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Atlas of CLINICAL GROSS ANATOMY

Atlas of CLINICAL GROSS ANATOMYSecond Edition

Kenneth Prakash Moses, MDFellow of the Royal Society of MedicineEmergency Room PhysicianBear Valley Community HospitalBig Bear Lake, Californiahttp://www.MosesMD.com

John C. Banks, Jr., PhDAssociate Professor of AnatomyDepartment of Pathology and Human AnatomyLoma Linda University School of MedicineLoma Linda, California

Pedro B. Nava, PhDProfessor of Anatomy and Vice-ChairDepartment of Pathology and Human AnatomyLoma Linda University School of MedicineLoma Linda, California

Darrell K. Petersen, MBAInstructorDirector of Anatomical ServicesBiomedical PhotographerDepartment of Pathology and Human AnatomyLoma Linda University School of MedicineLoma Linda, California

Prosections of the Head, Neck, and Trunkprepared by Martein MoningkaDepartment of Pathology and Human AnatomyLoma Linda University School of MedicineLoma Linda, California

1600 John F. Kennedy Blvd.Ste 1800Philadelphia, PA 19103-2899

ATLAS OF CLINICAL GROSS ANATOMY ISBN: 978-0-323-07779-8Copyright © 2013, 2005, by Saunders, an imprint of Elsevier Inc.Photographs © 2013 by Darrell K. Petersen.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the Publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Atlas of clinical gross anatomy / Kenneth P. Moses … [et al.] ; prosections of the head, neck, and trunk prepared by Martein Moningka.—2nd ed. p. ; cm. Clinical gross anatomy Includes index. ISBN 978-0-323-07779-8 (pbk. : alk. paper) I. Moses, Kenneth P. II. Title: Clinical gross anatomy. [DNLM: 1. Anatomy—Atlases. QS 17] 611.0022′2—dc23 2012003930

Working together to grow libraries in developing countries

www.elsevier.com | www.bookaid.org | www.sabre.orgPrinted in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Content Strategy Director: Madelene HydeSenior Content Development Specialist: Andrew HallPublishing Services Manager: Patricia TannianSenior Project Manager: Linda Van PeltDesign Direction: Ellen Zanolle

This book is dedicated to the One who has been there to

assist and guide me throughout the entire process.

K. P. MOSES

To my wife Patricia and daughters Erin and Kirsten, for

allowing me to spend so many hours in my anatomy lab.

J. C. BANKS, JR.

To the many teachers, professors, and mentors who have

had faith in me during my academic career.

P. B. NAVA

To my mother, for all of her love and support;

and to Heather, Jillian, and Megan.

D. K. PETERSEN

Preface

As we completed the manuscript that was to become the first edition of Atlas of Clinical Gross Anatomy, released in 2005, we were pleased with the features of this atlas. We were able to produce the original intended objectives, such as outstanding dissections and superb photographs, the general presentation of the sections from the head down to the foot, and the consistent organization within each chapter from superficial structures to deeper structures. These all came together nicely. The rewards for this endeavor came the next year with our atlas being awarded the R. R. Hawkins Award from the Professional and Scholarly Division of the Association of American Publishers in February 2006, and then winning the Richard Asher Prize in October 2006, from the Royal Society of Medicine and the Society of Authors. As exciting as these accolades were, we readily saw, as an author team and from comments and suggestions we received (especially from our students, who found this volume of great help), several ideas and changes that would greatly improve the usefulness of this atlas in the classroom as well as in the lab. Utilizing the time given us and the opportunity to collaborate physically at key moments over the past couple of years, we accomplished several notable changes to produce this second edition of Atlas of Clinical Gross Anatomy.

We feel that the most significant change in the second edition of our atlas has come in the form of 20 new dissections. We completely reworked the chapters on the heart (Chapter 30) and the lungs (Chapter 31). Additionally, the chapter on the vertebral column (Chapter 26) received three new and much-needed dissections featuring ligaments of the vertebral column and the costovertebral joints. The remaining new dissections were also within Section 3, with Chapter 33 now including a key dissection of the arteries of the celiac trunk and Chapter 34, the classic presentation of the branches

of the abdominal aorta. Chapters 36 to 38 on the pelvic girdle and viscera and the perineum were enriched with dissections of the iliac vessels, the female recto-uterine pouch, and the male perineal neurovascular structures.

A second significant change in this edition is in the titling and labeling of all the dissection images. First, each page of topography and dissection received a more accurate title within the color bar at the top of each page, giving the reader a quicker and clearer orientation of the image. The descriptive legend below each photograph was revisited for greater clarity. Key structures of each image were bolded for emphasis. The bolding of key structures helps to illustrate the main components of each dissection. We also made a few title changes in the Head and Neck section, which are now more accurate and all-inclusive.

Finally, another change worth mentioning is the reorganized sequence of Chapters 32 to 35, placing these chapters in a more logical progression. In this new edition, we begin with the anterolateral abdominal wall (Chapter 32) and proceed through the abdominal organs (Chapters 33 and 34), ending in Chapter 35 with the posterior abdominal wall.

