Anda di halaman 1dari 58

UPPER LIMB I OSTEOLOGY (1) Clavicle Peculiarities-No medullary cavity, first to start ossification and last to complete ossification,

long horizontal bone has 2 primary centers for ossification; membrane ossification Side Identification (1) Sternal end is round and enlarged (2) Subclavian groove is seen inferiorly (3) Medial 2/3rd is convex forward.

The coracoclavicular ligament is attached to conoid tubercle and trapezoid ridge. It transmits the weight of upper limb The subclavian groove has attachment of subclavius muscle and clavipectoral fascia Applied Importance - most important part prone to fracture is between medial 2/3rd and lateral 1/3rd--lead to drooping of shoulder. - also congenital absence may be there called cleido cranial dyastosis *It is pierced by middle supra clavicular nerve. II SCAPULA

-has 2 surface (costal and dorsal) 3 borders, 3 angles, 3 processes. -3 processes are coracoid, acromion and spinous Side Identification - (1) Glenoid cavity is laterally (2) Spine is backwards - (2)Inferior angle downwards. Vertebrae level- superior angle-T2, spine-T3, inferior angle-T7 Coracoids process- peculiarity atavistic epiphysis -Attachments-coracobrachialis, biceps short head, pectoralis minor, coracoclavicular ligament Suprascapular Foramen has suprascapular artery above and nerve below (AIR FORCE ABOVE, NAVY BELOW) Applied importance - Scaphoid scapula-In this condition medial border of scapulae is cornea - Paralysis of serattus anterior leads to winging of scapulae. Movements are- elevation, depression, pronation, retraction, forward rotation, backward rotation HUMERUS Parts -upper end has head, neck (surgical and anatomical), greater lesser tubercle, intertubercular sulcus (bicepital groove) - shaft- has radial groove, deltoid tuberosity - lower end- has - medial and lateral epicondyel, - Olecranon, coronoid, radial fossa - Trochlea and capitulum Side identification (1) Head lies upwards and medially (2) lesser tubercle lies anteriorly * Greater tubercle has attachments of supra spinatus, infra spinatus, teres minor [sII] * Lesser tubercle- has attachment of subscapularis

* The intertubercular sulcus has long tendon of biceps, anterior circumflex humeral artery * The humerus has 3 necks- surgical, anatomical and morphological. * Nerve related are axillary (to neck), radial (to radial groove) ulnar (medial epicondyel) * 2 lips of intertuberclar sulcus - lateral lip has pect major - Medial lip- Teres major - b/w them- latismus dorsi * Deltoid tuberosity is attachment of deltoid Changes at level of radial groove Medial epicondyle has a separate secondary center of ossification and appears at 5th year. Applied Importance (1) the head of humerus is dislocated inferiorly, usually (2) If there is a fracture between upper 2/3rd and lower 1/3rd of humerus there is delayed reunion due to low blood supply. (3) Major site of fractures are surgical neck, shaft, supracondylar region ULNA - homologous to fibula of lower limb. It has - upper end has colecranon and coronoid process and trochlear and radial notches - Shaft- has 3 BORDERS anterior,posterior and interosseous border. - Lower end-(head)- has head and styloid process. Side identification- (1) upper end has trochear notch. (2) The styloid process lies medially (3) Olecranon process is anteriorly The olecranon process has attachments of triceps, flexor carpi ulnaris, anconeus, ulnar collateral ligament, flexor degitorum profundus. Thestyloid process- has attachment of ulnar collateral ligament and extentor retinaculum. Applaied Importance In middle of radius and ulna if there is a fracture there may be crossed union between radius and ulna. Fracture of olcranon is common if there is a fall in point of elbow. RADIUS Parts it has upper end head, neck, Tuberosity (it has attachment of biceps in posterior part) -Shaft-has 3 borders, anterior, posterior and interosseous. -Lower end has styloid process. Side Identification (1) upper end is round and bears a head (2) Styloid process lies laterally (3) Listers tubercle lies possteriorly Radial tuberosity has attachment of biceps and oblique cord. Inferiorly it articulates with lunate (medial quadrangular part) and with scaphoid (lateral triangular part) The Listers tubercle lies inferiorly and is related medially to tendon of extensor pollicis longus and laterally to extensor carpi radialis longus and bravis Styloid process has attachment of lateral carpal ligament and beacheo radialis Applied importance (1) cooler fracture (2) smiths fracture (3) dislocation of head of humerus from annular ligament leads to pulled elbow.

CARPAL BONES It is arranged in 2 rows Proximal row (lateral to medial) - scaphoid, lunate, triquetral, pisiform. Distal row - trapezium, trapezoid, capitate, hamate (1) Saphoid It is boat shaped - Facture of it can lead to avascular necrosis leading to non union - Its lateral end at distal part has a tubercle that has attachment of flexor retinaculum, abductor pollicis longus bravis, lateral ligament (2) Lunate semilunar in shape. (3) Triquetral- pyramidal / wedge shaped (4) Pisiform pea shaped, it is sesamoid bone in flexor carpi ulnaris. Smallest of carpel bones. The pisiform will be completely formed only at age of 12.So that in x-ray age can be determined (5) Trapezium It has a crest and a groove. The groove lodges the tendon of flexor carpi ulnaris (6) Trapezoid boat shaped (7) Capitate has a head, largest of carpal bones (8) Hamate wedge shaped, has a hook like process - The hook has attachment of flexor retinaculum and forms medial boundary of carpal tunnel METACARPAL -5 in number they are short long bones - It has a head, base and a shaft. The head forms the knuckles. PHALANGES 14 in number also has a base (proximal) shaft and head (distally) BREAST- ESSAY They are located in both sides in pectoral region. They are hemispherical pendular with a constant circular base It is a modified sweat gland and a tubuloalveolar gland It extends vertically from 2nd to 6th rib and horizontally from lateral border of sternum to mid axillary line in the 4th rib (A) Mammary Bed It is the substance on which the gland lies. - It is made of medial 2/3 rd by pectoralis major, lateral 1/3 rd- by serratus anterior and the infero medial quadrant by external oblique (B) Retro mammary Space -lies between gland and mammary beds fascia is filled by loose areolar tissue. If it is filled by cancerous cells it leads to fixity of gland breast caner. (C) Nipple They are conical projection below the centre at the 4th intercostals space. They are pierced by 15-20 lactiferous ducts. It has circular and longitudinal muscles. The circular muscles(help to

erect the nipple for sucking) while the longitudinal muscles helps in retracting the nipple. They have a rich verve supply of sensory receptors (D) Areola Pigmented outer region around nipple. It has numerous modified sebaceous glandscalled Tubercles of Montgomery. *the skin of areola and nipple has no hair /subcutaneous fats. (E) Structure of Breast The gland has a capsule, glandular tissue(parenchyma), fibrous part (stroma) (a)*glandular tissue is made of 15 20 pyramidal lobes, each with a repeated duct. Each lobe is a cluster of alveoli and drained by lactiferous duct. The aleveolar duct is cuboidal in resting stage and columnar in secreting stage *myoepitheliocytes are cells in alveoli and ducts b/w epithelium and basement membrane, that fascilitates passage of milk from alveoli to nipple. (b) Fibrous tissues support the lobes. -suspensory ligaments of cooper are fibrous septae that arches the skin and gland to the pectoral fascia. (F) ARTERIAL SUPPLY -Upper part by superior thoracic and thoraco acromion artery - Lateral part by lateral thoracic artery - Medial part by perforating arteries of internal thoracic artery. The deep surface is supplied by lateral branch of intercostal artery (G) Venous Supply -Around the areola by circulero venosus - Lateral part by internal thoracic artery - Upper part by posterior intercostal artery via it, there is communication to the Batsons plexus and through it to the brain (H) Nerve supply - It is by anterior cutaneous branches of 4-6th intercostal nerves .It has no nervous conted over the execution (12) Lymph drainage The main lymp nodes are - axiliary has 5groups anterior along lateral thoracic artery -Posterior along subscapsular vessel -Lateral along axillary vein -central along upper part of axilla -apical- very deep - internal mammary-parasternal -supra clavicular *Drainage- superficial(except nipple and areola)-corresponding sueperfical lymph nodes of corresponding region - deep -75%- goes to axillary nodes mostly to anterior group central and lateral group apical group supra claviculargroup -some to posterior group -25%-internal mammary -5%- to posterior intercostal nodes

(13) Development Breast develop from an ectodermal ridge called mammary ridge /milkline (it extended from axilla to the groin). It appears in 4th week of intra uterine life. Later most of it disappears and they are retained only in the pectoral region called mammary pit. Secondary bud grows from floor of pit and they divide into small divisions. Nipple is everted at times of birth From birth puberty they are similar in male and females. At puberty there is secretion of esliogen Cholestrum is the first milk coming out of the breast.It is rich in fat, immuno globulins and poor in nutrition In lactation , the alveoli gets distended 5-6 months after lactation, it starts diminishing the secretion and after nine months it stops secretion Witches milk the milk secreted by infants breast due to influence of maternal estrogen. (14) Hormones influencing breast (1) Estrogen favours growth of lactiferous duct and the breast (2) Progesterone important in formation of alveoli (3) Prolactin and G H important in producing milk (4) Oxytocin- important in ejection of milk (15) Applied importance (1) If the malignancy is in upper outer quadrant then safe removal is possible In this case pectoralis major, minor, and axillary lymph nodes are removed (2) There may be secondary deposits sites of tumour eg: in other breast/in ovary, liver, bone, brain etc (3) Fibroadenoma- breast mouse (4) If there is discharge of blood from breast then there is infection of breast (5) In case of malignany, there is retraction of nipple and peau de orange appearance. There is edema of skin and sebaceous glands appear to be retracted BRACHIAL PLEXUS The brachial plexus is for med by the union of nerves of upper limb. (1) Formation It is for med by ventral rami of lower 4 cervical nerves and upper, thoracic nerve Anterior rami Trunk Division Cord Branches.

C5 upper A- lateral cord C5 upper p- posterior cord C6 upper A- lateral cord C6-upper p- posterior cord C7 lower A- lateral cord C7 lower - P- posterior cord

C8 middle A- medial cord C8 middle P- posterior cord T1- middle - A- medial cord T1- middle - P- posterior cord *Erbs point It is a point where 6 nerves meet . (Anterior rami of C5, C6, suprascapular N, nerve to subclavius, anterior and posterior division of upper trunk) - It is the region where there is maximum strech. The five stages in formation of Bracheal plexus are root, trunk, division, chord, branches, (in the post ale)( behind clavicle) (In axilla ) There may be also variations .eg: It may be prefixed (that has large contribution from C4 )or may be post fixed (if there is a large contribution from T2 but less fromC5). (2) Relations (a) of root and trunk related to posterior triangle, platysma, subclavian artery (b) of the division related to subclavian artery and vein (c) of cords and branches 1st part lateral and posterios cordd lies lateral to 1st part of axillary A while medial cord lies posteriorly - 2nd part- lateral cord lies lateral , while medial cord lies medial and posterior cord lies posterior to the axillary artery (3) Branches (a) supra clavicular branches (1) from root N to serratus anterior (C5,6,7), N to latismus dorsi (C5) (2) from trunk suprascapular nerve (C5,6),N to subclavius (C5,6) (b) infra clavicular branches (1) of lateral cord lateral pectoral N, musculocutaneous N, lateral root of median N. (2) medial cord Ulnar N, medial root of median nerve, medial pectoral N Medial cutaneous N of arm, medial cutaneous N of fore arm (3) Of posterior cord upper subscapular N, lower subscapular N, N to latismus dorsi , axillary N, radial N. CLINICAL IMPORTANCE (1) ERBS PALSY due to widening of angle b/w neck and shoulder - arm shows waiters tip (arm and shoulder abducted, Fore arm pronated , elbow extended, fore arm rotated) (2) Klumpkes paralysis lowes part of Brachial plexus is affected (3) If there is injury to the root along with paralysis of muscles Horner syndrome (sympathetic syndromes) are also seen (4) Cruchs paralysis / saturday night paralysis radial N affected :wrist drop is seen (5) Cervical rib due to extension of transverse process of C7 lead to Cervical Rib sydrome leads to pressure on the brachial plexus

