Anatomy of Upperlimb & Spinal nervers

7/27/2019 Anatomy of Upperlimb & Spinal nervers

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Roots (anterior rami)

Trunks

Divisions: anterior (to flexors) or posterior (to extensors)

Cords

Supraclavicular branches

Infraclavicular branches

Terminal branches (infraclavicular)

C5

C6

C7

Anteriorrami

C8

T1

Articular disc ofsternoclavicular joint

Costoclavicular ligamentThree posteriordivisions

Cords

Axillary nerve

Musculocutaneous

Terminal branches

nerve

Mediannerve

Radialnerve

Coraco-acromial ligament

Coracoclavicular ligament

Three anterior divisionssuperior, middle, and inferior

Three trunkssuperior, middle, and inferior

Ulnarnerve

Medial

Posterior

Lateral

Pectoralis minor

Spinal ganglion(dorsal root ganglion)

A. Anterior View

Anterior rami

C5

C6

C7

C8

T1

Dorsal scapular nerve

Suprascapular nerveSubclavian

nerve

Long thoracicnerve

Lateral pectoral nerve

Medial pectoral nerve

Medial cutaneous nerve of forearm

Medial cutaneous nerve of arm

Lower subscapular nerve

Thoracodorsal nerve

Upper subscapularnerve

Axillary nerve

Musculocutaneous nerve

Lateral root of median nerve

Medial root of median nerve

Radial nerve

Median nerve

Ulnar nerve

B. Anterior View


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364 SYSTEMIC OVERVIEW OF LOWER LIMB: NERVES

Lateral cutaneous branch ofsubcostal nerve (T12)

Femoral branch

Genitofemoralnerve

Genital branch

Ilioinguinal nerve

Cutaneous branchof obturator nerve

Anterior cutaneousbranches of femoralnerve (lateral group)

Saphenous nerve(from femoral nerve)

Deep fibular(peroneal) nerve

Lateral dorsal cutaneous nerve offoot (termination of sural nerve)

Superficial fibular (peroneal) nervebecoming dorsal digital nerves

Lateral sural cutaneousnerve (from common

fibular nerve)

Infrapatellar branchof saphenous nerve

Lateral cutaneousnerve of thigh,

anterior branches

L1

L3L2

Superiorclunial nerves

(posterior rami)Lateral cutaneous branchof iliohypogastric nerve

Lateral cutaneousnerve of thigh(posterior branches)

Lateral cutaneousnerve of thigh(continuation ofanterior branches)

Posterior cutaneous nerveof thigh

Lateral sural cutaneous nerve(from common fibular nerve)

Medial sural cutaneousnerve (from tibial nerve)

Communicating branch oflateral sural cutaneous nerve

Lateral plantar nerve

Sural nerve

Medial plantar nerve

Medial calcaneal branchesof tibial nerve

Saphenous nerve(from femoral nerve)

Anterior cutaneousbranches of femoralnerve (medial group)

Cutaneous branchesof obturator nerve

Medialclunial nerves

(posterior rami)

S1

S3S2

A. Anterior View B. Posterior View

Inferior clunial nerves

(branches of posterior

cutaneous nerve of

thigh)

CUTANEOUS NERVES OF LOWER LIMB

Cutaneous nerves in the subcutaneous tissue supply the skin of the lower limb. The cutaneous innervation

of the lower limb reects both the original segmental innervation of the skin via separate spinal nerves in its

dermatomal pattern (Fig. 5.8 ) and the result of plexus formation of segmental peripheral nerves. In B, the

medial sural cutaneous nerve (suralis Latin for calf ) is joined between the popliteal fossa and posterior aspect

of the ankle by a communicating branch of the lateral sural cutaneous nerve to form the sural nerve. The level

of the junction is variable and is low in this specimen.

