Contents

Embryology  1

Thorax  10

Abdomen  16

Head, Neck and Face  22

Neuroanatomy : Part 1  30

Neuroanatomy : Part 2  35

Upper Limb : Part 1  41

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Upper Limb : Part 2  46

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Lower Limb : Part 1  49
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Lower Limb : Part 2  54

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 Embryology 1

EMBRYOLOGY ----- Active space -----

Development of Germ Layers 00:00:23

Notochord Neural tube

Neural crest cells

Intra embryonic coelom Ectoderm

Lateral plate meso Mesoderm
Intermediate meso Endoderm
Para-axial meso
Germ layers

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Mesoderm :
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Lateral plate Intermediate mesoderm Para axial

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mesoderm (LPM) mesoderm

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Urogenital system
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Divided by Somites
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intra-embryogenic Urinary Genital

©

coelem bladder. ducts.

Somatopleuric LPM Splanchnopleuric LPM Dermatome Sclerotome. Myotome

• Dermis of front & limb. • Cardiac muscles. Dermis of back. • Skeletal muscles
• Appendicular skeleton. • Smooth muscles. (Except
pharyngeal
Exceptions to smooth muscles : muscles).
Smooth muscle Derivative of • Axial skeleton.
• Smooth muscles of ascending aorta,
pulmonary trunk, coronary artery Neural crest cells
• Ciliaris muscle
• Sweat gland
Ectoderm
• Mammary gland
• Sphincter & dilator pupillae Neuroectoderm

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 2 Anatomy

----- Active space ----- Neural Tube :

Formation :
Formed by stimulation of ectoderm by notochord.

Neural groove

Neural crest
cells (NCC)

Remnants of notochord :

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1. Apical ligament of dens.

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2. Nucleus pulposus (Central part of intervertebral disc).
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3. Tectorial membrane (Continuation of posterior longitudinal ligament).
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Derivatives :
Note :
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Forms CNS structures :

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Intervertebral disc : 2 parts.

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• Brain & spinal cord.

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• Outer : Annulus fibrosus.

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• Oligodendrocytes (Myelination).
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• Central : Nucleus pulposus.

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• Astrocytes (Blood brain barrier).

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• Ependymal cells (Lining of ventricles).

• Retina & pigment.
Neural Crest Cells (NCC) :
Present at the junction of neural tube & ectoderm.
Structures formed

PNS structures : Derivatives of head & neck :

• All ganglion. • Skull bones (Most).
• Enteric plexus. • Dentine (Odontoblasts).
• Schwann cells. • Pharyngeal arch cartilage.
• Adrenal medulla. • Dermis of head & neck.
• Parafollicular-C cells. • Conotruncal septum.
• Melanoblast/cyte.
Note : Adrenal cortex Derivative of intermediate mesoderm.
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 Embryology 3

Development of Diaphragm 00:16:08 ----- Active space -----

Derivatives :
Structure Derivative
Body wall mesoderm/ Muscles of
A
cervical somites diaphragm
A B
Dorsal mesentery of Crus of
B D
esophagus diaphragm
C Septum transversum Central tendon C
Pleuroperitoneal Incorporated
D
membrane by muscles

Applied Anatomy :
Congenital diaphragmatic hernia :
• Occurs d/t absence of pleuroperitoneal membrane

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Persistence of pleuroperitoneal canal (Bochdalek foramen)
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Intestinal herniation.
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• Left > Right.

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• Complication : Lung hypoplasia.

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Pharyngeal Arches
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00:20:45
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Core of mesoderm, lined by ectoderm on one side & endoderm on the other.
©

Pouch Endodermal
Mesoderm
Cleft
Endoderm
Ectodermal Ectoderm
Pharyngeal Clefts :

1st cleft :
• Only cleft that persists.
• Derivatives :
Cervical sinus
- External auditory canal.
- Outer layer of tympanic membrane.
Formed by outgrowth of 2nd arch ectoderm

Obliterates 2nd-4th clefts.

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 4 Anatomy

----- Active space ----- Applied anatomy :

Persistence of cervical sinus Branchial cyst : Swelling along sternocleidomastoid.

Pharyngeal Pouches :
Pouch Derivatives
• Inner layer of tympanic membrane
• Tympanic cavity
1
• Auditory tube/eustachian tube
• Mastoid antrum

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2 • Palatine tonsil

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• Thymus
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• Inferior parathyroid
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4 • Superior parathyroid
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Remnant of 5th pouch • Ultimobranchial body

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Note :
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C-cells : Derived from NCC > Ultimobranchial body.

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Applied anatomy :
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DiGeorge syndrome :
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• Anomaly of 3rd > 4th pouch.

• M/C micro-deletion syndrome : 22q11 deletion.
• Absent thymus & hypoparathyroidism.
DiGeorge syndrome

Pharyngeal Arch Cartilages

Arch Derivative structures
• Meckel’s cartilage Malleus & incus
1
• Mandible
• Stapes (Except footplate : Derived from otic capsule)
• Styloid process
2
• Stylohyoid ligament
• Lesser cornua of hyoid
• Greater cornua of hyoid
3
• Body of hyoid
4&6 • Laryngeal cartilages

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 Embryology 5

----- Active space -----

1st arch
2nd arch
3rd arch
4th arch
6th arch

Derivatives of pharyngeal arches

Arterial & Venous Development 00:31:23

VENOUS DEVELOPMENT
Rt. anterior cardinal V. Lt. anterior cardinal V. (Lt. ACV)
(Rt. ACV)

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mosis
Rt. brachiocephalic V. nasto Lt. brachiocephalic V.

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Oblique a
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Superior vena cava

Mesonephric V.
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R CCV L CCV Supracardinal V.

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Subcardinal V.
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Rt. posterior cardinal V. Lt. posterior cardinal V. Inter subcardinal

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anastomosis
©

Rt. HCC
Superior vena
cava 6 Lt. PCV

Rt. PCV 5 Adrenal veins/Supra renal veins :

Azygous V. (From cranial part of subcardinal V.)
Inter subcardinal anastomoses
Rt. Subcardinal V. 4
Lt. Subcardinal V.
Rt. Supracardinal V. Lt. Supracardinal V.
Rt Renal V. 3 Lt. Renal V.
2
Inferior vena cava
(1+2+3+4+5+6) 1

Gonadal veins
(From caudal part of Subcardinal V.)
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----- Active space ----- Vein Derivative of

Rt. brachiocephalic vein Right ACV
Lt. brachiocephalic vein Left ACV + Oblique anastomosis
Superior vena cava Right ACV + Right CCV
Right PCV
Right supracardinal
Inferior vena cava
+ Anastomosis
Right subcardinal
Right Right mesonephric vein
Renal vein
Left Left mesonephric vein + Intersubcardinal anastomosis
Azygos vein Right supracardinal vein > Right PCV
Gonadal vein Caudal part of subcardinal vein
Adrenal vein Cranial part of subcardinal vein

PHARYNGEAL ARCH ARTERIES

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Connect the developing heart in the front to the 2 dorsal aorta.

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Structure Arch artery
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• Aortic sac
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Arch of aorta • Left horn of aortic sac

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• Left 4th arch artery

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Brachiocephalic trunk Right horn of aortic sac

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CCA Proximal part of 3rd arch artery

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ICA Distal part of 3rd arch artery

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Left Left 7th cervical intersegmental artery

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Subclavian
artery • Right 4th arch artery
Right
• Right 7th cervical intersegmental artery
Pulmonary artery Proximal part of 6th arch artery
Ductus arteriosus Distal part of 6th arch artery

Applied aspect :
Recurrent laryngeal nerve (RLN)

Left side Right side

Hooks under left 6th arch artery 5th arch artery + Distal part of
(Limited by ligamentum arteriosum) right 6th arch artery disappears

Longer course. Hooks just below 4th arch artery

Shorter course.

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Rt. dorsal aorta Lt. dorsal aorta ----- Active space -----
Rt.RLN Lt.RLN

ICA ICA
ECA ECA
CC
A A
1 CC
2 Arch of aorta

3 DA Lt. 7th cervical intersegmental A.

Rt. 7th cervical LB LB
intersegmental A. Ductus arteriosus
AS
Brachiocephalic A. Lung buds
(Invaded by pulmonary A.)
Dysphagia lusoria :

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Obliteration of right Persistence of caudal Abnormal right

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4th arch artery part of right dorsal aorta subclavian artery

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Obliterated
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Rt. 4th arch A.

