Académique Documents
Professionnel Documents
Culture Documents
Back Thorax
Tho racic & Lumba r Vert ebrae 8 Thoracic Wall Muscle Facts 50
j oint s of th e Vert ebr al Colum n: Overv iew 14 Arter ies & Veins of th e Tho racic Wall 56
j oint s of t he Verteb ral Colum n: Craniovertebra l Region 16 Nerves of the Tho racic Wall 58
Vertebr al Ligame nts: Overview & Cerv ical Spine 18 Neurovascular Topography of th e Thoracic Wall 60
2 Muscles
6 Thoracic Cavity
Muscles of the Back: Overview 22
Int rinsic Mu scles of th e Cervical Spi ne 24 Divisio ns of th e Thoracic Cavit y 66
3 Neurovasculature 7 Mediastinum
Heart in Situ 82
Heart : Valves 86
Surface Anato my 40
Arteries & Vein s of t he Heart 88
Esoph agus 96
XI
8 Pleural Cavity Jej unum & Ileum 162
Cecum , Appendix & Colon 164
Pleura l Cavity 102
Rectum & Ana l Canal 166
Lungs in Situ 104
Liver : Overview 168
Lun g: Radio lo gy 106
Liver: Segments & Lobes 170
Bronchopulmonary Seg m ents of the Lung s 108
Gallb ladder & Bile Ducts 172
Trachea & Bronc hia l Tree 110
Pancreas & Spleen 174
Respirat ory Mechan ics 112
Kidneys & Supra renal Gland s: Overview 176
Pulmonary Arteries & Veins 114
Kidneys & Suprarena l Gland s: Feature s 178
Neurovascul at ure of t he Tracheobron chial Tree 116
Ureter 180
Lymp hatics of t he Pleura l Cavity 118
Urinary Bladd er 182
Urinary Bladder & Urethra 184
9 Surface Anatomy
XII
Supraclavicular Branche s & Posteri or Cord 322
Hu merus
256 23 Surface Anatomy
Muscle Fa ct s (I)
272
Femur 360
Anteri or Muscles of the Thigh , Hip & Glut eal Region (I) 36 6
Bon es of th e Wri st & Hand 29 8 Poster ior Muscl es of the Thigh , Hip & Glutea l Regi on (I) 37 0
j oints of t he Wrist & Hand 300 Posteri or Mu scles of t he Thigh, Hip & Glutea l Regi on (II) 372
Mu scles of th e Hand: Superfic ial & Midd le Layers 306 Muscl e Fa cts (III) 378
Mu scle Fa ct s (II) 3 14
22 Neurovasculature
Knee j oint: Ligam ents & Meni sci 38 6
XIII
Base of th e Skull 45 8
27 Neurovasculature
Nerves of th e Lum bar Plexus: Obt urato r & Fem oral Nerves .. 428
31 Cranial Nerves
Superfic ial Nerves & Vessels of t he Low er Limb 434
Transverse Sect io ns 44 8
CN IX: Glossopha ryng eal Nerv e 482
Muscles of t he Orbit 50 8
XIV
Topog raphy ofthe Orbit 512
Orbit & Eyelid 514
Eyeball 516
Corn ea. Iris & Lens 5 18
38 Surface Anatomy
xv
Bacl<
1 Bones, liga ments & Joints
Vertebra l Co lum n: Overview 2
Vertebra l Colum n: Eleme nts 4
Cervical Vertebrae 6
Thoracic & Lumba r Vertebrae 8
Sacru m & Coccyx 10
Intervertebral Disks 12
Joints of th e Vertebra l Column: Overview 14
Joint s of the Vert ebral Column: Cranioverteb ral Region 16
Vert ebral Ligament s: Overview & Cervical Spine 18
Vert ebr al Ligame nts: Thoraco lumbar Spine 20
2 Muscles
Muscles of t he Back: Overv iew 22
Int rin sic Muscles of t he Cervica l Spine 24
Intrinsic Mu scles ofthe Back 26
Muscle Facts (I) 28
Muscle Facts (11) 30
Muscle Facts (11 1) 32
3 Neurovasculature
Arteries & Veins of the Back 34
Nerves of t he Back 36
Neurovascular To pography ofthe Back 38
4 Surface Anatomy
Surface Anatomy 40
Vertebral Column: Overview
~ The vertebral colum n (spi ne) is divided int o four regio ns: t he and lumbar spines demon strate lo rd osis (inward curvat ure); the thoracic
IiIriiiiiII cerv ical, tho racic, lumbar, and sacral spi nes. Both the cerv ical and sacral spines demonstrate kypho sis (outward curvature).
C1 - (7
Craniocervical junction vertebrae
Cervical spine
Cervicothoracic junction
t':t.~ii=;::.}---- Spinous
process
Thoracic spine
Thoracolumbarjunction
l,...d~i::::~ Costal
Lumbar spine
facets
T1-T1 2
Lumbosacral junction vertebrae
Articular
Sacrum (sacral spine)
processes
A Region s of t he spine.
~ ·PP'...-----'o. Interverte
bral foramina
~ Clinical
Adult spinal
column
~~~~"l'!'I--- Sacral
Kyphotic
Transitional
phase ~
W
F- Cervical
Sacrum
(51-55
promontor y
~
spine lordosis
of the vertebrae)
newborn
- Thoracic
kyphosis
Coccyx [
[l.: Lumbar
\)~ lordosis B Bony vertebral col umn.
<~ Sacral
~)) kyphosis
A B c
2
Fig. 1.2 Normal anatomical position ofthe spine
Left lat eral view.
1-- - - External
Dens of axis (C2) - - - --;---c aud it o ry canal Dens of axis (C2)
Ton gu e
Laryn x
Spinous process of
vert ebr a pro m inens (C7)
Trachea
Line of gr avity - -- ---I Inflect ion point s
Spinal cord
Ascendi ng
aor t a
Vert ebral canal
Heart
Esophagus
Int ervert ebra l di sk
Diaphr agm
Spino us proce ss
'ilii.~~- Whol e-body Liver
center of gravit y
Sto ma ch Body of L1
Conus m edullari s
Abdom inal
aort a
. ~~~- Coccyx
Rectum
3
Vertebral Column: Elements
C1-(7
verte brae
Tl -Tl 2
verte brae
Ver tebral \~~~~~~- Inferio r scapular
body ang le (17)
L1 - - ---iIf,--J,1
Ll - L5
verteb rae
Sacrum [ Posterio r
(fused sacral
Sacrum
51- 55 foramin a
ver te brae) Anterior
sacral
for am ina
Coccyx [ Coccyx [
4
Fig. 1.5 Structural elements of a vertebra Fig. 1.6 Typical vertebrae
Left posterosuperior view . With th e exception of th e at las (C1) and axis Superior view.
(C2), all vertebra e consist of th e same struc tura l elem ent s.
Superior
articu lar Verte bral
Verteb ral -1'----- pro cess for am en
body
Superio r arti cular facet
Pedicle Transverse Pedicle
Verte proc ess ..-........_ ~ Posterior tubercle
bral Transverse process wit h
arch
1
Lamin a Spino us
pro cess
sulcus for spinal n.
Body Ant erior
Transverse foram en
tub ercle
Inferior
Transverse process
sacral crest
Spinous process
' C1 (atlas) and C2 (axis) are considered atyp ical (see pp. 6-7).
5
Cervical Vertebrae
~ The seve n verte brae of th e cervica l spine di ffe r most conspicu all di rect ions. ( 1 and (2 are known as t he at las and axis, respective ly.
~ ously fr om t he com mo n verte bral m orphology. They are special C7 is called the vertebra prominens for its long, palpab le spinous process.
ized t o bear th e weigh t of t he head and allow th e neck t o m ove in
Posterio r
arch of at las
Posterior
Transverse arch of at las
'-------~,r-- Zygapo
Transverse
Anterior ------,-L,f physeal j oi nt fo rame n process
Inferior
tu bercle
b ---':llr--- - Inferior art icular
articu lar facet
Posterior
process
tu bercle
process
Sulcus fo r
spinal n.
C7 (verte bra -
prom inens)
I articu lar facet -
Superior
articular facet
Transverse
Transverse - 'l/n;c--.ilI
- - Spinous
process process
foramen
Transverse fo ramen
Body
Transverse process
<:"'~--- Superio r articu lar facet
- ,",---~
6
~ Clinical
Transverse process
Vert ebral
Vert ebral arch
for am en
Inferior
art icular
Transverse
process
process
Superior
artic ular
Uncinate Vertebral foram en ~ Spinous pro cess
process process
Vert ebr al arch
Posterior Lam ina /
/ ' t ube rcle Trans Superior
Sulcus for
verse Pedicle ----,_ ---,.4'11. art icular facet
spinal n.
Ant erior process
tubercle Posterior tubercle
Transverse
Bod y process with Transverse
sulcus for foramen
Spinous spinal n. Body Ant erior
process tu bercle
7
Thoracic & lumbar Vertebrae
Fig. 1.11 Thoracic spine Fig. 1.12 Typical thoracic vertebra (TG)
Lef t lat eral vi ew.
Superior Superior
vertebral not ch art icular facet
Superio r \ Transverse
~
~
cost al facet process
l~~~~g~t~~:,- process
Superior art icular
Inferior Spinous
art icular facet pro cess
~---1r--- Transverse
proc ess
A Left lat er al v iew.
-r-.------ - Costal facet
on tran sverse
process Superior Transverse
art icular process Body process
~~~--- Zygapo
physeal j oint
Superior
cost al facet
Vertebral - ------!-
bod y I nfer i o r ~ Cost al facet
cost al facet on tr ansverse
pro cess
Inferior
Spinous proc ess - - articu lar facet
v~~~~~
B A nterior v iew.
Inter_ !
vertebral
for am en Superior - ---f--='-'--=- ,....,- Cost al facet on
vertebra l
tr ansverse pro cess
notc h
,,-----.l~- Transverse
process
12th tho racic - - 7--
Pedicle "':o ...,~.,..--- Superior
vert ebra (T12 )
articular facet
Inferior --........., Superior
costal facet vertebral not ch
Inferior
art icu lar facet Superior ~---+------- Body
cost al facet
C Superior vi ew.
8
Fig. 1.13 lumbar spine
Left lateral view.
vertebra (L1)
Supe rior
art icular process
Inferior
vert ebra l
-----.J-~~~~~~",.II"'l'\
Spinou s
1... . - Mammillaryprocess
Transverse
-~ii;;;iiii~iJ~
Inter- {
process
verteb ral notch
proce ss
foram en
Superior
Body !--- -
vertebral
notch Spinous
Zygapophyseal ~~:::~~~~ process
jo int Inferior
verte bral notch
Vert ebral
Inferior
body
Superior
art icular
Inferior Inferior
Body proc ess
articular process arti cular facet
I
~ Clinical
Osteoporosis
The spine is t he structure mo st aff ected by degenerative diseases of t he
skelet on, such as art hrosis and osteoporosis. In ost eoporosis, m ore bone
mate rial get s reabsorbed tha n buil t up, resulting in a loss of bone mass.
Symptoms include compression frac ture s and resulting back pain. Inferior - -
art icular facet
Inferior Spinous
articular process process
Spinous process - -
Mammillar y
process
Accessory Transverse process
process
I.
Vert ebral - ---'....'----'l.
Superior artic u
arch
lar process
Vert ebral
- -----.----1- ----/
Superior
forame n
verteb ral
Body -----\~-----'--____,- notch
9
Sacrum & Coccyx
~ The sacrum is fo rmed fro m five postnata lly fused sacral vert e vert ebra. and th e apex artic ulates w it h th e coccyx, a series of t hree or
~ brae. The base of the sacrum art iculates w it h th e fift h lum bar four rudimenta ry verte brae.
Lat eral
part
Apex of Superio r
sacrum art icular Sacral
~~:::::;:=iiifii9Gr--- Sacrococ cyg eal
j oi nt facet t ubero sit y
Sacral
canal
A Ant eriorview .
Auricular
surface
Lat eral
sacral crest
B Posterior view.
10
Base of
sacrum
.3l_ - - Superior
articu lar pro cess
Promon
tory
Poster io r
surface
Med ian
sacral crest
Superior Sacral
art icular proc ess canal
Median
sacral crest
Sacral
canal
Coccyx
t
Intervertebral Disks
Nucleus - -r..,*":-t-i':-
arch
Hyaline
cartila ge
end plate
Fig. 1.19 Relation of intervertebral Fig. 1.20 Outer zone of the anulus fibrosus
disk to vertebral canal Ant erior view of L3-L 4 w it h int ervertebral disk.
notc h fora m en
Inferior --~~,.-iir"llllll.r
artic ular
process
Spino us pro cess
2
~ Clinical
Cauda Fat in t he
equina epidural
space
L3
~ Herniat ed
Dural sleeve
disk
with spinal n.
L4 Cauda
equina in
Cent ral CSF'-filled
herniation dural sac
A Superio r view.
B Mid sagittal T2-w eig ht ed MRI (m agne ti c
reson ance image).
Spinal
dura mater
- ;l..:z>=;J-- Dural , ac
Spondylophyte
Dural sleeve
wit h spinal n.
Compressed
Posterolateral
nerve root s
herniat ion
Posterolat eral
herniation
Nucleus
pulposus \ .F""'_~ Intervert ebral disk
Vertebral arch
(pedicle divided)
Dural sleeve wit h spinal n.
Post erolat eral herniat ion (C. D) A post erol at eral hern iation may compress m edi ally posit ion ed . t he herni at io n m ay spare the nerv e at t hat level. but
t he spinal nerve as it passes t hro ug h th e int ervert ebral foram en. If more im pact nerves at inf erior levels.
13
Joints of the Vertebral Column: Overview
process
Il
Anterior
tub ercle
Zygapophyseal
joint
Sulcus for
spinal n.
A Cervi cal reg ion, lef t lat eral vi ew. Th e zyga po p hysea l joints lie -\-- - Costal facet
Vertebral foramen
Superior
art icular process
Tranverse
process
.:6Ii1.....-t- Tranverse
Zygapophyseal process
join t
B Tho racic regi on , lef t lat eral v iew. The j oints lie in th e coro nal p lane.
Inferior --"'::::;-0.1"' , "'~
articular process
C LUlIIUdl reql on, post er lor vie w . The j oints lie In th e sag ittal plan e.
4
Fig. 1.23 Uncovertebral joints
~ Clinical
Anterior vie w . Uncoverteb ra l j oints form during childhood between the
uncinate processes of (3-(6 and the verteb ra l bodies im m ed iate ly su pe
ri or. Th e joints may res ult from fi ssures in the cartilag e o f the di sk s that
Proximity of spinal nerve and vertebral artery
to the uncinate process
....
assume an arti cul ar charac te r. If the f issures b ecom e co m p let e t ear s, The spinal nerve and vert ebral artery pass throug h th e int ervertebral and
th e ris k of pu lp osu s hernia ti on is increased (see p. 13). t ransverse foramina, respect ively. Bony outgrowt hs (osteophytes) result ing
fro m uncoverteb ral art hrosis may comp ressboth the nerve and the arte ry
and can lead to chroni c pain in t he neck.
Dens
Vertebral a.
in t ransverse
foramen
atlantoa xial
joint
C1 spinal n. At las(Cl)
Axis (C2)
Uncinate - - ----'r 'iI
processes
Vertebral a.
=".....- - Verte bral body
Uncinate
process
verse
..'",~- Transverse
1
process Ant erior
process
t ubercle
Sulcus for
Spinal n.
spinal n.
in sulcus
Vertebral body (( 7)
Lamina Vertebral
foramen
Spinal
cord
Spinal n.
Posterior root -~'7""''''~~
(spinal) ganglion
Transverse
process
B Un cov ertebra l j oint (en larg ed ) , anterior vi ew o f corona l sect io n .
Transverse Uncinate
foramen process
15
Joints of the Vertebral Column: Craniovertebral Region
Occipital condyle
(temporal bone)
Groove for
Transverse
verteb ral a.
process
Spinous process
Externa l occipita l
/ N
",""'.
protub erance
Nuchal I.
Atlanto-occipital
Styloid process joint
• A Nuchal li gam ent and po st eri or at lan to B Posterio r long itud ina l lig am ent. Removed:
oc ci p it al m emb ran e. Spina l co rd ; verteb ral can al windowed .
16
~ The at lanto -occipita l joi nt s are th e t w o art iculat ion s between th e axial jo int s are t he t wo lat eral and one medial art iculat ions bet ween t he
IIIriiiiII convex occipita l condyles of th e occipita l bone and th e slight ly atla s (C1) and axis (C2).
concave superior art icu lar facets of t he at las (C1). The at lanto-
.....
process of at las
lat eral at lanto
occip ita l jo int
~--- Transverse process
Int ertransverse I.
Groove for
Lateral mass
vertebral a.
of t he at las Posterio r arch
Lo ngit udin al fascicles Post erio r of at las
Atia nto
occipita l
capsule Lon gitudinal
Alar I.
fascicles ' Lat eral
mass of C1
.-~~-- Transverse I. Dens. poste rio r
of at las' art icular surface
C Cruciform ligament of at las ( *) . Removed: D Alar and apical ligament s. Removed: Transverse
Tect orial membra ne. ligam ent of atlas, longit udinal fascicles.
~ ..
17
Vertebral ligaments: Overview & Cervical Spine
~ The ligam en t s of t he spina l co lumn bind t he vertebrae and enab le st resses and lim it t he ra nge of m o t io n. Th e lig am ent s ar e su bd ivid ed
IiIIiiiiII t he sp ine to wit hsta nd high m echanical lo ad s and shearing into vertebra l body ligam ent s and vertebral arch liga m ents.
Fig. 1.28 Anterior longitudinal ligament Fig. 1.29 Posterior longitudinal ligament
Anterior lo ng it ud inal ligament. Anterior view with ba se of sku ll rem oved. Posterior v iew wit h verteb ra l cana l w indowed an d spinal co rd removed.
8
Fig. 1.30 Ligaments ofthe cervical spine
Sella Apical ligam ent Hypoglossal Tector ial
t urcica of th e dens canal memb rane
Spheno id sinus
Occipital bon e,
basilar part
Facet join t
.....~~3r----+--- Ligament a f lava
capsule 1L---'.!lIo-:":'-'-----,-,- -'-:-+-- - Verte bral arch
Int ervert ebral disk - ---\;-;'- S\"-;:;:- .,----'-_ _ Intervert ebral fo rame n
Cerebellomedu llary
Apex of dens cistern
Posterior t ubercle
Body of axis of atlas
Nuchal ligament
Posterior longit u
dinal ligame nt
Vertebral body
19
Vertebral Ligaments: Thoracolumbar Spine
Interspinous ligament s
. +.--~- Supraspinous
ligament
-"=,.---- - - - - Superior
artic ular
process
Lamina
Inter
tran sverse Ligamenta
ligament s flava
Spinous process
Pedicles of
Posterior --~,-< , vertebral arches
longit udinal
ligam ent
Intervertebral
Intervertebral ------,~~~.~-:
foram en
disk
~-- Vert ebral
Gap in
body
ligamentous
reinfo rcement
Superior
of th e disk
arti cular facet
Transverse
process
21
Muscles of the Back: Overview
~ The mu scle s of the ba ck are divid ed in t o two gro ups. t he ext rin sic mu scles are co nsid ered m uscles of t he up per lim b t hat have m ig rated to
~ and t he intrinsic mu scle s. wh ich are separat ed by th e supe rfi cial th e back ; these muscle s are d iscu ssed in Unit 4 .
layer of t he t ho raco lumbar fascia. Th e supe rfici al extri nsic
m f -- Sternocleido
mastoid
Trapezius.
- -- - Acromion
Sca pular spine - - - ----f.1Wi'r;-;--;-- - - - Supraspinat us
Deltoid
Trapezius.
Serrat us anterior
ascending part
Serratus
posterior inferior
Thoracolumbar - --i!1;CT---f,
fascia. superficial
layer
Exte rnal
oblique
Olecranon ---lH+fT'l*"~"
Aponeurot ic -----!!'!HK~~~f---
origin of
- - - N -,rriilHW ilf.II--- Int ernal
latissimus
obliqu e
dorsi
Lumbar
t riangle.
internal
oblique
Iliac crest
Gluteal
aponeurosis
22
Fig. 2.2 Thoracolumbar fascia
Transverse sect ion, superior view . The intrinsic back mu scles are seques layer that unite at the lateral marg in of t he intrinsic back m uscles. In t he
tered in an osseof ibrous canal, formed by the thora columbar fascia, t he neck, t he superficial layer blend s w ith the nucha l fascia (deep layer),
vertebra l arches, and t he spinous and tran sverse processes of associated beco ming cont inuous with th e cervica l fascia (prevertebral layer).
vertebrae. The thoracolumbar fascia consist s of a superfi cial and a deep
Infrahyoid Visceral
m uscles Trachea Esoph agu s fascia
Thyroid glan d
Sternoc leidom asto id
Int ernal
j ug ular v.
l f
Cerv ical
fascia
Prevert ebrallayer
B
Vagus n. ---~~~~
Com m on
carot id a.
---7J~r;~i~~~~~~ ""'="""': ¥:-- - Lon gu s co lli
Levat or --'!~"''''
scapulae
Psoas fascia
Lateral
abd om inal
wa ll m uscles
back m uscles
Thoracolumba r
} fascia
23
Intrinsic Muscles of the Cervical Spine
protuberance
Semis pi nalis
capitis
Splenius capit is
24
Fig. 2.4 Short nuchal muscles
Posterior view. See Fig . 2.6.
Trapezius Superior nuchal lin e
Semispina lis
capit is
Ste rnocleido
posterior major
ma st oid
capit is superio r
Obliquu s ---~:.!
Transverse / "
vert ebral a.)
capit is inferio r
of axis (C2)
cerv icis
Transverse
Spino us ----'i"l~=-----ll'"""'
process of C7
proc ess of C7
--"_'!I"_,,,,",,,,",,~~---f-- Trapezius
St ernocleido
Spleniu s - ---1;; mastoid
cap iti s
Longissim us ---~'ftI
capiti s
Obliqu us
capitis inferior
25
Intrinsic Muscles of the Back
~ The extrinsic musclesof the back (trapezius, latissim us dorsi, serratus posterior, considered an intermediate extrinsic back muscle, has
~ levator scapulae, and rhomboids) are discussed in Unit 4. The been includedwith the superficial intrinsic muscles in this unit.
superio r
Semispinalis -~~\-,;-l
capit is
External
Trapezius ---fL-=f;{;ff.j~~-=------+'!
intercostal
mu scles
Splenius Thora columbar
capit is fascia (= deep layer
of nuchal fascia)
Spleniu s ----l~
cervici s
Thoraco
lum bar
fascia
Serrat us
posterior
inferio r
Inte rnal -~~\
oblique Lat issimus Exte rnal
dor si int ercost aI
apon euro sis m uscles
Ext ern al -~, . ,"" "~ Ext ern al
ob liqu e oblique
lIio - - -,lJh "..;;.4 -+-\":;
costalis
Iliac crest
Longi ssi --~~~~-!rl~
mu s
Exte rnal
o blique
Int ernal
Gluteu s
obliq ue
maximu s Iliac crest
26
Splenius capit is --~. Semispinalis
(cut edge) capiti s
Iliocostalis
th oracis External
intercost al
Levatores - -r.iF---=r--hbi rnuscles
costarum
Superior
nuchal line
SpinaIis - --iI!'-:T.: R-+ Lon
gissimus Splenius capit is Rectus capitis
Obliquus
capit is superior
Internal
obliqu e Longi ssimus - - - -----t1ll,liI Interspinales
abdomini s
Spinalis - -- - -4ttJiiJlf
cervicis
External
Spinalis -M"'---::",,",~~('/J_/~ , int ercostal
Gluteus Mult ifidus Thoracolumb ar
th oracis mu scles
maximu s fascia. deep layer
C Interm ed iate and deep intrin sic ba ck muscl es. Removed: Longissimus
th ora ci s and cerv icis, sple nius mu scles (left); ili o co st ali s (right). Note:
Th e d eep lay er of th e th ora columbar fas cia gives o ri g in t o the internal
o b li q ue and transver sus abd o m inus. Revealed: Deep mu scles of th e 12th rib
back .
-==--- Inter
Interspinales tra nsversarii
lumbo rum laterales
lumb orum
Transversus Transverse
abdomini s processes
Iliac crest
D Deep intrin sic back muscl es. Removed: Superficial and inte rmedi ate
intrin sic ba ck mu scle s (all); d eep fa scial layer and multifidu s (right) .
Revealed: Intertransversari i and quadratus lumborum (r ig h t ).
27
Muscle Facts (I)
Superior Inferio r
nuchal line nuchal line
\ Obliq uus
capit is superior
Rectu s capit is
post erior maj or
! capit is
:, @ Obliquus capit is: C2 (spinous : Bilateral: Ext end s head
, : C1 (t ransverse process)
infer ior : process) : Unilateral: Rot ates head to same side
Fig. 2.7 Prevertebral muscles Basilar part of Rectus
occipital bone capitis anterior
Basilarpart of
occipital bone
Atlas - -----::: Mastoi d -----X::1IJ"Mp:;'f~;1I! '''l1I~~:.JI~~;.f4 Rectus
process capitis lateralis
Axis - - - ,,*=
""",1,,,,-- '~,.;---- Transverse
process of atlas
Longus - - --f-
capitis
Axis Superior
C7 vertebra - - --7.- obli que
part
Lo ngus
colli
1st rib
13 vertebra
Prevertebral muscles
Muscle Origin Insertion Innervation Action
29
M uscle Facts (II)
~ The intrin sic back mu scles are divided into supe rficial, inte rme di nerves. not th e do rsa l ram i, which innervat e th e intrinsi c back muscl es.
~ at e, and deep layers. The posterior se rrat us muscl es are ext rinsic They are included here as th ey are encountered in dissec tion of th e ba ck
back muscl es, innervated by t he ven tral rami of inter cost a l mu sculature.
: serratus : 0 Posterior serratus • 8th- 12th ribs (inferior borders. : Spinal nn. T9- T1 2
• T11-L2(spinous processes) . . : Depresses ribs
inferior • nearangles) • (anterior rami)
................................................................................................................ .................................................................... . .
. : Ligamentum nuchae;
, Occipitalbone (lateralsuperior '. Spinal nn. Cl -C6 ''. Bilateral: Extends cervical spineand head
: <» Splenius capitis
: Splenius uu u uu. u..u.u u . ~? :::T~ ~s~ i ~.?~s ~~?C~Ss~s l. ~ ~~~a l li ~e ; rnast? i d pro~ess ) .......• (posterior rami. lateral • Unilateral: Flexesand rotates head to the
: @ Splenius cervicis • T3- T6(spinousprocesses) • C1-C2 (transverseprocesses) . branches) ...... ......... ... •.~a~ ~ side
Fig. 2.8 Superficial intrinsic back Fig.2.9 Intermediate intrinsic back muscles (schematic)
muscles (schematic) Right side. posterior view. These muscles are co llectively known as t he e re cto r spina e.
Right side, posterior view.
®
®
~ CD
® @
0
(])
Superior ---7"-----
nuchal line
Posterior - - - - 3
serrat us
superio r
Iliocost alis
t hor acis
Spinalis
th oracis
Lon gissimu s
th oracis
B Ere ct or sp inae : Ili o co st ali s. lon g issimu s. and spi n alis mu scl e s.
Muscle Facts (III)
~ The deep intrinsic back muscles are divided into two groups: spinalis muscles pass between the transverse and spinou s processes of
IIIiiiII transversospinal and deep segmenta l muscles. The transverso - the vertebrae.
Transversospinalis muscles
@
@- --"Iloe-
@
A Rotatores
m uscles , B Multifidus. C Semispinal is.
o Interspinales cervicis C1-C7 (between spinous processesof adjacent vertebrae) Spinal nn. Extends cervical and lumbarspines
Interspinales' (posterior
® Interspinales lumborum L1-L5 (between spinous processesof adjacent vertebrae) rami)
Intertransversarii anteriores Spinal nn.
C2-C7 (between anterior tuberclesof adjacent vertebrae)
cervicis (anterior rami)
Bilateral: Stabilizes and extends the
® Intertransversarii cervicaland lumbar spines
C2-C7 (between posterior tubercles of adjacent vertebrae)
posteriorescervicis
Inter
transversarii ' Unilateral: Bends the cervica land
@ Intertransversarii mediales lumbar spineslaterally to same side
L1- L5 (between mammillary processesof adjacent vertebrae)
lumborum
Spinal nn.
(posterior
® Intertransversarii laterales
L1- L5 (between transverseprocessesof adjacent vertebrae) rami)
lumborum
@ Levatores costarum breves Costalangle of next lower rib Bilateral: Extends thoracicspine
10 " " " '0 <
C7- T11 (transverse processes) Costalangle of ribtwo Unilateral: Bends thoracicspine to
costarum @ Levatores costarum longi
vertebrae below same side, rotates to opposite side
",'
•Boththe interspinales and intertransversarii musclestraverse the entirespine; onlytheir clinically releva nt components have been included.
Superior Fig. 2.13 Deep intrinsic back muscles
nuchal line Post eri or view.
Inferior -4~0iiI~~
nuchal line Semispinalis
capit is
Semispinalis
cervicis
Spinous process of (7 -------o~7\ \
Semispinalis
t horacis
Transverse
process
~~:~~~,~~~~~~~~- costa
Levat orures
lo ngi
m
Levat or es
costa rum
breves
Sacrum - - ---';-- --'1'1'''''''':.....".....
Internal External
carot id a. carot id a.
Fig. 3.1 Arteries of the back
The structures of t he back are supplied by branches of th e pos terior
intercostal arteries. which arise from the t horacic aorta or di rectly from
th e subc lavian ar t er y.
Thyrocervical tru nk
- Posterior intercostal aa. Costocervical
t runk Right subclavian a.
Anterior intercostal aa.
1st posterior
Thoracic intercostal a.
aort a Internal
thoracic a.
2nd posterior
Abdomin al ----<1IIO'IiC1iIIiL.
intercostal a.
aorta
""\,a..t.r --.......-'c".-- SubcostaI a.
Sternal Lateral
branches cutaneous
branch
Spinal
Internal branch
t horacic a.
Anterior - -1M
ramus
Medial
cutaneous
branch
Thoracic
aorta
E=:,-- - - - Abdominal
aorta
Median
sacral a.
34
Fig. 3.2 Veins of the back
Th e vein s of th e back dr ain into th e azyg os vein via t he superio r interco s
ta l vei ns, hemia zygos veins , and ascend ing lumba r vein s. Th e interi or of
th e spinal co lum n is d rain ed by th e vertebral venou s plexus t hat run s t he
length of t he spine.
1~ft~~~~= Azyg o S v.
... Superior venacava Transverse sinus
Sigmoid sinus
~~ ~~~~~l-- Posterior intercost al w .
Left
~~~ .!--==-~-+- Inferior vena cava brachiocephalic v.
Superior
{'_=--::-'-'+ - Subcostal v. vena cava
Accessory
hemiazygosv.
Azygosv.
Posterior
A Vein s of th e intercostal vv.
trunk , rig ht lat eral
vi ew. Hemiazygosv.
External vertebral
venous plexus
Posterior internal
vertebral venous plexus
Azygosv. -~~~~~~l~"
Anterior
intercost al v. Anterior ~~---,"--"'i-1
internal External
Anterior ext ernal
Hemiazygasv. vertebral
iliac v.
Internal vertebral
t horacicvv. venous plexus venous
Internal
plexus
iliac v.
35
Nerves of the Back
~ The back receives its inner vation from branches of th e spinal intrinsic mu scles of th e back. The ext rinsic mu scles of th e back are sup
-.iiiiiII nerves. The posterior rami of th e spinal nerves supply m ost of th e plied by th e anterior rami of th e spinal nerves.
Int ercost o
brachial nn.
Posterior
ramu s
Intercost al nn.
Anasto mosis
with medi al
brachial
cut aneous n.
Meningeal ramus
cuta neous
branch
Ante rior
Subcostal n. -
ram us
(12th int ercost al n.)
<,
Posteri or
ramu s
" The white and gray rami communicans carry pre- and postganglionic fibers bet ween the sym pat hetic trunk
and spinal nerve. Thcy arc show n on p. 622 .
36
Fig.3.4 Nerves of the nuchal region
Rig ht side, posteri or view. Like th e back, th e nu chal regi o n receives m ost
of its m otor and sensor y innervat io n fr om th e posterior rami of th e spinal
nerv es. The poste rio r rami of C1-C3 have spec if ic nam es: subocci pit al
nerve (C1), grea ter occipital nerv e (C2), and t hi rd occi pit al nerv e (C3).
The lesser occi pita l and gr eat auric ular nerves arise f rom th e anterior
rami of th e C1-C4 spinal nerves and inn er vat e t he skin of th e ant ero lat
eral head and neck. The anterio r ram i of C1-C4 also g ive rise t o th e ansa
-r-- -----,f=.= '"7"-- Lesser
cervicalis, wh ich in ner vates t he inf rahyoid m uscles (see p. 562). .liIlIllr~l\ occipital n.
I ~------ Greatauricular n.
Supraclavicular nn.
C5 spinal n.,
Fig. 3.5 Cutaneous innervation of the back posterior ramus
~ C2
~C5
Medial
cutaneous
branches
\
Spinal nn.,
(posterior
rami)
C6
Lateral --"'c----"-i~
cutaneous
branches +-:;>- Intercostal nn.,
(lateral cutaneous Tl
branch)
Superior _~-:--...
cluneal nn.
A Periph eral senso ry cu ta neous inn ervat ion of t he back. B Derma tomes: Segme nta l (rad icu lar) cut aneou s inn er vat ion of th e
back. Note: The posterior ram us of C1 is purely m otor : th ere is co nse
qu ently no C1 derm at om e.
37
Neurovascular Topography of the Back
superior
Occipital a.
Verteb ral a.
Rect us capitis
posterior major
Suboccipita l n.
Obliquu s capit is
inferior
Lesser occipita l n.
Sternocleido masto id
Deep cervical a.
Splenius capitis
Longissim us
/ capitis
38
Fig. 3.7 Neurovasculature of the back
Posterior view. Removed: Muscle fascia (except
superficial layer of thoracolumbar fascia); lati s
sim us do rsi (righ t). Reflected: Trapezius (rig ht) .
Revealed: Transverse cervical artery in th e deep
scapular region .
3rd
occip it al n.
Rhomboid major
Trapezius
Spinal nn.,
poste rior ram i
Deltoid
(m edial
cut aneous
branches)
Thoracolumb ar fascia
External oblique
Iliac crest
Superior --~~FI--'"S~'+-:ir:t-~
clunea l nn.
Midd le -----,~~-~f___c,__---i!%~~
clun eal nn.
39
Surface Anatomy
Vertebra
prom inens (Cl)
~ Greater
spine
tuberosity
Medial
bord er
Inferior
angle
6t h through
12th ribs
Iliac crest
}-- -- - - Anterior
superior
Posterior - - - - - - - :
iliac spine
superior
il iac spine Id E. -..-- .----- - - - - - Sacrum
...-- - - - Greate r
tr ochanter
.....,.=----- - - - - - - - Ischial
tub erosity
Trapezius
A Bony prominences.
~~==f- Teres
min or
Ter e s_-!----_~
major
Triceps
brachii
Glute us -+-_
mediu s
Gluteus
maximu s
B Musculatur e.
40
Fig. 4.2 Surface anatomy of the back
Posterior view.
SPinal _-----7------«
furrow
lJ Michaelis'
rhomboid
Anal _ _ ~----__;_;;::_____.....z
cleft
a:~~~1f------- Gluteal
fold
ili ac crest?
Sacral
] t riangle
Gluteal _ _--;~----'~~.
fold
41
Thorax
~ The th oracic skeleto n consists of 12 th oracic verte brae (p. 8). 12 prot ecti on to vit al organs. The female th orax is generally narrower and
~ pairs of ribs wit h costa l cart ilages, and th e ste rnum . In addition to shor ter t han th e male equiva lent.
participatin g in respirat or y m ovement s, it provides a measure of
Clavicular
notch ~~~:I;~~~-- tSuperior
.~ horacic apert ure
. . . - ..a..~~,- Costa l
cartilage
Tl verte bral
body
l:1li;;3 -- Spinous process
Sternum Intervertebral
disk
Inferior
thorac ic aperture
A Ante rior view.
=---=---==~t--
Transverse
process
~~!'S:9II!!::~~~_ Costo
t ransverse
joint
Tl 2 spinous
process
....lr-~......= - L1 spinous process
C Posterior view.
44
Fig. 5.2 Structure of a thoracic segment
Superior view of 6th rib pair.
Vertebral
foramen
Costal
cartilage
Sternum
: Body (includingcostalangle)
: : • • • •• • • • •• • • •• • • • • • • • • • • • •• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • n • • • • : • • ••• • • • • • • •• • • •• • • • •• • • •• • • • • • • • • • • • • • •• • • • • • • • • • • • •• • • • •• • •• • • • • •
.............................. . " ..
....r>-'' --- - - : Floating ribs ' 11, 12 : None
: ~ . .: .
45
Sternum & Ribs
e
o
Fig. 5.4 Sternum
The sternum is a bladelike bone consist ing of th e manub rium, body, and
t: xipho id process. The j unct io n of th e manubrium and body (t he ste rnal
angle) is ty pically elevate d and marks t he articulat io n of th e second rib.
The sterna l angle is an important landm ark for int ernal st ruct ures.
- +- - 1st costal
notch
angl e ang le
A Ant erior view. B Left lateral view. The costa l not ches are
site s of art iculatio n wit h the costa l carti lage
of th e t rue rib s (see Fig. 5.3 ).
46
12th Fig. 5.5 Ribs
rib Right ribs. superior view. See pp. 258-259 for
joints of th e shoulder.
Scapular
notch
Acrom ion
Acro m io ~..---""7--:l.
-1i10'-;-- - Dens of axis (C2)
clavicular j oint
- - - At las (C1)
Costa l Crest
t ubercle of neck
5t h rib
2nd rib Manubrium
~ N"k
A Variat ion s in rib size and shape. sterni
- - Head
Costa l
t ubercle
Costal
t ube rcle
Neck
Head
Head
Groove for
- - -- subclavian a.
Tubercle for
scalenus ante rior _ _ _ _ _ 2nd rib
Groove for
~ subclavian v.
- - Bod y
(shaft)
- - - - - - 5t h rib
C Right ribs. superior view.
47
Joints of the Thoracic Cage
Inspiration
Infrasternal
angle
diameter diameter
Expirat ion
Axisof
movement Axis of
movement
Increase in
transverse
diameter
..
Increase in
sagitta l diameter
48
Fig. 5.7 Sternocostal joints
Anterior view with right half of sternu m sect ioned fronta lly. True joints
are generally fo und on ly at ribs 2 to 5; ribs 1, 6, and 7 attach to th e ster
num by synchondroses.
Costo t ransverse
Superior Costal facet j oint
art icular facet (tra nsverse pro cess)
Costotransverse I. Neck of 8t h ri b
Radiate I.
jo int of head of rib
Inferior -~-==:-;o---.--rt- + - -
1""... Lateral costotr ans
Spinous process
Crest of
rib head
Superior
costot ransverse I.
Int ervert ebral ---f~~-::::~D~ "
disk
~-- Costal t ub ercle
Radiate I. ----l>------:~~~~
~_~_If/_
8th rib (neck)
_ ...
T8
49
Thoracic Wall Muscle Facts
~ The muscl es of t he th o raci c wa ll are primarily resp on sibl e fo r w ith th e sho ulder (see pp . 264-267), an d th e serrat us p o st er ior is d is
~ chest respirati on , alt ho ug h ot he r mu scles aid in deep inspi ratio n: cu ssed with th e ba c k (see p. 30).
th e pectora lis major and serrat us anterio r ar e di scu ssed
A Scale ne muscles, anterior v iew . B Inter co st al muscl es, anterior view. C Tra nsve rsus th oraci s, p o st eri or v iew.
Lower margin of lower ribs to inner surface of ribs t wo to t hree Variable lower
Subcosta l Raises ribs (inspiration)
ribs below int ercost al nn.
Ste rnum and xiphoid process ' 2nd to 6t h ribs (costal 2nd to 7th
IJ) Transversus t horacis Weakly lowe rs ribs (expirat ion)
(inner surface) carti lage, inner surface) intercostal nn.
50
----"1<,.--- - Atl as (Cl) Fig. 5.10 Muscles of the thoracic wall
Anterio r view. The exte rna l intercosta l m uscles
I -::~--- Axis (C2)
are rep laced anteriorly by the externa l int er
costa l membrane. The inte rna l intercostal
mu scles are replaced po ste rio rly by the interna l
Anterior longitu intercosta l membra ne (removed in Fig. 5.1 1).
dinal ligament
Posterior
scalene
:~~~--- Anterior
1st rib scalene
Manubrium
sterni External
int ercost als
Radiate
ste rnocost al ligaments
Ext ernal
Internal int er int ercostal
costals membrane
Ste rnum
External
inte rcostals
Costal
cart ilage
Manubr ium
ste rni
Int ernal
Exte rnal
int ercostals
intercost als
Transversus
th oracis Int ernal
int ercostals
Xiphoid
pro cess
Cost al - -'\,--('
cartilag e
Clavicle
Xiphoid
,..--e~ Caval process
apert ure
L1.
tra nverse
process
10t h rib
(1)
Right Left
crus crus
Esophageal Caval
Cent ral
apert ure apert ure
te ndon
B Poste ri or view.
Right
do me
Left dome
Median
arcuate
ligament
Right crus
Latera l
arcuate
ligament
Aortic
aperture
Quadrat us
~!-!"!-- Transversus
lum borum
abdomini s
Psoas
m ajor
C Coronalsection wit h diaphragm in Medial arcuate
intermediate position. Psoas min or ligament
Diaphragm
Muscle Origin Insertion Innervatio n Act ion
: CD Costa
.......... l part .......·..!. ~ ~
....................... t? l .~ t ~..ri~ s. . ~in~ e ~ s.u rfac ~ ; lo~~rrna ~~ i~. ofc ? s.ta I a. ~ch)
~ Medial part: L1- L3 vert ebral bodies. intervert ebral disks. Princi pal muscle of respiratio n
, 0 Lumb ar part : and ante rior longit udinal ligament as right and left cru ra : Cent ral : Phrenic n. (C3- C5, (diaphra gmat ic and th oracic
. Diaphragm
Lat~ r. ~l p~r ts : .I ~~ ~r~ I ~~ ~ F.~ ~ i ~ I .~ ~ ~ ~ ~te ligament s
: cervical plexus) breathing); aids in comp ressing
....................... .................. tendon abdominal viscera (abdominal press)
: Q) Sterna l part • Xiphoid process (posterior surface)
52
Ste rnumDiaphragm
Fig. 5.13 Diaphragm in situ
_ _~I _ _~ (sternal part )
Centra l
tendon
Caval
aperture
-'-'iI<-\-- Esophageal
Aort ic apert ure -----l~!'\ !!!!!.-~~-----~ apertu re
---f+.~- T 8
~Mr--- R i b
Endothora cic
Intrinsic fascia
back muscles
A Su pe rior v iew.
Sternum
Sterno costal Rectus
Caval tria ngle
aperture
Central
te ndo n
"0#-"--- Lumbocostal
Int ernal triang le
oblique (Bochdalek's
Transversus ~ tr iangle)
abdo mini s Lat issim us
do rsi
Quadratu s
lumborum
Lateral arcuate
ligam ent
B Inferio r view.
no
.........----"le...::..-- - T12
Aor ta
53
Neurovasculature of the Diaphragm
Hemiazygos v.
Mu sculop hrenic a.
Celiac tr un k
'>/oil
Inferio r vena cava
-f
Rib -
I
To pariet al pleur a.
mediast inal part
Int ercost al -
To parieta l pleur a.
diap hragmatic part
Inte rcost al nn .
Diaphragm
54
Blood vessels of the diaphragm
Arte ry Origi n Vein Drainage
Inferior phrenic aa. (chief blood supply) Abdominal aorta; occasionally fr om celiac trunk Posterior int ercostal w .
Superior phr enic aa. Thor acic aorta Superior phrenic w. Right side: Azygos v.; Left side:
Pericardiacophr enic aa. Hemiazygos v,
Int ernal thora cic a. Right superior int ercostal v.
Musculoph renic aa.
Parietal pleura.
costa l part
Rect us -------=-~-7O'='
abdo mi nis Diaphragm ,
centra l te ndon
Diaphragm ,
costa l part Left
phrenic n.
Caval
hiat us
Esophageal
Right phr enic n. hiatus
suprarenal a.
Left superior
Common
suprarenal a.
hepat ic a.
Splenic a.
Externa l and internal
ob lique, tranver sus Greater
abdo minis splanchnic n.
Diaphragm,
lumbar part Left ascending
lumb ar v.
55
Arteries & Veins of the Thoracic Wall
~ The post eri or interco st al arteries anosto mose wit h th e an t eri o r ao rta , w it h t he exce pt io n of th e 1st and 2 nd . w hic h ar ise f ro m t he su pe
~ inter co st al arte ries t o su p p ly t he st r uc t u res of the t horacic w all. rior interco st al artery (a br an ch of t he cos toce rvi ca l trunk).
Th e po sterio r interco st al arteri es b ran ch fr om t he t ho racic
Superior
Thyrocervical
th oracic a.
Arteries of the
t runk
thoracic wall
Thoracoacrom ial a.
Subclavian a.
Origin Branch
2nd intercost aI a.
! Subclavian a. : Thoracoacrom ial a.
.................................... , .
~ ~ Posterior
~
: Thoracic . Posterior intercostal aa.
"'" Intercostal a.
• aorta ! (3rd t hrough 12t h)
.................................. , .., .
Dorsal ~~
; Internal
: Anterio r intercostal aa,
: Musculo phrenic a.
: tho racic a.
Lateral
; Superior epigastr ic a.
cut aneous
branch
Anterior intercostal a.
Anter ior - -+'-"a- - -<
,------ Abdominal aorta
int ercost al aa.
Spi nal branch Ant erior Lateral cuta neous branch ' Anterio r t horacic
intercost al aa. wall
Anterio r Dorsa l ramu s
radicul ar a. ' The lateral mamm ary branch from t he lateral cutaneou s branch supplies th e
breast along wit h t he medial mam mary branch from t he internal t horacic
art ery.
56
~ The int ercostal veins drain prima rily into th e azygos system . but follow a sim ilar cour se to th eir art erial counterparts. However. th e veins
IIIiiiiII also int o th e int ernal thora cic vein. This blood ultimately return s of the vertebra l column fo rm an exte rnal vertebral venou s plexus that
to th e heart via th e superior vena cava. The inte rcost al veins trav erses th e enti re length of the spine (see p. 35).
Sub clavian v.
Int ern al
t ho racic v. Posterior
intercost al vv.
Superior
vena cava
Hem iazygo s v.
Posterio r
int ercosta l vv.
Inferior
vena cava
Subco stal v.
( 12t h intercostal v.)
A Anteri orvi ew with rib cage op ened. Int ern al jugu lar v. Exte rnal ju gu lar v.
Azygo s v. """"-----\:l.
Inferior vena cava --L
57
Nerves of the Thoracic Wall
Tl
Int ercost o
brachial nn. Anter ior cut a
neous branch
3rd and 4t h
inte rcosta l nn.
Anastomosis St ernal
wit h m edial branches
brachial
cuta neou s n.
Subcost al n.
( 12t h intercost al n.)
Supraclavicular nn.
Supraclavicu lar nn.
Medial
Anter ior cut aneous
cutaneous branches
branches Spinal nn.,
dorsal rami
Int ercost al nn. Lateral
cuta neous Intercost al nn.,
Lateral branches lateral cut aneou s
cut aneous Superior branches
branches cluneal nn.
Iliohypogastri c n.,
latera l cut aneous branch
58
Neurovascular Topography of the Thoracic Wall
La te ralt horacic
a. and v.
Thoracoepigast ric v.
Internal thoracic
a. and v. Anterior cutaneous}
branches
Intercostal aa..
Intercostal a.. Lateral cuta neous vv., and nn.
v.. and n. branches
Internal
oblique
Rectus
abdominis
~ Clinical
Pectoralis
major
Pleuraleffusion
Parietalpleura
"7-~f:'--;---'i:---- I ntercostaI
Visceral pleura
Endothoracic
fascia B Drainage tube is inserted C At ribs. the tub e is angled and
perpendicular to chest wall. advanced parallelto the chest
wallin the subcutaneous plane.
Rib
~~~- Chest tube
Pleuralspace
Puncture site
intercostal
external the tube is passed th rough the
intercostals intercostal muscles and advanced
A Coronal section. anterior view. into the pleural cavity.
60
Fig. 5.27 Intercostal structures in cross section
Transverse section, ant erosuperior view.
Intercostal n.,
posterior (dorsal) ramus
Right superior Intrinsic
phrenica. Costal Lateral branch Medial branch back muscles
groove
Latissimus
dorsi
Intercostal a.,
posterior
(dorsal) ramus
External
intercostals
Spinal cord (with
spinal ganglion)
Internal
intercosta ls !'!'!!!!=-- - - Intercostal nn.,
anterior
Innermost --~~~~?!L-.4~ (vent ral) rami
intercostals Posterior
intercostal aa.
Endothoracic -----'::;.;:~~-+-.!I andw.
fascia
Azygos v.
Central tendon
Thoracicaort a
~----- Esophagus
Serratus anterior ----i~ '\1l
Pericardium
Intercostal n.,
anterior cutaneous branch
61
Female Breast
~ The female breast, a modified sweat gland in the subcutaneous byconnective tissue. The breast is additionally supported by suspensory
~ tissue layer, consists of glandulartissue, fibrous stroma, and fat. ligaments. An extension of the breast tissue into the axil la,the axillary
The breast exte nds from the 2nd to the 6th riband is loosely at tail, is often present.
tached to the pectoral, axi llary, and superficialabdominalfascia
Nipple - - - --
~"----- Areola
Areolar
glands
Subclavian
a. and v.
Axillarya .
and v.
Lateral t horacic
a. and v.
Lateral mamma ry
branches
Mammar y
branches
Supraclavicular nn.
Intercostal nn.,
medial mamm ary
branches
Intercostal nn.,
lateral mammary
branches
62
~ The glandu lar t issue is com posed of 10 to 20 individua l lobes, sinus. Areolar elevations are t he open ings of t he areolar glands
~ each with its own lact iferou s duct. The gland ducts open on the (sebaceous). The glands and lacti ferous ducts are surrou nded by firm ,
elevate d nipple at the center of t he pigm ented areo la. Just pro xi fibrofatty tissue with a rich blood supply.
mal to th e duct opening is a dilated po rt ion called t he lact iferous
._+_~~ _ _ Suspensor y
(Cooper's) ligam ent s
Pecto ralis m inor
Mamma ry
Intercostal
lobes
mu scles
Nipple
Pectoralis m ajor
Lact iferous
Int ercostal
sinus
V., a., and n.
Lact iferou s du ct
Superfic ial
abdomin al fascia
Int erlobular
connect ive ti ssue
Lobules
B Duct system and portion s of a lobe, sagittal section . In the nonla ctat C Termi nal duc t lobular unit (TDLU). The clustered acini composing the
ing breast (shown here), t he lob ules contain clusters of rudimentary lobu le empty into a termina l ductu le; these str uctures are collectively
acini. known as the TDLU.
63
lymphatics of the Female Breast
~ The lym phat ic vessels of t he breast (not show n) are divided into on t heir relat io nship to t he pect oralis m inor (Table 5.7). The medial por
I5iiII t hree syste ms: superficial, subcut aneo us, and deep. These drain t ion of th e breast is drained by t he parasternal lym ph nodes, w hich are
primarily into t he axillary lym ph nodes, w hich are classified based associated w it h t he int ernal t horac ic vessels.
Axillarya.
Cent ral
axillary I.n. Cervical Ln.
Pect oralis major
Brachial v.
Biceps brachii
--==---,,:~-- Clavicle
Brachial a.
lZ~=--=~~~~----- Interpectoral
axillary Ln.
•I
~ u ?scap~ l~ r axillary I.n: ... H .
, Centra l l.n.
........................................................................., .....
~ II
... . j
Midd le axillary group : Along pecto ralis minor
.. • • • • • • • • • • • .• • H • • •• • • • • • • H " •• •• • H • . .•• • .• H ••••••••• H" •••• • • ••• H • • • • • • • H"': . I ~ ~ ~ r p. ~ ~ ~?ra l ~Xi lla. ~y I.n.
! III' : "'l.Jpper infraclavicu lar grou p ; Medial to pectora lis mi nor • Apical axillary Ln.
64
~ Clinical
Breast cancer
...Stem cells in th e int ralob ular connectiv e t issue give rise to t remendous cell makes the te rmin al duct lobu lar unit (TDLU) the mo st common site of origin of
growth. n ecessary for duct system proliferat ion and acini different iation . This maligna nt breast tumors .
Lobules
Lactiferousduct
~ 1O%
Terminal duct
lobular unit (TDLU )
Tumors originating in t hebreast spread via t he lym phat ic vessels. The deep colloids (techn etium [Tc] 99m sulfur rnkrocollotd). The downstream sent inel
system of lymphatic drainage (level III) is of parti cular importance . alt houg h node is th e fir st t o receive lymphatic drainage from the t um or and .is the refore
. th e parasternal lymph nodes provide a route by whic h tumorcells may spread the fir st to be visualized with radiolabeling. Once identified. it can then be
.across th e m idline. The survival rate in breast cancer correlates most strongl y · rem oved (via sentinel lymphadenectomy) and histologically exami ned for t umor
w it h t he number of lymph nodes involved at t he axil lary nodal level. Metastat ic cells. This m eth od is'98%accurate in predict ing the level of axillary nodal
involvement is gauged t hroug h scintigraphic mappingwith radiolabe led involvement .
Levell 65%
.................. .................... .........................
~ Level II 31%
, Level III - 0%
C Norm al mamm ogr am . D Mammogram of invasive duct al carcinoma. The large lesion has changed t he
archite cture of the neighb oring breast tissue.
65
Divisions of the Thoracic Cavity
~ The tho racic cavity is divided into t hree large spaces: t he medias
a.iiIII t inum (p. 76) and t he t wo pleural cavit ies (p. 102).
Rig ht pleural - -I-!iII'---- -~O\-- Left pleural Heart . pericar diu m . and roots of
Mediastinum Middle
cavity cavity (left lung) Inferio r great vessels
(rig ht lung) m ediastinum
Thor acic aorta. t ho racic duct .
Inferior -lYIf::::::="':L-\I\- Posterior esophagus. and azygos venous
mediastinum
syste m
~ ",---;r.+-- Diaphragm
Pleural Right
cavitie s
Left pleural cavity Left
I Trachea
Common carot id a.
