THEANATOMICALPOSITION

The anatomical position is the central concept behind all

descriptions of location within the body. It is similar to the
position of the famous Vitruvian Man, although a little less
exuberant! However, the basics are the same. Here is a
general description:
 A person standing upright, facing forward.

 Arms straight and hands held by the hips, palms facing

forward.

 Feet parallel and toes pointing forward.

201

ANATOMICAL TERMS OF MOVEMENT

Flexion and Extension

Flexion and extension are movements that occur in the sagittal
plane. They refer to increasing and decreasing the angle
between two body parts:

Flexion refers to a movement that decreases the angle

between two body parts. Flexion at the elbow is decreasing the
angle between the ulna and the humerus. When the knee
flexes, the ankle moves closer to the buttock, and the angle
between the femur and tibia gets smaller.
Extension refers to a movement that increases the angle
between two body parts. Extension at the elbow is increasing
the angle between the ulna and the humerus. Extension of the
knee straightens the lower limb.

Abduction and Adduction

Abduction and adduction are two terms that are used to
describe movements towards or away from the midline of the
body.

ANATOMICAL PLANES Abduction is a movement away from the midline – just as

abducting someone is to take them away. For example,
abduction of the shoulder raises the arms out to the sides of
There are three planes commonly used; sagittal, coronal and the body.
transverse. Adduction is a movement towards the midline. Adduction of
the hip squeezes the legs together.
 Sagittal plane – a vertical line which divides the body into In fingers and toes, the midline used is not the midline of the
a left section and a right section. body, but of the hand and foot respectively. Therefore,
 Coronal plane – a vertical line which divides the body into abducting the fingers spreads them out.
a front (anterior) section and back (posterior) section.
 Transverse plane – a horizontal line which divides the
body into an upper (superior) section and a bottom (inferior) Medial and Lateral Rotation
section. Medial and lateral rotation describe movement of the limbs
For example, a diagram may be labelled as a transverse around their long axis:
section, viewed superiorly. This indicates that you are looking
downwards onto a horizontal section of the body. Medial rotation is a rotational movement towards the midline.
It is sometimes referred to as internal rotation. To understand
this, we have two scenarios to imagine. Firstly, with a straight
leg, rotate it to point the toes inward. This is medial rotation of
the hip. Secondly, imagine you are carrying a tea tray in front
of you, with elbow at 90 degrees. Now rotate the arm, bringing
your hand towards your opposite hip (elbow still at 90
degrees). This is internal rotation of the shoulder.
Lateral rotation is a rotating movement away from the midline.
This is in the opposite direction to the movements described
above.
Circumduction
Circumduction can be defined as a conical movement of a limb
Elevation and Depression extending from the joint at which the movement is controlled.
Elevation refers to movement in a superior direction (e.g.
shoulder shrug), depression refers to movement in an inferior
It is sometimes talked about as a circular motion, but is more
direction.
accurately conical due to the ‘cone’ formed by the moving limb.
Pronation and Supination
This is easily confused with medial and lateral rotation, but the
difference is subtle. With your hand resting on a table in front
of you, and keeping your shoulder and elbow still, turn your
hand into its back, palm up. This is the supine position, and so
this movement is supination.
Again, keeping the elbow and shoulder still, flip your hand into
its front, palm down. This is the prone position, and so this
movement is named pronation.
These terms also apply to the whole body – when lying flat on
the back, the body is supine. When lying flat on the front, the
body is prone.

Dorsiflexion and Plantarflexion

Dorsiflexion and plantarflexion are terms used to describe
movements at the ankle. They refer to the two surfaces of the
foot; the dorsum (superior surface) and the plantar surface (the
sole).

Dorsiflexion refers to flexion at the ankle, so that the foot

points more superiorly. Dorsiflexion of the hand is a confusing
term, and so is rarely used. The dorsum of the hand is the
posterior surface, and so movement in that direction
is extension. Therefore we can say that dorsiflexion of the
wrist is the same as extension.
Plantarflexion refers extension at the ankle, so that the foot
points inferiorly. Similarly there is a term for the hand, which is
palmarflexion.

Inversion and Eversion

Inversion and eversion are movements which occur at the
ankle joint, referring to the rotation of the foot around its long
axis.
Inversion involves the lateral rotation of the foot, such that
the sole points medially.
Eversion involves the medial rotation of the foot, such that
the sole points laterally.

Opposition and Reposition

A pair of movements that are limited to humans and some
great apes, these terms apply to the additional movements that
the hand and thumb can perform in these species.

Opposition brings the thumb and little finger together.

Reposition is a movement that moves the thumb and the little
finger away from each other, effectively reversing opposition.
 CLASSIFICATION OF JOINTS Cartilaginous
 1 Fibrous Joints In cartilaginous joints, the bones are attached
o 1.1 Sutures by fibrocartilage or hyaline cartilage. There are two main
o 1.2 Gomphoses types – primary cartilaginous and cartilaginous secondary
o 1.3 Syndesmoses joints.
 2 Cartilaginous Cartilage is an excellent shock absorber, as it is essentially a
o 2.1 Synchondroses thick gel. The pelvis and spine are hugely important in this
o 2.2 Symphyses respect.
 3 Synovial
o 3.1 Hinge Synchondroses
o 3.2 Saddle Also known as primary cartilaginous joints, they only involve
o 3.3 Plane hyaline cartilage. The joints can be immovable (synarthroses)
o 3.4 Pivot or slightly movable (amphiarthroses).
o 3.5 Condyloid
o 3.6 Ball & Socket
The joint between the diaphysis and epiphysis of a growing
long bone is a synchondrosis. This is interesting in that it is a
temporary joint with no movement, and can be thought of as a
A joint is defined as the point at which two or more bones
bone-cartilage-bone sandwich. On an X-ray, cartilage is not
articulate. Not all joints move, and different classes of joint
visible; have a look at some growing bones, it looks like the
contain different tissues. The structure and tissue makeup of a
bony end plate is floating.
joint will define its properties, including the mobility, strength
and stability.
Symphyses
Joints can be easily classified by the type of tissue present. Also known as a secondary cartilaginous joint, it can
Using this method, we can split the joints of the body involve fibrocartilage or hyalinecartilage. These joints are
into fibrous, cartilaginous and synovial joints. slightly movable (amphiarthroses), an example of a which is
Joints can also be classified by whether they move a lot, a the pubic symphysis.
little, or not at all. In this article, we’ll be going through the
joints by tissue classification; but we’ll also make mention of
the mobility classification to which they belong. Synovial
A synovial joint is a joint filled with synovial fluid. These joints
Fibrous Joints tend to be fully moveable (known as diarthroses), and are the
A fibrous joint is where the bones concerned are bound by main type of joint found around the body. They allow a huge
tough, fibrous tissue – these are strength joints. Fibrous joints range of movements, which are defined by the arrangement of
can be further subclassified into sutures, their surfaces and the supporting ligaments and muscles.
gomphoses and syndesmoses. It is commonplace to classify synovial joints by their
movement. To understand some of the terms of movement,
have a look at our movement article which describes what the
terms mean.
Sutures
These are immovable joints (called a synarthrosis), only found
between the flat, plate-like bones of the skull. Hinge
There is limited movement until about 20 years of age, after
which they become fixed. They are most important in birth, as Permits flexion and extension. Elbow joint is a notable
at that stage the joints are not fused, allowing deformation of example.
the skull as it passes through the birth canal.
Saddle
Gomphoses Concave and convex joint surfaces unite at saddle joints, e.g.
These are also immovable joints, and can be found where the Metatarsophalangeal joint (toes).
teeth articulate with their sockets in the maxillae (upper teeth)
or the mandible (lower teeth). Plane
The fibrous connection that binds the tooth and socket is Permit gliding or sliding movements, e.g. Acromioclavicular
the periodontal ligament. joint (collarbone to shoulder blade).