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Arch of aorta
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Caudal part of
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Lt. dorsal aorta

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Persistant caudal
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Rt. dorsal aorta Fused dorsal

aortae

Double aortic arch : Persistence of both sides.

• 4th arch arteries &
• Dorsal aorta.
Arterial Derivatives :
Aortic arch Derivatives
1st arch Maxillary artery
2nd arch Hyoid & stapedial artery
3rd arch CCA & proximal ICA
Left : Arch of aorta
4th arch
Right : Part of right subclavian
5th arch Degenerates
Left : Proximal left pulmonary artery, distal ductus arteriosus
6th arch
Right : Right pulmonary artery

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 8 Anatomy

----- Active space ----- Mesogastrium & Derivatives 00:58:20

Ventral mesogastrium : Dorsal mesogastrium :

1. Triangular ligament 1. Gastrophrenic ligament
2. Coronary ligament 2. Lienorenal ligament
3. Falciform ligament 3. Gastrosplenic ligament
4. Lesser omentum 4. Greater omentum

Midgut :
Anomalies :
Anomaly Defect in rotation Features

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Non-rotation

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Herniation followed by arrest • Small intestine on right side.
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after 1st rotation • Large intestine on left side.

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Reverse rotation
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Herniation + normal 1st rotation Transverse colon overlapped

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followed by reverse rotation by SMA & small intestine

Mixed rotation

Subpyloric caecum held by

Absent 3 rotation
rd
Ladd Band Compresses
small intestine

Incomplete rotation

Incomplete 3rd rotation Subhepatic caecum

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 Embryology 9

Omphalocoele vs gastroschisis : ----- Active space -----

Omphalocoele Gastroschisis
• D/t incomplete lateral folding of embryo.
Failure of reduction of
Defect • Re-herniation of midgut from a defect in
physiological hernia
anterior abdominal wall.
A/w multiple anomalies
Associations Intestinal obstruction
High mortality

Genital Duct Derivatives :

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Intermediate mesoderm :

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• Mesonephric duct. gm Mesonephric duct
• Paramesonephric duct.
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Genital ridge
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• Genital ridge.
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Paramesonephric duct
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Males vs females :
Males Females
• Posterior wall of urethra
• Ureteric bud & derivatives
Mesonephric duct/ • Trigone
Wolffian duct Remnant :  Gartner’s duct
• Spermatic pathway
• Appendix of epididymis
In Broad ligament
Remnants : • Fallopian tube
Paramesonephric duct/
• Appendix of testes • Uterus
Mullerian duct
• Prostatic utricle • Upper vaginal wall
Genital ridge Testes Ovaries

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----- Active space ----- THORAX

Diaphragm  00:00:10

OPENINGS IN THE DIAPHRAGM

Foramen of Morgagni
Venacaval opening
Esophageal opening
Aortic opening
Medial arcuate ligament
Lateral arcuate ligament

Sympathetic chain

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T12 subcostal

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vessels & nerve

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Inferior view of diaphragm
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Major Openings :
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Opening Level Location Traversing structures

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• IVC
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1 Venacaval opening T8 Central tendon

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• Right phrenic nerve

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• Oesophagus
©

Muscular part,
• Right & left X nerve
2 Esophageal opening T10 Surrounded by
• Esophageal branch of
right crus
left gastric artery
• Aorta
B/w right &
• Azygos vein
3 Aortic opening T12 left crura of
• Hemiazygos vein
diaphragm
• Thoracic duct
Minor Openings :
Opening Transversing structures
1 Foramen of Morgagni Superior epigastric vessels
2 Medial arcuate ligament Sympathetic chain
3 Lateral arcuate ligament T12 subcostal vein, artery & nerve

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 Thorax 11

Thoracic Wall  00:07:15 ----- Active space -----

NEUROVASCULAR ARRANGEMENT IN INTERCOSTAL (I/C) SPACE

Internal Innermost
intercostal intercostal
External
intercostal Parietal fascia
Vein
Nerve block Artery
Nerve

Endothoracic fascia
Pleural tap

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Cross section of intercostal space

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Applied anatomy :
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• Pleural tap : Needle inserted at upper border of lower rib.

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• Intercostal nerve block : Administered at lower border of upper rib.

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Note : Ist intercostal space arrangement : Nerve Artery Vein.

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Intercostal Nerves :
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• T1, T2 : Contribute to upper limb.

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• T3 - T6 : Typical I/C nerve.

• > T6 : Supply anterior abdominal wall.

Intercostal Arteries :
Costocervical trunk Subclavian A
Internal Thoracic A
1st rib
PICA 2nd rib AICA (Anterior I/C artery)
A
O PICA
R PICA
T
A PICA
6th I/C space
Superior epigastric A
Musculophrenic A

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 12 Anatomy

----- Active space ----- • PICA (Posterior I/C artery) :

- 1st & 2nd I/C spaces : Branch of costocervical trunk of subclavian artery.
- Remaining I/C spaces : Branch of aorta.
- Course : Distal part of rib Costochondral junction.
• AICA :
- Branch of subclavian artery in all I/C spaces.
- Course : Costochondral junction Anastomose with PICA.

Applied anatomy : Post-ductal coarctation of aorta

3rd space onwards : Reverse blood flow from AICA PICA Descending aorta

Thick, engorged, tortuous arteries

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X-ray : Rib notching.

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Fate of internal thoracic artery : gm
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At 6th I/C space

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Musculophrenic artery Superior Epigastric artery

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AICA in 7th to 9th I/C spaces. Muscles of abdomen.

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Intercostal Venous Drainage :

©

Rt. Brachiocephalic V. Lt. Brachiocephalic V.

Rt. 1st posterior intercostal V. Lt. 1st posterior intercostal V.
(AKA highest intercostal V.) (AKA highest intercostal V.)

Rt. superior intercostal V. SVC (T4) Lt. superior intercostal V.

(Direct tributary of Azygos V.) (Directly drains into Lt. Brachiocephalic)
Accessory
hemiazygos V.
Azygos V.
IVC
Hemiazygos V.

• 1st I/C vein drains Drains Brachiocephalic vein.

• Superior I/C vein (2nd to 4th) :
- Right Azygos vein.
- Left Lt. Brachiocephalic vein.

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 Thorax 13

Bronchopulmonary Segment (BPS)  00:24:00 ----- Active space -----

• Portion of lung aerated by 1 tertiary bronchus.

• Right lung : 10 BPS, Left lung : 9 BPS.
Tertiary bronchus
Pulmonary A. : Bronchial A.
• Deoxygenated (Till respiratory
blood to alveoli. bronchiole)
• Till alveolus.
Visceral pleura
Pulmonary V. :
• Oxygenated Pulmonary septa
blood to alveoli. (Extension of
• Site : Intersegmental. Schematic of BPS visceral pleura)
Right lung :

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• Right bronchus : Shorter, wider, vertically oriented ↑ Chance of infection.

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(Aspiration)
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• Apical segment of upper lobe : Least vascular (Site for TB).
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• Right superior basal of lower lobe : Most dependent BPS in supine position.
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• Right posterior basal segment of lower lobe : Most dependent BPS in

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sitting/standing.
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Pericardial Sinuses & Interior of Heart  00:32:28

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PERICARDIAL SINUSES
©

Ascending aorta (AA)

Arterial tube
SVC Pulmonary trunk (PT)

Transverse sinus PV
PV
Venous tube PV
PV Fibrous pericardium (Opened)

Oblique sinus Esophageal impression

IVC

SVC : Superior Vena Cava

IVC : Inferior Vena Cava
PV : Pulmonary Vein
Sinuses of the heart
Transverse sinus :
• Continuous space b/w the arterial & venous tubes.
• Surgical importance : Site for ligation of ascending aorta & pulmonary trunk.
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----- Active space ----- Oblique sinus :

• Cul-de-sac : Closed above.
• Space b/w the 4 pulmonary veins, behind left atrium.
• Allows expansion of left atrium without compressing esophagus.

