Anatomy Companion Color

Introduction to Gross Anatomy
Teaching Faculty in the Department

of Anatomical Sciences
Dr RL Jordan, Chair of Department
Dr B Curry, Course Director
Dr F Brahim
Dr R Hage
Dr M Loukas
Dr CV Rao
Ms K Kryger
Mr W Merbs
Ms S Roemer
This Course Companion is not a substitute for a textbook or for attendance at lectures, nor
does it contain all of the information you are expected to learn in this course. It is designed
to serve as a navigational aid in your passage through the Gross Anatomy course. Its
proper use will enable you to coordinate your reading of the required text and anatomical
atlas with lectures, the dissection manual, and your dissection of the cadaver as you build a
three-dimensional visual image of the human body.
Central to the effectiveness of this Companion is the use and understanding of the specific
objectives for each learning session. These define, as precisely as possible, the theoretical
knowledge you are expected to master as you study the various regions of the human body.
These objectives define the required theoretical knowledge in this Gross Anatomy course.
Each lecture in the anatomy course has a section in the Companion, complete with
diagrams that were almost all taken from the Netter Atlas. The relevant section should be
read thoroughly before lecture, and the appropriate diagrams studied in the Atlas, so that
you have a basic understanding of the anatomy of the region in question. That anatomy
will be reviewed in lecture and additional information will be presented.
This Companion will continue to develop with informed input from students and faculty
and we welcome any input from you so that we may continue to refine and improve this
learning tool.
SGU Anatomical Sciences
Introduction
The Gross and Developmental Anatomy course comprises approximately 185 scheduled hours
devoted to you developing a three-dimensional image of the body and its development.
Lectures will be followed by dissection of human cadavers, or study of already dissected
cadavers (prosections), in the gross anatomy laboratory. Lectures will cover the following:
1.
2.
3.
4.
5.
General anatomical concepts

Embryology
Applied anatomy
Radiographic anatomy
Clinical anatomy
It is extremely important that you be familiar with the material to be covered in each lecture
session. Thus it is imperative that you read the pertinent material in this Companion, and in
the Embryology study guide, before attending lectures.
The textbook, Essential Clinical Anatomy by Moore and Agur, will serve as a primary
source of information for Gross Anatomy after lecture. Effective use of the text involves
more than just reading about the anatomical material. An understanding of the basic anatomy
in chapter 1 is essential and the clinical information in the blue boxes will greatly enhance
your understanding of the relevance of the anatomy involved.
The Dissection/Prosection Manual has been prepared to facilitate your dissection efforts. It
details each dissection in a step-by-step manner and provides a checklist of structures to be
identified. You should read the relevant section before coming to the dissection room and
refer to relevant illustrations in Netters Atlas of Human Anatomy as you study and dissect.
Throughout the course, special emphasis is placed on Living Anatomy as a corollary to the
anatomy learned in lecture and laboratory. Living Anatomy is designed to reinforce
dissection knowledge by demonstrating that many structures in the human body may be
palpated in the living individual. Many of the tests that are performed and techniques learned
will serve as an introduction to physical diagnosis.
General Aims and Objectives
The course provides the student with systematic dissection and study of the human body at
the gross level with applied clinical correlation. Its goals are directed toward the student:
1.
2.
3.
4.
5.
6.
acquiring a three-dimensional visual concept of future patients and their development

obtaining an anatomical basis for understanding and appreciating variations of the body
obtaining anatomical knowledge as a basis for subsequent preclinical and clinical study
effectively using anatomical knowledge as a basis for their clinical practice
excelling in the anatomical sections of future standardized medical examinations
describing the anatomical basis for clinical procedures and seeking an anatomical
solution to clinical problems
7. developing a broad anatomical background to allow one to proceed in any direction that
the future of medicine may require
8. acquiring the basis for continuing a lifelong process of self-education and self-evaluation
in anatomical related fields of medical science
Upon successfully completing the course, the student should be able to:
1. demonstrate a three-dimensional understanding of the body by discussing anatomical
concepts related to the following systems: skeletal, muscular, cardiovascular, respiratory,
neural, urogenital, integumentary and endocrine
2. identify gross anatomical structures in a cadaver and fully discuss the gross anatomy,
radiographic and cross-sectional anatomy, and functions and clinical correlates of these
structures according to the account given in the textbook and the specific objectives in the
Course Companion and Dissection Manual
Course and Instructor Critiques
The Student Handbook states that students are expected to attend all classes and other
related academic activitiesas defined for each course by the Course Director. One
such academic activity is your participation in the Course and Instructor Critique program.
Importance of Evaluation: Evaluation is a necessary component of any course. Just as you,
the student, anticipate a fair and accurate evaluation of your performance and achievement in
a course, SGU requires that faculty and course evaluations be completed each term.
Continual evaluation and assessment of faculty ensures that the program not only remains
consistent but also improves as student needs and expectations are considered.
Your Participation in the Evaluation Process is MANDATORY: When you are expected to
complete a course and/or instructor critique, the Office of Education Assessment (OEA) will
notify you via your SGU e:mail account and post a notice outside the lecture hall. This
notification will include instructions on how to access and complete the necessary critique(s).
Once you access a required course or instructor critique, you can either complete it or indicate
that you do not want to complete the critique by checking the appropriate box on the form.
Failure to submit a required critique will mean that you have not fulfilled all course
requirements as defined by the Course Director and you will receive a grade of incomplete
(I). The I grade remains on your transcript until all course work is completed or the
Incomplete is converted to an F. (See Student Handbook for a description of the SGU
Grading Policies).
Please be assured that the information you provide will remain strictly confidential. If you
have any questions about the Course and Instructor Critique System, please contact Nitsa
Topale at the OEA (X2431) or ntopale@sgu.edu.
Examination Policies (see the SGU Student Manual)

Student who fail to appear for an examination, or any other course assessment, without
a valid reason for their absence will receive zero points for that assessment.
Valid reasons for absence are personal health problems and family emergencies.
A student who misses an examination or other assessment due to valid reasons will be
allowed to sit a rescheduled assessment if the Course Director is notified prior to the
date of the original assessment.
Examinations and Course Grades
Two practical (identification) exams and two written exams will be given in Gross and
DevelopmentalAnatomy as part of the midterm and final exams for the course. The
practical exams will be composed of two parts; in the Dissection Room students will
identify 25 structures using multiple choice format. Some tagged structures will test your
conceptual and theoretical knowledge. As a prelude to the written exam, students will
identify 25 structures, shown on PowerPoint slides, using multiple choice format.
Each written examination will consist of 75 multiple choice questions which will generally
follow the format used in the United States Medical Licensure Examination (USMLE) and
will primarily cover material learned in that half of the term. However, approximately 10%
of the final written and practical examinations will cover material taught over the entire
course. ALL WRITTEN TEST BOOKLETS WILL BE SEQUESTERED AT THE END
OF EACH EXAMINATION. Students will have the opportunity to review the test and
their answer sheets after each exam.
Once grades have been posted for the midterm and the final, changes will only be
permitted if an error has been made.
Medical Imaging
Introduction
Radiological anatomy is the study of anatomy recorded on photographic film by means
of x-rays. An understanding of this field is imperative in the practice of medicine as
radiography and medical imaging are used widely as diagnostic tools.
Anode
Cathode
x-rays
Generation of x-rays
X-rays are created in a special vacuum tube when electrons are emitted from a tungsten wire
and accelerated by a large voltage. As these high velocity electrons contact electrons of a
tungsten sheet they give up energy, most of which is lost as heat. The remaining 1% is
transmitted as electromagnetic energy known as x-rays.
Unique properties of x-rays
Penetrate matter
High energy x-rays (those with shorter wavelengths) are more penetrating.
The greater the thickness and density of a material, the less likely it is that x-rays will
penetrate it.
Produce ionization of matter
Allows exposure of photographic films and production of fluorescence, but also poses health
risks since it can potentially cause genetic damage and various cancers to those exposed.
Application of x-rays
A narrow beam of x-rays is emitted perpendicular to the area under examination. A radiograph
is secured on the other side of the patient. A radiograph is a thin plastic sheet coated with
silver bromide or silver iodide which appears white (radio-opaque). When exposed to x-rays
and developed it turns black (radiolucent).
Radio-opaque substances are dense and absorb the most x-rays. On the radiograph, they
appear white and therefore unexposed. Bones have extensive calcium and phosphorus deposits
and are the most radio-opaque material in the body. Heavy metals such as lead are the most
radio-opaque substances. Composite (superimposed) tissues such as muscle mass (the heart)
may also cause radio-opacity.
Radiolucent substances are less dense and therefore allow x-rays to pass freely through them.
They appear dark because the x-rays expose the film. Soft tissues such as muscles and organs
are less dense and allow more radiation to pass through. Gases are the most radiolucent. The
lungs are the most radiolucent organs since they are mostly made up of air spaces.
There are different gradations of radiographic density. Clinically they may be referred to as:
1. Bone density: appears white
2. Water density: appears gray (blood vessels, soft tissues, fluid accumulations)
3. Air density: appears black (lungs, paranasal sinuses)
Plain x-ray images produce singular superimposed 2-D images of 3-D structures. They are, in
essence, summation shadowgrams. In order to acquire a complete understanding of the
structure being studied, it is customary to take two or more projections at right angles to each
other to obtain a third dimension.
Types of Projections
There are different positions from where x-ray images can be taken. It is very important to be
aware of the position in which the x-ray was taken and also to know the sides of the patient to
accurately interpret the radiograph,. The positions are named for the surface of the body in
contact with the x-ray film, or the direction in which the rays travel.
Anterior (P-A projection)
The anterior surface of the patient is in contact with the x-ray film and the x-rays enter the
body from the posterior surface.
Posterior projection (A-P projection)

The posterior surface of the patient is in contact with the x-ray film and the x-rays enter the
body from the anterior surface. This is the reverse of the anterior projection.
Lateral projection
Right lateral projection refers to the patient having the x-ray film in contact with their right side
and x-rays enter from the left side.
Oblique projections
Oblique radiographs are made with the body at an angle to the film. There are right and left
anterior oblique (RAO, LAO) and right and left posterior oblique (RPO, LPO) projections.
X-ray source
object
recording
plane
Geometry of x-ray images
object
shado
w
The x-ray image is sharper and closer to its actual size when the:
1. distance between the x-ray source and the x-ray film increases
2. distance between the object and the x-ray film decreases. To view a particular
structure, place it as close as possible to the film. To study the heart, a P-A
projection is taken.
The x-ray image is projected as its true size when:
1. the rays are projected perpendicular to the recording plane
2. the plane of the object is parallel to the recording plane and closest to the film
Structures which might cause superimposition are eliminated where possible, as in
abducting the scapulae in a chest x-ray by asking a patient to reach forward with both arms.
General format for interpreting x-rays
Radiographs must be approached systematically by looking at various structures in a
specific order. Once an abnormality is pinpointed, its presence must be accounted for based
on the history of the patient. Thus a sound knowledge of surface anatomy is extremely
helpful in interpreting radiograhs. The following is helpful when interpreting plain films:
A Alignment; Age of patient
B - Bone density
C - Contour
D - Distribution
S - Soft tissue; Sex of patient
Advantages of x-rays
1.
Fast
2.
Ideal for diagnosing bone fractures and trauma to joints
3.
First step in diagnosing tumors and stones
4.
Low cost and readily available
Disadvantages of x-rays
1.
Use ionizing radiation
2.
Not ideal for viewing soft tissues
Contraindications of x-rays
1.
Intracranial injuries
2.
Pregnant patients and young patients
Fluoroscopy
Structures in the body without natural contrast are best observed by using a contrast
medium. Contrast fluoroscopy utilizes this technique. A contrast medium, which is a
physiologically inert heavy metal that absorbs x-rays, is introduced into the body. As
it fills up the lumen into which it was injected (vessels) or ingested (esophagus, stomach,
gut) it blocks the passage of x-rays and projects a clear image of the structure.
This technique allows live x-ray images to be taken in succession. Instead of striking
a radiographic film the x-rays strike a fluorescent plate coupled to an image intensifier
linked to a television camera. Live images can be seen on a monitor. Examples include
A colloidal solution of barium sulfate to view the GI tract and iodine dyes to view the
gallbladder, kidneys, blood vessels or heart cavities.
Contrast fluoroscopy image

showing outline of stomach
and small bowel.
Other Techniques That Use X-Rays
Computed Axial Tomography (CT/CAT Scan)

Computed axial tomography uses conventional x-rays to produce 3-D cross-sectional images
of the body. Tomos is Greek for slice and graphy refers to drawing. In theory it is
equivalent to cutting the patient into cross-sectional slices and examining the anatomy. Each
body slice can be viewed as a flat area of unit volume which forms a geometric grid.
The CAT scan is a hollow tube or gantry which contains the x-ray source and a paired
electronic detector instead of a radiographic film. The patient lies on a table which extends
into the gantry. An x-ray beam passes through the part of the body to be studied. The beam
rotates around the patient and the detector rotates opposite the beam, capturing the minute
detail of the emerging unabsorbed x-rays. The electronic data are transmitted to a computer
which calculates the x-ray absorption and translates this information as visual digital images
on the screen.
10
CT Scan of Liver, Stomach and Spleen
CT Scan of Brain
Advantages of CT Scans
1. Produces anatomical cross-sections facilitating precise diagnosis
2. Gets rid of superimposing shadows
3. Relatively low cost ($200-$800)
4. Fast
5. Produces high quality images of soft tissues and bone
6. Further enhanced by intravenous injection of contrast medium to visualize vessels
or the GI tract
7. Optimal diagnostic tool for clinical problems within the chest and abdomen
Disadvantages of CT Scans
1. Uses 10 to 100 times more ionizing radiation than conventional x-rays
2. Can not be used on pregnant patients
3. Uses volume averaging
Contraindications of CT Scans
1. Pregnant patients
2. Patients with unstable vital signs
3. Obese patients
4. Patients with metal implants (could distort the images produced)
5. Patients allergic to dyes
11
Femoral Arteriogram
Internal Carotid Arteriogram
Angiography
This technique is performed to specifically diagnose diseases of the blood vessels of the
body, including the brain and the heart. Contrast material is introduced to the circulation
through a catheter. The vessels can then be visualized using plain x-rays. This provides a
clear view of the vessels and allows a radiologist to determine whether there is abnormal
flow, obstructions due to plaque build up, narrowing (stenosis) or aneurysms (weakened
vessel walls that bulge).
The technique is now used extensively by cardiologists, radiologists and vascular surgeons to
perform minimally invasive surgeries in order to introduce balloon angioplasty catheters and
stents that stretch the walls of a narrowed blood vessel and restore normal blood flow without
surgery. Therefore this technique can be used both as a diagnostic and therapeutic tool.
12
Right Internal Carotid Angiogram
Angiogram of Abdominal Aorta

Left Vertebral Angiogram
Digital Subtraction Angiography

This technique is similar to conventional angiography except that, instead of taking plain
x-ray images, a fluoroscope is used to take live images of the vessels. An image is taken of
the appropriate area prior to injecting contrast material. This image is the subtraction mask
and is digitally subtracted from the images taken after the contrast material is injected.
All structures that do not change due to the contrast material, such as bones and organs, are
subtracted and the changes (the injected contrast material) become clearly defined. The result
shows only the vessels containing contrast material. Such procedures are routinely performed
on lower extremity, pulmonary, abdominal, intestinal, cerebral and cardiac vessels.
13
Additional Imaging Techniques
T1 weighted MRI scan of brain
Magnetic Resonance Imaging (MRI)

This technique makes use of a strong magnetic field. At first the magnetic field is created in
the patient by a magnet, which causes the protons in water atoms to line up. A high field
electromagnetic pulse is sent out which knocks the protons out of alignment and as they
realign, they transmit resonance signals. These signals are measured by a very sensitive radio
antenna and are sent to a computer which translates them into 2-D images.
It works because of the presence of the different fluid concentrations in the body. Images can
be T1 or T2 weighted. Tissues that emit strong resonance signals appear white whereas those
that do not appear black on the scanned image.
Magnetic imaging provides not only cross-sections, but also sagittal, coronal and oblique
planes as well. The thickness of these sections can be varied as desired.
14
Coronal MRI scan of abdomen and thorax
Sagittal MRI scan of cervical spine
Advantages of MRI
1. Does not use ionizing radiation (i.e. does not use x-rays)
2. Effects on the body are temporary
3. Rapid. At times faster than CT
4. Produces high quality images of soft tissues
5. Produces customized sections of anatomy
6. Established technique to diagnose brain and spinal cord abnormalities
Disadvantages of MRI
1. Expensive (much more than CT)
2. Can not be performed on patients with metal implants because it magnetizes ironcontaining metals
Contraindications of MRI
1. Patients with electronic, mechanical and magnetically activated implants such as:
a. pacemakers
b. cochlear implants
c. metallic splinters in orbit
d. cereberal aneurysm clips
e. cardiac defibrillators
f. cardiac pacing wires
g. internal electrodes
15
Ultrasound of kidney
Ultrasonography
Ultrasonography is employed widely as a diagnostic medical tool. A narrow beam of high
energy sound waves is directed into the body and are reflected back. Visual images result
from the different density of tissues and their acoustic properties. Images appear white
against
a black background. This is a very useful technique used mainly to detect tumors in the
abdomen, perineum and breast and to view unborn babies.
Advantages
1. Does not use any form of ionizing radiation
2. Completely non-invasive
3. Relatively cheaper than CT scans
4. Can be performed by the bedside of very sick patients
5. Produces real-time images in sequential frames
Disadvantages
1. Images are not as clear or focused as CT scan or MRI images
2. Can not be used to diagnose lung or bone disease
16
Organisation of a
Typical Spinal Nerve
Specific Objectives
Be able to:
1. Describe the components of the central and peripheral portions of the nervous system.
2. Describe the structure of unipolar and multipolar neurons, and the location of their soma.
3. Differentiate between somatic and visceral paths in terms of structures innervated.
4. Differentiate between sensory/afferent and motor/efferent in terms of structures
innervated.
5. Describe a synapse in terms of presynaptic and post synaptic structures.
6. Describe a somatic reflexc arc in terms of receptor, afferent limb, location of synapse,
efferent limb, and effector.
7. Describe a cross section of the spinal cord in terms of dorsal, ventral and lateral horns,
and the neuron soma found in each.
8. Describe the organization of a spinal nerve in terms of dorsal and ventral roots and
rami, and the origin, and types, of nerve fibres found in each.
9. Describe the organization of a somatic plexus.
17
Dorsal horn
Dorsal root
Ventral root
Lateral horn
Ventral horn
Cross section of spinal cord

Spinal nerves
A. Cross section of cord
1. contains peripheral white matter and central gray matter
a. white matter comprises axons (nerve fibres), mainly myelinated, that
are part of ascending or descending nerve pathways in the cord
2. gray matter is divided into bilateral horns
3. dorsal horns
a. found at all cord levels
b. contain soma of sensory neurons that project to higher centres in CNS
4. ventral horns
a. found at all levels of the cord
b. contain soma of somatic motor neurons that innervate skeletal muscle
c. also known as lower motor neurons
5. lateral horns
a. found at cord levels T1-L2 and S2-4
b. contain soma of preganglionic visceral motor neurons
18
Dorsal root
ganglion
Spinal
nerve
Dorsal
horn
Ventral
horn
Dorsal
root
Ventral ramus
Dorsal ramus
Dorsal rootlets
Ventral rootlets
Ventral root
Roots and rami

B. Spinal Nerves
1. dorsal root(let)s
a. contain fibers (axons) of sensory/afferent neurons
b. soma of these neurons are located in dorsal root ganglion
c. neurons are unipolar
2. ventral root(lets)
a. contain axons of somatic motor/efferent neurons to skeletal muscle
b. roots T1-L2 and S2-S4 also contain axons of visceral motor neurons
3. cauda equina
a. lower lumbar, sacral, coccygeal dorsal and ventral roots descending below
conus in lumbasr cistern to exit through respective intervertebral foramina
4. spinal nerve
a. divides immediately after exiting intervertebral foramen into primary rami
19
Cutaneous
branches
Ventral ramus
Intrinsic back
muscles
Dorsal ramus
Cross section of body wall to show primary rami

4. dorsal (primary) ramus
a. carries somatic motor innervation to intrinsic back muscles
b. carries somatic sensory innervation from skin of back
c. carries visceral motor innervation to erector pili muscles, sweat
glands and smooth muscle in the walls of blood vessels in body wall
5. ventral (primary) ramus
a. carries somatic sensory from, and somatic motor innervation to,
the anterolateral body wall, extremities, and extrinsic back muscles
b. carries visceral motor innervation to erector pili muscles, sweat
glands and smooth muscle in the walls of blood vessels in body wall
c. form intercostal (T1-T11) and subcostal (T12) nerves, and somatic
nerve plexuses
20
Cervical
plexus
Brachial
plexus
Intercostal
nerves
Lumbar
plexus
Sacral
plexus
Somatic nerve plexuses
dermatomes
C. Somatic nerve plexuses

1. combination of ventral rami
a. cervical (C1-C4)
b. brachial (C5-T1)
c. lumbar (L1-4)
d. sacral (L4-S3)
e. brachial and lumbosacral plexuses innervate the upper and lower
limb respectively
2. carry somatic sensory neurons from, and somatic motor neurons to,
body wall plus visceral motor neurons to erector pili muscles, sweat
glands and smooth muscle in the walls of blood vessels
D. Dermatomes
1. strip of skin innervated by a pair of spinal nerves
21
Superficial Back and

Pectoral Region
Specific Objectives
Be able to:
1. Describe the body wall in terms of tissue layers.
2. Describe the intrinsic (deep) and extrinsic (superficial) muscles of the back in
terms of general attachments, actions and innervation.
3. Describe posterior muscles acting on the shoulder girdle and humerus in terms
of attachments, actions and innervation.
4. Describe the blood supply to the extrinsic muscles of the back.
5. Describe the cutaneous innervation of the back and shoulder.
6. Describe the spaces around the scapula in terms of borders and structures found
in, or passing through, the spaces.
7. Describe the anterior muscles that act on the shoulder girdle and shoulder joint
in terms of general attachments, actions and innervation.
8. Describe the major features of the mammary gland including the nipple, areola,
lobules of gland, septa, lactiferous ducts and sinuses, innervation, blood supply
and general pattern of venous and lymphatic drainage.
22
Serous
membrane
Deep fascia
Muscle
Skin
Superficial fascia
Loose connective
tissue
Cross section of body wall

Typical cross section of body
A. Layers
1. epidermis
a. stratified squamous epithelium of varying thickness
2. dermis
a. dense irregular connective tissue
b. contains blood vessels, nerve endings, errector pili muscles, hair follicles
3. superficial fascia (hypodermis)
a. loose connective tissue with varying amounts of subcutaneous fat
b. attaches dermis to underlying bone, muscle, connective tissue
c. contains cutaneous vessels and nerves
4. deep fascia
a. dense irregular connective tissue
b. invests muscles and other deep structures
5. skeletal muscle, bone, connective tissue
6. deep fascia
7. loose connective tissue
a. endothoracic fascia in thorax
b. extraperitoneal tissue in abdomen
8. parietal serous membrane
a. attached to deep fascia by the loose connective tissue layer
b. pleura in thoracic and peritoneum in abdominopelvic cavity
9. body cavity
10. visceral serous membrane
a. adherent to surface of viscera
23
Levator scapulae
Trapezius
Rhomboid
minor & major
Latissimus dorsi
Serratus posterior
superior & inferior
Extrinsic muscles of back

Extrinsic Back (hypaxial) Muscles
A. Superficial layer
1. all act on scapula or humerus
2 . trapezius
a. adducts (retracts) scapula; upper portion elevates (shrugging shoulders)
b. innervated by spinal accessory nerve (cranial nerve XI)
3. levator scapulae
a. elevates scapula
b. innervated by dorsal scapular nerve
4. rhomboideus
a. adducts (retracts) scapula
b. innervated by dorsal scapular nerve
5. latissimus dorsi
a. adducts and medially rotates humerus
b. innervated by thoracodorsal nerve (middle subscapular or nerve to lats dorsi)
B. Intermediate layer
1. serratus posterior superior and inferior
24
Supraspinatus
Infraspinatus
Teres minor
Teres major
Posterior scapular muscles

B. Posterior shoulder muscles
1. supraspinatus
a. abducts humerus through initial 15 degrees of movement
b. innervated by suprascapular nerve
2. infraspinatus
a. laterally rotates humerus
3. teres minor
a. laterally rotates humerus
b. innervated by axillary nerve
4. teres major
a. medially rotates and adducts humerus
b. innervated by lower subscapular nerve
5. rotator cuff muscles
a. supraspinatus, infraspinatus, teres minor and subscapularis
25
Subclavius
Deltoid
Pectoralis minor
Pectoralis major
Serratus anterior
Muscles of the pectoral region

Pectoral Region
A. Muscles
1. pectoralis major
a. medially rotates and adducts humerus
b. innervated by medial and lateral pectoral nerves
2. pectoralis minor
a. innervated by medial, with some fibres from lateral, pectoral nerve
3. subclavius
4. serratus anterior (not a true pectoral muscle)
a. abducts and upward rotates scapula (as in abducting arm above
horizontal
b. innervated by long thoracic nerve
26
Areola
Nipple
Pectoralis major
Suspensory
ligaments
Pectoralis
major
Glandular
lobules
Lactiferous
sinus
Retromammary
space
Female breast
B. Breast
1. extends from 2nd to 6th ribs and from sternum to midaxillary line
2. nipple
a. surrounded by ring of pigmented skin, the areola
b. has lactiferous ducts opening through it
3. blood supply
a. from branches of internal thoracic lateral thoracic and intercostal arteries,
and thoracoacromial trunk
4. innervation
a. usually by cutaneous branches of 4th to 6th intercostal nerves
5. mammary gland
a. divided into 15-20 lobules of glandular tissue
b. lactiferous duct drains each lobule and duct is enlarged to form sinus
c. the axillary tail is small part of gland that extends superolaterally,
sometimes through the deep fascia, to lie in the axilla
d. separated from deep fascia of pectoralis major by loose connective tissue
in retromammary space
e. connective tissue septa in upper part of gland run from dermis to deep
fascia of pectoralis major and serve as suspensory ligaments
27
Deep Back and Spinal Cord

Specific Objectives
Be able to:
1. Describe the major identifying features of cervical, thoracic, lumbar, sacral and
coccygeal vertebrae.
2. Describe the anatomy of typical, and atypical, intervertebral joints.
3. Describe the ligamentous structures supporting the vertebral column.
4. Describe normal curvatures of the vertebral column.
5. Describe the thoracolumbar fascia in terms of location and attachments.
6. Describe the erector spinae and transversospinalis muscle groups in terms of
attachments, unilateral and bilateral actions, and innervation.
7. Describe the spinal cord in terms of its relationship to the vertebral column, the
meninges, meningeal structures and meningeal spaces.
8. Describe blood supply and venous drainage of the vertebral column and spinal cord.
28
Spinous process
Vertebral
foramen
Superior
articular facet
Superior
articular process
Lamina
Transverse
process
Vertebral
arch
Sup articular
process
Pedicle
Body
Typical vertebra
Inf vertebral
notch
Inf articular
process
Vertebral column
A. Typical vertebrae (C3-L5)
1. body
a. anterior mass of bone supporting body weight
b. become progressively larger as the column is descended
2. vertebral arch
a. arises posteriorly from the body
b. two short pedicles attach to body
c. two broad flat laminae meet on midline
d. arch encloses vertebral foramen
e. vertebral canal is formed by all foramina in an articulated column
4. vertebral notches
a. indentations on superior and inferior edge of pedicle
b. superior and inferior notches of adjacent vertebrae form intervertebral foramen
3. muscular processes
a. spinous process is midline posterior projection for muscle attachment
b. transverse processes are lateral projections for muscle attachment
4. articular processes and facets
a. two superior and two inferior projections from vertebral arch
b. superior and inferior facets of adjacent vertebras form facet joint
29
Bifid spinous process
Cervical
Transverse foramen
Superior articular
process
Lumbar
Secondary
Primary
Thoracic
Inferior articular
process
Superior &
inferior demifacet
Regional characteristics and vertebral curvatures