It will be apparent to the reader that the major changes are to be found in the Trunk section of this book. We feel very pleased with the changes we made to improve the quality of this second edition of Atlas of Clinical Gross Anatomy, and we hope that this book will be useful in your study of human anatomy.

Kenneth Prakash Moses

John C. Banks, Jr.

Pedro B. Nava

Darrell K. Petersen

Left to right: Kenneth Prakash Moses, John C. Banks, Jr., Pedro B. Nava, Darrell K. Petersen

vii

Acknowledgments

The idea to write this book came to me while a first-year medical student. Thank you to each person who encouraged me to write this book: John, who was my anatomy professor in college and one of my favorite teachers; Ben, my medical school gross anatomy professor who is an excellent lecturer and now a good friend; and Darrell, who is, in my opinion, the world’s best medical photographer.

Thank you to the Elsevier staff for being such friendly co-workers on this large task and for being mindful of this author’s words and opinions. I truly enjoyed the entire process.

Thank you to Kendra Fisher, MD, for all of your assistance in helping us obtain and also review all of the radiographic anatomy in this book.

Thank you to my sister, Juanita Moses, MD, who has a great understanding of practical clinical medicine and an impeccable attention to detail; she edited the entire manuscript at each of the three proof stages.

And above all, a special thank you to my mother, Dr. Gnani Ruth Moses, for raising a son to believe that “all things are possible.”

K. P. Moses

Thanks must go to everyone who has assisted in the proofreading and checking of the manuscript.

Grateful thanks to Michigan State University for supplying the cadavers for the chapters on the upper and lower limbs. Special thanks go to Kristin Liles, Director of Anatomical Resources, and Bruce E. Croel, Anatomical Preparation Technician.

I would also like to thank Andrews University and the Department of Physical Therapy for the use of their anatomy

lab space, and for the interest and encouragement of its Chairs, Daryl W. Stuart, EdD, and Wayne L. Perry, PhD.

J. C. Banks, Jr.

I would like to express my appreciation to all of the individuals within the Division of Anatomy at Loma Linda University who supported this endeavor. A special thanks to Martein Moningka, Curator, for his many hours of hard work on numerous detailed dissections for this atlas. This project would not have been possible without the strong support from Thomas Smith.

Dawn, thank you for your inspiration and support.

P. B. Nava

I would first like to thank Ken for asking me to be a part of such a great project. Thanks also to my fellow authors—it has been a pleasure working with you over the years and I look forward to many more.

Dave, for being a mentor/instructor in school and, most important, for being my friend, I owe you many thanks.

I would like to thank Tom for always lending a hand. You deserve more thanks than you ever receive.

Rachel, you are amazing and very talented. Your words of encouragement inspire me to always do my best.

Madelene, thanks for your devotion, your vision, and for continually pushing us forward. You are truly a welcomed asset to our team.

D. K. Petersen

ix

Editorial Review Board

Peter Abrahams, MB BS, FRCS(Ed), FRCRSt. George’s UniversityGrenadaWest IndiesFellowGirton CollegeUniversity of CambridgeCambridgeExaminer to The Royal College of Surgeons

of EdinburghFamily PractitionerLondonUnited Kingdom

Gail Amort-Larson, MScOTAssociate ProfessorDepartment of Occupational TherapyFaculty of Rehabilitation MedicineUniversity of AlbertaEdmonton, Alberta, Canada

Judith E. Anderson, PhDProfessorDepartment of Human Anatomy and Cell

SciencesFaculty of MedicineUniversity of ManitobaWinnipeg, Manitoba, Canada

Seeniappa Palaniswami Banumathy, MS, PhD

Director and ProfessorInstitute of AnatomyMadurai Medical CollegeMadurai, India

Raymond L. Bernor, PhDProfessorDepartment of AnatomyHoward University College of MedicineWashington, DC

Edward T. Bersu, PhDProfessor of AnatomyDepartment of AnatomyUniversity of Wisconsin School of Medicine

and Public HealthMadison, Wisconsin

Homero Felipe Bianchi, MDThird ChairDepartment of Normal Human AnatomyFaculty of MedicineUniversity of Buenos AiresBuenos Aires, Argentina

David L. Bolender, PhDAssociate ProfessorDepartment of Cell Biology, Neurobiology

and AnatomyMedical College of WisconsinMilwaukee, Wisconsin

Dale Buchberger, DC, DACBSPPresidentAmerican Chiropractic Board of Sports

PhysiciansAuburn, New York

Walter R. Buck, PhDDean of Preclinical EducationProfessor of Anatomy and Course Director

for Gross AnatomyLake Erie College of Osteopathic MedicineErie, Pennsylvania

Stephen W. Carmichael, PhD, DScProfessor and ChairDepartment of AnatomyMayo Clinic College of MedicineRochester, Minnesota

