosi minoris.
7. Mastoid canaliculus starts on the floor of the jugular fossa and passes to the
tympanomastoid fissura.

17. Facial skull: bones that form it.

Bones of viscerocranium include: maxilla, zygomatic, nasal, palatine, lacrimal bones, vomer,
greater portion of the ethmoid, mandible and inferior nasal concha.

18. Maxilla: parts, processes, structure.

Maxilla – paired bone, has a body and four processes: frontal, zygomatic, alveolar and palatine.
Frontal process riches the nasal part of the frontal bone, medially it carries ethmoidal crest for
middle nasal concha. Zygomatic process joins zygomatic bone. Alveolar process carries dental
alveoli for insertion the teeth. Palatine process forms bony palatine. There are four surfaces in
maxillary body: anterior, upper (orbital), medial (nasal) and back (infraorbital). Anterior surface
is bordered by infraorbital margin where it is infraorbital foramen. Nasal surface carries
maxillary hiatus that communicates nasal cavity with maxillary (Haymory) sinus.

19. Mandible: parts, their structure.

Mandible (unpaired) has a body and two rami. There is alveolar arch with teeth alveoli.
Mandibular angle is located between, body and rami and it carries masseteric and pterygoid
tuberosities for attachment of mastication muscles. Ramus contains coronal and condilar
processes. Mandibular canal starts on the inner surface of the ramus and terminates by mental
foramen in body. It contains vessels and nerves that supply teeth in the lower jaw. This is only
bone that form synovial joint.

20. Temporal fossa: boundaries, walls.

Temporal fossa formed by frontal squama, temporal squama, greater wings of sphenoid bone and
parietal bone. It bordered superiorly by inferior temporal line, inferiorly – infratemporal crest
and zygomatic arch. Temporal fossa contains temporal muscle.

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 21. Infratemporal fossa: boundaries, walls, communications.

Infratemporal fossa bordered anteriorly by tuber maxillae, superiorly – infratemporal srest,

medially it continues into pterygopalatine fossa. Anteriorly infraemporal fossa communicates
with orbit through inferior orbital fissura. Medially infraemporal fossa communicates with
pterygopalatine fossa by pterygomaxillar fissura.

22. Pterygopalatine fossa: borders, walls, communications;

Pterygopalatine fossa formed anteriorly by maxillary tuber, posteriorly by base of pterygoid

process of the sphenoid bone and mediall – by the perpendicular plate of the palatine bone.
Pterygopalatine fossa communicates with internal cranial base through foramen rotundum, with
orbit by inferior orbital fissura, with mouth cavity through greater and lesser palatine canals,
with external cranial base (foramen lacerum) through pterygoid canal, and it communicates with
nasal cavity through sphenopalatine foramen.

23. Orbit: boundaries, wall connections, communications.

Orbit has a superior, inferior, lateral and medial walls. Upper wall formed by frontal bone and
sphenoid lesser alae. Lower wall composed by maxilla, zygomatic and palatine bones. Lateral
wall formed by zygomatic bone and sphenoid greater alae. Medial wall consists of frontal
process of the maxilla, lacrimal bone, orbital plate of the ethmoidal bone and sphenoid body.
Orbit opens out that bordered supraorbital and infraorbital margins. Superior orbital fissure
positioned between upper and lateral walls, inferior orbital fissure – lower and lateral walls.
Laterally one can find fossa for lacrimal gland. Infraorbital sulcus and canal are on the lower
wall. Canal opens by infraorbital foramen in canine fossa on facial surface of the skull. Anterior
and posterior ethmoid foramen are on medial orbital wall. Orbit communicates with skull cavity
by the optic canals and nasal cavity – through nasolacrimal canal (on medial orbital wall).

24. Nasal cavity: boundaries, wall, communications.

Bony cavity of the nose opens forward by piriform aperture, backward connects nasopharynx
through choanae. Nasal cavity has a superior, inferior, lateral and medial walls and it is separated
by bony septum into right and left halves.

Lateral wall formed by:

 frontal process of the maxilla
 lacrimal bone
 ethmoidal labyrynthum
 perpendicular plate of the palatine bone
 medial plate of the pterygoid process (sphenoid bone).

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 Upper wall (roof) formed by frontal bone and cribriform plate (ethmoid bone). Lower wall
composed by bony palatine (palatine process of the maxilla and horizontal plate of the palatine
bone). Bony nasal septum consists of perpendicular plate (ethmoid bone) and vomer.

25. Nasal meatuses and their structure, communications.

 Superior nasal meatus passes between upper and middle nasal conchae (ethmoid bone)
and communicates with sphenoid sinus through sphenoethmoidal recess. Posterior
ethmoid cells open into superior nasal meatus.

 Middle nasal meatus runs between middle and lower nasal conchae and communicates
with frontal (through ethmoid infundibulum) and maxillary (Haymory) sinus (through
semilunar hiatus), and with anterior and middle ethmoid cells.

 Inferior nasal meatus passes between lower nasal concha and bony palate; nasolacrimal
canal and incisive canal open in it

26. Bony palate: structure.

The hard palate formed by palatine processes of the maxillae and the horizontal plates of the
palatine bones covered by mucous membrane, which contains small salivary glands. Posteriorly
the hard palate is continuous with the soft palate.

27. Anatomical formation of internal and external surface of the calvaria.

The 5 bones that make up the skull base are the ethmoid, sphenoid, occipital, paired frontal, and
paired temporal bones. The skull base can be subdivided into 3 regions: the anterior, middle, and
posterior cranial fossae. (See the image below.) The petro-occipital fissure subdivides the middle
cranial fossa into 1 central component and 2 lateral components. This article discusses each
region, with attention to the surrounding structures, nerves, vascular supply, and clinically
relevant surgical landmarks.

28. Anatomical formation of external surface of the of skull base.

The outer surface of the skull possesses a number of landmarks. The point at which the frontal
bone and the two parietal bones meet is known as "Bregma". The point at which the two parietal
and occipital bones meet is known as "Lambda". Not only do these landmarks indicate
the fontanelle in newborns, they also act as reference points in medicine and surgery.

29. Internal surface of the skull base: borders, structure, communication of anterior cranial fossa.

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30. Internal surface of the of skull base: borders, structure, communication of middle
cranial fossa. (zdjęcia poniżej są do zadania 30 i 31)

Bones
There are 5 bones that make up the Base of the skull -

 Ethmoid bone
 Sphenoid bone
 Occipital bone
 Frontal bone
 Temporal bone

Sinuses

 Occipital sinus
 Superior sagittal sinus
 Superior petrosal sinus

Foramina of the skull

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 Foramen cecum
 Optic foramen
 Foramen lacerum
 Foramen rotundum
 Foramen magnum
 Foramen ovale
 Jugular foramen
 Internal auditory meatus
 Mastoid foramen
 Sphenoidal emissary foramen
 Foramen spinosum

Sutures
 Frontoethmoidal suture
 Sphenofrontal suture
 Sphenopetrosal suture
 Sphenoethmoidal suture
 Petrosquamous suture
 Sphenosquamosal suture

The middle cranial fossa, deeper than the anterior cranial fossa, is narrow medially and widens
laterally to the sides of the skull. It is separated from the posterior fossa by the clivus and
the petrous crest.
It is bounded in front by the posterior margins of the lesser wings of the sphenoid bone,
the anterior clinoid processes, and the ridge forming the anterior margin of the chiasmatic
groove; behind, by the superior angles of the petrous portions of the temporal bones and
the dorsum sellæ; laterally by the temporal squamæ, sphenoidal angles of the parietals, and
greater wings of the sphenoid. It is traversed by the squamosal, sphenoparietal,
sphenosquamosal, and sphenopetrosal sutures.
It houses the temporal lobes of the brain and the pituitary gland

31. Internal surface of the of skull base: borders, structure, communication of posterior
cranial fossa.

The posterior cranial fossa is part of the cranial cavity, located between the foramen
magnum and tentorium cerebelli. It contains the brainstem and cerebellum.

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This is the most inferior of the fossae. It houses the cerebellum, medulla and pons. Anteriorly it
extends to the apex of the petrous temporal. Posteriorly it is enclosed by the occipital bone.
Laterally portions of the squamous temporal and mastoid part of the temporal bone form its
walls.

Foramen magnum
The most conspicuous, large opening in the floor of the fossa. It transmits the medulla, the
ascending portions of the spinal accessory nerve (XI), and the vertebral arteries.

Internal acoustic meatus

Lies in the anterior wall of the posterior cranial fossa. It transmits the facial (VII)
and vestibulocochlear (VIII) cranial nerves into a canal in the petrous temporal bone.
Jugular foramen
Lies between the inferior edge of the petrous temporal bone and the adjacent occipital bone and
transmits the internal jugular vein (actually begins here), the glossopharyngeal(IX),
the vagus (X) and the accessory (XI) nerves.

Anterior condylar (hypoglossal) canal

Lies at the anterolateral margins of the f. magnum and transmits the hypoglossal (XII) nerve.

Other
Also visible in the posterior cranial fossa are depressions caused by the venous sinuses returning
blood from the brain to the venous circulation: Right and left transverse sinuses which meet at
the confluence of sinuses (marked by the internal occipital protuberance).
The transverse sinuses pass horizontally from the most posterior point of the occiput.
Where the apex of the petrous temporal meets the squamous temporal, the transverse sinuses
lead into sigmoid (S-shaped) sinuses (one on each side).
These pass along the articulation between the posterior edge of the petrous temporal and the
anterior edge of the occipital bones to the jugular foramen where the sigmoid sinus becomes
the internal jugular vein.
Note that a superior petrosal sinus enters the junction of the transverse and sigmoid sinuses. Also
an inferior petrosal sinus enters the sigmoid sinus near the jugular foramen.
The posterior cranial fossa is formed in the endocranium, and holds the most basal parts of the
brain.

32. Parts, structure and classification of tubular bones.

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Red marrow in adult is situated in cells of spongy matter of flat and short bones, in epiphysis of
long tubular bones.
Yellow marrow is situated in diaphysis of long tubular bones
Tubular – Tubular bones may be further classified as either long (eg, bones of the limbs) or short
(eg, bones of the hands and feet, such as the phalanges, metacarpals, and metatarsals). Tubular
bones with a hollow shaft and two ends.

33. The bones of the pectoral girdle: clavicle and scapula. Parts, structure. Determine
bones that belong to the right or left side.

Bones of the upper limb

In the upper limb we distinguish the shoulder girdle and the free extremity.
The shoulder girdle is formed by the scapulae and the clavicles.
Clavicle

Clavicle is an S-shaped bone. Toward the sternum is the sternal end with the sternal articular
facet and toward the scapula the flat acromi end with acromial articular facet and between the
two lies the body of the clavicle. Near the sternal end, on the lower surface of the clavicle, is the
impression for the cosloclavicular ligament. The sulcus for the subclavian muscle lies on the
undersurface of the clavicular body. The prominent conoid tubercle lies near the acromial end
close to the trapezoid line.

Scapula is a flat, triangular bone. It has a medial margin, a lateral margin and a superior
margin, which are separated from each other by the superior and inferior angles and lateral
angle. The anterior or costal surface is flat and slightly concave (subscapular fossa). It
sometimes shows clear lines of muscle attachments. The dorsal surface is divided by the spine of
the scapula into a smaller supraspinous fossa and a larger infraspinous fossa. The spine rises
laterally to terminate in a flattened process, the acromion. Near the lateral end lies an oval
articular facet for articulation with the clavicle.

14
 The lateral angle bears the glenoid cavity with supraglenoid tubercle and the infraglenoid
tubercle. The neck of the scapula is adjacent to the glenoid cavity.

The coracoid process lies above the glenoid cavity. On the upper margin of the scapula, lies
the scapular notch.

34. Humerus: parts, their structure, determine bone that belongs to the right or left side.

Humerus articulates with the scapula and the radius and ulna. It consists of the body and
upper (proximal) and lower (distal) ends.

The proximal end is formed by the head of the humerus, adjoining the anatomic neck. Thehe
are the greater tubercle, and medially is the lesser tubercle. Between these tubercles begins the
intertubercular sulcus, which is bounded distally by the crests of the lesser and greater
tubercles. The surgical neck lies proximally on tha body of the humerus. In the middle of the
body lies laterally the deltoid tuberosity and sulcus for the radial nerve. The body may be
divided into an anteromedial surface with a medial border, and an anterotateral surface with a
lateral border , which becomes sharpened distally and is called the lateral supracondylar crisla.
The distal end of the humerus bears on its medial side the large medial epicondyle and on the
lateral side the smaller lateral epicondyle.

The trochiea and the capitulum of the humerus form the humeral condyles for articulation
with the bones of the forearm. The radial fossa lies proximal to the capitulum and proximal to
the trochlea is the somewhat larger coronoid fossa.

Medial to the trochlea there is a shallow groove, the sulcus for the ulnar nerve. On the
posterior surface above the trochlea is a deep pit, the olecranon fossa.

35. Radius: parts, their structure, determine bone that belongs to the right or left side.

The radius consists of a shaft and proximal and distal ends. At the proximal end is the head
of the radius with the fovea articularis, which is continuous with the articular circumference.
On the medial side of the transition between the neck of the radius and the shaft lias the radial
tuberosity. The shaft has a medially facing interosseous border, an anterior surface, and anterior
border, a lateral surface and a posterior border, which forms the boundary between the lateral
and the posterior surfaces. At the lower end of the radius lies the styloid process and medial to it
is the ulnar notch. The carpal articular surface faces distally.

36. Ulna: parts, their structure, determine bone that belongs to the right or left side.

The ulna has a shaft and proximal and distal ends. The proximal end bears a hook-like
process, the olecranon. Anteriorly the trochlear notch extends as far as the coronoid process ,

15
and laterally is the radial notch into which the articular circumference of the radius fits. At the
junction with the shaft lies the ulnar tuberosity. Laterally lies radial notch. The interosseous
border lies laterally. The anterior surface is separated from the medial surface by the anterior
border. The latter in turn is separated from the posterior surface by the posterior margin. In the
middle of the ulna, on its anterior surface, is the nutrient foramen . The articular circumference
is on the head of the ulna. At the distal end of the ulna is the small styloid process

37. Hand: divisions; carpal bones, metacarpal bones, phalanges of the hand.

Bones of the hand consist of carpus, metacarpus and digits.

The carpus consists of eight carpal bones arranged in two rows of four. In the proximal
rowfrom lateral to medial are the scaphoid, lunate, triquetrum and pisiform. In the distal row
from the lateral to the medial side are the trapezium, trapezoid, capitate and hamate.

The five metacarpals of the hand each have a head, a body and a base. On all of the there
are articular facets at one end (base) for articulation with the carpals and at the other (head) for
the phalanges.

Each digit consists of bones namely a proximal, a medial and a distal phalanx. The sole
exception is the thumb, which has only two phalanges. At the distal end halanx there is the
tuberosity of the distal phalanx.

38. Lower limb: its parts and bones that form them.

Bones of the lower limb

Bones of the lower limb consist of girdle and free limb.

Pelvic girdle contains hip bones.

The hip bone (os coxae) consists of three parts, the pubis, the ilium and the ischium which
synostose in the acetabular fossa, which is bordered by the limbus of the acetabulum and is
surrounded by the lunate articular surface. The acetabular notch opens the acetabulum
inferiorly and thus limits the obturator foramen.

The Ilium is divided into the body and the ala. The body forms part of the acetabulum and is
delimited internally by the arcuate line. Internally the iliac fossa is visible. Behind the iliac fossa
there is the sacropelvic surface with the iliac tuberosity and the auricular surface. The iliac crest
starts anteriorly at the superior anterior iliac spine and divides into the outer and inner lips and
an intermediate line. The iliac crest ends in the posterior superior iliac spine. Beneath the latter
lies the posterior inferioriliac spine, whilst anteriorly beneath the anterior superior iliac spine
lies the anterior inferior iliac spine. The inferior gluteal, anterior gluteal and posterior gluteat
lines on the gluteal surface.

16
The pubis consists of a body, a superior ramus and an inferior ramus. The two rami
border the obturator foramen anteriorly and inferiorly. Near to the superior end of the
medially orientated symphysial surface lies the pubic tubercle, from which the pubic crest
extends medially and the pubic pecten runs laterally toward the arcuate line of the ilium.
At the transition of the superior ramus of the pubis into the ilium, there is the elevation of
the iliopubic eminence. The obturator groove lies inferiorly in the superior ramus.

The Ischium is divided Into the body and the ramus of the ischium, which together
with the inferior ramus of the pubis forms the inferior border of the obturator foramen. The
ischium bears the ischiat spine, which separates the greater sciatic notch from the lesser
sciatic notch. The ischial tuber develops on the ramus of the ischium.

Free portion of the lower limb is divided into thigh, leg and foot. Thigh contains
Femur.

The femur is the largest long bone in the body and is divided into the shaft with the
neck, and proximal and distal ends. Dorsally in shaft is the linea aspera. The medial and
lateral lips of the linea aspera diverge proximally and distally, and the lateral lip ends in
the gluteat tuberosity.

The head of the femur with the fovea of the head, has an irregular border with the neck.
The transit from the neck to the shaft of the femur Is marked anteriorly by the
intertrochanteric line, and posteriorly by the intertrochanteric crest. Immediately below
the greater trochanter lies the trochanteric fossa. The lesser trochanter projects
posteriorly and medially.

The distal ends are formed by the medial and lateral condyles. They are joined on the
anterior surface by the patellar articular surface and they are separated posteriorly by the
intercondylar fossa . The latter is demarcated from the posterior surface of the shaft by the
mtercondylar line, which forms the base of a triangle popliteal surface, the sides of which
are formed by the divergent lips of the linea aspera.

The patella is the largest sesamoid bone of the human body. It is triangular in shape
with its base facing proximally and its top, the apex patellae facing distally.

Tibia is positioned medially in leg and fibula – laterally.

The tibia has a somewhat triangular shaft and proximal and distal ends. At the
proximal end lie the medial and lateral condyles. The proximal surface, the superior
articular facet is interrupted by the intercondytar eminence. This elevation is subdivided
into a medial and a lateral intercondylar tubercle. In front of and behind the eminence lie
the anterior and posterior intercondylar area. The three-sided shaft of the tibia has a
medial, lateral margins and sharp anterior margin, which proximally becomes the tibial
tuberosity and is flattened distally. Margins separate the medial, lateral and posterior

17
surfaces. Proximally on the posterior surface of the shaft of the tibia is a slightly
roughened area, the musclu solei line.

The distal end is prolonged medially to form the medial malleolus with its malleolar
articular surface. The malleolar groove runs along its posterior surface. The inferior
articular surface of the tibia, which lies on the lower surface of the distal end of the tibia,
articulates with the talus. On the lateral side, in the fibular notch, there is a syndesmotic
connection, i. e., a fibrous joint, with the fibula.

Fibula consists of two extremities and a shaft. The proximal end is the head of the
fibula with its articular facet and a small protuberance, the apex of the flbula head. The
shaft of the fibula is approximately triangular in its middle part and has three margins and
three surfaces. On the lateral surface of the distal end, which expands distalward, there is
the large, flat lateral malleolus with a facet for articulation with the talus on its inner
surface. Behind it there is a deep groove, the lateral malleolar fossa, to which the posterior
talofibular ligament is attached.

Bones of the foot are divided into tarsal, metatarsal and phalanx bones.

Tarsal bones are positioned in 2 groups: proximal and distal. Proximal group includes
talus, calcaneus. Distal group contains navicular, cuboid, lateral, intermedial and
medial cuneiform bones.

Metatarsal bones (five) each have a head, a body and a base. On all of the there are
articular facets at one end (base) for articulation with the tarsal and at the other (head) for
the phalanges.

The bones of the digits: Each digit consists of more than one bone. namely a proximal,
a medial and a distal phalanx. The sole exception is the halux, which has only two
phalanges. At the distal end of the distal phalanx there is a the tuberosity of the distal
phalanx.

39. Hip bone: parts, structure, determine bone that belongs to the right or left side.

The hip bone (os coxae) consists of three parts, the pubis, the ilium and the ischium
which synostose in the acetabular fossa, which is bordered by the limbus of the
acetabulum and is surrounded by the lunate articular surface. The acetabular notch opens
the acetabulum inferiorly and thus limits the obturator foramen.

40. Ilium: parts, structure, determine bone that belongs to the right or left side.

The Ilium is divided into the body and the ala. The body forms part of the acetabulum

18
and is delimited internally by the arcuate line. Internally the iliac fossa is visible. Behind
the iliac fossa there is the sacropelvic surface with the iliac tuberosity and the auricular
surface. The iliac crest starts anteriorly at the superior anterior iliac spine and divides into
the outer and inner lips and an intermediate line. The iliac crest ends in the posterior
superior iliac spine. Beneath the latter lies the posterior inferioriliac spine, whilst
anteriorly beneath the anterior superior iliac spine lies the anterior inferior iliac spine. The
inferior gluteal, anterior gluteal and posterior gluteat lines on the gluteal surface.

41. Pubic bone: parts, structure, determine bone that belongs to the right or left side.

The pubis consists of a body, a superior ramus and an inferior ramus. The two rami
border the obturator foramen anteriorly and inferiorly. Near to the superior end of the
medially orientated symphysial surface lies the pubic tubercle, from which the pubic crest
extends medially and the pubic pecten runs laterally toward the arcuate line of the ilium.
At the transition of the superior ramus of the pubis into the ilium, there is the elevation of
the iliopubic eminence. The obturator groove lies inferiorly in the superior ramus.

42. Ischium bone: parts, structure, determine bone that belongs to the right or left
side.

The Ischium is divided Into the body and the ramus of the ischium, which together
with the inferior ramus of the pubis forms the inferior border of the obturator foramen. The
ischium bears the ischiat spine, which separates the greater sciatic notch from the lesser
sciatic notch. The ischial tuber develops on the ramus of the ischium.

43. Pelvis as a whole: parts. Name and describe the main dimensions of the pelvis.

Hip and sacral bones that joined by sacroiliac joint and pubic symphisis form the
pelvis which has upper and lower portions. Upper portion is major pelvis, lower is minor
pelvis. Major pelvis separates from minor by terminal line that includes promontorium,
arcuate line in iliac bones, pubic crests and upper margin of the symphisis. Major pelvis
bordered posteiorly 5th lumbar vertebrae body, laterally – iliac alae. Minor pelvis formed
by pubic and ischial bones, it has upper orifice (entrance) and lower orifice (exit).
Obturator foramen closed by fibrous plate – obturator membrane. On lateral wall of the
minor pelvis found greater and lesser sciatic foramen, that bordered by sacrospinal and
sacrotuberal ligaments.

Major pelvis has a transverse size:

 spinarum distance (25-27 cm) between right and left superior anterior iliac spines;

 cristarum distance (28-29 cm) between widest points on right and left iliac crests;

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  trochanteric distance (30-32 cm) between greater trochanters of the femurs.

Minor pelvis has a size:

 straight size of the inlet (11 cm) between symphisis and promontorium;

 oblique size of the inlet (12 cm) between sacroiliac joint in one side and iliopubic
eminence other side;

 transverse size of the inlet (13 cm) between the widest points of the terminal lines;

 straight size of the outlet from (9 cm) between apex coccyges and lower margin of
the pubic symphisis;

 transverse size of the outlet (11 cm) between inner margins of the ischiadic tuber.

Straight size of the entrance to the minor pelvis in female named gynecological
conjugate. Generally female has lower and wider pelvic than in male, promontorium
extends forward not so much, therefore pelvic aperture more rounded. The sacral bone in
female is wider and shorter and angle between inferior pubic rami is much 90o.

In vertical position of the body upper pelvic aperture bent forward with angle to the
horizontal plane 55-60o in female and 50-55o in male.
Conducting axis of the lesser pelvis connects the middle points of all straight sizes.
Normally conducting axis is the way for occipital fontanelle of the fetus during birth.

44. Femur: parts, structure, determine bone that belongs to the right or left side.

The femur is the largest long bone in the body and is divided into the shaft with the
neck, and proximal and distal ends. Dorsally in shaft is the linea aspera. The medial and
lateral lips of the linea aspera diverge proximally and distally, and the lateral lip ends in
the gluteat tuberosity.

The head of the femur with the fovea of the head, has an irregular border with the neck.
The transit from the neck to the shaft of the femur Is marked anteriorly by the
intertrochanteric line, and posteriorly by the intertrochanteric crest. Immediately below
the greater trochanter lies the trochanteric fossa. The lesser trochanter projects
posteriorly and medially.

The distal ends are formed by the medial and lateral condyles. They are joined on the
anterior surface by the patellar articular surface and they are separated posteriorly by the

20
intercondylar fossa . The latter is demarcated from the posterior surface of the shaft by the
mtercondylar line, which forms the base of a triangle popliteal surface, the sides of which
are formed by the divergent lips of the linea aspera.

45. Tibia: parts, structure, determine bone that belongs to the right or left side.

Tibia is positioned medially in leg and fibula – laterally.

The tibia has a somewhat triangular shaft and proximal and distal ends. At the
proximal end lie the medial and lateral condyles. The proximal surface, the superior
articular facet is interrupted by the intercondytar eminence. This elevation is subdivided
into a medial and a lateral intercondylar tubercle. In front of and behind the eminence lie
the anterior and posterior intercondylar area. The three-sided shaft of the tibia has a
medial, lateral margins and sharp anterior margin, which proximally becomes the tibial
tuberosity and is flattened distally. Margins separate the medial, lateral and posterior
surfaces. Proximally on the posterior surface of the shaft of the tibia is a slightly
roughened area, the musclu solei line.

The distal end is prolonged medially to form the medial malleolus with its malleolar
articular surface. The malleolar groove runs along its posterior surface. The inferior
articular surface of the tibia, which lies on the lower surface of the distal end of the tibia,
articulates with the talus. On the lateral side, in the fibular notch, there is a syndesmotic
connection, i. e., a fibrous joint, with the fibula.

46. Fibula: parts, structure, determine bone that belongs to the right or left side.

Fibula consists of two extremities and a shaft. The proximal end is the head of the
fibula with its articular facet and a small protuberance, the apex of the flbula head. The
shaft of the fibula is approximately triangular in its middle part and has three margins and
three surfaces. On the lateral surface of the distal end, which expands distalward, there is
the large, flat lateral malleolus with a facet for articulation with the talus on its inner
surface. Behind it there is a deep groove, the lateral malleolar fossa, to which the posterior
talofibular ligament is attached.

21
47. Foot: divisions; tarsal bones, metatarsal bones, phalanges of the foot.

Bones of the foot are divided into tarsal, metatarsal and phalanx bones.

Tarsal bones are positioned in 2 groups: proximal and distal. Proximal group includes
talus, calcaneus. Distal group contains navicular, cuboid, lateral, intermedial and
medial cuneiform bones.

Metatarsal bones (five) each have a head, a body and a base. On all of the there are
articular facets at one end (base) for articulation with the tarsal and at the other (head) for
the phalanges.

The bones of the digits: Each digit consists of more than one bone. namely a proximal,
a medial and a distal phalanx. The sole exception is the halux, which has only two
phalanges. At the distal end of the distal phalanx there is a the tuberosity of the distal
phalanx.

48. Classification of joints (fibrous and synovial articulations).

22
49. Syndesmosis: definition, types, examples.

An immovable joint in which bones are joined by connective tissue (e.g. between the
fibula and tibia at the ankle)

50. Synchondroses: definition, examples.

An almost immovable joint between bones bound by a layer of cartilage, as in the spinal
vertebrae.

Examples are the synchondroses between the occipital and sphenoid bones, between the
sphenoid and ethmoid bones of the floor of the skull and sternocostal joint (where the first
rib meets the manubrium)

51. Synostosis: definition, examples.

Synostosis (plural: synostoses) is fusion of two bones. It can be normal in puberty, fusion
of the epiphysis, or abnormal. When synostosis is abnormal it is a type of dysostosis.

Examples of synostoses include:

 craniosynostosis – an abnormal fusion of two or more cranial bones;

 radioulnar synostosis – the abnormal fusion of the radius and ulna bones of the
forearm;

23
  tarsal coalition – a failure to separately form all seven bones of the tarsus (the hind
part of the foot) resulting in an amalgamation of two bones; and
 syndactyly – the abnormal fusion of neighboring digits.

52. Synovial joint: definition, basic components of joint.

A synovial joint, also known as diarthrosis, joins bones with a fibrous joint capsule that is
continuous with the periosteum of the joined bones, constitutes the outer boundary of a
synovial cavity, and surrounds the bones' articulating surfaces. The synovial (or joint)
cavity is filled with synovial fluid.

Obligatory structural elements of the synovial joints:

1. Articular surfaces, covered by hyaline cartilage.
2. Articular capsule.
3. Articular cavity.
4. Synovia.

53. Additional components of synovial joints.

Additional structures of the joints: ligaments, bursae, plicae, disks,

meniscus, articular labium.

24
The structures of the synovial joint that allow it to move freely
The bones of a synovial joint are surrounded by a synovial capsule, which secretes
synovial fluid to lubricate and nourish the joint while acting as a shock absorber.
The ends of the joint bones are covered with smooth, glass-like hyaline cartilage which
reduces friction during movement.
A synovial joint contains a synovial cavity and dense, irregular connective tissue that
forms the articular capsule normally associated with accessory ligaments.

54. Anatomical classification of joints: simple and complex joints, compound,

combined, complex joints (definitions and examples).

According to the structure articulations are divided into:

1. simple joint – has only two articular surfaces; e.g. shoulder and hip joint.
2. compound joint – has more than two articular surfaces; e.g. radiocarpal joint.
3. combined joint – some joints that move only together in the same
time; e.g.
4. complex joint – has disks, meniscus or ligament that divide
articular cavity into two floors (Upper and Lower) e.g. knee joint.

55. Name the major axis and the movements that occur in the joint around these axes.
Classification of joints by the number of movements.

The major axis:

1.Uniaxial. movements: flexion&extension and rotation

2.Biaxial. movements: : flexion&extension(forward and backward) and

abduction&adduction

3.Multiaxial. movements: flexion&extension, adduction&abduction,medial

rotation&Lateral rotation, circumduction

25
56. Uniaxial joints: definition, types of uniaxial joint by the shape of joint surfaces,
possible movements.

Some joints allow movement in only one plane.

 Hinge: movements: flexion&extension; example: elbow join, knee joint, ankle

joint, intraphalangeal joint.

 Pivot: movements: rotation; example: radio-ulnar joint,.

 Spiral: Atlanto-axial joint

57. Biaxial joints: definition, types of biaxial joints by the shape of the articular
surfaces, possible movements.

Biaxial joints allow movements in two planes.

 Saddle joint: movement: flexion&extension(forward and backward) and

abduction&adduction(from side to side). Example: carpometacarpal joint of
the thumb.

58. Multiaxial joints: definition, types of multiaxial joints by the shape of the articular
surfaces, possible movements.

Multiaxial joint=ball and socket joint. All movement is possible in this type of joint.
Movement: flexion&extension, adduction&abduction,medial rotation&Lateral rotation,
circumduction. Examples: Hip joint and Shoulder joint.

26
59. Name the types of joints of the vertebral column. Articulations of vertebral
bodies: classification, structure of the intervertebral disc, function and significance;
ligaments that strengthen the articulation between the vertebral bodies.
1) intervertebral discs
-classification
1)normal
2)desiccation (replacement of the hydrophilic glycosaminoglycans within the
nucleus polposus with fibrocartilage)
3)annular fissure (defect allows an ingrowth of nerve endings and granulation
tissue)
4)disc bulge (annular tissue projects beyond the margins of the adjacent vertebral
bodies)
5)herniation (displacement of intervertebral disc material beyond the normal
confines of the disc)
6)pseudodisc of anterolisthesis (deformity of annular fibres)
- function
*provide the strongest attachment between the bodies of the vertebrae
*provides the surface for the shock-absorbing gel of the nucleus pulposus
-structure
*consist of an outer fibrous ring, which surrounds an inner gel-like center, the
nucleus pulposus
*anulus fibrosus consists of several layers (laminae) of fibrocartilage made up of
both type I and type II collagen
*intervertebral disc contains the nucleus pulposus
*nucleus pulposus contains loose fibers suspended in a mucoprotein gel
-significance
*acts as shock absorber between each of the vertebrae in the spinal column by
keeping the vertebrae separated when there is impact from activity
*serve to protect the nerves that run down the middle of the spine and intervertebral
disks
-ligaments
*the anterior longitudinal ligament and the posterior longitudinal ligament (run the
entire length of the spinal column; the anterior longitudinal ligament attaches to the front
of the vertebral bodies and the posterior longitudinal ligament to the back; they suport
intervertebral disc)
*ligamentum flavum (extend from one vertebral lamina to the next inside the
vertebral canal; they form the roof of the canal in the gaps between the boney vertebrae)
*supraspinal ligament and interspinal ligaments (extend from one vertebral spine to
the next; in the cervical region the supraspinal ligament becomes the ligamentum nuchae)

60. Name the types of joints of the vertebral column. Joints between the processes and
arcs of

INTERVERTEBRAL JOINTS ( ZYGAPOPHYSIALES)

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Classification :
a) shape: plane
b) type: combined,
c) function: 3 axises- frontal, sagittal, vertical

Structure:
- f.a. Processus art. Vertebra superior
- f.a. Processus art. Vertebra inferior

Movements: limited

Ligaments:
-yellow ligaments
-intertransversal ligaments
-interspinal ligaments
-supraspinal ligament
-nucha ligaments
- anterior and posterior longitudinal ligaments

61. Joints between the sacrum and coccyx: classification, structure, ligaments of
sacro-coccygeal joint.

Classification : amphiarthrodial joint

Structure:
- oval surface at the apex of the sacrum
- base of the coccyx

Ligaments:
- Anterior sacrococcygeal ligament
- posterior sacrococcygeal ligaments (superficial and deep parts)
- Lateral sacrococcygeal ligament
- Interposed Fibrocartilage.
- Interarticular

62. Atlantooccipital joint: classification, structure, movements, ligaments.

Classification :
a) shape: condyloid
b) type: combined,
c) function: 2 axises- frontal, sagittal

Structure:
- condili occipitales

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 - fovea art. superior atlantis

Movements: bending forward, backward and laterally

Ligaments:
- membrana a.-o. anterior
- membrana a.-o. posterior

63. Joints between I and II cervical vertebrae: classification, structure, movements

and ligaments.

ATLANTOAXIAL JOINT
Classification :
a) shape: 1) cylindrical 2) plane
b) type: combined,
c) function: 1 axis- vertical

Structure:
- fov. Dentis atlantis
- facies art. anterior dentis
- facies art. posterior dentis
- fov. art. inferior atlantis
- fov. art. superior axis
- lig. transversum atlantis

Movements: rotation right and left

Ligaments:
- lig. transversum atlantis
- lig. cruciformis atlantis
- lig. apicis dentis
- lig. alaria
- lig. flava
- membrana tectoria
64. Joints between the ribs and sternum: classification, their structure, movements
and ligaments.

STERNOCOSTAL JOINTS
Classification :
a) shape: plane
b) type: simple 1st rib- synchondrosis, 2nd complex
c) function: 3 axises (multiaxial)- vertical, frontal, sagittal

Structure:

29
- facies art. Incisurae
- costalis sterni
- extremitas sternalis
- cartilagini costalis

Movements: limited

Ligaments:
- ligament sternocostalis intraarticualiris- in 2nd rib
- ligament sternocostalis radiatum
Together create membrana sterni ( sternal membrane)

65. Joints between the ribs and vertebrae: types, their structure, classification,
movements and ligaments.

JOINT OF HEAD OF RIBS

Classification :
a) shape: ball(spherical)
b) type: combined, compound, complex
c) function: 3 axises- sagittal

Structure:
- facies articularis capitis costae
- facies articularis fovea costalis superior and inferior

Movements: lifting and descending of ribs

Ligaments:
- ligament capitis costae intraarticulare
- ligament capitis costae radiatum

COSTOTRANSVERSE JOINT
Classification :
a) shape: cylindrical
b) type: combined
c) function: 1 axis- frontal

Structure:
- facies art. tuberculi costae
- facies art. foveae costalis transversalis

Movements: lifting and descending of ribs

Ligaments: ligamenta costotransversaria

30
Joints are combined- they work together during exhalation and inhalation.

66. Classification of the articulations of the skull: fibrous, cartilaginous and synovial
joints.

1) Fibrus articulations ( SYNARTHROSIS (SYNDESMOSIS))

>SUTURA
- connect continuous externally with pericardium and internally with dura matter
- bones are bound together by Sharpey's fibres.
- a tiny amount of movement
- contributes to compliance and elasticity of skull
- the main sutures of the skull are the coronal, sagittal, lambdoid and squamosal sutures
a) plane suture
- located in palatine
- connect edges of bones, when are straight and lie together
b) squamous suture
- between squamous part of temporal bone and parietal bone
- oblique to edges of bone, when bone are overlapping
c) serrate suture
- the most occur ( ex. Suture saggitalis, lambdoidalis)
- are branched and dentate

>GOMPHOSIS (SYNDESMOSIS)
- in this way are located teeth in alveolus (peridontal ligament)

>Fontanels– 67 zadanie

2) Cartilaginous articulations
-not ossified cartilage skull base residues remain after birth as synchondrosis in places
where bone to unite
-in the original tissue is transformed from hyaline to age in the fibrous cartilage
examples:
- petrooccipital synchondrosis – pyramid of temporal bone connects with
base part of occipital bone
- sphenopetrosal synchondrosis – pyramid of temporal bone connects with
spine of sphenoid bone and body of sphenoid
bone
- sphenooccipital synchondrosis – body of sphenoid bone connects with
base part of occipital bone
- 2x intraoccipital anterior and 2x intraoccipital posterior – between four
parts of occipital
bone

31
3) Synovial joint
- mandible is only suspended movably on skull (temporomandibular joint) – 68 zadanie

67. Fontanels of the skull: structure, functional value, period of ossification.

Functional value
- allow for rapid stretching and deformation of the neurocranium as the brain
expands faster than the surrounding bone can grow;
- during birth, fontanelles enable the bony plates of the skull to flex, allowing the
child's head to pass through the birth canal;

Structure
- soft membranous gaps between cranial bones that make up calvaria,
- occur in fetus and infant
- 6 fontanels
a) unpair (2): ( membranous, fibrous nature)
+ anterior – it lies at the cross of the sagittal, coronal and frontal sutures
+ posterior – it lies at the cross of sagittal and lambdoid sutures
b) pair
+ anteriolateral sphenoidal – it lies at cross of parietal, sphenoid, temporal
and frontal bones; membranous and
fibrous nature
+ posteriolateral mastoid – it lies at cross of parietal, occipital and temporal
bones; closed by hyaline cartilaginous layer

Period of ossification
1) The posterior fontanelle generally closes 2 to 3 months after birth;
2) The sphenoidal fontanelle is the next to close around 6 months after birth;
3) The mastoid fontanelle closes next from 6 to 18 months after birth;
4)The anterior fontanelle is generally the last to close between 18-24 months.

68. Temporomandibular joint: structure, classification, movements and ligaments.

Blood supply and innervation of the temporomandibular joint

CLASSIFICATION:
- SHAPE: condyloid
- TYPE: combined
- FUNCTION: 3 axises (multiaxial) – vertical, frontal, sagittal

STRUCTURE:
- f.a. fossae mandibularis ossis temporalis,
- f.a. capitis mandibulae

MOVEMENTS:

32
 - Lifting-descending,
- forward-backward,
- right-left

LIGAMENTS:
- Lateral ligament,
- stylomandibular ligament

The arterial supply is provided by the branches of the external carotid, principally the
superficial temporal branch. Other contributing branches include the deep auricular,
ascending pharyngeal and maxillary arteries.
The TMJ is innervated by the auriculotemporal and masseteric branches of the mandibular
nerve (CN V3)

69. Sternoclavicular joint: articular surfaces, classification, movements, ligaments,

additional components. Blood supply and innervation the joints of the pectoral
girdle.

CLASSIFICATION
- SHAPE: ball(spherical)
- TYPE: simple(complex)
- FUNCTION: 3 axises (multiaxial)- vertical, frontal, sagittal

STRUCTURE
- Articular surface of clavicular notch of sternum and sternal extremity of clavicule

MOVEMENTS
- Lifting and descending,
- forward-backward,
- rotation

LIGAMENTS
- Anterior sternoclavicular ligament
- posterior sternoclavicular ligament
- interclavicular ligament
- costoclavicular lig.

Inside joint is articular disk, which divides articular cavity into 2 parts.

Arterial supply to the sternoclavicular joint is from the internal thoracic artery and the
suprascapular artery.

The joint is supplied by the medial supraclavicular nerve (C3 and C4) and the nerve to
subclavius (C5 and C6).

33
70. Acromioclavicular joint: articular surfaces, classification, movements, ligaments,
additional components. Blood supply and innervation the joints of the pectoral
girdle.

CLASSIFICATION
SHAPE: plane
TYPE: Simple (1/3 complex)
FUNCTION: 3 axises (multiaxial)-vertical frontal sagittal

STRUCTURE
- Articular surface of acromion and articular surface acromion extremity of
clavicule

MOVEMENTS
- Lifting descending

LIGAMENTS
-Acromioclavicular lig.
- Trapezoid lig+conoid lig =coracoclavicular lig
Vessels
The arterial supply to the joint is via two vessels:
Suprascapular artery– arises from the subclavian artery at the thyrocervical trunk.
Thoraco-acromial artery– arises from the axillary artery.
The veins of the joint follow the major arteries.

Nerves
The acromioclavicular joint is innervated by articular branches of the suprascapular and
lateral pectoral nerves. They both arise directly from the brachial plexus.

71. Shoulder joint: articular surfaces, classification, movements, ligaments, additional

components. Blood supply and innervation the shoulder joint.

CLASSIFICATION
SHAPE: Ball (spherical)
TYPE: simple
FUNCTION: 3 axises (multiaxial)-vertical, frontal sagittal

STRUCTURE
- Articular surface of head of humerus and articular surface glenoid cavity of
scapula

MOVEMENTS
- Flexion extension

34
 - abduction adduction
- rotation

LIGAMENTS
- Coracohumeral lig.

Arterial supply is via the anterior and posterior circumflex humeral arteries, and
thesuprascapular artery. Branches from these arteries form an anastomotic network around
the joint.

The joint is supplied by the axillary, suprascapular and lateral pectoral nerves. These
nerves are derived from roots C5 and C6 of the brachial plexus. Thus, an upper brachial
plexus injury (Erb’s palsy) will affect shoulder joint function

72. Elbow joint: articular surfaces, classification, movements, ligaments. Blood

supply and innervation the elbow joint.

HUMERORADIAL JOINT, HUMEROULNAR JOINT, RADIOULNAR PROXIMAL

JOINT

CLASSIFICATION
SHAPE: hinge
TYPE: compound
FUNCTION: 1 axis-frontal (1,2-frontal 3-vertical)

STRUCTURE
- Articular surface trochlea of humerus
- articular surface head of humerus;
- articular surface trochlear notch of ulna
- articular surface articular facet of head of radius
- articular surface articular circuit
- articular surface radial notch of ulna

MOVEMENTS
- Flexion extension

LIGAMENTS
- Ulnarcolateral lig.
- Radialcolateral lig.
- Quadratum lig.
- Annular lig of radius

Additional:
A bursa is a membranous sac filled with synovial fluid. It acts to cushion the moving parts

35
of a joint, preventing degenerative damage. There are many bursae in the elbow, but only a
few have clinical importance:
Intratendinosus –located within the tendon of the triceps brachii.
Subtendinosus –between the olecranon and the tendon of the triceps brachii, reducing
friction between the two structures during extension and flexion of the arm.
Subcutaneous –between the olecranon and the overlying connective tissue.

Innervation:
The elbow is innervated anteriorly by branches from the musculocutaneous,median, and
radial nerve, and posteriorly from the ulnar nerve and the branch of the radial nerve to
anconeus

Blood supply:
The arteries supplying the joint are derived from an extensive circulatory
anastomosis between the brachial artery and its terminal branches.
The superior and inferior ulnar collateral branches of the brachial artery and
the radial and middle collateral branches of the profunda brachii artery descend from above
to reconnect on the joint capsule, where they also connect with the anterior and posterior
ulnar recurrent branches of the ulnar artery; the radial recurrent branch of the radial artery;
and the interosseous recurrent branch of the common interosseous artery.
The blood is brought back by vessels from the radial, ulnar, and brachial veins.

73. Proximal and distal radioulnar joint: structure, classification, movements,

ligaments, additional components (interosseous membrane).

Distal radioulnar
CLASSIFICATION
SHAPE: cylindrical
TYPE: combined
FUNCTION: 1 axis- verical

STRUCTURE
ulnar notch of the radius, and the ulnar head

MOVEMENTS pronation supination

LIGAMENTS
– palmar radioulnar ligament
- dorsal radioulnar ligament
- articular disk

PROXIMAL RADIOULNAR
CLASSIFICATION
SHAPE: cylindrical

36
 TYPE: combined

STRUCTURE
head of the radius and the radial notch of the ulna.

MOVEMENTS pronation supination

LIGAMENTS – annular radial ligament,

The interosseous membrane is a sheet of connective tissue that joins the radius and ulna
together between the radioulnar joints.
It spans the distance between the medial radial border, and the lateral ulnar border. There
are small holes in the sheet, as a conduit for the forearm vasculature.
74. Radiocarpal joint: articular surfaces, classification, movements, ligaments,
additional components. Blood supply and innervation the radiocarpal joint.

WRIST JOINT
CLASSIFICATION
SHAPE: ellipse
TYPE: compound
FUNCTION: 2 axises- frontal, sagittal

STRUCTURE
- f.a. carpea radii
- discus triangularis
- f.a. proximales ossis scaphoidei, lunati, triquetri

MOVEMENTS
- Flexion, extension
- adduction, abduction
- circumduction

LIGAMENTS
- Lig. Intercarpeae
- lig. collaterale carpi radiale
- lig. collaterale carpi ulnare
-lig. radiocarpeum palmare
- lig. radiocarpeum dorsale

Blood supply - The wrist joint receives blood from branches of the dorsal and palmar
carpal arches, which are derived from the ulnar and radial arteries.

Innervation to the wrist is delivered by branches of three nerves:

37
Median nerve– Anterior interosseous branch.
Radial nerve– Posterior interosseous branch.
Ulnar nerve– deep and dorsal branches
Additional:
A fibrocartilage disc is present at the distal end of the ulna and lies between the distal ulna
and the triquetrum and lunate carpals. The disc is important for proper arthrokinematics of
the distal radioulnar joint.

75. Carpal-metacarpal joints: articular surfaces, classification, movements, ligaments.

Peculiarities of the 1st carpal-metacarpal joint. Blood supply and innervation of the
carpal-metacarpal joints

CARPOMETACARPAL JOINT
CLASSIFICATION
SHAPE: plane
TYPE: compound
FUNCTION: 3 axises

STRUCTURE – f.a. Distal carpal bones

- f.a. Base of metacarpal bones

MOVEMENTS - limited

LIGAMENTS
- lig. Carpometacarpal palmar
- lig. Carpometacarpal dorsal
- lig. Carpometacarpal interosseus

BLOOD SUPPLY -The second to fifth carpometacarpal joints are supplied by the posterior
carpal branches of the radial and ulnar arteries, by twigs from the anterior interosseous
artery, and from the palmar digital arteries.

INNERVATION - The second to fifth carpometacarpal joints are innervated by the deep
terminal branches of the ulnar nerve, the anterior interosseous branch of the median nerve,
and the posterior interosseous branch of the radial nerve.

1st carpal-metacarpal joint ( CARPOMETACARPAL POLLICIS)

CLASSIFICATION
SHAPE: saddle
TYPE: simple
FUNCTION: 2 axises – frontal, sagittal

STRUCTURE – f.a. Trapezium bone

- f.a. Base of metacarpal 1 bone

38
MOVEMENTS
- flexion and extension with reposition
- circumduction
- adduction and abduction

LIGAMENTS
- ligg. Carpometacarpal pollicis palmar
- ligg. Carpometacarpal pollicis dorsal

76. Joints of hand: intermetacarpal, metacarpal-phalangeal, interphalangeal joints,

articular surfaces, ligaments, classification, movements.
INTERMETACARPAL JOINT
CLASSIFICATION
SHAPE: plane
TYPE: compound
FUNCTION: 3 axises

STRUCTURE – f.a. Basis ossea metacarpea 2-5

MOVEMENTS - limited

LIGAMENTS
- lig. Metacarpea palmaria
- lig. Metacarpea dorsalia
- lig. Metacarpea interossea

METACARPAL-PHALANGEAL
CLASSIFICATION
SHAPE: ball (spherical)
TYPE: simple
FUNCTION: 2 axises – frontal, sagittal

STRUCTURE
- f.a. Distales ossis metacarpea
- f.a. Basis phalangea

MOVEMENTS
- flexion, extension
- adduction, abduction
- circumduction

LIGAMENTS
- lig. Collateralia

39
 - lig. Palmare
- lig. Metacarpea transversa profunda

INTERPHALANGEAL
CLASSIFICATION
SHAPE: trochlear
TYPE: simple
FUNCTION: 1 axis - frontal

STRUCTURE - f.a. phalangea

MOVEMENTS – flexion, extension

LIGAMENTS
- lig. Collateralia
- lig. Palmaria

77. Sacroiliac joint: articular surfaces, classification, movements, ligaments.

CLASSIFICATION
SHAPE: plane
TYPE: simple
FUNCTION: 3 axises

STRUCTURE
- f.a. Ossis sacri
- f.a. Ossis ilii

MOVEMENTS – limited

LIGAMENTS
- lig. Sacroiliaca interossea
- lig. Sacroiliaca ventralia
- lig. Sacroiliaca dorsalia
- lig. Iliolumbale
- lig. Sacrotuberale
- lig. Sacrospinale

78. Pubic symphysis: structure, ligaments, classification

CLASSIFICATION (nonsynovial hemi-arthrosis) CARTILAGINOUS

40
STRUCTURE
- between symphysial surfaces of right and left pubic bones
- has interpubic disc

LIGAMENTS
- superior pubic ligament
- arcuate (inferior) pubic ligament

79. Ligaments of the pelvis: describe and demonstrate on the preparations. Name
and demonstrate the foramina that are formed by the pelvis ligaments.

LIGAMENTS OF PELVIS:
- iliolumbar ligament = from tip of transverse process of L5 to posterior aspect of
inner lip of iliac crest; strengthens the lumbo-sacral joint.
- sacrospinous ligament = from ischial spine to lateral margins of the sacrum
- sacrotuberous ligament = from sacrum to tuberosity of the ischium
- posterior sacroiliac ligament is situated in a deep depression between
the sacrum and ilium behind
- anterior sacroiliac ligament = connect the anterior surface of the lateral part of
the sacrum to the margin of the auricular surface of the ilium and to the preauricular
sulcus.
- posterior sacrococcygeal ligament = ligament which stretches from the sacrum to
the coccyx and thus dorsally across the sacrococcygeal symphysis shared by these two
bones.
- anterior sacro-coccygeal ligament = which descend from the anterior surface of
the sacrum to the front of the coccyx
- lateral sacro-coccygeal ligament = pair of ligaments stretching from the lower
lateral angles of the sacrum to the transverse processes of the first coccygeal vertebra.
- obturator membrane is a thin fibrous sheet, which almost completely closes
the obturator foramen.

FORAMENS
1) GREATER SCIATIC FORAMEN - It is formed by the sacrotuberous and sacrospinous
ligaments.
2) LESSER SCIATIC FORMANEN - is formed by the sacrotuberous ligament which runs
between the sacrum and the ischial tuberosity and the sacrospinous ligament which runs
between the sacrum and the ischial spine.
3)OBTURATOR FORAMEN - is the large opening created by
the ischium and pubis bones of the pelvisthrough which nerves and blood vessels pass; is
converted into the obturator canal by a ligamentous band, a specialized part of
the obturator membrane

41
80. Hip joint: articular surfaces, classification, movements, ligaments, additional
components. Blood supply and innervation the hip joint.

CLASSIFICATION
SHAPE: cup
TYPE: simple
FUNCTION: 3 axises – vertical, frontal, sagittal

STRUCTURE
- f.a. Capitis femoris
- f.a. Lunatum acetabuli

MOVEMENTS
- flexion, extension
- adduction, abduction
- rotation
- circumduction

LIGAMENTS
- lig. Iliofemorale - extracapsular
- lig. Ischiofemorale - extracapsular
- lig. Pubofemorale - extracapsular
- lig. Capitis femoris - intracapsular
- lig. Transversum acetabule
- zona orbicularis

Blood supply - Vascular supply to the hip joint is achieved via the medial and
lateral circumflex femoral arteries, and the artery to head of femur.

INNERVATION - The hip joint is innervated by the femoral nerve, obturator nerve,
superior gluteal nerve, and nerve to quadratus femoris.

Additional components: labrum acetabule

81. Knee joint: articular surfaces, classification, movements, ligaments, additional

components. Blood supply and innervation the knee joint.

CLASSIFICATION
SHAPE: condyloid
TYPE: complex
FUNCTION: 2 axises- frontal, vertical when bended

STRUCTURE

42
 - f.a. Inferior femoris
- f.a. Superior tibiae
- f.a. Patellaris femoris
- f.a. patellae

MOVEMENTS
- flexion, extension
- rotation when bended

LIGAMENTS
- lig. Transversum genus
- lig. Collaterale tibiale
- lig. Collaterale fibulare
- lig. Popliteum obliqum
- lig. Popliteum arcuatum
- lig. Patellae
- retinacula patellae laterale, mediale
- lig. Cruciata anterior and posterior
- lig. Meniscofemorale anterior
- lig. Meniscofemorale posterior

Additional components:
a) Menisci ( medial meniscus, lateral meniscus) – located between condyles of femur and
tibia
b)Synovial plicae (plicae alares, plicae synoviales infrapatellaris)
c)Synovial bursae ( suprapatellar bursa, deep infrapatellar bursa, prepatella
bursa,semimembranosus patella)

BLOOD SUPPLY - The blood supply to the knee joint is through the genicular
anastomoses around the knee, which are supplied by the genicular branches of the femoral
and popliteal arteries.

INNERVATION - These are the femoral, tibial and common fibular nerves.

82. Ankle joint: articular surfaces, classification, movements, ligaments, additional

components. Blood supply and innervation the ankle joint.

CLASSIFICATION
SHAPE: trochlear
TYPE: compound
FUNCTION: 1 axis - frontal

STRUCTURE
- f.a. Tibiae inferior

43
 - f.a. Malleoli medialis
- f.a. Malleoli lateralis
- f.a. Superior trochlea
- f.a. Medialis trochlea
- f.a. Lateralis trochlea

MOVEMENTS
- flexion, extension
- lateral movements when bended

LIGAMENTS
- lig.mediale :
- tibionavicular part
- tibicalcaneal part
- anterior and posterior tibiotalar part
- lig. Talofibulare anterior lateral
- lig. Talofibulare posterior lateral
- lig. Calcaneofibulare

BLOOD SUPPLY - The arterial supply is derived from the malleolar branches of the
anterior tibial, posterior tibial and fibular arteries.

INNERVATION - is provided by tibial and deep fibular nerves.

83. Proximal and distal tibiofibular joint: structure, classification, movements,

ligaments, additional components (interosseous membrane).

PROXIMAL TIBIOFIBULAR JOINT

CLASSIFICATION
SHAPE: plane
TYPE: simple
FUNCTION: 3 axises

STRUCTURE
- articular surface of head of fibula
- articular surface of tibia

MOVEMENTS - limited

LIGAMENTS
- anterior and posterior ligament
- interosseus membrane

DISTAL TIBIOFIBULAR JOINT

44
CLASSIFICATION fibrous joint of the syndesmosis type
STRUCTURE
- surface of the medial side of the distal end of the fibula
- surface on the lateral side of the tibia

MOVEMENTS - small amount of gliding movement takes place during movements at

ankle joint (limited)
LIGAMENTS
- anterior ligament of lateral malleolus
- posterior ligament of lateral malleolus
- interosseous membrane
- inferior transverse ligament

Interosseus membrane
extends between interosseous crests of the tibia and fibula, helps stabilize the Tib-Fib
relationship and separates the muscles on the front from those on the back of the leg.
84. Transversal tarsal joint of the foot: articulations that form it, structure,
classification, movements and ligaments

TRANSVERSE TARSAL JOINT (calcaneocuboid joint + talocalcaneonavicular joint)

CALCANEOCUBOID JOINT
CLASSIFICATION
SHAPE: plane
TYPE: SIMPLE
FUNCTION: 3 axises

STRUCTURE
- f.a. Cuboiclea ossis calcanei
- f.a. Posterior ossis cuboiclei

MOVEMENTS - movement limited to a single rotation and some translation.

LIGAMENTS
- lig. Talonavicular
- lig. Calcaneocuboid plantar

TALOCALCANEONAVICULAR JOINT
CLASSIFICATION
SHAPE: ball
TYPE: compound
FUNCTION: 3 axises – vertical, frontal

STRUCTURE

45
 - f.a. Calcanei anterior et medii tali et navicular
- f.a. Anterior et medii ossis calcanei
- f.a. Posterior ossis navicularis

MOVEMENTS
- adduction
- plantar flexion
- pronation with abduction
- dorsal flexion

LIGAMENTS
- lig. Calcaneonavicular plantar
- lig. talocalcaneum interossea
- lig. Talocalcaneum medial
- lig. Talocalcaneum lateral

85. Joints of the foot: tarsal, tarsometatarsal joints, structure, classification,

movements, ligaments.

TARSOMETATARSAL JOINT ( LISFRANK'S JOINT)

CLASSIFICATION
SHAPE: plane
TYPE: compound
FUNCTION: 3 axises
STRUCTURE
- f.a. On cuneiform and cuboid bones
- f.a. Metatarsal nobes

MOVEMENTS - limited

LIGAMENTS
- ligg. Tarsometatarsal interosseous
- ligg. Tarsometatarsal mediale
- ligg. Tarsometatarsal median
- ligg. Tarsometatarsal lateral

TARSAL JOINT ( subtalar joint + calcaneocuboid joint + talocalcaneonavicular joint)

SUBTALAR JOINT
CLASSIFICATION
SHAPE: cylindrical
TYPE: simple
FUNCTION: 1 axis – sagittal

STRUCTURE

46
 - f.a. Calcanei posterior tali
- f.a. Posterius calcanei

MOVEMENTS – pronation and supination

LIGAMENTS – lig. Plantare longum

86. Joints of the foot: intertmetatarsal, metatarsophalangeal, interphalangeal joints,

structure, classification, movements, ligaments.

INTERMETATARSAL JOINT
CLASSIFICATION
SHAPE: plane
TYPE: compound
FUNCTION: 3 axises (multiaxial)

STRUCTURE - 2nd-5th metatarsal bones

MOVEMENTS - limited

LIGAMENTS
- Dorsal plantar metatarsal ligament,
- Interosseus metatarsal ligament

METATARSOPHALANGEAL JOINT
CLASSIFICATION
SHAPE: ball
TYPE: simple
FUNCTION: 3 axises (multiaxial)-vertical,frontal

STRUCTURE
- Articular surface of heads (tarsal bones),
- articular surface of bases (phalanges)

MOVEMENTS
- flexion,extension
- slight abduction

LIGAMENTS
- Collateral ligament,
- Plantar ligament,
- Deep transverse metatarsal ligament

INTERPHALANGEAL JOINT

47
CLASSIFICATION
SHAPE: trochlear
TYPE: simple
FUNCTION: 1 axis (uniaxial) - frontal

STRUCTURE - Articular surface on phalanges

MOVEMENTS - flexion,extension

LIGAMENTS
- Collateral ligament,
- Plantar ligament

87. Classification of muscles according to shape, position, direction of fibers, relation

to joints and functions.

Due to the function:

- Rectifiers
- Flexors
- Adductor
- Abductor
- Internal rotators
- External rotators

Due to position:
- Muscles of the head
*the facial muscles,
*the muscles Ruminal,
*the muscles of the tongue,
*the muscles of the eyeball
- Neck muscles
- Back muscles
- Chest muscles
- Stomach muscles
- The muscles of the upper limb:
*the muscles of the rim of the upper limb
*arm muscles - the biceps, triceps
*the muscles of the forearm
*the muscles of the hand
- The muscles of the lower limb:
*muscles rim of the lower limb
*thigh muscles
*the muscles of the lower leg

48
 *the muscles of the foot

Due to direction of fibers

- Parallel (fibers are parallel to the force-generating axis. Parallel muscles can be further
defined into three main categories: strap, fusiform, or fan-shaped.)
*strap (muscles are shaped like a strap or belt and have fibers that run
longitudinally to the contraction direction ex. the laryngeal muscles, the sartorius)
*fusiform/spindle (muscles are wider and cylindrically shaped in the center and
taper off at the ends. Fibers runs in a straight line between the attachment points which are
often tendons ex. biceps brachii in humans.)
*fan-shaped (fibers in fan-shaped muscles converge at one end (typically at a
tendon) and spread over a broad area at the other end. Because of this, some consider
muscles with this relative shape to be in a separate architecture type known as convergent
muscle ex. pectoralis major)
- Pannate (Pennate muscles have a large number of muscle fibres per unit and so are very
strong, but tire easily. They can be divided into:)
*Unipennate (These muscles have their fibres arranged to insert in a diagonal
direction onto the tendon, which allows great strength. Examples include the Lumbricals
(deep hand muscles) and Extensor Digitorum Longus (wrist and finger extensor))
*Bipennate (Bipennate muscles have two rows of muscle fibres, facing in opposite
diagonal directions,with a central tendon, like a feather. This allows even greater power but
less range of motion. An example is the Rectus Femoris)
*Multipennate (As the name suggests have multiple rows of diagonal fibres, with
a central tendon which branches into two or more tendons. An example is the Deltoid
muscle which has three sections, anterior, posterior and middle.)

Due to relation to joints

- ponds tillers - allow movement in one plane (eg. the joints międzypaliczkowe)
- biaxial joints - allow movement in two planes (eg. the knee joint)
- multi-axis joints - allow movement in all planes (eg. the shoulder joint)

Due to the shape:

- Circular Muscles (These muscles appear circular in shape and are normally sphincter
muscles which surround an opening such as the mouth, surrounded by Obicularis Oris and
Obicularis Oculi surrounding the eyes)
- Convergent Muscles (These are muscles where the origin is wider than the point of
insertion. This fibre arrangement allows for maximum force production. An example is
Pectoralis Major. Convergent muscles are also sometimes known as triangular muscles)
- Parallel Muscles (They are normally long muscles which cause large movements, are not
very strong but have good strength. Examples include Sartorius and Sternocleidomastoid)
- Fusiform Muscles (These muscles are more spindle shaped, with the muscle belly being
wider than the origin and insertion. Examples are Biceps Brachii and Psoas major)

49
88.Biomechanics of muscle, their effects on the joints, the concept of origin and insertion
of muscles, the fixed and mobile points

The sarcomere, containing the contractile proteins actin and myosin, is the basic functional
unit of muscle. Contraction of a whole muscle is actually the sum of singular contraction
events occurring within the individual sarcomeres. Contraction results from the formation
of cross-bridges between the myosin and actin myofilaments, causing the actin chains to
“slide” on the myosin chain. The tension of the contraction depends upon the number of
cross-bridges formed between the actin and myosin myofilaments. Contraction is initiated
by an electrical stimulus from the associated motor neuron causing depolarization of the
muscle fiber. When the fiber is depolarized, calcium is released into the cell and binds with
the regulating protein troponin. The combination of calcium with troponin acts as a trigger,
causing actin to bind with myosin, beginning the contraction.
Fiber length has a significant influence on the magnitude of the joint motion that results
from a muscle contraction. The fundamental behavior of muscle is shortening, and it is this
shortening that produces joint motion. A muscle’s moment arm has a significant effect on
the joint excursion produced by a contraction of the muscle. A muscle with a short moment
arm produces a larger angular excursion than another muscle with a similar shortening
capacity but with a longer moment arm.
Fixed of the point that to which the head is attached while the opposite point is termed the
movable point.

Origin and Insertion

Most skeletal muscle is attached to bone on its ends by way of what we call tendons. As
the muscles contract, they exert force on the bones, which help to support and move our
body along with its appendages.
In most cases, one end of the muscle is fixed in its position, while the other end moves
during contraction. The origin is the attachment site that doesn't move during contraction,
while the insertion is the attachment site that does move when the muscle contracts.
The insertion is usually distal, or further away, while the origin is proximal, or closer to
the body, relative to the insertion. For example, one could say the wrist is distal to the
elbow. Conversely, you can say the elbow is proximal to the wrist.
Muscular contraction produces an action, or a movement of the appendage. We will use
examples to describe how the origin and insertion affect the action of a skeletal muscle.

89.Muscles of the back: topographical classification, origin, insertion, action. Blood supply
and innervation the muscles of the back.

Muscles of the back subdivide into superficial and deep (proper) groups.

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Superficial Back Musculature
1. Trapezius
• Origin: 1. external occipital protuberance 2. along the medial sides of the superior
nuchal line 3. ligamentum nuchae (surrounding the cervical spinous processes) 4.
spinous processes of C1-T12
• Insertion: 1. posterior, lateral 1/3 of clavicle 2. acromion 3. superior spine of scapula •
Action: 1. elevates scapula 2. upward rotation of the scapula (upper fibers) 3. downward
rotation of the scapula (lower fibers) 4. retracts scapula
• Blood: transverse cervical artery
• Nerve: 1. spinal Accessory (XI) (efferent or motor fibers) 2. ventral ramii of C3 & C4
(afferent or sensory fibers)
2. Latissimus dorsi
• Origin: 1. spinous process of T7-L5 2. upper 2-3 sacral segments 3. iliac crest 4. lower
3 or 4 Ribs
• Insertion: lateral lip of the intertubercular groove
• Action: 1. adduction of humerus 2. medial rotation of the humerus 3. extension from
flexed position 4. downward rotation of the scapula
• Blood: thoracodorsal artery 33
• Nerve: thoracodorsal nerve, C6,7,8
3. Rhomboid major
• Origin: 1. spinous processes of T2-T5 2. supraspinous ligament
• Insertion: medial scapula from the scapular spine to the inferior angle
• Action: retract scapula
• Blood: 1. deep branch of transverse cervical artery, OR 2. dorsal scapular artery
• Nerve: dorsal scapular nerve, C5
4. Rhomboid minor
• Origin: 1. spinous process of C7 & T1 2. ligamentum nuchae 3. supraspinous
ligament
• Insertion: medial margin of the scapula at the medial angle
• Action: retract scapula
• Blood: 1. deep branch of transverse cervical artery, OR 2. dorsal scapular artery
• Nerve: dorsal scapular nerve, C5, [C4]
5. Levator scapulae
• Origin: transverse processes of C1-C3 or C4
• Insertion: superior angle of scapula toward the scapular spine
• Action: 1. elevates the scapula 2. extends and/or laterally flexes the head
• Blood: transverse cervical artery
• Nerve: 1. nerves off cervical plexus, C3,4 2. dorsal scapular nerve, C5
6. Serratus posterior superior
• Origin: vertebrae C7-Th2
• Insertion: 2-5 ribs
• Action: 1. elevates ribs

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 • Blood: 1. posterior intercostal art., deep cervical artery upper part
• Nerve: intercostal nernes, Th1-Th4
7. Serratus posterior inferior
• Origin: vertebrae Th11-L2
• Insertion: 8-12 ribs
• Action: 1. depresses the ribs
• Blood: posterior intercostal arteries
• Nerve: intercostal nernes, Th9-Th12

2 Deep Back Musculature

1. Splenius capitis
• Origin: 1. lower portion of ligamentum nuchae 2. spinous processes of C3-T3(4)
• Insertion: 1. superior nuchal line 2. mastoid process of temporal bone
• Action: 1. bilateral contraction: extend head & neck 2. unilateral contraction: rotate
and laterally bend head & neck to the contracted (same) side
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves
2. Splenius cervicis
• Origin: spinous process of T3-T6
• Insertion: posterior tubercles of transverse processes of C2-C4
• Action: 1. bilateral contraction: extend head & neck 2. unilateral contraction: rotate
and laterally bend head & neck to the contracted (same) side
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves

Erector Spinae Muscles: Iliocostalis lumborum

• Origin: common tendinous origin: (same for all lower erector spinae) 1. sacrum 2. iliac
crest 3. spinous processes of lower thoracic & most lumbar vertebrae 35
• Insertion: lower border of angles of ribs (5)6-12
• Action: (same for all erector spinae) 1. bilateral: a. extension of vertebral column b.
maintenance of erect posture c. stabilization of vertebral column during flexion, acting
in contrast to abdominal muscles and the action of gravity 2. unilateral: a. lateral bend
to same side b. rotation to same side c. opposite muscles contract eccentrically for
stabilization
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves

Iliocostalis thoracis

• Origin: upper border of ribs 6-12 (medial to I. lumborum’s insertion.)

• Insertion: lower border of angles of ribs 1-6 (sometimes transverse process of C7)

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 • Action: (same for all erector spinae)
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves

Iliocostalis cervicis

• Origin: angles of ribs 1-6

• Insertion: transverse processes of C4-C6
• Action: (same for all erector spinae)
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves
Longissimus thoracis
• Origin: common tendinous origin: (same for all lower erector spinae) 1. sacrum 2.
iliac crest 3. spinous processes of lower thoracic & most lumbar vertebrae
• Insertion: 1. transverse processes of all thoracic vertebrae 2. all ribs between tubercles
and angles 3. transverse processes of upper lumbar vertebrae
• Action: (same for all erector spinae) 1. bilateral: a. extension of vertebral column b.
maintenance of erect posture (pneumonic = I Like Standing) c. stabilization of
vertebral column during flexion, acting in contrast to abdominal muscles and the action
of gravity 2. unilateral: a. lateral bend to same side b. rotation to same side c. opposite
muscles contract eccentrically for stabilization
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves

Longissimus cervicis

• Origin: transverse processes of T1-T5(6)

• Insertion: transverse processes of C2-C6
• Action: (same for all erector spinae)
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves
Longissimus capitis
• Origin: 1. transverse and articular processes of middle and lower cervical vertebrae 2.
transverse processes of upper thoracic vertebrae
• Insertion: posterior aspect of mastoid process of temporal bone
• Action: (same for all erector spinae)
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves

Spinalis thoracis

• Origin: common tendinous origin: (same for all lower erector spinae) 1. sacrum 2.
iliac crest 3. spinous processes of lower thoracic & most lumbar vertebrae
• Insertion: spinous processes T3(4)-T8(9)

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 • Action: (same for all erector spinae) 1. bilateral: a. extension of vertebral column b.
maintenance of erect posture (pneumonic = I Like Standing) c. stabilization of
vertebral column during flexion, acting in contrast to abdominal muscles and the action
of gravity 2. unilateral: a. lateral bend to same side b. rotation to same side c. opposite
muscles contract eccentrically for stabilization 37
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves Spinalis cervicis
• Origin: spinous processes of C6-T2
• Insertion: spinous processes of C2 (and possibly extend to C3 or C4)
• Action: (same for all erector spinae)
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves

Spinalis capitis

• Origin: spinous processes of lower cervical & upper thoracic vertebrae

• Insertion: between superior & inferior nuchal lines of occipital bone
• Action: (same for all erector spinae)
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves
2. Transversospinal Muscles Semispinalis thoracis
• Origin: transverse processes of T6-T12 vertebrae
• Insertion: spinous processes of upper thoracic & lower cervical vertebrae
• Action: 1. bilaterally extends vertebral column, especially head and neck 2. controls
lateral flexion to side opposite contraction (eccentric for stability) 3. maintains head
posture
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves

Semispinalis cervicis

• Origin: transverse processes of T1-T6 vertebrae and can go down to lower thoracic
• Insertion: spinous processes of C2-T5(6)
• Action: 1. bilaterally extends vertebral column, especially head and neck 2. controls
lateral flexion to side opposite contraction (eccentric for stability) 3. maintains head
posture
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves

Semispinalis capitus

• Origin: 1. transverse processes of T1-T6 ÌÑ 2. articular processes of C4-C7

• Insertion: between superior & inferior nuchal lines of occipital bone

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 • Action: 1. bilaterally extends vertebral column, especially head and neck 2. controls
lateral flexion to side opposite contraction (eccentric for stability) 3. maintains head
posture
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves

Multifidus

• Origin: • cervical region: from articular processes of lower cervical vertebrae •

thoracic region: from transverse processes of all thoracic vertebrae • lumbar region: 1.
lower portion of dorsal sacrum 2. PSIS 3. deep surface of tendenous origin of erector
spinae 4. mamillary processes of all lumbar vertebrae
• Insertion: spinous process of all vertebrae extending from L5 – C2 (skipping 1-3
segments)
• Action: 1. bilaterally extends vertebral column 2. controls lateral flexion to side
opposite contraction (eccentric for stability) 3. unilaterally rotate vertebral bodies
(column) to opposite side
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves

Long rotators

• Origin: transverse process of one vertebra

• Insertion: skips one vertebra to insert on the base of spinous process of vertebra
above
• Action: 1. rotate to opposite side 2. bilateral extension
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves

Short rotators

• Origin: transverse process of one vertebra

• Insertion: base of spinous process of vertebra immediately above 39
• Action: 1. rotate to opposite side 2. bilateral extension
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves

Segmental Muscles:

5. Interspinalis

• Origin: spinous processes of each vertebra

• Insertion: to the spinous process of vertebra immediately above
• Action: extension of the vertebrae segments
• Blood: muscular branches of the aorta

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 • Nerve: dorsal rami of spinal nerves
6. Intertransversi
• Origin: (A to A and B to B) • cervical region: A. from the anterior tubercle of
transverse process B. from the posterior tubercle of transverse process • thoracic
region: (poorly developed) • lumbar region: A. lateral aspect of the transverse process
B. mamillary process
• Insertion: • cervical region: • to the anterior tubercle immediately above • to the
posterior tubercle immediately above • thoracic region: (poorly developed) • lumber
region: • lateral aspect of the transverse process immediately above B. to the accessory
process on the vertebra immediately above
• Action: 1. laterally flexes each respective pair of vertebrae 2. (also eccentric muscle
contraction provides stability)
• Blood: muscular branches of the aorta
• Nerve: dorsal rami of spinal nerves
8. Levators costarum (short and long)
• Origin: cervical and thoracic vertebrae
• Insertion: ribs
• Action: elevates ribs
• Blood: posterior intercostal artaries
• Nerve: intercostal nernes, C8 – Th1-Th10
9. Suboccipital Musculature Obliquus capitis inferior
• Origin: spinous process of axis (C2)
• Insertion: transverse process of atlas (C1)
• Action: rotates the head to the contracted side
• Blood: muscular branches of vertebral artery
• Nerve: suboccipital nerve, (dorsal rami C1)

Obliquus capitis superior

• Origin: transverse process of atlas (C1)

• Insertion: between superior and inferior nuchal line of occiput
• Action: 1.bilaterally extends the head 2.laterally flexes to the contracted side
• Blood: muscular branches of vertebral artery
• Nerve: suboccipital nerve, (dorsal rami C1)

Rectus capitis posterior major

• Origin: spinous process of axis (C2)

• Insertion: inferior nuchal line (lateral to minor)
• Action: 1.bilaterally extends the head 2.rotates the head to the contracted side
• Blood: muscular branches of vertebral artery
• Nerve: suboccipital nerve, (dorsal rami C1)

Rectus capitis posterior minor

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• Origin: posterior tubercle of atlas (C1)
• Insertion: inferior nuchal line (adjacent to midline)
• Action: bilaterally extends the head
• Blood: muscular branches of vertebral artery
• Nerve: suboccipital nerve, (dorsal rami C1) They differ some regions in back:
vertebral region, sacral region, scapular region, subscapular region, and lumbar region.

90.Muscles of the chest: topographical classification, origin, insertion, action. Blood

supply and innervation the muscles of the chest.

1. Pectoralis major
• Origin: 1. medial 1/3 of clavicle 41 2. anterior aspect of manubrium & length of body
of sternum 3. cartilaginous attachments of upper 6 ribs 4. external oblique’s aponeurosis
• Insertion: 1. lateral lip of bicipital groove to the crest of the greater tubercle 2.
clavicular fibers insert more distally; sternal fibers more proximally
• Action: 1. adducts humerus 2. medially rotates humerus 3. flexion of the arm from
extension (clavicular portion)
• Blood: 1. pectoralis branch of thoracoacromial artery (runs with lateral pec. nerve) 2.
lateral thoracic artery (lesser supply, and runs with medial pectoral nerve)
• Nerve: 1. lateral pectoral nerve, C5,6,7 to clavicular portion 2. medial pectoral nerve,
C8,T1 to sternal portion
2. Pectoralis minor
• Origin: outer surface of ribs 2-5 or 3-5 or 6
• Insertion: medial aspect of coracoid process of the scapula
• Action: 1. depresses & downwardly rotates the scapula 2. assists in scapular
protraction from a retracted position 3. stabilizes the scapula
• Blood: lateral thoracic artery
• Nerve: medial pectoral nerve, C8,T1
3. Subclavius
• Origin: first rib about the junction of bone and cartilage
• Insertion: lower surface of clavicle
• Action: assists in stabilizing the clavicle
• Blood: clavicular branch of thoracoacromial artery
• Nerve: nerve to the subclavius, C5,6
4. Serratus anterior
• Origin: fleshy slips from the outer surface of upper 8 or 9 ribs
• Insertion: costal aspect of medial margin of the scapula
• Action: 1. protract scapula 2. stabilize scapula ÌÑ 3. assists in upward rotation
• Blood: 1. lateral thoracic artery supplies the upper part 2. thoracodorsal artery
supplies the lower part
• Nerve: long thoracic nerve, C5,6,7
Follow muscles belong to Proper (deep) group of the thorax:
1. External intercostal muscles elevate the ribs

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 2. Internal intercostal muscles lower ribs
3. Subcostal muscles lower the ribs
4. Transversus thoracis muscles lower the ribs
5. Levators costarum (short and long). They originatefrom cervical and thoracic
vertebrae, inserte to ribs. Action: elevates ribs.

91.Diaphragm: definition of diaphragm, topography, parts, structure; foramina,

contents, triangles, functions.

