THE AUTHORS

Robert H. Whitaker MD, MChir, FRCS graduated from the University of Cambridge and trained at University College Hospital, London. He spent a year at Johns Hopkins Hospital, Baltimore, in the Urological Research Laboratories before returning to continue his training first at the St Peters Hospital group in London then as a Senior Lecturer in Urology at the London Hospital Medical School. He was appointed as a Consultant Urologist at Addenbrooke's Hospital in Cambridge in 1973 and spent 20 years practising mostly paediatric urology before retiring from clinical practice to join the Department of Anatomy in Cambridge to help with the teaching of students and trainee surgeons.

Neil R. Borley MB, BS, FRCS trained at Guy's Hospital, London and after performing house jobs in medicine and surgery there he embarked upon a career in surgery. He undertook a surgical rotation at Addenbrooke's Hospital, Cambridge, before becoming a Demonstrator in the Department of Anatomy in Cambridge under Professor Harold Ellis. He passed the Primary FRCS examination in 1993 for which he received the Hallet Prize and then continued his surgical training at Papworth Hospital and Kent and Canterbury Hospital. After moving to Oxford as Surgical Registrar, he is now Clinical Lecturer in Surgery and Clinical Tutor in the Nuffield Department of Surgery, Oxford.

We would welcome and value any reader feedback. Let us know how you think this approach could be improved by emailing us at the following email address: [email protected]. This page intentionally left blank INSTANT ANATOMY This page intentionally left blank Robert H. Whitaker MD, MChir, FRCS Department of Anatomy University of Cambridge Neil R. BorZey MB, BS, FRCS, FRCS (ed) Nuffield Department of Surgery University of Oxford

SECOND EDITION

Blackwell Science O 2000 by Blackwell Science Ltd a Blackwell Publishing company

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First published 1994 Second edition 2000 Reprinted 2001, 2004, 2005

Library of Congress Cataloging-in-Publication Data Whitaker, R. H. (Robert H.) Instant anatomy1Robert H. Whitaker, Neil R. Bor1ey.-2nd ed. p. cm. ISBN 0-632-05403-4 1. Human anatomy Outlines, syllabi, etc. I. Borley, Neil R. 11. Title. QM31.W55 2000 61 1-dc21 99-39812 CIP

ISBN 0-632-05403-4

A catalogue record for this title is available from the British Library

Set by Graphicraft Limited, Hong Kong Printed and bound in India using acid-free paper by Replika Press Pvt. Ltd

For further information on Blackwell Publishing, visit our website: www.blackwellpublishing.com CONTENTSCONTENTS

PrefacePreface tototo second second edition,edition,edition, ix ixix PrefacePreface tototo first firstfirst edition,edition,edition, X Xx NotesNotesNotes on on thethethe text,text,text, xixi xi .....,.-..., .. .__CY___.. ...I...._~...... F.._.*-...".....___... (...... mrn 11:1:: Arteries, Arteries,Arteries, 1 11 ......

2:2: Veins, Veins,v 47 47 ......

33: : LympLymphatics,Lymphatics, ha tics, 5 59 9 ......

4:4: Autonomic AutonomicAutonomic nervous nervousnervous system, system, 7272.:72 ......

5:J:L Cranial 11nnwnei nerves, ,111,ai 87

...... " ~ ...... <.....a...... ,./ ...... mrn... . 6:6:6:Peripheral Peripheral nerves,nerves,nerves, 1111 1 1 ......

7:7:DermatomesDermatomesDermatomes and andand cutaneouscutaneous nerve nervenerve distribution, distribution,distribution, 143 143143 rn 88: : Muscles,Muscles, Muscles, 15 1511 ...... _ ...... D 9:9:9 Joints, Joints,Joints, 177 177177 U 10: Ossifktion times, 185 m 1l: Foramina-skull and spine, 191

12: Spaces other than skull andspine, 197

13: Position of structures according to vertebral levels, 201 m 14: Pharyngeal derivatives, 203

viii We have been pleasantly surprised at the conventional corona1 view that appears success of this book and most grateful to all in all the textbooks and improved our the students and colleagues who have made understanding of this important area. We constructive criticisms. There were a number may be criticised for giving excessive space of errors of fact, expression and omission in for what might appear to some as less the original text and we very much hope that important aspects of anatomy but we have most of these have been corrected. done this because we are so aware of the We have resisted the temptation of those difficulty that some students have with who suggested that we illustrate each muscle learning these topics or even finding the as such information can be found in other information concisely in larger texts. larger texts and we fear for the loss of the We remain committed to teaching compactness that seems so popular with anatomy to a high standard even if limited in students. We have, however, expanded the the degree of complexity that has now been section on the autonomic system, partic- imposed on us by modern views on core ularly in respect to the head and neck and courses for students and dictated by those abdomen as these remain areas of wonder- who make the rules for surgical trainees. ment in the minds of many students, and We hope that this second edition will we suspect others as well (!) but they are, prove useful and be an inspiration for some of course, important clinically in respect to young surgeons. basic neurological and abdominal exam- ROBERT WHITAKER inations. We have included our favourite NEIL BORLEY lateral view of the cavernous sinus as we Cambridge and Oxford, 2000 believe that it adds considerably to the How many times have you looked up the encountered. The book has been compiled course of an artery or nerve in one of the with this in mind. excellent anatomy textbooks that are It is designed primarily for undergraduate available today only to find that the details medical students and prospective surgeons are spread over several sections of the book who are studying for a higher degree in and that an instant summary is not surgery. For each of these groups we believe available? At times like this you wish there it will be ideal. However, it should also be was a quick reference book with all the extremely useful for all clinicians who need answers neatly catalogued in dictionary to remind themselves of anatomical facts format. at all stages in their careers and for other We have attempted to provide such a professional groups such as nurses, concise text for rapid reference. Of course, physiotherapists and radiographers. we emphasise that this is not a text for Inevitably in a book of this size there has learning anatomy from scratch but one that been some selection of material for inclusion should be used in conjunction with one of and no attempt has been made to provide the fuller texts that has stood the test of details of minutiae that appear in the fuller time. The book is designed for those who texts. already have some working knowledge of The authors' original artwork was anatomy and need to find accurate facts redrawn with a graphics program by Jane quickly. Fallows, medical illustrator, to whom the Both authors have been sufficiently recent authors owe an immense debt of gratitude students of anatomy for higher degrees and for her skill and patience. for teaching undergraduate medical stu- ROBERT WHITAKER dents that each can remember the problems NEIL BORLEY that both students and they themselves Cambridge, 1994 The illustrations show the right side of inferior(1y) the body as viewed from in front, unless internal otherwise indicated. The two exceptions are interphalangeal the cervical and brachial plexuses where it joint(s) makes little difference as to which side they lateral(1y) are viewed and they are more conveniently ligament(s) drawn and remembered as they are shown medial(1y) here. Where there might be confusion, a metacarpal(s) small compass has been added to indicate metacarpophalangeal the left and right sides of the body. metatarsophalangeal Eponymous names appear sparingly and metatarsal(s) only when they are in common usage. The nerve(s) following abbreviations have been used as posterior(1y) appropriate throughout the text. proximal superior(1y) tarsometatarsal List of abbreviations vein(s) ant anterior(ly) art(s) artery(ies) Note: Abbreviations are not used for muscle branch(s) names or in titles. The following words are CMC carpometacarpal always written in full: greater, lesser, middle, div(s) division(s) superficial and combinations such as ext external mediolateral. This page intentionally left blank Coronary arteries 2 Thoracic (descending)aorta 28 Ascending & arch of aorta 4 Abdominal aorta 30 Internal carotid artery, vertebrobasilar External iliac artery 30 system & circle of Millis 8 Coeliac trunk 32 Ophthalmic artery 10 Superior mesenteric artery 34 External carotid artery 12 Inferior mesenteric artery 34 Maxillary artery 14 Internal iliac artery 36 Middle meningeal artery 14 Femoral artery 36 Su bclavian artery 16 Popliteal artery 38 Axillary artery 20 Anterior tibial artery 38 Brachial artery 22 Posterior tibial artery 40 Radial artery 24 Peroneal (fibular) artery 42 Ulnar artery 26 Arterial anastomoses around scapula 44 Arterial anastomoses around hip 45 Coronary arteries ARTERIES

Coronary arteries ARTERIES Coronary arteries

CORONARY ARTERIES auricle to reach the atrioventricular From: Ascending aorta groove where it divides into an anterior To: Myocardium interventricular (formally left anterior descending) artery and circumflex branches. Right coronary artery. Originates from the The circumflex artery runs in the atrio- anterior (new nomenclature: right) aortic ventricular sulcus around the left border of sinus. It passes anteriorly between the the heart to anastornose with the right pulmonary trunk and the right auricle to coronary artery. The anterior inter- reach the atrioventricular sulcus in which it ventricular artery descends on the anterior runs down the anterior surface of the right surface of the heart in the anterior cardiac border and then onto the inferior interventricular groove and around the surface of the heart. It terminates at the apex of the heart into the posterior interven- junction of the atrioventricular sulcus and tricular groove where it anastomoses with the posterior interventricular groove by the posterior interventricular branch of the anastomosing with the circumflex branch right coronary artery. The left coronary of the left coronary artery and giving off artery supplies the left atrium, left ventricle, the posterior interventricular (posterior anterior interventricular septum, sinuatrial descending) artery. It supplies the right node in 40% of cases and the atrioven- atrium and part of the left atrium, the tricular node in 20%. sinuatrial node in 60% of cases, the right ventricle, the posterior part of the inter- Dominance. In approximately 10% of hearts ventricular septum and the atrioventricular the posterior interventricular artery arises node in 80% of cases. from the circumflex artery (left coronary) and then most of the left ventricle and Left coronary artery. Arises from the left interventricular septum are supplied by the posterior (new nomenclature: left) aortic left coronary artery. The heart is said to have sinus. It passes laterally, posterior to the left cardiac dominance. pulmonary trunk and anterior to the left Ascending & arch of aorta ARTERIES

Ascending & arch of aorta ARTERIES Ascending & arch of aorta

ASCENDING & ARCH OF AORTA to the phrenic nerve. Lateral to all these From: Left ventricle structures are the pleura and left lung. To: Descending aorta Posterior and to the right of the arch are the trachea, deep cardiac plexus, left recurrent Ascending aorta. Arises at the vestibule of laryngeal nerve, oesophagus, thoracic duct the left ventricle at the level of the third left and the body of T4. Inferior to the arch are costal cartilage and passes upwards and the pulmonary bifurcation, the left main slightly to the right to a point behind the bronchus, the ligamentum arteriosum and sternum at the level of the manubriosternal the left recurrent laryngeal nerve. From its joint (second costal cartilage) where it superior surface emerge the brachiocephalic becomes the arch of the aorta. It is enclosed artery, the left common carotid and left in fibrous and serous pericardium. Anterior subclavian arteries. Within the adventitia to it are the right auricle, the infundibulum of the ascending and arch of the aorta lie of the right ventricle and pulmonary trunk. baro- and chemoreceptors. Posterior, lie the left atrium, the right pulmonary artery and right main bronchus. Brachiocephalic artery. Arises from the To the left lie the pulmonary trunk and the convexity of the aortic arch behind the left auricle. To the right are the superior vena manubrium sterni and passes upwards and cava and the right atrium. posteriorly to the right. It divides into the right subclavian and right common Arch of aorta. The arch begins posterior to carotid arteries posterior to the right the manubriosternal joint at the level of the sternoclavicular joint. Anterior to it are the second costal cartilage and passes posterior left brachiocephalic vein with the right and to the left, over the left main bronchus inferior thyroid vein entering it, and the to end at the left side of the body of T4 thymic remnants. The artery initially lies vertebra. Its highest level is the mid point of anterior to the trachea then passes to lie on the manubrium sterni and at this level its its right lateral side. On the right of the three main branches emerge. Anterior and artery are the right brachiocephalic vein, to the left of the arch are (from anterior to upper part of the superior vena cava, the posterior) the left phrenic nerve, vagal and pleura and the cardiac branches of the vagus. sympathetic contributions to the cardiac The main vagal trunk is more posterolateral. plexus, and the left vagus. Also, the left At the origin of the brachiocephalic artery superior intercostal vein runs forwards on the left common carotid artery lies the arch anterior to the vagus and posterior posteriorly on its left.

continued Ascending & arch of aorta ARTERIES

Ascending & arch of aorta ARTERIES Ascending & arch of aorta

Common carotid arteries. The right side. To its left lie the vagus, the left phrenic common carotid artery arises from the nerve and the left pleura and lung. brachiocephalic artery as it divides posterior to the right sternoclavicular joint, whilst Both common carotid arteries (cervical). the left common carotid arises from the Ascend in the neck slightly laterally from a convexity of the aortic arch. Both end as the point posterior to the sternoclavicular joint arteries bifurcate at the level of the upper to end at the level of the upper border of the border of the thyroid cartilage (C4). thyroid cartilage (C4)at which point there is a dilatation-the carotid sinus (a Left common carotid artery (thorax).Lying baroreceptor). On the posterior aspect of anterior to the thoracic part of this artery are the bifurcation there is the carotid body (a the left brachiocephalic vein and the thymic chemoreceptor). Lying between left and right remnant. Posterior to it in its lower part are arteries, and medial to each, progressively the left subclavian artery and the trachea from below are the trachea, recurrent whilst further superiorly there is the left laryngeal nerves, thyroid gland, larynx and recurrent laryngeal nerve, the thoracic duct pharynx. Each artery lies in its carotid sheath and the left side of the oesophagus. On its with the internal jugular vein lateral to it and right at its origin is the brachiocephalic the vagus nerve between and posterior to artery but as it ascends the inferior thyroid them both. veins and the trachea come to lie on its right Internal carotid artery ARTERIES

Internal carotid, vertebrobasilar system & circle of Willis Note: (I) Labyrinthine usually arises from anterior inferior cerebellar; (2) posterior spinal may come from vertebral ARTERIES Internal carotid artery

INTERNAL CAROTID ARTERY, Anterior cerebral artery is formed by the VERTEBROBASILAR SYSTEM & bifurcation of the internal carotid artery. It CIRCLE OF WlLLlS passes anteriorly over the optic nerve to arch From: Bifurcation of the common carotid over the genu of the corpus callosum on the arts (C4)& first parts of subclavian arts medial aspect of the cerebral hemispheres To: Terminal brs where it ends as terminal branches.

The internal carotid artery angles from the Middle cerebral artery is formed by the bifurcation slightly posteriorly to reach the bifurcation of the internal carotid artery. It carotid canal through which it enters the runs laterally into the sylvian fissure then skull to end as middle and anterior cerebral posterosuperiorly in the sulcus where it arteries. At its origin it possesses a dilatation divides into terminal branches. in which lie the carotid sinus and body. In the neck it is crossed laterally by, Basilar artery is formed by the junction of from below up, the pharyngeal branch of the left and right vertebral arteries (see the vagus (X),glossopharyngeal nerve (IX), subclavian artery, pp. 16-19) anterior to the stylopharyngeus and styloglossus. It lies on upper medulla. From there it ascends lying the pharyngeal wall and the pharyngobasilar angled forwards between the pons and the fascia. Within the carotid canal it turns 90 clivus in a slight depression on the anterior degrees anteromedially to run through the surface of the pons. It terminates at the upper petrous temporal bone where it lies medial border of the pons as posterior cerebral to the middle ear. It then turns 90 degrees arteries. superiorly to pass across the upper limit of the foramen lacerum. It then turns 90 Posterior cerebral artery is formed by the degrees anteriorly to pass forwards, lateral bifurcation of the basilar artery. It passes to the body of the sphenoid which it grooves. laterally around the cerebral peduncle to run Here it lies in the medial wall of the posteriorly above the tentorium cerebelli on cavernous sinus with the abducent nerve the inferomedial surface of the occipital lobe (VI) on its lateral side. At the anterior end where it divides into terminal branches. of the cavernous sinus it turns 90 degrees superiorly then 90 degrees posteriorly to (Other branches of the internal carotid pass medial to the anterior clinoid process artery, not illustrated, are caroticotympanic, and lateral to the pituitary stalk and optic pterygoid and cavernous arteries.) chiasma. It ends as terminal branches on the medial surface of the temporal lobe. Ophthalmic artery ARTERIES

Ophthalmic artery Note: Right side viewed from above ARTERIES Ophthalmic artery

OPHTHALMIC ARTERY medial orbital border deep to the superior From: Internal carotid art tarsal plate as branches which leave the orbit To: Terminal brs in orbit to anastomose with branches of the facial artery. It arises from the internal carotid artery as it lies medial to the anterior clinoid process Central retina1 artery. This small, important and runs anteriorly through the optic canal end artery supplies the optic nerve and within the optic nerve's dural sheath, lying retina. It leaves the ophthalmic artery below inferolateral to the nerve. Small branches the optic nerve and then, half way along the supply the proximal nerve. In the orbit the orbital part of the optic nerve, enters first the artery leaves the dural sheath and passes dural sheath and then the nerve itself. forwards around the lateral side of the nerve to cross anterior to it to reach the medial (Other branches, not illustrated, (1)of orbit. It then continues medially between ophthalmic artery are anterior meningeal superior oblique and medial rectus to pass and medial palpebral arteries; (2)of lacrimal out of the cone of muscles to reach the artery are lateral palpebral, zygomatic and medial wall of the orbit. The artery recurrent meningeal arteries; (3)of muscular continues forwards to terminate at the is anterior ciliary artery.) External carotid artery ARTERIES

External carotid artery ARTERIES External carotid artery

EXTERNAL CAROTID ARTERY Lingual artery. Runs superiorly looping over From: Upper border of thyroid cartilage (C4) the greater cornu of the hyoid bone and To: Terminal brs within parotid gland post passes medially (deep) to hyoglossus then to neck of mandible into the substance of the tongue.

The artery arises within the carotid sheath Facial artery. Arises from the anteromedial from the bifurcation of the common carotid surface of the external carotid artery and artery. It lies at first anteromedial to the runs above the hyoid bone deep to digastric internal carotid artery but spirals over it to and passes upwards to reach the posterior come to lie lateral to it at the level of C2. surface of the submandibular gland which Initially, it angles slightly forwards then it grooves deeply, lying medial to the body curves backwards as it ascends to enter the of the mandible. Here it lies on superior parotid gland between deep and superficial constrictor, directly lateral to the palatine lobes. During its course it is crossed by, from tonsil. It then follows a tortuous course below upwards: the upper root of the ansa looping at first inferiorly then upwards cervicalis, the hypoglossal nerve, the around the lower border of the mandible to posterior belly of digastric, stylohyoid, the cross the bone anterior to the insertion of stylohyoid ligament and the facial nerve masseter (where it is easily palpable). It then (within the parotid). Passing between it and runs in the superficial tissues of the face the internal carotid artery are, from below towards the angle of the mouth where it upwards, the pharyngeal branch of the turns superiorly towards the medial canthus vagus (X),glossopharyngeal nerve (IX), of the eye. (Other branches, not illustrated, stylopharyngeus and styloglossus. It lies on, are glandular (to submandibular gland) and from below upwards, pharyngeal wall, lateral nasal arteries.) superior laryngeal branch of the vagus (X) and deep parotid lobe. Superficial temporal artery. Runs superiorly between the deep and superficial lobes of Superior thyroid artery. Arises from the the parotid gland, over the posterior end anterior surface of the external carotid artery of the zygomatic process (where it is near its origin and runs inferiorly and easily palpable) and terminates in the forwards deep to omohyoid and lateral to subcutaneous tissues of the lateral scalp. the inferior constrictor and external laryngeal nerve to reach the upper pole of the thyroid gland. Maxillary artery ARTERIES Middle meningeal artery

Maxillary artery

Middle meningeal artery Maxillary artery ARTERIES Middle meningeal artery

MAXILLARY ARTERY terminates as branches which accompany the From: External carotid within parotid gland branches of the maxillary division of the To: Terminal brs in pterygopalatine fossa trigeminal nerve (Vb).

It arises from the external carotid artery Inferior alveolar artery. Passes within the parotid gland posterior to the inferolaterally posterior to the inferior neck of the mandible and ends as the alveolar nerve onto the medial surface of the sphenopalatine artery. The artery is divided ramus of the mandible which it grooves as it into three portions by its relationship enters the inferior alveolar (mandibular) posterior, in, or anterior to the lateral foramen in the mandible. It is distributed pterygoid muscle. The first part passes deep along the mandibular canal to the lower jaw to the neck of the mandible between the bone and teeth. Its terminal branch appears as the and the sphenomandibular ligament and mental branch through the mental foramen. runs anteriorly lateral to the inferior alveolar nerve to reach the border of the lateral (Other branches, not illustrated, (1)of pterygoid. The second part angles maxillary artery (third part) is artery of anteromedially between the two heads of pterygoid canal; (2)of inferior alveolar lateral pterygoid between anterior and artery are dental and mental; (3)of posterior divisions of the mandibular nerve. infraorbital artery are dental and anterior The third part leaves the lateral pterygoid to superior alveolar; (4)of posterior superior enter the pterygopalatine fossa where it alveolar artery is dental.)

MIDDLE MENINGEAL ARTERY deeply or tunnel through the bone at the From: First part of maxillary art apex of the greater wing. It passes across the To: Terminal brs inner aspect of the pterion onto the parietal bone. The posterior division runs almost It arises from the superomedial surface of the horizontally posterolateral over the inner maxillary (first part) to run between the two aspect of the squamous temporal bone onto rootlets of the auriculotemporal nerve as it the lower parietal bone where it gives passes vertically into the foramen spinosum terminal branches. in the greater wing of the sphenoid bone. After a very short course laterally over the Because of the problem of extradural greater wing of the sphenoid in the middle haemorrhage caused by damage to this cranial fossa it divides into anterior and artery, the surface anatomy is important. posterior divisions. The anterior division Anterior branch: 3 cm above mid point of runs anterolaterally on the floor of the zygomatic arch. Posterior branch: on a line middle cranial fossa beneath the dura mater vertically from the mastoid process and and grooves the greater wing of the sphenoid horizontal from the upper margin of the as it passes upwards to the junction of the orbit. lesser and greater wings. Here it may groove Subclavian artery ARTERIES

Subclavian artery Note: (I) The superficial cervical artery is named 'transverse cervical artery' if it gives origin to the dorsal scapular artery instead of the latter arising separately from the second part of the subclavian artery; (2) phrenic branch of musculophrenic artery anastomoses with inferior phrenic artery ARTERIES Subclavian artery

SUBCLAVIAN ARTERY Subclavian artery-second part. Lies From: Right-brachiocephalic trunk posterior to scalenus anterior and anterior Left-aortic arch to scalenus medius. Anterior to scalenus To: Axillary art anterior are the phrenic nerve and, slightly inferior, the subclavian vein. Postero-inferior The subclavian arteries arise as indicated are the suprapleural membrane and the above and end at the outer border of the first lower trunk of the brachial plexus. Superior rib where they become the axillary arteries. to it are the upper and middle trunks of the They each have three parts: (1)medial (three brachial plexus. branches); (2)behind (two branches); and (3)lateral (no branches) to scalenus anterior. Subclavian artery-third part. Begins at the lateral margin of scalenus anterior and Right subclavian artery-first part. Arises extends to the outer (lateral)margin of the from the brachiocephalic artery behind the first rib where it becomes the axillary artery. right sternoclavicular joint, lying initially Anterior to it is the external jugular vein posterior to the right common carotid artery, and its tributaries. Antero-inferior is the then passing upwards and laterally to reach subclavian vein. Postero-inferior is the lower the medial side of scalenus anterior. Anterior trunk of the brachial plexus and the first rib. to this first part are the vagus (X), its cardiac Posterosuperior are the upper and middle branches, sympathetic nerves, the internal trunks of the brachial plexus. jugular and vertebral veins. The ansa subclavia (sympathetic nerves) curls around Vertebral artery (see also internal carotid, the artery to lie both anterior and posterior vertebrobasilar system & circle of Willis, to it. As the artery arches laterally the pp. 8-9). Arises from the posterosuperior suprapleural membrane and the right aspect of the first part of the subclavian recurrent laryngeal nerve lie inferior and artery and ends where the arteries from the posterior to it. two sides join to form the basilar artery at the lower pons. It angles posteriorly between Left subclavian artery-first part. Arises from the medial border of scalenus anterior and the arch of the aorta just posterior and the lateral border of longus colli in the apex slightly to the left of the origin of the left of the pyramidal space before entering the common carotid artery at the level of the foramen in the transverse process of C6 intervertebral disc of T3lT4. It passes behind its anterior tubercle (carotid tubercle upwards and then, behind the left sterno- of Chassaignac). Lying anterior to this first clavicular joint, it arches laterally over the part are the common carotid artery and the suprapleural membrane to the medial edge vertebral vein and, more medially, the of scalenus anterior. Anterior to it in the inferior thyroid artery and middle cervical thorax are the left common carotid artery, ganglion. On the left the thoracic duct the left brachiocephalic vein, the left vagus crosses it anteriorly. Posterior to it are the and its cardiac branches and the left phrenic anterior primary rami of C7 and C8 nerves nerve. Posterior to it lie the left side of the and more medially the inferior cervical oesophagus, the thoracic duct and longus (stellate) ganglion. The second part of colli. Medial to it is the trachea, the left the artery ascends within the foramina recurrent laryngeal nerve and, more of the transverse processes of C6 to Cl, superiorly, the thoracic duct. In the neck accompanied by sympathetic nerves and it is crossed anteriorly by the left phrenic vertebral veins. It passes out posteriorly nerve and the thoracic duct. behind the lateral mass of the atlas before

continued Subclavian artery ARTERIES

Subclavian artery Note: (I) The superficial cervical artery is named 'transverse cervical artery' if it gives origin to the dorsal scapular artery instead of the latter arising separately from the second part of the subclavian artery; (2) phrenic branch of musculophrenic artery anastomoses with inferior phrenic artery ARTERIES Subclavian artery turning medially over its posterior arch. epigastric and musculophrenic arteries. It then turns anteriorly to pierce the (Other branches, not illustrated, are atlanto-occipital membrane lateral to the mediastinal, thymic, sterna1 and perforating cervicomedullary junction. It pierces the (mammary).) dura and arachnoid to ascend supero- medially around the anterior aspect of the Inferior thyroid artery. Ascends along the medulla where it joins the artery from the medial edge of scalenus anterior. Just below opposite side at the lower border of the pons the anterior tubercle of C6 it turns medially to form the basilar artery. (Other branches, to reach the lower thyroid gland, passing not illustrated, are spinal, meningeal and between vertebral artery and vein muscular.) (posteriorly) and carotid sheath and sympathetic chain (anteriorly). Its terminal Internal thoracic artery. Arises from the branches are often amongst the recurrent anterior aspect of the first part of the laryngeal nerve. (Other branches of inferior subclavian artery and passes inferiorly thyroid artery, not illustrated, are glandular, behind the brachiocephalic vein and the pharyngeal, oesophageal and tracheal.) phrenic nerve to reach the dome of the pleura. It then angles medially to lie Superior intercostal artery. Passes inferiorly, posterior to the upper six costal cartilages, anterior to the necks of the first two ribs to between the internal intercostal and provide the posterior intercostal arteries for transversus thoracis muscles. It terminates at the first two intercostal spaces. the 6th intercostal space to give the superior Axillary artery ARTERIES

Axillary artery ARTERIES Axillary artery

AXILLARY ARTERY the brachial plexus. Posterior to it are the From: Subclavian art posterior cord and subscapularis whilst To: Brachial art lateral to it is the lateral cord of the brachial plexus. This is the continuation of the subclavian artery. It commences at the lateral border of Third part extends from the lower border of the 1st rib and ends at the inferior border of pectoralis minor to the inferior border of teres major to become the brachial artery. teres major and has three branches. Anterior It is divided into three parts by pectoralis to it are pectoralis major, the clavipectoral minor. It is invested in a fascia1 sheath fascia and the median nerve. Medial to it lie arising from the prevertebral fascia. the axillary vein and the ulnar nerve. Posterior to it are the radial nerve, teres First part is medial to the upper border of major, subscapularis and the tendon of pectoralis minor and has one branch. latissimus dorsi. On its lateral side lie the Anterior to it is the clavipectoral fascia, musculocutaneous nerve, lateral root (head) subclavius and the lateral pectoral nerve. of the median nerve, the tendon of biceps in The axillary vein is medial whilst posterior the bicipital groove and coracobrachialis. to it are the upper part of serratus anterior, the long thoracic nerve, the medial pectoral Posterior circumflex humeral artery. Passes nerve and the medial cord of the brachial posteriorly through the quadrangular space plexus. Lateral to it are the lateral and with the axillary nerve to supply shoulder posterior cords of the brachial plexus. joint and surrounding muscles.

