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UPPER LIMBI OSTEOLOGY

(1) Clavicle

Peculiarities-No medullary cavity, first to start ossification and last to complete ossification, long horizontal bone has 2 primary centers for ossification; membrane ossification

Side Identification - (1) Sternal end is round and enlarged(2) Subclavian groove is seen inferiorly (3) Medial 2/3rd is convex forward.

The coracoclavicular ligament is attached to conoid tubercle and trapezoid ridge. It transmits the weight of upper limb The subclavian groove has attachment of subclavius muscle and clavipectoral fasciaApplied Importance - most important part prone to fracture is between medial 2/3rd and lateral 1/3rd--lead to drooping of shoulder.

- also congenital absence may be there – called cleido cranial dyastosis *It is pierced by middle supra clavicular nerve.

II SCAPULA

-has 2 surface (costal and dorsal) 3 borders, 3 angles, 3 processes.-3 processes are coracoid, acromion and spinous

Side Identification

- (1) Glenoid cavity is laterally (2) Spine is backwards - (2)Inferior angle downwards.

Vertebrae level- superior angle-T2, spine-T3, inferior angle-T7Coracoids process- peculiarity atavistic epiphysis

-Attachments-coracobrachialis, biceps short head, pectoralis minor, coracoclavicular ligament Suprascapular Foramen – has suprascapular artery above and nerve below (AIR FORCE ABOVE, NAVY BELOW) Applied importance - Scaphoid scapula-In this condition medial border of scapulae is cornea

- Paralysis of serattus anterior leads to winging of scapulae.Movements are- elevation, depression, pronation, retraction, forward rotation, backward rotationHUMERUS

Parts -upper end –has head, neck (surgical and anatomical), greater lesser tubercle, intertubercular sulcus (bicepital groove)

- shaft- has radial groove, deltoid tuberosity - lower end- has - medial and lateral epicondyel,

- Olecranon, coronoid, radial fossa- Trochlea and capitulum

Side identification (1) Head lies upwards and medially (2) lesser tubercle lies anteriorly* Greater tubercle has attachments of supra spinatus, infra spinatus, teres minor [sII]* Lesser tubercle- has attachment of subscapularis

* The intertubercular sulcus has long tendon of biceps, anterior circumflex humeral artery * The humerus has 3 necks- surgical, anatomical and morphological.* Nerve related are – axillary (to neck), radial (to radial groove) ulnar (medial epicondyel)* 2 lips of intertuberclar sulcus - lateral lip – has pect major

- Medial lip- Teres major- b/w them- latismus dorsi

* Deltoid tuberosity – is attachment of deltoid Changes at level of radial grooveMedial epicondyle – has a separate secondary center of ossification and appears at 5th year.Applied Importance

(1) the head of humerus is dislocated inferiorly, usually (2) If there is a fracture between upper 2/3rd and lower 1/3rd of humerus there is delayed

reunion due to low blood supply.(3) Major site of fractures are surgical neck, shaft, supracondylar region

ULNA - homologous to fibula of lower limb.

It has - upper end – has colecranon and coronoid process and trochlear and radial notches - Shaft- has 3 BORDERS – anterior,posterior and interosseous border.- Lower end-(head)- has head and styloid process.

Side identification- (1) upper end has trochear notch.(2) The styloid process lies medially(3) Olecranon process is anteriorly

The olecranon process has attachments of triceps, flexor carpi ulnaris, anconeus, ulnar collateral ligament, flexor degitorum profundus.Thestyloid process- has attachment of ulnar collateral ligament and extentor retinaculum. Applaied Importance

In middle of radius and ulna if there is a fracture there may be crossed union between radius and ulna.

Fracture of olcranon is common if there is a fall in point of elbow.RADIUS

Parts – it has – upper end – head, neck, Tuberosity (it has attachment of biceps in posterior part)

-Shaft-has 3 borders, anterior, posterior and interosseous.-Lower end – has styloid process.

Side Identification – (1) upper end is round and bears a head (2) Styloid process lies laterally(3) Listers tubercle lies possteriorly

Radial tuberosity has attachment of biceps and oblique cord. Inferiorly it articulates with lunate (medial quadrangular part) and with scaphoid (lateral triangular part)

The Listers tubercle lies inferiorly and is related medially to tendon of extensor pollicis longus and laterally to extensor carpi radialis longus and bravisStyloid process has attachment of lateral carpal ligament and beacheo radialisApplied importance

(1) cooler fracture(2) smiths fracture(3) dislocation of head of humerus from annular ligament leads to pulled elbow.

CARPAL BONESIt is arranged in 2 rows

Proximal row (lateral to medial) - scaphoid, lunate, triquetral, pisiform.Distal row - - trapezium, trapezoid, capitate, hamate

(1) Saphoid – It is boat shaped - Facture of it can lead to avascular necrosis leading to non union

- Its lateral end at distal part has a tubercle that has attachment of flexor retinaculum, abductor pollicis longus bravis, lateral ligament

(2) Lunate – semilunar in shape.(3) Triquetral- pyramidal / wedge shaped (4) Pisiform – pea shaped, it is sesamoid bone in flexor carpi ulnaris. Smallest of carpel bones. The pisiform will be completely formed only at age of 12.So that in x-ray age can be determined(5) Trapezium – It has a crest and a groove. The groove lodges the tendon of flexor carpi ulnaris(6) Trapezoid – boat shaped (7) Capitate –has a head, largest of carpal bones (8) Hamate – wedge shaped, has a hook like process - The hook has attachment of flexor retinaculum and forms medial boundary of carpal tunnelMETACARPAL

-5 in number – they are short long bones- It has a head, base and a shaft. The head forms the knuckles.

PHALANGES - 14 in number - also has a base (proximal) shaft and head (distally)

BREAST- ESSAY

They are located in both sides in pectoral region. They are hemispherical pendular with a constant circular baseIt is a modified sweat gland and a tubuloalveolar gland It extends vertically from 2nd to 6th rib and horizontally from lateral border of sternum to mid axillary line in the 4th rib

(A) Mammary Bed It is the substance on which the gland lies.

- It is made of medial 2/3 rd by pectoralis major, lateral 1/3 rd- by serratus anterior and the infero medial quadrant by external oblique

(B) Retro mammary Space -lies between gland and mammary beds fascia is filled by loose areolar tissue. If it is

filled by cancerous cells it leads to fixity of gland – breast caner.

(C) Nipple They are conical projection below the centre at the 4th intercostals space. They are pierced

by 15-20 lactiferous ducts. It has circular and longitudinal muscles. The circular muscles(help to

erect the nipple for sucking) while the longitudinal muscles helps in retracting the nipple. They have a rich verve supply of sensory receptors

(D) Areola Pigmented outer region around nipple. It has numerous modified sebaceous glands- called Tubercles of Montgomery.

*the skin of areola and nipple has no hair /subcutaneous fats.

(E) Structure of Breast The gland has a capsule, glandular tissue(parenchyma), fibrous part (stroma)(a)*glandular tissue – is made of 15 – 20 pyramidal lobes, each with a repeated duct.

Each lobe is a cluster of alveoli and drained by lactiferous duct. The aleveolar duct is cuboidal in resting stage and columnar in secreting stage

*myoepitheliocytes are cells in alveoli and ducts b/w epithelium and basement membrane, that fascilitates passage of milk from alveoli to nipple.

(b) Fibrous tissues –support the lobes.-suspensory ligaments of cooper are fibrous septae that arches the

skin and gland to the pectoral fascia.(F) ARTERIAL SUPPLY

-Upper part – by superior thoracic and thoraco acromion artery - Lateral part – by lateral thoracic artery - Medial part – by perforating arteries of internal thoracic artery. The deep surface is

supplied by lateral branch of intercostal artery

(G) Venous Supply-Around the areola – by circulero venosus - Lateral part – by internal thoracic artery- Upper part – by posterior intercostal artery – via it, there is communication to the

Batsons plexus and through it to the brain

(H) Nerve supply- It is by anterior cutaneous branches of 4-6th intercostal nerves .It has no nervous conted

over the execution

(12) Lymph drainageThe main lymp nodes are - axiliary – has 5groups –anterior – along lateral thoracic artery

-Posterior – along subscapsular vessel -Lateral – along axillary vein -central – along upper part of axilla -apical- very deep

- internal mammary-parasternal -supra clavicular

*Drainage- superficial(except nipple and areola)-corresponding sueperfical lymph nodes of corresponding region

- deep -75%- goes to axillary nodes –mostly to anterior group –central and lateral group –apical group –supra claviculargroup

-some to posterior group-25%-internal mammary -5%- to posterior intercostal nodes

(13) Development

Breast develop from an ectodermal ridge called mammary ridge /milkline (it extended from axilla to the groin). It appears in 4th week of intra uterine life. Later most of it disappears and they are retained only in the pectoral region called mammary pit. Secondary bud grows from floor of pit and they divide into small divisions. Nipple is everted at times of birth

From birth puberty they are similar in male and females. At puberty there is secretion of esliogen

Cholestrum is the first milk coming out of the breast.It is rich in fat, immuno globulins and poor in nutrition

In lactation , the alveoli gets distended 5-6 months after lactation, it starts diminishing the secretion and after nine months it

stops secretion Witches milk – the milk secreted by infants breast due to influence of maternal

estrogen.(14) Hormones influencing breast

(1) Estrogen – favours growth of lactiferous duct and the breast (2) Progesterone – important in formation of alveoli(3) Prolactin and G H – important in producing milk (4) Oxytocin- important in ejection of milk

(15) Applied importance(1) If the malignancy is in upper outer quadrant then safe removal is possible

In this case pectoralis major, minor, and axillary lymph nodes are removed (2) There may be secondary deposits sites of tumour eg: in other breast/in ovary, liver,

bone, brain etc(3) Fibroadenoma- breast mouse (4) If there is discharge of blood from breast then there is infection of breast (5) In case of malignany, there is retraction of nipple and ‘peau de orange’ appearance.

There is edema of skin and sebaceous glands appear to be retracted

BRACHIAL PLEXUSThe brachial plexus is for med by the union of nerves of upper limb.

(1) FormationIt is for med by ventral rami of lower 4 cervical nerves and upper, thoracic nerve

Anterior rami Trunk Division Cord Branches.

C5 – upper – A- lateral cord C5 – upper – p- posterior cord

C6 – upper – A- lateral cordC6-upper – p- posterior cord

C7 – lower – A- lateral cordC7 – lower - P- posterior cord C8 – middle – A- medial cord

C8 – middle – P- posterior cord

T1- middle - A- medial cord T1- middle - P- posterior cord

*Erbs point – It is a point where 6 nerves meet . (Anterior rami of C5, C6, suprascapular N, nerve to subclavius, anterior and posterior division of upper trunk)

- It is the region where there is maximum strech.The five stages in formation of Bracheal plexus are – root, trunk, division, chord,

branches, (in the post ale)( behind clavicle)(In axilla )

There may be also variations .eg: It may be prefixed (that has large contribution from C4 )or may be post fixed (if there is a large contribution from T2 but less fromC5).(2) Relations

(a) of root and trunk – related to posterior triangle, platysma, subclavian artery (b) of the division – related to subclavian artery and vein(c) of cords and branches – 1st part – lateral and posterios cordd lies lateral to 1st part of

axillary A while medial cord lies posteriorly- 2nd part- lateral cord lies lateral , while medial cord lies medial

and posterior cord lies posterior to the axillary artery(3) Branches

(a) supra clavicular branches (1) from root – N to serratus anterior (C5,6,7), N to latismus dorsi (C5)(2) from trunk – suprascapular nerve (C5,6),N to subclavius (C5,6)

(b) infra clavicular branches(1) of lateral cord – lateral pectoral N, musculocutaneous N, lateral root of

median N.(2) medial cord – Ulnar N, medial root of median nerve, medial pectoral N

Medial cutaneous N of arm, medial cutaneous N of fore arm (3) Of posterior cord – upper subscapular N, lower subscapular N, N to latismus

dorsi , axillary N, radial N.

CLINICAL IMPORTANCE

(1) ERBS PALSY – due to widening of angle b/w neck and shoulder - arm shows waiters tip (arm and shoulder abducted, Fore arm pronated , elbow

extended, fore arm rotated)

(2) Klumpkes paralysis – lowes part of Brachial plexus is affected (3) If there is injury to the root – along with paralysis of muscles Horner syndrome

(sympathetic syndromes) are also seen (4) Cruchs paralysis / saturday night paralysis – radial N affected :wrist drop is seen (5) Cervical rib – due to extension of transverse process of C7 – lead to Cervical Rib

sydrome leads to pressure on the brachial plexus

AXILLA

It is shallow 4 sided pyramidal structure between upper part of thoracic wall and upper part of arm.

*(1) parts it has an apex , base and 4 walls (anterior, posterior medial and lareral wall )(1) apex- is continuous with the neck by the cervico axillary canal.(2) Base – directed downwards and forwards – formed of skin and fascia(3) Arterior wall – is formed of skin, superficial fascia , deep fascia, pectoral muscles (4) Posterior wall – is formed of posterior axillary fold, lateral part of subclavius latismus

dorsi , teres major .(5) Medial wall – by upper 4 ribs, intercostals muscles, serratus anterior (6) Lateral wall – it is narrow intertubercular sulcus made of biceps and coracobrachialis

The space b/w pectoralis major and clavicle – is called clavepectoral fascia It is pierced by medial pedtoral N ,cephalic V, thoracoacromial artery .