Diaphragm – muscular and tendon organ that separates thoracic and abdominal
cavities. It has muscular portion and the tendon.
Muscular part is divided into three parts: sternal part, costal and lumbar parts. There
are weak places where diaphragmatic hernia can be happen – lubocostal and
sternocostal tringles. The diaphragm is the dome-shaped sheet of muscle that separates
the chest from the abdomen. It is attached to the spine, ribs and sternum and plays a
very important role in the breathing process. The lungs are enclosed in a kind of cage
in which the ribs form the sides and the diaphragm, an upwardly arching sheet of
muscle, forms the floor. When we breathe, the diaphragm is drawn downward until it is
flat. At the same time, the muscles around the ribs pull them up like a hoop skirt. The
chest cavity becomes deeper and larger, making more air space. The muscle fibers of
the diaphragm converge on the central tendon, which is a thick, flat plate of dense
fibers. There are openings in the diaphragm for the esophagus (esophageal hiatus), the
phrenic nerve (which controls the movements of the diaphragm to produce breathing),
and the aorta (aortic hiatus) and vena cava blood vessels (foramen venae cavae
inferioris), which lead to and from the heart. When air is drawn into the lungs, the
muscles in the diaphragm contract, pulling the central tendon down. This enlarges the
chest, and air then passes into the lungs to fill the larger space. The diaphragm
sometimes contracts involuntarily because the controlling nerves are irritated by eating
too fast (or for some other reason). At this time, if air is inhaled, the space between the
vocal cords at the back of the throat close suddenly, producing the clicking noise we
call “hiccups.”
Breathing
The diaphragm contracts and moves downward elongating the thoracic cavity while the
external intercostal muscles contract widening the thoracic cavity causing air to fill the
lungs through suction (inspiration). The diaphragm and external intercostal then relax,
decreasing the thorax size and reducing lung capacity forcing air out of the lungs
(expiration).

92.Blood supply and innervation of the diaphragm.

The halves of the diaphragm receives motor innervation from a phrenic nerve. The left
half of the diaphragm (known as a hemidiaphragm) is innervated by the left phrenic
nerve, and vice versa. Each phrenic nerve is formed in the neck within the cervical plexus,

58
and contains fibres from spinal roots C3-C5. The majority of the arterial supply to the
diaphragm is delivered via theinferior phrenic arteries, which arise directly from the
abdominal aorta. The remaining supply is from the superior phrenic, pericardiacophrenic,
and musculophrenic arteries. The draining veins follow the aforementioned arteries.

93.Abdominal muscles: topographical classification, origin, insertion, action. Blood

supply and innervation the abdominal muscles.

Muscles and Fasciae of the Abdomen The muscles of the abdomen may be divided
into three groups: (1) the anterior; (2) the lateral muscles; (3) the posterior
muscles.

Muscles of anterior abdominal wall

1. Rectus abdominis is a long flat muscle, which extends along the whole length of
the front of the abdomen, and is separated from its fellow of the opposite side by
the linea alba. The Rectus is crossed by fibrous bands, three in number, which are
named the tendinous intersectiones. Action – Rectus pulls ribs downward, bend the
backbone, takes part in ‘prelum abdominale’.
2. 2. The Pyramidalis pulls the linea alba. Lateral abdominal muscles include:
Obliquus externus abdominis, Obliquus internus abdominis, Transversus
abdominis.
1. The external abdominal oblique muscle lies on the sides and front of the abdomen
and is the largest and the most superficial of the three flat muscles in this area. It is
broad, thin and irregularly four-sided and occupies the lateral walls of the
abdomen, stretching across to the front. Both sides, acting together, flex the
vertebral column by drawing the pubis toward the xiphoid process. One side also
bends the vertebral column sideways and rotates it to opposite direction.
2. The internal abdominal oblique muscle is also irregularly foursided in form and lies
under the external oblique muscle. Both sides, acting together, flex the vertebral
column, drawing cartilages down toward the pubis. One side acting alone bends the
vertebral column sideways, rotating it to the same direction. Both of the abdominal
oblique muscles work to compress abdominal contents, assist in the digestive
process and in forced expiration.
3. The transversus abdominal muscle compresses the abdominal viscera. Actions.
When the pelvis and thorax are fixed, the abdominal muscles compress the
abdominal viscera by constricting the cavity of the abdomen, in which action they
are materially assisted by the descent of the diaphragm. By these means assistance
is given in expelling the feces from the rectum, the urine from the bladder, the fetus
from the uterus, and the contents of the stomach in vomiting. If the pelvis and
vertebral column were fixed, these muscles compress the lower part of the thorax,
materially assisting expiration. If the pelvis alone be fixed, the thorax is bent
directly forward, when the muscles of both sides act; when the muscles of only one

59
 side contract, the trunk is bent toward that side and rotated toward the opposite
side. If the thorax be fixed, the muscles, acting together, draw the pelvis upward, as
in climbing; or, acting singly, they draw the pelvis upward, and bend the vertebral
column to one side or the other. The Recti, acting from below, depress the thorax,
and consequently flex the vertebral column; when acting from above, they flex the
pelvis upon the vertebral column. The Pyramidales are tensors of the linea alba.
The Posterior Muscles of the Abdomen
The Quadratus lumborum is irregularly quadrilateral in shape, and broader below than
above. It arises by aponeurotic fibers from the iliolumbar ligament and the adjacent
portion of the iliac crest for about 5 cm., and is inserted into the lower border of the last
rib. In front of the Quadratus lumborum are the colon, the kidney. Actions. The
Quadratus lumborum draws down the last rib, and acts as a muscle of inspiration by
helping to fix the origin of the diaphragm. If the thorax and vertebral column are fixed,
it may act upon the pelvis, raising it toward its own side when only one muscle is put in
action; and when both muscles act together, either from below or above, they straighten
the trunk. In the middle line aponeurosis of the opposite obliqui muscles and
transversus abdominis muscles form the linea alba, which extends from the xiphoid
process to the symphysis pubis. Linea alba is the place of middle section (laparatomy).

94.Sheath of rectus abdominis muscle: walls and structure. Linea alba abdominis:
topography, structure.

Sheath of rectus abdominis muscle The Rectus is enclosed in a sheath (vagina for
rectus abdominis) formed by the aponeuroses of the Obliqui and Transversus, which
are arranged in the following manner. At the lateral margin of the Rectus, the
aponeurosis of the Obliquus internus divides into two lamellæ, one of which passes in
front of the Rectus, blending with the aponeurosis of the Obliquus externus, the other,
behind it, blending with the aponeurosis of the Transversus, and these, joining again at
the medial border of the Rectus, are inserted into the linea alba. This arrangement of
the aponeurosis exists 45 from the costal margin to midway between the umbilicus and
symphysis pubis, where the posterior wall of the sheath ends in a thin curved margin,
the linea arcuata, the concavity of which is directed downward: below this level the
aponeuroses of all three muscles pass in front of the Rectus. The Rectus, in the
situation where its sheath is deficient below, is separated from the peritoneum by the
transversalis fascia.

95.Inguinal canal: walls, rings, structure, content.

Inguinal canal Inguinal ligament is formed by lower margin of external oblique

abdominis muscle. It fixed between anterior superior iliac spine and pubic tubercle in
each side. A ligament is a tough band of white, fibrous, rather elastic tissue. Ligaments
support many internal organs; including the uterus, the bladder, the liver, and the
diaphragm. The inguinal ligament supports the region around the groin (between the
abdomen and the thigh), preventing an inguinal hernia, or protrusion of part of the

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intestine into the muscles of the groin. Inguinal canal exists at norm, length 4-5 cm. It
located above the inguinal ligament. Inguinal canal in male contains spermatic cord, in
female – round ligament of uterus. Anterior wall of the canal is formed by aponeurosis
of external oblique abdominis muscle, lower wall – by inguinal ligament, back wall –
by transversalis fascia, upper wall – by lower margin of internal oblique and trasversus
abdominis muscles. Inguinal canal has two rings. Superficial inguinal annulus enclosed
by medial and lateral crura of aponeurosis of external oblique abdominis muscle,
intercrural fibbers and reflected ligament. Deep inguinal annulus is formed by
convexity of tranversalis fascia. Inguinal rings, also linea alba, umbilical ring are weak
places of the front abdominal wall, where hernia can look out.

96.Muscles of the neck: topographic classification, origin, insertion, functions.

. NECK MUSCULATURE SUBDIVIDES INTO SUPERFICIAL AND DEEP

GROUPS Superficial Neck Musculature Platysma
• Origin: subcutaneous skin over delto-pectoral region
• Insertion: invests in the skin widely over the mandible
• Action: 1.depress mandible and lower lip 2.tenses the skin over the lower neck
• Blood: superficial vessels of the neck
• Nerve: cervical branch of facial nerve (VII cranial)
Sternocleidomastoid
• Origin: (two heads) 1.manubrium of sternum 2.medial portion of clavicle
• Insertion: mastoid process of temporal bone
• Action: 1.rotates to side opposite of contraction 2.laterally flexes to the contracted side
3.bilaterally flexes the neck
• Blood: 1.occipital artery 2.superior thyroid artery
• Nerve: 1.motor: spinal accessory (XI cranial) 2.sensory: ventral rami of C2,(C3) 51
Suprahyoid group
1. Stylohyoid
• Origin: styloid process of temporal bone
• Insertion: lateral margin of hyoid (near greater horn)
• Action: 1.pulls the hyoid superiorly & posteriorly during swallowing 2.fixes the hyoid
bone for infrahyoid action
• Blood: facial & occipital artery
• Nerve: facial nerve (VII cranial)
Digastric

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• Attachments: 1.post belly: mastoid process of temporal bone 2.anterior belly: digastric
fossa of internal mandible • both bellies meet and attach at the lateral aspect of body of
hyoid by a pulley tendon
• Action: 1.open mouth by depressing mandible 2.fixes hyoid bone for infrahyoid action
• Blood: branches of the external carotid
• Nerve: 1.posterior belly: facial nerve (VII cranial) 2.anterior belly: mylohyoid nerve
Mylohyoid
• Origin: inner surface of mandible off the mylohyoid line
• Insertion: 1.body of hyoid 2.along midline at mylohyoid raphe
• Action: 1.elevates the hyoid bone 2.raises floor of mouth (for swallowing) 3.depresses
mandible when hyoid is fixed
• Blood: lingual artery
• Nerve: mylohyoid nerve (branch of mandibular division, V3 cranial)
Geniohyoid
• Origin: inner surface of the mandible
• Insertion: body of hyoid (paired muscles)
• Action: 1.pulles the tongue 2.depress the mandible 3.works with mylohyoid
• Blood: lingual artery
• Nerve:
Infrahyoid group
1. Sternohyoid
• Origin: 1.posterior aspect of manubrium 2.sternal end of clavicle
• Insertion: body of hyoid
• Action: 1.depresses hyoid & larynx 2.acts eccentrically with the suprahyoid muscles to
provide them a stable base
• Blood: 1.inferior thyroid artery (primary) 2.superior thyroid artery
• Nerve: 1.upper portions: superior root of ansa cervicalis, C2 2.lower portions: inferior
root of ansa cervicalis, C2,3
Omohyoid
• Attachments: 1.superior belly: hyoid bone (lateral to sternohyoid) 2.inferior belly:
superior scapular border (medial to suprascapular notch) • both bellies meet at the
clavicle & are held to the clavicle by a pulley tendon
• Action: 1.depresses hyoid & larynx 2.acts eccentrically with the suprahyoid muscles to
provide them a stable base

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• Blood: 1.inferior thyroid artery (primary) 2.superior thyroid artery
• Nerve: 1.upper portions: superior root of ansa cervicalis, C2 2.lower portions: inferior
root of ansa cervicalis, C2,3
Sternothyroid
• Origin: posterior aspect of manubrium
• Insertion: oblique line of thyroid cartilage
• Action: 1.depresses hyoid & larynx 2.acts eccentrically with the suprahyoid muscles to
provide them a stable base
• Blood: 1.inferior thyroid artery (primary) 2.superior thyroid artery
• Nerve: 53 1.upper portions: superior root of ansa cervicalis, C2 2.lower portions:
inferior root of ansa cervicalis, C2,3
Thyrohyoid
• Origin: oblique line of thyroid cartilage
• Insertion: body of hyoid
• Action: 1.depresses hyoid 2.may assist in larynx elevation
• Blood: 1.inferior thyroid artery (primary) 2.superior thyroid artery
• Nerve: 1.upper portions: superior root of ansa cervicalis, C2 2.lower portions: inferior
root of ansa cervicalis, C2,3
Deep Neck Muscles have lateral, medial groups
Deep Lateral Neck Musculature Anterior scalene
• Attachment A: anterior tubercles of transverse processes of C3-C6
• Attachment B: 1st rib
• Action: if transverse process fixed: 1.elevates the ribs for respiration if ribs fixed:
2.rotates to side opposite of contraction 3.laterally flexes to the contracted side
4.bilaterally flexes the neck
• Blood: inferior thyroid artery (branch of the thyrocervical trunk)
• Nerve: ventral rami C3-C6
Middle scalene
• Attachment A: transverse processes of all cervical vertebrae
• Attachment B: 1st rib (behind anterior scalene)
• Action: if transverse process fixed: 1.elevates the ribs for respiration if ribs fixed:
2.rotates to side opposite of contraction 3.laterally flexes to the contracted side
4.bilaterally flexes the neck
• Blood: ascending cervical artery

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• Nerve: ventral rami C3-C8
Posterior scalene
• Attachment A: posterior tubercles of transverse processes of C5 & C6
• Attachment B: 2nd and/or 3rd rib
• Action: if transverse process fixed: 1.elevates the ribs for respiration if ribs fixed:
2.rotates to side opposite of contraction 3.laterally flexes to the contracted side
4.bilaterally flexes the neck
• Blood: ascending cervical artery
• Nerve: ventral rami C5-C7
Neck prevertebral deep Musculature
Longus colli
• Origin: lower anterior vertebral bodies and transverse processes
• Insertion: anterior vertebral bodies and transverse processes several segments above
• Action: flexes the head and neck
• Blood: muscular branches of the aorta
• Nerve: ventral rami C2-C6
Longus capitis
• Origin: upper anterior vertebral bodies and transverse processes
• Insertion: anterior vertebral bodies and transverse processes several segments above
• Action: flexes the head and neck
• Blood: muscular branches of the aorta
• Nerve: ventral rami C1-C3
Rectus capitis anterior
• Origin: anterior base of the transverse process of the atlas
• Insertion: occipital bone anterior to foramen magnum
• Action: flexes the head
• Blood: muscular branches of the aorta
• Nerve: ventral rami C2,3
Rectus capitis lateralis
• Origin: transverse process of the atlas
• Insertion: jugular process of the occipital bone
• Action: bends the head laterally

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 • Blood: muscular branches of the aorta
• Nerve: ventral rami C2,3

98.Fascia of the neck: layers, position, relations to the muscles, internal organs,
neurovascular bundles of the neck. Identify interfascial spaces, content and
communications.
Cervical fascia According V.M.Shevkunenko there are 5 cervical fasciae:
I – superficial cervical fascia envelops the platizma Proper cervical fascia has two
sheets: II – superficial lamina of the proper cervical fasciae starts from front surface
of the sternum and clavicle, lower margin of mandible and attaches the spinous
processes of the cervical vertebrae. It forms the sheath for sternocleidomastoid and
trapezius muscles.
III – deep lamina of the proper cervical fasciae starts from back surface of the sternum
and clavicle and attaches to the hyoid bone from sides bordered by omohyoid muscles.
This fascia forms linea alba of neck and the sheath for infrahyoid muscles.
Suprasternal interaponeurotic space made up between superficial and deep lamina
of the proper cervical fasciae. It contains jugular venous arch and fat tissue.
Suprasternal space connects with lateral recesses located behind the lower part of
sternocleidomastoid muscle.
IV – internal cervical fascia subdivides into parietal and visceral sheets. Parietal
lamina envelopes all organs of neck together and visceral – each organ separately.
Previsceral space positioned between parietal and visceral laminae and contains
adipose tissue, lymphatic nodes, and nerves and communicates with anterior
mediastinum. Pretracheal space located before trachea between parietal and visceral
sheets.
V – prevertebral fascia envelops all deep cervical muscles forming their sheathes.
Retropharyngeal space made up between V fascia and parietal lamina of IV fasciae.
Retrovisceral space positioned between internal cervical and prevertebral fasciae and
contains adipose tissue and continues into posterior mediastinum.
According international nomenclature (PNA) there are 3 laminae of cervical fasciae:
1. Superficial lamina meets the superficial lamina of the proper cervical fasciae
according V.M.Shevkunenko and contains the suprasternal space.
2. Pretracheal lamina meets the deep lamina of the proper cervical fasciae according
V.M.Shevkunenko and forms carotid sheath.
3. Prevertebral lamina meets the same fasciae according V.M.Shevkunenko.
Interscalenum space positioned between anterior and middle scalene muscles
where subclavian artery passes. Anterscalenum space located in front of scalene
muscles where subclavian vein passes. Deep lamina of the proper cervical fasciae
(V.M.Shevkunenko) associating infrahyoid muscles forms omoclavicular
aponeurosis or cervical sail (Rishe). Cervical sail assists to drain superficial veins
of neck that spliced with it.

99.Muscles of the head: classification. Masticatory muscles: origin, insertion, action.

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Muscles of the Head subdivided into Mastication and Facial Expression (mimetic)
groups.

Muscles of Mastication
Masseter
• Origin:
• Superficial: 1.zygomatic process of the maxilla 2.inferior border of zygomatic arch
• Intermediate: inner surface of zygomatic arch
• Deep: posterior aspect of inferior border of zygomatic arch • Insertion: • Superficial:
1.angle of mandible 2.lateral surface of mandibular ramus
• Intermediate: ramus of mandible
• Deep: 1.superior ramus of mandible 2.coronoid process of mandible
• Action: 1.closes the lower jaw (clenches the teeth) 2.may deviate mandible to opposite
side of contraction
• Blood: masseteric artery
• Nerve: masseteric nerve

Medial pterygoid
• Origin: 1.medial surface of lateral pterygoid plate of the sphenoid 2.palatine bone
3.pterygoid fossa
• Insertion: 1.inner surface of mandibular ramus 2.angle of the mandible
• Action: 1.closes the lower jaw (clenches the teeth) 2.can protrude the mandible in
combination with the lateral pterygoid
• Blood: medial pterygoid artery
• Nerve: medial pterygoid nerve

Lateral pterygoid
• Origin: 1.Superior head: lateral surface of the greater wing of the sphenoid 2.Inferior
head: lateral surface of the lateral pterygoid plate
• Insert together: 1.neck of the mandibular condyle 2.articular disk of the TMJ
• Action: 1.deviates mandible to side opposite of contraction (during chewing) 2.opens
mouth by protruding mandible (inferior head) 3.closes the mandible (superior head)
• Blood: lateral pterygoid artery
• Nerve: lateral pterygoid nerve

Temporalis
• Origin: Temporal fossa
• Insertion: coronoid process of the mandible
• Action:
1.closes the lower jaw (clenches the teeth)
2.retraction, pulles back

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100. Muscles of the head: classification. Muscles of the face (facial expression muscles):
peculiarities of facial muscles; origin, insertion, action.

Muscles of Facial Expression (mimetic)

Orbicularis oculi
• Origin: 1.orbital portion: nasal process of frontal bone 2.palpebral portion: palpebral
ligament 3.lacrimal portion: lacrimal crest of lacrimal bone
• Insertion: circumferentially around orbit meeting in palpebral raphe
• Action: powerfully closes the eye
• Blood: ophthalmic artery
• Nerve: zygomatic branch of facial nerve

Corrugator supercilii
• Origin: frontal bone just above the nose
• Insertion: skin of the medial portion of the eyebrows
• Action: draws the eyebrows downward and medially
• Blood: ophthalmic artery 49
• Nerve: zygomatic branch of facial nerve

Orbicularis oris
• Origin: 1.alveolar border of maxilla 2.lateral to midline of mandible
• Insertion: 1.circumferentially around mouth 2.blends with other muscles
• Action: 1.closes the lips 2.protrudes the lips
• Blood: facial artery
• Nerve: buccal branch of facial nerve

Levator labii superioris

• Action: 1.elevates the upper lip 2.flares the nostrils Zygomaticus minor
• Action: elevates the upper lip Zygomaticus major
• Action: lifts and draws back the angle(s) of the mouth (as in smiling) Risorius (may be
absent)
• Action: draws the mouth laterally (as in smiling) Levator anguli oris
• Action: lifts the angle(s) of the mouth (as in smiling) Buccinator
• Action: compresses the cheek(s) Depressor anguli oris
• Action: lowers the angle(s) of the mouth (as in frowning) Depressor labii inferioris
• Action: draws the lower lip downward and laterally Epicranial Musculature Occipitalis (2
bellies)
• Origin: 1.lateral 2/3 of superior nuchal line 2.external occipital protuberance
• Insertion: galea aponeurosis, over the occipital bone
• Action: draws back the scalp to raise the eyebrows and wrinkle the brow
• Blood: occipital artery
• Nerve: posterior auricular branch of facial nerve Frontalis (2 bellies)
• Origin: galea aponeurosis, anterior to the vertex
• Insertion: skin above the nose and eyes
• Action: draws back the scalp to raise the eyebrows and wrinkle the brow

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• Blood: ophthalmic artery
• Nerve: temporal branch of facial nerve

Anterior, posterior and superior auricularis muscles

• Action: draws the auricle There are parotid fascia, masseteric fascia and boccopharyngeal
fascia in head region. Regions of head: frontal, parietal, occipital, temporal, auditory,
mastoid and facial regions. Facial area has orbital, infraorbital, parotidomasseteric,
zygomatic, nasal, oral and mental regions.

101. Muscles of the shoulder girdle: origin, insertion, action. Blood supply and innervation
muscles of the shoulder girdle.

Shoulder Girdle Musculature

Deltoid
• Origin: 1. lateral, anterior 1/3 of distal clavicle 2. lateral boarder of the acromion 3.
scapular spine 57
• Insertion: deltoid tuberosity of humerus
• Action: 1. abducts arm
2. flexion and medial rotation (anterior portion)
3. 3. extension and lateral rotation (posterior portion)
• Blood: 1. posterior humeral circumflex artery 2. deltoid branch of thoracoacromial artery
• Nerve: axillary nerve, C5,6

Supraspinatus
• Origin: 1. supraspinous fossa 2. muscle fascia
• Insertion: uppermost of three facets of the greater tubercle of humerus
• Action: 1. abduction of arm (first 15-20°) 2. stabilizes glenohumeral joint
• Blood: suprascapular artery (poorly supplied)
• Nerve: suprascapular nerve, C5,6

Infraspinatus
• Origin: 1. infraspinous fossa 2. muscle fascia
• Insertion: middle facet of greater tubercle of humerus
• Action: 1. external rotation of the humerus 2. stabilizes the glenohumeral joint
• Blood: 1. suprascapular artery 2. scapular circumflex artery
• Nerve: suprascapular nerve, C5,6

Teres minor
• Origin: middle half of the scapula’s lateral margin
• Insertion: lowest of three facets of the greater tubercle of humerus
• Action: 1. lateral rotation of the humerus 2. stabilizes the glenohumeral joint
• Blood: scapular circumflex artery
• Nerve: axillary nerve, C5,6

Teres major
• Origin: inferior, lateral margin of the scapula

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• Insertion: crest of lesser tubercle (just medial to the insertion of latissimus dorsi)
• Action: 1. assists in adduction of arm 2. assists in medial rotation of arm 3. assists in
extension from an flexed position
• Blood: thoracodorsal artery
• Nerve: lower subscapular nerve, C5,6

Subscapularis
• Origin: subscapular fossa
• Insertion: lesser tubercle of humerus
• Action: 1. medial rotation of the humerus 2. stabilizes the glenohumeral joint
• Blood: Branches of subscapular artery
• Nerve: upper & lower subscapular nerves, C5,6

102. Muscles of the arm: anterior group, origin, insertion, action. Blood supply and
innervation of the anterior arm muscles.

Brachium (arm) Musculature

ANTERIOR GROUP

Coracobrachialis

• Origin: coracoid process of the scapula

• Insertion: medial shaft of the humerus at about its middle
• Action: 1.flexes the humerus 2.assists to adduct the humerus
• Blood: muscular branches of the brachial artery
• Nerve: musculocutaneous nerve, C5,6,(C7)

Biceps brachii

• Origin: 1.long head- supraglenoid tubercle and glenohumeral labrum 2.short head- tip
of the coracoid process of the scapula
• Insertion: 1.radial tuberosity 2.bicipital aponeurosis
• Action: 1.flexes the forearm at the elbow (when supinated) 2.supinates forearm from
neutral 3.stabilizes anterior aspect of shoulder 4.flexes shoulder (weak if at all) 59
• Blood: muscular branches of brachial artery
• Nerve: musculocutaneous nerve, C5,6

Brachialis

• Origin: 1.lower 1/2 of anterior humerus 2.both intermuscular septa

• Insertion: 1.ulnar tuberosity 2.coronoid process of ulna slightly
• Action: elbow flexion (major mover)
• Blood: 1.muscular branches of brachial artery 2.radial recurrent artery • Nerve:
musculocutaneous nerve, C5,6

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 103. Muscles of the arm: posterior group, origin, insertion, action. Blood supply and
innervation of the posterior arm muscles.

POSTERIOR GROUP

Triceps brachii

• Origin: 1.long head – infraglenoid tubercle of the scapula 2.lateral head – upper half
of the posterior surface of the shaft of the humerus, and the upper part of the lateral
intermuscular septum 3.medial head – posterior shaft of humerus, distal to radial
groove and both the medial and lateral intermuscular septum (deep to the long & lateral
heads)
• Insertion: 1.posterior surface of the olecranon process of the ulna 2.deep fascia of the
antebrachium
• Action: 1.long – adducts the arm, extends at the shoulder, and a little elbow flexion
2.lateral – extends the forearm at the elbow 3.medial – extends the forearm at the
elbow
• Blood: 1.muscular branches of the brachial artery 2.superior ulnar collateral artery
3.profunda brachii artery
• Nerve: radial nerve, C6,7

Anconeus

• Origin: posterior surface of the lateral epicondyle of the humerus

• Insertion: lateral aspect of olecranon extending to the lateral part of ulnar body
• Action: 1.extends the forearm at the elbow 2.supports the elbow when in full
extension
• Blood: middle collateral artery from the profunda brachii artery
• Nerve: radial nerve, C7,8

104. Muscles of forearm: anterior group, origin, insertion, action. Blood supply and
innervation of the anterior forearm muscles.

Antibrachial (forearm) Anterior (Flexor) Musculature

1st layer:
Brachioradialis
• Origin: 1.upper lateral supracondylar ridge of humerus (between the triceps and
brachialis muscles) 2.lateral intermuscular septum of humerus
• Insertion: 1.superior aspect of styloid process of radius 2.lateral side of the distal 1/2
to 1/3 of the radius 3.antebrachial fascia
• Action: 1.flexes the forearm at the elbow 2.pronates the forearm when supinated
3.supinates the forearm when pronated
• Blood: radial recurrent artery
• Nerve: 1.radial nerve, C5,6 OR 2.deep branch of the radial nerve

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Pronator teres

• Origin: 1.humeral head: a.upper portion of medial epicondyle via the CFT (common
flexor tendon) b.medial brachial intermuscular septum 2.ulnar head – coronoid process
of ulna 3.antebrachial fascia
• Insertion: lateral aspect of radius at the middle of the shaft (pronator tuberosity)
• Action: 1.pronates forearm (during rapid or forced pronation) 2.weakly flexes the
elbow • Blood: 1.muscular branches of ulnar artery 2.muscular branches of radial
artery
• Nerve: median nerve, C6,7

Flexor carpi radialis

• Origin: 1.medial epicondyle via the CFT (common flexor tendon) 2.antebrachial
fascia 61
• Insertion: base of the 2nd and sometimes 3rd metacarpals
• Action: 1.flexes the hand at the wrist 2.radially deviates the wrist 3.may assist to
pronate the forearm
• Blood: muscular branches of radial artery
• Nerve: median nerve, C6,7

Palmaris longus

• Origin: 1.medial epicondyle via the CFT (common flexor tendon) 2.antebrachial
fascia
• Insertion: 1.central portion of the flexor retinaculum 2.superficial portion of the
palmar aponeurosis
• Action: flexes the hand at the wrist
• Blood: muscular branches of ulnar artery
• Nerve: median nerve, C6,7

Flexor carpi ulnaris

• Origin: 1.humeral head – medial epicondyle via the CFT (common flexor tendon)
2.ulnar head: a.medial aspect of olecranon b.proximal 3/5 of dorsal ulnar shaft
c.antebrachial fascia
• Insertion: 1.pisiform & hamate bones (via the pisohamate ligament) 2.base of the 5th
metacarpal (via the pisometacarpal ligament)
• Action: 1.flexes the hand at the wrist 2.ulnarly deviates the wrist 3.stabilizes wrist to
permit powerful thumb motion
• Blood: muscular branches of ulnar artery
• Nerve: ulnar nerve, C8,T1
2nd layer:

Flexor digitorum superficialis

71
 • Origin: 1.humeral-ulnar head: a.medial epicondyle via the CFT (common flexor
tendon) b.medial boarder of base of coronoid process of ulna c.medial (ulnar) collateral
ligament d.antebrachial fascia 2.radial head: oblique line of radius along its upper
anterior boarder
• Insertion: both sides of the base of each middle phalanx of the 4 fingers
• Action: 1.flexes the proximal and middle phalanges 2.flexes the wrist if fingers are
extended
• Blood: 1.muscular branches of ulnar artery 2.muscular branches of radial artery
• Nerve: median nerve, C7,8,T1
3d layer:

Flexor digitorum profundus

• Origin: 1.anterior & medial surface of upper 3/4 ulna 2.adjacent interosseous
membrane • Insertion: distal phalanx of medial 4 digits (through FDS tunnel)
• Action: 1.flexes the distal IP joints and in so doing flexes the proximal and middle IP
joints 2.flexes the wrist if fingers are extended
• Blood: 1.muscular branches of the ulnar artery 2.muscular branches of the radial
artery 3.anterior interosseous artery (from ulnar artery)
• Nerve: 1.medial portion – ulnar nerve, C8,T1 2.lateral portion – anterior interosseous
branch of median nerve, C8,T1
Flexor pollicis longus
• Origin: 1.middle anterior surface of the radius 2.interosseous membrane 3.(may also
originate from lateral boarder of coronoid process 4.or medial epicondyle)
• Insertion: palmar aspect of base of the distal phalanx of thumb (deep to flexor
retinaculum)
• Action: 1.flexes the distal phalanx of the thumb (IP joint) 2.flexes the other joints to
the wrist (McP, CMc and weakly at the wrist)
• Blood: 1.muscular branches of radial artery 2.anterior interosseous artery
• Nerve: anterior interosseous branch of median nerve, C8,T1
4th layer:

Pronator quadratus

• Origin: distal 1/4 anteriomedial surface of ulna

• Insertion: distal 1/4 anteriolateral surface of radius
• Action: pronates the forearm and hand 63
• Blood: 1.anterior interosseous artery 2.muscular branches of the radial artery
• Nerve: anterior interosseous branch of median nerve, C8,T1

105. Muscles of forearm: posterior group, origin, insertion, action. Blood supply and
innervation of the posterior forearm muscles.

Antebrachial Posterior (Extensor) Musculature Superficial:

72
Extensor carpi radialis longus

• Origin: 1.lower lateral supracondylar ridge (below the brachioradialis) 2.lateral

intermuscular septum of humerus
• Insertion: base of 2nd metacarpal
• Action: 1.extends the hand at the wrist 2.radially deviates the hand at the wrist
3.weakly flexes the forearm at the elbow 4.weakly supinates the forearm
• Blood: radial recurrent artery
• Nerve: 1.radial nerve, C5,6 OR 2.deep branch of the radial nerve

Extensor carpi radialis brevis

• Origin: 1.lateral epicondyle via the CET (common extensor tendon) 2.radial collateral
ligament 3.antebrachial fascia
• Insertion: base of 3rd metacarpal
• Action: 1.extends the hand at the wrist 2.radially deviates the hand at the wrist
• Blood: radial recurrent artery
• Nerve: deep branch of the radial nerve, C6,7

Extensor digitorum

• Origin: 1.lateral epicondyle via the CET (common extensor tendon) 2.antebrachial
fascia • Insertion: 1.base of middle phalanx of each of the four fingers (central band)
2.base of distal phalanx of each of the four fingers (2 lateral bands)
• Action: 1.extends the four medial digits 2.extends the wrist if fingers flexed 3.abducts
the digits (spreads the digits as it extends them)
• Blood: posterior interosseous artery
• Nerve: posterior interosseous nerve of the radial nerve, C6,7,8

Extensor digiti minimi

• Origin: 1.lateral epicondyl via the CET (common extensor tendon) 2.antebrachial
fascia 3.ulnar aspect of extensor digitorum
• Insertion: 1.base of middle phalanx of the 5th digit (central band) 2.base of distal
phalanx of the 5th digit (2 lateral bands)
• Action: 1.extends the 5th digit 2.abducts the 5th digit
• Blood: posterior interosseous artery
• Nerve: posterior interosseous nerve of the radial nerve, C6,7,8

Extensor carpi ulnaris

• Origin: 1.1st head – lateral epicondyle via the CET (common extensor tendon) 2.2nd
head – posterior body of ulna 3.antebrachial fascia
• Insertion: medial side of base of the 5th metacarpal
• Action: 1.extends the hand at the wrist 2.ulnarly deviates the hand at the wrist

73
 • Blood: posterior interosseous artery
• Nerve: posterior interosseous nerve of the radial nerve, C6,7,8
Deep:
Supinator
• Origin: 1.lateral epicondyle of humerus 2.supinator crest of ulna 3.radial collateral
ligament 4.annular ligament 5.antebrachial fascia
• Insertion: proximal portion of anteriorlateral surface of the radius
• Action: supinates the forearm
• Blood: radial recurrent artery
• Nerve: deep branch of the radial nerve, C6

Abductor pollicis longus

• Origin: 1.posterior surfaces of ulna and radius 2.interosseous membrane

3.antebrachial fascia
• Insertion: lateral aspect of base of 1st metacarpal
• Action: 1.abducts the 1st metacarpal 2.assists to extend & rotate the thumb 3.radially
deviates the hand at the wrist 4.flexes the hand at the wrist
• Blood: posterior interosseous artery
• Nerve: posterior interosseous nerve of the radial nerve, C6,7,(C8)

Extensor pollicis brevis

• Origin: 1.posterior surfaces of radius (below abductor pollicis longus) 2.interosseous

membrane 3.antebrachial fascia 65
• Insertion: base of proximal phalanx of thumb (often a slip inserts into extensor
pollicis longus tendon)
• Action: 1.extends the proximal phalanx and 1st metacarpal of the thumb 2.radially
deviates the hand at the wrist
• Blood: posterior interosseous artery
• Nerve: posterior interosseous nerve of the radial nerve, C6,7,(C8)

Extensor pollicis longus

• Origin: 1.posterior surface of ulna 2.interosseous membrane 3.antebrachial fascia

• Insertion: distal phalanx of thumb
• Action: 1.extends distal phalanx of thumb 2.extends proximal phalanx of thumb
3.assists to extend the hand at the wrist (if fingers flexed)
• Blood: posterior interosseous artery
• Nerve: posterior interosseous nerve of the radial nerve, C6,7,8

Extensor indicis

• Origin: 1.posterior surface of ulna (distal to extensor pollicis longus) 2.interosseous

membrane 3.antebrachial fascia

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 • Insertion: base of middle and distal phalanx of the index finger
• Action: 1.extends the 2nd digit (McP & IP joints) 2.adducts the 2nd digit 3.assists to
extend the hand at the wrist 4.stabilizes McP joint for flexion of IP solely
• Blood: posterior interosseous artery
• Nerve: posterior interosseous nerve of the radial nerve, C6,7,8

106. Muscles of the hand: topographical classification, action. Blood supply and
innervation of the hand.

Hand & Wrist Musculature Thenar:

Abductor pollicis brevis

• Origin: 1.distal border of flexor retinaculum 2.trapezium (may be variable)

• Insertion: 1.lateral aspect of base of proximal phalanx of the thumb 2.may also send a
slip to the tendon of extensor pollicis longus
• Action: 1.abducts thumb (at the McP joint) 2.participates to flex the thumb (at the
McP joint) 3.if attached to extensor pollicis longus, it might assist to extend the thumb
• Blood: superficial palmar branches of radial artery
• Nerve: recurrent branch of median nerve, C8,T1

Flexor pollicis brevis

• Origin: 1.superficial head: a.distal border of flexor retinaculum b.trapezium 2.deep

head: a.floor of carpal tunnel b.indirectly to scaphoid & trapezium
• Insertion: 1.base of proximal phalanx of thumb 2.can also attach to the lateral
sesamoid bone at the McP joint
• Action: powerfully flexes the thumb (at the McP joint)
• Blood: superficial palmar branches of radial artery
• Nerve: 1.superficial head – recurrent branch of median nerve, C8,T1 2.deep head –
deep branch of ulnar nerve, C8,T1

Opponens pollicis

• Origin: 1.distal border of flexor retinaculum 2.trapezium

• Insertion: lateral aspect of the 1st metacarpal
• Action: opposes the thumb to the fingers
• Blood: superficial palmar branches of radial artery
• Nerve: recurrent branch of median nerve, C8,T1

Adductor pollicis

• Origin: 1.transverse head: 3rd metacarpal 2.oblique head: a.base of 1st, 2nd and 3rd
metacarpals b.floor of carpal tunnel
• Insertion: 1.medial aspect of the base of proximal phalanx 2.medial sesamoid at McP

75
 • Action: 1.adducts the thumb 2.may assist to flex the thumb (at the McP joint)
• Blood: superficial palmar branches of radial artery
• Nerve: deep branch of ulnar nerve, C8,T1
Hypothenar:
Palmaris brevis
• Origin: medial margin of palmar aponeurosis
• Insertion: 1.skin of ulnar border of palm 2.may insert on the pissiform 67
• Action: tenses the skin on the ulnar side, which is used in a grip action
• Blood: superficial palmar branches of ulnar artery
• Nerve: superficial branch of ulnar nerve, C8,T1

Abductor digiti minimi

• Origin: pisiform & tendon of flexor carpi ulnaris

• Insertion: 1.medial aspect of the base of proximal phalanx of the 5th digit 2.may send
a slip to the ulnar side of the dorsal expansion
• Action: 1.abduct 5th digit (requires pisiform stabilized by FCU) 2.assists to flex the
5th digit (at McP) 3.may assist in extension of 5th digit (at IP due to slips to extensor
digitorum)
• Blood: deep palmar branches of ulnar artery
• Nerve: deep branch of ulnar nerve, C8,T1

Flexor digiti minimi brevis

• Origin: 1.distal border of flexor retinaculum 2.hook of the hamate

• Insertion: medial aspect of the base of proximal phalanx
• Action: flexes the 5th digit (at the McP joint)
• Blood: deep palmar branches of ulnar artery
• Nerve: deep branch of ulnar nerve, C8,T1

Opponens digiti minimi

• Origin: 1.distal border of flexor retinaculum 2.hook of the hamate

• Insertion: medial aspect of the 5th metacarpal
• Action: 1.opposes the 5th digit with the thumb 2. assists to “cup” the palm
• Blood: deep palmar branches of ulnar artery
• Nerve: deep branch of ulnar nerve, C8, T1
Middle group:
Palmar interossei
• Origin: from the side of the metacarpal that faces the midline – to adduct them
• Insertion: 1.on the base of the proximal phalanx of the digit of origin (same side
toward the midline) 2.extensor hood of the same digit(s)
• Action: 1.adducts the fingers 2.flexes the fingers (at the McP while IP joints are
extended)

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 • Blood: palmar metacarpal artery of deep palmar arch
• Nerve: deep branch of ulnar nerve, C8,T1
Dorsal interossei
• Origin: between each metacarpal
• Insertion: 1.directly distal to the origin on the base of the proximal phalanx closest to
the midline (to abduct them.) 2.extensor hood of the same digit(s)
• Action: 1.abducts the fingers 2.flexes the fingers (at the McP while IP joints are
extended)
• Blood: palmar metacarpal artery of deep palmar arch
• Nerve: deep branch of ulnar nerve, C8,T1

Lumbricals

• Origin: 1.tendon of flexor digitorum profundus 2.1 & 2 have a single head of origin
(from radial aspect of tendon) 3.3 & 4 have two heads of origin (each head from an
adjacent tendon)
• Insertion: extensor hood of digits 2-5
• Action: 1.flexes the fingers (at the McP joints) 2.extend IPs
• Blood: palmar metacarpal arteryof deep palmar arch
• Nerve: 1.1 & 2 – median nerve, C8,T1 2.3 & 4 – deep branch of ulnar nerve, C8,T1

107. Retinaculum of forearm flexors: formation, topography, canals, content.

The flexor retinaculum (also known as the transverse carpal ligament) is a

rectangular-shaped fibrous band located at the ventral aspect of the wrist.
On the radial side, it attaches to the scaphoid tubercle and the ridge of the trapezium. On
the ulnar side, it attaches to the pisiform and the hook of the hamate.

The flexor retinaculum encloses and forms the roof of the carpal tunnel. The ulna aspect of
the flexor retinaculum forms the floor of Guyon's canal.

108. Retinaculum of forearm extensors: formation, topography, osteofibrous canals in

the area of the wrist, their content.

The fascia on the distal part of the posterior forearm is thickened to form the extensor
retinaculum, which is anchored to the radius and ulna. From the deep aspect of the
extensor retinaculum, septa produce half a dozen compartments for the extensor tendons
Each compartment contains a synovial sheath.
The palmar aspect of the carpus is concave and covered with the transverse carpal
ligament also called: the flexor retinaculum. An osteofibrous canal is thus formed, of
which the palpable boundaries are: proximally, the scaphoid and pisiform bones and
distally the trapezium and hamate bones.

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109. Synovial sheaths of the wrist: structure, topography, functional and practical
importance.

Tendons of flexor muscles that pass thorugh carpeal canal are covered by synovial
membrane which form such sheathes: • common synovial vagina of flexors – covers
tendons of musculus flexor digitirum superficialis and profundus till middle of palm (in
little finger it passes till nail phalanx); • synovial vagina of tendon for musculus flexor
pollicis longus– covers tendon of same name muscle; • synovial vaginae for tendons of
musculus flexor digitirum superficialis and profundus (of II, IV fingers) – covers
tendons of these muscles from base of proximal phalanx till top of the distal phalanx.

110. Axillary fossa and axillary cavity: walls, triangles, foramina their boundaries and
contents.
Axillary fossa is deepening between lateral surface of the chest and medial surface of
the arm. It is bordered at the front by fold of skin (lower margin of the pectoral major
level), from behind – by fold of skin (lower margin of the latissimus dorsi level).
Axillary cavity contains adipose tissue, vessels, lymphatic nodes, and nerves. It is
bordered at the front by pectoral major and minor muscles; from behind – by latissimus
dorsi, subscapular and major teres muscles; medially – by anterior serratus muscle;
laterally – surgical neck of the humerus and biceps muscles. There are three trigones in
anterior wall of axillary cavity: 1. claviculî-pectoral trigone – bordered by lower
margin of clavicle and upper margin of pectoral minor muscle; 2. pectoral trigone –
bordered by upper and lower margin of pectoral minor muscle; 3. subpectoral trigone –
bordered by lower margins of pectoral minor and pectoral major muscles. There are
two orifices in posterior wall of axillary cavity:
1. Trilaterum foramen – bordered by subscapular, teres major muscles and long head
of triceps brachii muscle, circumflexa scapulae artery passes through it;
2. Quadrilaterum foramen placed laterally from trilaterum foramen and bordered by
the same muscles and surgical neck of humerus, circumflexa humeri artery passes
through it. Fascia which covers deltoid muscle, passes into arm (brachial fascia). It
forms sheathes for muscle, also medial and lateral intermuscular septa (partitions)
of the arm that border anterior and posterior groups of muscles.
Medial bicipitis sulcus placed medially between biceps brachii muscle and brachial
muscle. There are vessels and nervous bundle runs here. Laterally one can find – lateral
bicipitis sulcus, where cephalic vein passes.
Canal of radial nerve positioned between sulcus in humerus and triceps brachii where
radial nerve and deep brachial artery and vein pass. Diamond-shaped cubital fossa
located between arm and forearm on front surface. It bordered from below by
brachiradialis muscle and pronator teres muscle. It bordered from above by brachial
muscle.

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111. Topography of arm: grooves, canal of radial nerve, cubital fossa, borders and
contents.

Radial nerve:
 In the posterior compartment winds in the spiral groove of the humerus with
the profunda brachii vessels
 Just above the elbow, it pierces the lateral intermuscular septum and continues
downward into the cubital fossa
 At the level of the elbow, it devides into superficial and deep branches
 Suferficial branch, a sensory nerve of the hand is the content of cubital fossa
 The deep branch of the radial nerve enters the posterior compartment of the
forearm

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 Contents of cubital fossa
 Median nerve
 Brachial artery
 Dividing into radial and ulnar arteries
 Tendon of biceps brachii
 Radial nerve and its two terminal branches (deep and superficial)
 Applied aspect
 The medial cubital vein is often the vein of choice for intravenous injections

The bicipital groove (intertubercular groove, sulcus intertubercular) is a deep groove on

the humerus that separates the greater tubercle from thelesser tubercle.

The radial sulcus ( also known as the musculospiral groove, radial groove, or spiral
groove) is a broad but shallow oblique depression for theradial nerve and deep brachial
artery. It is located on the center of the lateral border of the humerus bone.

112. Topography of forearm: grooves, borders and content.

Elbow fossa:
-laterally – brachioradial m.
-medially – pronator teres m.
-superiorly – brachial m.

Antebrachial grooves:
Lateral = radial: between brachioradial and flexor carpi radialis mm;
Median: between flexor carpi radialis and flexor digitorum superficialis mm;
Medial = ulnar: between flexor digitorum superficialis and flexor carpi ulnaris mm

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113. The external muscles of the pelvis: origin, insertion, action. Blood supply and
innervation the external muscles of the pelvis.

Pelvic (Gluteal) Musculature External group:

Tensor fasciae latae
• Origin: 1.anterior aspect of iliac crest 2.anterior superior iliac spine (ASIS)
• Insertion: anterior aspect of IT band, below greater trochanter
• Action: 1.hip flexion 2.medially rotate & abduct a flexed thigh 3.tenses IT tract to
support femur on the tibia during standing

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• Blood: 1.superior gluteal artery 2.lateral femoral circumflex artery
• Nerve: superior gluteal nerve, L4,5,S1
Gluteus maximus
• Origin: 1.outer rim of ilium (medial aspect) 2.dorsal surface of sacrum and coccyx
3.sacrotuberous ligament
• Insertion: 1.IT band (primary insertion) 2.gluteal tuberosity of femur
• Action: 1.powerful extensor of hip 2.laterally rotates thigh 3.upper fibers aid in
abduction of thigh 4.fibers of IT band stabilize a fully extended knee
• Blood: 1.inferior gluteal artery (primary) 2.superior gluteal artery
• Nerve: inferior gluteal nerve, L5,S1,2
Gluteus medius
• Origin: 1.outer aspect of ilium (between iliac crest and anterior and posterior gluteal
lines) 2.upper fascia (AKA gluteal aponeurosis)
• Insertion: superior aspect of greater trochanter
• Action: 1.anterior and lateral fibers abduct and medially rotate the thigh 2.posterior
fibers may laterally rotate thigh 3.stabilizes the pelvis and prevents free limb from
sagging during gait
• Blood: superior gluteal artery
• Nerve: superior gluteal nerve, L4,5,S1
Gluteus minimus
• Origin: outer aspect of ilium (between anterior and inferior gluteal lines)
• Insertion: 1.greater trochanter (anterior to medius) 2.articular capsule of hip joint
• Action: 1.abduct and medially rotate the thigh 2.stabilizes the pelvis and prevents free
limb from sagging during gait
• Blood: superior gluteal artery
• Nerve: superior gluteal nerve, L4,5,S1
Piriformis
• Origin: pelvic surface of sacrum (anterior portion)
• Insertion: medial surface of greater trochanter (through greater sciatic foramen)
• Action: 1.lateral rotation of extended thigh 2.abducts a flexed thigh
• Blood: 1.superior gluteal artery 2.inferior gluteal artery
• Nerve: nerve to piriformis, S1,2
Superior gemellus
• Origin: ischial spine

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• Insertion: medial aspect of greater trochanter via upper tendon of obturator internus
• Action: 1.laterally rotates femur 2.abducts thigh when flexed
• Blood: inferior gluteal artery
• Nerve: nerve to obturator internus, L5,S1,2
Inferior gemellus
• Origin: ischial tuberosity
• Insertion: medial aspect of greater trochanter via lower tendon of obturator internus
• Action: laterally rotates femur
• Blood: inferior gluteal artery
• Nerve: nerve to quadratus femoris, L4,5,S1
Obturator externus
• Origin: 1.medial surface of obturator foramen 2.external surface of obturator
membrane • Insertion: trochanteric fossa of femur
• Action: 1.laterally rotates thigh 2.assists in flexion of hip joint
• Blood: obturator artery
• Nerve: obturator nerve, L2,3,4
Quadratus femoris
• Origin: lateral aspect of ischial tuberosity
• Insertion: quadrate line (along posterior aspect of femur and intertrochanteric crest)
• Action: laterally rotates femur
• Blood: inferior gluteal artery
• Nerve: nerve to quadratus femoris, L4,5,S1

114. The internal muscles of the pelvis: origin, insertion, action. Blood supply and
innervation the internal muscles of the pelvis.

Muscles of internal group:

Obturator internus
• Origin: 1.internal aspect margins of obturator foramen 2.obturator membrane
• Insertion: medial aspect of greater trochanter (through lesser sciatic foramen)
• Action: 1.laterally rotates femur 2.abducts thigh when flexed
• Blood: inferior gluteal artery

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• Nerve: nerve to obturator internus, L5,S1,2
Iliopsoas muscle = Psoas major and minor muscles + Iliacus Psoas major and
minor
• Origin: 1.transverse processes of L1-L5 2.vertebral bodies of T12-L4 and the
intervening intervertebral discs
• Insertion: iliopsoas tendon to the lesser trochanter of the femur
• Action: 1.hip flexion 2.lateral rotation
• Blood: muscular branches of medial femoral circumflex artery
• Nerve: ventral rami, L1,2,3
Iliacus
• Origin: inner surface of upper iliac fossa
• Insertion: iliopsoas tendon to the lesser trochanter of the femur
• Action: 1.powerful hip flexion 2.lateral rotation
• Blood: muscular branches of medial femoral circumflex artery
• Nerve: femoral nerve, L3,4

115. Muscles of the thigh: anterior group, origin, insertion, action. Blood supply and
innervation of anterior femoral muscles

Anterior Thigh Musculature

Sartorius
• Origin: anterior superior iliac spine (ASIS)
• Insertion: 1.upper medial surface of body of tibia 2.contributes to pez anserine
• Action: 1.flexes hip and knee 2.laterally rotates thigh if flexed at the hip
• Blood: 1.muscular branches of profunda femoris artery 2.saphenous branch of
descending genicular artery
• Nerve: branches of femoral nerve, L2,3
Quadriceps femoris consists of: 1. Rectus femoris
• Origin: 1.anterior head: anterior inferior iliac spine (AIIS) 2.posterior head: ilium just
above the acetabulum
• Insertion: 1.common quadriceps tendon into patella 2.tibial tuberosity via patellar
ligament
• Action: 1.extends knee 2.flexes hip
• Blood: lateral femoral circumflex artery

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• Nerve: branches of femoral nerve, [L2],3,4 2.
Vastus lateralis
• Origin: 1.greater trochanter 2.lateral lip of linea aspera 3.lateral intermuscular septum
• Insertion: 1.common quadriceps tendon into patella 2.tibial tuberosity via patellar
ligament
• Action: 1.extends knee 2.can abnormally displace patella
• Blood: lateral femoral circumflex artery
• Nerve: branches of femoral nerve, [L2],3,4 3.
Vastus intermedius
• Origin: anterior lateral aspect of the femoral shaft
• Insertion: 1.common quadriceps tendon into patella 2.tibial tuberosity via patellar
ligament
• Action: extends knee
• Blood: lateral femoral circumflex artery
• Nerve: branches of femoral nerve, [L2],3,4 4.
Vastus medialis
• Origin: 1.intertrochanteric line of femur 2.medial aspect of linea aspera
• Insertion: 1.common quadriceps tendon into patella 2.tibial tuberosity via patellar
ligament
• Action: extends knee
• Blood: 1.muscular branches of profunda femoris artery 2.saphenous branch of
descending genicular artery
• Nerve: branches of femoral nerve, [L2],3,4

116. Muscles of the thigh: posterior group, origin, insertion, action. Blood supply and
innervation of posterior femoral muscles.

Posterior Thigh Musculature

Semitendinosus
• Origin: ischial tuberosity
• Insertion: 1.medial aspect of tibial shaft 2.contributes to the pez anserine
• Action: 1.extends hip 2.flexes knee 3.medially rotates tibia
• Blood: 1.perforating branches of profunda femoris 2.inferior gluteal artery (to upper)

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 • Nerve: tibial nerve of sciatic bundle, L5,S1,2
Semimembranosus
• Origin: ischial tuberosity
• Insertion: 1.posterior medial aspect of medial tibial condyle 2.fibers join to form most
of oblique popliteal ligament (& medial meniscus)
• Action: 1.flexes knee 2.extends hip 3.medially rotates tibia 4.pulls medial meniscus
posterior during flexion
• Blood: 1.perforating branches of profunda femoris 2.inferior gluteal artery (to upper)
• Nerve: tibial nerve of sciatic bundle, L5,S1,2
Biceps femoris
• Origin: 1.long head: ischial tuberosity 2.short head: lateral lip of linea aspera and the
lateral intermuscular septum
• Insertion: 1.head of fibula 2.maybe to the lateral tibial condyle
• Action: 1.flexor at the knee (mainly short head) 2.laterally rotates thigh if flexed at the
knee 3.extends hip (long head)
• Blood: 1.perforating branches of profunda femoris 2.inferior gluteal artery (to upper)
• Nerve: 1.long head – tibial nerve, L5,S1,2 2.short head – common peroneal nerve,
L5,S1 Adductor magnus, posterior fibers are sometimes considered part of this group.
Its information is listed below with the other thigh adductors.

117. Muscles of the thigh: medial group, origin, insertion, action. Blood supply and
innervation of medial femoral muscles.

The muscles in the medial compartment of the thigh are collectively known as the hip
adductors.The muscles in this group may also receive blood from obturator
artery. There are five muscles : pectineus, adductor longus, adductor brevis, adductor
magnus and gracilis.
Pectineus
• Origin: 1.pectineal line of the pubis 2.superior pubic ramus
• Insertion: the pectineal line of the femur (just below the lesser trochanter on the posterior
aspect of the femur)
• Action: 1.flexes hip 2.adducts thigh 3.medially rotates thigh
• Blood: muscular branches of medial femoral circumflex artery
• Nerve:• femoral nerve ( L2-L3)
Adductor longus
• Origin: anterior surface of pubis, just inferior to the pubic tubercle
• Insertion: medial lip of linea aspera on middle half of femur
• Action: 1.adducts thigh 2.flexes thigh 3.may laterally rotate thigh at the hip
• Blood: muscular branches of femoral artery

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• Nerve: obturator nerve (L2-L4)
Adductor brevis
• Origin: body & inferior ramus of pubis
• Insertion: superior portion of linea aspera
• Action: adducts thigh (major), aids in flexion of thigh and laterally rotate thigh at the hip
• Blood: muscular branches of femoral artery
• Nerve: obturator nerve (L2-L4)
Adductor magnus
• Origin: 1.anterior fibers: inferior pubic ramus 2.oblique fibers: ischial ramus 3.posterior
fibers: ischial tuberosity
• Insertion: 1.proximal 1/3 of linea aspera 2.adductor tubercle
• Action: 1.adducts the thigh 2.posterior fibers also extend and laterally rotate thigh
• Blood: muscular branches of profunda femoris
• Nerve: Anterior part is innervated by the obturator nerve (L2-L4), posterior part is
innervated by the tibial nerve (L4-S3).
Gracilis
• Origin: body of pubis & inferior pubic ramus
• Insertion: 1.medial surface of proximal tibia, inferior to tibial condyle 2.contributes to the
pez anserine (leg)
• Action: Adduction of the thigh at the hip, and flexion of the leg at the knee, medially
rotates tibia
• Blood: obturator artery
• Nerve: obturator nerve (L2-L4)

118. Muscles of the leg: anterior group, origin, insertion, action. Blood supply and
innervation of anterior leg muscles.

Tibialis anterior
• Origin: 1.lateral tibial condyle 2.proximal 2/3 of anteriolateral surface of tibia
3.interosseous membrane 4.anterior intermuscular septum & crural fascia
• Insertion: 1.medial & plantar surface of base of 1st metatarsal 2.medial & plantar surface
of the cuneiform
• Action: Dorsiflexion and inversion of the foot
• Blood: anterior tibial artery
• Nerve: deep peroneal nerve (L4-S1)
Extensor hallucis longus
• Origin: 1.medial aspect of the fibula 2.interosseous membrane 3.crural fascia
• Insertion: dorsal surface of base of proximal and distal phalanx of hallux
• Action: Extension of the great toe and dorsiflexion of the foot
• Blood: anterior tibial artery
• Nerve: deep peroneal nerve (L4-S1)
Extensor digitorum longus
• Origin: 1.lateral condyle of the tibia 2.upper anterior surface of fibula 3.interosseous
membrane 4.crural fascia

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• Insertion: dorsal surface of the bases of the middle & distal phalanxes of the 2nd-5th rays
(via 4 tendons and giving a fibrous expansion)
• Action: Extension of the lateral four toes and dorsiflexion of the foot
• Blood: anterior tibial artery
• Nerve: deep peroneal nerve (L4-S1)
Peroneus tertius
• Origin: 1.distal 1/3 of anterior fibula 2.distal & lateral aspect of extensor digitorum
• Insertion: dorsal surface of base of 5th metatarsal
• Action: Eversion and dorsiflexion of the foot
• Blood: anterior tibial artery
• Nerve: deep peroneal nerve (L4-S1)

119. Muscles of the leg: posterior group, origin, insertion, action. Blood supply and
innervation of posterior leg muscles.

The posterior compartment of the leg contains seven muscles, organised into two layers –
superficial and deep. The two layers are separated by a band of fascia.
Superficial:
Gastrocnemius
• Origin: 1.medial head: just above medial condyle of femur 2.lateral head: just above
lateral condyle of femur
• Insertion: calcaneus via lateral portion of calcaneal tendon
• Action: plantarflex the ankle, knee flexion and stabilizes ankle and knee when standing
• Blood: 1.sural branches of popliteal artery 2.muscular branches of peroneal artery 3.posterior tibial
artery
• Nerve: tibial nerve (S1-S2)
Soleus
• Origin: 1.upper fibula 2.soleal line of tibia
• Insertion: calcaneus via medial portion of calcaneal tendon
• Action: plantarflex the foot
• Blood: 1.sural branches of popliteal artery 2.muscular branches of peroneal artery
3.posterior tibial artery
• Nerve: tibial nerve (S1-S2)
Plantaris
• Origin: above the lateral head of gastrocnemius on femur
• Insertion: calcaneus, medial to calcaneal tendon, or blending with the calcaneal tendon
• Action: like a weak gastrocnemius (plantarflex the ankle, knee flexion and stabilizes
ankle and knee when standing)
• Blood: 1.sural branches of popliteal artery 2.muscular branches of peroneal artery
3.posterior tibial artery
• Nerve: tibial nerve (S1-S2)
Deep:
Popliteus
• Origin: 1.lateral femoral condyle 2.arcuate popliteal ligament 3.lateral meniscus 4.knee

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joint capsule
• Insertion: posterior tibial surface above the soleal line
• Action: laterally and medially rotates femur on tibia and unlocks knee
• Blood: sural branches of popliteal artery
• Nerve: tibial nerve (L5-S1)
Flexor digitorum longus
• Origin: 1.posterior surface of tibia 2.crural fascia
• Insertion: plantar surface of bases of the 2-5th distal phalanges
• Action: 1.primarily flexes 2nd – 5th toes 2.weak plantarflexor 3.weak inversion &
adduction of foot
• Blood: 1.peroneal artery 2.posterior tibial artery
• Nerve: tibial nerve (L5-S1)
Tibialis posterior
• Origin: 1.posterior, proximal tibia 2.interosseous membrane 3.medial surface of fibula
• Insertion: 1.navicular tuberosity (principle) 2.all 3 cuneiforms (plantar surface) 3.bases of
2nd-4th metatarsals 4.cuboid 5.sustentaculum tali of calcaneus
• Action: Inverts and plantarflexes the foot, maintains the medial arch of the foot, stabilizes
ankle
• Blood:1.peroneal artery 2.posterior tibial artery
• Nerve: tibial nerve (L5-S1)
Flexor hallucis longus
• Origin: 1.posterior, inferior 2/3 of fibula 2.interosseous membrane 3.crural fascia &
posterior intermuscular septum
• Insertion: plantar surface of distal phalanx of hallux
• Action: Flexes the great toe (hallux)
• Blood: 1.peroneal artery 2.posterior tibial artery
• Nerve: tibial nerve (L5-S1/S2)

120. Muscles of the leg: lateral group, origin, insertion, action. Blood supply and
innervation of lateral leg muscles.

Peroneus longus
• Origin: head of the fibula
• Insertion: first metatarsal and medial cuneiform
• Action: plantar flexion and foot eversion
• Blood: muscular branches of the peroneal artery
• Nerve: superficial peroneal nerve (L4/L5-S1)
Peroneus brevis
• Origin: lower two thirds of lateral surface of the fibula
• Insertion: lateral tubercle at base of fifth metatarsal
• Action: eversion of foot
• Blood: muscular branches of the peroneal artery
• Nerve: superficial peroneal nerve (L4/L5-S1)

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121. The muscles of the foot: topographical classification, action. Blood supply and
innervation the foot muscles.

The muscles acting on the foot can be divided into two distinct groups; extrinsic and
intrinsic muscles.
The extrinsic muscles arise from the anterior, posterior and lateral compartments of the leg.
They are mainly responsible for actions such as eversion, inversion, plantarflexion and
dorsiflexion of the foot.
The intrinsic muscles are located within the foot and are responsible for the fine motor
actions of the foot, for example movement of individual digits.
That muscles can be divided into those situated on the dorsum of the foot, and those in the
sole/plantar of the foot.
Dorsum
extensor hallucis brevis
• Action: extension of metatarsophalangeal joint of great toe
• Blood dorsalis pedis artery
• Nerve: deep peroneal nerve
extensor digitorum brevis
• Action: extension of toes II to IV
• Blood: dorsalis pedis artery
• Nerve: deep peroneal nerve
Plantar
There are 10 intrinsic muscles located in the sole of the foot. They act collectively to
stabilise the arches of the foot, and individually to control movement of the digits. All the
muscles are innervated either by the medial plantar nerve or the lateral plantar nerve,
which are both branches of the tibial nerve. The muscles of the plantar aspect are described
in four layers
Layer I
The first layer of muscles is the most superficial to the sole, and is located immediately
underneath the plantar fascia.
abductor hallucis muscle
• Action: flexes the big toe
• Blood: medial plantar artery
• Nerve: medial plantar nerve from tibial nerve
flexor digitorum brevis muscle
• Action: flexes toes 2-4
• Blood: medial and lateral plantar arteries
• Nerve: medial plantar nerve from tibial nerve
abductor digiti minimi muscle
• Action: abducts little toe
• Blood: lateral plantar artery
• Nerve: lateral plantar nerve from the tibial nerve
Layer II
quadratus plantae muscle

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• Action: assists flexor digitorum longus tendon in flexing toes 2 -4
• Blood: branch of the posterior tibial artery
• Nerve: lateral plantar nerve from tibial nerve
lumbrical muscles (4 muscles)
• Action: flexion of metatarsophalangeal joint and extension of interphalangeal joints
• Blood: medial and lateral plantar arteries
• Nerve: first lumbrical: medial plantar nerve from the tibial nerve
second, third and fourth lumbricals: lateral plantar nerve from the tibial nerve
Layer III
flexor hallucis brevis muscle
• Action: flexes the great toe
• Blood: medial plantar artery
• Nerve: medial plantar nerve
Adductor hallucis muscle
• Action: adducts great toe at metatarsophalangeal joint
• Blood: lateral plantar artery
• Nerve: lateral plantar nerve from tibial nerve
flexor digiti minimi brevis muscle
• Action: flexes 5th toe at metatarsophalangeal joint
• Blood: lateral plantar artery
• Nerve: lateral plantar nerve from tibial nerve
Layer IV
dorsal interossei muscles (4 muscles)
• Action: flexes and abduction of toes 2-4 at metatarsophalangeal joints
• Blood: lateral plantar arch
• Nerve: lateral plantar nerve (deep branch)
plantar interossei muscles (3 muscles)
• Action: flexes and abduction of toes 2-4
• Blood: lateral plantar arch
• Nerve: lateral plantar nerve (deep branch)

122. The fascia of lower limb: iliac fascia and its derivatives (iliopectineal arch,
lacuna vasorum, lacuna musculorum, structure and contents).

The portions investing the Iliacus (fascia iliaca; iliac fascia) is connected,
laterally to the whole length of the inner lip of the iliac crest; and medially, to the
linea terminalis of the lesser pelvis, where it is continuous with the periosteum.
Iliopectineal arch - a thickened band of iliac fascia and psoas fascia passing posteriorly
from the posterior aspect of the inguinal ligament across the anterior aspect of the femoral
nerve to attach to the iliopectineal eminence of the hip bone. The iliopectinal arch thus
forms a septum that subdivides the space deep to the inguinal ligament into a lateral lacuna
musculorum and a medial lacuna vasorum. When a psoas minor muscle is present, its
tendon of insertion blends with the iliopectineal arch.

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123. The fasciae of lower limb: fascia lata and derivatives (subcutaneous hiatus,
falciform border, formation and content).

The tensor fascia lata is a gluteal muscle that acts as a flexor, abductor and internal rotator
of the hip. Its nomenclature however, is derived from its additional role in tensing the
fascia lata.
The muscle originates from the iliac crest, and descends down the superolateral thigh. At
the junction of the middle and upper thirds of the thigh, it inserts into the anterior aspect of
the iliotibial tract. When stimulated, the tensor fasciae lata tautens the iliotibial band and
braces the knee, especially when the opposite foot is lifted.Superficial lamina of of fascia
lata lays in femoraltrigone and terminetes below by falciform margin that has superior
cornuand inferior cornu. Superior cornu inosculates with inguinal ligament,inferior cornu –
with deep sheet of fascia lata femoris. Hiatus saphaenusis formed under falciform margin
that covered by cribriform fascia (thinnestpart of fascia lata). While femoral hernia
happened hiatus saphaenus convert into external annulus of femoral canal.

124. Topography of the pelvis: suprapiriform and infrapiriform foramina, obturatory

canal, the structure and content.

The bony pelvis consists of the two hip bones (also known as innominate or pelvic bones),
sacrum and coccyx. Consists of three parts, the pubis, the ilium
and the ischium which synostose in the acetabular fossa, which is bordered
by the limbus of the acetabulum and is surrounded by the lunate articular
surface. The acetabular notch opens the acetabulum inferiorly and thus
limits the obturator foramen
There are four articulations within the pelvis:
Sacroiliac Joints (x2) – Between the ilium of the hip bones, and the sacrum
Sacrococcygeal symphysis – Between the sacrum and the coccyx.
Pubic symphysis – Between the pubis bodies of the two hip bones.
The pelvic inlet marks the boundary between the greater pelvis and lesser pelvis. Its size is
defined by its edge, the pelvic brim.

125. Topography of the thigh: muscular and vascular lacuna, femoral triangle,
femoral ring, borders, contents.

The femur is the largest long bone in the body and is divided into the shaft with the neck,
and proximal and distal ends. Dorsally in shaft is the linea aspera. The medial and lateral
lips of the linea aspera diverge proximally and distally, and the lateral lip ends in the
gluteat tuberosity.The opening to the femoral canal is located at its superior border, known
as the femoral ring. The femoral ring is closed by a connective tissue layer – the femoral
septum. This septum is pierced by the lymphatic vessels exiting the canal.Femoral triangle
is this anatomical triangle found in the upper thigh at the junction between the anterior
abdominal wall and the muscles of the upper thigh.
The opening to the femoral canal is located at its superior border, known as the femoral

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ring. The femoral ring is closed by a connective tissue layer – the femoral septum. This
septum is pierced by the lymphatic vessels exiting the canal.

126. The adductorius canal: walls, openings, contents.

The adductor canal is a narrow conical tunnel located in the thigh. It is 15cm long,
extending from the apex of the femoral triangle to the adductor hiatus (- a gap between the
adductor and hamstring attachments of the adductor magnus). The canal serves as a
passageway from structures moving between the anterior thigh and posterior leg.
The adductor canal is bordered by muscular structures:
Anterior: Sartorius.
Lateral: Vastus medialis.
Posterior: Adductor longus and adductor magnus.
It contains the femoral artery, femoral vein, nerve to the vastus medialis and the
saphenous nerve (the largest cutaneous branch of the femoral nerve).

127. Popliteal fossa: structure, communication with the canals of thigh and leg.

The popliteal fossa is a diamond shaped area found on the posterior side of the knee. It is
the main path in which structures move from the thigh to the leg. The popliteal fossa is the
main conduit for neurovascular structures entering and leaving the leg. Its contents are
(medial to lateral). The contents of the popliteal fossa : Popliteal artery, Popliteal vein,
Tibial nerve, Common fibular nerve. The popliteal fossa also has a floor and a roof. The
floor of the popliteal fossa is formed by the posterior surface of the knee joint capsule, and
by the posterior surface of the femur. The roof is made of up two layers; popliteal fascia
and skin. The popliteal fascia is continuous with the fascia lata of the leg. The tibial and
common fibular nerves are the most superficial of the contents of the popliteal fossa. They
are both branches of the sciatic nerve. The common fibular nerve follows the biceps
femoris tendon, running along the lateral margin of the popliteal fossa. The small
saphenous vein pierces the popliteal fascia of the popliteal fossa to enter the diamond, and
empty into the popliteal vein. In the popliteal fossa, the deepest structure is the popliteal
artery. It is a continuation of the femoral artery, and travels into the leg to supply it with
blood.

128. Topography of the leg: cruro-popliteal canal, superior and inferior

musculoperoneal canals, structure, contents.

Leg refers to the portion of the lower limb between the knee and ankle joints. Note that this
anatomical definition is different from the everyday use of the word "leg" which often
refers to the entire lower limb. The upper portion of the lower limb, between hip and knee
joints, is referred to as the thigh.
The cruropopliteal canal leads from the popliteal fossa into the leg. It resides in the back
between the deep muscles of the leg and the soleus.
Therefore, its anterior wall is formed by the tibialis posterior, while the anterior wall — by

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the soleus.
The canal has three openings — superior, inferior, and anterior. The superior opening of
the canal is bounded by the popliteus in the front and by the tendineous arch of the soleus
in the back.
The inferior opening resides between the tibialis posterior and soleus, where the latter
becomes the Achilles tendon. The anterior opening is located in the upper part of the
interosseous membrane of the leg.
The inferior musculoperoneal canal is the branch of the cruropopliteal canal in the
lateral direction. Its anterior wall is formed by the posterior surface of the fibula, while its
posterior wall — by the flexor hallucis longus. It transmits the fibular vessels.
The superior musculoperoneal canal is an independent canal, which resides in the upper
third of the leg between the lateral surface of the fibula and peroneus longus. It gives
passage to the superficial peroneal nerve.

129. Femoral canal: femoral ring (inlet), subcutaneous hiatus (outlet); walls of the
femoral canal.

The femoral canal is an anatomical compartment, located in the anterior thigh. It is the
smallest and most medial part of the femoral sheath. It is approximately 1.3cm long.
The femoral canal is located in the anterior thigh, within the femoral triangle. It can be
thought of as a rectangular shaped compartment.
The femoral ring boundaries are:
medial: lacunar ligament
anterior: medial part of the inguinal ligament
lateral: femoral vein within the intermediate compartment of the femoral sheath
posterior: pectineal ligament overlying the pectineus and its fascia covering the superior
pubic ramus
The opening to the femoral canal is located at its superior border, known as the femoral
ring. The femoral ring is closed by a connective tissue layer – the femoral septum. This
septum is pierced by the lymphatic vessels exiting the canal.
Femoral hernias occur through the femoral ring into the femoral canal. As three of the four
boundaries of the femoral ring are either ligamentous or osseous, the ring is unforgiving,
which explains the high risk incarceration of femoral hernias.

130. Oral cavity, parts. Vestibule of oral cavity: walls, their structure. Proper oral
cavity, walls, communications.

The cavity of the mouth is placed at the commencement of the digestive tube it is a nearly
oval-shaped cavityThe mouth consists of two regions, the vestibule (outer, smaller portion)
and the oral cavity proper (inner, larger part)
Vestibule - The horseshoe-shaped vestibule is situated anteriorly. It is the space between
the lips/cheeks, and the gums/teeth.
The vestibule communicates with the mouth proper via the space behind the third molar
tooth, and with the exterior through the oral fissure. The diameter of the oral fissure is

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controlled by the muscles of facial expression – principally the orbicularis oris.
Opposite the upper second molar tooth, the duct of the parotid gland opens out into the
vestibule, secreting salivatory juices.
The mouth proper lies posteriorly to the vestibule. It is bordered by a roof, a floor, and the
cheeks. The tongue fills a large proportion of the cavity of the mouth proper.
The roof of the mouth proper consists of the hard and soft palates..The floor of the oral
cavity consists of several structures:
Muscular diaphragm – comprised of the bilateral mylohyoid muscles. It provides structural
support to the floor of the mouth, and pulls the larynx forward during swallowing.
Geniohyoid muscles – pull the larynx forward during swallowing.
Tongue – connected to the floor by the frenulum of the tongue, a fold of oral mucosa.
Salivary glands and ducts.

131. Palate: Hard and Soft palate, structure. Muscles of the soft palate. Tonsils,
topography.

Palate consists of two regions: 1. the anterior two-thirds or bony

part – the hard palate. 2. the mobile posterior one-third or fibromuscular
part – the soft palate.
The hard palate - It is a bony plate that separates the nasal cavity from the oral cavity.
Formed by palatine processes of the maxillae and the horizontal plates of the palatine
bones covered by mucous membrane, which contains small salivary glands. Posteriorly the
hard palate is continuous with the soft palate. The soft palate is a posterior continuation of
the hard palate. In contrast to the hard palate, it is a muscular structure. The soft palate
contains a membranous aponeurosis and is a movable, fibromuscular fold that is attached
to the
posterior edge of the hard palate. The soft palate or velum palatinum extends posterior
inferiorly to a curved free margin from which hangs a conical process – the uvula. It
separates the nasopharynx superiorly from the oropharynx inferiorly. Laterally the soft
palate is continuous with the wall of the pharynx and is joined to the tongue and pharynx
by the palatoglossal and palatopharyngeal arches, between which locate the palatine tonsil.
Deep to the palatal mucosa are mucous glands. The soft palate is formad
by 5 muscles:
1. Tensor veli palatini muscle – stretches velum palatine and widens
aperture of uditory tube;
2. Levator veli palatini muscle – lifts soft palatine;
3. Uvulae muscle – lifts and shortens the uvula;
4. Palatoglossus muscle – lowers the velum palatinum, narrows the
fauceus and lifts the lingual root;
5. Palatopharyngeus muscle –narrows the fauceus and lifts the
pharynx.
Palatine tonsils, occasionally called the faucial tonsils, are the tonsils on the left and right
sides at the back of the throat, which can often be seen as flesh-colored, pinkish lumps.

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132. Tongue: parts, structure, mucous membrane, functions of the tongue.

The tongue is situated partly in the mouth and partly in the oropharynx. The tongue is a
muscular organ covered by oral mucosa which is specialised for manipulating food,
general sensory reception and the special sensory function of taste. It consists of three
parts: apex, body and root. The mucous membrane on the oral part of the tongue carries
numerous of the papillae:
The filiform papillae and conic papillae – contain afferent nerve
endings that are sensitive to touch.
The fungiform papillae – small and mushroom-shaped. They usually
appear as pink or red spots. Contain taste receptors located in the taste
buds.
The vallate papillae – are the largest papillae (1 to 2 mm in diameter).
They lie just anterior to the sulcus terminalis and carry taste buds.
The foliate papillae – are small lateral folds of the lingual margins.
They contain taste receptors
The first set we will consider are the intrinsic muscles. They only attach to other structures
in the tongue. They are named by the direction in which they travel, and so are named the
superior longitudinal, inferior longitudinal, transverse and vertical muscles of the tongue.
The extrinsic muscles are as follows:
Genioglossus
Attachments: Arises from the mental symphysis and inserts into the dorsum of the tongue
Function: Inferior fibres protrude the tongue, middle fibres depress the tongue, and
superior fibres draw the tip back and down
Hyoglossus
Attachments: Arises from the hyoid bone and inserts into the side of the tongue
Function: Depresses and retracts the tongue
Styloglossus
Attachments: Originates at the styloid process of the temporal bone and inserts into the
side of the tongue
Function: Retracts and elevates the tongue
Palatoglossus
Attachments: Arises from the palatine aponeurosis and inserts broadly across the tongue
Function: Elevates the posterior aspect of the tongue
All of the intrinsic and extrinsic muscles are innervated by the hypoglossal nerve (CN XII),
except palatoglossus, which has vagal innervation (CN X).

133. Blood supply and innervation of the tongue.

In the anterior ⅔, general sensation is supplied by the trigeminal nerve (V). Specifically the
lingual nerve, a branch of the mandibular nerve (CN V3).
On the other hand, taste in the anterior 2/3 is supplied from the facial nerve (VII). In the
petrous part of the temporal bone, the facial nerve gives off three branches, one of which is
chorda tympani. This travels through the middle ear, and continues on to the tongue.

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The posterior ⅓ of the tongue is slightly easier. Both touch and taste are supplied by the
glossopharyngeal nerve (IX).
The lingual veins, drain into the internal jugular vein. The floor of the mouth also receives
its blood supply from the lingual artery. There is also a secondary blood supply to the
tongue from the tonsillar branch of the facial artery and the ascending pharyngeal artery.

134. Teeth: parts of the tooth. Occlusion.

The teeth may be divided into deciduous (primary) teeth in chilhood age and permanent
teeth in adult. Each tooth consists of three parts: crown, neck and root. The crown has 5
surfaces: lingual, vestibular (labial or buccal), contact (proximal and distal), occlusal. The
neck is the part of the tooth between the crown and the root. The root is fixed in the
alveolar socket by a fibrous periodontal ligament (gomphosis). The tooth sits in alveolar
processes of the upper jaw (maxilla) or lower jaw (mandible). Each tooth is mainly
composed of dentin and is made up of several parts:
crown: portion of the tooth projecting out of bone (dentin is covered by enamel)
root: portion of tooth embedded in bone (composed of cementum)
pulp cavity : contains connective tissue, blood vessels, and nerves
apical foramen: lies at the apex of the tooth root
The roots of the teeth fit into sockets called dental alveoli in the alveolar process of the
mandible and maxillae. Each socket is lined with periodontal membrane.

