Spinal ganglion (dorsal root ganglion) Three trunkssuperior, middle, and inferior Three anterior divisionssuperior, middle, and

inferior Coracoclavicular ligament C6 Coraco-acromial ligament C7 C8 T1 Pectoralis minor Articular disc of sternoclavicular joint Anterior rami C5

Three posterior divisions Radial nerve Medial Posterior Cords Median nerve Lateral Ulnar nerve Axillary nerve

Costoclavicular ligament

A. Anterior View

Musculocutaneous nerve Dorsal scapular nerve Terminal branches Subclavian nerve C5

Suprascapular nerve

C6

Lateral pectoral nerve C7 Axillary nerve Lateral root of median nerve Musculocutaneous nerve Radial nerve Long thoracic nerve Upper subscapular nerve Thoracodorsal nerve Medial pectoral nerve Lower subscapular nerve Ulnar nerve Medial cutaneous nerve of arm Medial cutaneous nerve of forearm Medial root of median nerve T1 Roots (anterior rami) Trunks Divisions: anterior (to flexors) or posterior (to extensors) Cords Supraclavicular branches Infraclavicular branches Terminal branches (infraclavicular) C8 Anterior rami

Median nerve

B. Anterior View

364

SYSTEMIC OVERVIEW OF LOWER LIMB: NERVES

Lateral cutaneous branch of subcostal nerve (T12)

Femoral branch Genitofemoral nerve

Superior L1 clunial nerves L2 (posterior rami) L3

Genital branch

Lateral cutaneous branch of iliohypogastric nerve

Ilioinguinal nerve Lateral cutaneous nerve of thigh, anterior branches Cutaneous branch of obturator nerve Anterior cutaneous branches of femoral nerve (lateral group)

Medial S1 clunial nerves S2 (posterior rami) S3

Lateral cutaneous nerve of thigh (posterior branches) Inferior clunial nerves (branches of posterior cutaneous nerve of thigh) Lateral cutaneous nerve of thigh (continuation of anterior branches)

Cutaneous branches of obturator nerve

Anterior cutaneous branches of femoral nerve (medial group) Posterior cutaneous nerve of thigh

Infrapatellar branch of saphenous nerve

Saphenous nerve (from femoral nerve)

Lateral sural cutaneous nerve (from common fibular nerve)

Lateral sural cutaneous nerve (from common fibular nerve)

Saphenous nerve (from femoral nerve) Medial sural cutaneous nerve (from tibial nerve) Communicating branch of lateral sural cutaneous nerve

Superficial fibular (peroneal) nerve becoming dorsal digital nerves Sural nerve Medial calcaneal branches of tibial nerve Lateral dorsal cutaneous nerve of foot (termination of sural nerve) Lateral plantar nerve Deep fibular (peroneal) nerve Medial plantar nerve

A. Anterior View

B. Posterior View

5.5

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 re ects 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 (sural is 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.

Lower Limb
SYSTEMIC OVERVIEW OF LOWER LIMB: NERVES 369

T10 T11 T12

T10 S2 T11 C1 T12 S2 S3 L1 L5 S2

L3 L4 L5 S1 S3 S4 S5 C1

L1 S3 S4 L2

L2

S3

S4

S5

L2

L1

L3 L3 L2

L3

S2 Axial line Axial line S2 S1 L5 L3 L4 L4 L5

L4

L5

L4

S2 S1 S1 L5 S2 S1 L5 L4 S1

A. Anterior View

B. Posterior View

C. Anterior View

D. Posterior View

5.8

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.and B. 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.

432

ANTERIOR AND LATERAL COMPARTMENTS OF LEG, DORSUM OF FOOT

Patellar ligament

Common fibular (peroneal) nerve Superficial fibular (peroneal) nerve

Deep fibular (peroneal) nerve Deep fibular (peroneal) nerve Tibialis anterior

Anterior tibial artery

Deep fascia

Fibularis (peroneus) longus Extensor hallucis longus Fibularis (peroneus) brevis Extensor digitorum longus Sympathetic branch to vessel Extensor digitorum longus Tibialis anterior

Fibularis (peroneus) tertius

Extensor hallucis longus Anterior tibial artery Extensor digitorum brevis Perforating branch of fibular (peroneal) artery