Wayne Carver, PhDAssociate ProfessorDepartment of Cell and Developmental

Biology and AnatomyUniversity of South Carolina School of

MedicineColumbia, South Carolina

David Chorn, MMedSciAnatomy Teaching ProsectorSchool of Biomedical SciencesUniversity of Nottingham Medical SchoolQueen’s Medical CentreNottingham, United Kingdom

Patricia Collins, PhDAssociate ProfessorAnglo-European College of ChiropracticBournemouth, United Kingdom

Cynthia A. Corbett, ODDirectorVision CenterRedlands, California

Maria H. Czuzak, PhDAcademic Specialist—Anatomical InstructorDepartment of Cell Biology and AnatomyUniversity of ArizonaTucson, Arizona

Peter H. Dangerfield, MD, ILTMDirector, Year 1Senior LecturerDepartment of Human Anatomy and Cell

BiologyUniversity of LiverpoolLiverpool, United Kingdom

Jan Drukker, MD, PhDEmeritus Professor of Anatomy and

EmbryologyDepartment of Anatomy and EmbryologyFaculty of MedicineMaastricht UniversityMaastricht, The Netherlands

Julian J. Dwornik, PhDProfessor of AnatomyDepartment of AnatomyMorsani College of MedicineUniversity of South FloridaTampa, Florida

Kendra Fisher, MD, FRCP (C)Assistant Professor of Diagnostic ImagingLoma Linda University School of MedicineStaff PhysicianDepartment of Diagnostic ImagingLoma Linda University Medical CenterLoma Linda, California

Robert T. Gemmell, PhD, DScAssociate ProfessorDepartment of Anatomy and Developmental

BiologyThe University of QueenslandBrisbane St. Lucia, Queensland, Australia

Gene F. Giggleman, DVMDean of AcademicsParker College of ChiropracticDallas, Texas

Duane E. Haines, PhDProfessor and ChairmanProfessor of NeurosurgeryDepartment of AnatomyThe University of Mississippi Medical CenterJackson, Mississippi

Jostein Halgunset, MDAssistant ProfessorInstitute of Laboratory MedicineNorwegian University of Science and

TechnologyTrondheim, Norway

Benedikt Hallgrimsson, PhDAssociate ProfessorDepartment of Cell Biology and AnatomyUniversity of CalgaryCalgary, Alberta, Canada

Jeremiah T. Herlihy, PhDAssociate ProfessorDepartment of PhysiologyUniversity of Texas Health Science CenterSan Antonio, Texas

Alan W. Hrycyshyn, MS, PhDProfessorDivision of Clinical AnatomyUniversity of Western OntarioLondon, Ontario, Canada

S. Behnamedin Jameie, PhDAssistant ProfessorDepartment of Anatomy and Cellular and

Molecular Research CenterSchool of MedicineBasic Science CenterTehran University of Medical SciencesTehran, Iran xi

Elizabeth O. Johnson, PhDAssistant ProfessorDepartment of Anatomy, Histology and

EmbryologyUniversity of IoanninaIoannina, Greece

Lars Kayser, MD, PhDAssociate ProfessorDepartment of Medical AnatomyUniversity of CopenhagenCopenhagen, Denmark

Lars Klimaschewski, MD, PhDProfessorDepartment of NeuroanatomyMedical University of InnsbruckInnsbruck, Austria

Rachel Koshi, MB, BS, MS, PhDProfessor of AnatomyDepartment of AnatomyChristian Medical CollegeVellore, India

Alfonso Llamas, MD, PhDProfessor of Anatomy and EmbryologyDepartment of Anatomy, Medical SchoolUniversidad Autónoma de MadridMadrid, Spain

Grahame J. Louw, DVScProfessorDepartment of Human BiologyFaculty of Health SciencesUniversity of Cape TownCape Town, South Africa

Liliana D. Macchi, PhDSecond ChairDepartment of Normal Human AnatomyFaculty of MedicineUniversity of Buenos AiresBuenos Aires, Argentina

Bradford D. Martin, PhDAssociate Professor of Physical TherapyDepartment of Physical TherapySchool of Allied HealthLoma Linda UniversityLoma Linda, California

Martha D. McDaniel, MDProfessor of Anatomy, Surgery and

Community and Family MedicineChairDepartment of AnatomyDartmouth Medical SchoolHanover, New Hampshire

Jan H. Meiring, MB, ChB, MpraxMed(Pret)Professor and HeadDepartment of AnatomyUniversity of PretoriaPretoria, South Africa

John F. Morris, MB, ChB, MDProfessorDepartment of Human Anatomy and GeneticsUniversity of OxfordOxford, United Kingdom

Juanita P. Moses, MD, FAAPAssistant ProfessorDepartment of Pediatrics and Human

DevelopmentMichigan State University College of Human

MedicineStaff PhysicianDepartment of PediatricsDevos Children’s HospitalGrand Rapids, Michigan