*(2) Contents- Axillary artery , axillary vein, infra clavicular part of brachial plexus lymph nodes and

vessels, long thoracic nerve, axillary tail of Spence of breast in case of females.AXILLARY ARTERY

-continuation of subclavian artery

*right subclavian artery arises from bracheo cephalic artery where left subclavian artery arises from arch of aorta. - It extends from outer border of 1st rib to lower border of teres major. It continues as brachial artery

(1) Surface marking(1) mid point of clavicle (2) midpoint of epicondyles of humerus in cubital fossa

draw a line joining these 2 points with the arms abducted

The upper 1/3 rd represent axillary artery while lower 2/3rd represents brachial artery

(2) parts - divided in to 3 by the pectoralis minor .(a) part 1 –[proximal to pectoralis minor ]

Relations - Anteriorly – to skin, superficial fascia, platysma, medial surpraclavicularN, clavicular part of pectoralis major, clavipectoral fascia, communication b/w medial and lateral pectoral nerve

- Posteriorly – 1st intercostal space, 1st two digiations of serratus anterior, N to serratus anterior, medial cord of brachial plexus

- Lateral – lateral and posterior cords of brachial plexus - Medial – to axillary vein

(b) part 2 – [ below pectoralis minor ]

Relation - anterior – skin, deep and superficial fascia, pectoralis -posterior – upper part of subclavius, postior cord of brachial plexus - lateral – lateral cord of beachial plexus, short head of biceps,

coracobrachialis - medial – axillary V, medial cord of brachial plexus.

(c) part -3-[distal to pectoralis minor]

Relations – anterior – skin, superficial fascia, pectoralis major - posterior – lower part of subscapsularis, posterior cord, teres major. - medeal – axillaery V, medial cutaneous N of arm - lateral – branches of lateral cord of Brachial plexus, coracobrachialis, short

head of biceps.

(3) Branches*of the 1st part – superior thoracic artery *of 2nd part

(a) Thoracoacromial artery – pierces clavipectoral fascia an divides into pectoral, acromial, clavicular and deltoid branches

(c) Lateral thoracic artery – along anterior group of axillary lymph nodes

*of the 3rd part

(a) Subscapular artery - - largest branch. It gives a branch circumflex scapular artery – They are important in anastomosis around scapula.

(b) Anterior circumflex humeral artery – gives an ascending branch that run along intertubercular sulcus to supply the joint and humerus

(d) Posterior circumflex humeral artery – larger than anterior circumnflex humeral A. It accompanies axillary N. They anastomose with anterior circumflex humeral artery. It also gives a descending branch that anastomose with profunda brachi’s ascending branch

(4) axillary vein - It is the continuation of basillic vein . It lies medial to axillary artery - at the outer border of 1st rib- it becomes subclavian vein- it also recreive cephalic vein - It has no axillary sheath around it.So that it is free to expand in cases of

increased blood flow(2) Applied importance

(a) The axillary artey is compressed against the humerus (in lower part of latetal wall of axilla to decrease the bleeding)

(b) The axillary artery’s pulsations can be felt as against lower part of lateral wall of axilla

(c) Axilla has hair and sebaceous gland. So that infections and boils are commom here.

THE BACK

The junction between head and neck is external occipetal protuberence The cutaneous supply is by 12 thoracic nerve and 5th sacral nerve. The posterior rami

of these divide into medial and lateral branches and supply the back. The man muscles of the back include trapezius, latismus dorsi, levator scapulae, rhomboidus major and minor.

(1) Trapezius Origin – from medial 1/3rd superior nuchal line, external occipital protuberence,

ligamentum nuchae, C7 spine, T1-T12 spine Insertion – Upper fibres (from posterior border of lateral 1/3rd of clavicle), middle fibres

(medial margin of acromion), lower fibres (to deltoid tubercle).Nerve supply – spinal accessory – motor supply, and C3,4 – is proprioceptive

(2) latismus dorsiOrigin – posterior 1/3rd of outer lip of iliac crest, posterior layes of outer layer of lumbar

fascia, T7 – T12 spine, lower 4 ribs, inferior angle of scapula.Insertion – it winds around lower borrder of teres major, form a tendon and inseted into

intertubercular sulcusNerve supply – thoraco dorsal nerve.

(3) levator scapulae origin – transverse process of C1, C2, posterior tubercle of transverse process of C3,C4 insertion – superior angle and upper part of medial part of scapula nerve supply – branch of dorso scapular N, propriorceptive – is by C3 C4

(4) rhomboidus major origin – lower part of ligamentum nuchae, spine of C7- T1Insertion – to base of a triangular aera at root of spine of scapula.Nerve supply – dorsal scapular nerve.

(5) Rhomboidus minorOrigin – spine of T2 – T5, supraspinous ligament Insertion – medial border of scapula below root of spine.Nerve supply – dorsal scapular nerve.

Axillary Arch- it is a muscular slip from edge of latismus dorsi. It crosses the axilla ( in front

of vessels and nerves ) and joins tendon of pectoralis major, coracobrachialis

* Triangle of ausculatationmedial – by lateral border of trapezius lateral – medial border of scapulae inferiorly – upper border of latismus dorsl floor – by 7th rib , 6th 7th intercostal spaces.- this is only part of back that is not coverd by muscles

: Respiratory sounds and sounds of swallowing liquids can be heard on ausculatating here

Triangle of Petit

It is bounded – medially by – lateral border of latismus dorsi - lateral – by posterior border of external oblique

- inferiorly – illicac crest

It is associated with lumbar hernia

SHOULDER JOINT

It is a multi axial ball and socket type of syunovial joint

(1)Articular endsProximally – glenoid fossae and goenoid labrum

covered by hyaline cartilage.Distally – head of humerus – 4 times the size of glenoid cavity

(2) Ligaments

(a) Capsule

Attached – medially – to rim of glenoid labium larerally – to anatomical neck of humerus - superiorly and inferioly – also to anatomical neck of humerus

*The capsule is supported by the muscle – sapraspinatus, infraspinatus, teres minor subscapulris – [SITS]. This form rotator cuff / musculo tendninous cuff

It has two openings (1) anteriorly – below coronoid procese (2) for long tendon of bicep(b) Seproral membrane

lines inner suface of capsule. It secretes synovial fluid (c) Gleno humeral ligament

- has three parts – superior – from anterior part of margin of glenoid cavity - middle – just belwo the origin of superior part to margin of lesser tubercle- inferior – from antero inferior part to the neck

(d) Coraco humeral ligament- from the coracoid process to greater tuberlce

(e) Transverse humeral ligament – b/w 2 tubercles – it holds tendon of long head of biceps

(f) Coraco acromial ligament – has conoid and trapezoid part

(3) Bursae Mainly 3 – subscapular – b/w tendon of subscapularis and capsule - infraspinatus – b/w infraspinatus and capsule - subacromial

(4) Relations

(1) above – coracoid process ,acromion, coracoacromial ligament (2) below – long head of bices, posterior cirumfiex humeral A, axillary N (3) anteriorly – subscapularis (4) posterior – infraspinatus , teres minor

(5) blood supplyby anterios cirumflex humeral artery, posterior cirumflex humeral artery circumflex scapular artery, supra scapular artery

(6) Nerve supply Axillary N, suprascapularN, lateral pectoral N.

(7) MovementsThe main movement are flexion, extension, abduction, adduction , medial rotator lateral rotator and also cirumflexion

*for every 15 degree elevation (i.e abduction) – 5 degee is by movement of scapula 10 by the movement of shoulder jointThe abduction of 15-30 degree is by the supraspinatus , 30 – 90 – by deltoid 90-180 by trapezius and serratus anterior

flexion – by pectoralis major , deltoid , biceps extension – by posterior fibres of deltoid , latismus

dorsi adduction – pectoralis major, teres major, latismus dorsi lateral rotation – by deltoid, infraspinatus, teres minor medial rotation – pectoralis major, latismus dorsi

(8) Applied Importance(a) Dislocation of humerus – usually it will be anterior/ inferior dislocation (b) Recurrent dislocation – due to laxity of Rotator cuff (c) Supra spinatus tendinitis – inflammation of tendon:So that there will be

severe pain on abduction between 60 and 120 degree and after 120 degree/there is no pain – called Daw Burns Sign

(d) Injury to spinatus tendon – head of humerus may be displaced downwards.

THE ARM

It extends from shoulder to the elbow joint

FRONT OF ARMMedial epicondyle is best seen and felt in mid prone positionBrachial artery – seen medial to tendon of biceps – pulsations are felt here

*(1) Compartments of Arm - By medial and lateral intermuscular septae, arm is divided to anterior and

posterior compartment - These septae provide attachment to muscles - These septae also provide plane along with nerve and vessels pass - The medial septea is peirced by ulnar N and superior ulnar collateral

ligament

- Lateral septae is peirced by radia N and anterior descending branch of profunda brachi artery

- There is also a transeverse septae (seperate biceps from brachialis ) and an anterior posterior septae

*(2) Muscles of the Arm (a) – Coracobrachealis – oriin – from lip of coacoid process

inesrtion – to middle 5cm of medial border of humerusN.S – musculo cutaneous N* It represents medial compartment of arm.

(b) – Biceps- origin – short head- from tip of coracoid process- long head – supraglenoid tubercle of scapula- Insertion – posterior rough part of radial tuberosity and froms

bicepital aponeurosis and merge with deep fascia of fore arm - Nerve supply – musculo cutaneous N

(c) Brachial – origin – from lower half of front of humerus and medial / and lateral inter tubercular septae

- Insertion- to ulnar tuberosity and rough anterior surface of coronid tuberosity of ulna

Nerve supply – motor supply – by musculo cutaneous N - proprioceptive- radial N

(e) Triceps- origin – long head – from infra glenoid tubercle of scapula- lateral head – from oblique region from upper part of post sugace of humerus - medial head – medial alar area in humerus - insertion – to posterior surface of cutaneous process below radial groove

N S- by radial N.

*(3) Musculo Cutaneous Nerve - Main N of arm and it is a branch of lateral cord(C5-C7)

(A) Surface marking (a) a point lateral to axillary artery (3cm above the termination )(b) a point lateral to tendon of biceps brachi

(B) Coure and relations anteriorly – to pectorlis major* in lower part of axilla it is related

posteriorly - subscapularis

medially – axillary A, lateral root N of medianN

lateral- coracobrachialisIt then peice coracobrachialis and enters the arm

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

(C) Branches and Distribution Musular – coracobrachialis , biceps, brachialis

Cutaneous- lateral cutaneous N of fore arm Articular branches – supply the elbowAlso communicating branches to superior branch of radial N, posterior cutaneous N of fore arm, cutaneous branch of medial N

Sometime it may get fibres from median nerve.

*(4) Brachial Artery

It is the continuation of axillary artery. It starts from lower bordes of ters major to a point in front of elbow (at level of neck of radius).

(a) Surface marking (1) a point at junction of anterior 1/3rd and posterior 2/3rd of lateral wall of axilla

at its lower limit(2) at neck of radius medial to tendon of biceps brachi

(b) Course and relations *It runs dounwward and laterally from medial side of arm to front of elbow It is superficial through out its extends and it is accompanied by two venae

Commitants. Anteriorly it is related to medial cutaneous N of arm and in its middle part it is

crossed by median N from lateral side to medialside and in front of elbow related to bicepetal aponeurosis and median cubital vein

Posteriorly – related to triceps, radial N, profunda brachi Medially- ulnar N , basillic V median nerve Laterally related to coracobrchealis , biceps median N, tendon of biceps

(c) Branches (1) Profunda brachi- accompany nadial N

(2) superior ulnar collateral A – accompary ulnar N (3) inferior ulnar collateral/supra trochlear artery (4) nutrient artery to humerus (5) terminal brnaches- radial and ulnar artery

(d) Clinical Importance (1) Brachial pulsations are auscultaed medial to tendon of biceps(2) Bracial artery is compressed in middle of arm ,where it lies on coracobrachialis

*(5,) Anastomisis Around ElbowIn front of lateral epicondyle - anterior descending (radial collateral branch) of profunda brachi anastomose with radial recurrent banch f radial A Behind lateral epicondyle- posterior descending artery anastomose with inerosseous recurrent branch of posterior interosseous artery In front of medial epicondyle – inferior ulnar collateral A anastomose with anterior ulnar recurrent branch of ulnarA Behind medial epiondyle – Superior ulnar collateral A anastomose with posterior ulnar recuerrent branch of ulnarA

*(6)Profuda Brachi Artery It is a large branch arising from below teres major. They accompany the

radial N through radial groove. And before peircing the lateral intermuscular septae they divide into anterior and posterior descending branches

Branches

*Radial collateral / anterior descending – continuation of profunda brachi. It accompanies radaial N

*Posterior descending – largest terminal branch. It accompanies N to anconeus *Deltoid branch – ascend b/w long and lateral head of triceps *Nutrient A- are in radial groove.