Tibialis anterior tendon

Inferior extensor retinaculum (cut and retracted)

Inferior extensor retinaculum (cut and retracted)

A. Anterior View

B. Anterolateral View

5.62

ANTERIOR LEGDEEP MUSCLES, NERVES, AND VESSELS

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

Nerve Common bular Origin Sciatic nerve Course Forms as sciatic nerve bifurcates at the apex of popliteal fossa and follows medial border of biceps femoris; winds around neck of bula, dividing into super cial and deep bular nerves Arises deep to bularis longus and descends in lateral compartment of leg; pierces crural fascia at distal third of leg tobecome cutaneous Arises deep to bularis longus; passes through extensor digitorum longus, descends on interosseous membrane, and continues on dorsum of foot Distribution/Structure(S) Supplied Skin on lateral part of posterior aspect of leg via the lateral sural cutaneous nerve; lateral aspect of knee joint via its articular branch Fibularis longus and brevis and skin on distal third of anterolateral surface of leg and dorsum of foot Anterior muscles of leg, dorsum of foot, and skin of rst interdigital cleft; dorsal aspect of joints crossed via articular branches

Super cial bular Deep bular

Common bular nerve Common bular nerve

Spinal nerves: C1 Anterior ramus C5 T1 Peripheral nerves: Musculocutaneous nerve Radial nerve Ulnar nerve T12 L1 Superficial branch of radial nerve Deep branch of radial nerve Posterior interosseous nerve L5 S1 Superficial branch of radial nerve S5 Co Superficial branch of radial nerve Anterior ramus Posterior ramus (cut end)

Peripheral nerves: Axillary nerve

Median nerve Radial nerve Ulnar nerve

Ulnar nerve

Ulnar nerve

Median nerve

Obturator nerve Femoral nerve Sciatic nerve Saphenous nerve

Common fibular (peroneal) nerve Common fibular (peroneal) nerve Tibial nerve Superficial fibular (peroneal) nerve Superficial fibular (peroneal) nerve Deep fibular (peroneal) nerve Deep fibular (peroneal) nerve

Medial plantar nerve Lateral plantar nerve

C. Posterior View

D. Anterior View

362

SYSTEMIC OVERVIEW OF LOWER LIMB: NERVES

L2 Psoas Femoral nerve (L2L4) Iliacus L3 L4 Innervation of thigh: Obturator nerve (L2L4) Anterior compartment Medial compartment Posterior compartment Rectus femoris Pectineus Sartorius Anterior compartment of thigh Obturator externus Posterior branch Anterior branch Adductor brevis Adductor longus Medial compartment Adductor of thigh magnus Gracilis Posterior compartment of thigh Semitendinosus Biceps femoris (long head) Semitendinosus Adductor magnus Semimembranosus Biceps femoris (short head) Superior gluteal Gluteal nerve Inferior gluteal compartment nerve Sciatic nerve (tibial and common fibular)

Vastus lateralis Vastus intermedius Vastus medialis Articularis genu

Tibial nerve (L4S3) Gastrocnemius Posterior compartment of leg Popliteus

Common fibular (peroneal) nerve (L4S2) Plantaris Gastrocnemius

Common fibular (peroneal) nerve (L4S2) Superficial fibular (peroneal) nerve (L4S1) Lateral compartment of leg Fibularis (peroneus) longus Fibularis (peroneus) brevis

Deep fibular (peroneal) nerve (L5S2) Tibialis anterior Extensor hallucis longus Extensor digitorum longus Fibularis (peroneus) tertius

Soleus Flexor digitorum longus Posterior compartment of leg

Tibialis posterior

Anterior compartment of leg

Flexor hallucis longus

Innervation of leg: Extensor digitorum brevis Anterior compartment Lateral compartment Posterior compartment of leg and sole of foot

Medial plantar nerve (L4L5) Abductor hallucis Flexor digitorum brevis Flexor hallucis brevis Lumbrical to 2nd digit

Lateral plantar nerve (S1S2) All other muscles in sole of foot

A. Anterior View

B. Posterior View

5.4

OVERVIEW OF MOTOR INNERVATION OF LOWER LIMB

C2 C3 C4 C5 Spinal nerves C6 C7 C8 T1 C3 C4 C5 C6 C7 T1 T2 Infraspinatus Levator scapulae Rhomboids Suprascapular nerve Supraspinatus Shoulder region