Syndesmoses Pivot
These are slightly movable joints (called Allows rotation; a round bony process fits into a bony
an amphiarthrosis). Their structure is comprised of bones ligamentous socket. Examples include the atlantoaxial joint &
held together by an interosseous membrane. They are key proximal radio-ulnar joint (top of the neck and elbow).
joints in providing strength along the length of long bones,
preventing them from separating. Condyloid
The middle radio-ulnar and middle tibiofibular joint are
examples of syndesmosis joints. Permits flexion, extension, adduction, abduction and
circumduction e.g. Metacarpophalangeal joint (in the middle of
your hand).
 Ball & Socket
Articular Cartilage
Permits movement in several axis; a rounded head fits into a The bones of a synovial joint are covered by a thin layer of
concavity. An example is the glenohumeral joint (shoulder). hyaline cartilage which serves to line the epiphysis (end) of the
bone.

STRUCTURES OF A SYNOVIAL JOINT The smooth surface it provides has two functions; it minimises
friction upon joint movement and absorbs shock.
Accessory Ligaments
 1 Synovial Fluid
Accessory ligaments are separate ligaments or parts of the
 2 Articular Capsule joint capsule. They are made up of bundles of dense regular
 3 Articular Cartilage connective tissue, which are highly adapted for resisting strain.
 4 Accessory Ligaments This prevents any extreme movements that may damage the
 5 Bursae joint.
 6 Innervation
 7 Vasculature Bursae
 8 Clinical Relevance: Osteoarthritis A bursa is a small sac lined by synovial membrane and filled
with synovial fluid. They are placed at key points of friction in a
joint, providing the joint with free movement.
The synovial joint is the most common and most complex type They can become inflamed following infection or irritation by
of joint found in the body. over-use of the joint (bursitis). Examples of these friction
points are where tendons run over the joint, as they do in the
In this article we shall look at the anatomy of the structures of a knee, a common location for bursitis.
synovial joint, how they work together and how they can go Innervation
wrong.
Joints have a rich nerve supply provided by articular
nerves. Hilton’s Law states that the nerves supplying a joint
Synovial Fluid also supply the muscles moving the joint and the skin covering
Synovial fluid has three primary functions: their distal attachments.
The nerves of a joint transmit impulses which play a key role
in proprioception – the ability of the body to tell where parts of
 Lubrication
it are.
 Nutrient distribution Vasculature
Joints receive blood via articular arteries which arise from the
 Shock absorption. vessels around the joint. The articular arteries are
This fluid is found in the synovial cavity of a joint, which is the located within the joint capsule, mostly in the synovial
space enclosed by the articular capsule. Its nutritional abilities membrane.
are vital for healthy cartilage, which has a very poor blood A common feature of the articular arterial supply is
supply so relies on diffusion from the synovial fluid. frequent anastomoses (communications) in order to ensure a
blood supply to and across the joint regardless of its position.
In practice this usually means arteries are above and below a
Articular Capsule joint, curving round each side of it and joining via small
This is a fibrous capsule which is continuous with connecting vessels.
the periosteum of articulating bones. It consists of two layers: The articular veins accompany the articular arteries and are
 Outer fibrous layer – made up white fibrous tissue, called also found in the synovial membrane.
the capsular ligament. This holds together articulating bones
and supports the synovium. Clinical Relevance: Osteoarthritis
 Inner synovial layer (synovium) – a highly vascularised Osteoarthritis is the most common form of joint inflammation
layer of connective tissue. It absorbs and secretes synovial (arthritis). It stems from heavy use of articular joints over the
fluid, and is responsible for the mediation of nutrient course of many years, which can result in the wearing away
exchange between blood and joint. of articular cartilage, and often the erosion of the underlying
articulating surfaces of bones as well. The changes which
occur are irreversible and degenerative. This results in the
decreased effectiveness of articular cartilage as a shock
absorber and lubricated surface, as well as the roughened
edges causing further damage.
As a result of this degeneration, repeated friction can cause
symptoms of joint pain, stiffness and discomfort. This
condition usually affects joints that support full body weight,
such as the hips and the knees.
Arthritis can also come about through other causes, including;
(i) as a result of infection, due to the ease with which blood
(and any associated bacteria) can enter the joint cavity via the
synovial membrane; (ii) due to autoinflammatory causes, as
in rheumatoid arthritis, or; (iii) as a result of infection but not
involving infection of the joint itself, as in reactive arthritis.
JOINT STABILITY ULTRASTRUCTURE OF BONE

The stability of joints is a topic of great clinical importance; it  1 Components of Bone

explains why some joints are more prone to dislocation and  2 Structure of Bone
injury than others. It also underlies the clinical basis of treating  3 Ossification and Remodelling
joint injuries.
 4 Clinical Relevance – Disorders of Bone
In this article we shall look at the various factors that contribute
towards joint stability.
Bone is a specialised type of connective tissue. It has a unique
histological appearance, which enables it to carry out its
Shape, Size and Arrangement of Articular Surfaces numerous functions:

The joints of the body come in all shapes and sizes. The most  Haematopoiesis – the formation of blood cells from
important factor to consider here is the relative proportion of haematopoietic stem cells found in the bone marrow.
the two articulating surfaces.
For example, in the shoulder joint, the humeral head of the
 Lipid and mineral storage – bone is a reservoir holding
upper arm is disproportionately larger than the glenoid adipose tissue within the bone marrow and calcium within
fossa of the scapula that it sits in – making the joint more the hydroxyapatite crystals.
unstable, as there is less contact between the bones.  Support – bones form the framework and shape of the
In contrast, the acetabulum of the pelvis fully encompasses the body.
femoral head, and this makes the hip-joint far more stable.  Protection – especially the axial skeleton which surrounds
However, whilst the hip is more stable, the shoulder has a the major organs of the body.
greater range of movement. Each joint has this trade-off that is In this article, we shall look at the ultrastructure of bone – its
particular to its function. components, structure and development. We shall also
examine how disease how can affect its structure.