Second part has pectoralis minor lying Note. Lateral thoracic artery and pectoral anterior to it and has two branches. Medial branches of the thoraco-acromial trunk are to it is the axillary vein and medial cord of important supply vessels for the breast. Brachial artery ARTERIES

Brachial artery ARTERIES Brachial artery

BRACHIAL ARTERY arm and, distally, the median nerve. Lateral From: Axillary art to it high up are the median and musculo- To: Radial & ulnar arts cutaneous nerves. Coracobrachialis, biceps and its tendon also lie on its lateral This is the continuation of the axillary artery side. The artery lies first on the long and then beginning at the lower margin of the teres the medial head of triceps, then brachialis major and ending in the cubital fossa at the in the lower third of the arm. level of the neck of the radius as the radial and ulnar arteries. At first it lies medial to the Arteria profunda brachii. Leaves the humerus then it spirals around to lie anterior posteromedial aspect of the brachial artery to it. It is superficial throughout its course just below teres major and passes posteriorly and accompanied by venae commitantes. between the long and medial heads of triceps It is crossed from lateral to medial by the with the radial nerve and into the radial median nerve in the mid arm and by the groove before breaking up into its terminal bicipital aponeurosis in the cubital fossa. branches. Medial to it is the ulnar nerve in the upper Radial artery ARTERIES

Radial artery ARTERIES Radial artery

RADIAL ARTERY superficial palmar arch. The radial artery From: Brachial art in midline of cubital fossa then passes beneath the tendons of abductor To: Deep palmar arch in hand pollicis longus and extensor pollicis brevis to enter the anatomical snuff box. It passes The radial artery arises at the terminal across the snuff box on the scaphoid and bifurcation of the brachial artery in the trapezium and under the tendon of extensor cubital fossa at the level of the neck of the pollicis longus. It gives off a dorsal carpal radius. It crosses anterior to the biceps branch to the dorsal carpal arch which in tendon to lie initially on supinator. It then turn supplies the wrist joint, the dorsal passes down the radial side of the forearm aspects of the metacarpals and the dorsal lying consecutively on pronator teres, the digital arteries. The radial artery then gives radial head of flexor digitorum superficialis, off two named vessels-arteria radialis flexor pollicis longus and the insertion of indicis and princeps pollicis (first palmar pronator quadratus before passing onto the metacarpal artery). It next passes down lower end of the radius where its pulse is between the two heads of the first dorsal palpable as it lies lateral to the tendon of interosseous then between the two heads of flexor carpi radialis. It thus lies deep to adductor pollicis to enter the palm of the brachioradialis and, to a lesser extent, flexor hand and form the deep palmar arch. The carpi radialis. The superficial branch of the deep palmar arch lies 1cm proximal to the radial nerve lies lateral to it in the forearm. superficial palmar arch (ulnar artery). It It gives off a palmar carpal branch which supplies the palmar metacarpals, gives off a contributes to the palmar carpal arch. It then recurrent branch to the palmar carpal arch gives off a superficial palmar branch (palmar and three perforating branches which cutaneous branch) which supplies the thenar anastomose with the dorsal metacarpal muscles before anastomosing with the arteries. Ulnar artery ARTERIES

Ulnar artery ARTERIES Ulnar artery

ULNAR ARTERY into anterior and posterior interosseous From: Brachial art arteries. To: Superficial palmar arch in hand Anterior interosseous artery. Descends on The artery arises as the terminal bifurcation the anterior surface of the interosseous of the brachial artery in the cubital fossa at membrane together with the anterior the level of the neck of the radius. It leaves interosseous branch of the median nerve the fossa deep to the deep head of pronator lying between flexor digitorum profundus teres and deep to the fibrous arch of flexor medially and flexor pollicis longus laterally. digitorum superficialis just lateral to the Branches perforate the membrane to supply median nerve to cross beneath the nerve the extensor muscles. Above pronator before running down the ulnar side of the quadratus it gives off a small branch which forearm. It lies on flexor digitorum descends deep to the muscle to join the profundus with the ulnar nerve on its medial palmar carpal arch, then the anterior side. It lies lateral to flexor carpi ulnaris interosseous artery itself passes posteriorly before passing superficial to the flexor through the membrane to anastomose with retinaculum. The dorsal and palmar carpal the posterior interosseous artery which arteries contribute, with similarly named descends to join the dorsal carpal arch. arteries from the radial artery, to the dorsal and palmar carpal arches. The ulnar artery Posterior interosseous artery. Passes then gives off a deep branch to the deep posteriorly above the interosseous palmar arch before forming the superficial membrane and then runs between supinator palmar arch at the level of the distal border superficially and abductor pollicis longus of the extended thumb. The superficial arch deeply with the deep branch of the radial supplies the hypothenar eminence and gives nerve (posterior interosseous nerve) to off the palmar digital arteries. At the level of descend to supply the extensor muscles of pronator teres the ulnar artery gives off the the forearm. It anastomoses with the distal common interosseous artery which divides branches of the anterior interosseous artery and dorsal carpal arch. Thoracic (descending) aorta ARTERIES

Thoracic (descending) aorta ARTERIES Thoracic (descending) aorta

THORACIC (DESCENDING) AORTA are the hilum of the left lung (particularly From: Arch of aorta the left main bronchus), pericardium, To: Abdominal aorta left atrium, oesophagus and diaphragm. Posterior lie the necks of the ribs of T5-T6 This arises as the continuation of the arch of and the sympathetic chain at that level, the the aorta commencing to the left of the body vertebral bodies and hemiazygos veins. To of T4 and ends as it passes into the abdomen its right lie the right pleura and lung and at T12. It grooves the left side of the bodies thoracic duct. The oesophagus and its of T4-T6 vertebrae then it inclines medially surrounding plexus of nerves is initially to its to lie in the midline over the lower thoracic right but lower down it crosses the aorta to vertebrae. It passes out of the thorax at T12 lie anterior then slightly to the left. To its left posterior to the median arcuate ligament of are the left pleura and lung. (Other branch, the diaphragm to become the abdominal not illustrated, is pericardial.) aorta. Lying anterior to it from above down Abdominal aorta ARTERIES External iliac artery

Abdominal aorta & external iliac artery Abdominal aorta ARTERIES External iliac artery

ABDOMINAL AORTA internal iliac arteries, Anterior to each vessel From: Thoracic aorta are sympathetic contributions to the superior To: Common iliac arts hypogastric plexus, the ureter (near the terminal bifurcation of the vessel), This main artery arises as the continuation of peritoneum and small bowel. In addition the thoracic aorta as it passes, in the midline, on the left side the superior rectal artery posterior to the median arcuate ligament of lies anterior. Posterior to each vessel are the diaphragm at T12 and it ends slightly the sympathetic trunk, obturator nerve, to the left of the midline at L4 where it lumbosacral trunk, iliolumbar artery and the terminates as the left and right common bodies of L4 and L5 with the disc between iliac arteries. Anterior to it, from above them. In addition posteriorly on the right downwards, are the coeliac trunk and its side are the terminal portions of the common branches, the coeliac plexus, lesser sac, iliac veins and the commencement of the superior mesenteric artery, left renal vein, inferior vena cava. The left common iliac body of pancreas, commencement of vein lies posteromedial to the left common each gonadal artery, fourth part of the iliac artery. Psoas major lies lateral to each duodenum, posterior parietal peritoneum, vessel. attachment of the mesentery and inferior mesenteric artery. Posterior to it are the Gonadal artery. Descends passing obliquely lumbar arteries and left lumbar veins, inferiorly on the posterior abdominal wall anterior longitudinal ligament and vertebral to the level of the external iliac artery. The bodies with their intervertebral discs. To its testicular arteries pass around the lower right are the cisterna chyli, thoracic duct, border of the false pelvis to enter the inguinal azygos vein, right crus of diaphragm and canal through the deep ring to form part of inferior vena cava. To its left are the left the spermatic cord. The ovarian vessels crus of diaphragm, left coeliac ganglion, descend over the external iliac vessels into the duodenojejunal flexure (upper border the infundibulopelvic fold to supply the of L2), sympathetic trunk and inferior ovary via the broad ligament. The common mesenteric vessels. On both sides the relations of the arteries in both sexes are: phrenic, suprarenal and renal vessels are left, posterior-psoas, genitofemoral nerve, lateral whilst distal to the bifurcation of the ureter and external iliac artery; left, abdominal aorta is the median sacral artery. anterior-inferior mesenteric vein, left colic artery and sigmoid mesentery; right, Common ifiac arteries. These commence at posterior-inferior vena cava, psoas, the bifurcation of the abdominaI aorta just genitofemoral nerve, ureter and external to the left of the midline at L4 and pass iliac artery; right, anterior-third part of inferolaterally to the level between L5 and the duodenum, right colic artery and ileal S1 vertebrae where they bifurcate anterior to mesentery. the sacro-iliac joint to give the external and

EXTERNAL ILlAC ARTERY Posterior and lateral to it is the medial From: Common iliac art border of psoas major whilst the femoral To: Femoral art vein comes to lie medially. Anteromedially it is covered by peritoneum on which lies small The external iliac artery descends laterally bowel with sigmoid colon additionally on from the common iliac artery to pass under the left. It is crossed at its origin by the ureter the inguinal ligament at the mid inguinal and then by the gonadal vessels, genital point (half way between the anterior branch of the genitofemoral nerve, deep superior iliac spine and symphysis pubis) circumflex iliac vein and vas deferens or where it becomes the femoral artery. round ligament.

3 1 Coeliac trunk ARTERIES

Coeliac trunk ARTERIES Coeliac trunk

COELIAC TRUNK lienorenal ligament to reach the splenic From: Abdominal aorta at lower border of hilum. T12 To: Terminal brs-left gastric, splenic & Common hepatic artery. Runs common hepatic arts inferolaterally to the right in the posterior wall of the lesser sac towards the first part The coeliac trunk (axis)arises from the of the duodenum where it gives off first the anterior aspect of the abdominal aorta at the gastroduodenal and then right gastric level of the lower border of T12 and after arteries. It then curves anteriorly as the 1cm divides into its three terminal branches. hepatic artery to pass into the peritonea1 reflection which forms the inferior margin of Left gastric artery. Passes superolaterally on the opening of the lesser sac. It approaches the posterior wall of the lesser sac to reach the portal vein from its left side and then the apex of this structure at the cardio- comes to lie anterior to it, with the bile duct oesophageal junction where it divides into on its right, as it ascends in the free border of oesophageal branches to supply the lower the lesser omentum (anterior margin of the third of the oesophagus through the foramen of Winslow or epiploic foramen) oesophageal opening in the diaphragm. before terminating at the porta hepatis as the Its terminal gastric branches run inferiorly right and left hepatic branches. along the upper portion of the lesser curve of the stomach to anastomose with the right Gastroduodenal artery. Descends directly gastric artery. behind the first part of the duodenum to the left of the bile duct and divides at the upper Splenic artery. Passes laterally to the left, border of the pancreas into terminal angled slightly superiorly, running in the branches. posterior wall of the lesser sac. Its course is markedly tortuous as it runs along the Right gastric artery. Arises from the hepatic superior border of the pancreas, passing artery as it enters the lesser omentum and anterior to the left crus of the diaphragm, passes along the lesser curve of the stomach the upper pole of the left kidney and the to anastomose with the left gastric artery. left suprarenal gland before entering the Superior mesenteric artery ARTERIES Inferior mesenteric artery

Superior mesenteric artery ......

Inferior mesenteric artery

34 Superior mesenteric artery ARTERIES Inferior rnesenteric artery

SUPERIOR MESENTERIC ARTERY Inferior pancreaticoduodenal artery. Leaves From: Abdominal aorta the superior mesenteric artery as it begins to To: Terminal brs cross the duodenum and divides into an anterior and posterior branch. The anterior The superior mesenteric artery arises from branch passes to the right to anastomose the anterior surface of the abdominal aorta with the anterior superior pancreatico- at the level of L1. It passes inferiorly over the duodenal artery anterior to the head of the left renal vein with the splenic vein and body pancreas. The posterior branch passes also of pancreas anterior to it. It next lies on the to the right but posterior to the head of the uncinate process of the pancreas and the pancreas to anastomose with the posterior junction of the third and fourth parts of the superior pancreaticoduodenal artery. duodenum from where it passes obliquely and to the right into the mesentery of the Middle colic artery. Note that this artery small bowel before giving off its terminal arises early from the superior mesenteric branches. The superior mesenteric vein is artery to supply the transverse colon. This is on its right whilst posterior to the terminal logical as the right colic would otherwise branches are the inferior vena cava, the need to be excessively long. right ureter and psoas major. The superior mesenteric plexus of nerves surrounds the Ileocolic artery. Passes obliquely inferiorly to artery. It supplies bowel from the mid second the right in the root of the mesentery where it part of the duodenum, jejunum, ileum, passes anterior to the right ureter and right ascending and right two-thirds of transverse gonadal vessels to reach the caecum where it colon. divides into its terminal branches.

INFERIOR MESENTERIC ARTERY crossing the left common iliac artery medial From: Abdominal aorta to the left ureter. The inferior mesenteric To: Terminal brs vein lies on its left (lateral)side. It divides into its terminal branches in the descending This artery arises from the anterior surface mesocolon. It supplies the left third of the of the abdominal aorta at the level of L3 transverse colon, the descending and sigmoid posterior to the third and fourth part of the colon and the rectum to the dentate line of duodenum. It passes inferiorly and to the left the anus. Internal iliac artery ARTERIES Femoral artery

Internal iliac artery -...... *...... *...... -...... *...... *....*.,......

Femoral artery Internal iliac artery ARTERIES Femoral artery

INTERNAL ILlAC ARTERY the pelvis via this foramen, inferior to From: Common iliac art piriformis, before passing over the tip of the To: Terminal brs ischial spine to enter the ischio-anal fossa via the lesser sciatic foramen. In runs on The artery commences at the level of the disc the lateral wall of the ischio-anal fossa between L5 and S1 and passes posteriorly on obturator internus in the pudendal into the pelvis for 4cm before forming (Alcock's) canal. It passes into the deep anterior and posterior divisions which break perinea1 pouch where it gives off its terminal up into their terminal branches. Anterior lie branches. (Other branches of the perineal the ureter and fallopian tube and ovary in the branch, not illustrated, are transverse female. Posterior are the internal iliac vein, perineal and posterior scrotal.) lumbosacral trunk and sacro-iliac joint. On the lateral side are the external iliac artery Note: In the female the vaginal artery is and vein, obturator nerve and psoas major. equivalent to the inferior vesical artery in the The parietal peritoneum and small bowel lie male, and the uterine artery is equivalent to medially. the middle rectal artery. The round ligament is supplied by the uterine artery whilst the Internal pudend.~lartery. Arises fro-n the va.s deferens is usually snpplied by the anterior division of the internai iiizc artery inferior vesical or less often by the superior and descends on the lateral wall of the pelvis vesical artery. towards t5e greater sciatic foramen. It kaves

FEMORAL ARTERY the artery within the femoral triangle. As the From: External iliac art femoral artery enters the adductor canal it To: Popliteal art lies on adductor longus then adductor magnus. It is covered initially only by deep This is the continuation of the external iliac fascia then by sartorius; the saphenous nerve artery and commences posterior to the passes anteriorly from lateral to medial. inguinal ligament at the mid-inguinal point Anterolateral to the artery is vastus medialis. (half way between the anterior superior iliac spine and the symphysis pubis). It ends as Profunda fernoris is the main branch it passes through the adductor hiatus in of the femoral artery which is given off adductor magnus to become the popliteal posterolaterally just below the femoral artery. It emerges from under the inguinal sheath 3.5cm below the inguinal ligament. ligament with the femoral vein medial to it, It runs posteriorly between pectineus and both within the femoral sheath. Lateral to it adductor longus to pass into the deep thigh and outside the femoral sheath is the femoral where it provides the deep structures and the nerve. It lies on the tendon of psoas major posterior and medial compartments with and is separated from pectineus and their main arterial supply. Perforating and adductor longus by the femoral vein which descending branches anastomose with the comes to lie progressively more posterior to genicular branches of the popliteal artery. Popliteal artery ARTERIES Anterior tibial artery Popliteal artery ARTERIES Anterior tibial artery

POPLITEAL ARTERY distance below it. It enters the popliteal fossa From: Femoral art medial to the femur and becomes the deepest To: Ant & post tibial arts structure, lying with only fat between it and the popliteal surface of the femur. Lower This artery commences as the continuation down it lies on the capsule of the knee joint of the femoral artery as the latter passes and then on popliteus. Biceps femoris is through the hiatus in adductor magnus and lateral to it and semimembranosus medial. ends as it passes under the fibrous arch of Lower down it lies between the two heads soleus where it immediately divides into of gastrocnemius. It is crossed laterally to anterior and posterior tibial arteries. The medially by the tibial nerve and the popliteal popliteal artery extends from a hand's vein with the vein always between the artery breadth above the knee and to the same and nerve.

ANTERIOR TIBIAL ARTERY between the malleoli and there becomes the From: Popliteal art dorsalis pedis artery. Initially it lies between To: Dorsalis pedis art tibialis anterior (medially) and extensor digitorum longus (laterally), then between This artery commences at the bifurcation of tibialis anterior and extensor hallucis longus. the popliteal artery just under the fibrous At the ankle it is crossed anteriorly by the arch of soleus, at the distal border of extensor retinacula and also from lateral to popliteus. It supplies the structures in the medial by the tendon of extensor hallucis extensor compartment of the lower leg. It longus. The deep peroneal nerve is initially passes anteriorly between the heads of lateral to the artery high up in the extensor tibialis posterior to pass above the upper compartment but passes anterior to it half border of the interosseous membrane, way down the leg, becoming lateral to it medial to the neck of the fibula accompanied again under the extensor retinaculum. The by its venae commitantes. It descends on the anterior tibial veins run in close association interosseous membrane and crosses the with the artery throughout. lower tibia at the ankle joint, mid way Posterior tibial artery ARTERIES

Posterior tibial artery Note: viewed from behind ARTERIES Posterior tibial artery

POSTERIOR TIBIAL ARTERY from above downwards on tibialis posterior, From: Popliteal art flexor digitorum longus, the tibia and the To: Med & lat plantar arts ankle joint. It lies deep to gastrocnemius, soleus, the flexor retinaculum and abductor This artery arises at the bifurcation of the hallucis. Posterior to the medial malleolus it popliteal artery just under the fibrous arch of lies between the tendon of flexor digitorum soleus, at the lower border of popliteus, and longus and the tibial nerve which crosses ends by bifurcating into the medial and posterior to the artery mid way down the calf lateral plantar arteries deep to abductor from the medial side to become postero- hallucis. It supplies structures in the lateral. (Other branch, not illustrated, posterior compartment of the lower leg. It is is a communicating branch to peroneal accompanied by venae commitantes and lies (fibular) artery.) Peroneal (fibular) artery ARTERIES

Peroneal (fibular) artery ARTERIES Peroneal (fibular) artery

PERONEAL (FIBULAR) ARTERY of the fibula between tibialis posterior From: Post tibial art and flexor hallucis longus to divide into its To: Terminal brs terminal branches at the level of the inferior tibiofibular joint and the superior peroneal This is a branch of the posterior tibial artery (fibular) retinaculum. Thus, although arising 2.5 cm below its origin under soleus. it supplies the peroneal compartment by It supplies structures in the lateral compart- branches that pass laterally, the main ment of the lower leg. Due to the proximity peroneal artery itself remains in the posterior of origin of the three terminal branches of compartment. Above, it is covered by soleus the popliteal artery this point of origin is and deep fascia whilst in the lower leg flexor commonly referred to as the 'popliteal hallucis longus crosses it from lateral to trifurcation'. It passes inferolaterally medial. to reach and run along the medial crest ARTERIES

Arterial anastornoses around scapula ARTERIES

Arterial anastornoses around hip This page intentionally left blank Intracranial sinuses & veins 48 Internal & external jugular veins 50 Superior vena cava 52 Azygos veins 52 Inferior vena cava 54 Portal vein 56 lntracranial sinuses & veins VEINS

lntracranial sinuses & veins VEINS lntracranial sinuses & veins

INTRACRANIAL SINUSES & VEINS foramen at the inferior margin of which it From: Cerebrum, cerebellum & diploe of unites with the inferior petrosal sinus to the skull form the internal jugular vein. To: Internal jugular V Cavernous sinus. Lies on the lateral wall of The cerebrum, cerebellum and bones of the the body of the sphenoid bone and is a lateral skull are drained by the external, internal relation of the sella turcica, the pituitary and meningeal veins to the sinuses. The gland and the sphenoidal air sinus. It lies sinuses lie between the endosteal and medial to the medial gyrus of the temporal meningeal layers of the dura mater, either as lobe. Lying in it is the internal carotid artery an endothelial lined space in its free edge (carotid syphon) with the abducent nerve (inferior sagittal and straight sinuses), or a (VI) on its lateral surface and lying on its similarly lined space where the dura is lateral wall are nerves (from above down): reflected over the bone of the inner surface oculomotor (111), trochlear (IV),ophthalmic of the skull. They are characteristically thin (Va)and maxillary (Vb)divisions of the walled, contain no valves and communicate trigeminal. It has a sponge-like reticular freely with each other. structure and its connections, particularly those with the other major sinuses (as shown Superior sagittal sinus. Lies in the superior opposite), frequently provide both supply to, margin of the falx cerebri draining the and drainage from, the sinus. There are two arachnoid granulations as it does so. It intercavernous sinuses connecting the commences at the foramen caecum and, cavernous sinuses to each other. posteriorly, usually drains as a continuation into the right transverse sinus. It frequently Occipital sinus. Begins at the foramen connects at its termination with the left magnum and ascends to end in the transverse sinus. confluence of sinuses.

Inferior sagittal sinus. Runs in the inferior Confluence of sinuses is at the lowest, free margin of the falx cerebri draining posterior end of the superior sagittal sinus at medial cortical veins as it does so, and the point that it turns, usually to the right, to terminates by fusing with the great cerebral become the transverse sinus. It connects with vein of Galen and right and left basal veins to the straight, occipital and opposite transverse form the straight sinus. sinuses.

Straight sinus. Runs in the junction of the Sphenoparietal sinus. Runs along the lesser falx cerebri and tentorium cerebelli for a wing of the sphenoid bone and drains into short distance before terminating in its the cavernous sinus. continuation-the left transverse sinus. Superior petrosal sinus. Runs along the Transverse (lateral)sinus. Runs in the lateral petrous temporal bone where the edge of border of the tentorium cerebelli grooving the tentorium cerebelli attaches and hence the occipital and squamous temporal bones, connects the cavernous and transverse to terminate in the sigmoid sinus just as it sinuses. receives the superior petrosal sinus from the cavernous sinus on each side. Inferior petrosal sinus. Runs inferiorly to connect the cavernous sinus to the internal Sigmoid sinus. Deeply grooves the temporal jugular vein. It exits the skull through the bone as it passes inferomedially into the anterior compartment of the jugular posterior compartment of the jugular foramen with the glossopharyngeal nerve. Internal & external jugular veins VEINS

Internal & external jugular veins VEINS Internal & external jugular veins

INTERNAL JUGULAR VEIN its middle third and is overlaid by From: Sigmoid & inf petrosal sinuses sternocleidomastoid and the tendon of To: Brachiocephalic Vs omohyoid in its lower third.

It runs almost vertically downwards within the carotid sheath although its covering is EXTERNAL JUGULAR VEIN thin and readily stretched. Its relationship From: Various brs to the internal carotid artery is as follows: To: Subclavian V posterior to the artery at the level of C2, posterolateral at C3 and lateral at C4, the It arises from the junction of the posterior vagus nerve (X)lies between the two auricular vein and the posterior division of throughout. Outside the sheath it is sur- the retromandibular vein and drains into the rounded by deep cervical lymph nodes and subclavian vein. The external jugular system it lies on (from above down): the lateral lies within the superficial tissues of the neck mass of the atlas (Cl),prevertebral fascia, (as does the anterior jugular system). The scalenus medius, scalenus anterior and the external and anterior jugular veins pierce the dome of the cervical pleura. It is crossed at deep fascia of the neck, usually posterior to its origin by the spinal root of the accessory the clavicular head of sternocleidomastoid to nerve, the lower root of the ansa cervicalis in fuse before draining into the subclavian vein. Superior vena cava VEINS Azygos veins

Superior vena cava & azygos veins Note: (I) Accessory hemiazygos crosses to azygos at T7 and hemiazygos at T&each crosses behind thoracic aorta, oesophagus and thoracic duct; (2) left bronchial vein may enter accessory hemiazygos. *= oesophageal and mediastinal veins, IVC = inferior vena cava, SVC = superior vena cava Superior vena cava VEINS Azygos veins

SUPERIOR VENA CAVA system on the right whilst on the left there From: Brachiocephalic Vs are two-the hemiazygos and accessory To: Right atrium hemiazygos that drain over into the azygos separately. It is formed posterior to the right first costal cartilage and passes posterior to the right Azygos vein. Arises at the approximate level sternal border where it is a close posterior of the right renal vein either as a posterior relation of the right internal thoracic vessels tributary of the inferior vena cava or as a and sternal periosteum and is occasionally confluence of the right ascending lumbar and overlaid by the anterior segment of the right right subcostal vein. It passes through the upper lobe of the lung. It lies anterolateral to aortic opening of the diaphragm under the the trachea and upper right lung hilum with right crus at the level of T12 vertebra and the right phrenic nerve applied to its right ascends on the right side of the vertebral lateral surface. It receives the azygos vein bodies behind the oesophagus. It turns into its posterior surface at the level of T4. anteriorly to pass over the hilum of the right It enters the superior surface of the right lung, lateral to the oesophagus, trachea and atrium without any valvular mechanism right vagus, to enter the superior vena cava guarding its orifice. at the level of T4. Its tributaries are the lower eight right posterior intercostal veins, the Left brachiocephalic vein. Formed posterior right superior intercostal vein (draining the to the left sternoclavicular joint and anterior 2nd, 3rd and 4th right intercostal veins), to the cervical pleura. It passes obliquely bronchial and oesophageal veins and, from downwards to the right, posterior to the the left side, the two hemiazygos veins. manubrium, separated from it only by the thymus gland or its remnant. It lies Hemiazygos vein. Arises from the confluence anterior to the left common carotid and of the left ascending lumbar vein, the left brachiocephalic arteries and crosses the subcostal vein and often a tributary from the upper anterior aortic arch. Unlike the right left renal vein. It ascends through the aortic superior intercostal vein (see below) the left opening of the diaphragm and onto the left superior intercostal vein drains into the left side of the thoracic vertebra to the level of T9 brachiocephalic vein. Other tributaries (not from where it crosses posterior to the aorta, shown) are thymic and pericardial veins. oesophagus and thoracic duct to enter the azygos vein at T8. It drains the four lower Right brachiocephalic vein. Formed left posterior intercostal veins (9-12th). posterior to the right sternoclavicular joint and passes directly inferiorly behind the right Accessory hemiazygos vein. Drains the 54th side of the manubrium, anterolateral to the left posterior intercostal veins and runs trachea and anteromedial to the pleura over inferiorly on the left side of the vertebral the upper lobe of the lung. bodies to T8 where it crosses similarly to the hemiazygos vein to enter the azygos vein at T7. It also receives tributaries from the AZYGOS VEINS bronchial and mid-oesophageal veins. From: Inf vena cavalascending lumbar Vs To: Sup vena cava Note: The anterior intercostal veins drain to the musculophrenic and internal thoracic The azygos veins drain the upper lumbar veins. region and the thoracic wall. There is a single Inferior vena cava VEINS

Inf

lnferior vena cava VEINS Inferior vena cava

INFERIOR VENA CAVA It is hugged closely on its right side by the From: Common iliac Vs right suprarenal gland and forms the To: Right atrium posterior wall of the epiploic foramen of Winslow below this. After passing through It arises as the fusion of the common iliac the caval orifice in the central tendon of the veins anterolateral to the L5 vertebral body diaphragm (T8) with the right phrenic nerve lying posterior to the right common iliac lateral to it, it almost immediately enters the artery. It ascends, initially posterolateral to, pericardium and then the inferior aspect of then lateral to the aorta and lies anterolateral the right atrium. The vein possesses a 'valve- to the right of the bodies of L5-L1. It lies like' flap guarding the medial portion of its on (from below up): right lumbar arteries, orifice. right renal artery, right sympathetic chain, right suprarenal gland, right crus of the Lumbar veins. Drain somewhat incon- diaphragm and right inferior phrenic artery. sistently but usually the 3rd and 4th drain It is crossed by (from below up): the root of directly into the inferior vena cava whilst the ileal mesentery, the third part of the above this level they drain into the ascending duodenum, the head of the pancreas, the lumbar veins and hence to the azygos and bile duct, the portal vein, the first part of hemiazygos systems. There are, however, the duodenum, the posterior abdominal usually connections of the 3rd and 4th lumbar peritoneum and the bare area of the liver. veins with the ascending lumbar veins. Portal vein VEINS

Portal vein VEINS Portal vein

PORTAL VEIN drain to the azygos and hemiazygos systems From: Sup mesenteric & splenic Vs (systemic). To: Porta hepatis 2 Upper end of anal canal. At the anal columns in the upper half of the anal canal The vein is formed from the union of the there is a venous watershed between the superior mesenteric and splenic veins at the drainage above by the superior rectal veins level of the disc between L1 and L2 just at the (portal via inferior mesenteric vein) and right of the midline. At its formation it lies drainage below by the inferior and middle posterior to the neck of the pancreas and rectal veins (systemic via the pudendal and anterior to the inferior vena cava. It runs internal iliac veins). superiorly inclining slightly to the right, lying 3 Bare area of liver. Where the bare area of posterior to the first part of the duodenum the liver lies in contact with the diaphragm and anterior to the inferior vena cava. The there is a watershed of venous drainage bile duct comes to lie anterolateral to it from between the hepatic veins (portal)and the the right and the hepatic artery comes to lie inferior phrenic veins (systemic). anteromedial to it from the left. Ascending 4 Periumbilical. The ligamentum teres in the free border of the lesser omentum represents a venous watershed in that its it continues to lie posterior to these two inner portion is drained into the portal structures and forms the anterior margin system (via the left branch of the portal vein) of the aditus to the lesser sac (foramen of whilst its outer portion is drained into the Winslow). It divides into terminal right and systemic system (indirectly via the great left branches as it enters the porta hepatis. saphenous and axillary veins). 5 Retroperitoneal. Branches of the left and Portosystemic anastomoses right colic and splenic veins (portal)may 1 Lower end of oesophagus. The veins meet branches of the lumbar veins (systemic from the lower third of the oesophagus drain via inferior vena cava and azygos systems) in downwards to the left gastric vein (portal) the retroperitoneal area. and, above this level, oesophageal veins This page intentionally left blank Thoracic & right lymphatic ducts 60 Lymph glands: Head &neck 62 Thorax 64 Abdomen 66 Upper limb 68 Lower limb 70

Note: Deep lymphatics follow arteries and superficial ones follow veins. Thoracic & right lymphatic ducts LYMPHATICS

Thoracic & right lymphatic ducts LY MPHATICS Thoracic & right lymphatic ducts

THORACIC & RIGHT LYMPHATIC pleura and posterior to the initial part of the DUCTS left subclavian artery. It then passes anterior From: Cisterna chyli to the inferior cervical (stellate) ganglion To: Left subclavian V before arching anteriorly over the left vertebral and left subclavian arteries and the Thoracic duct dome of the pleura to lie along the medial Receives: edge of scalenus anterior before reaching the Left jugular trunk posterosuperior aspect of the left subclavian Left subclavian trunk vein as the latter joins the left internal jugular Cisterna chyli vein. Most thoracic lymphatics (except right upper thorax) Right lymphatic duct Drains: Receives: All body tissue below the diaphragm Right subclavian trunk Left arm Right jugular trunk Left head and neck Right bronchomediastinal trunk (right Left thorax upper thorax) Lower right thorax Drains: It originates from the upper cisterna chyli Right head and neck on the right anterolateral side of the body Right arm of T12, lying lateral to the abdominal aorta. Right upper thorax It passes posterior to the right crus of the The three trunks usually drain separately diaphragm and ascends on the right but the first two often join to give a right posterior intercostal arteries with the aorta lymphatic duct which ends in the right on its left and the azygos vein on its right. It subclavian vein. In which case it has a very slopes to the left in the mid thorax crossing short course from its formation anterior to the vertebral column posterior to the scalenus anterior, passing over the dome oesophagus at the level of TS. It continues of the cervical pleura to reach the right superiorly to the left of the vertebral column, subclavian vein as the latter joins with the posterolateral to the oesophagus, right internal jugular vein. posteromedial to the upper mediastinal Lymph glands-head & neck LYMPHATICS

Lymph glands - head & neck LYMPHATICS Lymph glands-head & neck

LYMPH GLANDS-HEAD & NECK Retro-auricular (mastoid) Pinna Circular nodal chain Posterior scalp Submental (bilateral) Occipital Anterior tongue Posterior scalp Floor of mouth Lower incisor and canine teeth Deep cervical chain Lower lip Jugulodigastric Skin of anterior chin Palatine tonsil Submandibular Upper pharynx Upper lip Posterior tongue Cheek Jugulo-omohyoid Nose Posterior half of nasal cavity and nasal Forehead and anterior scalp sinuses Middle tongue Palate (hard and soft) Lower molar and premolar teeth Retropharyngeal All upper teeth Pharynx Su blingual gland Paratracheal Submandibular gland Hypopharynx Anterior half of nasal cavity and nasal Larynx sinuses Trachea Deep and superficial pre-auricular (parotid) Thyroid Middle scalp Parathyroids Skin of temple Pinna Superficial cervical chain Parotid gland Skin of neck Posterior orbit Lymph glands-thorax LYMPHATICS

Lymph glands-thorax LYMPHATICS Lymph glands-thorax

LYMPH GLANDS-THORAX Left and right lower thoracic nodes drain directly to the thoracic duct or via a separate Pre-aortic left bronchiomediastinal trunk which joins Middle third of oesophagus the thoracic duct in the posterior superior Supradiaphragmatic mediastinum. Upper right thoracic nodes Diaphragm drain via the right bronchomediastinal trunk Subphrenic spaces which either drains into the right lymphatic Bare area of liver duct or directly into the right subclavian Tracheobronchial vein. Heart and all layers of pericardium Lungs and visceral pleura Note: Normal drainage from breast is to Extrapulmonary bronchi anterior and posterior axillary, infra- Trachea clavicular and internal thoracic groups. Thymus (occasionally thyroid isthmus) With pathological blockage from disease Para-aortic the spread can be to opposite side, cervical, Thoracic wall peritonea1 cavity and liver, and inguinal Parietal pleura glands. Anterior abdominal wall Internal thoracic Breast Anterior thoracic wall Upper abdominal muscles Diaphragm Lymph glands-abdomen LYMPHATICS