Inter muscular Space` There are 3 intermuscurlar spaces in scapular region

(1) Quadrangular space

superior- subscapularis, teres minor.Boundaries-

inferior- teres major

medial – long head of triceps

lateral – surgical neck of humerus Contents - axillary N, posterior cicumflex humeral A

(2) Upper triangular space Medially – teres minor

Boundaries - . Laterally – long head of humerus

Inferior – teres major

Contents – circumflex scapular A. It anastomose with suprascapular artery

(3) Lower triangular space

medially- long head of triceps Boundaries-

laterally – medial border of humerus

superiorly – teres major

Contents – radial N, profunda brahi vessels.

ANASTOMOSIS AROUND SCAPULA

By (a) Suprascapular artery – branch of thyrocerviclal trunk (b) Deep branch of transverse cervical A – branch of thyrocervical trunk(c) Circumflex scapular artery – branch of third part of axillary A - It is the anatomoses b/w 1st part of subclavian A and 3rd part of axillary artery.

(3) Anastomosis around Acromion- by acromial branch of thoraco acromial artery, suprascapular A and posterior

circumflex humerl artery

Clinical ImportanceThey provide collateral through which blood can pass when distal part of axillary A is

blocked

CUBITAL FOSSAE

It is a triangular hollow in front of elbow. It is homologous to popliteal fossae

Lateral – to medial border of brachio radialisBoundaries -

Medial – lateral border of pronator teres Base – by an imaginary line joining 2 epiondyles of humerus

Apex – directed forwards – formed by meeting point of lateral and medial boundaries

Roof – of skin , superficial fascis [having medial cubital vein, lateral cutaneous N of forearm and medial cutaneous N of forearm], deep fascia, bicepital aponeurosis

* Contents – from medial to lateral

(1) Median N – gives branch of flexor carpi radialis , palmaris longus, flexor digitorum superficialis and leave the fossa b/w 2 head of pronator teres

(2) Brachial A – it divides here into radial and ulnar artery (3) Tendon of biceps and bicepital aponeurosis(4) Radial N and radial collareral A- It lies in gap b/w brachialis medially and brachio

radialis and extensor carpi radialis laterally.

*Applied Importance -Medial cubital vein is used for IV injections - Brachial artery in cubital fossa is used to find B.P

ELBOW JOINTIt is a synovial joint of hinge variety(1) Articulating surfaces

- Upper – capitulum and trochlea of humerus - Lower – upper surface of head of radius with capitulum and trochlear notch

with ulna

(2) LIGAMENTS

(a) Capsule- Superiorly – attached to lower end of humerus [trochlea, radial fossae, coronoid fosas, olecranon fossae are intra capsular]

- Inferiorly – medially attached to margin of trochlea an laterally attached to annular ligament of superior radioulnar joint.

(b) Anterior and posterior ligament - They are thickening of the capsule

(c) Ulnar collateral ligament - It is a triangular ligament with the apex attached to the medial epicondyle of humerus

and base of ulna It has an anterior and posterior bands attached to conoid process and to the

olecranon. The lower ends of thick 2 bands are joined by an oblique band This ligament is crossed by ulanar N

Radial collateral ligament It is a fan shaped ligament extending from later epicondyle to the annular

ligament.(3) RELATIONS

Anteriorly – brahialis, median N, brachial artery, tendon of biceps Posteriorly – triceps , anconeus Medially- ulnar N, flexor carpi ulnaris, common flexorsLaterally – supinator- extensor carpi radialis bravis, other extensors

(4) BLOOD SUPPLY- By anastomosis around elbow

(5)Nerve Supply- By radial N, ulnarN, median , musculocutaneous nerve

(6) MOVEMENTS-Flexion – brachialis, biceps, brachioradialis.- Extension – triceps, anconeus

(7)Carrying angle The extended forearm makes an angle of 163 with the arm. This angle is called the

carrying angle. It disappears in full flexion and during pronation The factors responsible for carryig angle are

(a) Medias flage of trochlea is 6mm deeper then lateral flage (b) sSuperior articular surface of conoid process of ulna is oblique.

(8) Applied Importance (a) There is dislocation of joint, usually there is posterior dislocation(b) Subluxation of head of radius lead to pulled elbow. Seen in childern when the forearm

is pulled in the pronated position

© Inner elbow – is produced due to abrupt pronation – lead to pain in the lateral epicondyle. This is dueto spasm of radial collateral ligament

(d) Students’ elbow- due to inflammation of base over the subcutaneous posterior surface of olcranon process AXILLARY NERVE

Ithas root value C5, 6 and supplies deltoid,It arises from posterior cord of brachial plexus.

(1) Surface marking It is marked by a horizontal line on deltoid 2cm above midpoint between tip of olecranon and the insertion of deltoid

(2) Course In lower part of axilla it lies behind 3rd part axillary artery and is related medially to median N and laterally to coracobrachialis

The nerve wind around lower border of subscapularis to enter quadrangular space and is accompanied by posterior circumflex humeral artery

Anterior branch – Accompanied by posteriors circumflex humeral and wind around the surgical neck and supply deltoid and skin over it Posterior branch- supply teres minor, posterior part of deltoid

- the nerve to teres minor – has a psuedoganglion.- It peirces deep fascia at lower part of posterior border of deltoid and it

contiues as lateral cutaneous N of arm(3) Branches

- Musclular – to deltoid and teres minors - Cutaneous – upper lateral cutaneous never of arm - Articular – to the shoulder joint – from the main trunk of axillary N- Vascular – gives sympathetic to the posterior circumflex humeral artery.

(4) Clinical Importance- Axillary N is damaged by dislocation of shoulder or by fracture of surgical

neck of humerus- It leads to paralysis of deltoid:And round contour of shoulders is lost and there

will be sensory loss over lower half of deltoid

ANTERIOR OF FOREARM AND HAND

_ Has 8 muscles (5 superficial ,5 deep)- 3 neeves – median ulnar, radial - 2 arteries – radial and ulnar

* The posteriors surface of medial epicondyle is crossed by ulnar nerve. Pressure on the nerve produce tickling sensations on medial side of hand

* The styloid process of radius projet 1cm lower than styloid process of ulna

(1)* Superficial muscles – all these muscles rave common flexor origin From lateral to medial

- Pronator teres, flexor crapi radialis, Palmaris longus, flexor digitorum superficialis flexor crapi ulnaris

Pronator teres – origin- humeral head – from medial epicondyle - ulnar head – from medial margin of coacoid process of ulna

Nerve supply is by median never [the median N lies b/w two heads of pronator teres]* All muscles are supplied by median nerve except flexor carpi ulnaris which is supplied by ulnar N

* Piriformis is a sesamoid bone on flexor carpi ulnaris. By the pissohamate ligament the pull of the muscle is transfered to hook of hamate.

* Flexor digitorum superficialis is also called sublimes. It divides into four tendons into medial 4 digits and attached to middle phalanx of these fingers .

(2) Deep Muscles of Forearm - Three muscles-flexor digitorum profundus, flexor pollices longus, pronator teres. The

flexor digitorum profoundus has its medial half supplied by ulnar nerve while lateral half is supplied by anterior interosseous nerve. The other 2 muscles are supplied by anterior interossous nerve

(3) Radial ArterySurface marking – (1) point in front of elbow at level of neck of radius medial to tendon

of biceps.(2) A point in crest b/w radius laterally and flexor carpi radialis medially

* Course in Fore Arm - Smaller branch and has a concave course. Then they leave the fore arm and go to the

anatomical snuff box.Relations – anteriorly- brachio radialis [upper part] in lower part of only skin and fascia

- posteriorly – biceps, supinator, pronator teres, radial origin of flexor digitorum superficialis and flexur pollices longus,pronator quadratus

- medially – upper 1/3rd – pronator teres, lower 2/3rd – flexor capi radialis - Laterally – brachio radialis, radial N.

Branches in forearm – Radial recurrent – anastomose with radial collateral artery - Muscular branches – to the muscles of forearm- Palmar carpal branch- ends in anatomosing with palmar carpel branch of ulnar

A- supply bancs of wrist bones- Superficial palmar branch- It gives the branch before leaving the forearm. It

supplies the thenar eminence and join with terminal branch of ulnar A- to complete superficial palmar arch

* Course and Relations in Arm It passes through anatomical snuff box to enter proximal end of 1st interosseous

space. Then passés between two heads of 1st dorsal interossi and then b/w two heads of adductor pollices and continues are deep palmar arch of palm.

Branches in dorsum of hand – to lateral side of dorsum of thumb- 1st dorsal metacarpal artery

Branches in palm- princeps pollices- divide into two and supply proximal phalanx. - Radialis indices – supply lateral side of index finger.

It continues as the deep palmar arch.* Applied Importance

Radial artery is used for radial pulsations in forearm. (4) ULNAR ARTERY

(1) Apoint in front of elbow at level of neck of redius

Surface marking: (2) junction b/w upper 1/3rd and lower 2/3rd of medial border of arm (3) Lateral to pissiform

Its upper 1/3rd is oblique, and lower 2/3rd is vertical.

Course and Relations

It is the largest terminal branch of brachial artery and runs in forearm and enters the arm superficial to flexor retenaculum.

Relations – lateral- flexor digitorum superficialis- medial – ulnar N, flexor carpi ulnaris - posterior – flexor digitorum profundus - anteriorly – pronator teres, flexor carpi ulnaris, palmaris longus, flexor

digitorum superficalis in lower part of artery it is superficial

Branches

(1) anterior and posterios ulnar reccurrent – important in anastomosis around elbow (2) common interosseous artery – arises below radial tuberosity and in the upper border of

interosseous membrane divide into anterior and posterior interosseous artery

(a) anterior interosseous artery It is the deepest artery in front of forearm. They accompany anterior interosseous

nerve. It descends on the surface of anterior interosseous membrane b/w flexor digitorum profundus and flexor pollices longus. It then peirces interosseous membrane at upper border of pronator quadratus to enter extensor compartment. It gives muscular branches to deep muscles of forearm and nutrient artereis to radius and ulna.

(b) posterior interosseous artery - supply medial muscles of forearm

(3) muscular branches – to medial muscles f forearm.(4) Palmar and dorsal carpal branches – takes part is anastomosis around wrist. The

palmar carpal branch is important in formation of palmer carpal arch.The dorsal carpal branch and in the dorsal carpal arch.

PALMAR ASPECT OF HAND AND WRIST

The skin of the palmar aspect is creased immobile and very thick The superficial fascia is of dense fibrous bands which bind skin to the palmar

aponeurosis and the superficial fascia devide fat into small compartments. It has a subcutaneous muscle- palmaris bravis

The deep fascia has flexor retenaculum, the palmar aponeurosis [in palm] and the fibrous flexor sheaths[in fingers].

(1) Flexor Retinaculum It is a strong fibrous band that bridges the anterior concavity of carpal bones and converts it into a carpal tunnel. Its suface is concaes upwards and lower.one is concave downwards

attachment – medially – to pissiform, hook of hamate - laterally – tubercle of scaphoid, crest of trapezium.

Structures superficial to flexor retinaculum Tendon of palmaris longus, palmar cutaneous branch of ulnar and median N,

ulnar vessels and ulnar nerve.[flexor carpi ulnaris is partly inserted to it]

Structures deep to flexor retinaculumFlexor digitorum superficialis, flexor digitorum profundus, flexor polices longus,

ulnar bursa, radial bursa.

Tendon of flexor carpi radialis lies b/w the retinaculum and its deep slip is in groove of trapezium.

(2) Palmar aponeurosis- It represent deep fascia of central part of arm.- It covers the superficial palmar arch, long flexor tendon,terminal part of

median N and superficial branch of ulnar N.- It is triangular in shape – Its apex blends with flexor retinaculum

Base- it divides into 4slips opposite the head of metacarpals of medial 4 digits. Each slip divides into two[the digital vessels and N go through this] and is continous with flexor fibrous sheath

-It is representing degenerated tendon of palmaris longus - Dupuytrine Syndrome – It is inflammation of ulanar side of palmar aponeurosis.

i e there is thickening and contraction of aponeurosis:So proximal and middle phalanx are flexed [distal phalanx is less affected]. Usally ring finger is involved.

(3) Superficial palmar archNormally it begins as terminal branch of ulnar A on the flexor retenaculum distal to pissiform. It crosses the hook of hamate and turns laterally deep to plamar aponeurosis to join one of the branches of radial A. The distal part of arch lies at the same level as distal border of the thenar eminanace when thumb is fully extended.

Branches – a palmar digital branches - most medial is proper palmar branch to medial side of little finger

- others are common palmar branches and they supply by dividing into two and supply radial 3 and ½ fingers.

- They form a rich anastomosis in pulp space and the nail bed

(4) INTRINSIC MUSCLES OF HAND - 20 in number.- adductor pollices bravis(by medianN)- flexor pollices bravis- “- opponens pollices- “ - form thenar eminence

- adductor pollices – arises by an oblique head and a transverse head supplied by deep banch of ulnar nerve.

- palmaris brevis suplied by deep branch of ulnar N - form hypothenar

n eminence- abductor digiti minimi- flexor digiti minimi- opponents digti minimi

- Lumbricals – 4 in number arising from tendon of flexor digitorum profudus

The 1st and 2nd are unipinnate and 3rd and 4th are bipinnate.