135. Permanent and milk teeth: dental formula, types of teeth. Dentition terms of
permanent and milk teeth.

There are normally a total of 32 permanent (secondary) teeth in adults, with 16 per jaw and
eight in each quadrant, which consists of
2 incisors
1 canine
2 pre-molars
3 molars
There are 20 deciduous (primary) teeth in young children, with ten per jaw and five in each
quadrant, which consist of:
2incisors
1 canine
0 pre-molars
2 molars

Types of Teeth
Medial and lateral incisors – have a single root and chisel-shaped crown. Action: they cut
off portions of food.
Canine – has a single root, conical crown. Action: holding and bite the food.
Premolar – has a single root, sometimes upper tooth has bifurcated root. Crown carries
two tubercles. Action: crushing the food.

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Molar – upper teeth have three roots, lower teeth have two roots.
Crown carries 3-5 tubercles on occlusal surface. Action: grinding the food
Age terms of eruption of deciduous teeth and permanent teeth:
Type of tooth Deciduous Permanent
Incisors 6–9 months 7–9 years
Canines 16–20 months 10–13 years
First Premolar - 10–12 years
Second Premolar - 11–15 years
First Molar 12–15 months 6–7 years
Second Molar 20–24 months 13–16 years
Third Molar - 18–30 years

136. Parotid gland: topography, structure. Blood supply and innervation of the
parotid gland.

The parotid gland is a bilateral salivary gland located in the face. It produces serous saliva,
a watery solution rich in enzymes. This is then secreted into the oral cavity, where it
lubricates and aids in the breakdown of food.
It lies within a deep hollow, known as the parotid region. The parotid region is bounded as
follows:
Superiorly – Zygomatic arch.
Inferiorly – Inferior border of the mandible.
Anteriorly – Masseter muscle.
Posteriorly – External ear and sternocleidomastoid.
Several important neurovascular structures pass through the gland:

The facial nerve (cranial nerve VII), gives rise to five terminal branches within the parotid
gland. These branches innervate the muscles of facial expression.
The external carotid artery (ECA) ascends through the parotid gland. Within the gland, the
ECA gives rise to the posterior auricular artery. The ECA then divides into its two terminal
branches – the maxillary artery and superficial temporal artery.
The retromandibular vein is formed within the parotid gland by the convergence of the
superficial temporal and maxillary veins. It is one of the major structures responsible for
venous drainage of the face.
The parotid gland receives sensory and autonomic innervation. The autonomic innervation
controls the rate of saliva production.
Sensory innervation is supplied by the auriculotemporal nerve, a branch of the mandibular
nerve (V3).
The parasympathetic innervation to the parotid gland has a complex path. It begins with
the glossopharyngeal nerve (cranial nerve IX). This nerve synapses with the otic ganglion
(a collection of neuronal cell bodies). The auriculotemporal nerve then carries
parasympathetic fibres from the otic ganglion to the parotid gland. Parasympathetic
stimulation causes an increase in saliva production.
Sympathetic innervation originates from the superior cervical ganglion, part of the

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paravertebral chain. Fibres from this ganglion travel along the external carotid artery to
reach the parotid gland. Increased activity of the sympathetic nervous system inhibits
saliva secretion, via vasoconstriction.

Blood is supplied by the posterior auricular and superficial temporal arteries. They are both
branches of the external carotid artery, which arise within the parotid gland itself.
Venous drainage is achieved via the retromandibular vein. It is formed by unification of
the superficial temporal and maxillary veins.

137. Glands of oral cavity: classification. Minor salivary glands, topography and
morpho-functional characteristic.

Salivary glands may be subdivided into small and large. Small one (labial, buccal, palatine
and lingual) situated in mucous membrane of mouth cavity. Function: produce saliva,
which keeps the mouth and other parts of the digestive system moist. It also helps break
down carbohydrates and lubricates the passage of food down from the oro-pharynx to the
esophagus to the stomach.
Parotid gland is situated in retromandibular fossa: front and lower from auricle, laterally
from ramus mandibulae and posterior margin of masseter muscle. This is – compound
alveolar gland, which produces serous secret. Parotid duct opens on the cheeks into
vestibule of mouth cavity opposite the second superior molar. Parotid gland has superficial
part and deep part also can be additional parotid gland, which disposes on surface of
masticator muscle closely to parotid duct. Parotid gland secretes saliva through the parotid
duct into the mouth, to facilitate mastication and swallowing and to begin the digestion of
starches.
Submandibular gland lies in submandibular triangle, it is compound alveolar-tubular
gland, and produces mixed secret. Submandibular duct (Vartona) opens on sublingual
papilla. The submandibular gland accounts for 80% of all salivary duct calculi (salivary
stones or sialolith), possibly due to the different nature of the saliva that it produces and the
tortuous travel of the submandibular duct to its ductal opening for a considerable upward
distance.
Sublingual gland lies in the floor of the mouth between the mandible and the genioglossus
muscle. This is compound alveolar-tubular gland, it produces mucous secret. Greater
sublingual duct opens on sublingual papilla near submandibular duct (sometimes the ducts
open together as one). Lesser sublingual ducts open along sublingual fold. major salivary
glands in the mouth. They are the smallest, most diffuse, and the only unencapsulated
major salivary glands. They provide only 3-5% of the total salivary volume.
Minor salivary glands There are 800-1000 minor salivary glands located throughout the
oral cavity within the submucosa of the oral mucosa in the tissue of the buccal, labial, and
lingual mucosa, the soft palate, the lateral parts of the hard palate, and the floor of the
mouth or between muscle fibers of the tongue.

138. Sublingual and submandibular glands: topography, structure. Blood supply and
innervation of the sublingual and submandibular glands.

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Submandibular gland lies in submandibular triangle, it is compound alveolar-tubular
gland, and produces mixed secret. Submandibular duct (Vartona) opens on sublingual
papilla. The submandibular gland accounts for 80% of all salivary duct calculi (salivary
stones or sialolith), possibly due to the different nature of the saliva that it produces and the
tortuous travel of the submandibular duct to its ductal opening for a considerable upward
distance.
Parasympathetic innervation to the submandibular glands is provided by the superior
salivatory nucleus via the chorda tympani, a branch of the facial nerve, that becomes part
of the trigeminal nerve's lingual nerve prior to synapsing on the submandibular ganglion.
Increased parasympathetic activity promotes the secretion of saliva.
The sympathetic nervous system regulates submandibular secretions through
vasoconstriction of the arteries that supply it. Increased sympathetic activity reduces
glandular bloodflow, thereby decreasing the volume of fluid in salivary secretions,
producing an enzyme rich mucous saliva.
The gland receives its blood supply from the facial and lingual arteries.The gland is
supplied by sublingual and submental arteries and drained by common facial and lingual
veins.
Sublingual gland lies in the floor of the mouth between the mandible and the genioglossus
muscle. This is compound alveolar-tubular gland, it produces mucous secret. Greater
sublingual duct opens on sublingual papilla near submandibular duct (sometimes the ducts
open together as one). Lesser sublingual ducts open along sublingual fold. major salivary
glands in the mouth. They are the smallest, most diffuse, and the only unencapsulated
major salivary glands. They provide only 3-5% of the total salivary volume.
The chorda tympani nerve (from the facial nerve via the submandibular ganglion) is
secretomotor and provides parasympathetic supply to the sublingual glands. The path of
the nerve is as follows: junction between pons and medulla, through internal acoustic
meatus and facial canal to chorda tympani, through middle ear cavity, out petrous temporal
to join the lingual nerve, travels with lingual nerve to synapse at the submandibular
ganglion, then postganglionic fibers travels to the sublingual gland.
The gland receives its blood supply from the sublingual and submental arteries.Lymph
from the sublingual salivary gland drains into the submandibular lymph nodes.

139. Fauces: boundaries, connections. Tonsils, topography.

Fauces - The space between the cavity of the mouth and the pharynx, bounded by the soft
palate and the base of the tongue.

The isthmus of the fauces or the oropharyngeal isthmus is a part of the oropharynx directly
behind the mouth cavity, bounded superiorly by the soft palate, laterally by the
palatoglossal arches, and inferiorly by the tongue.
The fauces are regarded as the two pillars, formed by the palatoglossus and the
palatopharyngeus muscle, respectively, and covered with mucous membrane. The anterior
one is known as the palatoglossal arch, and the posterior one is known as the

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palatopharyngeal arch. Between these two arches is the palatine tonsil.
Each palatoglossal arch runs downwards, laterally and forwards, from the soft palate to the
side of the tongue. The approximation of the arches due to the contraction of the
palatoglossal muscles constricts the isthmus, and is essential to swallowing (deglutition).
In this species faucitis is usually caused by bacterial and viral infections although food
allergies need to be excluded in any diagnosis.

140. Pharynx: topography (holotopy, skeletotopy, syntopy), parts, communications;

lymphatic pharyngeal ring.

Pharynx - extends from skull base to level of C6 vertebra. The

pharynx is located posterior to the nasal and oral cavities and the larynx
and is the common route for air and food (conducts food to the oesophagus
and air to the larynx and lungs). Its cavity subdivides into nasal part, oral
part and laryngeal part.

Nasopharynx is respiratory part; it communicates by choanae with nasal cavity.

Nasopharynx extends to the bodies of C2 vertebrae. Lateral walls contain the pharyngeal
orifice of auditory tube, which communicate a pharynx with tympanic cavity. These
foramens are limited behind and from above by torus tubarius. Between last and velum one
can find pair agglomeration of lymphoid tissue – tubal tonsil. Pharyngeal (adenoid) tonsil
disposed on border of pharyngeal fornix and posterior wall Submucous layer of nasal part
is absent; instead it there is fibrous membrane, which does not allow walls to close the
cavity of nasopharynx.
Oropharynx communicates with mouth cavity by fauceus, which is limited by velum
palatine, root of tongue and palatine-pharyngeal arches. There are median glossoepiglottic
fold and lateral (pair) glossoepiglottic folds. Posteriorly the oropharynx is related to the
bodies of C2 to C4 vertebrae.
Laryngopharynx contains the entrance into larynx communicates with laryngeal cavity. It
is related to the bodies of C4 to C6 vertebrae. Piriform recesses are situated on sides from
entrance into larynx. Laryngopharynx continues with the oesophagus.

Waldeyer's tonsillar ring (pharyngeal lymphoid ring ) is an anatomical term collectively

describing the annular arrangement of lymphoid tissue in the pharynx. Waldeyer's ring
circumscribes the naso- and oropharynx, with some of its tonsillar tissue located above and
some below the soft palate.

141. Pharynx: structure of the mucosa, muscular and external coats. Blood supply
and innervation of the pharynx.

Innervation of the majority of the pharynx is achieved by the pharyngeal plexus, which
comprises of:
Branches of the glossopharyngeal nerve (CN IX)
Branches of the vagus nerve (CN X)

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Sympathetic fibres of the superior cervical ganglion.
Sensory: Each of the three sections of the pharynx have a different innervation:
The nasopharynx is innervated by the maxillary nerve (CN V2).
The oropharynx by the glossopharyngeal nerve (CN IX).
The laryngopharynx by the vagus nerve (CN X).
Motor: All the muscles of the pharynx are innervated by the vagus nerve (CN X), except
for the stylopharyngeus, which is innervated by the glossopharyngeal nerve (CN IX).

Arterial supply is via branches of the external carotid artery: ascending pharyngeal,
lingual, facial and maxillary arteries.
Venous drainage is achieved by the pharyngeal venous plexus, which drains into the
internal jugular vein.

There are two types of muscles that form the walls of the pharynx – longitudinal and
circular. Both types are innervated by the vagus nerve, except for the stylopharyngeus,
which is innervated by the glossopharyngeal nerve.
The circular muscles contract sequentially from superior to inferior to constrict the lumen
and propel the bolus of food inferiorly into the oesophagus.
They are stacked like glasses and are an incomplete muscular circle, anteriorly attaching to
structures in the neck.
They are all innervated by the vagus nerve (CN X):
Superior pharyngeal constrictor is found in the oropharynx.
Middle pharyngeal constrictor is found in the laryngopharynx.
Inferior pharyngeal constrictor is found in the laryngopharynx and has two components.
The superior component (thyropharyngeus) has oblique fibres that attach to the thyroid
cartilage and the inferior component (cricopharyngeus) has horizontal fibres that attach to
the cricoid cartilage.
The longitudinal muscles shorten and widen the pharynx, and elevate the larynx during
swallowing.
Stylopharyngeus: from the styloid process of the temporal bone to the pharynx, innervated
by the glossopharyngeal nerve (CN IX)
Palatopharyngeus: from hard palate of the oral cavity to the pharynx, innervated by the
vagus nerve (CN X)
Salpingopharyngeus: from the Eustachian tube to the pharynx, innervated by the vagus
nerve (CN X). In addition to contributing to swallowing, it also opens the Eustachian tube
to equalize the pressure in the middle ear with the atmosphere.

142. Esophagus: parts, topography (holotopy, skeletotopy, syntopy). Blood

supply and innervation of the esophagus.

The esophagus is about 25-30 cm of length tube, which extends from the pharynx to the
stomach. Esophagus has cervical part, thoracic part and abdominal part. Topography:
thoracic portion positioned in superior and posterior mediastinum. Esophagus is related to
the bodies of C6 to Th 11 vertebrae, also to trachea in cervical part and behind aorta in

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mediastinum.
The esophagus is innervated by the vagus nerve and the cervical and thoracic sympathetic
trunk.The vagus nerve has a parasympathetic function, supplying the muscles of the
esophagus and stimulating glandular contraction.The sympathetic trunk has a sympathetic
function. It may enhance the function of the vagus nerve, increasing peristalsis and
glandular activity, and causing sphincter contraction. In addition, sympathetic activation
may relax the muscle wall and cause blood vessel constriction.

The blood supply to the esophagus can roughly be divided into thirds, with anastamoses
between each area of supply
Esophageal branches of inferior thyroid artery (top third)
Esophageal branches of thoracic part of aorta (middle third)
Esophageal branches of left gastric artery (bottom third)

143. Esophagus: structure of the wall, anatomical and physiological

constrictions.

Oesophageal wall consists of mucous membrane, submucous stratum,

muscular membrane and external connective tissue adventitia. Submucous
stratum is well developed, that why mucous membrane forms the
longitudinal folds. Submucous stratum contains the numerous of
oesophageal glands. Muscular membrane consists of internal circular layer
and external longitudinal layer. In superior third a muscular membrane is
formed by striped muscles, in middle part gradually replaces by smooth
muscles, and inferiorly has only the smooth muscles. Abdominal part of
oesophagus is covered by peritoneum.

Oesophagus has 3 anatomic constrictions.

• pharyngeîesophageal constriction is in place of transition from
pharynx into oesophagus, on level of the C7 – 7th cervical vertebra;
• constriction of thoracic part is a place, where left principal bronchi,
presses an oesophagus is on level of the 5th thoracic vertebrae;
• phrenic constriction is a place, where an oesophagus passes through
the lumbar part of the diaphragm on level of the 9th –10th thoracic vertebrae.
Physiological constrictions (2):
• aortic constriction is a place, where aorta bends and adjoins to
oesophagus on level of the Th4 of thoracic vertebra;
• abdominal (cardiac) constriction is in place of entry into cardiac
portion of stomach – on level of the Th11 thoracic vertebra.

144. Stomach: topography (holotopy, skeletotopy, syntopy), parts. Blood

supply and innervation of the stomach

Holotopy: Stomach is disposed in left hypochondriac and proper epigastric areas;

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Skeletotopy: Stomach is related to the bodies of Th11 to L1 vertebrae. Cardiac ostium is
disposed on level of the Th11 on the left from backbone, and pyloric ostium – on level of
the Th12-L1 to the right side; stomach fundus reaches the 5th intercostal space on left
medioclavicular line;
Syntopy: the diaphragm, left liver lobe and anterior abdominal wall adjoin to anterior
stomach wall. Posterior stomach surface adjoins to spleen, pancreas, and left kidney with
left adrenal gland and transversal colon.

The stomach has four main regions; the cardia, fundus, body and pylorus:
Cardia – surrounds the superior opening of the stomach.
Fundus – the rounded portion superior to and left of the cardia.
Body – the large central portion inferior to the fundus.
Pylorus – connects the stomach to the duodenum.

The arterial supply to the stomach comes from the celiac trunk and its branches.
Anastomoses form along the lesser curvature by the right and left gastric arteries and along
the greater curvature by the right and left gastro-omental arteries:
Right gastric – branch of the common hepatic artery, which arises from celiac trunk.
Left gastric – arises directly from the celiac trunk.
Right gastro-omental – terminal branch of the gastroduodenal artery, which arises from the
common hepatic artery.
Left gastro-omental – branch of the splenic artery, which arises from the celiac trunk.
The veins of the stomach run parallel to the arteries. The right and left gastric veins drain
into the hepatic portal vein. The short gastric vein, left and right gastro-omental veins
ultimately drain into the superior mesenteric vein.

Innervation
The stomach receives innervation from the autonomic nervous system:
Parasympathetic nerve supply comes from the posterior vagal trunks, derived from the
vagus nerve.
Sympathetic nerve supply from the T6-T9 spinal cord segments pass to the celiac plexus. It
also carries some pain transmitting fibres.

145. Stomach: structure of the wall, describe the structure of the mucosa,
muscular and serous membranes; relation to the peritoneum, ligaments.

The stomach wall, like the wall of most other parts of the digestive canal, consists of three
layers: the mucosa (the innermost), the muscularis and the serosal – visceral sheet of
peritoneum (the outermost). The mucosal layer itself can be divided into three layers: the
mucosa (the epithelial lining of the gastric cavity), the muscularis mucosae (low density
smooth muscle cells) and the submucosal layer (consisting of connective tissue interlaced
with plexi of the enteric nervous system). Mucous membrane contains the gastric fields,
which carry the gastric pits, where the ducts of gastric glands open. Lesser curvaturae
carries group of longitudinal folds. Mucous membrane forms in area of pyloric ostium

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pyloric valve, which regulates transition of bolus of food into duodenum. The second
gastric layer, the muscularis, can also be divided into three layers: the longitudinal (the
most superficial), the circular and the oblique. The thickness of the circular layer increases
in the antrum and especially in the pyloric sphincter, which controls the rate of discharge
of stomach contents into the duodenum. The longitudinal layer of the muscularis can be
separated into two different categories: a longitudinal layer that is common with the
oesophagus and ends in the corpus, and a longitudinal layer that originates in the corpus
and spreads into the duodenum. The oblique layer of the muscularis is clearly seen in the
fundus and near the lesser curvature of the corpus, but the oblique fibbers disappear
distally (towards the antrum). The outermost main layer is the serosa. Double layer of
peritoneum forms hepatogastric, gastrophrenic,
gastrocolic and gastrolienal ligaments.

146. Regions of the anterior abdominal wall. Blood supply and innervation of the

abdominal wall.

Divisions of the abdomen

Can be Divided into 9 regions.

 Two vertical planes- midclavicular

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  Two horizontal planes:
o Subcostal plane – joining the most inferior points of the costal margins, and passing at L3.

o Transtubercular plane, joining the tubercles of the iliac crest.

Note the 9 regions.

 Right and left hypochondrial regions (1and 3)
 Middle epigastric region (2)
 Right and left lumbar regions (6 and 4)
 A middle umbilical region (5)
 Right and left iliac (inguinal) region (7and 9)
 A middle hypogastric or suprapubic region (8)

 Innervation:
o thoracoabdominal nerves (branches
of the VPR of T7-T11): travel
anteroinferiorly between the internal
oblique and transverse abdominal
muscles (remember the analogous
situation in the thorax). Supplies motor
(to the muscles) and sensory (cutaneous)
fibers. Distribution is as follows:
 T7-T9 - superior to umbilicus
 T10 - at level of umbilicus
 T11 (along with subcostal,
iliohypogastric, and ilioinguinal
nerves) - inferior to umbilicus.
o subcostal nerves (T12): travel anteroinferiorly between the internal oblique
and transverse abdominal muscles (remember the analogous situation in the
thorax) to innervate the wall inferior to the umbilicus. Supplies motor (to
the muscles) and sensory (cutaneous) fibers.
o iliohypogastric nerves (L1): path is somewhat similar to thoracoabdominal
nerves and subcostal nerves, that is, anteroinferiorly between the internal
oblique and transverse abdominal muscles for part of the way. However, the
iliohypogastric nerves and ilioinguinal nerves are different in that they
pierce the internal abdominal oblique at the anterior superior iliac spine to
travel superficial to it and deep to the external abdominal oblique. Supplies
motor (to the muscles) and sensory (cutaneous) fibers to the wall inferior to
the umbilicus.

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 o ilioinguinal nerves (L1): supplies motor (to the muscles) and sensory
(cutaneous) fibers to the wall inferior to the umbilicus. Sometimes
considered separate from the iliohypogastric nerves because ilioinguinal
nerves also innervate the scrotum or labia by sending branches through the
inguinal canal. The iliohypogastric nerves and ilioinguinal nerves are
different in that they pierce the internal abdominal oblique at the anterior
superior iliac spine to travel superficial to it and deep to the external
abdominal oblique.
 Blood Supply:
o superior epigastric arteries: continuation of the internal thoracic arteries.
They run inferiorly in the rectus sheath, deep to the rectus abdominis
muscle. The superior epigastric arteries anastomose with the inferior
epigastric arteries within the rectus sheath.
o inferior epigastric arteries: branches of the external iliac arteries. They
run superiorly in the rectus sheath, deep to the rectus abdominis. The
inferior epigastric arteries anastomose with the superior epigastric artery
within the rectus sheath.
o deep circumflex iliac arteries: branches of the external iliac arteries. They
run deep in the abdominal wall, parallel to the inguinal ligament.
o superficial circumflex iliac arteries: branches of the femoral arteries.
They run superficially in the abdominal wall, parallel to the inguinal
ligament.
o superficial epigastric arteries: branches of the femoral arteries. They run
superficially, superiorly toward the umbilicus.

147. Small intestine: parts, topography, relation to the peritoneum.

Small intestine :
Topography:
Holotopy- small intestine lies in abdominal cavity and occupies epigastrium, mesogastrium
and partly hypogastrium (pubic region).
Skelotopy-small intestine extends from the level of Th12 vertebral body till area of right
iliac fossa.
Syntopy-large intestine,duodenum,pancreas, liver, ductus choledochus, right kidney lie
around coils of small intestine.
The small intestine is divided into three structural parts.

 The duodenum is a short structure (about 20–25 cm long) continuous with the
stomach and shaped like a "C".[6] It surrounds the head of the pancreas. It receives
gastric chyme from the stomach, together with digestive juices from
the pancreas (digestive enzymes) and the liver (bile). The digestive enzymes break
down proteins and bile and emulsify fats into micelles.
The duodenum contains Brunner's glands, which produce a mucus-rich alkaline
secretion containing bicarbonate. These secretions, in combination with bicarbonate
from the pancreas, neutralize the stomach acids contained in gastric chyme.

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 The jejunum is the midsection of the small intestine, connecting the duodenum to the
ileum. It is about 2.5 m long, and contains the plicae circulares, and villi that increase
its surface area. Products of digestion (sugars, amino acids, and fatty acids) are
absorbed into the bloodstream here. The suspensory muscle of duodenum marks the
division between the duodenum and the jejunum.

 The ileum: The final section of the small intestine. It is about 3 m long, and
contains villi similar to the jejunum. It absorbs mainly vitamin B12 and bile acids, as
well as any other remaining nutrients. The ileum joins to the cecum of the large
intestine at the ileocecal junction.
The jejunum and ileum are suspended in the abdominal cavity by mesentery. The
mesentery is part of the peritoneum. Arteries, veins, lymph vessels and nerves travel within
the mesentery
148.Duodeum:parts , topography (holotopy, skelotopy, syntopy)
Duodeum subdivides into:
superior part (ampoule on level of the Th12-L1 vertebrae),
descending(on the level of L1-3 vertebrae )
horizontal part (on level of L3 vertebra)
ascending part (on the level of L 2-3 vertebrae).
The first part of the duodenum lies within the peritoneum but its other parts
are retroperitoneal.

149. Duodenum: structural features of the mucosa. Blood supply and innervation of the
duodenum.

Structure of duodenal wall is divided on:

-external membrane (fibrous and in front – anterior serous / peritoneum)
- middle membrane – muscular, which consists of external longitudinal and internal
circular fibers;
- internal membrane – mucous membrane with well-developed submucous stratum. there
are circular folds in all duodenal portions, medial wall of descending parts contains
longitudinal fold of duodenum, which carries Major papilla (ampoule of ductus
choledochus and pancreatic duct opens here) and minor papilla of duodenum, where
accessories duct of pancreas opens.
Superior Mesenteric Vein gives branches: Anterior and Posterior Inferior pancreatic-
duodenal vein, which pass alongside the arteries of the same name; the anterior superior
pancreaticoduodenal vein usually empties into the right Gastro-omental vein, and the
posterior superior pancreaticoduodenal vein usually empties directly into the portal vein.

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Is innervated by Nervus Vagus.

150. Small intestine: Structure of the wall, describe the structure of the mucosa,
muscular and serous membranes; relation to the peritoneum.
The wall consists of :
- Serous membrane
- Muscular membrane (formed by longitudinal layer and circular layer )
- Mucous membrane (forms numerous of circular folds )
Mucous membrane carries a numerous of specific finger-like processes
that project from the surface of the mucosa into the lumen. They are
fingerlike projections consisting of a core of reticular tissue covered by a
surface epithelium. The connective tissue core contains numerous blood
capillaries forming a plexus. The endothelium lining the blood capillaries
is fenestrated thus allowing rapid absorption of nutrients into the blood.
They are responsible for absorption of amino acids and carbohydrates,
present in digested food. Some villi contain a central lymphatic vessel
and called a lacteal (for absorption of fat). Solitary lymphatic follicles
represent lymphoid apparatus of mucous membrane of the jejunum.

Serous membrane /Peritoneum/ cover Jejunum and Ileum completely.

151. Small intestine: structure of the mucosa of the small intestine. Blood supply and
innervation of the small intestine.

Lymphoid apparatus of mucous

membrane of the ileum is represented by aggregated lymphatic follicles
(Payer’s patches).

The small intestine receives a blood supply from the coeliac trunk and the superior
mesenteric artery. These are both branches of the aorta.

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The jejunum and ileum receive blood from the superior mesenteric artery.

Small intestine is innervated by Vagus nerve .

152. Large intestine: parts, topography (holotopy, syntopy) . Blood supply and
innervation of the parts.

Large Intestine consists of five sections:

-cecum
-ascending colon
-transverse colon
-descending colon
-sigmoid colon
-rectum

Arterial Supply
As a general rule, midgut-derived structures are supplied by the superior mesenteric artery,
and hindgut-derived structures by the inferior mesenteric artery.

The ascending colon receives arterial supply from two branches of the superior
mesenteric artery; the ileocolic and right colic arteries. The ileocolic artery gives rise to
colic, anterior cecal and posterior cecal branches – all of which supply the ascending
colon.
The transverse colon is derived from both the midgut and hindgut, and so it is supplied by
branches of the superior mesenteric artery and inferior mesenteric artery:

 Right colic artery (from the superior mesenteric artery)

 Middle colic artery (from the superior mesenteric artery)
 Left colic artery (from the inferior mesenteric artery)
The descending colon is supplied by a single branch of the inferior mesenteric artery;
the left colic artery. The sigmoid colon receives arterial supply via the sigmoid arteries
(branches of the inferior mesenteric artery).

Venous Drainage
The venous drainage of the colon is similar to the arterial supply:

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 Ascending colon – ileocolic and right colic veins, which empty into the superior
mesenteric vein.
 Transverse colon – superior mesenteric vein.
 Descending colon – left colic vein, which drains into the inferior mesenteric vein.
 Sigmoid colon – drained by the sigmoid veins into the inferior mesenteric vein.
The superior mesenteric and inferior mesenteric veins ultimately empty into the hepatic
portal vein. This allows toxins absorbed from the colon to be processed by the liver for
detoxification.

Innervation
The innervation to the colon is dependent on embryological origin:

 Midgut-derived structures (ascending colon and proximal 2/3 of the transverse colon)
receive their sympathetic, parasympathetic and sensory supply via nerves from the
superior mesenteric plexus.
 Hindgut-derived structures (distal 1/3 of the transverse colon, descending colon and
sigmoid colon) receive their sympathetic, parasympathetic and sensory supply via
nerves from the inferior mesenteric plexus. The parasympathetic innervation is supplied
by the pelvic splanchnic nerves, and sympathetic innervation via the lumbar splanchnic
nerves.

153. Large intestine: Structural features of mucous, muscular and serous membranes,
relation with peritoneum.
Ascending Colon-retroperitoneal
Transverse Colon-intraperitoneal.
Descending Colon-retroperitoneal
Sigmoid Colon-intraperitoneal

154. Cecum: Topography (holotopy, syntopy), structural features. Blood supply and
innervation of the cecum.

The Cecum is situated in right iliac fossa, projected on right inguinal

region. Cecum covered by peritoneum fully (intraperitoneal position) and

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does not have own mesentery. In place of gathering of three teniae ostium
of worm-shaped 8-cm in length blind tube vermiform appendix disposes,
which has own mesentery.
The cecum is the most proximal part of the large intestine and can be found in the right
iliac fossa and suprapubic region. It lies slightly inferior to the iliocaecal junction, and can
be palpated in the right iliac fossa if enlarged due to faeces, gas or malignancy.
The appendix receives its blood supply via the appendicular artery (derived from the
ileocolic artery), and drains through the appendicular vein.
The autonomic nervous system innervates the cecum and appendix. It achieves this by
means of the ileocolic branch of the superior mesenteric plexus, which follows the same
course as the ileocolic artery

155. Portions of the colon, external and internal peculiarities of the colon. Specific
structure of mucous membrane.
The appendix, also known as the vermiform (worm-shaped) appendix is a narrow, blind
ended tube attached to the posteromedial end of the cecum. The position of the free-end of
the appendix is highly variable, and can be categorised into seven main locations. The
most common positions are retrocaecal and subileal. A simple way to remember the
positions is by imagining the appendix as the hour hand of a clock:
 Pre-ileal – Anterior to the terminal ileum – 1 o’clock.
 Post-ileal – Posterior to the terminal ileum – 2 o’clock.
 Sub-ileal – Parallel with the terminal ileum – 3 o’clock.
 Pelvic – Descending over the pelvic brim – 5 o’clock.
 Sub-caecal – Below the cecum – 6 o’clock.
 Paracaecal – Alongside the lateral border of the cecum – 10 o’clock.
 Retrocaecal – Behind the cecum – 11 o’clock

156. Rectum: parts, curvatures, relation to the peritoneum, the topography of male and
female organism.

The rectum is approximately 15cm long, and begins at the level of the S3 (as a
continuation of the sigmoid colon). It is macroscopically distinct from the colon, with
an absence of taenia coli, haustra, and omental appendices.
The course of the rectum is marked by two major flexures:

 Sacral flexure – anteroposterior curve with concavity anteriorly (follows the curve of
the sacrum and coccyx).

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 Anorectal flexure – anteroposterior curve with convexity anteriorly. This flexure is
formed by the tone of the puborectalis muscle, and contributes significantly to faecal
continence.
There are additionally three lateral flexures (superior, intermediate and inferior), which
are formed by transverse folds of the internal rectum wall.
The final segment of the rectum, the ampulla, relaxes to accumulate and temporarily store
faeces until defecation occurs. It is continuous with the anal canal; which passes through
the pelvic floor to end as the anus.

Peritoneal Coverings
In the superior third of the rectum, the anterior surface and lateral sides are covered by
peritoneum. The middle third only has an anterior peritoneal covering, and the lower 1/3
has no peritoneum associated with it.

In males, the reflection of peritoneum from the rectum to the posterior bladder wall forms
the rectovesical pouch. In females, the peritoneum reflects to the posterior vagina and
cervix, forming the rectouterine pouch (pouch of Douglas).

he rectum is located within the pelvic cavity, and is the most posterior of the pelvic
viscera. Its anatomical relations are different in men and women:
Anterior Posterior

Male Female Sacrum and coccyx

Piriformis
Rectovesical pouch Rectouterine pouch
Sigmoid colon Sigmoid colon Coccygeus

Ileum Ileum Levator ani

Bladder Vagina Sacral plexus

Prostate Cervix

Seminal vesicles

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157. Rectum: structural features of the mucosa, muscular and external membranes.
Blood supply and innervation of the rectum.

Neurovascular Supply
The rectum receives arterial supply through three main arteries:
 Superior rectal artery – terminal continuation of the inferior mesenteric artery.
 Middle rectal artery – branch of the internal iliac artery.
 Inferior rectal artery – branch of the internal pudendal artery.
Venous drainage is via the corresponding superior, middle and inferior rectal veins. The
superior rectal vein empties into the portal venous system, whilst the middle and inferior
rectal veins empty into the systemic venous system. Anastamoses between the portal and
systemic veins are located in the wall of anal canal, making this a site of portocaval
anastomosis.
Note: the rectum is also closely anatomically associated with the rectal venous plexus;
however this structure is more functionally related to the anal canal.
Innervation
The rectum receives sensory and autonomic innervation.

Sympathetic nervous supply to the rectum is from the lumbar splanchnic nerves and
superior and inferior hypogastric plexuses. Parasympathetic supply is from S2-4 via
the pelvic splanchnic nerves and inferior hypogastric plexuses. Visceral afferent (sensory)
fibres follow the parasympathetic supply.

The internal cavity of the rectum is divided into three or four chambers; each chamber is
partly segmented from the others by permanent transverse folds (valves of Houston) that
help to support the rectal contents. A sheath of longitudinal muscle surrounds the outside
wall of the rectum, making it possible for the rectum to shorten in length.

158. Liver: external structure: diaphragmatic and visceral surfaces, internal structure
(lobes, lobules).
159. Liver: topography (holotopy, skelotopy, syntopy), ligaments of liver relation to the
peritoneum.
160. Liver: portal triad, ducts of bile excretion. Blood supply and innervation of the
liver.

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Topography of the liver. Holotopy: Liver occupies right hypochondriac region,
proper epigastric region and small part of left hypochondriac region.
Skeletotopy: The upper edge of the liver projects in right 10 th intercostal space
(middle axillar line). Than it lifts to level of 4th rib (middle clavicular line) and passes
across the sternum a bit upper from xiphoid process, terminates in left 5th intercostal
space (between middle clavicular line and parasternal lines). The lower edge of the
liver passes along the costal arch from right 10th intercostal space (middle axillar
line). Than it crosses cartilage of right 9th rib and runs in epigastrium 1,5 cm lower
from xiphoid process to cartilage of left 8th rib and meets the upper margin.
We distinguish the convex diaphragmatic surface of the liver and lower visceral
surface. Visceral surface adjoins to the organs, which form on surface of the liver
suitable ‘tracks’: renal, adrenal, gastric, duodenal, oesophageal and colic
impressions. Diaphragmatic surface carries cardiac impression.
Liver is almost entirely covered with peritoneum except posteriorly positioned ‘area
nuda’. The superior surface is attached to the diaphragm and anterior abdominal
wall by a fold of peritoneum, the falciform ligament, in the free margin of which is a
rounded cord, the ligamentum teres.

Anatomical Position and Relations

© 2015-2016 TeachMeAnatomy.com

Fig 1.0 – Anatomical position of the liver in the abdomen.

The liver is located in the right hypochondrium andepigastric areas, extending into the
left hypochondrium.
During embryological development, the liver is formed within part of the ventral
mesentery, which suspends the foregut organs from the anterior abdominal wall. This is
useful for remembering the anatomical relations of the liver:
 Anterior to the liver is the anterior abdominal wall and ribcage.
 Superior to the liver is the diaphragm (separating the abdominal cavity from the
thoracic cavity)
 Posterior to the liver are the oesophagus, stomach, gallbladder, first part of the
duodenum (the foregut-derived organs).
Liver Surfaces

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The external surfaces of the liver can be classified by the structures they lie in close
proximity to. There are two liver surfaces – the diaphragmatic and the visceral.

The diaphragmatic surface refers to the anterosuperior surface of the liver. It is smooth
and convex, fitting snugly beneath the curvature of the diaphragm. A section of this
surface is not covered by visceral peritoneum, known as the ‘bare area’ of the liver.
The visceral surface covers the posteroinferior aspect of the liver. It is moulded by the
shape of the surrounding organs, making it irregular and flat. It lies in contact with the
oesophagus, right kidney, right adrenal gland, right colic flexure, duodenum, gallbladder
and the stomach.
Ligaments of the Liver
There are various ligaments that attach the liver to the surrounding structures. These are
formed by a double layer of peritoneum.

 © 2015-2016 TeachMeAnatomy.

Fig 1.2 – Ligaments of the liver.

Falciform ligament – attaches the anterior surface of the liver to the anterior
abdominal wall. The free edge of this ligament contains the ligamentum teres, a
remnant of the umbilical vein.
 Coronary ligaments (left and right)– attach the superior surface of the liver to the
diaphragm.
 Triangular ligaments (left and right)– attach the superior surface of the liver to the
diaphragm.
 Lesser omentum – consists of the hepatoduodenal ligament (extends from the
duodenum to the liver), and the hepatogastric ligament (extends from the stomach to the
liver).
In addition to these supporting ligaments, the posterior surface of the liver is secured to
theinferior vena cava by hepatic veins and fibrous tissue.
Hepatic Recesses
The hepatic recesses are spaces between the liver and surrounding structures. They are of
clinical importance, as infected fluids can collect in these areas, forming an abscess.

 Subphrenic spaces (left and right) – located between the diaphragm and liver, either
side of the falciform ligament.

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 Subhepatic space – located between the inferior surface of the liver and the transverse
colon.
 Morison’s pouch – the posterosuperior aspect of the right subhepatic space, located
between the visceral surface of the liver and the right kidney. This is the deepest part of
the peritoneal cavity when supine (lying flat), and this is where fluid is likely to collect
in a bedridden patient.
Structure of the Liver
The structure of the liver can be considered both macroscopically and microscopically.

Macroscopic
The entire liver is covered by a fibrous layer, known as Glisson’s capsule. The ligaments
and surface depressions of the liver divide it into four lobes.
It is divided into a right lobe and left lobe by the attachment of the falciform ligament (a
fold of peritoneum that attaches the liver to the anterior abdominal wall).
There are two further ‘accessory’ lobes that arise from the right lobe, and are located on
the visceral surface of liver:

 The caudate lobe is located on the upper aspect of the visceral surface. It lies between
the inferior vena cava and a fossa produced by the ligamentum venosum (a remnant of
the fetal ductus venosus).
 The quadrate lobe is located on the lower aspect of the visceral surface. It lies between
the gallbladder and a fossa produced by the ligamentum teres (a remnant of the fetal
umbilical vein).
Between the caudate and quadrate lobes is a deep fissure, known as the porta hepatis. It
transmits all the vessels, nerves and ducts entering or leaving the liver.
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Arterial Supply and Venous Drainage

 Hepatic artery proper – supplies the liver with arterial blood. It is derived from
the coeliac trunk.
 Hepatic portal vein – supplies the liver with deoxygenated blood, carrying nutrients
absorbed from the small intestine. This is the dominant blood supply to the liver
parenchyma and allows the liver to perform its gut-related functions, such as
detoxification.
Venous drainage of the liver is achieved through three hepatic veins, which drain into
the inferior vena cava.
Nerve Supply
The parenchyma of the liver is innervated by the hepatic plexus, which contains
sympathetic (from the coeliac plexus) and parasympathetic (vagus nerve) nerve fibres.
These fibres enter the liver at the porta hepatis and follow the course of branches of the
hepatic artery and portal vein.
Glisson’s capsule, the fibrous covering of the liver, is innervated by branches of the lower
intercostal nerves. Distension of the capsule results in a sharp, well localised pain.

161. Gallbladder: topography, parts, structure of the wall, function. Blood supply and
innervation of the gallbladder.
The GALLBLADDER is a pear-shaped, thin-walled bag, which
collects up to 30-50 ml bile. We distinguish fundus, body and neck of
gallbladder, which continues into cystic duct. The gallbladder lies in a
fossa in the liver to which it is attached by connective tissue and covered
by peritoneum from below (mesoperitoneal position).
It is a peritoneal structure, and lays high in the abdomen, in the right hypochondriac
region. Anatomically it is a small sac reminiscent of a pear in shape, laying in a fossa
between the right and quadrate lobes on the inferior aspect of the liver.

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 Fundus: The rounded, end portion of the gallbladder; which projects into the inferior
surface of the liver.
 Body: The largest part of the gallbladder. It is occasionally in contact with the
transverse colon and proximal duodenum.
 Neck: Here, the gallbladder tapers to become continuous with the cystic duct, leading to
the biliary tree. The neck contains a mucosal fold, known as Hartmann’s Pouch. This is
a common location for gallstones to become lodged, causing cholestasis.
Anatomical Relations
The Gallbladder is entirely surrounded by peritoneum, binding it to the visceral covering
of the liver. It lies in close proximity to the following structures:

 Anteriorly and superiorly: Inferior border of the liver and the anterior abdominal
wall.
 Posteriorly: Transverse colon and the proximal duodenum.
 Inferiorly: Biliary tree and duodenum.
Neurovascular Supply
Arterial supply to the gallbladder is via the cystic artery. This artery is derived from the
hepatic artery proper, a branch of the common hepatic artery. The gallbladder receives
venous drainage from the cystic vein, which drains directly into the portal vein.
In addition to the cystic artery and vein, the gallbladder communicates with the liver
through several very small veins and arteries.

The gallbladder receives parasympathetic, sympathetic and sensory innervation. The celiac
plexus carries sympathetic and sensory fibres, while the vagus nerve delivers
parasympathetic innervation. Parasympathetic stimulation produces contraction of the
gallbladder, and the secretion of bile into the cystic duct. However, the main stimulator of
bile secretion is cholecystokinin, which is secreted by the duodenum and travels in the
blood.

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162. Bile Ducts: formation, topography, structure, function.
The Biliary Tree
Bile is secreted from the gallbladder into the gastrointestinal tract via a series of ducts,
known as the biliary tree. These ducts extend from the liver, communicating with the
gallbladder and pancreas, and end at an opening into the duodenum.
The biliary tree begins with the left and right hepatic ducts, which drains bile from the
liver where it has been synthesised. These two ducts amalgamate to form the common
hepatic duct, which runs alongside the hepatic vein. As the common hepatic duct
descends, it is joined by the cystic duct, which is a continuation of the neck of the
gallbladder. The common hepatic duct and cystic duct combine to form the common bile
duct.
As the common bile duct continues to descend, it passes posteriorly to the proximal
duodenum and joins with the pancreatic duct of the pancreas, forming
the hepatopancreatic ampulla of Vater. This then empties into the duodenum. The
opening into the duodenum is known as the major duodenal papilla – it is regulated by a
muscular valve, the sphincter of Oddi.

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163. Pancreas: parts, topography, (skelotopy, syntopy) relation to the peritoneum.

Topography of the pancreas. Pancreas lies in upper abdominal region
behind the peritoneum (retroperitoneal position) at the level of the from
1st to 3d lumbar vertebrae. Along the upper margin of the pancreas runs the
splenic artery. The right kidney and adrenal gland adjoin to body of
pancreas. Anterior surface of gland touches the stomach, posterior surface –
inferior vena cava and aorta. Tail adjoins to splenic hilus.

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The pancreas is an oblong-shaped and flattened organ, about the size of a hand. Aside from
the tail, it is a retroperitoneal structure (lies behind the peritoneal cavity), located deep
within the upper abdomen in the epigastrium and left hypochodrium regions.

164. Exocrine and endocrine parts of the pancreas, ducts. Blood supply and innervation of
the pancreas.

Anatomical Structure
The pancreas is typically divided into five parts;

 Head: This is the widest part of the pancreas. It lies within the C-shaped curve created
by the duodenum, and is connected to it by connective tissue.
 Uncinate process: This is a projection arising from the lower part of the head and
extending medially to lie beneath the body of the pancreas. It lies posterior to the
superior mesenteric vessels.
 Neck: Located between the head and the body of the pancreas. It overlies the superior
mesenteric vessels which form a groove in its posterior aspect.
 Body: The body is centrally located, crossing the midline of the human body to
lie behind the stomach and to the left of the superior mesenteric vessels.
 Tail: The left end of the pancreas that lies within close proximity to the hilum of the
spleen. It is contained within the splenorenal ligament with the splenic vessels. This is
the only part of the pancreas that is intraperitoneal.
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The Duct System

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Fig 3 – The exocrine pancreas, secreting into the duodenum
The exocrine compartment is classified as aserous gland. It is composed of approximately
a million ‘berry-like’ clusters of cells called acini, connected by shortintercalated ducts.
Intercalated duct cells beginning within acini are called centroacinar cells. The
intercalated ducts drain into a network of intralobular collecting ducts, which in
turn drain into the main pancreatic duct.
The pancreatic duct runs the length of the pancreas and unites with the common bile duct,
forming the hepatopancreatic ampulla of Vater. This structure opens into the duodenum.
Secretions into the duodenum are controlled by a muscular valve – the sphincter of
Oddi.It surrounds the ampulla of Vater, acting as a valve.
Vasculature
The pancreas is supplied by the pancreatic branches of the splenic artery. The head is
additionally supplied by the superior and inferior pancreaticoduodenal arteries which
are branches of the gastroduodenal and superior mesenteric arteries, respectively.
Venous drainage of the head of the pancreas is into the superior mesenteric branches of
the hepatic portal vein. The pancreatic veins draining the rest of the pancreas do so into
the splenic vein.

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165. Peritoneum: definition, layers. Omenta, ligaments, mesenteries.

The peritoneum is a continuous transparent membrane which lines the abdominal cavity
and covers the abdominal organs (or viscera).

It acts to support the viscera, and provides a pathway for blood vessels and lymph. In this
article, we shall look at the structure of the peritoneum, the organs that are covered by it,
and its clinical correlations.

Structure of the Peritoneum

The peritoneum consists of two layers which are continuous with each other; the parietal
peritoneum and the visceral peritoneum. They both consist of a layer of simple
squamous epithelial cells, called mesothelium.
Parietal Peritoneum
The parietal peritoneum lines the internal surface of the abdominopelvic wall.

It is derived from somatic mesoderm in the embryo.

It receives the same somatic nerve supply as the region of the abdominal wall that it lines,
therefore pain from the parietal peritoneum is well localised and it is sensitive to pressure,
pain, laceration and temperature.
Visceral Peritoneum
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The visceral peritoneum invaginates to cover the majority of the abdominal viscera.

It is derived from splanchnic mesoderm in the embryo.

The visceral peritoneum has the same nerve supply as the viscera it invests. Unlike the
parietal peritoneum, pain from the visceral peritoneum is poorly localised and is only
sensitive to stretch and chemical irritation.
Pain from the visceral peritoneum is referred to areas of skin (dermatomes) which are
supplied by the same sensory ganglia and spinal cord segments as the nerve fibres
innervating the viscera.

Peritoneal Cavity
The peritoneal cavity is a potential space between the parietal and visceral peritoneum. It
contains a small amount of lubricating fluid.

Peritoneal Reflections
The peritoneum covers a multitude of viscera within the gut and conveys neurovascular
structures from the body wall to the viscera. In order to adequately fulfil its functions, the
peritoneum develops into a highly folded, complex structure and a number of terms are
used to describe the folds and spaces that are part of the peritoneum.

Mesentery
A mesentery is double layer of visceral peritoneum. It connects an intraperitoneal organ to
the (usually) posterior abdominal wall. It provides a pathway for nerves, blood vessels and
lymphatics from the body wall to the viscera.

The mesentery of the small intestine is simply called ‘the mesentery’. Mesentery related
to other parts of the gastrointestinal system is named according to the viscera it connects
to, for example the transverse and sigmoid mesocolons, the mesoappendix.
Omentum

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The omentum is a double layer of peritoneum that extends from the stomach and
proximal part of the duodenum to other abdominal organs.
Greater Omentum
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The greater omentum consists of four layers of peritoneum. It descends from the greater
curvature of the stomach and proximal part of the duodenum, then folds back up and
attaches to the anterior surface of the transverse colon.
It has a role in immunity and is sometimes referred to as the ‘abdominal policeman’
because it can migrate to infected viscera.

Lesser Omentum
The lesser omentum is considerably smaller and attaches from the lesser curvature of the
stomach and the proximal part of the duodenum to the liver. It consists of two parts: the
hepatogastric ligament and the hepatoduodenal ligament.
Peritoneal Ligaments
A peritoneal ligament is a double fold of peritoneum that connects viscera together or
connects viscera to the abdominal wall, for example the hepatogastric ligament which
connects the liver to the stomach.

166. Peritoneal cavity: departments (floors) , their boundaries .

Peritoneal cavity is complex of fissure between abdominal organs

and walls lined by parietal and visceral sheets that contain serous liquid.
It can be subdivided into superior storey and inferior storey, also cavity of
lesser pelvis.
Superior storey of peritoneal cavity positioned between diaphragm
and level of mesocolon of transverse colon. It contains:
• hepatic bursa surrounds right hepatic lobe and gallbladder;
• pregastric bursa accommodates left hepatic lobe and anterior wall
of stomach;

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• omental bursa is situated behind lesser omentum and it is in touch
with posterior stomach surface
167. Upper floor of peritoneal cavity: hepatic bursa, boundaries and communication.
168. Upper floor of peritoneal cavity: pregastric bursa, boundaries and communication.
169. Upper floor of peritoneal cavity: omental bursa, boundaries and communication.
Omental foramen, boundaries.

Peritoneal cavity is complex of fissure between abdominal organs and walls lined by
parietal and visceral sheets that contain serous liquid. It can be subdivided into superior
storey and inferior storey, also cavity of lesser pelvis. Superior storey of peritoneal cavity
positioned between diaphragm and level of mesocolon of transverse colon. It contains: •
hepatic bursa surrounds right hepatic lobe and gallbladder; • pregastric bursa
accommodates left hepatic lobe and anterior wall of stomach; • omental bursa is situated
behind lesser omentum and it is in touch with posterior stomach surface.
The lesser omentum (small omentum; gastrohepatic omentum; Latin: omentum minus) is
the double layer of peritoneum that extends from the liver to the lesser curvature of the
stomach and the start of the duodenum. The primitive mesentery of a six weeks’ human
embryo, half schematic. (Lesser omentum labeled at left.) Schematic and enlarged cross-
section through the body of a human embryo in the region of the mesogastrium, at end of
third month The lesser omentum is extremely thin, and is continuous with the two layers
ofperitoneum which cover respectively the antero-superior and postero-inferior surfaces of
the stomach and first part of the duodenum. When these two layers reach the lesser
curvature of the stomach and the upper border of the duodenum, they join together and
ascend as a double fold to the porta hepatis. To the left of the porta, the fold is attached to
the bottom of the fossa for the ductus venosus, along which it is carried to the diaphragm,
where the two layers separate to embrace the end of the esophagus. At the right border of
the lesser omentum, the two layers are continuous, and form a free margin which
constitutes the anterior boundary of the epiploic foramen. Anatomically, the lesser
omentum is divided into ligaments, each starting with the prefix "hepato" to indicate that it
connects to the liver at one end.
Greater omentum develops from 4 peritoneal sheets, which continue from gastrocolic
ligament and, freely hanging down, covers the abdominal organs in front. The gastrocolic
ligament connects the transverse colon with the greater curvature of the stomach. The
greater omentum (also the great omentum, omentum majus, gastrocolic omentum,
epiploon, or, especially in animals, caul) is a large fold of visceralperitoneum that hangs
down from the stomach. It extends from the greater curvature of the stomach, passing in
front of the small intestines and reflects on itself to ascend to the transverse colon before
reaching to the posterior abdominal wall. The common anatomical term "epiploic" derives
from "epiploon" from the Greek "epipleein" meaning to float or sail on, since the greater
omentum appears to float on the surface of the intestines. The functions of the greater
omentum are: · Fat deposition, having varying amounts of adipose tissue[1] · Immune

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contribution, having milky spots of macrophage collections[1] · Infection and wound
isolation; It may also physically limit the spread of intraperitoneal infections.[1] The
greater omentum can often be found wrapped around areas of infection and trauma. The
greater omentum is the largest peritoneal fold. It consists of a double sheet ofperitoneum ,
folded on itself so that it is made up of four layers. The two layers which descend from the
greater curvature of the stomach and commencement of the duodenum pass in front of
thesmall intestines, sometimes as low down as the pelvis; they then turn upon themselves,
and ascend again as far as the transverse colon, where they separate and enclose that part
of the intestine. These individual layers may be easily demonstrated in the young subject,
but in the adult they are more or less inseparably blended. The left border of the greater
omentum is continuous with the gastrolienal ligament; its right border extends as far as the
commencement of the duodenum. The greater omentum is usually thin, presents a
cribriform appearance, and always contains some adipose tissue, which in obese people
accumulates in considerable quantity.

170. Middle floor of peritoneal cavity: canals, sinuses, recesses, folds.

The middle floor peritoneal cavity located between the mesentery of the transverse colon
and the entrance to the pelvis. It houses the small intestine and the colon. Below the
mesentery of the transverse colon leaf peritoneum passes from the small intestine to the
posterior abdominal wall and hangs loop jejunum and ileum, forming a mesentery
(mesenterium). The root of the mesentery has a length of 18-22 cm, attached to the back of
the abdominal wall at the level II of the lumbar vertebrae on the left. Following from left to
right and top to bottom, consistently across the aorta, inferior vena cava, right ureter, it
ends right at the ilio-sacral joint. In the mesentery penetrate blood vessels and nerves. The
root of the mesentery divides the middle floor of the abdominal cavity on the right and left
mesenteric sinuses.
171. Lower floor of peritoneal cavity: pouches, arrangement of the peritoneum in the
male and female pelvis.
Due to the different pelvic organs, the peritoneal cavity differs in structure between the
sexes. This is the most distal portion of the cavity, and so any infected fluid is likely to
collect here. Thus, it is clinically important to be aware of the differences between males
and females. Male In the male, the rectovesical pouch is a double folding of peritoneum
between the rectum and the bladder. The peritoneal cavity is completely closed in males.
Females In females, the rectouterine pouch (pouch of Douglas) is a double folded
extension of the peritoneum between the rectum and the posterior wall of the uterus. The
vesicouterine pouch is a double fold of peritoneum between the anterior surface of the
uterus and the bladder. The peritoneal cavity is not completely closed in females. The
abdominal ostia of the uterine tubes open into the peritoneal cavity, providing a potential
pathway between the female genital tract and the abdominal cavity. Clinically, this means
that infections of the vagina, uterus and uterine tubes may result in infection and
inflammation of the peritoneum (peritonitis). This is, however, rare due to the presence of

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a mucous plug in the external os (opening) of the uterus which prevents the passage of
pathogens but allows sperm to enter the uterus.

172. Which organs belong to the respiratory system? What belongs to the upper
respiratory tract?
Nose
The nose is the primary upper respiratory organ in which air enters into and exits from the
body. Cilia and mucus line the nasal cavity and traps bacteria and foreign particles that
enter in through the nose. In addition, air that passes through the nasal cavity is humidified
and moistened.
The nasal septum divides the nose into two narrow nasal cavities: one area is responsible
for smell and the other area is responsible for respiration. Within the walls of the nasal
cavity there are frontal, nasal, ethmoid, maxillary, and sphenoid bones. Cartilage helps
form the shape of the nose.
Pharynx
Besides the nose, air can enter into the lungs through the mouth. The pharynx is a tubular
structure, positioned behind the oral and nasal cavities, that allows air to pass from the
mouth to the lungs. The pharynx contains three parts: The nasopharynx, which connects
the upper part of the throat with the nasal cavity; the oropharynx, positioned between the
top of the epiglottis and the soft palate; and the laryngopharynx, located below the
epiglottis.
Larynx
From the pharynx, air enters into the larynx, commonly called the voice box. The larynx is
part of the upper respiratory tract that has two main functions: a passageway for air to enter
into the lungs, and a source of vocalization. The larynx is made up of the hyoid bone and

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cartilage, which helps regulate the flow of air. The epiglottis is a flap-like cartilage
structure contained in the larynx that protects the trachea against food aspiration.
Bronchi
The bronchi allow the passage of air to the lungs. The trachea is made of c-shaped ringed
cartilage that divides into the right and left bronchus. The right main bronchus is shorter
and wider than the left main bronchus. The right bronchus is subdivided into three lobar
bronchi, while the left one is divided into two lobar bronchi.
Lungs
The lungs are spongy, air-filled organs located on both sides of the chest cavity. The left
lung is divided into a superior and inferior lobe, and the right lung is subdivided into a
superior, middle, and inferior lobe. Pleura, a thin layer of tissue, line the lungs to allow the
lungs to expand and contract with ease.
Respiration is the primary function of the lungs, which includes the transfer of oxygen
found in the atmosphere into the blood stream and the release of carbon dioxide into the
air.
Alveoli
The average adult has about 600 million alveoli, which are tiny grape-like sacs at the end
of the respiratory tree. The exchange of oxygen and carbon dioxide gases occurs at the
alveolar level. Although effort is required to inflate the alveoli (similar to blowing up a
balloon), minimal effort is needed to deflate the alveoli (similar to the deflating of a
balloon).
Diaphragm
The diaphragm is a muscular structure located between the thoracic and abdominal cavity.
Contraction of the diaphragm causes the chest or thorax cavity to expand, which occurs
during inhalation. During exhalation, the release of the diaphragm causes the chest or
thorax cavity to contract.

173. Structure of external nose. Nasal cavity; parts structure and communication.
Functional parts of the nasal cavity.
The middle floor peritoneal cavity located between the mesentery of the transverse colon
and the entrance to the pelvis. It houses the small intestine and the colon. Below the
mesentery of the transverse colon leaf peritoneum passes from the small intestine to the
posterior abdominal wall and hangs loop jejunum and ileum, forming a mesentery
(mesenterium). The root of the mesentery has a length of 18-22 cm, attached to the back of
the abdominal wall at the level II of the lumbar vertebrae on the left. Following from left to
right and top to bottom, consistently across the aorta, inferior vena cava, right ureter, it
ends right at the ilio-sacral joint. In the mesentery penetrate blood vessels and nerves. The
root of the mesentery divides the middle floor of the abdominal cavity on the right and left
mesenteric sinuses..

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The external nose is said to have a pyramidal shape. The nasal root is located superiorly,
and is continuous with the forehead. The apex of the nose ends inferiorly in a rounded
‘tip’. Spanning between the root and apex is the dorsum of the nose. Located immediately
inferiorly to the apex are the nares; piriform openings into the vestibule of the nasal cavity.
The nares are bounded medially by the nasal septum, and laterally by the ala nasi (the
lateral cartilaginous wings of the nose). The skeleton of the external nose is made of both
bony and cartilaginous components: Bony component – located superiorly, and is
comprised of contributions from the nasal bones, maxillae and frontal bone. Cartilaginous
component – located inferiorly, and is comprised of the two lateral cartilages, two alar
cartilages and one septal cartilage. There are also some smaller alar cartilages present.
Whilst the skin over the bony part of the nose is thin, that overlying the cartilaginous part
is thicker with many sebaceous glands. This skin extends into the vestibule of the nose via
the nares. Here there are hairs which function to filter air as it enters the respiratory
system.
Sensory innervation of the external nose is derived from the trigeminal nerve (CN V). The
external nasal nerve, a branch of the ophthalmic nerve (CN V1), supplies the skin of the
dorsum of nose, nasal alae and nasal vestibule. The lateral aspects of the nose are supplied
by the infrorbital nerve, a branch of the maxillary nerve (CN v2). Motor innervation to the
nasal muscles of facial expression is via the facial nerve (CN VII).
174. Paranasal sinuses: topography (holotopy, skeletotopy, syntopy) , parts , structure ,
boundaries . Blood supply and innervation of the larynx.
The paranasal sinuses are air-filled extensions of the respiratory part of the nasal cavity.
There are four paired sinuses, named according to the bone in which they are located;
maxillary, frontal, sphenoid and ethmoid. The function of the sinuses is not clear. It is
thought that they may contribute to the humidifying of the inspired air. They also reduce
the weight of the skull. Sinuses are formed in childhood by the nasal cavity eroding into
surrounding bone. As they are outgrowths of the nasal cavity, they all drain back into it –
openings to the paranasal sinuses are found on the roof and lateral walls of the nasal cavity.
The inner surface is lined by a respiratory mucosa. Frontal Sinuses: These are the most
superior in location, found under the forehead. The frontal sinuses are variable in size, but
always triangular-shaped. They drain into the nasal cavity via the frontonasal duct, which
opens out at the hiatus semilunaris on the lateral wall. Sphenoid Sinuses: The sphenoid
sinuses also lie relatively superiorly, at the level of the spheno-ethmodial recess. They are
found more posteriorly, and are related superiorly and laterally to the cranial cavity. The
sphenoid sinuses drain out onto the roof of the nasal cavity. The relationships of this sinus
are of clinical importance – the pituitary gland can be surgically accessed via passing
through the nasal roof, into the sphenoid sinus and through the sphenoid bone. Ethmoidal
Sinuses: There are three ethmoidal sinuses; anterior, middle and posteior. They empty into
the nasal cavity at different places: Anterior – Hiatus semilunaris Middle – Ethmoid bulla
Posterior – Superior meatus Maxillary Sinuses: The largest of the sinuses. It is located
laterally and slightly inferiorly to the nasal cavities. It drains into the nasal cavity at the
hiatus semilunaris, underneath the frontal sinus opening. This is a potential pathway for
spread of infection – fluid draining from the frontal sinus can enter the maxillary sinus.

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175. Larynx: topography (holotopy, skeletotopy, syntopy), parts, structure,
boundaries. Blood supply and innervation of the larynx.
The LARYNX is situated in anterior neck area on level IV-VI cervical vertebrae. At the
front infrahyoid muscles of neck cover it. Vessels and nervous bundles and lobes of
thyroid gland lie from sides of larynx. Laryngeal part of pharynx adjoins behind it. Larynx
has true vocal folds and glottis. Larynx begins by entrance into larynx, which is limited at
the front, by epiglottis, behind – by arytenoid cartilages, and laterally – by
arytenoepiglottic folds, where cuneiform and corniculate tubercles are situated (places of
the same name cartilages). Glottis is a most narrow place in laryngeal cavity; it is situated
between right and left vocal plicae. Laryngeal ventricle is fissure disposed between vocal
and vestibular plicae. Infraglottic cavity is inferior broadened part of larynx, which
continues into trachea. The larynx is innervated by branches of the vagus nerve on each
side. Sensory innervation to the glottis and laryngeal vestibule is by the internal branch of
the superior laryngeal nerve. The external branch of the superior laryngeal nerve innervates
the cricothyroid muscle. Motor innervation to all other muscles of the larynx and sensory
innervation to the subglottis is by the recurrent laryngeal nerve. While the sensory input
described above is (general) visceral sensation (diffuse, poorly localized), the vocal fold
also receives general somatic sensory innervation (proprioceptive and touch) by the
superior laryngeal nerve.
Injury to the external laryngeal nerve causes weakened phonation because the vocal folds
cannot be tightened. Injury to one of the recurrent laryngeal nerves produces hoarseness, if
both are damaged the voice may or may not be preserved, but breathing becomes difficult.

176. Larynx: cartilages (structure), joints, ligaments. Functions of the larynx.

Larynx skeleton consists of pair and odd cartilages.

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Odd cartilages:
• Thyroid cartilage, which consists of right and left plates (lamina dextra et sinistra), and
also has superior horns and inferior horns; the plates converge forming laryngeal
prominence (Adam’s apple);
• Cricoid cartilage which has anteriorly arch behind – plate of cricoid cartilage; •
Epiglottis cartilage. Paired cartilages:
• Arytenoid cartilage, which has a base and apex, muscular process and vocal process.
These cartilage lie on plate of cricoid cartilage;
• Corniculate cartilage lies in aryepiglottic fold on top of arytenoid cartilages;
• Cuneiform cartilage lies in aryepiglottic fold front of corniculate cartilages. In larynx
they distinguish such articulations:
• Cricoid-thyroid joint is between inferior cornu of thyroid cartilage and arch of cricoid
cartilage; in this joint movement is possible around transversal axis;
• Cricoid-arytenoid joint is situated between base of arytenoid cartilages and plate of
cricoid cartilage. Arytenoid cartilage can rotate slide to meet one another. Ligaments of the
larynx:
• Thyro-hyoid membrane, which hangs larynx to hyoid bone; • Crico-thyroid ligament; •
Thyro-epiglottic ligament;
• Hyoepiglottic ligament;
• Vestibular ligaments, which are situated over vocal ligaments. Fibroelastic membrane the
larynx:
• Elastic cone contains in its superior margin vocal ligament;
• Quadrangular membrane, which is situated over elastic cone and in its inferior margin
contains vestibular ligament. Fibroelastic membranes together with laryngeal cartilages
form a laryngeal skeleton.
Function of the Larynx:
 It allows air to be directed into the respiratory organs for gas exchange.
 The larynx is also the organ that is responsible for producing vocal sounds
(phonation) and therefore it is commonly known as the voice box.
 In addition, the larynx also plays a role in preventing food and drink from entering
the respiratory system.

177. Larynx: muscles, fibro-elastic structures of the larynx, vestibular ligament, vocal
ligament. Blood supply and innervation of the larynx.
The laryngeal Muscles subdivide on muscles that narrow/broaden the glottis, muscles that
change tension of vocal ligament. Constrictors of the glottis:
• lateral cricoarytenoid muscle;
• thyroarytenoid muscle;
• transverse arytenoid muscle;
• oblique arytenoid muscles. Muscles-dilators of the glottis

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• thyro-arytenoid muscle has thyro-epiglottic part. Action: it raises the epiglottis and
broadens an entrance into larynx and vestibule.
• posterior cricoid-arytenoid muscle. Muscles changing tension of vocal ligament:
• crico-thyroid muscle stretches a vocal ligament.
• vocal muscle is situated in thickness of vocal fold and changes an tension degree of
vocal cords.

Nerves of the Larynx

Superior laryngeal nerve

The superior laryngeal nerves arise from the inferior ganglia of the vagus nerve and
receive a branch from the superior cervical sympathetic ganglion on each side in the upper
neck. They descend adjacent to the pharynx on either side, behind the internal carotid
artery, and divide into internal and external branches.

The external branch (external laryngeal nerve) descends beneath the sternothyroid muscle
and supplies the cricothyroid muscle. Injury to this nerve during thyroidectomy or
cricothyrotomy causes hoarseness of the voice and an inability to produce high-pitched
sounds.

The internal branch (internal laryngeal nerve) pierces the thyrohyoid membrane and
supplies sensory innervation to the laryngeal cavity down to the level of the vocal folds. It
is responsible for the cough reflex.

Recurrent laryngeal branch of the vagus nerve (CN X)

The recurrent laryngeal branches of the vagus nerves ascend into the larynx within the
groove between the esophagus and the trachea. The left recurrent laryngeal nerve
originates in the thorax, looping under the aortic arch before ascending, while the right
recurrent laryngeal nerve originates in the neck.

These nerves are responsible for supplying sensory innervation to the laryngeal cavity
below the level of the vocal folds, as well as motor innervation to all laryngeal muscles
except the cricothyroid. Since the nerves run immediately posterior to the thyroid gland,
they are at risk of injury during thyroidectomies. Unilateral nerve damage presents with
voice changes, including hoarseness. Bilateral nerve damage may result in aphonia
(inability to speak) and breathing difficulties.

Vessels of the Larynx

Arteries

The superior and inferior laryngeal arteries supply the majority of blood to the larynx. The
superior laryngeal artery originates from the superior thyroid branch of the external carotid
artery and enters the larynx with the internal branch of the superior laryngeal nerve
through the lateral aperture of the thyrohyoid membrane. The inferior laryngeal artery

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originates from the inferior thyroid branch of the thyrocervical trunk, which is a branch of
the subclavian artery. It ascends into the larynx within the groove between the esophagus
and the trachea, along with the recurrent laryngeal branch of the vagus nerve (CN X).

Veins

The superior and inferior laryngeal veins drain the larynx and share the same course as the
arteries. The superior laryngeal veins drain into the superior thyroid veins, which empty
into the internal jugular veins. The inferior laryngeal veins drain into the inferior thyroid
veins, which both empty into the left brachiocephalic vein.

Lymphatics

The lymphatic vessels that drain above the vocal folds travel along the superior laryngeal
artery and drain to the deep cervical lymph nodes at the bifurcation of the common carotid
artery. The lymphatic vessels that drain below the vocal folds travel along the inferior
thyroid artery and drain to the upper tracheal lymph nodes.

178. Trachea and bronchi: topography, structure of the wall. Blood supply and
innervation of the trachea and bronchi.
The TRACHEA is a tube, which consists of 16-20 semicircular cartilages, joint each other
by annular ligaments. Last built by connective tissue with smooth muscular fibers. Behind
semi-rings communicate by each other by membranous tracheal wall. Trachea (windpipe)
extends from VI cervical to V thoracic vertebra, where it ramifies on two principal
bronchi. This place is tracheal bifurcation. Trachea has cervical part and thoracic part.
Cervical part at the front covered by infrahyoid muscles and isthmus of thyroid gland that
accords to the second-third tracheal ring. Esophagus (gullet) passes behind the trachea.
Thoracic part of trachea is situated in superior mediastinum. PRINCIPAL BRONCHI are
generated from the bifurcation of trachea and have similar structure as trachea. Right
principal bronchus is wider than left and it is continuation of trachea by its direction. It
consists of 68 cartilaginous semirings. Left principal bronchus is longer and narrower and
passes with angle from trachea than right. It consists of 9-12 cartilaginous semi-ring. The
principal bronchi are the bronchi of first order, the bronchial tree starts from them. The
extraneous things, especially in children, more frequently get into right principal bronchus.

Blood supply of trachea:

Branches from the inferior thyroid and bronchial arteries form anastomotic networks in the
tracheal wall. Veins drain to the inferior thyroid plexus.

Lymph drainage of trachea:

Lymphatic channels pass to the posteroinferior group of deep cervical nodes and to
paratracheal nodes.

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Nerve supply:
The mucous membrane is supplied by afferent (including pain) fibres from the vagi and
recur¬rent laryngeal nerves, which also provide parasympathetic fibres of uncertain
function. Sympathetic fibres from upper ganglia of the sympathetic trunks supply the
smooth muscle and blood vessels.

179. Lungs: topography (skeletotopy), external structure. The root of the lung:
topography, composition.
The LUNGS are the pair parenchymatic organs, which occupy larger part of thoracic
cavity. Each lung has a pulmonal base and apex; costal surface, diaphragmatic surface,
interlobar surface and medial surface. Medial surface subdivides into posterior (vertebral)
surface and anterior (mediastinal) surface. They distinguish anterior margin and inferior
margin on lungs. There is pulmonal hilus on mediastinal surface through which pulmonary
artery, bronchi and nerves, enter into the lung, lymphatic vessels and pulmonary veins
leave the lungs. All these elements, which enter and exite from lungs gates, form a
pulmonary root. Arrangement of vessels and bronchus in left pulmonary root: from above
downwards: pulmonary artery, bronchus and vein . Arrangement of vessels and bronchus
in right pulmonary root (from above downwards): bronchus, pulmonary artery, and vein .
180. Lungs: lobes, segments, structure. Blood supply and innervation of the
lungs.
The lungs are the essential organs of respiration; they are two in number, placed
one on either side within the thorax, and separated from each other by the heart and other
contents of the mediastinum. The substance of the lung is of a light, porous, spongy
texture; it floats in water, and crepitates when handled, owing to the presence of air in the
alveoli; it is also highly elastic; hence the retracted state of these organs when they are
removed from the closed cavity of the thorax. The surface is smooth, shining, and marked
out into numerous polyhedral areas, indicating the lobules of the organ: each of these areas
is crossed by numerous lighter lines.
At birth the lungs are pinkish white in color; in adult life the color is a
dark slaty gray, mottled in patches; and as age advances, this mottling assumes a black
color. The coloring matter consists of granules of a carbonaceous substance deposited in
the areolar tissue near the surface of the organ. It increases in quantity as age advances,
and is more abundant in males than in females. As a rule, the posterior border of the lung is
darker than the anterior.
The right lung usually weighs about 625 gm., the left 567 gm., but much variation
is met with according to the amount of blood or serous fluid they may contain. The lungs
are heavier in the male than in the female, their proportion to the body being, in the former,
as 1 to 37, in the latter as 1 to 43.
Each lung is conical in shape, and presents for examination an apex, a base, three
borders, and two surfaces.
The apex (apex pulmonis) is rounded, and extends into the root of the neck,
reaching from 2.5 to 4 cm. above the level of the sternal end of the first rib. A sulcus

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produced by the subclavian artery as it curves in front of the pleura runs upward
and lateralward immediately below the apex.
The base (basis pulmonis) is broad, concave, and rests upon the convex surface of
the diaphragm, which separates the right lung from the right lobe of the liver, and the left
lung from the left lobe of the liver, the stomach, and the spleen. Since the diaphragm
extends higher on the right than on the left side, the concavity on the base of the right lung
is deeper than that on the left. Laterally and behind, the base is bounded by a thin, sharp
margin which projects for some distance into the phrenicocostal sinus of the pleura,
between the lower ribs and the costal attachment of the diaphragm. The base of the lung
descends during inspiration and ascends during expiration.
Borders.—The inferior border (margo inferior) is thin and sharp where it separates
the base from the costal surface and extends into the phrenicocostal sinus; medially where
it divides the base from the mediastinal surface it is blunt and rounded.
The posterior border (margo posterior) is broad and rounded, and is received into
the deep concavity on either side of the vertebral column. It is much longer than the
anterior border, and projects, below, into the phrenicocostal sinus.
The anterior border (margo anterior) is thin and sharp, and overlaps the front of
the pericardium. The anterior border of the right lung is almost vertical, and projects into
the costomediastinal sinus; that of the left presents, below, an angular notch, the cardiac
notch, in which the pericardium is exposed. Opposite this notch the anterior margin of the
left lung is situated some little distance lateral to the line of reflection of the corresponding
part of the pleura.
The right lung is divided into three lobes, superior, middle, and inferior, by two
interlobular fissures. One of these separates the inferior from the middle and superior
lobes, and corresponds closely with the fissure in the left lung. Its direction is, however,
more vertical, and it cuts the lower border about 7.5 cm. behind its anterior extremity. The
other fissure separates the superior from the middle lobe. It begins in the previous fissure
near the posterior border of the lung, and, running horizontally forward, cuts the anterior
border on a level with the sternal end of the fourth costal cartilage; on
the mediastinal surface it may be traced backward to the hilus. The middle lobe, the
smallest lobe of the right lung, is wedge-shaped, and includes the lower part of the anterior
border and the anterior part of the base of the lung.
The right lung, although shorter by 2.5 cm. than the left, in consequence of the
diaphragm rising higher on the right side to accommodate the liver, is broader, owing to
the inclination of the heart to the left side; its total capacity is greater and it weighs more
than the left lung.
The Root of the Lung (radix pulmonis).—A little above the middle of
the mediastinal surface of each lung, and nearer its posterior than its anterior border, is its
root, by which the lung is connected to the heart and the trachea. The root is formed by the
bronchus, the pulmonary artery, the pulmonary veins, the bronchial arteries and veins, the
pulmonary plexuses of nerves, lymphatic vessels, bronchial lymph glands, and areolar
tissue, all of which are enclosed by a reflection of the pleura. The root of the right lung lies
behind the superior vena cava and part of the right atrium, and below the azygos vein. That
of the left lung passes beneath the aortic arch and in front of the descending aorta; the

136
phrenic nerve, the pericardiacophrenic artery and vein, and the anterior pulmonary plexus,
lie in front of each, and the vagus and posterior pulmonary plexus behind each; below each
is the pulmonary ligament.
The chief structures composing the root of each lung are arranged in a similar
manner from before backward on both sides, viz., the upper of the two pulmonary veins in
front; the pulmonary artery in the middle; and the bronchus, together with the bronchial
vessels, behind. From above downward, on the two sides, their arrangement differs, thus:
On the right side their position is—eparterial bronchus, pulmonary
artery, hyparterial bronchus, pulmonary veins, but on the left side their position is—
pulmonary artery, bronchus, pulmonary veins. The lower of the two pulmonary veins, is
situated below the bronchus, at the apex or lowest part of the hilus

181. Bronchial tree, structure of wall, function.

Bronchial tree includes branching of the bronchi starting from the principal bronchi and
finishing by terminal bronchioli. Next branching of the bronchial tubes they call acynus –
morpho-functional lung unit.
182. Acinus: definition, structure, functions.
Acynus contains 14-16 respiratory broncholi, which are ramification of one terminal
broncholi and they have alveoli in the wall. Each respiratory bronch³ forms to 1500
alveolar ductuli, which terminate In alveolar saccule. One pulmonary lobule contains 16-
18 acynuses. The acynus is covered by network of vessels. Gas-exchange between external
environment and blood takes place here.
183. Pleura: general characteristics, functions, pleural cavity and recesses. Borders of
pleural sac. Blood supply and innervation of the pleura.
Each lung is invested by an exceedingly delicate serous membrane, the pleura,
which is arranged in the form of a closed invaginated sac. A portion of the serous
membrane covers the surface of the lung and dips into the fissures between its lobes; it is
called the pulmonary pleura. The rest of the membrane lines the inner surface of the chest
wall, covers the diaphragm, and is reflected over the structures occupying the middle of the
thorax; this portion is termed the parietal pleura. The two layers are continuous with one
another around and below the root of the lung; in health they are in actual contact with one
another, but the potential space between them is known as the pleural cavity. When the
lung collapses or when air or fluid collects between the two layers the cavity becomes
apparent. The right and left pleural sacs are entirely separate from one another; between
them are all the thoracic viscera except the lungs, and they only touch each other for a
short distance in front; opposite the second and third pieces of the sternum the interval
between the two sacs is termed the mediastinum.
Reflections of the Pleura.—Commencing at the sternum, the pleura
passes lateralward, lines the inner surfaces of the costal cartilages, ribs, and Intercostales,
and at the back part of the thorax passes over the sympathetic trunk and its branches, and is
reflected upon the sides of the bodies of the vertebræ, where it is separated by a narrow
interval, the posterior mediastinum, from the opposite pleura. From the vertebral column
the pleura passes to the side of the pericardium, which it covers to a slight extent; it then
covers the back part of the root of the lung, from the lower border of which a triangular

137
sheet descends vertically toward the diaphragm. Above, its cupula projects through the
superior opening of the thorax into the neck, extending from 2.5 to 5 cm. above the sternal
end of the first rib; this portion of the sac is strengthened by a dome-like expansion of
fascia (Sibson’s fascia), attached in front to the inner border of the first rib, and behind to
the anterior border of the transverse process of the seventh cervical vertebra. This is
covered and strengthened by a few spreading muscular fibers derived from the Scaleni.
The free surface of the pleura is smooth, polished, and moistened by a serous fluid;
its attached surface is intimately adherent to the lung, and to the pulmonary vessels as they
emerge from the pericardium; it is also adherent to the upper surface of the diaphragm:
throughout the rest of its extent it is easily separable from the adjacent parts.