AXILLA It is shallow 4 sided pyramidal structure between upper part of thoracic wall and upper part of arm. *(1) parts it has an apex , base and 4 walls (anterior, posterior medial and lareral wall ) (1) apex- is continuous with the neck by the cervico axillary canal. (2) Base directed downwards and forwards formed of skin and fascia (3) Arterior wall is formed of skin, superficial fascia , deep fascia, pectoral muscles (4) Posterior wall is formed of posterior axillary fold, lateral part of subclavius latismus dorsi , teres major . (5) Medial wall by upper 4 ribs, intercostals muscles, serratus anterior (6) Lateral wall it is narrow intertubercular sulcus made of biceps and coracobrachialis The space b/w pectoralis major and clavicle is called clavepectoral fascia It is pierced by medial pedtoral N ,cephalic V, thoracoacromial artery . *(2) Contents - Axillary artery , axillary vein, infra clavicular part of brachial plexus lymph nodes and vessels, long thoracic nerve, axillary tail of Spence of breast in case of females. AXILLARY ARTERY -continuation of subclavian artery *right subclavian artery arises from bracheo cephalic artery where left subclavian artery arises from arch of aorta. - It extends from outer border of 1st rib to lower border of teres major. It continues as brachial artery (1) Surface marking (1) mid point of clavicle (2) midpoint of epicondyles of humerus in cubital fossa draw a line joining these 2 points with the arms abducted The upper 1/3 rd represent axillary artery while lower 2/3rd represents brachial artery (2) parts - divided in to 3 by the pectoralis minor . (a) part 1 [proximal to pectoralis minor ] Relations - Anteriorly to skin, superficial fascia, platysma, medial surpraclavicularN, clavicular part of pectoralis major, clavipectoral fascia, communication b/w medial and lateral pectoral nerve - Posteriorly 1st intercostal space, 1st two digiations of serratus anterior, N to serratus anterior, medial cord of brachial plexus - Lateral lateral and posterior cords of brachial plexus - Medial to axillary vein

(b) part 2 [ below pectoralis minor ] Relation - anterior skin, deep and superficial fascia, pectoralis -posterior upper part of subclavius, postior cord of brachial plexus - lateral lateral cord of beachial plexus, short head of biceps, coracobrachialis - medial axillary V, medial cord of brachial plexus. (c) part -3-[distal to pectoralis minor] Relations anterior skin, superficial fascia, pectoralis major - posterior lower part of subscapsularis, posterior cord, teres major. - medeal axillaery V, medial cutaneous N of arm - lateral branches of lateral cord of Brachial plexus, coracobrachialis, short head of biceps. (3) Branches *of the 1st part superior thoracic artery *of 2nd part (a) Thoracoacromial artery pierces clavipectoral fascia an divides into pectoral, acromial, clavicular and deltoid branches (c) Lateral thoracic artery along anterior group of axillary lymph nodes *of the 3rd part (a) Subscapular artery - - largest branch. It gives a branch circumflex scapular artery They are important in anastomosis around scapula. (b) Anterior circumflex humeral artery gives an ascending branch that run along intertubercular sulcus to supply the joint and humerus (d) Posterior circumflex humeral artery larger than anterior circumnflex humeral A. It accompanies axillary N. They anastomose with anterior circumflex humeral artery. It also gives a descending branch that anastomose with profunda brachis ascending branch (4) axillary vein - It is the continuation of basillic vein . It lies medial to axillary artery - at the outer border of 1st rib- it becomes subclavian vein - it also recreive cephalic vein - It has no axillary sheath around it.So that it is free to expand in cases of increased blood flow (2) Applied importance (a) The axillary artey is compressed against the humerus (in lower part of latetal wall of axilla to decrease the bleeding) (b) The axillary arterys pulsations can be felt as against lower part of lateral wall of axilla (c) Axilla has hair and sebaceous gland. So that infections and boils are commom here.

THE BACK The junction between head and neck is external occipetal protuberence The cutaneous supply is by 12 thoracic nerve and 5th sacral nerve. The posterior rami of these divide into medial and lateral branches and supply the back. The man muscles of the back include trapezius, latismus dorsi, levator scapulae, rhomboidus major and minor. (1) Trapezius Origin from medial 1/3rd superior nuchal line, external occipital protuberence, ligamentum nuchae, C7 spine, T1-T12 spine Insertion Upper fibres (from posterior border of lateral 1/3rd of clavicle), middle fibres (medial margin of acromion), lower fibres (to deltoid tubercle). Nerve supply spinal accessory motor supply, and C3,4 is proprioceptive (2) latismus dorsi Origin posterior 1/3rd of outer lip of iliac crest, posterior layes of outer layer of lumbar fascia, T7 T12 spine, lower 4 ribs, inferior angle of scapula. Insertion it winds around lower borrder of teres major, form a tendon and inseted into intertubercular sulcus Nerve supply thoraco dorsal nerve. (3) levator scapulae origin transverse process of C1, C2, posterior tubercle of transverse process of C3,C4 insertion superior angle and upper part of medial part of scapula nerve supply branch of dorso scapular N, propriorceptive is by C3 C4 (4) rhomboidus major origin lower part of ligamentum nuchae, spine of C7- T1 Insertion to base of a triangular aera at root of spine of scapula. Nerve supply dorsal scapular nerve. (5) Rhomboidus minor Origin spine of T2 T5, supraspinous ligament Insertion medial border of scapula below root of spine. Nerve supply dorsal scapular nerve. Axillary Arch - it is a muscular slip from edge of latismus dorsi. It crosses the axilla ( in front of vessels and nerves ) and joins tendon of pectoralis major, coracobrachialis

* Triangle of ausculatation medial by lateral border of trapezius lateral medial border of scapulae inferiorly upper border of latismus dorsl floor by 7th rib , 6th 7th intercostal spaces. - this is only part of back that is not coverd by muscles : Respiratory sounds and sounds of swallowing liquids can be heard on ausculatating here Triangle of Petit

It is bounded medially by lateral border of latismus dorsi - lateral by posterior border of external oblique - inferiorly illicac crest It is associated with lumbar hernia SHOULDER JOINT It is a multi axial ball and socket type of syunovial joint (1)Articular ends Proximally glenoid fossae and goenoid labrum covered by hyaline cartilage. Distally head of humerus 4 times the size of glenoid cavity (2) Ligaments (a) Capsule Attached medially to rim of glenoid labium larerally to anatomical neck of humerus - superiorly and inferioly also to anatomical neck of humerus *The capsule is supported by the muscle sapraspinatus, infraspinatus, teres minor subscapulris [SITS]. This form rotator cuff / musculo tendninous cuff It has two openings (1) anteriorly below coronoid procese (2) for long tendon of bicep (b) Seproral membrane lines inner suface of capsule. It secretes synovial fluid (c) Gleno humeral ligament - has three parts superior from anterior part of margin of glenoid cavity - middle just belwo the origin of superior part to margin of lesser tubercle - inferior from antero inferior part to the neck (d) Coraco humeral ligament- from the coracoid process to greater tuberlce (e) Transverse humeral ligament b/w 2 tubercles it holds tendon of long head of biceps (f) Coraco acromial ligament has conoid and trapezoid part (3) Bursae Mainly 3 subscapular b/w tendon of subscapularis and capsule - infraspinatus b/w infraspinatus and capsule

(4) Relations


(1) above coracoid process ,acromion, coracoacromial ligament (2) below long head of bices, posterior cirumfiex humeral A, axillary N (3) anteriorly subscapularis (4) posterior infraspinatus , teres minor (5) blood supply by anterios cirumflex humeral artery, posterior cirumflex humeral artery circumflex scapular artery, supra scapular artery (6) Nerve supply Axillary N, suprascapularN, lateral pectoral N. (7) Movements The main movement are flexion, extension, abduction, adduction , medial rotator lateral rotator and also cirumflexion *for every 15 degree elevation (i.e abduction) 5 degee is by movement of scapula 10 by the movement of shoulder joint The abduction of 15-30 degree is by the supraspinatus , 30 90 by deltoid 90180 by trapezius and serratus anterior flexion by pectoralis major , deltoid , biceps extension by posterior fibres of deltoid , latismus dorsi adduction pectoralis major, teres major, latismus dorsi lateral rotation by deltoid, infraspinatus, teres minor medial rotation pectoralis major, latismus dorsi (8) Applied Importance (a) Dislocation of humerus usually it will be anterior/ inferior dislocation (b) Recurrent dislocation due to laxity of Rotator cuff (c) Supra spinatus tendinitis inflammation of tendon:So that there will be severe pain on abduction between 60 and 120 degree and after 120 degree/there is no pain called Daw Burns Sign (d) Injury to spinatus tendon head of humerus may be displaced downwards.

THE ARM It extends from shoulder to the elbow joint FRONT OF ARM Medial epicondyle is best seen and felt in mid prone position Brachial artery seen medial to tendon of biceps pulsations are felt here *(1) Compartments of Arm

- By medial and lateral intermuscular septae, arm is divided to anterior and posterior compartment - These septae provide attachment to muscles - These septae also provide plane along with nerve and vessels pass - The medial septea is peirced by ulnar N and superior ulnar collateral ligament - Lateral septae is peirced by radia N and anterior descending branch of profunda brachi artery - There is also a transeverse septae (seperate biceps from brachialis ) and an anterior posterior septae *(2) Muscles of the Arm (a) Coracobrachealis oriin from lip of coacoid process inesrtion to middle 5cm of medial border of humerus N.S musculo cutaneous N * It represents medial compartment of arm. (b) Biceps- origin short head- from tip of coracoid process - long head supraglenoid tubercle of scapula - Insertion posterior rough part of radial tuberosity and froms bicepital aponeurosis and merge with deep fascia of fore arm - Nerve supply musculo cutaneous N (c) Brachial origin from lower half of front of humerus and medial / and lateral inter tubercular septae - Insertion- to ulnar tuberosity and rough anterior surface of coronid tuberosity of ulna Nerve supply motor supply by musculo cutaneous N - proprioceptive- radial N N S- by radial N. (e) Triceps- origin long head from infra glenoid tubercle of scapula lateral head from oblique region from upper part of post sugace of humerus medial head medial alar area in humerus insertion to posterior surface of cutaneous process below radial groove

*(3) Musculo Cutaneous Nerve - Main N of arm and it is a branch of lateral cord(C5-C7) (A) Surface marking (a) a point lateral to axillary artery (3cm above the termination ) (b) a point lateral to tendon of biceps brachi (B) Coure and relations anteriorly to pectorlis major * in lower part of axilla it is related posteriorly - subscapularis medially axillary A, lateral root N of medianN lateral- coracobrachialis It then peice coracobrachialis and enters the arm

In arm it run downwards and laterally b/w biceps and brachealis to reach lateral side of tendon of biceps pierce deep fascia.

(C) Branches and Distribution Musular coracobrachialis , biceps, brachialis Cutaneous- lateral cutaneous N of fore arm Articular branches supply the elbow Also communicating branches to superior branch of radial N, posterior cutaneous N of fore arm, cutaneous branch of medial N Sometime it may get fibres from median nerve. *(4) Brachial Artery It is the continuation of axillary artery. It starts from lower bordes of ters major to a point in front of elbow (at level of neck of radius). (a) Surface marking (1) a point at junction of anterior 1/3rd and posterior 2/3rd of lateral wall of axilla at its lower limit (2) at neck of radius medial to tendon of biceps brachi (b) Course and relations *It runs dounwward and laterally from medial side of arm to front of elbow It is superficial through out its extends and it is accompanied by two venae Commitants. Anteriorly it is related to medial cutaneous N of arm and in its middle part it is crossed by median N from lateral side to medialside and in front of elbow related to bicepetal aponeurosis and median cubital vein Posteriorly related to triceps, radial N, profunda brachi Medially- ulnar N , basillic V median nerve Laterally related to coracobrchealis , biceps median N, tendon of biceps (c) Branches (1) Profunda brachi- accompany nadial N (2) superior ulnar collateral A accompary ulnar N (3) inferior ulnar collateral/supra trochlear artery (4) nutrient artery to humerus (5) terminal brnaches- radial and ulnar artery (d) Clinical Importance (1) Brachial pulsations are auscultaed medial to tendon of biceps (2) Bracial artery is compressed in middle of arm ,where it lies on coracobrachialis *(5,) Anastomisis Around Elbow In front of lateral epicondyle - anterior descending (radial collateral branch) of profunda brachi anastomose with radial recurrent banch f radial A Behind lateral epicondyle- posterior descending artery anastomose with inerosseous recurrent branch of posterior interosseous artery In front of medial epicondyle inferior ulnar collateral A anastomose with anterior ulnar recurrent branch of ulnarA

Behind medial epiondyle Superior ulnar collateral A anastomose with posterior ulnar recuerrent branch of ulnarA *(6)Profuda Brachi Artery It is a large branch arising from below teres major. They accompany the radial N through radial groove. And before peircing the lateral intermuscular septae they divide into anterior and posterior descending branches Branches *Radial collateral / anterior descending continuation of profunda brachi. It accompanies radaial N *Posterior descending largest terminal branch. It accompanies N to anconeus *Deltoid branch ascend b/w long and lateral head of triceps *Nutrient A- are in radial groove. Inter muscular Space ` There are 3 intermuscurlar spaces in scapular region (1) Quadrangular space superior- subscapularis, teres minor. Boundariesinferior- teres major medial long head of triceps lateral surgical neck of humerus Contents - axillary N, posterior cicumflex humeral A (2) Upper triangular space Medially teres minor Boundaries . Laterally long head of humerus Inferior teres major Contents circumflex scapular A. It anastomose with suprascapular artery (3) Lower triangular space medially- long head of triceps Boundarieslaterally medial border of humerus superiorly teres major

Contents radial N, profunda brahi vessels.