INTERIOR OF THE HEART

Interior of Right Atrium :
Rough anterior wall
Parts Separated by crista terminalis.
Smooth posterior wall

Site of SA node

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Crista terminalis
Tendon of Todaro

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Musculi pectinati gm
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Opening for SVC FO Triangle of Koch Site of AV node

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Opening for IVC

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Septal cusp
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Opening for coronary sinus

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FO : Fossa ovalis (In interatrial septum)

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Interior of Right Ventricle :

©

Rough inflowing part

Parts Separated by supraventricular crest.
Smooth outflowing part

Smooth outflowing part (Infundibulum)

Supraventricular crest
Trabeculae carneae (Ridge/bridge/papillary muscle)
Cusp of tricuspid valve Rough inflowing part

Chordae tendinae
Papillary muscles (Chordae tendinae attachment)
Prevents backflow of blood

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 Thorax 15

Coronary Circulation 00:45:20 ----- Active space -----

Arterial Supply :

Aortic Sinus Circumflex A. Index :

R L LCA • LCA : Left coronary artery.
A • RCA : Right coronary artery.
Left marginal A.
(Obtuse marginal)
• LAD : Left anterior descending artery.
RCA • PIVA : Posterior interventricular artery.
Diagonal A. • Right (R), Left (L),
PIVA Anterior (A) : Aortic sinus.

LAD (Anterior interventricular A.)

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Right marginal A

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(Acute marginal A )
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Cardiac dominance :
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RCA Right dominance

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Based on origin of PIVA

Circumflex artery Left dominance
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Blood supply to the conduction system :

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• RCA : SA node, AV node, Bundle of His.

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• LCA : RBB & LBB.

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Venous Drainage :
©

Oblique V. of Lt. atrium

(Minor tributary).
Anterior cardiac V.
Great Cardiac V.
Directly open into
right atrium
Accompanied by :
• Lt. anterior descending A.
Coronary sinus • Circumflex A.

Small cardiac V. Posterior vein of Lt. ventricle

(Minor tributary)
Accompanied by :
• Rt. marginal A.
• RCA. Middle cardiac V. Accompanied
Tributaries of coronary sinus by : PIVA.

Note : Anterior cardiac veins are not tributaries of coronary sinus.

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----- Active space ----- ABDOMEN

Inguinal Canal  00:00:15

Relations of Inguinal Canal :

Fascia transversalis (FT)

External oblique muscle (EOM) Deep inguinal ring (DIR) Opening in FT.
Internal oblique muscle (lOM)
Inguinal canal
Transversus abdominis (TA)
Conjoint tendon
Arching fibres of TA & IOM Superficial inguinal ring (SIR)

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Ilioinguinal N.

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Opening in EOM aponeurosis
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External oblique gm
aponeurosis (EOA) (EOA).
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b8
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Inguinal Canal
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DIR
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FT
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Arching fibres of TA and IOM

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Conjoint tendon (CT)

TA Reflected part of inguinal
IOM ligament
EOA
SIR
Transverse section of inguinal canal
Anterior wall :
• External oblique aponeurosis.
• Internal oblique muscle (IOM).
Posterior wall :
• Fascia transversalis (FT).
• Conjoint tendon.
Roof : Arched fibers of internal oblique & transverse abdominis (TA).
Floor :
• Inguinal ligament.
• Lacunar ligament.
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Peritoneal Folds 00:06:30 ----- Active space -----

Falciform ligament :
Connects liver to
anterior abdominal wall. Lesser omentum

Gastrosplenic ligament : Free margin

Connects spleen and stomach. Bile ducts
Hepatic artery Portal triad
Portal vein
Splenorenal
ligament
Rt. suprarenal gland
Epiploic foramen :
Connection b/w greater Rt. kidney
T12 body IVC
sac & lesser sac.

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SP : Spleen L : Liver
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ST : Stomach IVC : Inferior vena cava
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Contents :
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Peritoneal fold Contents

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Falciform ligament Ligamentum teres (Remnant of left umbilical vein)

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• Splenic artery
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Splenorenal/lienorenal ligament
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• Tail of pancreas
©

• Short gastric artery

Gastrosplenic ligament
• Left gastroepiploic artery

Free margin : Attached margin :

Lesser Omentum • Hepatic artery • Left gastric artery
• Bile duct • Right gastric artery
• Portal vein

Epiploic Foramen/Foramen of Winslow :

Bile duct
Epiploic foramen
Anterior Hepatic artery

Portal vein Inferior vena cava

Rt. suprarenal gland Posterior
T12 vertebral body

Transverse section of epiploic foramen

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 18 Anatomy

----- Active space -----

Roof : Caudate lobe of liver

Floor : 1st part of duodenum

(Not pylorus of stomach)

Most dependent site of peritoneal cavity :

Supine : Hepatorenal pouch of Morrison
Females : Rectouterine pouch
Sitting/Standing
Males : Rectovesical pouch
Phrenicocolic Ligament :

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• Connects diaphragm to splenic flexure of colon.

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• Responsible for spleen being directed toward right iliac fossa in splenomegaly.
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Perineum 00:17:50
b8
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Pelvic Diaphragm :
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Superior-most layer of perineum, that separates the pelvis from perineum.

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Components :
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Pubococcygeus Iliococcygeus Ischiococcygeus

©

Modifications of pubococcygeus :
1. Pubourethralis Pubococcygeus
Levator ani
2. Pubovaginalis Iliococcygeus

3. Puborectalis Ischiococcygeus

Muscle of continence
(Maintain anorectal angle)

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 Abdomen 19

Urogenital Diaphragm : ----- Active space -----

Inferior layer of Bulb & bulbospongiosus (BS)

urogenital diaphragm
(Perineal membrane) Crus & ischiocavernosus (IC)

Superficial transverse perineal

muscle (STP)
Perineal body

External anal sphincter (EAS)

Inferior layer

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Urogenital diaphragm
IC

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(Inferior layer)

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Levator ani
STP
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Perineal body
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Pelvic diaphragm
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EAC
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Perineal Body :
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Paired (4) : Unpaired (2) :

©

1. Superficial transverse perinei. 1. External anal sphincter.

2. Deep transverse perinei. 2. Longitudinal muscle of anal canal.
3. Bulbospongiosus.
4. Levator ani.
Note : Ischiocavernosus is not a part of perineal body.
PERINEAL POUCH
Scarpa’s fascia Pelvic diaphragm
DPP Superior layer of urogenital diaphragm
Transverse perineal Inferior layer of urogenital diaphragm
ligament (Perineal membrane)
SPP
Deep perineal pouch : B/w superior &
inferior layer of urogenital diaphragm.
Superficial perineal pouch : Below
Dartos muscle & fascia the perineal membrane.
Colle’s fascia
Boundaries of deep perineal pouch
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 20 Anatomy

----- Active space ----- Extravasation of Urine :

Injury to

Membranous urethra Bulbar urethra

Deep perineal pouch Superficial perineal pouch

D/t deficient anterior wall

Extravasation of urine into :

Scrotum Anterior abdominal wall Thigh.

Contents :
Deep perineal pouch :

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• Membranous urethra.

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• External urethral sphincter. gm
• Bulbourethral (Cowper’s) gland (Male).
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Superficial perineal pouch :

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• Bulb of penis & bulbospongiosus.

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• Crus of penis & ischiocavernosus.

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ro

• Superficial transverse perinei & other muscles below perineal membrane.

ar
M

• Bartholin’s gland (Females).

©

ISCHIORECTAL FOSSA/ISCHIOANAL FOSSA

Obturator internus

Pudendal canal

Levator ani
Ischiorectal fossa
Ext. anal sphincter (EAS)
Coronal section

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 Abdomen 21

Levator ani Anal fascia ----- Active space -----

Lunate fascia
3
Obturator fascia
2
Obturator interna
EAS 1
Pudendal canal contains :
Perianal fascia • Pudendal nerve.
• Internal pudendal vessels.