5.5


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36

Lower Limb

SYSTEMIC OVERVIEW OF LOWER LIMB: NERVES

S3

S3

S3

S3

S4

S4

S4

S5

S5

L5

L5

L5

L5

L5

L5

L5

C1

C1

L1

L1

T12T12

T11 T11

T10T10

L1

S1

S1

S1S1

S1

S1

S2S2

S2

S2

S2

S2

S2

L2

L2

L2

L2

L3

L3

L3

L3

L3

L4

L4

L4

L4

L4L4

A. Anterior View C. Anterior ViewB. Posterior View D. Posterior View

Axial line

Axial lin

DERMATOMES OF LOWER LIMB

The dermatomal, or segmental, pattern of distribution of sensory nerve bers persists despite the merging of

spinal nerves in plexus formation during development. Two different dermatome maps are commonly used.

A. andB. The dermatome pattern of the lower limb according to Foerster (1933 ) is preferred by many because

of its correlation with clinical ndings. C.and D. The dermatome pattern of the lower limb according to Keegan

and Garrett (1948 ) is preferred by others for its aesthetic uniformity and obvious correlation with development.

Although depicted as distinct zones, adjacent dermatomes overlap considerably, except along the axial line.

5.8


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432


Patellar ligament

Anterior tibial artery

Deep fascia

Sympathetic branchto vessel

Tibialis anterior

Extensorhallucis longus

Anterior tibialartery

Perforating branch offibular (peroneal) artery

Inferior extensorretinaculum

(cut and retracted)Inferior extensorretinaculum(cut and retracted)

Extensordigitorum longus

Tibialis anteriortendon

B. Anterolateral ViewA. Anterior View

Extensor digitorumbrevis

Common fibular(peroneal) nerve

Superficial fibular(peroneal) nerve

Fibularis (peroneus)longus

Fibularis (peroneus)brevis

Fibularis (peroneus)tertius


Extensor hallucislongus

Extensor digitorumlongus

Tibialis anterior

5.62 ANTERIOR LEGDEEP MUSCLES, NERVES, AND VESSELS

ANTERIOR AND LATERAL COMPARTMENTS OF LEG, DORSUM OF FOOT

TABLE 5.13 COMMON, SUPERFICIAL, AND DEEP FIBULAR (PERONEAL ) NERVES

Nerve Origin Course Distribution/Structure(S) Supplied

Common bular Sciatic nerve Forms as sciatic nerve bifurcates at the apex of popliteal fossa and followsmedial border of biceps femoris; winds around neck of bula, dividing intosupercial and deep bular nerves

Skin on lateral part of posterior aspect of leg via the lateral suralcutaneous nerve; lateral aspect of knee joint via its articularbranch

Supercial bular Commonbular nerve

Arises deep to bularis longus and descends in la teral compartment ofleg; pierces crural fascia at distal third of leg to become cutaneous

Fibularis longus and brevis and skin on distal third of anterolateralsurface of leg and dorsum of foot

Deep bular Commonbular nerve

Arises deep to bularis longus; passes through extensor digitorum longus,descends on interosseous membrane, and continues on dorsum of foot

Anterior muscles of leg, dorsum of foot, and skin of rst in terdigitalcleft; dorsal aspect of joints crossed via articular branches


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Posterior ramus (cut end)Anterior ramus

Axillary nerve

Radial nerve

C1

C5

T1

T12

L1

L5

S1

S5Co

Ulnar nerve

Superficial branch of radial nerve


Posterior interosseous nerve

Obturator nerve

Sciatic nerve

Common fibular (peroneal) nerve

Tibial nerve

Superficial fibular (peroneal) nerve

Deep fibular (peroneal) nerve



Anterior ramus

Spinal nerves:

Peripheral nerves:

Peripheral nerves:


Median nerve

Radial nerve

Ulnar nerve

Deep branch of radial nerve


Femoral nerve

Saphenous nerve




C. Posterior View D. Anterior View

Ulnarnerve

Ulnarnerve

Median nerve


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362 SYSTEMIC OVERVIEW OF LOWER LIMB: NERVES

Semitendinosus

Popliteus

Sciatic nerve (tibial

and common fibular)

Biceps femoris

(short head)

Superior glutealnerveInferior gluteal

nerve


(L4S2)