Posterior cord of brachial plexus Subscapularis Teres major

Deltoid Teres minor Axillary nerve

Shoulder region

Radial nerve Latissimus dorsi Posterior compartment of arm Triceps brachii (lateral head) Triceps brachii (medial head) Superficial branch of radial nerve (sensory) Brachioradialis Anconeus Deep branch of radial nerve Extensor carpi radialis longus Extensor carpi radialis brevis Supinator Posterior compartment of forearm Posterior interosseous nerve

Triceps brachii (long head)

Extensor carpi ulnaris Extensor digiti minimi

Abductor pollicis longus

Extensor pollicis brevis Extensor digitorum Extensor pollicis longus Extensor indicis

C. Posterior View

Supraclavicular nerves (C3, C4) Supraclavicular nerves (C3, C4)

Superior lateral cutaneous nerve of arm (from axillary nerve) Intercostobrachial nerve Medial cutaneous nerve of arm (from medial cord of brachial plexus)

Intercostobrachial nerve (from 2nd/3rd intercostal nerve)

Superior lateral cutaneous nerve of arm (from axillary nerve)

Posterior cutaneous nerve of arm (from radial nerve) Inferior lateral cutaneous nerve of arm

Inferior lateral cutaneous nerve of arm (from radial nerve) Medial cutaneous nerve of forearm Posterior cutaneous nerve of forearm (from radial nerve) Lateral cutaneous nerve of forearm (from musculocutaneous nerve) Posterior cutaneous nerve of forearm (from radial nerve) Lateral cutaneous nerve of forearm Posterior branch (from musculoAnterior branch cutaneous nerve) Posterior branch Medial cutaneous nerve of forearm (from medial cord of brachial plexus) Anterior branch Medial cutaneous nerve, of forearm, posterior branches

Posterior cutaneous From radial nerve of forearm nerve

Posterior cutaneous nerve of forearm

Lateral cutaneous nerve of forearm, posterior branch

Radial nerve, superficial branch

Dorsal (cutaneous) branch of ulnar nerve Ulnar nerve Median nerve Palmar (cutaneous) branches of Dorsal (cutaneous) branch of ulnar nerve Dorsal digital branches Radial nerve, superficial branch Communicating branches

Median nerve

Superficial branch of radial nerve

Ulnar nerve, superficial branch

Median nerve, palmar digital branches

A. Anterior View

B. Posterior View

Distal phalanx

Middle phalanx

Proximal phalanx

1 H Tq L 4 5 1 Metacarpal 3 2 R C

H P

C S

Tz

Td

L Tq

J. Anterior View (Right Hand)

Capitate (C) Trapezoid (Td) 6 Hamate (H) 1 1 5 Pisiform (P) Triquetrum (Tq) Lunate (L) 12 3 4 Trapezium (Tz) 7

4 5

2 1

H Tq L P

Td C S R

Tz

Scaphoid (S) U

Numbers: approximate age of ossification of carpal bones in years

K. Anterior View

L. Antero-posterior View, Right Hand

Epiphyses in radiographs appear as radiolucent lines

C4 C5 C6 C7 Lateral cord of brachial plexus T1 T2 Medial cord of brachial plexus Coracobrachialis Musculocutaneous nerve

C4 C5 C6 C7 C8 T1 C6 C7 T1 T1 T2 C7 C8

Medial cord of brachial plexus

Anterior compartment of arm

Biceps brachii Median nerve

Brachialis

Ulnar nerve

Pronator teres Pronator teres Flexor carpi radialis Anterior interosseous nerve Flexor pollicis longus Pronator quadratus Palmaris longus Flexor carpi ulnaris Anterior compartment of forearm

Anterior compartment of forearm

Anterior compartment of forearm

Flexor digitorum superficialis Flexor digitorum profundus (lateral half to digits 2, 3) Palmar interossei