Ligaments
The ligaments of a joint prevent excessive movement that Components of Bone
could damage the joint. As a general rule, the Bone is a specialised form of connective tissue. Like any
more ligaments a joint has, and the tighter they are, the more connective tissue, its components can be divided into cellular
stable the joint is. components and the extracellular matrix.
However, tight ligaments restrict movement, and this is why
extra stability of a joint comes at the cost of loss of mobility. If Cellular Components
disproportionate, inappropriate or repeated stress is applied to
ligaments, they can stretch, tear or even damage the bone
they attach to – this is why sportspeople are more susceptible
to ligament injuries.
Tone of Surrounding Muscles
The tone of the surrounding muscles contributes greatly to the
stability of a joint. A good example of this is the support
provided by the rotator cuff muscles, which keep the head of
the humerus in the shallow glenoid cavity of the scapula. If
there is a loss of tone, such as in old age or stroke, the
shoulder can dislocate.
Dislocations of the shoulder joint can tear the rotator cuff Fig 1.0 – Cellular components of bone and their functions.
muscles, making the patient more susceptible to further There are three types of cells in bone:
injuries.

Similarly, the tone of muscles around the knee are crucial to its
 Osteoblasts – Synthesise uncalcified/unmineralised
extracellular matrix called osteoid. This will later become
stability. Through inappropriate or unbalanced training, the
knee can be made prone to injury through muscle imbalance. calcified/mineralised to form bone.
This can lead to chronic pain.  Osteocytes – As the osteoid mineralises, the osteoblasts
become entombed between lamellae in lacunae where they
mature into osteocytes. They then monitor the minerals and
proteins to regulate bone mass.
 Osteoclasts – Derived from monocytes and resorb bone by
releasing H+ ions and lysosomal enzymes. They are large
and multinucleated cells.

The balance of osteoblast to osteoclast activity is crucial in the

maintenance of the tissue’s structural integrity. It also plays a
role in conditions such as osteoporosis.
Extracellular Matrix
The extracellular matrix (ECM) refers to the molecules that
provide biochemical and structural support to the cells.
 The ECM of bone is highly specialised. In addition to collagen
Ossification and Remodelling
and the associated proteins usually found in connective tissue,
bone is impregnated with mineral salts, in particular calcium Ossification is the process of producing new bone. It occurs via
hydroxyapatite crystals. These crystals associate with the one of two mechanisms:
collagen fibres, making bone hard and strong. This matrix is
organised into numerous thin layers, known as lamellae.  Endochondral ossification – Where hyaline cartilage is
replaced by osteoblasts secreting osteoid. The femur is an
example of a bone that undergoes endochondral
Structure of Bone ossification.
Under the microscope, bone can be divided into two types:  Intramembranous ossification – Where mesenchymal
(embryonic) tissue is condensed into bone. This type of
 Woven bone (primary bone) – Appears in embryonic ossification forms flat bones such as the temporal bone and
development and fracture repair, as it can be laid down the scapula.
rapidly. It consists of osteoid (unmineralised ECM), with the In both mechanisms, primary bone is initially produced. It is
collagen fibres arranged randomly. It is a temporary later replaced by mature secondary bone.
structure, soon replaced by mature lamellar bone.
 Lamellar bone (secondary bone) – The bone of the adult Remodelling
skeleton. It consists of highly organised sheets of Bone is a living tissue and as such constantly
mineralised osteoid. This organised structure makes it much undergoes remodelling. This is the process whereby mature
stronger than woven bone. Lamella bone itself can be bone tissue is reabsorbed, and new bone tissue is formed. It is
divided into two types – compact and spongy. carried out by the cellular component of bone.

In both types of bone, the external surface is covered by a Osteoclasts break down bone via a cutting cone. The
layer of connective tissue, known as the periosteum. A similar nutrients are reabsorbed, and osteoblasts lay down new
layer, the endosteum lines the cavities within bone (such as osteoid. Remodelling occurs primarily at sites of stress and
the medullary canal, Volkmann’s canal and spongy bone damage, strengthening the areas affected.
spaces).

Lamellar bone can be divided into two types. The outer is Clinical Relevance – Disorders of Bone
known as compact bone – this is dense and rigid. The inner Bone has a unique histological structure, which is required for
layers of bone are marked by many interconnecting cavities, it to carry out its functions. Alterations to this structure,
and is called spongy bone. secondary to disease, can give rise to several clinical
conditions.

Compact Bone Osteogenesis imperfecta is a condition in which there is

Compact bone forms the outer ‘shell’ of bone. In this type of abnormal synthesis of collagen from the osteoblasts. Clinical
bone, the lamellae are organised into concentric circles, which features include fragile bones, bone deformities and blue
surround a vertical Haversian canal (which transmits small sclera. It is a rare disease and genetic in aetiology, with
neurovascular and lymphatic vessels). This entire structure is an autosomal dominant inheritance pattern. The fragility of the
called an osteon, and is the functional unit of bone. bones predisposes them to fracture – this has a medicolegal
importance, as in children it can be mistaken for deliberate
The Haversian canals are connected by injury.
horizontal Volkmann’s canals – these contain small vessels Osteoporosis refers to a decrease in bone density, reducing
that anastomose (join together) the arteries of the Haverisan its structural integrity. This is produced by osteoclast activity
canals. The Volkmann’s canals also transmit blood vessels (bone reabsorption) outweighing osteoblast activity (bone
from the periosteum. production). The bones are fragile, and at an increased risk of
fracture. There are three types:
Osteocytes are located between the lamellae, within small
 Type 1: Postmenopausal osteoporosis – Develops in women
cavities (known as lacunae). The lacunae are interconnected
after the menopause, due to decreased oestrogen
by a series of interconnecting tunnels, called canaliculi.
production. Oestrogen protects against osteoporosis by
increasing osteoblast and decreasing osteoclast activity.
Spongy Bone
Spongy bone makes up the interior of most bones, and is  Type 2: Senile osteoporosis – Usually occurs above the age
located deep to the compact bone. It contains many large of 70.
spaces – this gives it a honeycombed appearance.
 Type 3: Secondary osteoporosis – Where osteoporosis
occurs due to co-existing disease (e.g. chronic renal failure).
The bony matrix consists of a 3D network of fine columns,
which crosslink to form irregular trabeculae. This produces a Risk factors include: age, gender, diet (vitamin D and calcium),
light, porous bone, that is strong against multidirectional lines ethnicity, smoking and immobility. It is usually managed
of force. The lightness afforded to spongy bone is crucial in by bisphosphonates which are taken up by osteoclasts
allowing the body to move. If the only type of bone was causing them to become inactive and undergo apoptosis. This
compact, they would be too heavy to mobilise. limits further degradation of bone.
The spaces between trabeculae are often filled with bone Rickets is Vitamin D or calcium deficiency in childrenwith
marrow. Yellow bone marrow contains adipocytes growing bones. This means that the osteoid mineralises poorly
and red bone marrow consists of haematopoietic stem cells. and remains pliable. The epiphyseal growth plates can then
This type of bone does not contain any Volkmann’s or become distorted under the weight of the body, potentially
Haversian canals. leading to skeletal deformities.
 Osteomalacia is a Vitamin D or calcium deficiency turn is surrounded by a thick layer of connective tissue known
in adults with remodelling bones. Here the osteoid laid down as the epimysium.
by osteoblasts is poorly mineralised leading to increasingly
weak bones, increasing their susceptibility to fracture.
Note: Vitamin D deficiency can be due to poor diet, lack of
sunlight or a metabolic disorder. For example, kidney failure Ultrastructural Appearance of Skeletal Muscle
could interfere with the second hydroxylation of vitamin D or an The striated appearance of skeletal muscle fibres arises due to
intestinal disorder may prevent sufficient absorption. A calcium the organisation of two contractile proteins or
deficiency can be caused by diet or low vit. D. myofilaments, actin (thin filament) and myosin (thick
filament). The functional unit of contraction in a skeletal
muscle fibre is the sarcomere, which runs from Z line to Z
line. A sarcomere is broken down into a number of sections:
ULTRASTRUCTURE OF MUSCLE CELLS
 Z line – Where the actin filaments are anchored.
 M line – Where the myosin filaments are anchored.
 1 Types of Muscle  I band – Contains only actin filaments.
 2 Composition of Skeletal Muscle  A band – The length of a myosin filament, may contain
overlapping actin filaments.
 3 Ultrastructural Appearance of Skeletal Muscle
 H zone – Contains only myosin filaments.
 4 Sliding Filament Model
A useful acronym is MHAZI – the M line is inside the H zone
 5 Clinical Relevance which is inside the A band, whilst the Z line is inside the I band.
o 5.1 Cardiac Biomarkers
o 5.2 Disuse atrophy
o 5.3 Duchenne Muscular Dystrophy

