- Skin

Epidermis
o Originates from ectoderm
o Surface epithelium
o Derivatives include skin appendages e.g. sweat glands, sebaceous glands,
hair and nails
Sweat glands are coiled tubular structures that stem from the dermis
and subcutaneous tissue. They are abundant in the thick skin on
palms and soles and face. They are absent in skin of TM, glans penis,
labia minora, inner surface of prepuce, areolar. Innervated by
cholinergic sympathetic nerve fibres.
Apocrine glands are modified sweat glands that have bigger ducts that
open directly onto skin surface or into hair follicles. They are found in
axillae, periumbilical, perianal and genital regions. Innervation is
adrenergic sympathetic neurones.
Sebaceous glands extend into the dermis. They are found in hair
containing skin, and open up into the side of hair follicles. Hairless skin
including lips, areolae, nipples, glans penis, labia minora, inner surface
of prepuce also contain these glands. The palms and soles are absent
of these glands.
Hair and nails are types of hard keratin. They extend into dermis and
subcutaneous tissue. Hair is produced from hair matrix, which is a
group of epidermal cells that line the tubular hair follicle. As the cells
extend into epidermis, they lose their nuclei and became keratin. The
colour is determined by melanin, secreted from melanocytes. The
arrector pili (smooth) muscle is attached obliquely to hair follicle and
on contraction (sympathetic) it causes hair to stand up, and
compresses the sebaceous gland that lies between the arector pili and
hair.
Dermis originates from mesoderm
o Consists of collagen, blood vessels, lymphatics and nerve fibres
o Papillary (loosely arranged collagen fibres) and reticular layers (densely
arranged collagen fibres).
o Nerve fibres contain afferent fibres, which are somatic sensory neurones, and
efferent fibres, which are sympathetic neurones to smooth muscles (arector
pili, blood vessels) and sweat glands.
Langer lines / tension lines of the skin are due to the pattern of arrangement of
collagen fibres. Incisions along these lines reduces scar tissue formation and
improves cosmesis.
- Superficial fascia is between skin and underlying deep fascia / bone. The superficial
fascia consists of loose areolar connective tissue, with varying amount of adipose
tissue.
- Deep fascia is a membrane of fibrous tissue that wraps limbs and body wall.
- Ligaments are dense connective tissue made up of collagen fibres between bones.
- Tendons are dense connective tissue made up of collagen fibres between muscle and
bone.
Where tendons are involved in gliding against adjacent structures, the tendon is
covered in synovial sheath. This sheath is composed of parietal and visceral layers,
with a thin film of lubricating synovial fluid, which allows the gliding of tendons
under less friction.

- Cartilage
Dense connective tissue
Hyaline cartilage
o E.g. costal cartilage, articular cartilage of synovial joints, most of laryngeal
cartilage, tracheobronchial cartilage, nasal and epiphyseal growth plates.
o No capillaries. Exchange is via diffusion through the ground substance.
o May calcify and ossify with age.
Fibrocartilage

