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1 The bodyIn the ClinicDetermination of skeletal age16

Bone marrow transplants17

Bone fractures18

Avascular necrosis18

Osteoporosis19

Epiphyseal fractures20

Degenerative joint disease24

Joint replacement26

The importance of fascias27

Muscle paralysis28

Muscle atrophy28

Muscle injuries and strains28

Atherosclerosis29

Varicose veins30

Anastomoses and collateral circulation30

Lymph nodes33

Dermatomes and myotomes40

Referred pain52

Clinical CaseAppendicitis53

2 BackIn the ClinicSpina bifida76

Vertebroplasty77

Scoliosis77

Kyphosis78

Variation in vertebral numbers78

The vertebrae and cancer79

Osteoporosis79

Back pain81

Herniation of intervertebral discs81

Joints82

Ligamenta flava84

Vertebral fractures84

Pars interarticularis fractures85

Surgical procedures on the back86

Spinal fusion86

Nerve injuries affecting superficial back muscles101

Lumbar cerebrospinal fluid tap108

Herpes zoster110

Back pain—alte rnative explanations111

Clinical CasesSciatica versus lumbago118

Cervical spinal cord injury118

Psoas abscess119

Dissecting thoracic aneurysm119

Sacral tumor121

3 ThoraxIn the ClinicBreast cancer139

Cervical ribs147

Collection of sternal bone marrow147

Rib fractures147

Surgical access to the chest156

Chest drain(tube)insertion156

Imaging the lungs174

High—resolution lung CT174

Bronchoscopy174

Lung cancer175

Pericarditis179

Pericardial effusion179

Constrictive pericarditis180

Valve disease191

Clinical terminology for coronary arteries194

Coronary artery disease196

Common congenital heart defects197

Cardiac auscultation197

Cardiac conduction system200

Ectopic parathyroid glands in the thymus206

Venous access for central and dialysis lines208

Using the superior vena cava to access the inferior vena cava209

Coarctation of the aorta210

Thoracic aorta210

Aortic arch and its anomalies211

Abnormal origin of great vessels211

The vagus nerves,recurrent laryngeal nerves,and hoarseness214

Esophageal cancer217

Esophageal rupture217

Clinical CasesCervical rib233

Lung cancer234

Chest wound234

Myocardial infarction235

Broken pacemaker238

Coarctation of the aorta238

Aortic dissection239

Pneumonia240

Esophageal cancer241

Venous access242

4 AbdomenIn the ClinicSurgical incisions269

Cremasteric reflex288

Masses around the groin290

Inguinal hernias290

Femoral hernias291

Umbilical hernias291

Incisional hernias291

Other hernias291

Peritoneum294

Ventriculoperitoneal shunts294

Dialysis and peritoneal dialysis294

Peritoneal spread of disease294

The greater omentum296

Epithelial transition between the abdominal esophagus and stomach303

Duodenal ulceration303

Examination of the upper gastrointestinal tract304

Examination of the bowel lumen304

Examination of the bowel wall and extrinsic masses304

Meckel's diverticulum306

Computed tomography(CT)scanning and magnetic resonance imaging(MRI)306

Advanced imaging methods306

Carcinoma of the stomach306

Appendicitis310

Congenital disorders of the gastrointestinal tract313

Malrotation and midgut volvulus313

Bowel obstruction314

Diverticular disease315

Ostomies315

Gastrostomy315

Jejunostomy315