- They are inserted into basal digital expansion

1st and 2nd lumbricals are supplied by median nerve while 3rd and 4th by ulnar N - palmar interossi – 4 in number – they are adductors

there are no palmar interossi into middle finger.- Dorsal interossi – 4 in number – they are abductors – also supplied by ulnar

nerve * The palmar interossi are adductors and dorsal interossi are abductors of fingers.

Applied importance – paralysis of intrinsic muscles – lead to claw hand – i.e hyperextension of metacarpophalangeal joint and flxion of inter phalangeal joint.(5)DEEP PALMAR ARCH

It is formed as a direct continuation of radial artery and has a slight convexity to the fingers. It is competed by deep branch of of ulanar artery .It is marked by a horizontal line 4cm long just distal to hook of hamate It lies 1.2 cm proximal to superficial arch and acts as a 2nd communication b/w the radial and ulnar artery

Relations: It lies on proximal part of shaft of metacarpals and on interossi It lies under oblique head of adductor pollices, flexor tendon and lumbricals.

Branches- 3 palmar metacarpal artery – supply medial 4 metacarpels an termainate at

finger cleft joining common digital branch of superficial palmar arch

- 3 perforating artery – they pass through medial 3 interosseous space and. anastomose with dorsal metacarpel artery

- Recurrent branch- they arise along concavity of arch and supply carpal bones and end in plamar carpal branch.

BACK OF FORE ARM AND HAND

The olecranon process and 2 epicondyles of humerus forms an equilateral triangle when elbow is flexed at 90 degree. [ this gets changed when these are changed ].Styloid process of radius is 1.25 cm longer than that of ulna.

(1) Anatomical snuff box

Boundaries – anterior – tendon of abductor pollices longus , extensos pollices brevis.- Posterior – by tendon of extensor pollices longus - Roof – scaphoid and trapezium - Limited by – syloid process of radius

It has cephalic V and radial artery(2) Extensor Retinacula

Attachment – laterally- lower border of anterior part of radius- medially – by styloid process of ulna, triquetral, pissiform

Surface markingIt is marked by an oblique band directed downwards and medialy [2cm broad].Laterally- attached to radius and medially to pissiform, triquetral, styloid process

of ulna.

*The retinacula sends down septae which are attached to long ridges on posterios part of lower part of radius

(3) MUSCLES OF BACK OF FORE ARM

(1) Anconeus-Supplied by radial N. Th origin is from lateral epicondyle to and inserted to lateral aspect of olecranon process of ulna and upper 1/4th to posterior surface of ulna

(2) Brachio radialis- supplied by radial N (3) Extensor carpi radialis longus(4) Extensor carpi radialis brevis (5) Extensor digitorum- the tendon divides into 4 and it divide into 3 at proximal

phalanx. The two lateral slip is inserted to dorsal aspect of base of distal phalanx.(6) Extensor digiti minimi- supplied by posterior interosseous N.(7) Extensor carpi ulnaris(8) Supinator- origin- lateral epicondyle of humerus, radial collateral ligament,

annular ligament, supinator crest of ulna.- insertion – to upper 1/3rd of lateral surface of radius- nerve supply – by posterior interosseous N

(9) Abductors pollices longus

(10) Extensor pollices longus (11) Extensor pollices brevis(12) Extensor indices

Applied importance – paralysis of extensor muscles of forearm produce wrist drop [due to injury of radial N at level of origin of posterior interosseous nerve]

(4)DORSAL DIGITAL EXPANSION/EXTENSOR EXPANSION

They are a small triangular aponeurosis related to tendon of extensor digitorum.

* It has – covers the metacarpophalangeal joint- The tendon of extensor digitorum occupies contral part of it and is corperated

from meta carpo phalangeal joint by a bursae.* The postero lareral corners are joined by tendon of interossi and lumbricals – called wing tendons * The corners are attached to deep transveres metacarpel ligament * Near proximal interphalangeal joint, extensor tendon splits into 3. The central slip is attached to dorsum of middle phalanx the other 2 slips joins together and are inserted to dorsum of base of distal phalanx

(5) Posterior interosseous arteryIt is smaller terminal branch of common interosseous artery. It enters the back of forearm passing b/w oblque cord and upper margin of intersseous menbrane.They anastomose with anterior interosseous artery [as lower 1/4th of forearm is supplied by anterior artery.They also give interosseous recurrent artery – It is important in anastomosis on back of lateral epicondyle of humerus.

(5) Posterior Interosseous nerveBranch of radial N – [given with radial nerve]

FASCIAL SPACES OF HAND

They are potential space filled with fluid connective tissue

Fascial spaces in hand are – in palm – mid palmar, thenar space, radial bursa, digital synovial sheath, pulpspace of finger.

- in dorsum – dorsal subcutaneous space and dorsal sub aponeurotic space.- In lower end of forearm – space of parona.

* The palmar aponeurosis is attached laterally to anterior border of 1st metacarpel- called lateral septum and medially to medial end of anterior border 5th metacarpal.

* The space b/w medial and lateral septum is further divided by a septum into thenar space and a mid palmar space.

(1) Thenar space - the boundaries are medially – intermediate palmar septumlaterally- to lateral palmar septum anteriorly- lateral part of palmar aponeurosis , flexor tendon of index finger, flexor

polliceslongusposteriorly – transverse head of adductors pollices

(3) Mid palmar spaceLaterally – intermediate septumMedially – medial septumAnteriorly – flexor tendons of medial 3 fingers Posteriorly – fascia covering 3 medial metacarpel bones and intervening interosseous muscle.

* These spaces extend distally upto proximal crease.

When these space are filled with pus, this can lead to infection of lumbrical canal [lumbrical canals are fascial sheaths covering lumbricals] The thenar space is continuous with 1st lumbrical canal while mid palmar space is continuous with 2nd,3rd ,4th lumbrical canal.

(4) DIGITAL SYNOVIAL SHEATHS They are fascial sheaths covering the flexor tendon.

(4) Radial BursaThe synovial sheath covering flexor pollices longus when it passes through or to fibrous

canal.(5) Ulnar Bursa

The common synovial sheath of flexor digitorum superficialis and flexor digitorum profundus.Both radial and ulnar bursa decrease the friction under flexor retenaculum

(6) The dorsal spaces are dorsal; sub cutaneous space and dorsal sub aponeurotic space. Infections of the dorsal spaces are uncommon

(7) Forearm space of ParomaIt is a rectangular space related deep to lower part of forearm and just above the wrist It lies in front of the pronator quadratus and deep to long flexor tendons.

Superiorly – It extend up to oblique origin of flexor digitorum superficialis.Inferiorly – It exterend up to flexor retenaculm and communicate with mid palmar and

thenar space It may also infected by infections of ulnar bursae.

(8) PULP SPACE- Found in each finger and is filed with fat and they are seperated by fibrous septae

attached to periosteum of terminal pnalanges.- Blood supply – to distal phalanx pass through this: If there is infecteion then there will

be necrosis as blood supply to distal phalanx is affected - Inection of pulp space – whitlow / felom.

RADIAL NERVE

The root value is C 4,5,6,7,8,T1 and is the largest branch of brachial plexus arising from the posterior cord.

Course of the nerve and its branches

(1) In Axilla It lies behind the axillary artey in the axilla then passes through lower triangular space

and is accommpanied by profunda brachi artery.

Branches – to long head of triceps, medial head of triceps, posterior cutaneous N of arm.

(2) In the ArmIt enters the arm on the spiral groove [b/w lateral and medial head of triceps] and goes

from medial to the lateral side. Then it peirces lateral intermuscular septum and enters the anterior compartment of arm and it lies between brachialis medially and extesor carpi adialis longus laterally. Then they descend down and at the level of lateral epicondyle it divides into superficial and deep branches.

* Branches – in spiral goove – to lateral and medial head of triceps, to anconeus, to elbow joint.

cutaneous – it is lower lateral cutaneous N of forearm and posterior cuaneous N of forearm .* Branches that occur when it lies b/w brachialis – to lateral part of brachealis [ sensory]

- to brachioradialis and extensor carpi radialis longus.

(3) The superficial branch- It is purely sensory.

It passes antrior to pronator teres and behind brachio radialis. In middle of forearm it lies lateral to radial artery. About 7cm from the wrist joint it curves laterally and it gives 5 digital banches- 3 propers and 2 common.

* 1 proper to radial part of thumb, other to ulnar side of thumb, 3rd to radial side of index finger.*common digital branches – divide into 2 and supply adjacent side of index and middle fingers and others to adjacent side of middle and ring fingers.

These nerve supply upto root of nail in thumb up is middle of middle phalanx in index finger and 1st inter phalangeal joint of middle and ring finger.

(4) Deep branch / Posterior Interosseous Nerve - It passes through supinator muscle [b/w superficial and deep strita of the muscles] after

peircing the supinor, the branch is called posterior interosseous nerve then it lies b/w superficial and deep extensors of the forearm. At lower end of forearm the nerve passes deep to extensor pollices longus and it is associated with posterior interosseous artery. In wrist it forms a psuedoganglion

Branches - before peircing supinator – to supinator, extensor carpi radialis brevis

- while peircing – to supinator- after that- 3 short banches – to extensor carpi ulnaris, extensor digiti minimi,

extensor digitorum 2 long branches – medial – to extensor indices, extensor

pollices longus lateral – to abdutor polliceslongus , and extensor pollices brevis

- From pseudo ganglia – to wrist joint, inferior radio ulnar joint and inter carpel joints

(5) Applied ImportanceWrist drop – If the radial N injured in spiral groove [ extensor of arm are spared

while that of fore arm are affected] lead to wrist drop. Not able to extend the wrist.Crutch palsy – due to improper fitting of crutch. This will damage the posterior

cord of brachial plexus.

MEDIAN NERVE

The root value is C5- T1

Course and Branches

(1) In Axilla and Arm

In axilla it is formed by 2 roots lateral, from the lateral cored ,and medial root, from the medial cord.First it lies lateral to the artery. In the arm upto the middle it is lateral to axillary artery while in the lower part it crosses the artery in front and goes to the medial side of axillary artery .

Branches – muscular – to pronater teres – in lower part of arm - vascular – to the brachial artery

(2) In forearm * It passes through cubital fossa b/w 2 heads of pronater teres and then passes deep to

fibrous arch of flexor digtiorum supeficialis. Then lies deep to palmaris longus and enter the palm under flexor retinaculum.

Branches – In cubital fossa- muscular – flexor carpi radialis, flexor digitorum superficialis, palmaris longus.

- - articular – to elbow

- in the forearm- muscular – anterior interosseous nerve – that supply lateral half of flexor degitorum profundus, superficalis, and flexor pollices longus

- cutaneous – to lateral 2/3rd of palm.

(3) In the palmIn palm median N lies medial to muscles of thenar eminence. It also gives

cutaneous branch to lateral 3 and ½ finger, their nail beds and skin of distal phalanges on dorsum.

Branches – muscular – abductos pollices brevis, flexor pollices brevis, opponens pollices and 1st two lunbricals.

- Cutaneous – 2 digital branches to thumb and to lateral side of index finger.- 2 common branches to adjacent sides of middles and ring finger and to adjacent sides of index and middle fingers

Applied Importance

(1) Carpel Tunnel Syndrome – due to dislocation of lunate.- Frutcues are flattening of thenar eminence [ ape like hand ], loss of sensation

of lateral 3 and ½ finger., partial clawing of index and ring finger. There is oedema pigmentation of nail, dryness of skin.

(2) If injury occurs above the elbow – the forearm muscles also affected (3) Median N – Responsible for gross movements of finger.So median nerve is called

labourer’s nerve

ULNAR NERVE

THE ROOT VALUE IS

COURSE AND BRANCHES

(1) In Axilla and Arm In axilla it lies b/w axillaty vein and axillary artery in a deeper plane.

In arm it runs along with brachial artery. In the middle of humerus it peircescls medial inter muscular septum. On the back of medial epicondyle it can be palpated.

(2) In the Forearm They enter forearm b/w 2 heads of flexor carpiulnaris. Then it lies on medial part

of flexor digitorum profundus. It is accompanied by ulnar artery in lower 2/3rd. Then it peirces through medial part of flexor retinaculum [above it] and enter the arm. At distal border of retinaculum the nerve splits in to superficial and deep branches

Branches – muscular – medial half of flexor digitorum profundus and flexor carpi ulnaris - cutaneous – dorsal cutaneous branch – to medial half of hand.- palmar cutaneous branch- to medial 1/3rd of palm.

Digital branches to medial 1 and ½ finger- Articular – to digital vessels and joints of medial side of hand

(3) In the Parm The sperficial branch supply palmaris longus and digital branch to medial 1 and ½ figers Deep branch – to the intrinsic muscles.

Since it supply intrinsic muscles of hand – it is called musicious nerve

Clinical ImportanceThe nerve is most commonly injured in the wrist and it leads to motor loss to

muscles of arm and sensory loss in medial 1 and ½ finger including nail bed and dorsum of distal phalanges

Vascular changes – lead to oedema, dryness of skin, friable nails.Trophic changes – loss of hypothenar eminence, guttering b/w metacarpals It leads to partial claw hand [however of ulnar N and median nerve injured, it leads to complete claw hand ]

* If ulnar N is injured below the elbow clawing of finger is less as medial half of flexor digitorum profundus are also paralysed. So that lead to action of paradax.