Contents :
1. Fat
2. Inferior rectal nerves & vessels
3. Pudendal canal & its contents

om
l.c
ai
Applied anatomy : gm
9@

Drainage of Ischiorectal fossa abscess :

b8

• Risk of injury to inferior rectal nerves & vessels (D/t horizontal course)
bb

• Horseshoe recess : Communication of both IRF Spread of IRF abscess

he
sa

to the C/L side.

|
w
ro
ar
M
©

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 22

----- Active space ----- HEAD, NECK AND FACE

Cranial Nerve Nuclei & Columns 00:00:10

CRANIAL NERVE COLUMN

Efferent Afferent
GSE SVE GVE GVA & SVA GSA SSA
Pharyngeal arch
General Vision,
muscles General
Extraocular & Smooth muscles sensations olfaction,
Supply (Mastication, facial sensations from
tongue muscles & glands from viscera + hearing &
expression, palate, body wall
taste balance
pharynx, larynx)

om
III (Superior Mesencephalic CN 1 & II :

l.c
colliculus) No nuclei
Edinger
ai
Midbrain gm
IV (Inferior Westphal
9@

colliculus) CN VIII :
b8
bb

SSN Principal
V3
he

Pons VI (Facial sensory

sa

colliculus) VII ISN

|
w
ro
ar

IX Spinal
M

Dorsal
X nucleus
©

XII nucleus of NTS

Medulla XI Vestibulo-
vagus
Trigeminal cochlear
Nucleus ambiguus nucleus nucleus
Index :
GSE : General somatic efferent. GSA : General somatic afferent.
SVE : Special visceral efferent. SSA : Special somatic afferent.
GVE : General visceral efferent. SSN : Superior salivatory nucleus.
GVA : General visceral afferent. ISN : Inferior salivatory nucleus.
SVA : Somatic visceral afferent. NTS : Nucleus tractus solitarius.

Parasympathetic cranial nerves :

• III : GSE, GVE.
• VII
• IX SVE, GVE, GVA, SVA, GSA.
• X
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 Head, Neck and Face 23

General somatic afferent : Trigeminal nuclei 3 parts. ----- Active space -----

Part Function Location

1
Proprioception :
2 1. Mesencephalic • Mediates jaw reflex Midbrain
• Only site in CNS containing
3 pseudo-unipolar neurons
2. Principal sensory Touch & pressure Pons
3. Spinal nucleus Pain & temperature Medulla

Note :
Any nerve carrying general sensations from body wall can enter the trigeminal
nucleus. Eg :
• Arnold’s nerve.
• Glossopharyngeal nerve (Proprioception from stylopharyngeus).

om
Parasympathetic Ganglion :

l.c
ai
gm
GVE
9@

(Parasympathetic Ganglion Supply

b8

column)
bb
he

Midbrain :
sa
|

III nerve Sphincter pupillae

w
ro

& ciliaris muscle

ar

Edinger Westphal Ciliary ganglion

M
©

Pons :
Greater petrosal N.
Lacrimal gland
VII nerve
SSN Pterygopalatine ganglion
Submandibular &
Chorda tympani sublingual gland
Submandibular
ganglion
IX nerve
ISN Parotid gland
Otic ganglion
Medulla :
Smooth muscles &
X nerve
glands of thorax
& abdomen

Dorsal nucleus of X

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 24 Anatomy

----- Active space ----- Parasympathetic outflow : Cranio-sacral

CN III, VII, IX, X. S2, S3, S4.

Sympathetic outflow : Thoracolumbar T1 to L2.

RULE OF 17
Lesion : X + VII Lesion : XII + V
Deviation : Contralateral deviation Deviation : Ipsilateral deviation

• Right X nerve lesion • Left XII nerve lesion

Deviation of On protrusion, deviation

uvula to the left. of tongue to the left.

om
l.c
ai
• Right VII nerve lesion
gm • Left V nerve lesion
9@

Deviation of
b8

Deviation of facial
bb

muscles to the left. jaw to the left.

he
sa
|
w
ro
ar
M

Deep Cervical Fascia 00:29:11

©

Layers : Nerves Enclosed :

Recurrent laryngeal nerve :

Investing layer Tracheoesophageal groove.
Pretracheal layer : X nerve : Inside carotid sheath.
Encloses thyroid gland
Sympathetic chain : B/w carotid
Carotid sheath sheath & prevertebral fascia (PVF).
Prevertebral layer Phrenic nerve : B/w PVF &
scalenus anterior.
Cervical nerves : B/w scalenus
(Roots of anterior & medius.
brachial plexus)

Transverse section of neck

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 Head, Neck and Face 25

Danger Space of Neck : ----- Active space -----

• Between alar fascia & prevertebral fascia.
• Open below till diaphragm. Buccopharyngeal fascia :
Extension of pretracheal fascia
Infection/abscess can descend Retropharyngeal space
down to posterior mediastinum Alar fascia : Anterior
layer of PVF)
Dysphagia & dyspnea. Danger space of neck

Prevertebral fascia (PVF)

Carotid Sheath :
Receives contribution from Investing layer.
Pretracheal layer.
Prevertebral layer.

om
Contents :

l.c
ai
1. Common Carotid Artery (CCA). gm
9@

2. Internal Carotid Artery (ICA).

b8

3. Internal Jugular Vein (IJV).

bb

4. X nerve.
he

CCA IJV
sa

5. Traversed by IX, XI, XII nerve in the upper part.

|

X
w
ro

Relations :
ar
M
©

Anterior : Ansa cervicalis

CCA IJV

X
Posterior : Sympathetic chain

Investing Layer :
Rule of 2 :
• 2 muscles : Sternocleidomastoid & trapezius.
• 2 glands : Parotid & submandibular.
• 2 ligaments : Stylomandibular & sphenomandibular.
• 2 spaces : Suprasternal & supraclavicular.
• 2 pulleys : Digastric & omohyoid.

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 26 Anatomy

----- Active space ----- Cavernous Sinus & Muscles of Mastication 00:39:45

Cavernous Sinus :
Relations : Superior : Optic nerve & optic chiasma

III
Pituitary gland
Medial wall IV
Lateral wall
Body of sphenoid V1
V2

ICA VI
Contents :
• Internal Carotid artery (ICA).

om
• CN VI (Affected in cavernous sinus thrombosis).

l.c
ai
Applied anatomy : Rupture of ICA Carotidocavernous fistula
gm
9@

Pulsations from ICA

b8

transmitted to cavernous sinus

bb
he
sa

Pulsatile proptosis.
|

Muscles of Mastication :
w
ro

Insertion : Mandible.
ar
M
©

Muscle Temporalis Masseter Medial pterygoid Lateral pterygoid

Function

Elevation
Elevation & (Strongest muscle Elevation (Main), Protraction &
retraction of mastication) Protraction depression
Note :
Articular disc of TMJ (Temporomandibular
joint) : Extension of tendon of lateral pterygoid.

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 Head, Neck and Face 27

Triangles of Neck 00:47:37 ----- Active space -----

Digastric triangle : Submandibular gland

Closely related to lingual nerve : M/c nerve injured during

submandibular/Wharton’s duct Sx.
Posterior Triangle of Neck :
Contents :
Great auricular nerve.
Spinal accessory nerve.

Facial Mastoid
division division

E Great Auricular Nerve (GAN) :

om
J • Root value : C2-C3.

l.c
• Runs with EJV.
ai
V gm
• Supplies :
9@

- Ear lobule.
b8

- Skin at angle of mandible & parotid region.

bb

• Frey’s syndrome : Auriculotemporal nerve (ATN)

he

communicates to GAN (M/c).

sa

• Injured in parotid Sx Sensory loss in shaving area.

|
w
ro

Note : ATN injury during parotid Sx

ar
M
©

Sensory loss on upper 2/3rd of auricle & temple.

Spinal accessory nerve :

• Supplies SCM & trapezius.
• Runs b/w investing layer & prevertebral layer.
• Injury in posterior triangle SCM spared.
• Trapezius affected Difficulty in :
- Shrugging of shoulder.
- Retraction of scapula.
- Overhead abduction
Winging of scapula.