Ileostomy316

Colostomy316

Ileal conduit316

Annular pancreas322

Segmental anatomy of the liver325

Gallstones326

Jaundice326

Spleen disorders327

Vascular supply to the gastrointestinal system336

Hepatic cirrhosis339

Portosystemic anastomosis339

Surgery for obesity347

Psoas muscle abscess353

Diaphragmatic hernias354

Hiatus hernia355

Urinary tract stones361

Urinary tract cancer361

Nephrostomy363

Kidney transplant364

investigation of the urinary tract366

Abdominal aortic stent graft369

Inferior vena cava filter371

Retrope ritoneal lymph node surgery373

Clinical CasesTraumatic rupture of the diaphragm391

Chronic thrombosis of the inferior vena cava391

Liver biopsy in patients with suspected liver cirrhosis392

Hodgkin's lymphoma393

Inguinal hernia394

Ureteric stone395

Intra-abdominal abscess395

Complications of an abdominoperineal resection396

Carcinoma of the head of the pancreas398

Caval obstruction399

Diverticular disease400

Endoleak after endovascular repair of abdominal aortic aneurysm401

Gastrointestinal bleed401

Metastatic lesions in the liver403

5 Pelvis and perineumIn the ClinicLocating the position of the femoral artery421

Using the femoral artery for angiography and endovascular procedures421

Using the femoral vein for pulmonary angiography421

Bone marrow biopsy424

Pelvic fracture426

Common problems with the sacro-iliac joints428

Pelvic measurements in obstetrics433

Defecation435

Episiotomy439

Digital rectal examination439

Carcinoma of the colon and rectum441

Bladder stones443

Suprapubic catheterization443

Bladder cancer444

Bladder infection446

Urethral catheterization447

Testicular tumors448

Vasectomy450

Prostate problems451

Ovarian cancer455

Imaging the ovary455

Hysterectomy456

Tubal ligation457

Carcinoma of the cervix and uterus457

The recto-uterine pouch460

Pudendal block466

Prostatectomy and impotence471

Abscesses in the ischio-anal fossae480

Hemorrhoids482

Urethral rupture490

Clinical CasesVaricocele504

Sciatic nerve compression505

Pelvic kidney505

Left common iliac artery obstruction506

Iatrogenic ureteric injury507

Ectopic pregnancy508

Uterine tumor509

6 Lower limbIn the ClinicPelvic fractures528

Blood supply to the femoral head and neck532

Femoral neck fractures532

Femoral shaft fracture532

Varicose veins544

Deep vein thrombosis544

Vascular access to the lower limb547

Intramuscular iniections553

Muscle iniuries to the lower limb569

Peripheral vascular disease572

Chronic leg ischemia572

Acute on chronic ischemia572

Critical limb ischemia572

Soft tissue injuries to the knee582

Degenerative joint disease/osteoarthritis582

Examination of the knee joint583

Neurological examination of the legs592

Fracture of the talus606

Midfoot fractures606

Ankle fractures608

Bunions611

Morton's neuroma626

Clinical CasesVaricose veins638

Knee joint injury639

Fracture of neck of femur642

Deep vein thrombosis643

Ruptured calcaneal tendon644

Popliteal artery aneurysm645

Anterior talofibular ligament tear646

7 Upper limbIn the ClinicFracture of the proximal humerus668

Fractures of the clavicle and dislocations of the acromioclavicular and sternoclavicular joints673

