††††††††† 1 Muscles of the foot. Topography and fasciae of the lower limb.††††††

††††††††† 2 Preparation of head muscles††††††††††††††††††††††††††††††††††††††††††

††††††††† 3 Preparation of neck muscles†††††††††††††††††††††††††††††††††††††††††††

 

LESSON є 10

Theme 1. Muscles of the foot. Topography and fasciae of the lower limb.

Medial group

Abductor hallucis

Х Origin:

1.medial process of calcaneal tuberosity 2.flexor retinaculum 3.plantar aponeurosis 4.medial intermuscular septum

Х Insertion: medial aspect of base of proximal phalanx of hallux Х Action:

1.flexes the big toe (primary action) 2.may assist in abduction of big toe

Х Blood: medial plantar artery Х Nerve: medial plantar nerve, L5,S1

Flexor hallucis brevis

Х Origin:

1.medial aspect of the cuboid 2.lateral cuneiform

Х Insertion:

1.medial aspect of base of proximal phalanx of hallux 2.lateral aspect of base of proximal phalanx of hallux

Х Action: flexes hallux at MTP Х Blood: medial plantar artery Х Nerve: medial plantar nerve, L5,S1

 

Adductor hallucis

Х Origin:

1.oblique head: base of 2nd-4th metatarsals & long plantar ligament 2.transverse head: deep transverse metatarsal ligament & plantar ligaments at MTP joints

Х Insertion: lateral aspect of base of proximal phalanx of hallux Х Action:

1.adduction of hallux at MTP 2.flexes hallux at MTP

Х Blood: lateral plantar artery Х Nerve: lateral plantar nerve, S1,2

 

Middle group

Flexor digitorum brevis

Х Origin:

1.medial process of calcaneal tuberosity 2.plantar aponeurosis

Х Insertion:

Х both sides of the bases of the middle phalanx of rays 2-5 Х (each of the 4 tendons splits forming tunnel for FDL)

Х Action: flexes toes 2-5 Х Blood: medial plantar artery Х Nerve: medial plantar nerve, L5,S1

 

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Quadratus plantae

Х Origin:

1.medial head: medial calcaneus 2.lateral head: lateral calcaneus & long plantar ligament

Х Insertion:

Х lateral margin of tendon of flexor digitorum longus (FDL) Х may send slips into the distal tendons

Х Action:

1.assists FDL in flexing the distal phalanxes of 2nd-5th toes 2.corrects FDL from pulling toes medially

Х Blood: lateral plantar artery Х Nerve: lateral plantar nerve, S1,2

Lumbricals

Х Origin: from tendons of FDL:

1.1st: medial aspect of tendon to 2nd ray 2.2nd-4th: two heads between the tendons in which they lie

Х Insertion: extensor tendons of EDL on dorsal foot Х Action:

1.flex proximal phalanges at MTP 2.extend middle & distal phalanges at IP

Х Blood:

1.1st: medial plantar artery 2.2nd-4th: lateral plantar artery

Х Nerve:

1.1st: medial plantar nerve, L5,S1 2.2nd-4th: lateral plantar nerve, S1,2

 

Plantar interossei (3 muscles)

Х Origin: medial aspect of 3rd-5th metatarsals (each muscle has a single head) Х Insertion: medial aspect of base of proximal phalanx of the same ray (of 3rd-5th rays) Х Action:

1.adduct toes 3-5 2.flex toes 3-5

Х Blood: lateral plantar arch Х Nerve: lateral plantar nerve (deep branch), S1,2

Dorsal interossei (4 muscles)

Х Origin: from both metatarsals between which they lie Х Insertion: base of proximal phalanx closest to the axis of the foot (2nd ray) Х Action:

1.abduct toes 2-4 2.flexes toes 2-4 at MTP

Х Blood: lateral plantar arch Х Nerve: lateral plantar nerve (deep branch), S1,2

 

Lateral group

Abductor digiti minimi

Х Origin:

1.lateral & medial processes of the calcaneal tuberosity 2.plantar aponeurosis 3.lateral intermuscular septum

Х Insertion: lateral aspect of base of proximal phalanx of 5th ray Х Action:

1.abducts 5th toe 2.aids in flexing

Х Blood: lateral plantar artery Х Nerve: lateral plantar nerve, S1,2

 

Abductor ossis metatarsi quinti

Х Origin: from fibers of abductor digiti minimi Х Insertion: into the 5th metatarsal Х Action: abducts the 5th ray Х Blood: lateral plantar artery Х Nerve: lateral plantar nerve, S1,2

 

Flexor digiti minimi brevis

Х Origin:

1.base of 5th metatarsal 2.digital sheath of peroneus longus

Х Insertion: lateral aspect of base of proximal phalanx of 5th ray Х Action: flexes the 5th toe at MTP Х Blood: lateral plantar artery Х Nerve: lateral plantar nerve, S1,2

 

Opponens digiti minimi brevis

Х Action: opposes the digiti minimi

Х Blood: lateral plantar artery Х Nerve: lateral plantar nerve, S1,2

 

Dorsal foot muscles

Extensor hallucis brevis

Х Origin:

1.upper anterolateral calcaneus 2.inferior extensor retinaculum

Х Insertion: base of proximal phalanx of hallux Х Action: extends hallux Х Blood: dorsalis pedis artery Х Nerve: deep peroneal nerve, L4,5

 

Extensor digitorum brevis

Х Origin:

1.upper anterolateral calcaneus 2.inferior extensor retinaculum

Х Insertion: middle & distal phalanges of 2nd-4th rays (via EDL) Х Action: extends 2nd-4th rays Х Blood: dorsalis pedis artery Х Nerve: deep peroneal nerve, L4,5

 

 

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Theme 2. THE TOPOGRAPHY OF THE LOWER EXTREMITY

 

Topographic features of of the lower limb

 

Piriform muscle passing through the major ischiadic foramen does not fill it fully, so as result suprapiriform foramen and infrapiriform foramen appear.

Internal and external obturatorius muscles close obturatum foramen and make up obturatorius canal.