184. Mediastinum: definition, parts. Organs, blood vessels and nerves of the anterior
mediastinum.
The MEDIASTINUM is complex of organs, which is situated between two pleural sacs.
Mediastinum is limited – at front by sternum, behind by thoracic part of backbone, from
sides – by right and left mediastinal pleurae. Its superior boundary is superior foramen of
thoracic cavity, and inferior – diaphragm. Conventionally horizontal plane, carrying out
from joint of manubrium sterni and corpus sterni to cartilage between IV-V thoracic
vertebrae, divides mediastinum into superior mediastinum and inferior mediastinum. . In
anterior mediastinum heart, ascending aorta, aortal arch, superior vena cava, trachea, lung
root elements, phrenic nerves and thymus gland are placed. In posterior mediastinum
esophagus, descending aorta, inferior vena cava, azygos and hemiazygos veins, splanchnic
nerves, sympathetic trunk, thoracic lymphatic duct and vagus nerves are situated.
The Anterior Mediastinum exists only on the left side where the left pleura diverges from
the mid-sternal line. It is bounded in front by the sternum, laterally by the pleuræ, and
behind by the pericardium. It is narrow, above, but widens out a little below. Its anterior
wall is formed by the left Transversus thoracis and the fifth, sixth, and seventh left costal
cartilages. It contains a quantity of loose areolar tissue, some lymphatic vessels which
ascend from the convex surface of the liver, two or three anterior mediastinal lymph
glands, and the small mediastinal branches of the internal mammary artery.
185. Mediastinum: definition, topographic classification. Organs, blood vessels and
nerves posterior mediastinum.
The Posterior Mediastinum is an irregular triangular space running parallel with the
vertebral column; it is bounded in front by the pericardium above, and by the posterior
surface of the diaphragm below, behind by the vertebral column from the lower border of
the fourth to the twelfth thoracic vertebra, and on either side by the mediastinal pleura. It
contains the thoracic part of the descending aorta, the azygos and the
two hemiazygos veins, the vagus and splanchnic nerves, the esophagus, the thoracic duct,
and some lymph glands.
186. Which organs belong to the urinary system? Describe their functions.
URINARY SYSTEM includes pair organ – kidney (organ producing urine) and organs,
which store up and bring out urine (ureters, urinary bladder and urethra).

138
The kidneys are surrounded by a layer of adipose that holds them in place and protects
them from physical damage. The kidneys filter metabolic wastes, excess ions, and
chemicals from the blood to form urine.
The ureters are a pair of tubes that carry urine from the kidneys to the urinary bladder.
The urinary bladder is a sac-like hollow organ used for the storage of urine.
The urethra is the tube through which urine passes from the bladder to the exterior of the
body.

187. Kidneys: external structure, topography of the right and left kidney (holotopy,
skeletotopy, syntopy).
Two KIDNEYS are pair parenchymatic organs, which positioned in abdominal cavity
behind peritoneum (retroperitoneal position) in right and left lumbar regions. Kidney is
projected on front abdominal wall in epigastric, lateral and umbilical regions. Right kidney
extends from Th 12 vertebra till L 3 lumbar vertebra, left one – from Th 11 vertebra till L 2
lumbar vertebra. Posterior surface of each kidney in superior part adjoins to diaphragm,
and in middle and inferior – to muscular bed, which is formed by muscle: psoas major,
quadratus lumborum and transverse abdominis. To anterior surface of left kidney adrenal
gland adjoins above, to superolateral part – spleen, to middle portion – stomach and
pancreas, inferiorly – medially is loops of small intestine, and superolaterally – colon. To
anterior surface of right kidney suprarenal gland adjoins above, to middle part – liver, to
medial margin – duodenum, to inferiomedial – loops of small intestine and to inferiolateral
– large intestine. Each kidney has superior extremity and inferior extremity, anterior
surface and posterior surface, medial margin (concave) and lateral margin (convex). On
medial margin are situated the renal hilus, where artery, nerves enter, and vein, lymphatic
and renal pelvis exit. The renal hilus gets into kidneys, forming a renal sinus, filled by
adipose tissue, also major renal calices and minor renal calices and initial part of renal
pelvis are present there.
188. Kidneys: fixing apparatus, membranes. Describe renal fascia.
Two KIDNEYS are pair parenchymatic organs, which positioned in abdominal cavity
behind peritoneum (retroperitoneal position) in right and left lumbar regions. Kidney is
projected on front abdominal wall in epigastric, lateral and umbilical regions. Right kidney
extends from Th 12 vertebra till L 3 lumbar vertebra, left one – from Th 11 vertebra till L 2
lumbar vertebra. Posterior surface of each kidney in superior part adjoins to diaphragm,
and in middle and inferior – to muscular bed, which is formed by muscle: psoas major,
quadratus lumborum and transverse abdominis. To anterior surface of left kidney adrenal
gland adjoins above, to superolateral part – spleen, to middle portion – stomach and
pancreas, inferiorly – medially is loops of small intestine, and superolaterally – colon. To
anterior surface of right kidney suprarenal gland adjoins above, to middle part – liver, to
medial margin – duodenum, to inferiomedial – loops of small intestine and to inferiolateral
– large intestine. Each kidney has superior extremity and inferior extremity, anterior
surface and posterior surface, medial margin (concave) and lateral margin (convex). On
medial margin are situated the renal hilus, where artery, nerves enter, and vein, lymphatic
and renal pelvis exit. The renal hilus gets into kidneys, forming a renal sinus, filled by

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adipose tissue, also major renal calices and minor renal calices and initial part of renal
pelvis are present there. To parenchyma of the kidney a fibrous capsule adjoins. Outside
from last a fatty capsule is situated, which noticeable better near posterior surface of
kidney. More outer from adipose capsule renal fascia disposed, which consists of anterior
sheet and posterior sheet. They fused together by superior edges and laterally. From renal
fascia stratums of connective tissue draw to fibrous capsule kidney, which fix a kidney.
Peritoneum adjoins to anterior sheet of renal fascia. Kidneys are fixed by abdominal
pressure, renal fascia, muscular bed, renal vessels and nerves, which form a renal leg.
Renal parenchyma consists of cortex (superficially) and medulla (deep location). In
medulla they distinguish 7-10 renal pyramids, each from which has a base of renal
pyramids and a top (apex). Last terminates in renal papilla where cribriform area disposed.
The stratums of cortical matter, which form the renal columns, lie between pyramids.
Cortical matter consists of convoluted part, between which the stratums of medulla are
contained. They have a name medullar rays (radiata part). Each renal pyramid forms renal
lobe, and one convoluted part and one radita part form renal lobule in cortex. From top of
renal pyramid urine gets into minor renal calices (7-8 in number), from them urine flow
into 2-3 major calices, then it moves into renal pelvis, which continues into ureter.
189. Kidneys: structural and functional unit of the kidney (structure).
The basic functional unit of the kidney is the nephron, of which there are more than a
million within the cortex and medulla of each normal adult human kidney. Nephrons
regulate water and soluble matter (especially electrolytes) in the body by first filtering the
blood under pressure, and then reabsorbing some necessary fluid and molecules back into
the blood while secreting other, unneeded molecules. Reabsorption and secretion are
accomplished with both cotransport and countertransport mechanisms established in the
nephrons and associated collecting ducts.
190. Vascularity of the kidney. Blood supply and innervation of the kidney.
BLOOD SUPPLYING of KIDNEYS. Kidney supplied by renal artery, which ramifies in
hilus area into anterior branch and posterior branch. Last divide by segmental arteries, and
segmental branches – into interlobar arteries, which ramify on border of cortex and
medulla into arcuate arteries. Arcuate arteries give off the radial cortical (interlobular)
arteries in cortical matter. They give beginning for numerous of afferent vasa, which
disintegrate into arterial capillaries and form a renal glomerulus. From renal glomerulus
moves away efferent vasa, which disintegrates into secondary arterial capillaries, that
enshrouds the tubules of nephron. Such system of blood supplying, when arterial vessels
have double disintegration into cappillaries called as renal miracle arterial rete. Venous
capillaries form in cortical matter stellate venullae, which fall into arcuate veins. Arcuate
veins continue into interlobar veins, last form a renal vein, which empties in inferior vena
Cava
191. Kidneys: pathways of urine (components of kidneys excretory tract). Renal
sinus, contents.
Each kidney has superior extremity and inferior extremity, anterior surface and posterior
surface, medial margin (concave) and lateral margin (convex). On medial margin are
situated the renal hilus, where artery, nerves enter, and vein, lymphatic and renal pelvis

140
exit. The renal hilus gets into kidneys, forming a renal sinus, filled by adipose tissue, also
major renal calices and minor renal calices and initial part of renal pelvis are present there
The kidneys are bean-shaped excretory organs in vertebrates. Part of the urinary system,
the kidneys filter wastes (especially urea) from the blood and excrete them, along
with water, as urine. The medical field that studies the kidneys and diseases affecting the
kidney is called nephrology, from the Ancient Greek name for kidney;
the adjective meaning "kidney-related" is renal, from Latin.
Primary urine arises by filtration blood plasma in nephron capsule, which envelops each
renal glomerulus. Capsule of renal glomerulus together with glomerulus form a renal
corpuscle, which is situated in convoluted part of cortex. Proximal canalicule of nephron
passes from renal corpuscle, which continues into nephron loop (ansa of Henle). Last
continues into distal part of nephron canalicule which falling into collecting duct. All of
above counted urinary tubules braid by thick net of secondary arterial capillaries and by
reabsorbtion secondary urine here is formed. The elements, where urine is formed,
compose function and structural kidney unit – nephron. After nephron urine streams into
straight colligens (collecting) tubules, which terminate by pappillar foramens on top of
renal pyramid. Last open on cribriform area into minor renal calices. From small renal
calices urine flows into major renal calices, which join together and form a renal pelvis,
last continues into ureter.

192. Ureter: parts, topography (holotopy, skeletotopy, syntopy).

THE URETERS are pair organ length 25-30 cm, which lies retroperitoneally. Ureter has
abdominal part, pelvic part and intramural part. Last lies in the wall of urinary bladder and
opens on its fundus by foramen. Ureters wall consists of external membrane, muscular
membrane and mucous membrane. Muscular membrane has external circular and internal
longitudinal layers. Ureter has follow narrow places:

• at transition of renal pelvis into ureter;

• at transition of abdominal part into pelvic part;

• at transition of ureters into urinary bladder.

Syntopy of ureter

 Runs inferiorly from the apex of the renal pelvis at the hilum.
 Passes over the pelvic grim at the bifurcation of the common iliac artery.
 Runs along the lateral wall of pelvis and enters the urinary bladder.
 Abdominal parts adhere closely to the parietal peritoneum and are retroperitoneal
throughout their course.
 Three constrictions:
1. At junction between renal pelvis and ureter.

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 2. At crossing of brim of pelvic inlet.
3. During passage through wall of urinary bladder

193. Ureter: structure of wall, constrictions. Blood supply and innervation of the
ureters.

The urethra of the male is a tube of mucous membrane supported on a submucous layer
and an incomplete muscular coat. The membrane forms longitudinal folds when the tube is
empty; these folds are more prominent in the membranous and spongy parts. There are
many glands in the mucous membrane, and they are more common in the posterior wall of
the spongy part. The submucous layer is composed of fibroelastic connective tissue
containing numerous small blood vessels, including more venules than arterioles. The thin
muscular coat consists of smooth (involuntary) and striated (voluntary) muscle fibres. The
smooth muscular layer, longitudinally disposed, is continuous above with the detrusor
muscle of the bladder and extends distally as far as the membranous urethra, where it is
replaced and partly surrounded by striated muscle of the external sphincter. The somatic
nerves to the external sphincter are the efferent and afferent components of the pudendal
nerve, arising from the second, third, and fourth sacral segments of the spinal cord.

The female urethra has mucous, submucous, and muscular coats. As in the male, the lining
of the empty channel is raised into longitudinal folds. It also shows mucous glands,
mentioned in the preceding paragraphs as existing in the male urethra. The submucous coat
resembles that in the male, except that the venules are even more prominent. In both sexes,
but especially in females, this layer appears to be a variety of erectile tissue. The muscular
coat extends along the entire length of the female urethra and is continuous above with the
musculature of the bladder. It consists of inner longitudinal and outer circular layers, and
fibres from the latter intermix with those in the anterior wall of the vagina, in which the
urethra is embedded.

Blood supply

The ureters receive a segmental arterial supply, which varies along its course.

The upper part of the ureter closest to the kidney is supplied by the renal arteries

The middle part of the ureter is supplied by the common iliac arteries, direct branches from
the abdominal aorta, and gonadal arteries (the testicular artery in men or ovarian artery in
women)

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The lower part of the ureter closest to the bladder is supplied by branches from the internal
iliac arteries,as well as[citation needed]:

Superior vesical artery

Uterine artery (in women only)

Middle rectal artery

Vaginal arteries (in women only)

Inferior vesical artery (in men only)

Within the periureteral adventitia these arteries extensively anastomose thus permitting
surgical mobilization of the ureter without compromising the vascular supply as long as the
adventitia is not stripped. Lymphatic and venous drainage mostly parallels that of the
arterial supply

Nerve supply
The ureters are richly innervated by nerves that travel alongside the blood vessels, building
the ureteric plexus.The primary sensation to the ureters is provided by nerves that come
from T12-L2 segments of the spinal cord. Thus pain may be referred to the dermatomes of
T12-L2, namely the back and sides of the abdomen, the scrotum (males) or labia majora
(females) and upper part of the front of the high.

194. Urinary bladder: parts, topography (holotopy, skeletotopy, syntopy). Blood

supply and innervation of the urinary bladder.
THE URINARY BLADDER lies in cavity of lesser pelvis behind pubic symphysis. It has
an apex, body and fundus, which is directed down and posterior. Inferior part forms à neck,
which continues into urethra. Empty urinary bladder lies extraperitoneally. Full bladder
covered by peritoneum anteriorly, laterally and posteriorly – mesoperitoneal position.
Fundus of the bladder in male adjoins from below to prostate gland, seminal vesicles and
ampoule of ductus deferens, and behind – to ampoule of rectum. In female urinary bladder
behind adjoins to vagina and uterus.
The blood supply of the bladder is derived from the superior, middle, and inferior vesical
(bladder) arteries. The superior vesical artery supplies the dome of the bladder, and one of
its branches (in males) gives off the artery to the ductus deferens, a part of the passageway
for sperm. The middle vesical artery supplies the base of the bladder. The inferior vesical
artery supplies the inferolateral surfaces of the bladder and assists in supplying the base of
the bladder, the lower end of the ureter, and other adjacent structures.
The nerves to the urinary bladder belong to the sympathetic and the parasympathetic
divisions of the autonomic nervous system. The sympathetic nerve fibres come from the
hypogastric plexus of nerves that lie in front of the fifth lumbar vertebra. Sympathetic

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nerves carry to the central nervous system the sensations associated with distention of the
bladder and are believed to be involved in relaxation of the muscular layer of the vesical
wall and with contraction of sphincter mechanism that closes the opening into the urethra.
The parasympathetic nerves travel to the bladder with pelvic splanchnic nerves from the
second through fifth sacral spinal segment. Parasympathetic nerves are concerned with
contraction of the muscular walls of the bladder and with relaxation of its sphincter.
Consequently they are actively involved in urination and are sometimes referred to as the
emptying, or detrusor, nerves.

195. Urinary bladder: structure of the wall, relation to the peritoneum. Triangle of
urinary bladder, its boundaries (peculiarities of the mucosa).
The urinary bladder wall has a serous coat over its upper surface. This covering is a
continuation of the peritoneum that lines the abdominal cavity; it is called serous because it
exudes a slight amount of lubricating fluid called serum. The other layers of the bladder
wall are the fascial, muscular, submucous, and mucous coats.

The fascial coat is a layer of connective tissue, such as that which covers muscles. The
muscular coat consists of coarse fascicles, or bundles, of smooth (involuntary) muscle
fibres arranged in three strata, with fibres of the outer and inner layers running lengthwise,
and with fibres of the intermediate layer running circularly; there is considerable
intermingling of fibres between the layers. The smooth muscle coat constitutes the
powerful detrusor muscle, which causes the bladder to empty.

The circular or intermediate muscular stratum of the vesical wall is thicker than the other
layers. Its fibres, although running in a generally circular direction, do interlace. The
internal muscular stratum is an indefinite layer of fibres that are mostly directed
longitudinally. The submucous coat consists of loose connective tissue containing many
elastic fibres. It is absent in the trigone, a triangular area whose angles are at the two
openings for the ureters and the single internal urethral opening. Slim bands of muscle run
between each ureteric opening and the internal urethral orifice; these are thought to
maintain the oblique direction of the ureters during contraction of the bladder. Another
bundle of muscle fibres connects the two ureteric openings and produces a slightly
downwardly curved fold of mucous membrane between the openings.

The mucous coat, the innermost lining of the bladder, is an elastic layer impervious to
urine. Over the trigone it firmly adheres to the muscular coat and is always smooth and
pink whether the bladder is contracted or distended. Elsewhere, if the bladder is contracted,
the mucous coat has multiple folds and a red, velvety appearance. When the bladder is
distended, the folds are obliterated, but the difference in colour between the paler trigonal
area and the other areas of the mucous membrane persists. The mucous membrane lining
the bladder is continuous with that lining the ureters and the urethra.
196. Female urethra, topography, structure of the wall. Blood supply and innervation
of the urethra.

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 The female urethra is much shorter (three to 4.5 centimetres) and more distensible than the
corresponding channel in males and carries only urine and the secretions of mucous
glands. It begins at the internal opening of the urethra into the bladder and curves gently
downward and forward through the urogenital diaphragm, where it is surrounded, as in the
male, by the sphincter urethrae. It lies behind and below the symphysis pubis. Except for
its uppermost part, the urethra is embedded in the anterior wall of the vagina. The external
urethral orifice is immediately in front of the vaginal opening, about 2.5 centimetres
behind the clitoris, and between the labia minora, the inner folds at the outer opening of the
vagina.
Arteries, veins, lymph nodes and innervation
• Arteries – internal pudendal and vaginal arteries
• Veins – follow the arteries and have similar names
• Lymph nodes – sacral and internal iliac
• Innervation – pudendal nerve

197. Ovary: topography (holotopy, skeletotopy, syntopy), ligaments, external and

internal structure, functions. Blood supply and innervation of the ovaries.
The Ovary is a pair organ, is situated in cavity of lesser pelvis. It has medial surface and
lateral surface, free margin and mesenteric margin, uterine extremity and tubarius
extremity. Ovary is situated in peritoneal cavity, it is covered by embryonic epithelium
(not by peritoneum). Ovary attaches to uterus by proper ovaric ligament, and to pelvis
walls – by the medium of suspensory ovaric ligament. Ovaric mesentery approaches to
anterior margin, through which the vessels and nerves get into ovary hilus. Ovary
parenchyma consists of cortex and medulla. Ovule ripens in cortex, where primary folliculi
are situated, which then transforms into Graaf vesicle. After that as vesicle blowes up, an
oocyte gets out from the ovary and gets into uterine tube. Vesicle becomes as corpus
luteum [yellow body]. If there is not fecundation, then corpus luteum transform into corpus
albicans. In case of fecundation corpus luteum grows up and turns into corpus luteum
verum, which functions during pregnancy.
The ovaries receive blood from paired ovarian arteries, which arise directly from
the abdominal aorta, below the renal artery.
Venous drainage is achieved by a pair of ovarian veins. The left ovarian vein drains into
the left renal vein, and the right ovarian vein drains directly into the inferior vena cava.
Lymph from the ovaries drains into the para-aortic nodes.
The nerve supply to ovaries runs via the suspensory ligament of the ovary with the
vasculature, to enter the ovary at the hilum.

The ovaries receive sympathetic and parasympathetic nerve fibres from the ovarian and
uterine (pelvic) plexuses, respectively.

198. Uterus: topography (holotopy, skeletotopy, syntopy), the position of the uterus,
relation to the peritoneum.
The Uterus is an odd hollow organ, pear-shaped object, which is situated in cavity of lesser
pelvis. It has a fundus, body and neck of uterus, which opens into vagina by uterine

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ostium, limited by anterior labium and posterior labium. Uterine neck divided into
supravaginal portion and vaginal portion. Uterine body has vesical surface (anterior) and
intestinal surface (posterior). Place of transition body of uterus into neck is called as
isthmus. Anterior uterus surface adjoins to urinary bladder, and posterior– to rectum.
Attached to empty urinary bladder body of uterus is tilted forward. Such position is called
anteversio. Attached to full urinary bladder a fundus and uterus body displaces posteriorly
– this is retroversio. Also between body and uterus neck is formed a angle, open forward.
Such position is called anteflexio. Triangle-shaped cavity of uterus above communicate
with uterine tubes, and vagina through the cervical canal and ostium uteri.
199. Uterus: parts, structure of the wall, relation to the peritoneum, parametrium,
functions. Blood supply and innervation of the uterus.
Wall of uterus consists of three layers:
• mucous membrane (endometrium), submucous stratum is absent, so there is no folds on
internal surface of uterus;
• muscular membrane (myometrium) is formed by smooth muscle and consists of internal,
middle and external layers;
• serous membrane (perimetrium) is a peritoneum, which covers an uterus from all sides,
except part of front surface and lateral margins and supravaginal portion of neck
(mesoperitoneal position). Serous membrane forms ligamentum uteri latum, which forms
mesentery of uterus, mesentery of ovary and mesentery of uterine tube. Between sheets of
ligamentum latum uteri the vessels, nerves, adipose tissue (parametrium) and ligamentum
teres uteri are contained. Ligamentum teres [round] uteri passes through the inguinal canal
to pubis. Also uterus is fixed to pelvic walls by cardinal ligament.
The blood supply to the uterus is via the uterine artery. Venous drainage is via a plexus in
the broad ligament that drains into the uterine veins.
Lymphatic drainage of the uterus is via the iliac, sacral, aortic and inguinal lymph nodes.

Sympathetic nerve fibres of the uterus arise from the uterovaginal plexus. This largely
comprises the anterior and intermediate parts of the inferior hypogastric plexus.
Parasympathetic fibres of the uterus are derived from the pelvic splanchnic nerves (S2-S4).
The cervix is largely innervated by the inferior nerve fibres of the uterovaginal plexus.
The afferent fibres mostly ascend through the inferior hypogastric plexus to enter the
spinal cord via T10-T12 and L1 nerve fibres.

200. Cervix uteri: parts, structural features of the mucosa.

Cervix (cervix uteri; neck).—The cervix is the lower constricted segment of the uterus. It
is somewhat conical in shape, with its truncated apex directed downward and backward,
but is slightly wider in the middle than either above or below. Owing to its relationships, it
is less freely movable than the body, so that the latter may bend on it. The long axis of the
cervix is therefore seldom in the same straight line as the long axis of the body. The long
axis of the uterus as a whole presents the form of a curved line with its concavity forward,
or in extreme cases may present an angular bend at the region of the isthmus.
The cervix projects through the anterior wall of the vagina, which divides it into an
upper, supravaginal portion, and a lower, vaginal portion.

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 The supravaginal portion (portio supravaginalis [cervicis]) is separated in front from the
bladder by fibrous tissue (parametrium), which extends also on to
its sides and lateralward between the layers of the broad ligaments. The uterine arteries
reach the margins of the cervix in this fibrous tissue, while on either side the ureter runs
downward and forward in it at a distance of about 2 cm. from the
cervix. Posteriorly, the supravaginal cervix is covered by peritoneum, which is prolonged
below on to the posterior vaginal wall, when it is reflected on to the rectum, forming
the rectouterine excavation. It is in relation with the rectum, from which it may be
separated by coils of small intestine.
The vaginal portion (portio vaginalis [cervicis]) of the cervix projects free into the
anterior wall of the vagina between the anterior and posterior fornices. On its rounded
extremity is a small, depressed, somewhat circular aperture, the external orifice of the
uterus, through which the cavity of the cervix communicates with that of the vagina. The
external orifice is bounded by two lips, an anterior and a posterior, of which the anterior is
the shorter and thicker, although, on account of the slope of the cervix, it projects lower
than the posterior. Normally, both lips are in contact with the posterior vaginal wall.

201. Uterine tubes: topography, parts, structure of the wall, relation to the
peritoneum, functions. Blood supply and innervation of the uterine tubes.
The Uterine tube is a pair organ is situated in area of superior margin of ligamentum latum
uteri. Length of each tube is 8-18 cm. There are 4 parts:
• uterine part runs in wall of uterus and opens into uterine cavity by uterine ostium;
• isthmus of uterine tube lies closely to uterus
• ampulla of uterine tube is greater part of uterine tube;
• infundibulum of uterine tube – is broadened part, which opens by abdominal foramen of
uterine tube into abdominal (peritoneal) cavity and covered by fimbria, one of which –
ovaric fimbria is longer then other. Uterine tube is covered from all sides by peritoneum
and has its own mesentery. Tube has also muscular membrane (longitudinal and circular
layers) and mucous membrane. Fecundation realizes in uterine tube normally, than
fertilized ovule passes into uterus.

Blood supply
 arterial supply: tubal branch of the ovarian artery and terminal (tubal) branch of
the uterine artery
 venous drainage: similarly named veins

Lymphatic supply
Lymph drainage is predominantly laterally and up to the para-aortic lymph nodes (like the
ovaries).

Nerve supply
 ovarian and uterine plexuses (from T11 - L1)

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202. Vagina: topography, fornix, structure of the wall. Blood supply and innervation
of the vagina.
The Vagina is a tube of 7-9 cm in length that communicates uterine cavity with external
genital organs. Upper portion of vaginae envelopes the uterine neck forming vaginal
fornix. Vagina has anterior and posterior walls and opens by orifice into vestibule. Fold of
mucous membrane – hymen, closes this orifice in virgins. After defloration remainders of
hymen called caruncle. Internal mucous membrane contains columna rugarum that located
along the walls of vagine. Middle coat of vagina – muscular, external one – connective
tissue.
Blood is supplied to the vagina by the uterine and vaginal arteries, both branches of the
internal iliac artery.
Venous return is achieved by the vaginal venous plexus, which drains into the internal iliac
veins, via the uterine vein.
Lymphatic drainage is via the iliac and superficial inguinal lymph nodes

The parasympathetic and sympathetic nerves supplying the vagina are derived from
the uterovaginal nerve plexus. The uterovaginal plexus lies in the base of the broad
ligamenteither side of the supravaginal part of the cervix.
The inferior fibres from the uterovaginal plexus supply the superior part of the vagina.
These are derived from the inferior hypogastic plexus and the pelvic splanchnic nerves.
The inferior part of the vagina is innervated by a branch of the pudendal nerve called
thedeep perineal nerve.

203. External female genitalia: topography, structure. Blood supply and innervation
of the external female genitalia.
External female genital organs: Pudendal area with labia pudenda majora and labia
pudenda minora, vestibule of vagina, clitoris and mons pubisThe major pudenda labia limit
a pudenda rima. Right and left major pudenda labia communicate by each other by the by
means of anterior labial comissura and posterior comissura. Minor pudendal labia are the
skin folds without adipose tissue, they lie medially from major pudenda labia. Anterior
margin of minor pudendal labia bifurcates and forms prerutium of clitoris and frenulum of
clitoris. The Clitoris is by length 2-3 cm, is analogue of cavernous bodies of penis and
consists of head, body and legs of clitoris. The legs of clitoris attach to inferior rami of
pubic bone. The Vestibule vaginae are a fissure between minor pudendal labia. External
urethral ostium, vaginal foramen and ducts of minor and major (Bartolini) vestibular
glands open here. Bulbus vestibuli vagina consists of cavernous tissue, which is situated on
sides from inferior vaginal end (analogue of sponges body of penis).
Blood supply to the external genitalia is delivered by the paired pudendal arteries, with the
internal branch contributing mostly.
The veins of the vulva are the pudendal veins, with the smaller labial veins as tributaries.
During sexual activity, these veins become engorged, increasing the size of the clitoris.
Lymphatic drainage is to the superficial inguinal lymph nodes.

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The external female genitalia receives sensory and parasympathetic nervous supply.
With regards to sensory innervation, the vulva can be split into anterior and posterior
sections:

 The anterior portion of the vulva is supplied by the ilioinguinal nerve, and the genital
branch of the genitofemoral nerve
 The posterior portion of the vulva is supplied by the pudendal nerve, and by
the posterior cutaneous nerve of the thigh.
The clitoris and the vestibule also receive parasympathetic innervation from the cavernous
nerves, derived from the uterovaginal plexus.

204. Vestibule of vagina: boundaries. Openings of vestibule

Vestibule

 Extends from the external urethral opening to the external vulva, so combines
urinary and reproductive functions.
 Shorter than the vagina.
 Lies mostly behind the ischial arch, sloping ventrally to its opening at the vulva.
 The wall contains vestibular glands.
 Secretions from these glands keeps the mucosa of the vestibule moist and
facilitates coitus and parturition.
 At oestrus, the odour of these secretions sexually stimulates the male.


205. Mammary gland: topography, structure.

Mammary gland, milk-producing gland characteristic of all female mammals and present
in a rudimentary and generally nonfunctional form in males. Mammary glands are
regulated by the endocrine system and become functional in response to the hormonal
changes associated with parturition.

The mammary gland of a woman who has not borne children consists of a conical disk of
glandular tissue, which is encased in variable quantities of fat that give it its characteristic
shape. The glandular tissue itself is made up of 15–20 lobes composed of solid cords of
ductal cells; each lobe is subdivided into many smaller lobules, separated by broad fibrous
suspensory bands (Cooper’s ligaments), which connect the skin with the fascia, or sheet
of connective tissue, that covers the pectoral muscles beneath the breast. Each lobe is
drained by a separate excretory duct. These converge beneath the nipple, where they widen
into milk reservoirs, before narrowing again to emerge as pinpoint openings at the summit
of the nipple. Circular and radiating muscles in the areola, a circular disk of roughened
pigmented skin surrounding the nipple, cause the nipple to become firm and erect upon

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tactile stimulation; this facilitates suckling. The areola also contains sebaceous glands to
provide lubrication for the nipple during nursing.

206. Organs of the male reproductive system: topographical classification

MASCULINE GENITAL

Subdivide into internal male sexual organs (testicles, epididymis, spermatic cord, ductus
deferens, seminal vesicles, prostate gland and bulbourethral gland) and external genital
organs (scrotum and penis). Masculine urethra is not only for passing of urine also for
passing of sperm.

207. Testis: topography, external and internal structure. Blood supply and innervation of
the testis.

The Testicle is a pair parenchymatic organ, which is situated in scrotum and produces
sperm and masculine sexual hormones. Each testicle has superior extremity and inferior
extremity, medial surface and lateral surface, anterior margin and posterior margin.
Testicle is covered by tunica albuginea which on posterior margin to get in testicle
parenchyma and forms testicle mediastinum. Last gives off septula testis, which subdivide
organ into 150-200 lobules. In each lobule the tubuli seminiferi contorti are situated (1-2),
where masculine sexual cells – spermatozoon produced. Tubuli seminiferi contorti
continue into tubuli seminiferi recti [straight], and last run into rete testis in mediastinum.
Efferent ductuli (15 – 20) pass from testicle rete transfixing albuginea membrane, continue
into head of epididymis and form there the lobules of epididymis. Then spermatozoon runs
sufficiently rolled duct of epididymis, which reaches into length 2 m. Duct of epididymis
passes down to its tail, where continues into ductus deferens.

208. Epididymis: topography, part, structure, function.

The Epididymis adjoins to posterior testicle margin. There are head of epididymis, body
and tail of epididymis. Sinus of epididymis is situated between testicle and body of
epididymis.function: storage sperm and transport to the testis,

209. Vas deferens: size, parts, topography, structure of the wall, functions. Blood supply
and innervation of the vas deferens.

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The Ductus deferens has scrotal part, funicular part, inguinal part and pelvic part. It enters
to composition of spermatic cord, which passes in inguinal canal to internal ring. Here
ductus deferens separates from seminal funiculus, then it runs under fundus of urinary
bladder. Pelvic part joins with excretorial duct of seminal vesicles, forming ampoule of
ductus deferens. Attaching ducts generate ejaculatory duct (length 2 cm), which passes
over prostata and opens into prostatic part of urethra on top of seminal tubercle.

210. Seminal vesicle: topography, structure, function. Blood supply and innervation of the
seminal vesicles.

The seminal vesicles are a pair of glands that are positioned below the urinary
bladder and lateral to the vas deferens. Each vesicle consists of a single tube
folded and coiled on itself, with occasional diverticula in its wall.
The excretory duct of each seminal gland unites with the corresponding vas deferens to
form the two ejaculatory ducts, which immediately pass through the substance of
the prostate gland before opening separately into the verumontanum of the
prostatic urethra.
Each seminal vesicle spans approximately 5 cm, though its full unfolded length is
approximately 10 cm, but it is curled up inside the gland's structure.

The seminal vesicles secrete a significant proportion of the fluid that ultimately
becomes semen. Lipofuscin granules from dead epithelial cells give the secretion its
yellowish color. About 70-85% of the seminal fluid in humans originates from the seminal
vesicles, but is not expelled in the first ejaculatefractions which are dominated
by spermatozoaand zinc-rich prostatic fluid.

211. Ejaculatory duct: formation, location and opening

Ejaculatory duct, either of two hollow tubes, each formed by union of the ampulla of
a ductus deferens and the excretory duct of a seminal vesicle.Located in each sides of
prostate gland. The ducts, which open into the urethra about halfway through the prostate
gland, function to mix the sperm stored in the ampulla with fluids secreted by the seminal
vesicles and to transport these substances to the prostate.

212. Pathways of sperm.

The testes are where sperm are manufactured in the scrotum. The epididymis is a
tortuously coiled structure topping the testis, and it receives immature sperm from the
testis and stores it several days. When ejaculation occurs, sperm is forcefully expelled from

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the tail of the epididymis into the deferent duct. Sperm then travels through the deferent
duct through up the spermatic cord into the pelvic cavity, over the ureter to the prostate
behind the bladder. Here, the vas deferens joins with the seminal vesicle to form the
ejaculatory duct, which passes through the prostate and empties into the urethra. When
ejaculation occurs, rhythmic muscle movements propel the sperm forward.

213. Spermatic cord: composition, topography, tunics.

The Spermatic cord is a formation, which consists of arteries and testicle veins, arteries
and veins of ductus deferens, pampiniform venous plexus, cremaster muscle, vaginal
processes, nerves, lymphatic vessels and ductus deferens. Its serosal covering, the tunica
vaginalis, is an extension of the peritoneum that passes through the transversalis fascia.

3 layers of tissue:

 external spermatic fascia, an extension of the innominate fascia that overlies

the aponeurosis of the external oblique muscle
 cremasteric muscle and fascia, formed from a continuation of the internal oblique
muscle and its fascia
 internal spermatic fascia, continuous with the transversalis fascia

214. Prostate: topography, external structure

The Prostate is a musculî-secretory organ, for shape reminds the chestnut, has a base of
prostate, which adjoins to urinary bladder, and top of prostate, which is contact with
urogenital diaphragm. It has an anterior surface and posterior surface, right and left lobes
of prostate and isthmus of 113 prostate, that envelops a urethra. Prostate gland consists of
36 alveolartubular glandules, which produce prostate juice and open by numerous ductuli
into prostate part of urethra on base of seminal tubercle. Muscular apparatus contributes to
extrusion of secret from prostate gland during ejaculation and is as additional (involuntary)
urethral sphincter, which withholds the urine in bladder. Gland in old age atrophies and its
mass diminishes.

215. Prostate: parts, internal structure, function. Blood supply and innervation of the
prostate

Several distinct lobes make up the structure of the prostate:

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 On the anterior end of the prostate are the two lateral lobes, which are rounded and shaped
like orange slices when viewed in a transverse section. The lateral lobes are the largest
lobes and meet at the midline of the prostate.
 Posterior and medial to the lateral lobes is the much smaller anterior lobe, a triangle of
fibromuscular tissue just anterior to the urethra. The fibromuscular tissue of the anterior
lobe contracts to expel semen during ejaculation.
 The median lobe is found just posterior to the urethra along the midline of the prostate. The
median lobe contains the ejaculatory ducts of the prostate.
 The posterior lobe forms a thin layer of tissue posterior to the median lobe and the lateral
lobes.

functions: secretion,ejaculation,urination
The arterial supply to the prostate comes from the prostatic arteries, which are mainly
derived from the internal iliac arteries. They also arise from the internal pudendal and
middle rectal arteries.
Venous drainage of the prostate is via the prostatic venous plexus, draining into the
internal iliac veins. However, the prostatic venous plexus also connects posteriorly by
networks of veins, including the Batson venous plexus, to the internal vertebral venous
plexus.

The prostate receives sympathetic, parasympathetic and sensory innervation from

the inferior hypogastric plexus. The smooth muscle of the prostate gland is innervated by
sympathetic fibres, which activate during ejaculation.

216. Penis: parts, structure. Blood supply and innervation of the external male genitalia.

The Penis serves removal of the urine and ejaculation. It has a radix, corpus and head. Skin
which covers the penis in base of head forms the fold – preputium. Last thank to frenulum
connects with skin of head. Penis is formed by two cavernous bodies and spongious body.
All bodies of penis covered by tunica albuginea. Spongious body contains male urethra.

The skin of the penis is more heavily pigmented than that of the rest of the body. It is
connected to the underlying tunica albuginea by loose connective tissue.

The prepuce (foreskin) is a double layer of skin and fascia, located at the neck of the
glans. It covers the glans to a variable extent. The prepuce is connected to the skin of the
glans by the frenulum, a median fold of skin on the ventral surface of the penis. The
potential space between the glans and prepuce is termed the preputial sac.

The penis receives arterial supply from three sources:

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  Dorsal arteries of the penis

 Deep arteries of the penis

 Bulbourethral artery

These arteries are all branches of the internal pudendal artery. This vessel arises from
the anterior division of the internal iliac artery.
Venous blood is drained from the penis by two veins. The cavernous spaces are drained by
the deep dorsal vein of the penis – this empties into the prostatic venous plexus.
The superficial dorsal veins supply the superficial structures of the penis, such as the skin
and cutaneous tissues.

The penis is supplied by S2-S4 spinal cord segments and spinal ganglia.
Sensory and sympathetic innervation to the skin and glans penis is supplied by the dorsal
nerve of the penis, a branch of the pudendal nerve. Parasympathetic innervation is carried
by cavernous nerves from the prostatic nerve plexus, and is responsible for the vascular
changes which cause erection.

217. Male urethra: parts, topography, structure of the wall, constrictions and dilations.
Blood supply and innervation of the urethra.

Masculine urethra is a tube of length 16-22 cm, in which there distinguish prostatic part,
membranous part and spongious part. On its tract a urethra makes a superior (fixed) bend
and inferior (free) bend. Prostatic part passes through the prostate. In this part on the
urethral wall is situated seminal colliculus, on top of which prostatic utriculus disposed.
Ejaculatory duct opens at last and prostatic ductuli opens on tubercle base. Intermediate
(membranous) part of urethra shorter, it passes through urogenital diaphragm. Described
two parts have to fixed position within pelvis and perineum. Spongy part of urethra lies in
spongious body of penis and opens by external urethral ostium on head top. Male urethra
has following constrictions: external urethral ostium on head of penis; membranous part of
urethra; internal urethral ostium. Also a urethra has such expansions: all prostatic part;
expansion in bulb of penis; scaphoid fossa in head of penis.

Arteries, veins, lymph nodes and nerves

• Proximal two parts
– Arterial supply by Prostatic branches of inferior vesical and middle rectal arteries
– Veins follow the arteries and have same name
– Lymph drains mostly to internal iliac lymph nodes
– Nerves are derived from pudendal nerves and prostatic plexus

• Distal two parts

– Artery: Branches of internal pudendal artery
– Vein: Internal pudendal veins

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– Lymph nodes: Membranous urethra drains to internal iliac lymph nodes and most of
spongy urethra drains to deep inguinal lymph nodes
– Nerves: are branches of pudendal nerve
– Also derived from prostatic plexus
– Afferent fibers passes through pelvic splanchnic nerves

218. Bulbourethral gland: topography, structure, function.

The Bulbourethral gland is a pair alveolar-tubular gland, which is situated in thickness of

urogenital diaphragm. It has a duct of bulbourethral gland, which passes over bulb of penis
and opens into spongy part of masculine urethra. Gland produces a secret, which protects
mucous membrane of the urethra from irritation by urine.

219. List the glands that produce liquid part of semen.

Semen is produced and originates from the seminal vesicle, which is located in the pelvis.
The process that results in the discharge of semen is called ejaculation. It is secreted by
the gonads (sexual glands) and other sexual organs of male or hermaphroditic animals and
can fertilize female ovum.

220. Perineum: definition in the narrow and wide sense.

The perineum in narrow aspect is the soft tissues situated between anus and external
genital. In wide understanding a perineum is a complex of soft tissues, which closes the
pelvic outlet. Perineum is diamond-shaped area, which is limited by coccyx behind, by
inferior margin of pubic symphysis anteriorly and by sciatic tuber – laterally.

221. Perineum: parts, boundaries. Blood supply and innervation of the perineum.

Perineum subdivides by line between right and left sciatic tubers into anterior urogenital
triangle and posterior anal triangle. Anterior triangle lies in oblique frontal plane and
urethra passes through it in males, and in female – a vagina and urethra. Posterior triangle
lies in horizontal plane, is called by pelvic or anal triangle and terminal portion of rectum
passes through it.

Anatomical Boundaries:
 Anterior – Pubic symphysis.
 Posterior– The tip of the coccyx.
 Laterally – Inferior pubic rami and inferior ischial rami, and the sacrotuberous
ligament.
 Roof – The pelvic floor.
 Base – Skin and fascia.

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The perineum can be subdivided by a theoretical line drawn transversely between the
ischial tuberosities. This split forms the anterior urogenital and posterior anal triangles.
These triangles are associated with different components of the perineum.

Surface Borders
For clinical purposes, it is important to be aware of the surface anatomy which marks the
boundaries of the perineum. These boundaries are best shown when the lower limbs are
abducted, and a diamond shape is depicted. The skin boundaries of the perineum are:

 Anteriorly: Mons pubis in females, base of the penis in males.

 Laterally: Medial surfaces of the thighs.
 Posteriorly: Superior end of the intergluteal cleft.

The major neurovasculature supply to the perineum is from the pudendal nerve (S2 to S4)
and the internal pudendal artery.

222.Urogenital diaphragm: boundaries, the muscles and fasciae that form her. Which
organs penetrate urogenital diaphragm in male and female? 223. Pelvic diaphragm:
boundaries, muscles and fasciae that form it <-- tu dwa są razem :D

Pelvic diaphragm = Deep muscles + Superior fascia + Inferior fascia The ischioanal
[ischiorectal] fossa around the wall of the anal canal are large fascia-lined, wedge-shaped
space between the skin of anal region ÌÑ and the pelvic diaphragm. It contains adiposal
body and pudendal canal (Alcock‘s) with nerves and vessels. The urogenital triangle
Superior fascia of urogenital diaphragm is continuation of pelvic fascia and covers from
above deep muscles. A thin and tough sheet, the perineal membrane ( inferior fascia of
urogenital diaphragm) stretches between the two sides of the pubic arch and covers below
the anterior part of the pelvic outlet. The perineal membrane located between the
superficial and deep muscles. The perineal body is a fibromuscular mass located in the
midpoint between the anal canal and perineal membrane. Urogenital diaphragm = Deep
muscles + Superior fascia + Inferior fascia Superficial perineal fascia (investing fascia)
intimately invests superficial muscles of urogenital triangle. Anteriorly it is fused to the
suspensory ligament of the penis. Subcutaneous membranous layer (stratum) passes
superior to the labia majora (in female) and in males continuous with the dartos fascia in
scrotum. Superficial perineal pouch (compartment) is the potential space between
superficial investing fascia and perineal membrane. In males superficial perineal pouch
contains: root of the penis with associated superficial muscles, pudendal vessels and
nerves. In females superficial perineal pouch contains: crura of the clitoris and bulb of
vestibule, associated with them superficial muscles, pudendal vessels and nerves, greater
vestibular glands. Deep perineal pouch (space) is not an enclosed compartment; it is open
superiorly. This pouch is bounded below by the perineal membrane. In males deep perineal
pouch contains: membranous part of urethra, external urethral sphincter muscle,
bulbourethral glands, deep transverse perineal muscles, related nerves and vessels. In

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females the deep perineal pouch contains the: proximal part of urethra, external urethral
sphincter muscle, deep transverse perineal muscles, related nerves and vessels.

224. Ischiorectal fossa: location, walls, content.

Ischiorectal fossa, also known as the ishioanal fossa, is a wedge shaped space located on
each side of the anal canal. The base of this wedge-shaped fossa is superficial and is
formed by the skin. On the other hand, the apex lies deep and is formed by the junction of
medial and lateral walls.

The medial wall is formed by the sloping levator ani muscle and the anal canal. The lateral
wall is formed by the lower part of the obturator internus muscle, which is covered with
pelvic fascia.

Ischiorectal fossa has the following important contents:

 Fat: The fossa is filled mostly with dense fat that supports the anal canal. The
fat is important because it allows the distention of anal canal during
defecation.
 Pudendal canal: On the lateral wall of the ischiorectal fossa, there is a fascial
canal known as the pudendal canal. It houses the pudendal nerve and the
internal pudendal blood vessels.
 Inferior rectal vessels and nerves: These cross the ischiorectal fossa to reach
the anal canal.
225. Primary lymphoid organs: structure and function.

Primary lymphoid organs: The central or primary lymphoid organs generate lymphocytes
from immature progenitor cells.
The thymus and the bone marrow constitute the primary lymphoid tissues involved in the
production and early selection of lymphocytes.

In humans the largest part of the lymphocyte development ccurs in specialized tissue of
the primary lymphatic organs: bone marrow (liver in the fetal period) and thymus.
There a large number of immunocompetent lymphocytes are produced that colonize the
secondary lymphatic tissue.
One distinguishes two types of immunocompetent cells:

1. T lymphocytes that are responsible for the cellular immune response and mature in
the thymus
2. B lymphocytes that are responsible for the humoral immune reaction and mature in
the liver and in the bone marrow.

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 226. Primary lymphoid organs. Bone marrow: topography, structure, function

Bone marrow

The production of blood cells in bone marrow begins roughly 4-5 months after conception.
Stem cells immigrate from the liver into the bone marrow, where the "microenvironment"
is decisive for the development of stem cells. This stroma consists of endothelial cells, fat
cells, osteoblasts and fibrocytes. Here, among others, mature the B lymphocytes.
Macrophages also colonize the stroma, but they stem from hematopoietic stem cells. This
creates an environment that, according to need, stimulates the proliferation and differentiation
of the precursor cells. As soon as these cells are mature they proceed through the openings in
the sinusoids from the bone marrow into the blood stream.

227. Primary lymphoid organs: thymus, topography, structure, function, age

features.

Thymus

T cells mature out of stem cells produced in the bone marrow and transported into
the thymus. They emigrate out of the thymus, colonizing the secondary lymph organs, and
are active there as immunocompetent cells for the defense of the body against infections.
The thymus derives from the foregut out of the 3rd and 4th pharyngeal pouches. Its
stroma arises out of epithelial cells of ectodermal and also endodermal origins.

The thymus stroma plays a decisive role in the further development of the thymocytes into
T cells. The epithelial cells of the thymus medulla secrete chemokines (MDC =
macrophage-derived chemokines) that chemotactically attract the immature thymocytes,
i.e., the thymocytes express binding sites that are highly specific for these MDC. These
MDC are probably responsible for the maturation of the thymocytes

TOPOGRAPHY

the thymus consists of a paired pars cervicalis thymi and pars thoracalis thymi. Pars
cervicalis is formed of two lobes which adhere symmetrically to mm. sternohyoidei and
mm. sternocephalici. The posterior margins of the lobes are situated at the level of the
entrance to the thorax. From the ventral side the lobes of pars cervicalis thymi are covered
with a very large serous salivary gland with which they are connected with loose
connective tissue, and covered with subcutaneous tissue and skin . Pars thoracalis thymi is
situated in the lower part of the anterior mediastinum. The anterior margin reaches the
place of departure from the aortic arch of a. brachiocephalica and a. carotis communis sin.
It covers part of the aortic arch and pulmonary artery. The posterior margin reaches the
base of the heart, partly covering the auricle. It is connected with the pericardium by loose
connective tissue

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228. Secondary (peripheral) lymphoid organs: spleen, topography, external structure,
internal structure, function. Blood supply and innervation of the spleen

The spleen is an organ located in the upper left abdomen, roughly the size of a clenched
fist. In the adult, the spleen functions mainly as a blood filter, removing old red blood
cells. It also plays a role in the immune response.

In this article, we shall look at the anatomical position, structure and vasculature of the
spleen. We shall also consider the clinical correlations of its anatomy.

The spleen in located in the upper left quadrant of the abdomen, under cover of the
diaphragm and ribcage – and therefore cannot be palpated on clinical examination. It is
an intraperitoneal organ, entirely surrounded by peritoneum (except at the splenic hilum).
It lies in close proximity to other structures in the abdomen:

The spleen is connected to the stomach and kidney by parts of the greater omentum – a
double fold of peritoneum that originates from the stomach:
 Gastrosplenic ligament – connects the spleen to the greater curvature of the stomach.
 Splenorenal ligament – connects the hilum of the spleen to the left kidney. The
splenic vessels and tail of the pancreas lie within this ligament

Structure:The spleen has a slightly oval shape. It is covered by a weak capsule that protects
the organ, whilst allowing it to expand in size.
The outer surface of the spleen can be anatomically divided into two:

 Diaphragmatic surface – in contact with diaphragm and ribcage.

 Visceral surface – in contact with the other abdominal viscera.
It has anterior, superior, posteromedial and inferior borders. The posteromedial and
inferior borders are smooth, whilst the anterior and superior borders contain notches. In
enlargement of the spleen (known as splenomegaly), the superior border moves
inferomedially, and its notches can be palpated.

Nervovascular supply:

The spleen is a highly vascular organ. It receives its arterial supply from the splenic
artery. This vessel arises from the coeliac trunk, running laterally along the superior
aspect of the pancreas, within the splenorenal ligament. As the artery reaches the spleen, it
branches into five vessels – each supplying a different part of the organ.
These arterial branches do not anastomose with each other – giving rise to vascular
segments of the spleen. This enables a surgeon to remove one of these segments without
affecting the others (a procedure known as a subtotal splenectomy).

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Venous drainage occurs through the splenic vein. It combines with the superior mesenteric
vein to form the hepatic portal vein.
The nerve supply to the spleen is from the coeliac plexus.

229. Secondary (peripheral) lymphoid organs. Tonsils (topography, structure, function).

The tonsils (palatine tonsils) are a pair of soft tissue masses located at the rear of the throat
(pharynx). Each tonsil is composed of tissue similar to lymph nodes, covered by pink mucosa
(like on the adjacent mouth lining). Running through the mucosa of each tonsil are pits, called
crypts.

The tonsils are part of the lymphatic system, which helps to fight infections. However, removal
of the tonsils does not seem to increase susceptibility to infection. Tonsils vary widely in size
and swell in response to infection.

Tonsils in humans include, from anterior (front), superior (top), posterior (back), and
inferior (bottom).

230. Peripheral organs of the immune system: lymphatic nodes, classification, topography,
structure, function.

Lymph nodes are kidney shaped structures, typically around 2.5cm in diameter. On
average an adult has around 400 to 450 different lymph nodes spread throughout the body,
with the majority located within the abdomen. They filter foreign particles from the blood,
and play an important role in the immune response to infection.
Each node contains T lymphocytes, B lymphocytes, and other immune cells. They are
exposed to the fluid as it passes through the node, and can mount an immune response if
they detect the presence of a pathogen. This immune response often recruits more
inflammatory cells into the node – which is why lymph nodes are palpable during
infection.
Lymph fluid enters the node through afferent lymphatic channels and leaves the node
via efferent channels. Macrophages located within the sinuses of the lymph node act to
filter foreign particles out of the fluid as it travels through.

CORTEX AND MEDULLA

medulla contains large blood vessels, sinuses and medullary cords that contain antibody-
secreting plasma cells.
The medullary cords are cords of lymphatic tissue, and include plasma
cells, macrophages, and B cells. The medullary sinuses (or sinusoids) are vessel-like
spaces separating the medullary cords. Lymph flows into the medullary sinuses from

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cortical sinuses, and into efferent lymphatic vessels. Medullary sinuses
contain histiocytes (immobile macrophages) and reticular cells.
The cortex of the lymph node is the peripheral portion underneath the capsule and the
subcapsular sinus.[6] The subcapsular sinus drains to trabecular sinuses, and then the lymph
flows into the medullary sinuses.
The outer cortex consists mainly of the B cells arranged as follicles, which may develop a
germinal center when challenged with an antigen, and the deeper cortex mainly consisting
of the T cells. There is a zone known as the subcortical zone where T-cells (or cells that are
mainly red) mainly interact with dendritic cells, and where the reticular network is dense.
The predominant site within the lymph nodes which contain T cells & accessory cells is
also known as paracortex (reticular network)

231. Peripheral organs of the immune system: solitary and aggregated lymphoid nodules
(topography, function).

The Solitary lymphatic nodules (or solitary follicles) are structures found in the small
intestine and large intestine.
The solitary lymphatic nodules are found scattered throughout the mucous membrane of
the small intestine, but are most numerous in the lower part of the ileum.
Their free surfaces are covered with rudimentary villi, except at the summits, and each
gland is surrounded by the openings of the intestinal glands.
Each consists of a dense interlacing retiform tissue closely packed with lymph-corpuscles,
and permeated with an abundant capillary network.
The interspaces of the retiform tissue are continuous with larger lymph spaces which
surround the gland, through which they communicate with the lacteal system.
They are situated partly in the submucous tissue, partly in the mucous membrane, where
they form slight projections of its epitheliallayer.
The solitary lymphatic nodules of the large intestine are most abundant in
the cecum and vermiform process, but are irregularly scattered also over the rest of the
intestine.
They are similar to those of the small intestine.

Peyer's patches (or aggregated lymphoid nodules )are organized lymphoid nodules.
They are aggregations of gut associated lymphoid tissue that are usually found in the
lowest portion of the small intestine, the ileum, in humans; as such, they differentiate the
ileum from the duodenum and jejunum. The duodenum can be identified by Brunner's
glands. The jejunum has neither Brunner's glands nor Peyer's patches.

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Structure: eyer's patches are observable as elongated thickenings of the intestinal
epithelium measuring a few centimeters in length. About 100 are found in humans.
Microscopically, Peyer’s patches appear as oval or round lymphoid follicles (similar
to lymph nodes) located in the lamina propria layer of the mucosa and extending into the
submucosa of the ileum. The number of Peyer's patches peaks at age 15-25 and then
declines during adulthood
Function:
Peyer's patches thus establish their importance in the immune surveillance of the intestinal
lumen and in facilitating the generation of the immune response within the mucosa.Killing
microorganisms.

232. Peripheral organs of the immune system: vermiform appendix (topography, structure,
function).

Appendix, formally vermiform appendix, in anatomy, a vestigial hollow tube that is

closed at one end and is attached at the other end to the cecum, a pouchlike beginning of
the large intestine into which the small intestine empties its contents. It is not clear
whether the appendix serves any useful purpose in humans. Suspected functions include
housing and cultivating beneficial gut flora that can repopulate the digestive system
following an illness that wipes out normal populations of these flora; providing a site for
the production of endocrine cells in the fetus that produce molecules important in
regulating homeostasis; and serving a possible role in immune function during the first
three decades of life by exposing leukocytes (white bloodcells) to antigens in the
gastrointestinal tract, thereby stimulating antibody production that may help modulate
immune reactions in the gut. While the specific functions of the human appendix remain
unclear, there is general agreement among scientists that the appendix is gradually
disappearing from the human species over evolutionary time. Blockage of the appendix
can lead to appendicitis, a painful and potentially dangerous inflammation.

Structure:
The human appendix averages 9 cm in length but can range from 2 to 20 cm. The diameter
of the appendix is usually between 7 and 8 mm. The longest appendix ever removed was
26 cm long; it was removed from a patient in Zagreb, Croatia. The appendix is usually
located in the lower right quadrant of the abdomen, near the right hip bone. The base of the
appendix is located 2 cm beneath the ileocecal valve that separates the large intestine from
the small intestine. Its position within the abdomen corresponds to a point on the surface
known as McBurney's point.
The appendix is connected to the mesentery in the lower region of the ileum, by a short
region of the mesocolon known as the mesoappendix.

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233. Endocrine glands: Embryological classification.
Endocrine glans don’t have the ducts, their secret gets immediately into blond. Endocrine
gland is defined as a ductless gland, whose special cells secrete hormone.
Glands od endodermal origin subdivide into bronchiogenic group: thyroid, parathyroid and
thymus gland. Second group is gland developed from epithelium of intestinal tube;
endocrine part of pancreas
Glands of mesodermal origin include interstitial cells of sexual glans and cortex of arenal
glans.
Glands of ectodermal group include hypophysis (neurogenic group ) and medulla of
suprarenal glans and paraganglia.

234. Thyroid gland: topography (holotopy, skeletotopy, syntopy), parts, structure,

function.
Thyroid gland is situated In anterior Neck area on level of the 4-6 cervical vertebrae.
Consists of right and left lobes comunnicated by istmus, which continoues upward by
piramidal portion.
Thyroid gland is butli by parenchyma which subdivides into lobuli by septa. Follicles are
situated In lobu les which contain hormones such as thyroxine, triodothyronin, calcitonin.
They influence on All types of metabolism.

235. Parathyroid glands: topography, structure, function.

Parathyroid gland has pair superior parathyroid gland and interior parathyroid gland that
situated on back surface of thyroid gland. Parathyroid gland excretes parathyroid hormones
that regulates matabolism of phosphorus and calcium.

236. Topography of right and left adrenal glands (holotopy, skeletotopy, syntopy),
structure, function. Blood supply and innervation of the adrenal gland.
The adrenal glands lie in the posterior abdomen, situated between the superomedial kidney
and the diaphragm. They cover part of the anterior surface of each kidney. The adrenal
glands consist of an outer connective tissue capsule, a cortex and a medulla.
Blood Supply
The adrenal glands have a rich blood supply, which is supplied via three arteries:

 Superior adrenal artery – arises from the inferior phrenic artery

 Middle adrenal artery – arises from the abdominal aorta.
 Inferior adrenal artery – arises from the renal arteries.
Right and left adrenal veins drain the glands. The right adrenal vein drains into the inferior
vena cava, whereas the left adrenal vein drains into the left renal vein.
Neural innervation
The adrenal glands are innervated by the celiac plexus and abdominopelvic splanchnic
nerves. Sympathetic innervation to the adrenal medulla is via myelinated pre-synaptic
fibres, mainly from the T10 to L1 spinal cord segments.

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 237. Paraganglia: topography, structure, function.
Paraganglia are situated closely near abdominal aorta Or In thickness of sympathetic trunk
(sympathetic para ganglion ). Paraganglia has a functions analogic to function of medulla
suprarenal gland. Paraganglia are small agglomerations of chromaffin cells.

238. Pituitary gland: topography, parts, function.

The pituitary gland, also known as the hypophysis, is a major gland of the endocrine
system. It secretes hormones that control the actions of other endocrine organs and various
tissues around the body. It sits within a small depression in the sphenoid bone, known as
the sella turcica (‘’Turkish saddle’’). Pituitary gland has anterior lobe and posteriori lobe.
Anterior lobe can be divided into 3 parts: pars anterior, pars intermedia and pars tuberalis.

239. The pineal body: topography, function.

Pineal body is a small, conical reddish-gray body lies In the depression between the
superior colliculi and has endocrine role. The epiphysis produce hormone which inhibits
the hypophysis activity until puberty age and takes part In regulation of the metabolism.

240. The endocrine part of the pancreas: structure, function.

Endocrine part of pancreas is represented by islets of Langerhans- alpha, beta, gamma.
They produce insulin and glucagon, that regulate metabolism of carbohydrates , regulative
su gar contents In organism.

241. Name the twelve cranial nerves. Classification of cranial nerves according to
functional fibers.
1. Olfactory
2. Optic
3. Oculomotor
4. Trochlear
5. Trigeminal
6. Abucent
7. Facial
8. Vestibulo-cochlear
9. Glosso-pharyngeal
10. Vagus
11. Accessory
12. Hypoglossal
Purely sensory: Olfactory, optic, vestibulo- cochlear.
Purely motor: Oculomotor, trochlear, obducent, facial, accessowy, hypoglossal.
Mixed motor and sensory: glosso-pharyngeal, vagus, trigeminal,

242. Location of cranial nerves on base of brain.

1. Olfacotry- olfactory bulb,
2. Optic- optic chiasm,

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3. Oculomotor- interpeduncular fossa,
4. Trochlear- superior medullary velum,
5. Trigeminal- between the pons and medii cerebellar pedunculi,
6. Abducent- between the pons and pyramids,
7. Facial- cerebellopontine angle,
8. Vestibulo-cochlear- cerebellopontine angle,
9. Glosso-pharyngeal- dorsal Lateran sulcus of medulla oblongata,
10. Vagus- dorsal Lateran sulcus of medulla oblongata,
11. Accessory- dosral Lateran sulcus of medulla oblongata Lower XI pair,
12. Hypoglossal- between olive and pyramid.
243. The first cranial nerve: general characteristics, structure and topography.
The olfactory nerve contains the afferent nerve fibers of the olfactory receptor neurons,
transmitting nerve impulses about odors to the central nervous system. The
specialized olfactory receptor neurons of the olfactory nerve are located in the
olfactory mucosa of the upper parts of the nasal cavity. The olfactory nerves consist of a
collection of many sensory nerve fibers. Function- smell.
244. The second cranial nerve: general characteristics, structure and topography.
The optic nerve, also known as cranial nerve II, is a paired nerve that
transmits visual information from the retina to the brain. The optic nerve is composed
of retinal ganglion cell axons and glial cells.
Position- optic chiasm
Function- Vision.

245. The third cranial nerve: general characteristics, nuclei, position of the nerve on
the brain and skull, branches, areas of innervation.
The oculomotor nerve is the third cranial nerve. It enters the orbit via the superior orbital
fissure and innervates muscles that enable most movements of the eye and that raise the
eyelid. The nerve also contains fibers that innervate the muscles that enable pupillary
constriction and accommodation. The oculomotor nerve originates from the third
nerve nucleus at the level of the superior colliculus in the midbrain. The third nerve
nucleus is located ventral to the cerebral aqueduct.
The superior branch of the oculomotor nerve or the superior division, the smaller, passes
medially over the optic nerve. It supplies the superior rectus and levator palpebrae
superioris.
The inferior branch of the oculomotor nerve or the inferior division, the larger, divides
into three branches.

 One passes beneath the optic nerve to the medial rectus.

 Another, to the inferior rectus.
 The third and longest runs forward between the inferior recti and lateralis to
the inferior oblique. From the last a short thick branch is given off to the lower part of
the ciliary ganglion, and forms its short root.
Function- eye muscels.

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246. General structure of autonomic ganglia of the head: names, position, roots,
branches and objects of innervation.

The parasympathetic fibres begin in the central nervous system. The nerves supplying the
head and neck are situated within four nuclei, located within the brainstem. Each nucleus
is associated with a cranial nerve (the oculomotor, facial, glossopharyngeal and vagus
nerves) – these nerves carry the parasympathetic fibres out of the brain.
After leaving the brain, the parasympathetic fibres from each nuclei synapse in
a peripheral ganglion (a collection of neurone cell bodies outside the CNS). These
ganglia are typically located near to the target viscera. From the ganglia, post-ganglionic
parasympathetic fibres continue to the organs in the head and neck, providing
parasympathetic innervation.
There are four parasympathetic ganglia located within the head – the ciliary, otic,
pterygopalatine and submandibular. They receive fibres from the oculomotor, facial and
glossopharyngeal nerves (the vagus nerve only innervates structures in the thorax and
abdomen). We shall now examine these ganglia in more detail.

Superior Cervical Ganglion

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The superior cervical ganglion is located posteriorly to the carotid artery, and anterior to
the C1-4 vertebrae. Several important post-ganglionic nerves originate from here:

 Internal carotid nerve – hitch-hikes along the internal carotid artery, forming a
network of nerves. Branches from the internal carotid plexus innervate structures in the
eye, the pterygopalatine artery and the internal carotid artery itself.
 External carotid nerve – hitch-hikes along the common and external carotid arteries,
forming a network of nerves. It innervates the smooth muscle of the arteries.
 Nerve to pharyngeal plexus – combines with branches from the vagus and
glossopharyngeal nerves to form the pharyngeal plexus.
 Superior cardiac branch – contributes to the cardiac plexus in the thorax.
 Nerves to cranial nerves II, III IV, VI and IX.
 Gray rami communicantes – distributes sympathetic fibres to the anterior rami of C1-
C4.
Middle Cervical Ganglion
The middle cervical ganglion is absent in some individuals. When present, it is located
anteriorly to the inferior thyroid artery and the C6 vertebra. Its postganglionic fibres are:

 Gray rami communicantes – distributes sympathetic fibres to the anterior rami of C5

and C6.
 Thyroid branches – travel along the inferior thyroid artery, distributing fibres to
the larynx, trachea, pharynx and upper oesophagus.
 Middle cardiac branch – contributes to the cardiac plexus in the thorax.

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Inferior Cervical Ganglion
The inferior cervical ganglion is situated anteriorly to the C7 vertebra. It is occasionally
fused with the first thoracic vertebrae, forming the cervicothoracic ganglion. There are
three post-ganglionic fibres that arise from this ganglion:

 Gray rami communicantes – distributes sympathetic fibres to the anterior rami of C7,
C8 and T1.
 Branches to the subclavian and vertebral arteries – These innervate the smooth
muscle present in the arteries.
 Inferior cardiac nerve – contributes to the cardiac plexus in the thorax.

247. Ciliary ganglion: topography, roots, branches, areas of innervation.

The ciliary ganglion is located within the bony orbit. It is situated anteriorly to the
superior orbital fissure, between the lateral rectus muscle and the optic nerve.
Pre-ganglionic fibres: The ciliary ganglion is supplied by fibres from the Edinger-
Westphal nucleus (associated with the oculomotor nerve).
 Post-ganglionic fibres: The parasympathetic fibres leave the ganglion via the short
ciliary nerves. These fibres continue into the orbit to innervate structures of the eye.
 Target Organs: The post-ganglionic fibres from the ciliary ganglion innervate the
sphincter pupillae (contracts the pupil) and the ciliary muscles (accommodates for near
vision).

248. The fourth cranial nerve: general characteristic, nucleus, location on the brain
and skull, areas of innervation.
The trochlear nerve arises from the trochlear nucleus of the brain, emerging from the
posterior aspect of the midbrain (it is the only cranial nerve to exit from the posterior
midbrain).
It runs anteriorly and inferiorly within the subarachnoid space before piercing the dura
mater adjacent to the posterior clinoid process of the sphenoid bone.
The nerve then moves along the lateral wall of the cavernous sinus (along with the
oculomotor nerve, the abducens nerve, the ophthalmic and maxillary branches of the
trigeminal nerve and the internal carotid artery) before entering the orbit of the eye
via the superior orbital fissure.
The trochlear nerve innervates a single muscle – the superior oblique, which is a muscle
of oculomotion. As the fibres from the trochlear nucleus cross in the midbrain before they
exit, the trochlear neurones innervate the contralateral superior oblique.
249. The fifth cranial nerve: general characteristic, intracranial part of cranial nerve
V.
The trigeminal nerve (the fifth cranial nerve, or simply CN V) is a nerve responsible for
sensation in the face and motor functions such as biting and chewing. The three major
branches of the trigeminal nerve—the ophthalmic nerve (V1), the maxillary nerve (V2) and
the mandibular nerve (V3)—converge on the trigeminal ganglion located within Meckel's
cave and containing the cell bodies of incoming sensory-nerve fibers. The trigeminal

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ganglion is analogous to the dorsal root ganglia of the spinal cord, which contain the cell
bodies of incoming sensory fibers from the rest of the body. The sensory function of the
trigeminal nerve is to provide tactile, proprioceptive, and nociceptiveafference to the face
and mouth. Its motor function activates the muscles of mastication, the tensor
tympani, tensor veli palatini, mylohyoid and the anterior belly of the digastric.
250. Cranial nerve V: nuclei, topography, the location of central and peripheral
fibers.
The trigeminal nerve (the fifth cranial nerve, or simply CN V) is a nerve responsible for
sensation in the face and motor functions such as biting and chewing. The three major
branches of the trigeminal nerve—the ophthalmic nerve (V1), the maxillary nerve (V2) and
the mandibular nerve (V3)—converge on the trigeminal ganglion located within Meckel's
cave and containing the cell bodies of incoming sensory-nerve fibers. The trigeminal
ganglion is analogous to the dorsal root ganglia of the spinal cord, which contain the cell
bodies of incoming sensory fibers from the rest of the body. The sensory function of the
trigeminal nerve is to provide tactile, proprioceptive, and nociceptiveafference to the face
and mouth. Its motor function activates the muscles of mastication, the tensor
tympani, tensor veli palatini, mylohyoid and the anterior belly of the digastric.
251. The first division of trigeminal nerve - formation, location on the brain and skull,
branches, areas of innervation.
First division:
Ophthalmic Nerve
Ophthalmic nerve gives rise to 3 terminal branches: frontal, lacrimal and nasociliary,
which innervate the skin and mucous membrane of derivatives of the frontonasal
prominence derivatives:
 Forehead and scalp

 Frontal and ethmoidal sinus

 Upper eyelid and its conjunctiva

 Cornea (see clinical relevance)

 Dorsum of the nose

Parasympathetic Supply:
 Lacrimal gland: Post ganglionic fibres from the pterygopalatine ganglion (derived
from the facial nerve), travel with the zygomatic branch of V2 and then join the
lacrimal branch of V1. The fibres supply parasympathetic innervation to the lacrimal
gland.

252. The second division of trigeminal nerve - formation, location on the brain and
skull, branches, areas of innervation.
Second divison:
Maxillary Nerve

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 Maxillary nerve gives rise to 14 terminal branches, which innervate the skin, mucous
membranes and sinuses of derivatives of the maxillary prominence of the 1st pharyngeal
arch:
 Lower eyelid and its conjunctiva

 Cheeks and maxillary sinus

 Nasal cavity and lateral nose

 Upper lip

 Upper molar, incisor and canine teeth and the associated gingiva

 Superior palate

Parasympathetic Supply:
 Lacrimal gland: Post ganglionic fibres from the pterygopalatine ganglion (derived
from the facial nerve), travel with the zygomatic branch of V2 and then join the
lacrimal branch of V1. The fibres supply parasympathetic innervation to the lacrimal
gland.
 Nasal glands: Parasympathetic fibres are also carried to the mucous glands of the nasal
mucosa. Post-ganglionic fibres travel with the nasopalatine and greater palatine nerves
(branches of V2)

253. Pterygopalatine ganglion: topography, roots, branches, areas of innervation.

Pterygopalatine ganglion lies In pterygopalatine fossa. It receives parasympathetic
preganglionic fibers from superior salivary nucleus. Last forms n. canalis pterygoidei (
Vidian nerve ) with symapthetic rootlt, sympathetic neurons innervate blond vessels. The
postganglionic fibr es join the ganglionie (sensory ) nerves from maxillary nerve.
Zygomatic nerve carries parasympathetic fibers to the lacrimal nerve for innervating
lacrimal gland.
254. The third division of trigeminal nerve - formation, location on the brain and
skull, areas of innervation.
Mandibular nerve gives rise to four terminal branches in the infra-temporal
fossa: buccal nerve, inferior alveolar nerve, auriculotemporal nerve and lingual nerve.
These branches innervate the skin, mucous membrane and striated muscle derivatives of
the mandibular prominence of the 1st pharyngeal arch.
Sensory supply:
 Mucous membranes and floor of the oral cavity

 External ear

 Lower lip

 Chin

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 Anterior 2/3 of the tongue (only general sensation; special taste sensation supplied by
the chorda tympani, a branch of the facial nerve)

 Lower molar, incisor and canine teeth and the associated gingiva

Motor Supply:
 Muscles of mastication; medial pterygoid, lateral pterygoid, masseter, temporalis

 Anterior belly of the digastric muscle and the mylohyoid muscle (these are suprahyoid
muscles)
 Tensor veli palatini

 Tensor tympani

Parasympathetic Supply:
 Submandibular and Sublingual glands: Post-ganglionic fibres from the
submandibular ganglion (derived from the facial nerve), travel with the lingual nerve to
innervate these glands.
 Parotid gland: Post-ganglionic fibres from the otic ganglion ganglion (derived from
the glossopharyngeal nerve, CN IX), travel with the auriculotemporal branch of the V3
to innervate the parotid gland.

255. Submandibular ganglion: topography, roots, branches, areas of innervation.

Sumnadibular ganglion lies on medial surface same name slivary gland. Preganglionic
parasympathetic fibers start from superior salivary nucleus In composition of chorda
tympani. Last joins the lingual nerve that gives off sensory twigs for ganglion.
Postganglionic fibers from this ganglion together with sensory and sypmathetic fibers
innervate submandibular salivary gland.
256. Sublingual ganglion: topography, roots, branches, areas of innervation.
Sublingual ganglion located on external surface of sublingual salivary glands. It receives
ang gives off the same branches as submandibular parasympathetic ganglion.
257. Otic ganglion: topography, roots, branches, areas of innervation.
Otic ganglion adjons with mandibular of nerve under ovale foramen. This ganglion obtains
parasympathetic innervation from interior salivary nucleus- lesser petrosal nerve.
Postganglionic fibers In composition of auiculotemporal nerve innervate parotid salivary
gland. Postganglionic sypmathetic fibers (from Middle meningeal lexus) which innervate
the vessels of parotid salivary glands.
258. The sixth cranial nerve: general characteristic, nuclei, location on the brain and
skull, area of innervation.
The abducent nerve is a somatic efferent nerve that, in humans, controls the movement
of a single muscle, the lateral rectus muscle of the eye. The abducens nerve leaves the
brainstem at the junction of the pons and the medulla, medial to the facial
nerve. The abducens nucleus is located in the pons, on the floor of the fourth ventricle, at
the level of the facial colliculus. Axons from the facial nerve loop around the abducens
nucleus, creating a slight bulge (the facial colliculus) that is visible on the dorsal surface of

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the floor of the fourth ventricle. The abducens nucleus is close to the midline, like the other
motor nuclei that control eye movements (the oculomotor and trochlear nuclei). Within the
bony orbit, the abducens nerve terminates by innervating the lateral rectus muscle.
259. The sevens cranial nerve and intermediate nerve: general characteristic, nuclei,
topography, location on the brain and skull, branches, areas of innervation.
The facial nerve It emerges from the brainstem between the ponsand the medulla, controls
the muscles of facial expression, and functions in the conveyance of taste sensations from
the anterior two-thirds of the tongue and oral cavity. It also supplies
preganglionic parasympathetic fibers to several head and neck ganglia.
The path of the facial nerve can be divided into six segments.

1. intracranial (cisternal) segment

2. meatal segment (brainstem to internal auditory canal)
3. labyrinthine segment (internal auditory canal to geniculate ganglion)
4. tympanic segment (from geniculate ganglion to pyramidal eminence)
5. mastoid segment (from pyramidal eminence to stylomastoid foramen)
6. extratemporal segment (from stylomastoid foramen to post parotid branches)

The cell bodies for the facial nerve are grouped in anatomical areas
called nuclei or ganglia. The cell bodies for the afferent nerves are found in the geniculate
ganglion for taste sensation. The cell bodies for muscular efferent nerves are found in
the facial motor nucleus whereas the cell bodies for the parasympathetic efferent nerves are
found in the superior salivatory nucleus.

The main function of the facial nerve is motor control of all of the muscles of facial
expression. It also innervates the posterior belly of the digastric muscle,
the stylohyoid muscle, and the stapedius muscle of the middle ear. All of these muscles are
striated muscles of branchiomeric origin developing from the 2nd pharyngeal arch.

260. Autonomic ganglia of the head, associated with the intermediate nerve: roots,
branches, areas of innervation.
The parasympathetic fibres begin in the central nervous system. The nerves supplying the
head and neck are situated within four nuclei, located within the brainstem. Each nucleus
is associated with a cranial nerve (the oculomotor, facial, glossopharyngeal and vagus
nerves) – these nerves carry the parasympathetic fibres out of the brain.
After leaving the brain, the parasympathetic fibres from each nuclei synapse in
a peripheral ganglion (a collection of neurone cell bodies outside the CNS). These
ganglia are typically located near to the target viscera. From the ganglia, post-ganglionic
parasympathetic fibres continue to the organs in the head and neck, providing
parasympathetic innervation.
There are four parasympathetic ganglia located within the head – the ciliary, otic,
pterygopalatine and submandibular. They receive fibres from the oculomotor, facial and

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glossopharyngeal nerves (the vagus nerve only innervates structures in the thorax and
abdomen).

Ciliary Ganglion
The ciliary ganglion is located within the bony orbit. It is situated anteriorly to the
superior orbital fissure, between the lateral rectus muscle and the optic nerve.
 Pre-ganglionic fibres: The ciliary ganglion is supplied by fibres from the Edinger-
Westphal nucleus (associated with the oculomotor nerve).
 Post-ganglionic fibres: The parasympathetic fibres leave the ganglion via the short
ciliary nerves. These fibres continue into the orbit to innervate structures of the eye.
 Target Organs: The post-ganglionic fibres from the ciliary ganglion innervate the
sphincter pupillae (contracts the pupil) and the ciliary muscles (accommodates for near
vision).
In addition, two sets of nerve fibres pass through the ciliary ganglion without synapsing:

 Sympathetic nerves from the internal carotid plexus – innervate the dilator pupillae
muscle
 Sensory fibres from the nasociliary nerve (a branch of the ophthalmic division of the
trigeminal nerve) – innervate the cornea, ciliary body and iris.
Pterygopalatine Ganglion
The pterygopalatine ganglion (also known as sphenopalatine) is the largest of the four
parasympathetic ganglia. It is located within the pterygopalatine fossa – a space located
inferiorly to the base of the skull, and posteriorly to the maxilla.