CUTANEOUS SUPPLY AND DERMATOMES

SUPERFICAL VEINS

Most of superficial veins join to 2 large veins cephalic[preaxial V ] and basillic V [ postaxially]

The superficial veins move away from pressure points The preaxial vein is longers than the postaxial vein. The earlier a vein becomes deep

the better, because it helps in assisting venous retun by muscular compression.

Dorsal Venous Arch

- Lies in the dorsum of hand- The afferents are – dorsal digital vein, 3 dorsal metacatpal vein, dorsal digital

vein, 2 dorsal digital veins and most of veins from palm by passing through interosseous space.

- Efferents – Basillic vein and cephalic V.

Cephalic Vein

- It is the preaxial vein of upper limb and begins from lateral end dorsum of arch

- It runs through roof of anatomical snuff box - It then winds around lateral border of distal part of forearm.- It then continues upward in front of elbow and along lateral border of biceps - It peirces deep fascia at lower of pectoralis major

- It runs in delto pectoral groove then peirce clavipectoral fascia to join axillary V

* A great part of blood from cephalic V is carried to basillic V by median cubital vein and also to the deep veins by the perforator - It is accompanied by terminal part of radial N, lateral cutaneous N of forearm.

BASILLIC VEIN

- It is postaxial vein of upper limb – it is analogous to short saphenous V of leg - It begins at medial end of dorsal venous arch- It runs along back of medial border of forearm then winds around medial

border of elbow and upto front of medial epicondyle upto middle of arm. Then it peirces deep fascia. Then it runs along medial side of brachial A upto lower border of tere major to form axillary vein

- About 2.5 cm above medial epicondyle it is joined by medial cubital vein- It is accompanied by postrior branch of medial cutaneous N of forearm

MEDIAN CUBITAL VEIN - It shunts blood from cephalic vein to the basillic V.- It starts 2.5 cm below elbow below cephalic vein and runs obliquely upwards

and medialy and eds in basillic V, 2.5 cm above medial epicondyle.- It is seperated from brachial artery – by bicipital aponeurosis- It may reverse tributaries from front of forearm.- It is connected to deep vein via perforator veins that peirces bicepital

aponeurosis. It flexes the veine and : makes it sutable for I.V ingections.

THE MEDIAN VEIN OF FOREARM

It begins as a palmar venous network and ascends in one of the veins in front of elbow and ends in medial cubital V. It may sometimes divides into two and each of them enters basillic and cephalic vein, replacing medial cubital vein

APPLIED IMPORTANCE

(1) Median cubital vein – used in .IV ingections, withdrawing blood. It is fixed by perforator. They dont slip out during the procedure.

(2) The cephalic V – usually comminicates with external jugular veins by means of a small vein in front of the clavicle. In breast removal the axillary V may be removed. In such cases they acts as an alternate pathway.

LYMPH DRAINAGE

Lymph is formed from tissue fluid at capillaries

(1) Lymph Nodes(a) Infraclavicular – in the clavipectoral fascia along with cephalic vein

(b) Deltopectoral nodes – in the deltopectoral groove – along with cephalic V.

(c) Superficial cubital/supra trochlear – above the medial epicondyle along ulnar V.(d) There are also deep nodes alongs with medial side of brachial A, also along birfucation of brachial artery and arteries of foramen.

(2) Superficial veins - More numerous than deep.

(a) Medial side of forearm – goes to superficial – axillary lymph nodes.by lymphatics from cubital nodes.

(b) lymphatics from lateral side of forearm - to deltopectoral/ infra.

clavicular groove. - axillary lymph nodes

(c) The dense palmar plexus mainly drain into lymph vessels on the dorsum of arm. The lymph vessels of back of forearm curve around the medial and lateral floor to reach the axilla.

(3) Deep lymphatics- They are less numerous. They drain structures deep to deep fascia.- They ran along main blood vessels of limb and end in axillary nodes.

(4) Applied Importance(1) Inflammation of lymph vesels – is called lymphangitis – here skin is red with tendor

streaks (2) Inflamation of lymph nodes – called lymphadenitis – here nodes are palpable (3) Accumulation of lymph may occur due to obstruction of lymph vessels.

HISTOLOGY

MAMMARY GLAND – It is a tubulo alveolar gland The gland has – a cover – capsule

- A glandular tissue – parenchyma- imp in secretion - Fibrous part – has fat – stroma

Glandular tissue - Made of 15-20 pyramidal lobes each with seperate duct - The alveolar epithelium – cuboidal – in resting place

- columnar – during lactation, ducts streching

- Epithelium of duct of – small duct – of columanar epithelium - large- of two or more layers

- terminal part – made of stratified squamous keratinised epithelium.

- Myoepitheliocytes are cells in alveoli and ducts b/w the epithelium and basement membrane that fascilitates the passage of milk from alveoli to nipple.

Fibrous Tissue- It supports the lobes and is uniformly distributed

Suspensory ligament of coopes – are fibous septa that anchor the skin and gland to the pectoral fascia

- Dimples may be seen over the skin due to fixation to pectoralis major.

(1) MAMMARY GLAND INACTIVE

Identifying features – Tubulo allveolar gland with connective tussue storma- Glandular elements are minimum and are seen as

tubules resembling duct lined by cuboid epithelium.

(2) MAMMARY GLAND - ACTIVE

Identifying features – Tubulo alveolar gland with connective tissue stroma- Glandular tissue predominates with distended alveoli lined by

cuboidal cells and filled with milk secretion.

BRAIN

SPINAL CORD

They extend from foramen magnum to L1, and ocupies upper 2/3rd of vertebral coloumn.It has a conical end – called conus medularis, below it is cauda equina [having lumbar sacral and coccygeal N]. From the conus medularis there is a fine filament extending upto C1- called filum terminale.

*Spinal cord extends – upto S2 in fetus while only upto L1, in adult [due to difference in growth b/w spinal cord and vertebral coloumn] .It is about 43-45cm long and 30gm in weight and has two swellings. (a) Cervical swelling [from foramen magnum to T1- to accommodate more motor neurons for Brachial plexus] and (b)lumbar enlargement [from T10- T12- opposite lumbar plexus]

* Spinal Cord – has 31 paris of spinal nerves – 8 cervical, 12 thoracic, 52 lumbar, 5 sacral, 1 lumbar.

* (a) Coverings of spinal cord Has duramatter, arachnoid matter and piamatter .

(1) Duramatter – from foramen magnum to S2. Cranially it is continous with inner layer of cranial duramatter while lower part ends as blind tube.

(2) Epidural space – lies b/w periosteum and duramater. It has liquid fat, loose areolar tissue internal vertical venous plexus of vein.

(3) Arachnoid matter- made of delicate areolar tissue. They extend from foramen magnum to S2

b/w them and piamathes is subarachnoid space – has CSF

(4) Piamatter – it is closely inveted to spinal cord. It is avascular membrane – it gives sheath to spinal N to blood vessels.

*(B) 3 Modification of piamatter

(a) Anteroir median fissure – has a glezing patch called lina spendins(b) On either side, there are tooth like process – ligamentum denteculatum [ 21 pairs](c) Filum terminale – is about 20cm and is a fine filament extending to C1. It has two

parts- Filum terminale intimum – about 15cm – extend upto S2 – it lies inside dural

tubes- Filum terminale externum – about 5cm – extend upto coccyx.

*[c] Terminal ventricle - It is a small cavity at lower end of spinal cord at region of conus medularis. It is

continous to that of central canal.[d] SPINAL SEGMENTS

It is the part / segment of spinal cord that gives attachment of spinal nerve. There are 31 pairs of spinal segment but they don’t correspond to that of vertebral segments

[a] Cervical vertebrae-corresponding spinal segments are got by adding 1.[b] Upper thoracic - corresponding spinal segments are got by adding 2.[c] T7-T9 - corresponding spinal segments are got by adding 3.[d]T10- has L1 L2 spinal segments [e] T11 vertebrae- L3, L4 spinal segment[f] T12 – L5 spinal segment[G] L1 – sacral and cocygeal segment.

[E] BLOOD SUPPLY OF SPINAL CORD

- There are one anterior spinal artery and two posterior spinal arteries [ arise from 4th part of vertebral A]

- There are also feeder / radicular arteries.- The main feeder arteries are.[a] Spinal branch from 2nd part of vertebral A[b] Deep cervical branches of costo cervical artery [c] Ascending cervical branch of inferior thyroid artery [d] Posterior intercostal artery [e] Lumbar and sacral artery

Anterior Spinal Arteris – are two in number [they arise from 4th part of vertebral artery]. But soon join to form and descend in antero median fissure. They give two sets of branches – central [to substance of spinal cord] and vasoloina. Posterior Spinal Arteries – Two in number and each of them divide into 2 and they descend on each side one on front of dorsal root while other benind the dorsal root.

Radicular arteries – after entering the vertebral canal they divide into anterior and porterior branches and anastomoss with spinal A.Two of the Radicular arteries are big Arteria Radicularis Magna / artery of Adam kicury – largest radicular arteries.

[F] VENOUS DRAINAGE

It is by 6 tortus venous channels - i.e in anteromedian fissure, postersomedian sulcus, behind the lateral nerve

root [ antero lateral venous channel],1 passes behind dorsal nerve root [ postero lateral venous channel].

- They drain into cerebellar veins , coronal venous sinuses, internal vertebral venous plexus etc

Applied Importance(a) Lumbar puncture – b/w L3 and L4

- The structures peirced are skin, supuficial fascia, supra spinous, inter spinous ligaments, ligamentum flava, dura and arachnoid matter

(b) Epidural Anesthesia – Anesthesia into the epidural space – to prevent pain – done in child births

(c) Myclography – Here a contrast medium is ingected into subarachnoid space to visualise spinal cord.

(d) Lumbar / sacral disc prolapse – lead to a shooting pain in the spinal cord.

MEDULLA OBLONGATA

It lies b/w pons and spinal cord. It is piriform in shape.* Antero median fissures and postero lateral sulcus divide medulla into 2 halves.* Anterolateral sulcus – It gives origin to the rootlets of hypoglossal nerve.* Postero lateral sulcus – b/w posteriosr and lateral surface. It forms floor of 4th ventricle.[1] Pyramid

* B/w anterolateral sulcus and anteromedian sulcus is pyramid. The pyramids are more prominent where medulla comes near the pons. Lower down the medulla there is decussation of the pyramids

The pyramids – has corticospinal, corticobulbar and corticonuclear fibres.* Corticobulbar fibres – has fibres to reach the cerebellum via the inferior

cerebellar pedicle.* Corticonuclear fibres – has fibres for the motor nuclei of the opposites side

[2] Inferior Olfactory Nucleus - Has 3 compnents in tivary nuclear complex – medial olfactory nucleus / accessory

nucleus- seen medial to principal nucleus.- Principal nucleus – has appearence of

cunated bag. - Dorsal accesay nudras – sen darsal to

princcpalncders.

[3] raulr and cunrats juberde- made of graule and cunrate nulus . found in fliur of 4th ventride

*gaule hudeus – sun more medially – cary sensatios from lowuts ank ard lower umb. White

[4] juberculum uner iam * lernate nuclios – sun more lateratey – carey censation from apper limb and upper trunak

- sun b/w – fasciculas cahratus and postro laterial suleus.- it is formed by spinal tract and nucles of lfigrminal [it is a gude line for. Newiosugon to truect the trigeminal nudei in jrigiminal neveroglia]

SECTIONS OF MEDULLS

[A] AT pyuamidal decussation same features are

(1) pyeamidal dcussation is sun.(2) spinal nudeus of lrigeminal- exterlupto C2(3) part of gery malter is also sun .- vental nuclrus.- Lateral nwerous – they extend upto C5 and give to spinal accerssorey nerve (4) spinal cort – they are fiberes arering from uncpolas the geminal ganglion in

the merkils core / covum lrigiminets. They rates in has spinal ncrcees. They curey censations of pressues, vibration, propecoaption from ipsclateral side of face. The 2nd ordes newion from spinal nulees from the spinal tract

(5) posterios coloumn fibers are also seen.

[b] seclion at the leves of sensory decussation

the main featues seen are.(1) lental grey malter is more dosal.(2) Decussating internal arcuats fibrus are seen(3) Guymaltes – has nypogloosal nucleus – in the hypogtosal tiongle

- has dorsal nucles of vargas – has pre gang gang lionic para sympalthetis fibus for heart, be I system, roporatory tsact.

(4) nuclrues of lractus sout arius - reueve affeve fibess from hypoglossal nerve, veger and fased nerves is the

qurtalaony imputes - they then crose to oppoocts side and asand up and ten felary in the untial

posteromedion nuibus of thalomas.

[c] sidtion at lwel of olivary nudeus

the featural sen are

[1] it can be divided into 3 zones – medialzone – haspurameid, arivate nudeeus, the to spinal lract

- inter mediate part – has dorsal nudsus of vasus and inferios olivary nudew

- latial part – has inferios cubellas prduncje.[2] naderas ambiqas is also seen – daesloateral to dresal nudrus of vagus

they give rob to brachio motos fibes from glarso

PONS

Means bridge – les between midbian and medulla – it is about 2.5 cm long.