There is a space between inguinal ligament and iliac bone. It divided into two orifices lacuna vasorum (medially) and lacuna musculorum (laterally) by iliоpectineal arch that attached to iliоpectineal eminence. Lacuna vasorum contains femoral artery and vein; lacuna musculorum carries iliоpsoas muscle and femoral nerve.

Femoral annulus (positioned in lacuna vasorum) during passing of the femoral hernia convert into deep annulus of femoral canalу. It bordered laterally by femoral vein, medially - lacunar ligament, anteriorly Ц inguinal ligament and from behind Ц by pectinal ligament.

 

The first 4 cm. of the vessel is enclosed, together with the femoral vein, in a fibrous sheathЧthe femoral sheath. In the upper third of the thigh the femoral artery is contained in the femoral triangle (ScarpaТs triangle), and in the middle third of the thigh, in the adductor canal (HunterТs canal).

 

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The relations of the femoral and abdominal inguinal rings, seen from within the abdomen. Right side.

  The femoral sheath (crural sheath) is formed by a prolongation downward, behind the inguinal ligament, of the fasciæ which line the abdomen, the transversalis fascia being continued down in front of the femoral vessels and the iliac fascia behind them. The sheath assumes the form of a short funnel, the wide end of which is directed upward, while the lower, narrow end fuses with the fascial investment of the vessels, about 4 cm. below the inguinal ligament. It is strengthened in front by a band termed the deep crural arch (page 419). The lateral wall of the sheath is vertical and is perforated by the lumboinguinal nerve; the medial wall is directed obliquely downward and lateralward, and is pierced by the great saphenous vein and by some lymphatic vessels. The sheath is divided by two vertical partitions which stretch between its anterior and posterior walls. The lateral compartment contains the femoral artery, and the intermediate the femoral vein, while the medial and smallest compartment is named the femoral canal, and contains some lymphatic vessels and a lymph gland imbedded in a small amount of areolar tissue. The femoral canal is conical and measures about 1.25 cm. in length. Its base, directed upward and named the femoral ring, is oval in form, its long diameter being directed transversely and measuring about 1.25 cm. The femoral ring is bounded in front by the inguinal ligament, behind by the Pectineus covered by the pectineal fascia, medially by the crescentic base of the lacunar ligament, and laterally by the fibrous septum on the medial side of the femoral vein.

Saphenous opening at the upper and medial part of the thigh, a little below the medial end of the inguinal ligament, is a large oval-shaped aperture in the fascia lata; it transmits the great saphenous vein, and other, smaller vessels, and is termed the fossa ovalis. The fascia cribrosa, which is pierced by the structures passing through the opening, closes the aperture and must be removed to expose it. The fascia lata in this part of the thigh is described as consisting of a superficial and a deep portion.

 

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The fossa ovalis.

 

The Lacunar Ligament (ligamentum lacunare [Gimbernati]; GimbernatТs ligament) is that part of the aponeurosis of the Obliquus externus which is reflected backward and lateralward, and is attached to the pectineal line. It is about 1.25 cm. long, larger in the male than in the female, almost horizontal in direction in the erect posture, and of a triangular form with the base directed lateralward. Its base is concave, thin, and sharp, and forms the medial boundary of the femoral ring. Its apex corresponds to the pubic tubercle. Its posterior margin is attached to the pectineal line, and is continuous with the pectineal fascia. Its anterior margin is attached to the inguinal ligament. Its surfaces are directed upward and downward.

 

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The inguinal and lacunar ligaments.

 


The Reflected Inguinal Ligament (ligamentum inguinale reflexum [Collesi]; triangular fascia).ЧThe reflected inguinal ligament is a layer of tendinous fibers of a triangular shape, formed by an expansion from the lacunar ligament and the inferior crus of the subcutaneous inguinal ring. It passes medialward behind the spermatic cord, and expands into a somewhat fan-shaped band, lying behind the superior crus of the subcutaneous inguinal ring, and in front of the inguinal aponeurotic falx, and interlaces with the ligament of the other side of the linea alba
.


Ligament of Cooper.ЧThis is a strong fibrous band, which was first described by Sir Astley Cooper. It extends lateralward from the base of the lacunar ligament along the pectineal line, to which it is attached. It is strengthened by the pectineal fascia, and by a lateral expansion from the lower attachment of the linea alba (adminiculum lineæ albæ).

 

 

The superficial portion of the fascia lata is the part on the lateral side of the fossa ovalis. It is attached, laterally, to the crest and anterior superior spine of the ilium, to the whole length of the inguinal ligament, and to the pectineal line in conjunction with the lacunar ligament. From the tubercle of the pubis it is reflected downward and lateralward, as an arched margin, the falciform margin, forming the lateral boundary of the fossa ovalis; this margin overlies and is adherent to the anterior layer of the sheath of the femoral vessels: to its edge is attached the fascia cribrosa. The upward and medial prolongation of the falciform margin is named the superior cornu; its downward and medial prolongation, the inferior cornu. The latter is well-defined, and is continuous behind the great saphenous vein with the pectineal fascia.

  The deep portion is situated on the medial side of the fossa ovalis, and at the lower margin of the fossa is continuous with the superficial portion; traced upward, it covers the Pectineus, Adductor longus, and Gracilis, and, passing behind the sheath of the femoral vessels, to which it is closely united, is continuous with the iliopectineal fascia, and is attached to the pectineal line.

  From this description it may be observed that the superficial portion of the fascia lata lies in front of the femoral vessels, and the deep portion behind them, so that an apparent aperture exists between the two, through which the great saphenous passes to join the femoral vein.

 

Theme 3. FASCIAE, SYnoVIAL BURSAE AND SHEATHS OF THE LOWER EXTREMITY

Pelvic fascia is continuation of endoabdominal fascia and part of fasciae that cover iliacus and iliоpsoas muscles (iliac fascia). Pelvic fascia passes into thigh and forms fascia lata femoris. This fascia makes up sheathes for femoral muscles also lateral intermuscular septa and medial intermuscular septa that separate anterior group of femoral muscles from medial and posterior groups.