B. Regional characteristics
1. cervical (C3-7 are typical)
a. transverse processes have a transverse foramen for vertebral artery and veins
b. tips of spinous processes are bifid
c. articular facets lie midway between frontal and transverse planes
2. thoracic (T1-12)
a. costal facets, or superior and inferior demifacets, on bodies for heads of ribs
b. costal facets on transverse processes of T1-10 for tubercles of ribs
c. articular facets lie in frontal plane
3. lumbar (L1-5)
a. large body; strong, thick laminae and pedicles; short, square spinous process
b. articular facets lie in sagittal plane
4. sacrum (fused S1-5)
a. fused transverse processes form ala which contribute to sacroiliac joint
b. ventral and dorsal sacral foramina allow passage of rami of sacral spinal nerves
5. coccyx (fused Co1-3/4)
6. curvatures
a. primary is concave anteriorly; found in thoracic and sacrococcygeal regions
b. secondary curvature is convex anteriorly; found in cervical and lumbar regions
30
Facets for
occipital condyles
Atlas
Facet for anterior

arch of atlas
Axis
Odontoid
process
or dens
Groove for
vertebral a
Superior view
Anterior view
Body
Posterior arch
Lateral
mass
Anterior arch
Facets for axis
Atlas and axis

C.
Atypical vertebrae
1. atlas (C1)
a. has no body and no spinous process
b. lateral masses, which provide articulation for the skull and C2, are joined
by anterior and posterior arches
2. axis (C2)
a. has dens projecting superiorly from body
b. dens lies between lateral masses of C1 and is held in place by transverse
ligament of atlas and forms pivot joint with anterior arch of atlas
3. movements
a. atlanto-occipital joint provides flexion/extension of skull on C1 (nodding)
b. atlantoaxial joint provides rotation of C1 (and thus skull) on C2 (shaking head)
D. Typical intervertebral joints (between C2/C3-L5/S1) and movements

1. intervertebral disc between vertebral bodies
a. anulus fibrosus is outer wall of fibrocartilage
b. nucleus pulposus is inner, more elastic, mass with high water content
2. zygapophysis facet joint
a. paired synovial joints between facets on articular processes
3. movements
a. flexion/extension, lateral flexion and rotation in cervical and thoracic regions
b. flexion/extension and lateral flexion in the lumbar region, but no rotation
31
Ant longitudinal
Post longitudinal
Ligamentum
flavum
Interspinous
Supraspinous
Intervertebral disc
Posterior view of
vertebral bodies
Vertebral ligaments
E. Ligaments
1. anterior longitudinal
a. wide band from sacrum to occiput on anterior aspect of vertebral bodies and discs
2. posterior longitudinal
a. narrow band from sacrum to C2 on posterior aspect of vertebral bodies and discs
3. ligamentum flavum
a. connects laminae of adjacent vertebrae from axis to sacrum
4. intertransverse and interspinous
a. connect transverse and spinous processes respectively
5. supraspinous
a. continuous attachment to tips of spinous processes from sacrum to C7
6. nuchal
a. thickened continuation of supraspinous ligament from C7 to occiput
32
Spinalis
Semispinalis
Rotatores
Multifidus
Longissimus
Iliocostalis
Intrinsic muscles of back

F. Intrinsic (epaxial) muscles of back acting on vertebral column
1. all innervated segmentally by dorsal rami of spinal nerves
2. superficial layer
a. splenius cervicis and capitis
b. fibres have superolateral orientation
c. unilateral contraction rotates head and neck to same side
3. intermediate layer - erector spinae group
a. iliocostalis
b. longissimus
c. spinalis
d. fibres have a vertical orientation
e. extend vertebral column
4. deep layer - transversospinalis group
a. fibres have superomedial orientation from transverse to spinous processes
b. semispinalis cross 4-6 segments
c. multifidus cross 2-4 segments
d. rotatores cross 1-2 segments
e. unilateral contraction rotates vertebral column to opposite side
f. deep layer also includes interspinales, intertransversarii
33
Anterior layer
Transversus
abdominus
Intrinsic back
muscles
Posterior layer
Middle layer
Quadratus lumborum
Thoracolumbar fascia
G. Deep fascia
1. known as thoracolumbar (thoracodorsal) fascia in thoracic and lumbar
regions and encloses intrinsic muscles of the back
2. lumbar region
a. thick posterior layer from spinous processes
b. middle layer from transverse processes
c. anterior layer from transverse processes
d. layers fuse laterally to form the aponeurotic origin of transversus abdominus
3. thoracic region
a. from spinous processes to angles of ribs
34
Foramen magnum
Spinal nerves
8 cervical
12 thoracic
Conus medullaris at
disc between L1/L2
5 lumbar
5 sacral
1 coccygeal
Longitudinal view of spinal cord and nerves

Spinal cord
A. Segmental organization
1. spinal cord segment
a. area of cord supplying rootlets to a pair of spinal nerves
2. thirty one segments/31 pairs of spinal nerves
a. 8 cervical
b. 12 thoracic
c. 5 lumbar
d. 5 sacral
e. 1 coccygeal
3. nerve exit from vertebral column
a. C1-C7 pass through intervertebral foramen above same numbered vertebra
b. T1-Co1 pass below same numbered vertebra
B. Longitudinal structure
1. continuous with medulla oblongata of brain stem at foramen magnum
2. ends as conus medullaris at vertebral level L1-L2 in the adult
35
Dura
Epidural
space
Arachnoid
Pia
Subarachnoid
space
Denticulate
ligament
Meninges and spaces

C. Meninges
1. dura mater
a. outermost dense fibrous covering of cord
b. only attached to periosteum at foramen magnum
c. extends to vertebral level S2
2. arachnoid mater
a. thin membrane lining dura and extending to S2
3. pia mater
a. adherent to cord
b. denticulate ligament is bilateral extension attaching to dura
c. filum terminale is extension of pia from conus to coccyx
4. meningeal spaces
a. dura is separated from periosteum of vertebral canal by epidural space
containing fat and internal vertebral venous plexus
b.
subdural space is potential since CSF keeps arachnoid against dura
c.
subarachnoid space is between the arachnoid and pia mater
5. lumbar cistern
a. subarachnoid space between conus medullaris and end of dural/arachnoid sac
b. contains cerebrospinal fluid and cauda equina
36
Posterior spinal
Branches of
thyrocervical &
costocervical trunks
Posterior
intercostals
Lumbars
Anterior
spinal
Anterior
medullary
Lateral sacral
Spinal branch
Blood supply to cord

D. Blood Supply
1. one anterior and two posterior spinal arteries
2. additional blood is supplied by regional segmental arteries to body wall
a. ascending cervical, deep cervical and vertebral
b. posterior intercostal arteries
c. lumbar arteries
d. iliolumbar and lateral sacral arteries
3. segmental arteries give off spinal branches which further divide
a. anterior and posterior medullary arteries supplement anterior and
posterior spinal arteries
b. anterior and posterior radicular arteries supply roots of spinal nerves
c. branches to vertebral bodies
4. venous drainage corresponds with arterial supply and there are also two
valveless vertebral venous plexuses
a. internal venous plexus in epidural space has communication with veins
in pelvis, body wall and cranial vault
b. external venous plexus on external surface of the vertebrae
37
Axilla
Specific Objectives
Be able to:
1. Describe the boundaries and contents of the axilla.
2. Describe the organization of the brachial plexus.
3. Describe the course, branches, and distribution of subclavian and axillary arteries.
4. Describe the general pattern of superficial and deep lymphatic drainage of the
upper limb and pectoral region, and the five groups of axillary nodes.
38
Posterior cord of
brachial plexus
Axilla
Axillary artery
Pectoralis
muscles
Scapula
Subscapularis
Teres major
Lymph
nodes
Axillary
fascia
Lateral view of sagittal section of axilla

Axilla
A. Boundaries
1. apex - space between clavicle, coracoid of scapula and 1st rib
a. communication between brachial region and neck and thoracic cavity
2. base - axillary fascia
3. anterior wall - pectoralis major, pectoralis minor and subclavius
4. posterior wall - subscapularis, teres major and latissimus dorsi
5. lateral wall - bicipital groove of humerus and tendon of long head of biceps
6. medial wall - upper ribs, intercostal muscles and serratus anterior
7. contents
a. tail of mammary gland
b. axillary vessels
c. cords and named branches of brachial plexus
d. lymph nodes and fat
e. axillary sheath
39
Subclavian
Superior
thoracic
Subscapular
Post humeral
circumflex
Ant humeral
circumflex
Circumflex
scapular Thoracodorsal
Thoracoacromial
trunk
Lateral thoracic
Axillary artery and branches

B. Axillary artery
1. continuation of subclavian artery from lateral border of 1st rib to inferior
border of teres major
2. 1st part
a. medial to pectoralis minor
b. gives off one relatively unimportant branch
3. 2nd part
a. deep to pectoralis minor
b. gives off thoracoacromial trunk at medial border, and lateral thoracic
artery at lateral border, of pectoralis minor
4. 3rd part
a. lateral to pectoralis minor
b. gives off subscapular, anterior circumflex humeral and posterior
circumflex humeral arteries
c. subscapular divides into circumflex scapular and thoracodorsal arteries
40
Apical nodes
Central nodes
Lateral nodes
Posterior nodes
Anterior nodes
Parasternal
nodes
Axillary lymph nodes and breast lymphatics

C. Axillary lymph nodes
1. lateral (humeral) nodes
a. receive lymph from the upper limb
2. posterior (subscapular) nodes
a. receive lymph from posterior thoracic wall and posterior shoulder
3. anterior (pectoral) nodes
a. receive lymph from anterior and lateral thoracic wall including breast
4. central nodes
a. near base of axilla
b. receive lymph from the lateral, anterior and posterior groups
c. drain into apical nodes
5. apical nodes
a. lie at apex of axilla along axillary vein
b. receive lymph from all other axillary nodes
c. drain into subclavian trunks
6. lymph drainage of the breast
a. from lateral aspect to pectoral nodes and from medial aspect to parasternal
(internal thoracic) nodes
b. about 75% drains into pectoral nodes, including drainage of nipple, 20% to
parasternal nodes, and some to contralateral parasternal nodes
41
Roots
C5
Trunks
C6
C7
Divisions
A
A
Cords
P
P
C8
M
I
T1
P
P
Musc
Ax
A
M
Rad
Med
Uln
Brachial plexus
D. Brachial plexus
1. organization
a. roots - ventral rami C5-T1
b. trunks - superior, middle, inferior
c. divisions - 3 anterior, 3 posterior
d. cords - medial, lateral, posterior
e. branches - named nerves
2. supraclavicular branches originate from roots or trunks above clavicle
a. nerve to subclavius, dorsal scapular, suprascapular, long thoracic nerves
3. branches from lateral cord
a. lateral pectoral, lateral head of median, musculocutaneous nerves
4. branches from posterior cord
a. upper subscapular, thoracodorsal, lower subscapular, axillary, radial nerves
5. branches from medial cord
a. medial pectoral, medial brachial cutaneous, medial antebrachial cutaneous,
medial head of median, ulnar nerves
42
Shoulder and Brachial

Region
Specific Objectives
Be able to:
1. Describe the joints of the shoulder girdle.
2. Describe the structure, and movements, of the shoulder joint
3. Describe the course, branches and distribution of the brachial artery, and the
collateral circulation of the elbow.
4. Describe the muscles of the brachial region in terms of general attachments,
actions and innervation.
5. Describe the compartments of the brachial region and the muscular, vascular,
and nervous structures found in each.
6. Describe the cubital fossa in terms of its boundaries and contents.
7. Describe the structure of the elbow joint and the movements possible at the
humeroulnar and proximal radioulnar joints.
43
Sternoclavicular
ligaments
Meniscus
Sternoclavicular joint
Acromioclavicular
ligaments
Coracoclavicular
ligaments
Acromioclavicular joint
Joints of shoulder girdle

Shoulder girdle
A. Joints
1. sternoclavicular
a. medial end of clavicle articulates with manubrium of sternum to
form a synovial joint
b. meniscus divides joint cavity
2. acromioclavicular
a. lateral end of clavicle articulates with acromion of scapula to
form a synovial joint
b. coracoclavicular ligaments are important to stability of joint
3. movements of scapula
a. elevation and depression
b. abduction (protraction) and adduction (retraction)
c. upward and downward rotation refer to movement of glenoid
44
Acromioclavicular
joint
Glenohumeral
capsule
Coracoacromial
ligament
Anterior
Labrum
Infraspinatus
tendon
Supraspinatus
tendon
Teres minor
tendon
Lateral
Subscapularis
tendon
Glenohumeral joint
Shoulder
A. Glenohumeral joint
1. ball and socket joint between glenoid fossa and head of humerus
a. fossa deepened by glenoid labrum
b. reinforced superiorly by coracoacromial ligament
c. reinforced by tendons of supraspinatus, infraspinatus, teres minor,
subscapularis
2. glenohumeral ligaments are capsular thickenings
3. movements
a. flexion/extension in sagittal plane
b. aBduction/aDduction in frontal plane
c. medial/lateral rotation around longitudinal axis of humerus
45
Subclavius
Deltoid
Pectoralis minor
Pectoralis major
Serratus anterior
Muscles of the pectoral region

Pectoral Region
A. Muscles
1. pectoralis major
a. medial rotator and adductor of humerus
b. innervated by medial and lateral pectoral nerves
2. pectoralis minor
a. stabiliser of scapula
b. innervated by medial, with some fibres from lateral, pectoral nerve
3. subclavius
4. serratus anterior (not a true pectoral muscle)
a. abductor and upward rotator of scapula
b. innervated by long thoracic nerve
46
Supraspinatus
Infraspinatus
Teres minor
Teres major
Posterior scapular muscles

B. Posterior shoulder muscles
1. supraspinatus
a. initiates abduction of shoulder for deltoid
2. infraspinatus
a. lateral rotator of humerus
3. teres minor
a. lateral rotator of humerus
b. innervated by axillary nerve
4. teres major
a. medial rotator and adductor of humerus
b. innervated by lower subscapular nerve
5. rotator cuff
a. supraspinatus, infraspinatus, teres minor and subscapularis
47
Biceps brachii
short
long
Coracobrachialis
Triceps brachii
long
lateral
Brachialis
anterior
posterior
Brachial muscles
A. Muscles
1. biceps brachii
a. long head from supraglenoid tubercle with tendon passing through
shoulder joint
b. short head from coracoid process
c. both heads insert into radial tuberosity of radius
d. flexor of shoulder, flexor and supinator of forearm
2. coracobrachialis
a. slight flexion and adduction of arm
3. brachailis
a. major flexor of forearm
4. triceps brachii
a. long head from infraglenoid tubercle
b. medial and lateral heads from humerus
c. all heads insert into olecranon
48
Dorsal scapular a
Suprascapular a
Posterior circumflex
humeral a
Circumflex scapular a
Blood supply to shoulder

B. Blood supply to posterior shoulder
1. from thyrocervical trunk of subclavian artery
a. suprascapular
b. descending branch of transverse cervical or dorsal scapular
2. from axillary artery
a. circumflex scapular via subscapular
b. posterior circumflex humeral
3. scapular anastamosis
a. suprascapular from subclavian
b. dorsal scapular or descending branch of transverse cervical
c. circumflex scapular from axillary
C. Scapular spaces
1. quadrangular space
a. between teres minor, teres major, shaft of humerus, long head of triceps
b. contains axillary nerve and posterior circumflex artery
2. triangular space
a. between teres minor, teres major, long head of triceps
b. contains circumflex scapular artery
49
Musculocutaneous n
Biceps brachii
Medial
intermuscular
septum
Brachialis
Median n
Lateral
intermuscular
septum
Brachial
a & vv
Ulnar n
Radial n &
deep radial a
Triceps
Brachial fascia
Cross section of right mid brachium

B. Brachial Compartments
1. brachial fascia
a. continuous proximally with fascia of shoulder and trunk muscles
b. continuous distally with antebrachial fascia
c. attaches to epicondyles, supracondylar ridges and olecranon process
2. intermuscular septa
a. medial and lateral septa separate anterior and posterior compartments
3. anterior or flexor compartment
a. biceps brachii, brachialis and coracobrachialis muscles
b. all innervated by musculocutaneous nerve
c. contains median, ulnar, musculocutaneous nerves and brachial artery
and veins
4. posterior or extensor compartment
a. triceps brachii muscle
b. innervated by radial nerve
c. contains radial nerve, deep brachial artery and vein
50
Axillary a
Radial
collaterals
Deep brachial
Cephalic v
Brachial
Ulnar collaterals
Ulnar recurrents
Common interosseous
Ulnar
Radial
Basilic v
Median
cubital v
Brachial artery and superficial veins

B. Blood supply
1. brachial artery
a. continuation of axillary artery at inferior border of teres major
b. crosses elbow joint anteromedially and lies lateral to median nerve
2. deep brachial artery
a. branches from brachial artery
b. runs with radial nerve to posterior compartment
3. collateral circulation to elbow
a. middle and radial collaterals from deep brachial artery
b. superior and inferior ulnar collaterals from brachial artery
c. radial, ulnar and interosseous recurrents
C. Venous drainage
1. deep
a. paired brachial veins become continuous with axillary
2. superficial
a. basilic lies medially and joins brachials to form axillary
b. cephalic lies laterally, joins axillary through deltopectoral triangle
c. median cubital joins cephalic and basilic over cubital fossa
51
Radial collateral Annular
Ulnar collateral
Capsule
Elbow joint ligaments

D. Elbow joint
1. humeroulnar
a. joint between trochlea of humerus and trochlear notch of ulna
b. permits flexion and extension of elbow
2. humeroradial
a. joint between capitulum of humerus and fovea capitis of radius
b. contributes to elbow flexion/extension
3. proximal radioulnar
a. joint between head of radius and radial notch of ulna
b. permits supination and pronation of forearm
4. joint capsule
a. common for all three joints
b. reinforced by ulnar and radial collateral ligaments which originate
from epicondyles of humerus
c. annular ligament forms loop holding head of radius in radial notch
52
Brachial a
Median n
Radial n
Pronator
teres
Bicipital
aponeurosis
Brachioradialis
Biceps
brachii
tendon
Cubital fossa and contents

E. Cubital fossa
1. triangular area on anterior surface of proximal antebrachium
a. bordered by brachioradialis, pronator teres, line between humeral epicondyles
b. floor is supinator and brachialis, roof is antebrachial fascia and bicipital
aponeurosis
c. contains tendon of biceps brachii, brachial artery and its bifurcation, median
nerve
d. median cubital vein lies superficial to roof
53
Flexor Forearm and Hand

Specific Objectives
Be able to:
1. Describe the compartments of the forearm and the muscular, neural and vascular
contents of each.
2. Describe the attachments, actions and innervation of the muscles of the anterior
(flexor) forearm.
3. Describe the thenar, hypothenar, and mid palmar compartments of the hand and their
contents.
4. Describe the general attachments, actions, and innervation of the intrinsic muscles
of the hand.
5. Describe the blood supply to the forearm and hand.
6. Describe the cutaneous innervation of the anterior forearm and palmar hand.
7. Describe the fascial relationships of the flexor retinaculum and palmar aponeurosis.
8. Describe the course of the median and ulnar nerves in the forearm and hand.
54
Pronator teres
Supinator
Pronator
quadratus
Interosseous
membrane
Supinated
Pronated
Radioulnar relationships
Forearm
A. Radioulnar joints
1. proximal
a. head of radius in radial notch of ulna
b. held in place by annular ligament
2. distal
a. head of ulna in ulnar notch of radius
3. middle
a. interosseous membrane
b. transmits forces exerted through radiocarpal joint from radius to ulna
4. movements
a. rotation of radius around its longitudinal axis
b. supination - palm faces anteriorly in the anatomical position
c. pronation - radius rotates over ulna so that palm faces posteriorly in the
anatomical position
55
Brachioradialis
Flexor carpi
radialis
Palmaris
longus
Flexor digitorum
superficialis
Flexor
pollicis
longus
Flexor carpi
ulnaris
Radius
Flexor digitorum
profundus
Interosseous membrane
Antebrachial fascia
Cross section of right mid forearm

B. Compartments of the Forearm
1. antebrachial fascia
a. continuous with brachial fascia
b. attaches to posterior surface of ulna
c. continuous distally with deep fascia of hand
2. radius and ulna, and interosseous membrane, separate forearm into
flexor and extensor compartments
56
Brachioradialis
Pronator teres
Flexor pollicis
longus
Flexor carpi radialis
Palmaris longus
Flexor carpi ulnaris
Flexor digitorum
superficialis
Flexor digitorum
profundus
Superficial layer
Deep layer
Muscles of the flexor compartment

C. Flexor Compartment Muscles
1. superficial layer - all originate by common flexor tendon from medial
epicondyle
a. pronator teres
b. flexor carpi radialis
c. palmaris longus not always present
d. flexor digitorum superficialis
e. flexor carpi ulnaris
2. deep layer
a. flexor digitorum profundus
b. flexor pollicis longus
c. pronator quadratus
57
Radial a &
superficial
radial n
Brachioradialis
Flexor digitorum
superficialis
Ulnar a,v,n
Flexor carpi
ulnaris
Flexor digitorum
profundus
Anterior interosseous a,v,n

Interosseous membrane
Vessels and nerves in cross section of right mid forearm

D. Innervation
1. median nerve
a. passes through pronator teres to lie deep to flexor digitorum superficialis
b. innervates all forearm flexors except flexor carpi ulnaris and ulnar half
of flexor digitorum profundus which are innervated by ulnar nerve
c. gives off anterior interosseous nerve to deep layer of flexors
2. ulnar nerve
a. crosses elbow posterior to medial epicondyle and runs deep to flexor carpi
ulnaris
b. innervates flexor carpi ulnaris and ulnar half of flexor digitorum profundus
E. Blood supply
1. radial and ulnar arteries divide from brachial in cubital fossa
a. common interosseous branches from ulnar
b. anterior interosseous from common interosseous runs with anterior
interosseous nerve and supplies deeper structures
58
III
IV
Distal phalanx
II
2nd metacarpal
Middle phalanx
Proximal phalanx
Capitate
Hamate
Trapezoid
Triquetrum
Trapezium
Pisiform
Lunate
Scaphoid
Bones of the hand and wrist

Hand and Wrist
A. The carpus
1. group of eight small bones form the carpus, or wrist
a. 8 bones are arranged in two rows of four from radial to ulnar side
b. scaphoid and lunate of proximal row articulate with distal radius
c. distal row articulates with metacarpals
2. radiocarpal joint synovial joint
a. between radius proximally, scaphoid and lunate distally
b. movements are flexion/extension and adduction/abduction
3. metacarpophalangeal (MCP)
a. digits II-V - flexion/extension and abduction/adduction
b. digit I - flexion and extension
4. proximal and distal interphalangeal (PIP and DIP) synovial joints
a. movements are flexion/extension
5. 1st carpometacarpal joint - saddle joint
a. between trapezium and first metacarpal
b. movements at right angles to digits II-V
c. movements are flexion/extension, abduction/adduction and opposition
59
Palmaris longus
tendon
Palmar aponeurosis
Palmar
aponeurosis
Thenar
compartment
Hypothenar
compartment
Medial septum
Central
compartment
Lateral septum
Palmar surface of right hand and palmar compartments

B. Palmar aponeurosis and palmar compartments
1. triangular thickening of the deep fascia of the palm.
a. apex is attached to the flexor retinaculum
b. slips from base extend into digits to blend with fibrous digital sheaths
c. palmaris longus inserts proximally
d. septa attach to 3rd and 5th metacarpals and divide palmar region into
thenar, mid palmar and hypothenar compartments
e. central compartment contains digital flexor tendons and lumbricals
f. thenar compartment contains flexor pollicis brevis, abductor pollicis brevis
opponens pollicis
g. hypothenar compartment contains abductor digiti minimi, flexor digiti
minimi, opponens digit minimi
60
1st lumbrical
4th lumbrical
Tendon of flexor
digitorum superficialis
Tendon of flexor
digitorum profundus
4 DAb
Dorsal interossei
3 PAd
Palmar interossei
Lumbricals and interossei

C. Digital flexor tendons and lumbricals
1. digital flexor tendons pass through mid palmar compartment to digits II-V
2. flexor digitorum superficialis inserts at base of each middle phalanx
a. flexes MCP and PIP
3. flexor digitorum profundus tendon inserts at base of distal phalanx
a. flex MCP, PIP and DIP
4. four lumbrical muscles originate from the tendons of profundus and have
same split innervation as profundus I and II by median nerve
a. cross anterior to MCP joints and insert into extensor expansion
b. flex MCP while extending PIP and DIP
D. Dorsal and Palmar Interossei
1. palmar interossei; three muscles deep to digital flexor tendons and lumbricals
c. adduct digits II, IV and V
2. dorsal interossei: four muscles deep to palmar interossei
c. abduct digits II, III and IV
61
Abductor pollicis
brevis
Flexor pollicis
brevis
Flexor retinaculum
Common tendon
sheath
Flexor digiti
minimi
Abductor
digiti minimi
Adductor pollicis
Opponens
digiti minimi
Thenar and hypothenar muscles

E. Thenar and hypothenar eminences
1. thenar muscles
a. abductor pollicis brevis, flexor pollicis brevis, opponens pollicis
b. innervated by recurrent branch of the median nerve
2. hypothenar muscles
a. abductor digiti minimi, flexor digiti minimi, opponens digiti minimi
b. innervated by deep branch of the ulnar nerve
F. Tendon sheaths
1. common synovial sheath (ulnar bursa)
a. around tendons of the digital flexors
b. begins proximal to flexor retinaculum
c. ends in mid palmar compartment except for sheath to 5th digit which
continues into digit
2. sheath for flexor pollicis longus (radial bursa)
a. extends into 1st digit
62
Median
Ulnar
Recurrent branch
of median
Deep branch
of ulnar
Adductor
pollicis
Innervation of intrinsic hand muscles

G. Innervation of the intrinsic muscles of the hand
1. LOAF muscles are innervated by median nerve three thenar muscles
by recurrent branch of median
a.
L - lumbricals I and II
b. O - opponens pollicis
c. A - abductor pollicis brevis
d. F - flexor pollicis brevis
2. all other intrinsic muscles of hand are innervated by deep branch of
ulnar nerve
a. three hypothenar muscles
b. all interossei
c. lumbricals III and IV
d. adductor pollicis
63
Radial
Ulnar
Superficial
palmar arch
Deep palmar arch
Princeps pollicis
Common palmar
digital
Proper digital
Radialis indicis
Arterial supply to the hand

I. Blood Supply
1. superficial palmar arch
a. formed primarily by ulnar artery
b. lies superficial to digital flexor tendons
2. deep palmar arch
a. formed mostly by radial artery which enters palm through 1st dorsal
interosseous
b. lies deep to digital flexor tendons
3. dorsal carpal arch
a. formed by branch of radial in anatomical snuffbox
4. venous drainage
a. basilic drains medial aspect of forearm and joins brachial in arm
b. cephalic drains lateral aspect of the forearm and joins axillary vein
c. median cubital lies over cubital fossa and joins cephalic and basilic
d. dorsal veins of hand drain into cephalic and basilic
e. paired radial and ulnar veins form brachial veins in cubital fossa
64
Radial a
Canal of Guyon
Ulnar n, a
Median n
Digital flexor
tendons
Flexor
retinaculum
Hamate Trapezium
Carpal tunnel
J. Carpal tunnel
1. boundaries
a. three bony walls formed by carpals
b. roof formed by flexor retinaculum
2. contents
a. tendons of superficial and deep digital flexors in ulnar bursa
b. tendon of flexor pollicis longus in radial bursa
c. median nerve
3. ulnar nerve and vessels enters hand superficial to retinaculum through
separate fibrous compartment, the canal of Guyon
65
Extensor Forearm and Hand