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 o E.g. IV discs, pubis symphysis, labrum of shoulder and hip joints, menisci of
knee joints, articular cartilage of the bones that underwent intramembranous
ossification e.g. squamous temporal bone, mandible, and clavicle.
o Sparse blood supply.
o May calcify and ossify with age.
Elastic cartilage
o E.g. external ear (pinna), Eustacian tube, epiglottis.
o No capillaries.
o Never calcifies.
- Muscle
Skeletal
o Striated (actin-myosin arrangement)
o Long, cylindrical, non-branching fibres with multinucleated nuclei.
o Fibres are either parallel or oblique to the line of the pull of the whole muscle.
Oblique are subdivided into unipennate, bipennate, and multipennate
muscles.
o Skeletal muscle fibres can be intrafusal or extrafusal. Intrafusal fibres are
specialized fibres grouped together is fusiform connective tissue capsule that
inform the CNS about the state of contraction of the muscle via sensory
neurones. Intrafusal fibres are innervated by gamma motor neurones. The
extrafusal fibres are innervated by the larger alpha motor neurones.
o Skeletal muscle can be the prime mover, antagonist, synergist or fixator.
o The muscle fibres (cells) are surrounding in endomysium fascia. Bundles of
fibres are grouped via perimysium to form muscle fascicle. The entire muscle
is ensheathed by epimysium.
Cardiac
o Striated
o Broad, short, branching fibres (to increase surface area for conduction of
impulses)
o One or two nuclei
o Fibres are laid in spirals and whorls
Smooth muscle
o Narrow spindle-shaped fibres.
o Single nucleus cells.
o In muscles that have peristaltic contractions, the fibres are laid in layers
(circular and longitudinal) e.g. bowel, ureter. In muscles involved in non-
peristaltic contractions e.g. bladder, uterus, the fibres are laid out in spirals
and whorls.
- Bone
Dense connective tissue. Consists of organic substances, and cells embedded in a
matrix of organic material e.g. collagen, and inorganic material e.g. calcium and
phosphate salts.
Two type: Compact and cancellous.
o Compact bone is the type of bone in the cortex. The collagen fibres are laid in
concentric laminae parallel to the long axis of the bone. The laminae
surround a central canal (Haversian canal) containing blood vessels in a
Haversian system or osteons. The nutrients diffuse to the osteocytes. The
Haversian systems run in parallel to each other, and the circulation
communicates between systems and medullary cavity is via transversely
running Volkman canals.
o Cancellous bone is fine trabeculae bone that is arranged according to
stresses affecting the bone. Found in the interior of bones and articular ends
of long bones. The organization of collagen is also in lamellae, however there
are usually no blood vessels in cancellous bone, nutrients are delivered via
diffusion from medullary vessels.
Formed by either intramembranous ossification or endochondral ossification.
o Intramembranous ossification is when bone is laid down in membrane in
fibrous tissue without a cartilage precursor. This occurs in the thickening of
subperiosteal bone, formation of bones of the vault, face and clavicle.
o Endochondral ossification occurs in the rest of the body and in longitudinal
growth of long bone, and is the replacement of cartilage with bone. The

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 epiphysis is cartilaginous and therefore does not have a blood supply. The
epiphysis is supplied by branches from the periarticular vascular plexus.
When the epiphyseal growth plate cartilage is replaced by bone, the bone
cease to grow in length. The growing end of the diaphysis is called the
metaphysis, and is supplied by end arteries, therefore a vulnerable site of
infarction and embolism and hence osteomyelitis. However after ossification
of the epiphysis the blood supply of the epiphysis anastomoses with that of
the diaphysis, and therefore the metaphysis does not have a predilection for
osteomyelitis in adults.
Primary ossification centre is in the diaphysis, while secondary ossification centre
takes place in the epiphyses of long bones. Primary ossification starts during intra-
uterine life. Secondary ossification starts soon after birth.
The periosteum is a thick vascular fibrous tissue that lines the outer surface of bone.
Its inner layer is osteogenic. The blood supply to the periosteum is required for the
underlying bone. The periosteum adheres to the bone via strong Sharpeys fibres.
The inner lining of the bone is endosteum, and is also osteogenic.
The medullary cavity contains red and yellow marrow. At birth all marrow is red,
which is capable of haemopoesis. However with advancing age the red marrow is
replaced by yellow marrow, and this process starts distally. Red marrow is found in
the ribs, sternum, vertebrae, and proximal parts of the humerus and femur, girdle
bones which are the sites of metastasis.
Blood supply is one or two nutrient arteries. Within the medullary cavity they divide
into ascending and descending branches. Near the ends of bones, the periarticular
plexus provides anastomoses. Cortical bone is supplied by the periosteal blood
vessels.
Sesamoid bones appear where there may be change in direction of tendon or friction
between tendon and adjacent structures.