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----- Active space ----- Skull Foramina & Pterion 00:55:40

Foramen Lacerum :
Formation : Space left in b/w the following bones.
1. Sphenoid bone. Foramen lacerum
2. Apex of petrous temporal bone. Jugular foramen
3. Basilar part of occipital bone.
Contents :
True content : Skull foramina
1. Meningeal branches of ascending pharyngeal artery.
2. Emissary veins : Connects cavernous sinus to pterygoid venous plexus.
Partial content :
1. ICA.
2. Sympathetic plexus.

om
3. Deep petrosal nerve. Vidian nerve.

l.c
4. Greater petrosal nerve.
ai
gm
9@

Jugular Foramen :
b8

B/w petrous temporal & occipital bone.

bb
he

Contents :
sa
|

Inferior petrosal sinus

w
ro

IX : Separate dural sheath

ar
M

Common dural sheath X Meningeal branch of ascending

©

XI pharyngeal & occipital artery

Sigmoid sinus

Identification of Cranial Nerves With Dura Mater Intact :

II
Anterior clinoid process
III
IV
V
VI : Longest intradural nerve
VII & VIII : Internal acoustic meatus
IX, X, XI : Jugular foramen
XII : Hypoglossal canal

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 Head, Neck and Face 29

PTERION ----- Active space -----

Formation :
Meeting point of 4 bones :
1. Frontal bone 2. Parietal bone

3. Greater wing of sphenoid 4. Squamous part

of temporal bone
Structures Lying Deep to Pterion :
1. Anterior division of middle meningeal artery (MMA).
2. Middle cerebral vessels.

om
3. Sylvian fissure.

l.c
4. Insula.
ai
gm
5. Broca’s motor speech area (On the left).
9@

6. Lesser wing of sphenoid.

b8
bb

Applied anatomy :
he
sa
|

Fracture at pterion
w
ro
ar

Rupture of anterior division of MMA

M
©

Extradural haemorrhage.

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 30

----- Active space ----- NEUROANATOMY : PART 1

Spinal Cord Tracts 00:00:10

ASCENDING TRACTS
Fasciculus gracilis (LL)
Dorsal column tracts
Fasciculus cuneatus (UL)
Run on the same
Dorsal spinocerebellar tract side of spinal
Spinocerebellar tracts cord.
Ventral spinocerebellar tract
Lateral spinothalamic tract
Spinothalamic Decussate.

om
Anterior spinothalamic tract tracts

l.c
ai
gm
9@
b8

Tract Function
bb

• Conscious proprioception
he

Fasciculus gracilis (Lower Limb)

sa

• Fine touch
|

• Vibration
w
ro

Fasciculus cuneatus (Upper Limb) • Stereognosis

ar

• Minor : Pressure
M
©

Dorsal spinocerebellar tract

Unconscious proprioception
Ventral spinocerebellar tract
Lateral spinothalamic tract Pain & temperature
Anterior spinothalamic tract Crude touch & pressure

Spinothalamic Tract (STT) :

Spinal leminiscus Medial leminiscus
Level of injury Loss of function
Brainstem C/L Brainstem
Spinal cord C/L
At the level of entry of tract I/L Lateral STT Anterior STT

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 Neuroanatomy : Part 1 31

Applied aspect : ----- Active space -----

Brown sequard syndrome

Involvement of Lateral/Anterior spinothalamic tract (STT)

At the level of lesion Below the level of lesion

I/L loss of pain, temperature, C/L loss of pain, temperature,

crude touch, pressure crude touch, pressure

Dorsal Column Tract (DCT) :

Nucleus gracilis Nucleus cuneatus

om
Medulla

l.c
Fasciculus gracilus Fasciculus cuneatus
ai
gm
9@
b8

DCT
bb
he
sa
|
w
ro
ar

DCT injury I/L loss conscious propioception, vibration, stereognosis,fine touch.

M
©

Spinocerebellar Tract :
Superior cerebellar peduncle

Inferior cerebellar peduncle

Injury to spinocerebellar tract I/L ataxia, loss of unconscious proprioception.

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 32 Anatomy

----- Active space ----- DESCENDING TRACTS

Corticospinal Tract (CST)/Pyramidal Tract :
Responsible for voluntary movements
Lateral CST : Limb
muscles

Anterior CST : Axial

muscles

Cortex

Lower medulla oblangata Pyramidal decussation

UMN

LMN

om
LMN

l.c
LMN

ai
gm
9@
b8
bb

Applied aspect :
he

At the level of lesion I/L flaccid paralysis

sa

Brown-Seguard syndrome
Below the level of lesion I/L spastic paralysis
|
w
ro

Brainstem
ar

00:22:40
M
©

VENTRAL ASPECT OF BRAINSTEM

Cerebral peduncles
(Crus cerebri)
Midbrain CN III : Content of interpeduncular fossa
Interpeduncular fossa CN IV : Dorsal aspect of brainstem
CN V : Ventral aspect of pons

Pons CN VI
CN VII Ponto-medullary junction
Pyramid
CN VIII
CN IX
Medulla oblongata CN X Lateral
to olive
Olive CN XI (Spinal accessory nerve)
CN XII (Hypoglossal) B/w pyramid & olive

Cranial nerves emerging from ventral aspect of brainstem

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 Neuroanatomy : Part 1 33

DORSAL ASPECT OF BRAINSTEM ----- Active space -----

Thalamus
SC SC Superior colliculus (Connected to LGB)
LGB Corpora quadrigemina
IC IC Inferior colliculus (Connected to MGB)
MGB CN IV

Index :
LGB : Lateral geniculate body.
MGB : Medial geniculate body.
SC : Superior colliculus.
IC : Inferior colliculus.

om
l.c
ai
Floor Of IV Ventricle/Rhomboid Fossa : gm
9@
b8
bb
he
sa
|
w
ro

Superior cerebellar peduncle

ar

Sulcus limitans
M

Inferior cerebellar peduncle Facial colliculus

©

Hypoglossal triangle
Vestibular triangle

Vagal triangle

Facial colliculus :
• Elevation produced by the internal genu of facial nerve around the abducent
nucleus. VII nucleus
• Injury to facial colliculus : Affects VII nerve > VI nucleus VI nucleus

Muscles of facial expression > Lateral rectus VII nerve

Cranial nerve nuclei present deep to IV ventricle : VI, VIII, X, XII.

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 34 Anatomy

----- Active space ----- Leminisci 00:38:24

Auditory Pathway :
Mnemonic : E COLI MA.
Eighth nerve Cochlear nucleus Decussates SuperIor Olivary nucleus Lateral leminiscus
(Spiral ganglion)
Auditory cortex Medial geniculate body Inferior colliculus

Arrangement In The Brainstem :

Lateral lemniscus

Spinal lemniscus

Trigeminal lemniscus

om
Medial lemniscus

l.c
ai
gm
Injury :
9@
b8

Leminiscus Clinical features

bb

Lateral leminiscus C/L hearing loss

he
sa

Spinal leminiscus C/L loss of pain & temperature (Below face)

|
w

Trigeminal leminiscus C/L loss of sensations from face

ro
ar

C/L loss of :
M

• Touch
©

Medial leminiscus • Conscious proprioception

(Anterior STT & DCT) • Pressure
• Vibration
• Stereognosis

Examples :

Features Probable Diagnosis

Abducens/Facial nerve palsy +
Pontine syndrome with involvement of medial leminiscus
C/L loss of sensations
Tongue paralysis + C/L loss of
Medial medullary syndrome
conscious proprioception, vibration
Dysphagia, dysarthria (IX, X, XI) +
Lateral medullary syndrome
C/L loss of pain & temperature
Ptosis (III nerve palsy) +
Benedict syndrome
C/L loss of sensations

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 Neuroanatomy : Part 2 35

NEUROANATOMY : PART 2 ----- Active space -----

Cerebellum  00:00:05

Layers of Cerebellar Cortex :

Outside

Largest cells

Efferent from cortex

Only excitatory cell

om
l.c
ai
gm
-
9@

Inside
b8

Deep cerebellar nuclei (In white matter)

bb
he

Mnemonic : Doctor Eat Good Food

sa

Lateral • Dentate (Largest)

|
w

• Emboliform
ro

Nucleus interpositus
ar

• Globose
M
©

Medial • Fastigial
Efferents from cerebellum
Afferents :
ML
PL
Granule cell
GL
Cerebellar glomeruli

Climbing fibres
Mossy fibre
Purkinje cell

Climbing fibres : Mossy fibres :

• Terminates in molecular layer • Terminates in granular layer
• Eg : • Eg : Every other tract
- Olivocerebellar tract
- Paraolivocerebellar tract
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 36 Anatomy

----- Active space ----- Cerebellar Peduncles :

Superior Cerebellar Middle Cerebellar Inferior Cerebellar

Peduncle (SCP) Peduncle (MCP) Peduncle (ICP)