ANASTOMOSIS AROUND SCAPULA By (a) Suprascapular artery branch of thyrocerviclal trunk (b) Deep branch of transverse cervical A branch of thyrocervical trunk (c) Circumflex scapular artery branch of third part of axillary A - It is the anatomoses b/w 1st part of subclavian A and 3rd part of axillary artery. (3) Anastomosis around Acromion - by acromial branch of thoraco acromial artery, suprascapular A and posterior circumflex humerl artery Clinical Importance They provide collateral through which blood can pass when distal part of axillary A is blocked CUBITAL FOSSAE It is a triangular hollow in front of elbow. It is homologous to popliteal fossae Lateral to medial border of brachio radialis Boundaries Medial lateral border of pronator teres Base by an imaginary line joining 2 epiondyles of humerus Apex directed forwards formed by meeting point of lateral and medial boundaries Roof of skin , superficial fascis [having medial cubital vein, lateral cutaneous N of forearm and medial cutaneous N of forearm], deep fascia, bicepital aponeurosis

* Contents from medial to lateral (1) Median N gives branch of flexor carpi radialis , palmaris longus, flexor digitorum superficialis and leave the fossa b/w 2 head of pronator teres (2) Brachial A it divides here into radial and ulnar artery (3) Tendon of biceps and bicepital aponeurosis (4) Radial N and radial collareral A- It lies in gap b/w brachialis medially and brachio radialis and extensor carpi radialis laterally. *Applied Importance -Medial cubital vein is used for IV injections

- Brachial artery in cubital fossa is used to find B.P ELBOW JOINT It is a synovial joint of hinge variety (1) Articulating surfaces (2) LIGAMENTS (a) Capsule- Superiorly attached to lower end of humerus [trochlea, radial fossae, coronoid fosas, olecranon fossae are intra capsular] - Inferiorly medially attached to margin of trochlea an laterally attached to annular ligament of superior radioulnar joint. (b) Anterior and posterior ligament - They are thickening of the capsule (c) Ulnar collateral ligament - It is a triangular ligament with the apex attached to the medial epicondyle of humerus and base of ulna It has an anterior and posterior bands attached to conoid process and to the olecranon. The lower ends of thick 2 bands are joined by an oblique band This ligament is crossed by ulanar N Radial collateral ligament It is a fan shaped ligament extending from later epicondyle to the annular ligament. (3) RELATIONS Anteriorly brahialis, median N, brachial artery, tendon of biceps Posteriorly triceps , anconeus Medially- ulnar N, flexor carpi ulnaris, common flexors Laterally supinator- extensor carpi radialis bravis, other extensors (4) BLOOD SUPPLY - By anastomosis around elbow (5)Nerve Supply - By radial N, ulnarN, median , musculocutaneous nerve (6) MOVEMENTS -Flexion brachialis, biceps, brachioradialis. - Extension triceps, anconeus (7)Carrying angle The extended forearm makes an angle of 163 with the arm. This angle is called the carrying angle. It disappears in full flexion and during pronation Upper capitulum and trochlea of humerus Lower upper surface of head of radius with capitulum and trochlear notch with ulna

The factors responsible for carryig angle are (a) Medias flage of trochlea is 6mm deeper then lateral flage (b) sSuperior articular surface of conoid process of ulna is oblique. (8) Applied Importance (a) There is dislocation of joint, usually there is posterior dislocation (b) Subluxation of head of radius lead to pulled elbow. Seen in childern when the forearm is pulled in the pronated position Inner elbow is produced due to abrupt pronation lead to pain in the lateral epicondyle. This is dueto spasm of radial collateral ligament (d) Students elbow- due to inflammation of base over the subcutaneous posterior surface of olcranon process AXILLARY NERVE Ithas root value C5, 6 and supplies deltoid, It arises from posterior cord of brachial plexus. (1) Surface marking It is marked by a horizontal line on deltoid 2cm above midpoint between tip of olecranon and the insertion of deltoid (2) Course In lower part of axilla it lies behind 3rd part axillary artery and is related medially to median N and laterally to coracobrachialis The nerve wind around lower border of subscapularis to enter quadrangular space and is accompanied by posterior circumflex humeral artery Anterior branch Accompanied by posteriors circumflex humeral and wind around the surgical neck and supply deltoid and skin over it Posterior branch- supply teres minor, posterior part of deltoid - the nerve to teres minor has a psuedoganglion. - It peirces deep fascia at lower part of posterior border of deltoid and it contiues as lateral cutaneous N of arm (3) Branches - Musclular to deltoid and teres minors - Cutaneous upper lateral cutaneous never of arm - Articular to the shoulder joint from the main trunk of axillary N - Vascular gives sympathetic to the posterior circumflex humeral artery. (4) Clinical Importance - Axillary N is damaged by dislocation of shoulder or by fracture of surgical neck of humerus - It leads to paralysis of deltoid:And round contour of shoulders is lost and there will be sensory loss over lower half of deltoid ANTERIOR OF FOREARM AND HAND _ Has 8 muscles (5 superficial ,5 deep) - 3 neeves median ulnar, radial - 2 arteries radial and ulnar

* The posteriors surface of medial epicondyle is crossed by ulnar nerve. Pressure on the nerve produce tickling sensations on medial side of hand * The styloid process of radius projet 1cm lower than styloid process of ulna (1)* Superficial muscles all these muscles rave common flexor origin From lateral to medial - Pronator teres, flexor crapi radialis, Palmaris longus, flexor digitorum superficialis flexor crapi ulnaris Pronator teres origin- humeral head from medial epicondyle - ulnar head from medial margin of coacoid process of ulna Nerve supply is by median never [the median N lies b/w two heads of pronator teres] * All muscles are supplied by median nerve except flexor carpi ulnaris which is supplied by ulnar N * Piriformis is a sesamoid bone on flexor carpi ulnaris. By the pissohamate ligament the pull of the muscle is transfered to hook of hamate. * Flexor digitorum superficialis is also called sublimes. It divides into four tendons into medial 4 digits and attached to middle phalanx of these fingers . (2) Deep Muscles of Forearm - Three muscles-flexor digitorum profundus, flexor pollices longus, pronator teres. The flexor digitorum profoundus has its medial half supplied by ulnar nerve while lateral half is supplied by anterior interosseous nerve. The other 2 muscles are supplied by anterior interossous nerve (3) Radial Artery Surface marking (1) point in front of elbow at level of neck of radius medial to tendon of biceps. (2) A point in crest b/w radius laterally and flexor carpi radialis medially * Course in Fore Arm - Smaller branch and has a concave course. Then they leave the fore arm and go to the anatomical snuff box. Relations anteriorly- brachio radialis [upper part] in lower part of only skin and fascia - posteriorly biceps, supinator, pronator teres, radial origin of flexor digitorum superficialis and flexur pollices longus,pronator quadratus - medially upper 1/3rd pronator teres, lower 2/3rd flexor capi radialis - Laterally brachio radialis, radial N. Branches in forearm Radial recurrent anastomose with radial collateral artery - Muscular branches to the muscles of forearm - Palmar carpal branch- ends in anatomosing with palmar carpel branch of ulnar A- supply bancs of wrist bones - Superficial palmar branch- It gives the branch before leaving the forearm. It supplies the thenar eminence and join with terminal branch of ulnar A- to complete superficial palmar arch * Course and Relations in Arm

It passes through anatomical snuff box to enter proximal end of 1st interosseous space. Then passs between two heads of 1st dorsal interossi and then b/w two heads of adductor pollices and continues are deep palmar arch of palm. Branches in dorsum of hand to lateral side of dorsum of thumb - 1st dorsal metacarpal artery Branches in palm- princeps pollices- divide into two and supply proximal phalanx. - Radialis indices supply lateral side of index finger. It continues as the deep palmar arch. * Applied Importance Radial artery is used for radial pulsations in forearm. (4) ULNAR ARTERY (1) Apoint in front of elbow at level of neck of redius Surface marking: (2) junction b/w upper 1/3rd and lower 2/3rd of medial border of arm (3) Lateral to pissiform Its upper 1/3rd is oblique, and lower 2/3rd is vertical.

Course and Relations It is the largest terminal branch of brachial artery and runs in forearm and enters the arm superficial to flexor retenaculum. Relations lateral- flexor digitorum superficialis - medial ulnar N, flexor carpi ulnaris - posterior flexor digitorum profundus - anteriorly pronator teres, flexor carpi ulnaris, palmaris longus, flexor digitorum superficalis in lower part of artery it is superficial Branches (1) anterior and posterios ulnar reccurrent important in anastomosis around elbow (2) common interosseous artery arises below radial tuberosity and in the upper border of interosseous membrane divide into anterior and posterior interosseous artery (a) anterior interosseous artery It is the deepest artery in front of forearm. They accompany anterior interosseous nerve. It descends on the surface of anterior interosseous membrane b/w flexor digitorum profundus and flexor pollices longus. It then peirces interosseous membrane at upper border of pronator quadratus to enter extensor compartment. It gives muscular branches to deep muscles of forearm and nutrient artereis to radius and ulna. (b) posterior interosseous artery - supply medial muscles of forearm

(3) muscular branches to medial muscles f forearm. (4) Palmar and dorsal carpal branches takes part is anastomosis around wrist. The palmar carpal branch is important in formation of palmer carpal arch.The dorsal carpal branch and in the dorsal carpal arch. PALMAR ASPECT OF HAND AND WRIST The skin of the palmar aspect is creased immobile and very thick The superficial fascia is of dense fibrous bands which bind skin to the palmar aponeurosis and the superficial fascia devide fat into small compartments. It has a subcutaneous muscle- palmaris bravis The deep fascia has flexor retenaculum, the palmar aponeurosis [in palm] and the fibrous flexor sheaths[in fingers]. (1) Flexor Retinaculum It is a strong fibrous band that bridges the anterior concavity of carpal bones and converts it into a carpal tunnel. Its suface is concaes upwards and is concave downwards attachment medially to pissiform, hook of hamate - laterally tubercle of scaphoid, crest of trapezium. Structures superficial to flexor retinaculum Tendon of palmaris longus, palmar cutaneous branch of ulnar and median N, ulnar vessels and ulnar nerve.[flexor carpi ulnaris is partly inserted to it] Structures deep to flexor retinaculum Flexor digitorum superficialis, flexor digitorum profundus, flexor polices longus, ulnar bursa, radial bursa. Tendon of flexor carpi radialis lies b/w the retinaculum and its deep slip is in groove of trapezium. (2) Palmar aponeurosis - It represent deep fascia of central part of arm. - It covers the superficial palmar arch, long flexor tendon,terminal part of median N and superficial branch of ulnar N. - It is triangular in shape Its apex blends with flexor retinaculum Base- it divides into 4slips opposite the head of metacarpals of medial 4 digits. Each slip divides into two[the digital vessels and N go through this] and is continous with flexor fibrous sheath -It is representing degenerated tendon of palmaris longus - Dupuytrine Syndrome It is inflammation of ulanar side of palmar aponeurosis. i e there is thickening and contraction of aponeurosis:So proximal and middle phalanx are flexed [distal phalanx is less affected]. Usally ring finger is involved. (3) Superficial palmar arch

Normally it begins as terminal branch of ulnar A on the flexor retenaculum distal to pissiform. It crosses the hook of hamate and turns laterally deep to plamar aponeurosis to join one of the branches of radial A. The distal part of arch lies at the same level as distal border of the thenar eminanace when thumb is fully extended. Branches a palmar digital branches - most medial is proper palmar branch to medial side of little finger - others are common palmar branches and they supply by dividing into two and supply radial 3 and fingers. - They form a rich anastomosis in pulp space and the nail bed (4) INTRINSIC MUSCLES OF HAND - 20 in number. - adductor pollices bravis(by medianN) - flexor pollices bravis - opponens pollices - form thenar eminence n abductor digiti minimi flexor digiti minimi opponents digti minimi adductor pollices arises by an oblique head and a transverse head supplied by deep banch of ulnar nerve. palmaris brevis suplied by deep branch of ulnar N - form hypothenar eminence

- Lumbricals 4 in number arising from tendon of flexor digitorum profudus The 1st and 2nd are unipinnate and 3rd and 4th are bipinnate.