It has 2 surfaces – dorsal and vental.

Venteral surface- is rclatd to dius of the skull. It is repuated from divw of the skull by basillas

artery. It is convex and has transvase fobres that join to form middle uebellar pedanch – to enter the urbellum

dorsal sueface- those is a medan eminence and is limitrd by sulus limitants - uppes part of sulcar limitas is locvs covsubus. It has pigmented neuro – that

from the substantra fourigina.- In loes limit of salcus limitos is superios foves.- There is also fusual colliculus – produce due to the undulying abducent

nevron and the finers of fasual nerve around at - The lrigeminal narare from the dorsal swface.

[a] section theough lower part In the uentral part there are trans veres fibers arising from pontene nudeus pontere nueeus vertial fibue of certico sponal, cortrio nudras and lorteio bulbar fibus there are also there is also cocleas and veste bular nudei There is also centeral leqment tract.

[b] Section theough uppes part of pons The tectal part is conte nuation of medulla behind pyram ide.

There is also main sensry nudevs and motos nudeus of thigeminal nudious.There are also superios olivary nudrus.

* the parh of fasual nerve to the ligeminal nudeus it [ going of a motos nuer on to asinery nudel] is called beuso bioptar is

applred jmport ance

[1] poralys is of cortrco spinal bart and abdunt N – lead to ;ternating abducen demilegle or the reymonds syndrome[2] paralysar of lartrco spinal ract and 7th nerve – alter nating 7 ascal /lemoplega called millard biadas syndrome.

MIDBRAIN

- CORECTS THE hind brain to the fore brain- It has a cavty the ceubial aqueduct – that connets the 3rd and 4th ventridw.

Midbrain is related – arterio by to optce, posterios curtail astery, basal vein, frochlas nudsw

- posteriorly – reated to splrnium of cuplus callbiorum , greatcudal V, pinealbody

Subdivisions

[1] lectum – part of brain posterios the aguedut.[2] peduncs – is part of midbrain that kis anterios to the agueduct.

It is dveded into – crues cuebri- substabta niagia.- Jegnebtum.

The mnedial and lateral genicylate body are seen poatero lateral to midbrain the superios colliuli is connedrd to lateral beniculatera body by superios brachium. While inferios colliule is conneeted to medial geniculate body by inferios brachiam.

[a] section of mid brain at level of inferios collicule

The features are.[1] The peri ague ductal gurymlthes has nudeus of leochlear nudei and mesen uphalie nudei of tregminal – [seen lateral]

The mesen aphake nucleue caery propriouptive im pulser from murder of mastication and also from fasual, occulas mundes etc.

[2] Inferios colliculus – they reueve affvernts from lateral lemnerous.- The effrch is go ts medial genculats body.

* Impoetant in localesing sound.[3] Substantia niaga – has part – part rete eulares

- Pase compacto

[4] Crus curebei – has pyramidal traet in middle 2/3rd - Fronto pontrne fiues – in medial 1/6th .

[b] SECTION AT LEVEL OF SUPERIOR COLLICULI

IT HAS

(1) occulomotir nudeus – of both sides fured in median plane (2) mesen cephloie nudrus of lrigeminal(3) Superion collocalus – recever at ferents from etina.

- Efferents – govia tecta spinal to art – they are imperiont in controlling reflexes of eyes head and nck.

(4) preteatal nudeus – seen derp to superolateral part of su[erior collecul;us - it reuveve affentes frmopte tract - it qives efferent to edinges wetpal nudeus- it is mposion in light reflexes

(5) Red nuibwe - is bout. 5 cm in dranetes

- it reicues affuent fromet from – superios serebellar prdunfhs, globus pallidles, sub thalamia nulues and laretex

- it gives efferent to – retealar formation, thalamis, olivary nudias

Applied importamcy

[1] Lusion of the pretectal nudeus leads to Argyll Robertson pal. Pere aciomadation reflex is present but lefht reflex is abent

CEREBELLUM

IT IS THE BIGGEST part of bibd broin, found in the posteios cronal fosa jenroicm ceuebelli and theoccpital Labe of erebeum. Its werget is about 150g.

It lonsists of 2 hemesphus conectrd by vermis

Cerbellu mhas – superios sior sioface – there is no seperaltion b/w 2 hemisphous- Inferios supfoes – thouse is a gulles seperatering 2 hemisphees called

vallecuar.- Anterios serface – it has a ndeh – anterion webe llas batch.- P [ostion surface – has anotch – posterios werbillar notch.

80% of gerymaltes is bued and fromea leaf like stuctues- aebower vctar [jure of life]

*there are fissiore [to nsveroues] that divides cerebellum into lober

[1] Half and fessue – fram the middle uebellas pedande of 1 side to the opposite side

[2] Fissure 1- b/w anterm 2/3rd and post 1/3rd in the superios suface. They divide b/w anterios and posterios lober.

* There is also a flocculo nodulas lobe that is seperaterd by the postero lateral fessere. And foramen of lushks is foond in midlies of glocculon nodular lobe

[1] MORPHOLOGICAC CASSIFICATION

It is divided into 10 from 1-10

[2] PHYLOGENITIC CLASSITICATIONInts 3.

[a] achco cerebellum- linqeulla + flocculonodular lobe- Also called arrest bulo cerbellom. It is comerned with posture of the

body, muxle tone etc

[b] Paleo cerebellum – spino ceribellam - Anterios lobe exept liguila and + ulvula.- Important in esios correction, danping, fine movements etc

[c] Neo cuebellum – Postioios lobe – [pyamis and uvula]

- they are important in controlling cooecdrtid volunaery movements

[3] FUNCTION CLASSIFICATIONIT IS CLASIFED into 3

[a] vermis – has fastrgeal nadesus. It recoves fibue of vestrbulo spinal and rete culo spinal tract - It is conesned with movements of true murdes and murde tone

[b] Para median lobe – has nuclevs brlotaus and imbue form it rewes fibes from rubio spinal tract

[c] Latrial zone – has dentate nudlus Redeues fibies from losteco spinal, rubiospinal tract and also it also is connectrd

with dentate loetecal path way

[4] Nucceus of cerebeuum From lateral to medial – denate, embolfrom, bobosin, fastegal.

[5] Type of fibres- Mainly 5 types - Afferent - Assouation fibes- Progection fibres- Commissural fibres- Efferent fibues – may be mossy fibre- goes to the ronular layes

- Elimbing fibres – gers to the moleculas layes. They relay in to the parkinge ulls.

[6] CEREBELLAR PEDUNCCES [A] Infrioc curebellas prdvndes

[1] Affevent – posterios spinocerbellar, cunrofellar, anterios external aruate vestebulo curbllar, devcrbellar pouaolivcurbellar and reticular fibies

[2] Efferent – cerbello vertebular, cerbello olivary, cueellopind, ceubello retrcular

[b] Middle eubellar peduncles [1] Afferent – ponto reebellar;

[2] There are no efferent febees

[c] Saferios cuebellar pedunacle

[1] Afferent – anterso spino cuebellas, fecto urebellor, trigemino urebella ltypo thalamocerbllos, rulro wrebllar

[2] Effluent – asending- dentate thalamic / dentato rubral- Drscending – cucbeello reticular, urebeltonulear, lerebello

thalamio

[7]BLOOD SUPPLYSupeios surface – superios lerebellas, artery,Inferios surefore – anterios part – antrious inforeios rubellas artery

- poseruos part – posterior inferios cuebellas artery

[8] Relations of cerebellumAnterioly – relatiad to 4th enterdleDnsally – relatrd to superios suqital sinus, occipital sinus and occipital

protubuernaInfaialy – formen maqnum.

CERE BRUM

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

Corpower calbworm.The surfaus of cerbian are superolatial serface, inferios, and medial sufaus.

The bordus of brach are supero medial, infero medial and fefirolateral The poles of brain – are frontal, pauetal, tempoial, and occipital poles.

(1) SULCI AND GYRI OF BRAINTotal surface of bram – 2200cm2. Upto 3rd month of into wterine life there are nosulic

By 4th month – laral sulers develops. By 8th month all sulci are developrd.

[1] Types of sulci(1) Limiting – they separate 2 functrunal and structural are as – eg: centralsulers (2) Axial – eg: posterios part of calcarins crleus

(3) opercutatral- eg: lunate sulues – separate peri and parastriate cortex(4) Complete – they cuale eluation in ventrides eg: collateral Sulu and anterios

part of calcaine sulcus.

They may also be classifud as – 1- they develop infepndently- 2- they develop as deffuent parts and then unite

(3) lateral sulcvs / fissure of silvius

Theis sulurs comes from the inferior suface [neas the antherios perforted substance] and it is called the stem.

At the siluran posert – they divide into – anterios ascending rami - Anterios hoizondal rami- Posterios rami

Surface marking

[1] Pterion [2] 2cm above parlital prominence [3] 2cm above perion [4] 4cm in front of pbrion

Lonnecting [1] and [2] – we get pasterios ramiConncting [1] and [3] – we get anterion usending ramiConnecting [1] and [4] – we get antrios hodfondal rami

(3) Central sulcussurface marking [1] 1.5cm posterios to midpoint of line joining nerion and external

occeprtal prohunues a line joining [1] and going down that makes an angls of 70 with median sagrtal lone and about 8-10cm long.

(4) Parcet occipital sulci- They sepuata palatal and ocupetal lobes.

(2) LOBES OF THE BRAIN

By extrnding the parcr to occipital sulcus to the pre occipital notch and by extrnding latral sulcrs into parei to occipital sulcus and also by extrnding untral sulcus into the posterios ramus of untrol sulcus.By using there the brain is divided in 4 lobes – frontal, trmoral, parutal and occipital

[a] sulci and gyui of frontal lobeBy superios and inferios fiontal sulcus the frontal lobe is divided into superios middle and

inferios frontal gyri.There is also pre cebtral suleus.

And also by anterios ascending and anterios hosszondal rami, there is also pars oibitals, pars triangularis and pous opercularis.

[b] Sulci and lyyri of temoral lobeBy superios and inferios trmporalsuleus it is divided into superios middle and inferios

jemporal gyrus.

[c] Sulci and lypri of paeretol lobe There is an into paerutal suleus that aiviole it into superios and inferioi parietal lobule.

There is also a part central sulcus and anterios to is is post untral geyri lateral, superios and inferios trmparal sulcus also enter the parertal lobe to from supra marginal, angular and inferios gyrus.

[d] Occipital lobe * By lateral occepetal suleus – it is divrded into superios and inferioi occipital gyrus

There is also a lunate sulcus and inferios polas sulcus.

(3) INSULA / ISLAND OF REILIt is a submerged pyramidal corter setuatrd in the stem and posterios rames of the lateral

sulues. It is cloaid by the over gto with of temporal, parcetal and friontal lobes. A urcular sulus seperatrs insula from opercula. There is a central sulcus that it claustrum, external capsulr, lentr from nudeus.

[e] Sulci and gyri of inferios surfau- Offactoiy bulb lies in the alfaclory sulcur [medral to it is gyrus rectus] there is on H

shaped orbital sulurs – that divede into medral, lateral, anterios and posterios orbital sulures.

- In lentorial sufoce there is calcarine suleur. Limiouly to there is collateral sulues and anterios to it is rhenal sulcus- Medral to them is uncvs [antrioily], para hyopo campal gyrvs [Mors posterioily] and lingual gyrus [sren more posterioly].

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

(4) FUNCTIONAL AREAS OF BRAIN

- BY strmulation/ ablation studers, broad man found out 52 different aeras compel found out 20 areas, eiond 105 areas while vozifoundout 20 of unctronl areas

- The fernitronal areas of brainmarle – sensory – mainly 5 areas – auditory, offertry, vision, farte, toaeh

- Motos- Samas the/ assouation

- The functraonal areas may be stract corally – biranular, agranular and striate catrx.

Homunculus- represent the body of man in brain - The are a of representation of each area depends on the fornction. It may be

motos homunculus and ansory honenculos.- In sensory homenulus the area of represntaion depends on the no of reuplies

while in mostos homunculus it depends on function.

Main functronal areas of brain

1 motos areas = [area4] – it conscts of pre cntral gyrus and parantral lobale. The contral the volubtary munclrs

1 re mitis areas – [area band8] – gives argin to cortrconudeas, coeticobulbas and cortco spinal fibers

1 sens oty areas – [area 3, 1, 2] – granulas cortex – in the post central sulcvs. It helps to locales anayse modalrtes of cut aneoan and pro priooptive sensy

Som as thetrc arsouation area [area 5, 7] - important in perception and recugnison of grnual censes

Pre frontal area [area 9, 10, 11, 12] – important in deph of fuling, sensation jundgement hinking fore sight, tactfulners – called silent area of brain

1 visual area [area 17] – in posterios part of calcarine sulues. It is gtanula. The outer band of baillartger is prominent. It fores strias of gennari that redeves vesual infor mation.

Visual assouation area – area 18, 19, - oara abd peristrate area imprt art in recignision of obruts by relating to part experienues

1 audetary area – [area 41, 42] – rcuves 1 audrtoig imputses.Aundutioy assouation area – sren around 1 audrtoiyarea

Vernceks speech area – rnsion speech area.