- Joints
Three types: synovial, cartilage and fibrous.
Synovial joints have six features:
o Articular surfaces lined with hyaline cartilage
o Fibrous capsule
o The inner lining of the capsule and covering intra-articular structures is
synovial membrane, which secretes synovial fluid
o Cavity within the intra-articular space
o Ligaments, either intracapsular or extracapsular or both, reinforce the
capsule.
o Mobile joints
o A state of fully congruent articular surfaces is called close-packed, whereas
when surfaces the less congruent loose-packed.
Cartilage joints can be primary cartilage joints (synchondrosis) or secondary
cartilage joints (symphysis).
o Primary cartilage joints (synchondrosis) are between bone and cartilage e.g.
epiphysis and bone, costal cartilage and the adjoining rib. Primary cartilage
joints are very strong.
o Secondary cartilage joints (symphysis) occur in the midline and include the
pubic symphysis (bone fibrocartilage bone), manubrio-sternal joint.
Intervertebral disc (bone fibrocartilage bone).
Fibrous joints are where fibrous tissue joins bones. Largely immobile. They occur in
the suture lines of the bones of the vault, and syndesmosis of the tibia/fibula.
- Mucous membrane lines the inside of structures that communicate either directly or
indirectly with the exterior. The membrane consists of an epithelium and lamina propria
(connective tissue). Sometimes there is muscular component of the connective tissue
called muscularis mucosae.
- Serous membrane lines the closed cavities inside the body i.e. pleural, pericardial and
peritoneal cavities. Consists of mesothelial cells (derived from mesoderm) and
connective tissue. The membrane consists of two continuous layers parietal and
visceral. The mesothelial cells do not contain glands, the fluid between the two layers is
tissue fluid, and the cavity between the two layers represents a potential space. The
parietal layer has somatic innervation, and visceral layer has autonomic innervation.

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- Blood vessels
Arteries and veins have three layers:
o Tunica intima: single layer of endothelium, connective tissue and internal
elastic lamina (veins do not have a distinct internal elastic lamina)
o Tunica media: elastic connective tissue (greater amounts present in large
arteries), and smooth muscle (greater amounts present in arterioles).
o Tunica adventitia: external elastic lamina surrounded by connective tissue.
Anastomosis is a communication between blood vessels:
o Actual anastomosis: end-to-end anastomosis
o Potential anastomosis: Terminal arterioles can dilate to convey blood, but not
in case of sudden occlusion.
o Arterio-venous anastomosis: between arteriole and venule, which bypasses
the capillary bed.
Capillaries are single layer endothelium. No capillaries in cornea and hyaline
cartilage.
Veins have valves. But veins in the thorax and abdomen are valveless.
Sinusoids are large diameter endothelial tubes with fenestrations.

- Lymphatics and lymphoid tissue

Lymphatic capillaries are single layered endothelial cells. Larger lymphatic walls
have similar constitution to blood vessels but not in distinct layers. Lymphatics have
many more valves than veins. Superficial lymphatics run along with veins, and deep
lymphatics run along with arteries. Lymphatics drain tissue fluid, eventually via
thoracic duct back into venous system, however there are many anastomotic
channels.
Lymphoid tissue can be primary organs where lymphocytes are produced from
progenitor stem cells (bone marrow in adults, and liver, spleen and yolk sac in fetus)
and thymus (where they undergo proliferation) or secondary organs, which include
spleen, lymph nodes and MALT (mucosa associated lymphoid tissue), where
lymphocytes travel to.
Innate immunity is non-specific defense against microorganism/foreign body, and
includes phagocytosis.
Adaptive immunity is specific immune response and is subdivided into cell-mediated
(T-cell response) and humoral response (B cell response). The bone marrow produces
all lymphocytes. T cells must pass through the thymus gland for maturation. The B
and T cells circulate to and reside in secondary lymphoid tissue including lymph
nodes, spleen and MALT.
Lymphoid organs (lymph nodes, spleen, thymus) are encapsulated. Unencapsulated
lymphoid tissue occurs in MALT.
o MALT includes: Gut associated lymphoid tissue (GALT), bronchus associated
lymphoid tissue (BALT). Peyers patches in ileum and Waldeyers
peripharyngeal ring of tonsils are organized MALT.
o The histological appearance of lymphoid tissue consists of lymphoid follicles
with a germinal centre. This is the same in all lymphatic organs except the
thymus gland, which contains a cortex of continuous band of lymphocytes
with an inner medulla, which contains the thymic corpuscules of Hassall
(remnants of the epithelium of the 3rd pharyngeal pouches). There are also
macrophages present in lymphoid tissue.
o Spleen has white pulp and red pulp.
o Lymph nodes contain cortex with lymphocytes (B lymphocytes in follicles, and
T lymphocytes between follicles). Afferent lymph vessels.
B cells differentiate into (antibody producing) plasma cells and memory cells. T cells
differentiate into cytotoxic, regulatory and helper T cells.