Helen D. Nicholson, MB, ChB, BSc, MDProfessor and ChairDepartment of Anatomy and Structural

BiologyUniversity of OtagoDunedin, New Zealand

Mark Nielsen, MSBiology DepartmentUniversity of UtahSalt Lake City, Utah

Wei-Yi Ong, DDS, PhDAssociate ProfessorDepartment of AnatomyFaculty of MedicineNational University of SingaporeSingapore

Gustavo H. R. A. Otegui, MDDepartment of AnatomyUniversity of Buenos AiresBuenos Aires, Argentina

Ann Poznanski, PhDAssociate ProfessorDepartment of AnatomyMidwestern UniversityGlendale, Arizona

Matthew A. Pravetz, OFM, PhDAssociate ProfessorDepartment of Cell Biology and AnatomyNew York Medical CollegeValhalla, New York

Reinhard Putz, MD, PhDProfessor of AnatomyChairman, Institute of AnatomyLudwig-Maximilians-UniversitatMunich, Germany

Ameed Raoof, MD, PhDLecturerDivision of Anatomy and Department of

Medical EducationUniversity of Michigan Medical SchoolAnn Arbor, Michigan

James J. Rechtien, DOProfessorDivision of Anatomy and Structural BiologyDepartment of RadiologyMichigan State UniversityEast Lansing, Michigan

Walter H. Roberts, MDProfessor EmeritusDepartment of Pathology and Human

AnatomyLoma Linda University School of MedicineLoma Linda, California

xii Editorial Review Board

Rouel S. Roque, MDAssociate ProfessorDepartment of Cell Biology and GeneticsUniversity of North Texas Health Sciences

CenterForth Worth, Texas

Lawrence M. Ross, MD, PhDAdjunct ProfessorDepartment of Neurobiology and AnatomyThe University of Texas Medical School at

HoustonHouston, Texas

Phillip Sambrook, MD, BS, LLB, FRACPProfessor of RheumatologyUniversity of SydneySydney, Australia

Mark F. Seifert, PhDProfessor of Anatomy and Cell BiologyIndiana University School of MedicineIndianapolis, Indiana

Sudha Seshayyan, MSProfessor and HeadDepartment of AnatomyStanley Medical CollegeChennai, India

Kohei Shiota, MD, PhDProfessor and ChairmanDepartment of Anatomy and Developmental

AnatomyDirectorCongenital Anomaly Research CenterKyoto University Graduate School of

MedicineKyoto, Japan

Allan R. Sinning, PhDAssociate ProfessorDepartment of AnatomyThe University of Mississippi Medical CenterJackson, Mississippi

Bernard G. Slavin, PhDCourse DirectorHuman Gross AnatomyKeck School of MedicineUniversity of Southern CaliforniaLos Angeles, California

Terence K. Smith, PhDProfessorDepartment of Physiology and Cell BiologyUniversity of Nevada School of MedicineReno, Nevada

Kwok-Fai So, PhD(MIT)Professor and HeadDepartment of AnatomyFaculty of MedicineThe University of Hong KongHong Kong, China

Susan M. Standring, PhD, DScProfessor of Experimental NeurobiologyHeadDivision of Anatomy, Cell and Human BiologyGuy’s, King’s and St Thomas’ School of

Biomedical SciencesKing’s CollegeLondon, United Kingdom

Mark F. Teaford, PhDProfessor of AnatomyCenter for Functional Anatomy and EvolutionJohns Hopkins University School of MedicineBaltimore, Maryland

Nagaswami S. Vasan, DVM, PhDAssociate ProfessorDepartment of Cell Biology and Molecular

MedicineNew Jersey Medical SchoolNewark, New Jersey

Ismo Virtanen, MD, PhDProfessor of AnatomyAnatomy DepartmentHaartman InstituteUniversity of HelsinkiHelsinki, Finland

Linda Walters, PhDProfessor, Preclinical EducationMidwestern UniversityGlendale, Arizona

Joanne C. Wilton, PhDDirector of AnatomyDepartment of AnatomyThe Medical School, University of

BirminghamBirmingham, United Kingdom

Susanne Wish-Baratz, PhDSenior TeacherDepartment of Anatomy and AnthropologySackler Faculty of MedicineTel Aviv UniversityTel Aviv, Israel

David T. Yew, PhD, DSc, DrMed(Habil), CBiol, FIBiol

Professor and ChairmanDepartment of AnatomyThe Chinese University of Hong KongHong Kong, China

Henry K. Yip, PhDAssociate ProfessorDepartment of AnatomyFaculty of MedicineThe University of Hong KongHong Kong, China