- They are inserted into basal digital expansion 1st and 2nd lumbricals are supplied by median nerve while 3rd and 4th by ulnar N - palmar interossi 4 in number they are adductors there are no palmar interossi into middle finger. - Dorsal interossi 4 in number they are abductors also supplied by ulnar nerve * The palmar interossi are adductors and dorsal interossi are abductors of fingers. Applied importance paralysis of intrinsic muscles lead to claw hand i.e hyperextension of metacarpophalangeal joint and flxion of inter phalangeal joint. (5)DEEP PALMAR ARCH It is formed as a direct continuation of radial artery and has a slight convexity to the fingers. It is competed by deep branch of of ulanar artery . It is marked by a horizontal line 4cm long just distal to hook of hamate It lies 1.2 cm proximal to superficial arch and acts as a 2nd communication b/w the radial and ulnar artery

Relations: It lies on proximal part of shaft of metacarpals and on interossi It lies under oblique head of adductor pollices, flexor tendon and lumbricals. Branches 3 palmar metacarpal artery supply medial 4 metacarpels an termainate at finger cleft joining common digital branch of superficial palmar arch 3 perforating artery they pass through medial 3 interosseous space and. anastomose with dorsal metacarpel artery Recurrent branch- they arise along concavity of arch and supply carpal bones and end in plamar carpal branch. BACK OF FORE ARM AND HAND The olecranon process and 2 epicondyles of humerus forms an equilateral triangle when elbow is flexed at 90 degree. [ this gets changed when these are changed ]. Styloid process of radius is 1.25 cm longer than that of ulna. (1) Anatomical snuff box Boundaries anterior tendon of abductor pollices longus , extensos pollices brevis. - Posterior by tendon of extensor pollices longus - Roof scaphoid and trapezium - Limited by syloid process of radius It has cephalic V and radial artery (2) Extensor Retinacula Attachment laterally- lower border of anterior part of radius - medially by styloid process of ulna, triquetral, pissiform Surface marking It is marked by an oblique band directed downwards and medialy [2cm broad]. Laterally- attached to radius and medially to pissiform, triquetral, styloid process of ulna. *The retinacula sends down septae which are attached to long ridges on posterios part of lower part of radius (3) MUSCLES OF BACK OF FORE ARM (1) Anconeus-Supplied by radial N. Th origin is from lateral epicondyle to and inserted to lateral aspect of olecranon process of ulna and upper 1/4th to posterior surface of ulna (2) Brachio radialis- supplied by radial N (3) Extensor carpi radialis longus (4) Extensor carpi radialis brevis (5) Extensor digitorum- the tendon divides into 4 and it divide into 3 at proximal phalanx. The two lateral slip is inserted to dorsal aspect of base of distal phalanx. (6) Extensor digiti minimi- supplied by posterior interosseous N.

(7) Extensor carpi ulnaris (8) Supinator- origin- lateral epicondyle of humerus, radial collateral ligament, annular ligament, supinator crest of ulna. - insertion to upper 1/3rd of lateral surface of radius - nerve supply by posterior interosseous N (9) Abductors pollices longus (10) Extensor pollices longus (11) Extensor pollices brevis (12) Extensor indices Applied importance paralysis of extensor muscles of forearm produce wrist drop [due to injury of radial N at level of origin of posterior interosseous nerve] (4)DORSAL DIGITAL EXPANSION/EXTENSOR EXPANSION They are a small triangular aponeurosis related to tendon of extensor digitorum. * It has covers the metacarpophalangeal joint - The tendon of extensor digitorum occupies contral part of it and is corperated from meta carpo phalangeal joint by a bursae. * The postero lareral corners are joined by tendon of interossi and lumbricals called wing tendons * The corners are attached to deep transveres metacarpel ligament * Near proximal interphalangeal joint, extensor tendon splits into 3. The central slip is attached to dorsum of middle phalanx the other 2 slips joins together and are inserted to dorsum of base of distal phalanx (5) Posterior interosseous artery It is smaller terminal branch of common interosseous artery. It enters the back of forearm passing b/w oblque cord and upper margin of intersseous menbrane. They anastomose with anterior interosseous artery [as lower 1/4th of forearm is supplied by anterior artery. They also give interosseous recurrent artery It is important in anastomosis on back of lateral epicondyle of humerus. (5) Posterior Interosseous nerve Branch of radial N [given with radial nerve]

FASCIAL SPACES OF HAND They are potential space filled with fluid connective tissue Fascial spaces in hand are in palm mid palmar, thenar space, radial bursa, digital synovial sheath, pulpspace of finger. - in dorsum dorsal subcutaneous space and dorsal sub aponeurotic space.

- In lower end of forearm space of parona. * The palmar aponeurosis is attached laterally to anterior border of 1st metacarpel- called lateral septum and medially to medial end of anterior border 5th metacarpal. * The space b/w medial and lateral septum is further divided by a septum into thenar space and a mid palmar space. (1) Thenar space - the boundaries are medially intermediate palmar septum laterally- to lateral palmar septum anteriorly- lateral part of palmar aponeurosis , flexor tendon of index finger, flexor polliceslongus posteriorly transverse head of adductors pollices (3) Mid palmar space Laterally intermediate septum Medially medial septum Anteriorly flexor tendons of medial 3 fingers Posteriorly fascia covering 3 medial metacarpel bones and intervening interosseous muscle. * These spaces extend distally upto proximal crease. When these space are filled with pus, this can lead to infection of lumbrical canal [lumbrical canals are fascial sheaths covering lumbricals] The thenar space is continuous with 1st lumbrical canal while mid palmar space is continuous with 2nd,3rd ,4th lumbrical canal. (4) DIGITAL SYNOVIAL SHEATHS They are fascial sheaths covering the flexor tendon. (4) Radial Bursa The synovial sheath covering flexor pollices longus when it passes through or to fibrous canal. (5) Ulnar Bursa The common synovial sheath of flexor digitorum superficialis and flexor digitorum profundus. Both radial and ulnar bursa decrease the friction under flexor retenaculum (6) The dorsal spaces are dorsal; sub cutaneous space and dorsal sub aponeurotic space. Infections of the dorsal spaces are uncommon (7) Forearm space of Paroma It is a rectangular space related deep to lower part of forearm and just above the wrist It lies in front of the pronator quadratus and deep to long flexor tendons. Superiorly It extend up to oblique origin of flexor digitorum superficialis. Inferiorly It exterend up to flexor retenaculm and communicate with mid palmar and thenar space It may also infected by infections of ulnar bursae. (8) PULP SPACE

- Found in each finger and is filed with fat and they are seperated by fibrous septae attached to periosteum of terminal pnalanges. - Blood supply to distal phalanx pass through this: If there is infecteion then there will be necrosis as blood supply to distal phalanx is affected - Inection of pulp space whitlow / felom. RADIAL NERVE The root value is C 4,5,6,7,8,T1 and is the largest branch of brachial plexus arising from the posterior cord. Course of the nerve and its branches (1) In Axilla It lies behind the axillary artey in the axilla then passes through lower triangular space and is accommpanied by profunda brachi artery. Branches to long head of triceps, medial head of triceps, posterior cutaneous N of arm. (2) In the Arm It enters the arm on the spiral groove [b/w lateral and medial head of triceps] and goes from medial to the lateral side. Then it peirces lateral intermuscular septum and enters the anterior compartment of arm and it lies between brachialis medially and extesor carpi adialis longus laterally. Then they descend down and at the level of lateral epicondyle it divides into superficial and deep branches. * Branches in spiral goove to lateral and medial head of triceps, to anconeus, to elbow joint. cutaneous it is lower lateral cutaneous N of forearm and posterior cuaneous N of forearm . * Branches that occur when it lies b/w brachialis to lateral part of brachealis [ sensory] - to brachioradialis and extensor carpi radialis longus. (3) The superficial branch - It is purely sensory. It passes antrior to pronator teres and behind brachio radialis. In middle of forearm it lies lateral to radial artery. About 7cm from the wrist joint it curves laterally and it gives 5 digital banches- 3 propers and 2 common. * 1 proper to radial part of thumb, other to ulnar side of thumb, 3rd to radial side of index finger. *common digital branches divide into 2 and supply adjacent side of index and middle fingers and others to adjacent side of middle and ring fingers. These nerve supply upto root of nail in thumb up is middle of middle phalanx in index finger and 1st inter phalangeal joint of middle and ring finger. (4) Deep branch / Posterior Interosseous Nerve

- It passes through supinator muscle [b/w superficial and deep strita of the muscles] after peircing the supinor, the branch is called posterior interosseous nerve then it lies b/w superficial and deep extensors of the forearm. At lower end of forearm the nerve passes deep to extensor pollices longus and it is associated with posterior interosseous artery. In wrist it forms a psuedoganglion Branches - before peircing supinator to supinator, extensor carpi radialis brevis - while peircing to supinator - after that- 3 short banches to extensor carpi ulnaris, extensor digiti minimi, extensor digitorum 2 long branches medial to extensor indices, extensor pollices longus lateral to abdutor polliceslongus , and extensor pollices brevis - From pseudo ganglia to wrist joint, inferior radio ulnar joint and inter carpel joints (5) Applied Importance Wrist drop If the radial N injured in spiral groove [ extensor of arm are spared while that of fore arm are affected] lead to wrist drop. Not able to extend the wrist. Crutch palsy due to improper fitting of crutch. This will damage the posterior cord of brachial plexus.

MEDIAN NERVE The root value is C5- T1 Course and Branches (1) In Axilla and Arm In axilla it is formed by 2 roots lateral, from the lateral cored ,and medial root, from the medial cord. First it lies lateral to the artery. In the arm upto the middle it is lateral to axillary artery while in the lower part it crosses the artery in front and goes to the medial side of axillary artery . Branches muscular to pronater teres in lower part of arm - vascular to the brachial artery

(2) In forearm * It passes through cubital fossa b/w 2 heads of pronater teres and then passes deep to fibrous arch of flexor digtiorum supeficialis. Then lies deep to palmaris longus and enter the palm under flexor retinaculum. Branches In cubital fossa- muscular flexor carpi radialis, flexor digitorum superficialis, palmaris longus. - articular to elbow (3) In the palm In palm median N lies medial to muscles of thenar eminence. It also gives cutaneous branch to lateral 3 and finger, their nail beds and skin of distal phalanges on dorsum. Branches muscular abductos pollices brevis, flexor pollices brevis, opponens pollices and 1st two lunbricals. - Cutaneous 2 digital branches to thumb and to lateral side of index finger. - 2 common branches to adjacent sides of middles and ring finger and to adjacent sides of index and middle fingers Applied Importance (1) Carpel Tunnel Syndrome due to dislocation of lunate. - Frutcues are flattening of thenar eminence [ ape like hand ], loss of sensation of lateral 3 and finger., partial clawing of index and ring finger. There is oedema pigmentation of nail, dryness of skin. (2) If injury occurs above the elbow the forearm muscles also affected (3) Median N Responsible for gross movements of finger.So median nerve is called labourers nerve in the forearm- muscular anterior interosseous nerve that supply lateral half of flexor degitorum profundus, superficalis, and flexor pollices longus cutaneous to lateral 2/3rd of palm.

ULNAR NERVE THE ROOT VALUE IS COURSE AND BRANCHES (1) In Axilla and Arm In axilla it lies b/w axillaty vein and axillary artery in a deeper plane. In arm it runs along with brachial artery. In the middle of humerus it peircescls medial inter muscular septum. On the back of medial epicondyle it can be palpated.

(2) In the Forearm They enter forearm b/w 2 heads of flexor carpiulnaris. Then it lies on medial part of flexor digitorum profundus. It is accompanied by ulnar artery in lower 2/3rd. Then it peirces through medial part of flexor retinaculum [above it] and enter the arm. At distal border of retinaculum the nerve splits in to superficial and deep branches Branches muscular medial half of flexor digitorum profundus and flexor carpi ulnaris - cutaneous dorsal cutaneous branch to medial half of hand. - palmar cutaneous branch- to medial 1/3rd of palm. Digital branches to medial 1 and finger - Articular to digital vessels and joints of medial side of hand (3) In the Parm The sperficial branch supply palmaris longus and digital branch to medial 1 and figers Deep branch to the intrinsic muscles. Since it supply intrinsic muscles of hand it is called musicious nerve Clinical Importance The nerve is most commonly injured in the wrist and it leads to motor loss to muscles of arm and sensory loss in medial 1 and finger including nail bed and dorsum of distal phalanges Vascular changes lead to oedema, dryness of skin, friable nails. Trophic changes loss of hypothenar eminence, guttering b/w metacarpals It leads to partial claw hand [however of ulnar N and median nerve injured, it leads to complete claw hand ] * If ulnar N is injured below the elbow clawing of finger is less as medial half of flexor digitorum profundus are also paralysed. So that lead to action of paradax. CUTANEOUS SUPPLY AND DERMATOMES SUPERFICAL VEINS Most of superficial veins join to 2 large veins cephalic[preaxial V ] and basillic V [ postaxially] The superficial veins move away from pressure points The preaxial vein is longers than the postaxial vein. The earlier a vein becomes deep the better, because it helps in assisting venous retun by muscular compression.

Dorsal Venous Arch Lies in the dorsum of hand The afferents are dorsal digital vein, 3 dorsal metacatpal vein, dorsal digital vein, 2 dorsal digital veins and most of veins from palm by passing through interosseous space. Efferents Basillic vein and cephalic V.