Specific Objectives
Be able to:
1.
Describe the muscles of the extensor compartment in terms of attachments,

actions, and innervation.
2.
Describe the course of the radial nerve in the forearm.
3.
Describe the compartments and spaces of the forearm and the muscular, neural
and vascular structures found in each.
4.
Describe the boundaries and contents of the anatomical snuff box.
5.
Describe the cutaneous nerve distribution of the upper limb.
6.
Describe the actions of the intrinsic and extrinsic muscles of the hand in
providing movements of the wrist and digits.
66
Brachioradialis
Extensor carpi ulnaris
Extensor carpi radialis

longus &
brevis
Extensor digitorum
Abductor
pollicis longus
Extensor
pollicis longus
Extensor
pollicis brevis
Extensor
indicis
Extensor digiti
minimi
Extensor retinaculum
Forearm extensor muscles

Extensor forearm
A. Extensor compartment muscles
1. superficial layer all except brachioradialis and extensor carpi radialis
longus originate by common extensor tendon from lateral epicondyle
a. brachioradialis - flexes elbow when forearm is in neutral position
b. extensor carpi radialis longus
c. extensor carpi radialis brevis
d. extensor digitorum
e. extensor digiti minimi
f. extensor carpi ulnaris
2. deep layer
a. supinator
b. abductor pollicis longus
c. extensor pollicis brevis
d. extensor pollicis longus
e. extensor indicis
67
Superficial
radial n
Lateral
epicondyle
Deep
radial n
Posterior
interosseous n
Radial n in
radial groove
Brachium
Antebrachium
Radial nerve
B. Innervation
1. radial nerve
a. crosses the elbow anterior to lateral epicondyle
b. divides into superficial and deep branches deep to brachioradialis
c. deep branch enters posterior compartment through supinator to become
posterior interosseous nerve
d. innervates all muscles in extensor compartment
e. superficial branch lies deep to brachioradialis, crosses anatomical
snuffbox, and is sensory from dorsum of hand
C. Blood Supply
1. posterior interosseous artery, a branch of common interosseous
D. Lymphatic drainage of upper limb
1. superficial
a. from medial structures passes through cubital nodes to lateral axillary nodes
b. from lateral structures passes through apical nodes
2. deep
a. passes through lateral axillary nodes
68
Synovial
sheaths
Extensor tendon
Central
tendon
Extensor
reticulum
Interosseous
Extensor
expansion
Lumbrical
Extensor retinaculum and extensor expansion

E. Dorsum of the hand
1. extensor retinaculum
a. attaches to dorsal radius to form six osseofibrous tunnels
b. posterior compartment muscle tendons pass deep to retinaculum
2. extensor expansion
a. tendons of extensor digitorum form expansions at MCP joints
b. extensor expansions also serve as insertion for lumbricals and interossei
3. collateral ligaments of the MCP, PIP and DIP joints
a. tighten during flexion to provide greater stability when gripping
69
Superficial radial n
Radial a
Extensor pollicis
longus tendon
Abductor pollicis
longus tendon
Extensor pollicis
brevis tendon
1st dorsal
interosseous
Anatomical snuff box

F. Anatomical snuffbox
1. boundaries
a. anterior border is tendons of abductor pollicis longus and extensor pollicis brevis
b. posterior border is tendon of extensor pollicis longus
c. floor is styloid process of radius, scaphoid, trapezium
d. roof is antebrachial fascia
2. contents
a. radial artery passing from anterior antebrachium to dorsum of hand
70
Posterior
Anterior
Axillary
C7
C5
C6
Radial
Musculocutaneous
C8
Superficia
l
radial
Ulnar
Medial
brachial
T1
Dermatomes
Medial
antebrachial
Median
Cutaneous nerves and dermatomes of upper limb

G. Cutaneous innervation
1. dermatomes
a. area of skin supplied by single segment of spinal cord
b. there is considerable overlap of adjacent dermatomes, especially in trunk
2. cutaneous nerves
a. branches of dorsal or ventral rami that innervate skin
b. carry somatic sensory nerve fibres from receptors for conscious sensation
c. carry visceromotor nerve fibres to errector pili muscles, sweat glands, and
smooth muscle in walls of blood vessels supplying skin
3. cutaneous nerves of upper limb
a. intercostobrachial from T2
b. superior lateral brachial from axillary
c. medial brachial and antebrachial from medial cord
d. inferior lateral brachial, posterior brachial and antebrachial from radial
e. lateral antebrachial from musculocutaneous
f. hand receives dorsal, palmar and digital branches from radial, median and
ulnar nerves
71
Introduction to the
Autonomic Nervous System
Specific Objectives
Be able to:
1. Describe the sympathetic and parasympathetic parts of the autonomic nervous
system in terms of origin in the CNS, and location of ganglia.
2. Describe a cross section of a spinal cord segment with its pair of spinal nerves
between T1-L2, above T1, and between S2-S4.
3. Describe the pathway for sympathetic innervation of the body wall, thoracic
viscera, and abdominopelvic viscera.
4. Describe the pathway for parasympathetic innervation of thoracic viscera and the
gut to the left colic flexure, and of the gut beyond the left colic flexure and the
pelvic viscera.
5. Describe the pathways used by visceral afferents for pain and for normal
physiological function.
6. Describe the mechanism of referred pain.
72
CNS
Sympathetic
ganglion
Target tissue
smooth muscle
glands
cardiac muscle
Sympathetic
Nuclei
Target tissue
Parasympathetic
smooth muscle
glands
cardiac muscle
Parasympathetic
ganglion
Preganglionic neuron
Autonomic nervous system schematic
Postganglionic neuron
A. Divisions of the autonomic nervous system

1. sympathetic
a. regulates "fight or flight" responses
b. preganglionic neuron soma in spinal cord levels T1-L2 and axons
project to sympathetic ganglia
c. postganglionic neuron soma in ganglia and axons project to the
target tissue
2. parasympathetic
a. regulates responses to non-stress situations
b. preganglionic neuron soma in brainstem and cord levels S2-S4 and
axons project to parasympathetic ganglia
c. postganglionic neuron soma in ganglia and axons project to the
target tissue
73
Ventral ramus
White
ramus
Splanchnic n
Sympathetic
trunk
Thoracic
ventral
ramus
Paravertebral
ganglion
Gray
ramus
Thoracic spinal nerve

B. Autonomic structures on spinal nerves
1. white rami communicans
a. only found on ventral rami T1-L2
b. carry preganglionic sympathetic axons from ventral ramus to chain
ganglion
2. gray ramus communicans
a. found on all ventral rami
b. carry postganglionic sympathetic axons from chain ganglion to ventral
ramus
74
Cervical nerve
Sympathetic trunk
Lateral horn
Thoracic
splanchnic n
Chain
ganglio
n
Preaortic
ganglia
Gray ramus
communicans
White ramus
communicans
Spinal nerve below L2
Sympathetic structures
C. Sympathetic division
1. preganglionic neurons
a. all soma in lateral horn at cord levels T1-L2
b. all axons leave cord via ventral roots T1-L2 to enter spinal nerves T1-L2
c. all axons enter chain ganglia via white rami communicans
d. all axons synapse in chain/paravertebral, or preaortic/prevertebral, ganglia
2. postganglionic neurons
a. all soma lie in chain, or preaortic, ganglia
3. paravertebral ganglia
a. bilateral trunks extending from cervical to coccygeal regions
4. preaortic ganglia
a. lie around roots of, and are named for, major visceral arteries in abdomen
b. thoracic splanchnic nerves connect chain ganglia with preaortic ganglia
75
D. Sympathetic paths to structures in the body wall

1. preganglionic path soma in lateral horn T1-L2
a. axons carried by ventral roots, ventral rami and white rami of T1-L2
b. synapse in chain ganglia
2. postganglionic path
a. axons project through gray rami communicans to spinal nerves
b. postganglionic axon can leave chain at a different level to what the
preganglionic neuron entered
c. carried by ventral or dorsal rami to target tissue in body wall
E. Sympathetic paths to thoracic viscera
1. preganglionic path soma in lateral horn T1-4
a. axons project through ventral roots, ventral rami and white rami of T1-4
b. synapse in upper thoracic or cervical chain ganglia
a. axons project through cardiac nerves from chain ganglia
b. join cardiac or pulmonary plexi on way to target tissue
F. Sympathetic paths to abdominopelvic viscera
1. preganglionic soma in lateral horn T5-L2
a. most preganglionic axons project via white rami T5-L2 to thoracic and
lumbar splanchnic nerves
b. synapse in celiac, aorticorenal, superior or inferior mesenteric ganglia
c. some preganglionic axons descend in chain to synapse in lumbar or sacral
ganglia
a. most postganglionic axons follow visceral arteries from preaortic ganglia
b. some leave chain through lumbar and sacral splanchnic nerves
76
G. Parasympathetic division
1. preganglionic soma in nuclei of cranial nerves III, VII, IX, X or lateral
horn S2-4
a. axons project to ganglia in, or close to, target tissue
b. no parasympathetic innervation to body wall
H. Parasympathetic path to thoracic viscera and gut up to the left colic flexure
1. preganglionic soma in dorsal nucleus of vagus nerve (X)
a. axons project through vagus
b. join autonomic plexi and synapse in target tissue
I.
Parasympathetic path to gut beyond left colic flexure, pelvic viscera and
erectile tissues
1. preganglionic soma in lateral horn S2-4
a. axons project through ventral rami of S2-4 and pelvic splanchnic nerves
b. join autonomic plexi and synapse in target tissue
J. Autonomic plexus
1. postganglionic sympathetic axons and preganglionic parasympathetic axons
running together to innervate common structures, plus visceral afferents
K. Visceral afferent fibres
1. afferent fibres traveling with parasympathetic visceromotor fibres
a. generally carry unconscious sensation from viscera such as presence of
food in GI tract and changes in blood gases, chemistry or pressure
2. afferent fibres traveling with sympathetic visceromotor fibres
a. generally carry pain sensation from distension, ischaemia or infection
3. visceral or referred pain
a. usually perceived as being pain in body wall since wall is represented in
brain but viscera are not
b. visceral afferents join somatic afferents in dorsal roots and run together
into dorsal horn of spinal cord
c. brain interprets visceral pain as coming from area of body wall innervated
by somatic afferents entering CNS at same level as visceral afferents
77
Anteromedial Thigh
Specific Objectives
Be able to:
1. Describe the deep fascia of the thigh and the intermuscular septa.
2. Describe the femoral triangle, the adductor canal, and the contents of each.
3. Describe the course, and distribution, of the branches of the femoral artery.
4. Describe the deep and superficial venous drainage of the thigh.
5. Describe the anatomy of the hip and knee joints with reference to bony and
ligamentous structures.
6. Describe the muscles in the anterior and medial compartments of the thigh
with respect to attachments, actions, and innervation.
83
Anterior
Iliotibial band
Fascia lata
Medial
Intermuscular
septa
Lateral
Medial
Third
Great
saphenous vein
Fascia of femoral region

A. Femoral fascia
1. fascia lata
a. continuous with Scarpas fascia of abdominal wall
b. attaches proximally to iliac crest, sacrum, coccyx, sacrotuberous ligament,
ischial tuberosity, ischiopubic ramus, pubic tubercle, inguinal ligament
c. attaches distally to femoral and tibial condyles and head of fibula
2. iliotibial band/tract
a. lateral thickening of fascia lata from tubercle of iliac crest to lateral tibial
condyle
a. lateral and medial septa divide region into anterior and posteromedial
compartments
b. ill-defined 3rd septum subdivides posteromedial compartment into medial
and posterior compartments
84
Inguinal ligament
Femoral n
Iliopsoas
Sartorius
Femoral a
Femoral v
Pectineus
Adductor longus
Femoral Triangle
B. Femoral triangle
1. borders
a. medial border of sartorius
b. medial border of adductor longus
c. inguinal ligament
d. floor is iliopsoas, pectineus and adductor longus
e. roof is fascia lata
2. contents
a. femoral sheath
b. femoral nerve and branches
c. femoral artery/vein and branches/tributaries
3. subinguinal hiatus
a. inferior to inguinal ligament and superior to superior pubic ramus
b. passage between abdominopelvic cavity and anterior thigh
c. contains lateral femoral cutaneous nerve, iliopsoas, femoral nerve, femoral
sheath, femoral branch of genitofemoral nerve
4. adductor canal
a. runs deep to sartorius from apex of femoral triangle to adductor hiatus
b. contains femoral a and v, saphenous n, and n to vastus medialis
c. adductor hiatus is opening between vertical and adductor portions
of adductor magnus and contains femoral artery and vein
85
Inguinal
ligament
Femoral n
Lacunar
ligament
Femoral sheath
Femoral a
Femoral v
Great
saphenous v
Deep inguinal nodes
Femoral sheath
C. Femoral sheath
1. funnel-shaped fascial sheath emerging below inguinal ligament and
fusing distally with walls of femoral vessels
2. divided by septa into three compartments
a. lateral contains femoral artery
b. middle contains femoral vein
c. medial is femoral canal containing fat and deep inguinal lymph nodes
d. femoral ring is entrance to canal bordered medially by lacunar
ligament
e. great saphenous enters sheath to join femoral vein
86
deep circumflex iliac

supf. cirucumflex iliac
supf. epigastric
Femoral
Medial femoral
circumflex
Deep femoral
Lateral femoral
circumflex
Descending
branch
Popliteal
Descending
genicular
Genicular
anastomosis
Femoral artery
D. Arterial supply
1. obturator
a. through obturator canal to supply medial compartment and hip joint
2. femoral
a. through femoral triangle and adductor canal to adductor hiatus
b. becomes popliteal distal to hiatus
c. normally gives off superficial circumflex iliac, superficial epigastric,
external pudendal, deep femoral
3. deep femoral/profunda femoris
a. branch of femoral
b. normally gives rise to circumflex femorals and perforating arteries
c. runs deep on adductor magnus and is major supply to femoral region
4. medial circumflex femoral
a. major supply to neck and head of femur
5. lateral circumflex femoral
a. also supplies neck and head of femur
b. gives off descending branch which contributes to genicular anastomosis
6. perforating arteries
a. four vessels piercing adductor magnus to supply posterior compartment
b. 1st contributes to cruciate anastomosis of hip
c. 4th is terminal branch of the deep femoral
87
Iliopsoas
Pectineus
Adductor longus
Gracilis
Rectus femoris
Sartorius
Vastus lateralis
Vastus medialis
Quadriceps tendon
Muscles of the anteromedial thigh

E. Muscles
1. anterior compartment flex hip and/or extend knee
a. rectus femoris
b. vastus medialis
c. vastus lateralis
d. vastus intermedius
e. iliopsoas
f. pectineus
g. sartorius
h. innervation by femoral nerve except for psoas (L1-3 ventral rami) and
pectineus, which may also receive a branch of obturator nerve
2. medial compartment adduct hip
a. adductor magnus adductor and vertical portions
b. adductor longus
c. adductor brevis
d. gracilis
e. innervation by obturator nerve except vertical portion of magnus which
receives branch of tibial nerve
88
Ligament of
head of femur
Ischiofemoral lig
Labrum
Capsule
Pubofemoral lig
Obturator a
Iliofemoral lig
Medial and
lateral femoral
circumflex aa
Hip joint
F. Joints
1. hip
a. ball and socket synovial joint
b. strong capsule and fibres have inferolateral orientation anteriorly
which limits extension
c. capsule attaches to neck of femur and around acetabulum
d. flexion/extension, aBduction/aDduction, rotation
e. acetabular labrum attaches to edge of acetabulum
f. iliofemoral, pubofemoral and ischiofemoral ligaments are thickenings
of capsule
acetabular
g. ligament of head of femur carries branch of obturator artery to head

of femur
89
Lateral
collateral
ligament
Lateral
meniscus
Medial
collateral
ligament
Anterior
cruciate
Medial
meniscus
Posterior
cruciate
Lateral
collateral
ligament
Medial
collateral
ligament
Knee joint
2. knee joint
a. capsule incorporates patella and patellar tendon
b. flexion/extension, slight rotation
c. medial collateral ligament is attached to capsule and to medial meniscus
d. lateral collateral ligament is extra capsular
e. anterior and posterior cruciate ligaments are intracapsular
f. medial and lateral menisci deepen tibial plateau; attach to tibia and capsule
Iliotibial
band
Vastus
intermedius
Rectus
femoris
Vastus
medialis
Sartorius
Adductor
canal
Vastus
lateralis
Gracilis
Biceps
femoris
Adductor
longus
Sciatic n
Cross section of mid thigh

Semitendinosus
Semimembranosus
Adductor
magnus
Adductor
brevis
90
Iliac nodes
Inguinal
ligament
Deep inguinal
Superficial inguinal
(horizontal group)
(vertical group)
Great saphenous v
Lymphatics
G. Lymphatics
1. superficial inguinal nodes
a. vertical group at proximal end of great saphenous vein receives all
superficial drainage that does not pass through popliteal nodes
b. horizontal group lies just inferior to inguinal ligament and receives lymph
from gluteal and perineal regions, and abdominal wall below umbilicus
c. superficial nodes drain into deep inguinal to iliac nodes and then to
lumbar nodes
2. deep inguinal nodes
a. in femoral canal
b. receive all deep drainage from lower limb and all drainage from
superficial nodes
c. drain into iliac nodes and to lumbar nodes
H. Venous drainage
1. great saphenous vein
a. drains medial aspect of foot, crural region, knee, thigh
b. passes through saphenous opening and femoral sheath to join femoral vein
91
Gluteal Region and

Posterior Thigh
Specific Objectives
Be able to:
1. Describe the major bony and ligamentous structures of the pelvis and femur.
2. Describe the gluteal muscles and the six lateral rotators in terms of attachments,
3. Describe the muscles of the hamstring group in terms of attachments, actions,
and innervation.
4. Describe the course, and distribution, of the sciatic, superior and inferior gluteal,
tibial and common fibular nerves.
5. Describe the blood supply to, and venous drainage of, the gluteal region and
posterior thigh.
6. Describe the boundaries and contents of the popliteal fossa.
7. Describe the lymphatic drainage of the regions.
78
Gluteus medius
Gluteus minimus
Piriformis
Superior
gemellus
Gluteus maximus
Semitendinosus
Semimembranosu
s
Obturato
r
internus
Inferior
gemellus
Quadratus
femoris
Biceps femoris
long &
short head
Muscles of the gluteal region and posterior thigh

A. Entrances and exits of gluteal region
1. greater sciatic foramen
a. superior gluteal neurovascular bundle passes above, inferior gluteal and
pudendal neurovascular bundles and sciatic nerve pass below, piriformis
2. lesser sciatic foramen
a. pudendal neurovascular bundle crosses sacrospinous ligament to enter
perineum
B. Gluteal muscles
1. gluteus maximus, medius and minimus
2. lateral rotators piriformis, superior gemellus, obturator internus, inferior
gemellus, obturator externus (deep) and quadratus femoris
3. tensor fasciae latae lies lateral and acts on hip with medius and minimus
4. iliotibial band/tract is lateral thickening of fascia lata from iliac crest to lateral
tibial condyle which encloses tensor fasciae latae and serves as insertion for
tensor and gluteus maximus
79
Superior
gluteal
Inferior
gluteal
Pudendal
Sciatic
Posterior femoral
cutaneous
Sciatic
Common
fibular
Tibial
Nerves of the gluteal region and posterior thigh

C. Posterior thigh muscles
1. hamstrings
a. semimembranosus
b. semitendinosus
c. biceps femoris long head
2. biceps femoris short head
3. vertical head of adductor magnus
D. Gluteal innervation
1. superior gluteal (L4-S1) to medius, minimus and tensor fasciae latae
2. inferior gluteal to maximus (L5-S2)
E. Posterior thigh innervation
1. tibial division of sciatic
a. to semimembranosus, semitendinosus, long head of biceps femoris and
vertical head of adductor magnus
2. common fibular division of sciatic
a. to short head of biceps femoris
80
Femoral
Descending
branch of
lateral femoral
circumflex
Perforating
branches of
deep femoral
Medial femoral
circumflex
Descending
genicular
Genicular
anastomosis
Blood supply of the posterior thigh

F. Gluteal blood supply
1. superior gluteal artery
a. superficial branch lies between gluteus maximus and medius
b. deep branch lies between medius and minimus with supply to tensor
fasciae latae
2. inferior gluteal artery
a. supplies gluteus maximus and lateral rotators
3. cruciate anastomosis
a. between inferior gluteal, circumflex femorals and 1st perforating artery
81
Biceps femoris
Semimembranosus
Popliteal vessels
Semitendinosus
Tibial n
Common fibular n
Superior &
inferior medial
genicular aa
Short saphenous v
Gastrocnemius
medial &
lateral head
Popliteal fossa and contents

G. Posterior thigh blood supply
1. deep femoral
a. branch of femoral in triangle, passes deep to lie on adductor magnus
b. major supply to femoral region
2. medial and lateral circumflex femorals
3. four perforating branches pierce magnus to supply posterior compartment
4. popliteal artery
a. continuation of femoral distal to adductor hiatus in the popliteal fossa
5. genicular anastomosis
a. descending branch of lateral femoral cicumflex
b. descending genicular from femoral
c. anterior tibial recurrent
d. geniculars - medial superior and inferior, lateral superior and inferior, middle
all branch from popliteal artery
H. Popliteal fossa
1. superior borders - heads of hamstrings
2. inferior borders - heads of gastrocnemius
3. floor - popliteal surface of femur, knee joint capsule and popliteus
4. roof - fascia lata proximally and crural fascia distally
5. contents popliteal vessels and branches, tibial and common fibular nerves
82
Leg and Foot

Specific Objectives
Be able to:
1. Describe the fascial compartments of the leg and their contents.
2. Describe the muscles of the anterior, posterior and lateral compartments in
terms of attachments, actions, and innervation.
3. Describe the bony and ligamentous structures of the ankle joint.
4. Describe the relationships of tendons, blood vessels and nerves on the medial and
lateral aspects of the ankle joint.
5. Describe the fascial compartments of the foot and their contents.
6. Describe the muscles of the plantar surface of the foot in terms of layers, attachments,
7. Describe the blood supply, and the venous and lymphatic drainage, of the leg and foot
8. Describe the cutaneous innervation of the lower limb.
92
Interosseous
membrane
Tibia
Anterior and
posterior crural
septae
Fibula
Crural
fascia
Deep transverse
septum
Fascia and compartments of the leg

Leg
A. Crural fascia
1. attaches to anterior crest and medial surface of tibia, to malleoli and
calcaneus and has opening for small saphenous vein over popliteal fossa
a. anterior and posterior crural septa define lateral compartment
b. deep transverse septum divides posterior compartment into superficial
and deep compartments
3. interosseous membrane
a. between interosseous borders of tibia and fibula
b. deficient proximally to permit passage of anterior tibial vessels
c. serves as origin for some crural muscles
4. superior extensor retinaculum
a. transverse thickening of crural fascia attaching to fibula and tibia
b. covers tendons of anterior compartment muscles, vessels and nerves
5. flexor retinaculum
a. attaches to medial malleolus and calcaneus
b. covers tendons of deep posterior compartment muscles, posterior tibial
vessels and tibial nerve
6. fibular retinaculum
a. lateral malleolus to calcaneus
b. covers tendons of lateral compartment
93
Plantaris
Medial & lateral

gastrocnemius
Soleus
Popliteus
Tibialis
posterior
Flexor
digitorum
longus
Flexor
hallucis
longus
Calcaneal
tendon
Flexor retinaculum
Fibular retinaculum
Superficial and deep posterior compartment muscles

B. Muscles
1. superficial posterior compartment
a. gastrocnemius, soleus, plantaris
b. plantar flexors of talocrural joint and/or flexors of knee
2. deep posterior compartment
a. tibialis posterior, flexor digitorum longus, flexor hallucis longus
b. plantar flexors of ankle, invertors of foot, and flexors of digits
94
Tibialis
anterior
Fibularis longus
Extensor
digitorum longus
Fibularis brevis
Extensor
hallucis longus
Lateral malleolus
Fibularis tertius
tendon
Inferior extensor
retinaculum
Fibular retinaculum
Anterior and lateral compartment muscles

3. anterior compartment
a. tibialis anterior, extensor digitorum longus, extensor hallucis
longus, fibularis tertius (not always present)
b. dorsiflexors of talocrural joint, extensors of digits
4. lateral compartment
a. fibularis longus, fibularis brevis
b. plantar flexors of talocrural joint, evertors of foot
95
Common fibular
Common
fibular
Superficial fibular
Tibial
Deep fibular
Anterior
Posterior
Nerves of the leg

C. Innervation
1. tibial nerve
a. all posterior compartment muscles and plantar muscles of foot
b. becomes medial and lateral plantar nerves in foot
2. common fibular nerve
a. crosses neck of fibula and divides
3. deep fibular nerve
a. to all anterior compartment muscles
4. superficial fibular nerve
a. to lateral compartment muscles
96
1st layer
Abductor
hallucis
Abductor
digiti minimi
Flexor digitorum
brevis
Plantar aponeurosis
Plantar aponeurosis and 1st layer of plantar muscles

Foot
A. Pedal fascia
1. very thin dorsally
2. plantar aponeurosis
a. thickening of fascia that is continuous with fibrous flexor sheaths
a. attach borders of aponeurosis to 1st and 5th metatarsals
b. form medial central and lateral plantar compartments
4. inferior extensor retinaculum
a. covers tendons of anterior crural muscles, vessels and nerves
B. Muscles of plantar surface of foot
1. medial compartment
a. abductor hallucis, flexor hallucis brevis, flexor hallucis longus tendon
2. lateral compartment
a. flexor digiti minimi and abductor digiti minimi
3. central compartment
a. adductor hallucis, flexor digitorum longus tendons, quadratus plantae,
lumbricals, flexor digitorum brevis, dorsal and plantar interossei
97
2nd layer
3rd layer
Flexor
hallucis
brevis
1st lumbrical
Flexor hallucis
longus tendon
Flexor digiti
minimi
Adductor
hallucis
Flexor digitorum
longus tendon
Quadratus plantae
2nd and 3rd layers of plantar muscles

C. Innervation of intrinsic muscles of foot
1. LAFF muscles innervated by medial plantar nerve
a. L - 1st lumbrical
b. A - abductor hallucis
c. F - flexor hallucis brevis
d. F - flexor digitorum brevis
2. lateral plantar nerve supplies all other plantar intrinsic muscles
3. dorsum of foot
a. extensor digitorum brevis
b. extensor hallucis brevis
c. innervated by deep fibular nerve
98
Plantar arch
Popliteal
Anterior
tibial
Posterior
tibial
Fibular
Posterior
tibial
Medial &
lateral plantar
Posterior
tibial
Arteries of the posterior leg and plantar foot

D. Blood supply to leg and foot
1. popliteal artery
a. divides into anterior and posterior tibial deep to origin of soleus
2. posterior tibial
a. continuation of popliteal between superficial and deep compartments
b. gives off fibular to lateral side of posterior compartment
c. passes deep to flexor retinaculum and divides into medial and lateral
plantars
d. medial and lateral plantars form plantar arch (mainly from lateral)
deep to digital flexor tendons
e. plantar metatarsals from arch give off two plantar digitals to adjacent
digits
f. plantar arch gives off perforating branches to dorsal surface
3. venous drainage
a. great saphenous vein provides superficial drainage of medial aspect of
dorsum of foot, anteromedial leg and thigh before joining femoral vein
b. small saphenous vein provides drainage of lateral aspect of dorsum of
foot and posterolateral leg before joining popliteal vein
99
Anterior
tibial
Dorsalis
pedis
Arcuate
Arteries of anterior leg and dorsal foot