Gastrocnemius

Soleus

Tibialis

posterior

Flexor hallucis

longus


(S1S2)

All other muscles

in sole of foot

Flexor digitorum brevis

Flexor hallucis brevis

Lumbrical to 2nd digit

Abductor hallucis


(L4L5)

Flexor digitorum

longus

Gastrocnemius

Tibial nerve

(L4S3)

Semimembranosus

Adductor magnus

Semitendinosus

Biceps femoris

(long head)

Plantaris

Obturator nerve

(L2L4)

Fibularis (peroneus)

tertius


(L5S2)

Tibialis anterior

Extensor hallucis

longusAnterior

compartment

of leg

Gluteal

compartment

Posterior

compartment

of leg

Medial

compartment

of thigh

Anterior

compartment

of thigh

Posterior

compartment

of thigh

Posterior

compartment

of leg

Lateral

compartment

of legExtensor digitorum

longus

Gracilis

Adductor

magnus

Adductor longus

Adductor brevis

Obturator externus

Femoral nerve

(L2L4)

Rectus femoris

Sartorius

Vastus lateralis

Vastus intermedius

Articularis genu

Psoas

Iliacus

Pectineus


(L4S2)


(L4S1)


brevis


longus

Extensor digitorum brevis

A. Anterior View B. Posterior View

Posterior branch

Anterior branch

Vastus medialis

L2

L3

L4

Anterior compartment

Innervation of thigh:

Medial compartment

Posterior compartment

Anterior compartment

Innervation of leg:

Lateral compartment

Posterior compartmentof leg and sole of foot

OVERVIEW OF MOTOR INNERVATION OF LOWER LIMB5.4


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Spinalnerves

C3 C3

C4 C4

C5 C5

C6 C6C7

C7C8

T1T1

T2

C2

Extensor digitorum

Extensor digiti minimi

Extensor carpi ulnaris

Supinator

Anconeus

Posteriorcompartment

of forearm

Triceps brachii (long head)

Triceps brachii (medial head)

Teres major

Latissimus dorsi

Subscapularis

Levator scapulae

Rhomboids

Supraspinatus

Infraspinatus

Shoulderregion

Shoulderregion

Posteriorcompartmentof arm

Deltoid

Teres minor

Axillary nerve

Radial nerve

Triceps brachii(lateral head)

Brachioradialis


Superficial branch ofradial nerve (sensory)

Extensor carpi radialis longus

Extensor carpi radialis brevis


Abductor pollicis longus

Extensor pollicis brevis

Extensor pollicis longus

Extensor indicis

Suprascapular nerve

C. Posterior View

Posterior cord of brachial plexus


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Supraclavicular nerves (C3, C4)

A. Anterior View

Intercostobrachial nerve


(from medial cord of brachial plexus)

Medial cutaneous nerve

of forearm

Posterior

branch

Medial cutaneous

nerve of forearm

(from medial cord

of brachial plexus)

Anterior branch

Dorsal (cutaneous) branch of ulnar nerve

Ulnar nerve

Median nervePalmar (cutaneous)

branches ofSuperficial

branch of

radial nerve

Radial nerve, superficial branch

Anterior branch

Posterior branch

Posterior cutaneous nerve of forearm

(from radial nerve)

Lateral cutaneous nerve of forearm

(from musculocutaneous nerve)


(from radial nerve)

Inferior lateral cutaneous nerve

of arm (from radial nerve)

Superior lateral cutaneous

nerve of arm

(from axillary nerve) Intercostobrachial nerve

(from 2nd/3rd intercostal nerve)

B. Posterior View

Supraclavicular nerves

(C3, C4)

Superior lateral

cutaneous nerve of arm

(from axillary nerve)

Inferior lateral

cutaneous nerve

of arm

Posterior cutaneous

nerve of forearm

From

radial

nerve

Posterior cutaneous

nerve of forearm

Lateral cutaneous nerve

of forearm, posterior branch

Radial nerve,

superficial branchDorsal (cutaneous) branch

of ulnar nerve

Medial cutaneous nerve,

of forearm, posterior branches

Posterior cutaneous nerve


Median nerve,

palmar digital

branches

Communicating

branchesDorsal digital

branches

Lateral cutaneousnerve of forearm(from musculo-

cutaneous nerve)