Cortex

Thalamus Dentatothalamic tract &

Dentatorubrothalamic tract
SCP
Ventral spinocerebellar tract
Cortico ponto cerebellar tract : MCP
Remaining tract : ICP

om
l.c
ai
Corticospinal tract gm
9@
b8
bb

Sections of the Brain & Blood Supply 00:15:50

he
sa

Sagittal Section :
|
w
ro

3rd ventricle area

ar

Corpus callosum
M

Septum pellucidum :
©

Fornix Roof
Seperates the 2 lateral ventricles Choroid plexus
Habenular commissure
Anterior Anterior commissure
wall Lamina terminalis Pineal gland Posterior
(Cranial most end of neural tube) Posterior commissure wall
Aqueduct of Sylvius
Optic chiasma
Infundibulum Thalamus
Lateral
Mammillary body Hypothalamic sulcus wall
Floor Posterior perforating Hypothalamus
Substance
Tegmentum of
midbrain
Relation of 3rd ventricle

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 Neuroanatomy : Part 2 37

Transverse Section : ----- Active space -----

Anterior horn of LV
Forceps minor (Connects genu to frontal lobe)
Lentiform nucleus
Genu
Insula Head of caudate nucleus
Internal capsule
Posterior horn of LV Thalamus
Splenium

Tapetum Forceps major (Connects Splenium to occipital lobe)

• Lateral to posterior horn
• Connects to occipital lobe &
lower part of temporal lobe

om
Corpus Collosum :

l.c
ai
Parts : Fibres : gm
Body
9@

• Forceps Major.
b8

• Forceps Minor. Commisural fibres

bb

Genu
Splenium • Tapetum.
he
sa
|
w

Rostrum
ro
ar
M

Internal Capsule :
©

Major tracts :
Anterior limb

Corticonuclear tract
(UMN of cranial nerves) Genu
Posterior limb (PL)
Corticospinal tract
(Anterior 2/3 of PL)
Retrolentiform part
Optic radiation
Sublentiform part
Auditory radiation

Blood supply :
• Genu
Charcot’s artery Branch of MCA.
• Posterior limb

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 38 Anatomy

----- Active space ----- Coronal Section :

Body

Head Caudate nucleus

Thalamus

Corpus callosum Roof

Septum pellucidum Medial wall
Lateral ventricle
Body of caudate nucleus Internal capsule
Thalamo-striate vein Lentiform nucleus
Floor Fornix (2 in number)
Insular cortex :

om
Thalamus
Choroid plexus Hidden gyrus Seen on opening

l.c
lateral sulcus.
ai
(Rough area) gm
9@

3rd ventricle
b8
bb
he
sa
|
w

Relations of lateral ventricle

ro
ar
M
©

Fornix :

Thalamus
Fornix
Corpus collosum

Lateral ventricle

Mammillary body
Hippocampus
Termination
Origin

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 Neuroanatomy : Part 2 39

BLOOD SUPPLY ----- Active space -----

Corpus Callosum :
Body

Splenium
Genu

PCA
ACA
Rostrum

Blood Supply to the Cortex :

Paracentral lobule
Area of MCA

om
ACA
ACA

l.c
ai
MCA gm
9@

PCA
b8
bb

PCA Supplies inferior MCA

he

surface of temporal
sa

& occipital lobes

|

Superolateral surface Medial surface

w
ro
ar
M
©

Area Blood supply

• Broca’s area (44, 45)
MCA
• Wernicke’s area (22, 30, 40)
• Visual cortex PCA
• Lower limb (Sensory & motor)
• Paracentral lobule (Highest centre for
micturition & defecation)
ACA
Applied aspect :
ACA stroke C/L LL paralysis,
Incontinence

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 40 Anatomy

----- Active space ----- Thalamic Radiations Projecting on Cortex  00:53:02

Nuclei & their Output :

Motor cortex

Premotor area 3 Sensory cortex

6 4 1

Cingulate 2
gyrus Auditory cortex (41, 42)

Visual cortex (17, 18, 19)

Superior thalamic Inferior thalamic

radiation radiation

om
Anterior thalamic Posterior thalamic

l.c
radiation
ai
radiation gm
MGB
9@

ATN
b8

LGB
bb
he

Internal Medullary lamina

sa

VA VL VPL VPM
|
w
ro

Nuclei & their Input :

ar
M
©

Nuclei Input
ATN Mammillary bodies Via Mammilo-thalamic tract
Ventroanterior (VA) Globus pallidus Via Pallidothalamic tract
• Dentato-thalamic tract
Ventro lateral (VL)
• Dentato-rubrothalamic tract
Ventroposterolateral • Medial lemniscus Sensations from limbs
(VPL) • Spinal lemniscus
Ventroposteromedial • Trigeminal lemniscus : Sensations from mouth & face
(VPM) • Nucleus of Tractus Solitarius : Visceral sensations

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 Upper Limb : Part 1 41

UPPER LIMB : PART 1 ----- Active space -----

Brachial Plexus 00:00:05

Root value : C5, C6, C7, C8, T1.

Formation :
Roots

Trunks

Divisions : No branches

om
Cords : Based on relation to axillary artery

l.c
ai
gm
9@

Lateral Posterior Medial

b8
bb

Musculocutaneous nerve Radial nerve Ulnar nerve

he
sa
|
w

Note :
ro
ar

Median nerve : Lateral + medial cord.

M
©

Lower trunk
Middle trunk
C5
Upper trunk
C6
Dorsal division C7
Ventral division
C8
Lateral cord
T1

Posterior cord
Musculocutaneous nerve Dorsal division
Medial cord
Radial nerve
Median nerve
Ulnar nerve
Formation of brachial plexus

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 42 Anatomy

----- Active space ----- Injuries To The Brachial Plexus :

Erb’s palsy Klumpke’s palsy
Level of injury Upper trunk Lower trunk
Root value C5, C6 C8, T1
1. Axillary N. (C5, C6) 1. Ulnar N. + Median N. + Radial N.

Deltoid. • Intrinsic muscles of

2. Musculocutaneous nerve hand (Interossei &
Nerve involved & (C5, C6, C7) lumbricals).
Muscles affected
2. T1 sympathetic N. :
• Biceps (C5, C6).
• Brachialis (C5,C6).
• Coracobrachialis : Spared Sympathetic loss on face.
d/t C7 innervation.
Policeman’s tip/Waiter’s
tip hand/Porter’s tip hand 1. Complete claw hand

om
Deformity & deformity : • Hyperextension at MCP joint.

l.c
• Adducted shoulder. • Flexion at IP joint.
ai
manifestation gm
• Extended elbow. 2. Horner’s syndrome.
9@

• Pronated forearm.
b8
bb

Clavipectoral Fascia
he

00:13:15
sa

Pectoralis minor
|

Muscles enclosed
w

Subclavius
ro
ar
M

Clavipectoral fascia
Extensions :
©

• Superior : Continues with investing layer

Subclavius
(Posterior layer) of deep cervical fascia.
Pectoralis minor • Inferior : Suspensory ligament of axilla.

Suspensory ligament
of axilla
Clavipectoral fascia

Clavicle
Subclavius Structures piercing clavipectoral fascia :
2 1. Cephalic vein.
Clavipectoral fascia
2. Thoracoacromial trunk.
3
1 3. Lateral pectoral nerve.
4
4. Lymphatics.
Medial pectoral nerve
Pectoralis minor

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 Upper Limb : Part 1 43

Scapular Muscles & Cubital Fossa 00:19:47 ----- Active space -----

SCAPULAR MUSCLES

Levator scapulae
Trapezius Rhomboid minor
Rhomboid major
Supraspinatus
Infraspinatus
Teres minor Serratus Subscapularis :
anterior Origin : Subscapular fossa.
Teres major
Insertion : Lesser tubercle.
Costal surface of scapula

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Note :
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Rotator cuff muscles :
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1. Supraspinatus. 3. Teres minor.

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2. Infraspinatus. 4. Subscapularis.
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Muscle Action Nerve supply

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• Upper fibres : Shrugging of shoulder.

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• Middle fibres : Retraction of scapula.

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• Upper & lower fibres : Outward rotation of scapula Spinal accessory

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Trapezius
(Glenoid cavity rotated upwards) nerve
©

Overhead abduction.
Levator scapulae Elevation of scapula
Dorsal scapular
Rhomboid minor
Retraction of scapula Downward rotation of glenoid. nerve (C5 )
Rhomboid major
Supraspinatus 0-15˚ Abduction at shoulder -
Infraspinatus
External rotation at shoulder -
Teres minor
Teres major Internal rotation -
Long thoracic nerve/
Serratus anterior Nerve of Bell
Overhead abduction
AKA Boxer’s muscle Injury
Winging of scapula.
Upper & lower
Subscapularis Internal rotation at shoulder
subscapular nerve

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 44 Anatomy

----- Active space ----- CUBITAL FOSSA

Medial : Pronator teres.
Boundaries
Lateral : Brachioradialis.
Contents :
Medial Lateral : MBBS.
• Median nerve. • Biceps brachii tendon.
• Brachial artery. • Superficial branch of radial nerve.