Muscle tissue has a unique histological appearance which

enables it to carry out its function. In this article, we will
examine the histology of muscle and how it relates to
contractility.

Types of Muscle
There are three types of muscle:

 Skeletal – A form of striated muscle that is under voluntary

control from the somatic nervous system. Identifying features
are cylindrical cells and multiple peripheral nuclei.
 Cardiac – A form of striated muscle that is found only in the
heart. Identifying features are single nuclei and the
presence of intercalated discs between the cells.
 Smooth – A form of non-striated muscle that is controlled
involuntarily by the autonomic nervous system. The
identifying feature is the presence of one spindle-shaped
central nucleus per cell.
This article will deal mainly with skeletal muscle.
Sliding Filament Model
Myosin filaments have many heads, which can bind to sites on
the actin filament. Actin filaments are associated with two other
regulatory proteins, troponin and tropomyosin. Tropomyosin
Composition of Skeletal Muscle is a long protein that runs along the actin filament, blocking the
myosin head binding sites.
Troponin is a small protein that binds the tropomyosin to the
A muscle cell is very specialised for its purpose. One muscle actin. It is made up of three parts:
cell is known as a muscle fibre, and its cell surface membrane
is known as the sarcolemma.  Troponin I which binds to the actin filament.
T tubules are unique to muscle cells. These are invaginations  Troponin T which binds to tropomyosin.
of the sarcolemma that conduct charge when the cell is
 Troponin C, which can bind calcium ions.
depolarised.
Muscle cells also have a specialised endoplasmic reticulum –
The unique structure of troponin is the basis of excitation-
this is known as the sarcoplasmic reticulum and contains a
contraction coupling:
large store of calcium ions.
Muscles also have an intricate support structure of connective  When depolarisation occurs at a neuromuscular junction,
tissue. Each muscle fibre is surrounded by a thin layer of this is conducted down the t tubules, causing a huge influx of
connective tissue known as endomysium. These fibres are calcium ions into the sarcoplasm from the sarcoplasmic
then grouped into bundles known as fascicles, which are reticulum.
surrounded by a layer of connective tissue known  This calcium binds to troponin C, causing a change in
as perimysium. Many fascicles make up a muscle, which in conformation that moves tropomyosin away from the myosin
head binding sites of the actin filaments.
  This allows the myosin head to bind to the actin, forming a There are three major types of vessels; arteries, veins and
cross-link. The power strokethen occurs as the myosin capillaries. Arteries (with the exception of the pulmonary artery)
heads pivots in a ‘rowing motion’, moving the actin past the deliver oxygenated blood to the tissues. At the tissues, the
myosin towards the M line. oxygen and nutrient exchange is carried out by the capillaries.
 ATP then binds to the myosin head, causing it to uncouple The capillaries also return deoxygenated blood to the veins,
from the actin and allowing the process to repeat. which bring it back to the heart (with the exception of the
Hence in contraction, the length of the filaments does not pulmonary veins).
change. However, the length of the sarcomere decreases due
to the actin filaments sliding over the myosin. The H zone and I
band shorten, whilst the A band stays the same length. This
brings the Z lines closer together and causes overall length to
decrease.

Clinical Relevance
Cardiac Biomarkers
Cardiac Troponin I levels are measured in the blood to test
whether a patient has had a myocardial infarction, as elevated
levels in the serum indicate that cardiac myocytes have
undergone necrosis. Previously, the marker used was creatine
kinase (CK-MB), but cTnI is now widely considered more
sensitive and specific. In this article, we shall follow the path that blood takes around
Disuse atrophy the body, examining the structure and function of the major
types of blood vessels.
This can occur due to forced immobilisation or
Vessel walls can largely be split into three sections; tunica
denervation. Muscle fibres are constantly being remodelled to
intima (innermost), tunica media, and tunica adventitia. Each
meet demand, with the contractile myofilaments being replaced
must be considered.
every 2 weeks. If there is no stimulation, protein breakdown
exceeds synthesis. Hence, loss of power is due to protein loss
and reduced fibre diameter rather than decrease in the number The Arterial System
of muscle fibres. As a whole, the arterial system takes oxygenated blood from
the heart, and delivers it to the capillaries, where oxygen and
Duchenne Muscular Dystrophy nutrient exchange can occur.
This is a recessive X-linked genetic disorder in
which dystrophin, a protein which anchors the sarcolemma to There are four main types of artery in the body, each with a
the myofilaments, is not produced. This leads to the muscle distinct structure and function. We shall look at each in more
fibres tearing themselves apart on contraction, causing detail (in order of decreasing size).
progressive muscle weakness and wasting. It has an early
onset, with patients often being wheelchair-dependent by the
age of 12.
Large Elastic (Conducting) Arteries
These are the largest arteries found in the body, and are found
ULTRASTRUCTURE OF BLOOD VESSELS closest to the heart. They function to ‘conduct’ blood from the
heart to regions of the body, where it can be distributed.
Elastic arteries include most of the named vessels surrounding
 1 The Arterial System the heart, such as the aorta and pulmonary arteries.
o 1.1 Large Elastic (Conducting) Arteries
o 1.2 Medium Muscular (Distributing) Arteries Structure:
o 1.3 Arterioles  Tunica Intima: Endothelial cells with a thin subendothelium
o 1.4 Metarterioles of connective tissue and discontinuous elastic laminae.
 1.4.1 Clinical Relevance: Precapillary Sphincters  Tunica Media: The tunica media is comprised of 40-70
 2 The Capillaries fenestrated elastic membranes with smooth muscle cells and
 3 The Venous System collagen between these lamellae. It is the thickest part of an
o 3.1 Postcapillary Venules elastic artery.
 3.1.1 Clinical Relevance: Inflammation and  Tunica Adventitia: Thin layer of connective tissue
Postcapillary Venules containing lymphatics, nerves and vasa vasorum (Blood
o 3.2 Venules vessels that supply blood to the artery – arteries need blood
o 3.3 Veins to survive just like any other tissue!)
 3.3.1 Venae Comitantes

The average man has approximately six litres of blood in his

body. This blood is carried by several different types of blood
vessels, each of which are specialised to play their role in
circulating blood around the body.
 These gaps act as a sieve, controlling which molecules and
structures can leave the capillary. For example, in continuous
capillaries (located in skeletal muscle), only water and certain
ions can leave. In sinusoidal capillaries (located in the liver),
larger structures such as cells and proteins are able to exit.