Brachial plexus -------:.;;~b' Jn
~:2\~p,.----- Thymu s
Pericardiacophrenic --....,......--",ll~
a. and v.. phr enic n. Left recurr ent
laryngeal n.
Parieta l pleura.
- --.---"7';;---./ Left pulmonary a.
costal part
Parieta l pleura.
Right lung (wi t h
------.----;;;8'----~
med iastinal part
visceral pleura)
Left lung
Pericardium
66
Thoracic Fig. 6.2 Divisions of the mediastinum
inlet
Left pleural
L
cavity cavity Esophagus,
cervical part
Inferior --w.!!------=::----\1~
mediastinum Thoracic inlet Cervical part }
Trachea
Diaphragm Thoracic part
- \--'\:""\-- - - Superior
Thoracic Descending
vertebra aorta
67
Arteries of the Thoracic Cavity
~ The arch of the aorta has three major branches: the brachioce tho racicaorta at the level of the sternalangle and the abdominalaorta
~ phalictrunk. left common carotid artery. and left subclavian artery. once it passes through the aortic hiatus inthe diaphragm.
After the aortic arch.the aorta begins its descent, becoming the
Trachea
Left subclavian a.
Bronchial a.
Diaphrag m
Celiac t runk
rr-'-F--;;:- - ""'-"""--';Ji- - Abdo min al aorta
Lumbar a.
-s.a
B Thoracic aorta in situ. anterior view. Removed: Heart. lungs. portions of diaphragm.
68
Branches of the thoracicaorta
The thoracic org ans are supplied by dir ect branche s from the th oracic aor ta, as well as indirect branches f rom the subclavian art eries.
Vert ebral a.
Ant erior intercostal aa. Anteri or chest w all
Thym ic branch es Thymu s
Int ernal thoracic a.
Left subclavian a. Mediastin al branch es Poste rior m ediastinum
~ Clinical
Aorticdissection
A t ear in t he inner w all (intima) of th e aorta allow s blood to separate t he aor t ic dissect ion s may be t reated conservatively, provided t here are no
layers of t he aortlc wall. creatin g a "false lumen" and pot ent ially result ing in com plications (e.g., obst ruc t ion of bloo d supply to the organs, in wh ich case a
life-t hreat ening aorti c rupture. Symptoms are dyspnea (short ness of bloo d) stent may be inserted to restore perf usion) . Aor ti c dissect ions occurring at t he
and sudd eno nset of excruciati ng pain. Acute .aortic dissect ion s occur mo st base of a corona ry artery m ay cause myocardial inf arction.
ofte n in the ascending aorta and generally require surgery. More dist al
"Fa lselumen"
Ascending Intim a
aorta
Decending
aorta
A Aortic dissecti on . Parts of t he inti ma are st ill attached to th e connect ive B The flow in th e coronary arter ies is int act (arrow ).
t issue in th e wall of th e aorta (arrow) .
69
Veinsof the Thoracic Cavity
~ The superior vena cava is for me d by t he union of t he two brachio drained by th e azygos syste m (t he inferior vena cava has no t ributaries in
~ cephalic veins at t he level of t he 12-13 j unct io n. It receives blood t he th orax).
Middle scalene
Left subclavian v.
Azygos v. - - ----,!!.f,
m :--- - - Accessor y hemia zygos v.
Posterio r inte rcosta l vv . - - - ---7-::
Hemi azygos v.
70
Thoracic tributariesof the superior venacava
Major vein Tributaries Region drained
Pericardia l vv.
Left , up'" l UI v.
Int ernal t horacic v. Ant erior intercostal vv. Ant erior chest w all
Pericardium
v.
Note: Structures of the superio r med iasti num may also drain "'" ~ ~ " ,u th e brachioce phalic veins via t he tra cheal, and media stinal veins.
I
Left renaI v.
Right t estic ularJ
ovarian v. * }f-- - - -- - Lumbar w .
Left com mo n
ili ac v.
Inferior vena cava
71
lymphatics of the Thoracic Cavity
~ The body' s chief lymph vessel is t he thora cic duct. Beginning jug ular and subclavian vein s. The rig ht lymphatic duct drains to
IIIIiiiiII in the abdomen at th e level of L1 as t he cisterna chyli. t he t he right junctio n of t he interna l jugu lar and subclavian veins.
thoracic duct empties into the j unction of the left interna l
Comm on carotid a.
Jugular t runk
Subclavian a.
Subclavian tr unk
Left subclavian v.
Left brachio
ceph alic v.
Accessory
hemia zygo s v.
Thor acic du ct -r-r-r-r-i-rr
~r--- Intercostal
Diaphragm - - --.-:'i; lymphatics
Azygos v. - - -'-1i:
Hemia zygo s v.
72
Head and neck - - -- ) Fig. 6.8 Lymphatic pathways in
( the thorax
Right j ugular
Left j ugular
trunk
Thoracic tru nk
duct
Left int ernal
Right lymphat ic ~ jugular v.
duct
Right subclavian _ Left subclavian
t runk t runk
Left subclavian v.
Right broncho- _ _
Left bron cho
mediast inal tru nk
m ediastinal t runk
Pre-pericardiaIL n.
Lateral pericardialLn.
?
Paraesophageal Ln.
Paratracheal Ln.
Tracheobronchial Ln.
! \
Abdom en, pelvis, and lower limb Fig. 6.10 Thoracic lymph nodes
Transverse sectio n at level of tra cheal bif urca
t ion (T4), inf erior view. The thora cic lymph
Fig. 6.9 Lymphatic drainage nodes can be divid ed int o three broad groups:
by quadrants nod es of t he t horacic wa ll (pink), pulmonary
node s (b lue), and mediasti nal nodes (gr een).
Parasternal Ln. Trachiob ron chiall .n.
For detail s of lymphatics of t he mediast inum ,
see pp. 100- 101.
--:--7.:- Right lym phat ic duct Lymphati cs in
t runk wall
Thoracic duct
Intrapulmonary Ln.
~ Thoracic inn ervati on is m ostly auto no mic, arising from th e para pericardium and di aphragm (p. 54), and t he inte rcosta l nerves inn ervat e
IIIiiiiII verte bral sym pat het ic t runks and parasympat heti c vagus nerves, t he t horacic wa ll (p. 58).
There are t w o exceptions: t he phren ic nerves in nervat e t he
phr enic n.
Posterio r ----.-.:
Esoph agus,
Trachea cerv ical part Commo n carotid a.
Diaphragm
B Nerves of t he th orax in situ . Note: The recurrent laryngeal nerves have bet ween t he t rachea and the esophagus, m aking th em vulnerable du r
been slight ly ante rior ly retr act ed; norm ally, the y occupy t he groove ing th yroid gland surgery.
74
~ The a uto nom ic ne r vou s system innervates smooth muscle. car (red) a nd parasympathetic (b lue) ne r vo us systems. w hich toget her
IIIiiiII diac m uscle, a nd g la nds. It is subdivided into the sympathetic reg u lates b lood f low. secretions, and organ f unction .
C8
\-_.;---~,,-- Stellate gang lion
T1 Vagu s n. (CN X)
12
13 Cervica l
cardiac nn .
T4
T5
T6
T7
Pharyngea l plexus
T8
T9 Ext ernal
carotid plexus
T10 ~-.....
Cardiac plexus
tt
Esophageal
: chest wa ll
Esophageal plexus
: Sympathetic . branches
• Spinal cord . : Accompany Vagus n.
• Visceral
Brainst em Tracheal branches Trachea
: t runk ! intrath oracic aa.
! t arget s (CNX)
... .. .. . ... .. ..... . ...... .... . , - .
Pulmonary plexus
'., Gathe r in greate r and .
· Abdomen
Bronch ial branches (b ronchi, pulm on ary
. .... ...... . . lesser splanchnic nn.
vessels)
' The axons of presynapt ic neuron s exit t he spinal cord via t he anterior roots and '
' The gang lion cells of the parasympathetic nervous system are scattered in
synapse w it h post synapt ic neuro ns in t he sympa~ he tic~a n~lia: .
m icrosco pic groups in their t arget orga ns. The vagus nerve t hus carries the
presynaptic motor axons t o t hese ta rgets.
eN - cranial nerve.
75
Mediastinum: Overview
~ The medi astinum is th e space in th e th orax between the ple ural The inferior mediastinum is furth er divided into anterior, middl e, and
~ sacs of th e lungs. It is divided into two parts: superior and infer ior. posterior portion s.
Pretracheallayer }
Cervical
fascia
- - - - Investing layer
- - Left brachiocephalic v.
&-i - -
':;- - - Ma nubrium
\---'---cl":;;;,---- - Ascending aorta
.""""~--- Thymus (retrosternalfat pad)
Esophagus. thoracic part ---cr -----'." "'-l+-* ;-;c- .,...;--'- '-~--"<"<-:'L---_ Aortic valve
l'-'- - - Pericardialcavity
76
Thyroid gland, Thyroid Fig. 7.2 Contents of the mediastinum
rig ht lobe cart ilage
Scalenus ante rio r ________
muscle
Phrenic n. J\ I
Trachea
Common carot id a.
Vagus n. (CN X)
C Posterior view,
77
Mediastinum: Structures
l st rib ---------~~~~~~~
Right subclavian a. and v.
Brachiocep halic
lym ph nodes
Azygos v.
:-";~;'_;';,___--- Trachea
bronchus
-'i~----',---- Thymus
Righ t pulmo nary a. - - --'- -"-4 (ret roste rnal fat pad)
:=-.--'~~--- Fibrou s
pericardium
Common tr unk of - - ----.- S
mi ddle and inferior ~~--- Right pulm onary vv.
lobar bro nchi
costal part
v., and n.
.,...:-7'---- - - Diaphragm
Intercost al mu scles
78
Clavicle ------+-------:c,.-;7."~ 1st rib
Fibrous -----:!~~+'f_;¥_
pericardium
lym ph node
pericarcliaco
phrenic a. and v.
Hem iazygos v.
lym ph node
Diaphragm - - - 1--..-----;-';;
B Left lat eral view, parasagittal sect ion. Removed: Left lung and pariet al
pleura. Revealed: Posterior mediastin al st ruct ures.
79
Thymus & Pericardium
Thymus
=--"l!!:-'--..........f=- Phrenic n.,
pericardiacophrenic
a. and v
Fig. 7.5 Thymus
Anteri or view o f op en ed thora x of a 2-year- o ld
child. Th e t hy m us is w el l d eveloped at thi s
ag e, exte ndi ng inferi orl y into the anteri or
m edi asti n um (compare with Fig. 7.4) . Th e thy
mu s g ro ws t h ro ug ho ut child ho o d; at pubert y,
high level s of circulating sex hormones cause
th e thymu s to atrophy. Parietal pleura, Parietal pleura, Fibrous
diaphragmatic part mediastinal part pericardium
Common carot id a.
Subclavian
a. and v,
Trachea - - - i'=
....,.·+ - - Left
Brachio- - - - '- brachio
cephalic t runk cephalic v.
Right brachio- ~
cephalic v.
Superior - --"'''lllio-=c ~","",,===r--- Left
vena cava pulm onary a.
Thymus, -~"" "'''''h ~";~:o:!'l~- Thymu s,
Superior
vena cava
Fibrous
pericardium
Parietal pleura,
(~ external
mediast inal
layer)
part
Cardiac surface
Serous Diaphragm
pericardium,
visceral layer
80
'// ~";;";'----;;-;----.---- Trachea
Fig. 7.7 Serous pericardial reflections
Ante rior view. The parietal and visceral serous peri
Esophagu s ----;~~ cardium are continuous wi t h one anoth er around
=~~~- Lef t brachiocephal ic v. th e great vessels of th e heart. The passage bet ween
th e art erial- and venous-associated reflections is th e
F'--'-7.~rr-+- Ascending aor ta trans verse pericardial sinus (see B).
Right
pulmonary a.
Transverse -7."s;,::;-,-,n - Pericardial cavity
pericardial
sinus
Left at rium
Serous
pericardium
Superior ~'+\;;'¥',-1<-----:
phrenic
lymph
nod e
Attachme nt of liver
Lef t com mo n ----~ ~--- Left subclavian a.
to diaphr agm (bare area)
carot id a.
Brachiocephali c
A Sagittal section through th e mediastinum .
t runk
Not e the continuity of the parietal serous
Serous pericardium ,
parietal layer
Inferior vena cava - - - -f- Fibrou s
Left com mon pericardium
carot id a.
Left auricle - -
(at rial appendage)
~II-- Right pulmonary vv.
Serous pericardium,
visceral layer
Reflect ed edge
(cont inuous wit h
parietal layer of serous
pericardium)
the heart
Upper bod y
circulat ion
}
Diaphragm -----*~~><::-::':::'\;
~-......::!toZ;;;;::;;;;;::t_- - - - Cardiac apex
Pulmonary
circu lat ion
trun k
Right at rium
Left subclavian a. l:\'iiiiH---=--- Left vent ricle
Ste rnum
(rnanubrium )
Aortic arch
Superior - - - +---r.;;:ll
- +--+-- ---!! !-- Right vent ricle
--.......:;;;:;;~y
Pericardium
Diaphragm
aorta
} Lower body
circulat ion
82
Fig. 7.10 Heart in situ
Ant erior view.
Aortic arch
Superior
vena cava
Left pulm onary a.
Ascending
aort a
Pulm onary
Parietal pleura. tru nk
mediasti nal part --li~~~~~~ Left auricle
(at rial app endage)
Right auricle
(atrial appe ndage) Left coron ary a.
(ant erior
int erventri c-
ular branch)
Left
vent ricle
Card iac
apex
Diaph ragm
Fibro us
pericardium
Right
vent ricle
\
Stomach
83
Heart: Surfaces & Chambers
i!:
Fig. 7.11 Surfaces of the heart Left subclavian a.
The heart has t hree surfaces: anterior Left commo n Aor ti c arch
carot id a.
(sternocost al), post erio r (base), and inferior Ligamentu m arteriosum
(diaphragmat ic). Brachio- - - ----,:ll
cephalic trunk Left pulmo nary a.
Right -~......
Left pulm onary vv.
pulmo nary a.
':.1,---- - Pulmonary
trun k
~!::a.~-- Left
auricle
Right -------I-~~=
auricle Right - ---1- Pericardium
atri um (reflecte d edge)
Left
ventr icle
Pericardium Aortic arch
(reflect ed edge)
Coronary
sinus
Inferior vena cava
Left pulmon ary a. --J:~i!!! ... Right pulm onar y a.
Left - + -
vent ricle
==--------" - Posterior
inter vent ricular
sulcus
Pulmonary
tr unk
Right atrium
Left ventricle
Coronary sulcus _ --'liiiii'iOiilli
Inferior
vena cava
Valved or ifi ce of Valved orifi ce of
inferior vena cava coronary sinus
Chordae
t end ineae ":l!!!_ - Inferior
......",--r"'~ '
vena cava
Cardiac - j ..rlflliII;..,
apex
Post erior Left atrioventric
pap illary m uscle ular valve
~ The cardi ac valves are divid ed into t wo groups: semi lunar and passage of blood from t he ventricle s t o t he aorta and pu lmonary trunk.
~ atrioventricu lar. The two sem ilunar valves (aorti c and pu lmonary) The two at riove ntricu lar valves (left and righ t ) lie at t he interface be
locat ed at the base of th e two g reat arterie s of the heart reg ulate twe en t he at ria and ventricle s.
Left cusp }
Right cusp Aort ic valve
Posterior cusp
Righ t atrio
Coronary sinus
Left fibrous
anulus
Opening for the Rig ht fibrous
bundle of His anulus
86
Fig. 7.14 Semilunar valves Fig. 7.15 Atrioventricular valves
Va lves have been lo ng it ud inall y sect ioned and o pe ned . Anterior vi ew during ve nt ric u lar systo le.
~ Clinical
...................................... .................................................................................. .... ..............................................~ i~ht 2n~ .in~~~~~~~ ~lspa~e (atsterna l . l11ar9. i~)
, Aort ic valve : Left sternal border (at level of 3rd rib)
.
~~ lfll?n~r y' ~~ lve • Lef.t sternal border (at level of 3rd costal cartilage) .... .L ~ft~n~i~t~r.~~~t~l sp.~~~..( ~t..s~~r~~ II11~r~i ~) . . .
: Left atrioventr icular valve : Lef t 4t h/5th cost al cart ilage : Left 5t h int ercost al space (at midclavicular line) or cardiac apex
.. .... ..... ... : . . .
, Right atrio ventr icular valve : Sternum (at level of 3rd costal cartilage) • Left 5th intercost al space (at sternal margin)
87
Arteries & Veins of the Heart
Fig. 7.16 Coronary arteries and cardiac veins Pulm on ary Superio r left
Superior valve pulm on ary v.
vena cava At rial branches
Great cardiac v.
ventricular branch
Coronar y sinus
Right coronar y a.
Post erior v.
of left ventri cle
Sma ll cardiac v.
Right post erol ateral a.
~ Rightventri cle
B Posteroinferiorview. Note: The right and
Posterior intervent ricular left coronary arte ries t ypically anastomose
(descend ing) a. and v. posteriorly at the left atri um and ventr icle.
88
Fig. 7.17 Distribution of the coronary arteries ~ Clinical
An t er ior and po ste rior views of th e heart, w it h su perio r views o f tran s
ver se sect io ns th rough t he ven t ricl es. The d ist rib utio n of t he co ro nary
Disturbed coronary blood flow
ar te ries d iffers f rom per son t o per son . Right co ro ne ry art er y and
Alt hough t he coronary arte ries are connect ed
br an ch es (green) ; lef t coro na ry artery and br an ch es (red). by st ruct ural anastom oses, th ey are end
art eries from a funct ional st andpoint . The "
most frequent cause of deficient blood flow
Intervent ricular
Left
Right lumen due to plaque-like deposits on the
vent ricle vent ricle vesselwall. When the decrease in luminal size
a
(stenosis) reaches crit ical point , coronary '
blood flow is restricted, causing chest pain
(angina pecto ris). Initially , t his pain is induced
by physical effort . but event ually it persist s
at rest. often radiati ng to characterist ic sites
(e.g., left arm , left side of head and neck). A
Circumf lex branch myocardial infarcti on occursw hen deficient
blood supply causes myocardial tissue to die
Posterior left (necrosis). The locatio n and extent of t he
Right ventri cular branch Right infarctio n depends on t he stenosed vessel
corona ry a. coron arya . (see A- E, after Heinecker).
L -- - R
Left
coronary
a.
~ Areaof
P deficient
Circumflex branch blood flow
Right
coronarya.
89
Conduction & Innervation of the Heart
~ Contraction of ca rdiac mu scle is modu lated by th e ca rdi ac co nd uct io n syst em co nt ains t w o no d es, both lo cat ed in th e atri a: t he
~ conduction sy ste m . Thi s syst em of specia lized myocardial ce lls sinoa t rial (SA) node, kn own as the pac em aker, and th e atrioventricular
gen erates and conducts excit ato ry impul ses in t he heart. The (AV) nod e.
Left at rium
Left bundl e branch - - - - ,
Anterior fascicle
Interventri cular ---~
sept um Middle fascicle
Electrocardiogram (ECG)
The cardiac impu lse (a physical dipole)
t ravels across t he heart and may be
detect ed wit h electrod es. The use of t hree Pwave Rwave T wave
elect rodes that separately record electr ical
Lead vectors --~T--7
acti vity of the heart along t hree axesor
in Eint hoven's
vect ors (Eintho ven lim b leads) generates an triangle
elect rocardiog ram (ECG). The ECG graphs
th e cardiac cycle ("heartbeat") , reducing
it to ase ries of waves, segments, and
intervals. These ECG comp onents can be
Recording
used to determ ine w het her cardiac impulses electrodes
are nor mal or abnormal (e.g.• myocardial
infarct ion. chamb er enlargement ). Note:
Alth oug h only t hree leads are required, a Q wave Swave STsegment
st andard ECG exam inat ion includ es at least
.' two others (Goldberger, Wilson leads). A ECG recording elect rodes. B ECG.
90
~ Sympath eti c innervati on : Presynapti c neuron s from T1 to T6 cont ribute to th e cardiac plexus. Parasymp ath eti c inn ervation : Presyn
~ spinal cord segments send fib ers to synapse on post synapti c neu apt ic neurons and fib ers reach t he heart via cardiac branches, some of
ron s in th e cervical and upp er thoracic sym pat het ic gang lia. The w hich also arise in th e cervical region. They synapse on postsynapti c
three cervical cardiac nerves and t horacic cardiac branches neur ons near t he SA nod e and along the coro nary art eries.
nucleus
Superior, mi ddle,
Sympath etic
t runk
-~~1=t-7-"'\-H++t------,---+- Thoracic
cardiac branches Cardiac plexus -----'~::,..L';r-r'\
~
:1---
J
Pulmo nary a. and
pulm onary vv. with
pulm onary plexus
A Schemat ic.
Rig ht vagus n. ~
ganglion
Subclavian a.
Trachea
laryngeal n.
Left
phre nic n.
Pulmonary
plexus
Pulm onary
trunk
Cardiac
plexus
Phrenic n.
(on diaphrag m)
Right at rium
Right cardiac border Length of aorta ---------,"""--'-::~+.i~,
Superior vena cava
Apex Long-axis --------!-!'-----'--~"'----~
Left vent ricle
diameter
Aortic arch ("aor tic knob")
Pulmo nary tru nk Maximu m widt h
Left cardiac border on right side
Left atrium
Left ventricle Short-axis
diameter
Left vent ricle
Inferior cardiac border
Right vent ricle
Anterior Maximum widt h
midline on left side
Aortic arch
("aort ic knob ")
Right lung,
horizont al
fissure
Right lung,
Sternum
oblique fissure
(body)
Anterior Posterior
mediastinu m mediastin um
C Lat eral v iew. Visible: Diaph ragm leaf let s and lun gs. Th e aortic arc h
form s a sling over the left m ain b ron chu s. Note th e na rrowness of the
anterior me dias ti n um relative t o the poste ri o r medi ast inum . D Left lat eral chest rad io g raph .
92
Fig. 7.22 Heart in transverse section
Sternum Pulmonary
outf low tract
(t unnel betwee n right
vent ricle and pulmo nary a.
Right lung
Left lung
Right at rium
Ascending
aorta
Left auricle
Left atrium
Descending
aorta
A Hea rt in norma l chest magnetic reso nance ima g ing (MR I) . The cardiac
cha mbers are clearly displayed owing to the high signal in te nsi ty. and
the lungs are not vis ua lized .
Left lung.
superior lob e
Right lung.
midd le lobe Phrenic n.
(between fibrou s
pericardium and
parietal pleura.
Thoracic
(descending)
aort a
Azygos v.
93
Pre- & Postnatal Circulation
CD Oxygenate d and nutrient-rich fet al blood fr om th e placent a passes t o ® Blood fro m th e superior vena cava ente rs t he rig ht at rium, passes to
t he fet us via th e um bilical vein . the righ t ventricle, and moves into the pulmona ry t runk . Most of th is
blood ente rs t he aorta via t he duct us arteriosus, a rig ht-to -Ieft shunt.
eD Approx imate ly half of t his blood bypassesth e liver (via th e ductu s
venosus) and ente rs th e inferior vena cava. The rem aind er ente rs th e Gl The part ially oxygenate d blood in t he aorta return s to t he placent a via
po rta l vein to supply t he liver w it h nutri ent s and oxygen. t he paired um bilical arteries that arise fro m t he int ernal iliac arte ries.
Ao rt ic arch - - - -----:
Liver - - -----!'---
- - - - Abdo mi nal
CD Umbil ical v. - - -If aorta
Inferior
vena cava
Um bilical aa.
Um bilical aa.
Placenta - - \-\-
94
G) As pulmonary respiration begins at birth. Fig. 7.24 Postnatal circulation
pulmonary blood pressure falls. causing After Fritsch and Kuhnel,
blood from the right pulmonary t runk to
enter the pulmonary veins. Aortic arch
(perfused)
the umbilicalarteries occlude (except for arte riosus)
@) Blood to be
metabolized now passes Superior vena cava ------++- \ Left atr ium
through the liver.
(2) Foramen ovale ------!f-~._---,.'l\
(closed) Pulmo nary t runk
Right ventricle
Liver - - -+- /
Ligamentum venosum
(ob literated ductu s venosus)
I
~lTc':oT---iiiiii~---- Porta l v.
Rou nd ligament of liver - -+-- - --;7"'''-------------1'1
(oblit erat ed umb ilical v.)
+ - - - - Abdominal
aorta
Umbi licus
Septal defects
Sept al defects. th e most common t ype of
congenita l heart defect . allow bloo d from Obliter ated um bilical aa.
t he left chamb ers of t he heart to improperly (med ial um bilical ligam ent s)
passinto t he right chambers during systol e.
Ventr ical sept al defect (VSD. shown below)
is th e most common form. Patent foramen
ovale, t he most prevalent form of atrial septal
defect (ASD), results fro m im proper closure
ofthe fet al shunt.
95
Esophagus
~ The esophagus is divid ed into three parts: cervical (C6-T1), It descends slightly to the right of the thoracicaorta and pierces the
~ thoracic (T1 to the esophageal hiatus of t he diaphragm), and diaphragm slightly to the left, just below the xiphoid process of the
abdominal (the diaphragm to the cardiac orifice of the sto mach). ste rnum.
Pariet al pleura,
cervica l part
Aort ic arch
Thoracic aort a
Pulmonary t ru nk
Parietal pleura,
m ediastin al part
Sto mach
diaphragmat ic part t ho racic part pericardium
96
Mucosa (longitudinal fold s)
(longitudina l layer)
Muscular coat
,
(circular layer)
"
~-.--- Muco sa
Sub m ucosa
(i"~
: )
A Esop hagea l wa ll, o b liq u e left posterior view. Pharyn x (p. 552); C Functiona l architect ure of e sophageal m uscle.
t ra chea (p. 1 10 ).
~ Clinical
Esophageal diverticula
Inferior pharyngeal constrictor Diverticula (abnorma l outpouchings or sacs) generally develop at weak
spot s in t he esophageal wa ll. There are three mai n ty pes of esophageal
Zenker's divert iculum dive rticula :
from an inflam m ato ry process (e.g. , lymphangitis) and are t hus com
97
Neurovasculature of the Esophagus
~ Sympath etic inn ervation: Presynaptic fib ers ari se from th e T2- T6 and travel in th e vagu s nerves to form t he exten sive esophageal plexu s.
~ spi nal cord seg me nts. Postsynaptic fib ers arise from t he sym Note: The po stsyn aptic neurons are in th e wal l of th e eso phagus. Fibe rs
path eti c chain to j oi n th e esop hagea l plexu s. Parasympath et ic to the cervical portion of the eso phag us travel in the recurrent laryng eal
innervation: Presynapti c fibers arise from the dor sal vag al nucl eus nerves.
(cervical part )
I
Sympathetic
trunk
"-..-L-+--+-- Recurrent laryngeal n.
n
Fig. 7.29 Esophageal plexus
The lef t and rig ht vag us nerves initia lly descend on th e lef t and rig ht Right recurrent
Left recurrent
laryngeal n.
laryngeal n.
sides of th e esophagus . As they begin to co nt ribute to th e eso phageal
pl exu s, th ey shif t to ant erio r and po st eri or po sition s, resp ectively. As t he Right vagus n. - -ft--li r+-Jri-- Left vagus n.
vagu s nerves continu e into th e abdom en , th ey are nam ed t he anterior
and po sterior vaga l trunks.
3rd t hrough
Left vagusn. 6th thoracic
ganglia
Eso phageal ----!~,~
plexus
Right - -
Right recurrent
sympathetic \
laryngeal n. t runk
Righ t - ------'1 Anterior
vagus n. Left recurrent vagal t runk
laryngeal n.
Left vagus n.
Post erior
intercostal a., B Anterior vi ew . Note t he po st
intercostal n. sy napt ic sy m pat het ic co nt ribu Left
Eso phagus - ---;:::= vagus n.
Anterior tion to the esop hag eal plexu s.
(t horacic part) vagal trunk
~~~~- Thoracic
aort a
Esophageal
Sympathetic plexus
trunk
Greater - - - =
splanchnic n.
Posterior
vagal
trunk
C Posteri or Posterior
98 A Esophag eal pl exus in sit u. Anterior view . vi ew . gastric plexus
Fig. 7.30 Esophageal arteries Lef t com mon
Inferior carot id a.
Anterior view. Ant erior scalene
t hyroid a.
Verteb ral a.
Trachea
Aor tic arch
-..:;~-- Posteri or
Esophageal branches int ercostal aa.
(fr om thora cic aorta)
- - Diaphr agm
Gastr ic fu ndu s
Esophagea l branch
Celiac t run k
r-:.E""'- - - Lef t gastric a.
Com m on
Fig. 7.31 Esophageal veins hepati c a.
Ant erior view. Abdomina l aorta
Inferior
Ext ernal
j ugu lar v.
"~"'----- Subclavian v.
Right brachi o
cephalic v.
Superior
vena cava
~~#:~-- Accessory
hem iazygos v.
.............................................. . ... ..... .. ... .. ... ... ... .. ... ..... ... .. ........ ... ..... ... ....
99
lymphatics of the Mediastinum
~ The superio r phrenic lymph nodes d rain lymph from t he dla found in t he abdomen, co llect lymph from the diaph ragm and low er
~ phragm, pericardium . lower esop hagus . lun g , and liver into t he lo bes of t he lung and convey it to t he lum bar t ru nk. Note: The perica r
bronchom ed iastina l trunk. Th e infer ior ph renic lym ph nodes . dium may also drain superio rly to the brach iocephalic lym ph nodes.
=Ii*::;;;;;=---fr- - - Thoracic du ct
Tracheobronc hiall .n.
----7l~'-----4~
1F3'J""""~.';\----- Intercost al lymphat ics
i;f-~~::-'--T--- PrevertebralLn .
Fib rou 5 - -+-Jf--
pericardium - --"'\1-- Superior phrenic Ln.
A Lymp hatic dra inage of t he lef t cham bers, Bronchopulmonary Ln. -_~:'A.i"=- Bronchopulmonary I.n.
anterior view.
C Posterio r view.
100
~ The paraesophageal nod es drain t he esophagus. Lymphatic drain trun ks in t wo part s: th e upp er half drains cranially, and t he lower half
~ age of th e cervical part of th e esophagus is prim arily cranial, to drain s inferiorly via the superior phr enic lym ph node s. The bron chopul
the deep cervical lymph nod es and th en to th e jugular t runk . The monary and paratracheal nodes drain lymph from th e lung s. bron chi.
th or acic part of t he esophagus drains t o th e bronch om ediastinal and tra chea int o th e bron chom ediastinal trun k (see p. 118).
~-- Tr a c h e a
Paratrachea l l.n.
Right main
bronchus
Inferior trach eo
bronchiall.n .
~ Paraesophageal l.n.
Diaphragm - - - -
Cardiac lymph at ic
ring (inconst ant) Stomach Left com mon
carot id a.
Left internaI
A Ant erior view of ope ned t ho rax. j ugu larv. . +-- - - Trachea
Left subclavian
a. and v.
- - - - Paraesophageall.n.
- - -- Aortic arch
Bronchopulm onary I.n.
:.:ill~-- Azygos v.
Left pulm onary a. - ----'I
=.0:1--- - Paraesophageall. n.
Diaph ragm - -- -
B Posterior view of medi astinal lym ph node s.
101
Pleural Cavity
~ The paired pleural cavities contain the left and right lungs. They and are under negative atmospheric pressure (see respiratory mechan
~ are completely separated from each other by the mediastinum ics,pp.112-113).
-===l~i~~~~~~Q
trunk
Heart Diaphragm ~-+--- Li v e r
Spleen -
Left --~---ro~~~~Ct~~~~
suprarenal
gland
Liver. right lobe
T12
vert ebra
MA
MC St PV MC
A Anterior view . B Right lateral view. C Posterior view . D Left lateral view .
Sternal line (St) 7th rib 6th rib 4th rib 4th rib
Midclavicular line (Me) 8th costal cartilage 6th rib 6th rib 8th rib
Midaxillary line (MA) lath rib 8th rib 8th rib lath rib
Paravertebral line (PV) T12 vertebra lOth rib lOth rib T12 vertebra
102
Fig, 8.3 Parietal pleura
The p leur al cavit y is bound ed by t w o sero us layers. The vi sceral (pu l surfa ce of th e t horaci c cavi t y. Th e fou r parts of th e par ieta l pleu ra (cost al,
m on ary) p leur a co vers t he lu ng s, and t he parietal pleu ra lin es th e in ner diaph ragmat ic, m edi astin al, and cerv ical) are continu ou s.
8t h rib
K. .:': - - -- - Right lung
Diaphragm
Pa rietal pleura, ------'!--l~!\';fr--III I
Pariet al peritoneum
costal part
Costal part
Visceral perito neum
Costodiaphragmatic
recess
Costal --T--+'~':-;'i
groove
Endotho racic fascia
Diaphragmat ic
Ext ernal - - ;,-- Liver
part
- - - Fibrous intercost al
Internal
intercostal
intercost al
A Par t s of t he parietal pl eura. Opened: Rig ht B Costo dia p h rag ma t ic recess, co ro na l sec
pl eural cav ity, anterior view . ti on, anterio r vi ew . Ref lection of th e d ia
p h ragmati c p leura o nt o th e inn er th o racic
wa ll (becom ing t he costa l pl eu ra) fo rm s t he
costo diap h rag ma t ic recess.
Horizont al
fissure
Visceral pleura
Right lung,
middle lobe
Pa rietal pleura,
costal part
Oblique
Oblique
fissure
fissure
Left
main
broncus
Right lung,
inferior lobe
Left lung,
inferior lobe
Pa rietal pleura,
costal part
Phrenic n. Right Sympat hetic Spinal Azygosv., Hemiazygosv. Thoracic
main trunk cord aorta
thoracic duct ,
bronchus and left vagus n.
C Transver se sect io n, inferi o r view. Ref lect ion
of t he costa l pl eu ra o nto th e per icard ium
form s t he co st o m edia stina l recess.
103
lungs in Situ
---h~~ii~f::~~~
of th e pleural cavity. Not e that the left lung
is slight ly smaller than the right d ue to the Superio r lobe
~~-- Superior lobe
asymmetrica l position of th e heart . Hori zonta l fi ssure - -f:if.f'=l,,
Right Middl e lobe Left
44<.n"'--'1Iitt- Obliqu e fissure
lung Obliqu e fi ssure lung
Inferior lobe
Inferior lobe
Esophagus Descending
A Topographica l relations of t he lungs, aort a
tran sverse sect ion, inferior view .
Brachiocephalic
trunk
Left brachio
cephalic v.
Parieta l pleura.
costal part
104
~ Th e obliqu e and ho rizonta l fi ssur es divid e th e rig ht lung into three lu ng ex te nds into th e roo t of th e neck . Th e hilu m is th e lo cat io n at wh ich
IIIiiiJiII lo bes: su perio r, midd le, and inferior. The o bliq ue fissu re divid es the b ron chi and neu rova scu lar struct ures co nnec t t o t he lung .
the left lung int o t w o lo bes: su pe rio r and inferi o r. Th e apex of eac h
Superior
lobe
Anterio r Oblique
Horizontal border fissure
Cost al - ---!!c-+- - ----'...----' fissure
surface
lobe surface
Oblique fissure
Inferior border
Inferior border
Apex Apex
Branchesof right
Superior lobe
pulmonarya.
Anterior
Superior lobar
bronchus border
Mediastinal ~ J ..
Branches of
surface J~
Oblique fissure
left pulmo nary a.
Anterior
Inferior and
border
middle lobar Obliqu e ----!--.>.~
Superior and
bronchi fissure
inferior lobar
Hilum (commo n origi n) bronchi
Branches
Horizontal - --'!,-,:r;" ;
Hilum -~"-~-"-"I: Branches
of right
fissure
of left
pulmonary vv.
pulmo nary vv.
Inferior lobe Mediast inal --f""-~'-;;
surface
Cardiac Cardiac
Costal surface,
imp ression Inferior lobe -+~~-= im pression
vertebra l part
Costa l surface, Cardiac
Pulmo nary
vertebral part notch
ligament
Middle lobe
Inferior
border
Lingula
105
lung: Radiology
~ The reg ion s of the lungs show varying degrees of lucency in chest and segme nta l bron chi. The perihilar lung region is also covered by the
~ rad iograph s. The perihilar region where the main bronchi and heart. These "s hadows" app ear as white or bright areas on t he radio
vessels ent er and exit the lung is less radiol ucent than the periph graph (radi ograph s are negatives : areas that are imperm eable to
eral region , which conta ins small -caliber vascular branche s light wil l appear bright).
Pleural
dome
Clavicle
Aort ic
arch
Superior Left
venacava hilum
Ri ght
diaphragm
leaflet
Left
diaphragm
leaflet
106
~ Clinical
A Lingular pneumonia. The horizont al fissure can be seen (arrow). Note: The B Pulrnonary emphysema. The chest radiograph revealsdiaphragmatic depres
heart is much more diffi cult to visualize here due to increased opacity of sion (flattening of t he domes of t he diaphragm. arrows) wit h corresponding
segments IV and V. changesin t he orient at ion of t he cardiacshadow. The heart assumesa vert i
cal orientat ion due to t he low diaphragm (a lateral radiograph wo uld reveal
an increased retrosternal space). The cent ral pulmonary arteriesare dilated
but taper drarnatically at t he segmental level.
C Pulmonary edema complicating acute myocardial infarction. Dilation of ves D Tuberculosis. Note t he t hickening of t he pleura and th e radiat ing fi brous
sels increases the number of visible vascu lar st ruct ures.Thisimage shows a bands.This image does not contain the small pulmonary nodules (t ubercu
butt erfly pattern of edema and bilateral pleural effusion. lom as) ofte n found in th e upper zonesof th e lung.
107
Bronchopulmonary Segments of the lungs
~ The lung lobes are subdivided into bro nchop ulmonary segment s.
IIIiii3I each supplied by a tertia ry (segmenta l) bron chus. Note: These
subd ivision s are not defi ned by surfa ce bou ndaries but by or igi n.
Obliqu e
VII,VIII
fissure
Oblique
fissur e
Superior lobe
Inferior lobe
108
Fig. 8.10 Right lung: Bronchopulmonary segments
Horizonta l
fissure
Oblique
fissure
~ Clinical
Trachea
Segment I
of right lung
Superior lobe of - -
right lung
Left
lung
A Segme ntect omy (wedge resection): Rem oval of one or B Lob ectomy: Rem oval of lobe. C Pneum on ectomy: Rem oval of
more segm ents. ent ire lung.
109
Trachea & Bronchial Tree
~ Ator near the levelof the sternalangle, the lowest tracheal carti bifurcates at the carina into the right and left main bronchi. Each bron
~ lage extends anteroposter iorly, forming t he carina. The trachea chus givesoff lobar branches to the corresponding lung.
Tracheal
bifurcat ion
Cervical part
Thoracic
part
I
Trachea
bronchus
bronchus
Thyroid ----"=~
cart ilage
_-J~I---_ _ Median
Cricoid - -:;- cricot hyroid
cart ilage ligam ent
cart ilages ~
-~::.-- Annul ar
ligam ent s
Arytenoid ----'c:~"'"
main
Membranous - - i"-;-'Tracheal
posterior wall (with cart ilages
L ii -- - - Left
superior lo bar
superior
bron chus -. IV lob ar
i"SHI- - Muco sa bro nchus
IV
Right -~7~,jI . _ J
midd le lobar
bron chu s ... . r ............ VIII
Right/ left
Right inferior loba r
m ain bron chi
bronchus
B Anteriorview.
II
~ Clinical
IV
Foreign body aspiration
IV
Toddlers are at particu larly high risk of potentially fatal aspirat ion of foreign
main
bod ies. In general. foreig n bodies are mor e likely to becom e lodged in th e
VIII ~' '''''- U bronchus
right main bron chus than the left: th e left bronc hus diverge s mor e sharply
at the t racheal bifur cation, whi le t he right bronchus is relativ ely st raight .
X IX
Smooth mu scle
Segment al
bronchus
j ...:;1- - - Cart ilaginous
Elastic --=~'Il
(lattice arrangeme nt )
plate fibers
+ - Pulm onary
alveo lus
Large
subsegmenta l
bronchus
Respiratory
bronchioles
Sm all
subsegment al
bron chus
Interalveolar
sept um
Alveolar
Alveo lar du ct
sac Acinus
Alveolus
Respirato ry
bronc hiole
l see B B Respiratory po rt ion of the bro nchial t ree.
Alveolar f-
sacs L
~ Clinical
A Divisions of th e bronchial tree .
Respiratory compromise
The most com mon cause of respiratory com pro m ise at th e bronch ial level
Capillary Type II
Surfact ant is asthma. Com promise at t he alveolar level may result fro m increased
lum en pneum ocyt e
diffusion distance, decreased aerat ion (em physema) , or flui d infi ltra tio n
(e.g., pneumonia).
Condition of alveoli: In diseases like em phy sema, which occurs in chro nic
obst ructive pulm onary disease (COPD), alveo li are destr oyed or dam aged.
Thi s reduces t he surface area available fo r gaseous exchange.
111
Respiratory Mechanics
~ The m echanics of respirat ion are based on a rhyth m ic incr ease evident in th e pleural recesses: at funct ional residual capacity (rest ing po
~ and decrease in t horacic volume. with an associated expansion sit ion bet w een inspi rat io n and expirat ion). t he lung does not full y occ upy
and cont ract io n of th e lungs. Inspiration (red) : Cont racti on of th e t he pleural cavit y. As t he pleural cavity expands, a negat ive int rapleur al
diaphragm leaflet s low ers th e diaphragm into the inspiratory posi pressure is generated. The air pressure diff erent ial results in an influ x of
t ion, increasing t he volume of th e pleura l cavity along t he vert ical air (inspirat io n). Expiration (blue): During passive expirat io n. t he mu scles
axis. Contracti on of t he t horaci c mu scles (ext ernal intercost als w it h of t he t horacic cage relax and th e diaphragm returns to it s expiratory
t he scalene, int ercarti laginous. and post erior serrat us mu scles) el posit ion . Cont ract io n of t he lu ngs increases t he pulm onary pressure and
evates th e ribs, expanding th e pleural cavity along th e sagittal and expels airfro m th e lungs. Forforcible expirat ion. th e interna l int ercost al
t ransverse axes (Fig. 8.15A, B). Surface tension in t he pleural space mu scles (w ith th e t ransverse t hora cic and subco sta l m ucosa) can act ively
causest he visceral and pariet al pleura to adhere; t hus, changes in lower t he rib cage m ore rapidly and to a greater extent t han t hro ugh pas
t horacic volum e alter t he vo lume of t he lungs. This is part icularly sive elastic reco il.
--+;=::~~~~- Sternum
Diaphragm
E
Inspirat ion
I
Diaphragm
Fig. 8.17 Respiratory changes in lung
volume
Expansion Expansion
Contraction
(vertical axis)
Expiration
A Anterior view . B Left lat eral view . C Antero lat eral view .
112
Fig. 8.18 Inspiration: lung expansion Fig. 8.19 Expiration: lung contract ion Fig. 8.20 Movements of the lung and
bronchial tree
Rig ht lung (full inspirat ion) Right lu ng (full expirat ion) As the vo lume of t he lu ng ch ang es with th e
I
p~;;:~; t .
I
t horacic cav it y, t he ent ire bron chia l tree moves
within th e lung . Th ese st ructu ral movements
are more prono u nc ed in portion s of t he bron
chial tree d istant from the pu lmonary hilum.
Diaphragm
k
Diaphragm
Trachea
Lung
Lung
~ Clinical
Pneumothorax
The pleural space is normally sealed from th e outside environment. Injur y occurs w hen traumatically detached and displaced t issure covers t he defect
to t he parietal pleura, visceral pleura. or lung allows air to ente r t he pleural in the th oracic wall from th e inside. This mobile flap allow s air to enter, but
cavity (pneumothorax). The lung collapsesdue to it s inherent elasticity, and not escape, th e pleural cavity, causing a pressure buildup . The med iastinum
the patient' s ability to breath e is compromised. The uninjured lung continu es shifts to the normal side, w hich may cause kinking of th e great vessels and
to funct ion under normal pressure variation s, result ing in " mediast inal prevent th e return of venou s blood to the heart . With out treatment, ten sion
flutter": the mediast inum shifts toward the normal side during inspirati on pneumothorax is invariably fatal.
and return s to th e midline during expirat ion. Tension (valve) pneum oth orax
Right Left
lung
lung
Inspiration
Positive pressure
in pleural cavit y
Airflow out
of pleural
defect
Expirat ion
"Empty' pleural
cavity at
atmospheric
pressure
Cardiac shift
113
Pulmonary Arteries & Veins
~ The pulmonary t runk arises from the rig ht ventricle and divides pulmo nary arteries accompany and follo w th e branch ing of the bron
IIriiiiII into a left and right pulmonary arte ry for each lung. The paired chial tree , w hereas the pu lmonary veins do not , being located at th e
pu lmona ry veins open into th e left atrium on each side. The margin s of the pulmonary lobules.
~
Right .u g U l a r v. - : jugu larv.
pulm onarya . ""'/ left pulm onary
Right Left
subclavianv. ~~ subclavian v.
Right brachio- ~ - Left brachio
cephalic v. I / cephalic v.
~
c ava ~. - ~
(jf---'-- - - - - - Pulmonary
tr unk Superior vena Left
=-
C l i-=C-'-~~-----
pulm onary vv.
Inferior
vena cava
A Project ion of pulmonary arter ies on chest wa ll. B Projection of pu lmona ry veins on chest wa ll.
Trachea
Right main
bronchus
Left main
bronchus
pulm onary v.
Middle lobe
Inferior Right
Inferior lobe vena cava vent ricle Cardiac apex Inferior lobe
Aor t ic arch
Right
pu lrnonary a,
'--- - - Ligament um
Right /l eft
arteriosurn
superio r
Middl e
pu lm o nary v.
lobe a.
Left Right Jlef t
pu lrn onar y a. inferior
pulm on ary v.
@
A Sc hem ati c. A Sche m at ic.
® : Commo n basal v. @
. . .. . ................... ................. ...... ................. ..........................
(2) •@ : Inferior basal v. @
.. ....... .... .................... .... .
~ Clinical
, Pulmonary embolism
Pot ent ially lif e-t hreateni ng pu lm onary emb olism occurs w hen blood ori ginate fr om st ag nant blood in the vein s of th e lowe r limb 'and pelvis
clot s m igrat e throug h t he venou s system a nd become lodged in on e of (venous throm boembo li). Causes include im m obilizat ion, diso rdered blo od
t he arte ries supplying t he lu ngs. Sym pt oms include dyspn ea (diffi cult y coaq ulat ion , and trau ma . Note: A th romboem bolus is a t hro m bus (bloo d clot)
breat hing) and ta chycardia (increased heart rate). M ost pulm ona ry em bol i t hat has mig rated (em bo lised).
115
Neurovasculature of the Tracheobronchial Tree
e
o
Fig. 8.24 Pulmonary vasculature
The pulmonary syst em is respon sib le for
Bronchial a. - - -----."""'1
Branch of - - - ';;;:,H
c:: gaseous exchang e within th e lu ng . Pulmonary pulmonary a.
arteri es (shown in blu e) carry deoxygenated (deoxygenated
Fibrous sept um - -
between
pulmonary
lobules
Pulmonary -----H:--;i:~~--;i
alveolus
- -- - - Subpleural
connective
tissue
chial tree
cephalic t runk
Ascen ding
Posterior
intercostal a.
Bronchial
Right main branches (fro m
bronchus th e thoracic aort a)
Left main
bronchus
116
Fig. 8.26 Veins of the tracheobron Trachea
chial tree
Inferior - ----!.....,il!!!!lr---'.--+....
"""'=-- - Left brachio
cephalic v.
t hyroid v.
Lef t main
Superior vena cava ---1~- bro nchus
Azygos v. ----r-.~H-_l".I
[r-
- Hem iazygos v.
117
lymphatics of the Pleural Cavity
~ The lungs and bronchi are dr ained by two lym phati c drainage subpleural network collect s lym ph from t he perip heral lung and visceral
~ syste ms. The peribron chial net work follows th e bronchial tr ee, pleura.
draini ng lym ph from t he bro nchi and m ost of th e lungs. The
Trachea
Paratracheal l.n.
Paratr acheall.n.
IH-\-+-- Lymp hatics
in t he tru nk
wall
Peribro nchial
net work
B Subp leural net work, tr ansverse sect io n, Subpleural Trachea Int ercost al l.n.
superior view. net work
118
Fig. 8.29 lymph nodes of the pleural cavity
Anterior view of pulmonary nodes.
Left main
Superior t racheo
bro nchus
bronchial l.n.
VAii~-':--':--~-+---'':;;'-~-- Broncho
Rig ht main -----/-:iJ~~:-=====--~~~;;;~~~;1\ pulmona ry I.n.
bronc hu s_-~~~~2:::::-;:("--c:-~~~=]:~t;,,~
Inferior trac heo ,'r'o.)-------:===~~=-'<--- Intr a
bronchia l l.n. pulmona ry I.n.
rn=7----iliii-\~~---;------:--o---T-'"""'i-- Thoracic
aorta
..I
119
Surface Anatomy
Midclavicul ar
line (MCL)
Suprajugu lar
not ch
Coracoid
process
Xiphoid ------~_-~..___o:__:
process
- - - ----ir--------::---f-=<------- Subcost al
plane
Ant erior _
superio r
iliac spine
Delti od --~
Deltopectoral - -1-- - -
gro ove
Iliac crest
\ Um bilicus
B M u scul at u re.
120
Fig. 9.2 Surface anatomy of the thorax
Ant erior view. See pp. 40-4 1 for st ruct ures of t he back.
Nipp le - - - ---'---- ..
' - - -- Areola
A Female t horax.
121
Abdomen & Pelvis
Vagina 190
13 Internal Organs
Lymph Nodes of the Anterior Abd ominal Organs 230
Stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 58
Lymph Nod es ofthe Intestines 232
Du od enum 160
Lymph Nod es of the Genitalia 234
Ureter 180
18 Surface Anatomy
Urinary Bladder 182
14 Reproductive Organs
Overvi ew of th e Genital Organ s 186
Pelvic Girdle
.~
::.
~
~
Fig. 10.1 Pelvic girdle
Anterosuperior view. The pe lv ic g ird le consists
of t h e two hip bo nes and the sacrum (see
Fig. 10.2 Hip bone
Rig ht hip bone (ma le) .
p.358).
c:
~
E
0
"0 Sacroiliac Hip bone
.Q joint Iliac crest
o::c
Anterior Auricular
superior surface of
iliac spine ilium
Arcuate
line
Pubic Anterior
iliac spine
Ischial
Acetabular spine
rim
Symphyseal
Obt urator sur face
foram en
Iliac crest - - - -E Iliac
tu berosity Ischial
tub erosity
Superior U
pubi c ramu s ~ Ischial spine
Pectinea l - - - - - - ".
line Ischium (body)
124
Fig. 10.3 Triradiate cartilage of the hip bone
Rig ht h ip bon e, lateral view. Th e h ip b on e co nsists of t he ili u m, isc hi u m,
Iliac crest ---~"
Iliac wing
and pubi s.
-
<::I
txl
0
:J
~
Iliu m
....
Ilium (body) IQ'
Acetabu lum Q
3
Pubi s (bo dy) scr
-
Ischium Triradia te
cart ilage l(o
Superior
pubic ram us Acet ab-
ulum
-0:J,
Inferior
cr
pubic ram us
t ub erosit y foram en
A Junctio n o f t he t riradiate cartilage. B Rad io g ra ph o f a child ' s ace ta b u lu m . Right h ip b one, later al v iew .
Iliac crest
Poste rior
gluteal line
Gluteal surface
~
inf erior
iliac spine ~~------ Acetab ular rim
Pubic
tubercle
Obtu rator
foramen
Ischial - - -h
tuberosity
125
Male & Female Pelvis
Iliac
pub ic ram i
Poste rior
sciatic notch
infer ior
Sacru m
IIliac
Superior
I
Iliac crest Pelvic
Iliac crest tub erosit y Glut eal surface
Ala art icu lar proce ss
Sacral
canal Iliac
Ant erior Poster ior
A Anterior view.
B Post erior view.
126
Fig. 10.7 Female pelvis: Superior view Female Male
Interspinous
diameter
Right
ob lique
diam et er
Left
oblique
diame ter
Transverse
Linea
diam et er of
termin alis
pelvic inlet plan e
Sacral
Sacroiliac Iliac
canal
joi nt tub erosit y
Prom ont or y
Pub ic
Ala of sacrum
sym physis
l
j lliac crest
Inn erlip ~
Intermediate -..1
Iliac --=~ __ Subpubic
t ubercl e angle
lin e /i
Oute r lip _~'-- Iliac fossa B Fem al e. C Ma le.
Ant erior
Arcuat e
superior
lin e
and inf erior
iliac spines Gender-specific features of the pelvis
Ischial
spine
Structure
Pecten pubi s
Pubic False pelvis Wide and shallow Narro w and deep
t ubercle Heart- shaped
B Fema le p elvi s. Pelvic inlet Transversely oval
Iliac
crest
1
Inner lip
Intermediat e
line
Outer lip '"
l Median
sacral crest
Ala of
caesarean sectio n. Maternal causes include earlier pelvic t rauma and inna te
malfo rmation s. Feta l causes include hydrocephalus (disturbed circu lation
of cerebrospinal fluid , leading to brain dilat ion and cranial expansion).
sacrum
127
Pelvic Ligaments
Ante rior
sacroiliac - ---f- - - - - - - - -----;:::-
ligam ents
Ante rior _
superior iliac
spine
Sacrot uberous
ligam ent
Anter ior inferior - -----',
iliac spine ' --3II~~---~"L'---- Sacrospino us ligament
L4 spino us process
Iliac crest Iliol um bar ligam ent
Iliac t ubercle
Ilium , glute al
surface
Posterior superior
iliac spine
Posterior
Greater sciat ic - - ----'i:- - -
sacroiliac ligam ent s
foramen
Sacrospinous - - ----\:,.--- - _,
ligament Ischial spine
Obt urator
Lesser sciatic
m embrane
fora men
Coccyx
Sacrotubero us
ligament
'---- - - Ischial
B Po st er ior vi ew. tuberos ity
128
Fig. 10.10 Ligam ents of the sacroiliac joint Fig. 10.11 Pelvic measurements
Male pelvis. Righ t half of female pelvis. medial view.
See Table 10.1.
Diagonal
Int ervert ebral
conju gate
disk LS spinous
process True
conju gate
Pelvic ----~. Linea
inlet termi nalis
Sacrot uberous
ligament
~-.-\-~'&----- Sacral
tu berosity
~""+"'-- lI i u m
Ischial Coccyx
spine
Sacro
tub erous
ligam ent
Pubic
sym physis
B Oblique sect io n.
superior view.