Lymph gland s--abdomen LYMPHATICS Lymph glands-abdomen

LYMPH GLANDS-ABDOMEN Ureter Bare area of liver Coeliac Posterior abdominal wall Lower third of oesophagus Lateral pelvic nodes Stomach and greater omentum Lower rectum and dentate line First and upper second part of duodenum Bladder Spleen Urethra Pancreas Lower ureter Liver Female Gallbladder uterus Superior mesenteric cervix Lower second, third and fourth parts of upper vagina duodenum clitoris Jejunum labia minora Ileum Male Caecum and appendix vas deferens Ascending colon seminal vesicles Transverse colon prostate Inferior mesenteric bulk of penis Distal transverse colon Descending colon Endodermal (gut-tubelgut-derived) Sigmoid colon structures drain to lymph nodes lying along Upper rectum and rectal mucosa to their arteries of supply which are named dentate line according to the artery with which they are Para-aortic associated and are not listed individually. 1nferio.r surface of diaphragm Their number and exact position are vari- Suprarenal gland able. However, the position and drainage of Kidney the highest node groups (listed above) are Gonad (plus fallopian tube in female) constant. Superior lateral uterus Lymph glands-upper limb LY MPHATICS

Lymph glands-upper limb LYMPHATICS Lymph glands-upper limb

LYMPH GLANDS-UPPER LIMB Central Apical Axillary groups Supratrochlear Anterior (pectoral) Skin of anterior forearm and hand Breast Infraclavicular Anterior thoracic wall Skin of shoulder Upper anterior abdominal wall Skin of lower neck Posterior (subscapular) Skin of anterior upper thoracic wall Posterior thoracic wall Breast Tail of breast Upper posterior abdominal wall A useful mnemonic for the axillary nodes is Lateral the word APICAL-(A)nterior, (P)osterior, Arm (I)nfraclavicular,(C)entral, (A)pical, Forearm (L)ateral Hand Lymph glands-lower limb LYMPHATICS

Lymph glands-lower limb LYMPHATICS Lymph glands-lower limb

LYMPH GLANDS-LOWER LIMB Popliteal Skin of sole of foot Superficial inguinal Skin of posterior calf Uterine fundus (via round ligament) Skin of penis Note: Cloquet's node is the highest node of Labia minora/scrotum the lower limb and usually lies just inside the Skin of buttock femoral canal beneath the inguinal ligament, Skin of lower abdominal wall to umbilicus medial to the femoral vein and lateral to the Skin of thigh, anterior skin of calf and lacunar ligament. dorsum of foot Skin of anterior perineum Superficial inguinal lymphatics drain via the Deep inguinal saphenous opening into the deep inguinal Anterior perineum nodes and then via the femoral canal to Thigh Cloquet's node and the internal iliac nodes. Leg Foot Thoracic sympathetics AUTONOMIC NERVOUS SYSTEM

Thoracic sympathetics (T 1 - 1 2) Note: All splanchnic nerves synapse in collateral ganglia The autonomic nervous system, as the term contraction, hunger, nausea and sexual implies, is an internal (visceral)adjustment excitement. From the heart and lungs system which is largely controlled sensation is probably in both sympathetic automatically but is influenced, to some and parasympathetic systems whereas in extent, by somatic activity and the special the abdomen it is predominantly in the senses. It controls the activity of the viscera, sympathetic system. Sensation from pelvic glands, blood vessels, heart and smooth organs of cloacal origin travel with the muscle. parasympathetics. The two parts, working complementarily, are the sympathetic and parasympathetic Sympathetic systems. The sympathetic system is active at times of urgent activity or stress, summarised The following 10 'rules' summarise the as the fight, flight and fright response, at general plan for the sympathetics: which time blood is needed rapidly in 1 Sympathetic motor function stimulates: muscles and brain and can be diverted there sweating, pilo-erection and vascular from the skin and gut. There is, therefore, constriction in the skin. Throughout the rest selective vasoconstriction, increase in heart of the body it controls vascular calibre and rate and blood pressure together with smooth muscle tone, stimulating closure of bronchodilatation, decrease in intestinal sphincters (pylorus, internal anal, vesical). peristalsis and closure of sphincters. In It decreases glandular secretion; causes addition there are two further activities in ejaculation, bronchodilatation; and also the head and neck where the eyes open wide increases the heart rate. and the pupils dilate. On a less urgent basis 2 In addition to these it also has two special somatic nerves to skin carry sympathetic functions in the head and neck for dilating fibres which constantly adjust sweating the pupil and raising the eyelids. (sudomotor), blood flow (vasomotor) and 3 Sympathetic outflow from the spinal hair erection (pilomotor) as a means of heat cord occurs only from preganglionic cell regulation. bodies in the lateral horns of T1 to L2. These Conversely, parasympathetic activity myelinated preganglionic fibres (shown in predominates during periods of quiet black) exit with the somatic motor root from activity, rest and during and after feeding the ventral horn but soon leave the ventral when the salivary glands secrete and food ramus to pass to the ganglia of the is digested. There is maximal intestinal sympathetic chain in a white ramus activity and normal production of glandular communicans. secretions from mucosa throughout the 4 Although the spinal connections to the body. The heart rate is slowed, blood pres- sympathetic chain of ganglia are only sure is minimised, the bronchi constricted to between T1 and L2, the chain itself extends lessen the dead space of the airways and the the whole length of the body with a ganglion pupils are constricted. An extra task for the at the level of each spinal nerve in the parasympathetic is accommodation of lumbosacral region and three ganglia above the lens for near vision. T1-superior, middle and inferior cervical The efferent (motor)nerves of both ganglia. The inferior cervical ganglion is systems are accompanied by general visceral usually fused with the T1 ganglion and the afferent (sensory) fibres which detect visceral two together are then termed the stellate distension, excessive smooth muscle ganglion. Lumbosacralsyrnpathetics AUTONOMICNERVOUSSYSTEM

Lumbosacral sympathetics (L I -S5) Note: LI-2 have white rami communicans. Lumbar and sacral splanchnic nerves are all preganglionic. They synapse in the inferior hypogastric plexus and perhaps some in the superior hypogastric plexus AUTONOMIC NERVOUS SYSTEM Parasympathetics

5 When the preganglionic fibres reach ganglia of the sympathetic chain and the a ganglion of the sympathetic chain they white rami communicantes before reaching have two alternatives. They can leave that their cell bodies in the dorsal root ganglia. ganglion for distribution, with or without They enter the spinal cord with the somatic synapsing (see below). Alternatively, they sensory fibres via the dorsal horn. Note that can pass up or down the chain to a higher or the grey rami communicantes contain lower ganglion before leaving for distribu- postganglionic efferent sympathetics only tion, with or without synapsing (see below). whilst the white rami communicates contain Thus the upper thoracic sympathetics supply both preganglionic efferent sympathetic the arm and head and neck regions whilst fibres and afferent sympathetic fibres. the lower thoracic and upper lumbar sym- pathetics supply the lower trunk and leg. Parasympathetic 6 In the ganglion from which the sympathetic is destined to leave, the The following 10 'rules' summarize the preganglionic fibres always synapse and general plan for the parasympathetics: leave as postganglionic fibres unless they are 1 Parasympathetic motor function supplying gut or suprarenal gland in which stimulates: glandular secretions, particu- case they continue as preganglionic fibres. larly salivary glands and mucous glands 7 Each ganglion has a somatic (lateral) throughout the body; peristalsis; opening of branch from which unmyelinated post- sphincters (pylorus and internal anal); penile ganglionic fibres (shown in green) pass into erection; slowing of the heart; and bronchial a grey ramus communicans to reach the constriction. somatic nerve at the same level. 2 Two special functions in the head and 8 Each ganglion has a visceral (medial) neck are pupillary constriction and branch (shown in red) which supplies accommodation of the lens for near vision. internal organs, such as the heart, wi'th 3 The only parasyrnpathetic outflow in the unmyelinated postganglionic fibres. Note body is with the cranial nerves 111, VII, IX, X that fibres to the gut and suprarenal gland, and from sacral segments S2,3,4. in the form of greater, lesser, least, lumbar 4 All myelinated preganglionic efferent and sacral splanchnic nerves, are all pre- fibres (shown in red) that are destined to ganglionic (see 6 above). They synapse in supply structures in the head and neck collateral ganglia nearer the organ of distri- emerge from the brain stem with fibres of the bution (coeliac, renal, inferior hypogastric, relevant cranial nerve (111, V11 and IX) and etc.) before becoming postganglionic. The run to specific parasyrnpathetic ganglia medulla of the suprarenal gland can be where they synapse (see diagram, see p. 78). considered as a ganglion. 5 Each of these peripheral parasyrnpathetic 9 In addition to the somatic and visceral ganglia (ciliary, pterygopalatine, subman- branches, the three cervical ganglia have dibular and otic) have a characteristic vascular (anterior) branches (shown in grey) pattern of nerve connection in that in addition which are distributed as in the diagram. to the parasyrnpathetic synapse, there is a These vascular branches simply allow a sensory branch of the trigeminal nerve (V) wider distribution of sympathetics to major and vasomotor fibres of the sympathetic vessels and into the skull than is possible via both passing straight through the ganglion somatic or visceral branches. For the special (see diagram, see p. 79). Beyond the ganglion, function of pupillary dilatation and eyelid the sensory branch of the trigeminal nerve raising these sympathetics are distributed via carries the postganglionic, unmyelinated cranial nerves-ophthalmic division of parasyrnpathetic fibres (also shown in red) trigeminal and oculomotor respectively. and the sympathetic fibres to the end organ. 10 Sympathetic afferent (sensory) fibres (not 6 Each vagus nerve (X)has two cervical shown) from the viscera return along the parasyrnpathetic branches that pass down to visceral efferent branches, pass through the the heart and then each vagus continues to Cervical sympathetics AUTONOMIC NERVOUS SYSTEM

Cervical sympathetics (C 1-8) AUTONOMIC NERVOUS SYSTEM Parasympathetics supply parasympathetic fibres to thoracic thorax and abdomen (transmitting pain, and abdominal structures as far as two- visceral distension, etc.) which have their cell thirds along the transverse colon. The bodies in the inferior vagal ganglion and preganglionic fibres synapse in peripheral their central connections probably in the ganglia so that the postganglionic fibres are nucleus solitarius or dorsal vagal nucleus. usually short. For pelvic sensation similar fibres reach 7 The parasympathetic outflow in the sacral segments S2,3,4, with their cell bodies sacral region (S2,3,4) arises in the lateral in the dorsal root ganglia before they enter grey horn but emerges via the ventral horn the dorsal horn of the spinal cord. and the fibres constitute a pelvic splanchnic 9 Other sensory fibres running with the nerve. Each nerve passes to its inferior parasympathetics are special visceral hypogastric plexus (left and right together afferents which detect taste and changes in making the pelvic plexus) and then to the the baro- and chemoreceptors in the carotid walls of the pelvic viscera where these sinus and body respectively. preganglionic fibres synapse in small ganglia 10 The carotid sinus and body are supplied before distribution. On the left, post- by both the glossopharyngeal nerve (IX)and ganglionic fibres pass upwards to the left the vagus (X)with cell bodies in their colon and the left third of the transverse respective inferior ganglia. Taste is carried in colon via the superior hypogastric plexus VII, IX and X. The cell bodies for taste in V11 and then onto the colic vessels. are in the geniculate ganglion, those in IX 8 Although not strictly part of the are the inferior glossopharyngeal ganglion, parasympathetic system, there are afferent whilst those in X are in the inferior vagal (sensory) fibres running with the para- ganglion. Central connections are in the sympathetics. In the vagus (X)there are nucleus solitarius (see summary table of general visceral afferent fibres from the cranial nerve nuclei and fibres). Parasympathetics AUTONOMIC NERVOUS SYSTEM

Parasympathetic system Note: Afferent nerves and sympathetics that travel with parasympathetics have been omitted for clarity AUTONOMIC NERVOUS SYSTEM Parasympathetics

Typical and specific connections of the parasympathetic ganglia PPG; pterygopalatineganglion This page intentionally left blank Pathways for cranial outflow of parasympathetic nerves

Cranial Nerve carrying Nerve carrying nerve Central nucleus preganglionic fibres Pathway & foramen Site of ganglion Name of ganglion postganglionic fibres Organs supplied

Edinger-Westphal Ill+ Cavernous sinus-+ Between optic N & lat Ciliary Va Ciliary muscle for (midbrain) Nerve to inferior superior orbital rectus in apex of orbit Nasociliary & short accommodation. oblique fissure-+ orbit ciliary Circular muscle of pupil for constriction

Superior salivary Nervus intermedius Internal acoustic Pterygopalatine fossa Pterygopalatine Vb Mucosal glands of (pans) + VII+ greater meatus+ middle ear+ (maxillary branches) nose, nasopharynx, petrosal N+ N of middle cranial fossa + sinuses, soft palate pterygoid canal pterygoid canal Vb (infra-orbital + Lacrimal gland zygomatic -+ z- temporal) + Va (lacrimal)

Superior salivary Nervus intermedius Internal acoustic Below lingual N on Submandibular VC (lingual) Submandibular, (pans) + VII+ chorda meatus+ middle ear hyoglossus sublingual, ant. tympani -+ lingual N + petrotympanic lingual, mucosal fissure+ infratemporal glands on side of fossa tongue

lnferior salivary lX+ Middle ear +middle Below f. ovale on N Otic VC Parotid gland (medulla) tympanic branch + cranial fossa + f. ovale to tensor tympani & (auriculotemporal) lesser petrosal N palati

lnferior salivary Pharyngeal 81 Direct to oropharynx In mucosa of Mucosal glands of (medulla) laryngeal branches & post third of tongue oropharynx & post oropharynx, post third third of tongue of tongue

Dorsal motor Cardiac branches from On target organs All viscera of thorax & (medulla) neck+ plexus on abdomen + 213 across oesophagus transverse colon + abdomen (S2,3,4 for rest)

AUTONOMIC NERVOUS SYSTEM Taste

Summary of taste inferior glossopharyngeal and inferior vagal ganglia respectively. The sensation of taste originates in taste Taste buds are found as follows: buds in the mucosa of the tongue and 1 As single buds in the mucosa. oropharynx. The buds are surrounded by 2 In fungiform papillae on the anterior two- the endings of the gustatory nerves which thirds of the tongue. transmit taste as special visceral afferent 3 In the grooves around vallate papillae sensation to the nucleus of the tractus which are just anterior to the sulcus solitarius in the brain stem. The three terminalis of the tongue. cranial nerves involved are facial (VII), 4 In foliate papillae on the sides of the glossopharyngeal (IX)and vagus (X)and the anterior two-thirds of the tongue. cell bodies for taste are in the geniculate,

Position of taste bud Type of bud Nerve supply (1,2,3,4 as above)

Anterior two-thirds of tongue Chorda tympani (VII) Carried by lingual N Associated with posterior third of tongue Glossopharyngeal

Posterior wall of oropharynx Glossopharyngeal

Palatoglossalarches Glossopharyngeal

Oral aspect of soft palate Lesser palatine (maxillary division of trigeminal) and glossopharyngeal

Anterior surface of epiglottis Internal laryngeal branch of and valleculae superior laryngeal nerve (vagus)

Distributionof parasympathetics of head and neck This complex for reference only diagram is for those who want to see the global arrangement of the parasympathetics in the neck and head. Parasympathetics are shown in red. Cranial nerves carrying the pre- or postganglionic fibres are shown in black. Sympathetics are shown in yellow. Interrupted yellow lines indicate probable additional pathways for sympathetics (see p. 82, left hand Page) Abdominal autonornics AUTONOMIC NERVOUS SYSTEM

Abdominal autonomics RP Renal plexus GSN Greater splanchnic nerve SRP Suprarenal plexus LRSN Lesser splanchnic nerve AAP Abdominal aortic plexus LTSN Least splanchnic nerve IMP lnferior mesenteric plexus CG Coeliac ganglion SHP Superior hypogastric plexus ARG Aorticorenal ganglion IHP lnferior hypogastric plexus AUTONOMIC NERVOUS SYSTEM Abdominal autonomics

Abdominal autonomics upper ureter with sympathetic and parasym- pathetic fibres although the function of the The greater splanchnic nerve (T.5-9) supplies latter fibres is not clear. the coeliac and aorticorenal ganglia and The superior mesenteric plexus around the the suprarenal gland with preganglionic superior mesenteric artery is a downwards sympathetic fibres. extension of the coeliac plexus. Its mixed The lesser splanchnic nerve (T10,ll) sympathetic and parasympathetic fibres are supplies the aorticorenal ganglion with distributed on this artery. similar fibres. The abdominal aortic (intermesenteric) The least splanchnic nerve (T12)supplies plexus lies on the aorta between the superior the renal plexus with similar fibres. and inferior mesenteric arteries. It is Each of the splanchnic nerves pierces connected above to the coeliac ganglia and the crura of the diaphragm to enter the plexus, aorticorenal ganglia and vagus abdomen. They each carry efferent and nerves; below, it is in continuity with the afferent fibres. inferior mesenteric and superior hypogastric The coeliac ganglia lie on each side of plexuses. It also has preganglionic sym- the coeliac trunk. They are supplied by pathetic input from the first and second preganglionic sympathetic fibres from the lumbar splanchnic nerves. greater splanchnic nerves. Postganglionic The vagus nerves enter the abdomen via sympathetic fibres leave these ganglia and the oesophageal opening and distribute to form the coeliac plexus. abdominal organs and the bowel as far as The coeliac plexus connects the coeliac two-thirds along the transverse colon via the ganglia across the midline; it surrounds the coeliac and superior mesenteric plexuses. coeliac truck and extends down to become These preganglionic fibres synapse in small the superior mesenteric plexus. The coeliac ganglia in the walls of the organs or bowel. plexus also receives preganglionic parasym- The inferior mesenteric plexus surrounds pathetic fibres from the vagus nerves. The the beginning of the inferior mesenteric fate of these fibres, both sympathetic and artery and is supplied by the abdominal parasympathetic, is twofold. Many leave aortic plexus with additional preganglionic the plexus on branches of the coeliac trunk sympathetic input from the second and third to be distributed to the bowel and other lumbar splanchnic nerves. Parasympathetic organs such as liver and spleen. Others pass fibres from the sacral outflow (S2,3,4) downwards to reach other plexuses before ascend via the left inferior and superior being distributed similarly. hypogastric plexuses to be distributed with The aorticorenal ganglia are partially the sympathetic fibres on branches of the detached parts of the coeliac ganglia, lying inferior mesenteric artery. just inferiorly. They contribute to both the The suprarenal plexus on each side is coeliac and renal plexuses. As with the supplied by the greater splanchnic nerve coeliac ganglia, sympathetic fibres leaving and a branch from the coeliac ganglion. The these ganglia are postganglionic. majority of sympathetic fibres reaching it A renal plexus surrounds the beginning are preganglionic to the medulla. There is no of each renal artery. It has postganglionic parasympathetic supply to the suprarenal sympathetic contributions from the coeliac gland. and aorticorenal ganglia and preganglionic The lumbar splanchnics are sympathetic contributions from the least splanchnic nerve preganglionic fibres that leave the sym- and the first lumbar splanchnic nerve. It has pathetic chain to supplement the thoracic a few small ganglia for these preganglionic splanchnics. L1 joins the renal plexus, L1, fibres to synapse. In addition it has both L2 the abdominal aortic plexus, L2,L3 the sympathetic and parasympathetic contribu- inferior mesenteric plexus and L3,L4 the tions from the coeliac and abdominal aortic superior hypogastric plexus. plexuses. It supplies mainly the kidney and Abdominal autonomics AUTONOMIC NERVOUS SYSTEM

The superior hypogastric plexus lies over before distribution either on arteries or lying and just below the bifurcation of the aorta. free in the retroperitoneum. The fibres are It is supplied by fibres continuing down from preganglionic and synapse in the walls of the the abdominal aortic plexus (postganglionic) organs they supply. They are motor to large and the third and fourth lumbar splanchnic bowel beyond the left third of the transverse nerves (preganglionic).It contains a few colon, bladder and uterus. They are also small ganglia before forming left and right sensory to some pelvic organs (bladder, hypogastric nerves which pass down to the proximal urethra, ampulla of rectum, anal inferior hypogastric plexuses. It supplies the canal, cervix of uterus, upper vagina and iliac vessels via the iliac plexuses and the prostate). Ascending mostly from the left ureter. It also has pelvic parasympathetics inferior hypogastric plexus, are those fibres (S2,3,4) ascending through it on the way mentioned above that supply parasym- to the inferior mesenteric artery to supply pathetics to the left large bowel beyond the bowel from the left side of the transverse distribution of the vagus. Some of these colon downwards. fibres pass through the superior hypogastric There is an inferior hypogastric plexus on plexus and then the inferior mesenteric each side wall of the pelvis. The two together plexus to reach the inferior mesenteric make the pelvic plexus. They are supplied artery, whilst others may run directly to the by pre- and postganglionic sympathetic left colon via the retroperitoneum. fibres running in the hypogastric nerves from the superior hypogastric plexus and are Notes: supplemented by the first and second sacral 1 The neurotransmitter substance is splanchnics (preganglionic sympathetic) and acetylcholine at the endings of all the pelvic splanchnics (parasympathetic). preganglionic autonomic nerves whether They contain small ganglia for the synapses sympathetic or parasympathetic and also at of any remaining preganglionic sympathetic the postganglionic parasympathetic endings. fibres. The postganglionic sympathetic All these endings are termed cholinergic. outflow from this plexus runs on arteries All postganglionic sympathetic endings to give vasomotor supply and motor fibres have either noradrenalin or adrenalin as the to vas, seminal vesicles, prostate, anal and neurotransmitter except sweat glands which bladder sphincters and to inhibit peristalsis. are cholinergic. Sympathetic sensory fibres arise in the upper 2 Unless mentioned above as specific rectum and body of uterus. actions, the sympathetic efferent (motor) The sacral splanchnics are sympathetic fibres cause vasoconstriction, inhibit preganglionic fibres that leave the sym- intestinal peristalsis and glandular activity. pathetic chain to supplement the pelvic The parasympathetic efferent (motor)fibres, sympathetics. S1 and S2 join the pelvic however, cause glandular secretion and plexus or hypogastric nerve on each side. intestinal peristalsis but are inhibitory to S3 and S4 from each side form a plexus on the pyloric and ileocaecal sphincters. There the median sacral artery. are also specific actions of penile/clitoral The pelvic splanchnics are the caudal erection and contraction of the bladder and parasympathetic outflow (S2,3,4) and these uterus. fibres join the inferior hypogastric plexuses Olfactory nerve (I) 90 the brain and passing out to its terminal Optic nerve (11) 90 branches irrespective of whether the nerve Oculomotor nerve (111) 92 carries sensory, motor or a combination of Trochlear nerve (IV) 92 fibres. Sympathetics have generally been Trigeminal nerve omitted except in association with cranial Ophthalmic division (Va) 94 nerves Ifl and Vawhere they have specific Maxillary division (Vb) 96 functions and are carried by a branch of the Mandibular division (VC) 98 cranial nerve. Abducent nerve (VI) 100 Facial nerve (VII) 102 Colour coding in figures Vestibulocochlear nerve (VIII) 104 Somatic motor-black Glossopharyngeal nerve (IX) 104 Somatic sensory-black Vagus nerve (X) l06 Special visceral motor (branchial muscles) Accessory nerve (XI) l08 -blue Hypoglossal nerve (XII) 108 Special visceral sensory (taste and arterial receptors)--green General visceral motor Note: Apart from cranial nerves I and II, (parasympathetic)-red which clearly arise from specific sensory General visceral sensory areas and their fibres pass directly to the ( parasympathetic)-green brain, a nomenclature has been used to Special senses-black describe each nerve as arising centrally in Sympathetic-yellow Summary table of nuclei & fibres of cranial nerves General visceral motor Somatic motor Special visceral motor (branchial) (parasympathetic) General visceral sensory Special visceral sensory Somatic sensory Special senses

Smell Limbic system Sight Lat geniculate body Ill Nu: Oculomotor Nu: EdingercWestphal Reai (sup, med, inf), inf oblique, Ciliary ganglion levator palpebrae superioris Ciliary body & muscle, sphincter pupillae IV Nu: Trochlear Sup oblique v Nu: Motor of trigeminal Nu: Sensory of V M of mastication, mylohyoid, ant Mesencephalic: proprioception digastric, tensors palati & tympani Main: touch Spinal: pain &temperature For V (face, orbit, tongue) V1 Nu: Abducent Lat rectus v1 I Nu: Facial Nu: Sup salivary Nu: Solitarius Nu: Senson of V M of facial expression, buccinator. Pterygopalatine & Chorda tympani Some skin o

NB Motor nuclei for skeletal muscle Motor to muscles of branchial Motor nerves synapse in From heart, lungs &gut Taste; baro- & From skin & membranes. Cell Cell bodies in CNS origin. Cell bodies in CNS parasympathetic ganglia chemoreceptors bodies outside CNS except mesencephalic nu. 911 sensory fibres relay to: motor nuclei, cerebellum, opposite thalamus + sensory cortex CNS = central nervous system; M = muscles; Nu = nucleus CRANIAL NERVES Cavernous sinus

Lateral view of left cavernous sinus as a simplified box shape

89 Olfactory nerve CRANIAL NERVES Optic nerve

Olfactory nerve (I) ...... *...... *...... **...... *......

Optic nerve (11) Olfactory nerve CRANIAL NERVES Optic nerve

OLFACTORY NERVE (I) plate of the ethmoid bone where they From: Olfactory epithelium synapse in the olfactory bulb which lies on To: Olfactory cortex its superior surface. The bulb leads poster- Contains: Special sense (smell) iorly to the olfactory tract which lies in the anterior cranial fossa on the inferior surface The olfactory epithelium lines the superior of the frontal lobe and conveys fibres to the surface of the superior concha, upper medial anterior olfactory nucleus (in the posterior nasal septum and inferior surface of the aspect of the olfactory bulb), to the cribriform plate of the ethmoid bone. The prepiriform cortex, anterior perforating fibres of the olfactory cells run in the substance and septal areas. submucosa to pass through the cribriform

OPTIC NERVE (11) canal and runs forwards to pierce the dura From: Retina around the nerve inferomedially about l cm To: Lateral geniculate body behind the eyeball. The nerve continues Contains: Special sense (sight) posteriorly at first lateral to, then superior to, the sella turcica where it forms the optic The ganglion cells of the retina pass fibres chiasma. Fibres from both eyes are distrib- out of the globe of the eye via the optic disc uted to each optic tract with medial retina1 to enter the optic N which passes through the fibres (temporal visual fields) crossing to the orbit within the dural sheath and within the opposite side. Each tract passes from the cone of muscles. The nerve passes through posterolateral angle of the chiasma, lying the optic canal in the body of the sphenoid lateral to the pituitary infundibulum, to run bone into the middle cranial fossa where it lateral to the cerebral peduncle and medial lies medial to the anterior clinoid process. to the uncus of the temporal lobe to reach the The ophthalmic artery lies inferior to it in the lateral geniculate body. Oculomotor nerve CRANIAL NERVES Trochlear nerve

Oculomotor nerve (Ill)

Trochlear nerve (W) Oculornotor nerve CRANIAL NERVES Trochlear nerve

OCULOMOTOR NERVE (Ill) nasociliary branch of the ophthalmic From: Oculomotor nucleus (somatic motor) division of the trigeminal N. It then enters and Edinger-Westphal nucleus (general the orbit through the superior orbital fissure visceral motor), ventral to cranial part of within the tendinous ring having divided into aqueduct in midbrain superior and inferior divisions at the anterior To: Terminal brs end of the cavernous sinus. The superior Contains: Somatic motor & general visceral division runs lateral to the optic N on the motor inferior surface of the superior rectus, passing through this muscle to terminate in This nerve emerges medial to the cerebral levator palpebrae superioris. This division peduncle in the interpeduncular fossa to carries sympathetic supply to this muscle reach the middle cranial fossa. It runs for- from the internal carotid artery in the cavern- ward in close lateral relation to the posterior ous sinus. The inferior division divides into communicating artery below the margin of terminal branches shortly after passing the tentorium cerebelli. It pierces the dura through the tendinous ring, the nerve to lateral to the posterior clinoid process to inferior oblique carrying the general visceral enter the roof of the cavernous sinus lying motor fibres (parasympathetic) to the ciliary initially high in its lateral wall. It descends, ganglion. This lies posteriorly in the orbit passing medially over the trochlear N and inferolateral to the optic N.

TROCHLEAR NERVE (IV) just above the superior border of the pons. From: Trochlear nucleus in floor of aqueduct It runs below the edge of the tentorium in dorsal midbrain, level with upper part cerebelli between the posterior cerebral and of inferior colliculus the superior cerebellar arteries. It enters the To: Terminal brs roof of the cavernous sinus then onto its Contains: Somatic motor lateral wall where it is crossed medially by the oculomotor N from above down before The fibres decussate within the substance of entering the orbit through the superior the midbrain to appear on the opposite side. orbital fissure superolateral to the tendinous The nerve emerges dorsally and passes ring. It runs medially above levator lateral to the superior cerebellar peduncle palpebrae superioris to terminate as it then around the lateral aspect of the pierces superior oblique. midbrain in the middle cranial fossa to lie Trigeminal nerve (Va) CRANIAL NERVES

Trigeminal nerve-ophthalmic division (Va) CRANIAL NERVES Trigeminal nerve (Va)

TRlGEMlNAL NERVE-OPHTHALMIC the lateral upper eyelid. In its course it carries DIVISION (Va) parasympathetic fibres from the zygomatico- From: Terminal nuclei are chief sensory temporal branch of the maxillary N (Vb)to (touch),mesencephalic (proprioception) the lacrimal gland and sympathetic fibres and spinal (pain & temperature). They lie from the nearby lacrimal artery. in pons, midbrain & medullahpper cervical cord respectively Nasociliary N. Runs within the tendinous To: Terminal brs ring between superior and inferior division Contains: Somatic sensory of the oculomotor N, crossing superior to the optic N to lie over the medial rectus. It The sensory root of the trigeminal N emerges leaves the muscular cone giving terminal from the ventral surface of the upper pons to branches before running through the enter the middle cranial fossa from where it anterior ethmoidal foramen in the ethmoid passes to the trigeminal ganglion which lies bone on the medial orbital wall as the in Meckel's cave, a prolongation of dura at anterior ethmoidal N. It traverses the the apex of the petrous temporal bone. The anterior ethmoid sinus to run through its ophthalmic division leaves the trigeminal roof and onto the superior surface of the ganglion and runs forward in the lateral wall cribriform plate beneath the dura of the of the cavernous sinus below the trochlear N anterior cranial fossa. It passes through the and is crossed medially by the oculomotor plate again lateral to the crista galli onto N. It divides into three terminal branches the medial wall of the nose, first on the which pass through the superior orbital perpendicular plate of the ethmoid and then fissure separately. (Note: the mesencephalic on the inner surface of the nasal bone. It nucleus is unusual in that it receives primary passes into the skin of the nose beneath the neurones that do not have the cell bodies in inferior margin of the nasal bone as its the ganglion but in the nucleus itself.) terminal branch-the external nasal N.

Frontal N. Runs superolateral to the tendin- Short ciliary Ns. Each of these 8-10 nerves ous ring into the orbit where it continues emerges from the ciliary ganglion with a forwards and medially above levator sensory component from the nasociliary N, palpebrae superioris, to divide into terminal postganglionic parasympathetic fibres from branches which leave the orbit over its the oculomotor N and sympathetic fibres superior margin through similarly named which pass directly from the internal carotid notches. artery in the cavernous sinus.