(5) WHITE MATTER OF BRAIN

- THE white malter corests of 3 tpes of fiber, assouation fibres, commissual febeus, and proyction fibres.

[1] Assouation fibus – connect areas with in lobe.May be shart or long. The shart assouation fibrs are numerus.

The long assoualtion fion fibus are .

Undnate – goes from the frontal lobe to the te mopral lobe. It connects the speech area to auditoryarea.

Fronto occipital. Superios longitudinal boodle – most import – connects frontal to occipital lvbe Inferios longitudinal bundle – from occipital to the trmporal lobe. Cinguvs – seen deep to ungula to gyrus

[2] Commissural fibus – connect the right and liftlobes.

Anterios commissure – connict the 2 lobes.It has an – anterios bundle – reach artrios perforatrd sublance

- Posterios bundle* Posterios pommissuer – coonect superios colliculi to edrnges west pal nuclevs * Habenular commis – connrct the habenular nulei* Eoptrc cheasma.* Corpus calliusm

It is the largeust commissure of the brain. it connrcts all areas of the brain expt the anterios part of trmporal lobe.

Parts- have a genu, rostrum, splenium, and trunk.

[1] Genu – relaterd anterioly to anterios cubral artery and posteriosly to antrios hoen of lateral brin.

[2] Rostram – it ends in lame terminalis. It conncet the arbetal surface of 2 frontal lobes

[3] Lrank – lus b/w splenium and genu. Its superios suface is convex [before back wardes] and inferios surface.

[4] Splenium – it is the posterios most part and theikest the inferios surface is arlated to trlachoiodrae of 3rd ventride

It is superiorly relatrd to lnferios agitalsinus, and falx uerbi postrioly it is elated to great curbral V, straghtsinus, trndorium wernells.

* The fibers in corpue callousm areRos trum – connect arital part of frontal lobes Forups minor – connect fronto lateral lobes – corresponds to fibers of gena.

[Sren anteriorly]Forups mayor – connect occipitallobes- corresponds to fibres of cplenium.Japetum – connect the parital lobes – corresponds to fibres of trunk.

(3) PROJECTION FIBRESThey Aries from rebial cortex. The Fon out as coiona nadeato and then lecome intenal

capsule and lres b/w 2 nucleus striatum [ucaudate and lentr from nudrus]

Internal capsule It is a vshaped structures with apex facing medially. Fibes from internal eapsule

contrnues down as are werbilThe parts of in ternal capsule are – anterios limb, gena and posterios limb, sublente from

and retrolente from parts

Fibs content of each part of internal capsule [1] Anterrios limb

- Has –asunding finres – anterios thalamic radiation, loitrio petal fibres - Desending fibres – corteio pontrne fibers, coetriosriate fibers.

[2] Genu – has coite conuelear finres – from area 4, 5 to the cranial nudlei and corteco reticular fibres – which are drscending fibers.

- Ascending fibres – superothalamic radration[3] Pos terios limb

- Descrnding fibers – coritrlspinal, cortecoruleal, corteiostruare, coreco reteculas fibres

- Ascending fibres – superios thalamic radiation[4] Sablente from part

- Has ascendrng fibres – has audetoiy palh - Has descending fibres – has emperor pobtene, Pareto ponline fibers.

[5] Retro lentre form part - Ascending – visual and posterios thalamic radiation- Descending – occipito Pareto pantnebibres.

Due to the compact are ongement of frbe in the internal casuls lesion of thes area is more dangerous than that of coeona radiate.

Blood supply of intrsnal capsule - upper part of artesios limb, grnu and posterios limb is supply by striate brach

of niddle curbeal of krety- lower part of anterios limd is by – recuent branch / neupes artey of antrios

cerbrol A - Lower part of paoterios limb, reto lentr from and sublente from part – by

antrios chroidal artery – from anterios cerebral A.

Veins go to the deep lerbrd veih

* FORNIX

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

* INTER PEDUNCULAR FOSSA

Boumdares are – anterioely – optec chiasm - antero laterally – optec tracl- postero laterally – cerebial pedundes - Posterioely – upper part of pons.

Contnts are Tubes einerium, intundrbulum, mamilary body, and posterios perforated substance occulo

motoi nerve.

(6) VENTRICLES OF BRAIN

[1] 4th vertrids-It is cavtry of hind brain and it is triangulas in sagital section.All ventri des are lined by opendyma.

* Communication – saperiosly – to aqueduct of silvius - Inferiosly – to untralcannal - Lateral 2 apertues – foramen of lushka – to sub arach noid space- Medial aperture – foramen of magenta – communlcats to serebello medullare

cistern.

[a] recesses of 4th venteie

[a] lateral reurs – bet wern inferios cerebellas prdunele and flocculus. They extrna laterally upto upto foramen of lushka.

[b] Dosal reurs- median reues – it extend into whrte core of cerebellum- 2lateral – on eithers side of median reues – sern above

inferios medullary vellum

[b] Charonid plexur of 4th ventricle2on each side – has a vertrial and hollzondal limb. The artery is a branch of

posterios inferios cerbellas artery.Vertrcal trmb goesinto foramen of mauendi, wide hollzondal limb goes to lushka

[c] Parts – roof, floor, and lateral boundary[1] Roof of 4th vrtride = dosal wall

- it externds nack wards into recerse.- Superios part is made of superios urebellar [rdunds and superios medullau velom.

Jelachoeoidas – vasculas Laues + ependyma + piamaltrs

[2] Lateral boundary - Superios – by superios cerbellar prdunde - Inferios part – by inferios cerncllar prdunde

[3] flooe- rhombroid in shape: called rhomboid forsa.

* it is divided into 2 hays by a medran suleus * by streae medullarie [ delicate whrte fibres from arcuate nudas] it is deurded into apper [pontrne part and lower [ medullary ] part.

Pontrne part

* Just a bove streas there is fasuas colliculus. There is also a medran eminence and is limitrd by sulcus limitants limitants and it has nuclers cerruleus. It haspiqment newomelanin and serte nor adrnalen. There colls from substanria terugunea which is a part of krte formation

Medullary part Sulues lemetants has inferios fovera.

There is ahypoqloisal triangle – having hypoqlossal nucheue.- Lateral part – has nucles into calrtus.

Lateral arpect of fores – has vertrbular area – having vestrbulas nuleiLower to the nypoglossal trangle is vagal triangle – it has dorsal nucleus of vasue.At the lower and of vagal triangle – is a faint ridage of ependuma – tuniculus superuans

* Aera posterma – longue shaped is found has and it devoid of blood brain nafous and it has vetal ceteres

* Ventricles are formed from the cavitres of the nureal tube * There is a coevety b/w reptumpelluudum – called cavum pelluudum – it has trsas fleid

it is called the 5th ventrile.

(2) 3rd ventricle It is the covrty of the dren uphalon and it is found b/w 2 thalami

Boundaries [1] Roof – it is a fold of ependyma in clex relation to the forenix and uplum prlundum

- The roofhas trla charodrae and choeoid plexw [the charoid plexus has mare sueface area]. There trlachoroides and they 90 into 2 limbe of the lateral ventricle. The fissue thus forned is chroid fissures – also calred transverse fissures.

[2] Floor – is of ohalamus, optrc chasma, kypophuses, infundrbulum, trgmentum and mammilary body

[3] Anterios boundary – is made of a then felm of lamina terminals [it represent the uphalic end of neuraltube], optrc chraema, abterios idoumn of fornix and anterios commissure

[4] Posterios boundary - is of pinral body, agueduet, hafenular commissure

[5] Lateral wall – has an upper part and lower part reperatrd by lypothalamic sulcus.

- upper part – made of thalamus and epithalamus – pars darsales- lower part – made of hypothalamus – called part ventralis

Theres is also an inter thalamic adhesion. It actually has no crossing of fibus

Reues of 3rd ventricle

They are [1] infandebular reces, [2] supraoplec [3] pinal rcers [4] suprapineal reces [5] vulva of ventricle [b/w anterios commissure and anterios coloumn of fornix]

Inter nentricular foramen- connet 3rd venteride to lateral vrtridus.

It is boundrd – anteriely – by colomun of forinx]- posterioely – by anterios tubude of lhatanmus} it is uesentric in shape but inembrye it is round

LATERAL VENTRICLES

They are 2in numner [I in each cuebral humisphue] it has a body [in parutal bobe] an anterios horn [in frontallobe], posterios hoin [in occipitallobe], interioshrn [in jempord ldue]

Body - extrnd from intes uentricular foramen to the thalamus - roof – made of ependyma and copious callowm - Floor- of caudate nudeus, thalamus, Nucbus, corpus callousm, rostrum.- Medial wall – of septum pelluudam.

Ansterios hoen- It lies in the occipital lobe.

Boundates – roof and lateral wall – of japetum - Medial wall – has 2 elevallons – 1 bulb – due to forups major.

- Calcaraves – of calcar ine sulues

Inferios horn

- it lies in the tempoial lobe

Boundarles – roof – of fibers of lapetam - medealy there is cauduate nudleas and streae terminalis - anteriosly – of jail of caunate nudeus, strain tre mindaes, amgloidcomples

- Floor – of alveolus, fimnras and heppocamus- Lateral wall – has a lateral eminence made by collateral Sulius.

* Telo choioidac of 3rd and hateral ventricle

It les b/w splenium and copus callouem above and thalamus below. The posteroios and of it is transverse fissure / charoid fissure.It is leiangulas and is anterios end is called apex

- a medeal part of it is fromendin roof of lateral uentricle - The lateral part on either side peogect into the 2 lateral uentrete vra the intert

ventricular foramen.

The verles of trla chroidac coner from the theinternal carotd artery or the basullas artery the veins [prevent exus production of CSF] – drain to strrgh sinus ar to interios arebral vein.

* Cerebro spinal fluidIt is a clras transparent colourless fluid. The total volumes are about 80-150 ml and rate

of production is 5ml/minute. The jotal pureues is about 50 – 150 mm of ltg the CSF is measured in lumbar punctures in latual recumbent position. By the rateof coming out of the CSF – the CSF presurs can be found out – called spinal tap. CSF – has water, nacl, kci, glucae, protein lymphocytes [3ullu/mm3].

Functeors of CSF[a] protrction pf brain from lrauma [b] provede nutrition [c] oit provede buoyancy to the

brain [d] it he cps in taking pineal seuction to the pcturtary.

Crsternal puncture – jaking CSF from urebrbomedullary ustern

Chasoid plexus – of lateral wentrids – made of anterios and posterios choiidal artery- of 3rd ventride - made of poterios choroidal arlery - 4th ventricle- of postrios inferios cuebellas antery

Nydrocephalous – lncreared CSF production. May be acquired / conyemtal.The inureared itro uanal pressure cans lract to headache, impaunment of vrsion, vomctirg and papilodrma

Blood brain bouries- Made of endothe lium [has nofre nustr ations], basement membri are. There

are also asterouytes.- The pineal body, hypothalamus, charoid plexer – has no blood Brian baerur.

VII BLOOD SUPPLY OF BRAIN

Mainly by the branches ofvatrbal artery and internal caotrd artery by froming the urde of Willis. The internal carotid artery divrdes into anterior carbeal and middk cerebral artery. The 2 verebral ateries asand in the antero lateral arpect of medulla and unte at the bare of pons to from the busillas artery there then divide into posterios cuebral artery.

2 sets of branche ae given from uricle of willcs – lortcal – supply enter sueface of cuebral hmuples

- Untral – 4 groups [2 paled and 2 unpared]

Blood supply of different surfaus of brain [1] Superolateral surface

- Mainly by the middle cernral artery exypt a strip ½ an inch from the frortal pole to paruto occipctal suldu is spplied by anterios urebeal artery. The reqioon of inferios lempoeal qyus is upplied by post curebeal artery.

[2] Medial surface - Mainly by the anterios cerebral artery exept the bempral lobe and

occipitaobe which is upplied by temporal lobe and occipital lobe.[3] Inferios sueface

- Lateral part of orbital sueface by middle cerebial artey whete medial part of of orbital sueface is by anterios cerbial artery. The tentoeial sueface is supplied by meddle cerial artery.

* Area for maiula vesion is supplies by posterios cerbreal and middle cuebral A: Macular vision is not lost in the omboscs of posterios cerebral artery

* The atery dupplying areend oulays: they can easily lead to theomborts

Blood supply of the deep brain Mainly by seffernt groups of arteres from the uide of urllis they are

[1] Antro medran gtoup - They ar is from antery cuebral and anterios communicating artery they purie

anteuos peoratd subsfaceto the peoplrs and supa optis reqion of the anterios hypothalamus.[2] Postero median group

They ar is from posterios communicating and posterios cerebral A they pcuce the posterios percorating substance it is also called thalamo perforating beaches. They supply piturtary, hypo thalamus, subthamus, anterior medial part of thalamus, medeal part of midarain, leqmentum.

[3] Antro latrial groupThey arise from middles ceubral artery as sometrnes arise from antery cerebral A

– called striate artery. They pueces anterios aerforared substanu and upply corpun striateum and internal capsule.

[4] Postero latrial group They arise from posterios cubral artery. They are called thalamo geniculate artery.