 Pre-ganglionic fibres: The pterygopalatine ganglion is supplied by fibres from the

superior salivatory nucleus (associated with the facial nerve). These fibres travel within
the greater petrosal nerve and the nerve of the pterygoid canal to reach the ganglion.
 Post-ganglionic fibres: The parasympathetic fibres leave the ganglion by hitch-hiking
on branches of the maxillary nerve (derived from the trigeminal nerve).
 Target organs: The post-ganglionic fibres from the pterygopalatine ganglion provide
secretomotor innervation to lacrimal gland, mucous glands of posterosuperior nasal
cavity, nasopharynx, and the palate.
Sympathetic fibres from the internal carotid plexus and sensory branches from the
maxillary nerve pass through the pterygopalatine ganglion without synapsing.

Submandibular Ganglion
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The submandibular ganglion is located inferiorly to the lingual nerve, from which it is
suspended.
 Pre-ganglionic fibres: The ganglion is supplied by fibres from the superior salivatory
nucleus (associated with the facial nerve). These fibres are carried within a branch of
the facial nerve, the chorda tympani. This nerve hitch-hikes along the lingual branch of
the mandibular nerve to reach the ganglion.

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 Post-ganglionic fibres: Fibres leave the ganglion and travel directly to the
submandibular and sublingual glands.
 Target Organs: Secretomotor innervation to the submandibular and sublingual salivary
glands.
Sympathetic fibres from the facial artery plexus pass through the submandibular ganglion.
They are thought to innervate glands in the base of the oral cavity.

Otic Ganglion
The otic ganglion is located inferiorly to the foramen ovale, within the infratemporal
fossa. It is medial to the mandibular branch of the trigeminal nerve.
 Pre-ganglionic fibres: The ganglion is supplied by fibres from inferior salivatory
nucleus (associated with the glossopharyngeal nerve). Parasympathetic fibres travel
within a branch of the glossopharyngeal nerve, the lesser petrosal nerve, to reach the
otic ganglion.
 Post-ganglionic fibres: The parasympathetic fibres hitchhike along the
auriculotemporal nerve (branch of the mandibular division of the trigeminal nerve) to
provide secretomotor innervation to the parotid gland.
 Target Organs: The post-ganglionic fibres from the otic ganglion provide innervation
to the parotid gland.
Sympathetic fibres from the superior cervical chain pass through the otic ganglion. They
travel with the middle meningeal artery to innervate the parotid gland.

261. The eighth cranial nerve: parts, general characteristic, nuclei, topography.
The glossopharyngeal nerve is a mixed nerve that carries afferent sensory and efferent
motor information. It exits the brainstem out from the sides of the upper medulla, just
rostral (closer to the nose) to the vagus nerve. The motor division of the glossopharyngeal
nerve is derived from the basal plate of the embryonic medulla oblongata, while the
sensory division originates from the cranial neural crest.
From the anterior portion of the medulla oblongata, the glossopharyngeal nerve passes
laterally across or below the flocculus, and leaves the skull through the central part of
the jugular foramen. From the superior and inferior ganglia in jugular foramen, it has its
own sheath of dura mater. The inferior ganglion on the inferior surface of petrous part of
temporal is related with a triangular depression into which the aqueduct of cochlea opens.
On the inferior side, the glossopharyngeal nerve is lateral and anterior to the vagus
nerve and accessory nerve.
Branches[edit]

 Tympanic
 Stylopharyngeal
 Tonsillar
 Nerve to carotid sinus
 Branches to the posterior third of tongue
 Lingual branches

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 A communicating branch to the Vagus nerve

262. The ninth cranial nerve: general characteristic, nuclei, location on the brain and
skull, branches, areas of innervation.
-mixed
-nuclei:
1) nucleus ambigus (motor)
2) nucleus of tractus solitarius (sensory)
3) inferior salivatory nucleus (parasympathetic)
-location on brain and skull: medial eminence, medulla oblongata
-sensory fibers starts from a superior and inferior ganglia in region of jugular foramen,
reaches tongue root
-branches:
1) tympanic nerve (mixed; pass through tympanic canalicule; enter into tympanic
cavity; sensors branches with caroticotympanic nerves (sympathetic) form tympanic
plexus-->innervate mucous membrane of tympanic cavity and auditory tube;
parasympathetic preganglionic fibers -->start from inferior salivatory nucleus; exite from
tympanic cavity; go through hyatus nervi petrosi minoris as LESSER PETROSAL
NERVE; last passes in sulcus and enter into OTIC GANGLION)
2) pharyngeal branches (pass to lateral wall of pharynx; together with branches of
vagus nerve and sympathetic trunk form pharyngeal plexus; last provides innervating of
MUSCLES and MUCOUS MEMBRANE OF THROAT)
3) tonsillar branches ( pass to mucous membrane of PALATINE TONSILS and
PALATAL ARCHES)
4) branch of stylopharyngeal muscle
5) branch of carotid sinus (innervating receptors of CAROTID GLOMUS and
SINUS)
6) communicating branch with auricular branch of vagus nerve

263. The tenth cranial nerve: general characteristic, nucleus, location on the
brain and skull, parts, topography.
-mixed
-nuclei:
1) nucleus ambigus (motor) -->gives rise to the branchial efferent motor fibers of
the vagus nerve and preganglionic parasympathetic neurons that innervate the heart
2) nucleus of tractus solitarius (sensory)-->receives afferent taste information and
primary afferents from visceral organs
3) dorsal nucleus (parasympathetic) -->send output to the viscera, especially the
intestines
- location on the brain and skull: medial eminence, medulla oblongata, trigone of vagus
nerve
-parts and topography:
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1) cranial
- exits from the medulla oblongata in the groove between the olive and the inferior
cerebellar peduncle; it leaves the skull through the middle compartment of the jugular
foramen
2) cervical
- crosses anterior to the right subclavian artery, runs posterior to the superior vena cava,
descends posterior to the right main bronchus, and contributes to cardiac, pulmonary, and
esophageal plexuses
3) thoracic
-enters the thorax between left common carotid artery and left subclavian artery and
descends on the aortic arch
-lies beside the trachea (inferior cardiac branch)
-anterior and posterior surface of the root of the lung (anterior and posterior bronchial
branches)
-round esophagus, posterior surface of the pericardium (esophageal branches)
4) abdominal
-lie on front and back surfaces of stomach
-supply the pancreas, spleen, kidneys, adrenals, and intestine

264. The tenth cranial nerve: branches of the cranial and cervical parts -topography,
composition of fibers, areas of innervation.
a) cranial part
1) meningeal branch:
-starts from superior ganglion
-passes to cranial dura mater in posterior cranial fossa
-supplying the meninges of the posterior cranial fossa
2) auricular branch:
-starts from superior ganglion
-passes over mastoid canalicule of temporal bone
-innervates skin of extend surface of auricule and posterior wall of external acustic
meatus
b) cervical part
1) pharyngeal branch:
-crossing between the external and internal carotid arteries
-with branches of glossopharyngeal nerve and sympathetic trunk form pharyngeal
plexus
-innervates mucous membrane and muscles of throat (superior and middle
constrictors; levator veli palatini; palatopharyngeus and palatoglossus; uvual muscles)
2) superior cervical cardial branches
-pass downward along common carotid artery
-communicate with sympathetic nerve
-enter into cardiac plexus
-supply heart (sensory and parasympathetic innervating)
3) superior laryngeal nerve

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 -originate from inferior ganglion
-passes between the external and internal carotid arteries at the level of crossing of
cranial nerve XII
-at the tip of the hyoid, the superior laryngeal nerve divides into the external and
internal branches
-the internal laryngeal nerve pierces the thyrohyoid membrane to enter the larynx
-the external nerve passes inferiorly with the superior thyroid vessels to the inferior
pharyngeal constrictor muscle
-carry sensory, motor, parasympathetic ganglionic fibers
-motor fibers of external branch innervate cricothyroid and inferior constrictor
muscles
-sensory fibers of internal branch supply mucous membrane of larynx over vocal
fold, mucous membrane of epiglottis and tongue root
4) recurrent laryngeal nerve
-passes upward between esophagus and trachea
-right nerve branches from the vagus at the root of the neck around the right
subclavian artery
-left recurrent laryngeal nerve has a similar course to the right recurrent, except that
it loops around the aortic arch
-sends numerous twigs
5) inferior laryngeal nerve
-supplies mucous membrane of larynx below vocal fold and rest of muscles
(thyroarytenoid, lateral and posterior cricoarytenoid, transverse and oblique arythenoid,
vocalis)
6) cervical cardiac, tracheal, esophageal
-supply internal organs

265. The tenth cranial nerve: the branches of the thoracic part – topography,
composition of fibers, areas of innervation
1) thoracic cardiac branches
-lies beside the trachea
-on the left side, it originates from the recurrent laryngeal nerve only
-pass to cardiac plexus
-supplies heart
2) bronchial branches
-with sympathetic nerves form pulmonary plexus
-posterior bronchial branches are larger than the anterior and lie on the posterior
surface of the root of the lung
-last enters in lungs with bronchi (supplies them)
3) esophageal branch
-form esophageal plexus (posterior surface of the pericardium is supplied by
filaments from this plexus)
-round this organ

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 -supplies esophagus

266. The tenth cranial nerve: the branches of the abdominal part -topography,
composition of fibers, areas of innervation.
1) anterior vagal trunk
-located on front surface of stomach
-gives branches anterior gastric to reach coeliac plexus
2) posterior vagal trunk
-located on back gastric wall (supplies)
-gives off coeliac branches to reach coeliac plexus → supply the pancreas, spleen,
kidneys, adrenals, and intestine

267. The eleventh cranial nerve: general characteristic, nuclei, location on the brain
and skull, area of innervation.
-motor nerve
-nuclei:
1) cranial nucleus (motor)
2) spinal nucleus (motor)
-location on the brain and skull: medial eminence, spinal cord
-rootlets pass through jugular and magnum foramen
-trunk divides into:
1)internal branch
2)external branch → innervate sternocleidomastoid and trapezius muscle (neck)

268. The twelfth cranial nerve: general characteristic, nuclei, location on the brain
and skull, topography, areas of innervation.
-motor nerve
-nuclei:
1)hypoglossal nucleus-->in trigone of hypoglossal nerve (location on the brain and
skull)
-topography:
-exits from myelencephalon in furrow between pyramid and olive
-passes laterally across the posterior cranial fossa, within the subarachnoid space
-pass through of hypoglossal canal
-runs into submandibular triangle
-enter into tongue thickness
-gives off motor branches which innervate muscles (sternohyoid, sternothyroid,
omothyroid, thyrohyoid)

269. Nervous system: structural and functional classification. The gray matter of the
central nervous system: structure, function. White matter of the central nervous
system: structure, function.
a)structural classification:
-central nervous system

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 -peripheral nervous system (PNS is divided into somatic and autonomic branches;
autonomic contains the sympathetic and parasympathetic systems)
b)functional classification:
-sensory neurons which carry information to the CNS
-motor neurons which carry information from the CNS
c)gray matter of CNS
-structure → consisting of neuronal cell bodies, dendrites and axon terminals of
neurons
-function → serves to process information in the brain; process signals generated in
the sensory organs or other areas of the grey matter; this tissue directs sensory (motor)
stimuli to nerve cells in the central nervous system
d)white matter of CNS
-structure → bundles of myelinated axons
-functions → carry nerve impulses between neurons

270. The structure of simple and complex reflex arc.

a) simple (monosynaptic) reflex arc
-stimulus
-receptor → is specialized cell/group of nerve endings/specialized organ which
responds to sensory stimuli, receive stimulus from surrounding
-sensory or afferent neuron → conducts impulses from environment to CNS
-CNS (spinal cord) → receive sensory information from the environment, process
that information, and generate motor commands to effector
-motor of efferent neuron → transport impulses from the CNS to a muscle, gland,
or other effector tissue
-effector → muscle, gland, or other organ capable of responding to a stimulus
b) complex (polysynaptic) reflex arc
-stimulus
-receptor
-sensory or afferent neuron
-CNS (spinal cord)
-interneuron
-motor of efferent neuron
-effector

271. Spinal cord: topography, borders, the external structure. Place of cerebrospinal
fluid puncture.
a) topography:
-located in vertebral canal
-extends inferiorly from the position of foramen magnum of occipital bone to level
of 1st -2nd lumbar vertebra
-terminal portion is called conus medullaris (from it extends inferiorly filum
terminale to level 2nd coccyx vertebrae)
b) external structure

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 -cervical enlargement is located at level 6th cervical vertebrae
-lumbosacral enlargement is at level of 12Th-1L vertebrae
-anterior median fissure and right and left anterolateral sulcuses located on anterior
surface of sinal cord
-posterior median sulcus and also right and left posterolateral sulcus located on
back surface of spinal cord
-31 pairs of spinal nerves
c)borders
1)Dura mater
2)Arachnoid
3)Pia mater
d) place of cerebrospinal fluid
-subarachnoid cavity--> between arachnoid sheath and pia mater; filled with
cerebrospinal fluid

272. Cauda equina: topography, formation. Blood supply and innervation of the
spinal cord.
a)cauda equina topography:
-can be found in the bottom part of the spinal canal
-from the T12/L1 vertebrae to the coccyx
b)cauda equina formation:
-is a bundle of spinal nerves and spinal nerve roots,
-it consists of 9 to 11 pairs of spinal nerves (including the sciatic nerve)
-nerves communicate sensory and motor nerve messages between the central
nervous system and the organs from the pelvis and throughout the lower limbs
c)blood supply
-arteries:
*single anterior spinal artery → supplies the anterior two-thirds of the spinal cord
*paired posterior spinal arteries → supply the posterior one-third of the spinal cord
*anastomoses between the spinal arteries, called arterial vasocorona, supply the
peripheral lateral lateral columns
*radicular arteries → dorsal and ventral arteries arising from ascending cervical,
deep cervical, intercostal, lumbar and sacral arteries, supply nerve roots
*great anterior segmental artery (of Adamkiewicz) → contributes to two third of
circulation to inferior spinal cord
-venous:
*3 anterior and 3 posterior longitudinal spinal veins with tributaries from posterior
medullary and radicular veins. They drain into valveless vertebral venous plexus
*venous plexus is countinuous with cranial dural venous sinuses and contains no
valves; internal plexus drains spinal cord, external plexus connects with azygos vein and
superior and inferior vena cava
d)innervation:
spinal nerves → joining of ventral and dorsal spinal roots
-31 pairs (cervical, thoracic, lumbar, sacral)

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 -each spinal nerve has 2 roots: anterior or ventral (motor and sympathetic fibbers),
posterior or dorsal
-each spinal nerve gives off small meningeal branch which supply dura matter,
anterior/ventral and posterior/dorsal divisions, also white and grey communicating
branches for nearest sympathetic ganglion (in thoraco-lumbar part)

273. Parts and segments of the spinal cord. Relation of the segments to vertebrae.
There are 31 spinal cord nerve segments in a human spinal cord and 5 parts:
-C1-C2 spinal segment match to first two cervical vertebral levels
-from C2-C6 vertebra add 1 to obtain the spinal segment level
-from C7-C8 segments of spinal cord are situated to C7 bony vertebral levels
-from T1-T6 vertebra add 2 to obtain the spinal segment level
-from T7-T9 vertebrae add 3 to obtain the spinal segment level
-T10-T12 vertebrae have whole of lumbar segments
-L1 vertebra has sacral & coccygeal segments
-below L2, there is only spinal roots, called the cauda equina

274. Meninges, spaces and ligament of the spinal cord.

-meninges
1) Dura mater
-is separated from wall of vertebral canal by epidural cavity, which contains
quantity of fat tissue and plexus veins
-between dura mater and subjacent arachnoid is capillary interval, subdural cavity,
which contain small quantity of fluid, probably of nature of lymph
2) Arachnoid
-thin, transparent
-separated from pia mater by comparatively wide interval, subarachnoid cavity,
which is filled with cerebrospinal fluid
3) Pia mater
-closely invests medulla spinalis
-sends delicate septa into its substance
-ligamentum denticulatum
-narrow band
-extends along each of its lateral surfaces
-is attached by a series of pointed processes to inner surface of dura mater

275. Internal structure of the spinal cord in cross section. Formation of spinal roots
and nerves.
The gray substance consist of anterior, posterior and lateral columns (only in
thoracic-lumbar portion) also central intermediate zone round central canal. In transverse
section columns are looking as horns, so they differ anterior, posterior, lateral horns.
White substance contains only neuron long processes (axon), nerve fibbers which
form ascending (sensory, afferent) and descending (motor, efferent) pathways. White
substance divided by sulcuses and is arranged in three funiculi: anterior, lateral, and

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posterior. Both anterior funiculi are communicated each other by white commisura.
Anterior roots (ventral):
-formed by 5 nuclei located in anterior horns
-pass with spinal nerves to skeletal muscles of trunk and limbs
Posterior roots (dorsal):
-allow sensory neurons to enter the spinal cord
Nerves of spinal cord: -->joining of ventral and dorsal spinal roots
-31 pairs (cervical, thoracic, lumbar, sacral)
-each spinal nerve has 2 roots: anterior or ventral (motor and sympathetic fibbers),
posterior or dorsal
-each spinal nerve gives off small meningeal branch which supply dura matter,
anterior/ventral and posterior/dorsal divisions, also white and grey communicating
branches for nearest sympathetic ganglion (in thoraco-lumbar part)

276. The gray matter of the spinal cord: posterior horn, neurons and nuclei.
- receives several types of sensory information from the body including light touch,
proprioception, and vibration
-posterior horns contain intermediate cell
-cells receive impulse from sensory cells and carry them to another cell
-intermediate cells form:
-marginal zone nucleus → is found at all spinal cord levels as a thin layer of
column/tract cells (column cells) that caps the tip of the dorsal horn. The axons of its
neurons contribute to the lateral spinothalamic tract which relays pain and temperature
information to the diencephalon.
-substantia gelatinosa → is found at all levels of the spinal cord; it relays pain,
temperature and mechanical (light touch) information and consists mainly of column cells
(intersegmental column cells). These column cells synapse in cell at Rexed layers IV to
VII, whose axons contribute to the ventral (anterior) and lateral spinal thalamic tracts.
-nucleus proprius → this cell group, sometimes called the chief sensory nucleus, is
associated with mechanical and temperature sensations. It extends through all segments of
the spinal cord. The axons originating in nucleus proprius project to the thalamus via the
spinothalamic tract and to the cerebellum via the ventral spinocerebellar tract
-thoracic nucleus(Clarc-Steiling column) → axons from these cells pass uncrossed
to the lateral funiculus and form the dorsal (posterior) spinocerebellar tract (DSCT),
nucleus of Clarke is found only in segments C8 to L3 of the spinal cord and is most
prominent in lower thoracic and upper lumbar segments

277. Gray matter of the spinal cord: lateral horns, neurons, nuclei in different
segments.
-lateral horns in thoracic-lumbar portion contain autonomic cell (cell form lateral
intermediate nucleus-carry intermadiate cells)
-intermediate nucleus → is located in the intermediate zone between the dorsal and the
ventral horns in the spinal cord levels. Extending from C8 to L3, it receives viscerosensory
information and contains preganglionic sympathetic neurons, which form the lateral horn.

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A large proportion of its cells are cells which send axons into the ventral spinal roots via
the white rami to reach the sympathetic tract as preganglionic fibers. Similarly, cell
columns in the intermediolateral nucleus located at the S2 to S4 levels contains
preganglionic parasympathetic neurons
-receives input from brain stem, organs, and hypothalamus
-only present in the thoracic region and upper lumbar segments
-contains neurons supplying nerves to the muscles of the limbs, preganglionic cell bodies
of the autonomic nervous system and sensory relay neurons

278. Gray matter of the spinal cord: anterior horn, neurons and nuclei.
-contains motor cell consisting of α, β and γ motor neuron
*their axons form anterior roots that passes with spinal nerves to the trunk and
limbs
* are found at all levels of the spinal cord
-5 motor nuclei
-nucleus anterior medial
-nucleus anterior lateral
*this grup (medial and lateral anterior) extend for almost the entire length of the
spinal cord (except for some segments of the lumbar and sacral)
*mainly innervate the muscles of the back and torso muscles
-central nucleus
*it occurs only in certain sections of beads, cervical and lumbar
*in the cervical part innervating the diaphragm
-nucleus posterior medial
-nucleus posterior lateral
*this group (medial and lateral posterior) send axons to all limb
*it is the entire length of the spinal cord with the exception of the thoracic

279. White matter of the spinal cord: structure of anterior funiculus.

-both anterior funiculi are communicated each other by white commisura
-pathways:
a) descending
-anterior corticospinal (pyramidal) tract
-tectospinal tract
-reticulospinal tract
-olivospinal tract
-vestibulospinal tract
b) ascending
-anterior spinothalamic

280. White matter of the spinal cord: structure of the lateral funiculus.
-pathways:
a)descending
-corticospinal (pyramidal) tract

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 -rubrospinal tract (of Monakow)
b) ascending
-dorsal spinocerebellar tract (tract of Flechsig)
-vental spinocerebellar tract (tract of Gowers)
-lateral spinothalamic tract
-located between anterior and posterior column
-lateral funiculus connect with anterior funiculus by wide layer of white matter

281. White matter of the spinal cord: structure of the posterior funiculus.
-consist of:
-fasciculus gracilis (tract of Goll) → lies next posterior median septum
-fasciculus cuneatus (tract of Burdach) → laterally
-these fasciculus conduct impulses of conscious muscle sense
-left fasciculus posterior is seperate from right fasciculus posterior by posterior median
septum

282. Spinal ganglion: topography, structure, function.

SYMPATHETIC THORACOLUMBAR DIVISION
consist of:
-3 cervical gangla
-10-12 thoracic ganglia
-4-5 lumbar ganglia
-4-5 sacral ganglia
-1 coccigeal gangion
1) superior cervical gangion
-located in the level of transversal processes of 2-3 cervical vertebrae
-gives off following branches
*gray communicating rami for I-IV cervical spinal nerves
*internal carotid nerve → passes to carotid artery; deep petrosal nerve-sympathetic
rootlet from pterygopalatine ganglion (innervate vessels and gland of mucous membrane of
nose cavity and mouth, conjuctive and face skin)
*jugular nerve
*laryngo-pharyngeal nerves → form laryngopharyngeal plexus; innervation
mucous membrane and vessels of pharynx and larynx
*superor cervical cardiac nerve → passes down to cardiac plexus
2) middle cervical ganglionic
-located anteriorly from transversal process of 6th cervical vertebrae
-is connected with superior and inferior ganglia by interganglionic rami
-gives off branches:
*gray communicating branches to V-VI cervical spinal nerves
*common carotid nerves → take part in formation of external carotid plexus and
plexus of inferior thyroid artery
*middle cervical cardiac nerve → enters into part of cardiac plexus
3) inferior cervical ganglion

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 -flows together with 1st thoracic ganglion and forms cervicothoracic (stellate)
ganglion
-lies on neck of 1st rib, behind subclavian artery
-gives off branches:
*gray communicating branches to VI-VIII cervical spinal nerves
*subclavian nerves → form subclavian plexus
*branches to vagus nerve and phrenic nerves
*vertebral nerve → forms vertebral plexus round vertebral artery
*inferior cervical cardiac nerve → passes to deep part of cardiac plexuses
4) thoracic ganglia (10-12)
-located near caput of ribs laterally from vertebral bodies
-receive white communicating branches (containing preganglionic fibers)
-gives off branches:
*gray communicating branches → approach to intercostal nerves
*thoracic cardiac nerves → take part in forming of cardiac plexuses
*thoracic pulmonary branches → passing to bronchi and lungs, forming pulmonary
plexuses
*thoracic aortic rami → form thoracic aortic plexuses
*major splanchnic nerve → pass to abdominal plexus
*minor splanchnic nerve → enters into ganglia of abdominal plexuses
5) lumbar ganglia (4-5)
-are found on anterior-lateral surface of lumbar vertebrae bodies
-1st and 2nd lumbar ganglia approach to communicating white branches
-gives off:
*gray communicating branches → go to lumbar spinal nerve
*lumbar splanchnic nerves → pass to abdominal plexus
6) sacral ganglia (4-5)
-lie on pelvic surface of sacrum, medialy from pelvic sacral foramen
-left and right sympathetic trunk terminate in coccigeal ganglion
-gives off:
*communicating gray branches → for sacral spinal nerves
*sacral splanchnic nerves → pass to superior and inferior hypogastric autonomic
plexuses
7) paravertebral sympathetic ganglia
-lie at anterior surface of backbone closely to celiac trunk and superior mesenteric
artery
8) celiac ganglia
-celiac plexus supplies liver, spleen, stomach, pancreas, small and large
(descending colon) intestine
-celiac plexus continues around abdominal aorta, forming abdominal aortic plexus
→ innervate kidney, suprarenal gland, ureters, testicles (ovaries)
9) seperior mesenteric ganglionic
10) aortorenal ganglia
-postganglionic fibres from it pass to organ together with blood vessels and form

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same name plexus
11) phrenic ganglia
-postganglionic fibres from it pass to organ together with blood vessels and form
same name plexus
12) renal ganglia
-postganglionic fibres from it pass to organ together with blood vessels and form
same name plexus

PARASYMPATHETIC GANGLIA
has to parts:
-central
-located in midbrain and rhomboid fossa
-mesencephalic portion contain accessory oculomotor nucleus
-bulbar portion contain superior and inferior salivary nucleus and dorsal nucleus of
vagus nerve
-peripheral
-lie in gray matter of sacral segments SII-SIV of spinal cord
-carries parasympathetic nuclei
1) ciliary ganglion
-located in orbit near optic nerve
-preganglionic fibers → starts from accessory oculomotor nucleus in composition
of oculomotor nerve
-postganglionic fibers → pass in composition of short ciliary nerves to
1)sphincter muscle of pupil
2)ciliary muscle
2) pterygopalatine ganglion
-lies in ptreygopalatine fossa
-receive preganglionic fibers from superior salivary nucleus
-postganglionic fibers
*zygomatic nerve → innervate lacrimal gland
*nasal and palatine nerves → complete innervating of mucous membrane and
glands in nasal cavity and palate
3) submandibular ganglion
-lies on medial surface same name salivary gland
-preganglionic fibers
-postganglionic fibers → together with sensory and sympathetic fibers innervate
submandibular salivary gland (often also sublingual gland)
4) sublingual ganglion
-located on external surface of sublingual salivary glands
-gives off and receive same branches as submandibular parasympathetic ganglion
5) otic ganglion
-adjoin with mandibular of nerve under ovale foramen
-receive innervation from inferior salivary muscles (lesser petrosal nerve)
-postganglionic fibers innervate parotid salivary gland and its vessels

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6) intramural ganglia in parasympathetic vagus nerve
-enters to composition of cardiac, esophageal, pulmonary, gastric, intestinal, and
other splanchnic plexus
-postganglionic neurons supply smooth muscles, glands and vessels of internal
organ in neck, thoracic and abdominal regions
7) ganglia in sacral segments SII-SIV
-pelvis origin
-preganglionic fibers (pelvis splanchnic nerve) pass to terminal ganglia- near
organs
-postganglionic fibers innervate urinary bladder, reproductive organs, lower half of
descending colon, sygmoid colon and rectum

283. Posterior and anterior roots of spinal nerves: formation, topography, function.
1) posterior rami
a)formation and topography
-information is carried to the spinal cord by sensory cells located in the dorsal root ganglia
-the dorsal root fibers are the axons originated from the primary sensory dorsal root
ganglion cells
-axons entering the cord in the sacral region are found in the dorsal column near the
midline and comprise the fasciculus gracilis, axons that enter at higher levels are added in
lateral positions and comprise the fasciculus cuneatus
-suboccipital nerve
*1st dorsal cervical branches
*motor nerve
*runs to suboccipital muscles
-greater occipital nerve
*runs from II cervical ramus to skin and splenius capitis and cervicis and
longissimus muscles
-lumbar branches (superior cluneal nerves) → supply skin in upper part of buttocks
(pośladek)
-sacral branches (medii cluneal nerves) → supply the skin in middle part of buttocks
2) anterior rami
a)formation and topography
- go from ventral lateral sulcus as ventral rootlets
- the ventral rootlets unite and form the ventral root, which contain motor nerve axons
from motor and visceral motor neurons
- the visceral neurons send preganglionic fibers to innervate the visceral organs
- the α motor nerve axons innervate the extrafusal muscle fibers while the small γ motor
neuron axons innervate the intrafusal muscle fibers located within the muscle spindles
-form plexus (cervical, brachial, lumbar, sacral)

284. Development of the brain: sources, stage of three cerebral vesicles.

285. Development of the brain: stage of five cerebral vesicles and their
derivatives.

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1. During the 4th week develop from 3 primary cerebral vesicles:
-prosencephalon
-mesencephalon
-rhomboencephalon
2. Prosencephalon forms two secondary cerebral vesicles: telencephalon, diencephalon.
3. Rhomboencephalon gives origin for medulla oblongata and metencephalon.
4. Mesencephalon separates from rhomboencephalon by isthmus.
5. Metencephalon developes into pons and cerebellum.
6. Midbrain contain tectum and pedunculi cerebri.
7. Diencephalon contains thalamus and hypothalamus.
8. Telencephalon (forebrain) gives origin for rhiencephalon, basal nucei of gray matter,
pallium of hemispheres, corpus callosum and fornix.

286. Brain: parts (anatomical classification). Brainstem: parts.

a) The brain can be divided into 2 cerebral hemispheres, brain stem and cerebellum. A
hemispheres has a base, dorsolateral and medial surface.
b) On the brain base are:
-medulla oblongata
-pons
-medii cerebellar pedunculi
-cerebral pedunculi, interpeduncular fossa lies between two peduncles. Its floor is
perforated by large numbers of blood vessels, the posterior perforated substance
-2 mammillary bodies are located forward from interpeduncular fossa
-tuber cinereum with infundibulum that carries the hypophysis
-optic tracts which join each other and form optic chiasm
-optic nerve
-olfactory tringles with anterior perforated substance
-olfactory tracts
-olfactory bulbs

287. Medulla oblongata: borders, external structure.

-borders:
-upper border → lower margin of pons
-lower border → pyramidal decussation
-posterior border → nuclei cuneati and gracilis are bordered in midline by posterior
median sulcus (posterior surface form lower part of rhomboid fossa)
-anterior border → skull
-external structure:
VENTRAL PART
-anterior median fissure seperates pyramids
-anterior, posterior and lateral sulcus boudary olives (which are in the upper part of
the bulges)

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 -crossing fiber bundles form pyramidal decussation
-on both sides of the medial slot are pyramids
-from the side of the pyramid is lateral anterior sulcus
DORSAL PART
-upper medial
*triangular
*in place of dorsal column bundles appear on both sides inferior cerebellum
peduncles
-lower lateral
*medial posterior sulcus divide surface for 2 equal parts
*occure lateral posterior sulcus
*is narrow stripe which contain roots of IX, X, XI, XII cranial nerves

288. Medulla oblongata: gray and white matter, structure, topography, functional
significance.
a) gray substance of medulla oblongata is represented by:
*olivar nuclei
*gracilis and cuneatus nuclei
*cardiac, vasomotor and respiratory centers
*nuclei of IX-XII cranial nerves
b) white substance consist of:
*ascending tracts → form medial leminiscus
*descending tracts
*reticular formation
c) topography
*ventral part, which includes pathways starting in the cerebral cortex and the dorsal
part, which is reticular nucleus and gray matter
*in the posterior part of medulla obongata are nucleuses (gracilis and cuneatus), in
which ends sensory fibers of nucleuses (graclis and cuneatus)
d) functional significance
*contain respiratory center, the center of movement, vasomotor center, heart center,
the center suction center chewing, swallowing center, centers responsible for vomiting,
sneezing, coughing, yawning, sweating

289. Pons: borders, external structure.

a)borders
-is covered from the outside by cerebrospinal meninges
-lies above from medulla oblongata
-located between medulla oblongata and midbrain
-is bounded at the top of the branches of the brain (crura cerebri) by furrow lateral
midbrain
-at the bottom separates it from the medulla clear furrow sino-bridge
-dorsal surface of pons form upper part of rhomboid fossa
b)external structure

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 -striae medullares seperate pons from medulla oblongata
-on border between anterior and posterior parts of pons trapezoid body lies with
dorsal and ventral nuclei in base
-communicates with cerebellum by medii cerebellar peduncle

290. Pons: gray and white matter, structure, topography, functional significance.
a)gray matter → is presented by
*proper pontine nuclei
*nuclei of V-VIII cranial nerves
b)white matter → consist of:
*medial lemniscus
*descending pyramidal tracts
*reticular formation
c)topography
*ventral part (frontal) is the equivalent of the pyramids of medulla oblongata and
contain bundles of longitudinal fibers, transverse fibers and irregulary located nerve cells
(nuclei)
*dorsal part at lower part passes into dorsal part od medulla oblongata
d)functional significance:
*pontine disease can causes difficulty with sense of balance, walking, sense of
touch, swallowing and speaking
* include sensory roles in hearing, equilibrium, and taste, and in facial sensations
such as touch and pain, as well as motor roles in eye movement, facial expressions,
chewing, swallowing, and the secretion of saliva and tears

291. Reticular formation: topography, structure, functional significance.

Reticular Formation
The neurons of the brainstem and their network of communicating processes are known as
the reticular formation. It lies in the midpart of the tegmentum and extends from the
spinal cord to the midbrain. In the medial region there are large-celled nuclei from which
arise long ascending and descending tracts. Groups of nerve cells regulate respiration,
heartbeat and blood pressure (changes due to physical work or emotion). The reticular
formation influences on the motor system. Through its connections with the nonspecific
nuclei of the thalamus, the reticular formation influences the state of consciousness
(ascending activation system).
The reticular formation has been functionally cleaved both sagittally and coronally.
Traditionally the nuclei are divided into three columns

 In the median column – the raphe nuclei

 In the medial column – gigantocellular nuclei (because of larger size of the cells)

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 In the lateral column – parvocellular nuclei (because of smaller size of the cells)

Function:

1. Somatic motor control – Some motor neurons send their axons to the reticular
formation nuclei, giving rise to the reticulospinal tracts of the spinal cord. These
tracts function in maintaining tone, balance, and posture—especially during body
movements. The reticular formation also relays eye and ear signals to the
cerebellum so that the cerebellum can integrate visual, auditory,
and vestibular stimuli in motor coordination. Other motor nuclei include gaze
centers, which enable the eyes to track and fixate objects, and central pattern
generators, which produce rhythmic signals to the muscles of breathing and
swallowing.
2. Cardiovascular control – The reticular formation includes the cardiac
and vasomotor centers of the medulla oblongata.
3. Pain modulation – The reticular formation is one means by which pain signals from
the lower body reach the cerebral cortex.
4. Sleep and consciousness – The reticular formation has projections to
the thalamus and cerebral cortex that allow it to exert some control over which
sensory signals reach the cerebrum and come to our conscious attention.

292. Rhomboid fossa: formation, borders, topography. Nuclei of cranial

nerves.
Rhomboid fossa positioned on the dorsal surface of the pons and medulla oblongata and
forms the floor of the IVth ventricle. The inferior cerebellar peduncle, medii cerebellar
peduncle and the superior cerebellar peduncle border rhomboid fossa. The floor of the
rhomboid fossa shows bulges near the median sulcus over the nuclei of the cranial nerves:
medial eminence, facial colliculus, trigone of the hypoglossal nerve, trigone of the vagus
nerve and the vestibular area.
The rhomboid fossa is crossed by myelinated nerve fibers, the striae medullares, which
appear at the lateral recess. There are processes of the dorsal acoustic nucleus. Rhomboid
fossa contains nuclei of the V-XII cranial nerves.

Cranial Nerves
# Name Position Function
I Olfactory olfactory bulb smell

II Optic optic chiasm vision

III Oculomotor interpeduncular eye muscles
fossa
IV Trochlear superior eye muscles
medullary velum

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 V Trigeminal between the pons face sensation
and medn & mastication
cerebellar
pedunculi

VI Abducent between the pons eye muscles

and pyramids
VII Facial cerebellopontine face muscles,
angle salivary &
lacnmal glands
VIII Vestibulo- cerebellopontine hearing &
cochlear angle balance
IX Glosso- dorsal lateral pharynx,
pharyngeal sulcus of medulla tongue &
oblongata parotid gland
X Vagus dorsal lateral pharynx,
sulcus of medulla larynx &
oblongata lower thoracic and
X pair abdominal
viscera
XI Accessory dorsal lateral neck muscles
sulcus of medulla (Trapezius/
oblongata lower sternocl
XI pair eidomastoid)
XII Hypoglossal between olive and tongue & neck
pyramid muscles

293. Nuclei of cranial nerves, which are located in the dorsal part of the
medulla oblongata, functional characteristic.
The nuclei of CN IX, X, XI and XII are located in tegmentum (dorsal part) of the medulla.

# Name Position Function

IX Glosso- dorsal lateral pharynx,

pharyngeal sulcus of medulla
tongue &
oblongata parotid gland
X Vagus dorsal lateral pharynx,
sulcus of medulla
larynx &
oblongata lowerthoracic and
X pair abdominal
viscera
XI Accessory dorsal lateral neck muscles
sulcus of medulla (Trapezius/
oblongata lower sternocl
XI pair eidomastoid)
XII Hypoglossal between olive and tongue & neck
pyramid muscles

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294. Nuclei of cranial nerves, which are located in the dorsal part of the pons,
their functional characteristics.
The nuclei of CN V to VIII are located in the tegmentum at the level of the pons.

# Name Position Function

V Trigeminal between the pons face sensation

and medn & mastication
cerebellar
pedunculi

VI Abducent between the pons eye muscles

and pyramids
VII Facial cerebellopontine face muscles,
angle salivary &
lacnmal glands

295. Fourth ventricle: topography, wall, connections.

FOURTH VENTRICLE
Fourth ventricle is a cavity of the rhomboencephalon. Its roof is formed by the superior
medullary velum with the tela choroidea and the inferior medullary velum. The tela
choroidea contains the choroid plexus, its vessels secrets the cerebrospinal fluid. The floor
of the fourth ventricle is formed by rhomboid fossa (dorsal surface of the pons and medulla
oblongata). Fourth ventricle communicates with the third ventricle by cerebral aqueduct
(Sylvius), also with the subarachnoid space by median aperture (foramen of Magendie)
and 2 lateral aperture (Luschka’s foramen).

296. Isthmus rhombencephali.

the anterior portion of the rhombencephalon connecting with the mesencephalon.

Isthmus rhomboencephali develops between the Rhomboencephalon and Mesencephalon and comprises
three main parts:
1. the superior (cranial) cerebellar peduncle
2. the superior medullary velum
3. the trigone of the lemniscus, wich is bordered by cerebral peduncle, superior (cranial) cerebellar peduncle
and inferior brachii of the quadrigeminal plate.

297. Midbrain: boundaries, external structure, parts.

The mid-brain or mesencephalon is the short, constricted portion which connects the
pons and cerebellum with the thalamencephalon and cerebral hemispheres. It is directed

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 upward and forward, and consists of (1) a ventrolateral portion, composed of a pair of
cylindrical bodies, named the cerebral peduncles; (2) a dorsal portion, consisting of four
rounded eminences, named the corpora quadrigemina; and (3) an intervening passage or
tunnel, the cerebral aqueduct, which represents the original cavity of the mid-brain and
connects the third with the fourth ventricle

Specifically, the midbrain consists of:

o tectum
 inferior colliculi
 superior colliculi

o cerebral peduncle
 midbrain tegmentum
 crus cerebri
 substantia nigra

298. Midbrain: internal structure, white and gray matter and its functional
significance, pathways.
The most important portion of internal midbrain structure is grey matter which is arranged
in four groups:
 Grey matter which surrounds the aqueduct of sytlvius

 Grey nuclei embedded in quadrigeminal bodies

 The substantia nigra
 The red nucleus

The various functions which involve brainstem mechanism are controlling the respiratory
muscles, controlling the vocal cords enabling a person to phonate, controlling pharyngeal,
oral as well as nasal passages that are known to cause resonance effect and controlling the
palate, tongue, lips and mandible which are involved in articulation control.

These all functions are controlled by midbrain periqueductal gray and the cranial nerves
12, 10, 9, 5 & 7. The coordinated activities of laryngeal and oral facial tissues are
controlled by the midbrain periaqueductal gray due to which it has control over the way we
laugh and cry.

The mesolimbic pathway transmits dopamine from the ventral

tegmental area (VTA) to the nucleus accumbens. The VTA is located in
Mesocorticolimbic Mesolimbic
the midbrain, and the nucleus accumbens is in the ventral striatum. The
projection pathway
"meso" prefix in the word "mesolimbic" refers to the midbrain, or
"middle brain", since "meso" means "middle" in Greek.

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 The mesocortical pathway transmits dopamine from the VTA to
Mesocortical the prefrontal cortex. The "meso" prefix in "mesocortical" refers to the
pathway VTA, which is located in the midbrain, and "cortical" refers to the
cortex.
The nigrostriatal pathway transmits dopamine from the substantia
nigra pars compacta (SNc) to the caudate nucleus and putamen.
Nigrostriatal pathway
The substantia nigra is located in the midbrain, while both the caudate
nucleus and putamen is located in the dorsal striatum.

299. Brain stem: description of cranial nerves nuclei.

№ Name Position Foramen Function

I Olfactory olfactory bulb openings of the smell
cribriform plate
of ethmoid bone
II Optic optic chiasm optic canal vision
III Oculomotor interpeduncular superior orbital fissure eye muscles
fossa
IV Trochlear superior medullary superior orbital fissure eye muscles
velum
V Trigeminal between the pons (1) Ophthalmic: face sensation
and medii superior orbital fissure; & mastication
cerebellar (2) Maxillary:
pedunculi foramen rotundum;
(3) Mandibular:
foramen ovale
VI Abducent between the pons superior orbital fissure eye muscles
and pyramids
VII Facial cerebellopontine internal acoustic face muscles;
angle meatus, stylomastoid salivary &
foramen lacrimal
glands
VIII Vestibulo- cerebellopontine internal acoustic meatus hearing &
cochlear angle balance
IX Glosso- dorsal lateral jugular foramen pharynx;
pharyngeal sulcus of medulla tongue &
oblongata parotid gland
X Vagus dorsal lateral jugular foramen pharynx,
sulcus of medulla larynx &
oblongata lower viscera
X pair
XI Accessory dorsal lateral jugular foramen neck muscles

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 sulcus of medulla (Trapezius/ster
oblongata lower nocleido-
XI pair mastoid)
XII Hypoglossal between olive and hypoglossal canal tongue & neck
pyramid muscles

300. Cerebellum: external structure, cerebellar peduncles, functional

significance.
The cerebellum has the following features:

 three surfaces: anterior (petrosal), superior (tentorial), inferior (suboccipital)

 three fissures: primary (tentorial), horizontal (petrosal), prebiventral/prepyramidal
(suboccipital)
 two hemispheres
 single median vermis
Cerebellar peduncle is the part that connects cerebellum to the brain stem. There are 6
cerebellar peduncles in total, 3 on the left and 3 on the right. It may refer to:

 Superior cerebellar peduncle - primary output of the cerebellum with mostly fibers
carrying information to the midbrain
 Middle cerebellar peduncle - carry input fibers from the contralateral cerebral cortex
 Inferior cerebellar peduncle - receives ipsilateral proprioceptive information from the
spinal cord.

The cerebellum is the integrative organ for coordination and fine synchronization of body
movements and for regulation of muscle tone. It forms the roof of the IVth ventricle. Its
superior surface is covered by the cerebrum. The medulla oblongata is imbedded in its
inferior surface. There is an unpaired central part, the vermis of the cerebellum, and two
cerebellar hemispheres. This tripartition is only obvious on the inferior surface, where the
vermis forms the floor of a furrow, the vallecula of the cerebellum.
The outer surface of the cerebellum exhibits a number of small, almost parallel
convolutions, the cerebellar folia, separated by sulci. Flocculus located laterally from the
brainstem. On both sides the cerebellum is connected with the brain stem by the cerebellar
peduncles, through which pass all the afferent and efferent pathways. Between the two
cerebellar peduncles lies the roof of the IVth ventricle with the superior medullary velum
and the inferior medullary velum.

301. Cerebellum: parts, structure of gray matter, function.

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The cerebellum is the integrative organ for coordination and fine synchronization of body
movements and for regulation of muscle tone.

A transverse section reveals the cortex and nuclei of the cerebellum. In a sagittal section
the configuration of a tree appears, the so-called arbor vitae. The cerebellar nuclei lie
deep in the white matter:
1. The fastigial nucleus (roof nucleus) near the midline in the white matter of the vermis.
2. The nucleus globosus.
3. In the nucleus emboliformis, at the hilus of the Dentate nucleus
4. The Dentate nucleus, fibers of the cerebellar cortex in the region between the vermis
and the hemisphere (pars intermedia) are supposed to end.

The efferent and afferent tracts of the cerebellum run through the three cerebellar
peduncles:
1) through the inferior cerebellar peduncle, which contains the spinocerebellar tracts and
the connections with the vestibular nuclei.
2) through the middle cerebellar peduncle with fibers from the pons. These arise from the
pontine nuclei and form the continuation of the corticopontine tracts.
3) through the superior (cranial) cerebellar peduncle, which constitutes the efferent fiber
system to the red nucleus and the thalamus.

302. Diencephalon: boundaries, parts.

Diencephalon comprises the thalamencephalon and hypothalamus. Thalamencephalon

consists of thalamus opticus, epithalamus and metathalamus. Hypothalamus formed
by front optic part and back (olfactory) part.

The diencephalon consists of the following structures:

 Thalamus
 Hypothalamus including the Neurohypophysis
 Epithalamus which consists of
o Anterior and Posterior Paraventricular nuclei
o Medial and lateral Habenular nuclei
o Stria medullaris thalami
o Posterior commissure
o Pineal body
 Subthalamus

Borders of the Diencephalon

 Rostral: plane through the optic chiasm and anterior commissure.

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  Caudal: plane through the posterior commissure and the caudal edge of
the mammillary bodies.

 The rostral and caudal boundaries are approximate and semiarbitrary.

 Functionally continuous tissues extend through both boundaries.

 Medial: wall of third ventricle, stria medullaris thalami and massa intermedia.
 Lateral: the internal capsule, tail of caudate and stria terminalis.

 Dorsal: the fornix and floor of the lateral ventricles.

303. Thalamus: external structure, nuclei, functional significance.

Two poles

 Anterior pole (or end) - Lies behind the interventricular foramen

 Posterior pole (or end)

o Also called PULVINAR

o Lies just above and lateral to superior colliculus.

Superior (dorsal) surface -The superior (dorsal) surface of the thalamus is covered by a
thin layer of white matter, the stratum zonale

 It extends laterally from the line of reflection of the ependyma (taenia thalami), and
forms the roof of the third ventricle

 This curved surface is separated from the overlying body of the fornix by the
choroid fissure with the tela choroidea within it.

 More laterally it forms part of the floor of the lateral ventricle.

 related laterally to caudate nucleus

 Seperated from caudate nucleus stria terminalis and thalamostriate vein.

The medial surface - The medial surface of the thalamus is the superior (dorsal) part of
the lateral wall of the third ventricle.

It is usually connected by the contralateral thalamus by an interthalamic adhesion behind

the interventricular foramina.

The boundary with the hypothalamus is marked by an indistinct hypothalamic sulcus,

which curves from the upper end of the cerebral aqueduct to the interventricular foramen.

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The thalamus is continuous with the midbrain tegmentum, the subthalamus and the
hypothalamus

Inferior surface of thalamus

Inferior surface of the tegmentum is related to hypothalamus anteriorly and to ventral

thalamus posteriorly.

The ventral thalamus seperates the thalamus from tegmentum of midbrain

There are three basic types of thalamic nuclei:

i) relay nuclei;
ii) association nuclei
iii) nonspecific nuclei.

Relay nuclei receive very well defined inputs and project this signal to functionally distinct
areas of the cerebral cortex. These include the nuclei that relay primary sensations (the
ventral posterolateral - VPL, ventral posteromedial - VPM, medial geniculate and lateral
geniculate nuclei) and also the nuclei involved in feedback of cerebellar signals (ventral
lateral - VL) and in feedback of basal gangliar output (part of the VL and the ventral
anterior nucleus - VA). The association nuclei are the second type of thalamic nuclei and
receive most of their input from the cerebral cortex and project back to the cerebral cortex
in the association areas where they appear to regulate activity. The third type of thalamic
nuclei are the nonspecific nuclei, including many of the intralaminar and midline thalamic
nuclei that project quite broadly through the cerebral cortex, may be involved in general
functions such as alerting.

304. Metatalamus: parts, functional importance.

The Metathalamus comprises the geniculate bodies, a medial and a lateral. The medial
geniculate body (corpus geniculatum mediale) lies under cover of the pulvinar of the
thalamus. The inferior brachium from the inferior colliculus attaches to the medial
geniculate bodies. The lateral geniculate body (corpus geniculatum laterale) is an oval
elevation on the lateral part of the pulvinar. The superior brachium from the superior
colliculus attaches to the lateral geniculate bodies.

Definition and Site: It is the part of the diencephalon which is attached to posterior part of
the inferior surface of the thalamus.

Parts of the Metathalamus:

1. Lateral geniculate body (LGB): visual function.
2. Medial geniculate body (MGB): auditory function.

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305. Epithalamus: parts, functional importance.
Epithalamus consists of the pineal body (Epiphysis), and the habenulae with trigonum
habenulae, the posterior commissure. Pineal body is connected with thalamus by the
habenulae.

The function of the epithalamus is to connect the limbic system to other parts of the brain.
Some functions of its components include the secretion of melatonin and secretion of
hormones from pituitary gland by the pineal gland (involved in circadian rhythms), and
regulation of motor pathways and emotions.

306. Hypothalamus: parts, structure.

Anterior part of the Hypothalamus consists of the optic chiasm and tuber cinereum with
infundibulum that carries the hypophysis. Posterior part consists of the mammillary bodies
and subthalamic region that carries the corpus subthalamicum (nucleus of Luis).

The hypothalamus is a brain structure made up of distinct nuclei as well as less

anatomically distinct areas. It is found in all vertebrate nervous systems. In
mammals, magnocellular neurosecretory cells in the paraventricular nucleus and
the supraoptic nucleus of the hypothalamus produce neurohypophysial
hormones, oxytocin and vasopressin. These hormones are released into the blood in
the posterior pituitary. Much smaller parvocellular neurosecretory cells, neurons of the
paraventricular nucleus, release corticotropin-releasing hormoneand other hormones into
the hypophyseal portal system, where these hormones diffuse to the anterior pituitary.

307. Third ventricle: walls, connections

The third ventricle, the cavity of the diencephalon has 6 walls:
• lateral walls formed by medial surface of the thalamus
• lower wall (floor) formed by hypothalamic region. There are
infundibuli recess and optic recess
• anterior wall formed by terminal lamina, columna fornicis and
anterior cerebral commissura
• anterior wall is formed by the habenular commissure and posterior
commissure. There is suprapineal reces
• upper wall (roof) formed by tela choroidea of the III ventricle with
plexus choroideus

There is interventricular foramen (of Monro) between anterior thalamic tubercle and
columna fornicis. Foramen communicates the III ventricle with the lateral ventricles of
cerebrum. Cerebral aqueduct connects the III ventricle with the cavity of the IV ventricle.

308. Corpus calosum: topography, parts, functional significance.

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 The corpus callosum connect right and left cerebral hemispheres.

The corpus callosum gives rise to white matter fibres that project to a number of regions
within the cerebral cortex. The corpus callosum is divided into four
parts: rostrum, genu, body/trunk and splenium. The rostrum is continuous with the lamina
terminalis and connects the orbital surfaces of the frontal lobes. The genu is the bend of
the anterior corpus callosum and the forceps minor is a tract that projects fibres from the
genu to connect the medial and lateral surfaces of the frontal lobes. The body forms the
long central section and its fibres pass through the corona radiata to reach the surface of
the hemispheres. The splenium tapers away at the posterior section, with the forceps
major projecting fibres from the splenium to connect the two occipital lobes.

The corpus callosum is the largest fiber bundle in the brain, containing nearly 200
million axons. It is composed of white matter fiber tracts known as commissural fibers. It
is involved in several functions of the body including:

 Communication Between Brain Hemispheres

 Eye Movement and Vision
 Maintaining the Balance of Arousal and Attention
 Tactile Localization

309. Fornix: its topography, parts, functional significance.

The fornix cerebri located under corpus callosum and has a body, columna fornicis (anteriorly) and crura
fornicis (posteriorly). Crus fused with the hippocampus and form the fimbria hippocampi. Anterior
commissura positioned closly to the columna fornicis.

While its exact function and importance in the physiology of the brain is still not entirely
clear, it has been demonstrated in humans that surgical transection – the cutting of the
fornix along its body – can cause memory loss. There is some debate over what type of
memory is affected by this damage, but it has been found to most closely correlate
with recall memoryrather than recognition memory. This means that damage to the fornix
can cause difficulty in recalling long-term information such as details of past events, but it
has little effect on the ability to recognize objects or familiar situations.

310. Rhinencephalon and limbic system: parts, functional significance.

The Rhinencephalon, associated with the sense of smell, is the oldest part of the
telencephalon, and forms almost the whole of the hemisphere in some of the lower

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animals, e. g., fishes, amphibians, and reptiles. In man it is rudimentary. It divides into
central and peripheral parts. The central part includes the hippocampus, gyrus fornicatus
(gyrus cinguli + gyrus hyppocampi), gyrus dentatus, septum pellucidum and uncus. The
peripheral part includes the olfactory bulb, olfactory tract, olfactory trigone and anterior
perforated substance. Cortical smell analyzer located in the uncus. Rhinencephalon is a
center of emotional colouring of sensible perception of external environment (Limbic
system). Together from all subcortical centers it is by energy source for cortex and
answers for vitally important man reactions regulates activity of internal organs: hunger
feeling and thirst, sounds perceptions and smells. Here are the memory mechanisms.

The limbic system is a set of brain structures located on both sides of the thalamus,
immediately beneath the cerebrum. It has also been referred to as the paleomammalian
cortex. It is not a separate system but a collection of structures from
the telencephalon, diencephalon, and mesencephalon.
It includes the olfactory bulbs, hippocampus, hypothalamus, amygdala, anterior thalamic
nuclei, fornix, columns of fornix, mammillary body, septum pellucidum, habenular
commissure, cingulategyrus, parahippocampal gyrus, limbic cortex, and limbic midbrain areas.
The limbic system supports a variety of functions
including emotion, behavior, motivation, long-term memory, and olfaction.[4]Emotional life is
largely housed in the limbic system, and it has a great deal to do with the formation of
memories.

311. Basal nuclei: topography, structure, functional significance.

The basal ganglia (or basal nuclei) consist of multiple subcortical nuclei, of varied origin,
in the brains of vertebrates, which are situated at the base of the forebrain. Basal ganglia
nuclei are strongly interconnected with the cerebral cortex, thalamus, and brainstem, as
well as several other brain areas. The basal ganglia are associated with a variety of
functions including: control of voluntary motor movements, procedural learning, routine
behaviors or "habits" such as bruxism, eye movements, cognition and emotion.

Basal nuclei are the paired masses of gray matter located deep within the white matter in
base of the forebrain. Basal nuclei include 1) corpus striatum, 2) claustrum and 3) nucleus
amygdaloideus.
Corpus striatum is composed of caudate nucleus (it has a head, body and tail) and
lentiform nucleus (it consists of medial and lateral globus pallidus and putamen). There is
a thick lamina of white substance, the internal capsule between caudate nucleus and
globus pallidus. It has the prominence of the curve is called the genu, the frontal crus and

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the occipital crus. The occipital crus separates the lentiform nucleus from the thalamus and
carries optic and acoustic radiation.

The nucleus amygdaloideus is an ovoid gray mass situated at the lower end of the inferior
cornu of the lateral ventricle (in temporal lobe).

The claustrum is a thin, irregular, sheet of neurons that is attached to the underside of
the neocortex in the center of the brain. It is suspected to be present in the brains of
all mammals.

312. Lateral ventricles: parts, topography, walls, communication.

The two lateral ventricles are cavities situated in the lower and medial parts of the cerebral
hemispheres. They are separated from each other by a median vertical partition, the
septum pellucidum, but communicate with the third ventricle and indirectly with each
other through the interventricular foramen. Each lateral ventricle consists of a central
part, and three prolongations from it, termed anterior, posterior and inferior cornua.

The anterior horns passes forward into the frontal lobe. It bordered:
• medially – by lamina of septum pellucidum
• laterally – by head of caudate nucleus
• anteriorly and roof – by corpus callosum

Central part is found in parietal lobe. It is limited:

• below – by body of caudate nucleus and dorsal surface of the thalamus;
• upwards and laterally – by fibers of corpus callosum, which form a roof.

The posterior horns localised in occipital lobes and cover by white matter ‘tapetum’. They
carry the bulb and the calcar avis on medial wall, and a collateral triangle on the floor.

The inferior horns are found in temporal lobe. They are boundered:
• medially – by hippocampus;
• below – by white matter, which forms collateral eminence;
• superolaterally – by white matter;
• superomedially – by a tail of caudate nucleus.

The central part and temporal horn of lateral ventricle contain choroid plexus of lateral
ventricle generated of penetration pia mater by vessels. Choroid plexus passes to the III
ventricle through interventricular foramen. Choroid plexus takes part in formation of larger
half of cerebrospinal fluid.

313. Anterior horn of the lateral ventricle: topography, walls, communication.

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The anterior horns passes forward into the frontal lobe. It bordered:
• medially – by lamina of septum pellucidum
• laterally – by head of caudate nucleus
• anteriorly and roof – by corpus callosum

The anterior horn of lateral ventricle or frontal horn, passes forward and to the side,
with a slight inclination downward, from the interventricular foramen into the frontal
lobe, and curves around the front of the caudate nucleus. Its floor is formed by the upper
surface of the reflected portion of the corpus callosum, the rostrum. It is bounded medially
by the front part of the septum pellucidum, and laterally by the head of the caudate
nucleus. Its apex reaches the posterior surface of the genu of the corpus callosum.

314. Posterior horn of the lateral ventricle: topography, walls, communication.

The posterior horn of lateral ventricle or occipital horn, passes into the occipital lobe. Its
direction is backward and lateralward, and then medial ward. Its roof is formed by the
fibers of the corpus callosum passing to the temporal and occipital lobes. On its medial
wall is a longitudinal eminence, the calcar avis(hippocampus minor), which is an
involution of the ventricular wall produced by the calcarine sulcus. Above this the forceps
posterior of the corpus callosum, sweeping around to enter the occipital lobe, causes
another projection, termed the bulb of the posterior cornu. The calcar avis and bulb of the
posterior cornu are extremely variable in their degree of development; in some cases they
are ill-defined, in others prominent.

315. Inferior horn of the lateral ventricle: topography, walls, communication.

The inferior horn of lateral ventricle or temporal horn, is the largest of the horns. It
traverses the temporal lobe, forming a curve around the posterior end of the thalamus. It
passes at first backward, lateralward, and downward, and then curves forward to within
2.5 cm. of the apex of the temporal lobe, its direction is fairly well indicated on the brain
surface by the superior temporal sulcus. Its roof is formed chiefly by the inferior surface of
the tapetum of the corpus callosum, but the tail of the caudate nucleus and the stria
terminalis also extend forward in the roof of the temporal horn to its extremity; the tail of
the caudate nucleus joins the putamen. Its floor presents the following parts:
the hippocampus, the fimbria hippocampi, the collateral eminence, and the choroid plexus.
When the choroid plexus is removed, a cleft-like opening is left along the medial wall of
the temporal horn; this cleft constitutes the lower part of the choroidal fissure.

316. The central part of the lateral ventricle: topography, walls, communication.

The body of the lateral ventricle is the central portion, just posterior to the frontal
horn. The trigone of the lateral ventricle is a triangular area defined by the temporal horn
inferiorly, the occipital horn posteriorly, and the body of the lateral ventricle anteriorly.

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The cella media is the central part of the lateral ventricle. Ependyma cover the inside of the
lateral ventricles and are epithelial cells.

317. White matter of the cerebral hemispheres: classification, functional significance.

White Matter of the Cerebrum. The external capsule located between putamen and
claustrum. The extrema capsule separates the claustrum and cortex of the insula.
White matter is the tissue through which messages pass between different areas of gray
matter within the central nervous system. The white matter is white because of the fatty
substance (myelin) that surrounds the nerve fibers (axons). This myelin is found in almost
all long nerve fibers, and acts as an electrical insulation. This is important because it allows
the messages to pass quickly from place to place.
There are three different kinds of tracts, or bundles of axons, which connect one part of the
brain to another and to the spinal cord, within the white matter:

1. Projection tract extend vertically between higher and lower brain and spinal cord
centers, and carry information between the cerebrum and the rest of the body. The
cortico spinal tracts, for example, carry motor signals from the cerebrum to the
brainstem and spinal cord. Other projection tracts carry signals upward to the
cerebral cortex. Superior to the brainstem, such tracts form a broad, dense sheet
called the internal capsule between the thalamus and basal nuclei, then radiate in a
diverging, fanlike array to specific areas of the cortex.
2. Commissural tracts cross from one cerebral hemisphere to the other through
bridges called commissures. The great majority of commissural tracts pass through
the large corpus callosum. A few tracts pass through the much smaller anterior and
posterior commissures. Commissural tracts enable the left and right sides of the
cerebrum to communicate with each other.
3. Association tracts connect different regions within the same hemisphere of the
brain. Long association fibers connect different lobes of a hemisphere to each other
whereas short association fibers connect different gyri within a single lobe. Among
their roles, association tracts link perceptual and memory centers of the brain.
The brain in general (and especially a child's brain) can adapt to white-matter damage by
finding alternative routes that bypass the damaged white-matter areas, and can therefore
maintain good connections between the various areas of gray matter

318. White matter of the cerebral hemispheres: classification of associative fibers,

functional significance.

The long association fibers include the following:

Name From To

uncinate fasciculus frontal lobe temporal lobe

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cingulum cingulate gyrus entorhinal cortex

superior longitudinal frontal lobe occipital lobe

fasciculus
inferior longitudinal occipital lobe temporal lobe
fasciculus
vertical occipital inferior parietal lobule fusiform gyrus
fasciculus
occipitofrontal occipital lobe frontal lobe
fasciculus
fornix hippocampus mammillary bodies

Arcuate fasciculus frontal lobe temporal lobe

The short association fibers (also often referred to as "U-fibers") lie immediately beneath
the gray substance of the cortex of the hemispheres, and connect together adjacent gyri.

319. White matter of the cerebral hemispheres: commissural fibers, functional significance.

Connects gyri in opposite hemispheres

320. White matter of the cerebral hemispheres: projective fibers, classification,

functional significance.

white matter of the cerebral hemisphere basically contains two components

 myelinated nerve fibers
 neuroglia (mostly oligodendrocytes)

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The white matter of the cerebral hemisphere are of three types:
1. commissural fibers
2. association fibers
3. projection fibers

Commissural Fibers Association Fibers Projection Fibers

The commissural fibers These fibers connect the These fibers connect the cerebral
interconnect the various cortical regions of cortex with lower part of the
corresponding regions of a cerebral hemisphere. brain or brainstem and the spinal
the two cerebral These fibers permit the cord, in both directions.
hemispheres. cortex to function as a
coordinated whole. The corticopetal (afferent) fibers
include
Types of Association
They are as follows: fibers
- Corpus callosum  geniculocalcarine
- Anterior a) Short association radiation from the lateral
commissure fibers, or U fibers, geniculate body to the calcarine
- Posterior connect adjacent gyri. cortex,
commissure  auditory radiation from
- Fornix the medial geniculate body to the
- Habenular  intracortical auditory cortex, and
commissure fibers - located in the
 thalamic
deeper portions of the
radiations from the thalamic
white matter and
nuclei to specific cerebrocortical
 subcortical areas
fibers - located just
beneath the cortex

The corticofugal (efferent)

b) Long association fibers proceed from the cerebral
fibers connect more cortex to the thalamus, brain
widely separated areas. stem, or spinal cord.

uncinate fasciculus

arcuate fasciculus

sup. longitudinal
fasciculus

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 inferior longitudinal

occipitofrontal
fasciculus

321. White matter of the cerebral hemispheres: the internal capsule, the topography,
structure.

Internal Capsule
Most of the nerve fibers interconnecting the cerebral cortex with centers in the brainstem
and spinal cord, and with the thalamus pass through the interval between the thalamus and
caudate nucleus medially and lentiform nucleus laterally.

This region at the upper end of the brainstem form a compact band and is called
the internal capsule. Above, the internal capsule is continuous with corona radiate
and below, with the crus cerebri of midbrain.

As seen on the horizontal section, the internal capsule consists of

 The anterior limb lies between caudate nucleus medially and the anterior part of
the lentiform nucleus laterally
 The posterior limb lies between the thalamus medially and the posterior part of the
lentiform nucleus laterally
 And the genu where both limb meets.

322. Hemisphere: surfaces, lobes, borders.

 The cerebral hemispheres constitute the largest part of the brain

 Divided into right and left hemispheres.

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 Linked by corpus callosum.

Surfaces of cerebral hemispheres

A) Lateral surface:
 convex

B) Medial surface
 flat and vertical
 Separated by longitudinal fissure

C) Inferior surface
 Anterior = orbital surface of the frontal lobe
 Middle = under surface of the temporal lobe
 Posterior = tentorial surface

LOBES :

frontal , parietal , temporal , occipital

-Limbic lobe - cingulate gyrus, parahippocampal gyrus and hippocampus are referred to as
the limbic lobe
-insular lobe - The insular lobe is thought to be involved in sensory and motor visceral
functions as well as taste perception.
 PARIETAL
Plays role in integrating sensory information from various parts of the body,
knowledge of numbers and their relations, and in the manipulation of objects.
 TEMPORAL
The temporal lobe is involved in auditory perception and is home to the primary
auditory cortex

Borders of hemispheres

3 surfaces are separated by the following borders:

(a) Supero-medial, between the lateral and medial surfaces.

(b) Infero-lateral, between the lateral and inferior surfaces; the anterior part of this
border separating the lateral from the orbital surface, is known as the superciliary
border.

(c) Medial occipital, separating the medial and tentorial surfaces.

(d) Medial orbital, separating the orbital from the medial surface

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 Sulcus : A sulcus is depression or fissure in the surface of the brain.
( valleys )
Gyrus : A gyrus is a ridge on the cerebral cortex. It is generally surrounded by one or
more sulci
( hills )

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323. Sulci and gyri of ventrolateral surface of the cerebral hemisphere.

precentral sulcus,
superior frontal sulcus,
inferior frontal sulcus.

Theyseparate:
precentral gyrus,
superior frontal gyrus,
middle frontal gyrus,
inferior frontal gyrus

324. Sulci and gyri of medial surface of the cerebral hemisphere.

 calcarine sulcus

 Parietooccipital sulcus

 hippocampal sulcus

 CINGULATE GYRUS - Starts beneath the corpus callosum and goes back above it
and ends at the posterior end of it.
 CALLOSAL GYRUS - Separates corpus callosum from cingulate gyrus
 MEDIAL OCCIPITOTEMPORAL GYRUS
 gyrus parahippocampalis
 dentate gyrus
 Important structures on the medial surface
 Corpus callosum
 Paracentral lobule
 Precuneus
 Cuneus

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Corpus callosum
Bundle of axons
It connects the left and right cerebral hemispheres and facilitates interhemispheric
communication

325. Sulci and gyri of inferior surface of the cerebral hemisphere.

 COLLATERAL SULCUS - Separates cingulate gyrus from superior frontal gyrus

 occipitotemporal sulcus,
 rhinal sulcus
 orbital sulcus.

They separate the lateral :

-occipitotemporal gyrus,
-medial occipitotemporal gyrus,
-lingual gyrus,
-gyrus rectus
-orbital gyri.
 Lingual gyrus - Between collateral sulcus and calcarine sulcus
 Parahippocampal gyrus - Anterior to lingual gyrus

326. Sulci and gyri of frontal lobe. Localization of the cortical fields in the cortex of the
frontal lobe.

 Frontal lobe is separated from the parietal lobe by a space between tissues called
the central sulcus,

 from the temporal lobe by a deep fold called the lateral sulcus also called the
Sylvian fissure.

The precentral gyrus, forming the posterior border of the frontal lobe, contains the primary
motor cortex, which controls voluntary movements of specific body parts.

Sulci:
 Superior frontal sulcus.
 Inferior frontal sulcus.
 Precentral sulcus.

Gyri:

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  Superior frontal gyrus.
 Middle frontal gyrus.
 Inferior frontal gyrus.
 Precentral gyrus

Lateral part: Polar part: Orbital part: Medial part:

lateral part of Transverse Lateral orbital Medial part of
the superior frontal frontopolar gyri, gyrus the superior frontal
gyrus gyrus
middle frontal gyrus frontomarginal gyrus anterior orbital cingulate gyrus
gyrus
inferior frontal gyrus posterior orbital
gyrus
medial orbital
gyrus
gyrus rectus.

327. Sulci and gyri of parietal lobe. Localization of the cortical fields in the cortex of the
parietal lobe.

Parietal lobe Sulci:

 Post-central sulcus.
 Intraparietal sulcus.

Gyri:
 Post-central gyrus (Brodmann area 3), the primary somatosensory cortical area
 Superior parietal gyrus.
 Inferior parietal gyrus.

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The parietal lobe is defined by three anatomical boundaries:
- central sulcus separates the parietal lobe from the frontal lobe;
-parieto-occipital sulcus separates the parietal and occipital lobes;
- lateral sulcus (sylvian fissure) is the most lateral boundary, separating it from
the temporal lobe; and the medial longitudinal fissure divides the two hemispheres.

Within each hemisphere, the somatosensory cortex represents the skin area on the
contralateral surface of the body.

328. Sulci and gyri of temporal lobe. Localization of the cortical fields in the cortex of
the temporal lobe.

-Superior temporal gyrus - Superior temporal sulcus

-Median temporal gyrus - Inferior temporal sulcus
-Inferior temporal gyrus
Occipitotemporal Gyrus
Medial Occipitotemporal Gyrus
Lateral Occipitotemporal Gyrus
The temporal lobe communicates with the hippocampus and plays a key role in the
formation of explicit long-term memory

Adjacent areas in the superior, posterior, and lateral parts of the temporal lobes are
involved in high-level auditory processing

Auditory Visual Language recognition

superior temporal The ventral part of the The left temporal lobe holds
gyrus includes an area temporal cortices appear to the primary auditory cortex,
where auditory signals from be involved in high-level which is important for the
the cochlea first reach visual processing of complex processing of semantics in
the cerebral cortex and are stimuli such both speech and vision in
processed by the primary as faces (fusiform gyrus) and humans.
auditory cortex in the left scenes (parahippocampal
temporal lobe gyrus

Wernicke's area, which

spans the region between
temporal and parietal lobes,
plays a key role (in tandem

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 with Broca's area in
the frontal lobe)

The temporal lobe is involved in primary auditory perception, such as hearing, and holds
the primary auditory cortex

329. Sulci and gyri of occipital lobe. Localization of the cortical fields in the cortex of
the occipital lobe.

GYRI SULCUS
Superior/ middle / inferior /leteral occipital -lateral occipital
-lingual -calcarine
-cuneus - superior / inferior occipital

At the front edge of the occipital are several lateral occipital gyri, which are separated
by lateral occipital sulcus.

The occipital aspects along the inside face of each hemisphere are divided by the calcarine
sulcus. Above the medial, Y-shaped sulcus lies the cuneus, and the area below the sulcus is
the lingual gyrus.

primary visual cortex is Brodmann area 17, is located on the medial side of the occipital
lobe within the calcarine sulcus;

330. Meninges of the brain. Dura matter of brain, dural sinuses.

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The meninges are the 3 membranes that envelop the brain and spinal cord.
- dura mater,
- arachnoid mater,
-pia mater.

Cerebrospinal fluid is located in the subarachnoid space between the arachnoid mater and
the pia mater.The primary function of the meninges is to protect the central nervous
system.

DURA MATTER

-is a thick, durable membrane, closest to the skull and vertebrae.

-the outermost part, is a loosely arranged, fibroelastic layer of cells, characterized by

multiple interdigitating cell processes, no extracellular collagen, and significant
extracellular spaces.

The middle region is a mostly fibrous portion. It consists of two layers: the endosteal layer,
which lies closest to the calvaria (skullcap), and the inner meningeal layer, which lies
closer to the brain. It contains larger blood vessels that split into the capillaries in the pia
mater.

The dura mater is a sac that envelops the arachnoid mater and surrounds and supports the
large dural sinuses carrying blood from the brain toward the heart.

DURAL SINUSES

-are venous channels found between layers of dura mater in the brain

-They receive blood from internal and external veins of the brain, receive cerebrospinal
fluid (CSF) from the subarachnoid space, and ultimately empty into the internal jugular
vein.

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331. Productions and circulation of cerebrospinal fluid.

Cerebrospinal fluid (CSF) is a clear, colorless body fluid found in the brain and spine

WHERE IS IT?

The CSF occupies the subarachnoid space (between the arachnoid mater and the pia mater)
and the ventricular system around and inside the brain and spinal cord.

It constitutes the content of the ventricles, cisterns, and sulci of the brain, as well as
the central canal of the spinal cord.

PRODUCTION

Ependymal cells of the choroid plexus produce more than two thirds of CSF. The choroid
plexus is a venous plexus contained within the four ventricles of the brain

CIRCULATION

CSF circulates within the ventricular system of the brain. The ventricles are a series of
cavities filled with CSF, inside the brain.

1) The majority of CSF is produced from within the two lateral ventricles.

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2) From here, the CSF passes through the interventricular foramina to the third ventricle,
then the cerebral aqueduct to the fourth ventricle.

3) The fourth ventricle is an outpouching on the posterior part of the brainstem.

4) From the fourth ventricle, the fluid passes through three openings to enter
the subarachnoid space – these are the median aperture, and the lateral apertures.

The subarachnoid space covers the brain and spinal cord.[2] There is connection from the
subarachnoid space to the bony labyrinth of the inner ear making the cerebrospinal fluid
continuous with the perilymph

332. Subarachnoid space: formation, cisterns, connections.

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In the central nervous system, the subarachnoid space (subarachnoid cavity) is
the anatomic space between the arachnoid mater and the pia mater.

It is occupied by spongy tissue consisting of trabeculae (delicate connective tissue

filaments that extend from the arachnoid mater and blend into the pia mater) and
intercommunicating channels in which the cerebrospinal fluid is contained.

 cistern (Latin: "box") is any opening in the subarachnoid space of the brain created
by a separation of the arachnoid and pia mater. These spaces are filled
with cerebrospinal fluid.

- Cisterna magna also called cerebellomedullary cistern - the largest of the subarachnoid
cisterns. It lies between the cerebellum and the medulla oblongata.

-Pontine cistern . Surrounds the ventral aspect of the pons.

-Interpeduncular cistern. It is situated at the base of the brain, between the two cerebral
peduncles of mid brain and dorsum sellae

-Superior cistern - It is situated dorsal to the midbrain.

-Sylvian cistern.

333. Pathways of CNS: definition, classification. Descending pathways: classification.

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220
ascending tracts descending tracts
-pathways by which sensory The descending tracts are the pathways by
information from the peripheral which motor signals are sent from the brain to lower
nerves is transmitted to the cerebral motor neurones.
cortex. In some texts, ascending
tracts are also known The lower motor neurones then directly innervate
as somatosensory pathways or muscles to produce movement.
systems.

Functionally, the ascending tracts motor tracts can be functionally divided into two
can be divided into the type of major groups:
information they transmit; Pyramidal tracts – Extrapyramidal tracts –
conscious or unconscious: These tracts originate These tracts originate in
in the cerebral cortex, the brain stem, carrying
 Conscious tracts – Comprised carrying motor fibres to motor fibres to the spinal
of the dorsal column-medial the spinal cord and cord.
lemniscal pathway, and the brain stem.
anterolateral system.
 Unconscious tracts – They are responsible
Comprises of the for the voluntary
spinocerebellar tracts. control of the
musculature of the
body and face
They are responsible for
the involuntary and
automatic control of all
musculature, such as
muscle tone, balance,
posture and locomotion

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pyramidal tracts derive their name from the medullary pyramids of the medulla
oblongata, which they pass through.
These pathways are responsible for the voluntary control of the musculature of
the body and face.

Functionally, these tracts can be subdivided into two:

 Corticospinal tracts – supplies the musculature of the body.

 Corticobulbar tracts – supplies the musculature of the head and neck.

334. Cortico-spinal tract.

The corticospinal tracts begin in the cerebral cortex, from which they receive a range of
inputs:

 Primary motor cortex

 Premotor cortex
 Supplementary motor area
They also receive nerve fibres from the somatosensory area, which play a role in
regulating the activity of the ascending tracts.

internal capsule (a white matter pathway, located between the thalamus and the basal
ganglia)

NEXT
neurones pass through the crus cerebri of the midbrain, thepons and into the medulla

most inferior (caudal) part of the medulla, the tract divides into two:

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fibres within the lateral corticospinal The anterior corticospinal tract remains
tractdecussate (cross over to the other ipsilateral, descending into the spinal cord.
side of the CNS).
They then decussate and terminate in the
They then descend into the spinal cord, ventral horn of cervical and upper thoracic
terminating in the ventral horn (at all segmental levels
segmental levels).

From the ventral horn, the lower motor

neurones go on to supply the muscles of
the body.

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335. Cortico-nuclear tract. / Cortico-bulbar tract

The corticobulbar tracts arise from the lateral aspect of the primary motor cortex. They
receive the same inputs as the corticospinal tracts. The fibres converge and pass through
the internal capsule to the brainstem.

The neurones terminate on the motor nuclei of the cranial nerves. Here, they synapse with
lower motor neurones, which carry the motor signals to the muscles of the face andneck.

Many of these fibres innervate the motor neurones bilaterally. For example, fibres from
the left primary motor cortex act as upper motor neurones for the right and left trochlear
nerves

336. Extrapyramidal pathways.

The extrapyramidal tracts originate in the brainstem, carrying motor fibres to the spinal
cord. They are responsible for the involuntary and automatic control of all musculature,
such as muscle tone, balance, posture and locomotion.