Lacrimal N. Runs lateral to the tendinous Long ciliary Ns. Each of the 2-3 nerves has ring into the orbit. It passes laterally, close sensory fibres from the nasociliary N and to the periosteum of the orbital plate of the sympathetic fibres for the dilator pupillae frontal bone, to supply the lacrimal gland that are carried by the nasociliary N from and adjoining conjunctiva. It then leaves the the internal carotid artery in the cavernous orbit over its superolateral margin to supply sinus. Trigeminal nerve (Vb) CRANIAL NERVES

Trigeminal nerve-maxillary division (Vb) CRANIAL NERVES Trigeminal nerve (Vb)

TRlGEMlNAL NERVE-MAXILLARY groove in the orbital surface of the maxilla. DIVISION (Vb) It terminates in branches in the skin of the From: Terminal nuclei are chief sensory face having passed through the infra- (touch),mesencephalic (proprioception) orbital foramen which is the completed and spinal (pain & temperature). They lie continuation of the infra-orbital groove. in pons, midbrain & medullahpper cervical cord respectively Zygomatic N. Passes superiorly out of the To: Terminal brs pterygopalatine fossa through the inferior Contains: Somatic sensory orbital fissure to run in the lateral orbit outside the cone of muscles. It terminates on (See ophthalmic division for course to the the lateral orbital wall as facial and temporal trigeminal ganglion.) The nerve leaves the branches which pass through unnamed ganglion to run low down in the lateral wall canals in the zygomatic bone to reach the of the cavernous sinus before passing onto skin over the zygomatic bone and hairless the floor of the middle cranial fossa and it temple respectively. then exits through the foramen rotundum in the greater wing of the sphenoid bone. It Nasopalatine (previously sphenopalatine) N. runs into the upper pterygopalatine fossa, Passes through the sphenopalatine foramen giving branches via the pterygopalatine to enter the posterior upper nasal cavity to ganglion before passing into the orbit via the end as terminal branches. inferior orbital fissure to become the infra- orbital N. The pterygopalatine ganglion is Pharyngeal N. A few fine branches of this suspended from the maxillary N by one or nerve pass from the pterygopalatine ganglion two roots and receives parasympathetic into the orbit via the inferior orbital fissure fibres from the greater petrosal N in the to supply sensation and secretomotor fibres pterygopalatine fossa which are distributed to the sphenoidal and ethmoidal sinuses. with the terminal branches as shown. Note: Other branches pass through foramina Infra-orbital N. Passes laterally across the as indicated. Sympathetics have been posterior aspect of the palatine bone and omitted from the distribution of the maxilla to pass through the inferior orbital pterygopalatine ganglion to avoid fissure and to run into the infra-orbital complicating the diagram. Trigeminal nerve (VC) CRANIAL NERVES

Trigeminal nerve-mandibular division (VC) CRANIAL NERVES Trigeminal nerve (VC)

TRlGEMlNAL NERVE-MANDIBULAR Posterior division DIVISION (VC) Auriculotemporal N. Passes posteriorly, From: Terminal nuclei are chief sensory briefly dividing to encircle the middle (touch), mesencephalic (proprioception) meningeal artery, before running between and spinal (pain & temperature). They lie the neck of the mandible and the spheno- in pons, midbrain & medullahpper mandibular ligament. It winds around the cervical cord respectively. Motor nucleus neck of the mandible to pass laterally then (branchial muscles) is in upper pons superiorly lying between the temporo- To: Terminal brs mandibular joint and the external auditory Contains: Somatic sensory & special visceral meatus deep to the parotid gland. It motor terminates at the upper border of the gland as branches. The nerve receives general (See ophthalmic division for course to the visceral motor fibres (parasympathetic) from trigeminal ganglion.) The smaller motor root the lesser petrosal N via the otic ganglion leaves the ventral pons anteromedial to the which lies suspended from the nerve to sensory root. The sensory root leaves the tensor tympani near the foramen ovale. ganglion from its lateral part and passes, after a short course over the greater wing of the Lingual N. Passes forward and inferiorly to sphenoid bone, through the foramen ovale. lie between lateral pterygoid and tensor veli The motor root passes under the ganglion palatini, then between medial pterygoid and unites with the sensory root just beyond and the ramus of the mandible. It lies just the foramen ovale. The nerve that is so beneath the mucous membrane of the mouth formed passes into the infratemporal fossa posteromedial to the third molar tooth. It between tensor veli palatini and lateral passes lateral to styloglossus and hyoglossus pterygoid. It has a short course of 3-4mm and runs at first lateral, then inferior and before dividing into anterior and posterior then medial to the submandibular duct. divisions which provide terminal branches. It terminates over the lateral aspect of the anterior two-thirds of the tongue. It is joined Anterior division 2cm anterior and inferior to the foramen Deep temporal Ns. Usually two, run above ovale by general visceral motor and special the lateral pterygoid, over the infratemporal visceral sensory fibres of the chorda tympani crest and on the squamous temporal and which relay in the submandibular ganglion. greater wing of the sphenoid bones deep to This ganglion which is suspended from the temporalis to supply it. They lie with their nerve by two roots lies on hyoglossus above associated vessels deeply in the temporal the submandibular gland. fossa. Inferior alveolar N. Passes deep to lateral Lateral pterygoid Ns. Pierce the muscle pterygoid to lie between the spheno- directly to supply it. mandibular ligament and the rarnus of the mandible before entering the mandible via Masseter N. Runs laterally over the lateral the inferior alveolar foramen. It terminates pterygoid and over the mandibular notch as cutaneous branches reappearing through to pierce the deep surface of the muscle to the mental foramen in the anterior body of supply it and the temporomandibular joint. the mandible. The N to mylohyoid arises just before it enters the inferior alveolar foramen Buccal N. Runs forward over lateral and pierces the sphenomandibular ligament pterygoid and lies deep to temporalis, the to run in a groove on the medial surface of mandible and masseter. It runs through the body of the mandible below mylohyoid. buccinator to supply a small area of overlying skin. The nerve is sensory only. Abducent nerve (VI) CRANIAL NERVES

Abducent nerve (W) CRANIAL NERVES Abducent nerve (Vl)

P P-

ABDUCENT NERVE (VI) sellae. It arches forward directly over the From: Abducent nucleus in sup part of floor ridge of the petrous temporal bone passing of 4th ventricle in lower pons through the medial wall of the inferior To: Terminal brs petrosal sinus under the petroclinoid Contains: Somatic motor ligament and runs into the cavernous sinus. Here it lies directly lateral to the internal The fibres leave the pons at its lower border carotid artery before passing into the orbit above the pyramid of the medulla. It through the superior orbital fissure within traverses the pontine basal cistern running the tendinous ring. It passes forward and forwards and superiorly to pierce the dura laterally to sink into the medial surface of the over the clivus inferolateral to the dorsum lateral rectus muscle. Facial nerve (VII) CRANIAL NERVES

Facial nerve (W) CRANIAL NERVES Facial nerve (VII)

FACIAL NERVE (VII) which leave just medial to the anterior From: Facial motor nucleus deep to reticular border of the gland. formation in lower pons. Sup salivary nucleus (general visceral motor) distal to Greater petrosal N. Arises from the main motor nucleus. Gustatory nucleus (taste) nerve at the geniculate ganglion and passes in superior end of nucleus solitarius in medially through the petrous temporal bone medulla. Sensory nucleus of V (see to lie in a groove on its anterior surface trigeminal N) beneath the temporal lobe and dura of the To: Terminal brs middle cranial fossa. It runs beneath the Contains: Somatic sensory, special visceral trigeminal ganglion and then passes sensory & motor, general visceral motor anteromedially but lying anterolateral to the internal carotid artery as this vessel It leaves the pons at the cerebellopontine emerges across the upper end of foramen angle medial to the vestibulocochlear N lacerum. It is joined by the deep petrosal (VIII)as two nerve roots-the facial motor N (sympathetic) off the artery and this root and the nervus intermedius. The nervus combined nerve (the N of the pterygoid intermedius contains special visceral canal or Vidian's N) passes into the same sensory, general visceral motor and somatic named canal which commences a short sensory fibres which connect with gustatory, way into the anterior wall of the foramen superior salivary and sensory trigeminal lacerum at the root of the pterygoid process nuclei respectively. These two roots pass of the sphenoid. This canal exits into the across the subarachnoid space together to pterygopalatine fossa where the nerve enters enter the internal auditory meatus and pass the posterior aspect of the pterygopalatine laterally along it to reach and enter the facial ganglion and distributes its fibres with canal. The two roots then unite and pass branches of the maxillary division (Vb) of laterally onto the medial wall of the middle the trigeminal N. ear before turning 90 degrees posteriorly at the geniculate ganglion. It continues Chorda tympani. Arises from the facial nerve posteriorly running above the promontory in the facial canal during its descent from the and oval window and below the lateral medial wall of the middle ear. It runs back semicircular canal. Finally the nerve turns 90 into the middle ear on the posterior wall degrees inferiorly to run down in the medial before passing anteriorly between the two wall of the aditus of the mastoid antrum. It layers of the flaccid part of the tympanic leaves the middle ear via the stylomastoid membrane and over the handle of the foramen to pass between the mastoid pro- malleus. It leaves the middle ear by passing cess and the tympanic ring before passing into the petrous temporal bone and emerges between the deep and superficial portions via the petrotympanic fissure to pass into the of the parotid gland. Within the gland it infratemporal fossa medial to the spine of lies superficial to the styloid process, the sphenoid bone which it grooves. It runs retromandibular vein and external carotid antero-inferiorly, deep to lateral pterygoid, artery before dividing into terminal branches to join the lingual branch of the mandibular division (VC)2cm below the skull. Vestibulocochlear nerve (VIII) CRANIAL NERVES Glossopharyngeal nerve (IX)

Vestibulocochlear nerve (V111) ......

Glossopharyngeal nerve (IX) Vestibulocochlear nerve (VIII) CRANIAL NERVES Glossopharyngeal nerve (IX)

VESTIBULOCOCHLEAR NERVE (VIII) pierces the temporal bone in its antero- From: 4 Vestibular & 2 cochlear nuclei in inferior quadrant. The vestibular element floor of 4th ventricle in pons divides into upper and lower divisions to To: Inner ear pierce the temporal bone in its postero- Contains: Special sense (hearing, balance) superior and postero-inferior quadrants. The cochlear N runs in the cochlear modiolus to It emerges at the cerebellopontine angle as a end in terminal connections. The upper single nerve and traverses the subarachnoid vestibular division runs to supply the semi- space to enter the internal auditory meatus circular canals and the utricle, the lower where the cochlear element separates and division the saccule.

GLOSSOPHARYNGEAL NERVE (IX) and terminates in lingual and pharyngeal From: Sensory nucleus of V (common branches. sensation-see trigeminal N). Nucleus solitarius (taste-medulla). Nucleus Carotid N. Arises just below the ganglia and ambiguus (motor to branchial muscle- runs down closely adherent to the internal medulla). Inf salivary nucleus carotid artery within the carotid sheath to (secretomotor-lower pons) reach the carotid sinus and carotid body. To: Terminal brs Contains: Somatic sensory, general & special Lesser petrosal N. The tympanic branch visceral motor, special visceral sensory (Jacobson's N) of the glossopharyngeal N arises just below the ganglia to pass via the The fibres leave the medulla as three or four petrous temporal bone into the middle ear. rootlets lying posterior to the olive. They It mingles with parasympathetic fibres of the rapidly fuse into one nerve which passes facial N (VII)and sympathetics from the anterolaterally into the anterior compart- internal carotid artery over the promontory ment of the jugular foramen (between on the medial wall to form the lesser petrosal petrous temporal and occipital bones). N. This nerve then leaves the middle ear It passes lateral to the inferior petrosal via the medial side of the roof and passes sinus which separates it from the vagus and through the petrous temporal bone into the accessory Ns and runs anteriorly out of the middle cranial fossa. Here it lies beneath the compartment. It forms the glossopharyngeal dura to run forward before passing through ganglia below the compartment as it passes the foramen ovale and synapsing below in between internal jugular vein and internal the otic ganglion in the infratemporal fossa. carotid artery. It passes inferolaterally From here it is distributed with the auriculo- looping around the upper border of temporal branch of the mandibular division stylopharyngeus, runs deep to hyoglossus (VC)to the parotid gland. Vagus nerve (X) CRANIAL NERVES

Vagus nerve (X) CRANIAL NERVES Vagus nerve (X)

VAGUS NERVE (X) mucous membrane of the vallecula and From: Dorsal motor nucleus of vagus larynx down to the vocal folds. (general visceral motor-lower medulla). Nucleus ambiguus (branchial motor- External branch. Runs down over the medulla). Nucleus solitarius (taste & inferior constrictor accompanied by the general visceral sensory-medulla). superior thyroid artery to reach the Sensory nucleus of V (common sensation- cricothyroid muscle. see trigeminal N) To: Terminal brs Recurrent laryngeal N. In the neck the two Contains: Somatic sensory, general & special sides follow the same course ascending in visceral sensory, general & special visceral the tracheo-oesophageal groove. As the motor nerve passes medial to the lateral lobe of the thyroid gland it is intimately related to the The fibres emerge from the medulla as a inferior thyroid artery. It passes beneath the series of rootlets posterior to the olive inferior border of cricopharyngeus (inferior between the glossopharyngeal and cranial constrictor) to terminate within the sub- accessory rootlets. These form into a single mucosa of the larynx. The nerve on the right nerve that passes into the middle compart- originates from the vagus anterior to the ment of the jugular foramen. Below the subclavian artery around which it hooks foramen it forms superior and inferior posteriorly before running medially to ganglia before being joined by the cranial ascend in the tracheo-oesophageal groove. part of the accessory N. It passes vertically The nerve on the left originates from the down within the carotid sheath closely vagus inferolateral to the arch of the aorta related to the internal carotid artery and passing inferior to the arch and posterior to lying between it and the internal jugular the ligamentum arteriosum. It runs to the vein. right of the arch as it passes posteriorly over the left side of the trachea to reach the Pharyngeal branch. Passes from the vagus tracheo-oesophageal groove. at the inferior ganglion running between internal and external carotid arteries to Cardiac Ns. The upper branch arises below reach the lateral wall of the pharynx. These the inferior ganglion and the lower branch fibres are mostly from the cranial part of the arises in the root of the neck. On the right accessory N. they pass down anterior to the brachio- cephalic artery and on the left over the aortic Superior laryngeal N. Passes from the arch to terminate in the cardiac plexuses. inferior ganglion running steeply down anteriorly, lying posterior and then medial Note: General visceral motor (para- to the internal carotid artery. It pierces the sympathetic) and general visceral sensory carotid sheath to run on the wall of the fibres in the vagus to and from the thorax pharynx to the level of the greater cornu of and abdomen ariselend in the dorsal motor the hyoid bone where it divides. nucleus of vagus and nucleus solitarius respectively. Internal branch. Runs down anteriorly onto All branchial motor (special visceral the thyrohyoid membrane which it pierces motor) fibres in the vagus which supply at the level of the vallecula, and is then muscles arise in the nucleus ambiguus but distributed as terminal branches to the the majority, if not all, are supplied to the vagus by the cranial accessory (XI). Accessory nerve (XI) CRANIAL NERVES Hypoglossal nerve (XiI)

Accessory newe (XI)

Hypoglossal newe (XII) Accessory nerve (XI) CRANIAL NERVES Hypoglossal nerve (XII)

ACCESSORY NERVE (XI) posterior to the vagus and anterior to the From: Cranial root from nucleus ambiguus internal jugular vein. Inferior to the foramen (branchial motor-medulla). Spinal root the cranial element passes inferomedially from spinal nuclei (Cl-CS) to fuse with the vagus to which it adds its To: Terminal brs complement of special visceral motor fibres. Contains: Somatic motor (spinal), special visceral motor (cranial) Spinal root. Passes posterolaterally, usually posterior to the internal jugular vein, over The fibres of the cranial root emerge from the lateral mass of the atlas (Cl)and deep to the medulla as four to six rootlets posterior the occipital artery to enter the deep surface to the olive immediately below those of the of sternocleidomastoid. It traverses the vagus to fuse into a single nerve. They are posterior triangle of the neck from one-third joined by the spinal root as it ascends via of the way down the posterior border of the foramen magnum (see cervical plexus, sternocleidomastoid to one-third of the way pp. 112-1 13).The nerve passes out of the up the anterior border of trapezius where it posterior cranial fossa through the middle terminates. compartment of the jugular foramen

......

HYPOGLOSSAL NERVE (XII) fuse. The nerve runs out of the canal anteri- From: Hypoglossal nucleus in floor of 4th orly, lateral to the occipital, internal carotid, ventricle in medulla external carotid and lingual arteries before To: Terminal brs passing over the apex of the greater corm Contains: Somatic motor of the hyoid bone. It then runs anteriorly, looping lateral to hyoglossus, deep to Its fibres pass out of the anterolateral sur- mylohyoid, to end in terminal branches face of the medulla between the olive and beneath the submandibular gland. pyramid as a series of 10-15 rootlets. These fuse to form two roots which pass posterior Note: C1 fibres join the hypoglossal N (pp. to the vertebral artery as they run into the 112-1 13). This is not shown in this diagram hypoglossal canal where they themselves but they are seen leaving it. This page intentionally left blank Cervical plexus (C1,2,3,4,5) 112 Sacral plexus (L4,S,S1,2,3,4,5) 132 Brachial plexus (C5,6,7,8,Tl) 1l4 Sciatic nerve (L4,5,S1,2,3) 134 Radial nerve (C5,6,7,8,Tl) 1l6 Tibial nerve (L4,5,S1,2,3) 136 Musculocutaneous nerve (C5,6,7) 118 Common peroneal (fibular) nerve Median nerve (C6,7,8,T1) 120 (L4,5,S1,2) 138 Ulnar nerve (C8,Tl) 122 Superficial peroneal (fibular) nerve Phrenic nerve (C3,4,5) 124 (LS,S1,2) 138 Intercostal nerve (typical) 124 Deep peroneal nerve (L4,5,S1,2) 138 Lumbar plexus (T12,L1,2,3,4,5) 126 Lateral plantar nerve (S1,2) 140 Femoral nerve (L2,3,4) 128 Medial plantar nerve (L4,S) 140 Obturator nerve (L2,3,4) 130 Cervical plexus PERIPHERAL NERVES

Cervical plexus (C 1,2,3,4,5) PERIPHERAL NERVES Cervical plexus

CERVICAL PLEXUS (C 1,2,3,4,5) membrane between obliquus capitis superior From: C1,2,3,4,5 Ns and rectus capitis posterior major to To: Ns as shown terminate in muscular branches in the suboccipital triangle. It arises mostly from the anterior primary rami deep between scalenus medius and Greater occipital N (posterior primary rami scalenus anterior at the level of Cl-C4 of C2, and a small contribution from C3). vertebrae and is covered by prevertebral Emerges from the posterior spinal dura at fascia lying deep to sternocleidomastoid. The the intervertebral foramen and passes cutaneous branches pierce the prevertebral posteriorly over the transverse process of fascia and run into the posterior triangle of the axis (C2)below obliquus capitis inferior. the neck where they pierce the investing layer It then winds around this muscle to ascend of the deep cervical fascia to terminate in deep to semispinalis piercing it and trapezius subcutaneous Ns. near to their insertions into the superior nuchal line. It terminates as cutaneous Ansa cervicalis (Cl-C3). Superior root branches running in the scalp with the (anterior primary rami C1)-passes directly occipital artery. to the hypoglossal N (XII)between rectus capitis anterior and lateralis. It leaves the Spinal accessory N (XIS)(lateral roots hypoglossal N lateral to the occipital artery Cl-C5) is formed from the unique lateral and runs anterior to the internal and roots of Cl-C5 and ascends within the common carotid arteries where it joins the subarachnoid space lateral to the cord and inferior root. Inferior root (anterior primary posterior to the denticulate ligament, to pass rami C2,3)-passes laterally around the through the foramen magnum posterior to internal jugular vein having pierced the the vertebral artery to meet with the cranial prevertebral fascia at the level of C213. It root. runs forwards and anteriorly as a long loop to meet with the superior root anterior to the Phrenic N (see pp. 124-125). common carotid artery. Great auricular N (C2,3). Supplies skin over Suboccipital N (posterior primary ramus parotid gland and angle of jaw (this is the of Cl). Emerges through the dura to run only area of the face that is not supplied by a beneath the vertebral artery closely applied cranial nerve), lower lateral auricle below to the posterior arch of the atlas (Cl).It external auditory meatus, and whole of pierces the posterior atlanto-occipital posterior (medial)auricle. Brachial plexus PERIPHERAL NERVES

Brachial plexus (C5,6,7,8,T I) PERIPHERAL NERVES Brachial plexus

BRACHIAL PLEXUS (C5,6,7,8,TI) neck of the humerus running laterally to end From: Ant primary rami of C5,6,7,8,Tl in anterior and posterior divisions deep to To: Musculocutaneous, median, ulnar & deltoid. radial Ns Upper lateral cutaneous N of arm. Is a It emerges as five roots lying anterior to continuation of the posterior branch of the scalenus medius and posterior to scalenus axillary N and supplies skin over the lower anterior. The trunks lie in the base of the lateral deltoid. Damage to the axillary N posterior triangle of the neck, where they are (and hence this nerve) gives a 'regimental palpable, and pass over the 1st rib posterior badge' area of sensory loss. to the third part of subclavian artery to descend to lie behind the clavicle. The Thoracodorsal N (C5,6,7). Runs with the divisions form behind the middle third of the subscapular artery down the medial scapular clavicle lying on the upper fibres of serratus border over teres major and into latissimus anterior and around the axillary artery, as dorsi. they form the cords. The cords lie in the axilla related to the second part of the Long thoracic N of Bell (C5,6,7). Descends axillary artery lying medial, lateral and posterior to the trunks of the plexus and the posterior as their names indicate and first part of the axillary artery to lie on the posterior to pectoralis minor. Terminal lateral aspect of serratus anterior on the nerves are formed around the third part of medial axillary wall. the axillary artery posterior to the lower fibres of pectoralis major. Suprascapular N (C5,6). Arises in the posterior triangle of the neck, passes Axillary N (C5,6). Arises posterior to the posterolaterally deep to trapezius and third part of axillary artery. It runs omohyoid and runs through the supra- posteriorly on subscapularis to pass through scapular notch into the supraspinous fossa. the quadrangular space with the posterior It descends laterally around the scapular circumflex humeral artery. It is intimately spine into the infraspinous fossa. related to the medial aspect of the surgical Radial nerve PERIPHERAL NERVES

Radial nerve (C5,6,7,8,T I) PERIPHERAL NERVES Radial nerve

RADIAL NERVE (C5,6,7,8,T I) divides into terminal branches over the From: Post cord of brachial plexus lateral epicondyle. To: Terminal brs Superficial terminal branch. Runs over It arises as the continuation of the posterior supinator, pronator teres and flexor cord and descends posterior to the axillary digitorum superficialis and lies under and brachial arteries passing inferior to the brachioradialis running with the radial tendons of latissimus dorsi and teres major artery on its medial aspect from one-third of to run with the profunda brachii artery the way down the forearm. It passes between the long and medial heads of triceps posteriorly, emerging from under the tendon and through the lateral triangular space. It of brachioradialis proximal to the radial gives off the posterior cutaneous N of arm styloid and then passes over the tendons of before leaving the axilla. It then runs over the the snuff box where it terminates as cuta- spiral line of the humerus between medial neous branches to the dorsum of the hand. and lateral heads of triceps giving muscular and cutaneous branches, and pierces the Posterior interosseous N. Passes between the lateral intermuscular septum at the mid two heads of supinator three fingers' breadth point of the humerus to reach the anterior below radial head passing into the posterior compartment. Here it lies deep to the upper compartment where it breaks up into fibres of brachialis then brachioradialis, terminal muscular branches in the plane before entering the lateral cubital fossa. It between the deep and superficial muscles in this compartment. Musculocutaneous nerve PERIPHERAL NERVES

Musculocutaneous newe (C5,6,7) PERIPHERAL NERVES Musculocutaneous nerve

MUSCULOCUTANEOUS NERVE brachialis, usually adherent to the deep (C5,6,7) surface of biceps. The terminal branch is the From: Lat cord lateral cutaneous N of forearm. To: Terminal brs Lateral cutaneous N of forearm. Emerges It arises obliquely behind the lower fibres of lateral to the tendon of biceps in the cubital pectoralis minor lying lateral to the axillary fossa, piercing the deep fascia just below the artery and passes laterally between the two elbow and descends over the lateral aspect of conjoined heads of coracobrachialis. It runs the forearm to terminate in the skin over the laterally downwards between biceps and radial artery at the wrist. Median nerve PERIPHERAL NERVES

Median nerve (C6,7,8,T I) PERIPHERAL NERVES Median nerve

MEDIAN NERVE (C6,7,8,TI) superficialis about 5 cm proximal to the From: Med & lat cords wrist where it gives its palmar cutaneous To: Terminal brs branch and then passes deep to the flexor retinaculum between the tendons of flexor It is formed in the lower axilla by two roots digitorum superficialis and flexor carpi (heads)which clasp the axillary artery. The radialis. In the carpal tunnel it divides into nerve initially lies anterior to the axillary terminal branches-recurrent (muscular) artery and then lateral to it and subsequently branch and palmar digital Ns. lateral to the brachial artery. The median N then crosses the brachial artery, usually Anterior interosseous N. Arises just below anteriorly, at the level of the mid humerus, the two heads of pronator teres to run on to lie medial to the artery in the cubital fossa. the interosseous membrane between and It lies first on coracobrachialis and then covered by flexor digitorum profundus and brachialis. It passes beneath the bicipital flexor pollicis longus ending beneath aponeurosis at the elbow leaving the cubital pronator quadratus. fossa between the two heads of pronator teres before crossing superficial to the ulnar Recurrent branch of median N. Runs out of artery and giving its anterior interosseous the carpal tunnel over the distal border of the branch below this. It lies applied to the deep flexor retinaculum onto flexor pollicis brevis surface of flexor digitorum superficialis on to terminate by passing into the thenar flexor digitorum profundus. It emerges eminence. from the lateral side of flexor digitorum Ulnar nerve PERIPHERAL NERVES

Ulnar nerve (C8,T I) PERIPHERAL NERVES Ulnar nerve

ULNAR NERVE (C8,TI) lateral side from one-third of the way down From: Med cord of brachial plexus the forearm. It lies lateral to the tendon of To: Terminal brs flexor carpi ulnaris at the wrist and then passes superficial to the flexor retinaculum to It arises medial to the axillary artery and divide into terminal branches at the pisiform continues medial to the brachial artery lying bone. on coracobrachialis to the mid point of the Superficial terminal branch-lies super- humerus where it leaves the anterior com- ficial in the palm terminating as digital Ns. partment by passing posteriorly through It also supplies palmaris brevis if present. the medial intermuscular septum with the Deep terminal branch-passes through the superior ulnar collateral artery. It lies hypothenar eminence between flexor digiti between the intermuscular septum and the minimi and abductor digiti minimi grooving medial head of triceps passing posterior to the hook of the hamate and runs with the the medial humeral epicondyle and enters deep palmar arch, deep to the flexor tendons the forearm between the two heads of flexor to terminate in adductor pollicis. carpi ulnaris. It then lies medial to the Dorsal cutaneous branch-arises Scm coronoid process of the ulna, runs deep to proximal to the wrist, passes deep to flexor flexor carpi ulnaris and on flexor digitorum carpi ulnaris onto the medial aspect of the profundus, with the ulnar artery on its dorsum of the hand where it terminates as cutaneous Ns. Phrenic nerve PERIPHERAL NERVES Intercostal nerve

Phrenic nerve (C3,4,5)

Intercostal nerve Phrenic nerve PERIPHERAL NERVES Intercostal nerve

PHRENIC NERVE (C3,4,5) right atrium and inferior vena cava, lying From: Ant primary rami of C3,4,5 within the fibrous pericardium. It passes To: Terminal brs anterior to the hilum of the lung before traversing the diaphragm via the caval It arises deep between scalenus medius and orifice. Left-descends usually anterior to the scalenus anterior and runs over the lateral left internal thoracic artery lying lateral to border of scalenus anterior behind the the left common carotid artery. It runs down prevertebral fascia. It runs on scalenus over the aortic arch crossing anterior to the anterior from lateral to medial edges lying left vagus before running anterior to the left lateral to the ascending cervical artery and pulmonary artery and thus anterior to the it passes behind the suprascapular and hilum of the lung. It then runs lateral to transverse cervical arteries as it does so. It the left auricle and left ventricle within runs over the anterior part of the dome of the fibrous pericardium to traverse the the pleura to enter the mediastinum post- diaphragm in isolation via the muscular erior to the subclavian vein and anterior to portion of the diaphragm to the left of the subclavian artery where right and left central tendon. nerves take different courses. Right- An accessory phrenic N (CS)arising from spirals forwards to lie lateral to the right the N to subclavius may join the phrenic N brachiocephalic vein and continues on the near the 1st rib. lateral surface of the superior vena cava,

INTERCOSTAL NERVE (TYPICAL) T1. Has no lateral or anterior cutaneous From: Ant primary rami of thoracic N branches. To: Terminal brs T7-11. Run behind the costal margins in It emerges from the intervertebral foramen their anterior course to lie in the same muscle (giving off the posterior primary ramus as it plane in the abdomen. At their anterior limit does so) to pass between the pleura and the they pass deep to rectus abdominis in the inner muscle layer anterior to the transverse rectus sheath and pierce both of these struc- process where it connects via the grey and tures to give terminal anterior cutaneous white rami communicantes with the thoracic branches. These also supply rectus sympathetic chain. It passes posterior to the abdominis. intercostal artery to lie below it as it runs in the subcostal groove in the plane between T12. Passes below the 12th rib as the sub- internal and innermost muscle layers. The costal N having similar branches to those muscular collateral branch arises before the above. It emerges from behind the lateral posterior angle of the rib and runs in the arcuate ligament of the diaphragm. same plane but lies at the level of the upper border of the rib below. Lumbar plexus PERIPHERAL NERVES

Lumbar plexus (T I 2,L 1,2,3,4,5) PERIPHERAL NERVES Lumbar plexus

LUMBAR PLEXUS (T I2,L 1,2,3,4,5) passes over iliacus obliquely lying posterior From: Ant primary rami of Tl2,Ll,2,3,4,S to the caecum on the right and descending To: Ns as shown colon on the left. It runs forward to the anterior superior iliac spine where it The plexus is formed within the substance penetrates the inguinal ligament at irs of psoas major anterior to the transverse attachment to pass into the subcutaneous processes of L2-5 from the anterior primary tissue of the lateral thigh. rami as they emerge from the intervertebral foramina. Genitofemoral N (L1,2). Emerges onto the anteromedial surface of psoas lying posterior Iliohypogastric N (Ll).This main nerve to the ureter, gonadal and iliocolic vessels on emerges lateral to psoas on the lumbar fascia the right and ureter, gonadal and lower left at the level of L2 to pass posterior to the colic vessels on the left. It divides into genital lower pole of the kidney and over quadratus and femoral branches on the anterior aspect lumborum. It passes above the iliac crest, of psoas. between transversus and internal oblique abdominis to pierce the latter above the Genital branch. Crosses the external iliac anterior superior iliac spine. It supplies both artery, passes through the deep inguinal ring muscles before becoming cutaneous. into the inguinal canal and through the superficial inguinal ring to terminate in the Ilio-inguinal N (Ll).This collateral branch spermatic cord in the male and labium majus emerges lateral to psoas on the lumbar in the female. It may also supply a small area fascia, passes posterior to the lower pole of of scrotal/labial skin. the kidney, over quadratus lumborum and penetrates transversus and internal oblique Femoral branch. Continues down lateral to abdominis above the anterior superior iliac the external iliac artery, under the inguinal spine. It supplies the lowest fibres of these ligament and into the femoral sheath which muscles and the conjoint tendon. Its terminal it penetrates anteriorly to become branch enters the inguinal canal from above subcutaneous. to pass through the superficial inguinal ring before piercing the external spermatic fascia Lumbosacral trunk (L4,5). Emerges deep to become subcutaneous. from the medial aspect of psoas to pass over the pelvic brim to form the upper fibres of Lateral femoral cutaneous N (L2,3). the sciatic N. Emerges lateral to psoas below the iliac crest, Femoral nerve PERIPHERAL NERVES

Femoral nerve (L2,3,4) PERIPHERAL NERVES Femoral nerve

FEMORAL NERVE (L2,3,4) medialis running lateral to the femoral artery From: Post div of ant primary rami of L2,3,4 as far as the upper part of the adductor To: Terminal brs (Hunter's) canal before entering the muscle.