Dislocations of the glenohumeral joint674

Rotator cuff disorders675

Quadrangular space syndrome682

Damage to the long thoracic nerve690

Imaging the blood supply to the upper limb698

Trauma to the arteries of the upper limb699

Fracture of rib I699

Anterior dislocation of the humeral head699

Subclavian pinch-off syndrome699

Injuries to the brachial plexus709

Breast cancer711

Rupture of biceps tendon716

Blood pressure measurement720

Radial nerve injury in the arm724

Median nerve injury in the arm724

Elbow joint injury727

Supracondylar fracture of the humerus728

Transection of the radial or ulnar arteries728

Pulled elbow728

Fracture of the head of radius728

Epicondylitis728

Elbow arthritis729

Ulnar nerve injury729

Construction of a dialysis fistula731

Fractures of the radius and ulna734

Fracture of the scaphoid and avascular necrosis of the proximal scaphoid756

Carpal tunnel syndrome758

Snuffbox759

Allen's test770

Venipuncture770

Ulnar nerve injury772

Radial nerve injury774

Clinical CasesShoulder problem after falling on an outstretched hand786

Winged scapula786

Brachial plexus nerve block787

Complication of a fractured first rib787

Carpal tunnel syndrome788

Immobilizing extensor digitorum789

Torn supraspinatus tendon789

How to examine the hand790

Shoulder joint problem791

8 Head and neckIn the ClinicMedical imaging of the head828

Fractures of the skull vault and extradural hematoma829

Depressed skull fractures829

Compound fractures829

Pterion fractures829

Hydrocephalus834

Meningitis835

Brain tumors835

Stroke839

Intracerebral aneurysms840

Head injury845

Types of intracranial hemorrhage845

Clinical assessment of patients with head injury847

Treatment of head injury847

Cranial nerve lesions855

Parotid gland865

Facial nerve[Ⅶ]palsy(Bell's palsy)872

Central lesions872

Lesions at and around the geniculate ganglion872

Lesions at and around the stylomastoid foramen872

Trigeminal neuralgia873

Scalp laceration877

Homer's syndrome882

Surgically-induced Horner's syndrome882

Examination of the eye892

Loss of innervation of the muscles around the eye892

Glaucoma899

Cataracts899

Ophthalmoscopy900

Examination of the ear905

Tympanic membrane perforation906

Mastoiditis909

Lingual nerve injury935

Dental anesthesia937

Fascial planes of the head and neck952

Central venous access953

Jugular venous pulse961

Thyroid gland967

Thyroidectomy967

Thyroid gland pathology968

Clinical lymphatic drainage of the head and neck985

Tracheostomy1009

Clinical CasesMultinodular goiter1071

Parotid duct calculus1072

Extradural hematoma1073

Stenosis of the internal carotid artery1074

Posterior communicating artery aneurysm1075

Recurrent epistaxis1076

Complication of orbital fracture1077

Brainstem tumor1078

Pituitary macroadenoma1079

1 The bodyWhat is anatomy?4

How can gross anatomy be studied?4

Important anatomical terms4

Imaging7

Diagnostic imaging techniques7

Nuclear medicine imaging10

Image interpretation11

Plain radiography12

Computed tomography12

Magnetic resonance imaging13

Nuclear medicine imaging13

Safety in imaging13

Body systems14

Skeletal system14

Cartilage14

Bone15

Joints20

Skin and fascias26

Skin26

Fascia26

Muscular system27

Cardiovascular system29

Lymphatic system31

Lymphatic vessels31

Lymph nodes32

Lymphatic trunks and ducts32

Nervous system34

Central nervous system34

Functional subdivisions of the CNS34

Somatic part of the nervous system35

Visceral part of the nervous system41

Other systems52

Clinical cases53

2 BackConceptual overview56

General description56

Functions57

Support57

Movement57

Protection of the nervous system58

Component parts58

Bones58

Muscles60

Vertebral canal62

Spinal nerves63

Relationship to other regions64

Head64

Thorax,abdomen,and pelvis65

Limbs65

Key features65

Long vertebral column and short spinal cord65

Intervertebral foramina and spinal nerves66

Innervation of the back66

Regional anatomy67

Skeletal framework67

Vertebrae67

Intervertebral foramina75

Posterior spaces between vertebral arches75

Joints79

Joints between vertebrae in the back79

Ligaments82

Anterior and posterior longitudinal ligaments82

Ligamenta flava82

Supraspinous ligament and ligamentum nuchae83

Interspinous ligaments84

Back musculature86

Superficial group of back muscles86

Intermediate group of back muscles92

Deep group of back muscles93

Suboccipital muscles99

Spinal cord101

Vasculature102

Meninges104

Arrangement of structures in the vertebral canal106

Spinal nerves107

Surface anatomy112

Back surface anatomy112