Brachial artery

Biceps brachii tendon Median nerve

Pronator teres (Oblique)

Superficial branch of
radial nerve Ulnar artery

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Brachioradialis Radial artery

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gm
9@
b8

Cubital fossa
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Intrinsic Muscles Of Hand

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00:35:25
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Thenar Muscles :
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1. Abductor pollicis brevis

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2. Flexor pollicis brevis Median nerve

3. Opponens pollicis
4. Adductor pollicis Ulnar nerve.
Nerve injury Function affected
Median nerve
Opposition of thumb
(Irrespective of site)
Ulnar nerve Adduction of thumb
Radial nerve Extension of thumb

Note :
Thumb movements : Test all long nerves of upper limb.

Hypothenar Muscles :
1. Abductor digiti minimi. 3. Opponens digiti minimi.
2. Flexor digiti minimi. 4. Palmaris brevis.
(Subcutaneous muscle)
Nerve supply : Ulnar nerve.
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 Upper Limb : Part 1 45

----- Active space -----

Flexor digiti minimi Adductor pollicis : Grasping & gripping action

Flexor pollicis brevis
Abductor digiti minimi
Abductor pollicis brevis

Lumbricals :
Tendon to tendon muscle.
Origin : Flexor digitorum profundus (FDP).
Insertion : Extensor digitorum.

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Action :
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• Flexion at MCP joint. gm L2
Bipinnate L4 Unipinnate Median nerve
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• Extension at IP joint. L3 L1
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Ulnar nerve Adductor pollicis (Ad.P)

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FDP tendons
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Interossei :
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Palmar interossei (PI) : Dorsal interossei (DI) :

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• 4 in number. • 4 in number.
• Unipinnate • Bipinnate
• Supplied by ulnar nerve. • Supplied by ulnar nerve.
Action : Mnemonic
• PAD : Palmar interossei Adduction of fingers.
• DAB : Dorsal interossei Abduction of fingers.
Note :
• Middle finger : Devoid of PI.
• Thumb & little finger : Devoid of DI.
Middle finger has
Test : 2 dorsal interossei
• PI : Card test.
• DI : Egawa test.
2 2 1
4 3 4 3
1

Palmar Interossei Dorsal Interossei

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 46

----- Active space ----- UPPER LIMB : PART 2

Radial Nerve  00:00:08

Origin : Posterior cord of brachial plexus.

Root value : C5, C6, C7, C8, T1.
Course and Supply :
ECRL : Extensor carpi radialis longus
PIN : Posterior interosseous nerve A
Radial groove Triceps
B
Triceps

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ECRL

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Lateral epicondyle C
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Supinator
9@

D
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Superficial branch PIN

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Extensor digitorum
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Nail beds spared

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Median nerve
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Lateral 3½ dorsum of hand

by superficial branch

Radial Nerve Injuries :

B Saturday D Posterior Interosseous
A Crutch palsy : C Lateral
night palsy : nerve injury (M/c cause : Radial
Axilla injury epicondyle fracture
Radial groove head fracture)
Partial injury :
Triceps
Elbow flexed Weakness in Not involved Not involved
injury
elbow extension
Weak extension at
Wrist
Wrist drop Wrist drop wrist No wrist drop
extensors
d/t ECRL sparing
Finger
Finger drop Finger drop Finger drop Finger drop
extensors
Superficial Sensory loss at lateral Sensory loss at Sensory loss at
branch of 3½ lateral 3½ lateral 3½ No sensory loss
radial nerve dorsum of hand dorsum of hand dorsum of hand

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 Upper Limb : Part 2 47

Note : M/c injured medial/lateral epicondyle fracture Ulnar nerve. ----- Active space -----

Median Nerve 00:14:00

Root value : C5, C6, C7, C8, T1.

Course and Supply :

Brachial artery

A
Pronator teres

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AIN
Flexor digitorum superficialis (FDS)

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Flexor digitorum profundus (FDP)
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(Lateral 1/2)
9@

B
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Thenar muscles Palmar cutaneous branch

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(Except Adductor pollicis) Digital branch

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L1, L2
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Applied aspect : Carpal tunnel syndrome.

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Digital branch affected Sparing of palmar cutaneous branch

Sensory loss over digits. (Superficial to flexor retinaculum)
Sensations of palm preserved.

Digital branches
(Lateral 31/2 fingers : Palmar surface)

Palmar cutaneous branches

(Lateral palmar area)

Cutaneous supply : Palmar surface of hand

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 48 Anatomy

----- Active space ----- Median Nerve Injury :

A : Higher injury B : Lower injury
Thenar muscles Ape thumb deformity
While making a fist :
• Pointing Index finger
FDS & FDP : Spared : Absent pointing index/
OR
(Lateral 1/2) Hand of benediction
• Benediction hand : Cannot
flex index & middle finger
Palmar cutaneous Sensory loss : Lateral 3 1/2 Spared : No sensory loss in lateral
branch palmar surface of hand 31/2 palmar surface of hand
Digital branches Sensory loss : Lateral 3 1/2 fingers (Palmar surface)

Ulnar Nerve 00:28:00

Origin : Medial cord of brachial plexus.

Root value : C7, C8, T1.

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Course and Supply :

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FCU : Flexor carpi ulnaris

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Medial epicondyle
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FCU (Cubital tunnel)

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FDP (Medial 1/2)

Deep branch
Adductor pollicis Guyon’s canal
Graveyard of Ulnar nerve Palmaris brevis
L3, L4 Hypothenars
Interossei
Ulnar Nerve Injury :
Injury to ulnar nerve Intrinsic muscles of hand injured
Ulnar claw hand
(Not complete : L1, L2 supplied by median nerve)
Ulnar paradox
Prominent : Lower injury Less prominent : Higher injury
FDP spared : More flexion at DIP joint. FDP injured : No flexion at DIP.
Test :
Book test Froment sign + : Curling of thumb while trying to hold the book.
(D/t compensatory action of flexor pollicis longus).
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 Lower Limb : Part 1 49

LOWER LIMB : PART 1 ----- Active space -----

Lumbar Plexus & Iliotibial Band 00:00:20

LUMBAR PLEXUS

T12 : Not a part of lumbar plexus

Psoas major Iliohypogastric nerve
L1
Genitofemoral nerve Ilioinguinal nerve
LCNT (L2 - L3)
Iliacus
Femoral nerve

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Obturator nerve

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identification of
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lumbar plexus.
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Applied anatomy : Meralgia paresthetica.

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• Occurs d/t compression of LCNT (Lateral Cutaneous Nerve of Thigh).

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• Features : Sensory loss, tingling, numbness over lateral aspect of thigh.

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Genitofemoral Nerve :
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Pierces but does not supply psoas major (Does not obey Hilton’s law).
©

Branches :
Branch Structure supplied Importance
• Afferent for cremasteric reflex
Femoral Skin over femoral triangle
• Anesthetized in femoral vein cannulation
Genital Cremasteric muscle Efferent for cremasteric reflex
Important Relations :

T12
Iliohypogastric nerve Posterior relation
of kidney.
Genitofemoral Ilioinguinal nerve
Form LCNT Genitofemoral nerve : Forms
caecal bed. Femoral nerve posterior relation of ureter.

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 50 Anatomy

----- Active space ----- ILIOTIBIAL BAND

Modification of fascia lata (Deep fascia of thigh).
Origin : Tubercle of iliac crest.
Insertion : Lateral tibial condyle.
Muscle insertions :
1. Tensor fascia lata.
2. Gluteus maximus.
Applied Anatomy :
Iliotibial band contracture Iliotibial band

Hip joint : Knee joint :

FABER position Flexion & external
• Flexion. rotation of tibia.

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• Abduction.