3. anterior tibial
a. enters anterior compartment by passing through hiatus in interosseous
membrane; lies on membrane with deep fibular nerve
4. dorsalis pedis
a. continuation of anterior tibial distal to talocrural joint; becomes arcuate
b. arcuate gives rise to dorsal metatarsals which give rise to two dorsal
digitals to adjacent digits
c. arcuate receives perforating branches from plantar arch
100
Anterior & posterior

tibiofibular
Deltoid
ligament
Calcaneofibular
Tendon of
fibularis longus
Spring ligament
Collateral ligaments of the ankle

E. Joints of leg and foot
1. superior tibiofibular
a. synovial joint between head of fibula and lateral tibial condyle
2. inferior tibiofibular
a. fibrous joint
b. anterior and posterior tibiofibular ligaments
3. tibiotalar/talocrural
a. synovial joint between tibia/both malleoli and trochlea of talus
b. permits plantar flexion/dorsiflexion
c. deltoid ligament is fan-shaped capsular ligament on medial aspect
d. calcaneofibular ligament is narrow capsular ligament on lateral aspect
4. intertarsal/subtalar
a. synovial joints between adjacent tarsals
b. site of inversion/eversion
c. spring ligament supports head of talus
d. plantar ligaments help maintain arches of foot
5. tarsometatarsal
a. synovial joints between cuboid/cuneiforms and metatarsals I-V
6. metatarsophalangeal
a. synovial joints between metatarsals and proximal phalanges
b. flexion/extension, aBduction/aDduction
7. interphalangeal joints
a. synovial joints between adjacent phalanges
b. flexion/extension
101
(horizontal nodes)
(vertical nodes)
Popliteal
nodes
Great saphenous
Small saphenous
Lymphatics
F. Lymphatic drainage of lower limb
1. superficial drainage
a. vessels draining anteromedial aspect of leg and foot follow great
saphenous vein
b. vessels draining posterolateral aspect follow small saphenous vein
2. deep drainage
a. popliteal nodes receive lymph from deep vessels distal to knee and
from posterolateral superficial vessels
3. superficial inguinal nodes
a. vertical group at proximal end of great saphenous vein receives all
superficial drainage that does not pass through popliteal nodes
b. horizontal group just inferior to inguinal ligament receives drainage from
gluteal and perineal regions, and abdominal wall below umbilicus
c. drain into deep inguinal
4. deep inguinal nodes
a. in, and just inferior to, femoral canal
b. receive all deep drainage and superficial drainage as described above
c. drain into iliac nodes and then to lumbar nodes
102
Lateral
femoral
Obturator
Lateral
femoral
Femoral
Common
fibular
Tibial
Common
fibular
Cutaneous innervation of lower limb

G. Cutaneous innervation of lower limb
1. cutaneous nerves
a. anterior femoral from femoral
b. lateral femoral from L2,3
c. posterior femoral from S1,2,3
d. branches from obturator
e. superficial and deep fibular from common fibular
f.
medial and lateral sural from tibial and common fibular
g. medial and lateral plantar from tibial
103
Thorax, Lungs and Pleura

Specific Objectives
Be able to:
1. Describe the boundaries of the thorax.
2. Describe blood supply and cutaneous innervation of the thoracic wall.
3. Describe attachments, action and innervation of thoracic wall muscles.
4. Describe the relationships of parietal and visceral pleura.
5. Describe the anatomy of the lungs in terms of lobes, fissures and surface markings.
6. Describe the bronchopulmonary tree from trachea to segmental bronchi.
7. Describe the structures forming the root of the lung.
8. Describe the hilum of the lung, and the structures found there.
9. Describe the lymphatic drainage of the lungs and thoracic wall.
104
True ribs
Head with
facets for
costal demifacets
False ribs
Costal margin
Neck
Angle
Floating ribs
Tubercle
Body
Costal groove
Bony thoracic wall and typical rib

Thoracic wall
A. Thoracic Skeleton
1. superior thoracic opening
a. body of T1, 1st ribs, manubrium
2. inferior thoracic opening
a. body of T12, ribs 11-12, costal margins, xiphoid
3. thoracic vertebrae
a. synovial joints with heads of ribs
b. head of rib articulates with costal facet of one vertebra or superior
and inferior demifacets of adjacent vertebrae
c. T1-10 have synovial joint on transverse process with tubercle of ribs 1-10
4. ribs
a. true ribs (1-7) attach to sternum via costal cartilages
b. false ribs (8-12) have no direct articulation with sternum
c. costal cartilages of 8-10 connect to cartilage above forming costal
margin
d. floating ribs (11-12) do not articulate with sternum or other costal
cartilages
105
Intercostal
neurovascular
bundle
External intercostal
V
A
N
Internal intercostal
Innermost intercostal
Intercostal muscles
B. Muscles
1. external intercostals
a. fibres have inferomedial orientation
b. occupy posterior two thirds of intercostal spaces
2. internal intercostals
a. fibres have inferolateral orientation
b. occupy anterior two thirds of intercostal spaces
3. innermost intercostals
a. fibres have inferolateral orientation
b. occupy middle half of intercostal spaces
4. subcostals
a. part of posterior part of innermost intercostals
b. cross more than one intercostal space
5. transversus thoracis
a. lie anteriorly in same layer as innermost intercostals
6. levatores costarum
106
Dorsal ramus
Posterior
intercostal a
Intercostal n
External
intercostal m
Internal
intercostal m
Innermost
intercostal m
Transversus
thoracis m
Aorta
Internal
thoracic
a
Anterior
intercostal a
Intercostal nerves and vessels

C. Innervation
1. intercostal nerves - ventral rami of T1-11
a. lie between internal and innermost layers of muscles with intercostal
vessels; innervate intercostal, subcostal and transverse thoracis muscles
b. give rise to anterior and lateral cutaneous branches
c. ventral ramus of T12 is subcostal nerve lying below 12th rib
2. thoracic dorsal rami
a. innervate intrinsic back muscles in thoracic region
D. Blood supply of Thoracic Wall
1. internal thoracic arteries
a. give off anterior intercostals to intercostal spaces 1-6
b. divide in 6th space into superior epigastric and musculophrenic arteries
d. musculophrenic gives off anterior intercostals to spaces 7-9
2. thoracic aorta
a. gives rise to posterior intercostals to the lower nine intercostal spaces
b. posterior intercostal arteries to spaces 1-2 arise from branch of subclavian
3. posterior intercostal veins
a. most on right drain into azygos vein which joins superior vena cava
b. most on left drain into accessory hemi- and hemiazygos vein to join azygos
107
Inferior border
of lung
Costal margin
Inferior border of
parietal pleura
Topography of lungs and pleural cavity

Pleura and lungs
A. Pleura
1. visceral pleura
a. adherent to outer surface of lungs
b. continuous with parietal pleura at root of lung
2. parietal pleura lines thorax and forms lateral aspect of mediastinum
a. cervical (cupular)
b. costal
c. diaphragmatic
d. mediastinal
3. inferior extent of visceral and parietal pleura respectively
a. at the mid-clavicular line extends to 6th and 8th costal cartilages
b. at mid-axillary line - extend to ribs 8 and 10
c. at mid-scapular line - extend to ribs 10 and 12
d. cupula - extends into neck
e. costomediastinal recess - where costal and mediastinal pleura meet
f. costodiaphragmatic recess - where costal and diaphragmatic pleura meet
4. sensory innervation
a. somatic via intercostal and phrenic nerves from parietal pleura
b. visceral afferents from visceral pleura
108
Upper lobe
Lower lobe
Oblique fissure
of left lung
Horizontal fissure
of right lung
Pulmonary a
Main bronchus
Pulmonary v
Left
Right
Lobes, bronchopulmonary segments and hilum of lungs

B. Lungs
1. left
a. upper and lower lobes
b. separated by oblique fissure
2. right
a. upper, middle and lower lobes
b. separated by oblique and horizontal fissures
3. bronchopulmonary segments
a. ten on right
b. eight on left
4. root of lung
a. main bronchus, pulmonary artery and vein, lymph vessels, autonomic nerves
b. structures pass into/out of lung through hilum
c. visceral pleura reflects away from lung and forms pleural sleeve around root
5. hilum
a. area on medial surface of lung that is devoid of pleura
b. main bronchus lies posterior
c. right main bronchus lies posterior to pulmonary artery - eparterial bronchus
d. hilum also has bronchopulmonary (hilar) lymph nodes
109
Right
Lobar bronchi
Trachea
Main
Upper
Middle
Segmental
Lower
Intermediate
Carina
Tracheobronchial tree
C. Tracheobronchial tree
1. right main (primary) bronchus
a. shorter, wider, more vertical than left
b. gives off upper lobar bronchus and continues as intermediate bronchus
2. lobar (secondary) bronchi
a. intermediate bronchus divides into middle and lower lobar
3. left main bronchus
a. divides into upper and lower lobar
4. segmental (tertiary) bronchi
a. ten on right
b. eight on left
c. supply bronchopulmonary segments
110
Bronchomediastinal
trunk
Paratracheal nodes
Superior & inferior
tracheobronchial nodes
Pulmonary
nodes
Lymphatic drainage of lungs

D. Lymph Drainage from Lungs
1. nodes
a. pulmonary lie along lobar bronchi
b. bronchopulmonary (hilar) in hilum
c. inferior tracheobronchial (carinal)
d. superior tracheobronchial lie alongside bifurcation of trachea
e. paratracheal alongside trachea
2. left and right bronchomediastinal trunk
a. receive lymph from superior tracheobronchial and paratracheal nodes
b. also receive lymph from thoracic wall via parasternal and intercostal
nodes lying anterior and posterior respectively in intercostal spaces
c. drain into right lymphatic duct on right and thoracic duct on left
E. Systemic (non-respiratory) Blood Supply to Lungs
1. bronchial arteries
a. from thoracic aorta to supply tissues of lungs and bronchial tree
2. bronchial veins
b. drain into azygos system
111
Heart and Pericardium

Specific Objectives
Be able to:
1.
Describe the extent, attachments, layers and recesses of the pericardium.
2.
Describe the surfaces and borders of the heart in situ.
3.
Describe the major internal and external features of the heart chambers.
4.
Describe the atrioventricular and semilunar valves and their relationships to the
skeleton of the heart.
5.
Describe the major branches of the coronary arteries and the major tributaries of
the cardiac veins and coronary sinus.
6.
Describe the specialised conducting system of the heart and the sympathetic and
parasympathetic input to the cardiac plexuses.
112
Pulmonary trunk
Aorta
Transverse sinus
SVC
Pulmonary
veins
IVC
Pulmonary
veins
Oblique
sinus
Fibrous
pericardium
Pericardial sinuses
Pericardium
A. Layers
1. fibrous pericardium
a. sac containing heart and roots of great vessels
b. attached to roots of great vessels and central tendon of diaphragm
c. attached to sternum by sternopericardial ligaments
2. serous pericardium
a. parietal pericardium lines pericardial sac
b. visceral layer adherent to outer surface of heart as part of epicardium
3. innervation
a. somatic afferents from fibrous and parietal pericardium via phrenic nerves
b. visceral afferents from visceral pericardium via vagus and cardiac nerves
4. pericardial sinuses
a. oblique sinus - blind end sac between inferior vena cava and pulmonary
veins posterior to the heart
b. transverse sinus - posterior to ascending aorta and pulmonary trunk and
anterior to superior vena cava
113
Superior
vena cava
Aortic arch
Pulmonary
trunk
Right atrium
Right ventricle
Left ventricle
Heart in situ
Heart
A. Position
1. lies in fibrous pericardial sac in middle mediastinum
2. apex normally lies in left 5th intercostal space just medial to midclavicular line
3. base, formed mainly by left atrium, is posterior surface
4. anterior (sternocostal) surface is mainly right ventricle, partly left ventricle
5. inferior (diaphragmatic) surface is mainly left ventricle
6. right border is right atrium
7. left border is left ventricle
8. inferior border is primarily right ventricle
114
Limbus
Pectinate muscle
Crista terminalis
Conus
arteriosus
Fossa
ovalis
Opening of
coronary sinus
Anterior cusp of
tricuspid valve
Trabeculae carnae
Right atrium and ventricle
Anterior
papillary m
Moderator
band
B. Chambers
1. right atrium
a. receives blood from the superior and inferior venae cavae and coronary sinus
b. inner surface has smooth sinus venarum and an auricle with pectinate muscle
c. crista terminalis separates auricle from sinus venarum
d. fossa ovalis (foramen ovale in the fetus) in interatrial septum is partially
surrounded by limbus of fossa ovalis
e. opening of coronary sinus
2. right ventricle
a. receives blood from right atrium through right atrioventricular valve
b. three papillary muscles attach to valve cusps by chordae tendineae
c. trabeculae carneae on inner ventricular walls
d. septomarginal (moderator) band extends from interventricular septum to base
of anterior papillary muscle
e. conus arteriosus is smooth walled outflow tract leading to pulmonary trunk
115
Left pulmonary veins

Left atrium
To body above diaphragm
Anterior
papillary m
Bicuspid valve
To left lung
To right lung
Coronary sinus
From left lung
From right lung
To body below diaphragm
Left ventricle and atrium; blood flow through heart

3. left atrium
a. receives blood from four pulmonary veins
4. left ventricle
a. receives blood from left atrium through left atrioventricular valve
b. two papillary muscles attach to cusps by chordae tendineae
c. trabeculae carneae on walls
d. wall is much thicker than right ventricular wall
e. interventricular septum is also thick except for membranous upper
portion
116
Coronary sinus
Right coronary a
Left coronary a
Left circumflex a
Posterior cardiac v
Great cardiac v
Middle cardiac v
Right
marginal a
Anterior
interventricular a
Anterior
Posterior
interventricular a
Posterior
Right
coronary a
Circulation of the heart

C. Coronary Circulation
1. right coronary artery
a. arises from right aortic sinus
b. gives off right marginal branch
c. normally gives off posterior interventricular artery (right dominance)
d. normally supplies SA and AV nodes
2. left coronary artery
a. arises from left aortic sinus and bifurcates early
b. anterior interventricular artery (left anterior descending = LAD)
d. circumflex artery which may give rise to posterior interventricular
(left dominance)
3. cardiac veins
a. great cardiac vein accompanies anterior interventricular artery, and
continues as coronary sinus
b. middle cardiac vein accompanies posterior interventricular artery
c. coronary sinus receives middle, small and posterior cardiac veins and
drains into right atrium
d. anterior cardiac veins drain directly into right atrium
117
Left & right bundle

branches
SA node
AV node
Moderator band
AV bundle
Conducting system of the heart

D. Conduction System
1. sinuatrial (SA) node
a. located near root of superior vena cava in right atrial wall
b. acts as principal intrinsic pacemaker of heart
2. atrioventricular (AV) node
a. located in lower part of interatrial septum
b. receives impulses from SA node
3. atrioventricular (AV) bundle
a. from AV node to interventricular septum through cardiac skeleton
b. divides into right and left bundle branches which terminate as
Purkinje fibers
118
Pulmonary
valve
Aortic valve
A
S
A
Bicuspid
valve
Tricuspid valve
Posterior
Opening of
coronary arteries
A R
L
L R
P
Aortic
sinuses
Posterior
Cusps of heart valves

E. Heart Valves
1. skeleton of heart
a. valve orifices encircled by connective tissue, the fibrous skeleton,
which provides attachment for valves and provides electrical insulation
between atria and ventricles
2. right atrioventricular (tricuspid) valve
a. septal, anterior, and posterior cusps
b. septal, anterior and posterior papillary muscles attach to cusps by
chordae tendineae
3. left atrioventricular (bicuspid or mitral) valve
a. anterior and posterior cusps
b. anterior and posterior papillary muscles
4. pulmonary (semilunar) valve in root of pulmonary trunk
a. anterior, left and right cusps
5. aortic semilunar valve in root of ascending aorta
a. posterior, left and right cusps
b. dilations of aortic wall above the cusps are aortic sinuses
119
P
A
B
Valve locations
6. valve locations
a. pulmonary valve - 3rd costal cartilage and left side of sternum
b. aortic valve - posterior to left sternum at level of 3rd intercostal space
c. tricuspid valve - posterior to right sternum at level of 4th intercostal space
d. bicuspid valve - posterior to left sternum at level of 4th costal cartilage
e. auscultation sites are downstream from the valve sites
F. Autonomic innervation of the heart
1. cardiac plexuses
a. located between ascending aorta and tracheal bifurcation
b. receive bilateral sympathetic input from chain ganglia T1-4
c. receive parasympathetic input from vagus nerves
120
Mediastinum
Specific Objectives
Be able to:
1.
Describe the boundaries of the superior, anterior, middle and posterior mediastinum.
2.
Describe the contents of the superior mediastinum and their relationship to each other.
3.
Describe the contents of the anterior mediastinum and their relationship to each other.
4.
Describe the contents of the middle mediastinum and their relationship to each other.
5.
Describe the contents of the posterior mediastinum and their relationship to each other.
121
Sternal angle
Divisions of mediastinum
A. Divisions of Mediastinum
1. superior mediastinum
a. superior limit - superior thoracic opening
b. inferior limit - plane from sternal angle to inferior lip of T4
c. contains remnants of thymus gland, brachiocephalic veins, superior vena
cava, aortic arch and branches, trachea, roots of primary bronchi,
thoracic duct, lymph nodes, phrenic, vagus, left recurrent laryngeal nerves
2. inferior mediastinum
a. from level of sternal angle to diaphragm
b. further subdivided into anterior, middle and posterior portions
3. anterior mediastinum
a. anterior limit body of sternum
b. posterior limit - anterior surface of fibrous pericardial sac
c. contains sternopericardial ligaments, internal thoracic vessels, parasternal nodes
4. posterior mediastinum
a. posterior limit - vertebral bodies T5-T12
b. anterior limit - posterior surface of fibrous pericardial sac
c. contains - esophagus, vagus nerves, thoracic duct, azygos venous system,
thoracic aorta, splanchnic nerves, lymph vessels and nodes
5. middle mediastinum
a. limits - walls of fibrous pericardial sac
b. contains heart, roots of great vessels
c. phrenic nerves lie between fibrous pericardium and mediastinal pleura
122
Aorta
Left primary
bronchus
Carina
Esophagus
Trachea and esophagus

B. Trachea
1. from cricoid cartilage at C6 into superior mediastinum
2. lies posterior to aortic arch
3. bifurcates into mainstem bronchi at plane of sternal angle
a. carina is internal ridge positioned slightly to left of mid-tracheal line
C. Esophagus
1. from pharynx at C6 to cardiac orifice of stomach
2. three constrictions which show after barium swallow
a. cervical at pharyngoesophageal junction
b. thoracic as it crosses arch of aorta and left main bronchus
c. diaphragmatic as it passes through esophageal hiatus
3. lymphatic drainage
a. upper one-third to deep cervical nodes
b. middle one-third to superior and posterior mediastinal nodes
c. lower one-third to nodes along left gastric vessels
123
Brachiocephalic
trunk
Left subclavian
Left common
carotid
Bronchial
Posterior
intercostal
Esophageal
Branches of the aorta

D. Aorta
1. ascending
a. branches - right and left coronary arteries from aortic sinuses
2. aortic arch
a. located entirely in superior mediastinum
b. begins and ends at level of sternal angle
c. curves to left and posteriorly to become thoracic aorta
d. ligamentum arteriosum attaches to inferior surface of arch
e. branches (from proximal to distal) - brachiocephalic trunk, left common carotid
and left subclavian arteries
3. thoracic aorta
a. ends at aortic hiatus of diaphragm
b. branches - posterior intercostal, subcostal, pericardial, and superior phrenic
arteries are somatic; esophageal and bronchial are visceral
124
Vagus nerves
Left recurrent
laryngeal nerve
Esophageal
plexus
Anterior
vagal trunk
Vagus nerves
E. Nervous structures in the mediastinum
1. left vagus nerve
a. gives off left recurrent laryngeal nerve which loops around aortic arch
b. lies posterior to root of left lung and gives branches to pulmonary plexus
c. becomes part of esophageal plexus as anterior vagal trunk
2. right vagus nerve
a. gives off recurrent laryngeal nerve which loops around right subclavian
b. lies posterior to root of right lung and contributes to pulmonary plexus
c. becomes part of esophageal plexus as posterior vagal trunk
3. phrenic nerves
a. sensory from pericardium and mediastinal pleura
b. somatic motor to respective half of diaphragm
4. sympathetic trunks
a. chain of sympathetic ganglia on lateral aspects of thoracic vertebral bodies
5. splanchnic nerves innervate abdominal viscera
a. greater splanchnic receives preganglionic sympathetics from T5-T9
b. lesser splanchnic recieves preganglionic sympathetics from T10-11
c. least splanchnic receives preganglionic sympathetics from T12
6. cardiac plexuses
a. receive both sympathetic and parasympathetic fibers
b. lie on inferior aspect of aortic arch and between end of trachea and arch
125
SVC
Posterior
intercostals
Accessory
hemiazygos
Azygos
Hemiazygos
Subcostal
Ascending
lumbar
Azygos veins
F. Azygos system
1. azygos vein
a. arises from right ascending lumbar and subcostal veins and joins SVC
b. receives posterior intercostal veins from right thoracic wall
2. hemiazygos vein
a. arises from left ascending lumbar and subcostal veins and joins azygos
b. receives left posterior intercostal veins from lower spaces
3. accessory hemiazygos
a. receives left posterior intercostals from upper spaces and joins azygos
Fibrous
pericardium
Mediastinal
pleura
Left phrenic
nerve
Esophagus
Thoracic aorta
Cross section
of mediastinum
Thoracic duct
Hemiazygos vein
Azygos vein
126
Right lymphatic duct
Jugular trunk
Subclavian trunk
Bronchomediastinal
trunk
Thoracic duct
Level of diaphragm
Cisterna chyli
Thoracic and right lymphatic ducts

G. Lymphatics
1. thoracic duct
a. lies between aorta and azygos vein and posterior to esophagus
b. drains lymph from two lower, and left upper, quadrants of body
c. empties into junction of left internal jugular and subclavian veins
2. right lymphatic duct
a. drains upper right quadrant (head and neck, thorax, upper extremity)
b. empties into junction of right internal jugular and subclavian veins
3. right and left bronchomediastinal trunks
a. join proximal ends of right lymphatic or thoracic ducts
b. receive lymph from most of the mediastinum
3. lymph nodes
a. bronchopulmonary (hilar)
b. tracheobronchial drain lymph from lungs, tracheobronchial tree, heart
c. paratracheal
c. posterior mediastinal drain esophagus, pericardium, diaphragm
127
Anterior Abdominal Wall

Specific Objectives
Be able to:
1.
Describe the division of the abdomen into four quadrants or nine named regions,
and know the structures located in each region.
2.
Describe the muscles of the anterolateral abdominal wall in terms of attachments,

3. Describe how the anterolateral muscles contribute to the rectus sheath.

4. Describe the cutaneous innervation of the anterolateral abdominal wall.
5.
Describe the anatomy of the inguinal canal and spermatic cord, how the coverings
of the cord relate to the abdominal wall and testicular descent, and the course of
direct and indirect inguinal hernias.
6. Describe the lymphatic drainage of the abdominal wall.
128
RH
Epigastric
LH
RL
Umbilical
LL
Hypogastric
LI
Subcostal plane
Transtubercular
plane
RI
RU
LU
RL
LL
Midclavicular lines
Abdominal Regions
A. Abdominal regions
1. two vertical and two horizontal planes divide abdomen into nine regions
a. epigastric, right and left hypochondriac
b. umbilical, right and left lumbar
c. hypogastric, right and left inguinal
2. one vertical and one horizontal line divide the abdomen into four regions
a. right and left upper
b. right and left lower
129
External
oblique
Rectus
sheath
Rectus
abdominus
Camper's
fascia
Tendinous
intersection
Internal
oblique
Scarpa's
fascia
Figure 16.5 Abdominal muscles

Linea
alba
Linea
semilunaris
Fascia and muscles of abdominal wall

B. Superficial fascia
1. Campers fascia is superficial loose, fatty connective tissue layer
2. Scarpas fascia is fibrous connective tissue that is more defined inferiorly
C. Muscles
1. external abdominal oblique
a. inferior edge is free border forming inguinal ligament
b. fibres have an inferomedial orientation
c. unilateral contraction causes rotation to opposite side
2. internal abdominal oblique
a. fibres have an inferolateral orientation
b. unilateral contraction causes rotation to same side
3. transversus abdominus
a. fibres have a horizontal orientation
4. rectus abdominus
a. fibres have vertical orientation
b. belly of muscle divided horizontally by tendinous intersections
c. left and right bellies joined on midline by linea alba
d. lateral border may show on body surface as linea semilunaris
130
Above arcuate line
Anterior
rectus sheath
Linea alba
RA
EAO
RA
IAO
Extraperitoneal
tissue
TA
Parietal
peritoneum
Posterior
rectus sheath
Transversalis
fascia
Median
umbilical fold
Anterior
rectus sheath
Below arcuate line
Umbilical folds
Transversalis
fascia
Transverse section of abdominal wall

D. Rectus sheath
1. connective tissue surrounding rectus abdominus muscles
a. formed from aponeuroses of three lateral abdominal muscles
b. aponeuroses join on midline to form linea alba
2. superior 2/3rd of sheath
a. from xiphoid to midway between umbilicus and pubis
b. aponeuroses divide equally to form anterior and posterior walls of sheath
3. inferior 1/3rd of sheath
a. posterior wall is deficient because all three aponeuroses pass anterior to
rectus abdominus
b. inferior edge of posterior wall is arcuate line
c. below arcuate line transversalis fascia separates rectus abdominus from
extraperitoneal tissue and parietal peritoneum
4. umbilical folds - peritoneum covering underlying structures
a. median - obliterated urachus
b. medial - obliterated umbilical arteries
c. lateral - inferior epigastric arteries
131
Ventral
rami
Arteries
T7
T10
L1
Superior
epigastric
Anastomoses with
post intercostals
and lumbars
Inferior
epigastric
Innervation of abdominal wall

E. Innervation of wall
1. ventral rami T7-L1
a. umbilicus lies in T10 dermatome
2. neurovascular bundles lie between transversus and internal oblique
F. Blood Supply
1. arteries
a. lower posterior intercostals and lumbars
b. superior and inferior epigastrics
c. deep circumflex iliac
2. veins
a. lower posterior intercostals to azygos system
b. lumbars to ascending lumbars and IVC
c. ascending lumbars join subcostals to form azygos system
G. Lymph drainage
1. abdominal wall
a. above umbilicus drains to axillary nodes
b. below umbilicus, including scrotum/labia majora, drains to horizontal
group of superficial inguinal nodes
2. testes
a. to lateral aortic nodes in the abdominal cavity
132
Testicular vessels and vas

entering deep inguinal ring
in transversalis fascia
Transversalis
fascia
Superficial ring
Intercrural
fibers
Lateral crus
Medial crus
Spermatic cord
in superficial
inguinal ring
Inguinal region
H. Inguinal region
1. inguinal ligament
a. lateral attachment to anterior superior iliac spine
b. medial and lateral crura attach to medial pubic crest and pubic tubercle
2. intercrural fibers
a. run between crura and prevent them from spreading
3. conjoint tendon/falx inguinalis
a. fused aponeuroses of internal oblique and transversus abdominus
4. inguinal canal
a. superficial inguinal ring is opening between crura
b. deep inguinal ring is opening in transversalis fascia leading to
extraperitoneal tissue
c. posterior wall is transversalis fascia laterally plus conjoint tendon medially
d. anterior wall is external oblique plus internal oblique laterally
e. roof is arching fibres of internal oblique and transversus abdominus
f. floor is inguinal ligament
g. contains spermatic cord in male, round ligament of uterus in female, and
inguinal branch of ilioinguinal nerve in both
133
Vas deferens
Pampiniform
plexus
Epididymis
External
spermatic
fascia
Cremaster
muscle
Parietal layer of
tunica vaginalis
Visceral layer of
tunical vaginalis
on testis
Spermatic cord and scrotal contents/