There are four tracts in total.

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The vestibulospinal and reticulospinal tracts do not decussate, providing ipsilateral
innervation.

The rubrospinal and tectospinal tracts do decussate, and therefore provide contralateral
innervation

Vestibulospinal Tracts Reticulospinal Tracts

There are two vestibulospinal pathways;  The medial reticulospinal tract arises
medial and lateral. from the pons. It facilitates voluntary
movements, and increases muscle
tone.

They arise from the vestibular nuclei, which  The lateral reticulospinal tract arises
receive input from the organs of balance. The from the medulla. It inhibits voluntary
tracts convey this balance information to the movements, and reduces muscle tone.
spinal cord, where it remains ipsilateral.

Fibres in this pathway

control balance and posture by innervating
‘anti-gravity’ muscles (flexors of the arm, and
extensors of the leg), via lower motor
neurones.

337. Ascending pathways: bulbothalamic tracts. – NIE JESTEM PEWNA

The Leminiscal system, also known as the Dorsal Column Tract, is important for
conveying sensory information from the peripheral and internal structures to the brain

PATHWAY:

1. First order neuron - the tract starts at the dorsal root ganglion cell (pseudo-
unipolar cells) with its dendrites in the periphery; axons enter the posterior
funiculus and ascend in the posterior column nucleus (spinobulbar tract)

1. Second order neuron - nerve fibres reach the gracilis and cuneate nucleus in the
lower medulla oblongata, where its axons project to the thalamus (bulbothalamic
tract); fibres of the bulbothalamic tract are internal arcuate fibres, crossing the mid-
line (decussation) as they ascend, forming the medial Leminiscal pathway

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 1. Third order neuron - these neurons are located in the ventro-posterolateral (VPL)
and posterior nucleus of the thalamus (pulvinar) with VPL neurons terminating in
the primary somato-sensory cortex; fibres from the pulvinar of thalamus terminates
in the secondary somato-sensory and association cortex

FUNCTION:

 Form recognition
 Proprioceptive sensation
 Tactile discrimination
 Vibration sensation

338. Ascending pathways: ventral and dorsal spinocerebellar tracts.

The spinocerebellar tract is a set of axonal fibers originating in the spinal cord and
terminating in the ipsilateral cerebellum. This tract conveys information to the cerebellum
about length and tension of muscle fibers (i.e., unconscious proprioceptive sensation)

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339. Ascending pathways: anterior and lateral spinothalamic tracts.

SPINOTHALAMIC TRACTS -sensory pathway from the skin to the thalamus.

From the ventral posterolateral nucleus in the thalamus, sensory information is relayed
upward to the somatosensory cortex of the postcentral gyrus.

The spinothalamic tract consists of two adjacent pathways: anterior and lateral.

 The anterior spinothalamic tract carries information about crude touch.

 The lateral spinothalamic tract conveys pain and temperature

340. Olfactory organs: structure, function.

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The olfactory system, or sense of smell, is the part of the sensory system used for
smelling

NOSE, the prominent structure between the eyes that serves as the entrance to the
respiratory tract and contains the olfactory organ. It provides air for respiration, serves the
sense of smell,

The nose has two cavities, separated from one another by a wall of cartilagecalled the
septum. The external openings are known as nares or nostrils. The roof of the mouth and
the floor of the nose are formed by the palatine bone,

the soft palate, extends back into the nasopharynx, the nasal portion of the throat, and
during swallowing is pressed upward, thus closing off the nasopharynx so that food is not
lodged in the back of the nose.

341. Organ of taste: structure, function.

The tongue is a muscular organ in the mouth , is used in the act of swallowing.

The tongue's upper surface (dorsum) is covered in taste buds

It is sensitive and kept moist by saliva, and is richly supplied with nerves and blood
vessels.

The human tongue is divided into two parts, an oral part at the front and a pharyngeal part
at the back. The left and right sides are also separated along most of its length by a vertical

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section of fibrous tissue (the lingual septum) that results in a groove, the median sulcus on
the tongue's surface.

There are two groups of muscles of the tongue.

-The four intrinsic muscles alter the shape of the tongue and are not attached to bone.
-The four paired extrinsic muscles change the position of the tongue and are anchored to
bone.

The tongue also serves as a natural means of cleaning the teeth

A major function of the tongue is the enabling of speech

342. Eyeball: topography, external structure, tunics.

EYE : spheroidal structure containing sense receptors for vision

TOPOGRAPHY:

Eye brow
Angle of eye EYE nose
Cheek

EXTERNAL STRUCTURE :

a) Eyelids
b) Eyelashes
c) Sclera
d) Conjunctiva
e) Cornea
f) Tear Gland
g) Iris
h) Pupil

TUNICS
three tunics are:
(1) A fibrous tunic, sclera behind and the cornea in front;
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(2) a vascular pigmented tunic, choroid, ciliary body, and iris;
(3) a nervous tunic, retina.

343. Eyeball: fibrous, choroid membrane and retina, part, structure, functions.

1) FIBROUS TUNIC
-sclera is opaque, and constitutes the posterior five-sixths of the tunic;
- cornea is transparent, and forms the anterior sixth.

Functions of Cornea
1- The most powerful refractive medium of eye; 39 dioptres (2/3 of refractive power of
eye) -> formation of sharp clear image
2- Protective for sensitive intraocular structures:
- absorbs UV rays
- initiator of Corneal reflex which is a protective reflex

2) VASCULAR TUNIC
A) IRIS
is a thin, circular structure in the eye,

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responsible for controlling the diameter and size of the pupil and thus the amount of light
reaching the retina.
Eye color is defined by that of the iris.

B) CILIARY BODY
-part of the eye that includes the ciliary muscle, which controls the shape of the lens, and
the ciliary epithelium, which produces the aqueous humor.

The ciliary body is part of the uvea, the layer of tissue that delivers oxygen and nutrients to
the eye tissues.

C) CHOROID
-thin, highly vascular membrane,
-investing the posterior five-sixths of the globe;
- it is pierced behind by the optic nerve,

STRUCTURE

The choroid consists mainly of a dense capillary plexus, and of small arteries and veins
carrying blood to and returning it from this plexus.

3) RETINA

- delicate nervous membrane, upon which the images of external objects are received

-Behind, it is continuous with the optic nerve

STRUCTURE

-outer pigmented layer

- inner nervous stratum or retina proper.

344. Nucleus of the eyeball. Chambers of eyeball: borders and communications.

lens nucleus - the central structure of the lens

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that is surrounded by the cortex

345. Productions and ways of circulation of aqueous humor in eyeball.

Aqueous Humour - Clear transparent fluid filling anterior and posterior chambers
Formed by the epithelial lining of ciliary processes of ciliary body

Circulation & Drainage of Aqueous humor

Aq.H from ciliary processes -> flows between suspensory ligaments -> post.chamber ->
through pupil -> ant. Chamber -> through iridocorneal angle (filtration angle) ->space of
Fontana -> canal of Schlemm ->aqueous veins -> episcleral veins -> systemic veins.
Functions of Aqueous Humor
One of refractory media of the eye
Supply of O2 & nutrients for avascular cornea & lens.
Buffering & removal of acid products of anaerobic metabolism of cornea & lens.
Keeping intraocular pressure (IOP) constant by the balance between its formation
& drainage.

346. Additional structures of the eye: conjunctiva; the external muscles of the eyeball,
their action.

1) The conjunctiva lines the inside of the eyelids and covers the sclera (the white of
the eye).

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 It is composed of non-keratinized, stratified columnar epithelium with goblet cells, and
also stratified columnar epithelium. The conjunctiva is highly vascularised, with
many microvessels easily accessible for imaging studies

FUNCTION

-The conjunctiva helps lubricate the eye by producing mucus and tears, although a smaller
volume of tears than the lacrimal gland.

- It also contributes to immune surveillance and helps to prevent the entrance

of microbes into the eye

2) EXTERNAL MUSCLES OF EYEBALL

There are six muscles which are responsible for controlling the movement of the eyeballs.

1. Superior and Inferior Rectus Muscles,

2. Lateral and Medial Rectus Muscles,
3. Superior and Inferior Oblique Muscle.

The Rectus muscles are primarily responsible for the movement of the eyeballs in the four
cardinal directions:
-up,
-down,
-left and
-right.

The pair of Oblique muscles are responsible for controlling the adjustments involved in
counteracting head movements, in other words being able to keep your focus on something
whilst your head moves.

Superior Rectus Muscle

The Superior Rectus muscle is the agonist of the Inferior Rectus muscle and is responsible
for three movements of the eye. Primarily it is responsible for moving the eyes in an
upwards direction(elevation), secondly it rotates the top of the eye toward the nose
(intorsion) and thirdly it moves the eye inward (adduction).

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Inferior Rectus Muscle

The Inferior Rectus muscle is the antagonist of the Superiro Rectus muscle and is
responsible for three movements of the eye.Primarily it is responsible for moving the eye
in a downward direction (depression), secondly it rotates the top of the eye away from the
nose (extorsion) and thirdly it moves the eye inward (adduction)

Lateral Rectus

The Lateral Rectus muscle is the agonist of the Medial Rectus muscle and is primarily
responsible for moving the eye in an outward direction, away from the nose (abduction).

Medial Rectus

The Medial Rectus muscle is the antagonist of the Lateral Rectus muscle and is primarily
responsible for moving the eye in an inward direction, toward the nose (adduction).

Superior Oblique

The superior Oblique muscles is the agonist of the Inferior Oblique muscle and is
responsible for three movements of the eye. Primarily it is responsible for rotating the top
of the eye toward the nose (intorsion), secondly it moves the eye in a downward direction
(depression) and thirdly it moves the eye in outward direction(abduction).

Inferior Oblique

The Inferior Oblique muscles is the antagonist of the Superior Oblique muscle and is
responsible for three movements of the eye. Primarily it is responsible for rotating the top
of the eye away from the nose (extorsion), secondly it moves the eye in a upwards
direction (elevation) and thirdly it moves the eye in inward direction(abduction).

347. Lacrimal apparatus: parts, topography.

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 lacrimal apparatus consists of:
a) -lacrimal gland b) -lacrimal passages

Lacrimal gland –consists of 2 parts

A-orbital lobe situated in a fossa in outer

part of the orbital roof.

B-palpebral lobe situated in the outer part

above the superior fornix.

348. Pathways of visual analyzer.

1)Visual analyzer performs perception, transmission, analysis and synthesis of light stimuli
light-sensitive cells (rods and cones) at a speed of about 720 m/S.

2) Light rays pass through the cornea, the front and back of the camera eye, lens, vitreous
body on the retina.

3) Under the light of the rhodopsin rods and cones disintegrate, resulting in an energy that
is perceived by receptors 1 neuron presented in the retina bipolar cells.

4) Bipolar cells in contact with the ganglion cells, which II neuron

5) Axons ganglion cells radial going to the rear pole eyes, forming the optic nerve, which
comes out of the eye through the visual hole and sent to the base of the brain.

The optic nerve is composed of four types of fibers:

1) visual, starting from the temporal half of the retina;
2) visual, running from the bow half of the retina;
3) papillomatosic emanating from the macula;
4) light coming in bupropionsee the nucleus of the hypothalamus.

349.Ear: it's parts.External ear: parts,structure, functions.

Ear – hearing and wquilibrium organ.

Parts: a) outer (auricle) – auricle, external auditory meatus

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 b)middle – tympanic cavity, aubitory tube
c)internal – osseous labyrinth, membranous labyrinth
External ear: AURICLE
1) it's cartilage covered by skin
2)in inferior part cartilage is absent, there is auricullar lobule (earlobe)
3)has: helix, triangular fossa, antihelix, concha, tragus, antitragus
EXTERNAL AUDITORY MEATUS
1)is open outside
2) in depth from cavity of middle ear is dissociates by tympanic membrane
3)has: -cartilaginous part, ocupies one-third lenght of auditory meatus
-inner osseous part, ocupies two-third of auditory meatus
4)is curved S-like

350.Middle ear, parts. Tympanic cavity: topography, walls, connections, content.

Middle ear: 1) Tympanic cavity

2)Three auditory ossicles: malleus, incus, stapes, muscles
TYMPANIC CAVITY
-positioned in thickness of temporal pyramid
-has walls : 1)tegmental wall (superior)
2)jugular wall (inferior)
3)labyrinthic wall (medial):
- has 2 windows: 1)vestibular (oval)
2)cochlear (round)
- vestibular window is closed by base stapes
-round window is tightened by secondary tympanic membrane
4)mastoid wall (posterior)
-bordered by mastoid process and the bottom rear of the skull.
-here is located stapedius muscle
-superiorly posterior wall continues into mastoid cave
-mastoid cells open in it
5)membranous wall (lateral)
-is formed by tympanic membrane
-epitympanic recess contains head of malleus and body of incus

351. Auditory ossicles, muscles of middle ear.

1)Malleus : a)has :- head
-manubrium with anterior and lateral processes
b)Muscles-tensor of tympanic membrane handle fastened to malleus
2)Incus: a)consists of: - body-adjoins to head of malleus, forming incusomalleus joint
-short and long legs = unites with stapes
3)Stapes: a) has : -head
-anterior and posterior legs
-base stapes

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Legs and base stapes closes vestibular window
-musculus stapedius fastens to posterior leg of stapes
4) MUSCLES : -stapedius muscle (the smallest skeletal muscle, connect to stapes,
controlled by facial nerve. VII)
-tensor tympani muscle (connect to malleus and drum, controlled by
medial pterygoid nerve from
mandibular nerve from trigeminal nerve ,V)
Muscles of tympanic cavity regulate auditory ossicles and prevent their oscillation during
loud sounds. They contract when loud sound appear, the role is to reducing this sound
which pass to inner ear.

352. Auditory tube: topography, parts, connections, structure.

-starts in tympanic cavity, direct forward, downward and medially, enter into nasopharynx
-at first has bony walls, when exit from temporal bone has walls as cartilage, so auditory
tube has:
a)bony part(shorter)-lie in angle of petrous part and squamous part of temporal bone
b) cartilaginous part
-TOPOGRAPHY: a)pharyngeal opening of auditory tube is situated below of tympanic
opening
b)superiorly - cartilaginous part lies in cranial base in fissure between
petrous part of temporal bone and posterior margin of greater wing of sphenoid bone
c)inferiorly- cartilaginous part is near to superior margin of sphincter muscle of upper
throat
d) on front and laterally- cartilaginous part touch to tensor veli palatine muscle (separate
tube from spine of sphenoid bone)
e)posteriorly and medially- auditory tube touch to levator veli palatine muscle and
salpingopharyngeus muscle

353. Internal ear: parts. Osseous labyrinth: parts, structure of semicircular canals.
(in pyramid of temporal bone)

Internal ear consists of: - osseous labyrinth

-membranous labyrinth
Osseous labyrinth consists of : vestibulum, semicircular canals and cochlea.
Semicircular canals -3 arched tubes lying in 3 mutually perpendicular planes (anterior,
posterior, lateral)
-has broadened part in it’s base anterior, posterior and lateral osseous
ampule
-connect with vestibulum by medium of osseous legs (legs
containing ampule – ampular legs, legs
of anterior and posterior fuse together into one)
-semicircle osseous canals connect with vestibulum by 5 foramens

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354. Osseous labyrinth: vestibule, topography, connections, functions. (outer
labyrinth)
- it’s cavity, secrete perilymph (which conducts sound vibrations)
-lateral wall has vestibular and cochlear windows
-vestibular window contains base of stapes
-cochlear window is closed by secondary tympanic membrane
-in posterior wall occurs 5 foramens of semicircle canals
-anterior wall has big foramen conducting into cochlear canal
-crest of internal wall separates spherical recess from elliptic recess
-internal foramen of vestibular canalicule opens in elliptic recess
- ! FUNCTION ! : keep balance of the body
- TOPOGRAPHY : a) in front – cochlea
b) medially – internal acustic meatus
c)behind and superiorly– semicircular canals
d)laterally – tympanic cavity e)inferiorly- internal jugular vein

355. Cochlea: topography, structure, function.

(Cochlea = snail shell)
- TOPOGRAPHY --behind – vestibulum --inferiorly – internal jugular
vein
--laterally – tympanic cavity
-- medially – internal acustic meatus
--in front – canal of internal carotid artery
-represented by osseous tube forming 2 and half turns round cochlear axis (modiolus)
-there is osseous spiral plate inside cochlea, apex of cochlea – cupula
-in cochlear base of cochlear canaliculi is internal foramen
-FUNCTION : auditory center ->decrease frequency of sound
->transform vibrations of cochlear liquids and associated
structures into neural signal
-fluid-filled organ that translates vibrations of sound into electrochemical impulses(action
potentials) form brain

356. Membranous labyrinth: topography, structure, parts. (inner labyrinth)

-contains organ of Corti

-it’s complex of membranous canaliculi and sacs + utricle, filled by endolymph (which
conducts sound)
-insert in bony labyrinth
-has lesser dimensions
-repeats course of bony labyrinth
-perilymphatic space is situated between internal surface of bony labyrinth and external
surface of membranous l. and is filled with perilymph

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-consists of : vestibular part, semicircular canals, cochlear duct
-is connect with intradural space by endolymphatic duct
-TOPOGRAPHY: a)medially – internal acustic meatus e)superiorly – brain
b) laterally – tympanic cavity f)inferiorly – internal jugular
vein
c)in front –carotid artery
d)behind-mastoid cells of temporal bone
*is innervated by vestibulocochlear nerve (VIII)*

357. Membranous labyrinth: vestibular labyrinth, parts, topography, structure,

function.

-consists of: a) utricle->lies is elliptic recess of osseous labyrinth

->connects with semicircular ducts
b) saccule->lies in spherical recess of osseous labyrinth
->connect with cochlear duct by communicating duct
-utriculus and sacculus connect each other by utriculosaccular duct (from this duct starts
endolymphatic duct that passes in vestibular canalicule)
-endolymphatic duct ->passing from external foramen of vestibular canaliculus on
posterior surface of pyramide of
temporal bone
->reaches endolymphatic sacculus placed under cerebral dura
mater
-FUNCTION: ->specialized primarily to respond to linear accelerations of head and static
head position
-> provide information to brain about head position when it’s not moving
->organs of static equilibrium, which maintains stability of head and body
when they are motionless or
during linear movements
-TOPOGRAPHY : a)Utricle: - medially- elliptical recess
-laterally-free (into perilymphatic space)
-behind-semicircular ducts
-inferiorly-osseous labyrinth -in
front-cochlear duct
b)Saccule: -laterally - free (into perilymphatic space)
-medially – spherical recess
-behind – semicircular ducts
-inferiorly – osseous labyrinth
-in front - cochlear duct

358. Membranous labyrinth: semicircular ducts, topography, structure, function.

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-FUNCTION: their shape suggest that are specialized for responding to rotational
accelerations of head, respond to movement of head
-are inserted in osseous semicircular canals
-divide into : a)anterior semicircular duct
b)posterior semicircular duct
c)lateral semicircular duct
-they carry anterior, posterior and lateral membranous ampullae
-receptors of balance of rotating located in cristae ampullares
*receptors of balance are in static maculae in utriculus and sacculus
-TOPOGRAPHY: - behind – mastoid cells
-in front- vestibule
-laterally – tympanic cavity
-medialy- internal acustic meatus

359. Describe passage of sound vibrations through ear.

Sound waves are received by tympanic membrane from auricle and external acoustic
meatus.
Tympanic membrane -> malleus-> incus->stapes->perilymph->vestibular scala->
helicotrema->tympanic scala ->vestibular wall (Reisner’s membrane)-
>endolymph (in cochlear duct)-> sensory haircells of Corti organ

360. Pathways of auditory analyzer.

1)- 1st neuron (body lie in cochlear ganglion) gives off peripheral process which
terminates in organ of Corti
-central process of 1st neuron form cochlear part of VIII cranial nerve
(vestibulocochlear nerve)
-pass through internal auditory meatus into cranial cavity
2)-bodies 2nd neuron of cochlear nerve lie in anterior and posterior cochlear nucleus (in
lateral recess of rhomboid
fossa)
-axons form fasciales = trapezoid body
-terminates in superior olivar nucleus
-one from posterior cochlear nucleus form STRIAE MEDULLARIS (of 4th ventricle)
3)-3rd neuron lie in superior olivar nucleus
-axons, lateral lemniscus, runs through isthmus of rhombencephalon (triangle of
lemniscus) and reach subcortical
hearing centres
4) -4th neuron in medial geniculate body and inferior colliculus of midbrain
-axons run through posterior leg of internal capsule and reach Geshla gyrus (cortical
hearing analyzer in superior temporal gyrus)
-axons also can pass from inferior colliculus to anterior funiculus of spinal cord as
vestibulospinal tract

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*instantaneous reaction in response to sound (protective reflex) realizes by means of this
pathway *

361. Pathways of balance and equilibrium analyzer.

neurons of hair cells -> vestibular ganglion -> afferent fibers + afferent fibers of cochlear
ganglion -> vestibulocochlear nerve -> vestibular nucleus (medulla oblongata) -> cerebral
cortex, cerebellum, spinal cord, nuclei of control eye muscle

362. Brachiocephalic trunk: topography, branches.

-begins from aortic arch on level of right II costal cartilage

-passes upward and to the right on level of right sterno-clavicular joint
-divides into : ->right common carotid artery
->right subclavian artery
-TOPOGRAPHY: -in front->manubrium of sternum
-behind-> trachea
-medially-> left common carotid artery
-laterally->right brachiocephalic vein, vena cava superior, pleurae

363. Common and external carotid arteries, topography, classification of branches.

-TOPOGRAPHY of :
1) Common carotid artery:
a) Left common carotid artery(thoracic part) : -in front->manubrium of sternum, left
pleurae and lung
-behind-> trachea, oesophagus
-medially-> in lower part – left
brachiocephalic trunk
->in upper part -
trachea
-laterally->left vagus nerve, left
pleurae and left lung
b) Right and left common carotid artery(cervical part): -in front->platysma muscle,
sternocleidomastoid m.,
sternohyoid
m., sternohyoid m., omohyoid m.
-medially->larynx,
pharynx

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 -laterally->internal
jugular vein
-behind-> transverse
process of cervical vertebrae
-Common carotid artery -> doesn’t give off any branches
-> on level of upper margin of thyroid cartilage divides into
external and internal carotid
artery (BIFURCATION with carotid sinus and carotid
glomus)
-External carotid artery: ->starts from common carotid artery in carotid tringle on level
of superior margin of
thyroid cartilage, on level of mandibular neck divide into
two terminal branches
->Gives off branches of: anterior, posterior, medial and
terminal group
a)Anterior group: superior thyroid artery, lingual artery, facial artery
b)Posterior group: sternocleidomastoid branch, occipital artery, posterior auricular artery
c)Medial group: ascending pharyngeal artery
d)Terminal branches: superficial temporal a., maxillary a. (mandibular portion, pterygoid
portion, third portion)

364. Superior thyroid artery, topography, branches, areas of blood supply.

-supplies thyroid gland

-gives off: superior laryngeal artery (supplies muscles and mucous membrane of larynx)
-TOPOGRAPHY: -> starts from external carotid artery, above bifurcation of common
carotid artery
-> at first pass under greater horn of hyoid bone
-> then pass between common carotid artery and lateral wall of larynx
->in some part is cover by omohyoid muscle
->exit from triangle of carotid artery
->descend (with superior thyroid vein)to thyroid region

365. Lingual artery, topography, branches, areas of blood supply.

-supplies sublingual salivary gland

-gives off dorsal branches, deep lingual artery (supplies muscles and mucosa of tongue)
-TOPOGRAPHY : ->starts near triangle of carotid artery
->lie on level of greater horn of hyoid bone on surface of constrictor of
middle pharynx
->than go above hyoid bone, medially from hyoglossus muscle

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 -> in last portion pass between genioglossus muscle and inferior
longitudinal muscle

366. Facial artery, topography, branches, areas of blood supply.

-gives off: ->(in submandibular triangle) branches to submandibular salivary gland

-> ascending palatine artery (velum)
-> tonsilar branch (palatine tonsils)
->bending over margin of mandible in front of masseter muscle, gives off on
face, superior labial artery
and inferior labial artery
->angular artery (terminal branch) – passes to medial eye angle and
anastomoses with dorsal nasal artery
from internal carotid artery (ophthalmic artery)
-TOPOGRAPHY: ->goes above the lingual artery
->goes upwards, covered by posterior belly of digastrics muscle and
stylohyoid muscle
->hidden behind the angle of the mandible on the gland submandibular,
enter into it, then he
runs between body of mandibule and gland
->face out on masseter muscle, covered by platysma muscle
->goes upwards and forwards to medial angle of eye

367. Medial branch of external carotid artery, topography, branches, areas of blood
supply.

-gives off: -> ascending pharyngel artery

-supplies: pharynx, deep neck muscle, cerebral dura mater (posterior meningeal artery),
tympanic cavity (inferior tympanic artery)
-TOPOGRAPHY: ->runs between the external carotid artery and internal
->then between the internal carotid artery and lateral wall of the throat
(upwards to base of
skull), medially styloglossus muscle and stylopharyngeus muscle

368. Maxillary artery, topography, portions.

-the largest branch of external carotid artery

-has 3 parts: 1) mandibular portion
2) pterygoid portion
3) pterygopalatine portion
-TOPOGRAPHY : - Starts In parotid gland from external carotid artery
- Cover by neck of mandible (mandibular part)

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 - Then goes between neck and sphenomandibular ligament
- Then enter to infratemporal fossa (pterygoid part)
- Runs laterally from lateral pterygoid muscle , and medially to temporal
muscle
- Close to tumor jaw goes upward
- enter into pterygopalatine fossa (pterygopalatine part)
- divide into final branches

369. Maxillary artery, branches, areas of blood supply.

1) Mandibular part (gives off branches to temporo-mandibular joint)

a) deep auricular artery -> external ear + tympanic membrane
b) anterior tympanic artery -> tympanic cavity
c) middle meningeal artery -> dura matter (through spinous
foramen to scull)
d) inferior alveolar artery -> teeth + gingivae of lower jaw (runs
into mandibular canal,
continues as mental artery)
2) Pterygoid port (gives off branches to masticator muscle)
a) masseteric artery
b) deep temporal artery (anterior and posterior)
c) pterygoid branches (lateral and medial)
d) bucal artery
3) Pterygo-palatine part
a) Posterior superior alveolar arteries -> teeth of upper jaw: molars
and premolars +parodont
(through alveolar canals)
b) Infraorbital artery - gives off: anterior + middle superior alveolar
arteries -> maxilla, upper
teeth + gingivae, faces muscles (through inferior orbital fissure +
infraorbital canal)
c) Sphenopalatine artery -> mucous membrane of nasal cavity
d) Descending palatine artery -> palatine
e) Minor + major palatine arteries -> palatine

370. Superficial temporal artery, topography, branches, areas of blood supply.

-continuation of external carotid artery

-passes in front of auricle into temporal bone
-on level of supraorbital margin of frontal bone, divide into frontal + parietal branch ->
muscles + skin in frontal and parietal area
a) Parotid branches -> parotid salivary gland
b) Zygomaticoorbilat artery - transverse facial artery -> facial muscles
- anterior auricular branches -> auricle

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 - medial temporal artery -> temporal muscles

371. Posterior branches of external carotid artery, topography, branches, areas of

blood supply.

1) Posterior auricular artery -> outer + middle ear (by posterior tympanic artery)
TOPOGRAPHY: - in part covered by the initial salivary gland
- runs backward and upward on upper edge of posterior belly of
digastric muscle
- then forward and laterally to mastoid process
- runs towards the backward of auricle
- it is divided into two terminal branches, occipital + auricularis
2) Occipital artery -> posterior skin of occipital region
TOPOGRAPHY: -> enter obliquely upwards on internal jugular vein, covered by
posterior belly of digastric
muscle and parotid gland
->near transverse process of 1st vertebra runs in sulcus for occipital
artery, between lateral rectus
capitis and posterior belly of digastric muscle
->passes between splenius capitis muscle and semispinalis capitis
muscle
->then between trailers sternocleidomastoid muscle and trapezius
muscle
->at superior nuchal line goes upwards on occipitofrontal muscle
3) Sternocleidomastoid branch -> sternocleidomastoid muscle (can start from superior
thyroid artery or from occipital artery)
TOPOGRAPHY: - go from occipital artery
-goes downwards and with accessory nerve enter into
sternocleidomastoid muscle

372. Internal carotid artery, topography, portions.

- at beginning lies laterally and behind, than medially from external carotid artery
-passes vertically upward (cervical portion)
-get into external foramen of carotid canal in temporal pyramid
-passes through carotid canal (petrosal portion) and gives off caroticotympanic arteries (for
tympanic cavity)
-exit from internal foramen of canal internal carotid artery
-than lies into carotid sulcus of sphenoid bone

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-passes through cavernous sinus (cavernous portion)
-on level of optic canal gives off ophthalmic artery and divide into :
->anterior +
middle cerebral artery
->posterior
communicating artery

373. Anterior and middle cerebral arteries, topography, areas of blood supply.

a) Anterior cerebral artery ->supplies: medial surface of frontal, parietal and partly
occipital lobes of brain
->anastomoses with same artery of second side by medium
of anterior communicating
artery
->TOPOGRAPHY: -walks away at right angles from the
internal carotid artery
-runs over optic nerve, medially, gives
branches
- connect with artery of the same name
but on other side by anterior
communicating artery
-they pass together in longitudinal fissure
of brain, on front surface of
genu of corpus callosum
- goes backwards and connects with the
posterior cerebral artery
b) Middle cerebral artery ->the largest branch of internal carotid artery
-> is continuation of internal carotid artery
->supplies: superolateral hemispheres surface of cerebrum +
insula
->TOPOGRAPHY: - goes to lateral fossa of brain
- in lateral groove gives off branches on
surface of frontal, parietal,
and temporal lobes

374. Circle of Willis.

- cerebral arteries derived from internal carotid arteries and vertebral arteries
-on base anastomoses each other and form anterior cerebral circle (circle of Willis)
- from anterior side is form by anastomoses by anterior cerebral arteries by anterior
communicating artery

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-from posterior side is form by posterior cerebral arteries (derived from basilar artery
which derived from both vertebral arteries)
-posterior cerebral arteries from both sides anastomoses with internal carotid artery by
posterior communicating artery
- this circle include : ->mammillary bodies
-> posterior perforated substance
-> tuber cireneum
-> optic chiasm
-> lamina terminalis

375. Branches of internal carotid artery, areas of blood supply.

a) Caroticotympanic artery-> tympanic cavity

b) Ophthalmic artery-> all components of orbit, ethmoid cells, mucosa of ethmoid bone,
nasal septum, upper nasal
concha, sphenoid sinus, dura mater of anterior fossa of skull,
frontal sinus
c) Middle cerebral artery -> insula, frontal + occipital + temporal lobe, partially white
mater and forebrain nuclei
d) Anterior cerebral artery-> medial surface of frontal, parietal and partly occipital lobes
of brain, partially forebrain
nuclei, corpus callosum, rhinencephalon
e) Posterior communicating artery-> posterior part of optic chiasm and optic tract
-> posterior part of hypothalamus and mamillary
body
-> part of thalamus
f) Anterior choroideal artery->optic tract
-> lateral geniculate nucleus and lateral aspect of thalamus
->posterior limb of the internal capsule
-> lateral aspect of the midbrain
->choroid plexus of the anterior part of the temporal horns of
the lateral ventricles

376. Ophthalmic artery, topography, branches, areas of blood supply.

-together with optic nerve passes into orbit

-terminal branches: medial palpebral artery and dorsal nasi artery -> anastomoses with
angular artery of external
carotid artery
- gives off branches -> conjuctival arteries (conjuctiva)

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 -> lacrimal arteries (muscular rami supply glands and other auxiliary
apparatus of eye)
-> central retinal artery + anterior ciliary arteries + long and short
posterior ciliary arteries
(eyeball)
-> ethmoid arteries (mucous membrane of nose and paranasal
sinuses)
- TOPOGRAPHY: -> passes oblique and forward and laterally in direction of channel
visual
-> through channel goes into orbit with optic nerve (located inferiorly
and laterally)
-> at beginning of orbit lies on lateral wall
-> laterally from optic nerve, between lateral rectus muscle and
abducens nerve
->then goes across medially, it passes over the optic nerve (between
him and the muscle rectus)
-> comes to medial wall
-> goes forward on this wall and along superior oblique muscle
-> in medial corner of eye divided into a terminal branches

377. Veins of the neck, areas of draining.

The veins of head and neck collect deoxygenated blood and return it to heart.
Anatomically, the venous drainage can be divided into three parts:
-Venous drainage of brain and meninges: Supplied by the dural venous sinuses.
-Venous drainage of scalp and face: Drained by veins synonymous with arteries of face
and scalp. These drain into internal and external jugular veins.
-Venous drainage of neck: Carried out by anterior jugular veins.
Jugular veins – external, internal and anterior -> venous drainage of whole head and neck.
1) External jugular vein - > external face. Gives off:
-Posterior auricular vein – drains area of scalp superior and posterior to outer ear.
-Retromandibular vein (posterior branch) – drain face (formed by maxillary and superficial
temporal veins)
-Occipital vein
-Suprascapular vein
2) Anterior jugular vein -> drain superficial anterior aspect of neck
-> is formed by dermal vessels of floor of mouth
3) Internal jugular vein -> receives blood from
facial, lingual, occipital, superior and middle thyroid veins. These veins drain blood from
anterior face, trachea, thyroid, oesophagus, larynx, and muscles of neck
-superficial : -superior cerebral veins-> drain dorsal and medial surfaces of each
hemisphere
-superficial middle cerebral vein

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 -inferior cerebral veins-> drain lateral and inferior surfaces of each
hemisphere
-deep: (drain internal components of brain)
–> internal cerebral veins-> drain basal nuclei, white matter, hippocampus,
thalamus,
choroid plexuses
-Ophthalmic veins -> drain contents of orbit
-superior ophthalmic vein-> drains frontal area, superior eyelid, nasal cavity, lacrimal
gland,
superior part of eyeball + muscles
-inferior ophthalmic vein ->drains inferior eyelid, inferior portion of eyeball + muscles
EXTRACRANIAL : -Facial vein-> drains frontal region, nose, eyelids, lips, soft palate,
parotid gland, muscles of oral
diaphragm, submandibular gland
-Retromandibular vein-> drains superficial temporal and maxillary veins
is formed of: -superficial temporal veins-> drain several areas of head, face, external ear,
parotid gland,
tympanic cavity
-maxillary veins-> drain pterygoid plexus (drain masticatory muscles,
dura mater, upper and
lower teeth, oral and nasal mucosa)
-Lingual vein-> drains tongue
-Superior thyroid vein-> drains thyroid gland, larynx, cervical muscles
-Pharyngeal veins-> drain pharyngeal plexus

378. Internal jugular vein, topography, classification of tributaries.

Internal jugular vein

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The internal jugular vein collects blood from the skull, brain, superficial parts of face and
much of the neck. Internal jugular vein originates from sygmoid sinus of dura mater
encephali, where it begins on level of jugular foramen by superior bulb and lies behind
internal carotid artery and vagus nerve. The internal jugular vein descends in the carotid
sheath, and unites with the sub- clavian vein, posterior to the sternal end of the clavicle, to
form the brachiocephalic vein. Near its termination the vein dilates into the inferior bulb,
above which is a pair of valves.

Tributaries The inferior petrosal sinus, facial, lingual, pharyngeal, superior and middle
thyroid veins, and occasionally the occipital vein, are all tributaries of the internal jugular
vein. The internal jugular vein may communicate with the external jugular vein. The
thoracic duct opens near the union of the left subclavian and internal jugular veins, and the
right lymphatic duct opens at the same site on the right.

Mnemonic

Medical Schools Let Fun People In

 M: middle thyroid vein

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  S: superior thyroid vein
 L: lingual vein
 F: facial vein
 P: pharyngeal vein
 I: inferior petrosal sinus

379. Intracranial tributaries of internal jugular vein, areas of draining.

Follow vessels belong to intracranial tributaries of internal jugular vein:

• venous sinuses of dura mater encephali and veins of brain;
• diploic veins from skull bones;
• meningeal veins from cranial dura mater;
• superior ophthalmic vein and inferior ophtalmic vein is from sight organ;
• labyrinthic veins – from internal ear;
• emissary veins from intracranial veins and sinuses of dura mater
and communicate with extracranial veins.

Major dural sinuses that contribute to internal jugular vein are as follows:
1. Superior sagittal sinus begins at frontal bone, where it receives vein from nasal cavity,
and passes posteriorly to occipital bone along midline of skull deep to sagittal sinus. It

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usually angles to right and drains into right transverse sinus.
Regions drained: Nasal cavity; superior, lateral, and medial aspects of cerebrum; skull
bones; meninges.
2. Inferior sagittal sinus is much smaller than superior sagittal sinus. It begins posterior to
attachment of falx cerebri and receives great cerebral vein to become straight sinus.
Regions drained: Medial aspects of cerebrum and diencephalon.
3. Straight sinus runs in tentorium cerebelli and is formed by union of inferior sagittal
sinus and great cerebral vein. It typically drains into left transverse sinus.
Regions drained: Medial and inferior aspects of cerebrum and the cerebellum.
4. Sigmoid sinuses are located along posterior aspect of petrous temporal bone. They
begin where transverse sinuses and superior petrosal sinuses anastomose and terminate in
internal jugular vein at jugular foramen.
Regions drained: Lateral and posterior aspect of cerebrum and the cerebellum.
5. Cavernous sinuses are located on either side of sphenoid bone. Ophthalmic veins from
orbits and cerebral veins from cerebral hemispheres, along with other small sinuses, empty
into cavernous sinuses. They drain posteriorly to petrosal sinuses to eventually return to
internal jugular veins. Cavernous sinuses are unique because they have major blood vessels
and nerves passing through them on their way to orbit and face. Oculomotor (III) nerve,
trochlear (IV) nerve, ophthalmic and maxillary branches of the trigeminal (V) nerve,
abducens (VI) nerve, and internal carotid arteries pass through cavernous sinuses.
Regions drained: Orbits, nasal cavity, frontal regions of cerebrum, and superior aspect of
brain stem.

380. Extracranial tributaries of internal jugular vein, areas of draining.

Internal jugular has the following extracranial influxes:

• Pharyngeal veins
Begin in the pharyngeal plexus on the outer surface of the pharynx, and, after receiving
some posterior meningeal veins and the vein of the pterygoid canal, end in the internal
jugular.

• Lingual vein
Begin on the dorsum, sides, and under surface of the tongue, and, passing backward along
the course of the lingual artery, end in the internal jugular vein.
Tributaries:

1. Sublingual vein
2. Deep lingual vein
3. Dorsal lingual veins
4. Suprahyoid vein

• Superior thyroid vein

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Begins in the substance and on the surface of the thyroid gland, by tributaries
corresponding with the branches of the superior thyroid artery, and ends in the upper part
of the internal jugular vein.

• Facial vein
Is a relative large vein in the human face. It commences at the side of the root of the nose
and is a direct continuation of the angular vein where it also receives a small nasal branch.
It lies behind the facial artery and follows a less tortuous course. It receives blood from the
external palatine vein before it either joins the anterior branch of the retromandibular vein
to form the common facial vein, or drains directly into the internal jugular vein.

• Retromandibular vein

Is formed by the union of the superficial temporal and maxillary veins, descends in the
substance of the parotid gland, superficial to the external carotid artery but beneath the
facial nerve, between the ramus of the mandible and the sternocleidomastoideus muscle.

It divides into two branches:

 an anterior, which passes forward and joins anterior facial vein, to form the
common facial vein, which then drains into the internal jugular vein.
 a posterior, which is joined by the posterior auricular vein and becomes the
external jugular vein.

381. Heart: topography, variants of position and shape. Blood supply and innervation
of the heart

The heart is a hollow muscular organ, which is situated in thoracic cavity in middle
mediastinum. It has a heart apex, which is directed down to the left and heart base. Heart
has a sternocostal (anterior) surface, diaphragmatic (posterior) surface, right/left
pulmonary surfaces. Coronal sulcus passes on diaphragmatic and partially on sternîcostal
surfaces, which marks the border between ventricles and atriums. Anterior inter-
ventricular sulcus and posterior interventricular sulcus pass from coronal sulcus
downward and project borders between right and left ventricles. On heart base right and
left auricles are situated, which envelop the great vessels. On heart base at the anterior
from right ventricle pulmonary trunk passes, which subdivides into two pulmonary
arteries. Aorta passes behind pulmonary trunk; behind from aorta from right side superior
vena cava and inferior vena cava, and to the left four pulmonary veins.
Heart cavity subdivides on right and left atriums and right and left ventricles.
The heart receives nerve signals from the vagus nerve and from nerves arising from the
sympathetic trunk. These nerves form a network of nerves that lies over the heart called the
cardiac plexus.

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382. External structure of the heart (demonstrate on preparation).

383. Chambers of the heart - demonstrate on the preparation.

The heart has four chambers: two atria and two

ventricles.

 The right atrium receives oxygen-poor

blood from the body and pumps it to
the right ventricle.
 The right ventricle pumps the oxygen-
poor blood to the lungs.
 The left atrium receives oxygen-rich
blood from the lungs and pumps it to
the left ventricle.
 The left ventricle pumps the oxygen rich blood to the body.

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384. Right atrium: openings, relief of inner surface, interatrial septum.

Right Atrium
The right atrium forms the right border of the heart and receives blood from three veins:
the superior vena cava, inferior vena cava, and coronary sinus The right atrium is about 2–
3 mm in average thickness. The anterior and posterior walls of the right atrium are very
different. The inside of the posterior wall is smooth; the inside of the anterior wall is rough
due to the presence of muscular ridges called pectinate muscles, which also extend into
the auricle. The smooth and rough parts of the atrial wall are separated externally by a
shallow vertical groove, the sulcus terminalis or terminal groove and internally by a
vertical ridge, the crista terminalis or terminal crest. Between the right atrium and left
atrium is a thin partition called the interatrial septum). A prominent feature of this
septum is an oval depression called the fossa ovalis, the remnant of the foramen ovale, an
opening in the interatrial septum of the fetal heart that normally closes soon after birth.
Blood passes from the right atrium into the right ventricle through a valve that is called the
tricuspid valve because it consists of three leaflets or cusps . It is also called the right
atrioventricular valve. The valves of the heart are composed of dense connective tissue
covered by endocardium.

385. Right atrioventricular valve: topography, cusps, and their structure.

The tricuspid valve guards the right AV orifice ( located posterior to the body of the

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sternum at the level of the 4th and 5th intercostal spaces).The bases of the valve cusps are
attached to the fibrous ring around the orifice. Tendinous cords (L. chordae tendineae)
attach to the free edges and ventricular surfaces of the anterior, posterior, and septal cusps.
The tendinous cords arise from the apices of papillary muscles, which are conical muscular
projections with bases attached to the ventricular wall. The papillary muscles begin to
contract before contraction of the right ventricle, tightening the tendinous cords and
drawing the cusps together. Because the cords are attached to adjacent sides of two cusps,
they prevent separation of the cusps and their inversion when tension is applied to the
tendinous cords and maintained throughout ventricular contraction (systole)—that is, the
cusps of the tricuspid valve are prevented from prolapsing (being driven into the right
atrium) as ventricular pressure rises. Thus, regurgitation of blood (backward flow of blood)
from the right ventricle back into the right atrium is blocked during ventricular systole by
the valve cusps
Three papillary muscles in the right ventricle correspond to the cusps of the tricuspid valve
1. The anterior papillary muscle, the largest and most prominent of the three, arises from
the anterior wall of the right ventricle; its tendinous cords attach to the anterior and
posterior cusps of the tricuspid valve.
2. The posterior papillary muscle, smaller than the anterior muscle, may consist of
several parts; it arises from the inferior wall of the right ventricle, and its tendinous cords
attach to the posterior and septal cusps of the tricuspid valve.
3. The septal papillary muscle arises from the interven- tricular septum, and its tendinous
cords attach to the anterior and septal cusps of the tricuspid valve.

386. Right ventricle: communication, structure, relief of inner surface.

Right Ventricle
The right ventricle is about 4–5 mm in average thickness and forms most of the anterior
surface of the heart. The inside of the right ventricle contains a series of ridges formed by
raised bundles of cardiac muscle fibers called trabeculae carneae. Cusps of the tricuspid
valve are connected to tendonlike cords, the chordae tendineae), which in turn are
connected to cone-shaped trabeculae carneae called papillary muscles. Internally, the
right ventricle is separated from the left ventricle by a partition called the interventricular
septum. Blood passes from the right ventricle through the pulmonary valve (pulmonary
semilu- nar valve) into a large artery called the pulmonary trunk, which divides into right
and left pulmonary arteries and carries blood to the lungs.

387. Valve of pulmonary trunk: topography, structure.

392. Aortic valve: topography, structure.

SEMILUNAR VALVES

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Each of three semilunar cusps of the pulmonary valve (anterior, right, and left), like the
semilunar cusps of the aortic valve (posterior, right, and left), is concave when viewed
superiorly Semilunar cusps do not have tendinous cords to support them. They are smaller
in area than the cusps of the AV valves, and the force exerted on them is less than half that
exerted on the cusps of the tricuspid and mitral valves. The cusps project into the artery but
are pressed toward (and not against) its walls as blood leaves the ventricle. After relaxation
of the ventricle (diastole), the elastic recoil of the wall of the pulmonary trunk or aorta
forces the blood back toward the heart.
The edge of each cusp is thickened in the region of contact, forming the lunule; the apex of
the angulated free edge is thickened further as the nodule. Immediately superior to each
semilunar cusp, the walls of the origins of the pulmonary trunk and aorta are slightly
dilated, forming a sinus. The aortic sinuses and sinuses of the pulmonary trunk (pulmonary
sinuses) are the spaces at the origin of the pulmonary trunk and ascending aorta between
the dilated wall of the vessel and each cusp of the semilunar valves. The blood in the
sinuses and the dilation of the wall prevent the cusps from sticking to the wall of the
vessel, which might prevent closure.
The mouth of the right coronary artery is in the right aortic sinus, the mouth of the left
coronary artery is in the left aortic sinus, and no artery arises from the posterior aortic
(non-coronary) sinus.

388. Structure of interventricular septum

The interventricular septum (IVS), composed of muscular and membranous parts, is a

strong, obliquely placed partition between the right and left ventricles forming part of the
walls of each. Because of the much higher blood pressure in the left ventricle, the muscular
part of the IVS, which forms the majority of the septum, has the thickness of the remainder
of the wall of the left ventricle (two to three times as thick as the wall of the right ventricle)
and bulges into the cavity of the right ventricle. Superiorly and posteriorly, a thin
membrane, part of the fibrous skeleton of the heart , forms the much smaller membranous
part of the IVS. On the right side, the septal cusp of the tricuspid valve is attached to the
middle of this membranous part of the fibrous skeleton. This means that inferior to the
cusp, the membrane is an interventricular septum, but superior to the cusp it is an
atrioventricular septum, separating the right atrium from the left ventricle.

389. Left atrium: openings, auricle, relief of inner surface.

Left Atrium
The left atrium is about the same thickness as the right atrium and forms most of the base
of the heart It receives blood from the lungs through four pulmonary veins. Like the right
atrium, the inside of the left atrium has a smooth posterior wall. Because pectinate muscles
are confined to the auricle of the left atrium, the anterior wall of the left atrium also is
smooth. Blood passes from the left atrium into the left ventricle through the bicuspid

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(mitral) valve, which, as its name implies, has two cusps.. It is also called the left
atrioventricular valve.

390. Left atrioventricular valve: topography, cusps, structure.

The mitral valve has two cusps, anterior and posterior. The adjective mitral derives from
the valve’s resemblance to a bishop’s miter (headdress). The mitral valve is located
posterior to the sternum at the level of the 4th costal cartilage. Each of its cusps receives
tendinous cords from more than one papillary muscle. These muscles and their cords
support the mitral valve, allowing the cusps to resist the pressure developed during
contractions (pumping) of the left ventricle. The cords become taut just before and during
systole, preventing the cusps from being forced into the left atrium. As it traverses the left
ventricle, the bloodstream undergoes two right angle turns, which together result in a 180°
change in direction. This reversal of flow takes place around the anterior cusp of the mitral
valve

391. Left ventricle: communication, structure, relief of inner surface.

Left Ventricle
The left ventricle is the thickest chamber of the heart, averaging 10–15 mm and forms the
apex of the heart. Like the right ventricle, the left ventricle contains tra- beculae carneae
and has chordae tendineae that anchor the cusps of the bicuspid valve to papillary muscles.
Blood passes from the left ventricle through the aortic valve (aortic semilunar valve) into
the ascending aorta. Some of the blood in the aorta flows into the coronary arteries, which
branch from the ascending aorta and carry blood to the heart wall. The remainder of the
blood passes into the arch of the aorta and descending aorta (thoracic aorta and
abdominal aorta). Branches of the arch of the aorta and descending aorta carry blood
throughout the body.
During fetal life, a temporary blood vessel, called the ductus arteriosus, shunts blood from
the pulmonary trunk into the aorta. Hence, only a small amount of blood enters the
nonfunctioning fetal lungs. The ductus arteriosus normally closes shortly after birth,
leaving a remnant known as the ligamentum arteriosum, which connects the arch of the
aorta and pulmonary trunk

393. Valves of the heart: topography, structure, describe and demonstrate

on preparations

The heart valves and the chambers are lined with endocardium. Heart valves separate the
atria from the ventricles, or the ventricles from a blood vessel. Heart valves are situated
around the fibrous rings of the cardiac skeleton. The valves incorporate leaflets or cusps,
which are pushed open to allow blood flow and which then close together to seal and
prevent backflow. The mitral valve has two cusps, whereas the others have three. There are
nodules at the tips of the cusps that make the seal tighter.

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The four valves are known as:

1. The tricuspid valve

2. The pulmonic or pulmonary valve
3. The mitral valve
4. The aortic valve

394. Heart: structure of wall

The wall of heart consists of three layers, from superficial to deep:

1. Endocardium, a thin internal layer (endothelium and subendothelial connective tissue)
or lining membrane of the heart. Its double sheets form aortic and pulmonary trunk valves,
cusps of right and left atrioventricular valves.

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2. Myocardium, a thick, helical middle layer composed of cardiac muscle. The cardiac
muscle fibers are anchored to the fibrous skeleton of the heart. This is a complex frame-
work of dense collagen forming four fibrous rings (L. anuli fibrosi) that surround the
orifices of the valves, a right and left fibrous trigone (formed by connections between
rings), and the membranous parts of the interatrial and interventricular septa.
3. Epicardium, a thin external layer (mesothelium) formed by the visceral layer of serous
pericardium. Epicardium covers a heart, initial departments of aorta and pulmonary trunk,
and also terminal departments of venae cavae and pulmonary veins. Visceral sheet passes
into parietal sheet of serous pericardium on these vessels.

395. Heart: endocardium, structure. Which structures are formed by

endocardium?

Endocardium it is a thin internal layer (endothelium and subendothelial connective tissue)

or lining membrane of the heart. Its double sheets form aortic and pulmonary trunk valves,
cusps of right and left atrioventricular valves.

396. Heart: myocardium of atria, structure.

Myocardium of atria consists of two layers: superficial, which is common for both of atria
and consists of circulation fibres, and deep layer, which consists of longitudinal bundles
and is separate each from other.

397. Heart: myocardium of ventricles.

Myocardium of ventricles consists of three layers: external, middle and internal. External
(oblique) layer origines from fibrous annuli, continuos downward till apex cordis where
forms vortex cordis and passes into internal layer of opposite side with longitudinal
fibres. So, external and internal layers are common for both ventricles and middle
(circular) layer separate for each ventricle.

398. Conducting system of the heart: nodes, bundles, the topography,

function.

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Conducting heart system consists of specialized (self-excitable) cardiac muscle fibers
called autorhythmic fibers, which have ability to carry impulses from nerves of heart to
myocardium of atria and ventricles.

●11.) Cardiac excitation normally begins in the sinoatrial (SA) node, located in the right
atrial wall just inferior and lateral to the opening of the superior vena cava. SA node cells
do not have a stable resting potential. Rather, they repeatedly depolarize to threshold
spontaneously. The spontaneous depolarization is a pacemaker potential. When the
pacemaker potential reaches threshold, it triggers an action potential. Each action potential
from the SA node propagates throughout both atria via gap junctions in the intercalated
discs of atrial muscle fibers. Following the action potential, the two atria contract at the
same time.
2.) By conducting along atrial muscle fibers, the action potential reaches the
atrioventricular (AV) node, located in the inter- atrial septum, just anterior to the opening
of the coronary sinus. At the AV node, the action potential slows considerably as a result
of various differences in cell structure in the AV node. This delay provides time for the
atria to empty their blood into the ventricles.
3.) From the AV node, the action potential enters the atrioventricular (AV) bundle
(also known as the bundle of His). This bundle is the only site where action potentials can
conduct from the atria to the ventricles. (Elsewhere, the fibrous skeleton of the heart
electrically insulates the atria from the ventricles.)

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● 4.) After propagating along the AV bundle, the action potential enters both the right and
left bundle branches. The bundle branches extend through the interventricular septum
toward the apex of the heart.
● 5.) Finally, the large-diameter Purkinje fibers rapidly conduct the action potential
beginning at the apex of the heart upward to the remainder of the ventricular myocardium.
Then the ventricles contract, pushing the blood up- ward toward the semilunar valves.

399. Heart: blood supply.

The heart has its own unique blood supply, known as the coronary circulation, which
encircles the entire surface of the heart to supply its different regions. This begins with
the coronary arteries arising from the ascending aorta, through openings called coronary
ostia, which are located above the aortic valves. These arteries run along the surface of the
heart and so can also be reffered to as epicardial coronary arteries. There are two main
coronary arteries that branch from the ascending aorta, known as the left and right
coronary arteries. In essence, the left main coronary artery supplies the left atrium,
interventricular septum, left ventricle and the anterior wall of the right ventricle. On the
other hand, the right coronary artery supplies the right atrium, the right ventricle as well
as the sino-atrial node.

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400. Heart: right coronary artery, topography, branches, areas of blood
supply.

The right coronary artery supplies small branches (atrial branches) to the right atrium. It
continues inferior to the right auricle and ultimately divides into the posterior
interventricular and marginal branches. The posterior interventricular branch follows

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the posterior interventricular sulcus and supplies the walls of the two ventricles with
oxygenated blood. The marginal branch beyond the coronary sulcus runs along the right
margin of the heart and transports oxygenated blood to the myocardium of the right
ventricle.

The right coronary artery branches into:

 Right marginal artery

 Posterior descending artery

The right coronary artery supplies:

 right atrium
 right ventricle
 bottom portion of both ventricles and back of the septum
 The SA node (in approximately 60% of people). •
 The AV node (in approximately 80% of people).

The main portion of the right coronary artery provides blood to the right side of the heart,
which pumps blood to the lungs. The rest of the right coronary artery and its main branch,
the posterior descending artery, together with the branches of the circumflex artery, run
across the surface of the heart's underside, supplying the bottom portion of the left
ventricle and back of the septum.

401. Heart: the left coronary artery, topography, branches, areas of blood
supply.

The left coronary artery passes inferior to the left auricle and divides into:
 anterior interventricular
 circumflex branches.
The anterior interventricular branch or left anterior descending (LAD) artery is in the
anterior interventricular sulcus and supplies oxygenated blood to the walls of both
ventricles and the front of the septum.
The circumflex branch lies in the coronary sulcus and distributes oxygenated blood to the
walls of the left ventricle and left atrium.

402. Heart: anastomoses between the right and left coronary arteries, name and
describe the topography.

Anastomoses between branches of the coronary arteries, both subepicardial and

myocardial, and between these arteries and extracardiac vessels, are of prime medical
importance. Clinical experience suggests that anastomoses cannot rapidly provide
collateral routes sufficient to circumvent sudden coronary obstruction, and the coronary

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circulation is assumed to be end-arterial. Nevertheless, it has long been established that
anastomoses do occur, particularly between fine subepicardial branches, and they may
increase during individual life. The most frequent sites of extramural anastomoses are the
apex, the anterior aspect of the right ventricle, the posterior aspect of the left ventricle,
crux, interatrial and interventricular grooves, and between the sinoatrial nodal and other
atrial vessels.

There are four known communications between the left and right coronary arteries, at
different sites within the heart. They are:

1. The artery of the conus, which is a branch of the right coronary artery (RCA), with
the left anterior descending artery (LAD).
2. At the interventricular septum, with septal perforators between the left anterior
descending artery LAD and Patent Ductus Arteriosus PDA .
3. At the apex of the heart, with the LAD and PDA.
4. At the crux, between the left circumflex and PDA.

404. Heart: coronary sinus, topography, tributaries.

Coronary sinus
The large majority of cardiac veins drain into the wide coronary sinus, 2 or 3 cm long,
lying in the posterior atrioventricular groove between the left atrium and ventricle. The
sinus opens into the right atrium between the opening of the inferior vena cava and the
right atrioventricular orifice; the opening is guarded by an endocardial fold (semilunar
valve of the coronary sinus). Its tributaries are the great, small and middle cardiac veins,
the posterior vein of the left ventricle and the oblique vein of the left atrium; all except the
last have valves at their orifices.
Great cardiac vein The great cardiac vein begins at the cardiac apex, ascends in the
anterior interventricular groove to the atrioventricular groove and follows this, passing to
the left and posteriorly to enter the coronary sinus at its origin It receives tributaries from
the left atrium and both ventricles, including the large left marginal vein that ascends the
left aspect (obtuse border) of the heart.
Small cardiac vein The small cardiac vein lies in the posterior atrioventricular groove
between the right atrium and ventricle and opens into the coronary sinus near its atrial end
It receives blood from the posterior part of the right atrium and ventricle. The right
marginal vein passes right, along the inferior cardiac margin (acute border). It may join the
small cardiac vein in the atrioventricular groove, but more often opens directly into the
right atrium.
Middle cardiac vein The middle cardiac vein begins at the cardiac apex, and runs back in
the posterior interventricular groove to end in the coronary sinus near its atrial end.
Posterior vein of the left ventricle The posterior vein of the left ventricle is found on the
diaphragmatic surface of the left ventricle a little to the left of the middle cardiac vein. It
usually opens into the centre of the coronary sinus, but sometimes opens into the great

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cardiac vein.
Oblique vein of the left atrium The small vessel that is the oblique vein of the left atrium
descends obliquely on the back of ascends in the atrioventricular groove, near the right
coronary artery, and then anterior to the ascending aorta to end in a brachiocephalic node,
usually on the left.

405. Pericardium: structure, cavities, recesses.

The membrane that surrounds and protects the heart is the pericardium. It confines the
heart to its position in the mediastinum, while allowing sufficient freedom of movement
for vigorous and rapid contraction. The pericardium consists of two main parts:
(1) fibrous pericardium
(2) serous pericardium.
1. The superficial fibrous pericardium is composed of tough, inelastic, dense irregular
connective tissue. It resembles a bag that rests on and attaches to the diaphragm; its open
end is fused to the connective tissues of the blood vessels entering and leaving the heart.
The fibrous pericardium prevents overstretching of the heart, provides protection, and
anchors the heart in the mediastinum. The fibrous pericardium near the apex of the heart is
partially fused to the central tendon of the diaphragm and therefore movement of the
diaphragm, as in deep breathing, facilitates the movement of blood by the heart.
2. The deeper serous pericardium is a thinner, more delicate membrane that forms a
double layer around the heart. The outer parietal layer of the serous pericardium is fused
to the fibrous pericardium. The inner visceral layer of the serous pericardium, also called
the epicardium, is one of the layers of the heart wall and adheres tightly to the surface of
the heart. Between the parietal and visceral layers of the serous pericardium is a thin film
of lubricating serous fluid. This slippery secretion of the pericardial cells, known as
pericardial fluid, reduces friction between the layers of the serous pericardium as the
heart moves. The space that contains the few milliliters of pericardial fluid is called the
pericardial cavity.

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 406. Heart: heart projection on the anterior wall of the thorax.

The sternocostal surface of the heart is directed anteriorly, superiorly and slightly to the
left. It is formed by the left, right, superior and inferior borders of the heart.

It consists of the anterior surfaces of the:

• right atrium: to the right and superior to the anterior atrioventricular groove
• right ventricle:
forms two thirds of the anterior surface
separated by the anterior interventricular
groove from the anterior surface of the left
ventricle
• left atrium: minimal contribution; its
auricle may overlap the right superior
surface of the heart
• left ventricle: forms a small part of the far
left sternocostal surface

Anteriorly, the sternocostal surface is separated

by pericardium from the:

• posterior of the body of the sternum

• sternocostalis muscle
• third to sixth costal cartilages on the left
• mediastinal pleura
•
The acute angle at the anterior edge of the lungs
fills the pleurae and is almost continuous across the midline except for a small, triangular
area on the left of the sternocostal surface. The cardiac notch of the lung borders this
laterally.

407. Heart : regions of auscultation of heart valves.

Bicuspid (mitral, left atrioventricular) valve - is listened in the apex cordis area (left V intercostal
space, 1 – 1,5 cm medially form the middle clavicular line).
Aortic valve - is listened in right 2nd intercostal space to the right from the sternum.
Pulmonary valve - is listened in left 2nd intercostal space to the left from sternum.
Tricuspid (right atrioventricular) valve – is listened on the base of xiphoid process of sternum to the
right (joint of IV costal cartilage with sternum).

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408. Systemic circulation.
Systemic circulation (big circle) of the blood starts in the left ventricle by aorta and terminates in the
right atrium by vena cava superior and vena cava inferior. Systemic circulation provides in arterial
blood (oxygenated) all organs and tissues.

409. Pulmonary circulation.

Pulmonary circulation (small circle) of the blood starts in the right ventricle by pulmonary trunk and
terminates in the left atrium by 4 pulmonary veins.

410. Innervation of the heart: Cardiac nerve plexus, the topography, sources of formation,
composition of fibres.
The cardiac plexus is a plexus of nerves situated at the base of the heart. It is formed by cardiac
branches derived from both the sympathetic and parasympathetic nervous systems.
Sympathetic fibres pass from sympathetic trunk and form the superior, middle and inferior cervical
cardiac nerves. Also thoracic department of sympathetic trunk gives off the thoracic cardiac
sympathetic nerves. They fasten cardiac contractions and add their amplitude, broaden the coronal
vessels.
The parasympathetic fibres pass in composition of superior, inferior and thoracic cardiac branches of
vagus nerve. They slow a rhythm of cardiac contractions, reduce their amplitude and narrow space of
coronal arteries. The sensory fibres from heart wall receptor pass in composition of cardiac nerves and
cardiac branches to spinal cord.
The heart nerves form superficial extraorgan cardiac plexus and deep extraorgan cardiac plexus. The
branches of extraorgan cardiac plexus continue into one intraorgan cardiac plexus, which
conventionally subdivides on subepicardial plexus, intramuscular plexus and subendocardial plexus.
Subepicardial plexus is reach developed.

411. Heart: intramural nerve plexus, the topography, sources of formation, composition of fibres.

412. Fetal circulation.

Once the main arteries and veins as well as the heart are developed, usually after the 8th week of fetal
development, deoxygenated blood is returned from the fetal systemic circulation to the placenta via
two umbilical arteries, which branch off the fetal internal iliac arteries. Highly oxygenated, nutrient-
rich blood flows from the placenta to the fetus via the umbilical vein. Approximately half of the blood
in the umbilical vein bypasses the liver to flow into the ductus venosus, a fetal vessel connecting the
umbilical vein to the inferior vena cava. The other half flows into the sinusoids of the liver and enters
the inferior vena cava via the hepatic veins. Blood flow through the ductus venosus is regulated by a
sphincter mechanism close to the umbilical vein. When the sphincter contracts, more blood is diverted
to the portal vein and the hepatic sinusoids, and less to the ductus venosus. Although an anatomic

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sphincter in the ductus venosus has been described, its presence is not universally accepted. However,
it is generally agreed that there is a physiologic sphincter that prevents overloading of the heart when
venous flow in the umbilical vein is high, as seen during uterine contractions for example.
After a short course in the inferior vena cava, the blood enters the right atrium of the heart. Because the
inferior vena cava also contains poorly oxygenated blood from the lower limbs, abdomen, and pelvis,
the blood entering the right atrium flows in two streams, one highly oxygenated from the umbilical
vein and the other poorly saturated in oxygen. At the junction of the inferior vena cava and right
atrium, the Eustachian valve separates these two streams by directing the highly oxygenated blood
from the right atrium to the left atrium through the foramen ovale. It is then ejected by the left ventricle
into the ascending aorta to ensure a better perfusion of important fetal organs such as the myocardium
and brain. The poorly oxygenated blood in the right atrium flows through the tricuspid valve to be
ejected by the right ventricle , but around 90% of the flow in the pulmonary trunk is diverted into the
descending aorta by the ductus arteriosus due to a high pulmonary vascular resistance. The other 10%
flows into the fetal lungs to supply them with oxygen. The ductus arteriosus protects the lungs from
circulatory overloading and allows the right ventricle to strengthen in preparation for functioning at full
capacity at birth, when the transitional circulation establishes itself.

413. Aorta: parts, the topography. Arch of the aorta and branches.
Aorta is the largest arterial vessel of systemic circulation. It subdivides on:
- ascending part of aorta
- arch of aorta
- descending part of aorta (thoracic and abdominal parts)
Ascending part of aorta leaves the left ventricle behind left margin of sternum on the level 3rd
intercostal space. In initial part is has an expansion called aortic bulb, in which three aortic sinuses are
contained. Ascending part of aorta lies behind and to the right from the pulmonary trunk, rises up and
to the level of 2nd right costal cartilage and passes into arch of aorta.
The arch of the aorta turns posteriorly to the left from 2nd costal cartilage to the left side of IVth
thoracic vertebral body, where passes into descending aorta. Between concave aortic arch surface and
pulmonary trunk, on the beginning of left pulmonary artery, obliterated Botali duct (arterial ligament)
is situated. From convex aortic arch surface, starts from the right to the left: brachiocephalic trunk, left
common carotid artery and left subclavian artery.
Descending aorta has a thoracic part of aorta, which passes in posterior mediastinum and lies to the
left from the bodies of thoracic vertebrae and abdominal part or aorta, which starts on the level of
Th-XII, passes through aortic hiatus of diaphragm and extends to the level of L-IV. Abdominal part of
aorta is disposed in front of anterior surface of lumbar vertebrae to the left from midline. Here
abdominal aorta gives off the pair of parietal branches, pair and odd visceral branches and finishes in
bifurcation, divining into 2 common iliac arteries.

Branches of aortic arch:

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1. Brachiocephalic trunk begins from aortic arch on the level of right II costal cartilage. It passes
upward and to the right and on the level of right sterno-clavicular joint divides into two terminal
branches – right common carotid artery and right subclavian artery.
2. Common carotid artery passes behind sternocleidomastoid muscle upward and in front of
transverse processes of cervical vertebrae and does not give off any branches. On the level of upper
edge of thyroid cartilage, common carotid artery divides into external carotid artery and internal carotid
artery. The place is called bifurcation of carotid artery. Also there are located carotid sinus and carotid
glomus.
3. External carotid artery starts from common carotid artery in carotid triangle on the level of
superior margin of thyroid cartilage. On the level of mandibular neck it divides into two terminal
branches. On its extent external carotid artery gives off branches of anterior, posterior, medial and
terminal groups.

414. Subclavian artery: origin (right and left arteries), topographic divisions of subclavian
artery, branches in each portion.
Left Subclavian artery starts from the aortic arch and right subclavian artery from the
brachiocephalic trunk. It leaves the thoracic cavity through the superior aperture, rounds a pleura
cupola and gets into interscalenus space. Then the artery lies under the clavicle in the same name
sulcus of the first rib and runs into an axillary cavity where has a name axillary artery.
Subclavian artery conventionally subdivides into 3 portions: before interscalenus space, in
interscalenus space, and after interscalenus space.
Before interscalenus space subclavian artery gives off the following branches:
1. Vertebral artery is the largest branch of subclavian artery, passes on foramens of transversal
processes of cervical vertebrae, transfixes an atlanto- occipital membrane and dura mater of encephalon
and through occipital foramen magnum gets into the skull cavity. Behind a pons this right and left
artery flows together and forms basilar artery. Vertebral artery gives off anterior spinal artery,
posterior spinal artery and posterior inferior cerebellar artery. From basilar artery start: anterior
inferior cerebellar artery, labyrinthic artery, pontini arteries and artery mesencephalic.
Vertebral artery together with anterior spinal arteries form around medulla oblongata the circle of
Zakharchenka.
Basillar artery on the level of anterior margin of pons ramifies into 2 posterior cerebral arteries, which
supply occipital lobes of cerebrum. Posterior cerebral arteries connect by posterior communicating
artery with internal carotid artery. Also thanks to anterior communicating and cerebral arteries
arterial circle of brain (circle of Wills) is formed.
2. Internal thoracic artery (described in question no 417)
3. Thyro-cervical trunk has a length 1 -2 cm and subdivides into 4 branches: - inferior thyroid
artery (supplies thyroid gland, cervical part of esophagus, cervical portion of trachea
- inferior laryngeal artery (mucous membrane of the larynx)
- ascending cervical artery (muscles of neck)

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- superficial cervical artery (trapezius and rhomboid muscles and other neck muscles)
- suprascapular artery (supraspinatus and infraspinatus muscles)

In intersaclenius space the subclavian artery gives off:

- costo-cervical trunk which ramifies into deep cervical artery (supplies semispinalis capitis and
cervicis muscles)
- suprema intercostal artery which ramifies into I and II intercostal spaces, supplying intercostal
muscles.

After interscalenus space the subclavian artery gives off

- transverse coli artery which continues into dorsal scapulae artery. They supply rhomboid, levator
scapulae and shoulder girdle muscles.

415. Subclavian artery: vertebral artery, parts, the topography, branches of each part, areas of
blood supply.
The vertebral artery may be divided into four parts:
The first part runs upward and backward between the Longus colli and the Scalenus anterior. In front
of it are the internal jugular and vertebral veins, and it is crossed by the inferior thyroid artery; the left
vertebral is crossed by the thoracic duct also. Behind it are the transverse process of the seventh
cervical vertebra, the sympathetic trunk and its inferior cervical ganglion
The second part runs upward through the foramina in the transverse processes of the C6 to C2
vertebræ, and is surrounded by branches from the inferior cervical sympathetic ganglion and by a
plexus of veins which unite to form the vertebral vein at the lower part of the neck. It is situated in
front of the trunks of the cervical nerves, and pursues an almost vertical course as far as the transverse
process of the axis.
The third part issues from the C2 foramen transversarium on the medial side of the Rectus capitis
lateralis. It is further subdivided into the vertical part V3v passing vertically upwards, crossing the C2
root and entering the foramen transversarium of C1, and the horizontal part V3h, curving medially and
posteriorly behind the superior articular process of the atlas, the anterior ramus of the first cervical
nerve being on its medial side; it then lies in the groove on the upper surface of the posterior arch of the
atlas, and enters the vertebral canal by passing beneath the posterior atlantooccipital membrane. This
part of the artery is covered by the Semispinalis capitis and is contained in the suboccipital triangle—a
triangular space bounded by the Rectus capitis posterior major, the Obliquus superior, and the Obliquus
inferior. The first cervical or suboccipital nerve lies between the artery and the posterior arch of the
atlas.
The fourth part pierces the dura mater and inclines medialward to the front of the medulla oblongata;
it is placed between the hypoglossal nerve and the anterior root of the first cervical nerve and beneath

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the first digitation of the ligamentum denticulatum. At the lower border of the pons it unites with the
vessel of the opposite side to form the basilar artery.
Cervical part gives off:
- muscular branches (neck muscle)
- spinal branches (spinal cord)
- meningeal branch anterior and posterior (dura mater)
Intracranial part gives off:
- anterior and posterior spinal arteries (spinal cord)
- posterior inferior cerebellar artery (cerebellum and also send some branches to the bottom of the IV
ventricle)
Terminal branch – basilar artery

416. Vertebral artery: formation, topography, branches, areas of blood supply.

The vertebral arteries arise from the subclavian arteries, one on each side of the body, then enter deep
to the transverse process at the level of the 6th cervical vertebrae C6 or occasionally at the level of C7.
They then proceed superiorly, in the transverse foramen of each cervical vertebra. Once they have
passed through the transverse foramen of C1, the vertebral arteries travel across the posterior arch of
C1 and through the suboccipital triangle before entering the foramen magnum.
Inside the skull, the two vertebral arteries join to form the basilar artery at the base of the Pons. The
basilar artery is the main blood supply to the brainstem and connects to the Circle of Willis to
potentially supply the rest of the brain if there is compromise to one of the carotids. At each cervical
level, the vertebral artery sends branches to the surrounding musculature via the anterior spinal arteries.
Vertebral artery gives off:
1. Anterior spinal artery
2. Posterior spinal artery
3. Posterior inferior cerebellar artery.
4. Meningeal branches (anterior and posterior)
5. Basilar artery
Vertebral artery together with anterior spinal arteries form around medulla oblongata the circle of
Zakharchenka.
Vertebral arteries supply:
- the upper spinal cord
- brainstem
- cerebellum
- posterior part of brain

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417. Internal thoracic artery, topography, branches, areas of blood supply.
Internal thoracic artery begins from the inferior surface of the ascending part of the subclavian artery,
near the medical margin of anterior scalene muscle. It passes along I-VII cartilages of ribs near sternum
where divides into 2 terminal branches: musculophrenic artery and superior epigastric artery.
Branches of internal thoracic artery:
1. Mediastinal branches – organs of anterior mediastinum
2. Thymic branches – thymus
3. Tracheal and bronchial branches – inferior part of trachea and bronchi
4. Pericardiacophrenic artery – thymus, lymphatic nodes, pericardium, mediastinum pleura, bronchi
5. Sternal branches – direct medially to the posterior part of the sternum and together with the same
branches of opposite site create posterior arterial network of sternum. Supply: periosteum and posterior
membrane of the sternum.
6. Perforating branches – to periosteum and anterior membrane of the sternum, create anterior arterial
network of sternum. The arteries branch in the muscles (muscular branches), in the skin (cutaneous
branches), in women (mammary branches)
7. Anterior intercostal branches – muscles and parietal pleura. They are located in the first 6
intercostal spaces.
8. Musculophrenic artery – gives off anterior intercostal branches to the 7-10 intercostal spaces.
Supply the diaphragm and lateral muscles of the abdomen.
9. Superior epigastric artery – in the region of navel anastomoses with the inferior epigastric artery.
Supplies: rectus abdominis muscle, other muscles of the anterior abdominal wall and skin, the
diaphragm and falciform ligament of liver.

418. Subclavian artery: thyrocervical trunk, branches, areas of blood supply.

Thyro-cervical trunk has a length 1 -2 cm and subdivides into 4 branches:
- inferior thyroid artery (supplies thyroid gland, cervical part of esophagus, cervical portion of trachea
- inferior laryngeal artery (mucous membrane of the larynx)
- ascending cervical artery (muscles of neck)
- superficial cervical artery (trapezius and rhomboid muscles and other neck muscles)
- suprascapular artery (supraspinatus and infraspinatus muscles)

419.Subclavian artery: costocervical trunk, branches, areas of blood supply.

The costocervical trunk arises from the upper and back part of the second part of subclavian artery,
behind the scalenus anterior on the right side, and medial to that muscle on the left side.

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Passing backward, it splits into the deep cervical artery and the superior intercostal artery (highest
intercostal artery), which descends behind the pleura in front of the necks of the first and second ribs,
and anastomoses with the first aortic intercostal (3rd posterior intercostal artery).
Branches:
1. Deep cervical artery supplies: semispinalis capitis, semispinalis cervicis and adjacent muscles)
2. Superior intercostal artery is an artery that usually gives rise to the first and second posterior
intercostal arteries, which supply blood to their corresponding intercostal space.
They go to the posterior vertebral muscles, and send a small spinal branch through the corresponding
intervertebral foramen to the medulla spinalis and its membranes.

420. Aorta: parts, topography.

Aorta is the largest arterial vessel of systemic circulation. It subdivides on:
- ascending part of aorta
- arch of aorta
- descending part of aorta (thoracic and abdominal parts)
Ascending part of aorta leaves the left ventricle behind left margin of sternum on the level 3rd
intercostal space. In initial part is has an expansion called aortic bulb, in which three aortic sinuses are
contained. Ascending part of aorta lies behind and to the right from the pulmonary trunk, rises up and
to the level of 2nd right costal cartilage and passes into arch of aorta.

The arch of the aorta turns posteriorly to the left from 2nd costal cartilage to the left side of IVth
thoracic vertebral body, where passes into descending aorta. Between concave aortic arch surface and
pulmonary trunk, on the beginning of left pulmonary artery, obliterated Botali duct (arterial ligament)
is situated. From convex aortic arch surface, starts from the right to the left: brachiocephalic trunk, left
common carotid artery and left subclavian artery.

Descending aorta has a thoracic part of aorta, which passes in posterior mediastinum and lies to the
left from the bodies of thoracic vertebrae and abdominal part or aorta, which starts on the level of
Th-XII, passes through aortic hiatus of diaphragm and extends to the level of L-IV. Abdominal part of
aorta is disposed in front of anterior surface of lumbar vertebrae to the left from midline. Here
abdominal aorta gives off the pair of parietal branches, pair and odd visceral branches and finishes in
bifurcation, divining into 2 common iliac arteries.

421. Thoracic aorta: topography, branches, areas of blood supply.

Topography:
- in the posterior mediastinal cavity
- begins at the lower border of the fourth thoracic vertebra where it is continuous with the aortic arch

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- ends in front of the lower border of the twelfth thoracic vertebra at the aortic hiatus in the diaphragm
- at its commencement, it is situated on the left of the vertebral column; it approaches the median line
as it descends; and at its termination, lies directly in front of the column
- it is in relation:
 anteriorly, from above downward, with the root of the left lung, the pericardium, the esophagus,
and the diaphragm;
 posteriorly, with the vertebral column and the hemiazygos veins;
 on the right side, with the azygos vein and thoracic duct;
 on the left side, with the left pleura and lung.
Branches:
1. Visceral
- Pericardial (posterior surface of the pericardium)
- Bronchial ( back part of its bronchus, dividing and subdividing along the bronchial tubes, supplying
them, the areolar tissue of the lungs, the bronchial lymph glands, and the esophagus)

- Esophageal (esophagus, forming a chain of anastomoses along that tube)

- Mediastinal (the lymph glands and loose areolar tissue in the posterior mediastinum)

2. Parietal
- Intercostal (intercostal muscles, ribs, skin, breasts; lower posterior intercostal also supply muscles of
anterior abdominal wall)
- Subcostal
- Superior phrenic (lumbar part of diaphragm)

422. Thoracic aorta: topography, parietal branches, areas of blood supply.

Parietal branches of thoracic part of aorta:

- superior phrenic arteries are pair, pass to lumbar part of diaphragm;

- posterior intercostal arteries are 10 pairs in number, which pass in ІІІ-XІ intercostal spaces and
supply intercostal muscles, ribs, skin, breasts. Lower posterior intercostal arteries supply also muscles
of anterior abdominal wall. X posterior intercostal artery is situated under posterior margin of XІІ rib
and has a name of subcostal artery. From each posterior intercostal artery move away
the sprigs to muscles and posterior skin, to membranes of spinal cord and lateral and medial cutaneі
branches to breasts skin and abdominal, sprigs to mammary gland.