Medium Muscular (Distributing) Arteries

From the large elastic arteries, blood enters smaller distributing
arteries. They distribute the blood to sub-regions of the body.
Medium muscular arteries are similar in structure to large
elastic arteries.
The Venous System
Structure: As a whole, the venous system takes deoxygenated blood
 Tunica Intima: Consists of an endothelium, a subendothelial from the capillaries, and delivers it to the heart (with the
layer and a thick elastic lamina. exception of the pulmonary veins). From the heart, blood can
be pumped to the lungs and re-oxygenated.
 Tunica Media: Consists of around 40 layers of smooth
muscle connected by gap junctions in order to allow
coordinated contraction. Like the arterial system, the venous system is comprised of
different vessel structures. We shall look at each in more detail
 Tunica Adventitia: Thin layer of connective tissue
(in order of ascending size, as we move away from the
containing minor vasa vasorum, lymphatics and nerve fibres.
capillaries).
Arterioles
Arterioles are part of the microcirculation. They carry blood Postcapillary Venules
from the muscular arteries to the metarterioles.
Structure: A postcapillary venule receives blood from capillaries and
Arteries with a diameter of less than 0.1mm are classed as empties into venules. In addition, the surrounding tissue
arterioles. They generally have around 3 layers of smooth fluid tends to drain into them, as their pressure is lower than
muscle cells and the internal elastic lamina is absent. The that of capillaries or the tissue.
external elastic lamina is only present in larger arterioles. Structure:
Metarterioles The wall is an endothelial lining with associated pericytes and
a diameter of 10-30 micrometres. This is similar to the
Arteries that supply capillary beds are known structure of capillaries, but postcapillary venules are more
as metarterioles. permeable, making them the preferred site of white blood cell
Instead of having a continuous layer of smooth muscle cells, migration (e.g. to sites of infection).
intermediate rings of smooth muscle are located at certain
points. These rings are known as known as precapillary
sphincters, which contract to control blood flow to the capillary
bed.

Venules
Venules are continuous with the post-capillary venules. They
continue to move blood away from the capillary beds. Many
venules unite to form a vein.
Structure:
The endothelium is associated with pericytes or thin smooth
muscle cells (the beginning of a tunica media) to form a very
The Capillaries thin wall. Venules can have a diameter of up to 1mm. They
Capillaries consist of one layer of endothelium and its also contain valves that press together to restrict retrograde
concordant basement membrane. transport of blood.
They are specially adapted to provide a short diffusion distance Veins
for nutrient and gaseous exchange with the tissues they Veins are the major vessels of the venous system. They are
supply. the final step in the return of blood to the heart.
There are three types of Structure:
capillaries; continuous, fenestrated and sinusoidal, each of
which have variably sized gaps between the endothelial cells.
 Veins generally have a larger diameter and a thinner wall than connective tissue and finish by considering some conditions
the accompanying artery. The vessel wall contains more that arise when the normal structure is lost.
connective tissue, with less elastic and muscle fibres.
Neuronal Structure
Veins vary slightly in structure according to their size:
There are several different types of neurones found in the
nervous system. They all contain the same key structural
 Small and medium veins have a well developed tunica components – the cell body, dendrites, the axon and the axon
adventitia and a thin tunica intima and media. terminals.
 Large veins have diameters greater than 10mm and a
thicker tunica intima. They have well developed longitudinal Cell Body
smooth muscle in the tunica adventitia. The media has The cell body holds the nucleus. It is the site of protein
circular smooth muscle, which is usually not prominent, synthesis, which occurs on small granules of rough
except for the superficial veins of the legs. endoplasmic reticulum called nissl substance.
Veins contain valves that primarily prevent the back-flow of In the nervous system, many neuronal cell bodies can group
blood. They also act together with muscle contraction, together to form a distinct structure. In the CNS, this is known
squeezing the veins to propel blood towards the heart. as a nucleus, and in the PNS as a ganglion.
Venae Comitantes Dendrites
Venae comitantes are deep paired veins wrapped together The dendrites are elongated portions of the cell body. They
with an artery in one sheath. The pulsations of the artery extend outwards, receiving input from the environment and
promote venous return within the paired veins. from other neurones.

Axons
The axon is a long, thin structure down which action potentials
(the nerve impulse) are conducted. Whilst neurones have
many dendrites, most cells only have one axon.

Each axon is coated in myelin – a layer of insulating lipid.

Myelin is formed by cells wrapping themselves around the
nerve axon. In the CNS, this is performed
by oligodendrocyte cells. In the PNS, Schwann cells are
responsible for this action.
There are gaps between the myelin sheaths formed by
different cells. These gaps are known as nodes of Ranvier.
They allow for saltatory conduction of impulses.
Axon Terminals
The axon terminal is the most distal part of the axon. It is from
here that the neurone sends chemical signals to other cells –
usually via neurotransmitter release. To facilitate the secretion
of neurotransmitters, the axon terminals contain a large
number of mitochondria.

ULTRASTRUCTURE OF NERVES

 1 Neuronal Structure
o 1.1 Coverings
 2 Classification
o 2.1 Structural Classification
o 2.2 Functional Classification
 3 Clinical Relevance: Disorders of Nerve Tissue
o 3.1 Multiple Sclerosis
o 3.2 Motor Neurone Disease

The nervous system allows us to perceive, understand, and

respond to our environment. It comprises two different types of
cells:

 Nerve cells (neurones) – these form the functional basis of Coverings

the nervous system, responsible for transmitting signals as n the peripheral nervous system, the axons of neurons are
electrical or chemical signals. grouped together to form nerves. The axons are enclosed by
 Glial cells – these provide functional and structural support several connective tissue layers:
for the neurones. One example is a Schwann cell, which
produces the lipid sheath of peripheral neurones.  Endoneurium – Surrounds the axon of an individual
In this article, we will focus on the ultrastructure of nerves. We neurone.
will look at the general structure of nerves, their layers of
 Perineurium – Surrounds a fascicle, which is a collection of  Intermediate neurones – central cell body and many
neurones. dendrites.
 Epineurium – Surrounds the entire nerve, which is formed Sensory and motor nerves are located within the PNS,
by a collection of fascicles. It contains numerous small blood whereas intermediate nerves are found in the CNS.
vessels, which supply the nerve fibres. Epineurium appears
on the nerve as it exits the intervertebral foramen. It is
created by the fusion of arachnoid and pia mater, which are
layers of the meninges.
Clinical Relevance: Disorders of Nerve Tissue
Multiple Sclerosis

In multiple sclerosis, the myelin covering of neurones in the

central nervous system is lost. This means that the relay of
action potentials between sensory and motor neurones is
affected. This can lead to visual, motor and auditory problems.