Absence of lateral curvatures112

Primary and secondary curvatures in the sagittal plane112

Useful nonvertebral skeletal landmarks112

How to identify specific vertebral spinous processes114

Visualizing the inferior ends of the spinal cord and subarachnoid space115

Identifying major muscles116

Clinical cases118

3 ThoraxConceptual overview124

General description124

Functions125

Breathing125

Protection of vital organs125

Conduit125

Component parts125

Thoracic wall125

Superior thoracic aperture126

Inferior thoracic aperture126

Diaphragm127

Mediastinum128

Pleural cavities128

Relationship to other regions129

Neck129

Upper limb130

Abdomen130

Breast130

Key features130

Vertebral level TIV/V130

Venous shunts from left to right132

Segmental neurovascular supply of thoracic wall132

Sympathetic system134

Flexible wall and inferior thoracic aperture134

Innervation of the diaphragm134

Regional anatomy137

Pectoral region137

Breast137

Muscles of the pectoral region139

Thoracic wall141

Skeletal framework141

Intercostal spaces147

Diaphragm156

Venous drainage158

Innervation158

Movements of the thoracic wall and diaphragm during breathing158

Pleurol cavities159

Pleura159

Lungs163

Mediastinum176

Middle mediastinum177

Superior mediastinum204

Posterior mediastinum215

Anterior mediastinum223

Surface anatomy224

Thorax surface anatomy224

How to count ribs224

Surface anatomy of the breast in women225

Visualizing structures at the TIV/V vertebral level226

Visualizing structures in the superior mediastinum227

Visualizing the margins of the heart227

Where to listen for heart sounds228

Visualizing the pleural cavities and lungs,pleural recesses,and lung lobes and fissures228

Where to listen for lung sounds229

Clinical cases233

4 AbdomenConceptual overview246

General description246

Functions247

Houses and protects major viscera247

Breathing249

Changes in intra-abdominal pressure249

Component parts250

Wall250

Abdominal cavity251

Inferior thoracic aperture253

Diaphragm253

Pelvic inlet254

Relationship to other regions254

Thorax254

Pelvis254

Lower limb255

Key features256

Arrangement of abdominal viscera in the adult256

Skin and muscles of the anterior and lateral abdominal wall and thoracic intercostal nerves259

The groin is a weak area in the anterior abdominal wall260

Verterbral Level L1262

The gastrointestinal system and its derivatives are supplied by three major arteries262

Venous shunts from left to right264

All venous drainage from the gastrointestinal system passes through the liver265

Abdominal viscera are supplied by a large prevertebral plexus266

Regional anatomy268

Surface topography268

Four-quadrant pattern268

Nine-region pattern269

Abdominal wall270

Superficial fascia270

Anterolateral muscles272

Extraperitoneal fascia278

Peritoneum279

Innervation279

Arterial supply and venous drainage280

Lymphatic drainage282

Groin282

Inguinal canal284

Inguinal hernias288

Abdominal viscera292

Peritoneum292

Peritoneal cavity293

Organs297

Arterial supply327

Venous drainage337

Lymphatics341

Innervation341

Posterior abdominal region348

Posterior abdominal wall349

Viscera355

Vasculature366

Lymphatic system372

Nervous system in the posterior abdominal region374

Sympathetic trunks and splanchnic nerves374

Surface anatomy382

Abdomen surface anatomy382

Defining the surface projection of the abdomen383

How to find the superficial inguinal ring384

How to determine lumbar vertebral levels385

Visualizing structures at the L1 vertebral level386

Visualizing the position of major blood vessels387

Using abdominal quadrants to locate major viscera388

Defining surface regions to which pain from the gut is referred389

Where to find the kidneys390

Where to find the spleen390

Clinical cases391

5 Pelvis and perineumConceptual overview406

General description406

Functions406

Contain and support bladder,rectum,anal canal,and reproductive tracts406

Anchors the roots of the external genitalia408

Component parts408

Pelvic inlet408

Pelvic walls409

Pelvic outlet409

Pelvic floor411

Pelvic cavity411

Perineum412

Relationship to other regions414

Abdomen414

Lower limb414

Key features415

The pelvic cavity projects posteriorly415

Important structures cross the ureters in the pelvic cavity415

The prostate is anterior to rectum417

The perineum is innervated by sacral spinal cord segments417

Nerves are related to bone418

Parasympathetic innervation from spinal cord levels S2 to S4 controls erection418

Muscles and fascia of the pelvic floor and perineum intersect at the perineal body419