Fascia lata femoris has superficial lamina and profundus lamina. Profundus lamina of fascia lata femoris extends along the thigh and its most dense part forms tendon of musculus tensor fasciae latae which also called iliоtibial tract. Superficial lamina of of fascia lata lays in femoral trigone and terminetes below by falciform margin that has superior cornu and inferior cornu. Superior cornu inosculates with inguinal ligament, inferior cornu - with deep sheet of fascia lata femoris. Hiatus saphaenus is formed under falciform margin that covered by cribriform fascia (thinnest part of fascia lata). While femoral hernia happened hiatus saphaenus convert into external annulus offemoral canal.

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Cross-section through the middle of the thigh.

 

Femoral canal does not exist at norm (!), it can appear only during forming the cal femoral hernia (pathology). Canal has three walls:

Х lateral wall - femoral vein;

Х anterior wall - superficial lamina of fasciae latae, inguinal ligament and superior cornu of the falciform margin;

Х posterior wall - deep lamina of fasciae latae.

While femoral canal made up femoral annulus is its deep ring and hernia can exit under skin through the hiatus saphaenus (deep ring).

Femoral artery and vein passing through the lacuna vasorum run in iliоpectineus sulcus (between iliacus and pectineus muscles). Then femoral vessels positioned in anterior femoral sulcus which dispoced between adductor magnus medially and medial vastus muscle - laterally. On anterior surface of thigh they can notice femoral trigone, bordered by inguinal ligament above, medially Ц adductor longus muscle and laterally - sartorius muscle. Femoral trigone by its lower angle passes into adductorius canal (Hunter`s canal), that disposed between adductor magnus medially, vastus medial≥s laterally and fibrous laminae between these muscles. Adductorius canal opens below by hiatus into popliteal fossa. Saphaenus nerve also as descendent genu artery and vein pass through anterior hiatus.

Popliteal fossa formed on back surface where thigh passes into leg. It has a diamond shape, bordered above by biceps femoris muscle, semitendonous and semimembranous muscles - medially.

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Popliteal fossa bordered below by lateral and medial heads of gastrocnemius muscle, its floor is popliteal surface of femoral bone and rear surface of knee joint. Here crurо-popliteal canal (Hruber`s canal) originates and passes downward in leg between superficial and deep posterior muscles of the leg. Inferior musculofibular canal branches off from this canal. It is bordered by fibula and flexor hallucis longus muscle. Superior musculofibular canal is independent which dispoced between lateral surface of fibulae and musculus fibularis longus.

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Cross-section through middle of leg.

 

Fascia lata femoris passes into leg as crural fascia, which forms sheathes for muscles of the leg. Anterior intermuscular septa cruris and posterior intermuscular septa cruris spring from it that separate lateral group leg muscles from the anterior and posterior groups. When crural fascia transites on foot some fibrous stripes form:

1)   superior retinaculum musculorum extensorum pedis

2)   inferior retinaculum musculorum extensorum pedis

3)   superior retinaculum musculorum fibulorum

4)   inferior retinaculum musculorum fibulorum

5)   retinaculum musculorum flexorum pedis

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Retinaculum musculorum flexorum pedis covers three osseofibrous canals for tendons of deep posterior crural muscles and fibrous canal for vessels and nerves. Under retinaculum musculorum extensorum pedis three osseofibrous canals for tendons of anterior crural muscles and one fibrous canal for vessels and nerves. Superior retinaculum musculorum fibulorum covers one osseofibrous canal for tendons of peroneus longus and brevis muscles. Inferior one contains two osseofibrous canals for separate tendons of peroneal muscles. Tendons of muscles passing under retinaculum covered by synovial membrane which forms their synovial vaginae of tendons.

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Fascia cruris passes into foot, forming dorsal fascia pedis and plantar fascia. Plantar fascia has superficial lamina and deep lamina. Profundus lamina forms synovial vaginae for plantar muscles, also lateral intermuscular septa and medial intermuscular septa, that separate middle group of muscles from medial and lateral groups. Superficial lamina of plantar fasciae forms plantar aponeurosis, which strengthens the vault of foot. There are medial plantar sulcus between flexor digitorum brevis and abductor hallucis and lateral plantar sulcus between flexor digitorum brevis and abductor digiti minimi where plantar vessels and nerves pass.

The Fascia Covering the Psoas and Iliacus is thin above, and becomes gradually thicker below as it approaches the inguinal ligament.

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Muscles of the iliac and anterior femoral regions.

The portion covering the Psoas is thickened above to form the medial lumbocostal arch, which stretches from the transverse process of the first lumbar vertebra to the body of the second. Medially, it is attached by a series of arched processes to the intervertebral fibrocartilages, and prominent margins of the bodies of the vertebræ, and to the upper part of the sacrum; the intervals left, opposite the constricted portions of the bodies, transmit the lumbar arteries and veins and filaments of the sympathetic trunk. Laterally, above the crest of the ilium, it is continuous with the fascia covering the front of the Quadratus lumborum (see page 419), while below the crest of the ilium it is continuous with the fascia covering the Iliacus.

The portions investing the Iliacus (fascia iliaca; iliac fascia) is connected, laterally to the whole length of the inner lip of the iliac crest; and medially, to the linea terminalis of the lesser pelvis, where it is continuous with the periosteum. At the iliopectineal eminence it receives the tendon of insertion of the Psoas minor, when that muscle exists. Lateral to the femoral vessels it is intimately connected to the posterior margin of the inguinal ligament, and is continuous with the transversalis fascia. Immediately lateral to the femoral vessels the iliac fascia is prolonged backward and medialward from the inguinal ligament as a band, the iliopectineal fascia, which is attached to the iliopectineal eminence. This fascia divides the space between the inguinal ligament and the hip bone into two lacunæ or compartments, the medial of which transmits the femoral vessels, the lateral the Psoas major and Iliacus and the femoral nerve. Medial to the vessels the iliac fascia is attached to the pectineal line behind the inguinal aponeurotic falx, where it is again continuous with the transversalis fascia. On the thigh the fasciæ of the Iliacus and Psoas form a single sheet termed the iliopectineal fascia. Where the external iliac vessels pass into the thigh, the fascia descends behind them, forming the posterior wall of the femoral sheath. The portion of the iliopectineal fascia which passes behind the femoral vessels is also attached to the pectineal line beyond the limits of the attachment of the inguinal aponeurotic falx; at this part it is continuous with the pectineal fascia. The external iliac vessels lie in front of the iliac fascia, but all the branches of the lumbar plexus are behind it; it is separated from the peritoneum by a quantity of loose areolar tissue.