'-~ " I
129
Muscles of the Abdominal Wall
~ The oblique musclesof the abdominalwall consist of the external rioror deep abdominalwall muscles(notablythe psoas major)are func
~ and inte rnal obliquesand the transversus abdominis. The poste- tionally hip muscles(see p. 138).
ste rnocosta l
part
- -- - Ste rnum
Serrat us
anterior
External oblique -
- -
---.-J
-
cart ilage
External
int ercostals ' ..L::""-'e J- Xiphoid
Ant erior rect us - - -----j rl-- - - Umbili cus
process
sheat h
Rectu s -~~-~I+;~tf"t"-,
abdom inis
Inguin al --r-----;~
Exte rnal
ligament
oblique
Internal _ _--IlL
Superfic ial ----1-------~.=:O;'''''''
inguinal ring
oblique
'-.+- - - Umb ilicus
Internal obl iqu e
aponeurosis
130
_ --'!::::...__ Sternum
Tendi nou s
inte rsect ion s
Rectu s
abdo m inis
Ext ernal
Linea alba
oblique
Transversus
abdom inis
ligam ent
Ste rnum
Transversus ------J:'----~~~~--
abdo minis
apon eurosis
rectus sheat h)
Spermatic cord.
Rectu s - - .-,--
abdominis
131
Inguinal Region & Canal
~ The ingui nal region is th e ju nctio n of t he anterior abdo mina l wall th e passage of st ruct ures into and out of t he abdom inal cavity
~ and th e anterior th igh. The inguinal canal is an impo rta nt site for (e.g., compon ents of th e spermatic cord).
- - -- Linea alba
External ob liqu e
apo neuro sis
Pub ic tubercle
Su erf icial .
Inguin a ring {
Plane of
Medial crus sect ion in
Table 11.1
132
Structures of the inguinal canal
Structures
@
Formed by
External obli que apon eurosis
--
::to
0
Roof fascia ~
Q) Transversus abdom inis 3
S'
Wall Posterior w all
@
G)
Transversalis fascia
Fig. 11.3 Dissection of the inguinal region Fig. 11.4 Opening of the inguinal canal
Right side, anterior view. Right side, ant erio r view.
Ext ernal
ob liqu e - -....-.....-----<- - -- -- - -- - External
apo neurosis oblique
Internal -~~~!liii~
Inguinal ~...
aponeuro sis
obliq ue
ligam ent
Intercrural ------------'~-,...
femoral n..
branch
fibers genital branch
obliq ue
A Divided: Ext ernal ob lique aponeu rosis.
Transversus ----'~~~:..,;::..
triangle
abdomin is
Transversalis Reflecte d
Inguinal Rect us fascia inguinal
ligam ent abdo m inis
ligament
Transversalis .L...-~'=-.-'''!
133
Abdom inal Wall & Inguinal Hernias
Linea alba
Fig. 11.5 Abdominal wall and Transversalis
rectus sheath fascia
Plane of
section in B
Posterior - - -----iN
rect us sheat h
Transversus - -----""
abdom inis
Arcuate line - - - --;
Plane of _ _ ---';;~
sect ion in C
N-'i."L - - - - - Iliacus
Rect us -----~~~
abd om ini s
Membranou s layer.
Rect us
superficial fascia
sheat h (ant erior layer) Linea alba
Ext ernal ob lique
apon eurosis
Extern al
obliq ue
Internal Parieta l
Rect us sheat h
ob lique perit oneum
(post erior layer)
Transversus Internal
abdo m inis obliqu e
B Superior to Transversus
aponeurosis apon eurosis
arcuate line. abdo m inis
Int ernal
oblique apon eurosis
Rect us sheat h Superf icial
(ant erior layer) Linea alba abdom inal fascia
Pariet al
perito neum
C Inferio r to
arcuate line.
134
Fig. 11.6 Abdominal wall:
Internal surface anatomy Arcuate
-
):
0
Co ro nal sect io n, po st eri or v iew. Th e three Umbilical
line
folds
§
fo ssae of th e ante rio r abd o m inal wa ll (circled) ~ A~ ~
3
are sit es o f potenti al herni ati on. Transversus :i'
Transversalis
abdominis Medial Lateral
-
Q
fascia
Parietal
peritoneum
h;:¢,cT~-- Femoral n.
• = Lateral ing ui nal fossa Psoas major }
(deep ingu inal ring) Interfoveolar _ " /lU V •• ~L-. Iliacus Iliopsoas
ligament ----":~~~~~:a
• = Medial inguinal fossa
(Hesselbach's triang le) Femoral a. and v.
• = Femoral ri ng
Ductus
• = Supravesical fossa
Obturato r
deferens
a., v., and n.
~ Clinical
Deep
inguinal
ring
- -- - External oblique
Inferior --"y~---- aponeurosis
Inguinal I.
Superficial
epigastric
a. and v. Location of
Inguinal
inguinal ring Hesselbach's
canal
Peritoneum t riangle
of hernial sac _____ Transversalis
Femoral fascia
a. and vv. Transversalis -r-.- - Peritoneum
fascia ( ~ internal Cremasteric -+--_~----<
Inguinal I.
Deepinguinal lymph nodes ~ Superficial inguinalring
Femoral a. and v. - - - ----'-<U ·,. ,~~,.---- Uterine round I.
:----'---- - LacunarI.
Peritoneumof hernial sac --~---.----'--!f-+ p~-- Saphenoushiatus
Transversalisfascia ---=-----l '-~~~'t:.
C Femoral hernia.
135
Perineal Region
Anterior inferior ~ ~
iliac spine ~ Vagina
(vaginal orifice)
---
Anterio rsu perio r - - - --
~
iliac spine Poste rio r labial
com m issure
(~~=:=:;;=:~=====::'l='
Urog enita l }
trian gle Perineal
region
Anal t riangle
Perineal
raphe
Ischial
spine
Anus
Coccyx
Bulbospo ngios us
Superficia l Ischiocavernosus
perineal
(Colles' ) fascia
Perineal mem brane
Glute us maximu s
Inferior pelvic
Anococcygeal
ligam ent
Ext ernal anal
B Muscles of the pelvic floor. Coccyx Anal clef t sphincte r
136
~ The bilateral boundaries of t he perin eum in bot h sexes are th e tu berou s ligam ent , and th e coccyx. The gr een arrows indicate th e ante
~ pubic sym physis, ischiopubic ram us, ischial t uberosity, sacro- rior recess of t he ischioanal fossa, superior t o th e urog enit al mu scles.
......:t:
for t he genitalia.
O'"
go
Superior Scrot um Penis
pubi c ramus
3
S'
Glans penis
-
Q
Inferior
pubi c ram us
Ischial ram us
~-----.:---.:::,------------- Anus
Acetabulum
Ischial
.- =-- - - - ---,-,,,.-,---- - - - ---,,-,;-- - - - Coccyx
t uberosit y
Ischial
spi ne
Ischiocavernosus
Superficial
perineal
(Colles') fascia
Ischial ------.,..,-"'!!!!!~i;;;;,--.!:i!!:
t ubero sit y !!..,...,----:-;-""'~t-;:-------- Superficial tr ansverse
perineal
Inferior pelvic
diaphragm at ic fascia
Levat or ani
137
Abdominal Wall Muscle Facts
Fig. 11.9 Anterior muscles Fig. 11.10 Anterolateral muscles Fig. 11.11 Posterior muscles
Anterior view. Anterio r view . Ante rio r view. The psoas major and ilia
cus are togeth er known as th e iliopsoas.
Pubis (anterior to rectus Linea alba (run s w ithin the rectus Subcostal n. (12th
a> Pyramidalis abdominis) sheat h) int ercost al n.)
Tenses linea alba
T12- L4 vertebral bodies and Hip joi nt: Flexion and external rotation
Superficial Direct branches
® Psoas associated int ervertebral disks Lumb ar spine (wit h femu r fixed):
layer from lumbar
majo r (lateral surfaces) Femur (lesser trochanter) , joint Unilateral: Cont ract ion bends t runk laterally
insert ion as iliopsoa s muscle plexus (L2-L4)
Deep layer L1- L5 (costal processes)
Bilateral: Contraction raises trunk from supine
(j) Iliacus Iliac fossa Femoral n. (L2-L4) positio n
Unilateral: Bends t runk to same side
® Quadrat us Iliac crest and ilio lumbar ligament 12th rib, L1-L4 vertebrae T12, L1-L4
lum borum (not show n) (tran sverse processes) spinal nn. Bilateral: Bearing down and expi rat io n,
stabil izes 12th rib
l38
.J ~~-=~~~- 5t h rib
....
....
Xiphoid ~"='--..I~ )::.
process 0
Q.
External o
obliq ue 3
5'
Linea alba External
oblique
aponeurosis
Q
Anterio r superior
iliac spine
..... I~r~!!\---- I n g u i n a l
5t h rib inguinal
ring
B External o b li q ue.
l;;;;;;l1oiI~r.r-- Xip hoid
proce ss
Linea
Xiphoid -.L...---olIlH
alba
process
10t h rib
Quadratus --~
lurnborurn Linea - - ---+-.:.. - i= H-- Internal oblique
alba aponeurosis
sym physis
Iliopsoas -------f~~
C Int ern al ob liqu e.
Pubic ----,r--=--+--~
tu bercle
tr ochanter
Pyrami dalis
Pubic Xiphoid - --=_ H '
symphysis process
A A nte rior and pos terio r mu scle s.
Linea alba --4~
Transversus
Posterior --~~
abdomi nis
rect us
--;B_- - Aponeurosis of
sheat h
t ransversus abdom inis
Arcuate lin e ---,J-l.~ Inner lip of iliac crest
Anterior superior
Ante rior -----.lI~!-_ _________ iliac spine
rect us sheat h Inguinal ligament
Pubic -+-~(.J .~
symphysis
Obturator membrane and bony Femur (greater trochanter. Direct branches from Hip joint: Externa l rotation and abduction
Obturato r intern us'
bounda ries (inner surfa ce) medial surface) sacral plexus (L5-51) of flexed hip
Sphincter anderector muscles
Encircles anus (runs posteriorly from perineal body to
@ External anal sphincter Closes anus
anococc ygealligament)
® Exte rnal ureth ral sphincter Encircles ureth ra (divi sion of deep tra nsverse perineal muscle) Closes uret hra
-
Anococcygea l
raphe
A Superior view.
Pubic -----.~----.!L
sym physis Prerecta l fibers
Pubic arcuat e -------=:..--~_.liiiil:l:::.-,. Obtu rat or
ligam ent internu s
Levato r Pubo
hiat us rectal is
Acet abulum Pubo Levato r
coccyg eus ani
Ischial
llio
t ube rosity
coccygeus
Piriform is
B Inferior view.
lIioco ccygeus }
Pubo coccygeus Levator
I
Pirifo rm is --If----c-. .C Deep t ransverse Puborect alis ani
Coccygeus perineal
Levat or ani
1'4~
Divisions of the Abdominopelvic Cavity
Liver Suprarenal
glands
-'.;~r--- Stomach
!!-I~fT,.'~c---7-- Kidneys
~~~""i"';i~t=L-- Transverse
colo n 10+- - - - Abdomi nal
aorta
'--""--- - Ureters
Duodenum
l -i- - - Descending
colon
Int raperitoneal
B Midd le lay er. organ
: Ret roperitoneal • Duodenum (descending, horizonta l, and ascending) • Ascending and descending colon
: Secondarily
• Pa ncreas • Rectum (upper 2/3)
l l .
• Urinary bladder • Sem inal vesicle • Vagina
: Infraperitoneal/subperitoneal • Dist al ureters • Uterine cervix • Rectum (lower 1/3)
• Prostate
142
Fig. 12.3 Peritoneal relationships
Midsagittal section t hrou g h male pelvis.
viewed from the left side.
~'I----,I"-7:---i- Lesse r
Parietal ome nt um
peritoneum (o me nta l
bursa)
Visceral
Esophagus
perito neum
Liver. bare area
Omenta l foramen
Hepatogastric
ligam ent
Celiac trunk
Omenta l bu rsa
A Peritoneal cavity. The peritoneum is :':::;"-::-I\,t;~ti~--- Splenic a. and v.
show n in red. Pancreas
Lef t renaI a.
Abdomina l aorta
Jejun um --~HH
and ileum L5 vertebra
Rectovesical
Urinary bladder ---+---'-';~~.-"
pouc h
Scrotum,
septu m
~ Clinical
143
Peritoneal Cavity & Greater Sac
~ The larg est part of th e peri t on eal cavity is th e great er sac. Th e anteri or su rface of t he t ran sver se co lo n . Th e t ransver se co lo n di vid es th e
~ g reat er o me nt u m is an ap ron -li ke fold of per it on eum suspend ed periton eal cav ity into a su p raco lic co m part ment (liv er. ga llbladd er, and
fr om th e g rea te r curva t u re of th e st o m ac h and cove ring th e st o mac h) and an infracolic co mpart ment (intestin es).
Ligamentum - .,.__.,..
teres of liver
Transverse ---+-~I-'rlil
c,_ ;~+- Pa rietal
mesocolon
peritoneum
with middle
colic a. and v.
Jejunum
(covered by
visceral perit oneum)
Ascending - - -+-;:'=-.
colon
~=o;;;=":~~~-"~f~~~--___;r-- Transverse
colon
teres of liver
mesocolon fl exure
.-----~~---- Jejunum
- - - - - Descending
colic flexure
--4i--~--- Sigmo id
Ascending colon -------~.r m esocolon
Ileum ----=------~"=
Median - +- - - - - - - - - - - - -'---- - % -:----'d.; - j +--++- - - !'-- " ' - - ----':-- - !- - Medial umbilical fold
umb ilical fo ld (with oblit erated
(with obl it erated umb ilical a.)
urachus)
145
lesser Sac
A Boundaries of the lesser sac (omenta l bursa). B Posterior wall of t he lesser sac (omenta l bur sa).
Lesser sac
Stomach - -1+-
Transverse colon
Liver Pancr eas Lesser sac Boundaries ofthe lessersac (omental bursa)
Direction Boundary Recess
Anterior Lesser om entum , gastrocolic ligament -
Inferior Transverse mesocolon Inferior recess
Superior Liver (with caudat e lobe) Superior recess
Pancreas, aort a (abdominal part), celiac
t runk , splenic a. and v., gast rosplenic
Posterior -
fo ld, left suprar enal gland, left kidn ey
(superior po le)
B Transverse
Right Liver, duodenal bu lb -
sect ion, inferior Inferior
view. Left Spleen, gastrospl enic ligament Splenic recess
vena cava
146
Fig. 72.7 Omental bursa in situ
Ant erior view. Divided: Gastrocolic ligam ent. Retracted: Liver.
Reflected: Stoma ch.
Sto mach.
greater curvat ure
Stomach.
posterior surface
Lef t gastri c a.
Com m on
hepati c a.
Duod enum ,
Pancreas
descend ing part
Transverse
Righ t kidn ey mesocolon
Middl e colic a.
Right colic fl exure and v.
Gast rocolic ligament
. Direction Boundary
. Hepatoduodenalligament w it h th e portal v., proper hepatic a"
. Ant erior
, and bile duct
.. ... ... ... ......... ....... ............. .... ............ ............ .....
147
Mesenteries & Posterior Wall
Cardiac
orifice
Superior }
Gallbladder bord er
Spleen
Gast ric
surface
Lesser oment um,
hepatoduod enal
ligament Yfrfi - - - Gastrosplenic ligamenl
Om enta l foramen
Hfi':r- - - - Pancreas
Duode num , fH1-7- - - - Transverse
superior part m esocolon , root
Duodenum,
hor izont al part
Ileum ---+---------'~
;.w;=..- - - -.;::;r-- Sigmo id m esocolon
(cut)
Cecum ---f-------~k.i
148
Fig. 72.9 Posterior wall of the
peritoneal cavity
Parietal Diaphra gm , Hepatic Inferior Cardiac Anterio r vie w . Removed: All intrap eritonea l
perit oneum hepat ic surf ace vv. vena cava orifice o rgans. Revealed: St ru ct u res of th e retro p erito
neum (se e Tab le ' 2 .4 and p. , 80 ).
Right suprarenal
gland
Hepato duodenal
ligament (wi th portal
v.. proper hepat ic
a., and common !llI_ - - Splenic a. and v.
bile duct)
~---ii'!!t¥.~'----- Pancreas
Right kidney (body and t ail)
Duodenum
{ Descending - --'----"' II
Left colic a. and v.
part
Descending colon
Pancreas (head) - - - ---4-l...' (site of attac hme nt)
Ascendi ng colon
~-"------'-'-.;..,.!>'_____,~~'i'_"'-------+--- Sigmo id
(sit e of attachm ent )
mesocolon
Mesoappendix ---+---------->1l~
"?-- - - - -..,;!-- - Left ureter
Right ureter ---!-----------'~....::!!loi:~1!!i!
~-------""!--- Ext ernal iliac a.
Rect um --~'-----------''!1f!!.'-------__.J,\'-----::.-~
. ~~,..--------'~----+-- Lateral umb ilical
fold (w ith inferior
epigast ric a.
Rectu s abdo mi nis _ _ +- ~_=_~_:_.,--.....J~
and v.)
Right vas
deferens
Rectovesical
po uch
Perito neal
covering
of rectum
Rect um ~lF-H-----''------ Visceral
pelvic fascia
Parietal on bladder
pelvic fascia
on rectum Superio r
pubic ramu s
Right
uret er Urinary bladd er
Rectove sical
sept um Pubic sym physis
Scrotal sept um
150
Right common iliac Sigmo id Fig. 12.11 Female pelvis
a. and v. mesoco lon
Taeniae coli
Proper ovarian
ligament
Uteru s
Rectouterine
po uch
Perit on eal
coveri ng
of rectum
Rectum Visceral
pelvic fascia
Visceral
on bladde r
pelvic fascia
on rect um Superior
pub ic ramu s
Right uret er
Urinary bladd er
Levator Inferio r
ani mu scle pubi c ramus
Rectum Vesicouterine
pouch
Uterine cerv ix
Urinary bladd er
Post erior
vaginal fo rnix Pubic
sym physis
Ante rior
vaginal forn ix Vagi na
Yoll
151
Peritoneal Relationships
Fig. 72.72 Peritoneal relationships Broad ligament Rectouterine Utero sacral Ovarian suspensory
in the pelvis: Female of ute rus Rectum pouch fold ligament
Uterine
t ube
Left ovary
Sigmo id
Cecum - - ---:::= 00--
colon
Uter ine fundus -~~-----' -='--- Ovarian
ligament
Vesicouterine
po uch .--P'S''''-- - - - - Lateral umbilical
fold (with inferior
Transverse
epigastric a. and v.)
vesical fold
Urinary Rectus
bladder abdomin is
A Lesser pe lvis, anterosuperior view.
Median umbi lical Medial umbilicus fold
Retracted: Sma ll intestin e lo o ps and fold (with obliterated Supravesical (wit h obliterated
colon (port ions) . urachus) fossa umbilical a.)
Transverse
cervical
ligament
Levator ani
Superior and ----im:-~~' . ::
inferio r fascia
Ischioanal
of pelvic
fossa
diaph ragm
Perineal
membrane Sigm oid
Sphincter colon
Superficial Vesicouterine
urethr ae Vagina
perineal fascia pouch Uterus
152
Fig. 12.13 Peritoneal relationships Rect ovesical Transverse
in the pelvis: Male Ileum Rectum pouch vesical fold
Cecum - -- --,
Pariet al
---~~
perito neum
Vas
def erens
Vermi form
append ix ~ Sigmoid
", ~ colon
Lateral ing uina l
fossa --e;;;;,.o'I~J..,;.'/,,'~!
: ~ Lat eral um bilical fold
(w ith inferior epigastric
Urinary bladder a. and v.)
A Lesser pelvis, anteros uperior view. Median umb ilical fold Medial umb ilicus fold
(with underlying Rectus (w it h unde rlying ob lit erated
Retracted: Small int est ine loops and
ob literated urachus) abdom inis um bilical a.)
colon (po rtions).
parieta l layer
7':.,..*- - Vas
defere ns
fascia
Levator ani
of pelvic
diaphragm
153
Pelvis & Perineum
inlet. see p. 126). The contents of the perineum are separat ed by the pelvic
• Ileum (coil s)
.... .. . . .. .... • . . . •• •... ••.. •. .. ..... . • •. •• ••. •..... .
•.. ~.: . ~~g i na : u.t~~us :. ute~ i ~.~ . tubes . a n? OVar ies ramu s
, Pelv is proper Ischi ocaver- Bulbo- Vulva Superfi cial Skin
i 0 : Ductu s deferens. sem inal vesicle. and
nosus spong iosus perin eal
pro state (Colles' ) fascia
.............. . .... . ..............
A Femal e.
• Urethra (membranous)
• Vagina
i Deep pouch • Rectum
. ... .. ..... ... ..... .............. ...... .... ............ ....... ... ...... . Superficial
l evat or ani
• Perineum • Per ineal m embra n e
• Ischiocavernosus, bulbocavernosus, and Perin eal -----FF.it:~;;;;=::=:~~ k~~==::;:~5 Inferior
superficial transve rse perineal mm. me m brane
pelvic
Superficial --'>~ diaph rag
• Uret hra (penile)
• Superficial perineal mati c
• pouch H ~ ~ l itoris and penis ' HHHH H ' (Colles') fascia
fascia
• Interna l pude ndal a. and v., pudenda l n. and
bran ches
Ischiocaver- Urethra. Bulb of Bulbo
• Superficial perineal (Colles') fascia no sus memb rano us peni s spongiosus
, Subcutaneou s part
• Fat
i perineal space
B Mal e.
Sk in
o Peritoneal cavity
o lschioanal fossa
154
Fig. 12.15 Pelvis: Coronal
section Suspensory ligamen t Uteri ne External iliac
ofthe ovary Rectum fund us a. and v.
Ant erior view.
Iliacus
Ovary
ligam ent
Ischioanal Pudendal
Inferior pubic
Glut eus
m inim us
Venou s
Obt urat or
plexus
internus
Sem inal
Prost at e
colliculus
Ureth ra,
membranou s Obt urator
part exte rnus
Deep
Quadratus
tr ansverse
femoris
perineal
Inferior
pub ic ramus
155
Transverse Sections
Int ernal
thoracic Transverse Greater
Common a. and v. Duod enu m colon omentum
bile du ct
Intercostal
a.• v.. and n. Ome nt al
bursa
Interm ediate
lum bar Splenic v.
lymph nod es
Spleen
Kidney
(wi t h right
renal a.)
Transverse }
colon Left
col ic
flexure
Descend ing colon
Abdom inal
aorta Spinal cord Perirenal Left kidney
(in vert ebral canal) fat capsule
Vertebral
veno us plexus
156
Urinary Fig. 12.17 Pelvis:
Fem oral a., v.. and n. Pubis bladd er Pect ineus Transverse section
In ferio r v iew.
Obturator canal
(in let)
Head of femur
Sciat ic n.
Ischial spine
Rectum
Glute us
maximu s
A Femal e.
Urinar y
Rect us abdo m inis bladder
Ductu s
deferens
Iliop soas
Head of fem ur
Vesicopro static
Sem inal vesicle venous plexus
Coccyx
B Ma le .
157
Stomach
surface
Pancreat ic -~;--
surface
B Posterior view.
Greater
curvature
Duodenum
Esophagus, -
advent it ia
Muscular coat
of esophagus,
longitudinal layer
Esophagu s
Duod enum ,
superior part
Oute r longi- )
tudi nal layer
Middl . I Muscularis
I e circu ar t
ex rema
Iayer
Inner oblique fibers
Body with
longit udinal
rugal folds
teres of liver
~
o-
Liver. Q
rig ht lobe
~
Q
~--cf."-rii-- Fundus ~
Gallb ladder
~~-- Cardia
Hepato
esophageal
ligam ent
St omach
(body)
Lesser Spleen
omentu m
Lesser
Hepato curvat ure
gastric
ligam ent
curvat ure
~ Clinical
are associated with increased acid production and are caused by alcohol. stomach. while gast ric ulcers exte nd int o th e st omach wall. The gastric ulcer in
drugs such as aspirin. and the bacte rium Helicobacterpylori. Symptoms include C is covered with fibr in and shows hemati n spots.
lessened appeti te. pain. and even bleeding. whic h manifests as black stool or
Gastric
ulcer
Gastric
Rugal antrum
folds
159
Duodenum
Inferior
RUQ LUQ
Duode nal vena cava
bulb Celiac trunk
i
Superio r part Suspensory ligam ent
~
of duodenum
Py lori c
Comm on - - - - - f orifice
bile duct
Duodenum
(superior part)
Circular fold s
(valves of Kerckri ng)
Accessor y
pancreatic duct ------------- - Pancreas
Minor
duodenal papill a
Duodenum -----+~
(descendi ng part ) - -- -- ----1,----- - - Duodenojejunal
flexure
Main pancreati c
duct
Major Superio r
duod enal papill a mesenteric a. and v.
Longitudinal
layer
Muscularis {
exte rna Circular Jejunum
layer
Submucosa Duod enum
(hori zont al part )
160
Fig. 13.8 Duodenum in situ
An t eri or v iew. Removed: Sto mach , liver, sma ll intest ine, an d larg e por
tive ti ssu e.
Thinned: Retroper iton eal f at and co n nec
t ion s of t he t ran sver se co lo n .
-
w
5"
Pariet al Inferior Common Phrenicosplenic ~
perito neum vena cava Hepat ic vv. hepati c a. Esophagu s ligam ent :3Q
Diaph ragm Spleen
-
Hepat ic surface
Left gastr ic a.
of diaph ragm
Right suprarenal
gland
Pancreas Splenic a.
Right kidney
Inferior duodenal
recess
~ Clinical
Stomach
Circular
folds
Papillary
region Duodenal
diverti cula
A Endoscopic
appearance. B Radiog raph.
161
Jejunum & Ileum
Fig. 13.9 Jejunum and ileum: Location Fig. 13.10 Wall structure of the small intestine
Ant erior view. The int raperitoneal jejunum and ileum are enclosed Macroscopic view s of th e longit udinally opened small inte stine.
by t he mesentery proper.
RUQ LUQ
~~~~~r----
r Duod eno
jejunal flexure
Ascending
0~~~~~~- Jejunum
and ileum
colon
RLQ LLQ
Rectum
A Jej unum . B Ileum .
Fig. 13.11 Jejunum and ileum in situ Greater ome ntu m Epiploic Taeniae Transverse
Ant erior view. Reflected: Transverse colon. (reflect ed superior ly) appendi ces coli colon
A
Ligamentum
t eres of liver
Transverse
m esocol on (with
middle colic
a. and v.)
Ascending
colon
Crohn's disease
Crohn's disease, a chron ic inf lammat ion of the digestive t ract, occurs most
often in the termina l ileum (30%of cases). Patie nts are generally youngand
suffer from abdominal pain, nausea,elevated body temperature, and diarrhea .
Init ially, t hese symptoms can be confused w ith append icit is. Comp licatio ns of
Crohn's diseaseofte n include anal fist ulae (B).
-
IN
5"
~
3
-
Q
t hickened wa ll of
radiograp h. Arrow
Duodenum ,
horizont al part
Taeniaecoli ------~~
163
Cecum, Appendix & Colon
~ The large intestine consists of the cecum . appendix. colo n. and verse colon. and sigmoid colon are int raperi tonea l (suspended by
a.iiiiII rect um (see p. 166). The colon is divid ed into four parts: ascend the m esoappendix. transve rse mesoco lon. and sigmoid mesoco
ing. transverse. descending. and sigmoid . The appen dix. t rans- lon . respect ively).
Left colic
i
Ascending - - l -- Circular layer } Muscular
fl exur e
colon coat
Transverse Longitudina l layer
colon Ileal Superior lip
papilla.
ileocolic
labrum Inferior lip ---+----¥lr~iii;;;,
Cecum
RLQ LlQ
Rectum
Right --:>0'-------.
colic flexure
Descending
colon
Ascending
colon
Ileal papilla.
fr enulum
lliocecal labrum.
superior and
inferior lips
Cecum
Mesoappe ndix
(with
appendicu lar a.) Sigmoid
colon
Rectum (with
peritonea l reflect ion)
164
Fig. 13.16 large intestine in situ
-
!2J- - - Greater
oment um
w
Transverse :r
~
colon
~
mesocolon flexure Q
:::J
,P',j,lr'l- - - Jejunum VI
H-I:t- - - Descending
Right - -+--.:i colon
colic (hepatic)
flexure
Mesentery - --i-
(cut) Sig mo id
m esocolon
Left
Ascendi ng - - - ----.loll
colo n Sigmoi d colic
colon fl exure
Ileum --7------'~ Right colic
fl exure
Cecum --t-------'~
Rect um ----,t----~'i!:f--....".,
Transverse
colon
- Coloni c
Rectu s --+-----;:----,,.-~.._ haustra
abdomini s
Sacrum
Cecum - Ilium
A A nterio r view. Reflected: Tra n sv er se co lon
and greater o m entum. Removed: Intrap eri
t on eal sm all in t estin e. - Sigmoid
colon
~ Clinical
165
Rectum & Anal Canal
-":~~"=&-'------ Rectum
RLQ Coccyx
Ischi um
!~~~'?-=----- Perin eal
fl exure
f1L2- - Sigmo id
col on
YoU.
Parietal --------'=.. ~
perito neum
Superior fascia
Inferior t ransverse
Pelvic recta l fo ld
diap hragm
{ Levator ani
Inferior fascia ---~l(t~~ :~ '
Hem orrh oidal
plexus
Anal valves
Subcuta neou s ---...!!!!~---''''''''~
part Corrugato r
cuti s ani
Dentate line
-------,.----"'-------"'J~
~~;:o,-- Q)
0) Anal
canal
o Cut aneou s zone squamo us wit h sebaceous
glands
St ratifie d. keratinized
Anocuta - --=--c==:--'S - l - '1---,-,-------.,"""'--==----- @) o Perianal skin (pigmente d) squam ous wit h sebaceous
neousli ne ~---~~~L ®
gland s. hairs. and
167
liver: Overview
colon
Descending Ascending
Small colon colon
intesti ne
Omental bursa.
vestibu le
Liver
Fig. 13.22 liver in situ C Tran sv erse sec tio n, inferior view,
Anterior v iew w it h liver retracted . Removed:
Sto mach, jejun u m, and ile u m . The liv er is
intrape ritonea l except for it s "bare area"
(see Fig. 13.26); its mesenteries include
th e fa lciform, coronary, and trian gula r
Ligamentum
lig am ents (see Fig. 13.27). Right lobe teres of liver Hepatogastric Left lobe
Esophagus,
cardiac orifice
Gallbladder
Spleen
Lesser omentum,
hepat oduodenal
ligament
~=---- Gastrosplenic ligament
Omental foramen
!!-!+.~--- Pancreas (body)
Mesentery (cut)
Duodenum,
horizontal part
168
Fig. 73.23 Abdominal MRI
Inferior view . Right lobe Hepati c Left lobe Stomach (with Rectus
of liver porta l v. of liver left gastric a.) abdo minis
-..
w
5"
~
External
oblique
Left colic
f lexure
Caudate lobe
of liver
Inferior
Spleen
vena cava
A Transverse section Right lung Azygos v. Spinal cord (in Abdom inal Diaphragm Left lung
t hro ugh T12 verte bra. verte bral canal) aorta
Left renal v.
Right lobe
of liver
Jejunum
Decendi ng colon
Inferior vena cava
Diaphragm.
External oblique
rig ht crus
Renal sinus
Left
Right Renal pyramids
kidney
kidn ey RenaI cortex
Lati ssimus
dorsi
B Transverse secti on Iliocost alis Quadrat us Longissimus Spinal cord (in Abdominal Psoasmajo r
th rough L2 verte bra. lum borum t horacis verte bral canal) aorta
169
liver: Segments & lobes
• VII III
VI ~ Ligament um
teres of liver
V
Fibrous
appendix
A Diaphragma tic
surfac e, ante-
-. Inferior
riorview. vena cava
Branchesof hepati c veins
VI
Branches of porta l vein
Branches of proper hepatic artery III
Branches of hepat ic duct
V
B Vi scera l su r Ligamentum /
face, inferior ter es of liver
Fig. 13.25 liver: Areas of organ contact IV Gallbladder
view.
Visceral surface, inferior view.
Hepatic segments
Part Division Segment
Posterior part I Caudate lobe
II Left
- - -+ - Suprarenal Left part Left lateral division
III Left antero lateral
impression
Left medial division IV Left medial
- - i.-- - Renal
imp ression V Right anterome dial
Right medial division
VI Right antero lateral
Right part
VII Rig ht posterolatera l
Right lateral division
VIII Right posteromedial
Gastric Duodenal Colic
impr ession impr ession impr ession
Right -----'-_'+.~
suprarenal gland
Right
t riangular I. Duodenum - - - +-- - - - -
170
Fig. 13.27 Surfacesofthe liver
Coron ary I.
Th e liv er is divid ed by it s li gam ent s into four
lobes: right , lef t, caudate , and qu adrat e.
IN
5"
~
- - Left lobe,
diaphragm ati c
surface
-
Right lobe,
diaph ragm at ic '------- Falciform I.
surface
~ Ligamentum t eres
(contain s ob lit erated
umbil ical v.)
Inferior border
L. of Bare
Inferior vena cava area Caudate
A Anterior vie w . Fibrous process
appendix of liver
Coronary I.
Right lobe,
visceral surf ace
Left lobe,
visceral surface
Portal v.
Left hepati c duct
Proper hepat ic a.,
right branch
Proper hepatic a.,
left branch Right hepati c
duct
Proper hepati c a.
Cystic a.
Ligamentum
te res of liver
Quadr ate Bile duct Cyst ic duct Gallbladder
lob e
B In ferio r vi ew.
Fibr ous
app endix of liver
Bare area
Left lobe,
visceral surface
Caudat e pro cess
Quadrate lobe
Gallb ladde r
C Posterior view.
Right lobe, visceral surface
171
Gallbladder & Bile Ducts
I "
caudate lobe caudate lobe
Left hepat ic
duct
Commo n
hepaticR~~:~ ~.
Common ~_ -" t,:
l I . ,-
J~:-"'"
hepati c du ct
.
hepati c d uct I_ L ". . .:" .IN. .{:.<",
1 ~~ ,~~,~ - ..~~~~,
!!i_ _ ,{ ". ,,"
- -.=-- Liver,
Bile duct Cyst ic du ct • ,';f :-B''-' '<t ' ~' left lobe
=-- - - - - - - Ligament
of vena cava
Right hepatic
Ii!~~---- Com mo n
Neck - - -- - --!f.
am pulla
Sphincter of
hepat op ancreati c Infundibu lum - ------;_/:
amp ulla
-i-- - Bile du ct
Liver,
right lobe
Left
Left hepati c suprarenal
du ct gland
Common Splen ic a.
hepat ic duc t
Common
Cystic du ct - ----H--m , hepati c a.
Proper - - ....p,-;ffiO
hepati c a.
Right colic
flexure Left kid ney
Hepato
Jejunum
pancreat ic
duct (opening
on majo r
duodenal
papilla)
~ Clinical
Gallston es
173
Pancreas & Spleen
A Ant erior view. B Left lateral view. C Transverse section, inferior view.
Duodenum , - Pancreas
descendi ng (t ail)
part
"=-- - - --j!fc-- - Superior
me senteric
a. and v.
Pancreat ic du ct
pancreatic bud) D d
Gastri c
surface
Fig. 13.35 Spleen
~---'~- Hilum
Splenic a.
Splenic v.
Renal
surface
Inferior
bord er
Coli c
surface
Inferior
border
A Costal surface. B Visceral surface.
Diaphragm atic
surface
174
Fig. 13.36 Pancreas and spleen in situ
A nter io r vi ew . Removed: Liver, st o m ach. sm all Parietal Inferior Hepatic Com mon Left Celiac
perit oneum vena cava vv. hepat ic a. gast ric a. tr unk
inte st ine . and la rge in t est in e. Th e pancreas
is ret roper ito neal. w h ile th e sp lee n is Superior
border
} ....
IN
in t rap er it o neal. Gastric Spleen
surface
S"
~
Hepat ic surf ace
of diaphragm ~
-o
Q
Q
~
Pancreas - - \L\-\ill.
(body)
Duodenum, --~I'L
superio r part
Pancreas ---J+~
(head)
Duodenum , -----!~u
descending part
Descending
colon
Left colic
a. and v.
Inferior
vena cava
Splenic v.
Right suprarenal
gland Pancreas
(tail)
Spleen
Right renal a.
Right kidney
TranSVerse }
colon Left
colic
Abdo mi nal Descending flexure
aorta colon
L 1 vertebra Spinal cord (in Left kid ney and
vertebral canal) perir enal fat capsule 175
Kidneys & Suprarenal Glands: Overview
Fig. 13.38 Kidneys and suprarenal glands: Fig. 13.39 Kidneys: Areas of organ contact
Stomach
RUQ
(area of contac t)
Right
Spleen
suprarenal
A Anterior view.
Duod enum Right Left Left renal
(area of cont act) urete r ureter hilum
12th ri b
Subcostal n. Right lung
Right kidn ey
Pleural cavity Attachm ent
Iliohypo gastric n. bet w een liver
Diaphragm and diaphrag m
Ilioinguina l n.
Perir enal fat capsule
Liver
Right suprarenal
gland Hepatorenal
Ret rop eriton eum - ..,.....-' recess
Renal fascia,
ante rior layer
Right kidn ey - ---=--
Parietal
Renal hilum - - ---' .......--- perit oneum
~~;.-- Duodenum ,
B Posterior view with th e trunk wall opened. Renal - -- -1
descendi ng part
fi brous capsule
Transverse
Iliac crest - -- - "
colon
Right
suprarenal v.
~ Medial
border
Cortex
176
Fig. 13.42 Kidneys and suprarenal glands
in the retroperitoneum
Anteri or vi ew. Both th e kidn ey s and su p rare nal
g land s are retroperiton eal.
Diaphragm. Inferior Proper Splenic
hepatic surface Port al v. vena cava Esophagus hepatic a. fossa
Duodenum , -~~
superior part Transverse
mesocolon
Parietal - ----1lcTW (root )
peritoneum
Left renal
a. and v.
Left kidney
Attac hmen t
of ascending
colon
Left superior
suprarenal a.
Left suprarenal
gland
Celiac t runk
Left midd le
and inferior
suprarenal aa.
Left suprarenal v.
Right ureter
Iliohypogastric n.
Right ovarian/
test icular a. and v. Ilioinguinal n.
Inferior mesenteric a.
B Removed: Periton eum . sp leen. and ga stroin
t estinal o rg ans. al ong w it h fat cap sul e (l eft
side ). Ret ract ed: Esophagu s.
177
Kidneys & Suprarenal Glands: Features
Rig ht - - TH'iirtl
suprarenai gl and
Right ur et er - - tH:rl+
Rig ht suprarenal
Right sup rarenal gland
g land
Superio r pol e ..",;-- - Superior sup rarenal aa. - - ""
_ - - Right suprarena l v.
Renal
Inferior sup rarenal a.
cort ex
Ant erior '--- - - Medi al border Fibro us
surface capsule
Lat eral
bord er
-1 ...._~-- Right renal a. and v.
Renal
hilum
Renal "r-- - - Renal pelvis
hilum
Poster ior
..\ - - - Right ur et er
surface
178
Fig. 13.44 left kidney and suprarenal gland
Ant erior view. Removed: Perirenal fat capsule.
Retracted: Pancreas.
Superior Left suprarenal Inferio r ....w
Esophagus suprarenal aa. g land phrenic v.
5"
Inferior vena cava ~
Inferior phre nic a. -
Q
Port al v.
Left gastr ic a.
Midd le suprarenal a.
Pro per hepati c a.
Left suprarenal v.
Commo n hepat ic a. - ----',
Subcost al n.
Bile du ct
Pancreas (ta il)
Sple nic a. and v.
C Posterior view w it h upper half part ially remov ed. D Midl ong itu dinal sect ion. posterior view.
179
Ureter
Fig. 13.46 Ureters: Location ~ The ureters cross th e com mo n iliac artery at its bifurcation into
Ant erior view. ~ th e exte rnal and int ernal iliac arteries.
Left suprarenal
gland and kidn ey
Rig ht suprarenal
Left inferior
gla nd and v.
suprarenal a.
Perirenal - - 4 '=+-l
fat capsule
Ureter
Inferio r - ----iltff (abdo minal part )
mesent eric a.
Sacral plexus
Rect um Uret er
(pe lvic par t )
Urinary Median umb ilical
bladder Pubic ligam ent
sym physis
180
Fig. 13.48 Ureter in the male pelvis
Superior view.
-
IN
S'
-~
Rectum with periton eal
Right ureter covering on anterio r wa ll Left uret er Q
Right ovary
Uterosacral fo ld (wit h
uterosacral ligament )
Right uter ine
t ube Passage of left
ureter t hro ugh broad
Broad -,-.,..: ligament of uterus
ligament of ut erus
-l~~-- Ut erus. posterior
surface
Round ligament
of ut erus
Ut erine fundus
Right external iliac
a. and v.
Transverse
vesical fold
Pubic
Median umbilical
sym physis
ligament
181
Urinary Bladder
Cecum - - -J
Parieta l ----'~k-
perito neum
Ductu s
deferens ~
Vermifo rm
Sigmo id
appendix
colon
Latera l ingui nal
fossa Lateral umbilical fold
(with inferior epigastric
Urinary bladder a. and v.)
Median umbilica l fold Medial umb ilicus fo ld
(w it h underlying Rect us (with underlying
A Anterosuperior view. oblite rated urachus) abdomi nis obliterated umbi lical a.)
Taeniae coli
Right ductus
defe rens
Rectov esical
pou ch
Visceral
perit oneum
Right
ureter
Levator ani
~
-
o
Q
a
Uteri ne
t ube
...t_ - - Left ovary
Sigmo id
Cecum
colo n
Uteru s ---=P ..: Ovarian
ligament
Parietal -----"~_
peritoneum
Sigmo id colon
and mesocolon
Rectouterin e Vesicouterine
pouch
pouc h
Visceral
Visceral
peritoneum
peritone um
Rectum
Visceral
pelvic fascia
Visceral
pelvic fascia
Right ureter
Urinary
bladder
Levator ani
<u:
183
Urinary Bladder & Urethra
Uteri ne fund us
Uteri ne bod y
Round ligam ent
of ut erus
Rectu m
Uterin e cervix
Urinary bladd er ----+---\---"l~
Posterior
Pubic - - --\- - + ..,
vaginal fo rnix
sym physis
Ante rior
Vagi na ----'<---+--~~'="*-h~' r.~]' vaginal for r
Crus of clitori s ----~7"'-'--_t.\' Levator ani
Deep t ransverse
perin eal
B Right female hemip elvis.
Pariet al - - _~ ....-.--.r- Visceral Fig. 13.53 Male urinary bladder and urethra
perito neum perit on eum
Mid sagittal sect ion, viewed fr om th e left side.
Site of bladder / Rectoves ical
pun cture pouch
Urina ry Rect ovesical
bladder pouch Rectum
Am pulla of
vas deferens
Prostate
- -- Bulbospongiosus
184
Fig. 13.54 Wall structure
Anterio r vi ew of co ro na l secti on . Inte rurete ral Urinary bladder
fold (bo dy)
uvula of bladder)
(wi t h ischiocavernosus)
Urinary
bladder
185
Overview of the Genital Organs
Organ Function
Right uret er
Fig. 14.1 Female genital organs
B Urogenita l syst em. Note: The fema le urinary and genita l tracts are
functi ona lly separate, though topog raphically close.
186
Male genital organs
Organ Function
Prostat e
Bulbour et hra l --*--+~ \
gland -+----"~~-+ Median Ductus
umbilical ligam ent defere ns
8-- +-+'1-- - Uret hra
Penis - - - - + H-
Bulb of penis
(corpu s
spongiosum )
B Urogenital system. Note: The male urethra serves asa common uri
nary and genital passage.
187
Uterus & Ovaries
Uterus, --~
posterior surface
Mesometr ium
--~o=~----
Medial surface
Free margin
Longit udinal
Fig. 14.5 Curvature ofthe uterus ut erine axis
Midsagittal sect io n, lef t lat eral view. The po si Endomet rium (in uterine cavity)
tio n of th e uterus can be d escribed in term s o f Longitu dinal cervical axis
Myometri um (in cervical canal )
fl exion (CD) and ver sion (0),
Perimetri um
(serosa) --l-
Uterine fundus ~
Uterine body
o Version : An gl e between th e
Ut erine ist hm us
Supravaginal part
I Vesicouterine
pouch
Ut erine cervi x
~
188
Fig. 14.6 Uterus and uterine tube
Mesosalpinx (w ith
ovarian
fund us ut erine a. and v.)
I
Infund ibulum
A Posterosuperior view.
Uteri ne fundus
Ute rine Uterine
Mesovarial margin
ostium
Ampulla
Infundi bulum
Fimb riae at
Right ovary
Supravaginal
Uterine part
Cervical canal
cervix {
Vaginal part
Vaginal fornix. lat eral part
Ext ernal os
B CoronaI sect ion, poster io r view wit h
Vagina. ant erior wall
ut erus straight ened. Removed: Mesome
triu m .
~ Clinical
189
Vagina
(inlet )
(cut obliquely)
;~~,...-';~r:-'~F?----'-:;..,--- Obt urato r
internus
Ut erine cervix --~~~::-"S;....,.c---'-;~'iiM'",,----T---T"T'~~<
~T---f'H~T-~~:;':-:~~~io--- Uterovaginal
venous plexus
Sciatic n. --~~!!
'--;:'-=---=---=,r.!-- --'- - - Ischial spine
Rect um ---=~~---==~~----~
Gluteus
maxim us
190
Fig. 14.10 Female genital organs: Coronal section
Ant eriorvi ew. The vagi na is bot h pelvic and perinea l in locat ion. It is also
retroperit on eal.
Ilium -------.
Left uteri ne
t ub e
Vagina, posterior
~-:'2-'"".~ rugae
Dorsal clit or al
a. and n.
Fem ale
uret hra
Inferior
pubic ramu s
191
Female External Genitalia
~----- Anus
Ext ernal
urethral orifice
Labia m inora
Bulbospong iosus
Vaginal orifice
Vest ibule
Vest ibular bulb
Orifi ce of greater
vestibu lar gland
192
Fig. 14.14 Erectile muscles and tissue: Female
Lithotomy posit ion. Removed: Labia, skin, and perin eal mem brane;
erecti le mu scles (left side) .
Isch iocavernosus
Super ficial
tran sverse
perineal
~ Clinical
Episiotomy
Episiotomy is a common obstetric pro ced ure used to enlarge t he birth th ere is imminent danger of perineal lacerat ion, and an episiotomy is often
canal during t he expul sive st age of labor. The procedure is generally used to perf or med . More lat eral incisions gain more room , but th ey are more difficult
expedite the deliver y of a baby at risk for hypoxia d uri ng th e expulsive st age. to repair.
Alte rnately, if the perin eal skin turn s wh ite (indicating dim inished blood flow) ,
Bulbospon
giosus
Lateral Midline
episiotomy episiot omy
Perineum
~~~~- A n u s Ischio
cavernosus
Deep
transverse
Mediolateral perineal
episioto my
1'- - - - - Superf icial
A Typ es of episiot omy.
transverse
perineal
Obturator
internus
Posterior ------;~~~---:ill
Levator ani
commi ssure
B Mediolateral episiotomy at height of co nt ract io n. C Pelvic floo r w it h crow ning of feta l head.
193
Neurovasculature of the Female Genitalia
Sacral
plexus
Pudendal n.
Inferior
rectal nn.
External anal
sphincte r
A Ne rve sup p ly to the femal e ex te rna l Dor sal Posterior Perin eal nn.
g enitalia. Lesser pelvi s, left lat eral vi ew. clit or al n. labial branches
• Ilioinguinal n. and
genitofemora l n.,
genital branch
0 Pudendal n.
Posterior femoral
0 cutaneous n.
labium mi nus
Deep t ransverse
Superficial perineal
tr ansverse
perineal
Perineum
; -- - - - - - Post erior fem oral
cuta neous n.,
Perineal nn. perineal branches
(pudendal n.)
Poste rior fem oral
cut aneous n.
Ischial
tuberosity
Pudendal n.
Anus
Externa l anal Inferior recta l nn. levator Gluteus Inferior
sphincte r (pudendal n.) ani maxim us cluneal nn.
194
Fig. 14.16 Blood vessels of the female external genitalia
Inf er io r view.
....
~
~
Deep dorsal
Dorsal
~
Deep
clitora l a. Crus of clito ris clitoral v.
a
Q"
clitoral a. Vestibu lar bulb Deep clitoral vv. Venous plexus of t::
vestibu lar bulb ,.,.
n
-.
A. of
vestibular bulb
Superficial
tran sverse perineal Posterior ~
Posterior
vestibu lar bulb labial w . 0
labial branches
Perineal vv.
~
Q
Perineal a.
Inferior Inferior
Int ernal
pudendal v. =
VI
Superficial
A. of vestibular bulb
Posterior labial
branches (pudendal n.)
Inferior rectal
a. and v.
Pudendal n.
Internal
pud endal
a. and v.
195
Penis, Scrotum & Spermatic Cord
Processus
Epid idym is - - - - - -----::::; ; ? ' = - - - ---i vaginalis
vag inalis
{
Viscera/l ayer
Scro t um
genit al branch
Int ernal
Cremasteric a. and v.
spermat ic fascia
196
Fig. 14.20 Penis
Urin ary
bladder
Uret hra
(preprostatic
part )
Super ficial dorsal
Prostate pen ile v. Penile skin
Superficial
Urethra
penile fascia
(me mbra no us Dor sal
part ) penil e
Deep
a. and n. penile fascia
Bulbou rethra l
gland Urethral Deep
Tunica albug in ea
am pulla dorsal
of corpus
penile v.
cavernosum
Crus of penis
Cor pus
sponqiosurn ,
bulb of penis Uret hra
Deep
(spongy part )
penil e a.
Corpus
Orifices of
cavernosum
Penile sept um
urethral glands
Corpus
31~----:i'=--- Uret hra
cavernosum Tunica albug i
(spong y part)
nea of corp us
Branches of
deep penil e a. spo ngio sum
Corpus
Uret hral a. spongiosum
Glans penis Navicular
fossa
B Cross sect ion through the shaft of the penis.
External
urethra l orif ice.
urethral crest
A Longitudinal sectio n.
Corona
Pub ic sym physis
of glans
Dorsal
penile
a. and n.
I Deep
do rsal
Glans
penis
penil e v.
Corpus - - -+-)
~--'----";;.------- Deep caverno sum
Corpus penil e a.
caverno sum
Corpus
spongiosum
Body
of pen is
Bulb of penis. Superior
corpus spong io sum spo ng iosus pub ic ram us Crus of penis
Ischiocavernosus
Ischiopub ic ramu s
Root
Bulb of penis
of penis
Deep transverse
perineal
D Inferior view.
197
Testis & Epididymis
Epididymi s.
head ~.J---- Testi s wi t h tuni ca vaginalis,
vi sceral layer
Scrotu m
Testicular a.
Pampiniform
plexus (test icular vv.)
Epididymi s
~-4---- Epidid ymi s
(head)
(body)
Septu m -_~~..L.c.=. ..,
Epididymi s
(body) Rete test is _ _ ~~~2J~~ Ductu s
Mediast inum in testicular def erens
testi s m ediastinum
Ductu s deferens
Epididymi s Epididymis
(ta il) (t ail)
Lobul e
198
• II> .... • • • • .. • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • <II •••••••••••••••
Abdominal· .
. Covering of the testis
wall derivative
CD Scrotal skin Abdominal skin
External spermatic
Scrotal septum ------:::....::!~~lIlj/ll ® External oblique
fascia
Cremaster muscle
Testicular mediastinum ® Internal oblique
and fascia *
with rete testis
Internal spermatic Transversalis
®
fascia fascia
Tunica
Tunica vaginalis,
Testicular a. albuginea @
parietal layer
Peritoneum
Tunica vaginalis,
Ductus deferens Pampiniform plexus @
visceral layer
Testicular
vv. (pampini Testicular a.
form plexus)
A. of
Epididymal duct Epididymal duct
ductus deferens
(head of epididymis) (body of epididymis)
'I~
II Vv. of ductus
deferens
- - - - Cremasteric a. and v.
Efferent
ductules
Straight
seminiferous Ductus
tubules
deferens
Rete testis
o Seminiferous tubules.
199
Male Accessory Sex Glands
@) Urethra
Central zone
Ejaculatory
duct* Peripheral zone
®
Prostatic
capsule
Pubis
Urethral
sphincter
Neck of
bladder Base
Urethra
I Prostatic
isthmus
Prostate
Membranous
pa rt Ureth ra
Ejaculatory
duct orifices
Apex
~+'--~--+-- Seminal
colliculus
200
Fig. 14.25 Prostate in situ
Sagittal section through the male pelvis, left lateral view.
Retropubic space
Seminal vesicle
Superficial dorsal
penile v.
Rectum
Ejaculatory duct
Prostate
Rectoprostatic fascia
Deep transverse
Bulbourethral gland
Prepuce
Urethra,
navicular fossa Scrotal septum Scrotum
Prostaticcarclnoma:and hypertrophy ,
Prostatic carcinoma is on~ of the ,most common malignant tumors inolder of the gland, prostatic carcinoma does not cause urinary outflow obstruction
men, Qftengro\JVing ala subcapsular, location in the peripheral zone ofthe ' i~ 'its early stages. Being in the peripheral zone,the tumor i~ palpable a~'a firm
: prostate. Unlike benign prostatic hyperplasia, which begins inthe central, part mass'through the anterior wall of the rectum during rectal examination.
::!--+~~~- Rectouterine
Urinary ----=r--~~~ pouch
bladder
::::-:;-~~~~-- Rectum
Prostatic
carcinoma,
subcapsular
B Prostatic carcinoma
(arrow) with bladder
A Common site of prostatic carcinoma. infiltration.
201
Neurovasculature of the Male Genitalia
Fig. 14.26 Neurovasculature of the male genitalia Fig. 14.27 Neurovasculature of the penis and scrotum
Left lateral view.
Pudendal n.
Inferior
rectal nn.
Perineal nn.
Dorsal penile
Dorsal Deep Internal a. and n.
penile a. penile a. iliac a.
Superficial
Middle rectal a.
penile fascia
Internal
pudendal a.
Inferior rectal a.
External
pudendal a. and v.
Deep dorsal
B Arterial supply. penilev.
Dorsal penile
a. and n.
Prostatic
venous plexus
Tunica
Vesical venous albuginea
plexus
~,.......rr-- Internal
iliacv. Superficial dorsal
penile vv.
Deep Internal
penile vv. pudendal v.
Inferior
==r---- Deep penile
rectal vv.
fascia
Bulbar penile vv.