It is formed within psoas major and emerges Saphenous N (post division). Descends in the from its lateral border low down in the iliac femoral triangle to reach the adductor canal fossa to lie in the groove between psoas and where it spirals over the femoral artery to iliacus. It reaches the thigh beneath the lie medial to it. It pierces the deep fascia inguinal ligament lateral to the femoral through the apex of the canal and emerges artery lying on the tendon of iliacus and posterior to sartorius and anterior to gracilis psoas. In the femoral triangle it splits into to continue with the long saphenous vein. It anterior and posterior divisions which passes over the subcutaneous surface of the straddle the lateral circumflex femoral tibia and anterior to the medial malleolus artery. There are usually four short super- where it is palpable, closely related to the ficial branches. The deep branches continue long saphenous vein. It terminates in down the femoral triangle, the N to vastus branches over the medial side of the foot. Obturator nerve PERIPHERAL NERVES

Obturator newe (L2,3,4) PERIPHERAL NERVES Obturator nerve

OBTURATOR NERVE (L2,3,4) and posterior divisions which straddle From: Ant div of ant primary rami of L2,3,4 adductor brevis. The posterior division To: Terminal brs pierces a few fibres of obturator externus and runs deep to adductor brevis on This nerve is formed within psoas major and adductor magnus. The anterior division runs emerges from the medial aspect of the muscle on the anterior aspect of adductor brevis on the ala of the sacrum to pass behind the deep to pectineus and then deep to adductor common iliac vessels. It runs over the pelvic longus to end by contributing, together with brim on the lateral wall of the pelvis and over the saphenous and medial femoral cutaneous the upper fibres of obturator internus to pass N, to the subsartorial plexus which supplies through the upper anterior aspect of the the skin over the medial thigh. obturator foramen. It divides into anterior Sacral plexus PERIPHERAL NERVES

Sacral plexus (L4,5,S 1,2,3,4,5) PERIPHERAL NERVES Sacral plexus

SACRAL PLEXUS (L4,5,S 1,2,3,4,5) inferior to gluteus maximus to become sub- From: Lumbosacral trunk (L4,5) & ant cutaneous in the buttock. It supplies that primary rami from S1,2,3,4,5 part of the buttocks which touch when To: Definitive Ns standing and part when sitting.

Lies on piriformis on the posterior wall of Pudendal N (S2,3,4). Passes out of the pelvis the pelvis deep to the internal iliac vessels over the sacrospinous ligament close to the (and the sigmoid vessels on the left) and is ischial spine through the greater, and re- protected by a sheet of pelvic fascia overlying entering through the lesser, sciatic foramina. it. Its roots are characteristically related to It runs on the medial surface of the lower arteries which pass between them as shown. fibres of obturator internus in the pudendal (Alcock's) canal. It passes forwards in the Superior gluteal N (L4,5,Sl). Emerges from lateral wall of the ischio-anal fossa where it the upper roots of the sciatic N and passes gives off its inferior rectal branch. It passes out of the pelvis above piriformis through into the perineum and gives its terminal the greater sciatic foramen. It runs between branches, the perinea1 N being superficial to gluteus medius and minimus over the middle the urogenital diaphragm and the dorsal N gluteal line on the outer surface of the ilium deep to it. to terminate in muscular branches. It helps to remember that all six branches Inferior gluteal N (L5,S1,2). Emerges from leaving sacral roots before anterior and the middle roots of the sciatic N and passes posterior divisions begin with the letter 'P': out of the pelvis below piriformis through N to Piriformis S1,2 (remains in pelvis to the greater sciatic foramen to enter gluteus supply this muscle) maximus. Posterior femoral cutaneous N S1,2,3 (leaves pelvis via greater sciatic foramen) Posterior femoral cutaneous N (S1,2,3). Perforating cutaneous N S2,3 (leaves pelvis Passes out of the pelvis below piriformis via greater sciatic foramen) through the greater sciatic foramen. It runs Pudendal N S2,3,4 (leaves pelvis via greater on the sciatic N, over the long head of biceps sciatic foramen) femoris to become subcutaneous extending Pelvic splanchnics (parasympathetic) S2,3,4 as far as the popliteal fossa. (remain in pelvis to supply pelvic organs) Perinea1 branch of S4 (remains in pelvis to Perforating cutaneous N (S2,3). Passes supply levator ani) through the sacrotuberous ligament and Sciatic nerve PERIPHERAL NERVES

Sciatic nerve (L4,5,S 1,2,3) PERIPHERAL NERVES Sciatic nerve

SCIATIC NERVE (L4,5,S 1,2,3) N to quadratus femoris (L4,5,S1). Arises From: Ant primary rami of L4,S,Sl,2,3 from the anterior surface of the sciatic N To: Tibial & common peroneal (fibular) Ns in the pelvis and leaves the pelvis in this position through the greater sciatic foramen, It is formed in the upper sacral plexus and lying between the sciatic N and the ischium. passes out of the greater sciatic foramen Running deep to the tendon of obturator below piriformis. In the buttock and thigh it internus and the gemelli it supplies gemellus lies initially deep to gluteus maximus lying inferior before passing into quadratus on gemellus superior, obturator internus femoris from above. tendon and gemellus inferior and then on quadratus femoris and adductor magnus. It N to obturator internus (LS,S1,2). Arises passes out of the cover of gluteus maximus from the anterior surface of the sciatic N in and for a short distance it is covered by only the pelvis and leaves the pelvis through the deep fascia, before it passes deep to the two greater sciatic foramen below piriformis and heads of biceps femoris. It runs vertically medial to the sciatic N. It passes medially down in the midline of the posterior com- over the ischial spine (lateral to the pudendal partment of the thigh and terminates by neurovascular bundle) and sends a branch to dividing into common peroneal (fibular) and gemellus superior before turning forward to tibial Ns usually two-thirds of the way down pass through the lesser sciatic foramen, the thigh. In its course over the gemelli it is a penetrating and supplying obturator close posterior relation of the ischium and internus as it does so. posterior rim of the acetabulum. Tibial nerve PERIPHERAL NERVES

Tibial newe (L4,5,S 1,2,3) PERIPHERAL NERVES Tibial nerve

TIBIAL NERVE (L4,5,S 1,2,3) down the calf. It slopes gently medially in From: Sciatic N the lower calf passing behind the medial To: Med & lat plantar Ns malleolus of the lower tibia between the posterior tibial artery anterornedially It arises in the lower third of the thigh above and the tendon of flexor hallucis longus the apex of the popliteal fossa as the larger posterolaterally. It runs under the flexor terminal branch of the sciatic N, and passes retinaculum where it divides into terminal down in the midline into the fossa between branches. semitendinosus and biceps femoris, lying deep to them. It lies markedly lateral to the Sural N. Arises in the popliteal fossa, passing popliteal artery on entry to the popliteal out posteriorly over the 'V' behind the two fossa but then the artery crosses deep to the heads of gastrocnemius and is joined by the N to lie lateral to it. The tibial N and the sural communicating N from the common popliteal artery remain separated by the peroneal (fibular) N. It pierces the deep popliteal veins. The nerve leaves the fossa fascia to become subcutaneous. It runs down deep to the two heads of gastrocnemius by laterally accompanied by the short passing deep to the fibrous arch of soleus. It saphenous vein to pass behind the lateral then runs deep to soleus on tibialis posterior malleolus over the superior peroneal in the midline, crossing over the posterior (fibular) retinaculum to end in terminal tibial artery from medial to lateral half way branches on the lateral side of the foot. Peroneal (fibular) nerves PERIPHERAL NERVES

Common, superficial and deep peroneal (fibular) nerves Note: the common peroneal (fibular) nerve is viewed from behind but the superficial and deep nerves are viewed from in front PERIPHERAL NERVES Peroneal (fibular) nerves

COMMON PERONEAL [FIBULAR] subcutaneous. It runs downwards superficial NERVE (L4,5,S 1,2) to the superior and inferior extensor retin- From: Sciatic N acula to end as terminal branches over them. To: Superficial & deep peroneal (fibular) Ns

It arises in the lower third of the thigh above DEEP PERONEAL [FIBULAR] NERVE the apex of the popliteal fossa as the smaller (L495,S 1,2) terminal branch of the sciatic N. It passes From: Common peroneal (fibular) N into the popliteal fossa along the upper To: Terminal brs lateral boundary just beneath the edge of biceps femoris and runs over plantaris, the It arises deep to peroneus longus and passes lateral head of gastrocnemius and the forwards deep to the muscle to wind around posterior capsule of the knee joint. It runs the fibula and to pass through the anterior over the fibular attachment of soleus to wind intermuscular septum. It continues deep around the neck of the fibula from posterior to extensor digitorum longus to appear to lateral. It passes into peroneus longus between it and tibialis anterior lying on the where it divides. interosseous membrane in the upper quarter of the anterior compartment. It runs down the interosseous membrane with the anterior SUPERFICIAL PERONEAL [FIBULAR] tibial vessels, coming to lie between extensor NERVE (L5,S 1,2) hallucis longus and tibialis anterior in the From: Common peroneal (fibular) N lower three-quarters of the compartment. It To: Terminal brs passes anterior to the tibia at the ankle joint between the anterior tibial artery medially It arises deep to peroneus longus and passes and the tendon of extensor digitorum longus forwards and downwards to lie over the laterally, running beneath the superior and lateral surface of the fibula between peron- inferior extensor retinacula. It breaks up into eus longus and brevis. It pierces the deep terminal branches on the dorsum of the foot. fascia half way down the leg to become (Articular branch to ankle joint not shown.) Lateral plantar nerve PERIPHERAL NERVES Medial plantar nerve

Lateral plantar nerve (S 1,2)

Medial plantar nerve (L4,5) Lateral plantar nerve PERIPHERAL NERVES Medial plantar nerve

LATERAL PLANTAR NERVE (S 1,2) over the origin of flexor digitorum access- From: Tibial N orius beneath flexor digitorum brevis, and its To: Terminal brs superficial terminal branches appear more superficially between flexor digitorurn brevis It arises beneath the flexor retinaculum and and abductor digiti minimi. Its deep terminal runs forward with the lateral plantar artery branches run medially beneath the long around the sustentaculum tali of the cal- flexor tendons and across the metatarsa1 caneus deep to abductor hallucis. It runs shafts to end in muscular branches.

MEDIAL PLANTAR NERVE (L4,5) to abductor hallucis. It pierces the plantar From: Tibial N fascia in so doing and runs forward over the To: Terminal brs tendon of flexor digitorurn longus to appear more superficially again between abductor It arises beneath the flexor retinaculum and hallucis and flexor digitorum brevis in the runs with the medial plantar artery around sole of the foot. the sustentaculum tali of the calcaneus deep This page intentionally left blank

DERMATOMES AND CUTANEOUS NERVE DISTRIBUTION

Dermatomes: head and neck DERMATOMES AND CUTANEOUS NERVE DISTRIBUTION

Cutaneous nerves: head and neck DERMATOMES AND CUTANEOUS NERVE DISTRIBUTION

Dermatomes: upper limb DERMATOMES AND CUTANEOUS NERVE DISTRIBUTION

Cutaneous nerves: upper limb DERMATOMES AND CUTANEOUS NERVE DISTRIBUTION

Dermatomes: lower limb DERMATOMES AND CUTANEOUS NERVE DISTRIBUTION

Cutaneous nerves: lower limb DERMATOMES AND CUTANEOUS NERVE DISTRIBUTION

Dermatomes: thorax and abdomen Abductor digiti minimi (foot) 154 Extensor hallucis longus 158 Abductor digiti minimi (hand) 154 Extensor indicis 158 Abductor hallucis 154 Extensor pollicis brevis 159 Abductor pollicis brevis 154 Extensor pollicis longus 159 Abductor pollicis longus 154 External oblique a bdominis 159 Adductor brevis 154 Flexor carpi radialis 159 Adductor hallucis 154 Flexor carpi ulnaris 159 Adductor longus 154 Flexor digiti minimi brevis (foot) 159 Adductor magnus 154 Flexor digiti minimi brevis (hand) 159 Adductor pollicis 155 Flexor digitorum accessorius (quadratus Anconeus 155 plantae) (foot) 159 Articularis cubiti (subanconeus) 155 Flexor digitorum brevis (foot) 159 Articularis genu 155 Flexor digitorum longus (foot) 160 Aryepiglotticus 155 Flexor digitorum profundus (hand) 160 Auricularis 155 Flexor digitorum superficialis (hand) 160 Biceps brachii 155 Flexor hallucis brevis 160 Biceps femoris 155 Flexor hallucis longus 160 Brachialis 155 Flexor pollicis brevis 160 Brachioradialis 155 Flexor pollicis longus 160 Buccinator l56 Gastrocnemius 161 Bulbospongiosus l56 Gemellus inferior 161 Constrictor of pharynx-inferior 156 Gemellus superior 161 Constrictor of pharynx-middle 156 Genioglossus 161 Constrictor of pharynx-superior 1.56 Geniohyoid 161 Coracobrachialis 156 Gluteus maximus 161 Corrugator supercilii 156 Gluteus medius 161 Cremaster 156 Gluteus minimus 161 Cricothyroid 157 Gracilis 161 Dartos 157 Hyoglossus (&chondroglossus) 161 Deep transverse perinei 157 Iliacus 162 Deltoid 157 Inferior oblique (see also obliquus capitis Depressor anguli oris 157 inferior) l62 Depressor labii inferioris 157 Inferior rectus l62 Diaphragm 157 Infraspinatus l62 Digastric 157 Intercostals external 162 Erector spinae-iliocostocervicalis 157 Intercostals innermost 162 Erector spinae-longissimus 157 Intercostals internal 162 Erector spinae-spinalis 158 Internal oblique abdominis l62 Extensor carpi radialis brevis 158 Interossei-dorsal of foot (4) 163 Extensor carpi radialis longus 158 Interossei-dorsal of hand (4) l63 Extensor carpi ulnaris 158 Interossei-palmar of hand (3) 163 Extensor digiti minimi (hand) 158 Interossei-plantar of foot (3) 163 Extensor digitorum (hand) 158 Interspinales 163 Extensor digitorum brevis (foot) 158 Intertransversarii l63 Extensor digitorum longus (foot) 158 Intrinsic muscle of tongue 163 MUSCLES

Ischiocavernosus l63 Plantaris 168 Lateral cricoarytenoid 163 Platysma 168 Lateral pterygoid 163 Popliteus 169 Lateral rectus l64 Posterior cricoarytenoid l69 Latissimus dorsi l64 Procerus 169 Levator anguli oris l64 Pronator quadratus 169 Levator ani-coccygeus l64 Pronator teres 169 Levator ani-iliococcygeus l64 Psoas major 169 Levator ani-pubococcygeus l64 Psoas minor l69 Levator ani-puborectalis l64 Pyramidalis 169 Levator ani-pubovaginalis (levator Quadratus femoris l69 prostatae) 164 Quadratus lumborum 169 Levator la bii superioris l64 Quadratus plantae (see flexor digitorum Levator labii superioris alaeque nasi 164 accessorius) Levator palpebrae superioris 164 Rectus abdominis 170 Levator scapulae 165 Rectus capitis anterior 170 Levator veli palatini 165 Rectus capitis lateralis 170 Levatores costarum 165 Rectus capitis posterior major 170 Longus capitis 165 Rectus capitis posterior minor 170 Longus colli l65 Rectus femoris (quadriceps Lumbricals of foot (4) 165 femoris l) 170 Lumbricals of hand (4) 165 Rhomboid major 170 Masseter 165 Rhomboid minor 170 Medial pterygoid l65 Risorius 170 Medial rectus l65 Salpingopharyngeus 170 Mentalis 166 Sartorius 170 Musculus uvulae 166 Scalenus anterior 171 Mylohyoid 166 Scalenus medius 171 Nasalis (compressor & dilator) 166 Scalenus minimus 171 Oblique arytenoid 166 Scalenus posterior 171 Obliquus capitis inferior 166 Semimembranosus 171 Obliquus capitis superior 166 Semitendinosus 171 Obturator externus 166 Serratus anterior 171 Obturator internus 166 Serratus posterior inferior 171 Occipitofrontalis 166 Serratus posterior superior 171 Omohyoid 167 Soleus 171 Opponens digiti minimi (hand) 167 Sphincter ani (external) 172 Opponens pollicis l67 Sphincter urethrae 172 Orbicularis oculi 167 Splenius capitis 172 Orbicuiaris oris l67 Splenius cervicis 172 Palatoglossus l67 Stapedius 172 Palatopharyngeus 167 Sternocleidomastoid 172 Palmaris brevis 167 Sternohyoid 172 Palmaris longus l67 Sternothyroid 172 Pectineus 168 Styloglossus 172 Pectoralis major 168 Stylohyoid 172 Pectoralis minor 168 Stylopharyngeus 172 Peroneus brevis 168 Su bclavius 172 Peroneus longus 168 Su bcostalis 173 Peroneus tertius 168 Subscapularis 173 Piriformis 168 Superficial transverse perinei 173 MUSCLES

- P P-

Superior oblique (see also o bliquus capitis Tibialis posterior 175 superior) 173 Transverse arytenoid 175 Superior rectus 173 Transversospinalis-multifidus 175 Supinator 173 Transversospinalis-rotatores 175 Supraspinatus 173 Transversospinalis-semispinalis 175 Temporalis 173 Transversus abdominis 175 Temporoparietalis 174 Transversus thoracis (sternocostalis) 175 Tensor fasciae iatae 174 Trapezius 175 Tensor tympani 174 Triceps 176 Tensor veli palatini 174 Vastus intermedius (quadriceps Teres major 174 femoris 2) 176 Teres minor 174 Vastus lateralis (quadriceps femoris 3) 176 Thyro-arytenoid & vocalis 174 Vastus medialis (quadriceps femoris 4) 176 Thyro-epiglotticus 174 Zygomaticus major 176 Thyrohyoid 174 Zygomaticus minor 176 Tibialis anterior 174 Abductor digiti minimi MUSCLES Adductor magnus

ABDUCTOR DIGIT1 MINIM1 (foot) Action Abducts & extends thumb at CMC Arises Med & lat processes of post jnt calcaneal tuberosity Newe Post interosseous N (C7,8) lnserts Lat side of base of prox phalanx of Notes Forms radial side of snuff box 5th toe & 5th MT Action Flexes & abducts 5th toe. Supports lat longitudinal arch ADDUCTOR BREVIS Nerve Lat plantar N (S2,3) Arises Inf ramus & body of pubis lnserts Upper third of linea aspera Action Adducts hip ABDUCTOR DIGIT1 MINIM1 (hand) Nerve Ant div of obturator N (L2,3) Arises Pisiform bone & pisohamate lig lnserts Ulnar side of base of prox phalanx of little finger & extensor expansion ADDUCTOR HALLUCIS (+ sesamoid) Arises Oblique head: base of 2,3,4 MTs. Action Abducts little finger at MCP jnt Transverse head: plantar MT ligs & deep Newe Deep br of ulnar N (C8,Tl) transverse lig lnserts Lat side of base of prox phalanx of big toe & lat sesamoid ABDUCTOR HALLUCIS Action Adducts & flexes MTP jnt of big Arises Med process of post calcaneal toe. Supports transverse arch tuberosity & flexor retinaculum Newe Deep br of lat plantar N (S2,3) lnserts Med aspect of base of prox phalanx Notes If muscle fibres are attached to 1st of big toe via med sesamoid MT it can be regarded as opponens Action Flexes & abducts big toe. Supports hallucis med longitudinal arch Nerve Med plantar N (S1,2) ADDUCTOR LONGUS Arises Body of pubis inf & med to pubic ABDUCTOR POLLlClS BREVIS tubercle Arises Tubercle of scaphoid & flexor lnserts Lower two-thirds of med linea retinaculum aspera lnserts Radial sesamoid of prox phalanx Action Adducts hip of thumb & tendon of extensor pollicis Nerve Ant div of obturator N (L2,3,4) longus Action Abducts thumb at MCP & CMC jnts ADDUCTOR MAGNUS Newe Recurrent (muscular)br of median Arises Adductor portion: ischiopubic N (C8,Tl) ramus. Hamstring portion: lower outer Notes As this muscle is supplied only by quadrant of post surface of ischial median N, its action is used as a test for tuberosity this N in hand lnserts Adductor portion: lower gluteal line & linea aspera. Hamstring portion: adductor tubercle ABDUCTOR POLLlClS LONGUS Action Adductor portion: adducts hip. Arises Upper post surface of ulna & middle Hamstring portion: extends hip third of post surface of radius & Nerve Adductor portion: post div of interosseous membrane between obturator N (L2,3,4). Hamstring portion: lnserts Over tendons of radial extensors & tibial portion of sciatic (L4) brachioradialis to base of 1st MC & trapezium Adductor pollicis MUSCLES Brachioradialis

ADDUCTOR POLLlClS BICEPS BRACHll Arises Oblique head: base of 2nd & 3rd Arises Long head: supraglenoid tubercle of MCs, trapezoid & capitate. Transverse scapula. Short head: coracoid process of head: palmar border & shaft of 3rd MC scapula with coracobrachialis lnserts Ulnar sesamoid then ulnar side of lnserts Post border of bicipital tuberosity base of prox phalanx & tendon of of radius (over bursa) & bicipital extensor pollicis longus aponeurosis to deep fascia & Action Adducts CMC jnt of thumb subcutaneous ulna Newe Deep br of ulnar N (C8,Tl) Action Supinates forearm, flexes elbow, weakly flexes shoulder Newe Musculocutaneous N (C5,6) (from ANCONEUS lat cord) Arises Smooth surface at lower extremity Notes Supinates most effectively when of post aspect of lat epicondyle of humerus elbow flexed lnserts Lat side of olecranon Action Weak extensor of elbow. Moves (abducts) ulna in pronation BICEPS FEMORIS Newe Radial N (C7,8) Arises Long head: upper inner quadrant of post surface of ischial tuberosity. Short head: middle third of linea aspera, lat ARTlCULARlS CUBIT1 (subanconeus) supracondylar ridge of femur Arises Deep distal surface of med head of lnserts Styloid process of head of fibula, lat triceps collateral lig & lat tibial condyle lnserts Post capsule of elbow jnt Action Flexes & lat rotates knee. Long head Action Lifts capsule away from jnt extends hip Newe Radial (C6,7,8) Nerve Long head: tibial portion of sciatic N. Short head: common peroneal portion of sciatic N (both LS,S1,2) ARTlCULARlS GENU Arises Two slips from ant femur below vastus intermedius BRACHlALlS lnserts Apex of suprapatellar bursa Arises Ant lower half of humerus & med & Action Retracts bursa as knee extends lat intermuscular septa Newe Post div of femoral N (L2,3,4) Inserts Coronoid process & tuberosity of ulna Action Flexes elbow ARYEPIGLOTTICUS Nerve Musculocutaneous N (C5,6) (from Arises Apex of arytenoid cartilage lat cord). Also small supply from radial N lnserts Lat border of epiglottis (c71 Action Aids closure of additus of larynx Newe Recurrent laryngeal br of vagus N (X) BRACHlORADlALlS Note It is an extension of oblique arytenoid Arises Upper two-thirds of lat supracondylar ridge of humerus & lat intermuscular septum AURlCULARlS lnserts Base of styloid process of radius Arises Cartilage of auricle Action Flexes arm at elbow & brings lnserts Galeal aponeurosis forearm into midprone position Action Adjusts position of ear Newe Radial N (C5,6) Newe Temporal & posterior auricular brs Notes Overlies radial N & art as they lie on of facial N (VII) supinator Buccinator MUSCLES Cremaster

BUCCINATOR Action Aids swallowing Arises Ext alveolar margins of maxilla & Nerve Pharyngeal plexus (IX, X & mandible by molar teeth, to maxillary sympathetic) via pharyngeal br of X with tubercle & pterygoid hamulus & post its motor fibres from cranial accessory N mylohyoid line respectively, then via (XI) pterygomandibular raphe between bones lnserts Decussates at modiolus of mouth & interdigitates with opposite side CONSTRICTOR OF PHARYNX- Action Aids mastication by emptying SUPERIOR vestibule, tenses cheeks in blowing & Arises Lower two-thirds of med pterygoid whistling, aids closure of mouth plate, pterygomandibular raphe & post Nerve Buccal br of facial N (VII) end of mylohyoid line on mandible lnserts Upper midline pharyngeal raphe & pharyngeal tubercle of occiput BULBOSPONGIOSUS Action Aids swallowing Arises Perineal body (&midline raphe over Nerve Pharyngeal plexus (IX, X & corpus spongiosum in male) sympathetic) via pharyngeal br of X with lnserts Superficial perinea1 membrane & its motor fibres from cranial accessory dorsal penilelclitoral aponeurosis (XI) Action Male: aids emptying of urine & ejaculate from urethra. Female: closes vaginal introitus CORACOBRACHIALIS Newe Perineal br of pudendal N (S2,3,4) Arises Coracoid process of scapula with biceps brachii lnserts Middle third of med border of CONSTRICTOR OF PHARYNX- humerus INFERIOR Action Flexes & weakly adducts arm Arises Cricopharyngeus: lat aspect of arch Newe Musculocutaneous N (C5,6,7) of cricoid cartilage. Thyropharyngeus: (from lat cord) oblique line on laminar of thyroid Notes Ligament of Struthers as embryo- cartilage & fibrous cricothyroid arch logical 3rd head. Musculocutaneous N lnserts Cricopharyngeus: continuous with runs through muscle muscle of opposite side, behind pharynx. Thyropharyngeus: lower pharyngeal raphe CORRUGATOR SUPERClLll Action Aids swallowing. Cricopharyngeus Arises Med superciliary arch acts as upper oesophageal sphincter lnserts Skin of med forehead Newe Pharyngeal plexus (IX, X & Action Wrinkles forehead sympathetic) via pharyngeal br of X with Nerve Temporal br of facial N (VII) its motor fibres from cranial accessory (XI) Notes Killian's dehiscence is between the CREMASTER two parts post Arises Lower border of internal oblique & transversus abdominis in inguinal canal lnserts Loops around spermatic cord & CONSTRICTOR OF PHARYNX- tunica vaginalis & some fibres return to MIDDLE attach to pubic tubercle Arises Lower third of stylohyoid lig, lesser Action Retracts testis cornu & sup border of greater cornu of Nerve Sympathetic & somatic fibres in hyoid bone genital br (L2)of genitofemoral N (L1,2) lnserts Middle portion of pharyngeal raphe Cricothyroid MUSCLES Erector spinae-longissimus

CRICOTHYROID DEPRESSOR LABll INFERIORIS Arises Anterolateral aspect of cricoid Arises Outer surface of mandible cartilage inferomedial to mental foramen lnserts Inf cornu & lower laminar of lnserts Skin of lower lip thyroid cartilage Action Depresses & draws lower lip laterally Action Lengthens & tenses vocal cords by Nerve Mandibular br of facial N (VII) tilting thyroid cartilage forwards Nerve Ext br of sup laryngeal br of vagus N (X) DIAPHRAGM Arises Vertebral: crura from bodies of L1,2 (left), L1-3 (right),together giving median DARTOS arcuate lig. Costal: med & lat arcuate ligs, Arises Subcutaneous tissue of scrotum, inner aspect of lower six ribs and costal superficial to superficial fascia (Colles) cartilages lnserts Skin & midline fibrous septum of Sternal: two slips from post aspect of scrotum xiphoid Action Corrugates scrotal skin lnserts Trefoil central tendon Nerve Sympathetic fibres in genital br (L2) Action Inspiration & assists in raising of genitofemoral N (L1,2) intra-abdominal pressure Nerve Phrenic N (motor)(C3,4,5). Sensory: phrenic, intercostals (6-12) & DEEP TRANSVERSE PERlNEl upper two lumbar N roots Arises Med aspect of ischiopublic ramus & body of ischium within deep perineal pouch DlGASTRlC lnserts Midline raphe & perineal body Arises Ant belly: digastric fossa on post Action Fixes perineal body & supports surface of symphysis menti. Post belly: pelvic viscera base of med aspect of mastoid process Nerve Perinea1 br of pudendal N (S2,3,4) lnserts Fibrous loop to lesser cornu of hyoid bone Action Elevates hyoid bone. Aids DELTOID swallowing & depresses mandible Arises Lat third of clavicle, acromion, spine Nerve Ant belly: mylohyoid N (VC).Post of scapula to deltoid tubercle belly: facial N (VII)before it enters parotid lnserts Middle of lat surface of humerus gland (deltoid tuberosity) Action Abducts arm, ant fibres flex & med rotate, post fibres extend & lat rotate ERECTOR SPINAE- Nerve Axillary N (CS,6) (from post cord) ILIOCOSTOCERVICALIS Arises Post angles of ribs lnserts Transverse processes above & below DEPRESSOR ANGULI ORlS Action Extends & lat flexes spine Arises Outer surface of mandible inf to Nerve Post primary rami mental foramen Notes Divided into iliocostalis-lumborum, lnserts Modiolus at angle of mouth thoracis & cervicalis Action Depresses & draws angle of mouth laterally Nerve Mandibular br of facial N (VII) ERECTOR SPINAE-LONGISSIMUS Arises Transverse processes lnserts Transverse processes several levels above Erector spinae--spinalis MUSCLES Extensor indicis

Action Extends spine EXTENSOR DlGlTORUM (hand) Newe Post primary rami Arises Common extensor origin on ant Notes Divided into longissimus-thoracis, aspect of 1at epicondyle of humerus cervicis & capitis lnserts Extensor expansion to all phalanges of four fingers by four tendons. Tendons 3 & 4 usually fuse & little finger just ERECTOR SPINAE-SPINALIS receives a slip Arises Spinous processes Action Extends all jnts of fingers lnserts Spinous processes six levels above Newe Post interosseous N (C7,8) Action Lat flexion of spine Nerve Post primary rami Notes Divided into spinalis-thoracis, EXTENSOR DlGlTORUM cervicis & capitis BREVIS (foot) Arises Sup surface of ant calcaneus lnserts Four tendons into prox phalanx of EXTENSOR CARPI RADlALlS BREVIS big toe & long extensor tendons to toes 2, Arises Common extensor origin on ant 3 and 4 aspect of lat epicondyle of humerus Action Extends toes when foot fully lnserts Post base of 3rd MC dorsiflexed Action Extends & abducts hand at wrist Nerve Deep peroneal N (L5,Sl) Newe Post interosseous N (C7,8) Notes Med one of four tendons could be regarded as extensor hallucis brevis

EXTENSOR CARPI RADlALlS LONGUS EXTENSOR DlGlTORUM Arises Lower third of lat supracondylar LONGUS (foot) ridge of humerus & lat intermuscular Arises Upper two-thirds of ant shaft of septum fibula, interosseous membrane & sup lnserts Post base of 2nd MC tibiofibular jnt Action Extends & abducts hand at wrist lnserts Extensor expansion of lat four toes Nerve Radial N (C6,7) Action Extends toes & extends foot at ankle Nerve Deep peroneal N (L5,Sl) EXTENSOR CARPI ULNARIS Arises Common extensor origin on ant aspect of lat epicondyle of humerus EXTENSOR HALLUCIS LONGUS lnserts Base of 5th MC via groove by ulnar Arises Middle half of ant shaft of fibula styloid lnserts Dorsal base of distal phalanx of Action Extends & adducts hand at wrist great toe Newe Post interosseous N (C7,8) Action Extends big toe & foot. Inverts foot & tightens subtalar jnts Nerve Deep peroneal N (L5,Sl) EXTENSOR DIGIT1 MINIM1 (hand) Arises Common extensor origin on ant aspect of lat epicondyle of humerus EXTENSOR INDlClS lnserts Extensor expansion of little Arises Lower post shaft of ulna (below finger-usually two tendons which are extensor pollicis longus) & adjacent joined by a slip from extensor digitorum at interosseous membrane MCP jnt lnserts Extensor expansion of index finger Action Extends all jnts of little finger (tendon lies on ulnar side of extensor Nerve Post interosseous N (C7,8) digitorum tendon) Extensor pollicis brevis MUSCLES Flexor digitorurn brevis