Median nerve

Ulnar nerve,

superficial branch


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11

76

5

4

312

Numbers: approximate age of ossification of carpal bones in years

Trapezoid (Td)

Trapezium (Tz)

Scaphoid (S)

Capitate (C)

Hamate (H)

Pisiform (P)

Triquetrum (Tq)

Lunate (L)

K.Anterior View

Tq

J. Anterior (Right Hand)View

5

4 3 2

Td

1 Metacarpal

TzCH

L S

Distal phalanx

Middle phalanx

Proximal phalanx

L. Antero-posterior View, Right HandEpiphyses in radiographs appear as radiolucent lines

Tq

54 3

2

1

R

L

CH

H

P

PP

C

Td Tz

S

RL

Tq

U

54 3 2

1


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C4

C5

C6

C7

C8

T1

C4

C5

C6

C7

T1

T2

Coracobrachialis

Thenarmuscles

Flexorpollicislongus

Pronator teres

Brachialis

Biceps brachii


Median nerve

Pronator teres

Flexor carpi radialis

Palmaris longus

Flexor digitorumsuperficialis

Flexor digitorumprofundus (lateralhalf to digits 2, 3)

Lumbricals

to digits 2, 3

Dorsal interossei

Adductor pollicis

Flexor digitorum profundus(medial half to digits 4, 5)

Ulnar nerve

Flexor carpi ulnaris

Palmaris brevis

Hypothenar muscles

Lumbricals to digits 4, 5

Palmar interossei

T1

C8

C7

C6

C7

T1

T2

A. Anterior View B. Anterior View

Anteriorcompartment

of arm

Anteriorinterosseous

nerve

Pronatorquadratus

Anteriorcompartmentof forearm

Deep branch of ulnar nerve


Anteriorcompartment

of forearm

Lateral cord of brachial plexus

Medial cord ofbrachial plexus

Deep head, flexorpollicis brevis



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C3

C4

C4C4

C5

C5

C5

T3T2

T2 T2

T2

T4

T5

T6

T7

T8

T9

T10

T11

T12

L1

L2

L3L3L4

S2 S2

S2 S2

S3 S3S3

S3 S3

S3

L1

L2

C2

C6

C6

C6

C6C8

C8 C7C7C7

T1 T1T1 T1

S4S4S5

S1 S1S1 S1

S1

S1

L5

L4

L3L3

L4

L4

L5

L5

L5

L5

L5

C7C7

C6

Co

C3

C2

C4 C4

C5

C5C5

C6

C6

C6

C8C7

C7

C8

T2

T2T2

T1

T1

T2

T3

T4

T5

T6

T7

T8

T9

T10

T11

T12

L1

L2

S2

S2

S2

S2

S2

S2

S3S3

S4

S3S3

S1

S1

S1

S1

L2

L3

L3

L5

L5

L5

L4

Inferior View

Anterolateral View

Posterior View

A.


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Spinalnerves

C3 C3

C4 C4

C5 C5

C6 C6C7

C7C8

T1T1

T2

C2

Extensor digitorum

Extensor digiti minimi

Extensor carpi ulnaris

Supinator

Anconeus

Posteriorcompartment

of forearm

Triceps brachii (long head)

Triceps brachii (medial head)

Teres major

Latissimus dorsi

Subscapularis

Levator scapulae

Rhomboids

Supraspinatus

Infraspinatus

Shoulderregion

Shoulderregion

Posteriorcompartmentof arm

Deltoid

Teres minor

Axillary nerve

Radial nerve

Triceps brachii(lateral head)

Brachioradialis


Superficial branch ofradial nerve (sensory)