Gender determines the course of the urethra419

Regional anatomy421

Pelvis421

Bones421

Joints426

Orientation428

Gender differences428

True pelvis429

Viscera438

Fascia458

Peritoneum460

Nerves462

Blood vessels471

Lymphatics477

Perineum478

Borders and ceiling478

Ischio-anal fossae and their anterior recesses480

Anal triangle480

Urogenital triangle483

Somatic nerves490

Visceral nerves492

Blood vessels492

Veins494

Lymphatics496

Surface anatomy497

Surface anatomy of the pelvis and perineum497

Orientation of the pelvis and perineum in the anatomical position497

How to define the margins of the perineum497

Identification of structures in the anal triangle499

Identification of structures in the urogenital triangle of women500

Identification of structures in the urogenital triangle of men501

Clinical cases504

6 Lower limbConceptual overview512

General introduction512

Function513

Support the body weight513

Locomotion515

Component parts517

Bones and joints517

Muscles518

Relationship to other regions520

Abdomen520

Pelvis521

Perineum521

Key points521

Innervation is by lumbar and sacral spinal nerves521

Nerves related to bone525

Superficial veins525

Regional anatomy526

Bony pelvis526

Proximal femur529

Hip joint532

Gateways to the lower limb535

Nerves537

Arteries540

Veins542

Lymphatics542

Deep fascia and the saphenous opening544

Femoral triangle545

Gluteal region547

Muscles548

Nerves551

Arteries554

Veins554

Lymphatics554

Thigh555

Bones555

Muscles561

Arteries569

Veins573

Nerves573

Knee joint575

Tibiofibular joint584

Popliteal fossa584

Leg585

Bones586

Joints588

Posterior compartment of 588

Lateral compartment of 595

Anterior compartment of 596

Foot600

Bones600

Joints605

Tarsal tunnel,retinacula,and arrangement of major structures at the ankle612

Arches of the foot614

Plantar aponeurosis615

Fibrous sheaths of toes615

Extensor hoods616

Intrinsic muscles616

Arteries622

Veins624

Nerves624

Surface anatomy628

Lower limb surface anatomy628

Avoiding the sciatic nerve628

Finding the femoral artery in the femoral triangle630

Identifying structures around the knee630

Visualizing the contents of the popliteal fossa632

Finding the tarsal tunnel—the gateway to the foot633

Identifying tendons around the ankle and in the foot634

Finding the dorsalis pedis artery635

Approximating the position of the plantar arterial arch635

Major superficial veins636

Pulse points637

Clinical cases638

7 Upper limbConceptual overview650

General description650

Functions651

Positioning the hand651

The hand as a mechanical tool651

The hand as a sensory tool654

Component parts654

Bones and joints654

Muscles655

Relationship to other regions657

Neck657

Back and thoracic wall658

Key points659

Innervation by cervical and upper thoracic nerves659

Nerves related to bone663

Superficial veins663

Orientation of the thumb664

Regional anatomy665

Shoulder665

Bones665

Joints668

Muscles675

Posterior scapular region678

Muscles678

Gateways to the posterior scapular region680

Nerves682

Arteries and veins682

Axilla684

Axillary inlet685

Anterior wall686

Medial wall688

Lateral wall690

Posterior wall691

Gateways in the posterior wall692

Floor693

Contents of the axilla693

Arm710

Bones712

Muscles715

Arteries and veins717

Nerves720

Elbow joint724

Cubital fossa729

Forearm731

Bones732

Joints734

Anterior compartment of the forearm736

Muscles736

Arteries and veins742

Nerves743

Posterior compartment of the forearm745

Muscles745

Arteries and veins750

Nerves751

Hand751

Bones752

Joints754

Carpal tunnel and structures at the wrist756

Palmar aponeurosis758

Palmaris brevis759

Anatomical snuffbox759

Fibrous digital sheaths759

Extensor hoods760

Muscles762

Arteries and veins767

Nerves770

Surface anatomy775

Upper limb surface anatomy775

Bony landmarks and muscles of the posterior scapular region775

Visualizing the axilla and locating contents and related structures777

Locating the brachial artery in the arm779

The triceps brachii tendon and position of the radial nerve779

Cubital fossa(anterior view)779

Identifying tendons and locating major vessels and nerves in the distal forearm781

Normal appearance of the hand782

Position of the flexor retinaculum and the recurrent branch of the median nerve783