Action Extends all jnts of index finger FLEXOR CARPI ULNARIS Nerve Post interosseous N (C7,8) Arises Humeral head: common flexor origin of med epicondyle. Ulnar head: aponeurosis from med olecranon & upper EXTENSOR POLLlClS BREVIS three-quarters subcutaneous border of Arises Lower third of post shaft of radius & ulna adjacent interosseous membrane lnserts Pisiform, hook of hamate, base of lnserts Over tendons of radial extensors & 5th MC via pisohamate & pisometacarpal brachioradialis to base of prox phalanx of ligs thumb Action Flexes & adducts wrist. Fixes Action Extends MCP jnt of thumb pisiform during action of hypothenar Nerve Post interosseous N (C7,8) muscles Notes Forms radial side of snuff box Nerve Ulnar N (C7,8,T1) (by communication from lat cord) Notes Ulnar N passes between two heads EXTENSOR POLLlClS LONGUS Arises Middle third of post ulna (below abductor pollicis longus) & adjacent FLEXOR DIGIT1 MINIM1 BREVIS (foot) interosseous membrane Arises Base of 5th MT & sheath of lnserts Base of distal phalanx of thumb peroneus longus via Lister's tubercle (dorsal tubercle of lnserts Lat side of base of prox phalanx of radius) little toe Action Extends IP & MCP jnts of thumb Action Flexes MTP jnt of little toe Nerve Post interosseous N (C7,8) Nerve Superficial br of lat plantar N (S2,3) Notes Forms ulnar side of snuff box Notes A few muscle fibres to distal half of plantar surface of 5th MT represent opponens digiti minimi EXTERNAL OBLIQUE ABDOMlNlS Arises Ant angles of lower eight ribs lnserts Outer ant half of iliac crest, inguinal FLEXOR DIGIT1 MINIM1 BREVIS (hand) lig, pubic tubercle & crest, & aponeurosis Arises Flexor retinaculum & hook of of ant rectus sheath, linea alba & hamate xiphisternum lnserts Ulnar side of base of prox phalanx Action Supports abdominal wall, assists of little finger forced expiration, aids raising intra- Action Flexes MCP jnt of little finger abdominal pressure &, with muscles of Nerve Deep br of ulnar N (C8,Tl) opposite side, abducts & rotates trunk Nerve Ant primary rami (T7-12) Notes Interdigitates with four slips of FLEXOR DlGlTORUM ACCESSORIUS serratus anterior & four of latissimus (QUADRATUS PLANTAE) (foot) dorsi Arises Med & lat sides of calcaneus lnserts Tendons of flexor digitorum longus Action Assists flexor digitorum longus to FLEXOR CARPI RADIALIS flex lat four toes, especially when ankle is Arises Common flexor origin of med plantar flexed epicondyle of humerus Nerve Lat plantar N (S2,3) lnserts Bases of 2nd & 3rd MCs via groove in trapezium Action Flexes & abducts wrist FLEXOR DlGlTORUM BREVIS (foot) Nerve Median N (C6,7) (from med & lat Arises Med process of post calcaneal cords) tuberosity Flexor digitorurn longus MUSCLES Flexor pollicis longus lnserts Four tendons to four lat toes to both Action Flexes prox IP jnts & secondarily sides of middle phalanx. Tendons of flexor MCP jnts & wrist digitorum longus pass through them Nerve Median N (C7,8,T1) (from med & Action Flexes lat four toes. Supports rned & lat cords) lat longitudinal arches Notes Median N applied to under surface Nerve Med plantar N (S1,2) of muscle

FLEXOR DlGlTORUM LONGUS (foot) FLEXOR HALLUCIS BREVIS Arises Post shaft of tibia below soleal line Arises Cuboid, lat cuneiform & tibialis & by broad aponeurosis from fibula posterior insertion over the two remaining lnserts Base of distal phalanges of lat four cuneiforms toes lnserts Med tendon to rned side of base of Action Flexes distal phalanges of lat four prox phalanx of big toe. Lat tendon to lat toes & foot at ankle. Supports lat side of same, both via sesamoids longitudinal arch Action Flexes MTP jnt of big toe. Supports Nerve Tibial N (S2,3) rned longitudinal arch Notes Med two tendons receive slips from Nerve Med plantar N (S1,2) flexor hallucis longus & all four receive insertion of flexor accessorius & each gives a lumbrical FLEXOR HALLUCIS LONGUS Arises Lower two-thirds of post fibula between median crest & post border, FLEXOR DlGlTORUM lower intermuscular septum & inter- PROFUNDUS (hand) osseous membrane Arises Upper three-quarters of ant & rned lnserts Base of distal phalanx of big toe & surface of ulna as far round as subcutane- slips to rned two tendons of flexor ous border & narrow strip of interosseous digitorum longus membrane Action Flexes distal phalanx of big toe, lnserts Distal phalanges of rned four flexes foot at ankle, supports rned fingers. Tendon to index finger separates logitudinal arch early Nerve Tibial N (S2,3) Action Flexes distal IP jnts, then secondarily flexes prox IP & MCP jnts & wrist FLEXOR POLLlClS BREVIS Newe Median N (ant interosseous) Arises Superficial head: flexor retinaculum (C8,Tl) ulnar N (C8,Tl) & tubercle of trapezium. Deep head: Notes Nerve supply as above in 60%. In capitate & trapezoid 40% it is a 3: 1ratio either way lnserts Base of prox phalanx of thumb (via radial sesamoid) Action Flexes MCP jnt of thumb FLEXOR DlGlTORUM Newe Recurrent (muscular)br of median SUPERFICIALIS (hand) N (C8,Tl) (may also be from deep br of Arises Humeral head: common flexor ulnar N (C8,Tl)) origin of rned epicondyle of humerus, rned lig of elbow. Ulnar head: sublime tubercle (med border of coronoid process) & FLEXOR POLLlClS LONGUS fibrous arch. Radial head: whole length of Arises Ant surface of radius below ant ant oblique line oblique line & adjacent interosseous lnserts Tendons split to insert onto sides of membrane middle phalanges of rned four fingers lnserts Base of distal phalanx of thumb Gastrocnemius MUSCLES Hyoglossus (81chondroglossus)

Action Flexes distal phalanx of thumb GLUTEUS MAXIMUS Nerve Ant interosseous N (C7,8) Arises Outer surface of ilium behind post gluteal line & post third of iliac crest, lumbar fascia, lat mass of sacrum, GASTROCNEMIUS sacrotuberous lig & coccyx Arises Lat head: post surface of lat condyle lnserts Deepest quarter into gluteal of femur & highest of three facets on lat tuberosity of femur, remaining three- condyle. Med head: post surface of femur quarters into iliotibial tract (ant surface of above rned condyle lat condyle of tibia) lnserts Tendo calcaneus to middle of three Action Extends & lat rotates hip. facets on post aspect of calcaneus Maintains knee extended via iliotibial Action Plantar flexes foot. Flexes knee tract Newe Tibial N (S1,2) Nerve Inf gluteal N (LS,Sl,2) Notes Main propulsive force for jumping Notes Largest muscle in body

GEMELLUS INFERIOR GLUTEUS MEDIUS Arises Upper border of ischial tuberosity Arises Outer surface of ilium between post lnserts Middle part of rned aspect of greater & ant gluteal lines trochanter of femur lnserts Posterolateral surface of greater Action Lat rotates & stabilises hip trochanter of femur Nerve N to quadratus femoris (L4,5,S1) Action Abducts & rned rotates hip. Tilts pelvis on walking Nerve Sup gluteal N (L4,5,Sl) GEMELLUS SUPERIOR Arises Spine of ischium lnserts Middle part of rned aspect of greater GLUTEUS MINIMUS trochanter of femur Arises Outer surface of ilium between ant Action Lat rotates & stabilises hip & inf gluteal lines Nerve N to obturator internus (L5,S1,2) lnserts Ant surface of greater trochanter of femur Action Abducts & rned rotates hip. Tilts GENIOGLOSSUS pelvis on walking Arises Sup mental spine on post surface of Nerve Sup gluteal N (L4,5,S1) symphysis menti lnserts Central mass of tongue & mucous membrane GRAClLlS Action Protracts tongue Arises Outer surface of ischiopubic Newe Hypoglossal N (XII) ramus lnserts Upper rned shaft of tibia behind sartorius GENlOHYOlD Action Adducts hip. Flexes knee & rned Arises Inf mental spine on post surface of rotates flexed knee symphysis menti Nerve Ant div of obturator N (L2,3) lnserts Sup border of body of hyoid bone Action Elevates & protracts hyoid bone. Depresses mandible HYOGLOSSUS Nerve C1 fibres carried by hypoglossal N (& CHONDROGLOSSUS) Arises Sup border of greater cornu of hyoid bone lnserts Lat side of tongue lliacus MUSCLES Internal oblique abdominis

Action Depresses tongue Action Fix intercostal spaces during Nerve Hypoglossal N (XII) respiration. Aids forced respiration by elevating ribs Nerve Muscular collateral brs of intercostal ILIACUS Ns Arises Iliac fossa within abdomen lnserts Lowermost surface of lesser trochanter of femur INTERCOSTALS INNERMOST Action Flexes hip Arises Int lat aspect of ribs above & below Nerve Femoral N in abdomen (L2,3) lnserts Int aspect of ribs above & below Action Fix intercostal spaces during respiration INFERIOR OBLIQUE (see also obliquus Nerve Muscular collateral brs of intercostal capitis inferior) Ns Arises Orbital surface of maxilla behind Notes Innermost intercostals are one of orbital margin on med side three muscles that make up inner layer lnserts Post/inf quadrant of sclera behind of thoracic wall muscles. Others are equator of eyeball on lat side transversus thoracis (ant)& subcostalis Action Elevates eye in adduction. Extorts (post) eye in abduction Nerve Inf div of oculomotor N (111) INTERCOSTALS INTERNAL Arises Inf border of ribs as far back as post INFERIOR RECTUS angles. Beyond this is post (int)intercostal Arises Inf tendinous ring within orbit membrane lnserts Inf sclera ant to equator of eyeball lnserts Sup border of ribs below, passing Action Depresses eye. Extorts eye in obliquely downwards & backwards adduction Action Fix intercostal spaces during Nerve Inf div of oculomotor N (111) respiration. Aids forced inspiration by elevating ribs Nerve Muscular collateral brs of intercostal INFRASPINATUS Ns Arises Med three-quarters of infraspinous fossa of scapula & fibrous intermuscular septa INTERNAL OBLIQUE ABDOMlNlS lnserts Middle facet of greater tuberosity Arises Lumbar fascia, ant two-thirds of of humerus & capsule of shoulder jnt iliac crest & lat two-thirds of inguinal lig Action Lat rotates arm & stabilises lnserts Costal margin (ribs & costal shoulder jnt cartilages), aponeurosis of rectus sheath Nerve Suprascapular N (C5,6) (from upper (ant & post), conjoint tendon to pubic trunk) crest & pectineal line Notes Bursa under tendon over glenoid Action Supports abdominal wall, assists angle. Tendon forms part of rotator cuff forced respiration, aids raising intra- abdominal pressure &, with muscles of other side, abducts & rotates trunk. INTERCOSTALS EXTERNAL Conjoint tendon supports post wall of Arises Inf border of ribs as far forwards as inguinal canal costochondral junctions. Beyond this is Nerve Ant primary rami (T7-12) (conjoint ant (ext)intercostal membrane tendon ilio-inguinal N (Ll)) lnserts Sup border of ribs below, passing obliquely downwards & forwards Interossei-dorsal of foot MUSCLES Lateral pterygoid

INTEROSSEI-DORSAL OF FOOT (4) Action Extension of spine Arises Bipennate from inner aspects of Nerve Post primary rami shafts of all MTs lnserts Bases of prox phalanges & dorsal extensor expansions of med side of 2nd INTERTRANSVERSARII toe & lat sides of 2nd, 3rd & 4th toes Arises Transverse processes Action Abduct 2nd, 3rd & 4th toes from lnserts Transverse processes one above axis of 2nd toe. Assist lumbricals in Action Lat flexes spine extending IP jnts whilst flexing MTP jnts Nerve Post primary rami Nerve Lat plantar N (1-3: deep br; 4: superficial br) (S2,3) INTRINSIC MUSCLE OF TONGUE Arises Sup & inf longitudinal, transverse & INTEROSSEI-DORSAL OF HAND (4) vertical elements Arises Bipennate from inner aspects of lnserts Mucous membrane, septum & shafts of all MCs other muscles of tongue lnserts Prox phalanges & dorsal extensor Action Alter shape of tongue & so aid expansion on radial side of index & mastication, speech & swallowing middle fingers & ulnar side of middle & Nerve Hypoglossal N (XII) ring fingers Action Abduct index, middle & ring fingers from axis of middle finger. Flex MCP jnt ISCHIOCAVERNOSUS whilst extending IP jnts Arises Med aspect of ischium & Nerve Deep br of ulnar N (C8,Tl) ischiopubic ramus lnserts Inferolateral aponeurosis over crura INTEROSSEI-PALMAR OF HAND (3) of penis/clitoris Arises Ant shafts of 2,4,5 MCs Action Stabilises erect penis (unipennate) Nerve Perinea1 br of pudendal N (S2,3,4) lnserts Prox phalanges & dorsal extensor expansion on ulnar side of index & radial side of ring & little fingers LATERAL CRICOARYTENOID Action Adduct index, ring & little fingers to Arises Lat aspect of arch of cricoid cartilage axis of middle finger. Flex MCP jnt whilst lnserts Muscular process of arytenoid extending IP jnts cartilage Nerve Deep br of ulnar N (C8,Tl) Action Adducts & med rotates arytenoid cartilage (closes rima glottidis) Nerve Recurrent laryngeal br of vagus N INTEROSSEI-PLANTAR OF FOOT (3) Arises Inferomedial shafts of 3rd, 4th & (X) 5th MTs (single heads) lnserts Med sides of bases of prox LATERAL PTERYGOID phalanges with slips to dorsal extensor Arises Upper head: infratemporal surface expansions of 3rd, 4th & 5th toes of sphenoid bone. Lower head: lat surface Action Adduct 3rd, 4th & 5th toes to axis of lat pterygoid plate of 2nd toe. Assist lumbricals in extending Inserts Pterygoid fovea below condylar IP jnts whilst flexing MTP jnts process of mandible & intra-articular disc Nerve Deep br of lat plantar N (S2,3) & capsule of temporomandibular jnt Action Protrudes mandible & opens mouth INTERSPINALES by pulling condyle & disc forwards Arises Spinous processes Nerve Ns to lat pterygoid (ant div of lnserts Spinous processes one above mandibular N (VC)) Lateral rectus MUSCLES Levator palpebrae superioris

LATERAL RECTUS LEVATOR ANI-PUBOCOCCYGEUS Arises Lat tendinous ring within orbit Arises Post surface of pubis & ant half of lnserts Lat sclera ant to equator of eyeball fascial line over obturator internus Action Abducts eye lnserts Anococcygeal body Nerve Abducent N (VI) Action Supports pelvic viscera Nerve Ant primary rami (perineal brs) of S3,4 LATlSSlMUS DORSl Arises All thoracic spines & supraspinous ligs from T7 downwards & lumbar & LEVATOR ANI-PUBORECTALIS sacral spines via lumbar fascia, post third Arises Post surface of pubis iliac crest, last four ribs (interdigitating lnserts Midline sling post to rectum with ext oblique abdominis) & inf angle Action Supports & aids continence of of scapula rectum by maintaining anorectal angle lnserts Floor of bicipital groove of Nerve Ant primary rami (perineal brs) of humerus after spiraling around teres S3,4 major Action Extends, adducts & med rotates arm. Costal attachment helps with deep LEVATOR ANI-PUBOVAGINALIS inspiration & forced expiration (LEVATOR PROSTATAE) Nerve Thoracodorsal N (C6,7,8) (from Arises Post surface of pubis post cord) lnserts Midline raphe post to vaginalprostate Action Supports ant pelvic viscera LEVATOR ANGULI ORlS Nerve Ant primary rami (perineal brs) of Arises Ant surface of maxilla below infra- S3,4 orbital foramen lnserts Outer end of upper lip & modiolus LEVATOR LAB11 SUPERlORlS Action Elevates angle of mouth Arises Med infra-orbital margin Nerve Buccal br of facial N (VII) lnserts Skin & muscle of upper lip Action Elevates & everts upper lip Nerve Buccal br of facial N (VII) LEVATOR ANI-COCCYGEUS Arises Sacrospinous lig & ischial spine lnserts Anococcygeal body & coccyx LEVATOR LABll SUPERlORlS Action Supports pelvic viscera ALAEQUE NASl Nerve Ant primary rami (perineal brs) of Arises Upper frontal process of maxilla S4,S lnserts Skin of lat nostril & upper lip Action Dilates nostril & elevates upper lip Nerve Buccal br of facial N (VII) LEVATOR ANI-ILIOCOCCYGEUS Arises Post half of fascial line over obturator internus & ischial spine LEVATOR PALPEBRAE SUPERlORlS lnserts Anococcygeal body Arises Inf aspect of lesser wing of sphenoid Action Supports pelvic viscera bone just above tendinous ring Nerve Ant primary rami (perineal brs) of lnserts Sup tarsal plate & skin of upper S3,4 eyelid Action Elevates & retracts upper eyelid Nerve Sup div of oculomotor N (111) & sympathetic to smooth muscle portion Levator scapulae MUSCLES Medial rectus

LEVATOR SCAPULAE digitorum longus. Med 1: unipennate Arises Post tubercles of transverse origin from rned aspect of 1st tendon processes of Cl-4 lnserts Dorsal extensor expansion lnserts Upper part of rned border of scapula Action Extend toes at IP jnts & flex MTP Action Raises rned border of scapula jnts Nerve Ant primary rami of C3 & C4 & Nerve First: rned plantar N (S2,3). 2-4: dorsal scapular N (CS) deep br of lat plantar N (S2,3)

LEVATOR VELl PALATlNl LUMBRICALS OF HAND (4) Arises Within pharynx at apex of inf Arises Four tendons of flexor digitorum surface of petrous temporal bone & rned profundus. Radial 2: radial side only rim of auditory tube (unipennate). Ulnar 2: cleft between Inserts Palatine aponeurosis tendons (bipennate) Action Elevates, retracts & lat deviates soft lnserts Extensor expansion (dorsum of palate. May open auditory tube on prox phalanx) of fingers 2-5 radial side swallowing Action Flex MCP jnts & extend IP jnts of Nerve Pharyngeal plexus (IX, X, sympath- fingers etic) via pharyngeal br of vagus N (X)with Newe Lat 2: median N (C8,Tl). Med 2: its motor fibres from cranial accessory N deep br of ulnar N (C8,Tl) (XI) Notes 60% have nerve supply as above. 40% have 3:1 or l:3

LEVATORES COSTARUM Arises Transverse processes C7 to T11 MASSETER lnserts Post surface & angle of rib below Arises Ant two-thirds of zygomatic arch & Action Elevates ribs zygomatic process of maxilla Newe Post primary rami lnserts Lat surface of angle & lower ramus of mandible Action Elevates mandible (enables forced LONGUS CAPITIS closure of mouth) Arises Ant tubercles of transverse processes Newe Ant div of mandibular N (VC) of C3-6 lnserts Ant basilar occipital bone Action Flexes cervical spine & atlanto- MEDIAL PTERYGOID occipital jnt Arises Deep head. Med side of lat pterygoid Nerve Ant primary rami of Cl-3 plate & fossa between rned & lat plates. Superficial head: tuberosity of maxilla & pyramidal process of palatine bone LONGUS COLLl lnserts Med aspect of angle of mandible Arises Ant body of T1-3, ant tubercles of Action Elevates, protracts & lat displaces transverse processes of C3-7 mandible to opposite side for chewing lnserts Ant arch of atlas (Cl)& bodies of Nerve N to medial pterygoid (main trunk C2-4 of mandibular N (VC)) Action Flexes & rotates cervical spine Nerve Ant primary rami of C2-6 MEDIAL RECTUS Arises Med tendinous ring within orbit LUMBRICALS OF FOOT (4) lnserts Med sclera ant to equator of eyeball Arises Lat 3: bipennate origin from cleft Action Adducts eye between the four tendons of flexor Newe Inf div of oculomotor N (111) Mentalis MUSCLES Occipitofrontalis

MENTALIS Nerve Recurrent laryngeal br of vagus N Arises Incisive fossa on ant aspect of (X) mandible Notex It extends into aryepiglottic fold as lnserts Skin of chin aryepiglotticus Action Elevates & wrinkles skin of chin & protrudes lower lip Nerve Mandibular br of facial N (VII) OBLIQUUS CAPlTlS INFERIOR Arises Spinous process of axis (C2) lnserts Lat mass of atlas (Cl) MUSCULUS UVULAE Action Rotates atlanto-axial jnt Arises Post border of hard palate Nerve Suboccipital N (post primary ramus lnserts Palatine aponeurosis of Cl) Action Shapes uvula Nerve Pharyngeal plexus (IX, X, sympath- etic) via pharyngeal br of vagus N (X)with OBLIQUUS CAPlTlS SUPERIOR its motor fibres from cranial accessory Arises Lat mass of atlas (Cl) N (XI) lnserts Lat half inf nuchal line Action Lat flexes atlanto-occipital jnt Nerve Suboccipital N (post primary ramus MYLOHYOID of Cl) Arises Mylohyoid line on int aspect of mandible lnserts Ant three-quarters: midline raphe. OBTURATOR EXTERNUS Post quarter: sup border of body of hyoid Arises Outer obturator membrane, rim of bone pubis & ischium bordering it Action Elevates hyoid bone, supports & lnserts Trochanteric fossa on med surface raises floor of mouth. Aids in mastication of greater trochanter & swallowing Action Lat rotates hip Nerve Mylohyoid N (VC) Nerve Post div of obturator N (L3,4)

NASALIS (COMPRESSOR & OBTURATOR INTERNUS DILATOR) Arises Inner surface of obturator Arises Frontal process of maxilla membrane & rim of pubis & ischium lnserts Nasal aponeurosis bordering membrane Action Opens & closes nostrils, lnserts Middle part of med aspect of greater particularly in forced respiration trochanter of femur Nerve Buccal br of facial N (VII) Action Lat rotates & stabilises hip Notes Part of dilator nasalis is depressor Nerve N to obturator internus (LS,S1,2) septi from maxilla above central incisor to mobile part of nasal septum OCCIPITOFRONTALIS Arises Occipital: highest nuchal line & OBLIQUE ARYTENOID mastoid process. Frontal: sup fibres of Arises Muscular process of arytenoid upper facial muscles cartilage lnserts Galeal aponeurosis lnserts Sup pole of opposite arytenoid Action Wrinkles forehead & fixes galeal cartilage aponeurosis Action Adducts arytenoid cartilages (closes Nerve Post auricular & temporal brs of rima glottidis) facial N (VII) Omohyoid MUSCLES Palmaris longus

OMOHYOID Notes Accessory parts are incisivus labii Arises Suprascapular lig & adjacent superioris & inferioris scapula lnserts Inf border of body of hyoid bone Action Depresses hyoid bone & hence PALATOGLOSSUS larynx Arises Palatine aponeurosis Nerve Ansa cervicalis N (C1,2,3) lnserts Posterolateral tongue Notes Tendon between two bellies through Action Elevates post tongue & closes sling behind sternocleidomastoid oropharyngeal isthmus & aids initiation of swallowing Nerve Pharyngeal plexus (IX, X, sympath- OPPONENS DIGIT1 MINIM1 (hand) etic) via pharyngeal br of vagus N (X) Arises Flexor retinaculum & hook of with its motor fibres from cranial hamate accessory N (XI) lnserts Ulnar border of shaft of 5th MC Notes Forms palatoglossal arch Action Opposes (flexes & lat rotates) CMC jnt of little finger Nerve Deep br of ulnar N (C8,Tl) PALATOPHARYNGEUS Arises Palatine aponeurosis & post margin of hard palate OPPONENS POLLlClS lnserts Upper border of thyroid cartilage & Arises Flexor retinaculum & tubercle of blends with constrictor fibres. Upper fibres trapezium interdigitate with opposite side to give lnserts Whole of radial border of 1st MC Passavant's ridge Action Opposes (med rotates & flexes) Action Elevates pharynx & larynx. CMC jnt of thumb Passavant's muscle closes nasopharyngeal Nerve Recurrent (muscular)br of median isthmus in swallowing N (C8,Tl) (may also be from deep br of Nerve Pharyngeal plexus (IX, X, sympath- ulnar N (C8,Tl)) etic) via pharyngeal br of vagus N (X) with its motor fibres from cranial accessory N (XI) ORBlCULARlS OCULl Notes Forms palatoglopharyngeal arch Arises Med orbital margin & lacrimal fascia behind lacrimal sac (orbital, palpebral & lacrimal parts) PALMARIS BREVIS lnserts Lat palpebral raphe Arises Flexor retinaculum & palmar Action Closes eyelids, aids passage & aponeurosis drainage of tears lnserts Skin of palm into dermis Nerve Temporal & zygomatic brs of facial Action Steadies & corrugates skin of palm N (W to help with grip Nerve Superficial br of ulnar N (C8,Tl) Notes Only muscle supplied by this br of ORBlCULARlS ORlS ulnar N Arises Near midline on ant surface of maxilla & mandible & modiolus at angle of mouth lnserts Mucous membrane of margin of PALMARIS LONGUS lips & raphe with buccinator at modiolus Arises Common flexor origin of med Action Narrows orifice of mouth, purses epicondyle of humerus lips & puckers lip edges lnserts Flexor retinaculum & palmar Nerve Buccal br of facial N (VII) aponeurosis Pectineus MUSCLES Platysma

Action Flexes wrist & tenses palmar PERONEUS BREVIS aponeurosis Arises Lower two-thirds lat shaft of fibula Nerve Median N (C7,8) (from rned & lat lnserts Tuberosity of base of 5th MT cords) Action Plantar flexes & everts foot. Notes Absent in 13% Supports lat longitudinal arch Nerve Superficial peroneal N (L5,Sl)

PECTINEUS Arises Pectineal line of pubis & narrow PERONEUS LONGUS area of sup pubic ramus below it Arises Upper two-thirds of lat shaft of lnserts A vertical line between spiral line & fibula, head of fibula & sup tibiofibular jnt gluteal crest below lesser trochanter of lnserts Plantar aspect of base of 1st MT & femur rned cuneiform, passing deep to long Action Flexes & adducts hip plantar lig Nerve Ant div of femoral N (L2,3). Action Plantar flexes & everts foot. Sup- Occasional twig from obturator N (ant ports lat longitudinal & transverse arches div-L2,3) Nerve Superficial peroneal N (L5,Sl)

PECTORALIS MAJOR PERONEUS TERTIUS Arises Clavicular head-med half clavicle. Arises Third quarter of ant shaft of fibula Sternocostal head-lat manubrium & lnserts Dorsal shaft & base of 5th MT sternum, six upper costal cartilages & ext Action Extends & everts foot oblique aponeurosis Nerve Deep peroneal N (L5,Sl) lnserts Lat lip of bicipital groove of humerus and ant lip of deltoid tuberosity Action Clavicular head: flexes & adducts PlRlFORMlS arm. Sternal head: adducts & rned rotates Arises 2,3,4 costotransverse bars of ant arm. Accessory for inspiration sacrum between sacral foramina Nerve Med pectoral N (from rned cord) & lnserts Ant part of rned aspect of greater lat pectoral N (from lat cord) (C6,7,8) trochanter of femur Notes Muscle folds on itself so that Action Lat rotates & stabilises hip clavicular fibres insert lowest. Sternal Nerve Ant primary rami of S1,2 fibres are highest inserting into capsule of Notes Passes lat through greater sciatic shoulder joint foramen

PECTORALIS MINOR PLANTARIS Arises Ant aspect of 3,4,5 ribs Arises Lat supracondylar ridge of femur lnserts Med & upper surface of coracoid above lat head of gastrocnemius process of scapula lnserts Tendo calcaneus (med side, deep to Action Elevates ribs if scapula fixed, gastrocnemius tendon) protracts scapula (assists serratus Action Plantar flexes foot & flexes knee anterior) Nerve Tibial N (S1,2) Nerve Med & lat pectoral Ns (C6,7,8) (from rned & lat cords) Notes Landmark for axillary art & cords of PLATYSMA brachial plexus Arises Skin over lower neck & upper lat chest lnserts Inf border of mandible & skin over lower face & angle of mouth Popliteus MUSCLES Quadratus lumborum

Action Depresses & wrinkles skin of lower lnserts Just post to most prominent part of face & mouth. Aids forced depression of lat convexity of radius mandible Action Pronates forearm & flexes elbow Nerve Cervical br of facial N (VII) Newe Median N (C6,7) (from lat & rned cords) Notes Median N passes between its two POPLITEUS heads Arises Post shaft of tibia above soleal line & below tibial condyles lnserts A facet on lat surface of lat condyle PSOAS MAJOR of femur postero-inferior to epicondyle. Arises Transverse processes of L1-5, bodies Tendon passes into capsule of knee and a of Tl2-L5 & intervertebral discs below few fibres attach to lat meniscus bodies of T12-L4 Action Unlocks extended knee by lat lnserts Middle surface of lesser trochanter rotation of femur on tibia. Pulls back lat of femur meniscus Action Flexes hip Newe Tibial N (L4,5,S1) Nerve Ant primary rami of L1,2 Notes Popliteus bursa lies deep to tendon

PSOAS MINOR POSTERIOR CRICOARYTENOID Arises Bodies of T12 & L1 & intervening Arises Post aspect of cricoid cartilage intervertebral disc lnserts Muscular process of arytenoid lnserts Pectineal line of pubis & fascia over cartilage iliopsoas Action Abducts & lat rotates arytenoid Action Weak flexor of trunk cartilage (opens rima glottidis) Nerve Ant primary rami of L1 Nerve Recurrent laryngeal br of vagus N (X)

PYRAMIDALIS PROCERUS Arises Public crest ant to origin of rectus Arises Nasal bone & cartilages abdominis lnserts Skin of rned forehead lnserts Lower linea alba Action Wrinkles & 'frowns' forehead Action Reinforces lower rectus sheath Nerve Temporal br of facial N (VII) Nerve Subcostal N (T12)

PRONATOR QUADRATUS QUADRATUS FEMORIS Arises Lower quarter of anteromedial shaft Arises Lat border of ischial tuberosity of ulna lnserts Quadrate tubercle of femur & a lnserts Lower quarter of anterolateral shaft vertical line below this to the level of lesser of radius & some interosseous membrane trochanter Action Pronates forearm & maintains ulna Action Lat rotates & stabilises hip & radius opposed Nerve N to quadratus femoris (L4,5,S1) Nerve Ant interosseous N (C8,Tl)

QUADRATUS LUMBORUM PRONATOR TERES Arises Inf border of 12th rib Arises Humeral head: rned epicondyle, rned lnserts Apices of transverse processes of supracondylar ridge & rned intermuscular L1-4, iliolumbar lig & post third of iliac septum. Ulnar head: rned border of crest coronoid process Rectus abdominis MUSCLES Sartorius

Action Fixes 12th rib during respiration & lnserts Quadriceps tendon to patella, via lat flexes trunk ligamentum patellae into tubercle of tibia Nerve Ant primary rami (T12-L3) Action Extends leg at knee. Flexes thigh at hip Nerve Post div of femoral N (L2,3,4) RECTUS ABDOMlNlS Arises Pubic crest & pubic symphysis lnserts 5,6,7 costal cartilages, med inf RHOMBOID MAJOR costal margin & post aspect of xiphoid Arises Spines of T2-T5 & supraspinous ligs Action Flexes trunk, aids forced expiration lnserts Lower half of posteromedial border & raises intra-abdominal pressure of scapula, from angle to upper part of Nerve Ant primary rami (T7-12) triangular area at base of scapular spine Action Retracts scapula. Rotates scapula to rest position RECTUS CAPlTlS ANTERIOR Nerve Dorsal scapular N (CS)(from root) Arises Lat mass of atlas (Cl) lnserts Basilar occipital bone ant to occipital condyle RHOMBOID MINOR Action Flexes atlanto-occipital jnt Arises Lower ligamentum nuchae, spines of Nerve Ant primary rami of C1 C7 & T1 lnserts Small area of posteromedial border of scapula at level of spine, below levator RECTUS CAPlTlS LATERALIS scapulae Arises Lat mass of atlas (Cl) Action Retracts scapula. Rotates scapula to lnserts Jugular process of occipital bone rest position Action Lat flexes atlanto-occipital jnt Nerve Dorsal scapular N (CS) (from root) Nerve Ant primary rami of C1