N. Sezgie �Ylgi, PhDProfessorDepartment of AnatomyFaculty of MedicineHacettepe UniversityAnkara, Turkey

Editorial Review Board xiii

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Specialist Reviewers

ANATOMYBrad Martin, PhDRalph Perrin, PhD

AUDIOLOGYHeather L. Knutson, MA, CCC-A, FAAA

CARDIOLOGYMil Dhond, MD, FACCHusam Noor, MD

CARDIOTHORACIC SURGERYLeonard Bailey, MD, FACSAnees Razzouk, MD, FACS

DENTAL HYGIENEJolene N. Bauer, RDH

DENTISTRYWilliam A. Gitlin, DDSCarlos Moretta, DDS, RDH

DIETETICSArlene Campbell, RD

EMERGENCY MEDICINEMichael Dillon, MD, FACEPGreg Goldner, MD, FACEPEliot Nipomnick, MD, FACEP

FAMILY PRACTICETricia Scheuneman, MD

GENERAL SURGERYNathaniel Matolo, MD, FACSHamid Rassai, MD, FACSClifton Reeves, MD, FACSMark Reeves, MD, FACS

INTERNAL MEDICINESofia Bhoskerrou, MDJoseph Selvaraj, MD, MPH

NURSINGRobin Hoover, RN, ADNPam Ihrig, RN, BSNJoanna Krupczynski, RN, BSNSandy Manning, RN, BSNDenise K. Petersen, MSN, FNP

OBSTETRICS AND GYNECOLOGYTricia Fynewever, MDWilbert A. Gonzalez, MD, FACOGJeffrey S. Hardesty, MD, FACOGKathleen M. Lau, MD, FACOGSam Siddighi, MD

OCCUPATIONAL THERAPYKristina Brown, OT

OPHTHALMOLOGYJulio Narvaez, MD, FAAOWendell Wong, MD, FAAO

OROMAXILLOFACIAL SURGERYAllen Herford, MD, DDS, FACS

ORTHOPEDICSRaja Dhalla, MD, FACSChristopher Jobe, MD, FACSRichard Rouhe, MD, FACS

OTORHINOLARYNGOLOGYGeorge Petti, MD, FACSMark Rowe, MD, FACS

PATHOLOGYJeff Cao, MD

PHYSICAL MEDICINE AND REHABILITATION

Jien-sup Kim, MD

PHYSICAL THERAPYJames Ko, PT

PLASTIC AND RECONSTRUCTIVE SURGERYSubhas Gupta, MD, FACSBrett Lehocky, MD, FACSDuncan Miles, MD, FACSMichael Pickart, MD, FACSAndrea Ray, MD, FACSFrank Rogers, MD, FACSArvin Taneja, MD, FACS

UROLOGYH. Roger Hadley, MD, FACS, AUA

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Contents

1 Introduction to Anatomy 2

SECTION 1 HEAD AND NECK

2 Introduction to the Head and Neck 8

3 Skull 12

4 Scalp and Face 26

5 Parotid, Temporal, and Pterygopalatine Region 44

6 Orbit 60

7 Ear 74

8 Nasal Region 86

9 Oral Region 98

10 Pharynx and Larynx 108

11 Submandibular Region 124

12 Anterior Triangle of the Neck 132

13 Posterior Triangle of the Neck and Deep Neck 148

SECTION 2 UPPER LIMB

14 Introduction to the Upper Limb 164

15 Breast and Pectoral Region 166

16 Axilla and Brachial Plexus 178

17 Scapular Region 192

18 Shoulder Complex 204

19 Arm 218

20 Cubital Fossa and Elbow Joint 232

21 Anterior Forearm 248

22 Posterior Forearm 258

23 Wrist and Hand Joints 268

24 Hand Muscles 282

SECTION 3 TRUNK

25 Introduction to the Trunk 302

26 Vertebral Column 306

27 Suboccipital Region 322

28 Back Muscles 334

29 Chest Wall and Mediastinum 346

30 Heart 358

31 Lungs 374

32 Anterolateral Abdominal Wall and Groin 384

33 Gastrointestinal Tract 398

34 Abdominal Organs 418

35 Diaphragm and Posterior Abdominal Wall 432

36 Pelvic Girdle 446

37 Pelvic Viscera 460

38 Perineum 478

SECTION 4 LOWER LIMB

39 Introduction to the Lower Limb 494

40 Anteromedial Thigh 498

41 Hip Joint 512

42 Gluteal Region and Posterior Thigh 526

43 Knee Joint and Popliteal Fossa 540

44 Anterolateral Leg 556

45 Posterior Leg 568

46 Ankle and Foot Joints 580

47 Foot 594

Index 615

xvii

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Atlas of CLINICAL GROSS ANATOMY

2

Anatomy is the study of the structure of the body. Like any other discipline, it has its own language to enable clear and precise communication. Anatomists base all descriptions of the body and its structures on the “anatomical position.” In this position the body is erect, arms at the sides, palms of the hands facing forward, and feet together. The anatomical position is used by anatomists and clinicians as a frame of reference to place anatomy in a three-dimensional context and to standardize the terms for anatomical structures and their functions.