Posterior
scrotal vv. Corona of
glans
C Venous drainage.
Glans penis
202
Fig. 14.28 Nerves of the male Ilioinguinal n. and
Bulbo genitofemoral n.,
perineum and genitalia genital branch
Scrotum spongiosus Posterior scrotal nn.
Lithotomy position.
(pudendal n.) Pudendal n.
CJ
Posterior femoral
CJ cutaneous n.
CJ Anococcygeal nn.
Dorsal n. of penis
(pudendal n.) Middle cluneal nn.
Superficial Gracilis
CJ Superior cluneal nn.
transverse
perineal Ischio
CJ Inferior cluneal nn.
cavernosus
Perineum
Adductor
magnus
Pudendal n.
Ischial
tuberosity
Perineal nn.
(pudendal n.)
Anus
External anal Inferior rectal nn. Levator Gluteus
sphincter (pudendal n.) ani maximus
Bulbo
spongiosus Dorsal
penile n.
Posterior
scrotal nn. Muscular branches
Bulbourethral
Perineal nn. gland
Anus Ischial
tuberosity
Inferior
rectal nn. Internal
pudendal a. and v.
External anal
sphincter Pudendal n.
203
Development of the Genitalia
cf
Glans penis
t ~ ;~:~~~sa
raphe Glans of
clitoris
of penis
Vestibule
Scrotum of vagina
Perineal Perineal
Peritoneal
cavity
Obliterated _ _--+~----l.
processus ~------- Ductus
vaginalis deferens
Ductus Inguinal
deferens canal
204
Fig. 14.32 Development of
the internal genitalia
Anterior view.
Mesonephric -~ ~~-- Gonad primordium
(wolffian) duct
Uterus
i.~~4..1~~,.--~-----"..,."..,2.-- Epoophoron
Ductus deferens
Ovarian suspensory
Prostatic
ligament
utricle
Ovary
Prostate
--~------....,....-'"
gland
Gartner's duct
(embryonic remnant
Spermatic cord
of wolffian duct)
Vagina
A Genetically male embryo (testicular primordium). B Genetically female embryo (ovarian primordium).
205
Arteries of the Abdomen
Celiac trunk: Supplies the structures of the foregut, the anterior portion
of the alimentary canal. The foregut consists of the esophagus (distal
half), stomach, duodenum (proximal half), liver, gallbladder, and pan
I-~~~~+---- Celiac trunk
creas (superior portion). (L1)
Superior mesenteric a.
(L1)
Superior mesenteric artery: Supplies the structures of the midgut: '"'t--I1?"'----7-"--- Renal aa.
the duodenum (distal half), jejunum and ileum, cecum and appendix, Inferior mesenteric a. -------::::'::=---~~. (L1/L2)
ascending and transverse colons, and right colic (hepatic) flexure. (L3)
~~-f----t----- Left common
Aortic bifurcation iliac a.
Inferior mesenteric artery: Supplies the structures of the hindgut: the
(L4)
transverse colon (distal third), left colic (splenic) flexure, descending and
sigmoid colons, rectum, and anal canal (upper part).
. .. . .
@ The abdominal aorta gives rise to three major unpaired trunks (bold) and the
Right superior
Left superior unpaired median sacral artery, as well as six paired branches.
suprarenal a.
suprarenal a. ,..
Branch from abdominal aorta Branches
Common hepatic a.
@ ® Inferior phrenic aa. (paired) Superior suprarenal aa.
Right gastric a. ---;::~~
Left gastric a.
Proper hepatic a. Spl-enic a.
Gastroduodenal a. ~-- Left inferior @ Celiac trunk Proper hep~tic a.
- .
~ suprarenal a. Common
Right gastric a.
hepatica.
® r: a.
® Inferior mesenteric a.
External iliac a.
@ ® Common iliac aa. (paired)
Internal iliac a.
.... . .. . .. ... .. .. . . .. .. . . .... . . ....... .,
. @) Median sacral a.
206
Fig. 15.2 Celiac trunk Common Abdominal
hepatic a. aorta
Celiac
trunk
Left
gastric a.
Right gastro
A Location, anterior view. Duodenal branches
omental a.
Inferior pancreatico
duodenal a.
Esophagus
Stomach
CD Celiac trunk Liver
Inferior (supplies the foregut): Gallbladder
pancreatico Pancreas
-...tJ~~~~--- Superior Duodenum
duodenal a.
mesenteric a.
Jejunum and ileum
Middle
Pancreatico- -------;;D
I!----- Left
colic a.
Inferior --~-----"~~'.\I\
Common
mesenteric a.
1!!----- Superior
rectal a.
~-- Middle/
Superior
inferior
rectal a.
rectal aa.
207
Abdominal Aorta & Renal Arteries
Esophagus
Inferior
Left superior
vena cava
suprarenal aa.
Left inferior
phrenic a.
Aortic aperture
of diaphragm Left middle
suprarenal a.
Celiac trunk
Left inferior
suprarenal a.
Superior
mesenteric a. Left renal a.
Left 1 st
lumbar a.
Abdominal aorta
Inferior
mesenteric a. Left ova ria n a.
(testicular a.
Right common in males)
iliac a.
Left ureter
Median
sacral a.
Left iliolumbar a.
Right internal Left superior
iliac a. gluteal a.
Right external Left lateral
iliac a. sacral a.
Right Sacral
umbilical a. plexus
Right
Left deep
obturator a.
circumflex
iliac a.
Right inferior
vesical a.
Left inferior
epigastric a.
208
Fig. 15.7 Renal arteries
Left kidney, anterior view. The renal arteries arise at approximately the
level of L2. Each renal artery divides into an anterior and a posterior
branch. The anterior branch further divides into four segmental arteries
(circled).
Medullary pyramid
Interlobar a. Arcuate a.
(between the (at base of medullary
medullary pyramids) pyramids)
Major calix
Superior segmental a.
Anterior superior
segmental a.
Capsular branches
Interlobular a.
Inferior suprarenal a.
Fibrous capsule
(anterior branch)
Anterior inferior
Left renal a. segmental a.
(posterior branch)
Inferior segmental a.
Ureteral branches
Left ureter
(origin from
renal pelvis)
Renal hypertension'
The kidney i~ an importantbloodpressure sensor
209
Celiac Trunk
~
~
~ Fig. 15.8 Celiac trunk: Stomach, liver, and gallbladder
E Anterior view. Opened: Lesser omentum. Incised: Greater omentum. The
.g celiac trunk arises from the abdominal aorta at about the level of L1.
..Q
c::e
Proper hepatic a., Abdominal
left branch aorta Left gastric a.
Proper hepatic a., Inferior Lesser
right branch vena cava omentum
Liver
Stomach
Gallbladder Spleen
Cystic a.
Proper
hepatic a.
Portal v.
Common -~~~
hepatic a.
Bile duct
Right
gastric a.
Posterior
superior
pancreatico
duodenal a.
Gastro
duodenal a.
Splenic a.
210
Fig. 15.9 Celiac trunk: Pancreas, duodenum, and spleen
Anterior view. Removed: Stomach (body) and lesser omentum.
Splenic a.
Posterior
gastric a.
Short
gastric aa.
Cystic a. --------i
Proper -------'
hepatic a.
Portal v. - - -
Gastro- _-------w
duodenal a.
Left gastro
omental a.
Supra A. of pa ncre
duodenal a. atic tail
(variant)
Pancreatic
Posterior superior branches
pancreatico Great
duodenal a. pancreatic a.
Duodenal branch
211
Superior & Inferior Mesenteric Arteries
Note: The middle colic artery has been truncated (see Fig. 15.11). The
superior and inferior mesenteric arteries arise from the aorta opposite
Portal v.
Splenic a.
Left renal v.
Left
renal a.
Right gastro
omental a.
Superior
mesenteric
Anterior superior
a.
pancreatico
duodenal a. Middle
colic a.
Inferior pancreatico
duodenal a., anterior
and posterior branches
Jejunal aa.
Right colic a.
Marginal a.
Colic branch
Ileal branch
Posterior
cecal a. Vasa recta
Anterior
cecal a.
212
Fig. 15.11 Inferior mesenteric artery
Anterior view. Removed: Jejunum and ileum. Reflected: Transverse colon.
Greater
omentum
Transverse --~====:-,=-~~-i::=-=~~~--=='==::::::tl;s.'
colon
Middle Superior
colic a. mesenteric a.
Duodenum
Abdominal aorta
Right colic a.
Descending colon
Inferior vena cava
Inferior
Ascending colon mesenteric a.
Left colic a.
Colic branch
Superior
rectal a.
Ileal branch
Anterior
cecal a.
213
Veins of the Abdomen
Hemiazygos v.
Azygos v. ----~
@ -----:~~.. ~ ..p-P------!:!------- ®
(1)
®
Inferior vena cava
L4 vertebra ------,,-'==...,~
G------ Abdominal aorta
~--=,-"':'--- Common iliac v.
\.O.!------':*":!----@
Anastomosis
Inferior ---'---------+.::=oo
vena cava
® Median sacral v.
Right testicular! Left testicular!
ovarian v. ovarian v.
214
Fig. 15.14 Portal vein Left gastric v. (with Right Short
To hepatic vv. esophageal vv.) gastric v. gastric vv.
The portal vein (see p. 218) drains venous
blood from the abdominopelvic organs sup
plied by the celiac trunk and superior and
inferior mesenteric arteries.
,.,'o---t''h''---r---- Splenic v.
Cysti c v. -------':-----,=-:=--=----",----7"'--4'J
Left colic v.
Right colic v. ----\-~--+~~~.,,_J:u" __ .._?T
Appendicular v. ---+---+--71/
f+--f-.-+----~- Internal
thoracic v.
Porta I v. ------\-,.".,.........---.-,L-+--4:
~...,.;r------H--- Inferior
vena cava
Superior
Paraumbilical vv. --~-~-----f-I epigastric v.
* Clinical -'----,-..--~-~_.~-
/_A-~------jn-- Common
Superior -----i--:!---f.. iliacv. Cancer metastases' ".' " " ,,' ,.' ,
mesenteric v. Tumors in the region drained by the superior ;' '
Periumbilical vv. ---+-+--------'t-':---l.... rectal vein mayspread thro'ugh the portal,
Inferior
to
venous system the capillary bed of the
Inferior epigastric v. Iiver(hepatic metastasis).Turnors drained
mesenteric v. by the middle or inferior rectal veins may
Ascending metastasize to the capiilary bed ofthe lung
lumbarv. .(pulmonary metas~asis) via the inferior vena
Colic vv. cava and right heart..
Superior Middle/inferior
rectal v. rectal v.
Esophagus
Celiac trunk
Right suprarenal v.
Left suprarenal v.
Superior
mesenteric a.
Left renal a. and v.
Ureter
Left 3rd
Inferior --------i~~
lumbarv.
mesenteric a.
Left common
Right common
iliac a. and v.
iliacv.
Deep circumflex
iliac a. and v.
Right internal
Left latera I
iliacv.
sacral v.
gluteal v.
iliacv.
Right --------i~------=-'-:'-------"!'';;____''ii~~
obturator v.
~~~~~~~~~-- Median sacral
Right middle
a. and v.
rectal v.
Right inferior
'----7'-:;7---::iii~~~~~~~~~~g_-- Rectum
epigastric a.
(and rectal
and v.
venous plexus)
Right internal
pudendal v.
~~~~~~1- Uterine venous
plexus
Right inferior
gluteal v.
Vesical venous
plexus
Right uterine v.
Right inferior
vesical v.
216
Fig. 15.16 Renal veins
Anterior view. See p. 209 for the renal arteries in isolation.
Left inferior
phrenic v.
(anastomosis with
Right inferior
left suprarenal v.)
phrenic a. and v.
Left superior
Inferior vena cava suprarenal aa.
Left inferior
phrenic a.
Right superior
suprarenal a.
Celiac trunk
Right renal
a. and v.
Superior
mesenteric a.
Right testicular!
ovarian a. and v.
Left testicular!
ovarian a. and v.
Right ureter
Abdominal aorta
Ureteral branches
(from testicular!
ovarian a. or
Inferior
common iliac a.)
mesenteric a.
217
Portal Vein
Portal v. Short
gastric vv.
Spleen
Right kidney
and supra
renal gland Splenic
a. and v.
Gastro
duodenal a.
Posterior
superior Left gastro
pancreatico omental
duodenal a. a. and v.
Anterior
superior
pancreatico Splenic a.
duodenal a.
Pancreatico
duodenal v.
Greater
omentum
218
Fig. 15.18 Portal vein: Pancreas and spleen
Anterior view. Partially removed: Stomach, pancreas, and peritoneum.
cava
Short
gastric vv.
Proper hepatic
right branches
Portal v.
Splenic
a. and v.
Right
gastric a.
Gastro- -~~
duodenal a.
Left gastro
Right
omental a. and v.
gastric v.
Left supra
renal v.
Anterior and
posterior
superior
pancreatico Left renal
duodenal aa. a. and v.
Left ureter
Pa ncreatico
duodenal v.
Ri9ht~'··
~
gastro- \
Left ovarianj
testicular
219
Superior & Inferior Mesenteric Veins
Left gastric
a. and v.
Proper
hepatic a. Inferior vena cava
Portal v. ------::-::-'!~
~==-:-- Splenic a. and v.
Inferior ---------==-*-=~
vena cava
Jejunal aa.
Ileocolic ----===~~ and vv.
a. and v.
220
Fig. 15.20 Inferior mesenteric vein
Anterior view. Removed: Stomach, pancreas, small intestine, and
peritoneum.
Left gastric
a. and v.
Proper hepatic a.
Splenic a. and v.
Right gastric
a. and v. Left renal a.
Gastro Inferior
duodenal a. mesenteric v.
Right gastro
omental a. and v. Middle colic
a. and v.
Superior
mesenteric
a. and v.
Ileocolic
a. and v.
Jejunal/ileal
aa. and vv.
Inferior mesenteric
a. and v.
Left common
iliac a. and v.
Sigmoid
aa. and vv.
Cecal vv.
221
Arteries & Veins of the Pelvis
.. " " " ,. " " .. ••••••••••••••••••• " •• " •••••••••••••••••• (It
external
iliac a.
Right external
Superior iliacv.
®
Piriformis •
vesical a.
Inferior
epigastric a.
Prostatic ---~-~
occluded
Deep dorsal
part
A. of ductus penile v.
aorta
Right
Right
internal
internal
@ iliacv.
iliac a.
Uterine a.
Uterine vv.
®
Right---+---->
Vaginal a.
external
iliac a.
Right
external
®
Superior
iliacv.
vesical a.
Uterine
venous plexus
Vaginal branch and vaginal
of uterine a. venous plexus
The i,ilternal iliac artery gives off five parietal (pelvic wall) and four visceral
,(pelvicorgans) branches. * Parietal branches are shown in italics. '
CD Superior gluteal v.
Branches @ Lateral sacral v.
CD Jiolumbara. @ Obturator vv.
@,,, Superior gluteal a.
0 Vesical vv.
@
® Vesical venous plexus
A. of ductus deferens
Middle rectal w. (rectal venous plexus) (also superior and inferior
.0 Umbilicala . ®
Superior vesical a. rectal W., not shown)
(J) Middle rectal a. The male pelvis also contains a prostatic venous plexus and veins draining the
penis and scrotum. The female pelvis contains'the uterine and vaginal venous
® pudendal a. Inferior rectal a.,
plexus.
s .....
r
'It:' 'VI Y'Ult:'U
,~In the female pelvis. the uterine and vaginal arteries may arise directly from
the'internal iliac artery.
222
Fig. 15.21 Blood vessels of the pelvis
Abdominal aorta ------+:!!!H Idealized right hemipelvis, left lateral view.
Inferior mesenteric a.
Left common
iliac a. and v. Median sacral a.
Right iliolumbar a.
Right ureter
Right external
iliac a. and v.
Right superior gluteal a. and v.
Right obturator
Superior rectal a.
a. and v.
and v. (from/to inferior
mesenteric a. and v.)
Right superior
vesical a. and v.
deferens and a.
~+--,-,-------,5a--- Right middle rectal
inferior vesical
Prostate
a. and v.
Left internal pudendal
a. and v.
Posterior scrotal branches,
posterior scrotal v.
A Male pelvis.
Right internal
Right common iliac a.
iliac a. Median sacral a.
Right ovarian a. and v. ~ Right iliolumbar a.
Abdominal Inferior
To portal v. aorta vena cava
Inferior
mesenteric t /:: /
a. and v. Median sacral
a. and v.
Sigmoid
aa. and vv.
Superior rectal
a. and v.
Left externaI
iliac a. and v.
Right internal iliac a. and v.
Left obturator a.
224
Fig. 15.23 Blood vessels of the genitalia
Anterior view. Left ureter
tubal branch
Round ligaillent - -
and n.
of uterus
Uterine
Inferior
a. and v.
vesical a.
Vaginal a.
Mesometrium
Superior vesical
(of broad ligament)
a., vesical v.
YoIL
Umbilical a.
Inguinal ligament
Pampiniform plexus
(testicular vv.) Left ductus
deferens
deferens
Dorsal penile a.,
spermatic fascia
Testis
Left common
iliac Ln .
..............
/_._'\
. ..........
CD \~:~ aA
I " ;/'
j/~~-0
--l ~r-- CD Inferior phrenic Ln.
j ~l @ o Celiac Ln.
Cisterna _ _ bJ (_._-_._
chyli i Lumbar G) Superior mesenteric
i! Ln. Preaortic
Ln.
:~:!~
Ln.
j~~
® Common iliac Ln .
• • • • • • • • • • • • • • • • • • • ••'V , : : .
226
Fig. 16.2 lymphatic drainage of the rectum Fig. 16.3 lymphatic drainage of the bladder and urethra
Anterior view. Anterior view.
Abdominal aorta
Inferior mesenteric a.
and I.n.
L- Superior rectal a.
\\"'\
Common
iliac I.n.
1~
(/
/).-/
Internal ------'-,--'----~
Internal iliac a.
iliac Ln.
Superficial
Superficial and
inguinall.n.
deep inguinall.n.
Fig. 16.4 lymphatic drainage of the male genitalia Fig. 16.5 lymphatic drainage of the female genitalia
Anterior view. Anterior view.
,//. \
Right Common
}!. . common iliac I.n.
r( \\
I II iliac a.
\ .\., ..
) /'
\"1 ;
Internal
Internal iliac Ln. --,--".~--",. ~-~ ~
'c.:.-'
iliac I.n.
\
'"f------if-fu'>-+/--- Sacra I I. n.
External
External iliac I.n. Sacrall.n.
iliac I.n.
Superficial Deep
inguinall.n. inguinall.n.
(horizontal
group)
Superficial inguinall.n.
(vertical group)
Horizontal group
® Superficial inguinall.n.
Vertical group
® Sacral Ln.
• • • • .. • • • • • • • • • • • • • • . • • • • •• • • • • • • • • • • • • e' ~' , ". ; ,: ;
227
lymph Nodes of the Posterior Abdominal Wall
Celiac I.n.
Diaphragm
Right lumbar
trunk Retroaortic I.n.
Intermediate
lumbar I.n. Inferior mesenteric I.n.
Right lateral
cavall.n. Common
iliac I.n.
Common
iliac a.
Internal
iliac I.n.
Sacrall.n. --------:-''-=~-----'''~
External
iliac I.n.
Inguinal ----7----'---..:~_¥~.
ligament
Intermediate ----=-----:"-----.,-~-~~
lacunar I.n.
228
Fig. 16.7 Lymphatic nodes of the urinary organs
Anterior view.
Retrocava II. n.
Thoracic duct
t
Lateral aortic Ln.,
lJ;jtermediate h:lmbar I.n. :Preaortrc Ln.,
Retroaortic Ln. '
t
Obtwratbr L'n. Subaorticl;p. Sacral Ln. ,
229
Lymph Nodes of the Anterior Abdominal Organs
Left gastric
I.n.
Portal v. ----".;.-~
~~-- Left gastro
omentall.n.
Pancreatic I.n. --~~
Right gastro
omentall.n.
230
Fig. 16.10 lymph nodes of the spleen, pancreas,
and duodenum
Anterior view. Removed: Stomach and colon.
Splenic Ln.
Celiac Ln.
Suprapyloric Ln.
~---- Pancreatic I.n.
Retropyloric Ln. --~~~ (superior)
~~~..,------ Superior
(inferior)
mesenteric I.n.
Pancreaticoduodenal
Ln.
"Thoracic duct
Cisterna chyli
Cystic Ln.
Foraminal Ln.
1
Celiac I.n.
Pancreatic Ln.
(superior and inferior) Supra-, sub-, "and
retropyloric Ln.
231
Lymph Nodes of the Intestines
- - - - Abdominal aorta
cisterna chyli
~~~~f----- Superior
Transverse colon ---~~ mesenteric Ln.
Duodenum
~~-- Intermediate
mesenteric Ln.
JuxtaintestinalLn.
~-~--Ileum
Thoracic duct
t
Left lumbar trunk Cisterna chyli' . Intestinal trunks
Juxtaintestina·ll.n.
Prececall.n.
Retroceca II. n..
Left colic I.n.
Ileocolic Ln.·
Middle colic Ln. Appendicular Ln.
Right colic Ln. . ...
232
Fig. 16.14 Lymph nodes of the large intestine
Anterior view. Reflected: Transverse colon and greater omentum.
Epicolic I.n.
Superior
Middle colic I.n. mesenteric I.n.
Paracolic I.n.
Inferior -------=....:....,+-=:=
mesenteric I.n.
Sigmoid I.n.
Superior
Prececall.n. rectall.n.
233
lymph Nodes of the Genitalia
lumbar I.n.
~~~--- Common iliac Ln.
Abdominal --~;...+
aorta
External ----:---~~~~~
iliac a.
~~;--~i1'7--~-- Rectum
. . .~ ~·-.&Ullrl&iiii~~~~___=_+---Superficial inguinal
Urinary bladder -----====--=-=-:-=----:;,,.,,..::---~---=.-~ I.n. (horizontal group)
~~~'-------e:-:::-:~~~;-....--Superficial inguinal
I.n. (vertical group)
Epididymis ------;;--------~~~~~
~-------~---.--+--- Scrotum
234
Fig. 16. 16 lymph nodes of the female genitalia
Anterior view. Removed: Gastrointestinal tract (except rectal stump) and
peritoneum. Retracted: Uterus.
Promontory Ln. ~~
Ovary ---~----'-::~~
External iliac Ln.
Mesometrium --------i"'''---------''"~:.............,~~~
.....
~~~~~~~~--- Obturator Ln.
Thoracic duct
t
, Right lumbar trunk Cisterna chyli' ~'- left lu'inbar trunk
Left lumbar Ln.
Lateral c~lVal Ln. t LateraI aortic'I. n.
Precaval Ln; ~ntermediate lumbar I.n. Preaortic I.n.
, Retrocava II. n. Retroaortic Ln.
t
Lacunar I.n. (lateral. ---. Common iliac I.n. ~ Internal iliac I.n.
medial. and intermediate)
t
. Interiliac Ln. iliac Ln.
t
Visceral pelvic I.n.
Pararectall.n.
Jt
Parauterine Ln.
ParavaginaIL~.
Latera'i vesical Ln. ......t - - - - \ . , l
Pre- and retrovesicall.n.
235
Autonomic Plexuses
Sympathetic
trunk with
lumbar ganglia
A Celiac ganglia
Gastric plexus
Splenic plexus
plexus • Liver, gallbladder
• Stomach
• Spleen
Pancreatic plexus • Pancreas
Superior mesenteric plexus
• Pancreas (hea'd) • Cecum
• Duodenum • Colon (to left
• Jejunum colic flexure)
• Ileum
-:-~.UlJlraf·enal and renal plexus
• Pelvic viscera
• Uterus • Vagina
Uterovaginal plexus
• Uterine tube • Ovary
Ganglion
236
Fig. 17.1 Autonomic plexuses in the abdomen and pelvis
Anterior view of the male abdomen. Removed: Peritoneum and majority
of the stomach.
Right greater
splanchnic n.
Left greater
Right lesser
splanchnic n.
splanchnic n.
Left lesser
Celiac ganglion splanchnic n.
Suprarenal
Superior
plexus
mesenteric ganglion
Lumbar
Intermesenteric ------r-:;...= ganglia
plexus
Sympa
thetic
Ureteral plexus -----;~ Inter trunk
ganglionic
Inferior trunk
mesenteric
ganglion ~'<---- Testicularj
ovarian plexus
Sacral plexus
237
Innervation of the Abdominal Organs
Anterior
gastric plexus
Superior ---~~
mesenteric
plexus
(on superior
mesenteric a.)
238
Fig. 17.3 Innervation of the urinary organs
Anterior view of the male abdomen and pelvis. Removed: Abdominal
organs and peritoneum. See p. 246 for schematic.
~~-- Aorticorenal
Suprarenal plexus ganglia
Intermesen- ------=;-
teric plexus
Inferior mesen
teric plexus
Left hypo
Sympathetic trunk, gastric n.
sacral ganglia
1st sacral n.,
Right hypo --------'---'!O~ anterior ramus
gastric n.
Inferior hypo
gastric plexus
Pelvic splanchnic nn. --------,...="'---=-~~~
Middle rectal
plexus
Vesical plexus -------~--~
239
Innervation of the Intestines
Right greater
splanchnic n. Posterior vagal
trunk, celiac
branch
Left greater
splanchnic n.
Celiac ganglia
Splenic plexus
Left lesser
splanchnic n.
Aorticorenal
ganglion
Rena I plexus
Superior mesen
teric ganglion
Superior
mesenteric
Testicular
plexus
(ovarian) plexus
~:::;::~-~~----:;:~~~~~---
Jejunal and ileal aa.
(with autonomic
plexuses)
Right colic a. --~~~
(with autonomic
plexus)
Ileocolic a. -------;....-~~
(with autonomic
plexus)
240
Fig. 17.5 Innervation of the large intestine
Anterior view. Removed: Jejunum and ileum. Reflected: Transverse and
sigmoid colons. See p. 245 for schematic.
Transverse
colon
Left colic a.
Middle and right (with autonomic
colic aa. (with plexus)
autonomic
plexuses) Descending
colon
Intermesenteric
plexus
Inferior mesen
teric ganglion
Ileocolic a. (with
autonomic plexus) Inferior mesen
teric plexus
Ascending colon
241
Innervation of the Pelvis
Intermesen- ----r--f!-;'-O
teric plexus
Inferior mesen
teric plexus
gastric n.
1st sacral n.,
anterior ramus
242
Fig. 17.7 Innervation of the male pelvis
Right pelvis, left lateral view. See p. 247 for schematic.
Intermesen -~-...,...,
teric plexus
Grayramus ---~~~.....---~~~
Lumbar nn.,
communicans
anterior rami
Left hypogastric n.
Middle
rectal plexus
Deferentia I
plexus
Pudendal n.
Seminal vesicle -------':~b~~L6~
Inferior rectal
plexus
Vesical plexus ----~~,...=-~~-------:::
Cavernous ----...,~
nn. of penis
Posterior
Dorsal n. scrotal nn.
of the penis
243
Autonomic Innervation: Overview
Dorsal
vagal
nucleus
- - Sympathetic
trunk
[>- Sympathetic
1------4Eii (paravertebral)
ganglia
Thoracic ----':---'----+-----~-------I
splanchnic
nn.
Lumba r ~--';---------;---l
splanchnic nn.
Sacral S2
splanchnic nn.
54
Superior and inferior Pelvic
mesenteric ganglia (with splanchnic nn.
intermesenteric plexus)
Glands '
capsule Contraction
I_®
~-~~-=;;
~~
Anterior
gastric plexus
,'' I
~<' ~ ~ Pancreatic
plexus
-\--0
Posterior Branches of Branches of
Pyloric branches gastric plexus celiac plexus superior mesenteric plexus
Thoracic
splanchnic nn.
\\..~~===:::::t;~~---------=~-ti~,-----{---
Superior
mesenteric
plexus
~---ij:::::::::=-----+----+~~-!----- Inferior
Lumbar mesenteric
splanchnic nn. plexus
245
Autonomic Innervation: Urinary & Genital Organs
Vesical plexus
Prostate
~ Clinical-~-'---------_.'-~~~--
Referred pain from the intern'al organs . , .. . " ' :. .. ~ ' .~ . . ' ~. ,
The"converge'nce of somatic andvisceral afferent fibers to a common level of sites of pain, a phenomenon 'know l1 as referredpair;L Pain in)pulses.from a,
t~e sp.i~al cord confusesthe relationship bet~een the perceived and actual parti~ular organ are consistently projected to th~ same 0ell-defined skin ar.ea.
Pancreas
Gallbladder -
A c D
246
Fig. 17. 11 Autonomic innervation of the genitalia
Intermesenteric
plexus @ Intermesenteric
@
plexus
@
__--I·----<10J-----oo+--I
@
@
Hypogastric n.
Ovarian
plexus
Vesical
plexus
Prostatic
plexus Deferentia I
plexus Uterovaginal
plexus
Testicular
plexus
247
Surface Anatomy
~
c:
~
E
.g
..Q
-=:r:
Transumbilical
plane
(L3-4 disk)
Anterior superior - -
A Bony prominences.
Rectus --~~~=--_
abdominis
Tendinous ------F=~=~=~
insertion
----'-.....:=:..-:=::::=:===:;=:J!.....---- Li nea al ba
External --~"'-----
oblique
>
~~=;;.,--- Semilunar
line
~~~~~~S';---- Superficial
inguinal ring
Sartorius _:=--~
Quadriceps -----'0'===--
femoris
B Musculature.
248
Fig. 18.2 Surface anatomy of the abdomen and pelvis
Anterior view. See pp. 40-41 for structures of the back.
249
Upper Limb
Hume rus
256
joints of t he Shoulder
258
22 Neurovasculature
Anterior Muscles of the Shoulder & Arm (II)
266
20 Elbow & Forearm Superficial Veins & Nerves of the Upper Lim b 330
Elbow joint
282
Radioulnar joints
286
23 Surface Anatomy
21 Wrist & Hand
Surface Anatomy (I) 350
Arm
Scapula Scapular
spine
Elbow
)
" Wilr-- Head of radius
Forearm
~>-+---- Radius
Radiu s
Ulna Uln a -_~
1st
met acarp al
Hand
4t h proxim al phalanx
Phalanges
4t h mi dd le phalanx - - -H
4th di stal phalan x - - --f;
252
Fig. 19.2 Palpable bony prominences
Except for th e lunat e and trapezoid bon es, all of th e bon es in th e upp er
limb are palpable to some degree t hroug h t he skin and soft tissues.
Inferior
angle
Medial Inferior
bord er angl e
Hum erus
Lateral - - Medial
epicondyle epico ndy le Head of
radiu s
Olecrano n
Shaf t of ulna, - 1
po sterior surface
Ulna - -- -I
Radius - -- --\-
phalanx
Phalanges - '-f...--'--r.--q-i----!-,
1st distal
phalan x
253
Clavicle & Scapula
~ The shoulder gird le (clavicl e and scapula) connects th e bone s of (pair ed hip bon es) is firm ly int egrated into th e axial skeleto n (see p.
~ th e upper lim b to t he th oraci c cage. Wh ereas th e pelvic gird le 358) , the shoulder girdle is extr eme ly mobile.
Conoid
tubercle
Ste rnal
art icular surface
Shaft of
Sternal
clavicle
end
A Superior view .
Im pressio n for
costo clavic ular ligament
Groove for
subclavius mu scle
Conoi d
tub ercle
B Inferio r view.
Clinical
Scapular foramen
Scapular foramen
The superior tra nsverse ligarnent of th e
scapula (see p. 259) m ay becom e ossified.
tra nsfor ming t he scapular rio tch int o
an ano ma lous bony canal, th e scapular
fo rame n. This can lead to compression of
t he sup rascapular nerve as it passes th roug h
th e canal (see p. 33 3).
254
Acrom ion Coracoid Scapular Superior Superior Fig. 19.4 Scapula
pro cess not ch border angle Right scapula. In its normalanatomical posi
tion, the scapula extends from the 2nd to the
Subscapular 7th rib .
fossa
Supraglenoid
tu bercle
Acromion
Infraglenoid
Superior angle
tu bercle
Coracoid
Medial
process
Lateral bo rder
bo rder Supragleno id
Glenoid
t ubercle
cavity
Infr aglenoid
t ub ercle
A Anteriorview.
Inferior angle
Posterior Costal
surface surface
Acromio n
Supra
spinous Inferior ang le
fossa
Acromial B Right lateralview.
ang le
- - - - Glenoid
cavity
Medial
bord er
Infr aspinous
fossa
Lat eral
bo rde r
255
Humerus
groo ~e ~
t U be
" ro""si~t_y_
y neck hum erus t uberosity
tUberOS\ i t _
Intert ubercular
". Head of gro ove
Anat om
hum erus
ical neck
Lesser
~JlP-- Anatorn
t uberosity
ical neck
Surgical
-r-- - - Surgical neck
neck
Crest of
greater
Radial
tub erosit y
groove
~
Delt oid
/
tub erosity
Ant ero-
lat eral
surface
-<
Shaft of hum erus,
anterol ateral
surface
Medial -
bord er
Lateral
supracondy lar
ridg e
Med ial
\
Medial
supracondylar supracondylar
ridg e ridg e
~
Radial
_________ Coro noid
fossa
~ fossa
Lateral - --.-- .,"'" Radial fossa
(
Medial Medial
supra
epicondyle epicondyle
condy lar
ridg e Capit ellum
256
~ Clinical
Lesser
tuberosit y
-~ Greater
tub erosity
Inter
t ubercular
_ Lesser
tu berosity
groove
Crest of - -- " "
lesser
tu berosit y --~-- Head of
Anatomical hum erus
neck
Shaftof - (
hum erus.
anterom edial
surface
B Int ra-arti cular fract ure.
Med ial
Olecrano n fossa
border
C Comminute d fractu re.
D M edial view.
257
Joints of the Shoulder
joint
Subacromial
space
Acromioclavicular
joi nt (with acro mio-
clavicular I.)
N ~ _.....
.....
Coraco
acromial I.
Glenoh umera l
joint
Fig. 19.8 Scapulothoracic joint
Right side, superior vi ew. In all m ovements
of th e shoulder gird le, th e scapula glid es on a
curved surface of loose connective ti ssue be
tween th e serrat us ante rior and the subscapu
laris mu scles. This surface can be considered a
scapulot horacic joi nt.
Scapulotho racic
joint
Scapulot horacic Posterior Sternoclavicular joint
joint sternoclavicular I. (w ith anterior
sternoclavicular I.)
Acro mion - - +
Head of - !---'-----
hum erus
258
Fig. 19.9 Sternoclavicular joint Artic Costo
Anter ior
ular clavic
Anteri or view with sternum coronally sterno Inter
Clavicle di sk ular I. - - l st rib
sectio ned (left) . Note: A fibr ocartilaginous clavicular I. clavicular I.
artic ular disk com pensates for the mismatch
of surf aces between th e two saddle-shaped
art icular facet s of the clavicle and manub rium
st erni.
Costal
cartila ge Manubrium Ste rnoco sta l
stern i joint
Fig. 19.10 Acromioclavicular jo int
Ant erior view. The acromi oclavicular joint is a
plane joint. Because t he articulating surface s
are flat . th ey mu st be held in place by st rong
ligam ents. greatly lim it ing th e mobility of th e
joint.
Clavicle, Coracoclavicular I.
acromia l
Acrornio- end Conoid I.
clavicular I.
Acrom ion -,
Coraco
acromial
Coracoacrom iall. ~~~~~.~
arch
1 Coracoid process
--''----------~-- Superior t ransverse
scapular I.
:..,,--- - - - - - - - - - "rt-- Scapular notch
- Medial
border
Hume rus
~ Clinical
A St retching of ligaments. B Rupture of acrom ioclavicular ligament. C Com plete dislocati on of acrom ioclavicular jo int .
259
Joints of the Shoulder: Glenohumeral Joint
Acro m ion
Head of
hum erus
Greater
tu berosity
Gleno id
cavity
Inter
tu bercu lar
groove
Anatomical
neck
Infraspinous
fossa Hum erus
Head of humerus
Glenoid cavity
260
Fig. 19.13 Glenohumeral joint: Capsule and ligaments
Rig h t sho ulde r.
Acro mio Coraco Scapular Superior transverse
clavicu lar I. clavicular I. not ch scapular I.
Coraco Acromio
Clavicle clavicular I. clavicular I.
Acro mion
Inter ~-----.J!-
tu bercular
synovial
sheat h
Int er
t ubercular
groove
Fig. 19.14 Glenohumeral joint cavity Fig. 19.15 MRI of the shoulder
An t erior v iew . Superio r Co ro n al section, ant erio r v iew .
Acromio Coraco t ransverse
clavicular I. clavicular I. scapular I.
Subcoracoid
bursa
Head of
humerus
Transverse
I. of
hum erus
261
Subacromial Space & Bursae
Fig. 19.16 Subacromial space Fig. 19.17 Subacromial bursa and glenoid cavity
Right shoulder. Right shoulder. lateral view of sagittal sect ion with humerus remo ved .
Supra I
spinat us
Subacro m ial
bur sa ' -!"""';'!- - Subt endinous bursa Subacromi al
of subscapularis bu rsa Subte ndino us
Subdeltoid --~-~-
Infraspinat us ~~ II' U
bur sa of
bu rsa Greate r t uberosit y
subscapularis
--!!!'--J:-ll--- - Transverse ligam ent Glenoid cavity - - -td!'.. 'H:+- - Tendon of
of hu merus biceps brachii,
Glenoi d labrum --~-¥~~ lo ng head
'1'----/ -+-- - Int ertu bercu lar
t endon sheat h Joint capsule --~--'-----"'" ""'::::::::'~4~~ ~<------->...- Subscapularis
Infraspi nat us -----1~_. ,
Teres mi nor
Teres min o r - - -l!-"'-::!- Axillary recess
Biceps brachii,
long head Scapula. lat eral bo rde r
A Latera l view.
'-""="--K -_ Scapula
Subacrom ial
bursa
Subdelt oid
bursa
262
Fig. 19.18 Subacromial and subdeltoid bursae
Right shoulder. anterior view.
Subcut a-
Coracoacro m ial
neou s acrom ial
arch
Coracoacro mi al bu rsa
Trapezius
ligam ent I
~
Coracoclavicular
co racoi: crom ion ligam ent
process - - Clavicle
Subacromia l - - -- - -...,rc-
bursa Superior tra ns
~~o--- verse scapular
Subdeltoid - - - ---.--. ' ligament
bur sa - - - l st rib
Glenoh um eraI
----;f-----!'!---~~!____(
<
j oint capsule
~ Subt endinous
bur sa of
Deltoi d subscapularis
t ubercular
groove
Hum erus
Trapezius
Subacrom ial
bursa
Supraspinat us
tend on
263
Anterior Muscles of the Shoulder & Arm (I)
Clavicle
Trapezius
Verteb ra promin ens
(0 )
Sternocleido
mast oid
Clavicul ar
part
Coracob rachialis
=--::~~::::~---~~t-- Sternocos ta l Pect or alis
part major
Teres m ajor --~~'.HJ
Abdom inal
Latissimu s dor si --P.:1~ii--';lfilH-H-i
part
Biceps
brachii
1~~:~
Short - - -YfJ'-8'-f+ ---T-~~!- Sternum
head
Serrat us --~-+-I:-~+.B~~
ant erior
/
- - - - - - - - -- Rectussheath
Biceps brachii --~:E-l:-:f.~
264
D
7 (D)
Pect oralis Supra-
minor spinat us Subclavius
Clavicular p'"
Clavicle
>-----:;--- - - - Costa l
cart ilage
- - - -- - Sternum
\:7J!i!lCL--~~\-,-t-+-f----"!----J--+-------'------- Serratu s
~~: ~
ante rior
Biceps
brachii
{ Short - ---lifihf!f!-+ k - .
head
Pectorali s major.
ste rnocosta l part (0)
Lateral -
Medial
265
Anterior Muscles of the Shoulder & Arm (II)
Pect orali s
min or (l)
Coraco Coraco
brachialis brachialis
lon g long
head head
Com mo n head
of flexor s (0)
Brachialis Brachialis
- 7 . 7 - - -- Bicipit al - - - - - - Bicipita l
apon eurosis aponeurosis
A Removed: Thoracic skeleto n. Partially removed: Lat issim us dorsi and B Removed: Latissimus dorsi and serratu s anterior.
serrat us ante rior.
266
Deltoid
Biceps brachii,
Biceps brachii, Subclavius Serratus
short head (0)
shor t head. anterior
and coracobrachialis
Supra
Supra
spinatus (I)
spinat us
Intertub er
cular groove
Lati ssimus - -+-iH l-S
dorsi (I)
Latissimus - -e--
dorsi
Biceps
brachii,
Teres major -----I~
long head
Pectoral is
Pector alis
major
major (I)
. r;t;ii+'f.~---- Brachialis
Brachioradialis - - - -7
Extensor carpi
radialis longus ~
'------ - Brachialis
C Removed: Subscapularis and supraspinatus muscles. Partially removed: D Removed: Biceps brachil, coracobrachialis. and teres major.
Biceps brachii.
267
Posterior Muscles of the Shoulder & Arm (I)
Splenius
capiti s
Descend ing - - ---''---------',+ 'co '
part
Trapezius Transverse
part
---- --- - -==:-
- - - Scapular spine
Ascendi ng _ _ --".,---~L-_
part
Teres majo r
Triceps
brach ii
Olecranon
Thoraco lumbar .
fascia ______ L....!!........l~~- Flexor
carpi ulnaris
/
Ext enso r
carpi uln aris
Ext ensor
dig itorum
268
Superior - -----=--'---'-7:;;;;;;:>" ....~
nuchal line
--'~!-- Sterno cleid o
masto id
Splenius capiti s
Levato r scapulae
Rhomboid major
Acrom ion
Trapezius Supraspinatus
(cut)
Scapular spine
Teres mi nor
Teres major
Serrat us
posteri or inf erior
,
I
/ ,
B Deep di ssecti on. Partially removed: Trape Thoracolu mb ar Int ernal
zius and lati ssimu s do rsi. fascia oblique
269
Posterior Muscles of the Shoulder & Arm (II)
t;~~~;;~~~~~~l Deltoi d,
spinal part (0)
Teres m ino r
Infra
spinat us
Teres
m inor
Teres major
Triceps
Triceps brach ii, brachii, Triceps brachii.
lo ng head lat eral head long head
A Removed: Rhomb oid s maj or and m in or, B Removed: Deltoid and forearm mu scles.
serrat us ante rior, and levat or scapulae.
270
Supra Levator Supra
spinatus (0) Rhombo id scapulae spinat us Trapezius
m inor Delto id,
clavicular part
Supra Supra
spinatus (I) spinat us
Infra Infra
spinat us (I) spinatus
Teres
Teres
m inor (l )
m inor
Delt oid,
spinal part
Triceps Triceps
brachii, brachi i,
latera l head lat eral head
Teres major
Teres m ajor Deltoid (I) Delt oid
,,-"1!:--"! - - Triceps
brachi i,
lat eral head
(cut edge)
Common head - - -
of exte nsors
Triceps brachii
Anconeus ----'------'~--':-
C Removed: Su pra sp inatus, infra spi natus, an d t er e s min or. Partially D Removed: Tri cep s b rach ii and teres m ajor.
removed: Triceps b rac h ii.
271
Muscle Facts (I)
~ The actions of the three parts of the deltoid muscle depend on but at greater than 60 degrees, they act as abductors. As a result, the
a.iiIII their relationship to the position of the humerus and its axis of parts of the deltoid can act antagonistically as wellas synergistically.
motion. At less than 60 degrees, the muscles act as adducto rs,
Acromion
Fig. 19.23 Deltoid
Rig ht shoulder.
Clavicle
r"""""JC:::'.....,------ Delto id
(clavicular
part)
Scapula
A Parts of t he deltoid, right lateral view. B Right lateral view. Shaft of Deltoid
hum erus t uberosit y
Deltoid
Delto id
(spinal
-w-r-r-i-r-r- Scapula. part)
costal Scapula, -~~~. .~i\~
posterior
surface
surface
Deltoid
tu berosity
E - - Delt oid
Shaft of - t uberosity
hum erus --'+ - Shaft of
humerus
~ Q) Clavicular part : Lateral one t hird of clavicle : Flexion, internal rotati on, adduct ion
: Deltoid : @ Acrom ial part : Acromion : Humerus (delto id t uberosit y) ' Axillary n. (C5. C6)
272
Fig. 19.24 Rotator cuff
Right sho ulder. The rot ator cuff consist s of fou r mu scles: supraspinatus.
infraspinatu s. teres m inor. and subscapularis.
Acrom ion
Supra-
lI'" / spinat us
~ -. - Coracoid
process
Great er
t uberosity
Infra Subscap
spinat us ularis
A Posterior view. B Ant erior view.
Teres ------1~+-
Scapular Supra- Superior
Acrom ion not ch spinat us bord er m inor
Greater
Lateral --'Ii-'\-~
tu berosity
~ bor der
Lesser _--'----~~
tu berosit y
Intertuber
Inferior
cular groove
angle
Crest of lesser
- - --'-
tubero sity
Teres Shaft of
min or hum erus
E Posterior view.
. G) Teres m inor Lateral border : Axill ary n. (C5. C6) External rota tio n. w eak adduct ion
..... ... ...... ....... ..... .......... ..... ..
: @) Subscapularis Subscapular fossa . Lesser tu berosit y : Subscapular n. (C5. C6) : Internal rotation
... .. ,,,', - . ...... .:
: .
273
Muscle Facts (II)
Coracoid
process - - - ---'
ii~~~~~~~~:=.,----;~=: Pectorali
major s
(sternocostal
part)
Pectoralismajor ---~--7---t-Ik----¥''''''~
(abdominal part)
Clavicular --:-7li~"-""
part
Sternocostal
part
Abdominal
--~-11'
part
C Pectora lis major and coracobrach ialis.
, ~) Clavicu larpart ....•. ~ lav icl~ (lTl e~ ia l ha l~ . • Entire muscle: adduction, internal
• Medialand lateral : rotation
: Pectoralis major •.C?J St erno cost~ 1 pa rt H~t e.r~~rTl a.~~ H~o. s.t a.I ~ a.~~i la.~e s l ~6 H ~Uub::~~xr e st of greater • pectoral nn. • Clavicularand sternocostal parts:
• (C5-Tl) • flexion; assist in respiration when
• (}) Abdomi nal part : Rectussheath (anterior layer)
: shoulder is fixed
............................................... ............................................................. ........................... . .
Coracoid
process
Subclaviu s
A Schematic.
Pectorali s -----'--~---~-:?i'-''''''~~~~~~~~
minor
3rd ~--~r--+-~~~~~---f
through
Fig. 19.27 Serratus anterior 5th ribs
Right lateral view .
Coracoid
pro cess
Acrom ion
-==-----\-7- 1st rib
Glenoid
B Subclavius and pecto
cavit y
ralis minor.
Inferior -
angie
9t h rib
CD Subclavius 1st rib Clavicle (inferior surface) N. to subclavius (C5, C6) Steadies the clavicle in the sternoclavicular joint
Nuchal ligament
'-'liI- - - Trapezius
(descending part)
Trapezius
(t ransverse part)
+-L...~;Nr---l;-\ll-- Trapezius
(ascending
part)
C1 (atlas)_~~~JI'
C2 (axis) JA~...~;n:'f>- C1-C4
tr ansverse processes
Levator scapulae
A Trap ezius.
Rhomboid m inor
T12 spinous
proce ss
Fig. 19.29 Levator scapulae with C7 spinous _~--+
process
rhomboids major and minor
Acro mion
Rig ht side , poste rior view.
T1 -T4 1~;;; ,,~I , <c~~ - =.,,-~- Scapular
spinous spine
pro cesses
~ \----¥-T--'~;_i"- Medial
Rhomboid ~ bord er
major
~~-I---+-"- Scapula,
posterior
surface
'---'.l.~---__- Inferior
angle
Q) Descending Occipital bone; spinous Draws scapula obliquely upward; rotates glenoi d cavity
Clavicle (lateral one third)
part process of C1-0 superiorly; til ts head to same side and rot ates it to opposite
Accessory n.
Trapezius
o Transverse Apone uro sis at T1- T4
Acromion (CN X); cervical Draws scapula medially
part spino us processes
plexus (C3-C4)
Q) Ascending Spinou s process of Draw s scapula media lly downward
Scapular spine
part T5- T12 Entire m uscle: steadies scapula on thora x
Transverse process of Draws scapula media lly upwa rd w hile moving inferior ang le
o Levator scapulae C1-C4
Scapula (supe rio r angle)
medially; inclines neck to same side
Dorsal scapular
® Rho mboid m inor Spino us process of C6. C7 Med ial bo rder of scapula n. ((4 -(5)
Spinous process ofT 1- T4 above (mi nor) and below Steadies scapula; draws scapula media lly upwa rd
® Rhom boid major (majo r) scapular spine
~ vertebrae
CN = cranial nerve.
Fig. 19.30 latissimus dorsi and teres major
Post erior view .
Scapula
Teres majo r
'---------!---U_ _ Lati ssim us dor si
(scapular part)
- - - - - T7 spi nous
processes
L- Lati ssimu s dor si
(verte bral part )
-~I---- Ilium
Coracoid
Acrom io n process Clavicle
'G~~~~-L- Scapula,
costa l surface
~ The ant erior and poste rior mu scles of t he arm may be classified part of the anteri or compartm ent , it is f unctiona lly grouped with the
~ respect ively as flexors and exten sors relative to th e move ment of m uscles of the shoulder (see p. 274) .
the elbow jo int. Altho ugh t he coracobrac hialis is topographically
Lesser --~~l
t uberosity
Intert uber- - ----L-l.-+
cular gro ove
Shaf t of
Biceps brachii - ------1r..I.1 humerus
(long head)
A Schemat ic.
Biceps
brachii
Med ial
epicond yle
Lat eral -
epicon dyle
278
Fig. 19.32 Triceps brachii and anconeus
Rig ht ar m, p os t erio r v iew.
Long
head Radial groove
I Greater
tub erosit y
;. ~"""",.-. " r-.I.i:I - - Inf raglenoid Medial head
tub ercle
- .,m - - Shaft of
hum erus D Sche matic.
Anconeus
Triceps brachii
(m edial head)
B Partially removed:
Triceps brachii Triceps brachii Lat er al head o f
(long head) (lateral head)
triceps brachii .
- Shaft of
hum erus
Lat eral
head
Medial head
Medial - Lateral
epicondy le epicondyle
Olecranon Anconeus
Tendo n of
insert ion
Anconeus
Radius
A Tr ice ps b rac hi i and anco neus. C Partiallyremoved:
Long h ead of
tric eps b rac hii.
: Q) Lateral head I :~;~~~r humerus. proximal to radia groove ; ateral interm uscular. , : ,.•: (C6-C8 )
: exte nsion and adducti on
Coron oid
process Radial
Neck of Neck of
radius notch radius
Radial
notch
Shaf t of ulna,
ant erior
----K Posterior
bo rder
Ante rior
surface
Med ia l ~\'
border surface
Int erosseou s
border
Posterior
surface
--< Lateral
surface
Dorsal
Articu lar Head of tu bercle
circum Head of ulna
ference ulna
Styloid process Carpal art icular St yloid process Sty loid proc ess Styloid process
of radius surface of ulna of ulna of radiu s
280
Olecranon
Proxim al -~~-- Olecranon
radiou lnar joint
t Dor sal
Trochlear
not ch
Trochlear
notch
fovea process
Coronoid
Head of
artic ular notc h process
radius
circumf erence
Radial
tub erosit y
t Dorsal
Posterior Radial Ulnar
t
Poste rio r
border border
Ant erior
bord er
Shaft of ulna,
anterior surface
\
\ I,
.- .$., ..".......
Radius \-?
Int erosseous I Ulna
Lateral Ante rior Ant erior membran e Anterior Medial
surface border surface surface surface
Int erosseous
Interosseous
border Art icular St yloid process
m embrane
circumference of ulna
t Dor sal
Head of ulna
Sty loid process Dista l radioulnar Sty loid pro cess Carpal art icular Dist al radioulnar
of radius joint of radi us surface joint
281
ElbowJoint
,§
....,j
Right limb. The elbow consists of three articulations between the humerus,
li; ulna , and radius: the humeroulna r, hurneroradial, and proximal radiou lnar
Q. joints.
:§
Lateral border
Medial
Lateral _________
supracon dylar
supracondylar ~ ridge Medial
ridge supracondylar
Coronoid "-- - - Lateral
Radial fossa ridg e
fossa supracondylar
Lateral _________ Olecranon fossa - - - --<-- ..,;l ridge
Medial
Radial - - - +
tub erosity Radius
Humerus - -- Humerus
Capitellum
Medial
epicondyle Capitellum
Olecran on
Humerou lnar
joint
C M edial vi ew . D Latera l vi ew .
282
Fig. 20.3 M RI of the elbow joint ~ Clinical
Sagittalscc tion.
Assessing elbow injuries
The fat pads between the fibrous capsule and synovial mem brane are
part of the norm al anato my of t he elbow jo int . The anterior pad is most
readily seen on a sagit t al MRI while the poste rior pad is of ten hidde n within
the bony fossa (Fig. 20.3) . With an effusion of the joi nt space, thei nferior
edge of th e anterior pad app ears concave as it get s pushed superiorly by
th e intra- artic ular fl uid. This causest he pad to resemb le t he shape of a
ship's sail, t hus creating a characteristic "sail sign ." The a lig nm ent of t he
prom inences in t he elbow also aids inthe ident ification of fr act ures and
dislocations. · ..
A Posterior view of exte nded elbow : The epicondyles and olecrano n lie in a
st raight line.
Fat pad
.~f---ff:"t:1~-----;:--- Corono id
fossa
(-""","""~,"",,,:-"'---~-- Olecranon
fossa
C Posterior view of flexed elbow : The t w o epicondyles and th e t ip of t he
Olecranon olecranon form an equilateral tr iang le. Fract ures and dislocat ion s alter
bursa t he shape of t he t riang le.
Trochlea
Olecranon
Trochlear
notch
283
Ligaments of the ElbowJoint
Lateral
sup raco ndy lar
ridge
Olecranon - - ---------77
fossa
Medial - Lateral
epicon dy le epicon dy le
Radial
Hum erus
collate ral I.
Olecranon
Medial
epicon dyle
Ulnar collateral I.
(posterior part)
\i I
Ulnar collateral I.
(t ransverse
Lesser tu berosit y. part)
supracondy lar Ulna Coro noid Olecranon
ridge process
B Medial view.
Lateral
epicondy le
Saccifor m
recess Radius
I. of radius radius
'. Proximal •.• Radiu s (art icular .: Ulna (radial
: Annu lar I.
C Lateral view. : radioulnar jo int ! CIrc umference) ; notch ) . nnn n nn . nn n . .. .