RlSORlUS RECTUS CAPlTlS POSTERIOR MAJOR Arises Deep fascia of face & parotid Arises Spinous process of axis (C2) lnserts Modiolus & skin at angle of mouth lnserts Lat half of inf nuchal line Action Retracts angle of mouth Action Extends & rotates atlanto-occipital Nerve Buccal br of facial N (VII) jnt Nerve Suboccipital N (post primary ramus Cl) SALPINGOPHARYNGEUS Arises Inf cartilage & mucosa of pharyngeal orifice of auditory tube RECTUS CAPlTlS POSTERIOR lnserts Upper border of thyroid cartilage & MINOR inf constrictor muscle fibres Arises Post process of atlas (Cl) Action Elevates pharynx & larynx & aids lnserts Med half of inf nuchal line swallowing. Opens auditory tube during Action Extends atlanto-occipital jnt swallowing Nerve Suboccipital N (post primary ramus Nerve Pharyngeal plexus (IX, X, c1 sympathetic) via pharyngeal br of vagus N (X)with its motor fibres from cranial accessory N (XI) RECTUS FEMORIS (QUADRICEPS FEMORIS I) Arises Straight head: ant inf iliac spine. SARTORIUS Reflected head: ilium above acetabulum Arises Immediately below ant sup iliac spine Scalenus anterior MUSCLES Soleus lnserts Upper rned surface of shaft of tibia SEMITENDINOSUS Action Flexes, abducts, lat rotates thigh at Arises Upper inner quadrant of post surface hip. Flexes, rned rotates leg at knee of ischial tuberosity Newe Ant div of femoral N (L2,3) lnserts Upper rned shaft of tibia behind gracilis Action Flexes & rned rotates knee. Extends SCALENUS ANTERIOR hip Arises Ant tubercles of transverse processes Nerve Tibial portion of sciatic N (L5,S1,2) of C3-6 lnserts Scalene tubercle on sup aspect of 1st rib SERRATUS ANTERIOR Action Accessory to inspiration. Lat flexion Arises Upper eight ribs & ant intercostal of neck when 1st rib fixed membranes from midclavicular line. Newe Ant primary rami of C5,6 Lower four interdigitating with external oblique lnserts Inner rned border scapula. 1 & 2: SCALENUS MEDIUS upper angle; 3 & 4: length of costal Arises Post tubercles of transverse surface; 5-8: inf angle processes of C2-7 Action Lat rotates & protracts scapula lnserts Sup aspect of 1st rib, ant to its Newe Long thoracic N of Bell (CS,6,7) tubercle (from roots) slips from ribs 1 & 2: CS; 3 & Action Accessory to inspiration 4: C6; 5-8: C7 Nerve Ant primary rami of C3-8

SERRATUS POSTERIOR INFERIOR SCALENUS MINIMUS Arises Spinous processes & supraspinous Arises Ant tubercle of transverse process of ligs of T11-L2 C7 lnserts Post aspect of ribs 9-12 lnserts Suprapleural membrane (Sibson's Action Assists forced expiration fascia) Newe Ant primary rami (T9-12) Action Supports suprapleural membrane Nerve Ant primary rami of C7 SERRATUS POSTERIOR SUPERIOR Arises Spinous processes & supraspinous SCALENUS POSTERIOR lig of C7-T2 Arises Post tubercles of transverse lnserts Post aspect of ribs 2-5 processes C4 - 6 Action Assists forced inspiration lnserts Posterolateral surface of 2nd rib Newe Ant primary rami (T2-5) Action Accessory to inspiration Nerve Ant primary rami of C6-8 SOLEUS Arises Soleal line & middle third of post SEMIMEMBRANOSUS border of tibia & upper quarter of post Arises Upper outer quadrant of post shaft of fibula including neck surface of ischial tuberosity lnserts Tendo calcaneus to middle of three lnserts Med condyle of tibia below facets on post surface of calcaneus articular margin, fascia over popliteus & Action Plantar flexes foot (aids venous oblique popliteal lig return) Action Flexes & rned rotates knee. Extends Nerve Tibial N (S1,2) hip Notes Main propulsive force for walking & Newe Tibial portion of sciatic N (LS,S1,2) running Sphincter ani MUSCLES Subclavius

SPHINCTER AN I (external) Nerve Spinal root of accessory N (XI) Arises Circular anatomical sphincter (lat roots Cl-5) lnserts Deep, superficial & subcutaneous Notes Effectively four separate muscles portions Action Maintains continence of faeces Nerve Inf rectal br of pudendal N (S2,3,4) STERNOHYOID Arises Sup lat post aspect of manubrium lnserts Inf border of body of hyoid bone SPHINCTER URETHRAE Action Depresses hyoid bone & hence Arises Circular anatomical sphincter larynx lnserts Fuses with deep transverse perinei Nerve Ansa cervicalis N (C1,2,3) Action Maintains continence of urine Nerve Perinea1 br of pudendal N (S2,3,4) STERNOTHYROID Arises Med post aspect of manubrium SPLENIUS CAPITIS lnserts Oblique line of lamina of thyroid Arises Lower lig nuchae, spinous processes cartilage & supraspinous ligs C7-T3 Action Depresses larynx lnserts Lat occiput between sup & inf Nerve Ansa cervicalis N (C1,2,3) nuchal lines Action Extends & rotates cervical spine Newe Post primary rami of C3,4 STYLOGLOSSUS Arises Ant surface & apex of styloid process & upper quarter of stylohyoid lig SPLENIUS CERVlClS lnserts Superolateral sides of tongue Arises Spinous processes & supraspinous Action Retracts & elevates tongue, aids ligs of T3-6 initiation of swallowing lnserts Post tubercles of transverse Nerve Hypoglossal N (XII) processes of Cl-3 Action Extends & rotates cervical spine Nerve Post primary rami of C5,6 STYLOHYOID Arises Base of styloid process lnserts Base of greater cornu of hyoid bone STAPEDIUS Action Elevates & retracts hyoid bone. Arises The pyramid (post wall of middle ear) Aids swallowing & elevates larynx lnserts Neck of stapes Nerve Facial N (VII) before it enters Action Protects & critically damps parotid gland ossicular chain Newe Facial N (VII), in middle ear STYLOPHARYNGEUS Arises Med aspect of styloid process STERNOCLEIDOMASTOID lnserts Posterolateral border of thyroid Arises Ant & sup manubrium & cartilage superomedial third of clavicle Action Elevates larynx & pharynx. Aids lnserts Lat aspect of mastoid process & ant swallowing half of sup nuchal line Nerve Muscular br of glossopharyngeal N Action Acting alone it laterally flexes (W cervical spine & rotates head on neck to bring ipsilateral ear to ipsilateral shoulder. Acting together they protrude head & if SUBCLAVIUS head is fixed, aid respiration Arises Costochondral junction of 1st rib Subcostalis MUSCLES Temporalis lnserts Subclavian groove on inf surface of Notes Passes around trochlear sling on middle third of clavicle frontal bone Action Depresses clavicle & steadies it during shoulder movements Nerve N to subclavius (C5,6, upper trunk) SUPERIOR RECTUS Arises Sup tendinous ring within orbit lnserts Sup sclera ant to equator of eyeball SUBCOSTALIS Action Elevates eye. Intorts eye in Arises Int post aspects of lower six ribs adduction Inserts Int aspects of ribs two to three levels Newe Sup div of oculomotor N (111) below Action Depresses lower ribs Nerve Muscular collateral brs of intercostal SUPINATOR Ns Arises Deep part (horizontal): supinator Notes Subcostalis is one of three muscles crest & fossa of ulna. Superficial part that make up inner layer of thoracic wall (downwards):lat epicondyle & lat lig of muscles. Others are innermost intercostals elbow & annular lig (lat) & transversus thoracis (ant) lnserts Neck & shaft of radius, between ant & post oblique lines Action Supinates forearm. Only acts alone SUBSCAPULARIS when elbow extended Arises Med two-thirds of subscapular Nerve Post interosseous N (C6,7) fossa Notes Post interosseous N passes between lnserts Lesser tuberosity of humerus, upper its two heads med lip of bicipital groove, capsule of shoulder jnt Action Med rotates arm & stabilises SUPRASPINATUS shoulder jnt Arises Med three-quarters of supraspinous Nerve Upper & lower subscapular Ns fossa of scapula, upper surface of spine (C5,6) (from post cord) (bipennate) Notes Subscapular bursa beneath tendon, lnserts Sup facet on greater tuberosity of usually connected with jnt. Tendon forms humerus & capsule of shoulder jnt part of rotator cuff Action Abducts arm & stabilises shoulder jnt Newe Suprascapular N (C5,6) (from upper SUPERFICIAL TRANSVERSE PERlNEl trunk) Arises Body of ischium Notes Subacromial bursa lies above its lnserts Perineal body tendon. Tendon forms part of rotator cuff Action Fixes perinea1 body Newe Perineal br of pudendal N (S2,3,4) TEMPORALIS Arises Temporal fossa between inf SUPERIOR OBLIQUE (see also obliquus temporal line & infratemporal crest capitis superior) lnserts Med & ant aspects of coronoid Arises Body of sphenoid superomedial to process of mandible tendinous ring Action Elevates mandible & post fibres lnserts Postlsup quadrant of sclera behind retract it equator of eyeball on lat side Nerve Deep temporal brs from ant div of Action Depresses eye in adduction. Intorts mandibular N (VC) eye in abduction Nerve Trochlear N (IV) Temporoparietalis MUSCLES Tibialis anterior

TEMPOROPARIETALIS TERES MINOR Arises Aponeurosis above ear Arises Middle third lat border of scapula lnserts Galeal aponeurosis above teres major Action Fixes galeaI aponeurosis lnserts Inf facet of greater tuberosity of Nerve Temporal br of facial N (VII) humerus (below infraspinatus) & capsule of shoulder jnt Action Lat rotates arm & stabilises TENSOR FASCIAE LATAE shoulder jnt Arises Outer surface of ant iliac crest Nerve Axillary N (C5,6) (from post cord) between tubercle of the iliac crest & ant Notes Functionally part of infraspinatus. sup iliac spine Tendon forms part of rotator cuff lnserts Iliotibial tract (ant surface of lat condyle of tibia) Action Maintains knee extended (assists THYRO-ARYTENOID & VOCALIS gluteus maximus) & abducts hip Arises Lower post surface of angle between Nerve Sup gluteal N (L4,5,S1) laminae of thyroid cartilage lnserts Vocal process of arytenoid cartilage TENSOR TYMPANI Action Shortens & relaxes vocal cords by Arises Cartilaginous & bony margins of approximating arytenoid cartilage to auditory tube thyroid cartilage lnserts Handle of malleus (via processus Nerve Recurrent laryngeal br of vagus N trochleariformis) (X) Action Protects & critically damps Notes Vocalis is that part of thyro- ossicular chain arytenoid that inserts into vocal cord itself Nerve Off N to med pterygoid (main trunk of mandibular N (VC)) THYRO-EPIGLOTTICUS Arises Lower post surface of thyroid TENSOR VELl PALATlNl cartilage Arises Scaphoid fossa, med aspect of spine lnserts Lat border of epiglottis of sphenoid bone & lat cartilage of Action Widens additus of larynx auditory tube Nerve Recurrent laryngeal br of vagus N lnserts Palatine aponeurosis (via pulley of (X) pterygoid hamulus) Action Tenses soft palate prior to elevation. Opens auditory tube on swallowing THYROHYOID Nerve Off N to med pterygoid (main trunk Arises Oblique line on lamina of thyroid of mandibular N (VC)) cartilage lnserts Inf border of body of hyoid bone Action Elevates larynx or depresses hyoid TERES MAJOR bone Arises Oval area (lower third) of lat side of Nerve C1 fibres carried by hypoglossal N inf angle of scapula below teres minor (XII) lnserts Med lip of bicipital groove of humerus Action Med rotates & adducts arm. TlBlALlS ANTERIOR Stabilises shoulder jnt Arises Upper half of lat shaft of tibia & Nerve Lower subscapular N (C5,6,7) (from interosseous membrane post cord) lnserts Inferomedial aspect of med Notes Functionally part of subscapularis cuneiform & base of 1st MT Tibialis posterior MUSCLES Trapezius

Action Extends & inverts foot at ankle. TRANSVERSOSPINALIS- Holds up med longitudinal arch of foot SEMlSPlNALlS Nerve Deep peroneal N (L4,S) Arises Transverse processes Notes Inversion is at subtalar & mid tarsal lnserts Spinous processes six levels above joints Action Extends & lat flexes spine Newe Post primary rami Notes Three types-thoracis, cervicis & TlBlALlS POSTERIOR capitis Arises Upper half of post shaft of tibia & upper half of fibula between median crest & interosseous border, & interosseous TRANSVERSUS ABDOMlNlS membrane Arises Costal margin (ribs & costal lnserts Tuberosity of navicular bone & all cartilages), lumbar fascia, ant two-thirds tarsal bones (except talus) & bases of of iliac crest & lat half of inguinal lig metatarsals 2-4 lnserts Aponeurosis of post & ant rectus Action Plantar flexes & inverts foot. sheath & conjoint tendon to pubic crest & Supports med longitudinal arch of foot pectineal line Nerve Tibial N (L4,S) Action Supports abdominal wall, aids forced expiration & raising intra- abdominal pressure. Conjoint tendon TRANSVERSE ARYTENOID supports post wall of inguinal canal Arises Post surface & muscular process of Newe Ant primary rami (T7-12). Conjoint arytenoid cartilage tendon: ilio-inguinal N (L1) lnserts Corresponding surfaces of opposite cartilage Action Adducts arytenoid cartilages (closes TRANSVERSUS THORACIS rima glottidis) (STERNOCOSTALIS) Nerve Recurrent laryngeal branch of vagus Arises Lower third of inner aspect of N (X) sternum & lower three costosternal junctions lnserts Second to sixth costal cartilages TRANSVERSOSPINALIS- Action Depresses upper ribs MULTlFlDUS Nerve Muscular collateral brs of intercostal Arises Laminae of vertebra from sacrum to Ns C2 Notes Transversus thoracis is one of three lnserts Spinous processes two to three muscles that make up inner layer of thor- levels above acic wall muscles. Others are innermost Action Extends spine intercostals (lat) & subcostals (post) Nerve Post primary rami

TRAPEZIUS TRANSVERSOSPINALIS- Arises Med third sup nuchal line, lig ROTATORES nuchae, spinous processes & supraspinous Arises Transverse processes ligs to T12 lnserts Spinous processes one above lnserts Upper fibres to lat third of post Action Rotates spine border of clavicle; med acromion & lat Nerve Post primary rami spine of scapula. Lower fibres to med end Notes Two types-thoracis & cervicis et of spine of scapula as far as deltoid tubercle lumborum Action Elevates & retracts scapula. Rotates it during abduction of arm. If scapula is fixed, extends & lat flexes neck Triceps MUSCLES Zygomaticus minor

Nerve Spinal root of accessory N (XI) (lat supracondylar ridge & lat intermuscular roots, Cl-5) (spinal nerves C3 & C4 for septum proprioception) lnserts Lat quadriceps tendon to patella, via ligamentum patellae into tubercle of tibia TRICEPS Action Extends knee Arises Long head: infraglenoid tubercle of Nerve Post div of femoral N (L2,3,4) scapula. Lat head: upper half post humerus (linear origin). Med head: lower half post humerus inferomedial to spiral VASTUS MEDIALIS (QUADRICEPS groove & both intermuscular septa FEMORIS 4) lnserts Post part of upper surface of Arises Lower intertrochanteric line, spiral olecranon process of ulna & post capsule line, med linea aspera & med Action Extends elbow. Long head stabilises intermuscular septum shoulder jnt. Med head retracts capsule of lnserts Med quadriceps tendon to patella elbow jnt on extension & directly into med patella, via Nerve Radial N (C6,7,8) (from post cord), ligamentum patellae into tubercle of tibia four brs Action Extends knee. Stabilises patella Nerve Post div of femoral N (L2,3,4)

VASTUS INTERMEDIUS (QUADRICEPS FEMORIS 2) ZYGOMATICUS MAJOR Arises Ant & lat shaft of femur to one Arises Ant surface of zygomatic bone hand's breadth above condyles lnserts Modiolus at angle of mouth lnserts Quadriceps tendon to patella, via Action Elevates & draws angle of mouth ligamentum patellae into tubercle of tibia laterally Action Extends knee Nerve Buccal br of facial N (VII) Nerve Post div of femoral N (L2,3,4)

ZYGOMATICUS MINOR VASTUS LATERALIS (QUADRICEPS Arises Lat infra-orbital margin FEMORIS 3) lnserts Skin & muscle of upper lip Arises Upper intertrochanteric line, base of Action Elevates & everts upper lip greater trochanter, !at linea aspera, lat Nerve Buccal br of facial N (VII)

Aide memoir for nerve supply of groups of muscles in head and neck

All muscles of Supplied by: Except: Which is supplied by:

Pharynx Pharyngeal plexus (IX, X, sympathetic) Stylopharyngeus Glossopharyngeal (IX)

Palate Pharyngeal plexus (IX, X, sympathetic) Tensor palati Off N to med pterygoid (VC)

Tongue Hypoglossal (XII) Palatoglossus Pharyngeal plexus (IX, X, sympathetic)

Mastication Mandibular (VC) Buccinator Facial (V11)

Larynx Recurrent laryngeal (X) Cricothyroid Ext br of superior laryngeal (X)

Facial expression Facial (VII) & buccinator Classification of joints Joints with double cavities separated by intra-articular Fibrous Fibrous tissue between bones ligaments-not fibrocartilaginous Primary cartilaginous Hyaline cartilage discs between bones Secondary cartilaginous As for primary Costovertebral (ribs 2-10) but fibrocartilage between the layers of Sternochondral(2nd rib) hyaline cartilage (symphysis) Synovial Joint cavity with synovial fluid. Joints classified by type Hyaline cartilage on surface of bones. Articular disc can be present Fibrous joints Atypical synovial Joint cavity with synovial Arytenocorniculate (can be synovial) fluid. Fibrocartilage on surface of bones. Costotransverse (ribs 11 and 12) Articular disc can be present Cuboideonavicular (can be synovial) Gomphosis (teeth) Radio-ulnar (interosseous membrane) Types of synovial joint Skull sutures Plane Sliding only Tibiofibular (inferior) Hinge (ginglymus) One plane of Tibiofibular (interosseous membrane) movement Modified hinge (bicondylar) One plane of Primary cartilaginous joints movement + rotation Costochondral Condyloid (ellipsoid) Two planes of Sternochondral(1st rib) movement (circumduction) Spheno-occipital Saddle condyloid (sella) Two planes of movement + controlled rotation Secondary cartilaginous joints Pivot (trochoid) Rotation only. One plane Intervertebral of movement Manubriosternal Ball and socket (spheroidal) Multi-axial. Sacrococcygeal Three planes of movement Symphysis pubis Xiphisternal Joints with interarticular Atypical synovial joints fibrocartilaginous discs Acromioclavicular Acromioclavicular (usually incomplete) Sternochondral (ribs 2-7) Femorotibial (knee) (incomplete-menisci) Sternoclavicular Radiocarpal (wrist) Temporomandibular Sternoclavicular Temporomandibular Typical synovial Acetabulofemoral (hip) Atlanto-axial (dens & facets) Atlanto-occipital Calcaneocuboid Carpometacarpal Costotransverse (ribs 1-10) JOINTS

Costovertebral Cuneocuboid (see intertarsal) Crico-arytenoid Cuneonavicular (see intertarsal) Crico-thyroid Elbow (see humero-ulnar, humeroradial & Cuneocu boid superior radio-ulnar) 181 Cuneonavicular Facet (vertebral articulations) (see Femorotibial (knee) zygapophyseal) Glenohumeral (shoulder) Femorotibial (knee) 181 Humeroradial (elbow) Glenohumeral (shoulder) 181 Humero-ulnar (elbow) Gomphosis (dento-alveolar) 181 Intercarpal Hip (see acetabulofemoral) Interchondral (cartilages 6-10) Humeroradial (elbow) 181 Intercuneiform Humero-ulnar (elbow) 181 Intermetacarpal Intercarpal (midcarpal) (see also Intermetatarsal pisotriquetral) Interphalangeal Interchondral 181 Metacarpophalangeal Intercuneiform (see intertarsal) Metatarsophalangeal Intermetacarpal (see carpometacarpal- Pisotriquetral fingers 2-5) Radiocarpal (wrist) Intermetatarsal 181 Radio-ulnar (superior & inferior) Interphalangeal (fingers & toes) 181 Talocalcaneal Intertarsal-cuboideonavicular 181 Talocalcaneonavicular Intertarsal-cuneocuboid 181 Tarsometatarsal Intertarsal-cuneonavicular 182 Tibiofibular (superior) Intertarsal-intercuneiform l82 Tibiotalal (ankle) Intervertebral 182 Zygapophyseal (intervertebral facet) Intervertebral facets (see zygapophyseal) Intervertebral joints of Luschka Unclassified (neurocentral or uncovertebral) l82 Intervertebral joints of Luschka Knee (see femorotibial) Manubriosternal l82 Metacarpophalangeal 182 Named joints Metatarsophalangeal 182 Acetabulofemoral (hip) 180 Midcarpal (see intercarpal) Acromioclavicular 180 Midtarsal (see calcaneocuboid & Ankle (see tibiotalal) talonavicular part of Arytenocorniculate (larynx) 180 talocalcaneonavicular ) Atlanto-axial-lateral 180 Pelvic (see sacro-iliac & symphysis Atlanto-axialmedian 180 pubis) Atlanto-occipital 180 Pisotriquetral 182 Calcaneocuboid (midtarsal) 180 Radiocarpal (wrist) l82 Carpometacarpal-fingers 2 -5 (including Radio-ulnar-inferior l82 intermetacarpal) 180 Radio-ulnar-interosseous membrane & Carpometacarpal-thumb 180 oblique cord 182 Costochondral 180 Radio-ulnar-superior 182 Costotransverse-ribs 1-10 180 Sacrococcygeal 182 Costotransverse-ribs 11,12 180 Sacro-iliac l82 Costovertebral 180 Shoulder (see glenohumeral) Crico-arytenoid (larynx) 180 Skull sutures l83 Cricothyroid (larynx) 181 Spheno-occipital 183 Cuboideonavicular (see intertarsal) Sternochondral (sternocostal) l83 JOINTS

Sternoclavicular (manubrioclavicular) 183 Tibiotalal (ankle) l83 Sternocostal (see sternochondral) Vertebral (see intervertebral) Subtalar (see talocalcanean & talocalcaneal Wrist (see radiocarpal & interarticular disc part of talocalcaneonavicular) of inferior radio-ulnar) Symphysis pubis l83 Xiphisternal 184 Talocalcaneal (subtalar) (see Zygapophyseal (intervertebral facet) 184 talocalcaneonavicular) Talocalcanean (subtalar) 183 All joints are paired except the following Talocalcaneonavicular 18 3 which are single midline joints: Talonavicular (midtarsal) (see Median atlanto-axial talocalcaneonavicular) Intervertebral Tarsometatarsal l83 Manubriosternal Temporomandibular 183 Spheno-occipital Tibiofibular-inferior 183 Symphysis pubis Ti biofibular-interosseous membrane l83 Xiphisternal Tibiofibular-superior 183 Acetabulofemoral JOINTS Crico-arytenoid

ACETABULOFEMORAL (hip) CARPOMETACARPAL-FINGERS 2-5 Classification Synovial (including intermetacarpal) Type Ball & socket Classification Synovial Articulation Acetabulum with femur Type Plane Articulation Carpal bones with MCs & between MCs ACROMIOCLAVICULAR Notes Usually continuous cavity between Classification Atypical synovial CMC, intermetacarpal & intercarpal jnts Type Plane Articulation Acromion with clavicle Notes Often an articular disc in upper part CARPOMETACARPAL-THUMB of jnt, usually incomplete Classification Synovial Type Saddle condyloid Articulation Trapezium with 1st MC ANKLE (see tibiotalal) Notes Joint is separate from others in hand

ARYTENOCORNICULATE (larynx) COSTOCHONDRAL Classification Fibrous or synovial Classification Primary cartilaginous Articulation Arytenoid cartilage with Articulation Bony rib with costal cartilage corniculate cartilage

COSTOTRANSVERSE-RIBS 1-1 0 ATLANTO-AXIAL-LATERAL Classification Synovial Classification Synovial Type Plane Type Plane Articulation Med facet of tubercle of rib Articulation Articular facets of atlas with with transverse process of own vertebra axis

COSTOTRANSVERSE-RIBS I I, 12 ATLANTO-AXIAL-MEDIAN Classification Fibrous (ligamentous) Classification Synovial Articulation Tubercle of rib with Type Pivot transverse process of own vertebra Articulation Dens of axis with atlas Notes Second cavity (bursa) posteriorly COSTOVERTEBRAL Classification Synovial ATLANTO-OCCIPITAL Type Plane Classification Synovial Articulation Head of rib with vertebral Type Condyloid body Articulation Atlas with occipital bone Notes 1st rib articulates with T1 vertebra only (single cavity jnt). Ribs 2-10 with own vertebra & one above (double cavity CALCANEOCUBOID (midtarsal) jnts separated by intra-articular lig). Ribs Classification Synovial 11 & 12with own vertebra only (single Type Saddle condyloid cavity jnts) Articulation Calcaneus with cuboid Notes This is one part of midtarsal jnt. Other is talonavicular part of CRICO-ARYTENOID (larynx) talocalcaneonavicular Classification Synovial Type Features of ball & socket Cricothyroid JOINTS Intertarsal-cuneocuboid

Articulation Cricoid cartilage with Articulation Trochlea of humerus with arytenoid cartilage ulnar trochlear notch Notes Jnt cavity is shared with humeroradial & sup radio-ulnar jnts CRICOTHYROID (larynx) Classification Synovial Type Plane (rotational).Two together give INTERCARPAL (MIDCARPAL) hinge movement (see also pisotriquetral) Articulation Facet on side of cricoid Classification Synovial cartilage with inf horn of thyroid Type Plane individually but together give cartilage effective mixture of condyloid, saddle condyloid & ball & socket Articulation Between scaphoid, lunate, ELBOW (see humeroradial & humero-ulnar) triquetral, hamate, capitate, trapezoid & trapezium Notes Single cavity between the seven FEMOROTIBIAL (knee) bones usually communicating also with Classification Synovial CMC & intercarpal jnts of fingers 2-5 Type Modified hinge Articulation Femur with tibia Notes Menisci are incomplete discs of INTERCHONDRAL fibrocartilage Classification Synovial Type Plane Articulation Between costal cartilages 617, GLENOHU MERAL (shoulder) 7/8,8/9,9/10 Classification Synovial Type Ball & socket Articulation Glenoid fossa of scapula with INTERMETATARSAL humerus Classification Synovial Type Plane Articulation Between MTs G0 MP H 0 Sl S (dento-alveolar) Classification Fibrous Articulation Tooth with bone of jaw INTERPHALANGEAL (fingers &toes) Classification Synovial Type Hinge H I P (see acetabulofemoral) Articulation Between phalanges

HUMERORADIAL (elbow) INTERTARSAL- Classification Synovial CUBOIDEONAVICULAR Type Hinge Classification Fibrous (can be synovial) Articulation Capitulum of humerus with Articulation Cuboid with navicular radial head Notes Jnt cavity is shared with humero- ulnar & sup radio-ulnar jnts INTERTARSAL-CUNEOCUBOID Classification Synovial Type Plane HUMERO-ULNAR (elbow) Articulation Lat cuneiform with cuboid Classification Synovial Notes Cuneocuboid shares cavity with Type Hinge cuneonavicular & intercuneiform jnts Intertarsal-cuneonavicular JOINTS Sacro-iliac

INTERTARSAL-CUNEONAVICULAR Type Condyloid Classification Synovial Articulation MTs with phalanges Type Plane Articulation Cuneiforms with navicular Notes Cuneonavicular shares cavity with M l DTARSAL (see both talonavicular part of cuneocuboid and intercuneiform jnts talocalcaneonavicular and calcaneocuboid)

INTERTARSAL-INTERCUNEIFORM PISOTRIQUETRAL Classification Synovial Classification Synovial Type Plane Type Plane Articulation Between cuneiforms Articulation Pisiform with triquetral Notes Intercuneiform jnts share cavity with cuneonavicular & cuneocuboid jnts RADIOCARPAL (wrist) Classification Synovial INTERVERTEBRAL Type Condyloid Classification Secondary cartilaginous Articulation Radius & triangular Articulation Between vertebral bodies fibrocartilaginous articular disc with scaphoid, lunate & triquetral

INTERVERTEBRAL JOINTS OF LUSCH KA (neurocentral or RADIO-ULNAR-INFERIOR uncovertebral) Classification Synovial Classification Unclassified Type Pivot Type Unclassified Articulation Radius with ulna Articulation Lateral lip of upper surface of Notes Cavity separated from cavity of wrist C3-7 & T1 vertebrae with adjacent by triangular fibrocartilaginous disc vertebral body above Notes Often small cavity which is degenerative (not synovial) RADIO-ULNAR-INTEROSSEOUS MEMBRANE & OBLIQUE CORD Classification Fibrous KNE E (see femorotibial) Articulation Radius with ulna

MANUBRIOSTERNAL RADIO-ULNAR-SUPERIOR Classification Secondary cartilaginous Classification Synovial Articulation Manubrium with sternum Type Pivot Notes May cavitate to give appearance of Articulation Radius with ulna synovial jnt Notes Cavity is continuous with humero- ulnar & humeroradial jnts

METACARPOPHALANGEAL Classification Synovial SACROCOCCYGEAL Type Condyloid Classification Secondary cartilaginous Articulation MCs with phalanges Articulation Sacrum with coccyx

METATARSOPHALANGEAL SACRO-ILIAC Classification Synovial Classification Synovial Shoulder JOINTS Tibiotalal

Type Plane Notes This is a posterior, separate jnt that is Articulation Sacrum with iliac bone one-half of subtalar jnt

SH 0 U LDE R (see glenohumeral) TALOCALCANEONAVICULAR Classification Synovial Type Features of ball & socket SKULL SUTURES Articulation Talus with calcaneus & Classification Fibrous navicular Articulation Between diploae of skull Notes This is a two part jnt. Talocalcaneal part (two facets) is part of subtalar jnt, other being talocalcanean. Talonavicular SPHENO-OCCIPITAL part (one facet) is part of midtarsal jnt, Classification Primary cartilaginous other being calcaneocuboid. Articulation Sphenoid with basi-occiput

TARSOMETATARSAL STERNOC H OND RAL (sternocostal) Classification Synovial Classification 1st: primary cartilaginous; Type Plane 2nd-7th: atypical synovial Articulation Tarsal bones with MTs Type 2nd-7th: plane Articulation 1st rib with manubrium. 3rd-7th ribs with sternum. 2nd with TEMPOROMANDIBULAR both Classification Atypical synovial Notes 2nd jnt has two cavities separated by Type Condyloid intra-articular lig Articulation Temporal bone with mandible Notes Separated into two cavities by fibrocartilaginous disc STERNOCLAVICULAR (manubrioclavicular) Classification Atypical synovial TIBlOFlBULAR-INFERIOR Type Features of ball & socket Classification Fibrous Articulation Clavicle with manubrium Articulation Tibia with fibula Notes Separated into two cavities by fibrocartilaginous disc TIBIOFIBULAR-INTEROSSEOUS MEMBRANE SUBTALAR (see both talocalcanean & Classification Fibrous talocalcaneal part of talocalcaneonavicular) Articulation Tibia with fibula