I. Testes
1. covered almost completely by parietal and visceral layers of tunica vaginalis
2. epididymis
a. highly coiled tube that receives efferent ductules from testis at head
b. tail continuous with vas deferens
3. scrotum
a. sac of skin, dartos muscle (smooth), and superficial fascia divided by septum
J. Spermatic cord
1. wall layers
a. external spermatic fascia - extension of external oblique aponeurosis
b. cremaster muscle - longitudinal fibres derived from internal oblique
c. internal spermatic fascia - extension of transversalis fascia
2. contents
a. ductus (vas) deferens
b. testicular artery
c. pampiniform plexus
d. remnant of processus vaginalis
e. genital branch of genitofemoral n (L1-2) - somatic motor to cremaster muscle
134
GI Tract and Peritoneal Cavity

Specific Objectives
Be able to:
1. Describe the structure, position, relationships, peritoneal coverings and attachments
of all abdominal viscera.
2. Describe the following peritoneal structures in relation to their attatchments to body
wall and viscera: falciform ligament, round ligament of the liver, coronary ligaments,
triangular ligaments, mesentery of the small bowel, transverse mesocolon, sigmoid
mesocolon, suspensory ligament of the duodenum.
3. Describe intraperitoneal versus retroperitoneal (primary and secondary) locations
and which organs are found in each.
4. Describe the anatomy of the stomach, small and large intestine to include the
duodenum and its divisions, the jejunum, ileum, ileocecal valve, cecum, ascending,
transverse, descending and sigmoid colon.
5. Describe the blood supply, venous drainage, lymphatic drainage and autonomic
innervation of the gastrointestinal tract.
135
Lesser curvature
Esophagus
Fundus
Cardiac
region
Duodenum
Pyloric sphincter
Antrum
Greater
curvature
Stomach
Gastrointestinal tract
A. Gut
1. esophagus
a. begins at level of cricoid cartilage and ends at stomach
b. constricted at pharygoesophageal junction, where aortic arch and left main
bronchus cross, hiatus in diaphragm
2. stomach
a. regions are fundic, cardiac, body, pylorus
b. pyloric sphincter lies at distal end of pyloric region at gastroduodenal
junction
c. lesser curvature is attached to liver by the hepatogastric ligament
d. greater curvature gives rise to greater omentum
136
Duodenojejunal
junction
Duodenum
1st
2nd
3rd
Jejunum
4th
Cecum
Ileum
Ileocecal
junction
Small bowel
3. duodenum
a. initial short part of small bowel forming C-shape with concavity to left
b. divided into 1st, 2nd, 3rd, 4th parts
c. head and uncinate process of pancreas lie on concave curvature
d. hepatopancreatic duct system empties into 2nd part
4. jejunum
a. begins at end of 4th part of duodenum
b. duodenojejunal flexure supported by suspensory ligament of duodenum
5. ileum
a. longest part of small bowel
b. normally ends in right iliac fossa at ileocecal junction
137
Transverse
colon
Epiploic
Appendages
Haustra
Ascending
colon
Descending
colon
Taenia coli
Cecum
Sigmoid
colon
Appendix
Rectum
Large bowel
6. cecum
a. initial portion of large bowel
b. ileocecal valve lies at ileocecal junction
c. appendix is blind-end extension of inferomedial cecal wall usually
lying in retrocecal position
7. colon
a. divided into ascending, transverse, descending and sigmoid parts
b. three bands of longitudinal muscle form taeniae coli from cecum to
end of sigmoid colon
c. colon is telescoped by taeniae to form haustra
d. omental/epiploic appendages are fatty tags on wall of colon
138
Common hepatic
Celiac trunk
Short gastrics
Proper hepatic
Right gastric
Left gastric
Gastroduodenal
Left gastroomental
Right gastroomental
Splenic
Branches of celiac trunk

B. Arterial supply
1. celiac trunk branches
a. left gastric, common hepatic, and splenic arteries
b. supply derivatives of foregut (lower esophagus, stomach, proximal
half of duodenum, liver, gall bladder, pancreas) and spleen
c. left gastric supplies lesser curvature of stomach and lower esophagus
d. gastroduodenal from common hepatic supplies greater curvature via
right gastroomental, and upper duodenum and pancreas via superior
pancreaticoduodenal
e. proper hepatic supplies liver, gall bladder and biliary tree
f. splenic supplies spleen and greater curvature of stomach via short
gastrics and left gastroomental
139
Superior
mesenteric
Vasa recta
Arcades
Jejunal
Ileal
Arteries of the small bowel

2. superior mesenteric artery branches
a. supply derivatives of midgut - distal half of duodenum to left colic flexure
b. inferior pancreaticoduodenal to lower duodenum and pancreas
c. jejunal and ileal branches form arcades which give rise to vasa recta
d. ileocolic, right and middle colic arteries to colon
3. inferior mesenteric artery branches
a. left colic, sigmoid, superior rectal
b. supply derivatives of hind gut - left colic flexure to superior rectum
4. marginal artery
a. anastomotic channel formed by branches of all arteries supplying colon
Superior mesenteric
Inferior mesenteric
Middle colic
Marginal
Right colic
Left colic
Ileocolic
Sigmoid
Superior rectal
Arteries of the large bowel

140
Portocaval anastomoses
1. Paraumbilical
Gastric
2. Esophageal
Hepatic portal
Splenic
3. Rectal
Inferior
mesenteric
Superior
mesenteric
Venous drainage
C. Venous drainage
1. hepatic portal vein
a. formed by union of superior mesenteric and splenic veins
b. inferior mesenteric normally joins splenic vein
2. hepatic veins
a. join IVC on posterior surface of liver
3. examples of portocaval venous anastomoses
a. left gastric (portal) to esophageal (caval) to azygos system to SVC
b. superior rectal (portal) to middle rectal (caval) to internal iliac to IVC
c. paraumbilical (portal) to superficial epigastrics (caval) to femoral to IVC
or to thoracoepigastrics (caval) to axillary to IVC
141
Greater
splanchnic
nerve
Celiac ganglion
Lumbar chain
ganglion
Lumbar
splanchnic
nerve
Superior
mesenteri
c
ganglion
Aorticorenal
ganglion
Inferior
mesenteric
ganglion
Sympathetic innervation
D. Innervation of viscera
1. sympathetic
a. via thoracic and lumbar splanchnic nerves to preaortic ganglia
b. ganglia are celiac, aorticorenal, superior and inferior mesenteric
2. parasympathetic
a. via vagus nerve to gut up to left colic flexure
b. preganglionics from S2-4 to gut beyond left colic flexure
3. visceral afferents
a. found in plexuses and follow sympathetic or parasympathetic paths
to CNS
4. plexuses
a. postganglionic sympathetics join parasympathetic preganglionics in
celiac, superuior mesenteric and inferior mesenteric plexuses
b. plexuses are joined to each other by intermesenteric plexus
c. superior hypogastric plexus carries sympathetics from lumbar
splanchnics nerves to merge with inferior hypogastric plexus
d. inferior hypogastric plexus carries parasympathetics from pelvic
splanchnic nerves, and sympathetics from superior plexus, to innervate
pelvic viscera and visceral afferents from the viscera
142
Thoracic
duct
Cisterna
chyli
Celiac nodes
Superior
mesenteric
nodes
Intestinal nodes
Intestinal trunk
Lymphatic drainage of gut

E. Lymphatic drainage of gut
1. lymph vessels from gut follow branches of celiac, superior and inferior
mesenteric vessels
a. drain through peripheral intestinal nodes into celiac, superior and inferior
mesenteric (preaortic) nodes
2. vessels from preaortic nodes form intestinal trunk
a. trunk drains into cisterna chyli and then into thoracic duct
143
Liver
Lesser omentum
Omental bursa
Stomach
Transverse
colon
Transverse
mesocolon
Mesentery of
small bowel
Small bowel
Bladder
Peritoneal reflections
Peritoneal Cavity
A. Peritoneum
1. parietal peritoneum
a. lines abdominopelvic cavity
b. attached to abdominal wall by extraperitoneal tissue
2. visceral peritoneum
a. covers organs
3. peritoneal cavity
a. omental bursa (lesser sac) is smaller part of cavity posterior to stomach
and lesser omentum
b. greater sac (rest of cavity) communicates with omental bursa through
epiploic/omental foramen
c. foramen lies posterior to hepatoduodenal ligament, anterior to IVC,
inferior to liver and superior to 1st part of duodenum
4. mesentery
a. parietal layer reflects from wall to viscera as double layer of peritoneum
b. contain all structures running from body wall to viscera
c. called peritoneal ligament when attaching organ to organ
144
Visceral
peritoneum
Parietal
peritoneum
Descending
colon
Liver
Kidney
Extraperitoneal
tissue
Aorta
Pancreas
Intraperitoneal and retroperitoneal structures

B. Location of viscera within peritoneum
1. retroperitoneal location
a. outside parietal peritoneum in extraperitoneal tissue
2. intraperitoneal location
a. covered in visceral peritoneum and suspended in mesentery or ligament
3. peritoneal cavity
a. potential space between parietal and visceral layers
4. intraperitoneal structures
a. organs that develop in mesentery and remain there
b. liver, gall bladder, stomach, spleen, tail of pancreas, 1st part of duodenum,
jejunum, ileum, appendix, transverse colon, sigmoid colon
c. cecum is intraperitoneal but has no mesentery
5. primarily retroperitoneal structures
a. develop in extraperitoneal tissue on posterior abdominal wall
b. kidneys, ureters, aorta and branches, IVC and tributaries, sympathetic trunks
6. secondarily retroperitoneal structures
a. develop in mesentery; are drawn back to attach to posterior abdominal wall
b. 2nd, 3rd, 4th part of duodenum, head and body of pancreas, ascending
and descending colon, upper rectum are secondarily retroperitoneal
7. peritoneal gutters
a. left and right medial and lateral paracolic gutters are depressions lying
either side of ascending and descending colon
145
Liver, Pancreas and Spleen

Specific Objectives
Be able to:
1. Describe the liver with respect to surfaces, borders, lobes and peritoneal attachments,
structures of the porta hepatis, blood supply, innervation and lymphatic drainage.
2. Describe the pancreas with respect to borders, surfaces, relationships to surrounding
structures, blood supply, innervation and lymphatic drainage.
3. Describe the structure of the gall bladder and its relationship to the liver, blood
supply, innervation and lymphatic drainage.
4. Describe the organization of the hepatopancreatic duct system and its relationship to
the duodenum.
5. Describe the spleen with respect to surfaces, relationships to surrounding structures,
blood supply, innervation and lymphatic drainage.
146
Anterior and posterior

coronary ligament
Ligamentum
venosum
Diaphragm
IVC
L
L
Porta hepatis
Q
Falciform
ligament
Liver
Gall bladder
Liver
A. Structure and location
1. surfaces
a. convex diaphragmatic surface is superior
b. visceral is inferior
c. porta hepatis is transverse fissure through which portal triad enters/leaves liver
2. anatomical lobes
a. left lies to left of falciform ligament and ligamentum venosum
b. right is subdivided by line joining left borders of IVC and gall bladder
c. caudate and quadrate lie between left and right anatomical lobes
d. quadrate is anterior and separated from caudate by porta hepatis
3. physiological/portal lobes
a. left portal lobe includes caudate and quadrate lobes
3. peritoneal attachments
a. falciform ligament attaches liver to diaphragm and anterior abdominal wall
b. coronary ligaments are extensions of falciform ligament around bare area
c. lesser omentum extends from visceral surface to lesser curvature of stomach
(hepatogastric ligament) and 1st part of duodenum (hepatoduodenal ligament)
B. Blood supply
1. proper hepatic artery from celiac trunk
2. hepatic portal vein carries venous blood from gut tube
3. venous drainage via hepatic veins to IVC
147
Fundus
Common
hepatic duct
Spleen
Body
Neck
Hilum of
spleen
Cystic duct
Pancreas
Common
bile duct
Tail
Body
Uncinate
process
Head
Pancreas and gall bladder

Other viscera
A. Gall Bladder
1. structure
a. divided into fundus, body and neck
b. lies on visceral surface of right hepatic lobe
2. blood supply
a. cystic artery from right hepatic artery
3. venous drainage
a. cystic vein into hepatic portal vein
B. Pancreas
1. structure
a. divided into head, body, tail, uncinate process
b. head and uncinate process lie in concavity of duodenum
c. secondarily retroperitoneal except for tail in lienorenal ligament
2. blood supply
a. branches from splenic, superior and inferior pancreaticoduodenal
3. venous drainage parallels arterial supply
C. Spleen
1. structure
a. convex diaphragmatic surface; hilum, with splenic vessels, lies medially
b. intraperitoneal; supported by gastrolienal and lienorenal ligaments
2. blood supply
a. splenic artery from celiac trunk
b. splenic vein joins superior mesenteric to form hepatic portal vein
148
Left and right

hepatic ducts
Common
hepatic duct
Cystic duct
Common
bile duct
Hepatopancreatic
ampulla
Major duodenal
papilla
Main
pancreatic
duct
Hepatopancreatic duct system

C. Hepatopancreatic duct system
1. hepatic ducts
a. leave liver through porta hepatis
b. join to form common hepatic duct
2. cystic duct
3. (common) bile duct
a. formed from junction of common hepatic and cystic ducts
b. joins pancreatic duct in head of pancreas
4. hepatopancreatic ampulla
a. formed from junction of bile duct and main pancreatic duct
b. opens into 2nd part of duodenum through major duodenal papilla
c. hepatopancreatic sphincter is in wall of distal part of ampulla
5. accessory pancreatic duct drains into duodenum above major duodenal papilla
149
Posterior Abdominal Wall

and Pelvis
Specific Objectives
Be able to:
1. Describe psoas major, psoas minor and quadratus lumborum muscles in terms of
attachments, actions, and innervation.
2. Describe the respiratory diaphragm in terms of attachments, action, innervation,
central tendon, vertebrocostal triangle, caval foramen, esophageal and aortic hiatus.
3. Describe the course of the parietal and visceral branches of the abdominal aorta and
their area of distribution.
4. Describe the course of the parietal and visceral branches of the inferior vena cava
and their area of drainage.
5. Describe the structure of the kidneys in terms of cortical and medullary structures,
blood supply, innervation, the relationships of fascial and fatty tissues around the
kidneys, and the course and relationships of the ureters.
6. Describe the suprarenal glands in terms of location, blood supply and innervation.
7. Describe the organization of the lumbar plexus, including the named terminal nerves.
8. Describe the structure of the bony pelvis, the ligamentous structures that stabilise the
sacroiliac and iliolumbar joints, and the boundaries of the greater and lesser sciatic
foramina and the structures passing through each.
9. Describe lymphatic drainage of the posterior abdominal wall and associated viscera.
150
Central tendon
Caval
foramen
Esophagus
Left and
right crus
Arcuate ligaments
Lateral
Medial
Quadratus
lumborum
Median
Psoas major
and minor
Muscles of posterior abdominal wall

Posterior Abdominal Wall
A. Muscular wall
1. muscles
a. span space between lumbar vertebrae, ribs 11 and 12, and iliac crest
b. quadratus lumborum, psoas major and minor
2. diaphragm
a. origin from xiphoid, costal margin, ribs 11 and 12, vertebral column
b. attachments to fascia covering psoas major and quadratus lumborum form
medial and lateral arcuate ligaments
c. insertion is central tendon
d. caval foramen at T8 through central tendon
e. esophageal hiatus at T10 through muscle
f. aortic hiatus at T12 between crura and posterior to median arcuate ligament
g. blood supply from musculophrenic, superior and inferior phrenic arteries
h. innervation from phrenic nerves (C3,4,5)
151
Diaphragm
Transversus
abdominus
Suprarenal
gland
Left kidney
Quadratus
lumborum
Psoas
Kidneys in situ
B. Kidneys
1. location
a. left lies on diaphragm, ribs 11 and 12 and quadratus lumborum
b. right lies on diaphragm, rib 12 and quadratus lumborum
c. enclosed in capsule and surrounded by renal fascia
d. suprarenal glands lie on superior pole of each kidney
Kidney
Pararenal fat
(extraperitoneal tissue)
Quadratus
lumborum
Renal fascia
Perirenal fat
Psoas major
Cross section of trunk showing kidneys in situ

152
Renal
column
Minor calyx
Renal cortex
Renal pyramid
Renal papilla
Fat in renal sinus
Renal pelvis
Major calyx
Ureter
Frontal section of right kidney

2. structure
a. cortex is outer region of kidney
b. medulla is inner region divided into pyramids separated by renal columns
c. renal sinus is fat-filled space containing collecting system and vessels
3. renal collecting system
a. urine drains from each pyramid through renal papilla into minor calyx
b. several minor calyces join to form major calyx
c. major calyces join to form renal pelvis
d. pelvis leaves renal sinus through hilum to become the ureter
4. blood supply
a. renal arteries arise from aorta and enter renal sinus
b. renal veins join IVC
5. ureter
a. from renal pelvis to bladder
b. lies on psoas and crosses bifurcation of common iliac artery to lie on
lateral pelvic wall
153
Unpaired
Celiac trunk
Superior
mesenteri
c
Paired
Inferior
phrenic
Superior
middle and
inferior
suprarenal
Renal
Inferior
mesenteric
Gonadal
Lumbar
Median sacral
Common iliac
Branches of abdominal aorta

D. Abdominal aorta
1. paired parietal branches
a. inferior phrenics
b. 4 lumbars
c. divides into common iliacs at vertebral level L4
d. median sacral is small unpaired vessel arising at bifurcation of aorta
2. paired visceral branches
a. middle suprarenals (superior and inferior from inferior phrenic and renal)
b. renal arteries at L1
c. testicular or ovarian at L2
3. unpaired visceral branches
a. celiac trunk at T12 supplies foregut derivatives
b. superior mesenteric at L1 supplies midgut derivatives
c. inferior mesenteric at L3 supplies hindgut derivatives
4. autonomic ganglia and plexuses
a. celiac
b. superior mesenteric
c. aorticorenal
d. inferior mesenteric
e. superior hypogastric
154
Hepatics
Right suprarenal
Inferior phrenic
Left suprarenal
Renal
Right gonadal
Left gonadal
Common iliac
Lumbar
Tributaries of inferior vena cava

E. Inferior vena cava
1. correspond to arteries with the following exceptions
a. suprarenal drains into IVC on right and renal vein on left
b. gonadal drains into IVC on right and renal vein on left
c. lumbars are linked, by ascending lumbars, with iliacs and azygos veins
F. Lymphatics
1. lumbar nodes drain posterior abdominal wall; drain into left and right lumbar
trunks which join cisterna chyli
Cisterna chyli
Right lumbar trunk

Lumbar nodes
Common iliac nodes
Lymphatics of the posterior abdominal wall

155
Subcostal
Iliohypogastric
Ilioinguinal
Lateral femoral
cutaneous
Genitofemoral
Femoral
Obturator
Lumbosacral trunk
Lumbar plexus
G. Lumbar plexus
1. ventral rami of L1-4 with contribution from T12 (subcostal nerve)
a. iliohypogastric and ilioinguinal (L1)
b. genitofemoral (L1-2) divides into genital and femoral branch
c. lateral femoral cutaneous (L2-3)
d. femoral (posterior divisions of L2-4) innervates quadriceps muscles
e. obturator (anterior divisions of L2-4) innervates adductor muscles of
thigh
f. lumbosacral trunk (L4-5) runs over sacral ala to join sacral plexus
156
PSIS
Ilium
ASIS
Sacroiliac joint
Acetabulum
Ischium
Obturator
canal
Pubis
Obturator
membrane
Pelvic
brim
Pubic symphysis
Bony pelvis
Pelvis
A. Bony Pelvis
1. os coxae
a. ilium, ischium, pubis joined by sacrum
b. pelvic brim separates major pelvis from minor pelvis
2. joints
a. pubic symphysis is fibrocartilaginous joint
b. sacroiliac is synovial joint between auricular surfaces of sacrum and ilium
Major pelvis
Minor
pelvis
Pelvic brim
Line of
pelvic outlet
Major and minor pelvis

157
Iliolumbar ligament
Anterior
sacroiliac
ligament
Sacrospinous
ligament
Greater sciatic
foramen
Lesser sciatic
foramen
Sacrotuberous
ligament
Pelvic ligaments
3. ligaments
a. anterior and posterior sacroiliac
b. iliolumbar from transverse processes of L4-5 to posterior iliac crests
c. sacrotuberous from lateral sacrum to ischial tuberosity
d. sacrospinous is deep (anterior) to sacrotuberous from lateral sacrum to
ischial spine
4. pelvic openings
a. pelvic inlet from major to minor pelvis is described by pelvic brim
b. pelvic outlet is described by conjoint rami, ischial tuberosities, ischial
spines, coccyx
c. subinguinal hiatus inferior to inguinal ligament provides access to
anterior thigh
d. obturator canal through obturator membrane gives access to medial thigh
e. greater sciatic foramen is major entrance/exit between abdominopelvic
cavity and gluteal region
f. lesser sciatic foramen provides access to perineum
158
Tendinous arch
Urogenital hiatus
Levator ani
Pubococcygeus
Iliococcygeus
Puborectalis
Obturator
internus
Coccygeus
Piriformis
Pelvic diaphragm
Anococcygeal
raphe
5. muscular wall
a. piriformis (posterior)
b. obturator internus (lateral)
c. pelvic diaphragm (floor)
6. pelvic diaphragm
a. funnel-shaped muscular floor of pelvis providing support for viscera
b. comprises levator ani and coccygeus
c. has superior and inferior covering of pelvic fascia continuous with
transversalis fascia
d. origin is body of pubis, tendinous arch of obturator fascia and sacrospinous
ligament
e. insertions are coccyx and anococcygeal raphe where fibres fuse on midline
f. pubococcygeus and iliococcygeus form levator ani
g. puborectalis is medial part of pubococcygeus that forms a sling around the
anorectal junction
g. coccygeus originates from sacrospinous ligament frequently diminished
or absent in humans
h. urogenital hiatus is central opening bordered by medial fibres of pubococcygeus
159
Pelvis
Specific Objectives
Be able to:
1. Describe the structure, position, relationships and major peritoneal coverings and
reflections of the female pelvic organs.
2. Describe the structure, position, relationships and major peritoneal coverings and
reflections of the male pelvic organs.
3. Describe the general pattern of blood supply and lymphatic drainage of pelvic
structures.
4. Describe the organization of the sacral plexus.
5. Describe the autonomic innervation of pelvic viscera.
160
Rectovesical pouch
Rectum
Bladder
Ovary
Uterus
Rectouterin
e
pouch
Rectum
Vesicouterine
pouch
Bladder
Prostate
Vagina
Pelvic contents and pouches

A. Peritoneal pouches
1. male peritoneal relations
a. rectovesical pouch is reflection of peritoneum from bladder onto rectum
2. female peritoneal relations
a. vesicouterine pouch is reflection of peritoneum from bladder onto uterus
b. rectouterine pouch is reflection from uterus onto rectum
161
Female
Trigone
Male
Opening
of ureter
Urethra
Prostatic
Membranous
Urethra
Penile
Erectile tissue
of penis
Bladder and urethra

B. Urinary structures
1. ureters
a. extend from kidney and cross pelvic brim to lie on lateral pelvic wall
b. join bladder on posteroinferior aspect by entering obliquely
2. bladder
a. neck lies inferiorly and is firmly attached by pubovesical ligaments
b. wall contains smooth detrusor muscle and is lined by transitional
epithelium
c. trigone is non-contractile triangular area with ureters entering at
superolateral corners and urethral orifice at apex
3. urethra
a. leaves neck of bladder at apex of trigone
b. internal urethral sphincter is circular arrangement of detrusor muscle
around internal urethral orifice
c. short, relatively straight course in female opening into vestibule
d. male has prostatic, membranous and penile portions with major curve
in proximal part of the penile urethra
162
Sigmoid
colon
Rectum
Pararectal
fossa
Levator ani
Ischioanal
fossa
Anal canal
Rectum in situ
C. GI tract
1. rectum
a. continuous with sigmoid colon at S3
b. ends at tip of coccyx as it passes through pelvic diaphragm
c. inferior portion is ampulla which lies below inferior rectal fold
Superior, middle and

inferior rectal folds
Ampulla
Anorectal junction
Internal anal sphincter
Anal canal
External anal sphincter
Rectum
163
Infundibulum
Ampulla
Fundus
Isthmus
Fimbria
Ovary
Body
Internal and external

cervical os
Lateral fornix
Female internal genitalia

D. Female internal reproductive organs
1. uterus
a. has fundus, body, and cervix
b. normally curves anteriorly over bladder
c. normally angled anteriorly at junction of cervix and body (anteflexed)
d. normally angled anteriorly at junction of vagina and cervix (anteverted)
e. horns/cornua are points at which uterine tubes join body
f. cervix is inferior portion of uterus projecting into vagina
2. vagina
a. smooth muscle tube opening inferiorly into vestibule
b. anterior and posterior walls in contact except where cervix projects
into vagina to form fornices
c. innervation is somatic to lower 1/4th of vagina
3. uterine tubes
a. extend laterally from horns of uterus
b. isthmus is short, thick-walled proximal portion
c. ampulla is widest and longest portion
d. infundibulum is funnel-shaped distal end surrounding ostium with fimbriae
e. most of ovary, distal ampulla and infundibulum not covered by peritoneum
164
Suspensory
ligament of
ovary
Mesosalpinx
Mesovarium
Ovarian
ligament
Mesometrium
Uterosacral
ligament
Supports of female reproductive structures

4. broad ligament
a. mesometrium extends laterally from body of uterus to pelvic walls
and contains round ligament of uterus travelling to deep inguinal ring
b. mesovarium is on posterior surface of mesometrium and attaches to
ovary and ovarian ligament
c. mesosalpinx is above mesovarium enclosing uterine tube
5. other supports
a. ovarian ligament attaches ovary to lateral aspect of uterus
b. round ligament of uterus is continuation of ovarian ligament which
passes through inguinal canal to attach to labium majorum
c. uterosacral ligament is thickening of endopelvic fascia that attaches
cervix to sacrum
d. transverse cervical ligament attaches cervix to lateral pelvic wall
e. suspensory ligament of ovary is fold of parietal peritoneum covering
vascular bundle and attached to lateral pole of ovary
165
Ductus
deferens
Ampulla
Ureter
Epididymis
Head
Body
Seminal
vesicle
Prostate
Tail
Ductus deferens and seminal vesicles

E. Male internal reproductive organs
1. vas/ductus deferens
a. from tail of epididymis to duct of seminal vesicle posterior to bladder
b. enlarges proximally to form ampulla
2. seminal vesicles
a. paired glands lying on posterior surface of bladder
b. duct and ampulla form ejaculatory duct which joins prostatic urethra
3. prostate
a. walnut-sized gland around prostatic urethra surrounded by fibrous capsule
c. base lies inferior to neck of bladder
d. apex lies on perineal membrane
e. posterior surface is closely related to anterior wall of rectal ampulla
4. bulbourethral glands
a. secrete into penile urethra
Seminal
vesicle
Prostate
Prostatic
urethra
Ejaculatory
duct
Male internal genitalia

166
Internal iliac
External iliac
Iliolumbar
Lateral sacral
Deep
circumflex
iliac
Superior
gluteal
Obturator
Obliterated
umbilical
Inferior gluteal &
internal pudendal
Middle rectal
Superior
vesicle
Blood supply of pelvis