Cephalic Vein It is the preaxial vein of upper limb and begins from lateral end dorsum of arch It runs through roof of anatomical snuff box It then winds around lateral border of distal part of forearm. It then continues upward in front of elbow and along lateral border of biceps It peirces deep fascia at lower of pectoralis major It runs in delto pectoral groove then peirce clavipectoral fascia to join axillary V

* A great part of blood from cephalic V is carried to basillic V by median cubital vein and also to the deep veins by the perforator - It is accompanied by terminal part of radial N, lateral cutaneous N of forearm. BASILLIC VEIN It is postaxial vein of upper limb it is analogous to short saphenous V of leg It begins at medial end of dorsal venous arch It runs along back of medial border of forearm then winds around medial border of elbow and upto front of medial epicondyle upto middle of arm. Then it peirces deep fascia. Then it runs along medial side of brachial A upto lower border of tere major to form axillary vein About 2.5 cm above medial epicondyle it is joined by medial cubital vein It is accompanied by postrior branch of medial cutaneous N of forearm

MEDIAN CUBITAL VEIN - It shunts blood from cephalic vein to the basillic V. - It starts 2.5 cm below elbow below cephalic vein and runs obliquely upwards and medialy and eds in basillic V, 2.5 cm above medial epicondyle. - It is seperated from brachial artery by bicipital aponeurosis - It may reverse tributaries from front of forearm. - It is connected to deep vein via perforator veins that peirces bicepital aponeurosis. It flexes the veine and : makes it sutable for I.V ingections. THE MEDIAN VEIN OF FOREARM It begins as a palmar venous network and ascends in one of the veins in front of elbow and ends in medial cubital V. It may sometimes divides into two and each of them enters basillic and cephalic vein, replacing medial cubital vein APPLIED IMPORTANCE (1) Median cubital vein used in .IV ingections, withdrawing blood. It is fixed by perforator. They dont slip out during the procedure.

(2) The cephalic V usually comminicates with external jugular veins by means of a small vein in front of the clavicle. In breast removal the axillary V may be removed. In such cases they acts as an alternate pathway. LYMPH DRAINAGE Lymph is formed from tissue fluid at capillaries (1) Lymph Nodes (a) Infraclavicular in the clavipectoral fascia along with cephalic vein (b) Deltopectoral nodes in the deltopectoral groove along with cephalic V. (c) Superficial cubital/supra trochlear above the medial epicondyle along ulnar V. (d) There are also deep nodes alongs with medial side of brachial A, also along birfucation of brachial artery and arteries of foramen. (2) Superficial veins - More numerous than deep. (a) Medial side of forearm by lymphatics from (b) lymphatics from lateral side of forearm goes to superficial cubital nodes. - to deltopectoral/ infra. clavicular groove. axillary lymph nodes.

- axillary lymph nodes

(c) The dense palmar plexus mainly drain into lymph vessels on the dorsum of arm. The lymph vessels of back of forearm curve around the medial and lateral floor to reach the axilla. (3) Deep lymphatics - They are less numerous. They drain structures deep to deep fascia. - They ran along main blood vessels of limb and end in axillary nodes. (4) Applied Importance (1) Inflammation of lymph vesels is called lymphangitis here skin is red with tendor streaks (2) Inflamation of lymph nodes called lymphadenitis here nodes are palpable (3) Accumulation of lymph may occur due to obstruction of lymph vessels. HISTOLOGY MAMMARY GLAND It is a tubulo alveolar gland The gland has a cover capsule - A glandular tissue parenchyma- imp in secretion - Fibrous part has fat stroma Glandular tissue - Made of 15-20 pyramidal lobes each with seperate duct - The alveolar epithelium cuboidal in resting place

- columnar during lactation, ducts streching epithelium. Myoepitheliocytes are cells in alveoli and ducts b/w the epithelium and basement membrane that fascilitates the passage of milk from alveoli to nipple. Epithelium of duct of small duct of columanar epithelium - large- of two or more layers - terminal part made of stratified squamous keratinised

Fibrous Tissue - It supports the lobes and is uniformly distributed Suspensory ligament of coopes are fibous septa that anchor the skin and gland to the pectoral fascia - Dimples may be seen over the skin due to fixation to pectoralis major. (1) MAMMARY GLAND INACTIVE Identifying features Tubulo allveolar gland with connective tussue storma - Glandular elements are minimum and are seen as tubules resembling duct lined by cuboid epithelium. (2) MAMMARY GLAND - ACTIVE Identifying features Tubulo alveolar gland with connective tissue stroma - Glandular tissue predominates with distended alveoli lined by cuboidal cells and filled with milk secretion. BRAIN SPINAL CORD They extend from foramen magnum to L1, and ocupies upper 2/3rd of vertebral coloumn. It has a conical end called conus medularis, below it is cauda equina [having lumbar sacral and coccygeal N]. From the conus medularis there is a fine filament extending upto C1- called filum terminale. *Spinal cord extends upto S2 in fetus while only upto L1, in adult [due to difference in growth b/w spinal cord and vertebral coloumn] . It is about 43-45cm long and 30gm in weight and has two swellings. (a) Cervical swelling [from foramen magnum to T1- to accommodate more motor neurons for Brachial plexus] and (b)lumbar enlargement [from T10- T12- opposite lumbar plexus] * Spinal Cord has 31 paris of spinal nerves 8 cervical, 12 thoracic, 52 lumbar, 5 sacral, 1 lumbar.

* (a) Coverings of spinal cord Has duramatter, arachnoid matter and piamatter . (1) Duramatter from foramen magnum to S2. Cranially it is continous with inner layer of cranial duramatter while lower part ends as blind tube. (2) Epidural space lies b/w periosteum and duramater. It has liquid fat, loose areolar tissue internal vertical venous plexus of vein. (3) Arachnoid matter- made of delicate areolar tissue. They extend from foramen magnum to S2 b/w them and piamathes is subarachnoid space has CSF (4) Piamatter it is closely inveted to spinal cord. It is avascular membrane it gives sheath to spinal N to blood vessels. *(B) 3 Modification of piamatter (a) Anteroir median fissure has a glezing patch called lina spendins (b) On either side, there are tooth like process ligamentum denteculatum [ 21 pairs] (c) Filum terminale is about 20cm and is a fine filament extending to C1. It has two parts - Filum terminale intimum about 15cm extend upto S2 it lies inside dural tubes - Filum terminale externum about 5cm extend upto coccyx. *[c] Terminal ventricle - It is a small cavity at lower end of spinal cord at region of conus medularis. It is continous to that of central canal. [d] SPINAL SEGMENTS It is the part / segment of spinal cord that gives attachment of spinal nerve. There are 31 pairs of spinal segment but they dont correspond to that of vertebral segments [a] Cervical vertebrae-corresponding spinal segments are got by adding 1. [b] Upper thoracic - corresponding spinal segments are got by adding 2. [c] T7-T9 corresponding spinal segments are got by adding 3. [d]T10- has L1 L2 spinal segments [e] T11 vertebrae- L3, L4 spinal segment [f] T12 L5 spinal segment [G] L1 sacral and cocygeal segment. [E] BLOOD SUPPLY OF SPINAL CORD There are one anterior spinal artery and two posterior spinal arteries [ arise from 4th part of vertebral A] - There are also feeder / radicular arteries. - The main feeder arteries are. [a] Spinal branch from 2nd part of vertebral A [b] Deep cervical branches of costo cervical artery [c] Ascending cervical branch of inferior thyroid artery [d] Posterior intercostal artery

[e] Lumbar and sacral artery Anterior Spinal Arteris are two in number [they arise from 4th part of vertebral artery]. But soon join to form and descend in antero median fissure. They give two sets of branches central [to substance of spinal cord] and vasoloina. Posterior Spinal Arteries Two in number and each of them divide into 2 and they descend on each side one on front of dorsal root while other benind the dorsal root. Radicular arteries after entering the vertebral canal they divide into anterior and porterior branches and anastomoss with spinal A.Two of the Radicular arteries are big Arteria Radicularis Magna / artery of Adam kicury largest radicular arteries. [F] VENOUS DRAINAGE It is by 6 tortus venous channels - i.e in anteromedian fissure, postersomedian sulcus, behind the lateral nerve root [ antero lateral venous channel],1 passes behind dorsal nerve root [ postero lateral venous channel]. - They drain into cerebellar veins , coronal venous sinuses, internal vertebral venous plexus etc Applied Importance (a) Lumbar puncture b/w L3 and L4 - The structures peirced are skin, supuficial fascia, supra spinous, inter spinous ligaments, ligamentum flava, dura and arachnoid matter (b) Epidural Anesthesia Anesthesia into the epidural space to prevent pain done in child births (c) Myclography Here a contrast medium is ingected into subarachnoid space to visualise spinal cord. (d) Lumbar / sacral disc prolapse lead to a shooting pain in the spinal cord. MEDULLA OBLONGATA It lies b/w pons and spinal cord. It is piriform in shape. * Antero median fissures and postero lateral sulcus divide medulla into 2 halves. * Anterolateral sulcus It gives origin to the rootlets of hypoglossal nerve. * Postero lateral sulcus b/w posteriosr and lateral surface. It forms floor of 4th ventricle. [1] Pyramid * B/w anterolateral sulcus and anteromedian sulcus is pyramid. The pyramids are more prominent where medulla comes near the pons. Lower down the medulla there is decussation of the pyramids The pyramids has corticospinal, corticobulbar and corticonuclear fibres. * Corticobulbar fibres has fibres to reach the cerebellum via the inferior cerebellar pedicle. * Corticonuclear fibres has fibres for the motor nuclei of the opposites side [2] Inferior Olfactory Nucleus

- Has 3 compnents in tivary nuclear complex medial olfactory nucleus / accessory nucleus- seen medial to principal nucleus. - Principal nucleus has appearence of cunated bag. - Dorsal accesay nudras sen darsal to princcpalncders. [3] raulr and cunrats juberde - made of graule and cunrate nulus . found in fliur of 4th ventride *gaule hudeus sun more medially cary sensatios from lowuts ank ard lower umb. White [4] juberculum uner iam * lernate nuclios sun more lateratey carey censation from apper limb and upper trunak - sun b/w fasciculas cahratus and postro laterial suleus. - it is formed by spinal tract and nucles of lfigrminal [it is a gude line for. Newiosugon to truect the trigeminal nudei in jrigiminal neveroglia] SECTIONS OF MEDULLS [A] AT pyuamidal decussation same features are (1) pyeamidal dcussation is sun. (2) spinal nudeus of lrigeminal- exterlupto C2 (3) part of gery malter is also sun . - vental nuclrus. - Lateral nwerous they extend upto C5 and give to spinal accerssorey nerve (4) spinal cort they are fiberes arering from uncpolas the geminal ganglion in the merkils core / covum lrigiminets. They rates in has spinal ncrcees. They curey censations of pressues, vibration, propecoaption from ipsclateral side of face. The 2nd ordes newion from spinal nulees from the spinal tract (5) posterios coloumn fibers are also seen. [b] seclion at the leves of sensory decussation (1) (2) (3) (4) the main featues seen are. lental grey malter is more dosal. Decussating internal arcuats fibrus are seen Guymaltes has nypogloosal nucleus in the hypogtosal tiongle - has dorsal nucles of vargas has pre gang gang lionic para sympalthetis fibus for heart, be I system, roporatory tsact. nuclrues of lractus sout arius - reueve affeve fibess from hypoglossal nerve, veger and fased nerves is the qurtalaony imputes - they then crose to oppoocts side and asand up and ten felary in the untial posteromedion nuibus of thalomas.

[c] sidtion at lwel of olivary nudeus

the featural sen are [1] it can be divided into 3 zones medialzone haspurameid, arivate nudeeus, the to spinal lract - inter mediate part has dorsal nudsus of vasus and inferios olivary nudew - latial part has inferios cubellas prduncje. [2] naderas ambiqas is also seen daesloateral to dresal nudrus of vagus they give rob to brachio motos fibes from glarso PONS Means bridge les between midbian and medulla it is about 2.5 cm long. It has 2 surfaces dorsal and vental. Venteral surface - is rclatd to dius of the skull. It is repuated from divw of the skull by basillas artery. It is convex and has transvase fobres that join to form middle uebellar pedanch to enter the urbellum dorsal sueface - those is a medan eminence and is limitrd by sulus limitants - uppes part of sulcar limitas is locvs covsubus. It has pigmented neuro that from the substantra fourigina. - In loes limit of salcus limitos is superios foves. - There is also fusual colliculus produce due to the undulying abducent nevron and the finers of fasual nerve around at - The lrigeminal narare from the dorsal swface. [a] section theough lower part In the uentral part there are trans veres fibers arising from pontene nudeus pontere nueeus vertial fibue of certico sponal, cortrio nudras and lorteio bulbar fibus there are also there is also cocleas and veste bular nudei There is also centeral leqment tract. [b] Section theough uppes part of pons The tectal part is conte nuation of medulla behind pyram ide. There is also main sensry nudevs and motos nudeus of thigeminal nudious. There are also superios olivary nudrus. * the parh of fasual nerve to the ligeminal nudeus it [ going of a motos nuer on to asinery nudel] is called beuso bioptar is applred jmport ance

[1] poralys is of cortrco spinal bart and abdunt N lead to ;ternating abducen demilegle or the reymonds syndrome [2] paralysar of lartrco spinal ract and 7th nerve alter nating 7 ascal /lemoplega called millard biadas syndrome. MIDBRAIN CORECTS THE hind brain to the fore brain It has a cavty the ceubial aqueduct that connets the 3rd and 4th ventridw.