Motor function of the median and ulnar nerves in the hand783

Visualizing the positions of the superficial and deep palmar arches784

Pulse points784

Clinical cases786

8 Head and neckConceptual overview796

General description796

Head796

Neck798

Functions799

Protection799

Contains upper parts of respiratory and digestive tracts799

Communication800

Positioning the head800

Connects the upper and lower respiratory and digestive tracts800

Component parts800

Skull800

Cervical vertebrae802

Hyoid bone803

Soft palate804

Muscles804

Relationship to other regions805

Thorax805

Upper limbs805

Key features806

Vertebral levels CIII/IV and CV/VI806

Airway in the neck806

Cranial nerves807

Cervical nerves808

Functional separation of the digestive and respiratory passages808

Triangles of the neck811

Regional anatomy812

Skull812

Anterior view812

Lateral view814

Posterior view816

Superior view818

lnferior view819

Cranial cavity822

Roof822

Floor823

Meninges830

Cranial dura mater830

Arachnoid mater833

Pia mater833

Arrangement of meninges and spaces834

Brain and its blood supply835

Brain835

Blood supply837

Venous drainage842

Cranial nerves848

Olfactory nerve[Ⅰ]849

Optic nerve[Ⅱ]850

Oculomotor nerve[Ⅲ]850

Trochlear nerve[Ⅳ]850

Trigeminal nerve[Ⅴ]851

Ophthalmic nerve[Ⅴ1]852

Maxillary nerve[Ⅴ2]852

Mandibular nerve[Ⅴ3]852

Abducent nerve[Ⅵ]852

Facial nerve[Ⅶ]852

Vestibulocochlear nerve[Ⅷ]853

Glossopharyngeal nerve[Ⅸ]853

Vagus nerve[Ⅹ]853

Accessory nerve[Ⅺ]854

Hypoglossal nerve[Ⅻ]854

Face856

Muscles857

Parotid gland863

Innervation865

Vessels869

Scalp873

Layers873

Innervation874

Vessels876

Lymphatic drainage877

Orbit878

Bony orbit878

Eyelids879

Lacrimal apparatus882

Sensory innervation882

Fissures and foramina885

Fascial specializations886

Muscles887

Vessels892

Innervation893

Eyeball898

Ear902

External ear903

Middle ear906

Internal ear913

Temporal and infratemporal fossae920

Bony framework920

Temporomandibular joints922

Masseter muscle925

Temporal fossa926

Infratemporal fossa929

Pterygopalatine fossa940

Skeletal framework940

Gateways941

Contents942

Neck947

Fascia948

Superficial venous drainage950

Anterior triangle of the neck954

Posterior triangle of the neck968

Root of the neck976

Pharynx985

Skeletal framework986

Pharyngeal wall987

Fascia990

Gaps in the pharyngeal wall and structures passing through them990

Nasopharynx991

Oropharynx993

Laryngopharynx993

Tonsils993

Vessels994

Nerves996

Larynx997

Laryngeal cartilages998

Extrinsic ligaments1000

Intrinsic ligaments1001

Laryngeal joints1002

Cavity of the larynx1003

Intrinsic muscles1005

Function of the larynx1008

Vessels1010

Nerves1012

Nasal cavities1013

Lateral wall1014

Regions1015

Innervation and blood supply1016

Skeletal framework1016

External nose1018

Paranasal sinuses1018

Walls,floor,and roof1020

Nares1024

Choanae1024

Gateways1024

Vessels1026

Innervation1028

Oral cavity1030

Multiple nerves innervate the oral cavity1031

Skeletal framework1031

Walls:the cheeks1034

Floor1035

Tongue1037

Salivary glands1044

Roof—palate1047

Oral fissure and lips1055

Oropharyngeal isthmus1055

Teeth and gingivae1056

Surface anatomy1061

Head and neck surface anatomy1061

Anatomical position of the head and major landmarks1062

Visualizing structures at the CIII/CIV and CVI vertebral levels1063

How to outline the anterior and posterior triangles of the neck1063

How to locate the cricothyroid ligament1064

How to find the thyroid gland1065

Estimating the position of the middle meningeal artery1066

Major features of the face1067

The eye and lacrimal apparatus1068

External ear1069

Pulse points1070

Clinical cases1071

Index1081