Extensor carpi radialis longus

Extensor carpi radialis brevis


Abductor pollicis longus

Extensor pollicis brevis

Extensor pollicis longus

Extensor indicis

Suprascapular nerve

C. Posterior View

Posterior cord of brachial plexus


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Anterior cerebral artery

Blood is supplied to the cerebral hemispheres by the:

Middle cerebral artery

Posterior cerebral artery

Anterior communicating*

Anteromedial central

Anterolateral central

striate (lenticulostriate)

Anterior choroidal

Posteromedial central

Distal medial striate

*Anterior cerebral

Anterior cerebral

Ophthalmic

Internal carotid

Hypophysial

Middle

cerebral

*Posterior cerebral

Posterolateral

central

Superior cerebellar

Pontine

LabyrinthineBasilar

Anterior inferior

cerebellar

Vertebral

Posterior inferior

cerebellar

Anterior spinal

*Posterior communicating

A.Inferior (Ventral) View

B.Lateral View

C. Medial View* Components of cerebral arterial circle (Willis)


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820 OVERVIEW OF CRANIAL NERVES

Motor: lateral rectus

muscle of eye

AbducentCN VI

Sensory: smell

OlfactoryCN I

VestibulocochlearCN VIII

Vestibular nerve, sensory:

orientation, motion

Cochlear nerve, sensory:

hearing

Motor (efferent)

Sensory (afferent)

Cranial nerve fibers

FacialCN VII

Intermediate nerve

Motor: lacrimal, nasal, palatine,

submandibular, and sublingual

glands

Sensory: taste to anterior two

thirds of tongue, soft palate

Motor: superior oblique

muscle of eye

TrochlearCN IV

TrigeminalCN V

Sensory root

Sensory: face; oral, nasal

and sinus mucosa; teeth

and anterior two thirds of

tongue

TrigeminalCN V

Motor root

Motor: muscles of

mastication and 4 other

muscles (see table 9.1)

HypoglossalCN XII

Motor: all intrinsic and

extrinsic muscles of tongue

(excluding palatoglossus

a palatine muscle)

Spinal accessoryCN XI

Motor: sternocleidomastoid

and trapezius

VagusCN X

Motor: palate, pharynx,

larynx, trachea, bronchial

tree, heart, GI tract to left

colic flexure

Sensory : pharynx, larynx;

reflex sensory from tracheo-

bronchial tree, lungs, heart,

GI tract to left colic flexure;

taste to epiglottis, palate

GlossopharyngealCN IX

Motor: stylopharyngeus,

parotid gland

Sensory: pharynx, tonsillar

sinus, pharyngotympanic

tube, middle ear cavity;

taste to posterior third of

tongue

FacialCN VII

Primary root

Motor: muscles of facial

expression and 3 other

muscles (see table 9.1)

Sensory: vision

OpticCN IIOculomotorCN III

Motor: ciliary muscles,

sphincter of pupil, all

extrinsic muscles of eye

except those listed for

CN IV and VI

CN I

CN II

CN III

CN VI

CN V

CN V

CN XII

CN XI

CN X CN IX

CN VIII

CN VIICN VII

CN IV

SUMMARY OF CRANIAL NERVES9.3


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Supraclavicular nerves (C3, C4)

A. Anterior View

Intercostobrachial nerve


(from medial cord of brachial plexus)

Medial cutaneous nerve

of forearm

Posterior

branch

Medial cutaneous

nerve of forearm

(from medial cord

of brachial plexus)

Anterior branch

Dorsal (cutaneous) branch of ulnar nerve

Ulnar nerve

Median nervePalmar (cutaneous)

branches ofSuperficial

branch of

radial nerve

Radial nerve, superficial branch

Anterior branch

Posterior branch


(from radial nerve)

Lateral cutaneous nerve of forearm

(from musculocutaneous nerve)


(from radial nerve)

Inferior lateral cutaneous nerve


Superior lateral cutaneous

nerve of arm

(from axillary nerve) Intercostobrachial nerve

(from 2nd/3rd intercostal nerve)

B. Posterior View

Supraclavicular nerves

(C3, C4)