284
Fig. 20.6 Joint capsule of the elbow
Right elbow in ext ension, anterior view.
Me dial
epicon dyle
Joint ----~
capsule
Lat eral
epicondy le
Radial
collateral I. Ulnar
collatera l I.
Ann ular I. ------,~-- ;;;;:;,....
of radi us
Radial ----!-'-~ c
ft ·~J-- Ulnar
tub erosit y
tub ero sit y
Radius - - - - Ulna
Radial fossa
Ulnar collateral I.
Coronoid
process
Ulna
285
Radioulnar Joints
~ The proxim al and dista l radiou lnar joint s fu nct ion toge t her to en for pronat ion and supinat ion run s obliquely from th e cente r of th e hu
~ able pron ati on and supinatio n movem ent s of t he hand. The joint s meral capite llum th rough th e cente r of th e radial articular fovea down t o
are fun cti onally linked by t he interosseous membrane. The axis th e sty loid pro cess oft he ulna.
Axis of Olecranon
pronatlonr
supinati on
Radial ~ Trochlear
collateral !. ~ not ch
Corono id
Art icular - ----''= pro cess
fovea
Ulnar Proxima l radio
collateral l. ulnar joi nt
-<1
Ant erior - - - - f ----t- - - Shaft of ulna
border
Inte rosseous
bord er
of ulna "
Interosseous
bord er
of ulna
Interosseous
bor der
of radius
Head of ulna
-...#-J-- Dorsal
Palmar
Head of ulna ---;;~.~;;:.,... tub ercle
radioulnar I.
Styloid process - - - -----".'1
Sty loid process of ulna
Sty loid process of ulna
of radius
286
Fig.20.10 Distal radioulnar joint rotation
~ Clinical
Right forearm, dista l vi ew of articu lar su rfaces of radius and ulna. The dorsal
and pa lma r radi ouln ar ligam ent s st abilize th e di stal rad io ulnar joint.
. Subluxation of the radial head ("nursemaid's elbow") ..
When small children are abrupt ly pulled up by thei r arm. t he im matur e
head of t he radius can dislocate from the annular ligament. resulti ng in
Radius, carpal
painfu l pronation.
art icular surface
- ---J- - Olecranon
Head of radius. Art icular
lunula fovea Dorsal radiouln ar
Sty loid I.
Trochlear process
notch Extensor
of radius Dorsal carpi ulnaris Styloid process
t ubercle tendon of ulna
A Supinati on .
---r-~-----i=----- Ulnar
- ---,1- - Olecranon
not ch
--..L- + - - -----=''--Art icular
Trochlear circumference
notch
Styloid process
of ulna
Annular Radial not ch Coronoid
B Sem ipronation.
I. of ulna process
Radius fracture
Fallsonto the outstretched arm often result in fract uresof th e dist al radius.
In a "Colies'.fractu re." t he dista l fragment is t ilt ed dorsally. Head of ulna
Dorsal -
-
C Pronati on .
Styloid processof
A B radius
287
Muscles of the Forearm (I)
Brachialis
~~I-- Palmaris
longus
Flexor
carpi ulnaris
Flexor - - lHl-'J
Flexo r - --;'r.
pollici s longus
po llicis longus
Abductor
pollici s longus
. il-----='T - Flexor
carpi ulnari s (I)
Abductor
-\l"*~-+--- Palm aris pol licis
longus longus (I)
of in serti on I
+--- -----!rB- --\--2"--- - --' Flexor digi tor um +-----1H!----'~----' Flexor digitorum
profu ndus, tendon s profu ndus
of insert ion tendon s
A Superfi cial f lexor s and radialis group . B Removed: Radialis group (brachioradialis, ext ensor carpi radialis longus,
and ext ensor carpi radialis brevis), flexor carpi radialis, flexor carpi
ulnaris, abdu ct or pollici s longu s, palm aris longu s, and biceps brachii.
288
Brachialis I!!lii! - - - - Brachiali s
Pronator teres.
hum eral head
Pron ator te res.
Extensor carpi ---~ Medial epicondyle.
hum eral head (0)
radialis brevis common
Com mon head of
flexor s (0)
Lateral epicondy le. ~ head of flexor s
com m on head of
exte nsors. supinator Flexor digitorum
superficialis.
Flexor digito rum ulnar head
superfic ialis.
Pronato r teres.
Biceps brachii (I) --t---~ ulnar head (0 ) Biceps brachii - - ----,D-
ulnar head
Pronator
quadratu s
Brachioradialis --iJ.~::=::;"''''
• •"i-----::r-- - Flexo r
carpi ulnaris
Abductor
po llicis longu s
Flexor
carpi radialis
C Removed: Pronator tere s and flexor digitorum superficialis. D Removed: Brachialis, supinator. pronator quadratus. and deep flexors.
289
I Muscles of the Forearm (II)
Medial ------'
Olecrano n
Exte nsor carpi epicondyle. Extensor carpi
radialis brevis com mo n radialis longus
head of flexor s (0)
Anconeu s Extensor carpi Anconeus (0 and I) Extensor carpi
radialis long us radialis brevis
Exte nsor
Extensor polli cis brevis
polli cis brevis Ext ensor
indicis
I H-Hc'J,-- - Dorsal
tubercle
A Superficial extensors and radia lis group. B Removed: Triceps brachii, anconeus, flexor carpi ulnaris,extensor carpi
ulnaris, and extensordigitorum .
290
Brachioradia lis (0) Brachioradialis
Extensor carpi
radialis longus
digitorum digitoru m
Flexor - - -- - f--o":
carpi ulnaris
Pronat or t eres
---.~-- Abduct or
pollicis longus
--~--- Interosseous
membrane
Brachioradialis (I) Brachioradialis
:';-- - - Dorsal
tu bercle
Abductor Abducto r
poll icis longus (I) pollicis longus
Extensor carpi -----.f--;~rl-----l e-~ ......- - Ext ensor carpi Exte nsor carpi -----.~"..__t---llr.... R'--~--"o:-- Extensor carpi
radialis brevis (I) radialis longus (I) radialis brevis radialis longus
Ext ensor
polli cis brevis
C Removed: Ab d uc tor po ll icis lo n g us, ex t ens o r p ol lici s lon g u s, and rad ia o Removed: Flexor digito r u m profu ndus, su p inato r, ex t enso r p o llicis
lis group. brev is, and ex t enso r indici s.
291
Muscle Facts (I)
;
,
A Superficial. C Deep.
B Intermediate.
· Superficial group
· Intermediat e group
: Elbow: weak flexor ..
: Hum eral head: media l epicondyle Sides of m iddle phalanges of
: ® Flexor digitorum superficia lis : Ulnar head: coro noid process : Median n, (C8. T1) : Wr ist. MCP. and PIPjoi nts of 2nd to
2nd to 5th digits
! 5th digits: flexion
· Deep group
: Dist al quarter of ulna (anterior : Dista l qua rter of radi us : Hand: pronat ion
: ® Pronator quad ratus : surface) : (anterior surface) : Distal radioulna r joint: stabilization
: DIP = dista l inte rpha langeal; IP = interphalangeal; MCP = metacarpopha langeal; PIP = proxima l inte rpha langeal.
... ................................. .............................
Fig.20.14 Superficial and intermediate groups Fig.20.15 Deep group
Right forearm , anter ior view. Right forearm, anter ior view.
Iv
<:>
!:!!
0
- - - Medial 0
epicondy le s
(common ~
head of Cor ono id (;1
flexo rs) process tilQ
§
Radial Radial
Ulnar
t ube rosit y t uberosity
tuberosity
Pronator
teres Int erosseous
Palmaris
m emb rane
long us
Flexor
carpi
Flexor
radialis
carpi
ulnaris
Flexor
digit orum
pro fundus
Flexor pollicis
longu s
Flexor
digitorum
superf icialis
Pro nator
quadratus
Base of 2nd Pisiform bon e
metacarpal Tubercle of
Hook of t rapezium
hamat e Pisiform
bone
Base of 5t h
m eta carpal
Palmar
apo neurosis
If ~it---TlHl-1.t-~1F:t-----:>---'I--'''''----- 2nd
t hrough 1st distal
5t h m idd le phalanx, base
phalanges
293
Muscle Facts (II)
)
/
: Distal humerus(distal surface), lateral : Sty loid processof the radius ! Radial n. (C5.C6) : Elbow: flexion
: CD Brachioradialis
: intermuscular septum : Forearm: semipronation
: Lateral supracondylar ridge of distal
: 0 Extensor carpi radialis longus . h ! 2nd metacarpal (base) ! Radial n. (C6. 0) .!. Elbow'.weakflexion
! umerus,lateral intermuscular septum
.... . ,.................................................................... . ! Wrist: extensio n andabduction
! ill Extensor carpi radialis brevis : Lateral epicondyle of humerus : 3rd metacarpal (base) ! Rad ial n. (C7, C8)
Fig. 20.17 Radialis muscles ofthe forearm
Right forearm.
Humerus - - -
,rjL ~a--- Hum erus
Brachioradia lis
Olecranon
Extensor carpi
radiali s long us
radiali s brevi s
-1-++- - - Radius
1- - - - Brachioradialis,
te ndo n of
insert ion
Baseof 3rd - - -. /
metacarpal I ~Hl.Rc------",c---- Baseof 2nd
metacarpa l Baseof 3rd -------j~__4'~+._:...,. Baseof 2nd
metaca rpa l metaca rp al
-I----T-~-'-:--- 2nd
me tacarpa l
3rd
met acarp al
B Posterior view.
295
Muscle Facts (III)
e-+--- @
•~--,;--- CD
, Deep group
, Ulna (poste rior surface) and • Posterior digital extension of i Wrist: extens ion
: ® Extensor indicis
! interosseo us membrane • 2nd digit : MCP,PIP, and DIPof 2nd dig it: extens ion
, DIP = distal interphalangeal; IP = interphalangeal: MCP ~ metacarpophalangea l: PIP = prox ima l interpha langeal.
296
Fig.20.20 Muscles of the posterior forearm
Right forea rm , posterior view.
---'-1- - - Radiu s
~Hl-- Abdu ct or
pollicis longus
Extensor ---~,....
ind icis
Base of 1st
Base of 5th m et acarpal
m et acarpal
5t h proxim al
phalanx, 2nd -----:-----7--f-i--f-+~,....
base meta
carpal
r-"---.l!-+-:::->----[-;;-;--r----F,;1--l!---~,.,..___+-- Dor sal
digit al
expansio n,
int ert endi
nous con
nect ions 1st dista l
phalanx,
base
Phalanges '
2nd distal phalanx -
Meta
carpals
I Carpal
bones
and hand
Metacarpal
Triquetru m
Lunate
Styloid process
of radius Styloidprocess
of ulna
298
Fig. 27.3 Radiograph of the wrist
Antero pos te rior v iew of lef t lim b.
I
Tuberosit yof - - Hook of
distal phalanx
hamate
Capita te Pisiform
Scaphoid
Triqu etrum
Head
Mid dle
Shaft phalanx
Lunate
Base
~ Clinical
Scaphoid Fractures
Scaphoid fr act ures are the most com mon
carpal bo ne fractures. gener ally occurring at
the narrow ed w aist between t he pro ximal
and dist al poles (A. right scapho id) . Because
blood supply to th e scaphoid is t ransm itted
via th e distal segment, fractures at the waist
can comp rom ise t he sup ply to th e proxima l
segme nt, of t en result ing in nonunion and
~-!!------ Sesam oid avascular necrosis.
bon es
Meta Distal
Shaft
carpal
t
Trapezoid
trap ezium
Lunate
Tubercle of
scaphoid
St yloid
Ulna
of radiu s
{ Head
- -f-- - Radius
299
Joints of the Wrist & Hand
~'""'-- Proxima l
int erphalangeal
joint
phalangeal
joint of
thumb -r~l/f--- Met acarpo
phalangeal Tuberosit y of -
joint distal phalanx T - - - Distal
phalanx
Met acarpo
phalangeal
joint of
t humb
Middl e
phalanx
Carpom etacarpal
joints
Mid carpal
Carpom etacarpal joint
Proximal
joint of thumb
phalanx
1Il!!~~~...[iI:~'1'l Ra diocarpal
Ii join t
Dist al
radtou lna' 1st - - -\
joint Head
proxima l
phalanx
Meta
Shaft
A Jo int s of th e wri st and han d . Right hand, carpal
1 s t ---~
pos t erior (dorsa l) view. m etacarpal
Base
Trapezoid
Trapezium --8-_
Capitat e
,r'!f--- - - Lunat e
Radius Ulna
B Carpom etaca rpa l join t of the th umb. Radia l vi ew. Th e 1st metac arpal
b one ha s bee n m oved slig h t ly d ista lly to exp o se t he articu lar sur face
o f the t rap eziu m. Two car d inal axes o f moti on are sho wn here:
C Rad iograph of wri st. Radia l v iew. (a) f lexion / exten sio n and (b) abduction/adduction .
300
Fig. 21.5 Wrist and hand: Coronal section
Right hand.
I n''''''~------if-',----;i-t-- Dist al interphalangeal
joint
Dist al
phalanx
Middle
'r \-c\----I--+--+++-- - n-=''T- - Proximal
phalanx
int erphalangeal
jo int
-'iliic''1<Tm--';>--- Interosseous
m embr ane
A Joint s of th e w rist and hand.
Midd le phalanx -
Collate ral
lig aments
Proxim al ~
phalanx
- - - Metacar pophalangeal
jo int
Carpometaca rpal
Interosseous
m et acarpal ligament joi nt
Trapezoid Hamate
Triquetru m
Capitate
301
ligaments of the Wrist & Hand
~
~
Distal interphalangeal
joint (collateral II.)
I ~-r--+t- Proxim al
interphalangeal
L-,'I"l--#--i\llr -- DorsaI
Dorsal carpo metacarpal II.
metacarpal II.
Dorsal ------'.;~r~----~_...:
Ulnar carpal
intercarpal II.
collatera l I. -t-'-- +- Palmar II.
Radial carpal
Proximal -~::-i-~"'"
collate ral I.
Dor sal inte r
geal joi nt
capsule
Dor sal
radiou lnar I.
Deep - - - -'!'r- r- JI
tr ansverse
metaca rpal II.
Metacarpo
A Post erior (dorsal) view.
phalangeal
joi nt capsule
Palma r ----:~'\--+_\",.t.
metacarpal II.
~'='c'-7-.~- Palmar
Palmar --r-"'--l'~- carporneta
interca rpal II. carpaili.
ulnocarpal I.
Palmar
radioca rpal I.
Palma r
radioulnar I.
302
Fig. 21.7 ligaments ofthe carpal tunnel
Right hand , anterio r view.
l\J
-..
Hookof --+.--T..£~
hamat e
Pisiform - ---¥.'l.---
bon e
Carpal Tubercle of
t unnel trap ezium
ent rance
- --1f-- - Radius
Ulna ------;!---
A Carpal tunn el and flexor reti naculu m . Ulnar { Hook of .. ;:""'"'7--"",,-- Carpometacarpal jo int
carpal hamate of t he t humb
em inence Pisiform - ----.ll - ~;7--- Flexor ret inaculum
(tran sverse carpal l.)
Triq uet rum
Radial
Tubercle of t rapezium carpal
Lunate }
Tubercle of scaphoid em inence
Pisiforrn .;1::, \
~.r, i.~. ; ".
.. ~ . ·~:~. .·\2
. .. ,
/
.--------
Carpal t un nel
_ /
/
Passage fo r
flexor carpi
radialis t endon
(considered
part of t he
..1.
.. i '. L
Carpal t un nel
carpal t unnel)
Trapezoid
303
ligaments of the Fingers
AS C3 A4 C2 A3 Cl
- - - Meta
carpal
bon e
Accessory
Al collatera l I.
Flexor
tendo n tendon
Deep
tra nsverse
metaca rpal I.
Palm ar I.
Flexor Flexor
dig itoru m digitorum
profundus te ndon Annular I. superfi cialis
(Al) te ndon
Metacarpal
bone ~
Flexor - - ----i+ -+_
digitorum
superf icialis
tendon
Flexor digitorum
profundu s tendo n
~5~~t::::;:~~~- Palm ar I.
~~;':::;=--e:§~;';;;;;::::;;-- Flexor digitorum
profundus tendon
305
Muscles of the Hand: Superficial & Middle layers
fascicles
mini m i
Palmaris Flexor
longu s polllcis
te ndo n longus
tendon
306
~ Clinical
-
Tendon sheath commu nication
I\J
The digital tendon sheath of t he th umb is •
conti nuous wit h the carpal t endon sheath
of thepollicis longus. The remaining fingers
show variable commu nicat ion wit h t he carpal
tendon sheaths (A is t he most comm on
variat ion). Infecti ons wit hin t he.tendon
sheaths from punct ure wounds of t he f ingers
can tr ack proximally to comm unicating spaces
of th e hand.
Deep
tra nsverse 1st dor sal
metacarpal I. int erosseus
Adductor pollicis
(t ransverse head)
Lumbricals
Adductor pollicis
(obliqu e head)
Flexor po llicis
A B c
brevis (super
Opp onens ficial head)
digit i minimi
Flexor Abductor
digit i minim i pollicis brevis
Abductor
pollicis
longus
Flexor pollicis
longus tendon
Flexor digitorum
superficialis
C Superficia l muscles of th e han d . tendon s
Removed: Ten do n sheaths.
Flexor digito rum
prof undus t endons -~tl..~~~~~I~.\~i-"1J.\J-
Opponens pollicis
"""';n;or-- - Flexor pollicis br evis
Flexor digiti minimi (superf icial head)
307
Muscles of the Hand: Middle & Deep Layers
I
I'
Flexor polli cis
longus tend on
Flexor
Adducto r po llici s
dig itoru m
(tran sverse head)
superficialis
~
Flexor pollicis
Abduc to r - brevis
digiti mini m i
. -~/J Abd ~ctor pollieis
Flexor ' / brevis
digit i m inimi
308
Fig. 21.15 Origins and insertions
Righ t hand. Muscle origins show n in red,
insert ions in blu e.
Extensor - - - - -----,.:IL Ext ensor
-
l\J
Extensor
dig ito rum
Palmar and
do rsal
inte rossei
Extensor
polli cis longus
Extensor
pollicis brevis
Adducto r
Dorsal intero ssei
pollicis
Abducto r Extensor
pollicis longus carpi ulnaris
pro fundus
Abducto r
digit i mi nimi
309
Dorsum of the Hand
Fig. 21.16 Extensor retinaculum and dorsal carpal Fig.21.17 Muscles and tendons ofthe dorsum
Dorsal carpal
t endon
sheaths
0 - - -+-... ·
~~,.
Extensor
retinac ulum
Extensor
Dorsal digitorum
t ubercle Extensor
carpi ulnaris
Exten sor
digiti minim i
Ext ensor
A Po st erio r (dorsal) view. pollicis brevis
Dorsal compartments
for extensor tendons Exte nsor Extensor
polli cis Ext ensor dig iti
Abductor poll icis longu s longus indicis m inimi
Dor sal t uber cle
~
Extensor pollicis brevis
Ext ensor carpi radiali s brevis \
Extensor carpi radialis "-J lf:-- .JJN
Extensor carpi radialis brevis Extenso r carpi radia lis lon gu s - --.,<')) ....
310
Fig.21.18 Dorsal digital expansion
Right hand, midd le fin g er. Th e d or sal d ig ita l ex pansio n perm it s th e lon g
di gita l flexors and th e short m uscles of t he hand t o act o n all three finge r
-
I\J
j o int s.
Distal
phalanx
Lateral --f'-+."'-'
bands
Extensor
Cent ral slip - -----!---'--i digitorum t endon
Lumbrical slip
t Dorsal t
I 3rd metacarpal
~
~
\ .i-> 3rd dorsal interosseus
Collateral II.
»>: (fibersattac hed to
extensor tendon)
I 3rd dorsalinterosseus
J (fibersattached
2nd
to bone)
lumbrical
Deep transverse - "':r =t-- Deep transverse
~
rnetacarpal l. metacarpal I.
, ,p
~ Annular I. (A1)
2nd lumbrical
Flexor Flexor
digitorum digitorum
metacarpal tendon
A Posterio r view. B Cro ss sect io n t h ro ug h 3rd m etacarpa l head , pro xima l v iew.
PT ~
Distal Extensor jo int joint longum metacarpal I.
digit orum
tendon
~.. . ........ I
Vincula Flexor
311
Muscle Facts (I)
~ The in trinsic muscles of the hand are divided into three groups: The thenar muscles are resp onsible fo r movement of the thumb. wh ile
a.iiiiII the thenar. hypothenar. and metacarpal mu scles (see p. 3 14). the hypothenar muscle s m ov e the 5t h d ig it.
Thenar muscles
M uscle Origin Insertion Innervation Action
: <D Adductor pollicis U~~ lm~ r. . s. ~.r f~.~e ) . : Via the ulnar
Ulnar n.
CMCjoint of thum b: adduction
: Oblique head: capitate bone. : sesamoid MCPjoint of thumb: flexion
! 2nd and 3rd metacarpals (bases)
................................................. . : Thumb (base .............. ....................................... ....... ..... ..... .......
. :.' Scaphoid bone and tr apezium , .
; G)Abducto r pollicis brevis : of proximal : Median n. : CMCjoint of thu mb: abduction
: flexor reti naculum
...... .. .. ....... ..... .: phalanx) .................. ..... . .... .. ............ C8. Tl
...~ OP.~.o. nens.P.o. IU.~i S. . : Trapezium First metacarpal (radial border) ! Median n. : CMCjoin t ofthumb: opposition
Hypothenar muscles
M uscle Origin Insert ion Innervatio n Action
312
Fig. 21.20 Thenar and hypothenar muscles
Righ t hand . palmar (ant erior ) view.
5th proximal
phalanx
1st proximal
phalanx
digit i minimi
Abducto r
Opponens --~~~ pollicis brevis
digiti minimi
Hook of
hamate
-~~~---..::l~-- Capitate
Pisiform - - --. .
Trapezium
Scaphoid
5th
proximal
phalanx 1 st
proximal
phalanx
R"-~~-- Flexor
pollicis
brevis
Hook of _+~,-""I,-"!,-",,,,=~"" ~ o p po n en s
hamate pollicls
.-.r--_ Capitate
Trapezium
313
Muscle Facts (II)
~ The metacarpa l mu scle s of the hand con sist of the lu m br ical s and
~ int ero ssei. They are resp o nsib le for th e movement of the digits
(with the hypoth enars, which act on the 5th digit) .
1314
Fig. 21.24 Metacarpal muscles
Right ha nd . palmar (a nte rior) view.
1st lumbrical
2nd lumbrical
2nd palmar
interosseus
3rd palmar
interosseus
2nd thro ug h
5th metacarpals
315
Arteries of the Upper limb
Thyrocervical
Brachiocephalic --,---'ozz;~~7.IT-:"::=,,",::' ~
t runk t runk
Subclavian a.
Axillary a. -~-5-~
Common carot id a.
_II
t horacic a.
Radial
collater al'; :
Middle
collate ral a.
~
Radial
A M ai n art eria l seg me nt s.
recurren t a.
Ulnar a.
Superficia l -~~~~~r;
palmar branch
(radial a.) Deep palmar arch
Superficial palm ar arch
Commo n palma r
digit al aa.
B Co u rse o f t h e arteries.
316
Fig. 22.2 Branches of the subclavian artery Fig. 22.3 Scapular arcade
Right side, ant erior view. Right side, poste rior view .
Ascendi ng Vertebra l a.
cerv ical a.
Subclavian a.
Supe rficia l cerv ical a. Thyro
Sup rascapular a.
(sup erficial branch) cerv ical
t runk
Dorsal scapular a.
(d eep branch) Transverse _ _ -§--Y
Acrom ial
cervic al a. br anches
Transverse
cervica l a. Axillarya .
Inferior Ant erio r
th yroid a. Circum flex --.JI--7------,::>""'.L:-=::::::~ circumflex
scapular a. hu me ral a.
Com mo n
,, ".-.a!'i~-- Posterior
carot id a. circum flex
Dorsa l
scapular a. humeral a.
Supra Thyroce rv icaI
scapular a. t runk Subscapular a.
Profunda
Axil larya. Cost ocervical
br achii a.
t runk
Subclavian a. Brach ial a.
Clavicle
1st rib
cost al a. t horacic a.
Ant erior intero sseo us a. - " '--71 Posterior -+----'1:--~-'-I- Ant erior
int ero sseou s a. intero sseous a.
Ulnar a.
Dorsal Palmar
Posterior Radial a. Radial a.
inte rosseous a. Int erosseous
membrane
Do rsal
dig it al aa.
A Righ lilliddle finger , lateral view . B Ante rior (palmar) view . C Posterior (dorsal) view .
317
Veins & Lymphatics of the Upper Limb
Fig. 22.5 Veins of the upper limb Fig. 22.6 Veins ofthe dorsum
Rig ht lim b, an te rio r view. Rig ht hand , p o st eri or view.
gro ove
Axillar y v. - --i- - h r
I'-.Jf-- - Cephalic v.
Thoraco - - -7---'-----,H - --!
Cephalic v. - - ---.--1 epigast ric v.
Median
- -- +-!----=-:' . A'c------'c-+- - Dorsal digita l vv.
cub ita l v.
Perforatorw.
Basilic v.
Median
Cephalic v. cephalic v. Cephalic v.
jf-~- Median
" ....'9--\-f- Median
cubita l v. cubital v.
I/;-- -\-- Deep Accessory
H H - Median
ant e- cubital v. Median
basilic v.
brachial v. cephalic v.
Cephalic v. Basilic v.
Basilic v. II---F--+-- Median
antebrachial v.
A M- shaped . B Acc essory cep ha lic ve in . C Absent m edi an cub ita l vein.
318
~ Lymph from the upper lim b and br east drains to t he axil lar y lymph subcutaneous ti ssue, w hi le t he deep lym phat ics accompa ny t he art eries
~ nodes. The superficial lymp hati cs of the upper lim b lie in th e and deep veins . Numerous anast o m oses exist bet ween t he two system s.
lymph
arm territory
nodes
Dorsomedial
arm territor y
Middle _ --!<V/I'/
arm territory
Radial bundle
territory
Radial bundle Ulnar bundle
territory territory
f)f-fc+f - MiddIe
forearm
territ ory
Radial group
of lymphati cs
Ulnar group
of lymphat ics
I"'--t--T-;i--- Dorsa I
descending
A Anterior vi ew . lymphati cs B Posterior view.
Fig. 22.9 l ymphat ic drainage of the hand Fig. 22.10 Axillary lymph nodes
Right hand , radia l view. Most of the hand drai ns to the axillary nod es Right side, anterior view. The axi llary lymp h nodes are divided into t hr ee
via cubita l nodes. However, t he t humb, inde x fi ng er, and dorsum of t he
hand drain directly.
l.evel l t evel l
\~
J
the palmar to dorsal side
Right
lymphati c
duct
Radial
bundle
territory - -----'--- Level III
Radial group of
lymphatics
Pectoralis
minor
319
Nerves of the Brachial Plexus
~ A lmost all m uscles in t he upper lim b are inn ervated by t he t hree trunks, six div ision s (three anter ior and t h ree po steri or) , and t hree
~ br ach ial plexu s, w hic h arises fro m spi na l co rd segm ent s ( 5 t o T 1. co rds. The inf raclavicu lar pa rt of t he b rach ial p lexus co nsist s o f shor t
The ante rio r ram i of t he sp inal nerv es give of f direct b ranches br an ch es t hat arise dir ectly fr o m th e cord s and lon g (term ina l) bran ch es
(sup raclavi cul ar part of th e br ach ial p lexu s) and m erg e to form th at traver se the limb.
Dorsal scapular n.
Nervesof the brachial plexus
Suprasca pular n. C5
Posterior Supraclavicularpart
cord
Lateral cord · Direct branches from the anterior rami or plexus trunks
. ...... ..... ...... .................... ...................... ..... .•.••.•••• .• ..•.... ... . .. . .. . . . . . ..• . .
Phrenic n.
•
: Infraclavicular part
: Suprascapular n.
.............................................. .......................... ........... .....:
: N. to th e subclavius
...................................... ..........................................., : -
: Long t horacic n.
' C5-C6 '
: C5-C7
:
; C4- C6
:
N. to th e
Axillary n. _-"--\c---:t9~'ll,r I subclavius
Long
thor acic n.
Musculo
cutaneous n.
: C6-C7
Medial brachial : : ~
cutaneous n. : Medial
, .root
Medial and : - : .
Rad ial n/
/
Radial n. - - - "'S
Deep
branch
Tho raco
dorsal n.
•
; cord ; cutaneous n.
.... .... .............................
• Medial brachial
; cutaneous n.
.......................
• Ulnar n.
. ...... ..........,
•cz-r:
.
Superficial
: yp p~r s~ b<;c~ p ~ larn . • C5-C6. H
_
branch
: Thoracodorsal n. : C6- C8
·
_
• •
...., ..,
: Posterior
; cord
:
:
:
H · H H
• C5- T1
.
.. ,•,.
.....
320
Fig. 22.11 Brachial plexus
Right side, ant erior view.
Ant erior
(vent ral)
rami
divisions
Axillary n. - - - -I
Musculo- -~~r.JIVi
_rs~~--- (5 spinal n.
cut aneous n.
Radial n. - Median n.
r.l--I!- Midd le scalene -------i~.• Phrenic n.
Anter io r scalene
A Structure oft he brachial plexus. Upper tru nk
Midd le t runk
'---'~-- Tl spinal n.
Int erscalene space
Commo n carot id a.
Subclavian a.
Lateral
cord
Subscapular n. -----,-.;----'~~---..llMo--'
Medial
cord
r~ . .......::!~ _ _~~_ _=~,,---- Long t horacic n.
Axillary a. - ----I- i-----lb--H
Axillary n. ---~~!--~
"------ -----"''=. - - - -- 'k - - Int ercostobra chial n.
Posterior - - -..----1:f!---- ,
circumflex
hum eral a. ~----~~---..:;:-!------ Medial brachial
Musculo ---i-'::'~"----L cut aneous n.
cuta neous n.
------"'~;;;:-::-::~--~I----- Medial pect oral n.
Radial n. ----+~'-S'1_
321
Supraclavicular Branches & Posterior Cord
Fig. 22 .12 Supraclavicular branches ~ The supraclavic u lar b ran ch es of the br achi al plexus arise d irect ly
Rig ht sho u lde r. ~ fr om th e p lexu s ro ots (anteri o r rami of t he spina l n erves) o r f rom
t he p lexu s t ru nks in t h e lat eral cerv ical t rian g le.
promin ens
~ Scapula.
(C7)
superior ang le
Rhomboid
minor
Suprascapu lar n. in
the scapular not ch
Acromi on
A Dorsal sca p ula r n erve. Po st erio r v iew.
Supra ----4.!!!""'~"...
.,/ Greater
spinat us tuberosit y
Scapular
spine
spinat us
C5 spinal n. ---=-~~)
N. to t he subclavius
B Supra sca pu lar n erve. Posterio r view.
1st rib
Long
Serrat us
thora cic n.
ante rior
Supraclavicular branches
Levator scapulae
Dorsal scapular n. C4-C5
Rhomb oids major and min or
Supraspinatus
Sup rascapular n. C4- C6
9t h rib ---s~:--~""'!!!!'-= Infraspinat us
Subclavius
Nerve to the subclavius C5-C6
Int ercostobr achial nn.
C Long th o raci c n er ve and nerv e to t he su b
Long th oracic n. (5-0 Serratus anterio r
clavius . Rig ht lat eral v iew .
322
Fig.22.13 Posterior cord: Short branches ~ The poste rio r cord gives off th ree shor t branch es
Right sho ulder. ~ (ari sing at th e level of th e plexus cord s) and two
long branch es (te rmi nal nerves, see pp. 324-325).
( 5 spinal n.
Subsca pularis
Upper subscapular n.
Lower subscapular n.
(6 spinal n.
T1 2 spinous - -
process
Branches of the posterior cord
Short branches
Upper subscapular n. Subscapularis Thoraco Iliac crest
323
Posterior Cord: Axillary & Radial Nerves
Superio r
lateral
~
brachial
Fig. 22.15 Axillary nerve
cutaneous n. Right side, ant erior v iew .
(axillary n.)
\ C5 spinal n. ---l-i~~=''''~~ ..
Middle scalene -----"~c l
Phrenic n. - -- -+-f-.\'
Axillary nerve
((5-(6)
M otor branches Innervated mu scles
Deltoid
: Muscular branches
Teres min or
Sensory branch
324
Fig.22.16 Radial nerve: Sensory distribution Fig. 22.17 Radial nerve
Righ t limb, ante rior vie w with fo rearm pr onat ed .
(
\ Post erior
brachial
Posterior cord
cuta neous n.
Axillarya . - - - --to",
( Inferior
latera l
! brachial
cutaneous n.
Posterior
antebrac hial
Posterior brachial - -
cutaneo us n.
/
cuta neo us n.
Inferior lateral -------'>;
brachial cutaneous n.
Triceps --+.'J~-7
brachii
1~i1"---- Brachialis
A An t eri or v iew . B Post erio r vi ew. f :Mr'b''-- - - - Radial n.• deep branch
(in supinat or canal)
Supinator --if+-~
• S u pin.~ to r
: Ext ensor digitorum Dorsal digi t al nn.
Sen so ry b ranch es
Chronic radial nerve comp ression in the axilla (e.q., due to exte ndedj
Inferior lateral brachi al cutan eous n.
improper crutch use) may cause loss of sensatio n or motor func t ion in
Posterior antebrac hial cuta neous n, the hand , forearm. and posterior arm . More distal inju ries (e.g., during
. . •. • .... . .. . . .... •.. ••. •. . •. •••. . . . . . •••. . • ••. . ... ..
anesthesia) affect fewer muscles. pot ent ially result ing in w rist drop with
: Dor sal digital nn.
Superficial branches ............................................................................. ..................
intact t riceps brachii functi on.
: Ulnar comm unicati ng branch
325
Medial & Lateral Cords
~ The medial and lat eral cords give off fo ur short branches. The of t he brachial plexus, alt hough t hey are act ually t he cuta neous
~ int ercostobrachial nerves are included wi t h th e short branches branc hes of t he 2nd and 3rd intercos t al nerves,
Branches of the medialand lateral cords Fig.22.18 Medial and lateral cords: Short branches
Right side, ante rior view.
Nerv e level Cord Innervated muscl e
Short branches
Lateral pect oral n. C5-0 Lateral cord Pect oralis major
Medial pectoral n. C8- Tl Pect oralis major and min or ..-'9ow.~~- Brachial plexus
Lateral cord
Medial brachial (C5-Tl )
Tl Late ral
cuta neous n.
Medial cord pect or al n.
Medial antebrachial - (sensory branches)
C8-Tl
cutaneous n.
intercostobrachial n.
Posterior 2nd and 3rd
ramus inte rcosta l nn.
Medial ante
., ~~_P":n"';;;--;;J-- B
-«
Int ercosto vertebra l
brachial nn. ~ ..... body
/7~
~ A n te r i o r
cutaneous
Anastomosis
with med ial branch of 2nd
brachial int ercost al n.
,""OW", n. ~ Lateral
cutaneous
branch of 4th
int ercost al n.
326
Fig.22.20 Musculocutaneous nerve
Musculocutaneous
Right limb. ante rior view.
nerve ((5-C7)
proc ess co rd
Mu scular br anches : Biceps brachii .
Int ertu bercu lar
groove , Brachi alis
: Sensory branches
lo ng head
Coraco brachialis
Brachialis
Brachialis --~'H-i--BI
Lateral
ante brachial
cut aneous n.
Radius
327
Median & Ulnar Nerves
~ The median nerve is a term inal branch arising from both t he Fig.22.23 Median nerve:
~ medial and lat eral cords. The ulnar nerve arises exclusively from Sensory distribution
th e media l cord.
Axillary a. --~----:-:1
Median n.
{
Medial root
Median n. --~~
1llJEl---'i.-¥.1'---i"....,.----;;.,.--- - Proper palmar Median nerve injury caused by fract ure! Art icular branches: Capsulesof the elbow and
dislocation of the elbow joint may result in ...... ...... .... ..... ... .... ........ ............................. ..... .... ... .. .....•.
compromised grasping abilit y and sensory loss l. r..a. lm ar branch of m~d. i a..~ ~ .(~~~.~ a. r. ~r.n. inence! .
in t he fing e rt ips (se e Fig. 22 .23 for t errit ori e s).
Commu nicating branch to ulnar n.
Seealso carpal tunnel syndrome (p. 343). . .
328
Fig.22.24 Ulnar nerve:
Sensory distribution
Fig.22.25 Ulnar nerve
Right lim b, ante rio r v iew.
Medial cord
Axil lary a.
I \
\
J
Ulnar n. ---~!!--1i
branch
Com mo n
and pro per
palmar Dor sal ---L..---H'+!.
digita l nn. digital nn.
-~ " _ Medial
epicondyle
A A nte rio r view. B Post er ior v iew . Ulnar groove
'..~b?~.c~?~?igiti .~ in.i mi
: Muscular branches
: from deep ulnar n. ' P~'I ~~'; ~ ~'d'd~~;~ I "" "" "-J >i 1,-.1-- - Superficial branch
, interosseous muscles
.... ... -. .•... ... -.., .
Deep branch
: Adductor polli cis 4t h com mo n
.............................
digit al nn.
and metacarpophalangeal joi nts
periphe ral nerve damage. The ulnar nerve
............................................... .... is mo st vulnerable to trau ma or chron ic
: Dorsalbranch (terTTli n~ I b.r.~ n.~h.~~:??r~~ I ? i.9. i~a. I .n.~ .) compres sion in th e elbow joint and ulnar
Palmar branch tunn el (see p. 343 ). Nerve damage causes
"clawin g" of t he hand and atrophy of t he
...r..r?p.~r..p..a.I.f1la.r..? i~ it al .n. ~ . (f.r?f1ls~~erfic i a l.br~ nc~ ) .. interossei. Sensory losses are ofte n lim ite d
: Com mon palmar digit al n. (from superficial branch: to the 5th digit.
. terf1l inalb~a n.~he s:proper ~almar di9.ita l . n.n :) ...
329
Superficial Veins & Nerves of the Upper limb
Fig. 22.26 Cutaneous innervation of the upper limb: Fig. 22.27 Superficial cutaneous veins and nerves
Anterior view of the upper limb
/"( Supra
1 - clavicular nn.
branches
-s:
" /
Supra
clavicular nn.
~
Late ral ta l nn. Superior - - --fH
7~
II K. cut aneous Intercost al nn.,
C4 - --f-
- - - 12
- - 13 I~~--r---- Medial
antebrachial
C5 - -13 cuta neous n.
--------- 13
%--'-'--t1f------ PaImar
aponeurosis
C7
C8
330
Fig. 22.28 Cutaneous innervation of the upper limb:
Posterior view
Superi or
Int ercost o lat eral br achi al
brachial n. cuta neo us n. \ \'-tft--+ - Radia l n.
(axil lary n.)
Medial Media l
brachial _ - Y}- - - Posterior brachial ante brac hial
cuta neo us n. cuta neo us n. cuta neo us n .
(radia l n. )
Mu sculo cu t aneou s n.
.\ J .J"il-- - - Inferior
lat eral brachi al
cu ta neo us n.
~~~~~
(radial n.)
Ulnar n. {
C6
Radial n.,
superf icial
br anch T1
Ulnar n., - - --,f
dorsal branc h
net w or k
331
Posterior Shoulder & Axilla
Trapezius, ---~----4,--
descending part
Suprascap ular a.
(with superior t ransverse
Posterior rami - - - ( scapular ligament )
of spinal nn.,
medi al branches c- -=
..,,;;,:::.,......;;;..:... Sup rascapular n.
(in scapu lar not ch)
Trapezius, ---------~'___""==,;:
t ransverse part
Coracoclavicular
Sup raspinat us
ligam ent
Accessory n. and
bran ches of Scapu lar spine
cerv ical plexus
332
Neurovascular tractsof the scapula
Transmitted
CD , not ch
: scapula
"-"'! ~---+- Inferio r tra nsverse
............. ..... ...... .. .... ....... ... ...... .... ... .. .... ,. . .
scapular ligament
0 : Medial bord er [ Scapula : Dor sal scapular a. and n.
•. . •.•• •. . . . . .. . . . . . . . . . . . . . . •. • •• . .
Q)
j Triang ular
: Teres maj or and mino r ' j Circumflex scapular a.
[ space
...................................
Clavicle
Shoulder j o int
capsule
Infraspinat us ----~~'--o-'3"'"''''
~-=---- Teres m inor
Deltoid
- - -- Triceps brachi i,
Circumflex ---T~""--------,----'.i~ lat eral head
scapular a.
Radial n.,
Teres majo r ----=.---...L....--6'=-c--~-,...-----o'- ~ m uscu lar branches
Profunda brach ii a.
and rad ial n.
(in rad ial groove)
Long
head
Triceps {
br achi i
Lat eral
head
333
Anterior Shoulder
~
Q.
s
Superficia l
Pectoralis - -f"::-+
Clavipectora l
minor
fascia
Pectoralis
major
External
jugular v.
Subclavian v.
Clavipectora l fascia
Tho racoacromia l a.
Biceps brach ii
Brachial fascia ~
Lat issimu s dors i
334
Fig. 22.32 Shoulder: Transverse section
Right sho u ld er, inferior view.
Head of Deltoid
humer us
Subdeltoid
z.:~~~::.-- Pectoralis
1 bur sa
major
..".lIil'-.,;;lilII'''--- - Coracobrachialis
t Anter ior
Axillary a. and v.,
cords of brachial plexus
Subscapularis
Delto id
) - -- -- Ribs
~"'------ Serrat us
anterior
+Posterior
Glenoid
labrum
Rhomboid
major
Thoracoacromial a.
Deltoid
Ext ernal ju gular v.
Subclavian a. and v.
Clavicle
Pector alis major - - -,",
Subclavius
Superior t horacic a.
Median n.
Long t horacic n.
Ulnar n.
Subclaviu s
Long
Deltoid thoracic n.,
superior
thoracic a.
Cepha Iic v. - ----,P --s-c7-''--<
Pectoral is ------..~~~,.,.::....--,=:..
major
'~E~~~~!~=----
!~ Medial
lateral and
pectoral nn.
Median n.
Ulnar n.
~~~..-----=---- Pectoralis
m ajor
Subscapularis
Posterior wa ll Teres major
Latissimu s dorsi Biceps brachii,
Lateral thoracic wall '----- - - - - - - - Serratu s
Medial wall ante rior
Serratus ant erior
___- - - - - - Subscapularis
~--c-::;:-c-:;~--- R i b
~ I------='='
Posterior cord
Scapul a
... 1O . .. .. " .. .. . "
336
Subscapu lar a.
co rd br anches
Axillarya .
Radial n. Medial co rd
Axillary v.
Brachial a.
Upp er subscapular n.
Ulnar n.
Thoracodo rsal
Brachial v.
a. and n.
Posteri or Deltoid
cord
Coraco id
pro cess
Pect or alis
min or
Delt oi d
Upp er subscapular n.
Low er subscapular n.
Radial n.,
mo tor branches
C Removed: Media l and Serratus
lateral cor ds, and axillary Lon g head ante rio r
vessels. Revealed: Poste Triceps brachii
rior cord . Teres majo r
337
Topography of the Brachial & Cubital Regions
Pect oralis
Pectoralis major min or
Axil lary
a. and v.
Medial brach
ial cutan eou s n.
Medial cord
~.----- Medial ante
brachial cuta
neo us n.
Bicipi t al
apon eurosis scapularis
Cubital
fossa
Ulnar n.
Teres
major
Long head
M e~
Triceps brachii
Ulnar n. (in Inferior ulnar Latissimu s Serrat us
ulnar gr oove) collat eral a. dor si anter io r
338
Fig. 22.36 Cubital region
Righ t elb ow, anteri o r v iew .
ti ssue
,-,r- - - Basilic v.
Biceps - - ----cit
cut aneo us n.
Medial
epicondyle
-+---+--'~e--tt--- Median cubita l v.
Median
basilie v.
Cephalic v. ----.-,--\;;H~
Biceps brachii
Median ante- --+-~""~fP-- 1 __ -fl.t-- - Basilic v.
Brachial a.,
brachial v. ...,..- .....
Brachialis median n.
Triceps brachii
Musculocut aneous n.
Brachioradialis -----j~ Superior ulnar
A Cutaneo us neu ro vascu la r st ruc t u res in t he
collate ral a.,
~~~~~I: ~
cubital fo ssa. ulnar n.
. Deep - ---.E----C'
Rad raI n.
j
branch
Superficial -
branch
--i--iil1
+t.-"-': -cH-- - Median n.
Biceps --r-1W'
Medial ant ebrachial brachi i te ndon 1.---" HUmeral )
head Pro -
Superficial fascia cuta neo us n. Radial nator
recurr ent a. Ulnar teres
Ulnar a. head
(m usculo
Perf orator v.
RadiaI a. - -+-1l-H'--++
.r ",,=hI-- Bicipital
radialis longu s
Cephalic v. -~'-"<i~"
Medial ante- ~~.Jo;;;o::U,h.tl
brachial v,
339
Topography of the Forearm
Triceps
brachii
longus
super ficialis
I+ t -"--"'=-- - + - Med ian n. Flexor carpi tendons
radialis tendon
"" 77 - - - Ulnar n. Ulnar a. and n.
(in ulnar t unn el) -~iI-+--- Flexor
retinacul um
~~-- Hypoth enar
'''l:''''~ . . .' muscles '!X,-'~- Hypoth enar
m uscles
A Superficia l layer. Removed: Fasciae and superficia l B Middle layer. Part ially removed: Superficial fl exor s (pronato r
neurovasculature. t eres, f lexor di gitorum superficialis, palmari s longus, and
f le xor car p i radiali s).
340
Fig.22.38 Posterior forearm
Right forea rm, ant erior view du ring pronation. Reflected: Anconeus and
tr iceps brachii. Resected: Exte nsor carpi ulnari s and ext ensor digit orum .
Median n.
Muscular
branches - -+.2r- - Brachialis
Extensor carpi
Radial n. Super ficial Olecranon - - radialis lon gus
branch
;'---+':-- Biceps Arterial
Deep Anco neus - - -i1f--1 net w ork of
branch brachii t endon
elbow and
lat eral
Extensor - - -,--,.-'Ji!-, epico ndyle
carpi ulnaris
Passa ge --~~'
through Exte nsor
Brachio
int erosseou s digit orum
radialis
memb rane
tlf.i=- - - Posterior
int erosseou s n.
Pronator --+f-'!---t4!~
Posterior - - h :-lof'l
teres int erosseous a.
341
Topography of the Carpal Region
,...-lr - - Median n.
Pronator
quadratus
Flexor digitorum
A Ulnar t unnel and deep palm . superficia lis
Opponens po llicis
Superficia l
branch
UI'OC' { Deep branch
Flexor retinacu lum
(transve rse carpal ligament )
Ulnar a. -----o;c7-'~_HI
Flexor carpi radialis
and n.
342
Fig.22.40 Ulnar tunnel Palmar
Right hand, ante rio r .-------- aponeurosis
(palm ar) view.
Hook of -~~::;;;;;......-=~~ Ulnar a. and n.,
hamat e superficial
branches
Hypoth enar -...,....:~
muscles
I
I
Super fic ial Deep
palmar arch palma r Ulnar t unnel
arch (d istal hiat us)
::::~;:;~--- Palmar carpal
Hook of Pisiform ligament
hamate
l" Pisiform
Flexor carpi - -
ulnaris
--!-J'-- I Palmaris
longus
--~~,.:.;=;=~~~~~~~~~~;~~~~~~
Flexor carpi
Palma r carpal radialis te ndon
ligam ent
Ulnar a. and n. ----:'-!---..J-~;,;;
Median n.
Flexor pollicis
longus tend on
Synovial cavity -~Hi 'j
Scaphoid
343
Topography of the Palm of the Hand
~
--+--f---+-~ Palmar digital nn.
(exclusive area of
median n.)
Palmar
(exclusive palmar
I Lr~f!h- Palm ar digital aa.
area of branch
ulnar n.)
Palmar ----l:¥--'~-~~r-"'-'ff,i_-'t.i
digital nn.
Ulnar n., - - ,-----
palmar
Radial n.,
branch
dor sal
digital n.
Com mo n ----t1rt.-~-=fri-'---__'_H''cll
palmar digita l aa.
I~--ffi~- Palmar
A Sensory territori es. Extensiv e overlap exists digital nn.
between adjacent areas. Exclusive nerve of thum b
territori es indi cat ed w it h darker shading.
I""::;:;i!!:!:~~~~'--- Add ucto r
pollicis
Abd ucto r ----I~:...~ ~~
digiti mini mi Flexor pollicis
brevis, super
Palmar ------;~----""'R~-r'=\--
ficial head
aponeuro sis
- - - - Abdu ct or
Palmaris ---------.::~~:-..~;:: polli cis brevis
brevis
Fig.22.43 Neurovasculature
of the finger
Palmar dig it al n.
Vincula Vincula
Prop er palm ar Commo n palm ar brevia longa
digita l a. and n. digit al a.
344
Fig.22.44 Deep neuro Fig.22.45 Innervation
vascular structures patterns in the palm
Median
of the palm Right ha nd , comm unicat ing
Right ha nd, anterior view. branch
anterior v iew.
Ulnar
comm unicating
PaIm ar ----..:-H--R'Ir----L---¥.---::'.tIl
branch
digital aa.
and nn.
Palmar
digital nn.
Flexor digitorum
superf icialis
I Median n.
Pronato r
C No co m m u nicating
bra nc hes (20 %) .
Flexor -
quadratus
and brevis
Common -----I,I+-,~'l'£--~l+_l__"'l_:
A Su pe rf ici al palma r arc h. palmar
digital aa. - - -f{I'---S:Il - Lumbricals
Abducto r -r-c-a
:-r-~~-i!I---'---- Adduct or po llicis,
digit i m inimi
t ransverse head
Flexor digi t i - """' .n"
minimi Abducto r
Palmar met a pollicis brevis
carpal aa. Flexor
Opp onens poll icis
dig iti m inim i brevis
Superf icial Deep palmar arch
palmar arch
Adductor polli cis,
Deep
j
obli que head
Ulnar n. branch
Superficial Opponens
branch pollicis
Ulnar a., Radial a.,
deep branch superficial
palma r
Ulnara. branch
and n.
Radial a.
Pronator
quadratu s
B Deep pa lmar ar ch.
Flexor carp i Ant erior
ulnari s interos
seous a. 345
Topography of the Dorsum of the Hand
Radia ln.•
super ficial branch
~
and dor sal
digi t al nn.
Radial n.,
superficial branch
A Nerves of th e dor sum . B Sensory territ or ies. Ext ensive overlap exists between adjacent areas.
Exclusive nerve t erritories indi cated with darker shadi ng.
Extensor carp i
Ext enso r dig itorum Trape Exte nsor carp i Ext ensor
and ext ensor ind icis zium radialis brevi s poi lic is lo ngus
Radial n.,
Radia l a.,
do rsal carpa l
~~~~~i~~~;!~~~~~~:!~F!~'""""""
~~- Scaphoid
branc h
346
Fig.22.48 Neurovascular structures of the dorsum
int erossei
Ext ensor
digit orum
pollicis brevis
~Hr+-'l--IJ--MHW-- Radial a., dor sal
Extensor carpi --'""",~'-'01"""' \ carpal branch
radialis brevis
and longu s Exte nsor digit i m inim i
Exte nsor
Dor sal carpal retin aculum
net work Exte nsor
carpi ulnaris
Dor sal
A Superficial st ruct ures.
digit al aa.
Extensor
po llicis longu s Dor sal
metacarpal aa.
Radial a. - ---";:-.:-':':! ;
347
Transverse Sections
Triceps
brachii
Biceps ----*i~
Deltoid ---~'-f'-,L
br achi i
Brachialis
Medial
epicondyle,
com mon head
of fl exors
Brachio- -----+~L,+
radiali s
Brachio - - - --H
~--- Flexor
radia lis
carpi ulnaris
Flexo r ---+-~'Il
po llicis lon gu s I,!
Abducto r
po llicis lon gus
--1
Flexo r carp i - -"'--H!-i--
radi alis
Biceps ------'-+L!~L_flf+_+
brachii
+--7-+---- - - - Palmaris
lo ng us
348
Fig. 22.50 Transverse sections
Right lim b, proxim al (superior) view.
Posterior
(dor sal)
t Triceps brachii,
lateraI head
Triceps brachi i,
long head
Triceps brachll,
Radial n.
media l head
Brachialis --~-c+I'
Brachial a. and v.
Median n.
Biceps brachii,
Ante rior short head
(vent ral)
Posterior
(do rsal) Abdu ct or
Interosseous
a.. v.• and n.
po llicis long us
Extensor
m embrane carpi ulnaris
Extensor Extenso r
poll icis brevis po llicis longus
Extensor
digitorum
Brachio radialis
Flexor digito rum
superficialis
Radial n.
(superf icial branch)
Palm aris
Pronator Flexor long us
te res carpi radialis
Ante rior
(ventra l) Radial a. Median n.
349
Surface Anatomy (I)
- ----+- Cephalic v.
(in deltopect oral
Pectoralis - - gro ove)
major
Biceps - - Triceps brachii,
brachii lateral head
Cephalicv.
Median -----ti~"""~
- - Exte nsor carpi
cubital v.
radialis longus
- - Brachioradialis
Flexor carpi
ulnar is
1.-'-',--":-- Palmaris longus
tendon
Fig. 23.2 Palpable
Hypoth enar
bony prominences
Palm eminence
~"'!l'''l.-- Palmer venous Rig ht limb .
1st digit
net wor k
(t humb )
Clavicle
_ _ 5t h digit
(little finger) Acrom ion
Coracoid process -------''''- I.......
A Surface anato my, right limb . B Musculature, left limb. Greater and lesser
tubercles
Latera l - - Medial
epicondy le epicondy le
Tubercle of
scaphoid
Tubercle of
trape zium , -' - --'-" ' - Metacarpo
phalangeal joi nt s
A Anterio r vie w.
Int er- '-----<c---~_+."f
phalangeal
joints
350
Ql: Wh ich cut aneous nerves are m ost vulner Fig.23.3 Upper limb:
able durin g int ravenous pun ctures (e.g., Acrom ion ---=...,-'~ Scapular _ _~_ Posterio r view
dr awin g blood, inject ions)? spine
Infraspinatu s - -
Teres majo r - -- -
Lon g head } Triceps
Lati ssimu s ~.
Lat eral head brachi i
dor si
-+- - - Acrom ion A Surface anatom y, left limb. B Musculature, right limb.