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423. Thoracic aorta: topography, visceral branches, areas of blood supply.

Visceral branches of thoracic part of aorta:

- bronchial branches - to trachea, bronchі and lung;

- esophageal branches to esophagus;

- pericardial branches to posterior part of pericardium;

- mediastinal branches supply connective tissue and lymphatic nodes in posterior mediastinum.

424. The abdominal aorta: topography, classification of branches, named.

Extraperitoneally, in front of the vertebral column, a little to the left from the middle line. Surrounded
by connective tissue, sympathetic plexuses and ganglia, vessels and lymphatic nodes.
Begins: at the aortic hiatus of the diaphragm, in front of the lower border of the body of the Th-XII.
Descends: in front of the vertebral column.
Ends: on the body of the L-IV, and divide into 2 common iliac arteries and also give off a thin
median sacral artery.
Relations:
Anteriorly:
Covered by the lesser omentum and stomach, behind which are the branches of the celiac artery and the
celiac plexus; below these, by the lienal vein, the pancreas, the left renal vein, the inferior part of the
duodenum, the mesentery, and aortic plexus.

Posteriorly:
Separated from the lumbar vertebræ and intervertebral fibrocartilages by the anterior longitudinal
ligament and left lumbar veins.

Right side:
Relation above with the azygos vein, cisterna chyli, thoracic duct, and the right crus of the
diaphragm—the last separating it from the upper part of the inferior vena cava, and from the right
celiac ganglion; the inferior vena cava is in contact with the aorta below.

Left side:
The left crus of the diaphragm, the left celiac ganglion, the ascending part of the duodenum, and some
coils of the small intestine.

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The branches of abdominal aorta are divided in 3 groups: visceral, parietal and terminal.

425. The abdominal aorta: parietal branches, the topography, areas of blood supply.
1. Inferior phrenic arteries – (diaphragm)
- Superior suprarenal arteries – (suprarenal glands)

1. Inferior phrenic arteries; 2- variety in origin, may arise separately from the front of the aorta,
immediately above the celiac trunk or as a common trunk from the aorta or from the celiac artery. They
diverge from one another across the crura of the diaphragm and run obliquely upward and laterally
under its surface. Left passes behind the esophagus. Right passes behind the inferior vena cava. Near
the back part of central tendon each one divides into a medial and lateral branch. Each of them gives
off superior suprarenal branches.
Supply:
- Diaphragm
- Suprarenal glands
2.Lumbal arteries; usually 4 on each side, arise from the back of the aorta, opposite of the bodies of
the upper four lumbar vertebra. Arteries of the right side pass behind the inferior vena cava.
Branches:
- Dorsal ramus: (muscles and skin of the back)
- Spinal ramus: (spinal cord)
3.Middle sacral artery; arises from the back of the aorta, a little above its bifurcation. Descends in the
middle line in front of the 4th and 5th lumbar vertebra, the sacrum and coccyx and ends in the glomus
coccygeum.
Supplies: pelvic wall.

Parietal branches Region of supplying

a. phrenica inferior Diahpragm

a. phrenica inferior ---- aa.suprarenales superiores Glandulae suprarenales

4 aa. lumbales ---------- r. dorsalis, r. spinales Muscles and skin of back and
Spinal cord

a. sacralis mediana Pelvic wall

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426. The abdominal aorta: visceral branches, their classification, topography, areas of blood
supply.

Visceral branches of abdominal aorta are divided into paired and unpaired branches.
The topography of these arteries is contained in questions no 427, 430, 431, 432, 433

Paired and unpaired branches:

427. The abdominal aorta: paired visceral branches, topography, areas of blood supply.

Paired Visceral branches Region of supplying

a.suprarenales medii Suprarenal glands

a. renalis Kidney, Suprarenal glands

a. testicularis or a. ovarica Testis or Ovary

The middle suprarenal arteries are two small vessels which arise, one from either side of the aorta,
opposite the superior mesenteric artery. They pass lateralward and slightly upward, over the crura of

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the diaphragm, to the suprarenal glands, where they anastomose with suprarenal branches of the
inferior phrenic and renal arteries. In the fetus these arteries are of large size.
The renal arteries are two large trunks, which arise from the side of the aorta, immediately below the
superior mesenteric artery. Each is directed across the crus of the diaphragm, so as to form nearly a
right angle with the aorta. The right is longer than the left, on account of the position of the aorta; it
passes behind the inferior vena cava, the right renal vein, the head of the pancreas, and the descending
part of the duodenum. The left is somewhat higher than the right; it lies behind the left renal vein, the
body of the pancreas and the lienal vein, and is crossed by the inferior mesenteric vein. Before reaching
the hilus of the kidney, each artery divides into four or five branches; the greater number of these lie
between the renal vein and ureter, the vein being in front, the ureter behind, but one or more branches
are usually situated behind the ureter. Each vessel gives off some small inferior suprarenal branches
to the suprarenal gland, the ureter, and the surrounding cellular tissue and muscles. One or two
accessory renal arteries are frequently found, more especially on the left side they usually arise from
the aorta, and may come off above or below the main artery, the former being the more common
position. Instead of entering the kidney at the hilus, they usually pierce the upper or lower part of the
gland.

The internal spermatic arteries are distributed to the testes. They are two slender vessels of
considerable length, and arise from the front of the aorta a little below the renal arteries. Each passes
obliquely downward and lateralward behind the peritoneum, resting on the Psoas major, the right
spermatic lying in front of the inferior vena cava and behind the middle colic and ileocolic arteries and
the terminal part of the ileum, the left behind the left colic and sigmoid arteries and the iliac colon.
Each crosses obliquely over the ureter and the lower part of the external iliac artery to reach the
abdominal inguinal ring, through which it passes, and accompanies the other constituents of the
spermatic cord along the inguinal canal to the scrotum, where it becomes tortuous, and divides into
several branches. Two or three of these accompany the ductus deferens, and supply the epididymis,
anastomosing with the artery of the ductus deferens; others pierce the back part of the tunica albuginea,
and supply the substance of the testis. The internal spermatic artery supplies one or two small branches
to the ureter and in the inguinal canal gives one or two twigs to the cremaster.

The ovarian arteries are the corresponding arteries in the female to the internal spermatic in the male.
They supply the ovaries, are shorter than the internal spermatic, and do not pass out of the abdominal
cavity. The origin and course of the first part of each artery are the same as those of the internal
spermatic, but on arriving at the upper opening of the lesser pelvis the ovarian artery passes inward,
between the two layers of the ovariopelvic ligament and of the broad ligament of the uterus, to be
distributed to the ovary. Small branches are given to the ureter and the uterine tube, and one passes on
to the side of the uterus, and unites with the uterine artery. Other offsets are continued on the round
ligament of the uterus, through the inguinal canal, to the integument of the labium majus and groin.

428. The abdominal aorta: odd visceral branches, topography, areas of blood supply.
1.Celiac trunk (quesiton no 429)
- Left gastric artery

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- Common hepatic artery
- Lienal artery
2. Superior mesenteric artery (432)
3.Inferior mesenteric artery (433)
429. The abdominal aorta: celiac trunk, topography, branches, areas of blood supply.
It is short and thick, about 1,25cm in length, arises from the front of the aorta, just below the aortic
hiatus of the diaphragm and passes nearly horizontally forward and divides into 3 large branches:
1. Left gastric artery
2. Hepatic artery (430)
3. Splenic artery (431)

Topography:
- the celiac trunk is covered by the lesser omentum
- on the right side is in relation with the right celiac ganglion and the caudate process of the liver
- on the left side: left celiac ganglion and the cardiac end of the stomach
- below upper border of the pancreas and the lineal vein

1. The Left Gastric Artery the smallest of the three branches of the celiac artery, passes upward and to
the left, posterior to the omenal bursa to the cardiac orifice of the stomach. Here, it distributes branches
to the esophagus, which anastomose with the aortic esophageal arteries, others supply the cardiac part
of the stomach, anastomosing with branches of the lineal artery. It then runs from left to right, along
the lesser curvature of the stomach to the pylorus, between the layers of the lesser omentum; it gives
branches to both surfaces of the stomach and anastomoses with the right gastric artery.

430. Celiac trunk: common hepatic artery, topography, branches, areas fo blood supply.
Hepatic artery:
- it is first directed forward and to the right, to the upper margin of the superior part of duodenum
- crosses the portal vein anteriorly and ascends between the layers of the lesser omentum, and in front
of the epiploic foramen to the porta hepatis where divides into 2 branches: right and left hepatic artery,
which supply corresponding lobes of the liver
Branches:
1. Right gastric artery (supplies lesser curvature of stomach)
2. Gastroduodenal artery
- right gastroepiploic artery (supplies greater curvature of stomach, greater omentum
- superior pancreaticoduodenal artery (supplies pancreas and duodenum)
3. Cystic artery (supplies gallbladder)

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431. Celiac trunk: splenic artery, topography, branches, areas of blood supply.
The lineal or splenic artery:
- the largest branch of the celiac trunk
- it passes horizontally to the left, behind the stomach and the omental bursa of the peritoneum, along
the upper border of the pancreas accompanied by lineal vein which lies below it
- it crosses in front of the upper part of the left kidney
- arrives near the spleen and divides into branches
Branches:
1. Pancreatic branches (supply pancreas: body and tail)
2. Short gastric arteries (supply fundus of stomach)
3. Left gastroepiploic artery (supplies greater curvature of stomach and greater omentum)

432. The abdominal aorta: superior mesenteric artery: topography, branches, areas of blood
supply.
Superior mesenteric artery Th-XII – L-I arises from the front of the aorta, about 1,25cm below the
celiac artery and is crossed at its origin by the lienal vein and the neck of the pancreas. It passes
downward and forward, anterior to the uncinated process of the head of the pancreas and inferior part
of duodenum, and descends between layers of the mesentery to the right iliac fossa. In its course it
crosses in front of the inferior vena cava, the right ureter and psoas major, and forms an arch, the
convexity of which is directed forward and downward to the left side, the concavity backward and
upward to the right. It is accompanied by the superior mesenteric vein, which lies to it its right side and
it is surrounded by superior mesenteric plexus of nerves.

Superior mesenteric artery is a large vessel which supplies:

- the whole length of the small intestine (except the superior part of the duodenum)
- the cecum and the ascending part of the colon
- about one-half of the transverse part of the colon

Branches:
1. Inferior pancreaticoduodenal artery (branches to the head of the pancreas and to the descending and
inferior part of duodenum)
2. Ileocolic artery (colic, anterior and posterior cecal branches, appendicular artery and ileal branch)
3. Intestinal arteries ( jejunal and ileal arteries)
4. Right colic artery (supplies ascending colon)
5. Middle colic artery (supplies transverse colon)

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433. The abdominal aorta: inferior mesenteric artery: topography, branches, areas of blood
supply.
Inferior mesenteric artery L-III is smaller than a superior mesenteric artery, arises from the aorta
about 3-4 cm above its division into the common iliac arteries and close to the lower border of the
inferior part of the duodenum. It passes downward posterior to the peritoneum, lying at first anterior
and then on the left side of the aorta. It crosses the left common iliac artery and is continued into the
lesser pelvis under the name of the superior haemorrhoidal artery, which descends between the two
layers of the sigmoid colon and ends on the upper part of the rectum.

Inferior mesenteric artery supplies:

- the left half on the transverse part of the colon
- the whole of the descending and iliac parts of the colon
- the sigmoid colon
- the greater part of the rectum
Branches:
1. Left colic artery (supplies the descending colon and the left part of the transverse colon)
2. Sigmoid arteries (supplies the lower part of the descending colon, the iliac colon, and the sigmoid or
pelvic colon)
3. Superior rectal artery (supplies rectal ampulla)

434. Arterial anastomoses between the branches of the abdominal aorta.

Anastomoses of inferior mesenteric artery:
- Ascending branch of the left colic artery anastomoses with middle colic artery.
- Descending branch of the left colic artery anastomoses with the highest sigmoid artery.
- Sigmoid arteries anastomoses above with the left colic

Anastomoses of superior mesenteric artery:

- Inferior pancreaticoduodenal artery with superior pancreaticoduodenal artery.
- Superior branch of ileocolic artery with the right colic artery.
- Inferior branch of the ileocolic artery anastomoses with the end of the superior mesenteric artery.
- Ascending branch of the right colic artery anastomoses with the middle colic artery.
- Left branch of middle colic artery anastomoses with the left colic artery (branch of the inferior
mesenteric artery)
Other anastomoses:

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- pancreatic branches from lienal artery with the pancreatic branches of the pancreaticoduodenal and
superior mesenteric artery
- right gastric artery with left gastric artery
- right gastroepiploic artery with left gastroepiploic artery
- superior pancreaticoduodenal artery with inferior pancreaticoduodenal artery from superior
mesenteric artery
- short gastric arteries (from lienal a.) with branches of the left gastric and left gastroepiploic arteries

435. Common iliac artery: formation, topography, branches.

On the level of IV lumbar vertebra, abdominal aorta divides into 2 common iliac arteries – aorta
bifurcation. Each is about 5cm in length. They pass downward and lateralward and on the level of
sacro-iliac joint divide into 2 branches: external iliac artery and internal iliac artery.

Right common iliac artery:

- longer than left
- in front: the peritoneum, the small intestines, branches of the sympathetic nerves and at its point of
division – the urether.
- behind: it is separated from the bodies of the IV and V lumbar vertebra and the intervening
fibrocartilage by the terminations of the 2 common iliac veins and the commencement of the inferior
vena cava.
- laterally: above -inferior vena cava and the right common iliac vein and below psoas major muscle.
- medially: common iliac vein
Left common iliac artery:
- in front: the peritoneum, the small intestine, branches of the sympathetic nerves, the superior
hemorrhoidal artery and it is crossed at its point of bifurcation by the ureter
- it rest on the bodies on IV and V lumbar vertebrae and the intervening fibrocartilage.
- medially and and partially behind – the left common iliac vein
- laterally: psoas major muscle

The common iliac arteries give off small branches to the peritoneum, psoas major, ureters and the
surrounding areolar tissue. Occasionally give origin to the iliolumbar or accessory renal arteries.

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436 Internal iliac areter: formation, topography, branches
437 Internal iliac artery: parietal branches, the topography,areas of blood supply.
438 Internal iliac artery: visceral branches the topography, area of blood supplying
439 Internal iliac artery: internal pudental artery, topography branches, areas of blood
supplying
The major artery of the pelvis and perineum is the internal iliac artery on each side. In
addition to providing a blood supply to most of the pelvic viscera, pelvic walls and floor, and
structures in the perineum, including erectile tissues of the clitoris and the penis, this artery
gives rise to branches that follow nerves into the gluteal region of the lower limb. Other
vessels thatoriginate in the abdomen and contribute to the supply of pelvic structures include
the median sacral artery and, in women, the ovarian arteries.
The internal iliac artery
The internal iliac artery originates from the common iliac artery on each side, approximately
at the level of the intervertebral disc between LV and SI and lies anteromedial to the sacro-
iliac joint . The vessel courses inferiorly over the pelvic inlet, then divides into anterior and
posterior trunks at the level of the superior border of the greater sciatic foramen. Branches
from the posterior trunk contribute to the supply of the lower posterior abdominal wall, the
posterior pelvic wall, and the gluteal region. Branches from the anterior trunk supply the
pelvic viscera, the perineum, the gluteal region, the adductor region of the thigh, and, in the
fetus, the placenta.

Posterior trunk

Branches of the posterior trunk of the internal iliac artery are the iliolumbar artery, the lateral
sacral artery, and the superior gluteal artery.
 The iliolumbar artery ascends laterally back out of the pelvic inlet and divides into a
lumbar branch and an iliac branch. The lumbar branch contributes to the supply of the
posterior abdominal wall, psoas, quadratus lumborum muscles, and cauda equina, via
a small spinal branch that passes through the intervertebral foramen between LV and
SI. The iliac branch passes laterally into the iliac fossa to supply muscle and bone.
 The lateral sacral arteries, usually two, originate from the posterior division of the
internal iliac artery and course medially and inferiorly along the posterior pelvic wall.
They give rise to branches that pass into the anterior sacral foramina to supply related
bone and soft tissues, structures in the vertebral (sacral) canal, and skin and muscle
posterior to the sacrum.
 The superior gluteal artery is the largest branch of the internal iliac artery and is the
terminal continuation of the posterior trunk. It courses posteriorly, usually passing
between the lumbosacral trunk and anterior ramus of S1, to leave the pelvic cavity
through the greater sciatic foramen above the piriformis muscle and enter the gluteal
region of the lower limb. This vessel makes a substantial contribution to the blood
supply of muscles and skin in the gluteal region and also supplies branches to
adjacent muscles and bones of the pelvic walls.

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 POSTERIOR TRUNK

ANTERIOR TRUNK

Branches of the anterior trunk of the internal iliac artery include the superior vesical artery,
the umbilical artery, the inferior vesical artery, the middle rectal artery, the uterine artery,

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the vaginal artery, the obturator artery, the internal pudendal artery, and the inferior gluteal
artery.
 The first branch of the anterior trunk is the umbilical artery, which gives origin to the
superior vesical artery, then travels forward just inferior to the margin of the pelvic
inlet. Anteriorly, the vessel leaves the pelvic cavity and ascends on the internal aspect
of the anterior abdominal wall to reach the umbilicus. In the fetus, the umbilical artery
is large and carries blood from the fetus to the placenta. After birth, the vessel closes
distally to the origin of the superior vesical artery and eventually becomes a solid
fibrous cord. On the anterior abdominal wall, the cord raises a fold of peritoneum
termed the medial umbilical fold. The fibrous remnant of the umbilical artery itself is
the medial umbilical ligament.
 The superior vesical artery normally originates from the root of the umbilical artery
and courses medially and inferiorly to supply the superior aspect of the bladder and
distal parts of the ureter. In men, it also may give rise to an artery that supplies the
ductus deferens.
 The inferior vesical artery occurs in men and supplies branches to the bladder, ureter,
seminal vesicle, and prostate. The vaginal artery in women is the equivalent of the
inferior vesical artery in men and, descending to the vagina, supplies branches to the
vagina and to adjacent parts of the bladder and rectum.
 The middle rectal artery courses medially to supply the rectum. The vessel
anastomoses with the superior rectal artery, which originates from the inferior
mesenteric artery in the abdomen, and the inferior rectal artery, which originates from
the internal pudendal artery in the perineum.
 The obturator artery courses anteriorly along the pelvic wall and leaves the pelvic
cavity via the obturator canal. Together with the obturator nerve, above, and obturator
vein, below, it enters and supplies the adductor region of the thigh.
 The internal pudendal artery courses inferiorly from its origin in the anterior trunk and
leaves the pelvic cavity through the greater sciatic foramen inferior to the piriformis
muscle. In association with the pudendal nerve on its medial side, the vessel passes
laterally to the ischial spine and then through the lesser sciatic foramen to enter the
perineum. The internal pudendal artery is the main artery of the perineum. Among the
structures it supplies are the erectile tissues of the clitoris and the penis.
 The inferior gluteal artery is a large terminal branch of the anterior trunk of the
internal iliac artery. It passes between the anterior rami S1 and S2 or S2 and S3 of the
sacral plexus and leaves the pelvic cavity through the greater sciatic foramen inferior
to the piriformis muscle. It enters and contributes to the blood supply of the gluteal
region and anastomoses with a network of vessels around the hip joint.
 The uterine artery in women courses medially and anteriorly in the base of the broad
ligament to reach the cervix. Along its course, the vessel crosses the ureter and passes
superiorly to the lateral vaginal fornix. Once the vessel reaches the cervix, it ascends
along the lateral margin of the uterus to reach the uterine tube where it curves laterally
and anastomoses with the ovarian artery. The uterine artery is the major blood supply
to the uterus and enlarges significantly during pregnancy. Through anastomoses with

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 other arteries, the vessel contributes to the blood supply of the ovary and vagina as
well.

440 General anatomy of the veins: anatomic classification, classification by the

structure of the wall, functions of different groups of veins
Veins are blood vessels which carry deoxygenated (or very low levels of oxygen) blood back
to the heart. The exception to this rule is the pulmonary vein, which carries oxygenated
blood, from the lungs, back to the heart, ready to be pumped around the rest of the body.At
tissue level, capillaries drain blood into venules, which are very small veins, which as they
return to the heart merge into larger veins before reaching either the Superior Vena Cava (if
returning from tissues and organs above the heart) or the Inferior Vena Cava (if returning
from tissues and organs below to the heart). The Inferior Vena Cava is larger than the
Superior Vena Cava. These two large arteries merge and return blood to the right atrium of
the heart.

Structure
The structure of veins is similar to that of arteries, again consisiting of three layers:
 Tunica Adventitia: This is the strong outer covering of arteries and veins which consists
of connective tissues, collagen and elastic fibres.
 Tunica Media: This is the middle layer and consists of smooth muscle and elastic fibres.
This layer is thinner in veins.
 Tunica Intima: This is the inner layer which is in direct contact with the blood flowing
through the vein. It consists of smooth endothelial cells. The hollow centre through which
blood flows is called the lumen. Veins also contain valves which prevent the back flow of
blood and aid venous return.

Types of veins:
 Superficial veins are those closer to the surface of the body, and have no
corresponding arteries.
 Deep veins are deeper in the body and have corresponding arteries.
 Perforator veins drain from the superficial to the deep veins. These are usually
referred to in the lower limbs and feet.
 Communicating veins are veins that directly connect superficial veins to deep veins.
 Pulmonary veins are a set of veins that deliver oxygenated blood from the lungs to the
heart.
 Systemic veins drain the tissues of the body and deliver deoxygenated blood to the
heart.

Veins also are subdivided into three classes:

 Large veins contain some smooth muscle in the tunica media, but the thickest layer is
the tunica externa. Examples of large veins are the superior vena cava, the inferior
vena cava, and the portal vein.

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  Small and medium veins contain small amounts of smooth muscle, and the thickest
layer is the tunica externa. Examples of small and medium veins are superficial veins
in the upper and lower limbs and deeper veins of the leg and forearm.
 Venules are the smallest veins and drain the capillaries.

Although veins are similar in general structure to arteries, they have a number of
distinguishing features.
 The walls of veins, specifically the tunica media, are thin.
 The luminal diameters of veins are large.
 There often are multiple veins (venae comitantes) closely associated with arteries in
peripheral regions.
 Valves often are present in veins, particularly in peripheral vessels inferior to the level
of the heart. These are usually paired cusps that facilitate blood flow toward the heart.

441 Superior vena cava: formation(roots), topography, tributaries

Superior vena cava The vertically oriented superior vena cava begins posterior to the lower
edge of the right first costal cartilage, where the right and left brachiocephalic veins join,
and terminates at the lower edge of the right third costal cartilage, where it joins the right
atrium
The lower half of the superior vena cava is within the pericardial sac and is therefore
contained in the middle mediastinum. The superior vena cava receives the azygos vein
immediately before entering the pericardial sac and may also receive pericardial and
mediastinal veins.

442 azygous vein:formation, topography classification tributaries

443 azygous vein: visceral tributaries, areas collecting venous blood
444 azygous vein: parietal tributaries, areas of colletting of venous blood

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 Azygos vein
The azygos vein arises opposite vertebra LI or LII at the junction between the right
ascending lumbar vein and the right subcostal vein. It may also arise as a direct branch of
the inferior vena cava, which is joined by a common trunk from the junction of the right
ascending lumbar vein and the right subcostal vein.
The azygos vein enters the thorax through the aortic hiatus of the diaphragm, or it enters
through or posterior to the right crus of the diaphragm. It ascends through the posterior
mediastinum, usually to the right of the thoracic duct. At approximately vertebral level TIV,
it arches anteriorly, over the root of the right lung, to join the superior vena cava before the
superior vena cava enters the pericardial sac.
Tributaries of the azygos vein include:
 the right superior intercostal vein (a single vessel formed by the junction of the
second, third, and fourth intercostal veins);
 fifth to eleventh right posterior intercostal veins;
 the hemiazygos vein;
 the accessory hemiazygos vein; esophageal veins;
 mediastinal veins;
 pericardial veins;
 and right bronchial veins.

445 Hemiazygous vein: formation, topography, classification, tributaries

446hemiazygous vein: visceral tributaries, areas of collecting venous blood
447 hemiazygous vein:parietal tributaries, areas of collecting of venous blood
Hemiazygos vein

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 The hemiazygos vein (inferior hemiazygos vein) usually arises at the junction between the
left ascending lumbar vein and the left subcostal vein. It may also arise from either of these
veins alone and often has a connection to the left renal vein. The hemiazygos vein usually
enters the thorax through the left crus of the diaphragm, but may enter through the aortic
hiatus. It ascends through the posterior mediastinum, on the left side, to approximately
vertebral level TIX. At this point, it crosses the vertebral column, posterior to the thoracic
aorta, esophagus, and thoracic duct, to enter the azygos vein.
Tributaries joining the hemiazygos vein include:
 the lowest four or five left posterior intercostal veins;
 esophageal veins;
 and mediastinal veins.
Inferior Hemiazygos Vein
The inferior hemiazygos vein is often formed by the union of the left ascending lumbar vein
and the left subcostal vein. It ascends through the left crus of the diaphragm and, at about
the level of the eighth thoracic vertebra, turns to the right and joins the azygos vein. It
receives as tributaries some lower left intercostal veins and medias- tinal veins.
Superior Hemiazygos Vein
The superior hemiazygos vein is formed by the union of the fourth to the eighth intercostal
veins. It joins the azygos vein at the level of the seventh thoracic vertebra

448 Accessory hemiazygous vein: topography, tributaries

Accessory hemiazygos vein
The accessory hemiazygos vein (superior hemiazygos vein) descends on the left side from the
superior portion of the posterior mediastinum to approximately vertebral level TVIII. At this
point, it crosses the vertebral column to join the azygos vein, or ends in the hemiazygos vein,
or has a connection to both veins. Usually, it also has a connection superiorly to the left
superior intercostal vein.
Vessels that drain into the accessory hemiazygos vein include:
 the fourth to eighth left posterior intercostal veins;
 and sometimes, the left bronchial veins.

449 Intercostal veins: topography,tributaries, areas of collecting venous blood

Intercostal vein is a term that is used to describe the numerous veins that function to drain
the rib cage's intercostal spaces. The intercostal spaces, often abbreviated as ICS, are located
between two ribs. Rib cages consist of 11 of these spaces in total. Another common word for
the intercostal spaces is "costae." A handful of different divisions of these veins exist. These
divisions are posterior veins, anterior veins, superior veins, supreme veins, and subcostal
veins. The posterior veins drain the spaces from the back. The anterior veins drain out the
anterior regions. The superior veins drain blood from the second, third, and fourth intercostal
spaces. The supreme veins drain from the first costae. Lastly, the subcostal veins are situated
directly under the lowermost rib and are similar to the posterior veins.

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450 Veins of vertebral collumn: vertebral venous plexus, the topography, ways venous
outflow

451 Inferior vena cava: formation(roots), topography classification, tributaries.

452 Inferior vena cava: visceral tributaries, areas of collecting venous blood
453 Inferior vena cava: parietal tributaries, areas of collecting venous blood

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The inferior vena cava forms at the superior end of the pelvic cavity when the common iliac
veins unite to form a larger vein. From the pelvis, the inferior vena cava ascends through the
posterior abdominal body wall just to the right of the vertebral column.Along its way through
the abdomen, blood from the internal organs joins the inferior vena cava through a series of
large veins, including the gonadal, renal, suprarenal and inferior phrenic veins. The hepatic
vein provides blood from the digestive organs of the abdomen after it has passed through the
hepatic portal system in the liver. Blood from the tissues of the lower back, including the
spinal cord and muscles of the back, enters the vena cava through the lumbar veins. Many
smaller veins also provide blood to the vena cava from the tissues of the abdominal body
wall. Upon reaching the heart, the inferior vena cava connects to the right atrium on its
posterior side, inferior to the connection of the superior vena cava.The inferior vena cava and
its tributaries drain blood from the feet, legs, thighs, pelvis and abdomen and deliver this
blood to the heart. Many one-way venous valves help to move blood through the veins of the
lower extremities against the pull of gravity. Blood passing through the veins is under very
little pressure and so must be pumped toward the heart by the contraction of skeletal muscles
in the legs and by pressure in the abdomen caused by breathing. Venous valves help to trap
blood between muscle contractions or breaths and prevent it from being pulled back down
towards the feet by gravity.

454 Portal vein: formation(roots), tributaries, area of collecting venous blood, topography
455 Portal hepatic vein: branching in the liver functional significance
Portal vein (PV) (sometimes referred to as the main or hepatic portal vein) is the main
vessel in the portal venous system and drains blood from the gastrointestinal tract and spleen
to the liver.The portal vein, usually measures approximately 8 cm in adults. It originates

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behind the neck of the pancreas and is classically formed by the confluence of the superior
mesenteric and splenic veins, and also receives blood from the inferior mesenteric, gastric,
and cystic veins.Immediately before reaching the liver, the portal vein divides into left portal
vein (supplying liver segments II, III, IV) and the right portal vein, which subsequently
divides further into anterior (supplying liver segments V and VIII) and posterior (supplying
liver segments VI and VII) portal veins.It ramifies further, forming smaller venous branches
and ultimately portal venules. Each portal venule courses alongside a hepatic arteriole and the
two vessels forming the vascular components of the portal triad. These vessels ultimately
empty into the hepatic sinusoids to supply blood to the liver.75% of the blood supplied to the
liver comes from the portal vein, but it only supplies 50% of the oxygen supply to the liver.

456 Internal iliac vein: topography classification of tributaries

457 Internal iliac vein: parietal tributaries, topography, areas of collecting venous blood
The internal iliac vein is responsible the majority of pelvic venous drainage, and receives
numerous tributaries from veins that drain the pelvic region. It is formed near the greater
sciatic foramen, ascending anteriorly to the sacroiliac joint, before combining with the
external iliac vein to form the common iliac vein.
With the exception of the iliolumbar vein (which drains into the common iliac), the
tributaries of the internal iliac vein correspond with the branches of the internal iliac artery. It
receives venous blood from the:
 Superior and inferior gluteal veins – drains the buttock and upper thigh.
 Internal pudendal vein – drains the reproductive organs and part of the rectum (via the
inferior rectal vein).
 Obturator vein
 Lateral sacral veins – drains part of the sacrum.
 Middle rectal vein – drains the bladder, prostate (in males only), and part of the rectum.
 Vesical veins – drains the urinary bladder via the vesical venous plexus.
 Uterine and vaginal veins – drain the female reproductive organs via the vaginal and
uterine venous plexuses.

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 458 Venous plexus pelvis: formation, topography, areas of collecting venous blood

459 Venous anastomoses definition

An anastomosis (plural anastomoses) is a connection or opening between two things
(especially cavities or passages) that are normally diverging or branching, such as between
blood vessels, leaf veins, or streams. Such a connection may be normal (such as the foramen
ovale in a fetus's heart) or abnormal (such as the patent foramen ovale in an adult's heart); it
may be acquired (such as an arteriovenous fistula) or innate (such as the arteriovenous shunt
of a metarteriole); and it may be natural (such as the aforementioned examples) or artificial
(such as a surgically created one, for example, ileorectal anastomosis as part of colectomy).
The reestablishment of an anastomosis that had become blocked is called a reanastomosis.
Anastomoses that are abnormal, whether congenital or acquired, are often called fistulas.

460 Porto-caval venous anastomoses: in the area of esophagus

461 Porto-cava anastomoses: in the area of rectum
462 Porto-caval anastomoses: on the posterior wall of abdominal cavity
463 Cava-caval anastomoses:on the anterior wall of the abdominal cavity

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1.Lower third of the Esophagus- the esophageal branches of the left gastric vein (portal
tributaries) anastomose with the esophageal veins draining the middle third of the esophageal
into azygos vein (systemic tributaries).
2.Paraumbilical Ares- they connect the left branch of the portal vein with the superficial veins
og the abdominal wall (systemic tributaries).
3.Anal Canal- The superficial rectal vein (portal tributary) draining the upper half of the anal
canal anastomose with the middle and inferior rectal veins (systemic tributaries), which are
tributaries of the internal iliac and internal pudendal veins, respectively.
4.Retroperitonal- The veins of the ascending colon, descending colon, duodenum, pancreas
and liver (portal tributary) anastomose with the renal, lumbar and phrenic veins (systemic
tributaries).

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5.Bare Areas of Liver- There is some anastomosis between portal venous channels in the
liver and azygous system of veins above the diaphragm across the bare area of the liver.

464 Porto-cava-caval anastomoses: on the anterion wall of the abdominal cavity

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465.466
Cava-caval,Porto-cava-caval anastomoses on the posterior wall of the abdominal cavity.
Cava caval anastomosis is between superior vena cava and inferior vena cava e.g between
lateral thoracic vein(a tributary of axillary vein) and superficial epigastric vein( tributary of
femoral vein) and porto caval anastomosis is between vena cava and portal vein.e.g
anastomosis in esophagus,, rectum, paraumbilical region.

467. Lymphatic system: general characteristics, functions.

The lymphatic system is part of the circulatory system and a vital part of the immune system,
comprising a network of lymphatic vessels that carry a clear fluid called lymph
The lymphatic system has multiple interrelated functions:[20]
 It is responsible for the removal of interstitial fluid from tissues
 It absorbs and transports fatty acids and fats as chyle from the digestive system
 It transports white blood cells to and from the lymph nodes into the bones
 The lymph transports antigen-presenting cells, such as dendritic cells, to the lymph
nodes where an immune response is stimulated.

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468. Lymph vessels: classification, topography, function.

Afferent vessels
The afferent lymph vessels enter at all parts of the periphery of the lymph node, and after
branching and forming a dense plexus in the substance of the capsule, open into the lymph
sinuses of the cortical part. It carries unfiltered lymph into the node. In doing this they lose all
their coats except their endothelial lining, which is continuous with a layer of similar cells
lining the lymph paths.
Afferent lymphatic vessels are only found in lymph nodes. This is in contrast to efferent
lymphatic vessel which are also found in the thymus and spleen.
Efferent vessels
The efferent lymphatic vessel commences from the lymph sinuses of the medullary portion
of the lymph nodes and leave the lymph nodes either to veins or greater nodes. It carries
filtered lymph out of the node.

469. Lymphatic system: thoracic duct, roots, topography, tributaries, confluence of the
venous system.

In human anatomy, the thoracic duct is the largest lymphatic vessel of the lymphatic system.
It is also known as the left lymphatic duct, alimentary duct, chyliferous duct, and Van
Hoorne's canal. It carries chyle, a liquid containing both lymph and emulsified fats, rather
than pure lymph. Thus when it ruptures, the resulting flood of liquid into the pleural cavity is
known as chylothorax
Tributaries
The microscopic lymph capillaries merge to form lymphatic vessels. Small lymphatic vessels
join to form larger tributaries, called lymphatic trunks, which drain large regions. Lymphatic
trunks merge until the lymph enters the two lymphatic ducts. The right lymphatic duct drains
lymph from the upper right quadrant of the body. The thoracic duct drains all the rest.

470. Lymphatic system: the right lymphatic duct, roots, topography, confluence of the
venous system

The right lymphatic duct, about 1.25 cm. in length, courses along the medial border of the
Scalenus anterior at the root of the neck. The right lymphatic duct forms various
combinations with the right subclavian vein and right internal jugular vein. A right lymphatic
duct that enters directly into the junction of the internal jugular and subclavian veins is
uncommon.
471. Lymph vessels and nodes of the thoracic cavity.
Lymphatic nodes of the thorax may be divided into two sets, parietal and visceral. There
distinguish the following parietal nodes of thorax:
1. Parasternal nodes collect lymph from pericardium, pleura, anterior thoracic wall,

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diaphragmatic surface of liver, mammary gland. The vessels from these nodes carry lymph
into right and left venous angles.
2. Intercostal nodes empty lymph into thoracic duct, and from superior nodes - into
deep lateral jugular lymphatic nodes.
3. Superior phrenic nodes carry lymph into parasternal nodes, nodes inferior
tracheobronchic and into bronchоpulmonary nodes.
4. Prepericardial nodes transport lymph into parasternal nodes, nodes inferior
tracheobronchic and into bronchоpulmonary nodes.
5. Prevertebral nodes are disposed between backbone and esophagus.
6. Paramammary nodes are disposed laterally from breasts and drain them.

472. Lymph vessels and nodes of the abdominal cavity.

In abdominal cavity, as and in pelvis, lymphatic nodes may be divided into two sets,
parietal and visceral.
The Visceral lymphatic nodes dispose along the course of big vessels come away from
abdominal aorta, they receive lymph from all internal abdominal organs: coeliac nodes,
right/left gastric nodes, lymphatic unnulus of cardia, right/left gastroepiploic nodes, pyloric
nodes, pancreatic nodes, splenic nodes, pancreatoduodenal nodes, hepatic nodes, superior
mesenteric nodes and inferior mesenteric nodes. The lymphatic vessels of the small intestine
receive the special designation of lacteals or chyliferous vessels; they differ in no respect
from the lymphatic vessels generally excepting that during the process of digestion they
contain a milk-white fluid, the chyle. The lymphatic vessels and nodes of the small intestine
positioned in mesentery and empty into intestinal trunk. The vessels take away lymph from
these nodes, pass to lumbar nodes. Efferent vessels of last form the lumbar trunks, which
flowing together form a thoracic duct.

473. Lymph vessels and nodes pelvic cavity.

The parietal lymphatic nodes disposed around aortae and inferior vene cava - right/left
and intermidiate lumbar nodes, lateral aortic nodes, preaortic nodes, retroaortic nodes,
lateral caval nodes, precaval nodes, retrocaval nodes, inferior phrenic nodes and inferior
epigastric nodes.
Lymphatic vessels of superior half of abdominal wall pass upward to the axillar
lymphatic nodes. The vessels of inferior half of abdominal wall pass downward to
inguinal lymphatic nodes.
The Lymph nodes of the Abdomen and Pelvis—The Lymph nodes of the abdomen and pelvis
may be divided, from their situations, into (a) parietal, lying behind the peritoneum and in
close association with the larger bloodvessels; and (b) visceral, which are found in relation to
the visceral arteries.

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The parietal nodes include the following groups:

Iliac
External Iliac. Lateral Aortic.
Circumflex.

Common Lumbar
Hypogastric. Preaortic.
Iliac.

Epigastric. Sacral. Retroaortic.

474 Autonomic part of the peripheral nervous system (autonomic nervous system): parts,
functions, object innervations

The peripheral nervous system (PNS) is the part of the nervous system that consists of the
nerves and ganglia outside of the brain and spinal cord. The main function of the PNS is to
connect the central nervous system (CNS) to the limbs and organs, essentially serving as a
communication relay going back and forth between the brain and spinal cord with the rest of
the body.Unlike the CNS, the PNS is not protected by the bone of spine and skull, or by the
blood–brain barrier, which leaves it exposed to toxins and mechanical injuries. The peripheral
nervous system is mainly divided into the somatic nervous system and the autonomic nervous
system. In the somatic nervous system, the cranial nerves are part of the PNS with the
exception of cranial nerve II, the optic nerve, along with the retina. The second cranial nerve
is not a true peripheral nerve but a tract of the diencephalon. Cranial nerve ganglia originate
in the CNS.

475. Differences between somatic nervous system and autonomic nervous system.

The somatic nervous system (SoNS) is the part of the peripheral nervous system associated
with the voluntary control of body movements through the skeletal muscles and mediation of
involuntary reflex arcs.
The autonomic nervous system (ANS) is the part of the peripheral nervous system that
controls visceral functions that occur below the level of consciousness.

476. Morphological differences reflex arc autonomic part of the peripheral nervous system
(autonomic nervous system).

Autonomic reflexes control and regulate smooth muscle cells, cardiac muscle cells and
glands. In general these reflexes contain the same basic components as somatic reflexes but a

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key difference is that autonomic reflexes have the ability to both stimulate or inhibit the
smooth muscle/gland.

Tendon Reflexes
Tendons represent the weakest element of the musculoskeletal system and can be broken
relatively easily compared to other aspects of the system. In some cases, muscle contractions
can be so powerful that the tendon either breaks or detaches and trauma can also have a
similar effect. Tendon reflexes represent a reflex arc that is designed to prevent tendon
damage from occurring.

Withdrawal Reflexes
The withdrawal reflex is behind the system that automatically withdraws any area of the body
that experiences pain or discomfort and is commonly used as a check for the depth of
anaesthesia of surgery patients. Examples of the withdrawal reflex would be an animal that
experiences heat e.g. a cat walking onto an electric hob, chemical or cold stimuli amongst
many others.

Stretch Reflexes
Stretch reflexes have been included here as they play an important role in posture and balance
of animals and are often overlooked as this reflex functions with such efficiency it is
performed totally unconsciously. Stretch reflexes are specifically used to control and
coordinate the length of skeletal muscles which is particularly important in ensuring the
smooth movement of limbs during locomotion.
477. Morphological differences between the sympathetic and parasympathetic parts of the
autonomic part of the peripheral nervous system (autonomic nervous system).

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478. The autonomic nervous system: the central part, classification, topography,
formation.

The autonomic nervous system is a division of the peripheral nervous system that influences
the function of internal organs. Within the brain, the autonomic nervous system is regulated
by the hypothalamus. Autonomic functions include control of respiration, cardiac
regulation (the cardiac control center), vasomotor activity (the vasomotor center), and
certain reflex actions such as coughing, sneezing, swallowing and vomiting. Those are
then subdivided into other areas and are also linked to ANS subsystems and nervous systems
external to the brain. The hypothalamus, just above the brain stem, acts as an integrator for
autonomic functions, receiving ANS regulatory input from the limbic system to do so.
The autonomic nervous system has two branches: the sympathetic nervous system and the
parasympathetic nervous system.

479. The autonomic nervous system: peripheral part, components.

The peripheral nervous system (PNS) is the part of the nervous system that consists of the
nerves and ganglia outside of the brain and spinal cord The main function of the PNS is to
connect the central nervous system (CNS) to the limbs and organs, essentially serving as a
communication relay going back and forth between the brain and spinal cord with the rest of
the body.

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480. Autonomic ganglia: classification, structure, topography.

An autonomic ganglion is a cluster of nerve cell bodies in the autonomic nervous system.
The two types are sympathetic ganglion and parasympathetic ganglion.
Sympathetic ganglion deliver information to the body about stress and impending danger,
and are responsible for the familiar fight-or-flight response.
The parasympathetic ganglia is primarily a homeostatic or anabolic system promoting the
quiet and orderly processes of the body.

481. Sympathetic trunk: topography, departments, units, their connections.

The sympathetic trunks are a paired bundle of nerve fibers that run from the base of the
skull to the coccyx. Sympathetic ganglia can be divided into two major groups, paravertebral
and prevertebral, on the basis of their location within the body. Paravertebral ganglia
generally are located on each side of the vertebrae and are connected to form the sympathetic
chain, or trunk.

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The superior ganglion innervates viscera of the head, and the middle and stellate ganglia
innervate viscera of the neck, thorax, and upper limbs. The thoracic sympathetic ganglia
innervate the trunk region, and the lumbar and sacral sympathetic ganglia innervate the pelvic
floor and lower limbs. All the paravertebral ganglia provide sympathetic innervation to blood
vessels in muscle and skin, arrector pili muscles attached to hairs, and sweat glands.

482. White communicating branches: formation, topography.

The white rami communicantes is the preganglionic sympathetic outflow from the spinal
cord.
The cell bodies for the preganglionic sympathetic myelinated fibers in the white rami
communicantes lie in the ipsilateral intermediolateral cell column in the spinal cord which
extends from T1-L2 .

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483. Gray communicating branches: formation, topography.

Each spinal nerve receives a branch called a gray ramus communicans from the adjacent
paravertebral ganglion of the sympathetic trunk. The gray rami communicantes contain
postganglionic nerve fibers of the sympathetic nervous system and are composed of largely
unmyelinated neurons.

484. Cervical part of sympathetic trunk: ganglia, topography, sources of preganglionic

fibers.

The cervical ganglia are paravertebral ganglia of the sympathetic nervous system.
Preganglionic nerves from the thoracic spinal cord enter into the cervical ganglions and
synapse with its postganglionic fibers or nerves.

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485. Cervical part of sympathetic trunk: superior cervical ganglion, topography, sources
preganglionic fibers, branches, areas of innervation

The superior cervical ganglion is part of the autonomic nervous system (ANS) responsible
for maintaining homeostasis of the body. More specifically it is part of the sympathetic
nervous system, a division of the ANS most commonly associated with the fight or flight
response. The SCG also contributes to the cervical plexus. The cervical plexus is formed
from a unification of the anterior divisions of the upper four cervical nerves.Superior
cervical ganglion (largest) - adjacent to C2 & C3; postganglionic axon projects to
target: (heart, head, neck) via "hitchhiking" on the carotid arteries

486. Cervical part of sympathetic trunk: middle ganglion, topography, sources of

preganglionic fibers, branches, areas of innervation.

The middle cervical ganglion is the smallest of the three cervical ganglia, and is occasionally
absent. It is placed opposite the sixth cervical vertebra, usually in front of, or close to, the
inferior thyroid artery. It sends gray rami communicantes to the fifth and sixth cervical
nerves, and gives off the middle cardiac nerve.It is formed by the coalescence of two ganglia
corresponding to the fifth and sixth cervical nerves.middle cervical ganglion (smallest) -
adjacent to C6; target: heart, neck

Branches
1. Gray Rami Communicantes to the anterior rami of the fifth and sixth cervical nerves.

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 2. Thyroid Branches which pass along the inferior thyroid artery to the thyroid gland.
3. The middle cardiac branch, which descends in the neck and ends in the cardiac plexus
in the thorax

487. Cervical part of sympathetic trunk: Inferior cervical ganglion, topography, sources of
preganglionic fibers, branches, areas of innervation.

The inferior cervical ganglion is situated between the base of the transverse process of the
last cervical vertebra and the neck of the first rib, on the medial side of the costocervical
artery. inferior cervical ganglion. The inferior ganglion may be fused with the first thoracic
ganglion to form a single structure, the stellate ganglion. - adjacent to C7; target: heart,
lower neck, arm, posterior cranial arteries
The inferior cervical ganglion gives off two branches:
• The Inferior cardiac nerve
• offsets to bloodvessels form plexuses on the subclavian artery and its branches.

488. Thoracic part of sympathetic trunk: ganglia, the topography, sources preganglionic
fibers, branches, areas of innervation.

The thoracic portion of the sympathetic trunk typically has 12 thoracic ganglia. Emerging
from the ganglia are thoracic splanchnic nerves that help provide sympathetic innervation to
abdominal structures.

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489. Large, small and lowest splanchnic nerves: their formation, composition of fibers
topography

The splanchnic nerves are paired visceral nerves , carrying fibers of the autonomic nervous
system (visceral efferent fibers) as well as sensory fibers from the organs (visceral afferent
fibers). All carry sympathetic fibers except for the pelvic splanchnic nerves, which carry
parasympathetic fibers.
The term splanchnic nerves can refer to:
• Cardiopulmonary nerves
• Thoracic splanchnic nerves (greater, lesser, and least)
• Lumbar splanchnic nerves
• Sacral splanchnic nerves
• Pelvic splanchnic nerves
greater
The nerve travels through the diaphragm and enters the abdominal cavity, where its fibers
synapse at the celiac ganglia. The nerve contributes to the celiac plexus, a network of nerves
located in the vicinity of where the celiac trunk branches from the abdominal aorta.
lesser
The nerve travels inferiorly, lateral to the greater splanchnic nerve. Its fibers synapse with
their postganglionic counterparts in the superior mesenteric ganglia, or in the aorticorenal
ganglion.
lowest
The nerve travels into the abdomen, where its fibers synapse in the renal ganglia.

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490. Lumbar part of sympathetic trunk: ganglia, the topography, sources of preganglionic
fibers, branches, areas of innervation.

Branches;
splanchnic nerves,gray rami communicatnes

491. Sacral part of sympathetic trunk: ganglia, topography, sources of preganglionic

fibers, branches, areas of innervation

Sacral splanchnic nerves are splanchnic nerves that connect the inferior hypogastric plexus
to the sympathetic trunk in the pelvis
The sacral sympathetic nerves contain a mix of preganglionic and postganglionic sympathetic
fibers, but mostly postganglionic. They also contain visceral afferent fibers. They are found
in the same region as the pelvic splanchnic nerves, which arise from the sacral spinal nerves
to provide parasympathetic fibers to the inferior hypogastric plexus.
The sacral sympathetic nerves arise from the sacral part of the sympathetic trunk, emerging
anteriorly from the ganglia. They travel to their corresponding side's inferior hypogastric
plexus, where the preganglionic nerve fibers synapse with the postganglionic sympathetic
neurons, whose fibers ascend to the superior hypogastric plexus, the aortic plexus and the
inferior mesenteric plexus, where they are distributed to the anal canal. From the inferior
hypogastric plexus, they also innervate pelvic organs and vessels.

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492. Autonomic plexuses of the abdominal cavity: formation, topography, composition of
fibers, areas of innervation

Autonomic plexuses are formed from sympathetic and parasympathetic fibers that innervate
and regulate the overall activity of visceral organs.
The autonomic plexuses include the cardiac plexus, the pulmonary plexus, the esophageal
plexus, the abdonimal aortic plexus, and the superior and inferior hypogastric plexuses.
• Autonomic plexuses are formed from sympathetic postganglionic axons,
parasympathetic preganglionic axons, and some visceral sensory axons.
Plexuses provide a complex innervation pattern to the target organs, since most organs are
innervated by both divisions of the autonomic nervous system.

493. Abdominal aortic plexus: plexus secondary, the topography, composition of fibers,
ganglia, areas of innervation
•

The abdominal aortic plexus is formed by branches derived, on either side, from the celiac
plexus and ganglia, and receives filaments from some of the lumbar ganglia.
It is situated upon the sides and front of the aorta, between the origins of the superior and
inferior mesenteric arteries.From this plexus arise part of the spermatic, the inferior
mesenteric, and the hypogastric plexuses; it also distributes filaments to the inferior vena
cava.

494. Autonomic pelvic plexus: formation, topography, composition of fibers, areas of

innervation

Sacral and coccygeal plexuses:

The sacral and coccygeal plexuses are situated on the posterolateral wall of the pelvic cavity
and generally occur in the plane between the muscles and blood vessels. They are formed by
the ventral rami of S1 to Co, with a significant contribution from L4 and L5 which enter the
pelvis from the lumbar plexus Nerves from these mainly somatic plexuses contribute to the
innervation of the lower limb and muscles of the pelvis and perineum. Cutaneous branches
supply skin over the medial side of the foot, the posterior aspect of the lower limb, and most
of the perineum.

Sacral plexus:

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The sacral plexus on each side is formed by the anterior rami of S1 to S4, and the
lumbosacral trunk (L4 and L5). The plexus is formed in relation to the anterior surface of the
piriformis muscle, which is part of the posterolateral pelvic wall. Sacral contributions to the
plexus pass out of the anterior sacral foramina and ourse laterally and inferiorly on the pelvic
wall. The lumbosacral trunk, consisting of part of the anterior ramus of L4 and all of the
anterior ramus of L5, courses vertically into the pelvic cavity from the abdomen by passing
immediately anterior to the sacro-iliac joint.

Components and branches of the sacral and coccygeal plexuses:

Gray rami communicantes from ganglia of the sympathetic trunk connect with each of the
anterior rami and carry postganglionic sympathetic fibers destined for the periphery to the
somatic nerves. In addition, special visceral nerves ( pelvic splanchnic nerves) originating
from S2 to S4 deliver preganglionic parasympathetic fibers to the pelvic part of the
prevertebral plexus.

495. Inferior hypogastric plexus: topography, composition of fibers, areas of

innervation.

Within lesser pelvis, the superior hypogastric plexus split into left and right inferior
hypogastric plexuses, found laterally from the urinary bladder and the rectum. They also
comprise the ganglia and association branches. The inferior hypogastric plexus accepts the
sacral splanchnic nerves and the parasympathetic fibers from the sacral parasympathetic
nuclei. The inferior hypogastric plexus supplies the pelvic viscera via the respective plexuses:
- the superior rectal plexus
– the middle rectal plexus
– the inferior rectal plexus
– the visceral plexus
– the prostatic plexus
– deferential plexus
– uterovaginal plexus

496. Axillary artery: topography, parts, branches, areas of blood supply.

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Relations of the axillary artery:

The axillary artery is direct continuation of the subclavian artery. It is continuous with
the brachial artery. The upper boundary of the artery is assigned to the outer border of the
first rib: the lower border – to the inferior borders of the pectoralis major (anteriorly) and the
latissimus dorsi ( posteriorly ). The artery occupies the axillary fossa. There it descends
posteriorly and laterally from the axillary vein. The axillary artery neighbors the cords of
brachial plexus ( they run medially, laterally, and posteriorly from the vein. With respect to
triangles of axillary fossa, the artery is subdivided into three parts:

1) The part related to the clavipectoral triangle gives the following branches
- the superior thoracic artery is small branch that supplies the intercostal muscles in the first
and second intercostal spaces
- the thoaco-acromial artery , supplies the acromion ( the acromnion branche),the deltoid
muscle ( the deltoid branch ), and the pectoralis major ( the pectoral branches )
2) The part related the pectoral triangle gives:
- the lateral thoracic artery, it crosses the axillary vein anteriorly and descend along the
serratus anterior. Apart from the serratus anterior, it supplies the mammary glans ( the lateral
mammary branchs )
3) Within the subpectoral triangle, the artery givs branches as folows
- the subcapsular artery is the greatest branch of the axillary artery. It descends along the
inferior border of the subscapularis. The artery gives two termianl barnches
* the thoracodorsal artery , continues the way along the subscapularis. It supplies the
scapular muscles, the latissimus dorsi and the serratus anterior
* the circumflex scapular artery leaves the axillary fossa via the triangular opening and
reaches the posterior surface of scapula to supply related muscles. The artery anastomoses
with the suprascapularis artery (give the subclavian artery)
– the anterior circumflex humeral artery a small artery that rounds the surgical neck of
humerus anteriorly
– the posterior circumflex humeral artery a thicker one, it passes the quadrangular
opening together with the axillary nerve, rounds the surgical neck posteriorly and terminates
within the deltoid. It anastomoses with the anterior circumflex. Both circumflex arteries
supply neighboring muscles and shouder joint.

497. Brachial artery: topography, branches, areas of blood supply.

Relation of the brachial artery

The brachial artery is a direct continuation of the axillary artery. It joins the
neurovascaular bundle that runs along that runs along the medial bicipital groove. On

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reaching the cubital fossa, the artery gives rise to radial and ulnar arteries. The greates branch
of the brachail artery is the deep artery of the arm.
The deepartery of the arm ( profunda brachii artery ) arise from the upper portion of
the brachial artery. It descends posteriorly and enters the radial canal ( there it neighbors the
radial nerve ). It supplies the triceps brachii with numerous muscular branches. Apart from
this, it gives several terminal branches:

1) the middle collateral artey I the direct continuation of thr deep artery of arm. It
descends to the lateral epicondyle of humerus where ansatomoses with recurrent interosseus
artery.
2) The radial collateral artery also reaches the lateral epicondyle to anastomoses with
recurrent radial artery.
3) The humeral nutrient artery enters the nutrient foramen to supply the humerus

The ulnar collateral arteries arise on the medial aspect of arm:

1) the superior ulnar collateral artery arise from the brachial artery in it is middle third
and descends along the ulnar groove of humerous it anastomoses with the posterior branch of
thre recurrent ulnar artery
2) the inferior ulnar collateral artery arise from the brachial artery immidiately above
the medial epicondyle. It descends anteriorly to anastomoses with the anterior branch of the
same recurrent ulnar artery

The ulnar collateral arteries supply the brachial muscles and participate in formation
of the arterial network of elbow joint. Apart from this, the brachial artery gives several large
musculat branches, to the brachial muscles.

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498. Brachial artery: the deep artery of the arm, topography, branches, areas of blood
supply.

The deep artery of the arm ( profunda brachii artery ) arise from the upper portion of
the brachial artery. It descends posteriorly and enters the radial canal ( there it neighbors the
radial nerve ). It supplies the triceps brachii with numerous muscular branches. Apart from
this, it gives several terminal branches:

1) the middle collateral artey I the direct continuation of thr deep artery of arm. It
descends to the lateral epicondyle of humerus where ansatomoses with recurrent interosseus
artery.
2) The radial collateral artery also reaches the lateral epicondyle to anastomoses with
recurrent radial artery.
3) The humeral nutrient artery enters the nutrient foramen to supply the humerus

499. Radial artery: topography, branches, areas of blood supply.

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Relations of the radial artery

The radial artery occupies the radial groove of forearm together with paired venae
comitances and the superficial branch of radial nerve. There it gives numerous muscular
branches. In the lower portion of forearm, the artery is covered with skin and fascia only.
Here, pulsation of artery is palpable. Then the artery declines laterally, passes the “anatomical
snuffbox” and finally appears on the dorsal surface of hand. After that, the artery traverses the
muscles of first interossous space of hand and reaches the deep layers of palmar surface. Here
it gives rise to deep palmar arch.
Except for the muscular branches, the artery gives some terminal branches in the
forearm:

1) the recurrent radial artery arise from the beginning of artery. It ascend laterally to the
cuboidal fossa where anastomoses with the radial collateral artery ( given by the deep artery
of arm )
2) the superficial palmar branch a thin branch that arises next to the radial styloid
process. On the palmar surface of hand it joins the ulnar artery from the superficial palmar
arch
3) the palmar carpal branch becomes evident in the distal portion of foramen. It
anastomoses with a branch of the ulnar artery participitating thus information of palmar
carpal network
4) the dorsal carpal branch passes the “ anatomical snuffbox “ and appears on the dorsal
surface of foramen. It joins the dorsal carpal arch.

500. Ulnar artery: topography, branches, areas of blood supply.

Relations of the ulnar artery

The ulnar artery is the greater branch of the brachial artery. From the origination
point, the artery descends medially, traverses the pronator teres and enters the ulnar groove in
the lower half of the forearm. Then it descends to the wrist joint together with the ulnar nerve
and reaches the hand on passing through the flexor retinaculum. On reaching the middle of
hand, it declines laterally to become continous with the superficial palmar arch.

This artery give off the branches:

1) the ulnar recurrent artery arises from the beginning of main trunk and ascends to the
median epicondyle. There it splits into the anterior and posterior branches which
anastomosis with the superior and inferior ulnar collateral arteries
2) the common interosseus artery a short branch that gives the anterior and posterior
interosseous arteries:
1. the anterior interosseous artery runs along the anterior surface of interosseous
membrane. On reaching the pronator quadratus, the artery penetrates the membrane and

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terminates at the dorsal carpal arch. Before entering the dorsal surface of hand it gives off the
palmar branch
2. the posterior interosseouos artery penetrates the interosseous mambrane immediately
upon origination. The arteries gives the recurrent interosseous artery, that anastomoses with
the middle collateral artery

501. Elbow arterial network: formation, topography, areas of blood supply

Brachial artery The major artery of the arm, the brachial artery, is found in the anterior
compartment (Fig. 7.66). Beginning as a continuation of the axillary artery at the lower
border of the teres major muscle, it terminates just distal to the elbow joint where it divides
into the radial and ulnar arteries. In the proximal arm, the brachial artery lies on the medial
side. In the distal arm, it moves laterally to assume a position midway between the lateral
epicondyle and the medial epicondyle of the humerus. It crosses anteriorly to the elbow joint
where it lies immediately medial to the tendon of the biceps brachii muscle. The brachial
artery is palpable along its length. In proximal regions, the brachial artery can be compressed
against the medial side of the humerus. Branches of the brachial artery in the arm include
those to adjacent muscles and two ulnar collateral vessels, which contribute to a network of
arteries around the elbow joint. Additional branches are the profunda brachii artery and
nutrient arteries to the humerus, which pass through a foramen in the anteromedial surface of
the humeral shaft. There are also Branches of the profunda brachii artery which supply
adjacent muscles and anastomose with the posterior circumflex humeral artery. The artery
terminates as two collateral vessels, which contribute to an anastomotic network of arteries
around the elbow joint.

502.Superficial palmar arch: formation, topography, branches, areas of blood supply.

The superficial palmar arch resides below the palmar aponeurosis and above the
tendons of flexors. The arch is formed of the terminal portion of the ulnar artery and the small
branch of the radial artery ( the superficial palmar branch ). The latter branch may be absent.
In this case, the arch appears to be open. The arch give off the common palmar digital
arteries, that neighbor the lumbricals. A next to proximal phalange base, each common artery
gives two proper palmar digital arteries. They run along adjacent aspect of the fingers 2
through 5. the artery to the ulnar aspect of the small finger arteries directly from the ulnar
artery

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503. Deep palmar arch: formation, topography, branches, areas of blood supply

The deep palmar arch is formed of the terminal portion of radial artery and the deep
palmar branch of the ulnar artery. The arch resides deep below the tendons of flexors of
fingers, on the bases of metacarpal bones. The deep palmar arch gives three palmar
metacarpal arteries. They run along the interosseous muscles to reach the common palmar
digital arteries ( around the bases of proximal phalanges ). apart from this they anastomoses
with the dorsal metacarpal arteries by means of perforating branches.

504. Dorsal carpal rete: formation, topography, branches, areas of blood supply.

The dorsal carpal arch resides on the dorsal surface of hand below the extensors
tendons. The arch receives the dorsal carpal branch from the radial artery. Except for the
branch mentioned, the arch receives the carpal branch from the ulnar artery and the endings
of the interosseous arteries. The arch gives rise to the dorsal metacarpal arteries, which run
along the interosseous spaces. On reaching the fingers, they split into thin dorsa digital
arteries.

505. Palmar carpal rete: formation, topography, areas of blood supply.

The palmar carpal arch resides next to the wrist joint and the carpal bones. The arch
receives the palmar carpal branch. The palmar carpal branches given by the radial and the
anterior interosseous arteries also participate in formation of the arch. The arch anastomoses
with the deep palmar arch.

506. Arterial anastomoses of the hand.

1) the palmar carpal branch anastomoses with branch of the ulnar artery participitating
thus in formation of palmar carpal network
2) three palmar metacarpal arteries anastomoses with the dorsal metacarpal arteries by
means of perforating branches
3) anterior and posterior branches, which anastomose with the superior and inferior ulnar
collateral arteries.

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4) The recurrent interosseous artery anastomoses with the middle collateral artery
5) the palmar carpal arch anastomoses with the deep palmar arch

507. The veins of the upper limb: classification. Superficial veins: the topography, areas
to the confluence of the veins. Anastomosis between the superficial veins,
508. The veins of the upper limb: classification. Deep veins, the topography, feature the
location on the hand, forearm and arm.

Superficial veins The major superficial veins of the upper limb are the cephalic and basilic
veins. As their name suggests, they are located within the subcutaneous tissue of the upper
limb. The basilic vein originates from the dorsal venous network of the hand. It ascends the
medial aspect of the upper limb. At the border of the teres major, the vein moves deep into
the arm. Here, it combines with the brachial veins to form the axillary vein. The cephalic vein
arises from the dorsal venous network of the hand. It ascends the antero-lateral aspect of the
upper limb, passing anteriorly at the elbow. At the shoulder, the cephalic vein travels between
the deltoid and pectoralis major muscles (known as the deltopectoral groove), and enters the
axilla region via the clavipectoral triangle. Within the axilla, the cephalic vein terminates by
joining the axillary vein. Deep veins The deep veins of the upper limb are situated underneath
the deep fascia. They are paired veins that accompany and lie either side of an artery. The
brachial veins are the largest in size, and are situated either side of the brachial artery. The
pulsations of the brachial artery assists the venous return. Veins that are structured in this way
are known as vena comitantes. Perforating veins run between the deep and superficial veins
of the upper limb, connecting the two systems.

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509. Axillary artery: topography, branches

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Relations of the axillary artery:
The axillary artery is the direct continuation of the subclavian artery. It is continuous
with the brachial artery. The upper boundary of the artery is assigned to the outer border of
the first rib. The lower border – to the inferior borders of the pectoralis major ( anteriorly )
and the latissimus dorsi ( posteriorly ). the arterise occupies the axillary fossa. There it
descends posteriorly and laterally from the axillary vein. The axillary artery neighbors the
cords of brachial plexus ( they run medially, laterally, posteriorly from the vien ). with
respeact to triangles of axillary fossa, the artery is subdivided into three parts.
The part related to clavipectoral triangle gives the following branches
1) the superioe thoracic artery is a small branch that supplies the intercostal muscle in
the first and second intercostal space
2) the thoraco-acromial artery supplies the acromian , the deltoid muscle and the
pectoralis major
The part related to the pectoral triangle gives
1) the lateral thoracic artery it crosses the axillary vein anteriorly and descend along the
serratus anterior. Apart from serrartus anterior, it supplies the mammary gland
Within the subpectoral triangle the artery gives the branches as follows
1) the subcapsular artery it is a greatest branch. It descends along the inferior border of
the subcapsularis. The artery gives two terminal branches
1. the thoracodorsal artery supplies the scapular muscle the latissimus dorsi ans serratus
anterior
2. the circumflex scapular artery the artery anastomoses with the suprascapular artery.
2) The anterior circumflex humeral artery a small artery that rounds the surgical neck of
humerous anteriorly
3) the posterior circumflex humeral artery a thick one, it passes the quadrangular
opening.

510. Lymphatic vessels and lymph nodes of the superior extremity.

Lymph from the upper limb flows within the superficial and deep lymph vessels that
reach the cubital and axillary lymph nodes.
The superficial lymph vessel from lateral, medial and middle groups that drain skin
and subcutaneous fat:
1) the lateral lymph vessel drain the fingers 1 through 3 and the lateral aspect od hand,
forearm and arm. These vessels run along the cephalic vein and terminate at the axillary
nodes
2) the medial lymph vessel drain the medial finhers 4 through 5 an medial aspect of

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wrist, forearm and arm. These vessel run along the antero-medial side of upper limb and
terminate at the cubital and axillary nodes
3) the middle lymph vessels drain the anterior surface of wrist and forearm. The vessels
ascend along the median cubital vein to reach the cubital and axillary nodes
The deep lymph vessels are responsible for drainage of the muscles, tendons, fasciae,
joint capsule, ligaments, periosteum and nerves. These vessels accompany great blood vessels
of upper limb. Some vessels reach the cubital nodes yet majority of vessels reach the axillary
nodes.
The lymph nodes of upper limb, joint into two groups -the cubital and axillary nodes.
The cubital nodes occupy the cubital fossa. They are subdivided into the superficial
and deep nodes. The superficial nodes reside outside the superficial fascia and deep nodes
resides deeper. The cubital nodes receive certain portion of lymph fro hand and forearm.
Their efferent vessels pass to the axillary nodes.
The axillary lymph nodes are the principal regional lymph nodes of thr upper limb.
They are embedded into the axillary fat and from 6 groups around the neurovascular bundle:
the lateral nodes, the medial nodes, the central nodes, the posterior nodes, the anterior nodes.
In this region,one can also see the interpectoral nodes and the deltopectoral nodes.
All nodes listed anastomose via the lymph vessles. The axillary nodes drain the upper
limbs, breats, thoracic walls and back. The efferent vessels give rise to the subclavian trunks.
The right subclavian trunk joins the right lymphatic duct or any vein of the right venous
angle. The left subclavian trunk joins the ccervical part of thoracic duct or any vein of the left
venous angle.

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511. The external iliac artery: formation, topography, branches, areas of blood supply.

Relations of the external iliac artery

The external iliac artery descends on the medial aspect of the psoas major and quits
the lesser pelvis via the vascular space. Within the femoral triangle, the artery continuous
with the femoral artery. The external iliac artery gives the branches as follows:
1) the inferior epigastric artery arise from the main trunk above the inguinal ligament
and then ascends medially along the internal surface of the anterior abdominal wall
occupying the lateral umbilical ligament. Then the artery enters the rectus sheath and ascend
along its posterior surface to reach the umbilical ring. Here it anastomoses with the superior
hypogastric. In the beginning the artery gives off anastomotic branch to the obturator artery.
2) The deep circumflex iliac artery runs laterally along the inguinal ligament and the
iliac crest. It supplies the iliacus and the muscle of abdominal walls

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512. Femoral artery: topography, branches, areas of blood supply,
513. Femoral artery: the deep femoral artery, topography, branches, areas of blood
supply.

The main artery of the lower limb is femoral artery. It is a continuation of the external iliac
artery (terminal branch of the abdominal aorta). The external iliac becomes the femoral artery
when it crosses under the inguinal ligament and enters the femoral triangle.
In the femoral triangle, the profunda femoris artery arises from the posterolateral aspect of
the femoral artery. It travels posteriorly and distally, giving off three main branches:
• Perforating branches – Consists of three or four arteries that perforate the adductor
magnus, contributing to the supply of the muscles in the medial and posterior thigh.
• Lateral femoral circumflex artery – Wraps round the anterior, lateral side of the
femur, supplying some of the muscles in the lateral side of the thigh.
• Medial femoral circumflex artery – Wraps round the posterior side of the femur,
supplying the neck and head of the femur. In a fracture of the femoral neck, this artery
can easily be damaged, and avascular necrosis of the femur head can occur.

After exiting the femoral triangle, the femoral artery continues down the anterior surface of
the thigh, via a tunnel known as the adductor canal. During its descent the artery supplies
the anterior thigh muscles.
The adductor canal ends at an opening in the adductor magnus, called the adductor hiatus.
The femoral artery moves through this opening, and enters the posterior compartment of the
thigh, proximal to the knee. The femoral artery now known as the popliteal artery.

The deep artery of the thigh, (profunda femoris artery or deep femoral artery) is a branch of
the femoral artery that, as its name suggests, travels more deeply (posteriorly) than the rest
of the femoral artery.

The deep artery of the thigh gives off the following branches:
• Lateral circumflex femoral artery
• Medial circumflex femoral artery
• Perforating arteries - perforate the adductor magnus muscle to the posterior and
medial compartments of the thigh.

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514. Popliteal artery: topography, branches, areas of blood supply.

The popliteal artery descends down the posterior thigh, giving off genicular branches that
supply the knee joint. It moves through the popliteal fossa, exiting sandwiched between the
gastrocnemius and popliteus muscles. At the lower border of the popliteus, the popliteal
artery terminates by dividing into anterior and posterior tibial arteries.
The posterior tibial artery continues inferiorly, along the surface of the deep muscles (such
as tibialis posterior). It accompanies the tibial nerve in entering the sole of the foot via
thetarsal tunnel. During the descent of the posterior tibial artery in the leg, the fibular
arteryarises. This artery moves laterally, penetrating the lateral compartment of the leg. It
supplies muscles in the lateral compartment, and adjacent muscles in the posterior
compartment.
The other division of the popliteal artery, the anterior tibial artery, passes anteriorly between
the tibia and fibula, through a gap in the interosseous membrane. It then moves inferiorly
down the leg. It runs down the entire length of the leg, and into the foot, where it becomes the
dorsalis pedis artery.

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515. Anterior tibial artery: topography, branches, areas of blood supply.

The structure indicated is the anterior tibial artery of the leg.

The anterior tibial artery is a branch of the popliteal artery, which supplies the anterior
compartment of the leg. The popliteal artery arises from the superficial femoral artery as it
passes from the anterior compartment of the thigh to the posterior compartment via the
adductor hiatus – an opening in the distal adductor magnus muscle. The popliteal artery gives
rise to two branches, the anterior tibial artery and the posterior tibial artery. The anterior tibial
artery passes through an opening superiorly in the interosseous membrane between the tibia
and the fibula.
The anterior tibial artery descends the length of the leg, accompanied by the tibial vein, and
becomes the dorsal pedis artery on the dorsal surface of the foot.
The anterior tibial artery has the following branches:

• Anterior tibial recurrent artery

• Posterior tibial recurrent artery
• Anterior medial malleolar artery
• Anterior lateral malleolar artery
• Muscular branches
• Perforating branches

516. Posterior tibial artery: topography, branches, areas of blood supply,

517. Posterior tibial artery: peroneal artery, topography, branches, areas of blood
supply

Theposterior tibial arterybegins at the lower border of the Popliteus, opposite the interval
between the tibia and fibula; it extends obliquely downward, and, as it descends, it
approaches the tibial side of the leg, lying behind the tibia, and in the lower part of its course
is situated midway between the medial malleolus and the medial process of the calcaneal
tuberosity. Here it divides beneath the origin of the Adductor hallucis into the medial and
lateral plantar arteries.

Branches.—The branches of the posterior tibial artery are:

Peroneal. Posterior Medial Malleolar.

Nutrient. Communicating.
Muscular. Medial Calcaneal.

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The peroneal artery (a. peronæa) is deeply seated on the back of the fibular side of the leg.
It arises from the posterior tibial, about 2.5 cm. below the lower border of the Popliteus,
passes obliquely toward the fibula, and then descends along the medial side of that bone,
contained in a fibrous canal between the Tibialis posterior and the Flexor hallucis longus, or
in the substance of the latter muscle. It then runs behind the tibiofibular syndesmosis and
divides into lateral calcaneal branches which ramify on the lateral and posterior surfaces of
the calcaneus.
It is covered, in the upper part of its course, by the Soleus and deep transverse fascia of the
leg; below, by the Flexor hallucis longus.

Branches.—The branches of the peroneal are:

Muscular. Perforating.
Nutrient. Communicating.
Lateral Calcaneal.

518. Arterial network of knee: formation, topography, areas of blood supply.

Discussion: - blood supply to skin around the knee is random (as opposed to axial) - there are
multiple small overlapping vessels that are interrupted by multiple small incisions; - random
supply is sustained by both intrinsic and extrinsic sources; - intrinsic contributors to skin
overlying knee are perforationg branches of the superior and inferior genicular systems; -
extrinsic supply: 3 sources; - descending genicular (supreme genicular artery) branch of
superficial femoral artery - arises superomedial to the knee from SFA; - after sending
saphenous branch inferiorly, SGA heads into VM and sends perforators to overlying skin thru
musculocutaneous insertion of VM into patella; - recurrent branch of anterior tibial artery; -
emerges from anterior tibial artery as it perforates interosseous foramen; - this branch passes
superiorly and in the direction of patellar tendon, supplying the skin overlying patellar
tendon; - descending branch of the lateral femoral circumflex artery; - one of the major
communications between deep and superficial femoral systems of the leg; - it travels down
fascia lata & sends multiple perforators to skin overlying fascia lata & lateral aspect of knee;
- Anatomy: - middle genicular - arises approximately at the level of the joint line and passes
anteriorly to pierce the oblique popliteal ligament and posterior joint capsule; - traverses the
posterior joint capsule at level of intercondylar notch; - supplies the ACL and PCL -
references: - Anatomic study of the middle genicular artery. - Vascular anatomy of the human
cruciate ligaments and surrounding structures. - medial superior genicular - lies anterior to the
semimembranous & semitendinosus muscles; - medial inferior genicular - passes underneath
origin of gastrocnemius, located at the superior surface of the popliteus muscle and passes
around medial aspect of proximal tibia, passes deep to the superficial MCL to reach front of
knee, 2 cm distal to joint; - anastomosis w/ the saphenous branch of the descending genicular

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branch; - anastomosis w/ anterior tibial recurrent - references: - Arteriovenous fistula with
false aneurysm of the inferior medial geniculate artery. A complication of total knee
arthroplasty. - Traumatic aneurysm of the inferior lateral geniculate artery after total knee
replacement - lateral superior genicular - anastomosis w/ the descending branch of LCFA; -
references: - Therapeutic embolization for the treatment of recurrent hemarthrosis after total
knee arthroplasty due to an arteriovenous fistula - False aneurysm of the superior lateral
geniculate artery following total knee replacement - lateral inferior genicular - anastomosis
w/ anterior tibial recurrent artery; - passes underneath origin of gastrocnemius to reach front
of knee - passes deep to lateral collateral ligament at level of the joint (passing superficial to
the popliteus tendon); - passes over the lateral limb of the arcuate ligament and popliteal
musculotendinous junction and the lateral meniscus; - references: - Recurrent hemarthrosis
after total knee arthroplasty - Persistent haemarthrosis following total knee arthroplasty
caused by unrecognised arterial injury - descending branch of lateral circumflex femoral; -
descending genicular branch of the femoral artery; - recurrent vessels: - anterior tibial - ref:
Atraumatic haemarthrosis following total knee replacement treated with selective
embolisation. - posterior tibial (posterior tibial recurrent) - circumflex fibular - (anterior tibial
recurrent)

519. Medial malleolar network: formation, topography, areas of blood supply, 520.
Lateral malleolar network: formation, topography, areas of blood supply.

The arteries around the ankle-joint anastomose freely with one another and form net-works
below the corresponding malleoli. The medial malleolar net-work is formed by the anterior
medial malleolar branch of the anterior tibial, the medial tarsal branches of the dorsalis pedis,
the posterior medial malleolar and medial calcaneal branches of the posterior tibial and
branches from the medial plantar artery. The lateral malleolar net-work is formed by the
anterior lateral malleolar branch of the anterior tibial, the lateral tarsal branch of the dorsalis
pedis, the perforating and the lateral calcaneal branches of the peroneal, and twigs from the
lateral plantar artery.

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521. Plantar medial artery: formation, topography, branches, areas of blood supply.

Supply:
Superficial branch:
Medial side of the first toe
Deep branch:
Adductor hallucis muscle
Flexor hallucis brevis muscle
・Course:
The Posterior tibial artery divides into the medial and the Lateral plantar artery.
The Medial plantar artery runs forward along the Medial plantar nerve on the medial side of
the foot, and divides into a superficial and a deep branch.