F. Blood supply to pelvis
1. external iliac artery
a. deep circumflex iliac
2. internal iliac artery variable but normally has anterior and posterior divisions
3. posterior division
a. iliolumbar and lateral sacral from internal iliac or posterior division
b. superior gluteal leaves pelvis via greater sciatic foramen above piriformis
4. anterior division
a. obturator passes through obturator canal may arise from inferior epigastric
b. inferior gluteal and internal pudendal arise from common trunk and leave
through greater sciatic foramen below piriformis
c. umbilical gives off superior vesicals then becomes obliterated umbilical
d. middle rectal supplies middle 1/3rd of rectum
e. uterine supplies uterus, uterine tubes, vagina
f. inferior vesical supplies inferior bladder, prostate, seminal vesicles
5. venous drainage via corresponding veins into internal iliac vein
167
Lumbar
Common
iliac
Superficial
inguinal
horizontal
vertical
Internal
iliac
External
iliac
Deep
inguinal
Lymph nodes of pelvic region

G. Lymphatic drainage of pelvic viscera
1. mainly into internal iliac nodes
a. internal iliac to common iliac to lumbar nodes
2. rectum
a. superior part of rectum drains to pararectal to inferior mesenteric
to lumbar nodes
b. inferior part of rectum drains to internal iliac nodes
3. uterus
a. fundus drains to lumbar nodes
b. body drains to external iliac nodes
c. cervix drains to internal iliac nodes
168
L4
L5
Superior gluteal
S1
S2
Inferior gluteal
S3
Lumbosacral trunk
Pelvic splanchnics
S4
N to Piriformis
S5
Cx1
Common
fibular
Tibial
Pudendal
Posterior femoral
cutaneous
Sciatic
L4
L5
S1
Lumbosacral
trunk
S4
Obturator
Sacral plexus nerves

H. Nervous structures
1. sacral plexus
a. lumbosacral trunk (L4/5) joins S1ventral ramus
b. superior gluteal (L4,5,S1)
c. inferior gluteal (L5, S1,2)
d. pudendal (S2-4) to perineum
e. sciatic (L4-S3) formed by common fibular and tibial nerves
f. tibial (L4-S3)
g. common fibular (L4-S2)
169
Sympathetic
trunk
Lumbar
splanchnics
Superior hypogastric
plexus
Hypogastric nerve
Inferior hypogastric
plexus
Autonomics of abdominopelvic region

2. pelvic autonomics
a. superior hypogastric plexus receives lumbar splanchnic nerves and
divides into right and left hypogastric nerves - contains sympathetic
fibres and visceral afferents
b. pelvic plexuses (inferior hypogastric plexuses) receive parasympathetic
fibres from pelvic splanchnics and sympathetic fibres from sacral
splanchnics and from superior hypogastric plexus
170
Perineum
Specific Objectives
Be able to:
1. Describe the boundaries, subdivisions and contents of the urogenital and anal
triangles in the male and female.
2. Describe the organization of the superficial perineal and deep perineal pouches in
terms of fascial layers and contents in the male and female.
3. Describe the structure of the penis and clitoris in terms of erectile tissues and
associated muscles.
4. Describe the motor and sensory innervation, blood supply, and lymphatic drainage
of the male and female perineum.
171
Urogenital triangle
Anal triangle
Ischial tuberosity
Male and female perineum
A. Perineum
1. diamond-shaped area described by the pubic symphysis, ischial
tuberosities, and coccyx
2. urogenital triangle
a. area between ischiopubic rami and a line joining ischial tuberosities
b. contains external genitalia and urinary structures
3. anal triangle
a. area between coccyx, sacrotuberous ligaments and the line joining
ischial tuberosities
b. contains anus
172
Deep perineal
pouch
External anal
sphincter
Perineal body
Superficial perineal fascia
Perineal membrane
Deep perineal fascia
Male perineal fascia and pouches
4. perineal membrane
a. strong connective tissue sheet attached to ischiopubic rami
b. posterior border attaches to fascia of external anal sphincter
c. muscles lie superior to it in deep perineal pouch
d. membrane and muscles used to be called 'urogenital diaphragm'
5. deep perineal pouch (space)
a. fascial space superior to perineal membrane
b. contains deep transverse perineal and sphincter urethrae muscles
c. contains bulbourethral gland in male
d. muscle fibres around urethra form external urethral sphincter
6. perineal body
a. connective tissue mass
b. attaches posterior edge of perineal membrane to deep fascia of
external anal sphincter of pelvic diaphragm
173
Deep perineal
pouch
Body of
clitoris
Labium majorum
Perineal body
Labium minorum
Perineal membrane
Female perineal fascia and pouches

7. superficial perineal pouch
a. space between perineal membrane and superficial perineal fascia
b. contains crura of clitoris, ischiocavernosus muscles, bulbs of
vestibule, and bulbospongiosus muscles, greater vestibular glands
in female
c. contains crura of penis, ischiocavernosus muscles, bulb of penis,
and bulbospongiosus muscle in male
8. perineal fascia
a. superficial perineal fascia is continuation of Scarpas fascia and
attaches to posterior edge of perineal membrane
b. deep perineal fascia covers muscles on crura and bulb(s) of penis
and clitoris
174
Mons pubis
Prepuce
Labium
majorum
Glans of
clitoris
Urethral
orifice
Vestibule
Labium
minorum
Vaginal
orifice
Anal
orifice
Female perineum - superficial

B. Female perineum
1. pudendum or vulva is the external genitalia and comprises labia majora,
labia minora, mons pubis and all areas/structures within these
2. labia majora
a. fat-filled, hair-bearing folds of skin
b. provide protection for vaginal and urethral orifices
3. labia minora
a. thin folds of skin lying medial to labia majora
b. converge anteriorly/superiorly and surround glans of clitoris as prepuce
4. vestibule
a. space between labia minora
b. receives vagina, urethra, ducts of vestibular glands
c. greater vestibular glands lie posterolaterally to vaginal orifice and secrete
mucus into vestibule
d. lesser vestibular glands lie anterior to greater vestibular glands and also
secrete mucus into vestibule
175
Body of clitoris
Bulb of
vestibule
Ischiocavernosus
over crus
Greater
vestibular
gland
Bulbospongiosus
over bulb
Perineal
body
Perineal
membrane
Pelvic
diaphrag
m
Female perineum - deep

4. bulbs of vestibule
a. two masses of corpus spongiosum lying lateral to vestibule
b. bulbospongiosus muscle is skeletal muscle covering bulbs
5. clitoris
a. erectile tissue structure with body and glans
b. body is paired corpora cavernosa which separate proximally as
crura and attach to perineal membrane
c. ischiocavernosus muscle covers crura
176
Dorsal artery and nerve

Bulb of penis
Perineal
membrane
Superficial and
deep dorsal
veins Deep
fascia
Crus of penis
Corpus
cavernosum
Penile
urethra
Deep artery
Corona
Glans of penis
Corpus
spongiosum
Longitudinal and transverse section of the penis

C. Male perineum
1. scrotum
a. sac of skin, dartos muscle (smooth), and superficial scrotal fascia
b. divided by central septum into bilateral compartments
c. scrotal raphe represents line of fusion of labioscrotal swellings
2. penis
a. three masses of erectile tissue enclosed by tunica albuginea
b. deep (Buck's) fascia of penis lies superficial to tunica albuginea
c. ventral surface has penile raphe
d. corpora cavernosa form crura which attach to perineal membrane
e. corpus spongiosum expands as bulb of penis and glans penis, and
contains penile urethra
f. prepuce is double layer of skin extending distally over glans
3. spongy/penile urethra
a. continuation of membranous urethra in corpus spongiosum
b. receives ducts of bulbourethral (Cowper's) glands which lie in deep pouch
4. penile blood supply
a. deep artery of penis in each corpus cavernosum and paired dorsal arteries
are branches of internal pudendal
b. venous drainage into deep dorsal vein
177
Body of
penis
Bulbospongiosus
over bulb
Ischiocavernosus
over crus
Perineal
body
Perineal
membrane
Pelvic
diaphragm
Male perineum - deep

6. muscles of superficial pouch in male
a. ischiocavernosus muscle covers crura
b. bulbospongiosus muscle covers bulb of penis
D. Ischioanal fossa
1. fat-filled space either side of anal canal permiting expansion of anal canal
2. borders
a. perineal membrane and deep pouch structures lie inferior
b. ischium and obturator internus lie lateral
c. levator ani lie superomedial
3. contains pudendal neurovascular bundle on lateral wall in pudendal canal
Rectum
Pararectal fossa
Levator ani
Obturator
internus
Ischioanal fossa
Pudendal canal
Anal canal
Fig 18.8 Rectum in situ

178
Anal column
Anal valve
Ampulla of
rectum
Anorectal junction
Anal canal
Anus
Anus
Pectinate line
Internal anal
sphincter
External anal
sphincter
3. anal canal
a. from anorectal junction to anus - pectinate line is inferior limit of anal valves
b. canal above pectinate line is from hind gut; blood supply is superior rectal
c. canal below line is from body wall; blood supply is middle and inferior rectal
d. external anal sphincter is skeletal muscle of anal canal
e. internal anal sphincter is thickened circular smooth muscle of gut wall
E. Perineal blood supply
1. external pudendals from femoral artery supply superficial perineal tissues
2. internal pudendals from internal iliac supply deep perineal tissues
F. Perineal innervation
1. pudendal n (S24)
a. somatic motor to external anal and urethral sphincters, muscles of both pouches
b. somatic sensory from perineal skin, external genitalia including lower part of
vagina, anal canal below pectinate line
2. branches of ilioinguinal and genitofemoral nerves
a. somatic sensory from external genitalia and perineal skin
3. pelvic splanchnic (parasympathetics) and sacral splanchnics (sympathetics)
G. Lymph drainage
1. superficial (skin, external genitalia, anal canal below pectinate line) to horizontal
group of superficial inguinal nodes
2. deep
179
Osteology of the
Head and Neck
Specific Objectives
Be able to:
1. Describe the anatomy of the cervical vertebrae.
2. Describe the major distinguishing features of the extracranial anatomy.
3. Describe the neurocranium in terms of bones and their major features.
4. Describe the viscerocranium in terms of bones and their major features.
5. Describe the major distinguishing features of individual skull bones and their
articulations in the intact skull.
6. Describe the basic developmental anatomy of the skull in terms of fontanelles
and sutures.
7. Describe the major openings of the skull in terms of location and the structures
traversing them.
180
Anterior fossa
Crista galli
Openings
Cribriform plate
Anterior
Olfactory foramina
Lesser wing
Middle fossa
Greater wing
Middle
Sup orbital fissure
Optic canal
Squamous portion
Foramen rotundum
Sella turcica
Foramen ovale
Dorsum sellae
Foramen spinosum
Petrous portion
Foramen lacerum
Posterior fossa
Posterior
Int auditory meatus
Groove for
transverse sinus
Jugular foramen
Foramen magnum
Hypoglossal canal
Cranial fossae and their major landmarks

E. Cranial fossae
1. anterior
a. supports frontal lobe of cerebral hemispheres
2. middle
a. supports temporal lobe of hemispheres
3. posterior
a. supports cerebellum
181
Frontal
Supraorbital notch
Superior & inferior
orbital fissure
Temporal
Sphenoid
Ethmoid
Nasal
Infraorbital
foramen
Zygomatic
Maxilla
Mandible
Middle & inferior

nasal concha
Alveolar process
Mental foramen
Norma frontalis
A. Divisions of skull
1. neurocranium/cranial cavity
a. calvaria ("brain case") enclosing brain and brain stem
b. comprises 4 unpaired bones - frontal, occipital, sphenoid and ethmoid
c. 2 paired bones - temporal and parietal
2. viscerocranium/facial skeleton
a. comprises 2 unpaired bones - mandible and vomer
b. 6 paired bones - maxilla, zygomatic, nasal, lacrimal, palatine, inferior
nasal concha
c. surround the openings of the respiratory and digestive tracts
3. several bones, such as ethmoid and sphenoid, contribute to both
neurocranium and viscerocranium
182
Frontal
Parietal
Nasal
Temporal
Lacrimal
Ethmoi
d
Zygomatic
Sphenoid
Occipital
Maxilla
Mandible
Norma lateralis - sutures and major landmarks
B. Joints of skull
1. most are sutures
2. temporomandibular joints
a. synovial joints between mandibular fossa and condyle of mandible
3. mandible
a. paired bones united by mandibular symphysis becomes a synostosis
postnatally
4. frontal bone
a. paired bones united by metopic suture - normally becomes a synostosis
postnatally
C. Openings
1. for respiratory, digestive tracts and sensory systems
2. for cranial nerves and branches passing from cranial cavity to periphery
3. for branches of carotid and vertebral arteries and venous counterparts
183
Bregma
Vertex
Coronal suture
Squamosal
suture
Glabella
Lambdoidal
suture
Nasion
Sutural
bone
Anterior nasal
spine
Inion
Pterion
Mastoid process
Mental
protuberance
Styloid process
Zygomatic arch
Norma lateralis - sutures and major landmarks

D. Sutures
1. most skull bones articulate via sutures, many of which gradually become
synostoses starting in late twenties
a. sagittal between parietals
b. coronal between frontal and parietal
c. squamosal between temporal and parietal
d. lambdoidal between occipital and parietal
2. intramembranous ossification
a. most skull bones form from membranes and grow towards one another
b. anterior, posterior, sphenoidal, and mastoid fontanelles are non-ossified
areas of membrane
Metopic suture
Parietal bone
Occipital
bone
Frontal bones
Fontanelles
Anterior
fontanelle
Posterior
fontanelle
184
Palatine process
Horizontal plate
Incisive fossa
Pterygoid process
Greater palatine
foramen
Vomer
Foramen ovale
Greater wing
Foramen lacerum
Styloid process
Opening to
carotid canal
Mastoid process
Stylomastoid foramen
Occipital condyle
Jugular foramen
External occipital
Protuberance
Superior nuchal line
Norma basalis
F. Openings for cranial nerves
Openings
Olfactory foramina in cribriform plate
Cranial nerve(s)
I
Optic canal in sphenoid
II
Superior orbital fissure in sphenoid
III, IV, V1, VI
Foramen rotundum in sphenoid
V2
Foramen ovale in sphenoid
V3
Internal auditory meatus in temporal
VII, VIII
Jugular foramen between occipital/temporal
IX, X, spinal XI
Hypoglossal canal in occipital
XII
185
Posterior Triangle of the Neck

Specific Objectives
Be able to:
1. Describe the layers of deep fascia and facial spaces of the neck.
2.
Describe the boundaries and contents of the posterior, occipital and

supraclavicular triangles of the neck.
3.
Describe the sternocleidomastoid, omohyoid, anterior scalene, middle scalene,

posterior scalene, levator scapulae, splenius capitis, semispinalis capitis and
prevertebral muscles in terms of attachments, actions, and innervation.
4.
Describe the distribution of the cervical plexus including the ansa cervicalis,
supraclavicular, transverse cervical, great auricular and lesser occipital nerves.
5.
Describe the boundaries and contents of the scalene hiatus.
6.
Describe the supraclavicular portion of the brachial plexus.
186
Infrahyoid muscles
Deep fascia
Sternocleidomastoid
Pretracheal
Buccopharyngeal
fascia
Platysma
Carotid
sheath
Scalenes
Investing
Prevertebral
Trapezius
Prevertebral muscles
Intrinsic back muscles
Deep cervical fascia

A. Cervical fascia
1. superficial fascia
a. thin layer containing platysma, cutaneous nerves, superficial veins
2. deep fascia
a. investing layer encloses trapezius and sternocleidomastoid, parotid and
submandibular glands
b. pretracheal layer has muscular component, enclosing infrahyoid muscles,
and visceral component, enclosing thyroid gland, trachea, esophagus,
which is continuous with buccopharyngeal layer
c. carotid sheath is continuous with visceral layer and contains common
and internal carotid arteries, internal jugular vein and vagus nerve
d. prevertebral layer surrounds prevertebral, scalene, levator scapulae,
intrinsic back muscles and extends laterally as axillary sheath
3. retropharyngeal space
a. potential space, between prevertebral layer and buccopharyngeal
fascia, which is continuous with superior mediastinum
187
Sternocleidomastoid
Splenius capitis
Levator scapulae
Posterior scalene
Middle scalene
Anterior scalene
Trapezius
Inferior belly of omohyoid
Posterior triangle
B. Boundaries of posterior triangle
1. posterior is anterior border of trapezius
2. anterior is posterior border of sternocleidomastoid
3. apex is attachment of these muscles to the occiput and mastoid process
4. base is mid-region of clavicle
5. floor is semispinalis capitis, splenius capitis, levator scapulae, posterior,
middle and anterior scalene muscles, and prevertebral layer of fascia
6. roof is investing layer of deep fascia
7. posterior triangle is divided by inferior belly of omohyoid
a. occipital triangle lies superior to omohyoid
b. supraclavicular triangle lies inferior to omohyoid
188
Occipital a
Lesser occipital n
Sternocleidomastoid
Great auricular n
Spinal accessory n
Inferior belly
of omohyoid
Transverse cervical a
Suprascapular a
Brachial plexus
Subclavian a
Contents of posterior triangle

C. Contents of triangle
1. parts of cutaneous branches of cervical plexus (C1-4)
a. lesser occipital (C2), great auricular (C2,3), transverse cervical (C2,3),
supraclavicular (C3,4)
2. spinal accessory nerve (XI)
3. occipital, transverse cervical and suprascapular arteries
4. trunks of brachial plexus and suprascapular nerve
5. 3rd part of subclavian artery
6. cervical lymph nodes
189
Middle scalene
Anterior scalene
Phrenic n
C5 ventral ramus
Superior trunk
3rd part of
subclavian a
Transverse cervical a
Suprascapular a
Thyrocervical trunk
Root of the neck

D. Scalene hiatus (scalene gap)
1. triangular space between anterior and middle scalene muscles
2. contents
a. roots, forming the trunks, of brachial plexus
b. 2nd part of subclavian artery
190
Anterior Triangle of the Neck

Specific Objectives
Be able to:
1.
Describe the boundaries of the anterior, digastric, submental, carotid, and muscular
triangles of the neck, and their contents.
2.
Describe the anatomy of the ansa cervicalis and the motor distribution of the cervical
plexus.
3.
Describe the sternocleidomastoid, and the infrahyoid and suprahyoid muscles, in

terms of general attachments, actions and innervation.
4.
Describe the boundaries of the root of the neck and superior thoracic opening, and
describe the relationships of the brachiocephaliac veins, subclavian veins and arteries,
external, anterior and internal jugular veins, thyrocervical and costocervical trunks
and branches, brachiocephalic artery, vertebral arteries, phrenic nerves, vagus nerves,
recurrent laryngeal nerves, cervical sympathetic chain, and the thoracic duct.
5.
Describe the anatomy of the trachea, and the thyroid and parathyroid glands.
6.
Describe the anatomy and contents of the carotid sheath.
7.
Describe the origin, course and distribution of the branches of the external carotid
artery within the carotid triangle.
8. Describe the location and organization of the sympathetic cervical ganglia.
191
Subtriangles
Submandibular
Sternocleidomastoid
Submental
Carotid
Anterior &
posterior bellies
of digastric
Muscular
Midline
Inferior & superior

bellies of omohyoid
Anterior triangle
A. Boundaries:
1. large triangle with four smaller subtriangles contained within its borders
a. anterior is midline of neck
b. superior is body of mandible
c. posterior is anterior edge of sternocleidomastoid muscle
d. apex is located at jugular notch of manubrium
2. subtriangles
a. submental triangle between midline, anterior digastric, hyoid and genu
of mandible; may also be regarded as single triangle spanning midline
b. submandibular triangle between bellies of digastric and mandible
c. carotid triangle between superior omohyoid, sternocleidomastoid and
posterior digastric
d. muscular triangle between superior omohyoid, sternocleidomastoid and
midline
192
Anterior
digastric
Mylohyoid
Stylohyoid
Superior belly
of omohyoid
Inferior belly
of omohyoid
Posterior
digastric
Thyrohyoid
Sternothyroid
Sternohyoid
Muscles of anterior triangle
B.
Musculature
1. infrahyoid (strap) muscles
a. omohyoid (superior belly)
b. sternohyoid
c. sternothyroid
d. thyrohyoid
2. suprahyoid muscles
a. anterior and posterior bellies of digastric
b. stylohyoid
c. mylohyoid
d. geniohyoid
193
Hypoglossal
C1
to geniohyoid
C2
to thyrohyoid
C3
Superior root
C4
to sup belly
of omohyoid
Inferior root
to sternothyroid
to sternohyoid
to inf belly
of omohyoid
Phrenic
Spinal
accessory
Ansa cervicalis
C. Innervation of anterior triangle muscles
1. ansa cervicalis
a. lies superficial to the carotid sheath and is made up of two roots
b. superior root formed by C1
c. inferior root formed by C2 and C3
2. infrahyoid muscles
a. innervated by branches from ansa cervicalis (C1,2,3)
b. thyrohyoid receives a separate branch from C1 (via hypoglossal nerve)
3. suprahyoid muscles
a. geniohyoid innervated by C1
b. stylohyoid and posterior belly of digastric innervated by facial nerve
c. mylohyoid and anterior belly of digastric innervated by mylohyoid nerve
Ansa
cervicalis
Hypoglossal
Vagus
Nerves found in the anterior triangle

194
Deep cervical
Transverse
cervical
Ascending cervical
Vertebral
Inferior thyroid
Suprascapular
Thyrocervical trunk
Costocervical trunk
Internal thoracic
Branches of the subclavian artery

D. Subclavian artery
1. divided into three parts by the anterior scalene
2. 1st part medial to scalene
a. vertebral ascends in neck through transverse foramina of C6-C1
b. internal thoracic
c. thyrocervical trunk normally branches into suprascapular, transverse
cervical, and inferior thyroid (which gives off ascending cervical to
deep muscles of neck)
3. 2nd part posterior to scalene
a. costocervical trunk which gives off deep cervical, to deep muscles
of neck, and superior intercostal to upper two intercostal spaces
4. 3rd part lateral to scalene
a. dorsal scapular may arise if it does not branch from transverse
cervical
195
Posterior
auricular
Posterior belly
of digastric
Occipital
Ascending
pharyngeal
Superficial
temporal
Maxillary
Facial
Lingual
Internal carotid
Carotid sinus
Superior thyroid
Common carotid
Branches of the external carotid artery

E. Carotid arteries
1. common carotid, in carotid sheath, divides at superior border of thyroid
cartilage
2. internal carotid remains in sheath and gives off no branches in neck
3. external carotid leaves carotid sheath
a. ascending pharyngeal
b. superior thyroid
c. lingual
d. facial - may arise with lingual from linguofacial trunk
e. occipital
f. posterior auricular
g. maxillary and superficial temporal are terminal branches
196
Facial
Retromandibular
External
jugular
Anterior
jugular
External
jugular
Superior
thyroid
Internal
jugular
Venous drainage
F. Jugular veins
1. external jugular
a. formed by union of posterior auricular with posterior branch of
retromandibular vein
b. lies between platysma and sternocleidomastoid muscles
2. anterior jugular
a. drains submental region and joins external jugular
3. internal jugular
a. begins at jugular foramen as continuation of sigmoid dural venous sinus
b. lies in carotid sheath with internal carotid and vagus nerve and with
common carotid and vagus more inferiorly
c. ends by joining subclavian to form brachiocephalic vein
d. tributaries correspond fairly closely with branches of external carotid
artery
197
Vagus
Carotid
nerve
Cardiac nerves
Superior cervical
ganglion
Middle cervical
ganglion
Inferior cervical
ganglion
1st thoracic
ganglion
Autonomic nerves of neck

G. Sympathetic trunk and ganglia
1. sympathetic trunk lies posterior to carotid sheath on prevertebral fascia
2. superior cervical ganglion
a. located at level of C1-C2 vertebrae
b. sympathetic postganglionic fibres travel in carotid nerve to form carotid
plexuses and are distributed on branches of internal and external carotid
arteries to structures in the head
c. also gives rise to superior cardiac nerve to cardiac plexus
3. middle cervical ganglion
a. gives rise to middle cardiac nerve to cardiac plexus
4. inferior cervical ganglion
a. gives rise to inferior cardiac nerve to cardiac plexus
b. may be fused with 1st thoracic ganglion to form cervicothoracic/stellate
ganglion
198
Hyoid bone
Right lobe of
thyroid
gland
Pyramidal
lobe
Isthmus
Thyroid cartilage
of larynx
Trachea
Brachiocephalic vein
Viscera in the anterior triangle

H. Viscera
1. thyroid gland
a. comprises right and left lobes
b. lobes connected by isthmus across trachea at 2nd and 3rd tracheal rings
c. may have pyramidal lobe (embryonic remnant) arising from isthmus
d. enclosed in visceral pretracheal layer of deep cervical fascia
e. supplied by superior and inferior thyroid artery and drained by superior,
middle and inferior thyroid veins
2. parathyroid glands
a. usually two on posterior surface of each thyroid lobe
199
Face and Scalp

Specific Objectives
Be able to:
1. Describe the five layers of the scalp, its sensory innervation, and blood supply.
2. Describe the general attachments, actions, and innervation of the following
muscles: frontalis, occipitalis, orbicularis oculi, zygomaticus, levator labii
superioris, orbicularis oris, buccinator, depressor anguli oris, depressor labii
inferioris and platysma.
3. Describe the course and distribution of the motor branches of the facial nerve.
4. Describe the course and cutaneous distribution of the three divisions of the
trigeminal nerve on the face and scalp.
5. Describe the course, major branches, and distribution of the facial artery and the
areas of drainage and intracranial connections of the facial vein.
6. Describe the parotid gland in terms of location, autonomic innervation, and
structures passing through the gland.
200
Skin
Connective tissue
Aponeurosis
Loose connective
tissue
Pericranium
Cranial bone
epicranial
aponeurosis
Frontalis
Occipitalis
Scalp
A. Scalp
1. five layers of tissue with three superficial layers fused to form single unit
a. skin
b. connective tissue is thin fibrofatty layer with abundant blood supply
c. epicranial aponeurosis/galea aponeurotica is a dense connective tissue
connection between frontalis and occipitalis muscles
d. loose connective tissue loosely connects aponeurosis to underlying
periosteum and provides mobility for three fused layers
e. pericranium is external periosteum over cranial bones
2. muscles
a. frontalis originates from skin and fascia of eyebrow and inserts into
aponeurosis
b. occipitalis originates from superior nuchal line and inserts into
aponeurosis
201
C2/3 dorsal
rami
V1
V2
V3
Greater
occipital
C2/3 ventral
rami
Supratrochlear
Supraorbital
Auriculotemporal
3rd occipital
Lesser
occipital
Great
auricular
Sensory innervation of scalp

3. innervation
a. branches of V1, V2 and V3
b. lesser occipital (C2), greater occipital (C2) and 3rd occipital (C3)
4. blood supply
a. supratrochlear and supraorbital from ophthalmic branch of internal carotid
b. superficial temporal, posterior auricular and occipital from external carotid
5. venous drainage
a. emissary veins connect scalp veins with intracranial dural sinuses via
emissary foramina
b. supratrochlear and supraorbital drain into angular and then into facial; there
is also communication with the superior ophthalmic
c. superficial temporal drains into retromandibular, the posterior branch
of which joins the posterior auricular to form the external jugular
d. ophthalmic drains into cavernous sinus
202
1 of the 2 terminal
branch of external
carotid, other being
the supf. temporal
Infraorbital
Maxillary artery and its branches

supf. temporal
Star denotes
maxillary artery
Deep
Temporal
supply temporalis
m.
Posterior
Superior
Alveolar
Inferior
alveolar
supply, lower set of
teeth
laterla pterygoid
divdes maxillar
artery to 3 parts
External
Carotid
Maxillary artery and its branches

pterygopalatine
fossa
Sphenopalatine
Deep
temporal
Middle
Meningeal
Descending
palatine
MAXILLARY ARTERY
3rd PART
Sphenop~latine
2nd PART
Deep Temporal
1st PART
Accessory Meningeal
Infra-orbital
Anterior Tympanic
Deep Aurkular
Muscles of Facial Expression (CN VII)

know all muscles,
know 5 branches
the facial nerve
Nerves:
Temporal
Zygomatic
Buccal
Mandible
Cervical
levator palpebrae
perioris
levator labii
oculi
depressor
orbicularis
Frontalis
Orbicularis
oculi
Occipitalis
Levator labii
superioris
Zygomaticus
major
Orbicularis
oris
Buccinator
Platysma
Depressor labii
inferioris
Depressor
anguli oris
Facial muscles
B. Facial muscles
1. paired muscles lying in superficial fascia
a. origin typically from facial/skull bones
b. insertion into dermis or other facial muscles
2. innervated by branches of facial nerve (CN VII)
Temporal
Zygomatic
Buccal
Posterior
auricular
Mandibular
post. auricular
Cervical
ext. carotid
Facial nerve motor branches