Midbrain is related arterio by to optce, posterios curtail astery, basal vein, frochlas nudsw - posteriorly reated to splrnium of cuplus callbiorum , greatcudal V, pinealbody Subdivisions [1] lectum part of brain posterios the aguedut. [2] peduncs is part of midbrain that kis anterios to the agueduct. It is dveded into crues cuebri - substabta niagia. - Jegnebtum. The mnedial and lateral genicylate body are seen poatero lateral to midbrain the superios colliuli is connedrd to lateral beniculatera body by superios brachium. While inferios colliule is conneeted to medial geniculate body by inferios brachiam.

[a] section of mid brain at level of inferios collicule The features are. [1] The peri ague ductal gurymlthes has nudeus of leochlear nudei and mesen uphalie nudei of tregminal [seen lateral] The mesen aphake nucleue caery propriouptive im pulser from murder of mastication and also from fasual, occulas mundes etc. [2] Inferios colliculus they reueve affvernts from lateral lemnerous. - The effrch is go ts medial genculats body. * Impoetant in localesing sound. [3] Substantia niaga has part part rete eulares - Pase compacto [4] Crus curebei has pyramidal traet in middle 2/3rd - Fronto pontrne fiues in medial 1/6th . [b] SECTION AT LEVEL OF SUPERIOR COLLICULI

IT HAS (1) occulomotir nudeus of both sides fured in median plane (2) mesen cephloie nudrus of lrigeminal (3) Superion collocalus recever at ferents from etina. - Efferents govia tecta spinal to art they are imperiont in controlling reflexes of eyes head and nck. (4) preteatal nudeus seen derp to superolateral part of su[erior collecul;us - it reuveve affentes frmopte tract - it qives efferent to edinges wetpal nudeus- it is mposion in light reflexes (5) Red nuibwe - is bout. 5 cm in dranetes - it reicues affuent fromet from superios serebellar prdunfhs, globus pallidles, sub thalamia nulues and laretex - it gives efferent to retealar formation, thalamis, olivary nudias Applied importamcy [1] Lusion of the pretectal nudeus leads to Argyll Robertson pal. Pere aciomadation reflex is present but lefht reflex is abent

CEREBELLUM IT IS THE BIGGEST part of bibd broin, found in the posteios cronal fosa jenroicm ceuebelli and theoccpital Labe of erebeum. Its werget is about 150g. It lonsists of 2 hemesphus conectrd by vermis Cerbellu mhas superios sior sioface there is no seperaltion b/w 2 hemisphous - Inferios supfoes thouse is a gulles seperatering 2 hemisphees called vallecuar. - Anterios serface it has a ndeh anterion webe llas batch. - P [ostion surface has anotch posterios werbillar notch. 80% of gerymaltes is bued and fromea leaf like stuctues- aebower vctar [jure of life] *there are fissiore [to nsveroues] that divides cerebellum into lober [1] Half and fessue fram the middle uebellas pedande of 1 side to the opposite side

[2] Fissure 1- b/w anterm 2/3rd and post 1/3rd in the superios suface. They divide b/w anterios and posterios lober. * There is also a flocculo nodulas lobe that is seperaterd by the postero lateral fessere. And foramen of lushks is foond in midlies of glocculon nodular lobe [1] MORPHOLOGICAC CASSIFICATION It is divided into 10 from 1-10 [2] PHYLOGENITIC CLASSITICATION Ints 3. [a] achco cerebellum- linqeulla + flocculonodular lobe - Also called arrest bulo cerbellom. It is comerned with posture of the body, muxle tone etc [b] Paleo cerebellum spino ceribellam - Anterios lobe exept liguila and + ulvula. - Important in esios correction, danping, fine movements etc [c] Neo cuebellum Postioios lobe [pyamis and uvula] - they are important in controlling cooecdrtid volunaery movements [3] FUNCTION CLASSIFICATION IT IS CLASIFED into 3 [a] vermis has fastrgeal nadesus. It recoves fibue of vestrbulo spinal and rete culo spinal tract - It is conesned with movements of true murdes and murde tone [b] Para median lobe has nuclevs brlotaus and imbue form it rewes fibes from rubio spinal tract [c] Latrial zone has dentate nudlus Redeues fibies from losteco spinal, rubiospinal tract and also it also is connectrd with dentate loetecal path way [4] Nucceus of cerebeuum From lateral to medial denate, embolfrom, bobosin, fastegal. [5] Type of fibres - Mainly 5 types - Afferent - Assouation fibes - Progection fibres - Commissural fibres - Efferent fibues may be mossy fibre- goes to the ronular layes

- Elimbing fibres gers to the moleculas layes. They relay in to the parkinge ulls. [6] CEREBELLAR PEDUNCCES [A] Infrioc curebellas prdvndes [1] Affevent posterios spinocerbellar, cunrofellar, anterios external aruate vestebulo curbllar, devcrbellar pouaolivcurbellar and reticular fibies [2] Efferent cerbello vertebular, cerbello olivary, cueellopind, ceubello retrcular [b] Middle eubellar peduncles [1] Afferent ponto reebellar; [2] There are no efferent febees [c] Saferios cuebellar pedunacle [1] Afferent anterso spino cuebellas, fecto urebellor, trigemino urebella ltypo thalamocerbllos, rulro wrebllar [2] Effluent asending- dentate thalamic / dentato rubral - Drscending cucbeello reticular, urebeltonulear, lerebello thalamio [7]BLOOD SUPPLY Supeios surface superios lerebellas, artery, Inferios surefore anterios part antrious inforeios rubellas artery - poseruos part posterior inferios cuebellas artery

[8] Relations of cerebellum Anterioly relatiad to 4th enterdle Dnsally relatrd to superios suqital sinus, occipital sinus and occipital protubuerna Infaialy formen maqnum.

CERE BRUM It is the largest mass in the fore brain. The latgest transverse dramets is b/w 2 pautal tuberosital. The conneation b/w 2 hem ispbes is a longitanal mass of commissoural fbees, the

Corpower calbworm. The surfaus of cerbian are superolatial serface, inferios, and medial sufaus. The bordus of brach are supero medial, infero medial and fefirolateral The poles of brain are frontal, pauetal, tempoial, and occipital poles. (1) SULCI AND GYRI OF BRAIN Total surface of bram 2200cm2. Upto 3rd month of into wterine life there are nosulic th By 4 month laral sulers develops. By 8th month all sulci are developrd. [1] Types of sulci (1) Limiting they separate 2 functrunal and structural are as eg: centralsulers (2) Axial eg: posterios part of calcarins crleus (3) opercutatral- eg: lunate sulues separate peri and parastriate cortex (4) Complete they cuale eluation in ventrides eg: collateral Sulu and anterios part of calcaine sulcus. They may also be classifud as 1- they develop infepndently - 2- they develop as deffuent parts and then unite (3) lateral sulcvs / fissure of silvius Theis sulurs comes from the inferior suface [neas the antherios perforted substance] and it is called the stem. At the siluran posert they divide into anterios ascending rami - Anterios hoizondal rami - Posterios rami

Surface marking [1] Pterion [2] 2cm above parlital prominence [3] 2cm above perion [4] 4cm in front of pbrion Lonnecting [1] and [2] we get pasterios rami Conncting [1] and [3] we get anterion usending rami Connecting [1] and [4] we get antrios hodfondal rami (3) Central sulcus surface marking [1] 1.5cm posterios to midpoint of line joining nerion and external occeprtal prohunues a line joining [1] and going down that makes an angls of 70 with median sagrtal lone and about 8-10cm long. (4) Parcet occipital sulci - They sepuata palatal and ocupetal lobes.

(2) LOBES OF THE BRAIN By extrnding the parcr to occipital sulcus to the pre occipital notch and by extrnding latral sulcrs into parei to occipital sulcus and also by extrnding untral sulcus into the posterios ramus of untrol sulcus. By using there the brain is divided in 4 lobes frontal, trmoral, parutal and occipital [a] sulci and gyui of frontal lobe By superios and inferios fiontal sulcus the frontal lobe is divided into superios middle and inferios frontal gyri. There is also pre cebtral suleus. And also by anterios ascending and anterios hosszondal rami, there is also pars oibitals, pars triangularis and pous opercularis. [b] Sulci and lyyri of temoral lobe By superios and inferios trmporalsuleus it is divided into superios middle and inferios jemporal gyrus. [c] Sulci and lypri of paeretol lobe There is an into paerutal suleus that aiviole it into superios and inferioi parietal lobule. There is also a part central sulcus and anterios to is is post untral geyri lateral, superios and inferios trmparal sulcus also enter the parertal lobe to from supra marginal, angular and inferios gyrus. [d] Occipital lobe * By lateral occepetal suleus it is divrded into superios and inferioi occipital gyrus There is also a lunate sulcus and inferios polas sulcus.

(3) INSULA / ISLAND OF REIL It is a submerged pyramidal corter setuatrd in the stem and posterios rames of the lateral sulues. It is cloaid by the over gto with of temporal, parcetal and friontal lobes. A urcular sulus seperatrs insula from opercula. There is a central sulcus that it claustrum, external capsulr, lentr from nudeus. [e] Sulci and gyri of inferios surfau - Offactoiy bulb lies in the alfaclory sulcur [medral to it is gyrus rectus] there is on H shaped orbital sulurs that divede into medral, lateral, anterios and posterios orbital sulures. - In lentorial sufoce there is calcarine suleur. Limiouly to there is collateral sulues and anterios to it is rhenal sulcus - Medral to them is uncvs [antrioily], para hyopo campal gyrvs [Mors posterioily] and lingual gyrus [sren more posterioly]. [f] Sulci and gyri of medial surface

- There is corpus callourm [it has commissural fibres] - There is also callousal sulurs and sulevs angerli - Below sulcw anguli is gyrus singali - Extrnsion of untral, pre and para contal sulcus from parauntral sulurs - B/w the calcarine sulare and occipital suibous is urnus and above it is pre cunevs

(4) FUNCTIONAL AREAS OF BRAIN - BY strmulation/ ablation studers, broad man found out 52 different aeras compel found out 20 areas, eiond 105 areas while vozifoundout 20 of unctronl areas - The fernitronal areas of brainmarle sensory mainly 5 areas auditory, offertry, vision, farte, toaeh - Motos - Samas the/ assouation - The functraonal areas may be stract corally biranular, agranular and striate catrx. Homunculus represent the body of man in brain The are a of representation of each area depends on the fornction. It may be motos homunculus and ansory honenculos. In sensory homenulus the area of represntaion depends on the no of reuplies while in mostos homunculus it depends on function.

Main functronal areas of brain 1 motos areas = [area4] it conscts of pre cntral gyrus and parantral lobale. The contral the volubtary munclrs 1 re mitis areas [area band8] gives argin to cortrconudeas, coeticobulbas and cortco spinal fibers 1 sens oty areas [area 3, 1, 2] granulas cortex in the post central sulcvs. It helps to locales anayse modalrtes of cut aneoan and pro priooptive sensy Som as thetrc arsouation area [area 5, 7] - important in perception and recugnison of grnual censes Pre frontal area [area 9, 10, 11, 12] important in deph of fuling, sensation jundgement hinking fore sight, tactfulners called silent area of brain 1 visual area [area 17] in posterios part of calcarine sulues. It is gtanula. The outer band of baillartger is prominent. It fores strias of gennari that redeves vesual infor mation. Visual assouation area area 18, 19, - oara abd peristrate area imprt art in recignision of obruts by relating to part experienues 1 audetary area [area 41, 42] rcuves 1 audrtoig imputses.

Aundutioy assouation area sren around 1 audrtoiyarea Vernceks speech area rnsion speech area.