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

Thenar muscles Lumbricals to digits 2, 3

Deep head, flexor pollicis brevis Adductor pollicis

Deep branch of ulnar nerve Palmaris brevis Hypothenar muscles

Lumbricals to digits 4, 5 Dorsal interossei

A. Anterior View

B. Anterior View

C2

C2

C3 C3 C4 C5 T2 T2 T3 T4 T5 T2 T6 T7 T8 T9 T10 T11 T12 L1 C6 C8 C7 L2 L2 S4 S2 S2 L3 L3 S2 L5 L5 S1 S2 L5 L4 L4 S1 L5 L5 S1 L5 S1 L5 S2 L4 L4 L5 S2 C6 S3 C7 C8 S3 L2 S3 S4 S3 T2 T2 T1 C6 C8 C7 C6 T1 L1 L3 S3 C5 C4 C5 C5 C6 C4 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L4 T2 C4 C4 C5

T2

C6 T1

T1 L3 S3 Co S5

C6

C6 C8 C7

S2

S2

L3

Inferior View
L5 S1 S1

Anterolateral View

A.

Posterior View

C2 C3 C4 C5 Spinal nerves C6 C7 C8 T1 C3 C4 C5 C6 C7 T1 T2 Infraspinatus Levator scapulae Rhomboids Suprascapular nerve Supraspinatus Shoulder region

Posterior cord of brachial plexus Subscapularis Teres major

Deltoid Teres minor Axillary nerve

Shoulder region

Radial nerve Latissimus dorsi Posterior compartment of arm Triceps brachii (lateral head) Triceps brachii (medial head) Superficial branch of radial nerve (sensory) Brachioradialis Anconeus Deep branch of radial nerve Extensor carpi radialis longus Extensor carpi radialis brevis Supinator Posterior compartment of forearm Posterior interosseous nerve

Triceps brachii (long head)

Extensor carpi ulnaris Extensor digiti minimi

Abductor pollicis longus

Extensor pollicis brevis Extensor digitorum Extensor pollicis longus Extensor indicis

C. Posterior View

Anterior cerebral Distal medial striate

Anterior communicating* Anteromedial central Anterolateral central striate (lenticulostriate)

*Anterior cerebral
Ophthalmic Internal carotid

Middle cerebral Hypophysial Anterior choroidal Posteromedial central Blood is supplied to the cerebral hemispheres by the: Anterior cerebral artery Middle cerebral artery Posterior cerebral artery Pontine Labyrinthine Basilar

*Posterior communicating *Posterior cerebral

Posterolateral central Superior cerebellar

B. Lateral View

Anterior inferior cerebellar Vertebral Posterior inferior cerebellar Anterior spinal

A. Inferior (Ventral) View

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

820

OVERVIEW OF CRANIAL NERVES

TrochlearCN IV Motor: superior oblique muscle of eye OculomotorCN III Motor: ciliary muscles, sphincter of pupil, all extrinsic muscles of eye except those listed for CN IV and VI OpticCN II Sensory: vision Cranial nerve fibers Motor (efferent) Sensory (afferent) FacialCN VII Primary root Motor: muscles of facial expression and 3 other muscles (see table 9.1)

AbducentCN VI Motor: lateral rectus muscle of eye

OlfactoryCN I Sensory: smell

CN I TrigeminalCN V Sensory root Sensory: face; oral, nasal and sinus mucosa; teeth and anterior two thirds of tongue CN II

CN III CN IV CN VI CN VII CN VII

CN V

FacialCN VII Intermediate nerve Motor: lacrimal, nasal, palatine, submandibular, and sublingual glands Sensory: taste to anterior two thirds of tongue, soft palate

CN VIII CN V

TrigeminalCN V Motor root Motor: muscles of mastication and 4 other muscles (see table 9.1) CN XII CN XI

CN X

CN IX

VestibulocochlearCN VIII Vestibular nerve, sensory: orientation, motion Cochlear nerve, sensory: hearing

VagusCN X Motor: palate, pharynx, larynx, trachea, bronchial tree, heart, GI tract to left colic flexure Sensory : pharynx, larynx; reflex sensory from tracheobronchial 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

HypoglossalCN XII Motor: all intrinsic and extrinsic muscles of tongue (excluding palatoglossus a palatine muscle) Spinal accessoryCN XI Motor: sternocleidomastoid and trapezius

9.3

SUMMARY OF CRANIAL NERVES

Supraclavicular nerves (C3, C4) Supraclavicular nerves (C3, C4)

Superior lateral cutaneous nerve of arm (from axillary nerve) Intercostobrachial nerve Medial cutaneous nerve of arm (from medial cord of brachial plexus)