203
Supraorbital
Supratrochlear
Infratrochlear
Zygomaticotemporal
Zygomaticofacial
Great
auricular
Infraorbital
Mental
Buccal
Auriculotemporal
Sensory innervation of face

D. Sensory innervation of the face by the trigeminal nerve (CN V)
1. ophthalmic nerve (V1)
a. supratrochlear
b. supraorbital
c. lacrimal
d. infratrochlear
2. maxillary nerve (V2 )
a. infraorbital
b. zygomaticofacial
c. zygomaticotemporal
3. mandibular nerve (V3 )
a. mental
b. buccal
c. auriculotemporal
204
Superficial
temporal a&v
Supraorbital
a&v
Occipital
a&v
Posterior
auricular a&v
Infraorbital
a&v
External
jugular v
Transverse
facial a&v
Facial a&v
internal jugular
Ext. jugular
External
carotid a
Internal
jugular v
Blood vessels of face and scalp

E. Blood supply to face
1. facial from external carotid
a. crosses inferior border of mandible and takes a tortuous route by angle
of mouth to terminate at medial angle of eye as angular artery
2. infraorbital from maxillary
3. transverse facial from superficial temporal
4. supraorbital and supratrochlear from ophthalmic
5. venous drainage
a. supratrochlear and supraorbital veins join to form angular which drains
into facial
b. angular connects with superior ophthalmic and thus with cavernous sinus
c. facial receives anterior branch from retromandibular to become common
facial which joins internal jugular vein
205
External
acoustic
meatus
Facial
nerve
Parotid duct
Mastoid
process
Masseter
Parotid
gland
Posterior
auricular v
Anterior & posterior

branches of
retromandibular v
External
jugular v
Parotid gland
F. Parotid gland
1. lies in fibrous capsule anterior to external acoustic meatus covering posterior
part of masseter muscle
2. contains divisions of facial nerve motor root, retromandibular vein and
external carotid artery
3. parotid duct pierces buccinator muscle to open into vestibule of mouth
opposite 2nd upper molar
4. parasympathetic innervation from IX via auriculotemporal nerve of V3
Supf - parotid gland - facial nerves and a. - masster musscle - buccinator - deep
206
Head and Neck Autonomics

Specific Objectives
Be able to:
1. Describe the organization of the trigeminal and facial nerves as in module #26.
2. Describe the organization of the autonomic nervous system as in module #06.
3. Describe the pathway for parasympathetic innervation of intrinsic muscles of
the eye.
4. Describe the pathway for parasympathetic innervation of lacrimal, sublingual,
submandibular, and parotid glands.
5. Describe the pathways for parasympathetic innervation of mucous membranes.
6. Describe the pathways for sympathetic innervation of head structures.
207
Oculomotor nerve
Edinger-Westphal
nucleus
Superior salivatory
nucleus
Facial nerve
Inferior salivatory
nucleus
Glossopharyngeal
nerve
Vagus nerve
Dorsal motor nucleus of X
Cranial nerves and nuclei of parasympathetic pathways

A. General parasympathetic pathways
1. preganglionic soma in nuclei of cranial nerves III, VII, IX and X
a. Edinger-Westphal nucleus of oculomotor nerve
b. superior salivatory nucleus of facial nerve
c. inferior salivatory nucleus of glossopharyngeal nerve
d. dorsal motor nucleus of vagus nerve
2. preganglionic axons project in cranial nerves III, VII, and IX to named
ganglia in head, and in X to unnamed ganglia in neck
a. ciliary ganglion for innervation to eye
b. pterygopalatine ganglion for innervation of lacrimal gland
and mucosa of nasal cavity and paranasal sinuses
c. submandibular ganglion for innervation of submandibular and sublingual
glands
d. otic ganglion for innervation of parotid gland
e. ganglia in wall of pharynx and larynx for vagus nerve innervation of
mucosa
3. postganglionic axons from named ganglia carried by branches of trigeminal
nerve to target tissue
208
Zygomatic
Lacrimal
Lacrimal
gland
Short ciliary
Ciliary
ganglion
Communicating
branch
Branch of
oculomotor
N of pterygoid
canal
Pterygopalatine ganglion
Parasympathetic paths to orbit

B. Specific parasympathetic pathways
1. innervation of intrinsic muscles of eye
a. preganglionic soma in Edinger-Westphal nucleus of midbrain
b. preganglionic axons carried by oculomotor nerve
c. synapse in ciliary ganglion
d. postganglionic axons to constrictor pupillae and ciliary muscles via short
ciliary nerves (V1)
2.
innervation of lacrimal gland

a. preganglionic soma in superior salivatory nucleus of pons
b. preganglionic axons carried by nervus intermedius, greater petrosal
nerve, nerve of pterygoid canal
c. synapse in pterygopalatine ganglion
d. postganglionic axons carried in zygomatic (V2), communicating branch,
lacrimal nerve (V1) to gland
209
Greater
petrosal
Auriculotemporal
Lesser
petrosal
Chorda
tympani
VII
Chorda
tympani
Lingual
Submandibular
ganglion
Otic
ganglion
Submandibular &
sublingual glands
Lingual
Auriculotemporal
Parasympathetic paths to salivary glands

3. innervation of submandibular and sublingual salivary glands
a. preganglionic soma in superior salivatory nucleus of pons
b. preganglionic axons carried by nervus intermedius, chorda tympani,
lingual nerve
c. synapse in submandibular ganglion
d. postganglionic axons to submandibular gland in branches from ganglion,
and to sublingual gland in lingual nerve (V3)
4. innervation of parotid gland
a. preganglionic soma in inferior salivatory nucleus of medulla
b. preganglionic axons carried by glossopharyngeal, tympanic, lesser
petrosal nerves
c. synapse in otic ganglion
d. postganglionic axons to gland in auriculotemporal nerve (V3)
5. innervation of glandular tissue of mucous membranes
a. parasympathetic postganglionic axons from pterygopalatine ganglion
carried in branches of trigeminal which provide somatic sensory
innervation to the particular region
210
Carotid plexus
Carotid nerve
Superior cervical
ganglion
Sympathetic pathways
C. Sympathetic pathways
1. postganglionic neurons
a. soma in superior cervical ganglion
b. axons carried by carotid nerve and carotid plexus which surrounds carotid
arteries
c. distributed to target tissue on branches of the carotid vessels, or by
various branches of the trigeminal nerve, supplying the area
211
Cranial Nerves V and VII

Specific Objectives
Be able to:
1. Describe the course of the trigeminal nerve and its branches from its origin in
the cranial vault to the tissues innervated.
2. Describe the fibres carried in each branch of the trigeminal nerve.
3. Describe the relationship between cranial nerves III, VII, and IX (carrying
preganglionic parasympathetic fibres) and terminal branches of the trigeminal
nerve carrying parasympathetic postganglionic fibres.
4. Describe the course of the facial nerve and its branches from its origin in the
cranial vault to the tissues innervated.
5. Describe the fibres carried in each branch of the facial nerve.
6. Describe the relationship between the chorda tympani and the trigeminal nerve.
212
Trigeminal ganglion
V1
V2
V3
Trigeminal nerve in situ

Trigeminal Nerve
A. Exit from skull
1. leaves cranial vault and enters dural recess (trigeminal/Meckel's cave)
which contains trigeminal/semilunar ganglion (somatic sensory)
2. ophthalmic nerve (V1)
a. lies in lateral wall of cavernous sinus and branches enter orbit via
superior orbital fissure
3. maxillary nerve (V2)
a. lies in lateral wall of cavernous sinus and enters pterygopalatine fossa
through foramen rotundum
b. named branches leave fossa via same named openings
4. mandibular nerve (V3)
a. passes through foramen ovale and is joined by motor root of the trigeminal
as it enters infratemporal fossa
b. divides into posterior and anterior division
B. Function
1. somatic sensory from dura mater, skin of anterior 2/3rds of scalp, face,
conjunctiva, mucous membranes of oral and nasal cavities, paranasal sinuses
2. all branches innervating mucous membrane carry parasympathetic fibres
3. motor to muscles of mastication
4. branches of trigeminal carry parasympathetic postganglionic fibres from the
parasympathetic ganglia to target organ/tissue
213
Anterior &
posterior ethmoidal
Frontal
Lacrimal
Supraorbital
Supratrochlear
Infratrochlear
Nasociliary
Long
ciliary
Short
ciliary
Branch from
oculomotor
Ciliary
ganglion
Branches of the ophthalmic nerve

C. Ophthalmic nerve branches
1. nasociliary nerve
a. ethmoidal nerves carry sensory from nasal cavity, sphenoid and ethmoid
sinuses
b. infratrochlear nerve carries sensory from upper eyelid and skin of nose
c. long ciliary nerves carry sympathetic fibres to iris, sensory from eye
d. short ciliary nerves carry parasympathetic from ciliary ganglion to ciliary
body and iris of eye, sensory from eye
2. frontal nerve
a. divides into supraorbital and supratrochlear nerves carrying sensory from
anterior scalp
3. lacrimal nerve
a. carries sensory from upper eyelid
b. carries parasympathetic fibres from pterygopalatine ganglion to lacrimal
gland
214
Zygomaticofacial
Zygomaticotemporal
Zygomatic
Infraorbital
Pterygopalatine
ganglion
Greater &
lesser palatine
Post, middle, & ant
superior alveolar
Branches of the maxillary nerve

D. Maxillary nerve branches
1. zygomatic nerve
a. divides into zygomaticofacial and zygomaticotemporal nerves which
carry sensory from cheek and temporal regions
b. zygomaticotemporal has communicating branch with lacrimal nerve
which carries parasympathetic fibres from pterygopalatine ganglion to
lacrimal gland
2. greater and lesser palatine nerves
a. sensory from mucosa of palate
b. lesser palatine carries some taste fibres from soft palate
3. nasopalatine nerve
a. sensory from mucosa of nasal cavity and anterior palate
4. infraorbital nerve
a. continuation of maxillary nerve in floor of orbit
b. passes through inferior orbital fissure, infraorbital groove, canal, foramen
c. sensory from skin of nose, cheek, lower lid, upper lip
d. gives off middle and anterior superior alveolar nerves (posterior arises
from maxillary nerve) which are sensory from maxillary teeth
215
Motor branches
Auriculotemporal
Buccal
Inferior
alveolar
Chorda tympani
Mental
Lingual
Nerve to mylohyoid
Submandibular ganglion
Inferior alveolar
Branches of the mandibular nerve

E. Mandibular nerve branches
1. gives off nerve to medial pterygoid which also supplies tensor tympani
and tensor veli palatini
a. auriculotemporal nerve is sensory only from auricle, scalp and outer surface
of tympanic membrane
b. lingual nerve is somatic sensory from anterior 2/3rds of tongue
c. inferior alveolar nerve is mainly sensory from mandibular teeth but
gives off nerve to mylohyoid
a. buccal nerve is sensory from cheek
b. motor branches to temporalis, lateral pterygoid and masseter
4. chorda tympani nerve
a. branch of CN VII which joins lingual
b. carries taste fibres from anterior 2/3rds of tongue and parasympathetic
fibres to the submandibular ganglion which innervates sublingual and
submandibular salivary glands
216
Greater petrosal
Geniculate ganglion
Motor root of VII

Nervus intermedius
Vestibulocochlear
Chorda tympani
Internal acoustic
meatus
Facial nerve in situ

Facial Nerve
A. Exit from skull
1. leaves cranial vault via internal acoustic meatus
2. leaves meatus and passes through facial canal in petrous part of temporal bone
a. canal takes a sharp posterior turn on medial wall of middle ear
b. geniculate ganglion lies at the turn
c. canal turns inferiorly and ends at stylomastoid foramen
B. Function
1. motor root
a. carries motor fibres to stapedius, stylohyoid, posterior belly of digastric,
muscles of facial expression
2. nervus intermedius
a. carries somatic sensory from external auditory meatus, parasympathetic
preganglionics and taste fibres
b. greater petrosal nerve carries parasympathetics to pterygopalatine ganglion
and taste from soft palate
217
Greater petrosal
Geniculate ganglion
Facial motor
root
Chorda tympani
Inferior alveolar
Lingual
Medial view of chorda tympani

C. Chorda tympani nerve
1. leaves facial canal in posterior wall of middle ear and crosses middle ear
cavity between malleus and incus on deep surface of tympanic membrane
2. enters infratemporal fossa via petrotympanic fissure
3. joins lingual nerve
a. parasympathetic fibres from nervus intermedius are carried in chorda tympani
to lingual nerve; synapse in submandibular ganglion and postganglionics are
distributed to submandibular and sublingual salivary glands
b. taste fibres from anterior 2/3rds of tongue travel in lingual nerve and are
carried in chorda tympani to nervus intermedius
218
Pterygopalatine
ganglion
V2
Greater
petrosal
Deep
petrosal
Nerve of
pterygoid canal
Greater and
lesser palatine
Petrosal nerves
D. Greater petrosal nerve and nerve of pterygoid canal
1. greater petrosal carries parasympathetic and taste fibres
2. leaves facial canal at geniculate ganglion
3. passes over foramen lacerum
a. joined by deep petrosal nerve carrying sympathetic fibres from
carotid plexus to form nerve of pterygoid canal
4. nerve joins pterygopalatine ganglion in pterygopalatine fossa
219
Temporal
Zygomatic
Buccal
Posterior
auricular
Mandibular
Cervical
Motor root
motor root
E. Facial nerve motor root
1. leaves skull via stylomastoid foramen and gives off branches to stylohyoid
and posterior belly of digastric
2. divides into motor branches within parotid gland
a. temporal to anterior and superior auricularis, frontalis, orbicularis oculi
b. zygomatic to orbicularis oculi
c. buccal to buccinator and other muscles between orbit and mouth
d. mandibular to muscles below mouth
e. cervical to platysma
f. posterior auricular to posterior auricularis and occipitalis
220
Infratemporal Fossa
Specific Objectives
Be able to:
1. Describe the boundaries of the infratemporal fossa.
2. Describe the muscles of mastication in terms of general attachments, actions,
and innervation.
3. Describe the course and distribution of the maxillary artery within the
infratemporal fossa, and corresponding venous drainage.
4. Describe the course and distribution of the mandibular division of the trigeminal
nerve.
5. Describe the functional components of the chorda tympani nerve and its
relationship to the facial and trigeminal nerves.
6. Describe the temporomandibular joint in terms of articular surfaces, joint capsule,
lateral ligament and articular disc.
221
What is the Infratemporal fossa?

It is the space inferior to the temporal fossa
Roof
Greater wing of sphenoid
Temporal bone
Foramen ovale and spinosum
Posterior wall
Styloid process
Mastoid process
Stylomastoid foramen (CNVII)
Lateral Wall
Ramus of mandible
Mandibular foramen
Anterior wall
Maxilla
Medial wall
Lateral pterygoid plate
Pterygomaxillary fissure (gateway to PT fossa)
to expose remove
the zygomatic arch
Contents
Maxillary artery
Pterygoid venous plexus
Mandibular division of the trigeminal nerve
Chorda tympani
Otic ganglion
Lateral Pterygoid muscle
Medial pterygoid muscle
Temporal muscle
Bones forming the boundaries

outlines the
temporal fossa
Temporal
Lateral
Pterygoid
plate
Maxilla
Condyle
Mandibular
ramus
Bones forming the boundaries

Mandibular
ramus
Maxilla
Temporal
Lateral
Pterygoid plate
Condyle
Lateral view
Medial view
Infratemporal
surface of
sphenoid
coronoid process
of mandible
Lateral
pterygoid
plate
Zygomatic
arch
Body of
maxilla
Styloid
process
angle
Ramus of
mandible
Bony walls of infratemporal fossa

A. Location
1. area deep to zygomatic arch and ramus of mandible
2. borders
a. lateral is ramus of mandible
b. medial is lateral pterygoid plate
c. anterior is posterior body of maxilla
d. posterior is mastoid and styloid processes
e. superior is infratemporal surface of sphenoid
f. inferior is insertion of medial pterygoid on angle of mandible
3. contents
a. pterygoid muscles, insertion of temporalis, maxillary artery and
branches, pterygoid venous plexus, mandibular nerve (V3) and
branches, chorda tympani nerve, otic ganglion
222
Superior head
Lateral pterygoid
Inferior head
Medial
pterygoid
Temporalis
Muscles of mastication
Masseter
B. Muscles of mastication
1. temporalis
a. fan shaped muscle attached to coronoid process of mandible
b. closes jaw
c. innervated by V3
2. lateral pterygoid
a. origin from lateral side of lateral pterygoid plate
b. superior head attaches to articular disc, inferior head to neck of
mandibular condyle
c. protrudes and opens jaw
d. innervated by V3
3. medial pterygoid
a. origin from medial side of lateral pterygoid plate
b. closes jaw, with masseter
c. innervated by V3
4. masseter
a. lies outside fossa
b. origin from zygomatic arch
c. closes jaw
d. innervated by V3
223
Muscular
branches
Post sup
alveolar
Inferior
alveolar
Middle
meningeal
Superficial
temporal
Maxillary
External carotid
Maxillary artery branches

C. Blood supply
1. maxillary artery
a. external carotid ends deep/posterior to neck of mandible by
dividing into maxillary and superficial temporal arteries
b. maxillary crosses infratemporal fossa transversely to enter
pterygomaxillary fissure
c. divided into three parts by lateral pterygoid
d. 1st part gives rise to middle meningeal and inferior alveolar arteries
e. 2nd part gives rise to named muscular branches supplying muscles
of mastication
f. 3rd part enters pterygomaxillary fissure to supply nasal and oral
cavities and midface and gives off posterior superior alveolar as it
passes through fissure
2. pterygoid venous plexus (valveless)
a. drains anteriorly into facial vein
b. drains posteriorly into maxillary and then retromandibular veins
c. connects superiorly via ophthalmic veins to cavernous sinus
224
Motor branches
Auriculotemporal
Buccal
Inferior
alveolar
Chorda tympani
Nerve to mylohyoid
Lingual
Mandibular nerve branches
Submandibular
ganglion
D. Mandibular nerve
1. gives off nerve to medial pterygoid which also supplies tensor tympani
and tensor veli palatini
a. auriculotemporal nerve is sensory only from auricle and scalp
b. lingual nerve is somatic sensory from anterior 2/3rds of tongue
c. inferior alveolar nerve is mainly sensory from mandibular teeth but
gives off nerve to mylohyoid
a. buccal nerve is sensory from cheek
b. motor branches to temporalis, lateral pterygoid and masseter
4. chorda tympani nerve
a. branch of CN VII which joins lingual
b. carries taste fibres from anterior 2/3rds of tongue and parasympathetic
fibres to the submandibular ganglion which innervates sublingual and
submandibular salivary glands
225
Articular eminence
Meniscus
Condyle of
mandible
Superior & inferior heads
of lateral pterygoid
Medial pterygoid
Temporomandibular joint
E. Temporomandibular joint
1. synovial joint between mandibular fossa of temporal bone and mandibular
condyle of mandible
2. meniscus/articular disc
a. attached to capsule and divides joint into two parts
b. moves with condyle
c. lateral pterygoid inserts into capsule, disc and neck of mandible and
draws condyle and disc anteriorly in protraction/protrusion of mandible
226
Eye and Orbit

Specific Objectives
Be able to:
1. Describe the anatomy of the bony orbit.
2. Describe the lacrimal apparatus with respect to gland and duct system.
3. Describe the six extrinsic eye muscles, and levator palpebrae superioris, in
terms of attachments, actions, and innervation.
4. Describe the course and major branches/tributaries of the ophthalmic artery
and veins.
5
Describe the course and branches of the ophthalmic division of the trigeminal,
optic, oculomotor, trochlear and abducens nerves.
227
Superior orbital
fissure
Optic canal
Frontal
Lacrimal
groove
Sphenoid
Ethmoid
Inferior orbital
fissure
Zygomatic
Palatine
Lacrimal
Maxillary
Bones of right orbit

Orbit
A. Bony structure
1. formed by parts of ethmoid, sphenoid, frontal, maxilla, zygomatic, lacrimal,
and palatine bones
2. periorbita is thickened periosteum of orbital bones that is continuous with
periosteal dura and periosteum of external skull via optic canal, orbital
fissures, orbital margins
3. orbital margin
a. frontal, maxilla and zygomatic bones
4. walls
a. superior is mainly orbital plate of frontal bone
b. medial is mainly thin orbital plate of ethmoid
c. inferior is mainly very thin orbital plate of maxilla with sinus lying
inferiorly
d. lateral is mainly thick zygomatic bone
228
Levator palpebrae
superioris
Bulbar
conjunctiva
Palpebral
conjunctiva
Tarsal plate
Papillae
Orbicularis
oculi
Fornix
Palpebrae
B. Palpebrae
1. tarsal plates
a. connective tissue in eyelid with levator palpebrae superioris inserting
into superior plate
b. palpebral part of orbicularis oculi lies superficial to plates
2. lacrimal papilla
a. raised structure, with punctum, at medial end of margin of each lid
3. conjunctiva
a. palpebral layer lines eyelids and reflects onto eye as bulbar conjunctiva
b. fornices are recesses formed by reflection of conjunctiva onto eye
4. medial and lateral canthus
a. angle formed by meeting of palpebrae
b. medial has lacrimal lake, a reddish area with lacrimal caruncle
c. plica semilunaris is fold of conjunctiva lateral to caruncle
229
Lacrimal gland
Puncta
Canaliculus
Lacrimal sac
Nasolacrimal duct
Lacrimal apparatus
C. Lacrimal apparatus
1. lacrimal puncta
a. openings of lacrimal canaliculi at apex of lacrimal papillae
2. lacrimal sac
a. lies in lacrimal groove of maxilla/lacrimal bones and receives canaliculi
b. empties into nasolacrimal duct which drains into nasal cavity
3. lacrimal gland
a. lies in superolateral aspect of orbit
b. secretes via several ducts through superolateral fornix
230
Superior
SO
Lateral
SR
LR
LEV
SO
SR
LR
IR
MR
Common
tendinous ring
IR
MR
IO
Extrinsic muscles of right eye

D. Extrinsic eye (extraocular) muscles
1. origins
a. four recti from common tendinous ring
b. levator palpebrae superioris and superior oblique from above ring
c. inferior oblique from inferomedial orbit
2. innervation LR6(SO4)3
a. lateral rectus by VI
b. superior oblique by IV
c. all others, including levator palpebrae superioris, by III
3. actions (independent of other muscles)
a. lateral rectus
- aBduction
b. medial rectus
- aDduction
c. superior rectus - elevation and aDduction
d. inferior rectus
- depression and aDduction
e. superior oblique - depression and aBduction
f. inferior oblique - elevation and aBduction
4. levator palpebrae superioris
a. inserts into superior tarsal plate
b. superior tarsal muscle is smooth muscle attaching to superior tarsal plate
and innervated by sympathetics
231
Supratrochlear
Supraorbital
lacrimal gland
Ethmoidals
Lacrimal
Ciliary
Central artery
of retina
Ophthalmic
Internal carotid
Branches of ophthalmic artery

E. Ophthalmic artery
1. branch of internal carotid which enters orbit through optic canal
a. central artery of retina pierces dural sheath of optic nerve to enter eye
through optic disc as sole supply to retina
b. ethmoidal arteries to nasal cavity, frontal sinus and ethmoid air cells
c. supratrochlear and supraorbital cross superior orbital margin to supply
anterior scalp
d. ciliary arteries to eyeball
e. Lacrimal
F. Venous drainage
1. conforms to branches of ophthalmic artery
2. superior and inferior ophthalmic veins
a. superior communicates with cavernous sinus
b. inferior communicates with pterygoid plexus and with cavernous sinus
via superior ophthalmic
232
Levator and sup rectus removed

Supratrochlear
Infratrochlear
Ciliary ganglion
Long ciliary
Supraorbital
Lacrimal
Frontal
IV
Ethmoidals
Nasociliary
VI
Optic chiasm
III
Nerves of orbit
G. Ophthalmic nerve
1. sensory branch of trigeminal that divides at superior orbital fissure
a. nasociliary divides into ethmoidal nerves, which innervate nasal cavity
and nasal sinuses, short ciliary nerves which carry parasympathetics to
ciliary and constrictor pupillae muscles, and long ciliary nerves which
carry sympathetics to dilator pupillae muscle
b. frontal divides into supratrochlear and supraorbital and innervates
anterior scalp
c. lacrimal innervates conjunctiva, upper lid and carries parasympathetic
postganglionic fibres to lacrimal gland
233
Cranial Cavity and Ear

Specific Objectives
Be able to:
1. Describe the layers, spaces and major reflections of the meninges.
2. Describe the intercranial venous drainage with particular reference to the
dural venous sinuses.
3. Describe the anatomy of the external, middle and inner ear.
4. Describe the bony walls and contents of the middle ear.
5. Describe the organization of the cerebral arterial circle.
234
Periosteal dura
Dural venous
sinus
Pia
True
dura
Arachnoid
Meninges
Subarachnoid
space
The Cranial Cavity

A. Meninges
1. dura mater
a. in cranium dura is fused to periosteum in most places
b. periosteal (endosteal) dura is internal periosteum of calvaria
c. true (meningeal) dura is dura mater proper
d. continuous at foramen magnum with spinal dura
e. major blood supply is middle meningeal artery
2. dural septa
a. dura reflects away from periosteum to form septa that support hemispheres
and cerebellum and prevent displacement of these structures
b. falx cerebri lies in longitudinal fissure between cerebral hemispheres
c. tentorium cerebelli lies between occipital lobes and cerebellum
d. falx cerebelli lies between cerebellar hemispheres
e. diaphragma sellae lies over sella turcica
3. arachnoid mater lies against dura due to pressure of cerebrospinal fluid
4. pia mater is adherent to surface of CNS
5. meningeal spaces
a. epidural is potential space
b. subdural is potential space
c. subarachnoid is space containing CSF and cerebral arteries
235
Falx
cerebri
Inferior
petrosal
Inferior
sagittal
Superior sagittal
Cavernous
Superior
petrosal
Great
cerebral vein
Straight
Transverse
Tentorium
cerebelli
Dural venous sinuses

B. Dural venous sinuses
1. spaces between periosteal and true dura
a. receive cerebral veins and veins draining calvaria, orbit, and scalp
b. arachnoid projects through true dura into sinus to form arachnoid villi
which allow return of cerebrospinal fluid to systemic venous system
2. superior sagittal sinus
a. in superior margin of falx cerebri
b. receives cerebral veins and most arachnoid villi
3. inferior sagittal sinus
a. joined by great cerebral vein to form straight sinus
4. straight sinus
a. at junction of falx cerebri with tentorium cerebelli
5. confluence of sinuses
a. receives superior sagittal and straight
6. transverse sinuses
a. lie in lateral border of tentorium cerebelli
b. drain confluence of sinuses
7. sigmoid sinuses
a. leave tentorium inferiorly to become internal jugular vein at jugular
foramen
236
Pituitary Gland
CN III
CN IV
CN VI
Internal
carotid
CN V1
CN V2
Sphenoid sinus
Cavernous sinus and contents