(5) WHITE MATTER OF BRAIN - THE white malter corests of 3 tpes of fiber, assouation fibres, commissual febeus, and proyction fibres. [1] Assouation fibus connect areas with in lobe. May be shart or long. The shart assouation fibrs are numerus. The long assoualtion fion fibus are . Undnate goes from the frontal lobe to the te mopral lobe. It connects the speech area to auditoryarea. Fronto occipital. Superios longitudinal boodle most import connects frontal to occipital lvbe Inferios longitudinal bundle from occipital to the trmporal lobe. Cinguvs seen deep to ungula to gyrus

[2] Commissural fibus connect the right and liftlobes. Anterios commissure connict the 2 lobes. It has an anterios bundle reach artrios perforatrd sublance - Posterios bundle * Posterios pommissuer coonect superios colliculi to edrnges west pal nuclevs * Habenular commis connrct the habenular nulei * Eoptrc cheasma. * Corpus calliusm It is the largeust commissure of the brain. it connrcts all areas of the brain expt the anterios part of trmporal lobe. Parts- have a genu, rostrum, splenium, and trunk. [1] Genu relaterd anterioly to anterios cubral artery and posteriosly to antrios hoen of lateral brin.

[2] Rostram it ends in lame terminalis. It conncet the arbetal surface of 2 frontal lobes [3] Lrank lus b/w splenium and genu. Its superios suface is convex [before back wardes] and inferios surface. [4] Splenium it is the posterios most part and theikest the inferios surface is arlated to trlachoiodrae of 3rd ventride It is superiorly relatrd to lnferios agitalsinus, and falx uerbi postrioly it is elated to great curbral V, straghtsinus, trndorium wernells. * The fibers in corpue callousm are Ros trum connect arital part of frontal lobes Forups minor connect fronto lateral lobes corresponds to fibers of gena. [Sren anteriorly] Forups mayor connect occipitallobes- corresponds to fibres of cplenium. Japetum connect the parital lobes corresponds to fibres of trunk. (3) PROJECTION FIBRES They Aries from rebial cortex. The Fon out as coiona nadeato and then lecome intenal capsule and lres b/w 2 nucleus striatum [ucaudate and lentr from nudrus] Internal capsule It is a vshaped structures with apex facing medially. Fibes from internal eapsule contrnues down as are werbil The parts of in ternal capsule are anterios limb, gena and posterios limb, sublente from and retrolente from parts Fibs content of each part of internal capsule [1] Anterrios limb - Has asunding finres anterios thalamic radiation, loitrio petal fibres - Desending fibres corteio pontrne fibers, coetriosriate fibers. [2] Genu has coite conuelear finres from area 4, 5 to the cranial nudlei and corteco reticular fibres which are drscending fibers. - Ascending fibres superothalamic radration [3] Pos terios limb - Descrnding fibers coritrlspinal, cortecoruleal, corteiostruare, coreco reteculas fibres - Ascending fibres superios thalamic radiation [4] Sablente from part - Has ascendrng fibres has audetoiy palh - Has descending fibres has emperor pobtene, Pareto ponline fibers. [5] Retro lentre form part - Ascending visual and posterios thalamic radiation - Descending occipito Pareto pantnebibres. Due to the compact are ongement of frbe in the internal casuls lesion of thes area is more dangerous than that of coeona radiate. Blood supply of intrsnal capsule

upper part of artesios limb, grnu and posterios limb is supply by striate brach of niddle curbeal of krety lower part of anterios limd is by recuent branch / neupes artey of antrios cerbrol A Lower part of paoterios limb, reto lentr from and sublente from part by antrios chroidal artery from anterios cerebral A.

Veins go to the deep lerbrd veih

* FORNIX it is a area ued bind of whete malter mastly proye dron febres and partly commisscual fihes of the neppoiamaus. The body of fornix is suspended by coipus callourm and it is in cloos contaet with trla choroufae of the 3rd venreide. It aud posteroily it diviede into 2 aea each areing from fimbrae of corresponding sde. The 2 crieo are conneted by febes crossing from each othes called hippo campal conmissous. At anterios and also them diveds into 2 halfs called coloumene and they turn down words infront of ventsiculas foramen into mamillary body.

* INTER PEDUNCULAR FOSSA Boumdares are anterioely optec chiasm - antero laterally optec tracl - postero laterally cerebial pedundes - Posterioely upper part of pons.

Contnts are Tubes einerium, intundrbulum, mamilary body, and posterios perforated substance occulo motoi nerve. (6) VENTRICLES OF BRAIN [1] 4th vertridsIt is cavtry of hind brain and it is triangulas in sagital section. All ventri des are lined by opendyma.

* Communication saperiosly to aqueduct of silvius - Inferiosly to untralcannal - Lateral 2 apertues foramen of lushka to sub arach noid space - Medial aperture foramen of magenta communlcats to serebello medullare cistern. [a] recesses of 4th venteie [a] lateral reurs bet wern inferios cerebellas prdunele and flocculus. They extrna laterally upto upto foramen of lushka. [b] Dosal reurs- median reues it extend into whrte core of cerebellum - 2lateral on eithers side of median reues sern above inferios medullary vellum [b] Charonid plexur of 4th ventricle 2on each side has a vertrial and hollzondal limb. The artery is a branch of posterios inferios cerbellas artery. Vertrcal trmb goesinto foramen of mauendi, wide hollzondal limb goes to lushka [c] Parts roof, floor, and lateral boundary [1] Roof of 4th vrtride = dosal wall - it externds nack wards into recerse. - Superios part is made of superios urebellar [rdunds and superios medullau velom. Jelachoeoidas vasculas Laues + ependyma + piamaltrs [2] Lateral boundary - Superios by superios cerbellar prdunde - Inferios part by inferios cerncllar prdunde

[3] flooe- rhombroid in shape: called rhomboid forsa. * it is divided into 2 hays by a medran suleus * by streae medullarie [ delicate whrte fibres from arcuate nudas] it is deurded into apper [pontrne part and lower [ medullary ] part. Pontrne part * Just a bove streas there is fasuas colliculus. There is also a medran eminence and is limitrd by sulcus limitants limitants and it has nuclers cerruleus. It haspiqment newomelanin and serte nor adrnalen. There colls from substanria terugunea which is a part of krte formation Medullary part Sulues lemetants has inferios fovera. There is ahypoqloisal triangle having hypoqlossal nucheue. - Lateral part has nucles into calrtus. Lateral arpect of fores has vertrbular area having vestrbulas nulei Lower to the nypoglossal trangle is vagal triangle it has dorsal nucleus of vasue.

At the lower and of vagal triangle is a faint ridage of ependuma tuniculus superuans * Aera posterma longue shaped is found has and it devoid of blood brain nafous and it has vetal ceteres * Ventricles are formed from the cavitres of the nureal tube * There is a coevety b/w reptumpelluudum called cavum pelluudum it has trsas fleid it is called the 5th ventrile. (2) 3rd ventricle It is the covrty of the dren uphalon and it is found b/w 2 thalami Boundaries [1] Roof it is a fold of ependyma in clex relation to the forenix and uplum prlundum - The roofhas trla charodrae and choeoid plexw [the charoid plexus has mare sueface area]. There trlachoroides and they 90 into 2 limbe of the lateral ventricle. The fissue thus forned is chroid fissures also calred transverse fissures. [2] Floor is of ohalamus, optrc chasma, kypophuses, infundrbulum, trgmentum and mammilary body [3] Anterios boundary is made of a then felm of lamina terminals [it represent the uphalic end of neuraltube], optrc chraema, abterios idoumn of fornix and anterios commissure [4] Posterios boundary - is of pinral body, agueduet, hafenular commissure [5] Lateral wall has an upper part and lower part reperatrd by lypothalamic sulcus. - upper part made of thalamus and epithalamus pars darsales - lower part made of hypothalamus called part ventralis Theres is also an inter thalamic adhesion. It actually has no crossing of fibus Reues of 3rd ventricle They are [1] infandebular reces, [2] supraoplec [3] pinal rcers [4] suprapineal reces [5] vulva of ventricle [b/w anterios commissure and anterios coloumn of fornix] Inter nentricular foramen- connet 3rd venteride to lateral vrtridus. It is boundrd anteriely by colomun of forinx] - posterioely by anterios tubude of lhatanmus} it is uesentric in shape but inembrye it is round LATERAL VENTRICLES They are 2in numner [I in each cuebral humisphue] it has a body [in parutal bobe] an anterios horn [in frontallobe], posterios hoin [in occipitallobe], interioshrn [in jempord ldue] Body extrnd from intes uentricular foramen to the thalamus

roof made of ependyma and copious callowm Floor- of caudate nudeus, thalamus, Nucbus, corpus callousm, rostrum. Medial wall of septum pelluudam.

Ansterios hoen - It lies in the occipital lobe. Boundates roof and lateral wall of japetum - Medial wall has 2 elevallons 1 bulb due to forups major. - Calcaraves of calcar ine sulues Inferios horn it lies in the tempoial lobe Boundarles roof of fibers of lapetam - medealy there is cauduate nudleas and streae terminalis - anteriosly of jail of caunate nudeus, strain tre mindaes, amgloidcomples - Floor of alveolus, fimnras and heppocamus - Lateral wall has a lateral eminence made by collateral Sulius. * Telo choioidac of 3rd and hateral ventricle It les b/w splenium and copus callouem above and thalamus below. The posteroios and of it is transverse fissure / charoid fissure. It is leiangulas and is anterios end is called apex - a medeal part of it is fromendin roof of lateral uentricle - The lateral part on either side peogect into the 2 lateral uentrete vra the intert ventricular foramen. The verles of trla chroidac coner from the theinternal carotd artery or the basullas artery the veins [prevent exus production of CSF] drain to strrgh sinus ar to interios arebral vein. * Cerebro spinal fluid It is a clras transparent colourless fluid. The total volumes are about 80-150 ml and rate of production is 5ml/minute. The jotal pureues is about 50 150 mm of ltg the CSF is measured in lumbar punctures in latual recumbent position. By the rateof coming out of the CSF the CSF presurs can be found out called spinal tap. CSF has water, nacl, kci, glucae, protein lymphocytes [3ullu/mm3].

Functeors of CSF [a] protrction pf brain from lrauma [b] provede nutrition [c] oit provede buoyancy to the brain [d] it he cps in taking pineal seuction to the pcturtary. Crsternal puncture jaking CSF from urebrbomedullary ustern Chasoid plexus of lateral wentrids made of anterios and posterios choiidal artery

of 3rd ventride - made of poterios choroidal arlery 4th ventricle- of postrios inferios cuebellas antery

Nydrocephalous lncreared CSF production. May be acquired / conyemtal. The inureared itro uanal pressure cans lract to headache, impaunment of vrsion, vomctirg and papilodrma Blood brain bouries - Made of endothe lium [has nofre nustr ations], basement membri are. There are also asterouytes. - The pineal body, hypothalamus, charoid plexer has no blood Brian baerur. VII BLOOD SUPPLY OF BRAIN

Mainly by the branches ofvatrbal artery and internal caotrd artery by froming the urde of Willis. The internal carotid artery divrdes into anterior carbeal and middk cerebral artery. The 2 verebral ateries asand in the antero lateral arpect of medulla and unte at the bare of pons to from the busillas artery there then divide into posterios cuebral artery. 2 sets of branche ae given from uricle of willcs lortcal supply enter sueface of cuebral hmuples - Untral 4 groups [2 paled and 2 unpared] Blood supply of different surfaus of brain [1] Superolateral surface - Mainly by the middle cernral artery exypt a strip an inch from the frortal pole to paruto occipctal suldu is spplied by anterios urebeal artery. The reqioon of inferios lempoeal qyus is upplied by post curebeal artery. [2] Medial surface - Mainly by the anterios cerebral artery exept the bempral lobe and occipitaobe which is upplied by temporal lobe and occipital lobe. [3] Inferios sueface - Lateral part of orbital sueface by middle cerebial artey whete medial part of of orbital sueface is by anterios cerbial artery. The tentoeial sueface is supplied by meddle cerial artery. * Area for maiula vesion is supplies by posterios cerbreal and middle cuebral A : Macular vision is not lost in the omboscs of posterios cerebral artery * The atery dupplying areend oulays: they can easily lead to theomborts Blood supply of the deep brain Mainly by seffernt groups of arteres from the uide of urllis they are [1] Antro medran gtoup - They ar is from antery cuebral and anterios communicating artery they purie anteuos peoratd subsfaceto the peoplrs and supa optis reqion of the anterios hypothalamus. [2] Postero median group

They ar is from posterios communicating and posterios cerebral A they pcuce the posterios percorating substance it is also called thalamo perforating beaches. They supply piturtary, hypo thalamus, subthamus, anterior medial part of thalamus, medeal part of midarain, leqmentum. [3] Antro latrial group They arise from middles ceubral artery as sometrnes arise from antery cerebral A called striate artery. They pueces anterios aerforared substanu and upply corpun striateum and internal capsule. [4] Postero latrial group They arise from posterios cubral artery. They are called thalamo geniculate artery. They supply carudal part of the lamus be 2 buenculats body, lateral thalamic nudri [5] Reccuent nranch of antrios cucbral / nubneus artery - They arise from anterios unbral artery proximal to or destal to antrios communicating artery. It supplies the caudate nludeus, lower limb of anterios part of internal capsules, putamen, and exteunal capsule ec [6] Antrios choroidal artery Arise from internal cartead artery destal to posteios commcuicating artery. They passbckwad and enter the inferios hoen of lateral ventride theough choroids fissure. They supply the optec lract, uncus, amydala, heppoiam pus.laterial geniculate body, reteo lente orm part of internal capsule, [7] Posterios choidal artery They arise from postrios cerebral artery and give branches to ctum choioid plexus of lateral ventrde. Some of its branches anastomous with ant eros choeoidal artery. Applied importance [1] * one of the branches of antero lateral group is larges- called choucote artery. Ot is called artery of cerebral ldacmoes haye. It easily ruptued in hypes lension [2] * acuts arrest of ucebral urculation canlead to unconciouenes in fase and if grcates than tminutes- it canlead to reprable damage [3] * latral medullay syndrome / wallen berg syndrome - Dueto leision of posterios inferios cuebellas artery. Thay the poseterios aspect of medulais affected The nudeus amnigus, spinal lemnercus, spinal nudeus and tract of lrigeminal are affeded.. Some temes inferios ecebellas peduncts and vertrbulas nudeus also affeded Symptoms are Terndency to fall, loes of jone, nystagmus, dysphasia, hosners syndrome uosed hemi anes thesia [4] * medral medullary syndrome - Artery affected is vertebral artery Pyramids, medeal lemniscus and hypoqloresal nerves are affecred Symptoms are chondrolateral hemiplrgia, chondro lateral loss of rensation of movement, lacterle desuim ination, ipscclateal paralysci of jonque murds. Blood supply of brain stem

of mid broin by posterios cerebral artery of pons by pontence nranches of basillat artery Of medalla medullary braches of vcestrbral artres and branches of posteios crbellas artery.