Superficial Fascia.ЧThe superficial fascia forms a continuous layer over the whole of the thigh; it consists of areolar tissue containing in its meshes much fat, and may be separated into two or more layers, between which are found the superficial vessels and nerves. It varies in thickness in different parts of the limb; in the groin it is thick, and the two layers are separated from one another by the superficial inguinal lymph glands, the great saphenous vein, and several smaller vessels. The superficial layer is continuous above with the superficial fascia of the abdomen. The deep layer of the superficial fascia is a very thin, fibrous stratum, best marked on the medial side of the great saphenous vein and below the inguinal ligament. It is placed beneath the subcutaneous vessels and nerves and upon the surface of the fascia lata. It is intimately adherent to the fascia lata a little below the inguinal ligament. It covers the fossa ovalis (saphenous opening), being closely united to its circumference, and is connected to the sheath of the femoral vessels. The portion of fascia covering this fossa is perforated by the great saphenous vein and by numerous blood and lymphatic vessels, hence it has been termed the fascia cribrosa, the openings for these vessels having been likened to the holes in a sieve. A large subcutaneous bursa is found in the superficial fascia over the patella.

Deep Fascia.ЧThe deep fascia of the thigh is named, from its great extent, the fascia lata; it constitutes an investment for the whole of this region of the limb, but varies in thickness in different parts. Thus, it is thicker in the upper and lateral part of the thigh, where it receives a fibrous expansion from the Glutæus maximus, and where the Tensor fasciæ latæ is inserted between its layers; it is very thin behind and at the upper and medial part, where it covers the Adductor muscles, and again becomes stronger around the knee, receiving fibrous expansions from the tendon of the Biceps femoris laterally, from the Sartorius medially, and from the Quadriceps femoris in front. The fascia lata is attached, above and behind, to the back of the sacrum and coccyx; laterally, to the iliac crest; in front, to the inguinal ligament, and to the superior ramus of the pubis; and medially, to the inferior ramus of the pubis, to the inferior ramus and tuberosity of the ischium, and to the lower border of the sacrotuberous ligament. From its attachment to the iliac crest it passes down over the Glutæus medius to the upper border of the Glutæus maximus, where it splits into two layers, one passing superficial to and the other beneath this muscle; at the lower border of the muscle the two layers reunite. Laterally, the fascia lata receives the greater part of the tendon of insertion of the Glutæus maximus, and becomes proportionately thickened. The portion of the fascia lata attached to the front part of the iliac crest, and corresponding to the origin of the Tensor fasciæ latæ, extends down the lateral side of the thigh as two layers, one superficial to and the other beneath this muscle; at the lower end of the muscle these two layers unite and form a strong band, having first received the insertion of the muscle. This band is continued downward, under the name of the iliotibial band (tractus iliotibialis) and is attached to the lateral condyle of the tibia. The part of the iliotibial band which lies beneath the Tensor fasciæ latæ is prolonged upward to join the lateral part of the capsule of the hip-joint. Below, the fasciæ lata is attached to all the prominent points around the knee-joint, viz., the condyles of the femur and tibia, and the head of the fibula. On either side of the patella it is strengthened by transverse fibers from the lower parts of the Vasti, which are attached to and support this bone. Of these the lateral are the stronger, and are continuous with the iliotibial band. The deep surface of the fascia lata gives off two strong intermuscular septa, which are attached to the whole length of the linea aspera and its prolongations above and below; the lateral and stronger one, which extends from the insertion of the Glutæus maximus to the lateral condyle, separates the Vastus lateralis in front from the short head of the Biceps femoris behind, and gives partial origin to these muscles; the medial and thinner one separates the Vastus medialis from the Adductores and Pectineus. Besides these there are numerous smaller septa, separating the individual muscles, and enclosing each in a distinct sheath.

BursæЧThree bursæ are usually found in relation with the deep surface of GLUTEUS muscle. One of these, of large size, and generally multilocular, separates it from the greater trochanter; a second, often wanting, is situated on the tuberosity of the ischium; a third is found between the tendon of the muscle and that of the Vastus lateralis.

The Fasciæ and Muscles of the Head. a. The Muscles of the Scalp

Epicranius

The Skin of the Scalp.ЧThis is thicker than in any other part of the body. It is intimately adherent to the superficial fascia, which attaches it firmly to the underlying aponeurosis and muscle. Movements of the muscle move the skin. The hair follicles are very closely set together, and extend throughout the whole thickness of the skin. It also contains a number of sebaceous glands.

 

The superficial fascia in the cranial region is a firm, dense, fibro-fatty layer, intimately adherent to the integument, and to the Epicranius and its tendinous aponeurosis; it is continuous, behind, with the superficial fascia at the back of the neck; and, laterally, is continued over the temporal fascia. It contains between its layers the superficial vessels and nerves and much granular fat.

  The Epicranius (Occipitofrontalis) is a broad, musculofibrous layer, which covers the whole of one side of the vertex of the skull, from the occipital bone to the eyebrow. It consists of two parts, the Occipitalis and the Frontalis, connected by an intervening tendinous aponeurosis, the galea aponeurotica.

  The Occipitalis, thin and quadrilateral in form, arises by tendinous fibers from the lateral two-thirds of the superior nuchal line of the occipital bone, and from the mastoid part of the temporal. It ends in the galea aponeurotica.

 

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Muscles of the head, face, and neck.

The Frontalis is thin, of a quadrilateral form, and intimately adherent to the superficial fascia. It is broader than the Occipitalis and its fibers are longer and paler in color. It has no bony attachments. Its medial fibers are continuous with those of the Procerus; its immediate fibers blend with the Corrugator and Orbicularis oculi; and its lateral fibers are also blended with the latter muscle over the zygomatic process of the frontal bone. From these attachments the fibers are directed upward, and join the galea aponeurotica below the coronal suture. The medial margins of the Frontales are joined together for some distance above the root of the nose; but between the Occipitales there is a considerable, though variable, interval, occupied by the galea aponeurotica.