Anatomical planes pass through the body in the anatomical position and are used for reference. The three main descriptive planes (Fig. 1.1) are

• the median plane—a vertical plane that divides the body into left and right halves (strictly speaking, this is called the median sagittal plane)

• sagittal planes—any vertical plane parallel to the median plane, for example, midway between the median plane and the shoulder

• the frontal (or coronal) plane—a vertical plane oriented at 90° to the median plane that divides the body into front (anterior) and back (posterior) sections

• the horizontal (transverse or axial) plane, which divides the body into upper (superior) and lower (inferior) sections and in some situations is referred to as a “cross section”

Specific terms of description and comparison, based on the anatomical position, describe how one part of the body relates to another:

• anterior (ventral)—toward the front of the body• posterior (dorsal)—toward the back of the body• superior (cranial)—toward the head• inferior (caudal)—toward the feet• medial—toward the midline of the body• lateral—away from the midline of the body• proximal—toward the point of origin, root, or

attachment of the structure• distal—away from the point of origin, root, or attachment

of the structure• superficial (external)—toward the surface of the body• deep (internal)—away from the surface of the body• dorsum—superior surface of the foot and posterior

surface of the hand• plantar—inferior aspect of the foot• palmar (volar)—anterior aspect of the hand

There are also terms for movement. Movements take place at joints, where bone or cartilage articulates. Most movements occur in pairs, with the movements opposing each other:

• Flexion decreases the angle between body parts, and extension increases the angle.

• Adduction is movement toward the median plane of the

body, whereas abduction is movement away from the median plane.

• Medial rotation turns the anterior surface medially or inward.

• Lateral rotation turns the anterior surface laterally or outward.

• Supination is lateral rotation of the forearm, for example, such that the palm starts the movement facing down and ends the movement facing up, whereas pronation is medial rotation of the forearm, for example, such that the palm starts the movement facing up and ends the movement facing down.

• Inversion is movement of the foot so that the sole faces medially, and eversion is movement of the foot so that the sole faces laterally.

1 Introduction to Anatomy

FIGURE 1.1 Anatomical planes and orientation.

Median (sagittal) plane

Frontal (coronal)plane

Horizontal plane

Anterior

Posterior

Medial

Lateral

Superior(cranial)

Inferior(caudal)

Proximal

Distal

Right

Left

3

Intro

du

ction

to A

nato

my

• pennate (feather-like)• bipennate• multipennate• sphincteric (circular)

The attachment of a muscle that moves the least is the origin; the more mobile attachment is the insertion. In some instances these roles are reversed.

Connective TissueIndividual muscle cells are covered by specialized connective tissue (endomysium). Because each cell is extremely long, the term fiber is used more often than cell. A bundle of several fibers (a fascicle) is surrounded by a sheet of connective tissue (perimysium). In addition, the entire muscle is surrounded by a sheath of connective tissue (epimysium). These three levels of connective tissue (also known as investments) are interconnected and provide a route for nerves and blood vessels to supply the individual muscle cells. They also transmit the collective pull of individual muscle cells, fascicles, and entire muscles to the points of muscle attachment.

Muscle GroupsMuscles combine in groups to perform complex or powerful movements. Groups of muscles that initiate a movement are prime movers; those that oppose the movement are antagonists. Muscles that contract to support a primary movement are synergists. Paradoxical muscles are muscles that relax against the pull of gravity.

NERVOUS SYSTEMThe nervous system, which consists of the brain, spinal cord, and all peripheral nerves (Fig. 1.2), is the main control center for the body’s numerous functions; it processes all external and internal stimuli and responds appropriately. Its main structural and functional subdivisions are

• the central nervous system (CNS), comprising the brain, brainstem, and spinal cord

• the peripheral nervous system (PNS), composed of 12 pairs of cranial nerves arising from the brain and 31 pairs of spinal nerves arising from the spinal cord

• the autonomic division (see later), composed of elements from both the CNS and PNS

A neuron (nerve cell) comprises a cell body, an axon, and dendrites. The axon is the long fiber-like part of the nerve between the cell body and the target organ. In special circumstances, for example, in the autonomic division (autonomic part of the PNS, see later) when two neurons meet, the axon of one neuron meets the dendrites of another at a junction called the synapse.

Motor nerves (efferent nerves) carry impulses from the CNS to the PNS and innervate muscles. Sensory nerves (afferent nerves) receive information from sense receptors throughout the body and relay it back to the CNS for processing and interpretation.

Autonomic DivisionThe autonomic division is subdivided into two parts—the sympathetic and parasympathetic nervous systems—and allows the body to respond appropriately to any given set of circumstances with very little conscious control.

Axons from neurons in the CNS (preganglionic fibers) run to autonomic ganglia outside the CNS. The preganglionic fiber from a central neuron synapses with a second neuron within the ganglion. Nerve fibers (postganglionic fibers) then travel from this second neuron to the target organ or cell. A ganglion is therefore a collection of neuron bodies outside the CNS that acts as a point of transfer for stimulation of neurons. Both the

• Opposition is action whereby the thumb abducts, rotates medially, and flexes so that it can meet the tip of any other flexed finger.