They supply carudal part of the lamus be 2 buenculats body, lateral thalamic nudri[5] Reccuent nranch of antrios cucbral / nubneus artery

- They arise from anterios unbral artery proximal to or destal to antrios communicating artery. It supplies the caudate nludeus, lower limb of anterios part of internal capsules, putamen, and exteunal capsule ec

[6] Antrios choroidal artery Arise from internal cartead artery destal to posteios commcuicating artery. They

passbckwad and enter the inferios hoen of lateral ventride theough choroids fissure. They supply the optec lract, uncus, amydala, heppoiam pus.laterial geniculate body, reteo lente orm part of internal capsule,

[7] Posterios choidal arteryThey arise from postrios cerebral artery and give branches to ctum choioid plexus

of lateral ventrde. Some of its branches anastomous with ant eros choeoidal artery.

Applied importance[1] * one of the branches of antero lateral group is larges- called choucote artery. Ot is

called artery of cerebral ldacmoes haye. It easily ruptued in hypes lension[2] * acuts arrest of ucebral urculation – canlead to unconciouenes in fase and if grcates

than tminutes- it canlead to reprable damage

[3] * latral medullay syndrome / wallen berg syndrome - Dueto leision of posterios inferios cuebellas artery. Thay the poseterios aspect of

medulais affectedThe nudeus amnigus, spinal lemnercus, spinal nudeus and tract of lrigeminal are affeded..

Some temes inferios ecebellas peduncts and vertrbulas nudeus – also affeded

Symptoms are Terndency to fall, loes of jone, nystagmus, dysphasia, hosners syndrome uosed hemi anes thesia

[4] * medral medullary syndrome- Artery affected is vertebral artery

Pyramids, medeal lemniscus and hypoqloresal nerves are affecred

Symptoms are – chondrolateral hemiplrgia, chondro lateral loss of rensation of movement, lacterle desuim ination, ipscclateal paralysci of jonque murds.Blood supply of brain stem

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

artery.

Veins of cerebrumThe veine of brain are devoidof murdes, lkey hower no valver and have to ndency to

maintain patencySuperios cerebral N

External cerebral vein TheVeins superficial middle cerebral N

Internal lerenial Deep middle cerebral N

Inferios cerebral N

Antrios cereberl N

Terminal veins great cerebral V

Basal V

[1] Superios cerebral veins – They are about 6-12 in number. They supply the cpero lateral surface and termidate into

superios saqittalsinus

[2] Superfiual middle cerebral veinDrain the area aeound the postrios ramus of sulcus and to minate into couanoursinus

orinto spero paretal vein. Through superios and inferios andsto motre vein they communicate with superios sagittal and transuerse sinus.[3] Seep middle cerebral vein

- They also communicate with superfiual cerebralvein. It drains the scuface of insula and tesminate into basal vein [4] Inferios cerebral vein

Mainly of 2tyoes – orbital – terminate in the superios bralvens - Jemporal – they end in cavernour sinus.

[5] Anterios cerebral veinsThey are small veins that dram corpue callourem and antrios part of in edral sureface of

hemiophare and drain into baer/vein

[6] Internal cerebral veinThey are one on each side and are formed by the cnion of rgalamo strcate and choroidal

vein at the apex of tela choaroiclae on 3rd ventride the right and left veins join to from great unbeal vein.[7] Great cerebral vein

it is a single medran vein formud by union of 2 intrnal certral vein and there tributaries are basal V, vein from pinral body and veins from adjoining part of occeptal lobe of cerebrum.[8] Basal vein

There is vein of each side. It formud at the anterios pufoated substana by the union of deep middle cerebral, anterios cerebral vein, riate vein. It runs posterioly and wind around cerebral peduncle and cerminates joining the gereat cerebral vein

It also recrives small veins from cerebral pedundes, oeins from into prdenulas sruities, tectum of mid brain, para leppocanpal gyrus.

VIII BASAL GANGLIA

It is a sub corteal mar of gey malter.It includes caredls nudrus, lentr nuleus, amygdaloid nuders complex, daertiom

Laudate nucleus + lentform nudus = coepers striatumLentrfrom nudleus = putamen + globus pallrdiumCaudate nucles + putamen = strcatum.

The basal ganglra also includes sub thalamic nudleus and substantra niagra.

[1] cuudate nudleus

- has head, body and tail. It is clorely relatd to the lateral venteids.- Anteios pat of the head is fured with lent from nudrus – to from tunders striate- Thefandues stroateis contrnuom with anterios perforated substance.

[a] head It frms the floor of anterios Han of lateral ventride and medeal wall of anterios limb of

interal capsule.

[b] Bodyit forms the central part of lateral ventricle and lies medial to pasterios limb of internal

capsule. It is separated from thalamus by treac lerminalis and jhalamo striate vein.

[c] Tail from roof of inferios haen of lateral uentride. It ends joining the amydaloid body at thetrmpoeal pole.

[2] lente from nudleusit is lens shped.

It has 3 surface – lateral – convex – is relatrd to external capsule, elostrum outermost capsle and insula

- medially – related tointernal capsule, cavdate nucleus and the lamus - inferios surface – related to sublentr from part of inter and capsule that

sperates it from optec tract. It is grooved by anterios commissure behind anterios piforated subdtance

it has 2 budeus – put amen – structurally erlated to cuudate nucleas - neostriatum – mare new – of putamen and culdate nuclive – called stratum.

[3] amyloid body it is a nudeus mass in the trmporal kobe [ lying anterios superios to inferios hoin of latral

uenteride.]jopographicalty- it is contrnus with tail of caudate nudles while functe conally it is

relateal to strios tesminalis

it is also a part of lim bic system – afferent – come from olfactory traet - efferent – go vea stria to minadis and end in anterios

commissure

[4] claustrumluaus shaped nucleus b/w putamen and insula. Inferioily it is contrnuous with anterios

perforated substance.

Connection of basal gangtia

[1] * cortex is connedted to striatum – vio coete steriate fibus [2]* striatum is also conneclid to rects cular formation and also ectecular formation [3]* it is also connected to substantea niagea by the niageo striate pathway one of such path ways seorete dopamine

[4]* striatum is also connected to polledruem – called sttria to pollrdeal pathway the main nevero transmitthes has is GA BA.

[5]* striatum also main seueues afferent from thalamus by thalam ostriate path way.

[1] and [2] aemain afferent pathway whle 2,3, and 4 are main efferent pathway.

Applied impoetance

* lesion of ibasal ganglia leads to pcukinsonumdue to drgrnesation of negrostriate pathway : releare of dopamine the features are

chrea, ahetoser, lead pipeigidrty, masked face, reting temos, pill rolling muts.

Blood supply of basal ganglia

[1] of caudate nucleus – head – by reccreont branch / nurebners artry - body – latral striate branch]- tail – anterios coroidal artery

[2] blod supply of rlobus pallidus – by anterios wrebral artry and lateral striate artery [3] blood supply of putamen – lateral stridate branch, and heubners artery.

IX THALAMUS It is part of cleon cephalon.

Anterior pole – lies just behind inter ventricular foramen.

It has 2 polesPosterior – Pulvinar – seprates from geniculate body by the

superior brachiam

Medial – it forms the latual wall of 3rd ventricle and is linedby ependyna. It has interthalamic adheion

that is a hypohalomic sulus that seprated it from hypothalamus.

Superior surface – themedial part of it separated from ventricle by farnix and a fold of Tela choroidac

* it has 4 surfaces

Inferior surface – related to hypothalamus and ventral thalamus

Lateral surface – related to internal capsule, lente form nucleus and external medllary lamina.

The superior surface of thalamus is covered by white matter – called stratum zonule.

Internally thalamus is divided by internal medullary lamina ( a Y shaped fibres)

Anterior group – has interomedial, ontero cloisal, antero ventral nuclei

Medial group – medial closisal nucleusVentral anterior

Ventral group Ventral lateral

ventral postero lateral

Nuclei of thalamus Ventral posterior ventral posters medial

Lateral group

Lateral group lateral cloisalLateral posteriorPuluinar

Other nuclei

Inter ondaminar, mid line, medial geniculate body and lateral geniculate body.

CONNECTIONS OF THALAMUS

It acts as a relay station for all sensations exept olfaction

(1) Sensations by medial lemuous and spinthalamic tract come and relay in ventral posterio lateral nucleus and then to 1o sensory cortex

(2) Sensations by Trigemnal lemniscue and solitaro thalamic tract relay on ventral postero medial nucleus and then go 18 1o sensory cortex.

(3) Impulses from globus pallidus substantia niagra and cerebellas, vertibular nuclei relay on ventral lateral nuclei and then relay on area 4 6 8 on the cortex

(4) Impulses from retina relay on superior colliculus pre tectal avas and then relay to lateral daisal, lateral posterior and pulvinar nuclei

(5) Impulses from hypothalamus relay on the anterior nuclei and from there it goes to ungulate gyrus, Hypothalamus, limbic system

It is concerned with emotional drive, memory drive and loss of memory(6) Impulses from thalamus and hypothalamus relay on Dorsal medial nuclei then relay on

area 9,10,11,12.This is important in memory, mood elevation, emotional balance

(7) Auditory impulses come to inferior colliculus and then relay on medial geniculate body and then relay on area 41, 42.

(8) Visual impulses come via superior colliculus to the medial geniculate body and then relay to 1o visual area.

(9) Intralaminar nuclei receive fibres from reticular formation and send fibres to the corpus striatum, other calamic nucleids.

It is concerned with consciousness, alertness

(10) Mid line nucleus also receive fibre from reticular formation It is concerned with arousal and emotional behaviour.

BLOOD SUPPLY OF THALAMUSPosterior cerebral artery, Basellar artery and posterior communicating artery.

X LIMBIC SYSTEM

- It is part of brain controlling food and sensual behaviour.- parts are – olfactory system, fornex,steriac terminals, anterior commissure,

anterior perforated substance, amydala- Functions – (1) It controls the habit, (2) It controls sexual behaviour

(3) It controls behavioral expression.

XI EPITHALAMUSIt consist of

Habenular commissure – part of limbic system Pineal body – has body and stalk.It has rich network of blood vessels and sympathetic

fibres.It has 2 types of cells pinealocytes neuroglial Labenulas nuclei Posterior commissure

XII HYPOTHALAMUS

- called head ganglion of autonomic nervous system

- Boundaries are anteriorly (optic chiasma), posteriorly (posterior perforated substance) and on either side (optic tract and cruscerebri)

Optic part – supra optic nuclei, para ventricular nuclei

- Hypotalamas Tubal part – ventral medial nuclei, Dorsomedial nuclei, tuberal nucleihas

mammilory part – posterior nuclei, lateral nuclei

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

HISTOLOGY

(1) Spinal Cord

It has grey matter – ( H-shaoped) inside and white matter outside grey matter has anterior horn, posterior horn

Anterior horn has large multipolar cells – motor Dorsal horn – has clarkes coloumn of cells, posteriomarginal nucleus, nucleus

peoprius, and substalia gelatinosa.

There is also a central cannal that is lined by ependymal cellsCoverage of spinal cord include duramatter, arachnoid matter and pra matter. It develop from caudal; part of neural tubeSpinal cord terminates at level of L, in adults and L2 in infants.

(1) H shaped grey matter with anterior horn and posterior hornIdentifying Features

(2) Central cannal is seen at centre of grey mater

(2) Cerebellum

- has 4 layers – molecular layer, granular layer, pukinge layer, white matter- The cells found are

- Purkinge cells - large flusk shaped cells – forms 1 single layers- their axons form main afferent path way- their dentrites synapse with axons of granule cells

- Granule cells - they synapse with mossy fibres forming glomertilus- Their axons enter the molecules layer and divide into

parallel fibres

- Golgi cells - They acclong stellate cells.- Their axons enter the molecular layer.

- Stellate cells - In molecular layer

- Basket cells - found in molecular layer. Their axons form a network around purkinge cells :. Called basket cells

Molecular layer – has stellate and basket cells Cells Purkinge cells - has purkinge cells

Granular layer – has golgi and granule cells

Identifying Features

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

* Cerebellum develop from alar lamina of mesen cephalon

(3) Cerebrum

It consists of 6 layers

(1) Molecular layer – mainly fibres – made of horizontal cells, golgi cells, stellate cells(2) External granular layer – due to closely packed stellate cells. Their axons forms

association fibres(3) External pyramidal layer - usually small pyramidal cells. Their axons forms

commissure of fibres

(4) Internal granular layer - has band of bailarger – it has transverse fibres formed by closely packed stellate cells

(5) Internal pyramidal layer - made of cells of bet & and maletenote. Their fibres farm projection fibres.They have a transverse band called internal band of bailarger

(6) multiform layer/ layet of fusi form cells

The cells found here are

(a) Pyramidal cells - most abundant - It is triangular. The axons cerese from the base(b) Stellate cells - called granule cells. Axons are very short and mainly sensory.© Horizontal cells - the dentrites are parallel to the surface(d) fusiform cells - Here 2 dentrites arise from 2 ends one goes to the superficial layer and

other goes to the deep layer.

(e)cells of marte note – are triangular cells (f) Golgi type II cells - cells with small processes

* Cerebram - develop from prosencephaton

Identifying Features(1) outer grey matter and inner white matter(2) six layers are there in cortex