The galea aponeurotica (epicranial aponeurosis) covers the upper part of the cranium; behind, it is attached, in the interval between its union with the Occipitales, to the external occipital protuberance and highest nuchal lines of the occipital bone; in front, it forms a short and narrow prolongation between its union with the Frontales. On either side it gives origin to the Auriculares anterior and superior; in this situation it loses its aponeurotic character, and is continued over the temporal fascia to the zygomatic arch as a layer of laminated areolar tissue. It is closely connected to the integument by the firm, dense, fibro-fatty layer which forms the superficial fascia of the scalp: it is attached to the pericranium by loose cellular tissue, which allows the aponeurosis, carrying with it the integument to move through a considerable distance.

Variations.ЧBoth Frontalis and Occipitalis vary considerably in size and in extent of attachment; either may be absent; fusion of Frontalis to skin has been noted.

 

Nerves.ЧThe Frontalis is supplied by the temporal branches of the facial nerve, and the Occipitalis by the posterior auricular branch of the same nerve.

Actions.ЧThe Frontales raise the eyebrows and the skin over the root of the nose, and at the same time draw the scalp forward, throwing the integument of the forehead into transverse wrinkles. The Occipitales draw the scalp backward. By bringing alternately into action the Frontales and Occipitales the entire scalp may be moved forward and backward. In the ordinary action of the muscles, the eyebrows are elevated, and at the same time the aponeurosis is fixed by the Occipitales, thus giving to the face the expression of surprise; if the action be exaggerated, the eyebrows are still further raised, and the skin of the forehead thrown into transverse wrinkles, as in the expression of fright or horror.

  A thin muscular slip, the Transversus nuchæ, is present in a considerable proportion (25 per cent.) of cases; it arises from the external occipital protuberance or from the superior nuchal line, either superficial or deep to the Trapezius; it is frequently inserted with the Auricularis posterior, but may join the posterior edge of the Sternocleidomastoideus.

 

Muscles of the Head subdivided into

Mastication and Facial Expression (mimetic) groups

 

Muscles of Mastication

Masseter

Х Origin:

Х Superficial: 1.zygomatic process of the maxilla 2.inferior border of zygomatic arch

Х Intermediate: inner surface of zygomatic arch Х Deep: posterior aspect of inferior border of zygomatic arch

Х Insertion:

Х Superficial: 1.angle of mandible 2.lateral surface of mandibular ramus

Х Intermediate: ramus of mandible Х Deep: 1.superior ramus of mandible 2.coronoid process of mandible

Х Action: 1.closes the lower jaw (clenches the teeth) 2.may deviate mandible to opposite side of contraction

Х Blood: masseteric arteryХ Nerve: masseteric nerve

 

Medial pterygoid

Х Origin:

1.medial surface of lateral pterygoid plate of the sphenoid 2.palatine bone 3.pterygoid fossa

Х Insertion:

1.inner surface of mandibular ramus 2.angle of the mandible

Х Action:

1.closes the lower jaw (clenches the teeth) 2.can protrude the mandible in combination with the lateral pterygoid

Х Blood: medial pterygoid artery Х Nerve: medial pterygoid nerve

 

Lateral pterygoid

Х Origin:

1.Superior head: lateral surface of the greater wing of the sphenoid 2.Inferior head: lateral surface of the lateral pterygoid plate

Х Insert together:

1.neck of the mandibular condyle 2.articular disk of the TMJ

Х Action:

1.deviates mandible to side opposite of contraction (during chewing) 2.opens mouth by protruding mandible (inferior head) 3.closes the mandible (superior head)

Х Blood: lateral pterygoid artery Х Nerve: lateral pterygoid nerve

 

Temporalis

Х Origin:

Х Temporal fossa

Х Insertion: coronoid process of the mandible

Х Action:

1.closes the lower jaw (clenches the teeth) 2.retraction, pulles back

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Muscles of Facial Expression (mimetic muscles) have such peculiarities:

1.                Originate in bones of face and insert into skin

2.                Do not throw over joints

3.                Do not have proper fasciae (exception is buccinator muscle)

4.                Placed round natural orifices of the face (eyes, nostrils, ears and mouth)

5.                They have an antagonists Ц elastic skin

 

Muscles of Facial Expression (mimetic)

 

Orbicularis oculi

Х Origin:

1.orbital portion: nasal process of frontal bone 2.palpebral portion: palpebral ligament 3.lacrimal portion: lacrimal crest of lacrimal bone

Х Insertion: circumferentially around orbit meeting in palpebral raphe

Х Action: powerfully closes the eye Х Blood: ophthalmic artery Х Nerve: zygomatic branch of facial nerve

 

Corrugator supercilii

Х Origin: frontal bone just above the nose Х Insertion: skin of the medial portion of the eyebrows Х Action: draws the eyebrows downward and medially Х Blood: ophthalmic artery Х Nerve: zygomatic branch of facial nerve

 


Orbicularis oris

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Scheme showing arrangement of fibers of Orbicularis oris.

 

Х Origin:

1.alveolar border of maxilla 2.lateral to midline of mandible

Х Insertion:

1.circumferentially around mouth 2.blends with other muscles

Х Action:

1.closes the lips 2.protrudes the lips

Х Blood: facial artery Х Nerve: buccal branch of facial nerve

 

Levator labii superioris

Х Action: 1.elevates the upper lip 2.flares the nostrils

 

Zygomaticus minor

Х Action: elevates the upper lip

 

Zygomaticus major

Х Action: lifts and draws back the angle(s) of the mouth (as in smiling)

 

Risorius (may be absent)

Х Action: draws the mouth laterally (as in smiling)

 

Levator anguli oris

Х Action: lifts the angle(s) of the mouth (as in smiling)

 

Buccinator

Х Action: compresses the cheek(s)

 

Depressor anguli oris

Х Action: lowers the angle(s) of the mouth (as in frowning)

 

Depressor labii inferioris

Х Action: draws the lower lip downward and laterally

 


Epicranial Musculature

 

Occipitalis (2 bellies)

Х Origin:

1.lateral 2/3 of superior nuchal line 2.external occipital protuberance

Х Insertion: galea aponeurosis, over the occipital bone Х Action: draws back the scalp to raise the eyebrows and wrinkle the brow Х Blood: occipital artery Х Nerve: posterior auricular branch of facial nerve

 

Frontalis (2 bellies)

Х Origin: galea aponeurosis, anterior to the vertex Х Insertion: skin above the nose and eyes Х Action: draws back the scalp to raise the eyebrows and wrinkle the brow Х Blood: ophthalmic artery Х Nerve: temporal branch of facial nerve

 

Anterior, posterior and superior auricularis muscles

Х Action: draws the auricle

 

There are parotid fascia, masseteric fascia and boccopharyngeal fascia in head region.