- Nervous system
Central nervous system (brain and spinal cord) and peripheral nervous system.
Two types of cells: neurons and neuroglia. Neuron fibres are specialized cells that
conduct nerve impulses. Neuroglia are supporting cells in the CNS e.g. astrocytes,
oligodendrocytes (ectodermal orgin) and microglia (phagocytic cells of mesodermal
origin); in PNS e.g. schwann cells.

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 A collection of neuron cell bodies in the CNS is called nucleus, and in PNS it is called
ganglion.
A collection of nerve processes in the CNS is called tract, and in PNS is called nerve.
Neurons are classified according to their conduction velocity, which is related to size:
o Group A (large high velocity fibres)
Alpha motor (extrafusal muscle fibres), proprioception
Beta touch, vibration
Gamma intrafusal motor
Delta pain, touch, temperature
o Group B
Myelinated. Pre-ganglionic autonomic.
o Group C (small fibres)
Unmyelinated. Pain, touch. Post-ganglionic autonomic.
Myelin sheath produced by oligodendrocytes (CNS) and schwann cells (PNS) increase
velocity of conduction.
Neurotransmitters are released at synapse (between two neuron processes) and
neuromuscular endplate.
There are 31 pairs of spinal nerve.
o 8 cervical nerves.
o 12 thoracic nerves.
o 5 lumbar nerves.
o 5 sacral nerves.
o 1 coccygeal nerve.
Each spinal nerve is made by rootlets from the spinal cord joining to form ventral
and dorsal roots, respectively. The ventral root contains motor fibres, autonomic
fibres, and a small number of unmyelinated pain fibres that have double-backed
from the dorsal root ganglion to enter the spinal cord via the ventralroot rather than
dorsal root. The dorsal root contains sensory fibres, with its cell bodies in the dorsal
root ganglion. The dorsal root ganglion contains unipolar neurons, of which the
process has bifurcated going to the CNS and sensory receptor. The ventral and
dorsal roots joint to form the spinal nerve. The mixed spinal nerve immediately
divides into anterior and posterior rami. The anterior rami are large, and posterior
rami are small. The plexuses are only made up of anterior rami.
o Large nerves have their own nerve supply called nervi nervorum. The blood
supply to nerves is from branches of local arteries.
o The peripheral spinal nerve is composed of neurons or nerve fibres, which are
covered in thin connective tissue called endoneurium. Bundles of neurons are
wrapped in perineurium to form fascicles. The entire spinal nerve is covered
in epineurium.
Nerve supply to the body wall:
o Posteriorly: the posterior rami of spinal nerves. The posterior rami provide
sensory supply to the skin and motor supply to the extensors of the back and
neck (erector spinae muscles, transversospinalis muscles, and levator costae
muscles, in the neck the splenius and muscles deep to it are supplied). The
posterior ramus divides into medial and lateral branches. The medial
branches supply the skin in the top part of the thorax up to T6, and lateral
branches supply the remainder. C1 has not cutaneous supply. The posterior
rami of C6, C7, L4, L5 do not have sensory supply.
o Laterally: the anterior rami of spinal nerves enter intercostal nerves, which
run in the neurovascular plane between the innermost intercostal muscles
and internal intercostal muscles. The intercostal nerves give off lateral
cutaneous branches, which supply the lateral aspect of the body wall skin.
o Anteriorly: the intercostal nerves give off anterior cutaneous branches, which
supply the anterior body wall skin.
o The anterior rami supply the pre-vertebral flexor muscles e.g. psoas,
quadratus lumborum, scalene muscles.
o The anterior rami of the spinal nerves T1-T6 enter the intercostal nerves,
which supply the intercostal muscles in the intercostal spaces.
o The anterior rami of T7 T12 pass below the costal margin and supply the
skin of the abdominal wall segmentally.