Great er
t ube rcle
Scapular
spine
Stylo id pr ocess
of ulna
Triq uet rum bone ~
Capitate bo ne
Met acarpaIs - -'i-ii-'r-"T-7---"
351
Surface Anatomy (II)
Fig.23.4 Palpable bony structures Fig. 23.5 Surface anatomy of the wrist
Left hand. Lef t wri st, ob lique ant ero latera l view .
Pisifor m
-«--- Proximal int erpha lang eal Flexor carpi
(PIP) join t ulnaris t endon
Thenar - - - --
em inence
Metac arpop halangeal
(MCP) j oint
- - - Palmari s
longus
tend on
Flexor
~"""--- Hook of hamate
carpi radialis
Tubercle of ---=>;.-... tend on
t rapezium
Tubercle of
scaphoid Q3: How can t he palpab le tendo ns in the w rist
Ulna
be used to dete rm ine the location of key
Sty loid pro cess
of radius
arte ries and nerves?
352
Fig. 23.7 Palm
DIPjoint
crease
PIPjoint
crease
Mep j oint
crease
/ Dist al tr ansverse
/ 1 crease
~ Proxima l tr ans Palmar veno us
verse crease network
-----~- Midd le crease
- - - Hypot henar -=-~~'----- Flexor pollicis brevis
em inence
Adu ct or pollicis brev is
353
~ ----"""
Lower Limb
Femur 360
Muscl es of th e Sole of th e Foot 412
27 Neurovasculature
Posterior Muscles of the Thigh , Hip & Gluteal Region (II) 372
25 Knee & Leg Nerves of the Lumbar Plexus: Obturator & Femoral Nerves . . 428
Cruciat e Ligaments 38 8
28 Surface Anatomy
26 Ankle & Foot
Surface Anatomy 450
Lesser
tro chanter
--\- - Femur
Thigh
Lateral
condy le
Med ial
Pate lla epicondyle Knee joint
Tibia
Fibula
Low er leg Fibula
Ankle Media l
mortise malleolus
Talocrura l
-..!,.,-- - (ank le) joint
Lateral
Tarsals { mal leolus
Calcaneus
Metatarsals{ Calcaneus , ~ Tuberosit y of
5t h m et at arsal
Phalanges {
356
Fig. 24.2 Line of gravity Fig.24.3 Palpable bony prominences in the lower limb
Righ t lateral view. The line of gravityruns verti Mostskeletal elements of the lower limb have bony prominences.
cally from the whole-body center of gravity margins. or surfaces (e.g.. medialor tibial surfaces) that can be palpated
to the ground with characteristic points of through the skin and soft tissues.
intersection.
Pubic
/ tub ercle
Infl ecti on po int s Greater ----' Greate r
of vert ebral troc hante r - - Pubic sy mphysis t roch anter
colum n
Ischial
tu berosity
Hip joint
:--- - - Tibia,
medial
surface
-:-- - - Tuberosity of
- - - Metata rso
5t h m etatarsal
phalangeal joint s
357
Pelvic Girdle & Hip Bone
Fig. 24.4 Pelvic girdle ~ Each pelvic gird le consists of a hip bone cart ilag ino us pubic sy m physis and t o t he
An terior view. Pelvic ring in red. IIIiiIII (coxal bo ne, innominate bone), which sacr um via th e sacro iliac joints . These at
articu lates with the head of a femur. t achm ent s create the bony pelv ic ring (red) ,
Hip bone Sacrum Sacroiliacjoint Un like t he shoulder girdle, the pe lvic permitting very little motion . This stability is
girdle is firm ly integrated into th e an important prerequisite for the transfer of
axia l skeleton: t he paired hip bon es trunk loads to the low er lim b (necessary for
are connected to each other at th e norma l gait).
Ischial spine
Inferior Obturator
pubic ramus foramen
+-- - - - - Arcuat e
line
Anterior inferior - --+
iliac spine
"1-- -Ischial
spine
./' Pectineal
./' line
Symphysea l
surface
Obturator
foramen
Ischial
A Anterior view. tuberosity
358
Fig. 24.6 Components of the hip bone
Rig ht hip bone. The three bony elements of the hip bone (il ium, ischium,
and pubis) come toget her at the aceta bulum. Defi nitive fusion of the
V-shaped growth plate (triradiate cartilage) occurs between the 14th
and 16th years of life.
Iliac w ing
(ala)
Ilium --~------
(body) Aceta bulum
-- Triradiate
cartilage
Superior
Acetab
pubic ramus
ulum
Pubis
Inferior
Ischium pubic ramus
(body )
A Triradiate cartilageof the hip bone. Lateral view. B Radiograph of right acetab ulum of a child.
Iliac crest
Ante rior
gluteal line
Greater
,~_---- Lunat e surface
Acetab ulum
sciat ic notch F--+- - - - Acetabu lar fossa
i"k--"'.....= ,--- Acetabul ar notch
Pubic
t ubercle
- + -0;''------ Obturator
foramen
Ischial - - -'"=
t uberosity
359
Femur
~ Trochant eric
....o fossa
.:.---~~~-- Intertrochan
teric crest
Intert rochan Lesser
te ric line t rochant er
~~- Gluteal
t uberosit y
Shaft Lateral
lip
} Lin ea
aspera
Medial
lip
supracondylar supracondylar
line line
Adduc to r
t ubercle Popliteal surface
Medial
epicondy le Intercondylar
line
360
Fig.24.8 Head of femur in the hip joint
Right hip joint, superior view.
Acetab ular
Ilio pect ineal
labrum Pat ella bursa
II Patellar
_ ~ surface
~ of femu r
Aceta bulum
_ ---3.. ....:.,-__ Head of Head of
femur fem ur
Fovea of .:
femoral -t Fibro us
~ ..., Ligam ent - - - - ---J\'! H>\y '+.r
- 'o--------;-t- Neck of membrane
:;~;~~' "
head of head
femu r
of fem ur Neck of
femu r
Greate r
> Acet abulum
Greater
t ro chant er
t rochant er
Medial
condyle
Lat eral
co ndy le Ischium
~~~~~~~i~~~~
~ ~;fII1I!l~~,+- Trochant eric
bur sa
361
Hip Joint: Overview
Anterior - - -..:,,
superior
iliac spine
Iliac crest
Posterior superior
iliac spine
Greater
trochanter ~ Pubic
t ubercle
Posterio r ~
inferior
t eric line
of fem ur
Int ertrochan
teric crest
B Posterior view.
362
Fig.24.10 Hip joint: Coronal section
Right hip joint, anterior view.
Epiphyseal
line
Neck of Ilium
fem ur
Acetabu lum
Head of
femur
liga me nt
of head of
fem ur
Acet abu lar
fossa
Acet abular
labrum
Shaft of
Trochanteric femur B Tl -weight ed MRI.
bursa
~ Clinical
' ~i '.4J~J';
_", J 'Ii.', ;~ " '''''b
,• :"
Acetabular - - -- -'
~ t.·
labrum
f labrum
I IJ, ' : ' .
, • Ossification
.t. ~ ~;
center
I '
Femur -+-f-. /
~r~'
Femur ----t--t-t
.
tt,, \~·"¥J, u
Inferior Inferior
margin margin
of ilium of ilium
JJ• '.....
~
' • f,' •
A Normal hip j oint in a 5-mo nth -old. B Hip dislocation and dysplasia in a 3-mo nth -ol d.
Hip Joint: ligaments & Capsule
.Q ~ The hip jo int has t hree major ligaments: ili ofemoral. pub ofemo
,5
-.I
IIIiiiiiII ral, and ischiofemoral. The zona orbicularis (annu lar ligament )
is not visib le ext ernally and encircles th e femora l neck like a
~
o
buttonho le.
-.I
Fig.24.11 Hip joint: lateral view
Ingu inal I.
Sacrum
Pubofemo ral I.
Sacrospi no us I.
Pubic t ub ercle
Iliofemo ral I.
Greater trochant er
Ischiofemoral I.
Femu r
~;d~~;-ll'-- Fovea o n
femo ral
,,~~-:-;-,~'---- Acet abular Acet abular fossa head
labr um
ti:'i<i'i-- - Aceta bular Obt urat o r Great er
roof me m brane trochante r
"''''k-- - Joint
capsule
L. of
head offem ur
364
Fig.24.12 Hip joint: Anterior view
___ L4 verteb ra
J I
Iliac crest - - - L5 verteb ra
- - Sacral promontory
Inguinal I. - - -- ",
!lIt---;-'--- - Sacrotuberous I.
::"''';;;;:;:fi-;cf-- Sacrospinous I.
Iliofemoral I. - ----'-'----:
Ischial spine
Neck of femur
Greater
Pubic symphysis
troc hanter
Greater
trochanter
Intert rochan- - + -
t eric line
teric line
Iliolum bar I.
L4 verteb ra
Iliac crest
LS vertebra
/~--+- Intertrochanteric
crest
Sacrotuberous I. ------'l:--~k-
Lesser trochant er
C Jo in t capsu le.
365
Anterior Muscles of the Thigh, Hip & Gluteal Region (I)
..Q Fig.24.14 Muscles of the hip and thigh: Anterior view (I)
.§ Right limb. Muscle origin s (0) are shown in red . insertions (I) in blue.
...
-.l
~
.....o Iliac crest - - - - --:-;,.-9"
- - Ant erior
long it udinal
ligam ent
Iliacus - - -I--b* [---; Sacral
prom ont o ry
Anterior - - + Psoas major
super ior
ili ac spine
Tensor - ---j!-
fasciae lat ae
Pect ineus
A Removed: Fa scia lata of thigh (to the lateral iliotibia l tract) . B Removed: Sartoriu s and rectus femoris.
366
."",!i.b- - - - Psoas
Psoas major (O)
major
Iliacus - - ---,!'-..,, Iliacus (0)
Sartorius (0) ~
Sarto rius (0 )
Tensor
fasciae latae
Gluteu s
Piriformi s Glut eus ~~~--'-=';-- Piriformi s
medi us
m edius
Rectu s ~!'!!~--=- Rectus
Glut eus - - +-.It'-+ '1 Glute us
femoris (0) femoris
mi nimu s minimus
Piri formi s ------,~4"'--.. Pirif ormi s Pecti neus (0)
IIiofemora I - - ---+----';o-t' 4----,-.1f'
ligam ent Obt urato r Obt urato r
ext ernus ext ernus
Iliopsoas
Vastus
Pecti neus Iliopsoas (I) .?:l'l+-I-- - - Adducto r
lateralis
brevis
Adductor
minimu s
Vast us - - - +.'- -'*:. v
m edialis Adducto r Vastus
brevis medialis (0)
Addu ctor
longu s
;a--- - Gracilis
Gracilis
Vast us
Vastus ---'iil-iifi--1i-- -r-- Add ucto r
int erm edius
int ermedius (0) magnus
ff6-+~--- Adduc t or
magnu s
;eon~:o~f
Biceps ....... ...' ---- Gracilis (I)
femoris (I)
IE':+7 - - Pes anserinus IF+-- - - Sarto rius (I) )
Quadriceps insert ion
femori s (I) IH - - - Sem i (pes anserinus)
tendinosus (I)
C Removed: Rectu s fem ori s (compl etely) , va stu s later ali s, vastu s media D Removed: Qu adriceps fem ori s (r ectus fem oris, vastu s lateral is, va stus
li s, iliop so as, and t en sor fasci ae lata c . mediali s, vastu s interm ediu s), ilio psoas, t en sor fascia e lat ae, p ectineus ,
and mid p orti on of adductor longus.
367
Anterior Muscles of the Thigh, Hip & Gluteal Region (II)
Fig. 24.15 Muscles ofthe hip and thigh: Anterior view (II)
Right lim b. Muscle origin s (0) ar e shown in red , in sertio ns ( I) in blue.
Iliacus
Sarto rius
Vast us -------1~
int ermedius
Art icularis
Adducto r genus
hiatu s
Tendin ous
insert ion of
adducto r magnus
Adduct or Adduct or
t ubercle magnu s
A Removed: Gluteu s m ed ius and minimus. piriform is. obturator ex te rn us, B Removed: A ll mu scles.
ad d uc to r br evis and lo ng us. and graci lis.
368
Fig. 24.16 Muscles of the hip, thigh,
and gluteal region : Medial view
Midsagitta lsection.
LSvertebra l body
Iliac crest ~--
Pubic ------,E-ll-'-:-
sym physis
Glute us
maximu s
Gracilis
Sem i
memb ranosus
Vast us ------'Ltt--f"--H
m edialis
Patella - ----'l-
(co m mo n tendon
of insert ion)
Tibia
369
Posterior Muscles of the Thigh, Hip & Gluteal Region (I)
Fig. 24.17 Muscles ofthe hip, thigh , and gluteal region : Posterior view (I)
Right lim b. Mu scle origin s (0 ) are show n in red, inserti ons (I) in blue.
L5 spino us
pro cess
maxim us
lL"'. -=-'------Ci'-T- - Glute us
Gemellu s
medius
inferior
Obturator ----!'---'.\~
int ernu s -~"---+-- Quadratu s
Great er femoris
trochant er
Sarro - - ------0
:1'----,- - Gluteus
maximu s
tuberous
ligam ent
;f,'-- -i-- - Adductor
Ischial
magn us
t ubero sity
Addu ct or - -+-..
magnu s
Iliot ibial
Y
t ract
Gracilis Gracilis
Sem i Semi
m em branosus m em branosus
Pesanserinus - -.;-"=\\
A Removed: Fascia lata (to iliotibial tract) . B Partially remo ved: Gluteu s m axim us an d m edius.
370
Tensor Tensor
fasciae fasciae
latae (0) lat ae (0)
Gemellus
Geme llus , - - - - Rectu s
superior
superio r fem oris (0)
~'>!!.--- Piriformis
Geme llus Piriformi s
Gemellu s
inferior
inferior
Gluteus
Glute us Obturator
Obt urator
medius and
medius (I) int ernus
intern us
min imu s (I)
~""'::=+-.F-- Quadrat us
~=-+---;~- Quadrat us
femori s Sem imem- --+~-+-=
femoris
Sacro
branosus (0)
tu berous
.....,_ . ---- - Vastus
ligament
lateralis (0) Biceps femoris
(lo ng head) and '''''''' ,IfM-- - Glut eus
Adducto r ..... ~m'----- Gluteus
semite ndinosus (0) maximus (I)
magnu s maximu s (I)
~--- Biceps
Sem i femori s, ---i- - - - Vastus
t endin osus (cut) short head lat eralis (0)
-h~--- Biceps
femor is,
Gracilis Biceps short
femori s, Adductor ---:--f-+ head (0 )
lon g head hiatus
lr - - - - Plantaris (0)
1"~-7--- Plantaris
Gastro cnem ius, -----,;=--~'"
medial and
lateral heads (0)
C Removed: Sem ite nd inos us an d bi ce ps femo ri s (partia lly) ; g luteu s m axi D Removed: Ham strings (sem it end inos us. sem imem b ra nos us, and b icep s
mu s and m ed iu s (compl et ely) . femori s), gl uteus minim us, gastrocnem iu s, and muscles o f th e leg . 371
Posterior Muscles of the Thigh, Hip & Gluteal Region (II)
.Q Fig.24.18 Muscles of the hip, thigh, and gluteal region: Posterior view (II)
,5
-.I
Right limb. Muscle origins(0) are shown in red, insertions(I) in blue.
~
....o
Tensor
fasciae latae
Glut eus
mi nim us
Adductor
brevis
Adducto r
brevis Vastus - - - Vastus
medialis int ermedi us
Addu cto r
lon gus
} - - - Add ucto r l.' }--- - Add uctor
mag nus (I) magnus
Adductor --~
longu s
. r.~---- Biceps
femo ris,
short head
Vastus - - - - _+"
m ediali s (0)
Popliteus - - - - - - - '
1lH7f---7tC't----"- Soleus
A Removed: Pi riformis, obturator internus, quadratus femoris. and B Removed: All muscles.
372 adductor magnus.
Fig.24.19 Muscles of the hip, thigh, and gluteal region: lateral view
Note: The iliotibial tract (the thickened band of fascia lata) functions as a tension band
to reduce the bending loads on the proximal femur.
L4 spi no us ----~i~n
pr ocess r-_ _ J
Rectu s
femori s
Lo ng head
Biceps
femoris
Shor t head
Vastus
lat eralis
~-- Patella
1''1'.-·'1 -- - - Patellar
Head of fibul a -------,F--'!-" ligam ent
;+lIr--- - Tibiali s
Gastrocnem ius - - -#-- ante rio r
373
Muscle Facts (I)
, Psoas minor
~;{-- ~
U --1O--- @
(j)
- - Iliot ibial
t ract
Gluteal muscles
. ® Quadratu s femori s ·' · L~~~ ;~ l b~~d~~ ~f ~h~ i ~~h i~ I ~~b~ ~~~ i~;·· Intertrochanteric crest of th e fem ur • : Exte rnal rot atio n and adduct ion of the hip joi nt
Fig.24.21 Psoas and iliacus muscles Fig. 24.22 Superficial muscles of the gluteal region
Right side, anterior view . Right side, post erior view .
Iliac crest
~"1-- Gluteus
Thoraco
.
medius
lum bar
fascia
n~X
Tensor
Gluteus fasciae
rnaxirnus lat ae
L5 vert ebra
Sacral promontory
- Iliot ibial
- - --jl-- Iliacus
t ract
Anterior
superio r
iliac spine
- - - Inguinal
ligament
Sacrospinous ligament
Greater
t rochanter
Tibia
~~#-- Inter
trochanteric
line
Lesser
t rochante r
Piriformis Piriform is
Gemellus superior Obturator internus Gemellus superior
Obturator int ernus ~ and infe rior and inferior
Quadratus femo ris Ischial spine -AkLO~i~?;;~~ Quadratus femoris
Greater troc hanter \ ; - Greatertrochanter
Sacrotuberous
ligam ent
~ Intertrochanteric
crest
Ischial
Glutea l tube rosity
tuberos ity
A Deep layer with gluteus maxim us removed . B Deep layer with glute us med ius removed.
Muscle Facts (II)
~
....o
Fig.24.24 Medial group: Superficial layer
Righ t side. ante rior view .
cJ
"=,,-£'---"....-;""7 - - Superior
Greate r pubic ram us
t rochanter
Lesser ---+--~
t rochante r
Pect ineus
~~w--- CD
~-,k~-- Patella
A Schematic.
Fibula
Tibi a - +
: Femora l n., • Hip joint: adducti on, exte rnal rotation, and slight
: Femu r (pectinea l line and t he
j ill Pectineus j Pect en pubis : obtu rato r n. flexion
: proximal linea aspers)
: (L2, L3) • St abilizes t he pelvis in t he coronal and sagittal planes
. ..... .. ... .... .. .. . - ' ' .
, Superior pubic ram us and ' Obtu rator n. • Hip join t: adduct ion and flexion (up to 70 degrees);
, Q) Adductor longus , . id f h hvsi Femur (linea aspera, medial lip in • (L2-L4)
T T i b j ~ ( ~ ~d j ~ i b~ ;d ~ ; ~f th ~
...• Obtu rator n.
.• Inferior pubic ramus below ' (L2 L3) • Hip joi nt: add uct ion and flexion
; @ Gracilis : t uberosity, along w it h t he tendons : •
: th e sym physis • Knee joi nt: flexion and internal rot ation
: of sartorius and semite ndinosus)
... .... .... ..... -...... ........ ..•....
Fig.24.25 Medial group: Deep layer
Right side . ante rio r vi ew .
~=---"--~,"""f""=-~-- Superio r
Greater pubic ram us
t rochanter
Lesser ---+--~
tro chanter
~!----- Fem ur
\ ,
\ \ t-- +- - Adducto r
magn us
J\
+',, - ---1'--- - Adductor hiatu s
e+-----,1--~!----- Adduct or
magnus,
tendin ous
part
('-.
\
-,-c*+-- - Patella
\
A Sche ma tic.
- £ H _ - Tibial
t uberosit y
Fibula
B Deep ad d uc to r group.
Out er surface of th e obt urato r • Hip joint: adduction and ext ernal rotation
CD Obt urato r exte rnus Trochanteric fossa of th e femur Obtu rato r n. (L3. L4)
membran e and it s bony bou ndaries • St abilizes the pelvis in th e sagittal plane
Hip joint: adduction exten sion. and slig ht
@ Adduct or minimus Inferior pubic ramu s Medial lip ofthe linea aspera Obtu rato r n. (L2-L4)
flexion of the hip joint
• Deep part ("fl eshy insert ion" ): • Deep part: obt urato r • Hip joint: adduction. extention, and slig ht
med ial lip of the lin ea spine n. (L2-L4 ) flexion (the tendinous insert ion is also
Inferior pubic ramus. ischial ramus.
Q) Adductor m agnus • Superfi cial part ("tendinous active in internal rotation)
and ischial tub erosity • Superfi cial part:
insert io n"): adductor tub ercle • Sta bilizes the pelvis in th e coro nai and
tibial n. (L4) sagittal plane
of the femur
Muscle Facts (III)
Anterior superio r
iliac spine -
Ant erior inferior
iliac spine
Greater
Greater
troch anter
trochanter
Intert rochante ric -~~
line
Rectu s
Lesser
femori s
trochant er
'D- - - Sartorius Vastus
interm edius Quadriceps
~~=r---- Rectu s ~~~...- - Vast us femori s
femoris lateralis
~-- ® Vastus
m edialis
~-- ®
Vastu s Vast us
lat eralis media lis .f--~!I---- Rectu s
femo ris
Tendon of - - --.s,..-f
insert ion
of quadriceps - --r-llt-- Patella Sartorius
femoris Medial patellar
retin aculum
-c.J'---- - Tibial
A Sch ematic. tuberosit y
"The ent ire muscle insert s on the tibial t ubero sity via the patellar ligament.
Fig. 24.27 Posterior thigh muscles
Right sid e, posterior view.
Sacro
tu berou s
ligam ent
Ischial
Gluteal tu berosit y Com m on
tub erosit y
head
Linea aspera
Medial tibi al
A Sche matic. Semi memb ranosus ~ condy le
t endon (part) Head of fi bula
Popliteus ------''+.-~.J..\
Pop lit eus
Interosseous
Pes anserinu s - --h t:
membran e
.Q ~ The tib ia and fib ula artic ulate at two joint s, allowing limi t ed mu scles in t he leg. It also acts wit h th e ti biofibu lar syndesmo sis t o sta bi
,§ ~ m ot ion (ro tatio n). The crural intero sseous m emb rane is a sheet lize th e ankle joi nt.
........ of tough connective t issue th at serves as an orig in for several
~
....o
Fig. 25.1 Tibia and fibula
Right leg.
380
~ Clinical
Fibular fracture
Int ercond ylar Posterior inter When d iagnosing a fib ular fract ure. it
em inence cond ylar area is im port ant to determ ine whether t he
syndesmosis (see p. 380) is disrupt ed. Fibular
fracturesmay occur distal t o. level w ith. or -
proxim al to t he syndesmosi s: t he latter t w o
frequently involve tearing of the syndesm osis.
Fibula
Tibia
Syndesmosis
Medial
malleolus Lat eral
malleolus
Talus
Calcaneus
Lateral Medial
condy le con dyle
Ant erio r
Tibia l int erco ndylar
t uberosity area
C Proximal view.
surface
I Medi al
~ surface
Fibula Media l
surface
- - - Ant erior
border
t
Lat eral Medial
malleolus malleo lus
Lateral
malleo lar fossa Tibia
E Distal view.
381
Knee Joint: Overview
..Q
~ In th e knee jo int . th e femu r art iculate s with th e t ibia and pat ella. in th e knee jo int (cont rast to th e hum erus in th e elbow ; see p. 282).
.S
..... ~ Both joints are cont ained w ithin a com mon capsule and have Instead. it form s a separate rigid articu latio n with th e tibia.
communicating arti cular cavities. Note: The fibu la is not includ ed
~
c Fig. 25.2 Right knee joint
.....
Intercondylar not ch
Patella -----T--f-~-
Medial Lateral epicondy le
Lateral epicondyle - - + - epicondyle
Lateral femoral condyle
Lateral femoral condy le - ---\-'--;C- Medial femor al
condyle ~---oJI--- Int ercondylar
Lateral ti bial condy le -------,;~~~~iI eminence
Head of fibula
Soleal line - - \ (
Fibula - Fibula
Tibia Tibia - --,-
Lateral - -->,,--
femoral condyle
-'--~~~- Lateral
t ibial
condyle
Tib ial
t uberosity
- + - - Tibia
C Lateral view.
382
Fig. 25.4 Patella
Ba se
~-------:-- Articular
surface
Medial facet
Patella - - -+ -----l''-;--;,L,t-.e.c..,.
" 1-'' ':-- - - - Ra diographic
LateraI facet - ---+-----.H'l-H ---4-==,...,. view in D
....._"""'''---'''~'-cP.-'c-~--- Joint space
Gastrocnemius -----"&--'~~~r-T~;.-
383
Knee Joint: Capsule, Ligaments & Bursae
~
o
Ext rinsic ligaments
..... : Patellar I.
. .
, Medial lon git udi nal patellar Femur
, retinac ulum
................................
: Lateral longit udinal patellar
: Anter ior side : reti naculum
, Medial tran sverse patellar
ret inaculum
Vastus
Lat eral transverse patellar
int erm ediu s.
retinacu lum tendon of
........ ..............................................................................................
: Medial and lateral ' Medial (t ibial) collater al I. inserti on
Vast us --~~~
: sides Late ral (fib ular) collateral I. lateralis Vast us
.... . .... ... ..... .... .... ...... ..
medialis
Oblique pop litea l I.
, Posterior side ...... ........................................
: Arcuate poplit eal I.
!1II1/:,-¥liiJ- - - - Medial
longit udinal
Head offibula - - - - If,--- patellar
retinaculum
~~-- Patellar I.
.-f.h,..L--!!IL--_ TibiaI
tuberosity
- .Jf- - Tibia
384
Fig. 25.6 Capsule, ligaments, and periarticular bursae ~ Clinical
Posterior view of right knee. The joint cavity communicates with peri
articular bursae at the subpop liteal recess, semimembranosus bursa,
Gast rocnemlo-semlmemb ranosus bursa (Baker's cyst)
and medialsubtendinous bursa of the gastrocne mius. Painful swelling behind t he knee may be caused by a cyst ic outpouching
of t he joi nt capsule (synovial pop liteal cyst ). This frequent ly result s fro m a
rise in int ra-art icular pressure (e.q., in rheumat oid arth ritis) .
Semi ----';--1l+'ti~,
membranosus
Poplit eal
fossa
Femu r - - - ; --
Medial
subte ndinous Lateral
bur sa of subtendi nou s
gastrocn em ius bur sa of
gastrocn em ius A Baker's cyst in th e right pop liteal fossa. Baker's cyst s of ten occu r in
t he m edial part of t he pop lit eal fossa between t he sem ime m branosus
tendon and th e medial head of t he gastrocn em ius at t he level of t he
posterom edial femoral condyle .
Obliq ue
poplit eal I.
- - Lateral
collatera ll.
Medial
collatera l !. Arcuate
pop liteal I.
Sem i
membranosus
bursa Poplit eus
Subpo plitea l
recess
----t - Fibula B Axial mag net ic resonance imagin g (MRI) of a Baker' s cyst in t he popliteal
Tibia - - .;L-
fossa, inferior view.
385
Knee Joint: Ligaments & Menisci
Femu r - - - -
Femoropate llar
joint
Patella
---i~-- Medial epicondy le
Patellar I.
--;-=-+i+--flil=- - Medial Posterior I. of --~~/'i
collater al I. fibular head
~ V;-tI-'------;=----'---+-,"~-- Anterior I.
of fibular
head
Tibia. - - ,....-
m edial
surf ace
386
Fig.25.8 Menisci in the knee joint
Right t ibial plat eau, pr oxima l vi ew.
'b) Clinical
! Anterior cruciate I. ':;iiiiiiiili~~b-- Patellar I.
Injury of the menisci
The less mobile medial meniscus is more
Medial Transverse I. suscept ible to injury th an t he lateral
meniscus of knee meniscus. Trauma generally result s from
sudden extension or rot ation of th e flexed
knee while t he leg is fixed.
Tibio
fibular
joint
Medial Lateral
collateral I. collateral I.
Pa tella
Ext ension
Patellar
ligament
Lateral
collateral
ligament
Flexion
387
Cruciate Ligaments
.....
Int ercondylar
notc h
Patellar
surface Lateral fem oral
of fem ur condyle
Med ial
Ant erior Anter ior
femora l
cruciate I. cruci at e I.
cond yle
Transverse I. Posterior
Posterior
of knee m enisco
cruciate I.
fem oral I.
Lateral Medial Lateral
m eniscus meniscus meniscus
Lateral Lateral
Medial
collater al I. collat eral I.
collate ral I.
388
~ Clinical
Lateral Medial
m eniscus meniscus
Tibia
389
Knee Joint Cavity
Lateral
Lateral collate ral I. meni scus
rc-- - --;;;i!"""=- .2:----- Femur.
-!-- - Pat ellar l. pate llar
Subpop litea l surface
Lateral
bursa co ndy le
me niscu s
--~--#--- Infra
Fig. 25.15 Attachments of the joint capsule pate llar
Right knee j oint, ante rior view. fat pad
Fibula - - - ; - -~-- Ti bi a
390
Fig. 25.16 Suprapatellar pouch during flexion
Right knee jo int. medial view.
.._---!.-- - Sites of
attac hment
of the joint Patella
capsule
Supra
patellar
pouch
Quadriceps
tendon
Anterior
cruciate I.
Tibia
391
Muscles of the Leg: Anterior & Lateral Views
~
o
-.I
Rectu s ---\--'"",",~-tt l '
femo ris
Femur
Gracili s
Vastus ---'+~'''''
~i
lateralis
.£-- - Sartorius
Iliot ibial -----'~ "
tr act
~--- Vastus
medialis
- ---'YL---''Hi-- - - Patella
Fibularis --~ " I
.....~-- Tibial
longus (0)
tub erosit y
Pes anserinus
Tibial --~-:,-!--f-';+-- (comm on t endon
tub erosit y of insert ion of
sart orius. gracilis.
and sem ite ndinosus) _ _'---4 Tibialis
ant erior (0)
Gast rocnemi us.
medial head
Ext ensor --~
Fibularis digitorum longu s
longus Soleus
Tibia
-~---- Extensor
hallucis longus
Extensor - - --;--f--'\'
digitorum longus
Fibul aris
brevis
\:>,...- - Medial
malleolu s
tertius (I)
ant erior (I)
Int erossei
~f.L1'1H'!.HMl-~~~- Extensor
digitorum long us
Biceps -----!:'~~
femoris.
long head
.*'~--- Vast us
lat eralis
Biceps femo ris, - - - + ;:-'-;:rl;t"l
~--"-;-----:lf-- Pat ella short head
lo ng us
Tibi alis
Ext ensor anter ior
digi torum lon gus
Soleus - ----!;;-J-+
~~~--- Ext ensor
digit orum longu s
Triceps - -'----'l-"---fu:1I'
Ext ensor
surae
hall ucis lo ngus
Fibularis - --
brevis
t ert ius
V hallucis longus
Exte nsor
digitorum brevis
Fibularis tertius
(variable)
Exte nsor halluci s
brevis and
ext ensor
Extenso r
d ig itorum brevis
Ext ensor
di g it o rum
Exte nsor
lo ngus
hallu cis lo ngu s
393
Muscles of the leg: Posterior View
~
o
.....
Gracilis
Gast ro cnemius,
lat eral head (0 )
Semi- - --''-IH 6fff.
memb rano sus Plantari s
Sol eus
Achillestendon
Soleu s
Flexor
Flexor
digitoru m longus dig itorum long us
Flexor Flexo r
hallucis lo ng us hallucis lo ngus
Lateral
ma lleo lus
hallucis lo ng us
A Note: Th e b u lg e o f t h e calf is p rodu ced main ly by th e tri cep s su rae B Removed: Gas trocn e m ius (b oth head s) .
394 (so le us and th e t w o h ead s of th e ga st ro cn emiu s).
1'1- - - - Planta ris (0 ) ; - - - - Planta ris
Gastrocn em ius. - - --r.i!T Gast rocne m ius. - - -----;'!:!lI"
med ial head (0) med ial head
·v !..----- - Gastrocne m ius. ~. '!l.------- Gastrocnem ius.
lat eral head (0) lateral head
brev is
Crural - - -- --i
chiasm
J-~iiIi.:4I'~~-- Triceps Planta ris ---I~"II~~r--- Triceps
surae (I) surae
Plant aris (I)
Flexor Flexor
hallucis lon gu s digit or um longus
Flexor
hall ucis longu s
Go!.---'l!'''---'' - ---'- Flexor
digitorum longu s
C Removed: Triceps surae, planta ris. poplit eus, and fibul aris D Removed: All m uscles.
longus muscles. 395
Muscle Facts (I)
- -+-- - Femur
Fig.25.22 Lateral compartment
Righ t leg and foot.
-:-;:--;:-'-j~- Lateral
tibi al
condyle
Lateral t ibial
1st metatarsal
surface
1-:-- + - - Interosseous
memb rane ...,:a.- - Medial
cuneiform
CD Cuboid
Fibularis
longus
tendon
Fibularis -----li~-S
t ertiu s
Lateral
malleolus
Lateral compartment
Muscle Origin Insertion Innervation Action
: Fibula (head and proximal t wo third s of th e • Talocrural joi nt: plant arfl exion
. CD Fibularis : Medial cuneifor m (plantar side).
. lat eral surface. arising partl y from th e • Subta lar joint: eversion (pronation)
longus ; 1st metatar sal (base) : Superficial
intermuscular sept a) • Supports t he tran sverse arch of the foot
................................................................................................... .....: fibu lar n. . .
Fem ur
Fig. 25.23 Anterior compartment
Right leg, anterior view.
Lateral
t ibial
condyle
Head of A
fi bula
Tibial
tuberosit y
Shaft of t ibia
.,-'-~rl--- Tibialis
ante rior
IP MTP
Muscle Facts (II)
~--- Fe m u r
Gastrocnemius.
medial head
(cut)
- - Lateral femoral Plantaris
Medial femoral epicondyle
epicondyle Gastrocnemius.
Plantari s
lateral head (cut)
Plantaris
Gastrocn emi us. -~--,
t endon Soleus
lateral head
Gastrocnemius.
A Sch emati c. Fo ot Triceps Gast rocnemius. - ---ii;lc---- Triceps
medial head
surae medial head surae
in p lantar fl exio n .
Gast rocnemius.
lat eral head
- +-- - Femur
) -0
Pop liteus
A Schemati c.
t uberosit y
Calcaneal - i..L.f'e,.., Lateral Calcaneus - - - t-
Late ral
tu berosit y malleolus malleolus
Tibialis - I
Tibialis -----,--~, ~... Tuberosit y
Tuberosit y
post erior posterior ~r.t--- of 5t h
Talus t endo n
of cuboid tendons met at arsal
Tibialis post erior -~~,'1lI[
tend on Tuberosit y
Flexor H.,.~1¥t-~-- 1st th ro ugh
of 5t h hallucis
Medial 5t h m et a
me tata rsal longus
cuneifo rm \+->t7W"---- Flexor tarsal s
tendon digit orum
longus
tendons
............................ ......................................., .
.. . . . . . . . .. . ... . . . . .. .: ~ Su.p po rts th e medial long itudinal arch
: Lateral fem oral condyle, posterior : Posteri or tibi al surface (above th e ' Tibial n. : Knee joint: flexion and internal rotati on (stabilizes th e
: @) Popliteus : horn of th e lateral m eniscus • origin at th e soleus) (L4-S 1) . knee) . . .
: , ; ..
• IP = inter phalangeal: MTP ~ met at arsophalangea.'.: .
Bones of the Foot
.Q Fig. 26.1 Subdivisions of the Fig. 26.2 Bones of the righ t foot
,§ pedal skeleton
.... Right foot, dor sal view. Descript ive anatomy
~ divides th e skeleta l element s of th e foot into
, st distal phalanx - - - -
....o th e t arsus, metata rsus, and forefoot (ante
ta rsus). Funct ional and clin ical crit eria divide
Forefoot
(phalanges)
j } Foref oot
Head ----7---'''' 5th proximal phalanx
!
, st met a- Shaft _ _ ~,.----.
Metatarsus tarsal
(metatarsal bones)
~-- 5th metat arsal
Calcaneus
Talus
Calcaneus , st metatarsal
Cal
caneal -l.-+-"
tuber
osity
La teral
cuneiform
Lateral process of Medial process of Tuberosity of 5t h 5t h proximal 5t h middle 5th distal
calcaneal tub erosity calcanealt uberosity 5t h met atarsal metatarsal phalanx phalanx phalanx
B Lateral view.
400
..........------- 1st dista l phalanx
---.ll- - l st
met atarsal
Med ial
cuneifo rm
Intermediate
Tuberosity of cuneiform
5t h m etatarsal ~
- - - Lateral
Groove for ------'=.-~~ cuneiform
fi bularis
longus ten don ~ -'l"- - Navicular
Tuberosit y
of cubo id - -c"-- Head
Cubo id - - - - Neck
. ~--- Body
Talus
Calcaneus - -+---:-
.;- - - - Posterior
process
ta li
C Plantar (in ferior) vi ew. Neck
Head Body
1 st
Medial
~
et a ta rs a l
t ubercle Posterior
Proxim al phalanx Base process
Late ral ) of t alus
of big toe Shaft ~ t ubercle
~ Head
~, c. Base
Shaft
Head
Calcaneal
tub erosity
401
Joints of the Foot (I)
Talocrural (ankle)
joint
~
Metatarsophalangeal
joints
Proxima l
inte rphalangeal Fibula
joints , t,l7~f,l-T---- Tibia
Lateral
malleolus
i:J.,!,~~"!-;;',...;-",,=---- Talocru ral (ank le)
Interosseous joint
Distal
talocalca nean
int erpha langeal
. ' ~7'T--- Medial
ligament
joints
malleolus
Calcaneus
Talonavicular
A Anterior view. Transverse jo int
ta rsal jo int Calcaneo
cubo id joi nt jo int
Cubo id - - -+---+-p.,;. ;.:l:'!~..;;.---- Interm ediate
Intercuneiform ---r--;'!T.rt,,*~~ffi'¥.'4'+-J cuneifo rm
joint s
402
Fig.26.4 Proximal articula r surfaces Fig.26.5 Distal articular surfaces
Right foot. proximal view. Right foot . distal view.
Base of 1st
proxim al
Superior tro chlear
sur face of ta lus
~ A
to..J
O'l
I
~
phalanx :t:.
B
-
:::l
;:I;
l'tl
Q
1(0
Head of ta lus (w it h
articu lar surface
C cr
...,.
0
fo r navicular)
i
A Metata rsophalangeal joi nts.
D
- Calcaneus
t
~--r---,---,----,- 1st throu gh
Calcaneus (w ith art icular
5t h met at arsals surface fo r cubo id)
A Talonavicular and
calcaneocuboid joints.
cuneifor m cuneifo rm
Talus
Intermediate
cuneifo rm
Medial
cuneiform
----'l~-- Cubo id
Medial - ----''t-
cuneiform
......lII;::;:iill.-l-- Tuberosity of
5t h me tata rsal
Calcaneus
~
l st
Base met ata rsal
Shaft
Navicular - -'t---IL- - ---1~-- Cuboid Head
403
Joints of the Foot (II)
Talocrural jo int
Talus
1st
met atarsal Tuberosit y of 5t h metat arsal
Calcaneal tuberosity
Ankle m or ti se
Ext ensor
Tibialis halluci s
anterior
Ext ensor
digito rum
Flexor
hallucis longus
Fibularis longu s
Posterior - --7"----'
tib ial aa, and vv.
404
Fig. 26.7 Talocrural and subtaler joint s: Sagittal section
Interosseous Tibia
Right foot , medial view.
ta localcanean ligament
Talocr ural joint
Talocalcaneonavicular joint
(anterior compartment
Navicular
f+7+-- Achi lles'
Cuneiforms tendon
2nd metatarsa l
Calcaneus
Fibula Fibula
- +- Ank le
Media l mortise
malleo lus
Lateral
Talus
malleo lus
Superior t roch lear surfac e of ta lus Sustentac Superio r troch lear surface of
(anterior diam eter ) ulum ta li ta lus (posterior diameter)
Inferior
Anter ior articular surface
diameter
Media l
ma lleo lar
surface
Media l
Superio r ma lleo lus
troch lear
surface
Posterio r ...J
diameter
Lateral ma lleo lar Media l malleolar
Lateral tubercle art icu lar surface articu lar surface
C Proximal (superior) view of ta lus. D Distal (infe rior) view of ankle mort ise.
405
Navicular Lateral ma lleolar Fig. 26.10 Talus and calcaneus
artic ular surface surface The t wo tar sal bon es have been separate d at
Anterior t alar art icular th e subta lar joint t o demon strat e th eir art icu
surface lar surfaces.
Posterio r
process
ofta lus
t ubercle
Groove fo r
flexor hallucis
lon gus tend on
~ /I - --!!! -- Posterior t alar
artic ular
surface
Lat eral Sustent ac-
tubercle ulum t ali
Lateral malleolar
su rface ~
Posterior calcaneal Navicular artic ular
art icular surface surface
Posterior t alar
artic ular surface Midd le ta lar
artic ular surface
Sinus t arsi
B Lateral view.
Cubo id art icular Middl e calcaneal
Sulcus ta li
flexor hallucis
articu lar surface
longu s tendo n
Medial t ubercle
Medial
Anterior ta lar - -
art icular surf ace ~---=~~- Sustentac
~
ulum t ali
Cuboid articular
surface --.",-'!~-- Calcaneus
D Medial view.
407
~--+--- Inte rosseous
membrane
+- - Fibula
Deltoid I. Lateral
malleolus
lWJi!-- - - Calcaneofibular
I.
Calcaneus
~r--- Tibia
Fibula - - -
Lateral
m alleol us
Dorsal tar sal II.
Anterior ta lo
fibular ligament
Calcaneus ----:-'- - -
Long plantar I.
Bifurcate I.
Medial - --',,---'S---..'-1f+l
rays Lateral rays
Cuneiforms --f';'~~h--;; l
Cuboid
Talus ---,- B Pes rect us: C Pes p lanus: Loss O Pes cav us: E Pes t ransve rse
Norma l p lant ar of lo ngitud in al Increa sed heig ht p lanu s: Loss of
arches. arch (flat fo ot) . o f lo ngit udi nal tran sver se arch
arch. (splay foot).
Plantar
ligament
B A nt er ior arch
(fo refoot) , Base of 1st Deep transverse
Deep --Pw"---::3--'h~ 1st proximal phalanx
p roxim al v iew . proximal phalanx met atarsal ligament
tr ansverse
met at arsal 1st met at arsophalangeal
ligament joint Adductor
hallucis,
~"4'H;--+- Adducto r hallucis, transverse
t ransverse head head
Tibialis posterior
Fibularis
-
longus
Medial malleolus
Sustentaculum
tali
410
Fig. 26.14 Stabilizer s of the longitudinal arch
Right foot , medial view.
Flexor hallucis
longu s
Flexor digitorum
Navicular Talus lon gus
_ _-.!~-!+ Medial
Medial
cuneifo rm m alleo lus
Medial
t ubercle
Quadratus
planta e
Plantar aponeurosis
411
Muscles of the Sole of the Foot
Transverse
Fig.26.16 Intrinsic muscles
fascicles Right fo ot, p lantar view.
Flexordigiti - --l;-r,.
min imi brevis ,7 77- - Flexor
hallucis brevis
3rd plantar ---l-h~' 'lI ' k
int erosseus
. :~--- Medial
plant ar septum
-~ii~~~~M~:10~~':I~1
Abduct or
hallucis Flexor
digitorum
Plantar ------'\'--'c-----'~\"(.
brevis ,,!--fh tl/l-- Flexor
aponeurosis
tendons hallucis
longus
tendon
4th do rsal
- - - - Flexor interosseus --If-+4-'!'l~' hallucis brevis
hallucis longus
Flexor digit i - ----+-+<l, ff-IHilf-'iiI -- - Flexor
minimi brevis dig itorum
- - -- Calcaneal tub erosity brevis
Abductor
digit i minimi
Abductor
hallucis
Fibularis _ _ -+1
longus Tibialis posterior
'!I---_ _ Flexor
Plantar - ----liI'I-"''---!....}'--'
digitorum longus
aponeurosis
.~;,----- Flexor
hallucis longus
412
FIexor ---, +-if",---;lfiIjtT:jffi;ift;IJ
digitorum brevis ......h drH-- - Flexor hallucis
tendons longus t endon
Flexor --*\.'..I.~~--\\\-WHi-V-
digito rum longus ,1d~4-",r:,:n 4.f-fl!ilIf--- Adducto r halluc's,
tendons tran sverse head
~t-\-W;;rl!H\~~f!~"; Iw.iIll--- Lumbricals
3rd planta r
~~-- Flexor
interosseus
Flexor digiti - - H k
-~-IJ- "';'T- - - Flexor
min imi brevis di gitorum longus
Abductor
'.H,-7.----t+~-"-1t_-- Fibularis longus
digiti minim i
tendon
Abduct or
hallucis
Quadrat us ---,----~~
plantae
Flexor digitorum
Flexor
longus
digit orum -+._- - Flexor hallucis
" ••.1- Flexor hallucis
brevis longus
longus
digitorum
brevis
tendons
hallucis longus
413
Muscles & Tendon Sheaths of the Foot
Flexor digiti m inimi brevis --ft~ \ "'-- - Tibialis ant erior tendo n
--n- - - Tibi a
Ext ensor - - ---f-jP 'T:
digitorum longu s -t-~4lt--- Exte nsor
hallucis longus
Fibulari s -
brevis
Superior - - - --H";,-- -
extensor
Medial
retinaculum
mall eolus
Fibularis
brevis .--1.r"'\-¥-~+-- Tendo n sheat h
Tibialis -
Fibularis terti us - - --:cc-JI ~e:r,~:-+--- Ext ensor hallucis brevis ant erior ',~I;-i-7---- Triceps
(variable)
nTfliHilll\-lk--i\lH'~--- Extensor surae
Tuberosity of Tibia - -tt--
digitorum brevis
5th met atar sal -+-,ITH--i- - - Flexor
Extensor digitorum digitorum longu s
Superior ______
Abduct or longus tendons
digit i min imi extensor ----- Tibialis posterior
!J+.-f-IbI---RcMa,.U --;I.+-,, - - Int erossei retinaculum
-1"'-'. - Exte nsor Medial malleolus
hallucis longus
~!..-l--- Flexor
tendon
hallucis longu s
c. '-'!t+-- - Tendon sheat h
Achilles' tendon
----'~--'-+-- Flexor
retinaculu m
Fibularis
Inferior te rt ius
extensor reti naculum
Ext ensor
Lateral malleo lus digito rum brevis
Exten sor digitorum
longus tendons
Superio r ----t------::;;~-
Extensor
fibu lar retina culum
hallucis longus tendon
/ Exte nsor
Fibularis longus digitorum
Inferior brevis t endon s
fi bular retin aculum
Abducto r
dig iti minimi
C Lateral view.
Dor sal aponeurosis
415
Muscle Facts (I)
~ The dorsal surface (dorsum) of th e foot contains only two brevi s. The sale of t he foot , how ever, is com posed of fou r comp lex layers
~ muscl es, t he exte nsor digitorum brevis and the exten sor halluci s that mai nt ain t he arches of t he foot.
.--?r- - Extensordigitorum
brevistendons
5t h distal phalanx
1st ----.-
proximal
phalanx 5th middle phalanx
Navicular - -F--.,.-,
Tuberosity of 5t h metatarsal
!f----- - - Calcaneus
o Extensor hallucisbrevis 1st toe (at dorsal aponeurosisand proximal phalanx) : Extension of t he MTPjointsof t he 1st toe ;
~~~I---- Cruciform
ligament s
Sesa moids
:"=~~:-:tl---- Flexor
digitorum brevis
1- - Plantar
aponeurosis
Calcaneal tube rosit y 1st t oe (base of proximal phalanx via • 1st MTPjoint: flexion and abduction of the 1st toe
Q) Abdu ctor hallucis
(m edial process) the medial sesamo id) Medial plantar • Supports the longitudinal arch
2nd to 5th to es (sides of middl e n. (S1, S2) • Flexes the MTPand PIP joints ofthe 2nd to 5th toe s
o Flexor digitorum brevis Calcaneal tuberos it y phalanges) • Supports the longitudinal arch
(medial tubercle), • Flexesthe MTPjoint of the 5th toe
plantar aponeurosis 5th toe (base of proximal phalanx), Lateral plantar
G) Abdu ct or digiti minimi • Abdu cts the 5th t oe
5th metatarsal (at tuberosity) n. (S1-S3)
• Supports the longitudinal arch
.ll'-\lli'-ili~~i--- ®
(j) ------;~'J1\\\ft
G)- -"--"
Flexor digitorum
longus tendon
CD Quadratus Calcaneal tuberosity (medialand Flexor digitorum longus tendon Redirects and augments the pullof flexor
Lateral plantar n. (51- 53)
plantae plantar borders on plantar side) (lateral border) digitorum longus
1st lumbrical: medial plantar • Fl exes the MTP joints of 2nd to 5th toes
o Lumbricals Flexor digitorum longus tendons 2nd to 5th toes (at dorsal n. (52, 53) • Extension of IP joints of 2nd to 5th toes
(four muscles) (medial borders) aponeuroses) 2nd and 4th lumbrical: lateral • Adducts 2nd to 5th toes toward the
plantar n. (52, 53) bigtoe
Medialhead: medial plantar
1st toe (at base of proximal n. (51, 52)
Q) Flexor hallucis Cuboid, lateral cuneiforms, and • Flexes the first MTP joint
phalanx via medial and lateral
brevis plantar calcaneocuboid ligament Lateral head: lateral plantar n, • Supports the longitudinalarch
sesamoids)
(51,5 2)
Flexor
digitorum
longu s
tendon s
1stthroug h
4th
lumbri cals
3rd planta r
--~"
interosseus
Medial
cuneiform Lateral sesamo id
Met atarso "---~,,,"=~+--!--c~~~~--"-;'!S--f!
)( phalangeal Medial sesamo id
Tuberosit y joint
of 5t h capsules
met atarsal Quadratu s TranSVerse}
plant ae head Addu cto r
digi t orum
longu s Flexor -~L;, I. Medial }
Fibul aris - head Flexor
longus digiti
Lateral hallucis
t endon minimi
head
Flexor brevis
digitorum
brevis
Fibularis
- ~..,.. ~~-,-!..!-~~ Tibialis
longu s
posterior
t endon
t endon
Lateral process
- --\--
419
Arteries of the Lower Limb
Abd ominal
~ ~- Abdomi nal
aorta
Comm on -----.-i'~ aor ta
iliac a. Comm on
Int ernal iliac a.
iliac a.
Ext ernal
------'.,...-~ Deep circum Internal iliac a.
iliac a.
flex iliac a. Superior and inferior
- ---¥- - Inguinal glut eal aa.
Superficial
ligam ent
epigast ric a. Ext ernal iliac a.
Superf icial circum - - - --I-"........r. ~~;L_ Inferior
Profunda
femo ris a.
- i U>-- flex iliac a. epigastric a.
Piriform is ~~h--9-- Ext ernal
pud endal aa.
Addu cto r
- - -L.... iJ Lateral circum -~c-~;x~I p..~~
flex femoral a.
canal
Profunda
- - + --PI-..!!I Medial circum flex
fem oris a.
femo ral a.
1st t hro ugh 3rd
----+'-'H---iW I
perforating aa.
B-- - - Femora l a.
genicular aa.
Medial superior and
inferior genicular aa.
A B Anterior tib ial
------'~rl
recurrent a.
Anterior - - -+-H :
\"P-----!I------,~ Proper plant ar ti bial a.
digita l aa.
Arcuate a.
- - 4 ,f;
hallucis
Lateral
---~--'IlII.1 Dorsal metatarsa l
plantar a.
aa.
Medial
plantar a.
Posterior
t ibial a. C Course o f t h e arteries , ante rio r view.
420
~ Clinical Fig. 27.3 Arteries of the femoral head
Rig ht hip joint. anterior view.
Acetabular roof
Acetabu
Femoral lar fossa
neck vessels
Ligam ent
of head
Synovial Foveal a. of fem ur
m emb rane
Medial circum
Fibrous -~~--~C¥~.
flex femo ral a.
mem brane
Zona
Iliopsoas orbicularis
tendon
Profu nda
femoris a.
Lateral circumfl ex
femoral a.
Lesser t rochant er
A Right fe mur.
Popliteal a.
Lateral superior
genicular a.
Medial superior
genicular a.
Sural aa.
Popliteal a.
Medial malleolar
branches
Medial
~ )-7.b---- Calcaneal
plantar a. branches
A Perforating arteri es, poster ior view. C Arterie s o f th e p o sterior leg . 421
Veins & lymphatics of the lower limb
.Q Fig. 27.5 Veins of the lower limb Fig. 27.7 Veins ofthe leg
.§ Righ t limb, anterio r view. Right leg, posterior view.
-.l
~o
Superficial
circum fle x
Superfi cial
epigastric v.
-.l iliacv. Fem ora - - -+--\
Inguinal ~dc--- Ext ern al popli t eal v.
External ligament "r--+--- Popli t eal
Femo ral v. i1 iacv.
(in sapheno us pud endal vv. v.
Pir iformis Long
hiatu s) sapheno us
Ante rior
v.
fem oral Lat eral Medial
Accessory circ umflex
cut aneo us v. circum flex
saphenous v. femora l fem or al
vv. vv.
Deep l----ft-,------:::- Long
femora l v. saphen ous Post erior - - --,-, Short
v. arch v. saphenous
Fem oral Accessory v.
v. sapheno us
v.
Lon g
sapheno us v. Ad ductor
canal
Poplitea l
v,
Add ucto r
hiatu s I+ -+-- Add uctor A Superfi cial (epifascial) veins.
magnu s
network
saphenous v. Shor t
sapheno us v.
Ante rio r
A Superficial (epifascial) veins.
tibial v.
Anterior ----\~-;
Fibularvv.
ti bial vv.
Fig. 27.6 Veins of the sole of the foot
Right foot, plant ar view.
Posterior Sho rt
t ibia l vv. sapheno us v.
Short --~ II ' J'l1
sapheno us
v.
W'-'tf-~---f'=n>-q.-- Piant ar
di gital
Plant ar - - +-H''--\--,,,*---jl w .
meta t arsal
Dor sal _-"---=CLU ,
IJ-r---H:--+! -- Do rsal
vv.
veno us
veno us Lateral
arch network malleo lus
Pianta r ---t--\-'-'---\7--'11
ofthe foo t
veno us
arch
f"'---"=--- Medi al
plant ar v.
B Deep veins.
v.
Sho rt
saph enou s
v.
Post erior
tibial vv.