• Circumduction is circular movement of the limbs that combines adduction, abduction, extension, and flexion (e.g., “swinging the arm around in a circle”).

• Elevation lifts or moves a part superiorly, whereas depression lowers or moves a part inferiorly.

• Protrusion (protraction) is to move the jaw anteriorly, and retrusion (retraction) is to move the jaw posteriorly.

Structures may be unilateral or bilateral. The heart is an example of a unilateral structure: it exists on only one side of the body. Bilateral structures, such as the vessels of the arm, are present on both (bi-) sides of the body. Two similar adjectives—ipsilateral, meaning on the same side of a structure, and contralateral, meaning on the opposite side—are often used in anatomical descriptions.

Body SystemsA body system is a combination of organs with a similar or related function that work together as a unit. Body systems work together to maintain the functional integrity of the body as a whole.

MUSCULOSKELETAL SYSTEMSkeletonThe human skeleton of 206 bones comprises

• the axial skeleton—the skull, vertebrae, ribs, sternum, and hyoid bones

• the appendicular skeleton—shoulder girdles with the upper limbs and hip girdles with the lower limbs

MusclesMuscle cells contract. Movement is produced when the contraction occurs in a muscle that is attached to a rigid structure, such as a bone.

There are three types of muscle that differ in location, histologic appearance, and how they are controlled (voluntary versus involuntary control).

• Skeletal muscles are mainly under voluntary—conscious—control and are the muscles of most interest in gross anatomy. They are attached at each end—either to bone or to connective tissue—via tendons and aponeuroses. They usually span a single joint such that contraction causes the joint to move in a specific direction.

• Smooth muscle is found in the digestive, respiratory, and cardiovascular systems and is under involuntary control. It helps maintain and change the lumen of the gut, bronchi, and blood vessels. In the gut, rhythmic contractions of smooth muscles generate the peristaltic waves that push food through the gastrointestinal tract.

• Cardiac muscle is present only in the heart and is under involuntary control. Contractions of cardiac muscle are the driving force behind the circulation of blood.

Muscle NamesMuscles generally have descriptive names that give an indication of their shape, number of origins, location, number of bellies, function, origin, or insertion. Muscles are classified according to the arrangement of their bundles of muscle fibers (fasciculi), which affects the degree and type of movement of an individual muscle. The fiber arrangements may be

• strap-like (parallel)• fusiform (spindle-like)• fan shaped

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sympathetic and parasympathetic subdivisions of the autonomic division contain ganglia. Most organs receive input from both subdivisions of the autonomic division; however, the body wall does not receive parasympathetic nerve fibers.

Sensory (e.g., pain) fibers from the viscera reach the CNS via either or both of the autonomic pathways, but there is no peripheral synapse for visceral sensory nerves. Their cell bodies are located in either the spinal ganglion (dorsal root ganglion) or the sensory ganglion of certain cranial nerves.

The sympathetic nervous system sends signals from the CNS to prepare the body for action—dilating the pupils, increasing the heart and respiratory rates, and causing sweating, vasoconstriction, cessation of gastrointestinal movements, and constriction of urinary and anal sphincter muscles.

Parasympathetic nerve fibers do the opposite—they relax the body, constrict the pupils, slow the heart rate, promote salivary secretion, increase peristalsis (gastrointestinal tract stimulation), and relax the urinary and anal sphincters.

CARDIOVASCULAR SYSTEMThe heart is in the middle mediastinum between the lungs. It has four chambers that pump blood throughout the body. The right side of the heart receives deoxygenated blood from the body and pumps it to the lungs: pulmonary circulation. The left side receives oxygenated blood from the lungs and sends it to the body: systemic circulation, with arteries carrying blood from the heart to tissues and organs and veins returning blood to the heart.

ArteriesThe aorta is the largest artery in the body. It carries oxygenated blood from the left ventricle of the heart to the rest of the body. Ascending from the heart, the aorta forms an arch that curves toward the left side of the body and then descends in the chest toward the abdomen. The first arteries that branch from the aorta are the relatively small coronary arteries,

FIGURE 1.2 Nervous system.

Brain

Spinal cord

Centralnervous system

Peripheralnervous system

Cranial nerve

Brachial plexus

Anterior ramiof spinal nerve

Sacral plexus

Lumbar plexus

Spinal nerve

Posterior (dorsal)root

Spinal sensory(dorsal root)ganglion

Sympatheticganglion

Sympathetictrunk

FIGURE 1.3 Arterial system.