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 o C2-C4 supply skin in the neck by branches of the cervical plexus.
o C5-T1 supply skin of the upper limb via the brachial plexus.
o The nerves run on the outside of the vasculature.
o Every spinal nerve carries post-ganglionic sympathetic fibres, mainly to
arterioles.
Nerve supply to the limbs:
o The limb buds grow out from the lateral body wall, and therefore take its
nerve supply with it. The lateral branches of the anterior rami supply the
lateral body wall. The upper limb is supplied by spinal nerves C5 T1. The
lower limbs are extended and medially rotatedfrom fetal position, and
supplied by spinal nerves T12 S3.
o Muscles of the lower limb are supplied as follows:
L2, L3 (hip flexion, internal rotation, adduction)
L4, L5 (hip extension, external rotation, abduction)
L3, L4 (knee extension)
L5, S1 (knee flexion)
L4, L5 (ankle dorsiflexion)
S1, S2 (ankle plantarflexion)
L4 (foot inversion)
L5, S1 (foot eversion)
o Muscles of the upper limb are supplied as follows:
C5 (shoulder abduction, lateral rotation)
C6, C7, C8 (shoulder adduction, medial rotation)
C5, C6 (elbow flexion)
C7, C8 (elbow extension)
C6, C7 (wrist flexion and extension)
C6 (supination)
C7, C8 (pronation)
C7, C8 (finger and thumb flexion and extension)
T1 (intrinsic hand muscles)
Spinal reflexes / deep tendon reflexes / myotatic reflexes
o Monosynaptic reflex arc composed of two neurons.
o Tapping the tendon stretches the intrafusal fibres of the muscle spindle,
which causes alpha motorneurons to transmit impulses to the extrafusal
muscle fibres, and thereby causes contraction on the muscle.
Biceps: C6
Triceps: C7
Knee: L3
Ankle: S1
o Superficial skin reflexes which are multi-synaptic.
Abdominal reflex
Anal wink reflex
Plantar reflex (extension is normal before age of 1 as the corticospinal
tracts have not yet been myelinated)
Autonomic nervous system
o Sympathetic: thoracolumbar outflow
There are preganglionic and postganglionic neurons.
The preganglionic neuron cell body is in the lateral horns of the spinal
cord. It travels within the ventral root, spinal nerve, anterior ramus,
white ramus communicans, sympathetic trunk (within which are
ganglia 3 cervical [the first 4 merge to form the superior cervical
ganglion, the next 2 form the middle cervical ganglion, and the inferior
2 +/- T1 ganglion form the inferior cervical ganglion/stellate ganglion],
11 thoracic, 4 lumbar).
The preganglionic neuron synapses with postganglionic neurons in
ganglia in the sympathetic trunk at the same level, or above, or below
that level. Alternatively the preganglionic neurons do not synapse in
the ganglion, and instead pass through the ganglion and travel to the
autonomic plexus in the viscera for synapsing. A third possibility is the
preganglionic neuron does not synapse in the sympathetic ganglion