Regions of head: frontal, parietal, occipital, temporal, auditory, mastoid and facial regions. Facial area has orbital, infraorbital, parotidomasseteric, zygomatic, nasal, oral and mental regions.

 

Neck Musculature

Subdivides into superficial and deep groups

 

Superficial Neck Musculature

Platysma

Х Origin: subcutaneous skin over delto-pectoral region Х Insertion: invests in the skin widely over the mandible Х Action: 1.depress mandible and lower lip 2.tenses the skin over the lower neck

Х Blood: superficial vessels of the neck Х Nerve: cervical branch of facial nerve (VII cranial)

 

Sternocleidomastoid

Х Origin: (two heads)

1.manubrium of sternum 2.medial portion of clavicle

Х Insertion: mastoid process of temporal bone Х Action:

1.rotates to side opposite of contraction 2.laterally flexes to the contracted side 3.bilaterally flexes the neck

Х Blood:

1.occipital artery 2.superior thyroid artery

Х Nerve:

1.motor: spinal accessory (XI cranial) 2.sensory: ventral rami of C2,(C3)

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Suprahyoid group

1. Stylohyoid

Х Origin: styloid process of temporal bone Х Insertion: lateral margin of hyoid (near greater horn) Х Action:

1.pulls the hyoid superiorly & posteriorly during swallowing 2.fixes the hyoid bone for infrahyoid action

Х Blood: facial & occipital artery Х Nerve: facial nerve (VII cranial)

 

2. Digastric

Х Attachments:

1.post belly: mastoid process of temporal bone 2.anterior belly: digastric fossa of internal mandible

Х both bellies meet and attach at the lateral aspect of body of hyoid by a pulley tendon Х Action:

1.open mouth by depressing mandible 2.fixes hyoid bone for infrahyoid action

Х Blood: branches of the external carotid Х Nerve:

1.posterior belly: facial nerve (VII cranial) 2.anterior belly: mylohyoid nerve

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3. Mylohyoid

Х Origin: inner surface of mandible off the mylohyoid line Х Insertion:

1.body of hyoid 2.along midline at mylohyoid raphe

Х Action:

1.elevates the hyoid bone 2.raises floor of mouth (for swallowing) 3.depresses mandible when hyoid is fixed

Х Blood: lingual artery Х Nerve: mylohyoid nerve (branch of mandibular division, V3 cranial)

 

4. Geniohyoid

Х Origin: inner surface of the mandible

Х Insertion: body of hyoid (paired muscles)

Х Action:

1.pulles the tongue 2.depress the mandible 3.works with mylohyoid

Х Blood: lingual artery Х Nerve:

 

Infrahyoid group

1. Sternohyoid

Х Origin:

1.posterior aspect of manubrium 2.sternal end of clavicle

Х Insertion: body of hyoid Х Action:

1.depresses hyoid & larynx 2.acts eccentrically with the suprahyoid muscles to provide them a stable base

Х Blood:

1.inferior thyroid artery (primary) 2.superior thyroid artery

Х Nerve:

1.upper portions: superior root of ansa cervicalis, C2 2.lower portions: inferior root of ansa cervicalis, C2,3

 

2. Omohyoid

Х Attachments:

1.superior belly: hyoid bone (lateral to sternohyoid) 2.inferior belly: superior scapular border (medial to suprascapular notch)

Х both bellies meet at the clavicle & are held to the clavicle by a pulley tendon Х Action:

1.depresses hyoid & larynx 2.acts eccentrically with the suprahyoid muscles to provide them a stable base

Х Blood:

1.inferior thyroid artery (primary) 2.superior thyroid artery

Х Nerve:

1.upper portions: superior root of ansa cervicalis, C2 2.lower portions: inferior root of ansa cervicalis, C2,3

 

3. Sternothyroid

Х Origin: posterior aspect of manubrium Х Insertion: oblique line of thyroid cartilage Х Action:

1.depresses hyoid & larynx 2.acts eccentrically with the suprahyoid muscles to provide them a stable base

Х Blood:

1.inferior thyroid artery (primary) 2.superior thyroid artery

Х Nerve:

1.upper portions: superior root of ansa cervicalis, C2 2.lower portions: inferior root of ansa cervicalis, C2,3

 

4. Thyrohyoid

Х Origin: oblique line of thyroid cartilage Х Insertion: body of hyoid Х Action:

1.depresses hyoid 2.may assist in larynx elevation

Х Blood:

1.inferior thyroid artery (primary) 2.superior thyroid artery

Х Nerve:

1.upper portions: superior root of ansa cervicalis, C2 2.lower portions: inferior root of ansa cervicalis, C2,3

 

Deep Neck Muscles have lateral, medial groups

 

Deep Lateral Neck Musculature

Anterior scalene

Х Attachment A: anterior tubercles of transverse processes of C3-C6 Х Attachment B: 1st rib Х Action:

if transverse process fixed: 1.elevates the ribs for respiration

if ribs fixed: 2.rotates to side opposite of contraction 3.laterally flexes to the contracted side 4.bilaterally flexes the neck

Х Blood: inferior thyroid artery (branch of the thyrocervical trunk) Х Nerve: ventral rami C3-C6

 

Middle scalene

Х Attachment A: transverse processes of all cervical vertebrae Х Attachment B: 1st rib (behind anterior scalene) Х Action:

if transverse process fixed: 1.elevates the ribs for respiration

if ribs fixed: 2.rotates to side opposite of contraction 3.laterally flexes to the contracted side 4.bilaterally flexes the neck