Right common carotid artery

Right subclavian artery

Brachiocephalic trunk

Aortic arch

Axillary artery

Abdominal aorta

Pulmonary trunk

Celiac trunk

Renal arteryBrachial artery

Gonadal artery

Inferior mesenteric artery

Radial artery

Ulnar artery

Common iliac artery

Deep arteryof the thighFemoral artery

Popliteal artery

Posterior tibial artery

Anterior tibial artery

Fibular artery Dorsalis pedis artery

which supply blood to the heart itself. The first large branch from the aorta is the brachiocephalic trunk, which gives rise to the right common carotid and right subclavian arteries. These vessels supply blood to the head, neck, and right upper limb, respectively (Fig. 1.3). The left common carotid and left subclavian arteries are the next arterial branches and supply blood to the left side of the head and neck and to the left upper limb, respectively. After these branches, the aorta turns inferiorly toward the abdomen. Branches of the descending thoracic aorta supply the viscera within the thorax and the chest wall, mediastinum, and diaphragm.

The thoracic aorta pierces the diaphragm at the level of the thoracic vertebra TXII to become the abdominal aorta. The abdominal aorta gives rise to three main unpaired arteries:

• the celiac trunk (at vertebral level TXII)• the superior mesenteric artery (at vertebral level TXII/

LI)• the inferior mesenteric artery (at vertebral level LIII)

These three arteries supply blood to the abdominal viscera and are derivatives of the embryonic foregut, midgut, and hindgut, respectively. The abdominal aorta also supplies blood to the body wall via paired lumbar segmental arteries. The renal arteries (at the LI level), suprarenal arteries, and gonadal arteries (at the LII/LIII vertebral level) are paired arteries that supply the viscera of the posterior abdominal wall. Inferiorly, the abdominal aorta divides into the left and right common iliac arteries at the level of the LIV vertebra. As the common

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LYMPHATIC SYSTEMThe lymphatic system is composed of a series of lymphatic vessels and lymph nodes (filters) that transport excess tissue fluid (lymph) from the tissue spaces to the venous system (Fig. 1.5). Lymphatic vessels also transport nutrient-rich lymph from the intestines to the blood and play a role in immunity.

Lymph flow through the body is slow. In many areas it is unidirectional because of the presence of one-way valves in the vessels. Flow is promoted by the massaging of lymph vessels by adjacent arteries and—in the limbs—by skeletal muscle and vessels and by differences in pressure between the abdominal and thoracic cavities.

Lymphatic vessels begin as blind-ended capillaries within the tissue spaces. Excess tissue fluid enters these vessels and becomes a colorless, clear fluid—lymph—which then passes through a series of lymph nodes as they convey the lymph toward the venous system:

• The jugular trunks lie beside the internal jugular vein and receive lymph from each side of the head and neck.

• The subclavian trunks drain the upper limbs and chest.• The bronchomediastinal trunks drain the organs of the

thorax.In the abdomen, the thoracic duct drains lymph from the lower limbs, pelvis, and abdomen. Lymph from the thoracic duct drains to the junction of the left subclavian and left internal jugular veins. The thoracic duct receives the left jugular lymph trunk, the left subclavian lymph trunk, and the left bronchomediastinal lymph trunks. Essentially, the thoracic duct drains the lower part of the body, the left upper limb, and the left side of the head and neck. Lymph from the right upper limb and the right side of the head and neck drains to the right jugular lymph trunk via reciprocal vessels, which enter the venous system at the union of the right internal jugular and right subclavian veins.

iliac arteries descend into the pelvis, they subdivide into vessels that supply the pelvis and both lower limbs.

VeinsVeins transport deoxygenated blood from tissues and organs back to the heart (Fig. 1.4). Systemic veins direct blood from the body to the superior and inferior venae cavae, which drain to the right atrium of the heart. The pulmonary vein, unlike the rest of the veins, transports oxygenated blood from the lungs to the left atrium of the heart.

The superior vena cava receives blood from the head and neck, chest wall, and upper limbs via the internal jugular, azygos, subclavian, and brachiocephalic veins. The inferior vena cava receives blood from the pelvis, abdomen, and lower limbs.

The portal system is a special set of veins that drains blood from the intestines and supporting organs. Its venous blood is rich in nutrients absorbed from the digestive tract. The hepatic portal vein is formed by the union of the splenic and superior mesenteric veins. Blood flows from the hepatic portal vein to the liver. From the liver, hepatic veins drain into the inferior vena cava.

FIGURE 1.4 Venous system.

Brachiocephalic vein

Cephalic vein

Basilic vein

Subclavian vein

Superior vena cava

Inferior vena cava

Deep femoral vein

Femoral veinGreat saphenous vein

Aortic arch

Pulmonary trunk

Hepatic portal vein

Inferior mesenteric vein

Gonadal vein

Renal vein

Superior mesenteric vein

Pulmonary arteries

FIGURE 1.5 Lymphatic system.

Thoracic duct

Right jugular lymph trunk

Cervical lymph nodes

Right lymphatic duct

Thoracic duct

Axillary lymph nodes

Cisterna chyli

Lymphatics of mammary gland

Lumbar lymph nodesPelvic lymph

nodes

Inguinal lymph nodes

Lymphatic vesselsof lower limb

Iliac lymphnodes