The etiology of Multiple Sclerosis (MS) is still uncertain.

However, the causes are thought to either be as a result
of autoimmune destruction of myelin, or the failure of
oligodendrocytes to myelinate the interneurons.
Motor Neurone Disease
Classification Motor Neurone Disease describes a group of conditions that
Neurones can be classified by structure or by function. include Amyotrophic lateral sclerosis, better known as ALS. In
Neurones with different functions have differing structures, these diseases, motor neurones become damaged for reasons
which is visible histologically. that are not entirely clear, but are thought to include
dysfunctional mitochondria.
Structural Classification
Neurones can be either unipolar, pseudounipolar, bipolar or The damage to the motor neurones is progressive, making this
multipolar. a degenerative disease. It often begins with damage to
peripheral nerves, and works its way up through the limbs until
 Unipolar – Here the cell body is at one end of a single the central nervous system is compromised. This disease is
unbranched axon, and there are no dendrites. These can be fatal, with a median survival length of 3-5 years post diagnosis.
found in the cochlear nucleus of the brain.
 Pseudounipolar – They have one axon which is divided into
two branches by the presence of the cell body. Sensory
neurones are all pseudounipolar.
 Bipolar – These neurones have two processes arising from
a central cell body – typically one axon and one dendrite.
These cells are found in the retina.
 Multipolar – They have one axon and many dendrites, with
a cell body displaced to one side of the axon. Motor
neurones are a prime example of this.

Functional Classification
There are three broad functional classifications of nerves –
sensory (afferent), intermediate and motor (efferent). There
are key structural differences between these three types:
 Sensory nerves – small axons and psuedounipolar
structure.
 Motor nerves – larger axons and multipolar structure.
 THE LYMPHATIC SYSTEM Lymph fluid enters the node through afferent lymphatic
channels and leaves the node via efferent
channels. Macrophages located within the sinuses of the
 1 Lymph Organs lymph node act to filter foreign particles out of the fluid as it
travels through.
 2 Lymph Nodes
 3 Lymph Vessels
 4 Lymph Fluid
 5 Clinical Relevance – Lymphoma

The lymphatic system is a series of vessels and nodes that

collect and filter excess tissue fluid (lymph), before returning it
to the venous circulation. It forms a vital part of the body’s
immune defence.

In this article, we shall look at the components of the lymphatic

system, their structure and their clinical correlations.

Lymph Vessels
The lymphatic vessels transport lymph fluid around the body.
There are two main systems of lymph vessels – superficial and
deep:

 Superficial vessels – arise in the subcutaneous tissue, and

tends to accompany venous flow. They eventually drain into
deep vessels.
 Deep vessels – drain the deeper structures of the body,
such as the internal organs. They tend to accompany deep
arteries.
The drainage of lymph begins in lymph channels, which start
as blind ended capillaries and gradually develop into
vessels. These vessels travel proximally, draining through
several lymph nodes.
Eventually the vessels empty into lymphatic trunks (also
known as collecting vessels) – and these eventually
converge to form the right lymphatic duct and the thoracic duct.
Lymph Organs The right lymphatic duct is responsible for draining the lymph
from the upper right quadrant of the body. This includes the
There are a number of organs that contain lymphatic tissue.
right side of the head and neck, the right side of the thorax and
They are involved in blood filtering and the maturation of
the right upper limb. The thoracic duct is much larger and
lymphocytes.
drains lymph from the rest of the body. These two ducts then
empty into the venous circulation at the subclavian veins, via
 Spleen – Functions mainly as a blood filter, removing old the right and left venous angles.
red blood cells. It also plays a role in the immune response.
 Thymus – Responsible for the development and maturation
of T lymphocyte cells.
 Red bone marrow – Responsible for maturation of
immature lymphocytes, much like the thymus.
In addition, some lymphatic tissue is located in the tonsils,
appendix, and in the walls of the gastrointestinal tract.

Lymph Nodes
Lymph nodes are kidney shaped structures, typically around
2.5cm in diameter. On average an adult has around 400 to 450
different lymph nodes spread throughout the body, with the
majority located within the abdomen. They filter foreign
particles from the blood, and play an important role in the
immune response to infection.
Each node contains T lymphocytes, B lymphocytes, and other
immune cells. They are exposed to the fluid as it passes
through the node, and can mount an immune response if they
detect the presence of a pathogen. This immune response
often recruits more inflammatory cells into the node – which is
why lymph nodes are palpable during infection.
 It is a versatile structure with a wide range of functions; and its
exact composition varies across different regions of the body’s
Lymph Fluid
surface.
Lymph is a transudative fluid that is transparent and yellow. It
is formed when fluid leaves the capillary bed in tissues due to
In this article, we will discuss the function, gross structure and
hydrostatic pressure. Roughly 10% of blood volume becomes
ultrastructure of our skin.
lymph.
The composition of lymph is fairly similar to that of blood
plasma, with the majority of the volume (around 95%)
comprised of water. The remaining 5% is composed of
proteins, lipids, carbohydrates (mainly glucose), various ions
and some cells (mainly lymphocytes), although this can vary
depending on where in the body the lymph is produced. For
example, chyle (lymph that is produced in the gastrointestinal
system) is particularly rich in fats.
The average adult produces between 3-4 litres of lymphatic
fluid each day, although this can vary in illness.

Clinical Relevance – Lymphoma

A lymphoma is one of a group of tumours developing
from lymphatic cells. They make up around 3-4% of all
cancers worldwide and typically have a 5-year survival rate of Gross Structure
70-85%, depending on the subtype. The two main The composition of skin varies across the surface of the body.
subtypes are Hodgkin lymphoma (HL) and non-Hodgkin Skin can be thin, hairy, hirsute, or glabrous. Glabrous skin is
lymphoma (NHL), with roughly 90% of lymphomas being the thick skin found over the palms, soles of the feet and flexor
NHLs. Risk factors for these lymphomas include: surfaces of the fingers that is free from hair.
 Infection with Epstein-Barr virus (HL) Throughout the body, skin is composed of three layers; the
 Autoimmune diseases (NHL) epidermis, dermis and hypodermis. We shall now examine
these layers in more detail.
 HIV/AIDs (NHL)
 Eating a large amount of meat and fat (NHL)

A diagnosis is reached following a lymph node biopsy, if

histological features of lymphoma are found, further tests such
as immunophenotyping can be carried out to determine the
subtype.
Symptoms of lymphoma often include:
 Lymphadenopathy – swelling of lymph nodes
 Fever
 Night sweats
 Weight loss
 Loss of appetite
 Itching
 Fatigue

ULTRASTRUCTURE OF SKIN

 1 Functions of Skin Ultrastructure

 2 Gross Structure Epidermis
 3 Ultrastructure The epidermis is the most superficial layer of the skin, and is
o 3.1 Epidermis largely formed by layers of keratinocytes undergoing terminal
 3.1.1 Layers of the Epidermis maturation. This involves increased keratin production and
o 3.2 Dermis migration toward the external surface, a process
 3.2.1 Hair Follicles and Sebaceous Glands termed cornification.
 3.2.2 Sweat Glands There are also several non-keratinocyte cells that inhabit the
o 3.3 Hypodermis epidermis:
 4 Clinical Relevance – Disorders of Skin  Melanocytes – responsible for melanin production and
pigment formation.
o Note – individuals with darker skin have increased
The skin is the largest organ in the human body, and melanin production, not an increased number of
comprises approximately 8% of total body mass. melanocytes.
 Langerhans cells – antigen-presenting dendritic cells.
 Merkel cells – sensory mechanoreceptors. Hypodermis
Layers of the Epidermis The hypodermis, or subcutaneous tissue, is immediately deep
The epidermis can be divided into layers (strata) of to the dermis.
keratinocytes – this reflects their change in structure and It is a major body store of adipose tissue, and as such can vary
properties as they migrate towards the surface. From deepest in size between individuals depending on the amount of fatty
to most superficial, these layers are: tissue present.