422
Fig. 27.8 Clinically important Fig. 27.9 Superficial lymphatics
""'\ ~
-
perforating veins Rig ht limb. Arrows indi cate t h e ma in direc tion s o f lymphati c dra in age.
Right leg , med ial vi ew. /
-,//
External
iliacv.
\ Superficial ---;-,,-,
inguinal
Ln.
Scrot um -t ~:-c:-_
~\, "
Long
saphenous A An t eri or v iew. B Post erior v iew.
v.
Boyd's vv.
Fig.27.10 Lymph nodes and drainage
Right limb, anter ior view.
Com mo n iliac v.
Supero medial
(
Ln.
Inferior
Ln. Deep iliac lymph nodes
Superficial ing uinal lymph nodes Inguinal ligam ent • Receive drainage from
• Receive drainage from - Deep portions of
th e lower limb
- Skin ofthe limb Long
- Lower back
- External genitalia
Femora l v.
(in women, also the ut erine fundus
Superficial popliteal
Deep popliteal lymph nodes lymph nodes
423
lumbosacral Plexus
~ The lum bosacral plexus supplies sensory and mot or inn ervati on t he lum bar and sacral spinal nerves, w it h cont ribut ions from t he subcos
~ t o th e lower lim b. It is fo rmed by t he ant erior (ventral) ram i of t al nerve (T12) and coccygea l nerve (Col).
ilioinguinal n.
Genitof emoral n.
Pudendaln. --~--~~
Inferior ------'r~
cluneal nn.
cut aneous n.
• Ilioing uinal n. . __ - ~ 427
: Sacralplexus
Deep
fibu lar n.
Tibial n. ----t-+-----;,
Superficial
fi bular n.
Medial and
lateral
plantar nn.
424
0- T12 Fig. 27.11 lumbosacral plexus
Subcostal n. ~ Right side, anterior view.
k j- Ll
lIiohyp o- - - - -,;
gastri c
n.
Ilioinguinal
n.
lumbar
plexus
~ ...--- l S
, -' - - Tl 2
12t h rib
~--.;~ 4Iiiiil~l_
.... . . :-· vert ebra
Subcost al n.
Superior
glut eal n.
Iliohyp ogast ric n. _______
Inferior
gluteal n.
Sciatic n. - - ---'I"
- Co l
-----:;-----"~~~~~
Sacral
plexus Genit o-
femor al n.
Coccygeal plexus.
anococcygea l nn. ~~~~~- Coccygealn .
Muscular
branches
Ant erior Pudendal n.
fem oral - --!----..- - - -r--<0f:7tt,
cuta neous Inguinal
branches ligament
Femo ral n.
Muscular - - H r -;-
branches
Saphenous n. _ _ l--++--;-~~
Sciatic n.
(common fib ular n.
and t ibial n.)
.Q
Nerves of the lumbar plexus
.§
-.I
Nerve Level Innerva ted m uscle Cut aneous branches
~o Iliohypoga stric n. T12- Ll Anter ior and lateral cut aneous branches
-.I Transversus abdomin is and internal obli que (inferior por ti ons) d : Ant erior scrot al nn.
Ilioingu inal n. L1
9: Ant erior labial nn.
Genita l branch
Genitofem oral n. Ll-L2 ci : Cremast er (genit al branch)
Femoral branch
Lateral fem oral cutaneous n. L2-L3 - Lateral femo ral cutaneo us n.
Obt urato r n. L2-L4 See p. 428
Femoral n. L2- L4 See p.429
Psoas major
Quadratu s lumborum
Short, direct muscular branches T12- L4 -
Iliacus
Intertransversarii lumborum
Lateral
cutan eous
Iliohyp o branch
gast ric
n. Ante rio r - - -+!-I-'--+- - - - ---,
cut aneous
branch Ext ernal inguin al ring
Ilioinguinal n.
426
Fig.27.13 Nerves of the lumbar plexus
Righ t side. anterior view wit h the anteri or abdom ina l wa ll rem oved .
Iliacus - ---..-..,
Lateral Iliacus
cut aneous
branch
n f - - - - Quadratu s
lumborum
Iliacus
:.=~-- Genit ofemor al n.
Late ral femor al
Inguinal
=-- - Psoas majo r cut aneous n.
ligam ent
Iliacus - - -L....-''!!
Inguinal - ------'- _
ligament
Spermat ic
Fascia lat a _--.L.--+_ -+\ _ cord
Femoral
- - -+---<.. Genit al branch
branch
C Genitofemora l ne rve .
427
Nerves of the Lumbar Plexus: Obturator & Femoral Nerves
~
....e
Pectin eus
brevis
; Sensorybranches
: Cutaneous branch
428
Fig. 27.16 Femoral nerve
Rig ht side . ante rior view.
Iliacus ---';---'-;---7'Ii--'-<-,
cuta neo us
branches
Infr a-llar
pate
Pecti neus
branch Saphenou s
Medial n.
; -- - - - - -i-- - Saphenou s
cut aneous
n.
branches
Muscular
branches
Vastu s
int ermediu s
Vastus
lateralis
Vastus
media lis
..,L-__ Sartorius Fernoralnerve{ 12-L4)
Motor branches Innervated muscles
Pecti neus
i Muscular branch es
i Sartorius
.............................................
: Quadriceps fem ori s
, Sensory branches
. Saphenou s n.
Ti-:- - - Sapheno us n.
429
Nerves of the Sacral Plexus
Gluteus medius
Superior gluteal n. L4-s1 Gluteus minimus -
Tensor fasciae latae
Inferio r glut eal n. L5-s2 Gluteus maxim us -
: Inferior clun eal nn.
Posteri or femora l cut aneous n. 51- 53 - Posterior fem ora l cutan eous n.
: Perineal branches
N. of pir iformis 51-52 Piriformis -
Obturator internus
Direct branches N. of obturator internus -
L5-s1 Gemelli
N. of quadratus femoris Quadratus fem ori s -
Common fibular n. L4- s2 See p. 432
Sciat ic n.
Tibial n. L4-s3 See p. 433
Fig. 27.18 Sensory innervation of the gluteal region Fig.27.19 Posterior femoral cutaneous nerve:
Right limb, posterior view. Sensory distribution
Right limb , post erior view.
Dorsal
ramu s
430
~ Clinical
Shifte d
center
of gravity
Pelvis
--'ii l i- - - GIute us sags
m edius
~--- Tensor
fasciae Stance leg
latae
Swing leg
- - - - Iliot ibial
t ract
Piriform is
(w it h n.)
~---i.<;-JJr-T--- Glut eus Gem ellus
Inferior ------,,r-- -.,.-'---'-.J maximus Obt urato r superior
glute al n. internu s (wi t h n.)
::::::~"""'----''<--- Gemellus
Muscular Sacrotuberous inferio r
branches iigament
Quadratus
fem oris
(w it h 11 .)
Sciatic 11 . - -----<. Sciat ic n. - -- - - - - ----:-1
B Inferi o r g luteal n erve. Poste rio r vi ew . C D ir ect bra nch es. Poste rior vi ew.
431
Nerves of the Sacral Plexus: Sciatic Nerve
~ The sciat ic nerve gives off several direct mu scular branc hes
~ before dividing into t he t ibial and com mo n fibu lar nerves
proximal to t he pop lit eal fo ssa.
Fig.27.23 Common fibular nerve
Fig. 27.22 Common fibular nerve: Sensory distribution Right lim b, lateral view.
."'j"-- Anterior
superior
iliac spine
Lateral sural
cutan eous n. Sciat ic n. - - _.. ...
Fibul ar
communicati ng
branch
A Right leg, anterior view. B Right leg, lat eral view. H ,:tt4I----!- - Biceps femoris.
long head
432
Fig. 27.24 Tibial nerve Fig. 27.25 Tibial nerve: Sensory
Rig h t li mb. distribution
Rig ht low er lim b. po st er ior v iew .
Proper
plant ar
-~~H1+1kNi\--H
digit al
nn.
~\ .'lh- Muscular
ficial branch cut aneous
branches n.
Abducto r
dig iti mi nimi ;.-<-+-- - Fibu lar
--\H1r1--4-- Flexor communicati ng
digitorum branch
longus
tendon Sural --1-4---1
Lateral _ _..L.._
n.
plant ar n. - Abductor
hall ucis
Quadrat us
i N .!-l-- - - Lateral dor sal
plant ae
Medial cutan eou s n.
Medial
plantar Flexor calcaneal ~' ~.!.f----- Lateral calcaneal
Sciat ic n. --~~*~',
digit or um branches branches
n.
brevis and ~-.--!-+---,_-- Prop er plant ar
plantar digit al nn.
Sacro --~o'!l~~( apo neu rosis
tu berous
ligam ent Tibial n.
A Po st eri or v iew.
433
Superficial Nerves & Vessels of the lower limb
.Q Fig. 27.26 Cutaneous innervation: Anterior view Fig. 27.27 Superficial cutaneous vein s and nerves
,5
.... Right limb . Right limb.
~
....o lIiohypo - - - -IF- Genit ofem ora l n.
gast ric n.
Exte rnal
pud endal vv.
Obt urator n. Accessory
Femora l n. Femoral n., ------::'----i-i~
saphenous v.
ant erior femora l
cutaneou s
branches
Lon g
saphenous v.
Fascia lat a -----'o--f-+---'---f--
Cf~~~~~.
Obt urat or n.
Sciat ic n.
{
Tibial n.
Saphenous n.,
infrapatellar
branch
A Periphe ral sensory cuta neous inn ervation .
Saphenous n.
(fem oral n.)
Lateral sural
cuta neo us n.
---/'i
~
Lon g
saphenous v.
52 --I'---~+
(common
L2 - -!-- - fib ular n.)
L3 - -\'r-....,..,,
Superf icial
fibular n.
Deep fi bular
n.
L5 ---+-+
51 - --+ A Anter ior view.
B Segmental, radicu lar cuta neous
inn ervat ion (dermato mes).
.. . . . ..... . .. ~ . ..... . . . .
434
Fig. 27.28 Cutaneous innervation: Posterior view
Right limb.
Inferior
- - -'k:;:----<
cluneal nn.
Lateral femoral
Com mo n
cuta neous n.
fib ular n.
Medial sural
cut aneous n.
(ti bial n.)
Saphenous n.
(femoral n.) Lateral sural
cut aneous n.
L3
(common fibular n.)
55
L4
54
L5
-t
53
Short ---~~~
saphenous v. h--i~--- Sural n.
52
(tib ial n.)
51
Calcaneal
branches
...IJIi'~-- Lateral dorsal
cut aneous n.
(tib ial n.)
branches
L4
--~..'
B Post er ior vi ew.
B Segmenta l. radi cu lar cutaneou s L5
inn ervation (d erm atomes).
• • • • • • .. ~ .. • • • • • • .. • . o. o....o.o.o..o.o.. . t • • • • • • • • • • • • •
435
Topography of the Inguinal Region
Long
saphe nous
v.
abdo m inis
Transversus
abdomin is - - - - -+l - - - - - Ant erior rectu s
cuta neous n.
iliac a. and v.
Superf icial
inguinal Ilioinguin al n.
ring
~<""::,,,-----~r..:---.----- Genitofemora l
Ext ernal
Ant erior
fem ora l
cuta neo us v. Long sap he no us v. Pe ct in eu s
436
Ilioin guinal ligament
Structures in t he inguinal region
Anterio r
~ Region Boundari es Conten ts
superior
j Ant erior superio r iliac : Femoral n.
iliac spine
: CD Lacu na : spine : Lat eral fem oral cut aneous n.
mu scul orum : Ingui nal ligament : Iliacus
.· l l i?p.~~t i~~~ I ~ rch : Psoas majo r .
: Ingui nal liga me nt : Femo ral a. and v.
: 11) Lacu na
: Ilio pectin eal arch : Genit of emora l n. (femora l branch)
vasoru m
Iliopect ineal
~a~u.~~~ l ig~ rnent~?s~~rn u lle~·~ Iy.rn Ph node
arch Reflex ing ui nal • Med ial cru s j Ilioing uinal n.
ligam ent :0 Ext ern al
: Lat eral crus : Genitofemo ral n. (genita l branch)
lIio pu bic in gu inal ring
Pubic tubercle : Reflex inguinal ligam ent : Sperm at ic cord
em inence
Ext ern al
--.,------2~~~
obl iq ue
Fem or al n. --------~--'Il
Lacuna {
m usculo rum Iliacus --~~~
Iliopsoas { Int ercr ural fi bers
Psoasmajo r
Medial crus Exte rnal
Ilio pectin eal bursa Lateral crus } ingu inal ring
Lacunar ligament
Femo ral branch of
genit ofemo ral n. Pubic sym physis
Lacuna Femora l a.
vasorum and v,
{
Rosenrnuller's I.n.
Ischial spine
Ischial tu berosit y
437
Topography of the Gluteal Region
~
o
-.l
(glute us maximu s)
lateral branch
Gluteal fascia C Deep g lutea l reg ion . Partially removed: Gluteu s ma ximu s.
(gluteus m edius)
Midd le
cluneal nn.
Glut eus
maximu s
Inferior
cluneal nn.
Addu ctor
magnu s
cuta neous n.
lon g head)
Semi
Sem it endi nosus
m embranosus
438
Sciatic foramina
Posterior Transm itted
Foram en Boundaries
superio r st ruct ures
iliac spine
Q) Suprapirifor m Superior gluteal a.,
portion and n.
V. ,
Glute us
Posterior superior ----t-":r----~ mi nim us
iliac spine
Tensor fasciae
latae
Superior gluteal
a. and n. Piriformi s
Geme llus
Inferior glutea l n. ~....::o..._~_,---'- superior
439
Topography of the Anterior & Posterior Thigh
- -- -- - External obliq ue
Superficial aponeurosis
circumflex iliac
a.
Tensor
fasciae latae
Iliopsoas --f-'-~.--j,.,-
Pect ineus
Profu nda _---.!Ll-!!.-~~I~
femo risa.
---¥'P'--';- - - Superio r
cluneal nn.
Iliohypo
gastr ic n.,
lateraI branch
Gluteal fascia
(g lute us
mediu s)
~~-- M i d d l e
cluneal
nn.
-'.'-!~i----
Glute us
ma Ximu s ~
Glute us ~~=-,,"=-- Glut eus
maximu s medius
Superior
:'-.----:--<+;+- - Inferio r glut eal a., V.,
cluneal and n.
4$;1\-. - - - Glut eus
nn. mini mu s
Inferior
*-'------c::'-!!-_ Adducto r glut eal n. Piriform is
mag nus
Pudendal n.
Medial circu m flex
~---"",=~!-- Post erior femoral a.
femoral Inferior
cuta neo us glut eal a. Trochante ric
n. Sacrot uberous
bursa
ligament Glute us
Posterior --~*"' maximu s
Fa scia lata, femo ral Quadratu s
iliot ibial t ract cutaneous n. femoris
Biceps femoris,
long head
~-t!'l:'------l-+- Add ucto r
mag nus
fibu lar n.
Gracil is ------1~
Addu ct or ----~+-~c__~
IP.:b::!\-- f'+- - Sural n. hiatu s -ilt r - - Biceps fem oris,
short head
Commo n
A Glutea l reg io n and t hig h . Removed: Fascia lat a.
Semi ---L.....tct-cH~ fibu lar n.
membranosus = i\f- - - Biceps femo ris,
long head
Tibial n. --~-t'--..l
Plant aris
Medial sural - - - .H-F----';
cuta neous n.
,f tr+- - - Lateral sural
cuta neous n.
Gastrocn em ius
B Neu ro vascul ature o f th e post eri or t high. Partially removed: Gluteus ma xi
rn u s, g lut eus m edius, and bicep s fem or is. Retracted: Sem im embra nosus. 441
Topography of the Posterior & Medial leg
~
o
-.l
Sem i- --H~.
Sem i- - . ------''?<-- H ten di nosus
tendi nosus ,""";'-4--'*- - - Biceps Gracilis
fem or is
Sem i- ---';~.,-----'-fl;-'
Sem i
me m bra nosus
m embranosus
Po plit eal a.
'\+'lv.r.-rt'-'lIT+-- - Med ial suraI and v.
cut aneou s n.
Tend ino us arch ---~-T
Long -1-% ;-- - Lateral sural of so leus Soleus
saphenous v. cut aneous n.
of th e leg
,+ -tD_- - - Fibul ar a.
Flexo r d ig it orum - --1ilI-...J'-c
lon gu s
+-1-- - - Tibi alis
post erior
Fibul aris
Flexor halluci s ----.----ii-7-fH-- ---,lj:-'
brevis
lon g us
Perforating }
br anch Fibular a.
Com m uni
cat ing br anch
Latera l malleolu s
m edial calcaneal
A Superf icial neurovascular st ruct ures. B Deep neurova scular st ruct ures.
442
Poplitea l Biceps femoris . Fig.27.37 Popliteal region
a. and v. Sciatic n. lon g head Right leg, posterior view.
Gastrocn emius.
Planta ris
Gastroc ----h--.~-~
med ial head
Subtendinous genicular a.
Short
bur sa of the
,..,,-----"'--- -'7- - - Lateral superior saphenous v.
media l gastroc
nemiu s head genicular a.
Planta ris
Midd le genicula r a.
I'",=~~~r--
~
Gastroc
nemiu s,
Sem imem branosus
lateral head
bur sa
Obliqu e pop liteal - -----;-+----'::: ~!?i~~~+-- Lateral inferior
ligam ent genicular a. B Deep lymph nodes of th e poplit eal region.
A Deep neurovascular str uct ures. Tibia - - .;+- h,..1"-'~-~- Tibial n.,
posterio r t ibial a.
Superior extensor
reti naculum
Medial
Medial malleolus ma lleo lar
(w ith subcutaneous bur sa) branches
Tibialis
po sterior
Inferior exte nsor
reti naculum Flexor digi
torum longus
Tibiali s ant erior
i-IJ--D --'_ - - Flexor hallucis
longu s
Medial
tarsa l aa. Achilles'
tend on
Ext ensor hallucis ~
longus te ndon ~ ~~+-;l-- Media l
Flexor
retina culum
443
Topography of the lateral & Anterior leg
Head of - - - - -
fibula
Short
head Iliotibial
Biceps {
~
Ti bia
fem oris Lon g tr act
Anterior
head """'- - "" Deep fibular n..
intermuscular
.• anter ior t ibi al
sept um • a. and v.
Patella
Super ficial
j~~~~~~~~d~[~~~-
fi bular n.
lo ng
Saphenous n.•
saphenous v.
Common
fibular n. Lateral t ibial Fibu la Interosseou s
cond yl e me mbrane
Posterio r
Head of fib ula --,j~-+t-'-'-'" Tibi al n.,
Ant erior crural intermuscular
sept um posterior tib ial
intermu scular
a. and v.
septum Fibular a.
and v.
Later al sural ----,fl!-,~---!-li ll ~!!--- Deep fibular
cutaneo us n.
n. Transverse Deep fascia
Superf icial inte rm uscular Sural n., short of t he leg
Gastr oc septum saphenous v.
nem ius fibu lar n.
Fibularis
Medial sural _II lon gus
cuta neo us Compartments of the leg
n. (t ibial n.)
Tibialis Neurovascula r
anter io r Compartment M uscular contents
Cornrnu - * -\"-:: conte nt s
nicating
branch ' - - Extensor Tibialis anterior
Fibularis tertius
Lateral
calcaneal
b ranches
444
~ Clinical
Fig.27.40 Neurovasculature of the leg and foot:
Anterior view
Rig ht lim b wi t h fo ot in p lan t ar f lexi o n .
Compart ment syndrome
Muscle edema or hematom a can lead to a rise in t issue pressure in th e
. st ruct ures m ay cause ischemia and irreversible muscle and nerve damage.
suffer excruciat ing pain and cannot dorsifl ex t he toes . Eme rgency incision
Pate lla - - --\--;:::-
of t he fascia of th e leg may be performed to relieve compression .
Pes anserinus
Pate llar ligament - - -----i\-+----:,-- (insert ion of
sartorius,
gracilis. and
semit end inosus)
Gast rocne mi us
Fibularis longus
Tibialis
anter ior
Fibula
_ - - - - - Tibia
Dorsal ---~f-~
Deep cuta neous n. Exte nsor
tendons aa,
Exte nsors ----.rif.H 'T:
digit orum I'\"f!-'--t-N-~c--- Deep fibu lar
longus and n., cutaneou s
brevis branch
tendon s B Ne u ro v asc u lat ure o ft he leg . Removed:
Dorsal ----rn~:i---HiJ+_'f_---+l_R_+l---H Skin, su bc u ta ne o us ti ssu e, an d fasciae.
digit al nn.
Retracted: Ti b ialis anter io r an d exte nso r
ha ll uc is lon gu s.
Dorsal -----~fdI'-------{~~-----tl-\l
digita l aa.
445
Topography of the Sole of the Foot
~
digital aa.
o
-.l Proper plant ar ------ff~:w.----'l1'H\:'--.L.Jiffi-_+._\\
dig it al nn.
Com mo n -"-4.----''---c-'*¥.'.-~~H...,..,.I
plant ar Medial plant ar
digit al nn. n.
Medial planta r
Lat eral -+~\ )
a., super
plantar a.
ficial bra nch
~
Lateral ------l--"I-----7.~rI-i1~. digital aa.
planta r sulcus Medial plant ar and nn.
sulcus
Flexor digi ------.~-----;:~U/~~~i"fh'I~'W,.;,nil1 11U~ '
toru m brevis,
Abdu ct or te ndo ns
halluci s
~,~~~HHil>,H;,~--.!!ii~H!---- Commo n
plantar
A Superficial layer. Removed: Skin, subcut ane Lateral plantar -----..:-'~-'m digital nn.
n., super
ous ti ssue, and fascia.
ficial branch Medial plant ar
a., super
Lat eral ---;-~~\-1 ficial branch
plant ar n.,
deep branch Medial plant ar
a., deep
branch
Quadrat us ---7+~'<-'
plantae Flexor digi
t orum longus
te ndo n
Medial
planta r n.
Abducto r
hall ucis
..L--;ll~-'----- Plant ar
apon eurosis
Plant ar
int erossei
Transverse
head
Obliqu e
1f Addu ctor
hallu cis
Plant ar met at arsal head
aa.
Flexor hallucis brevi s
Deep ----.,...-.b*'"*~~
plant ar arch
Medial plant ar
a., deep branch
Lateral -------,,;-~~~::t_J
plantar n., Flexor hallucis
deep branch longus t endon
Media l
plantar n.
Int ermediate
dor sal cuta
Interossei neous n.
Exte nsor
C Deep layer. Removed: Flexor digitorum digitorum longus Deep fibular n..
longus . Windowed: Add uctor hallucis dorsal pedal a.
3rd m etat arsal
(ob lique head). Extensor
halluci s brevis
Ext ensor
digitorum longu s
Dor sal m et a
Medial cuneifo rm
Abdu ct or
digiti min im i
Deep layer of
plantar fascia
Flexor digiti
---;----;;---~
m inim i brevi s
Lateral plant ar
a. and v.
Lateral
plant ar sept um
Lateral plantar
n., deep bran ch
Lateral plant ar n.,
supe rf icial branch Flexor hall ucis
brevis
Quadr atu s Apon euro sis
plant ae of fl exor Flexor halluci s longu s
digi toru m longus
Fibularis
longu s Flexor Deep Medial plantar
digitorum brevis plantar arch septum 447
Transverse Sections of the Thigh & leg
Glut eus
maximu s
Glut eus
Piriformi s
minimu s
Gem ellus
superior and
inferio r
Obtu rato r
inte rnus
Glut eus
maximu s
Gracilis Vastus
lateralis
Addu ctors brev is
and longus Biceps
femo ris.
Sciat ic n. short head
....L- - - Iliot ibial
Adductormagnu s --~~ t . I, 1
tra ct
Sem itendinosus ---~t-;!!--
Biceps
femoris,
Sem ime m branosus -----'fl'H~!.
long head
Plantari s
Gastrocnemius
Fibula
Tibia - - -!- - -
Interosseous
membra ne
Soleus
Triceps
surae Gastroc --7'L.-~
{
nerruus
Achilles'tendon - - - -4!-
448
Fig. 27.44 Transverse sections Quadri ceps femoris
--,
Right lim b, proxima l (superior) view. ~ .A~
Medial
sept um
Femu r
Sartori us
Femoral
a. and v.
deep femora l v.
Adduct or Sciat ic n.
brevis
Addu ct or
longus Lateral
inter
mu scular
Gracilis sept um
Anterior
interm uscular
Int erosseous septu m
m embrane
Fibularis
brevis
Tibialis
posteri or Fibularis
longus
Flexor
digitorum Posterior in
longus t ermu scular
sept um
Tibial n., posteri or
t ibial a. and v.
Fibula
Plantaris
te ndo n
Soleus
Transverse Flexor
Fibular
int ermuscular hallucis longu s
a. and v.
sept um
Gastro cnemiu s, Gastrocn emius,
medi al head lat eral head
449
Surface Anatomy
Fig. 28.1 lower limb: Anterior view Fig.28.2 Palpable bony prominences
Right lim b.
Iliac crest - --
Anter ior -
Anterior superior - superior
iliac spine - - Tensor fascia iliac spine
lata Pubic
/ t ubercle
Greater -
troc hanter - - Pubic
- --Rectus symphysis
femoris
Ischial
Adductor
tub erosity
long us
Vastus
medialis
Lateral tibial -
condyle 1 - - - Medial tibial
Tibial
condyle
tu berosit y
Tibial
tuberosity
- - Fibularis
longus
Gastroc
nemius - - -Tibialis
i -- - Medial
anter ior
surf ace
of ti bia
Medial
Lateral mall eolus
malleolus Navicular
I ~' tube rosity
F -'r-.-f::-- Extensor Tuberosity ----() /
of 5th .....r-:-.~-t--- Metatarso
Extensor digitorum
metatarsal phalangeal
hallucis tendons joi nts
longus
Interphalangeal joi nts of the foot
A Surface anatomy, right limb . B Musculature, left limb. A Ant erior view .
450
Fig.28.3 lower limb: Posterior view
Po steri o r ~
superior
Glut eus
iliac spine
m edius
Sacrum »->
Glut eus - - -
maxim us
Glut eal
fo ld Ilioti bial
t ract
-~~- B icep s
femoris
Medial - epicondyle
fossa
epicondyle
Head of fibula
Achilles'
t endon
Flexor -
--''--- - Calcaneal
Navicular tube rosity
digitorum I
longus
tuberos ity ~;L--- Sole of
- - - Tuberosity of tendon
foot Iiir:!~.--- Fibularis
5t h metatar sal longus
tendo n
B Posterior view . A Surface anato my, left lim b. B Musculature, right lim b.
451
Head & Neck
31 Cranial Ne rves
36 Oral Cavity & Phar ynx
Cranial Nerves: Overview 470
CN III, IV s VI:
Tem poroma ndibular Joint 540
38 Surfac e Anatomy
Eyeball 516
Nasion
/
Front al Parieta l bon e
in cisure
Suprao rbita l
Supraorbit al ~ . foramen
marg In I ._______________ ~:#~;r--- Sphe noi d bone,
Nasal bon e • greate r w ing
Orb it
Ethmoid bone,
plate
Maxi lla
Vome r -
spine
Mandibl e ---~--
~~~--;iif---- Ment al
for amen
~ Clinical
455
Fig. 29.4 Calvaria Fig. 29.5 Structure of the calvaria
Cross secti on .
Dural
sinus
Dura
mater
---"----~""'"~-- Fronta l
bone
Coronal
suture
Parietal
bone
Sagitta l
sut ure
Fronta l
Fronta l Fronta l
crest
bone sinus
Parieta l Lamb do id
fo ramen sut ure
Occipita l bo ne
Arter ial
grooves
Groove
for
Parietal superior
bo ne sagittal
sinus
Granular
foveolae
(for arachnoid
granulatio ns)
457
Fig. 29.7 Cranial fossae
The interior of th e skull base consists of three successive fossae th at
become progressively deeper in th e frontal-t o-occipit al directi on .
- ,,---';k - - - Ante rior
Ante rior
cranial fossa
cranial fossa
Middle Jugum
cranial fossa spheno idale ~~-- Lesser wing of
Poster ior sphenoid bone
cranial fossa
Dorsum _---;';~~~-"-c-___,
sellae
Forame n -~~~
magnu m
Foram en
mag num
A Midsagittal sect ion, left lat eral view. Fronta l B Superio r view of opened skull.
crest Front al
Et hmo id bon e,
Optic canal cri sta galli
Foramen
spinosurn Greate r wi ng
Sphenoid
Ar te rial bon e
groove Hypoph yseal
fossa (sella
Foramen lacerum
t urcica)
Dor sum sellae _~!,;;--:!=~""=~:o--:,.--------;---f.c------------:
Clivus
Hypoglossal --p;~~~~
canal
Internal
acoustic meatus
Jugula rforamen
For am en magnu m
Groove for
transver se
sinus Poster ior cranial
(cerebellar) fossa
Confluence of th e sinuses
(interna l occi pital
prot uberance)
"
-----;O-~~---- Cerebral fossa
459
Lesser Sphenoid Fig. 29.10 Sphenoid bone
wing crest The sphenoid bon e is th e most st ruct urally
comp lex bon e in th e human body.
--~'.!-+- Orbita l surface
Pterygo id
process
)
A Ant erior
view.
...r«'-~~'-!-!..--- Greater
wing
~-----,.;--- Foram en
rotundu m
Anteri or clino id
process
Opt ic
canal
Superior orbi t al
fissure
Anter ior
clinoid .,,-- -;;;='--- - Greaterwing.
process cerebral surface
Foram en
rot undum
Cancellous tr abeculae
Foram en
rotundum
l
~~-i---'-----'--- Lat eral plate proc ess
I Temporal
. ' ~d~+--- For amen ovale
su rrace
Foramen spinosum
461
Galea
apo neurot ica
Auricularis
superior
Temporo
pariet alis
Orbicularis
oculi
Nasalis
Levator labii
superioris
alaeque nasi
Levator labii
superioris
Zygomat icus
minor
Orbicularis Auricularis
ori s posterior
Zygomat icus
major
Menta lis
Depressor
anguli oris
B Left lat eral view . Platy sma
f,:7'7"'-- Temporalis
~
B Deep layer. Removed:
Mandib le (coro noid
PP",' p ro cess) and low er
Dec }
A Sup erficial layer. Masseter t empo ra li s.
Superficial part
463
Fig.30.5 Skull base: Origins and insertions
Inferior view of extern al skull.
Mm. of mastication:
Trigeminal n.• mandib
ulardivision (CNV3)
Massete r
Medial
pte rygo id
Lateral
pterygoid
Pharyngeal mm.:
Tem porali s
Glossopharyngeal
n. (CN IX) and
vagus n. (CNX)
Lingual rnrn.: Hypo
glossal n. (CNXII) Tensor veli palat ini
Digast ric.
Prevertebralmm.:
ante rior belly
Ventral cervical n.
rami and cervical
plexus
Nuchaland intrinsic
baCkmm.: ~. Rectu s capit is
lateralis
Dorsalrami of
cervical nn.
Longus capitis
Splenius capit is
Rect us capit is
Longissim us capitis ante rio r
Obliquus
capit is superior
Sternocleidomastoid
Rectus capitis and trapezius: Acces
posterior m ajor sory n. (CNXI)
Mylohyoid
--...._-~IC---- Stylohyoid
Sternothyroid Sternohyoid
~~---~
Omohyoid Sternohyoid Omo hyoid Sternothyroid
465
Fig. 30.10 Muscles ofthe mouth
Left later al view.
Mouth
CD Zygo matic us majo r Zygomatic bo ne (lateral surface, Skin at corner of th e m outh Pulls corner of m outh superio rly and laterally
m inor posterior part ) Upper lip just medial to corn er of th e mouth Pulls upp er lip superio rly
Maxilla (front al proc ess) and Elevates uppe r lip, dilates nostril. raises ang le of
Q) Levato r labii supe rioris Skin of upp er lip. alar cartilages of nose
infra or bital region th e mouth
Mandi ble (ant erior porti on of Lower lip at midline: blends with m uscle
@ Depressor labii inf eriori s Pull s low er lip inferiorly and laterally
oblique line) from op posite side
® Levator anguli oris Maxilla (below inf raorbi tal fo ramen) Skin at corner of th e mouth Raises angl e of m outh , help s for m nasolabi al furrow
Mand ible (oblique line below canine. Skin at corner of t he m outh: blend sw it h
® Depressor anguli oris Pull s angle of m outh inferiorly and latera lly
prem olar. and first mola r teeth) orbicu laris or is
Risorius (see p. 46 2) Fascia over masset er Skin of corner of th e mouth Retracts corner of mouth as in grima cing
® Ment alis Mandi ble (incisive fossa) Skin of chin Elevates and protrudes lower lip
Neck
Depressesand wrink lesskin of lower face and
Skin over lowe r neck and upper Mandi ble (inferior bord er), skin over lower
Platysma (see p. 463 ) mouth; t enses skin of neck; aids in forced depression
lateral th orax face, angle of m outh
of th e mandibl e
* T he re are no bo ny in se rt ion s fo r t he muscles of Facia l e xpress io n .
"" All mu scles of facial are innervated v: ,,'c '''~' ''' '''I "" CC, 'fJU' ''' buccal, mandibular, or cervical branches arising from it s parotid plexus.
467
Muscles of mastication: Pterygoid muscles
Muscle Origin Insertion Innervation Action
. .
: 0 Superior head
Greater w ing of sphenoid bone : Tem porom andibular joint : Bilateral: Protr udes mandible l
(infratemp oral crest ) .. U a.r t icular disk) Mandibular n. (CN V3
) via : (pulls artic ular disk forward ) :
.. .......... ...............
: Lateral pt erygoid
: Lateral pt erygoid plate (lateral lateral pt erygoid n. ~ Unilateral: Lat eral movements '
, @) Inferior head , Mandib le (condylar process) : of mandible (chewing)
: surface)
............................................ . .
, @ Superficial head : Maxilla (tub erosity) ~ Pterygoid t uberosit y on
~. Medial pterygoid · ···',:· · M~d i~ I ~~ rf~~~ ~i i~~~r; i pH;ery·g~ id: medial surface of th e l.' Mandibular n. (CN V 3) via .' Elevates (adduct s) mandib le
.®D h d . medial pterygoid n.
~ eep ea : plate and pterygoid fossa : mand ibu lar angle
........ ....... .
Sty loid
process
A Schemat ic.
B Left lat eral pt erygoid mu scle. Coronoid
process (cut )
Removed: Coro noid pr ocess
of m andib le.
Pterygoid
process.
lateral plate
Medial
pterygoid
(superf icial Medial
head) pterygoid
A Schema t ic. \ (deep head)
B Lef t m edial pteryg oi d \
mu scle. Removed: Coro
noid process of mandi ble. Mandib ular
angle
Superior
head Lat eral
"J,I-D':rl-- Inferior pterygoid
head
Deep part »->:
Masseter J
Superficial
l part
Medial
pterygoid
A Schemat ic.
-
:::J
Q'
Classification of cranial nerve fibers and nuclei
This color coding is used in subsequent chapters to indicat e fiber and nuclei classificat ions.
General visceral efferent Innervate smooth mu scle of t he viscera, : Conduct impulses fro m ret ina, audito ry and
Special somat ic afferent
(visceromotor func t ion) int raocular muscles, heart, salivary glands, etc. : vestibular apparat uses
•...
Innervat e skeletal and cardiac m uscle derived General visceral aff erent
Special visceral efferent : Conduct impuls es from viscera, blood vessels
from branchial arches (visceral sensatio n)
....... .. . - .
•
Efferent (motor) nuclei Afferent (sensory) nucle i
CN I: Olfactory n. Telencephalon'
Oculomotor n. Trigeminal n.
nuclei (CNIII) ~ nuclei (CN V) CN II: Opt ic n. Diencephalon'
• ....
• •
abducent n. (CN VI)
CN VI: Abducent n.
Pons
•
CNVII: Facial n.
••• •
CNVIII: Vest ibulocochlear n.
•
Salivatory nuclei - - - - ---1"""'=_ CN IX: Glossopharyngeal n.
•• •••
Nucleus ambi guu s CN X: Vagus n.
Medulla oblongata
•• •••
Dorsal vagal nucleus
CN XI: Accessory n.
• •
Nucleus of
hypog lossal n. (CN XII)
,
»>: Spinal nucleus
of t rigeminal n. (CN V)
:
• The olfactory and optic nerves are extensions of th e brain rather th an tru e
•
nerves; they are t herefore not associate d wit h nuclei in t he brainstem.
Spinal nucleus of
accessory n. (CN XI)
Nucleus of ~ ~ Nucleus of
tr ochlear n. (CN IV)
oculomotor n. I / ' ./
Mesencephalic
nucleus
CN V Mot or nucleus
Principal (partia l)
sensory nucleus
471
Lateral Opt ic Lat eral genicu Fig. 31.4 Optic nerve (eN II)
ventricle tra ct late body The optic nerve passes fro m t he eyeball through the optic canal into the
a'
midd le cranial fossa. The t wo optic nerves jo in below th e base of the di
encephalon to form th e optic chiasm, before dividing int o the two optic w
tracts. Each of th ese tracts divid es int o a lat eral and m edial root. Many
Opti c retina l cell gangli on axons cross th e midlin e to the contralateral side of
radia ::l
-
the brain in the opt ic chiasm. See p. 619 for the mechani sms of sig ht.
tion
Q'
St riate
f
area
Opt ic Meyer's
chiasm loop
Late ral
geniculate
Opt ic bod y Thalam us
t ract
Optic ----f--i.4--~...-~
chiasm
Opt ic
t ract
Opticn. 7 Lateral
geniculate
body
Opt ic
chiasm
Medial
geniculate
bod y
Mesencephalon
Opt ic ----'o-~l----'i4..
Opti c n.
Opt ic
tr act
Opt ic
canal D Optic nerve in th e left orbit, lat eral view.
Super ior orb ital
473
~ Note: The oculomotor nerve supplie s parasympathetic innerva superioris) . It s parasympathetic fib ers synapse in th e ciliary ganglion .
IIIIiiiII ti on to the int raocular muscles and somat ic motor innervat ion Note: Oculomotor nerve palsy may affect exclusively the parasympa
to most of the extraocular muscl es (also th e levator palpebrae th etic or somat ic fibers. or both concurr ent ly.
Superior
Oculomoto r n. ob lique
(CN III)
~~---~~~:e------,---.lf--- Lateral
rect us
(cut)
Supraorbita l n.
Levator palp e
Superior Levator palpe Superior brae superioris
opht halm ic v, brae superior is rectu s
Superior Superior
Superior
rect us
rect us
ob lique
Optic n. Trochlear n. #""'----- - - - - - - Abducent n.
Oculomo to r n.
(CN III) Optic n.
(CN II)
Inferio r
rect us
B Ante rio r view. CN II exits th e orb it via th e C Super ior view of th e ope ned orbit. Note t he
optic canal. w hich lies medial to t he supe relati on ship between t he optic canal and
475
Fig. 31.9 Course of the trigeminal nerve divisions
Right lateral view. Ante rior
Posterior et hmoidal n.
eth moidal n.
Frontal n.
Superior
orbit al fi ssure
....".- - - - - - Lacrim al n. (w ith gland)
Nasociliary n.
~--""--~-- Infrat rochlear n.
Recurrent m eningeal ---...::~~~i~~~q
branch f+;~->,---I--- Long cili ary nn.
Opht halmic SJ
division (CN V,) , - """""'-\--1'- Shor t ciliary nn.
Nasociliary
Ciliary ganglion
root
Commu nicati ng
branch to
zygo mati c n.
A Opht halmic divi sion (CN VJ Part ially
ope ned righ t orbit.
Meningeal branch
: i-.'iIii'tI.:=--a~-=---- Midd le superio r
Ganglio nic branches to alveolar n.
pterygopa lat ine gangl ion ;:---rr---"lo","-=~-- Ante rior superior
alveo lar
Pterygopa lat ine branches
ganglion
Posterio r superior
alveolar nn.
Infraor bit al
for amen
:-~---------}--- Buccal n.
Auriculotemp oral n.
Masseteric n.
~~~~~~~~2~~~t- Inferior
~ branches dental
C Mandi bul ar division (CN VJ Partia lly Lingual n. lr'~t"="~l--- Mental n.
opened mandible w it h th e zygo mat ic arch (in mental
foramen)
remove d. No te: The mylohy oid nerve (not
shown) branches from t he inferior alveo lar Inferior alveolar n.
nerve ju st befor e t he mandibular foram en. (in mandibular canal) 477
Facial nerve (CN VII)
: Innervate:
Effects of
nerve injury
w
Q
Q
~
~
: angle bet ween the pons and efferent : Peripheral facial
• Digastric (post erior belly)
~ olive; passes through the ~ nerve injur y:
• Stapedius
; internal acoustic meatu s into ..[ paralysis of
; the temp oral bone (petrous ~ Synapse wit h neurons in t he pterygopa latin e or submandibular ganglion. ~ muscles of facial
: part) , where it divid es int o: : Innervat e: • expression on
• Greater petrosa l nerve Visceral • Lacrimal gland ~ affected side
: Superior salivatory
• Stapedial nerve • effe rent (para- • Sm all glands of nasal mucosa, hard and soft palate
; nucleus
• Chorda t ympani • sym pathetic)" • Submand ibu lar gland : Associated
• Sublingual gland : disturbances
• Certain visceral efferent fiber s ....................................................~ Small salivary glands of tong ue (dorsum) ...: of tast e,
~ pass t hrough th e st ylomastoid : Special visceral ~ Nucleus of the : Peripheral processesof fibers from geniculate ganglion form t he chorda : lacrimation,
~ foram en to t he skull base, ' . ~ f~~ r.~ n t ~..... .. ; solitary t ract : tympani (gustatory fibers from tongue) : salivat ion, etc.
~ forming th e int raparotid plexus
•. Sensory fibers from th e auricle, skin of the auditory canal, and oute r surface of t he t ympan ic
~ Somatic afferent
.... : membrane trave l via CN VII to the princip~ lse~~ a.ry..~ucleus?~th.~~ri~~~i~a ln ~r~~ ,..... .. .
~ • Group ed to form nervus intermedius, w hich aggregat es wit h th e visceral effe rent fiber s from the facial nerve nucleu s.
. .. . .
branch to
zygomat ic n.
Deep
Int ernal carot id a. pet rosal n.
(wit h int ernal (sym pat het ic) CNV,
carot id plexus) Nasal glands
Superior saliva
tory nucleus'
\
Chorda t ymp ani
Glandular branches
Subm andibular
gland
• Parasympatheti c
479
Fig. 31.15 Vestibular and cochlear
(spiral) ganglia
Note: The vestibu lar and cochlear roo ts are
st ill separate st ruct ures in th e pet rous
part of t he t em pora l bone .
CNV III
Sem icircular
duct s
Superio r
-TL--.tI~-- part Vestibular
:"~;--- Inferior
gang lion
part
~~~~--c-- Spiral
ganglia
Utr icle
Geniculate Cochlea
ganglion
Posterior sem i
circular canal
Facia l n.
Round Tym panic Internal Tym panic n. Greate r
(in facial canal)
w indow plexus jugularv.
Transverse crest
A Medial wall of th e t ympanic cavity ,
Facial n. (CN VII)
oblique sagit ta l sect io n.
Nervus
int erm ediu::s__, ,, ~,,,,,
B Cranial nerves in th e
inte rnal acoustic meatu s.
Posterior oblique view of
t he rig ht meat us.
Cochlear n.
CNV III {
Vestib ular n. Sacculo Poster ior
am pullary n. Utricu lo am pullary n.
ampullary n.
48
A B E F
Fig. 31.19 Glossopharyngeal nerve in the tympanic cavity Fig. 31.20 Visceral efferent (parasympathetic)
Left antero lateral view. The tympanic nerve contai ns visceral effe rent fibers of CN IX
(presynapt ic parasympath eti c) fib ers for th e ot ic ganglio n. as well as
somatic afferent fibers for th e t ymp anic cavity and pharyng ot ympani c
tube. It join s w it h sym pat het ic fib ers from th e internal caroti d plexus Tymp anic n.
(via t he carot icoty m panic nerve) to form th e t ymp anic plexus.
Glossopharyngeal n.
(CN IX)
Mandibular
~
Tubarian Carot ico divi sion
branch tym panic n. (CNV J )
Tymp anic
plexus
~.-/\--'------------ Lesser
pet rosal n.
Otic
gang lion
Tym panic
Prom ont or y of
labyrint hine w all
483
Fig. 31.22 Course of the vagus nerve
The vagus nerve gives off four major branches in the neck. The inferior
laryngeal nerves are the termin al branches of the recurrent laryngeal
nerves. Note: The left recurrent laryngeal nerve winds around the aortic
arch, while t he right nerve win ds around the subclavian artery.
@ Superiorlaryngeal n.
(CNX)
Cervical cardiacbranches
- -7--- CD
......---'-,- CD
A Branches of t he vagus nerve in t he neck. Anterior view. B Innervation of the pharyngeal and laryngeal muscles. Left lat eral view.
485
Fig. 31.25 Hypoglossal nerve Precentra l
gyr us
Post erior view of t he brainstern w it h t he cerebellum rem oved.
Note: C1, w hich inn ervates t he t hyro hyoid and geniohyoid. runs
briefly wit h t he hypoglossal nerve. ;t" ~/ w
.....
~
Q
Q
:::I
-
Q'
Nucleus of
the hypo
~ Genioglossus
X
I
glossal n.
Hyoglossus
glossal n.
Foram en
magnum
Hypoglossal
canal C1 spinal n.
~
Nucleus of th e
hypoglossal n.
A Normal genioglossus
Olive Tongu e
mu scles.
B Cross sect ion throug h t he medu lla B Unilateral nuclear or
oblongata . periph eral lesion.
487
~
Fig. 32.2 Sensory innervation of the face Ophthalm ic
divisio n
_ _-----';-_ _ Greaterocci
pita l n. (C2)
Trigemina l n. Maxill ary
(CNV) divi sion
Spinal nn.,
J
A
Mandi bu lar dor sal rami
Supr aorb it al n. divi sio n ~
(fro m CN V,)
Transverse
cervical n. ~-f-- - ",,----- Supraclavic
C3, {
vent ral Great auri cular n. / ular nn.
ram i Lesser occipita l n.
Infrao rbit al n.
(from CN V,)
B Sensory innervation of the head and neck, left lateral view. The oc
cipu t and nuchal regions are supp lied by t he dor sal rami (b lue) of t he
spinal nerves (the greate r occip ita l nerve is the dorsal ram us of (2) .
Ment al n.
(fro m CNV )
Supraorbit al n.
Supr atrochlear n.
Trigeminal
ganglion
Pterygopa lati ne
gangli on
Mand ibu lar d ivision
(CN V 3 )
Masseteric n.
Buccal n.
Lingual n.
Infer ior
alveolar n.
Menta l n.
Myloh yoi d n.
489
~ Clinical
Termi nal
branc hes
I
Medial
~--#--",-"'!""';-;,==~=.;;<..::;~-- Superficial
branch
t empo ral a.
Posterior
;o..;;~'------ auricular a.
Occipita l a.
A Sche matic o f th e ex terna l carot id artery. j -- -- Maxillarya .
kiii~e.iF.'",=------ Ascending
pharyngea l a.
Superior t hyro id a.
~"~=-~.¢--- Vertebra l a.
Common
• Ante rior (p. 492) Lingual a.
...................... . .. ... ................................ carot id a.
: Facial a.
• Posterior auricular a.
; ~ax i l la ry a.
• Terminal (p. 494)
L ~ uperfic ia l tempor al a.
B Co urse of t he external carot id ar te ry.
491
Fig. 32.6 Posterior branches
Left lat er al vi ew. Th e po st eri or br an ch es of th e
exte rna l ca rotid artery su p p ly th e ear (p . 534 ),
po st erior sku ll (p. 499), and po st eri o r neck
muscles (p . 58 5).
I
rr-- - - Vertebral a.
I
I
r
Posterior
branch
Superficial
t emporal a.
Maxillarya .
Ascending
pharyngeal a. Occipit aI a.
Facia l a. - - --'t:'I
Lingual a. ---~I I
Internal carot id a.
B Course of th e po st er io r br an ch es.
: Superior t hyroid a.
........ . 'H ~ la n.d ~ l~r ?ra nch (to thy roid gland); superior laryngeal ~ : ; st: rn.?cl ~i 9. ?':l ~ st o.i~br~n. ~.~
, Dorsal lingual branches (to baseof tongue, epiglottis); sublingual a. (to sublingual gland, tongue, oral floo r,
: Lingual a.
~ Anterior branch ....... . ....... : oral C~~ ity)
: Ascending palatine a. (to pharyngeal wall, soft palate, pharyngot ympani c t ube); to nsillar branch (to palatine
Facial a.
~ ton sils); submental a. (to oral floor, submandibular gland); labial aa.; angular a. (to nasal root)
...... .. ... ..... ... ..... .................. ....... ........ .......... ... ... .. ...... .... ..... ..... ... .... ... ...... ...... ... . ... ...... ... ..... .... .... ... ......... ....... .............. ..... .. ....................
493
Fig. 32.8 Maxillary artery ~ Clinical
Left lateral view. The maxillary arte ry consists of three part s: mandibul ar
(blue) , pt erygoid (g reen), and pt erygop alatin e (yellow ).
Middle men ingeal artery
The mid dle m eningeal ar te ry supplies t he men inges and overly ing calvaria.
Rupt ure of th e arte ry (gene rally du e t o head traum a) results in an epidu ral
he matoma .
Buccal a.
Inferior alveolar a.
A Right mid dle m eningeal arte ry, med ial view of open ed skull.
Infra Calvaria
orb ital a. Spheno
Rupt ured middle
palat ine a.
meninge al a.
Deep tem Fract ure .------ -- Arachnoid
por al aa.
- -- - Dura mater
Epidural
B Epidural hematoma
Pter ygoi d hem at om a.
br anch Schema t ized
coro nal sect ion.
Buccal a.
Lateral posterior Posterior sept al
nasal aa. branches
An te rio r and
Spheno
Menta l palat ine a.
posterior
branch
superio r
Descending
palatin e a.
495
Fig. 32.10 Deep veins of the head
Lef t lat eral vi ew. Removed: Upper ram us,
Deep Cavernous Superficial co ndy lar and co ro no id pro cesses o f mandibl e.
t emporal w. sinus t emporal v. Th e pteryg o id ple xu s is a venou s network sit u
at ed betw een th e mandibular ramu s and th e
muscl es of ma stica ti on . The cavern o us sinus
Superior
mic v.
Superior
and
inferior
Angularv. petro sal
sinuses
Deep
facial v.
I ..lf-"-~f- Retromandibular v.
Facial v.
Venous anastomoses
The extensive venous anast om oses in th is region provide rout es for t he spread of infections.
~ • Deep spread of bacterial infect ion from th e facial region may result in cavernous s i nu s t.h.~?rn bos is .
497
Fig. 32.13 Superficial neurovasculature of the head
Left lat era Iview.
Superficia l tempora l a.• Superfi cial temporal Superficial tem poral a.,
fronta l branch a. and v. parietal branch
Supraorbital n.
(branch of CN V,)
Supratrochlear n.
(branch of CN V,)
Auriculotempora l n.
Angula r v.
Transverse
facial a.
Infraorbit al n.
(branch of
CN V2 )
Buccinator
Lesser
occipita l n.
Ste rnocleido
Ment al n. mastoid
(branch of
CN V)
Occipita l v.
Parotid gland
499
Fig. 32.15 Temporal fossa
Left lateral view. Removed: Sternocleidomas
toid and masseter. Revealed: Temporal fossa
and temporomand ibula r joint (p. 540).
Tem porom andibular
joint capsule
Coronoid
process
Facial n.
Paroti d
duct
Hypoglossal n.
Superio r
cervical ganglion
Int ernal
carot id a.
Ext ernal
carot id a.
Facial a.
and v.
501
Fig. 32.17 Deep layer
Left lateral view. Removed: Lateral pt erygoid mu scle (both heads). Revealed:
Deep infratemp ora l fossa and mandibular nerve as it ente rs th e mandibu
lar canal via th e foramen ovale in t he roof of th e fossa.
Sphenopalatine a.
~~ ~~f---j,-- Mandibular n.
(CNV,)
Posterior superior
alveolar a. ~---~~~--"':'------- Midd le
meningeal a.
Buccal a. and n.
Maxillarya.
Buccinato r
Medial pterygoid
Lingual n.
Mandibular
foramen
Mandibu lar
division (CN V,)
Mandibular div ision
Mening eal (CNV ,)
branch
N. of tensor t ympan i
Deep (w it h mu scle)
te mporal nn.
--:=-- _.....-... ..~_- N. of tensor
Lateral veli palatini
pterygoid n. Sty lomasto id (w ith mu scle)
for amen
Medial Lesser petr osal n.
pt erygoid n. ~ Auriculo
Inferio r
fL ~ te m poral n.
alveolar n. i A Auriculo- Commu nicat ing
Buccal n. =="I"fi.~l!!r~"f\ I I t emp or al n. branch to auric Otic ganglion
ulote mporal n.
Lingual n. )
Parotid
branches Chorda t ympani
Medial Lingual n.
pterygo id n.
(w it h mu scle)
Inferior . .~- Mylohyoid n.
alveolar n.
A Left lat eral view. B Medial view .
503
~ The maxillary division of the trigeminal nerve (eN v 2 • see p. of the pterygopalatine ganglionsynapse with ganglion cells t hat inner
IIIiii3I 477) passes from the middle cranialfossa through the foramen vate the lacrimal. small palatal. and small nasal glands. Thesympathetic
rotundum into the pterygopalatine fossa. The parasympathetic fibers of the deep petrosal nerve (sympathetic root) and sensory fibers
pterygopalatine ganglion receives presynaptic fi bers from the of the maxillary nerve (sensory root) pass through the pterygopalatine
greate r pet rosal nerve (the parasympathetic root of the nervus ganglion without synapsing.
intermedius branch of the facial nerve). The preganglionic fi bers
Inferior orbital
fi ssure
Deep petrosal n.
Pharyng eal n.
~-- Internal
carot id plexus
Interna l carot id a.
.....................................................................
: Pterygoid canal : A. of pterygoid canal (with accom panyi ng vv.)
: Palate
: Lesser palatine canals , CD Lesser palatine nn.
.... ... .. ..... ... .. ... .. .. .. .. .. .... ... . ... ... ....... .... ... .... ..... ... .... .... .... ... ... ... ...... ... .
505
Frontal bone.
orbita l surface
Fro nt al Superior
Maxilla.
Inferior
orbita l surface
Certai n deeper st ruct ures also have a clinically impo rtant relati onship
Infraorbit al
to the orbit:
.............. .......................................
canal
Sphenoid sinus : Hypophysis (pituitary)
................ ....... ....... ......... ........ .... ... ..... ............ ......