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• External rotation.
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Anterior & Medial Compartment of Thigh
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00:12:45
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ANTERIOR COMPARTMENT : FEMORAL TRIANGLE

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Boundaries of Femoral Triangle :

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Iliacus
Psoas major
Floor of femoral triangle : Note : Hamstring :
Pectineus
- Knee : Flexion.
Adductor longus - Hip : Extension.
Sartorius :
Same as iliotibial • Hip joint : FABER. Rectus femoris :
band contracture • Knee joint : Flexion. • Knee : Extension.
• Hip : Flexion.
Vastus Vastus
lateralis medialis
Medial boundary : Medial border of adductor longus.
Lateral boundary : Medial border of sartorius.

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 Lower Limb : Part 1 51

Contents : ----- Active space -----

Femoral nerve + femoral sheath (2 + 3 + 4).

1. Femoral nerve
Femoral sheath : Contents (Lateral Medial)

Femoral canal

3. Femoral artery + 4. Femoral 5. Lymph node of Cloquet

Femoral branch of vein (Drains glans/clitoris)
genitofemoral nerve

Formation of femoral sheath :

Anterior : Fascia transversalis.

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Posterior : Fascia iliaca.

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Femoral Nerve : gm
• Content of femoral triangle, lies outside femoral sheath.
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• Root value : L2-L4 (Dorsal division of L2-L4).

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Trunk of femoral nerve supplies :

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• Iliacus.
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• Pectineus.
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Anterior division supplying sartorius

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Intermediate cutaneous nerve of thigh Posterior division supplies :

• Quadriceps.
Medial cutaneous nerve of thigh • Hip joint.
Saphenous nerve
Great saphenous vein (Longest cutaneous nerve)

Applied anatomy :
1. Saphenous vein grafting Injury to saphenous nerve Sensory loss on
medial side of leg &
foot up to great toe.

Cutaneous supply
of saphenous nerve

2. Referred pain of hip joint to medial side of leg & foot : D/t femoral nerve.
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 52 Anatomy

----- Active space ----- MEDIAL/ADDUCTOR COMPARTMENT OF THIGH

Muscles :
1. Gracilis.
2. Obturator externus.
3. Adductor longus.
4. Adductor brevis.
5. Adductor magnus.

Nerve supply : Obturator nerve (Ventral division of L2-L4).

Anterior division Posterior division

Pectineus Obturator externus

Adductor longus

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Adductor Adductor magnus :

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brevis Hybrid muscle Additional supply by

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Gracilis
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Gluteal Region & Popliteal Fossa 00:30:28

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GLUTEAL REGION
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Gluteus medius Superior gluteal nerve

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Gluteus maximus :
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Gluteus minimus
Inferior gluteal nerve
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Superior gluteal nerve & vessels

P.I.N. Piriformis : Identification of gluteal vessels

• Pudendal nerve. Inferior gluteal nerve & vessels
• Internal pudendal
vessels. Sciatic nerve
• Nerve to obturator
internus.

Applied Anatomy :
1. Injury to ischial spine
Greater sciatic notch
Pudendal nerve injury

Perineal muscles affected. Ischial spine P.I.N

(Level of coccyx)
Lesser sciatic notch

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 Lower Limb : Part 1 53

2. Trendelenburg sign : ----- Active space -----

Gluteus medius & minimus:

GT • Abduction.
Iliopsoas LT • Internal rotation.
Flexion of hip Gluteus maximus : Inserted
(Main muscle) at gluteal tuberosity.

• Injury to I/L superior gluteal nerve.

• Injury to I/L gluteus medius/minimus. Inability to abduct & internally rotate
• I/L greater trochanter injury.
C/L pelvic drop. I/L lurching.
POPLITEAL FOSSA

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Boundaries :

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Superolateral : Biceps femoris

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Semitendinosus
Superomedial
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Semimembranosus
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Plantaris
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Inferolateral
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Lateral head of
©

Inferomedial :
gastrocnemius
Medial head of
gastrocnemius

Contents :
1. Popliteal artery.
Deep
2. Popliteal vein.
3. Sciatic nerve Tibial nerve.
Common peroneal nerve. Superficial.

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 54

----- Active space ----- LOWER LIMB : PART 2

Arches of Foot & Ligaments of Ankle  00:00:06

ARCHES OF FOOT
Index :
T : Talus
C : Calcaneum
I II N : Navicular
III IV MC : Medial cuneiform
Lisfranc ligament V IC : Intermediate cuneiform
MC IC LC LC : Lateral cuneiform
Connects medial cuneiform N Cub : Cuboid

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to base of 2nd metatarsal Cub

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T gm II
III Metatarsals
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C
IV
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V
Dorsum of foot
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Bones Main joint

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9 bones :
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• Talus.
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Medial • Navicular. Talocalcaneonavicular

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longitudinal arch • Medial half of calcaneum. (Ball & socket joint)

• I, II, III metatarsals.
• Medial, intermediate & lateral cuneiform.
4 bones :
• IV, V metatarsal. Calcaneocuboid joint
Lateral • Cuboid. (Saddle joint)
longitudinal arch • Lateral half of calcaneum.
LIGAMENTS
Medial Side :
3 medial ligaments : 1. Deltoid ligament :
3. Plantar calcaneonavicular ligament
• Posterior fibres
(AKA Spring ligament) :
• Middle fibres
• Present on plantar surface.
• Anterior fibres
• Extends b/w calcaneum &
navicular tuberosity.
N • Support head of Talus :
2. Sustentaculum tali
• Sustains talus. Ligament tear Flat foot.
C
• Extension of
calcaneum. 3
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 Lower Limb : Part 2 55

Deltoid ligament : ----- Active space -----

Strong ligament of ankle that prevents eversion injury.

Fibres Insertion Origin

Anterior Navicular bone & spring ligament
Middle Sustentaculum tali (Calcaneum) Tibial malleolus
Posterior Talus
Lateral Side :
Lateral collateral ligament of ankle : Formed by 3 bands.

1. Anterior talofibular ligament :

M/c injured in inversion injury at
ankle (Plantar flexed position).

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3. Posterior talofibular ligament

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2. Calcaneofibular ligament
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Tendons of peroneus longus & brevis.

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Sole of Foot
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MUSCLES IN THE SOLE OF FOOT

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4 layers + : Superficial Deep.

Nerve Supply :
Tibial nerve

Flexor Retinaculum of ankle

Medial plantar Lateral plantar

nerve (MPN) nerve (LPN)

Note :
• Adductors
Hand : Ulnar nerve.
• Bipinnates Supplied by dominant nerve
Foot : Lateral plantar nerve.
• Interossei

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 56 Anatomy

----- Active space ----- Ist Layer : IInd Layer :

Origin : Calcaneum.

Lumbricals
• L 1 : Unipinnate
• L2
• L3 4 Bipinnate
Abductor hallucis • L4
Flexor digitoneum longus tendon
Flexor digitorum brevis
Flexor digitorum accessorius /
Abductor digiti minimi Quadratus plantae

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IIIrd Layer : IVth Layer :

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Adductor hallucis
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Flexor hallucis brevis

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Flexor digiti minimi

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Plantar interossei Dorsal interossei

(Unipinnate) (Bipinnate)

Sciatic Nerve 00:25:40

Root value : L4, L5, S1, S2, S3.

Muscle innervation : Hamstring group.

Course :
• Sciatic nerve divides into 2 components :
- Tibial component.
- Common peroneal component.

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 Lower Limb : Part 2 57

Sciatic nerve ----- Active space -----

Tibial component Common peroneal Short head of
component biceps femoris
Hamstrings :
• Semitendinosus
• Semimembranosus Popliteal fossa
• Long head of CPN Neck of fibula
biceps femoris TN
• Adductor magnus
DPN SPN
(Hamstring part)

Flexor retinaculum

MPN
LPN

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Skin over medial margin Saphenous nerve Sural nerve

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Division :
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At popliteal fossa
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Tibial nerve (TN) Common peroneal nerve (CPN)

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Plantar flexors Winds around the neck of fibula

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Deep peroneal nerve (DPN) Superficial peroneal

nerve (SPN)
• Dorsiflexors.
• Skin over 1st web space. • Evertors.
• Majority of skin
over dorsum of foot.
Applied anatomy :
Great saphenous vein : Saphenous nerve.
• Nerve injured during vein grafting
Short saphenous vein : Sural nerve.

• # Neck Injury to Loss of dorsiflexion Foot drop Equino varus

of fibula CPN Eversion Inverted foot
High stepping gait.

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©
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©
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