SYMPHYSIS PUBIS TIBIOFIBULAR-SUPERIOR Classification Secondary cartilaginous Classification Synovial Articulation Between pubic bones Type Plane Notes May cavitate Articulation Tibia with fibula

TALOCALCANEAN (subtalar) TlBIOTALAL (ankle) Classification Synovial Classification Synovial Type Plane (effectivelyball & socket) Type Hinge Articulation Talus with calcaneus Articulation Tibia with talus Wrist JOINTS Zygapop hyseal

W RIST (see radiocarpal & interarticular disc ZYGAP0 PHY S EAL (intervertebral facet) of inferior radio-ulnar) Classification Synovial Type Plane Articulation Between intervertebral facets XIPHISTERNAL Classification Secondary cartilaginous Articulation Xiphoid with sternum

Ossification times

Centre appears at: Bones Forms in Centres (number if membrane (M) primary (P) or Gestation After unpaired) or cartilage (C) secondary(S) Site (weekslrnonths) birth Fused by

Mandible (l) Near mental forarnen (each side) Symphysismenti 1-3 Y

Hyoid (l) Greater cornu (each side) Body (2 centres) Lesser cornu (each side) Puberty

Occiput ( I ) Squamous (each side) Lateral (each side) Basilar

Sphenoid (I) Approximately 14 centres

Temporal Squamous Tympanic Petromastoid(several centres)

Parietal Near tuberosity (2 centres) Frontal (2 3 I ) Near each tuberosity (2 centres, one each Metopic suture 2 Y side)

Ethrnoid ( l ) Labyrinth (one each side) Perpendicular platelcristagalli lnf concha

Lacrimal

Nasal

Vomer ( I ) (2 centres)

Maxilla (3 centres)

Palatine Perpendicular plate Zygomatic M P 8W

Ear ossicles C P Stapes 4M C P Malleus 4M C P lncus 4M

Scapula C P Body 8W IY C S Coracoid process 15Y C S Su bcoracoid Puberty 20 Y C S Medial border Puberty 20 Y C S Glenoid (lower rim) Puberty 20 Y C S Acromion (2 centres) Puberty 20 Y C S Inferior angle Puberty 20Y

Clavicle M P Medial & lateral (2 centres) 5W M S Sterna1 end Late teens 20Y

Humerus (upper C P Shaft 8W end is growing end) C S Head 6M Upper epiphysis 18-20 Y C S Greater tuberosity 2Y C S Lesser tuberosity 5Y C S Capitulum & lat ridge of trochlea IY C S Medial trochlea IOY C S Medial epicondyle 5Y Lower epiphysis 14-1 6 Y C S Lateral epicondyle 12Y 8W Radius (lower C P Shaft end isgrowing end) C S Head 4Y 14-17Y C S Distal end 8W IY 17-19Y Ulna (lower end C P Shaft is growing end) C S Olecranon (2 centres) 9Y 14-16Y C S Distal end 5Y 17-18Y

Carpus C P Capitate 2M C P Hamate 3M C P Triquetral 3Y C P Lunate 4Y

continuedon p.I88 Ossification times continued

Centre appears at: Bones Forms in Centres (number if membrane (M) primary (P) or Gestation After unpaired) or cartilage (C) secondary (S) Site (weekslmonths) birth Fused by

Scaphoid Trapezium Trapezoid Pisiform

Metacarpal ( l st) Shaft Base

Metacarpals (2nd-5th) Shaft Head

Phalanges (hand) Shaft Base lnnominate Pubis (superior ramus) lschium (body) Ilium (above greater sciatic notch) lliac crest (2 centres) Puberty Acetabulum (2 centres) Puberty Anterior superior iliac spine Puberty lschial tuberosity Puberty Pubic symphysis Puberty

Femur (lower end Shaft is growing end) Greater trochanter Lesser trochanter Head Distal end

Patella (Several centres) Puberty Superolaterally Puberty ( Tibia (upper end is C P Shaft growing end) Plateau Distal end Tuberosity

Fibula (upper end is Shaft growing end) Distal end Head

Talus

Calcaneus

Navicular

Cuneiform lateral

Cuneiform medial (May have 2 centres)

Cuneiform intermediate

Cuboid Metatarsal ( l st) Shaft Base

Metatarsals (2nd-5th) Shaft Head

Phalanges (foot) Shaft Base

continued on p. 190 Closure of skull sutures Ant fontinelle: closes 18 M; post fontinelle: closes 6 M-l Y Notes: (I) All bones are paired unless otherwise stated. (2) Single centre of ossification unless specified otherwise. (3) Variability of ossification usually a sex difference, females appearing and uniting earlier. (4) Fusion times for epiphyses are given if clinically relevant OSSIFICATION TIMES

Ossification times continued-eruption of teeth

Eruption of teeth Incisor Canine Premolar Molar

(upper) (lower) First dentition (months) 7,8 69 18

Second dentition* (years) 7,8 7,8 I I 9, 10 6, 12, 18

* Lower teeth erupt slightly earlier Aqueduct of the vestibule 192 Mastoid foramen 194 Carotid canal 192 Mental foramen 194 Condylar canal 192 Nasolacrimal canal 194 Cribriform foramina 192 Optic canal 194 Facial canal 192 Palatovaginal canal 194 Foramen caecum (unpaired) 192 Petrosquamous fissure 194 Foramen lacerum 192 Petrotympanic fissure 194 Foramen magnum (unpaired) 192 Pterygoid canal 194 Foramen ovale 192 Pterygomaxillary fissure 194 Foramen rotundum 192 Sphenoidal foramen 194 Foramen spinosum 192 Sphenopalatine foramen 194 Foramen transversarium 192 Squamotympanic fissure 194 Greater palatine foramen 192 Stylomastoid foramen 195 Hypoglossal canal 193 Superior orbital fissure 195 Incisive canal 193 Supra-orbital foramen 195 Incisive foramen 193 Vertebral foramen (unpaired) 195 Incisive fossa (unpaired) 193 Vomerovaginal canal 195 Inferior orbital fissure 193 Zygomaticofacial foramen 195 Infra-orbital canal 193 Zygomatico-orbital foramen 195 Infra-orbital foramen 193 Zygomaticotemporal foramen 195 Internal acoustic meatus 193 Intervertebral foramen 193 Notes: (1) Most smaller emissary veins and Jugular foramen 193 meningeal arterial supplies have been Lesser palatine foramina 193 omitted. (2)All structures are paired unless Mandibular canal (inferior alveolar otherwise indicated. canal) 193 Mandibular foramen (inferior alveolar foramen) 193 Aqueduct of the vestibule FORAMI NA-SKU LL AND SPl NE Greater palatine forarnen

AQUEDUCT OF THE VESTIBULE temporal & basilar occipital bones in Site In post aspect of petrous temporal bone middle cranial fossa in post cranial fossa, 1cm post to int Contains Int carotid art enters behind & acoustic meatus exits above. Greater petrosal N enters Contains Endolymphatic duct & sac, small behindlabove & leaves ant as N of the art & V pterygoid canal

CAROTID CANAL FORAMEN MAGNUM (unpaired) Site In inf surface of petrous temporal bone Site In occipital bone in post cranial fossa in middle cranial fossa Contains Medulla oblongata, meninges, Contains Int carotid art enters with sym- vertebral arts, ant & post spinal arts, pathetic plexus on it. Int carotid venous spinal roots of accessory Ns (XI), plexus connecting cavernous sinus & int sympathetic plexus on vertebral art, jugular vein apical ligament of dens, tectorial membrane

CONDYLAR CANAL Site In lower sigmoid groove in occipital FORAMEN OVALE bone in post cranial fossa. Exits at con- Site In greater wing of sphenoid bone in dylar fossa behind condyle (not always middle cranial fossa present) Contains Mandibular N (VC),lesser Contains Emissary V connecting sigmoid petrosal N, accessory meningeal art sinus & occipital Vs. Meningeal br of occipital art FORAMEN ROTUNDUM Site In greater wing of sphenoid bone in CRlBRlFORM FORAMINA middle cranial fossa Site In cribriform plate of ethmoid bone in Contains Maxillary N (Vb) ant cranial fossa Contains Olfactory filaments & ant ethmoidal N & vessels FORAMEN SPINOSUM Site In greater wing of sphenoid bone in middle cranial fossa FACIAL CANAL Contains Middle meningeal vessels, Site In petrous temporal bone leading from meningeal br of mandibular N (VC) int acoustic meatus to stylomastoid foramen Contains Facial N (VII) FORAMEN TRANSVERSARIUM Site In pedicle of cervical vertebrae bordered by-lat: intertubercular lamella FORAMEN CAECUM (unpaired) (costotransverse bar), med: body of Site Between frontal crest of frontal bone & vertebra crista galli of ethmoid bone in ant cranial Contains Vertebral art & V in Cl-6. Vein fossa only in C7 Contains Emissary Vs connecting nose & sup sagittal sinus GREATER PALATINE FORAMEN Site Between maxilla & palatine bone at lat FORAMEN LACERUM edge of hard palate Site Between sphenoid, apex of petrous Contains Greater palatine N & vessels Hypoglossal canal FORAMINA-SKULL AND SPINE Mandibular foramen

HYPOGLOSSAL CANAL Contains Facial N (VII), nervus Site In occipital bone above condyle in post intermedius, vestibulocochlear N (VIII), cranial fossa labyrinthine art Contains Hypoglossal N (XII) & meningeal br of ascending pharyngeal art INTERVERTEBRAL FORAMEN Site Between vertebrae, bordered by-sup INCISIVE CANAL & inf: pedicles of vertebrae, ant: vertebral Site In ant maxilla extending from nose to bodies & intervertebral disc, post: lig incisive foramina flavum covering sup & inf articular Contains Nasopalatine N, greater palatine processes vessels Contains Spinal art & V, dorsal root ganglion, spinal N. Nerves Cl-7 emerge via foramen above same numbered INCISIVE FORAMEN vertebra; nerve C8 exits below C7 Site Midline, in ant hard palate. Openings vertebra & below this all nerves emerge of incisive canals into incisive fossa via foramen below the same numbered Contains Nasopalatine N, greater palatine vertebra vessels

JUGULAR FORAMEN INCISIVE FOSSA (unpaired) Site Between jugular fossa of petrous Site Median, in ant hard palate leading temporal bone & occipital bone in post upwards to incisive foramina cranial fossa Contains Nasopalatine Ns, greater palatine Contains Glossopharyngeal N (IX),vagus vessels (X), accessory N (XI), inf petrosal & sigmoid sinuses enters it, int jugular V emerges below INFERIOR ORBITAL FISSURE Site Between greater wing of sphenoid bone & maxilla LESSER PALATINE FORAMINA Contains Infra-orbital & zygomatic brs of Site Two or three foramina in med & inf maxillary N (Vb),infra-orbital vessels, inf aspects of pyramidal process of palatine ophthalmic Vs, orbital brs of bone pterygopalatine ganglion Contains Lesser palatine Ns & vessels

INFRA-ORBITAL CANAL MANDIBULAR CANAL (INFERIOR Site Within orbital aspect of maxilla ALVEOLAR CANAL) Contains Infra-orbital N & vessels Site In body & ramus of mandible between mandibular & mental foramina Contains Inf alveolar N & vessels INFRA-ORBITAL FORAMEN Site Below infra-orbital margin in maxilla. Ant opening of infra-orbital canal MANDIBULAR FORAMEN (INFERIOR Contains Infra-orbital N & vessels ALVEOLAR FORAMEN) Site Med aspect of ramus of mandible, overlapped anteromedially by lingula INTERNAL ACOUSTIC MEATUS Contains Inf alveolar N & vessels Site In post surface of petrous temporal bone in post cranial fossa Mastoid foramen FORAMINA-SKULL AND SPINE Squamotympanic fissure

MASTOID FORAMEN Contains Chorda tympani, ant lig of Site In petrous temporal bone in post malleus, ant tympanic br of maxillary art cranial fossa, post to sigmoid groove. Exits behind mastoid process Contains Emissary V connecting sigmoid PTERYGOID CANAL sinus & occipital Vs, meningeal br of Site In pterygoid process of sphenoid bone occipital art connecting ant wall of foramen lacerum to pterygopalatine fossa Contains N & art of pterygoid canal MENTAL FORAMEN Site Outer aspect of ant ramus of mandible by second premolar tooth, leading from PTERYGOMAXILLARY FISSURE mandibular (inf alveolar) canal Site Between lat pterygoid plate & post Contains Mental N & vessels surface of maxilla connecting infra- temporal & pterygopalatine fossae, continuous above with post end of inf NASOLACRIMAL CANAL orbital fissure Site Between lacrimal bone & maxilla at Contains Terminal brs of maxillary art, antlinflmed corner of orbit passing in, post sup alveolar Ns passing Contains Nasolacrimal duct out

OPTIC CANAL SPHENOIDAL FORAMEN Site In body of sphenoid bone in middle Site In greater wing of sphenoid in middle cranial fossa between body & two roots of cranial fossa med to foramen ovale (40% lesser wing of skulls) (venous foramen of Vesalius) Contains Optic N (H),dural sheath, Contains Emissary V connecting cavernous ophthalmic art sinus & pterygoid plexus

PALATOVAGINAL CANAL SPHENOPALATINE FORAMEN Site Between upper surface of sphenoidal Site Between body of sphenoid bone & process of palatine bone & lower surface sphenopalatine notch of palatine bone of vaginal process of root of med ptery- (sup border of perpendicular plate & goid plate in base of skull orbital & sphenoidal processes). In med Contains Pharyngeal Ns from maxillary wall of pterygopalatine fossa (Vb)and pterygopalatine ganglion & Contains Sphenopalatine art, nasopalatine pharyngeal br of maxillary art & sup nasal Ns from pterygopalatine fossa

PETROSQUAMOUS FISSURE Site Between squamous temporal bone & SQUAMOTYMPANIC FISSURE tegmen tympani (petrous temporal bone) Site Between tympanic part (plate)of Contains No structures temporal bone & mandibular fossa (squamous temporal bone) in base of skull. It is divided by tegmen tympani PETROTYMPANIC FISSURE (petrous temporal bone) into petro- Site Between tympanic part (plate) of tympanic and petrosquamous fissures temporal bone & tegmen tympani (also Contains Deep auricular br of maxillary part of temporal bone) in base of skull artery Stylomastoid foramen FORAMINA-SKULL AND SPINE Zygomaticotemporal

STYLOMASTOID FORAMEN Contains Spinal cordlcauda equina, dura, Site Between styloid & mastoid processes archnoid & pia mater, cerebrospinal fluid, of temporal bone in base of skull internal vertebral venous plexus & spinal Contains Facial N (VII) & stylomastoid br arts of post auricular art

VOMEROVAGINAL CANAL SUPERIOR ORBITAL FISSURE Site Between lower aspect of ala of vomer Site Between body & lesser & greater wings & upper aspect of vaginal process of root of sphenoid bone in middle cranial fossa of med pterygoid plate in base of skull Contains Ophthalmic N (Va)(lacrimal, (not always present) frontal, nasociliary brs), ophthalmic Vs, Contains Pharyngeal br of sphenopalatine oculomotor N (sup & inf divs) (111), art trochlear N (IV),abducent N (VI), sympathetic fibres, brs of middle meningeal & lacrimal arts ZYGOMATICOFACJAL FORAMEN Site In lat surface of zygomatic bone Contains Zygomaticofacial N & vessels SUPRA-ORBITAL FORAMEN Site In supra-orbital margin of frontal bone, 2cm from midline ZYGOM.ATIC0-ORBITAL FORAMEN Contains Supra-orbital N & vessels Site In orbital surface of zygomatic bone Contains Zygomatic br of maxillary N (Vb)

VERTEBRAL FORAMEN (unpaired) Site Bordered by-ant: body of vertebra, ZYGOMATICOTEMPORAL FORAMEN post: laminae, lat: pedicles & articular Site In posteromedial surface of zygomatic processes. Collectively making the spinal bone canal Contains Zygomaticotemporal N & vessels This page intentionally left blank Adductor (Hunter's/subsartorial) Lesser sciatic foramen 199 canal 198 Medial triangular space 199 Anterior triangle of neck 198 Obturator canal 199 Cubital fossa 198 Popliteal fossa 199 Deep inguinal ring 198 Posterior triangle of neck 200 Epiploic foramen of Winslow (aditus to Pudendal (Alcock's) canal 200 lesser sac) (unpaired) l98 Quadrangular space 200 Femoral ring & canal 198 Snuff box 200 Femoral triangle l98 Superficial inguinal ring 200 Greater sciatic foramen l98 Urogenital triangle 200 Inguinal canal 199 Inguinal (Hasselbach's) triangle 199 Notes: (1) Including fossae, spaces, rings, Ischio-anal (ischiorectal) fossa 199 canals, triangles, sacs and foramina. (2)All Lateral triangular space 199 paired unless otherwise indicated. Lesser sac (omental bursa) (unpaired) 199 Adductor canal SPACES OTHER THAN SKULL AND SPINE Greater sciatic

ADDUCTOR (HUNTER'S1 DEEP INGUINAL RlNG SUBSARTORIAL) CANAL Site A defect in transversalis fascia in lower Site A groove in thigh extending from apex abdominal wall above mid point of of femoral triangle to hiatus in adductor inguinal lig. Borders-sup & lat: curved magnus. Bordered by-lat: vastus medialis, fibres of transversus abdominis. Inf: med: adductor longus & magnus, roof: inguinal lig. Med: transversalis fascia & fascia in which lies the subsartorial plexus inf epigastric vessels. Int spermatic fascia & on which lies sartorius attached to its edges Contains Femoral art & vein; saphenous N; Contains Vas deferens; testicular, vasal, N to vastus medialis cremasteric arts & Vs; obliterated processus vaginalis; genital br of genitofemoral N; autonomic Ns; ANTERIOR TRIANGLE OF NECK lymphatics Site Borders-inf border of mandible, midline & ant border of sternocleidomastoid. Subdivided into EPlPLOlC FORAMEN OF WINSLOW carotid, digastric, submental & muscular (ADITUS TO LESSER SAC) (unpaired) triangles Site In upper abdomen. Borders-ant: Contains Muscles: digastric, stylohyoid, portal V, bile duct & hepatic art in free mylohyoid, geniohyoid, sternohyoid, edge of lesser omentum, post: inf vena omohyoid, thyrohyoid, sternothyroid, cava, inf: first part of duodenum, platysma. Hyoid bone, larynx, thyroid & sup: caudate lobe of liver parathyroid glands, trachea, oesophagus, Contains Nil submandibular gland, lymph nodes. Arteries: common, int & ext carotids; brs of ext carotid: sup thyroid, ascending FEMORAL RlNG & CANAL pharyngeal, lingual, facial (submental). Site In lower abdomen. Femoral ring is Mylohyoid art (maxillary via inf alveolar). upper end of femoral canal. Borders-ant: Veins: int & ant jugular. Nerves: hypo- inguinal lig, med: lacunar lig, post: glossal, ansa cervicalis, vagus & its int, ext pectineal lig & pectineus, lat: femoral V & recurrent laryngeal & pharyngeal brs, Contains Cloquet's node; lymphatics mylohyoid N from VCvia inf alveolar N

FEMORAL TRIANGLE CUBITAL FOSSA Site In ant thigh. Borders-med: rned border Site Triangular space in ant aspect of arm. of adductor longus, lat: rned border of Borders-sup: intercondylar line, med: lat sartorius, sup: inguinal lig, floor: adductor border of pronator teres, lat: rned border longus, pectineus, iliacus & psoas, roof: of brachioradialis, floor: brachialis, fascia lata supinator, roof: fascia (see below for what Contains Femoral N, art, V & their brs; lies in it) deep inguinal lymph nodes Contains From rned to lat: median N, brachial art & its accompanying Vs, biceps tendon, radial & post interosseous GREATER SCIATIC FORAMEN Ns seen under edge of brachioradialis. Site In pelvis between greater sciatic notch Roof: bicipital aponeurosis, median of ischium/ilium & both sacrotuberous & basilic & cephalic Vs, rned & lat sacrospinous ligs cutaneous Ns of forearm Contains From above downwards: sup gluteal N & vessels, piriformis, inf gluteal N & vessels, int pudendal art, pudendal N, sciatic N, post femoral cutaneous N, lnguinal canal SPACES OTHER THAN SKULL AND SPINE Popliteal fossa

perforating cutaneous N, N to obturator LESSER SAC (OMENTAL BURSA) internus, N to quadratus femoris (unpaired) Site Diverticulum from general peritonea1 cavity in upper abdomen opening via INGUINAL CANAL epiploic foramen of Winslow Site In lower abdomen between deep & Contains Its peritoneal lining lies against- superficial inguinal rings. Borders-ant: ant (from above down): post surface of external oblique abdominis & a small liver; lesser omentum; body & fundus of portion of internal oblique abdominis, stomach; greater omentum. Inf: transverse post: transversalis fascia, inf epigastric colon. Post: inf vena cava; first 2.5cm of vessels & conjoint tendon, sup: curved duodenum; aorta; coeliac trunk & brs; fibres of internal oblique & transversus body of pancreas; left suprarenal gland; abdominis, inf: inguinal lig upper pole left kidney; sup: caudate lobe Contains Vas deferenslround lig of uterus; of liver; med (right): opening of sac with testicular, cremasteric & vasal arts & inf vena cava in post edge; portal V, Vs; obliterated processus vaginalis; hepatic art & bile duct in ant free edge; lat ilio-inguinal, genital br of genitofemoral (left): gastrosplenic & lienorenal ligs with & autonomic Ns; lymphatics; int spleen between them spermatic & cremasteric fasciae

LESSER SCIATIC FORAMEN INGUINAL (HASSELBACH'S) Site In pelvis between lesser sciatic notch of TRIANGLE ischium & both sacrotuberous & Site Post aspect of ant abdominal wall in sacrospinous ligs inguinal region. Borders-lat: inf epigastric Contains Passing out: tendon of obturator art, med: lat edge of rectus a bdominis, internus & int. pudendal V. Passing in: N inf: inguinal lig, floor: transversalis fascia, to obturator internus, int pudendal art, conjoint tendon & post wall of inguinal pudendal N canal Contains Nil. Site of direct inguinal herniation MEDIAL TRIANGULAR SPACE Site In post wall of axilla. Borders- suplmed: subscapularis (teres minor ISCHIO-ANAL (ISCHIORECTAL) viewed from behind), infllat: teres major, FOSSA lat: long head of triceps Site Wedge-shaped area lat to anal canal. Contains Circumflex scapular art Borders-med: anal canal & levator ani, lat: obturator internus & ischial tuberosity, inf (floorlbase): post aspect of OBTURATOR CANAL perinea1 body, urogenital diaphragm, Site In ant aspect of obturator foramen in sacrotuberous lig & gluteus maximus lat wall of true pelvis. Borders-ant: post Contains Fat; pudendal canal containing public ramus, suplinflmed: obturator int pudendal N & int pudendal vessels; inf & its fascia rectal N & vessels as brs of above Contains Obturator N & vessels

LATERAL TRIANGULAR SPACE POPLITEAL FOSSA Site In post wall of axilla. Borders- Site Diamond shaped, behind knee. suplmed: teres major, inflmed: long head Borders-supllat: biceps femoris, of triceps, lat: med shaft of humerus suplmed: semitendinosus & Contains Radial N; profunda brachii vessels semimembranosus, inflmed & infllat: Posterior triangle SPACES OTHER THAN SKULL AND SPINE Urogenital triangle

heads of gastrocnemius, floor: post distal Contains Axillary N; post circumflex femur, post capsule of knee & popliteus, humeral art & V roof: fascia Contains Plantaris; popliteal art & V & brs; tibial, common peroneal, sural & SNUFF BOX sural communicating Ns; lymph nodes & Site A triangular depression on dorsolateral fat. Short saphenous V & post femoral side of hand formed by tendons of cutaneous N in fascia of roof extensor pollicis longus (ulnar side) & extensor pollicis brevis & abductor pollicis longus (radial side) POSTERIOR TRIANGLE OF NECK Contains Scaphoid, trapezium, radial art; Site Between post border of terminal brs of radial N pass over it sternocleidomastoid, ant border of trapezius & middle third of clavicle. Floor: prevertebral fascia over semispinalis SUPERFICIAL INGUINAL RING capitis, splenius capitis, levator scapulae, Site In lower abdominal wall at med end of scalenus medius & ant. Roof: investing inguinal canal as a V-shaped opening of layer of deep fascia ext oblique aponeurosis. Ext spermatic Contains Occipital, transverse cervical, fascia is attached to its edges suprascapular & third part of subclavian Contains In female: ilio-inguinal N & arts; transverse cervical, suprascapular & round lig of uterus. In males: ilio-inguinal ext jugular Vs; muscular & cutaneous N & spermatic cord (vas deferens; brs of cervical plexus (lesser occipital, testicular, cremasteric & vasal arts & Vs; great auricular, transverse cervical, obliterated processus vaginalis; genital br supraclavicular); three trunks of brachial of genitofemoral & autonomic Ns; plexus; spinal root of accessory N; inf lymphatics; int spermatic & cremasteric belly of omohyoid; superficial cervical fasciae) lymph nodes

UROGENITAL TRIANGLE PUDENDAL (ALCOCK'S) CANAL Site In perineum. Borders-lat: ischiopubic Site Lies within a fascial sheath in lat wall rami, ant: post aspect of symphysis pubis, of ischio-anal fossa between lesser sciatic post: transverse line at level of perineal notch & deep perineal pouch. Borders- body & ischial tuberosities lat: obturator internus & ischial tuber- Contains Deep perineal pouch (space) osity, med: fat within sup & inf fascial layers of the Contains Pudendal N; int pudendal vessels urogenital diaphragm perforated by urethra with surrounding ext sphincter; deep transverse perinei; brs of int QUADRANGULAR SPACE pudendal vessels & pudendal N. In male Site In post wall of axilla. Borders-sup: diaphragm contains bulbo-urethral glands subscapularis (teres minor viewed from & supports penis, scrotum & superficial behind), inf: teres major, med: long head transverse perinei from its inf surface. In of triceps, lat: med shaft of humerus female it is perforated by vagina Notes: (1) Al(ob1ique stroke) between two End of arch of aorta levels indicates that the structure lies at a Azygos vein enters superior vena level between these two vertebrae. (2)A - cava (dash) between two levels indicates that the structure occupies the equivalent level to Manubriosternal angle of Louis these vertebrae inclusively. Bifurcation of trachea Start of arch of aorta Spinal root of accessory nerve crosses transverse process of atlas Thoracic duct crosses midline Open mouth and dens Sternum Superior cervical ganglion Upper border of liver Body of hyoid bone Inferior angle of scapula Upper border of thyroid cartilage Accessory hemiazygos vein crosses Bifurcation of common carotid midline to azygos vein arteries Caval opening in diaphragm Cricoid cartilage Inferior vena cava Larynx becomes trachea Right phrenic nerve Pharynx becomes oesophagus Left phrenic nerve pierces diaphragm Middle cervical ganglion lat to central tendon Vertebral artery enters foramen Hemiazygos vein crosses to right to transversarium of C6 vertebra join azygos vein Carotid tubercle of Chassaignac Inferior thyroid artery crosses to Sternoxiphisternal joint thyroid gland Superior epigastic vessels traverse First clearly palpable spinous process diaphragm (vertebra prominens) Xiphoid Stellatelinferior cervical ganglion Oesophageal opening in diaphragm Superior border of scapula Oesophagus Brs of left gastric vessels Suprasternal notch Anterior and posterior vagi

Medial end of spine of scapula Aortic 'opening' in diaphragm End of oblique fissure of lung posterior to median arcuate lig posteriorly at spine of T3 Aorta Azygos & hemiazygos veins Top of arch of aorta Thoracic duct Origin of coeliac axis (lower border Manubrium sterni of T12) POSITION OF STRUCTURES ACCORDING TO VERTEBRAL LEVELS

Splanchnic nerves pierce crura of L2 Subcostal plane diaphragm Formation of azygos and Sympathetic trunk passes posterior hemiazygos veins to medial arcuate ligament Duodenojejunal flexure, ligament Subcostal neurovascular bundle of Treitz (upper border of L2) passes posterior to lateral arcuate lig L3 Origin of inferior mesenteric artery

L1 Transpyloric plane of Addison (half L314 Umbilicus way between suprasternal notch and symphysis pubis) L4 Supracristal plane (iliac crests) Fundus of gallbladder Bifurcation of aorta Hila of kidneys Second part of duodenum L5 Formation of inferior vena cava Neck of pancreas Origin of superior mesenteric S2 Sacral dimple artery Mid point of sacro-iliac joint Origin of portal vein Post superior iliac spine Pylorus Dural sac ends Attachment of transverse mesocolon S3 Start of rectum Hilum of spleen (spleen on ribs 9, 10,ll) S4 Sacral hiatus Tip of 9th costal cartilage End of vertebral canal

L112 Origin of renal arteries Col Filum terminale inserts Spinal cord ends in adults Pharyngeal derivatives Pharyngeal derivatives

Arch derivatives Lateral pouch derivatives Artery Nerve

Mesoderm Endoderm Endoderm Ectoderm

Cartilages, bones, Muscles Arch ligaments

I 'Mandibular' arch lncus Masseter Mucous membrane Auditory tube External acoustic Part of maxillary Mandibular cartilage = Malleus Temporalis & glands of Inner layer of meatus artery division of Meckel's Anterior lig of Pterygoids anterior 213 of tympanic Outer layer of trigeminal (VC) malleus Mylohyoid tongue membrane tympanic Sphenomandibular lig Anterior belly of (Part of middle ear) membrane (Lingula) digastric (Mastoid antrum) (Tragus of ear) (Mandible*) Tensor veli palatini (Skin of lower face) Tensor tympani

2 'Hyoid' arch Upper body & lesser Stapedius Supratonsillar fossa Overgrowth of Stapedial artery Facial (VII) cartilage = cornu of hyoid Stylohyoid Tonsillar crypts ectoderm over Reichert's Stylohyoid ligament Posterior belly of Surface epithelium arches 3,4 & 6 Styloid process digastric of tonsil* Stapes Muscles of facial (Part of middle ear) expression including buccinator & platysma 3 'Thyrohyoid' arch Inferior body & Stylopharyngeus Mucous membrane Ventral: epithelia1 Internal carotid Glossopharyngeal greater cornu of & glands of cells of thymus*" artery (including (IX)

hyoid posterior 1l3 of Dorsal: inferior carotid sinus) tongue parathyroid

4 Thyroid cartilage Palatoglossus Valleculae & Ventral: ultirno- Right: part of right Vagus (X) Palatopharyngeus anterior branchial bodiest subclavian Pharyngeal & Salpingopharyngeus epiglottis Dorsal: superior artery superior Cricothyroid parathyroid Left: aortic arch laryngeal Levator veli palatini branches Striated of oesophagus Pharyngeal constrictors

Cricoid cartilage Cricopharyngeus Lung buds Ventral: pulmonary Vagus (X) Vocal ligs All intrinsic muscles of artery Recurrent Arytenoid, larynx Dorsal: ductus laryngeal corniculate & arteriosus branch cuneiform cartilages

*The mandible forms in membrane around the ventral aspect of the first arch cartilage. *The lymphoid tissue of the tonsil and thymus arises from the surrounding mesenchyme and is not arch derivative. t Ultimobranchial bodies develop from ventral parts of fourth (and possibly fifth) pouch and fuse with the developing thyroid to give parafollicular (C) cells which produce calcitonin. Notes: (I) The thyroid gland arises from between the first and second arch as a diverticulum (thyroglossal duct) which grows downwards leaving the foramen caecum at its origin. (2) The epiglottis comes from the inferior part of the hypobranchial eminence and is thus not a true arch derivative. (3) Bracketed information is of additional interest