Х Blood: ascending cervical artery Х Nerve: ventral rami C3-C8

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Posterior scalene

Х Attachment A: posterior tubercles of transverse processes of C5 & C6 Х Attachment B: 2nd and/or 3rd rib Х Action:

if transverse process fixed: 1.elevates the ribs for respiration

if ribs fixed: 2.rotates to side opposite of contraction 3.laterally flexes to the contracted side 4.bilaterally flexes the neck

Х Blood: ascending cervical artery Х Nerve: ventral rami C5-C7

 

Neck prevertebral deep Musculature

Longus colli

ХOrigin: lower anterior vertebral bodies and transverse processes Х Insertion: anterior vertebral bodies and transverse processes several segments above Х Action: flexes the head and neck Х Blood: muscular branches of the aorta Х Nerve: ventral rami C2-C6

 

Longus capitis

Х Origin: upper anterior vertebral bodies and transverse processes Х Insertion: anterior vertebral bodies and transverse processes several segments above Х Action: flexes the head and neck Х Blood: muscular branches of the aorta Х Nerve: ventral rami C1-C3

 

Rectus capitis anterior

Х Origin: anterior base of the transverse process of the atlas Х Insertion: occipital bone anterior to foramen magnum Х Action: flexes the head Х Blood: muscular branches of the aorta Х Nerve: ventral rami C2,3

Rectus capitis lateralis

Х Origin: transverse process of the atlas Х Insertion: jugular process of the occipital bone Х Action: bends the head laterally Х Blood: muscular branches of the aorta Х Nerve: ventral rami C2,3

 

Theme 3. THE TOPOGRAPHY AND FASCIAE OF THE HEAD AND NECK

Topography of the neck

Neck has follow regions:

Anterior region is bordered overhead by lower margin of mandible, from below by sternum, from one side Ц by the sternocleidomastoid muscle. Median line of the neck divides anterior region into right and left anterior triangles. There are some areas in each triangle:

1.                Submandibular trigone bordered by lower margin of mandible and both bellies of digastric muscle

2.                There is lingual trigone of Pyrohov in Submandibular triangle that bordered by back margin of mylohyoid muscle, tendon of posterior belly of digastric muscle and hypoglossal nerve. There is lingual artery in this triangle.

3.                Carotid trigone bordered by posterior belly of digastric muscle, superior belly of omohyoid, anterior margin of the sternocleidomastoid and linea alba of the neck.

4.                Muscular (omotracheal) trigone bordered by superior belly of omohyoid, anterior margin of the sternocleidomastoid and linea alba of the neck.

5.                Mental trigone bordered by anterior bellies of both digastric muscles, hyoid bone and mandible.

 

The Fascia Colli (deep cervical fascia) lies under cover of the Platysma, and invests the neck; it also forms sheaths for the carotid vessels, and for the structures situated in front of the vertebral column.

  The investing portion of the fascia is attached behind to the ligamentum nuchæ and to the spinous process of the seventh cervical vertebra. It forms a thin investment to the Trapezius, and at the anterior border of this muscle is continued forward as a rather loose areolar layer, covering the posterior triangle of the neck, to the posterior border of the Sternocleidomastoideus, where it begins to assume the appearance of a fascial membrane. Along the hinder edge of the Sternocleidomastoideus it divides to enclose the muscle, and at the anterior margin again forms a single lamella, which covers the anterior triangle of the neck, and reaches forward to the middle line, where it is continuous with the corresponding part from the opposite side of the neck. In the middle line of the neck it is attached to the symphysis menti and the body of the hyoid bone.

  Above, the fascia is attached to the superior nuchal line of the occipital, to the mastoid process of the temporal, and to the whole length of the inferior border of the body of the mandible. Opposite the angle of the mandible the fascia is very strong, and binds the anterior edge of the Sternocleidomastoideus firmly to that bone. Between the mandible and the mastoid process it ensheathes the parotid glandЧthe layer which covers the gland extends upward under the name of the parotideomasseteric fascia and is fixed to the zygomatic arch. From the part which passes under the parotid gland a strong band extends upward to the styloid process, forming the stylomandibular ligament. Two other bands may be defined: the sphenomandibular (page 297) and the pterygospinous ligaments. The pterygospinous ligament stretches from the upper part of the posterior border of the lateral pterygoid plate to the spinous process of the sphenoid. It occasionally ossifies, and in such cases, between its upper border and the base of the skull, a foramen is formed which transmits the branches of the mandibular nerve to the muscles of mastication.

  Below, the fascia is attached to the acromion, the clavicle, and the manubrium sterni. Some little distance above the last it splits into two layers, superficial and deep. The former is attached to the anterior border of the manubrium, the latter to its posterior border and to the interclavicular ligament. Between these two layers is a slit-like interval, the suprasternal space (space of Burns); it contains a small quantity of areolar tissue, the lower portions of the anterior jugular veins and their transverse connecting branch, the sternal heads of the Sternocleidomastoidei, and sometimes a lymph gland.

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Section of the neck at about the level of the sixth cervical vertebra.

Showing the arrangement of the fascia coli.

 