Veins of cerebrum The veine of brain are devoidof murdes, lkey hower no valver and have to ndency to maintain patency Superios cerebral N External cerebral vein The Veins superficial middle cerebral N Internal lerenial Deep middle cerebral N Inferios cerebral N Antrios cereberl N

Terminal veins

great cerebral V Basal V

[1] Superios cerebral veins They are about 6-12 in number. They supply the cpero lateral surface and termidate into superios saqittalsinus [2] Superfiual middle cerebral vein Drain the area aeound the postrios ramus of sulcus and to minate into couanoursinus orinto spero paretal vein. Through superios and inferios andsto motre vein they communicate with superios sagittal and transuerse sinus. [3] Seep middle cerebral vein - They also communicate with superfiual cerebralvein. It drains the scuface of insula and tesminate into basal vein [4] Inferios cerebral vein Mainly of 2tyoes orbital terminate in the superios bralvens - Jemporal they end in cavernour sinus. [5] Anterios cerebral veins They are small veins that dram corpue callourem and antrios part of in edral sureface of hemiophare and drain into baer/vein

[6] Internal cerebral vein

They are one on each side and are formed by the cnion of rgalamo strcate and choroidal vein at the apex of tela choaroiclae on 3rd ventride the right and left veins join to from great unbeal vein. [7] Great cerebral vein it is a single medran vein formud by union of 2 intrnal certral vein and there tributaries are basal V, vein from pinral body and veins from adjoining part of occeptal lobe of cerebrum. [8] Basal vein There is vein of each side. It formud at the anterios pufoated substana by the union of deep middle cerebral, anterios cerebral vein, riate vein. It runs posterioly and wind around cerebral peduncle and cerminates joining the gereat cerebral vein It also recrives small veins from cerebral pedundes, oeins from into prdenulas sruities, tectum of mid brain, para leppocanpal gyrus. VIII BASAL GANGLIA

It is a sub corteal mar of gey malter. It includes caredls nudrus, lentr nuleus, amygdaloid nuders complex, daertiom Laudate nucleus + lentform nudus = coepers striatum Lentrfrom nudleus = putamen + globus pallrdium Caudate nucles + putamen = strcatum. The basal ganglra also includes sub thalamic nudleus and substantra niagra. [1] cuudate nudleus has head, body and tail. It is clorely relatd to the lateral venteids. Anteios pat of the head is fured with lent from nudrus to from tunders striate Thefandues stroateis contrnuom with anterios perforated substance.

[a] head It frms the floor of anterios Han of lateral ventride and medeal wall of anterios limb of interal capsule. [b] Body it forms the central part of lateral ventricle and lies medial to pasterios limb of internal capsule. It is separated from thalamus by treac lerminalis and jhalamo striate vein. [c] Tail from roof of inferios haen of lateral uentride. It ends joining the amydaloid body at thetrmpoeal pole. [2] lente from nudleus it is lens shped. It has 3 surface lateral convex is relatrd to external capsule, elostrum outermost capsle and insula - medially related tointernal capsule, cavdate nucleus and the lamus

inferios surface related to sublentr from part of inter and capsule that sperates it from optec tract. It is grooved by anterios commissure behind anterios piforated subdtance

it has 2 budeus put amen structurally erlated to cuudate nucleas - neostriatum mare new of putamen and culdate nuclive called stratum. [3] amyloid body it is a nudeus mass in the trmporal kobe [ lying anterios superios to inferios hoin of latral uenteride.] jopographicalty- it is contrnus with tail of caudate nudles while functe conally it is relateal to strios tesminalis it is also a part of lim bic system afferent come from olfactory traet - efferent go vea stria to minadis and end in anterios commissure [4] claustrum luaus shaped nucleus b/w putamen and insula. Inferioily it is contrnuous with anterios perforated substance. Connection of basal gangtia [1] * cortex is connedted to striatum vio coete steriate fibus [2]* striatum is also conneclid to rects cular formation and also ectecular formation [3]* it is also connected to substantea niagea by the niageo striate pathway one of such path ways seorete dopamine [4]* striatum is also connected to polledruem called sttria to pollrdeal pathway the main nevero transmitthes has is GA BA. [5]* striatum also main seueues afferent from thalamus by thalam ostriate path way. [1] and [2] aemain afferent pathway whle 2,3, and 4 are main efferent pathway. Applied impoetance * lesion of ibasal ganglia leads to pcukinsonum due to drgrnesation of negrostriate pathway : releare of dopamine the features are chrea, ahetoser, lead pipeigidrty, masked face, reting temos, pill rolling muts. Blood supply of basal ganglia [1] of caudate nucleus head by reccreont branch / nurebners artry - body latral striate branch] - tail anterios coroidal artery [2] blod supply of rlobus pallidus by anterios wrebral artry and lateral striate artery [3] blood supply of putamen lateral stridate branch, and heubners artery.

IX THALAMUS It is part of cleon cephalon. Anterior pole lies just behind inter ventricular foramen. Posterior Pulvinar seprates from geniculate body by the superior brachiam Medial it forms the latual wall of 3rd ventricle and is lined by ependyna. It has interthalamic adheion that is a hypohalomic sulus that seprated it from hypothalamus. Superior surface themedial part of it separated from ventricle by farnix and a fold of Tela choroidac

It has 2 poles

* it has 4 surfaces Inferior surface related to hypothalamus and ventral thalamus Lateral surface related to internal capsule, lente form nucleus and external medllary lamina. The superior surface of thalamus is covered by white matter called stratum zonule. Internally thalamus is divided by internal medullary lamina ( a Y shaped fibres) Anterior group has interomedial, ontero cloisal, antero ventral nuclei Medial group medial closisal nucleus Ventral group Ventral anterior Ventral lateral ventral postero lateral Nuclei of thalamus Ventral posterior ventral posters medial

Lateral group

Lateral group

lateral cloisal Lateral posterior Puluinar

Other nuclei Inter ondaminar, mid line, medial geniculate body and lateral geniculate body. CONNECTIONS OF THALAMUS It acts as a relay station for all sensations exept olfaction (1) Sensations by medial lemuous and spinthalamic tract come and relay in ventral posterio lateral nucleus and then to 1o sensory cortex (2) Sensations by Trigemnal lemniscue and solitaro thalamic tract relay on ventral postero medial nucleus and then go 18 1o sensory cortex. (3) Impulses from globus pallidus substantia niagra and cerebellas, vertibular nuclei relay on ventral lateral nuclei and then relay on area 4 6 8 on the cortex (4) Impulses from retina relay on superior colliculus pre tectal avas and then relay to lateral daisal, lateral posterior and pulvinar nuclei (5) Impulses from hypothalamus relay on the anterior nuclei and from there it goes to ungulate gyrus, Hypothalamus, limbic system It is concerned with emotional drive, memory drive and loss of memory (6) Impulses from thalamus and hypothalamus relay on Dorsal medial nuclei then relay on area 9,10,11,12. This is important in memory, mood elevation, emotional balance (7) Auditory impulses come to inferior colliculus and then relay on medial geniculate body and then relay on area 41, 42. (8) Visual impulses come via superior colliculus to the medial geniculate body and then relay to 1o visual area. (9) Intralaminar nuclei receive fibres from reticular formation and send fibres to the corpus striatum, other calamic nucleids. It is concerned with consciousness, alertness (10) Mid line nucleus also receive fibre from reticular formation It is concerned with arousal and emotional behaviour.

BLOOD SUPPLY OF THALAMUS Posterior cerebral artery, Basellar artery and posterior communicating artery. X LIMBIC SYSTEM It is part of brain controlling food and sensual behaviour. parts are olfactory system, fornex,steriac terminals, anterior commissure, anterior perforated substance, amydala Functions (1) It controls the habit, (2) It controls sexual behaviour (3) It controls behavioral expression.


EPITHALAMUS It consist of Habenular commissure part of limbic system Pineal body has body and stalk.It has rich network of blood vessels and sympathetic fibres.It has 2 types of cells pinealocytes neuroglial Labenulas nuclei Posterior commissure


HYPOTHALAMUS called head ganglion of autonomic nervous system Boundaries are anteriorly (optic chiasma), posteriorly (posterior perforated substance) and on either side (optic tract and cruscerebri) Optic part supra optic nuclei, para ventricular nuclei

- Hypotalamas has

Tubal part ventral medial nuclei, Dorsomedial nuclei, tuberal nuclei mammilory part posterior nuclei, lateral nuclei

Functions (1) Endocrine (2) Neural secretion of oxytocen, ADH (3) Autonomous control chiefly sympathetic (4) Temperature regulation (5) It is important in biological clock (6) It is also important in water and food intake.

HISTOLOGY (1) Spinal Cord It has grey matter ( H-shaoped) inside and white matter outside grey matter has anterior horn, posterior horn Anterior horn has large multipolar cells motor Dorsal horn has clarkes coloumn of cells, posteriomarginal nucleus, nucleus peoprius, and substalia gelatinosa.

There is also a central cannal that is lined by ependymal cells Coverage of spinal cord include duramatter, arachnoid matter and pra matter. It develop from caudal; part of neural tube Spinal cord terminates at level of L, in adults and L2 in infants. (1) H shaped grey matter with anterior horn and posterior horn Identifying Features (2) Central cannal is seen at centre of grey mater (2) Cerebellum has 4 layers molecular layer, granular layer, pukinge layer, white matter The cells found are - Purkinge cells - large flusk shaped cells forms 1 single layers - their axons form main afferent path way - their dentrites synapse with axons of granule cells - Granule cells - they synapse with mossy fibres forming glomertilus - Their axons enter the molecules layer and divide into parallel fibres - Golgi cells - They acclong stellate cells. - Their axons enter the molecular layer.

- Stellate cells - In molecular layer - Basket cells - found in molecular layer. Their axons form a network around purkinge cells :. Called basket cells Cells Molecular layer has stellate and basket cells Purkinge cells - has purkinge cells Granular layer has golgi and granule cells

Identifying Features 1* Cortex has 3 layers ( outer molecular, purkinge cell layer, inner granular layer) 2* White matter is seen inner to the cortex

* Cerebellum develop from alar lamina of mesen cephalon (3) Cerebrum It consists of 6 layers (1) Molecular layer mainly fibres made of horizontal cells, golgi cells, stellate cells (2) External granular layer due to closely packed stellate cells. Their axons forms association fibres (3) External pyramidal layer - usually small pyramidal cells. Their axons forms commissure of fibres (4) Internal granular layer - has band of bailarger it has transverse fibres formed by closely packed stellate cells

(5) Internal pyramidal layer - made of cells of bet & and maletenote. Their fibres farm projection fibres.They have a transverse band called internal band of bailarger (6) multiform layer/ layet of fusi form cells The cells found here are (a) Pyramidal cells (b) Stellate cells Horizontal cells (d) fusiform cells - most abundant - It is triangular. The axons cerese from the base - called granule cells. Axons are very short and mainly sensory. - the dentrites are parallel to the surface - Here 2 dentrites arise from 2 ends one goes to the superficial layer and other goes to the deep layer.

(e)cells of marte note are triangular cells (f) Golgi type II cells - cells with small processes * Cerebram - develop from prosencephaton Identifying Features (1) outer grey matter and inner white matter (2) six layers are there in cortex