 Stratum basale – mitosis of keratinocytes occurs in this

layer.
 Stratum spinosum – keratinocytes are joined by tight Clinical Relevance – Disorders of Skin
intercellular junctions called desmosomes.
 Alopecia Areata – alopecia is marked by autoimmune
 Stratum granulosum – cells secrete lipids and other destruction of hair follicles, causing hair loss.
waterproofing molecules in this layer.
 Vitiligo – Like alopecia, vitiligo is an autoimmune disease,
 Stratum lucidum – cells lose nuclei and drastically increase where melanocytes are targeted and destroyed. Areas of
keratin production. symmetrical depigmentation appear, which are more
 Stratum corneum – cells lose all organelles, continue to apparent in darker-skinned individuals.
produce keratin.  Psoriasis – In psoriasis, the mitosis of keratinocytes in the
A keratinocyte typically takes between 30 – 40 days to travel stratum basale is drastically increased, producing a
from the stratum basale to the stratum corneum. thickened stratum spinosum. This is clinically apparent as
“scaly” skin, typically on the knees and elbows.

Dermis
The dermis is immediately deep to the epidermis and is tightly
connected to it through a highly-corrugated dermo-epidermal
junction.
The dermis has only two layers, which are less clearly defined
than the layers of the epidermis. They are the
superficial papillary layer, and the deeper reticular layer. The
reticular layer is considerably thicker, and features thicker
bundles of collagen fibres that provide more durability.
The following cell types and structures can be found in the
dermis:

 Fibroblasts – these cells synthesise the extracellular

matrix, which is predominantly composed of collagen and
elastin.
 Mast cells – these are histamine granule-containing cells
of the innate immune system.
 Blood vessels and cutaneous sensory nerves
 Skin appendages – e.g. hair follicles, nails, sebaceous DERMATOMES
and sweat glands. Although present in the dermis, these
structures are derived from the epidermis which descend
into the dermis during development. A dermatome is defined as ‘a strip of skin that is innervated by
Hair Follicles and Sebaceous Glands a single spinal nerve‘. They are of great diagnostic importance,
The hair follicles and sebaceous glands combine to form as they allow the clinician to determine whether there is
a pilosebaceous unit – which is only found on hirsute skin. damage to the spinal cord, and to estimate the extent of a
Sebaceous glands release their glandular secretions via a spinal injury if there is one present.
holocrine mechanism into the hair follicle shaft. The hair follicle In this article, we shall look at the embryonic origins of
itself is associated with an arrector pili muscle, which dermatomes, and explore their clinical uses.
contracts to cause the follicle to stand upright.
Sweat Glands
There are two main types of sweat glands: Origins of Dermatomes
We can trace back the origins of dermatomes to the 3 rd week
 Eccrine glands – the major sweat glands of the human of embryogenesis. At around day 20, the tri-laminar disc has
body. They release a clear, odourless substance, been established and the middle layer (mesoderm) has
comprised mostly of sodium chloride and water – which is differentiated into its different types. The portion that is directly
involved in thermoregulation. adjacent to the neural tube is called paraxial mesoderm.
 Apocrine glands – larger sweat glands, located in the From day 20 onwards the paraxial mesoderm differentiates
axillary and genital regions. These apocrine glandular into segments called somites. 44 pairs of somites are formed,
products can be broken down by cutaneous microbes, but 13 of these break down leaving 31 somites. This
producing body odour. corresponds to the 31 sets of spinal nerves in the body.
The somites themselves are comprised of a ventral and a
dorsal portion. The ventral portion consists of sclerotome, the
precursor to the ribs and vertebral column.
The dorsal portion consists of dermomyotome. Over time, By using their knowledge of dermatomal and peripheral
the myotome proliferates and the dermatome disperses to cutaneous innervation, and noting any regions of
form dermis. As the limbs grow, the dermis associated with paresthesia, the clinician is able to ascertain whether there
the precursor of the limbs is stretched and moved down the is any nerve involvement. Also, they can determine whether
limb, creating the segmental innervation that is associated with this is at the spinal root orperipheral nerve level.
the Keegan and Garrett dermatome map of 1948.

MYOTOMES
Dermatome Maps An adult myotome is defined as ‘a group of muscles innervated
There are two main maps that are accepted by the medical by a single spinal nerve root‘. They are clinically useful as they
profession. The first is the Keegan and Garret map of 1948. can determine if damage has occurred to the spinal cord, and
This depicts dermatomes in a way that correlates with the at which level the damage has occurred.
segmental progression of limb development. The second is In this article we shall look at the embryonic origins of
the Foerster map of 1933 which depicts the medial part of the myotomes, their distribution in the adult and their clinical uses.
upper limb as being innervated by T1-T3 which follows the
distribution of pain from angina or an MI. This is the most
commonly used map, and features in the ASIA scale of Origin of Myotomes
assessing spinal injury. Skeletal muscle development can be traced to the appearance
Both maps depict progression of limb growth around an axial of somites. By day 20 the trilaminar disc has formed and
line. Across this line there is no overlap between dermatomes, the mesodermhas differentiated into different areas. The area
but often those adjacent each other have a slight overlap. directly adjacent to theneural tube is known as the paraxial
mesoderm.
From day 20 onwards the paraxial mesoderm begins to
differentiate further into segments known as somites. 44 pairs
of somites are formed, however some of these regress until 31
pairs remain, corresponding to 31 pairs of spinal nerves in the
adult.
Somites are composed of a dorsal and ventral portion. The
ventral portion forms the sclerotome, the precursor of the ribs
and vertebral column. The dorsal portion consists of
the dermomyotomes. As the embryo continues to develop
the myotome proliferates and eventually develops into muscle.

Distribution of Myotomes
Most muscles in the upper and lower limbs receive innervation
from more than one spinal nerve root. They are therefore
comprised of multiple myotomes. For example, the biceps
brachii muscle performs flexion at the elbow. It is innervated by
the musculocutaneous nerve, which is derived from C5, C6
and C7 nerve roots. All three of these spinal nerve roots can
be said to be associated with elbow flexion.