  The fascia which lines the deep surface of the Sternocleidomastoideus gives off the following processes: (1) A process envelops the tendon at the Omohyoideus, and binds it down to the sternum and first costal cartilage. (2) A strong sheath, the carotid sheath, encloses the carotid artery, internal jugular vein, and vagus nerve. (3) The prevertebral fascia extends medialward behind the carotid vessels, where it assists in forming their sheath, and passes in front of the prevertebral muscles. It forms the posterior limit of a fibrous compartment, which contains the larynx and trachea, the thyroid gland, and the pharynx and esophagus. The prevertebral fascia is fixed above to the base of the skull, and below is continued into the thorax in front of the Longus colli muscles. Parallel to the carotid sheath and along its medial aspect the prevertebral fascia gives off a thin lamina, the buccopharyngeal fascia, which closely invests the Constrictor muscles of the pharynx, and is continued forward from the Constrictor pharyngis superior on to the Buccinator. It is attached to the prevertebral layer by loose connective tissue only, and thus an easily distended space, the retropharyngeal space, is found between them. This space is limited above by the base of the skull, while below it extends behind the esophagus into the posterior mediastinal cavity of the thorax. The prevertebral fascia is prolonged downward and lateralward behind the carotid vessels and in front of the Scaleni, and forms a sheath for the brachial nerves and subclavian vessels in the posterior triangle of the neck; it is continued under the clavicle as the axillary sheath and is attached to the deep surface of the coracoclavicular fascia. Immediately above and behind the clavicle an areolar space exists between the investing layer and the sheath of the subclavian vessels, and in this space are found the lower part of the external jugular vein, the descending clavicular nerves, the transverse scapular and transverse cervical vessels, and the inferior belly of the Omohyoideus muscle. This space is limited below by the fusion of the coracoclavicular fascia with the anterior wall of the axillary sheath. (4) The pretrachial fascia extends medially in front of the carotid vessels, and assists in forming the carotid sheath. It is continued behind the depressor muscles of the hyoid bone, and, after enveloping the thyroid gland, is prolonged in front of the trachea to meet the corresponding layer of the opposite side. Above, it is fixed to the hyoid bone, while below it is carried downward in front of the trachea and large vessels at the root of the neck, and ultimately blends with the fibrous pericardium. This layer is fused on either side with the prevertebral fascia, and with it completes the compartment containing the larynx and trachea, the thyroid gland, and the pharynx and esophagus.  

   

Variations.ЧThe Sternocleidomastoideus varies much in the extent of its origin from the clavicle: in some cases the clavicular head may be as narrow as the sternal; in others it may be as much as 7.5 cm. in breadth. When the clavicular origin is broad, it is occasionally subdivided into several slips, separated by narrow intervals. More rarely, the adjoining margins of the Sternocleidomastoideus and Trapezius have been found in contact. The Supraclavicularis muscle arises from the manubrium behind the Sternocleidomastoideus and passes behind the Sternocleidomastoideus to the upper surface of the clavicle.

 

Triangles of the Neck.ЧThis muscle divides the quadrilateral area of the side of the neck into two triangles, an anterior and a posterior. The boundaries of the anterior triangle are, in front, the median line of the neck; above, the lower border of the body of the mandible, and an imaginary line drawn from the angle of the mandible to the Sternocleidomastoideus; behind, the anterior border of the Sternocleidomastoideus. The apex of the triangle is at the upper border of the sternum. The boundaries of the posterior triangle are, in front, the posterior border of the Sternocleidomastoideus; below, the middle third of the clavicle; behind, the anterior margin of the Trapezius. The apex corresponds with the meeting of the Sternocleidomastoideus and Trapezius on the occipital bone. The anatomy of these triangles will be more fully described with that of the vessels of the neck (p. 562).

 

Nerves.ЧThe Sternocleidomastoideus is supplied by the accessory nerve and branches from the anterior divisions of the second and third cervical nerves.

 

Actions.ЧWhen only one Sternocleidomastoideus acts, it draws the head toward the shoulder of the same side, assisted by the Splenius and the Obliquus capitis inferior of the opposite side. At the same time it rotates the head so as to carry the face toward the opposite side. Acting together from their sternoclavicular attachments the muscles will flex the cervical part of the vertebral column. If the head be fixed, the two muscles assist in elevating the thorax in forced inspiration.

 

Sternocleidomastoid region answers the projection of the same name muscle.

Lateral region of the neck is bordered by back margin of the sternocleido-mastoid, anterior margin of the trapezius muscle and upper margin of clavicle. There are follow areas in this region:

1.                Omo-trapezial trigone is bordered by back margin of the sternocleidomastoid, lower belly of omohyoid and anterior margin of the trapezius muscles.

2.                Omo-clavicular (greater supraclavicular) trigone of neck is bordered by back margin of the sternocleidomastoid, lower belly of omohyoid and upper margin of the clavicle.

Posterior region answers the projection of the trapezius muscle.

Cervical fascia

According V.M.Shevkunenko there are 5 cervical fasciae:

I - superficial cervical fascia envelops the platizma

Proper cervical fascia has two sheets:

II - superficial lamina of the proper cervical fasciae starts from front surface of the sternum and clavicle, lower margin of mandible and attaches the spinous processes of the cervical vertebrae. It forms the sheath for sternocleidomastoid and trapezius muscles.

III - deep lamina of the proper cervical fasciae starts from back surface of the sternum and clavicle and attaches to the hyoid bone from sides bordered by omohyoid muscles. This fascia forms linea alba of neck and the sheath for infrahyoid muscles.

Suprasternal interaponeurotic space made up between superficial and deep lamina of the proper cervical fasciae. It contains jugular venous arch and fat tissue. Suprasternal space connects with lateral recesses located behind the lower part of sternocleidomastoid muscle.

IV - internal cervical fascia subdivides into parietal and visceral sheets. Parietal lamina envelopes all organs of neck together and visceral Ц each organ separately. Previsceral space positioned between parietal and visceral laminae and contains adipose tissue, lymphatic nodes, and nerves and communicates with anterior mediastinum. Pretracheal space located before trachea between parietal and visceral sheets.

1.                V - prevertebral fascia envelops all deep cervical muscles forming their sheathes. Retropharyngeal space made up between V fascia and parietal lamina of IV fasciae. Retrovisceral space positioned between internal cervical and prevertebral fasciae and contains adipose tissue and continues into posterior mediastinum.

2.                Superficial lamina meets the superficial lamina of the proper cervical fasciae according V.M.Shevkunenko and contains the suprasternal space.

3.                Pretracheal lamina meets the deep lamina of the proper cervical fasciae according V.M.Shevkunenko and forms carotid sheath.

4.                Prevertebral lamina meets the same fasciae according V.M.Shevkunenko.

 

According international nomenclature (PNA)

there are 3 laminae of cervical fasciae:

Interscalenum space positioned between anterior and middle scalene muscles where subclavian artery passes. Anterscalenum space located in front of scalene muscles where subclavian vein passes.

Deep lamina of the proper cervical fasciae (V.M.Shevkunenko) associating infrahyoid muscles forms omoclavicular aponeurosis or cervical sail (Rishe). Cervical sail assists to drain superficial veins of neck that spliced with it.

 

Prepared by

Reminetskyy B.Y.