8. cavernous sinus
a. lies either side of body of sphenoid bone but communicates across
midline
b. receives ophthalmic veins
c. contains internal carotid artery, sympathetics, cranial nerve VI
d. cranial nerves III, IV, V1, V2, are embedded in lateral wall of sinus
9. superior petrosal sinuses
a. from cavernous sinus to transverse/sigmoid junction in lateral border
of tentorium cerebelli
10. inferior petrosal sinuses
a. from cavernous sinus to internal jugular vein
237
External ear
Middle ear
Internal ear
Helix
Antihelix
Auricle
Lobule
Regions of the ear
Tympanic
membrane
The Ear
A. External ear
1. from auricle/pinna to tympanic membrane
2. auricle
a. elastic cartilage and skin
b. lobule is fatty tissue with no cartilage
3. external auditory meatus
a. canal is 2/3rd bone and 1/3rd cartilage
238
View through roof

Cochlea
Middle ear
Vestibular apparatus
Malleus
Tympanic membrane
Incus
Chorda tympani
Round
window
Promontory
Tensor
tympani
View of lateral wall
Auditory
tube
Stapes
Posterior wall
View of medial wall
Middle ear cavity

B. Middle ear
1. box-shaped space lined with mucous membrane and filled with air
2. located in petrous portion of temporal bone
3. contents
a. auditory ossicles
b. chorda tympani nerve and tympanic nerve plexus
c. tendons of tensor tympani and stapedius muscles
4. borders/walls
a. lateral is tympanic membrane on which malleus rests
b. medial between middle and inner ear has oval window with footplate of stapes,
round window occupied by a membrane, and horizontal part of facial canal
c. anterior (carotid) wall separates middle ear from internal carotid artery and
has opening of auditory tube, which is mainly cartilage
d. posterior (mastoid) wall separates middle ear from mastoid air cells
e. floor (jugular wall) separates middle ear cavity from internal jugular vein
f. roof is tegmen tympani separating middle ear from middle cranial fossa
239
Semicircular ducts in
semicircular canals
Ampulla
Utricle & saccule
in vestibule
Stapes in
oval window
Tympanic
membrane
Membrane of
round window
Cochlear duct
in cochlea
Inner ear
C. Inner ear
1. osseous/bony labyrinth is passages and chambers in petrous portion of temporal
bone
a. divided into semicircular canals, vestibule and cochlea
2. membranous labyrinth is series of tubes and sacs within bony labyrinth
a. divided into semicircular ducts, utricle, saccule, and cochlear duct
D. Sensory innervation of ear
1. auricle
a. great auricular, lesser occipital, branch of vagus
2. external acoustic meatus and external surface of tympanic membrane
a. auriculotemporal with small contributions from VII and X
2. middle ear cavity, auditory tube and internal surface of tympanic membrane
a. tympanic branch of IX via tympanic plexus
3. inner ear
a. special sensory from organ of Corti by cochlear portion of VIII
b. special sensory from maculae and cristae by vestibular portion of VIII
240
Internal
carotid
Anterior
communicating
Anterior cerebral
Middle cerebral
Posterior communicating
Posterior cerebral
Basilar
Vertebral
Cerebral arterial circle

Blood supply to central nervous system
A. Internal carotid artery
1. petrous portion
a. lies in carotid canal and runs medially
2. cavernous portion
a. turns superiorly in carotid grooves of sphenoid bone
b. turns through 180 degrees in cavernous sinus
3. supraclinoid portion
a. emerges from cavernous sinus above anterior clinoid processes
b. gives off ophthalmic artery
c. gives off anterior cerebral artery
d. continues as middle cerebral artery
B. Cerebral arterial circle (of Willis)
1. left and right internal carotids
2. anterior cerebrals from internal carotids
3. anterior communicating between anterior cerebrals
4. posterior communicating arteries
5. posterior cerebrals
6. basilar (receives from vertebrals)
241
Nasal Cavity and

Pterygopalatine Fossa
Specific Objectives
Be able to:
1. Describe the bone and cartilage components of the external nose and nasal
septum.
2. Describe the bony structures forming the nasal cavity and paranasal sinuses,
meati, sphenoethmoidal recess, ethmoid bulla, semilunar hiatus, and openings
associated with these structures.
3. Describe the innervation of the nasal cavity and adjacent structures with
particular reference to the nasopalatine, ethmoidal, greater and lesser palatine
nerves.
4. Describe the blood supply and venous drainage of the nasal cavity and adjacent
structures with particular reference to the sphenopalatine, ethmoidal, and the
descending, greater and lesser palatine vessels.
5. Describe the boundaries of the pterygopalatine fossa, the openings to the nasal
cavity, palate, orbit, and their contents.
6. Describe the course and distribution of branches of the maxillary division of the
trigeminal nerve (V2) and of the pterygopalatine ganglion.
7. Describe the course and distribution of the branches of the maxillary artery
arising in the pterygopalatine fossa.
242
Ethmoid
Frontal
Lacrimal
Superior & middle
nasal conchae
Nasal
Lateral & alar
cartilages
Sphenoid
Maxilla
Palatine
Inferior nasal concha
Nose and nasal cavity

Nose and nasal cavity
A. Bony and cartilaginous framework
1. nose
a. nasal and frontal bones, frontal processes of maxillae
b. nasal septum formed by vomer, perpendicular plate of ethmoid and
septal cartilage
c. paired alar and lateral cartilages
2. nasal cavity
a. nasal septum divides nasal cavity into left and right nasal passages which are
entered through nares and exited through choanae into nasopharynx
b. floor is palatine process of maxilla and horizontal plate of palatine
c. roof is nasal, frontal, ethmoid and sphenoid bones
d. lateral wall is maxilla, lacrimal, ethmoid, inferior nasal concha, perpendicular
plate of palatine
e. meati are spaces under each nasal concha
243
Anterior
ethmoidal
Posterior lateral
nasal branches
Branch of
anterior ethmoidal
Nasopalatine
V2
Nerve of
pterygoid canal
Greater palatine
To lateral wall
Pterygopalatine
ganglion
Sphenoid sinus
To septum
Innervation of nasal cavity

B. Innervation of cavity
1. lateral wall
a. primarily via nasal branches of greater palatine (V2) and contributions
from anterior ethmoidal (V1)
2. septum
a. primarily nasopalatine (V2) and contributions from anterior ethmoidal (V1)
C. Blood supply
1. lateral wall and septum
a. anterior and posterior ethmoidal, greater palatine and sphenopalatine
b. nares also receive blood from superior labial and nasal branches of facial
244
Ethmoid air cells
Sphenoethmoidal
recess
Frontal
sinus
Middle &
inferior meatus
Maxillary
sinus
Sphenoid
sinus
Semilunar
hiatus
Ethmoid
bulla
Paranasal sinuses and nasal meati

D. Paranasal sinuses
1. air-filled spaces in frontal, ethmoid, sphenoid, and maxilla lined by mucous
membrane
a. ethmoid sinus is series of small air cells whereas other sinuses are larger
spaces that vary in shape and size
b. maxillary sinus has alveolar process of maxilla forming floor and thin
orbital plate forming roof
2. drainage
a. superior meatus receives opening of posterior ethmoid air cells
b. middle meatus receives openings of frontal and maxillary sinuses,
anterior and middle ethmoid air cells, through semilunar hiatus
c. inferior meatus receives opening of nasolacrimal duct
d. sphenoid sinus opens above superior concha into sphenoethmoidal recess
245
Infratemporal
surface
of sphenoid
Lateral
pterygoid plate
Sphenopalatine foramen
Pterygomaxillary fissure
Maxilla
Pterygopalatine fossa
Pteryopalatine Fossa
A. Boundaries
1. posterior wall is pterygoid process of sphenoid
2. anterior is posterior surface of maxilla
3. medial is vertical plate of palatine
4. roof is infratemporal surface of sphenoid
5. lies medial to pterygomaxillary fissure and lateral to sphenopalatine
foramen
B. Openings and contents
1. inferior orbital fissure opens anteriorly to orbit
a. contains infraorbital neurovascular bundle
2. palatine canal opens inferiorly to palate
a. contains greater and lesser palatine nerves, descending palatine artery
3. sphenopalatine foramen opens medially to nasal cavity
a. contains sphenopalatine vessels and nasopalatine nerve
4. pterygomaxillary fissure opens laterally to infratemporal fossa
a. contains maxillary artery and posterior superior alveolar nerve
5. foramen rotundum and pterygoid canal open posteriorly to middle cranial
fossa
a. contain maxillary nerve in rotundum and nerve of pterygoid canal
246
Zygomatic
Pterygopalatine
ganglion
Maxillary
Nerve of
pterygoid canal
Greater &
lesser palatine
Posterior
superior alveolar
Maxillary nerve in fossa

C. Nerves of fossa
1. V2 enters fossa via foramen rotundum and leaves via inferior orbital fissure
2. branches
a. nasopalatine nerve from V2 via ganglion
b. greater and lesser palatine nerves from V2 via ganglion
c. zygomatic nerve branches from V2
d. posterior superior alveolar nerve from V2
e. infraorbital is continuation of V2 through inferior orbital fissure
f. nerve of pterygoid canal joins ganglion
g. pharyngeal branch from V2 via ganglion
D. Branches of maxillary artery in fossa
1. second part of artery passes from infratemporal fossa through pterygomaxillary
fissure to become third part in fossa
2. branches run with named nerves
a. posterior superior alveolar enters posterior maxilla to supply posterior teeth
b. sphenopalatine follows nasopalatine nerve on nasal septum to supply nasal
cavity and anterior hard palate
c. descending palatine divides into greater and lesser palatine to supply palate
d. infraorbital leaves fossa through inferior orbital fissure
e. pharyngeal branch to nasopharynx
3. corresponding veins join pterygoid plexus
247
Venous and Lymphatic

Drainage of the Head
and Neck
Specific Objectives
Be able to:
1. Describe the pattern of superficial venous drainage of the head.
2. Describe the pattern of deep venous drainage of the head.
3. Describe communications between extracranial and intracranial drainage.
4. Describe the pattern of venous drainage of the neck.
5. Describe the location of the groups of regional lymph nodes occipital, retroauricular,
parotid, buccal, submandibular, submental, anterior and superficial cervical,
retropharyngeal, laryngeal, tracheal and the deep cervical nodes.
6. Describe the pattern of lymphatic drainage from head and neck structures.
248
Superficial
temporal
Supratrochlear &
supraorbital
Occipital
Posterior
auricular
Retromandibular
External
jugular
Transverse
facial
Internal
jugular
Facial
Superior thyroid
Superficial venous drainage

Venous drainage
A. Superficial veins
1. supratrochlear and supraorbital
a. join to form angular which drains into facial
b. drain anterior scalp
2. superficial temporal and maxillary
a. join to form retromandibular
b. drain lateral scalp and pterygoid plexus
3. posterior auricular
a. drains posterior scalp
b. joins posterior branch of retromandibular to form external jugular
4. occipital
a. drains posterior scalp
b. may drain into internal or external jugular
5. facial
a. drains face
b. receives anterior branch from retromandibular to form common facial
which joins internal jugular
6. external jugular
a. joins subclavian
b. receives transverse cervical, suprascapular and anterior jugular
249
Supratrochlear
vv
& supraorbital
Nasofrontal v
Superior ophthalmic v
Angular v
Cavernous
sinus
Facial v
Retromandibular v
Maxillary v
Pterygoid plexus
Deep veins
B. Dural venous sinuses
1. receive blood from cerebral veins and emissary veins
2. drain, directly or indirectly, into internal jugular vein at jugular foramen
C. Deep veins
1. vertebral
a. receives branches from vertebral venous plexuses and deep cervical veins
b. joins brachiocephalic
2. ophthalmics
a. inferior drains into pterygoid plexus and also joins superior to drain into
cavernous sinus
3. internal jugular
a. direct continuation of sigmoid sinus at the jugular foramen
b. joins subclavian to form brachiocephalic vein
c. receives facial, pharyngeal, lingual and thyroid veins
D. Communication between intracranial and extracranial veins
1. emissary veins from scalp communicate with dural sinuses
2. supraorbital and supratrochlear from scalp form angular which communicates
via nasofrontal and superior ophthalmic veins with cavernous sinus
250
Mastoid
Parotid
Buccal
Submandibular
Occipital
Superficial cervical
Jugulodigastric
Submental
Anterior cervical
Superior deep
group
Juguloomohyoid
Inferior deep
group
Lymph node groups of head and neck

Lymph drainage
A. Lymph nodes
1. regional nodes receive regional lymph drainage and empty into deep cervicals
2. groups a through h below form 'cervical collar'
a. occipital drain posterior scalp
b. mastoid drain posterolateral scalp and posterior auricle
c. parotid drain anterolateral scalp, anterior auricle and upper lateral face
d. buccal drain lateral face
e. superficial cervical drain auricle and angle of jaw
f. submental drain anterior lower face, anterior floor of mouth, tip of tongue
g. submandibular nodes drain upper and lateral face, nose, floor of mouth
h. anterior cervical drain anterior neck
i. retropharyngeal lie in retropharyngeal space and drain nasopharynx
j. laryngeal lie anterior to larynx and drain surrounding structures
k. tracheal lie along trachea and drain thyroid gland and local neck structures
2. deep cervical nodes
a. lie in fascia of carotid sheath and are divided into superior and inferior groups
b. receive drainage from all superficial nodes
c. inferior group forms jugular trunk which joins right lymphatic or thoracic duct
d. large node posteroinferior to angle of mandible is jugulodigastric draining
tonsils and posterior tongue
e. large node at tendon of omohyoid is juguloomohyoid draining anterior tongue
251
Mouth, Tongue and Palate

Specific Objectives
Be able to:
1. Describe the oral vestibule and oral cavity with respect to the palate, dental arches
and anterior tonsillar pillars.
2. Describe the extrinsic muscles of the tongue - styloglossus, genioglossus,
hyoglossus and palatoglossus with respect to attachments, actions and
innervation.
3. Describe the muscles of the soft palate - levator veli palatini, tensor veli palatini,
uvular muscle, palatoglossus and palatopharyngeus with respect to attachments,
4. Describe the muscles supporting the floor of the mouth - digastric, mylohyoid,
and geniohyoid with respect to attachments, actions and innervation.
5. Describe the parotid, submandibular and sublingual salivary glands, their ducts
and openings, and their innervation.
6. Describe the pattern of general and special sensory innervation of the mouth
and tongue.
7. Describe the blood supply and venous drainage of the oral cavity.
252
Soft palate
Palatoglossal arch
Palatine
tonsil
Posterior wall
of oropharynx
Uvula
Oral vestibule and cavity

Mouth
A. Regions
1. oral vestibule
a. between lips/cheeks and dental arches
2. oral cavity proper
a. from dental arches anterolaterally to palatoglossal arches posteriorly
b. roof is hard and soft palate
c. floor is mucous membrane covering muscles of floor of mouth
c. palatoglossal arches (anterior tonsillar pillars) join uvula to form fauces
which is opening from oral cavity to oropharynx
B. Teeth
1. dental formula
a. deciduous 2 incisors, 1 canine, 2 molars (20 total)
b. permanent 2 incisors, 1 canine, 2 premolars, 3 molars (32 total)
C. Muscles of floor of oral cavity
1. mylohyoid innervated by V3
2. geniohyoid innervated by C1
D. Sensory innervation to mucous membrane
1. cheeks by buccal (V3)
2. palate and maxillary gingiva by branches of V2
3. floor of mouth and mandibular gingiva by branches of V3
253
Papilla of
submandibular
gland
Lingual
frenulum
Sublingual
gland
Submandibular
gland and duct
Parotid gland
and duct
Salivary glands and ducts

E. Salivary glands
1. parotid gland
a. overlying masseter muscle
b. secrete through parotid ducts into vestibule opposite upper second molars
2. submandibular glands
a. deep to angle and body of mandible
b. secrete through submandibular ducts which open into oral cavity through
papillae adjacent to frenulum
3. sublingual glands
a. lie deep to mucous membrane of floor of oral cavity proper
b. secrete through multiple ducts into oral cavity
254
Tensor veli
palatini
Levator veli
palatini
Pterygoid
hamulus
Palatine
aponeurosis
Uvular muscle
Palatopharyngeus
Posterior view of muscles of palate

Palate
A. Structure
1. hard palate
a. palatine processes of maxillary bones
b. horizontal plates of palatine bones
2. soft palate
a. tensor veli palatini tendon turns around pterygoid hamulus to insert
into palatine aponeurosis
b. levator veli palatini raises aponeurosis/soft palate
c. uvular muscle raises uvula to close oropharynx from nasopharynx
d. palatoglossus raises posterior part of tongue
e. palatopharyngeus shortens pharynx
3. blood supply
a. greater and lesser palatine arteries
4. innervation
a. greater palatine provides somatic sensory (V2) and parasympathetic (VII)
to mucous membrane of most of hard palate and gingiva
b. nasopalatine provides somatic sensory (V2) and parasympathetic (VII)
to mucous membrane of anterior hard palate and gingiva
c. lesser palatine supplies somatic sensory (V2), parasympathetic (VII)
and taste (VII) to mucous membrane of soft palate
d. vagus innervates all palate muscles except tensor veli palatini (V3)
255
Palatoglossus
Styloglossus
Hyoglossus
Genioglossus
Mylohyoid
Geniohyoid
Extrinsic muscles of tongue

Tongue
A. Structure
1. papillae lie on dorsal surface
a. vallate form V-shape anterior to sulcus terminalis
b. fungiform scattered on anterior 2/3rd of tongue
c. filiform cover anterior tongue
2. tongue is freely movable but attached to floor of mouth by lingual frenulum
3. muscles of tongue
a. genioglossus protrudes tongue
b. hyoglossus depresses lateral aspect of tongue and assists in retraction
c. styloglossus retracts and elevates tongue
d. palatoglossus elevates tongue
e. intrinsic muscles do not attach to bone and only alter shape of tongue
4. innervation
a. XII to all extrinsic and intrinsic muscles except palatoglossus (X)
b. lingual (V3) carries somatic sensory and taste from anterior 2/3rd
c. IX carries somatic sensory and taste from posterior 1/3rd
5. blood supply
a. lingual artery gives off dorsal lingual posteriorly and deep lingual anteriorly
b. deep lingual veins lie either side of frenulum
256
Pharynx and Larynx

Specific Objectives
Be able to:
1. Describe the nasal, oral and laryngeal divisions of the pharynx in terms of
boundaries and internal features.
2. Describe the constrictor and vertical muscles of the pharyngeal wall in terms
of attachments, actions, and innervation.
3. Describe the sensory innervation of the three parts of the pharynx.
4. Describe the pharyngeal, palatine and lingual tonsils in terms of blood supply,
venous and lymphatic drainage.
5. Describe the cartilaginous and membranous framework of the larynx - thyroid,
cricoid, epiglottic, and arytenoid cartilages thyrohyoid and cricothyroid
membranes, and vocal ligament.
6. Describe the boundaries of the laryngeal opening, vestibule, ventricles, rima
glottidis, vestibular and vocal folds.
7. Describe the intrinsic muscles of the larynx - cricothyroid, thyroarytenoid,
vocalis, posterior cricoarytenoid, lateral cricoarytenoid, transverse and oblique
arytenoid - in terms of attachments, actions, and innervation.
8. Describe the sensory innervation and blood supply of the larynx.
257
Buccinator
Pharyngeal
constrictors
Superior
Raphe
Middle
Inferior
Stylopharyngeus
Thyropharyngeus
Cricopharyngeus
Pharyngeal constrictors
Pharynx
A. Pharyngeal constrictor muscles
1. circular skeletal muscles of pharynx
2. all attach posteriorly to median pharyngeal raphe
3. superior constrictor muscle
a. attaches posteriorly to pharyngeal tubercle of occipital bone
b. attaches anteriorly to pterygomandibular raphe
c. auditory tube passes above muscle
4. middle constrictor muscle
a. attaches anteriorly to hyoid bone
b. stylopharyngeus, glossopharyngeal nerve, stylohyoid ligament pass above
5. inferior constrictor muscle
a. attaches anteriorly to thyroid and cricoid cartilages
b. internal laryngeal nerve and superior laryngeal vessels pass above
6. innervation mainly from X via pharyngeal plexus plus external laryngeal
nerve (X) to lower part of inferior constrictor
258
Tensor veli
palatini
Levator veli
palatini
Salpingopharyngeus
Superior
constrictor
Palatopharyngeus
Stylopharyngeus
Pterygomandibular
raphe
Middle
constrictor
Stylohyoid
ligament
Deep view of pharyngeal muscles

B. Vertical pharyngeal muscles
1. all insert into wall of pharynx and serve to shorten/elevate pharynx during
swallowing
a. salpingopharyngeus from torus of auditory tube
b. stylopharyngeus from styloid process
c. palatopharyngeus from aponeurosis of soft palate
2. innervation
a. salpingopharyngeus and palatopharyngeus from X via pharyngeal plexus
b. stylopharyngeus from IX
259
Pharyngeal
tonsil
Opening of
auditory tube
Palatine
tonsil
Nasopharynx
Soft palate
Oropharynx
Epiglottis
Lingual
tonsil
Vestibule
of larynx
Laryngopharynx
Lamina of
cricoid
cartilage
Esophagus
Divisions of pharynx
C. Divisions of pharynx
1. nasopharynx
a. area posterior to nasal cavity that extends inferiorly to level of soft palate
b. lateral walls have opening of auditory tube surrounded by raised torus
c. levator and tensor veli palatini lie laterally
2. oropharynx
a. from soft palate to level of superior tip of epiglottic cartilage
b. includes valleculae and lingual tonsil anterior to epiglottis
c. opens into oral cavity at palatoglossal arch
d. palatine tonsils lie between palatoglossal and palatopharyngeal arches
3. laryngopharynx
a. from tip of epiglottic cartilage to inferior border of cricoid cartilage
b. has laryngeal opening anteriorly into vestibule of larynx
c. continuous inferiorly with esophagus
c. piriform recesses lie anterolaterally
a. nasopharynx by V2 and IX (via pharyngeal plexus)
b. oropharynx and upper laryngopharynx from IX (via pharyngeal plexus )
c. lower laryngopharynx from X (via pharyngeal plexus)
d. piriform recess by internal laryngeal (X) and recurrent laryngeal (X)
260
Pharyngeal
tonsil
Vallecula
Torus of
auditory tube
Soft palate
Palatoglossal
arch
Palatine tonsil
Palatopharyngeal
arch
Lingual tonsil
Epiglottis
Tonsils
D. Tonsils
1. pharyngeal
a. lies on posterosuperior wall of nasopharynx
2. palatine
a. lie on lateral wall of oropharynx in depressed tonsillar bed
b. palatoglossal arch lies anterior and palatopharyngeal arch lies posterior
c. primary arterial supply is tonsillar branch of facial in tonsillar bed
3. lingual
a. lies on posterior aspect of tongue in oropharynx
261
Epiglotti
s
Thyrohyoid membrane
Thyroid
Arytenoid
Vocal
ligament
Cricothyroid
ligament
Anterior view
Cricoid
Midsagittal view
Laryngeal cartilages
Larynx
A. Cartilaginous framework
1. epiglottic cartilage
a. mobile laryngeal cartilage that helps protect laryngeal opening
b. vallecula is space between epiglottis and base of tongue
2. thyroid cartilage
a. largest cartilage forming laryngeal prominence anteriorly
b. open posteriorly
c. attached to hyoid bone by thyrohyoid membrane
3. cricoid cartilage
a. complete ring of cartilage with tall lamina posteriorly
b. attached to thyroid cartilage by cricothyroid membrane and two
synovial joints
4. arytenoid cartilages
a. pyramidal cartilages attached to cricoid lamina by synovial joints
b. have vocal process anteriorly and muscular process laterally
262
Soft
palate
Palatine tonsil
Palatopharyngeal
arch
Inferior
constrictor (cut)
Epiglottis
Aryepiglottic fold
Piriform recess
Lamina of cricoid
Posterior view of larynx with pharynx opened

B. Laryngeal opening
1. surrounded by epiglottis anteriorly and aryepiglottic folds posterolaterally
a. folds form, with lateral wall of laryngopharynx, channels from epiglottis
through piriform recess to esophagus
b. food normally passes along channels during swallowing
263
False vocal fold

Rima glottidis
Closed glottis
Vocal fold
Aryepiglottic fold
Vestibular fold
Vocal fold
Vestibule
Cricoid cartilage
Sagittal section of larynx; glottis

C. Laryngeal mucosa folds and spaces
1. aryepiglottic fold
a. fold of mucosa over aryepiglottic muscle
2. vestibular fold
a. lies superior to vocal fold
3. vocal fold
a. mucosa covering vocal ligament
b. ligament attaches from vocal process of each arytenoid cartilage to deep
surface of laryngeal prominence
c. rima glottidis is slit-like opening between vocal folds
d. glottis is formed by vocal folds and other structures surrounding rima
4. vestibule is that part of larynx superior to the vestibular folds
5. ventricle is bilateral recess between vestibular and vocal folds
a. internal laryngeal from superior laryngeal (X) to mucosa above vocal folds
b. inferior laryngeal from recurrent laryngeal (X) to mucosa below folds
264
Thyroarytenoid
Lateral
cricoarytenoi
d
Transverse &
oblique arytenoids
Posterior
cricoarytenoid
Cricothyroid
Intrinsic muscles of larynx

D. Laryngeal muscles
1. extrinsic
a. suprahyoids elevate larynx
b. infrahyoids depress larynx
2. intrinsic
a. move cartilages relative to one another
b. movement alters tension in, and/or distance between, vocal ligaments
c. posterior cricoarytenoid is only abductor of vocal folds
3. innervation
a. external laryngeal branch from superior laryngeal to cricothyroid
b. recurrent laryngeal to posterior and lateral cricoarytenoid, transverse
and oblique arytenoids, thyroarytenoid, vocalis
265

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Introduction to Gross Anatomy

Teaching Faculty in the Department

SGU Anatomical Sciences

General anatomical concepts

acquiring a three-dimensional visual concept of future patients and their development

SGU Anatomical Sciences

Examination Policies (see the SGU Student Manual)

SGU Anatomical Sciences

SGU Anatomical Sciences

SGU Anatomical Sciences

Posterior projection (A-P projection)

SGU Anatomical Sciences

Geometry of x-ray images

Contrast fluoroscopy image

SGU Anatomical Sciences

Other Techniques That Use X-Rays

Computed Axial Tomography (CT/CAT Scan)

SGU Anatomical Sciences

CT Scan of Liver, Stomach and Spleen

SGU Anatomical Sciences

Internal Carotid Arteriogram

SGU Anatomical Sciences

Right Internal Carotid Angiogram

Angiogram of Abdominal Aorta

Digital Subtraction Angiography

SGU Anatomical Sciences

Additional Imaging Techniques

T1 weighted MRI scan of brain

Magnetic Resonance Imaging (MRI)

SGU Anatomical Sciences

Coronal MRI scan of abdomen and thorax

Sagittal MRI scan of cervical spine

SGU Anatomical Sciences

SGU Anatomical Sciences

SGU Anatomical Sciences

Cross section of spinal cord

SGU Anatomical Sciences

Roots and rami

SGU Anatomical Sciences

Cross section of body wall to show primary rami

SGU Anatomical Sciences

Somatic nerve plexuses

C. Somatic nerve plexuses

SGU Anatomical Sciences

Superficial Back and

SGU Anatomical Sciences

Cross section of body wall

Extrinsic muscles of back

Posterior scapular muscles

SGU Anatomical Sciences

Muscles of the pectoral region

SGU Anatomical Sciences

Deep Back and Spinal Cord

SGU Anatomical Sciences

Bifid spinous process

Regional characteristics and vertebral curvatures

SGU Anatomical Sciences

Facet for anterior

Facets for axis

Atlas and axis

D. Typical intervertebral joints (between C2/C3-L5/S1) and movements

SGU Anatomical Sciences

SGU Anatomical Sciences

Intrinsic muscles of back