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 and travels to the adrenal glands, where it synapses with medullary
cells, which are modified postganglionic cells.
The postganglionic neurons from the sympathetic trunk ganglions
travel to the viscera via visceral branches (cardiac branch from the
cervical region (all three cervical ganglia superior, middle and
inferior cervical ganglions) and then forms the cardiac plexus, where it
is supplemented by fibres from thoracic ganglia).
The splanchnic nerves (from thoracic, lumbar and sacral regions) and
they form the coeliac plexus, superior hypogastric plexus, and right
and left inferior hypogastric plexus. The postganglionic neurons can
pass from the ganglion back into the spinal nerve via grey ramus
communicans (grey because these are unmyelinated fibres), and
these sympathetic postganglionic neurons travel to the blood vessels,
sweat glands and arector pili muscle.
The sympathetic ganglia also give off vascular branches which give
branches to the large blood vessels e.g.e the superior cervical
ganglion gives off the internal carotid nerve, which runs with the
internal carotid artery and forms the internal carotid plexus on the
artery as it enter the skull.
Every spinal nerve is connected to sympathetic chain via grey ramus
communicans. However only thoracolumbar (first 2 lumbar segments)
spinal nerves have both white and grey rami communicantes. The
ganglia connected to cervical, lower lumbar and sacral nerves receive
sympathetic preganglionic neurons via the sympathetic chain.
The sympathetic supply is to the entire body to cardiac muscle,
smooth muscle, sweat glands and apocrine glands.
o Parasympathetic: craniosacral outflow
The preganglionic neuron cell bodies lie in nuclei (accessory
oculomotor nucleus[edinger-westphal nucleus], superior salivatory
nucleus of CN 7, inferior salivatory nucleus of CN 9, and dorsal motor
nucleus of vagus) and lateral horn of sacral spinal cord.
The preganglionic neuron travels in the spinal nerve, anterior ramus
and synapses in the parasympathetic ganglia (this is the case for
preganglionic neurones which have cell bodies in the accessory
oculomotor nucleus, superior salivatory nucleus of CN 7, and inferior
salivatory nucleus of CN9), while preganglionic neurons from the
dorsal motor nucleus of vagus travel via vagus nerve and synapse
with postganglionic neurons at the effector organ via visceral plexuses
i.e. coeliac plexus.
The sacral preganglionic neurons have cell bodies in the lateral horns
of the spinal cord S2-S4, and travel in the anterior rami of sacral
splanchnic nerves S2 S4 and synapse in the walls of the abdominal
viscera to enter into the formation of the inferior hypogastric plexus.
Parasympathetic nerves join the sympathetic visceral plexuses.
Parasympathetic supply is only to viscera, not to limbs or trunk.
However, adrenal glands and gonads do not have parasympathetic
innervation.
o Parasympathetic ganglion
In the head and neck. Site of synapse for three of the four cranial
parasympathetic nuclei (edinger-westphal, superior salivatory nucleus,
inferior salivatory nucleus).
Each contains parasympathetic root, sensory root, sympathetic root.
However only the parasympathetic root synapses within the ganglion
Ciliary ganglion
Preganglionic parasympathetic neurons from Edinger-Westphal
nucleus (brain stem nucleus) travel in the oculomotor nerve to
the ciliary ganglion, where postganglionic neurons supply the
ciliary muscle and sphincter pupillae (causes iris to contract).
Sensory fibres from the ophthalmic division of trigeminal nerve.
Sympathetic fibres from the internal carotid plexus (originates
from superior cervical sympathetic ganglion).

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 Pterygopalatine ganglion
Preganglionic parasympathetic neurons from the Superior
Salivatory nucleus of CN VII (brainstem nucleus) travel in
Nervus Intermedius (branch of CNVII), which gives a branch
called nerve of pterygoid canal, and synapses in the
pterygopalatine ganglion. The postganglionic neurons supply
the lacrimal gland, nasal glands, and palatal glands.
Sensory fibres from the maxillary division of trigeminal nerve
pass through the pterygopalatine ganglion.
Sympathetic fibres from the internal caroid artery plexus
(originates from superior cervical sympathetic ganglion) pass
through the pterygopalatine ganglion.
Submandibular ganglion
Preganglionic parasympathetic neurons from the Superior
Salivatory nucleus of CN VII (brainstem nucleus) travel in the
Nervus Intermedius, then lingual nerve, and synapse in the
submandibular ganglion with postganglionic neurons that
supply the submandibular gland and sublingual gland.
Sensory supply from mandibular division of trigeminal nerve
passes through the submandibular ganglion.
Sympathetic fibres from the external carotid artery plexus
(originates from superior cervical sympathetic ganglion).
Otic ganglion
Preganglionic parasympathetic neurons from the inferior
salivatory nucleus of CN IX (brainstem nucleus) pass through
glossopharyngeal nerve and synapse in the otic ganglion. The
postganglionic fibres supply the parotid gland.
Sensory supply from mandibular division of trigeminal nerve.
Sympathetic neurons from external carotid (originates from
superior cervical sympathetic ganglion).
The otic ganglion is the only parasympathetic ganglion to have
motor fibres passing though it (the motor root), which supply
the tensor tympani and tensor palati muscles.
o Afferent fibres also pass with the parasympathetic (as they do with
sympathetic neurons) to higher centres for reflex control of respiratory rate,
heart rate, blood pressure and gastrointestinal activity.

- Embryology