Superior lateral

cutaneous nerve of arm

(from axillary nerve)

Inferior lateral

cutaneous nerve

of arm

Posterior cutaneous

nerve of forearm

From

radial

nerve

Posterior cutaneous

nerve of forearm

Lateral cutaneous nerve

of forearm, posterior branch

Radial nerve,

superficial branchDorsal (cutaneous) branch

of ulnar nerve

Medial cutaneous nerve,

of forearm, posterior branches

Posterior cutaneous nerve


Median nerve,

palmar digital

branches

Communicating

branchesDorsal digital

branches

Lateral cutaneousnerve of forearm(from musculo-

cutaneous nerve)

Median nerve

Ulnar nerve,

superficial branch


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828 CRANIAL NERVES III, IV, AND VI: OCULOMOTOR, TROCHLEAR, AND ABDUCENT

Superior rectusand inferior oblique

MedialrectusRest position

Lateralrectus

Inferiorrectus

Inferior rectus

Superiorrectus

Inferioroblique

Superiorrectus

Oculomotor nerve

CN III

CN III

Cavernous sinus

Superior oblique

Levator palpebraesuperioris (cut)

Superior rectus

Lateral rectus (cut)

Lateral rectus (cut)

Internal carotid artery

Internal carotid artery

Medial rectus

Inferior oblique

Inferior rectus

Nucleusof CN III

CN IV

Nucleusof CN IV

CN VI

Nucleusof CN VI

CN V1

CN V2

Trochlear nerve

CN IV

Abducent nerve

CN VI

Inferioroblique

Lateralrectus

Medialrectus

Superioroblique

Superior oblique

Superioroblique

Inferiorrectus

A

B

CN III

CN IV

CN VI

9.9 OCULOMOTOR (CN III), TROCHLEAR (CN IV), AND ABDUCENT (CN VI) NERVES

A. Schematic overview. B. Binocular movements and muscles producing them. All movements start from the

rest (primary) position.

TABLE 9.4 OCULOMOTOR (CN III), TROCHLEAR (CN IV), AND ABDUCENT (CN VI) NERVESa

Nerve FunctionalComponents

Cells of Origin/Termination Cranial Exit Distribution and Functions

Oculomotor Somatic motor Nucleus of CN III

Superior orbitalssure

Motor to superior, inferior, and medial recti, inferior oblique, and levator palpebrae superiorismuscles; raises upper eyelid, directing gaze superiorly, inferiorly, and medially

Visceral motor(parasympathetic)

Presynaptic: midbrain (Edinger-Westphalnucleus); Postsynaptic: ciliary ganglion

Motor to sphincter pupillae and ciliary muscle that constrict pupil and accommodate lens ofeyeball

Trochlear Somatic motor Nucleus of CN IV Motor to superior oblique that assists in directing gaze inferolaterally

Abducent Somatic motor Nucleus of CN VI Motor to lateral rectus that directs gaze laterally


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C4

C5

C6

C7

C8

T1

C4

C5

C6

C7

T1

T2

Coracobrachialis

Thenarmuscles

Flexorpollicislongus

Pronator teres

Brachialis

Biceps brachii


Median nerve

Pronator teres

Flexor carpi radialis

Palmaris longus

Flexor digitorumsuperficialis

Flexor digitorumprofundus (lateralhalf to digits 2, 3)

Lumbricals

to digits 2, 3

Dorsal interossei

Adductor pollicis

Flexor digitorum profundus(medial half to digits 4, 5)

Ulnar nerve

Flexor carpi ulnaris

Palmaris brevis

Hypothenar muscles

Lumbricals to digits 4, 5

Palmar interossei

T1

C8

C7

C6

C7

T1

T2

A. Anterior View B. Anterior View

Anteriorcompartment

of arm

Anteriorinterosseous

nerve

Pronatorquadratus


Deep branch of ulnar nerve


Anteriorcompartment

of forearm

Lateral cord of brachial plexus


Deep head, flexorpollicis brevis


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Anatomy of Upperlimb & Spinal nervers