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The Superficial branch runs forward and medialward to supply the medial side of the first toe.
The deep branch runs forward deep to the adductor hallucis muscle, lateral to the lateral head
of the flexor hallucis brevis muscle to join the first plantar metatarsal artery.
・Source:
Posterior tibial artery
・Branches:
Superficial branch
Deep branch

522. Plantar lateral artery: formation, topography, branches, areas of blood supply

Lateral plantar artery

• branch off the posterior tibial artery

• larger calibre vessel
• crosses the sole obliquely towards the base of the fifth metatarsal bone
• gives off cutaneous branches that perforate the plantar aponeurosis between flexor
digitorum brevis and abductor digiti minimi
• gives off a superficial branch that follows its respective nerve
• continues as a deep trunk to form the plantar arch

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523. Dorsal pedis artery: formation, topography, branches, areas of blood supply.

Carries oxygenated blood to the dorsalsurface of the foot. It arises at the anterior aspect of
the ankle joint and is a continuation of the anterior tibial artery. It terminates at the proximal
part of the first intermetatarsal space, where it divides into two branches, the first dorsal
metatarsal arteryand the deep plantar artery. The dorsalis pedis communicates with the
plantar blood supply of the foot through the deep plantar artery.

1. Medial plantar artery

branch off the posterior tibial artery

smaller calibre vessel

supplies the medial side of the foot, abductor hallucis and flexor digitorum brevis.

provides the arterial digital supply to the big toe

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 gives off cutaneous branches that perforate the plantar aponeurosis between
abductor hallucis and flexor digitorum brevis

Lateral plantar artery

● branch off the posterior tibial artery

● larger calibre vessel

● crosses the sole obliquely towards the base of the fifth metatarsal bone

● gives off cutaneous branches that perforate the plantar aponeurosis

between flexor digitorum brevis and abductor digiti minimi

● gives off a superficial branch that follows its respective nerve

● continues as a deep trunk to form the plantar arch

Plantar arch

● anastomosis of the lateral plantar artery and dorsalis pedis artery

● only arterial plantar arch in the foot

● lies in the neurovascular plan deep to the plantar aponeurosis, superficial to

the long tendons (between the first and second anatomical layers)

● travels across the bases of the fourth, third, and second metatarsals

● joins the dorsalis pedis artery in the proximal part of the first intermetatarsal space

525.The Superficial Veins of the Lower Limb

The superficial veins of the lower limb run in the subcutaneous tissue. There are two major
superficial veins – the great saphenous vein, and the small saphenous vein.

The Great Saphenous Vein

The great saphenous vein is formed by the dorsal venous arch of the foot, and the dorsal
vein of the great toe. It ascends up the medial side of the leg, passing anteriorly to the
medial malleolusat the ankle, and posteriorly to the medial condyle at the knee.

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As the vein moves up the leg, it receives tributaries from other small superficial veins.
The great saphenous vein terminates by draining into the femoral vein immediately
inferior to theinguinal ligament.

The Small Saphenous VeinThe small saphenous veinis formed by the dorsal venous arch
of the foot, and the dorsal vein of the little toe. It moves up the posterior side of the leg,
passing posteriorly to the lateral malleolus, along the lateral border of the calcaneal tendon.
It moves between the two heads of the gastrocnemius muscle and empties into the popliteal
veinin the popliteal fossa.

526. The great saphenous vein originates from where the dorsal vein of the big toe(the
Hallux) merges with the dorsal venous arch of the foot. After passing in front of the medial
malleolus (where it often can be visualized and palpated), it runs up the medialside of the
leg. At the knee, it runs over the posterior border of the medial epicondyleof the femur
bone. The GSV then courses anteriorly to lie on the anterior surface of the thigh before
entering an opening in the fascia latacalled the saphenous opening. It forms an arch, the
saphenous arch, to join the common femoral veinin the region of the femoral triangleat the
sapheno-femoral junction.

527.The Deep Veins of the Lower Limb

The deep venous drainage system of the lower limb is located beneath the deep fascia of the
lower limb. As a general rule, the deep veins accompany and share the name of the major
arteries in the lower limb. Often, the artery and vein are located within the same vascular
sheath– so that the arterial pulsations aid the venous return.

The Foot and Leg

The main venous structure of the foot is the dorsal venous arch, which mostly drains into
the superficial veins. Some veins from the arch penetrate deep into the leg, forming the
anterior tibial vein.

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 Fig 1.0 – Overview of the deep veins of the lower limb.

On the plantar aspect of the foot, medial and lateralplantar veins arise. These veins
combine to form the posterior tibialand fibularveins. The posterior tibial vein
accompanies the posterior tibial artery, entering the leg posteriorly to the medial
malleolus.

On the posterior surface of the knee, the anterior tibial, posterior tibial and fibular veins
unite to form the popliteal vein. The popliteal vein enters the thigh via the adductor canal.

The Thigh

Once the popliteal vein has entered the thigh, it is known as the femoral vein. It is situated
anteriorly, accompanying the femoral artery.

The deep vein of the thigh (profunda femoris vein) is the other main venous structure in the
thigh. Via perforating veins, it drains blood from the thigh muscles. It then empties into the
distal section of the femoral vein.

The femoral vein leaves the thigh by running underneath the inguinal ligament, at which
point it is known as the external iliac vein.

The Gluteal Region

The gluteal region is drained by inferiorand superior glutealveins. These empty into the
internal iliacvein.

528 - 529 . LYMPHATIC VESSELS AND NODES OF HEAD & NECK

The lymphatic vessels of the head and neck can be divided into two major groups;
superficial vessels and deep vessels.

Superficial Vessels

The superficial vessels drain lymph from the scalp, face and neck into the superficial
ringof lymph nodes at the junction of the neck and head.

Deep Vessels

The deep lymphatic vessels arise from the deep cervical lymph nodes.They converge to

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form the left and right jugular lymphatic trunks:

● Left jugular lymphatic trunk– joins the thoracic duct at the root of the neck.
● Right jugular lymphatic trunkempties into the right lymphatic duct at the root of
the neck.

Lymph Nodes

The lymph nodes of the head and neck can be divided into two groups; a superficial ring of
lymph nodes, and a vertical group of deep lymph nodes.

Superficial Lymph Nodes

The superficial lymph nodes of the head and neck receive lymph from the scalp, face and
neck. They are arranged in a ring shape;extending from underneath the chin, to the
posterior aspect of the head. They ultimately drain into the deep lymph nodes.

● Occipital:There are usually between 1-3 occipital lymph nodes. They are
located in the back of the head at the lateral border of the trapezius muscle and
collect lymph from the occipital area of the scalp.

● Mastoid:There are usually 2 mastoid lymph nodes, which are also called the post-
auricular lymph nodes. They are located posterior to the ear and lie on the
insertion of the sternocleidomastoid muscle into the mastoid process. They collect
lymph from the posterior neck, upper ear and the back of the external auditory
meatus (the ear canal).

● Pre-auricular:There are usually between 1-3 pre-auricular lymph nodes. They

are located anterior to the auricle of the ear, and collect lymph from the
superficial areas of the face and temporal region.

● Parotid:The parotid lymph nodes are a small group of nodes located superficially
to the parotid gland. They collect lymph from the nose, the nasal cavity, the
external acoustic meatus, the tympanic cavity and the lateral borders of the orbit.
There are also parotid lymph nodes deep to the parotid gland that drain the nasal
cavities and the nasopharynx.

● Submental:These lymph nodes are located superficially to the mylohoid

muscle. They collect lymph from the central lower lip, the floor of the mouth
and the apex of the tongue.

● Submandibular:There are usually between 3-6 submandibular nodes. They are

located below the mandible in the submaxillary triangle and collect lymph from
the cheeks, the lateral aspects of the nose, upper lip, lateral parts of the lower

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 lip, gums and the anterior tongue. They also receive lymph from the submental
and facial lymph nodes.

● Facial:This group comprises the maxillary/infraorbital, buccinator and

supramandibular lymph nodes. They collect lymph from the mucous
membranes of the nose and cheek, eyelids and conjunctiva.

● Superficial Cervical:The superficial cervical lymph nodes can be divided into the
superficial anterior cervical nodes and the posterior lateral superficial cervical
lymph nodes. The anterior nodes lie close to the anterior jugular vein and collect
lymph from the superficial surfaces of the anterior neck. The posterior lateral
nodes lie close to the external jugular vein and collect lymph from superficial
surfaces of the neck.

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Fig 1 – The superficial and deep lymph nodes of the head and neck.

Deep Lymph Nodes

The deep (cervical) lymph nodes receive all of the lymph from the head and neck – either
directly or indirectly via the superficial lymph nodes. They are organised into a vertical
chain, located within close proximity to the internal jugular vein within the carotid
sheath. The efferent vessels from the deep cervical lymph nodes converge to form the
jugular lymphatic trunks.

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The nodes can be divided into superiorand inferiordeep cervical lymph nodes. They are
numerous in number, but include the prelaryngeal, pretracheal, paratracheal,
retropharyngeal, infrahyoid, jugulodigastric (tonsilar), jugulo-omohyoid and supraclavicular
nodes.

530. Lymphatic Vessels

Superficial Lymphatic Vessels

The superficial lymphatic vessels of the upper limb initially arise from lymphatic
plexuses in the skin of the hand (networks of lymphatic capillaries beginning in the
extracellular spaces). They then ascend up the arm, in close proximity to the major
superficial veins:

213. The vessels shadowing the basilic veingo on to enter the cubital lymph
nodes. These are found medially to the vein, and proximally to the medial
epicondyle of the humerus. Vessels carrying on from these nodes then continue
up the arm, terminating in the lateral axillary lymph nodes.
214. The vessels shadowing the cephalic veingenerally cross the proximal part of
the arm and shoulder to enter the apical axillary lymph nodes, though some
exceptions instead enter the more superficial deltopectoral lymph nodes.

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Fig 1 – The lymphatic vessels of the hand. They give converge to produce th
superficialymphatic vessels of the upper limb.

Deep Lymphatic Vessels

The deep lymphatic vessels of the upper limb follow the major deep veins (i.e. radial, ulnar
and brachial veins), terminating in the humeral axillary lymph nodes. They function to
drain lymph from joint capsules, periosteum, tendons and muscles. Some additional lymph
nodes may be found along the ascending path of the deep vessels.

Lymph Nodes

The majority of the upper lymph nodes are located in the axilla. They can be divided
anatomically into 5 groups:

● Pectoral (anterior)– 3-5 nodes, located in the medial wall of the axilla. They
receive lymph primarily from the anterior thoracic wall, including most of the
breast.
● Subscapular (posterior)– 6-7 nodes, located along the posterior axillary fold
and subscapular blood vessels. They receive lymph from the posterior thoracic
wall and scapular region.

● Humeral (lateral)– 4-6 nodes, located in the lateral wall of the axilla,
posterior to the axillary vein. They receive the majority of lymph drained
from the upper limb.

● Central– 3-4 large nodes, located near the base of the axilla (deep to pectoralis
minor, close to the 2nd part of the axillary artery). They receive lymph via
efferent vessels from the pectoral, subscapular and humeral axillary lymph node
groups.

● Apical– Located in the apex of the axilla, close to the axillary vein and 1st part of
the axillary artery. They receive lymph from efferent vessels of the central
axillary lymph nodes, therefore from all axillary lymph node groups. The apical
axillary nodes also receive lymph from those lymphatic vessels accompanying
the cephalic vein.

Efferent vessels from the apical axillary nodes travel through the cervico-axillary canal,
before converging to form the subclavian lymphatic trunk . The right subclavian trunk
continues to form the right lymphatic duct, and enters the right venous angle (junction
of internal jugular and subclavian veins) directly. The left subclavian trunk drains

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directly into the thoracic duct.

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531. Lymphatic Vessels

The lymphatic vessels of the lower limb can be divided into two major groups; superficial
vessels and deep vessels. Their distribution is similar to the veins of the lower limb.

Superficial Lymphatic Vessels

The superficial vessels can be divided into two major subsets; (i) medial vessels, which
closely follow the course of the great saphenous vein and; (ii) lateral vessels which are
more closely associated with the small saphenous vein.

Medial Vessels

The medial group originate on the dorsal surface of the foot. They travel up the anterior
and posterior aspects of the medial lower leg, with the great saphenous vein, passing with
it behind the medial condyleof the femur. This group of vessels ends in the groin, draining
into the sub inguinal group of the inguinal lymph nodes.

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Lateral Vessels

The lateral vessels arise from the lateral surface of the foot and either accompany the
small saphenous veinto enter the popliteal nodes,or ascend in front of the leg and cross
just below the knee joint to join the medial group.

Deep Lymphatic Vessels

These are far fewer in number than their superficial counterparts and accompany the deep
arteries of the lower leg. They are found in 3 main groups: anterior tibial, posterior tibia
land peronealfollowing the corresponding artery respectively, and entering the popliteal
lymph nodes.

Fig 1 – The superficial and sub-inguinal lymph nodes.

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Inguinal Nodes

The inguinal nodes are found in the upper aspect of the femoral triangleand are 1—20
in number.

They are subdivided into 2 groupings determined by their position relative to a horizontal
line drawn at the level of termination of the great saphenous vein. Those below this line are
the sub-inguinal nodes(consisting of a deep and superficial set) and those above are the
superficial inguinal nodes.

Superficial Inguinal Nodes

These form a line directly below the inguinal ligament and receive lymph from the penis,
scrotum, perineum, buttock and abdominal wall.

Superficial Sub-Inguinal Nodes

These are located on each side of the proximal section of the great saphenous vein.They
receive afferent input primarily from the superficial lymphatic vessels of the lower leg.

Deep Sub-Inguinal Nodes

These are often found in one to three in number and are most commonly found on the
medialaspect of the femoral vein.The afferent supply to these nodes is from the deep
lymphatic trunks of the thigh which accompany the femoral vessels.

Popliteal Nodes

The popliteal lymphatic nodes are small in size, usually between five and seven in number,
and are often found imbedded in fat reserves in the popliteal fossa. They receive lymph from
the lateral superficial vessels.

The efferent vesselsof the popliteal nodes pass almost entirely alongside the femoral
vessels to empty into the deep inguinal nodes.However, some will accompany the great
saphenous veinand drain into the sub-inguinal nodes.

532. It begins at the adductor canal(also known as Hunter's canal) and is a continuation of
the popliteal vein. It ends at the inferior margin of the inguinal ligament, where it becomes
the external iliac vein.

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533.The peripheral nervous system(PNS) is the part of the nervous systemthat consists of
the nerves and gangliaoutside of the brain and spinal cord. [1]The main function of the PNS
is to

connect the central nervous system(CNS) to the limbs and organs, essentially serving as a
communication relay going back and forth between the brain and spinal cord with the rest of
the
body. [2]Unlike the CNS, the PNS is not protected by the bone of spine and skull, or by the

blood–brain barrier, which leaves it exposed to toxinsand mechanical injuries. The

peripheral nervous system is mainly divided into the somatic nervous systemand the
autonomic nervous system.

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534. Spinal nerve: formation, topography, branches, conformity segments of the
spinal cord.

A spinal nerve is a mixed nerve, which carries motor, sensory, and autonomic signals
between the spinal cord and the body. In the human there are 31 pairs of spinal nerves, one
on each side of the vertebral column. These are grouped into the
corresponding cervical, thoracic, lumbar, sacral and coccygeal regions of the spine. There
are 8 pairs of cervical nerves, 12 pairs of thoracic nerves, 5 pairs of lumbar nerves, 5 pairs
of sacral nerves, and 1 pair of coccygeal nerves. The spinal nerves are part of
the peripheral nervous system.

Each spinal nerve is formed from the combination of nerve fibers from
its posterior and anterior roots. The posterior root is the afferent sensory root and carries
sensory information to the brain. The anterior root is the efferent motor root and carries
motor information from the brain. The spinal nerve emerges from the spinal column
through an opening (intervertebral foramen) between adjacent vertebrae. This is true for all
spinal nerves except for the first spinal nerve pair (C1), which emerges between
the occipital bone and the atlas(the first vertebra). Thus the cervical nerves are numbered
by the vertebra below, except spinal nerve C8, which exists below vertebra C7 and above
vertebra T1. The thoracic, lumbar, and sacral nerves are then numbered by the vertebra

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above. In the case of a lumbarized S1 vertebra (aka L6) or a sacralized L5 vertebra, the
nerves are typically still counted to L5 and the next nerve is S1.
Outside the vertebral column, the nerve divides into branches. The posterior
ramus contains nerves that serve the posterior portions of the trunk carrying visceral motor,
somatic motor, and somatic sensory information to and from the skin and muscles of the
back (epaxial muscles). The anterior ramus contains nerves that serve the remaining
anterior parts of the trunk and the upper and lower limbs (hypaxial muscles) carrying
visceral motor, somatic motor, and sensory information to and from the ventrolateral body
surface, structures in the body wall, and the limbs. The meningeal branches (recurrent
meningeal or sinuvertebral nerves)branch from the spinal nerve and re-enter the
intervertebral foramen to serve the ligaments, dura, blood vessels, intervertebral discs,
facet joints, and periosteum of the vertebrae. The rami communicantes contain autonomic
nerves that serve visceral functions carrying visceral motor and sensory information to and
from the visceral organs.

535. Posterior branches of spinal nerves

Shortly after a spinal nerve exits the intervertebral foramen, it branches into the posterior
ramus, anterior ramus, and rami communicantes. Each of these carries
both sensory and motor information. After it is formed, the posterior ramus (plural: rami)
of each spinal nerve travels backward, except for the first cervical, the fourth and
fifth sacral, and the coccygeal.
Posterior rami divide into medial, intermediate, and lateral branches. The lateral branch
supplies innervation to the iliocostalis muscle, as well as the skin lateral to the muscle on
the back. The Intermediate branch supplies innervation to the spinalis muscle and the
longissimus muscle. The medial branch supplies innervation to the rest of the epaxial
derived muscles on the back (inlcuding the transversospinalis muscles, intertransversarii
muscles, interspinalis muscles, and splenius), and the zygapophyseal joints.
Nomina Anatomica lists dorsal primary rami as "rami dorsales" for each group of spinal
nerves: 1) cervical (nervorum cervicalium ), 2) thoracic (nervorum thoracicorum ), 3)
lumbar (nervorum lumbalium ), 4) sacral (nervorum sacralium ), and 5) coccygeal (nervi
coccygei ).

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536. Posterior branch of I and II cervical spinal nerves :
First
The posterior division of the first cervical or suboccipital nerve is larger than the anterior
division, and emerges above the posterior arch of the atlas and beneath the vertebral artery.
It enters the suboccipital triangle and supplies the muscles which bound this triangle, viz.,
the Rectus capitis posterior major, and the Obliqui superior and inferior; it gives branches
also to the Rectus capitis posterior minor and the Semispinalis capitis. A filament from the
branch to the Obliquus inferior joins the posterior division of the second cervical nerve.
The nerve occasionally gives off a cutaneous branch which accompanies the occipital
artery to the scalp, and communicates with the greater and lesser occipital nerves.

Second
The posterior division of the second cervical nerve is much larger than the anterior
division, and is the greatest of all the cervical posterior divisions. It emerges between the
posterior arch of the atlas and the lamina of the axis, below the Obliquus inferior. It
supplies a twig to this muscle, receives a communicating filament from the posterior
division of the first cervical, and then divides into a large medial and a small lateral
branch.
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 The medial branch (ramus medialis; internal branch), called from its size and
distribution the greater occipital nerve, ascends obliquely between the Obliquus
inferior and the Semispinalis capitis, and pierces the latter muscle and the Trapezius
near their attachments to the occipital bone. It is then joined by a filament from the
medial branch of the posterior division of the third cervical, and, ascending on the back
of the head with the occipital artery, divides into branches which communicate with
the lesser occipital nerve and supply the skin of the scalp as far forward as the vertex
of the skull. It gives off muscular branches to the Semispinalis capitis, and
occasionally a twig to the back of the auricula.
 The lateral branch (ramus lateralis; external branch) supplies filaments to the
Splenius, Longus capitis, and Semispinalis capitis, and is often joined by the
corresponding branch of the third cervical.

537. Anterior branches of spinal nerves

The anterior ramus (pl. rami) (Latin for branch) (ventral ramus), is the anterior division of
a spinal nerve. The anterior rami supply the antero-lateral parts of the trunk and the limbs.
They are mainly larger than the posterior rami.
Shortly after a spinal nerve exits the intervertebral foramen, it branches into the dorsal
ramus, ventral ramus, and rami communicantes. Each of these latter three structures carries
both sensory and motor information. Because each spinal nerve carries both sensory and
motor information, spinal nerves are referred to as “mixed nerves.”
In the thoracic region they remain distinct from each other and each innervates a narrow
strip of muscle and skin along the sides, chest, ribs, and abdominal wall. These rami are
called the intercostal nerves. In regions other than the thoracic, anterior rami converge with
each other to form networks of nerves called nerve plexuses. Within each plexus, fibers
from the various anterior rami branch and become redistributed so that each nerve exiting
the plexus has fibers from several different spinal nerves. One advantage to having
plexuses is that damage to a single spinal nerve will not completely paralyze a limb.
There are four main plexuses formed by the anterior rami: the cervical plexus contains
anterior rami from spinal nerves C1-C4. Branches of the cervical plexus, which include the
phrenic nerve, innervate muscles of the neck, the diaphragm, and the skin of the neck and
upper chest. The brachial plexus contains anterior rami from spinal nerves C5-T1. This
plexus innervates the pectoral girdle and upper limb. The lumbar plexus contains anterior
rami from spinal nerves L1-L4. The sacral plexus contains anterior rami from spinal nerves
L4-S4. The lumbar and sacral plexuses innervate the pelvic girdle and lower limbs.
Anterior rami, including the sinuvertebral nerve branches, also supply structures anterior to
the facet joint, including the vertebral bodies, the discs and their ligaments, and joins other
spinal nerves to form the lumbo-sacral plexus.

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538. Thoracic spinal nerves
The thoracic nerves are the twelve spinal nerves emerging from the thoracic vertebrae.
Each thoracic nerve T1 -T12 originates from below each corresponding thoracic vertebra.
Branches also exit the spine and go directly to the paravertebral ganglia of the autonomic
nervous system where they are involved in the functions of organs and glands in the head,
neck, thorax and abdomen.
Anterior divisions: The intercostal nerves come from thoracic nerves T1-T11, and run
between the ribs. At T2 and T3, further branches form the intercostobrachial nerve.
The subcostal nerve comes from nerve T12, and runs below the twelfth rib.
Posterior divisions: The medial branches (ramus medialis) of the posterior branches of the
upper six thoracic nerves run between the semispinalis dorsi and multifidus, which they
supply; they then pierce the rhomboid and trapezius muscles, and reach the skin by the
sides of the spinous processes. This sensitive branch is called the medial cutaneous ramus.
The medial branches of the lower six are distributed chiefly to the multifidus
and longissimus dorsi, occasionally they give off filaments to the skin near the middle line.
This sensitive branch is called the posterior cutaneous ramus.

539. Intercostal nerves

The intercostal nerves are part of the somatic nervous system, and arise from the anterior
rami of the thoracic spinal nerves from T1 to T11. The intercostal nerves are distributed

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chiefly to the thoracic pleura and abdominal peritoneum and differ from the anterior rami
of the other spinal nerves in that each pursues an independent course without plexus
formation.
The first two nerves supply fibers to the upper limb in addition to their thoracic branches;
the next four are limited in their distribution to the walls of the thorax; the lower five
supply the walls of the thorax and abdomen. The 7th intercostal nerve terminates at
the xyphoid process, at the lower end of the sternum. The 10th intercostal nerve terminates
at the navel. The twelfth (subcostal) thoracic is distributed to the abdominal wall and groin.
Branches
Numerous slender muscular filaments supply the Intercostales, the Subcostales,
the Levatores costarum, the Serratus posterior superior, and the Transversus thoracis. At
the front of the thorax some of these branches cross the costal cartilages from one
intercostal space to another.

 Lateral cutaneous branches (rami cutanei laterales) are derived from the intercostal
nerves, about midway between the vertebræ and sternum; they pierce the Intercostales
externi and Serratus anterior, and divide into anterior and posterior branches.
 The anterior branches run forward to the side and the forepart of the chest, supplying
the skin and the mamma; those of the fifth and sixth nerves supply the upper
digitations of the Obliquus externus abdominis.
 The posterior branches run backward, and supply the skin over
the scapula and Latissimus dorsi.
The lateral cutaneous branch of the second intercostal nerve does not divide, like the
others, into an anterior and a posterior branch; it is named the intercostobrachial nerve.

540. General principles of the structure of somatic nerve plexus.

Structure

There are 43 segments of nerves in the human body. With each segment, there is a pair of
sensory and motor nerves. In the body, 31 segments of nerves are in the spinal cord and 12
are in the brain stem.

Besides these, thousands of association nerves are also present in the body.

Thus somatic nervous system consists of two parts:

 Spinal nerves: They are peripheral nerves that carry sensory information into and
motor commands out of the spinal cord.
 Cranial nerves: They are the nerve fibers that carry information into and out of the
brain stem. They include smell, vision, eye, eye muscles, mouth, taste, ear, neck,
shoulders, and tongue.

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542. Cervical plexus: formation, topography, sensory branches, areas of innervation.

543. Cervical plexus: phrenic nerve, topography, branches, areas of innervation.

The Cervical plexus is formed by the ventral rami of the upper four cervical nerves and the
upper part of fifth cervical ventral ramus. The network of rami is located deep to the
sternocleidomastoid within the neck. The cervical plexus innervates muscles of the neck
and areas of skin on the head, neck and chest. The deep branches innervate muscles, while
the superficial branches supply areas of skin. A long branch (C4; nervus phrenicus)
innervates muscles of the diaphragm. The cervical plexus also communicates with
the cranial nerves vagus nerve and hypoglossal nerve.

543. Cervical plexus: phrenic nerve, topography, branches, areas of innervation.

The phrenic nerve is a nerve that originates in the neck (C3-C5) and passes down between
the lung and heart to reach the diaphragm. It is important for breathing, as it passes motor
information to the diaphragm and receives sensory information from it. There are two
phrenic nerves, a left and a right one.
The phrenic nerve originates mainly from the 4th cervical nerve, but also receives
contributions from the 5th and 3rd cervical nerves (C3-C5) in humans. Thus, the phrenic
nerve receives innervation from parts of both the cervical plexus and the brachial plexus of
nerves.
The phrenic nerves contain motor, sensory, and sympathetic nerve fibers. These nerves
provide the only motor supply to the diaphragm as well as sensation to the central tendon.
In the thorax, each phrenic nerve supplies the mediastinal pleura and pericardium.

545. Brachial plexus: trunks, bundles, the topography

Trunks: At the base of the neck, the roots of the brachial plexus converge, forming three
trunks. These structures are named by their anatomical position:
Superior trunk: A combination of C5 and C6 roots.
Middle trunk: A continuation of C7.
Inferior trunk: A combination of C8 and T1 roots.
The trunks begin to move laterally, crossing the posterior triangle of the neck
Bundles:
The ‘roots’ refer the beginning of the brachial plexus. They are formed by the spinal
nerves C5, C6, C7, C8 and T1.

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The five roots are the five anterior rami of the spinal nerves, after they have given off their
segmental supply to the muscles of the neck. The brachial plexus emerges at five different
levels; C5, C6, C7, C8, and T1. C5 and C6 merge to establish the upper trunk, C7
continuously forms the middle trunk, and C8 and T1 merge to establish the lower trunk.
Prefixed or postfixed formations in some cases involve C4 or T2, respectively. The dorsal
scapular nerve comes from level C5 and innervates the rhomboid muscles which retract the
scapula. The subclavian nerve originates in both C5 and C6 and innervates the subclavius,
a muscle that involves lifting the first ribs during respiration. The long thoracic arise from
C5, C6, and C7. This nerve innervates the serratus anterior, which draws the scapula
laterally and is the prime mover in all forward-reaching and pushing actions

546. Brachial plexus: supraclavicular part, topography, components.

Supraclavicular part: the part of the brachial plexus that lies superior to the clavicle; it
includes the roots, trunks, and divisions that give rise to the dorsal scapular, long thoracic,

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suprascapular and subclavian nerves

The brachial plexus formed by the ventral rami of spinal nerves C5-T1. It lies on the deep
neck muscles and is divided into a supraclavicular part and an infraclavicular part.
Supraclavicular Part passes through the interscalenus fora­men and consists of the
superior, middle and inferior trunks and gives off motor nerves to the muscles of the
shoulder girdle:
· the dorsal scapular nerve (which supplies the levator scapulae muscle and the
rhomboideus major and minor muscles),
· the suprascapular nerve (supraspinatous muscle and infraspinatous muscle)
· the subscapular nerve (passes to the subscapular and teres major muscle)
the subclavius nerve (to the subclavius muscle)
· lateral and medial pectoral nerves (which supply the pectoralis major and pectoralis
minor muscles)
· the long thoracic nerve (whose branches supplies the serratus anterior muscle)
· the thoracodorsal nerve (which sup­plies the latissimus dorsi muscle)
· Axillary nerve branches off from posterior cord of the Infraclavicular Part. It passes
deep in the axillary fossa through the quadrilaterum foramen to the back surface of the
scapula. It supplies the capsule of the shoulder joint and gives off motor branches for
deltoid and teres minor mus­cles. Branch superior lateral brachial cutaneous nerve passes
to the skin, which it supplies the skin in the deltoid region.
547. Short branches of the brachial plexus: the topography, areas of innervation.
1. The dorsal scapular nerve- arise from the plexus root (anterior/ventral ramus) of C5.
It provides motor innervation to the rhomboid muscles, which pull the scapula towards the
spine and levator scapulae muscle, which elevates the scapula.
2. The long thoracic nerve- supplies the serratus anterior muscle. arises from the anterior
rami of three spinal nerve roots: the fifth, sixth, and seventh cervical nerves (C5-C7)
3. The medial and lateral pectoral nerve- ) arises from the medial cord of the brachial
plexus and through it from the eighth cervical and first thoracic roots. Supplies medial ->
m. piersiowy większy; lateral-> m. piersiowy mniejszy
4. The subclavian nerve arises from the point of junction of the fifth and sixth cervical
nerves. The subclavian nerve descends to the subclavius muscle
5. The suprascapular nerve. It is responsible for the innervation of some of the muscles
that attach on the scapula, namely the supraspinatus and infraspinatus muscles
6. Subscapular nerves. These nerves are part of a group of nerves that innervate the
muscles that move the scapula
7. The thoracodorsal nerve. It supplies the latissimus dorsi muscle Roots: C6, C7, C8.
• Nerve: Thoracodorsal nerve.
• Muscles Innervated: Latissimus dorsi.
• Innervation Route: C6, C7, C8 → posterior cord → thoracodorsal nerve → latissimus
dorsi.
8. Axillary nerve.
548. Short branches of the brachial plexus: axillary nerve, topography

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 axillary nerve- the biggest of short branches
Roots: C5 and C6.
Motor Functions: Innervates the teres minor and deltoid muscles and long head of triceps
brachii
Sensory Functions: Gives off the superior lateral cutaneous nerve of arm, which
innervates the inferior region of the deltoid.
axillary nerve also carries sensory information from the shoulder joint, as well as the skin
covering the inferior region of the deltoid muscle - the "regimental badge" area (which is
innervated by the superior lateral cutaneous nerve branch of the axillary nerve).
549. Brachal plexus: subclavian part, topography, components.
The subclavian nerve descends to the subclavius muscle in front of the third part of the
subclavian artery and the lower trunk of the brachial plexus, and is usually connected by a
filament with the phrenic nerve

550. Long branches of the brachial plexus: the topography, areas of innervation
1. musculo-cutaneous nerve.
2. median nerve
3. ulnar nerve
4. The medial brachial cutaneous nerve- is distributed to the skin on the medial brachial
side of the arm. Roots: C8, T1.
• Nerve: Medial brachial cutaneous nerve.
• Sensory Territory: Medial aspect of the arm.
• Innervation Route: C8, T1 → medial cord → medial antebrachial cutaneous nerve.
5. Medial Antebrachial Cutaneous Nerve
• Roots: C8, T1.
• Nerve: Medial antebrachial cutaneous nerve,
• Sensory Territory: Medial aspect of the forearm.
• Innervation Route: C8, T1 → medial cord → medial antebrachial cutaneous nerve.
6. Radial nerve

551. Long branches of the brachial plexus: musculo-cutaneous nerve, formation,

topography, branches, areas of innervation.
Roots: C5, C6, C7.
Motor Functions: Innervates the brachialis, biceps brachii and coracobrachiali muscles.
Sensory Functions: Gives off the lateral cutaneous branch of the forearm, which
innervates the lateral half of the anterior forearm, and a small lateral portion of the
posterior forearm.
552. Long branches of the brachial plexus: the median nerve, formation, topography,
branches, areas of innervation
Motor Functions: Innervates most of the flexor muscles in the forearm, the thenar
muscles, and the two lateral lumbricals that move the index and middle fingers.

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Sensory Functions: Gives off the palmar cutaneous branch, which innervates the lateral
part of the palm, and the digital cutaneous branch, which innervates the lateral three and a
half fingers on the anterior (palmar) surface of the hand.

553. Long branches of the brachial plexus: ulnar nerve, formation, topography, branches,
areas of innervation
Roots: C8 and T1.
Motor Functions: Innervates the muscles of the hand (apart from the thenar muscles and
two lateral lumbricals), flexor carpi ulnaris and medial half of flexor digitorum profundus.
Sensory Functions: Innervates the anterior and posterior surfaces of the medial one and
half fingers, and associated palm area.
554. Long branches of the brachial plexus: radial nerve, formation, topography, branches,
areas of innervation.
Roots: C5-C8 and T1.
Motor Functions: Innervates the triceps brachii, and the extensor muscles in the posterior
compartment of the forearm.
Sensory Functions: Innervates the posterior aspect of the arm and forearm, and the
posterior, lateral aspect of the hand.

555. Long cutaneous branches of the brachial plexus: their formation, topography, areas of
innervation
1. The medial brachial cutaneous nerve- is distributed to the skin on the medial brachial
side of the arm. Roots: C8, T1.
• Nerve: Medial brachial cutaneous nerve.
• Sensory Territory: Medial aspect of the arm.
• Innervation Route: C8, T1 → medial cord → medial antebrachial cutaneous nerve.
2. Medial Antebrachial Cutaneous Nerve
• Roots: C8, T1.
• Nerve: Medial antebrachial cutaneous nerve,
• Sensory Territory: Medial aspect of the forearm.
• Innervation Route: C8, T1 → medial cord → medial antebrachial cutaneous nerve.

556. Lumbar plexus: formation, topography, branches, areas of innervation:

The lumbar plexus is formed from part of Th12 and L1 - L4 ventral rami of the thoracic
and lumbar spinal nerves. Lumbar plexus lies inside the psoas major muscle. The lumbar
plexus gives off motor branches directly to the psoas major and psoas minor muscles, the
quadratus lumborum muscle. The plexus is formed lateral to the intervertebral
foramina and passes through psoas major. Its smaller motor branches are distributed
directly to psoas major, while the larger branches leave the muscle at various sites to run
obliquely down through the pelvis to leave under the inguinal ligament, with the exception
of the obturator nerve which exits the pelvis through the obturator foramen.
The branches of the lumbar plexus may therefore be arranged as follows:

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Nerves of the lumbar plexus[2]
Nerve Segment Innervated muscles Cutaneous branches

• Anterior cutaneous
Iliohypogastric T12-L1 ramus
• Transversus • Lateral cutaneous ramus
abdominis
• Abdominal internal • Anterior scrotal
oblique nerves in males
Ilioinguinal L1
• Anterior labial nerves in
females

• Femoral ramus
Genitofemoral L1, L2 • Cremaster in males
• Genital ramus

Lateral femoral • Lateral femoral

L2, L3
cutaneous cutaneous

• Obturator externus
• Adductor longus
• Adductor brevis
Obturator L2-L4 • Cutaneous ramus
• Gracilis
• Pectineus
• Adductor magnus

• Iliopsoas
• Anterior cutaneous
• Pectineus
Femoral L2-L4 branches
• Sartorius
• Saphenous
• Quadriceps femoris

• Psoas major
Short, direct muscular • Quadratus lumborum
T12-L4
branches • Lumbar
intertransverse

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557. Lumbar plexus: femoral nerve, topography, branches, areas of innervation.
Patrz tabelka na górze!
Femoral 2, 3, 4 L.
The femoral nerve passes on the lateral margin of the psoas major muscle as far as the
inguinal ligament, and through the muscular lacuna to the anterior surface of the thigh.
Beneath the inguinal ligament the nerve trunk divides into a number of branches: a
primarily sensory ventral group, anterior cutaneous branches for the skin of thigh, a motor
branches to the anterior muscles of the thigh, and the saphenous nerve. The femoral nerve
supplies the rectus femoris, the vastus medialis, lateralis and the vastus intermedius; the
sartorius muscle. It gives off small sensory twigs to the capsule of the knee joint and
vessels. The saphenous nerve runs into the adductor canal. It is a purely sensory nerve and
gives off an intrapatellar branch, to supply the skin below the patella. Then saphenous
nerve supplies the skin on the anterior and medial surfaces of the lower leg, the medial
margin of the foot as far as the great toe.
Branches
Within the abdomen the femoral nerve gives off small branches to the iliacus muscle, and a
branch which is distributed on the upper part of the femoral artery; the latter branch may
arise in the thigh.
Anterior
In the thigh, the anterior division of the femoral nerve gives off anterior cutaneous and
muscular branches.

 Anterior cutaneous branches: The anterior cutaneous branches comprise the following
nerves: intermediate femoral cutaneous nerve and medial femoral cutaneous
nerve (Note the lateral femoral cutaneous nerve is a branch from the lumbar plexus.)
 Muscular branches: The nerve to the Pectineus arises immediately below the inguinal
ligament, and passes behind the femoral sheath to enter the anterior surface of the
muscle; it is often duplicated. The nerve to the Sartorius arises in common with the
intermediate cutaneous.

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Posterior
The femoral nerve has two groups of posterior branches, muscular (to the four parts of
the Quadriceps femoris), and articular, to the knee.
Muscular branches to the quadriceps include:

 The branch to the Rectus femoris enters the upper part of the inner surface of the
muscle, and supplies a filament to the hip.
 A large branch to the Vastus lateralis accompanies the descending branch of the lateral
femoral circumflex artery to the lower part of the muscle. It gives off an articular
filament to the knee.
 The branch to the Vastus medialis descends lateral to the femoral vessels in company
with the saphenous nerve. It enters the muscle about its middle, and gives off a
filament, which can usually be traced downward, on the surface of the muscle, to the
knee.
 The branches to the Vastus intermedius, two or three in number, enter the anterior
surface of the muscle about the middle of the thigh; a filament from one of these
descends through the muscle to the Articularis genus and the knee-joint. The articular
branch to the hip-joint is derived from the nerve to the Rectus femoris.
There are three articular branches:

 A long slender filament, derived from the nerve to the Vastus lateralis; it penetrates the
capsule of the joint on its anterior aspect.
 A branch derived from the nerve to the Vastus medialis, can usually be traced
downward on the surface of this muscle to near the joint; it then penetrates the
muscular fibers, and accompanies the articular branch of the highest genicular artery,
pierces the medial side of the articular capsule, and supplies the synovial membrane.
 A third branch is derived from the nerve to the Vastus intermedius.

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558. Lumbar plexus: obturator nerve, topography, branches, areas of innervation.

Obturator 2, 3, 4 L.

The obturator nerve supplies motor fibers to the adductor muscles (*) of the thigh. The
nerve passes through the obturator canal where it extends to the thigh. It supplies a
muscular branch to the obturator externus muscle and then divides into a superficial and a
deep branches. Cutaneous branch to the skin of the medial surface of the thigh. (* -
adductor longus, adductor brevis muscles, pectineus and the gracilis muscles, adductor
magnus muscle).

Innervation:
The obturator nerve is responsible for the sensory innervation of the skin of the medial
aspect of the thigh.
The nerve is also responsible for the motor innervation of the adductor muscles of
the lower extremity (external obturator.[2] adductor longus, adductor brevis, adductor
magnus, gracilis) and the pectineus (inconstant). It is, notably, not responsible for the
innervation of the obturator internus, despite the similarity in name.

Branches:

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The anterior branch of the obturator nerve is a branch of the obturator nerve found in
the pelvis and leg.
It leaves the pelvis in front of the obturator externus and descends in front of the adductor
brevis, and behind the pectineus and adductor longus; at the lower border of the latter
muscle it communicates with the anterior cutaneous and saphenous branches of
the femoral nerve, forming a kind of plexus.
It then descends upon the femoral artery, to which it is finally distributed. Near
the obturator foramen the nerve gives off an articular branch to the hip joint.
Behind the pectineus, it distributes branches to the adductor longus and gracilis, and
usually to the adductor brevis, and in rare cases to the pectineus; it receives a
communicating branch from the accessory obturator nerve when that nerve is present.

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The posterior branch of the obturator nerve pierces the anterior part of the Obturator
externus, and supplies this muscle; it then passes behind the Adductor brevis on the front
of the Adductor magnus, where it divides into numerous muscular branches which are
distributed to the Adductor magnus and the Adductor brevis
It usually gives off an articular filament to the knee-joint.

Occasionally the communicating branch to the anterior cutaneous and saphenous branches
of the femoral is continued down, as a cutaneous branch, to the thigh and leg, as
the cutaneous branch of the obturator nerve.
When this is so, it emerges from beneath the lower border of the Adductor longus,
descends along the posterior margin of the sartorius to the medial side of the knee, where it

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pierces the deep fascia, communicates with the saphenous nerve, and is distributed to the
skin of the tibial side of the leg as low down as its middle.

559. Sacral and coccygeal plexus: formation, topography, classification of branches.

The sacral plexus is formed from LIV-LV, SI-SIV ventral rami of the lumbar and sacral
spinal nerves. Sacral plexus lies on the piriform muscle and gives off short and long
branches.

The coccygeal plexus is formed from ventral rami of the sacral and coccygeal spinal
nerves (SV , CoI ). It is located on coccygeal muscle. Anococccygeal nerves start there and
innervate the skin in adjacent area.

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Classification of branches: short and long

560. Sacral plexus: short branches, the topography, areas of innervation.

SHORT BRANCHES:
 small muscular branches pass directly to muscles in the pelvic region: internal obturator,
superior and inferior gemelli piriform quadratus femoris muscles
 superior gluteal nerve passes through the suprapiriform foramen to supply the motor
innervation of the medius and minimus gluteus muscle and tensor fasciae latae
 inferior gluteal nerve leaves the pelvis through the infrapiriform foramen and supplies
several branches to the gluteus maximus muscle
 pudendal nerve leaves the pelvis through the infrapiriform foramen and passes dorsally
around the ischial spine to enter the ischiorectal fossa through the lesser sciatic foramen. It
gives off here inferior rectal nerves to external anal sphincter, perineal nerves to

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ischiocavernosus, bulbospondiosus, transversi perinei superficial and profundus muscles
and skin. Posterior scrotal (labial) nerves and dorsal penis (clitoridis) nerve supplies
external genitals and sphincter urethrae.

561. Short branches of the sacral plexus: pudendal nerve, fiber composition,
topography, areas of innervation.
The Pudendal Nerve (n. pudendus; internal pudic nerve) derives its fibers from the
ventral branches of the second, third, and fourth sacral nerves. It passes between the
Piriformis and Coccygeus muscles and leaves the pelvis through the lower part of the
greater sciatic foramen. It then crosses the spine of the ischium, and reënters the
pelvis through the lesser sciatic foramen. It accompanies the internal pudendal
vessels upward and forward along the lateral wall of the ischiorectal fossa, being
contained in a sheath of the obturator fascia termed Alcock’s canal, and divides into
two terminal branches, viz., the perineal nerve, and the dorsal nerve of the penis or
clitoris. Before its division it gives off the inferior hemorrhoidal nerve.
areas of innervation:
The pudendal nerve supplies sensation to the penis in males and the clitoris in females,
through the branches dorsal nerve of penis and dorsal nerve of clitoris. The posterior
scrotum in males and the labia in females are also supplied, via the posterior scrotal nerves
(males) or posterior labial nerves (females). The pudendal nerve is one of several nerves
supplying sensation to these areas. Branches also supply sensation to the anal canal. By
providing sensation to the penis and the clitoris, the pudendal nerve is responsible for the
afferent component of penile erection and clitoral erection. It is also responsible for
ejaculation. Branches also innervate muscles of the perineum and pelvic floor; namely the
bulbospongiosus and ischiocavernosus muscles, the levator ani muscle (including the
Iliococcygeus, pubococcygeus, puborectalis and either pubovaginalis in females or
pubourethralis in males), the external anal sphincter (via the inferior anal branch), and
male or female external urethral sphincter.

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562. Long branches of sacral plexus: the topography, areas of innervation.
LONG BRANCHES:
nervus gluteus superior ( superior gluteal nerve) : The superior gluteal nerve is
a nerve that originates in the pelvis and supplies the gluteus medius, the gluteus
minimus and the tensor fasciae latae muscle.
nervus gluteus inferior ( inferior gluteal nerve): The inferior gluteal nerve is the main
motor neuron that innervates the gluteus maximus muscle. The muscle is supplied by the
inferior gluteal nerve which arises from the dorsal branches of the ventral rami of the fifth
(L5), the first (S1) and second (S2) sacral nerves. The lumbosacral trunk, which is made up
of L5 and a small branch of L4, effectively connects the lumbar and sacral plexuses. The
lower branches of the L4 and the L5 nerves enter the sacral plexus.The sacral plexus is
formed by the lumbosacral trunk, the first to third sacral ventral rami, and part of the
fourth, the remainder of the last joining the coccygeal plexus. The sacral plexus is formed
in the pelvis in front of the piriformis muscle. The sacral plexus is formed anterior to the
piriformis muscle and gives rise to the sciatic nerve, the superior and inferior gluteal
nerves, and the pudendal and posterior femoral cutaneous nerves.
nervus cutaneus femoris posterior: It is a cutaneous nerve. Its fibers derived from ventral
spinal nerve branches S1, S2, S3. It is a long branch of the sacral plexus (lat. Sacralis
plexus). innervate the skin of the lower part of the buttock, innervate the skin of the upper,
medial thighs, perineum skin,
nervus ischiadicus ( sciatic nerve): It begins in the lower back and runs through
the buttock and down the lower limb. It is the longest and widest single nerve in the human
body, going from the top of the leg to the foot on the posterior aspect The sciatic nerve
provides the connection to the nervous system for nearly the whole of the skin of the leg,

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the muscles of the back of the thigh, and those of the leg and foot. It is derived from spinal
nerves L4 to S3. It contains fibers from both the anterior and posterior divisions of
the lumbosacral plexus.
nervus pudendus ( pudendal nerve): It carries sensation from the external genitalia of
both sexes and the skin around the anus and perineum, as well the motor supply to various
pelvic muscles, including the male or female external urethral sphincter and the external
anal sphincter. If damaged, most commonly by childbirth, lesions may cause sensory loss
or fecal incontinence. The nerve may also be temporarily blocked as part of an anaesthetic
procedure.
nervus coccygeus: sensory and motor nerve. Its fibers are derived from the branches of the
ventral spinal nerves S5 and Co . It is a long branch of the sacral plexus (lat. Sacralis
plexus). With branches abdominal spinal nerves S3 and S4 creates a small plexus
coccygeus. Moving away from him, nerves anogenital coccyx (lat. Nervi anococcygei) and
branches muscle (lat. Musculares arm).

563. Long branches of sacral plexus: sciatic nerve, topography, branches, areas of
innervation.

From Lumbar and sacral plexus (L4-S3)

To Tibial and common fibular nerve

Innervates Lateral rotator

group (except piriformis and quadratus
femoris) and the posterior compartment
of thigh

The sciatic nerve is formed from the L4 to S3 segments of the sacral plexus, a collection of
nerve fibres that emerge from the sacralpart of the spinal cord. The fibres unite to form a
single nerve in front of the piriformis muscle. The nerve passes beneath piriformisand
through the greater sciatic foramen, exiting the pelvis. From here, it travels down the
posterior thigh to the popliteal fossa. The nerve travels in the posterior compartment of the
thigh behind (superficial to) the adductor magnus muscle, and is itself in front of (deep to)
one head of the biceps femoris muscle. At the popliteal fossa, the nerve divides into its two
branches:

 The tibial nerve, which travels down the posterior compartment of the leg into the foot

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 The common peroneal nerve (also called the common fibular nerve), which travels
down the anterior and lateral compartments of the leg into the foot
The sciatic nerve is the largest nerve in the human body.
Areas of innervation:

The sciatic nerve supplies sensation to the skin of the foot, as well as the entire lower leg
(except for its inner side). Sensation to skin to the sole of the foot is provided by the tibial
nerve, and the lower leg and upper surface of the foot via the common fibular nerve.The
sciatic nerve also innervates muscles. In particular:Via the tibial nerve, the muscles in the
posterior compartment of the leg and sole of the foot (plantar aspect). Via the common
peroneal nerve (also called the common fibular nerve), the muscles in the anterior and
lateral compartments of the leg.

Branches into tibial and common fibular nerve

564. Tibial nerve, formation, topography, branches, areas of innervation.

The Tibial Nerve (n. tibialis; internal popliteal nerve) the larger of the two terminal
branches of the sciatic, arises from the anterior branches of the fourth and fifth lumbar and
first, second, and third sacral nerves. It descends along the back of the thigh and through
the middle of the popliteal fossa, to the lower part of the Popliteus muscle, where it passes
with the popliteal artery beneath the arch of the Soleus. It then runs along the back of the

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leg with the posterior tibial vessels to the interval between the medial malleolus and the
heel, where it divides beneath the laciniate ligament into the medial and lateral plantar
nerves. In the thigh it is overlapped by the hamstring muscles above, and then becomes
more superficial, and lies lateral to, and some distance from, the popliteal vessels;opposite
the knee-joint, it is in close relation with these vessels, and crosses to the medial side of the
artery. In the leg it is covered in the upper part of its course by the muscles of the calf;
lower down by the skin, the superficial and deep fasciæ. It is placed on the deep muscles,
and lies at first to the medial side of the posterior tibial artery, but soon crosses that vessel
and descends on its lateral side as far as the ankle. In the lower third of the leg it runs
parallel with the medial margin of the tendo calcaneus.
The branches of this nerve are: articular, muscular, medial sural cutaneous, medial
calcaneal, medial and lateral plantar.

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565. Common peroneal nerve: formation, topography, branches, areas of innervation.

Details

From sacral plexus via sciatic nerve (L4-S2)

To Deep fibular nerve and Superficial

fibular nerve

Innervates Anterior compartment of leg, lateral

compartment of leg, extensor digitorum
brevis

The Common Peroneal Nerve (n. peronæus communis; external popliteal nerve; peroneal
nerve) about one-half the size of the tibial, is derived from the dorsal branches of the fourth
and fifth lumbar and the first and second sacral nerves. It descends obliquely along the
lateral side of the popliteal fossa to the head of the fibula, close to the medial margin of the
Biceps femoris muscle. It lies between the tendon of the Biceps femoris and lateral head of
the Gastrocnemius muscle, winds around the neck of the fibula, between the Peronæus

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longus and the bone, and divides beneath the muscle into the superficial and deep peroneal
nerves. Previous to its division it gives off articular and lateral sural cutaneous nerves.
Branches
Previous to its division it gives off articular and lateral sural cutaneous nerves.

 The articular branches are three in number:

 Two of these accompany the superior and inferior lateral genicular arteries to the
knee; the upper one occasionally arises from the trunk of the sciatic nerve.
 The third (recurrent) articular nerve is given off at the point of division of the
common peroneal nerve; it ascends with the anterior recurrent tibial artery through
the tibialis anterior to the front of the knee.
 The lateral sural cutaneous nerve supplies the skin on the posterior and lateral
surfaces of the leg.
 The motor branches:
 As the common peroneal nerve exits the popliteal fossa, it courses around the
lateral aspect of the leg just below the head of the fibula. Here it is apposed with
fibula and gives off two branches, the superficial peroneal branch and deep
peroneal branch.
 The superficial peroneal nerve supplies the muscles of the lateral compartment of
the leg namely: peroneus longus and peroneus brevis. These two muscles assist
with eversion and plantar flexion of the foot.
 The deep peroneal nerve innervates the muscles of the anterior compartment of the
leg which are: tibialis anterior, extensor hallucis longus, extensor digitorum
longus, and the peroneus tertius. Together these muscles are responsible
for dorsiflexionof the foot and extension of the toes.
 The deep peroneal nerve also innervates intrinsic muscles of the foot including the
extensor digitorum brevis and the extensor hallucis brevis.

innervation:
The common peroneal nerve innervates the short head of the biceps femoris muscle via a
motor branch that exits close to the gluteal cleft. The remainder of the peroneal-innervated
muscles are innervated by its branches, the deep peroneal nerve and superficial peroneal
nerve.
It provides sensory innervation to the skin over the upper third of the lateral aspect of the
leg via the lateral cutaneous nerve of the calf. It gives the peroneal communicating nerve
which joins the sural nerve in the midcalf.

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566. Superficial peroneal nerve: topography, branches, areas of innervation.

Details

From Common peroneal nerve

To Medial dorsal cutaneous nerve, intermediate

dorsal cutaneous nerve

The Superficial Peroneal Nerve (n. peronæus superficialis; musculocutaneous nerve)

supplies the Peronei longus and brevis and the skin over the greater part of the dorsum of
the foot. It passes forward between the Peronæi and the Extensor digitorum longus, pierces
the deep fascia at the lower third of the leg, and divides into a medial and an intermediate
dorsal cutaneous nerve. In its course between the muscles, the nerve gives off muscular
branches to the Peronæi longus and brevis, and cutaneous filaments to the integument of
the lower part of the leg.

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567. Deep peroneal nerve: formation, topography, branches, areas of innervation.

Details

From common peroneal nerve

Innervates anterior compartment of leg

The Deep Peroneal Nerve (n. peronæus profundus; anterior tibial nerve) begins at the
bifurcation of the common peroneal nerve, between the fibula and upper part of the
Peronæus longus, passes obliquely forward beneath the Extensor digitorum longus to the
front of the interosseous membrane, and comes into relation with the anterior tibial artery
above the middle of the leg; it then descends with the artery to the front of the ankle-joint,
where it divides into a lateral and a medial terminal branch. It lies at first on the lateral side
of the anterior tibial artery, then in front of it, and again on its lateral side at the ankle-joint.
In the leg, the deep peroneal nerve supplies muscular branches to the Tibialis anterior,
Extensor digitorum longus, Peronæus tertius, and Extensor hallucis prop ius, and an
articular branch to the ankle-joint.

Medial terminal branch

The medial terminal branch (internal branch) accompanies the dorsalis pedis artery along
the dorsum of the foot, and, at the first interosseous space, divides into two dorsal digital

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nerves which supply the adjacent sides of the great and second toes, communicating with
the medial dorsal cutaneous branch of the superficial peroneal nerve.
Before it divides it gives off to the first space an interosseous branch which supplies
the metatarsophalangeal joint of the great toe and sends a filament to the first Interosseous
dorsalis muscle.
Lateral terminal branch
The lateral terminal branch (external or tarsal branch) passes across the tarsus, beneath
the extensor digitorum brevis, and, having become enlarged like the dorsal interosseous
nerve at the ankle, supplies the extensor digitorum brevis.
From the enlargement three minute interosseous branches are given off, which supply
the tarsal joints and the metatarsophalangealjoints of the second, third, and fourth toes.
The first of these sends a filament to the second interosseus dorsalis muscle.
It runs with the lateral tarsal artery.

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In the leg, the deep peroneal nerve supplies muscular branches to the anterior compartment
of extensor muscles in the leg which include the tibialis anterior, extensor digitorum
longus, peroneus tertius, and extensor hallucis longus (propius), and an articular branch to
the ankle-joint. After its bifurcation past the ankle joint, the lateral branch of the deep

peroneal nerve innervates the extensor digitorum brevis and the extensor hallucis brevis,
while the medial branch goes on to provide cutaneous innervation to the webbing between
the first and second digits.

568. Coccygeal plexus: formation, topography, branches, areas of innervation.

Details

From S4-S5, coccygeal nerve

To anococcygeal nerve

The coccygeal plexus is a plexus of nerves near the coccyx bone

The coccygeal plexus is formed from ventral rami of the sacral and coccygeal spinal
nerves (SV , CoI ). It is located on coccygeal muscle. Anococccygeal nerves start there and
innervate the skin in adjacent area.
The coccygeal plexus consists of the coccygeal nerve and the fifth sacral nerve, which
innervate the skin in the coccygeal region, around the tailbone (called the coccyx).

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372
569. Innervation the skin of the head.

The twelve pairs of cranial nerves provide the majority of nervous control to the head. The
sensation to the face is provided by the branches of the trigeminal nerve, a cranial nerve.
The sensation to other portions of the head is provided by the cervical nerves.
Nerves of Face and Scalp
Cutaneous innervation of the face and anterosuperior part of the scalp is provided primarily
by the trigeminal nerve (CN V), whereas motor innervation to the facial muscles is
provided by the facial nerve (CN VII).

CUTANEOUS NERVES OF FACE AND SCALP

The trigeminal nerve originates from the lateral surface of the pons of the midbrain by two
roots: motor and sensory. These roots are comparable to the motor and sensory roots of
spinal nerves. The sensory root of CN V consists of the central processes of
pseudounipolar neurons located in a sensory ganglion at the distal end of the root, which is
bypassed by the multipolar neuronal axons making up the motor root. CN V is the sensory
nerve for the face and the motor nerve for the muscles of mastication and several small
muscles. The peripheral processes of the neurons of the trigeminal ganglion constitute
three divisions of the nerve: the ophthalmic nerve, the maxillary nerve, and the sensory
component of the mandibular nerve. These nerves are named according to their main areas
of termination: the eye, maxilla, and mandible, respectively. The first two divisions are
wholly sensory. The mandibular nerve is largely sensory, but it also receives the motor
fibers from the motor root of CN V that mainly supply the muscles of mastication.
Cutaneous branches of cervical nerves from the cervical plexus extend over the posterior
aspect of the neck and scalp. The great auricular nerve in particular innervates
the inferior aspect of the auricle and much of the parotid region of the face.

NERVES OF SCALP
Innervation of the scalp anterior to the auricles of the external ears is through branches of
all three divisions of CN V, the trigeminal nerve. Posterior to the auricles, the nerve supply
is from spinal cutaneous nerves (C2 and C3).

MOTOR NERVES OF FACE

The motor nerves of the face are the facial nerve to the muscles of facial expression and
the motor root of the trigeminal nerve/mandibular nerve to the muscles of mastication.
These nerves also supply some more deeply placed muscles.

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374
570. Innervation the skin of the neck..

571. Innervation the upper limb skin.

Cutaneous Innervation of Upper Limb:
Most cutaneous nerves of the upper limb are derived from the brachial plexus, a major
nerve network formed bythe anterior rami of the C5–T1 spinal nerves. The nerves to the
shoulder, however, are derived from the cervical plexus, a nerve network consisting of a
series of nerve loops formed between adjacent anterior rami of the fi rst four cervical
nerves. The cervical plexus lies deep to the sternocleidomastoid muscle on the antero
lateral aspect of the neck.
There are lateral, medial, and posterior cutaneous nerves of the arm and forearm.

Motor Innervation (Myotomes) of Upper Limb:

Somatic motor fibers traveling in the same mixed peripheral nerves that convey sensory
fibers to the cutaneous nerves transmit impulses to the voluntary muscles of the upper

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limb. The unilateral embryological muscle mass receiving innervation from a single spinal
cord segment or spinal
nerve constitutes a myotome. Upper limb muscles usually receive motor fi bers from
several spinal cord segments or nerves. Thus most muscles are made up of more than one
myotome, and multiple spinal cord segments are usually involved in producing the
movement of the upper limb. The intrinsic muscles of the hand constitute a single
myotome.

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572. Innervation of the skin of the shoulder.
The nerves supplying the shoulder joint all arise in the brachial plexus. They are the
suprascapular nerve, the axillary nerve and the lateral pectoral nerve.
 Axillary nerve, C5, 6 - is a branch of the posterior cord. The site of the axillary
nerve may be represented by a horizontal line through the middle of the deltoid. At
the lower border of the subscapularis, it turns posteriorward through the
quadrangular space, between the long and lateral heads of the triceps. It divides into
anterior and posterior branches. The former winds around the surgical neck of the
humerus and supplies the deltoid and gives some cutaneous twigs. The posterior
branch supplies the teres minor and deltoid and becomes the upper lateral brachial
cutaneous nerve.
 Suprascapular nerve – supplies supraspinatus and infraspinatus muscles and can be
entrapped or diseased.

573. Innervation of the skin of the arm.

Four main nerves pass through the arm: median, ulnar, musculocutaneous,
and radial. Their origins from the brachial plexus, courses in the upper limb
 Musculocutaneous nerve, from C5, C6, C7, is the main supplier of muscles of the
anterior compartment. It originates from the lateral cord of the brachial plexus of

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 nerves. It pierces the coracobrachialis muscle and gives off branches to the muscle,
as well as to brachialis and biceps brachii. It terminates as the anterior cutaneous
nerve of the forearm.
 Radial nerve, which is from the fifth cervical spinal nerve to the first thoracic spinal
nerve, originates as the continuation of the posterior cord of the brachial plexus.
This nerve enters the lower triangular space of the arm and lies deep to the triceps
brachii. Here it travels with the deep artery of the arm, which sits in the radial
groove of the humerus. This fact is very important clinically as a fracture of the
shaft of the bone here can cause lesions or even transections in the nerve.
 Median nerve, origin C5-T1, which is a branch of the lateral and medial cords of
the brachial plexus. This nerve continues in the arm, travelling in a plane between
the biceps and triceps muscles. At the cubital fossa, this nerve is deep to the
pronator teres muscle and is the most medial structure in the fossa. The nerve
passes into the forearm.
 Ulnar nerve, C8-T1, is a continuation of the medial cord of the brachial plexus.
This nerve passes in the same plane as the median nerve, between the biceps and
triceps muscles. At the elbow, this nerve travels posterior to the medial epicondyle
of the humerus. This means that condylar fractures can cause lesion to this nerve.

574. Innervation of the skin of the forearm.

The nerves of the forearm are the median, ulnar, and radial. The median nerve is the
principal nerve of the anterior compartment of the forearm. Although the radial nerve
appears in the cubital region, it soon enters the posterior compartment of the forearm.
Besides the cutaneous branches, there are only two nerves of the anterior aspect of the
forearm: the median and ulnar nerves.

 Median nerve supplies muscular branches directly to the muscles of the superfi cial
and intermediate layers of forearm flexors, and deep muscles via its branch, the
anterior interosseous nerve.
The median nerve has no branches in the arm other than small twigs to the brachial artery.
Its major branch in the forearm is the anterior interosseous nerve. In addition, the
following unnamed branches of the median nerve arise in the forearm:
• Articular branches. These branches pass to the elbow joint as the median nerve passes it.
• Muscular branches. The nerve to the pronator teres usually arises at the elbow and enters
the lateral border of the muscle. A broad bundle of nerves pierces the superficial flexor
group of muscles and innervates the FCR, the palmaris longus, and the FDS.
• Anterior interosseous nerve. This branch runs distally on the interosseous membrane with
the anterior interosseous branch of the ulnar artery. After supplying the deep forearm
flexors, it passes deep to
and supplies the pronator quadratus, then ends by sending articular branches to the wrist
joint.

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• Palmar cutaneous branch of the median nerve. This branch arises in the forearm, just
proximal to the flexor retina culum, but is distributed to skin of the central part of the palm.

 Ulnar nerve does not give rise to branches during its passage through the arm. In
the forearm it supplies only one and a half muscles, the FCU and the ulnar part of
the FDP, which sends tendons to the 4th and 5th digits. The ulnar nerve and artery
emerge from beneath the FCU tendon and become superficial just proximal to the
wrist. They pass superficial to the flexor retinaculum and enter the hand by passing
through a groove between the pisiform and the hook of the hamate. A band of
fibrous tissue from the flexor retinaculum bridges the groove to form the small
ulnar canal. The branches include unnamed muscular and articular branches, and
cutaneous branches that pass to the hand:
• Articular branches pass to the elbow joint while the nerve is between the olecranon and
the medial epicondyle.
• Muscular branches supply the FCU and the medial half of the FDP.
• The palmar and dorsal cutaneous branches arise from the ulnar nerve in the forearm, but
their sensory fibers are distributed to the skin of the hand.

 Radial nerve serves motor and sensory functions in both the arm and the forearm.
However, its sensory and motor fibers are distributed in the forearm by two
separate branches, the superficial and deep radial/posterior interosseous nerve. The
two branches immediately part company, the deep branch winding laterally around
the radius, piercing the supinator en route to the posterior compartment. The
posterior cutaneous nerve of the forearm arises from the radial nerve in the
posterior compartment of the arm, as it runs along the radial groove of the humerus.
Thus it reaches the forearm independent of the radial nerve, descending in the
subcutaneous tissue of the posterior aspect of the forearm to the wrist, supplying
the skin.The superficial branch of the radial nerve is also a cutaneous nerve, but it
gives rise to articular branches. It is distributed to skin on the dorsum of the hand
and to a number of joints in the hand, branching soon after it emerges from the
overlying brachioradialis and crosses the roof of the anatomical snuff box. The
deep branch of the radial nerve, after it pierces the supinator, runs in the fascial
plane between superficial and deep extensor muscles in close proximity to the
posterior interosseous artery. It supplies motor innervation to all the muscles with
fleshy bellies located entirely in the posterior compartment of the forearm.

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575. Innervation of the skin of the hand.

The median, ulnar, and radial nerves supply the hand. In addition, branches or
communications
from the lateral and posterior cutaneous nerves may contribute some fibers that supply the
skin of the dorsum of the hand.
 Median nerve enters the hand through the carpal tunnel, deep to the flexor
retinaculum, along with the nine tendons. The carpal tunnel is the passageway deep
to the flexor retinaculum between the tubercles of the scaphoid and trapezoid bones

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 on the lateral side and the pisiform and hook of the hamate on the medial side.
Distal to the carpal tunnel, the median nerve supplies two and a half thenar muscles
and the 1st and 2nd lumbricals. It also sends sensory fibers to the skin on the entire
palmar surface, the sides of the first three digits, the lateral half of the 4th digit, and
the dorsum of the distal halves of these digits.
 Ulnar nerve leaves the forearm by emerging from deep to the tendon of the FCU. It
continues distally to the wrist via the ulnar canal. Here the ulnar nerve is bound by
fascia to the anterior surface of the fl exor retinaculum as it passes between the
pisiform and the ulnar artery. Just proximal to the wrist, the ulnar nerve gives off a
palmar cutaneous branch, which passes superficial to the flexor retinaculum and
palmar aponeurosis and supplies skin on the medial side of the palm. The dorsal
cutaneous branch of the ulnar nerve supplies the medial half of the dorsum of the
hand, the 5th finger, and the medial half of the 4th finger. The ulnar nerve ends at
the distal border of the flexor retinaculum by dividing into superfi cial and deep
branches. The superficial branch of the ulnar nerve supplies cutaneous branches to
the anterior surfaces of the medial one and a half digits. The deep branch of the
ulnar nerve supplies the hypothenar muscles, the medial two lumbricals, the
adductor pollicis and all the interossei.

 Radial nerve supplies no hand muscles. The superficial branch of the radial nerve is
entirely sensory. It pierces the deep fascia near the dorsum of the wrist to supply
the skin and fascia over the lateral two thirds of the dorsum of the hand, the dorsum
of the thumb, and proximal parts of the lateral one and a half digits.

576. Innervation the lower limb skin.

Cutaneous nerves in the subcutaneous tissue supply the skin of the lower limb.These
nerves, except for some proximal unisegmental nerves arising from the T12 or L1 spinal
nerves, are branches of the lumbar and sacral plexuses. The areas of skin supplied by the
individual spinal nerves, including those contributing to the plexuses, are called
dermatomes. The dermatomal pattern of skin innervation is retained throughout life but is

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distorted by limb lengthening and the torsion of the limb that occurs during development.
Although simplified into distinct zones in dermatome maps, adjacent dermatomes overlap,
except at the axial line, the line of junction of dermatomes supplied from discontinuous
spinal levels.
Motor nerves
Somatic motor fibers traveling in the same mixed peripheral nerves that convey sensory
fibers to the cutaneous nerves transmit impulses to the muscles of the lower limb. The
unilateral embryological muscle mass receiving innervation from a single spinal cord
segment or spinal nerve comprise a myotome. Lower limb muscles usually receive motor
fibers from several spinal cord segments or nerves. Thus, most muscles are composed of
more than one myotome, and most often multiple spinal cord segments are involved in
producing the movement of the lower limb.

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577. Innervation of the skin of the gluteal area.
 Clunial nerves
The skin of the gluteal region is richly innervated by superior, middle, and inferior clunial
nerves. These superficial nerves supply the skin over the iliac crest, between the posterior
superior iliac spines, and over the iliac tubercles. Consequently, these nerves are
vulnerable to injury when bone is taken from the ilium for grafting.
1. Deep gluteal nerves are the superior and inferior gluteal nerves, sciatic nerve, nerve
to quadratus femoris, posterior cutaneous nerve of the thigh, nerve to obturator
internus, and pudendal nerve. All of these nerves are branches of the sacral plexus
and leave the pelvis through the greater sciatic foramen. Except for the superior
gluteal nerve, they all emerge inferior to the piriformis.
 The superior gluteal nerve runs laterally between the gluteus medius and minimus
with the deep branch of the superior gluteal artery. It divides into a superior branch
that supplies the gluteus medius and an inferior branch that continues to pass
between the gluteus medius and the gluteus minimus to supply both muscles and
the tensor fasciae latae.
 The inferior gluteal nerve leaves the pelvis through the greater sciatic foramen,
inferior to the piriformis and superficial to the sciatic nerve, accompanied by
multiple branches of the inferior gluteal artery and vein. The inferior gluteal nerve
also divides into several branches, which provide motor innervation to the
overlying gluteus maximus.
 Sciatic nerve is the largest nerve in the body and is the continuation of the main
part of the sacral plexus. The branches converge at the inferior border of the
piriformis to form the sciatic nerve, a thick, flattened band approximately 2 cm
wide. The sciatic nerve is the most lateral structure emerging through the greater
sciatic foramen inferior to the piriformis. Medial to the sciatic nerve are the inferior
gluteal nerve and vessels, the internal pudendal vessels, and the pudendal nerve.
The sciatic nerve runs inferolaterally under cover of the gluteus maximus, midway

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 between the greater trochanter and ischial tuberosity. The nerve rests on the
ischium and then passes posterior to the obturator internus, quadratus femoris, and
adductor magnus muscles. It supplies the posterior thigh muscles, all leg and foot
muscles, and the skin of most of the leg and foot. It also supplies the articular
branches to all joints of the lower limb.
 The nerve to the quadratus femoris leaves the pelvis anterior to the sciatic nerve
and obturator internus, and passes over the posterior surface of the hip joint. It
supplies an articular branch to this joint and innervates the inferior gemellus and
quadratus femoris muscles.
 The posterior cutaneous nerve of the thigh supplies more skin than any other
cutaneous nerve. Its fibers from the anterior divisions of S2 and S3 supply the skin
of the perineum via its perineal branch. Some of the fibers from the posterior
divisions of the anterior rami of S1 and S2 supply the skin of the inferior part of the
buttocks. Other fibers continue inferiorly in branches that supply the skin of the
posterior thigh and proximal part of the leg.
 The pudendal nerve is the most medial structure to exit the pelvis through the
greater sciatic foramen. It descends inferior to the piriformis, posterolateral to the
sacrospinous ligament, and enters the perineum through the lesser sciatic foramen
to supply structures in this region.
 The nerve to the obturator internus arises from the anterior divisions of the anterior
rami of the L5–S2 nerves and parallels the course of the pudendal nerve. As it
passes around the base of the ischial spine, the nerve supplies the superior
gemellus. After entering the perineum via the lesser sciatic foramen, the nerve
supplies the obturator internus muscle.

578. Innervation of the skin of the thigh.

Three nerves run through the region of the anterior and medial thigh:
 Femoral nerve (L2–L4): This nerve runs from the lumbar plexus along the psoas
major past the inguinal ligament to enter the femoral triangle. It has branches that
innervate the anterior thigh muscles and the hip joint.
 Obturator nerve (L2–L4): This nerve runs along the psoas major through the
obturator foramen, where it divides into anterior and posterior branches. It
innervates the adductor longus, adductor brevis, gracilis, pectineus, obturator
externus, and adductor magnus.
 Saphenous nerve: This nerve is the terminal cutaneous branch of the femoral nerve.
It accompanies the femoral artery and innervates the skin and fascia of the knee,
leg, and foot.

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579. Innervation of the skin of the leg.

NEUROVASCULAR STRUCTURES AND RELATIONSHIPS IN POPLITEAL FOSSA

All important neurovascular structures that pass from the thigh to the leg do so by
traversing the popliteal fossa. Progressing from superficial to deep within the fossa, as in
dissection, the nerves are encountered first, then the veins. The arteries lie deepest, directly
on the popliteal surface of the femur, joint capsule, and investing fascia of the popliteus
forming the floor of the fossa.
Nerves in Popliteal Fossa. The sciatic nerve usually ends at the superior angle of the
popliteal fossa by dividing into the tibial and common fibular nerves. The tibial nerve is
the medial, larger terminal branch of the sciatic nerve derived from anterior divisions of
the anterior rami of the L4–S3 spinal nerves. The tibial nerve is the most superfi cial of the
three main central components of the popliteal fossa. The tibial nerve bisects the fossa as it
passes from its superior to its inferior angle. While in the fossa, the tibial nerve gives
branches to the soleus, gastrocnemius, plantaris, and popliteus muscles. The medial sural
cutaneous nerve is also derived from the tibial nerve in the popliteal fossa. It is joined by
the sural
communicating branch of the common fibular nerve at a highly variable level to form the
sural nerve. It
supplies the lateral side of the leg and ankle.
NERVE OF ANTERIOR COMPARTMENT OF LEG
The deep fibular nerve is one of the two terminal branches of the common fibular nerve,
arising between the fibularis longus muscle and the neck of the fibula. After its entry into
the anterior compartment, the deep fibular nerve accompanies the anterior tibial artery,
first between the TA and EDL and then between the TA and EHL. The deep fibular nerve
then exits the compartment, continuing across the ankle joint to supply intrinsic muscles,

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and a small area of the skin of the foot. A lesion of this nerve results in an inability to
dorsifl ex the ankle.
NERVES IN LATERAL COMPARTMENT OF LEG
The superficial fibular nerve, a terminal branch of the common fi bular nerve, is the nerve
of the lateral. The superficial fibular nerve continues as a cutaneous nerve, supplying the
skin on the distal part of the anterior surface of the leg and nearly all the dorsum of the
foot.
NERVES IN POSTERIOR COMPARTMENT
The tibial nerve (L4, L5, and S1–S3) is the larger of the two terminal branches of the
sciatic nerve. It runs vertically through the popliteal fossa with the popliteal artery, passing
between the heads of the gastrocnemius, the two structures exiting the fossa by passing
deep to the tendinous arch of the soleus.
The tibial nerve supplies all muscles in the posterior compartment of the leg. Postero-
inferior to the medial malleolus, the tibial nerve divides into the medial and lateral plantar
nerves. A branch of the tibial nerve, the medial sural cutaneous nerve, is usually joined by
the sural communicating branch of the common fibular nerve to form the sural nerve.This
nerve supplies the skin of the lateral and posterior
part of the inferior third of the leg and the lateral side of the foot. Articular branches of the
tibial nerve supply the knee joint, and medial calcaneal branches supply the skin of the
heel.

580. Innervation of the skin of the foot.

The cutaneous innervation of the foot is supplied;

• Medially by the saphenous nerve, which extends distally to the head of 1st metatarsal.
• Superiorly by the superficial and deep fibular nerves.
• Inferiorly by the medial and lateral plantar nerves; the common border of their
distribution extends along the 4th metacarpal and toe or digit.
• Laterally by the sural nerve, including part of the heel.

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• Posteriorly by medial and lateral calcaneal branches of the tibial and sural nerves,
respectively.

The saphenous nerve is the longest and most widely distributed cutaneous branch of the
femoral
nerve; it is the only branch to extend beyond the knee. In addition to supplying the skin
and fascia on the anteromedial aspect of the leg, the saphenous nerve passes anterior to the
medial malleolus to the dorsum of the foot, where it supplies articular branches to the
ankle joint and continues to supply skin along the medial side of the foot as far anteriorly
as the head of the 1st metatarsal.
Superfi cial and Deep Fibular Nerves. After coursing between and supplying the fibular
muscles in the lateral compartment of the leg, the superficial fibular nerve emerges as a
cutaneous nerve about two thirds of the way down the leg. It then supplies the skin on the
anterolateral aspect of the leg and divides into the medial and intermediate dorsal
cutaneous nerves, which continue across the ankle to supply most of the skin on the
dorsum of the foot. Its terminal branches are the dorsal digital nerves that supply the skin
of the proximal aspect of the medial half of the great toe and that of the lateral three and a
half digits.
The medial plantar nerve, the larger and more anterior of the two terminal branches of the
tibial nerve, arises deep to the flexor retinaculum. It enters the sole of the foot by passing
deep to the abductor hallucis. It then runs anteriorly between the AH muscle and the flexor
digitorum brevis, supplying both with motor branches on the lateral side of the medial
plantar artery. After sending motor branches to
the flexor hallucis brevis and 1st lumbrical muscle, the medial plantar nerve terminates
near the bases of the metatarsals by dividing into three sensory branches. These branches
supply the skin of the medial three and a half digits, and the skin of the sole proximal to
them.
The lateral plantar nerve, the smaller and more posterior of the two terminal branches of
the tibial nerve, also courses deep to the AH, but runs anterolaterally between the 1st and
2nd layers of plantar muscles, on the medial side of the lateral plantar artery. The lateral
plantar nerve terminates as it reaches the lateral compartment, dividing into superficial and
deep branches. The superficial branch divides, in turn, into two plantar digital nerves that
supply the skin of the plantar aspects of the lateral one and a half digits, the dorsal skin and
nail beds of their distal phalanges, and skin of the sole proximal to them.
The sural nerve is formed by union of the medial sural cutaneous nerve and sural
communicating branch of the common fibular nerve, respectively. The level of junction of
these branches is variable; it may be high or low. Sometimes the branches do not join and,
therefore, no sural nerve is formed. In these people, the skin normally innervated by the
sural nerve is supplied by the medial and lateral sural cutaneous branches. The sural nerve
accompanies the small saphenous vein and enters the foot posterior to the lateral malleolus
to supply the ankle joint and skin along the lateral margin of the foot.

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