The list below details which movement is most strongly

associated with each myotome:
 C5 – Elbow flexion
 C6 – Wrist extension

 C7 – Elbow extension

 C8 – Finger flexion

Clinical Relevance: Assessing Spinal Cord Lesions  T1 – Finger abduction

 L2 – Hip flexion

Following a traumatic injury that may involve the spinal cord,  L3 – Knee extension
the clinician can test dermatomes to determine the presence
and the extent of a spinal cord lesion.  L4 – Ankle dorsiflexion
Firstly, the clinician uses cotton wool to test for light touch
sensation along the limbs and torso, touching areas which  L5 – Great toe extension
correspond to the different dermatomes. Secondly the clinician  S1 – Ankle plantarflexion
uses a small pin to test for responsiveness to pain. The patient
is instructed to close their eyes and say when they feel contact
with their skin (Light touch and pain are tested separately as
their fibres travel in different parts of the spinal cord –
see here).
 the tips of the future digits. The interdigital spaces are then
Clinical Relevance: Assessing Spinal Cord Lesions
progressively sculpted by cellular apoptosis.
In the assessment of a suspected spinal cord lesion, the
clinician can test myotome function. This can help determine
if there is spinal cord damage, and where the damage is
located. Clinical Relevance – Limb Abnormalities
Myotomes are tested in terms of power, and graded 1-5: Congenital limb and digit defects occur in between 1 in 500
and 1 in 1000 live births. They are often associated with other
 0 = total paralysis. birth defects, such as congenital heart malformations.
 1 = palpable or visible contraction.
The common limb abnormalities are:
 2 = active movement, full range of motion (ROM) with gravity
eliminated.
 Amelia – complete absence of a limb.
 3 = active movement, full ROM against gravity.  Meromelia – partial absence of one or more limb structures.
 4 = active movement, full ROM against gravity and moderate The common digit abnormalities are:
resistance in a muscle specific position.  Syndactyly – fusion of digits, which occurs due to a lack of
apoptosis between the digits during development.
 5 = (normal) active movement, full ROM against gravity and  Polydactyly – increased number of digits.
full resistance in a muscle specific position expected from an
otherwise unimpaired person.
DEVELOPMENT OF THE RESPIRATORY SYSTEM

DEVELOPMENT OF THE LIMBS

 1 Initial Development
o 1.1 Clinical Relevance: Tracheoesophageal Fistula
The upper and lower limbs (including the shoulder girdle and  2 Ongoing Development
pelvic girdle) begin development in the 4th week of o 2.1 Pseudoglandular Stage: Weeks 8-16
gestation. Usually the upper limb begins development first, with o 2.2 Canalicular Stage: Weeks 16-26
the lower limb often lagging 2-3 days behind. The limbs are o 2.3 Terminal Sac Stage: Week 26 onwards
well differentiated by week 8.  3 Clinical Relevance: Respiratory Distress Syndrome

In this article we shall cover the basic embryological

development of the limbs, as well as some important clinical The lower respiratory system consists of the trachea,
conditions. bronchi, bronchioles and alveoli.
It develops relatively late in the embryo – which can cause
Formation of Limb Buds problems when babies are born prematurely.

In this article, we will discuss the development of the

The limb buds are the precursor structures of the limbs. Their respiratory tract and its clinical implications.
formation begins in the 4th week, with the activation of
mesenchymal cells in the somatic layer of lateral Initial Development
plate mesoderm. The respiratory system is derived from the primitive gut
The limb buds first appear on the ventrolateral body wall tube – the precursor to the gastrointestinal tract. The gut tube
initially and extend ventrally. They consist of a central core is a endodermal structure which forms when the embryo
of undifferentiated mesenchymetipped with a layer of undergoes lateral folding during the early embryonic period.
ectoderm, the apical ectodermal ridge (AER). At approximately week 4 of development, an outpocketing
Elongation occurs through proliferation of the underlying appears in the proximal part of the primitive gut tube (the
mesenchyme core, in which the AER plays a crucial role in foregut) – this is known as the respiratory diverticulum.
ensuring that the mesenchyme immediately underneath it Initially, the respiratory diverticulum is continuous with the
remains undifferentiated. As growth proceeds, the proximal foregut; but this is not compatible with life. This is rectified by
mesenchyme loses signals from the AER and begins to the formation of the tracheoesophageal septum, which is a
differentiate into the constituent tissues of the limbs. longitudinal ridge that separates the two structures from each
The AER itself is maintained by the Zone of Polarising other.
Activity (ZPA) which is found in the posterior base of the limb The diverticulum separates into two buds, which become the
bud. The ZPA’s secondary responsibility is to ensure left and right primary bronchi. The primary bronchi then
asymmetry in the limbs. proliferate to give off secondary, and tertiary bronchi.
The position of the AER is important as it marks the boundary
between the dorsal and ventral limb ectoderm – the ectoderm
is able to exert ‘dorsalising and ventralising’ influences over
the mesenchyme core. For example, it removes hair follicles
from the palms and soles of the feet.
Formation of the Digits
As elongation continues, the mesenchyme condenses into
plates forming the cartilaginous models of the future digital
bones. The AER then breaks up and is maintained only over
 result, they will have difficulty expanding their lungs to take
their first breath.

If a pre-term delivery is unavoidable or inevitable, the mother

can be given glucocorticoids to stimulate surfactant production
in the foetus.

Ongoing Development
Pseudoglandular Stage: Weeks 8-16
Each bronchopulmonary segment will become a specific
portion of the lung, carrying its own tertiary bronchus and
branches of the bronchial and pulmonary arteries. During
weeks 8-16, the ducts develop within bronchopulmonary
segments. Bronchiolar buds branch off from the tertiary
bronchi, and begin to proliferate.

At this stage, there is no gas exchange yet, and so the lungs

are unable to oxygenate blood. However, the lungs are a
metabolically active, developing tissue, which means they are
able to remove large amounts of oxygen from the blood.

In order to stop the lungs from starving the body of oxygen, the
ductus arteriosus shunts blood from the pulmonary artery
directly to the aortic arch. This closes at birth in the vast
majority of people.

Canalicular Stage: Weeks 16-26

Throughout the canalicular stage, the respiratory bronchioles
develop, budding off from the terminal bronchioles formed
within the pseudoglandular stage. Despite this, there is still no
gas exchange membrane, and so the lungs are not yet
functional. Therefore, the vast majority of babies born during
this stage will not survive.

Terminal Sac Stage: Week 26 onwards

From week 26 onwards, the alveoli develop. Within these
alveoli there are two types of cell; type I and type II
pneumocytes. Type I cells are basic simple sqaumous
epithelial cells, which make up 90% of the alveolus. The other
10% is composed of type II cells, which produce surfactant.

Surfactant is amphipathic, meaning it is able to bind to both

hydrophobic and hydrophilic molecules simultaneously. In this
case, surfactant binds to water and air within the alveoli. This
has the effect of reducing the surface tension. As a result of
the reduced surface tension, the alveoli are able to expand to
greater volumes at a given pressure.

Simply put, surfactant allows us to expand our lungs with

minimal effort.

Clinical Relevance: Respiratory Distress Syndrome

If a baby is born prior to the development of type II
pneumocytes, they will be unable to produce surfactant. As a