Inferior Maxillary
Midd le cranial fossa ; Cavernous sinus
.. .... .... .... ........... ............. . .
Palatine bone.
pyramidal
pro cess
Sphenoid bone.
lesser w ing
Perpendicular
plate
Opt ic canal
Ethmoid bone.
Superior
orbital plate
orbital fissure
(lam ina papyracea)
Superior
Sphenoid bone.
nasal concha
greate r w ing
Zygoma t ic bone.
orbita l surface
Infraorbital
canal
Midd le
nasal concha
Maxillary
sinus
Inferior
nasal concha
Vome r
Palat ine
process of th e
maxilla
o Coronal section , ant erior view.
507
Fig.33.4 Innervation of the extraocular muscles
Righ t eye, lat eral view with t he tem poral wall of t he orbit rem oved.
Medial
rect us Superior
Levator palpebrae
superioris obl iqu e (with tr ochlea)
Com m on
tendin ous ring
-----"''''=~----.----- Superior
rectus
Oculomotorn. ~
(CN III)
Lat eral
Trochlear n. C rectus
(CN IV)
Inferior
oblique
Inferior
rect us
Inferior orbital
fissure
Maxillar y
Clivus sinus
~ Clinical
Oculomotor palsies
Oculom ot or palsies may result from a lesion involving an eye m uscle or its Im pairm ent of t he coord inated actio ns of t he extraocular m uscles may cause
associated cranial nerve (at th e nucleu s or along t he cour se of the nerve). If the visual axis of one eye to deviate fro m it s no rma l position. The patient will
one ext raocular muscle is weak or paralyzed, deviation of t he eye wi ll be not ed. the refo re perceive a doub le image (diplopia).
A Abdu cent nerve palsy. Disabled: B Trochlear nerve palsy. Disabled: ~-+- Superior
Lateral rect us. Supe rior obliq ue. rectus
.~+---- Lateral
rectus
C Compl ete ocul om otor palsy. Disabled: Superior, inferior. and me dial rect i
and inf erior ob liqu e.
D Norm al visual and orbital axes.
509
Fig. 33.7 Innervation ofthe orbit
Lateral view of the right orbit. Removed: Fronta l n.
Lacrima l n.
Temporal bony wall. Oculom ot or n., (wit h gland)
superior bra nch
Ocul om ot or Suprao rbital n.
n. (CN III) Inte rnal caroti d
a. w it h internal
carot id plexus Infra
t roc hlear n.
Trochlear n.
(CN IV)
Opht halmic
division
(CNV,)
Trigemina l
Parasym
gangli on
Mandi bular pathetic
divi sion roo t
(CN Vl )
..
'
Caverno us sinus
511
Fig.33.11 Neurovascular contents of the orbit
Sup er io r v iew. Removed: Bo ny ro o f o f o rb it , p er itorbit a, and
retro-o rbita l fat. Superior
opht hami c n.
Supraorbit al
aa. and nn.
- -- - Superior rectu s
Levato r palpebrae
Medial superioris
rectu s
Superio r rect us
Superior
oblique
Superior
opht halmic v.
513
Fig.33.14 Lacrimal apparatus
Righ t eye, ante rior view. Removed: Orbit al sept um (parti al). Divided:
Levat or palpebrae superioris (t endon of insert ion) .
Levato r palpebrae
Orbit al - - - - - "' - - + - - --.,...-- - --"'::".--
superioris
sept um
Lacrimal
caruncle
Lacrim al gland, - - - - - - - - - - - ;1-- - --.£11
orbita l part
Superior and
inferior lacrim al
canaliculi
Upper eyelid
Nasolacrimal
duct
Infraorb it al Inferior
foram en nasal concha
~ Clinical
515
Fig. 33.16 Blood vessels of the eyeball
Tra nsv erse section at the leve l o f the optic /
-- Lesser art erial circle of iris
Anterior
ciliaryaa .
Long
Art erial circle of Zinn posterior
Vorti cose v.
(and von Haller) cillaryaa .
~ Clinical
The opti c fundus is th eonly place in the body wher e capillaries can be examined direct ly. Exami nation of
I
the optic fundu s permits observat ion of vascular changesthat may be caused by high blood pressure or
diabetes. Examinat ion of t he opt ic di sk is important in determ ining intr acranial pressure and diagno sing
multiple sclerosis.
Physiological cup
B Normal opt ic fundus in the opht halmo scopic
examinat ion.
Opt ic disk
(blind spot)
(sites of
ent ry and
emergence)
Lens
Iris
Ciliary bod y.
t pars plicata
Ciliary bod y.
pars plana
Chor o id
Zo nular Retin a.
fibe rs o pt ical part
Ciliary proc esses Ciliary m uscle Ora serrat a
Lens
519
Super ior
meatus
Sphenoid bon e.
lesser w ing
Maxilla. fr ont al
pro cess
Superior concha
(et hm oid bone)
Midd le meatu s
meatu s
B Lateral wall of th e right nasal cavity. Sagitt al sect ion. medial view.
Removed: Nasal sept um. Note: The superior and middle conchaeare
partsof th e et hmoid bone. whereasth e inferior nasalconchaeis a
separate bone.
Superior nasal
concha (cut )
Sphenoid sinus
Uncinate --------:~~-~:------:-~
process
!"
Inferior
concha (cut )
process
Fro nt al bone
Sphenoid bone.
lesser wing
Maxillary
sinus
Midd le Middle
et hm oid sinus ----'~-----~L: meatus
sinus
Inferior
meat us
Inferior Palatine
concha process
Vomer of maxilla
~ Clinical
Deviated septum
The norm al positi on of th e nasal septum creates two rough ly sym m et rical
Sinusitis
When t he mucosa in th e et hmoi d sinuses becomes swollen due to
and maxillary sinuses in th e osteom eatal unit (see Fig. 34.4) . This
inflam mat ions. In pati ent s wi t h chron ic sinusiti s. the narrow sites can be
523
Cribrifor m plate Sphenoi d sinus Fig.34.8 lateral nasal wall
Sphenoet hmo id
recess
\
Superior
----~"---,""'
meatu s
Mid dle -
meatus
- 4 -7 ~?~~~iii;~~l~'-T,;~;:----- Pharyngea l
t on sil
Inferior
f-'B=-;----;7:c-\T-- - SaIping 0
nasal concha
pharyngeal
fo ld
Limen nasi
Uvula
Ante rior
- - - - -.F-----i'--,
et hm oidal a.
Pte rygo palat ine
ganglion
Inferior poste rior
nasal branches.
lateral po sterior
Descending
nasal aa. palat ine a..
greate r
and lesser
palatine nn.
~ Clinical
Nosebleeds
Vascular supply to t he nasal cavity arises
fibers (CN I)
Ante rio r
Lateral
ethmoid al n. superior
(CNV,) poster ior
External
CN V, nasal
nasal
branches
branch
Med ial
nasal
~~;:.:::::~~t,:-.~~~~~-- Pterygo
branches palati ne
.=~r--- Trigeminal ganglion
ganglion
Inferior
po sterior
nasal branches
Medial superior Pterygopalat ine
gang lion (in Lesser
posterior nasal
pterygop alat ine palati ne nn.
branches (CN V,)
fossa) Greater
Nasop alat ine n. (CN V,) Spheno palat ine
foram en Internal nasal branches palatine n.
A Nerves oft he nasal sept um. B Nerves of t he lat eral nasal wall.
525
Fig.35.2 Part s of the temporal bone
- - - - - --r'---- Squamo us
part
Petro us
part
A Left lateral view. B Inferior view.
~ Clinical
Chorda Mastoid
t ympani Facial n. (CN VII) air cells
membrane
The pet ro us portio n of t he t emp oral bone contains th e mi ddl e and inn er
Pharyngot ympanic
ear as we ll as t he tym panic mem brane. The bo ny sem ici rcular canals are
(audit ory) tube
oriented at an approxim ate ly 4 5-deg ree ang le fro m t he coronal. t ransver se.
and sagitta l planes.
Anterior Posterior
semicircular canal semicircular canal
Lat eral
semicircular
canal
Mastoi d process
527
Fig. 35.5 Structure of the auricle
The auricle of th e ear encloses a ca rti lag inous f ram ew ork t hat forms Auricular is Temp oro
a fu n n el- sha pe d recept o r fo r aco u sti c v ib ratio ns. The mu scl es o f th e superior parieta lis
(posterior part
-a
Auricularis
poste rior
Ext ernal
Scaphoid
audit ory OJ
0
fossa
canal :::I
/'t)
Antitragicus
Tragicus l(o
-------- Tragus
~ Intert ragic
, ~ mcisure Auricularis - --+. Obliquus
Antih elix I Antitragus
superior auriculae
Fig. 35.6 Arteries of the auricle C Carti lag e an d m uscl es of t he au ricle , m ed ial view of p ost eri or surface.
Superficial
te mpora l a. Perf orati ng
Perforating
branches Anterior
branc hes
Aur icularis
posterior
----<
auricular aa.
v iew.
th e rig ht au ricle .
- -- Auricul ot emporal n.
(tr igemina l n., CN V)
t h e righ t auricle.
529
Tendon of
tensor
tympa ni
Meso
ty mpanum
""""=~02'!~- Hypo
ty m panum
Pharyngo
tympa nic
t ube
Malleus -----,-~~
_ _ Fac ial n. (CN VII) in
facial canal
Incus ------;:'r.c~~ Prom inence of lateral
semicircular canal
Chorda tympa ni ---F:~~""-''-::-'''''F=---
~"¥:'~:T.i'-i--- Promin ence of
facial canal
Tensor tympa ni
'--,;r'---,*,~h1"'~- Stapes
Tendon of
st apedius
. r'--:-:-"1:~"""--~~.-'--- Tympanic n.
B Rig ht t ympan ic cav ity. A nterio r v iew
wi t h th e anteri or wall rem ov ed .
!/
Ante rior sem i- Roof of ty mpanic Geniculate
circular canal cavity (teg men ty mpani) ganglio n Vestibular n. (CN VIII)
Posterior semi
~ Facial n. (CN VII)
~ Coch t e ar n . (CN VII I)
circular canal
-,
Lateral semi
Greater petrosa l n.
·t.;.:",;,.
Oval window --~~~iji.!~~~~ '\.t· "_\.'f. ....
. Semicanat of
tensor ty m pani
Internal caroti d a.
+- - - Pharyngotympan ic
Promontory
(audito ry) t ube
Internal
carot id plexus
Anterior walt of
tympa nic cavity
Incudo
mall eo lar joint
Annu lar
st apedial
ligam ent
Tendon of
Staped ial t ensor tympani
membrane
Tensor t ympani
Incu do
st apedial j oi nt
Int ernal carot id a.
~ Clinical
oval w ind ow, w hich com mun icates them t o th e fl uid column of the inner ear. chain. If the ossicular chain fails to transform the sound pressure between t he
Soundwaves in fluid meet w it h highe r im pedance;they m ust th erefore be t ym panic mem brane and th e footplat e of t he st apes, t he patie nt will experience
amp lified in t he mid dle ear. The diff erence in surface area bet w een the tympa nic condu ctive hearing loss of magnitude 20 d B. See p. 519 for hearing.
Malleus Incus
A Vibr at ion of th e tympan ic memb rane causes a rocking movem ent in the
ossicular chain. The mechanical advantage of t he lever act ion of the os
Pyramidal _
/ : wit h annular
Basilar
B The st apes in it s norm al posi Stapedius ------------'7- st apedial
membrane
ti on lies in th e plan e of th e oval t endon ! ligament
~----'-:'-""'o-cc.--- Tympanic
w indow .
membrane
533
Fig. 35.18 Arteries of the middle ear: Tympanic cavity
Right petr ous bone, ante rior view. Removed: Malleus, incus, portions of
chorda t ympani. and anteri or tympanic arte ry.
-.
Ante rio r semicircular
Subarcuate a. Superficial pet rosal a.,
canal
ascending branch
Int ernal
auditor ya . Facial n. (CN VII)
Superf icial
pet rosal a..
descending
branch
Anter ior
crural a.
Int ernal
carotid a.
Carot ico
ty mpanic aa.
Mastoid a. Posterior
t ymp anic branch Deep auricular a. Inferior t ympani c a.
535
Inner Ear
~ The inner ear co nsist s of th e vesti bular apparat us (fo r balan ce) a bo ny labyrint h fi lled wi t h peri lymph and em bedded in th e petrous part
IIriiiiiII and t he audito ry appa rat us (for hearing ). Bot h are for me d by a of th e te mpo ral bon e.
m em b ranou s labyrin th fi lled w it h endo lym ph fl oat ing withi n
Endolymphatic Anterior
Semicircular
canals
df~ duct ampullary n.
Superior
part
Vestibular
ganglion
u~;t
-f-- - - Inferior } (CNV III)
part
-~-=-;:l---- Utricl e
Ductus Saccule (wit h utricular n.)
reuniens
Posterior Ductus
Endolymphatic ampullary n. reuniens
duct
B Struct ure of th e vest ibular app arat us.
Fig. 35.20 Auditory apparatus
The coc hlear labyrint h and its bon y shell form t he coc hlea, w hic h co n
t ain s t he sensory epit he lium of t he aud ito ry appa ratus (o rgan of Cort i).
Lesser
"'•\ ~\ \-
C hi d t Cochlear
7 ~
I~
-
--
oc ear uc canal
Scalaty mpani
A Schematic.
- - Chorda
t ympani
Internal
acoustic
meatus
Spiral
ganglion -. . . . .'i~~:g~~===~~~~
Temporal bone. Semicircular canals
petrous part
536
Fig. 35.21 Innervation of the membranous labyrinth
Right ear, ante rior view. The vesti bul ocochlear nerve (eN VIII; see p. 480) t he vest ibular and cochlear nerves. Note: The sensory organs in t he sem i
t ransmit s afferent im pulses from t he inner ear t o th e brainste m th rough circular canals respond t o ang ular accelerat ion, and th e macular orga ns
the int ernal acousti c meatus . The vestibulocochlear nerve is divided into respond to horizontal and vert ical linear acceleration.
/ Vestibu lar
ganglion,
Dura mater ~ inferio r part
Endolymphati c ----...... /
Cochlear commu
sac ,...,::",:---......,,~ nicati ng branch
Lat eral
~ J--f~~~i1~~~~i:- Nervus inte rmedi us
amp ullary n.
""""'--~"=-~~'--'~~~~r--- Ut ricular n.
"...-";~~~~~-- Posterior
Lateral
am pu llary n.
sem icircular
du ct
Posterior
~~~~- Spiral
sem icircular
gangl ion
duct
of cochlea
Posterior
am pulla
Round
window
/ Internal auditory
a. and vv.
F~'.-;'ijj;l---------- Common
cochlear a.
.,~_\-.),~~~~~~------- Vestibulo
cochlear a.
V. of round
wi ndow
V. of cochlear aqueduct
537
Bones of the Oral Cavity
~ The floor of the nasalcavity (the maxilla and palatine bone) forms during development. eventually fusing at the median palatine sut ure.
~ the roof of the oralcavity.the hard palate. The two horizontal Fai lure to fuse results in a cleft palate.
processes of the maxilla (the palatine processes) grow together
Inferior view
fossa
of maxilla
~-- Median
palatin e sut ure
Lesser
palat ine foramen
Pte rygoid
..
clinoid process sphenoid sinus Opt ic canal
",.~--------- Superior
orbita l fissure
Middle
concha
Ethmoid bone.
orbita l fissure
~~'---- Inferior
Choana conc ha
Median - - - - -"-;;J=-':
Pterygoid process
palatine suture Medial plate
Palatine bone
Incisive
foram en Palati ne process of maxilla
538
--~-- Head Fig. 36.4 Mandible
The mandible (jaw) is connecte d to th e viscero
Coronoid - - --+- 11
cranium at t he t empo romandibular joint
process (p.540) .
Head
Ramus
Alveolar -~~----\
part
Mandibular - ----,H a.
Alveoli forame n
Ment al
foramen (to oth sockets)
Body
Ment al
protu berance
Ramus
Alveolar
part
Ment al
~ Angle
tub ercle
Mental Oblique
C Obliqu e left lateral view. fo ramen line
- y- Body Body
Lingu la
Mylohyo id
groove
Pterygospino us
ligament
Joint
capsule
Lateral
ligament
ligam ent
Pterygoid process,
medial plate
540 A Lateral view of t he left temp oromandibular joint. B Medial view of t he right t emp oromandibu lar joi nt.
Fig.36.8 Movement of the temporomandibular joint ~ Clinical
Left lateral view. Upto 15 degrees of abduction, the head of the man
dible remains in the mandibular fossa. Past 15 degrees. the head of the
Dislocat ion of the
A Mo uth closed.
B Mouth opened to
Massete ric n.
15 degrees.
541
Teeth
- - Enamel
- - - Dentin
and root.
Interalveolar
sept um
Mesial
.......1... Labial
Incisive -~~~~i>
...............
suture
Mesial .............
Molars
Lingual
Bucca l
Buccal
Palatal
M
"?,
..
..
.,/
Distal ,/
~...../
t":-""" ~-- Premolars Mesial ":-:-::,,,'y""
Labial
Interalveolar
septum Canine
Incisors
B Mandibular t eeth . Superio r view
542 of the mand ib le.
Fig.36.13 Coding of the teeth
In t he Unit ed St ates, th e 32 permanent t eeth are num bered sequent ially coded A t o J (upper arch), and K t o T in a sim ilar clockwise fashion. The
(not assigned t o quadrant s). Note: The 20 decid uous (baby) t eet h are t hird upper rig ht molar is 1; th e second upper right premo lar is A.
(P) (0 )
Maxillary
sinus
32 - -+---+-'=='---
Impa cted ,,-'-- Mandi bular
t hird mo lar
ang le
(wi sdom t oot h)
31
Mandibular
30 canal
Bit e guide
* Not fu lly erupte d. 28 27 26 25 of scanner 543
Oral Cavity Muscle Facts
f!";-_-----O - - Styloid
process
~;;-~-- Mastoid
process
'-- - - Digastric
(posterior
A Suprahyoid muscles, belly)
Hyoglossus ---i'---------'''------------~
left lateral view.
Mylohyoid ------''o-------------:o~ rZ~~-- Stylohyoid
Digastric
(anterior belly)
Infrahyoid
m uscles
Sublingual
fold
~~"'-\o-~~-- Genioglossus
Geniohyoid
C Suprahyo id m uscles,
superior view .
Mylohyoid - - ----;;_ ::lli
544
Suprahyoid muscles
: Mylohyoid n.
@ Anterior belly : Mandi ble (digastric fossa) : Via an intermediate
Ufr~ rn CN V3 )
: Q) Digastric
.
....
: Temporal bone (mastoid notch,
: tendon with a
fibro us loop
······1 Elevateshyoid bone (during swallow ing), !
: assists in opening mandible i
: @ Posterior belly : medial to mastoid process)
Facial n. (CN VII) :
: @ St ylohyoid : Temporal bone (styl oid process) : Via a split ten do n
H
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • •• •• • • • • • • • • • •• • • • • • • • •• •• 0 •
Palatine - _
_ --,,~
aponeurosis
Pterygoid
Musculus
ham ulus
uvulae
: Palati ne
i aponeurosis:
Accessory n. (CN
545
Innervation of the Oral Cavity
Zygomatic n.
Infraorb ita l n.
(and foramen)
Auriculo
te mpo ral n.
Masseteric n.
Lingual n.
Inferior alveolar n.
(in mandibular canal)
(eN V2 ) . The arteries of th e hard palat e arise from th e maxillary art ery.
Superior - - - - - ---=.........-4..
labial
branches
Ant erior
and midd le
superio r
Incisive foramen
Infraorbit al n.
alveolar
branches
Posterior
superior - - -- Greater Greater palatine
alveolar palatin e n. n. and a.
branches
Greate r palatine
foram en
A Sensor y inn ervation . Note: The buccal nerve is a branch of t he man Pterygoid process
546 d ibul ar d ivi sion (eN V 3 ) . B Nerves and art eries.
~ The m uscles of t he oral f loor have a com plex nerve supply wit h
~ contribut io ns from t he t rigeminal nerve (CN V 3 ) . facial nerve
(CN VII), and C1 spinal nerve via th e hypog lossal nerve (CN XII).
Inferior
alveolar n.
- - - - - Lingual n.
Tymp anic
plexus
Trige mi nal
Sub mand ibu lar gang lion Facia l n.
gang lion (CNVII)
Chorda
A Mylohyoid nerve (CN VJ Left lat eral view t ym pani
w it h th e left half of t he mand ible rem oved.
Stylomasto id
Lingual n.
foram en
Hypoglossal n.
B Facial nerve (CN V II). Sagitta l sect ion
Lingual n. (CNX II)
th rough t he right petro us bone at t he level
of th e mast oid process, medial view .
•":"h";'=7."""""iiiii:~ii~ C1 spinal n.
(ant erior ram us)
Genioh yoid
Superior root
(descendens
Inferior roo t
hyp oglossus)
(descendens
cervicalis)
547
Tongue
~ The dors um of the tongu e is covered by a high ly specialized powe rfu l mu scular body t o support it s motor properties during mastica
~ mucosa that supports it s sensory fun cti ons (ta ste and fine tactile tion, swallowing, and speaking.
discrimination; see p. 616) . The t ongu e is endowed with a very
} Lingual
aponeurosis
} Lingual mu scles
Foramen
cecum
Palati ne
ton sil
Palat o
glossal
arch
~%:~-- Mylohyoid
Apex of - -
tongue
Geniohyoid
548
Fig. 36.22 Somatosensory and taste Taste Somatic sensation
innervation of the tongue
A nter io r v iew.
Vagu s n. --------l!!!~ -~~---- Vagus n. (CN X)
(CNX )
Fig.36.23 Neurovasculature of
the tongue
Th e lingu al mu scl es receive so ma to mot o r
Glossophary ngeal n.
inn erv at ion f ro m th e hy p o gl o ssal ner v e (CN (CN IX)
XII), w it h th e exceptio n oft h e p alat o g lo ssus - -----!- - - - Lingual n.
Facial n. -------l;~-:<:
(CN VII, via
cho rda t ymp ani)
- - - Ant erior
lingual glands
- - Deep lingual
a. and v.
Subling ual ~-£'-- Lingu al n.
fold Deep
Submandibu lar lingual a.
Sublingual ---~i"':~IIt;;;,;;.-----'-- :
duct
papill a Lingual n. Sty loid
(CNV l ) proc ess
,. f~~- Glosso
A Inferio r su r fa ce of t he t on gu e.
pharyngeal n.
(CN IX)
Subma ndibular
ganglion
- - - Hypogl ossal n.
(CNX II)
Lingual a. (from
exte rnal carotid a.)
Lingual v. (t o
inte rnal ju gul ar v.)
~ Clinical
! .~ A pex
A Active protrusion unilateral hypn
there fo re do m ina t e. u flull pro uustou .the side
w it h an intac t glossal nerve
t ongue will deviate toward th e paralyzed side.
hypoglossal nerve. ~ of to ngue lesion.
549
Topography of the Oral Cavity & Salivary Glands
I \ \\,-- - Laryngo
phary nx
A Organizatio n of
Right choana --~,--;!,-.....-'<~7
t he oral cavity. 'f;-:C'ffi--~~._IiiiiO'~:;-- Dens of axis (C2)
~ii'iT"~'-"-7-~-- At las (C1)
Sof t palate -~~!!f~~~~H~~~
Salpingopharyng eal
Uvu la fold
Palat ine tons il
Lingual t onsil
Hyoid bo ne Epiglotti s
Frenul um of
upp er lip
B Bou ndaries of the oral cavity.
Oral
vestib ule Hard
palate
Palatoglossal
Sof t
arch
palate
Palatop haryn
geal arch Uvula
Divisions of the oral cavity
Fa ucial Palatin e
isthmus ton sil Part Anterior boundary Posterior boundary
of to ng ue
proper • Oral cavity prop~r H H ~e n.t~la rch~ s ~~ I~~? 9.I ?~~~ l arc h .
: Fauces(t hroat) • Palatog lossal arch : Palato pharyngea l arch
Oral Frenulum of
vest ibule low er lip
550
~ The th ree large. paired salivary glands are the parot id. subman (watery) salivary gland . The sublingua l gland is predom inantl y m ucous;
~ dibular, and subling ual glands. The parotid gland is a purely serous the submandibular gland is a mi xed serom ucous gland .
Superficial temporal
a. and v.
Parotid
gland.
superfici al
part
Parotid
plexus
Facialn. ---~7--¥.~
(( N VII)
Faciala. Submandibular Sternocleido B Facial nerve in the parotid gland. left lateral
and v. gland mastoid view. The ram ification of th e facial nerve
into th e parot id plexus (see p. 478) sepa
A Parotid gland . left lateral view. Note: The
rates th e parot id gland int o a superficial
parotid duct penet rate s the bucci nator
and deep part.
mu scle to open opposite th e second
upper m olar.
Sublingual - - - r'
fold ---='l--c-+- - Oral mucosa
-="''..-~--- Genioglossus
! ~'(-=ih~-'i~~---- Sublingual
gland
Geniohyoid
f1---,-----~-- Submandib
ular duct
Mylohyoid ----"~~
Submandib
ulargland
Lingual a. Hyoglossus
Stylohyoid
Soft --~
Choana Roof of pharynx
palate
Tonsillar
fossa Nasal - - -
septum
. -~~~~----- Phary ngeal
t on sil
Torus - - - - - - :
tub ariu s
~87+-c:-:..,p----.-;.------ Pharyng eal
orifice of
pharyng o
t ympanic
tube
Soft --~......- ,- :5-''-f--!+--- - Dens of axis
palate (C2)
A Pa latine ton sils, anterior view. ~~~'-f>'i'H--- Salpingo
pharyn geal
fold
Uvu la --~~
ton sil
pharyn geal
ton sil)
Soft palate
---"ll~--=-----~'---- Uvul a
L~~\----!J--- Palati ne
Lymphatic t issue
ton sil
of lateral band s
alon g salpingo
"T;- - -';l- - - Lingual
Structures in
¥.- ----:!!------ Epiglotti s Waldeyer's ring
Tonsil #
Pharyng eal tonsil 1
552
~ Clinical
Tonsilinfections
Abnormal enlargement of t he Particularl y well developed in En larged
Enlarged palatine tonsil Choana pharyngeal tonsil
palat ine to nsils due to severe viral young child ren, th e pharyngeal
Choanae
Stylohyoid
Pa latopha ryngeal
arch =.. . ,-=-- - - Aryepiglottic fold
Root of tongu e
(lingual to nsil)
Epiglotti s
Piriform ------!'i~~
recess
553
Pharyngeal Muscles
Sty lohyoid
Buccinator --"~hij~-:;Jtt~~=~~~
Digastr ic m uscle
(anter ior belly)
Inferior pharyngeal
const ricto r
Cricot hyroid
~_-- 51
52
Superior Pharyngeal constrictors
pharyngeal
-- - -53 const ricto r Superior pharyngeal constrictor
• 51
" H H. .. , ~ ~e r y g ? ~ ~ ~ ~ y~ ~ ~ ~ I ~ ~ r t
,------ - - - - 54 : 52 : Buccopharyngeal part
: 53
.. .. . H H H L H~~I ?p~ ~. rx ~ g ~ a ly~ ~ ~ H H H H'
, 54 : Glossop haryngeal part
~~~~~~g ea l
M1 }
: Middle pharyngeal constrictor
M2 constr ict or
• M1 H HH H.H H. ~ h. ? ~.~ r ? ~ h a ry ~ ~ ~~ l pa r t
: M2 • Ceratopharyngeal part
11 } Inferior
· 11
. ...........................H ! ~X~? ~h.~ry~ g e.~ I .~ .a. r.t .
12 : Cricopharyngeal part
pharyngeal
const ricto r
12
Pharyngoba silar
fascia
_~-- Accessory
m uscle bundle
Superior -
phary ngeal r ',:!' ----r- Masset er
constri ctor
Digastri c mu scle,
posterior belly
Stylohyoid
Stylopharyngeus
Hyoid bon e, ~
great er horn Pharyngeal
ton sil
Inferior pharynge al
Pharyng eal - --t"----7-'--- --? constr ict or
raphe Pharyn got ymp anic
tub e, carti laginous
Levator veli part
palatin i
Salping o --~"L!~~~i
pharyn geus
Superior - _ -=-,;=_
pharyng eal
constrictor Pterygoi d pro cess,
Esophagu s med ial plate
Musculus uvul ae
Palato Pterygoid hamulus
pharyngeu s
A Muscles of the posterior pharynx. B Muscles of the soft palate and pharyngo
tympanic tube . The muscles of the fauces
Tensor veli palatini Levato r veli palatin i form the posterior boundary of the oral
cavity.
I
Pharyng eal
elevato rs pharyngeus '---'t'#-- - Medial
pterygoid
-; -- - - Posterior
cricoaryten oid
Mesen- Cerebra l
cephalon aquedu ct
Pon s
Medulla
ob longa ta
-_J1 Vest ibu locochlear n.
(CNVIII)
Olive
Glossopharyngea l n. Pyramid of
A Levelsof the brainst em . (CN IX) m edull a
ob longat a
Vagus n. (CN X)
Hypoglo ssal n.
(CN XII) Anterior
med ian fi ssure
Cerebral Brachium of
peduncl e inf erior collic ulus Accessory n.
(CN XI) C1 spinal n..
Trigemina l {
nerve
M~;:~ *~ com
,",";:::: :;, Brachium of Brachium of
pedu ncle Pineal superior coll iculus inf erior colliculus
Sensory
root Midd le Superior
cerebellar
peduncle
and inferior
colliculi I
Superior
CNVIII - - - Inferior
m edullary
yz
cerebellar
velum .J.~--- CN IV
peduncle
Superior
P":~ili...""""t.-A- - Lateral cerebellar CNV
aperture peduncle
Medial
CN X Middle <, '_ em inence
Nervus int erm ediu s
cerebellar ;-..::::: Rhomboid
CN XI peduncl e
CN IX fossa
I n feri or ~
cerebellar
peduncle
Vestibular - ----';-".... Facial
area colliculus
Tubercle of
nucleus cuneatu s
Tubercle of
nucl eus gracilis
599
Spinal Cord
Fig. 39.20 Spinal cord and segments Fig.39.21 Spinal cord in situ
The spinal cord consists of 31 segments innervat ing a specific area in t he t runk or lim bs (see Fig. Posterior view wi t h vertebral canal windowed.
39 .22) . Affe rent (sensory) poste rior rootlets and efferent (motor) anterior root let s form the poste
rior and anter ior roots, respective ly. The two roo ts fuse to form a m ixed spinal nerve, which then
div ides into various branches . Med ulla
C2 spi nal n.
o blon gat a
Posterior root (with At las (C1)
spinal gang lion)
Spi nal
ganglia Spinal n.
Vert ebra
prom inens Cer vical
Spinal
Gray ram us
com mu nica ns
Wh ite ram us
Cauda J Ante rior commun ican s
equina 1 root lets
Sympat hetic
gang lio n
Lumbar cord
lesion
ffI
Conus/cauda
equina lesion
A Spinal cord segments . B Derm atome s. Each spinal C Spina l cord lesion s.
cord segment innervates
a parti cu lar skin area
(dermatom e).
600
Fig.39.23 Spinal cord in situ: Transverse section ~ Clinical
Superior view .
Lumbarpuncture
A needle int roduced into t he dural sac (lumbar
cistern) generally slips past t he spinal nerve
root s wi t hout inj uring t he spinal cord. Cerebro
spinal flui d (CSF) samples are t herefor etaken
Epidural space
between t he L3 and L4 vertebrae (2), once
Subarachnoid r- - - Post erior int ernal t he pat ient has leaned forw ard t o separate th e
space vertebra l spino us processes of th e lum bar spine.
venou s pl exus
Arachno id
Dent iculat e Conus ---;.,-- ----:' t-
Spinal ligame nt medul laris
du ra mater
.,..A-_ Int ervert ebral Cauda -----=,---j-;~.m \ . ' : r.;;_\
foram en equina
~~ <-- - Spinal
gang lio n
'.Zioi:-':~ Spinal n.
Ver tebral a.
Vert ebral vv. Ant erior inte rnal Root 3
verteb ral venou s plexus sleeve
Epidura l space
Cauda
eq uina
L4
spinal
gang lion
Sl
B Cauda equina at level of L2 vert ebr a. spinal
gang lio n
Sacral
plexu s
601
Meninges
~ The brain and spinal cord are covered by membranes called me The subarachnoid space, locat ed between the arachnoid and pia. con
~ ninges. The meninges are com posed of three layers: du ra mater tain s cerebrospinal f luid (CSF, see p. 604) . See p. 601 for th e coverings of
(dura), arachnoi d (arachnoid me m brane) , and pia mater. th e spinal cord.
Dura m ater
Pia mate r (on
cerebral surface)
Oute r - - - - r-:
table ., "
Cranial 0'
Bridg ingw.
bo ne Diploe - -;0
(t o superior sagitta l sinus)
Inner --;;.
1t able .r
Lat eral lacuna - --";f . - -?-_-" Superior
Superior
(closed) cerebral vv.
cerebralw.
Superior
saggit al sinus
Middle
cerebral a.
Inferior
Lateral lacuna - + - - -- - - 1M
(b ranches) cerebral w .
(open)
Arachnoid _.£.I~----'l'&1 Bridging vv.
granulatio ns
(arachnoid
villi)
Bridgin gw.
(to tranver se
sinus)
A Superior view. Left side: Dura mater (outer B Arachn oid (mi ddle layer), lef t ante rior
layer). Right side: Pia mate r (inner layer). oblique view .
Arachn oid granulatio ns (protrusions of t he
arachnoi d) are sites fo r reabsorpti on of CSF.
Neuroth elium
J~~~~~~~ii~~~111~1-
Arachnoid
Arachno id -~n!!!~. : Subdural
hemorr hage
trab eculae
Cerebra l cort ex ~
/
Pia mate r Cerebral a. Subarachnoid Cerebral v. Falx Bridgi ng v. Superio r
space cerebri cerebral vv.
C Layers of th e m eninges, coro nal sect ion. D Dura mater and calvarium , coro nal sectio n,
ant eri or view . anterior view.
602
~ Clinical
Superior
sagitt al
Rupture d
sinus
middle
Subarachnoid
meningeal a. "'"'il .~~- Falx cerebri
space
- - -- Dura mater -..!,'/§= - Inferior Ruptu red
sagitt al aneurysm
Calvaria sinus
A Epidura l hema t oma (above t he du ra). B Subdu ral hematom a (be low the dur a). C Subarachnoid hemo rrhage.
CN V,. V, .
and V 3
(me ningea l
~~~- C N V3
br anches)
(meni ngeal
bra nch)
1st and 2nd - ---F.-f!!!!!fo!!!!!!o----=''''---f ------'
cervical nn .
Fig.39.28 Arteries of the dura mater (me ningea l
br anches)
Mid sagittal sec t io n , lef t lat eral vi ew. See p . 608 ~~-- C N X
for t he arteries of th e b rain . (me ningeal
CNV, and V, branc hes)
(tentoria l
bra nches)
Middl e me ninge al a.
(parietal branch)
-~'+,'---- Occipita l a.
(mastoid br anch )
Vert ebra l a.
(branches) 603
Ventricles & (SF Spaces
Choroid plexus
(3rd ventr icle)
Superior
------,L-~
sagitta l sinus
Ambie nt cistern
Int er
hem ispheric
cistern
Straig ht sinus
Int er
vent ricular
Cerebral
foramen
aqueduct
~-+--- Confluence
of t he sinuses
j
cistern
Basa l
Cerebellom edu llary ciste rn
cistern
Interpeduncular (cisterna mag na)
cistern
Median
Pontomedu llary aperture
cistern
Spinal cord
IW \I li"'r-'~.".----- Verte bral
venous plexus
Subarachnoi d
space
Subarachnoi d space
Endone ural
Vent ricle space
Vein
Choroi d plexus
l Spinal n.
604
Fig. 39.30 Ventricular system
The vent ricular syst em is a cont inuat ion of the cent ral spinal canal int o
th e brain. Cast specimens are used to demon strate th e connect ions (
between th e four ventri cular cavit ies.
"
Ante rior - - - -----c.
ho rn
Right lateral
Inferior
vent ricle
horn
Cerebral
Left lateral aqueduct
vent ricle
Collat eral
trig one
-
transverse section .
Posterior
_ _ ---'\,.
horn
Anterior horn
4t h vent ricle
Posterior horn
Int erventri cular -~=--j
foram en
Inferior horn
3rd
vent ricle
Cerebral
aqueduct
callo sum ~ ,
Ante rior Interventri cular
com mi ssure fo ramen
Sept um
pellucidum
Lateral <; ~
vent ricle
Forni x
Corpus (ant erior
callosum horn )
Supraoptic recess
Optic chiasm
-Infundibular
~
!
recess
Hypoph ysis
A 3rd and 4th ventricles in t he midsagitta l sectio n. B Vent ricular system with neighboring st ruct ures.
605
Dural Sinuses & Veins of the Brain
Parietal fora m en
and emissary v.
.®
Tentorium
cerebelli ~---+-------~ti"- Superior
sagittal
sinus
Principal dural sinuses
Upper gro up Low er group
~ CD : Superior sagittal : Q)
Cavernous sinus
: sinus
.. ........ .....
.....................
and emissary v.
Transverse sinus
® : Superior pet rosal Venous plexus aroun d
: sinus t he for amen magn um
(ma rginal sinus)
: @ : Inferior pet rosal
: ® ; Sigmoid sinus , sinus Venous plexus
of hypoglossal
Inferior
anastom oti c v. Internal
Medial and occipita l v.
lateral ~~-......~~~ Gre a t
superio r cerebral v,
cerebellar w . Straight sinus
Conflu ence of Conf luence of
t he sinuses t he sinuses
Superior and inferior Transverse sinus
petro sal sinuses Transverse sinus
Occipital sinus
Pet rosal v.
Internal jugu lar v. - - --SII
Posteromedian
medul lary v.
606
Fig. 40.3 Basal cerebral venous system Fig. 40.4 Veins of the brainstem
Basa l view. Basal view.
.tl.
0
-tl:l
0
0
e,
Basilar v.
Int erpedun ~
VI
Ante rior cularw. VI
Inter cerebr al v. ttl
Pont om esen Vi
pedun
cularv.
Deep
m iddl e Trigem inal n.
cephalic v.
-.
0
...,.
Inferior cerebral v. (CNV) Superior ::r
ttl
choroidal v. petrosal v.
tl:l
Basilarv. Superior t3-.
Internal Transverse cerebellar vv. ~
Posterior cerebra l v. po nt ine vv. l(o
venou s Great
Ant ero latera l
and ante ro
~
-.
confluence cerebra l v. ~
Transverse
median
pontin e v. -
b'
medu llary vv.
a.
Posterom edian
medu llary v.
Fig. 40.5 Dural sinuses in the skull base
Superior view of the opened cranial cavity.
Removed: Tento rium cerebel li (right side).
~=--=,,~~~,;--- Superior
opht halm ic v.
=-~~w::---- Sphenoparietal @
Ante rior sinus
®
8 intercavernous
sinus
Cavernous (J)
sinus
Venous plexus of
foramen ovale "",,-"'--~~"--- Petros qu amous
sinus
Post erior - --o-""-f.
~.,=:;;r--- Midd le
® int ercavernous m eningeal v.
sinus
~-------';"'----;-~i-:--- Superior pet rosal ®
Basilar plexus sinus
Inferior
-'-------~j__- Jug ular
@ pet rosal sinus
for am en
Inferior Occipita l
cerebraI vv. sin us
® Straight sinus
Conflu ence of t he sinu ses @)
Internal
carot id a.
Cerebral
part
Pet rous
part
< : Poste rior
Fig. 40.7 Arteries ofthe brainstem
and cerebellum
Left lat eraI view.
Basilar a. cerebral a.
Superior
cerebellar a.
Cerv ical
part
External
caroti d a.
Com mo n _ _ ----',--'<-'-----,:;= '._~~""""'-- CN V
caroti d a.
"'l~~k-~J-- Vertebral a.
Postcommunicating Anterio r
part (A2) com m unic ating a.
Ante rior
cerebra l a. Internal caroti d a.
Precom m unicat ing
part (A l) Sphenoidal }
part (Ml)
Middl e
cereb ral a.
Postcommunicatin g Insular
part (P2) part (M2)
Ante rior
choroidal a.
Lateral occipita l a.
(P3) Pont ine aa.
Posteroinferior
cerebellar a. Medial occipital a. (P4)
608
Fig. 40.9 Cerebral arteries
A. of central sulcus
Lateral Caudat e
ventri cle nucleus
~~~~f= Ante r io r .
m iddl e. and
posterior
t em por al
branches
campus pallidus
Polar -~"""""'~"~!:I...
fro ntal a.
__ ~.
branch
"'.?-~""''''''".-- Parietal
branch
Medial
occipit al
Posterior a. (P4)
cerebra l a. Lateral Middl e and posterior
occi pit al a. (P3) te m poral branches
609
I Arteries & Veins of the Spinal Cord
~ Like t he spinal cord it self. t he arte ries and veins of t he spinal cord
~ consist of m ultiple hori zont al system s (blood vessels of th e spinal
cord segments) th at are integr ated int o a vert ical syst em.
t erior int ercostal. lum bar. or lateral sacral arte ries. spinal a.
1-/''---- - - Subclavian a.
Posterior
intercost al aa.
~_ _ Posterior
segme ntal
rnedullary a.
Lumb ar aa.
610
Fig. 40.12 Veins of the spinalcord ___........,r- ,~."..jJi-- Posteri or
The inte rior of th e spinal cord dr ains via venou s plexuses into an ante rior spi nal v.
and a posterior spinal vei n. The radicul ar and spinal vein s connect th e
veins of th e spinal cor d wi t h t he int ernal verteb ral venous pl exus. The
intervert ebral and basiver te bral vein s connect th e inte rnal and exte rnal
venou s plexuses, w hich drain into th e azygo s syst em.
Spinal v.
Lef t brachio
Int er
cephalic v.
verte bral v.
Int ernal
j ugular v.
,'1---- Subcostal v.
• "_'k-J~'!!----- Medial
and lateral
Basiver te bral v. ---=~'-'---~~ I
epidura l vv.
Inferi or - - H
vena cava
no-L1i!J~'.---- Co m mo n
iliac v.
Int ernal
iliac v.
Ext ernal
iliac v.
Anter io r
int ernal ver te bral
venou s plexus
A Venou s dr ainage D Vein s in t he sacral
syste m . and lumbar canals.
611
Circuitry
Afferent Efferent
(sensory) (motor)
Joints, skin.
skeletal muscle ~ Skeletal muscle
<,
Somatosensory Somatomotor
Somatic fibers fibers
<,
i"
eNS
~
~ j
<,
-: <,
Autonomic Viscerosensory Visceromotor
(visceral) fibers fibers
)L <,
Glands, smooth
Viscera, vessels muscle,cardiac
muscle
Posterior
Nuclear
horn (sensory) \
column Anterior
Lateral horn
root
(visceromotor) ~
:L ~
nuclei
Columns Nuclei
612
Fig. 41.4 Reflexes Fig. 41.5 Sensory and motor systems
Mu scu lar fun ct ion at th e un co nsci ou s (ref lex) level is co nt ro lle d by th e The senso ry syste m (see p. 614) and m otor syst em (see p. 615) are so
g ray m at t er o f t he spinal co rd . fu ncti on ally interrelat ed th ey may be describ ed as o ne (sensorim oto r
syste m).
Monosynaptic refl ex Polysynaptic refl ex
Precentral gyrus (primary Central
Posterior root Posterior horn motor cortex, M1) sulcus
/ Postcent ral gyrus
Pseudounipolar
Supplementary
motor cortex
1_
Y
-> (primary sornato
sensory cort ex)
cell body (in
spinal ganglion) Premotor -r-r-r-rr-r-r-x-r-rr-r-;
cort ex
proprius
Funiculi
Sulcomarginal ~ Tracts
fasciculus
B W hite m atter of t he spinal co rd . The w hite m atter of th e spinal co rd
co nta ins ascend ing tracts (afferent, see p. 614) and d escend ing tra cts
(ef ferent, see p. 615), w hi ch are th e CNS eq uivalent of periph eral
nerves.
B Pri ncip al intrin sic fascicl es of th e spi nal co rd. Th e intrin sic f ascicles are Interneuron
t he co nduc t io n app arat us of th e intrinsic circu it s, allowing axons t o
ascend and descend t o coo rdi nate spi nal ref lexes for multisegm ental Upper motor --7..---""~5:O>~~-- Neuron in the
neuron (in the
muscles. sensory cortex
motor cortex)
_.V.f--~+-- Terti ary afferent
Spinal ganglion (sensory) neuron
/l~
~~ I
\ \ e1r-- - - Secondary afferent
(sensory) neuron
a-moto r
- - -"---....>J
neuron
Inter
calated cell
Projection
- - --7-- +-11---,
neuron
Commissural
- - - - -+
cell
Association
cell
a-mot or
neuron
1--'-1+- Mot or interneuron
3rd neurons
Accessory
nucleus
cuneatu s
Nucleus
cuneatus
Medial ""-.
lemni scus
Unconscious
proprioception
Position sense,
consciouspropriocepti on,
vibratio n, touch
Pressure, touch
Pain, temperature
' The fasciculi cuneatus and gracilus convey infor mat ion from th e upper and
lower limbs, respect ively. At th is spinal cord level, only the fasciculus cuneatu s
is present .
Fasciculu s Pat hway for positi on sense (con sciou s Conveys inf orm ation fr om upper
® cuneatus propriocept ion) and fine cutaneous lim b (not present below T3) ("II bod ies of 1st neuro n l o . ~ t " d in spinal
Posterior
sensation (touch, vibrat ion, gang lio n; pass uncrossed t o th e do rsal colum n
Fasciculus fu niculu s Conveys inf orm ation fr om lower
® fine pressure sense, t w o-p oint nucl ei
gracilis' discrim inat ion) limb
614
Pyram idal (co rticospin al) t ra ct Extrapyramidal motor system Fig.41.7 Motor pathways
(descending tracts)
Supplement ary
motor corte xes
Corticos pinal
fi bers From
cerebellum
Ventr al
lateral
CNV II --;~"--'--- nucleus
Posterior root
/ ;t;7 - Decussation
of pyram ids r
Ante rior
root
® ®
Descending tracts of the spinal cord
Tract Function
Optic Meyer's
chiasm loop
Optic /
~~ Tempora l ~
W ---m
~ crescent
B Inferior view .
t ract
~
Lateral
geniculat e
body
@Y ~
®~@
Optic n.
Optic chiasm _
Optic tract G®
~ Superio r
colliculus
-~--f~----t?----~~
~
Lat eral
geniculate
Lateral geni
culate body
Visual
cortex Reticular
form at ion
A Geniculate path way. Left visual hemifield. B Non-genicul ate pathw ay.
616
~ Clinical
~,-.;~::--- Pupillary
sphinct er
G)
Short ciliary nn.
CD ~--- Oculomoto r n.
G iliary ganglion (CN III)
/L
Optic n. (CN II) -~_/" i>:>s:ff:
Oculomotor n. (CN III,
Optic tract - -"c--:0. r
parasympathetic
. '- ---"'--- - Nucleusof oculomotor n.
port ion)
(medial rectus)
area
617
', ' , Fig. 41.14 Auditory system (hearing)
See p. 480 for th e vestibulocochlear nerve (eN VIII).
Acoustic radiation
Nucleus of medial
geniculate body
Inferior collicular
nucleus (and commissure)
Posterior
Lateral lemni scus - -----c------'l cochlear
(and nuclei) nucleus "'-.-.:~- 200 Hz
/ Cochlear duct
Medullary - - ---1++1---..
st riae
Superior
olivary nucleus
Nucleus of
trap ezoid
body Fig. 41.15 Gustatory system (taste)
When specialized epithelial cells (second ary sensory cells with no axon)
in the tongue are chemically st im ulat ed, the cell bases release gluta
mate , st im ulati ng th e periph eral proce sses of affe rent crani al nerves VII,
IX, and X. Note: Spicy foods may also st im ulat e trig eminal fib ers (not
show n).
Postcentr al
gyrus
--II
( {
Insula
Vent ral
posterom edial
nucleus of
th alamus
Geniculate
Nerve territories gangli on
Inferio r < r-Hf----,#--~.--------- Medial parabrachial nucleus
(pet rosal)
,.r "~::;;;;:~- S o li t a r y tr act nucleus (gustat or y part)
gangli on
I ' f'<'c-J~H--D or s al vagal nucleus
Va g us n ' ---T-~
(CNX)
619
Sensory Systems (III)
Olfact or y - - - - - - ----->",....--7 - -
tr act
---=~--- Prepiriform
area
Lateral and
----;-------,,'~~i!c----r---.
medial stria
~~!'-----;;;---- Amygdala'
Am bient -------;~---.;r==__
gyrus
Medial
olfactory st ria \"'--=;;;~-----"!~- Stria term inalis
~~:;:§
'#-~!,--:--~l'---- Habenular
nuclei
Anterior
perf orate substance ------i-t---c~~~::~s:i:::~iii~~~ _~\--I-~~'-TT-- Interpeduncular
nucleus
Olfactory ------::>~--'-:~~J:1 '
~""'<::,---'---'---- Dorsal t egmenta l
mucosa (wit h
olfact ory fi bers) nucleus
Amygdala
620
~ Th e lim bic syste m, wh ich excha nges and integr at es in form ati on regulat es dr ive and affec t ive behav ior. It plays a cr ucia l role in m em or y
~ bet w een th e t elencepha lon, d ien cepha lon , and m esen ceph alon , and learning .
Corpus - - -.'
callosum
\
\
~ Hippocampus
A Midsagit ta l sectio n, left B Hippo campus, left
• The inner arc also contains th e diagonal band of Broca (not shown).
Fig. 41.17 limbic system nuclei Fig.41 .18 limbic regulation ofthe peripheral autonomic
Th is neu ron al circ uit (Papez circuit) estab lishes a conn ect ion betwee n nervous system
inform ation sto re d at th e co nsc ious and un con scious level. The limbic syste m receives affe rent feed back sig na ls fro m its t arg et
organs. See p. 623 fo r th e auto nomic nervou s syste m .
Corpus callosum
li m bic
Thalamo
syste m
Emot ional
cingular
drive
tract
Hypothalamus
Cingulo
hippocampal
Homeostasis
fibers
Medulla
Anterior
Circulatory and oblongata
t halamic nuclei
respiratory
homeostasis
Mammillo Spin al cord
t halamic
Spinal reflexes
t ract
Mamm illary t
Targ et organs
body Hippocampus Fornix
621
Sympathetic Parasympathetic Fig. 42.5 Autonomic nervous system
Parasympathet ic
CN III
ganglia (in t he head)
Lacrim al and
salivary glands
parasym pathetic
Parasympath eti c
ganglia • Ste llate ganglion =
(close t o organs) inferior cervical
Heart ganglion and T1
sympat het ic ganglion
Lung
T3 Greater
splanchnic n.
T4 Stomach
Sym pat het ic Parasympat heti c
T5
~ CN S I
T6
T7
T8
Liver
Pancreas
s y mpa t~-pr--
ganglion
'"
e-~--___I
- ~--;--
synaptic
neuron s
I Parasymp at heti c
ganglion
T9 Celiac ganglion
/
Postsynapt ic ----.J
T10 1-------<.... Kidney neurons
T ll f- - - __
Target organ
T 12 f - - - -...... Intestin e
L5
Bladder
Sacral part
} parasympath et ic
nuclei)
Inferior
hypogastri c plexus
A
Art eries Vasoconstricti on Vasodilat ion of the arteries of th e penis and clito ris (erect ion)
Index 628
Ql: The superio r bound aries of Michaelis' rhomb oid run from th e Ql: Use a verti cal and a hori zont al line through th e umbilicus (at ap
spino us process of L4 to th e posterior superior iliac spines. The proxim ately th e level of L4) to divide th e abdo me n and pelvis int o
rhomboid th en foll ow s th e curve of th e iliac crest to th e anal cleft. right and left upp er and lower quadrant s (see p. 140).
Q2: The inferior angle of th e scapula is at th e level of th e T7 spinous Liver, sto mach. tr ansverse colon, small int estin e.
process. The iliac crest is at th e level of t he L4 spinous process. LUQ spleen, pancreas, du odenum . descending colo n. left
See p. 40 fo r palpable bony landm arks. kid ney and suprarenal gl and, left urete r.
Liver. sto mach, t ransverse colo n, small intest ine.
Thorax (pp. 120-121) RUQ gallbl add er, pancreas. duod enum . ascending colon,
right kidn ey and suprare nal gland, rig ht uret er.
Ql : After carefu l inspection, undertake a syste mat ic palpation of each
Small intest ine, descending colon, left uret er. urinary
breast. Pa lpate th e tissue of each breast by qu adrant in th e foll ow ing llQ
sequence: inf erior lateral, inferior medial, superio r media l, and su bladd er. reprodu ct ive org ans.
perior lateral. Palpate th e axilla t o examine th e axillary t ail of breast Small int estin e. ascending colo n (with cecum and
t issue. The majority of lymph drainage from t he breast is t o t he RlQ vermiform appendix) , right ureter. urinary bladder,
axillary lymph nod es. The parasternal lymph nod es, w hich run along reprodu cti ve organs.
t he int ernal t ho racic vessels. drain t he me dial por t ions of t he breast.
See p. 64 for t he axillary lym ph nodes. Q2: Direct inguinal herni as are most com mon in middl e-aged or older
males and are believed t o be caused by "wear and tear." They t ypi
Q2: The aort ic and pulm onary valves are best auscultated at th e 2nd cally occupy th e medial por ti on of t he inguinal canal (having exite d
right and left intercosta l spaces. respecti vely. Locat e th e 2nd th e abdo me n th rough th e inguinal t riang le). They may also exit via
intercostal spaces by fi ndi ng th e usually palpable ste rnal angle (t he th e superficial inguinal ring . Ra rely, t hey ente r th e scrot um . Indirect
j unctio n between th e manubrium and body of th e ste rnum) . The hernias are seen in male chil dren and you ng adults and are believed
2nd ribs attach to th e sternum at th e ste rnal angle. The t ricuspid to have a congenit al basis. They generally exit via t he deep inguinal
(right at riovent ricular) and bic uspid (left at riovent ricular) valves ring and th us may occupy th e ent ire length of th e inguinal canal.
are best ausculta te d at t he left 5th int ercostal space. If t he rib s are They may also exit via th e superficial inguin al ring, and occasio nally
visible/pal pable. th e 5th rib can be fo und by count ing up from below ente r th e scrot um. See p. 133 for inguin al hernias.
(t he lowest rib at th e mi dclavicular line is t he 10th rib). See p. 87 for
auscult at ion sites; see p. 120 for reference lines in th e t ho rax.
626