Intercostobrachial nerve (from 2nd/3rd intercostal nerve)

Superior lateral cutaneous nerve of arm (from axillary nerve)

Posterior cutaneous nerve of arm (from radial nerve) Inferior lateral cutaneous nerve of arm

Inferior lateral cutaneous nerve of arm (from radial nerve) Medial cutaneous nerve of forearm Posterior cutaneous nerve of forearm (from radial nerve) Lateral cutaneous nerve of forearm (from musculocutaneous nerve) Posterior cutaneous nerve of forearm (from radial nerve) Lateral cutaneous nerve of forearm Posterior branch (from musculoAnterior branch cutaneous nerve) Posterior branch Medial cutaneous nerve of forearm (from medial cord of brachial plexus) Anterior branch Medial cutaneous nerve, of forearm, posterior branches

Posterior cutaneous From radial nerve of forearm nerve

Posterior cutaneous nerve of forearm

Lateral cutaneous nerve of forearm, posterior branch

Radial nerve, superficial branch

Dorsal (cutaneous) branch of ulnar nerve Ulnar nerve Median nerve Palmar (cutaneous) branches of Dorsal (cutaneous) branch of ulnar nerve Dorsal digital branches Radial nerve, superficial branch Communicating branches

Median nerve

Superficial branch of radial nerve

Ulnar nerve, superficial branch

Median nerve, palmar digital branches

A. Anterior View

B. Posterior View

828

CRANIAL NERVES III, IV, AND VI: OCULOMOTOR, TROCHLEAR, AND ABDUCENT
Nucleus of CN III Cavernous sinus CN III CN IV CN V1 CN V2 CN III Internal carotid artery Nucleus of CN IV CN IV Levator palpebrae superioris (cut) Superior rectus Medial rectus CN VI Lateral rectus (cut) Inferior oblique Internal carotid artery Nucleus of CN VI Inferior rectus Lateral rectus (cut) Inferior oblique Superior rectus Superior rectus and inferior oblique Superior rectus Inferior oblique CN VI Superior oblique

Oculomotor nerve CN III Lateral rectus Medial rectus Medial rectus Lateral rectus Trochlear nerve CN IV

Rest position

Superior oblique

Inferior rectus

Inferior rectus Superior oblique

Inferior rectus

Superior oblique

Abducent nerve 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. OCULOMOTOR (CN III), TROCHLEAR (CN IV), AND ABDUCENT (CN VI) NERVES a
Functional Components Somatic motor Cells of Origin/Termination Nucleus of CN III Superior orbital ssure Cranial Exit Distribution and Functions Motor to superior, inferior, and medial recti, inferior oblique, and levator palpebrae superioris muscles; raises upper eyelid, directing gaze superiorly, inferiorly, and medially Motor to sphincter pupillae and ciliary muscle that constrict pupil and accommodate lens of eyeball Motor to superior oblique that assists in directing gaze inferolaterally Motor to lateral rectus that directs gaze laterally

TABLE 9.4
Nerve Oculomotor

Visceral motor Presynaptic: midbrain (Edinger-Westphal (parasympathetic) nucleus); Postsynaptic: ciliary ganglion Trochlear Abducent Somatic motor Somatic motor Nucleus of CN IV Nucleus of CN VI

C4 C5 C6 C7 Lateral cord of brachial plexus T1 T2 Medial cord of brachial plexus Coracobrachialis Musculocutaneous nerve

C4 C5 C6 C7 C8 T1 C6 C7 T1 T1 T2 C7 C8

Medial cord of brachial plexus

Anterior compartment of arm

Biceps brachii Median nerve

Brachialis

Ulnar nerve

Pronator teres Pronator teres Flexor carpi radialis Anterior interosseous nerve Flexor pollicis longus Pronator quadratus Palmaris longus Flexor carpi ulnaris Anterior compartment of forearm

Anterior compartment of forearm

Anterior compartment of forearm

Flexor digitorum superficialis Flexor digitorum profundus (lateral half to digits 2, 3) Palmar interossei

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

Thenar muscles Lumbricals to digits 2, 3

Deep head, flexor pollicis brevis Adductor pollicis

Deep branch of ulnar nerve Palmaris brevis Hypothenar muscles

Lumbricals to digits 4, 5 Dorsal interossei

A. Anterior View

B. Anterior View